Right aortic arch causing left bronchus obstruction.

A case is reported of a right aortic arch vascular ring composed of a right aortic arch with mirror image branches and a retroesophageal left aortic diverticulum with a left ductus arteriosus that appeared as a possible foreign body aspiration in an infant. This vascular ring caused partial occlusion of the left main bronchus with air trapping. A discussion of right aortic arch vascular rings and vascular anomalies that have caused unilateral lung hyperinflation is included in this report.

Management of penetrating and blunt diaphragmatic injury.

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.

The human tumor clonogenic assay in the treatment of patients with lung cancer.

The human tumor clonogenic assay has allowed the growth of human tumor cells and their testing to chemotherapeutic agents in vitro in a manner much like bacterial antibiotic sensitivities. This report deals with the in vitro test results compared with the in vivo therapeutic sensitivities of human lung cancer. Three hundred twenty-six lung tumor specimens from either primary or metastatic disease were plated using a two-layer technique. Of these, 68% (223) were grown and 41% (133) were applicable to chemosensitivity testing. Only 28 patients were considered for a retrospective analysis of in vitro tumor sensitivity versus in vivo tumor response to chemotherapeutic agents. Among them the percentage of true positives for the assay was 60%, while the percentage of true negatives was 91%. This technique has been encouraging in its initial stages and, with further development, may have an expanding role in the treatment of patients with lung cancer.

Myocardial preservation: effect of venous drainage.

We compared the effect of three methods of venous drainage on myocardial temperature, coronary blood flow as determined with radioactive microspheres, myocardial metabolites (lactate, adenosine triphosphate [ATP], and glycogen), and left ventricular function before, during, and after cardiopulmonary bypass with hypothermic, hyperkalemic cardioplegic arrest. Venous drainage was established in the 6 dogs in Group 1 using a Sarns 51F cavoatrial catheter, in the 7 dogs in Group 2 using two USCI 32F vena caval catheters with tourniquets, and in the 7 dogs in Group 3 using two USCI 32F vena caval catheters without tourniquets. The lowest myocardial temperature was achieved in Group 1 (7.26 degrees +/- 0.45 degrees C compared with 10.45 degrees +/- 0.56 degrees C in Group 2 and 9.78 degrees +/- 0.43 degrees C in Group 3) (p less than 0.001). Myocardial rewarming to 20 degrees C was not significantly different among the groups. Myocardial ATP and lactate levels were similar in all three groups. Myocardial glycogen levels were maintained during ischemia in Group 1 (1,010 +/- 76 mg/dl compared with 686 +/- 39 mg/dl in Group 2) (p less than 0.005). Myocardial blood flow was similar in all groups during the preischemic periods, but during reperfusion a markedly decreased flow was seen in all areas of the myocardium in Group 1 compared with Group 2 (p less than 0.004). Left ventricular function, as measured by the maximum rate of rise of left ventricular pressure, stroke work, and pressure/volume curves, was similar in all groups. We interpret the postischemic blood flow data, glycogen levels, and ventricular compliance differences to suggest that the dogs in Group 1 had less ischemia.

Comparison of flow differences among venous cannulas.

1. Double caval cannulas with snares provide maximum venous decompression, especially of the superior vena cava. Decompression of the right side of the heart is passive and in the heart being perfused requires venting of the right atrium by release of tapes or atrial suction. 2. Double caval cannulas without snares provide good and consistent venous and atrial decompression. The ventricle is decompressed well except when the perfused heart is in the circumflex position. 3. A large single cannula (e.g., USCI 40F) can decompress both the venous system and right side of the heart, although venous and atrial drainage are much less efficient when the heart is in the circumflex position. 4. The Sarns 51F cavoatrial cannula decompressed the venous system as efficiently as the double caval cannulas. In fact, decompression of the atrium and ventricle were consistently much better with the cavoatrial cannula than with any of the other methods. 5. Efficient venous and myocardial decompression using the 51F cavoatrial cannula requires the atrial drainage ports to be positioned in the upper middle section of the atrium. Clinically, the cannula position is correct when both the single and double marking bands on the cannula are outside the atrium.

Effect of venting on myocardial protection by hypothermic cardioplegic arrest.

UNLABELLED: Myocardial rewarming between cardioplegic (CP) infusions is in part attributable to blood circulating through the heart from collateral channels. This experiment was performed to determine if the type of left ventricular (LV) venting affects myocardial temperature (temp) or alters myocardial protection. Twelve dogs underwent cardiopulmonary bypass (CPB) at 37 degrees C and were subjected to 100 min of cardioplegic arrest by intermittent coronary infusion of 300 ml 0-4 degrees C CP solution. Arterial, central venous, left atrial, and LV pressures; cardiac output; systemic, septal (S), right ventricular (RV), and LV temp; myocardial ATP and glycogen were measured; LV pressure/volume curves and LV dp/dt were calculated. Group A (6 dogs) had an LV vent during CPB, and Group B (6 dogs) had the aorta vented via the CP line. CP infusion lowered LV temp to 8 degrees C in Group A vs 13 degrees C in Group B (P less than 0.000002); S temp was lowered to 7 degrees C in Group A vs 11 C in Group B (P less than 0.00007); and RV temp was lowered to 16 degrees C in Groups A and B. Ten minutes after CP, LV and S temp increased to 20-21 degrees C in Groups A and B, and RV temp to 24-25 degrees C in Groups A and B. Twenty minutes after CP all temperatures were the same. Hemodynamics and myocardial metabolic studies were similar in the two groups. CONCLUSIONS: Hearts vented via the LV cooled to a lower temperature vs those vented via the aorta. Venting did not affect myocardial rewarming, myocardial metabolites, or ventricular function.

Comparison of roller pump versus pressurized bag administration of potassium cardioplegic solution.

We sought to determine the relative efficacy of administering cardioplegia by the pressurized bag versus roller pump technique. Fourteen dogs were placed on cardiopulmonary bypass at 30 degrees C and subjected to 2 hours of cardioplegic arrest. Group 1 (7 dogs) was administered cardioplegic solution from a plastic bag under pressure into the ascending aorta every 20 minutes for the 2-hour period, and Group 2 (7 dogs) was given cardioplegia by means of a roller pump. Myocardial temperature decreased in Group 1 to 13.4 degrees C following administration of the cardioplegic solution, and to 13.1 degrees C in Group 2 (not significant). These temperatures were reached in 3.0 minutes in Group 1 and 1.9 minutes in Group 2 (p less than 0.03). Aortic root pressures during cardioplegic infusion were 31 +/- 2 mm Hg in Group 1 versus 46 +/- 2 mm Hg in Group 2 (p less than 0.01). No significant differences between groups were noted in myocardial distribution of cardioplegia, myocardial blood flow or metabolism, or left ventricular hemodynamics. We conclude that both methods of administering cardioplegia lowered myocardial temperature adequately and protected the myocardium for a period of 2 hours in these normal hearts. The roller pump method facilitated faster cooling and produced significantly higher aortic perfusion pressures, however, which may be important in hearts with coronary stenosis.

Growth of lung cancer in a human tumor clonogenic system.

The human tumor clonogenic assay system has enabled human cancer cells to be grown in vitro and has the potential of providing chemosensitivity results in a manner much like bacterial antibiotic sensitivities. The in vitro growth of human lung cancer cells using this assay has not been previously reported. Over the past 2 years, 3,100 specimens have been plated by means of the two-layer agar technique as developed by Hamburger and Salmon, 302 of which were primary or metastatic lung tumors. Histologic, karyotypic, and nude mice studies confirmed that the colonies were composed of tumor cells. Growth rates (significant growth being greater than or equal to 5 colonies per plate) and plating efficiencies (the number of colonies grown per number of nucleated cells plated) were tabulated for each lung tumor cell type for primary, metastatic, and malignant pleural and pericardial fluids. The average overall growth rate was 199 of 302 (66%)--17 of 19 (90%) large cell carcinomas, 46 of 71 (65%) oat cell carcinomas, 57 of 91 (63%) adenocarcinomas, (* = p less than 0.05 when compared to large cell carcinomas) *40 of 68 (59%) squamous cell carcinomas, *and 39 of 53 (74%) of an undetermined cell type were grown. The average plating efficiency was 0.0236%. In primary tumors, large cell carcinomas had a plating efficiency of 0.0348%, adenocarcinoma 0.0247%, *oat cell 0.0224%, *and squamous cell 0.0113%.* It was concluded that lung tumor cells can be grown in vitro from 66% of lung tumor specimens. The highest growth rates and plating efficiencies were found in large cell carcinomas and the lowest rates in squamous cell carcinomas. This technique may provide a means of testing for the sensitivity of patients' lung tumor cells to various chemotherapeutic agents.