Duncan A. Killen

Post-Traumatic Aneurysm of the Left Ventricle

Three cases of left ventricular aneurysm secondary to external violence are reported. Each patient presented with a pseudoaneurysm of the left ventricle, following penetrating trauma in two instances and blunt trauma in the third instance. The interval between injury and diagnosis ranged from 5 months to 24 years. Two patients underwent successful resection of the aneurysm. Repair was not attempted in the third patient. Only 16 cases of post-traumatic left ventricular aneurysm have previously been reported. In 13 of the 19 cases available for review, the trauma was blunt and in six penetrating. The aneurysm could be determined to be a true aneurysm in five instances and a false aneurysm in eight instances. Complications (rupture, cardiac failure, embolism, and arrhythmia) proved fatal in eight cases. Each of the eight patients subjected to aneurysmectomy survived.

Bio-Medicus ventricular assist device for salvage of cardiac surgical patients

Over a 5-year period, 41 (1%) of 4,193 patients undergoing cardiac operations underwent intraoperative or early postoperative insertion of a Bio-Medicus ventricular assist device when it became apparent that the patient could not otherwise survive. Fourteen patients were in cardiogenic shock and 7 were in cardiac arrest at the time of initiation of their primary cardiac surgical procedure, and in no instance was the device planned as a bridge to cardiac transplantation. Bleeding, sepsis, and thromboembolism were frequent postoperative complications. Central nervous system deficits were observed in 16 patients during their postoperative course. Eight patients (19.5%) were long-term survivors. Of the preoperative risk factors evaluated only age was significantly associated with survival, with 7 (33%) of the 21 younger (39 to 63 years) patients surviving. Blood product usage and hospital cost were analyzed in an attempt to assess cost/effectiveness of use of this device for attempted salvage of such desperately ill patients.

Accuracy of treadmill testing in assessment of direct myocardial revascularization.

Near-maximal treadmill exercise tests (TET) performed at the time of coronary arteriography and bypass graft visualization an average of 13 months after direct myocardial revascularization were analyzed in 217 consecutive patients to assess the accuracy of the TET in predicting completeness of revascularization. TET results were correlated with bypass patency and extent of revas- cularization. Although conversion of a TET from an abnormal to a normal test or relief of TET-induced angina following surgery is closely correlated with bypass graft patency, the high incidence of normal exercise tests in the presence of residual coronary disease limits their usefulness in the individual postoperative patient in estimating the completeness of revascularization.

Surgical Treatment of Papillary Muscle Rupture

Between 1971 and 1979, 16 patients underwent mitral valve replacement for papillary muscle rupture after infarction. Nine of these patients were operated on within 3 days of papillary muscle rupture. Eight patients had low cardiac output syndrome prior to operation. Six patients had concomitant coronary artery bypass, and 1 patient had resection of an associated left ventricular aneurysm. There were 3 operative deaths (19% mortality). Surviving patients have been followed for a total of 49 patient-years. There have been 2 late deaths, each a result of coronary artery disease. Six of the 11 surviving patients are asymptomatic; the others are in New York Heart Association Functional Class II or III. The actuarial 5-year survival was 75%. These data support the concept that an aggressive attitude should be taken toward early diagnosis and surgical treatment of postinfarction papillary muscle rupture.

Effect of preservation of the pyloric sphincter during antrectomy on postoperative gastric emptying

Abstract 1. 1. In a dog, it is possible to perform gastric antrectomy in such a manner as to completely excise the antral mucosa yet preserve the pyloric sphincter. 2. 2. The gastric emptying of hypertonic solutions following such a sphincter preserving antrectomy is more normal than that which follows the conventional (sphincter destroying) antrectomy. 3. 3. Such a sphincter preserving antrectomy would seem feasible in certain clinical situations.

Repair of intrapericardial rupture of left sinus of Valsalva aneurysm.

A 62-year-old man with no history of preexisting heart disease was seen in cardiogenic shock. Prompt cardiac catheterization and aortography revealed pericardial tamponade and aneurysms of the right and left sinuses of Valsalva. Immediate sternotomy relieved the tamponade, which was secondary to an aneurysm of the left sinus of Valsalva rupturing into the transverse pericardial sinus. Endoaneurysmorrhaphy was performed successfully.

Aneurysm and arterial occlusive disease of the abdominal aorta and its major branches associated with horseshoe kidney

Abstract The combination of intra-abdominal arterial lesions requiring surgical intervention and an associated horseshoe kidney is rare. Two such cases are reported. One patient underwent successful resection of an abdominal aortic aneurysm. Review of the literature revealed that there had been seven previously reported cases of this combination of lesions. The multiplicity and anomalous origin of renal arteries in horseshoe kidney make operative management of an aortic aneurysm often difficult. Of the eight reported cases, one was unresectable at exploration because of vascular anomalies. The remaining seven patients underwent resection of the aneurysm with survival. In three instances it was necessary to divide the isthmus of the horseshoe kidney and in two patients renal arteries were of necessity ligated to perform the aneurysmectomy. The second case is that of obstructive lesions of the iliac arteries and the left renal artery. There was intermittent claudication on the basis of iliac occlusion and hypertension on the basis of unilateral renal artery stenosis. Revascularization of the femoral arterial trees and the left renal artery resulted in cure of both claudication and hypertension. No similar case could be found in a review of the literature. Establishment of the diagnosis of renovascular hypertension in the presence of a horseshoe kidney is more difficult than it is in the usual patient because of the frequent association in horseshoe kidneys of acquired renal lesions which in themselves could account for renal hypertension.

Fifteen-year results of coronary artery bypass for isolated left anterior descending coronary artery disease

During 1971 through 1975, 266 patients underwent primary coronary artery bypass grafting for occlusive disease confined to the left anterior descending coronary artery. Actuarial survival at 15 years was 72.7% with 60% of survivors being free from angina. Although the cause of death was cardiac related in 50% of the patients who died, survival was comparable with that of an age-matched and sex-matched general population. During follow-up, 48 secondary or tertiary repeat coronary artery bypass as well as 44 percutaneous transluminal coronary angioplasty procedures were performed. Acute event-free status (freedom from acute myocardial infarction, repeat coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, or death) persisted at 15 years in 43.2% of patients. The differences in survival when patients were segregated according to age, sex, number of grafts performed, or graft conduit (internal mammary artery versus vein) were not significant. However, comparison of graft conduits revealed a significantly better (p = 0.02) overall acute event-free survival when the internal mammary artery was used.

Colonic injury resulting from angiographic contrast media

Abstract It appears that selective inferior mesenteric arteriography can be performed with relative safety using sodium iothalamate. Although a toxic effect was demonstrated in the present study, the minimal inherent toxicity of this angiographic contrast agent is such that mechanical trauma associated with performance of selective inferior mesenteric arteriography is the major determinant of the risk factor.

Operative risk in coronary revascularization of patients with ventricular dysfunction

Abstract The initial sixteen month experience in patients undergoing simple revascularization of coronary arteries shows that 81 per cent of these patients were either Class III or Class IV on the basis of the New York Heart Association scale preoperatively; 57 per cent had some degree of ventricular dysfunction on left ventricular cineangiography, 50 per cent had elevated left ventricular graft dysfunction at rest, and 57 per cent had elevation post angiography. The hospital mortality was 1.6 per cent in the first 252 patients, and 2 per cent of the patients had a definite perioperative myocardial infarction and a further 6 per cent had a possible myocardial infarction. The total number of patients operated on between January 1971 and March 1974 now exceeds 1,000 with a total over-all hospital mortality of ten patients or 1 per cent. We believe that mortality and morbidity are essentially unchanged and that the flow study instances of myocardial infarction, pericarditis, and arrhythmia are representative of our over-all experience. Whenever significant valvular disease or ventricular aneurysm is associated with occlusive coronary artery disease, we believe that revascularization is necessary to achieve lower mortality and that ventricular dysfunction per se in patients undergoing revascularization is only a relative contraindication to revascularization.