Thoracic organ donor characteristics associated with successful lung procurement.

PURPOSE: A shortage of suitable donors is the major impediment to clinical lung transplantation. The rate of lung recovery from potential donors is lower than that for other organs. The purpose of this study was to evaluate what factors could be modified to improve the rate of cadaver lung recovery. METHODS: We performed a retrospective review of records from all thoracic organ donors procured by the California Transplant Donor Network between 1 January 1995 and 31 May 1997 (251 donors) to determine which donor management factors were associated with an increased likelihood of successful lung procurement. RESULTS: There were 88 lung donors (L) and 163 donors from which hearts but no lungs were procured (H). Longer time to donor network referral was associated with a reduced chance for successful lung procurement. Donor age, cause of death, and time of admission were not important factors. Most donors in this study had an acceptable A-a gradient at admission to the hospital but lung function deteriorated in group H. Corticosteroid usage and initially clear breath sounds were independent predictors of successful procurement by multivariate analysis. CONCLUSIONS: Early contact with the donor referral network, and corticosteroids may help to improve the lung procurement rate from potential donors.

Collection of process data after cardiac surgery: initial implementation with a Java-based intranet applet.

BACKGROUND: Using a Java-based intranet program (applet), we collected postoperative process data after coronary artery bypass grafting. METHODS: A Java-based applet was developed and deployed on a hospital intranet. Briefly, the nurse entered patient process data using a point and click interface. The applet generated a nursing note, and process data were saved in a Microsoft Access database. In 10 patients, this method was validated by comparison with a retrospective chart review. In 45 consecutive patients, weekly control charts were generated from the data. When aberrations from the pathway occurred, feedback was initiated to restore the goals of the critical pathway. RESULTS: The intranet process data collection method was verified by a manual chart review with 98% sensitivity. The control charts for time to extubation, intensive care unit stay, and hospital stay showed a deviation from critical pathway goals after the first 20 patients. Feedback modulation was associated with a return to critical pathway goals. CONCLUSIONS: Java-based applets are inexpensive and can collect accurate postoperative process data, identify critical pathway deviations, and allow timely feedback of process data.

Late outcomes of open heart surgery in patients 70 years or older.

BACKGROUND: The purpose of this study is to examine the long-term survival and quality of life, including the influence of comorbidities, in patients 70 years of age and over after open heart surgery. METHODS: This was a retrospective study of 401 consecutive patients, who were 70 years of age or older at the time of surgery. Survival and quality of life of these patients were measured at 6- to 8-year follow-up. RESULTS: The 5-year survival rate was 85%, and was comparable with the age- and gender-matched West Virginia population. Survival declined with increasing preexisting comorbidities. Of the 176 respondents completing the quality of life (SF-36) survey, most scores were similar to or substantially better than the US population normative scores for individuals 70 years of age or older. CONCLUSIONS: Survival rates vary by presence or absence of specific comorbid conditions. Quality of life in the appropriately selected elderly after open heart surgery appears to be similar to the US population normative scores.

Giant tumors of the chest: preoperative embolization and resection.

Giant tumors of the chest are rare. These tumors comprise a spectrum of disease from benign lesions to highly aggressive malignant tumors with cells of origin in the pleura, pulmonary parenchyma, blood vessels, thymus, and connective tissues. We report four cases of giant tumors of the thorax treated with preoperative arterial embolization followed by complete surgical resection. Their diagnostic and treatment courses, imaging, and pathology are described.

A 5-year experience with surgical repair of atrial septal defect employing limited exposure.

BACKGROUND: There has been a trend in recent years towards less invasive therapy for many congenital cardiac malformations. For the past 5 years, we have employed a technique of limited surgical exposure when repairing atrial defects within the oval fossa. METHODS: Over the 5-year period from July 1992 to August 1997, 115 consecutive patients underwent surgical repair of an isolated atrial septal defect in the region of the oval fossa by a single surgeon. The patients had a limited midline skin incision starting at the line of the nipples and extending inferiorly across 2 to 3 intercostal spaces. A partial sternotomy was performed, sparing the manubrium. Standard instruments and cannulation techniques were used for cardiopulmonary bypass and fibrillatory arrest. RESULTS: There were no deaths and no major complications. The median time to extubation after leaving the operating room was 3 hours (30 minutes to 8 days). Mediastinal drains were removed the morning after surgery. The median stay in the intensive care unit was 7 hours (3 hours to 10 days), and patients were discharged from the hospital a median of 4 days postoperatively (2 to 23 days). CONCLUSIONS: This approach using limited exposure can be applied safely without any new instruments and without peripheral incisions or sites of vascular access, while providing a comfortable exposure for the surgeon and achieving a cosmetically superior result for the patient.

A case of relapsing polychondritis involving the tragal and the conchal bowl areas with sparing of the helix and the antihelix.

We describe a 65-year-old white man with a 21-year history of recurrent, afebrile episodes of painful, tragal, conchal bowl and eyelid swelling accompanied by occasional conjunctivitis. The remainder of the auricle was not involved. Episodes were both self-remitting and responsive to intramuscular steroid injections. Cutaneous and cartilaginous tissues were examined histologically following a therapeutic debulking procedure. The histologic features included dermal edema, vascular dilatation, and small vessel inflammation with a dense polymorphous inflammatory infiltrate rich in eosinophils. Perichondrial inflammation and cartilage degeneration with fibrosis were characteristically observed. Bacterial cultures demonstrated normal flora. This case fulfills the revised diagnostic criteria of relapsing polychondritis. It demonstrates an unusual presentation within the disease spectrum of relapsing polychondritis with tragal and conchal bowl involvement and sparing of the helix and the antihelix.

Maze procedure and homograft replacement of a rheumatic mitral valve.

A 64-year-old woman presented with congestive heart failure due to severe mitral valve stenosis and chronic atrial fibrillation. A Maze III procedure was performed, and the mitral valve replaced with a mitral homograft. Postoperatively, the patient regained normal sinus rhythm, had trivial mitral regurgitation, regained her atrial transport function, and had improved myocardial function.

Repair of secundum atrial septal defect: limiting the incision without sacrificing exposure.

A simple and effective technique for repair of secundum atrial septal defect is described. The heart is exposed through a limited midline skin incision and partial sternotomy, and the atrial septal defect is closed through a right atriotomy with ascending aortic and dual venous cannulation. This approach achieves a cosmetically superior result with standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions.

Pulmonary metastases of endocrine origin: the role of surgery.

PURPOSE: To determine the clinical course and outcome of patients undergoing pulmonary resection for metastatic endocrine tumors. METHODS: Retrospective review of 47 patients with known endocrine tumors and pulmonary metastases who were evaluated for surgical resection between 1975 and 1996. RESULTS: Tumors evaluated included the following: carcinoid (16), thyroid (12), pancreatic adenocarcinoma (10), adrenocortical carcinoma (6), pheochromocytoma (2), and parathyroid (1). Thirty-three patients were asymptomatic. Hormone secretion was noted in five patients. Twenty-five patients, who had isolated lung metastases, good control of the primary tumor, and no medical contraindication had surgical resection. The number of pulmonary nodules was not a limiting factor as long as all disease could be resected with adequate residual pulmonary function. CT was successful in directing resection in all patients. Twenty-six operations were performed in 25 patients and 22 patients were treated medically. Wedge resection was performed for lesions <2 cm (15), and lobectomy for larger or multiple nodules (10). Four patients had bilateral nodules resected. There was no operative mortality and no major complications. Actuarial 5-year survival was 61% for surgically treated patients. Independent predictors of poor survival included positive mediastinal lymph nodes at time of surgery (p=0.004) and shorter disease-free interval (p=0.01). At a median of 6.7+/-1.2 years, six patients have developed radiographic appearance of a recurrence. A single patient with recurrent Hürthle cell cancer has had a successful reresection. The remaining patients have received chemotherapy. No patient with pancreatic carcinoma or adrenocortical carcinoma was a candidate for resection. All medically treated patients died within 6 months. CONCLUSION: Patients with endocrine tumors and pulmonary metastases are usually asymptomatic, their conditions are diagnosed accurately with CT, and they can achieve long-term survival comparable to other tumors (sarcoma) after pulmonary metastasectomy. CLINICAL IMPLICATIONS: Patients with carcinoid, thyroid, pheochromocytoma, and parathyroid tumors with pulmonary metastases should undergo surgical resection if there is the following: (1) no evidence of extrathoracic disease; (2) good control of the primary tumor; (3) no medical contraindications for surgery; and (4) pulmonary function that can tolerate resection of all documented disease. The role of adjuvant chemotherapy in patients with positive lymph nodes needs further study.

Cardiac valve surgery in octogenarians: improving quality of life and functional status.

BACKGROUND: Although cardiac valve procedures are being performed more frequently in the elderly, long-term functional outcomes have not been well characterized. OBJECTIVE: To evaluate changes in quality of life and functional status in octogenarians after cardiac valve surgery. DESIGN: Retrospective medical record review and patient telephone interview. Median follow-up 30 months (range, 6-95 months). SETTING: Tertiary care university hospital. PATIENTS: Octogenarians undergoing cardiac valve surgery (N = 61; mean age, 83.5 years; range, 80-89 years). INTERVENTIONS: Forty-seven patients had aortic valve replacement, 14 had mitral valve replacement and/or repair, and 27 had a combined procedure with coronary artery bypass grafting. OUTCOMES: Actuarial survival, morbidity, length of hospital stay, and discharge disposition were evaluated. Functional status, using the New York Heart Association classification, and Karnofsky performance status were evaluated preoperatively and postoperatively at 1 and 3 months after hospital discharge. RESULTS: Operative (<30 days) mortality occurred in 7 (11.4%) of 61 patients. Preoperative intensive care unit stay (P < .001) and New York Heart Association class 4 (P < .02) were independent predictors of early death by multivariable analysis. Among hospital survivors, there were no major complications in 34 patients (63%), and this group had a mean (+/- SD) postoperative hospital stay of 12.2 +/- 5.5 days. Twenty patients (37%) incurred significant complications, the most common of which were bleeding, pneumonia, and renal insufficiency. The mean (+/- SD) postoperative hospital stay in this group was 25 +/- 17 days. Although significant complications were associated with an increased postoperative stay, this was not predictive of disposition to a skilled nursing facility or the final score on the postoperative Karnofsky performance scale. Actuarial survival was 85% at 1 year and 66% at 5 years. Patients with perioperative complications had significantly decreased actuarial survival by the Cox proportional hazards regression model (P < .001). Among hospital survivors, the score on the Karnofsky performance scale 1 month after discharge had improved 50% from a preoperative median score of 30% (severely disabled, requiring special care) to a postoperative median score of 80% (being able to perform normal activity with only moderate symptoms). The New York Heart Association classification improved a median of 2 classes in this group. These benefits were sustained at the 3-month follow-up. CONCLUSION: Although greater resource expenditure is required for the initial perioperative convalescence, octogenarians can be expected to have an excellent functional outcome and long-term performance status after cardiac valve surgery.

Giant solitary fibrous tumor of the pleura.

Solitary fibrous tumors of the pleura are rare. Approximately 600 cases have been described in the literature. We report a case of a young man with a giant solitary fibrous tumor of the pleura that filled his entire left hemithorax and anterior mediastinum and extended into the right side of his chest. The diagnostic modalities employed, the operation, and the postoperative management resulting in complete resection of the tumor and full lung reexpansion are described.

Magnesium sulphate versus diazepam in the management of eclampsia.

This clinical trial was conducted to compare the anticonvulsant response of magnesium sulphate and diazepam in the management of eclampsia. The study was carried out at the eclampsia unit of Dhaka Medical College Hospital during the period from October, 1995 to January, 1996. Two hundred consecutive admitted patients were recruited for the study and randomly assigned to two treatment groups: magnesium sulphate and diazepam. One hundred patients received injection magnesium sulphate and another one hundred received injection diazepam. All patients of both the group were matched for baseline characteristics. Convulsion was controlled in 95% of the patients of magnesium sulphate group and 74% of the patients of diazepam group (p < .0005). The mean controlling time is also significantly lower in magnesium sulphate group than diazepam group (8.50 hours vs 9.39 hours). Patients of magnesium sulphate group regain consciousness much earlier (mean time 20.62 hrs.) than the patients of diazepam group (mean time 40.62 hrs.). No significant difference was observed in controlling blood pressure and foetal outcome. The study finding shows that magnesium sulphate has some advantage over diazepam in controlling convulsion and regaining consciousness. If magnesium sulphate can be made available in the market by local production it may be recommended to use this drug in the primary health care without any hazzard before referring to other hospital.

Treatment of aortic dissection and ruptured abdominal aneurysm with coronary bypass.

We present a patient with a descending aortic dissection and contained rupture of a large abdominal aortic aneurysm with a history of inferior myocardial infarction and right coronary occlusion. The technique of combined repair of the descending thoracic aortic dissection with replacement of the ruptured infrarenal abdominal aorta and coronary artery bypass grafting is described.

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: perioperative (30-day) results.

PURPOSE: The early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared. METHODS: Three hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups. RESULTS: The incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP.

Sleep apnea syndrome: A report of 20 Saudi patients.

Patients with sleep apnea syndrome (SAS) suffer considerable morbidity and increased mortality. The most common symptoms of SAS include excessive daytime sleepiness, nocturnal breath cessation, snoring and gasping sounds. We reviewed the characteristics of 20 Saudi patients with sleep apnea (15 males, five females) who were studied at our tertiary care center in 1992 and 1993. The ages ranged from 15 to 61 years. All were obese. Two each were acromegalic and hypothyroid. Hypertension was noted in seven (35%) patients and one had symptomatic bradycardia. Two (10%) patients presented with recurrent pulmonary emboli and two were involved in multiple road traffic accidents as a result of falling asleep while driving. One male student had poor performance at school. Three patients were known to have chronic obstructive airway disease. Six males and one female were hypercapnic (PCO2; > 6.1 kPa) while 10 patients had hypoxemia (paO2; < 8.0 kPa). Four patients were polycythemic. Pulmonary function tests showed that 15 (75%) had restrictive patterns, three (15%) had obstructive patterns and two (10%) had mixed patterns. A "saw-tooth" pattern was seen in the inspiratory limb of a flow-volume curve in four patients. Daytime polysomnography showed that eight had obstructive sleep apnea, four had central sleep apnea and six had mixed type sleep apnea. Both hypothyroid patients improved with replacement therapy; one acromegalic patient and one patient with tracheal stenosis responded to specific treatment. Nasal positive airway pressure machine (BIPAPtrade mark Resperonics Inc) was effective in relieving apnea and reducing symptoms in five patients. None of the patients were able to lose a substantial amount of weight. All these patients were investigated extensively at different places prior to establishing the diagnosis.

Nasal or oral oil application on infants: a possible risk factor for adult bronchiectasis.

Lipid pneumonia has been observed in infants exposed by inhalation of oil or butter applied into the nose or throat as part of an old custom. We performed a case-control study to test the hypothesis, that this ancient tradition may be a predisposing factor to bronchiectasis. A case group of 59 patients with bronchiectasis and three control groups -46 patients with COPD, 32 asthmatics, and 71 healthy Saudis-were questioned about possible risk factors of bronchiectasis including nasal or oral application of oil/butter at infancy. The risk of witnessed exposure to this old folk remedy was significantly higher among the cases than the controls (OR = 3.9 (1.7-8.8), (95% confidence interval) p < 0.001). Application of oil or butter into the nasal or oral cavity of infants may be a risk factor for bronchiectasis.

Active compression-decompression resuscitation: effects on pulmonary ventilation.

This investigation was designed to test the hypothesis that active compression-decompression resuscitation is able to independently provide improved levels of minute ventilation when compared to high-impulse manual cardiopulmonary resuscitation (CPR). Eight adult beagles (10-15 kg) were studied after induction of ventricular fibrillation. Single 1-min CPR trials were performed while arterial blood gases and minute ventilation were monitored. ACD and high-impulse CPR were performed sequentially, in random order at compression rates of 120/min, 1.5- to 2.0-inch compression depth and 50% duty cycle. Minute ventilation averaged 3.6 +/- 0.77 1 during high-impulse CPR and increased to 4.9 +/- 0.88 1 during ACD CPR. No difference was observed in arterial blood pH, PCO2, or PO2 when ACD was compared to high-impulse CPR. We conclude that ACD CPR provides improved levels of minute ventilation when compared to high-impulse manual CPR in this canine model of cardiac arrest. Improved minute ventilation may contribute to the mechanism of improved cardiopulmonary hemodynamics reported in previous investigations of ACD CPR. Further investigation is warranted to determine the effects of ACD CPR on pulmonary ventilation in human subjects after cardiac arrest.

Bronchial carcinoid tumor: experience over 20 years.

Nineteen cases of bronchial carcinoid tumor seen over 20 years in a 1,000-bed, tertiary medical center were retrospectively reviewed. They consisted of 0.4 per cent of all patients with lung tumors. Initial complaints were hemoptysis, persistent pulmonary infection, chest pain, and diarrhea. Two of the five patients with atypical carcinoid tumors came to the hospital with diarrhea as a result of their chemically active tumors. However, seven patients (36%) were asymptomatic and were diagnosed after an abnormal chest radiograph was noted incidentally. Of 13 patients receiving bronchoscopic examination, 9 (69%) had visible tumors. Bronchial biopsy was performed in 7 patients and led to a diagnosis in all seven. Significant bleeding was noted in 3 patients as a result of biopsy. Lobectomy was the most common surgical procedure in this series. Follow-up of these patients was from 6 months to 15 years. The general outcome for patients with typical carcinoid was good. However, all patients with atypical carcinoid died as a result of dissemination.