Leiomyomatosis metastatic to the tricuspid valve complicated by pelvic hemorrhage.

Metastatic leiomyomatosis is a rare but potentially life-threatening tumor of smooth muscle cells. Leiomyomas originate predominantly in the uterus and can spread to the lung and, rarely, the heart. We present a case of a 36-year-old woman with known pelvic leiomyomatosis with metastasis to the tricuspid valve. Tricuspid valve replacement was complicated by retroperitoneal hemorrhage from residual pelvic tumor. This potentially catastrophic occurrence should be considered when undertaking resection of intracardiac leiomyomatosis.

Extended aortic arch atherectomy.

We report 2 cases of extensive atherosclerosis of the ascending aorta, arch of the aorta, innominate artery, and bilateral carotid arteries treated surgically at St. Vincent and Veterans Administration Medical Centers of Portland, Oregon.

Extralobar pulmonary sequestration presenting as a mediastinal malignancy.

Pulmonary sequestration is an uncommon congenital anomaly usually diagnosed in childhood. It frequently presents as a lower lobe mass with symptoms from vascular shunting, anatomic impingements, or associated anatomic defects. This case report describes an adult with asymptomatic extralobar sequestration involving the mediastinum and left upper lobe. The unusual location and radiographic appearance, suggestive of malignancy, led to prompt surgical exploration. We review the literature on this topic, focusing on anatomic variability and difficulties with preoperative diagnosis.

Reversed bevel technique for anastomosis at the aortic arch.

We describe a method for performing the distal anastomosis in replacement of the ascending and the proximal arch of the aorta with specific attention to obtaining accurate length and orientation of the graft. This method reduces the incidence of both anastomotic dehiscence due to tension and obstruction caused by redundant graft.

Adventitial inversion technique in repair of aortic dissection.

We describe a new technique for aortic anastomosis in the repair of acute dissection. The aorta is buttressed by inverting the adventitia without the use of Teflon or other synthetic materials. This technique provides a safe and secure anastomosis.

Inadequate internal mammary artery graft as a cause of postoperative ischemia: incidence, diagnosis and management.

Inadequate left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) was encountered in 10 of 3,076 patients between 1984 and July 1990. The mean number of bypass grafts was 2.9 per patient. All patients with inadequate LIMA grafts were stable preoperatively with normal to moderately reduced left ventricular function. No technical difficulties were encountered during surgery. All patients were weaned off cardiopulmonary bypass with minimal or no inotropic support. Each patient developed myocardial ischemia of the LAD territory and/or circulatory collapse or recurrent ventricular dysrhythmia during the first 24 h postoperatively. Six patients, who were immediately re-operated on and had an additional saphenous graft to the LAD, recovered with no infarction and good functional results. Four patients, who were medically treated, developed myocardial infarction. In cases of refractory circulatory collapse and/or ventricular dysrhythmia, inadequate LIMA flow should be suspected. We recommend urgent re-operation with additional saphenous vein graft to the LAD.

Long-term results of Ionescu-Shiley valve in the tricuspid position.

A retrospective analysis of the long-term results of using the Ionescu-Shiley pericardial bioprosthesis in the tricuspid position was carried out on 73 patients (8 men, 65 women). Of these procedures, ten were tricuspid valve replacement alone and the remainder were in combination with other valve procedures. The mean follow-up was 9.6 years (range, 4 to 18 years). The mean age of the patients was 53 years (range, 27 to 78 years). Seventy-one of the patients suffered tricuspid valve dysfunction from rheumatic heart disease. There were 13 postoperative deaths (within 30 days), giving a mortality rate of 17.8%. The actuarial survival at 10 years was 71% +/- 4.2%. Of the survivors, 49 (79.6%) were in functional class I or II. Primary tissue valve failure in the tricuspid position occurred in 1 patient 12 years after implantation and required reoperation. In another patient bioprosthetic tricuspid valve endocarditis developed. There was no incidence of thromboembolic complications. We conclude that the Ionescu-Shiley pericardial bioprosthesis was a satisfactory prosthesis in the tricuspid position in patients with acquired valvar dysfunction.

Reoperation after pericardial closure with bovine pericardium.

To reduce the risk of damage to the anterior surface of the right ventricle after resternotomy, it has been recommended that the pericardium be closed with a patch after open heart operations. We have examined 4 patients undergoing resternotomy for the third time 3 to 8 years after bovine pericardium valve replacement. On each occasion the pericardium was closed with a patch of bovine pericardium. In all cases, the patch was frozen to the inner aspect of the sternum, increasing the difficulty of resternotomy. Histological examinations of the patches confirmed dense fibrous connective tissue, patchy calcification, and foreign body giant cell reaction. Bovine pericardium appears to increase the difficulty of repeat cardiac operations. We recommend its use be discontinued.