Subxiphoid pericardial window for pericardial effusive disease.

A subxiphoid pericardial window made in 123 patients allowed drainage and diagnosis of pericardial effusions. In 40 patients with malignancy and effusions, median drainage was 450 ml; cytology was positive in 17 or 36 (47%), and pericardial biopsy showed cancer in 13 (43%) of 30 patients. In 11 patients with malignancy, both cytology of effusions and biopsy of the pericardium were negative. In 83 patients with benign effusions, median drainage was 400 ml. Effusions recurred in 14 of the 123 patients (11%); nine patients in the benign group and five in the malignant group. Five of these 14 underwent thoracotomy (3 to 542 days postoperatively); two underwent median sternotomy and one underwent pericardiocentesis. Two intraoperative deaths resulted from cardiac arrest. Mortality at 30 days was 25% (10/40 patients) in the malignant group and 11% (9/83 patients) in the benign group. No deaths resulted from recurrent effusions. The establishment of a subxiphoid pericardial window allows rapid and safe drainage of pericardial effusions with sampling for cytology and pericardial biopsy. It has minimal morbidity and few recurrent effusions.

Tumors of the heart: surgical considerations.

A series of 23 cardiac tumors is reported. Six were diagnosed at autopsy; 17 tumors were surgically explored. Eleven of the 17 were myxomas within the left atrium. Eight of the 17 patients presented with congestive heart failure; peripheral and cerebral emboli were also common. The diagnosis was made preoperatively in 10 patients. Two-dimensional echocardiography was the most reliable diagnostic tool. Follow-up averages 55 months; there have been no late deaths or recurrences. The other six surgically treated tumors were: a left ventricular rhabdomyoma, a septal lipoma, a right atrial calcified endocardial mass, a right ventricular fibrosarcoma, a rhabdomyosarcoma, and a sarcoma metastatic to the pericardium and right atrium. From this series and a review of the literature, we concluded that: benign cardiac tumors can usually be excised with a low morbidity and excellent long-term results; malignant cardiac tumors have a dismal prognosis, and operation is primarily diagnostic; tumors metastatic to the heart should be operated upon only if successful palliation seems possible.

Digoxin and propranolol in the prophylaxis of dysrhythmias after coronary artery bypass grafting.

Serious tachydysrhythmias occur in 10% to 30% of patients early after coronary artery bypass grafting (CABG). We studied the effects of digoxin and propranolol in preventing these dysrhythmias over the first week after CABG (average number of grafts, 2.7/patient). Consecutive patients (n = 179) undergoing CABG were randomized to a drug (group 1) or a control (group 2) group. Excluded were patients given digoxin before CABG and those with ejection fractions of less than 40%, those with dysrhythmias within 18 hr after CABG, those being pacer dependent, and those with low-output syndrome after CABG. Risk factors were comparable in both groups. Electrocardiographic examination showed perioperative myocardial infarction in five patients (2.8%). Digoxin (1 mg iv given over 24 hr, then 0.25 mg/day) and propranolol (10 mg given every 6 hr) were started 6 hr after CABG. Supraventricular dysrhythmias requiring treatment occurred in 3.4% of 89 group 1 patients and in 30% of 90 group 2 patients (p less than .001); ventricular dysrhythmias occurred in 1.1% of group 1 and 8.9% of group 2 patients (p less than .01). In this study, a regimen of post-CABG digoxin and propranolol significantly reduced the incidence of supraventricular and ventricular dysrhythmias without causing adverse reactions.

Hyperextension injury of the cervical spine with esophageal perforation. Case report.

A case is presented of esophageal perforation following a hyperextension-flexion cervical injury. The patient recovered without complication. Hyperextension-flexion injuries of the cervical spine have proved to be a rare cause of esophageal perforation. The mechanism may be impingement of the esophagus against an exostosis or the edge of a vertebral body, or entrapment of the esophageal wall between the vertebral bodies as hyperextension changes to flexion. If not detected and treated early, the perforation may cause mediastinitis, retropharyngeal abscess, aspiration pneumonia, or death.