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We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well.To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.

Eighty-three cases of tracheopleuropulmonary injuries complicating enteral tube feeding are analyzed to identify the patterns of injury, and precipitating factors and ways to avoid them. Six new cases observed by the authors and 77 other cases cited in British literature between 1976 and 1987 are presented. In recent years, reports of this complication have been increasing, apparently in a geometrical progression: 8%, 18%, and 74% were reported between 1976 to 1979, 1980 to 1983, and 1984 to 1987, respectively. Sixty-one percent occurred in patients aged 60 years or older. Most of the patients (84%) were seriously ill, which compounded their complications. Seventy-four percent of all injuries were committed by house staff; the narrow bore tube with guide wire was used in 77% of cases. Less than reliable methods were used to confirm tube position in most instances. The presence of cuffed endotracheal tubes did not offer protection. The patients on mechanical ventilation tended to deteriorate if they developed a pneumothorax once the malpositioned tubes were removed. Of the cases reviewed for this report, 18 deaths occurred; 72% being directly related to the tube injuries. Lack of awareness, inadequate confirmatory methods, and insufficient supervision accounted for most of these preventable complications. Educating house/nursing staff in the use of the new tubes, closer supervision, and the application of equal measures of care and caution as employed in other invasive and potentially dangerous procedures are recommended to avoid disastrous outcome.

Axillofemoral bypass grafts have been in common use for more than 20 years in the treatment of severe aortoiliac occlusive disease in poor-risk patients. A persistent periprosthetic fluid collection is an unusual complication of this procedure. We describe a technique by which a tense periprosthetic collection was kept successfully decompressed by the construction of a "window" from the cavity to the peritoneum. In our hands it proved to be safely and easily performed with the patient given local anesthetics; no morbidity occurred.

Survival following ruptures of the thoracic aorta at sites other than the aortic isthmus is exceedingly rare. Herein we describe a successful outcome in a 62-year-old woman with ascending and isthmic aortic lacerations compounded by disruptions of the subclavian-innominate artery junction and the left vertebral-subclavian junction. Chest wall instability and a myocardial contusion further complicated her case.

A case of traumatic rupture of the diaphragm with partial gastric herniation is reported. The initial radiographic presentation was left lower lobe pneumonia. Subsequent strangulation and perforation of the stomach caused pneumothorax. Serial chest radiographs, computed tomography of the chest and abdomen with oral contrast, and a high index of suspicion were instrumental to the diagnosis. Pneumothorax, though rare, must be recognized as a morbid, obstructive phase complication of traumatic diaphragmatic hernia requiring immediate surgical intervention.

The preoperative profiles of a predominately non-white group of patients undergoing coronary artery bypass grafting were reviewed. Data were obtained from a retrospective analysis of medical records of 163 patients operated on at Howard University Hospital between July 1983 and July 1986. The analysis was carried out primarily to determine whether patients requiring myocardial revascularization were somehow different from their non-black counterparts. Ninety-one percent of the patients were black, 5 percent white, 0.5 percent Hispanic, and 3.5 percent others (Iranian, Filipino, etc).The study was not designed to review the prevalence of coronary disease in blacks, or to determine the natural history following coronary artery bypass grafting, but to determine whether those with established coronary disease of such a severity as to warrant revascularization had the usual clustering of risk factors. Patient records were reviewed to determine the prevalence of hypertension, diabetes, obesity, cigarette smoking, previous myocardial injury, and total serum cholesterol. Because of the well-recognized increased incidence of hypertension in black patients, and its role as a major risk factor in coronary heart disease, the sequelae of hypertension were considered in relation to results of surgical therapy.The study population included 93 men (57 percent) and 70 women (43 percent); mean age was 59 years (fourth to ninth decade). Seventy-four percent of the patients were hypertensive, 35 percent were diabetic, and 77 percent had a smoking history. Obesity was prevalent among the female patients in general, with 36 percent of the diabetics and 21 percent of the nondiabetics being greater than 50 percent over ideal body weight. Ninety percent of the female patients and 80 percent of the male patients presented with New York Heart Association class III or IV angina. Left ventricular function was, on the average, well preserved. The immediate surgical mortality (following exclusion of patients in extremis) was 4 percent. The surgical mortalities were related to easily identifiable factors. Peri-operative infarctions were profoundly influenced by the presence of diabetes.Although this group was distinguished from most reported groups of patients undergoing aortocoronary bypass grafting by the presence of advanced age, the large percentage of women and diabetics and the marked prevalence of hypertension, and the usual risk factors for coronary artery disease reported in the majority population, the study reconfirms previous epidemiologic findings. It appears that racial "clumping" of a heterogeneous non-white population has minimal usefulness, except as it may be related to socioeconomic status and access to quality health care.