Right atrial rupture due to blunt chest trauma.

Violent injury currently accounts for the majority of deaths among young people. Cardiac trauma is responsible for 15% of deaths from thoracic injury, and the incidence of cardiac injury in blunt chest trauma is as high as 76% in some clinical series. Many of these cardiac injuries consist of myocardial contusions. Recently, however, there has been increasing recognition of chamber disruption caused by blunt chest trauma. Cardiac injury is usually the result of direct compression of the heart between the sternum and the dorsal spine. These patients are frequently in extremis, with signs of pericardial tamponade, hypotension, and/or massive hemothorax. Successful management is dependent upon prompt diagnosis and surgical repair. To date there have been only 28 survivors (including the three patients in this report) of this catastrophic and frequently unrecognized injury.

Thrombotic catastrophe in the patient with multiple Björk-Shiley prostheses.

Thrombosis of the Björk-Shiley prosthesis has been a recognized problem for many years. Review of 172 patients at the University of Kentucky Medical Center who had one or more Björk-Shiley valves inserted between January, 1975, and July, 1980, revealed special problems in those patients with multiple prostheses. Diagnosis and therapy prove more difficult, and the cumulative incidence of thrombosis in the patients with multiple prostheses is 26.8% at six years. Projected long-term use of multiple Björk-Shiley prostheses is discouraged.

General surgical manifestations of cardiac prosthetic dysfunction.

A growing number of patients have prolonged survival after cardiac valve replacement. Longer life-spans increase the eventual risk of development of general surgical problems in these patients. Additionally, prosthetic dysfunction such as thrombosis, endocarditis, or dehiscence may lead to abdominal symptoms, systemic illness, or thromboembolic phenomena. a team approach, including the general surgeon, cardiologist, and thoracic surgeon, should be sought in the care of such patients.

A regional ultrasonic technique to measure left ventricular performance during coronary artery bypass.

Miniaturized, highly accurate pressure transducers and segment length measuring devices have been proven a safe, practical and stable method of analyzing cardiac performance in both acute and chronic animal experimentation. We have utilized a micromanometer-tipped intraventricular catheter and an ultrasonic segment length gauge implanted in the subendocardial layer of the left ventricle at the time of cardiac surgery to measure changes in systolic function and diastolic compliance prior to and after the completion of the operative procedure in man. No complications of this technique were encountered in the thirty patients studied. Continuous improvements in instrument design, data collection and data processing suggest future clinical applications are possible and desirable.

Multiple bilateral pulmonary arteriovenous fistulas.

This case documents the successful treatment of multiple bilateral arteriovenous fistulas using the mechanical stapling technic with intraoperative Doppler Flowmeter. The simplicity of technic and low morbidity justify its application in similar cases.

Influence of potassium cardioplegia versus ischemic arrest on regional left ventricular diastolic compliance in humans.

To compare the effects of hypothermic ischemic arrest versus hypothermic potassium cardioplegia, regional left ventricular performance was monitored in 20 adult male patients undergoing saphenous vein bypass operation. Twelve patients received ischemic arrest (Group 1), and 8 received potassium cardioplegia (Group 2). Groups 1 and 2 did not differ in left ventricular ejection fraction (0.62 versus 0.60), number of bypassed vessels (3.7 versus 3.4), mean cross-clamp time (75 versus 63 minutes), or mean cardiopulmonary bypass time (182 versus 170 minutes). Before cardiopulmonary bypass was begun, a pair of ultrasonic crystals was secured in the left ventricular anterior myocardium to measure segment motion and a micromanometer-tipped catheter was placed in the left ventricular chamber. All patients received a saphenous vein bypass graft to a vessel supplying the anterior left ventricular wall in the region of the ultrasonic crystals. Comparison of changes in systolic measurements revealed no significant differences between Groups 1 and 2. After saphenous vein bypass grafting, the left ventricular end-diastolic pressure (11.4 to 17.0 mm HG) and modulus of left ventricular segment stiffness (0.37 to 0.67, p less than 0.02) were elevated in Group 1 but no changes were observed in Group 2 (14.0 to 15.6 mm Hg, and 0.16 to 0.24, respectively). Compared with hypothermic ischemic arrest, hypothermic potassium cardioplegia is not associated with an increased left ventricular diastolic stiffness shortly after saphenous vein bypass grafting in humans.

Repair of mycotic aneurysms of the aorta involving the aortic valve.

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis. In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.

The role of thymectomy in red cell aplasia.

Red cell aplasia is an unusual cause of anemia. Fifty percent of all patients with red cell aplasia will have a thymoma. Twenty-five to 30% of those who undergo thymectomy will be cured. Data are presented that suggest that any patient with red cell aplasia should have thymectomy through a median sternotomy. One of 3 such patients who underwent the operation has had complete remission for two years.

The effect of supine rotation on left ventricular dimensions in man: a study using radio-opaque epicardial markers.

It has been reported that patient rotation into the left lateral decubitus position (30 degrees rao) produces significant changes in the regression equations used for left ventricular volume determination and that normal values for echocardiographic left ventricular dimensions obtained from supine patients differ from those obtained after rotation. The purpose of this study was to establish whether patient rotation is associated with changes in left ventricular size and systolic function. The distances between left ventricular epicardial markers attached at the time of cardiac surgery were measured using biplane cineradiography in 14 patients in order to determine left ventricular dimensions before and after rotation. Supine epicardial left ventricular dimensions were not significantly different from those obtained with the patient rotated 30 degrees rao. These results suggest that reported changes in invasive and noninvasive measurements of left ventricular function associated with patient rotation are not primarily due to changes in left ventricular size.

Acute traumatic hemothorax.

Over the past 5 years, 107 patients have been evaluated for acute traumatic hemothorax at the University of Kentucky Medical Center. Immediate tube thoracostomy was performed on 90 patients for evacuation of blood and air. Only 2 patients died. Thoracotomy was performed as part of the initial therapy in 9 patients. Thoracotomy for continued hemorrhage from a pulmonary parenchymal injury was required in 3 patients from the entire group. Thoracentesis or observation was the initial therapy for limited hemothorax in 8 stable patients. Three of these patients subsequently required tube thoracostomy 2 to 23 days following injury due to expanding effusions, and 1 patient required multiple thoracotomies for sepsis, fibrothorax, and empyema. These observations indicate that early evacuation of blood by means of a tube thoracostomy is essential to minimize morbidity in acute traumatic hemothorax. If continuing hemorrhage after tube thoracostomy occurs, there is a higher association of injury to additional vital structures.

Giant tracheoesophageal fistula: management by esophageal diversion.

Giant tracheoesophageal fistulas complicating the management of respiratory insufficiency are often difficult to close successfully because of suture line tension and narrowing of the trachea or esophagus or both. Recovery of lung function often depends on successful diversion of gastrointestinal contents from the tracheobrachial tree. We have managed six patients with giant tracheoesophageal fistula. In three cases the lesions were related to overinflation of low-pressure balloon cuffs. The only survivors were two of three patients managed by esophageal diversion and reconstruction through extrathoracic incisions. The techniques, advantages, and disadvantages of esophageal diversion for giant tracheoesophageal fistula are presented.

Carcinoma of the breast in young women.

The clinical records of 111 young women with breast carcinoma aged thirty years and younger have been analyzed with respect to the clinical stage of disease when first seen, the histologic status of the regional lymph nodes, and ten year survival. Survival in these young women with mammary carcinoma is equivalent to that of older women when the cancer is in its earliest stage, Stage A, but only if the regional lymph nodes are free from metastatic disease. Once the regional lymph nodes are involved by cancer, the prognosis for these young women is indeed dismal, with less than 20 per cent ten year survival regardless of clinical stage.