Management of complicated pneumatocele.
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Air↗
Biomedical subjects
R Espada
Publications and source records attributed to R Espada.
Thoracic splenosis 25 years after gunshot wound to the abdomen.
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Abdominal Injuries↗
Intermittent brachiocephalic vein obstruction secondary to a thymic cyst.
Mediastinal thymic cysts are usually asymptomatic and found incidentally on a routine chest roentgenogram. Rarely, they may cause symptoms of vascular obstruction. A 55-year-old woman presented with intermittent swelling in her left neck. The swelling was positional and was worse while supine and disappeared while upright. Evaluation revealed a thymic cyst causing extrinsic compression of the left brachiocephalic vein. The cyst was resected with complete resolution of the left neck swelling.
Brachiocephalic Veins↗
Chest radiograph heterogeneity predicts functional improvement with volume reduction surgery.
BACKGROUND: Using a historical cohort study model, we tested the hypothesis that heterogeneity of emphysematous changes on the preoperative chest radiograph correlated with favorable outcome of lung volume reduction surgery. METHODS: The test population consisted of 21 patients with severe emphysema who were being treated at a 1,000-bed university-affiliated tertiary teaching hospital. A simple but quantitative index of heterogeneity has been devised, whereby the preoperative posteroanterior chest radiographic lung fields are divided into four geometric quadrants. Each quadrant is scored (0 to 4) for emphysematous changes by two radiologists blinded as to subsequent patient management and outcome. Criteria for determining presence of emphysema were hyperlucency, decreased vascular markings, and parenchymal crowding indicating compressed lung. Heterogeneity index is the sum of the two highest scores minus the two lowest, with a maximum index of 8 and a minimum of 0. Preoperative chest radiographs and postoperative changes in forced expiratory volume in 1 second were examined. RESULTS: The heterogeneity index was positively correlated with change in forced expiratory volume in 1 second after operation with an r2 of 0.31 and an average increase of 117 mL per unit increase in heterogeneity index (p < 0.009). CONCLUSIONS: This simple index of heterogeneity may be useful as a predictor of improved pulmonary function after lung volume reduction surgery.
Aged↗
Relation of the contractile reserve of hibernating myocardium to myocardial structure in humans.
BACKGROUND: Although dobutamine echocardiography (DE) is widely used to assess myocardial viability in humans, little is known about the relation between contractile reserve and myocardial structure. METHODS AND RESULTS: We evaluated 20 patients with coronary disease (64+/-13 years old, ejection fraction 28+/-7.5%) with DE (up to 40 micrograms . kg(-1). min(-1)), rest-redistribution (201)Tl single photon emission CT, and quantitative angiography before bypass surgery. During surgery, patients underwent transmural myocardial biopsies (n=37) guided by transesophageal echocardiography to determine the extent of interstitial fibrosis and intracellular and interstitial proteins by histopathology and immunohistochemistry. Among the 37 segments biopsied, 16 recovered function as assessed 2 to 3 months later. Segments with postoperative functional recovery had more wall thickening at low-dose DE (28% versus 3%, P<0.001), higher thallium uptake (69% versus 48%, P=0.03), and less interstitial fibrosis (2% versus 28%, P<0.001). Quantitative angiographic parameters did not predict recovery of function. Segments with DE viability (contractile reserve and/or ischemia) had less fibrosis (2.7% versus 28%, P<0.001), less vimentin and fibronectin (both P<0.01), more glycogen (P=0.016), and higher thallium uptake (64% versus 35.5%, P<0.05) than those without viability. Viable segments by both DE and thallium had less fibrosis (1%) than those viable by 1 of the 2 techniques (9%) or not viable by both (28%, P=0.005). Thickening at low-dose DE correlated well with the extent of interstitial fibrosis (r=-0.83, P<0.01). CONCLUSIONS: Contractile reserve during DE correlates inversely with the extent of interstitial fibrosis and the amount of fibronectin and vimentin and directly with rest-redistribution thallium uptake.
Adrenergic beta-Agonists↗
The anatomical aspects of minimally invasive cardiac valve operations.
Cadaveric dissections were carried out to examine the relationship of the cardiac valve structures to the surface anatomy of the chest as it relates to our approaches to minimally invasive valvular operations. The techniques of upper hemisternotomy and lower hemisternotomy as used at our institution are described.
Cardiac Surgical Procedures↗
Orthotopic cardiac transplantation after minimally invasive direct coronary artery bypass.
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Adrenomedullin↗
Methods of acute postcardiotomy left ventricular assistance.
OBJECTIVE: Despite many technological advances in cardiovascular surgery, some patients still experience postcardiotomy left ventricular (LV) failure that is refractory to both inotropic support and intra-aortic balloon pump (IABP) placement. The primary author (MJR) recently changed from inflow cannulation at the right superior pulmonary vein/left atrial junction to inflow cannulation at the dome of the left atrium. The purpose of this study was to compare data collected during placement of a left ventricular assist device (LVAD) at the junction of the right superior pulmonary vein with positioning the device in the dome of the left atrium. Experimental design, setting, and participants: the medical records of all patients undergoing cardiac surgery by one author (MJR) between 1994 and 1997 were retrospectively reviewed, and 4 patients requiring LVAD placement for short term postcardiotomy support were identified. Each patient's chart was reviewed for duration of LVAD support, average LVAD blood flows, pulmonary capillary wedge pressures (PCWP), preoperative characteristics, postoperative complications, and final outcome for the patients. RESULTS: Accessing the left atrium through the dome resulted in excellent blood flow through the LVAD and allowed for good LV decompression. Hemostasis remained the most common complication regardless of the technique employed; however, the enhanced visibility provided by accessing the left atrium via the dome made repairs less technically difficult. Three patients (75%) were able to be weaned from the LVAD and were discharged from the hospital to home. Two of these patients were cannulated via the left atrial dome making removal of the LVAD easier, thus exposing the patients to less additional operative time. One patient could not be weaned from LVAD support secondary to development of right ventricular failure requiring RVAD insertion and subsequent development of multiple organ failure syndrome. CONCLUSIONS: Patients requiring LV assistance following cardiopulmonary bypass surgery traditionally have high levels of morbidity and mortality. In spite of the complications associated with the placement of an assist device, we remain encouraged by the excellent LV decompression and systemic flows we achieved following implantation of the LVAD through the dome of the left atrium. The superior ease of implantation and decannulation provided better operative care and postoperative management for our patients.
Acute Disease↗
Operation for acute and chronic aortic dissection: recent outcome with regard to neurologic deficit and early death.
BACKGROUND: We reviewed our experience in the repair of acute and chronic aortic dissection with regard to early neurologic deficit and death. METHODS: Between February 1991 and June 1996, we performed 206 operations on 195 patients for aortic dissection. Ascending or arch repair, or a combination (type A dissection) was performed on 92 of 206 patients (45%); 44 of 92 (48%) were acute dissection and 48 of 92 (52%) were chronic. Descending or thoracoabdominal repair (type B dissection) was performed on 114 of 206 patients (55%); 22 of 114 (19%) were acute and 92 of 114 (81%) were chronic. RESULTS: Among type A cases, strokes occurred in 6 of 92 patients (7%) overall; 4 of 44 (9%) were acute cases and 2 of 48 (4%) were chronic (p < 0.34). Early deaths for type A were 11 of 92 (12%) overall; 9 of 44 (20%) acute and 2 of 48 (4%) chronic (p < 0.02). In type B cases, neurologic complications were 15 of 114 (13%) overall; 7 of 22 (32%) were acute cases and 8 of 92 (9%) were chronic (p < 0.004). Early deaths for type B were 12 of 114 (11%) overall; 3 of 22 (14%) acute and 9 of 92 (10%) chronic (p < 0.6). Preoperative hypotension was significant in acute type A patients, with strokes in 2 of 7 (29%) hypotensives compared with 2 of 37 (5%) normotensives (p < 0.05) and early death in 4 of 7 (57%) hypotensives versus 5 of 37 (14%) normotensives (p < 0.009). CONCLUSIONS: Morbidity and mortality for repair of chronic dissection types A and B were acceptable. Preoperative hypotension in acute type A dissection was a major predisposing factor toward stroke (29% versus 5%, p < 0.05). Acute type B dissection had acceptable mortality (14%) but a high rate of neurologic complications (32%).
Acute Disease↗
Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair.
BACKGROUND: In previous studies of the neurologic outcome of patients undergoing thoracoabdominal aortic aneurysm repair with the simple cross-clamp technique, cross-clamp time of greater than 30 minutes was identified as an important risk factor. We retrospectively examined the effect of clamp time of 30 minutes or greater on outcome for patients undergoing repair with the addition of surgical adjuncts. METHODS: Between February 1991 and June 1996 we operated on 370 patients for thoracoabdominal or descending thoracic aortic aneurysm. Two hundred seventy-one of these patients with cross-clamp times of 30 minutes or greater were included in this study. One hundred twelve patients underwent simple cross-clamp repair, whereas 159 were operated on with the surgical adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. RESULTS: By multivariate analysis, acute dissection, surgical adjuncts, and aneurysm extent proved most significant in overall patient outcome. The overall rate of early neurologic deficits was 23 of 271 (8.5%). For highest risk patients with type II thoracoabdominal aortic aneurysms, the rate of neurologic deficits was 11 of 29 (38%) for cross-clamp versus 6 of 82 (7.3%) for adjunct operation patients (odds ratio = 0.13; p < 0.001). CONCLUSIONS: The adjuncts of cerebrospinal fluid drainage and distal aortic perfusion decreased the risk of extended cross-clamp time during thoracoabdominal aortic aneurysm repair, particularly for highest risk type II.
Aged↗
Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision.
PURPOSE: Although some authors advocate hypothermic circulatory arrest for spinal cord protection in descending thoracic and thoracoabdominal repair, this method has been associated with high morbidity and mortality rates in other studies. The safety and effectiveness of this surgical adjunct were evaluated. METHODS: Between February 1991 and April 1997, 409 patients underwent thoracic or thoracoabdominal aortic repair. Because of an inability to gain proximal aortic control because of anatomic or technical difficulty, hypothermic circulatory arrest was used in 21 patients (4.9%). Thirteen patients were men, 8 were women, and the median age was 57 (range, 21 to 81 years). Four patients (19%) had Marfan's syndrome, and 1 had aortitis. Seven patients (33%) had aortic dissection (4 chronic type A, 2 chronic type B, 1 acute B), and 1 had aortic laceration. All but 6 patients had hypertension. Fifteen patients (73%) were operated on for repair of the distal arch and descending thoracic aorta, 4 (19%) for repair of the distal arch and thoracoabdominal aorta, and 2 for repair of either the thoracoabdominal or descending thoracic aorta alone. Surgery for 9 patients (43%) also included bypass grafts to the subclavian or innominate arteries. Six operations (29%) were urgent. RESULTS: The overall 30-day mortality rate was 29% (6 of 21 patients). Among urgent patients, the mortality rate was 50% (3 of 6 patients) versus 20% (3 of 15) for elective patients. Of the remaining 15 patients, renal failure occurred in 1 (7%) and heart failure in 2 (13%). Ten patients (67%) had pulmonary complications. Encephalopathy occurred in 5 patients (33%) and stroke in 2 (13%), and spinal cord neurologic deficit developed in 2 (13%). The median recovery was 28 days (range, 10 to 157 days). CONCLUSION: Hypothermic circulatory arrest did not reduce the incidence of deaths and morbidity to a rate comparable with our conventional methods. We recommend the judicious application of this method in rare instances when proximal control is not feasible or catastrophic intraoperative bleeding leave the surgeon with no other option.
Adult↗
New developments in mitral valve repair.
The etiology of mitral valve disease is changing. The predominance of rheumatic pathology has given way to degenerative pathology in an increasingly elderly population. Mitral valve conservation by repair rather than replacement has several advantages. Repair is associated with a lower incidence of thromboembolism, hemolysis, and infectious endocarditis. For patients in sinus rhythm, thromboembolism is rare and anticoagulation can be discontinued. Repair also is associated with improved long-term survival. This article reviews the current literature on different types of surgical techniques for repair of the mitral valve and discusses future trends.
Heart Valve Diseases↗
Correlation of serum magnesium and serum lipid levels in hemodialysis patients.
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Female↗
Mitral valve injury from blunt trauma.
Mitral valve injury from blunt trauma to the chest is an uncommon entity. We report a case of mitral valve injury after a fall, and its repair. The English literature is reviewed from the earliest report in 1873 to the present. The diagnosis, types of injury and surgical correction are discussed.
Accidental Falls↗
Assessment of myocardial viability with 99mTc-sestamibi tomography before coronary bypass graft surgery: correlation with histopathology and postoperative improvement in cardiac function.
BACKGROUND: Assessment of myocardial viability by 99mTc-sestamibi remains controversial. Accordingly, we investigated the use of sestamibi as a marker of myocardial viability, defined by histopathology, and for predicting improvement of myocardial function after coronary artery bypass graft surgery (CABG). METHODS AND RESULTS: 99mTc-sestamibi perfusion tomography and radionuclide angiography were performed within 2 days before CABG in 21 patients with > or = 75% stenosis of the left anterior descending coronary artery and resting anterior wall dyssynergy. During CABG, transmural myocardial biopsies were obtained from the dyssynergic anterior wall and from normal myocardial segments to determine the extent of viable myocardium by histopathology. Improvement of regional left ventricular function was evaluated by radionuclide angiography at 6 to 8 weeks after CABG. There was a good correlation (r=.85, P<.001) between the quantified sestamibi activity and the extent of viable myocardium determined morphometrically. Among 21 biopsied dyssynergic myocardial segments, 11 improved their function after CABG and 10 failed to improve. Biopsied segments with improved postoperative function had significantly higher sestamibi activity (81+/-5% versus 49+/-16%, P<.0001) and significantly lower extent of interstitial fibrosis (7+/-4% versus 31+/-21%, P=.0002) than segments that failed to improve. A 55% threshold of 99mTc-sestamibi activity had positive and negative predictive values of 79% and 100%, respectively, for recovery of function after CABG in the biopsied segments. CONCLUSIONS: Myocardial 99mTc-sestamibi activity correlates well with the extent of viable myocardium and predicts improvement in regional function after CABG. This lends support to the use of sestamibi as a myocardial viability agent.
Adult↗
Visualization of ventricular fibroelastoma with a video-assisted thoracoscope.
Left ventricular papillary fibroelastomas are associated with a high risk of cerebral embolization. Two-dimensional echocardiography and intraoperative transesophageal echocardiography are helpful in diagnosing tumors, planning a surgical approach, and achieving adequate excision. A video-assisted thoracoscope via the left atrium was used to visualize a left ventricular papillary fibroelastoma. Thoracoscopic visualization facilitated excision of a mass within the chordae tendineae between the anterolateral papillary muscle and the left ventricular wall. Video-assisted thoracoscopy greatly facilitates exposure/excision of deeper intracavitary left ventricular masses.
Endoscopy↗
Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment.
Left ventricular free wall rupture is the third leading complication and the second most common cause of death after myocardial infarction. Its occurrence has been considered an unpredictable event usually leading to death. An increased appreciation for the clinical presentation of this syndrome and the nearly ubiquitous use of echocardiography have fostered a rise in the antemortem diagnosis of left ventricular free wall rupture, allowing the possibility of operative repair. Despite the increased reporting of left ventricular free wall rupture, the experience of any one surgeon or surgical group tends to be quite small. We review the current status of rupture prediction, clinical presentation, diagnosis, and treatment options. A recent case of left ventricular free wall rupture referred to the Baylor Cardiothoracic Surgery Group with the misdiagnosis of ruptured dissection of the ascending thoracic aorta is presented to illustrate our approach to this clinical situation.
Heart Rupture, Post-Infarction↗
CT reconstruction of an unusual chronic posttraumatic aneurysm of the thoracic aorta.
Chronic traumatic aneurysm of the thoracic aorta is an unusual occurrence. Previously, arteriography was performed on all patients seen in our institution with this entity to allow confirmation of the diagnosis and anatomic delineation for operation. A case of chronic traumatic aneurysm of the distal descending aorta discovered on a routine chest roentgenogram and evaluated with chest computed tomographic scanning with three-dimensional reconstruction is presented. It is our belief that not all thoracic aneurysms require arteriography, and improved methods of computed tomographic scanning allow adequate diagnosis and anatomic delineation with decreased morbidity and cost.
Accidents, Traffic↗