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A rare window type of patent ductus arteriosus is reported that was large (15 mm in maximal transverse dimension) but had virtually no length and hence was externally invisible. The smaller aortic isthmus (4 mm in diameter), which was intrapericardial, was mistaken for the ductus and was inadvertently clip-occluded, leading to death. After a specific diagnosis is made, the large window ductus should be patched on cardiopulmonary bypass with a transpulmonary approach.

Pulmonary dysfunction after cardiopulmonary bypass has been attributed to the damaging effects of complement activation on the lung. To further explore this phenomenon, we measured plasma levels of activated complement components (radioimmunoassay), assessed neutrophil n-formyl-methionyl-leucyl-phenylalanine (FMLP) receptor status (radioligand saturation binding assay), and quantified pulmonary epithelial permeability as radioaerosol lung clearance of technetium 99m-labeled diethylenetriamine pentaacetic acid in a series of 8 patients undergoing cardiopulmonary bypass. Significant elevations of plasma C3adesArg, C4adesArg, and C5adesArg levels were seen just after CPB, indicating activation of both the classic and alternate complement pathways. Neutrophil activation was evident as increased expression of neutrophil FMLP surface receptors after bypass. Despite the presence of complement and neutrophil activation, increased pulmonary epithelial permeability was not seen. These data support the hypothesis that complement and neutrophil activation during cardiopulmonary bypass is not associated with acute lung injury, at least not pulmonary epithelial injury. One can therefore infer that increased pulmonary epithelial permeability in patients at high risk for and experiencing sepsis-induced and trauma-induced adult respiratory distress syndrome may be due to factors other than complement and neutrophil activation.

A 34-year-old man had a posttraumatic, pelvic arteriovenous fistula (AVF) and false aneurysm of 18 years' duration. He had undergone four previous unsuccessful attempts at operative repair, the last of which almost resulted in exsanguination. After the false aneurysm was exposed, the patient was placed on cardiopulmonary bypass. Core cooling (25 degrees C) allowed the perfusion flow rates to be lowered (less than 0.5 L/min/m2) while the aneurysm was opened, thereby permitting visualization and ligation of the arteriovenous communications within the aneurysm. Total circulatory arrest was not required. There were no complications and the patient was discharged on the eleventh postoperative day. Arteriography 5 months later showed complete ablation of the AVF. We believe that cardiopulmonary bypass with hypothermia and reduced blood flow is a useful adjunct in the repair of complex AVFs and arteriovenous malformations. This technique avoids the use of total circulatory arrest, which increases the risks of air embolism and ischemic organ injury.