Timothy B. Icenogle

Use of Pericardial Fat Pad Flap to Prevent Bronchopleural Fistula

Use of the pericardial fat pad flap to cover the bronchial stump following pulmonary resection can minimize the occurrence of bronchopleural fistula, a serious complication. The surgical technique as shown is safe and easily accomplished.

Extracorporeal pulsatile biventricular support after cardiac transplantation

A donor heart failed to adequately sustain hemodynamic function after cardiac transplantation. The cause of the donor heart dysfunction was unknown, and there were no definite risk factors identified to suggest the heart would not recover. A Symbion Acute Ventricular Assist Device System was used to support both ventricles. The heart gradually recovered and the system was explanted after 1 week of support. The patient recuperated and has been discharged from the hospital.

Pneumocystis carinii Pneumonia After Heart Transplantation

Five patients with Pneumocystis carinii pneumonia after heart transplantation are reported. Four had severe clinical symptoms, whereas 1 was asymptomatic. Mechanical ventilatory support was necessary in 1 because of respiratory distress. Pneumocystis carinii infection developed in 4 patients within the first 4 postoperative months, and 1 patient had clinical disease 1 year after transplantation with a recurrence 9 months later. All were treated with trimethoprim-sulfamethoxazole either orally or intravenously (10 to 20 mg.kg-1.day-1 of trimethoprim). All patients recovered from infection and received the same drug prophylactically for 2 to 20 months after the infection. All patients are doing well after Pneumocystis carinii infection except 1 who died after an acute myocardial infarction 4 years after infection. We conclude that trimethoprim-sulfamethoxazole is an effective agent for the treatment of Pneumocystis carinii pneumonia after heart transplantation.

Management of difficult sternal closure after sternal infection

To the Editor: In spite of antibiotics and good surgical technique, sternal infection occurs in a small proportion of patients undergoing coronary operations. The incidence of infection with the use of bilateral mammary arteries for coronary bypass grafting has been reported to be as high as 8.5% [l] and as low as 1.6% to 4.0% [2, 31. In those situations in which infection occurs in the superficial soft tissues only and has not resulted in serious destruction or fracture of the sternum, primary closure with wire in a routine fashion can often be performed after a limited period of open drainage. At the time of closure mediastinal tissues are closely adherent to the underside of the sternum and there is no distinct surgical plane. In this setting, difficulties can be encountered in placing wires in or around the sternum to obtain secure and safe closure. Saphenous veins and mammary arteries are at risk of being damaged because dissection under the sternal halves can be tedious and hazardous. The exact location of these conduits is unknown without repeat angiography. We have recently had the unfortunate experience of reclosing a patients sternum because of nonunion and inadvertently placing the sternal wire around the left internal mammary artery graft. This was not suspected or discovered at operation and resulted in the patients death several hours later. This was verified at autopsy. We subsequently encountered a patient with a superficial wound infection after coronary bypass grafting with bilateral internal mammary arteries. There was no destruction or involvement of the sternum or mediastinum. He was treated by reopening of the wound, removal of all sternal wires, wet to dry dressings, and antibiotic therapy. Sixteen days later, after resolution of local signs and symptoms of infection, the patients wound was closed utilizing a new technique. No attempt was made to mobilize soft tissues on the underside of either sternal half. The sternal wire was brought down at 90 degrees to the outer table of the sternum, and the wire was brought out straight through the marrow just superior to the inner table (Fig 1). The needle was then advanced through the marrow on the opposite side just above the inner table, keeping the curve of the needle parallel to the inner table. In this manner all wires passed anterior to the inner table of the sternum, thereby avoiding all grafts. The sternum was then approximated