Severe left main coronary arterial stenosis with right coronary arterial occlusion: results of bypass graft surgery.

A detailed study was made of preoperative, operative and postoperative data from 69 patients with severe (70 percent or greater) luminal narrowing of the left main coronary artery and occlusion of the right coronary artery who underwent bypass surgery from December 1970 through December 1978. Preoperatively, 40.6 percent of patients were in functional class III and 55.1 percent in class IV. Ninety-six percent of those tested had a positive electrocardiographic treadmill test. Coronary bypass grafting was accomplished using standard techniques in all patients. An average of 2.7 grafts/patient were placed. The hospital mortality rate was 4.3 percent, and an additional 4.3 percent died before the end of 1 year. A history of congestive heart failure was a significant predictor (p less than 0.05) of postoperative mortality. An intraaortic balloon pump was not inserted in 64 patients, and our experience suggests that it was a necessary preoperative adjunct. A postoperative treadmill test was negative in 92 percent of those patients tested. Of those surviving 1 year postoperatively, 89 percent were in functional class I and 8 percent in class II. This study demonstrates a surgical mortality rate comparable with that of patients with left main coronary stenosis alone and a significantly better survival rate than that of similar patients treated medically.

Doppler ultrasonic assessment of aortic stenosis by analysis of axillary arterial blood velocity upstroke time.

Rate-corrected velocity upstroke time (VUT) was calculated from analogue Doppler ultrasound recordings of axillary artery blood flow velocity in 25 patients with aortic stenosis documented by cardiac catheterization and in 14 normal individuals. The mean VUT in normal individuals was 0.11 +/- 0.02 second (+/- 1 SD), which was significantly lower than that of patients with aortic stenosis: 0.15 +/- 0.05 second (P less than 0.005). The VUT correlated with the aortic valve index and the aortic valve mean pressure gradient with correlation coefficients of 0.62 and 0.64, respectively (P less than 0.005). Arterial blood flow velocity assessment by Doppler ultrasound may be a useful noninvasive technique to evaluate patients with aortic valve disease.

Patent ductus arteriosus in premature infants. Indications for surgery.

In order to establish more objective criteria for surgical intervention, the literature and our clinical experience with operative closure of patent ductus arteriosus in 11 premature infants was reviewed. A wide range of age at the time of operation underscored the spectrum of clinical presentation and the difficulty of interpreting the course of therapy. The presence of a typical continuous murmur established the diagnosis of patent ductus arteriosus in patients with respiratory distress syndrome. Cardiac catheterization confirmed the diagnosis and provided quantitation of the left-to-right shunt flow through the ductus arteriosus in 6 patients but did not influence the decision to operate. Progress of the clinical course as determined by the heart size on chest roentgenogram and the presence of hypercarbia (Paco2greater than60 mm. Hg) after respiratory assistance and medical decongestive measures were the two most helpful signs indicating the need for surgical intervention.

Replacement of ruptured chordae tendineae of the mitral valve with autologous pericardial chordae.

Severe mitral regurgitation owing to rupture of chordae tendineae has been repaired in 10 patients by construction of new chordae from autologous pericardium. The site of rupture was the posterior leaflet in eight patients, the anterior leaflet in one patient, and both leaflets in one patient. Cardiac catheterization demonstrated severe mitral regurgitation (average 49%) and a left atrial V wave of 45 mm. Hg. The reconstruction was carried out with pericardium rolled into a chorda with one end attached to the appropriate papillary muscle and the other attached to the flail edge of the mitral valve leaflet being repaired. One patient died on the seventh postoperative day from pneumonia. The remaining nine patients are alive and well (Functional Class I) from 6 months to 9 1/2 years (average 3 years) following the operation. None requires anticoagulants.

Cardiac surgery under age two years. A review.

To assess the current status and risks of both open and closed cardiac procedures for congenital heart disease in patients under the age of 2 years, we reviewed all cardiac catheterizations and cardiac operations done from January, 1974, through December, 1977, at The Children's Orthopedic Hospital and Medical Center in Seattle, Washington. In this interval 370 patients under 2 years of age were catheterized. Eighty open procedures were performed in patients under 2 years of age, with seven hospital deaths. One hundred twenty-four closed heart procedures were performed on children under the age of 2 years, with eight deaths, for a hospital mortality rate of 6.5 percent. This review of consecutive cases over a 4 year period suggests that the judicious application of palliation or open repair using current techniques can lead to an overall mortality rate of between 6 and 7 percent for both open and closed heart procedures in children under 2 years of age. Since all deaths except one in the open-heart group occurred in patients with the most complex multiple defects, it seems reasonable to suggest that improved intraoperative and postoperative techniques have lowered the time for repair of straightforward congenital heart defects to under 2 years of age.

Tetralogy of Fallot: selective staged management.

One hundred twenty-four patients with tetralogy of Fallot have undergone either primary total repair (61), shunt and later repair (30), or an initial shunt (33). The mean ratio of pulmonary anulus to descending thoracic aorta increased from 0.80 +/- 0.25 before the shunt to 1.22 +/- 0.26 before the repair (p less than 0.0001). The mean ratio in the primary repair group was 1.23 +/- 0.25. A transannular patch was necessary in only six of 91 patients (6.6%). Postrepair right ventricular/left ventricular pressure ratio averaged 0.50 +/- 0.11 in the shunt plus repair group and 0.43 +/- 0.12 in the primary repair group. Only four patients had a right ventricular/left ventricular pressure ratio less than 0.65. A significant inverse linear relationship existed between this ratio and the pulmonary anulus size measured at operation and normalized for the patient's height (p less than 0.01). Postoperative complications occurred in 21% of patients after a shunt and 20% of patients after open heart repair. The early mortality was 0.8% (1/124). An initial shunt in patients with a small pulmonary anulus can result in an increased anulus size and better hemodynamic result with frequent avoidance of a transannular patch. Staged repair may result in improved overall mortality rates.

Directional arterial flow velocity: a sensitive index of changes in peripheral vascular resistance.

The effect of peripheral vascular resistance of directional arterial flow velocity was determined utilizing the directional Doppler velocity detector under experimental conditions. Femoral arterial resistance was increased and decreased, and arterial pressure, venous pressure, volume flow, and directional flow velocity were measured in the femoral artery. An increase in peripheral vascular resistance was associated with a marked increase in reverse flow and a decrease in forward flow velocity. Reverse flow decreased and forward flow velocity increased when resistance was lowered. The ratio of peak and mean reverse/forward (r/f) flow velocity changed in a linear relationship with vascular resistance. The increase in resistance associated with progressive hypovolemia was paralleled by an increase in r/f flow velocity which occurred before blood pressure declined. Thus alterations in directional arterial flow velocity can be used as a sensitive indicator of changes in peripheral vascular resistance.

The role of prostaglandin E in the hemodynamic response to aortic clamping and declamping.

The infrarenal aorta was occluded for one hour in 11 control dogs and in eight dogs in which biosynthesis of prostaglandin E (PGE) was inhibited by administration of indomethacin (2.5 mg. per kilogram). The mean arterial pressure (MAP) in the indomethacin group was significantly (p less than 0.001) higher than in the control group at the end of 60 minutes of aortic occlusion (187 +/- 3 vs. 137 +/- 4 mm. Hg, mean +/- S.E.M.) and remained higher (p less than 0.001) after declamping. However, the decline in MAP at the time of aortic declamping was essentially the same for both groups. Total peripheral resistance (TPR) was higher in the indomethacin group than in the control group at the end of one hour of occlusion (159 +/- 13 vs. 124 +/- 12%, p less than 0.001) and remainded higher throughout the period following occlusion. The plasma concentration of PGE in the control group increased significantly (p less than 0.05) above control (630 +/- 110 to 1,299 +/- 261 pg. per milliliter) during the 60 minute period of occlusion with further increases to 1,447 +/- 389 and 1,523 +/- 256 pg. per milliliter (p less than 0.001) at 10 and 60 seconds after declamping, respectively. In the indomethacin group, PGE remained essentially unchanged throughout the clamping and declamping period and therefore was significantly (p less than 0.05) lower than in the control group. A similar pattern was observed in the tissue levels of PGE. This study suggests that PGE is released during and after infrarenal aortic occlusion and may be responsible for maintaining reduced TPR and MAP. However, hypotension after declamping is not affected by inhibition of PGE biosynthesis.

Doppler jugular flow velocity to differentiate cardiac tamponade from failure.

Jugular venous flow velocity (JVFV) was analyzed by the directional Doppler velocity detector in an experimental model to distinguish postoperative acute cardiac tamponade from myocardial failure in eight dogs. Cardiac tamponade was produced by infusion of saline solution into the pericardial cavity; acute myocardial failure was created by temporary occlusion of the left anterior descending artery and circumflex coronary artery. A decrease in mean arterial pressure of only 10% was associated with a decrease in JVFV of 30% +/- 6% (mean +/- SE) in the tamponade group compared to 10% +/- 2% in the myocardial failure group. The difference was statistically significant (P less than .005) and persisted to severe levels of hypotension. An increase in venous pressure to 8 mm Hg resulted in a decrease in JVFV of 41% +/- 11% in the tamponade group. Thus, there is an early notable decrease in JVFV in tamponade, which allows differentiation from myocardial failure.

Method for replacement of the ascending aorta and aortic valve with reimplantation of the coronary arteries.

A method for replacing the entire ascending aorta and aortic valve is described that employs direct anastomosis of the coronary ostia to the graft, facilitated by appropriately time periods of hypothermic ischemic cardiac arrest. The advantages of this technique are that proper placement of sutures around the coronary ostia is simplified and that hemostasis at the aortic annulus and coronary anastomosis can be evaluated before the aortic clamp is removed and suture lines become inaccessible.

Congenital coronary artery- cardiac chamber fistula. Review of operative management.

Eight patients who had surgical correction of coronary artery-cardiac chamber fistula at our center and 163 from a review of the literature are presented. The patients are usually asymptomatic, and the diagnosis is suspected by observing a continuous cardiac murmur. Electrocardiographic findings are nonspecific. Angina pectoris or electrocardiographic evidence of severe ischemia are surprisingly uncommon since coronary artery steal syndrome is also rare. Cardiac catheterization with angiocardiography is required to establish the diagnosis and identify the involved coronary artery and the cardiac chamber into which the fistula terminates. Left-to-right shunt flow is usually low (average Qp/Qs = 1.5). Indications for operation are not precise. If there should be a large shunt flow (2.0) and symptoms of heart failure are present, the decision to operate is clearly justified. This situation is unusual, and operation is nearly always performed in an asymptomatic patient in whom the fistula is closed to prevent future symptoms or complications. The operation chosen is generally interruption of the fistula by direct ligation. Sometimes cardiopulmonary bypass is required. The results are good, with low morbidity (3.6% myocardial infarction) and low mortality (2%) justifying the operation, to be carried out prophylactically even in asymptomatic patients.

Intraoperative transesophageal echocardiography of coronary artery fistulas.

Coronary artery fistula is a rare abnormality but one with substantial surgical importance, as operation abolishes the fistulous shunt volume, progressive coronary dilatation, and potential coronary steal. Prior reports emphasize the utility of direct inspection on cardiopulmonary bypass, with visualization of drainage of blood or cardioplegia from the fistulous connection, to define the drainage site. We report 3 patients in whom intraoperative transesophageal echocardiography was used for precise localization of the fistulous drainage site, selective demonstration of vessels feeding the fistulas, and documentation of abolition of fistulous flow, all without need for cardiopulmonary bypass. In addition, the technique provides for continuous monitoring of ventricular function, providing the opportunity to detect inadvertent ischemic effects of ligation. This approach appears to have considerable utility.

Radical enlargement of the aortic root and outflow tract to allow valve replacement.

A method of radical enlargement of the aortic root and outflow tract is described. The technique consists of incising the aortic annulus, the anterior mitral leaflet, and the superior aspect of the left atrium. Valve replacement is then possible, with patch reconstruction of the resulting defects.

Surgical repair of anatomically corrected malposition of the great arteries.

Anatomically corrected malposition of the great arteries is a rare malformation in which the aorta and pulmonary artery arise from their appropriate ventricles but in an abnormal spatial relationship. This report describes 2 patients with anatomically corrected malposition who underwent closure of a ventricular septal defect and placement of a right ventricle-pulmonary artery conduit. A review of the literature indicates that surgical results have been good (92% survival) in those patients with situs solitus and atrioventricular concordance [S,D,L]. However, when there is atrioventricular discordance, that is, [S,L,D] or [I,D,L], hypoplastic right heart structures, or both conditions, the outcome after palliative procedures has been poor (29% survival). The results of surgical treatment should improve as this entity is recognized earlier and prompt surgical treatment is undertaken.

Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries.

Long-term follow-up data from several leading centers concerning patients undergoing coronary artery bypass clearly demonstrate the superiority of the internal mammary artery (IMA) with patency rates of 83 to 94% at 7 to 12 years compared with the saphenous vein and its patency rates of 41 to 53%. Our experimental studies provide a biological basis for understanding this difference. Thin-walled arterial autografts undergo no histological change after being implanted in the arterial system, while venous autografts undergo major changes with an initial scattered loss of endothelium and marked thickening due to a proliferative reaction. The challenge to the cardiac surgeon is to revascularize the entire left ventricle with the IMAs. We have found this possible in most patients with advanced three-vessel disease by using both IMAs either as in situ grafts or free grafts with as many sequential anastomoses as necessary to achieve full revascularization. Our use of the term in situ refers to the graft's origin from the subclavian artery as opposed to a free IMA graft arising from another site.

Transesophageal echocardiography during repair of congenital cardiac defects: identification of residual problems necessitating reoperation.

One advantage of intraoperative transesophageal echocardiographic (TEE) evaluation during surgery for congenital heart disease is detection of suboptimal repairs, thus providing the opportunity to return to cardiopulmonary bypass (CPB) to repair residual defects. The purpose of this study was to evaluate the impact of TEE on decisions to return to CPB. Two-hundred-thirty infants and children with a variety of defects were studied with size-appropriate TEE probes. Patients were grouped by anatomic defect or surgical procedure for which TEE was requested. After CPB, pre- and post-CPB TEE anatomic, functional, and flow evaluations were compared. TEE findings prompted a return to CPB to repair residual defects in 17 of 230 (7.4%) patients. By diagnosis, return to CPB occurred in 9 of 28 (32%) patients with left ventricular outflow tract obstruction, 5 of 78 (6.4%) patients with ventricular septal defect, 1 of 16 (6%) patients with switch-repaired transposition, 1 of 32 (3%) with aortic valve disease, and 1 of 3 with double outlet right ventricle. All post-CPB diagnoses were confirmed during reoperation. Although post-CPB TEE provided reassuring information in patients with other diagnoses, TEE impact on return to CPB appears to be significant in a small group of primary diagnoses. The sensitivity and specificity of TEE determination of the need for reoperation were 89% and 100%, respectively. By identifying the site, severity, and mechanism of residual problems, TEE offers substantial utility in detection of residual problems in need of reoperation.

Left ventricular outflow tract obstruction: an indication for intraoperative transesophageal echocardiography.

Transesophageal echocardiography (TEE) provides detailed anatomic imaging of both discrete and complex forms of left ventricular outflow tract (LVOT) obstruction, and Doppler techniques provide additional information regarding the site, mechanism, and severity of the obstruction. Because the transaortic surgical approach to LVOT obstruction often provides limited direct visualization during surgery, we sought to evaluate the utility of intraoperative TEE during surgery for LVOT obstruction. We tested the hypotheses that intraoperative TEE would (1) be useful in defining the level and nature of LVOT obstruction, (2) serve to direct the surgical approach, (3) define the adequacy of relief of LVOT obstruction, and (4) detect surgical complications. Study population consisted of a consecutive series of 27 infants and children undergoing surgery for LVOT obstruction. Patient age ranged from 0.5 to 17.9 years, and weight from 5.4 to 71.2 kg. In 14 patients LVOT obstruction resulted from a discrete membrane, whereas 13 had complex forms of LVOT obstruction. Fully anesthetized and monitored patients were examined with 5 MHz TEE probes appropriate to the size of the patient. In the 14 patients with discrete LVOT obstruction, discrete membranes were identified by TEE in all; gradients ranged from 36 to 75 mm Hg. In 13 of 14 patients, postbypass TEE demonstrated removal of the membrane and excellent relief of gradients. In one of these patients, TEE demonstrated a small ventricular septal defect acquired during resection; the patient was returned to bypass for closure. In one patient, return to bypass for further resection of LVOT obstruction was prompted by TEE demonstration of a high residual gradient. In the 13 patients with complex LVOT obstruction, TEE demonstrated the complexity of LVOT obstruction in all. Gradients ranged from 4 to 95 mm Hg. Although this information was used in surgical planning, five patients had high residual gradients after bypass and underwent further resection. An additional two were returned to bypass for mitral valve replacement. Overall, 8 of 27 patients (29.6%) were returned to bypass based on TEE demonstration of residual anatomic or hemodynamic abnormalities. This occurred significantly more frequently in complex LVOT obstruction than in discrete LVOT obstruction (p = 0.045). We conclude that intraoperative TEE has substantial utility in the demonstration of site, mechanism, and severity of LVOT obstruction and for surgery designed to relieve LVOT obstruction. We believe that TEE should be an integral part of surgical management of LVOT obstruction.

Double aortic arch causing tracheoesophageal compression.

Since 1972, 17 patients have been surgically treated for double aortic arch at our institution. The procedure became necessary before 12 months of age in 11 patients and before 24 months in 16 patients. The major symptoms were respiratory distress, noisy breathing, and respiratory infections; four patients also had dysphagia. A high degree of clinical suspicion should warrant further investigation. Barium swallow and bronchoscopy were diagnostic and revealed extrinsic compression of the esophagus and trachea, respectively. Division of the anterior arch was performed in 16 patients; the right (posterior) arch was divided in the remaining patient. Kommerell's diverticulum was found in four patients and was resected in order to avoid recurrence of dysphagia by compression. A vascular suspension procedure was necessary in 13 patients to further release the trachea and esophagus. There was no mortality in this series, and symptomatic improvement was achieved in all patients. A degree of tracheomalacia may be responsible for some residual symptoms in four patients.

Staged repair of interrupted aortic arch with ventricular septal defect compared with primary repair in infancy.

Interrupted aortic arch is a poor prognosis cardiac anomaly with nearly 100 percent mortality if not recognized and treated early. The associated intracardiac lesions often lead to death if only the arch defect is repaired. Several recent reports have described patients with interrupted aortic arch who were treated as infants by primary repair of the arch defect with simultaneous repair of the intracardiac lesions. The improved survival data from these series have been attributed to the simultaneous repair of both lesions. We report herein on nine patients with both interrupted aortic arch and ventricular septal defect seen at Children's Hospital and Medical Center in Seattle from 1979 to 1987. Three patients had partial expression of DiGeorge's syndrome. All patients underwent primary repair of the interrupted aortic arch with concomitant pulmonary artery banding during infancy (mean age 18 days, range 2 days to 4 months). Operative mortality was 11 percent (1 of 9 patients). Eight patients had eventual repair of the ventricular septal defect (mean age 18 months, range 6 to 29 months) with one death occurring at 5 months postoperatively (12 percent mortality). The overall mortality of these nine patients was 22 percent. Staged repair of interrupted aortic arch with associated ventricular septal defect can be performed with results comparable to simultaneous primary repair in infancy. The improved survival from either approach is more likely to be attributable to improved perioperative stabilization, particularly the use of prostaglandin E.

Results of combined left ventricular aneurysmectomy and coronary artery bypass: 1974 to 1980.

Left ventricular aneurysm repair with coronary artery bypass grafting was performed in 104 patients from 1974 through 1980. The patients' mean age was 57 years. Preoperatively, 48 percent were in New York Heart Association functional class III and 31 percent were in class IV. Stenosis of multiple vessels was common, as was a reduced ejection fraction (24 percent had an ejection fraction of less than 30 percent). Thrombus was present in 47 percent of resected aneurysms. Bypass grafting was performed to all graftable coronary vessels. Actuarial survival rates were 89.3 percent at 1 year, 86.1 percent at 2 years, and 74.5 percent (standard error 5.1 percent) at 5 years. One year postoperatively, 86 percent of the surviving patients were in class I, 11 percent class II, 1 percent class III, and 2 percent class IV. Patients who presented with angina alone had an excellent result, with 95 percent hospital survival. Congestive heart failure was an ominous finding, since four of five patients who developed it before discharge died in the hospital, and 38 percent of those who went into heart failure after discharge have died.