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Query: UMLS:C0030552 (paresis)
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The incidence of neurological deficits of the upper extremity was studied in a prospective trial on 201 consecutive patients who underwent median sternotomy at cardiac surgery. In 13 patients (6.5%), a brachial plexus paresis was diagnosed postoperatively. We were unable to demonstrate any statistically significant correlation between brachial plexus paresis and the side of arm placement, the side of cannulation of the jugular vein, the duration of operation, the bypass time, sex, or type of operation. All patients who suffered from neurological deficit were aged 50 years and more, however without any statistically significant correlation. In our opinion, brachial plexus lesions following median sternotomy in cardiac surgery depend on the extent of sternal spread and the height of placement of the retractor in dependence of the rigidity of the rib cage. By reason of the iatrogenic cause of brachial plexus lesions, it appears to us that these complications should be included in those of which the patient needs to be informed preoperatively.
Thorac Cardiovasc Surg 1991 Dec
PMID:Brachial plexus lesions following median sternotomy in cardiac surgery. 166 91

Techniques are available for carinal resection and reconstruction for bronchogenic carcinoma involving the carina. Successful outcome depends on careful patient selection, thorough preoperative evaluation, careful anesthetic management, strict attention to surgical technique, and compulsive postoperative care. Since 1973 we have performed 37 carinal resections for bronchogenic carcinoma: 21 right carinal pneumonectomies, 7 carinal resections, 7 carina plus lobe resections, and 2 carina plus pneumonectomy stump resections. Five patients had diseased N2 nodes and 13 patients had diseased N1 nodes. Complications included pulmonary (8), vocal cord paresis (3), atrial fibrillation (9), anastomotic stenosis (4), and anastomotic separation (3). There were 3 early postoperative deaths (8%). All were related to adult respiratory distress syndrome and were unresponsive to aggressive treatment. There were 4 late postoperative deaths between 2 and 4 months (10.9%). All late postoperative deaths were related to anastomotic complications (stenosis [1] and separation [3]). There are 5 absolute 5-year survivors and an actuarial 5-year survival rate of 19%.
J Thorac Cardiovasc Surg 1991 Jul
PMID:Carinal resection for bronchogenic carcinoma. 207 21

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.
J Thorac Cardiovasc Surg 1990 Nov
PMID:Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience. 140 78

Nonpulsatile perfusion techniques with extracorporeal circulation for open-heart surgery and aortocoronary bypass grafting are widely used; this treatment is often followed by temporary or permanent neurological deficits. Experimental studies suggest that pulsatile flow may be of greater benefit because of its ability to ameliorate cerebral microcirculation. We therefore investigated 22 men who underwent aortocoronary bypass grafting. Patients were randomly divided into either a group undergoing nonpulsatile (n = 14) or pulsatile flow (n = 8). Neurological examinations were done prior to the operation and on the 7th postoperative day. EEG, cerebral blood flow (CBF), and the metabolic rates of O2 (CMR O2) and glucose (CMR Glucose) were measured before anaesthesia and 30 minutes after the start of extracorporeal circulation, when venous blood temperature was 26 degrees C. Postoperative neurological symptoms consisted of cranial nerve palsies, dysfunctions of the visual cortex, cerebellar symptoms, and slight arm paresis, but no differences between the two treatment groups were detected. Moreover, changes in EEG, CBF, and CMR rates during anaesthesia did not differ between the two groups. Our data suggest that pulsatile flow is not superior to the nonpulsatile perfusion technique, but to confirm this larger patient samples are required.
Thorac Cardiovasc Surg 1990 Apr
PMID:Cerebral dysfunction following extracorporeal circulation for aortocoronary bypass surgery: no differences in neuropsychological outcome after pulsatile versus nonpulsatile flow. 234 53

Between January 1977 and September 1985, 75 patients in our department underwent elective surgery for myasthenia gravis through a median sternotomy. The main prerequisite was optimal stabilization by medical treatment with the best possible vital capacity. The Osseman types were as follows: type I (22), type IIa (19), type IIb (26), type III (7), and type IV (1). All patients, except for 3 who were mechanically ventilated for a few hours after surgery, were immediately extubated at the end of the operation. The most frequent histologic finding was thymic hyperplasia (36%); 21.3% of the patients had thymomas. No surgery-related deaths occurred. Wound healing was impaired in 6.7% of the patients, including one patient with complete sternal instability, while 5.3% developed pneumonia. The most serious complications were myasthenic (9.3%) and cholinergic (2.7%) crises. Paresis of the phrenic (2.7%) and recurrent laryngeal (1.3%) nerves occurred only in the thymoma patients, who also had a higher frequency of all other complications. The effect on the myasthenic symptoms 3 months after surgery was as follows: 7.5% of the patients were in complete remission, 61.2% had improved, 9% had deteriorated. In a logistic regression model, the parameters age, sex, duration of disease, Osserman type, histology, pre-operative antibody titer to acetylcholine receptors, and post-operative change in titer were examined with respect to their influence on the effect of surgery. Only thymic histology had an appreciable influence (p = 0.057). The effect of these parameters on the success of surgery as well as the type and frequency of complications in relation to perioperative procedure are discussed in detail.
Thorac Cardiovasc Surg 1987 Oct
PMID:Complications and efficacy of transsternal thymectomy in myasthenia gravis. 244 70

We reviewed the records of 167 neonates and older children undergoing ligation of a patent ductus arteriosus to determine the prevalence of recurrent laryngeal nerve injury and identify risk factors that might increase the likelihood of injury. Paralysis or paresis of the left vocal cord was identified by fiberoptic laryngoscopy in seven patients. All seven weighted less than 1500 gm at the time of operation and the ductus had been ligated with a metal clip. All had persistent symptoms when observed for 5 to 19 months. Injury to the left recurrent laryngeal nerve occurs infrequently but may have long-term consequences.
J Thorac Cardiovasc Surg 1989 Oct
PMID:Paralyzed left vocal cord associated with ligation of patent ductus arteriosus. 279 67

This study was designed to assess the long-term effects of balloon angioplasty for coarctation of the aorta. Eleven asymptomatic children, aged 4 to 6 years, underwent balloon angioplasty. Mean peak gradient fell from 50.5 +/- 4.7 mm Hg before angioplasty to 21.7 +/- 3.1 immediately after angioplasty. Children were then followed up at 3 to 6 month intervals and were recatherized 5 to 14 months after balloon angioplasty. On the basis of these catheterization findings, patients were divided into three groups: group I--four patients, residual gradient less than 10 mm Hg and no anatomic abnormalities; Group II--three patients, increase of gradient to greater than 25 mm Hg, mean 34 mm Hg; Group III--four patients, aneurysmal dilatation in the area of the balloon angioplasty. The seven patients in groups II and III underwent elective resection of their coarctation at 7 to 28 months after balloon angioplasty with end-to-end anastomosis. Somatosensory evoked potentials were monitored during the operation. There were no operative deaths and no gradients between arm and leg pressures postoperatively. One patient had mild paresis of the lower extremities. Pathologic examination of the specimens revealed an absence of muscle and elastic lamella in the area of the aneurysms. This finding was present in all specimens regardless of whether there was aneurysmal dilatation. Neofibroelastic proliferation at the site of the tear was responsible for persistent gradients. Balloon angioplasty may result in aneurysmal formation and/or recurrent stenosis in the area of the tear necessitating elective surgical repair. Surgical treatment is the same as for native coarctation when done early after balloon angioplasty, but may be associated with increased risk because of the lack of collateral circulation. Continued follow-up of these lesions is necessary.
J Thorac Cardiovasc Surg 1987 Nov
PMID:Surgical treatment of coarctation of the aorta after balloon angioplasty. 295 19

In a series of 1006 aortic operations for atherosclerotic occlusive or aneurysmal disease a femoral neuropathy with paresis of the quadriceps femoris muscle and sensory disturbances occurred in 34 patients or 3.4%. The femoral nerve palsy was left-sided 23 times, right-sided 9 times and bilateral twice. Twenty-nine patients had a complete recovery after 1/2 to 1 years. It is suggested that the femoral neuropathy is of ischaemic nature and caused by aortic clamping. The scant blood supply of the intrapelvic section of the femoral nerve is derived from the iliolumbar artery, a branch of the internal iliac artery, and from the deep circumflex iliac artery, a branch of the external iliac artery. On the right side the deep circumflex iliac artery gives more branches to the nerve and there are more anastomoses with the fourth and fifth lumbar arteries, than on the left side. This may be the explanation for the preference of the nerve palsy for the left side.
J Cardiovasc Surg (Torino)
PMID:Femoral neuropathy as a complication of aortic surgery. 303 15

Heart-lung transplantation for treatment of end-stage cardiopulmonary disease continues to be plagued by many problems. Three primary ones are the technical difficulties that can be encountered, particularly in those patients who have undergone previous cardiac operations, the additional restriction on donor availability imposed by the lack of satisfactory preservation techniques, and the need for lung size compatibility. Two of these difficulties and others surfaced postoperatively in a heart-lung transplant recipient who presented a series of unique operative and therapeutic challenges. A 42-year-old woman with chronic pulmonary hypertension and previous atrial septal defect repair underwent a heart-lung transplantation in August 1985. The operative procedure was expectedly complicated by bleeding from extensive mediastinal adhesions from the previous sternotomy and bronchial collateralization. Excessive chest tube drainage postoperatively necessitated reoperation to control bleeding from a right bronchial artery tributary. Phrenic nerve paresis, hepatomegaly, and marked abdominal distention caused persistent atelectasis and eventual right lower lobe collapse. Arteriovenous shunting and low oxygen saturation necessitated right lower lobectomy 15 days after transplantation, believed to be the first use of this procedure in a heart-lung graft recipient. Although oxygenation improved dramatically, continued ventilatory support led to tracheostomy. An intensive, psychologically oriented physical therapy program was initiated to access and retrain intercostal and accessory muscles. The tracheostomy cannula was removed after 43 days and gradual weaning from supplemental oxygen was accomplished. During this protracted recovery period, an episode of rejection was also encountered and successfully managed with steroid therapy. The patient continued to progress satisfactorily and was discharged 83 days after transplantation. She is well and active 20 months after discharge.
J Thorac Cardiovasc Surg 1987 Sep
PMID:Postoperative complications necessitating right lower lobectomy in a heart-lung transplant recipient with previous sternotomy. 311 65

In 1980 we described bilateral pulmonary thromboendarterectomy with median sternotomy, cardiopulmonary bypass, deep hypothermia, and circulatory arrest for the relief of pulmonary hypertension caused by chronic pulmonary embolism. In our subsequent experience, which totals 41 patients, we have identified three groups of patients characterized by differences of intraoperative management. In Group A (N = 16) myocardial protection consisted of single-dose crystalloid cardioplegia followed by pericardial irrigation with cold saline. Extrapericardial dissection of the pulmonary arteries was performed. Group B (N = 7) was treated the same as Group A except for the substitution of saline slush contained in a laparotomy pad for iced saline. In Group C (N = 18) myocardial protection was single-dose blood cardioplegia followed by the application of a specially designed cooling jacket to the right and left ventricles. Another modification was that of intrapericardial dissection of the pulmonary arteries with extension of the dissection into the hilar tissues without entrance into the pleural spaces. The hospital mortalities of Groups A, B, and C were 18.7%, 14.3%, and 5.5%, respectively (not statistically significant differences). However, other statistically significant differences (p less than 0.05) among the groups were observed: Phrenic nerve paresis occurred in five of seven (71%) Group B patients but in no Group A or C patients; Group B patients required ventilatory support for 32.2 days compared with 8.4 days for Group A and 6.2 days for Group C; time in the intensive care unit was 36 days for Group B patients versus 13 for Group A and 10.3 for Group C; pulmonary vascular resistance decreased 59% (649 versus 259) intraoperatively in 13 patients in Group C. We believe simultaneous bilateral pulmonary thromboendarterectomy with median sternotomy, cardiopulmonary bypass, deep hypothermia with circulatory arrest, and the modified methods of myocardial preservation and dissection represent current optimal surgical management of this problem.
J Thorac Cardiovasc Surg 1987 Feb
PMID:Modifications of techniques and early results of pulmonary thromboendarterectomy for chronic pulmonary embolism. 380 98


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