Harry K. Daugherty

Congenital quadricuspid aortic valve with displacement of the left coronary orifice

Abstract A case of a 35 year old woman with quadricuspid aortic valve and displacement of the left coronary orifice is presented. The aortic regurgitation caused by maladaptation of the supernumerary cusps was corrected surgically.

Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

Abstract During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patients own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.

The Value of Angiography in the Diagnosis of Unruptured Aneurysms of the Abdominal Aorta

Abstract The advisability and value of angiographic studies in patients with abdominal aneurysm has been debated by many. Some believe that aortography is too dangerous for routine use and that diagnosis can always be established without it; further necessary information can be obtained safely at the time of operation [24]. Others [1, 6, 11] follow a middle-of-the-road policy and perform contrast-injection studies only if the clinical diagnosis is doubtful. Our experience based upon aortographic studies of 271 patients suspected of having unruptured aneurysm of the abdominal aorta is presented. The technique based on percutaneous catheter aortography proved to be safe, simple, and highly informative. Remote injections [3, 5, 10, 23, 24] were ruled out because they provided inadequate details. Two clinical signs, pulsating tumor and curvilinear calcification on conventional roentgenography, proved to be absolutely pathognomonic. A number of patients, however, had large abdominal aneurysms in the absence of both of these signs. Besides its value in diagnosing abdominal aneurysm, we also found that aortography supplied important additional information which in the average patient aided in effective preoperative planning. In the patient who was a doubtful candidate for operation, complete knowledge of pathological vascular anatomy permitted a more informed decision on whether to operate or not. We have never regretted the omission of aortography in our patients—Stipa and Shaw [24]

Beneficial metabolic effects of methylprednisolone sodium succinate in acute myocardial ischemia.

The metabolic and hemodynamic effects of methylprednisolone sodium succinate (40 mg/kg body weight) after acute myocardial ischemia were determined in 24 heparinized mongrel dogs. Myocardial ischemia was produced by ligation of the left anterior descending coronary artery. Catheters in the coronary sinus and the vein draining the left anterior descending coronary arterial area were used to collect blood samples from nonischemic and ischemic myocardium. Lactate, pyruvate, glucose, free fatty acids and oxygen were measured in arterial and venous blood from ischemic and nonischemic areas before and 3, 30 and 60 minutes after myocardial ischemia in animals with (Group II) and without (Group I) steroid treatment. In both Groups I and II glucose, lactate, free fatty acids, oxygen and coronary blood flow in nonischemic areas were not significantly changed, whereas glucose uptake in ischemic areas was significantly increased with myocardial ischemia and remained elevated. In Group I lactate uptake in ischemic areas became negative after coronary arterial ligation and remained so; in Group II, it increased after 30 (70%) and 60 (111%) minutes. Free fatty acid uptake in ischemic areas was reduced after myocardial ischemia in Group I, but in Group II it increased after 30 (224%) and 60 minutes (173%), and there was a concomitant increase in oxygen uptake. Pyruvate uptake in nonischemic areas decreased after 60 minutes in Group I, whereas it was reduced after 30 (68%) and 60 minutes (513%) in Group II. The changes were similar in ischemic myocardium. There were no significant changes in hemodynamic indexes. Coronary blood flow in ischemic areas decreased in Group I after myocardial ischemia and further after 30 and 60 minutes, but in Group II it increased after 30 (82%) and 60 minutes (53%). The data indicate that administration of methylprednisolone results in improved collateral blood flow into the infarcted area and a significantly improved metabolic response of ischemic myocardium. The glucocorticoid may also have a direct benefical effect on carbohydrate metabolism and cause the increased pyruvate neccesary to maintain the generation of energy-producing substrates. The results also suggest that methylprednisolone increases cell survival time and results in greater salvage of ischemic myocardium.

Thoracoabdominal aortic aneurysms. A review and current status.

Surgical management of the thoracoabdominal aortic aneurysm is a formidable undertaking. Presently two fairly distinct operative methods are available. The conventional technique, pioneered by Etheredge, involves replacement of the aneurysm with a synthetic graft and then, step by step, revascularization of the abdominal organs with prosthetic side limbs taken from the primary graft. Individual organ ischemic time is limited to that time required for the performance of each distal side limb anastomosis. The second operative method, first described by Crawford, consists of proximal and distal control of the aneurysm, followed by its incision to simultaneously expose the origin of all four major intra-abdominal arteries. Replacement is then rapidly performed with a tubular Dacron® graft including anastomosis of these major intra-abdominal arteries to four elliptical graft incisions, from within the aneurysm. Total operating time is reduced at the expense of prolonged organ ischemia. The conventional method allows for step-by-step intraoperative planning and action, and this technique is accordingly recommended to most surgeons, who have had little experience with this unusual lesion. Our recent successful experience with two cases of extensive thoracoabdominal aortic aneurysms is described as well as a discussion of additional measures which may become useful in certain cases to favor a successful outcome. Finally the problem of potential resultant paraplegia is discussed.

Transplantation of “live” hearts

Abstract A “stabilized” form of heart-lung preparation is presented, which enabled the authors to transplant hearts experimentally in a fully perfused, beating stage, without the assistance of parabiosis or extracorporeal circulation. This method proved to be most effective in maintaining the donor heart viable and functioning in the extracorporeal phase, as well as during the process of transplantation.

Pseudocoarctation associated with aneurysm of the aortic arch.

typical reverse E-shaped deformity of the descending thoracic aorta with &dquo;poststenotic&dquo; dilation. The hemodynamic difference between these two conditions is, however, distinct: true coarctation represents a severe obstruction to the aortic blood flow, whereas in pseudocoarctation the impediment of the flow is moderate or absent. This explains why the clinical diagnosis of these two anomalies is based mainly on functional rather than on morphologic findings. This report concerns a 42-year-old woman with pseudocoarctation and aneurysm of the aortic arch who underwent successful surgical repair.

Aneurysm of the superior caval vein.

Aneurysms of the central venous system are extremely rare. Abbott (1-3) in his recent comprehensive monograph found only five such cases reported in the medical literature. Venous aneurysms practically never rupture and seldom cause symptoms of compression; however they may create a puzzling diagnostic problem. In this paper a case of a young woman is reported, who presented herself with an undiagnosed mediastinal mass, which proved to be an aneurysm of the superior caval vein at exploratory thorocotomy.

Emergency Thrombectomy of the Prosthetic Mitral Valve

The formation of thrombus on prosthetic valves is a common cause of postoperative morbidity and mortality. 1-3 These thrombi may embolize or cause malfunction of the valve poppet. Recent technical improvements on these prostheses and anticoagulation have decreased but certainly not eliminated the danger of this serious complication (fig. 1). Methods of managing patients with malfunctioning valves have not been

Indium 111-labeled platelet deposition in woven and knitted Dacron bifurcated aortic grafts with the same patient as a clinical model.

A study was designed to compare platelet deposition between knitted and woven Dacron grafts in the same patient. Twenty patients received aortoiliac or aortofemoral bifurcated Dacron grafts, each composed of one woven and one double-velour knitted limb. External nuclear graft imaging was carried out after injection of autologous platelets labeled with indium 111. The patients were studied postoperatively in time periods ranging from 6 days to 42 months. Platelet accumulation was almost identical in knitted and woven limbs in all patients. This study appears to indicate that there is no difference in thrombogenicity between knitted and woven bifurcated Dacron grafts in the aortoiliac or aortofemoral positions measured by platelet accumulation.