Don C. Wukasch

Ischemic contracture of the heart: “Stone heart”

Open heart surgery using cardiopulmonary bypass has enjoyed an exciting 15 year history during which many technical modifications were made and baffling complications encountered. For the past 8 years we have routinely employed a simplified technique using simple intravenous solutions to “prime” the extracorporeal circuit, maintained the patient and his heart at normothermic levels and induced ischemic cardiac arrest to control or prevent myocardial injury during the period of bypass.1,2 Periods of induced ischemia have been tolerated by some patients for more than 2 hours without apparent myocardial damage. However, we have seen a relatively small number of patients who died in the operating room from an unusual type of myocardial failure. Rather than the poorly contracting, overdistended ventricle of myocardial failure, a small spastic heart, literally frozen in systole, develops. The ventricular chamber is decreased notably in volume because of the contracture, and even vigorous manual massage does not produce an adequate stroke volume. Changes in peripheral resistance, cardiotonic agents, electrolyte solutions, adrenergic. blocking and stimulating agents and assist devices have not altered its inevitable course. On palpation the heart is in a contracted state similar to the uterine contraction ring or the tetanic contraction of striated muscle as seen in the laboratory. This characteristic state is recognized readily at the time of surgery. Ultimately, cardiopulmonary bypass cannot be discontinued without the patient dying because of the maintained contractile state. We have named this irreversibly contracted ventricle the “stone heart.” Fortunately, the stone heart is rare. Of the 4,732 patients (1,407 for congenital lesions and 3,325 for acquired) who have undergone open heart surgery at the Texas Heart Institute during the 5 years from July 1966 to July 19’71, 51 patients (1 percent) died during operation from acute myocardial insufficiency. Of that group, less than a third (13 patients) experienced severe contracture of the heart and the criterion we recognize as stone heart. We have reviewed the clinical and patho-

Ascending Aorta-Abdominal Aorta Bypass: Indications, Technique, and Report of 12 Patients

Use of the supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation.

Coronary Artery Bypass

Aortocoronary saphenous vein bypass (CAB) has become the preferred technique for myocardial revascularization in patients with ischemic heart disease (1–4). Evaluation of the results of CAB is essential for comparison with the accumulated knowledge of the natural course of coronary heart disease and for improvement of patient selection.

Sinus Venosus Atrial Septal Defect: Early and Late Results Following Closure in 109 Patients

The clinical course of 109 patients who underwent closure of a sinus venosus atrial septal defect is reviewed, with emphasis on the incidence, type, and severity of arrhythmias before and after operation. There were no operative deaths and only 1 late death. No instances of obstruction of the superior vena cava were detected clinically. One patient had a probable hemorrhagic pulmonary infarction that cleared; another may have a persistent left-to-right shunt. Excellent results were achieved in 72% of the patients, good results in 5%, and poor results in 3%. The type of arrhythmia, both before and after operation, varied with the age of the patient: younger patients had bradyarrhythmias, and older patients had tachyarrhythmias. Ten patients experienced persistent new arrhythmias postoperatively, but none were disabled, required a pacemaker, or died. The arrhythmias in all severely symptomatic patients were supraventricular tachycardias that had occurred before operation. Although functional classification after operation was clearly related to age at the time of the procedure (with younger patients having the best functional results), 19 of 21 patients over age 40 were noticeably improved after surgical closure of the sinus venosus atrial septal defect.

Aneurysm and fistula of the sinus of Valsalva. Clinical considerations and surgical treatment in 45 patients.

Aneurysms and fistulas of the sinus of Valsalva, although rare, present a challenging surgical problem. Forty-five patients with this lesion have undergone operative treatment during the last 17 years. The series includes 32 male and 13 female patients ranging in age from 2 to 68 years with a mean age of 35.3 years. Only 1 early death occurred in the series, a hospital mortality of 2.2%. Diagnosis of the aneurysm was made preoperatively in 30 patients and discovered at operation 15. The lesion involved the right coronary sinus in 28 patients, the noncoronary sinus in 19, and the left coronary sinus in 5. The aneurysm had not ruptured in 22 patients and had formed a fistulous communication between the right coronary sinus and the right ventricle in 13. Acute rupture occurred in 10 patients (22.2%). Long-term follow-up data were obtained in 38 patients after 1 to 15 years. Late mortality is low. A nonruptured aneurysm of the sinus of Valsalva should be managed conservatively when it occurs as an isolated lesion. Our experience supports the concept that perforated aneurysms and fistulas of the sinus of Valsalva, even if asymptomatic, should be treated operatively.

Diffuse muscular subaortic stenosis: Surgical treatment

Abstract Diffuse muscular subaortic stenosis results from impingement of the hypertrophied interventricular septum upon the mitral valve during systole. Mitral valve replacement was used as definitive treatment of this condition in 9 patients, all of whom had associated mitral insufficiency of mild to moderate hemodynamic significance. Relief of outflow obstruction was accomplished in all patients, although 2 died from complications not related directly to the type of operation. On the basis of these observations, mitral valve replacement should be considered the surgical procedure of choice in patients with advanced hypertrophie stenosis. Three stages are described on the basis of clinical and hemodynamic findings, and appropriate medical and surgical treatment is suggested. The name mitrogenic subaortic stenosis is proposed for this cardiac disease.

Aortocoronary saphenous vein bypass. Results in 1,492 patients, with particular reference to patients with complicating features.

Abstract During a 33-month period ending June, 1972, 1,492 patients underwent aortocoronary saphenous vein bypass (ACB). The early mortality with ACB alone was 7.1%, while mortality was more than double (14 of 86 patients died) when ACB was combined with resection or plication of a ventricular aneurysm. Twenty of 84 patients died in the early period following combined ACB and valve resection. One patient among 8 who had concomitant resection of an ascending aortic aneurysm died after operation. Factors that increased mortality in this series were advanced age, female sex, high coronary artery scores, left main coronary artery lesions, high left ventricular end-diastolic pressure, left ventricular dysfunction, congestive heart failure, the requirement for endarterectomy to perform the anastomosis, and recent acute myocardial infarction. Actuarial data from patients who underwent ACB without concomitant procedures show an annual attrition rate of 2.7% per year, which compares to rates of 4, 6, and 10% for patients with single, double, and triple coronary disease treated without operation. In 311 men and women under the age of 70 who had a coronary artery score below 13 and none of the other risk factors, the early mortality was 1.6% (5 patients) and the late mortality was 1.0% (3 patients).

Total anomalous pulmonary venous return. Review of 125 patients treated surgically.

One hundred twenty-five patients undergoing surgical correction of total anomalous pulmonary venous return were studied. The overall mortality was 37% and was related to age at the time operation was required. Mortality was 57% during the first year of life, 29% in patients between 13 and 24 months, and 15% in those between 2 and 10 years; no deaths occurred in those over 10 years. Mortality was highest in patients with infracardiac lesions (62%), and lowest in those with cardiac defects (30%). The major cause of death was pulmonary edema, and survival was closely related to the degree of increased pulmonary vascular resistance. Surgical treatment should be delayed until at least 6 months of age, but the development of congestive heart failure may necessitate earlier operation.

Ruptured abdominal aortic aneurysm: Treatment and review of eighty-seven patients

Abstract Between 1954 and 1973 at the Texas Heart Institute, eighty-seven patients underwent operation for resection of ruptured abdominal aortic aneurysms. Included in this series were eighty-one men and six women who ranged in age from forty-four to eighty-four years. Hospital mortality, including intra- and postoperative mortality (within thirty days of operation), was 21 per cent. Mortality for men was 19.8 per cent and for women, 33.3 per cent. The lower mortality indicates that abdominal aortic aneurysms should be excised electively. When rupture does occur, aggressive surgical treatment can produce gratifying results.

Myocardial cell damage in “stone hearts”

Abstract The “stone heart” syndrome is a rare pattern of irreversible cardiac arrest in systole during or immediately after total cardiopulmonary bypass. In 13 cases reported a marked left ventricular hypertrophy with conduction disturbances was present in all, and generally a high pressure gradient across a stenotic aortic valve was present. The main histologic finding was a widespread degenerative process of the myofibrils in hyper-contracted cardiac muscle fibers, with anomalous acidophilic, transverse band formations and subsequent loss of the alloplasmic material. The result is a myocytolytic myocardial necrosis which is seen in a variety of both human and experimental conditions, especially in catecholamine-induced necrosis. Hypothermia has been successfully used to reduce the incidence of “stone heart” and more recently a beta-adrenergic receptor blocking agent has been effectively used.