F. Henry Ellis

Surgical Relief of Diffuse Subvalvular Aortic Stenosis

Direct surgical relief of diffuse subvalvular aortic stenosis has been accomplished in two cases by open operation through a left ventriculotomy.

Ventricular Septal Defect with Aortic Valvular Incompetence Surgical Considerations

Nineteen patients with ventricular septal defect and severe aortic valvular incompetence have been operated on at the Mayo Clinic. There were two early deaths and two late deaths. The ventricular septal defect was located high and anteriorly in the septum and was often small. Aortic valvular incompetence was due, in most cases, to a deformed, prolapsing right coronary cusp. Mild to moderate degrees of infundibular pulmonary stenosis coexisted in nine patients.Repair of the ventricular septal defect was readily accomplished in most cases by direct suture, and relief of obstruction to right ventricular outflow was effected, when required, by resection of the crista supraventricularis. Repair of the aortic incompetence was attempted by a variety of means, but the incidence of persistent significant regurgitation was high, except when prosthetic cusp replacement was used.It is currently our policy to defer operation in children unless there are significant symptoms. When the patient is past the age of about 12 to 14 years, operation is advised under proper circumstances, and it consists generally of suturing of the ventricular septal defect and replacement of the right coronary cusp of the aortic valve.

Problems in the Diagnosis and Surgical Treatment of Pulmonic Stenosis with Intact Ventricular Septum

Obstruction to pulmonary blood flow may occur in the pulmonic valve, in the infundibulum or in both. Cardiac catheterization aids in the determination of the site of obstruction. Criteria for the differentiation at operation of valvular and infundibular pulmonic stenosis are enumerated, and the usefulness of accurate pressure tracings during operation is emphasized. The accurate identification of the site or sites of obstruction to pulmonary blood flow is essential to proper surgical management. A correctly selected operation must be carried out in as complete a manner as possible.

Anatomy of feline esophagus with special reference to its muscular wall and phrenoesophageal membrane.

Abstract The muscular wall of the esophagus and the hiatal anatomy of 13 cats were studied, with special reference to the amount of smooth muscle present and the phrenoesophageal membrane attachments. The lower esophageal wall of the cat has more smooth muscle than that of the dog, but less than that of the human. The distribution of myenteric plexi was more symmetric in the cat than in the dog or the human. The phrenoesophageal membrane of the cat differed from that of the dog or the human in that its descending limb was attached below the esophagogastric angle and its esophageal attachments were superficial.

Late Results of Operation for Acquired Aortic Valvular Disease

Of the 614 open-heart operations performed at the Mayo Clinic for acquired aortic valvular disease, 130 were performed on patients who also required repair of other valves. Review of the remaining 484 operations resulted in the following observations.Operation for acquired aortic valvular disease may now be accomplished with a hospital mortality rate of 4%. The incidence of late death and failure of patients to improve has averaged 44% for previously employed techniques of valvular repair. Failure of the valve or prosthesis to function properly was the most common cause of late failure after operations in which these earlier methods were used. In the 138 more recent cases, in which operations employing the aortic ball valve (Starr-Edwards prosthesis) were used, the incidence of late failure has been reduced to 14%, and failure of the prosthesis to function properly has not yet occurred in the absence of infection. Late bacterial endocarditis and thromboembolism were the most serious problems associated with use of the ball-valve prosthesis. In contrast with the late results of the former techniques, use of the ball valve has resulted in improvement for 79% of the patients; in the great majority of these there has been a dramatic return to normal living.Despite the highly satisfactory results of current methods, the fact that 14% of patients have already died after an initially successful operative result, and that another 12% have suffered complications causing their late result to be less than totally satisfactory, indicates that the policy of recommending for operation only those patients who have significant and progressive cardiac disability should be continued.

Results of Surgical Treatment for Congenital Aortic Stenosis

Open operation by means of extracorporeal circulation has been used on 47 patients with congenital aortic stenosis at the Mayo Clinic between April 1955 and July 1, 1960; 33 patients had valvular stenosis, 11 had subvalvular stenosis, and three had supravalvular stenosis. The over-all operative mortality rate was 13 per cent; 6 per cent of patients with valvular aortic stenosis died in the hospital. Severe aortic insufficiency did not develop in any patient operated on for valvular aortic stenosis although a diastolic murmur was present after operation in some. Rarely, however, was the transvalvular gradient completely eliminated by operation although 90 per cent of the surviving patients were either asymptomatic or had definite clinical improvement. Late follow-up hemodynamic studies suggest that a persistent transvalvular gradient may regress in time. Relief of obstruction caused by subvalvular variety of aortic stenosis is difficult whether stenosis is localized or diffuse. Even in this gruop, however, it has been possible to achieve good results with careful attention to certain technical details. Patients with congenital aortic stenosis should be operated on before the development of the sequelae of severe left ventricular hypertension.

Surgical management of persistent common atrioventricular canal.

Abstract Persistent common A-V canal is only one of a wide variety of interatrial communications. This condition includes defects of one or both septums and one or both atrioventricular valves. The over-all term of “endocardial cushion defect” has been used to designate these and other similar congenital heart defects. Our surgical experience includes forty-eight patients with the partial form of the defect and eighteen with the complete form. Extracorporeal circulation was used for all operations. There were two hospital deaths among patients undergoing repairs of the partial form, a mortality rate of 4.2 per cent, whereas twelve of the eighteen patients with the complete form died, a mortality rate of 66.7 per cent.

The effect of denervation on feline esophageal function and morphology

Abstract Denervation of the feline esophagus leads to a severe motility disorder which is different from that recorded after denervation of the dog and monkey esophagus. Bilateral cervical vagotomy resulted in complete paralysis of the body of the esophagus, but peristalsis returned to that portion composed of smooth muscle. Esophageal dilatation occurred, and the incidences of relaxation and contraction of the inferior sphincter in response to swallowing were markedly reduced. These sphincteric abnormalities returned to normal after 6 months, but those in the body of the esophagus were unchanged for periods of 9 months. Esophageal dilatation occurred after vagotomy in all cats. Esophagomyotomy did not prevent this. Periesophageal vagotomy had a very inconstant effect. Sympathectomy had little effect on esophageal motility but caused marked diminution in the resting pressure of the inferior sphincter. When combined with vagotomy, sympathectomy prevented the effect of vagotomy on the sphincter but not on the body of the esophagus. None of these procedures induced a loss of ganglion cells in Auerbachs plexus.

Costophrenic Septal Lines in Pulmonary Venous Hypertension

On the thoracic roentgenograms of patients with mitral stenosis, costophrenic septal lines are frequently seen. These lines are a sign of pulmonary venous hypertension. They were not seen in a representative group of patients with pulmonary arterial hypertension but without pulmonary venous hypertension.

A study of the anatomy of the human esophagus with special reference to the gastroesophageal sphincter

Summary The muscular wall of the normal esophagus below the level of the first thoracic vertebra was taken from 7 cadavers and examined serially by histologic methods. Quantitative and qualitative evidence was found to refute the presence of an anatomic gastroesophageal sphincter. The details of attachment of the phrenoesophageal ligament have been described, together with extensions of the insertion of this ligament in continuity into a dense elastic framework within the esophageal wall. The presence of submucosal muscle “brackets” was confirmed, and these structures were also identified between the main longitudinal and circular muscular layers.