Tracheoesophageal fistula developing during chemotherapy for non-Hodgkins lymphoma.

Lymphoma is an unusual cause of tracheoesophageal fistula (TEF). Most fistulas develop after radiation therapy and are a rare occurrence in patients treated with chemotherapy alone. The presence of a TEF is usually indicative of active lymphoma. This report describes a tracheoesophageal fistula that developed during chemotherapy for diffuse large cell lymphoma.

Ultrafiltration of the waste plasma effluent from cardiopulmonary bypass circuit contents processed with a cell-washing device.

Blood conservation methods are commonly practiced throughout most hospitals that conduct cardiothoracic surgery. In an effort to reduce patients' exposure to homologous blood products and due to cost effectiveness of blood conservation techniques, this present study combines autotransfusion of the remaining blood in the extracorporeal circuit and ultrafiltration of the plasma effluent, and describes the resulting product. Seven patients, greater than 19 years of age, requiring cardiopulmonary bypass (CPB) were incorporated into this study. Exclusion criteria included age limitation. At termination of CPB, the remaining blood in the circuit was transferred to an autotransfusion machine and processed. Plasma (1054 +/- 206 ml) effluent was collected directly from the centrifugal bowl and processed through a ultrafiltrator, with a constant flow rate and negative pressure, until the plasma effluent concentrated down to an end processed volume of approximately 150 ml. The following variables were either measured or calculated: plasma-concentrate volumes per three minute interval, inlet/outlet pressures of an ultrafiltrator, transmembrane pressure (TMP), plasma free hemoglobin, fibrinogen, total protein, and colloid osmotic pressure. The average ultrafiltrate volume taken off from the plasma effluent was 828 +/- 237 ml, with an average ultrafiltrate volume of 115 ml in every three minute interval. The TMP did not change over the first 15 minutes of processing but became significantly elevated at the 18th minute interval and continued to increase and reach a maximum TMP of 286.5 +/- 2.1 mmHg at the end of concentration. Fibrinogen levels increased from pre-concentration values of 118.2 +/- 64 to 317 +/- 177 mg/dl (p = .03) along with increases in plasma free hemoglobin from 97.7 +/- 46 to 402.1 +/- 180 mg/dl (p = .0002). The total protein concentration increased by over 330% from baseline values. Ultrafiltrating plasma effluent from autotransfused cell salvaged CPB circuit contents could prove beneficial, but further study is required to discover ways to separate unfavorable products, such as activated platelet-leukocyte products and reduced plasma free hemoglobin, and to lower heparin concentrations of the plasma-concentrate.

Cystic adenomatoid malformation involving an entire lung in a 22-year-old woman.

Congenital cystic adenomatoid malformation is an uncommon cause of respiratory distress in infants and is a rare entity in adults. Presentation in older patients is that of recurrent pulmonary infections. Usually a single lobe is involved. This report describes congenital cystic adenomatoid malformation involving the entire right lung in a 22-year-old woman presenting with gastrointestinal bleeding due to cavernous transformation of the portal and splenic veins.

Glucocorticoid reduction of bronchial epithelial inflammation during cardiopulmonary bypass.

Tumor necrosis factor-alpha (TNF-alpha) is released in inflammatory lung conditions, raising airway nitric oxide (NO) concentrations through the cytokine-mediated induction of nitric oxide synthase (NOS). Cardiopulmonary bypass (CPB) creates an inflammatory state, characterized by the release of TNF-alpha, that may result in lung injury following CPB. This study measured plasma levels of TNF-alpha and interleukin-6 (IL-6) as well as airway NO concentrations during CPB, and the effect of methylprednisolone (MPSS) on the levels of these inflammatory products. Twenty adult males scheduled for coronary artery bypass grafting (CABG) were anesthetized and randomized to a group given MPSS at 1 gm intravenously 5 min before CPB (Group S) or a group not given MPSS (Group N). Plasma levels of TNF-alpha and IL-6 were measured by enzyme-linked immunosorbent assay (ELISA) and the airway NO concentration by chemiluminescence. TNF-alpha was significantly (p < 0.05) increased at 30 min after the termination of CPB, while IL-6 was significantly (p < 0.05) increased at 50 min into CPB and 30 min after the end of CPB in Group N as compared with controls in the same group and with Group S at the same time intervals. A group of 10 patients undergoing repair of infrarenal aortic aneurysms, which served as a control group for plasma levels of TNF-alpha, showed no significant changes in TNF-alpha concentrations at any time during aneurysm repair. Airway NO increased significantly (p < 0.01) in Group N as compared with Group S at 5, 20, 35, and 50 min of CPB.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients.

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Myocardial protection for acquired heart disease surgery: results of a national survey.

To study current myocardial protection practices, all 4,393 United States board-certified thoracic surgeons were surveyed in 1992. Of the 1,413 respondents (32% total response), 936 are in active practice dealing with acquired heart disease. Based on their frequency of cases, respondents perform approximately 32% of all acquired heart disease operations in the United States yearly and individually average 157 patients/year. For myocardial protection, 98% of respondents routinely use cardioplegic arrest. The primary method of cardioplegia delivery is antegrade 36%, retrograde 4%, and a combination of antegrade and retrograde 60%. The types of cardioplegic solutions used are blood 72%, crystalloid 22%, and oxygenated crystalloid 6%. Continuous warm blood cardioplegia is used by 10% of respondents, whereas most (75%) have adopted a skeptical "wait and see" attitude or have abandoned it (6%). Overall, most surgeons (78%) report that they are very satisfied with their present methods of myocardial protection, whereas only 2% are dissatisfied. Still, the three areas believed most important for future research are reperfusion injury (74%), acutely infarcting myocardium (61%), and metabolic enhancers in cardioplegia (58%).

Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas.

Acute multiloculated thoracic empyemas incompletely drained by tube thoracostomy alone usually require operation. To avoid a thoracotomy yet treat this difficult problem, intrapleural fibrinolytic agents were employed. Between April 1, 1990, and April 1, 1993, 13 consecutive patients presenting with a fibrinopurulent empyema were demonstrated to have incomplete drainage. To facilitate drainage, streptokinase, 250,000 units in 100 mL 0.9% saline solution (3 patients), or urokinase, 100,000 units in 100 mL 0.9% saline solution (10 patients), was instilled daily into the chest tube, and the tube was clamped for 6 to 12 hours followed by suction. This routine was continued daily for a mean of 6.8 +/- 3.7 days (range, 1 to 14 days) until resolution of the pleural fluid collection was demonstrated by computed chest tomography and clinical indications. This regimen was completely successful in 10 of 13 patients (77%), who had resolution of the empyema, eventual withdrawal of chest tubes, and no recurrence. Two patients, both pediatric liver transplant patients, had an initial good response but eventually required decortication. One patient with a good radiographic response became increasingly febrile during streptokinase therapy and underwent a thoracotomy, but no significant undrained fluid was found. This patient's continued fever was believed to be a streptokinase reaction. Urokinase was used subsequently. No treatment-related mortalities or complications occurred. Intrapleural fibrinolytic agents, especially urokinase, are safe, cost-effective means of facilitating complete chest tube drainage, thereby avoiding the morbidity of a major thoracotomy for 77% of a group of multiloculated empyema patients who traditionally would have required open surgical therapy.

Intrapleural doxycycline control of malignant pleural effusions.

The intrapleural instillation of agents for pleural sclerosis has proved effective in preventing the reaccumulation of symptomatic malignant pleural effusions. Because manufacture of the most popular agent, tetracycline, was recently discontinued, a preliminary study was undertaken to evaluate an alternative agent, doxycycline, for treating symptomatic malignant pleural effusions. From November 1991 to September 1992, 21 patients with symptomatic malignant pleural effusions have undergone overnight chest tube drainage followed by intrapleural instillation of 10 mL 1% lidocaine and then doxycycline, 500 mg in 30 mL 0.9% saline solution. The chest tube was clamped 2 hours with patient repositioning every 15 minutes. Tubes were removed when drainage was less than 50 mL/8 h. Of surviving patients, a complete objective response at 1 month was obtained in 88% (15/17), who were free of a symptomatic or radiographic recurrence of the effusion. Complications included mild pain in 23% (5/21), moderate pain requiring analgesics in 19% (4/21), and mild fever in 5% (1/21). There were no treatment-related deaths. The mean time for chest tube removal was 1.7 +/- 0.7 days after the last treatment. Based on this preliminary study, we conclude that doxycycline is a highly effective agent for the palliative treatment of symptomatic malignant pleural effusions. Its safety profile and efficacy compare favorably with those of tetracycline and other agents used for pleural sclerosis.

Permanent pacing in heart transplant recipients: underlying causes and long-term results.

Although the majority of heart transplant recipients have a satisfactory heart rate, a substantial number require a permanent pacemaker. In 7 of 46 heart transplant patients at our institution symptomatic bradycardia developed, necessitating implantation of a transvenous pacemaker. The average time from heart transplantation to pacer insertion was 25 days. The average donor age, ischemic period, and crossclamp time was 28 years, 182 minutes, and 113 minutes, respectively. A long aortic crossclamp time (greater than 83 minutes) increased the risk for conduction abnormalities in the sinoatrial node. No patient had rejection before the pacer implantation. Five of the seven patients continue to be paced a significant amount of a 24-hour period. Only one patient has had considerable improvement in 3 years, requiring pacing only 3% of a monitored 24-hour period. This patient had the longest ischemic time and the most rejection episodes after implantation of the pacemaker. One patient was paced 100% until a second heart transplantation was done, without a subsequent need for pacing. The other five patients' hearts continue to be paced between 80% and 100% of a 24-hour monitored period. The donor intrinsic heart rates of these five patients produce symptomatic bradycardia. The success of AAI pacing in all patients indicates normal conduction below the sinoatrial node. The injury or dysfunction resulting in bradycardia was isolated to the sinoatrial node. Long-term follow-up in three patients (greater than 3 years) shows the need for pacing to be intermittent but long term. Most patients never fully recover from symptomatic bradycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenine nucleotide content in cold preserved human donor hearts and subsequent cardiac performance after orthotopic heart transplantation.

Myocardial high-energy phosphate content has been used as a parameter to evaluate the adequacy of donor organ preservation. The purpose of this study was to assess current techniques of preservation by measuring high-energy phosphates in cold preserved (4 degrees C) human donor hearts. Endomyocardial biopsy samples of the donor heart right ventricular septum (n = 24) were compared with samples from patients with normal cardiac function evaluated before chemotherapy (n = 12). Left ventricular and right ventricular ejection fractions were measured by means of radionuclide angiography early (24 to 72 hours) and late (mean 42 days) postoperatively. Mean total cold ischemic time was 146 +/- 54 minutes (range, 89 to 340 minutes). ATP nmol/mg noncollagenous protein in donor hearts was 38.2 +/- 10.7 and 31.9 +/- 13.6 (p = NS) in normal hearts. Early postoperative left ventricular and right ventricular ejection fraction was 55% +/- 14% and 40% +/- 9%, respectively. Late postoperative left ventricular and right ventricular ejection fraction was 64% +/- 14% and 50% +/- 10%, respectively; both represent significant increases in right and left ventricular ejection fraction (p less than 0.05). No correlation was found between ischemic time and donor ATP, ischemic time and ejection fraction, or ejection fraction and ATP. Three patients with normal donor heart ATP content had severe, but reversible, early graft dysfunction. In summary, currently used human donor heart preservation techniques are associated with normal values of high-energy phosphates and usually excellent early and late postoperative graft function.(ABSTRACT TRUNCATED AT 250 WORDS)

Platypnea-orthodeoxia: an unusual indication for surgical closure of a patent foramen ovale.

Platypnea-orthodeoxia is an infrequently reported clinical form of position dependent dyspnea and oxygen desaturation. There are several diverse etiologies for this syndrome. This case report of a patient with platypnea-orthodeoxia is the first known presentation of a case secondary to a patent foramen ovale and idiopathic hemidiaphragm paralysis. A major problem with this disease is the clinical recognition of its existence. Full recovery is possible with proper assessment of clinical signs and symptoms, appropriate noninvasive diagnostic tests, and corrective surgery in selective cases.

Left recurrent laryngeal nerve paralysis: an unusual presentation of histoplasmosis.

A case of histoplasmosis seen as left recurrent laryngeal nerve paralysis in a 49-year-old man is described. The patient had roentgenographic findings of a solitary, noncalcified left upper lobe mass and mediastinal adenopathy. Tissue diagnosis of histoplasmosis was obtained using a thoracotomy, allowing institution of appropriate treatment.

Correlation of gross and microscopic appearance of skin buttons in total artificial heart animals.

Pneumatic artificial hearts are powered by compressed air that is delivered through percutaneous tubes. A stress relief device, termed a skin button, surrounds these tubes as they exit from the recipient's tissues. The skin button is designed to protect the tissues from damage and provide a secure material-tissue interface. Prevention of superficial and invasive infection is the primary goal of the skin button. Eight calves were studied prospectively to identify gross or microscopic infection with the skin button. All animals who survived more than sixty days (62-136) had both gross and microscopic evidence of infection. All animals surviving less than 60 days (13-43) had no gross evidence of infection but one had subcutaneous microscopic abscess formation. No animal died secondary to a skin button infection. Skin buttons cannot prevent infection but they can contain the pathologic process in the superficial tissues with no evidence of systemic effects.

Combined blunt traumatic rupture of the heart and aorta: two case reports and review of the literature.

Blunt chest trauma resulting in combined aortic disruption and cardiac rupture, although a common autopsy finding, was found reported only once previously in a surviving patient. We report two cases repaired through a left posterolateral thoracotomy in which the cardiac injury was unsuspected and presented as an intraoperative finding of hemopericardium. With improved emergency resuscitation in the field and faster transport of these cases to tertiary care centers, this combination of lesions may be seen more frequently. Suggestions for their diagnosis and management are presented.

Successful biventricular circulatory support as a bridge to cardiac transplantation during prolonged ventricular fibrillation and asystole.

The indications for biventricular versus left ventricular mechanical circulatory support as a bridge to cardiac transplantation are not well established. In this study, 27 potential heart transplant candidates who were in imminent risk of dying before donor heart procurement were implanted with Thoratec prosthetic ventricles (21 biventricular and six left ventricular) at three medical centers. A total of 21 patients (16 biventricular and five left ventricular) underwent successful cardiac transplantation after 1-65 days of circulatory support, and 19 were discharged from the hospital. Seven of the patients (all biventricular; diagnoses: four cardiomyopathy, two acute myocardial infarction, one end-stage coronary artery disease plus acute myocardial infarction) had prolonged arrhythmias that normally would have been lethal (six cases of ventricular fibrillation from 2 to 22 days, one asystole for 3 hours), but complete support of the systemic and pulmonary circulations was maintained in all seven patients with biventricular devices. Mean systemic blood flow during this period (4.6 +/- 0.6 l/min) was unchanged compared with that during sinus rhythm. Six of these patients survived to receive heart transplants. The use of right plus left prosthetic ventricles does not prevent the occurrence of arrhythmias but removes the threat and simplifies patient management. We conclude that biventricular support is indicated in bridge-to-transplant patients with potentially lethal arrhythmias.

Effect of a total artificial heart on adaptive hormonal responses in humans with end-stage heart failure.

The J-7 total artificial heart (TAH) can restore normal vascular hemodynamics in humans treated for end-stage heart failure, but less is known regarding its effect on hormones elevated under these conditions. A 49-year-old man with NYHA Class IV end-stage heart failure received a J-7-70 TAH as a bridge to transplantation. Pre-TAH cardiac index was less than 2 L/min/m2 with end organ dysfunction, increased venous and pulmonary pressures, and a low arterial pressure. The TAH provided an immediate cardiac index greater than 3 L/min/m2 with normal hemodynamics and organ function. Pre-TAH renin, aldosterone, and atrial natriuretic factor (ANF) levels were markedly elevated: 147 ng/dl, 29.4 ng/dl, and 380 pg/ml, respectively. All values declined dramatically by the fifth postoperative day, with the aldosterone and ANF values returning to normal at 11.5 ng/dl and 37 pg/ml, respectively. Renin levels reached normal values by the fourth postoperative week. Once normal values were obtained, they remained in this range for the 57 days of TAH function. The TAH, used in end-stage heart failure, restores normal hemodynamics and compensatory hormonal levels. These hormones can be used as indicators of proper TAH function in such patients.

The role of beta receptors in the peripheral vasculature of calves with a total artificial heart.

Drugs given to a total artificial heart (TAH) calf isolate their vascular effects independent of the myocardium. During experiments, the TAH maintains full ejection, constant heart rate, and percent systole, and uses no vacuum. Cardiac output (CO) varies solely and directly with preload. Six calves received an infusion of isoproterenol, a beta agonist, and three calves received propranolol, a beta antagonist. The isoproterenol was resumed after beta blockade. Isoproterenol alone caused a significant increase in CO, an effect that was attenuated but not eliminated with beta blockade. Both isoproterenol and propranolol decreased AoP, but only isoproterenol increased preload. Beta receptors play a significant role in decreasing venous capacitance with increased preload and CO, independent of the myocardium.