Surgical experience with left ventricular free wall rupture.

BACKGROUND: Autopsy studies reveal that left ventricular free wall rupture (LVFWR) accounts for 7% to 24% of deaths after myocardial infarction. The condition occurs up to 10 times more often than papillary muscle or interventricular septal rupture. A high index of suspicion must be maintained to differentiate LVFWR from infarct extension, cardiogenic shock, pulmonary embolus, and even Dressler's syndrome. METHODS: Since 1980, we have operated on 18 patients with LVFWR. Fourteen patients had experienced "blow-out" rupture associated with cardiogenic shock. Four patients had "stuttering" ruptures, a less spectacular occurrence. Echocardiography was the most important diagnostic tool. Repair was performed, usually using infarctectomy and direct suture closure. RESULTS: Eleven patients (61%) died after operation, 4 patients as a result of rerupture 1 to 12 hours after operation. Recently, we have used a "patch/glue" technique to repair ruptures in 2 patients. We believe this technique is superior to direct suture closure in preventing rerupture. There have been 7 long-term survivors (39%) from 6 months to 15 years. CONCLUSIONS: Left ventricular free wall rupture is not always sudden and dramatic. Yet, the operating staff must be willing to race to the operating room even with the patient in full resuscitation. Echocardiography is the most sensitive and efficient diagnostic tool. All rupture sites should be aggressively repaired, possibly combining direct suture and patch/glue techniques.

Simultaneous aortic reconstruction and bilateral renal revascularization. Is this a safe and effective procedure?

Between 1982 and 1987, 32 patients with severe aortorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56%) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3%). Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 +/- 1.18 mg/dl preoperatively and 1.65 +/- 0.48 mg/dl postoperatively (p less than 0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/dl), mean SC was 3.90 +/- 0.85 mg/dl before and 1.79 +/- 0.69 mg/dl after operation (p less than 0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.

Distal bypass for limb salvage in very elderly patients.

During the last 3 1/2 years, 40 bypasses to a tibial or peroneal artery (distal bypass) were performed for severe leg ischemia in 34 patients who were 80 years of age or older (range, 80-91; mean, 85). The operative mortality rate was 5 per cent. Cumulative life-table limb salvage rates for the 40 extremities were 91 per cent at 1 year and 81 per cent at 3 years. Graft patency rates at 1 and 3 years were 88 per cent and 56 per cent, respectively. Survival rates for the 36 patients were 91 per cent and 58 per cent at 1 and 3 years, respectively. Among 134 patients younger than 80 years who underwent 142 distal bypasses during the same 3 1/2-year period, no operative deaths occurred. In this younger group, cumulative life-table rates at 1 and 3 years were 89 per cent and 89 per cent, respectively, for limb salvage, 86 per cent and 85 per cent, respectively, for graft patency, and 93 per cent and 78 per cent, respectively, for survival. There were no statistically significant differences in these figures for the younger group when compared with corresponding figures for the older group. Among the 36 very elderly patients who underwent distal bypass for limb salvage, 24 patients (67%) with 25 revascularized limbs are alive and have a salvaged, functional extremity after follow-up as long as 41 months (mean, 21 months). These results suggest that an aggressive approach using distal bypass is warranted for limb salvage in very elderly patients.

Sudden blowout rupture of the myocardium after infarction: urgent management. Report of four cases.

Blowout rupture of the myocardium is intended to describe a syndrome of sudden hemodynamic deterioration after myocardial infarction. Characterized by abrupt hypotension, cardiac tamponade, or electromechanical dissociation, it is an emergency of the first order with no time for cardiac catheterization. Frequently one must make the diagnosis and race for the operating room almost simultaneously. We have managed four such patients, one with a ruptured false aneurysm and three patients with acute rupture of recently infarcted myocardium. All patients were placed on femoro-femoral bypass initially and all survived operation. Two patients died in the hospital of irreversible brain damage and two are long-term survivors. A high index of suspicion, a well-coordinated operating team, and a willingness to take the bold step to the operating room, frequently on the basis of clinical judgment alone, are necessary to salvage patients with this syndrome.

Pulmonary pseudolymphoma.

Pseudolymphomas of the lung are extremely rare with approximately 30 cases reported in the literature. Histologically it may be impossible to distinguish a benign pseudolymphoma from a malignant lymphoma. Immunoperoxidase staining has been proposed to help predict the benign or malignant potential of these conditions. Results thus far have been inconclusive, but a monoclonal pattern has tended to predict malignant potential. We have reported a pulmonary pseudolymphoma that failed to stain with the immunoperoxidase technique due to improper tissue fixation. After four years of clinical follow-up, the patient remains disease free.

Endobronchial non-Hodgkin's lymphoma.

Four patients with endobronchial non-Hodgkin's lymphoma are presented. Although endobronchial Hodgkin's disease is not uncommon, endobronchial non-Hodgkin's lymphoma is extremely rare. All patients had disseminated disease at the time of their endobronchial involvement. Chest radiographs revealed hilar masses and/or varying degrees of lobar collapse in each case. Two had multiple endobronchial lesions. Three patients died within two years of the diagnosis of endobronchial disease. The fourth patient is currently undergoing chemotherapy for disseminated disease. Lobar collapse in a patient with non-Hodgkin's lymphoma should include endobronchial involvement in the differential diagnosis. Therapy should include chest radiation in an attempt to re-expand the collapsed lung lobes and systemic chemotherapy. Prognosis is guarded due to disseminated disease at the time of diagnosis.

Pulmonary arteriovenous fistula simulating a vanishing tumor.

In a patient with an asymptomatic left upper lobe pulmonary arteriovenous fistula, preoperative chest roentgenograms simulated bronchogenic carcinoma, but no overt feeding vessel was demonstrated. Intraoperatively no lesion could be palpated. Postoperative evaluation revealed a pulmonary arteriovenous fistula. This entity should be considered in the differential diagnosis of single or multiple pulmonary nodules. Careful review of chest roentgenograms for feeding arteries, or draining veins, and observation under fluoroscopy for changing size will aid in diagnosis, and potentially avoid bronchoscopy and possible transbronchoscopic biopsy of these vascular lesions.