W.L. Sugg

Intraaortic balloon counterpulsation in patients in cardiogenic shock, medically refractory left ventricular failure and/or recurrent ventricular tachycardia

Of the 27 patients described, 23 were in cardiogenic shock, 2 had severe left ventricular failure, and 2 had medically refractory ventricular tachycardia. Utilizing intraaortic counterpulsation, adequate systemic blood pressure was initially restored in 19 patients. Nine of these were subsequently weaned from circulatory assistance, but only three were discharged from the hospital and are currently alive. The remaining 10 patients who derived initial benefit from circulatory assistance were balloon-dependent in that they could not be weaned from circulatory assistance. Eight of these patients subsequently underwent cardiac catheterization; four had inoperable disease. The remaining four patients underwent surgery for either resection of the area of infarction and/or for myocardial revascularization; only one survived to subsequently leave the hospital. Ventricular volumes were abnormal and ejection fractions were below 30 per cent in all the patients in cardiogenic shock except one who underwent cardiac catheterization and ultimately died. Ejection fractions were greater than 30 per cent in the two patients with cardiogenic shock who were weaned from balloon support and survived to leave the hospital without surgery. Both of these patients had inferior myocardial infarction. The data obtained from this experience suggest that intraaortic counterpulsation is a very useful adjunct to currently existing medical measures to treat both cardiogenic shock and medically refractory left ventricular failure but that most patients have such extensive disease that they can neither be weaned from balloon support nor undergo successful infarctectomy or myocardial revascularization.

Injuries of the trachea and bronchi

Abstract There were 105 injuries of the trachea and bronchi in Dallas County over the ten-year period 1958 through 1967. Twenty-four patients were alive (AOA) and 81 were dead (DOA) on admission. Survival to reach the hospital was related to age, wounding agent, site and severity of injury, and major associated injuries, particularly cardiovascular. Diagnosis in AOA patients could be suspected on the basis of symptoms and was confirmed by bronchoscopy. Definitive treatment included primary suture in 17 patients and tracheostomy alone in 4. Of the 21 patients with injuries to the trachea, 18 did well. Poor results were related to associated injuries or inadequate treatment. The 3 patients with bronchial injuries were treated by primary suture. One patient died of late stricture. Although most tracheal and bronchial injuries are associated with other fatal injuries, the prognosis in those patients who arrive alive is good. Immediate primary closure of the wound offers the best chance for a good result.

Technetium stannous pyrophosphate myocardial scintigrams in the recognition of myocardial infarction in patients undergoing coronary artery revascularization.

Myocardial imaging using technetium 99m stannous pyrophosphate (99mTc-PYP) has been utilized preoperatively and three to five days postoperatively to detect myocardial infarction in 48 patients undergoing aortocoronary bypass grafting, including 7 having valve replacement (5 aortic, 2 mitral) in addition to revascularization. In the total group of patients operated on there were 3 deaths (6%). Preoperatively, 26 patients had unstable angina and 10 had severe left main coronary artery disease. Eleven of the 48 (23%) were women. ECG and enzyme-proved infarctions occurred in 6 of the 48 patients (12%), but the addition of 99mTc-PYP myocardial imaging demonstrated scintigraphic evidence of infarction in 15 patients (31%), including 2 who died in the operating room. The 99mTc-PYP myocardial imaging technique, which has proved safe, simple, and relatively inexpensive in these patients, suggests that the incidence of infarction after coronary bypass operations is somewhat higher than has been previously recognized from just ECG and enzyme changes. This technique also has been of value in helping to exclude myocardial infarction in difficult clinical situations such as postoperative arrhythmias and the postpericardiotomy syndrome.

Traumatic Esophageal Perforation

Abstract Thirty-two consecutive unselected patients with traumatic esophageal perforation treated in the past seven years were reviewed. Perforation was due to gunshot wounds, stab wounds, instrumentation, or massive lye ingestion. Of the 12 patients seen in the first four years (Group I) who were treated with primary closure or tube thoracostomy, intravenous fluids, and antibiotics, 5 died. In a second group of 15 patients seen in the last three years (Group II) who received 2,000 to 3,000 calories daily either intravenously or by tube feeding, only 1 patient died; 5 other patients with high, isolated injuries of the cervical esophagus who went home within one week were excluded from Group II. The time from perforation to definitive therapy was approximately the same in both groups, as was the severity and type of perforation. Complications were similar in each group and included abscess, empyema, mediastinitis, hemorrhage, fistula, and pneumonia. Three times the associated injuries per person occurred in Group II as in Group I. Therefore there appeared to be a greater potential for complications and death, but only 1 of the 15 patients died as compared with 5 of the 12 Group I patients. This limited mortality appeared to be due to the increased nutritional regimen.

Prolonged Survival of the Anoxic Lung with Metabolic Inhibitors in Normothermic and Hypothermic Conditions

istant as we may seem to be from a solution of the complex problems of pulmonary transplantation, there is no doubt D that many of them, including transient preservation of the ischemic lung, have been resolved to practical application. Many workers have shown that the warm ischemia time of the lung must be very brief if irreversible damage is to be avoided. Methods of intracorporeal preservation are needed since, with rare exceptions, lungs for clinical use can be obtained only from cadavers. Intracorporeal preservation would extend the period of utilization of an ischemic lung to allow adequate preparation of the recipient and also a comfortable, unhurried surgical procedure. The present experimental work is based on metabolic inhibition with magnesium, which can reduce substrate utilization comparable to that achieved by mild hypothermia and extend several-fold the anoxic survival time of the isolated heart [16, 201. The metabolic inhibitors may stabilize membranes of the cell or of subcellular structures, prevent enzyme depletion, or delay autodigestion of the cell by its metabolically active enzymes. In addition, by reducing metabolism they may prevent intoxication of the cell by accumulating toxic products. Thus, the metabolic inhibitors could allow the in situ preservation of cadaver organs for a longer period without impairment of their anatomical and functional integrity. In this study, we have used a simple lung-preservation technique by perfusion of the lung in situ with magnesium sulfate under nor-

Protective effect of ethyl alcohol in profound hypothermia

Summary These studies evaluate the effect of alcohol on cardiac action in rats in profound hypothermia. Two milliliters of 50% alcohol were injected intraperitoneally in 250-g rats, and the animals were respired with room air with diminishing tidal volumes while cooled by immersion in iced salt water (−15°C). Rectal temperatures and electrocardiograms were monitored. Rewarming was by 40°C waterbath and a heat lamp focused over the chest. In 24 alcoholic rats cardiac standstill occurred at 3.1°C (range 0 to 6°C), with body temperatures dropping to an average of 0°C and a range of −2 to 1°C. The heart restarted at 12 to 15°C compared to 25 to 30°C in the controls. All 10-min arrested animals were permanent survivors; all 30-min arrested animals returned to normal cardiac action and spontaneous respiration. In 16 control rats cardiac arrest occurred at 5.1°C (range 2 to 9.0°C), with body temperature falling to 1°C average (range −1.0 to + 2°C). Only 3 animals (with only 10-min arrests) survived—2 for 2 hrs and one permanently. Arterial blood gases at the end of arrest showed pCO 2 ranging from 21 to 63 mm Hg, pO 2 from 32 to 90, pH from 6.7 to 7.1, and profound base deficits. Alcoholic rats did not cool or warm appreciably faster, and fibrillation occurred only twice in each group. The electrocardiographic changes were modified by alcohol, which prevented A-V dissociation and disappearance of the P wave until much lower temperatures had been reached than in the controls. Thus, alcohol does offer definite cardiac protection and better survival during profound hypothermia, apparently by allowing cardiac function to continue to a low temperature.

Long-Term Membrane Oxygenation in Respiratory Failure

Abstract Three patients with acute terminal respiratory failure who did not respond to maximum constant controlled-volume ventilation at 100 cm. H 2 O inhalation pressure with constant positive-pressure breathing of 20 cm. H 2 O were treated by membrane oxygenation for a total of 12 days. There was marked clearing of the lungs on roentgenogram. Compliance increased, and shunting decreased. All patients were able to maintain an adequate arterial Po 2 off membrane oxygenation and on intermittent positive-pressure breathing before their deaths. Deaths were due to anoxia, renal failure, and a cerebrovascular accident (CVA). Each patient was potentially a survivor; however, the CVA and renal failure were the results of pumping and heparinization. The best route for cannulation is still unknown, so both venovenous and venoarterial cannulations were done in these patients.

Bile ptyalism associated with chest trauma and sickle cell crisis simulating bronchobiliary fistula.

Abstract Bile ptyalism, the elaboration of copious amounts of sputum virtually indistinguishable from bile, is nearly always indicative of the presence of a bronchobiliary fistula, a lesion usually produced by trauma and requiring surgical correction. This report deals with 4 patients, in 3 of whom the appearance of bilious sputum was known to have been preceded by chest trauma. None of these patients had a bronchobiliary fistula. However, all 4 had sickle cell disease and were suffering a hemolytic crisis complicated by pulmonary consolidation at the time. Although it is a rare complication, the fact that biliary ptyalism not due to fistula may occur during crisis in patients with sickle cell disease is important knowledge in the management of victims of this disorder.

Changes in 2,3-Diphosphoglycerate After Cardiopulmonary Bypass

Abstract Red cell 2,3-diphosphoglycerate (2,3-DPG) is an important metabolite controlling oxygen transport to tissues. To examine the effect of extracorporeal circulation (ECC) on oxygen transport we made serial measurements of 2,3-DPG in 34 patients before, during, and after bypass. Before operation 2,3-DPG was elevated in 14 patients. The 2,3-DPG levels in the oxygenator prime were below normal in 5 instances, probably due to the age of the banked blood used to prime. Slight 2,3-DPG changes were measured after operation, but the levels at the conclusion of ECC were within normal limits. The possible mechanisms of these changes in 2,3-DPG are discussed.

Aortic aneurysm with aortic insufficiency

Abstract Six globular aneurysms of the ascending aorta due to cystic medial necrosis producing aortic valvular insufficiency were successfully repaired without valve replacement. Although the procedure is not feasible in every situation, the excellent hemodynamic results and minimal operative and long-term risks make conservation of autogenous valvular tissue desirable wherever possible.