Congenital coronary artery obstruction associated with aortic anomalies in children: report of two cases.

Coronary arterial obstruction associated with congenital aortic valve disease is rare in children. We studied two children with aortic valve disease and symptoms of coronary insufficiency. Cineangiography revealed localized obstruction of the proximal left coronary artery. In one patient, a membrane-like structure partially covered the left sinus of Valsalva, almost isolating the ostium of the left coronary artery; the other patient had severe stenosis of the proximal left coronary artery and a congenitally hypoplastic left coronary cusp. Surgical repair was successful in both cases. Symptoms of myocardial ischemia in children with aortic valve disease should be investigated promptly to exclude obstruction of the coronary arteries.

Successful triple coronary artery bypass in a child with multiple coronary aneurysms due to Kawasaki's disease.

A 9-year-old girl developed ischemic cardiac symptoms 3 years after she first presented with characteristic manifestations of Kawasaki's disease, namely, high fever, conjunctivitis, lymphadenopathy, macular truncal skin rash, and erythema of both hands followed by desequamation of the skin of the fingertips. This acute illness resolved spontaneously within 2 weeks. Because of progressive and severe anginal symptoms and electrocardiographic signs of myocardial ischemia, she underwent cardiac catheterization and coronary angiography, which demonstrated multiple aneurysms of both right and left coronary artery systems. The two larger aneurysms of the right main and left main coronary arteries were clotted, causing complete occlusion of these vessels. Only collateral branches from the proximal right coronary artery which were supporting the entire coronary circulation, prevented her from having a myocardial infarction. A triple saphenous vein bypass was performed with excellent immediate results. One year later the patient was completely free of symptoms; she was living a normal life and a stress electrocardiogram was entirely normal.

[Surgical valve therapy combined with aorto-coronary bypass (author's transl)]. / Terapia chirurgica valvolare associata a bypass aortocoronarico.

The AA. analyse a series of 720 patients who have undergone an aorta coronary by-pass combined with surgical valve therapy at the Texas Heart Institute up to an including 1977. 384 of these cases involved the aortic valve, 306 the mitral valve and 30 both valves. The combined operation was shown to be necessary since the disregarded or untreated coronary lesion in patients with valve pathology increases both the early and late mortality rate or reduces the results after surgical valve therapy. The double operation, on the other hand, reduces mortality, eliminates the symptoms, improves long-term survival and prevents myocardial infarction. Therefore emphasis is placed on the need for coronarographic investigation for valve patients over 40. However, the association of mitral or anuloplastic valve replacement does not lead to a significant improvement in long-term survival when mitral valve insufficiency is accompanied by an ischaemic aetiology.

Direct myocardial revascularisation: experience with 9364 operations.

Between July 1968 and December 1976, 9364 consecutive patients with coronary insufficiency underwent direct myocardial revascularisation using aortocoronary bypass (ACB). Among these patients 8017 had ACB alone, and the remaining 1347 had ACB in addition to correction of other cardiac and vascular lesions. In the series of patients having ACB alone the hospital (early) mortality was 3.9%, but for 2383 surgical patients in 1976 this figure was 2.2%. Operative mortality was higher for women (6.85%) than for men (3.5%), but late survival was about the same for both sexes. Among surviving patients 88% were improved or symptom-free after undergoing ACB. According to our data, at the end of eight years 80% of the patients will be survivors. These results, when compared with other series of patients treated medically, indicate the superiority of surgical treatment both in terms of symptomatic relief and also in increased life expectancy.

Sinus venosus atrial septal defect: early and late results following closure in 109 patients.

The clinical course of 109 patients who underwent closure of a sinus venosus atrial septal defect is reviewed, with emphasis on the incidence, type, and severity of arrhythmias before and after operation. There were no operative deaths and only 1 late death. No instances of obstruction of the superior vena cava were detected clinically. One patient had a probable hemorrhagic pulmonary infarction that cleared; another may have a persistent left-to-right shunt. Excellent results were achieved in 72% of the patients, good results in 5%, and poor results in 3%. The type of arrhythmia, both before and after operation, varied with the age of the patient: younger patients had bradyarrhythmias, and older patients had tachyarrhythmias. Ten patients experienced persistent new arrhythmias postoperatively, but none were disabled, required a pacemaker, or died. The arrhythmias in all severely symptomatic patients were supraventricular tachycardias that had occurred before operation. Although functional classification after operation was clearly related to age at the time of the procedure (with younger patients having the best functional results), 19 of 21 patients over age 40 were noticeably improved after surgical closure of the sinus venosus atrial septal defect.

Reoperation following direct myocardial revascularization.

Among the 5507 patients who underwent aortocoronary bypass between October 1969 and June 1975, 41 patients (0.007%) developed recurrent angina and required reoperation. The factors necessitating reoperation were graft thrombosis in 10 patients (24%), progression of disease in 12 (29%), graft thrombosis and critical unbypassed lesions in one (2.4%), graft failure and progression of disease in in 12 (29%), graft failure and critical unbypassed lesions in four (10%), and all three factors in two patients (4.8%). Among 10 patients with 50% lesions present but not bypassed at the initial operation, nine of these lesions progressed to significant stenosis and in five patients this was the sole reason for reoperation. At the second operation, total revascularization was achieved in 32 patients (78%). One patient (2%) experienced a perioperative myocardial infarction and one patient (2%) died. This study emphasizes the importance of "complete" revascularization at initial operation, the concept that arteries with 50% obstruction should be routinely bypassed, and the conclusion that risks of reoperation are comparable with those of initial aortocoronary bypass, but that long-term relief of angina is less favorable.

Ascending aorta-abdominal aorta bypass: indications, technique, and report of 12 patients.

Use of the supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation.

Surgical treatment of aneurysms of the ascending aorta.

From January 1970 to April 1975, 132 patients underwent surgical repair of aneurysms of the ascending aorta at this institution, 24 of whom had acute dissections. In almost all cases the ascending aorta was replaced with a Dacron tube graft. Aortic valve replacement was performed in 100 patients and 23 patients underwent coronary artery revision or bypass. Fifteen hospital deaths occurred. Although chronic or nondissecting aneurysms may be dealt with on an elective basis, acute dissections require prompt surgical intervention. Symptomatology and radiographic findings are such that angiography may not be necessary to establish the diagnosis. Clinical evidence of aortic regurgitation in an acute dissecting aneurysm is sufficient indication for immediate operation. Improvements in surgical techniques, fabric grafts, and valve prostheses have all contributed to the successful surgical treatment of aneurysms of the ascending aorta.

Surgical versus medical treatment of coronary artery disease: long-term survival.

In an attempt to answer the question as to whether or not aortocoronary bypass (ACB) does increase life expectancy of patients with coronary artery occlusive disease (CAOD), 4,766 consecutive patients undergoing ACB at the Texas Heart Institute from October, 1969 through June, 1975, were reviewed and followed for five and one half years. Overall early mortality was reduced from 9.7 percent during the first full year (1970) of the study to 3.3 percent during the last full year (1974). Early mortality in males (86.5 percent) was reduced to 3 percent during 1975, but in females only to 8.4 percent. However, late mortality in females was only 2.6 percent as compared to 3.4 percent in males. Long-term survival was similar for both males and females at five and one-half years when early mortality was considered. Males also experienced better symptomatic results than females with 90.3 percent of males remaining asymptomatic, while only 86.6 percent of females remained in this category. Early mortality increased as more vessels were bypassed, but late mortality decreased and symptomatic results improved as more complete revascularization was performed. Only 55 percent of late deaths were cardiac related. Actuarial comparison of this surgical series with the most comparable series in the literature of patients treated medically, demonstrated significant (P less than 0.001) increased survival in the surgical group as compared to medically treated patients at every year up to five and one-half years, for patients with double and triple vessel disease and for the entire series. In those patients with single vessel disease, the survival curves were similar to four years, following which survival was increased in the surgical patients at the end of the fifth and sixth reporting years. In summary, these data appear to suggest that surgical treatment of coronary artery occlusive disease does provide a favorable effect upon life expectancy.

Aortocoronary artery bypass: present indications and risk factors.

From 1969 through 1974, a total of 4,522 patients were operated on for coronary artery occlusive disease. This article is an in-depth analysis of a consecutive series of 275 of these patients, operated on during 1974. The mortality was 1.8% and perioperative myocardial infarction occurred in 3.6%. On analysis of risk factors, it was found that 24% of the patients were over the age of 60; 57% had some degree of left ventricular dysfunction; 9% had generalized hypokinesis; 24% were New York Heart Association functional class IV; 13% had left main coronary artery stenosis; and 11% had preinfarction angina. On analysis of the early mortality, the limiting factor was diffuse coronary arteriosclerosis combined with poor ventricular function. This resulted in inadequate or incomplete myocardial revascularization. Since these two risk factors are usually predictable, coronary artery bypass can be recommended not only for patients with intractable angina, but also for patients with impaired left ventricular function associated with angina, and in patients without angina who have a positive stress electrocardiogram.

Treatment of severe coronary artery disease with quadruple and quintuple saphenous vein grafts. Review of 100 consecutive patients.

In order to establish the anatomic criteria, the functional results, and the safety of complete myocardial revascularization for severe coronary artery disease, 100 consecutive patients who received four or five saphenous-vein grafts were analyzed. Ages ranged from 37 to 75 years (mean, 56 years). Men predominated by a ratio of 12:1. As an indication of the severity of multiple-vessel disease, 28 percent were in functional class 4, and left ventricular function was classified as good in 47 percent, as fair in 44 percent, and as poor in 8 percent. Coronary arterial scores ranged from 9 to 15 (average, 12.2). Fourteen patients had significant left main coronary arterial obstruction. All 100 patients had grafts to the left anterior descending coronary artery; 96 to the right coronary artery; 94 to the obtuse marginal branch of the circumflex; 78 to a diagonal branch of the left anterior descending; and 27 to the distal circumflex. Operative mortality was 5 percent. Nonfatal perioperative myocardial infarction occurred in 10 percent, and only one of these had low cardiac output. Follow-up from 5 to 23 months showed 95 percent of the patients to be improved, with 70 percent free of angina. Two late deaths occurred, for an overall mortality of 7 percent.

Aortocoronary bypass in Jehovah's Witnesses: review of 46 patients.

The hemodilution technique for cardiopulmonary bypass using blood substitutes for priming has permitted open heart operations in Jehovah's Witnesses who refuse to accept blood, and has reduced the need for massive blood transfusion in certain procedures including aortocoronary bypass. A series of 46 Jehovah's Witness patients underwent aortocoronary bypass procedures. Of these, two patients died, representing a mortality of 4.3 per cent. Neither patient's death was related to lack of blood transfusions. The hospital stay and recovery time of all the other patients was not affected by failure to transfuse blood. The excellent short- and long-term results of this particular group paralleled those observed in our larger series of over 2700 other patients who have undergone coronary bypass surgery since 1969. Among these patients not of the Jehovah's Witness religion, blood transfusion was not necessary in about 30 per cent, while the remainder averaged less than two units per patient. Our results with Jehovah's Witness patients encourage our policy of avoiding blood transfusions whenever possible in all operations. Further justification for our conservative attitude is provided by the current shortage of blood in relation to a projected continuous increase of aortocoronary bypass procedures in the future.

Long-term survival following coronary artery bypass. Analysis of 4,522 consecutive patients.

A consecutive series of 4,522 patients who received aortocoronary bypass (ACB) from October 1969 through December 1974 has been analyzed with respect to cumulative (actuarial) survival, cause of late death, and late postoperative complications. Through December 1973, 2,676 patients received ACB alone. Cumulative survival was 85.9% for five years. Late cumulative mortality averaged 2.7% per year. Causes of death were myocardial in origin in only 60.4% of the patients. Late complications of nonfatal myocardial infarction occurred in 4.1% of the patients, and congestive heart failure occurred in 10.2%. However, preoperative congestive heart failure was present in 25% of these subjects. Mortality in 1974 was 3.4% in patients who underwent ACB only, and 4.2% for all patients who received ACB procedures (1,478 patients). Comparison to previous medical data makes it appear that this surgery increased the actuarial survival over long-term follow-up.

Surgical palliation of tricuspid atresia.

In the 20-year period ending December 31, 1973 we operated on 105 patients for palliation of tricuspid atresia (TA) with reduced pulmonary blood flow. Pott's anastomosis (85), Blalock-Taussig anastomosis (19), intrapericardial aorta (Ao)-to-right pulmonary artery (RPA) (18), Glenn procedure (3) and miscellaneous shunts (2) have been used. Of patients undergoing operation more than 15 years ago, 45% (9/20) are still alive. The over-all operative mortality was 9%. It was highest in patients less than one month of age (7/23, 30%). There were no operative deaths in patients older than 12 months. The median age at first operation for the entire series was five months. Our results indicate the Pott's anastomosis and Ao-to-RPA anastomosis are superior to the Blalock-Taussig anastomosis (BT) for palliation of TA. Of patients surviving BT, 69% (11/16) required reoperation, compared to 22% (17/78) surviving Pott's anastomosis and 13% (2/16) surviving Ao-to-RPA shunts. All three patients undergoing Glenn procedures (superior vena cava-to-RPA anastomosis) required reoperation or died without significant benefit. Ballon atrial septosomy and Pott's anastomosis appear to be indicated for infants less than six months of age, and Ao-to-RPA shunt with simultaneous atrial septectomy (if indicated) for older children.