H.C. Stansel

Early Extubation Following Pediatric Cardiothoracic Operation: A Viable Alternative

A protocol is presented that facilitates early extubation following pediatric cardiothoracic operations. A total of 197 consecutive patients were managed according to this protocol. Fifty percent of the patients were less than 3 years old. Cardiopulmonary bypass was required in 113 (57%) of the surgical procedures. Extubation immediately following the surgical procedure was accomplished in 142 (72%) of the patients. Pulmonary complications occurred in 8 of these 142 patients (6%) and in 10 (18%) of the 55 patients requiring postoperative mechanical ventilation. Of the patients having early extubation, 5 (4%) required reintubation. One death in this group was unrelated to pulmonary function. There were 16 deaths among the 55 patients managed with mechanical ventilation. Carefully conducted early extubation provided specific advantages over routine postoperative mechanical ventilation. Modern techniques of anesthesia and surgical repair of congenital heart disease can decrease the requirement for postoperative mechanical ventilation and the potential for related complications.

Postoperative Studies in Patients with Tetralogy of Fallot

Abstract The present series demonstrates that hemodynamic abnormalities persist following intracardiac repair of tetralogy of Fallot despite clinical improvement. The incidence of residual ventricular communication and residual outflow obstruction is consistent with previous reports. The pulmonary incompetence is well tolerated when it exists as an isolated residual abnormality. The use of Teflon cloth to relieve the outflow obstruction has not led to aneurysm formation. This report calls attention to the occurrence of tricuspid insufficiency in patients with tetralogy of Fallot and the increased postoperative morbidity with this combination. Finally, aortic regurgitation is part of the pathophysiology of tetralogy of Fallot and may well affect the results of the intracardiac repair. The long-term consequences of these abnormalities are left to future consideration.

Certain Hazards of the Central Venous Catheter

Monitoring of the central venous pressure has been widely accepted and applied clinically, primarily to the patient who has sustained major trauma or is undergoing certain operative procedures, in particular those dealing with the cardiovascular system. Plastic central venous catheters are placed either by the percutaneous technique or by surgical exposure of a peripheral vein. Except for the incidence of hemopneumothorax associated with percutaneous subclavian vein catheterization, both methods share similar complications, namely, thrombosis with or without embolism, infection, local hematoma, embolization of a catheter segment and perforation of the vein by the catheter tip. We have encountered three

Apical-aortic shunts in children

Experience with four children undergoing apicalaortic shunts for relief of aortic valvular disease is reported. All children tolerated the procedure uneventfully, and postoperative cardiac catheterization in three revealed restoration of normal hemodynamics. In one unique case severe aortic regurgitation in a two year old boy was managed by suture closure of the aortic valve producing total left ventricular output through the apical-aortic conduit.

One hundred consecutive coarctation resections followed from one to thirteen years

The technique of operative repair for coarctation of the aorta is now well standardized and the immediate surgical mortality has been lowered to less than 5% in most large series. Long term follow up, however, is only recently being reported. This paper describes the current status of 100 consecutive patients who underwent elective resection from 1--13 yr ago. There was only one operative death. In contrast with other reports, residual systemic hypertension is rare in the 97 survivors. These observations confirm that coarctation of the aorta can be repaired surgically with an acceptable operative mortality; the outlook of the survivors appears excellent.

Ischemia and subsequent amputation by the upper extremity following axillo-femoral bypass.

SYNOPSIS Early experience has shown good success with the axillo-femoral graft in the high risk patient with aorto-iliac disease in the hands of the vascular surgeon. Loss of the upper limb following occlusion of an axillo-femoral bypass graft is reported. However, it should be noted, there are inherent risks in the use of a good

Extraanatoinical Reconstruction for Bilateral Intrathoracic Subclavian Artery Aneurysms

Successful extraanatomical repair of bilateral intrathoracic arteriosclerotic subclavian artery aneurysms is reported. Rupture of the left subclavian aneurysm required emergency thoracotomy for proximal and distal ligation. The right subclavian aneurysm was repaired electively. Because of constraints resulting from the arterial anatomy (origin of aneurysm at innominate artery bifurcation), prior operation (coronary artery bypass grafting and repair of aneurysm of the sinus of Valsalva), and the patients occupation (young, employed craftsman with dominant right hand), an extraanatomical reconstruction was devised to exclude the aneurysm and revascularize the head and arm. The reconstruction consisted of an external ilioaxillary Gore-Tex bypass graft in conjunction with an end-to-end distal subclavian to distal common carotid Gore-Tex graft. This is believed to represent the first reported successful repair of bilateral intrathoracic arteriosclerotic subclavian aneurysms, and the first application of this extraanatomical reconstruction.

Cervical Aortic Arch with Retroesophageal Aortic Obstruction: Report of a Case with Successful Surgical Intervention

The clinical, roentgenographic, hemodynamic, and angiographic features of a patient with a right cervical aortic arch and retroesophageal aortic obstruction associated with a ventricular septal defect are presented. Surgical relief of the aortic obstruction was successfully achieved by placement of a bypass graft between the left common carotid artery and the descending thoracic aorta.

Markedly improved pulmonary function after open heart surgery in infancy utilizing surface cooling, profound hypothermia, and circulatory arrest

The use of surface-induced profound hypothermia with limited cardiopulmonary bypass and circulatory arrest markedly diminished the need for mechanical ventilation for patients undergoing cardiac surgery. Eleven of twenty-two patients were extubated in the operating room and five more patients within 70 minutes postoperatively. Five patients required mechanical ventilation. Four of the five were extubated within 24 hours (mean, 19.05 hours); only one patient required mechanical ventilation greater than 24 hours. This experience would indicate that as the age of surgery is decreased, in conjunction with improved technics of cardiac surgery and anesthesia, the need for mechanical ventilation should be diminished.

Abdominal angina: Intestinal absorption eight years after successful mesenteric revascularization

Abstract A woman with panmalabsorption and symptoms characteristic of abdominal angina underwent successful revascularization of the superior mesenteric artery. Laboratory studies obtained eight years postoperatively were compared with preoperative data. Her stool fat was reduced to 29 per cent of the preoperative quantity, although her dietary intake of fat was increased fivefold. The d-xylose tolerance test was increased to 346 per cent of the preoperative value, serum carotenes to 817 per cent, serum albumin to 172 per cent, hematocrit to 148 per cent, and cholesterol to 296 per cent. Her weight had risen from 69 to 122 pounds. We conclude that the panmalabsorptive defect associated with mesenteric vascular insufficiency is reversible and that the intestine may function normally for a prolonged period of time after revascularization.