Azai Appelbaum

Cardiac contusion in the patient with multiple injuries

We have treated 20 patients with multiple injuries and concomitant myocardial contusion. The diagnosis of myocardial contusion was based mainly on serial ECG tracings which showed arrhythmias, dynamic ischaemic patterns or conduction disturbances. The clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries. Furthermore, they are overshadowed by the overt manifestation of cerebral, thoraco-abdominal and skeletal injuries. Awareness and prompt diagnostic measures are essential in the diagnosis of cardiac injury. Strict cardiac monitoring following multiple trauma will prevent serious or even fatal outcome of cardiac injury.

Long-Term Results of Surgical Repair of Coarctation of the Aorta-Evaluation by Exercise Test

Thirty-six patients have been operated on for coarctation of the aorta. The age at operation ranged from 4 to 45 years with a mean of 14 years. Preoperative systolic blood pressure (BP) was above the normal mean + 2 SD in 34 (94%) of the patients. The surgical techniques used for correction of coarctation were: resection and end-to-end anastomosis (50%), resection and graft interposition (25%), patch graft angioplasty (22%) and subclavian artery to descending aorta bypass graft (3%). There was no hospital mortality. Systolic BP measured on hospital discharge available in 30 patients showed an average decrease of 26 mm Hg. The mean follow-up period in 16 of 30 patients (53%) was 7.2 years. All of these patients had a further decrease in systolic BP, and in 14 of 16 (87%) BP was within the mean + 2 SD. Twelve patients were examined in the vascular diagnostic laboratory to determine adequacy of the repair by hemodynamic measures. After average of 7.8 years following operation, all of them had ankle systolic BP higher than brachial systolic pressure; ankle BP did not drop after treadmill walking exercise and the directional Doppler velocity curves from the legs were normal. This study suggested that BP continued to decrease after hospital discharge. We were unable to demonstrate correlation between age at operation and decrease in BP. The adequacy of surgical repair can be assessed by mild effort stress test combined with ankle/arm ratio measurement and directional Doppler velocity curves.

Exercise Performance in Patients with Impaired Left Ventricular Function Following Aorto Coronary Bypass

We studied 40 patients with preoperative ejection fraction (EF) of 0.35 or less who underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were 7 late deaths (3 cardiac and 4 non-cardiac). The 5-year cardiac actuarial survival rate was 74 +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.

Pericardial Meshing: A New Technique to Facilitate Primary Tension-Free Pericardial Closure

A method is described to facilitate pericardial approximation at the conclusion of open-heart surgical procedures. Before sternal closure, the anterior pericardium is meshed by multiple longitudinal incisions until tension-free closure is possible. The technique was developed by animal experimentation and is now being performed in patients. It has proven to be simple, safe, and effective.

Early Calcification and Obstruction of a Mitral Porcine Bioprosthesis

A patient is described in whom severe prosthetic valvular stenosis developed ten months after mitral valve replacement with an Angell-Shiley porcine heterograft. At emergency operation, calcification of the prosthesis was revealed. Early calcification and stenosis of a porcine heterograft valve is a life-threatening complication that must be recognized promptly and treated by emergency valve replacement.

Prevention of "strut-snagging" during mitral valve replacement with stented tissue valves.

Abstract A technique is described for preventing snagging of the struts during replacement of the mitral valve by stent-supported bioprostheses. The method is simple and is particularly applicable when the mitral valve annulus or the left atrium is small.

A New Method of Sternal Reclosure

A new method is described for stabilizing dehiscence or instability of median sternotomy incisions using stainless steel retention sutures. The method has been used successfully in patients who had disruption of the sternum following open-heart surgery and resulted in no complications. It is recommended also as a preventive measure for closure of the sternum in elderly, debilitated patients with a fragile sternum and with prolonged low cardiac output after operation.