Late right heart reconstruction following repair of tetralogy of Fallot.

Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.     

Traumatic incarceration of the jejunum between two lumbar vertebrae.

An unusual case of traumatic herniation of the upper jejunum into the lumbar spine is presented. A suggested mechanism of injury is discussed.     

Valve Replacement in Patients with Native Valve Endocarditis: What Really Determines Operative Outcome?

The influence of 27 variables on operative mortality and late complications (defined as residual or recurrent endocarditis or late bland periprosthetic leak) was determined using discriminant analysis for 108 patients undergoing valve replacement for native valve endocarditis at Stanford University Medical Center from March, 1964, to January, 1983. Congestive heart failure was the indication for valve replacement in 86% of patients. Aortic valve replacement was required in 68% and mitral valve replacement, in 26%. Patients were arbitrarily defined as having active (58%) or healed (42%) endocarditis. Follow-up included 515 patient-years and extended to a maximum of 19 years. Operative mortality was 15 +/- 4%, and 17 patients had late complications (linearized rate, 3.3% per patient-year). Seven variables were significantly related to operative mortality in the univariate analysis, but only organism (Staphylococcus aureus versus all others, p = 0.0302) was a significant independent predictor of operative mortality. For late complications, only 2 of 7 significant univariate covariates proved to be significant independent determinants: organisms on valve culture or gram stain and the presence of annular abscess. Patients with S. aureus endocarditis not showing prompt response to antibiotic treatment must be considered for early operation. Similarly, timely operative intervention for patients with annular abscess will be essential in decreasing late valve infections and perivalvular leaks.     

A dynamic myocutaneous flap for hand reconstruction

Relocation of functional units by neurovascular pedicle transfer is firmly established in reconstructive hand surgery. Transfer of muscle and overlying skin, the myocutaneous flap, to provide skin cover is equally established. The dynamic myocutaneous flap is an extension of these concepts. Injection studies confirmed that the abductor digiti quinti muscle and its overlying hypothenar skin could be transferred on its neurovascular bundle. This dynamic myocutaneous flap was used to reconstruct both skin cover and functional opposition following resection of an arteriovenous malformation involving the thumb. Other clinical applications would include reconstruction of thenar skin and muscle lost secondary to electrical burns, avulsion, or tumor resection.     

Simultaneous Correction of Aortic Coarctation and Partial Anomalous Pulmonary Venous Return

A 23-year-old asymptomatic woman with aortic coarctation and anomalous drainage of the right inferior and left pulmonary veins underwent correction. Coarctation repair was followed by anastomosis of the anomalous vertical vein to the left atrium under femoral-femoral bypass. A left thoracotomy offered excellent exposure for simultaneous repair of this unusual combination of vascular anomalies.     

Patient-related risk factors as predictors of results following isolated mitral valve replacement

Results following isolated mitral valve replacement in 897 consecutive patients over a twelve-year period were analyzed with regard to the influence of various preoperative patient-related risk factors. Actuarial data analysis allowed definition of major preoperative, etiological, clinical, and hemodynamic correlates to both perioperative and long-term postoperative patient survival. Patient age below 60 years, preoperative New York Heart Association Functional Class of III or less, cardiac index greater than 2.0, and left ventricular end-diastolic pressure of less than 12 mm Hg were all highly significant correlates of improved perioperative as well as long-term patient survival. Patients whose predominant functional lesion was mitral insufficiency had only a 53% five-year survival (187 of 352 patients) following mitral valve replacement as opposed to 70% (521 of 745 patients) for those who had mixed or stenotic mitral lesions. Primary ischemic mitral dysfunction was associated with only 31% five-year survival (17 of 54 patients) after mitral valve replacement in contrast to 69% (480 of 695 patients) for patients with rheumatic mitral lesions. The presence of occlusive coronary artery disease coexisting with, but not the primary cause of, mitral dysfunction was associated with decreased perioperative and late postoperative survival. Results support both earlier operative intervention and wider use of associated procedures, ie, coronary bypass grafting, with mitral valve replacement. Recognition of major preoperative patient-related risk factors should enhance survival following this procedure.     

Compartment syndromes of the forearm: early recognition using tissue pressure measurements.

A compartment syndrome of the forearm can be a devastating injury if not relieved promptly by early fasciotomy. Of five patients who developed compartment syndromes, compartment pressures were measured in four and found to average 69 mm Hg. Tissue pressure measurements provided early objective evidence of the presence of the compartment syndrome and contributed significantly to the ultimate functional recovery. We would advise repeating the measurement for pressures in excess of 30 mm Hg in the upper extremity, and fasciotomy for pressures in excess of 40 mm Hg when accompanied by any neurovascular compromise.     

Double-Patch Technique for Correction of Complete Atrioventricular Canal

This technique involves the use of a crescent-shaped Teflon patch to close the ventricular septal defect and resuspend the septal components of the atrioventricular valves. A pericardial patch is used to close the atrial septal defect. Exposure is excellent and allows accurate leaflet rearrangement.     

Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease

Phrenic nerve injury (PNI) with resulting hemidiaphragmatic paralysis occurred in 19 (2.1 +/- 0.5%) of 891 closed cardiac surgical procedures during a twenty-three-year period. Diagnosis was confirmed by standard radiographic criteria. Phrenic nerve injury was most commonly noted following systemic-pulmonary artery anastomosis, ligation of persistent ductus arteriosus plus pulmonary artery banding, and atrial septectomy. Most patients were managed conservatively (nasotracheal or orotracheal intubation and positive end-expiratory pressure). Although no deaths were a direct result of PNI, major complications occurred in 15 of the 19 instances of PNI (79% +/- 10%). The serious morbidity and the hospital costs associated with this complication, however, underscore the cardinal importance of prevention. If injury does occur, early surgical intervention (diaphragmatic plication) in very young infants may reduce the attendant morbidity, but the complete role of diaphragmatic plication remains to be defined.     

Heart-Lung Transplantation for Irreversible Pulmonary Hypertension

Combined heart and lung transplantation was carried out in 17 patients at Stanford University between March, 1981, and December, 1983. The recipients were between 22 and 45 years old. All patients had end-stage pulmonary hypertension; 10 had Eisenmenger's syndrome and the remaining 7, primary pulmonary hypertension. Five patients died within the first few postoperative weeks. The remainder are well between four weeks and 33 months from operation.The immunosuppressive protocol has consisted of cyclosporine with an initial course of rabbit antithymocyte globulin. Azathioprine also was given for the first two weeks and then was replaced with prednisone. Rejection, as diagnosed by cardiac biopsy, was treated with high doses of methylprednisolone. Modifications of technique that have developed include the removal of the recipient heart and lungs separately, and preservation of the lungs with a modified Collins' solution instead of a cardioplegic solution.Rejection occurred in 6 of the 12 survivors. Infections developed in 9 patients, but only one resulted in a fatal outcome (Legionella). Thus, the results of clinical heart-lung transplantation have been considerably superior to clinical efforts in lung transplantation. It is suggested that the combined operation is preferable for the following reasons: (1) all diseased tissue is removed, thus eliminating recurrent infection and ventilation/perfusion disparity; (2) transplantation of the entire heart-lung block preserves coronary–bronchial vascular anastomoses and makes airway dehiscence less likely; and (3) to date, diagnosis of rejection by cardiac biopsy has appeared to be a satisfactory method of diagnosing and treating pulmonary rejection. Cardiopulmonary transplantation represents a viable therapeutic approach for patients with end-stage pulmonary hypertension with or without associated congenital heart disease.     

Clinical experience with a porcine aortic valve xenograft for mitral valve replacement

Between March, 1971, and July, 1973, 103 patients underwent mitral valve replacement with a glutaraldehyde-preserved porcine aortic valve mounted on a flexible polypropylene, Dacron-covered stent. Overall operative survival was 95.1%. Actuarial analysis of late postoperative results indicates 92% survival through 2 years, with functional improvement in nearly all patients. The rate of systemic thromboembolism has been approximately 1.7% per patient-year without anticoagulants. No valve failure has occurred. We conclude that this xenograft prosthesis provides a technically and functionally satisfactory valve substitute, the durability of which appears to significantly exceed that of previously available tissue valves for mitral replacement.     

Simplified operative method for heart and lung transplantation

An operative method was developed to facilitate heart and lung transplantation. Four consecutive operations in small cynomolgus monkeys (average 4.7 kg) are described in which central cannulation and cardiopulmonary bypass were employed. The major modification from previous reports is the use of a retained portion of the right atrium for a single inflow anastomosis. Preservation of the donor sinoatrial node assures normal sinus rhythm postoperatively. The method obviates potential caval stenosis, and would facilitate the operation in man where the intrathoracic component of the inferior vena cava is short.     

Surgical management of transposition of the great arteries.

Sixty-two patients with transposition of the great arteries, ranging in age from one week to thirty-five years, underwent total corrective surgery during a seven year period at Stanford University Hospital. Reported herein are the first pateint to undergo complete correction at out hospital and every subsequent patient until October 1974. Eleven patients died, an overall hospital mortality of 18 per cent. Two of thirty-two patients with transposition of the great arteries and intact ventricular septum died, one of pulmonary hypertension at seven days of age. Nine of thirty patients with transposition of the great arteries and ventricular septal defect with or without pulmonary stenosis died. Cause of death usually was high pulmonary vascular resistance. The Donovan-Rastelli procedure was performed in ten patients, with three deaths, but all patients survived when the inserted right ventricular outflow contained a xenograft aortic valve. Transposition of the great arteries in the first weeks of life must be considered on the individual merits of each case, but the combined medical and surgical approach must be both expedient and thorough if the patient is to survive.     

Surgical implications of low cardiac output syndrome after myocardial infarction

There is a spectrum of conditions that can occur after severe myocardial infarction which cause inadequate cardiac output. Severe and generalized infarction may result in inadequate perfusion of sufficient myocardium to maintain the cardiac work load. Management is limited to supportive measures, including the use of the intraaortic balloon pump. More localized defects of myocardial blood supply can give rise to myocardial rupture. These ruptures may occur in the free wall, within the septum, or within a papillary muscle. Conservative therapy is only indicated as long as improvement continues. Surgical measures should not be delayed in the face of clinical deterioration. They consist of debridement of dead tissue and repair of the defect (or mitral valve replacement if papillary muscle rupture is present).     

Human Heart Transplantation: Current Status

The overall survival rate for 97 heart transplant recipients operated on from 1968 to 1975 has been 49% at one year and 23% at five years. Progressive improvement in one-year survival has been achieved, from 22% in 1968 to 62% in 1974. The major factors responsible for increasing survival are better understanding and management of acute and chronic rejection. Current results suggest that heart transplantation deserves wider application in the treatment of selected patients with end-stage myocardial insufficiency.