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Type A intramural hematoma (IMH) is an uncommon entity, the pathophysiology of which is thought to be related to a contained hemorrhage within the medial layer of the aorta as a result of either rupture of the vasa vasorum or an atherosclerotic plaque. We present a case of type A IMH in the setting of acute type B aortic dissection with suspicion for malperfusion syndrome and discuss the treatment algorithm of this uncommon entity., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiovascular disease is the main cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). SLE as a risk factor for adverse outcomes during mitral surgery has not been studied. The purpose of this investigation was to compare procedure selection and outcomes of patients with and without SLE., Methods: The 2005-2008 Nationwide Inpatient Sample database was searched to identify patients ≥18 years of age undergoing isolated mitral repair or replacement. Patients with and without SLE were compared on baseline characteristics and hospital outcomes. Within patients with SLE, those undergoing repair and replacement were compared., Results: SLE patients comprised 0.9% (620/70,969) of the isolated mitral valve surgery population. Patients with SLE were significantly younger, more likely to be female, less likely to be white, had higher Charlson comorbidity index, and less often presented electively. Patients with SLE had a higher incidence of prolonged hospitalization (LOS > 10 days; 44.4% vs. 34.7%, p = 0.0392). Mortality was similar for patients with and without SLE undergoing isolated mitral valve surgery (OR = 0.76, 95% CI 0.28-2.05, p = 0.5821). Patients with SLE were less likely to have mitral valve repair (27.1% vs. 45.6%, p = 0.0002). Baseline characteristics were similar between SLE repair and replacement subsets. Median LOS was higher for replacement (10 days vs. 7 days, p = 0.0014). Hospital mortality was 0% for SLE mitral repair patients and <4.0% for SLE replacement patients., Conclusions: Patients with SLE present for isolated mitral valve surgery at a much younger age and with worse preoperative profiles. Although mitral repair rates were lower in patients with SLE, hospital outcomes were excellent, and comparable to those of patients without SLE., (© 2012 Wiley Periodicals, Inc.)

Objectives: Video-assisted thoracoscopic surgery (VATS) and median sternotomy (MS) are two approaches in lung-volume reduction surgery (LVRS). This study focused on the two surgical approaches with regard to postoperative pain., Methods: In this prospective, non-randomized study, pain was measured preoperatively and postoperatively using the visual analog scale (VAS) and the brief pain inventory (BPI). Incentive spirometry (IS) assessed restriction of the thoracic cage due to pain. Factors associated with treatment complications, medication usage, hospital stay, operating times, and chest-tube duration differences were examined between groups., Results: Of 85 patients undergoing LVRS, 23 patients underwent reduction via MS and 62 patients via bilateral VATS. VAS scores revealed no difference in postoperative pain except for VAS scores on days 6 (PM) and 7 (PM). BPI scores yielded higher scores in the VATS group on postoperative day (POD) 1 in the reactive dimension, but no other overall differences. MS patients receiving tramadol consumed a higher mean amount than VATS patients on POD 5 and POD 6. IS change from baseline to postoperative were similar between groups, and increased pain correlated with decreased IS scores on POD 1. Chest-tube duration, complications, and pain medication were similar between groups., Conclusions: Bilateral VATS and MS offer similar outcomes with regard to postoperative pain and complications. These results suggest that the choice of LVRS operative approach should be dependent on disease presentation, surgeon expertise, and patient preference, not based upon differences in perceived postoperative pain between MS and bilateral VATS.

Objective: The literature is inconsistent regarding the role of chronic obstructive pulmonary disease (COPD) as a risk factor for blood product transfusion during coronary artery bypass graft (CABG). One reason may be lack of objective criteria to define COPD in previously published reports. We examined the role of COPD as a risk factor for transfusion using a strict definition based on objective pulmonary function test (PFT) data., Methods: We identified 180 patients, who underwent primary isolated non-emergent CABG and had PFTs performed preoperatively. COPD was defined as forced expiratory volume in 1s/forced vital capacity (FEV1/FVC) <70% and further stratified into mild/moderate/severe/very severe based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Patients with and without COPD were compared with respect to preoperative and postoperative characteristics and transfusion requirements., Results: The overall transfusion rate was 59.4% (107/180). COPD patients (31.1%, 56/180) were older (66.6 ± 11.4 vs 62.3 ± 10.3 years, p = 0.01), had lower body mass index (BMI) (28.5 ± 5.8 vs 31.7 ± 6.0 kg/m(2), p=0.001), and were more often smokers (51.8% vs 36.3%, p = 0.05). COPD patients had shorter cardiopulmonary bypass (CPB) times (99.4 ± 27.9 vs 110.9 ± 32.4 min, p = 0.02), but left internal mammary artery (LIMA) use, number of bypass grafts, mortality, and postoperative complications were similar (p > 0.05). Transfusion rates were similar for patients with and without COPD. Further stratification into mild/moderate/severe/very severe COPD failed to identify COPD as a predictor of blood transfusion., Conclusions: Using objective PFT data, our study clarifies the disagreement in the literature with respect to the role of COPD as a risk factor for transfusion in CABG. Decreased pulmonary function does not appear to increase risk of transfusion during CABG, even for patients with severe COPD., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Primary focal hyperhidrosis has a significant, negative impact on quality of life, causing impairments in social, physical, leisure, and occupational activities. The outcome of different surgical and medical treatment modalities is best assessed by using a combination of tools. Quantitative tools include gravimetry, evaporimetry, and Minor's starch and iodine test. Qualitative assessment tools include general health surveys and hyperhidrosis-specific surveys. Of these, the HDSS has been found to have a good correlation to other assessment tools and to be practical in the clinical setting. The surgical literature has primarily used qualitative tools to assess outcomes and many of these tools are investigator-developed, rather than standardized surveys, which may be partly because of the largely retrospective nature of these studies. A surgical investigator's goal tends to be focused on obtaining specific postoperative information regarding symptom improvement and potential surgical complications. The VATS can have a major positive impact on the quality of life of patients who have hyperhidrosis. The impairment that this disorder causes is often underappreciated by the medical community.

Background: Success with thoracoscopic sympathectomy (TS) for hyperhidrosis is 93% to 100%. We wished to determine if hyperhidrosis patients who do not undergo TS have decreased quality of life (QOL)., Study Design: Data collection was retrospective, with telephone calls to hyperhidrosis patients who qualified for sympathectomy. Data collection included assessing sweating severity; overall QOL; social, professional, and cosmetic satisfaction; and comfort with daily activities., Results: Between 1998 and 2005, 60 patients met the criteria for sympathectomy. Twenty-two patients who qualified but did not undergo operations (no TS) and 26 TS patients were contacted. Change in symptoms on a 10-point scale for hands was: no TS, -0.30 and TS, -6.25, p < 0.0001, and QOL, on a 1-to-5 scale, increased (no TS, 0.27 and TS, 1.65, p=0.0003). Satisfaction was very good/excellent socially for 9 of 22 no TS patients and 23 of 26 TS patients (p=0.002); professionally for 12 of 22 no TS patients and 23 of 26 TS patients (p=0.021); and cosmetically for 10 of 22 no TS patients and 23 of 26 TS patients (p=0.004). Patients were very satisfied with shaking hands (9 of 22 no TS patients and 24 of 26 TS patients, p=0.0003); writing (9 of 11 no TS patients and 25 of 26 TS patients, p=0.0001); eating (11 of 22 no TS patients and 25 of 25 TS patients, p=0.0008). TS patients had more sweating on the abdomen (no TS patients, 0.0 and TS patients, 1.75, p=0.0001), on the groin (no TS patients, 0.00 and TS patients, 2.9, p=0.0009), and on the back (no TS patients, 0.48 and TS patients, 4.96, p=0.0001). QOL was very good/excellent at followup for 13 of 22 no TS patients and 23 of 26 TS patients (p=0.04)., Conclusions: TS controls palmar hyperhidrosis, and, despite compensatory sweating, patients having the procedure are very satisfied. Patients who did not have surgery have decreased satisfaction, comfort, and QOL, and increased symptoms.

Endobronchial valves have recently emerged as a possible alternative to lung volume reduction surgery to treat incapacitating emphysema. The early experience with placement of these valves has been shown to be safe, with short-term improvements of quality of life in this patient population. We report a case in which these valves were used to treat a patient with a persistent air leak.

Background: Atrial fibrillation after coronary artery bypass is reported from 17% to 53%. Hypomagnesemia after this surgery is considered a contributing factor., Methods: Two hundred-two coronary bypass patients were randomized to magnesium (n = 105) or placebo (n = 97). The experimental group received 80-mg magnesium sulfate per kilogram ideal weight in 100 mL dextrose 5% water 30 minutes preoperatively. Postoperatively, patients received 8-mg magnesium sulfate per kilogram ideal weight intravenous per hour more than 48 hours. The control group received dextrose 5% water at these intervals., Results: After the first bolus serum magnesium was experimental 4.75 mg/dL versus control 1.91 mg/dL, p less than 0.001, and remained different until postoperative day 4 (experimental 2.33 mg/dL vs control 2.26 mg/dL, p = 0.24). Atrial appendage and strap muscle were analyzed after the first bolus and after revascularization. There were no differences between groups in tissue magnesium or calcium. Urinary magnesium was elevated in the experimental (experimental 324.5 mg/24 hours, vs control 45.1 mg/24 hours, p = 0.01). Calcium excretion was higher (experimental 370 mg/24 hours vs control 186 mg/24 hours, p < 0.001) and was associated with lower serum calcium. Serum calcium was higher in the control through the fourth postoperative day. The incidence of atrial fibrillation was experimental 32 of 105 (30.5%) versus control 41 of 97 (42.3%) p = 0.08. Atrial fibrillation was different on the first postoperative day (experimental 3/105, 2.9% vs control 9/97, 9.3%), p = 0.05., Conclusions: Overall prophylactic magnesium supplementation does not significantly reduce atrial and ventricular arrhythmias. The only significant benefit of magnesium supplementation was on the first postoperative day.

Many individuals with cardiovascular diseases undergo periodic physical conditioning with or without medication. Therefore, this study investigated the interaction of exercise training and chronic nitroglycerin treatment on blood pressure (BP) and alterations in nitric oxide (NO), glutathione (GSH), antioxidant enzyme activities and lipid peroxidation in rats. Fisher 344 rats were divided into four groups: (1) sedentary control, (2) exercise training for 8 weeks, (3) nitroglycerin (15 mg/kg, s.c. for 8 weeks) and (4) training + nitroglycerin for 8 weeks. BP, heart rate (HR) and respiratory exchange ratio (RER) were monitored weekly for 8 weeks using tail-cuff method and oxygen/carbon dioxide analyzer, respectively. The animals were sacrificed 24 h after last treatments and plasma isolated and analyzed using HPLC, ELISA and UV-VIS spectrophotometric techniques. The results show that exercise conditioning significantly enhanced NO production (p < 0.001), GSH levels (p < 0.001), GSH/GSSG ratio (p < 0.05) and the up-regulation of the activities of catalase (CAT) (p < 0.05), glutathione peroxidase (GSH-Px) (p < 0.001), and glutathione reductase (GR) (p < 0.05), and depression of lactate levels (p < 0.001) in the plasma of the rat. These biochemical changes were accompanied by a significant increase in RER (p < 0.001) without a significant change in BP and HR. Chronic nitroglycerin administration significantly increased NO levels (p < 0.05), GSH levels (p < 0.001), superoxide dismutase (SOD) activity (p < 0.05), GST activity (p < 0.05), and decreased MDA levels (p < 0.05). These biochemical changes were accompanied by a significant decrease in BP (p < 0.05) and without any significant changes in HR and RER. Interaction of exercise training and chronic nitroglycerin treatment resulted in normalization of plasma NO, MDA, lactate levels, and CAT activity. The combination of exercise and nitroglycerin significantly enhanced GSH levels (p < 0.05), and the up-regulation of SOD (p < 0.001), GSH-Px (p < 0.05), GR (p < 0.05) and GST (p < 0.001) activities. These biochemical changes were accompanied by normalization of BP and a significant increased in RER (p < 0.001). The data suggest that the interaction of physical training and chronic nitroglycerin treatment resulted in the maintenance of BP and the up-regulation of plasma antioxidant enzyme activities and GSH levels in the rat.

Glomus tumors are uncommon. A review of the literature for tracheobronchial glomus tumors revealed 13 tracheal glomus tumors. The diagnosis may be elusive and so the true incidence of tracheobronchial glomus tumors may be greater than that reported. Three of the 14 glomus tumors were initially believed to be carcinoid. Glomus tumors should be included in the differential diagnosis of tracheobronchial tumors.

Background: The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach., Methods: We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure., Results: All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication., Conclusions: Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.

Background: It has been suggested that bilateral thoracoscopic lung volume reduction (BTLVR) yields significantly better long-term survival than unilateral thoracoscopic lung volume reduction (UTLVR)., Methods: All perioperative data were collected at the time of the procedure. Follow-up data were obtained during office visits or by telephone., Results: A total of 673 patients underwent thoracoscopic LVR: 343 had either simultaneous or staged BTLVR and 330, UTLVR. As of July 1998, follow-up was available on 667 (99%) of the 673 patients with a mean follow-up of 24.3 months. The patients in the BTLVR group were significantly younger (62.6+/-8.0 years versus 65.4+/-8.1 years; p < 0.0001), had a higher preoperative arterial oxygen tension (69.7+/-12 mm Hg versus 65.3+/-11 mm Hg; p < 0.0001), and had a superior preoperative 6-minute walk performance (279.9+/-93.6 m [933+/-312 feet] versus 244.5+/-101.4 m [815+/-338 feet] p < 0.0001). There was no difference in the operative mortality rate between the two groups (UTLVR, 5.1%, and BTLVR, 7%). Actuarial survival rates for the UTLVR group at 1 year, 2 years, and 3 years were 86%, 75%, and 69%, respectively versus 90%, 81%, and 74%, respectively, for the BTLVR group (p = not significant)., Conclusions: Contrary to previous reports, survival after BTLVR was not superior to that after UTLVR even though the former group appeared to have a lower risk preoperatively because of younger age, higher arterial oxygen tension, more advantageous anatomy, and better functional status. Despite thoracoscopic LVR, the actuarial mortality rate approached 30% at 3 years, and this calls into question whether this procedure offers any survival advantage to patients with end-stage emphysema.

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1-4), and hospital stay was 2 days (range, 1-9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posterior neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.

Background: Lung volume reduction operations have been shown to improve the quality of life and functional status of some patients with end-stage emphysema., Methods: Because of a perceived increase in the occurrence of postoperative gastrointestinal (GI) complications, we reviewed our experience in 287 patients who had lung volume reduction operations to determine the frequency of GI complications and to identify risk factors., Results: Using a broad definition of postoperative GI complications (nausea, vomiting, abdominal distension, gastroesophageal reflux, diarrhea, constipation) there were 137 complications in 67 patients (23%). More severe GI complications (bowel ischemia, GI bleeding, perforation, ulceration, ileus, colitis, cholecystitis, pancreatitis) occurred 49 times in 27 patients (9.4%). Seven of the 27 patients required abdominal operations. Risk factors identified as predictive of severe complications include diabetes (p = 0.0003), lower preoperative hematocrit (p = 0.01), steroid use (p = 0.02), and use of parenteral meperidine analgesic (p = 0.002). Stepwise logistic regression demonstrated that diabetes was 7.02 times more likely to produce severe complications. Other risk factors included steroids (2.81), number of different pain medications (2.59), hematocrit decrease of 5% (1.96), and hematocrit decrease of 1% (1.14). In the patients with severe GI complications there were six of 27 (22%) hospital deaths compared with five of 260 (2%) in those without GI complications (p = 0.0001)., Conclusions: Severe GI complications in patients with emphysema who had lung volume reduction operations are not uncommon (9.4%) and influence the perioperative mortality rate. Heightened awareness to identified risk factors will allow earlier recognition, prevention, and perhaps decrease morbidity and mortality rates in these high-risk patients.

Lung volume reduction surgery (LVRS) has been a popular procedure since the early 1990s. It appears that there has developed a consensus in the literature that the ideal patient is one with evidence of marked hyperinflation and heterogenous disease. In this patient profile, LVRS has produced excellent results with respect to lung function and improved exercise tolerance. General areas of controversy are discussed which include the role of lasers; unilateral versus bilateral procedures; the role of a staged unilateral procedure; and which surgical route is best for patients. The existing literature is reviewed on these issues.

Background: We explored the efficacy of laparoscopic fundoplication (LF) in patients with uncomplicated, medically recalcitrant pathologic gastroesophageal reflux disease (GERD) for whom we previously would have recommended open surgical repair., Methods: From January 1994 to January 1998, we performed LF on 150 patients (80 men and 70 women) with GERD recalcitrant to maximal medical therapy. No patient suffered from esophageal stricture or epithelial dysplasia; however 16% (24 of 150) had benign Barrett's mucosa. Preoperative esophageal manometry and 24-hour pH testing were obtained in 93% (139 of 150) and 89% (134 of 150) of patients, respectively. Nissen LF (n = 123), Toupet LF (n = 26), or Dor LF (n = 1) were accomplished over a large (54 F) intraesophageal bougie. Preoperative (1 month) and postoperative (>6 month) symptom scoring were assessed on a 0 to 10 scale. Thirty-eight patients with a greater than 6-month postoperative period had manometry and pH studies performed., Results: The laparoscopic approach was successful in 99% (148 of 150) of patients, and there has been no mortality. Operative time was 160+/-59 minutes. Open conversion was required for 2 patients: because of difficulty with dissection owing to adhesions in 1 case and due to perforation in another. Reoperation was required for 5 patients (1 paraesophageal, 2 dysphagia, 2 recurrent reflux). Major postoperative complications involved stroke and pancreatitis in 1 patient each. Mean hospital stay was 2.6+/-1.2 days, full activity resumed by 7 days. Postoperative esophageal pH testing among 38 patients tested more than 6 months after operation demonstrated normal esophageal acid exposure in all but 2. GERD symptoms were relieved at 1 month, 6 months, and after 1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients, respectively., Conclusions: Intermediate-term results with LF suggest this to be a reasonable approach to surgical management of medically recalcitrant uncomplicated GERD. Thoracic surgeons interested in GERD should become familiar with minimally invasive surgical approaches.

Background: Lung volume reduction operations have proved beneficial for emphysematous patients, but questions remain about the role of a unilateral procedure., Methods: Fifty patients were prospectively enrolled in a lung volume reduction surgery program for emphysema with staged unilateral video-assisted thoracoscopic procedures (VATS group). These patients were compared with 29 patients having bilateral lung volume reduction procedures by median sternotomy., Results: The VATS group was slightly older and had shorter 6-minute walk distances, but otherwise the two groups were similar. Hospital stays were shorter for each unilateral VATS procedure, but the total of the two hospital stays was longer than the stay for the sternotomy group (21.1 versus 14.8 days). Complications were comparable, there were no in-hospital deaths, and there was significant difference in the 1-year mortality rate (VATS, 6% versus sternotomy, 13.8%; p = 0.137). Functional test results were comparable between the groups with improvements in percent predicted forced expiratory volume in 1 second (VATS, 41%, and sternotomy, 40%), 6-minute walk distances (VATS, 48%, and sternotomy, 26%), dyspnea scores, and acid base measurements., Conclusions: Staged lung volume reduction operations do not appear to offer any measurable advantages over a single hospitalization and bilateral lung volume reduction procedures.

Background: A previous operation is generally considered to be a relative contraindication to the minimal access approach. We reviewed our combined experience from three centers with video-assisted thoracic surgery on reoperated chests., Methods: From September 1992 to December 1996, 2,477 patients underwent video-assisted thoracic surgery of whom 40 patients (33 men; age range, 9 to 78 years) had prior operations on the ipsilateral side of the chest: 23 after prior open procedures (22 thoracotomies, 1 median sternotomy) and 17 after video-assisted thoracic surgery. The second procedures consisted of bullectomy or bulla ligation (8), mediastinal and hilar mass biopsy (8), wedge lung resection (6), pericardial window (5), lung volume reduction (4), redo thoracodorsal sympathectomy (3), talc insufflation alone (3), decortication (2), and suturing of a pleural rent (1)., Results: Adhesions were noted in all patients ranging from minimal to strong fibrous adhesions. However, in only 2 patients (5%) were the procedures abandoned because of adhesions. Video-assisted thoracic surgery was safely completed in all other patients. There was no mortality or intraoperative complications and mean hospital stay was 5.1 +/- 3.2 days (range, 0 to 17 days)., Conclusions: Video-assisted thoracic surgery on reoperated chests is feasible and does not carry a higher morbidity or mortality compared with first-time operations, even though it may be technically more difficult. Experience and clinical judgment, however, are required to select these patients for reoperation with video-assisted thoracic surgery.

Background: The risk of lung cancer is increased with cigarette smoking and obstructive lung disease. Patients having a lung volume reduction operation represent a high-risk population for cancer., Methods: Between March 1994 and December 1996, 281 patients underwent a lung volume reduction operation. All had severe obstructive lung disease with hyperinflation. The incidence of lung nodules and their management were addressed., Results: Of the 281 patients, 39.5% had at least one lung nodule identified. Fifty-two nodules had typical benign calcification patterns. Of the remaining nodules, 78 were resected and 20 were followed up. Seventeen nodules resected were cancerous, of which 13 were primary lung cancers. Of the resected nodules there were 28 nodules not identified by the preoperative radiologic evaluation., Conclusions: Nodules are frequently seen in patients undergoing lung volume reduction operations. The overall incidence of cancer was 6.4%, with several only identified in the pathologic examination. Survival at short follow-up has been excellent for those with primary lung cancer. Nodules seen in this group of patients should be aggressively diagnosed and managed.

Background: Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak., Methods: One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips., Results: The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups ($22,108 bovine, $22,060 no bovine) in spite of the shortened hospital stay., Conclusions: The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

Background: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care--anatomic lobectomy., Methods: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection (n = 42), video-assisted wedge resection (n = 60), and lobectomy (n = 117) to assess morbidity, recurrence, and survival differences between these approaches., Results: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy (p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study (p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014)., Conclusion: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable "compromise" surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve.

Thoracic applications for thoracoscopy or video-assisted thoracic surgery (VATS) remain many. Wedge resection for lung nodules and lung biopsy remains the most frequently performed VATS procedure. Thoracoscopy has been very valuable as a diagnostic technique for undiagnosed lung nodules and infiltrates. Using VATS for therapeutic resection of metastatic nodules remains controversial with potential adverse consequences. Recently there has been a great deal of interest and enthusiasm for VATS techniques in emphysematous patients. Surgical procedures such as resection of apical blebs and bullae have become standard. However, VATS volume reduction is aimed at a different segment of the emphysema population. The theoretic and potential surgical role in emphysema is discussed. VATS offers decreased pain and shortened hospital stays for many disorders and as such remains a valuable tool for the surgeon.

The prevalence and malignant potential of pulmonary lesions found preoperatively in patients undergoing coronary artery bypass grafting (CABG) surgery are poorly defined. In a review of 3364 consecutive patients undergoing CABG, 191 (5%) were found to have pulmonary lesions. Granulomatous disease was suspected in all patients who had only calcified lesions (n = 151). These were empirically observed with no changes seen at follow-up. The 40 patients with noncalcified lesions (NCLs) were managed variously. Twenty patients underwent resection of the suspicious pulmonary lesion at the time of cardiac surgery. One patient underwent wedge resection of a pulmonary lesion (benign granuloma) 4 days before CABG. Eighteen patients underwent concomitant pulmonary resection and CABG through the median sternotomy (7 benign, 11 malignant). A delayed pneumonectomy was performed 17 days after CABG in another patient. Three of 40 patients died during the perioperative period without pathologic diagnosis. The remaining 17 were followed with serial roentgenograms. Three of 17 (18%) had lesional enlargement in the follow-up period their lesions were found to be malignant. The remaining 14 patients have been observed without surgical intervention now with a mean follow-up of 5.7 years (range, 20 months to 13 years). The prevalence of malignancy in lesions found on CABG preoperative chest roentgenograms was 15 out of 191 (7.8%); however, among patients with NCL the prevalence of malignancy was 15 out of 40 (37%), and malignancy was present in 12/13 (92%) of patients with NCLs that were >/= 2 cm in diameter. When malignancy is diagnosed in an NCL before CABG surgery, the decision to proceed with CABG should be based upon the coronary pathophysiology and the stage and cell type of the malignancy. Concomitant CABG and pulmonary resection is possible in most cases; however, we prefer a staged resection of all newly diagnosed NCLs when these are identified in patients requiring emergent revascularization or when these lesions are difficult to access through sternotomy. The mortality rate may be slightly increased in patients having concomitant procedures (5.47%) versus isolated CABG (3%). The incidence of malignancy in these NCLs is related to size. If a staged resection is not undertaken after CABG, careful observation of NCLs is important, as 18 per cent of these so managed were ultimately found to be malignant.

Video-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence.

Over a 13-year period, 668 patients 70 years of age or older underwent isolated primary coronary artery bypass grafting at our institution. There were 472 men and 196 women, ranging from 70 to 90 years of age (median age, 74 years). Hospital mortality was 5.2% (35/668). In patients 70 to 79 years of age, hospital mortality was 4.2% (25/600), whereas in patients 80 years of age or older, mortality was 14.7% (10/68; p < 0.001). Twenty-seven clinical or hemodynamic variables hypothesized as predictors of operative mortality were examined. Mortality was higher in women than in men (9% versus 3.6%; p = 0.006). Those who died were a mean of 3 years older (77 versus 74 years old; p < 0.05) and were more likely to have unstable angina or Canadian class III or IV angina (p < 0.01). Patients requiring urgent operations, preoperative intraaortic balloon assist, intravenous nitroglycerin, or inotropic agents, and those with preoperative hypotension or cardiac arrest were most likely to die in the hospital (p < 0.001). Multivariate logistic regression analysis revealed advancing age, female sex, bypass time, urgency of operation, preoperative cardiac arrest, and unstable angina as primary determinants of mortality (p < 0.05). Although mortality after coronary artery bypass grafting increases with age, the greatest risk of death is in the acutely ill patient with few options for management other than surgical intervention.

Exploratory thoracotomy was necessary to establish the diagnosis of a rare incarcerated parahiatal hernia. Symptomatology, signs, and radiographic findings are compared with those of paraesophageal hernias.

Renal insufficiency and pulmonary edema are frequently observed in patients who require centrifugal ventricular assist for postcardiotomy ventricular failure. We describe a technique of using a rate-limited ultrafiltration device in parallel with the assist device circuit to remove excess intravascular volume.

Advances in myocardial preservation have led to improved patient survival after open heart operations. However, few studies have detailed the nature of national or regional patterns of cardioplegia use. To determine the regional pattern, all open heart surgery programs in Missouri were surveyed. During 1 year, it was found that cardioplegia was administered to 8,382 patients by 61 cardiothoracic surgeons at ten academic affiliated hospitals and 16 nonteaching hospitals. All cardioplegic solutions were hospital produced. Of 13 crystalloid solutions, 11 differed from one another and eight were intracellular formulations. Of 28 multidose blood-based cardioplegic solutions, there were 23 different mixtures. Most crystalloid (69%) and blood-based (89%) solutions differed substantially from commonly reported formulations. The incidences of the various additives to crystalloid solutions were as follows: bicarbonate, 92%; glucose, 69%; lidocaine, 54%; mannitol, 46%; magnesium, 31%; calcium, 23%; methylprednisolone, 15%; heparin, 8%; and acetate, 8%. Of the common blood-based cardioplegic solution additives, the following incidences were observed: glucose, 79%; bicarbonate, 43%; trishydroxyaminomethane, 36%; acetate, 29%; magnesium, 29%; procaine (or lidocaine), 25%; citrate-phosphate-dextrose, 18%; mannitol/albumin, 14%; nitroglycerin, 11%; glutamate/aspartate, 11%; calcium, 7%; insulin, 3%; and methylprednisolone, 3%. No calcium channel blocker or high-energy phosphate additives were reported. We conclude that many different cardioplegic admixtures that have not been tested experimentally are used routinely in clinical practice, presumably with acceptable results. Because the salutary effects of induced cardiac arrest and hypothermia may mask suboptimal solutions, further study of customized cardioplegia should be considered, particularly with regard to high-risk patients.

We have used the Sarns centrifugal pump for uni- or biventricular assist in 58 patients with postcardiotomy cardiogenic shock. This device utilizes a spinning impeller pump that is magnetically coupled to a motor imparting rotary motion to incoming perfusate. Nine patients (16%) experienced 22 device failures, which consisted of a nonvisible disruption of the seal within the pumphead. This allowed fluid to accumulate between the pumphead and the motor necessitating change of the pumphead. The time to seal disruption was 10-149 h (median 48). Of the 22 seal disruptions, 18 occurred in 73 left ventricular pumps (25%), and 4 occurred in 38 right ventricular pumps (11%) p = 0.015. Left ventricular pumps failed at 10-144 h (median 48), and right ventricular pumps failed at 48-149 h (median 83) p = 0.02. The Sarns centrifugal pump is dependable for its intended use of cardiopulmonary perfusion. However, when used for postcardiotomy assist, seal disruption should be expected. It occurs sooner and is more common during left ventricular assist. We recommend inspection of the magnet chamber for evidence of seal disruption every 12 h with left ventricular assist and every 24 h with right ventricular assist.

Appropriate interventional treatment for coronary artery disease is an important component in controlling health care expenditures. We conducted a retrospective study to compare the patient charges associated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). All patients underwent treatment for left anterior descending coronary artery stenosis over a 3 year 9 month time period from March 1987 to December 1990 and were followed for 7-58 months (median 43 months) after treatment. The two groups were constructed in such a way that they were balanced for common vessels diseased, number of vessels diseased, sex, age, and ejection fraction (EF). The study included 26 PTCA patients between the ages of 33 and 86 years, 18 males and eight females, with a mean EF of 58 per cent, and 26 CABG patients from 39 to 80 years of age, 18 males and 8 females, with a mean EF of 61 per cent. Charges were categorized as to hospital, professional, cardiac medication, follow-up, and total costs. While CABG was initially more expensive, nine of the PTCA patients (38%) required further interventional treatment (3 PTCA, 5 CABG, 1 PTCA and CABG), whereas none of the CABG patients required further intervention (P < .001). This short-term follow-up demonstrated, that although initially less expensive, repeat interventional charges are significantly higher in PTCA patients. With the escalating costs of health care, the appropriate initial interventional therapy for coronary artery disease must be carefully selected to reduce long-term health care expenses.

A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.

Surgical wound infections after cardiovascular surgery may be life threatening and are resource intensive. Second-generation cephalosporins are purported to have a broader antimicrobial spectrum than first-generation cephalosporins and, therefore, may be more efficacious for infection prophylaxis. We have conducted a randomized prospective study of 702 patients undergoing open heart surgery to test the hypothesis that the second-generation cephalosporin, cefuroxime, will be more efficacious for infection prophylaxis than the first-generation cephalosporin, cefazolin. Patients were randomized to receive cefazolin 1 g intravenously every 8 hours for 48 hours begun 1 hour preoperatively plus 1 g after 4 hours of surgery (8 doses, n = 425) or cefuroxime 1.5 g 1 hour prior to surgery plus 1.5 g every 12 hours for 3 additional doses (4 doses, n = 277). Infection was defined as a draining wound with or without a positive culture. There was no difference in the wound infection rate between the groups (p = 0.68). Chest wound infections occurred in 2.1% of patients treated with cefazolin and 2.9% of patients treated with cefuroxime (p = 0.79). The rate of true mediastinitis requiring exploration and drainage was 0.7% in both groups (p = 0.084). Leg infections occurred in 6.6% of cefazolin-treated patients and 5.6% of cefuroxime-treated patients (p = 0.83). The second-generation cephalosporin, cefuroxime, did not reduce the incidence of wound infection when compared with the first-generation cephalosporin, cefazolin. Since institutional antibiotic acquisition and administration costs vary, careful analysis of these factors will allow determination of the most cost-effective infection prophylaxis regimen in cardiac surgery.

Sudden cardiac death is the leading cause of death in the United States. A relatively new technology used to treat ventricular dysrhythmias that lead to sudden cardiac death is the automatic implantable cardioverter defibrillator. This device uses patches on the heart to deliver an energy current to convert lethal dysrhythmias. The nurse practitioner can expect to encounter these devices when seeing patients for a variety of diagnoses. This article will serve as a resource for clinical management and patient education.

We report our experience with 27 (22 male and 5 female) patients who were from 16 to 82 years of age (median 29 years) who underwent surgical repair for traumatic pseudoaneurysm of the thoracic aorta. The cause of injury in all cases was blunt trauma. Repair was accomplished with partial bypass by means of a roller pump with systemic heparinization in 6 (23%), Gott shunt in 7 (27%), clamp-and-sew technique in 6 (23%), and centrifugal pump without systemic heparinization in 8 (30%). Significant postoperative complications occurred in 12 patients. Paraplegia occurred in 1 patient (clamp and sew), anterior spinal cord syndrome in 1 (clamp and sew), renal failure in 1 (Gott shunt), temporary vocal cord paralysis in 2 (Gott shunt, centrifugal pump), permanent vocal cord paralysis in 1 (roller pump), and coagulopathy in 2 (centrifugal pump, Gott shunt). Hospital mortality occurred in 5 of 27 (19%), (1 clamp and sew, 1 Gott shunt, 1 centrifugal pump, 2 roller pump). Follow-up of survivors (1 week to 20 years, median 2.1 years) revealed no further problems from either aortic graft or primary repair. Although patient numbers are small, evaluation of each of the four surgical techniques leads us to favor repair with shunting with a centrifugal pump without heparin. The potential advantage of left atrial-left femoral artery shunt with centrifugal pump support was evident in operative field exposure, afterload reduction, avoidance of clamp injury, and maintenance of stable distal aortic perfusion without heparin.

Since October 1986, we have had experience with 96 Sarns centrifugal pumps in 72 patients (pts). Heparinless left atrial to femoral artery or aorta bypass was used in 14 pts undergoing surgery on the thoracic aorta with 13 survivors (93%). No paraplegia or device-related complications were observed. In 57 patients, the Sarns centrifugal pump was used as a univentricular (27 pts) or biventricular (30 pts) cardiac assist device for postcardiotomy cardiogenic shock. In these patients, cardiac assist duration ranged from 2 to 434 h with a hospital survival rate of 29% in those requiring left ventricular assist and 13% in those requiring biventricular assist. Although complications were ubiquitous in this mortally ill patient population, in 5,235 pump-hours, no pump thrombosis was observed. Hospital survivors followed for 4 months to 6 years have enjoyed an improved functional class. We conclude that the Sarns centrifugal pump is an effective cardiac assist device when used to salvage patients otherwise unweanable from cardiopulmonary bypass. Partial left ventricular bypass using a centrifugal pump has become our procedure of choice for unloading the left ventricle and for maintenance of distal aortic perfusion pressure when performing surgery on the thoracic aorta. This clinical experience with the Sarns centrifugal pump appears to be similar to that reported with other centrifugal assist devices.

Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (less than 3 cm) in the outer third of the lung. Patients with preoperative histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttrium-aluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 +/- 3.0 days. Mean postoperative stay was 5.7 +/- 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The reported clinical use of the Sarns centrifugal pump (Sarns, Inc./3M, Ann Arbor, Mich.) as a cardiac assist device for postcardiotomy ventricular failure is limited. During a 25-month period ending November 1988, we used 40 Sarns centrifugal pumps as univentricular or biventricular cardiac assist devices in 27 patients who could not be weaned from cardiopulmonary bypass despite maximal pharmacologic and intraaortic balloon support. Eighteen men and nine women with a mean age of 60.4 years (28 to 83) required assistance. Left ventricular assist alone was used in 12 patients, right ventricular assist in 2, and biventricular assist in 13. The duration of assist ranged from 2 to 434 hours (median 45). Centrifugal assist was successful in weaning 100% of the patients. Ten of 27 patients (37%) improved hemodynamically, allowing removal of the device(s), and 5 of 27 (18.5%) survived hospitalization. Survival of patients requiring left ventricular assist only was 33.3% (4/12). Complications were common and included renal failure, hemorrhage, coagulopathy, ventricular arrhythmias, sepsis, cerebrovascular accident, and wound infection. During 3560 centrifugal pump hours, no pump thrombosis was observed. The Sarns centrifugal pump is an effective assist device when used to salvage patients who otherwise cannot be weaned from cardiopulmonary bypass. Statistical analysis of preoperative patient characteristics, operative risk factors, and postoperative complications failed to predict which patients would be weaned from cardiac assist or which would survive.

Reported experience with ventricular assist devices (VAD) routinely includes the rate of thromboembolic events, which is commonly calculated from clinically evident findings. Fifty-four patients have had postcardiotomy circulatory support with the Sarns centrifugal device at our institution. We have reviewed 43 patients who failed to survive VAD support to compare the thromboembolism rate diagnosed clinically to that determined at autopsy. In the 35 patients who had no autopsy, there was one clinically apparent thromboembolic event (2.3%). In eight similar patients who had autopsy, there was no clinically apparent thromboembolism. Five of these eight patients (63%) had acute thromboembolic infarcts determined at autopsy. Three had evidence of pulmonary thromboembolism, two cerebrovascular infarction, two liver infarcts, two splenic infarcts, two kidney infarcts, and one each gastric, pancreatic, prostate, adrenal, cervical, and ileal infarcts. All had left and/or right ventricular infarctions. It is concluded that patients dying following VAD have commonly suffered perioperative myocardial infarction. When evaluating complications associated with VAD, one should consider that the true incidence of thromboembolic events is underestimated by clinical findings.

Heparin is usually administered to patients with intra-aortic balloon pumps (IABP) to prevent thromboembolism. In addition to thrombocytopenia caused by IABP mechanical damage to platelets, exposure to heparin can cause heparin induced thrombocytopenia (HIT). Heparin induced thrombocytopenia is caused by an immune mechanism in which heparin antibodies are produced, causing platelet aggregation, leading to bleeding or thromboembolic complications. Over a 9 year period, 35 of 764 (4.5%) patients with IABPs have been diagnosed as having HIT. Surgical procedures included coronary artery bypass (CABG) in 14 (40%), valve repair or replacement in 7 (20%), and CABG and other cardiac procedure in 14 (40%). Lowest platelet counts ranged from 17,000-114,000/mm3 (median, 44,000/mm3). Thirty-three of 35 (94.3%) had mediastinal hemorrhage requiring infusion of multiple blood products, and 6 of these 35 (17%) required return to the operating room. Seventeen of 35 (48.6%) experienced thromboembolic complications. Hospital mortality was 15 of 35 (42%). Etiology of thrombocytopenia in patients on IABPs is multifactorial. Patients on an IABP who develop thrombocytopenia should be tested for heparin dependent anti-platelet antibodies to rule out HIT. When a heparin antibody is present, heparin must be discontinued and alternate forms of anticoagulation/platelet inhibition initiated to reduce morbidity and mortality.

Should automatic implantable cardioverter defibrillator (AICD) power sources be explanted and discontinued if they have not pulsed during the first generator life? We have followed 59 patients an average of 23 months (range, 3 days to 8.4 years) after AICD implantation. The indication for AICD implantation was based on clinical dysrhythmia, history of sudden death, and findings at electrophysiologic study. Thirty-eight of 59 patients (64%) had experienced sudden death and 52/58 (90%) were inducible at electrophysiologic study. Excluding 5 inappropriate pulsing episodes, 31 of 59 patients (53%) had 235 pulses (range, 1 to 36; median, 2 pulses). The time to first pulse after implantation ranged from 1 day to 3.5 years with a median time of 2 months. In 6 patients, the first pulsing occurred later than 1 year after AICD implantation. Fifteen generators demonstrating impending power source failure have been replaced in 11 patients. Power source depletion occurred at an average of 24.1 months (range, 8 to 40 months). In 3 patients, the first pulsing occurred after generator depletion and replacement. By univariate analysis, none of 13 variables (sex, age, cardiac disease process, functional class, previous myocardial infarction, sudden death history, ejection fraction, type of dysrhythmia, inducibility with electrophysiologic testing, number of extra stimuli required for induction, left ventricular aneurysm resection, endocardial resection, or concomitant operation) was found to be a predictor of pulsing (p greater than 0.05). We conclude that the majority of patients with pulses after AICD implantation will have them during the first 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Most patients undergoing open heart operations have had exposure to heparin for diagnostic and/or therapeutic procedures. Heparin antibody formation and heparin-induced thrombocytopenia with repeat heparin administration can cause high morbidity and mortality from thrombotic complications, especially when delay in diagnosis occurs. From 1981 to 1991, heparin-induced thrombocytopenia was diagnosed in 82 of 4,261 open heart surgical patients (1.9%). Platelet counts less than 100 x 10(9)/L (100,000/microL) or new or recurring thrombotic events prompted suspicion of heparin-induced thrombocytopenia. Heparin-dependent antibody was diagnosed preoperatively in 12 patients (group I) and postoperatively in 70 patients (group II). Heparin was not given postoperatively in group I patients, and complications in this group were limited to bleeding in 3 patients. There were no thromboembolic events and all patients survived. Group II patients had late recognition of heparin-dependent antibody postoperatively, and heparin exposure was continued for varying periods postoperatively. Thirty-seven group II patients (53%) had bleeding complications and 31 (44%) had thromboembolic complications. These complications led to death in 23 group II patients (33%). Heparin-dependent antibody may occur in patients having open heart operations and is a major cause of morbidity and mortality if not diagnosed early with cessation of heparin therapy.

Paraesophageal herniation is a potentially devastating condition of the gastroesophageal hiatus commonly manifesting in patients of advanced age with other significant medical problems. Surgical treatment is generally indicated to avoid catastrophe related to gastric volvulus. The operative approach utilized should be individualized to the patient's pathophysiologic condition rather than attempting to apply a single repair for all patients with this heterogeneous clinical problem.

We have performed a retrospective study of patients undergoing coronary artery bypass grafting for postinfarction angina in an effort to determine the influence of recency of myocardial infarction and unstable angina on operative mortality. Time from myocardial infarction to bypass was arbitrarily divided into five intervals. Nine hundred ninety-three patients having isolated coronary bypass for postinfarction angina were analyzed, and a significant trend of increased operative mortality with recency of myocardial infarction was found (p less than 0.001). When patients were operated on during the time interval zero to 24 hours after infarction, the operative mortality rate was 18.6%. In the interval from 1 day to 1 week after infarction, the operative mortality rate was 7.4%; 1 week to 3 weeks, 5.9%; and 3 weeks to 3 months, 2.7%. In patients operated on more than 3 months after infarction, the operative mortality rate was 3.9%. The operative mortality rate in 360 patients with postinfarction stable angina was 0.83% compared with 7.3% in 633 patients with postinfarction unstable angina (p less than 0.001). Of 18 risk factors tested, 12 were found by univariate analysis to be independent predictors of operative mortality, including recency of myocardial infarction and unstable angina. Stepwise logistic regression analysis of independent predictive variables revealed that unstable angina, previous surgical revascularization, preoperative hypotension, nonelective surgery, preoperative cardiac arrest, and female sex were the strongest predictors of mortality; recency of myocardial infarction was not a factor. When acute surgical reperfusion is not the primary treatment strategy for patients with myocardial infarction, operative mortality with coronary bypass is increased with the recency of myocardial infarction. The reason for this increase in operative mortality is a patient selection process in which those with persistent or intermittent myocardial ischemia, as reflected in the clinical syndrome of unstable angina, are selected for operation. Unstable angina is a major determinant of operative mortality after myocardial infarction. In patients with stable angina, operative mortality is not increased by the recency of myocardial infarction.

The recent explosion of interest in surgical endoscopic techniques has revived the application of an old thoracic surgical procedure--thoracoscopy. We report a case of a transthoracoscopic neodymium: yttrium-aluminum garnet laser resection of a limited-stage peripheral adenocarcinoma of the lung accomplished in an elderly man with serious chronic obstructive pulmonary disease.

Twenty-seven patients with advanced gastroesophageal reflux disease have been treated with combined transthoracic parietal cell vagotomy and Collis-Nissen fundoplication. Gastric acid analyses (n = 20) obtained preoperatively and 6 months postoperatively demonstrated a significant late reduction in gastric acid output. Twenty-six patients (96%) have experienced relief of gastroesophageal reflux disease at a mean of 13.3 months (range, 6 to 25 months) without postvagotomy symptoms. Transthoracic parietal cell vagotomy may be considered as an adjunct to mechanical surgical control of advanced gastroesophageal reflux disease.

The surgical management of posterior mediastinal goiters can pose considerable technical difficulty. We illustrate a method of sterile spoon extraction that can facilitate the cervical or limited cervicomediastinal approach to these lesions.

The neodymium:yttrium-aluminum garnet laser is a new approach to limited pulmonary resection. It avoids distortion of surrounding pulmonary tissue and potential pleural space problems, which can occur with mechanical stapler resections. We have recently used this laser to manage 39 pulmonary lesions in 20 patients. There were no major postoperative complications, and air leak after resection was minimal. Neodymium:yttrium-aluminum garnet laser excision is a useful method that may have an advantage over mechanical stapling techniques for the limited resection of many pulmonary lesions.

Giant tracheoesophageal fistulae occurring in ventilator-dependent patients usually result in significant ventilatory embarrassment. Cervical exclusion of the fistula can safely control the fistula and quickly restore adequate ventilation to these critically ill patients.

The indications for and preferred approaches to operative stabilization of posttraumatic chest wall instability are uncertain. We suggest this simple, rapid, and effective approach to surgical stabilization by Luque rod strutting of the flail segment when operation is required.

Increased interest in alternative approaches to thoracotomy has developed because of the considerable morbidity associated with the standard posterolateral technique. We conducted a prospective, randomized, blinded study of 50 consecutive patients to compare postoperative pain, pulmonary function, shoulder strength, and range of shoulder motion between the standard posterolateral and the muscle sparing thoracotomy techniques. Pulmonary function (forced expiratory volume in 1 second and forced vital capacity), shoulder strength, and range of motion were measured preoperatively and at 1 week and 1 month postoperatively. Pain was quantitated by postoperative narcotic requirements, the visual analogue scale, and the McGill pain questionnaire. Morbidity, mortality, and hospital stay were compared between the standard posterolateral and muscle-sparing techniques. There were no differences in postoperative pulmonary function, shoulder range of motion, extent of lung resection, surgical approach time, mortality, or hospital stay. There was significantly less postoperative pain in the muscle-sparing group. The narcotic requirement was less in the first 24 hours (p = 0.0169), and visual analogue scale scores were significantly lower (p less than 0.05) throughout the first postoperative week. Shoulder girdle strength was decreased at 1 week in the standard incision group whereas the strength was preserved with the muscle-sparing approach. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 23% in the muscle-sparing group and 0% in the standard incision group (p = 0.0125). We have demonstrated that the muscle-sparing incision may be a reasonable alternative to the standard posterolateral approach.