Richard E. Wood

Operative therapy of coronary arterial aneurysm

In summary, a patient with multiple coronary aneurysms and operative therapy is described and 17 previously reported similar cases are reviewed. The proper type of operation for this condition is as yet unclear, but, nevertheless, the reported cases and our case with operative therapy have done well postoperatively despite a variety of procedures performed.

Objective Diagnosis (Ulnar Nerve Conduction Velocity) and Current Therapy of the Thoracic Outlet Syndrome

Abstract Analysis of 155 operations in 138 patients with thoracic outlet syndrome demonstrates the validity of resection of the first rib as the optimal method of therapy in patients who are not relieved by conservative management. The ulnar nerve conduction velocity (UNCV) study has provided a reliable, positive, objective method for diagnosis, selection, and evaluation of therapeutic modalities in patients with thoracic outlet syndrome. Median and musculocutaneous nerve compression can be the etiological factor in patients with atypical pain distribution in whom the UNCV is normal. Conduction study of these nerves confirms the diagnosis of thoracic outlet compression. The transaxillary approach allows complete resection of the first rib with decompression of the neurovascular bundle and is associated with a reduced morbidity and hospital stay.

Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina)

Abstract Forty-four patients presenting with chest pain suggesting coronary artery disease had normal exercise stress tests and selective coronary angiography and subsequently were found to have an unsuspected thoracic outlet syndrome. Thirteen additional patients had both significant coronary artery disease and thoracic outlet syndrome. Esophageal and pulmonary disease were ruled out and the diagnosis of brachial plexus compression in the thoracic outlet established by a reduction of the ulnar nerve conduction velocity (UNCV) below normal, the normal value being 72 meters per second. Clinical improvement from thoracic outlet compression resulted either from physical therapy if the UNCVs were above 55 m./sec, or from transaxillary surgical extirpation of the first rib if the UNCVs were below 55 m./sec. Thirteen patients with coronary artery disease and thoracic outlet syndrome required therapy for both problems before improvement ensued. Although the usual symptomatology for thoracic outlet syndrome involves pain and paresthesias of the shoulder, arm, and hand, the chest wall is frequently involved. If the chest pain is predominant with minimal shoulder-hand symptoms, the diagnosis is not suggested clinically and can only be established by the high index of suspicion, positive UNCV reduction, and a normal coronary angiogram. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm.

Prospective analysis of endoscopic vein harvesting

BACKGROUNDnUtilization of bridging vein harvesting (BVH) of saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG) results in large wounds with great potential for pain and infection. Endoscopic vein harvesting (EVH) may significantly reduce the morbidity associated with SVG harvesting.nnnMETHODSnA prospective database of 200 matched patients receiving EVH and BVH was compared. The patients all underwent CABG done over a period of 4 months (April to August 2000). Patients were excluded if they had prior vein harvesting.nnnRESULTSnThe EVH and BVH group included 100 patients each with similar demographics. The patients in the EVH group had significantly fewer wound complications, mean days to ambulation, and total length of stay (P <0.05). There was no difference in harvest time or vein injuries.nnnCONCLUSIONnEndoscopic vein harvesting results in significantly fewer wound complications, decrease in days to ambulation, and the total length of stay. EVH is superior to BVH in patients undergoing CABG.

Surgical Advantages of Selective Unilateral Ventilation

Abstract Two hundred major thoracic operations have been performed using controlled selective unilateral pulmonary ventilation with no morbidity or mortality related to this technique. A group of 20 patients ventilated selectively with a double-lumen endotracheal tube and 5 additional patients ventilated with a single-lumen tube were studied to determine the physiological effects of each technique. Blood gases and physiological shunt determinations showed better values with selective ventilation, whereas some derangement was noticed in the group ventilated with a single-lumen tube. The physiological and technical advantages provided by the double-lumen endobronchial tube make selective ventilation safer and more practical.

An Improved Surgical Technique for the Complicated Hiatal Hernia with Gastroesophageal Reflux

Abstract Although so-called valve reconstruction procedures at the gastroesophageal junction provide marked relief for most patients with gastroesophageal reflux and hiatal hernia, there is a recurrence rate of 10 to 15%. Many of the recurrences are in patients with obesity, severe pulmonary disease, or stricture, or in patients who have developed a recurrence from other previous types of surgical therapy. Since the primary cause of failure in hiatal hernia repair is tension on the distal esophagus, which is created as a result of securing an adequate length of intraabdominal esophagus, the Collis gastroplasty, which lengthens the esophagus by construction of a tube of the lesser curvature of the stomach, combined with a Belsey reconstruction of the gastroesophageal angle and dilation in cases of stricture, has been successfully employed over the past three years in patients with factors that predispose to recurrence. This technique provides adequate length without tension, and in more than 39 such patients there has been no evidence of reflux or recurrence of hernia by clinical symptoms or cine esophagogram. No mortality or significant morbidity has been observed.

Clinical benefits of continuous leukocyte filtration during cardiopulmonary bypass in patients undergoing valvular repair or replacement

Valve operations in the form of repair or replacement make up a significant population of patients undergoing surgical procedures in the USA annually with the use of cardiopulmonary bypass. These patients experience a wide range of complications that are considered to be mediated by activation of complement and leukocytes. The extracorporeal perfusion circuit consists of multiple synthetic artificial surfaces. The biocompatibility of the blood contact surfaces is a variable that predisposes patients to an increased risk of complement mediation and activation. This can result in an inflammatory process, causing leukocytes to proliferate and sequester in the major organ systems. The purpose of this study was to determine whether filtration of activated leukocytes improved clinical outcomes following surgical intervention for valve repair or replacement. In this paper, we report a retrospective matched cohort study of 700 patients who underwent valve procedures from June 1999 to December 2002. The control group (CG) consisted of patients who had a conventional arterial line filter. In the study group (SG), patients had a conventional arterial line filter and a leukocyte arterial line filter (Pall Medical, NY). In the SG, blood diverted to the cardioplegia system was also leukocyte depleted to enhance myocardial preservation by adapting this device to the outflow port on the filter. Patient characteristics were similar for the SG and the CG, including 228 males and 122 females, mean age (62.4 versus 64.2 years), cardiopulmonary bypass time (1279/64 versus 1169/53 min), and aortic crossclamp time (849/23 versus 819/23 min). Our results demonstrate that the SG achieved statistically significant reduction in the time to extubation (p=0.03) and the number of patients with prolonged intubation in excess of 24 hours (p=0.04), in addition to improved postoperative oxygenation (p=0.01), and decreased length of hospital stay (p=0.03). We believe that leukocyte filters are clinically beneficial, as demonstrated by the results presented in this study.

Distal CO2 Coronary Artery Endarterectomy and Proximal Vein Bypass Graft

Abstract Distal carbon dioxide coronary gas endarterectomy with a proximal vein bypass graft provides immediate direct revascularization of the myocardium in patients whose blood vessels are diffusely or totally occluded and who are not amenable to standard vein bypass graft procedures. Evaluation of 15 patients revealed improved ventricular function with patent grafts in 14 and 1 late death. The advantages of this procedure over standard CO 2 gas endarterectomy are that a high-flow vein bypass graft replaces arteriotomy closure; the left coronary system, either the anterior descending or circumflex coronary artery, can be revascularized with this technique without jeopardizing the other vessel; blind aortic inflow endarterectomy is avoided; and competitive flow is decreased because the proximal obstruction is not removed.