Successful management of left ventricular rupture following myocardial revascularization.

Left ventricular (LV) rupture is a common cause of death following myocardial infarction, but it is rarely noted following coronary bypass surgery. This is true despite the increasing number of coronary bypass operations performed for postinfarction angina, often following transmural infarction. A 59-year-old woman underwent successful repair of left ventricular free-wall rupture that occurred after coronary surgery performed for postinfarction angina. To our knowledge, this is the first report to establish the feasibility of successful surgical repair of left ventricular free-wall rupture in the postoperative patient with tamponade or intrathoracic bleeding.

Mucin-producing carcinoid ("composite tumor") of upper third of esophagus: a variant of carcinoid tumor.

An unusual upper esophageal polypoid tumor was found to be predominantly a carcinoid tumor and in part a mucin-producing adenocarcinoma. A review of literature showed this to be a unique tumor in this location.

Results and complications of intraaortic balloon pumping in surgical and medical patients.

The intraaortic balloon was attempted for therapy in 94 patients and successfully placed in 86. The balloon catheter could not be passed through the femoral or iliac artery in 12 patients (13 percent) of the group; in 4 of these the balloon was inserted through an aortic arch graft. The medical indications were cardiogenic shock and preinfarction angina. Ten of the 14 patients in the group with shock survived when treated with an aortic balloon without emergency surgery. Indications for balloon pumping in the surgical group included inability to wean the patient from the pump-oxygenator, postoperative shock and prophylactic placement of the balloon for poor ventricular function. Inability to remove a patient from pump-oxygenator support was the most common surgical indication, and 47 percent of patients were long-term survivors. Only 1 of the 17 patients for whom balloon pumping was used prophylactically died. Complications occurred in 17 percent of the entire group of 86 patients although the rate for medical patients with cardiogenic shock was 50 percent. The most common complication was arterial insufficiency requiring removal of the balloon. Four patients had permanent damage to the legs from ischemia, one patient requiring bilateral amputation. The overall incidence of serious arterial obstruction was 10 percent. Other complications included balloon displacement with arterial obstruction and pericardial tamponade from anticoagulant agents resulting in death.

Left ventricular wall resection for aneurysm and akinesia due to coronary artery disease: fifty consecutive patients.

Left ventricular wall resection with or without vein bypass grafting was performed in 50 consecutive patients with aneurysm or an akinetic segment with poor left ventricular hemodynamics. Ejection fraction averaged 29% and left ventricular end-diastolic pressure averaged 20 mm Hg. Associated valve disease was present in 14 patients (28%). Hospital mortality was 22% (11 patients) and late mortality was 20% (10 patients). The lowest mortality (3%, 1 death) was found in patients who had anterior apical resection with associated vein bypass, in whom prophylactic balloon pumping was used when needed for ejection fractions of less than 30%. A high mortality occurred with associated valve replacement (6 deaths, 86%) and posterior aneurysm. Among 39 patients followed for an average of twenty-four months, 34 (87%) improved one class and 18 (46%) improved two classes of the New York Heart Association Functional Classification.

An improved technique for coronary vascular anastomosis.

A vein holder is described that is used for anastomosis of both ends of aortocoronary bypass grafts. It minimizes handling of the graft, ensures precision in placing sutures with excellent visualization, and provides maximum patency at the anastomotic sites.

Aggravation of atherosclerosis by hypertension in a subhuman primate model with coarctation of the aorta.

The interrelationships between hypertension and atherosclerosis were investigated in a subhuman primate model (cynomolgus monkey) with hypertension produced by surgically coarcting the miathoracic aorta. The hypertensive coarcted monkey fed a low cholesterol diet for 6 months did not develop complicating atherosclerosis but did develop focal intimal lesions as well as marked thickening of the musculoelastic media of both the large and small arteries. Fibrocellular thickening of the intima and media occurred in the vessels proximal to the coarctation but not distal to the coarctation suggesting that a high level of blood pressure with resulting increase in arterial wall tension is responsible for these changes. The hypertensive coarcted monkey fed a hypercholesterolemic diet (2% cholesterol and 10% butter) for 6 months developed severe coronary atherosclerotic disease with fibrous plaque formation. The disease produced over 65% luminal narrowing of the major coronary arteries and their extramural and intramural branches. In contrast the noncoarcted normotensive animal fed the same diet developed mild atherosclerosis of only the major coronary arteries which caused an average luminal narrowing of 12%. Aggravation of atherosclerosis by hypertension also appeared to occur in the other arteries above the coarctation particularly the cerebral arteries. When the hypertensive coarcted monkey with preestablished coronary atherosclerosis was treated with a low cholesterol diet and a combination of antihypertensive drugs (hydrochlorothiazide, hydralazine, and reserpine), the progression of the disease was arrested. There also was evidence that treatment caused some regression of the coronary lesions which appeared to "heal" by fibrosis. The treatment of both hyperlipidemia and hypertension appeared to be more effective than the treatment of hyperlipidemia, alone.

The role of intraaortic balloon counterpulsation in patients undergoing cardiac operations.

Intraaortic balloon counterpulsation (IABC) was used to assist 60 patients undergoing cardiac operations for reasons of acute left ventricular failure (18 patients) or electively for indications in high-risk coronary and valvular heart disease (42 patients). Nine of 18 patients achieved hemodynamic stability when treated for acute perioperative or postoperative cardiogenic shock. Four of these died from problems unassociated with postoperative left ventricular failure and 5 were long-term survivors, indicating a potential salvage of 50%. In 42 high-risk patients, IABC was used electively to control preinfarction angina before operation (21 patients) and prophylactically to prevent postoperative low-output failure in another 21 patients with severe coronary and valvular heart disease. Thirty-nine, or 93%, of these patients survived. There were no deaths in the preinfarction angina group, 1 death in the group with coronary disease and ejection fractions less than 30%, and 2 deaths in those with valvular heart disease and congestive failure. Seven patients developed thrombotic or ischemic complications, but no permanent damage resulted. IABC is an important form of assistance for any patient with preoperative, intraoperative, or postoperative left ventricular failure and adds safety and hemodynamic stability for the high-risk patient with preinfarction angina or poor ventricular function.

Arterial wall metabolism in experimental hypertension of coarctation of the aorta of short duration.

Coarctation of the mid-thoracic aorata was surgically produced in mongrel dogs which were sacrificed from 4-12 wk after the operation. As compared to the findings in control animals, the sodium, chloride, and water content of the hypetensive portion of the coarcted thoracic aorta was significantly elevated, whereas the electrolyte and water content of the relatively normotensive portion of the coarcted aorta was normal. The sodium, potassium, and water content of the pulmonary artery, skeletal muscle, and cardiac muscle of the coarcted dog was not altered. These observations suggest that an elevated arterial pressure may influence the electrolyte and water composition of the arteries. The arterial pressure also may influence the content and synthesis of acid mucopolysaccharides (MPS) in the arteries since the content of sulfated MPS and the incorporation of injected radiosulfate into sulfated MPS were significantly increased in the hypertensive portion of the coarcted thoracic aorta but were significantly reduced in the relatively normotensive ("hypotensive") portion of the coarcted aorta. The observed increase in MPS may have been a factor directly responsible for the increase in the sodium content of the hypertensive aorta since MPS can act as polyelectrolytes and bind cations. Although the arterial pressure may influence certain metabolic functions in the arteries, it did not appear to have a direct effect on the arterial lipids since the lipid content of the hypertensive and of the relatively normotensive portions of the coarcted aorta were comparable to the values found in the normal aorta.