Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections. Comparison between the transpectoral and subpectoral approaches.

A right submammarian incision with anterior thoracotomy was performed in 89 female patients to repair simple and complex forms of atrial septal defects. Patients' ages ranged from 8 to 38 years (mean 21.5 years). Seventy-seven had secundum-type atrial septal defects, one had the primum type, and 11 had an associated partial anomalous pulmonary venous connection. The patients were divided into two groups: 57 patients in group A, in whom, after a breast flap was elevated, a transpectoral approach was used to enter the chest; 32 patients in group B, in whom the pectoral muscle was not divided and a subpectoral approach was used. Aortic cannulation was accomplished without difficulty in all 89 patients. There were no early or late deaths in either group. Follow-up ranged from 24 to 108 months (mean 63.7 months) and included 86 patients, who were free of symptoms. In group A, however, among 54 patients examined, the volume of the right breast and pectoral muscle was smaller than the left in four patients (7.4%), and 21 (38.8%) had persistent right periareolar numbness. In 32 patients evaluated in group B, no difference was noted in the size of the breasts, and persistent numbness was present in four patients (12.5%). In summary, atrial septal defects or anomalous pulmonary venous connections can be safely repaired through a right submammarian thoracotomy in female patients. The subpectoral approach offers better results because breast asymmetry and paresthesias are significantly less prevalent (p less than 0.01).

Loud systolic and diastolic murmurs originating on a right atrial metastatic tumor.

A 36-year-old asymptomatic man, who two months before had a normal clinical examination, developed two loud, grade 5/6 harsh systolic and diastolic murmurs, audible over the entire precordium. Two-dimensional echocardiography revealed a huge tumoral mass, attached to the right atrium near the tricuspid valve, pedicellated and of great mobility, reaching the right ventricular outflow tract during diastole, and coming back to the atrium in systole. Right-sided angiography confirmed the diagnosis, and after ablation of the tumor, the auscultation was normal again. Two loud murmurs constitute a quite uncommon manifestation of an intracavitary mass, and this unusual finding has not previously reported in the medical literature available to the authors.

Risk of recoarctation in neonates and infants after repair with patch aortoplasty, subclavian flap, and the combined resection-flap procedure.

Between September 1980 and August 1988, 47 patients younger than 12 months (27 neonates and 20 infants) underwent repair of aortic coarctation. Three surgical techniques were used: patch aortoplasty (group A: 5 neonates and 3 infants, mean age 4.5 months), subclavian flap (group B: 11 neonates and 8 infants, mean age 3.1 months), and the combined resection-flap procedure (group C: 11 neonates and 9 infants, mean age 2.7 months). There were 8 early deaths (3 in group A, 3 in group B, and 2 in group C) and 2 late deaths (both in group B), all of which occurred in patients with complex coexisting anomalies. Follow-up included 37 patients (5 in group A, 14 in group B, and 18 in group C) and ranged from 28 to 108 months (mean 68.0, 60.8, and 51.7 months, respectively). Residual arm-leg pressure gradients greater than 10 mm Hg were detected in 4 of 5 patients in group A, 11 of 14 patients in group B, and 1 of 18 patients in group C (p less than 0.005). There were no reoperations in any infant operated on after 1 month of age in any group (0% risk). However, 4 patients who underwent repair during their neonatal period, with recurrent gradients greater than 20 mm Hg, have required reoperation: in group A, 1 of 5 patients (20% risk) (1 of 2 neonates or 50% risk); in group B, 3 of 14 patients (21% risk) (3 of 9 neonates or 33% risk); and none in group C (0% risk in infants and neonates) (p less than 0.001). In summary, residual gradients and risk of recoarctation are significantly higher when a patch or a subclavian flap had been used for repair. The combined resection-flap procedure (an end-to-end anastomosis enlarged with a subclavian flap) is more effective in avoiding gradients and preventing recoarctation, especially in neonates.

Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue. Follow-up to 6 years.

We present an analysis of 59 patients operated on between 1983 and 1987 for acute type A dissecting aneurysm with aortic valve insufficiency. The ascending aorta was replaced with a Dacron tube, the layers of the dissection were unified with gelatin-resorcine-formaldehyde glue, and the natural aortic valve was preserved. Follow-up every 6 months was subject to actuarial analysis. The hospital mortality rate was 22%. The survivors were studied for 35.9 +/- 18.6 months (mean +/- standard deviation). Eight patients died (six of cardiovascular causes, one of cancer of the colon, and one of an unknown cause). Seventeen (36.9%) had aortic insufficiency, eight mild and nine moderate to severe. Four patients with severe insufficiency had reoperation with valve replacement. Excluding patients who have died or undergone reoperation, 29 of the remainder (90.6%) are free of symptoms. The follow-up survival rate is 61% +/- 6.93% (standard error) including hospital mortality. It is 55.4% +/- 7% (standard error) excluding reoperation and 44.2% +/- 7.1% (standard error) additionally excluding modest or severe aortic insufficiency. The use of gelatin-resorcine-formal glue allowed preservation of the native aortic valve, obviating the need for anticoagulants, and no embolic or hemorrhagic episodes were registered.

Comparison of two levels of anticoagulant therapy in patients with substitute heart valves.

After cardiac valve replacement patients were blindly randomized into two groups, both receiving aspirin (330 mg) and dipyridamole (75 mg) twice daily and the oral anticoagulant acenocoumarol (Sintrom). An international normalized ratio of 2.0 to 2.99 was assigned to group A and 3.0 to 4.5 to group B; both groups were subsequently analyzed for thromboembolic and hemorrhagic complications. Final evaluation included 51 and 48 patients, respectively. The follow-up was 626 months for group A (12.3 months/patient) and 486 months for group B (10.1 months/patient). The frequency of thromboembolism was equal in both groups: one transient ischemic attack in group A (a rate of 1.92/100 patient-years) and two transient ischemic attacks in group B (a rate of 4.94/100 patient-years). There was, however, a statistical difference in bleeding complications between the two groups (p less than 0.02). Two patients bled in group A, a rate of 3.9% (3.8/100 patient-years), which represents an incidence of one episode each 25.6 years of treatment; 10 patients bled in group B, a rate of 20.8% (24.7/100 patient-years) representing an incidence of one episode each 4 years of treatment. We conclude that an international normalized ratio of 2 to 3 is safer than a ratio of 3 to 4.5 and confers good protection from thromboembolism when oral anticoagulant therapy is used conjointly with platelet function-inhibiting drugs in patients with mechanical substitute heart valves.

Experimental acute right ventricular failure and right ventricular assist in the dog.

We describe a technique for the production of acute progressive right ventricular failure in experimental animals that mimics the hemodynamic characteristics of right ventricular failure found in some patients being weaned from extracorporeal circulation after surgical repair of left ventricular abnormalities. The technique combines three alterations of right ventricular state: excision of the tricuspid valve, ventriculotomy, and ligation of the right coronary artery. Seven control dogs died within 3 hours after this intervention. Death was due to low cardiac output as a result of low left atrial and pulmonary arterial pressures. Right atrial pressure was high. Use of a right ventricular assist device in an additional seven dogs to pump blood from the right atrium to the pulmonary artery confirmed good preservation of left ventricular function by reestablishing adequate left ventricular filling pressure. All seven dogs survived for more than 3 hours. The validity of the technique in restricting failure principally to the right ventricle was thus demonstrated.

Animal model of acute pulmonary thromboembolism treated by local recirculation of streptokinase through the lung.

Massive acute pulmonary thromboembolism has a high mortality within the first few hours. Surgical intervention can remove only larger thrombi. Systemic fibrinolytic administration requires many hours for adequate treatment. We describe an anesthetized dog model of acute, massive, disseminated pulmonary thromboembolism achieved by injection of 1.7 ml/kg of 1-hour-old thrombi directly into the pulmonary artery. The emboli were lysed with 50,000 IU streptokinase recirculated for 20 minutes through the isolated pulmonary vascular bed by use of a roller pump while the systemic bed was supported by conventional cardiopulmonary bypass. On reestablishing natural circulation all hemodynamic parameters returned to preembolism values. Success of lysis was histologically confirmed. Perfusion of the pulmonary vascular bed without inclusion of streptokinase in the perfusate worsened the hemodynamic state of the animals compared with an untreated nonperfused control group.

Laparoscopic cholecystectomy in heart transplant recipients.

To our knowledge these are the first three cases of laparoscopic cholecystectomy in heart transplant recipients. In one case the procedure was performed in the early posttransplant period. All three patients had uneventful postoperative outcomes and early hospital discharge. Laparoscopic cholecystectomy may be a safe alternative for elective cholecystectomy in heart transplant recipients.

Right atrial approach for surgical correction of tetralogy of Fallot.

Total correction of tetralogy of Fallot was performed without a ventriculotomy in 39 patients aged 8 months to 39 years (mean age, 9.1 years) between May 1984 and July 1988. A transatrial approach was used to resect the obstructed infundibulum and to close the ventricular septal defect. In 14 patients, the pulmonary annulus was not enlarged (group 1). Twenty-five patients required a transannular patch (group 2), placed by extending the pulmonary artery incision 1 cm into the right ventricular infundibulum. Eleven patients had repair of pulmonary artery branch stenosis, and associated intracardiac anomalies were simultaneously corrected in 10 patients. After repair, the right ventricular to left ventricular systolic pressure ratios ranged from 0.36 to 0.59 (mean ratio, 0.45) in group 1 and 0.33 to 0.70 (mean ratio, 0.51) in group 2. There were no hospital or late deaths in group 1. Two patients in group 2 with a small left ventricle died shortly after operation. The 37 survivors were followed for 2 to 51 months. Postoperative catheterization in 7 patients detected no residual ventricular septal defects, mild pulmonary regurgitation in 2 patients (group 2), and right ventricular to left ventricular pressure ratios ranging from 0.25 to 0.42 (mean ratio, 0.34). Only 1 patient with a previous total repair by ventriculotomy is symptomatic and requires antiarrhythmic agents and diuretics. The other 36 patients are asymptomatic. In conclusion, tetralogy of Fallot can be safely repaired at any age without a ventriculotomy. The results indicate a minimal incidence of postoperative arrhythmias and pulmonary regurgitation, as well as improved right ventricular function.