Charles A. Hufnagel

CHRONIC THROMBOTIC OBSTRUCTION OF MAJOR PULMONARY ARTERIES. REPORT OF A CASE SUCCESSFULLY TREATED BY THROMBENDARTERECTOMY, AND A REVIEW OF THE LITERATURE.

Abstract A case is reported of chronic massive thromboembolic occlusion of major pulmonary arterial branches successfully treated with embolectomy and endarterectomy. The historic features, physical signs and pathophysiologic alterations which form the basis for the diagnosis of this disorder are reviewed.

Hemochromatosis heart disease: An unemphasized cause of potentially reversible restrictive cardiomyopathy

Cardiac involvement in hemochromatosis typically results in congestive cardiomyopathy; a restrictive cardiomyopathy due to hemochromatosis is distinctly rare. A restrictive cardiomyopathy, which developed in the patient described in this report, was due to hemochromatosis which mimicked constrictive pericarditis clinically, echocardiographically and hemodynamically, and resulted in a thoracotomy for attempted surgical therapy. The fact that hemochromatosis represents the only cause of a restrictive cardiomyopathy that is potentially reversible by medical therapy makes early recognition of hemochromatosis heart disease important.

Superior vena cava obstruction: a review of the literature and report of 2 cases due to benign intrathoracic tumors.

A review of the literature shows an increasing number of cases of superior vena cava obstruction associated with malignancy and a marked decrease in the number of patients with caval obstruction of benign origin. In contrast to granulomatous diseases and aneurysms of the ascending thoracic aorta, which have decreased, the incidence of benign tumors is essentially unchanged. Clinical features of superior vena cava obstruction in relation to the anatomical site of obstruction and collateral pathways are correlated. Diagnostic approaches, including angiography and technetium scanning, are usually definitive in outlining the site of obstruction. Experimental data and the numerous available techniques for surgical correction indicate that an entirely satisfactory procedure is not available for all patients. Methods include the use of venous bypass or Teflon prostheses and the addition of a small arteriovenous fistula proximally. Two new cases of superior caval obstruction due to benign tumor are reported. In 1 patient, who had intrapericardial bronchogenic cyst with fibrotic caval obstruction and thrombosis, a method for caval reconstruction while maintaining venous return to the right atrium is described. The second patient had an intrathoracic thyroid adenoma and caval obstruction without thrombosis.A review of the literature shows an increaseing number of cases of superior vena cava obstruction associated with malignancy and a marked decrease in the number of patients with caval obstruction of benign origin. In contrast to granulomatous diseases and aneurysms of the ascending thoracic aorta, which have decreased, the incidence of benign tumors is essentially unchanged. Clinical features of superior vena cava obstruction in relation to the anatomical site of obstruction and collateral pathways are correlated. Diagnostic approaches, including angiography and technetium scanning are usually definitive in outlining the site of obstruction. Experimental data and the numerous available techniques for surgical correction indicate that an entirely satisfactory procedure is not available for all patients. Methods include the use of venous bypass or Teflon prostheses and the addition of a small arteriovenous fistula proximally. Two new cases of superior caval obstruction due to benign tumor are reported. In 1 patient, who had intrapericardial bronchogenic cyst with fibrotic caval obstruction and thrombosis, a method for caval reconstruction while maintaining venous return to the right atrium is described. The second patient had an intrathoracic thyroid adenoma and caval obstruction without thrombosis.

Hemolytic Anemia of Mechanical Origin with Aortic-Valve Prosthesis

HEMOLYTIC anemia that followed the use of prosthetic materials in dogs was reported by Stohlman and his associates,1 who described the development of anemia accompanied by hemoglobinemia, hemoglobi...

Intrapericardial bronchogenic cysts

A rare case of large intrapericardial bronchogenic cyst with superior vena caval obstruction is reported. The cyst was successfully removed and the superior vena cava, which was narrowed by pressure fibrosis and thrombosis, was reconstructed satisfactorily and has maintained patency. In another case a large cyst of the same type without vena caval obstruction was successfully treated surgically. The features of these 2 cases are compared with those of 20 reported cases. The angiographic data in these cases appear to be sufficiently characteristic to suggest the nature of the lesion and the clinical finding of pericarditis early in the course of the disease may also suggest the diagnosis.

Severe aortic regurgitation secondary to idiopathic aortitis

Clinical and morphologic features are described in two relatively young adults with aortic regurgitation secondary to chronic aortitis. The regurgitation in each was severe enough to require aortic valve replacement. Both patients had normochromic, normocytic anemia, considerable weight loss despite congestive cardiac failure, and negative serologic tests for syphilis. These systemic manifestations in association with the aortitis suggest that both had Takayasus arteritis. In addition, one patient had total occlusion at the origin of one subclavian artery (classic pulseless disease). Takayasus arteritis must be added to the list of causes of severe aortic regurgitation.

Abdominal Aortic Aneurysms: Diagnostic Review and New Technique

A new technique of computed tomography (CT) applied to the diagnosis of abdominal aortic aneurysms is described, and the experience in 58 patients is reviewed. In all instances the abdominal aorta was clearly demonstrated, even when wall calcification was absent. A series of 37 patients with abdominal aortic aneurysm underwent evaluation by physical examination, abdominal roentgenograms, and ultrasonic and CT scanning. Measurements of the transverse diameter at the point of maximal dilatation were compared with the measurements made at operation. CT not only confirmed the diagnosis in all patients but the measurements obtained by this technique were the most accurate, correlating extremely well with the true dimensions of the aneurysm. The addition of contrast enhancement to CT scanning allowed clear delineation of the aortic lumen and intraaneurysmal thrombus, not possible with any other method, including ultrasonography. The technique appears useful as a screening procedure and in the differential diagnosis of a tortuous abdominal aorta. Patients with a small aortic dilatation can be followed accurately by scanning.

Characteristics of materials for intravascular application.

In the early part of t h i s century, there were many attempts to replace arterial segments with an extensive variety of materials, including glass, gold, silver, rubber and aluminum, as well as tubes lined with paraffin. Temporary patency was the usual result. Thrombosis occurred after varying short intervals. Between 1944 and 1946,l extensive work with the methyl methacrylate polymers in a lengthy series of experiments in dogs demonstrated that prostheses made of these materials under certain conditions tended to resist thrombosis. This was the first step toward the solution of the problem of arterial replacement, and the principles made possible the concept of intracardiac prostheses. These early studies showed that there was an interrelationship between the physical, chemical and electric properties of the blood-plastic interface and clot formation. At that time, certain factors were already shown by these studies to decrease the incidence of thrombosis in experimental arterial replacement. The first of these favorable characteristics was a hemorepellant surface, which was an extension of an older observation that blood in paraffin-lined tubes had a much longer clotting time than those in plain glass tubes. Second, a lack of water absorption was an additional property which related to the first. It was noted that those plastics which tended to have high water absorption had a high incidence of clot formation. Third, a lack of toxic plasticizers and stabilizers. Fourth, total polymerization of the plastic without residual monomer or catalysts. Fifth, the lack of leeching of toxic materials. Sixth, a mechanical smoothness of the surface of the material in the prosthetic biologic interface. And finally, seventh, a high degree of biologic tolerance by the host to the implanted material. When implants are placed into the arterial tree, the prevention of the production of an injury tissue potential in the region of the junction of the prosthesis with the adjacent tissue is an important factor in the prevention of thrombosis. These relatively simple principles were well delineated in this work. As a result, there has been general agreement that it is highly desirable to have these characteristics in any blood interface when blood must be brought into contact with a nonendothelial surface either inside or outside the body. This has been practically applied in plastic blood bags, the artificial kidney, and all phases of extracorporeal circulation. When materials must be employed which do not in themselves have these characteristics, it has been found that coating of the material in such a way as to bring about such desirable properties improves the performance. The use of silicone compounds to coat certain metallic surfaces is an example of this. The development of intracardiac devices of varying design for valvular replacement has evolved from these basic principles. The first of these devices was the ball-valve, first clinically .used in 1952* (FIGURE 1). It introduced, for the first time, the concept that a device made entirely of plastic materials could be permanently implanted into the cardiovascular system, be activated by the force

Calcified atrial myxoma: Diagnostic significance of the “systolic tumor sound” in a case presenting as tricuspid insufficiency

Abstract A calcified right atrial myxoma presenting as tricuspid insufficiency was successfully excised, and the destroyed valve replaced with a prosthesis. The case is presented to illustrate two useful but previously unemphasized diagnostic features. (1) A “systolic tumor sound,” distinctive both in timing and quality, was identified. (2) Calcification was shown to have additional diagnostic value when properly sought by fluoroscopy in addition to routine x-ray examination. A review of the literature suggests that tricuspid insufficiency is the predominant hemodynamic disturbance in cases of right atrial myxomas which are grossly calcified. This otherwise lethal tumor is surgically curable if diagnosed early.

Etiology of hoarseness associated with mitral stenosis: improvement following mitral surgery.

Abstract Two cases of mitral stenosis associated with hoarseness were improved by mitral surgery. The mechanism of recurrent laryngeal nerve paralysis was proved to be due to an enlarged pulmonary artery. It is felt hoarseness from this etiology is an added indication for mitral commissurotomy.