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Background: Rupture of the innominate artery is the second most common intrathoracic arterial injury from blunt trauma. It is frequently accompanied by major trauma to other organs. The traditional management is expeditious surgical repair. Methods: Three patients presented to the Emergency Department after motor vehicle collisions with traumatic rupture of the innominate artery from 2001 to 2003. One patient presented with an isolated innominate artery injury. The other two patients presented with multi-system trauma. All patients underwent surgical repair; however, repair was individualized in each case. Results: Diagnosis was obtained via arteriography in all patients after the admission chest radiographs suggested mediastinal injury. In the patient with isolated traumatic innominate artery rupture, urgent repair was performed. In the remaining two, the repair was intentionally delayed (hospital day 4 and 19) until they stabilized or recovered from other injuries or complications. In one of these patients, repair was delayed after an endovascular repair failed. In both patients who underwent delayed repair, mean arterial pressure was maintained at

To determine whether delay of the repair of the ruptured thoracic aorta in patients with other major injuries is safe and has a potential positive impact on survival.The accepted treatment for acute traumatic rupture of the thoracic aorta has been repair of the injury as soon as possible. This form of management, however, has been accompanied by a death rate of 0% to 54% mortality, often related to the presence of other injuries.The records of 30 consecutive patients with rupture of the thoracic aorta from blunt trauma treated from 1995 to 2001 were retrospectively reviewed. Two of them died shortly after admission and were excluded from further consideration. The remaining 28 patients were divided according to the time of the repair of the rupture into two groups. Group 1 patients underwent repair of the rupture immediately after the diagnosis was made. Group 2 patients, who had associated injuries that were likely to increase the risk of surgical death, had either repair more than 48 hours after injury (subgroup 2A) or had no repair (subgroup 2B). The patients in group 2 had their mean arterial pressure maintained at less than 70 mm Hg with medication to eliminate shear stress on the aortic tear while being observed.Twenty-eight patients (22 men, 6 women) with an average age of 36 years (range 19-76) were treated. Twenty-five had rupture of the descending thoracic aorta and three had rupture in the ascending thoracic aorta. Group 1 comprised 14 patients, 5 of whom died during surgery or in the early postoperative period. Group 2 comprised 14 patients, 9 in subgroup 2A and 5 in subgroup 2B. Two patients in subgroup 2A and three patients in subgroup 2B died of associated injuries or illnesses. Rupture of the traumatic pseudoaneurysm of the thoracic aorta did not occur in any of the patients in group 2.Delayed repair of acute traumatic aortic rupture is safe under appropriate treatment and should be considered in selected patients.

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975–1985; 113 patients) and Period 2 (1986–1996; 79 patients) were by χ2 or Fisher's exact tests. Statistical significance was defined as P ≤ 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30–90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

A variety of benign or malignant tumors may arise in the esophagus. Benign tumors may be epithelial, such as polyps, adenomas, papillomas, and cysts, or nonepithelial, such as leiomyomas, fibromas, fibromyomas, and lipomas. However, these neoplasms are exceedingly rare, accounting for less than 1% of all esophageal tumors. The majority of malignant esophageal tumors are either squamous cell carcinomas or adenocarcinomas, but other tumors, such as sarcomas and melanomas, can be found in the esophagus.

The authors present the case of a 40-year-old female with a massive anterior mediastinal tumor who presented with acute respiratory distress. She required emergent intubation and ventilatory support for respiratory compromise caused by lung compression. Preoperative computed tomographic scan results suggested a mediastinal lipomatous mass. Resection of the tumor resulted in immediate improvement in her pulmonary status. Because thymolipomas can attain enormous dimensions and compress adjacent structures, they should be resected at the time of diagnosis.

Pneumocephalus resulting from a subarachnoid-pleural fistula most commonly occurs after trauma. Such a complication is very rarely seen after thoracotomy alone, with 15 cases reported to date in the literature. We report a case of pneumocephalus and subarachnoid-pleural fistula that developed secondary to thoracotomy. It was diagnosed by postmyelography computed tomography and treated with open surgical repair after a trial of conservative therapy failed. The presenting symptoms and signs, diagnostic methods, and options for therapy are reviewed.

A 45-year-old man presented to our hospital with severe dyspnea 4 months after antibiotic treatment for aortic valve endocarditis. Transesophageal echocardiography revealed severe aortic regurgitation and an aneurysm of the anterior leaflet of the mitral valve. In addition to aortic valve replacement, we excised the aneurysm and repaired the anterior leaflet of the mitral valve. Clinical suspicion, appropriate preoperative imaging, and timely surgical intervention are essential to recognize and treat this rare complication of bacterial endocarditis.

Background . Rupture of the heart is usually a fatal injury in patients sustaining blunt trauma. Those arriving in the emergency department alive can be saved with prompt diagnosis and treatment. Methods . We describe the cases of 4 consecutive patients with rupture of the free cardiac wall whom we treated at Grady Hospital. Two had a tear of the right ventricle, 1 had a tear of the right atrium, and 1 had two tears of the left atrium. All patients were involved in motor vehicle accidents. The diagnosis was made by ultrasound in 3 patients and during exploratory surgical intervention in the other. All tears were repaired primarily without the aid of cardiopulmonary bypass. Results . Three of the patients survived, and 1 died. Conclusions . Rarely are patients with rupture of the free cardiac wall seen in an emergency department. The improvements in the prehospital care and the transportation may result in an increase in the numbers of such patients. Physicians treating patients with blunt trauma must suspect the presence of cardiac rupture. Immediate use of ultrasonography will establish the diagnosis and prompt repair of the injury may improve overall survival.

Background . Rupture of the ascending aorta caused by blunt trauma rarely has been diagnosed and treated. As a result, the clinical manifestations and management of this injury have not been clearly defined. Methods . We describe the clinical presentation, diagnosis, and management of 3 consecutive patients with ascending aortic rupture treated during the last 3 years. We also review the cases with this injury reported in the English-language literature until 1996. Results . The predominant clinical manifestations of all patients, including reviewed case reports, were those of other organ injuries, and 5 had signs of aortic regurgitation and 1 of cardiac tamponade. The mediastinal silhouette was normal in 6 and widened in 14 patients, 1 of whom had also rupture of the subclavian artery. The aortic tears were managed with primary repair or with graft interposition and the valve injury with replacement or repair. Three of 20 patients died, for an overall mortality of 15%. Conclusions . Ascending aortic rupture should be considered in any patient with severe blunt trauma who has widened mediastinum or cardiac tamponade, as well as in patients with associated major thoracic injuries. Absence of a widened mediastinal silhouette does not exclude the diagnosis. The repair is relatively straightforward, but survival depends primarily on the severity of associated injuries.

Trauma is the leading cause of absenteeism from work and the leading cause of death among young adults in the industrialized nations.1,2 Injuries to the various intrathoracic structures play a major role in this morbidity and mortality.3 Most injuries to the chest, including wounds to the heart, can be repaired without the aid of total or partial cardiopulmonary bypass (CPB) or any form of shunts. Only a few injuries to the heart, to the great vessels, and, occasionally, to the major, airways call for some form of CPB support. The aim of this chapter is to describe the various traumatic lesions that require extracorporeal support for their repair.

Doctor Dwight E. Harken made numerous contributions to the field of cardiac surgery, and in particular the management of cardiac missiles. A few highlights are reviewed.

Tracheobronchial rupture from blunt trauma is usually single and transverse but may be longitudinal or complex, a combination of various sites and forms of rupture. From 1970 to 1990, 183 cases of rupture of the airways were reported in the literature: 136 (74%) transverse, 33 (18%) longitudinal, and 14 (8%) complex. During the same 20 years at Grady Memorial Hospital, 6 patients with such injuries were treated. One had complex injury consisting of rupture of the distal trachea and both main bronchi, 1 had a longitudinal tracheal rupture and rupture of the innominate artery, and 4 had a transverse rupture, 1 of whom also had a traumatic false aneurysm of the left pulmonary artery. Cardiopulmonary bypass was used only for the repair of the complex injury, whereas the repair of the left main bronchial rupture associated with a false aneurysm of the left pulmonary artery was done with standby cardiopulmonary bypass. All 6 patients had satisfactory results from the correction of their lesions except 1 child in whom stenosis developed at the rupture site. This study suggests that complex injuries are rarely seen, and their repair is often quite involved. In some of these cases, the use of cardiopulmonary bypass increases the margin of safety during operation and may encourage repair rather than resection of the affected lung.

The histologic and mechanical properties of the aorta following its segmental wrapping or replacement was investigated in two groups of dogs. In Group I (5 dogs) a 3- to 4-cm segment of the ascending and of the descending aorta were wrapped with prosthetic graft (2 dogs with woven and 3 with knitted Dacron). In Group II (5 dogs), a 3-cm segment of the de scending aorta was replaced with prosthetic graft. After an average stay of eight months, the dogs were sacrificed and the aorta was submit ted for histologic and tensile strength studies. There was no change in rup ture strength in either the wrapped or the replaced aortas in comparison with normal control aortas. However, the incidence of rupture at the suture line in Group II was significantly greater. The incidence of rupture site in Group I was 43.5% at the normal aortic segment, 17.4% at the junction between wrapped and nonwrapped aortic segment, and 39.1 % at the wrapped aortic segment. The inci dence of rupture site in group II was 28.9% at the normal aortic segment, 68.9% at the suture line, and 2.2% at the grafted segment. In Group I dogs the outer one third to one half of the media of the wrapped aortic segment was replaced with fibrous tissue.

The records of the patients with tracheoesophageal fistula from carcinoma of the esophagus treated from 1970 to 1983 were reviewed to assess the length and quality of their survival. Twenty-four patients with malignant tracheoesophageal fistula were treated during this period. The site of the carcinoma was the middle third of the esophagus in 18 patients, the lower third in 5, and the upper third in 1. Three patients received only supportive treatment, and 1 had only radiation therapy. Nine patients underwent insertion of a Mousseau-Barbin or Celestin tube with or without gastrostomy, and 7 patients had gastrostomy alone. Four patients had exclusion of the tracheoesophageal fistula, 3 with esophagogastrostomy and 1 with colon interposition. The 3 patients who received only supportive treatment survived 5 days, 1 week, and 2 weeks. The 7 patients who had gastrostomy lived 3 days to 18 weeks (mean, 6 weeks). The 9 patients with a Mousseau-Barbin or Celestin tube lived 1 week to 6 months (mean, 8 weeks). The 4 patients who had exclusion of the tracheoesophageal fistula survived 5 weeks, 4 months, 7 months, and 26 months following operation. This study suggests that the treatment for patients with tracheoesophageal fistula from carcinoma of the esophagus should be individualized and that in selected patients, exclusion of the fistula with esophagogastrostomy improves the quality of life and prolongs survival.

During the past 12 years, 13 patients with atrial (10 left and 3 right) myxoma have been treated. The tumors of the left atrium produced signs and symptoms of mitral valve obstruction and/or subacute bacterial endocarditis and those of the right atrium manifestations of tricuspid valve disease or of pulmonary embolus or hypertension. The diagnosis was established by angiocardiography in 8 patients, at surgery performed for suspected mitral stenosis in 3 patients, and at autopsy in 2 patients. Resection of the atrial myxoma alone in 5 patients or with atrial septum where the atrial myxoma was attached in 4 or with the whole right atrial wall where the atrial myxoma was attached in one patient was performed and all are doing well without evidence of recurrence. Studies of experimentally produced 1.5-3 cm in diameter left atrial thrombus in 30 dogs divided into 5 groups and followed cineangiocardiographically and sacrificed from 14 days to 6 months indicated that the implanted thrombus is absorbed over a 3 to 6 month period. These experimental and human left atrial thrombi were found to be histologically and histochemically different from human atrial myxomas. The electron microscopic studies performed on some of the resected atrial myxomas suggested that the atrial myxoma cells are active cells of endotheilial origin. These observations suggest that atrial myxoma is a primary tumor of the heart which can mimic other clinical entities, and the results of its surgical treatment are gratifying and long lasting.

The 14 year follow-up is presented of a patient in whom the free wall of the left ventricle was replaced with a Dacron graft subsequent to a self-inflicted gunshot wound. The excellent surgical results are evidenced by a benign clinical course and confirmed physiologically by serial exercise tests and anatomically by repeat angiocardiography.

Pulmonary artery balloon counterpulsation was used in 3 patients who underwent open-heart operation for the treatment of acquired cardiac lesions. This form of support was initiated because the patients could not be weaned from cardiopulmonary bypass even with intraaortic balloon counterpulsation and maximal pharmacological support. After pulmonary artery balloon pumping was instituted, cardiopulmonary bypass was successfully terminated in all 3 patients. One of them is alive and well one year after operation.

Four cases with unusual aortic dissection found unexpectantly at the time of operation, and their aortographic and anatomic findings and surgical treatment are described. One of the patients had a type I aortic dissection with intimo-intimal intussusception and another had a type I dissection with one portion of the intimal wall unidentifiable up to the origin of the innominate artery. One patient had a type III dissecting aneurysm with retrograde dissection into the aortic arch and ascending aorta, and the fourth patient had a dissecting aneurysm involving the ascending aorta and the innominate, right common carotid, and right vertebral arteries with a re-entry at the aortic arch.

The coagulation system was investigated in five dogs undergoing autotransfusion from experimental hemothorax. One fourth of the blood volume was bled into the pleural space, drained, and autotransfused. The hemothorax blood showed: very prolonged PT and PTT; very low platelets and fibrinogen; midly elevated FDP; very low coagulation factors VIII, and V; reduced XII, prothrombin, X, XI, and VII. Partial clotting, mild fibrinolysis, and fibrin deposition over the pulmonary pleura seemed to cause incoagulability of hemothorax blood. Post autotransfusion arterial blood showed: normal PT and PTT; 25% decrease in platelets, and 31% decrease in fibrinogen from baseline values. There was also an overall 20% reduction of fibrinogen from baseline values. There was also an overall 20% reduction of all clotting factors, but their levels remained above 50% activity. It was concluded that autotransfusion from a hemothorax of 25% the blood volume in dogs causes a mild loss of hemostatic components, but does not significantly compromise the clotting mechanism.

Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, “early group,” were operated upon within 12 hours from the onset of their symptoms and five, “late group,” were operated upon between 20-76 hours (average 41) after rupture. All four patients in the “early group” had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the “late group” one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the “late group” were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.

During a 3-year period, 45 patients with esophageal carcinoma (18 of the lower and 27 of the middle third) underwent esophagectomy and esophagogastrostomy. All patients were considered to be in Stage I and Stage II preoperatively, but at the time of operation, 66% were found to have Stage III disease. All patients underwent mobilization of the stomach through a laparotomy, and resection of the esophagus and reconstruction of the continuity of the gastrointestinal tract through a separate right lateral thoracotomy incision. Following operation, 22 patients (10, Stage I and II and 12, Stage III) received no radiotherapy and 23 patients (5, Stage I and II and 18, Stage III) received radiotherapy. Two patients died in the immediate postoperative period, for a surgical mortality of 4.8%. Because of the acceptable survival and enhancement of quality of life, esophagectomy and esophagogastrostomy should be offered not only to Stage I and II patients with esophageal carcinoma but also to selected patients with Stage III disease and those with lower and middle third esophageal lesions.

The management of penetrating wounds of the heart has been controversial. During the last 10 years we have used 3 different therapeutic approaches for the treatment of these wounds and the obtained results comprise this report. From 1964 to 1974 we treated 102 patients, four of whom expired immediately after their arrival to the clinic. The remaining 98 patients were divided into five groups according to their clinical presentation and treatment. Group I, 17 patients (14 with stab and 3 with bullet wound) seen with cardiac tamponade from 1964 to 1967 were treated first with pericardiocentesis and then were operated upon if pericardiocentesis yielded no results or if cardiac tamponade recurred. Fourteen patients recovered and three died, with an overall mortality of 17.5% Group II, 34 patients (23 with stab and 11 with bullet wound) were seen with cardiac tamponade from 1968 to 1971. The patients with stab wound were managed the same as group I patients and those with bullet wound were operated upon immediately. Twenty-nine recovered and 5 died, with an overall mortality of 14.7%. Group III, 20 patients (12 with stab and 8 with bullet wound) were seen with cardiac tamponade from 1972 to 1974. All of them were operated upon immediately and pericardiocentesis was used in this group only to provide time for a safe operation. Nineteen recovered and one died, with an overall mortality of 5%. Group IV, 20 patients (5 with stab and 15 with bullet wound) with massive bleeding, were operated upon immediately. Ten (4 out of the 5 with stab and 6 out of the 15 with bullet wound) recovered, with a mortality rate of 50%. Group V, seven patients were seen throughout the study period without bleeding or cardiac tamponade. Some of them were operated upon electively and others are being followed and all have done well. This study suggests (1) that patients with penetrating wound of the heart and cardiac tamponade or bleeding will derive better results if they are operated upon as soon as possible and if pericardiocentesis is used to provide time for a safe operation and (2) that those with other manifestations should be evaluated and if their lesion is significant, they should be operated upon electively.

The case history of a 30-year-old man with severe mitral and aortic stenosis and slight aortic regurgitation who underwent replacement of both valves is presented. At the initial surgical procedure, because of the small-size annuli, a small Beall mitral prosthesis and a No. 19 Bjork-Shiley aortic prosthesis were used. The subsequent recurrence of severe symptoms and findings of an 80 mm. Hg gradient across the Bjork-Shiley aortic valve led to repeat exploration and corrective surgery. The operative procedure to relieve left ventricular outflow obstruction is described. It is felt that this procedure can be used not only for the relief of severe aortic annular stenosis but also for other forms of severe left ventricular outflow tract obstruction such as idiopathic hypertrophic subaortic stenosis and particularly in the patients who have experienced poor results with one of the known surgical procedures for this clinical entity.

The term "great arteries" refers to the major intrathoracic arterial structures and includes the aorta and its major branches, the innominate, left common carotid, and left subclavian arteries; and the pulmonary artery trunk with its two branches. The gross surgical anatomy of these arteries, their main embryologic malformations, and the best possible surgical approaches to them are reviewed.

In general, appropriate use of tube thoracostomy results in complete drainage of the collected air and fluid in the pleural space and allows full expansion and occupation of the entire pleural space by the lung, thus protecting the lung and pleural space from subsequent complications. In addition, the drainage of the pleural space with a tube thoracostomy allows more accurate monitoring of the rate of accumulation of air and blood in the pleural space. Thus, it provides valuable information for the subsequent management of some patients, such as those with traumatic hemothorax.

The effects of cross-clamping the descending aorta for 90 minutes were studied in 45 dogs divided into four groups. In all animals the left atrial, central venous, carotid artery, and femoral artery pressures, urine output, and thermal dilution cardiac output were constantly recorded, and blood samples were drawn every 30 minutes for the determination of epinephrine, norepinephrine, and plasma renin activity. During aortic cross-clamping, Group I dogs (n = 15) were placed on femoral vein-femoral artery cardiopulmonary bypass and Group II dogs (n = 15) were given intravenous sodium nitroprusside; in Group III dogs (n = 5) an external shunt from the ascending aorta to femoral artery was used, and in Group IV dogs (n = 10) no adjunct was employed. During aortic cross-clamping, the following hemodynamic parameters significantly increased: in Groups II, III, and IV, carotid artery pressure; in Group III, cardiac index; and in Groups III and IV, cardiac stroke work. While the descending aorta was cross-clamped, mean femoral artery pressure decreased in all groups: 47.5% in Group I, 79% in Groups II and IV, and 44.8% in Group III. During aortic cross-clamping, plasma epinephrine and norepinephrine levels markedly increased in Group IV, and plasma renin significantly increased in all groups. The hemodynamic findings on the fifth and seventh postoperative days were similar to those before cross-clamping of the aorta in all groups. There was no paraplegia in Groups I and III dogs, but 60% of group IV and 40% of Group II dogs were paralyzed.

A high index of suspicion of the presence of post-traumatic residual sequelae usually leads to early diagnosis of these lesions. The type and site of the traumatic impact and the presenting symptoms and signs frequently suggest the type of problem. The use of the appropriate diagnostic tests and the institution of suitable therapy will protect the patients from more serious subsequent complications and frequently will result in the restoration of their health to its preinjury status.

Systemic arterial air embolization following penetrating injury of the lung has been previously reported. As we had not recognized this complication clinically, we studied this problem in 11 healthy dogs. In each of them, a mock circulation was created by establishing two central external arteriovenous shunts with transparent plastic tubing in which air bubbles could be seen. Also, a Doppler flow detector capable of sensing intravascular air was attached to a carotid artery. Systemic arterial and pulmonary capillary wedge pressures were recorded, and a standard lung laceration was produced. In 5 of the dogs, in addition, tension pneumothorax was induced by injection of air into the pleural space. The dogs were monitored for intravascular air for 15 minutes before and after the induction of hypotension by withdrawal of blood from the shunts. In no animal was air seen in the shunts, nor was there the characteristic deflection of the Doppler seen with intravascular air, although the preparation was sensitive to the detection of as little as 1 ml. of air injected into the left atrium. These observations lead us to question whether arterial air embolism occurs with penetrating pulmonary trauma in man.

Two cases of symptomatic myocardial bridging of the left anterior descending coronary artery requiring surgery for relief are reported. One patient experienced the sudden onset of ventricular fibrillation, had evolving electrocardiographic evidence of an anterior myocardial infarction and subsequently continued to have chest pain. The second patient presented with a long-standing history of repeated episodes of paroxysmal supraventricular tachycardia accompanied by chest pain. During one such episode he had prolonged chest pain and a syncopal episode, but evidence for myocardial necrosis did not develop. On coronary arteriography the only abnormality noted was severe systolic narrowing of the left anterior descending coronary artery in the first patient and similar narrowing of both this artery and a large diagonal vessel in the second. Each patient successfully underwent coronary arterial debridging and, in addition, had a bypass graft to the distal left anterior descending artery. Both patients are In stable condition and show considerable improvement 46 and 9 months, respectively, after operation. Although in most cases of bridging detected on coronary arteriography there is no evidence of ischemic heart disease, the occurrence of symptoms with tachycardia and, in particular, the unusual length of the bridged segments and the severity of systolic narrowing may have played a significant role in the development of disease in these two patients.

The clinical course of five patients with acute endocarditis resulting in aortic regurgitation and aortico-left ventricular discontinuity was reviewed. All five patients were operated upon less than 6 weeks after the onset of the antibiotic therapy. Aortic valve replacement and repair of the left ventricular discontinuity were done successfully in all five patients. The repair was accomplished in two patients primarily, with interrupted horizontal pledget-supported sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining three patients, the repair was performed with the interposition of a Dacron patch between the left ventricle and the aorta, and the valve prosthesis was then sutured to the graft and to the remaining native aortic anulus. The latter technique has many attractive features for the repair of left ventricular discontinuity when there exists a large gap between the aorta and left ventricle.

Eventration of the diaphragm, although a relatively rare clinical entity, should be considered in all patients with respiratory distress during the neonatal period, particularly in babies born after difficult delivery by breech presentation or forceps extraction. The diagnosis can be made in the majority of spontaneously breathing patients by chest roentgenography or by fluoroscopy. The treatment initially should be supportive, including assisted ventilation if needed. If the infant cannot be weaned off the respirator after a week to ten days of respiratory support, surgical correction of the elevated diaphragm should be carried out. The results of surgical treatment in these desperately sick infants is usually most gratifying.

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eighty-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.

An unusual case of acute respiratory obstruction caused by multicentric granular cell tumors of the laryngotracheobronchial tree is presented. The patient also had granular cell tumors in the tongue, vulva, and chest wall. Multiplicity of the lesions in the left lung and recurrent episodes of intercurrent pulmonary infections necessitated left pneumonectomy. The extreme rarity of such a clinical circumstance is illustrated by a review of the literature. Salient clinical and pathological features of the tumor are briefly discussed.

During the past 10 years, 18 patients with gunshot wounds of the trachea, 13 of the cervical and five of the intrathoracic trachea, were admitted to Grady Memorial Hospital. There were 16 male and two female subjects with ages ranging from 15 to 60 years. In addition to the tracheal injuries, four patients had injuries to major vessels and six patients had esophageal injury, four of the cervical and two of the intrathoracic esophagus. Three patients with esophageal injury had tracheoesophageal fistula. The diagnosis of tracheal injury was suspected because of the site of the wound and the clinical manifestations; hemoptysis, air escaping from the cutaneous wound, subcutaneous emphysema, and so on. This was confirmed by tracheoscopy in nine patients, by exploratory operation in eight patients, and when the bullet was expectorated in one patient. The treatment of the tracheal injury was dependent upon the magnitude of the tracheal wound and the presence of injury to adjacent organs. Seven patients underwent primary repair of the tracheal wound, two had primary repair with reinforcement of the suture line with tissue flap, three had repair of the tracheal wound and tracheostomy, one underwent construction of a tracheocutaneous stoma, two had temporary orotracheal intubation for 24 to 48 hours, and three patients were observed. Seventeen patients recovered from the injuries and one patient, with extensive tracheal and esophageal injury and extensive mediastinal infection, died of respiratory insufficiency. This study suggests that the management of bullet wounds of the trachea should be individualized according to the magnitude of the wound and the presence of other organ injury. Primary repair without concomitant tracheostomy can be accomplished with gratifying results in the majority of civilian victims.

The function of the distal esophageal segment, after incision, primary repair, and enforcement with a Belsey-type fundoplication, was studied in 32 opossums divided into four groups. In groups I-A and I-B, the fundoplicated esophageal segment was left above the diaphragm and in groups II-A and II-B, it was secured below the diaphragm. The pre- and postoperative esophageal sphincteric function was studied by manometry, acid reflux testing, and cineesophagography. The preoperative results were not significantly different from those of 2 months postoperative.

The cases of 7 patients with aortic rupture treated at Grady Memorial Hospital during the last four years and all the reports in the English literature of patients with aortic rupture who were treated surgically within the first three postinjury weeks were reviewed. This combined experience revealed the frequent occurrence of a triad which appears to be of great value in the early diagnosis of rupture of the aorta. This triad consists of (1) increased pulse amplitude and blood pressure in the upper extremities, (2) decreased pulse amplitude and blood pressure of the lower extremities, and (3) roentgenographic evidence of widening of the mediastinum. Aortography is the only confirmatory diagnostic test and should be done as soon as the diagnosis of aortic rupture is suspected. Repair of the ruptured aorta should be performed as soon as possible.

1. The function of the transplanted ileocecal valve in the region of the cardioesophageal sphincter was evaluated in experimental animals. 2. The ileocecal valve at this location appeared to be fully as effective in preventing regurgitation of gastric contents as was the normal cardioesophageal sphincter. 3. Whether the observed findings were the result solely of the valvular function of the transplanted ileocecal segment or of the valvular and the sphincteric action cannot be defined from presently available data.

Mitral ball valve prosthesis malfunction is uncommon but may be associated with serious morbidity and may be fatal. The diagnosis may be suspected clinically and confirmed phonocardiographically and echocardiographically. It would appear reasonable to perform these studies serially at intervals of 3 to 6 months in patients with a mitral ball valve prosthesis, and whenever symptoms suggestive of peripheral embolization or of the onset or worsening of congestive heart failure are present.