Geoffrey H. Wooler

Atrial septal defect in adults: Clinical and hemodynamic results of surgery☆

Abstract Secundum type atrial septal defects were closed in 32 adults aged 30 to 57 years, with the use of cardiopulmonary bypass. Before operation, 12 had functional class II disease and 11 class III disease (New York Heart Association classification). Eight had a history of congestive cardiac failure, and 6 had atrial fibrillation. Cardiothoracic ratio ranged between 50 and 76 percent. Sixteen patients had moderate to severe pulmonary hypertension, but none had reversed shunt. There was 1 operative and 1 late death. Neither death was related to the complications usually associated with atrial septal defect in this age group. The remaining patients were followed up for 6 months to 12 years. All but 2 had functional class I disease after operation. Postoperatively a statistically significant reduction was noted in cardiothoracic ratio and pulmonary arterial pressures, and there was consistent rise in calculated pulmonary to systemic resistance ratio. A small residual shunt of 1.6:1 was present in 2 patients. It is concluded that irrespective of preoperative complications (pulmonary hypertension, atrial fibrillation and congestive heart failure), repair of atrial septal defect with left to right shunt in adults produces considerable clinical and hemodynamic improvement, and has low mortality and morbidity rates.

Magnesium in patients undergoing open-heart surgery

Measurements of serum and urinary magnesium levels were made together with the other electrolytes, haematocrit, pH, and albumin in patients comprising two groups—one group of 50 patients undergoing heart valve replacement, and the other, 30 patients undergoing non-perfusion thoracic operations. Low serum magnesium levels were found in some patients admitted to hospital who were or had recently been in congestive heart failure. All patients were found to have low serum magnesium levels postoperatively, but to a greater degree and for a longer period following open-heart surgery. The latter group exhibited hypomagnesuria postoperatively. The literature is reviewed in an attempt to explain the reasons for the changes in the magnesium levels. It is concluded that the changes observed in this limited study warrant further detailed investigation including the use of a double blind trial for assessing the therapeutic value of administering magnesium salts of patients undergoing open-heart surgery.

Tracheo-oesophageal fistula and oesophageal atresia: results of 30 years' experience

One hundred and sixteen cases of oesophageal atresia and tracheo-oesophageal fistula operated upon during the period 1939-67 are reviewed. Current views on, initially, surgical care and ultimate management are discussed.

Mitral valve replacement with aortic heterografts in humans

The complications associated with the implantation of prosthetic valves and the experimental attempts to graft the mitral valve are described. Because of the disadvantages connected with the use of artificial valves and as the experimental methods of grafting the mitral valve did not prove satisfactory for clinical use, the authors developed a technique for mitral valve replacement using heterologous aortic valves—reinforced by a semirigid Teflon ring—placed above the mitral annulus inside the atrial cavity. The technique of collecting, preparing, and inserting these grafts is described in detail. Using this method, seven patients with mitral incompetence or mitral disease were operated upon between February and April, 1967. One patient died five weeks after the operation from bacterial endocarditis in a period of severe hospital infection with staphylococcus. The other six patients had a very good clinical result immediately after surgery. At the present time they are symptom-free and have normal heart sounds. Clinical and experimental data are discussed concerning the long-term fate of aortic heterografts in the mitral position.

Replacement of heart valves with frame-mounted tissue grafts

Ionescu, M. I., Pakrashi, B. C., Mary, D. A. S., Bartek, I. T., and Wooler, G. H. (1974). Thorax, 29, 56-67. Replacement of heart valves with frame-mounted tissue grafts. Between April 1969 and March 1973, 213 patients had heart valve replacement with frame-mounted autologous or homologous fascia lata or with heterologous pericardial grafts. There were 111 single aortic, 95 single mitral, and seven tricuspid valve replacements. The incidence of hospital and late mortality was each 10% for the entire series and the main causes were myocardial failure and infective endocarditis. The majority of patients obtained significant symptomatic improvement. In patients with aortic replacement there was a statistically significant reduction in cardiothoracic ratio and in the voltage of the electrocardiogram. Regurgitant murmurs developed in 11·6% of aortic patients and in 51·6% after mitral replacement (in 37·5% the murmur has not increased in intensity while in 14·1% it has gradually progressed). None of these mitral patients requires reoperation. Grafts in the tricuspid position have not shown signs of dysfunction or failure. Graft failure has not occurred in the aortic replacement series. From the mitral position six grafts have been removed due to failure. All six were made of autologous fascia and all showed varying degrees of thickening and retraction of cusps. There were six episodes of peripheral embolization (five transient) and one left atrial thrombosis. All seven patients are alive. Anticoagulants were not used. The results of haemodynamic studies and in vitro hydrodynamic experiments are discussed and an explanation for graft dysfunction in the mitral position is presented. The actuarial analysis of this series of patients over a period of up to 54 months post-operatively has shown encouraging results.

Morbidity and mortality of oesophageal perforation

Thirty-three patients with oesophageal perforation seen within a 20-year period are reviewed. Endoscopic perforation in patients with neoplastic disease of the oesophagus carried a 100% mortality despite early diagnosis and immediate resection of the growth. Only two deaths occurred after instrumental perforation of the thoracic oesophagus for benign pathology in patients who were in the extremes of life. Twelve cases with spontaneous perforation were seen. Although the mortality figure of only 8% was encouraging, the morbidity in terms of postoperative complications was considerable, occurring in all but one of the survivors. The importance of early diagnosis and adequate treatment in relation to postoperative morbidity and mortality is discussed.

Late results of elective and emergency portacaval anastomosis: With particular reference to the type of stoma used

Summary A retrospective study of the late results of elective and emergency portacaval anastomosis over a sixteen year period between 1951 and 1967 is presented. The findings in seventy-eight consecutive cases in which surgery was required for gastrointestinal bleeding are reviewed. After elective portacaval anastomosis there was a 20 per cent mortality within six months of surgery. Approximately half of the patients were alive ten years after operation. In comparison, emergency portacaval shunts were associated with a very high early mortality (45 per cent) and the ten year survival was only 23 per cent. All of the patients who died in the immediate postoperative period had signs of severe liver failure before surgery. The simpler end to side anastomosis was preferred for emergency shunting and was associated with a lower mortality. Although the results of side to side anastomosis were marred by a higher incidence of encephalopathy, there were no cases of occlusion of the shunt within this group compared with the remaining patients in this study.

Massive retrosternal goitre presenting with hypertension

A patient presented to her doctor with dyspnoea on exertion. Hypertension was diagnosed and she was subsequently found to have a large retrosternal goitre. The blood pressure returned to normal after the tumour had been removed. To our knowledge no such case has previously been reported. Early removal of mediastinal tumours is advocated.

Mousseau-Barbin tubes for benign strictures of the oesophagus

Two patients with benign strictures in the lower third of the oesophagus underwent insertion of Mousseau-Barbin tubes as palliative treatment for chronic dysphagia. The reasons for this particular form of treatment are discussed along with the unsatisfactory outcome.

Mitral valve replacement with Alvarez prosthesis: long-term results

The high mortality and morbidity that follow insertion of the Alvarez valve in the mitral position, and particularly the thrombo-embolic complications, stopped us from using it clinically in the Leeds General Infirmary.