Surface-electrode Rydberg-Stark decelerator.

Hydrogen atoms in Rydberg states with principal quantum numbers between 23 and 70 have been accelerated, decelerated, and electrostatically trapped using a surface-electrode Rydberg-Stark decelerator. By applying a set of oscillating electrical potentials to a two-dimensional array of electrodes on a printed circuit board (PCB), a continuously moving, three-dimensional electric trap with a predefined velocity and acceleration is generated. From an initial longitudinal velocity of 760 m/s, final velocities of the Rydberg atoms ranging from 1200 m/s to zero velocity in the laboratory-fixed frame of reference were achieved. Accelerated or decelerated atoms were detected directly by pulsed electric-field ionization. Atoms trapped at zero mean velocity above the PCB were reaccelerated off the PCB before field ionization.

Calcified abdominal aortic aneurysm in a 12-year-old boy.

The authors report a case of an idiopathic, isolated infrarenal abdominal aortic aneurysm with dense intramural calcification and sterile mesenteric lymphadenopathy in a 12-year-old boy. Aneurysmal disease in the pediatric population is very uncommon. The majority of previously reported cases have clear associated causes, such as connective tissue disorders, infectious processes, inflammatory states, or trauma. A minority of cases have no distinguishable cause and are classified as idiopathic. Isolated abdominal aortic aneurysms are very uncommon in children, and those with densely calcified walls are rare, with only 2 case reports in the literature. The authors found no previous reports of abdominal aortic aneurysm with associated sterile mesenteric lymphadenopathy. The etiology of this patient's aneurysm remains unknown.

Hypogastric artery embolization in endovascular abdominal aortic aneurysm repair.

PURPOSE: Iliac artery anatomy is a central factor in endoluminal abdominal aortic aneurysm therapy. It serves as the conduit for graft deployment and as the region of distal graft seal. Thirty-eight percent of iliac vessels in our patients require special treatment because of aneurysms, tortuosity, or small size. Bilateral hypogastric artery exclusion has been avoided because of concerns of colorectal ischemia, hip/buttock claudication, and impotence. We suggest that elective, staged, bilateral hypogastric embolization can be performed safely with reasonably low morbidity and can expand the anatomic boundaries for stent-graft abdominal aortic aneurysm repair. METHODS: This study was performed as a retrospective chart review of patients requiring hypogastric artery embolization for endovascular repair of abdominal aortic aneurysms between June 1998 and June 2000. Patients with otherwise appropriate anatomy and common iliac artery aneurysms were informed of the option for stent-graft repair with internal iliac artery embolization with its risks of impotence, hip/buttock claudication, and bowel ischemia. Patients underwent unilateral or staged bilateral coil embolizations of their proximal hypogastric arteries with an approximate 1-week interval between procedures. Hospital and office records were reviewed; phone interviews were performed. Follow-up ranged from 1 to 12 months. RESULTS: During a 24-month period, 65 patients underwent endovascular abdominal aortic aneurysm repair; 18 patients (28%) required hypogastric artery embolization. Seven (39%) of these patients underwent bilateral embolization. There were no episodes of clinically evident bowel ischemia. Lactate levels were normal in all measured patients. Postoperative fevers (> 101.0 degrees F) were documented in 10 (56%) of 18 patients. The average white blood cell count was 12.8 x 10(9)/L (range, 8.5-22.9). There were no positive blood culture results. The return to the full preoperative diet occurred in 1 to 3 days. Hip/buttock claudication occurred in approximately 50% of patients with persistent but improved symptoms at 6 months. Eighty-seven percent of patients had preoperative erectile dysfunction. Only two patients noted worsening of erectile function postoperatively. CONCLUSIONS: Preliminary results indicate that bilateral hypogastric artery embolization can be performed, when necessary, with reasonable morbidity in patients undergoing stent-graft abdominal aortic aneurysm repair.

Bloodless medicine and surgery.

Our hospital is a center for bloodless medicine and surgery (CBMS). It is one of 56 such centers located in the United States. The mission of the center is to provide surgical and medical treatment without the administration of blood or blood-related products. Patients' rights to autonomy and self-determination are respected. Development of the CBMS program required the writing and implementation of specific guidelines, developing standards of care, revising existing policies and procedures, and educating staff members. The CBMS program is multifaceted and multidisciplinary.

Congenital coronary arteriovenous fistula: spontaneous rupture and cardiac tamponade.

Congenital coronary arteriovenous fistula is an unusual, but not rare, coronary anomaly. Management of asymptomatic fistulas is controversial because of great variability in natural history. We describe an 82-year-old female patient with spontaneous rupture of a previously undetected left main coronary artery-to-pulmonary artery coronary arteriovenous fistula, with resulting hemopericardium and cardiac tamponade. Emergent surgical exploration and repair provided successful treatment.

Fast-track recovery of the coronary bypass patient.

A new approach termed "fast-track recovery" ws undertaken at both the Baystate Medical Center and Hartford Hospital. The fast-track protocol involves the following principles: (1) preoperative education; (2) early extubation; (3) methylprednisolone sodium succinate before bypass followed by dexamethasone for 24 hours postoperatively; (4) prophylactic digitalization, metoclopramide HCl, docusate sodium, and ranitidine HCl; (5) accelerated rehabilitation; (6) early discharge; (7) a dedicated fast-track coordinator to perform both daily telephone contact and a 1-week postoperative examination; and (8) a routine 1-month postoperative visit with a PA or MD. To evaluate the effects of this approach on patient care, a retrospective 1-year analysis was undertaken in both institutions with all coronary artery bypass grafting patients compared in a consecutive manner before the origin of the fast-track protocol and subsequent to its beginning. There were 280 patients in the fast-track and 282 in the non-fast-track group. The two groups were not significantly different except inexplicably there was a lower ejection fraction in the fast-track group and a longer cross-clamp time. Postoperatively, the mean time to extubation decreased from 22.1 to 15.4 hours, and peak weight gain decreased from 2.8 to 1.6 kg from the non-fast-track to the fast-track group (p < 0.01). This was accompanied by significant (p < 0.001) decreases in intensive care unit duration from 2.4 to 1.9 days and in postoperative length of stay from 8.3 to 6.8 days from the non-fast-track to the fast-track group. There was no increase in morbidity or mortality associated with the fast-track protocol either early or late. Thirty-day hospital readmission was not significantly different between the two groups. Fast-track methodology is effective, and we routinely employ this approach for all patients undergoing cardiopulmonary bypass.

Ventricular pseudoaneurysm associated with cardiopulmonary resuscitation 6 weeks after mitral valve replacement.

Trauma to the heart and mediastinum is associated with external cardiac massage. A patient had undergone a redo mitral valve replacement and experienced an uneventful postoperative course. During a visit to her physician 6 weeks after operation, she experienced ventricular fibrillation that required external cardiac massage and subsequent defibrillation. Postresuscitation evaluation revealed a posterior pseudoaneurysm of the ventricle. This was repaired via a transthoracic approach with the use of profound hypothermia.

Hypothermic circulatory arrest in the treatment of thoracic aortic lesions.

The use of hypothermic circulatory arrest has been established in the treatment of aortic arch lesions. We recently used this method of arrest in the treatment of 10 consecutive patients with thoracic aortic lesions. Seven of these patients had dissecting aneurysms of the ascending aorta with extension into the aortic arch. One patient had a mycotic aneurysm of the arch, and 2 patients had arteriosclerotic aneurysms of the ascending aorta and entire aortic arch. All patients were supported and cooled with cardiopulmonary bypass. Circulatory arrest was maintained for periods of 21 to 63 minutes. All 10 patients survived the operative procedure. Nine patients remained intact neurologically. Renal function returned to baseline in all patients. Average blood replacement was 2.9 units. All patients have experienced an excellent surgical result. The average follow-up is 21.1 months. The technique facilitates a surgical approach to these lesions and appears to be the safest form of vital-organ preservation.

Quality care and cost-effectiveness. An organized approach to problem solving.

The reflexive approach to rising hospital costs and decreased revenue is to balance the budget by curtailing expenses. This places budgetary limitations on personnel, supplies, and equipment and ultimately has an impact on the quality of care. An alternative approach is to modify traditional practice patterns so that quality is preserved and costs are reduced. We reviewed elective class I and II coronary artery bypass graft surgery on a cost basis to identify potential problems. High costs in blood and blood-product usage were identified. An in-depth analysis of practice patterns was conducted, and comparisons were made between data from our hospital and other institutions. Modifications that improved quality and reduced costs were designed. Blood and blood-product usage was reduced from an average of 9.2 U to 3.4 U per case, resulting in an estimated cost avoidance of $111,286 per year. No cost advantage was observed with the use of cell savers, membrane oxygenators, or automated coagulation analysis in these routine short pump run surgeries. Though not cost-effective, the cell saver did allow the salvage of 2 U of blood per case. Mediastinal drainage systems (Sorenson) as well as reeducation regarding the safe, albeit low, hematocrit (no transfusions for hematocrits above 25% [0.25]) were effective in eliminating unnecessary use of potentially dangerous and expensive blood products.

F-Met-Leu-Phe and echo 9 virus interaction with human granulocytes. Changes of cell membrane structure.

Biophysical and biochemical methods were applied for investigation of cell membrane properties of human polymorphonuclear leukocytes (PMNs) exposed to the chemotactic peptide N-formylmethionyl-leucylphenylalanine (f-Met-Leu-Phe) and echovirus type 9, strain A, Barty. Steady-state fluorescence depolarization with diphenylhexatriene demonstrated no gross changes of the total membrane fluidity under the different experimental conditions. However, by means of the monomer-excimer technique with pyrenedecanoic acid (PDA), significant changes of the local membrane structure were detected for both agents. As demonstrated by a higher excimer ratio, the membrane area available for the PDA molecules was restricted by f-Met-Leu-Phe. This effect was dependent on the dose and on the time of interaction of the chemotactic peptide. These experimental findings were explained by the formation of functional receptor units ("activated membrane"). Echo 9 virus exhibited the opposite effect, characterized by a higher ratio of monomers, which also depended on the viral dose and the time of virus-PMN interaction. These virus-induced findings were explained by the dissolution of functional receptor units. Consecutive exposure of the PMNs to f-Met-Leu-Phe and echovirus, or vice versa, demonstrated a virus-predominant effect on the membrane structures.

Report of 37 patients with traumatic rupture of the thoracic aorta.

The records of 37 patients with ruptured thoracic aorta were reviewed. Twenty-six were operated on, and 11 died before they could reach the operating room. Three patients died in the postoperative period: one of massive pulmonary contusion, one of pulmonary insufficiency secondary to fat emboli, and one of massive central nervous system damage. The operative complication of most concern was the anterior spinal syndrome, which occurred in three patients. Twenty-three patients survived with no sequelae from their aortic injury.

Infection of cardiac suture line after ventricular aneurysmectomy. Report of two cases.

Two cases of sepsis following ventricular aneurysmectomy are presented. In both, the source of sepsis was an infected caridac suture line in which Teflon felt strips were used to reinforce the closure. One patient had a pseudoaneurysm and a chronic empyema of the left side of the chest, and the second had a ventriculocutaneous fistula. Early operation with removal of the foreign body is warranted in this major complication of a ventricular aneurysmectomy.