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SUMMARY An experimental study was undertaken to evaluate the relative merits of closure of the bronchial stump following lobectomy by means of interrupted silk sutures, Eastman 910 monomer, and Eastman 910 adhesive. Results indicate that suture closure is easier from a technical standpoint and is safer than closure with either the monomer or the adhesive.

Intraatrial transposing of the venous return is a satisfactory method of treating transposition of the great arteries. Serious complications include atrioventricular conduction disturbances and pulmonary venous obstruction. Simple technical modifications that should eliminate these complications are described.

Percutaneous insertion of myocardial electrodes and electrical pacing were employed in the treatment of ten patients with A-V block complicating myocardial infarcts. The technique of wire insertion is given and representatives cases are described. Prognosis in such cases is dependent primarily on the extent of cardiac damage produced by the infarction, but electrical pacing will complement the usual therapeutic regimen.

The morphogenesis of pulmonary vascular lesions produced by autogenous clot embolism has been studied for comparison with lesions produced by hyperkinetic pulmonary hypertension. Embolic lesions differ from those produced by hyperkinetic hypertension. The embolic lesion is an eccentric fibrous plaque that protrudes into the lumen of the vessel and replaces in large part the vascular media beneath it.

Hyperkinetic pulmonary hypertension has been produced in dogs with an aorta-left pulmonary artery anastomosis. The pulmonary artery proximal to the shunt was banded so as to restrict the increased pressure to a segment of the pulmonary vasculature. Pulmonary hypertension was observed when the shunt was directed into the entire left lung of the dog, but no vascular lesions were demonstrated after as long a period of time as 93 weeks. Pulmonary hypertension and arterial lesions were found when the shunt was directed into the left lower lobe of the lung. Study of the lesions produced by this form of hyperkinetic pulmonary hypertension revealed them to be quite different in appearance and morphogenesis from lesions produced by autogenous clot embolism. The reversibility of arterial lesions was studied by restoring normal pressure in the left lower lobe. Vascular lesions characterized by medial hypertrophy of muscular arteries, muscular arterioles, and minimal to moderate degree of intimal thickening were observed to resolve. Marked intimal thickening and plexiform lesions did not resolve when followed for as long as 37 weeks.

The diagnosis and treatment of congenital lung cysts producing severe symptoms are discussed. The cases of six infants form the basis of this report. All had such severe dyspnea and cyanosis that emergency operations were necessary. All six infants made uneventful recoveries. The youngest child was five days old.

THE treatment of traumatic ventricular septal defects produced by penetrating injuries of the heart is a subject of controversy. Some advocate surgical closure of all such defects whereas others su...

Atrioventricular conduction blocks were produced in dogs, and ventricular stimulation was accomplished by the use of electrodes implanted either into normal myocardium or scar tissue on the myocardium. Stimulation through scar tissue requires several times the power necessary for stimulation through normal myocardium, but both are well within the limit of standard, commercially available, transistorized pacemakers. Failure of stimulation of the ventricle was not due to excessive scarring. Failure of stimulation was in every instance due to wire breakage or actual loss of contact between the wire and the myocardium.

A young male patient with bilateral rupture of the diaphragm due to blunt trauma is presented. A separate tear occurred in each hemidiaphragm but recognition and repair of the right side was delayed. After healing of other injuries successful operation was performed 55 days postinjury by a transthoracic approach.

Three standard tracheostomy incisions in dogs were compared to determine whether any were more likely associated with stomal stenosis. Each incision resulted in an average reduction in tracheal lumen of 25 per cent, with a 50 per cent maximum. The incision selected should depend on the conditions present.

Cardiac tamponade was diagnosed in 197 patients admitted over 20 years (1955-1974) to the Charity Hospital of New Orleans, for emergency treatment of pentrating mediastinal injuries. Of the 197, 174 definitively treated patients followed one of three patterns of management: 96 had OR thoracotomy, 68% were unstable, and preoperative pericardiocentesis reduced mortality from 25 to 11% (p less than 0.01); 44 had emergency thoracotomy, 91% were unstable, and prethoractomy pericardiocentesis decreased mortality from 94 to 63% (p less than 0.05); 34 patients primarily with isolated stab wounds, were treated nonsurgically with pericardiocentesis and observation, only 50% were unstable and there was 15% mortality. Recurrent tamponade did not significantly increase overall or operative mortality in patients with pericardiocentesis.early, even presumptive, diagnosis of tamponade; immediate pericardial decompression via pericardiocentesis; and rapid transfer to OR for thoracotomy or sternotomy and cardiorrhaphy with continous pericardial decompression via intrapericardial catheter.

From March, 1969, through June 1976, 108 porcine aortic xenograft valves were used for mitral or aortic valve replacement in 95 patients. This experience provides one of the longest follow-ups available for evaluation of the porcine bioprosthesis. The first fifteen valves were locally mounted on Cutter stents and preserved in buffered formalin. Subsequent valves were prepared by the Edwards and Hancock Companies with glutaraldehyde preservation. Oral anticoagulation was routinely used for the first 6 weeks following surgery. Hospital mortality was unrelated to the valve type. All but four of the surviving patients with formalin preserved valves have required reoperation because of valve failure. There have been two valve failures in the patients who received gluteraldehyde valves, but there have been no embolic or thrombotic complications. Late cardiac catheterization has shown hemodynamic results equal to or better than prosthetic valves. The continuing long-term results indicate that the porcine xenograft is the valve of choice for cardiac valve replacement.

The technic of banding the pulmonary artery is described. Twenty infants with intractable cardiac failure secondary to interventricular septal defects have had banding with one operative and one late death. The operation is palliative, and definitive surgery probably must be done when the child is 3 to 5 years of age. Banding the pulmonary artery is a relatively safe procedure but the mortality of banding plus ventricular closure and unbanding remains to be evaluated.

Fourteen patients submitted to open-heart surgery were studied by serial acid-base and electrolyte determinations in order to demonstrate the sequence and magnitude of disturbances associated with the procedure. Under conditions of the study, including the use of 100 per cent oxygen as the perfusing gas for the oxygenator, respiratory alkalosis develops as the initial change during perfusion but is followed by a "metabolic shift" characterized by falling pH and CO 2 content, while a stable, moderately low pCO 2 is maintained by the oxygenator. The resulting state of mixed respiratory alkalosis and metabolic acidosis changes into a state of relatively pure metabolic acidosis as pCO 2 and bicarbonate content rise while pH falls after perfusion. The factors involved in the "metabolic shift" responsible for development of metabolic acidosis are not identified by this study although length of perfusion, perfusion pressure, and rate of flow are considered as possible factors. Acidosis persists through the early phases of the recovery period but ordinarily resolves without administration of alkali. Serial sampling technics as used in this study may aid in the interpretation of postoperative acidosis, distinguishing between patients who are deteriorating and those who are passing through a transient phase in the process of recovery.

ONE OF THE therapeutically reversible acute complications of recent myocardial infarction is the development of complete heart block. When the heart rate falls below 25 to 30 beats per minute, syncopal or convulsive seizures develop accompanied by the clinical picture of shock. This emergency requires immediate therapy not only for survival, but to prevent cerebral, cardiac, and renal complications resulting from repeated episodes of inadequate circulation. In the above situation we have employed a procedure similar to that described by Dr. C. W. Lillehei 1 for therapy of heart block complicating surgical repair of ventricular septal defects. The procedure consists of inserting a No. 18 spinal needle into the right ventricular cavity by puncturing the chest wall just medial to the point of maximal impulse and directing the needle superiorly and medially toward the second right costochondral junction. Then a No. 26 stainless steel wire is passed through the needle

THE CONCEPT of surgical excision as a treatment for myocardial infarction was proposed by Murray, 1 who in 1947 observed improvement in cardiac function after excision of experimentally produced infarcts. Experimental and clinical studies by Heimbecker et al 2 demonstrated the feasibility of this method of treatment and stimulated our interest in the problem. Our own experimental results, 3 as well as those of Jude et al, 4 support the work of Heimbecker. Our experimental and clinical experience with this form of treatment is described in this paper. Experimental Method Forty mongrel dogs weighing 13.0 to 20.2 kg were studied. Animals were anesthetized with intravenously administered pentobarbital sodium and respiration was supported by endotracheal insufflation with room air using a respirator. The inferior vena cava was catheterized via the right femoral vein for central venous pressure measurements. The left femoral vein was cannulated for infusion of fluids and for dye

SINCE Clark and Bargeron** introduced the hydrogen-electrode principle for detection of intracardiac shunts, this method has found widespread application. We have recently utilized a 100-cm. single-lumen No. 6 Cournand-type cardiac catheter with three radiopaque platinum electrodes (Fig. 1 and 2) to facilitate the determination of the site of a left-to-right shunt. The distal electrode is 1 mm. from the tip of the catheter; the second electrode is 6 cm. proximal, and the third electrode is 16 cm. proximal to the tip. These electrodes are connected by insulated platinum wire woven into the lining of the catheter to three 1-cm. copper sleeves . . .