Carl H. Almond

True and false aneurysms of the left ventricle following myocardial infarction

Anterolateral myocardial infarction resulted in the formation of both true and false aneurysms in a 75 year old man in whom severe congestive heart failure subsequently developed as the false aneurysm became progressively larger. Left ventriculography detected and quantified both aneurysms, and demonstrated reasonable function of the remaining volume-overloaded left ventricle. Resection of both aneurysms was accomplished with marked relief of symptoms. The literature on false aneurysm is reviewed, and the dilemma posed by the need to recognize false aneurysms before they become symptomatic or rupture is discussed.

Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries.

Patients with penetrating pericardial trauma whose vital signs stabilize after fluid administration may present a therapeutic dilemma. Two-dimensional echocardiography has emerged as a diagnostic technique to help determine whether surgical intervention may be required. We present 5 patients with penetrating pericardial trauma whose vital signs stabilized after fluid administration and who had minimal clinical findings. In 3 of these patients, a small effusion was seen; in 2 others, no abnormalities were noted. All 5 underwent surgical exploration and had major intrapericardial injuries. We conclude that a normal echocardiographic study does not rule out major intrapericardial injury in patients with penetrating chest trauma. Furthermore, small areas of effusion seen on echocardiography in these patients represent indications for surgical exploration.

PSYCHOLOGICAL ADJUSTMENT AND PSYCHIATRIC COMPLICATIONS FOLLOWING OPEN HEART SURGERY

A consecutive series of 110 adult open heart surgical patients were evaluated to assess postoperative psychiatric complications. This evaluation included psychological, social, and medical factors in the preoperative and postoperative periods. Psychological factors were assessed with the Minnesota Multiphasic Personality Inventory (MMPI). Many of the predisposing and precipitating factors studied were found to be differentially contributory among subgroups of male and female patients. This suggested certain hypotheses concerning the inter-relationships between psychological factors and the other factors which appear to play an important role in postoperative psychiatric complications. Male open heart surgery patients revealed a high rate of postoperative psychiatric complications. These were found to be related to age, type of surgical procedures, and a clinical picture characterized by depression, anxiety and physical complaints. Female open heart surgery patients revealed a lower incidence of postoperative psychiatric complications than male patients. Their complications were found to be significantly associated with a history of family or marital problems, or problems requiring psychiatric care, and with a significant incidence of brain damage following surgery. Correlated psychological data indicated symptoms and complaints of depression, anger, interpersonal discord, and unusual or bizarre feelings and experiences. It was hypothesized that good psychological adjustment prior to surgery may preclude a postoperative reaction and/or make it easier for a person to accept and effectively adjust to disturbing emotional experiences following surgery whatever their etiology. Some degree of psychological maladjustment would raise the probability for a postoperative reaction, but its ultimate occurrence would be dependent on other factors, such as age and/or type of operation, whose effects seem different in male and female patients. Some of the difficulties involved in the delineation of the role of psychological factors in open heart surgery were discussed, with specific attention called to the lack of clarity and consensus among the various definitions of postoperative psychiatric problems, and the lack of comparable methods used in quantifying psychological or behavioral factors. The importance of the assessment of preoperative psychiatric symptomatology was stressed in relation to both expectations of complications and to a basis for possible ameliorative preoperative procedures.

Psychological adjustment and acute response to open heart surgery.

Recent research has produced findings which indicate a significant role for psychological factors in determining the nature of a patients acute response to open heart surgery. In the present study a consecutive series of 68 adult open heart surgical patients were considered for psychological evaluation with the Minnesota Multiphasic Personality Inventory (MMPI) during the week preceding each operation. After determining that the 54 patients who were able to provide pre-operative psychological data were not a unique subsample of the originally referred patients, several parameters were analyzed in relation to survival of the surgical procedures. The factors of age, sex and pre-operative cardiac disability were not found to be significantly related to operative mortality in the present patient sample. Separate analysis of the MMPI scale scores for male and female patients revealed distinct group differences in personality characteristics, both with respect to each other and in relation to survival of the operation. Agitation was found to be more pronounced among male patients who did not survive the open heart operation than among those who did. This agitation was felt to be indicative of a basic vulnerability to stress without effective psychological coping mechanisms. Female patients who did not survive surgery were characterized by increased physical complaints and emotional overcontrol and appeared less accepting of any emotional component related to their physical disabilities than were the surviving female patients. These findings were also compared with previous reports based both on clinical interviews and on responses on standard psychological tests. Comparative analyses were also done between the groups of male and female open heart patients who survived the surgical procedures and matched groups of medical patients who did not have diagnoses directly involving the cardiac system or receive any operative procedures. These comparisons revealed high similarity between the groups for both male and female patients and were felt to further distinguish the personality features noted among the nonsurvivors of the open heart operation. The results were felt to indicate that attention to preoperative symptoms of severe psychiatric disturbance, symptoms of pronounced anxiety among male patients and symptoms of emotional overcontrol among female patients may help reduce mortality in open heart surgery.

Combined superior vena cavography and azygography in patients with suspected lung carcinoma.

Intraosseous costal or spinous process azygography has occasionally been used for visualization of the thoracic venous system in the preoperative assessment of carcinoma of the lung (2, 7). Obstruction of the superior vena cava or extrinsic compression or invasion of its lumen is a relatively frequent finding in the natural history of pulmonary carcinoma, especially when the lesion originates in the right lung (3). In 85 per cent of 33 cases coming to autopsy in one series, cancer was the etio-logic agent producing superior vena caval obstruction (1). To our knowledge, the combined use of superior vena cavography and azygography as part of the preoperative assessment of pulmonary carcinoma has not been previously reported. Our experience with 63 consecutive patients who have been evaluated for suspected primary lung carcinoma by the use of superior vena cavography and azygography forms the basis of this report. The roentgenographic patterns of abnormality are evaluated and presented. The importance of pro...

Perforation of the Heart by a Permanent Transvenous Pacemaker

Excerpt Long-term cardiac pacing has unquestionably improved the prognosis for patients with complete heart block associated with Adams-Stokes syncope. However, problems may result from failure of ...

Failure of preoperative staging to assess unresectability in MO bronchogenic carcinoma

Despite extensive preoperative staging, unresectability of a bronchogenic carcinoma may not be known until an exploratory thoracotomy is done. Failures in anatomic staging occur because of inability to detect local extent of hilar lesions and inability to detect small deposits of metastatic disease. At the University of South Carolina, nine of 75 patients who underwent thoracotomies were found to be unresectable. Using an extensive staging protocol, the “back out” thoracotomy rate can be reduced to a minimum whereas no patient is denied a chance for surgical cure.

Carotid Endarterectomy: Emphasis on Necessity of Long-Term Postoperative Evaluation

Carotid endarterectomy remains an effec tive means of preventing a stroke in patients with extracranial carotid lesions. Although long-term patency may be assumed, the true incidence of recurrent pathology is not known. In the past, follow-up angiography has been performed only when recommended for recurrent symptoms and some postoper ative bruits. Four different pathologic condi tions found at the endarterectomized bifur cation site are discussed as are their treat ments. Long-term follow-up evaluation is strongly recommended. Angiography is in dicated for recurrent symptoms. Carotid bruits are difficult to evaluate on a yearly basis. Vascular laboratory studies are recom mended 4 months after surgery and then on a yearly basis. Hopefully, early and late res tenosis will be identified. An artery should be explored when symptoms and angiog raphic findings indicate recurrent pathology.