Recurrent "traumatic" bone cysts of the mandible.

An unusual case of several recurrences of multiple and bilateral "idiopathic, traumatic, hemorrhagic" bone cysts in the same patient, with long-term follow-up, is presented. The etiology and pathogenesis of idiopathic bone cysts are discussed. It is recommended that patients be followed for a longer period of time after treatment.

Intracoronary thrombolysis in patients with acute myocardial infarction: comparison of the efficacy of urokinase with streptokinase.

The efficacy of intracoronary urokinase and streptokinase were compared in 80 patients with acute myocardial infarction in a prospective, randomized, double-blind study. Urokinase was infused into the occluded coronary artery at 6000 U/min, and streptokinase was infused at 2000 U/min. Maximal duration of infusion was 2 hr. The frequency of successfully opening the artery was similar for patients receiving urokinase (27 of 45, 60%) and those receiving streptokinase (20 of 35, 57%). Fibrinogen levels after infusion were measured in 63 patients. Nineteen of 29 streptokinase recipients had fibrinogen levels less than 100 mg/dl compared with levels of two of 34 urokinase recipients (p less than .001). Five of 45 (11%) patients receiving urokinase and 10 of 35 receiving streptokinase (29%) had bleeding complications (p less than .05). Major bleeding after early coronary artery bypass surgery was more frequent in the streptokinase group (four of five compared with a similar group of patients receiving urokinase (none of five). This study demonstrates that while urokinase and streptokinase have equal intracoronary thrombolytic efficacy, patients receiving urokinase have less systemic fibrinolysis and less perioperative bleeding with early surgery than do patients receiving streptokinase.

Surgical procedures after percutaneous transluminal coronary angioplasty.

Since Gruentzig's introduction of percutaneous transluminal coronary angioplasty in 1974, there has been increasing clinical use of this technic. At St. Thomas Hospital in Nashville, 50 patients were selected for coronary angioplasty through December 1981. Twenty of the 50 have ultimately had coronary artery bypass surgery. Excellent dilatation of the selected coronary artery was accomplished in 19 patients. Fair dilatation was achieved six times, and four of these patients have had elective coronary artery bypass surgery. In 18 patients the vessels could not be dilated, and 12 of this group had coronary artery bypass, three on an urgent basis. In the remaining seven patients, the affected coronary stenosis was converted to 100% occlusion during the angioplasty, resulting in four emergency operations and one death. It appears that percutaneous transluminal coronary angioplasty is not as easy to master as had been anticipated, and that the results are just good enough in our hands to justify perseverence.

Further evaluation of the surgical treatment of obstructive disease of the left main coronary artery.

A protocol for the operative management of two patient groups with left main coronary artery disease has been evaluated. The period prior to and during induction of anesthesia is managed without using aortic balloon counterpulsation. Of the 86 patients undergoing coronary artery bypass for left main coronary artery disease from 1970 to 1973, there was a surgical mortality of 8.1%. Follow-up of the survivors from 48 to 87 months revealed three coronary and five non-coronary related deaths with survival to seven years of 75.6 +/- 5%. If the operative mortality is excluded, there is an observed survival to seven years of 82.4 +/- 4.8%, almost the same as a "normal" population of similar age and sex. Utilizing the same protocol, 90 similar patients undergoing coronary artery bypass in 1976 had an operative mortality of 4.4%. The deaths were not related to induction of anesthesia. The perioperative infarction rate (2%) and postoperative cardiac enzyme determinations were no greater in a random group having the same operation for less severe forms of coronary artery disease during the same time period. This method of management for patients with significant left main coronary artery disease is judged superior to other more complex techniques.

Ischemic cardiomyopathy: medical versus surgical treatment.

The natural history of patients with ischemic heart disease and depressed left ventricular function is dismal, and medical therapy has failed to alter its course. To assess the results of aorta-coronary bypass grafting in patients with coronary artery disease and decreased left ventricular ejection fraction (LVEF less than or equal to 0.3), we compared 70 medically treated patients to 46 patients having aorta-coronary bypass grafting. The duration of follow-up was 6 to 72 months (mean 19 months). All patients had angina pectoris. Congestive heart failure was present in 56 percent (39/70) of the medical and 43 percent (20/46) of the surgical group. The medical group had a mean LVEF of 0.20 and a mean left ventricular end-diastolic pressure (LVEDP) of 29 mm. Hg. The surgical group had a mean LVEF of 0.21 and a mean LVEDP of 24 mm. Hg. Three vessel disease was found in 60 percent (42/70) of the medical group and 83 percent (38/46) of the surgical group. The operative mortality rate in the surgical group was 4 percent (2/46). There were four late deaths. The 2 year actuarial survival rate for medical and surgical groups was 47 percent and 83 percent, respectively. Significant improvement in angina pectoris and/or congestive heart failure was found in 16 percent (11/70) of medically treated patients and 95 percent (38/40) of the surgically treated patients. Aorta-coronary bypass grafting can be performed in patients with poor left ventricular function with a low operative mortality rate, relief of angina pectoris, and improvement in symptoms of congestive heart failure.

[Ectopic coronary ostia and their importance for coronary and valvular surgery (author's transl)]. / Kongenitale Abgangsanomalien der Koronararterien und ihre Bedeutung für die Koronar- und Klappenchirurgie.

The incidence of ectopic coronary ostia location was investigated in coronary angiograms of 5350 adult patients without associated congenital heart disease. Ectopic coronary origin from the right coronary sinus was observed more than twice as frequently than ectopias from the left coronary sinus. The most common variation (0.7% of all patients) was the origin of the left circumflex branch from the right coronary sinus. Praeoperative knowledge and angiographic demonstration of ectopic coronary arteries is essential in order to avoid damage of these vessels during prosthetic valvular surgery or by aortotomy, to achieve complete revascularization in bypass surgery, and to prevent complications during intraoperative coronary perfusion.

Coronary artery spasm as the cause of myocardial infarction during coronary arteriogarphy.

Catheter-induced coronary artery spasm has been observed frequently. It is usually transient, reacts to the administration of nitroglycerin, and its distribution is generally confined to an area in proximity ot the intubated catheter. A 43-year-old woman with recurrent chest pain was found to have a rather long segment of tight proximal obstruction of the right coronary artery and experienced a myocardial infarction during coronary catheterization. Because of recurrent attacks of severe chest pain, coronary artery bypass surgery was performed which failed to result in significant improvement of her symptoms. Two repeat coronary cineangiograms seven weeks and three years after surgery revealed the proximal right coronary artery to be free of stenotic lesions or of luminal irregularities. After considering possible mechanisms of myocardial necrosis in the presence of normal coronary arteries it is concluded that myocardial necrosis can result from catheter-induced coronary artery spasm in spite of administration of nitroglycerin.

[Transfemoral coronary angiography. I. Report on the decreasing complication rate in the increasing number of cases]. / Transfemorale Koronarangiographie. Teil I: Erfahrungsbericht über abnehmende Komplikationsrate bei steigender Fallzahl

4950 coronary arteriographies performed by the percutaneous transfemoral technique (Judkins) are reviewed with respect to mortality, morbidity of myocardial infarctions and cerebral emboli, incidence of femoral thrombectomies and incidence of threatening events like arrhythmias and contrast reactions. With increasing number of coronary arteriographies that were performed yearly the incidence of all complications could be reduced by more than 90%.

[Transfemoral coronary angiography. II. Technical aspects of risk lowering]. / Transfemorale Koronarangiographie. Teil II. Technische Aspekte zur Verminderung des Risikos

Based on an experience of 4950 coronary arteriographies and a review of the literature common complications of transfemoral coronary arteriography are named, their mechanisms are analyzed and technical modifications of the procedure are suggested that we found useful to decrease the risk associated with this diagnostic test. Since throboembolic complications are a central problem of the transfemoral technique, various mechanisms producing myocardial and cerebral emboli are carefully analyzed. The significance of routine systemic heparinization has been emphasized repeatedly, but the contribution to safety of mechanical catheter tip debridement that can be reliably achieved by a meticulous ritual of appropriate steps is not universally recognized. These steps include a careful guidewire technique, insisting on spontaneous free back-dripping of blood from newly introduced catheters after removal of the guidewire, aspiration of blood with a syringe and flushing with saline and contrast. Careful observation of the blood pressure contour is mandatory whenever the catheter is advanced. In view of the time-thrombogenicity relation of catheter material, the procedure has to be performed expeditiously. After apparent solution of the problem of thromboembolic accidents, the only major complications occurred in patients with severe left main coronary artery lesions. Whenever disease of the left main coronary artery can be anticipated by a suggestive history, by highly abnormal ECG changes with exercise or by calcifications of the coronary arteries, the number of contrast injections should be reduced to a minimum necessary to adequately demonstrate the severity of the stenosis and the anatomy of the peripheral vessels for possible bypass surgery.

Percutaneous catheter emboli: sources and prevention.

Percutaneous coronary arteriography has been associated with numerous reports of embolic complications. Efforts to minimize such complications have focused upon normal hemostatic functions and the possible preventative role of systemic heparin. In considering the source and prevention of catheter emboli it is useful to review the mechanisms by which particulate matter may be introduced into the aortic root and to recognize that foreign material unaffected by anticoagulation may constitute a significant source of emboli. A simple technical protocol described in this communication has been followed during 3,500 percutaneous transfemoral coronary arteriograms using the Judkins approach. During this experience no embolic complications have been observed.

Temporomandibular joint ankylosis: review of the literature and report of two cases of bilateral involvement.

The factors predisposing to ankylosis and the probable pathogenesis are discussed, as treatment, both past and present. Arthroplasty with Silastic interposition is presented as an acceptable means of managing ankylosis, as shown in two case reports. The ultimate postoperative result is dependent on surgical timing, surgical technique, and attention to postsurgical physiotherapy.

Percutaneous transfemoral coronary arteriography; prevention of morbid complication.

During a six-year experience involving 3,089 selective coronary arteriograms (99 percent by the percutaneous transfemoral method), modifications of technique have reduced the incidence of morbid complications. Modifications have involved guidewire technique, systemic heparinization, attention to spontaneous catheter back-bleeding after guidewire removal, and caution in approaching sever main left coronary artery lesions.