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Giant bullae of the lungs are readily recognizable on plain chest x-ray films and are rare. Only 17 of more than 500 cases of thoracoscopic treatment of bullous lung disease over the past 3 years involved giant bullae, which included both types 1 and 4. Type 1 bullae have smooth internal lining without trabeculae and type 4 have trabeculae. The indications were dyspnea in 10 cases, spontaneous pneumothorax in 6, and infection in 1. The mean age of the patients was 55 years. Five patients were oxygen dependent, 1 was wheelchair-bound, and 3 were steroid dependent. Preoperative spirometry was available in 1 patient with type 1 bullae (forced vital capacity = 95% and forced expiratory volume in 1 second = 55% of the predicted values) and in 10 patients with type 4 bullae (forced vital capacity = 46.90% +/- 15.29% and forced expiratory volume in 1 second = 23.50% +/- 7.46% of the predicted values). Under general anesthesia with one-lung ventilation, the giant bullae were excised, plicated, or contracted by the laser, depending on the type, by means of thoracoscopy. Thoracoscopic surgery was successful in all patients, and no procedure was converted to thoracotomy. The duration of anesthesia was 4.44 +/- 1.49 hours, postoperative ventilatory support 42.24 +/- 64.22 hours, and postoperative air leaks 14.59 +/- 14.11 days. All patients did very well and pain was minimal. There was no recurrence for up to 3 years of follow-up. In conclusion, thoracoscopic treatment of giant bullae of the lungs is an effective alternative to conventional thoracotomy with minimal morbidity.

Background. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema by means of a contact neodymium:yttrium-aluminum garnet laser was evaluated by a retrospective analysis of the first consecutive 500 procedures in 443 patients. The indication for thoracoscopic laser pneumoplasty was intractable dyspnea. Methods. Advanced age (mean age, 67 years), high oxygen dependency (70%), steroid use (46%), and markedly diminished physical capacity (2% bedridden and 27% wheelchair-bound) were noted. Thoracoscopic laser pneumoplasty was carried out under general anesthesia and one-lung ventilation. Type 3 bullae (381 procedures) were contracted by contact neodymium:yttrium-aluminum garnet laser and type 4 bullae (119 procedures) excised. The operative mortality rate was 4.8%. Results. Subjective improvement was reported by 87% of the patients. Follow-up functional evaluation was available in 229 patients, which showed highly significant improvement. A comparison of preoperative and postoperative functional tests between type 3 and 4 bullae patients showed no significant difference, except the latter had higher decrease in airway resistance, residual volume, and total lung capacity. Conclusions. Thoracoscopic laser pneumoplasty is an effective treatment for both type 3 and 4 bullous emphysema with an acceptable risk.

A reversed autogenous saphenous vein graft placed between the ascending aorta and the nonstenosed circumflex coronary artery in a dog was studied thirteen years after operation. The aortic anastomosis was round despite the fact that only a slit aortotomy was originally made. The heel side of the distal anastomosis was narrowed but the toe side was not. The intimal thickening was very minimal, and the elastic membrane was intact.

Recurrent (6 patients) or persistent (4 patients) spontaneous pneumothorax was treated with thoracoscopic ablation of blebs using an electrocautery as an alternative to lung resection. Patients' ages ranged from 17 to 39 years (mean age, 29 years). Ablation was successful in 9 but failed in 1. The mean postoperative hospital stay of the successful cases was 2.1 days. The only failure in this series had an extensive bullalike air cyst involving the apex, and cauterization could not ablate it completely. The follow-up period ranged from 2 to 22 months. During this period, no recurrence was noted.

A study was undertaken to ascertain the protective effect of topical hypothermia on the anoxic heart. The presence or absence of myocardial damage was judged by myocardial contractility. The papillary muscle of an excised rabbit heart was detached from the mitral annulus and interposed between a fixed point and a force/displacement transducer. The maximal net developed tension (T Nmax ) of the papillary muscle with normothermic coronary perfusion was used as an index of myocardial contractility. With each temperature drop of 10°GC, the anoxia time that resulted in the same recovery level of T Nmax was prolonged by a factor of 2.8. A nomogram was constructed correlating percent of myocardial recovery seen with different degrees of myocardial hypothermia during various anoxic periods. Optimum protection was noted at a myocardial temperature of 18°GC.

The protective effects of procaine hydrochloride on the anoxic heart were investigated using the papillary muscle contractility of an isolated, blood-perfused rabbit heart as an index of myocardial function. Fifty-four experiments were divided into nine groups of six experiments each, in which anoxic periods (30, 45, 60 minutes) and concentration of procaine (solution 3, 0.3%) were the variables. The hearts arrested significantly faster with solution 3 compared with solution 2 or 1 (p0.01). After 30 minutes of anoxia, the recovery of the contractility was 81.1 +/- 4.2% with solution 1, 90.7 +/- 3.4% with solution 2, and 90.6 +/- 3.3% with solution 3. After 45 minutes of anoxia, the recovery was 31.8 +/- 19.0% with control, 67.5 +/- 15.8% with 0.03% procaine, and 58.1 +/- 22.8% with 0.3% procaine. After 60 minutes of anoxia, the recovery was 2.2 +/- 2.7% with control, 18.7 +/- 14.1% with 0.03% procaine, and 5.0 +/- 7.3% with 0.3% procaine. After each anoxic period, the best recovery occurred with those hearts arrested by solution 2. Although the difference in recovery between the procaine groups was not statistically significant, a longer time was required for the hearts arrested with solution 3 to reach full functional recovery. This study indicated that procaine per se has a protective effect on the anoxic hearts and that although high concentration (0.3%) of procaine arrests the heart rapidly, it delays the recovery of contractions. We recommend the use of 0.03% procaine in cardioplegic solution.

Data favoring pulsatile over nonpulsatile left heart bypass are conflicting. To study this problem, renal cortical and medullary tissue oxygen availability (O 2 a) and total renal oxygen flow were compared with total renal oxygen consumption during four hours of pulsatile and nonpulsatile bypass in dogs. Although there was no difference in renal tissue O 2 a during the first two hours, thereafter the decrease in renal O 2 a was greater during nonpulsatile bypass; total renal blood flow was greater with pulsatile bypass, and at the given renal oxygen flow, renal oxygen consumption was greater during pulsatile bypass. These data, along with previous work, support the superiority of pulsatile bypass.

A technique using cotton gloves to lift the heart up out of the pericardial cavity is described. The fingers can be used to widen the arteriotomy and to blot blood or cardioplegia solution in the arteriotomy.