Repair of tricuspid atresia in 100 patients.

One hundred consecutive patients with situs solitus of the atria and tricuspid atresia have undergone surgical repair since 1968. In patients with ventriculoarterial concordance, a nonvalved Dacron conduit or an aortic valve homograft was interposed between the right atrium and right ventricular outlet chamber. In patients with ventriculoarterial discordance, an aortic valve homograft established continuity between the right atrium and pulmonary artery. Among 73 patients with ventriculoarterial concordance, the hospital mortality rate was 11% (eight deaths), and in 27 patients with ventriculoarterial discordance, it was 15% (four deaths). Before 1974, the year of operation was a significant determinant of hospital mortality (p less than 0.001). Thereafter, the hospital mortality declined and is currently 3.7%. In 82 patients with ages ranging from 4 to 16 years, there were six deaths (7.3%) whereas there were six deaths (33.3%) in 18 patients less than 4 or more than 16 years (p less than 0.001). Mode of ventriculoarterial connection and type of repair did not influence significantly the hospital mortality. There were six late deaths due to infection (two), reoperation (two), heart failure (one), and sudden death (one). Regardless of the mode of ventriculoarterial connection, use of a homograft valve produced better results, i.e., more asymptomatic patients (NYHA Class I) (p = 0.0168) and higher postoperative exercise capacity. Postoperative catheterization data and angiocardiographic measurements in patients with ventriculoarterial concordance demonstrated significant advantages with the interposition of a homograft valve between the right atrium and outlet chamber. Of 82 surviving patients, 94% are in NYHA Class I or II.

Congenital malformations of the mitral valve in children. Pathology and surgical treatment.

A systematic study of congenital mitral valve malformations was undertaken on a surgical basis in an attempt to develop techniques of valvular reconstruction adapted to the various lesions. Forty-seven children between the ages of 4 months and 12 years (average 6 years, 4 months) have been operated upon between January, 1970, and March, 1976. Valvular lesions were classified into four group: Group I, mitral insufficiency owing to valvular lesions: Group II mitral insufficiency with subvalvular lesions; Group III, mitral insufficiency and stenosis; Group IV, stenosis. Associated lesions (ventricular or atrial septal defects, coarctation, or aortic valve stenosis) were present in 31 patients (65 per cent) and were corrected during the same operation. Valve reconsruction was possible in 38 patients whereas valve replacement was necessary in 9 patients. In the valve repair group there were three operative deaths (8 per cent), no late deaths, one reoperation for residual ventricular septal defect, and one myocardial infarction. In the valve replacement group of 9 patients, there were three operative deaths, three late deaths, and one case of repeated embolization. Thirty-one of 38 patients in the valve repair group were classified into Functional Class I after the operation (86 per cent), 2 were in Class II, and one in Class III. Minimal or moderate regurgitation and cardiomegaly persisted in the majority of the patients. Pulmonary artery pressure significantly decreased, however, as demonstrated by postoperative catheterization in 17 patients.

Horizontal submammary skin incision for median sternotomy.

Usual techniques in open-heart operations leave a vertical median skin scar. Especially for women this is rather embarassing since it looks ugly. The use of horizontal submammary skin incision for access to the heart is described here. Although obtaining the usual midsternal exposure takes some extra time, long-term results have shown the value of this approach and its benefit to the patient. The surgical technique is simple, and wound healing, in the long run, is unimpaired.

The effectiveness of venoarterial perfusion in treatment of arterial air embolism during cardiopulmonary bypass.

In an experimental study using 6 pigs, the clinical situation of accidental air embolism was mimicked by introducing a known amount of pure nitrogen into the aortic perfusion line during standard hypothermic cardiopulmonary bypass. The treatment after embolization consisted of 15 minutes of perfusion flow reversal. A special device was built to enable quantitative assessment of the amount of gas that escaped through the aortic cannula during venoarterial perfusion. This showed that only 47% of the injected gas bolus could be removed from the circulation. However, microscopic and histological examinations of the brain of each pig one week post-operatively did not reveal trapped gas or ischemic tissue damage. It is concluded that hyperbaric treatment after a clinical accident involving air embolism should be used if the embolus has reached the periphery before flow reversal can be effected. Since over 50% of the amount of gas introduced into the vasculature may remain behind even after prolonged venoarterial perfusion, ischemic damage of organs is still possible.

Uptake and localisation of O-(beta-hydroxyethyl)-rutosides in the venous wall, measured by laser scanning microscopy.

The uptake and localisation of O-(beta-hydroxyethyl)-rutosides (HR) in the venous wall was studied in 8 patients undergoing crossectomy for a varicose long saphenous vein. The fluorescence of cross-sections of the vein wall was measured by laser scanning microscopy, based on the autofluorescence of HR. Four patients (treated group) received 2 x 1.5 g HR IV before surgery, and four (untreated patients) served as controls. Uptake of HR into the veins from treated patients was seen, with a mean fluorescence intensity of 80.9 units compared to 49.4 units in the untreated veins. The increase in fluorescence was clearly demarcated on the endothelial side of the vein wall. It is concluded that HR passes into the vascular wall, where it is localised in the endothelial and sub-endothelial areas.