C. Walton Lillehei

Left retrograde cardioangiography in acquired cardiac disease: Technic, indications and interpretations in 700 cases∗☆

Abstract Application of retrograde left cardioangiography to 700 patients, both adults and children, with acquired valvular diseases is described. The technic employed for the test is described. Pressures from the aorta and left ventricle are obtained during the same procedure as angiography to determine whether stenosis of the aortic valve is present. The method may be used to estimate the degree of aortic or mitral insufficiency or both. Mitral stenosis may be identified by a fixed filling defect of the left ventricular cavity. The value of this information in the surgical management of many forms of cardiac disease is emphasized. Complications have occurred infrequently and, in most instances, the patients have responded to appropriate therapy. Three deaths occurred. These were caused by ventricular fibrillation in 1 patient and cardiac tamponade in 2. The most common complication was thrombosis of the femoral artery at the site of arteriotomy. This complication occurred in about 4 per cent of cases; but in none did gangrene occur, and pulsatile flow was restored in all cases by immediate re-exploration of the femoral artery as soon as the diagnosis was made.

The developmental complex of "parachute mitral valve," supravalvular ring of left atrium, subaortic stenosis, and coarctation of aorta.

Abstract A developmental complex is described in which four obstructive anomalies of the left side of the heart and aorta coexist. These anomalies are (1) parachute mitral valve; (2) supravalvular ring of left atrium; (3) subaortic stenosis of either the muscular or membranous type; and (4) coarctation of the aorta. Eight cases form the basis of this report. In 2 cases, each of the four anomalies was present; all of the other 6 cases represent partial forms of the complex, or formes frustes, in that only two or three of the anomalies were present. The clinical picture is compounded of the effects of the several anomalies of the complex and of the frequent association with still other anomalies, including ventricular septal defect.

Congenital Anomalies Involving the Coronary Sinus

A classification is presented of anomalies involving the coronary sinus. These anomalies are classified into four anatomic groups on the basis of (1) enlargement of the coronary sinus, (2) absence of the coronary sinus, (3) atresia of the right atrial coronary sinus ostium, and (4) hypoplasia of the coronary sinus. Anomalies involving the coronary sinus often are associated with other venous anomalies, either of the systemic or the pulmonary circulation. In some there is no basic disturbance of the circulation. Those conditions involving the coronary sinus which are of major functional significance participate in shunts, either left-to-right or right-to-left in nature. Enlargement of the coronary sinus in the absence of a shunt usually indicates that a systemic venous channel joins the coronary sinus anomalously.

Aortico-Left Ventricular Tunnel

To be distinguished from aneurysm of an aortic sinus (Valsalva) is the rare condition in which an abnormal channel begins in the ascending aorta (above the right coronary artery), bypasses the aortic valve, and leads through the ventricular septum into the left ventricular cavity. This entity, which has not previously been diagnosed during life, to our knowledge, is herein named aortico-left ventricular tunnel. The cases of three patients (aged 3, 5, and 10 years) with this rare condition are described. The clinical, electrocardiographic, and radiological features were similar in each case and resembled those in aortic valvular insufficiency. The diagnosis may be established clinically through selective aortography. This reveals that the origin of the abnormal communication lies in the anterior wall of the ascending aorta above the levels of the coronary arterial origins. The abnormal communication leads to the left ventricle. The condition is distinguished from aortic sinus aneurysm by its origin above t...

Congenital Communication of a Coronary Artery with a Cardiac Chamber or the Pulmonary Trunk ("Coronary Artery Fistula")

Anatomic, clinical, hemodynamic, and roentgenographic findings in six patients with congenital communication of a coronary artery with a cardiac chamber or the pulmonary trunk are presented. The literature is reviewed. A coronary artery may communicate anomalously, with any of the cardiac chambers, more commonly with those on the right side. In the six cases presented, the right coronary artery communicated with the right atrium in one case and with the right ventricle in another. The left coronary artery communicated with the right atrium and right ventricle in one case each, and with the pulmonary trunk in two cases. The most striking feature observed clinically was a continuous murmur. If a continous murmur is localized in an area atypical for patent ductus arteriosus, the diagnosis should be suspected. Conventional roentgenographic and electrocardiographic studies yielded no specific diagnostic features. The results of cardiac catheterization may reveal a left-to-right shunt, but they are diagnostically useful only when correlated with clinical findings. The only precise method of demonstrating the abnormality is by means of selective aortography performed by injecting medium into the very origin of the aorta. Cure is possible by surgical interruption of the fistulous tract.

Surgical Treatment of Ruptured Aneurysms of the Sinus of Valsalva

Aneurysms of the sinus of Valsalva are usu- ally congenital in origin. When they rupture, it is generally into the right atrium or the right ventricle. Signs of a left- to-right shunt, aortic runoff, and cardiac decompensation are the cardinal features. Early diagnosis and surgical cor- rection result in cure. We report our experience with 28 patients. In all patients, we used a combined aortocameral approach, and we recommend a sandwich patch for the repair. Aortic valve replacement is needed only in patients with severe degenerative changes. The overall operative mortality was 21.4%, but in the last 10 years, mortality was only 11.7%. The causes of operative and late mortality are discussed. Ruptured aneurysms of the sinus of Valsalva represent a form of arteriovenous communication that is challenging to the surgeon and potentially lethal for the patient. Sur- gical closure of the fistula offers the only form of perma- nent cure. Although ruptured aneurysms of the sinus of Valsalva may be congenital or acquired in origin, most of them are the result of a congenital defect. Edwards and Bur- chell (l) attributed the congenital variety to a discon- tinuity between the aortic media and the annulus fibrosis of the aortic valve. The coexistence of a ventricu- lar septa1 defect (VSD) in a significant percentage of pa- tients with this malformation further substantiates the congenital nature of the condition.

Late results (30 to 35 years) after operative closure of isolated ventricular septal defect from 1954 to 1960.

This study was designed to determine the clinical status, cause of death, and effects of pulmonary vascular disease and conduction abnormalities 30 to 35 years after surgery in 296 consecutive surviving patients of closure of ventricular septal defect. Of the 296 patients, current status was determined by contact with patient and physician in 290 cases, with 6 (2%) lost to follow-up (7,912 patient years are included). Cardiac catheterization after surgery in 168 patients showed complete closure of the defect in 80%. Death occurred in 59 patients (20%), with higher mortality rates in those operated on after the age of 5 years, those with pulmonary vascular resistance greater than 7 units (51%), and those with complete heart block (78%). Of 37 patients with transient heart block after surgery, 8 (22%) have died (3 pulmonary vascular disease, 2 sudden death, 2 unknown causes and 1 complete heart block). Twenty other patients had a dysarrhythmia after surgery, and none of these died. Nine episodes of endocarditis occurred (11.4/10,000 patient years). Nine of 296 (3%) offspring had cardiac malformation. Most patients are in New York Heart Association class I, 57% attended college and 15% received an advanced degree. The data show good results for this group of patients operated on during an early era (1954 to 1960) of open cardiac surgery. They support the current trend toward operation in patients with ventricular septal defects at an early age and with low pulmonary vascular resistance.

Control of Complete Heart Block by Use of an Artificial Pacemaker and a Myocardial Electrode

The combined use of an artificial pacemaker and the insertion of a myocardial electrode has been described and demonstrated to be an effective method of controlling the heart rate at low voltages and low current amplitudes when complete heart block is present. The cardiac output and mean aortic pressures of dogs have been restored to preblock levels throngh the application of electric stimuli applied directly to the myocardium. No complications from insertion of removal of the wire in the heart wall were observed. The heart rates of 18 patients with surgically induced complete atrioventricular dissociation have been successfully managed by the method described with an important reduction in the mortality associated with this complication of open heart surgery.

Anomalous Muscle Bundle of the Right Ventricle Hemodynamic Consequences and Surgical Considerations

Seven examples of anomalous muscle bundles of the right ventricle have been presented. In one patient having an associated ventricular septal defect, spaces between the anomalous muscle were confused surgically with the ventricular septal defect. In the remaining six cases, the anomalous muscle bundle caused obstruction within the right ventricular cavity. Five of these patients had associated ventricular septal defect, with a clinical picture resembling that of the cyanotic or acyanotic tetralogy of Fallot. The cases served to demonstrate that the surgeon who exposes the right ventricle to relieve an obstructive lesion in the right ventricular infundibulum or in the pulmonary valve, may find no such lesions in these locations but instead may be dealing with an obstruction more proximal than these areas. Relief of the obstruction within the right ventricle may be attained by resecting the anomalous muscle mass. In one patient having intact ventricular septum and pulmonary valvular stenosis, an anomalous muscle bundle within the right ventricle which lay proximal to the infundibulum was responsible for persistent right ventricular obstruction after pulmonary valvotomy. Anomalous muscle bundles in the right ventricle may be suspected when, in the angiocardiogram, they cause filling defects within the right ventricle.

Surgical treatment of hypertension with reference to baropacing

Abstract Hypertension is a serious cardiovascular disorder. The most common forms of hypertension are those due to increased total peripheral resistance. Currently, two mechanisms are held responsible for increased total peripheral resistance; (1) salt and water retention and (2) neurogenic vasoconstriction. The latter constitutes a significant component of hypertension as may be judged by the effectiveness of sympatholytic drugs, ganglion-blocking agents and sympathectomy in reducing the vasoconstriction on a neurogenic basis. Baropacing attempts to achieve this result through restoring the baroreceptor function in hypertensive states towards normal, thus lowering the blood pressure. Baropacing might be considered a form of “total body physiologic sympathectomy.” The account of baropacing in the first two clinical cases is presented.