John M. Moran

Treatment of cardiogenic shock in myocardial infarction by intraaortic balloon counterpulsation and surgery

Thirty-seven patients in cardiogenic shock due to acute myocardial infarction were treated with intraaortic balloon counterpulsation and/or surgery. Eighteen of these patients were treated with counterpulsation alone; eight survived and five were in functional class I or II at the time of follow-up; two were in functional class III, and one was in functional class IV. Nineteen patients were treated surgically, eight survived and seven were in functional class I or II at the time of follow-up; one was in functional class III. Good functional recovery with counterpulsation alone is most common with inferior infarction. With surgery, functional recovery depends not only on the extent of the infarction and the coronary anatomy, but also on the ability to perform surgery within 12 hours of infarction or to support the patient with mechanical means for 10 to 14 days after the infarction and then perform surgery.

Hypertonic saline attenuates the hormonal response to injury

We reported previously in a randomized double-blinded study in 20 postoperative coronary bypass patients that hypertonic saline (1.8% NaCl, HS) provides early hemodynamic benefits, increased osmolality and net negative fluid balance compared to 0.9% NaCl (NS). To investigate the effects of HS on the hormonal response to injury, we measured ACTH, cortisol, angiotensin II (AII), aldosterone, vasopressin (AVP), and atrial natriuretic factor (ANF) in these patients. ACTH and cortisol concentrations increased in the NS group but were suppressed in the HS group (p less than 0.05). Aldosterone increased in NS patients, but was suppressed in HS patients (HS: delta Aldosterone 13.0 +/- 3.0 vs. NS: delta Aldosterone 26.0 +/- 7.0 ng/dl, p less than 0.05). The AII response was suppressed at six and eight hours (p less than 0.05) in patients receiving HS but did not change in patients receiving NS. ANF did not change significantly for either group. The significant increases in AVP were similar in both groups (p less than 0.05), but correlated with increases in osmolality only in the NS group (r = 0.8, p less than 0.009). Other than AVP, HS suppressed the responses of some of the hormones that normally increase in response to injury, relative to NS. Attenuation of the neuroendocrine response and other previously reported effects of HS suggest that HS may be an efficacious solution for resuscitation in the postoperative and postinjury period.

The hiatal hernia-reflux complex. Current approaches to correction and evaluation of results.

Abstract Experience with forty cases in which Belsey and Nissen fundoplication operation were performed for hiatus hernia-reflux complex is reviewed. The series was composed largely of cases complicated by stricture, ulceration, bleeding, aspiration, or previous repair. A system of clinical scoring is used and proposed as a method for objective evaluation of results. Follow-up study is complete, both clinically and radiographically, and recurrent hernia with reflux has developed in one patient. Late stricture was treated by simple correction of reflux, combined with intraoperative dilatation, with eight of ten initial successes, two patients requiring further therapy. The mean lower esophageal sphincteric pressure is improved by fundoplication, but its importance in preventing reflux after operation is secondary to the creation of an effective valve at the gastroesophageal junction.

Reactive Hyperemia in Lower Extremity Arteriography: An Evaluation

The value of reactive hyperemia in improving visualization in aortofemoral arteriography has been previously stressed (1, 2, 3) but the method has not yet found general acceptance. We have performed angiography after tourniquet occlusion almost routinely for the last three years, and have been impressed by the simplicity and safety of the method and the improvement in quality of the arteriograms. From a group of 200 patients with arterial disease studied in this manner, we have selected 55 in whom the timing of arterial blood flow with and without reactive hyperemia could be evaluated in serial films. We have analyzed the effect of reactive hyperemia and attempted to determine the influence of various clinical factors upon the response to tourniquet occlusion. Material and Methods Arteriography was performed either by percutaneous femoral catheterization or by translumbar injection. For this study, however, only retrograde femoral arteriograms were selected. A PE 240 J-tipped catheter was inserted via a c...

Giant hypertrophic gastritis.

Abstract 1. 1. Six cases of giant hypertrophic gastritis are reported. One case with massive bleeding is described, and this frequent complication is emphasized. 2. 2. Review of the literature indicates that this condition is not so rare as is frequently stated. 3. 3. The etiology is obscure and diagnostic methods usually lead to suspicion of gastric cancer. 4. 4. The results of treatment have varied. Partial gastrectomy is recommended for those patients with hemorrhage or obstruction, but does not appear to be necessary in uncomplicated cases.

Operative therapy of malignant ventricular rhythm disturbances.

Pre- and postoperative electrophysiologic study (EPS), intra-operative cardiac mapping, and extended endocardial resection of scar (EER) has enabled us to identify subgroups among 94 patients who have had operation to control or prevent malignant ventricular arrhythmia. Operative mortality was 8.5% and cure or prevention of ventricular arrhythmia was accomplished in 92% of survivors. Group 1: 13 patients were resuscitated from “sudden death” due to ventricular fibrillation (VF). All had exercise-induced VF and/or ventricular tachycardia (VT). Preoperative EPS revealed no inducible VT/VF. All had coronary artery disease, without evidence of myocardial infarction (MI) or ventricular wall motion abnormality; all were cured with conventional myocardial revascularization. Group 2: 65 patients had MI with residual left ventricular wall motion abnormality, usually aneurysm. The malignant arrhythmia, either sustained VT (38 patients) or VF (27 patients), was inducible by EPS but not usually by exercise, and all were refractory to medical therapy. Treatment was operative mapping, aneurysmectomy, EER, and coronary revascularization. Operative mortality was 11.9%; 90% of survivors are arrhythmia free, off drugs; 10% are now drug responsive. Group 3: 3 patients without coronary disease had VT or VF caused by endocardial sarcoidosis or operative scar from a previous congenital heart operation. Treatment was EPS, operative mapping, and excision of abnormal endocardial scar with no operative mortality. Group 4: 13 patients underwent aneurysmectomy for indication other than arrhythmia, but had preoperative ventricular irritability which was not life-threatening. Operation was aneurysmectomy, prophylactic EER, and revascularization with no mortality and no postoperative arrhythmic events. After many years of unpredictable and unsatisfactory results from various empirical surgical approaches, the operative treatment of malignant ventricular arrhythmia is now based on sound electrophysiologic principles.

Vena Cava Interruption for Thromboembolism: Partial or Complete? Influence of Cardiac Disease upon Results

A VARIETY of techniques have recently been advocated for partial occlusion of the inferior vena cava to prevent pulmonary embolism. These methods are intended to filter emboli while affording flow through the vena cava on the assumption that undesirable sequelae of caval ligation will be minimized. During the past three years, we have accumulated nearly equal series of patients who have had ligation (25 patients) or partial caval occlusion by a serrated Teflon clip (29 patients). Patients with serious heart disease formed the largest single group in which caval interruption became necessary, yet the mortality rate in this group and from the underlying disease is inordinately high, despite