George Robinson

Informed Consent: Recall by Patients Tested Postoperatively

Abstract When tested for recall between 4 and 6 months following operation, 20 patients failed to remember accurately major portions of their informed consent interview. Documentation of the details of consent in the clinical record is considered advisable.

Aortic Dissection and the Left Renal Artery

Angiographic and/or autopsy evidence of compromises of arterial circulation to the left kidney was found in 22 of 37 patients with aortic dissection. Severe hypertension occurred in 6 patients with renal ischemia, suggesting that marked blood pressure elevations occasionally seen in patients with aortic dissection are due to acute renal artery damage. The combination of a large intimal tear, good flow in the dissected channel, and re-entry of the renal artery resulted in a considerable contribution from the false lumen. Angiographic evaluation of the extent of aortic dissection is an important consideration in therapy.

Coronary gas endarterectomy

ince the development of selective coronary angiography, the direct surgical repair of obstructive coronary disease has attracted widespread interest. Direct intervention employing standard endarterectomy and patch graft angioplasty for localized lesions achieved only limited application because of either excessive mortality rates or failure to regularly achieve long term patency of the operated vessels. Consequently, these procedures were abandoned in favor of indirect revascularization with internal mammary artery implantation. While the implants have been successfully performed and subsequently proved to be functional angiographically, a desire to perform successful direct surgery continued to attract experimental and clinical interest. In 1967 the first use of gas endarterectomy in coronary arteries was reported. It was felt at that time that certain technical advantages of this new approach would lead to a more favorable and widespread application of the endarterectomy principle in coronary disease. A careful analysis of the earlier attempts at mechanical endarterectomy revealed the following important considerations to be responsible for the unsatisfactory results previously obtained : 1. Preoperative assessment of the location and extent of coronary lesions was impaired due to the unavailability of suitable coronary radiography. 2. Incomplete “cleanout” of a diffusely diseased vessel occurred. 3. Technical difficulties related to closure of the arteriotomy site were present. 4. Failure to reopen side branches (“snow plow” effect) with consequent impaired runoff occurred. 5. Application of endarterectomy to the left coronary tree with its attendant high mortality was a factor. 6. A lack of appreciation of the ability of the dominant right coronary artery to collateralize the left coronary tree was also responsible. With the problem of accurate coronary angiography solved, and having overcome the technical difficulties related to endarterectomy described above, gas endarterectomy has now become a part of the surgical armamentarium available to treat obstructive coronary disease. In the past three years it has been applied in more than 75 cases in five medical centers in this country. Complete removal of disease from a dominant right coronary artery via one or two arteriotomies is readily accomplished. Less than 60 min. of cardiopulmonary bypass time has been usual. Three to 6 inch multibranched casts of the right coronary artery from coronary ostia to posterior descending

Internal Mammary Artery-Saphenous Vein Composite Conduit: An Alternative for the Proximal Coronary Anastomosis

A patient who had previously undergone saphenous vein bypass grafting was seen with recurrent angina requiring reoperation. At the second operation, technical problems with the ascending aorta ultimately excluded its use for the proximal anastomosis for the second of two bypass grafts. Anastomosis of the left internal mammary artery to the proximal end of the saphenous vein graft successfully resolved the problem.

Location of the Proximal Left Anterior Descending Coronary Artery

Abstract An easy method of exposing a hidden proximal left anterior descending coronary artery during a revascularization procedure is described. The technique has been used successfully in 2 patients.

Precise determination of cardiac arrhythmias during open heart surgery by monitoring of myocardial electrograms

Abstract Monitoring and analysis of the cardiac rhythm during open heart surgery by the recording of multiple-lead epicardial electrograms is presented. The cardiac rhythm, the time relation between atrial and ventricular activation and the presence or absence of A-V conduction disturbances is always clearly delineated by the electrograms but frequently not by standard electrocardiographic tracings. The use of epicardial electrogram recordings offers an additional and highly accurate method for analysis of complex cardiac arrhythmias and determination of the functional state of the A-V conducting system. Further utilization of this technic should provide greater insight into arrhythmia analysis and allow a more physiologic approach to the treatment of disturbances of cardiac rhythm.

Limitations of Phonocardiography Assessment of Ball Variance

etermining the presence or absence of ball variance in patients with Starr-Edwards prosthetic aortic valves is of critical imporD tance. Phonocardiographic recording in the aortic area of an opening-to-closing prosthetic click ratio below 0.50 had been considered diagnostic of variant ball [4]. However, false-positive results have been reported in some patients with this finding [ l , 2, 5, 61. This paper describes 15 patients with aortic valve prostheses (12 Starr-Edwards 1000 series, 2 Starr-Edwards 1200 series, and 1 Magovern valve) who had persistent reduction of the amplitude of the opening click, with an opening-to-closing click ratio of less than 0.50. Ball variance was demonstrated subsequently in only 2 of these 15 patients.

Surgical Treatment of Wolff-Parkinson-White Syndrome: Division of an Anomalous Pathway Using the Superior Approach

The superior approach to the mitral valve through the dome of the left atrium was used for division of a left free wall anomalous pathway. It has been the approach of choice for mitral valve operations at our institution for the past 15 years, facilitating operations particularly when the left atrium is normal in size. Other approaches to the mitral valve are discussed.

Surgical treatment of valvular heart disease

Abstract Aortic valve replacement can be readily accomplished either with a prosthetic valve or a homo- or heterograft placed in the subcoronary position. The operative mortality rate of all procedures is under fifteen per cent. Complications of thrombosis, embolization, and ball variance have plagued the prosthetic ball valve. Fibrosis of valve leaflets, calcification, and late stenosis and insufficiency of the homo- and heterografts have been reported. The ideal aortic valve replacement has not yet been devised, but very satisfactory clinical relief of aortic valve disease is now possible with either prosthetic or grafted valves.

Interventricular septal defects with associated major vascular anomalies: Report of three cases

Abstract Three cases of ventricular septal defect are reported in which associated anomalies were simultaneously and successfully corrected by open-heart surgery. These included patent ductus arteriosus, anomaly of the aortic arch, anomalous left upper lobe pulmonary vein draining into the left innominate vein, and coarctation of the aorta.