Internal temporary aortic shunt for managing lesions of the descending thoracic aorta.

An intraaortic shunt was used to maintain distal organ perfusion during experimental descending aortic cross-clamping and graft interposition in the descending aorta. None of the dogs in which this form of shunt was employed developed paraplegia, whereas 60% of the dogs in which no adjunct was used during aortic cross-clamping became paraplegic.

Aortic-left ventricular discontinuity and aortic regurgitation from acute endocarditis.

During the past 14 years, eight patients have had surgical intervention for acute aortic endocarditis and aortic-left ventricular discontinuity at our institution. Repair of the defect between the aorta and left ventricle was accomplished in two patients with interrupted horizontal pledgeted sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining six patients the repair was done with the interposition of a Dacron patch graft between the left ventricle and the aorta, and then the valve prosthesis was sutured to the graft and to the remaining native aortic annulus. One patient died during the operation, one was lost to follow-up four months after operation, and one died of cerebral hemorrhage two years postoperatively. The remaining five patients have had from three months to four years of follow-up. Closure of large defects between the aorta and left ventricle with a patch graft and then suturing the aortic valve to the patch and to the remaining native aortic annulus allows debridement of all necrotic tissue, placement of the sutures through normal tissue, closure of the defect under no tension, and suturing of the new valve at its normal anatomic level. It also requires no surgical manipulation of the coronary arteries and allows completion of the procedure in the shortest time possible.

Acute endocarditis: surgical treatment of aortic regurgitation and aortico--left ventricular discontinuity.

The clinical course of five patients with acute endocarditis resulting in aortic regurgitation and aortico--left ventricular discontinuity was reviewed. All five patients were operated upon less than 6 weeks after the onset of the antibiotic therapy. Aortic valve replacement and repair of the left ventricular discontinuity were done successfully in all five patients. The repair was accomplished in two patients primarily, with interrupted horizontal pledget-supported sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining three patients, the repair was performed with the interposition of a Dacron patch between the left ventricle and the aorta, and the valve prosthesis was then sutured to the graft and to the remaining native aortic anulus. The latter technique has many attractive features for the repair of left ventricular discontinuity when there exists a large gap between the aorta and left ventricle.

Immediate and long-term outlook for valve replacement in acute bacterial endocarditis.

The clinical course of 22 patients with acute endocarditis treated surgically less than six weeks after the onset of antibiotic therapy was reviewed. The aortic valve was infected in 13 patients, the mitral in six, the tricuspid in two, and one patient had both aortic and mitral valve involvement. The indications for surgical intervention before the completion of adequate antibacterial therapy included uncontrollable congestive heart failure, persistent sepsis, systemic embolization, and multiple septic pulmonary embolizations. The annulus was involved by the infectious process in five of the 13 patients with aortic valve endocarditis, in one of the two patients with tricuspid valve infection, and in none of the patients with mitral valve endocarditis. There were two surgical deaths, for a mortality of 9.1%. During the follow-up period, four patients died three months, seven months, four years, and seven years after surgery. The remaining patients have been followed up for a period of five months to 10 years. One patient has a hemodynamically insignificant paravalvular leak, and another developed paravalvular regurgitation and a false aneurysm of the left sinus of Valsalva two weeks after the initial operation. She subsequently underwent successful valve replacement and repair of the aneurysm. This study confirms that valvular replacement should be done for acute endocarditis as soon as indicated, and that the incidence of reinfection and/or the development of valvular or paravalvular problems is small even in the patients with incomplete antimicrobial therapy, whether or not the annulus is involved by the infectious process.