Joe R. Utley

The Role of Thymectomy in Red Cell Aplasia

Red cell aplasia is an unusual cause of anemia. Fifty percent of all patients with red cell aplasia will have a thymoma. Twenty-five to 30% of those who undergo thymectomy will be cured. Data are presented that suggest that any patient with red cell aplasia should have thymectomy through a median sternotomy. One of 3 such patients who underwent the operation has had complete remission for two years.

Acute Traumatic Hemothorax

Over the past 5 years, 107 patients have been evaluated for acute traumatic hemothorax at the University of Kentucky Medical Center. Immediate tube thoracostomy was performed on 90 patients for evacuation of blood and air. Only 2 patients died. Thoracotomy was performed as part of the initial therapy in 9 patients. Thoracotomy for continued hemorrhage from a pulmonary parenchymal injury was required in 3 patients from the entire group. Thoracentesis or observation was the initial therapy for limited hemothorax in 8 stable patients. Three of these patients subsequently required tube thoracostomy 2 to 23 days following injury due to expanding effusions, and 1 patient required multiple thoracotomies for sepsis, fibrothorax, and empyema. These observations indicate that early evacuation of blood by means of a tube thoracostomy is essential to minimize morbidity in acute traumatic hemothorax. If continuing hemorrhage after tube thoracostomy occurs, there is a higher association of injury to additional vital structures.

Cardiac output, coronary flow, ventricular fibrillation and survival following varying degrees of myocardial contusion.

Abstract Varying degrees of myocardial contusion was produced in 10 dogs. Two animals died of left ventricular rupture. Six of the other eight developed ventricular fibrillation. Depression of cardiac output was significantly correlated with percentage myocardial contusion. None of the hemodynamic effects of contusion could be attributed to alterations in coronary flow to contused or non-contused portions of the heart. Attempts to quantitate degree of myocardial contusion may be useful in patients with blunt chest trauma.

Subendocardial vascular distortion at small ventricular volumes

Abstract Greater distortion of subendocardial vessels compared to subepicardial vessels with decreasing ventricular volume was predicted from a simple mathematical model. The left ventricular wall near the base behaves as the wall of a sphere with changing ventricular volumes. Photomicrographs of barium injected coronary vessels at different ventricular volumes demonstrates the distortion of subendocardial vessels at small ventricular volumes. Venous obstruction was observed in the subendocardium of the contracted fibrillating heart following cardiopulmonary bypass. Small ventricular volume appears to predispose the heart to subendocardial hemorrhagic lesions.

Hyperparathyroidism: A clinicopathologic evaluation

Abstract Thirty-nine cases of hyperparathyroidism have been studied. Follow-up study showed that in five patients recurrent hyperparathyroidism developed. No reliable pathologic criteria were found to differentiate adenoma from chief cell hyperplasia in a single gland. Patients with primary chief cell hyperplasia may have glands that fulfill the classic criteria of adenoma. Adenoma and primary chief cell hyperplasia of the parathyroid glands may be manifestations of the same basic process.

Hemodynamic Observations During and After Pulmonary Artery Banding

Abstract Analysis of cardiac catheterization in 25 patients with nonrestrictive ventricular septal defect (Prv/Plv > 0.6) shows that the pulmonary vascular resistance and systemic vascular resistance function as resistances in parallel. Furthermore, studies in the presence of right ventricular outflow obstruction, by either pulmonary artery band (9 patients) or pulmonary stenosis and ventricular septal defect with left-to-right shunting (12 patients), show that the right ventricular outflow obstruction (band) functions as a resistance in series with the pulmonary vascular resistance. The sum of pulmonary vascular resistance plus band resistance is in parallel with systemic resistance. This concept allows better explanation of the great pressure variability across bands observed at operation. It is impossible to completely evaluate a pulmonary artery band with pressures alone. Flow measurements are necessary for better understanding of pulmonary artery bands. The variability of clinical response after banding may be explained by the variations in pulmonary vascular resistance and systemic vascular resistance during and after pulmonary artery banding.

Experimental and Clinical Evaluation of Heparin-Impregnated Cloth-Covered Cardiac Valves Used Without Systemic Anticoagulation

Abstract The results of a pilot study to determine whether heparin-impregnated cloth-covered cardiac valves may offer increased protection against thromboembolism are reported. In animal studies the heparin-impregnated valves in the tricuspid position were encapsulated within 3 months by a thin, smooth, uniform neointima. In contrast, the control valves had a nodular accumulation of tissue with a thickness of 1 to 2 mm. In a clinical evaluation, 32 patients were managed in a standard fashion postoperatively with orally administered anticoagulants (Group 1) while 34 patients were given heparin-impregnated valves (Group 2). Six of the 32 patients in Group 1 had a cerebral embolic episode. In contrast, the Group 2 patients, without systemic anticoagulation, had a lower incidence of cerebral embolism (2 of 34). The use of heparin-impregnated cloth-covered valves without systemic anticoagulation did not increase the incidence of thromboembolism, and it may reduce the potential complications of anticoagulant therapy.

Visceral artery reconstruction

Abstract The mortality from thrombosis of the superior mesenteric artery remains very high. Most of these patients have prodromal symptoms of visceral angina. Elective surgical reconstruction of visceral arteries has been remarkably successful both immediately and in long-term relief of these symptoms. A case presentation illustrates the course of this disease. As physicians become more generally aware of this syndrome an increasing number of these patients will be treated.

Hemodynamic determinants of risk in pulmonary artery banding

Summary A classification of left to right shunts is presented based on pulmonary to systemic flow and resistance ratios as well as right ventricular and left ventricular systolic pressure ratios. The results of banding are poor when the ratio of pulmonary flow to systemic flow (Q P /Q S ) is less than 2.0. Banding may be detrimental when right ventricular systolic pressure is low. Patients at the lowest risk for banding are those with high right ventricular pressures and large shunts.

Repair of Mycotic Aneurysms of the Aorta Involving the Aortic Valve

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis. In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.