James V. Richardson

Operation for Aortic Arch Anomalies

Forty-two patients with aortic arch anomalies resulting in tracheoesophageal compression were treated during the period 1948 through 1978. These anomalies are important causes of upper respiratory and esophageal obstruction in babies and small children and can be corrected safely with excellent relief of symptoms. Nineteen patients (45%) had a right aortic arch with a ligamentum arteriosum, 17 patients (40%) had double aortic arches, and 6 patients (15%) had aberrant right subclavian arteries. Other associated congenital malformation and mental retardation were seen in 15 patients (36%). Diagnosis was accurately made in 38 patients (90%) by barium esophagogram. Basic surgical principles include exposure through a left thoracotomy, complete identification of the aortic arch anatomy, and division of the constricting ring. Surgical treatment resulted in 2 deaths (5%), and 1 patient died late. Early postoperative respiratory complications were common. All survivors were relieved of their symptoms late (median, 94 months) postoperatively.

Surgical Treatment of Atrial Myxomas: Early and Late Results of 11 Operations and Review of the Literature

Eleven patients underwent surgical excision of atrial myxomas during a 15-year period, with no hospital deaths. The operation consisted of excision of the tumor with a generous portion of atrial septum or wall. Patch reconstruction of the atrial septum was required in most patients. There were 2 late deaths (14 and 121 months after operation). Late recurrences have been reported in other series but no recurrences were diagnosed in any of the patients in this series reexamined by echocardiography 7 to 156 months (mean, 48 months) after operation. Late functional results were excellent (78%, New York Heart Association Class D. The pertinent literature is reviewed.

Aortopulmonary Septal Defect: Hemodynamics, Angiography, and Operation

Twenty-five patients with malseptation of the aortopulmonary trunk resulting in aortopulmonary septal defect (window) were evaluated in a unique combined surgical series assembled from two institutions participating in the USA-USSR Health Exchange Program. Typical aortopulmonary septal defect or window (type I) with the connection between the ascending aorta and main pulmonary artery was found in 21 patients. Four had a more cephalad defect (type II) between the ascending aorta and the origin of the right pulmonary artery. Hemodynamics were the consequence of a large left-to-right shunt (mean ratio of pulmonary to systemic flow, 3.0) with right ventricular hypertension (mean right ventricular pressure, 86 mm Hg) and increased pulmonary vascular resistance (mean, 7.4 U) (mean ratio of pulmonary to systemic vascular resistance, 0.33). Angiography may provide patterns that allow preoperative distinction between the two types of aortopulmonary septal defect and provide information important in planning the details of corrective operation. Operative techniques included ligation, direct suture, and patch closure of the aortopulmonary septal defect. The best method appeared to be patch closure by the transaortic approach; real and potential problems were associated with other techniques.

The role of endothelium in the patency of small venous substitutes

Twenty-one dogs received Dacron grafts (9 dogs) or silastic Replamineform prostheses (12 dogs) as unilateral segmental femoral vein substitutes. Eight autogenous endothelialized Dacron grafts and eleven autogenous endothelialized silastic Replamineform grafts were also placed as femoral vein substitutes. The latter two groups of grafts had been implanted into the infrarenal aorta for 12 weeks and were well endothelialized as demonstrated by scanning and transmission electron microscopy. Patency was assessed by venography immediately and on Days 3, 7, 14, and 21 post-operatively. Endothelialized Dacron grafts had greater percentage patency (48, 50%) than Dacron grafts (19, 11% (P = N.S.). Endothelialized silastic Replamineform prostheses had significantly better patency (911, 82%) than silastic Replamineform prostheses (012, 0%) (P < 0.02). The combined results of the endothelialized grafts (1319, 69%) were better than the combined results for the Dacron-silastic Replamineform grafts (121, 5%) (P < 0.005). These data indicate that Dacron and silastic Replamineform grafts are not suitable small venous substitutes. Conversely, endothelialization significantly improves the early and late patency of both silastic Replamineform grafts and Dacron grafts. The endothelialized silastic Replamineform prosthesis is the only prosthesis which achieved continuous patency (comparable to autogenous vein grafts) in this experimental model.

Repair of large ventricular septal defects in infants and small children.

It is possible to achieve excellent results for primary closure of ventricular septal defects regardless of the age of the patients when surgical intervention is required. Thirty-two severely symptomatic patients, age 1-24 months, with large ventricular septal defects (m Qp/Qs = 3.4, m R VSD = 4.0), had primary repair of the defects with one (3%) hospital death. Seven patients (22%) had increased pulmonary vascular resistance ranging from 5.4 to 12 units/m2. It was possible to close the ventricular septal defect through the right atrium in 26 patients (81%). Pulmonary artery banding was not performed in any patient with isolated ventricular septal defect during the period of this study. The 31 survivors have been followed an average of four years, and 30 of them are remarkably improved and remain New York Heart Association Class I or II. Only one patient, with obstructive pulmonary vascular disease (pulmonary resistance = 12 U/m2), died suddenly 16 months after operation. Follow-up catheterization was offered to all patients, and to date, 18 (60%) have been restudied. These hemodynamic data show that pulmonary vascular resistance after surgery is usually normal or only minimally elevated; except for one patient with a large residual ventricular septal defect, functionally significant left to right shunts were eliminated. These results and the analysis of results of combined series reported in the literature for primary and staged operations for the continued practice of primary repair of isolated large ventricular septal defects in infants and children who require surgery.

Intramyocardial Electrical and Metabolic Activity during Hypothermia and Potassium Cardioplegia

Hypothermic potassium cardioplegia is widely used to reduce myocardial metabolism as a means of myocardial protection. To investigate the efficacy of intramyocardial electrical activity as an indicator of myocardial metabolism, 12 dogs were placed on cardiopulmonary bypass and myocardial oxygen consumption, partial pressure of carbon dioxide (PCO2) in the coronary sinus, myocardial temperature, and intramyocardial and surface electrocardiograms were measured. The hearts were fibrillated and cooled to 15 degrees C. In Group 1 (6 dogs), potassium cardioplegia was given at 15 degrees C. In Group 2 (6 dogs), it was given at 25 degrees C. Maximum coronary sinus PCO2 and oxygen consumption occurred at 36 degrees C and gradually decreased, but there was still evidence of metabolic activity and intramyocardial electrical activity at 15 degrees C. When cardioplegia was given at 15 degrees C, all electrical activity ceased and there was a further significant reduction in metabolic activity (coronary sinus PCO2 and oxygen consumption). In Group 2 similar findings were found at 25 degrees C, and there was no further reduction in metabolic activity at 15 degrees C. These data indicate that: (1) myocardial metabolic activity is lowest when there is electrical quiescence as measured with an intramyocardial electrode; (2) potassium arrest and hypothermia are both necessary to achieve electrical quiescence; and (3) in the potassium-arrested heart, lowering temperature from 25 degrees to 15 degrees C does not result in a further reduction of metabolic activity.

Esophageal Atresia and Tracheoesophageal Fistula

Fifty-seven babies were surgically treated for esophageal atresia and tracheoesophageal fistula between 1968 and 1978. Forty-eight (84%) had proximal esophageal atresia and a distal tracheoesophageal fistula, 2 (4%) had proximal and distal esophageal atresia and no tracheosophageal fistula, and 7 (12%) had a tracheosophageal fistula without esophageal atresia. Primary repair was accomplished in 43 patients (75%), colon interposition was required in 5 (9%), while the remainder had staged or palliative reapirs. Forty-six (81%) survived surgical treatment. All 21 babies in Waterston Category A, 90% of 20 in Category B, and 44% of 16 in Category C survived surgical treatment. Serious complications occurred in 17 (30%), and dilatable strictures and other minor problems developed in 27 (47%). Late follow-up (mean, 48 months) revealed 3 (7%) late deaths, 2 of which were due to congenital heart disease. Three patients required late colon interposition, and several require frequent dilatations of the esophagus. The Category A and B survivors are all functionally well, while the 5 surviving Category C patients are all significantly impaired by associated anomalies.

The effect of autologous blood salvage techniques upon bank blood usage and the cost of routine coronary revascularization

Preservation of autologous blood during cardiac surgery may reduce the need for homologous blood transfusions. We reviewed our experience for patients undergoing primary coronary revascularization to determine the effect of the use of the Haemonetics Cell-Saver upon blood bank resources and upon the cost of operation. The quantity of homologous blood required by two groups of patients was compared. One group of 46 patients had operation prior to use of the Cell- Saver ; the other group of 31 patients was entered into Cell-Saver protocols. The mean number of homologous blood units transfused per patient fell strikingly (p < 0.0001) from 4.2 before to 0.5 after introduction of the Cell- Saver. Of the 31 patients in the Cell-Saver protocol, 71 % required no homologous blood while they received 2.5 units of autologous blood processed by the Cell-Saver. Related to this, the mean number of units prepared by typing and compatibility testing in anticipation of surgery fell from 10 units to five. The projected cost to the patient fell 23%. There were no adverse effects from the use of the Cell-Saver. We conclude that the use of the Cell-Saver is justified not only to reduce the potential risks of homologous blood transfusion, but also to reduce the strain upon blood bank resources and the patient cost of primary coronary revascularization.

Tined Transvenous Endocardial Electrodes: Results of a Randomized Prospective Study

The early (30-day) dislodgment rate of standard-use flange-tipped and of tined endocardial electrodes was compared in a randomized prospective clinical trial. Four of 16 (25%) of the flange-tipped leads and none of the 18 tined leads dislodged within 30 days of implantation (p = 0.01). We believe that the tined electrode represents a major improvement in electrode design and is clearly superior to the flange-tipped electrode in reducing the incidence of early dislodgment.