Richard D. Sautter

History and physical examination in acute pulmonary embolism in patients without preexisting cardiac or pulmonary disease

The history and physical examination were assessed in 215 patients with acute pulmonary embolism uncomplicated by preexisting cardiac or pulmonary disease. The patients had been included in the Urokinase Pulmonary Embolism Trial or the Urokinase-Streptokinase Embolism Trial. Presenting syndromes were (1) circulatory collapse with shock (10 percent) or syncope (9 percent); (2) pulmonary infarction with hemoptysis (25 percent) or pleuritic pain and no hemoptysis (41 percent); (3) uncomplicated embolism characterized by dyspnea (12 percent) or nonpleuritic pain usually with tachypnea (3 percent) or deep venous thrombosis with tachypnea (0.5 percent). The most frequent symptoms were dyspnea (84 percent), pleuritic pain (74 percent), apprehension (63 percent) and cough (50 percent). Hemoptysis occurred in only 28 percent. Dyspnea, hemoptysis or pleuritic pain occurred separately or in combination in 94 percent. All three occurred in only 22 percent. The most frequent signs were tachypnea (respiration ate 20/min or more) (85 percent), tachycardia (heart rate 100 beats/min or more) (58 percent), accentuated pulmonary component of the second heart sound (57 percent) and rales (56 percent). Signs of deep venous thrombosis were present in only 41 percent and a pleural friction rub was present in only 18 percent. Either dyspnea or tachypnea occurred in 96 percent. Dyspnea, tachypnea or deep venous thrombosis occurred in 99 percent. As a group, the identified clinical manifestations, although nonspecific, are strongly suggestive of acute pulmonary embolism. Conversely, acute pulmonary embolism was rarely identified in the absence of dyspnea, tachypnea or deep venous thrombosis.

Platelet Dysfunction Associated with Cardiopulmonary Bypass

The clinical significance and pathogenesis of the platelet dysfunction following cardiopulmonary bypass were studied in conjunction with the degree of functional impairment associated with the use of membrane and bubble oxygenators. Forty consecutive patients had the following tests preoperatively and postoperatively: complete blood count (CBC), platelet count, prothrombin consumption time, bleeding time, prothrombin time, partial thromboplastin time, fibrinogen, euglobulin clot lysis, fibrin degradation products, and platelet aggregation tests. Six patients were given 14C-serotonin tests before and after operation, and preoperative and postoperative electron micrographs were made of the platelets of 3 patients. The amount of blood lost, the blood transfused, and plasma hemoglobin levels were also measured. Abnormal aggregation of platelets was found, with no difference between the membrane and bubble oxygenators. In vitro aggregation tests with protamine sulfate and hemoglobin solutions, as well as the 14C-serotonin studies and electron micrographs, suggest that platelets acquire storage pool deficiency and an abnormal membrane during cardiopulmonary bypass.

Benign cecal ulcers: Spectrum of disease and selective management

Benign ulceration of the cecum is an uncommon lesion. Most cases are diagnosed intraoperatively and most authors have advocated right hemicolectomy due to the difficulty in differentiating benign from malignant lesions. Recently colonoscopic diagnosis and conservative treatment have been reported. We describe six cases of cecal ulcer ranging from asymptomatic lesions diagnosed at colonoscopy and healing with conservative management to perforated ulcers with intra-abdominal abscesses requiring right hemicolectomy. A selective approach to patient management is advocated, including stapler wedge cecectomy with frozen section diagnosis to avoid extensive bowel resection and retain the ileocecal valve.

Pulmonary embolectomy: Review and current status

D ISCUSSIONS regarding pulmonary embolectomy are traditionally opened with a reference to Dr. Trendelenburg. I The controversy stimulated by this procedure has resulted in continued and considerable accrual of information regarding massive pulmonary embolism. Dialogue remains heated, both in the literature and from the speakers podium. Many authors, myself included, owe Dr. Trendelenburg a great debt; how many of our patients have such an obligation remains debatable. The Congress of German Surgeons in 1908 indeed must have been a stellar event. There were reports of the benefit of early ambulation as it affects thrombotic and embolic phenomena, technique of transplantation of the thyroid gland and bone, intravenous novocaine for anesthesia of the extremities, successful transnasal hypophysectomy for acromegaly, use of positive and negative atmospheric pressure for intrathoracic operations, and the description and use of an intraoperative gastroscope. It was in this setting that Trendelenburg reported his technique for pulmonary embolectomy. Although none of the patients upon whom he operated survived, the technique still bears his name. Kirschner, 2 a student of Trendelenburg, in 1924 reported the first success utilizing the procedure. In this country the first such success was reported in 1958 by Steenburg? Temporary inflow occlusion of the circulation, and tourniquet occlusion of the inferior and superior vena cava, was first used to do embolec-

Reduction of intraoperative myocardial infarction by means of exogenous anaerobic substrate enhancement: prospective randomized study.

In a prospective study, patients who had an ejection fraction of 40% or more and who were undergoing elective coronary artery operation were randomly divided into three groups that differed in the method of anaerobic substrate enhancement during cardiopulmonary bypass. Group 1, the controls (n = 157), received no additional glucose, insulin, and potassium solutions and experienced immediate spontaneous defibrillation (10%), transmural myocardial infarction (10.3%), malignant ventricular arrhythmias (26%), and severe atrial arrhythmias (20%). Group 2 (n = 120) received a bolus of hypertonic glucose, insulin, and potassium in the pump perfusate before aortic cross-clamping. In this group, the rate of spontaneous defibrillation was 41%, of transmural infarction, 8.3%, of malignant ventricular arrhythmias, 31%, and of severe atrial arrhythmias, 19%. Group 3 (n = 114) had the aortic root continuously infused with glucose, insulin, and potassium solution at 4 degrees C during aortic cross-clamping. This group was significantly improved; the rate of spontaneous defibrillation was 60%, there were no transmural myocardial infarctions and the incidence of severe atrial arrhythmias was 6% and that of malignant ventricular arrhythmias, 5%. It is proposed that the superior clinical results in Group 3 resulted from better myocardial preservation achieved by more efficient means of providing continuous anaerobic substrate, coronary washout, and elution of lactic acidosis, uniform global hypothermia, and direct supplemental myocardial potassium in addition to mere cardioplegic effects.

Prognostic Value of Electroencephalography in Cardiac Surgery

One hundred seventeen patients undergoing cardiac operations over a two-year period were studied. Electroencephalograms were recorded preoperatively, in the recovery room (up to 12 hours following operation), 24 hours later, and further as required. Operative and anesthesia data were correlated with EEG findings. All patients had normal EEGs preoperatively. This unusual occurrence may largely reflect the absence of congenital heart disease and the small number of valvular lesions in our patients. Prognosis was not significantly influenced by age. Bypass time appeared directly related to outcome by group but not individually. Hypotension prior to pumping occurred most often and mean blood loss was greatest in the patients who had abnormal EEGs in the recovery room with progressively worsening patterns until death. In the recovery room many patients were awake, while others were either drowsy, lethargic, or asleep. Some were comatose. The level of consciousness was not as prognostic as was the EEG. The pattern of EEGs in the first few postoperative days is more important than any single record by itself. All those who showed progressive deterioration in the first two or three days died shortly thereafter.

Tandem Coarctations of Thoracic and Abdominal Aorta with Intervening Hypoplastic Thoracic Aorta: Treatment with Unilateral Axillofemoral Graft

Tandem coarctations of the thoracic and abdominal aorta with an intervening segment of hypoplastic thoracic aorta were discovered unexpectedly in a 14-year-old boy brought to the emergency room for a displaced fracture of the radius. After the fracture healed, the boys potentially dangerous anomalies were treated successfully with a unilateral axillofemoral prosthetic graft. This has remained patent for 42 months, and the boy has done well.

Vena cava umbrella placement: Its place in the over-all management of thromboembolic disease

Abstract A series of patients who underwent placement of a vena cava umbrella is presented. Morbidity was minimal and there was no mortality related to umbrella filter placement per se. One patient had a nonfatal episode of recurrent embolization. The role of umbrella placement in the over-all management of thromboembolic disease is discussed and it is concluded that only 10 to 15 per cent of patients with documented pulmonary emboli will be candidates for umbrella placement.

Can the Frequency of Myocardial Infarction Be Reduced during Coronary Artery Operations

A prospective experiment was carried out in 56 patients undergoing coronary artery revascularization to determine whether those having a glucose-insulin-potassium (GIK) perfusion during the procedure would have fewer myocardial infarctions (MI) compared with patients given a control perfusion of Normosol-R. Six patients (11%) developed an MI, defined as a 24-hour creatine phosphokinase MB isoenzyme value of 100 IU per liter or greater. Four (13%) had control perfusions and 2(8%) had GIK perfusion. One MI in a double-graft recipient who had GIK perfusion occurred because of a technical surgical error; therefore, the corrected MI rate was 13% in control patients compared with 4% for the GIK group. These data, as well as the more frequent spontaneous defibrillation in patients who had GIK perfusion, suggest that GIK was of benefit.

Quadruple Coronary Artery Bypass Grafting

In our last 150 consecutive revascularization operations, 30 patients (20%) have had 4 or more bypass grafts. One patient died after quadruple grafting (mortality, 3%). Twenty-two (75%) of the survivors have been rehabilitated to active work status and 25 (86%) were considered by their cardiologists to have improved function postoperatively by New York Heart Association criteria. Preoperatively 15 patients (50% of the group) had either a markedly diminished ejection fraction (EF) or extreme elevation in left ventricular end-diastolic pressure (LVEDP) or both. Complete revascularization, with resection of ventricular aneurysms when present, can be carried out successfully in a high-risk group of patients. Elevated LVEDP or diminished EF per se is not a valid contraindication to myocardial revascularization.