Search

This case describes a patient with cholesteryl ester storage disease who underwent liver transplantation for progressive cirrhosis, portal hypertension, ascites, and uncontrollable gastrointestinal bleeding. Four and one-half years posttransplant, her growth improved, cholesterol levels have returned to normal, and she is clinically well except for mild hypersplenism and an elevated blood urea nitrogen (BUN) and creatinine. Serum triglycerides remain elevated, but there have been no signs of progressive renal, intestinal, vascular, or pulmonary disease.

Of 1,393 consecutive patients operated on for aneurysm of the abdominal aorta between 1964 and 1978, 61 consecutive patients had undergone emergency operation for ruptured abdominal aortic aneurysm, for an incidence of 4.4% (61 of 1,393). There were 57 men and four women; their mean age was 77.5 years, with a range of 49 to 93 years. In 21 patients the diagnosis of aneurysm had been known from 1 day to 5 years prior to rupture. Hypotension (less than 100 mm Hg systolic) was present in 27.9% of patients (17 of 61) on admission to hospital and prior to operation in a total of 44.3% patients (27 of 61). Operation was begun in eight patients with an initially unrecordable blood pressure. The perioperative mortality rate (30 day) was 14.8% (nine of 61). The two factors most influencing survival were age [no patient younger than 60 years died vs. 40% of patients (four of 10) older than 80 years] and the magnitude of blood loss (survivors lost a total of 4,513 ml vs. 8,500 ml in those who died). Thus the most common cause of death was myocardial infarction (six of eight) in elderly patients, secondary to poorly tolerated severe hypovolemia. The results of this study suggest the need for avoidance of technical problems during operations, earlier referral of patients with known abdominal aortic aneurysms, especially the elderly, and early diagnosis with immediate operation for ruptured aneurysms.

We have determined the clinical course of 200 consecutive patients (mean age, 67.5 years) in whom epicardial pacing was established by the left subcostal route by insertion of 2 sutureless myocardial electrodes and a demand bipolar generator. There was 1 intraoperative death (0.5%). The overall 30-day perioperative mortality was 4 of 200 patients (2.0%). The principal postoperative complications included postpericardiotomy syndrome in 8 patients (4.0%), pneumonia or marked atelectasis in 2 patients (1.0%), and pulmonary embolus in 1 patient. Hemiplegia developed in 2 patients at 9 and 10 days, respectively, after operation, and transient monoparesis developed in another patient (1.5%). There were no wound infections, but the one wound dehiscence required resuturing. Follow-up has been completed in all patients from 1 to 39 months postoperatively (mean, 14.9 months). There have been 21 late deaths. Late lead thresholds were recorded for 45 individual leads from 26 patients up to 35 months after operation. The results obtained indicate that for patients undergoing primary implantation, the sutureless myocardial electrode provides reliable lead function. However, patients who required reoperation because of previous pacemaker failure due to threshold rise have done poorly as a group and may be better managed with lithium high-output pacemaker generators.