Haemodynamic effects of verapamil administration after large doses of fentanyl in man.

Thirteen patients with good left ventricular function undergoing coronary artery revascularization were studied to determine the cardiovascular effects of verapamil, 75-150 micrograms X kg-1, after a large dose (100 micrograms X kg-1) of fentanyl, with pancuronium for muscle relaxation. The patients were continued on their usual cardiovascular medications until the time of surgery, which included nitrates, beta adrenergic blockers, and nifedipine. Anaesthesia with fentanyl was associated with decreases in mean arterial blood pressure, systemic vascular resistance, left ventricular stroke work index, and circulating catecholamine levels. Mean values were not further changed by verapamil, but individual patients had additional modest decreases in blood pressure and systemic vascular resistance. Cardiac index, however, was well maintained. Plasma catecholamines remained depressed after verapamil under the study condition. Thus, in patients with good left ventricular function, clinically relevant doses of verapamil were well tolerated even in the presence of an anaesthetic that included large doses of fentanyl, with suppression of circulating catecholamine levels.

Thrombolytic therapy for superior vena caval thrombosis following superior vena cava-pulmonary artery anastomosis.

Immediate postoperative thrombosis of left superior vena cava-left pulmonary artery anastomosis in a modified Fontan procedure for single ventricle and pulmonary artery stenosis is described. Before thrombolytic therapy with streptokinase is initiated, confirmation of thrombosis by venography is mandatory to lessen the risk of cardiac tamponade or hemothorax. By this technique major surgical intervention is avoided, but close attention to the dose of streptokinase and the coagulation profile is essential. Measures to be taken if bleeding occurs with streptokinase therapy are described.

Surgical correction of pulmonary atresia and ventricular septal defect with large systemic-pulmonary collaterals.

A two-stage surgical procedure was performed in a young adult with pulmonary atresia and a ventricular septal defect with upper lobe pulmonary artery flow from confluent central pulmonary arteries and lower lobe pulmonary blood flow originating from two large systemic-pulmonary collaterals. Initially a Dacron Y graft was anastomosed between the ascending aorta and the collaterals and a graft to the left pulmonary artery. At the second operation, continuity was established between the right ventricle and the Y graft by using a valved Dacron conduit and the ventricular septal defect was closed.

Right heart function during left heart assist and the effects of volume loading in a canine preparation.

A significant fraction of patients in whom mechanical left ventricular assist devices are implanted for refractory cardiac failure after open heart surgery have had the complication of right heart failure. To evaluate the effects of left ventricular assistance and pressure unloading on right ventricular function, we performed experiments in the normal hearts of open-chest, anesthetized, large mongrel dogs. We compared right ventricular function before and after left ventricular-to-aortic bypass with a roller pump at right atrial pressure levels of 1, 3, 5, and 7 mm Hg produced by volume loading. No significant changes were found in cardiac output or stroke volume over this range of right atrial pressures when comparing that before to that during left ventricular bypass, which at a right atrial pressure of 1 mm Hg reduced peak left ventricular pressure from 96 +/- 6 to 15 +/- 9 mm Hg and at a right atrial pressure of 5 mm Hg reduced it from 113 +/- 3 to 29 +/- 12 mm Hg, while maintaining aortic pressure. There was no evidence of right ventricular failure under these conditions: (from before to during bypass) at a right atrial pressure of 1 mm Hg cardiac output was 3.4 +/- 0.4 to 3.7 +/- 0.6 liter/min and stroke volume was 28 +/- 5 to 33 +/- 6 ml; during volume loading at a right atrial pressure of 7 mm Hg cardiac output was 5.6 +/- 0.6 to 5.7 +/- 0.7 liter/min and stroke volume was 47 +/- 5 to 52 +/- 5 ml.(ABSTRACT TRUNCATED AT 250 WORDS)

An improved method of pulmonary artery banding.

Banding of the pulmonary artery is a difficult procedure that often requires band readjustment. A new technique for placing and adjusting pulmonary artery bands using an adjustable snare is presented, together with cases illustrating its application.

Profound hypotension from rapid vancomycin administration during cardiac operation.

Profound hypotension from rapid vancomycin administration resulted in cardiac arrest. Successful resuscitation was performed with inotropic support.

Cardiac valve replacement in systemic lupus erythematosus. A review.

Three cases of cardiac valve replacement for Libman-Sacks endocarditis and their long-term follow-up are described. From the review of the literature, an additional nine patients who required cardiac valve replacement are studied. Steroids probably increase the incidence of valve incompetence, but most patients presumably die of other associated organ involvement before undergoing a cardiac operation. Operation is indicated because of change in the intensity or character of the murmur, and a new murmur with resultant, resistant congestive cardiac failure. Both the aortic and mitral valves should be explored. Valve reconstruction in these young patients, with the expectation of avoiding prosthetic valve dysfunction and repeat operation, is not possible. Bioprosthetic valve replacement may be preferable, since it eliminates the need for anticoagulation during steroid treatment. Overall mortality was 25%.

Pulmonary chondroma, extra-adrenal paraganglioma, and gastric leiomyosarcoma: Carney's triad.

The triad of pulmonary chondroma, extra-adrenal paraganglioma, and gastric leiomyosarcoma has been reported in five patients, all young women. The association of tumors apparently constitutes a syndrome. This paper describes the sixth affected patient, also a young woman, draws attention to the frequency of thoracic paraganglioma in the syndrome, and notes that the pulmonary cartilaginous lesion has frequently been misinterpreted as pulmonary hamartoma. Early exploration of the chest is indicated not only to rule out the possibility of metastatic gastric tumor but also to search for paragangliomas.

Analysis of 29 cases of pancreatic pseudocyst treated surgically.

Twenty-nine cases of pancreatic pseudocyst requiring operative management were reviewed to determine the method of diagnosis and to analyse the results of internal and external drainage. Pain and the presence of an intra-abdominal mass were the two most common clinical features in the 29 patients. Serum amylase values were elevated in 50%. Diagnosis was confirmed by barium contrast roentgenography and abdominal ultrasonography in 60% of cases. Endoscopic retrograde cholangiopancreatography was a valuable diagnotic technique in four problem cases. The most common form of surgical treatment was internal drainage of the pseudocyst (18 patients). Th mortality resulting from internal drainage was 6% and there was an overall complication rate of 44%. External drainage was carried out in seven patients (six required emergency operation). The mortality associated with external drainage was 43% and the overall complication rate 86%.

Traumatic abdominal hernia.

Traumatic abdominal hernias are rare, but are easily missed in patients with multiple injuries in whom life-threatening injuries take precedence. A case is reported in which difficulty was experienced with closure of the abdominal wall; at re-exploration a diagnosis of abdominal hernia was made, and a tear in the retroperitoneum with herniation of 2 feet of small bowel on the right side of the abdomen found. The hernia was reduced and the patient's recovery was uneventful. In all cases of celiotomy for trauma, complete exploration of the abdomen should be performed before closure to assure normal anatomic relationships of all structures.

Aortocoronary bypass for critical stenosis of the left main coronary artery.

Over a 2-year period 33 patients with symptomatic stenosis (greater than 75%) of the left main coronary artery underwent aortocoronary bypass. Intra-aortic balloon counterpulsation was used preoperatively in only two patients as a therapeutic measure for medically unstable angina. There were no operative deaths. Follow-up study 3 to 27 months (mean 13.3 months) after operation revealed one death. Twenty-two patients were free of pain. The authors conclude that aortocoronary bypass surgery for severe stenosis of the left main coronary artery can be safely accomplished, without prophylactic use of intra-aortic balloon counterpulsation in the majority of cases, with an acceptable operative mortality and morbidity.

Seat belt aorta: acute dissection and thrombosis of the abdominal aorta.

Aortic trauma mainly involves the thoracic aorta (95%), while the abdominal aorta is infrequently involved (5%). Of growing interest is the role of seat belts in abdominal aortic injuries. Although seat belts are known to cause injuries to the abdominal viscera, they rarely produce aortic trauma. We report here an acute dissection with thrombosis of the abdominal aorta leading to complete peripheral occlusion as a result of lap-type seat belt injury. The two previously reported cases of similar injuries which resulted in incomplete occlusion are reviewed. A hypothesis for the causal mechanism of these injuries is described. The authors also stress careful follow-up of all patients with seat belt injuries since other intra-abdominal vascular injuries may be present.

Assessment of the isolated right atrium as a pump.

The ability of the hemodynamically isolated dog right atrium to pump against a resistance equivalent to normal pulmonary artery pressure was tested in an in vivo preparation. At a preload of 10 mm. Hg, the right atrium reached a peak systolic pressure of 18.2 mm. Hg (+/- 1.3 S.E.M.) against an afterload of 12 mm. Hg, but it could eject a flow only equivalent to 53 percent (+/-6) of the dog's cardiac output (n = 6). At a preload of 15 mm. Hg, a peak systolic pressure of 21.5 mm. Hg (+/- 0.8) was recorded against an afterload of 17 mm. Hg, but again, only 55 percent +/-5) of the dog's cardiac output was ejected. It appears that the cardiac output from the nonhypertrophied right atrium is limited by the strength of the right atrial contraction and the physiological limits imposed by the venous driving pressure.

Friedreich's disease--a family study.

Friedreich's disease occurring in 4 male siblings in a sibship of seven caused cardiac and neurological abnormalities and one twin of an affected member died in cardiac failure; at autopsy characteristic pathological features of Friedreich's disease were demonstrated in the nervous system and heart. One female sibling had a patent ductus arteriosus which was treated surgically and a continuous murmur was present in another sister but cardiac catheterization in childhood had been normal.