Earle B. Mahoney

Echocardiographic Recognition of the Congenital Bicuspid Aortic Valve

Twenty-one patients (age four to 25 years) with bicuspid aortic valves proved by surgery and angiography (12) or angiography alone (9) were studied by echocardiography. Seventeen patients had aortic valve disease (11 stenosis, 6 incompetence) and four had coarctation of the aorta with normally functioning aortic valves. A comparison group of 16 patients (9 with aortic valve disease and 7 without aortic valve disease) who had proven tricuspid aortic valves was also studied. Echocardiograms in tricuspid aortic valve patients showed the closed position of the cusps near the middle of the aortic lumen. In contrast marked eccentricity of the aortic valve cusp echoes in diastole could be demonstrated in all with bicuspid aortic valves. The Eccentricity Index (½ aortic lumen diameter/minimum distance of the diastolic cusp echo from the nearest aortic margin) was low (range 1.0-1.25) with tricuspid aortic valves and high (range 1.5-5.6) with bicuspid aortic valves (P < 0.001). This index was not significantly affected following successful valvotomy. Bicuspid aortic valve cusps showed normal systolic motion pattern resulting in marked asymmetry of leaflet images. About half of patients with bicuspid aortic valves also showed multilayered echoes in diastole in the absence of fluoroscopic evidence of valvular calcification. Echocardiography appears to be specific in the recognition of the bicuspid aortic valve.

Long-term survival following aortic valve replacement

Study was made of 95 survivors of aortic valve replacement during the early years of this procedure (1964 to 1970). The average follow-up time was 50.2 months. Survival was not related to hemodynamic parameters, such as cardiac index or left ventricular pressure, and did not appear to be influenced by the type of preoperative valve lesion. A history of angina pectoris and a New York Heart Association Class IV grouping were associated with shorter survival. Associated coronary artery disease was a leading cause of death in those patients surviving less than 2 years and angina pectoris the leading cause of morbidity in the long-term survivors. Sudden death occurred in five patients. Once a patient survived 36 months after the operation, the prognosis was excellent.

Right atrial myxoma

Abstract Two cases of right atrial myxoma are presented, together with a review of 16 other published cases. The clinical course of these patients is characterized by progressive right heart failure, usually refractory to medical therapy, without evidence of underlying pulmonary disease or left heart failure. A low-pitched diastolic murmur along the lower left sternal border is the most characteristic ausculatory finding. Right atrial hypertension and a diastolic gradient across the tricuspid valve are consistent findings at cardiac catheterization. Angiocardiography is the definitive diagnostic method for establishing the diagnosis of right atrial myxoma, and a characteristic filling defect is noted in every reported case. Since cure may be obtained by utilizing open-heart surgery with cardiopulmonary bypass, an early and accurate preoperative diagnosis is of great importance.

Surgical Treatment of Traumatic Rupture of the Normal Aortic Valve

Abstract The histories of 2 patients who had successful repair of traumatic injury to the aortic valve are reported, and the literature is reviewed. Various types of injury cause this lesion, but violent compression of the chest with high intrathoracic pressure appears to be a common feature. Valvular injuries include avulsion of commissural attachments and tears of the leaflets. Patients present with chest pain and severe congestive heart failure, and an unusually musical murmur of aortic insufficiency is sometimes heard. Attempts at valvuloplasty have not been uniformly successful, and prosthetic valve replacement is recommended.

Right ventricular fibrosarcoma causing pulmonic stenosis

Abstract This report describes a fibrosarcoma of the right ventricle in a 19 year old girl who had rapid onset of severe right heart failure with clinical signs of pulmonic stenosis and tricuspid insufficiency. Electrocardiographic changes were consistent with right ventricular hypertrophy and right bundle branch block. Cardiac catheterization demonstrated findings consistent with pulmonary valvular and infundibular stenosis. Right ventricular angiocardiography demonstrated a filling defect caused by the tumor. Surgical removal of the tumor was followed by dramatic improvement. Four months after the operation she had recurrence of symptoms due to recurrence of the tumor. Radiation therapy produced only transient beneficial effects.

Echocardiographic Assessment of Left Ventricular Outflow Width in the Selection of Mitral Valve Prosthesis

Assessment of left ventricular outflow tract (LVO) width was made from preoperative mitral valve echocardiograms in 26 patients with pure or predominant mitral stenosis who later had valve replacement. LVO width was measured as the minimum space between the ventricular septal echo and the anterior mitral leaflet at beginning systole. Prosthesis encroachment on LVO (PE) was estimated by comparing the length of the poppet expected to protrude into the LVO in systole with LVO width determined by ultrasound (poppet length/LVO width × 100). Group 1 (12 patients) had normal LVO widths (≥20 mm) and received Starr-Edwards prostheses. There was one in-hospital death in this group. Group 2 (seven patients) had narrow LVO (<20 mm) and also received Starr-Edwards prostheses. Five patients died, four of them due to low cardiac output syndrome. Group 3 (seven patients) also had narrow LVO, but Cross-Jones disc prostheses were used. Only one died. The high mortality in Group 2 appears to be related to obstruction of LVO by the caged ball prosthesis; PE in this group ranged from 60% to 80% while it was less than 50% in all but two patients in Group 1. A low profile prosthesis appears desirable when the LVO width measures <20 mm by echocardiography.

The Effectiveness of Hypertonic Glucose in Resuscitation of the Hypothermic Heart Following Potassium Chloride Arrest

Cardiac arrest was produced by coronary perfusion of potassium chloride in hypothermic dogs during sinus rhythm and during ventricular fibrillation. Resuscitation of rhythmic beats was facilitated by injection of hypertonic glucose when the ventricles responded to a light tap (responsive phase).

Fate of Splinted Venous Homo- and Autografts in Thoracic Aorta of Dogs

1 Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York. At the turn of the century, Carrel (1) and Klotz, Permar, and Guthrie (2) presented evidence that fresh and preserved arterial and venous grafts could be used successfully to bridge arterial defects in experimental animals. Gross and his co-workers (3) rekindled interest in the use of arterial homografts and improved techniques for the procurement and storage of these grafts. Gross began using homografts in situations encountered in procedures for coarctation of the aorta and tetralogy of Fallot; he inserted his first homograft in a thoracic aorta in May, 1948 (3, 4). This work stimulated a great deal of clinical and laboratory investigation, resulting in a study of methods of storage (5, 6) and observation of the fate of various types of grafts (7-15). Aortic autografts retain the cellular structure of the host aorta and function