Biomedical subjects
Publications and source records attributed to L E Samuels.
Air bags have been shown to decrease mortality from automobile accidents. Herein is a unique case of bilateral pneumothorax following deployment and rupture of an air bag with no other associated chest trauma. One may posit that rupture of the air bag allowed high-pressure gases to be expelled into the patient's lungs resulting in explosive barotrauma.
Acute myocardial infarction during pregnancy and in the puerperium is a rare event: the incidence ranges from 1 per 10,000 to 1 per 30,000 deliveries. Although the etiology is unknown, the pathology may involve thrombosis, spasm, or dissection of the coronary artery. We present the case of a 34-year-old white woman who presented to our institution in cardiogenic shock after an acute myocardial infarction 2 weeks postpartum. This case reinforces the concept that postpartum coronary artery dissection is a fatal disorder. We were able to successfully support the myocardium and the end-organs with a ventricular assist device. We performed concomitant coronary artery bypass grafting in an attempt to salvage the remaining myocardium. Management with emergency coronary revascularization and ventricular assist device support is described.
The importance of recognizing congenitally absent left pericardium in the setting of acquired cardiovascular disease was recently appreciated during a case of coronary artery bypass grafting. An associated defect in the left hemidiaphragm and an abnormal location of the left phrenic nerve were found. Careful dissection of the phrenic nerve from the surface of the heart and closure of the diaphragmatic defect were necessary to avoid injury to the former and prevent hernia through the latter structure. Absent left pericardium discovered during cardiac surgery requires attention to the location of the left phrenic nerve and recognition of associated defects in the diaphragm.
BACKGROUND: The implantable cardiac defibrillator (ICD) was introduced clinically in 1980 for the management of ventricular arrhythmias. METHODS: From January 31, 1989, through May 29, 1996, 329 ICD devices were implanted at Allegheny University Hospital, Hahnemann Division, Philadelphia, Pennsylvania. All device-related infections were examined. RESULTS: Fifteen patients (5%) experienced infection of the generator component of the ICD. There were 14 male and 1 female patients with a mean age of 62 years (range, 38 to 79 years). All infections involved the generator with or without other component involvement. Complete removal of the system was performed in 7 patients, partial removal in 5, and the entire system was left intact in 3. In 4 patients (27%), further procedures were performed to remove additional infection. Three patients (20%) died during the hospital stay. CONCLUSIONS: Infection of ICD devices is a devastating event. We favor complete removal of the ICD generator and all the components when possible. Partial removal of the ICD unit (ie, generator only) is reserved for patients in whom the risk of complete removal is too high and infection is confined to the generator only.
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Sternal wound infection with atypical mycobacteria following open heart surgery is a rare occurrence. Previous reports have described infection by Mycobacterium fortuitum, an acid-fast bacillus and member of a larger family of rapidly growing mycobacteria. The source and mode of transmission have not been identified. Surgical debridement and the combination of aminoglycosides and quinolones have been shown to be effective methods of treatment. More recently, clarithromycin has been shown to be the drug of choice against rapidly growing mycobacteria. We describe a 49-year-old woman who underwent infundibular stenosis repair and in whom M fortuitum sternal osteomyelitis developed. Total sternectomy, muscle flap reconstruction, and antibiotic treatment successfully eradicated the infection.
BACKGROUND: Use of the left internal thoracic artery as a bypass graft has been shown to result in better long-term patency and improved survival. In elderly patients, the internal thoracic artery has been used less often for coronary artery bypass grafts because of the belief that greater morbidity and mortality are associated with this procedure. This study was undertaken to test this premise in the octogenarian population. METHODS: Over an 8-year period, 474 consecutive patients 80 years of age and greater had coronary artery bypass grafting. The left internal thoracic artery was used in 188 patients (39.7%) (group 1) and saphenous vein grafts only (group 2), in 286 (60.3%). The mean age was 82.6 years (range, 80 to 95 years). There were 312 men (65.8%) and 162 women (34.2%). RESULTS: Use of the internal thoracic artery as a graft has risen steadily each year, as has the number of patients who are octogenarians. The hospital mortality rate was 7.8%. Patients in group 1 had a mortality rate of 9.0% and patients in group 2, a mortality rate of 7.0%. The mortality rate among survivors at 1 year was 6.7%. Long-term survival was significantly greater in group 1. CONCLUSIONS: On the basis of this study, we conclude that the internal thoracic artery is the bypass graft of choice, especially in regard to long-term mortality, and should not be denied to this high-risk group.
A 68-year-old white man with lung carcinoma underwent removal of the lower lobe of the left lung. Four months later, the patient developed a hemothorax requiring exploratory thoracotomy, evacuation of hemothorax, and decortication. Postoperatively a persistent airspace with prolonged air leak developed. Bronchoscopic application of fibrin glue failed to seal the leak. Percutaneous transthoracic application of fibrin glue with CT scan guidance partially obliterated the space and completely sealed the leak. We describe this simple and effective technique for management of this special problem.
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A retrospective review of 756 blunt trauma cases at a level I trauma center was conducted to determine the role of thoracolumbar (TL) spine roentgenograms in the management of asymptomatic patients. Thoracolumbar spine films were obtained on 106 patients. The charts from 99 patients were available for thorough review. Fifty-five patients had negative clinical evidence of TL spine injury; all of these (100%) had negative radiographic evidence of fracture or dislocation on the TL spine films. Twenty-four patients had positive clinical evidence of TL spine injury; 14 (58%) had corresponding radiographic evidence of TL spine injury. Of the 20 patients in whom the clinical examination was equivocal, one (5%) had radiographic evidence of TL spine injury. We conclude that physical examination is reliable for assessing the TL spine, and that in the absence of clinical evidence of injury, TL spine films are unnecessary. In patients with equivocal examinations, TL spine films should be obtained because 7% (one of 15) of the injuries were identified in this group.
Vascular injury is not uncommon in cases of major pelvic trauma. Venous injury is by far the most common associated problem and may lead to exsanguinating hemorrhage. Arterial injury is less common, but certainly not without associated morbidity and mortality. It can lead to persistent bleeding after fixation and stabilization of the pelvic girdle, and occlusion of major pelvic arteries can cause limb ischemia and limb loss. The potential problems with revascularizing the ischemic extremity are (1) other life-threatening injuries that may be present and (2) a retroperitoneal hematoma that can interfere with an anatomic approach. Our solution to the latter problem, as presented here, is placement of a cross-femoral bypass graft, which rapidly and safely restores blood flow in the presence of pelvic fracture and an occluded external iliac artery. The pelvic hematoma is avoided, thereby restoring circulation more quickly, with less blood loss and greater ease.
Parathyroid carcinoma is a rare entity, representing less than 1% to 5% of patients with primary hyperparathyroidism. Parathyroid carcinomas are often symptomatic, have markedly elevated calcium levels, have palpable masses, are equally distributed between the sexes, and present 10 years younger than their benign counterparts. Parathyroid carcinoma is often undiagnosed preoperatively, suspected intraoperatively, and only confirmed postoperatively. When diagnosed, the treatment of choice is an en-bloc resection of the tumor.
OBJECTIVES AND BACKGROUND: The purpose of this study was to document our initial experience with patients 90 years of age and older and to determine whether cardiac surgery is justified in this age group. Cardiac surgery in octogenarians has proven to be a successful and worthwhile procedure. A small group of nonagenarians with severe coronary artery disease (CAD) and aortic valve disease refractory to medical therapy have been considered for surgery. METHODS: Fourteen patients aged 90 or more underwent cardiac surgery for symptomatic CAD or aortic valvular disease refractory to medical therapy. Eight patients underwent isolated coronary artery bypass grafting (CABG) and six patients underwent aortic valve replacement (AVR). All patients were in NYHA Class IV preoperatively. RESULTS: Hospital mortality occurred in one patient (7%). Hospital morbidity occurred in 10 patients (71%) and included 7 cardiac, 5 neurological, 1 gastrointestinal, 1 infectious, and 1 pulmonary event. All survivors left the hospital symptomatically improved. The mean length of stay was 26 days. Four CABG patients went on to die at a mean of 2 years and 2 months, and 3 remain alive at a mean of 2 years and 4 months. Three AVR patients expired at a mean of 3 years and 4 months, and 3 remain alive at 4 years and 1 month. CONCLUSIONS: Cardiac surgery in carefully selected nonagenarians is justified and can be performed with acceptable results.
BACKGROUND AND AIMS: Chronic renal failure (CRF) is known to increase the morbidity and mortality in patients undergoing cardiac operations. Successful outcome of coronary artery bypass grafting (CABG) in some patients with CRF has been reported, but remains controversial. METHODS: Forty-four patients with CRF who underwent CABG were examined. Two groups were analyzed. Group I consisted of 13 patients with end-stage renal disease on hemodialysis. Group II consisted of 31 patients with a creatinine > or = 1.6 gm/dL for a minimum of 6 months, but were not on dialysis. There were 36 male and 8 female patients, with a mean age of 71 years. RESULTS: The hospital mortality was 10 patients (23%) with 4 (31%) hospital deaths in Group I, and 6 (19%) in Group II. There was major morbidity in 35 (80%) patients. In Group II there were 8 (26%) patients who required permanent postoperative dialysis. A control group of 547 patients 70 years of age who underwent CABG had 30 hospital mortalities (5%) and 75 morbidities (13%). The average length of stay was 27 days. Fifteen patients died at a mean of 34 months after being discharged from the hospital. Nineteen of the original 44 patients remain alive at a mean of 32 months. The total mortality at 6 years and 4 months was 57%. CONCLUSIONS: Older and sicker patients with CRF who undergo CABG are at an exceptionally high risk for mortality and morbidity. For CRF patients not on dialysis with a creatinine 2.5 gm/dL, there is a strong likelihood of permanent postoperative dialysis. Long-term follow-up shows survival to be well below their non-CRF counterparts.
BACKGROUND AND AIM: Coronary artery disease (CAD) and coronary artery bypass grafting (CABG) in young patients are different than their older counterparts. The purpose of this study is to more fully define the issues of CABG in patients in their third decade of life. METHODS: The medical records from all patients under forty years of age undergoing CABG at Allegheny University Hospital, Hahnemann Division, Philadelphia, PA from July 1990 to June 1995 were examined. Surgical outcome, psychosocial, and sexual issues were examined. Lipid analyses were compared perioperatively. RESULTS: There were 43 male and 9 female patients. The mean age was 35 years (23 to 39 years). Risk factors included 43 (83%) patients with a history of smoking, 34 (65%) with familial hypercholesterolemia, 25 (48%) with a family history of CAD, 23 (44%) with hypertension, and 11 (21%) with diabetes. The mean preoperative serum cholesterol was 241 mg/dL. There were no hospital mortalities. Morbidities were found in 18 (35%) patients, including 9 (17%) cardiac, 5 (10%) pulmonary, 3 (6%) infectious, and 1 (2%) renal. In follow-up, three cardiac-related mortalities occurred within five years of surgery. Sixteen patients were readmitted to a hospital for cardiac related causes. Thirty-two (62%) patients failed to return to work, twenty-five (48%) failed to engage in regular exercise, and twenty-four resumed smoking. Psychosocial changes were found postoperatively in thirty (58%) patients. Eight (15%) patients admitted to sexual changes following surgery. Postoperative lipid profiles were minimally altered from preoperative values. CONCLUSIONS: Surgical revascularization is successful in alleviating symptoms with minimal risk. Postoperatively, a number of cardiac related events occurred. A significant number of patients resume smoking, fail to engage in regular exercise, fail to resume work, and fail to take prescribed lipid-lowering agents. Psychosocial and sexual dysfunctions are prominent.
BACKGROUND/AIM: The traditional approach to postcardiotomy shock includes inotropic support followed by the application of an intra-aortic balloon pump (IABP). Consideration toward insertion of a ventricular assist device (VAD) becomes necessary when these maneuvers fail to restore hemodynamic stability. The definition of maximal inotropic support, however, is lacking such that a standard formula for VAD insertion remains problematic. The purpose of this paper is to define the pharmacological thresholds for VAD implantation in the setting of postcardiotomy cardiogenic shock. METHODS: The medical records of all adult open-heart operations performed at Hahnemann University Hospital, Philadelphia, PA, from 1 July 1996 through 1 July 1999 were reviewed. Specific data were collected on the hemodynamics and inotrope levels upon separation from cardiopulmonary bypass (CPB). The hospital course was reviewed with attention toward documenting hospital mortality. Cardiogenic shock was defined as systolic blood pressure (SBP) < 100 mmHg, mean pulmonary artery blood pressure (mPAP) > 25 mmHg, central venous pressure (CVP) > 15 mmHg, and cardiac index (CI) < 2.0 L/min/per m2. Inotrope dosages were defined as low, moderate, and high according to assigned values. A formula for VAD insertion was established if cardiogenic shock parameters were present in the setting of two or more high dose inotropes. Early VAD insertion was defined as implantation within three hours of the first attempt to wean from CPB. The VAD recipients were divided into two groups. Group A were VADs placed in conjunction with the formula. Group B was VADs placed in violation (excess) of the formula. The results of these two groups were compared. [table: see text] RESULTS: From 1 July 1996 to 1 July 1999, there were 3462 adult open-heart operations performed at Hahnemann University Hospital, Philadelphia, Pa. The hospital mortality for patients successfully separating from CPB on no inotropes, low-dose, moderate-dose, one high-dose, two high-dose, and three high-dose inotropes were approximately 2.0%, 3.0%, 7.5%, 21%, 42%, and 80% respectively. During this time there were 29 patients supported with the Abiomed BVS (Danvers, Mass) system for postcardiotomy cardiogenic shock. For the entire group of VAD recipients, there were 18 (62%) who were successfully weaned and 8 (28%) who were discharged from the hospital. For the 20 VAD recipients in group A, there were 16 (80%) who were successfully weaned and 8 (40%) who were discharged from the hospital. For the nine VAD recipients in group B, there were two (22%) who were successfully weaned and zero (0%) who were discharged from the hospital. Multiple organ system failure occurred in three (15%) in group A versus seven (78%) in group B patients, respectively. Early VAD insertion was accomplished in 17 (85%) group A patients and 2 (22%) group B patients. CONCLUSIONS: Hospital mortality correlates with the number and level of inotropic support necessary to separate from CPB following adult open heart surgery. The application of a standard pharmacological formula together with hemodynamic criteria for VAD insertion after postcardiotomy cardiogenic shock results in earlier insertion, lower incidence of postoperative MOSF, and improved wean and discharge rates.