Faculty Bibliography

Two cases of disinsertion of the left innominate vein from the superior vena cava (S.V.C.) during primary median sternotomy have been encountered during the past 6 years. Methods of management consisting of either (1) ligation and division of the left innominate vein and patch angioplasty of the SVC injury, or (2) patch angioplasty of the disinsertion injury itself with preservation of the left innominate vein are presented. The rationale and possible complications of each method of treatment are discussed based on the anatomy and collateral circulation of the left innominate vein and other experiences with division of the left innominate vein.

The natural progression of arteriosclerotic descending thoracic aneurysms results in rupture in a high percentage of patients. Reports of surgical experience with these problems are not common although much as been written about elective resection of thoracic aneurysms. Two patients with ruptured non-traumatic descending thoracic aneurysms are presented. hemorrhage into the right hemithorax was a presenting manifestation in both patients. The mechanism for this type of rupture is discussed. Both patients were operated upon with one survivor. Preoperative evaluation, operative approach, and methods of bypass are discussed.

Experience with 29 patients who underwent intra-aortic counterpulsation between January, 1975, and December, 1977, was reviewed to determine (1) if the results of this method of treatment were similar at the community hospital and university hospital levels and (2) if earlier institution of counterpulsation made possible by easy availability of equipment resulted in improved survival. The balloon was successfully inserted in 27 patients. Arterial blood pressure was below 80 mm. Hg in all patients prior to institution of either pharmacologic or balloon therapy. Pulmonary capillary wedge pressure was greater than 12 mm. Hg in the 22 patients in whom it was measured. In 15 patients counterpulsation was instituted less than 12 hours after infarction (Group A), and in the 14 elapsed time was greater than 12 hours (Group B). There was no difference in precounterpulsation hemodynamic measurements between Group A and Group B. Ten patients in Group A were weaned and survived hospitalization. Seven (54 percent) are long-term survivors (6 months to 2 years). Four are in New York Heart Association Class I, two are in Class II, and one is in Class III. Ten patients in Group B were weaned, seven survived hospitalization, and five are long-term survivors (35 percent). Two are in N.Y.H.A. Class I, two are in Class II, and one is in Class III. These results indicate that counterpulsation is possible at the local hospital level and that early institution of the intra-aortic balloon pumping may improve long-term results.

A 15 month old black male who developed near fatal intravascular hemolysis two days after repair of an ostium primum septal defect with a teflon patch is presented. One month after initial operation, reoperation was required for control of hemolysis. At that time a piece of pericardium was placed over the underendothelialized left atrial side of the patch and the mitral cleft was repaired. He initially did well but within several days developed mitral regurgitation. Hemolysis recurred two months postoperatively, but then spontaneously subsided. We propose that the recurrent mitral insufficiency created a defect in the pericardial patch and that caused recurrent hemolysis. Normal endothelial ingrowth probably covered this small defect and hemolysis subsided. Following the second hemolytic episode six months ago, the patient continues to do well