Repair of Left Atrial Abnormalities in Children by the Superior Approach

We have used the superior approach through the dome of the left atrium to repair cardiac lesions in the left atrium in 15 children ranging from 3 months to 17 years old. The single hospital death occurred in a 16-month-old infant with levo (L) transposition of the great arteries, Ebstein's malformation of the left atrioventricular valve, and ventricular septal defect. Exposure of the intraatrial structures was excellent, injury to adjacent cardiac structures did not occur, and hemorrhage from the left atrial suture line was not a problem. Though a few transient arrhythmias were seen, all survivors are in sinus rhythm without evidence of sick sinus syndrome, except 1 patient in whom atrial flutter associated with cardiomyopathy developed 1 year after operation. The excellent surgical exposure obtained of the interior of the left atrium and the absence of important complications related to the incision cause us to recommend this approach in children.     

A new clamp for patch graft angioplasty of coarctation of the aorta

A new clamp controls the great vessels in the region of aortic coarctation, allowing unhampered access to the aortotomy in patch graft angioplasty.     

Tetralogy of Fallot Associated with Complete Atrioventricular Canal

A 6-year-old girl had the clinical appearance of tetralogy of Fallot but was found at cardiac catheterization to have tetralogy of Fallot associated with complete atrioventricular canal. She underwent repair, and at recatheterization two years later, the hemodynamic result was excellent. Proper angiography is necessary to diagnose this combination, and correct preoperative diagnosis is necessary to plan a rational operative approach.     

Aortoplasty compared with resection for coarctation of the aorta in young children

We repaired coarctation of the aorta in a group of 18 children less than 3 years old, using either resection with end-to-end anastomosis (8 patients, Group 1) or patch graft aortoplasty (10 patients, Group 2). The two groups were similar preoperatively in age, pressure difference between proximal and distal aorta (delta PA0), and severity of aortic arch hypoplasia. Three patients, all less than 2 months old, died early postoperatively. Among the survivors, the right brachial artery systolic pressure was significantly higher in Group 1 (133.1 +/- 7.0 mm Hg) (mean +/- standard error of the mean) than in Group 2 (102.5 +/- 7.2 mm Hg) (p less than 0.05). The delta PA0 was significantly higher in Group 1 (33.0 +/- 7.5 mm Hg) than in Group 2 (5.1 +/- 2.3 mm Hg) (p less than 0.01). Three patients in Group 1 required reoperation and were treated with patch graft aortoplasty; relief of delta PO0 was complete in 2. Patch graft aortoplasty is more effective than resection in reducing proximal aortic systolic pressure and in relieving delta PA0 in infants and small children with coarctation of the aorta.     

Growth of the aorta after prosthetic patch aortoplasty for coarctation in infants

We have shown that patch aortoplasty relieves the aortic pressure gradient substantially better than resection with end-to-end anastomosis in infants with coarctation of the aorta. Growth of the intact posterior wall of the unresected coarctation after aortoplasty, however, has not yet been demonstrated to occur. We studied 21 infants less than 2 years of age who underwent prosthetic patch repair of coarctation after 1975. Associated lesions were present in 16 patients, and 12 had a concomitant procedure. Two patients died in the hospital, and 4 died later, all of causes unrelated to the coarctation repair. Systolic blood pressure in the right arm declined from 140 +/- 41 mm Hg (mean +/- standard deviation) preoperatively to 101 +/- 19 mm Hg postoperatively in the whole group and to 95 +/- 12 in 10 patients followed for more than 3 years. The right arm-left leg systolic pressure gradient declined from 66 +/- 22 mm Hg to 5 +/- 14 in all patients and to 4 +/- 13 in the group followed more than 3 years. Hypoplastic transverse arch was seen in all but 2 patients. Its relative diameter increased in 6 of 9 patients who underwent catheterization postoperatively and increased more than 50% in 3 patients. Two patients have evidence of narrowing of the aorta at the patch, but both have normal blood pressure in the right arm. In the patient with longest follow-up, an 8-month-old infant seen 8 years after operation, angiograms show the diameter of the aorta at the coarctation to be greater than that at the transverse arch and at the descending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)     

Tetralogy of Fallot with Coexisting Type II Aortopulmonary Window

An infant had a coexisting tetralogy of Fallot and type II aortopulmonary window between the ascending aorta and the right pulmonary artery in which the communication acted as a palliative systemic-pulmonary shunt. Surgical repair is described, and the appropriate literature is reviewed.     

Chemoradiation therapy and resection for carcinoma of the esophagus: short-term results

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in patients in whom the protocol was applicable. The chemotherapy consisted of mitomycin-C, 10 mg as a bolus intravenous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glucose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carcinoma of the esophagus whose disease remained or became operable during or following the course of the chemoradiation. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate remained about the same as in our previous experience. The operative mortality was lessened appreciably. The percentage of resected specimens of the esophagus showing residual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any improved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection without the chemotherapeutic adjunct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Flow in coronary artery bypass grafts to totally and partially occluded left anterior descending coronary arteries

Flow was determined by electromagnetic flowmeter in vein bypass grafts in 20 patients with a totally occluded left anterior descending (LAD) coronary artery and on 61 patients with a partially occluded LAD. The median flow in LAD grafts was 14.5 ml/min with total LAD occlusion, and 40 ml/min with partial LAD occlusion (p less than 0.001). In cases of total LAD occlusion, the presence of mild or moderate anteroseptal wall dysfunction was associated with more satisfactory flow than was the case with severe anteroseptal wall dysfunction (p less than 0.02). Flows over 25 ml/min were found only when the LAD distal to total occlusion was 1.5 mm or greater. Unsatisfactory flows were consistently found with total LAD occlusion, poor ventricular function, and a distal LAD less than 1.5 mm. Repeat catheterizations to determine an unsatisfactory patency rate under these conditions would be necessary to alter our policy of grafting all suitable vessels beyond a total occlusion.     

An Improved Method for Collection of Shed Mediastinal Blood for Autotransfusion

A standard method for collection of shed mediastinal blood has been modified to incorporate underwater-seal drainage and manometer-controlled suction through the chest catheter. This method is useful for autotransfusion of shed mediastinal or thoracic blood following cardiac surgical procedures.     

Application of Multivariate Analysis to the Enzyme Patterns in the Serum of Patients Undergoing Coronary Artery Operation

Serial determinations of serum glutamic oxaloacetic transaminase, lactic dehydrogenase, and creatine phosphokinase were performed in 50 consecutive patients undergoing cardiac operation for coronary artery bypass or combined valve replacement and coronary artery bypass. Thirty-seven patients (74%) who demonstrated minimal or no changes on the electrocardiogram manifested a recognizable pattern of distribution of the enzyme sequences. The pattern of these patients served as controls for the detection of abnormal patterns. All other patients were grouped together, regardless of clinical behavior. Perioperative myocardial infarction was established in 5 patients (10%) and resulted in 1 death. The purpose of this study was to apply discriminant analysis to two clinically determined patient groups in order to ascertain whether the three enzyme readings can be used to classify patients into their respective groups. The results suggest that enzyme profiles reflect degrees of myocardial damage that can serve to identify clinical infarction.     

Pain Amelioration after Thoracotomy: A Prospective,Randomized Study

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 ± 9.2% (standard deviation; p < 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 ± 7.5% (p < 0.05) than in the control group (38.4 ± 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.     

A Comparison of the Effects of Membrane and Bubble Oxygenators on Platelet Counts and Platelet Size in Elective Cardiac Operations

To compare the effects of membrane and bubble oxygenators on platelet counts and the size of circulating platelets, serial hematocrits, platelet counts, and platelet sizing were measured in 23 patients undergoing elective cardiac operations. In 10 patients a bubble oxygenator was used and in 13, a SciMed membrane oxygenator. The two groups were statistically similar with respect to age, weight, time on bypass, and mean blood flow rates during bypass.It was found that platelet counts, when corrected for hemodilution, did not fall from control levels during or up to 24 hours after cardiopulmonary bypass in either group. In both groups, the relative number of platelets per gram of hemoglobin increased slightly during and after bypass, and this increase was significant in the bubble oxygenator group. The average size of circulating platelets increased only in the bubble oxygenator group, and then only in the one-day postoperative sample. These findings suggest that the membrane oxygenator offers no advantage with respect to preservation of platelets during cardiopulmonary bypass lasting up to 2 to 3 hours.     

Atrial Pacing during Intraaortic Balloon Pumping

Intraaortic balloon pumping and atrial pacing are both useful in treating postoperative low output syndrome. However, the electrocardiographic atrial pacing spike can interfere with the electrocardiogram tracking mechanism of many balloon consoles. Bipolar epicardial pacing can avoid this problem and allow simultaneous atrial pacing and intraaortic balloon pumping.     

Electrolyte versus Blood Cardioplegia: Randomized Clinical and Myocardial Ultrastructural Study

In 40 consecutive patients undergoing coronary artery bypass, one of two solutions for cardioplegia, each containing 30 mEq/L of K⁺ was used randomly. The groups were comparable except for intramyocardial temperature. With electrolyte solution (Group A), it was 16.5° ± 0.34°C, while with blood from the pump-oxygenator (Group B) it was 20.3° ± 0.41°C (p < 0.001). After bypass left atrial pressure (LAP) was 11.9 ± 0.67 torr in Group A and 8.1 ± 0.49 torr in Group B (p < 0.001). CPK-MB was elevated in 45% of Group A patients versus 15% in Group B (p < 0.05). No patient died. Two myocardial infarctions occurred in Group A and one in Group B. Stereological morphometric electron microscopy was performed on biopsy specimens taken from the left ventricle (1) before perfusion, (2) after cardioplegia, and (3) 30 minutes after reperfusion. Group A showed marked intracellular edema, mitochondrial swelling, pronounced depletion of glycogen stores, and focal myofibrillary disorganization. Group B showed near normal myocardial ultrastructure with increased glycogen stores and minimal mitochondrial swelling. Morphometric analysis revealed a statistically significant increase in the degree of mitochondrial swelling (51%) in Group A compared with Group B after reperfusion (p < 0.001). Thus, blood K⁺ cardioplegia resulted in better preservation of myocardial ultrastructure, lower ventricular filling pressure, and lesser CPK-MB release compared with this particular electrolyte cardioplegia.     

The management of Hemophilus influenzae, Type B, pericarditis.

The incidence of Hemophilus influenzae, type B, infections in children has been increasing recently, so the number of cases of pericarditis is likely to rise also. We describe the clinical manifestations and treatment of H. influenzae, type B, pericarditis based on 4 patients and a review of the literature. The most common complication is cardiac tamponade, which requires drainage. All patients should be treated with antibiotics (chloramphenicol, ampicillin) and a drainage procedure. Because of several recently reported cases of subsequent constrictive pericarditis, we recomment anterior interphrenic pericardiectomy both for drainage and to prevent constrictive pericarditis. With appropriate therapy the survival rate should be very high.     

Repair of Tetralogy of Fallot after Aortopulmonary Anastomosis

Thirty-eight corrective operations have been performed in patients with tetralogy of Fallot and a functioning aortopulmonary shunt. There were 3 operative deaths (7.9%) and 1 late death (2.6%), and 3 patients have required reoperation for significant residual defects. Only 1 of 10 patients studied postoperatively by radionuclide scanning has a significant reduction in blood flow to the lung on the side of the closed shunt. We conclude that the presence of an aortopulmonary shunt does not add to the risk of repair in patients with tetralogy of Fallot and that mortality after such operations is related to the complex anatomy often present in patients of this group.     

Tined Transvenous Endocardial Electrodes: Results of a Randomized Prospective Study

The early (30-day) dislodgment rate of standard-use flange-tipped and of tined endocardial electrodes was compared in a randomized prospective clinical trial. Four of 16 (25%) of the flange-tipped leads and none of the 18 tined leads dislodged within 30 days of implantation (p = 0.01). We believe that the tined electrode represents a major improvement in electrode design and is clearly superior to the flange-tipped electrode in reducing the incidence of early dislodgment.     

A method for rapid tailoring of the intraatrial baffle in transposition of the great vessels.

Numerous reports have described successful use of the Brom "trouser-shaped" baffle in the Mustard procedure. A simple technique to fashion the baffle accurately by use of a prefashioned template is described.     

Intermuscular abdominal implantation of permanent pacemakers in infants and children.

Pacemaker implantation in infants and young children presents technical problems because of the relatively large size of the units. Various implantation sites have been employed to avoid the problems of unsightliness, migration, skin necrosis with infection, and patient discomfort. We are presenting a new technique which obviates these difficulties. The pacemaker generator is located in a space developed between the muscles and fascia of the abdominal wall. This site will accept even the largest of demand pacemakers with cosmetically acceptable results.     

The cardiac lymphatics

The cardiac lymphatic system is well developed. Investigations related to the lymphatics of the heart are recorded as early as the seventeenth century, and with improved techniques, many studies have produced new knowledge of the system during this century. Controversy remains, however, regarding the presence of lymphatics in certain areas of the heart such as the atrioventricular valves. Many investigators believe that malfunction of the cardiac lymphatics might be a factor in disease states for which the pathogenesis is still unknown. This review outlines the history, anatomy, and physiology of the cardiac lymphatics and their possible relationship to cardiac disease.