Penetrating atherosclerotic ulcer of the aorta.

PURPOSE: To describe a case of penetrating atherosclerotic ulcer of the aorta with a review of its natural history, diagnosis and management. CASE REPORT: An elderly patient with a history of hypertension presented to the emergency room with the sudden onset of severe chest pain radiating to the back. The electrocardiogram showed left ventricular hypertrophy; the chest radiograph revealed mediastinal widening. Computed tomography was suspicious for a mediastinal hematoma without aortic dissection. Transesophageal echocardiography was also negative for dissection. An aortogram revealed a penetrating atherosclerotic ulcer of the descending thoracic aorta. The patient underwent successful resection and repair of the lesion. CONCLUSIONS: Penetrating atherosclerotic ulcer of the aorta is a potentially lethal lesion that must be promptly diagnosed and treated.

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.