Direct drainage of the right pulmonary veins into the coronary sinus with intact interatrial septum: a case report.

Partial anomalous pulmonary venous connection to the coronary sinus is rare. This anomaly is even more rare in the absence of interatrial communication. Usually, the anomalous right pulmonary veins drain to the right atrium or venae cavae, while the anomalous left veins connect to the coronary sinus or left innominate vein. The present report is the first in the English literature to document a situs solitus case in which all three right pulmonary veins drained directly into the coronary sinus without an atrial septal defect. Closure of the coronary sinus orifice and unroofing of the coronary sinus into the left atrium is a safe and effective way of treating this anomaly.

Persistent hypoxemia occurring as a complication of tricuspid valve endocarditis.

A 33-year-old woman had intravenous drug-associated tricuspid valve infective endocarditis. Despite resolution of septic pulmonary emboli, hypoxemia persisted. We report a case of right-to-left shunting across a previously insignificant patent foramen ovale documented by contrast transesophageal echocardiography. Although a rare complication of tricuspid endocarditis, clinicians should be aware of this potential correctable complication.

Aortic dissection: a rare complication of osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder, a group that includes Ehlers-Danlos syndrome, Marfan's syndrome and pseudoxanthoma elasticum. OI is a heterogeneous disease of collagen I biosynthesis characterized by variable clinical phenotypes, including skeletal and cardiovascular manifestations. A 65-year-old man with OI who had extensive prior successful cardiac valve surgeries is described. He survived for 18 years after his initial valve surgery, but died of multiorgan failure and sepsis after repair of a spontaneous type A aortic dissection. This is the fourth reported case of aortic dissection secondary to OI and illustrates the extensive cardiovascular pathology associated with OI. Aggressive management of arterial dissection risk factors, such as systemic arterial hypertension, is advocated for patients with OI.

Balloon pulmonary valvuloplasty in the management of cyanotic congenital heart defects.

Twenty-three children with cyanotic congenital heart defects, aged 3 days to 11.5 years, weighing 2.9 to 30 kg, underwent percutaneous balloon pulmonary valvuloplasty to improve pulmonary oligemia. The patients were divided into two groups: group I with intact ventricular septum and group II with ventricular septal defect. In 12 group I patients, there was an increase of systemic arterial oxygen saturation [83 +/- 8% (mean +/- SD) vs. 94 +/- 5%, P less than 0.001] and pulmonary-to-systemic flow ratio (0.7 +/- 0.1 vs. 1.0 +/- 0.2, P less than 0.001). Peak systolic pressure gradient across the pulmonary valve decreased (P less than 0.001) from 105 +/- 48 to 25 +/- 18 mm Hg. In 11 group II patients, arterial oxygen saturation (67 +/- 13 vs. 83 +/- 13%, P less than 0.01) and pulmonary-to-systemic flow ratio (0.7 +/- 0.4 vs. 1.2 +/- 0.5, P less than 0.02) increased following valvuloplasty. Peak systolic pressure gradient across the pulmonic valve (52 +/- 16 vs. 32 +/- 22 mm Hg, P less than 0.05) decreased while infundibular and total pulmonary outflow tract gradients were unchanged (P greater than 0.1). Immediate surgical intervention was avoided in all cases in both groups. On follow-up, 1 to 36 months after valvuloplasty, arterial oxygen saturation, pulmonary-to-systemic flow ratio, and pulmonary valve gradients remain improved in both groups. However, in group I, repeat balloon valvuloplasty was required in two children. In group II, six children with tetralogy of Fallot (TOF) underwent successful total surgical correction 4 months to 2 years after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term clinical results with the Ionescu-Shiley pericardial xenograft.

From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued.

Atypical hepatic vein leiomyoma extending into the right atrium: an unusual cause of the Budd-Chiari syndrome.

A 14-year-old male presented with a one week history of weakness, lightheadedness and vomiting. Bilateral pleural effusions were evident on chest radiography; electrocardiogram revealed decreased voltages. Echocardiogram, abdominal ultrasound and magnetic resonance imaging revealed a mass in an hepatic vein and the inferior vena cava extending up to and filling the right atrium. Under deep hypothermia and extracorporeal circulation the mass was removed en bloc. It originated from the hepatic vein. Pathology revealed a smooth muscle tumour intermediate between benign and malignant (atypical leiomyoma). This is the first reported pediatric primary leiomyoma of the hepatic vein. It caused the Budd-Chiari syndrome, a rare pediatric entity.

An assessment of the risk of neoplasia in long-term ileal reservoirs using the DMH rodent model.

This study was undertaken to determine if the construction of an ileal reservoir induces mucosal changes that can potentiate the effect of a chemical carcinogen (1,2-dimethylhydrazine) on ileal mucosa. Animals were divided into three groups: 1) sham operation (n = 19), 2) total colectomy with ileorectal anastomosis (n = 20), 3) total colectomy with an ileal reservoir made of terminal ileum sutured to the rectum (n = 20). An adaptation period of 12 weeks was allowed to promote fecal stasis and the histologic changes before exposure to weekly subcutaneous injections of DMH (25 mg/kg) for 16 weeks. Sodium butyrate was added to the diet as a tumor promotor. All animals were sacrificed one month later. Fecal stasis, along with enlargement, occurred in all the reservoirs (mean dimensions, 74 X 58 X 43 mm). Their mean volume was 88 +/- 14 ml. The histologic changes in the ileal reservoirs were: chronic inflammation (14/20), villous atrophy (14/20), and atrophy of the glands (8/20). In group 3, five carcinomas were seen. There were three in the duodenum and two in the reservoirs. In contrast, 21 carcinomas were detected in the control groups. There were 17 in the colon, 3 in the jejunum, and 1 in the ileum. No significant difference in the number of carcinomas was seen in the ileum with and without reservoir. Although it is possible to induce carcinomas in ileal reservoirs, the incidence remained significantly less than in the colon. In conclusion, the histologic changes induced by the construction of an ileal reservoir do not increase the risk of malignant transformation in the DMH model for intestinal carcinogenesis.

Balloon pulmonary valvuloplasty for congenital cyanotic heart defects.

Eight infants with congenital cyanotic heart defects, aged 7 days to 10 months, weighing 2.9 to 10.0 kg, underwent percutaneous balloon pulmonary valvuloplasty as a palliative procedure to improve pulmonary oligemia. The indication for valvuloplasty was cyanotic heart defect not amenable to total surgical correction at the age and size at presentation but at the same time requiring palliation of pulmonary oligemia. After balloon valvuloplasty, there was an increase in the pulmonary blood flow index (1.83 +/- 0.55 to 3.14 +/- 1.38 L/min/m2; p less than 0.05), pulmonary-to-systemic flow ratio (0.55 +/- 0.35 to 1.19 +/- 0.63; p less than 0.05), and pulmonary artery pressure (15.5 +/- 6.6 to 29.1 +/- 12.1 mm Hg; p less than 0.02). Arterial oxygen saturation, although increased from 69.6 +/- 11.5% to 81.4 +/- 12.3%, did not attain statistical significance (p greater than 0.05). Immediate surgical intervention was avoided in all eight patients. At follow-up, 4 to 12 months after balloon valvuloplasty, all infants were thriving with decreased hypoxemia and polycythemia. Follow-up catheterization data were available from six patients, 3 to 10 months after valvuloplasty, and in all of them the immediate postballoon valvuloplasty improvement persisted or further improvement noted. These data suggest that pulmonary valvuloplasty offers excellent palliation of pulmonary oligemia in cyanotic heart defects, thus avoiding the risks of immediate surgical palliation and paving the way for a better result of eventual total surgical correction.

Do symptoms reflect a change in left ventricular function after aortocoronary bypass grafting in patients with depressed left ventricular function?

Seventy-nine patients with moderate to severe left ventricular dysfunction who underwent aortocoronary bypass grafting between 1971 and 1977 had follow-up heart catheterization at a mean interval of 3 years. Thirty-three patients (42%) had angiographic improvement in left ventricular function at follow-up and 18 (25%) had a decrease in left ventricular end-diastolic pressure. Fifty-eight patients (73%) had improvement in angina of at least one New York Heart Association class at follow-up. There was no correlation between late improvement in left ventricular function and improvement in angina. Improvement in left ventricular function did not correlate with preoperative indices of severity of coronary disease or with indices of completeness of surgical repair.

Valve failure caused by cusp tears in low-profile Ionescu-Shiley bovine pericardial bioprosthetic valves.

The pathologic findings in two low-profile Ionescu-Shiley bioprostheses that failed because of cusp tears are presented. Both valves were in the mitral position, one in place 28 months and the other 40 months. Observation of the valves and their tears suggests that stress at the cusp alignment stitches may be important in the genesis of the tears.

Submammary skin incision as a cosmetic approach to median sternotomy.

Median sternotomy is the incision of choice to allow access to the anterior mediastinum, heart, or both lungs. The vertical skin incision leaves an unsightly scar for many female patients. A bilateral submammary horizontal skin incision with dissection of a flap including the subcutaneous tissue and breasts allows exposure of the sternum so that a median sternotomy can be performed. Since November 1981, we have used this incision 40 times in female patients undergoing open heart surgery. The exposure of the mediastinum was excellent, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Complications associated with this incision are insignificant if close attention is paid to details.

Mitral valve replacement with Hancock porcine bioprostheses: up to 7-year follow-up.

From February 1976 to May 1981 at the University of Ottawa Heart Institute, 137 mitral valves were replaced with the Hancock porcine bioprosthesis. This study concerns 111 patients (55 men, 56 women) who had single-valve replacement. The average age of the patients was 53.0 years. The predominant lesion in the 102 patients who were receiving their first substitute valve was stenosis in 46% and regurgitation in 42%. Preoperatively, 82% were New York Heart Association (NYHA) class III or IV. Additional procedures were performed in 44 patients (39.6%). The 26 patients who had multiple valves replaced were considered only for durability studies. Hospital mortality was 8.9% for isolated replacement and 22% for replacement associated with aortocoronary bypass grafting. At the time of discharge, 50% of patients were in atrial fibrillation, 14% were taking warfarin and 82% antiplatelet agents. Follow-up was available for a total of 374 patient-years (average of 5.4 years per patient). The mean symptomatic improvement was 1.6 NYHA classes per patient. Actuarial analysis indicated a survival rate of 70% at 8 years. Of the 18 late deaths, 4 (22%) were valve-related. The rates of endocarditis and thromboembolism were 1.1% and 5.8% patient-year respectively. In the 137 prostheses at risk, intrinsic failure occurred at the rate of 4.7% patient-year for a cumulative rate of 35% at 8 years. The authors conclude that the Hancock porcine bioprosthesis provides good relief of symptoms in the mitral position with an acceptable rate of thromboembolism even without anticoagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Ionescu-Shiley pericardial xenografts: follow-up of up to 6 years.

The results of valve replacement with the Ionescu-Shiley pericardial xenograft compare favorably with results obtained with other bioprostheses. From March, 1977, to July, 1983, 497 Ionescu-Shiley pericardial valves were implanted in 463 patients at the University of Ottawa Heart Institute. There were 292 patients who had aortic valve replacement (AVR), 140 with mitral valve replacement (MVR), 28 with double valve replacement, and 3 with triple valve replacement. The survivors were followed regularly. Actuarial analysis of late results indicates an expected survival of 71% at 6 years for patients who underwent AVR and 72% at 3 years for patients who had MVR. The only valve-related deaths were due to endocarditis, which occurred at a rate of 3.9% per patient-year for aortic valves and 0.6% per patient-year for mitral valves. Despite a low usage of formal anticoagulation, embolic complications occurred at a rate of 1.4% per patient-year for aortic valves and 4.0% per patient-year for mitral valves. Five valves were removed for intrinsic failure after 36 to 72 months of follow-up. New York Heart Association Functional Class improved an average of 1.28 classes per patient.

First septal artery: direct or indirect grafting.

We retrospectively analyzed the revascularization of the septal artery achieved either directly through a coronary artery bypass graft (CABG) to the first septal artery (S1), or indirectly through endarterectomy and CABG of the anterior descending coronary artery (LAD). From July 1, 1976 to May 1, 1979, 21 84% (11 of 13). During the same period, 15 patients with a large S1 received endarterectomy and CABG of the LAD. Six of these 15 patients (40%) had an excellent flow into S1 as seen on the postoperative angiogram, whereas nine (60%) showed no improvement. The vein graft was patent and considered normal in 14 patients and the distal flow in the LAD was adequate in 10 patients (66%). We conclude that better revascularization of S1 is achieved by direct CABG. However, endarterectomy of the LAD allows revascularization of arteries that could not be grafted otherwise because of severe diffuse disease.

Direct revascularization of the septal artery.

Between July 1, 1976 and May 1, 1979, 21 patients underwent coronary artery grafting of the first septal artery. Blood flow in the septal bypass averaged 60.2 ml/min and the diameter of the distal anastomoses averaged 2.1 mm. Among the 20 survivors, 13 were subjected to angiography at an average of 7 months after the operation (from 2 weeks to 2 years). The bypass graft to the first septal artery was patent in 84% of the patients (11 of 13) and 90% of the grafts were open (57 of 63). The authors believe that if a patient has an important stenosis in the first septal artery, direct revascularization may be carried out. However, because of technical difficulties during dissection and anastomosis it is wise to select an artery at least 2 mm in diameter which supplies a large area.