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• Pancreatic complications following cardiopulmonary bypass are infrequent but are associated with high mortality. All cases of pancreatic complications following cardiopulmonary bypass from 1972 to 1987 at a single institution were retrospectively reviewed. Of 5621 patients who underwent cardiopulmonary bypass, 25 (0.44%) sustained pancreatic complications. There were 15 cases of acute pancreatitis and 10 cases of pancreatic necrosis, with 11 deaths in the group reviewed, a mortality rate of 44%. Factors that were correlated with mortality associated with pancreatic complications in this study include preoperative hypotension, preoperative use of inotropic agents, and renal failure (preoperative and postperative). Factors that have been previously associated with mortality from pancreatic complications in other studies, such as fluid sequestration, respiratory failure, sepsis, tachycardia, hypocalcemia, age greater than 55 years, and abnormal laboratory findings, were not found to be significantly associated with mortality in this study. Of the five patients for whom complete data were available, not one patient received greater than 800 mg of calcium per square meter of body surface area in the perioperative period. While the exact mechanism of pancreatic injury remains unclear, based on experimental studies and clinical correlation, it is likely that pancreatic ischemia remains a significant contributing factor. We conclude that no factor specifically associated with cardiopulmonary bypass was correlated significantly with mortality. ( Arch Surg . 1992;127:1225-1231)

Sternal wound infection remains a source of substantial morbidity and mortality after coronary artery bypass grafting. We noted an association between bacteremias and sternal wound complications in these patients. A review of 835 consecutive coronary bypass patients showed a 3.2% incidence of bacteremia and a 1.9% incidence of deep and superficial sternal wound infection. The sternal wound was the most common source of bacteremia, accounting for 59% of the infections. Coagulasc-negative Staphylococcus was responsible for one half of the sternal wound infections. Often, a positive blood culture was the first manifestation of wound infection, occurring before local signs were manifest. We recommend multiple blood cultures in postoperative coronary bypass patients with pronounced fever. If no source of infection can be identified, sternal wound aspirate may be revealing. Appropriate early wound management can then be carried out, maximizing chances for good recovery.

Ten patients with localized small cell carcinoma of the lung (clinical stages I and II) were treated by surgical resection more than 2 years ago; operation was followed by a course of intensive combination chemotherapy. Relapse of the disease has occurred in the central nervous system in 1 patient. One patient died of a surgical complication, and another died more than 4 years later of an unrelated malignancy. All others remain well, and 3 patients have survived longer than 5 years following resection.

To expand the search for central pulmonary arteries in six patients with absence of cardiac-pulmonary continuity, computerized axial tomography (CAT) of the chest was performed. The CAT scans were compared with previous arteriograms and pulmonary vein wedge angiograms. Three patients with type IV truncus arteriosus were studied, and none had a central, right or left pulmonary artery on CAT scan. However, two patients with tetralogy of Fallot with pulmonary atresia and a patent ductus arteriosus to the right lung demonstrated the presence of a left pulmonary artery. In addition, one child with truncus arteriosus with "absent" left pulmonary artery demonstrated a left pulmonary artery on the CAT scan. The CAT scan may therefore enhance our ability to search for disconnected pulmonary arteries in children with complex cyanotic congenital heart disease.

Reversal of the usual relationship between aortic and radial artery pressure can occur in patients following cardiopulmonary bypass. Radial systolic (and often radial mean) pressures were lower, relative to aortic pressure, after cardiopulmonary bypass than before bypass in all 18 patients studied. The systolic pressure difference (aortic minus radial) was large enough to be of clinical concern (12-32 mmHg) in 13 patients. The change persisted for 10-60 min, gradually returning toward normal. The change temporally was associated with warming at the end of cardiopulmonary bypass and lowered forearm vascular resistance. Relative forearm vascular resistance (x) predicted the systolic aortic minus radial pressure difference (y) by the equation y = -0.34x + 17 for all patients (r = -0.49, P less than 0.001). The authors conclude that radial artery pressure does not accurately reflect central aortic pressure in the immediate postbypass period.

Spontaneous aortoenteric fistulas are rare but appear to be increasing. They may occur anywhere from the esophagus to the rectum but most often between the duodenum and an infrarenal abdominal aortic aneurysm. Four patients (two with aortoesophageal, one with aortoduodenal, and one with aortocolic fistulas) are presented. The patient usually presents with the clinical triad of aortic aneurysm, pain suggesting aortic disruption, and gastrointestinal hemorrhage. The final exsanguinating hemorrhage is usually preceded by prodromal hemorrhages of varying severity which may be present for weeks to months. Endoscopy is the most helpful diagnostic procedure. Prompt aggressive surgical therapy is the only hope for survival. Successful reconstruction requires placement of the graft in uninfected tissue—often in an extraanatomic position—and interposition of healthy tissues between the graft and the repaired enteric tract.

I have recently reported evidences of deviant sex-role adiustment among women alcoholics (1). The present study was undertaken to determine whether comparable indications of deviant femininity would be found among women who are heavy drinkers at an earlier age than that at which alcoholism most commonly has its onset. These reports parallel my earlier studies which found deviant masculinity among both men alcoholics and young men heavy drinkers (2, 3). The study seeks to determine (1) whether heavy-drinking young women show a lower level of femininity of role-relevant preferences and greater personal maladjustment than do their moderate and light-drinking (or abstaining) peers, and (2) whether the young heavy drinkers are more similar in these respects to women alcoholics than to women moderate drinkers. Limited tests of variation in indicators of familial "morale" were also made. METHOD

Thirty patients with 33 vascular injuries from blunt trauma to the brachiocephalic branches of the aortic arch are reported. To our knowledge, this is the largest series reported to date of blunt injuries to these vessels. Mechanisms of injury included deceleration, traction, and crush. Half of the injured vessels were the innominate artery, and a quarter each were the common carotid and subclavian arteries. Common associated injuries were head injuries, hemopneumothorax, lung contusion, long bone fractures, and brachioplexus injuries. Widened mediastinum and extrapleural hematoma were common radiographic findings, and aortic rupture was frequently suspected. Angiography was performed in all patients to identify precisely the nature and site of the injury. Surgical approaches varied with the anatomical site of the injury and required consideration of vascular control in chest, neck, and upper extremity. Twenty-seven patients are alive 6 months to 10 years after injury. Eighteen of 20 vascular reconstructions were patent at follow-up. No patient with brachioplexus injury had return of neurological function.

Autotransfusion following cardiopulmonary bypass has been used infrequently. Certain patients are noted for the potential of serious hemorrhage following conclusion of bypass. A new auto-transfusion technique for use in such patients is described. The method involves a simple modification of the basic cardiopulmonary bypass setup and requires no separate autotransfusion unit. It can be utilized for several minutes after the administration of protamine. Blood salvage can be considerable and at times lifesaving.

Most ventricular aneurysms result from transmural myocardial infarction and are located in the left ventricle. Right ventricular aneurysms are unusual, and their origin at times is obscure. A patient with two discrete right ventricular aneurysms is reported. The literature on operative excision of right ventricular aneurysms is reviewed, and the various etiological factors are discussed.

Twenty-three patients underwent left ventricular aneurysmectomy without coronary artery bypass or other surgical procedure. Fourteen patients (Group 1) benefitted from surgery, and nine fared poorly (Group 2), including the four postoperative deaths. Among the 19 survivors, 17 had postoperative catheterizations. Pre- and postoperative left ventriculograms in the right anterior oblique projection were analyzed by planimetry of the aneurysmal and non-aneurysmal areas. This method provided data favorably altered by surgery in the improved patients and unchanged in the others. None of the preoperative ventriculographic measurements effectively separated the postoperative patient groups. The poor results in the Group 2 patients were of heterogeneous origin arising from pre-, peri- and postoperative factors. The more important factors were the largest and smallest aneurysms, surgically induced mitral insufficiency, and progressive coronary artery disease. Thus, the improvement in surgical results from better angiographic preoperative case selection is possible, but limited.

Summary Of 197 consecutive patients having aortocoronary bypass grafts over a 30 month period, 38 (19 per cent) had ECG evidence of myocardial infarction. The infarctions occurred more commonly in patients receiving multiple grafts. The infarctions were usually in areas supplied by grafted vessels. The infarctions occurred most often in the inferior wall, even when multiple vessels were grafted. Eleven patients with intraoperative infarction have had repeat postoperative coronary arteriograms. Seven had all grafts patent; three of these patients had hypokinesis of the infarcted wall. Four of the 11 patients had one or more occluded grafts; three of these patients had an area of hypokinesis. We conclude that intraoperative myocardial infarction is a common problem in aortocoronary bypass surgery and is not necessarily caused by graft occlusion.

Systemic-pulmonary artery shunts remain an important treatment in cyanotic patients. Central shunts continue to pose early and late problems when standard Blalock-Taussig shunts are not possible. Twenty patients underwent subclavian-pulmonary artery shunt procedures with polytetrafluoroethylene (PTFE) prostheses between October, 1980, and August, 1982. Their ages ranged from 1 day to 15 years; 11 patients were less than 14 days old. The arterial oxygen tension rose from 30.7 +/- 11.9 mm Hg to 51.3 +/- 9.1 mm Hg (standard deviation; p less than 0.001) and from 26.4 +/- 7.5 mm Hg to 50.5 +/- 9.3 mm Hg (p less than 0.001) among the 11 neonates. There were no hospital deaths and only 2 late deaths (not shunt related). All patients have patent shunts and excellent relief of cyanosis. The 18 survivors have been followed for an average of 19 months (range, 7 to 29 months). No patient has required reoperation for shunt inadequacy or thrombosis. Recatheterization in 11 patients has demonstrated normal pulmonary pressures and good pulmonary artery growth without vessel distortion. Subclavian-pulmonary shunts using PTFE provide long-term palliation in cyanotic patients. This type of shunt appears to offer important advantages over other shunt procedures, including the classic Blalock-Taussig operation, in newborns.

Antegrade and retrograde pressures and flows have been measured in the coronary arteries distal to an obstructive lesion and the retrograde flow and pressure correlated with the arteriographically determined degree of stenosis and extent of collateral circulation. Antegrade pressure and flow were roughly proportional to the estimated degree of proximal obstruction, with little change being noted below 70% obstruction. Below 90% obstruction, minimal collateral flow was demonstrable either by arteriogram or by retrograde flow measurement. Retrograde pressures proved to be surprisingly low, usually being about one-third of the systemic pressure and almost never over 30 mm. Hg. Retrograde pressures were relatively independent of the degree of proximal stenosis or of arteriographically demonstrable collateral circulation. Retrograde flows likewise proved to be surprisingly small, even though the method of measurement allowed for absolutely maximal backflow. Retrograde flow, however, did correlate well with the degree of collateral circulation demonstrated in the arteriograms. Patients with the preinfarction syndrome had the lowest antegrade flows and retrograde flows, which were usually too small to be measured.

This paper discusses a complication that is associated with mitral valve replacement utilizing the porcine heterograft and that, to the best of our knowledge, has not been reported previously. Severe mitral insufficiency developed early in 2 patients following mitral valve replacement with a porcine bioprosthesis. Both patients required reoperation. In each patient, it was discovered that one of the cusps of the mitral prosthesis was in the fixed-open position with no evidence of perivalvular leak. The assumption was that failure of the leaflet to close properly had been present from operation. Careful inspection of the valve and assurance that all leaflets close properly should be made at the time of initial valve replacement.

Since its introduction, M-mode echocardiography became quickly established as the method of choice in the diagnosis of left atrial (LA) myxoma. 1 Further definition of tumor size, mobility, site of attachment and other features became possible with the evolution of 2-dimensional echocardiography, henceforth referred to as transthoracic echocardiography (TTE). 2 The introduction of transesophageal echocardiography (TEE) provided the echocardiographer with a new window through which an unimpeded view of both atria and atrial septum became possible with high degrees of resolution and accuracy. 3,4 The following is a report of 3 patients with surgically proven LA myxoma, who were investigated preoperatively with TTE and TEE.

Prospects for the patient with small cell carcinoma of the lung have been partially turned around during the past decade. This dramatic achievement remains very incomplete, but it continues to gather momentum and seems to carry promise of greater advance in the future. An essential feature of the new approach to treatment is that it depends on cooperative and interdisciplinary effort; in all probability, increasing cooperation will be necessary for future progress. We will attempt to review here the current approaches to the understanding and management of this disease, as they may be of concern to surgeons, and to try to define the areas of failure and controversy.

Excision of bullous cysts combined with pleural abrasion and tracheostomy appear to be the only surgical procedures available which afford significant improvement. The necessity of preoperative evaluation and meticulous preparation cannot be overemphasized.

Results of gas endarterectomy of the right coronary artery were evaluated in 29 consecutive patients. There were one surgical and two early postsurgical deaths. All three had postmortem examination, and in two there was occlusion of the gas endarterectomy. Five patients did not have repeat catheterization. Twenty-one patients were completely re-evaluated and had repeat cardiac catheterization one to sixteen months after surgery (mean eight months). Ten patients (Group A) had gas endarterectomy without a saphenous vein graft to the right coronary artery. Only one patient had significant vessel patency. Eleven patients (Group B) had the combined procedure of a saphenous vein graft anastomosed to the segment of artery that had the endarterectomy. There was excellent graft patency in seven patients (64%) and good distal flow into the segment that had endarterectomy in six of the seven patients. In conclusion, gas endarterectomy is not of value unless it can be combined with a saphenous vein graft to provide good flow to the distal vessel that had endarterectomy. Results with the combined procedure suggest that even with a severely diseased artery, gas endarterectomy can often provide continuing distal runoff for the graft.

The danger of irreversible ischemic damage to the spinal cord following repair of traumatic aortic rupture has prompted many techniques designed to decrease this risk. Surgical repair was performed on 41 consecutive patients, using four different methods. These included: group 1 (15 patients), left-heart pump bypass with systemic administration of heparin; group 2 (7 patients), heparinized shunt from the ascending aorta to the descending aorta or to the femoral artery; group 3 (14 patients), heparinized shunt from the left ventricle to the aorta or femoral artery; group 4 (5 patients), aortic cross-clamp only. Spinal cord ischemia was not seen in groups 1 or 2, but paraparesis or paraplegia developed in 4 patients in group 3. Severe shock accompanied rupture in all patients in group 4, and no time was taken for a shunt or bypass. Four of the 7 deaths occurred in the operating room in patients who had arrived moribund and in severe shock. In our experience, shunts from the left ventricle to the aorta have failed to protect the spinal cord against ischemia. Left-heart bypass or aorta-to-aorta shunts are now our procedure of choice.

The outcome of patients developing early bacteremia was investigated in 890 patients following cardiac valve replacement over a ten-year period. Thirty-two patients developed bacteremia during the hospital recovery period from valve replacement (3.6%). Sixty per cent of the organisms involved were gram-negative. Twenty-one of 23 patients had white blood counts greater than 14,000 at the time of positive blood culture. Nine patients died, seven of septic complications. Only two patients developed endocarditis. No patient with bacteremia diagnosed within ten days of surgery developed endocarditis, however two patients developed gram-negative sepsis in this period. The diagnosis and treatment of bacteremia requires continual vigilance if significant mortality and morbidity are to be averted.

The patient presented in this report is unique in that he survived two aortobronchial fistulas. With such fistulas, intermittent hemoptysis is always present; pain is an infrequent symptom. Plain roentgenograms of the chest are helpful in denoting the presence of an aneurysm and the affected portion of the tracheobronchial tree. Aortography rarely demonstrates the fistula. Bronchoscopy should be conducted only with care when the diagnosis is in doubt since disaster can attend disruption of the clot in the fistula. Successful repair usually requires maintenance of distal circulation, repair of the aorta either by closure or by graft replacement, and repair of the tracheobronchial tree either by resection or primary suture. Anesthesia management should include selective endobronchial intubation to control possible intraoperative hemorrhage. Interposition of healthy living tissue to protect the suture lines is encouraged to prevent recurrence.

Sixteen months' experience with intraaortic balloon pumping in a cardiac surgical unit is reported. Eight patients presented in cardiogenic shock and required immediate pumping prior to cardiac catheterization and operation. Sixteen patients undergoing elective cardiac procedures had pumping in the immediate postoperative period because of myocardial depression. Twenty of these 24 patients were able to be restored to cardiovascular stability. Mortality and morbidity in these patients are discussed as well as complications of intraaortic balloon counterpulsation. Our current methods of balloon insertion and deployment are presented.

Subacute bacterial endocarditis involving the common atrioventricular (AV) valve is a rare complication of complete endocardial cushion defect. This report describes our experience with an 18-year-old patient who was seen with this problem. Diagnosis was established by two-dimensional echocardiography. The operative findings and technique of repair are described. We believe this to be among the first successful reports of complete repair of active endocarditis involving the common AV valve in this congenital anomaly.

A patient with primary osteogenic sarcoma of the left atrium with clinical features of severe congestive heart failure is described. The operative procedure required excision of the posterior atrial wall in continuity with the left pulmonary veins. The resultant defect in the atrium was reconstructed with the left atrial appendage. The left pulmonary artery was ligated, and the lung was removed at a subsequent procedure. The patient survived operation but subsequently was found to have distant metastasis. He died seven months after the operation.

Between 1972 and 1982, 9 patients underwent successful excision of atrial myxomas at the Upstate Medical Center. Eight patients had a left atrial myxoma and 1 a biatrial myxoma. There were 5 female and 4 male patients ranging from 16 to 63 years of age. Preoperative findings consisted of cerebral or peripheral emboli, congestive heart failure, and nonspecific symptoms. Diagnosis was confirmed by echocardiography and angiography in all but 1 patient. A biatrial operative approach was utilized in all patients except 1. Complete excision of the tumor with a cuff of normal tissue was performed. All heart chambers were carefully explored for presence of multicentric myxomas or tumor debris. There were no operative deaths or intraoperative embolizations. Follow-up has been 1 1/2 to 11 years. There has been 1 late noncardiac death. All patients underwent echocardiography postoperatively with no recurrence. The risk of intraoperative embolization and late recurrence is minimal with the biatriotomy technique. Two-dimensional echocardiography is extremely accurate in early diagnosis of myxomas and in the late follow-up of patients.

A case is reported of ventricular septal defect resulting from septal infarction following repair of a tetralogy of Fallot. The infarct probably resulted from division of a septal coronary artery during resection of the hypertrophied infundibulum. The superficial position of the septal artery on the right side of the septum in tetralogy makes it surprising that this complication has not been previously reported.

A variety of hemostatic abnormalities has been reported in patients following open-heart surgery. Since surgery itself may induce changes in the coagulation system, the analyses of postoperative coagulation assays in the bleeding patients may be extremely difficult to interpret without an understanding of the coagulation dynamics in the nonhemorrhagic postoperative patients. Thus, we studied the pattern of change in several coagulation assays performed on 36 consecutive patients before and during the first two postoperative weeks. Approximately one third of the patients has some clotting abnormality before surgery. Shortened prothrombin time (PT) and activated partial thromboplastin time (APTT) were observed within the first three postoperative days. Only following warfarin therapy (initiated on the third postoperative day) was significant prolongation of PT and APTT observed. During the 14 postoperative days, fibrinogen levels and fibrinogen degradation products progressively increased without prolongation of the thrombin time or decrease in the euglobulin clot lysis time. On the first postoperative day, the platelet count and platelet adhesiveness values were significantly less than before surgery (p less than 0.01 and p less than 0.05). Over the following two weeks, the platelet count and platelet adhesiveness returned to normal. Although there was slight lengthening of the Ivy bleeding time on the first postoperative day, this assay was never abnormal. Thus, we conclude that the following cardiopulmonary bypass there is (1) probably activation of circulating procoagulants, (2) progressive increase in fibrinogen levels, (3) activation to the fibrinolytic system, and (4) transient thrombocytopenia with a superimposed platelet defect.

Two hundred fifty-five determinations of the protamine sulfate test, the staphylococcal clumping test, and the tanned red blood cell hemagglutination inhibition immunoassay were performed on 30 patients undergoing cardiovascular surgery. The level of serum fibrin-fibrinogen degradation products rose in all patients and reached the highest levels between the fifth and ninth postoperative day. After the first postoperative day, a fibrin-fibrinogen degradation product increase of greater than 10μg/ml within 24 to 48 hours was associated with clinically recognized thrombotic complications in only two out of five patients. Isolated levels of serum fibrin-fibrinogen degradation products as high as 67μg/ml could not be correlated with clinically evident thrombotic disease or serious complications of surgery. Increased excretion of urinary fibrin-fibrinogen degradation products was associated with, but not predictive of, acute ischemic renal failure.

We studied plasma renin activity (PRA) in eight children before and after surgical correction of aortic coarctation. These eight children underwent a combination of low-sodium diet and diuresis before surgery, and PRA was measured shortly thereafter. Thirty-two to 51 months after successful surgical correction, PRA was measured again. The mean PRA was 21.4 +/- 1.3 ng/ml/hour (+/- SD) preoperatively and 5.5 +/- 1.5 ng/ml/hour postoperatively. These findings provide further evidence of the significance of increased renin-angiotensin activity in patients with aortic coarctation.

Mechanical complications that cause heart failure after acute myocardial infarction may be corrected early by surgery. The development of effective cardiac assistance by intra-aortic balloon pumping (IABP) has proved invaluable in resuscitating patients in over-whelming cardiac failure, maintaining them during diagnostic evaluation, and affording long-term (up to two weeks) postoperative support. Four of five patients with acutely expanding ventricular aneurysms, two of six patients with acute mitral regurgitation, and one of two patients with acute ventricular septal defects are living and well. Ten of these 13 patients required IABP. Seven of the group, which was totally refractory to medical therapy, are long-term survivors as a result of this combined supportive, diagnostic, and surgical approach. Usually the heart can be repaired successfully. Patients are lost primarily from the ravages, prior to surgery, of over-whelming cardiac failure on other organs.

• A grass inflorescence (flowering head) aspirated by a child is difficult to diagnose, and frequently cannot be retrieved by bronchoscopy. Of four pediatric patients with aspirated grass inflorescences, two had severe hemoptysis and the other two were septic at the time of diagnosis. Their chronic debilitation and bronchiectasis necessitated an eventual pulmonary resection, with full recovery in all four patients. (Arch Surg115:979-983, 1980)

THIS report deals with the treatment of pulmonary embolism by the application of the partially occlusive Mortez 1 clip to the inferior vena cava in 62 patients over a five-year period. The effectiveness of the clip in controlling recurrent pulmonary emboli was evaluated. The patency of the inferior vena cava has been determined in 31 of 43 patients surviving six months or more, and the degree of venous insufficiency has been examined. The Moretz clip is but one of many nonligation techniques described which offer the theoretical advantage of inferior vena caval patency while protecting the patient against a fatal pulmonary embolus. 1 There have been many reports dealing with the various methods of achieving this using a filter, 2 plication with suture, 3 or staples, 4 or with a clip, with 5 or without compartmentalization. 1 It seemed apparent that more information was needed to evaluate the long-term caval