In 120 patients with severe emphysema evaluated for participation in the National Emphysema Treatment Trial, pulmonary hemodynamics and ventricular function were assessed. Pulmonary function tests were (%predicted): FEV(1) = 27%; residual volume = 224.6%; diffusion capacity = 26.7%. In 90.8% of patients, end-expiratory pulmonary artery mean pressure was > 20 mm Hg; in 61.4%, end-expiratory wedge pressure was > 12 mm Hg. Cardiac index was normal. Mean pulmonary artery pressure correlated inversely with arterial PO(2), and severity of emphysema, and directly with wedge pressure. Multiple stepwise regression revealed that arterial PO(2) was not an independent predictor of mean pulmonary artery pressure. No correlation was found between indices of emphysema severity and PA pressures. Diastolic ventricular pressures were increased without evidence of systolic dysfunction. We conclude that (1) elevations of pulmonary vascular pressures are common, (2) pulmonary hypertension may be related to factors other than hypoxia, (3) pulmonary hypertension does not impair resting systemic O(2) delivery, and (4) elevated cardiac diastolic pressures do not represent systolic dysfunction.

Hemodynamic characterization of patients with severe emphysema.

Thrombotic and bleeding complications of prosthetic heart valves.

Disruption and infection of median sternotomy wounds are grave complications often associated with prolonged hospitalization, high cost, and significant mortality. Effective prevention techniques are still debated. Successful management requires early recognition based on a high index of suspicion, detailed physical examination, appreciation of the clinical signs and symptoms, timely imaging studies, and prompt surgical therapy. Improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates. Sternal salvage and direct sternal reclosure are possible when the infection is diagnosed early. Techniques utilizing lateral sternal support should be first-line options in the condition. Muscle flap techniques should be the next consideration when direct closure has failed or cannot be attempted.

Disruption and infection of median sternotomy: a comprehensive review

The adult respiratory distress syndrome (ARDS) represents a common denominator of acute lung injury leading to alveolar flooding, decreased lung compliance, and altered gas transport. In the absence of specific etiology and therapy, the management of ARDS remains largely supportive. Ubiquitous use of intermittent positive-pressure ventilation with positive end-expiratory pressure (PEEP) improves arterial oxygenation but with some risk of pulmonary barotrauma and decreased cardiac output. The recent understanding of lung inflation as a modulator of right heart afterload and the effect of the right ventricle on global cardiac performance continues to redefine optimal patterns of ventilatory and hemodynamic intervention in ARDS.

The adult respiratory distress syndrome.

Pseudoaneurysm of the ascending aorta following cardiac surgery.

Measurement of ejection fraction by thermal dilution techniques.

Complications of median sternotomy are infrequent (0.5%-5%) but have a very high mortality and morbidity. Conventional radiographic techniques are of limited value in assessing these complications. Twenty sternotomy patients without problems and 12 with clinical problems were studied with CT. In the control group, focal edema, focal hematomas, and minor sternal irregularities were universal. In the problem group, CT was able to distinguish the six patients without significant infection from the six with major infections. In the latter group, CT was of great value in determining whether the infection was limited to the presternal tissues, the anterior mediastinum, or both.

Eldred D. Mundth

Papers

Measurement of ejection fraction by thermal dilution techniques.

Complications of median sternotomy: computed tomographic evaluation.

Use of computed tomography to assess mediastinal complications after median sternotomy.

Clinical and echocardiographic evaluation of the St. Jude cardiac valve prosthesis: follow-up of 126 patients

Comparison of techniques for intraaortic balloon insertion