Rupture of sinus of Valsalva aneurysm into both right atrium and right ventricle. A case report.

A young man had a congenital sinus of Valsalva aneurysm originating from the right coronary sinus, complicated by fistulas draining into both right atrium and right ventricle, as well as a congenitally abnormal aortic valve with mild aortic insufficiency. His dramatic clinical presentation, with the sudden appearance of severe biventricular cardiac failure unresponsive to intensive medical therapy, was an important clue to making the correct pre-operative diagnosis. The use of non-invasive techniques, such as phonocardiography and M-mode and two-dimensional echocardiography, is highlighted. Full cardiac catheterization was employed to define the cardiac pathophysiology. This was one of the few cases documented in which a catheter could be passed from the aorta into the right ventricle via the fistula connecting these two chambers. The fistulas were closed and the aortic valve replaced. Postoperative investigations confirmed the success of corrective surgery. As far as we are aware this is the first documented case of successful repair of a congenital sinus of Valsalva aneurysm rupturing into both the right atrium and right ventricle, accompanied by aortic insufficiency.

[Aortocoronary bypass surgery at Tygerberg Hospital, 1978 - 1980]. / Aortokoronêre omleidingschirurgie te Tygerberg-hospitaal, 1978-1980.

Between January 1978 and December 1980. 118 patients underwent saphenous vein bypass surgery for obstructive coronary artery disease at Tygerberg Hospital. Sixteen patients in addition to bypass surgery underwent mitral and/or aortic valve replacement or resection of a ventricular aneurysm. The operative and hospital mortality was 3,0% (4/134) for all patients and 3,3% (4/118) for patients who had aortocoronary bypass surgery as the sole procedure. Follow-up of the surviving patients for a mean period of 16,4 months revealed a low incidence of late myocardial infarction of 3.6% (4/112) resulting in the death of only 1 patient; 89.1% of patients were free of angina pectoris and the majority of these resumed their normal work or enjoyed their retirement.

Supravalvular aortic stenosis in the adult. A case presentation with unique associated features.

A 42-year-old symptomatic woman with possible adult Williams's syndrome (mental retardation, 'elfin facies' and supravalvular aortic stenosis (SVAS)) is documented. This patient displayed many unique features in addition to the severe SVAS (peak systolic gradient 96 mmHg): there was an associated persistent left superior vena cava draining into the coronary sinus, mitral valve prolapse (Barlow's syndrome) and complete right bundle-branch block on ECG. Peripheral pulmonary artery stenosis was absent. M-mode echocardiograhy in the adult with SVAS is described for the first time in the literature, as is the use of the 60 degrees cross-sectional scan. Both these non-invasive procedures proved of value in the diagnosis. The degree of subendocardial ischaemia, as determined by the 'endocardial viability ratio', was calculated and the possible mechanisms producing angina pectoris with 'coronary artery hypertension' in this condition are discussed. The literature on associated mitral valve abnormalities in SVAS is reviewed. A successful surgical result was obtained; the various forms of operation are outlined.

Penetrating wounds of the heart and pericardium.

Fifty-seven patients with penetrating cardiac or pericardial trauma were treated at the Department of Cardio-Thoracic Surgery, University of Stellenbosch at the Tygerberg Hospital during a 6 1/2 year period from June 1971 to January 1978. Eleven patients were treated by aspiration alone because tamponade was mild, or because they were seen between 24 hours and 3 weeks after injury. Six patients underwent late elective surgery. Cardiopulmonary bypass had to be employed in four patients to correct intracardiac lesions. All other patients underwent emergency operations 8 minutes to 2 hours after admission to hospital. The hospital mortality was 4 of 57 patients (7%), lower than rates reported in other series. Some selected cases will be described more fully and our present plan of management is outlined.

[Ventricular aneurysmectomy and infarctectomy]. / Ventrikulêre aneurismektomie en infarktektomie

During a 22-month period, April 1972 to February 1974, 4 patients underwent ventricular aneurysmectomy at the Karl Bremer and Tygerberg Hospitals for congestive cardiac failure. In addition, 1 patient with an aneurysm and 3 patients with acute myocardial infarcts, ranging from 16 to 28 days postinfarction, underwent emergency surgery for recurrent malignant arrhythmias. The preoperative treatment, cardiac catheterisation data and surgical findings are outlined. The over-all survival rate is 75% for a mean follow-up period of 12,5 months (range 8-22 months). It is concluded that aneurysmectomy, for congestive cardiac failure, and infarctectomy, for life-threatening ventricular arrhythmias, are gratifying and worthwhile procedures.

Penetrating wounds of the heart and great vessels. Experience with 24 cases including 3 with intracardiac defects.

Twenty-four cases of penetrating cardiac injuries due to stab wounds, which were seen over a 3-year period, are reviewed. Ten patients were treated by aspiration alone because tamponade was mild, or because they were seen more than 12 hours after injury. One patient with multiple stab wounds in the ventricles and left atrium died during emergency thoracotomy in the admission room. The mortality rate of 4,5% is considerably lower than rates reported in other series. Two cases of traumatic ventricular septal defects, one case of traumatic aortic incompetence and sinus of Valsalva fistulae with rupture into the right ventricle and right atrium, and one case of ascending aorta-innominate vein fistula are discussed. Our present plan of management is outlined.