Norris B. Harbold

Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

Abstract During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patients own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.

Beneficial metabolic effects of methylprednisolone sodium succinate in acute myocardial ischemia.

The metabolic and hemodynamic effects of methylprednisolone sodium succinate (40 mg/kg body weight) after acute myocardial ischemia were determined in 24 heparinized mongrel dogs. Myocardial ischemia was produced by ligation of the left anterior descending coronary artery. Catheters in the coronary sinus and the vein draining the left anterior descending coronary arterial area were used to collect blood samples from nonischemic and ischemic myocardium. Lactate, pyruvate, glucose, free fatty acids and oxygen were measured in arterial and venous blood from ischemic and nonischemic areas before and 3, 30 and 60 minutes after myocardial ischemia in animals with (Group II) and without (Group I) steroid treatment. In both Groups I and II glucose, lactate, free fatty acids, oxygen and coronary blood flow in nonischemic areas were not significantly changed, whereas glucose uptake in ischemic areas was significantly increased with myocardial ischemia and remained elevated. In Group I lactate uptake in ischemic areas became negative after coronary arterial ligation and remained so; in Group II, it increased after 30 (70%) and 60 (111%) minutes. Free fatty acid uptake in ischemic areas was reduced after myocardial ischemia in Group I, but in Group II it increased after 30 (224%) and 60 minutes (173%), and there was a concomitant increase in oxygen uptake. Pyruvate uptake in nonischemic areas decreased after 60 minutes in Group I, whereas it was reduced after 30 (68%) and 60 minutes (513%) in Group II. The changes were similar in ischemic myocardium. There were no significant changes in hemodynamic indexes. Coronary blood flow in ischemic areas decreased in Group I after myocardial ischemia and further after 30 and 60 minutes, but in Group II it increased after 30 (82%) and 60 minutes (53%). The data indicate that administration of methylprednisolone results in improved collateral blood flow into the infarcted area and a significantly improved metabolic response of ischemic myocardium. The glucocorticoid may also have a direct benefical effect on carbohydrate metabolism and cause the increased pyruvate neccesary to maintain the generation of energy-producing substrates. The results also suggest that methylprednisolone increases cell survival time and results in greater salvage of ischemic myocardium.

Management of the patient with a prosthetic heart valve.

Approximately 20,000 heart valve prostheses are inserted yearly in the United States. Even after successful heart operations, the patients who receive them cannot be regarded as healthy individuals but are a special group with special problems who need close medical attention for the rest of their lives. They are susceptible to many unusual complications because of their implanted foreign body, and it is a challenge to all physicians in contact with them to be aware of their peculiar problems in order to prevent complications if possible and to treat them immediately if they occur. General therapy, surgical complications, infection, and mechanical problems are reviewed, with means for management outlined. These difficulties can be dealt with only by careful follow-up and well-coordinated teamwork between the family physician and the institution where the operation was performed.

Pulmonary Blood Flow Measurements Following Vena Cava-to-Pulmonary Artery Anastomosis

Abstract The distribution of pulmonary blood flow was investigated in 2 patients 13 and 9 years following vena cava-to-pulmonary artery anastomosis. Angiographic and radioactive flow studies revealed a wide-open vena cava-to-pulmonary artery anastomosis which became larger proportional to the patients growth. The passage of contrast material through the lung was swift and unimpeded; however, perfusion of the apical portion of the right lung appeared less than satisfactory. There was a complete separation between the systems of the superior and inferior caval veins, and contrast material and radioactive albumin injected into the system of the superior caval vein entered the right lung exclusively. On the basis of these observations, it is our opinion that if vena cava-to-pulmonary artery anastomosis is done with a proper operative indication and a satisfactory surgical technique, one should not expect late development of intercaval collaterals and decrease in the efficiency of the vena cava-to-pulmonary artery shunt.

A New Self-Anchoring Endocardial Electrode

We describe a new electrode which uses the self-anchoring property of an ejectable dart to remain in permanent contact with the right ventricular myocardium. In longrange animal experiments, there were neither disloca tions nor mechanical failures. Both acute and chronic threshold measure ments, as well as sensing characteristics, remained acceptable. The experi mental lead was applied in a clinical case refractory to treatment by other electrodes. The application of this dart-electrode appears to be indicated when elec trode instability occurs. Further well-controlled clinical trials appear to be necessary before it could be recommended for routine clinical use for all patients requiring transvenous pacemaker implants.