Surgical management of an aneurysm of the left main coronary artery

A 28-year-old woman underwent cardiac catheterization three months after sustaining an acute anterolateral myocardial infarct. An aneurysm of the left main coronary artery was found at angiography and also was visualized by two-dimensional echocardiography. The patient had no evidence of atherosclerotic vascular disease. At operation, vein grafts were placed to bypass the aneurysm and the orifice of the left coronary artery was oversewn to exclude the aneurysm from the coronary circulation.

PEEP and CPAP following open-heart surgery in infants and children

The cardiorespiratory effects of 5 cm H2O end-expiratory pressure were studied in 22 infants and children an hour after open-heart surgery during mechanical ventilation with positive end-expiratory pressure (PEEP) and prior to endotracheal extubation approximately 15 hours later during spontaneous breathing (CPAP). Thermodilution cardiac output determinations and respiratory airflow, volume and pressure recordings were made to assess the effects of airway pressure changes on the respiratory waveform and oxygen delivery. Neither PEEP nor CPAP had a significant effect on cardiac output, intrapulmonary shunting, oxygen consumption, or oxygen utilization. Patients who had had pulmonary hypertension preoperatively did not behave differently from those without pulmonary hypertension when removed from ventilatory supprot. Expiratory airflow was significantly prolonged when positive end-expiratory pressure existed during both controlled and spontaneous respiration. During CPAP, this "expiratory braking" was associated with an increase in tidal volume and decreases in respiratory rate and minute volume. Because of the lack of improvement in cardiopulmonary function in this group of patients, and the possibility of untoward effects from sustained end-expiratory pressure, PEEP and CPAP might properly be reserved as temporary supportive techniques should respiratory function be compromised.

Discontinuity between the heart and the pulmonary circulation. Its management with the use of a valved external conduit

The Hancock conduit that contains a porcine xenograft valve has been used in part of the cardiac repair of 22 patients with complex congenital heart disease. Five patients had a severe form of tetralogy of Fallot; six had pulmonary atresia; five had transposition of the great vessels, ventricular septal defect (VSD), and pulmonic stenosis; five had truncus arteriosus; and one had "corrected" transposition, VSD, and pulmonic stenosis. The hospital mortality was 2/22. This conduit has proved a satisfactory method to establish right ventricular-pulmonary artery continuity.

Delayed appearance of left-to-right shunt following aortic valvular replacement. Report of two cases

Two cases are presented in which a left-to-right shunt occurred late following aortic valvular replacement. In one patient a fistula was found between the aortic root and the right atrium and ventricle. In the second patient a defect developed in the membranous septum, allowing shunting from the left ventricle to both the right atrium and right ventricle.

The determinants of survival following reoperation on prosthetic cardiac valves

In an effort to identify the determinants of survival following reoperation on patients with prosthetic cardiac valves, the experience with a group of 33 patients at the University of Rochester Medical Center was reviewed. The survival rate was 58% (19/33). Survival was not related to the valve involved, the age of the patient, or the technical hazards of a second cardiac operation. Ten (77%) of the 13 patients in New York Heart Association (NYHA) Functional Class II survived compared with 8 (40%) of the 20 in Class III or IV. The survival rate for patients with a paravalvular fistula was 79% (11/14); with valve dysfunction, 50% (6/12); and with prosthetic valve infection, 29% (2/7). The determinants of survival seem to be similar to those for primary operation (i. e., NYHA patient classification and indication for operation) and less related to the potential operative complications of a reoperation.

Current results with construction and interruption of the Waterston anastomosis

The Waterston anastomosis was constructed in 21 infants and neonates between 1973 and 1977. Sixteen neonates were 1 week old or less and 8 were less than 24 hours old. There were 2 operative deaths, giving a hospital survival of 90%. There were 3 late deaths. All surviving infants received satisfactory palliation except 1 who required a Potts anastomosis one year later. During the same time interval, 9 other patients who had had a Waterston anastomosis underwent complete intracardiac repair. Seven of them had significant angulation of the right pulmonary artery necessitating patch reconstruction. All patients survived operation, and follow-up pulmonary angiograms demonstrated only a slight persistent narrowing of the right pulmonary artery in 2 patients. We conclude that the Waterston anastomosis can be constructed with a low operative mortality even in the severely cyanotic neonate and that it can be taken down at the time of complete repair with minimal morbidity and no mortality even if it has significantly angulated the right pulmonary artery.

An assessment of cardiac output by thermodilution in infants and children following cardiac surgery

A 4 F thermodilution catheter for measuring cardiac output was evaluated for accuracy and linearity in the laboratory and by comparison with the dye dilution method in infants and children following cardiac surgery. When 2 ml of 0 degrees C injectate were used, the correlation of computer determined flows to calibrated pump flows, over a range encountered clinically, was r = 0.998. The means of triplicate determinations by both the thermal and dye methods were compared in 8 of 25 patients and the comparison found to be favorable (r = 0.976). The complications of thermodilution catheter placement are described and related to the need for post-surgical chest x-ray and thermodilution recordings. The simplicity of the thermodilution technique and other advantages over the dye method in children, such as repeatability, and ease of calibration are discussed in relation to the increased flexibility in management which accrues.

Double-outlet right ventricle (S,D,D), VSD related to pulmonary artery, and pulmonic stenosis absent. Correction with an intraventricular conduit in infancy

The case history of a 5-month-old infant with double-outlet right ventricle (S,D,D) ventricular septal defect (VSD) related to the pulmonary artery, and absence of pulmonic stenosis is reported. The anomaly was repaired with an internal intraventricular conduit. This is the youngest infant with this subset of DORV to survive complete repair and the youngest in whom an intraventricular conduit was used. The diagnosis was not suspected preoperatively, and it is fortunate that the intracardiac anatomy permitted this type of repair at this age. The optimal management program for this subset of DORV should be initial pulmonary artery banding with later complete repair.

An infant intracardiac suction instrument

An infant intracardiac suction instrument that neither sticks against the heart wall nor obscures the operative field is described.

A technique to narrow the lumen of a Waterston anastomosis

A technique is described for narrowing the Waterston anastomosis by placing a horizontal mattress suture buttressed with felt pledgets through the aortic wall at the cephalad side of the anastomosis. This maneuver produces a slight but safe narrowing of the anastomotic lumen.

Automated identification of cardiac conduction tissue in L-TGV and Ebstein's anomaly

The specialized cardiac conduction tissue was identified quickly and easily at operation in 2 patients with corrected transposition (L-TGV) and 1 with Ebstein's anomaly. In each of the former cases the tissue was located along the upper rim of the VSD, beneath the pulmonary outflow tract; in neither patient was there a disturbance in cardiac rhythm as a result of operation. In the patient with Ebstein's anomaly the bundle of His descended onto the ventricular septum more directly than was anticipated. There was only a transitory disturbance in atrioventricular conduction following tricuspid valve replacement. Accurate identification of the cardiac conduction tissue is a prerequisite to the safe repair of certain forms of complex congenital heart disease.

The technique of ventricular septal defect closure in L-transposition of the great vessels

Heart block has been a frequent complication of ventricular septal defect closure in L-transposition of the great vessels. Intraoperative mapping of the conduction tissue combined with accurate suture placement should significantly reduce the incidence of heart block produced by direct injury to the conduction tissue.

Dissection of the aorta complicating intra-aortic balloon counterpulsation

A 61-year-old man with recent myocardial infarction complicated by a ventricular aneurysm and recurrent ventricular tachycardia underwent intra-aortic balloon counterpulsation prior to angiography and left ventricular aneurysmectomy. A dissecting aneurysm of the descending aorta adjacent to the position of the balloon catheter was found at autopsy. No intimal tear or cystic medial degeneration of the aorta was present to account for the dissection. The authors suggest that lateral and shearing forces generated by inflation of the balloon could result in dissection of the aorta.

The Waterston anastomosis with no deaths in the neonate

The Waterston anastomosis has been performed with no deaths in 11 consecutive neonates during the past 24 months. Seven neonates had pulmonary atresia with either single ventricle or hypoplastic right ventricle, 3 had tetralogy of Fallot, and one had severe pulmonary stenosis with a normal right ventricle. Six neonates were one day old and only one was older than 7 days. All have obtained symptomatic and documented (increase Po2) benefit. This level of success is attributed to (1) minimal delay between the recognition of cyanosis and operation (mean time between hospital admission and catheterization was 3 hours and between catheterization and operation, 4 hours); (2) correction of any base deficit prior to, during, and after operation; (3) accurate construction of the anastomosis to avoid excessive size, and (4) careful postoperative management of the pulmonary subsystem by experienced personnel. We have demonstrated that the high mortality rate previously reported for the Waterston anastomosis in the neonate can be markedly improved by an appropriate patient management program.

Closure of a ventricular septal defect through the aortic valve: a note of caution regarding resultant narrowing of the aortic valve annulus

Closure of ventricular septal defects through the aortic valve annulus has been described for a variety of cardiac anomalies. This technique is most appropriate when simultaneous aortic valve replacement is anticipated. A continuous suture through the patch material may produce a purse-string effect upon the aortic valve annulus. The appropriate size of the aortic valve prosthesis should be determined after the closure of the ventricular septal defect is completed to avoid selecting one which may be too large.

Reconstruction of right ventricular-pulmonary artery continuity with a valved external conduit: unusual technical considerations

The Hancock conduit containing a porcine xenograft valve has been used as part of the repair in 14 patients having complex congenital heart disease. The single death in this series resulted from the consequences of pulmonary vascular disease in a patient with truncus arteriosus. Several unusual technical considerations such as previous pulmonary artery banding, angulated Waterston anastomoses, and dextroversion required modifications in the standard approach to the correction of several of the anomalies encountered. This conduit has provided a satisfactory method to establish right ventricular-pulmonary artery continuity.

Support of the myocardium with intra-aortic balloon counterpulsation following cardiopulmonary bypass

Intra-aortic balloon counterpulsation (IABC) was instituted in 27 patients in cardiogenic shock who had undergone cardiopulmonary bypass (CPB). Patients who required IABC either prior to CPB or else to be weaned from CPB had a survival rate of 22 per cent (2/9). In contrast, the survival rate for those patients requiring IABC after CPB had been discontinued was 72 per cent (13/18). The composition of these two groups was different. The first group contained primarily patients with either severe coronary artery disease or aortic valve stenosis, whereas the latter group contained patients with either less severe coronary artery disease or mitral valve disease. Most patients had an initial satisfactory response to IABC. The over-all survival rate was 55 per cent (15/27). IABC was particularly beneficial for those patients in cardiogenic shock following CPB who had not had massive and irreveraible myocardial injury.

Double-outlet right ventricle. A collective review with a surgical viewpoint

Double-outlet right ventricle (DORV) should be classified according to its various subsets. Van Praagh's symbolic terminology provides an appropriate mechanism for doing that. Each of these subsets is described in terms of its pathology, clinical characteristics, cardiac catheterization findings, and operative repair. The operative repair for each is different. The presence or absence of continuity between the semilunar and atrioventricular valves is unimportant from the standpoint of operation and should not be a criterion for classification.

Complete correction of double-outlet right ventricle with situs inversus, 1-loop, and 1-malposition (I,L,L) with subaortic VSD and pulmonary stenosis

The repair a unique case of double-outlet right ventricle is reported. This case illustrates the increasingly difficult problem of developing an appropriate nomenclature in complex congenital heart disease. A classification of double-outlet right ventricle based upon Van Praagh's symbolic terminology is suggested.

A family systems approach to home dialysis

Dramatic increases in the cost of the end stage renal disease program are producing an emphasis on home dialysis with the patient and his family carrying the responsibility for this treatment. This requires an adjustment of the family's emotional system and role assignment to sustain members through the continued stress of chronic catastrophic illness. We are suggesting a model of intervention in which family members are encouraged to recognize stress caused by one member's illness and to make necessary changes in the family functioning.

Correction of truncus arteriosus after pulmonary artery banding

Correction of truncus arteriosus can be performed in the older child with low mortality. However, many infants are severely symptomatic with increased pulmonary blood flow and require banding of the pulmonary artery at an age when correction has a high mortality. The pulmonary artery band can complicate the usual technique of the subsequent repair. An alternative approach following pulmonary artery banding is to interrupt the pulmonary artery--truncus continuity with a patch from within the truncus and then place the external valved conduit onto the pulmonary artery in an end-to-side manner.

Regional myocardial infarction at operation. An automated system of identification

The difference between normal and infarcted myocardium at operation cannot always be defected by inspection or palpation. Infarcted myocardium may be identified by a decrease in the amplitude of the ventricular bipolar electrogram. Although this method is reliable and reproducible, it requires a second observer's visual analysis and interpretation of the electrogram signal. This method is therefore subject to the vagaries of human observation, analysis, and accounts of rapidly changing data. We have designed and built an automated instrument to simplify the recognition of transmural infarction.

Simultaneous operative correction of aortic valve stenosis and idiopathic hypertrophic subaortic stenosis

Idiopathic hypertrophic subaortic stenosis (IHSS) may coexist with aortic valve stenosis (AVS). This combination of lesions is uncommon and may not be identified by the usual preoperative clinical evaluation and laboratory studies including cardiac catheterization. Surgical relief of AVS without concomitant septal myectomy to relieve unrecognized underlying IHSS may be followed by a low cardiac output, evidence of residual outflow tract obstruction, and death. Echocardiography (ECHO) will accurately identify IHSS and should be performed in all patients suspected of having AVS. This report describes the first three patients in whom the preoperative diagnosis of both AVS and IHSS was made and who subsequently had both lesions corrected at the same operation. All patients survived operation. The outflow tract gradient was abolished in two patients and significantly reduced in the third. All patients with this combination of lesions should be offered operation for the same indication as isolated aortic valve stenosis. The operation should include a septal myectomy as well as relief of the aortic valve stenosis.

Echocardiography of the intra-atrial baffle in dextro-transposition of the great vessels

Twelve patients with dextro-transposition of the great vessels (age eight months to four years) were studied by echocardiography following Mustard's procedure. Nine of them had also been studied preoperatively. Postoperatively all patients demonstrated structural echoes in the atrial cavity behind the pulmonary root. In ten, the motion pattern generally resembled that of a stenotic atrioventricular valve iwth a sharp anterior movement followed by flattening in diastole and rapid posterior excursion in systole. The maximum amplitude of motion ranged from 4 to 9 mm (average 6.6 mm). In the remaining two cases, the anterior diastolic movement was attenuated. Similar moving, linear echoes with larger amplitudes of motion (10-14 mm) were observed behind the tricuspid valve in four patients while poorly moving, multiple or thick conglomerate echoes (2-11 mm wide) were detected in seven cases. Echocardiographic contrast studies performed by injecting indocyanine green via catheters placed on either side of the intra-atrial baffle identified it as the source of these echoes. Following operation, coarse diastolic undulations of the mitral valve (ten cases) and the tricuspid valve (nine cases) were noted. Also, fine flutter of both atrioventricular valves, not present before, appeared after operation in three patients. These findings may be related to the altered pathway of blood flow and turbulence resulting from the insertion of the baffle in the atria. Echocardiography appears useful in delineating the character and movement pattern of the intra-atrial baffle and this may have potential in evaluating its long-term functional status.

Action of prostaglandin F2alpha on pregnancy in hamsters: luteolytic and extra-ovarian effects

Pregnancies in hamsters may be terminated by 10 mug PGF2alpha administered b.i.d. on days 4, k and 6 of gestation. Small (250 mug and above) daily injections of progesterone on the same days will reverse this PG effect; in contradistinction, 10 mg of progesterone per day failed to maintain normal pregnancies in hamsters spayed on day 5. Daily administration of 3 mg of progesterone and 1 mug of estrone essentially normalized the gestation; administration of PGF2alpha at 10 mg on days 5, 6 and 7 of pregnancy in steroid-maintained rats, resulted in pregnancy termination in all animals, while 1 mg was partly effective. These data demonstrate an extra-ovarian site of action of prostaglandin F2alpha on pregnancy in hamsters.

Sutureless epicardial pacemaker lead: a satisfactory preliminary experience

The first pacemaker systems used the epicardial electrode. The transvenous endocardial electrode rapidly supplanted the epicardial electrode since it could be positioned with less morbidity and mortality and was associated with a lower incidence of wire breakage. The long term complication rate of the transvenous electrode had not been inconsequential. The sutureless epicardial electrode combines the greater reliability of the epicardial lead system with the ease of insertion and low morbidity of the endocardial lead system. We have used this electrode in 33 patients. The electrode was positioned using the subxiphoid approach and local anesthesia in most patients. There have been few complications and none that resulted in long term morbidity. There have been no deaths related either to the operative approach or to the pacing system. There has been no instance of lead failure during the follow-up period.

Echocardiography in the diagnosis of idiopathic hypertrophic subaortic stenosis co-existing with aortic valve disease

Echocardiographic studies demonstrated the presence of co-existing idiopathic hypertrophic subaortic stenosis (IHSS) in six patients with aortic valve disease (four calcific aortic stenosis, two pure aortic incompetence). The characteristics of IHSS were a narrow left ventricular outflow tract, a systolic anterior movement of the mitral valve (SAM), and asymmetric ventricular septal hypertrophy. Large SAMs were observed in two patients with pure aortic incompetence and one with aortic stenosis. Relatively small, inconstant, and often incomplete SAMs were noted in the remaining three patients with aortic stenosis. In contrast to isolated IHSS, the small SAMs observed in this group did not become prominent with the Valsalva maneuver or amyl nitrite inhalation. These features may be related to the afterload provided by the fixed, distal stenosis. Echocardiographic evidence of aortic valve disease was present in all patients. Clinically, co-existence of IHSS was not suspected in five patients. Associated IHSS was established using provocative measures during cardiac catheterization in three cases, while in the remainder it was substantiated at surgery. Three of four patients who underwent myotomy/myectomy concomitant with aortic valve replacement survived and postoperative echocardiographic studies revealed complete absence of SAMs in two of them. Echocardiography appears to be useful in the diagnosis of associated IHSS in the presence of aortic valve disease.