Tracheobronchial disruption: postoperative management with jet ventilation to minimize airway pressures.

The case of a 17-year-old male victim of blunt trauma with complex tracheobronchial injury identified by flexible bronchoscopy is discussed. The paper also describes the surgical treatment used and good results obtained.

Intra-aortic balloon pump for combined myocardial contusion and thoracic aortic rupture.

The coexistence of myocardial contusion and thoracic aortic injury is probably more common than recognized following rapid deceleration multisystem trauma. This report describes the successful application of intra-aortic balloon counterpulsation in a critically injured patient requiring emergent repair of a thoracic aortic tear complicated by ventricular failure due to cardiac contusion.

Long-term follow-up of a patient with quadruple valve replacement.

A 60-year-old woman who had suffered from rheumatic fever as a child required replacement of the aortic, mitral, and pulmonary valves. Subsequently, because of severe regurgitation, the tricuspid valve was also replaced. This case proves that, with satisfactory intraoperative cardiac protection, quadruple valve replacement can produce a good long-term functional result.

A practical approach to prosthetic valve endocarditis.

Prosthetic valve endocarditis (PVE) is an infrequent but dread complication, occurring in 1 to 2% of patients both early (less than 60 days) and late postoperatively. Diagnosis is always (99%) possible by two sets of blood cultures, but occasional exogenous causes of bacteremia may cloud the diagnosis, as will culture-negative cases of PVE and skin contaminants. With obvious exogenous sources of bacteremia, achieving sterile blood cultures after eradication of the noncardiac source permits discontinuation of antibiotics after two weeks. When skin contaminants are suspected, withholding antibiotics and obtaining two sets of blood cultures is recommended, because the bacteremia with PVE is continuous. Preventive measures, including perioperative antibiotics, are warranted but will probably not significantly reduce the low incidence of infection already achieved. The major cause of improved survival in recent years is earlier operation (valve rereplacement). This has been demonstrated in the last ten years and is absolutely indicated for major heart failure, ongoing sepsis, fungous etiology, valve obstruction, new-onset heart block, and unstable prosthesis by fluoroscopy.

Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds.

Previous studies have emphasized injury mechanism, wound site, and presenting vital signs as critical determinants for survival following penetrating cardiac injury. Our experience suggests pericardial tamponade is another crucial factor and is the basis for this study. Prognostic features were reviewed in 100 consecutive, unselected patients with acute cardiac injuries. Mechanism was stab wound in 57, and gunshot injury in 43. Location included right ventricle in 55, left ventricle in 49, right atrium in 16, and left atrium in seven. Overall salvage was 31%,; 27 (47%) of 57 stab wounds, four (9%) of 43 gunshot wounds, 22 (49%) of 45 right, and nine (23%) of 39 left heart wounds. The presence or absence of pericardial tamponade was documented in 77 patients. Patients with tamponade had a survival of 73% (24/33) compared to 11% (5/44) in those without its protective effect. The presence of tamponade improved survival (p less than 0.05) following stab injuries (77% vs. 29%), gunshot wounds (57% vs. none), right heart wounds (79% vs. 28%), left heart injuries (71% vs. 12%), and overall in patients arriving with vital signs (96% vs. 50%). Multivariant discriminant analysis by logistic regression demonstrated cardiac tamponade was a critical independent factor in patient survival, and suggested that it may be more influential than presenting vital signs in determining outcome.

Aortocardiac fistula with aortic valve injury from penetrating trauma.

A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability. Life-threatening sequelae (hemorrhage and cardiac tamponade) result from the external injury rather than the intracardiac component. Intracardiac damage is most commonly manifested as the delayed recognition of a cardiac murmur and some degree of congestive heart failure, and when these appear one must suspect intracardiac trauma. We recommend cardiac catheterization and elective repair, maintaining control of both ends of the intracardiac fistula with bolstered suture. Aortic valve injury can often be primarily repaired. Patients with combination aortic valve and aortocardiac fistula injuries, more so than those with a single intracardiac lesion, fail with nonoperative management. Of the 18 patients, 17 underwent surgery. One of these died: the others did well during short-term followup (less than 1 year).

Delayed presentation of traumatic diaphragmatic hernia.

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).

Temporary cardiac pacing in traumatic arrest victims.

Temporary ventricular pacing was successfully employed in two patients suffering refractory bradycardia following traumatic cardiac arrest. The hemodynamic response to pacing was dramatic and both patients eventually recovered fully from an apparent moribund state. Cardiac pacing may be an effective adjuvant in the early resuscitation of the massively injured patient.

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months.

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent). All patients underwent closure of the ductus arteriosus and patch angioplasty of the aorta to produce a luminal diameter of at least 16 mm. In addition, 9 of the 17 patients (53 percent) with a large shunt ventricular septal defect underwent pulmonary arterial banding. There was one hospital death 42 days after operation secondary to bowel perforation and sepsis. Hospitalization beyond 21 days postoperatively was always due to other unrepaired cardiac lesions. The three late deaths at 3, 9 and 18 months after operation were associated with additional major anomalies. Fourteen patients have had postoperative catheterization. No gradient was found across the site of coarctation repair, but one patient had a gradient between the left carotid and left subclavian arteries. Surgical repair of critical coarctation of the aorta in infants can safely be offered despite the presence of other cardiac anomalies.

Late complications following surgical repair of total anomalous pulmonary venous return below the diaphragm.

Between May, 1975, and June, 1977, we surgically repaired an infracardiac total anomalous pulmonary venous return in 4 infants under deep hypothermic cardiac arrest. All patients had pulmonary hypertension and a patent ductus arteriosus. All survived operation and required positive end-expiratory pressure with mechanical ventilation. Late complications included patent ductus arteriosus not visualized at initial catheterization, breakdown of an oversewn atrial septal defect repair, and pulmonary venous obstruction despite an anastomosis diamter of 1.5 to 2.5 cm. At reoperation, there was scarring and contraction at the junction of the pulmonary veins and left atrium. One infant with these complications died post-operatively. In another patient, there was kinking of the left lower pulmonary vein at its juncture with the left atrium. In view of these complications we currently recommend the following: ligation of the ductus arteriosus regardless of catheterization findings; a right-sided approach to avoid pulmonary vein kinking; prosthetic patch closure of the atrial septal defect to avoid excessive tension on suture lines and to maintain maximum left atrial size; stellate anastomosis to provide the largest possible drainage channel; awareness that an unusually high positive end-expiratory pressure may be required postoperatively; and early recatheterization.

Evaluation of technetium scanning for myocardial contusion.

Myocardial contusion is a serious problem not easily diagnosed. Laboratory and clinical studies carried out on myocardial infarction suggested that Technetium scanning might clarify this diagnostic dilemma. Radionuclide imaging with Technetium was carried out in 29 patients suspected of having myocardial contusion. Of 13 patients in whom contusion was confirmed electrocardiographically, scan was positive in only two. Use of the technique in diagnosis of myocardial contusion is not recommended.

Thoracic traction for median sternotomy dehiscence.

Standard management of median sternotomy dehiscence sometimes fails to achieve lasting reduction and fixation of the sternal halves. An effective method of external thoracic traction that augments internal fixation of the sternal fracture is presented.

Tension pneumomediastinum.

Tension pneumomediastinum is an infrequently diagnosed but potentially fatal condition. The collection of air under pressure in the mediastinum compromises venous return to the heart and compresses major bronchi, leading to sudden and profound cardiovascular collapse. Although its mechanism was elucidated in the 1940's, when tension pneumomediastinum was most commonly a complication of tuberculosis, the same mechanism explains its formation in neonates with respiratory distress and in patients ventilated with volume respirators. Awareness of this condition will lead to more frequent diagnosis, but, more important, will also lead to prompt mediastinotomy and relief of this rapidly fatal condition.

Three unusual complications resulting from attempted repair of partial anomalous pulmonary venous drainage.

The correction of shunts resulting from partial anomalous pulmonary venous drainage has become an accepted surgical procedure. Surgical complications, other than those that were purely postoperative, have been rare. The present report details the case histories of three patients with unusual complications resulting from this type of surgery. Unilateral pulmonary venous obstruction and repeated infections occurred in one patient. In another, obstruction of the superior vena cava resulted. In the third patient, an indaequate operation was performed when the site of partial anomalous pulmonary venous drainage into the coronary sinus was not recognized initially at the time of surgery.

Bronchial adenoma.

Thirty-three patients with bronchial adenoma have been treated in U.S. Army hospitals. These included 27 with carcinoid, 3 with mucoepidermoid carcinoma, and 3 with adenoid cystic carcinoma. No deaths could be directly related to the adenomas during an average follow-up of 14.5 years.