Prune belly syndrome in adult man.
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Age Factors↗
Biomedical subjects
R S Hartz
Publications and source records attributed to R S Hartz.
Pulmonary thromboendarterectomy for pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension is a term that has been proposed by Dr. Kenneth Moser to describe a progressively debilitating process that occasionally follows venous thrombosis and pulmonary embolism. In the past, the disease was dramatically underdiagnosed for several reasons: 1) the initial event--deep vein thrombosis or pulmonary embolism--is usually clinically silent; 2) there is a subsequent asymptomatic "honeymoon period" in most patients; 3) there is no clinical description of chronic thromboembolic pulmonary hypertension in most textbooks of medicine and surgery; and 4) until recently, surgical therapy could be performed by only a few surgeons, and with a prohibitive operative mortality. Intensive efforts by physicians at the University of California, San Diego have led to increased recognition of the disease, a better understanding of its pathophysiology, and development of a curative procedure with an acceptable operative mortality. Chronic thromboembolic pulmonary hypertension is truly the "aortic stenosis" of the pulmonary circulation, and the clinical improvement after pulmonary thromboendarterectomy is even more dramatic than that seen after aortic valve replacement.
Endarterectomy↗
Comparison of transesophageal and transthoracic echocardiography for diagnosis of right-sided cardiac lesions.
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Echocardiography↗
Characterization of the sodium current in single human atrial myocytes.
Patch-clamp recording techniques have permitted measurement of the fast Na+ current (INa) in isolated cardiac cells from a number of species in recent years. However, there is still only very little information concerning human cardiac INa. The purpose of this study was to describe the kinetics of INa in normal-appearing, Ca(2+)-tolerant, enzymatically isolated human atrial myocytes using whole-cell voltage-clamp techniques. Atrial specimens were obtained from 46 patients undergoing open heart surgery. Cs+ was substituted for K+ in both pipette and external solutions and F- was added to the former. The reversal potential of the rapid inward current varied approximately 57 mV at 17 +/- 1 degrees C with a 10-fold change in [Na+]o, and the current was completely blocked by 100 microM tetrodotoxin, findings typical of the fast cardiac Na+ current. The tetrodotoxin dose-response curve was best fitted by an equation describing binding to high- and low-affinity sites. INa was activated at a voltage threshold of -70 to -60 mV, and peak inward current was obtained at approximately -30 mV (holding potential, -140 mV). The inactivation time course was voltage dependent and was fitted best by the sum of two exponentials. The relation between voltage and steady-state availability (h infinity) was sigmoidal with the half-inactivation at -95.8 +/- 0.9 mV and a slope factor of 5.3 +/- 0.1 mV (n = 46), and we did not observe a significant difference with disease and age. The overlap of the h infinity and activation curves suggested the presence of a Na+ "window" current. Recovery from inactivation also was voltage dependent and best fitted by a model describing the sum of two exponentials. Recovery occurred after an initial delay at potentials positive to -140 mV, suggesting that inactivation of human atrial INa is a multistate process. We conclude that INa of normal-appearing, Ca(2+)-tolerant human atrial myocytes is similar to that of other mammalian cardiac cells with the possible exception of having two tetrodotoxin binding sites.
Adolescent↗
Oblique transseptal left atriotomy for optimal mitral exposure.
Twenty patients underwent mitral valve replacement or other surgical procedures within the left atrium with Dubost's transseptal left atriotomy. The left atrium was grossly enlarged in six patients. Exposure was considered to be excellent in 13 patients and poor in only two. One patient (with a second aortic and mitral valve replacement) required a permanent pacemaker after operation, none had a residual shunt at the atrial level, and none required reoperation for bleeding. The Dubost transseptal left atriotomy affords excellent exposure of left atrial structures, is easy to close, and does not increase the prevalence of postoperative rhythm disturbances.
Adolescent↗
New uses of the laser in thoracic and cardiovascular surgery.
Lasers have been accepted in general thoracic surgery as resectional tools which allow precise hemostasis and maximal salvage of normal lung tissue. Used endoscopically, with or without associated photodynamic therapy, we have provided acceptable palliation in some patients with obstructing tumors of the tracheobronchial tree and esophagus. Cardiovascular uses of the laser have been under extensive investigation at our medical center for many years. We have demonstrated that laser-assisted anastomosis of small vessels is possible, that early tensile strength and patency are excellent, but that long-term aneurysm formation is excessive. In addition, CO2 laser injury of the arterial intima leads to a marked increase in atheromata formation in animal models of atherosclerosis; this may be eliminated with the excimer laser. We have begun using the excimer laser to open obstructed peripheral and coronary arteries. New technology is emerging which allows dual fiber catheters which allow identification of tissue in an artery, ie calcium, atheromata, clot, media, etc. and instantaneous computer sensing/integration which initiates "fire" or "no fire" signals in the enclosed laser system, thus decreasing the chance of vessel perforation. These technologies, in association with balloon angioplasty, intravascular stents, and atherectomy devices are offering exciting alternate therapy for patients with obstructing atherosclerosis.
Cardiac Surgical Procedures↗
CO2-laser radiation damage of the arterial wall.
This study describes the effects of CO2 laser radiation on the histology of the normal rabbit arterial wall, using models that simulate laser angioplasty and anastomosis. Rabbit arteries were exposed to laser treatments similar to those used clinically; 40, 0.5 sec pulses of 40-60 mW, CO2 continuous wavelength laser, or a 1/2-circumferential laser anastomosis with a 60-80 mW continuous pulse. Aneurysms developed in 8 of 22 femoral, 1 of 22 carotid, and no controls at 12 week. There were small breaks in the internal elastic lamina with atrophy, loss of muscularis, "packing" of the elastica, thinning of the muscularis at the damage site, and enlargement of the arterial diameter. Aneurysms developed in one femoral and no carotid anastomosed artery. Laser anastomoses demonstrated more muscle damage and loss, with extensive scarring and a wider area of elastic loss than the controls. The intima was reestablished with focal reduplication of the internal elastic lamina. There were no histologic differences between the arteries which developed aneurysms and those which did not in either series. These results suggest that low power laser damage of the arterial wall consists mainly of destruction of the muscularis propria, with minimal damage to the elastica.
Anastomosis, Surgical↗
A method of decreasing anastomotic leaks and delivering cardioplegia in aortic root replacement.
Ascending aortic root replacement is associated with a significant incidence of bleeding from composite graft to annulus anastomosis and from coronary to composite anastomosis. We describe a technique for composite graft to annulus and coronary to composite graft anastomoses with circular Teflon donuts. We also describe a method for delivery of antegrade cardioplegia that allows assessment of anastomoses prior to weaning from bypass.
Anastomosis, Surgical↗
Computed tomography in patients with esophageal perforation.
Contrast esophagram is the diagnostic procedure of choice in patients with clinically suspected perforation of the esophagus. In patients in whom the usual clinical signs or symptoms are unrecognized and in whom the diagnosis is obscure, the diagnosis of a perforated esophagus may be suggested by the finding of mediastinal fluid and air on CT. Three patients are reviewed. The perforations included one spontaneous, one from erosion of an esophageal carcinoma, and one iatrogenic. In two of the three patients, the diagnosis of perforated esophagus had not been made initially and in one patient the initial esophagram was interpreted as normal. Computed tomography of the chest in each patient led to the suspected diagnosis of perforated esophagus. Prompt appropriate surgical intervention followed. The findings of mediastinal fluid and more importantly mediastinal air on CT of the chest are strongly suggestive of esophageal perforation.
Adult↗
Inhibition of electrogenic Na(+)-pumping in isolated atrial tissue from patients treated with digoxin.
The effect on the cardiac sarcolemmal Na+,K(+)-pump of therapeutic concentrations of cardiac glycosides administered long-term to humans in a clinical setting is uncertain. We therefore examined Na+,K(+)-pump activity in atrial tissue from two groups of patients undergoing cardiac surgery. Fourteen patients received digoxin long-term until the time of surgery and 12 "controls" never received digoxin. The hyperpolarization produced by the electrogenic Na+,K(+)-pump in response to an increase in intracellular Na+ activity was utilized to evaluate Na+,K+)-pump activity. After excision from the patients, specimens of atrial tissue were Na(+)-loaded by cooling to 2-3 degrees C for 1 hr. They were then warmed to 30 degrees C in Tyrode's solution containing 20 mM K+. After warming the resting membrane potential of the tissues from both groups transiently hyperpolarized to levels more negative than the equilibrium potential for K+ (= approximately -50 mV in 20 mM K+) indicating that the hyperpolarization was the consequence of electrogenic Na(+(-pumping. The maximal hyperpolarization of the resting potential in tissue from patients receiving digoxin long-term (-58.4 +/- 1.9 mV, mean +/- S.D.) was significantly (P less than .01) less negative than that in tissue from patients in the control group (-69.9 +/- 2.2 mV). These data support the hypothesis that digoxin, administered therapeutically in the clinical setting, can inhibit the Na(+)-pump in human heart, and that during long-term administration of digoxin the inhibition can be sustained.
Digoxin↗
Implications of prosthetic valve implantation: an 8-year follow-up of patients with porcine bioprostheses.
Nurses in cardiovascular critical care settings routinely care for patients with implanted valvular prostheses. The presence of an artificial valve substitutes a new disease state for the preexisting valvular disease. Five hundred nine patients who underwent cardiac valve replacement with porcine bioprostheses and who were followed for a total of 1633 patient-years provide the data base for discussion of long-term survival, functional capacity, and morbidity associated with valvular prostheses. Seventy-two percent of patients survived 5 years after operation. New York Heart Association functional class was improved in 84%. Three major types of morbidity were documented: thromboembolism, endocarditis, and valve failure. Cardiovascular nurses should be familiar with the implications of valvular prostheses to provide appropriate patient education and to facilitate the prompt detection and treatment of valve-related complications.
Actuarial Analysis↗
Pulmonary venous anastomosis in lung transplantation without donor left atrium. Experimental and clinical results.
Single lung transplantation now is a therapeutic option for some patients with end-stage lung disease. Cyclosporine immunosuppression and refinements in bronchial anastomosis have been responsible for recent successes. Since 1953, the usual pulmonary venous anastomosis, both in experimental animals and in humans, has been an atrium-to-atrium connection. This technique may limit the availability of usable donor lungs, since the donor heart, along with the atrium, is usually harvested for another recipient. Although techniques can be developed to allow both transplant teams to harvest atrial tissue, this study was undertaken to determine if, in fact, anastomosis with donor left atrium is necessary. Twenty-four dogs were anesthetized and a left thoracotomy performed. After heparinization (3 mg/kg), the pulmonary artery and left atrium were occluded. One of four different pulmonary venous anastomoses was performed at 3.5x magnification: superior pulmonary vein end to end (group I), inferior pulmonary vein end to end (group II), superior pulmonary vein implantation into left atrium (group III), and left atrium-to-left atrium anastomosis as control (group IV). Everting mattress sutures of 7-0 polypropylene were used in groups I, II, and III and 6-0 in group IV. Average crossclamp time for group I, group II, and group IV was 20 minutes. The average crossclamp time for group III was 10 minutes. All anastomoses were patent at the time of 1-week reevaluation. Gross and microscopic examination demonstrated establishment of an intimal lining; organized nonocclusive thrombus was present in only one anastomosis. We conclude that atrium-to-atrium anastomosis is not necessary for a successful single lung transplantation, and that transplantation of a single lobe is feasible. The best alternative is implantation of the pulmonary vein into the left atrium, which will easily allow use of the heart and both lungs from a single donor to different recipients. We have used this anastomosis in one patient without difficulty.
Anastomosis, Surgical↗
Laser-assisted parenchyma-sparing pulmonary resection.
The neodymium:yttrium-aluminum-garnet laser is an excellent tool for removing lesions while sparing surrounding normal tissue. Local excision of 32 pulmonary lesions in 26 patients was performed with the Nd:YAG laser. Fourteen patients had moderate to severe impairment of pulmonary function: average forced vital capacity = 2.2 +/- 0.3 L and forced expiratory volume in 1 second = 1.3 +/- 0.3 L. Limited thoracotomy was used in the last 23 patients. The resected lesions included 16 primary malignant tumors: nine adenocarcinomas, five squamous carcinomas, and two large cell carcinomas. Eight of these lesions were classified as T1 N0, seven were T2 N0; and one was T1 N2. There were 10 metastatic lesions: three lymphomas, two adenocarcinomas, two leiomyosarcomas, and one case each of melanoma, squamous cell carcinoma, and renal cell carcinoma. There were six benign lesions: three granulomas, two hamartomas, and one carcinoid. Twelve lesions were deep seated, could not have been removed by wedge resection or segmentectomy, and would have necessitated lobectomy without this technique. With the laser, the lesion could be precisely excised with minimal loss of lung parenchyma. Mean operating time was 80 +/- 20 minutes; laser resection time was 15 +/- 8 minutes. Resection necessitated 10,000 to 20,000 J. Total blood loss was minimal (less than 100 ml). Chest tubes were always used and remained in place 5 +/- 2 days. The mean hospitalization time was 10 +/- 2 days. Pulmonary function testing, perform 6 weeks to 6 months after discharge, showed no significant difference from preoperative levels. To date, there have been no local recurrences (longest follow-up 2 years). The Nd:YAG laser is an excellent adjunct for pulmonary resection in patients who have marginal pulmonary function or who have deep parenchymal lesions not amenable to wedge resection. The operative technique for laser resection is presented.
Female↗
New approach to defibrillator insertion.
The automatic implantable cardioverter/defibrillator has become an integral part of the management of patients with life-threatening ventricular rhythm disturbances. The considerable size of the device (250 gm, 10.8 by 7.6 cm) results in protrusion from the abdominal wall, with an associated alteration in self-image in all patients. In thin patients, erosion through the skin can occur. We have devised an operation in which the generator is implanted in, and becomes part of, the chest wall. The two patients in whom this approach has been used are virtually unaware of the presence of the device. We propose this operation as an alternative to abdominal wall insertion when the latter is unsuitable for technical reasons.
Aged↗
Risk assessment of coronary artery bypass grafting within one month of acute myocardial infarction.
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Combined Modality Therapy↗
Coronary embolism following atrial septal defect repair.
To our knowledge, coronary embolism following repair of atrial septal defect has not been reported previously. A 29-year-old woman had an angiographically documented embolus to the circumflex coronary artery on the fifth postoperative day after pericardial patch repair of a secundum atrial septal defect. This complication might have been prevented by temporary postoperative anticoagulation.
Adult↗
Autotransfusion after cardiac operation. Assessment of hemostatic factors.
Reinfusion of mediastinal blood after coronary bypass grafting reduces the need for homologous transfusion with its hazards. To determine the efficacy of autotransfusion using the cardiotomy reservoir used during operation as a postoperative collection system, we studied the characteristics of reservoir blood (minimum 500 ml, mean 810 ml) and compared the hematologic profiles of 21 patients before and after blood infusion. The mean hematocrit value of the shed blood was 25% +/- 7%, platelet count 60,000 +/- 39,000/microliter, fibrinogen 19 +/- 25 mg/dl, and factor VIII 11% +/- 7%. The fibrinopeptide A concentration was 400 ng/ml, and the B beta 15-42 peptide was 28 +/- 14 pmol/ml. These values indicate defibrination of the blood before collection (no clots were found in the reservoirs), and no significant differences were detected between the types of reservoirs used (Bentley, n = 10, Shiley, n = 11). Infusion of reservoir blood between 500 and 1860 ml did not significantly affect the factor VIII, fibrinopeptide A, or B beta 15-42 peptide levels. Fibrinogen levels increased from 254 to 395 mg/dl (p less than 0.001). Only six of 21 patients received bank blood before discharge. These findings indicate that extensive coagulation occurs within the mediastinum before the blood is collected, that mediastinal blood can be safely infused without inducing fibrinolysis or disseminated intravascular coagulation, and that use of the cardiotomy reservoir is a safe and inexpensive method of autotransfusion after coronary artery bypass grafting.
Blood Transfusion, Autologous↗
Pulmonary procedures assisted by optosurgical and electrosurgical devices: comparison of damage potential.
Electrosurgical devices have been used widely in thoracic surgery to assist in dissection and to reduce hemorrhage. Recent experimental data have shown that lasers may be used to resect and control small air leaks while conserving normally functioning lung. This investigation quantitates the amount of damage produced by the electrosurgical unit (ESU), the carbon dioxide laser (CO2), and the neodymium: YAG laser (YAG) compared to standard suture (SU) techniques. Six dogs were anesthetized, intubated, and ventilated. The left chest was opened and the lower lobe exposed, where four sets of lesions were created using each device. All lesions were visually similar to those lesions that would be created for sealing at the time of a pulmonary resection. The lesions were harvested immediately following wounding as well as at 1, 3, and 6 week intervals. They were examined histologically and ranked from least to most damage produced at each interval. A grading system (0-4+) was also devised to compare the injury to simultaneously harvested normal lung. Immediately following injury, histologic ranking was: CO2 (2+), suture (2+), ESU (3+), YAG (4+). By 6 weeks, the suture damage had become minimal and the ranking was: suture (1+), CO2 (2+), YAG (4+), ESU (4+). The ESU consistently produced more extensive damage than any other device. It appears that the most suitable long-term adjunctive devices to assist in pulmonary surgery are suture and the CO2 laser. The YAG laser may have specific indications in circumstances when significant blood loss may be encountered. ESU usage should be minimized when attempting to preserve functioning lung tissue.
Animals↗