Durability of measured mitral annuloplasty: seventeen-year study

This report describes the technique and results of measured mitral annuloplasty performed in 196 patients having isolated mitral valve disease during the 17 years between January, 1961, and January, 1978. These patients represent 35% of all of those operated upon for isolated mitral valve disease during this period. Ages ranged from 3 to 70 years. Annuloplasty was performed in 115 patients and both commissurotomy and annuloplasty in another 81 patients. The operative mortality rate was 4.5% and the late mortality rate 8.7%. There were six arterial embolic episodes during the 17 years. Reoperation was required in 8% with another repair of the valve being possible in one third of them. This study suggests that measured repair of mitral regurgitation resulted in lower operative mortality, late mortality, and incidence of embolization when contrasted with mitral valve replacement. This operation appears to be the preferred procedure for certain subsets of patients (1) who require operation during infancy or childhood, including during active carditis; (2) who require operation during the childbearing age; and (3) in whom anticoagulation poses a severe threat to life or quality of life.

Release of nucleosides from canine and human hearts as an index of prior ischemia

During ischemia, myocardial adenosine triphosphate is degraded to adenosine, inosine and hypoxanthine. These nucleosides are released into coronary venous blood and may provide an index of ischemia; adenosine may also participate in the autoregulation of coronary flow. In dogs, the temporal relations between reactive hyperemic flow and nucleoside concentrations in regional venous blood were correlated after brief occlusions of a segmental coronary artery. Reactive hyperemia and adenosine release peaked together in 10 seconds, persisted for 10 to 30 seconds and then decreased in a pattern consistent with the hypothesis that they are related. During initial reflow after 45 seconds of ischemia, mean concentrations of adenosine, inosine and hypoxanthine increased, respectively, to 52, 67 and 114 nmol/100 ml plasma; after 5 minutes of ischemia, the respective levels increased to 58, 1,570 and 1,134 nmol and fell quickly. In nine patients there was a similar release of nucleosides into coronary sinus blood during reperfusion after 59 to 80 minutes of ischemic arrest during cardiac surgery. With initial reflow, adenosine, inosine and hypoxanthine levels reached 65, 655 and 917 nmol/100 ml of blood, respectively. Inosine and hypoxanthine concentrations remained high for 5 to 10 minutes after cardiac beating resumed, often when production of lactate had decreased. The results indicate that postischemic release of nucleosides reaches significant levels in man as well as animals, is parallel with the duration of ischemia, is temporary and may be a useful supplement to measurement of lactate as an index of prior myocardial ischemia.

Chylothorax as a manifestation of rheumatic mitral stenosis: its postoperative management with a diet of medium-chain triglycerides

Chylothorax occurred as a manifestation of severe congestive heart failure resulting from rheumatic mitral stenosis. Following replacement of the mitral valve, chylothorax recurred and was treated by thoracocentesis initially and then resolved during six months of therapy with a diet of medium-chain triglycerides. Ultimately, the patient resumed a regular diet with no further accumulation of pleural fluid.

Long-term results in 1375 patients undergoing valve replacement with the Starr-Edwards cloth-covered steel ball prosthesis

The two principal considerations with prosthetic valves are durability and thromboembolism. With the widespread interest in recently developed prosthetic valves (porcine, tilting disc, Cooley), the long-term results at one institution with a single prosthesis were considered of particular importance. Accordingly, a 97% follow-up has been completed on 1375 patients (pts) undergoing prosthetic valve replacement with the Starr-Edwards cloth-covered steel ball prosthesis at New York University between October 1967 and December 1975. Operative procedures were as follows: aortic valve replacement (AVR): 470 pts; mitral valve replacement (MVR): 362 pts; combined AVR and MVR: 129 pts; other combined procedures: 414 pts. Overall operative deaths were 13.7%, 9% for AVR, 10.8% for MVR, and 18.6% for combined AVR and MVR. At seven years, AVR survival was 64%, and MVR survival 64.5%. There has been widespread pessimism, usually without significant data, about the cloth-covered prosthesis, because of concern of cloth wear, hemolysis and other complications. Therefore, a particularly significant finding by actuarial analysis was that 85% of surviving patients with isolated AVR remained free of emboli for five years. In pts surviving isolated MVR, 80% remained free of emboli for five years. Of those having embolic episodes, 33% were not on anticoagulants. Fatal hemorrhage from anticoagulants occurred in 0.8% of pts. Endocarditis occurred in 5.7% of the entire group, with 1.3% requiring reoperation. Clinically significant hemolysis occurred in 5.1% of the group, with only 0.2% requiring reoperation. Hence, the total frequency of clinically significant cloth-wear was less than 0.5%. These data indicate both the reliability and the limitations of the Starr-Edwards cloth-covered steel ball valve and can be used in comparing experiences with the more recently developed prostheses.

Infective endocarditis. An analysis of 54 surgically treated patients

One hundred seventy-seven patients were admitted to the New York University Medical Center from 1970 through 1975 with infective endocarditis. Fifty-four of these patients required surgical treatment. The over-all mortality rate was 28 per cent. Two thirds of the deaths were early (10 patients) and one third late (5 patients). The mortality rate was 90 per cent in 10 patients treated for 4 to 6 weeks in whom the infection was uncontrolled and the clinical condition was deteriorating. However of the 12 patients with uncontrolled infection who were operated upon promptly within 10 days, 83 per cent survived. The fact that fungal and gram-negative infections responded poorly to medical therapy suggests the need for prompt, early surgical intervention. The mortality rate in the 32 patients operated upon in whom the infection was controlled was 12.5 per cent. It is our conclusion that all patients with infective endocarditis who develop progressive congestive failure, recurrent embolization, or progressive sepsis, despite treatment, shold have prompt valve replacement within 7 days of the institution of appropriate antimicrobial therapy.

Operative management of tricuspid regurgitation

From January 1968 to June 1975 tricuspid regurgitation was encountered in 238 patients of a total of 1074 patients undergoing operations on the mitral valve. During this time tricuspid annuloplasty (TA) was performed in 137 patients and the tricuspid valve was replaced (TVR) in 101 patients. Comparison of hospital mortality of 15% (20 of 137) for TA as against 40% (40 or 101) for TVR suggests the superiority of repair over replacement. A new technique for repair makes this operation even more attractive. It satisfies the dual objectives of producing competency but not obstruction by creating a measured orifice. As experience with TA was gained, the incidence of valve replacement dropped from 69% (22 of 32) in the first 2 years of the study to 16% (11 of 70) for the last 2 years.

Measured tricuspid annuloplasty: a rapid and reproducible technique

A technique for repairing the tricuspid valve that involves principles successfully used in operative repair of the mitral valve is described. A measured orifice produces competence but not obstruction and eliminates the trial-and-error aspects of annuloplasty. The procedure can be performed with the heart beating, though it can be transiently fibrillated so that the suture may be tied without tension.

The influence of diabetes and hypertension on the results of coronary revascularization

The effects of diabetes and hypertension on the early postoperative course of patients undergoing coronary revascularization were studied by reviewing the records of 177 patients operated upon in 1972. There were 121 nondiabetic, nonhypertensive; 32 hypertensive; ten diabetic; and 14 diabetic-hypertensive patients. The incidence of postoperative low cardiac output, renal insufficiency and arrhythmia was significantly higher in the hypertensive patient. Operative mortality ranged from 0 in diabetic patients, to 0.8 per cent in nondiabetic, nonhypertensives, to 7.1 per cent in diabetic-hypertensives and 12.5 per cent in hypertensive patients, suggesting an increased risk for the hypertensive patient. The one- to two-year follow-up results documented symptomatic improvement in 90.7 per cent of patients with little adverse effect apparent from diabetes or hypertension. Pre- and postoperative coronary angiography was carried out in 103 patients between 1968 and 1973 with a mean elapsed time between operation and postoperative angiogram of 9.3 months. The progression of atherosclerosis was graded on a 0-4 basis in both grafted and ungrafted coronary arteries. While hypertension appeared to contribute to disease progression, the incidence of vein graft and internal mammary artery bypass occlusion was not significantly affected by either diabetes or hypertension. This study has shown that while hypertension contributes to increased morbidity and mortality in the early postoperative period and an increased rate of progression of atherosclerosis, neither diabetes nor hypertension appeared to influence the one- to two-year results of coronary revascularization.

Cystic thymoma simulating contrictive pericarditis. The role of echocardiography in the differential diagnosis

A case is presented of a 60-year-old woman with fatigue, dyspnea, and chest pain. A chest x-ray film revealed an abnormal cardiac silhouette. Echocardiography revealed a large, echo-free area with well-demarcated, discrete borders adjacent to the right heart border. This structure decreased in size with inspiration and did not show pulsatile cardiac motion. Cardiac catheterization confirmed the extracardiac nature of the lesion and also showed a "constrictive" pattern with equalization of diastolic pressures. Surgical exploration revealed a large cystic thymoma. With removal of the tumor, intracardiac pressures returned to normal.

The long-term influence of coronary bypass grafts on myocardial infarction and survival

Approximately 1,000 coronary bypass procedures were performed at New York University between February 1968 and December 1973. This report reviews all elective operations performed for angina between 1968 and 1972, a total of 448 patients. In this five-year period the percentage of diseased arteries bypassed rose from 40% to 84%, and operative mortality decreased from 28% to less than 3%. There were a total of 28 operative deaths, mostly from myocardial infarction and low cardiac output. Operability was nearly 95%. The only fixed contraindication was chronic congestive failure. Over one-half of the patients had an abnormal ventriculogram, and there was some history of mild congestive failure in nearly 20%. Elevation of left ventricular end-diastolic pressure above 20 mm before operation was associated with a higher operative mortality, but the late mortality was similar to those with a normal preoperative end-diastolic pressure. In 383 surviving patients, angina was eliminated or greatly improved in 86%, unimproved in 12% and worse in 2%. Late angiograms were performed on 201 patients, studying a total of 445 venous grafts with an overall patency rate of 71%. Graft occlusion was sporadic and unpredictable, but over 90% of patients with multiple grafts remained with at least one patent graft. A late myocardial infarction occurred in 32 out of 420 patients surviving operation, and was fatal in eight. The cumulative incidence over a period of five years was 17%. Twenty-three deaths occurred following discharge from the hospital. Life-table analyses showed a five-year survival of 77% when all deaths were included, and a five-year cardiac survival of 81% when non-cardiac deaths were withdrawn alive at the time of death. The expected survival in a comparable population group without coronary disease was 92%, while data published by Sones of patients treated without operation showed a five-year cardiac survival of 66%. Current operative techniques have an operative mortality of 2-3% and a subclinical infarction rate of 5-10%. The ideal graft is yet evolving, but data with internal mammary artery grafts are most encouraging. A future goal should be a five-year graft patency of at least 80%. Because many infarcts probably develop from a relatively small decrease in coronary blood flow, either during rest or mild activity, the likelihood that future data will demonstrate a marked increase in longevity with bypass grafting is great.

Release of adenosine from human hearts during angina induced by rapid atrial pacing

This study was designed to determine whether human hearts release adenosine, a possible regulator of coronary flow, during temporary myocardial ischemia and, if so, to examine the mechanisms involved. Release of adenosine from canine hearts had been reported during reactive hyperemia following brief coronary occlusion, and we initially confirmed this observation in six dogs hearts. Angina was then produced in 15 patients with anginal syndrome and severe coronary atherosclerosis by rapid atrial pacing during diagnostic studies. In 13 of these patients, adenosine appeared in coronary sinus blood, at a mean level of 40 nmol/100 ml blood (SE = +/-9). In 11 of these 13, adenosine was not detectable in control or recovery samples; when measured, there was concomitant production of lactate and minimal leakage of K(+), but no significant release of creatine phosphokinase, lactic acid dehydrogenase, creatine, or Na(+). THERE WAS NO DETECTABLE RELEASE OF ADENOSINE BY HEARTS DURING PACING OR EXERCISE IN THREE CONTROL GROUPS OF PATIENTS: nine with anginal syndrome and severe coronary atherosclerosis who did not develop angina or produce lactate during rapid pacing, five with normal coronaries and no myocardial disease, and three with normal coronaries but with left ventricular failure. The results indicate that human hearts release significant amounts of adenosine during severe regional myocardial ischemia and anaerobic metabolism. Adenosine release might provide a useful supplementary index of the early effects of ischemia on myocardial metabolism, and might influence regional coronary flow during or after angina pectoris.

Lethal postoperative infections following cardiac surgery. Review of four years' experience

Seventeen of 1,494 patients (1.1%) succumbed to infection following open-heart operations at New York University Hospital between January, 1968 and December, 1971. All but two of these patients had Starr-Edwards ball-valve prostheses inserted. One had repair of a tetralogy of Fallot, and one had aortic commissurotomy and a double coronary bypass graft. The sites of infection were pulmonary (15 patients), urinary tract (14), mediastinum or pleura (10), and blood (15). Pulmonary infection appeared as the source of endocarditis in 13 patients and as a source of pleural or mediastinal infection in nine. Candida species infection was directly responsible for the deaths of 10 of the 17 patients, being the sole organism isolated in 5 of the 10.

Predisposing factors to infection were preoperative bacterial endocarditis 2 patients, prolonged cardiopulmonary bypass (>3½ hours) 6 patients, a "low output" state following operation 12 patients, postoperative cerebral dysfunction 6 patients, and postoperative disseminated intravascular coagulation 4 patients.

The debilitated state of the patients, multiple sites of infection, degree of tissue destruction, and the variety and resistance of the organisms involved all combined to produce treatment failure. Removal of the infected valvular prosthesis coupled with antimicrobial therapy is considered the treatment of choice in instances of bacterial endocarditis when chemotherapy fails and in all cases of established fungal endocarditis.