Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia.

Over the past twelve years, surgical treatment of descending thoracic aneurysms has been performed in 360 patients. Three different operative strategies were employed during resection to provide distal aortic perfusion by temporary bypass (Group 1, 75 patients) or shunt (Group 2, 22 patients) or to simplify the operative procedure with aortic cross-clamping alone (Group 3, 263 patients). The surgical results were determined primarily by patient-related and disease-related variables. Advanced age (older than 70 years), atherosclerotic cause, and emergency operation significantly increased the risks of early mortality and morbidity. The incidence of death (11.7%), paraplegia (6.5%), or renal failure (6%) was not reduced by the use of adjunctive perfusion, and bleeding complications increased significantly in Groups 1 and 2. Spinal cord injury was increased significantly by emergency operations, cross-clamp times exceeding 30 minutes, and extensive aneurysms (p less than 0.05). The risk of renal failure was increased by advanced age and atherosclerotic cause (p less than 0.05). With an experienced surgical team, the primary risks of descending thoracic aneurysmectomy are not influenced by the method of adjunctive perfusion, but are determined by patient factors such as the nature and extent of the aneurysm.

Cor triatriatum: operative results in 25 patients.

Twenty-five patients with cor triatriatum underwent surgical correction at the Texas Heart Institute during a 21-year period from 1959 to 1980. Patients ranged in age from 4 months to 38 years. Diagnosis was established preoperatively in 14 patients (56%), at the time of operation for correction of associated lesions in 10 patients (40%), and during reoperation in 1 (4%). In the earlier part of this series, diagnosis was more common at the time of operation. Associated cardiovascular anomalies were present in 20 patients (80%), major anomalies in 14 others (56%). Simultaneous correction or palliation of associated lesions and total excision of the anomalous membrane were done in 18 patients utilizing temporary cardiopulmonary bypass. Cor triatriatum alone was repaired in 5 patients (20%) with the aid of extracorporeal circulation. Two patients underwent reoperation: 1 because of incomplete excision of the septum and the other because the condition had not been diagnosed during a first operation for correction of total anomalous pulmonary venous return. Excision of the membrane was accomplished utilizing the left atrium in 10 patients (40%), the right atrium in 12 (48%), or both in 3 (12%). Four patients (16%) died early after operation; all were infants who had severe associated cardiac anomalies. Among the 21 surviving patients, results were excellent in 20.

The surgical treatment of aortopulmonary window.

From 1956 through July 1981, 15 patients, ranging in age from 9 days to 20 years, underwent surgical correction of aortopulmonary (AP) window. Surface hypothermia and venous inflow occlusion were used in the first patient. In four patients, the technique for closure of AP window was similar to that for patent ductus arteriosus: in one, the AP window was ligated; and in three, clamping, division and suture were performed. Cardiopulmonary bypass was used in ten patients. In five patients, division and primary closure were done. In five, a patch was used to close the defect by using the transaortic and/or pulmonary approach. Associated cardiovascular anomalies were repaired concomitantly in four of seven patients. Two patients died during the immediate postoperative period; both were infants and had serious associated cardiovascular anomalies. One patient died from increased pulmonary vascular resistance and right heart failure 1 year after replacement of the tricuspid valve. Of 12 patients who survived the operation, 11 had excellent results. For the surgical treatment of patients with AP window, we stress the safety and ease afforded by extracorporeal circulation and a preference for the transaortic approach and fabric patch closure.

The role of preoperative mesenteric arteriography in colon interposition.

In a series of mesenteric arteriograms, the marginal artery in the right colon was present in six of 20 studies (30 percent); in the left colon it was present in all of the 20 cases studied (100 percent). Such preoperative knowledge of the vascular pattern permits the surgeon to choose a suitable segment of bowel for successful colon interposition and assists him in shortening the operative time. When this information was applied in 19 consecutive left colon interpositions, only one major suture line dehiscence in the neck was encountered (5.3 percent).

The surgical treatment of congenital coronary to pulmonary artery fistula.

Six patients with coronary to pulmonary artery fistula underwent surgical treatment between January 1973 and August 1975. All fistula terminated in the main pulmonary artery just distal to the pulmonary valve. Two patients had severe coronary artery disease associated with the fistula. In all patients, the fistula was over-sewn from within the pulmonary artery in addition to ligation to the fistulous vessel on the surface of the pulmonary artery or heart, cardiopulmonary bypass being employed. Two patients underwent concomitant aortocoronary artery saphenous vein bypass for occlusive coronary artery disease. Follow-up data revealed that three patients were free of symptoms and two were improved, while one was lost to follow-up.

Azygography in the pre-treatment evaluation of oesophageal carcinoma.

Azygography is a useful technique for the pre-operative detection of unresectability of oesophageal malignancies. Invarison of the azygos vein by oesophageal carcinoma occurs because of the anatomic proximity of the thoracic oesophagus and the azygos vein. Azygography may be performed by either intraosseous injection of a rib or by direct retrograde catheterization. Complete obstruction of the azygos vein indicates that an oesophageal carcinoma is unresectable if no other intrathoracic disease is evident.

Interruption of the aortic arch. Surgical considerations.

During a 10 year period, January, 1965, through January, 1975, 5 patients with interruption of the aortic arch (IAA) underwent operation at the Texas Heart Institute. The mortality rate was 60 per cent; 2 patients survived the operation. One 11-day-old infant with IAA, type A, a ventricular septal defect (VSD), and a patent ductus arteriosus (PDA) underwent successful two-stage treatment. A left subclavian-ductus anastomosis, closure of the PDA, and banding of the pulmonary artery were done initially. The VSD was closed later. The second survivor, a 3-year-old girl, had IAA, type B, with a PDA and VSD. Total correction was done with the aid of cardiopulmonary bypass and hypothermia. Considerations include palliative and staged procedures versus total correction with either conventional cardiopulmonary bypass or deep hypothermia and circulatory arrest. Survival rate is improved if associated lesions are totally repaired or palliated at the time of reconstruction of IAA.