Biomedical subjects
Publications and source records attributed to C R Hatcher.
The adrenal gland is a common site of metastasis from carcinoma of the lung. In selected patients, especially those in whom the adrenal mass is on the ipsilateral side of the lung lesion, the adrenal gland can be biopsied by a transthoracic transdiaphragmatic approach. Our technique of transdiaphragmatic adrenal biopsy in the staging of carcinoma of the lung is described.
The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.
Between June, 1982, and July, 1983, 6 children with partial anomalous pulmonary venous connection to the middle or high segment of the superior vena cava (SVC) underwent repair of the anomaly by division of the SVC proximal to the site of entry of the anomalous pulmonary veins. Continuity between the cephalad end of the SVC and the right atrium was established by direct anastomosis to the right atrial (RA) appendage or by creation of a pedicle conduit of RA appendage, RA free wall, and pericardium. The anomalous pulmonary veins remained in situ on the lower segment of SVC, blood being directed to the left atrium through an atrial septal defect by a pericardial patch placed within the right atrium well away from the sinoatrial node, anomalous pulmonary veins, and cavoatrial junction. All children have survived, remain in normal sinus rhythm, and have no evidence of vena caval or pulmonary venous obstruction. Follow-up cardiac catheterizations, angiocardiograms, and Holter recordings support the efficacy of this technique as an alternative in the management of anomalous pulmonary veins joining the SVC well above the cavoatrial junction.
The records of the patients with tracheoesophageal fistula from carcinoma of the esophagus treated from 1970 to 1983 were reviewed to assess the length and quality of their survival. Twenty-four patients with malignant tracheoesophageal fistula were treated during this period. The site of the carcinoma was the middle third of the esophagus in 18 patients, the lower third in 5, and the upper third in 1. Three patients received only supportive treatment, and 1 had only radiation therapy. Nine patients underwent insertion of a Mousseau-Barbin or Celestin tube with or without gastrostomy, and 7 patients had gastrostomy alone. Four patients had exclusion of the tracheoesophageal fistula, 3 with esophagogastrostomy and 1 with colon interposition. The 3 patients who received only supportive treatment survived 5 days, 1 week, and 2 weeks. The 7 patients who had gastrostomy lived 3 days to 18 weeks (mean, 6 weeks). The 9 patients with a Mousseau-Barbin or Celestin tube lived 1 week to 6 months (mean, 8 weeks). The 4 patients who had exclusion of the tracheoesophageal fistula survived 5 weeks, 4 months, 7 months, and 26 months following operation. This study suggests that the treatment for patients with tracheoesophageal fistula from carcinoma of the esophagus should be individualized and that in selected patients, exclusion of the fistula with esophagogastrostomy improves the quality of life and prolongs survival.
One hundred and fifty-two patients age 70 years or more underwent aortic valve replacement (AVR) at Emory University Hospital between July 1, 1974 and July 1, 1982. Of these, 98 had isolated AVR (elderly AVR group) and 54 had concomitant coronary artery bypass grafts (elderly AVR/CABG group). Results of surgery in these patients were compared to results in patients aged 20 to 69 years operated on in the same period (young AVR/CABG groups). Comparative descriptors with statistically significant differences included a higher incidence of both stable and unstable angina in patients undergoing concomitant CABGs ; less cardiomegaly in the young AVR/CABG group; less hypertension, a higher incidence of pure aortic regurgitation, and less frequent use of inotropes in the young AVR group; a higher perioperative stroke rate in elderly AVR/CABG patients; a higher perioperative psychosis rate in patients having CABGs regardless of age; and a longer postoperative hospital stay for the elderly patients. There were no significant differences between the four groups for the following descriptors: sex ratio; history of congestive heart failure; the presence of atrial fibrillation; left ventricular end diastolic pressure, ejection fraction and contractility; number of diseased coronary arteries; number of vessels bypassed; use of the intra-aortic balloon pump; re-exploration for hemorrhage; perioperative myocardial infarction rate; and major wound infection rate. Operative mortality was 5.1% for the elderly AVR group, 5.6% for the elderly AVR/CABG group, 1.9% for the young AVR group, and 5.1% for the young AVR/CABG group (p = NS). Overall, hospital mortality was 3.3%. Actuarial survival curves for all elderly versus all young patients showed no significant difference. The curve for elderly patients compares favorably with the actuarial survival of the same age group in the general population. Actuarial survival curves for the four subgroups did not differ significantly when compared at a follow-up of 36 months after surgery. We conclude that AVR with or without concomitant CABGs can be performed in elderly patients with an acceptably low mortality and morbidity, and the postoperative survival compared favorably both with younger patients and with the general population of the same age.
A new permanent epimyocardial Medtronic 4951 "stab-in" or "fishhook" pacing electrode was implanted in 16 children. Identical technique, with particular attention to the direction of the coronary circulation, was utilized to implant the leads. There were 10 atrial implantations (5 active, 5 redundant) and 18 ventricular implantations (15 active, 3 redundant). Pacing modes were VVI (12), VDD (1), DVI (2), and DDD (1). Experience with the lead covers 280 patient months (3 days to 21.8 months, mean 14 months). Patients were followed monthly via telephonic transmission. With the exception of the single patient who expired three days after implantation, each patient has returned for follow-up analysis including chronic threshold determinations using the programming capabilities of the pulse generators. Only one lead required more than the minimum obtainable voltage output from the pulse generator to effect capture. No other lead required more than 5.0 volts at 0.5 ms pulse width. There have been no lead fractures or dislodgements. In this evaluation the Medtronic 4951 lead performed well in both atrium and ventricle in a group of children with diverse cardiac pathology. The small diameter of the lead and the low profile of the electrode are advantageous for use in pediatric patients.
Acute myocardial ischemia is a serious complication of percutaneous transluminal coronary angioplasty, often requiring emergency myocardial revascularization. Since our initial report of 17 such patients, we have encountered an additional 32 patients requiring emergency myocardial revascularization since September, 1981. The indication for emergency myocardial revascularization was ischemic chest pain in all 32 patients. Percutaneous transluminal coronary angioplasty resulted in injury to the right coronary artery in 11 patients, the left anterior descending artery in 19 patients, and the left main artery in two patients. The onset of ischemia was immediate in 26 patients but delayed up to 22 hours in six patients. Chest pain was associated with ST-segment elevation in 21 patients, hypotension in 7 patients, and cardiac arrest in 6 patients. Immediate intra-aortic balloon pumping was instituted in the angioplasty suite in 16 patients. The mean time from onset of ischemia to completed revascularization was 156 minutes with a mean of 1.6 grafts performed per patient. Seventeen patients (53%) had enzyme evidence of myocardial infarction postoperatively, with a significantly higher (p less than 0.01) incidence of myocardial infarction in those patients with preoperative ST elevation (76% versus 9%). In the 21 patients with ST-segment elevation, the incidence of Q wave infarction was 20% (3/15) with balloon pumping and 50% (3/6) without balloon pumping. Complications associated with intra-aortic balloon pumping occurred in one patient (6%). There were no hospital or late deaths with follow-up extending 16 months. The spectrum of injury resulting from percutaneous transluminal coronary angioplasty extends from chest pain alone to severe transmural ischemia with hypotension or cardiac arrest. Presentation may be immediate or delayed. Urgent emergency myocardial revascularization remains the accepted therapy for this complication. Immediate preoperative intra-aortic balloon pumping is a useful adjunct to emergency myocardial revascularization in the group of patients with acute ischemia and ST-segment elevation.
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Three groups of patients were analyzed to ascertain the risk of combined carotid/coronary operations and the risk factors for perioperative stroke following coronary artery bypass (CAB). Group 1 (N = 132) had simultaneous carotid endarterectomy and CAB, Group 2 (N = 51) were patients having perioperative stroke following elective CAB, and Group 3 (N = 169) had CAB alone but had prior history of either asymptomatic cervical bruit, stroke/transient cerebral ischemic attack (TIA), or carotid endarterectomy. Hospital mortality and perioperative stroke rate in the combined carotid/coronary group were 3.0% (4/132) and 1.6% (2/126), respectively. These rates were not significantly different from those of a control group having CAB alone. Overall incidence of postoperative stroke in 5,676 patients having CAB alone was 0.9% (51 patients). The incidence of perioperative stroke in patients with asymptomatic bruit or prior history of stroke or TIA undergoing CAB alone was 3.3% (2/60) and 8.6% (6/70), respectively. The majority of strokes following CAB appear to be embolic in origin. Indications for simultaneous carotid/coronary operations are bilateral carotid disease and symptomatic carotid vascular disease associated with unstable angina, left main obstruction, or diffuse multivessel disease. Staged procedures are recommended for patients with stable angina and symptomatic carotid lesions and for difficult carotid revascularization procedures. CAB alone may be performed for most patients with asymptomatic cervical bruit, moderate or mild carotid artery obstruction, and unstable angina associated with prior stroke, although in the third situation postoperative risk of neurological injury may be increased.
The repair of many congenital heart anomalies would be facilitated by a tissue replacement for the atrial wall or pulmonary artery which would grow with the child. Such a tissue has not previously been identified. In 12 puppies a broadly based flap of pericardium was sutured over the right atrial free wall. The atrial wall was excised from beneath the flap. In four animals the flap was then cut away from its pericardial attachments superiorly, inferiorly, and along the phrenic nerve, leaving an autogenous pericardial patch. In the other eight animals the flap was left intact, allowing retention of neural and vascular supply. The animals were put to death 263 +/- 23 days later. In four animals having a pericardial patch, the area of the patch did not increase (94% of original size, NS) despite an increase in body surface area (BSA) to 169% (p less than 0.05) of original BSA. In eight animals with a pericardial flap, the area of the flap increased to 214% (p less than 0.01) of the original size with an increase in BSA to 199% (p less than 0.01) of original BSA. The flap size index (size/BSA) increased to 109% of the original index while the patch size index decreased to 54% of the original, a significant difference (p less than 0.01). The broadly based pericardial flap grew in a manner parallel to BSA increase in these puppies.
Spontaneous rupture of the esophagus can simulate a variety of disease processes. Ours is the first reported case in the English literature of Boerhaave's syndrome occurring concomitantly with acute myocardial infarction.
Complications arising from manipulation of the diseased ascending aorta constitute a significant portion of the morbidity and mortality of coronary revascularization. A case is described in which coronary revascularization was achieved by extension of the left internal mammary artery with a segment of reversed saphenous vein. The major advantage of this technique is that it obviates any instrumentation of the aorta or great vessels.
Cardiac Data Bank records of 1,238 patients with triple-vessel disease (greater than or equal to 50% diameter reduction) who had undergone coronary bypass surgery were reviewed and divided into 2 groups depending on whether complete (n = 773) or incomplete (n = 465) revascularization had been accomplished. Patients with complete revascularization had a higher incidence of a normal preoperative electrocardiogram than did patients with incomplete revascularization (23 versus 14%, respectively, p less than 0.0001). The ejection fraction for both completely and incompletely revascularized patients was good (m = 0.60 and 0.57, respectively). The mean number of grafts per patient for the 2 groups was 3.8 and 2.6 (p less than 0.0001). There was no significant difference between the 2 groups with regard to postoperative inotropic requirements (8 and 7%), ventricular arrhythmias (1.8 and less than 1%), necessity for intraaortic balloon pumping (1.6 and 1.5%, hospital mortality (1.2 and 2.8%), or myocardial infarction (4.3 and 4.8%). Survival at 5 years was significantly greater (p less than 0.001) in patients with complete (88.5%) than in those with incomplete revascularization (83.5%). Reemployment occurred more often in patients with complete (52%) than in those with incomplete revascularization (40%) (p less than 0.001), and more patients were free of angina after complete (70%) than after incomplete revascularization (58%) (p less than 0.0005). Long-term survival appeared to be mediated primarily through improved revascularization rather than through differences in left ventricular function.
Thirty-seven patients with vein graft stenosis following coronary artery bypass underwent percutaneous transluminal vein graft angioplasty to avoid another operation. Location of the stenoses was at the aortic anastomosis in 3 patients, in the vein body in 12, and at the distal anastomosis in 22. All patients had disabling angina pectoris. Initial success (greater than 20% reduction of stenosis) was achieved in 35 patients. Vein graft angioplasty was performed within a year after bypass in 28 patients. The percent of stenosis and the pressure gradient across the obstruction were reduced from 84 to 24% and from 58 to 15 mm Hg, respectively. Complications of the procedure included emergency coronary artery bypass in 2 patients, myocardial infarction in 2, and ventricular fibrillation in 1. There were no deaths. Of 15 patients with stenosis at the aortic anastomosis or vein body, the dilation was initially successful in 14 but restenosis occurred in 7 within the first year after angioplasty. Only 2 of the remaining 7 were asymptomatic after vein graft angioplasty. However, for patients having vein graft angioplasty of the distal anastomosis, restenosis occurred in only 3, while 12 were asymptomatic at the end of the first year. The average hospital cost of a repeat coronary artery bypass operation was 2.8 times the cost of vein graft angioplasty.
The records of 176 patients admitted to Grady Memorial Hospital over a 10-year period with a history of ingestion of corrosive material were reviewed. Esophagoscopy was performed in 168 patients an average of 15 hours after ingestion. In 94 patients, no esophageal burn was found. Seventy-four others had injury of the esophagus of varying degree; 3 of these had no evidence of oropharyngeal burn. The patients with esophageal injury were treated with steroids for two weeks and antibiotics for 5 days. No complications resulted from esophagoscopy or steroid therapy in any patient. Stricture did not develop in any of the patients in whom esophagoscopy was negative. Documented stricture occurred in 29 patients with esophagoscopic evidence of esophageal burns, 7 of whom did not respond to periodic esophageal dilation and subsequently underwent esophageal bypass. Three patients had symptoms and signs of gastric perforation on the first, sixth, and eighth days after ingestion, respectively, and at laparotomy all of them were found to have severe gastric injury. One of these patients died on the postoperative day 28; this was the only death among all patients seen with history of ingestion of corrosive material. This study suggests that with early esophagoscopy, approximately 55% of patients who ingest corrosive material can be spared the agony and prolonged treatment of possible esophageal injury. Appropriate management will result in preservation of the esophagus in most patients.
The clinical situation of heterogeneous cardioplegia was simulated in a canine model by temporary ligation of the circumflex coronary artery during a three-hour interval of cardioplegic arrest. Nifedipine and lidoflazine, administered prior to aortic clamping, were evaluated as adjuncts to cold (2 degrees C) crystalloid cardioplegia. Assessment was made of regional function (sonomicrometer systolic shortening) and of global function by measuring left atrial (LA) pressure at constant cardiac output (CO), aortic pressure, and heart rate, and by measuring stroke work at constant LA pressure, aortic pressure, and heart rate. Among 14 control dogs, only 7 could achieve a CO of 5 liters per minute following cardioplegic arrest. Left anterior descending coronary arterial systolic shortening recovered to only 86% of prearrest values (p less than 0.05), circumflex coronary arterial systolic shortening recovered only 28% (p less than 0.01), stroke work recovered 59% (p less than 0.01), and LA pressure was 6.7 mm Hg higher (p less than 0.01) than prior to cardioplegic arrest. Lidoflazine provided no statistically significant benefit in these animals (N = 4). However, dogs given nifedipine (N = 6) had very little change in left anterior descending coronary arterial systolic shortening (99% recovery), stroke work (93% recovery), and LA pressure (delta = 0.4 mm Hg). None of these changes was statistically significant. There was some deterioration in circumflex coronary arterial systolic shortening (56% recovery; p less than 0.05). All 6 dogs given nifedipine achieved a CO of 5 L/min following cardioplegic arrest. Clinical cardioplegia is typically heterogeneous cardioplegia. Calcium-channel blockade appears to be useful in this situation.
The hemodynamic interactions of verapamil and isoflurane were studied in eight dogs. Left ventricular function was analyzed using a right heart bypass preparation to permit rigid hemodynamic control. Hemodynamic studies were performed at 0.7, 1.05, and 1.40% isoflurane before and during the maintenance of two stable levels of verapamil, administered intravenously by combining a bolus dose (0.2 mg X kg-1) with an infusion (3.0 and 6.0 micrograms X kg-1 X min-1). Isoflurane produced a concentration-dependent depression of left ventricular function as indicated by dP/dt max, per cent systolic shortening, and left ventricular function curves. This depression was enhanced in a dose-plasma concentration-dependent manner by verapamil and was reversed by calcium chloride. Isoflurane alone and the combination of verapamil and isoflurane decreased systemic vascular resistance in a dose-dependent fashion that was antagonized partially by calcium chloride. Therefore, verapamil can enhance the hemodynamic effects of isoflurane in a dose-related manner that needs to be considered when both drugs are administered together.
Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease (CAD), thus possibly redefining candidates for coronary bypass surgery (CABS). Between October 1980 and June 1982, 777 patients having PTCA and 2068 patients having CABS were analyzed for differences in clinical presentation, complications, and early outcome. Patients having CABS were significantly older, had a higher incidence of hypertension (46% vs. 32%), more multivessel disease (80% vs. 12%), and poorer left ventricular function (nl. wall motion = 88% vs. 52%). The incidence of myocardial infarction in patients after PTCA was 1.0% (8/777). Emergency CAB was required in 5.3% of patients following PTCA. There were no deaths following the angioplasty procedure and 25 deaths in 2068 patients having CABS (hospital mortality rate = 1.2%). Since 1973, there has been a progressive decline in hospital mortality rate (now, less than 1%), postoperative infarction (now, 3%), requirement for inotropic drugs (now, 5%) and frequency of IABP (less than 1%). Increasing ability to achieve complete revascularization now means improved survival and freedom from angina with CAB surgery. PTCA and CAB are both procedures that may be used effectively for selected patients, depending on clinical presentation, extent of CAD, and left ventricular function (LVF). Careful patient selection affords the opportunity for use of PTCA in patients with single-vessel disease (SVD) and good LVF and CABS in patients with multivessel disease, regardless of LVF. Symptomatic patients with SVD and total vessel occlusion are not candidates for PTCA. Our data demonstrate that both PTCA and CABS may be accomplished with very low perioperative complications and hospital mortality.