Cerebral aspergillosis: report of two cases

Two cases of cerebral aspergillosis in Tamilians presenting as intracranial space-occupying lesions are reported. The first patient had a left frontal lobe abscess and a specific diagnosis was made by histopathology and isolation of Aspergillus versicolor. He responded well to excision followed by anticonvulsant therapy. In the other, the diagnosis was based on histopathology alone and she died after surgery. These are the first cases reported from Tamil Nadu and probably only one similar case has been reported from India so far.

Aortic origin of the right pulmonary artery

A seven-week-old infant with aortic origin of the right pulmonary artery and patent ductus arteriosus is reported. During preoperative studies, a balloon catheter was used to occlude the ductus arteriosus in order to define the status of the pulmonary vascular bed. Corrective operation was performed by anastomosis of the anomalous right pulmonary artery to the main pulmonary trunk and ligation of the ductus arteriosus. Preoperative assessment of the presence of pulmonary vascular obstructive disease is discussed.

Successful correction of a complete form of atrioventricular canal associated with tetralogy of Fallot: case report

This is the third reported case of successful correction of a complete form of atrioventricular (AV) canal associated with tetralogy of Fallot. The surgical mortality rate from this combination is high, in part due to failure to recognize the associated anomaly and to completely close the ventricular septal defect. This successful correction was accomplished by giving the ventricular portion of the patch more width and by suturing it from both the atrium and ventricle. This patient reported herein is doing well 6 months after the operation.

Deep hypothermia

Early correction of congenital cardiac defects has been facilitated by the use of deep hypothermia and cardiocirculatory arrest. The technique currently used by us consists of surface cooling to 24 degrees C, total hemodilution, cardiopulmonary bypass to 20 degrees C and complete cardiocirculatory arrest. Rewarming is achieved with a pump oxygenator. In over 266 small children, 67% of whom were in the first year of life, lesions corrected included transposition of the great arteries (TGA)(43%), ventricular septal defect (16%), tetralogy of Fallot (16%), and total anomalous pulmonary venous drainage (5%). Early primary correction with deep hypothermia has a risk that is comparable to or better than staged repair.

Mycetomas in Madras

In 90 of 150 cases clinically diagnosed as mycetoma in the Department of Pathology, Madras Medical College, from January 1964 to June 1975, histopathological study revealed granules. Besides special staining procedures, cultural methods were undertaken in recent cases. The age and sex incidence, site of lesion and the species of fungi identified on the basis of histological morphology of the granules are analysed. The disease was predominatly seen in the age group 21-40. Men were more frequently affected than women and the commonest site of the lesion was foot. Actinomycotic mycetoma (68-9%) was more often found than the maduromycotic type. Madurella mycetomi (37-8%) and Actinomadura madurae (26-7%) were the commonest causal agents. Nocardia spp. were the next most common (21-1%) followed by A. pelletieri (15-5%), S. somaliensis (5-6%) and presumably Allescheria/Cephalosporium spp. from only 3 cases of white grain mycetoma.

Electroencephalographic and neurological correlates of deep hypothermia and circulatory arrest in infants

At present there is much interest in the use of surface-induced deep hypothermia with circulatory arrest in infants undergoing an open-heart procedure for repair of congenital defects. This paper presents our experience with infants who have been monitored by preoperative, intraoperative, and postoperative electroencephalograms as well as by preoperative and postoperative neurological assessments. Our results indicate that young infants tolerate deep hypothermia with circulatory arrest quite well, and we therefore continue to advocate use of this procedure in operations for congenital cardiac disease.

Surface-induced profound hypothermia in infant cardiac operations: a new system

A new system of surface-induced profound hypothermia for infant cardiac operations has been developed in order to overcome problems inherent in the current techniques using crushed ice, water baths, and similar methods. The hypothermic chamber consists of two parts: a lower part, containing a refrigeration unit and a blower fan capable of lowering the air temperature in the chamber to -6 degrees C, and an upper part made of Plexiglas that has a completely detachable end to allow easy access to cannulas, the anesthesia hose, and the infant. A temperature panel recorder to monitor the infant's esophageal and rectal temperatures and the ambient chamber temperature is incorporated into the unit. Following evaluation in the animal laboratory, the hypothermic chamber has been successfully used in 10 infants without any complications attributable to the technique. This method provides a rapid and uniform drop of the body temperature and even skin cooling, eliminates the possibility of contact skin lesions, saves medical and paramedical personnel time in preparation of the infant and equipment, and allows observation of the child during the cooling phase. This hypothermic chamber has facilitated infant hypothermic operations.

Coarctation of the aorta in children and adolescents. Surgical treatment and review of 120 patients

Between September 1967 and April 1975, a total of 120 patients between one day and 20 years of age underwent surgery for coarctation of the thoracic aorta. Thirty-two patients were below two years of age (group 1) and 88 were above two years (group 3). All patients in group 1 initially had congestive heart failure. Twenty-eight had associated cardiac defects, and 18 had signficant pulmonary arterial hypertension (greater than 50 mm Hg). Operative deaths occurred only in group 1, all in infants below five months of age. Common features in the 13 deaths were congestive heart failure, pulmonary hypertension, patent ductus arteriosus, large ventricular septal defect, concomitant pulmonary arterial bandling or open-heart procedures. The only recurrence occurred in an infant first operated at 14 days of age. Resection of aortic coarctation can be safely performed as an elective procedure; however, it still presents a high surgical risk in infants with associated intracardiac defects. Late follow-up shows the salutary effects of repair of the coarctation on hypertension.

Failure of the Jatene procedure in a patient with D-transposition and intact ventricular septum

Anatomical correction by arterial "switch" procedure was performed in a patient with transposition of the great arteries, intact ventricular septum, and left ventricular hypertension due to distal pulmonary stenosis. The patient died from left ventricular failure. The reasons for the failure of this procedure are discussed.

Human thymus cells: blastogenic response to mitogens, antigens and allogeneic cells

Over 90 per cent of the thymus cells from each of twenty-six donors were T lymphocytes, identified by E-rosetting and less than 3 per cent of the cells were B lymphocytes identified by EAC-rosetting. With advancing age, the proportion of T lymphocytes decreased while that of B lymphocytes increased. The degree of (3H)thymidine incorporation of thymus cells was inversely proportional to the age of the thymus-cell donor. The PHA or PWM- induced blastogenic response of thymus cells gradually increased with advancing age when the response was expressed as the stimulation index. However, the actual rate of (3H)thymidine incorporation in all three groups was rather similar when cells were cultured with mitogens. The difference in stimulation index was due to the variation in incorporation rate in cultures without stimulants. The PHA response was approximately four-fold higher than that of PWM response. Thymus cell response to allogeneic lyphocytes, on the other hand, had no correlation with the age of thymus donor. The most surprising result in the present study was that the thymus cells from each of ten donors, aged 1-14 years, were incapable of responding to all four different recall antigens. Peripheral blood lymphocytes from nine to ten randomly selected age-matched children responded very well to one or more antigens.

Congenital aortic stenosis. Experience with 43 patients

Between September, 1967, and January, 1975, 43 patients underwent intracardiac repair for congenital aortic stenosis at the Buffalo Children's Hospital. The patients ranged in age from 2 days to 24 years, 6 of them being below one year of age. Valvular aortic stenosis was found in 21 cases (4 infants [Group I-A] and 17 older patients [Group I-B]), discrete subaortic membranous diaphragm in 11 (Group II); diffuse subvalvular muscular obstruction in 3 (Group III), supravalvular stenosis in 4 (Group IV), and multiple-level obstruction in 4 (2 infants [Group V-A] and 2 older patients [Group V-B]). Preoperatively, 58 per cent of the patients were symptomatic and 67 per cent had abnormal electrocardiograms. Associated congenital cardiac defects were found in 28 per cent of the cases. The over-all hospital mortality rate was 9 per cent (3 patients in Group I-A and one in Group V-A), with no deaths occurring in patients older than 3 months of age at the time of operation. Two late deaths occurred (Groups I-B and V-B). A complete heart block developed in one patient (Group III). The average intraoperative peak systolic left ventricular-aortic gradient decreased in all groups after repair but progressively increased in the late hemodynamic studies obtained in symptomatic patients. Six patients were reoperated upon for recurrent obstruction. Late results were evaluated on the basis of symptoms, electrocardiographic findings, valve function, and hemodynamic data. They showed excellent or satisfactory results in 59 per cent of the patients in Group I-B, in 45 per cent in Group II, in 66 per cent in Group III, and in 25 per cent in Group I-V. Results were fair or poor in Groups, I-A, V-A, and V-B. In children and adolescents, effective relief of the obstruction and of the symptoms can be obtained with minimal operative risk and minimal morbidity. In symptomatic infants, despite the high operative mortality rate, surgical intervention is indicated because of the poor prognosis.

Surgical treatment of congenital valvular aortic stenosis

Twenty-two patients with congenital valvular aortic stenosis were surgically treated between 1967 and July 1975. Five (23%) were under 1 year of age (group I) and 17 (77%) were between 2 and 24 years (group II). All infants exhibited severe congestive heart failure and electrocardiographi (ECG) evidence of left ventricular hypertrophy (LVH) with strain pattern. In group II, angina was present in three cases, syncope and fatigue in two; the ECG indicated LVH in 10 cases (59%) with strain pattern in five (29%). A bicuspid aortic valve was present in 77% (17/22) of the cases; 32% had other cardiac anomalies. Aortic valvotomy was performed on cardiopulmonary bypass in 20 cases, and with deep hypothermia and circulatory arrest in two. Three infants under 1 month of age with associated anomalies died (hospital mortality 14%). Intraoperative average peak left ventricular-aortic systolic pressure gradient decreased from 86 to 21 mmHg (P less than 0.001). Late clinical (in all cases) and haemodynamic (26%) follow-up showed severe restenosis in two patients of group II; one of them had a second operation, the other one died three and a half years postoperatively. Results assessed on the basis of symptoms, ECG changes, aortic valve function, and/or haemodynamic findings were fair in the two surviving infants. Results in group II were excellent in three, satisfactory in seven, fair in four, and poor in two cases. In infants, aortic valvotomy is a palliative procedure which carries a high risk. In the older age group, early and late results are more gratifying.

Pulmonary blood flow distribution in transposition of the great arteries

Pulmonary blood flow distribution was studied by scintillation scanning of the lungs after the infusion of iodine- 131-labeled macroaggregates of human albumin before and after the Mustard operation in 53 patients with transposition of the great arteries. The patients were classified as follows: Group I (24 infants with uncomplicated transposition of the great arteries); Group II (18 patients with transposition and ventricular septal defect); and Group III (11 patients with transposition, ventricular septal defect and pulmonary obstruction). Before operation, 21 patients had a normal distribution of pulmonary blood flow, 10 had preferential flow to the right lung and 2 had preferential flow to the left lung. After operation, 19 had a normal pattern of pulmonary blood flow, 21 had preferential flow to the right lung and 3 had preferential flow to the left lung. The scanning studies have proved helpful in follow-up of patients to rule out recurrence of the shunt, pulmonary of systemic venous obstruction, development of pulmonary hypertension and occlusion of a palliative systemic-pulmonary shunt.

Mustard procedure after Baffes operation

Patients in whom Baffes' procedure has been done for palliative treatment of transposition of the great arteries may develop symptom recurrence later in life that deserves further treatment. A modified Mustard procedure is suitable for this purpose; the main difficulty in performing a formal Mustard operation is the proximity of the superior vena cava and of the inferior vena caval graft openings that enable the left pulmonary veins to drain without obstruction into the new atrium. This report deals with a 15-year-old patient in whom a modified Mustard technique was employed as a palliative method.

Complete correction of transposition of the great arteries with left juxtaposition of the atrial appendages

Juxtaposition of the atrial appendages is an uncommon anomaly which is usually associated with transposition of the great arteries. Experience with five patients with transposition of the great arteries in combination with juxtaposition of the atrial appendages in whom Mustard's operation was performed is reviewed. Technically, the existence of juxtaposition of the atrial appendages in corrective surgery for transposition does not present any additional surgical problems. Emphasis is placed on the advantages of early complete correction, avoiding the need for palliative procedure.

Aneurysm of the membranous ventricular septum. Surgical consideration and experience in 29 cases

Twnety-nine cases of aneurysm of the membranous septum in association with various cardiac abnormalities are described. These aneurysms are more common than has been previously thought (10% of the total associated anomalies managed surgically). The patients' ages ranged from 3 months to 28 years. All of the 29 patients were divided into three groups. Group I consisted of 15 patients with ventricular septal defect (VSD), 5 of whom had associated artrial septal defect (ASD). Group II consisted of 5 patients with VSD and pulmonic obstruction, and Group III comprised 9 patients with transposition of the great arteries (TGA). Complete correction was performed in all the patients, and the aneurysm was imbricated in the suture line of the VSD in all cases but one. There was only one hospital death, the result of subpulmonic obstruction. This occurred in the first patient of this series, who had aneurysm of the membranous septum in TGA and VSD and in whom the aneurysm was not suspected preoperatively and was overlooked at surgery. There were no late deaths. In 5 patients a small residual VSD and in 3 patients a small recurrent aneurysm were found in a postoperative study. When these accompanying aneurysms are encountered during surgery or are previously diagnosed, resection or imbrication of the sac should be accomplished in order to prevent further enlargement or postoperative arrhythmias and, especially in TGA, to avoid fatal subpulmonic obstruction as occurred in our only death. According to the present data, in the presence of an aneurysm, even a small VSD should be closed by a patch and the aneurysm should perhaps be excised.

Human thymus cells. Excellent responders but poor stimulators in 'One Way' mixed lymphocyte reaction

Human allogeneic 'one-way' mixed lymphocyte reactions between thymus cells and thymus cells were entirely absent. Of twenty-one mixed lymphocyte reactions between peripheral blood lymphocytes as responding cells and thymus cells as stimulating cells, only eleven had a weak but significant reaction. In contrast, a highly significant response was observed in each of eighteen mixed lymphocyte reactions between thymus cells as responding cells and peripheral blood lymphocytes as stimulating cells and in each of eleven mixed lymphocyte reactions between peripheral blood lymphocytes and peripheral blood lymphocytes. These findings indicate that the thymus cells (T lymphocytes) possess excellent proliferative capacity, with little or no stimulating capacity, while peripheral blood lymphocytes (T and B lymphocytes), on the other hand, are good responders, as well as good stimulators, in the mixed lymphocyte reaction.