Transsternal radical thymectomy for myasthenia gravis: a 15-year review.

Thymectomy is an accepted therapeutic modality for patients with myasthenia gravis. The selection of patients for operation and the surgical approach are controversial. We reviewed 52 patients (aged 18 months to 82 years; mean age, 34 years) treated with transsternal radical thymectomy between 1972 and 1987. Patients were symptomatically staged according to the modified Osserman classification. There was one hospital death and postoperative follow-up was obtained on 51 patients. Improvement after thymectomy was observed in 3 of 11 patients (27%) in Osserman stage I, 16 of 25 patients (64%) in Osserman stage IIA, and 13 of 15 patients (86%) in combined Osserman stages IIB, III, and IV. Preoperative Osserman stage, patient sex, and thymic histology correlated with postoperative clinical response. Transsternal radical thymectomy is effective therapy for myasthenia gravis. Sustained improvement is obtained in patients with moderate and advanced disease. The majority of patients with ocular disease do not benefit from operation.

Digoxin prophylaxis following coronary artery bypass surgery.

The effect of the postoperative administration of digoxin to patients undergoing coronary artery bypass surgery on the incidence of supraventricular arrhythmias was studied. Patients were randomly assigned to a control group (n = 51) or digoxin group (n = 47) on a prospective basis. Patient characteristics were similar in both groups, and no patients were receiving digoxin therapy preoperatively or other antiarrhythmic medications. All patients had normal systolic ejection fractions, renal function, and hepatic function. Eight patients (16%) in the control group developed postoperative arrhythmias while seven patients (15%) in the digoxin group developed supraventricular arrhythmias. This difference was not significant. Two patients in the digoxin group developed digoxin-induced arrhythmias, and two other patients experienced digoxin-related nausea and vomiting, which were resolved with discontinuation of the drug. The postoperative administration of digoxin to patients undergoing coronary artery bypass surgery had no effect on the incidence of supraventricular arrhythmias. The prophylactic use of digoxin therapy in this patient population is not recommended unless there is a history of arrhythmias responsive to digoxin therapy.

Pleural effusion as a complication of solitary eosinophilic granuloma of the rib.

A 57 year old man presented with a two week history of right sided chest pain. An admission chest x-ray examination revealed a 2 by 1 cm. lytic lesion of the ninth right rib and right sided pleural effusion. The patient underwent a right thoracotomy during which 700 cc. of blood tinged pleural fluid was drained and a 10 cm. segment of the right ninth rib was excised. The rib lesion showed classic features of eosinophilic granuloma of bone. Cytologic examination of the pleural fluid disclosed abundant histiocytes and eosinophils, consistent with eosinophilic granuloma invading the pleural space. This case is unusual because of the age of the patient and the development of a pleural effusion secondary to the rupture of the tumor into the pleural cavity, the latter not previously reported in the literature.

Use of nitroprusside for control of pulmonary hypertension in repair of ventricular septal defect.

After repair of ventricular septal defect (VSD) in a 3-year-old child with markedly elevated pulmonary vascular resistance (PVR), sodium nitroprusside was administered by intravenous infusion at 3.0 microgram per kilogram of body weight per minute. Nitroprusside was effective in reducing pulmonary artery pressure and increasing systemic blood pressure in the intraoperative and early post-operative periods. It is suggested that nitroprusside may facilitate the perioperative management and enhance the early survival in patients with increased PVR secondary to a VSD.

Transverse femoral arteriotomy for intraaortic balloon insertion.

A technique for intraaortic balloon placement employing a transverse femoral arteriotomy is described. After balloon removal, the arteriotomy can be closed primarily. Avoidance of retained graft material or use of a vein patch reduces the likelihood of vascular complications.

Warfarin induced necrosis of the skin.

Necrosis of the skin is a rare complication of oral anticoagulation therapy by coumarin congeners. Three males receiving prophylactic warfarin anticoagulation therapy following cardiac valve replacement and one female similarly receiving anticoagulation drugs because of bilateral deep thrombophlebitis associated with carcinoma of the pancreas had typical skin necrosis develop. The lesions passed rapidly through stages beginning with pain, edema, erythema and petechiae. Ecchymoses followed in the localized area with a large bullae containing deep red fluid. Biopsy of the skin revealed involvement of the dermovascular loops with localized necrosis from extensive occlusion of dermal capillaries and venulae by fibrin thrombi. There was red cell extravasation, but inflammatory changes were inconstant. In the patients, in our study, the involvement ranged from small localized lesions of the trunk to extreme extensive skin involvement of both legs with full thickness necrosis in areas. This condition is not dose related nor the result of simple hypoprothrombinemia. It appears to be a conditioned and localized toxicity, although hypersensitivity has not been excluded. Once the diagnosis is made, orally administered anticoagulant drugs must be stopped immediately, and heparinization may be beneficial in confining the process.

Intermuscular abdominal implantation of permanent pacemakers in infants and children.

Pacemaker implantation in infants and young children presents technical problems because of the relatively large size of the units. Various implantation sites have been employed to avoid the problems of unsightliness, migration, skin necrosis with infection, and patient discomfort. We are presenting a new technique which obviates these difficulties. The pacemaker generator is located in a space developed between the muscles and fascia of the abdominal wall. This site will accept even the largest of demand pacemakers with cosmetically acceptable results.

A method of enlarging the distal transverse arch in infants with hypoplasia and coarctation of the aorta.

Immediate operation in infants suffering from severe congestive heart failure and coarctation of the aorta associated with hypoplasia of the distal transverse aortic arch often poses a difficult technical problem. Frequently the anastomosis between the hypoplastic arch and the descending thoracic aorta fails to relieve the gradient across the hypoplastic segment appreciably. A technique of enlarging the lumen of the distal arch and thereby further lowering the gradient has been found effective and is presented.

The role of intraaortic balloon counterpulsation in patients undergoing cardiac operations.

Intraaortic balloon counterpulsation (IABC) was used to assist 60 patients undergoing cardiac operations for reasons of acute left ventricular failure (18 patients) or electively for indications in high-risk coronary and valvular heart disease (42 patients). Nine of 18 patients achieved hemodynamic stability when treated for acute perioperative or postoperative cardiogenic shock. Four of these died from problems unassociated with postoperative left ventricular failure and 5 were long-term survivors, indicating a potential salvage of 50%. In 42 high-risk patients, IABC was used electively to control preinfarction angina before operation (21 patients) and prophylactically to prevent postoperative low-output failure in another 21 patients with severe coronary and valvular heart disease. Thirty-nine, or 93%, of these patients survived. There were no deaths in the preinfarction angina group, 1 death in the group with coronary disease and ejection fractions less than 30%, and 2 deaths in those with valvular heart disease and congestive failure. Seven patients developed thrombotic or ischemic complications, but no permanent damage resulted. IABC is an important form of assistance for any patient with preoperative, intraoperative, or postoperative left ventricular failure and adds safety and hemodynamic stability for the high-risk patient with preinfarction angina or poor ventricular function.

A method for rapid tailoring of the intraatrial baffle in transposition of the great vessels.

Numerous reports have described successful use of the Brom "trouser-shaped" baffle in the Mustard procedure. A simple technique to fashion the baffle accurately by use of a prefashioned template is described.

Control of acute aortic dissection.

An experimental model of acute aortic dissection has been designed in an effort to examine myocardial contractility and systolic arterial pressure as factors influencing the progression of dissection. Thirty mongrel dogs divided into three experimental groups underwent left thoracotomy and construction of a standard intimal tear in the proximal descending aorta. Nine of ten animals in the control group showed progression of the aortic dissection a mean of 81.5 percent of the distance from the aortotomy to the celiac axis. Group II consisted of ten dogs pretreated with propranolol. The myocardial contractility (dp/dt) was significantly depressed in this group without change in systolic pressure. However, progression of dissection occurred in nine of ten animals as in the control group. In Group III, ten dogs were pretreated with trimethaphan lowering the systolic blood pressure to 90 mm. Hg and depressing the dp/dt to levels equal to those of Group II. There was no progression of aortic dissection in any of the animals in this group. The results indicate that, under these experimental conditions, depression of myocardial contractility alone has no inhibitory effect on the progression of dissection. When controlled hypotension is added to myocardial depression, aortic dissection is inhibited completely.