The Nuss procedure for pectus excavatum correction.

Pectus excavatum is an anterior chest wall deformity that now can be corrected with a minimally invasive technique known as the Nuss procedure. Patient criteria and assessment for this new surgical procedure are defined clearly in advance to ensure the need for surgical intervention. A multidisciplinary team approach has been established at Children's Hospital of The King's Daughters, Norfolk, Va. Team members work cooperatively throughout the perioperative cycle, addressing not only the surgical procedure but also pain management and postoperative recovery. This dedicated team approach helps ensure a successful outcome for the patient.

Outcome of men with ischemic cardiomyopathy, asymptomatic nonsustained ventricular tachycardia, and negative electrophysiologic studies.

The natural history of patients with ischemic cardiomyopathy, asymptomatic nonsustained ventricular tachycardia, and negative electrophysiologic studies was assessed in a retrospective analysis of 55 consecutive patients. The results suggest that the prognosis for arrhythmic death in these patients is not necessarily benign.

Evaluation of left ventricular ejection fraction as a measure of pump performance in patients with chronic mitral regurgitation.

Left ventricular (LV) ejection fraction may not adequately detect a reduction in LV systolic performance resulting from chronic mitral regurgitation (MR), due to ventricular unloading into the low-impedance left atrium. To determine whether LV ejection fraction sufficiently gauges myocardial function in MR, nine patients were studied using micromanometer-measured LV pressures and biplane cineventriculography before and 1 year after mitral valve surgery. Six control patients were also studied. LV ejection fraction was normal in MR patients, despite an increase in LV end-systolic volume index. LV end-systolic pressure-volume and stress-volume ratios in MR patients were lower than in controls (P < 0.05 and P < 0.01), suggesting that LV systolic performance fell. One year after mitral valve surgery, LV ejection fraction decreased (P < 0.05) even though LV end-systolic volume index (P < 0.05), pressure-volume (P < 0.05), and stress-volume ratios (P < 0.01) all improved. Thus, LV ejection fraction inadequately reflected LV systolic function in MR patients before and after mitral valve surgery.

Thoracic surgery training at the University of Michigan.

The process of thoracic surgery resident education is and always has been taken very seriously at the University of Michigan, where it is regarded as a key mission of the faculty. More attention is paid to the details of providing a supportive educational environment using established principles of education, curriculum planning, evaluation, and feedback. Resident education is the order of business today and, although challenged by the demands of managed care and cost containment, it remains among the most important priorities at the University of Michigan.

Intravenous diltiazem and acute renal failure after cardiac operations.

BACKGROUND: Perioperative administration of intravenous diltiazem to patients undergoing cardiac procedures has been shown to decrease the incidence of ischemia and arrhythmias. However, after adopting this practice in our cardiac surgery program, we perceived an increased incidence of postoperative renal dysfunction. METHODS: A directed record review of postoperative renal function was conducted for consecutive patients undergoing cardiac operation for the time periods before and after adoption of prophylactic intravenous diltiazem (0.1 mg.kg-1.h-1 for 24 hours). The two groups were compared using chi 2 and two-sample t tests. The risk of development of postoperative renal failure was modeled with logistic regression. RESULTS: Diltiazem-treated patients (n = 271) were similar to the control patients (n = 143) in terms of age (64 versus 61 years; p = 0.14), ejection fraction (0.46 versus 0.47; p = 0.61), baseline serum creatinine level (1.2 versus 1.1 mg/dL; p = 0.27), prevalence of comorbid conditions, and surgical characteristics. The prevalence of left main coronary artery disease was lower in the diltiazem group than the control group (39% versus 52%; p = 0.01). During the 7-day postoperative period, the average peak serum creatinine level was higher in the diltiazem group (1.7 +/- 0.9 mg/dL; mean +/- 1 standard deviation) than the control group (1.5 +/- 0.5 mg/dL; p = 0.003). The incidence of acute renal failure requiring dialysis was 4.4% in the diltiazem group versus 0.7% in the control group (p = 0.04). There was no difference in length of hospitalization or mortality. The risk of acute renal failure was strongly associated with intravenous diltiazem (adjusted odds ratio [AOR] 6.3; p = 0.08), age (AOR 2.5 per 10 years; p = 0.07), baseline serum creatinine (AOR 4.8 per 1 mg/dL; p = 0.02), the presence of left main coronary disease (AOR 5.3; p = 0.02), and the presence of cerebrovascular disease (AOR 4.5; p = 0.05). CONCLUSIONS: Our retrospective analysis suggests that prophylactic use of intravenous diltiazem in patients undergoing cardiac operations was associated with increased renal dysfunction. Further studies of the risk and benefits of intravenous diltiazem in this setting should be undertaken.

Comparison of early and late complications in patients undergoing coronary artery bypass graft surgery with and without concomitant placement of an implantable cardioverter defibrillator.

Previous studies have reported a significant morbidity and mortality associated with coronary artery bypass graft (CABG) surgery in conjunction with the placement of an implantable cardioverter defibrillator (ICD) with an epicardial lead system. In the absence of a control group, how significantly the component of concomitant placement of the ICD system contributes to these untoward outcomes remains unknown. The purpose of this study was to assess the short- and long-term complications in patients undergoing CABG surgery in conjunction with the placement of an ICD with epicardial leads and to compare these complications with those of patients who had only CABG surgery (control group). The study group (group A) consisted of 56 patients who underwent CABG surgery and placement of an ICD pulse generator with epicardial leads. A control group (group B) consisted of 56 patients who underwent CABG surgery only during the same time period. The two groups were matched for age, sex distribution, left ventricular function, surgical approach, number of bypass grafts per patient, bypass pump time, and length of follow-up period. The early mortality for group A was 7.1% versus 1.8% for group B (p > 0.05). The incidence of early morbidity (congestive heart failure, infection, supraventricular and ventricular arrhythmias) for groups A and B was similar (26.8% vs 25.0%, p > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary amyloidoma of the chest wall.

Primary amyloidoma of the chest wall presents as an aggressive tumor that causes local destruction. It is best treated with wide local excision and reconstruction as required, which usually is curative. A search for occult systemic disease also is recommended.

Incidence, presentation, diagnosis, and management of malfunctioning implantable cardioverter-defibrillator rate-sensing leads.

Recognition of tachyarrhythmia by an implantable cardioverter-defibrillator (ICD) requires an intact rate-sensing lead. We retrospectively examined 266 consecutive patients requiring an ICD to characterize the incidence, clinical presentation, diagnosis, and management of a defective rate-sensing lead. To identify clinical parameters that may contribute to lead complications, we also assessed the effects of age, gender, type of rate-sensing lead, manufacturer of the lead, and surgeon. Over a follow-up period of 30 +/- 22 months (mean +/- standard deviation), a defective lead was found in 9 (3.4%) patients, in 9 (1.7%) of 514 leads over a period of 2 to 39 (mean 17 +/- 15) months after implantation. Except for 1 patient, in whom a lead fracture was incidently found during ICD generator replacement, these patients had multiple inappropriate shocks of recent onset. Clinical parameters were not helpful in identifying patients at risk for lead complication. An abnormal beeping signal obtained while the patients performed various maneuvers was helpful in confirming a defect. All of the defective leads were epicardial. These cases were managed by placement of a transvenous endocardial lead.

Relation of regional function, perfusion, and metabolism in patients with advanced coronary artery disease undergoing surgical revascularization.

BACKGROUND: Imaging of myocardial glucose metabolism using [18F]fluorodeoxyglucose (FDG) with positron emission tomography (PET) has been proposed for identification of tissue viability in patients with advanced coronary artery disease. This study was designed to evaluate the predictive value of flow and metabolic imaging for functional recovery after revascularization in myocardial segments of varying degrees of dysfunction. METHODS AND RESULTS: Thirty-seven patients (mean age, 59 +/- 11 years) with coronary artery disease and impaired left ventricular function (ejection fraction, 34 +/- 10%) were studied with PET using FDG and [13N]ammonia before surgical coronary revascularization (3 +/- 1 grafts per patient). Tissue was scintigraphically characterized as normal, nonviable (concordant reduction of perfusion and FDG uptake), viable without discordance of perfusion and metabolism (mildly reduced perfusion and metabolism), or ischemically compromised (mismatch of reduced perfusion and maintained FDG uptake). Functional outcome was assessed by serial radionuclide ventriculography before and at 13 +/- 13 weeks (median interval of 8 weeks) after coronary revascularization. Preoperatively impaired regional wall motion improved significantly in ischemically compromised (mismatch) revascularized segments but not in nonviable myocardium or in viable myocardium without discordance of perfusion and metabolism. The negative predictive value of PET for functional recovery was 86%, whereas the positive predictive value in revascularized regions ranged from 48% to 86% depending on severity of baseline wall motion abnormalities. CONCLUSIONS: PET identifies metabolically active tissue, which benefits from revascularization. Although the negative predictive value of PET for recovery was high, functional improvement of viable but ischemically compromised tissue was less frequent than previously reported. The predictive value of PET was highest in left ventricular segments with severe dysfunction and a mismatch or reduced perfusion but preserved metabolism. Integration of PET, angiographic, and functional data is necessary for the optimal selection of patients with advanced coronary artery disease and impaired left ventricular function for revascularization.

Wound complications and treatment of the infected implantable cardioverter defibrillator generator.

Since 1980, the automatic implantable cardioverter defibrillator (ICD) has evolved as effective therapy for prevention of sudden cardiac death following documented sustained ventricular tachycardia or fibrillation. During a 5-year period, 412 ICD devices were implanted at the University of Michigan Hospitals with a wound complication rate of 4.1%. In this group, there were 13 infections, 3 erosions of the generator pocket, and 1 wound hematoma. Of the 16 patients with infection or erosion, 12 patients were treated with a rectus abdominis muscle flap closure and 4 with ICD generator removal. In 83% (n = 12) of the muscle flap patients, the wound healed uneventfully. Preoperative chest CT scanning was found to be helpful in identifying probable infection of the epicardial leads. In these cases, all hardware had to be removed to achieve resolution of the infection. We concluded that rectus abdominis muscle flaps were helpful in salvaging infected or exposed ICD generators in the absence of infected epicardial leads.

Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction.

OBJECTIVES: We tested the hypotheses that left ventricular chamber elastance would detect impaired contractile function in patients with long-term mitral regurgitation and a normal ejection fraction and that these patients would have unique temporal left ventricular size and ejection fraction responses to mitral valve surgery. BACKGROUND: Although it has been suggested that left ventricular contractile function may begin deteriorating in patients with long-term mitral regurgitation whereas ejection fraction remains normal, no data exist in humans. METHODS: We studied 11 control patients and 28 patients with long-term mitral regurgitation using micromanometer-measured pressures, biplane contrast cineventriculography and radionuclide angiography under control conditions and with alterations in load during right atrial pacing to calculate left ventricular chamber elastance and myocardial stiffness. RESULTS: The patients with mitral regurgitation were classified into subgroups: Group I, normal contractile function; Group II, impaired contractile function (reduced Emax) but normal ejection fraction, and Group III, impaired contractile function (reduced Emax) with reduced systolic myocardial stiffness. Twenty-two of the patients with mitral regurgitation underwent mitral valve surgery. In Group I, comparable decreases in left ventricular volume indexes (p < 0.01 and p = 0.05, respectively) were associated with no change in ejection fraction at 3 months and 1 year. In contrast, in Group II, reductions in volume indexes (p < 0.0001 and p < 0.001) were associated with a short-term decrease in ejection fraction (p < 0.001) that recovered at 1 year (p < 0.01 vs. short-term). Finally, in Group III, variable responses in volume indexes were associated with a consistent decrease in ejection fraction at 3 months and 1 year. CONCLUSIONS: An analysis of left ventricular chamber elastance provides data to support the concepts that 1) contractile function is impaired in some patients with long-term mitral regurgitation and a normal ejection fraction, 2) impaired contractile function may not be irreversible in all of these patients, and 3) an earlier consideration of mitral valve surgery may be warranted to preserve contractile function in these patients.

Superiority of controlled surgical reperfusion versus percutaneous transluminal coronary angioplasty in acute coronary occlusion.

Although percutaneous transluminal coronary angioplasty is successful in more than 90% of patients after acute coronary occlusion, overall mortality remains approximately 10% with higher subgroup mortality (i.e., occlusion of the left anterior descending coronary artery, multivessel disease, age older than 70 years, cardiogenic shock) and early recovery of regional wall motion is marginal. This multicenter report shows that controlled surgical reperfusion in patients with acute coronary occlusion reduces overall and subgroup mortality and restores substantial early contractility. In a survey from six institutions, 156 consecutive patients with acute coronary occlusion documented by angiography underwent surgical revascularization with controlled reperfusion using amino acid-enriched blood cardioplegic solution on total vented bypass. Ventricular wall motion was studied by echocardiography or multiple gated acquisition scan on postoperative days 5 to 7 and scored independently (0 = normal, 1 = mild hypokinesia, 2 = severe hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared with results in 1203 patients with acute coronary occlusion treated by angioplasty in five reported medical series. Surgically treated patients were revascularized at longer ischemic intervals (6.3 versus 3.9 hours, p < 0.05) and had a greater incidence of left anterior descending occlusion (61% versus 43%, p < 0.05), multivessel disease (42% versus 22%, p < 0.05), and cardiogenic shock (41% versus 10%, p < 0.05), with 12 patients undergoing cardiopulmonary resuscitation en route to the operating room. Surgical results were superior in all categories, with overall mortality reduced from 8.7% after angioplasty to 3.9% after coronary bypass (p < 0.05). All surgical deaths occurred in patients with preoperative cardiogenic shock. Regional wall motion recovered significantly (score < 2) in 131 of 150 (87%) surgically treated patients with an average score of 0.9 +/- 0.8 (normal to mild hypokinesia) despite longer ischemic times.

Outcome of endocardial resection in 33 patients with coronary artery disease: correlation with ventricular tachycardia morphology.

The results in 33 patients with ventricular tachycardia (VT) treated by endocardial resection were reviewed, with special emphasis on the presence of single or multiple morphologies preoperatively and intraoperatively. Multiple VT morphologies were induced in 16 patients and a single VT morphology was induced in the remaining 17. Intraoperative programmed stimulation failed to induce VT in eight patients and visually-directed endocardial resection was performed. The remaining patients underwent map-guided resection. The surgical success rate did not correlate with any morphologic characteristics of the VT, such as bundle branch block pattern or axis. In addition, concordance of VT morphologies preoperatively and intraoperatively before resection did not correlate with the surgical success rate. However, patients in whom multiple morphologies of VT were induced intraoperatively had a significantly higher success rate (100%) compared with those patients in whom only a single morphology was induced intraoperatively (50%, p < 0.05). Long-term follow-up was maintained in 26 patients. Ventricular tachycardia recurred in two patients and VF recurred in two others who did not have inducible VT 1 week after endocardial resection. In conclusion, neither the preoperative morphologic characteristics of VT nor discordance between the morphologies of VT induced preoperatively and in the operating room influenced the outcome of endocardial resection. However, the surgical success rate is higher when multiple morphologies of VT are inducible in the operating room than when only one VT morphology is inducible.

Warm glutamate/aspartate-enriched blood cardioplegic solution for perioperative sudden death.

This report describes an initial experience applying warm glutamate/aspartate substrate-enriched blood cardioplegic solution to resuscitate hearts in 14 patients with witnessed perioperative arrest. Ten patients were in stable hemodynamic condition in the catheterization laboratory (n = 3) or intensive care unit when sudden irreversible fibrillation developed. It progressed to electromechanical arrest in six patients. In patients with preoperative or postoperative arrest, conventional cardiopulmonary resuscitation and defibrillation were unsuccessful and extracorporeal circulation was started 22 to 150 minutes after arrest. The left ventricle was vented, the aorta clamped, and warm (37 degrees C) aspartate/glutamate blood cardioplegic solution was given at a rate of 150 ml/min for 20 minutes. All bypass grafts were open with good flows in patients who had had coronary bypass, and coronary bypass was done in the three patients who had preoperative arrest. Eleven of 14 hearts resumed normal sinus rhythm after aortic unclamping, only two electrocardiographically proved infarctions occurred, and 13 patients had complete hemodynamic recovery with improved ejection fraction. Three patients died: one of progressive cardiogenic shock, another of mediastinitis, and the third of irreversible neurologic damage. Eleven patients were discharged from the hospital and are well after a follow-up period between 3 and 9 months. We conclude that witnessed perioperative arrest with intractable ventricular fibrillation should be treated aggressively by administering cardiopulmonary resuscitation during prompt transfer to the operating room for total vented bypass and delivery of warm substrate-enriched blood cardioplegic solution. This treatment may salvage hearts thought to be damaged irreversibly and may be a feasible approach to intractable witnessed cardiac arrest, provided cardiopulmonary resuscitation maintains satisfactory cerebral perfusion pressure.

Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography.

OBJECTIVE: The aim of this study was to determine the prognostic significance of perfusion-metabolism imaging in patients undergoing positron emission tomography for myocardial viability assessment. BACKGROUND: Positron emission tomography using nitrogen-13 ammonia and 18fluorodeoxyglucose to assess myocardial blood flow and metabolism has been shown to predict improvement in wall motion after coronary artery revascularization. The prognostic implications of metabolic imaging in patients with advanced coronary artery disease have not been investigated. METHODS: Eighty-two patients with advanced coronary artery disease and impaired left ventricular function underwent positron emission tomographic imaging between August 1988 and March 1990 to assess myocardial viability before coronary artery revascularization. RESULTS: Forty patients underwent successful revascularization. Patients who exhibited evidence of metabolically compromised myocardium by positron emission tomography (decreased blood flow with preserved metabolism) who did not undergo subsequent revascularization were more likely to experience a myocardial infarction, death, cardiac arrest or late revascularization due to development of new symptoms than were the other patient groups (p less than 0.01). Concordantly decreased flow and metabolism in segments of previous infarction did not affect outcome in patients with or without subsequent revascularization. Those with a compromised myocardium who did undergo revascularization were more likely to experience an improvement in functional class than were patients with preoperative positron emission tomographic findings of concordant decrease in flow and metabolism. CONCLUSIONS: Positron emission tomographic myocardial viability imaging appears to identify patients at increased risk of having an adverse cardiac event or death. Patients with impaired left ventricular function and positron emission tomographic evidence for jeopardized myocardium appear to have the most benefit from a revascularization procedure.

Cardiogenic shock complicating acute myocardial infarction: the use of coronary angioplasty and the integration of the new support devices into patient management.

Conventional therapy for cardiogenic shock complicating acute myocardial infarction continues to be associated with a high in-hospital mortality rate. Hemodynamic support with new mechanical devices and emergency coronary revascularization may alter the long-term prognosis for patients with this complication. Between July 1985 and March 1990, 68 patients presented to the University of Michigan with acute myocardial infarction and cardiogenic shock. Interventions performed included thrombolytic therapy (46%), intraaortic balloon pump counterpulsation (70%), cardiac catheterization (86%), coronary angioplasty (73%), emergency coronary artery bypass grafting/ventricular septal defect repair (15%), Hemopump insertion (11%), percutaneous cardiopulmonary support (4%) and ventricular assist device (3%). The 30-day survival rate was significantly better in patients who had successful angioplasty of the infarct-related artery than in patients with failed angioplasty (61% vs. 7%, p = 0.002) or no attempt at angioplasty (61% vs. 14%, p = 0.003). This difference was maintained over the 1-year follow-up period. The only clinical variable that predicted survival was age less than 65 years. The early use of the new support devices in 10 patients was associated with death in 8 (80%), but this poor outcome may reflect a selection bias for an especially high risk population. Collectively, these recent data continue to suggest that emergency revascularization with angioplasty may reduce the mortality rate, but further study is required to define optimal utilization and integration of new support devices.

Adjuvant treatment using transfer factor for bronchogenic carcinoma: long-term follow-up.

Transfer factor, a dialyzable lymphocyte extract that may act as an immune stimulator by transferring antigen-specific immunity between genetically dissimilar individuals, was administered in a prospective, randomized study to patients with non-small cell bronchogenic carcinoma. Between 1976 and 1982, 63 patients who underwent pulmonary resection, mediastinal lymph node dissection, and, when indicated by the presence of mediastinal lymph node involvement, mediastinal irradiation were randomized into two groups. Group 1 (n = 28) received 1 mL of pooled transfer factor at 3-month intervals after operation; group 2 (n = 35 ) served as controls and received saline solution. There were no statistically significant differences between the two groups with respect to age, sex, tumor histology, stage of disease, or extent of resection. One patient was lost to follow-up at 96 months; follow-up was complete in all others through July 1990. In patients receiving transfer factor, the 2-, 5-, and 10-year survival rates were 82%, 64%, and 43% respectively, whereas in controls they were 63%, 43%, and 23%. Survival in patients receiving transfer factor was consistently better than in those receiving placebo. Furthermore, survival in patients receiving transfer factor was greater at all stages of disease for both adenocarcinoma and squamous cell carcinoma. Although these long-term results were not statistically significant using survival analysis with covariates (p = 0.08), they confirm our previously reported short-term findings suggesting that administration of transfer factor, either through nonspecific immune stimulation, enhancement of cell-mediated immunity, or an as yet undefined mechanism, can improve survival in patients with bronchogenic carcinoma.

Effect of antiarrhythmic drug therapy on the incidence of shocks in patients who receive an implantable cardioverter defibrillator after a single episode of sustained ventricular tachycardia/fibrillation.

Seventy-four patients (16 women, 58 men, age 58 +/- 11 years, mean +/- standard deviation) who received an implantable cardioverter defibrillator (ICD) after experiencing a single episode of ventricular tachycardia or ventricular fibrillation were followed to determine if antiarrhythmic drug therapy affects the incidence of ICD discharges. Thirty-three patients (group A) were treated with an antiarrhythmic drug that was either untested or previously demonstrated during electropharmacological testing to be ineffective in suppressing the induction of ventricular tachycardia. Forty-one patients (group B) were not treated with an antiarrhythmic drug. There were no significant differences between the two groups in regards to age, sex, incidence of coronary artery disease, left ventricular function or the type of ICD pulse generator used. During a mean follow-up of 14 months for the entire cohort, 15 patients (46%) in group A and 18 patients (44%) in group B experienced at least one ICD shock. The time to the first appropriate shock (5 +/- 5 months in both groups) and the frequency of ICD shocks (0.3 +/- 0.2/month in group A vs 0.4 +/- 0.5/month in group B) were similar in both groups. The incidence of syncope at the time of ICD discharge was higher in group A than group B patients (31% vs 5%, P less than 0.05). In conclusion, antiarrhythmic drugs that are untested or have failed electropharmacological testing do not appear to reduce the probability of ICD discharge over a short-term (mean 14 months) follow-up in patients who have had only one clinical episode of VT/VF and may increase the risk of syncope during ICD discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetrating atherosclerotic aortic ulcer with dissecting hematoma: control of bleeding with percutaneous embolization.

A case is presented in which left subpleural hematoma and hemothorax resulted from a penetrating atherosclerotic aortic ulcer with an aortic pseudoaneurysm and intramedial hematoma. Percutaneous transfemoral embolization of the ulcer with use of coils and thrombin resulted in stabilization of the patient's hemodynamic status. The patient died 6 days later of pneumonia. In certain clinical situations, treatment of bleeding from penetrating aortic ulcers with percutaneous embolization may stabilize the patient's condition, allowing elective surgical intervention.