Invasive carcinoid tumor of the heart.

Carcinoid tumors have been described in almost every organ and may affect virtually every body system. Cardiac involvement manifesting as right-sided valvular disease is characteristic of the carcinoid syndrome; however, direct myocardial involvement is unusual. We present a case of an invasive carcinoid tumor whose primary manifestation was myocardial invasion.

Wegener's granulomatosis mimicking a sternal abscess.

Bone destruction as a manifestation of Wegener's granulomatosis has been reported, but these cases were limited to the head and face. We present a case in which a sternal abscess was the initial manifestation of Wegener's granulomatosis. We believe this is the first reported case of bone destruction due to Wegener's occurring in a location other than the head and face.

Cadaver lungs for transplantation. Effect of ventilation with alveolar gas.

In an effort to increase the donor pool for lung transplantation (LTX), we have demonstrated the feasibility of LTX from circulation-arrested cadavers in a canine LTX model. We hypothesized that ventilation of the cadaver lung with alveolar gas (20% O2, 5% CO2, balance N2) (AG) would be superior to ventilation with 100% oxygen (O2) after circulatory arrest of the donor. Twelve mongrel dogs were intubated, heparinized and euthanized by pentothal injection and ventilated with AG (n=6) or O2 (n=6). Four hours later, donor animals underwent sternotomy, and the lungs were flushed with cold modified Euro-Collins solution, harvested, and stored inflated in ice slush. Left lung allotransplantation was performed, and recipients were made dependent o n the transplanted lung by occlusion of the contralateral bronchus and pulmonary artery. Recipient animals were ventilated with an FiO2 of 0.4 and followed for 8 hr. Total ischemic time was 7.9 hr for both groups. Pulmonary edema developed in all recipients of AG lungs; one recipient survived the 8-hr observation period with poor oxygenation. In contrast, three of six recipients of O2-ventilated lungs survived for 8-hr with excellent gas exchange. Specimens of donor lungs before and after transplant were evaluated histologically utilizing trypan blue exclusion as an indicator of cell viability. At the time of organ retrieval 4 hr after death, 6% of cells were nonviable in the O2-ventilated cadaver lungs. Circulation-arrested cadaver lungs ventilated with 100% O2 prior to organ retrieval have superior pulmonary function after transplant compared with lungs ventilated with AG. Ventilation of cadaver lungs with AG induces pulmonary injury in this model. retrieval of donor lungs from circulation-arrested cadavers has potential for increasing the pulmonary donor pool.

Donor lungs from ventilated cadavers: impart of a free radical scavenger.

BACKGROUND: The shortage of donors for lung transplantation may be alleviated with the use of lungs retrieved from cadavers. The purpose of this study was to determine whether a free radical scavenger, dimethylthiourea, would improve the function of lungs retrieved from ventilated cadavers. METHODS: Left lung transplantation was performed in 21 dogs. Donors were sacrificed then ventilated with 100% oxygen. After 2 hours, donor lungs were flushed in a blinded fashion with 2 L of modified Euro-Collins solution, with either dimethylthiourea (n = 10) or saline solution (n = 11) added, then harvested. A donor right lung lobe was perfused with trypan blue vital dye to assess cell viability at harvest and after the transplantation. Percentage of nonviability was similar in the dimethylthiourea and control groups (13 versus 20 at retrieval and 38 versus 41 at graft reperfusion). After transplantation, the right pulmonary artery and bronchus were occluded, rendering the recipient on the pulmonary graft. The recipient's lungs were ventilated for 8 hours, with the inspired oxygen fraction maintained at 0.4. RESULTS: Seven of ten dogs in the dimethylthiourea group survived the 8-hour period, compared with 4 of 11 dogs in the control group. Compared with the control survivors (n = 4) at 8 hours after the operation, the dimethylthiourea survivors (n = 7) had a higher mean arterial oxygen pressure (144 +/- 21 versus 98+/- 12 mm Hg) and cardiac output (2.2 +/- 0.2 versus 1.6 +/- 0.2 L/min) and a lower mean pulmonary vascular resistance (946 +/- 96 versus 1414 +/- 128 dynes.sec-1.cm5, p < 0.05) and extravascular lung water (10.6 +/- 1.2 versus 12.3 +/- 3.2 ml/kg). Differences between groups during the 8-hour period were usually insignificant. CONCLUSIONS: This model imposes a rigorous challenge to the single transplanted lung, and yet cadaver lungs still supported life in half of the recipients. Dimethylthiourea may confer a benefit to recipients of cadaver lungs.

Single-stage replacement of the entire thoracic aorta via transverse thoracosternotomy.

The transverse thoracosternotomy provides excellent exposure for repair of lesions involving the entire thoracic aorta. This approach has been made more feasible by other recent technical advances, such as retrograde perfusion of the brain during circulatory arrest, allowing single-stage replacement of the ascending and descending aorta and aortic arch. The two cases presented here illustrate the use of these advancements in the treatment of extensive aneurysms of the thoracic aorta.

Innominate artery and tracheal compression due to aberrant position of the thymus.

A 3-month-old infant with failure to thrive was found on bronchoscopy to have tracheal obstruction thought to be secondary to innominate artery compression. Subsequent diagnostic evaluation with magnetic resonance imaging revealed superior and posterior extension of the thymus with resultant compression of the innominate artery and trachea within the narrow confines of the thoracic inlet. Resection of the aberrantly positioned and enlarged thymus and aortopexy resulted in relief of tracheal compression.

Vertical muscle-sparing thoracotomy.

In our armamentarium of various thoracic incisions, we have incorporated a vertical skin incision with a muscle-sparing approach to gain access to the thorax. We find this incision gives excellent exposure, preserves function of the chest wall musculature, and leaves a cosmetically superior result.

A simple method of removing residual intrathoracic air post-thoracotomy in children.

A simple and effective method of aspirating residual intrathoracic air is described. This method can be used when air leaks or persistent fluid accumulations are not expected. This technique may be easily adapted for use in older children or adults when similar circumstances are present. Standard postoperative monitoring, including serial roentgenogram of the chest, should be used to verify appropriate pulmonary re-expansion.

Acute appendicitis following blunt abdominal trauma. Incidence or coincidence?

Inflammation of the appendix is a common cause of acute abdominal pain. The etiology and pathophysiology of appendicitis have been well described. The initiating factor often is obstruction of the appendiceal lumen by inspissated stool, barium, food, parasites, or hyperplastic lymphoid tissue. Two patients have been identified who developed appendicitis temporally related to blunt abdominal trauma, without other clear etiology. Although absolute documentation of trauma as an etiologic factor in these cases is difficult, theoretical mechanisms for the occurrence are discussed. In the setting of right lower quadrant pain following mild to moderate blunt abdominal trauma, acute appendicitis should be considered as a possibility.