Case Series of Percutaneous Mechanical Aspiration of Mitral Valve Endocarditis

Infective endocarditis of the mitral valve that is refractory to medical therapy requires surgical debridement. However, patients who are high risk for surgery have limited options. We report 3 cases of refractory infective endocarditis involving the mitral valve that were treated with percutaneous mechanical aspiration with an embolic protection system. (Level of Difficulty: Intermediate.)

Pulmonary Artery and Intercostal Artery Pseudoaneurysms After Penetrating Injury

Traumatic pulmonary artery and intercostal artery pseudoaneurysms are rare pathologies that can occur after a penetrating injury. Most times, there is only one pseudoaneurysm that needs addressed. Options for management include simple observation, endovascular intervention with coiling, embolization, and stenting, and surgical intervention ranging from ligation to pneumonectomy. We present the case of a 20-year-old male who developed multiple pulmonary artery pseudoaneurysms and an intercostal artery pseudoaneurysm after sustaining a single gunshot wound to the chest. After multiple episodes of bleeding from several pseudoaneurysms, the patient ultimately required a pneumonectomy.

Comprehensive Comparison of Right and Left Recurrent Laryngeal Nerves in the Tracheoesophageal Groove

OBJECTIVE

A left-sided cervical approach to esophageal mobilization is considered safer given the perceived oblique path and more lateral orientation of the right recurrent laryngeal nerve (RLN) in the tracheoesophageal groove. Given the risk of recurrent laryngeal nerve, the current study investigated if there are differences in right and left RLN location in the tracheoesophageal groove.

METHODS

Right and left RLNs were carefully exposed in human cadavers. Comparison of location was determined at tracheal rings 2, 4, and 6 using 3 parameters: depth of the RLN from the anterior margin of the tracheal ring, lateral distance of the RLN from the posterior margin of the tracheal ring, and distance of the RLN to the anterior midline trachea following the curvature of the trachea. Statistical analysis was used to determine differences between the right and left sides.

RESULTS

Compared with the right RLN, the left RLN was slightly over 1 mm deeper at the second tracheal ring. Despite this trend, there was no significant difference in RLN location between individual sides or as an aggregate for any of the 3 parameters at tracheal rings 2, 4, or 6.

CONCLUSIONS

Careful characterization of RLN location precludes avoiding hoarseness, aphonia, and vocal cord paralysis. Counter to common surgical perception and educational beliefs, this study demonstrated that right and left RLN anatomical courses do not significantly differ along the trachea. Therefore, ensnarement on either side during a blind mobilization of the cervical esophagus is equally likely to occur.

Erosion of a right ventricular pacer lead into the left chest wall

Background

Erosion of a pacer lead into the chest wall may result in pericardial effusion with cardiac tamponade. Free rupture into the pleura or mediastinum can result in hypotension and cardiac arrest.

Case presentation

We report a unique case of a right ventricular pacer lead which eroded through the right ventricle into the left chest wall and penetrated a rib. The patient presented with a tender chest wall mass without pericardial or pleural effusion. The segment of rib which the pacing lead had penetrated was removed.

Conclusions

The patient tolerated the procedure well and was discharged 1 week after the operation. This case adds to the current literature the justification of removal of temporary and non-functional pacing leads.

Optimal timing of coronary artery bypass grafting in acute myocardial infarction

The timing of surgical coronary artery revascularization after an acute myocardial infarction is not well defined. The inherent difficulties of mobilizing a surgical team at odd hours has led to the adoption of a percutaneous coronary intervention strategy when possible or a clot-busting drug regimen when percutaneous coronary intervention is not available. Despite the difficulties and risks of surgical revascularization, there are situations where it may be indicated. We conducted a review of the literature to better understand the timing, scope, and risks of surgical coronary revascularization after an acute myocardial infarction.

Risk stratification and prognostic effects of internal thoracic artery grafting during acute myocardial infarction

OBJECTIVE

Surgeons are occasionally requested to perform coronary artery bypass grafting during acute myocardial infarction. We intended to test the safety of coronary artery bypass grafting and internal thoracic artery grafting early after myocardial infarction using the Society of Thoracic Surgeons database.

METHODS

The database was queried for isolated coronary artery bypass grafting less than 24 hours after a myocardial infarction from 2002 to 2008. By using multivariable logistic regression and classification trees, risk models were created to stratify this group of patients. The independent prognostic effect of internal thoracic artery grafting was examined using standard risk-adjusted mortality comparisons.

RESULTS

A total of 44,141 patients were identified, with an overall operative mortality of 7.9%. Cardiogenic shock occurred in 21%, percutaneous coronary intervention within 6 hours before surgery was performed in 11%, myocardial infarction within 6 hours before surgery occurred in 37%, preoperative intra-aortic balloon pump was used in 50%, and internal thoracic artery grafting was performed in 79% of the patients. Myocardial infarction in less than 24 hours was associated with higher operative mortality (odds ratio, 3.25) and major morbidity (odds ratio, 2.54). Emergency/salvage status (odds ratio, 6.43), age more than 80 years (odds ratio, 4.07), dialysis (odds ratio, 3.08), and cardiogenic shock (odds ratio, 2.79) were independent mortality predictors. Patients with nonemergence salvage status, absence of cardiogenic shock, creatinine less than 1.5 mg/dL, and age less than 70 years represented 48% of the population and exhibited a lower mortality rate of 2%. Internal thoracic artery grafting was independently associated with a lower risk of mortality (odds ratio, 0.52; P < .0001) and did not seem to compromise outcomes.

CONCLUSIONS

Coronary artery bypass grafting less than 24 hours after myocardial infarction carries a higher operative risk but can be performed safely in selected patients. Although confounding variables may exist, internal thoracic artery grafting was associated with improved outcomes. Internal thoracic artery use in this setting is less than ideal, and taking time to harvest internal thoracic artery grafts in patients with acute myocardial infarction might be encouraged.

Secondary abdominal compartment syndrome causing failure to wean from cardiopulmonary bypass

The abdominal compartment syndrome has been associated with trauma or primary abdominal procedures. The secondary abdominal compartment syndrome which is not associated with a primary abdominal process is seen in burns and other clinical situations where aggressive fluid resuscitation is needed. This case report describes a secondary abdominal compartment syndrome that occurred during an elective coronary revascularization which resulted in an inability to wean from cardiopulmonary bypass (CPB). After a decompressive laparotomy was done, the patient was successfully weaned from bypass.

Secondary pneumomediastinum: a retrospective comparative analysis

Pneumomediastinum is an uncommon radiographic finding of potential clinical significance. Secondary pneumomediastinum (SPM) has a variety of etiologies that can lead to potentially morbid outcomes. There are limited data regarding the etiologies, diagnosis, and outcomes of this entity. A retrospective comparative study was conducted over an 11-year period of patients developing pneumomediastinum secondary to a specific pathologic or traumatic event. Forty-five patients were identified with an underlying condition resulting in SPM. Demographic data, radiologic findings, length of hospital stay, and mortality were recorded. Statistical comparison was conducted between patients with blunt thoracic trauma- and barotrauma-induced pneumomediastinum. Logistic and multiple linear regression analyses were performed to discover factors predictive of mortality and length of hospital stay. Median age of the patients was 40 years and 69% were men. Subcutaneous emphysema was identified in 44%, pneumothorax in 47%, and pleural effusion in 11%. Pneumomediastinum was identified by plain radiograph (CXR) in only 47% compared to 100% by computed tomogram (CT scan). Average length of hospital stay was 19 days and mortality was 38%. Patients with blunt thoracic trauma had a lower sensitivity for CXR to discover pneumomediastinum, were more likely to develop subcutaneous emphysema or pneumothorax, and had lower mortality and length of hospital stay compared with those with barotrauma-induced pneumomediastinum. Barotrauma was an independent predictor for hospital mortality. Secondary pneumomediastinum is a morbid condition with distinctive etiologies, radiologic findings, and outcomes. Barotrauma-induced pneumomediastinum is associated with a prolonged recovery and high mortality rate.

Comparison of Spinal Cord Protection Utilizing Left Atrial-Femoral with Femoral-Femoral Bypass in Patients with Traumatic Rupture of the Aortic Isthmus

INTRODUCTION

Postoperative paraplegia remains a dreaded complication of repair of traumatic rupture of the aortic isthmus. Claims have been made that left atrial-femoral bypass provides better spinal cord protection. To test the hypothesis that left atrial-femoral bypass is better than femoral vein-to-femoral artery bypass in regard to postoperative paraplegia, we concurrently compared the two techniques.

METHODS

We compared the occurrence of paraplegia in 18 patients whose ruptures were repaired utilizing left atrial-femoral bypass with 10,000 units of systemic heparin (group A) and 72 patients with femoral-femoral bypass with heparin 300 units/kg and an oxygenator (group B) operated on between January 1995 and July 2004.

RESULTS

The mortality rate was 5.6% (5/90), with no statistical difference between the two groups. Postoperative paraplegia was present in three (16.7%) group A patients and five group B (6.9%) patients. However, the specific etiology of the neurologic defect was not clear, as one patient's paraplegia was transient following a period of cardiac arrest, and four others had had neurologic injuries prior to the aortic repair. Median aortic cross-clamp times were shorter in group A (34 minutes vs. 49 minutes). No patient required reexploration for bleeding, and no patient developed a graft infection.

CONCLUSIONS

Paraplegia rates were higher in the left atrial-femoral group, but the difference was not statistically significant. This occurred despite the decreased cross-clamp times in this group. In patients undergoing repair of traumatic rupture of the aortic isthmus, left atrial-femoral bypass does not provide better spinal cord protection than femoral-femoral bypass.

Percutaneous Intervention Versus Coronary Bypass Surgery for Patients Older Than 70 Years of Age With High-Risk Unstable Angina

BACKGROUND

The Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) study was a multicenter Veterans Affairs randomized trial and registry that compared long-term survival of percutaneous coronary intervention with coronary artery bypass graft surgery for the treatment of patients with medically refractory myocardial ischemia and at least one additional risk factor for an adverse outcome with bypass. Both the randomized trial and the registry demonstrated comparable 3-year survival. The purpose of this study was to compare bypass and percutaneous intervention survival of AWESOME patients who were older than 70 years of age.

METHODS

Over a 5-year period (1995 to 2000), 2,431 patients with medically refractory myocardial ischemia and at least one of the following five risk factors (prior heart surgery, myocardial infarction within 7 days, left ventricular ejection fraction less than 35%, age > 70 years, intraaortic balloon pump requirement to stabilize) were identified. Of these patients, 1,278 were older than 70 years of age. Eight hundred, seventy-one patients were turned down by at least one physician, 407 were acceptable to both physician and surgeon for randomization, and 236 (60%) consented to randomization. Of the 1,042 eligible patients who were not randomized, 871 had their revascularization directed by a physician who was not involved in the study. One hundred, seventy-one patients who were acceptable for randomization by both the interventional cardiologist and the cardiac surgeon refused consent.

RESULTS

Bypass and percutaneous intervention survival were compared using Kaplan-Meier curves and log rank tests. Bypass and percutaneous intervention 36-month survival rates for patients older than 70 years of age were 76% and 75%, respectively, among the eligible patients. Survival was 71% and 78% among those patients who were randomized and 76% and 67% in the physician-directed subgroup. Of those patients who chose their revascularization techniques, the survivals were 79% and 85%, respectively. The survival differences are not large, and none of the global log rank tests of bypass compared with percutaneous intervention survival showed a statistically significant difference over 5 years.

CONCLUSIONS

Both the randomized and registry subgroups of patients who were older than 70 years of age support the trial conclusions that either bypass or percutaneous intervention effectively relieves medically refractory ischemia among high-risk unstable angina patients whose age was greater than 70 years.

Minimal aortic injury: a lesion associated with advancing diagnostic techniques

BACKGROUND

With the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000.

METHODS

All patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma.

RESULTS

Of the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms.

CONCLUSION

Ten percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.

Traumatic rupture of the aortic isthmus: program of selective management

Two hypotheses were investigated: (1) helical computed tomography (CT) of the chest on victims of decelerating trauma can yield a diagnosis of, or "rule out," a traumatic rupture of the aorta (TRA) without the need for an aortogram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol. Screening helical CT examinations were done on 6169 victims of blunt thoracic trauma; 47 were found to have TRA; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated with a proved TRA. It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries. Drugs (beta-blockers +/- vasodilators) to decrease the stress in the aortic wall were used in 93 patients when the diagnosis was suspected and were continued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done between 2 days and 25 months in 15 patients who were deemed to be excessive risks for emergency aortic repair; there were 2 deaths (13. 3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether repaired emergently, electively, or not at all, developed free rupture of the periaortic hematoma and death from TRA.

Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture

OBJECTIVE

There were two aims of this study. The first was to evaluate the application of helical computed tomography of the thorax (HCTT) for the diagnosis of blunt aortic injury (BAI). The second was to evaluate the efficacy of beta-blockers with or without nitroprusside in preventing aortic rupture.

SUMMARY BACKGROUND DATA

Aortography has been the standard for diagnosing BAI for the past 4 decades. Conventional chest CT has not proven to be of significant value. Helical CT scanning is faster and has higher resolution than conventional CT. Retrospective studies have suggested the efficacy of antihypertensives in preventing aortic rupture.

METHODS

A prospective study comparing HCTT to aortography in the diagnosis of BAI was performed. A protocol of beta-blockers with or without nitroprusside was also examined for efficacy in preventing rupture before aortic repair and in allowing delayed repair in patients with significant associated injuries.

RESULTS

Over a period of 4 years, 494 patients were studied. BAI was diagnosed in 71 patients. Sensitivity was 100% for HCTT versus 92% for aortography. Specificity was 83% for HCTT versus 99% for aortography. Accuracy was 86% for HCTT versus 97% for aortography. Positive predictive value was 50% for HCTT versus 97% for aortography. Negative predictive value was 100% for HCTT versus 97% for aortography. No patient had spontaneous rupture in this study.

CONCLUSIONS

HCTT is sensitive for diagnosing intimal injuries and pseudoaneurysms. Patients without direct HCTT evidence of BAI require no further evaluation. Aortography can be reserved for indeterminate HCTT scans. Early diagnosis with HCTT and presumptive treatment with the antihypertensive regimen eliminated in-hospital aortic rupture.

Blunt injuries of the brachiocephalic artery

Blunt injury of the brachiocephalic artery can pose diagnostic and management problems for the trauma and thoracic surgeon. To arrive at recommendations for dealing with this injury, we reviewed a seven-year experience at our trauma center. Between 1988 and 1995, five patients presented with blunt injuries of the brachiocephalic artery. All patients were stabilized and underwent repair through a median sternotomy with extension of the incision anterior to the sternocleidomastoid muscle. All patients had restoration of flow to the subclavian and carotid arteries utilizing bypass grafts (4) or primary repair (1). All patients survived to leave the hospital with no complications related to the procedure. Postoperative neurologic findings were present before the operative repair. Patients with blunt injuries of the brachiocephalic artery should be stabilized, and circulation of the subclavian and carotid arteries should be restored with graft placement or primary repair. Cardiopulmonary bypass and heparin or temporary shunts were not needed in this series of patients. Complications were related to associated injuries.

Perfluorocarbons: future clinical possibilities

Perfluorocarbons are now being used as oxygen carriers in clinical settings. Because these chemicals may have a role as a blood substitute, in organ preservation, and in the management of respiratory failure, we have reviewed some of the research leading to these applications.

Subclavian artery injuries

Thirty-two consecutive patients with subclavian artery injuries were evaluated to assess the mechanism of injury, types of repair, and results. In this series, most wounds were from firearms. Although the mortality was high (19%), most patients had the vessel repaired successfully. Associated injuries, especially to neural structures, led to significant morbidity. Principles used in dealing with these injuries should be 1) proximal and distal control prior to exposing the injury site, 2) reestablishing distal circulation through primary repair or graft placement, and 3) identifying and treating associated injuries.

Combined gunshot injuries of the trachea and esophagus

During an 8-year period between 1985 and 1993, twelve patients were treated with combined gunshot wounds to the trachea and esophagus. All patients survived, but there were complications, including one tracheoesophageal fistula. Combined injuries of the trachea and esophagus should be repaired primarily, and drains do not necessarily have to be placed. The benefit of a muscle flap placed between the repairs was not confirmed in this series. Complications should be recognized early and treated aggressively to minimize damage to the airway.

Preoperative assessment of the high-risk patient for lung resection

BACKGROUND

We wanted to determine if cardiopulmonary exercise testing could better identify the threshold where physiologic function is irreparably impaired for patients with borderline pulmonary function who are being considered for lung cancer resection.

METHODS

We performed an open, prospective preoperative trial and a postoperative outcome evaluation with a combined medical, surgical, and exercise physiology evaluation at three university hospitals. All eligible patients had spirometry, lung volume determination, and quantitative perfusion scanning and performed a cardiopulmonary stress test, stair climbing, and a 12-minute walk for distance. Functional status was determined with an Eastern Cooperative Oncology Group score, a dyspnea score, and a cardiopulmonary risk index.

RESULTS

We identified 12 patients who met strict criteria for borderline pulmonary function during a 1-year study period. The mean forced expiratory volume in 1 second (FEV1) was 1.38 L (48% of predicted). The mean predicted postoperative FEV1 based on pneumonectomy was 700 mL. Eleven of the patients did the stair climb and 10 passed. All 12 patients achieved a maximum oxygen consumption greater than or equal to 10 mL x kg(-1) x min(-1) (mean value, 13.8 mL x kg(-1) x min(-1)). Thirteen operations were performed on the 12 patients. Nine complications occurred in 7 patients.

CONCLUSIONS

Patients with borderline pulmonary function can undergo resection safely if they have an FEV1 equal to or greater than 1.6 L or 40% of its predicted value, a predicted postoperative FEV1 of 700 mL or more, a maximum oxygen consumption of 10 mL x kg(-1) x min(-1) or greater, or stair climbing of three flights or more. Cardiopulmonary stress testing and stair climbing add valuable clinical information for patients with an FEV1 of less than 1.6 L.

Is routine carotid screening for coronary surgery needed?

An association between carotid and coronary artery disease is well recognized. Routine preoperative duplex carotid screening of all coronary surgery patients is common, but may delay surgery and increase cost. To evaluate such a policy: A retrospective review of the records of 308 consecutive patients undergoing coronary surgery at one hospital was performed. Duplex studies were done on 210. A history of TIA/RIND, CVA, AS-PVD, AAA, neck bruit, or prior carotid surgery was considered suggestive for carotid disease. The history and/or physical exam (HPE) suggested carotid disease in 114; 37 of these (32%) had a positive scan. Of 96 patients without +HPE, three (3%) had a significant stenosis. A prospective study of cardiac surgery patients was done, categorized into "carotid" (n = 33) or "no-carotid" (n = 50) disease by two independent observers, based on +HPE. Positive scans were found in 27 per cent of the "carotid disease" group; No positive scans were found in the "no-carotid disease" group. We conclude that coronary surgery patients with peripheral or cerebral vascular disease or a neck bruit should have preoperative carotid studies. Duplex carotid screening of all cardiac patients is neither medically efficient nor cost-effective.

Coronary operations in patients with spinal cord injury

BACKGROUND

The risk of heart disease in patients with spinal cord injury is similar to that in the general population. The physiologic derangements raise special problems in patients with SCI having coronary operations.

METHODS

From January 1980 to May 1995, we performed coronary artery bypass procedures on 20 patients with SCI; 4 were tetraplegic and the remainder were paraplegic. The indication for operation was angina: unstable (13), exertional (4), or postinfarctional (3). Bowel and bladder care was given immediately before operation; operating room tables were double padded and a pelvic wrap was used to protect the back. Electric wheelchairs were used for early mobilization.

RESULTS

Vasomotor instability from cardiopulmonary bypass was not present in patients with SCI. Pharmacologic support was required in the operating room by 4 patients for low vascular resistance, but in only one case in the intensive care unit. One patient required ventilation support for more than 24 hours. All patients were able to cough effectively. No thoracic wound complications occurred. There were three operative deaths, all in patients with multiple risk factors. The acute hospital stay averaged 9.3 days; patients were then transferred to an SCI unit for rehabilitation, were upper-extremity weight bearing was restricted for 2 to 4 weeks.

CONCLUSIONS

Patients should not be denied coronary artery bypass procedures because of an SCI, but their special needs must be managed properly.

Combined tracheal and esophageal trauma from gunshot wounds

During a 5-year period between 1988 and 1993, nine patients with combined tracheal and esophageal injuries were treated at our institution. All injuries resulted from gunshot wounds and all were repaired. All patients survived, but complications included one tracheoesophageal fistula. Combined injuries of the trachea and esophagus should be repaired primarily, and drains do not necessarily have to be placed. The benefits of a muscle flap placed between the repairs were not confirmed in this series. Complications should be recognized early and treated aggressively to minimize damage to the airway.

Noniatrogenic esophageal trauma

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.

Removal of an aspirated gold crown utilizing the laparoscopic biopsy forceps: a case report

An aspirated gold crown could not be removed with standard instruments. The crown was successfully grasped and removed with a large biopsy forceps commonly used in the performance of laparoscopic cholecystectomy.

Doppler-guided cannulation of the internal jugular vein: a prospective, randomized trial

OBJECTIVES

The internal jugular vein (IJ) is commonly used as an access to the central venous system. Despite the high success rate for cannulation of the IJ, the incidence of complications (1% to 16%) has remained essentially the same, with most complications resulting from unintentional punctures of surrounding structures. In an attempt to reduce the complication rate of this technique, we evaluated the use of a Doppler-guided needle device to cannulate the IJ.

METHODS

The study was performed on 41 patients scheduled for cardiothoracic or major vascular surgery requiring central vein cannulation as part of their anesthetic management.

RESULTS

The number of needle advances in the Doppler group was 1.35 (SD 0.88) compared with 2.8 (SD 2.78) in the control group (p = 0.037). A significantly greater percentage of cannulations were successful on the first attempt in the Doppler group (85%), compared with the control group (55%) (95% CI for proportion = 0.3 to 0.57).

CONCLUSION

The Doppler-guided cannulation technique can reduce the number of attempts required for successful IJ cannulation.

Routinely performed multigated blood pool imaging (MUGA) as a predictor of postoperative complications of lung resection. A two-year retrospective

The results of routinely performed multigated blood pool studies (MUGA) were compared with the presence of postthoracotomy complications in 46 adult men in a retrospective chart review. Pulmonary function measurements were also examined in relation to the presence of complications experienced. There was only one death, but survivable complications were not predicted by the MUGA results. The addition of MUGA as a routine preoperative cardiac screening technique did not result in increased ability to predict postoperative cardiopulmonary complications.

Infected biatrial myxoma: transesophageal echocardiography-guided surgical resection

We identified a biatrial myxoma using transesophageal echocardiography whose right atrial component was missed with conventional transthoracic techniques. Identifying the biatrial component directs a safer approach to right heart catheterization. Infected biatrial myxomas are both rare and successfully managed using prolonged intravenous antibiotic therapy followed by resection. Atrial septal defects created during the resection of an infected myxoma may be safely repaired using a prosthetic patch.

Perioperative respiratory management in cardiac surgery

The perioperative respiratory care of the cardiac surgical patient can present many challenges to the caring physician that he or she may not see among the usual patient population. Knowledge of the effects of the heart-lung machine on pulmonary performance, awareness of the anatomic changes brought on by the surgeon, and consideration of the patient's baseline cardiac and pulmonary function need to be addressed so that the pulmonary problems that they present can be managed optimally.

Physiology of lung resection

Although we speak intuitively about the effects of lung resection, little thought is given to the precise physiologic mechanisms. The effects of different thoracic incisions on the chest wall mechanics, the removal of pulmonary parenchyma on lung function, and the interaction of the cardiopulmonary apparatus all combine to result in specific physiologic derangements after thoracic surgery.

Safe intraaortic balloon pump placement through the ascending aorta using transesophageal ultrasound

Intraaortic balloon pumping salvages a substantial number of patients who fail to be weaned from cardiopulmonary bypass after an open heart operation. Patients with severe peripheral vascular disease may require ascending aortic balloon pump insertion. We describe a simple method of direct aortic puncture for intraaortic balloon pump placement using transesophageal ultrasound as a means of avoiding complications during insertion and documenting correct balloon position.

Stair climbing as an exercise test to predict the postoperative complications of lung resection. Two years' experience

The results of a clinically performed preoperative stair climb was compared to the presence of postthoracotomy complications in the retrospective hospital record review of 54 adult men. The stair climb was a maximum of five flights (125 steps) performed at the patient's rate and terminated at his request. Pulmonary function measurements and facets of the stair climb physiology were also examined in reference to the presence, type, and severity of complications experienced. Most minor complications such as transient arrhythmias, atelectasis, and pneumonia were clearly not predicted by the stair climb performance. The ability to climb three flights preoperatively most clearly separated those patients having the longer postoperative intubation and hospital stay, greater frequency of complications, and cumulative complication score (p less than 0.005). This retrospective study did not have sufficient numbers of fatal cardiopulmonary complications to exclude the possibility that these may be predicted by the results of this simple test.

Pneumocystis carinii pneumonia manifested as a hilar mass and cavitary lesion: an atypical presentation in a patient receiving aerosolized pentamidine prophylaxis

A case of Pneumocystis carinii pneumonia (PCP) in a patient with AIDS was manifested radiographically as a hilar mass and cavitary lesion. The patient had been receiving aerosolized pentamidine as prophylaxis against PCP. Nonuniform deposition of aerosolized pentamidine was probably responsible for this atypical radiographic appearance of PCP.

Failure of preoperative staging to assess unresectability in M0 bronchogenic carcinoma

Despite extensive preoperative staging, unresectability of a bronchogenic carcinoma may not be known until an exploratory thoracotomy is done. Failures in anatomic staging occur because of inability to detect local extent of hilar lesions and inability to detect small deposits of metastatic disease. At the University of South Carolina, nine of 75 patients who underwent thoracotomies were found to be unresectable. Using an extensive staging protocol, the "back out" thoracotomy rate can be reduced to a minimum whereas no patient is denied a chance for surgical cure.

Submaximal invasive exercise testing and quantitative lung scanning in the evaluation for tolerance of lung resection

Lung resection in patients with cardiopulmonary dysfunction is associated with increased risk. We studied 52 elderly male patients with airflow obstruction and a lung mass. Studies were performed at rest with routine ventilatory tests and lung scan quantitation of right-left lung function. Cycle ergometry exercise was then performed at 2 submaximal work loads (25 and 40 watts). Data were obtained using systemic and pulmonary artery catheterization for blood pressures, thermal dilution cardiac output, and blood gases. Twenty-nine patients underwent lung resection and seven failed to tolerate the procedure (death within 60 days or prolonged ventilator dependence). Those parameters most clearly separating the group tolerating surgery (n = 22) from the intolerant group (n = 7) were obtained during exercise and included: cardiac index (tolerant 5.5 +/- 1.3 vs intolerant 3.9 +/- 0.3 L/min/m2, p less than .01), O2 delivery (p less than .01) and calculated VO2 ml/kg/min (tolerant 11.3 +/- 2.1 vs intolerant 7.8 +/- 1.5 ml/kg/min, p less than .001). Pulmonary vascular pressures and calculated resistance did not predict intolerance. Calculated VO2 at 40 watts did not separate those patients who had survivable complications from those who did not (p much greater than .05). Multivariate analysis suggests that exercise VO2 is an important predictor of tolerance of lung resection because it reflects the effects of cardiac function and O2 transport. In our patients with COPD, submaximal exercise testing predicted intolerance of lung resection better than calculation using quantitative lung scanning. Exercise testing may accomplish this goal by uncovering deficits in O2 transport.

Echocardiography in determining nonresectability of carcinoma of the lung. A brief report

Numerous techniques are currently employed to determine resectability of lung cancer to spare patients an unnecessary thoracotomy. Echocardiography may be used to demonstrate invasion of hilar lesions into the heart. We report a case in which echocardiography demonstrated nonresectability of a lung cancer which was confirmed via a Chamberlain procedure.

Stair climbing as an indicator of pulmonary function

Seventy male patients with a mean age of 56.8 years scheduled for pulmonary function testing were subjected to a stair climb in order to determine the relationship, if any, between the number of steps climbed and the results of pulmonary function testing. The number of steps completed was plotted against the different parameters which may be used as predictors of post-thoracotomy outcome. The stair climb acts as a stress test and, although there is a strong relationship to pulmonary function tests, it also is an indicator of many other parameters including cardiovascular status, cooperation, and determination. Based on results of this study, the stair climb can be used as a reliable screening test of pulmonary function. Also, preoperative patients who are unable to perform pulmonary function tests can be evaluated accurately for lung resection by use of the stair climb test.