Agustin Arbulu

Hemodynamic consequences of total removal of the tricuspid valve without prosthetic replacement

Tricuspid valvulectomy without prosthetic replacement has been advocated as a life-saving measure in the treatment of Pseudomonas endocarditis of the tricuspid valve. This report describes the hemodynamic data obtained in 10 patients before and after removal of the tricuspid valve. Seven patients remained free of carciac decompensation, but right heart failure developed in three. Analysis of the preoperative data did not permit differentiation of these two groups of patients.

Gunshot Wounds of the Heart

Abstract Of 245 patients with penetrating wounds of the heart who reached the emergency room of Detroit General Hospital (Receiving Branch) alive during a 13 1/2 year period, 27 had gunshot wounds. These wounds are increasing in frequency both relatively and absolutely, so that now almost 50% of the heart wounds seen are caused by gunshots. A program of treatment characterized by immediate respiratory support, blood volume expansion, and thoracotomy with direct control of the cardiac injury resulted in the survival of 20 of the 27 patients. Other factors favorably influencing survival rate were an initial blood pressure of 50 mm. Hg or higher, cardiac tamponade, and injury to only one chamber. All 9 patients with damage to only one chamber and tamponade survived.

Management of Infective Endocarditis: Seventeen Years' Experience

Infective endocarditis remains a serious illness with a high mortality. In more than 75% of 417 patients, the infection was due to gram-positive microorganisms. The non-drug-addicted patients (33%) were elderly and debilitated with advanced illness that preceded the endocarditis. The drug-addicted patients (67%) were young and were infected with multiple kinds of microorganisms. The blood cultures grew strains of Staphylococcus aureus resistant to methicillin sodium and nafcillin sodium in a majority of patients. Gram-negative microorganisms and fungi were cultured almost exclusively from samples from the drug-addicted patients. The high mortality among the non-drug-addicted patients (28%) was related to their advanced age and debilitating illness. The high mortality among the drug-addicted patients (21%) was related to the complex bacteriology of their infections and the severe anatomical disruption of the valvular complexes of the heart. When cured of their disease after treatment with intravenously administered antibiotics or a valve procedure or both, their long-term survival was related to whether or not they abstained from their habit. If the patient abstained from the use of drugs, the chances of survival were good; if not, death invariably ensued. This experience strongly supports our contention that if a patient returns to the use of drugs and reinfects the valve after initial cure, a second valve operation is contraindicated.

LIFE-THREATENING HEMOPTYSIS IN PRIMARY LUNG ABSCESS

Abstract Seven patients developed life-threatening hemoptysis while receiving medical treatment for primary lung abscesses. The first 6 patients all underwent pulmonary resection. One of these patients died; he was 1 of 2 who had had a second episode of hemoptysis before being operated upon. The next 4 patients were operated upon after the first episode; all did well. All 6 of the operated group had roentgenograms that showed one or more of three patterns: (1) emptying-refilling, (2) air-fluid level to movable mass, and (3) persistent radiodensity. Each of these patterns reflects the presence of blood clots in the abscess cavity. A seventh patient died during his first episode of hemoptysis two weeks after he showed the emptying-refilling pattern on chest roentgenograms. Our experience with these 7 patients suggests that if a patient with a primary lung abscess has either life-threatening hemoptysis or roentgenographic evidence of blood clots within the abscess cavity, he should undergo pulmonary resection.

Penetrating wounds of the pericardium and heart.

The outcome of treatment of patients with penetrating injuries to the heart is directly dependent upon the speed and accuracy of diagnosis and institution of treatment. The most important therapeutic steps are immediate endotracheal intubation when necessary, establishment of large intravenous catheters and rapid infusions of fluids and blood, early relief of cardiac tamponade, and control of hemorrhage from the cardiac wound.

Cecal perforation due to adynamic ileus.

SummaryThree cases of cecal perforation due to adynamic ileus are described—one following fracture of the right femur and two following elective surgical procedures consisting of routine herniorrhaphy and transthoracic vagotomy. The mechanism of perforation is though to be ischemia and gangrene on the antemesenteric border of the cecum, due to stretching and narrowing of the nutrient vessels during distention. Cecostomy and decompression are the treatment recommended.

Improved surgical palliation of advanced carcinoma of the esophagus.

Fifty-four patients with far-advanced carcinoma of the esophagus were operated on between the years 1974 and 1976. No attempts were made to resect the lesion. The stomach was used fifty-three times to bypass the lesion and the right colon was used once. In twenty-eight patients the stomach was placed substernally and the anastomosis was done in the neck. Twenty-five patients had the anastomosis to the esophagus done in the chest. The thirty day operative mortality was 7.4 per cent and the average survival was five months. These figures compared favorably with a group of thirty-five patients with far-advanced carcinoma of the esophagus seen between the years 1971 and 1973 and handled with a variety of modalities. In this group the thirty day mortality was 31.4 per cent (11/35) and the average survival was three and a half months.

Physiological Manometric Tested Tricuspid Valvuloplasty

Abstract Tricuspid insufficiency associated with severe left‐sided valvular heart disease carries a poor prognosis. Twenty‐two patients with severe pulmonary hypertension and tricuspid insufficiency underwent a tricuspid valvuloplasty in addition to left‐sided single or double valve replacement. The tricuspid valvuloplasty was performed after weaning the patient from cardio‐pulmonary bypass. The efficacy of the tricuspid valvuloplasty was gauged by continuous right atrial pressure recordings as the annuloplasty was completed. Obliteration of the peak of the V wave of the right atrial pressure recordings indicated that the tricuspid annuloplasty was secured. Twenty‐one patients were long‐term survivors, and 19 patients are in good condition for an average follow‐up of 6.1 years (1 to 12 years postoperatively).