Oblique transseptal left atriotomy for optimal mitral exposure.

Twenty patients underwent mitral valve replacement or other surgical procedures within the left atrium with Dubost's transseptal left atriotomy. The left atrium was grossly enlarged in six patients. Exposure was considered to be excellent in 13 patients and poor in only two. One patient (with a second aortic and mitral valve replacement) required a permanent pacemaker after operation, none had a residual shunt at the atrial level, and none required reoperation for bleeding. The Dubost transseptal left atriotomy affords excellent exposure of left atrial structures, is easy to close, and does not increase the prevalence of postoperative rhythm disturbances.

Carotid bruit as a risk factor in aortoiliac reconstruction.

Records of 248 patients undergoing aortoiliac reconstruction for occlusive disease between 1957 and 1975 were reviewed. Carotid bruits were ausculted in 35 patients (14%). Five of the patients with bruits also were thought to have symptoms of transient ischemia. Strokes occurred after operation in four of the 248 patients (1.6%). No patient with a previously noted bruit developed postoperative stroke. Two patients with transient cerebral ischemia and no confirmed bruit before operation did develop postoperative strokes. Cerebral angiography was performed in 18 of the patients with carotid bruits. Two of these patients underwent carotid endarterectomy prior to aortoiliac reconstruction. None of these 18 patients developed strokes following their carotid surgery of aortoiliac reconstruction. A third patient with no bruit but with retinal cholesterol emboli also underwent arteriography and endarterectomy without complication. The results suggest that the asymptomatic carotid bruit alone does not indicate an increased risk of stroke during aortoiliac reconstruction. The authors conclude that their experience does not support prophylactic carotid endarterectomy in the asymptomatic patient prior to aortoiliac reconstruction.

Major hepatic vein ligation necessitated by blunt abdominal trauma.

An unusual case involving avulsion of the middle and left hepatic veins secondary to blunt trauma is presented. Operative management of the injury resulted in ligation of both veins without resection of the parenchyma acutely deprived of venous outflow. The postoperative evaluation and review of the literature indicate that liver tissue will survive acute interruption of a major portion of its venous outflow. This case demonstrates that if after ligating major hepatic vein, the condition of the obstructed parenchyma stabilizes or improves under direct observation and if the condition of the patient does not deteriorate, resection may not be required.