Coronary artery bypass grafting in the elderly: changing trends and results.

The subgroup of candidates age 75 and older for coronary artery bypass grafting (CABG) is increasing. Changing demographics have also influenced current practice. Between January 1985 and December 1989, 1498 patients underwent CABG; 109 (7.3%) were 75 or older (mean 77.3, range 75-87). This increased from 4.0% in 1985 to 12.2% in 1989. Mortality was 9.2% (elective cases 7.6%, emergent 50%), early mortality (0-10 days) 3.7%, and late deaths (11-90 days) 5.5%. Early deaths were attributable to cardiac failure and late mortality resulted from noncardiac organ failure. Actuarial probability of survival was 86% at 33 months (range 11-68). Mortality was highest in concomitant valve replacement (18.8%), NYHC IV (13.0%), postoperative bleeding (11.8%), and emergent priority (50%). Average cost for hospitalization per patient was $27,183; average length of stay in the hospital was 21.3 days. Changing trends have had a positive impact on improved long-term survival and quality of life, justifying continued elective cardiac surgery in selected patients.

Management of esophageal gunshot wounds.

The records of 20 patients with gunshot wounds of the esophagus seen from 1973 through 1985 were reviewed. Nine perforations were cervical, 10 were thoracic, and 1 was abdominal. Because physical findings and plain roentgenograms lack specificity, a high index of suspicion based on the path of the bullet tract is essential for early diagnosis. Esophageal injury should especially be suspected when the bullet wound is transcervical or transmediastinal. Perforation was diagnosed by esophagoscopy in 9 patients, esophagography in 4, and surgical exploration in 7. Mean time from admission to operation was 3.8 hours. Associated injuries occurred frequently. Eighteen patients were treated by primary closure and wide drainage, and 2 were managed by esophageal exclusion. There were 2 perioperative deaths, both in patients with associated aortic injuries, and 1 late death, for an overall mortality of 15%. There was one postoperative leak following a cervical repair. No leaks occurred in patients having a thoracic repair. The findings indicate that esophageal perforation must be sought by a variety of methods. With prompt diagnosis and early operation, primary repair can be safely accomplished. When sepsis from esophageal leak is avoided, mortality and major morbidity are related to associated injuries.

Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography.

Peritoneovenous shunts have become an accepted mode of therapy for ascites refractory to medical treatment. However, their use is known to be associated with significant morbidity and mortality. Reported is the case of a patient with a Denver shunt who developed massive intracardiac thrombosis and subsequent shunt malfunction, despite preserved shunt patency.

Management of acute cardiac trauma.

It is estimated that approximately 165,000 people die of traumatic causes every year. Thoracic trauma accounts for 25 per cent of all these traumatic deaths, and primary cardiac injury is a major contributing cause. Thus, every member of a trauma team must have a thorough knowledge of the diagnosis and management of cardiac injuries--penetrating and blunt--to effect an improvement in the overall survival of this group of trauma patients.

Early medical and surgical intervention for tetralogy of Fallot with absence of pulmonic valve.

Tetralogy of Fallot with absent pulmonic valve is a rare but life-threatening syndrome. Children with this complex may have aneurysmally dilated pulmonary arteries which compress the tracheobronchial tree and cause airway compromise and death. This paper reviews the course of 10 children with this syndrome who were seen at our institution from 1962 until the present. Two infants with respiratory distress secondary to tetralogy plus absent pulmonary valve were treated with early aggressive medical intervention followed by operation. After closure of the ventricular septal defect and reconstruction of the right ventricular outflow tract, the pulmonary artery aneurysms were resected. Both children are growing and are well more than 1 year after the operations. Our experience with these two patients suggests that such infants may benefit from this form of therapy.

A thoracic benign mesenchymoma in association with hemihypertrophy.

A thoracic benign mesenchymoma was removed from an 18-year old caucasian male who also had hemihypertrophy. The very large benign mesenchymoma which was removed was found to consist of an admixture of cytologically mature vascular spaces, adipose tissue, and smooth muscle. After removal of the tumor, the patient has had no recurrence with one year of follow-up. Patients with hemihypertrophy appear to be at high risk to develop neoplasms. Malignant neoplasms of the adrenal gland, kidney, and liver are most common. It is suggested that patients with hemihypertrophy should be followed periodically for their entire life because of their propensity to develop tumors.

Management of laryngotracheoesophageal cleft.

Laryngotracheoesophageal cleft (LTE) is a rare disorder that is still associated with a high mortality. Often the mortality is associated with other coexisting severe congenital anomalies, but even in those infants in whom the LTE cleft is the only anomaly, the mortality rate is still unacceptably high. This paper explores two avenues aimed at reducing the mortality. There are two main factors responsible for the high mortality. First, the diagnosis may be difficult and hence delayed; and second, once the diagnosis is made, management reported to date does not adequately prevent aspiration of stomach contents, which is the main mechanism of the infant's death. With respect to early diagnosis, the key symptom is respiratory distress exacerbated by attempts at feeding. The key diagnostic radiological procedure is a cineesophagram which shows a high spillover of contrast into the trachea on swallowing. The definitive diagnosis is made by endoscopy. Endoscopic evaluation can be confusing but if the anomaly is considered by the surgeon, an important maneuver at endoscopy, under general anesthesia, is to pass an endotracheal tube into the larynx. The tube stents open the edges of the cleft, which can clearly be seen while performing esophagoscopy, thus confirming the diagnosis. With respect to early management, the commonest cleft is a partial LTE cleft. Initially the airway should be maintained either by placement of an endotracheal tube or a tracheotomy. The more entensive the cleft, the more easily does the indwelling tube slip over the edge of the defect into the esophagus. In all but the mildest of clefts, gastric decompression and alimentation are required. This still allows for considerable reflux of gastric contents into the lungs, and we advocate a high total gastric section with a double gastrostomy to minimize the possibility of aspiration of stomach contents. After the infant's general condition is stabilized, definitive early surgical repair is undertaken. This paper includes a detailed case report of one patient, illustrating the above points of early diagnosis, total gastric division and early repair.

Late results of reconstruction of the right ventricular outflow tract with porcine xenografts in children.

Thirty-three children, aged 2.5 to 17.5 years (mean, 8.3 years), having xenograft external conduits placed between the right ventricle and pulmonary artery were followed for 1 to 6 years postoperatively (mean, 3.5 years). There were no late deaths in the study group, and no infection of a valved conduit has been demonstrated. Twenty of these children were catheterized during the follow-up period. The gradients from the right ventricle to pulmonary artery ranged from 8 to 90 mm Hg (average, 31 mm Hg). A total of 8 patients were classified as having hemodynamically documented conduit failure, and an additional 2 patients are clinically expected to have conduit failure. This represents a total incidence of 30% xenograft conduit failure in a 6-year follow-up. Although the etiology of this dysfunction is probably multifactorial, factors such as valve size, conduit angulation, and immunological competence bear special consideration. We conclude that although valved external conduits continue to play an important role in the treatment of complex congenital heart disease, a valved conduit with greater longevity is needed for use in children.

Complete sternectomy for chronic osteomyelitis with reconstruction using a rectus abdominis myocutaneous island flap.

We believe the rectus abdominis myocutaneous island flap offers a reliable alternative method of midchest reconstruction in selected cases of chronic osteomyelitis of the sternum, in conjunction with complete resection of injected sternal bone and cartilage. This single-stage procedure provides an en bloc unit of muscle with overlying skin and soft tissue, reaching from the xiphoid to the sternal notch. Three successful cases demonstrating the method are presented, with follow-up ranging from two months to two years.

Tracheoplasty for tracheal stenosis in the pediatric burned patient.

Until recently, the only therapy available for a tracheal stricture has been repeated dilations of the stenotic area or resection and anastomosis. Upper-airway burns in the pediatric patient have occasionally resulted in tracheal stenosis. Two children with a long tracheal stenosis secondary to inhalation injury have been successfully treated surgically. A costal cartilage graft has been used in these two children in the management of a long tracheal stenosis. Both have an adequate airway, and future surgical correction of a subglottic stenosis is planned for both. The results, although initially successful, will need to be tested by time before they can be considered the definitive treatment for long areas of tracheal stenosis.

Nitroprusside and epinephrine for treatment of low output in children after open-heart surgery.

We evaluated the acute hemodynamic effects of treatment of the low output state with sodium nitroprusside and epinephrine in 13 children after intracardiac operation. The 13 patients were selected from a consecutive series of 106 children undergoing cardiopulmonary bypass. They had a cardiac index less than 2.0 L/min/m2, even after an increase in left ventricular filling pressure and during infusion of nitroprusside. Although the nitroprusside brought about a significant increase in cardiac output and decrease in systemic vascular resistance, the cardiac index remained critically low (less than 2 L/min/m2). Epinephrine resulted in a further significant increase in the cardiac index, without a significant change in systemic resistance. This study suggests that in selected patients the simultaneous use of both a vasodilator drug (sodium nitroprusside) and a positive inotropic agent (epinephrine) is advantageous in the short-term treatment of the low cardiac output state after intracardiac operation.

Low-cost daily pacemaker monitoring system.

To reduce the cost of pacemaker monitoring, we developed an inexpensive cardiac pacemaker interval monitor that detects electromagnetic radiation of the electrical pulse generated by an implanted pacemaker. The pulse interval is timed by logic systems and a piezoelectric crystal. Pulse interval is computed to the nearest 0.1 msec. The device is battery powered and can be used at home by the patient to monitor pulse interval daily with little cost after the initial expenditure. The unit may also be used by the physician to detect the stability or constancy of random variation of the pulse interval. From a daily record of measurements of the pulse interval, limits are set by the physician to predict impending battery exhaustion. Eight patients have been monitored for up to 24 months.

Mycotic tuberculous aneurysm of the thoracic aorta.

Tuberculous mycotic aneurysm has been reported with surprising frequency, especially in the aorta. Because the diagnosis can often be made on clinical and roentgenologic grounds, and because of the very poor prognosis if untreated and surgical curability if recognized, experience with three cases is reported. The aneurysm is generally of the false variety, representing a walled-off perforation of the aorta. Contiguous tuberculosis in the form of lymphadenitis or Pott abscess is generally responsible for the aortic involvement that results in the aneurysm. Miliary tuberculosis, which is often present, is probably a result rather than the cause.

Cardiac performance and oxygen consumption during intracardiac operations in children.

Cardiac performance and oxygen consumption in 30 patients undergoing surgical treatment for congenital cardiac disease were determined from intraoperative measurements. Arterial pressure, cardiac index, mean left ventricular hydraulic output power, pulmonary artery oxygen saturation were obtained at average mean left atrial pressures of 8.1 and 15.2 cm H2O after cardiopulmonary bypass in 20 patients. These same variables were measured at an average pulmonary artery saturation of 65 and 75% in 30 patients. A composite of measurements of cardiac performance was desirable to guide precise patient care intraoperatively, especially if myocardial function was compromised. It is suggested that left atrial pressure be maintained at a level that results in a pulmonary artery saturation greater than 65%.