Richard L. Prager

Arteriovenous Fistula of the Lung

Pulmonary arteriovenous fistula is an unusual but not rare abnormality with more than 450 cases reported in the literature. Studies during the last 30 years have established the effective prevention of morbidity and relief of symptoms by operative excision. During the last 25 years, the Vanderbilt University Affiliated Hospitals have seen 7 patients with pulmonary arteriovenous fistula. This experience prompted a review of the literature. Particular emphasis is placed on current means of diagnosis and therapy.

The feasibility of adjuvant surgery in limited-stage small cell carcinoma: A prospective evaluation

Forty patients with limited-stage small cell carcinoma of the lung were prospectively evaluated for adjuvant surgery after intensive chemotherapy to determine resectability. All patients giving informed consent and having a Karnofsky performance status greater than or equal to 50% were included in the study, which ran from May, 1980, to September, 1982. Ages ranged from 40 to 70 years (median, 59 years). One patient was lost to follow-up. Thirty-nine patients were evaluated for operation 9 to 15 weeks after diagnosis and after having received two to four cycles of chemotherapy intravenously every 3 weeks (cyclophosphamide, 1,000 mg/m2; doxorubicin, 50 mg/m2; vincristine, 1 mg/m2; VP-16, 300 mg/m2). Two patients had clinical Stage I tumors; 12 patients, Stage II; and 25 patients, Stage III. At the time of reevaluation there were 13 (33%) complete responders, 21 (54%) partial responders, and 5 (13%) with stable disease. Eleven (28%) of the 39 patients underwent thoracotomy using standard resection criteria for non-small cell carcinoma. Eight of these 11 had resectable lesions (2, Stage I; 3, Stage II; 3, Stage III); five pneumonectomies and three lobectomies were performed. Tumor was present in six of eight specimens. Twenty-eight patients were not candidates for operation for various reasons: poor pulmonary function, 5; unresectable tumors, 10; refusal, 6; very poor medical condition, 6; and primary site not identified, 1. Median survival for complete responders was 17 months and for partial responders, 11 months. We have prospectively identified suitable candidates for adjuvant surgery among the total group (denominator population) of patients with limited-stage small cell carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac surgery in patients with chronic renal disease

The combination of chronic renal failure and cardiovascular disease is identified frequently and results in high morbidity and mortality without appropriate medical and surgical therapy. Experience during the last eighteen years has shown that cardiac operations can be undertaken in this high-risk group with acceptable morbidity and mortality and with reasonable expectation of symptomatic improvement. In a six-year period, 17 patients with chronic renal disease underwent cardiac procedures at the Vanderbilt University Affiliated Hospitals. Ten patients were on long-term hemodialysis, and 7 had a functioning renal transplant. Thirteen patients had a coronary artery bypass procedure alone, 1 had a bypass procedure plus aortic valve replacement, 1 had a bypass procedure plus repair of the mitral valve, 1 had a bypass procedure and resection of a left ventricular aneurysm, and 1 had aortic valve and mitral valve replacement for endocarditis. Sixteen patients survived and were discharged. The hospital stay was shorter for patients with a renal transplant than for those on hemodialysis (mean, 11 days versus 22 days, respectively), and perioperative complications were less frequent in the transplant group. There has been 1 late death unrelated to the operative procedure. Fifteen long-term survivors have been followed a mean of 26 months (range 7 to 108 months). All have achieved symptomatic improvement and are in New York Heart Association Functional Class I or II. These results in this high-risk patient group provide a basis for cautious optimism and for a continued aggressive approach in patients with chronic renal disease who require cardiac operation.

The Subxiphoid Approach to Pericardial Disease

During the 36-month period from July, 1978, through July, 1981, 25 patients underwent a subxiphoid pericardial window procedure for diagnosis and therapy. Twelve patients were operated on for uremic pericarditis, 6 for malignancy, and 7 for etiological diagnosis of the pericarditis. All 12 patients with renal failure had enlarging effusions, despite aggressive dialysis. Eleven of the 12 are alive, free from recurrence, 3 to 36 months postoperatively. Six patients were operated on for suspected pericardial malignancy with hemodynamic compromise. Histological diagnosis was made from the pericardial tissue in all patients; only 1 patient lived more than 43 days following the procedure. In the group of 7 patients operated on for diagnosis, 4 were thought preoperatively to have tuberculous pericarditis. All 4 were treated with anti-tuberculosis chemotherapy and are asymptomatic, without evidence of calcification, 12 to 31 months postoperatively. This diverse group of patients demonstrates that the subxiphoid pericardial window is an effective approach for relief of uremic effusions and may adequately treat effusive tuberculous pericarditis when combined with multidrug chemotherapy. Patients with suspected malignant pericardial disease and hemodynamic compromise need to be carefully studied before an operative procedure is considered as a means of diagnosis and therapy.

Perioperative Beta Blockade with Propranolol: Reduction in Myocardial Oxygen Demands and Incidence of Atrial and Ventricular Arrhythmias

To determine the effect of beta blockade with propranolol on myocardial oxygen demands and postoperative arrhythmias in patients having coronary bypass operations, 50 patients with chronic stable angina undergoing operation were randomized in a double-blind fashion to receive either propranolol (60 mg every 6 hours) or a placebo. Drug administration began 24 to 48 hours prior to operation and continued through the operative period and for one month after operation. There were no deaths. Two perioperative myocardial infarctions occurred, both in patients receiving a placebo. Myocardial oxygen demand as measured by the rate-pressure product (heart rate X mean arterial pressure) was significantly reduced during induction of anesthesia (7,658 +/- 451 versus 5,786 +/- 340; p less than 0.002) and during sternotomy (8,400 +/- 550 versus 6,756 +/- 384; p less than 0.02) in propranolol-treated patients. In the first two postoperative days, nitroprusside was required for control of hypertension of 10 patients in the placebo group but in only 3 patients given propranolol (p less than 0.05). Postoperatively, 15 of the 26 patients who received a placebo had 45 episodes of arrhythmia. Seven of the 24 propranolol-treated patients had 17 episodes (p less than 0.04). We conclude that propranolol given perioperatively in doses large enough to induce beta blockade significantly reduces myocardial oxygen demands in the vulnerable period during induction of anesthesia and sternotomy, reduces the need for antihypertensive therapy in the immediate postoperative period, and causes a marked reduction in the incidence and frequency of both supraventricular and ventricular arrhythmias in the postoperative period.

Repair of Interrupted Aortic Arch and Associated Malformations in Infancy: Indications for Complete or Partial Repair

There is uncertainty regarding the best method of repair of interrupted aortic arch. The question is whether to perform primary definitive repair of this anomaly plus the associated defects versus arch repair only and palliation of the intracardiac defects, usually by pulmonary artery banding. Since 1976, 16 infants with interrupted aortic arch have been treated surgically. They were seen at 5.2 +/- 3 days of age and weighed 3.2 +/- 0.7 kg. The interruption occurred between the left carotid and left subclavian arteries (type B) in 9 and between the left subclavian artery and the descending aorta in 7 (type A). Isolated ventricular septal defect (VSD) was the only associated anomaly in 7 and aortopulmonary window, in 4. Two patients had truncus arteriosus type 1. Three had transposition of the great arteries: 1 with VSD and 2 with single ventricle. Prior to 1980, our policy was to palliate all patients. Between 1976 and 1980, 4 infants underwent left thoracotomy with arch repair plus pulmonary artery banding (3, VSD; 7, transposition of the great vessels and single ventricle) with only 1 (25%) survivor. Because of this high mortality, 8 patients with interrupted aortic arch and VSD or aortopulmonary window, seen since 1980, received complete repair with median sternotomy, end-to-end arch anastomosis, and closure of the VSD or aortopulmonary window utilizing profound hypothermia and circulatory arrest. All 8 survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Early Operative Intervention in Aortic Bacterial Endocarditis

Since 1974, 14 patients have required valve replacement for native aortic valve bacterial endocarditis at Vanderbilt University Medical Center. There were 7 male and 7 female patients ranging from 11 to 65 years old. Nine of the patients were less than 27 years old. All patients had congestive heart failure as a complication of the bacterial endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. Two patients were seen initially with arrhythmias, 3 had episodes of septic emboli, and 1 patient was operated on immediately after sustaining a cardiac arrest. Echocardiogram was utilized in 9 patients, and cardiac catheterization was performed in 6 patients who were suspected to have concomitant mitral valve or coronary artery disease. All patients were operated on within two weeks after the institution of antibiotic therapy, and there were no operative or early postoperatively deaths. Preoperative blood cultures were positive in 13 patients, with streptococcus cultured in 6 patients and staphylococcus in 4. Escherichia coli and enterococcus were the other pathogens cultured. All patients received antibiotics intravenously for a total of six weeks. There has been 1 late postoperative death, which occurred 2 months following operation in a patient with myocardial failure unresponsive to treatment. Two patients underwent reoperation, 1 because of a persistent aorto-right ventricular fistula and the second because of paraprosthetic aortic regurgitation. Nine patients are now in NYHA Functional Class I and 4 are in Class II.

Surgical approach to intracardiac renal cell carcinoma.

Abstract Renal cell carcinoma frequently extends into the vena cava, and the tumor thrombus occasionally continues into the right atrium. Patients often have symptoms of right-sided congestive heart failure of recent onset and signs of inferior vena cava obstruction. Previous reports have documented the value of very aggressive operative management in these situations; the present patient and the literature surveyed support this therapeutic approach.

Pulmonary, Mediastinal, and Cardiac Presentations of Histoplasmosis

Sixty-one patients with histoplasmosis were identified. They ranged from 14 months to 67 years old. There were 56 male and 5 female patients. Disease presentations were categorized into pulmonary (47), mediastinal (11), pericardial (2), and cardiac (1). Twenty of the patients with pulmonary involvement had histoplasmomas treated by wedge resection (18) or lobectomy (2). Twenty-two of the 27 cavitary lesions were treated by lobectomy and 4 by segmental resection, and 1 required pneumonectomy. The patients with mediastinal granulomas or fibrosis underwent exploration for diagnosis and curative or palliative procedures. Two patients with pericardial histoplasmosis required pericardial windows to relieve acute tamponade. One patient with disseminated histoplasmosis required aortic valve replacement for histoplasmosis valvulitis with severe regurgitation. The 1 operative death was a patient requiring pneumonectomy for mediastinal histoplasmosis. Indications for operative intervention in pulmonary histoplasmosis included resection of a new or enlarging pulmonary nodule to provide a definite pathological diagnosis and resection of persistent thick-walled pulmonary cavities. Mediastinal granuloma with or without fibrosis required exploration for diagnosis, palliation, or cure. Fungal endocarditis necessitated treatment with amphotericin B and valve replacement to stabilize the patients hemodynamic status and prevent embolization of large fungal vegetations. Pericardial effusion, a rare manifestation of histoplasmosis, was seen as acute tamponade requiring emergency intervention.

Alterations in Pulmonary Function Following Pneumonectomy for Bronchogenic Carcinoma

Twenty-one patients who underwent pneumonectomy for bronchogenic carcinoma at the Nashville Veterans Administration Hospital from November, 1977, to March, 1980, were evaluated with standard pulmonary function tests preoperatively and postoperatively. Twelve patients had Stage I disease, 4 patients had Stage II, and 5 patients had Stage III disease. The interval between the operative procedure and postoperative testing ranged from 2 to 33 months (mean, 12.4 months). Mean functional loss of pulmonary capacity after pneumonectomy was based on analysis of preoperative and postoperative forced vital capacity (FVC) and initial-second forced expiratory volume (FEV1) indices. The mean functional loss as expressed by FVC was 41.5% after right pneumonectomy and 34.0% after left pneumonectomy. The mean functional loss as expressed by FEV1 was 40.2% after right pneumonectomy and 38.3% after left pneumonectomy. The postoperative functional status of each patient was classified according to the New York Heart Association criteria. Nineteen of the 21 patients were in Class I or II preoperatively. Postoperatively, 10 patients were in Class I or II and 11 in Class III or IV. The results indicate that a postoperative FVC less than 2.5 liters and FEV1 less than 1.5 liters are not compatible with active life.