Dwight C. Mcgoon

Clinical, angiographic, and hemodynamic assessment of late results after Mustard operation.

SUMMARYSince 1974, late results of the Mustard procedure for correcting complete transposition of the great arteries have been evaluated by cardiac catheterization, electrocardiography, roentgenography, history, and physical examination of 48 Mayo Clinic patients. Of these, 15 were studied I month to 2 years postoperatively because of clinical deterioration. The other 33 had been asymptomatic but were asked to return for hemodynamic reevaluation one-half to 1I years postoperatively. Of the asymptomatic group, 19 underwent exercise electrocardiography prior to catheterization and eight performed supine exercise during catheterization. Cardiac catheterization proved the most effective mode of study.Significant cardiovascular abnormalities (caval obstruction, residual pulmonary stenosis, etc.) were found in 35 of the 47 patients -including 20 of the 33 who were asymptomatic. Eight of the symptomatic group and three of the others have died since this restudy. These poor results warrant renewed effort to devise better methods for correcting complete transposition.

Absence of Anatomic Origin from Heart of Pulmonary Arterial Supply

Among certain patients with cardiovascular malformations, a common phenomenon is a ventricular septal defect and absence of anatomic origin of the pulmonary arterial supply from the heart. In this situation, true pulmonary arteries may be present or absent. In the latter case, the pulmonary arterial supply comes through bronchial arteries. When true pulmonary arteries are present, the left and right pulmonary arteries either may be in continuity at their origins (confluence) or they may arise from separate sites (nonconfluence).When confluence is present, the two pulmonary arteries may arise either from an atretic pulmonary trunk or from certain forms of persistent truncus arteriosus. Pulmonary atresia may be localized to the proximal end of the pulmonary trunk or diffuse in this vessel. When nonconfluence is present, each pulmonary artery arises separately from one of three possible sources as follows: (1) a form of persistent truncus arteriosus, (2) through ducti arteriosi from the aortic arch system, or (3) through bronchial arteries from the descending aorta.

Aortic Sinus Fistula—Surgical Considerations and Results of Operation

Abstract From 1956 to 1971, 21 Mayo Clinic patients underwent surgical correction of aortic sinus fistula. The 12 male and 9 female patients were from 3 to 52 years old (median 27 years). In 16 patients the right aortic sinus had ruptured into the right ventricle, and in 1, into the right atrium; in 4 patients a noncoronary sinus fistula communicated with the right atrium. The appearance of 4 fistulas was related to trauma, but all 21 fistulas were basically congenital in origin. Associated lesions were common; 15 patients had one or more of the following: ventricular septal defect (VSD) (14 patients), aortic insufficiency (7 patients), and pulmonary stenosis (3 patients). All patients survived operation. Three required reoperation: 1 for closure of a recurrent VSD (deterioration of an Ivalon sponge patch), 1 for recurrence of the fistula and VSD, and 1 to replace a malfunctioning Teflon cusp with a prosthetic valve. Follow-up has been carried out for as long as fourteen years (median seven years) after operation. One patient has moderate aortic insufficiency but remains well compensated; the remaining patients are free of symptoms and clinical signs of cardiac dysfunction. Currently, an aortic sinus fistula should be repaired when it is diagnosed because the disability is progressive, operative risk is negligible, and long-term results are excellent.

Atrial Septal Defect: Factors Affecting the Surgical Mortality Rate

Analysis of accumulated experience with the repair of atrial septal defect in 119 adults has revealed several factors determinable preoperatively that appear to have a strong influence on the operative risk. These factors are related to the presence of pulmonary vascular disease or heart failure and contribute importantly to the selection of patients for operation.

Pulmonic Stenosis with Intact Ventricular Septum

Pulmonic stenosis unassociated with a ventricular septal defect of significant size is often a complex abnormality. The stenosis may be valvular, infundibular, or both, and may be associated with an atrial septal defect or even with a small ventricular septal defect. Preoperative studies cannot accurately predict these variations. The surgical approach selected for such patients should permit the correction of each of the cardiac defects encountered. That this can be accomplished by means of extracorporeal circulation and open cardiotomy is demonstrated by the presented series of 10 cases without operative mortality.

Tetralogy of Fallot with Anomalous Tricuspid Valve Simulating Pulmonary Stenosis with Intact Septum

An anatomicopathologic entity of the tetralogy of Fallot with an additional finding of an accessory flap of tricuspid valvular tissue is described. In the 3 cases reported in this paper, the outstanding hemodynamic finding was a right ventricular systolic pressure that was significantly greater than the systemic systolic pressure. The hemodynamic findings were explained by the fact that the accessory tricuspid flap partially closed the large ventricular septal defect. The clinical picture was similar to that of either severe pulmonary stenosis with an intact ventricular septum or severe pulmonary stenosis with a small ventricular septal defect and a right-to-left shunt at the ventricular level.

Double-Outlet Right Ventricle with Pulmonic Stenosis: Surgical Considerations and Results of Operation

The results of complete repair of double-outlet right ventricle with pulmonic stenosis in 22 Mayo Clinic patients were analyzed. The overall mortality rate was 32%. Since 1960, the mortality rate has been reduced to 16%. Anomalies of the distribution of the right coronary artery, a second ventricular septal defect of the atrioventricular canal type, and significant residual pulmonic stenosis were associated with a higher mortality rate. The difficulties in the diagnosis of this uncommon condition are emphasized.Complete repair is best carried out after the patient is 4 years old. A systemic-to-pulmonary arterial shunt is the procedure of choice for those who are younger than this. In the occasional patient with anomalous distribution of the right coronary artery which precludes adequate relief of the pulmonic stenosis, use of an aortic homograft from the right ventricle to the pulmonary artery should be considered.

Total Correction of Ventricular Septal Defect in Infancy Using Extracorporeal Circulation: Surgical Considerations and Results of Operation

Abstract Between 1955 and 1970, 143 Mayo Clinic patients less than 2 years old (78 boys and 65 girls; ages 10 weeks to 24 months, median age 14 months) underwent total correction of a ventricular septal defect using extracorporeal circulation. The distribution of associated lesions was as follows: 66% had no other lesions, 11% had an atrial septal defect, 9% had pulmonary stenosis, 8% had a patent ductus arteriosus, and 6% had other lesions. Two patients were asymptomatic; clinical features in the remainder included congestive heart failure (76%), failure to thrive (55%), and repeated respiratory infections (32%). Operative mortality was inversely related to age and weight. Neither of the asymptomatic patients died. The overall mortality was 21% for the entire interval; for the most recent five-year period, the rate was 10% (22% for infants less than 12 months and 0% for those 12 to 24 months). These data compare favorably with our previous experience and that of others for palliative pulmonary artery banding in infancy followed by correction at a later age, and they support our current approach of closure of the ventricular septal defect using extracorporeal circulation in almost all infants who require surgical aid.

Truncus arteriosus with unilateral absence of a pulmonary artery. Criteria for operability and surgical results.

In 15 of 126 (12%) patients with truncus arteriosus who were catheterized at the Mayo Clinic from 1967 through 1975, natural agenesis of one pulmonary artery was present. Ten truncus patients with either natural or acquired absence of one pulmonary artery have undergone definitive operation. The criteria for operability, based on a calculation of pulmonary resistance, are different in patients with single pulmonary artery than in patients with two pulmonary arteries. Study revealed that, if the calculated pulmonary resistance in the patient with single pulmonary artery is halved, this new value provides a more reliable assessment of the reactivity of the pulmonary arteriolar bed than does the total calculated pulmonary resistance value. Follow-up information suggests that the patient with single pulmonary artery may be at potentially high risk of continued progression of pulmonary vascular disease after surgical correction, possibly because of the postoperative obligatory increased flow through the single pulmonary arteriolar bed as a result of the entire cardiac output passing through it. Surgical correction of truncus arteriosus during infancy, before significant pulmonary vascular disease has developed, appears to be particularly desirable in this subgroup of patients with single pulmonary artery.

Fate of outflow tract in tetralogy of Fallot.

Abstract Cardiac catheterization studies were performed in 37 selected patients with tetralogy of Fallot. In 25 patients the ratio of right ventricular to left ventricular systolic pressures (RV/LV ratio) decreased between completion of repair and restudy by a mean of 36% (range, 10 to 53%). In 4 patients the ratio was unchanged, and in 8 patients it increased by a mean of 33% (range, 10 to 73%). Patients with patch graft reconstruction of the outflow tract showed significantly less likelihood (p = 0.02) of a late increase in RV/LV ratio than patients without a patch graft. A greater late decrease in RV/LV ratio occurred in patients who had good immediate relief of outflow tract obstruction. The most common site of outflow tract obstruction at restudy was the pulmonary valve and valve ring. Stenosis of the pulmonary valve recurred in 5 patients despite the fact that a patch traversed the valve ring in 2 of them.