Lari A. Attai

Bypass Grafts for Recurrent or Complex Coarctations of the Aorta

Twenty-three patients aged 5 to 53 years with recurrent or complex coarctations of the aorta were successfully operated upon using bypass grafts. This technique of repair was selected for 5 patients with recurrent coarctation, 11 with long-segment coarctation with or without hypoplasia of the transverse aortic arch, and 7 with inadequate collateral circulation. Nineteen patients had bypass grafts from the left subclavian artery to the distal descending thoracic aorta. The other 4 had a combined approach through a left thoractomy and median sternotomy with grafts between the ascending and descending thoracic aorta. All patients survived the operative procedure. One patient were reexplored for a hemothorax and 5 developed transient postoperative hypertension. There were no instances of abdominal vasculitis or lower extremity paralysis. These patients have been followed from 3 months to 11 years postoperatively, and all but 1 are alive and well. Twenty-two are normotensive, and none have the sequelae of hypertensive disease. Gradients up to only 15 mm Hg exist between upper and lower extremity blood pressures. Five patients have undergone postoperative catheterization and aortography, and all have patent grafts. This procedure is a useful and adjunct in difficult coarctations of the aorta and can be safely performed with excellent reproducible long-term results.

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.

Diagnosis and Reversal of Rejection in Experimental and Clinical Lung Allografts

Abstract Experience in our patients and dogs with lung transplants has provided reliable criteria for diagnosing rejection and distinguishing it from other pathological processes such as pneumonia and ischemic injury. These criteria include fever; dyspnea; malaise; increased sputum production; decreased arterial oxygen tension; and, most importantly, the rapid development (often within hours) of a roentgenographic alveolar infiltrate without any change in the sputum bacteriology. Using these criteria we have identified multiple rejection episodes in 2 patients and in comparably immunosuppressed dogs. In almost every instance all acute manifestations of rejection, including the roentgenographic infiltrates, have been completely reversed by three to seven large intravenous doses of methylprednisolone given at 12- to 24-hour intervals. In the dogs, reversal of rejection has also been confirmed by gross and microscopical examination of the allograft. These findings show that acute rejection in lung allografts can be reliably identified by noninvasive criteria and successfully reversed.

A simple technique for tension-free pericardial closure.

Closure of the pericardium after cardiac operations is desirable but is not always possible to achieve. We describe here a simple technique for tension-free, anterior closure of the pericardium.

SINGLE-LUNG TRANSPLANTATION IN EMPHYSEMA

Abstract A patient with severe bilateral emphysema has survived more than 31/2 months after receiving a single-lung allograft. At least seven presumed episodes of rejection were identified and reversed by massive pulsed intravenous doses of methyl prednisolone. When allograft rejection was controlled, no serious or progressive ventilation-perfusion imbalances occurred and the allograft provided the majority of effective ventilation and pulmonary blood-flow, with consequent improvement in the patients respiratory status.

Surgical treatment of valvular heart disease. Part III. Surgical repair of the stenotic mitral valve

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.

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 valvular heart disease: Part VI. Aortic valve surgery

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.

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.

Coronary Embolism Following Mitral Valve Replacement: Intraoperative Diagnosis and Successful Embolectomy

Abstract A 48-year-old man undergoing mitral valve replacement sustained an intraoperative embolism to the left main coronary artery. This resulted in acute cardiac decompensation in spite of all conventional resuscitative measures. The condition was suspected, and successful coronary embolectomy was carried out through an ascending aortotomy. Following this, the postoperative course was uneventful.