Aortic valvoplasty for traumatic aortic insufficiency: a 2-year follow-up.

A 23-year-old man sustained acute rupture of an aortic valve cusp in a motorcycle accident. We repaired the valve using an autologous pericardial patch. A 2-year follow-up two-dimensional echocardiogram and Doppler study show completely normal appearance and function.

Percutaneous tracheostomy--a new method.

A rapid method of definitive low tracheostomy utilizing an original instrument kit and percutaneous approach is described. Through a horizontal, shallow (1.5-cm) skin incision in the neck, a 12-ga needle is introduced into the tracheal lumen. A flexible metal guidewire is gently introduced through the needle, which is then removed. A specially designed percutaneous tracheostomy tool slides over the guidewire into the trachea; by squeezing its handles, the intercartilaginous space is enlarged, securing the placement of a cuffed tracheal cannula. After extensive and successful investigation in both cadaver and animal trials, the procedure was carried out in 80 patients who had a variety of underlying diseases, without serious complications. Of these 80 patients, 33 required airway control after neurosurgical interventions or after severe head trauma, 23 had percutaneous tracheostomy performed before radical excision for head and neck cancer, and the remaining 24 suffered from severe cardiorespiratory problems. Twenty-nine procedures were performed in the operating theater, and 51 procedures were carried out at the patient's bedside in the ICU, ED, or in the ward. There was no infection at the stoma site, and late healing was remarkable. It should be strongly emphasized that in the majority of our patients the procedure was carried out safely at the bedside. This resolved the logistic problem of moving very sick ICU patients (who are sometimes on high PEEP levels) to the OR. Although our experience is totally restricted to elective situations, we do postulate that it could be as effective in a variety of urgent situations.

A simplified concept for a bileaflet atrioventricular valve that maintains annular-papillary muscle continuity.

We have developed a simplified concept for a bileaflet atrioventricular prosthesis that can be constructed from a simple sheet of glutaraldehyde preserved pericardium. The valve has no rigid ring or stent and no cloth sewing ring. Insertion of the valve reestablishes normal continuity between the annulus and the papillary muscles. We have replaced the mitral valve in nine dogs using this prosthesis. All valves have been competent with excellent valve opening areas as confirmed by echo-Doppler assessment. Studies up to 4 1/2 months have confirmed excellent hemodynamics and there has been no evidence of early tissue failure. Possible advantages of this simple valve design are improved hemodynamics, ease of construction and insertion, and low cost.

A technique to facilitate mitral valve replacement.

Replacement of the damaged mitral valve with a biological or mechanical prosthesis occasionally can be difficult. A technique is described that facilitates (a) exposure of the mitral valve, (b) safe excision of the mitral and subvalvular apparatus, (c) good access to the annulus for placement of interrupted sutures in an operative setting that provides good venous return, adequate myocardial protection, and the opportunity for complete removal of air. The procedures described are particularly helpful in reoperative mitral valve surgery when adhesions may limit exposure. The principles have been derived from the need for superb mitral valve exposure during reparative surgery. Perivalvular leak and myocardial rupture have been virtually eliminated by adoption of the principles outlined.

A technique for selective graft perfusion during aortocoronary bypass.

A technique is described that provides early reperfusion of acutely ischemic myocardium during the construction of saphenous vein bypass grafts to the coronary arteries. Selective vein graft perfusion provides early and appropriate cooling of the most ischemic zones identified by either electrocardiographic changes or intramyocardial temperature probes and allows warm blood reperfusion during construction of proximal anastomoses. The technique may be applicable to patients who present with acute ischemia and evolving infarction, failed angioplasty, or left main coronary artery stenosis.

Separation and quantitation of ventricular myosin heavy-chain from human atrial myocardium.

A discrepancy observed in electrophoretic mobility of human atrial and ventricular myosin heavy chains permitted the determination of these protein isoforms in myocardial biopsies. In ventricular biopsies we found only the heavy chain specific to this tissue whereas in atrial specimens we sometimes detected an extra heavy chain comigrating with the ventricular species. The peptide mapping of such preparations revealed peptides unique to ventricular heavy chain. Patients suffering from pressure overload expressed ventricular heavy chain at a higher frequency than those suffering from coronary heart disease (66% VS.29%), but this disparity was not found statistically significant (0.1 greater than P greater than 0.05).

Protective effect of hydrocortisone on the myocardium during anoxic arrest.

The protective effect of hydrocortisone on the myocardium during anoxic arrest was investigated in nonworking, isolated rat heart preparations subjected to cardioplegia. In control preparations (no cardioplegia) there was no inotropic effect of hydrocortisone. After both 60 and 120 min of anoxic arrest, recovery of contractility in hearts treated with cardioplegia and hydrocortisone was significantly better than that of hearts treated with cardioplegia only--98 vs. 85%, respectively, at 60 min, and 100 vs. 87% at 120 min. The addition of hydrocortisone to cardioplegia solution apparently results in better protection of the myocardium during anoxic arrest.