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Empyema thoracis (ET) is associated with substantial morbidity and mortality. The optimal means for draining the pleural space remains controversial but there may be increasing bias for less invasive strategies. This study compared outcome after a nonsurgical versus a surgical approach to ET.Patients with ET over a 10-year period (n = 93) were reviewed and stratified into nonsurgical (thoracentesis and/or closed tube thoracostomy) and surgical (thoracotomy, decortication, and/or open window thoracostomy) groups based on pleural drainage techniques. Hospital course was analyzed except when altered by death (n = 12), noncompliance (n = 3), or severe comorbidities (n = 3).Seventy-five patients were stratified into nonsurgical (n = 32) and surgical (n = 43) groups. Demographics, comorbidities, signs and symptoms, and causative organisms were similar between groups. Mortality did not significantly differ in nonsurgical (16%) versus surgical (10%) groups (P = 0.7). Although delay in diagnosis and number of therapeutic interventions were nearly identical, the time to definitive therapy was longer in the surgical versus the nonsurgical group (18 +/- 3.8 versus 8.5 +/- 3.8 days, P = 0.023). The time to discharge after definitive therapy (20.0 +/- 3.5 versus 35.6 +/- 14.0 days, P0.001), and overall hospital stay (40.6 +/- 5.3 versus 47.4 +/- 15 days, P = 0.01) was significantly decreased in the surgical versus nonsurgical treatment groups, respectively.The treatment of ET is complex. Failure to adequately evacuate the pleural space and/or persistent signs of infection should prompt surgical intervention. Surgical therapy is preferred for advanced stages of ET. Delaying definitive surgical treatment is largely responsible for prolonging hospital course.

Purpose: Cellular stress has been shown to induce a group of proteins called heat shock proteins (HSPs). Recent evidence suggests that a group of small HSPs may modulate vascular smooth muscle contraction (HSP27) and/or relaxation (HSP20). In this investigation, we hypothesized that cellular stress would alter contraction and/or relaxation of intact vascular smooth muscles and would lead to changes in the induction and/or phosphorylation of the small HSPs. Methods: Bovine carotid arteries were obtained from an abattoir, and physiologic contractile responses were determined in a muscle bath. Phosphorylation state–specific antibodies were produced and characterized against HSP27. Phosphorylation events were determined with phosphorylation state–specific antibodies or whole-cell phosphorylation and two-dimensional gel electrophoresis. Results: Cellular stress induced by arsenite or heat shock did not alter basal tone or the magnitude of contractions induced by serotonin or high extracellular potassium chloride. However, cellular stress led to inhibition of forskolin and sodium nitroprusside–induced vasorelaxation. This impaired vasorelaxation was associated with increases in the phosphorylation of HSP27 and decreases in forskolin-induced phosphorylation of HSP20. Conclusion: Cellular stress, which leads to increases in the phosphorylation of HSP27, inhibits cyclic nucleotide-dependent vascular relaxation and cyclic nucleotide-dependent increases in the phosphorylation of HSP20. (J Vasc Surg 2000;31:343-53.)

Activation of cyclic nucleotide-dependent signaling pathways leads to relaxation of bovine carotid artery smooth muscle contractions and is associated with increased phosphorylation of the small heat shock-related protein (HSP20). Previous reports have shown that human umbilical artery smooth muscle is uniquely resistant to cyclic nucleotide-dependent relaxation, and HSP20 is not phosphorylated. In this investigation, we determined the phosphorylation events associated with cyclic nucleotide-dependent inhibition of smooth muscle contraction. In carotid artery, activation of cyclic nucleotide-dependent signaling pathways inhibited contractile responses to serotonin but did not inhibit myosin light chain phosphorylation or oxygen consumption. The inhibition of contraction was associated with increases in HSP20 phosphorylation. In umbilical artery, activation of cyclic nucleotide-dependent signaling pathways did not inhibit serotonin-induced contraction or myosin light chain phosphorylation. The lack of contractile inhibition in umbilical artery was not associated with significant increases in HSP20 phosphorylation. In conclusion, cyclic nucleotide-dependent contractile inhibition is independent of the inhibition of myosin light chain phosphorylation or oxygen consumption but does correlate with increased HSP20 phosphorylation.

Purpose: Increases in the phosphorylation of a small heat shock protein (HSP20) are associated with cyclic nucleotide-dependent vasorelaxation. The effect of pressure and flow on vessel diameter was studied. We hypothesized that physiologic conditions that induce vasorelaxation would lead to increases in HSP20 phosphorylation. Methods: Flow-dependent changes in vessel diameter, at different intraluminal pressures, were measured with a laser optical micrometer in intact bovine carotid arteries. Experiments were performed in the presence and absence of norepinephrine (10-5 mol/L). Increases in the phosphorylation of HSP20 were determined with isoelectric focusing immunoblots. Results: The increase in vessel diameter was most significant at low intraluminal pressures (20 mm Hg), high flow rates (200 mL/min), and in the presence of the vasoconstrictor norepinephrine (10-5 mol/L). The addition of methylene blue (a guanylate cyclase inhibitor) completely inhibited flow-induced vasodilation. Under conditions in which maximal flow induced vasodilation occurred, there were significant increases in the phosphorylation of HSP20. Conclusion: Flow-dependent vasodilation in isolated perfused segments of bovine carotid arteries was maximal when the intraluminal pressures were low and when the vessels were precontracted with norepinephrine. Flow-dependent vasodilation was inhibited by methylene blue and was associated with increases in the phosphorylation of HSP20, suggesting that the vasodilation was mediated by endothelial production of nitric oxide. (J Vasc Surg 1999;29:678-84.)

Postpartum vasospasm in the umbilical arteries may be due to impaired vasorelaxation secondary to alterations in the expression of heat shock proteins. The contractile responses of pre- and full-term bovine umbilical artery smooth muscles were determined in a muscle bath. Heat shock protein expression was determined in bovine and human arterial tissues using western blotting with specific antisera. Full-term bovine and human umbilical artery smooth muscle was refractory to relaxation induced by the nitric oxide donor, sodium nitroprusside. This impaired vasorelaxation was associated with the expression of the inducible form of the heat shock protein, HSP70i, and increases in the expression of the small heat shock protein, HSP27. Small heat shock proteins have been implicated in modulating contraction and relaxation responses in vascular smooth muscles. Thus, alterations in heat shock protein expression may play a role in umbilical artery vasospasm.

Background: Cyclosporine immunosuppression for organ transplantation is associated with hypertension and nephrotoxicity. Because the effects of cyclosporine as an immunosuppressant are mediated by the effect of cyclosporine as a phosphatase inhibitor, and phosphatase inhibitors are potent vascular smooth muscle contractile agents, we hypothesized that cyclosporine might induce contraction of the renal artery vascular smooth muscle directly. Methods: Strips of bovine renal, carotid, superior mesenteric, or coronary arteries were obtained fresh from an abattoir. The strips were equilibrated in a muscle bath, and the contractile responses to cyclosporine and FK506 were determined. Results: Cyclosporine (50 to 5000 μg/ml), but not FK506, induced rapidly developing, sustained contractions of renal and coronary artery smooth muscle. The magnitude of the cyclosporine-induced contractions of carotid and superior mesenteric artery smooth muscles was significantly less. The magnitude of renal artery smooth muscle contractions induced by cyclosporine was enhanced in the presence of an intact endothelium. Conclusions: Although these effects occurred in vitro to relatively high doses of cyclosporine, these data suggest that cyclosporine may selectively induce renal artery smooth muscle contraction through activation of the Ca 2+ -dependent phosphatase (calcineurin) in the smooth muscle, and these contractions may be enhanced by the release of endothelial-derived contracting factors. (Surgery 1998;123:456-60.)

Background: In the setting of arterial injury, thrombin contributes to the hemostatic process by activating the coagulation cascade and platelets. We hypothesized that thrombin also contributes to hemostasis by inducing vasospasm. The purpose of this investigation was to characterize the cellular signaling mechanisms that modulate thrombin-induced vascular smooth muscle contractions. Methods: Contractile responses of intact bovine carotid artery smooth muscles were determined in a muscle bath. Contractile responses were correlated with phosphorylation events as determined with whole cell phosphorylation and two-dimensional gel electrophoresis and with immunoblotting of glycerol-urea or two-dimensional gels. Results: Thrombin (1 to 1000 units/ml) induced sustained vascular smooth muscle contractions of similar magnitude as the potent contractile agonist, endothelin. Thrombin-induced contractions were associated with increases in the phosphorylation of the myosin light chains (MLC20) and in the tyrosine phosphorylation of mitogen-activated protein kinase. Conclusions: These data suggest that thrombin is a potent physiologic contractile agonist that may modulate some forms of vasospasm. Thrombin-induced contractions are associated with the activation of two cellular signaling pathways, the myosin light chain kinase and the mitogen-activated protein kinase pathways. (Surgery 1998;123:46-50.)

Human umbilical artery smooth muscle is uniquely refractory to cyclic nucleotide-dependent vasorelaxation. Small heat shock proteins (HSPs) have been implicated as contractile regulatory proteins. Thus, we hypothesized that alterations in the phosphorylation of small HSPs may contribute to human umbilical artery smooth muscle vasospasm. Physiologic contractile responses were determined in a muscle bath and compared with phosphorylation events determined with whole-cell phosphorylation and 2-dimensional gel electrophoresis. Precontraction of bovine carotid artery smooth muscle with serotonin followed by relaxation with forskolin was associated with increases in the phosphorylation of HSP27 and HSP20. Precontraction of umbilical artery with serotonin followed by forskolin treatment led to increases in the phosphorylation of HSP27. However, the umbilical artery smooth muscle did not relax, nor was there an increase in the phosphorylation of HSP20 with forskolin treatment. These data suggest that impaired cyclic nucleotide-dependent relaxation of umbilical artery smooth muscle is associated with a lack of phosphorylation of HSP20.

Background . Although conceptually sound, the use of multiple internal thoracic artery (ITA) bypass grafts to improve long-term clinical results remains controversial. This operation typically involves grafting the left ITA to the anterior descending artery and the right ITA to the right coronary artery. Past clinical studies of bilateral ITA operations have not examined comparative results associated with which coronary arteries received the ITA bypass grafts. Because grafting a superior conduit to an artery of lesser physiologic importance might reduce the clinical benefits, we compared the outcomes of patients receiving different configurations of bilateral ITA operations. Methods . The study group was 498 consecutive bilateral ITA operations, constituting the 10-year experience of a single surgeon. Follow-up averaged 7.1 years (mode 7.3 years), and was 94.2% complete. These patients were divided into two groups, 311 patients (group I) who underwent the traditional operation (left ITA to the left anterior descending artery, right ITA to the right coronary artery), and 187 patients (group II) who received revascularization of branches of the left coronary artery (left ITA to the circumflex system and right ITA to the left anterior descending artery). Results . The study groups were similar in age, severity of disease, number of bypassed arteries, ejection fraction, diabetes, hypertension, and duration of operation. There were more male patients in group II (91.4% versus 82.3%). A multivariate analysis showed that the location of ITA bypass grafts influenced survival independent of gender ( p = 0.0288). Operative morbidity and mortality were similar between groups. Ninety-three patients had repeat angiography with equivalent patency rates of the ITA conduits (91.7% versus 89.6%; p = 0.67). The Kaplan-Meier actuarial survival estimate demonstrated a significant improvement in survival of patients in group II who received both ITA bypass grafts to left-sided arteries ( p = 0.021), with the survival curves diverging at 6 years. More patients in group II were in New York Heart Association class I or II, but the difference was not statistically significant (94.6% versus 91.6%). Only 2 patients required reoperation. Conclusions . It appears that maximum long-term benefit from bilateral ITA operations is achieved by grafting the ITA conduits to coronary arteries that supply more left ventricular muscle.

Activation of cyclic nucleotide-dependent signaling pathways leads to the relaxation of various smooth muscles. One of the major phosphorylation events associated with cyclic nucleotide-dependent vasorelaxation in bovine trachealis and carotid artery smooth muscle is the phosphorylation of two 20-kDa phosphoproteins with pI values of 5.7 and 5.9 (previously designated pp8 and pp3, respectively). The present studies sought to determine the identities of pp3 and pp8 in vascular smooth muscle. The phosphopeptide maps for the pp8 and pp3 proteins were similar. Preparative two-dimensional gel electrophoresis and amino acid sequencing of a peptide fragment of the pp3 protein revealed a sequence identical to a 20-kDa heat shock-related protein (HSP20) previously purified from skeletal muscle. Western blot and immunoprecipitation analysis with anti-HSP20 antibodies demonstrated that the pp3 and pp8 proteins are phosphorylated forms of HSP20. In addition, HSP20 could be phosphorylated in vitro by both cAMP-dependent protein kinase and cGMP-dependent protein kinase. These data suggest that the phosphorylation of the heat shock-related protein HSP20 is associated with cyclic nucleotide-dependent relaxation of vascular smooth muscle.

Background . Origin of the left circumflex coronary artery from the right sinus of Valsalva is the most common anatomic variation of the coronary artery circulation. However, there are few reports about the operative approach to this anomalous vessel. Methods . Forty patients having this anomaly were identified from 10,216 adult cardiac catheterization procedures. Forty percent of the anomalous circumflex coronary arteries (ACCAs) had critical atherosclerotic lesions. Eighty cases needed bypass grafting. Results . For diagnosis of ACCA, the aortic root sign was positive in 94.9% of the diagnosed patients and the nonperfused myocardium sign was found in 92.5%. Eighty percent of ACCAs were larger than 2 mm in radiographic diameter before their passage into the atrioventricular groove. However, after emerging from the atrioventricular groove, 70% measured less than 1.5 mm. Consequently, a technique was developed to bypass the proximal ACCA and was used in 2 cases. Six other patients with more distal disease and larger vessels underwent conventional bypass grafting. Conclusions . The aortic root sign and nonperfused myocardium are useful in diagnosing ACCA. The ACCA is usually too small for use of the conventional graft technique. Therefore, a technique was developed to graft more proximally and was applied successfully in 2 cases. (Ann Thorac Surg 1997;63:377–81)

Purpose. Intravascular interventions such as balloon embolectomy lead to endothelial injury. The extent and functional consequences of this endothelial injury are not known. Methods. Segments of bovine carotid artery were equilibrated in a vasomotor perfusion apparatus (VPA). Smooth muscle function was determined by the contractile responses to 10 -5 M norepinephrine (NE). Endothelial function was evaluated by the extent of vasorelaxation to the subsequent addition of 10 -5 M acetylcholine (ACh). To determine the pattern of injury throughout the length of the vessel, strips of artery from along the vessel length were also evaluated in a muscle bath. Morphology was examined by scanning electron microscopy (SEM). Results. No significant differences were noted in the contractile response to NE after embolectomy. Balloon embolectomy significantly decreased the relaxation response to ACh from 97 ± 1% before embolectomy to 89 ± 1% after embolectomy (n = 5 vessels, P < 0.01, ANOVA). In the muscle bath, the vasorelaxation of strips pre-contracted with NE was variable throughout the length of the vessel suggesting that endothelial injury was diffuse. The relaxation response to ACh was inhibited by L-NMMA. SEM revealed patchy areas of endothelial denudation. Conclusion. Embolectomy produces no change in smooth muscle function and partial injury to the endothelium in intact vessels. However, there remains sufficient endothelial function after balloon embolectomy to produce NO-dependent vasorelaxation and modulate vasomotor tone.

Activated macrophages (M phi s) are important participants in host defense, but their uncontrolled activation leads rapidly to septic shock and death. One mechanism for regulating other dangerous cells in the immune system is programmed cell death, or apoptosis. Monocytes are known to undergo spontaneous apoptosis upon leaving the circulation unless provided with specific survival signals, but mature tissue M phi s are more robust cells, and it was not clear that they could be similarly regulated by apoptosis. We now show that during differentiation monocytes rapidly lose their sensitivity to apoptosis triggered by passive cytokine withdrawal, but they may retain a novel pathway which initiates apoptosis after activation with specific stimuli (zymosan and phorbol esters). Sensitivity to activation-induced apoptosis was developmentally determined, being downregulated by the maturation-promoting cytokine macrophage colony-stimulating factor but stably upregulated by even transient exposure to the proinflammatory cytokine interferon gamma (IFN-gamma). Apoptosis began within 2-4 h of activation, occurred in > 95% of susceptible cells, and in mixed cocultures selectively affected only those M phi s with a history of IFN-gamma priming. Consistent with a possible role for protein kinase C in the signaling pathway leading to cell death, the kinase inhibitor staurosporine was protective against both phorbol ester- and zymosan-induced apoptosis. Our studies describe a novel form of activation-induced M phi apoptosis which is developmentally regulated by two physiologically relevant cytokines. We speculate that apoptosis may serve to restrict the destructive potential of inflammatory M phi s.

Objective data on the ability of cineangiography to predict the size of reconstituted totally occluded coronary arteries, as well as the clinical outcome of such revascularization, are sparse. Accordingly, we reviewed 200 consecutive cases of coronary revascularization to determine the answers to these questions. Group I patients (n = 57, with 86 totally occluded coronary arteries) had at least one coronary artery with a 100% proximal occlusion that reconstituted distally. Group II patients (n = 143, with 205 subtotally occluded coronary arteries) had 50% to 99% proximal stenosis of at least one coronary artery. Cineangiograms were blindly reviewed to measure the size of the coronary arteries, which were compared with the actual vessel size at operation. In group I, the totally occluded coronary arteries had a cineangiographic size of 1.9 +/- 0.7 mm and an actual size of 1.6 +/- 0.4 mm (p = 0.00004). In group II, the subtotally occluded coronary arteries had a cineangiographic size of 1.8 +/- 0.4 mm compared with an actual size of 1.8 +/- 0.3 mm (p = not significant). The site of bypass grafting was significantly smaller in group I (1.6 +/- 0.4 mm versus 1.8 +/- 0.3 mm; p = 0.00008). The two groups were similar with respect to preoperative and intraoperative parameters. Operative mortalities were similar (group I, 1.8%; group II, 3.5%; p = 0.68). Creatine kinase isoenzyme profiles and electrocardiographic changes were similar, except for a significant late rise of creatine kinase-MB in group I (56.1 +/- 14.7 versus 30.7 +/- 33.7 MIU/mL; p < 0.001). In conclusion, cineangiography significantly overestimates the size of totally occluded coronary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Conventional blood conservation techniques have been insufficient to decrease transfusion needs in increasingly complex cardiac operations. To evaluate combinations of conservation techniques, 300 patients were divided into three equal groups. Group 1 had intraoperative autotransfusion and return of mediastinal drainage for 4 hours postoperatively. Group 2 had these measures plus intraoperative plasmapheresis. These two groups were given a transfusion for a hematocrit of less than 0.21 on cardiopulmonary bypass. Group 3 was treated with the same measures as group 2 but did not receive transfusions while on pump unless the hematocrit decreased to less than 0.15. The percentage of patients in each group given transfusions in the operating room was 34% in group 1, 28% in group 2, and 7% in group 3 (p less than 0.05). The percentage of all patients receiving transfusions during hospitalization was 68% in group 1, 36% in group 2 (p less than 0.05), and 18% in group 3 (p less than 0.05). Average total units transfused were 2.16 +/- 0.25 in group 1, 0.7 +/- 0.15 in group 2 (p less than 0.05), and 0.37 +/- 0.07 in group 3 (p less than 0.05). The perioperative morbidity rates including myocardial infarctions and strokes were similar. There were no deaths in group 3. Combining complementary conservation measures is effective in reducing homologous blood transfusions, and the need for transfusion can be safely reduced by allowing profound hemodilution during bypass.

It is now well established that cells from the cardiac neural crest (CNC) are essential for normal conotruncal septation. The truncal septation complex consists of the aorticopulmonary (AP) septum and the myocardial sheath of the truncus. The principal role of the CNC cells during septation appears to be their differentiation into the elastogenic smooth muscle that forms the AP septum proper. The objective of this study was to integrate serial reconstruction and specific histochemical markers in order to provide a unified analysis of the relationships between the CNC and the other components of the truncal septation complex. The development of the septation complex was compared normal embryos vs. embryos from which the CNC had been surgically ablated. Embryos from each group were harvested after incubation periods of 4-8 days (Hamburger-Hamilton stages 23-34). Histochemical procedures were performed for positive identification of the elastic matrix and smooth muscle alpha-actin; the presence of these proteins was used as the criterion for "septal cells" and to define the boundaries of the septum. The results indicate that the shape, components, boundaries, and degree of organization of the septation complex may be different from previous descriptions. Furthermore, all of the components of the truncal septation complex are dysgenic in the absence of the CNC. Of special significance in the absence of CNC. Of special significance in the absence of CNC are: 1) the failure of the myocardial sheath to retract; 2) the apparently random distribution of surrogate ectomesenchyme; and 3) the impairment of truncal elastogenesis. These results indicate that the cells of neural crest origin interact with the surrounding mesenchyme during septation and that the entire septation complex depends upon the presence of the neural crest cells for normal development.

The cells that form the aorticopulmonary septum in the avian embryo have been shown to be similar to the cells that form the walls of the great vessels in two ways: both are derived from the cardiac neural crest and both are able to synthesize an elastogenic matrix in the early embryo. Because of these similarities, and because ablation of the cardiac neural crest causes congenital defects of the outflow tract that are related to failure of proper septation, it was hypothesized that such an ablation also would cause the walls of the great vessels to be defective. The purpose of this study was to compare the elastic matrix in the mediae of the great vessels of normal embryos with those from which the cardiac neural crest had been ablated. The results show that the elastic matrix in the great vessels of the experimental embryos was impaired (1) in the rate of downstream propagation of the initiation of elastogenesis among younger embryos, incubation days 4–8 and (2) in the spatial configuration of the elastic matrix among the older embryos, incubation days 16–20. These results may provide a biological explanation for the elastin defect that affects the pulmonary artery of many patients with cyanotic congenital heart defects.

Background: We hypothesized that smooth muscle contraction and relaxation responses in a muscle bath (isometric tension) would be different than responses of intact vessels (isotonic tension). Methods: Bovine carotid artery contractile responses to the catecholamine, norepinephrine, and smooth muscle relaxant, 3-isobutyl-1-methylxanthine, were examined in strips of vessels in a muscle bath and in intact whole vessels in an isolated perfused whole-vessel perfusion apparatus. Results: The maximal tension in the muscle bath depended on the length of the strip. The responses of whole vessels to increasing pressure was curvilinear. The maximal decrease in vessel diameter in intact vessels in response to the catecholamine and norepinephrine occurred at low intraluminal pressures. The dose-response curve to norepinephrine was shifted to the left in intact vessels compared with strips of vessels in the muscle bath, which suggests that whole vessels were more sensitive to norepinephrine. The maximal increase in diameter to increasing intraluminal pressure occurred in the presence of the phosphodiesterase inhibitor, 3-isobutyl-1-methylxanthine, which suggests that there was significant intrinsic tone in the vascular smooth muscle. Conclusions: These results suggest that there are differences in the contractile properties of the vascular smooth muscle that are related to the ex vivo system used to examine smooth muscle responses. Responses obtained in isolated perfused whole vessels may more closely approximate in vivo responses. (Surgery 2000;127:148-54.)

Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.

The small heat shock-related protein 20 (HSP20) is present in four isoforms in bovine carotid artery smooth muscles. Three of the isoforms are phosphorylated and one is not. Increases in the phosphorylation of two isoforms of HSP20 (isoform 3, pI 5.9; and 8, pI 5.7) are associated with cyclic nucleotide-dependent relaxation of bovine carotid artery smooth muscles. Increases in the phosphorylation of another isoform (isoform 4, pI 6.0) are associated with phorbol ester-induced contraction of bovine carotid artery smooth muscles. In this investigation we determined that isoforms 3 and 8 are phosphorylated on Ser16 of the HSP20 molecule during activation of cAMP-dependent signaling pathways. Phosphorylation state-specific antibodies produced against a peptide containing phosphorylated Ser16 recognized isoforms 3 and 8 but not isoform 4. In human vascular tissue, only isoform 3 is present. Incubation of transiently permeabilized strips of bovine carotid artery smooth muscle with synthetic peptides in which Ser16 is phosphorylated, inhibits contractile responses to high extracellular KCl and to serotonin. These data suggest that phosphorylation of HSP20 on Ser16 modulates cAMP-dependent vasorelaxation.

Right bundle branch block following coronary surgery is a common occurrence. Among 759 coronary surgery cases, 104 patients (13.7%) had a new right bundle branch block. Of these right bundle branch blocks, 62 were transient, and 42 (40.4%) were permanent. The large number of bypasses (3.20 versus 2.75, P = 0.0001) and stenosis of the right coronary artery (81.7% versus 66.5%, P = 0.003) was strongly associated with a new right bundle branch block. In the analysis of the permanent right bundle branch block, blood cardioplegia prevented the block from becoming permanent (35.7% versus 75.8%, P = 0.0001). Therefore, it is concluded that perioperative right bundle branch block occurs predominantly in patients who have a critical stenosis in an artery which supplies the conduction system and in those undergoing more extensive procedures. In addition, blood cardioplegia affects the conduction system less severely than does crystalloid cardioplegia.

OBJECTIVE: The authors evaluate operative and extended outcomes of coronary artery bypass surgery using the bilateral internal thoracic arteries (ITAs) as bypass grafts. The authors conclude that the procedure is viable and of long-term benefit to most patients. SUMMARY BACKGROUND DATA: Multiple ITA grafting was met with early enthusiasm by the surgical profession, but skepticism and controversy arose with reports of increased operative morbidity, insufficient graft blood flow, a high incidence of failure of the right ITA, and uncertainty about durability and long-term benefits. METHODS: To assess the actual incidence and impact of these complications and long-term results, the authors prospectively studied 500 consecutive patients with multiple ITA bypasses, constituting the closely observed and carefully documented experience of one surgeon over an 11-year period. RESULTS: Operative mortality in the series of 500 patients was 1.8%, perioperative myocardial infarction (new Q wave) rate was 0.6%, and deep sternal wound infection occurred in 1%. Six patients (1.2%) had strokes, and nine patients (1.8%) were returned to the operating room to control bleeding. One hundred ninety-eight patients who had abnormal stress test results before surgery were retested within 3 months of surgery. Ninety-four percent of these were normal, 3% were nondiagnostic, and 3% were abnormal. After a mean follow-up of 7.1 years (mode, 7.2 years), 87.5% of patients in the sample were alive, and 93.2% of this group have experienced continuing good clinical results (New York Heart Association class I or II). Eighty-nine patients who underwent an angiogram had 90.8% patency rates of ITA bypasses and 84.5% patency of vein grafts. Only two patients required repeat operations. CONCLUSIONS: The operative results did not support the contention that the coronary artery bypass using ITA procedure produces higher than acceptable mortality and morbidity rates. Multiple ITA bypasses can be performed without excessive morbidity, with low reoperation rates and long-term outcomes that should encourage skeptics to reconsider the procedure's clinical value.

The case of a mild hemophiliac who underwent a successful and uncomplicated myocardial revascularization is presented. The procedures was safely performed while the patient was receiving factor VIIIC. Copyright © 1996 The International Society for Cardiovascular Surgery.

A 56-year-old man with confirmed sickle-cell trait AS underwent successful triple-vessel myocardial revascularization with internal mammary artery and vein conduits. Variations in routine technique included limitation in hypothermia (32 degrees C), avoidance of intraoperative autologous salvage, hypoxia, severe anemia (< 25% hematocrit), acidosis and postoperative reinfusion of mediastinal drainage.

A technique for wedge resection of the lung using a linear cutter stapler without staples on the specimen is presented.

It has been assumed that patients with neurological residua after a completed stroke are at increased risk of neurological complications associated with cardiac operations requiring cardiopulmonary bypass. To evaluate these assumptions, we reviewed retrospectively 1,163 consecutive patients undergoing cardiac operations with cardiopulmonary bypass. Among these 1,163 patients were 43 patients having a previously completed stroke with neurological residua, but without clinically significant extracranial carotid artery disease. Forty-one underwent coronary artery bypass grafting; of these, 1 required concomitant aortic valve replacement, 1 had mitral valve replacement, and 1 had aortic valve replacement. There was one death in this group of 43 patients, due to massive pulmonary embolism. Only 1 of these 43 patients experienced new neurological symptoms after operation, which would appear to indicate that patients with a previous, completed stroke may not be at increased risk of neurological complications from cardiac operations requiring cardiopulmonary bypass.

Early diagnosis of postoperative cardiac tamponade is impeded by its clinical similarity to left ventricular failure. Moreover, the hemodynamic changes necessary to diagnose cardiac tamponade are detected by conventional monitoring technique only after clinical compromise. Early signs of cardiac tamponade and left ventricular failure were studied with emphasis on right ventricular function in anesthetized dogs. One group (n = 20) had cardiac tamponade produced by incrementally increasing pericardial pressure (2 to 20 mm Hg), and another group (n = 20) had acute left ventricular failure produced by successive ligation of the anterior descending coronary artery at the lower, middle, and upper thirds. Besides standard hemodynamic measurements, right ventricular function was examined with a rapid-response thermodilution catheter. During cardiac tamponade, cardiac output, right ventricular ejection fraction, right ventricular stroke volume, and right ventricular end-diastolic volume were significantly decreased from baseline values after a pericardial pressure of 8 mm Hg or more (p less than 0.05). Right atrial and pulmonary arterial pressures were not significantly elevated until 14 and 20 mm Hg of pericardial pressure, respectively. Although cardiac function in the left ventricular failure group was reduced after each ligation, right ventricular ejection fraction remained unchanged. This study suggests that right ventricular indices may facilitate earlier diagnosis of cardiac tamponade with greater accuracy.

Massive hemoptysis due to broncholithiasis is rare. Such a case is presented here, and the literature is reviewed. Surgical resection is the preferred definitive therapy, as a lack of bronchial artery collaterals limits the utility of bronchial artery embolization.

Previous studies have shown that the cells of the aorticopulmonary (AP) septum are similar to the smooth muscle cells of the mediae of the great vessels in their common origin from the cardiac neural crest and in their common expression of an elastic extracellular matrix. The purpose of this study was to test the cells of the AP septum for the presence of certain cytoplasmic proteins, especially smooth muscle alpha-actin (SMAA) whose presence is definitive of smooth muscle. A monoclonal antibody against SMAA was applied to normal chicken embryos at 3.5–8 days of incubation and to age-matched embryos from which the cardiac neural crest had been ablated surgically. Antibodies against the intermediate filaments desmin, cytokeratin, and vimentin also were applied. The results showed that the AP septal cells expressed SMAA during the process of septation, days 5–8; but when the cardiac neural crest was ablated and septation was defective, no cells in the conotruncal connective tissue expressed SMAA. None of the intermediate filament proteins were detected in the septum. These results indicate that the AP septal cells are smooth muscle and therefore may be hypothesized to have an active role in septation.

Isolated right ventricular aneurysms are rare. Postinfarction right ventricular aneurysm associated with a ventricular septal defect is a very unusual complication. We present such a case that was successfully treated surgically.

Today, surgeons are able to manage both blunt and penetrating wounds of the heart with increasing success, including those with associated intracardiac injuries. After diagnosis by cardiac catheterization, substantial intracardiac lesions are repaired using cardiopulmonary bypass. Among more than 300 patients treated for cardiac wounds in our city-county hospital in recent years, 15 were found to have marded intracardiac defects. These defects included ventricular septal defects, aorta--right ventricle fistulas, aortic valve injuries, a mitral valve injury, and a coronary artery--right ventricle fistula. Thirteen of the 15 patients required repair of the intracardiac defects. One was repaired acutely and 12 were repaired electively. All 15 patients were alive and asymptomatic at the time of writing.

Survivors of innominate and other major cardiovascular injuries are being seen with increasing frequency. Penetrating injuries more frequently involve the distal innominate artery and innominate veins. Associated subclavian and carotid artery injuries are more frequent following penetrating trauma. Blunt trauma typically involves the proximal innominate artery. A variety of operative exposures is useful but the selection of incision frequently depends upon the presence or absence of associated mediastinal injuries. Partial or complete median sternotomy in combination with various cervical and thoracic extensions is advised. Successful management of innominate artery injury can be performed without the aid of cardiopulmonary bypass or arterial shunts.

Both penetrating and blunt cardiac injuries require urgent management. Delayed sequelae and complications have been reported to occur in 4 to 56% of survivors and frequently required secondary surgical corrections. Between January 1980 and June 1984, 204 patients presented with heart injuries. One hundred twenty-eight of these patients survived. Of the 90 undergoing cardiorrhaphy in the operating room, 78 survived. Two-dimensional (2-D) and pulsed-Doppler echocardiography (echo) and/or cardiac catheterization were performed in 40 patients for suspected significant residual injury. Eight of the 40 required secondary cardiac operations. Two-dimensional echo demonstrated pericardial effusion, abnormal chamber enlargement, abnormal cardiac wall motion, intracardiac missile, and intracardiac and pleural thrombus. Pulsed-Doppler findings included ventricular septal defect, tricuspid insufficiency and right ventricular turbulence secondary to arteriovenous fistulae. Cardiac catheterization detected lesions undetected by 2-D echo in one patient with a gunshot wound. It is concluded that in the absence of cardiac bullets seen on routine chest X-ray, 2-D with pulsed-Doppler echo is an excellent screening technique. With a positive echo study or a residual bullet overlying the cardiac silhouette, cardiac catheterization is indicated in selected patients.

The acutely injured patient may require emergency thoracotomy as an integral part of resuscitation. In critical circumstances, thoracotomy in the emergency center for control of hemorrhage, cardiac massage, and direct repair of crucial injuries can be lifesaving. Such an approach may be required for urgent repair of cardiac injuries. Between January, 1970, and December, 1973, over 6,000 emergency operations were performed for blunt and penetrating trauma at Ben Taub General Hospital. Emergency thoracotomy was required in more than 400 cases. Of these, 148 patients required thoracotomy in the Emergency Center due to rapid deterioration in their clinical condition. Forty-eight of these patients had injury to the heart. This aggressive approach allowed salvage of 67.5 per cent of these critically wounded patients with cardiac injuries who had any sign of life on arrival at the hospital. Autotransfusion, emergency cardiopulmonary bypass, and fine-screen filtration of transfused blood have been valuable adjuncts to this lifesaving measure. Thoracotomy in the Emergency Center should be considered as a primary modality in the management of moribund patients with penetrating wounds of the chest.

New and reportedly safet techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature [55--59]; yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.

Particulate microemboli and in vitro platelet aggregation were studied in blood of patients during cardiac operations with an electronic particle size analyzer. A small gradient of microemboli developed on passage of blood through a bubble oxygenator but not through a membrane oxygenator. However, with both types of oxygenators, there was a sustained increase in the volume of microemboli in cardiotomy return blood which was much greater than in aterial blood. After cardiopulmonary bypass with both oxygenators, there was a comparable reduction in the volume of circulating platelets which exceeded that of the hemoglobin concentration, indicating platelet loss exceeded that that expected from hemodilution alone. However, the total volume and mean size of platelet aggregates induced in blood of patients after membrane oxygenation was significantly greater than similar measurements after bubble oxygenation. This study shows that membrane oxygenation reduces particulate microembolization and preserves platelet function in patients undergoing cardiac operations when compared to bubble oxygenation.

A 55-year-old Saudi Arabian female presented with a 3-year history of progressive dyspnea on exertion and paroxysmal nocturnal dyspnea. Examination showed a mitral systolic and diastolic m...

Major abdominal vascular injuries present problems in diagnosis, exposure, and management. Combined injuries to the abdominal aorta and vena cava are particularly lethal due to extensive blood loss, difficulty in sequential exposure, and the high incidence of associated injuries. Between 1953 and December 1974, ninety-one patients required emergency operations for abdominal aortic trauma at our city-county charity hospital. Twenty-nine of these had combined injuries to the abdominal aorta and vena cava, ten of whom had either an audible bruit preoperatively or a palpable thrill at exploration suggesting acute fistulas. Twenty-three injuries were secondary to gunshot wounds. Ten were located in the suprarenal aorta and vena cava. Management involved a variety of technics including intravascular shunts, adaptive exposures, Dacron prostheses, and autotransfusion. Survival rate was 27 per cent. Sixty-two per cent of the deaths were a function of extreme difficulty in controlling hemorrhage and exposure. There were no late recurrences of arteriovenous fistulas. Successful management of acute traumatic injury to both the abdominal aorta and vena cava requires rapid, aggressive surgical management, adaptive sequential control maneuvers, and application of technics and principles developed for elective vascular surgery.

Advances in the management of penetrating and blunt cardiovascular trauma have paralleled developments in the operative treatment of acquired vascular disease. Nevertheless, upper abdominal vascular trauma still presents a challenge to the surgeon in terms of control of hemorrhage, operative exposure, and multiple organ injury. Between January 1969 and December 1973, forty-six patients were seen with injuries to the upper abdominal aorta, vena cava, portal vein, or proximal few centimeters of the celiac axis or superior mesenteric arteries. Eighty-seven per cent of the patients presented in shock. Control of arterial hemorrhage was achieved by approaching the aorta from a posterolateral position after reflection of the viscera. Vena caval injuries were controlled by utilizing extensive liver mobilization as well as both transthoracic and transabdominal intracaval shunts. Dacron prostheses were employed successfully in the suprarenal position of both the aorta and vena cava. Through prompt resuscitative management, rapid assessment of intra-abdominal injuries, systematic approach to organ involvement, and adaptive exposure, control of upper abdominal vascular trauma was achieved with a reduced requirement for blood replacement and lower mortality. Adjunctive measures of intraoperative autotransfusion and microfiltration of homologous blood further improved survival in these patients with complex injuries.

Particulate matter accumulates in stored blood and may be directly infused into the pulmonary microvasculature by blood transfusion, causing the respiratory distress syndrome (RDS). The protective effect of fine screen filtration by a 40-μ filter in massive blood transfusion was studied prospectively in 54 patients with trauma. Seventeen patients (control) received from 10 to 40 units (mean 18.8 units) of blood through the standard 170-μ blood filter and were compared to 27 patients (filter) who received from 10 to 63 units (mean 17.9 units) of blood through the 40-μ filter. Seven of the 17 control patients developed the clinical picture of RDS following treatment of their trauma. Despite the similarity in source of injury, anatomic area injured and surgical treatment, only two of the 27 patients with a filter developed the clinical signs of RDS. Three of the seven patients with RDS in the control group and both of the patients with RDS in the group in whom the filter was used had significant chest injury. Three patients in the control group without chest trauma died of intractable hypoxemia. Open lung biopsies and needle biopsies were performed in ten additional patients. Particulate matter in the precapillary arterioles was present in four patients receiving massive blood transfusion without the fine screen filter and in no patients with the fine screen filter. The fine screen filter is recommended to protect the pulmonary microvasculature in transfusions of stored blood.

During 1982, 312 patients with 408 vascular injuries and 48 cardiac injuries were seen. Two or more vascular or cardiac injuries were present in 34% of patients. Over 87% of injuries were secondary to gunshot wounds, stab wounds, or shotgun wounds. Vascular injuries were most commonly seen in the extremities (39.9%) or abdomen (31.9%). The most common arterial injuries occurred in the brachial artery (39 patients), while the most common venous injuries occurred in the internal jugular vein (26 patients). Arterial injuries were treated by the insertion of substitute vascular conduits (33.9%), ligation (22.6%), lateral arteriorrhaphy (18.6%), or end-to-end anastomosis (15.4%). Venous injuries were treated by lateral venorrhaphy (63.7%) or ligation (25.1%). In the 272 patients admitted with only vascular injuries, survival was 84.2%. Cardiac injuries in 38 patients most commonly occurred in the right ventricle (50%) and right atrium (25%). In the 34 patients who had only cardiac injuries and less than 4 minutes of prehospital cardiopulmonary arrest prior to arrival in the emergency center, survival was 64.7%.

Greater civilian use of firearms and improved transportation and resuscitation of the injured have provided our institutions with an increasing experience with subclavian vascular injuries. Ninety-three patients with subclavian vascular injuries are presented and two time periods are compared. Principles of management gained from the earlier experience have been utilized with a decline in mortality to 4.7% among the patients admitted with a palpable pulse or blood pressure. Successful treatment as before still lies in the recognition of the severity of the injury, rapidity of preparation for operation, and adequacy of surgical exposure. Recent trends have included an increased reliance on selective arteriography when the patient is stable, extensive use of the 'book' thoracotomy as a primary incision, preoperative and intraoperative autotransfusion, and a more frequent use of interposition grafting for vascular repair. Primary arterial repair was seldom accomplished; most patients required segmental resection with end-to-end anstomosis or interposition grafts.

Records of 373 patients with penetrating wounds of the lung seen at the Ben Taub General Hospital over a 1-year period were reviewed. Intercostal tube thoracostomy was the only therapy required in 282 patients. Thoracotomy was performed in 91 patients with repair of a pulmonary lesion in only 45 patients. Pneumonorrhaphy was performed in 33 patients, segmentectomy in six, and lobectomy in two. Four patients required repair of tracheal injuries. Fourteen patients initially treated with intercostal tube drainage required thoracotomy for complications of clotted hemothorax in eight and empyema in six. There were 29 deaths. Penetrating lung trauma in the majority of patients may be treated conservatively with a low incidence of infection or complication. Of the patients who require thoracotomy, associated injuries will frequently represent the major operative indication. Early thoracotomy for complication of clotted hemothorax or empyema is encouraged.

During the period from 1961 to 1981, 40 pulmonary embolectomies were performed in 39 patients who were in extremis at the time of initiation of cardiopulmonary bypass. In a 460-bed hospital with more than 17,000 acute admissions and 4,000 operations per year, this small number represents the few patients who are potentially salvageable by urgent embolectomy. Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. Excluding two patients with tumor occlusion of the pulmonary arteries and three patients with chronic cor pulmonale from old pulmonary emboli, the survival rate was 50%. Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. Portable cardiopulmonary bypass affords the possibility of survival in moribund patients with acute massive pulmonary embolism. Preoperative angiography is recommended to guide appropriate surgical management.

Thoracotomy is infrequently required for penetrating or blunt thoracic trauma. Complications of thoracic trauma, such as clotted hemothorax and empyema, significantly increase morbidity, mortality, and length of hospitalization. Among approximately 9,000 patients with blunt or penetrating thoracic trauma seen during a recent eleven year period, 33 per cent (3,000 patients) presented with hemothorax or pneumohemothorax. The average length of hospitalization in the patient with uncomplicated thoracic trauma was less than six days. Among the 3,000 patients with hemothorax or pneumohemothorax, 2,600 (85 per cent) were treated with a drainage procedure. Among this group, clotted hemothorax or posttraumatic empyema developed in 85 (3.3 per cent). Among ten patients undergoing evacuation of a clotted hemothorax within five days of admission, there was zero mortality and an average hospital stay of ten days. Forty-one patients undergoing decortication more than five days after injury had a 2.4 per cent mortality, with the average period of hospitalization being twenty-five days. Thirty-four patients requiring decortication and drainage of empyema had a 12 per cent mortality and an average hospital stay of forty-one days. Among those patients in whom empyema developed, the most frequently associated injuries were enteric. These complications occurred due to inadequate evacuation of the original hemothorax, nonfunctioning tube thoracostomy, physician delay in recognition of the pathologic process, and bacterial contamination of the hemothorax. When complications secondary to tube thoracostomy dysfunction occurred, early operative evacuation of clotted hemothorax decreased the mortality, morbidity, and hospital stay and prevented the development of empyema.