David O. Monson

Extended aortic valvuloplasty for recurrent valvular stenosis and regurgitation in children.

Recurrent significant aortic valvular stenosis or regurgitation, or both, after balloon or open valvotomy in pediatric patients often necessitates aortic valve replacement. In an attempt to preserve the aortic valve, we performed extended aortic valvuloplasty in 21 children with recurrent aortic valve stenosis or regurgitation from January 1989 to March 1993. Previous related procedures were one open aortic valvotomy or more (n = 15), balloon valvotomy (n = 4), balloon valvotomy after surgical valvotomy (n = 1), and repair of iatrogenic valve tear (n = 1). Mean age at the time of the extended aortic valvuloplasty was 6 +/- 3.4 years. Mean pressure gradient across the aortic valve was 56 +/- 12 torr. Regurgitation was moderate (grade 2 to 3) in nine and severe (grade 4) in 12 patients. Extended aortic valvuloplasty techniques consisted of thinning of valve leaflets (n = 15), augmentation of scarred and retracted leaflets with autologous pericardium (n = 11), resuspension of the augmented leaflet (n = 14), release of the rudimentary commissure from the aortic wall (n = 5), extension of the valvotomy incision into the aortic wall on both sides of the commissure (n = 20), patch repair of the sinus of Valsalva perforation (n = 1), reapproximation of tears (n = 5), and narrowing of the ventriculoaortic junction (n = 2). No operative deaths occurred. The postoperative mean pressure gradient, assessed by most recent Doppler echocardiography or cardiac catheterization at a follow-up of 18 +/- 6 months, was 19 +/- 6 torr (p < 0.01 versus the preoperative gradient). Aortic regurgitation was absent in 13, mild in 6, and moderate-to-severe, necessitating subsequent aortic valve replacement, in 2. This short-term experience indicates that extended aortic valvuloplasty is a safe and effective surgical approach that minimizes the need for aortic valve replacement in children with significant recurrent aortic valve stenosis or regurgitation.

Inferior vena cava interruption with the hunter-sessions balloon: Eighteen years' experience in 191 cases***

Over a period of 18 years, 191 consecutive patients had interruption of the inferior vena cava with the Hunter-Sessions balloon for complications of deep venous thrombosis and pulmonary embolism. Causes of deep venous thrombosis and pulmonary embolism included the postoperative state (33%), cancer (32%), and stroke (11%). There were 93 females and 98 males; ages ranged from 17 to 90 years (average, 57 years). Indications for placement of the Hunter-Sessions balloon were as follows: contraindication to anticoagulants (33%), anticoagulant complications (24%), pulmonary embolism despite anticoagulants (45%), and others including inferior vena cava thrombus (12%). Sixty-eight percent had clinical phlebitis and 36% had positive venography results. Pulmonary embolism had occurred in 165 patients (86%). It was diagnosed by ventilation-perfusion scanning (75%), angiography (23%), or on clinical grounds (2%) in patients with confirmed deep venous thrombosis. At the time of the procedure 52% were in significant cardiopulmonary distress, and 10% were intubated and on respirators. Transjugular placement was done in 188 patients, and transfemoral placement was performed in three. All All tolerated inferior vena cava interruption. Thirty patients (15%) died while in the hospital an average of 21 days after balloon placement, which was unrelated to the deaths. Follow-up was 45 months. Ninety-four patients are dead, 95 are alive, and the status of two patients is unknown. Twenty-nine of 64 patients (45%) who died after they left the hospital died of cancer. At last follow-up, 75% of patients had legs free of edema and 25% had need for elastic stockings. No malfunction or migration has occurred with the device. No patient had a pulmonary embolism while in the hospital after insertion of the Hunter-Sessions balloon, and no patient died of pulmonary embolism. Late minor pulmonary embolism occurred in three patients.

Flexible Fiberoptic Bronchoscopy

Abstract The flexible fiberoptic bronchoscope has become an invaluable diagnostic and therapeutic instrument in the management of pulmonary disease. Advantages over the conventional rigid bronchoscope include airway examination to the subsegmental level, increased accuracy of diagnosis in pulmonary malignancy, patient comfort, ease of bedside examination, and atraumatic aspiration of postoperative secretions. Disadvantages include cost, inability to remove foreign bodies, and lack of a satisfactory technique for infant endoscopy. The extended range of diagnostic and therapeutic capabilities of the flexible bronchoscope makes it an important instrument for the thoracic surgeon.

Intratracheal insufflation combined with intermittent positive pressure ventilation for treatment of terminal respiratory failure in a child: a new technique.

I NTERMITTENT positive-pressure ventilation (IPPV) mimics spontaneous breathing in providing a large tidal volume at a slow respiratory rate.’ This method of convection flow ventilation has been a valuable technique for respiratory support during anesthesia and for treatment of respiratory failure. The addition of positive end-expiratory pressure (PEEP) to IPPV has been shown to improve gas exchange in patients with moderate and severe respiratory failure, despite alterations of cardiovascular and renal function.2-4 In 1971, Jonzon et al demonstrated that the use of a small tidal volume at a high respiratory rate can provide adequate gas exchange by a combination of convective flow and facilitation of gas diffusion.’ This technique of high-frequency ventilation (HFV) was also shown to improve gas exchange in patients with respiratory failure and has been valuable in patients with a bronchopleural fistula.637 Therapy with IPPV-PEEP and HFV in a child with severe respiratory failure was associated with complications, and death was imminent as a result of progressive hypoxemia. Therefore, a new technique for respiratory support was developed. A combination of continuous intratracheal insufflation (TI) and IPPV was used to provide convective-diffusion ventilation. This clinical report shows the gas exchange achieved with the use of TI-IPPV for a period of 14 days in a child with severe respiratory failure.

Coarctation of the Aorta: Four Unusual Instances

Four unusual instances of coarctation of the aorta are presented. Three coarctations were located proximal to the left subclavian artery, and the other was in the normal location with a patent ductus arteriosus and an anomalous distal right subclavian artery. Unusual coarctations can be identified on physical examination on the basis of variations of blood pressure and pulses in the upper extremities. Unilateral rib notching may be noted on chest roentgenogram, and an aortogram can delineate its exact location. Four separate means of surgical repair are described.

Bilateral carotid endarterectomy: impact of staging on early results

Successive bilateral carotid endarterectomies were performed in 323 pa tients ; 193 (60%) had both sides operated on within fourteen days during the same hospitalization (Group I), and 130 (40%) were discharged after the first operation and readmitted for contralateral carotid endarterectomy more than two weeks later (Group II). High-risk patients who were older and sicker com prised the majority in Group II. Otherwise no attempt had been made to be selective based on preconceived criteria. There were 4 deaths (2.1 %) in Group I, and 1 death (0.7%) in Group II. Permanent neurologic complications occurred in 10 (5.2%) Group I patients and 8 (6.1%) Group II patients. Transient neuro logic complications were found in 8 (4.1%) of patients in Group I and 14 (10.8%) in Group II. No patients in Group II suffered any neurologic compro mise because of the waiting period between operations. A history of hyperten sion or previous cerebral infarction was found to place patients at increased risk for the development of permanent neurologic complications. Postoperative hy pertension after the second endarterectomy was greater in Group I than in Group II patients. Observations from this retrospective review support the concept that staging of bilateral carotid endarterectomies in two hospitalizations allows elderly, sicker patients to be operated on as safely as younger, otherwise healthy individ uals. The indications for staging bilateral carotid endarterectomies in separate hospitalizations should be liberalized in order to minimize complications.

Prevention of Air Embolism after Mitral Valve Replacement with a Porcine Heterograft Prosthesis

The production of prosthetic valve incompetence during atriotomy closure is among the operative maneuvers utilized to prevent air embolism in mitral valve replacement. The leaflets of a porcine bioprosthesis may be retracted safely and effectively, thereby producing temporary valve incompetence, by placing three polypropylene sutures through the valve orifice and around the sewing ring to encircle the leaflets. These traction sutures are eaily pulled out through the atriotomy suture line after all air has been displaced from the heart. The technique has been effective, easily accomplished, and without complications.