Early risks of open heart surgery for mitral valve disease.

During 1972 and 1973, a total of 235 patients had open heart surgery for mitral valve disease unassociated with significant aortic or rheumatic tricuspid valve disease. Thirty-one underwent closed heart mitral commissurotomy, without mortality. Of the 204 patients undergoing open operation, 125 had sequential measurement of cardiac output and mixed venous oxygen pressure. The hospital mortality rate was 6.4 percent in the larger group of 204 patients and in the 125 with cardiac output measurements. The rate was greater in those with class IV disability (New York Heart Association criteria) preoperatively than in those with class III or II disability. The mean +/- standard deviation of the average cardiac index early postoperatively was 2.05 +/- 0.579 liters-min--1-m--2. Cardiac index was lower in the patients who died early postoperatively than in those who did not. The probability of hospital death was a significant function of cardiac index. The predicted probability of death was 10 percent with an average cardiac index of 1.42 liters-min--1-m--2 and increased sharply with lower indexes. Cardiac index was lower early postoperatively than preoperatively, and was lower in patients in class IV than in those in class III. There was no significant difference in cardiac index between patients with mitral valve replacement and those in repair. A history of closed commissurotomy, age, duration of cardiopulmonary bypass, duration of cardiac ischemia and method of myocardial preservation did not significantly influence cardiac index or hospital mortality rate. There was no significant relation between mixed venous oxygen pressure and hospital death. Further improvement in results of mitral valve surgery requires adequate preservation of left ventricular performance before, during and after operation.

Afterload reduction and cardiac ouptut in infants early after intracardiac surgery.

Sixteen infants less than 18 months old were studied within 3 hours of intracardiac surgery. Initial mean arterial pressure and systemic vascular resistance levels were higher than normal in each infant (99 +/- 17.2 mm Hg and 48 +/- 18.1 units'm2', respectively [mean +/- standard deviation]); cardiac index was low (1.9 +/- 0.48 liters'min-1-2) and mean left and right atrial pressures were 11.4 +/- 2.39 and 12.5 +/- 3.10 mm Hg, respectively. Mean pulmonary arterial pressure was 29 mm Hg; pulmonary vascular resistance was 8.6 units'm2'. When nitroprusside was infused to reduce mean arterial pressure to about normal, cardiac index increased 17 percent and mean left and right atrial pressures decreased 25 and 22 percent, respectively. Mean pulmonary arterial pressure decreased 31 percent. When atrial pressures returned to initial values after infusion of blood with continued infusion of nitroprusside, cardiac index increased another 24 percent. When administration of nitroprusside was discontinued, cardiac index decreased to 116 percent of the initial value and mean atrial pressure increased to 90 percent of the initial value. The study demonstrated the favorable effect on cardiac output of vasodilator therapy in combination with blood volume expansion in hypertensive infants early after intracardiac surgery. An empirical equation interrelating atrial and arterial pressures and cardiac index was derived from the data.

Surgical treatment for closed thoracic aortic injuries.

Eighteen patients with acute aortic tear secondary to nonpenetrating thoracic trauma and seven with chronic tears have been operated upon. Of the patients with acute injury, 28% had normal chest x-ray on admission. The diagnosis of acute aortic tear was made by aortography in all patients. Two patients died from causes unrelated to the aortic injury. In the group of 18 patients in which some method of perfusing the distal aorta was used, two developed paraplegia; in the group of 7 treated with simple aortic cross-clamping none occurred. The average aortic cross-clamp time 69 and 23 minutes, respectively, and average blood administration 3,139 and 1,700 ml., respectively. We conclude that the diagnosis of acute aortic tear cannot be reliably made on clinical grounds, and that with properly trained personnel the method of choice is usually simple aortic cross-clamping during repair.

Surgical treatment of truncus arteriosus, with emphasis on infants and small children.

Two of 10 children with truncus arteriosus, Type I, II, less than 2 years of age, 6 of 7 between 2 and 5 years of age, and all 5 older than 5 years survived after complete repair. Five of the nine hospital deaths are believed related to inadequate intra- and postoperative management. One late death has occurred 42 months postoperatively. The low hospital mortality rates in those 2 years of age and older, good long-term results to date, and the poor prognosis of children not operated upon indicate the advisability of elective repair at age 2 to 3 years. Although results in infants less than 2 years old have not been good, current improvements of intra- and postoperative care and the lack of a better alternative suggest that prompt primary repair is indicated for infants with intractable heart failure or increasing pulmonary vascular resistance.

Hemodynamic responses to dopamine infusion at controlled normal and low cardiac output states in the anesthetized dog.

In order to isolate the renal and pulmonary vascular effects of dopamine, we employed a dog preparation utilizing fixed venous return in order to control cardiac output at either a normal or low flow state. Dopamine infusion was carried out at doses of 8 and 16 microng/Kg./min. Heart rate, mean systemic arterial pressure, mean pulmonary artery pressure, and renal blood flow were measured. Changes in mean systemic arterial pressure, mean pulmonary artery pressure, and renal blood flow were not significant at either doses of dopamine. There was a dose-related increase in heart rate, most significant with a dose of 16 microng/Kg./min. and low cardiac output. No evidence was found to substantiate the existence of a specific dopaminergic receptor in the renal vasculature when cardiac output was controlled.

Opitmal age and results in repair of large ventricular septal defects.

The hospital mortality rate was 9.1 per cent (three deaths) in 33 patients less than 2 years old undergoing primary repair of single large ventricular septal defects (VSD's) since January 1972, and was not related to age; it was zero in 50 patients older than 2 years (Group A). The mortality rate with multiple VSD's was 36.4 per cent, not related to age. Age at operation, preoperative pulmonary vascular resistance, and pulmonary artery pressure were directly related to mean pulmonary artery pressure 5 or more years later in 74 patients (Group B) operated upon between 1955 and 1968. Over-all probability of "surgical cure" for single large VSD (surviving the early and late postoperative period with normal or near-normal pulmonary artery pressure 5 years later) is 92 per cent when pulmonary vascular resistance is 4 units - sq. M. and operation performed at age 27 months, 87 per cent when resistance is 8 and operation done at age 6 months, and 80 per cent when resistance is 12 and operation done at less than 6 months of age. These and other probability curves are examined and compared with natural history to determine optimal age for elective repair for large VSD's.

Quadruple valve commissurotomy.

A 12-year-old girl in congestive heart failure was diagnosed to be suffering from severe polyvalvular disease due to a combination of congenital and rheumatic lesions. Cardiac catheterization demonstrated stenotic lesions of all the heart valves. The child underwent quadruple valve commissurotomy and is symptom free and thriving 2 years later.

Cardiac rupture and ventricular septal defect in isolated right coronary artery disease.

A patient is described who had both ventricular septal defect and then cardiac rupture with death within 24 hours of the onset of acute posteroinferior myocardial infarction. At autopsy he was found to have single-vessel disease involving the right coronary artery. Isolated disease of the right coronary artery can produce unexpected, fatal mechanical complications.

Pericardial meshing: an effective method for prevention of pericardial adhesions and epicardial reaction after cardiac operations.

Cardiac reoperations, particularly for coronary revascularization, are becoming more frequent and carry increased risk of damage to the heart during resternotomy. We experimentally evaluated a pericardial meshing technique to facilitate primary pericardial closure. In 18 mongrel dogs, an 8 by 5 cm pericardial flap was fashioned through a left thoracotomy. A standardized procedure for induction of pericardial adhesions was carried out in all animals. Animals were divided into three groups of six animals each: Group I (control)--the pericardial flap was primarily resutured; Group II--the flap was meshed and then resutured; and Group III--the flap was replaced by a pericardial substitute. Animals were put to death 8 weeks postoperatively and the pericardial space was examined for adhesions and epicardial reaction. The extent of adhesions and epicardial reaction was graded as: 0--none; 1--minimal; 2--moderate; and 3--severe. Both in Group I and Group III severe pericardial adhesions (grade 2-3) and epicardial reactions (grade 2-3) were formed, which obscured the underlying coronary anatomy. In Group II pericardial adhesions and epicardial reactions were none to minimal (grade 0-1) and the underlying coronary anatomy was not obscured. The meshed pericardium was completely regenerated by normal pericardium within several weeks. This study demonstrates that pericardial meshing facilitates primary tension-free pericardial closure. Free drainage of intrapericardial blood is achieved. A complete anatomic layer between heart and sternum is restored. Pericardial meshing is superior to the pericardial substitutes examined, as adhesions and epicardial reactions are significantly reduced, and the coronary anatomy is readily identifiable.

A new method of sternal reclosure.

A new method is described for stabilizing dehiscence or instability of median sternotomy incisions using stainless steel retention sutures. The method has been used successfully in patients who had disruption of the sternum following open-heart surgery and resulted in no complications. It is recommended also as a preventive measure for closure of the sternum in elderly, debilitated patients with a fragile sternum and with prolonged low cardiac output after operation.

Pericardial meshing: a new technique to facilitate primary tension-free pericardial closure.

A method is described to facilitate pericardial approximation at the conclusion of open-heart surgical procedures. Before sternal closure, the anterior pericardium is meshed by multiple longitudinal incisions until tension-free closure is possible. The technique was developed by animal experimentation and is now being performed in patients. It has proven to be simple, safe, and effective.

Surgical treatment of right ventricular myxoma in infancy.

Myxomas are the most common of all primary cardiac tumors in adults. They are extremely rare in infancy. We report on a 5-month-old infant who was admitted in a state of cardiogenic shock. Echocardiography showed a right ventricular myxoma completely occluding the right ventricular outflow tract. prompt surgical removal of the tumor resulted in a excellent outcome.

Early calcification and obstruction of a mitral porcine bioprosthesis.

A patient is described in whom severe prosthetic valvular stenosis developed ten months after mitral valve replacement with an Angell-Shiley porcine heterograft. At emergency operation, calcification of the prosthesis was revealed. Early calcification and stenosis of a porcine heterograft valve is a life-threatening complication that must be recognized promptly and treated by emergency valve replacement.

The diagnostic accuracy of mammography in the evaluation of male breast disease.

BACKGROUND: The role of mammography in the evaluation of male patients presenting with breast disease is controversial. This controversy is a function of the lack of specific data concerning the diagnostic accuracy of mammography when used in this clinical setting. The purpose of this study was to define the diagnostic accuracy of mammography in the evaluation of male breast disease. METHODS: One hundred and four prebiopsy mammograms from 100 patients with tissue diagnoses were read blindly by two independent radiologists, and placed into one of five predetermined categories: definitely malignant, possibly malignant, gynecomastia, benign mass, and normal. Radiologic/pathologic correlation was performed and the sensitivity (Sn), specificity (Sp), positive (Ppv) and negative predictive value (Npv), and accuracy (Ac) for each of the mammographic diagnostic category determined. RESULTS: The pathologic diagnoses were 12 cancers, including 1 patient with bilateral breast cancer, 70 cases of gynecomastia, 16 benign masses, and 6 normals. The accuracy data for the mammographic diagnostic categories are as follows: malignant (combined definitely and possibly malignant), Sn 92%, Sp 90%, Ppv 55%, Npv 99%, Ac 90%; and overall benignity (combined gynecomastia, benign mass, and normal), Sn 90%, Sp 92%, Ppv 99%, Npv 55%, Ac 90%. Six cancers (50%) coexisted with gynecomastia. CONCLUSIONS: Mammography can accurately distinguish between malignant and benign male breast disease. Although not a replacement for clinical examination, its routine use could substantially reduce the need for biopsy in patients whose mammograms and clinical examination suggest benign disease.

Systemic to pulmonary shunting masquerading as patent ductus arteriosus: a pitfall in clinical diagnosis.

Patent ductus arteriosus (PDA) frequently complicates the course of respiratory distress syndrome in premature infants. A 920-g, 28 weeks' gestation infant with clinical and radiographic evidence of left to right shunting, was presumed to have a patent ductus arteriosus. Following ductal ligation the signs persisted. Aortic angiogram demonstrated multiple collateral vessels arising from the systemic circulation and communicating with pulmonary vessels. Accurate diagnosis of left to right shunting is imperative if such collateral shunting is not to go undiagnosed.

Developmental retardation in infants as a concomitant of physical child abuse.

The impact of child abuse on the developmental functioning of infants was investigated. Thirty verified cases of physically abused children were compared to a reference group of 30 nonabused children matched for age, sex, race, and socioeconomic status. Abused children scored significantly lower in terms of cognitive and motor development as measured by the Bayley Scales of Infant Development. Development delays on three of the four sectors of the Denver Developmental Screening Test, personal-social, language, and gross motor, were also found in the abused children. There were, however, relatively few item differences between the two groups on the 30 more general behavioral variables constituting the Bayley Infant Behavior Record. Results appear to confirm clinical observation of abused children as developmentally retarded with specific delays in the language and gross motor areas. Although methodologically complex, longitudinal studies are clearly indicated to assess the stability and/or reversibility of the present findings.

Hypothesis: new concepts on the pathogenesis of early prosthetic valve endocarditis.

During the years 1970-1980, 697 patients had valve replacement surgery at our institution. Thirty patients subsequently developed prosthetic valve endocarditis (P.V.E.). Reexamination of the native valves of 25 of these patients revealed histopathological evidence of thromboendocarditis in 7, 5 of whom subsequently developed early P.V.E. In 3 out of 25 matched controls in whom P.V.E. was not diagnosed clinically, similar pathological findings were found; these patients all had fever pre- or post-operatively and were treated with a short antibacterial course, but no definite clinical diagnosis was made. We suggest that there is a close relationship between subclinical thromboendocarditis on the native valve and the early development of infective endocarditis on the implanted artificial valve.

Delayed sternal closure following cardiac operations.

In 13 patients, sternal closure was delayed at the end of open heart procedures. Seven patients underwent coronary artery bypass surgery (CAB), 5 valve replacements, and one left ventricular aneurysmectomy and closure of post myocardial infarction VSD. In all, primary closure of the sternum was considered impossible or inadvisable. The major indications for delaying sternal closure were: cardiac dilatation with tamponade-like behaviour upon attempted sternal closure (8 patients); intractable bleeding (2); intractable arrhythmia (1); insertion of mediastinal assist devices (3) and intraoperative non-cardiogenic pulmonary edema (1). In all, only the skin was closed. Delayed sternal closure (DSC) was performed 36-120 hours later on 10 of the patients, when their condition had stabilized. Nine patients are long term survivors. None of these patients has developed mediastinitis, wound infection, osteomyelitis or instability of the sternum. The judicious use of DSC in selected situations has several advantages: hemodynamic deterioration from pressure upon the heart may be prevented; a quick access to the heart in case of tamponade or intractable arrhythmia is obtained; insertion of mediastinal assist devices is facilitated. With careful technique the risk of infection is low.

Improved functional results following myocardial revascularization in patients with left ventricular dysfunction.

Between February 1978 and October 1982, 40 patients with preoperative ejection fraction (EF) of 0.35 or less underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were seven late deaths (3 cardiac and 4 non-cardiac). The five-year cardiac actuarial survival rate was 74% +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.

Exercise performance in patients with impaired left ventricular function following aorto coronary bypass.

We studied 40 patients with preoperative ejection fraction (EF) of 0.35 or less who underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were 7 late deaths (3 cardiac and 4 non-cardiac). The 5-year cardiac actuarial survival rate was 74 +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.