James W. DuShane

Anatomic and Pathologic Studies in Ventricular Septal Defect

In a necropsy study of 50 cases of ventricular septal defects, the anatomic position and relations of ventricular septal defects, the causes of and ages at death, and association of ventricular septal defects with other cardiovascular malformations were determined. The present availability of surgical closure of ventricular septal defects makes this information of practical significance.

The Atrioventricular Conduction System in Persistent Common Atrioventricular Canal Defect Correlations with Electrocardiogram

Serial histologic sections of the atrioventricular (A-V) conduction system were studied in four hearts with persistent common A-V canal, and the anatomic findings were related to the abnormal ECG patterns. Two hearts were examples of the partial form and two of the complete form of A-V canal. The major anatomic abnormalities were: (1) postero-inferior displacement of the A-V node; (2) relatively short distances between the A-V node and the origin of the left bundle branching; (3) marked posteroinferior displacement of the left bundle branching system; and (4) relative hypoplasia of the anterior (superior) left bundle branches. The anatomic configuration of the A-V conduction system in A-V canal could result in relatively early impulse propagation to the posterior aspect of the ventricular septum as suggested by reported electrophysiologica studies. The anatomic findings are considered to be related closely to the known ECG patterns of A-V canal.

The Electrocardiogram of Patients with Atrioventricular Cushion Defects (Defects of the Atrioventricular Canal)

Abstract The electrocardiogram is the most important single item in alerting the physician to the diagnosis of congenital cardiac anomalies stemming from defective formation of the atrioventricular canal. It is characterized by left axis deviation with the early manifest frontal vector characteristically in the 0 ° to −60 ° zone. The tracings usually show evidence of enlargement of the right ventricle, particularly an rSR configuration in right precordial leads, the picture of volume overloading of the right ventricle. Different hemodynamic profiles (for instance, the amount of shunting at the atrial and ventricular levels, the degree of mitral insufficiency and the pulmonary hypertensive level) will be additively reflected in the basic electrocardiographic pattern. The typical electrocardiogram may be encountered occasionally in other types of congenital heart disease, particularly ventricular septal defects located posteriorly under the septal tricuspid leaflet. It is believed that the electrocardiographic pattern is related to a congenital aberration of the left bundle branch system.

The Pulmonary Arterial Tree in Ventricular Septal Defect: A Quantitative Study of Anatomic Features in Fetuses, Infants, and Children

The pulmonary vascular tree was studied in 12 cases of uncomplicated atrial septal defect in fetuses, infants, and children. The ages of these subjects ranged from 24 weeks of fetal life to 11 years. A quantitative analysis was made of the medial thickness and of the index of medial surface area (ratio of medial tissue to pulmonary parenchyma) of the pulmonary arterial branches. In contrast to subjects with ventricular septal defect in corresponding age groups, the three fetuses in this series had medial hypertrophy, as indicated by a high index of medial surface area. In the postnatal group, both the medial thickness and the index of medial surface area were also usually greater than in the controls of corresponding ages, notably in two patients, who, at the ages of 7 weeks and 4 months, died of cardiac failure. No satisfactory explanation for these unexpected findings can be offered. Slight to moderate intimal proliferation was observed in some muscular and elastic pulmonary arteries, in bronchial arter...

A complex of congenital cardiac anomalies: ventricular septal defect, biventricular origin of the pulmonary trunk, and subaortic stenosis.

Abstract Four cases are reported that presented an anatomic complex consisting of ventricular septal defect with biventricular origin of the pulmonary trunk and subaortic stenosis. The ventricular septal defect in this complex is unusual in that it is located anteriorly in the outflow tract of the right ventricle and does not involve the membranous portion of the ventricular septum. The subaortic stenosis is the consequence of a muscular ridge that lies across the outflow tract of the left ventricle and encroaches on the width of the subaortic portion of this outflow tract. The pulmonary artery is not transposed and overrides the ventricular septal defect. Associated anomalies of the aortic arch were present in all cases. Early infantile death from pulmonary hemorrhage and edema occurred in these cases.

The Pulmonary Arterial Tree in Ventricular Septal Defect

A quantitative analysis was made of the pulmonary arterial medial thickness and index of medial surface area (ratio of medial tissue to pulmonary parenchyma) in 50 cases of uncomplicated ventricular septal defect in fetuses, infants, and children. The ages of the subjects ranged from 26 weeks of fetal life to 12 years. The results were compared with those obtained from a control group of the same age. During the fetal and newborn period, both the thickness and the index of surface area of the media were generally within normal limits, although in an occasional case pulmonary arterial branches were considerably thinner than those in corresponding controls. The subjects between 1 week and 5 weeks of age had a medial thickness and an index of medial surface area that were lower than the average values at the time of birth. In this regard the pulmonary arterial tree in cases of ventricular septal defect corresponded with that in normal newborn infants. Soon after, however, and most clearly from 8 weeks on, th...

Pulmonary atresia with intact ventricular septum Report of two cases studied by selective angiocardiography and right heart catheterization

Abstract Two cases of pulmonary atresia and intact ventricular septum have been presented. In one case a right ventricular cavity of small size was present (Type 1), and in the other a right ventricular cavity of large size was found (Type 2). The patient with the Type 1 defect had high right ventricular pressure and a normal contour of atrial pressure. Injection of opaque medium into the right ventricular cavity demonstrated anomalous myocardial sinusoids. The patient with the Type 2 lesion had a normal right ventricular pressure and a dominant “v” wave in the contour of the right atrial pressure curve. An angiocardiogram showed a large, dilated right ventricular cavity, gross tricuspid regurgitation, and a tricuspid valve displaced to the left. The surgical implications of these findings were discussed briefly.

Ventricular Septal Defect and Aortic Insufficiency: Surgical Considerations and Results of Operation

Abstract Ventricular septal defect (VSD) is uncommonly associated with valvular aortic insufficiency (AI). From 1957 through 1971, 51 patients with this combination underwent operation at the Mayo Clinic; these patients made up 2.2% of all patients with VSD repaired during that period. The most frequent aortic valve abnormality was a prolapsing right cusp. Surgical management of AI consisted of: (1) no procedure on the aortic valve in 25 patients, (2) plastic repair of the aortic valve in 13 patients, and (3) partial or total replacement of the aortic valve in 13 patients; in the group with severe AI prior to operation, those treated by replacement did better than those treated by repair. Early closure is indicated for VSD associated with mild AI. With severe AI, VSD closure and valve plication are preferred, although valve replacement may be necessary either at the primary operation or at some future date. In adults, replacement with a prosthesis is indicated for severe AI.

THE ELECTROCARDIOGRAPHIC AND HEMODYNAMIC FINDINGS IN PULMONARY STENOSIS WITH INTACT VENTRICULAR SEPTUM.

In certain forms of heart disease when the diagnosis is readily apparent from clinical examination, it would be desirable to assess the degree of hemodynamic abnormality by the simplest method. If electrocardiographic data could provide a sufficiently accurate indication of altered function, the need for cardiac catheterization might be obviated. However, detailed electrocardiographic criteria1, 2 do not appear to correlate with the weight of the ventricle or the thickness of the ventricular wall.3 A more definitive result might be obtained from correlations of the electrocardiographic details with function, as attempted by Cosby and co-workers,4 rather than with anatomic structure. For this functional approach, Cabrera and Monroy5 disseminated the concepts of the systolic and the diastolic overloading of the ventricle. Statistical support for these ideas is not yet available even though modified views have been presented.6 Studies of correlation between the severity of pulmonary stenosis and electrocardiographic evidence of right ventricular hypertrophy7–11 disclose a wide variability. From a functional view, the simplicity of the abnormality makes pulmonary stenosis an ideal disease to study; there is solely a systolic or pressure overload of the right ventricle. In order to overcome obstruction to outflow through the pulmonary valve, the right ventricular systolic contraction takes a longer time and becomes more powerful. Recent investigators12, 13 have compared the peak right ventricular systolic pressure with various aspects of the electrocardiogram. But as Haywood, Selvester, and Griggs14 realized, pressure data alone are insufficient to assess hemodynamic function; flow must also be considered. For example, to double the flow rate through an orifice, the pressure gradient must be quadrupled if there is no change in resistance to flow due to altered turbulence. The purpose of this study is to determine the relationships between the electrocardiographic data and hydraulic data that consider the effect of blood flow.

Indications for repair of ventricular septal defects

Abstract The indications for operation in patients with ventricular septal defect are presented. The bases for these indications lie in the natural history of the disease in its various forms and in the risks and results of operation.