Search

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 debridement 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.

• Thirty-five carotid endarterectomy patients and 17 peripheral vascular surgery controls were evaluated psychologically preoperatively and postoperatively. The endarterectomy sample was restricted to patients with transient ischemic attacks. Neuropsychological tests included measures of language, attention, memory, problem solving, and sensory and motor skills. Personality tests included measures of general psychopathology, with specific evaluation of anxiety and depression. Mean scores of the endarterectomy and control groups were not statistically significantly different preoperatively for any test. Postoperatively, only the enderterectomy group showed mean improvement on measures of memory and verbal fluency. Both groups showed improvement on several other neuropsychological measures, and in reduction in state anxiety and on another indicator of psychopathology. Endarterectomy patients whose cognition improved postoperatively were younger, better educated, and had lower admitting systolic blood pressure; they also tended to have a lesser incidence of generalized vascular disease.

Abnormal radiographic densities in the midportion of the chest are most commonly caused by neoplasms, cysts, or inflammatory disease. However, vascular lesions may present an identical x-ray appearance, with no distinguishing clinical history or physical findings. The cardiothoracic surgeon must be aware of this similarity in order to ensure the most appropriate diagnostic and therapeutic approach. In our experience, the most frequent problem in differential diagnosis is a lesion of the thoracic aorta or its arch branches simulating neoplasm. Nine such cases are presented, with pertinent conventional radiographs angiograms, and computed tomographic (CT) scans. These are considered in anatomic sequence: (1) ruptured sinus of Valsalva aneurysm; (2) ascending aortic aneurysm; (3) tortuosity or aneurysm of the innominate and subclavian arteries; (4) transverse arch aneurysm; (5) pseudocoarctation; and (6) descending aortic aneurysm. Such vascular lesions must be considered early in the evaluation of any juxta-aortic chest density, particularly if the patient is hypertensive and has other manifestations of atherosclerosis. Angiography and computed tomography establish the diagnosis in most instances, although both are less reliable when thrombus fills all or part of an aneurysm. If these methods fail to establish a vascular origin, the possibility of neoplasm is pursued. When neither a vascular nor neoplastic origin can be proved, surgical exploration is indicated in the otherwise good-risk patient.

Despite a 15 year experience with the aorta-coronary bypass operation, indications for its use remain unsettled, especially in the elderly. Between January, 1974, and June, 1980, 2,667 patients underwent coronary artery revascularization with an overall mortality of 3.8% (101/2,667). During the last 12 months the mortality has decreased to 1%. There were 2,562 patients below the age of 70, with a mortality of 3.5% (90/2,562), in contrast to 105 patients over the age of 70, with a mortality of 10.5% (11/105) (p = 0.002). In patients less than 70 years of age there was a significant difference between the mortality of men, 3.12% (67/2,146). and that of women, 5.53% (23/416) (p = 0.015). This disparity of operative risk was far more pronounced in patients over 70 years of age: men 6 % (5/84) and women 28.6% (6/21) (p = 0.002). The overall operative mortality of women, 6.6% (29/437), was significantly different from the overall mortality of men, 3.2% (72/2,230) (p = 0.001). An in depth analysis of past medical history, risk factors, and catheterization data is presented in those patients over the age of 70. The average number of vessels bypassed was 2.40: men 2.47 and women 2.09 (p = NS). The ages varied from 70 to 81 years with a mean of 72.5. Smoking (p = 0.012) and diabetes (p = 0.0078) were significant risk factors for coronary disease. Smoking (p = 0.032) and abnormal pulmonary artery pressures (p = 0.0429) were significant variables affecting mortality. A 97.1% follow-up was obtained up to 78 months. Coronary artery revascularization can be performed in men below the age of 70 with acceptable mortality, but there is a twofold increase above the age of 70. Women can undergo revascularization below the age of 70 with a significantly higher risk than males. Those above the age of 70 are at severe risk and should undergo revascularization only after careful selection.

Excisional therapy has been employed in 32 patients with fusiform aneurysms of the descending aorta. Based on the addition of one of the bypass techniques employed to minimize the hemodynamic abnormalities of aortic clamping, the series is divided into 2 groups, each comprised of 16 patients. In Group I either extracorporeal circulation or indwelling temporary shunts were employed during the period of aortic occlusion, while in Group II simple aortic cross-clamping was utilized to manage the lesion. No adjuncts were used to avoid ischemia in the latter group. The only death and 2 instances of paraplegia occurred in the shunt group. In general, there were fewer complications in the no-shunt group, with approximately 2/3 of the patients experiencing an uncomplicated postoperative course. These differences are considered significant, since the 2 groups were similar in respect to the extent and nature of the lesions and other factors influencing operative risk.

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.

Successive bilateral carotid endarterectomies were performed in 323 pa tients ; 193 (60%) had both sides operated on within fourteen days during the same hospitalization (Group I), and 130 (40%) were discharged after the first operation and readmitted for contralateral carotid endarterectomy more than two weeks later (Group II). High-risk patients who were older and sicker com prised the majority in Group II. Otherwise no attempt had been made to be selective based on preconceived criteria. There were 4 deaths (2.1 %) in Group I, and 1 death (0.7%) in Group II. Permanent neurologic complications occurred in 10 (5.2%) Group I patients and 8 (6.1%) Group II patients. Transient neuro logic complications were found in 8 (4.1%) of patients in Group I and 14 (10.8%) in Group II. No patients in Group II suffered any neurologic compro mise because of the waiting period between operations. A history of hyperten sion or previous cerebral infarction was found to place patients at increased risk for the development of permanent neurologic complications. Postoperative hy pertension after the second endarterectomy was greater in Group I than in Group II patients. Observations from this retrospective review support the concept that staging of bilateral carotid endarterectomies in two hospitalizations allows elderly, sicker patients to be operated on as safely as younger, otherwise healthy individ uals. The indications for staging bilateral carotid endarterectomies in separate hospitalizations should be liberalized in order to minimize complications.

A case of spontaneous abdominal aortocaval fistula is reported. The patient was successfully operated on but died three months later of unknown causes. Thirty cases of spontaneous aortocaval fistula found in the literature, including our own, were analyzed and compared with eight cases of post-traumatic aortocaval fistula. The striking differences in course are discussed.

Emergency operations were performed in 7 adult patients for severe aortic insufficiency caused by acute aortic dissection. Dissection beginning in the aortic root involved the entire thoracoabdominal aorta in at least 3 patients. The operative findings consisted of an arch of relatively normal caliber, supravalvular intimal tear, circumferential dissection, and prolapse of the aortic cusps into the left ventricle. Repair of the proximal dissected layers and elevation of the cusps to their normal position restored valve competence in every patient. Six survivors have retained normal aortic valve function four months to six years postoperatively. The review emphasizes the feasibility of restoring aortic valve competence without using a valve substitute in treating aortic insufficiency caused by acute aortic dissection.

The clinical experience with mitral valve replacement at the Presbyterian-St. Luke's Hospital in Chicago since August 1961 is reviewed. The over-all operative mortality was 20 per cent with an additional 11 per cent late deaths during a mean follow-up period of 20 months. In reviewing the factors influencing the results of surgery, a direct correlation was found between the operative mortality and the level of pulmonary vascular resistance, the preoperative functional classification of the patients and whether or not a previous mitral operation had been performed. Sixty-nine per cent of the patients are still alive; of these, 90 per cent have benefited greatly from the operation. Disabling late complications have been rare. It is concluded that this modality of treatment should be utilized only in patients whose progressive cardiac decompensation indicates poor prognosis without surgery. Likewise, patients in New York Heart Association functional classification III should not be permitted to progress into class IV before valve replacement is offered since cumulative mortality doubles when this occurs.

1. 1. Improvement of the nutritional state of all patients prior to any resection is the single most important preoperative step. 2. 2. The operation should be divided into two stages, i.e., the resective and the reconstructive stages. 3. 3. The right colon provides a very satisfactory substitute for the thoracic esophagus. 4. 4. Gangrene of the colonic segment is the most feared and serious complication. Steps to be taken in minimizing this danger are discussed. 5. 4. The late results of treatment of benign conditions has been very satisfactory, while the appearance of recurrent and metastatic tumors in the patients with carcinoma has been discouraging.

Hypertensive diseases are of two general types: essential or idiopathic, and secondary. Although not common during childhood, abnormal blood pressure has a special significance when it does occur because it is invariably of the secondary type. Among the causes of secondary hypertension are renovascular lesions with the associated Goldblatt phenomenon. Approximately seventeen cases are recorded in the literature of such renal artery abnormality in children associated with hypertension. An instance of bilateral renal artery stenosis resulting in extreme hypertension in a five year old girl is presented. The hypertension was relieved in this patient by surgical restoration of normal renal blood flow.

Summary Two male patients, 62 and 53 years of age, suffered rapidly progressive congestive heart failure secondary to the rupture of otherwise normal aortic valves. The cause of rupture was a nonpenetrating chest injury in the first patient, and severe and sustained strain in the second case. Detachment of the posterior commissures and a sizable tear in the left anterior cusp were the causes of aortic insufficiency in the first patient. In the second patient, the left anterior cusp was torn and the other two cusps contained large perforations. Surgical correction consisted of replacement of the aortic valve with a No. 12 Starr-Edwards prosthesis in each case. Both patients have remained asymptomatic with perfectly functioning prosthetic valves, now 16 and 9 months postoperatively. The authors are grateful to Drs. Ewald Sorenson and Jan Szatkowski who referred these patients to the Presbyterian‘-St. Luke's Hospital in Chicago.

Atherosclerotic lesions of the extracranial portion of the brachiocephalic system are segmental and amenable to surgical procedures currently available. The value of carotid endarterectomy in palliation of symptoms and in prevention of stroke has been demonstrated.

• 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 arotic 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. ( Arch Surg 115:1491-1497, 1980)

Safety of carotid artery surgery depends on proper case selection, meticulous surgical technique, and appropriate protection of the brain during carotid artery cross-clamping. Various methods have been devised to determine the adequacy of collateral circulation, none of which has been proven practical and totally reliable. Attempts at increasing cerebral perfusion to the ischemic portion of the brain by induced hypertension, hypercarbia, and hypocarbia have been ineffective. The purpose of this presentation is to report our experience with routine intraluminal shunting in carotid artery surgery during the past 17 years. Advantages of routine shunting include maintenance of regional cerebral blood flow at the preclamping level and the elimination of any need for monitoring and haste during surgery. Insertion of the tube, properly done, does not injure the arterial wall and should not cause embolization. The presence of the tube within the arterial lumen does not interfere with exposure of the atheroma, yet it facilitates repair of the incision and prevents stricture by faulty suturing technique. Results of carotid artery surgery measured by the incidence of stroke are compared between shunted and nonshunted series. A review of the literature confirms our impression that shunting reverses ischemic changes detected by EEG and regional cerebral blood flow determinations. The usefulness of shunting in the surgical management of internal carotid aneurysm, kinked carotid artery, carotid body tumor, and carotid-subclavian bypass graft is also described.

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.

• 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. ( Arch Surg 115:1324-1330, 1980)

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.

• 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. (Arch Surg 111:1258-1262, 1976)

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.

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.

Encouraged by reports on the safety of simple aortic cross-clamping for resection of descending aortic aneurysm, we began utilizing this technique more liberally in 1976. This study was undertaken to examine the results of operation in 36 patients, equally divided into two distinct groups. In Group 1, either extracorporeal circulation or indwelling temporary shunts were employed during the period of aortic occlusion. In Group 2, simpleaortic cross-clamping was utilized to manage the lesion. No adjuncts were used to avoid ischemia in the latter group. The only 2 early deaths and two instances of paraplegia occurred in Group 1. In general, there were fewer complications in Group 2, with approximately two-thirds of the patients experiencing an uneventful postoperative course. These differences are considered important since the two groups were similar in respect to the extent and nature of the lesions and other factors contributing to operative risk.

Summary 1. A case of esophageal stricture in a 5-year-old child which resulted from ingestion of a single Clinitest urinesugar reagent tablet is presented. Successful treatment by esophageal resection and end-to-end anastomosis is described. 2. The nature of the trauma is examined and correlated with clinical, roentgenographic, and pathologic findings. 3. Suggestions for prevention and treatment of future cases are developed.

Fifty-six asymptomatic patients were treated surgically for severe internal carotid artery stenosis in preparation for other elective surgical procedures or prior to medical management of hypertension. There was one hospital mortality and two postoperative strokes. During a follow-up period of up to six years for an average of 36 months, two patients developed mild stroke with total recovery. Fifteen patients died during the interval; none from cerebral vascular accident. Twelve patients died from acute myocardial infarction. The majority of them had a history of myocardial ischemia prior to operation. The high incidence of early and late mortality and the limited length of survival in hypertensive patients past the age of 65 years with a history of myocardial infarction makes routine carotid endarterectomy in asymptomatic patients with multiple risk factors inadvisable. In younger patients, however, not burdened with several risk factors, carotid endarterectomy is indicated for severe internal carotid artery stenosis.

Arterial lesions capable of producing transient episodes of cerebral dysfunction due to cerebrovascular insufficiency or the more lasting lesion, a brain infarct, may be found at any level of either the carotid or vertebral systems. Lesions of the extracranial portions of these systems have come under particular attention because their surgical relief plays a part in the prevention and perhaps the relief of strokes. By far the most commonly encountered stenosing lesion of the cerebral arterial supply amenable to surgical relief is that located at the carotid bifurcation. The symptoms produced by this particular lesion are widely varied, in both type and duration. Most commonly, however, they are intermittent and transient. General mental deterioration suggests that diffuse intracranial arterial disease is present in addition to the extracranial arterial stenosis. When the cerebral deficit is lasting rather than transient, a total occlusion is likely to be present. The severity of the

Eighteen patients, 15 to 74 years of age, in intractable and life-threatening heart failure underwent emergency open heart surgery. There were 14 long term survivors. One hundred percent mortality was predicted without the application of surgery. The cause of failure was valvular heart disease in 14 and coronary heart disease in four patients. Assisted circulation during the most critical period, namely, the interval between the induction of anesthesia and the institution of total cardiopulmonary bypass, proved life-saving, at least in five patients. On the basis of this study it is postulated that no heart patient is too sick to be operated upon if he is dying from a surgically remediable underlying cardiac condition.

A system for providing near-physiologic flow patterns in the coronary arteries during cardiac surgery is described. Results in 40 dogs demonstrate the effectiveness of the method.

Not infrequently, the replacement of the aortic valve is complicated by significant narrowing of the aortic root, particularly the segment between the valve annulus and the commissural attachments. This anatomical variation causes not only technical difficulties, but mortality1,2and certain postoperative complications and, therefore, deserves special attention. In the past four years we have encountered the association of aortic valve disease and significantly small aortic root in 11 patients, requiring aortic valve replacement. The review of the records of these patients forms the basis for this report (Table 1). Materials and Results Of the 11 patients under consideration, four were men and seven were women. Their ages ranged from 23 to 64 years with a mean of 47 years. All patients had calcific aortic stenosis and two, in addition, had mitral valve disease requiring surgical intervention. The majority were in cardiac decompensation and of these, two were in intractable