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An endobronchial tumor, resected from a 77-year-old man, had an endometrioid histologic pattern consistent with fetal adenocarcinoma. A distinctive feature of the neoplasm was prominent neuroendocrine differentiation, including single, discrete neuroendocrine cells; aggregates of neuroendocrine cells resembling miniature carcinoid tumors; and a single focus of undifferentiated small cell carcinoma. Immunohistochemical staining of neuroendocrine cells revealed the presence of neuronspecific enolase, chromogranin, somatostatin, insulin, and serotonin. The heterogeneous cell populations caused problems in differential diagnosis and histologic classification. This case demonstrates that fetal adenocarcinoma may occur as a central endobronchial mass and express a variable degree of neuroendocrine differentiation. Cancer 1994; 73:1383–9.

Objective: To evaluate the cardiovascular effects of a propofol-ketamine combination in patients undergoing coronary artery surgery. Design: Prospective, randomized study. Setting: Tertiary care teaching hospital, single center. Participants: Seventy-eight adult patients. Interventions: Patients were randomly allocated to receive propofol-ketamine for induction and maintenance of anesthesia (n = 36) or fentanyl-enflurane (controls, n = 42). Measurements and Main Results: Hemodynamics and other variables were recorded during and after surgery and for 24 hours in the intensive care unit. Before cardiopulmonary bypass (CPB), there was similar incidence of treatment for hypotension (42% of patients in both groups), tachycardia (propofol-ketamine, 6%; controls, 5%), and myocardial ischemia (propofol-ketamine, 3%; controls, 12%). In the propofol-ketamine group, there was a decreased requirement for inotropic agents after CPB (22% of patients) compared with controls (49% of patients; p = 0.02). There was a reduced incidence of myocardial infarctions (creatine kinase myocardial band > 133 U/L) in the propofol-ketamine group compared with the control group (0% v 14%; p = 0.02; Fisher's exact test). Patients in the propofol-ketamine group were more likely to have their tracheas extubated within 8 hours of arrival in the intensive care unit compared with controls (33% v 7%; p = 0.01; Cochran-Mantel-Haenzel test). Conclusions: The propofol-ketamine combination was associated with a similar incidence of pre-CPB hypotension and ischemia, a decreased need for inotropes after CPB, an earlier time to tracheal extubation, and a reduced incidence of myocardial infarctions compared with controls. Copyright © 2000 by W.B. Saunders Company

We compared the clinical, hemodynamic, and morphological findings in 18 young sheep in which porcine valvular bioprosthesis (eight animals) and bovine pericardial bioprostheses (10 animals) were implanted in the tricuspid position. At the time of terminal elective studies (mean of 5.2 +/- 0.2 months after implantation), six animals had ascites, 16 had hepatic congestion, and four had bioprosthetic valvular infection. Hemodynamic studies (n = 10) showed that the tricuspid transvalvular mean diastolic gradients were not different at implantation and at termination of the study (4.7 +/- 0.8 versus 4.9 +/- 0.9 mm Hg); however, tricuspid valve end-diastolic gradients increased from 1.2 +/- 0.6 to 3.9 +/- 0.5 mm Hg (p less than 0.01). Each of the 18 valves had calcific deposits. Quantitative studies revealed that implanted porcine valvular bioprosthesis (n = 7) contained a mean of 323 +/- 165 mg of calcium/gm of dry weight of cuspal tissue, in contrast to 0.2 mg/gm in unimplanted porcine valvular prostheses. Similarly, implanted bovine pericardial bioprostheses (n = 6) contained a mean of 421 +/- 115 mg of calcium/gm of dry weight of cuspal tissue, in contrast to 0.3 mg/gm im unimplanted bovine pericardial bioprostheses. Morphological findings in both types of bioprostheses included calcific deposits, collagen degeneration, leaflet immobilization and retraction, and fibrous sheaths. The latter were more extensive in bovine pericardial bioprostheses than in porcine valvular bioprostheses. We conclude: (1) that the pathological alterations which develop in bovine pericardial bioprostheses are generally similar to those in porcine valvular bioprostheses, but may be more severe; (2) that these alterations lead to physiological and clinical sequelae similar to those of bioprosthetic valvular failure in human subjects; and (3) that young sheep constitute an excellent experimental model for in vivo testing of bioprosthetic cardiac valves.

Records of 520 patients who underwent mitral valve operations were reviewed to determine the pathophysiology, etiology, anatomy of the valve lesion and use of valvuloplasty techniques. Pure mitral regurgitation, present in 269 patients (52%), was the most common lesion while rheumatic valvulitis, seen in 286 patients (55%), was the most common etiology. Degenerative lesions were found in 168 patients, 33% of the total and 63% of the pure mitral regurgitation group. Two-hundred seventy patients (52%) were treated with valvuloplasty techniques. The incidence of reconstructive procedures was determined for each of the various patient subsets. Overall hospital mortality was 5.6% in the series: 8.4% for mitral replacement compared with 3% for mitral valvuloplasty (p = 0.007). Among patients undergoing primary isolated mitral procedures, hospital mortality for replacement was 7.5% compared with 1.4% for valvuloplasty (p = 0.018). Mitral valvuloplasty seems to provide a therapeutic alternative applicable to the spectrum of mitral valve pathology seen in a North American population.

In 1986, 273 patients at The Cleveland Clinic Foundation had surgery on their native mitral valves. Mitral insufficiency occurred in 153 (56.0%) of these patients, mitral stenosis in 70 (25.6%), and mixed lesions in 50 (18.3%). Valvular lesions were due to rheumatic valvulitis in 134 (49.1%) patients, degenerative mitral valve disease in 97 (35.5%), ischemia in 23 (8.4%), and varied causes, including bacterial endocarditis and congenital lesions, in the rest. There were 10 deaths in the entire series, a 3.7% operative mortality rate. Operative mortality was similar for mitral stenosis, mitral insufficiency, and mixed lesions. The low operative mortality rate and wide applicability of mitral valvuloplasty, which avoids the complications associated with a mitral valve prosthesis, should encourage surgical intervention before ventricular function deteriorates or atrial fibrillation becomes irreversible.