Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function.

Late survival and freedom from myocardial infarction were determined for 192 patients with coronary artery disease and depressed left ventricular ejection fraction at rest (less than or equal to 35%) determined by biplane angiography who were evaluated between 1970 and 1977. Seventy-seven patients had coronary artery bypass grafting and 115 patients were treated medically and were considered surgical candidates. The medical and surgical groups were comparable in all baseline characteristics examined except frequency of three vessel disease and angina pectoris, which occurred in a significantly greater percent of the surgically treated patients (p less than 0.01). Only three medically treated patients (2.6%) underwent coronary bypass grafting in the follow-up period. Seven year actuarial survival was 63% in the surgical and 34% in the medical group (p less than 0.001). Ninety-three percent of patients in the surgical group and 81% of those in the medical group were free of nonfatal myocardial infarction (p = 0.01), and 62 and 33%, respectively, were alive and free of myocardial infarction (p less than 0.001) at 7 years. Significant differences in survival favoring surgical treatment were observed for the subsets of patients with an ejection fraction of 25% or less (p = 0.0002) and 26 to 35% (p = 0.01), and for the subsets with three vessel coronary disease (p less than 0.001), normal left ventricular end-diastolic volume (less than or equal to 100 ml/m2) (p = 0.005) and elevated end-diastolic volume (greater than 100 ml/m2)(p = 0.001). After adjustment for other important prognostic variables, the type of treatment remained significant in predicting the relative risk (medical to surgical) of mortality at 5 and 7 years (2.58 and 2.12, respectively). These data corroborate the trends observed in several randomized trials of medical and surgical therapy in patients with abnormal left ventricular function. If hospital mortality for coronary artery bypass grafting is less than 5%, substantial benefit can be anticipated for the majority of patients with depressed ventricular function.

Prospective detection by Doppler color flow imaging of additional defects in infants with a large ventricular septal defect.

The use of Doppler color flow imaging and axial contrast angiography in the preoperative detection of additional ventricular septal defects (in the setting of a known large defect) were compared in a prospective fashion. One hundred seventy-nine infants with two ventricles (each of at least normal size) and a large, nonrestrictive ventricular septal defect underwent reparative surgery before 2 years of age. The reference standard for the presence of additional defects was intraoperative verification or (in cases in which the surgeon did not visualize any additional defect) subsequent identification at postoperative angiography, postoperative color Doppler examination or reoperation. Only six patients (3%) had additional ventricular septal defects confirmed at the time of repair; an additional five (3%) had defects found only postoperatively. The negative predictive value of Doppler color flow imaging and angiography was 0.95 (168 of 176) and 0.97 (168 of 174), respectively. The sensitivity was 0.27 (3 of 11) and 0.45 (5 of 11), respectively. For certain malformations with a very low prevalence of additional muscular defects (such as perimembranous ventricular septal defect with normally aligned great arteries), a clinical trial of reparative surgery without prior invasive study appears reasonable.

Postmortem echocardiography and tomographic anatomy of hypoplastic left heart syndrome after palliative surgery.

A study was undertaken to improve the understanding of the 3-dimensional (3-D) topology of a complex surgical reconstruction. The pathologic anatomy was investigated by first fixing postmortem heart specimens in such a way as to preserve the 3-D relations. Next, a technique for postmortem 2-D echocardiography was developed to aid in selection of tomographic planes for sectioning the specimens. Subsequent adjustment of planes of section was made to better show particular facets of the anatomy. The material for this investigation was drawn from cases of hypoplastic left heart syndrome after surgical palliation by the Norwood procedure. Three potential hemodynamic sequelae--restrictive inter atrial communication, aortic obstruction at any level and distortion of the pulmonary artery confluence--served as the anatomic focus for this study. Careful preservation of 3-D topology and postmortem 2-D echocardiographic imaging coupled with tomographic sectioning of specimens led to development of new, clinically relevant echocardiographic views for imaging specific atrial septal and aortic arch anomalies. These techniques offer insight into the spectrum of anatomic sequelae of this type of surgery and may be applied to echocardiographic imaging of patients and refinement of surgical technique for other forms of complex congenital heart disease.

Fate of the pulmonic valve after proximal pulmonary artery-to-ascending aorta anastomosis for aortic outflow obstruction.

Transection of the main pulmonary artery and end-to-side anastomosis of the proximal pulmonary artery to the ascending aorta has been increasingly used in palliative surgery for cardiac malformations such as single ventricle with small outlet foramen (bulboventricular foramen) and hypoplastic left-heart syndrome. To evaluate pulmonary valve competence after this operation, we used color Doppler flow mapping to examine 45 survivors of pulmonary artery-to-ascending aorta anastomosis a median of 202 days postoperatively. Of 37 patients with hypoplastic left heart syndrome, mild regurgitation was detected in 9 (24%) and moderate regurgitation in 1 (3%). Of 8 with other lesions, mild regurgitation was observed in 2 and moderate regurgitation in 1. Seven of 11 patients imaged greater than or equal to 12 months postoperatively had regurgitation. In summary, one-fourth of survivors developed mild pulmonary regurgitation. Its presence should not be considered a contraindication to eventual application of Fontan's principle, although further follow-up appears warranted because the long-term fate of pulmonary valve function is not yet known.

Transposition of the great arteries with aortic arch obstruction. Anatomical review and report of surgical management.

Transposition of the great arteries (S,D,D) is a common congenital cardiovascular malformation that is occasionally associated with ventricular septal defect and left ventricular outflow tract obstruction. Recently right ventricular outflow tract obstruction associated with an aortic arch anomaly has been recognized as an infrequent but important variant of transposition of the great arteries, and this constellation presents a unique surgical challenge. Five infants with this constellation whose systemic circulation was dependent on flow through the ductus arteriosus have undergone definitive surgical treatment with four survivors. An anatomical review of 129 specimens with transposition of the great arteries revealed that 17% had right ventricular outflow tract obstruction and 7% had associated aortic arch obstruction as well. All specimens with aortic arch obstruction and ventricular septal defect except one had a malalignment type ventricular septal defect. Although several treatment options may be considered, recent experience with arterial switch repair in the neonate with transposition of the great arteries (S,D,D) prompted repair in these patients by arterial switch, ventricular septal defect closure, repair of aortic arch obstruction, and augmentation of the right ventricular outflow tract.

Coronary sinus septal defect associated with tricuspid atresia.

Coronary sinus septal defects are unusual congenital anomalies that may assume particular clinical importance in patients undergoing a modified Fontan procedure. Two of 10 patients with tricuspid atresia who underwent a modified Fontan procedure between January, 1984, and December, 1984, were noted to have coronary sinus septal defects in the early postoperative period. A pathologic review of 159 specimens of tricuspid atresia revealed coronary sinus septal defects in four. Although infrequent, coronary sinus septal defects may permit significant persistent right-to-left interatrial shunting after a modified Fontan procedure. Ideally, preoperative recognition allows for selective direct closure or closure of the coronary sinus orifice. Alternatively, routine baffling of the coronary sinus into the left atrium obviates this potential source of interatrial communication.

Pulmonary artery configuration after palliative operations for hypoplastic left heart syndrome.

Pulmonary artery architecture and symmetry after palliative operations for hypoplastic left heart syndrome may affect subsequent suitability for a modified Fontan operation. Two-dimensional echocardiography was used to measure pulmonary artery diameter and assess symmetry after two types of systemic-pulmonary artery shunts: modified right Blalock-Taussig shunt (14 patients) and central shunt (from underside of aortic arch gusset to pulmonary artery confluence) (14 patients). Age, weight, preoperative diameter of right and left pulmonary arteries (proximal, middle, and distal segments), and mean interval between preoperative and postoperative echocardiographic studies (20.2 +/- 4.4 days in the Blalock shunt group; 19.1 +/- 6.8 days in the central shunt group) were similar. Early postoperatively, patients with a Blalock shunt showed a significant decrease in the diameter of all pulmonary artery segments except the distal right pulmonary artery. The diameters tapered from distal right to distal left pulmonary artery in this group. Patients with the central shunt had a significant decrease in the diameter of all pulmonary artery segments. There were no significant differences when cross comparisons were made of the various pulmonary arterial segments in patients after a central shunt. Similar findings persisted in 19 patients from both groups who had a late postoperative echocardiogram (mean interval between studies = 271 days in the group of 10 patients with Blalock shunt and 167 days in the group of nine patients with a central shunt). In conclusion, the central shunt preserves pulmonary artery symmetry, which may be important in candidates for the Fontan operation in infancy.

Effects of potassium cardioplegia on high-energy phosphate kinetics during circulatory arrest with deep hypothermia in the newborn piglet heart.

The protective effects of hypothermia and potassium-solution cardioplegia on high-energy phosphate levels and intracellular pH were evaluated in the newborn piglet heart by means of in vivo phosphorus nuclear magnetic resonance spectroscopy. All animals underwent cardiopulmonary bypass, cooling to 20 degrees C, 120 minutes of circulatory arrest, rewarming with cardiopulmonary bypass, and 1 hour off extracorporeal support with continuous hemodynamic and nuclear magnetic resonance spectroscopic evaluation. Group I (n = 5) was cooled to 20 degrees C; group II (n = 4) was given a single dose of 20 degrees C cardioplegic solution; group III (n = 7) was given a single dose of 4 degrees C cardioplegic solution; and group IV (n = 4) received 4 degrees C cardioplegic solution every 30 minutes. At end ischemia, adenosine triphosphate, expressed as a percent of control value, was lowest in group I 54% +/- 6.5% but only slightly greater in group II 66% +/- 7.0%. Use of 4 degrees C cardioplegic solution in groups III and IV resulted in a significant decrease in myocardial temperature, 9.9 degrees C versus 17 degrees to 20 degrees C, and significantly higher levels of adenosine triphosphate at end ischemia; with group III levels at 72% +/- 6.0% and group IV levels at 73% +/- 6.0%. Recovery of adenosine triphosphate with reperfusion was not related to the level of adenosine triphosphate at end ischemia and was best in groups I and II, with a recovery level of 95% +/- 4.0%. In group IV, no recovery of adenosine triphosphate occurred with reperfusion, resulting in a significantly lower level of adenosine triphosphate, 74% +/- 6.0%, than in groups I and II. Recovery of ventricular function was good for all groups but was best in hearts receiving a single dose of 4 degrees C cardioplegic solution. In this model, multiple doses of cardioplegic solution were not associated with either improved adenosine triphosphate retention during arrest or improved ventricular function after reperfusion, and in fact resulted in a significantly lower level of adenosine triphosphate with reperfusion. The complete recovery of adenosine triphosphate in groups I and II, despite a nearly 50% adenosine triphosphate loss during ischemia, may result from a decrease in the catabolism of the metabolites of adenosine triphosphate consumption in the newborn heart.

Age-related differences in response to neutrophil-mediated reperfusion injury in the neonatal piglet heart.

BACKGROUND: Neonatal hearts have altered adhesion molecule interactions in response to ischemia-reperfusion. How this affects myocardial function is unknown. METHODS: Isolated, buffer perfused 0- to 2-day (newborn) and 2-week piglet hearts were first subjected to 20-minute global, normothermic ischemia, followed by 45 minutes of reperfusion during which 150 x 10(6) newborn or 2-week neutrophils were infused. In some hearts, an antibody to SLe(x) (CSLEX-1) was infused with neutrophils during reperfusion. Hemodynamic variables, including left ventricular developed pressure (LVDP), were recorded at timed intervals. Neutrophil CD-18, L-selectin, and SLe(x) contents were measured by flow cytometry. RESULTS: Full recovery of LVDP was observed in newborn hearts receiving newborn or 2-week-old neutrophils. Recovery of LVDP was depressed (p < 0.01, ANOVA) in 2-week-old hearts receiving 2-week old, not newborn, neutrophils. Infusion of CSLEX-1 in 2-week-old hearts restored LVDP to baseline. Whereas flow cytometry showed higher (p < 0.01, Student's t test) CD-18 and L-selectin expression on newborn versus 2-week-old neutrophils, newborn neutrophils expressed lower (p < 0.01) SLe(x) levels. CONCLUSIONS: Initial "loose" neutrophil-endothelial selectin interactions are a necessary prelude to "firm" adhesion and reperfusion injury. Operations performed soon after birth may be better tolerated than when surgery is delayed; anti-SLe(x) preparations may prove beneficial when performing cardiac procedures on older infants.

Palliative reconstructive surgery for hypoplastic left heart syndrome.

From August, 1985, through August, 1987, 104 consecutive, nonselected neonates underwent palliation of hypoplastic left heart syndrome. The technique included pulmonary artery homograft augmentation of the diminutive ascending aorta and aortic arch, atrial septectomy, transection of the main pulmonary artery with patch closure of the distal main pulmonary artery, anastomosis of the proximal main pulmonary artery to the augmented ascending aorta, and a 4-mm, modified, right Blalock-Taussig (N = 21) or central (N = 83) shunt. There were 30 early and 11 late deaths. Early mortality was most commonly associated with hypoventilation. Complications included development of aortic arch obstruction (N = 11) and progressive hypoxemia (N = 11). Alterations in surgical techniques and perioperative management should permit continued improvement in early and long-term survival.

Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis.

A 23-day-old female newborn was evaluated for acyanotic respiratory distress immediately after birth. Echocardiogram and cardiac catheterization revealed absence of the right pulmonary artery. Subsequent course was complicated by necrotizing bronchopneumonia. Despite antibiotic therapy and ventilator support she failed to improve; right pneumonectomy was performed to remove the source of sepsis. This case represents an example in which an infectious complication in a rare congenital pulmonary malformation served as an indication for neonatal pneumonectomy.

An enclosed system for continuous postoperative mediastinal aspiration.

Blockage of mediastinal drainage tubes in the postoperative cardiac surgical patient can result in tamponade, and the small child, with a necessarily small drainage tube, is particularly susceptible to instability arising from accumulating blood in the mediastinum. A system for continuous evacuation of blood in drainage tubes is described that decreases the likelihood of blocked tubes and resultant tamponade.

Carnitine supplementation improves myocardial function in hearts from ischemic diabetic and euglycemic rats.

BACKGROUND: Nonischemic myocardial dysfunction in patients with diabetes mellitus appears to be attenuated with long-term L-carnitine therapy. The effect of acute L-carnitine supplementation on rat hearts from euglycemic and diabetic animals subjected to ischemia and reperfusion is investigated in this study. METHODS: Study rats had diabetes mellitus induced by streptozocin (65 mg/kg intraperitoneally), and control rats had injection of saline solution (n = 12 per group). About 1 month later, the hearts were suspended on a Langendorff apparatus and perfused with either standard buffered Krebs-Henseleit solution or this standard solution supplemented with L-carnitine (5 mmol/L). After stabilization, normothermic, zero-flow ischemia was instituted for 20 minutes followed by 60 minutes of reperfusion. There were four study groups (n = 6 per group): hearts that were from euglycemic rats and that were perfused with standard buffered Krebs-Henseleit solution (E-STD); hearts that were from diabetic animals and that were perfused with the same standard buffered solution (DM-STD); hearts taken from diabetic animals and perfused with L-carnitine-enriched solution (DM-CAR); and hearts taken from euglycemic rats and perfused with the enriched solution (E-CAR). RESULTS: At 60 minutes of reperfusion, left ventricular developed pressure was significantly better in hearts from both groups (diabetic and euglycemic) with carnitine supplementation (DM-CAR versus DM-STD and E-CAR versus E-STD, p < 0.01 for both, by analysis of variance). Left ventricular end-diastolic pressure was significantly lower in the DM-CAR group compared with all other groups (p < 0.01 by analysis of variance). CONCLUSIONS: These findings suggest that acute L-carnitine supplementation significantly improves the recovery of the ischemic myocardium in diabetic and euglycemic rats.

Recent advances in cardiac surgery.

Virtually all forms of congenital heart disease can be repaired or significantly palliated. The risk of surgery in infancy continues to decline, and many lesions are being routinely repaired at an early age. This may permit an improved functional result later in life. Other recent advances include the arterial switch procedure for transposition of the great arteries, the palliative repair of hypoplastic left heart syndrome, and the increased application of the Fontan procedure in patients with only one effective ventricle. Combined with an ever-growing understanding of cardiopulmonary physiology, anatomy, and biochemistry, the future of congenital cardiac surgery is bright and exciting.

Recent advances in congenital cardiac surgery.

Today, the natural history of virtually all congenital cardiac malformations can be significantly altered by reconstruction surgery. It now appears that repair is feasible in most, very early in life, with the potential for achieving the best long-term functional outcome and minimizing multiple operations.

Palliative therapy for metastatic breast cancer.

Breast cancer may recur in the form of localized or generalized metastatic disease. Although localized metastasis is almost always evidence of more widespread occult disease, local therapy is often of prolonged palliative value. Generalized metastasis calls for systemic therapy, and hormone methods in many cases can provide long-term control before chemotherapy must be resorted to. The therapeutic approach depends on whether the patient is premenopausal or postmenopausal. Generally, ablative is more effective than additive hormone therapy. Whether a given patient will respond can be predicted to a degree by hormone receptor tests.

Description of a nonselective cation current in human atrium.

Ion currents were examined in isolated human atrial myocytes by using the whole-cell patch-clamp technique. When currents were recorded with a K(+)-containing pipette solution, depolarizing voltage pulses elicited a rapidly activating outward current that decayed to an apparent steady state. Exposure of cells to 10 mmol/L 4-aminopyridine markedly reduced current amplitude; however, a rapidly activating current that was approximately 30% of the steady state current amplitude remained. When pipette K+ was replaced with Cs+, a similar rapidly activating current that reversed polarity at approximately 0 mV was recorded. This current was seen in 100% of the cells tested from 17 different hearts (n = 142), and its amplitude was approximately 40% of the amplitude of the steady state current recorded in the presence of pipette K+. The current amplitude was not significantly different in cells isolated from adult (6.31 +/- 1.35 pA/pF, n = 8) and pediatric (5.54 +/- 1.04 pA/pF, n = 9) hearts. Studies designed to determine the charge-carrying species indicated that changes in bath Cl- concentration had no effect on either the amplitude or the reversal potential of this current, whereas removal of pipette Cs+ and bath Na+ dramatically reduced this current. In addition, this current was not modulated by either isoproterenol (1 mumol/L, 22 degrees C) or cell swelling. This study provides the first description of a nonselective cation current in human atrial myocytes, which may play an important role in repolarization in human atria.