Hagop Hovaguimian

Infective Endocarditis: Ten-Year Review of Medical and Surgical Therapy

BACKGROUND Infective endocarditis is a complex disease process. Optimal outcome often requires both medical and surgical expertise. The need for and timing of surgical intervention is controversial and continues to evolve in parallel to advancements in diagnosis and treatment. Our experience with the treatment of infective endocarditis is reviewed herein. METHODS A retrospective review was compiled of 140 consecutive patients who fulfilled the modified von Reyn criteria for the diagnosis of endocarditis between January 1982 and April 1992. RESULTS Patient characteristics, symptoms, and risk factors are described. Follow-up averaged 3.5 +/- 0.8 years and totaled 491 patient-years. New York Heart Association functional class at presentation had a significant influence on survival (p < 0.0001). Long-term survival was significantly greater (p = 0.036) in patients treated medically/surgically than those treated with medical therapy alone (75% versus 54% at 5 years). Medical treatment of aortic and prosthetic endocarditis was associated with higher mortality (58% and 67%, respectively) when compared with combined medical/surgical treatment (28% and 38%, respectively). Among the survivors, New York Heart Association class at follow-up was better (p < 0.0001) in the medical/surgical group (1.05 +/- 0.04) versus the medical treatment group (1.70 +/- 0.14). CONCLUSIONS Combined medical/surgical treatment for infective endocarditis is associated with improved survival. Patients with aortic or prosthetic endocarditis are identified as subgroups that benefit most from surgical intervention. Valvular dysfunction incited by the infective process is an important factor that should be weighed carefully in the therapeutic decision.

Aortico-Left Ventricular Tunnel: A Clinical Review and New Surgical Classification

This is a collective review of aortico-left ventricular tunnel (ALVT) in the English-language literature. We include the long-term follow-up of a previously reported patient, and a report on 2 new patients. To date, 37 cases of ALVT have been reported. Controversies regarding the definition, etiology, local anatomy, and treatment are discussed. The ages of the patients ranged from 1 day to 25 years old, and the male to female ratio was 2:1. There were associated anomalies in 27% of the patients, and moderate to severe heart failure in 59% of them. Mortality was 100% in the medically managed group; the surgical mortality was 16%. Previous surgical techniques utilized were simple closure, patch closure of the aortic end, and obliteration of the tunnel on both ends. Progressive aortic incompetence seems to be a common, but not well-documented problem on long-term follow-up. We have classified the lesion into four types (I, II, III, and IV) that have a bearing on the appropriate surgical techniques of repair, and describe a new technique for the repair of type III ALVT in which septal aneurysm is present.

Anterior pulmonary translocation for repair of truncus arteriosus with interrupted arch

A newborn was found to have truncus arteriosus and an interrupted aortic arch, and underwent primary repair. The patient did well initially, but, by 8 weeks postoperatively, showed evidence of severe compression of the right pulmonary artery. At reoperation, the pulmonary artery was found to be compressed by a large aortic root (truncal root) and the retroaortic area was narrowed. The pulmonary artery bifurcation was therefore translocated anteriorly to alleviate the compression.

Bilateral internal mammary-to-pulmonary artery fistulas after a coronary operation

A case of bilateral internal mammary artery-to-pulmonary artery fistulas presenting as recurrent angina late after revascularization is described. Objective evidence of ischemia was documented using stress electrocardiography and thallium-201 scintigraphy. The patient was managed conservatively to date with medical therapy. Fistula formation may complicate internal mammary artery bypass grafting and should be considered as a potential cause of recurrent angina.

Coarctation Repair: Modification of End-to-End Anastomosis With Subclavian Flap Angioplasty

BACKGROUND Subclavian angioplasty and resection and end-to-end anastomosis for coarctation repair carry a substantial risk of recurrence of coarctation. The combined technique using both these methods has shown good results but requires a longer period of continuous cross-clamping of the aorta. METHODS A modified technique using intermittent cross-clamping with a period of reperfusion between cross-clamping periods was used. After the end-to-end anastomosis the clamps are released for 10 minutes and reapplied to do the subclavian angioplasty. Between 1991 and 1996 this was done in 26 infants (mean age, 5 weeks; range, 1 day to 6 months; median, 3 weeks). Mean weight was 3.85 kg (range, 1.5 to 8.4 kg). Mean length of follow-up was 23 months. Twenty-two patients (85%) had associated anomalies, excluding patent ductus arteriosus, and 5 patients (19%) had another procedure performed at the same time. RESULTS There was no mortality. The mean echocardiographic gradient was 4 mm Hg in the immediate postoperative period and 2.9 mm Hg during follow-up. Residual or recurrent coarctation as detected by significant echocardiography or blood pressure gradient did not develop in any infant. CONCLUSIONS This modified technique of anastomosis is an effective way of relieving coarctation with excellent intermediate-term results.

Use of autologous umbilical artery and vein for vascular reconstruction in the newborn

Autologous umbilical artery and vein were evaluated as vascular conduits in newborn lambs. Eight newborn lambs were delivered transabdominally under sterile conditions at term. The umbilical artery and vein were dissected from the cord and stored in culture media. On the same day, each lamb underwent bilateral superficial femoral artery transection and reconstruction. Nine arteries were reconstructed with autologous umbilical vein interposition grafts, five with umbilical artery interposition grafts, and two by primary native artery anastomosis. After the birth weight of the lambs quadrupled (37 to 45 days), they were killed and all grafts and anastomoses were examined grossly and histologically. At the conclusion of the study, both native artery anastomoses (2/2) were patent. Five umbilical vein (5/9) and two umbilical artery (2/5) autografts were also widely patent. Patent autografts retained an intact endothelium supported by a viable media. The nonpatent autografts had become atrophic remnants displaying histologic signs of early closure. Graft failures are attributed to the extreme vasoactive nature of the umbilical vessels. These preliminary results suggest that umbilical vessels may be useful as a vascular autograft if the vasoactive nature of these vessels can be overcome during the immediate perioperative period.

Commissurotomy and bileaflet pericardial augmentation-resuspension for bicuspid aortic valve stenosis.

We describe a valve reconstruction technique for congenital bicuspid aortic valve stenosis employing a commissurotomy, resection of raphe between conjoint leaflets, and bileaflet augmentation-resuspension using a triangular strip of glutaraldehyde-preserved autologous pericardium. This maneuver relieves aortic valve stenosis, preserves the native valve leaflets, reproduces the natural trileaflet scalloping of the aortic valve annulus, and improves cusp coaptation.