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Five hundred twenty-eight pulmonary artery catheters were inserted in 500 patients at the New York University Medical Center between May and November, 1981. Complications occurred in 126 of 528 catheterizations. Serious complications occurred in only 23 of these 528 catheterizations (4.4 percent). These complications, while serious, did not contribute directly to any of 31 deaths seen in these patients. Pulmonary artery catheters were reported by clinicians to have been of benefit in the management of 80 percent of these patients. We conclude, in view of this experience, that the wide use of these catheters is justified, but only if there is a probability that the catheters will significantly contribute to the management of the individual patient.

The principal question with coronary bypass is its influence on longevity. To investigate this, we recently studied 1,174 consecutive patients undergoing elective coronary bypass surgery at New York University between 1968 and 1975 (98 percent follow-up). Most patients were operated upon for disabling angina refractory to medical therapy. Patients undergoing concomitant valve replacement, ventricular aneurysmectomy, and emergency bypass surgery were excluded from this analysis. The over-all operative mortality rate was 5.2 percent, decreasing from 28 percent in 1968 to 2 to 3 percent in the last 3 years (1972 to 1975). Multiple grafts (two to six) were used in 88 percent of the group. Angina was cured or greatly improved in 92 percent of surviving patients. The 5 year survival rate (computed by life-table analysis including operative deaths but excluding late, non-cardiac-related deaths) was high, 88 percent. Only 49 deaths from cardiac causes occurred after dismissal from the hospital in the entire group of 1,174 patients. Nonfatal myocardial infarctions were similarly uncommon, 2.6 percent (actuarial analysis). These data show a better survival rate than do previous surgical reports (average late mortality rate of 3 percent per year) and a much greater survival rate than for medically treated patients with double or triple artery disease (5 year mortality rate of 35 and 55 percent, respectively). The significance of these findings are discussed in detail.

Intrathoracic extramedullary hematopoiesis is a rare tumor occurring predominantly in the posterior mediastinum, most commonly in patients with congenital hemolytic anemias. The first reported case of this entity’s occurring in the anterior mediastinum is described in a 68-year-old man with an incompletely characterized anemia. Definitive diagnosis was established only after median sternotomy and removal of the tumor.

Normothermic anoxic arrest of 15 and 30 minutes, repeated for up to a total of 90 minutes of anoxia was employed in 24 pigs. The purpose was to determine the effect of varying the duration of anoxia on coronary blood flow, coronary vascular resistance, and the distribution of coronary flow to the free wall of the ventricle. Five minutes of reperfusion at pressures of 50 and 100 mm. Hg, with the ventricle fibrillating, was employed between each anoxic interval. Results were compared to control studies performed during ventricular fibrillation without anoxic arrest in 12 pigs. Prolonging the anoxic interval to 30 minutes served to create a maldistribution of coronary flow away from the left ventricular endocardium and to reduce the reactive hyperemic response to anoxia. Increasing the perfusion pressure to 100 mm. Hg accentuated these changes. Both light and electron microscopy of sections demonstrated edema and early myocardial necrosis in the subendocardial layer of the left ventricle subjected to repeated 30 minute intervals of anoxia at a high perfusion pressure. We postulate that repeated anoxic insults with inadequate repayment of oxygen debt results in subendocardial edema, a decrease in perfusion, increasing necrosis, and further edema. A myocardial infarction must result if this vicious cycle cannot be interrupted.

From January, 1968, through June, 1973, 78 tricuspid annuloplasties and 90 tricuspid valve replacements were performed in association with mitral or mitral-aortic valve procedures. Tricuspid insufficiency was not recognized preoperatively (either clinically or by cardiac catheterization) in 35 per cent of these patients, a fact which emphasizes the importance of routine digital palpation of the tricuspid valve. The severity of tricuspid disease was roughly comparable in the two groups. The hospital mortality rate was 14 per cent in the annuloplasty group and 34 per cent in the replacement group. Late deaths occurred in 17 and 19 per cent of the two groups, respectively. Sixty-nine per cent of the patients having tricuspid annuloplasty are currently alive, as compared to 45 per cent of the patients having tricuspid valve replacement. Tricuspid insufficiency recurred in 5 patients after annuloplasty and resulted from an inadequate mitral valve procedure or left ventricular failure. The present study suggests that tricuspid annuloplasty is a rapid and reliable means of correcting tricuspid insufficiency and is superior to tricuspid valve replacement.

Myocardial infarction may develop during an uneventful open-heart operation. In order to better understand this complication, we undertook an experimental study. The left circumflex coronary artery of 20 dogs was narrowed to 50 per cent of its area by a metal screw clamp to produce a localized coronary stenosis. Regional myocardial perfusion in the distribution of both the stenotic circumflex and normal left anterior descending (LAD) coronary arteries was measured by injection of a radioactive-labeled microsphere (15 ± 5 μ). Circumflex coronary artery flow was measured with an electromagnetic flow probe. An epicardial electrogram was recorded in the distribution of the left circumflex. Measurements of regional myocardial perfusion, circumflex flow, and the epicardial electrogram were performed in each animal during the control (prebypass) state and during cardiopulmonary bypass with a beating and fibrillating ventricle. Half the animals had cardiopulmonary bypass performed at 50 mm. Hg perfusion pressure and half at 100 mm. Hg. The animals were put to death at the end of the study, and the hearts were sectioned, weighed, and counted. A cast was made of the stenotic circumflex coronary artery, the degree of stenosis is measured, and the per cent area stenosis calculated. The study showed that the effect of a 50 per cent coronary stenosis in reducing distal flow is apparent only during cardiopulmonary bypass at reduced pressure. The mechanism whereby a myocardial infarction develops during cardiopulmonary bypass could evolve from the development of a “critical” stenosis out of a mild-moderate one at a reduced perfusion pressure during cardiopulmonary bypass.

At the New York University Medical Center from January, 1969, through December, 1973, esophagogastrostomies were performed in 56 patients. In 30 (Group A), fundoplications were combined with the esophagogastrostomies; in the other 26 (Group B), esophagogastrostomies only were performed. These two groups have been compared in an effort to determine the effectiveness of fundoplication in preventing gastric reflux following esophagogastrostomy. The operative mortality rate (10 per cent) and the 3 year survival rate (20 per cent) were approximately equal in the two groups. Clinical evidence of reflux was noted in 10 per cent of Group A and 47 per cent of Group B patients, while complications of reflux were noted in 5 per cent of Group A and in 33 per cent of Group B patients. The results of the present study suggest that fundoplication, while not prolonging survival, does prevent the symptoms and complications of gastric reflux and improves the quality of survival in these unfortunate patients. This leads us to recommend the routine use of fundoplication with esophagogastrostomy in patients with carcinoma of the esophagus and gastric cardia.

Median sternotomy incision was routinely employed for 1,042 open-heart operations over a two-year period. Seventeen patients developed mediastinitis; seven died. Recognition of mediastinitis depended on sternal wound drainage or sternal dehiscence. Two patients with Candida albicans mediastinitis developed neither unstable sternum nor draining wound, and both died. Therapy in 15 patients consisted of mediastinum debridement followed by continuous irrigation of the closed wound with antibiotic solutions. Five of the 15 patients died. Mediastinum irrigation, usually with neomycin sulfate-bacitracin, resulted in C albicans overgrowth in six patients. Candida albicans was directly implicated in four patients' deaths and the development of chronic chondritis in three others. Early debridement of the mediastinum upon the initial appearance of a draining, purulent sternal infection followed by continuous irrigation of the mediastinum by broad-spectrum antibiotic solution and specific systemic antibiotic therapy is the recommended therapy for postoperative mediastinal infection. The survival of ten patients out of 15 so treated strongly recommends this approach.

INTRODUCTION N UMEROUS collateral pathways develop to maintain the circulation to the arm following occlusion of the proximal subclavian or innominate artery.2,8,9,11 Under certain circumstances, all branches of the proximal subclavian artery, certain branches of the external carotid artery, and even the internal carotid artery may supply blood to the ischemic arm. The vertebral artery, however, because of its size and direct connection to the contralateral vertebral at its junction with the basilar artery, is the most important of these. The reversal of vertebral artery flow which occurs with proximal subclavian artery occlusive lesions may deprive the brain of sufficient arterial blood flow so that significant neurological manifestations result.14 The terms "subclavian steal syndrome"4 and "brachial-basilar insufficiency syndrome"10 have been used in reference to this association and are descriptive of the hemodynamic alterations which occur.A review of our arteriographic experience in patients with symptoms and/or

The DL-A system of histocompatibility plays an important role in conditioning the survival of cardiac allografts in the unmodified canine host. The mean survival time of six cardiac allografts performed in DL-A-compatible littermate dogs obtained from a closely bred colony of beagles was 53.2 days, while the MST of transplants performed in seven DL-A-incompatible animals was 7.3 days. The MST of cardiac allografts performed in nine DL-A-compatible nonlittermate beagles was 26.3 days, as compared with 6.3 days in six DL-A-incompatible nonlittermate transplants. The results did not appear to be affected by Swisher erythrocyte-group incompatibilities. The MST of 28 cardiac allografts performed in randomly selected mongrel dogs was 10.0 days. Incompatibilities for DL-A antigens e, f, g, l, and m may constitute major barriers to transplantation, but antigens b, c, d, and k appeared to act as weak histocompatibility antigens. Under controlled conditions of donor-recipient DL-A compatibility, cardiac allografts may be less immunogenic than renal transplants. Heart transplants performed across major donor-recipient DL-A incompatibilities appeared, however, to be more vulnerable to the events of allograft rejection than renal allografts performed under similar conditions. The selection of optimally compatible donor-recipient combinations for organ transplantation may be aided materially by genetic studies of the transmission of DL-A antigens to the animals under consideration.

The article presents a reprint of the article "The Antipodean Manifesto," by Charles Blackman and colleagues which appeared in the August 4 to 15, 1959 issue of "The Antipodeans." It states that paintings allow artists to communicate with their audience by representing their perceptions and imaginative experiences in images. It suggests that artists should consider their life experiences as materials of their art.

Several letters to the editor are presented in response to articles in the October 17, 2006 issue including an article by Ian Campbell about how to control climatic changes, "Water on the Brain," and "Korea Crisis."