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Objectives Immunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors. Methods This is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy. Results In this study we outline testing the feasibility of adding SBRT to pembrolizumab. Conclusion The ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.

Sotorasib is a first-in-class small molecule that irreversibly inhibits KRAS G12C, locking it in an inactive state, inhibiting oncogenic signaling, and inducing a proinflammatory microenvironment. Here, we report the first case of life-threatening hepatitis in a patient with NSCLC shortly after commencing sotorasib, in which biopsy result was consistent with checkpoint inhibitor (CPI) immune-related adverse event, implicating sotorasib as being able to trigger CPI immune hepatitis. Given the large proportion of patients potentially treatable with sequential sotorasib after CPI, coupled with limited trial data, sotorasib-triggered CPI immune-related hepatitis should be considered in patients with sotorasib hepatotoxicity.

Liver metastasis from breast cancer is associated with poor prognosis and is a major cause of early morbidity and mortality. When liver resection is not feasible, minimally invasive directed therapies are considered to attempt to prolong survival. Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is a liver-directed therapy that can improve local control of liver metastases from colorectal cancer. We present a case of a patient with a ductal breast adenocarcinoma, who developed liver and bone metastasis despite extensive treatment with systemic chemotherapies. Following SIRT to the liver, after an initial response, the patient ultimately progressed in the liver after 7 months. Liver tumor histology obtained 20 months after the SIRT intervention demonstrated the presence of the resin microspheres in situ. This case report demonstrates the long-term control that may be achieved with SIRT to treat liver metastases from breast cancer that is refractory to previous chemotherapies, and the presence of microspheres in situ long-term. Keywords: Selective internal radiation therapy, SIRT, Transarterial radioembolization, Liver-directed therapy

Intensity-modulated radiation therapy (IMRT), an innovative treatment option for prostate cancer, has rapidly diffused over the past decade. To inform our understanding of racial disparities in prostate cancer treatment and outcomes, this study compared diffusion of IMRT in African American (AA) and Caucasian American (CA) prostate cancer patients during the early years of IMRT diffusion using the Surveillance, Epidemiology and End Results (SEER)–Medicare linked database. A retrospective cohort of 947 AA and 10,028 CA patients diagnosed with localized prostate cancer from 2002 through 2006, who were treated with either IMRT or non-IMRT as primary treatment within 1 year of diagnoses was constructed. Logistic regression was used to examine potential differences in diffusion of IMRT in AA and CA patients, while adjusting for socioeconomic and clinical covariates. A significantly smaller proportion of AA compared with CA patients received IMRT for localized prostate cancer (45% vs. 53%, p < .0001). Racial differences were apparent in multivariable analysis though did not achieve statistical significance, as time and factors associated with race (socioeconomic, geographic, and tumor related factors) explained the preponderance of variance in use of IMRT. Further research examining improved access to innovative cancer treatment and technologies is essential to reducing racial disparities in cancer care.

After a few years of feeling good, many patients feel secure enough to let their cardiology monitoring lapse. Are you ready to assume responsibility follow-up after bypass, valvuloplasty, and other surgeries? [ABSTRACT FROM AUTHOR]

Background: Observational studies have shown that men with systemic sclerosis have an increased risk of interstitial lung disease (ILD) and mortality compared with women. However, previous studies have not controlled for treatment effect or evaluated the biological mechanism or mechanisms underlying this sex difference. We aimed to compare ILD progression and long-term morbidity and mortality outcomes in male and female participants of two randomised controlled trials for systemic sclerosis-associated ILD., Methods: For this post-hoc analysis, data from all participants in the Scleroderma Lung Study (SLS) I and SLS II were analysed. The primary objective was to explore the effect of sex on the course of the percentage predicted forced vital capacity (FVC) during and after active treatment over the 24-month study periods. In SLS I, 158 participants (111 women, 47 men) were randomly assigned to receive oral cyclophosphamide (cyclophosphamide; ≤2 mg/kg daily) or placebo; in SLS II, 142 participants (105 women, 37 men) were randomly assigned to receive oral mycophenolate mofetil (1500 mg twice daily) or oral cyclophosphamide (≤2 mg/kg daily). Sex (ie, male or female) was self-reported in both studies by the participants. Changes in radiographic fibrosis and time to death and respiratory failure were secondary outcomes of the present analysis. Baseline levels of biomarkers implicated in the pathobiology of systemic sclerosis-associated ILD were measured in bronchoalveolar lavage fluid in SLS I., Findings: In the SLS I placebo group, the rate of decline in percentage predicted FVC from 3 months to 12 months was greater in men than in women, but the difference was not significant (estimated effect -0·29 [95% CI -0·67 to 0·10]; p=0·14). In SLS II, the rate of decline in percentage predicted FVC from 3 months to 12 months was significantly worse in men treated with either cyclophosphamide (estimated effect -0·72; [95% CI -1·14 to -0·31]; p=0·00060) or mycophenolate mofetil (estimated effect -0·34 [-0·58 to -0·10]; p=0·0051) than in women. A greater proportion of men had a decline in percentage predicted FVC of 10% or greater compared with women for the pooled active treatment groups from SLS I and SLS II and the placebo group of SLS I. Men had worse radiographic outcomes at 2 years than women in SLS II, even after adjusting for baseline disease severity and treatment arm assignment. Long-term survival was worse in men in SLS I (log-rank test p=0·080) and SLS II (log-rank test p=0·030). In SLS II, male sex was independently associated with increased mortality (hazard ratio 2·42 [95% CI 1·16 to 5·04]; p=0·018). In bronchoalveolar lavage fluid, men had increased concentrations of pro-fibrotic mediators (eg, matrix metalloproteinase-13 and tissue inhibitor of metallopeptidase 1), whereas women had increased pro-inflammatory mediators (eg, interleukin [IL]-12, IL-7, and granulocyte-colony stimulating factor)., Interpretation: In two randomised controlled trials, men with systemic sclerosis-associated ILD had a less favourable course of ILD both with and without active treatment, as well as worse long-term survival. Sex differences in pro-fibrotic or inflammatory mediators of disease might account for these differences and warrant future study., Funding: US National Institutes of Health; US National Heart, Lung, and Blood Institute; US National Institute of Arthritis and Musculoskeletal and Skin Diseases; Bristol Myers Squibb; and Hoffmann-LaRoche., Competing Interests: We report no financial or personal relationships related to the submitted work. ERV reports the following financial relationships outside of the submitted work on SLS I and SLS II outcomes: consulting and speaking fees (Boehringer Ingelheim); and institutional support received for performing systemic sclerosis studies for Kadmon, Forbius, Boehringer Ingelheim, and Horizon. DPT reports receiving modest financial support from Genentech for participation in an investigator-initiated trial outside of the submitted work. RS reports institutional support received for performing systemic sclerosis studies for Boehringer Ingelheim outside of the submitted work. SA reports the following financial relationships outside of the submitted work on SLS I and SLS II outcomes: consulting (Boehringer Ingelheim, Corbus, Novartis, CSL Behring, AbbVie, and AstraZeneca); payment or honoraria for lectures or presentations (Integrity CE and the North Carolina Rheumatology Association); institutional support received for doing systemic sclerosis studies for Momenta, Boehringer Ingelhim, Janssen, Scleroderma Research Foundation, the US Department of Defense and the NIH; and a leadership role (unpaid volunteer) for the Scleroderma Clinical Trial Consortium and the Scleroderma Foundation Medical Advisory Board. GHK reports being a research consultant for MedQIA and has a patent issued on the radiographic quantification of ILD (UC-2015-0324982-A1). JG is the founder of MedQIA. MDR reports receiving institutional support from Genentech for leading an investigator-initiated clinical trial in systemic sclerosis-associated ILD outside of the SLS I and SLS II studies reported here. All other authors declare no competing interests outside of the submitted work.

Objective: To compare safety and efficacy outcomes between the cyclophosphamide (CYC) arms of Scleroderma Lung Study (SLS) I and II., Methods: Participants enrolled in the CYC arms of SLS I (n = 79) and II (n = 69) were included. SLS I and II randomized participants to oral CYC for 1 year and followed patients for an additional year off therapy (in SLS II, patients received placebo in Year 2). Eligibility criteria for SLS I and II were nearly identical. Outcomes included the forced vital capacity (FVC%)-predicted and DLCO%-predicted (measured every 3 mos) and quantitative radiographic extent of interstitial lung disease (measured at 1 and 2 yrs for SLS I and SLS II, respectively). Joint models were created to evaluate the treatment effect on the course of the FVC/DLCO over 2 years while controlling for baseline disease severity., Results: SLS I and II CYC participants had similar baseline characteristics. After adjusting for baseline disease severity, there was no difference in the course of the FVC%-predicted (p = 0.535) nor the DLCO%-predicted (p = 0.172) between the SLS I and II CYC arms. In both groups, treatment with CYC led to a significant improvement in the FVC%-predicted from 3 to 12 months, but no significant improvement beyond this point. Treatment with CYC had no effect on the DLCO for either group., Conclusion: Treatment with 1 year of oral CYC led to similar improvements in lung function in both SLS I and II, although the effects were not sustained following cessation of CYC. These results suggest that increasing the duration of ILD therapy may improve outcomes for patients with systemic sclerosis-ILD.

Background: With the increasing population of patients with prior mediastinal irradiation, cardiac surgeons will encounter patients with radiation-induced damage to the heart and the great vessels. Awareness of the pathology and the surgical management is essential to provide optimal care for these patients., Methods: Eight patients with radiation-induced heart disease were encountered in the last 10 years. After a brief clinical presentation, the surgical management of radiation-induced heart disease is reviewed., Results: Radiation can affect all the structures in the heart, including the coronary arteries, the valves, and the conduction system. The pericardium is the most commonly involved, and the conduction system is the least involved. Pericardiectomy is quite effective in patients with symptomatic pericardial effusion or constriction. The coronary lesions are located predominantly in the ostial or proximal regions of the epicardial vessels. Percutaneous transluminal coronary angioplasty alone appears to have a high rate of restenosis. Surgical revascularization has good long-term results, and the internal mammary artery should be used if it is satisfactory. The aortic and mitral valves are more commonly involved than the tricuspid and pulmonary valves. Myocardial dysfunction predominantly affects the right ventricle and requires particular attention during cardiopulmonary bypass and in the postoperative period. Restoration of sinus rhythm is essential in view of stiffness of the ventricles. Flexibility in the surgical approach with selective use of thoracotomy will facilitate the surgical procedure in certain patients., Conclusions: Surgeons should be well versed in all the manifestations and the management of radiation-induced heart disease.

The differential diagnosis of cavities in the ascending aorta includes pseudoaneurysms, intimal flaps, and abscesses. We describe the transesophageal echocardiographic and pathologic appearance of a fusiform ascending aortic aneurysm that contained atypical outpouchings that were initially confused with an intimal flap. Awareness of this unreported abnormality and its echocardiographic features will avoid the misdiagnosis of more serious aortic pathology such as acute aortic dissection or infective endocarditis.

Anatomical variations in aortic root pathology, including combinations of dissection, aneurysmal dilatation, annuloaortic ectasia, and valve disease, defy standardized repair and mandate application of various surgical reconstructions. To examine these techniques, and their influence on morbidity and mortality, we reviewed 53 consecutive patients undergoing aortic root procedures. Thirty-two patients underwent total root reconstruction. Of these, 21 underwent Bentall procedures, 9 had a modification thereof, and 2 underwent a Cabrol reconstruction. Less extensive pathology was corrected in 21 patients with a partial root reconstruction. These included aortic valve replacement (AVR) and a separate tube graft in 14 patients, AVR and primary aortic repair +/- wrapping in 4 individuals, and AVR and patch aortic root enlargement in 3 patients. Mean age was 53.2 years (range 20 to 79). Nearly 20% had undergone previous cardiac surgery and 7.5% were emergencies. Early mortality was 4%. Complications included dysrhythmias (48%), myocardial infarction (4%), stroke (4%), pneumonia (14%), and pancreatitis (2%). There were no reoperations for bleeding. Three late complications, one pseudoaneurysm and two perivalvular leaks, were successfully repaired. Late deaths (13.7%) were caused by congestive heart failure (3), myocardial infarction (MI) (1), cancer (1), stroke (1), and accidental fall (1). Kaplan-Meier analysis reveals 1-, 5-, and 10-year survivals of 98%, 81%, and 66%. Survival and mortality data did not differ between groups, and except for the incidence of atrial dysrhythmias, complication rates also were not significantly different. This series illustrates the need for and the successful application of a selective approach to aortic root reconstruction.

Surgical approaches for implantation of the automatic cardioverter defibrillator are sternotomy, left thoracotomy, subxiphoid, and subcostal. Although any one of these may be combined with insertion of one or more of the electrodes transvenously, surgical entry into the chest is required for every noninvestigational defibrillator implantation operation. The approaches differ in exposure provided for selecting electrode sites and for handling untoward events, in amount and location of tissue that must be divided or dissected, and in average time required. The operation is an electrical one. Its purpose is to obtain reliable rhythm sensing so that defibrillation or cardioversion shocks will occur only when necessary, and to obtain low enough defibrillation thresholds for shocks of 30 joules or less to have a 10-joule defibrillation safety margin. Many of the patients have had previous cardiac operations. They usually have low or very low ejection fractions. Intraoperative electrophysiological testing with often multiple defibrillation episodes is required. The choice of approach varies with the state of the patient, the institutional experience, and the surgeon. This article describes technique, and the advantages and disadvantages of the four approaches as used by four surgeons in four different institutions.

The association of aortic stenosis and syncope is well recognized. Oculopneumoplethysmography (OPG) can provide an accurate index of carotid stenosis and indirectly measure cerebral perfusion. The possibility that OPG would be influenced by aortic valve disease was assessed in patients prior to valve replacement. 31 patients were studied. 19 patients had aortic stenosis (AS), 3 had aortic insufficiency (AI), and 10 had mixed lesions. OPG was positive in 15 patients (48%). Considering all forms of aortic valve disease, the likelihood that a positive OPG was indicative of AS with a gradient of greater than 60 mmHg was significant (P = .002). Of 18 patients with AS alone, no patient with a valve gradient greater than 60 mmHg had a negative OPG (P = .0001). OPG became normal in 11 of 12 patients restudied postoperatively. Critical aortic stenosis results in uneven distribution of blood flow into the brachiocephalic vessels. OPG accurately identifies this effect which becomes evident at aortic valve gradients greater than 60 mmHg.

Between 1970 and 1982, 126 inferior vena cava (IVC) balloon occlusions were performed for complications of venous thromboembolism (VTE). Forty, or 32%, were in patients with cancer. There were 20 men and 20 women. The average age was 60.8 +/- 2 years. Cancers of the brain, lung, and breast, along with diffuse metastatic disease with unknown primary disease, were equally common and represented 50% of our cases. Indications for IVC occlusion included pulmonary embolus despite anticoagulation (AC); 50% VTE and contraindication to AC, 38%; and complications of AC, 12%. Three patients died from ongoing complications of previous AC. Eight additional patients died of cancer, for a hospital mortality rate of 28%. Twenty-nine patients were discharged an average of 28.4 +/- 4.3 days after IVC balloon occlusion. Twenty of these patients subsequently died of cancer an average of 13 +/- 4.7 months after hospital discharge. Eight patients remain alive, four for more than 4 years. Pulmonary emboli did not occur after balloon occlusion, and there were no balloon complications. Only 4 of 29 discharged patients had mild leg edema. Hunter balloon occlusion of the IVC represents a safe and effective method for managing complications of VTE in patients with cancer. Early hospital discharge is possible, treatment is permanent, and future chemotherapy is not compromised by the need for long-term anticoagulation.

The advantage of aortic cannulation over femoral cannulation in cardiopulmonary bypass has been well established in our experience. Over a four year period, we compared the incidence of complications of these two modalities in a large group of patients. Specific emphasis is placed on the lack of lower extremity neurological deficit and retrograde dissection in patients who underwent aortic cannulation.

One percent of 2,545 patients undergoing coronary revascularization with the saphenous vein over a 5 year period sustained leg wound complications which necessitated extra care. Fourteen complications were minor and required only drainage, a new antibiotic, and dressing changes. Thirteen major wound complications required wide debridement and, of these, five could be closed only with skin grafts. Eight wounds were infected, two with Staphylococcus aureus and six with mixed gram-negative flora. Ninety-three percent of these wounds were in the thigh. Average weight of patients with leg wound complications was 73.5 +/- 3.5 kg and not different from that of a randomly selected control group (73.8 +/-1.2 kg). However, 40% of the patients were women, a much higher incidence than control (p less than 0.005). Hospital stay increased significantly from 12.1 +/- 0.5 days for the control group to 24 +/- 2.6 days for the group with wound complications (p less than 0.005). Average hospital stay was 33.6 +/- 3.8 days (p less than 0.001) in those patients with major wound complications (estimated hospital cost $9,900). Leg wound complications of saphenous vein harvest are infrequent but serious. Efforts to prevent this complication should include minimal dissection, careful hemostasis, and closure in layers. Development of skin slough, infection, and necrosis necessitating débridement and drainage is a major and expensive complication. Wide excision and direct closure are necessary to minimize hospital stay and reduce the requirement for skin grafting.

The success of total aortic root replacement in conditions such as annuloaortic ectasia and complicated redo surgery has stimulated its use in acute dissection of the ascending aorta. We believe this radical approach is, in most cases, unwarranted, considering the excellent results with valve conservation. From 1970-1978, 20 consecutive patients with acute anterior aortic dissection and aortic insufficiency were operated at Rush-Presbyterian-St. Luke's Medical Center. Only one patient (5%) required reoperation for hemorrhage. The three operative deaths (15%) were associated with right coronary artery disruption, aortic-right atrial fistula and preoperative intrapericardial false lumen rupture. In eight patients, valve resuspension was combined with primary aortic repair and nine with ascending graft interposition, but aortic valve replacement was required in three because of annuloaortic ectasia or tissue friability. One patient treated by primary repair in 1971 underwent successful reoperation for redissection 7 years later (1.4% per patient-year risk of late reoperation), but the remaining 16 patients, followed 2-10 years, remain free of aortic insufficiency or recurrent aneurysm. This experience supports the use of valve reconstruction rather than replacement in most cases of acute anterior dissection of the aorta.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.

Cryoablation is recognized as a useful modality for diagnostic mapping, as well as for permanent obliteration of arrhythmogenic foci. This technique has been used to eradicate irritable foci at the base of papillary muscles. We report a case of mitral valve dysfunction requiring valve replacement following cryoablation of the posterior papillary muscle. Based on this experience, we caution against extensive cryoablation of papillary muscle tissue because of the possibility of disrupting mitral valve function.

Over a period of 18 years, 191 consecutive patients had interruption of the inferior vena cava with the Hunter-Sessions balloon for complications of deep venous thrombosis and pulmonary embolism. Causes of deep venous thrombosis and pulmonary embolism included the postoperative state (33%), cancer (32%), and stroke (11%). There were 93 females and 98 males; ages ranged from 17 to 90 years (average, 57 years). Indications for placement of the Hunter-Sessions balloon were as follows: contraindication to anticoagulants (33%), anticoagulant complications (24%), pulmonary embolism despite anticoagulants (45%), and others including inferior vena cava thrombus (12%). Sixty-eight percent had clinical phlebitis and 36% had positive venography results. Pulmonary embolism had occurred in 165 patients (86%). It was diagnosed by ventilation-perfusion scanning (75%), angiography (23%), or on clinical grounds (2%) in patients with confirmed deep venous thrombosis. At the time of the procedure 52% were in significant cardiopulmonary distress, and 10% were intubated and on respirators. Transjugular placement was done in 188 patients, and transfemoral placement was performed in three. All All tolerated inferior vena cava interruption. Thirty patients (15%) died while in the hospital an average of 21 days after balloon placement, which was unrelated to the deaths. Follow-up was 45 months. Ninety-four patients are dead, 95 are alive, and the status of two patients is unknown. Twenty-nine of 64 patients (45%) who died after they left the hospital died of cancer. At last follow-up, 75% of patients had legs free of edema and 25% had need for elastic stockings. No malfunction or migration has occurred with the device. No patient had a pulmonary embolism while in the hospital after insertion of the Hunter-Sessions balloon, and no patient died of pulmonary embolism. Late minor pulmonary embolism occurred in three patients.

The clinical presentation and surgical results in 124 consecutive patients who underwent aorta to right coronary arterial bypass surgery from January 1970 through June 1977 were reviewed. Preoperatively, 75 percent of the patients were in New York Heart Association functional class III or IV, 9 percent presented with unstable angina and 5 percent had life-threatening ventricular arrhythmias. All patients had high grade occlusive disease confined to the right coronary artery; 34 percent of the patients had associated nonsignificant disease (less than 50 percent intraluminal narrowing) of the left anterior descending or circumflex artery. Left ventricular function was normal in 63 percent and minimally impaired in 37 percent. The operative mortality rate was 1.6 percent. The course of the 122 survivors was followed up for 3.7 years. There were four late deaths, and the 5 year mortality rate was 4.0 percent. Eight patients were reoperated on because of recurrence of symptoms and occlusion of the graft or progression of occlusive disease of the other major coronary arteries, or both. Of the remaining 110 patients, 98 are either in functional class I or II, 60 are taking no cardiovascular medications, 52 are working full time without angina nad 73 are asymptomatic. In summary, bypass surgery for isolated right coronary artery disease has a low mortality rate and results in excellent long-term symptomatic improvement.

Twenty-five patients with recurrent ventricular tachyarrhythmias underwent implantation of an automatic implantable cardioverter-defibrillator. The mean length of follow-up was 11.9 +/- 10.8 months. Before the implantation, the patients had survived one or more cardiac arrests (mean, 1.7; range, 1 to 4) and episodes of syncope (mean, 2.2; range, 2 to 3) and had received 6.0 +/- 1.0 antiarrhythmic drug trials. The in-hospital complications included death (two patients), reoperation (one patient), intraoperative myocardial infarction (one patient), sensing-failure (one patient), infection (five patients), and pocket seroma (two patients). The posthospital complications included device failure (four patients), device deactivation (one patient), and inappropriate discharge (two patients). The device discharged appropriately in seven patients due to sustained ventricular tachycardia. During electrophysiologic measurements, the energy requirement for successful cardioversion-defibrillation was related to the type of ventricular arrhythmia induced (monomorphic or pleomorphic ventricular tachycardia or fibrillation). Ventricular tachycardia acceleration occurred in ten patients (40%). No significant changes were found in the size of the electrograms or in the cardioversion threshold during early and late follow-up measurements. Life table analysis showed a 12-month survival rate of 86% and an arrhythmic death survival rate of 100%. We confirm the improved rate of survival in this high-risk group of patients, despite significant complications.

Intracardiac migration of an intravenous cathether was treated transvenously in 5 patients successfully. Using local anesthesia and fluoroscopic guidance, a bronchoscopy forceps was passed through the right jugular vein to the right atrium and afforded efficient and safe retrieval of the embolus. The direct route to the right atrium provided by the right internal jugular vein and the precise control offerred by the rigid forceps make this the preferred method of retrieval of a transvenous catheter embolus.

From 1970 to 1978, 39 patients underwent simultaneous aortic and renal artery reconstruction. Of these, 37 had severe single or bilateral renal lesions in combination with an aortic aneurysm, or symptomatic or asymptomatic aortoiliac disease. Two patients had renal arteries that originated from an abdominal aortic aneurysm. Thirty-two patients were hypertensive, one had chronic renal failure, and three others had asymptomatic renal lesions that were bypassed prophylactically. Operations performed included aortic replacement plus: single renal graft; bilateral renal grafts; renal graft plus contralateral nephrectomy; and renal graft plus mesenteric revascularization. All early postoperative deaths (four) occurred in patients with aneurysmal disease. Twenty-nine patients were available for long-term evaluation. In patients who were hypertensive preoperatively, 64.0% experienced long-term cure or improvement. Cardiac and cerebral disease, lower extremity claudication, and the need for subsequent cardiovascular surgery occurred with substantial frequency during the follow-up period.

Dissection nearly always begins in the thorax, but it commonly extends into the abdominal aorta, which may become the focal point of the disease. We report five patients who illustrate the surgical management of this disease variant. Clinical manifestations included retroperitoneal rupture, expanding false aneurysm, and lower aortic occlusion. All patients had an aortic bifurcation graft, with reentry of the false lumen at the renal level. Two patients also had thoracic-aortic resection or plasty or both. Although one patient had thoracic aortic rupture at the five-year interval, these abdominal aortic resections provided effective palliation in all. This successful experience in managing complex dissections shows that when aortic dissection extends into the abdomen, resection of the distal aorta with a reentry procedure may be appropriate therapy.

Although the formation of a left ventricular aneurysm (LVA) is a common and well-recognized complication of myocardial infarction (MI), diaphragmatic LVA is a rare clinical entity. Of 354 consecutive patients who underwent LVA resection, we describe the clinical features and surgical results of 22 patients (6%) with diaphragmatic LVA. All patients had a history of MI. The principal clinical indication for surgery was heart failure in nine patients, angina pectoris in ten patients, and recurrent ventricular tachycardia unresponsive to medical therapy in three patients. A ventricular septal defect was present in two patients, and moderate to severe mitral regurgitation was present in four patients. Three of the four surgical deaths (operative mortality, 18%) occurred in patients with mitral regurgitation or with ventricular septal defect. Eleven patients are alive at a mean follow-up of 40 months. Six of them are asymptomatic and two have angina at a higher level of physical activity than before surgery. Notable differences exist in the clinical presentation and surgical findings between patients with diaphragmatic and anterior LVA.

Late unilateral limb thrombosis was encountered in 45 of 601 patients discharged from the hospital with functioning aortic bifurcation grafts, an incidence of 7.5%. It was invariably associated with clinical manifestations of arterial insufficiency to the affected limb more serious than those of the extremity prior to the initial operation. Although the specific cause could not be determined, it was usually due to either progression of the disease distal to the reconstructed segment or to certain compromises at the time of the first operation or both. Among several procedures employed, unilateral reconstruction of the thrombosed limb is the procedure of choice. The reoperation was successful in 75% of the patients.

Traditional operations to obstruct the IVC are often unsatisfactory because the morbidity and mortality is appreciable: poor risk patients do not tolerate surgical and anesthetic trauma. Furthermore, if the patient is anticoagulated, an operation requires that such desirable treatment be stopped. Ten years ago a study was begun to develop a transvenous method of IVC occlusion in the awake anticoagulated patient. Animal studies were done prior to patient application. A technique was evolved wherein IVC interruption could be accomplished with a balloon bearing catheter inserted through the jugular vein. The balloon was positioned with venography and after inflation held in place by lateral pressure in the distensible IVC. The catheter was then removed, leaving the balloon in position. Balloon occlusion has been used in the management of 60 selected patients since 1970. Twenty-nine patients were simultaneously anticoagulated without complication. Very sick patients tolerated the procedure well. No patient experienced further pulmonary emboli. Nine hospital deaths occurred from a variety of causes, none related to the balloon catheter. Late follow-up shows that the occluding balloon gradually deflates in about 12 months. The remnant has remained stable in all patients, contained in a scar that permanently interrupts the IVC.

Successful surgical treatment of spontaneous rupture and dissection of the abdominal aorta in Ehlers-Danlos syndrome has not been previously reported. A 16-year-old male sustained spontaneous rupture and dissection of the abdominal aorta. Successful surgical treatment included placement of an abdominal aortic bifurcation graft. Genetical, biochemical and clinical differences of seven types of the syndrome are outlined. A brief guideline for treatment and prevention of vascular complications is discussed.

Six requirements were defined that would characterize a safe and effective technique of transvenous inferior vena cava (IVC) interruption: (1) the instrument should be placed transjugularly under local anesthesia; (2) the instrument should have "built-in" capability for venography; (3) the technique should produce complete occlusion of the IVC; (4) the occluder must adapt to any variable in IVC diameter; (5) the intracaval device must have no sharp edges, pins, or points; and (6) the technique must permit simultaneous heparin therapy. These specifications were met by a catheter-delivered detachable balloon that could be inflated to any needed diameter. This technique was used in 96 patients, with a follow-up period to ten years. Time and experience confirm the validity of the six requirements for a safe and effective technique.

One hundred thirty-two patients with ventricular aneurysm had cardiac catheterization, coronary anglography, and ventriculography. More than 50 percent of the patients, in addition to aneurysmectomy, had other procedures consisting of revascularization, mitral valve replacement, and closure of ventricular septal performation. The overall mortality was 10 percent. Aneurysmectomy alone had a higher mortality (9 percent) when compared with combined resection of the aneurysm and coronary bypass (5.4 percent). During a six-month to 4-1/2-year follow-up (mean, 21 months), seven patients died, representing a late mortality of 6 percent. This study confirms the importance of complete cardiac evaluation in patients with ventricular aneurysm and shows that, in spite of extensive combined operative procedures required in more than 50 percent of the patients, the results are favorable.

Ruptured abdominal aortic aneurysm complicated by renal failure is associated with a mortality greater than 90%. Aggressive management, which included the early use of hemodialysis, was employed. Between 1970 and 1973, a total of 43 patients had surgery for proved ruptured abdominal aortic aneurysm. Fourteen patients developed acute and fixed renal failure. Nine of these 14 patients had undergone hemodialysis with treatments beginning as early as the second postoperative day and lasting as long as ten weeks. There were six survivors, with a hospital mortality of 33%. This represents an improvement in survival compared with our earlier experience where the mortality in this type of patient was 93%. Early use of hemodialysis in the postoperative management of patients with acute renal failure complicating ruptured abdominal aortic aneurysm is recommended.

Twenty-four patients were operated on for mitral regurgitation secondary to coronary heart disease. Their common features consisted of a history of myocardial infarction, congestive heart failure, coronary occlusive disease, left ventricular dysfunction, low cardiac output, pulmonary hypertension, and increased left ventricular end-diastolic pressure. Fourteen patients were in intractable congestive heart failure at the time of operation. The operative procedures employed consisted of aneurysmectomy in 4 patients; mitral valve replacement (MVR) in 7;MVR and revascularization in 4; MVR and aneurysmectomy in 5;MVR, revascularization, and partial ventricular resection in 3; and MVR with closure of ventricular septal perforation in 1 patient. Six patients died, a hospital mortality of 25%, and only 42% had good results. The degree of associated coronary artery disease and the status of the left ventricular myocardium were the most important prognostic factors.

In a series of 3,206 consecutive coronary artery bypass procedures performed between 1976 and 1981, 89 patients died (2.8% mortality) and 32 patients (1%) suffered major neurological syndromes. Among the latter patients, four distinct groups were identified. Group 1 consisted of 10 patients who remained unresponsive after operation. In Group 2 were 10 patients who awakened after operation but had clinical evidence of focal cerebral infarction. Group 3 included 6 patients who were initially intact neurologically but in whom neurological deficits later developed. In Group 4 were 6 patients who had severe mental aberration but no focal neurological deficits. The incidence of coma or focal deficit occurring without a lucid interval (Groups 1 and 2) was 0.62%, and these patients had a 30% mortality. Causative factors were suspected in 70% of the patients in Groups 1 and 2, and included atheromatous embolism, perioperative hypotension, carotid artery occlusive disease and air embolism. The outcome was poor for unresponsive patients, with 70% dying or remaining comatose, but nearly all of the patients with focal deficits or severe mental aberration demonstrated notable improvement.

We have studied a series of 24 cases of carotid body tumor, comprising our total experience during the past two decades. Twelve patients had symptoms related to compression or invasion of the surrounding structures. Two patients had malignant changes, while three individuals had bilateral lesions. Thirteen patients underwent neck exploration for diagnosis or attempt at surgical removal of the tumor prior to admission to our institution. Definitive procedures in 24 cases resulted in one postoperative death, a rate of 4%. Internal carotid flow was preserved in every case. Intraluminal shunting was employed during the last decade, and no instance of cerebral damage was encountered. It is our intention to emphasize the importance of an accurate diagnosis by carotid angiography prior to surgical management. We also wish to encourage routine excision of these tumors as they are diagnosed, before they reach an enormous size.

A clostridial mycotic aneurysm of the right coronary artery was diagnosed by the use of multiple imaging modalities including gated magnetic resonance imaging. Percutaneous drainage was performed as a palliative measure in hope of avoiding repeat sternotomy.

Of 4,124 patients undergoing median sternotomy for cardiac operations, 1.8% had sternal wound complications. These included wound drainage, skin separation, unstable sternum, and sternal dehiscence with or without infection. Septicemia and mediastinal abscess were found in all 19 patients who died. Incision and drainage of skin and subcutaneous tissue with frequent changes of dressing or irrigation (Method A) is recommended for those patients with (I) serosanguineous drainage only or (2) a stable sternum and superficial infection without systemic reaction. Surgical débridement of the sternum and mediastinum with reclosure followed by mediastinal irrigation via drainage tubes with 0.5% povidone-iodine solution (Method B) is recommended for patients with (1) a draining, unstable sternum, (2) infection involving the retrosternal space, or (3) infection causing a systemic reaction unresponsive to Method A. None of the eight patients in the latter group with more serious infections died when managed by Method B, and only one had recurrent infection. In contrast, of 28 patients of the latter group not treated with Method B, 11 died of infection-related causes and 13 returned with recurrent infection.

Conventionally, during aortic valve replacement the left ventricle is vented to achieve a dry field, remove air, and prevent ventricular distention. This report demonstrates the feasibility of performing aortic valve replacement without cannulation of either the left ventricle or the left atrium. The technique has been utilized in 54 patients with 1 early death due to pulmonary embolism and 1 late death presumably secondary to ventricular arrhythmias.