Biomedical subjects
Publications and source records attributed to J S McLaughlin.
Rupture of the ascending aorta is lethal in virtually all cases. In the recent literature, fewer than 9 cases of chronic, traumatic pseudoaneurysm of the ascending aorta have been documented. Reported herein is such a case, discovered incidentally and repaired successfully under cardiopulmonary bypass using a graft prosthesis. Aortogram remains the diagnostic method of choice in these patients.
We report the case of a 6-year-old child who underwent definitive conversion to the Fontan circulation using a newly conceived operative technique. This new procedure allows the operation to be performed as a totally extracardiac operation and is based on the hydrodynamic principles of the total cavopulmonary connection.
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One hundred nine penetrating cardiac injuries were reviewed: 49 gunshot wounds and 60 stab wounds. They were classified into four groups: group 1 (lifeless), 38; group 2 (agonal), 16; group 3 (shock), 33; and group 4 (stable), 22. Thirty-six patients in group 1 (94%) and 8 of 16 patients in group 2 (50%) underwent emergency room thoracotomy; 24 of 33 in group 3 (73%) and 20 of 22 (90%) underwent thoracotomy in the operating room. Twenty-one (38%) of 55 patients undergoing emergency room thoracotomy survived, whereas 47 (87%) of 54 patients undergoing operating room thoracotomy survived. Survival was 12 of 38 (31%) in group 1, 11 of 16 (69%) in group 2, 26 of 33 (79%) in group 3, and 18 of 22 (82%) in group 4 with an overall survival of 67 of 109 (61%). Gunshot wounds of the heart portend a worse prognosis than stab wounds. Survival of gunshot wounds was 20 of 49 (40%) compared with 47 survivors of 60 stab wounds (78%). Aggressive treatment, including emergency room thoracotomy, is justified for lifeless and deteriorating cardiac injury victims.
The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.
The benefits of coronary sinus (CS) cardioplegia are well known, yet CS cardioplegia is not used widely owing to the need for bicaval cannulation, snares, and an atriotomy. We designed and used in 225 consecutive patients a catheter containing a flexible removable stylet that, when shaped into a hockey-stick configuration, enabled blind intubation of the CS through a small pursestring in the right atrium, guided easily into the CS using a finger on the atrioventricular groove at the inferior vena cava. The CS was intubated in all patients; a pressure-limited balloon at the catheter tip was inflated after cross-clamping. An integral distal pressure line measured CS pressure. Catheters were placed distally within the great cardiac vein beyond the posterior interventricular vein; the position did not alter cooling: right ventricular free wall, septum, and left ventricular free wall temperatures were 7 degrees +/- 2 degrees, 8 degrees +/- 2 degrees, and 7 degrees +/- 2 degrees C, respectively, after an initial 10 mL/kg of blood cardioplegia. Transatrial CS cardioplegia was used in 45 aortic valve replacements, 22 mitral valve replacements, 4 triple-valve replacements, 6 congenital lesions, and 148 coronary revascularizations, including 40 redo operations. Atheromatous material was routinely flushed retrogradely from cut old vein grafts during revascularization; 70 revascularizations (47%) were performed urgently for acute infarction or jeopardized myocardium. No heart block or CS injury occurred, and inotrope use dropped to 10% of patients (from 38% in the previous 256 patients with antegrade blood cardioplegia). We conclude that the CS can be cannulated transatrially and that CS cardioplegia is more facile than antegrade cardioplegia.(ABSTRACT TRUNCATED AT 250 WORDS)
The cases of 78 patients with primary esophageal carcinoma treated from 1977 to mid-1987 were retrospectively analyzed. Fifty-two of the patients underwent transthoracic esophagogastrectomy (TTE) and 26, transhiatal esophagectomy (THE). The two groups were statistically similar in preoperative characteristics except that more of the THE group had received chemotherapy; this group had relatively more tumors of the upper esophagus; and 20 (77%) of the THE group, compared with 50 (96%) of the TTE group, had tumors in stages III and IV. The incidence of major postoperative complications did not differ significantly between the two groups. There were five (19%) anastomotic leaks in the THE group, but only one led to a prolongation of hospital stay by more than 14 days, whereas all three (6%) of the leaks in the TTE group caused hospital stay to be prolonged several weeks. Overall morbidity was high: 75% (39/52) for the TTE patients and 85% (22/26) for the THE patients (p greater than 0.10). Hospital mortality was 6% (3/52) in the TTE group and 8% (2/26) in the THE patients (p greater than 0.10). There was no significant difference in actuarial survival either between the two groups as a whole or between those patients in each group who had stage III or IV tumors. We conclude that THE, among the types of patients for whom we used the procedure, provides long-term survival comparable with that provided by TTE without causing a significant increase in hospital mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)
Conduction system disturbances after cardioplegia are well described. Our four-man group changed in mid-1987 from standard crystalloid cardioplegia (35 mEq/L of KCl) to blood cardioplegia (4 parts blood to 1 part cardioplegia) (18 mEq/L of KCl) based on experimental and clinical evidence that blood cardioplegia provides better myocardial protection. Shortly thereafter, we anecdotally noted increased conduction abnormalities. This prompted us to compare serially all patients undergoing coronary artery bypass grafting during 1987 for perioperative and late conduction system disturbances after either crystalloid or blood cardioplegia. Surgeons and techniques including topical cooling did not differ. Forty-one (23%) of 179 patients with crystalloid cardioplegia had conduction disturbances versus 141 (49%) of 289 patients with blood cardioplegia (p less than 0.001). Perioperative complete heart block requiring atrioventricular sequential pacing occurred in 20 patients with crystalloid cardioplegia versus 67 patients with blood cardioplegia (p less than 0.002), and atrioventricular block requiring permanent pacing was present in 4 and 12 patients (p less than 0.001), respectively. Left bundle-branch block was found in 8 patients given crystalloid cardioplegia and 28 patients with blood cardioplegia (p less than 0.05); right bundle-branch block, 12 and 68 patients (p less than 0.001); left anterior hemiblock, 8 and 37 patients (p less than 0.001); and interventricular conduction delay, 15 and 53 patients (p less than 0.005), respectively. Bifascicular block occurred in 4 patients receiving crystalloid cardioplegia versus 23 receiving blood cardioplegia (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Chick embryo corneal fibroblasts were grown in culture to study the processes whereby fibroblasts regulate the deposition and organization of the collagenous, secondary stroma. The effects of an existing type I collagen substratum, cell density, and serum concentration on type V collagen synthesis were investigated. Type V collagen represented approximately 20% of the total fibrillar collagen synthesized, regardless of whether the cells were subcultured, grown on untreated or collagen-coated plastic, grown under confluent or subconfluent conditions, or grown in the presence of low (0.1%) or high (10.0%) serum concentrations. The synthesis of type V collagen remained constant at 20% of the total collagen when cells were grown in 1.0% serum, even though total collagen synthesis increased nearly twofold when compared to total synthesis in 0.1% or 10.0% serum. Immunocytochemistry with anti-collagen, type-specific monoclonal antibodies revealed a homogeneous population of cells synthesizing types I and V collagen. The fibrils deposited by cells grown in a three-dimensional collagen matrix contained a helical epitope on the type V molecule that was inaccessible unless the fibrillar structure was disrupted, mimicking the situation in situ. The production in vitro of heterotypic fibrils, with a constant I/V ratio and molecular packing mimicking the natural stroma, offers opportunities for studying in more detail this important process, which is essential for optical transparency.
During a 30-month period, 20 median sternotomy wound infections or endocarditis occurred after 20 of 1204 (1.7%) cardiac surgery procedures in adults at the University of Maryland Hospital. We examined four risk factors related to the individual undergoing surgery: age, sex, and index of obesity (weight/height), and presence of diabetes mellitus. The odds ratio estimates of the relative risk of infection observed with use of a population control group were as follows: sex (female) 3.5 (p less than 0.05), obesity 2.0, and presence of diabetes mellitus 3.8. For a second control group matched for age, type of operative procedure, and date of operation, the estimated relative risks of infection were sex (female) 2.1, obesity 6.2 (p less than 0.05), and diabetes mellitus 2.0. More precise definition of the relative risk of sternotomy infection associated with obesity and diabetes is required to aid surgeons and patients in making judgments about the relative benefits of surgery and to alert nursing personnel to be particularly aware of early signs of infection in patients at high risk.
Rupture of the posterior left ventricle is a serious complication following mitral valve replacement. A successful method of repair is illustrated. The causes, other methods of repair, and means to prevent this complication are discussed.
Between 1964 and 1986, 19 patients underwent resection of both a primary lung cancer and the associated brain metastasis. One patient underwent resection of 2 separate primary lung cancers and the associated metastases. The 12 men and 7 women ranged in age from 42 to 67 years (mean, 54.6 years). The cell type was adenocarcinoma in 12 tumors, squamous or adenosquamous cell in 5, large cell undifferentiated or anaplastic in 2, and malignant carcinoid in 1 tumor. The types of resection were as follows: lobectomy for 12 neoplasms, pneumonectomy for 5, bilobectomy for 2, and wedge resection for 1 neoplasm. Radiotherapy to the brain was given in connection with sixteen of the twenty craniotomies. The patient with 2 separate primary neoplasms survived 19 years before dying 5 months after the second craniotomy. The mean survival is 8.0 +/- 2.1 years (+/- the standard error), and the median survival is 1.67 years. Survival at 1 year was 65 +/- 10.7% and at 5 years, 45 +/- 11.1%. On univariate analysis, the following factors were found to correlate significantly with longer survival: a lung tumor in Stage I or II; negative mediastinal nodes; curative rather than palliative resection of the lung tumor; and age younger than 55 years. However, on multivariate analysis, only curative resection was a significant factor (p less than 0.01). We believe these results justify continued application of this combined surgical approach to patients having limited-stage lung cancer with a solitary brain metastasis.
Survival after repair of postinfarction ventricular septal defects remains poor, often due to extensive loss of contractile muscle in the septum or left ventricle. We evaluated whether a contractile flap of right ventricular muscle could be used to repair a similar ventricular septal defect to augment left ventricular performance in 7 fully instrumented mongrel dogs (weight, 23 to 28 kg). By using hypothermic bypass and cold fibrillatory arrest, a trapezoidal right ventricle flap was fashioned from the free wall of the mid to lower right ventricle, basing its widest portion anteriorly on the septum and left ventricle. A large, 2-cm-diameter core of septum was excised beneath this flap to simulate a postinfarct ventricular septal defect. The right ventricular flap was then invaginated through the defect and sewn to the left ventricular side of the septum with pledgeted sutures taken full thickness through the flap and septum in a "vest-over-pants" fashion. Contraction of the right ventricular flap was confirmed visually and by postbypass multiple gated acquisition scans. The right ventricular defect was closed with fascia lata. All dogs were weaned from bypass without inotropes. Precardiac and postcardiac outputs of 2.5 +/- 0.5 versus 2.3 +/- 0.4 L/min and left ventricular end-diastolic pressures of 4 +/- 2 versus 4 +/- 3 mm Hg were identical. No shunts were detected by oxygen saturation. Autopsies confirmed the integrity of the repair. We conclude that septal defects can be repaired by using contractile right ventricular muscle, thus preserving left ventricular function. This technique offers promise for repair of postinfarction ventricular septal defects by using autologous, already conditioned to contract, cardiac muscle, but its application in humans must await long-term testing.
A simplified technique to gain repeated access to the median sternotomy incision is presented. The technique involves the use of a sterile polyester zipper attached to the skin edge. The sternum remains open. Unzipping the zipper allows for repeated relief of cardiac tamponade and viewing of cardiac action. Other advantages include prevention of cardiac compression or kinking of assist device cannulas from sternal closure, ease in changing of dressings, and quick removal of ventricular assist devices without reopening the sternum.
Transhiatal esophagectomy was performed in 26 patients with esophageal carcinoma. The patients were selected for this procedure by means of transhiatal palpation of the tumor at laparotomy. Twenty had squamous cell carcinoma and 6, adenocarcinoma. The tumor locations were the upper third in 8, middle third in 12, and lower third in 6. On postoperative staging, 15 patients had Stage III and 6, Stage IV neoplasms. Among 25 elective resections there was 1 hospital death, which was due to severe coronary artery disease. One patient who had an urgent resection for a perforated carcinoma died of multisystem failure 32 days postoperatively. Complications included splenic injury requiring splenectomy in 5 patients; tracheal laceration in 2 patients (only 1 requiring a thoracotomy); azygos vein laceration requiring sternotomy for repair in 1 patient; chylothorax in 1; recurrent laryngeal nerve paralysis in 3 (temporary in 2); and transient anastomotic leaks in 3. Five patients had pneumonia with transient respiratory failure. Twelve of the operative survivors died of cancer 3.2 to 32 months postoperatively, and 12 are alive 3 to 28 months after operation. The actuarial survival is 53 +/- 11% (+/- standard error) at one year and 46 +/- 12% at two years. Transhiatal esophagectomy is a reasonable, safe operation that should be considered for tumors at all levels of the esophagus.
During a 30-month period, median sternotomy wound infections or endocarditis developed during the first 60 days postoperatively following 20 of 1,204 (1.7%) adult cardiac procedures at the University of Maryland Hospital. Fifty percent of the infected patients received perioperative clindamycin prophylaxis. A retrospective study was conducted in which the odds ratio estimate of the relative risk of sternotomy infection or endocarditis for patients receiving clindamycin prophylaxis compared with patients receiving cefamandole was found to be 17.0 (p less than .001) using population controls and 8.25 (p less than .001) using matched controls. Seventy-five percent of the organisms causing infections, principally Staphylococcus epidermidis, were resistant in vitro to clindamycin. Perioperative clindamycin administration was not fully effective in preventing wound infection following cardiac surgery at our hospital, thus providing indirect evidence for the efficacy of prophylaxis with cephalosporin-containing regimens. Trials of alternative antibiotics to clindamycin for prophylaxis in penicillin-allergic patients undergoing cardiac surgery are indicated.
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The cases of 51 patients with bronchial adenomas were reviewed. There were 43 bronchial carcinoids, 5 adenoid cystic carcinomas, 2 mixed tumors, and 1 mucoepidermoid carcinoma. The carcinoid group was divided into typical (31, 72%) and atypical (12, 28%) subgroups. Nine carcinoids (20%) were categorized as metastasizing adenomas; in this group, 7 lesions were atypical and 2 were typical. Thirty-two lobectomies, 7 bilobectomies, 8 pneumonectomies, 2 sleeve resections, and 2 tracheal resections were performed. Ten-year survival was 88% for patients with typical carcinoids and 59% for those with atypical carcinoids. In the group with adenoid cystic carcinoma, 1 patient died postoperatively, 1 had recurrence of the tumor, 2 were alive and free from disease 16 and 23 years later, and 1 died of heart disease at 11 years. The patient with mucoepidermoid carcinoma was alive without recurrence 15 years after operation. In conclusion, bronchial adenomas of the carcinoid type are potentially malignant. Their prognosis depends on the histology of the tumor, and on the presence of metastasis to the regional lymph nodes and distant organs.