Donor mitral valve repair in cardiac transplantation.

INTRODUCTION: For many patients suffering from end-stage heart failure, heart transplantation remains the only hope for survival, but the shortage of donor organ is increasing. The growing number of patients awaiting heart transplantation has led many centers to expand the donor pool by liberalizing donor criteria, including advances in surgical techniques on the donor heart, such as valve repair. PATIENTS AND RESULTS: We subjected 4 donor hearts to bench repair of the mitral valve. The first heart was from a 35-year-old woman whose echocardiogram showed mild to moderate sclerotic leaflets. We performed a posteromedial commissurotomy and posterior annuloplasty. Transthoracic echocardiography at 57 months after transplantation demonstrated mild mitral regurgitation and no enlargement of VE. The second organ was from a 17-year-old woman with no history of heart disease and an echocardiogram that showed evidence of slightly sclerotic leaflets and mild mitral regurgitation. We performed a posterior annuloplasty. Echocardiography at 12 months demonstrated minimal mitral regurgitation. The third heart was from a 28-year-old woman with a normal echocardiogram. After harvesting, we found a torn head of the posterior papillary muscle, which was reimplanted. Two weeks later, the echocardiogram showed no mitral regurgitation. The fourth was from a 47-year-old woman with no history of heart disease and a normal echocardiogram. Examination before implantation showed central insufficiency, for which we performed posterior annuloplasty. Echocardiography at 12 months showed no mitral regurgitation. CONCLUSION: An aggressive approach to use hearts from marginal donors expands the pool and decreases waiting time for patients who desire heart transplantation.

Heart transplantation from donors of different ABO blood type.

INTRODUCTION: ABO blood group compatibility between donors and recipients of heart transplants is required to reduce the risk of hyperacute rejection. Ideally, ABO-identical cardiac grafts should be used but transplantating using ABO compatible types allows reduced waiting times among recipients with rarer types without a significant increase in hyperacute rejection. However, previous reports have indicated that use of donors with minor ABO mismatches may adversely influence late outcomes, although more recent studies do not confirm this suggestion. Our purpose was to analyze this practice in our center. METHODS: We analyzed 121 patients who underwent heart transplantation between November 2003 and May 2008. One hundred nine patients (90.0%) received ABO-matched grafts (population 1 [P1]) and 12 (9.9%) received ABO-compatible grafts (population 2 [P2]). P1 included 60 group A, 44 group 0, and 5 group B patients; P2 included 5 group A, 5 group B, and 2 group AB patients. The populations did not differ statistically in age, gender, urgency status, surgical technique, ischemic time, donor features, or immunosuppression. They were assessed for left ventricle ejection fraction (LVEF), rejection, and mortality. RESULTS: There were no significant differences in total mortality (P1, 13.7%; P2, 8.3%), rejection grade > or =2R (P1, 21.1%; P2, 33.3%), or LVEF (6 months: P1, 65%; P2, 71%; 1 year: P1, 68%; P2, 69%). CONCLUSION: Minor ABO mismatches did not adversely affect 1-year outcomes of heart transplantation. This practice may facilitate organ allocation for end-stage heart failure patients, thereby reducing waiting time for heart transplantation.

Hyperthermia Severely Affects the Vascular Effects of MDMA and Metabolites in the Human Internal Mammary Artery In Vitro.

3,4-Methylenedioxymethamphetamine (MDMA or "ecstasy") is a recreational drug used worldwide for its distinctive psychotropic effects. Although important cardiovascular effects, such as increased blood pressure and heart rate, have also been described, the vascular effects of MDMA and metabolites and their correlation with hyperthermia (major side effect of MDMA) are not yet fully understood and have not been previously reported. This study aimed at evaluating the effects of MDMA and its main catechol metabolites, alpha-methyldopamine (α-MeDA), N-methyl-alpha-methyldopamine (N-Me-α-MeDA), 5-(glutathion-S-yl)-alpha-methyldopamine [5-(GSH)-α-MeDA] and 5-(glutathion-S-yl)-N-methyl-alpha-methyldopamine [5-(GSH)-N-Me-α-MeDA], on the 5-HT-dependent vasoactivity in normothermia (37 °C) and hyperthermia (40 °C) of the human internal mammary artery (IMA) in vitro. The results showed the ability of MDMA, α-MeDA and N-Me-α-MeDA to exert vasoconstriction of the IMA which was considerably higher in hyperthermic conditions (about fourfold for MDMA and α-MeDA and twofold for N-Me-α-MeDA). The results also showed that all the compounds may influence the 5-HT-mediated concentration-dependent response of IMA, as MDMA, α-MeDA and N-Me-α-MeDA behaved as partial agonists and 5-(GSH)-α-MeDA and 5-(GSH)-N-Me-α-MeDA as antagonists. In conclusion, MDMA abuse may imply a higher cardiovascular risk associated both to MDMA and its metabolites that might be relevant in patients with underlying cardiovascular diseases, particularly in hyperthermia.

Prognosis with preoperative pulmonary function and lung volume assessment in infants with congenital diaphragmatic hernia.

OBJECTIVES: To determine whether fatal pulmonary hypoplasia, as assessed by functional residual capacity (FRC), can be distinguished from other reversible causes of respiratory failure in infants with congenital diaphragmatic hernia (CDH). METHODS: In the present study, 25 term neonates having CDH without other anomalies (mean birth weight +/- SD, 3.25 +/- 0.50 kg) were enrolled prospectively into a protocol evaluating pulmonary function. Lung compliance (CL) and FRC were measured before diaphragmatic repair and compared with the highest oxygenation index (OI) and lowest PaCO2, also obtained preoperatively. Pulmonary function assessment was repeated after diaphragm repair on postoperative days 3 and 7. CL was determined by esophageal manometry and pneumotachography, and FRC was determined by helium dilution. RESULTS: Fifteen infants (60%) survived to hospital discharge. Eighteen (72%) required extracorporeal membrane oxygenation (ECMO) for support, and of these, 8 (44%) survived. PaCO2 was similar preoperatively in infants grouped as survivors without ECMO, survivors with ECMO, and nonsurvivors. In nonsurvivors (all of whom received ECMO), the preoperative OI was significantly higher (51 +/- 21), CL was less (0.11 +/- 0.04 mL/cm of water per kg), and FRC was smaller (4.5 +/- 1.0 mL/kg) than in the survivors who required ECMO (26 +/- 18, 0.18 +/- 0.08 mL/cm of water per kg, and 12 +/- 5 mL/kg, respectively), as well as in the survivors without ECMO, (6 +/- 2, 0.32 +/- 0.16 mL/cm of water per kg, and 15.8 +/- 4 mL/kg, respectively). The group surviving with ECMO had a higher OI than the infants surviving without ECMO. All nonsurviving infants had FRCs of less than 9.0 mL/kg preoperatively. In contrast, only 2 of the 15 survivors had preoperative FRCs less than 9 mL/kg. CONCLUSIONS: The results of this study suggest that preoperative assessment of FRC may predict fatal pulmonary hypoplasia in most infants with CDH.

Isolated replacement of a prosthesis or a bioprosthesis in the aortic valve position.

The operative results of 203 aortic prosthetic valve reoperations performed in 175 patients from 1974 through 1986 were reviewed to identify groups at greater risk. Two to 4 reoperations were performed in 23 patients. The mean interval between the first and second valve procedures was 74 +/- 57 months. The most common indications for reoperation were thrombosis of mechanical prostheses (25%), degeneration of homografts (22%) and mechanical valve dysfunction (19%). Eighteen patients (9%) died. This mortality rate was significantly higher (p less than 0.05) than that of primary valve procedures performed during the same period. Mortality rates were higher among patients with prosthetic valve endocarditis (6 of 26 cases, 23%) and among those who underwent operation on an emergency basis (15 of 20, 25%). No significant correlation was found between mortality rates and the age or gender of the patients and the types of prostheses used originally.

Isolated replacement of a prosthesis or a bioprosthesis in the mitral valve position.

The operative results of 249 mitral valvular reoperations performed in 215 patients from 1974 through 1986 were reviewed to identify groups at greater risk. Two to 4 reoperations were performed in 28 patients. The mean interval between the first and second valve procedures was 47 +/- 40 months. The most common indications for reoperation were degeneration of bioprostheses (44%) and thrombosis of mechanical prostheses (26%). Thirty patients (12%) died. This rate was significantly higher (p less than 0.02) than that for primary valve procedures performed during the same period. The mortality rate for elective reoperations was 7%. Mortality rates were higher among patients with prosthetic valve endocarditis (6 of 17 cases, 35%), in those undergoing operation on an emergency basis (19 of 82, 23%) and when tricuspid valve replacement or anuloplasty was also performed (9 of 38, 24%) (p less than 0.02). No significant correlation was found between mortality rates and the age or sex of the patients and the types of prosthesis used originally.

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis.

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.

Functional anatomy of severe mitral regurgitation in active rheumatic carditis.

The mechanism of severe mitral regurgitation (MR) due to active rheumatic carditis is ill defined. This study involved 73 patients, aged 7 to 27 years (mean 13), with severe MR and active rheumatic carditis who were subjected to surgery. Sixty-one were studied retrospectively (group 1) and 12 prospectively (group 2). Active rheumatic carditis was diagnosed according to the modified Jones' criteria, morphologic appearances of the heart at operation and histology of the valve. All patients had preoperative 2-dimensional echocardiographic and intraoperative assessment of the mitral valve apparatus. The presence of mitral valve prolapse--defined as failure of leaflet edge coaptation resulting in systolic displacement of the free edge of the involved leaflet toward the left atrium--was determined in all patients. Mitral anular diameter and maximal systolic chordal length were measured at 2-dimensional echocardiography in group 2 patients and compared to values obtained from matched control subjects. Anular and chordal dimensions in 6 of the group 2 patients were correlated with precise measurements obtained at surgery. Mitral valve prolapse involving the anterior leaflet was detected on echocardiography and confirmed at surgery in 69 patients (94%). Mitral anular dilatation was observed at operation in 70 patients (96%). Maximal anular diameter was significantly greater (p less than 0.0001) than in matched control subjects (37 +/- 4 vs 23 +/- 2 mm). The mean anular dimension measured at surgery (36 +/- 3 mm) was similar to that obtained by echocardiography and individual values using the 2 methods correlated well (r = 0.93). Chordal elongation was observed in 66 patients at operation (90%).(ABSTRACT TRUNCATED AT 250 WORDS)

Submitral left ventricular aneurysms. Correction by a new transatrial approach.

Submitral left ventricular aneurysm is a widely recognized but relatively unknown entity that occurs almost exclusively in African patients and is often associated with mitral regurgitation. In the past 2 1/2 years, nine patients with submitral aneurysm were operated on by a new transatrial approach that exposes the neck of the aneurysm through an incision in the floor of the left atrium (roof of the aneurysm). There were four female and five male patients and the mean age was 28 +/- 3 years (range 23 to 35 years). All patients but one had significant mitral valve regurgitation and were in New York Heart Association Class III or IV. All operations were performed with standard cardiopulmonary bypass. At operation the neck of the aneurysm was invariably found beneath the posterior mitral valve anulus, at any site between the anterolateral and posteromedial commissures. The transverse diameter was variable, replacing up to two thirds of this portion of the annulus. In one patient the aneurysm perforated into the left atrial cavity. The neck of the aneurysm was closed directly in all patients and all mitral valves were preserved. Comprehensive valvuloplasty, including a Carpentier ring, was required in four patients. One patient died on the operating table of an uncontrolled diffuse pericardial hemorrhage. The remainder were discharged from the hospital and have good mitral valve function postoperatively. The transatrial approach to the repair of submitral left ventricular aneurysms results in a lower operative mortality and morbidity and almost invariably permits conservation of the mitral valve.

Valve replacement in the elderly. Is the mechanical valve a good alternative?

The controversy surrounding the choice of a prosthesis for valve replacement in the elderly patient prompted me to review the performance of mechanical (Medtronic Hall [Medtronic, Inc., Minneapolis, Minn.] and St. Jude Medical [St. Jude Medical, Inc., St. Paul, Minn.]) valves implanted in 213 patients 65 years and older (mean 70.4 years) from 1980 to 1985. There were 63 mitral, 131 aortic, and 19 double (aortic and mitral) valve replacements. Most patients undergoing aortic valve replacement had stenotic lesions, but half of the patients in the mitral valve replacement group had regurgitation with or without stenosis. Early mortality rates for mitral, aortic, and double valve replacement were 4.8%, 6.1%, and 21.1%, respectively (p less than 0.01). The mortality rate for patients 65 to 74 years old was 6.5% and that for those older than 75 years was 9.1%. The cumulative follow-up for the survivors was 850 patient-years. The late mortality rate was 8.1% per patient-year but was valve-related in only 1.3% per patient-year. Noncardiac causes accounted for 43.5% of the late deaths. The late mortality rate was significantly higher in patients who had regurgitant lesions than in those who had stenotic or mixed disease. It was also higher in the older patients (10.3% per patient-year) than in the younger group (7.6% per patient-year; p less than 0.05). Reoperation was required in only six patients (0.7% per patient-year). Thrombotic obstruction of the prosthesis and systemic thromboembolism occurred at linearized rates of 0.6% per patient-year and 2.5% per patient year, respectively, and significant anticoagulant-related hemorrhage at a rate of 0.6% per patient-year. With the exception of late mortality, the incidence of all late complications was similar to that of patients younger than 65 years operated on during the same period. Actuarially, global survival (58% +/- 4%) and freedom from reoperation (95% +/- 2%), from thrombotic obstruction (96% +/- 1%), from thromboembolism (92% +/- 2%), from all valve-related mortality and morbidity (82% +/- 3%), and from valve failure (93% +/- 2%) were also similar to those of the younger patients. Mechanical prostheses perform well in elderly patients. I could not confirm an increase in thromboembolic or hemorrhagic episodes, and the respective mortality and morbidity indexes were similar to those observed in younger patients.

Ventricular septal defects and arteriovenous fistulas, with and without valvular lesions, resulting from penetrating injury of the heart and aorta.

Thirty-one patients with post-traumatic intracardiac shunts or arteriovenous fistulas were treated surgically in the past 8 years. All patients had had penetrating injuries of the heart, ascending aorta, or aortic arch 1 week to 4 years earlier, but only three had an early emergency operation. Eleven patients (35%) had ventricular septal defects and seven (23%) had other types of intracardiac fistulas. The remaining 13 patients had fistulas between the aorta and the main pulmonary artery or innominate vein. Nine patients (29%) had injury of one of the four cardiac valves. All patients but six with aorta-innominate vein fistulas were operated on with the assistance of cardiopulmonary bypass. All affected valves were successfully repaired. There were no operative deaths but two patients (6%) died late. The remaining 29 patients were alive and well when last seen, with no signs of residual shunt and with good valve function. The high prevalence of late complications necessitates routine investigation of patients with penetrating injuries of the heart and the aorta. Surgical correction carries a low mortality and morbidity and is advised in all patients with symptoms.

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.

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.

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.

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.

Medtronic Hall valve replacement in a third-world population group. A review of the performance of 1000 prostheses.

Between May 1980 and December 1984, 1000 Medtronic Hall prostheses (538 mitral and 462 aortic) were implanted in 852 patients (mean age 30 +/- 15 years) of a third-world type of population group. The most common valve lesions were aortic and mitral regurgitation, and 32% of the patients were in New York Heart Association class IV or greater. Double valve (aortic and mitral) operations were performed in 209 patients. The 782 operative survivors were followed up for 2 to 6.5 years (mean 3.5 years) for a cumulative 2676 patient-years. Valve performance was analyzed in each position separately for valve-related complications. Results for the whole group for the following events are expressed in both linearized (percent/patient-year) and actuarial (percent +/- standard error of the mean freedom at 5 years) terms, respectively: valve-related mortality, 2.9 and 92 +/- 2; reoperation, 1.9 and 90 +/- 2; systemic thromboembolism, 3.3 and 85 +/- 2; thrombotic obstruction, 1.2 and 95 +/- 1; prosthetic valve endocarditis, 0.7 and 97 +/- 1; anticoagulant-related hemorrhage, 0.7 and 98 +/- 1; and periprosthetic leak, 0.7 and 97 +/- 1. Corresponding composite figures for valve failure were 4.3 and 85 +/- 2, and for all valve-related morbidity and mortality were 6.7 and 75 +/- 3. Thrombotic obstruction (fatal in 71% of the cases), anticoagulant-related hemorrhage (61% fatal), and prosthetic endocarditis (44% fatal) were the most lethal complications. Although the differences did not reach statistical significance, aortic prostheses appeared to have a higher incidence of complications than the mitral prostheses. When analyzed against the background of an essentially noncompliant population group, the Medtronic Hall prosthesis proved to be reliable and remarkably free from structural failure. The high incidence of thromboembolism and thrombotic obstruction still mandates anticoagulation.

Clinical performance of St. Jude and Medtronic-Hall prostheses: a randomized comparative study.

Newer and improved models of mechanical prostheses are regularly added to surgeons' armamentarium. This study was designed to compare the clinical performance of two of the most used current models of mechanical prostheses. From August 1983 through July 1985, 182 white patients were prospectively randomized to implantation of the St. Jude Medical (95 patients) or Medtronic-Hall (87 patients) prostheses. There were 84 mitral, 85 aortic, and 13 double (mitral and aortic) valve replacements. There were no differences between the two groups with regard to sex distribution, age, functional class, emergency operation, and site of implantation. Early mortality was 3.2% for patients with the St. Jude valve and 5.7% for those with the Medtronic-Hall (p = NS). The survivors were followed for 3 to 5 years (mean, 4.2 +/- 0.6 years; cumulative follow-up, 559 patient-years). Late mortality was 7.1%/patient-year for the St. Jude group and 3.2%/patient-year for the Medtronic-Hall group (p less than 0.05). However, the valve-related mortality was equal (1.4%/patient-year) for both groups. Noncardiac causes accounted for most of the difference between the St. Jude and Medtronic-Hall groups (2.5%/patient-year and 0.4%/patient-year, respectively). There were no cases of thrombotic obstruction, whereas serious systemic thromboembolism occurred at the rate of 1.8%/patient-year (5 episodes) for the St. Jude group and 2.5%/patient-year (7 episodes) for the Medtronic-Hall group (p = not significant); there were another nine episodes of systemic embolism that left no sequelae. Three patients (St. Jude, 2; Medtronic-Hall, 1), all of whom had aortic valve replacement, required reoperation (0.5%/patient-year) because of prosthetic endocarditis, with two deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute traumatic rupture of the aorta: repair by simple aortic cross-clamping.

This report describes the techniques used in 16 patients for repair of acute traumatic rupture of the aorta. Direct aortic cross-clamping (13 to 27 minutes) was used without additional methods of spinal cord protection. Direct suture was possible in (56%) of the 9 patients with partial rupture of the aorta but in only 1 (14%) of the 7 patients with complete disruption. In the remaining patients, the repair was carried out by interposing Gore-Tex patches (4 patients) or open tubular grafts (6 patients) using a simplified method, which is described. The 2 deaths, 1 intraoperative and 1 postoperative, were unrelated to the technique. There were no additional perioperative complications. Direct aortic cross-clamping and repair by direct suture or open tubular graft, as described, greatly simplify the correction of acute traumatic rupture of the aorta, and their use is strongly recommended.

Transposition of the great arteries: correction with conversion from single to dual coronary artery system.

We describe the case of a newborn child with D-transposition of the great arteries who was found to have an uncommon single-origin coronary artery system. Surgical correction by arterial switch was performed but resulted in tension of the left coronary branch, which prevented discontinuation of cardiopulmonary bypass. The problem was eventually resolved by conversion into a dual coronary artery system through direct implantation of the left coronary branch into the aorta. The patient remains well, free from ischemia and with a patent left coronary artery, 2 years after operation.

Tricuspid annuloplasty: a modified technique.

A modification of the de Vega semicircular annuloplasty for tricuspid regurgitation is presented. This technique has been used successfully in 48 patients since January, 1979.