Surgical correction of ventricular septal defects in black and white children--an 11-year study.

The clinical and ECG features, anatomical subtypes and outcome in 309 children (169 black; 140 white; 58% female) who underwent surgical closure of ventricular septal defects (VSDs) are presented. Clinical presentation was more severe in the black children; with recurrent pulmonary infections in 65% blacks compared with 34% whites. Congestive cardiac failure was noted in 60% blacks and in 37% whites. At cardiac catheterisation a left to right shunt greater than 2.5/1 was found in 45.5% of the black and in 39.3% of the white children. Severe pulmonary hypertension (greater than 80% of systemic systolic pressure) was evenly distributed in both groups. Of the 140 white children, 74.3% underwent surgery under the age of 2 years compared with 68.6% of the 169 blacks. A perimembranous VSD was found in 65% of patients in each group. Infundibular (muscular outlet) defects were observed in 28.6% of white and 30.8% of black children. Left axis deviation (LAD) on ECG was found in 11.9% of white and 9.2% of black patients; and 93% of the total of 27 cases had a perimembranous defect. Early mortality was 3.6% in white and 7.1% among the black children. Of the 17 fatal cases in the total group, 16 had severe pulmonary hypertension. It is concluded that: (i) operative results compared favourably with those reported elsewhere; (ii) the anatomical subtypes occurred with equal frequency in both ethnic groups; and (iii) this was also the case for LAD on ECG, which was most commonly associated with a perimembranous VSD.

Valvuloplasty for rheumatic mitral valve disease. A surgical challenge.

From January 1981 through February 1985, 241 patients with rheumatic mitral valve disease (mean age 21.5 +/- 11.8 years) were subjected to comprehensive mitral valvuloplasty. One hundred seven patients (44.4%) were 15 years or younger and 63 (26.1%) were 12 years or younger. One hundred seventy five patients had pure or predominant regurgitation (mean age 19.3 +/- 10.7 years) and 40 (16.6%) had active rheumatic carditis at the time of the operation. Almost all patients (229) were in New York Heart Association Functional Class III or IV. The techniques used included shortening of anterior leaflet chordae tendineae (136 patients), resection of secondary, tertiary, and basal posterior leaflet chordae (156 patients), commissurotomy (113 patients), and implantation of a Carpentier ring (164 patients). Current operative mortality is 1.9%. The survivors were followed up for 576 patient-years (mean 2.64 +/- 1.32 years). Late mortality was 2.60% per patient-year and was valve related in 1.04% per patient-year. Reoperation was required in 25 patients (4.34% per patient-year), mostly (72%) in the first year. There were only two cases (0.35% per patient-year) of thromboembolism and three cases (0.52% per patient-year) of infective endocarditis. Hence valve failure occurred at a linearized rate of 6.08% per patient-year but was fatal in only 22% of the patients. There was no relationship between valve failure and the type of lesion or procedure performed, but reoperation was required more frequently in patients aged 12 years or less (7.33% per patient-year) than in those older than 12 years (3.29% per patient-year) (p less than 0.05). Actuarial survival rate at 41/2 years was 90%, and 82% of the patients were free from valve-related complications. Valve function after valvuloplasty was assessed clinically. Eighty-four percent of the patients had a good immediate result, but this figure dropped to 69% at the end of the follow-up period (p less than 0.05). The remainder had moderate valve dysfunction. However, 85% of the patients remain in New York Heart Association Functional Class I. Mitral valvuloplasty is an excellent alternative to valve replacement in young patients with rheumatic mitral valve disease. Persistent or reactivated rheumatic carditis may be a significant factor of valve failure, and penicillin prophylaxis is mandatory after operation.

St. Jude Medical valve replacement. An evaluation of valve performance.

St. Jude Medical cardiac valve replacement was performed in 791 patients: 335 had aortic, 330 mitral, and 126 had multiple valve replacements. Follow-up extended from 4 to 64 months (mean 34 months) with a cumulative postoperative survival of 2,111 patient-years. The overall actuarial survival rate at 5 years was 76% +/- 3%. Late valve-related mortality occurred in 28 patients (1.33%/pt-yr) and was most often caused by anticoagulant-related hemorrhage. The linearized incidences of valve failure, thromboembolism, thrombotic obstruction, prosthetic valve endocarditis, periprosthetic leak, and all valve-related complications were as follows: 1.80% /pt-yr, 2.45% /pt-yr, 0.52% /pt-yr, 0.33% /pt-yr, 0.14% /pt-yr, and 4.0% /pt-yr, respectively. Actuarially, 94% +/- 2% of patients were free of valve-related mortality at 5 years; the corresponding figures for valve failure, thromboembolism, thrombotic obstruction, and all valve-related complications were 91% +/- 2%, 89% +/- 2%, 96% +/- 1%, and 83% +/- 3%, respectively. Prosthetic valve endocarditis was uniformly fatal, and 45% of patients with thrombotic obstruction died. The greater incidence of thrombotic obstruction after mitral valve replacement was statistically significant. The performance of the St. Jude Medical valve compares most favorably with other substitute valves. Nevertheless, it retains all the imperfections and hazards of other mechanical valves, most notably, thromboembolism and thrombotic obstruction.

Surgical treatment of aneurysms of the ascending aorta associated with severe aortic regurgitation.

From January 1979 to June 1982 31 patients have had simultaneous ascending aortic aneurysm repair and aortic valve replacement. Fifteen patients (group 1) received a composite graft; seven patients (group 2) had separate aortic valve and supracoronary ascending aorta prostheses; and nine patients (group 3) had aortic valve replacement and "tailoring" of the ascending aorta. The mean age was 50 (SD 14) years. Nine patients had acute dissection, five with the coronary ostia affected. Emergency surgery was performed in 10 cases. There were six early deaths (19.4%), none of them due to technical complications during surgery. The mortality rate was 56% for patients with acute dissection operated on as an emergency and 4.5% for patients having elective operations. Appreciable haemorrhage occurred in four patients (12.9%). No neurological complications occurred. There was one late death. The survivors were followed up for one to four years. There was one case of recurrence of aneurysm. No ischaemic complications resulted from coronary reimplantation. There were no significant differences in the results of the three groups. Simultaneous ascending aortic aneurysm repair and aortic valve replacement can be accomplished with an acceptable mortality rate and little morbidity.

Hypothermia and circulatory arrest for surgical resection of aortic arch aneurysms.

In the 6 year period 1976 through 1981, 13 patients had surgical correction of aneurysms of the aortic arch with the use of deep systemic hypothermia (15 degrees to 24 degrees C) and partial (lower body only) or complete circulatory arrest. Three pathological groups were recognized: Group I (seven patients), with involvement of the aortic arch only; Group II (two patients), with extension of disease from the arch into its major vessels; and Group III (four patients), with predominant involvement of the major vessels. In the first eight patients (1976 to 1979), the carotid arteries were perfused directly with circulatory arrest of the rest of the body. Three of the eight patients (37.5%) died, two of cerebral complications and one of respiratory failure. Another patient had a nonfatal neurologic complication. In the last five patients (1980 to 1981), the carotid arteries were not perfused and variable periods of cerebral ischemia under hypothermic protection (18 degrees C) were permitted. All patients survived, and only one showed transient, minor neurologic changes. Our current recommended technique includes deep systemic hypothermia (15 degrees to 18 degrees C) using femoro-femoral bypass, complete circulatory arrest, and temporary occlusion of the carotid arteries. Additional protection of the myocardium is achieved by cold potassium (20 mEq/L) cardioplegia. Repair of the aneurysm is performed from within the aortic arch in a bloodless field. The hitherto high mortality and morbidity following resection of aneurysms of the aortic arch can be greatly reduced using this simplified technique.

Patch graft aortoplasty for repair of coarctation of the aorta in infants under 1 year of age.

Patch graft angioplasty for symptomatic coarctation of the aorta was carried out in 34 infants aged from 6 days to 9,5 months (mean 49,4 days). Congestive cardiac failure was present in 32 and severe hypertension alone in 2 patients. Of the 34 children, 21 (61,8%) had significant associated cardiac lesions and 25 (73,5%) were less than 6 weeks of age. Systolic blood pressures were recorded by the Doppler technique before and after the operation. There were 6 hospital deaths (17,6%) and 3 late deaths, giving a total mortality of 26,5%. Pre-operative systolic pressure gradients between upper and lower limbs ranged from 20 to 92 mmHg (mean 54,5 mmHg). Of the 28 early survivors, 1 was lost to follow-up. Duration of follow-up ranged from 3,5 to 62 months (mean 24,5 months). Postoperative residual gradients of less than 20 mmHg were found in 19 of the 27 cases followed up (70,4%), while 8 patients had significant residual gradients (40 - 90 mmHg). Of these 8, 7 had undergone surgery when less than 6 weeks old, and 6 of them have subsequently undergone a second corrective operation. It is concluded that while patch graft angioplasty is a life-saving procedure for the correction of symptomatic coarctation of the aorta in early infancy, a significant proportion of the patients develop a recurrence of coarctation necessitating further surgery later.

Intermittent aortic regurgitation following aortic valve replacement with the Hall-Kaster prosthesis.

Intermittent aortic regurgitation (AR) was encountered in four of 160 consecutive patients subjected to aortic valve replacement (AVR) with the Hall-Kaster prosthesis. In all four cases, mechanical obstruction to the free movement of the occluder was carefully excluded. All cases were confirmed at reexploration of the valve. The major orifice of the valve was reorientated with correction of AR. A possible mechanism for this phenomenon is wide opening of the occluder beyond the axis of blood flow, resulting in nonclosure during diastole. Meticulous care should be taken in the orientation of this aortic prosthesis to avoid its opening beyond the axis of flow and resulting in postbypass AR.

Cardiac operation during active infective endocarditis: results of aortic, mitral, and double valve replacement in 94 patients.

Cardiac valve replacement was performed in 94 patients (95 operations) in the presence of active infective endocarditis. Most of the patients were extremely ill. The operation was performed as an emergency or semiemergency lifesaving procedure in 88% of them, and more than half received little or no antibiotic treatment prior to the operation. The hospital mortality was 16%--14% for aortic valve replacement (AVR) and 11% for double valve replacement (DVR) but 31% for isolated mitral valve replacement (MVR). The mortality was not higher in patients operated on urgently (emergency or semiemergency), nor was it higher in patients who had aortic annular abscesses or aneurysms. Prosthetic valve endocarditis (PVE) (in each case occurring more than 60 days after the previous valve operation) carried a higher mortality (33%) than native valve endocarditis (NVE) (14%). The relatively high early mortality for MVR may have been related to the fact that we operated upon MVR patients after intensive medical treatment had failed. The late results were good: Sixty-six patients are alive and well, 51 of them in Functional Class I. Six patients were reoperated upon for aortic periprosthetic leaks, and five are now well. Eight patients died late (9%), one of them because of a periprosthetic leak and one because of a clotted valve. In seven of the eight deaths, the cause of death was probably not related to the timing of the original operation. We recommend early valve replacement for patients with infective endocarditis. We believe that early operation reduces mortality, prevents emboli, and is associated with excellent long-term results.

Emergency heart valve replacement: an analysis of 170 patients.

The results of 170 emergency heart valve procedures performed during a 4 1/2-year period were analyzed. Five pathological groups of patients were recognized: those with infective endocarditis (Group 1, 28 patients); acute rheumatic carditis (Group 2, 43 patients); previous valve operation (Group 3, 29 patients); acute-on-chronic cardiac disease (Group 4, 67 patients); and miscellaneous conditions (Group 5, 3 patients). Mitral, aortic, and multiple valve procedures were performed on 58, 65, and 44 patients, respectively. The most common functional lesion was regurgitation. Hospital mortality was highest in Groups 3 (34%) and 4 (31%). By contrast, among the hospital survivors, the highest rate of attrition was in Group 2. Myocardial failure was the predominat cause of death. In view of the hopeless prognosis without operation, the 52% overall 3-year actuarial survival is a gratifying salvage. Unnecessary procrastination can only jeopardize the prospects for surgical cure.

Gastrobronchial fistula diagnosed and treated four years after a shooting accident. A case report.

A case of gastrobronchial fistula complicating thoraco-abdominal trauma is presented. Possible pathogenesis is discussed and a further cause for failure of a fistula to close is suggested.