Isolated mitral valve replacement and ventricular rupture: presentation of 6 patients.

The cases of 6 patients who had ventricular wall rupture after isolated mitral valve replacement and were seen in our service are reviewed. In the first 2, the main lesion was mitral stenosis and calcification was severe. Injury to the ventricular myocardium during removal of the valve was the causative factor in 1 and the most likely explanation in the other. In the other 4 patients, the dominant lesion was insufficiency. Calcium was absent, and fibrosis of the valves was minimal. Defects of technique were not obvious. All perforations were beneath the annulus. The first of these 4 latter patients underwent operation just after cardioplegic solutions were introduced for myocardial protection in our service. During that period, the incidence of ventricular wall rupture was 7.3% for mitral valve replacement (55 patients). Causing 3 deaths, it became the most important mortality factor. After reviewing the problem, we decided to change our technique by leaving practically all the posterior leaflet and most of the chords intact and placing sutures through fibrous tissue only, never into muscle, as had already been suggested. Since then, we have not seen another rupture in 23 valve replacements.

Removal of infected epicardial electrodes by traction.

Five patients who had infected cardiac pacemakers with epicardial electrodes have been managed by exteriorization of the pulse generator and placement of an endocardial unit. In each case the remaining electrode leads where detached from the myocardium and removed by simple traction, avoiding a surgical procedure. In 4 patients, sets of cables had been sutured to the myocardium through an anterior thoracotomy, in some instances using Teflon pledgets as buttresses. In one of these procedures a pericostal suture had been used to secure the leads from the thoracic cavity against the ribs. The remaining patient had received a subxiphoid pacemaker also implanted with sutures. This is a consecutive series, and we have had no failures so far. All pulse generator units were bipolar and located beneath either the pectoral or the rectus muscle. All of them were functioning properly when infection was diagnosed. This procedure constitutes an alternative method of management when more conservative techniques, such as closed irrigation and debridement, cannot be utilized.

Retroclavicular route for electrode placement in endocardial pacemakers.

In order to avoid skin erosion and electrode infection in endocardial pacemakers placed through the external jugular vein, we direct the wires from their point of entry into the vessel to the pacing unit placed in the pectoral region by dissecting a retroclavicular tunnel. This can be done under general or local anesthesia, and so far we have not seen any injuries to the subclavian vein. In this way the entire pathway of the cables is deep enough so that they cannot be palpated through the skin, and the dangers of exposure through erosion are minimized.