Results of radionuclide assessment of cardiac function following transplantation of the heart

Radionuclide assessment of ejection fraction was determined early and late postoperatively following cardiac transplantation in 16 patients. In 11 patients, ejection fraction was determined within 48 hours of an endocardial biopsy. There was no relationship between the severity of histologically evident rejection and the ejection fraction (Pearson correlation coefficient [r] = -0.11; p = 0.47). In 2 patients, severe graft fibrosis developed with consequent diminution in ejection fraction. There was no relationship between severity and duration of rejection or the amount of immunosuppression required to treat acute rejection and the development of graft fibrosis. The mean resting ejection fraction in 7 patients in follow-up ranging from 6 to 21 months after transplantation was 0.59 +/- 0.06 (standard deviation), and the mean exercise ejection fraction in 6 of these patients was 0.72 +/- 0.08. Radionuclide-determined ejection fraction is not predictive of rejection early after operation. During short-term late follow-up, systolic left ventricular function at rest and exercise has been retained at normal levels.     

Morbidity and mortality of coronary bypass grafting in patients 70 years of age and older

The hospital mortality and major factors contributing to hospital morbidity and postoperative length of stay were examined in 597 consecutive patients 70 years of age and older who underwent isolated coronary artery bypass grafting (CABG) between January, 1978, and December, 1983. The mean age of the patients was 73 years, and 66% were men. Unstable angina was present in 59% of patients, left main coronary disease in 13%, and moderate or severe left ventricular dysfunction in 10%. The mean number of arteries grafted per patient was 3.4. The hospital mortality was 2.7% (16 patients) and was higher than the mortality among 4,125 patients less than 70 years of age (0.4% in 18 patients) operated on during the same interval (p less than 0.001). In multivariate regression analyses, age of 80 years or greater, evolving myocardial infarction, serious coexisting illness, major left ventricular dysfunction, emergent operation, and the development of major postoperative complications were significant (p less than 0.05) independent predictors of increased hospital mortality. Major complications occurred in 135 patients (23%). In multivariate analyses, the presence of vascular disease, serious concomitant illness, and the need for urgent or emergent operation were significant independent predictors of the development of major postoperative complications. The mean duration of postoperative hospital stay was 10.6 +/- 6 (standard deviation) days. In multivariate analyses, the development of major postoperative complications was the only variable independently predictive of prolonged hospital stay. With current techniques, CABG procedures can be safely performed in the elderly with mortality and morbidity rates only slightly higher than those in younger patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Concepts and practices in surgery for total anomalous pulmonary venous connection.

In the last ten years there have been extensive refinements in the surgical approach to total anomalous pulmonary venous connection (TAPVC). This communication reviews determinants of hosptal mortality and controversies in surgical management. As examples of current experience with repair of TAPVC, recent results at the University of Alabama and a combined analysis of hospital mortality for Alabama, Children's Hospital Medical Center in Boston, and Green Lane Hospital are reported. From July, 1974, to July 1977, the Alabama hospital mortality among the 17 infants with supracardiac, cardiac, and infracardiac TAPVC was 12% (2 infants).     

Survival and probability of cure without and with operation in complete atrioventricular canal.

Actuarial analysis based on postmortem examination of patients who had been treated nonsurgically for complete atrioventricular (A-V) canal defect shows that only 54% survive to 6 months of age, 35% to 12 months, 15% to 24 months, and 4% to 5 years of age. Our surgical experience since 1975 in 39 patients confirms the idea that primary repair is feasible in small infants. The highest risk of hospital death is when the operation is done in the early months of life; it falls to 17% by age 12 months. Between 1967 and October, 1976, the five-year survival rate among patients leaving the hospital alive after repair was 91%. The age-specific probability of "surgical cure" of patients operated upon for complete A-V canal (alive five years later with mean pulmonary artery pressure less than 25 mm Hg) is maximal at 73% when the operation is done at about 14 months of age. Urgent earlier repair is frequently necessitated by the life history of the disease.     

Early Results of Valve Replacement with the Björk-Shiley Convexoconcave Prosthesis

The Björk-Shiley convexoconcave prosthetic valve has design characteristics that may result in a lower incidence of thromboembolic complications than the conventional spherical Björk-Shiley prosthesis. We evaluated the results of valve replacement with the convexoconcave prosthesis in 248 patients receiving 301 prosthetic valves between March, 1979, and June, 1981. One hundred thirteen patients had aortic valve replacement (AVR), 73 had mitral valve replacement (MVR), and 62 had multiple valve replacement. Two hundred nine (84%) were in New York Heart Association Class III or IV. The median duration of follow-up was 13 months, and follow-up information was available for 246 (99%) of the patients. The actuarial incidence of freedom from thromboembolism at two years was 98% in the AVR group, 97% in the MVR group, and 87% in the group having multiple valve replacement. There were no documented episodes of valve thrombosis or mechanical failure and no fatal thromboembolic complications. The absence of valve thrombosis is in marked contrast to the results reported with the spherical disc valve. Although longer follow-up is necessary, it appears that the convexoconcave design represents a major improvement in the Björk-Shiley prosthesis.     

Bullet Emboli to the Pulmonary Artery: A Report of 2 Patients and Review of the Literature

Bullet embolization to the pulmonary artery is a rare event. The purpose of this study is to report our experience with 2 patients and to review the 15 patients reported in the literature, with special emphasis on a rather peculiar complication that has occurred in 4 of the 9 patients who underwent bullet embolectomy: dislodgment of the missile during the surgical procedure and migration to the down-side lung, for which a second thoracotomy was required in 3 of those patients.The usual untoward effects of foreign bodies in the vascular system were seen in this series: embolization with thrombosis, sepsis, erosion and hemorrhage, and vascular occlusion with infarction.This review suggests that operative removal of a bullet in the pulmonary artery is necessary. The operation is safe and uncomplicated if precautions are taken to prevent the missile from migrating during manipulation of the lung.     

Detection of Myocardial Injury after Coronary Artery Bypass Grafting Using a Hypothermic,Cardioplegic Technique

Fifty patients undergoing isolated coronary artery bypass grafting procedures using a clear, cold cardioplegic solution, topical hypothermia, and reduced systemic flow for intraoperative myocardial protection were evaluated for myocardial injury by serial plasma creatine kinase–MB isoenzyme (CK-MB) measurements and electrocardiograms. Forty-one (82%) of the patients had three-vessel disease. Preoperative left ventricular contractility determined angiographically was normal in 13 patients (26%), mildly abnormal in 26 (52%), and moderately or severely abnormal in 11 (22%). The number of arteries grafted ranged from 2 to 6 (mean, 3.5). The mean duration of aortic clamping was 38.6 ± 1.6 minutes. There were no hospital deaths. Enzymatic and electrocardiographic (ECG) evidence of myocardial infarction occurred in 1 patient. Nonspecific ECG changes occurred in 16 patients (32%), and the electrocardiograms were unchanged in the remaining 33 patients (66%). In the 49 patients without ECG evidence of infarction, the mean peak plasma CK-MB value, which occurred 6 hours after the onset of cardiopulmonary bypass, was 7.9 ± 0.8 IU/L (standard error of the mean) and the mean integrated area 158 ± 19.5 IU/L × hours. There was no correlation between these CK-MB values and the extent of disease, number of arteries grafted, or the duration of myocardial ischemia. These data document a low incidence of perioperative myocardial injury with this technique, and can serve as a baseline for comparison with other techniques for intraoperative myocardial protection in this setting.     

The Early Risk of Re-replacement of Aortic Valves

One hundred two patients underwent re-replacement of the aortic valve, 95 having a first reoperation, 6 a second, and 1 a third. The early (30-day) mortality among the 81 patients undergoing an elective first reoperation was 3.7% (with 70% confidence limits of 1.63% and 7.32%). Fourteen patients undergoing their first reoperation did so urgently, and 6 (42.9%) died early postoperatively. Technical problems during reoperation were uncommon. Fifteen of the 102 patients underwent reoperation because of infection in or around the device; 2 (13.3%) died early postoperatively, and at least 3 more died within nine months of operation. These data, with their 70% confidence limits, are useful in arriving at a decision for or against reoperation in individual patients.     

Classic shunting operations as part of two-stage repair for tetralogy of Fallot.

One hundred forty-nine consecutive patients with tetralogy of Fallot, with or without pulmonary atresia, underwent Blalock-Taussig or Waterston operation for initial palliation. Of these patients, 45 were less than 6 months old, and 63 were less than 1 year old. The type of shunt, and the presence or absence of pulmonary atresia did not have a significant effect (p greater than 0.2) on hospital mortality. Parametric analysis showed a significant effect of age (p = 0.03), the risk of hospital death being 6% at 1 month of age, 4% at 3 months, 3% at 6 months, and 2.5% at 12 months. No late deaths occurred before the age of 3 years. Six patients (4.2% of the hospital survivors) required another operation before they were 3 years old. Severe arm ischemia occurred after a Blalock-Taussig shunt in 1 infant with Down's syndrome.     

Low-energy direct defibrillation of the human heart.

A direct cardiac defibrillation study in 30 patients who underwent heart operations with cardiopulmonary bypass and moderate systemic hypothermia is presented. No patient required more than 10 watt-seconds of energy for defibrillation, and, in 21 of them, 5 watt-seconds or less were sufficient.     

The Performance of the Braunwald-Cutter Aortic Prosthetic Valve

Four hundred seventy-five patients underwent aortic valve replacement with the Braunwald-Cutter ball-valve prosthesis at two institutions. The early (30-day) hospital mortality was 4.7% for those with isolated aortic valve replacement and 6.9% for the entire group. For the former, 5-year actuarial survival of the hospital survivors was 72 ± 5.7%; for the latter group it was 71 ± 4.4%. Eleven patients (5 since the date of follow-up inquiry) have Suffered poppet escape, 9 of whom died. The actuarial incidence of known poppet escape is 4 ± 2.6% at 47 months; when the 5 patients suffering poppet escape since the date of follow-up inquiry are included, with certain assumptions, the incidence is 3.7 ± 1.14%. The projected probability of poppet escape using all 11 patients is 12.2% at 5 years; the 70% confidence bands of projected probability of poppet escape separate from those of the risk of rereplacement at 61 months. This and other analyses indicate that in general, patients with the Braunwald-Cutter aortic prosthesis should have it replaced 4 1/2 to 5 years after its insertion.     

Surgical experience with unroofed coronary sinus.

Between January, 1967, and October, 1977, we performed intracardiac repair in 24 patients with unroofed coronary sinus. Eight patients had the so-called pure form of the syndrome, with the concomitant findings of total absence of the partition between the coronary sinus and left atrium, connection of the left superior vena cava (LSVC) to the upper left corner of the left atrium, and a coronary sinus type of atrial septal defect. In 2 additional patients this combination was repaired, along with repair of the common atrium in 1 and tetralogy of Fallot in the other. In 4 patients with either a partial or complete atrioventricular canal defect, only the distal or downstream portion of the sinus was unroofed so that the coronary sinus ostium was considerably to the left of its usual location. In 6 patients, 5 of whom had situs ambiguous, the unroofed coronary sinus was associated with complex congenital heart disease, and in 5 there was a L(contralateral) SVC. Three of these 6 patients died. The basic repair consists of roofing the coronary sinus from within the left atrium, so that the LSVC drains through the newly created coronary sinus and its ostium into the right atrium. In the absence of a LSVC, the basic repair is simply closure of the coronary sinus atrial septal defect. This leaves the coronary veins draining into the left atrium.     

Cardiac Surgery in a Small Community: An Eight-Year Experience

Long-term results of 374 open-heart procedures performed over an eight-year period in a small community hospital are presented. Patients were followed up for an average of 49 months. The heart unit did not conform to the yearly volume of cases suggested by current national guidelines. Nonetheless, we obtained some interesting results. 1. The hospital mortality in nonemergency coronary artery bypass operations was 1.8%; in all types of bypass operation, 3.3%; and 5.1% for all types of cardiac operation. 2. The attrition rate was less than 1% per year for all types of patients with a total long-term survival of 92%. 3. Patients having coronary artery bypass had a yearly attrition rate of 0.66% and a total long-term survival of 94.2%. 4. The average hospital cost per patient having open-heart operation was $9,670 in 1978 and $11,073 in 1979.Case volume requirements for an open-heart-surgery unit in our area allowed an exception from the guidelines with emphasis on quality of results rather than quantity. This permitted comprehensive cardiac care especially for the poor and those with fixed incomes unable to afford the cost of traveling and associated expenses. Further similar reports may be valuable in the formulation of health policies for small communities that guarantee the health rights of all segments of the population.     

The tri-F titer: a rapid test for estimation of plasma fibrinogen and detection of fibrinolysis, fibrin(ogen) split products, and heparin

The use of extracorporeal circulation has been associated with operative and postoperative hemorrhage. In patients on the pump there are a number of different pathogenetic mechanisms that lead to hemorrhagic disorders. In essence the hemorrhagic diathesis is caused by the increased utilization or destruction of hemostatic factors, the presence of circulating anticoagulants, a reduction in hemostatic factors due to underproduction or dilution by transfused banked blood, or all three. The tri-F titer (TFT) is a new rapid and reproducible test that gives an estimate of the fibrinogen concentration and detects the presence of fibrinolysis, fibrin(ogen) split products, and circulating heparin. The use of the TFT in the diagnosis of various coagulopathies is discussed. The TFT, which depends on the formation and observation of clots in vitro, is considered to have distinct advantages over other tests which rely on immunological, solubility, and other physicochemical phenomena.     

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.     

Air gun pellet injury of the heart with popliteal embolus

An air gun pellet cardiac injury, in which there was penetration through the right ventricle, interventricular septum, and anterior papillary muscle and ejection from the left ventricle, is described. The pellet embolus was removed from the left popliteal artery with restoration of flow. The particular implications of pellet embolization are discussed and contrasted with those of bullet embolism.     

A Rational Approach to Total Thymectomy in the Treatment of Myasthenia Gravis

Thymectomy is important in the treatment of myasthenia gravis. Total removal of the gland is considered indicated. Although median sternotomy has been the accepted surgical procedure, the transcervical approach has been advocated as a safer method of achieving total thymectomy.A surgical-anatomical study of the thymus was made in 22 patients. A high incidence of surgically important variations in thymic anatomy was found in the neck and in the mediastinum. We believe wide exposure by way of median sternotomy with direct vision is required to remove all of the extracapsular mediastinal thymus in many patients, and good cervical exposure is required to remove the anomalous tissue in the neck.If a total thymectomy is to be achieved, we recommend a median sternotomy and a cervical incision, using the meticulous dissection described.     

Treatment of severe coronary artery disease with 5, 6, and 7 saphenous vein bypasses: review of 131 consecutive patients.

One hundred thirty-one consecutive patients who received 5, 6, and 7 bypass grafts are analyzed. Ages ranged from 31 to 74 years. The male-to-female ratio was 7:1. As an indication of severity of disease, 25% were classified as having impending myocardial infarction and 46.6% were classified in New York Heart Association Functional Class IV. Left ventricular function was impaired in 37.4%, and 30% of the patients had left main coronary obstruction. Nonfatal perioperative myocardial infarction occurred in 4.6%. The hospital mortality was 3%. One hundred percent follow-up (5 to 55 months) revealed 4 late deaths, 3 presumably of cardiac origin. Only 7 patients in the postoperative follow-up group have complained of angina; 1 has since undergone successful reoperation.     

Traumatic pulmonary pseudocysts.

From July, 1973, to June, 1977, 25 patients in an immunosuppressed state from underlying reticuloendothelial neoplasm or associated chemotherapy, underwent open biopsy of the lung at the University of Maryland Hospital for diagnosis of unilateral diffuse pulmonary infiltrates. Eight patients were in marked respiratory distress, 13 in moderate distress, and 4 in little or no distress at the time of open lung biopsy. There were 3 postoperative deaths (12%). The operation-related morbidity was 1 out of 25 (4%). Two of the patients who died were found to have irreversible pulmonary fibrosis secondary to bleomycin drug therapy. The subsequent treatment of all 25 patients was influenced by the biopsy findings as follows: upgrading the disease stage or establishing treatment failure in 11 patients; establishing the presence of inflammatory disease in 3 patients; establishing the diagnosis of fibrosis associated with drug treatment without recurrent disease or infection in 11 patients. The preferability of open lung biopsy as opposed to transbronchial or percutaneous techniques is discussed.     

The relationship of glucagon and insulin to sequential changes in metabolic fuel utilization in shock

Previous studies in the dog have demonstrated significant alterations in the mobilization of metabolic fuel during shock. In particular, mobilization of depot fat is markedly depressed. The present study examines the sequential utilization of nonlipid fuels over a 24-hr shock period. Metabolic rates were unchanged from controls. Skeletal muscle glycogen fell exponentially from 7.0 ± 0.5 to 2.7 ± 0.2 mg/g (P < 0.001) after 24 hr of shock. Protein breakdown as reflected by urea production was linear throughout the period and increased 50% over controls (P < 0.001). Lactate levels did not reflect changes in metabolic rate but fell to nearly normal levels once muscle glycogen was depleted. The contribution of CHO and protein combined to CO₂ production fell from 70% in early shock to 42% in the final 12 hr of the 24-hr shock period. This compares to 23% in controls. Protein catabolism alone accounted for an average of 32% of CO₂ production in shock. While insulin levels rose slightly in early shock and then fell, glucagon rose rapidly in the first 5 hr of shock and then remained significantly and constantly elevated throughout the entire shock period. The insulin-glucagon molar ratio remained in the severely catabolic range throughout.