Fibrovascular lipoma of the cerebellopontine angle mimicking trigeminal neuralgia.
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Adult↗
Biomedical subjects
A G Marrangoni
Publications and source records attributed to A G Marrangoni.
Right ventricular outflow obstruction with intact ventricular septum in adults.
Cardiothoracic surgeons whose practice is limited to adults rarely see patients with right ventricular outflow obstruction and an intact ventricular septum. Of more than 10,000 open-heart procedures performed at our institution from 1983 to 1993 (in patients 18 to 75 years old), only 5 procedures were for correction of this problem. Both the pulmonary valve and the subvalvular area were abnormal in these 5 patients, and 4 of the 5 had subvalvular stenosis. The gradient across the right ventricular outflow tract was measured by cardiac catheterization before repair in all patients and averaged 118 mmHg. Various surgical approaches were used for repair. In the 2 patients whose pressures were measured postoperatively, the gradients were 25 mmHg and 45 mmHg, respectively. There were no operative deaths. At follow-up (range, 2 months to 5 years after surgery), all patients were in New York Heart Association functional class I and all had murmurs. Those who underwent echocardiography were found to have minimal gradients across the right ventricular outflow tract.
Adult↗
Recurrent ischemic heart disease: the effect of advancing age.
Four thousand four hundred and thirty open heart operations were performed at Mercy Hospital of Pittsburgh from January 1, 1988, to June 30, 1992. During that period, 168 patients were evaluated for recurrent ischemic heart disease after prior coronary artery revascularization. Forty-four were treated non operatively, the mode of therapy being transluminal angioplasty or medical management. The remaining 124 patients underwent repeat coronary revascularization. An attempt was made to define the impact of advancing age on the magnitude of risk factors, morbidity, and mortality. Advancing age is not a contraindication to repeat coronary artery revascularization. The average interval between the initial operation and the need for repeat revascularization is eight years. Younger patients have progression of their coronary artery disease, but progression of the arteriosclerotic process is in their extracranial cerebral arteries, renal arteries, and aortic segments as well as the coronary arteries. The utilization of tobacco, recent myocardial infarction, diabetes mellitus, and elevation of cholesterol are strong indicators for recurrent disease and add to the risk of repeat surgical intervention.
Age Distribution↗
Advantages of laparoscopic cholecystectomy in the elderly and in patients with high ASA classifications.
Two hundred and thirty-three patients underwent cholecystectomy at Mercy Hospital of Pittsburgh during the popularization of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was performed in 167 of these patients while the remaining 66 patients had an open cholecystectomy. A statistically significant increase in the incidence of morbidity was observed with advancing age (p < 0.001, odds ratio 2.33) as well as in patients with higher ASA classes (p < 0.001, odds ratio 2.31). Overall, laparoscopic cholecystectomy was associated with a markedly lower incidence of morbidity than the open procedure (7% versus 47%, p < 0.001). A multiple logistic regression model was applied to the study population due to the fact that those patients who underwent open cholecystectomy tended to be older individuals with more clinically significant associated medical conditions than those individuals who underwent the laparoscopic procedure. When the logistic regression model was applied to control for the differences in age, associated illnesses, and ASA class between the two groups; a seven fold increase in the risk of morbidity was found in the open group as compared to the laparoscopic group (p < 0.001, odds ratio 7.31). These findings favor the use of laparoscopic cholecystectomy over open cholecystectomy in all eligible patients, especially elderly patients and those patients in higher ASA classes.
Adolescent↗
Normothermic retrograde continuous cardioplegia for myocardial protection during cardiopulmonary bypass. A modified technique.
Normothermic retrograde continuous cardioplegia is a revolutionary development for myocardial preservation in cardiac surgery. Despite excellent reports regarding this technique, the surgical community has expressed concern over technical problems encountered. The method of normothermic retrograde continuous cardioplegia in current use requires both large total crystalloid volumes and large potassium loads to deliver adequate cardioplegia. We have developed a technique that eliminates these problems. The heart is stopped by an initial infusion of normothermic cardioplegic solution through a coronary sinus catheter. The infusate is then converted to normothermic pump blood. Small boluses of potassium chloride are added intermittently to maintain cardiac arrest. We applied this technique to 35 patients undergoing cardiac valve surgery. The average volume of crystalloid cardioplegia required was 125 mL (range, 40 to 155 mL), and the average total potassium load was 52 mEq (range, 2 to 100 mEq). Clinically significant sequelae were noted in 4 patients (11%), and 1 (3%) died of pneumonia on the 28th postoperative day. The method we describe is a safe and effective alternative to the current technique of normothermic retrograde continuous cardioplegia and offers both physiologic and technical advantages to patients undergoing cardiac valve procedures.
Aged↗
Vascular grafts in microvascular surgery. An experimental study.
The patency of microvascular grafts depends on the luminal diameter, which is determined by the amount of fibrin and platelets deposited on the intraluminal surface and the anastomotic site, and the extent of pseudointimal formation. An experimental microvascular model in rats has been developed in our laboratory using Indium-111-labeled platelets to measure the amount of deposition on grafts inserted into the infrarenal aorta. This study was designed to assess the patency rates in these grafts and the pathologic maturation as determined by light and electron microscopy. Our study suggests that substantial patency rates can be achieved in aspirin-treated rats, although there was little influence on the pathologic maturation. Indium-111 oxine-labeled platelets can be used to document platelet aggregation, and the technique can be a valuable adjunct in the study of microvascular grafts.
Animals↗
Contraindications for percutaneous transluminal coronary angioplasty in treatment of unstable angina pectoris.
In recent years, the indications for percutaneous transluminal coronary angioplasty have expanded to include multivessel disease, unstable angina pectoris, stenosis of coronary bypass grafts, and recent total coronary occlusion. To evaluate our experience in using percutaneous transluminal coronary angioplasty to treat unstable angina, we reviewed the records of the patients who underwent this procedure at our hospital between January 1983 and December 1986. Of the 689 patients who underwent balloon angioplasty during the study period, 454 had stable angina and 235 had unstable angina; of the latter group, 34 (14.5%) required emergency coronary artery bypass grafting after balloon angioplasty failed. This outcome was associated with 2 risk factors: previous myocardial infarction and triple-vessel disease. Our data suggest that, in cases of unstable angina pectoris, percutaneous transluminal coronary angioplasty should be reserved for patients with single-vessel disease and no evidence of previous myocardial infarction. They also lend credence to the conclusion that the disease process in unstable angina is different from that in stable angina, and that therapy should be directed towards reducing platelet aggregation and correcting global ischemia, rather than towards balloon angioplasty of "culprit lesions."
Journal Article↗
Management of blunt injury to the internal carotid artery.
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Carotid Artery Injuries↗
Massive chylopericardium after coronary artery bypass surgery.
Massive isolated chylopericardium is a rare postoperative complication of coronary artery bypass surgery. In the following case, massive chylopericardium developed after a coronary artery bypass procedure in which the left internal mammary artery was used for revascularization. The chylopericardium resulted from direct trauma to the thoracic duct during mobilization of the left internal mammary artery to its origin at the subclavian artery. With adequate drainage, the problem was resolved. In cases in which drainage persists, ligation of the thoracic duct may be necessary.
Journal Article↗
Blunt rupture of both atrioventricular valves.
Younger patients are surviving extensive damage to the heart and supporting structures, often associated with multiple systems injuries. A 23-year-old patient who sustained blunt trauma to the chest resulting in a pericardial laceration, injury to tricuspid and mitral valves, myocardial contusion, and paresis of the left phrenic nerve is reported. Porcine bioprosthetic valve replacement of both atrioventricular valves was necessary. Prompt diagnosis and aggressive intervention of such injuries can lead to successful repair of complex cardiac trauma.
Adult↗
Myocardial revascularization combined with aortic valve replacement.
We reviewed 50 consecutive patients who had undergone complete myocardial revascularization combined with aortic valve replacement during a 5-year interval ending in June 1983. A cold blood cardioplegia technique, utilizing not only the native circulation but also the vein conduits, was used. All patients had greater than 70% stenoses of the major coronary arterial system. No patient had valve replacement alone, and no patient was refused operation. The mean number of arteries grafted was 2.3. There were two hospital deaths. One patient had evidence of perioperative myocardial infarction. There were two late deaths and one non-fatal myocardial infarction during the follow-up period, which averaged 16 months. The technique of hypothermic blood cardioplegia used provides a uniform distribution for myocardial protection, especially in the hypertrophied ventricle, and is superior to previously employed methods. This study indicates that myocardial revascularization combined with aortic valve replacement should be performed in patients with coexisting aortic valvular and coronary disease.
Journal Article↗
Traumatic aortic insufficiency after blunt chest trauma.
Traumatic aortic insufficiency is an uncommon result of blunt trauma. The typical clinical features include trauma, followed by pain (and often syncope), a musical aortic diastolic murmur, and progressive cardiac decompensation. Shock is an unusual manifestation of traumatic aortic insufficiency. In this report, a patient is described who experienced shock, a widened mediastinum, and failure to respond to fluid resuscitation after cardiac injury in an automobile accident. Emergency surgery was performed and an intimal tear was repaired. A #25 Carpentier-Edwards bioprosthesis was used to replace the aortic valve, which was avulsed from the commissure of the right and left cusps. Since aortic valve replacement offers an excellent prognosis, it should be done at the first signs of cardiac decompensation.
Journal Article↗
Revascularization of the circumflex coronary artery in the atrioventricular groove.
Complete myocardial revascularization entails the grafting of all vessels of adequate size demonstrating occlusive arteriosclerotic vascular disease. Revascularization of the circumflex coronary artery in the atrioventricular groove has been a major surgical challenge because of the difficulty of exposing it. We discuss here our operative technique in 12 consecutive patients requiring revascularization of that segment of the circumflex coronary artery. Eleven grafts studied in the postoperative period were found to be patent, and the clinical course of the remaining patient and direct observations, including enzyme studies and periodic stress testing, have not shown any evidence of graft failure.
Adult↗
Etiology of the obstructive pattern in hepatobiliary imaging.
The records of all patients undergoing hepatobiliary imaging at our hospital from January 1980 to March 1983 were reviewed and 29 scans met the criteria for a pattern consistent with complete biliary tract obstruction. Biliary tract obstruction (due to choledocholithiasis, primary or secondary carcinoma involving the common bile duct, and pancreatitis) was documented in 24 of these patients. However, the remaining five patients had a patent common bile duct, and the etiologic factor was intrahepatic cholestasis secondary to sepsis in four and peritonitis in one. A classification of altered biliary dynamics in hepatobiliary imaging, which is based on the classification of jaundice, is proposed.
Animals↗
Endotoxic shock and its effects on hepatobiliary scanning in dogs.
Hepatobiliary scans were obtained with Tc-99m-disofenin in 15 dogs. Of these, 5 served as controls, 5 were infused with E. coli endotoxin for 4 hours (endotoxic shock group), and 5 were bled to a mean pressure similar to that of the endotoxic shock group (hemorrhagic shock group). Scans of the controls and hemorrhagic shock group were identical. Scans of the endotoxic shock group were markedly abnormal, with a prolonged hepatic phase and little excretion of isotope into the biliary tract, a pattern characteristic of mechanical obstruction of the common bile duct. These results should alert the clinician to the potential danger of abnormal hepatobiliary scans in the septic patient.
Animals↗
Traumatic forequarter amputation.
Traumatic forequarter amputation is a rare and devastating injury in which the arm, scapula, clavicle, and pectoral muscles are avulsed from the body by a tremendous force. The case of a man who survived this injury is presented. Replantation at this level has not been successful: treatment recommended consists of control of hemorrhage, wound debridement, ligation of vessels and nerves, coverage of their exposed stumps with muscle, unless excess contamination is present; electrical or cosmetic prostheses can be fitted later.
Amputation, Traumatic↗
Multiple cardiac lesions from blunt trauma.
Blunt chest trauma may produce a variety of cardiac lesions, which may occur alone or in combination. A case with a ventricular septal defect, left ventricular aneurysm, and coronary arteriovenous fistula with an associated rupture of the thoracic aorta following blunt trauma is presented in order to demonstrate that multiple, life-threatening cardaic lesions may be managed successfully. Surgical repair 32 days postinjury with Teflon patch plus ligation of the fistula were followed by recovery in the patient presented.
Adolescent↗
Recurrent fibrovascular polyp of the esophagus.
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Esophageal Fistula↗