Paul C. Adkins

Indications for Early Thoracotomy in the Management of Chest Trauma

Trauma to the thorax represents a significant portion of injuries seen in an inner-city emergency room. Although most of these patients may be successfully managed without thoracotomy, a certain percentage require operative intervention either immediately or within several hours. The records of more than 380 patients with major chest trauma seen in recent years have been reviewed. Three hundred twenty-one of these patients (84%) required only good supportive measures such as correction of hypovolemia, temporary ventilatory support, tube thoracostomy, and careful observation. Forty-four additional patients (12%) required immediate operation following preliminary resuscitative treatment. Indications included hemorrhage, cardiac tamponade, injury to a great vessel, and rupture of the diaphragm. There were 10 deaths in this group. In 15 other individuals (4%) delayed operation was undertaken following careful reappraisal of initial injuries by continued examination, monitoring of vital signs, and appropriate roentgenographic and laboratory studies. Indications for delayed operation included continued or recurrent bleeding, widening of the mediastinum, hemoptysis, and recurrent hemothorax. There was only 1 death in this group. Thus, although it may be clear which patients require immediate operation, only careful and continuous monitoring can identify those who initially appear to be in stable condition but eventually will require exploration.

Traumatic aneurysm of left anterior descending coronary artery with fistulous opening into left ventricle and left ventricular aneurysm after stab wound of chest: Report of case with successful surgical repair

Abstract A patient survived a stab wound of the heart, and an aneurysm of the left anterior descending coronary artery developed with a fistulous communication into the left ventricle and a postinfarction ventricular aneurysm. All lesions were successfully repaired by surgery 4 years later. Preoperatively the patient suffered from angina pectoris presumably due to a coronary arterial “steal syndrome” and recurrent myocardial infarction presumably due to coronary embolism from thrombi formed within the coronary aneurysm. The combination of a coronary arterial aneurysm and a coronary arterial-left ventricular fistula produced a diastolic murmur that disappeared after surgery.

The Society of Thoracic Surgeons Manpower Survey for 1976: A Summary

The results of a 1977 survey regarding places and types of thoracic surgical procedures performed in the United States are analyzed. Responses gathered from 2,240 thoracic surgeons showed that active thoracic surgeons between 34 and 54 years old performed 195,850 major thoracic or cardiac operations per year. Fifty-four percent of active surgeons responding were in solo practice, 40% practiced in groups of 2 to 5 surgeons, and the reamining 6% were in groups of 6 or more. Community size, regional distribution of services, proportion of professional activities allocated to various procedures, and estimates of additional capacity are also summarized.

Scar Carcinoma of the Lung: Fact or Fantasy?

Abstract Previous reports on lung surgery have considered scar carcinoma of the lung as a separate clinical entity associated with a fairly favorable prognosis. The clinical and morphological characteristics of peripheral adenocarcinoma or adenosquamous cell carcinoma in 75 patients and of scar carcinoma in 19 individuals were compared. Location of the lesions, sex distribution, patient age, and tumor size were similar for both groups. Although the extent of vascular invasion was also similar, lymph node involvement was greater in the group with scar carcinoma. Five-year survival was far less in the scar carcinoma group (5%) than in the adenocarcinoma (22%) or adenosquamous cell carcinoma (28%) groups. The characteristics of scar carcinoma of the lung appear to be no different than those of similar cell types without scarring.

The totally occluded internal carotid artery: indications for surgery.

Surgery for treatment of the totally occluded internal carotid artery has been controversial since the first case was reported in 1958. Two cases and a review of the literature are presented to show that complete cerebral angiography should be the determining factor for operating in those patients with symptoms referable to the totally occluded internal carotid artery.

Pulmonary varix regression after mitral valve replacement

Pulmonary varix is a rare finding; only 35 documented cases have been reported. The first case was described in 1843 as an icidental postmortem finding. The first clinical diagnosis was not made until 1951. In more than half of the 35 cases, the varix was present in the absence of congenital and acquired heart disease. Six patients have had concomitant mitral rheumatic heart disease. This communication describes the second patient with rheumatic mitral regurgitation in whom the pulmonary varix became radiographically invisible after prosthetic mitral valve replacement.

Pulmonary and Cardiovascular Implications of Drug Addiction

Abstract One hundred thirteen patients were seen with pulmonary or cardiovascular complications secondary to intravenous drug abuse. More than 60% of these patients had such pulmonary problems as pulmonary edema, recurrent septic pulmonary emboli, asymptomatic hilar adenopathy, or pneumonia. Twelve patients were treated for bacterial endocarditis; 6 subsequently required valve replacement. Vascular complications included complete venous occlusion of the hand, transient arterial insufficiency, and mycotic aneurysm secondary to intraarterial injections of narcotics.

Acute Severe Mitral Regurgitation from Papillary Muscle Dysfunction in Acute Myocardial Infarction Successful Early Surgical Treatment by Combined Mitral Valve Replacement and Aortocoronary Saphenous Vein Bypass Graft

A patient with acute severe mitral regurgitation resulting from papillary muscle dysfunction which developed on the third day of acute myocardial infarction underwent early successful mitral valve prosthetic replacement with concomitant aortocoronary saphenous vein bypass. The concept of acute severe mitral regurgitation due to an infarcted papillary muscle which has not actually ruptured and an aggressive approach to such a catastrophic event early in the course of acute myocardial infarction are emphasized. The risk is well worth the gratifying result obtained in our patient who successfully underwent such a combined operative procedure for one of the early complications of acute myocardial infarction.

Mural Thrombus in the Left Atrium Secondary to Transseptal Catheterization of the Left Side of the Heart

TRANSSEPTAL catheterization of the left side of the heart, as introduced by Ross et al.,1 has many advantages over previous methods of entering the left chambers of the heart. Studies in animals di...

Clinical Effects of Membrane Lung Support for Acute Respiratory Failure

Extrapulmonary support in respiratory failure has become possible for prolonged periods with clinical application of the membrane lung oxygenator. The membrane lung may be perfused in a venovenous circuit, in which case it functions by prepulmonary venous oxygenation, or it may be pumped in venoarterial perfusion as partial or total cardiopulmonary bypass. Four patients were placed on venovenous membrane lung (GE-Peirce) perfusion for periods ranging from 6 to 112 hours. In oxygenating blood flows of less than 50% of the cardiac output, a viable PaO2 (mean, 52 mm Hg) was obtained in 2 patients with 60% FIO2, including 1 survivor who was weaned from the membrane lung. The remaining 2 patients had heart failure and insufficient venovenous membrane lung flows to improve systemic oxygenation (mean PaO2, 45 mm Hg on 100% FIO2). Four other patients were placed on venoarterial membrane lung (GE-DuaLung) bypass for 18 to 110 hours. With 40 to 85% of the cardiac output bypassed through the membrane oxygenator, immediate improvement was seen in systemic oxygenation (mean PaO2, 75 mm Hg), effective compliance (mean increase of 75%), and reduction in pulmonary hypertension (mean decrease, 15 mm Hg). These changes during bypass allowed the lungs to be put at rest with a decrease in FIO2 and positive end-expiratory pressures. This clinical experience indicates that venoarterial membrane lung bypass may be both supportive and therapeutic, decompressing the pulmonary circuit and maintaining systemic oxygenation. Membrane lung supported by either mode of perfusion has been shown to be clinically effective in patients suffering acute respiratory failure.