Total anomalous pulmonary venous return. Review of 125 patients treated surgically.

One hundred twenty-five patients undergoing surgical correction of total anomalous pulmonary venous return were studied. The overall mortality was 37% and was related to age at the time operation was required. Mortality was 57% during the first year of life, 29% in patients between 13 and 24 months, and 15% in those between 2 and 10 years; no deaths occurred in those over 10 years. Mortality was highest in patients with infracardiac lesions (62%), and lowest in those with cardiac defects (30%). The major cause of death was pulmonary edema, and survival was closely related to the degree of increased pulmonary vascular resistance. Surgical treatment should be delayed until at least 6 months of age, but the development of congestive heart failure may necessitate earlier operation.     

Surgical treatment for anomalous origin of left coronary artery from pulmonary artery.

Anomalous origin of the left coronary artery from the pulmonary artery carries a poor prognosis; most patients die early in life from myocardial infarction and congestive heart failure. During a 12-year period at the Texas Heart Institute, 13 patients with this congenital malformation ranging in age from 1 to 24 years underwent operation. The anomalous coronary artery was sutured or ligated, or both, close to the pulmonary artery in 3 patients, 2 before 1965. Aortocoronary bypass was performed in the remaining 10 patients, using an autogenous saphenous vein graft in 9 and a Dacron tube in 1. More recently a distal end-to-side anastomosis has been employed and is not the preferred method. If necessary, a pump oxygenator may be used to complete the procedure. The only death was that of the first patient in the series who underwent ligation of the left coronary artery and mitral annuloplasty for severe mitral insufficiency; Of the 12 patients available for long-term follow-up study, all but 1 were asymptomatic. Follow-up angiographic studies showed the graft to be patent in 7 patients; the longest period of graft patency was 8 years. Definitive operative therapy is preferable to simple ligation because it eliminates the left-to-right shunt from the right coronary artery to the pulmonary artery and establishes a double coronary artery system.     

The terminal pathway of the lymphatic system of the human heart

Aantomical dissections in 9 human cadavers revealed the terminal pathway of the lymphatic system of the left ventricle to be constituted mainly by channels emptying into the right angulus venosus (junction of the internal jugular and subclavian veins) at the base of the right side of the neck. This observation has clinical implications because it has been shown that a sampling of cardiac lymph provides the best method for analyzing myocardial metabolic abnormalities and that drainage of cardiac lymph alleviates the myocardial changes produced by ischemic injury.     

Aortocoronary saphenous vein bypass. Results in 1,492 patients, with particular reference to patients with complicating features

During a 33-month period ending June, 1972, 1,492 patients underwent aortocoronary saphenous vein bypass (ACB). The early mortality with ACB alone was 7.1%, while mortality was more than double (14 of 86 patients died) when ACB was combined with resection or plication of a ventricular aneurysm. Twenty of 84 patients died in the early period following combined ACB and valve resection. One patient among 8 who had concomitant resection of an ascending aortic aneurysm died after operation. Factors that increased mortality in this series were advanced age, female sex, high coronary artery scores, left main coronary artery lesions, high left ventricular end-diastolic pressure, left ventricular dysfunction, congestive heart failure, the requirement for endarterectomy to perform the anastomosis, and recent acute myocardial infarction. Actuarial data from patients who underwent ACB without concomitant procedures show an annual attrition rate of 2.7% per year, which compares to rates of 4, 6, and 10% for patients with single, double, and triple coronary disease treated without operation. In 311 men and women under the age of 70 who had a coronary artery score below 13 and none of the other risk factors, the early mortality was 1.6% (5 patients) and the late mortality was 1.0% (3 patients).     

Effects of an Abdominal Left Ventricular Assist Device on Myocardial Oxygen Supply/Demand Ratios in Normally Perfused and Ischemic Bovine Myocardium

The effects of an abdominal left ventricular assist device (ALVAD) on subendocardial oxygen supply/demand ratios as reflected by diastolic pressure-time index/tension-time index (DPTI/TTI) were investigated in calves. Control DPTI/TTI ratios were 1.09 ± 0.12 (mean ± SD). With ALVAD actuation the ratios increased to 5.73 ± 3.2. Following circumflex coronary artery occlusion, control ratios decreased to 0.04 ± 0.05 in the ischemic area and 0.97 ± 0.20 in the nonischemic areas. With ALVAD actuation in the presence of circumflex occlusion, the depressed ratios were increased to 1.37 ± 0.39 in the ischemic zone and 9.71 ± 2.5 in the nonoccluded segments. Subendocardial oxygen supply/demand ratios were significantly improved by ALVAD assistance following induced subendocardial ischemia.     

Transaortic repair of ventricular septal defect

A technique is described for repairing defects of the interventricular septum using an aortotomy incision. This approach allows excellent access to the membranous septum, where more than 80% of defects occur. While the standard transventricular or transatrial approach serves best in most instances, the transaortic exposure may be a useful alternative in the small defect, to avoid ventriculotomy, or in some complicated anomalies.     

Conduit reconstruction of right ventricular outflow tract. Experience with 17 patients.

Evaluation was made of 17 patients who underwent conduit reconstruction of the right ventricular outflow tract (for anomalies other than truncus arteriosus) at the Texas Heart Institute between December, 1965, and June, 1974. Fifteen patients survived the operation and have shown substantial clinical improvement. Several different conduits were used, principally an allograft aorta with the aortic valve and mitral leaflet attached, a woven Dacron prosthesis containing a xenograft (porcine) valve, and a valveless Dacron tube graft. Allograft conduits are sometimes difficult to procure and keep and tend to calcify with passage of time. Woven Dacron prostheses are favored because they are readily available in a wide range of sizes. We believe it is not necessary for the conduit to contain a valve unless the patient has pulmonary hypertension, in which case we use a xenograft (porcine) valve because this valve does not require the long-term use of anticoagulants, a difficult regimen to manage in children. The largest possible prosthesis must be used; otherwise right ventricular hypertension will persist. Indications for conduit reconstruction include anomalous coronary arteries crossing the right ventricular outflow tract, discontinuity of the pulmonary arteries, and pulmonary atresia with a ventricular septal defect. Our current method of managing pulmonary atresia with ventricular septal defect (pseudotruncus arteriosus) includes palliative shunting to relieve hypoxemia during infancy and to permit full development of the pulmonary arteries for eventual total correction at a more optimal age when a larger conduit may be used.     

Contoured knitted Dacron baffle for repair of transposition of the great vessels

Complications related to the late deterioration in the autologous pericardial baffle used in the surgical correction of transposition of the great vessels may be prevented by using a fabric graft. A contoured knitted baffle is described that may be fabricated from available knitted crimped Dacron vascular prostheses.     

Single (left) superior vena cava draining into the left atrium. Surgical repair

Anomalous drainage of a single left superior vena cava into the left atrium is rare, and correction presents a technical problem. This report describes a patient with absent right superior vena cava, a persistent large left superior vena cava draining to the left atrium, and an intact interatrial septum.Surgical correction was accomplished by removing the entire septum and placing a cloth baffle to cover the orifices of the pulmonary veins and mitral valve, thus partitioning pulmonary venous blood into the left ventricle. This technique of septal excision and replacement is applicable to other complicated anomalies involving the systemic and pulmonary venous channels and their relationship to the two atria.The surgical management of related anomalies of the superior vena cava is also discussed.     

An Abdominal Left Ventricular Assist Device: Preclinical Studies

An abdominally positioned left ventricular assist device (ALVAD) has been evaluated in our most recent series of 25 calves weighing 99 ± 12 kg. The ALVAD is a pneumatically actuated bladder pump, positioned subdiaphragmatically and connected between the left ventricular apex and the infrarenal abdominal aorta. The mean survival time in the calves was 41 days and the longest 65 days. The major effects of the pump are reductions of all indices of left ventricular work and increases in systemic perfusion. In the awake, unanesthetized calf, left ventricular pressure, dP/dt, and stroke work were decreased while peak aortic pressure, stroke volume, and cardiac output increased. These effects were corroborated at cardiac catheterization two to four weeks postoperatively; left ventriculograms also showed increases in ejection fraction. These data demonstrate the ALVAD's effectiveness in assuming left ventricular function and support over extended periods. The device has been developed for short-term postoperative clinical use in patients with reversible left ventricular failure.     

Late Embolization of Prosthetic Mitral Valve Occluder with Survival Following Reoperation

Embolization of the occluder from a prosthetic mitral valve is an extremely rare event. Previous reports in the literature have described the uniformly fatal outcome of this complication. A case in which the occluder from a Wada-Cutter mitral prosthesis embolized five years following implantation is presented. The patient survived following emergency reoperation. Several unique features of escaped mitral poppet are discussed. Depending upon cardiac reserves, patients who have this complication may live long enough to allow emergency operative intervention and eventual recovery.     

The hypertrophic scar: Location of glycosaminoglycans within scars

Parallel chemical and histochemical studies were made on several hypertrophic scars in order to identify the localization of the elevated chondroitin-4-sulphate found in hypertrophic scars. For chemical and electrophoretic studies, the nodular areas were dissected from the rest of the scar and studied separately using electrophoretic methods of separation with and without chondroitinase AC and chondroitinase ABC. For histochemistry, glycosaminoglycan-specific stains were used before and after use of hyaluronidase, chondroitinase AC and chondroitinase ABC.In active hypertrophic scars the histochemical studies indicated that either chondroitin-4-sulphate or chondroitin-6-sulphate was localized in the nodular area. Electrophoretic studies indicated that chondroitin-6-sulphate was not present to an appreciable extent and that the nodular areas were much higher in chondroitin-4-sulphate. Hypertrophic scars undergoing maturation had lesser amounts of chondroitin-4-sulphate, but the nodular areas were higher in this glycosaminoglycan than was the respective total scar. One scar which was most mature, by histological examination, had essentially the same chondroitin-4-sulphate levels in both nodular areas and total scar tissue areas.These results suggest that the nodular regions are the actively proliferating areas in hypertrophic scars and that the presence of chondroitin-4-sulphate is related to this proliferation.     

Anomalous origin of the right coronary artery from the pulmonary artery.

Three patients with anomalous origin of the right coronary artery from the pulmonary artery are presented together with a review of the 14 patients with this anomaly previously reported. One of the current patients is the youngest to be diagnosed before operation and the youngest to undergo corrective operation. Although the lesion is usually asymptomatic, it may contribute to sudden death. The only suggestive physical finding is a continuous murmur with diastolic accentuation, which is present only in some patients. There are no diagnostic electrocardiographic or chest roentgenographic changes. Diagnosis is made best by selective left coronary arteriography showing retrograde filling of the right coronary artery from collateral vessels. Operative repair should consist either of direct reimplantation of the proximal right coronary artery into the aortic root or of saphenous vein bypass graft to the coronary artery with ligation of its origin. Operation is recommended when the lesion is recognized.     

Reversibility of lesions in experimental pulmonary hypertension. Preliminary observations.

Severe pulmonary hypertension with obliterative vascular disease was induced in 13 of 44 dogs subjected to systemic-to-pulmonary artery anastomosis to the left diaphragmatic lobe. In 11 of these, plus 4 with high pressure but normal histology and 4 with normotensive lobes, for a total of 19, reanastomosis to the main pulmonary artery was performed. Only 1 of the histologically abnormal lobes maintained vascular patency; the 5 other dogs with patent reanastomoses had normal vascular histology. Our findings support the reluctance of surgeons to correct cardiac shunts when obstructive vascular disease due to severe pulmonary hypertension is present; in humans pulmonary artery pressure would not drop as much as in our model since the pulmonary vascular resistance of both lungs is high. On the other hand, if a normal lung were transplanted at the same time, the retained abnormal lung would probably lose vascular perfusion.     

Surgical Treatment of Aneurysms of the Transverse Aortic Arch: Experience with 25 Patients Using Hypothermic Techniques

Surgical treatment of aneurysms of the transverse aortic arch has been a challenge to cardiovascular surgeons. The problems include protection of the brain and spinal cord from ischemic or embolic injury, prevention of hemorrhage and coagulopathy, and prevention of myocardial damage during prolonged extracorporeal circulation.Two methods are described. Group 1 included 20 patients in whom deep hypothermic conditions were induced (12° to 16°C) followed by circulatory arrest and partial exsanguination. In this group a 50% hospital mortality occurred. Patients in Group 2 underwent moderate induced hypothermia (24° to 26°C) with continuous cerebral perfusion during the period of peripheral circulatory arrest. Four of 5 patients survived this technique, leading us to believe this method is preferred over the deeper levels of hypothermia.A method of preclotting the Dacron graft with platelet-rich plasma and autoclaving is described. It has eliminated interstitial bleeding through fabric grafts.     

Modified Procedure for Correction of Truncus Arteriosus,Types II and III

A new modified procedure for correction of types II and III truncus arteriosus defects is described. This method of intraluminal aortic patch placement to partition the pulmonary and systemic circulation has certain distinct technical and anatomical advantages in patients with this type of congenital defect. Further, as the patient grows, it may prove to be a more versatile procedure.     

A review of pulmonary problems following valve replacement in 100 consecutive patients: The case against routine use of assisted ventilation

Using strict indications for its use, controlled ventilation was found necessary in only 10 of 100 consecutive patients undergoing valve replacement performed by the authors. The remainder were extubated promptly following operation and did not require controlled ventilation at any time during their postoperative course. While controlled ventilation was more common in patients in certain subclassifications based on preoperative data (N.Y.H.A. Class IV, elevated pulmonary artery pressure, age over 60), 5 of the 10 patients (50%) required respiratory support on the basis of developments occurring during or after operation.Our data indicate that routine use of controlled ventilation following cardiac surgery is unnecessary, as the majority of patients ventilate satisfactorily after operation without the use of respirators. Not using respirators simplifies the postoperative care of these patients and avoids any associated undesirable sequelae.     

Takayasu's arteritis: surgical considerations.

Takayasu's arteritis, the nonspecific occlusive disease originally believed to affect young Oriental women exclusively, was identified in a 19-year-old man who had severe involvement of the aortic arch and its branches. Successful surgical treatment was accomplished with a bypass from the ascending aorta to the supraceliac abdominal aorta using a tube graft. The right vertebral artery, as the single patent vessel reaching the head, was revascularized distal to the stenosis with a tube graft that extended from the aortic graft. Revascularization of ischemic organ systems and body areas may be accomplished in most patients with Takayasu's arteritis using the bypass concept and fabric conduit grafts.     

Prefabricated Dacron baffle for use in correction of transposition of the great arteries.

Interatrial venous transposition for correction of transposition of the great arteries (TGA) is facilitated by using a premolded Dacron baffle. Fine-mesh Dacron is easily fashioned to the desired shape in a metallic brass mold at 200 degrees C. The resultant baffle material can be autoclaved without losing its shape or altering the fabric characteristics of flexibility and porosity. This premolded baffle has been used in our last 7 patients with TGA over the past two years without complication, and the use of Dacron in 13 survivors over the past seven years has shown no pulmonary or venous obstructions related to the material.     

Protection of the Myocardium with High-Energy Solutions

An approach to intraoperative protection of the myocardium is described that attempts to increase glucose utilization by infusion of high-energy solutions during aortic cross-clamping. Infusion of hypertonic glucose or glucose plus insulin prior to aortic cross-clamping has enhanced contractility and increased high-energy phosphate moieties in animals with induced ischemia. Recent pilot experiments in our laboratory suggest that infusions of creatine may result in increased production of creatine phosphate, which in turn induces phosphorylation of adenosine diphosphate to adenosine triphosphate, possibly enhancing myocardial contractility. The intraoperative clinical benefits of these infusions remain to be proved, however.