Frank Gerbode

Thrombosis and Degeneration of Hancock Valves: Clinical and Pathological Findings

Of 415 Hancock valves implanted in 370 patients, 26 valve specimens were recovered at postmortem examination and 8 at reoperation. In 9 of these 34, thrombosis had formed without apparent alteration of the heterograft tissue (Group A). All were mitral prostheses, and the thrombi were attached to the sewing ring. Six of the patients died in the early postoperative period following prolonged low cardiac output syndrome and coagulation disturbances. Three patients had late valve thrombosis 12 to 26 months after operation and were in chronic atrial fibrillation with a very large left atrium. Four valve specimens (Group B) demonstrated degenerative changes of the heterograft leaflets such as shrinkage, perforation, and calcification. The clinical courses and possible pathogenesis are discussed.

Ruptured aneurysms of the aortic sinuses of Valsalva

Abstract The basic defect of a congenital aneurysm of the aortic sinuses of Valsalva is a lack of continuity between the media of the aorta and the annulus fibrosus of the aortic valve ring. Most of the aneurysms arise in the right and noncoronary cusps and rupture into the right ventricle or right atrium. Rupture of the aneurysm leads to an aorticocardiac fistula which overloads the right heart leading to severe congestive failure. The murmur is usually continuous, loud and superficial and most frequently heard best in the third and fourth intercostal spaces to the left of the sternum. These fistulas and associated defects can be corrected with open heart surgery with a low mortality rate.

The surgical management of bacterial endocarditis: a review.

A total of 239 surgically treated patients with primary endocarditis were reviewed both from the literature and from our own experience. The age range was 10 to 74 years with a male to female ratio of 3:1. A wide variety of organisms was found. However, as a group, gram positive organisms predominate. The onset of congestive failure was the major indication for surgery. The aortic valve was predominantly involved with the mitral valve running a distant second. The hospital mortality rate was 20% and the late mortality rate was 6.7% with an overall mortality of 26.7%. The prognosis in infective endocarditis when congestive failure develops, even in the presence of antibiotic therapy, is poor (79–89% mortality). In view of this poor prognosis, an aggressive attitude with regard to early surgical intervention can greatly improve the outcome of valvular endocarditis.

THE MANAGEMENT OF ABNORMAL BLEEDING FOLLOWING EXTRACORPOREAL CIRCULATION

Excerpt In the early days of the development of artificial heart-lung machines, abnormal postoperative bleeding was a very frequent phenomenon, and an unmanageable hemorrhagic diathesis is an occas...

Endocardial cushion defects.

Although there are at least fourteen possible combinations of endocardial cushion defects, their classification falls under two basic headings: simple or complete.[1,2,3] These include minor variations as well such as a cleft in the tricuspid valve confluent with the cleft to the mitral valve. A cleft mitral valve and no atrial septal defect as well as a very small secundum type of septal defect with a cleft mitral valve can also be listed as variations.

Treatment of Atrial Fibrillation After Surgical Repair of the Mitral Valve

Excerpt Atrial fibrillation, a common sequel to mitral valvular disease, profoundly affects the course of the disease. It adversely affects the performance of the heart; significant symptoms may fi...

The use of potassium arrest in open cardiac surgery

Abstract The clinical usefulness of elective cardiac arrest with potassium citrate solution is an important adjunct in the modern technics of open cardiac surgery. The technical features of the procedure and the various complications which may arise are discussed and four cases of special interest in which cardiac arrest was used are presented.

Patterns of myocardial oxygen and lactate extraction in patients undergoing cardiopulmonary bypass.

Abstract Forty-nine patients with acquired mitral or aortic valve disease had myocardial oxygen metabolic studies performed during cardiopulmonary bypass and moderate hypothermia. Twenty-two of these also had lactate determinations performed; lactate production was considered indicative of myocardial anaerobiasis. Metabolic data were obtained during specific intraoperative events such as crossclamping of the aorta, unclamping of the aorta with restoration of coronary autoperfusion, initiation of continuous direct coronary perfusion, arrhythmias, electrocardiographically demonstrable ischemia, and ventricular fibrillation and defibrillation. In all cases ECG evidence of ischemia was accompanied by alterations in O 2 extraction patterns and lactate production, but metabolic derangement often continued to be present after the ECG had returned to normal. Ventricular fibrillation occurred more commonly during coronary artery perfusion than during ischemic cardioplegia and was associated with pronounced increases in calculated myocardial oxygen consumption, as well as lactate production. Seventy-five per cent of patients having ischemic cardioplegia induced by intermittent aortic crossclamping had diminished myocardial extraction of O 2 throughout the operative procedure, with associated production of lactate. Seventy-two per cent of patients having continuous direct coronary perfusion showed an increase in myocardial O 2 extraction with concomitant lactate production during bypass. The pattern of either decreased or increased O 2 extraction persisted in any given patient and was felt to be due to operative technique (ischemic cardioplegia versus direct coronary perfusion) rather than to the underlying lesion. Possible mechanisms involved in the two patterns of O 2 extraction, both associated with anaerobiasis, are discussed. It is concluded that, under the operative conditions prevailing during this study, (1) the surface ECG gives a poor indication of myocardial metabolic dysfunction, (2) spontaneous ventricular fibrillation may be detrimental to cardiac function as the increase in myocardial oxygen consumption is not met by an increase in coronary blood flow, (3) intermittent aortic crossclamping might produce derangement in cellular oxidative metabolic processes, and (4) continuous direct coronary artery perfusion does not meet, and is inadequate to meet, myocardial metabolic demands.

Effect of altered ventilation patterns on compliance during cardiopulmonary bypass.

HERE ARE MANY conflicting reports in T the literature regarding the management of lungs during cardiopulmonary bypass. Edmunds and Austenl reported that when lungs were ventilated throughout bypass, the volume-pressure relationships changed insignificantly, but there were marked changes when there was no ventilation. Cartwright’s group2 reports that no decrease in compliance occurs after extracorporeal circulation. Sullivan and coworkers3 reported that with static inflation during total heart-lung bypass averaging 2% hours, there was no significant alteration in the mechanical properties of the lung-thorax system. The work of Blair and associates4 showed either no change or an improvement in elastic properties during cardiopulmonary bypass, but considered it desirable to ventilate the lungs during bypass.

Reversibility of Pulmonary Hypertension Following Cardiac Surgery

PULMONARY hypertension is a serious consequence of many congenital cardiac malformations and is a common sequel to valvular heart disease. Successful surgical treatment of such forms of heart disease often hinges upon the reversibility of pulmonary hypertension. Surgical treatment may instantly relieve passive pulmonary hypertension by reducing left atrial pressure, and hyperkinetic pulmonary hypertension by the elimination of increased pulmonary blood flow. However, there is some controversy about the reversibility of elevated pulmonary vascular resistance (PVR) in response to cardiac operations. This report presents data obtained from serial cardiac catheterizations in patients with elevated pulmonary vascular resistance who underwent cardiac surgery.