Repeat mitral commissurotomy: long-term results.

Fifty-three patients underwent reoperation for open mitral commissurotomy (OMC) with one (1.9%) in-hospital death. The previous mitral operation was an OMC in 14 patients and a closed commissurotomy in 39. Mean age at the time of repeat OMC was 46 years (range 27 to 64), and NYHA functional class was II in 19 patients, III in 31, and IV in three. Follow-up of the 52 in-hospital survivors at a postoperative interval of 1 to 23 years (mean 10) documented 13 late deaths (mean interval 117 months, range 17 to 209) and survival of 96%, 83%, and 63% at 5, 10, and 15 postoperative years, respectively. Sixteen patients underwent subsequent mitral valve surgery (one OMC and 15 mitral valve replacements) 1 to 223 months after repeat OMC (mean 99), three patients within 5 years of repeat OMC. Reoperation-free survival was 94%, 74%, and 52% at 5, 10, and 15 postoperative years, respectively. Univariate testing did not document any correlation between age, functional class, rhythm, and either survival or reoperation-free survival. When feasible, repeat OMC can afford patients excellent long-term survival and relative freedom from prosthetic valve replacement.

Penetrating injuries of the mediastinum.

This study reviews 47 patients who were operated on for acute penetrating mediastinal wounds. These included 40 cases of cardiac tamponade, 2 mediastinal hematomas, 1 contused myocardium, 3 esophageal wounds, and 1 VSD. Stab wounds were most common (73%) followed by gunshot wounds (23%), and shotgun wounds (4%). When measured, central venous pressure was 15 cm or greater in 28 out of 32 patients (87.5%) with proven tamponade. By contrast, Beck's criteria (distended neck veins, distant heart sounds, hypotension) were noted in only 19 (48%) of 40 cases of tamponade. Emergency room pericardiocentesis resulted in improvement in 20 of 22 cases (91%), affording time for definitive operative therapy. The majority of entrance wounds (85%) occurred in the anterior mediastinal region. Peritoneal lavage in 15 cases yielded 5 true positive, 9 true negative, and 1 false positive tests. Most commonly injured areas were right ventricle (20 patients), left ventricle (11 patients), pericardium (5 patients), and right atrium (4 patients). Isolated esophageal injuries occurred in 3 of 11 gunshot wounds (27%). Complications were numerous (70%) and mortality ranges as follows: GSW 27% SW 15% SGW 0%. Central venous pressure determination and early pericardiocentesis are useful in suspected cases of tamponade. In GSW, an esophagogram is indicated to rule out isolated injury. Median sternotomy is the operative exposure of choice for mediastinal injuries causing cardiac tamponade.

Pigskin as a topical hemostat in arterial, liver, and splenic injuries.

Pigskin made commercially available as porcine-derived dermal collagen (PDC) contains a macrofibrillar collagen surface that initiates platelet aggregation and the intrinsic pathway clotting mechanism. Sterile-irradiated PDC, nonirradiated PDC, and lyophilized PDC were tested for hemostatic effectiveness and cost for hemostasis against each other and Avitene powder, Avitene web, Collastat, Gelfoam, Superstat, and Thrombostat. Canine arterial, liver, and splenic bleeding models were used. In arterial wounds PDC was more effective than Avitene powder, Avitene web, and Gelfoam (p less than 0.05) and also Superstat and Thrombostat (p less than 0.01). First application success rates revealed that PDC agents were more successful overall (85%) than the next three most successful agents: Avitene powder, Avitene web, and Collastat (56%) (p less than 0.01). Differences in success rates of hepatic and splenic wounds were less marked but still significant. Cost of hemostasis was relatively low for PDC agents in comparison to the other agents. PDC is an effective topical hemostatic agent in experimental canine arterial, liver, and splenic wounds when compared with several currently used agents and can also result in cost savings.