Ronald V. Pellegrini

Quality of life and coronary artery bypass surgery patients

Abstract A sample of 95 coronary artery bypass surgery (CABS) patients was studied in order to examine the relationship between quality of life and CABS. Quality of life is studied through measures of social situation, physical limits, and work status. Findings indicate that quality of life improvement is a function of the patients post-operative experience and perception of their physical limits, which, in turn, is likely to influence their desire to work. Retirement rates are high, particularly among patients over 55 years of age. Unemployment rates are high among those patients between 49–54 years of age. However, surprisingly few patients saw themselves as physically limited, a reflection of the high overall satisfaction with surgical outcome. The discussion focuses upon the use of productivity rather than work status measures as indicators of CABS success. The importance of the affiliative experience leads to specification of conditions under which life quality can be improved as a result of CABS. Surgery is discussed as a part of a complex interplay of physical and social experiences which influence individual and social benefits.

Interlocking figure-of-8 closure of the sternum

Sternal dehiscence and mediastinitis are two of the most severe complications of a median sternotomy. A technique of closure is described that appears to provide a more stable sternal approximation without any increase in overall complication rate. Using this technique in 978 consecutive patients, no cases of sternal dehiscence or mediastinitis have been seen.

Blunt rupture of both atrioventricular valves

Younger patients are surviving extensive damage to the heart and supporting structures, often associated with multiple systems injuries. A 23-year-old patient who sustained blunt trauma to the chest resulting in a pericardial laceration, injury to tricuspid and mitral valves, myocardial contusion, and paresis of the left phrenic nerve is reported. Porcine bioprosthetic valve replacement of both atrioventricular valves was necessary. Prompt diagnosis and aggressive intervention of such injuries can lead to successful repair of complex cardiac trauma.

Blunt traumatic rupture of the right atrium and the right superior pulmonary vein.

Blunt trauma to the chest may produce a spectrum of cardiac lesions extending from asymptomatic myocardial contusion to rapidly fatal cardiac rupture. A case is discussed in which a patient with signs of cardiac tamponade after blunt trauma was found to have a rupture of the atrium. During repair of the cardiac injury, an unusual tear of the right superior pulmonary vein was also discovered. Both injuries were successfully repaired and the patient recovered.

Tracheoesophageal fistula from nonpenetrating trauma.

A patient with a tracheoesophageal fistula from blunt chest trauma is presented and the literature is reviewed. A common pathophysiologic factor is the involvement of a young male in a deceleration injury. Early surgical intervention with division of the fistula and repair of the tracheal and esophageal defects is recommended.

Pneumonectomy for unremitting hemoptysis in unilateral absence of pulmonary artery

Unilateral absence of pulmonary artery is a rare malformation that can present as an isolated lesion or may be associated with other congenital heart defects. Clinical presentation is subtle when the lesion occurs alone, and may include hemoptysis, which results from rupture of abundant bronchial submucosal vessels perfused by enlarged systemic collaterals that supply the affected lung. Pneumonectomy is recommended as definitive treatment in such an adult patient.

Multiple cardiac lesions from blunt trauma.

Blunt chest trauma may produce a variety of cardiac lesions, which may occur alone or in combination. A case with a ventricular septal defect, left ventricular aneurysm, and coronary arteriovenous fistula with an associated rupture of the thoracic aorta following blunt trauma is presented in order to demonstrate that multiple, life-threatening cardaic lesions may be managed successfully. Surgical repair 32 days postinjury with Teflon patch plus ligation of the fistula were followed by recovery in the patient presented.

Rupture of the left atrium from blunt trauma.

Severe cardiac injury may occur in multiple-trauma patients and the associated injuries may obscure a significant and potentially fatal cardiac wound. In the patient presented, a left auricular appendage tear was found after he suddenly became hypotensive intraoperatively. After its repair he has recovered and returned to his previous employment.

Revascularization of the Circumflex Coronary Artery in the Atrioventricular Groove

Complete myocardial revascularization entails the grafting of all vessels of adequate size demonstrating occlusive arteriosclerotic vascular disease. Revascularization of the circumflex coronary artery in the atrioventricular groove has been a major surgical challenge because of the difficulty of exposing it. We discuss here our operative technique in 12 consecutive patients requiring revascularization of that segment of the circumflex coronary artery. Eleven grafts studied in the postoperative period were found to be patent, and the clinical course of the remaining patient and direct observations, including enzyme studies and periodic stress testing, have not shown any evidence of graft failure.

Streptokinase therapy in arterial thromboembolic disease

A review of the world literature on streptokinase treatment of arterial thromboembolic disease is presented, followed by two cases of peripheral arterial thromboembolic disease successfully treated with streptokinase. The role of streptokinase in the treatment of arterial occlusive disease is discussed, and its emerging role as a primary mode of therapy in thromboembolic arterial disease is predicted. The successful management of venous embolic and occlusive disease by treatment with streptokinase is well-known, including its use in treating pul monary emboli, deep venous thromboses and clotted hemodialysis shunts. However, the role of streptokinase in the management of arterial thromboem bolic disease has not received much attention in the United States, although it has been used extensively in Europe. The purpose of this paper is to review the literature on the use of strep tokinase in treating thromboembolic arterial disease, to present two cases successfully treated with this technique, and to discuss the emerging role of streptokinase in arterial thromboembolic disease.