Use of coronary Palmaz-Schatz stent in the percutaneous treatment of vertebral artery stenoses.

A case of chronic vertebrobasilar insufficiency due to severe stenoses at the origins of both vertebral arteries was treated with percutaneous transluminal angioplasty and coronary Palmaz-Schatz stents. Use of stents led to a better angiographic result than angioplasty alone. The patient is improved 8 mo later.

Urgent thoracotomy for pulmonary or tracheobronchial injury.

Three hundred eighty-eight of 7,283 (5.3%) admitted trauma patients underwent urgent thoracotomy. In 61 patients (15.7%), pulmonary or tracheobronchial injury prompted thoracotomy (11, blunt; 50, penetrating). Pulmonary hemorrhage necessitated thoracotomy in 54 patients (88.5%); tracheobronchial injury in five patients (8.2%). The mortality was 27.9%. Nine patients (14.8%) underwent pneumonectomy: eight died of intractable hemorrhagic shock during thoracotomy despite rapid control of pulmonary hemorrhage: one died of sepsis. Eleven patients (18.0%) underwent lobectomy: six (54.5%) died of concomitant injuries. Thirty-six patients (59.0%) underwent pneumonorrhaphy: one died of concomitant injuries. Five (8.2%) patients underwent tracheobronchial repair: one died of concomitant injuries. Pneumonectomy was uniformly fatal and should be a procedure of last resort in the treatment of pulmonary injury, as lobectomy and pneumonorraphy are better tolerated by these critically ill patients.

Cardiac transplantation in a Jehovah's witness.

Between July 1982 and October 1987, surgeons at our institution performed 215 cardiac transplantation procedures, 1 of which was in a 46-year-old Jehovah's Witness with congestive cardiomyopathy, who required preoperative intra-aortic balloon pump support. At surgery, the cardiopulmonary bypass system was primed with 1600 ml of Ringer's lactate solution and dextrose. In the 57 minutes during which the patient was on cardiopulmonary bypass, the intra-aortic balloon was removed and successful orthotopic heart transplantation was performed. No supplemental blood or blood product was used, either during or after the procedure. The estimated intraoperative blood loss was 300 ml, and the postoperative chest tube drainage amounted to 1495 ml. Postoperative hematologic abnormalities (mild hypoprothrombinemia, mild thrombocytopenia, mild platelet dysfunction, and moderate hypochromic microcytic anemia) were corrected with Imferon, vitamin K, and desmopressin acetate administered intravenously, and with ferrous sulfate administered orally. This case, which to our knowledge is only the 2nd cardiac transplant in a Jehovah's Witness, further establishes that these patients can undergo even the most major of open-heart procedures without supplemental blood.

Biochemical consequences of protein depletion in the rabbit heart.

We showed previously that cardiac function was depressed in rabbits subjected to 6 weeks of protein depletion and was restored after 4 weeks of protein refeeding. To identify nutritional or metabolic factors that underlie cardiac dysfunction, we assessed the nutritional status and myocardial content of energy-providing substrates in three groups of rabbits: group I served as control; group II was fed a protein-free diet; and group III was fed a protein-free diet and then repleted. Animal weights were 2.73 +/- 0.22 kg in group I, 1.92 +/- 0.28 kg in group II, and 2.78 +/- 0.12 kg in group III. Serum albumin concentrations decreased from 3.70 +/- 0.12 g/dl in group I to 2.81 +/- 0.10 g/dl in group II, and returned to normal (3.71 +/- 0.11 g/dl) in group III. The heart weights; myocardial contents of water, nitrogen (N), total fat, and glycogen; skeletal muscle N concentrations; and liver N contents were measured. Protein depletion produced a reduction in total cardiac mass due to decreased nitrogen and glycogen contents, but there was an increased fat content. Comparison with other organs suggests that cardiac muscle plays a role in energy homeostasis, undergoing glycogenolysis and proteolysis similar to those of liver and skeletal muscle. Protein repletion restored normal mass of the heart, but not of the liver. We conclude that adequate nutrition may be important in maintaining cardiac function.

Hemopericardium and tamponade following intracoronary thrombolysis with streptokinase.

Two patients underwent surgery for hemopericardium and pericardial tamponade after intracoronary thrombolysis by streptokinase for acute myocardial infarction. In both instances, the artery had reopened, but left ventricular function had not improved. A subxiphoid pericardial window relieved the tamponade, and both patients made good recovery. Hemopericardium is rare in myocardial infarction without cardiac rupture or anticoagulant therapy, and may constitute a specific complication of reperfusion with streptokinase. Pericardial window may be preferable to pericardiocentesis because of the possibility of cardiac rupture.

Cardiac surgery in children of Jehovah's Witnesses.

A retrospective study was done of 73 consecutive Jehovah's Witness children less than 2 years of age who were operated on for lesions of the heart and major vessels. The series was divided into three groups: (1) neonates less than 31 days old, (2) children between 31 days and 2 years, and (3) children requiring cardiopulmonary bypass. The overall mortality rate for the series was 12.3% (9/73). Only three of the nine deaths were complicated by blood loss and anemia. The mortality rate for Group I was 18.2% (2/11). Only one of the two deaths was partly attributable to anemia. The overall mortality rate for Group II was 14.9% (7/47). Only two of these seven deaths were complicated by anemia. No deaths occurred among the 15 patients in Group III. Bloodless prime hemodilution techniques were used in all patients. Based upon our data, we have concluded that cardiac surgery can be performed when indicated on children of Jehovah's Witnesses with acceptable mortality rates and relatively straightforward perioperative care.

Unusual sequelae of colon interposition for esophageal reconstruction: late obstruction requiring reoperation.

Colon interposition has become a favored technique for esophageal reconstruction. Late morbidity is generally related either to technical problems associated with the procedure or to the development of new disorders in the transposed segment. Two patients are discussed who were seen with obstruction of colon interposition grafts ten and five years after esophageal reconstruction. In the first patient, a volvulus of the interposed colon associated with a chronically narrowed area distal to the looped segment resulted in obstruction. In the second patient, the redundant intrathoracic segment of the colon interposition became kinked at the diaphragmatic hiatus leading to dilatation and incomplete emptying. Both patients underwent successful reoperations and are doing well 10 and 12 months later. The causes and possible prevention of these and other late complications of colon interposition are discussed.