Ventricular septal rupture secondary to myocardial infarction. Clinical approach and surgical results.

Twenty-four patients underwent operation for ventricular septal rupture secondary to acute myocardial infarction. There were 14 hospital survivors (58%) and two late deaths (8%). There were eight hospital deaths (62%) of 13 patients referred in cardiogenic shock, but only two deaths (18%) of 11 patients not in shock at time of referral. All 12 current survivors showed clinical improvement, and 11 of them are in New York Heart Association functional class I or II. Eleven patients had bedside catheterization with a balloon catheter and were operated on immediately thereafter, and eight survived (73%) with no late deaths at five years. With formal heart catheterization followed by operation, there were only six survivors of 13 operated on (46%).

Long-term results of operations for mitral insufficiency secondary to coronary artery disease.

There are few published reports regarding the long-term results of the operative treatment of significant mitral insufficiency secondary to coronary artery disease. The few available reports deal with mitral replacement and myocardial revascularization. However, we prefer mitral repair to mitral replacement with myocardial revascularization. Eighty-seven patients were operated upon with ejection fractions between 0.1 and normal. In 16 patients it was necessary to replace the mitral valve; however, the valve was repaired in the remaining 71 patients. By actuarial curve the survival rate at 9 years was 60 percent for the entire series, and 18 percent in the 16 patients with mitral valve replacement and revascularization. This contrasted with a 73 percent survival rate for those patients with repair of the mitral valve and revascularization. We feel strongly that if repair is done properly, it is far superior to mitral valve replacement for the patient with mitral insufficiency secondary to coronary artery disease.

Aortic valve replacement in patients with poor ventricular function-early and late results with long-term follow-up.

A series of 62 consecutive patients with an ejection fraction of 0.4 or less (mean 0.28 with a range from 0.10 to 0.40; 22 between 0.10 and 0.20, 18 between 0.21 and 0.30, and 22 between 0.31 and 0.40) who underwent aortic valve replacement from January 18, 1972 to December 20, 1976 was reviewed. Preoperatively two patients were in Class II, 35 in Class III and 25 in Class IV of the New York Heart Association functional classification (N.Y.H.A.). Thirty-nine patients (Group 1) underwent isolated aortic valve replacement and 23 patients (Group 2) underwent aortic valve replacement with associated procedures including aortocoronary bypass in 15. The operative mortality was 8 percent in Group 1, 17 percent in Group 2, and 11 percent overall. In the group of 15 patients with coronary artery disease, the operative mortality of aortic valve replacement and aorto-coronary bypass was 27 percent. Since January 1974, isolated aortic valve replacement was performed with no operative deaths in 25 consecutive patients in Group 1 including 10 patients with an ejection fraction of 0.2 or less. Five-year survival rates were 70 percent in Group 1, 64 percent in Group 2 and 68 percent overall. In the 38 currently living patients, 32 showed clinical improvement and 27 are in Class I or II of N.Y.H.A. In conclusion, isolated aortic valve replacement can be performed with a low mortality and a high survival rate in patients with impaired left ventricular function.

Surgical treatment of mitral insufficiency secondary to coronary artery disease.

From 1970 to 1978, 61 patients were operated upon for mitral insufficiency secondary to coronary artery disease. These patients were between 44 and 71 years of age and all were in Class III or IV of the New York Heart Association Classification. The left ventricular end-diastolic pressure was 15 mm Hg or more in 32 of the 39 patients in whom it was measured. Twenty-four of 31 patients in whom right heart catheterization was performed had a systolic pulmonary artery pressure of 50 mm Hg or greater. All 61 patients had myocardial revascularization, 52 had repair of the mitral valve, and nine had mitral valve replacement. There were five hospital deaths in these 61 patients. Among the nine patients with a preoperative ejection fraction of 0.1 to 0.2, there were two hospital deaths; among the 20 patients with a preoperative ejection fraction of 0.25 to 0.40, there were two hospital deaths; and among the 32 patients with a preoperative ejection fraction of 0.45 to 0.70, there was only 1 hospital death. For those patients with repair and revascularization, the survivability was 81% at 7 years. In the patients with repair and myocardial revascularization, the incidence of peripheral embolization was 0.5% per patient-year.

Mitral valve repair for significant mitral insufficiency.

There has been skepticism since the early days of open heart surgery that good long-term or even short-term results were possible with repair of pure mitral insufficiency. The authors report 145 patients in whom a markedly insufficient mitral valve was repaired 6 months to 17 years previously and another 55 patients in whom repair of the insufficient mitral valve was performed along with myocardial revascularization from 6 months to 7 years previously. Comparative data with other published work reveals superior results with repair than with replacement with Starr-Edwards and Hancock glutaraldehyde-treated porcine valves and with far less emboli. Conservatism is urged in operating upon patients with mitral insufficiency. Repair of the valve rather than replacement is stressed for those patients requiring surgery.

Resection of postinfarction left ventricular aneurysm with and without revascularization.

Twenty-four patients had resection of their ventricular aneurysm and 29 had resection plus revascularization. Sixty percent of the patients received no blood in the heart lung machine during surgery or at any time during hospitalization. One of 24 patients with ventricular resection and two of 29 patients with resection plus revascularization died during hospitalization, for an overall mortality of 5.7%. Fifty of the 53 patients had an ejection fraction of 0.4 or less and 23 of these had an ejection fraction of 0.2 or less. Survival rate was 75.5% at four years for all 53 patients compared to only 12% of patients alive at five years with medical treatment. For the patient with a large ventricular aneurysm, resection and myocardial revascularization can be performed with a low risk even for the patient with poorly functioning residual myocardium.

Repeat aortocoronary bypass grafting. Early and late results.

Seventy-nine patients underwent repeat myocardial revascularization between March 1971 and January 1977. The initial procedure was performed at the St. Vincent Medical Center, Los Angeles, in 70 (2.0 percent) of 3,526 patients undergoing surgery for coronary arterial disease and in nine more patients was performed at other hospitals; the second operation followed the first procedure at an interval of from three weeks to 78 months. Five deaths (6 percent) occurred while patients were hospitalized, and six deaths (8 percent) occurred later. Two of the six later deaths were from noncardiac causes. Complications were not different from those that occurred during primary procedures. Thirty-six (60 percent) of 60 patients undergoing repeat surgery since 1973 did not receive any transfusions of blood during or after surgery. Of 48 patients followed-up for periods ranging from 12 to 70 months after the second operation, angina was completely relieved in 18 patients (38 percent), improved in 16 patients (33 percent), unchanged in 11 patients (23 percent), and worse in three patients (6 percent).

Surgery for mitral and tricuspid insufficiency associated with secundum atrial septal defect.

Pure mitral insufficiency associated with secundum atrial septal defect is not an unusual finding. Thirteen patients with significant mitral insufficiency and an associated secundum defect were operated upon. Two of these patients also had severe tricuspid insufficiency. The mitral valve was repaired in 12 patients and replaced in one. The tricuspid valve was reapired in the two patients with associated tricuspid insufficiency. There were two early deaths due to mediastinitis and one late death due to a cerebral embolus in the only patient who had valve replacement; this patient died 3 years after the operation. It is concluded that mitral and tricuspid valve repair should be performed for patients with significant mitral and tricuspid insufficiency associated with atrial septal defect of the secundum variety. Replacement of the values should be avoided if possible.

Intraaortic balloon pumping assist following open heart surgery for coronary artery disease.

Intraaortic balloon pump (IABP) assist was employed in 36 patients after surgical operation for coronary artery disease. In 31 patients, the aid of IABP was required because cardiopulmonary bypass could not be terminated without it. In three of these patients, IABP assist was started before the surgical procedure because these patients were in cardiogenic shock due to myocardial infarction. In the remaining five patients, IABP assist was applied for refractory cardiogenic shock in the early postoperative period. The overall survival rate was 58 percent. IABP assist was used in 13 patients with an ejection fraction of 0.1 to 0.2 (normal 0.7). Nine of these patients survived. From our experience, it would appear that this temporary mechanical circulatory support provides a significant advantage in saving patients who might otherwise die after surgical procedures involving the coronary artery.

A useful instrument for aortocoronary bypass operations.

A punch biopsy forceps is described that is used to make openings in the aorta for anastomosing one end of a saphenous vein graft to the ascending aorta. It can be very successful in myocardial revascularization when there is severe calcification of the aortic wall.