Biomedical subjects
Publications and source records attributed to O H Frazier.
We report the case of a 2-year-old child with severe adenovirus type 7 pneumonia and myocarditis who survived after seven days of ECMO. Our patient demonstrates the possible applications of ECMO to pediatric lung diseases and reemphasizes the importance of lung biopsy in screening possible candidates.
Recognizing the problems of thromboembolism and anticoagulation in children and the high incidence of calcification in porcine valves in children, we hoped that the Ionescu-Shiley valve might be a good choice in the younger age group. We implanted 2,372 Ionescu-Shiley valves in 2,167 patients between 1978 and 1982, of which 30 were in children 16 years of age and younger. Although there have been no known instances of thromboembolism, valve infection, or valve disruption in this group of children, seven (23%) have already required reoperation for calcific stenosis. Although calcification appears maximal in postpubertal children less than 17 years of age, we consider it unwise currently to place these valves in any child and have returned to mechanical valves for this purpose.
Potential hepatotoxicity from systemic hyperthermia (43 degrees C) +/- simultaneous hepatic artery infusion with 5-FU was evaluated in an animal model. Twenty-two dogs had aorta-vena caval shunts (8 mm Dacron grafts) placed, and 10 of these dogs had silastic catheters inserted in their hepatic arteries. Two weeks later, Group I (n = 8) was heated to 43 degrees C for one hour (distal esophageal + intrahepatic temperature) using the shunts and blood-heat exchangers; Group II (n = 6) was heated to 43 degrees C for one hour with simultaneous intrahepatic infusion of 5-FU (10 mg/kg); Group III (n = 8) was shamheated (37 degrees C) and underwent a one hour intrahepatic infusion with 5-FU (10 mg/kg). Serum alkaline phosphatase, SGOT, SPGT (IU/ml) and bilirubin were measured, and liver biopsies were obtained at 0 and 1 hour, at one and seven days. Mean SGOT levels increased significantly (P less than 0.05) in Group II from 19 +/- 2 to 31 +/- 6 and 63 +/- 18 at one hour and one day; these levels rose slightly in Group I from 31 +/- 5 to 40 +/- 8 and 47 +/- 8 at one hour and one day. Hepatocellular enzyme levels returned to normal at seven days in both groups. Mean SGOT and SGPT levels remained similar in Group III at all time periods. No significant differences in mean serum alkaline phosphatase or bilirubin levels were noted. There was no histologic evidence of hepatocellular necrosis at any time period. Survival was 6/8, 5/6 and 8/8 dogs in Groups I, II, and III, respectively. Systemic hyperthermia to 43 degrees C for one hour in dogs does not adversely affect serum hepatic enzymes or cell structure; reversible serum hepatic enzyme changes occurred when hyperthermia was combined with hepatic artery infusion with 5-FU.
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A review of operative therapy in 244 patients with esophageal cancer from 1960 to 1980 was done to evaluate the impact of TPN in 72 patients treated from 1973 to 1980 with 43 non-TPN patients treated during the same period and to 129 patients operated upon before 1973. Mean age, sex distribution, site, stage, and treatment of the disease were similar for the two study groups. The TPN group lost less weight during treatment (3 lbs vs. 11 lbs) and had fewer overall complications postoperatively (24% vs. 41%). Significant reductions in major wound, infectious, and postoperative complications were noted in these patients who received at least 5 days of preoperative TPN compared with postoperative TPN or the non-TPN groups (4% vs. 24% and 23%). Malnourished esophageal cancer patients can more safely undergo aggressive operative therapy and radiation treatment when adequate perioperative nutritional support is added to the treatment armamentarium.
Cardiac arrest is most commonly encountered as the end result of severe derangements in metabolic homeostasis. These derangements may include toxic, ischemic, or electrophysiological causes of circulatory and/or respiratory arrests. Occasionally, mechanical obstruction or impediment to circulation may cause cardiac arrest, and forms of resuscitation other than closed chest massage may be required to remove or relieve obstruction. Two cases of cardiac arrest due to mechanical impairment of blood flow are presented. Both occurred during thoracic invasive procedures, and in both cases, the usual externally applied closed chest resuscitative measures were not, and could not have been effective. Emergency thoracotomy promptly restored functional hemodynamics, and allowed the potential for definitive therapy.
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One hundred fifty patients underwent radionuclide left ventricular performance studies before and one week after resection of a left ventricular aneurysm. The patients were classified according to pre-and postoperative ejection fraction into five classes as follows: Class I > 50%, Class II = 41%-50%, Class III = 31%-40%, Class IV = 21%-30%, and Class V = < 21%. They were also classified into groups according to the size of the aneurysm and wall thickness. Operative mortality was 4.6% (7/150). One hundred one patients (67%) improved at least one "ejection-fraction class" postoperatively; whereas in a similar group of patients who underwent aortocoronary bypass without left ventricular aneurysm resection, only 42.3% (58/137) improved (p <.01). Preoperatively, ejection fraction was < 40% in 136 patients (90.6%); and postoperatively, it was > 40% in 59 patients (39.3%) (p <.01). Improvement of at least one "ejection-fraction class" occurred in 22 patients (47.8%) with small aneurysms, 54 patients (69.2%) with moderate size aneurysms (p <.05), and 25 patients (96.1%) with large aneurysms (p <.01). Sixty-nine patients (88.4%) with thin-walled aneurysms and 32 patients (44.4%) with thick-walled aneurysms improved (p <.01). Resection of a left ventricular aneurysm improves left ventricular function, particularly in patients with large, thin-walled aneurysms. A less aggressive surgical approach is warranted when dealing with thick-walled akinetic areas as patients with these lesions do not respond well to resection.
Blood compatibility is a major objective in the development of long-term, implantable circulatory assist (left ventricular assist devices) and replacement (total artificial heart) devices. An important problem in experimental studies in animals has been the propensity for calcification to occur at the blood/material interface. Presented is a summary of our experience (27 studies) with blood pump calcification and a review of the current literature regarding this complication.
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An intracorporeal (abdominal) left ventricular assist device (ALVAD) or partial artificial heart was designed, developed, extensively tested in vitro and in vivo, and subsequently approved for controlled clinical trials in institutions. The ALVAD is pneumatically actuated, synchronously or asynchronously, with an external console and is interposed between the apex of the left ventricle and infrarenal abdominal aorta. The implantation techniques are straightforward and replicable. The ALVAD was used in weaning from cardiopulmonary bypass to support the circulation in cardiogenic shock after infarction and as a bridge to cardiac transplantation. It was found that the profoundly depressed human left (and right) ventricles initially incapable of ejection can recover if totally supported with this device. This experience strongly suggests that ALVADs should be used early in instances of intra-aortic balloon pump inadequacy.
Surgical treatment of aneurysms of the transverse aortic arch has been a challenge to cardiovascular surgeons. The problems include protection of the brain and spinal cord from ischemic or embolic injury, prevention of hemorrhage and coagulopathy, and prevention of myocardial damage during prolonged extracorporeal circulation. Two methods are described. Group 1 included 20 patients in whom deep hypothermic conditions were induced (12 degree to 16 degree C) followed by circulatory arrest and partial exsanguination. In this group a 50% hospital mortality occurred. Patients in Group 2 underwent moderate induced hypothermia (24 degree to 26 degree C) with continuous cerebral perfusion during the period of peripheral circulatory arrest. Four of 5 patients survived this technique, leading us to believe this method is preferred over the deeper levels of hypothermia. A method of preclotting the Dacron graft with platelet-rich plasma and autoclaving is described. It has eliminated interstitial bleeding through fabric grafts.
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A patient with acute bacterial endocarditis in whom ischaemic contracture of the left ventricle (stone-heart syndrome) developed during aortic and mitral valve replacement had an emergency implantation of an intracorporeal partial artificial heart (an abdominal left-ventricular assist device of ALVAD). This device functioned as a total artificial heart for nearly 6 days, while a donor heart for transplantation was sought. The ALVAD was then removed, and the patient received allografts of a heart and a kidney. The transplanted heart functioned well, but the patient died 15 days later from gram-negative sepsis. There was no evidence of cardiac or renal allograft rejection.
The presence of carcinomatous pulmonary metastases is a common clinical problem viewed by many physicians as beyond the realm of definitive surgical considerations. However, a number of patients dying with pulmonary metastases will have the totality of their disease confined to the lungs. In this select population, there is some potential for long term control or effective palliation through aggressive surgical management. This study quantitatively assesses the value of surgery in this setting and examines the prognostic effect of several important clinical variables. A single set of criteria were adhered to in the selection of patients. Cases were stratified in accordance with the intent of surgery, namely, 1) complete control and ablation of all known disease, or 2) reduction of total tumor burden to examine the possibilities for enhanced control by adjunctive therapeutic modalities.