Considerations in the surgical management of ventricular septal defect and aortic insufficiency--a case report.

A 23-year-old man presented with progressive exercise-related dyspnea and easy fatigability. He gave a history of a murmur of aortic insufficiency since childhood. Cardiac catheterization demonstrated severe aortic insufficiency. At surgery the patient was found to have prolapse of the right coronary cusp into a significant supracristal ventricular septal defect. Repair was carried out with a Dacron patch closure of the septal defect and replacement of the valve with a 29-mm St. Jude valve. The patient recovered uneventfully and is fully active and employed 5 years later. Review of the literature documents that this is an uncommon lesion. The approaches to preoperative diagnosis include transesophageal echo. The management techniques have included ventricular septal defect closure, alone and with valvuloplasty, and septal defect closure with aortic valve replacement. The anatomic and patient characteristics guide selection of the most suitable management of these patients.

The role of lasers in the management of peripheral vascular disease.

Although it has been almost twenty-five years since the first studies of McGuff et al, who employed the laser for atheroablation, problems still require resolution. The various laser wavelengths from ultraviolet through visible to infrared have been employed for atheroablation. The laser's greatest appeal and the most spectacular results have been in reopening channels in totally occluded vessels. The laser's greatest problem has been damage of the arterial wall and even perforation. The purpose of this presentation is to clarify the present status of available lasers for the treatment of peripheral vascular disease of the lower extremities. To this end, the initial experience with angioscopically guided laser-assisted angioplasty with a new hybrid laser probe is reported.

Intraoperative angioscopically monitored laser-assisted angioplasty in treating lower-extremity atherosclerotic occlusive disease.

As part of an ongoing multi-institutional study, our surgical center offered laser-assisted angioplasty to patients with significant, documented lower-extremity atherosclerotic occlusive disease, as an alternative to standard femoral-popliteal or femoral-tibial bypass. During the 1st 12 months of the study (September 1987 through August 1988), 31 patients had laser-assisted angioplasty in 34 limbs. The procedures were performed with an argon-powered laser probe that features a heated metallic tip and a window that furnishes 20% of the laser energy as a direct argon laser beam. Angioscopic monitoring was provided in each case. The immediate recanalization rate was 82% (28 of 34 limbs). After a follow-up period of 6 to 18 months (mean, 14 months), the patients continue to show clinical improvement of pretreatment symptoms, and noninvasive studies continue to reveal improved segmental arterial pressures. On the basis of this experience, we conclude that angioscopically monitored laser-assisted angioplasty has a role in the management of lower-extremity atherosclerotic occlusive disease.

Vascular complications associated with the use of intraaortic balloon pumping.

Our 11-year experience with intraaortic balloon pumping (IABP) was analyzed to determine the incidence and evaluate the management of vascular complications. Between 1973 and 1984, 637 patients were candidates for IABP. In 41 cases, IABP was precluded because peripheral vascular disease inhibited balloon catheter insertion. Of the 596 patients who underwent IABP, 304 (51.0%) survived the hospital period, and late follow-up information was available for 283 (93%) of these. The late results were analyzed with respect to the duration of survival and the presence of lower-extremity claudication. Sixty-six (11.1%) of the 596 patients experienced vascular complications (mainly in the form of limb ischemia). Balloon removal, followed by thromboembolectomy, restored limb viability in the majority of cases. When continued IABP was required, creation of a femoral-femoral bypass to the portion of the limb distal to the balloon allowed viability to be maintained.

Experience with intraaortic balloon counterpulsation.

An eleven-year experience with intraaortic balloon pumping (IABP) or counterpulsation in 637 patients was analyzed with respect to early and late results. Intraaortic balloon pumping was employed for left ventricular pump failure, for coronary insufficiency, and in association with cardiac operations. Late results were analyzed by follow-up of 283 (93%) of the 304 patients leaving the hospital, and were studied with respect to duration of survival, activity status, occupational status, presence of cardiac symptoms, use of cardiac medications, and presence of lower extremity claudication. Early results were analyzed for hospital survival (304/637 [48%]). Patient complications of IABP included wound infection (1/637 or 0.2%), vascular complications (66/637 or 10.4%), and balloon failure (8/637 or 1.3%). No deaths were attributable to complications of IABP. Survival did not correlate with the duration of IABP. Survival was improved in patients who had revascularization in association with IABP.

Aortocoronary bypass following unsuccessful PTCA: experience in 100 consecutive patients.

This study reviews the experience in a community hospital with aortocoronary bypass in 100 consecutive patients following failed percutaneous transluminal coronary angioplasty (PTCA) in terms of timing of intervention, morbidity, and mortality. Patients undergoing operation within 24 hours of PTCA are defined as the urgent group (68%) and those with intervention at greater than 24 hours, the elective group (32%). Mean interval from PTCA to operation was 43.5 days; among patients with apparently initially successful PTCA and hospital discharge, mean interval to operation was 138 days. Complete revascularization was carried out in all patients using standard techniques. Although the difference was not statistically significant, patients in the urgent group required intraaortic balloon pump support and inotropic infusions more often and experienced greater postoperative blood loss. Significant increases in the use of lidocaine and blood products were noted in the urgent group. The rates of major complications were 54.4% in the urgent group and 18.8% in the elective group. Mortality was 4.4% in the urgent group and 3.1% in the elective group (not significant); all deaths were cardiac related. There were no late deaths among survivors followed for 3 months to 4 years; 86% were in Functional Class I. We conclude that PTCA is a reasonable approach for some patients with ischemic heart disease. However, mandatory urgent aortocoronary bypass in these patients carries an increased morbidity and mortality, and patients should be selected with care.

Ventilatory pattern, intrapleural pressure, and cardiac output.

Continuous positive-pressure ventilation may decrease cardiac output. However, a few reports have separated the effects of positive and end-expiratory pressure (PEEP) from those of mechanical ventilation. Ten surgical patients requiring mechanical ventilatory support had catheters inserted for measurement of right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), intrapleural, radial artery, airway, and atrial filling pressures, and cardiac output. All patients breathed spontaneously between mechanical breaths delivered every 30 seconds by intermittent mandatory ventilation (IMV). Measurements were made with 0, 5, and 10 cm H2O PEEP, and during intermittent positive-pressure ventilation (IPPV) with 12 breaths/min without PEEP. Airway pressure (Paw), intrapleural pressure, RAP, and PAOP were increased by PEEP and IPPV. Intrapleural pressure increased most during IPPV (p less than 0.001). Atrial filling pressures and cardiac output were unaffected by PEEP but decreased during IPPV (p less than 0.001). Patients receiving IMV maintained negative intrapleural pressure, atrial filling pressure, cardiac output and, therefore, O2 delivery, regardless of PEEP level. The authors conclude that patients requiring mechanical respiratory support, with or without PEEP, may maintain better cardiopulmonary function when allowed some spontaneous ventilatory activity.

Tricuspid valve prosthetic replacement. Early and late results with the Starr-Edwards prosthesis.

The total experience (154 patients) with ball-valve (Starr-Edwards) replacement of the tricuspid valve, alone and in combination, through Dec. 31, 1971, at the Mayo Clinic is reviewed. The early mortality rate with isolated tricuspid replacement was twice that for tricuspid replacement combined with replacement of other valves. Among patients receiving three valves, those with "functional'' tricuspid insufficiency and those who were in New York Heart Association (N.Y.H.A.) Class IV preoperatively had a higher early mortality rate. The early mortality rate for the total group was 28%. Of those surviving tricuspid plus mitral valve replacement, 70% were alive at 3 years; at latest follow-up, 94% of those surviving were functionally improved. Of those surviving triple valve replacement, 56% were alive at 3 years; at latest follow-up, 93% of those surviving were functionally improved. Previous cardiac surgery with residual tricuspid valve dysfunction and severe disability, as judged by N.Y.H.A. class, influenced the outcome adversely. The experience reported here provides a standard against which never prostheses can be compared.

Diverticular disease of the right colon.

Diverticular disease of the right colon is uncommon. Most frequently, rightsided diverticula occur in the cecum, and usually, they are solitary. Generally, the diverticular are true diverticular containing all coats of the intestine, and usually the younger age group is affected. Right-sided diverticulitis mimics appendicitis. The diverticulum and adjacent reaction may be mistaken for carcinoma. Surgical excision is indicated to prevent recurrent symptoms as well as confusion at later barium studies.

Cystic disease of the liver.

The clinical presentation, pathology, and appropriate surgical management of cysts of the liver were analyzed in a review of 150 cases of hepatic cystic disease encountered surgically at the Mayo Clinic from Jan. 1, 1954, through Dec. 31, 1971. The incidence of this disease was 17 per 10,000 abdominal explorations. The series included 82 solitary cysts, of which 15 produced symptoms; 49 multiple cysts, of which 7 were symptomatic; 13 hydatid cysts, of which 12 were symptomatic; 3 traumatic cysts, of which 2 were symptomatic; and 3 inflammatory cysts, of which 1 was symptomatic. Symptoms, when present, comprised (in order of frequency) the presence of an abdominal mass, abdominal pain, and hepatomegaly. Congenital and hydatid cysts were located most often in the right lobe of the liver. The smallest cysts were the multiple cysts (average diameter, 4.3 cm) and the largest were the hydatid cysts (average diameter, 10.5 cm). Histologically, the lining of the congenital cysts most often was of cuboidal epithelium. The treatment of congenital cysts included simple biopsy, aspiration, and excision. In cases of hydatid cysts, preliminary sterilization was found to be essential prior to aspiration. Hydatid cysts may be excised or opened, evacuated, and the cavity obliterated. In certain cases hepatic resection may be warranted in order to remove all of the hydatid disease.