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Coronary artery bypass graft (CABG) surgery is performed 350,000 times annually in the United States, making it one of the most commonly performed major operations. A 1-2% stroke rate, which includes spinal artery infarct, is associated with CABG primarily in the elderly population (1). Spinal cord infarction is infrequent, but only incomplete or indirect data are available on incidence or prevalence. A large study showed that only 9 of 3784 autopsies revealed spinal cord infarction, with an occurrence rate of 0.23% at death. Conversely, if spinal stroke accounts for approximately 1.2% of all strokes, an overall annual incidence of 12 in 100,000 can be estimated (1). After an extensive literature review, we found only one case of spinal cord infarction after CABG surgery.

Objective: This study compared the transfusion rates of patients treated with heparin-bonded circuits with the transfusion rates of patients treated with standard bypass circuits with and without -aminocaproic acid (EACA)., Design: Prospective double-blind (drugs), open trial (cardiopulmonary bypass circuits)., Setting: University medical center., Participants: Seventy-one patients undergoing elective am admission coronary artery bypass graft surgery., Measurements and Main Results: Patients were randomized to receive either heparin-coated cardiopulmonary bypass circuits (HBCPB), nonheparin-coated cardiopulmonary bypass circuits and EACA (EACPB), or nonheparin-coated bypass circuits and placebo (control). Patients were transfused if their hematocrit was <18% while on cardiopulmonary bypass or <25% at any time after the cardiopulmonary bypass period. The rate and number of transfused packed red blood cells (pRBCs), platelets, fresh frozen plasma, and cryoprecipitate were measured. A Fisher exact test showed that the transfusion rate was as follows: the HBCPB group (5.0%), the EACPB group (18.2%), and the control group (36%), (p = 0.034)., Conclusions: The heparin-bonded cardiopulmonary bypass-treated patients in this study received fewer pRBCs than did the control group. A nonsignificant reduction in the pRBC transfusion rate was found between those with heparin-bonded bypass circuits and those with standard circuits who received epsilon-aminocaproic acid.

The radial artery is used frequently in cardiac revascularization and requires an average 23-cm forearm incision. With proper instrumentation (Tsukuba-West Virginia Endoscopic Radial Artery: TW-ERA series, Takumi Cardio Co., Chiba, Japan), the radial artery can be harvested utilizing two small transverse incisions. The authors report six cases of endoscopic harvest of a radial artery graft. Length of the endoscopic incision is 2 cm proximally and 3 cm distally. Operation time and tourniquet times were approximately 80 to 120 minutes. No complications such as hematomas, nerve damage, or delay in healing were observed at the donor sites. Plastic surgeons, with their expertise in radial forearm flaps, hand surgery, and subcutaneous endoscopic techniques, can contribute greatly to the minimally invasive harvesting of the radial artery, preventing associated morbidity and improving the aesthetic and functional outcome of the donor site.

A 65-year-old-man was admitted for evaluation of a transient ischemic attack. A 4.5 x 5.3-cm right atrial mass and a patent foramen ovale were identified by echocardiography. A 0.5-cm lesion was identified in the left temporal lobe of the brain by magnetic resonance imaging. Positron emission tomography was used to differentiate a tumor from an infarct in the brain. The cardiac and the brain lesions were successfully resected. Histopathologic study of the atrial and cerebral tissue demonstrated that these were metastases from a previously excised scalp desmoplastic malignant melanoma. The patient remains well at 14 months' follow-up.

Pneumoconioses are characterized as irreversible, progressive respiratory diseases. No effective therapy exists to prevent progression of these diseases. Whole-lung lavage (WLL) might limit the rate of disease progression through the removal of dust, inflammatory cells, and cytokines. We performed WLL on a 54-year-old underground miner employed as a motorman and roof bolter and a 55-year-old driller at a surface coal mine. Both demonstrated normal lung function and chest radiographs showing ILO profusion category 2 nodular interstitial changes. From Subject 1, we recovered 5.24 x 10(8) cells (90% macrophages) from the right lung and 3.45 x 10(8) cells (94% macrophages) from the left lung. WLL removed 1.82 g of mineral dust (non-coal) on the right and 1.64 g on the left. From Subject 2, we recovered 7.49 x 10(8) cells (46% macrophages) from the right and 9.78 x 10(8) cells (69% macrophages) from the left lung. WLL removed 0.40 g of mineral dust on the right and 0.53 g on the left. Proinflammatory cytokines, growth factors, and cellular enzymes were also recovered. In cases of pneumoconiosis, WLL is capable of removing relatively large quantities of dust, cells, and soluble materials from the lungs. Only long-term follow-ups of individuals with progressive dust-induced disease who receive WLL therapy in the context of a clinical trial will provide information regarding the importance of removing mineral dust and inflammatory cells from the lung.

Early surgical intervention for atrial myxomas mitigates morbidity and usually offers cure. The operative approach to resect these tumors is controversial. The purpose of this study was to review our experience with the biatrial approach between 1964 and 1994. The location of the myxoma was left atrium in 17 and right atrium in 3. Mean preoperative New York Heart Association functional classification was 2.7. Surgical approach to the tumor was biatrial in all patients. There were no perioperative strokes, myocardial infarctions, or deaths. Mean follow-up was 7.5 years (range, 2 mo to 27 years) with a postoperative New York Heart Association functional classification of 1.4. One late death occurred, which was unrelated to the myxoma. Advantages of biatrial approach include (1) definition of tumor pedicle by direct visualization, (2) minimal manipulation of the tumor, (3) adequate margins of excision, (4) inspection of all heart chambers, and (5) secure closure of the atrial septal defect. Long-term follow-up demonstrates the efficacy of this operative approach to atrial myxomas.

Durable, covalently bonded, heparin-coated cardiopulmonary bypass (CPB) circuits with oxygenators have been developed. Proposed advantages of heparin-coated CPB circuits include improved biocompatibility and thromboresistance. The purpose of this study was to evaluate our experience with heparin-coated CPB circuits in 20 patients. Heparin was given to maintain an activated clotting time equal to or greater than 200 seconds, while flow rates were kept equal to or greater than 2 L/min. Indications for use of this circuit included recent stroke, posttraumatic injuries, recent gastrointestinal bleeding, protamine allergies, combined cardiac and noncardiac procedures, and ventricular assist. Mean heparin dosage was 0.50 +/- 0.18 mg/kg and protamine dosage was 57.14 +/- 39.36 mg. Postoperative blood loss and transfusion requirements were minimal. Postoperative complement levels of C3a and C5a were normal, suggesting excellent biocompatibility. There were no deaths or perioperative complications. Heparin-coated CPB circuits using a pump oxygenator can be used safely with low-dose heparin administration in select patients requiring CPB.

We analyzed our experience at a university medical center from 1977 to 1990 to assess our success in using esophagoscopy and related treatments for removing esophageal impactions. There were 157 episodes of impaction in 150 patients, consisting of 39 pediatric and 111 adult patients. In the pediatric cases, foreign bodies were most often the cause of impaction, while adult cases were usually caused by food or bones. Esophagoscopy was performed successfully in 32 of 34 pediatric patients in which it was attempted; there was only one complication. Other forms of therapy that were infrequently tried met with variable results. Esophagoscopy was successful in removing the impaction in 104 of 109 attempts in adults. Two perforations occurred, with one resulting in death. Various other methods achieved success in the remaining patients. The data suggest that esophageal impaction can be treated successfully by endoscopy with very low morbidity and mortality.

Sternal wound infection with mediastinitis is a dreaded complication of cardiac surgery. Even more devastating is perforation of the heart or great vessels secondary to advanced mediastinitis. The exsanguinating hemorrhage and presence of extensive infection usually lead to a poor salvage rate in these patients. Citations in the English literature of successful management of cardiac rupture associated with mediastinitis are, as expected, scare. Recently, the capability for immediate muscle flap coverage in the repair of associated rupture of the heart secondary to active mediastinal infection has been discussed in two reports. This article presents another report, in which bilateral pectoralis major muscle flaps were used successfully in salvage of a patient who sustained rupture of the right ventricle after debridement of an extensively purulent sternal wound and mediastinum.