Repair of right ventricular free wall defect with a pedicled muscle flap.

A unique case of repair of a full-thickness cardiac defect and simultaneous reconstruction of an infected median sternotomy wound is presented. A right ventricular defect, 6 cm in diameter, was closed with a fascia lata graft and reinforced with a rectus abdominis muscle flap. The superior portion of the mediastinum was obliterated with a pectoralis major muscle flap. The patient tolerated the procedure well and remains free of cardiac symptoms seven months postoperatively, with no evidence of residual infection.

Reconstruction of infected median sternotomy wounds.

Infected median sternotomy represents a major complication of cardiac surgery, with significant morbidity and mortality. The treatment of choice is immediate drainage and closure over suction irrigation catheters. However, when this conservative approach fails or radical debridement makes primary closure impossible, muscle flap closure is indicated. This form of reconstruction facilitates the obliteration of large mediastinal wounds; prevents spreading of infection on the heart, suture lines, grafts, or prosthetic material; and significantly decreases morbidity and mortality. We performed muscle flap closure in 11 consecutive patients in whom conservative treatment of infected median sternotomy wounds failed. All patients required closure with at least two muscle flaps or omentum for the complete obliteration of the mediastinal wounds. There was one postoperative death in our series due to acute heart failure. There were two superficial skin losses requiring skin grafting and one persistent draining sinus after reconstruction. Based on our experience and that of others, we conclude that muscle flap reconstruction should be considered as an important technique for the reconstruction of infected median sternotomy wounds.

Outcome of coronary artery bypass grafting in black persons.

Relatively little attention has been given to coronary artery disease in black persons in the United States. During 31 months, 73 consecutive black patients drawn from an urban working class inner city population who had undergone coronary artery bypass grafting were studied. In the total series of elective and emergency operations, 3 patients (4%) died within the first 30 days and 3 more died by the end of the first year of follow-up. Functional capacity was assessed by interviews and a questionnaire in a subset (n = 39) at least 6 months after operation. Although 79% of the patients felt that the operation had resulted in improvement of symptoms, half of them continued to report angina. Only one-third of the patients were working in the period immediately before the operation; 13% were working postoperatively. Coronary artery bypass grafting had an acceptable mortality risk in these patients, although the functional outcome was disappointing.

Long-term results of repair of incomplete persistent atrioventricular canal.

We evaluated the late results following repair of otherwise anatomically uncomplicated incomplete persistent atrioventricular canal in 39 consecutive operative survivors who underwent operation at our institution prior to 1976. Average follow-up was 12 years. Postoperative cardiac catheterization was performed in 35 patients (90%) at an average of 11 months after operation. Seven (20%) had residual mitral regurgitation with elevated mean pulmonary arterial wedge of left atrial pressures with abnormal v waves. Regurgitation was mild to moderate (pulmonary artery wedge or left atrial pressure 12 to 15 mm Hg) in five and severe (pulmonary artery wedge pressure over 20 mm Hg) in two patients. Clinically significant arrhythmias including complete heart block, sudden death, nodal rhythm, and chronic atrial fibrillation occurred in seven patients (18%). Two patients have required reoperation for mitral regurgitation. Five have clinically recognizable mild-to-moderate mitral regurgitation controlled with medical management; 25 patients are asymptomatic at current evaluation. Estimated actuarial survival rate at 13 years is 88% +/- 6%, with an actuarial survival free of reoperation of 82% +/- 6%. However, actuarial survival free of any late complication including late death, reoperation, serious arrhythmia, or mitral regurgitation is only 52% +/- 10% at 13 years.