Ross procedure for complex left ventricular outflow tract obstruction.

BACKGROUND: Complex left ventricular outflow tract (LVOT) obstruction in children continues to pose a significant therapeutic challenge to cardiac surgeons. The Ross procedure, in combination with resection of subaortic stenosis or a Konno type septal incision, is an important option for these difficult patients. METHODS: Recently two children aged 14 and 5 years with LVOT obstruction involving combined subaortic and valvar stenosis underwent surgical correction using the pulmonary autograft. Clinical presentation, operative technique, outcome and intermediate follow-up are detailed. RESULTS: One patient had resection of an isolated subaortic membrane in combination with a pulmonary autograft and the second a Ross Konno procedure. Postoperative hospital stays were without complication. Both patients were discharged at 5 days and have no significant obstruction nor semilunar valve insufficiency at 3 years' follow-up. CONCLUSIONS: Pulmonary autografts can be used in combination with resection of subaortic tissue or a septal incision for reconstruction of complex left ventricular outflow tract obstruction. This technique renders excellent short term valve function, relief of obstruction, avoids anticoagulation and provides potential for future growth.

Pericardial tamponade and massive pleural effusion complicating orthotopic heart transplantation.

Pericardial and pleural effusions occur commonly after open cardiac procedures. However, the combination of tamponade and massive pleural effusion is not often observed. We present a case of such a patient who received an orthotopic heart transplant in a setting of previously diagnosed systemic sarcoidosis. Treatment ultimately required the creation of a pericardial window and chemical pleurodesis.

Active venovenous bypass of the retrohepatic vena cava utilizing two atrial cannulae.

Injuries to the hepatic veins and retrohepatic vena cava have a high mortality due to uncontrolled hemorrhage. Successful repair may necessitate interruption of flow through the retrohepatic vena cava. Active bypass of the area is then needed to provide adequate venous return. Published methods for active bypass require cannulation of axillary and femoral veins in addition to clamping of the vena cava above and below the liver, often with limited exposure and significant risk. This report describes active bypass of the retrohepatic vena cava utilizing two right atrial cannulae. The simplicity of establishing the bypass together with the excellent exposure allowed repair of a bullet wound of the vena cava in one patient and the orderly performance of a left trisegmentectomy for a huge hepatic tumor in a second patient.

The gene expression index c-myc x E2F-1/p21 is highly predictive of malignant phenotype in human bronchial epithelial cells.

Recent methodological developments allow expression measurement of many genes simultaneously, thereby revealing patterns of gene expression that can be related to phenotype. We hypothesized that through the use of such methods we could identify patterns of gene expression associated with the malignant phenotype in human bronchial epithelial cells (BEC). To test this hypothesis, a recently developed quantitative reverse transcriptase polymerase chain reaction method was used to assess simultaneously expression of 15 genes mechanistically associated with cell-cycle control (c-myc, E2F-1, p21, rb, PCNA, cyclin D2, cyclin D3, cyclin E, cdc2, CDK2, CDK4, mad, max p21, max p22, and p53) in normal cell cultures from five individuals and in nine different malignant BEC lines. Relative to the mean expression levels in cultured normal cell populations, expression of c-myc, E2F-1, PCNA, cyclin E, and CDK4 messenger RNA (mRNA) were significantly increased and expression of p21 and p53 mRNA were significantly decreased in one or two, but not all three subtypes (squamous, adenocarcinoma and small cell) of carcinoma cell lines evaluated. No single cell-cycle control gene discriminated all three subtypes from normal cell populations. In contrast, the gene expression index c-myc x E2F-1/p21 separated all carcinoma cell lines from all normal cell populations initially evaluated. This malignancy index was validated in an additional three cultured normal BEC and three carcinoma cell lines, as well as three pairs of matched primary normal bronchial epithelial and primary bronchogenic carcinoma samples, and three pairs of matched primary normal lung parenchyma and primary bronchogenic carcinoma tissue. Again, the c-myc x E2F-1/ p21 index successfully discriminated all cultured and primary normal from malignant samples and thereby had a predictive value of 1 (no false positives and no false negatives). We hypothesize that because of functional mutations in cell-cycle regulatory genes (e.g., p53 and/or rb), cells lose the ability to maintain a pattern of gene expression mechanistically associated with normal, division-limited homeostatic equilibrium. Because the c-myc x E2F-1/p21 gene expression index has high specificity for malignant tissue, it will allow confirmation that there is a significant amount of tumor tissue present in small (e.g., fine-needle) biopsy specimens prior to evaluating them for expression of other genes, such as those involved in chemoresistance or radioresistance. In addition, the goal of most gene therapy efforts is to alter levels of gene expression quantitatively. This index and others derived in a similar manner may better define potential gene therapy targets as well as response of targeted genes to therapy.

Preliminary results of neoadjuvant paclitaxel and carboplatin in the treatment of early stage non-small cell lung cancer.

The purpose of this study is to determine the feasibility of delivering neoadjuvant paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and carboplatin to patients with clinical early stage (stage I and II) non-small cell lung cancer. Although neoadjuvant chemotherapy appears to prolong survival in patients with stage IIIA non-small cell lung cancer, several studies have demonstrated an increase in perioperative mortality associated with this approach. This study is designed to address whether three cycles of paclitaxel (200 mg/m2/3 hour, day 1) and carboplatin (area under the concentration-time curve 5, day 2) can be given preoperatively to patients with clinical stage I and II non-small cell lung cancer and to assess the associated toxicities, pathologic response rate, disease-free survival, and overall survival of this group of patients. Thus far, five patients have been enrolled. Three have successfully undergone resection, with no perioperative complications noted. One patient had a pathologic complete remission and two had pathologic partial remissions. Preliminary results indicate that this approach is well tolerated and results in major tumor response.

A late sternal wound infection caused by hematogenous spread of bacteria.

A 56-year-old man presented with a sternotomy wound infection 6 months after coronary artery bypass grafting. The organism responsible was group B beta-hemolytic Streptococcus. This organism was simultaneously cultured from an infected diabetic ulcer on the patient's foot as well as from a total knee prosthesis. The Streptococcus apparently spread hematogenously to the sternum, an extremely rare cause of sternotomy wound infection.

Placement of an endotracheal tube in the short tracheal stump.

Placement of an endotracheal tube in the short tracheal stump, such as after a mediastinal tracheostomy, can be a difficult task. The tube may easily slide into the right main bronchus or slip out of the trachea completely. We have described a method for securing such an airway for ventilation during general anesthesia.

Method for assuring accuracy of bone biopsy using technetium 99 bone scan.

In the clinical staging of malignancy, radionuclide bone scanning has played an increasingly important role. An area of increased radionuclide uptake on technetium 99 (99Tc) bone scan which is not visualized on skeletal radiographs can present a significant diagnostic dilemma. This can be further compounded by nonrevealing percutaneous or open surgical biopsies. The authors present a method of definitively localizing the appropriate site for bone biopsy in such circumstances. Use of this technique has allowed us to ascertain that isolated rib lesions in two patients with extra-osseous malignancies were not due to metastatic disease.