Anomalous origin of the right coronary artery from the main pulmonary artery. A case report.

A fifty-nine-year-old, asymptomatic woman with anomalous origin of the right coronary artery from the main pulmonary artery is presented. The diagnosis was established by catheterization and angiocardiography. The indications for surgery in this condition are discussed, with special reference to asymptomatic patients. In this patient, surgery was not undertaken, because of the absence of signs of impairment of left ventricular perfusion and function. The patient remains asymptomatic after eight years of observation.

Haemodynamic significance of the atrioventricular plane displacement in patients with coronary artery disease.

Echocardiographic quantitative assessment of the atrioventricular plane displacement (AVPD) in systole towards the apex has been used to estimate global left ventricular (LV) function. The study population consisted of 106 patients with coronary artery disease (CAD) with or without previous myocardial infarction and 40 age-matched healthy subjects. The AVPD was recorded from the apical four- and two-chamber views at four sites corresponding to the septal, lateral, anterior and posterior walls of the left ventricle. A mean displacement (AVmean) was calculated from the above sites. AVmean was significantly decreased in patients with CAD compared to healthy subjects (P less than 0.001). In patients in whom the left ventricular ejection fraction (LVEF) was calculated from cineangiograms a good correlation between AVmean and LVEF was found (r = 0.89, P less than 0.001, SEE = 6.4). Selecting an AVmean of 10 mm or more to define a normal LVEF (greater than or equal to 55%) resulted in a sensitivity of 92% and a specificity of 87% in predicting a normal versus abnormal left ventricular systolic function. It is concluded that the ease of recording the AVPD by echocardiography provides a simple and valuable noninvasive method to assess global left ventricular function in patients with CAD.

Intraaortic balloon tamponade during hemorrhagic shock in sheep.

Two groups (n = 10 in each) of adult sheep were exposed to hemorrhagic shock resulting in mean arterial pressure (MAP) below 25 mmHg for 10 min. Following that, group A received crystalloids (8% of body wt) during one hr together with supraceliac intraaortic balloon tamponade during the first 30 min, while group B (controls) received crystalloids only. The central circulation was rapidly restored in group A, as indicated by increased MAP and increased systemic vascular resistance (SVR). After deflation of the balloon MAP dropped to the same value as in the control group, while cardiac index increased gradually with volume replacement and was significantly higher at the end of the resuscitation period (60 min) than in the control group (P less than 0.05). Despite a more rapid restoration of central hemodynamics in group A, lactic acidosis was more severe, acute renal failure and neurological complications more frequent, and mortality higher than in the control group. It was concluded that continuous supraceliac aortic occlusion for 30 min had deleterious effects on organs dependent on aortic blood flow distal to the aortic tamponade and may contribute to the development of multiple organ failure after resuscitation from hemorrhagic shock. Further studies are needed to evaluate the effects of intermittent intraaortic balloon tamponade in hemorrhagic shock.

Intra-arterial mitomycin C and intravenous bleomycin as induction chemotherapy in advanced head and neck cancer--a phase II study.

Fifty-six patients with previously untreated, unresectable squamous cell carcinomas of the head and neck region were treated with repeated intra-arterial chemotherapy with mitomycin C using a selective or super-selective angiographic technique, and bleomycin given i.v., followed by radical radiotherapy. In addition, restricted tumour-reductive surgery was done in 18 of these patients. The response rate (CR + PR) after completion of the integrated treatment was 89%, with 63% of the patients showing CR. The toxicity of this regimen was, however, far from negligible. The median survival for this series of patients with advanced head and neck cancers is 19 months, and 17 are still alive after 16 + -66 + months.

Angiographic evaluation of scintigraphic abnormalities in screening for pulmonary embolism after total hip replacement.

Among 240 consecutive patients subjected to total hip replacement, 206 underwent perfusion scintigraphy in screening for pulmonary embolism 10 to 14 days after surgery. All patients with perfusion abnormalities (n = 77) also underwent ventilation scintigraphy with a dry 99Tcm microaerosol. The scintigraphic abnormalities were classified according to a detailed coding system and in 50 patients pulmonary angiography was performed within 24 hours for correlation. Emboli were diagnosed in 19 patients at angiography. All patients with ventilated segmental (n = 6) or larger (n = 5) perfusion defects or multiple subsegmental defects larger than half a segment (n = 2) had emboli. Two of 8 patients with abnormally ventilated subsegmental perfusion defects larger than half a segment had emboli. Four of 21 patients with wedge-shaped subsegmental perfusion defects smaller than half a segment or defects with a rounded border towards the hilum and a peripheral extension equal to or less than that of a segment had emboli. In one of them the site of the emboli correlated to the site of the perfusion defect but occurred in normally perfused areas in the remaining 3. Ventilation scintigraphy was of no value in this group of patients. No emboli were found in patients who had areas with decreased but not totally lost perfusion (n = 8). No emboli were diagnosed in 27 lungs with a normal perfusion.

Scintigraphy and chest radiography in the screening of pulmonary embolism after total hip replacement.

210 patients were screened for pulmonary embolism after total hip replacement with chest radiography and perfusion-ventilation scintigraphy using a new, dry 99mTc-microaerosol and a detailed system for coding scintigraphic abnormalities. Chest radiography did not contribute significantly to the diagnosis of pulmonary embolism. In spite of careful evaluation, false-negative and false-positive scintigraphic diagnoses of PE are still possible.

Percutaneous transluminal angioplasty of arteriosclerotic lesions in the pelvis and lower extremities.

The experience of percutaneous transluminal angioplasty (PTA) in 66 patients (71 stenoses) with arteriosclerotic lesions in the pelvic and lower extremity arteries is reported. The PTA was technically successful in 70 stenoses. Complications were seen in eleven patients. The follow-up time was 19 months (2-44). The frequency of recurrencies was clearly related to the location of stenosis, the more distal the lesion the higher the recurrency rate. The immediate roentgenologic result had no prognostic value to protect recurrencies. To conclude PTA is an alternative to surgery in patients with short stenoses in the iliac arteries, but very strict indications should be used when lesions are localized below the inguinal ligament.

Pre- and postoperative lung function in sitting and supine position related to postoperative chest X-ray abnormalities and arterial hypoxaemia.

Spirometry in both sitting and supine position was performed before and 3-5 days after elective upper abdominal surgery in 53 men, aged 41-72 years. The results were related to postoperative respiratory complications as defined by chest radiography and to measurements of the arterial oxygen tension. Preoperative total lung capacity (TLC), functional residual capacity (FRC) and wash-out volume (WOV) were lower in both positions among patients who were to develop major chest X-ray abnormalities than among patients with normal chest radiographs postoperatively. All patients who developed major chest X-ray abnormalities had a negative value for FRC - closing capacity (CC) in the supine position preoperatively, indicating 'airway closure' during tidal breathing. Preoperative WOV and lung clearance index (LCI) were higher in both sitting and supine positions in patients who developed postoperative hypoxaemia than in patients who did not. The postoperative decrease in TLC, FRC and WOV in the sitting position was greater among patients with major X-ray abnormalities and/or arterial hypoxemia postoperatively than among patients without these complications. According to our results, conventional spirometry in the supine position is not superior to conventional spirometry in the sitting position as part of pre- or post-operative assessment of patients. On the other hand, both preoperative 'airway closure' and arterial oxygen tension, measured in the supine position, showed a correlation with postoperative chest X-ray abnormalities.

Intravenous arteriography in the preoperative evaluation of advanced atherosclerosis.

Intravenous arteriography may be used as an alternative to translumbar or transaxillary angiography in cases with occlusion or severe stenosis of the aorta or iliac arteries, to determine the extension of the disease. During a 10-year period the method was used in 117 patients. For the examination, 80 to 100 ml of contrast medium was injected into the right atrium and after a delay of 10 to 20 seconds the lumbar aorta, iliac and femoral arteries were demonstrated. The quality of the examination was excellent or good in 92 per cent. No complications occurred. In 19 patients a continuous pressure recording was made in the main pulmonary artery. The pulmonary artery pressure increased to a significantly higher degree after contrast medium injection than after injection of the same amount of isotone saline. In all patients the pressure returned to normal within 4 minutes.

The clinical significance of postoperative chest X-ray abnormalities, arterial hypoxemia and clinically recorded respiratory complications.

The clinical consequences of postoperative complications as defined by signs and symptoms, chest radiography and measurements of the arterial oxygen tension were studied in 53 men, aged 40-75, who were electively operated for peptic ulcer or gallbladder disease. Clinical signs of a respiratory complication were detected in 4 patients. Of the 28 patients with chest X-ray abnormalities and 23 with arterial hypoxemia only 2 had clinical signs of a disordered pulmonary function. None of the remaining patients with arterial hypoxemia and/or chest X-ray abnormalities required any specific treatment. Hospital stay was not prolonged in patients with respiratory complications. Arterial hypoxemia and chest X-ray abnormalities in patients without clinical signs of a disordered pulmonary function had no influence on postoperative course or rehabilitation and were in all cases reversible without treatment.

Remission by chemotherapy of the Eaton-Lambert myasthenic syndrome in a patient with small cell bronchogenic carcinoma.

A 70-year-old man developed symptoms compatible with the Eaton-Lambert syndrome, and a small cell bronchogenic carcinoma was diagnosed. During treatment with cytostatics his muscular strength was restored and the lung tumour as well as the electrophysiologic findings characteristic of the Eaton-Lambert syndrome disappeared. To our knowledge, it has not been reported before that chemotherapy alone of a small cell bronchogenic carcinoma has resulted in clinical, roentgenologic, and electrophysiologic remission of the Eaton-Lambert syndrome.

Vincristine, Adriamycin, cyclophosphamide, and etoposide (VP16-213) in small-cell anaplastic carcinoma of the lung.

Twelve patients with small-cell anaplastic carcinoma of the lung were treated with vincristine 1 mg/m2 i.v. day 1, adriamycin 50 mg/M2 i.v. day 1, cyclophosphamide 1,000 mg/m2 i.v. day 1, and etoposide 80 mg/m2 i.v. day 2, 4, 6 given on an outpatient basis and repeated at 3-week intervals. As consolidation therapy seven patients received two courses of BCNU median 29 mg/m2 (range 24-73 mg/m2) short term intraarterial infusion in the bronchial artery with 2 to 3-weeks intervals. One patient with limited disease had no evidence of disease for 13+ months and one patient complete remission for 3+ months. Four of ten patients with extensive disease had complete remission for median 5 months (range 2+ to 5+ months) and four patients had partial remission for median 5 months (range 4 to 5+ months). Despite side effects the chemotherapy was well tolerated by the patients. The results correspond to those obtained with other effective regimens in small-cell anaplastic carcinoma of the lung.

Respiratory complications after upper abdominal surgery. The incidence of chest X-ray abnormalities, arterial hypoxemia and clinically recorded pulmonary complications.

The incidence of postoperative chest X-ray abnormalities, arterial hypoxemia and clinically recorded pulmonary complications was studied in fifty-two 40-75-year-old men admitted for elective surgery for peptic ulcer or gallbladder disease. Twenty-eight (54%) patients had an abnormal chest X-ray and twenty-three (43%) arterial hypoxemia, whereas only four patients (8%) were identified with clinical signs and symptoms of respiratory complications. Forty-one patients (79%) were found with pulmonary complications by at least one of the three methods. Twelve patients had both an abnormal chest X-ray and arterial hypoxemia. Only two of these were identified with clinical signs indicating pulmonary complications. The great discrepancy between results based on clinical signs and symptoms noted in the patients' records and results based on postoperative chest X-ray and measurements of the arterial oxygen tension, respectively, should be of great importance when comparing the incidence of pulmonary complications after different forms of surgery and when assessing risk factors and clinical consequences of respiratory complications.