Loren C. Winterscheid

The Wolff-Parkinson-White syndrome: problems in evaluation and surgical therapy.

Two patients with WPW syndrome underwent surgery to ablate accessory conduction pathways. Endocardial and epicardial mapping in both patients had indicated an area of early right ventricular depolarization. Surgical transection of the areas of early depolarization failed in both cases to normalize the electrocardiogram. In the first patient, additional resection in the area of the A-V node failed to produce heart block and the ECG remained abnormal. However, the paroxysmal tachycardia ceased, and she has remained asymptomatic and active 12 months after surgery. In the second patient, as the A-V node was about to be sectioned, pressure and procaine near the A-V node caused the ECG to normalize transiently and after resection permanently. Microscopic study of this tissue showed “P cells.” Postoperatively the patient demonstrated normal A-V nodal function. He was discharged with a normal ECG but expired soon after discharge. Postmortem examination of the heart demonstrated the A-V node and bundle of His plus the location of the resection adjacent to the bundle of His. These two cases illustrate disparities between electrophysiologic mapping and actual site of the accessory conduction pathway. In one of the cases an accessory bundle was demonstrated histologically.

Changes in Maximal Exercise Performance in the Evaluation of Saphenous Vein Bypass Surgery

To evaluate the improvement in myocardial oxygen delivery following saphenous vein graft surgery (SVG) for angina pectoris (AP), 46 patients underwent a multistage treadmill test of maximal exercise capacity before and 3-22 (average 8) months after SVG. Variables from exercise testing were correlated with symptomatic response, left ventricular hemodynamics, and graft patency.Functional capacity (NYHA) improved in 38 (85%), while 27 (59%) had a significant improvement in exercise performance. Functional aerobic impairment (FAI), or the percentage deviation from expected VO2max, improved by a mean of 16% (P < 0.001). Maximal systolic pressure-rate product/100 increased 36 (P < 0.002). Twenty of 29 (66%) with presurgical S-T segment depression had a normal response after surgery.Thirty-three patients were studied for graft patency and had quantitative angiography. Seventeen had all grafts patent and demonstrated a mean improvement of 21% in FAI (P < 0.0007). Those with occluded grafts showed no improvement in exercise performance. Sixteen of 22 (73%) with severe exercise impairment showed significant improvement, but only four of 14 (29%) with mild impairment showed a significant improvement. There were no mean changes in left ventricular end-diastolic pressure, cardiac index, contraction plot, or systolic ejection fraction (SEF) in any of the patients. Preoperatively nine had a depressed SEF (<50%), and no improvement in exercise performance could be demonstrated.Maximal treadmill testing has demonstrated objectively that SVG can improve functional capacity and that it is correlated with graft patency. Ideal surgical candidates appear to be those with severe exercise impairment and unimpaired ventricular performance.

Traumatic rupture of the thoracic aorta: a review of the literature and a report of five cases with attention to special problems in early surgical management.

Traumatic Rupture of the Thoracic Aorta: A Review of the Literature and a Report of Five Cases with Attention to Special Problems in Early Surgical Management Edward Rittenhouse;David Dillard;Loren Winterscheid;K. Merendino; Annals of Surgery

Correction of Total Anomalous Pulmonary Venous Drainage in Infancy Utilizing Deep Hypothermia with Total Circulatory Arrest

Four critically ill infants aged 3, 5, 5, and 13 months; weighing 3.7, 4.6, 5.3, and 6.5 kg, respectively; with total anomalous pulmonary venous drainage, underwent complete correction of their lesions with the utilization of surface-induced deep hypothermia. Although this series is small, we are not aware of any other consecutive series in this age group with a comparable mortality rate. Rectal temperatures of 17.5 to 20.2 C were utilized, with periods of cardiac arrest and total circulatory interruption of 32 to 41 minutes. Important aspects of the technique are surface cooling, deep ether anesthesia, intravenous low-molecular-weight dextran, induced respiratory alkalosis during cooling, and electrical pacing during resuscitation. This method works well in the infant, in contrast with perfusion techniques in which surgical mortality is excessively high.

Open Heart Surgery in Infective Endocarditis

Fourteen patients with bacterial endocarditis had open heart surgery. Thirteen were operated upon because of congestive heart failure, and in one the indication for surgery was persistent infection. The aortic valve alone was involved in six patients; two patients had both aortic and mitral valve endocarditis. Five patients had infection of the mitral valve, and one patient had tricuspid valve involvement. All the patients received preoperative antibiotics for a variable period.Ten patients left the hospital and four died in the hospital. Of the 10 patients discharged, one died 9 months later of congestive heart failure. Seven patients developed valvular leaks either through the suture line or the homograft, and two deaths resulted. Nine patients are alive and in good functional status. Antibiotics were given for 5 to 10 days postoperatively; one patient, however, received antibiotics for 49 days.Early open heart surgery is recommended in bacterial endocarditis if heart failure is progressive. Shorter postoperative antibiotic therapy is proposed once the source of residual infection is removed.

Repair of Mitral Incompetence Secondary to Ruptured Chordae Tendineae

Twenty-two patients with ruptured chordae tendineae are presented. Etiology was rheumatic heart disease in seven patients, bacterial endocarditis in four patients, both rheumatic heart disease and endocarditis in two patients, trauma in one patient, and aortic regurgitation in one patient. Exact cause of rupture was unknown in seven patients. Plastic repair of the leaflet and/or posteromedial annuloplasty was done in all the patients. In two patients the annuloplasty broke down soon after the operation and necessitated valve replacement. There was one hospital death. One patient died two years after operation probably because of cerebral embolism; a large thrombus was found in the left atrium at autopsy. All survivors have been followed for 7 months to 8 years and, except for two, are either working full-time or leading an active life.In ruptured chordae early and five-year results after repair of the leaflet and/or posteromedial annuloplasty are very good irrespective of the left atrial enlargement and “V” wave size. Results were better in the rheumatic group than in the nonrheumatic group. In our opinion this method of treatment is superior to prosthetic valve replacement for this condition, except if the annulus is thin and attenuated.

Effects of Isoproterenol on Carbohydrate Metabolism of Isolated Canine Heart

Chronotropic and inotropic effects of intraarterial infusion of isoproterenol were monitored in the isolated, metabolically supported preparations of the canine heart. The time-dosage relationship was found to be hyperbolic over a narrow range of concentration of isoproterenol. Increasing concentration beyond the optimal range by a factor of about two produced arrhythmias and A-V conduction defects. Oxidative metabolism increased significantly and proportionally to heart rate. Since utilization of glucose remained the same, pyruvate utilization increased slightly and lactate was excreted; the augmented oxidative metabolism could not be accounted for by the observed changes in carbohydrate substrates. Myocardial glycogen concentrations were insignificantly changed during this inotropic stimulation.

The surgical therapy of extracardiac anomalous pulmonary drainage.

The English surgical literature was reviewed for a 10-year period between 1950 and 1960. A total of 166 patients with anomalous pulmonary venous drainage treated surgically was found. Of this number, 65 patients had total anomalous pulmonary venous drainage (40 per cent). Ninety-five patients (57 per cent) had anomalous venous drainage via extracardiac channels. The over-all survival rate for 166 patients was 74 per cent. The single lesion with the lowest survival rate (35 per cent) was total anomalous pulmonary venous drainage via a persistent left anterior cardinal vein. Of the 34 patients in this category, only three (9 per cent) had a complete repair of the anomalous drainage with survival. A series of 10 patients with anomalous venous drainage via extracardiac channels operated on with the aid of extracorporeal circulation is reported. There were three deaths. Drainage occurred via the superior vena cava (six patients), the coronary sinus (two patients), and a persistent left anterior cardinal vein (two patients). Included in the series is a fourth instance of successful complete repair of total anomalous pulmonary venous drainage via a persistent left anterior cardinal vein. The clinical features, methods of repair, and perfusion data are reviewed. An important aspect of treatment for total anomalous pulmonary venous drainage is the realization that impedance of pulmonary venous outflow is extremely hazardous. It is suggested that pulmonary venous pressure be monitored when complete repair is contemplated. If complete occlusion of decompressive channels causes a significant increase in the pulmonary venous pressure, some avenue of decompression should be left; otherwise, venous infarction of the lungs with probable fatality will result.

The spectrum of patients with pulmonary embolism

Abstract 1. 1. Eight patients with the clinical diagnosis of pulmonary embolism have been studied, using lung scanning, arteriography, arterial blood gases, and right heart pressure measurements in addition to the routine studies available for the diagnosis of this disease. 2. 2. Two patients underwent pulmonary embolectomy. In the first instance, the operation was carried out after the patient had been resuscitated after cardiac arrest. This patient expired thirty-six hours postoperatively. The second patient is alive and well. 3. 3. Two patients with extensive embolism were treated with inferior vena cava ligation or clipping. Postoperative arteriography and lung scanning documented the resolution of the emboli and restoration of pulmonary arterial flow. 4. 4. Two patients thought to be candidates for pulmonary embolectomy on the basis of the usual clinical signs and symptoms and routine studies were found by pulmonary arteriography to have no pulmonary emboli. 5. 5. Patients with hypotension, complete unilateral pulmonary artery embolic occlusion, elevated right heart pressure and arterial oxygen desaturation that does not improve with inhalation of 100 per cent O 2 should undergo embolectomy and inferior vena caval plication. Patients in whom the occlusion is incomplete but involves a major portion of blood flow to both lungs are also candidates for embolectomy. 6. 6. Patients with partial embolie occlusion of major pulmonary arteries, without hypotensive and without arterial oxygen desaturation (or if the arterial oxygen desaturation improves with inhalation of 100 per cent O 2 ), should undergo inferior vena caval plication. 7. 7. All patients should be anticoagulated and be treated with other therapy directed toward prevention of further venous stasis thrombophlebitis.

Left ventricular function following internal mammary inplantation

Abstract The effect of internal mammary arterial revascularization of the myocardium on left ventricular (LV) function was studied in 12 patients before and 11 to 24 months after operation by quantitative LV biplane angiocardiography and hemodynamics. An additional four patients who were not treated surgically were also studied. Preoperatively all were rated as clinical class II or III; all had moderate impairment of treadmill exercise tolerance; none had mitral regurgitation or heart failure. Seven had definite myocardial infarctions. Six received single and six double mammary implants. Prior to therapy, the average LV enddiastolic volume (EDV) was 71 ± 22 c.c. per square meter; the end-systolic volume (ESV) was 25 ± 20 c.c. per square meter; the systolic ejection fraction (SEF) was 68 ± 15; the LV mass (LVM) was 99 ± 26 Gm. per square meter; the LV pressure (LVP) was 9 mm. Hg; and the angiographic cardiac index (ACI) was 3.62 ± 0.4 L. per minute per square meter. Only one patient had abnormal contraction involving more than 25 per cent of the left ventricle. Following therapy clinical class improved in four, declined in five, and was constant in seven. None became Class I. A test of exercise capacity (functional aerobic impairment) showed an insignificant improvement from 39 ± 11 to 30 ± 18 per cent. Mitral regurgitation was present in one and heart failure in one. Underlying coronary artery lesions progressed in two and improved in one. LV studies showed EDV, 78 ± 25 c.c. per square meter; ESV, 34 ± 20 c.c. per square meter; SEF, 58 ± 16 per cent; LVP, 10 mm. Hg; and ACI, 3.40 ± 0.9 L. per minute per square meter. Contraction patterns had become worse in six of 15 patients, and none improved. In nine successful implants four showed good anastomoses and five minimal anastomosis with the coronary arterial bed. Stability or improvement in clinical class and exercise performance could not be related to improvement in LV function following myocardial revascularization; in fact, some patients had deterioration in LV function, suggesting that injury to the myocardium occurs at the time of operation.