Primary surgical closure of large ventricular septal defects in small infants.

Herein, a policy of primary surgical closure of large ventricular septal defects in infants is reviewed. Forty-eight infants met criteria for inclusion in the study, and were divided into two groups based on weight: group 1 infants weighted 4 kg or less (n = 23), and group 2 infants weighed more than 4 kg (n = 25). Both groups had similar variation in ventricular septal defect location (paramembranous versus muscular) and number (single versus multiple), as well as incidence of major associated extracardiac diseases. No early deaths occurred in group 1, compared with 1 infant (4%) in group 2. Major complications occurred similarly in both groups (9% versus 12%). There were two late deaths in group 1 (9%) and none in group 2. No surviving patients have required a second ventricular septal defect operation, and the majority no longer receive anticongestive therapies. These results indicate that primary surgical closure of large ventricular septal defects, even multiple muscular defects, can be performed in very small infants with no difference in mortality or serious complication rates compared with larger infants. Protracted medical efforts to achieve larger size before primary repair and palliative pulmonary artery banding are not necessary.

Simplified method for femoral venous cannulation.

A simple method for rapidly achieving femoral venous cannulation is described. We have found this method to be particularly useful for femoral cannulation when the patient is in the thoracotomy position.

Quantitative digital subtraction coronary angiography using videodensitometry. An in vivo analysis.

A videodensitometric method for measuring absolute cross-sectional area and diameter has been tested in living dogs with coronary artery stenoses created surgically by placement of small Silastic cuffs. Coronary arteriograms were performed using a circular tomographic unit to provide multiple views of each lesion, and measurements were made from logarithmically subtracted digital images. Dimensions of 13 stenoses of cross section 1 to 5 mm2 and adjacent reference segments (2 to 9 mm2) were determined by histologic sectioning of the segments after injection with a rapidly hardening plastic fixative under physiologic pressure. Two different methods were tested for calculating cross-sectional area. On 238 measurements, 102 of normal vessel segments and 135 of stenoses, both methods showed good correlation with histologic measurements, with slopes of 0.929 + (SD) 0.037 (r = 0.8563) and 0.948 + (SD) 0.037 (r = 0.8554). Multiple measurements of each segment produced values within 30% of the true absolute cross sectional area in most cases. The method shows promise as a means for quantitating absolute dimensions of vessels in clinical arteriography.

Rational preoperative evaluation.

Clinical data from two hundred consecutive patients undergoing surgical procedures at the Salt Lake City VA Hospital form the basis of this study. Results of nine commonly ordered preoperative tests (blood count, differential, electrolytes, chemistry panel, urinalysis, prothrombin time, partial thromboplastin time, electrocardiogram, and chest X-ray) were matched with the preoperative history and physical examination and the outcome of surgery in each patient. Each test was examined by the frequency with which it was ordered, the frequency with which it was abnormal, and the frequency with which the abnormal result affected preoperative care. A prevalence of medical illness was found in this population, with 47.5% having a major cardiovascular diagnosis, 35.5% a metabolic or endocrine disease, and 28% a major pulmonary diagnosis. A total of 1271 tests were performed, with 477 (35.5%) showing some abnormality. However, only 76 (5.9%) changed the patient's management before surgery. All but five of these abnormalities were predictable from the clinical evaluation and these five were minor. The overall postoperative complication rate was 9%. No complication was attributed to the omission of a preoperative test. No surgical cases were cancelled during the study period based solely on a preoperative test. We conclude that many preoperative tests can be safely eliminated by ordering only those based on a specific abnormality in the history or physical examination, resulting in more cost-effective surgical care.