Cor triatriatum sinistrum: one institution's 28-year experience.

Twelve patients with cor triatriatum sinistrum were treated over a 28-year period. Their ages ranged from 1 month to 7.5 years. Congestive heart failure was the most common presentation. Cardiac catheterization was performed on six of the 12 patients and a correct diagnosis of cor triatriatum was made on angiography in only four of the six. Of the remaining six patients, three were diagnosed as having cor triatriatum by echocardiography and three by autopsy. Echocardiography is now considered to be the diagnostic modality of choice in our institution. Seven patients were operated on and five died prior to diagnosis or treatment Associated cardiac anomalies included persistent left superior vena cava, atrial septal defects, coarctation of the aorta, and total anomalous pulmonary venous drainage. A right atrial, transseptal approach to the common pulmonary chamber and excision of the left atrial membrane was found to be the treatment of choice and was used in six of the seven patients operated on. One patient died in the postoperative period. Thus, cor triatriatum sinistrum, a rare and potentially lethal congenital cardiac anomaly, can be diagnosed by echocardiography and successfully treated surgically with a low operative mortality.

High-risk reparative surgery. A neglected alternative to heart transplantation.

The selection of patients for either high-risk reparative operations on the heart or for transplantation has become increasingly difficult as a result of improved results with both modalities. A retrospective review was done of patients referred for heart transplantation who were not considered candidates for conventional cardiac surgery, yet instead underwent reparative procedures rather than transplantation. Of 23 adult patients referred during a 7-year period, 18 had coronary artery disease, and five had valvular heart disease. All had New York Heart Association class IV symptoms. Preoperative left ventricular ejection fractions were in the range 0.08-0.63 (mean, 0.28). Ten of 18 patients with coronary artery disease required insertion of an intra-aortic balloon pump for hemodynamic support perioperatively. Seven patients had primary coronary artery bypass grafts, and 10 had reoperative coronary bypass procedures. One patient had a left ventricular aneurysmectomy, and one had endocardial stripping in addition to myocardial revascularization procedures. Of the patients with valvular disease, three had aortic valve replacement, of which two were reoperations, and two others had mitral valve replacements with tricuspid annuloplasties. With a mean follow-up of 25 months, 1-, 3-, 12-, and 24-month actuarial survival rates were 91%, 87%, 82%, and 76%, respectively. One patient who underwent aortic valve replacement in this study successfully received heart transplantation 19 months postoperatively. These results compare favorably with the current results for patients undergoing first-graft heart transplantation. All survivors enjoy New York Heart Association class I or II functional capacity.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-stage management of sternal wound infections.

Deep median sternotomy wound infection is a significant source of morbidity after cardiac operations. Accepted approaches in treating this complication include débridement with either sternal closure over an irrigation system or open dressings and closure by secondary intention. Muscle flaps are often used in subsequent procedures for wound closure. A single-stage procedure was developed to eliminate irrigation, open wound management, or reoperation for muscle flap closure. This approach consists of débridement and immediate closure with a pectoral musculocutaneous flap. The following report describes 31 patients treated by such a method. Compared with results of previous techniques in treating sternal wound infections, hospital study is decreased, fewer reoperations are needed, and patient management is simplified.

Cardiac valve replacement in children: a twenty-year series.

Ninety-four children ranging from 3 months to 19 years of age underwent cardiac valve replacement at Columbia Presbyterian Medical Center from 1965 to 1985. The overall operative mortality was 12%, but mortality was higher among patients less than 2 years of age, patients who had had previous cardiac operations, and patients requiring double-valve replacement. Seven of 11 patients who received mechanical valves and no anticoagulation experienced major thromboembolic events. An episode of gastrointestinal hemorrhage that was easily controlled represents the only bleeding complication in the entire series. Valve replacement in children continues to be a high-risk procedure, and efforts to preserve native valve function should be attempted when technically feasible. Our data also suggest that anticoagulation can be safely accomplished in the pediatric age group and should be employed in patients requiring placement of a mechanical prosthesis, especially in the mitral position.

Adjustable annuloplasty for tricuspid insufficiency.

De Vega described a technique for tricuspid annuloplasty using synthetic suture to reduce the size of the dilated annulus. We present our experience with an adjustable modification of de Vega's suture annuloplasty technique. The records of 12 patients followed for 15 to 30 months were reviewed. All 10 survivors had a significant drop in right-sided filling pressure (average, 39% decrease) and an associated improvement in clinical status. The 2 deaths in the series were not related to persistent tricuspid insufficiency. This technique represents a reliable, rapid, and readily teachable method for the surgical management of tricuspid insufficiency.

Hemostatic effectiveness of fibrin glue derived from single-donor fresh frozen plasma.

Fibrin glue derived from pooled human blood is an effective sealant for high-porosity vascular grafts and a valuable topical hemostatic agent in heparinized patients. Use of this agent in the United States is prohibited because of potential transmission of hepatitis B, acquired immunodeficiency syndrome, and other serologically transmitted illnesses. We have developed a cryoprecipitation technique that allows preparation of fibrin glue from single-donor fresh frozen plasma. Use of this agent presumably entails no greater risk of disease transmission than intravenous administration of single-unit fresh frozen plasma. This report describes our early clinical experience with this material. Fibrin glue was used as a sealant for porous woven Dacron tubular prostheses and cardiovascular patches in 19 patients. The fibrin glue sealant has also been employed to control bleeding from needle holes and small anastomotic tears in 22 patients. No patient in this series had a bleeding complication from a suture line or graft treated with fibrin glue. This experience indicates that like fibrin glue from pooled blood, fibrin glue from single-donor plasma is effective as a graft sealant and topical hemostatic agent. Preparation of fibrin glue from single-donor plasma is simple and economical, and may provide cardiothoracic surgeons in the United States with a widely available, valuable hemostatic adjunct.

Preparation of fibrin glue from single-donor fresh-frozen plasma.

Fibrin glue is used widely in Europe as a tissue sealant and hemostatic agent. The European glue is prepared commercially from pooled human blood. It is not available in this country because of the risk of transmission of hepatitis B, acquired immune deficiency syndrome, and other blood-transmitted diseases. We describe a cryoprecipitation technique for preparation of fibrin glue from single-donor fresh-frozen plasma. This technique enables the glue to be made in large quantities with no greater risk of disease transmission than with that from the transfusion of single-unit fresh-frozen plasma. We have found that the glue is a useful tool in surgery. By helping to control difficult bleeding, its use can decrease the need for blood transfusions and shorten operating room time. It also is effective as a means to pretreat highly porous vascular prostheses that currently are used infrequently because of bleeding. These porous grafts offer potential advantages in handling, suturing, and long-term patency. This new technique of fibrin glue preparation may make this useful surgical adjunct as readily available in this country as it is in Europe.

Temporary unilateral pulmonary artery occlusion: a method for controlling Swan-Ganz catheter-induced hemoptysis.

A patient undergoing mitral and aortic valve replacement suffered catheter-induced pulmonary artery trauma and massive hemoptysis during weaning from cardiopulmonary bypass. Hemorrhage ceased when the ipsilateral pulmonary artery was occluded. Forty-eight hours later the temporary band was removed, and the patient did well without further bleeding.

Pharmacologic antagonism of propranolol in dogs. III. Effects of dopamine-isoproterenol and glucagon on hemodynamics and myocardial oxygen consumption in ischemic hearts during chronic propranolol administration.

In 31 dogs chronically beta blocked with oral propranolol (12 to 14 mg/kg/day), glucagon (20 micrograms/kg) and combined dopamine (10 micrograms/kg/min) and isoproterenol (0.2 micrograms/kg/min) were given intravenously and tested for hemodynamic efficacy. Dogs were divided into four groups. Basal hemodynamics were obtained In Group I (n = 8) without cardiopulmonary bypass. In Group II (n = 8), hemodynamics were studied after 15 minutes of global ischemia during cardiopulmonary bypass. In Group III (n = 8), hemodynamics were studied after regional ischemia produced by ligation of the proximal left anterior descending coronary artery. In Group IV (n = 7), myocardial oxygen consumption and left ventricular mechanics were studied before and after 1 hour of cardiopulmonary bypass. Our results indicate the following: (1) Dopamine-isoproterenol improves hemodynamics in basal, post-global ischemic, and post-regional ischemic states. Glucagon improves hemodynamics either insignificantly or to a lesser extent than dopamine-isoproterenol. Furthermore, glucagon produces a larger increase in heart rate, which is not desirable. (2) Both dopamine-isoproterenol and glucagon increase myocardial oxygen consumption in comparison with control.

Postoperative assessment of porcine-valved right ventricular-pulmonary artery conduits.

Insertion of extracardiac right ventricular (RV)-pulmonary artery (PA) conduits for repair of severe forms of RV-PA discontinuity has become a widely used technique. During a 10-year period, 76 patients had open heart repair with a porcine-valved RV-PA external conduit. The most common diagnoses were truncus arteriosus (15%) and pulmonary atresia with ventricular septal defect (15%). The patients were 18 days to 37 years old (median 7 years). The postoperative median follow-up period was 4 years. Four patients (8%) have been lost to follow-up. Nineteen patients (25%) died in the early postoperative period and there were 10 late deaths (13%). Calculated probability of survival was 66% at 8 years. Thirty-six patients have undergone late hemodynamic studies. A residual shunt was present in 14% of the patients; moderate to severe PA hypertension was present in 25% and significant RV-PA gradients (greater than 30 mm Hg) in 50%. The mean RV pressure for the group was 78.5 +/- 38 mm Hg. The severity of the gradients appeared to be greater in patients who had been followed longer. Ten patients have undergone reoperation because of conduit obstruction or residual shunting; 6 are alive and well. Of the surviving patients, 95% are acyanotic and without significant exercise intolerance and only 5% have cardiovascular symptoms. Thus, open heart repair using an external RV-PA conduit provides a marked improvement in the quality of life in patients who survive.

Mechanical assistance of the pulmonary circulation after right ventricular exclusion.

The Fontan procedure is often associated with elevated right-sided pressures and low cardiac output during the early postoperative period. A dog model was established to test the effect of pulmonary artery counterpulsation after atriopulmonary anastomosis. After exclusion of the right ventricle by a purse-string suture at the right AV orifice, placed during inflow occlusion, a valved conduit was inserted between the right atrial appendage and the pulmonary artery. This created a circulatory pattern comparable to a Fontan procedure. Counterpulsation was achieved by inserting a cannula into the conduit distal to the valve in eight dogs; alternatively, in four, counterpulsation could be achieved through a 10 mm side-arm graft connected to the conduit distal to the valve. Twenty-four observations were made. Without counterpulsation the circulatory status of the dog deteriorated rapidly. Counterpulsation resulted in a mean increase in cardiac output of 48% (p less than 0.0001). Right atrial pressure fell significantly with a mean drop of 4 mm Hg (p less than 0.003). This allowed for a further increase in right-sided filling pressure by transfusion, with a subsequent further increase in cardiac output. Left atrial pressure did not change significantly unless altered by transfusion. Counterpulsation instituted through the 10 mm side-arm graft gave similar results. Pulmonary vascular resistance decreased with counterpulsation (mean decrease 35%; p less than 0.002). The use of a side-arm graft connected to the conduit after a Fontan procedure affords a clinical method of circulatory support without the need for additional surgical intervention for decannulation. These data suggest that mechanical assistance of the failing right atrium after atriopulmonary anastomosis is both feasible and effective.

The relationship of human atrial cellular electrophysiology to clinical function and ultrastructure.

Although previous studies have described the electrophysiological and ultrastructural characteristics of human cardiac fibers, no attempt has been made as yet to describe quantitatively the relationship between the ultrastructural and cellular electrophysiological derangements occurring with cardiac disease, and their clinical manifestations. In this study, we used standard microelectrode techniques to record the action potential characteristics of human atrial fibers obtained during cardiac surgery and correlated the electrophysiological parameters with clinical and ultrastructural data. Ultrastructure was studied by optical and electron microscopy. We found a multiple linear regression among maximum diastolic potential, atrial size and pressure, P wave duration and ultrastructure changes. Proliferations of Z band material, widening of intercalated discs, and degenerative changes were quantified and correlated with electrophysiological and clinical data. These studies emphasize the relationship between hemodynamic anomalies and resultant changes in both human atrial fiber structure and electrical function. Finally, the likelihood of occurrence of arrhythmias can be predicted using the analytic method described.

Psychological and behavioral responses after coronary artery bypass surgery.

One hundred consecutive patients who underwent coronary artery bypass surgery at the Columbia-Presbyterian Medical Center from December 1972 through February 1975 were evaluated at surgery and then followed for as long as 4 1/2 years to study their postoperative psychosocial and behavioral course. One patient died during the first 30 days. At 4 1/2 years, 23 patients were reported as deceased, 15 from cardiac causes. The majority of the long-term survivors had substantially less angina and greater exercise capacity; surgery did not increase the number of patients who were employed, but led to substantial improvements in the quality of life, including general pleasure, reduction of anxiety and depression and subjective improvement in job and family roles. Sexual adjustment improved the least; the frequency of sexual relations tended to decrease. Compliance with the medical regimen was relatively good for smoking and exercise, but not for diet or type A behavior, suggesting a need for psychological intervention.

Four-contact glove probe method for rapid recording of cardiac electrograms during surgery.

A technique is presented for recording four simultaneous electrograms from the heart during operation for cardiac arrhythmias. this technique permits intraoperative maps of cardiac electrical activity to be constructed more rapidly than is possible with single-point mapping, thereby decreasing the risks to the patient and yielding more information about cardiac events.

Muscular ventricular septal defects repaired with left ventriculotomy.

Between 1974 and 1979 nine patients, aged 10 months to 4 years, underwent left ventriculotomy for closure of single or multiple defects in the muscular ventricular septum. The vertical incision paralleled the anterior descending branch of the left coronary artery near the apex of the left ventricle and ranged from 2.5 to 3.5 cm in length. Four patients also had a right ventriculotomy with closure of a high perimembranous ventricular defect in two. Serial electrocardiograms indicated changes of myocardial ischemia or necrosis. Left bundle branch block did not develop in any patient. Three patients died in the early postoperative period. The six surviving patients are living and well 2 to 7 years later. There is apparent complete closure of the ventricular defects, which was documented by cardiac catheterization in four cases. Two patients had cardiomegaly and left ventricular dysfunction as assessed with echocardiographic and angiographic study, whereas four displayed good cardiac function. In three of the latter patients, cardioplegia or deep hypothermia techniques were utilized intraoperatively. The observations indicate that left ventriculotomy of limited size is an acceptable approach to the difficult problem of repair of muscular ventricular defects but may involve some risk of compromise of the coronary circulation.