Faculty Bibliography

A 76-year-old woman presented with respiratory failure that was later determined to be a result of a right aortic arch with an aberrant left brachiocephalic artery. This vascular ring compressed the trachea, requiring operative intervention. A median sternotomy gave access for an aorta-to-left brachiocephalic artery bypass and division of the vascular ring. This is a unique case, because vascular rings rarely present in elderly patients with such acute life-threatening symptoms. To our knowledge, this is the oldest and heaviest patient ever reported with symptomatic presentation and one of only 4 patients over the age of 50. The current literature on vascular rings of the thoracic aorta in adults is reviewed.

We present the case of a 72-year-old woman who had an acute massive pulmonary embolism after abdominal surgery. The patient had undergone a right hemicolectomy and pancreaticoduodenectomy for locally invasive colonic adenocarcinoma. Six hours postoperatively, she required emergent intubation when she suddenly became cyanotic, severely hypotensive, and tachypneic, with an oxygen saturation of 50%. An acute massive pulmonary embolism was suspected, and an emergency transesophageal echocardiogram confirmed the diagnosis. On the basis of the patient's clinical condition and the echocardiographic findings, we performed an emergent pulmonary embolectomy, with the patient on cardiopulmonary bypass. We evacuated multiple large clots from both pulmonary arteries. The patient recovered and was discharged from the hospital 61 days postoperatively. Herein, we review the current literature on open surgical pulmonary embolectomy. This case supports the use of open pulmonary embolectomy for the treatment of hemodynamically unstable patients on the basis of clinical diagnosis. We discuss the role of emergent transesophageal echocardiography in the diagnosis and management of massive pulmonary embolism

We treated a 52-year-old man for a large pleural effusion that had occurred after he fell from a ladder. Upon discharge from the hospital, the patient collapsed and was nonresponsive and hypotensive. We suspected the cause to be pulmonary embolism. When it became evident that this patient would die without emergent intervention, he was taken to surgery. A massive clot was removed from the left pulmonary artery, and multiple smaller clots were removed from both pulmonary arteries. The patient recovered and was discharged from the hospital on the 11th postoperative day. To our knowledge, this is the 1st report of pulmonary embolectomy being performed on the basis of clinical diagnosis alone.

We present the case of a 57-year-old woman who had an intramural hematoma of the ascending aorta and aortic arch. After initial blood pressure control and imaging studies, the patient underwent limited surgical repair that consisted of ascending aortic replacement. One week postoperatively, the aortic arch hematoma progressed to a full dissection that extended into the proximal descending aorta. Emergent aortic arch replacement was required. Current world medical literature regarding thoracic aortic intramural hematoma is presented. This case supports the treatment of intramural hematomas of the ascending aorta and arch by surgical replacement of both segments with a Dacron graft, with the patient under deep hypothermic circulatory arrest.

OBJECTIVES: To differentiate surgical bleeding requiring re-exploration from postoperative coagulopathy and determine the differences in patient outcomes. METHODS: This was a retrospective chart review of 2,263 adult patients undergoing elective and emergency open heart procedures encompassing coronary artery bypass, valvular, and a combined procedure to determine the impact of source of bleeding leading to re-exploration. RESULTS: Eighty-two patients (3.6%) required re-exploration. Sixty-six percent had surgical bleeding; the remaining 34% were coagulopathic. Postoperative coagulopathy was associated with preoperative heparin use (37% vs. 19.9% for controls p<0.05). Re-operative procedures combined bypass/ valve (p<0.001) and prolonged cardiopulmonary bypass and aortic cross-clamp times (p<0.05) were more prevalent in the coagulopathy group. Postoperative inotrope use was increased in patients who were re-explored (p<0.001), as were cardiac, pulmonary, renal and abdominal complications (p<0.001), and in all cases those patients with medically related bleeding had worse acute outcomes than the group with surgical causes for re-exploration. The hospital stay was prolonged for both patients with surgical bleeding (23.5 days) and patients with coagulopathy (27.1 days) compared to patients not undergoing re-exploration for bleeding (12.0 days, p<0.001). Survival was 91.3% for patients with surgical bleeding, 87.5% for patients with coagulopathy, and 98.0% for all others (p<0.01). CONCLUSIONS: Severe postoperative hemorrhage is associated with significant morbidity and increased mortality. Postoperative hospital stay, morbidity, and mortality were significantly worse in patients suffering from coagulopathy when compared to those patients with hemorrhage from surgical causes.