Surgical Approach to Corrected Transposition of the Great Vessels and Situs Inversus {I,D,D} with Ventricular Septal Defect and Systemic Atrioventricular Valve Regurgitation

Successful surgical repair of a 4-year-old boy with situs inversus {I,D,D} and corrected transposition of the great vessels (TGV) as well as hemodynamically significant ventricular septal defect (VSD), systemic atrioventricular (tricuspid) valve regurgitation, and atrial septal defect is described. Unique technical aspects of VSD and tricuspid valve repair in association with corrected TGV and situs solitus or inversus are discussed and clarified.     

Intraventricular Repair of Double-Outlet Left Ventricle

A 3 ½-year-old child with double-outlet left ventricle and subaortic ventricular septal defect underwent successful surgical intervention with an intraventricular repair and a boomerang-shaped piece of Dacron patch. While an intraventricular repair for double-outlet left ventricle has been reported, we discuss here its application to this particular type of double-outlet left ventricle.     

A New Instrument for Surgical Creation of an Atrial Septal Defect

An instrument for surgical creation of an atrial septal defect (ASD) was designed and tested in puppies weighing an average of 4.7 kg. Oxygen saturations were obtained in both atria, the superior vena cava, and the inferior vena cava before and after septectomy. The instrument has a cutting cylinder introduced into the right atrium (RA) through the right atrial appendage with a second part (baseplate) inserted into the left atrium (LA) just posterior to the interatrial groove. In 21 animals (Group 1), a single hole was created in dogs killed 48 hours later. In 9 animals (Group 2), an attempt was made to create two adjoining holes. In 14 animals (Group 3), a single hole was created and the dogs were allowed to triple their body weight before they were killed.Group 1 dogs demonstrated a 10% increase in average venae cavae—RA oxygen saturation immediately after septectomy and a 9.4 ± 0.37 mm diameter of the ASD at death; in Group 2, there was a 14% average step-up and a 12.7 ± 0.6 mm diameter of the ASD; and in Group 3, the diameter of the ASD was 11.5 ± 0.4 mm, representing a 50% increase in average area with dog growth compared with that of Group 1. After this experience in the production of ASDs in 44 experimental animals, we find that this instrument seems to be reliable, simple, and safe.     

Surgical Treatment of Primary Sternal Osteomyelitis

Four patients with primary sternal osteomyelitis are described. Pseudomonas aeruginosa was the infective organism. Three of the 4 were heroin addicts. Limited surgical resection with preservation of the posterior periosteum is recommended for an infected sternum. Postoperative antibiotic therapy for a period of six weeks is also recommended. Preservation of the posterior sternal periosteum rather than conventional radical excision is important for maintaining physical stability and avoiding chest wall deformity in this group of patients.     

Surgical treatment of aneurysms of the sinus of Valsalva.

From 1962 to 1976, 15 patients with aneurysms of the sinus of Valsalva underwent operative correction. All patients survived operation. Follow-up has been carried out for as long as fifteen years (median, six years) after operation. There have been no late deaths and no recurrences. Aortic insufficiency, present in 2 patients before and in 2 after operation, remained well compensated and required no further aortic valve procedure. A double approach, that is, through both the aorta and the involved cardiac chamber, is recommended for sufficient correction.     

Cyanosis in atrial septal defect due to persistent eustachian valve

Two cyanotic patients had venoarterial shunting from the inferior vena cava to the left atrium in an uncomplicated atrial septal defect with normal right ventricular pressures. Cyanosis was due to a large, anomalous inferior vena caval valve, the eustachian valve. The mechanism of cyanosis and technical problems for surgical repair are discussed.     

Acquired Left Ventricular–Right Atrial Fistula Following Aortic Valve Replacement

Intracardiac communications produced as a complication of valve replacement can result in left-to-right shunts and a poor surgical result. The successful surgical closure of a left ventricular–right atrial fistula following aortic valve replacement is discussed. The intricate relationships of the membranous interventricular septum, the aortic, mitral, and tricuspid valves, and the aortic root predispose to the creation of abnormal intracardiac shunts when aggressive debridement of extensive valvular calcification is performed at the time of valve excision and replacement.     

Simultaneous Repair of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery and Mitral Regurgitation

A 20-month-old boy with anomalous origin of the left coronary artery from the pulmonary artery was successfully treated by combining aortic implantation of the left coronary artery and simultaneous mitral valve replacement. We describe our operative technique and emphasize that in the definitive treatment of this anomaly, it is advisable to not only correct the malformation but also repair the mitral valve damage caused by secondary changes due to infarction.     

An Electric Cutter for All Surgical Prostheses

A new electric cutter for surgical prostheses has been developed and was compared with surgical scissors for efficacy. This comparison of the two methods was done by cutting the edges of nine popular prostheses. It was concluded from gross and microscopical results after pulling both edges of the grafts cut by the two methods that the electric cutter is much more effective for surgical prostheses.     

Unstable Coronary Artery Disease: Comparison of Medical and Surgical Treatment

In eighty-eight patients with arteriographic findings of obstructive coronary artery disease and the clinical picture of unstable angina pectoris, a decision on operative or nonoperative management was made by the attending physician. Fifty-three of them subsequently underwent aortocoronary saphenous vein bypass grafting and 35 were continued on a program of medical therapy. A marked difference in the course after the first 30 days was noted, with most of the surgically managed patients being either asymptomatic or greatly improved following coronary artery bypass. Two-thirds of the medically treated patients had persistent severe angina pectoris and none was asymptomatic in a follow-up period averaging 20 months. There were 2 late deaths in the medical group and none in the surgical group.These findings indicate that coronary artery bypass operations can be performed with low risk during the unstable phase of coronary artery disease and that relief of angina can be anticipated. In contrast, nonoperative management of unstable coronary artery disease carries an appreciable risk of death or myocardial infarction, and the majority of patients treated nonoperatively continue to experience angina.     

Surgical management of congenital pulmonary valve dysplasia.

Pulmonary valvular stenosis secondary to congenital valve dysplasia differs markedly from the classic variety of pulmonary stenosis. The reported mortality of patients treated by standard commissurotomy is 38 to 66%. The clinical features and operative management of 14 patients with dysplastic pulmonary valves are reviewed. Three groups of patients were studied. Group 1 consisted of 5 patients treated by commissurotomy. Group 2 comprised 3 patients treated by partial excision of the valve. In neither group were there operative deaths, but 5 of the 8 patients developed recurrent stenosis; 3 required reoperation. In 1975, because of the high incidence of recurrent stenosis, total valvectomy was begun. Ten patients (Group 3) have undergone valvectomy with 1 death. Nine patients were doing well at 3 to 15 months of follow-up. Based on the reported mortality and present findings, total excision of the valve is recommended for relief of stenosis in pulmonary valve dysplasia.     

Surgical treatment of annuloaortic estasia: experience in 7 consecutive patients.

Seven patients with annuloaortic ectasia were treated according to the method described by Bentall and De Bono. A Björk-Shiley valve in a composite graft was the prosthesis of choice and was used in all patients except 1, who received a Starr-Edwards valve. Profound topical cooling without selective coronary perfusion was applied in 5 patients for myocardial preservation during aortic occlusion.There was 1 operative death and 1 late death, the latter from cerebral thromboembolism. Five survivors have been followed from 1 year 5 months to 2 years 10 months with an average follow-up of 2 years. Excellent results were obtained in all survivors, their physical capabilities putting them in Class I of the New York Heart Association Functional Classification. Postoperative aortograms showed no signs of kinking or compression of vascular prostheses nor abnormalities of prosthetic valves. A modified technique to secure graft fixation is discussed.     

Endotracheal tube with movable blocker to prevent aspiration of intratracheal bleeding

A newly developed endotracheal tube with a movable blocker was found to be lifesaving in patients with copious and persistent intratracheal bleeding. The cases of 4 patients are presented. In 3 patients, severe intratracheal bleeding was attributed to the extensive bronchopulmonary laceration caused by blunt chest trauma. In the remaining patient, the bleeding was due to rupture of the sutured site in the right pulmonary artery; the rupture was caused by a postoperative bronchopleural fistula. In these patients, spread of blood was completely prevented and pulmonary resection was performed safely by using the blocker in this new device.     

Surgical correction of unusual double-outlet right ventricle.

This paper presents the case history of an 8-year-old girl who had total situs inversus and double-outlet right ventricle with pulmonary stenosis and severe tricuspid insufficiency in the presence of dextrocardia with ventricular discordance. A successful repair was performed using the Rastelli technique in conjunction with replacement of the tricuspid valve with a Bjork-Shiley prosthesis. The postoperative course was uneventful, and follow-up catheterization revealed a good operative result. However, the patient died suddenly during an emotionally upsetting period about two months after the operation. Postmortem examination revealed only signs of moderately severe cardiac decompensation. Some anatomical and embryological comments are made.     

Successful closure of ventricular septal defect through a left-sided ventriculotomy in corrected transposition of the great vessels.

Corrected transposition of the great vessels is often associated with other cardiac anomalies. Ventricular septal defect (VSD) is the most common among them. Closure of a VSD is usually performed through a right-sided ventriculotomy. We had previously closed the VSD through the right-sided ventricle in 2 patients with corrected transposition of the great vessels and in 2 others with double-outlet right ventricle with ventricular inversion, which resulted in complete heart block. Recently we have closed the VSD through the left-sided ventricle in 3 patients with corrected transposition, and no block resulted.     

Acquired benign bronchoesophageal fistulas in the adult

In a twenty-year period we have seen 7 patients with acquired nonmalignant bronchoesophageal fistulas at the Vanderbilt University Affiliated Hospitals. There were 5 men and 2 women ranging from 24 to 82 years old. Six patients were seen initially with a history of pulmonary inflammatory disease with cough and fever or with an abnormal chest roentgenogram. One patient had a traumatic fistula following blunt chest trauma. Six of the patients were treated surgically with no operative mortality. Five were repaired through a right-sided thoracotomy with division of the fistulous tract and closure of the bronchus and esophagus. One patient required esophageal resection and later reconstruction for permanent fistula closure. The remaining patient was diagnosed at bronchoscopy and was not treated surgically because of supervening complications following an extensive abdominal operation. Once the diagnosis was established, operative management resulted in complete closure of the fistulas, with no mortality and no late recurrences in these patients.     

Recurrence of thymoma: clinicopathological features, therapy, and prognosis

Factors influencing the recurrence or persistence of thymoma after therapy were investigated in 127 patients with thymoma, including 75 with thymoma and myasthenia gravis. The rate of recurrence or persistence was 19% (24 of 127 patients) overall, 11% (8 of 75 patients) in myasthenic thymoma, and 31% (16 of 52 patients) in nonmyasthenic thymoma. The more advanced the clinical stage, the higher the rate of recurrence or persistence. The recurrence/persistence rate for patients with the same clinical stage was higher in those with nonmyasthenic thymoma (8% in Stage I, 11% in Stage II, 36% in Stage III, and 75% in Stage IV) than in those with myasthenic thymoma (0 in Stage I, 13% in Stage II, 18% in Stage III, and 20% in Stage IV). The prognosis for patients having subtotal resection of tumor was good in myasthenic thymoma (recurrence/persistence rate, 17%) in contrast with nonmyasthenic thymoma (recurrence/persistence rate, 78%). These results suggest that nonmyasthenic thymoma is more malignant than myasthenic thymoma. Postoperative radiotherapy was effective in preventing the recurrence or persistence of thymoma after therapy.     

Coarctation of the Aorta in Infants and Children: 25 Years of Experience

Repair of coarctation of the aorta was performed in 334 patients ranging from less than a year to 16 years of age at Children's Hospital of Pittsburgh from 1953 to 1977. Resection and end-to-end anastomosis were performed in 310, interposition grafts in 7, and other procedures in 17. There were 41 operative deaths among the 95 infants less than 1 year old (43% mortality); all of these infants had associated cardiac anomalies. Only 1 operative death occurred in patients older than a year (0.4% mortality). No hospital deaths occurred in patients with isolated coarctation of the aorta. Eleven late deaths were due to associated anomalies (7) and unrelated or unknown causes (4). Postoperatively, hemorrhage occurred in 7, paradoxical or persistent hypertension in 128, postcoarctectomy syndrome in 32, neurological problems in 14, pulmonary complications in 53, and infections in 12 patients. Restenosis occurred in 26 patients (8%); only 10 have required reoperation. Residual hypertension was present in 28 of 264 patients (11%). Mortality from coarctation resection remains high in infants, but is minimal in children older than 1 year. Based on minimizing the risk of restenosis and residual hypertension, elective repair of coarctation is recommended when the patient is about 6 years of age.     

Cardiopulmonary Dynamics during Arteriovenous Perfusion: Cardiac Output,Pulmonary Arterial Resistance,and Right Ventricular Stroke Work

The effects of arteriovenous perfusion on myocardial performance, pulmonary circulatory dynamics, and organ preservation were studied in dogs in order to evaluate the applicability of arteriovenous extracorporeal membrane oxygenation for partial respiratory support. Studies were made on normally oxygenated dogs, on dogs made hypoxic by oxygen deprivation and ventilatory depression, and on dogs with pulmonary injury and moderate pulmonary hypertension induced by injection of oleic acid into the right ventricle. The latter two groups were included to assess the changes that occur in cardiopulmonary dynamics in the presence of hypoxia and pulmonary hypertension. A micro-channel membrane oxygenator was employed to provide partial respiratory support to the group of animals with pulmonary injury. The results indicate that no deleterious hemodynamic changes occurred in any of the groups of animals with arteriovenous flow for periods of up to 5 hours at rates corresponding to 20 to 35% of the total cardiac output. Adequate systemic oxygenation was provided by the microchannel oxygenator at these rates of arteriovenous perfusion.