Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest.

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eight-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.

Infected descending aortic fistula.

Two patients, each with an infected descending thoracic aortic fistula, are described. The first patient had a postpneumonitic empyema. Thoracostomy tube drainage resulted in obliteration of the empyema cavity.

Pulmonary artery balloon counterpulsation for treatment of intraoperative right ventricular failure.

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.

Partial replacement of the left ventricular free wall with a Dacron graft: a 14 year follow-up.

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.

Tracheoesophageal fistula from carcinoma of the esophagus.

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.

Esophagitis secondary to ingestion of caustic material.

The records of 176 patients admitted to Grady Memorial Hospital over a 10-year period with a history of ingestion of corrosive material were reviewed. Esophagoscopy was performed in 168 patients an average of 15 hours after ingestion. In 94 patients, no esophageal burn was found.

Aortic-left ventricular discontinuity and aortic regurgitation from acute endocarditis.

During the past 14 years, eight patients have had surgical intervention for acute aortic endocarditis and aortic-left ventricular discontinuity at our institution. Repair of the defect between the aorta and left ventricle was accomplished in two patients with interrupted horizontal pledgeted sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining six patients the repair was done with the interposition of a Dacron patch graft between the left ventricle and the aorta, and then the valve prosthesis was sutured to the graft and to the remaining native aortic annulus.

Acute endocarditis: surgical treatment of aortic regurgitation and aortico--left ventricular discontinuity.

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.

Immediate and long-term outlook for valve replacement in acute bacterial endocarditis.

The clinical course of 22 patients with acute endocarditis treated surgically less than six weeks after the onset of antibiotic therapy was reviewed. The aortic valve was infected in 13 patients, the mitral in six, the tricuspid in two, and one patient had both aortic and mitral valve involvement. The indications for surgical intervention before the completion of adequate antibacterial therapy included uncontrollable congestive heart failure, persistent sepsis, systemic embolization, and multiple septic pulmonary embolizations.

Esophageal gunshot injuries.

During a 15-year period from August 1964 to August 1979, 48 patients with gunshot wound of the esophagus (24 of the cervical, 17 of the thoracic, and seven of the abdominal) were treated at Grady Memorial Hospital. In the majority of the patients, the initial history, physical findings, and chest roentgenograms were nondiagnostic for esophageal injury. Esophageal perforation was mainly suspected because the bullet tract was in close proximity to the esophagus or the bullet had traversed the mediastinum.

Intimo-intimal intussusception and other unusual manifestations of aortic dissection.

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.

Pulmonary arteriovenous fistula, pulmonary artery aneurysm, and other vascular changes of the lung from penetrating trauma.

Pulmonary arteriography was performed in 22 patients with penetrating injury of the lung(s) within the first 72 post-injury hours and no vascular lesion directly attributable to the injury was found. Pulmonary arteriovenous fistula or pulmonary artery aneurysm secondary to penetrating pulmonary injury, are extremely rare lesions, but they should be suspected in a patient with penetrating wound of the chest with signs and symptoms of pulmonary arteriovenous fistula or with chronic residual well circumscribed density on chest roentgenogram. The treatment of these lesions should be excision of the lesion with preservation of the lung, whenever possible, or resection of the involved lobe.