Rupture of the posterior wall of the left ventricle after mitral valve replacement.

Rupture of the posterior wall of the left ventricle is an unusual but often lethal complication following mitral valve replacement (MVR). We have encountered it six times with a 100 per cent mortality rate in a series of 1,154 operations for MVR. Sites of rupture were located at the base of the resected papilary muscle or close to the artioventricular groove in the area adjacent to the resected posterior mitral leaflet. T stongly indicates the overzealous resection of the mitral leaflets and papillary muscle as an important eitiologic factor. Other possible etiologic factors are discussed and important pitfalls to be avoided during MVR are stressed.

Selection of the candidate for myocardial revascularization; a profile of high risk based on multivariate analysis.

A survey of 60 patients who died from cardiac related causes after vein or artery bypass operations alone (1967 to 1973) was made with respect to 26 clinical, angiographic, and operative variables. These factors were compared with identical characteristics of 1,188 survivors operated upon in 1973. Through discriminant analysis, the various characteristics, isolated or multiple in any combination, have been converted into risk related to operative death. The distinctive features of the mortality group were vastly different from those in the surviving group. Ten patients (16.67 per cent) of the mortality group were in the ninety-ninth percentile of risk, whereas these factors or variables of similar weight produced an equivalent risk of only 0.34 per cent of the survivors; thus, operative death in these circumstances could be predicted with an estimated 98.0 per cent assurance. Each of 6 patients with mortality risks above 0.99999 had (1) marked cardimegaly, (2) uncompensated congestive heart failure (CHF), (3) triple vessel coronary artery disease and/or obstruction of the left main coronary artery, (4) generalized impairment of left ventricular contraction or segmental left ventricular scar, and (5) evelated left ventricular end-diastolic pressure. As a single factor, congestive heart failure (CHF) exerted the most influence on the probability of dying. A new and more desctiptive statistical interpretation of the factors presumed to affect risk is presented.

Aorta-coronary bypass grafting with the internal mammary artery: clinical experience in 70 patients.

Clincal and angiographic results in 70 patients who received free internal mammary artery (IMA) grafts are reviewed. One postoperative death occurred, but it was not related to the free IMA technique. Forty-seven patients underwent postoperative arteriography. The average interval between operation and catheterization was 10.7 months, and the patency rate for 49 free IMA grafts was 89.8 per cent. Of the 29 patients who recieved free IMA grafts as the only revascularization procedure, 21 patients (80 per cent) progressed to Functional Class I and only 5 patients did not have improvement in their functional status.

Bridge saphenous vein graft.

Single aorta-coronary artery vein grafts (bridge grafts) were constructed to two coronary branches with a side-to-side anastomosis in 250 patients. Most of these grafts were constructed between circumflex branches (96 grafts), circumflex and diagnol branches (47 grafts), and anterior descending and diagonol branches (79 grafts). The aim of the bridge graft is to decrease the number of anastomoses, decrease the operative time, and improve graft patency. The hospital mortality rate in this group of patients was 1.2 per cent, and the incidence of postoperative myocardial infarction was 3.6 per cent. One hundred ten patients were restudied after surgery; the average time of restudy was 1 year. Ninety-two grafts of 83.6 per cent had two anastomosis patent; 6 grafts (5.4 per cent) had one anastomosis patent; and in 12 grafts (10.9 per cent), both anastomoses were occluded. One hundred twenty-six associated grafts were studied all the same time; the patency rate was 84.1 per cent. From this experience, we believe the bridge graft is a useful procedure for bypassing the small coronary artery branches.

Internal mammary--coronary artery anastomosis. "No-touch" technique.

A simple technique for internal mammary--coronary artery anastomosis that can be applied to all branches of the coronary circulation is described. The anastomosis can be constructed in 10 to 15 minutes. This technique eliminates pinching of the internal mammary artery by forceps.

Management of aneurysms in segments of saphenous vein grafts.

A technique to manage aneurysmal dilatation of a segment of saphenous vein is presented. A vein sleeve is used to cover the dilated segment. Avoidance of subsequent venovenous anastomosis and the ease of application justify its clinical use.

The structural study of the saphenous vein.

From November, 1971, to September, 1974, 1,179 patients received aortocoronary saphenous vein bypass grafts at the Cleveland Clinic Hospital. Segments of saphenous vein from each patient were sent for microscopical analysis. These vein segments were classified as normal or abnormal (phlebosclerotic). Four hundred ninety-six normal vein grafts in 295 patients were restudied and had a patency of 87.9%. One hundred forty-four abnormal vein grafts in 86 patients were restudied and showed 89.5% patency. This study suggests that histopathological identification of an abnormal (phlebosclerotic) vein segment does not constitute a determining factor as far as late patency is concerned in a vein segment that is not grossly sclerotic.

Postinfarction ventricular aneurysmectomy.

Most operations performed for the treatment of ventricular aneurysm do not achieve maximal rehabilitation of the damaged heart. Cardiac surgeons generally ignore the importance of the flail septum that results from anteroseptal infarction. Many believe that the obstructed left anterior descending coronary artery must be carefully avoided during closure of the ventriculotomy incision. In addition, many surgeons believe that it is necessary to buttress all ventricular sutures with Teflon. For some reason, there seems to be a fear that the left ventricular volume will be reduced to an intolerable level after proper ventricular aneurysmectomy. Between January 1976 and December 1982, 102 patients underwent ventricular aneurysmectomy at St. Joseph's Hospital Health Center. The hospital mortality rate was 5.9 percent. The operative technique described emphasizes the need for foreshortening the fibrosed septum in an effort to minimize residual paradoxic motion. The left anterior descending coronary artery is routinely incorporated in the eversion technique; Teflon buttressing is never employed. Our surgical technique has evolved from a surgical experience that began in 1962 at the Cleveland Clinic Hospital.

Nonoperative management of unusual blunt traumatic rupture of the thoracic aorta.

A conservative nonoperative method of management was utilized in an atypical case of blunt traumatic rupture of the thoracic aorta. In unusual or complicated tears of the aortic arch, as described here, a delayed or expectant method of management may be justified.

Operative approaches to the left atrium and mitral valve apparatus.

Traditional and alternative approaches to the mitral valve apparatus are presented. The median sternotomy and vertical left atriotomy approach affords adequate exposure in most cases. However, there are occasions when an alternative approach may be warranted.

Myocardial revascularization 1978.

After more than ten years of clinical application, direct myocardial revascularization with saphenous or mammary vein grafts is becomining one of the most common types of elective major surgery performed in the United States. The need for and the results of revascularization surgery are determined by cine coronary arteriography. The principles on which this type of surgery is based are simple. Critical occlusion of a coronary artery may produce an arteriographically identifiable area of myocardial perfusion deficit in the left ventricle. The functional demand for blood that results is usually manifested by anginal pain. When the occlusion is reduced by rest and administration of vasodilators, the immediate threat of infarction is alleviated. When pain persists in spite of treatment, direct revascularization surgery should be considered. This type of surgery need not involve ultrasophisticated adjuncts. Some of these adjuncts increase morbidity and contribute appreciably to the cost of operation and hospitalization. The record of myocardial revascularization suggests that the surgical treatment of coronary artery disease can and should be done in qualified community hospitals.