Dale G. Hall

Healing Basis and Surgical Techniques for Complete Revascularization of the Left Ventricle Using Only the Internal Mammary Arteries

Long-term follow-up data from several leading centers concerning patients undergoing coronary artery bypass clearly demonstrate the superiority of the internal mammary artery (IMA) with patency rates of 83 to 94% at 7 to 12 years compared with the saphenous vein and its patency rates of 41 to 53%. Our experimental studies provide a biological basis for understanding this difference. Thin-walled arterial autografts undergo no histological change after being implanted in the arterial system, while venous autografts undergo major changes with an initial scattered loss of endothelium and marked thickening due to a proliferative reaction. The challenge to the cardiac surgeon is to revascularize the entire left ventricle with the IMAs. We have found this possible in most patients with advanced three-vessel disease by using both IMAs either as in situ grafts or free grafts with as many sequential anastomoses as necessary to achieve full revascularization. Our use of the term in situ refers to the grafts origin from the subclavian artery as opposed to a free IMA graft arising from another site.

Transesophageal Echocardiography During Repair of Congenital Cardiac Defects: Identification of Residual Problems Necessitating Reoperation

One advantage of intraoperative transesophageal echocardiographic (TEE) evaluation during surgery for congenital heart disease is detection of suboptimal repairs, thus providing the opportunity to return to cardiopulmonary bypass (CPB) to repair residual defects. The purpose of this study was to evaluate the impact of TEE on decisions to return to CPB. Two-hundred-thirty infants and children with a variety of defects were studied with size-appropriate TEE probes. Patients were grouped by anatomic defect or surgical procedure for which TEE was requested. After CPB, pre- and post-CPB TEE anatomic, functional, and flow evaluations were compared. TEE findings prompted a return to CPB to repair residual defects in 17 of 230 (7.4%) patients. By diagnosis, return to CPB occurred in 9 of 28 (32%) patients with left ventricular outflow tract obstruction, 5 of 78 (6.4%) patients with ventricular septal defect, 1 of 16 (6%) patients with switch-repaired transposition, 1 of 32 (3%) with aortic valve disease, and 1 of 3 with double outlet right ventricle. All post-CPB diagnoses were confirmed during reoperation. Although post-CPB TEE provided reassuring information in patients with other diagnoses, TEE impact on return to CPB appears to be significant in a small group of primary diagnoses. The sensitivity and specificity of TEE determination of the need for reoperation were 89% and 100%, respectively. By identifying the site, severity, and mechanism of residual problems, TEE offers substantial utility in detection of residual problems in need of reoperation.

Axillofemoral bypass: A critical reappraisal of its role in the management of aortoiliac occlusive disease

Two hundred twenty-four consecutive patients (361 graft limbs) who underwent bypass grafting with the USCI Sauvage filamentous velour Dacron arterial prosthesis for aortoiliac occlusive disease over the 9 year period 1970 to 1979 are reviewed. Eighty-four axillofemoral (23 percent of patients), 210 aortofemoral (47 percent of patients), and 67 femorofemoral grafts (30 percent of patients) had cumulative patency rates of 72.1, 91.1, and 86.4 percent, respectively. Experimental and clinical factors influencing the patency of axillofemoral grafts are discussed, and the concept of an improved porous Dacron prosthesis specific for the axillofemoral site is presented.

Pneumopericardium and pneumomediastinum in infants and children

Abstract The increasing use of continuous positive airway pressure (CPAP), and positive end-expiratory pressure (PEEP) in the treatment of pulmonary insufficiency is associated with an increased frequency of pneumothorax, pneumomediastinum, and pneumopericardium in children. While the clinical implications and treatment of pneumothorax are well documented, the treatment of pneumomediastinum and pneumopericardium in the presence of continuing elevated airway pressures is not. In the presence of continuing positive-pressure ventilation in the newborn compression of the heart and great veins, sudden bradycardia, and loss of blood pressure lead to a fatal outcome unless the pericardium is decompressed. In older patients, routine palpation for subcutaneous emphysema aids in early diagnosis. When positive-pressure ventilation is needed to sustain life, early measures to decompress the trapped air are necessary.

A Five-to Seven-Year Experience with Externally-Supported Dacron Prostheses in Axillofemoral and Femoropopliteal Bypass

We have examined the clinical results of 56 externally-supported (EXS) Dacron grafts in the axillofemoral position and 117 in the femoropopliteal position. Results have been analyzed from two perspectives: primary patency concerns only those grafts that had never occluded; extended patency refers to all open grafts including those whose continued patency is the result of thrombectomy. The 5-to 7-year life-table patency rates are: axillofemoral 8 mm and 6 mm bypass: primary 75% and extended 97%; above-knee femoropopliteal 6 mm bypass: primary 78% and extended 93%; below-knee 6 mm femoropopliteal bypass: primary 41% and extended 91%. In contrast, the results for the 5 mm grafts used for femoropopliteal bypass were inferior to the 6 mm grafts: femoropopliteal 5 mm bypasses had an above-knee primary patency rate of 44% and an extended rate of 55%, with a below-knee primary patency rate of 15% and an extended rate of 32%. Rendering the noncrimped porous Dacron prosthesis kink and compression resistant by an external support coil appears to increase its potential for successful use, especially in 8 mm axillofemoral and 6 mm femoropopliteal bypasses.

Needle localization for thoracoscopic resection of small pulmonary nodules in children

BACKGROUND Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules. METHODS Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected. RESULTS Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications. CONCLUSION CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

Position of rectal fistula in relation to the hymen in 46 girls with imperforate anus

Forty-six records of infant girls with so-called imperforate anus have been reviewed to determine the position of the rectal opening in relation to the hymen. Eight of these children proved to have the cloacal deformity, in which the rectum enters high into a single tube and just behind the opening of a double or septate vagina, with the urethra entering anteriorly at the same level. No normal hymen was visible in these eight children. Seventeen patients had a normal-appearing hymen, and no rectal opening on the perineum. In each of these 17 children the rectal opening was found above the tissue flap overlying the posterior vestibule. In the remaining 21 patients, the hymen was visible and appeared normal, and there was a rectal opening somewhere on the perineum between the vestibule and the normal position for the external sphincters. These findings suggest that in the presence of a normal-appearing hymen, and in the absence of a normal anus, the rectal opening will be either in the posterior part of the vestibule or on the perineum. Where no hymen was visible, we have found in a limited experience that the rectal opening was high in the pelvis in some degree of the so-called cloacal deformity.

Left Ventricular Outflow Tract Obstruction: An Indication for Intraoperative Transesophageal Echocardiography

Transesophageal echocardiography (TEE) provides detailed anatomic imaging of both discrete and complex forms of left ventricular outflow tract (LVOT) obstruction, and Doppler techniques provide additional information regarding the site, mechanism, and severity of the obstruction. Because the transaortic surgical approach to LVOT obstruction often provides limited direct visualization during surgery, we sought to evaluate the utility of intraoperative TEE during surgery for LVOT obstruction. We tested the hypotheses that intraoperative TEE would (1) be useful in defining the level and nature of LVOT obstruction, (2) serve to direct the surgical approach, (3) define the adequacy of relief of LVOT obstruction, and (4) detect surgical complications. Study population consisted of a consecutive series of 27 infants and children undergoing surgery for LVOT obstruction. Patient age ranged from 0.5 to 17.9 years, and weight from 5.4 to 71.2 kg. In 14 patients LVOT obstruction resulted from a discrete membrane, whereas 13 had complex forms of LVOT obstruction. Fully anesthetized and monitored patients were examined with 5 MHz TEE probes appropriate to the size of the patient. In the 14 patients with discrete LVOT obstruction, discrete membranes were identified by TEE in all; gradients ranged from 36 to 75 mm Hg. In 13 of 14 patients, postbypass TEE demonstrated removal of the membrane and excellent relief of gradients. In one of these patients, TEE demonstrated a small ventricular septal defect acquired during resection; the patient was returned to bypass for closure. In one patient, return to bypass for further resection of LVOT obstruction was prompted by TEE demonstration of a high residual gradient. In the 13 patients with complex LVOT obstruction, TEE demonstrated the complexity of LVOT obstruction in all. Gradients ranged from 4 to 95 mm Hg. Although this information was used in surgical planning, five patients had high residual gradients after bypass and underwent further resection. An additional two were returned to bypass for mitral valve replacement. Overall, 8 of 27 patients (29.6%) were returned to bypass based on TEE demonstration of residual anatomic or hemodynamic abnormalities. This occurred significantly more frequently in complex LVOT obstruction than in discrete LVOT obstruction (p = 0.045). We conclude that intraoperative TEE has substantial utility in the demonstration of site, mechanism, and severity of LVOT obstruction and for surgery designed to relieve LVOT obstruction. We believe that TEE should be an integral part of surgical management of LVOT obstruction.

Intraoperative transesophageal echocardiography of coronary artery fistulas.

Coronary artery fistula is a rare abnormality but one with substantial surgical importance, as operation abolishes the fistulous shunt volume, progressive coronary dilatation, and potential coronary steal. Prior reports emphasize the utility of direct inspection on cardiopulmonary bypass, with visualization of drainage of blood or cardioplegia from the fistulous connection, to define the drainage site. We report 3 patients in whom intraoperative transesophageal echocardiography was used for precise localization of the fistulous drainage site, selective demonstration of vessels feeding the fistulas, and documentation of abolition of fistulous flow, all without need for cardiopulmonary bypass. In addition, the technique provides for continuous monitoring of ventricular function, providing the opportunity to detect inadvertent ischemic effects of ligation. This approach appears to have considerable utility.

Surgical treatment of esophageal stricture secondary to gastroesophageal reflux

Of 180 patients, 115 evaluated for gastroesophageal reflux (GER) over a 4-yr period were found to be positive. Fourteen patients, ages 3 mo to 15 yr, presented with symptoms of esophageal stricture. Seven patients had a history of previous repair of esophageal atresia (EA). GER was diagnosed variously by barium swallow, radionuclide gastroesophagography, acid reflux test, and endoscopy with biopsy. The stricture may have acted as a barrier and altered the diagnosis of GER higher in the esophagus. Esophageal manometric were performed in 11 of the 14, and were uniformly abnormal. When the diagnosis of persistent esophageal stricture in association with GER was apparent, intraoperative esophageal dilatation and antireflux surgery with intraoperative manometrics were carried out in 13 patients. There was no operative mortality. In 10 of the 13 patients clinical resolution of the stricture was confirmed by barium swallow or esophagoscopy. The remaining 3 patients with stable dense fibrous strictures from long-standing GER, still requie dilatations. Stricture resolution occurred in 9 patients without the need for postoperative dilatations, including 5 with previously repaired EA. There was 1 esophageal perforation and 1 disrupted fundoplication, both of which responded to surgery. Esophageal stricture may be a result of insidious GER. Early diagnosis and surgical correction of GER, aided by esophageal manometrics, will result in healing of esophagitis and rapid resolution of strictures in the majority of patients. Long-standing strictures may require persistent dilatation. Esophageal resection and substitution should be required infrequently.