Francis Robicsek

A New Method to Treat Fusiform Aneurysms of the Ascending Aorta Associated with Aortic Valve Disease: An Alternative to Radical Resection

A new method designed to deal with special forms of fusiform aneurysms of the ascending aorta associated with aortic valve disease is presented. The procedure consists of replacing the aortic valve, decreasing the aortic diameter by excision of an oval segment, placing a well-tailored Dacron vascular graft around the ascending aorta, and anchoring it with previously placed sutures driven through the sewing ring of the valve prosthesis through the aortic wall. The technique has been applied in 6 patients with postoperative observation ranging from six weeks to two and a half years. Technically the operation was carried out without difficulty, and all the patients are doing well.

Successful Clinical Laser Ablation of Ventricular Tachycardia: A Promising New Therapeutic Method

This preliminary report describes 5 consecutive patients operated on for drug-resistant ventricular tachycardia (VT). All were successfully treated with laser photocoagulation ablation alone. The continuous-wave neodymium:yttrium-aluminum garnet (Nd:YAG) laser (wavelength, 1.06 micron) was chosen because of its capability for controlled deep tissue penetration, which can be adjusted by manipulating the power and exposure time of the beam. All patients had severe coronary artery disease. Preoperative left ventricular ejection fractions were low (0.18 to 0.29). Risk factors associated with increased failure rates by conventional surgical approaches were frequent: absence of discrete left ventricular aneurysm (5 patients) and multiple VT morphologies with disparate sites of origin (4 patients). All patients recovered fully. VT was not inducible prior to discharge, and no patient was placed on a regimen of antiarrhythmic drugs. Current direct surgical approaches to drug-resistant VT have markedly improved operative results compared with indirect procedures. However, failures and mortality remain high. Laser photocoagulation obviates some of the problems associated with conventional methods. It is similar to cryotherapy in that the structural integrity of affected tissues is maintained. In contrast to cryosurgery, however, laser photocoagulation is achieved more rapidly and with more precise myocardial destruction. One of the most promising features of laser coagulation is that it is administered to the perfused normothermic heart. Consequently, each morphological form of induced VT is observed to disappear as its area of origin is systematically located by mapping and then ablated.

Congenital quadricuspid aortic valve with displacement of the left coronary orifice

Abstract A case of a 35 year old woman with quadricuspid aortic valve and displacement of the left coronary orifice is presented. The aortic regurgitation caused by maladaptation of the supernumerary cusps was corrected surgically.

Traumatic tears of the thoracic aorta: Improved results using the bio-medicus pump

Traumatic disruption of the descending thoracic aorta is a relatively rare but dramatic injury. Controversy remains regarding the use of shunts during operative repair. Discouraged by our results using the no shunt technique, we adopted the recently reported technique using the Bio-Medicus pump for left atrium-femoral artery bypass without heparin sodium. At Charlotte Memorial Hospital and Medical Center, 39 patients were treated for tears of the descending thoracic aorta between January 1979 and October 1988. Eight patients died before repair could be completed. Four patients underwent repair using femorofemoral bypass with 1 death and no instances of paraplegia. Fifteen patients had repair using the no-shunt technique with 4 deaths and three instances of paraplegia. Since January 1986, 12 patients have been treated using the Bio-Medicus heparinless pump with no deaths and no instances of paraplegia. We present our experience to confirm the reports of others regarding the efficacy of this technique. We believe it reduces the morbidity and mortality associated with this serious injury and aids in the hemodynamic management of the patient during aortic clamping.

Marlex Mesh Support for the Correction of Very Severe and Recurrent Pectus Excavatum

A method for the correction of very severe and recurrent pectus excavatum is presented. The technique consists of mobilization of the sternum, transverse osteotomy, parasternal resection of the costal cartilages (modified Ravitch procedure), followed by placement of Marlex mesh behind the sternum and suturing the edge of the Marlex mesh to the peripheral stump of the resected ribs. This method has been used with good results in 6 patients, 2 of them with recurrent deformities.

Limited value of balloon dilatation in calcified aortic stenosis in adults: Direct observations during open heart surgery

Percutaneous balloon dilatation was recently recommended as a treatment for management of calcified aortic valvular stenosis. This procedure was initially reserved for patients who were not considered surgical candidates; it is now regarded by some as an acceptable alternative for valve replacement. To investigate the validity of this postulate, balloon valvuloplasty was performed under direct vision in the operating room in 16 patients just before excision and replacement of their ossified aortic valve. Changes after valvuloplasty were evaluated by inspection as well as by geometric measurements. The authors found that balloon valvuloplasty did not make a detectable impact on valvular anatomy in about two-thirds of the patients and induced enlargement of the functional aortic orifice judged as minimal or moderate in one-third of the cases. In no patient was there significant increase in the functional orifice size. Other investigators have shown that hemodynamic and clinical improvement may be induced in some patients by small increases in the aortic orifice; based on the observations herein, such an improvement, if it occurs at all, would be short-lasting; the procedure should be offered only to those who present truly prohibitive risk by standards of modern surgery.

Balloon Valvuloplasty in Calcified Aortic Stenosis: A Cause for Caution and Alarm

Balloon dilation by the percutaneous route has recently been recommended as an alternative to surgical intervention in the management of calcified aortic valvular stenosis. To investigate the validity of balloon valvuloplasty, this procedure was carried out in the operating room under direct vision in 30 patients just prior to excision and replacement of the ossified aortic valve. Changes induced by balloon dilation were evaluated by visual inspection as well as by geometric measurements. By visual observation, balloon valvuloplasty did not have a detectable impact on the valvular anatomy in about 19 of the patients and induced enlargement of the functional aortic orifice judged as minimal or moderate in only 11. In no patient was there a substantial increase in the functional orifice size. These findings were supported by geometrical measurements. Therefore, we believe that the virtues of this procedure have been grossly overstated by its proponents and that it should be offered only to patients who present a truly forbidding risk by standards of modern surgery.

Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

Abstract During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patients own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.

Ascending-Distal Abdominal Aorta Bypass for Treatment of Hypoplastic Aortic Arch and Atypical Coarctation in the Adult

Repair of aortic coarctation is usually an easy operation. However, it can be very difficult under certain circumstances. These include operating on an adult or operating when specific anatomical variations, such as hypoplasia of the transverse aortic arch or calcification of the coarctation area, are present. We recommend that in such cases the situation be handled using ascending aorta-lower abdominal aorta bypass grafts rather than conventional resection and anastomosis of the coarctation itself. The cases of 2 patients are presented in whom a hypoplastic aortic arch associated with atypical coarctation was repaired using such a procedure.

The Value of Angiography in the Diagnosis of Unruptured Aneurysms of the Abdominal Aorta

Abstract The advisability and value of angiographic studies in patients with abdominal aneurysm has been debated by many. Some believe that aortography is too dangerous for routine use and that diagnosis can always be established without it; further necessary information can be obtained safely at the time of operation [24]. Others [1, 6, 11] follow a middle-of-the-road policy and perform contrast-injection studies only if the clinical diagnosis is doubtful. Our experience based upon aortographic studies of 271 patients suspected of having unruptured aneurysm of the abdominal aorta is presented. The technique based on percutaneous catheter aortography proved to be safe, simple, and highly informative. Remote injections [3, 5, 10, 23, 24] were ruled out because they provided inadequate details. Two clinical signs, pulsating tumor and curvilinear calcification on conventional roentgenography, proved to be absolutely pathognomonic. A number of patients, however, had large abdominal aneurysms in the absence of both of these signs. Besides its value in diagnosing abdominal aneurysm, we also found that aortography supplied important additional information which in the average patient aided in effective preoperative planning. In the patient who was a doubtful candidate for operation, complete knowledge of pathological vascular anatomy permitted a more informed decision on whether to operate or not. We have never regretted the omission of aortography in our patients—Stipa and Shaw [24]