Major mediastinal injury from crossbow bolt.

We treated a 26-year-old male who sustained a self-inflicted injury to the mediastinum with a crossbow bolt. Injuries involved penetration of the sternum 1 cm below the sternomanubrial joint, right lung, pericardium, ascending aorta, right pulmonary artery, esophagus, and azygos vein. He was treated successfully with cardiopulmonary bypass and hypothermia. Exposure was achieved with a combination of a sternotomy and right thoracotomy.

Traumatic rupture of the thoracic aorta: ten-year experience with follow up.

In the past 10 years, 13 cases of acute traumatic rupture of the thoracic aorta were treated at the Dunedin Hospital. Ages ranged from 16 to 77 years, with a mean of 27 years. Twelve of the patients were involved in high speed motor vehicle accidents and one sustained a fall. The diagnosis was suspected in all 13 cases by a widened mediastinum on plain chest X-ray and confirmed by aortography in all cases. Associated injuries were common. The time interval from injury to surgery ranged from 5 h to 16 days, with a mean of 3 days. A Gott Shunt was used in five patients, seven had partial bypass and one had simple aortic cross-clamping. Mean aortic cross-clamp time was 62 min. Mortality was 15%, both deaths occurring in the bypass group. There were two cases of paraplegia, one occurring in the bypass group and the other in the patient having simple cross-clamping of the aorta. Follow up was possible in 8 of 13 patients and ranged from 3 months to 10 years, with a mean of 39 months. Delayed death due to heart failure occurred after discharge in a 77 year old man 40 days after operation. The long-term results were satisfactory in all survivors, apart from one poorly rehabilitated paraplegic.

Resection for congenital tracheal stenosis.

A case of congenital tracheal stenosis is reported. The diagnosis was made on plain X-ray, tomography and computerized axial tomography of the trachea when the child was 8 years old. The operative approach was via a median sternotomy and anaesthesia maintained with dual simultaneous ventilation of the right upper lobe bronchus and distal trachea. Histology of the stenotic area revealed the cartilaginous rings to be completely encircling the trachea.

Tissue plasminogen activator and cardiopulmonary bypass for massive pulmonary embolus.

Massive pulmonary embolus resulting in cardiac arrest and doubtful cerebral status may result in indecision as to whether to proceed to pulmonary embolectomy, especially if there is continuing cardiorespiratory instability. A case is reported on the use of fibrinolysis and cardiopulmonary bypass, allowing for the cerebral status of the patient to become more clearly defined while maintaining cardiopulmonary stability and attempting to treat the underlying pathological process.

Pericardial closure after cardiac operations. An animal study to assess currently available materials with particular reference to their suitability for use after coronary artery bypass grafting.

An experimental study to assess the performance of currently available pericardial substitutes is described with particular reference to their use after coronary artery bypass grafting. Seventy-two ewes, (six groups of 12 animals) had a 7 x 5 cm portion of the pericardium excised. Each group had either the defect left open, primarily resutured, replaced with coarse Dexon No. 2 mesh (American Cyanamid Co., Danbury, Conn.), replaced with fine Dexon No. 8 mesh, replaced with glutaraldehyde-preserved bovine pericardium, or replaced with polytetrafluoroethylene 0.1 mm surgical membrane. Six animals from each group were assessed at 3 months and the remaining six animals were assessed at 6 months. The open-defect and resutured groups served as control animals. None of the substitutes proved superior to the open-defect group in the prevention of chest wall/lung-to-pericardium adhesions at either 3 or 6 months. The limitations of the animal model in assessing this aspect of substitute performance are discussed. Whereas the bovine pericardium, polytetrafluorethylene, and Dexon No. 8 mesh groups were superior to the resutured group in the prevention of pericardium-to-epithelium adhesions in the area of the patch, this advantage was lost at 6 months when resuturing proved as effective as polytetrafluoroethylene and bovine pericardium. In all groups there was little tendency to produce generalized pericardial adhesions. At 3 months Dexon No. 8 mesh and bovine pericardium produced the least amount of significant epicardial reaction. In two animals in the 3-month polytetrafluoroethylene group and in one animal in the 6-month polytetrafluoroethylene group, a "fibrous peel" was encountered on the inner surface of the patch, which had also become adherent to the epicardium and had obscured the underlying anatomy. At 6 months the open-defect, resutured, and bovine pericardium groups had produced no significant epicardial reaction. In one animal at 6 months the bovine pericardium had become markedly thickened and degenerative. We do not recommend routine closure of the pericardium after coronary artery operations with any of the substitutes investigated in our study.