Frank P. Catinella

Long-Term Results of Open Radical Mitral Commissurotomy: Ten Year Follow-Up Study of 202 Patients

Two hundred two patients undergoing open radical mitral commissurotomy for mitral stenosis between 1967 and 1978 were evaluated. Follow-up data were obtained in 98 percent of patients (follow-up range 1 to 122 months, mean 42). One hundred forty-four patients (71 percent) underwent only commissurotomy; 58 patients required associated cardiac procedures. One hundred twenty-eight patients (63 percent) had a history of rheumatic fever and 15 (7 percent) had undergone prior closed mitral commissurotomy. Preoperative emboli were recorded in 25 percent. Cardiopulmonary bypass and left atriotomy were utilized to perform a radical valvulotomy, not only eliminating the mitral valve gradient, but also opening the valve as much as possible without producing insufficiency. The left atrial appendage was routinely checked for thrombus and usually closed with sutures. Induced aortic regurgitation by retrograde insertion of a perforated catheter was utilized to detect mitral insufficiency after commissurotomy. Mitral anulopiasty was performed when necessary. The operative mortality rate was 1.7 percent and the long-term mortality rate 2.5 percent. Preoperatively, 155 patients (77 percent) were in New York Heart Association functional class III or IV. At follow-up examination, 90 percent (178) were in functional class I or II. Postoperative emboli were rare (3 percent), but occurred more often after preoperative embolism or failure to obliterate the left atrial appendage. Multifactorial analysis showed that the presence of a residual mitral gradient or regurgitation indicated a poor prognosis. The 5 year complication-free survival rate in this group was significantly less than that in patients without residual valve dysfunction (75 versus 87 percent, p < 0.05). Open radical mitral commissurotomy appears to be a safe method for relieving valve obstruction. It allows removal of thrombus and oversewing of the left atrial appendage, which may reduce the possibility of significant postoperative embolic events. Reduction in turbulent blood flow by creating a widely patent and competent mitral valve diminishes progressive valve fibrosis and generally obviates the need for future valve replacement.

Vein Contraction and Smooth Muscle Cell Extensions as Causes of Endothelial Damage during Graft Preparation

Meticulous preservation of the endothelial lining of vein grafts harvested during vascular operations is undoubtedly an important factor in determining patency rates following bypass procedures. Destruction of the vein grafts endothelial lining prior to graft implantation results in a more thrombogenic graft which is essentially a collagen-lined tube. This study used light, transmission, and scanning electron microscopy to investigate effects of various methods of vein graft preparation on endothelial and smooth muscle cells of the dog cephalic vein. Veins were removed and stored in one of three heparin-ized solutions at 10 C for either five minutes or one hour: autologous blood, Plasmalyte™ or Plasmalyte™ with 0.6 mg/ml papaverine HCl added. The vein wall was extremely sensitive to dissection, manipulation, or introduction of fixative solutions and reacted to such stimuli with severe contraction which not only diminished the luminal diameter but also resulted in protrusion of endothelial cells into the lumen and formation of cytoplasmic extensions of medial smooth muscle cells. Such cytoplasmic extensions were particularly frequent in the immediate subendothelial area and appeared to be instrumental in elevating, separating, or desquamating the endothelial cell lining. Veins stored in blood alone demonstrated the greatest vessel wall contraction and endothelial cell loss. Veins soaked in Plasmalyte™-papaverine solution had the most relaxed and normal appearance with minimal endothelial cell loss. Papaverine-treated veins which were subjected to brief periods of distension at pressures of 100 mmHg or greater demonstrated large gaps between the endothelial lining cells. The results suggest pretreatment with papaverine greatly reduces vein graft endothelial cell loss due to contraction, although such relaxation may be detrimental if vein grafts are subjected to excessive pressure prior to reversal of relaxation

Myocardial protection with cold blood potassium cardioplegia during prolonged aortic cross-clamping.

The efficacy of cold blood potassium cardioplegia during periods of aortic cross-clamping (greater than 100 minutes) was assessed in 127 patients undergoing a variety of open-heart surgical procedures at New York University Medical Center from january, 1978, to April, 1979. Ischemic intervals ranged from 100 to 267 minutes (mean, 128 minutes). Cardiac-related deaths occurred in only 3 patients (2.4%), and overall operative mortality was 8.7% (11 patients). The rate of perioperative infarction was 10%. Fourteen patients (11%) required vasopressor support or balloon counterpulsation after cardiopulmonary bypass despite the lengthy cross-clamp intervals. Multivariate analysis revealed no significant relationship between the length of cross-clamp time and operative mortality (p = 0.29), incidence of perioperative infarction (p = 0.54), or the occurrence of low-output syndrome postoperatively (p = 0.68). These findings suggest that cold blood potassium cardioplegia provides adequate myocardial protection when periods of arrest as long as 3 to 4 hours are required for complex cardiac surgical procedures.

Early Open Radical Commissurotomy: Surgical Treatment of Choice for Mitral Stenosis

Between 1967 and 1979, 411 patients underwent surgical treatment of isolated mitral stenosis at our institution. Open radical mitral commissurotomy was performed in 150 patients (1967-1978; mean follow-up, 46 months; range, 4 to 116 months). Mitral valve replacement using a porcine prosthesis was performed in 74 patients (1976-1979; mean follow-up, 23 months; range, 2 to 48 months). Mitral valve replacement with a cloth-covered Starr-Edwards prosthesis was performed in 187 patients (1967-1975; mean follow-up, 45 months; range, 2 to 106 months). Preoperative characteristics were similar in the three groups. The open commissurotomy and Starr-Edwards groups were followed up to 9 years and the porcine valve group up to 4 years, with 97% follow-up in each group. Life-table analysis (6-month intervals) of all postoperative complications revealed significantly greater complication-free survival for patients who had open radical commissurotomy compared with Starr-Edwards (p less than 0.05) valve replacement. Similar analysis of thromboembolic and warfarin-related complications revealed significantly fewer complications in commissurotomy patients. No significant differences were found (p greater than 0.05) when comparing the need for subsequent reoperation in each group. Operative mortality following open radical mitral commissurotomy (0%; 0 out of 150) was significantly less (p less than 0.05) than after mitral valve replacement in both porcine (8.1%; 6 out of 74) and Starr-Edwards (11.2%; 21 out out 187) groups. Life-table analysis of late cardiac-related mortality revealed a significantly greater cumulative survival rate for the commissurotomy versus the Starr-Edwards groups at all intervals from 12 to 108 months (100 versus 84 +/- 5%, p less than 0.05). No significant differences were noted between commissurotomy and porcine valve groups during the 4-year follow-up period (100 +/- 0% versus 96 +/- 3%, p greater than 0.05). Based on these findings, we conclude that when the anatomy is favorable, the surgical treatment of choice for isolated mitral stenosis is open radical mitral commissurotomy.

Increased release of cyclic adenosine monophosphate into jugular vein in response to isoproterenol administration

Catecholamine administration elevates plasma cyclic AMP (cAMP) levels but the source of the cAMP is unknown. To determine possible sources, plasma cAMP levels were determined in blood vessels across the head, liver, kidney and lung in anesthetized dogs infused with the beta-adrenergic agonist, isoproterenol. Only the head showed an increased release of cAMP into the blood. The kidneys removed cAMP from the blood while liver and lung showed no change. This in vivo demonstration of release of cAMP from the head represents contributions from brain and facial muscles and may be a useful approach to study brain involvement in the action of various hormones and drugs.