Luigi Chiariello

Conduit Reconstruction of Right Ventricular Outflow Tract: Experience with 17 Patients

Evaluation was made of 17 patients who underwent conduit reconstruction of the right ventricular outflow tract (for anomalies other than truncus arteriosus) at the Texas Heart Institute between December, 1965, and June, 1974. Fifteen patients survived the operation and have shown substantial clinical improvement. Several different conduits were used, principally an allograft aorta with the aortic valve and mitral leaflet attached, a woven Dacron prosthesis containing a xenograft (porcine) valve, and a valveless Dacron tube graft. Allograft conduits are sometimes difficult to procure and keep and tend to calcify with passage of time. Woven Dacron prostheses are favored because they are readily available in a wide range of sizes. We believe it is not necessary for the conduit to contain a valve unless the patient has pulmonary hypertension, in which case we use a xenograft (porcine) valve because this valve does not require the long-term use of anticoagulants, a difficult regimen to manage in children. The largest possible prosthesis must be used; otherwise right ventricular hypertension will persist. Indications for conduit reconstruction include anomalous coronary arteries crossing the right ventricular outflow tract, discontinuity of the pulmonary arteries, and pulmonary atresia with a ventricular septal defect. Our current method of managing pulmonary atresia with ventricular septal defect (pseudotruncus arteriosus) includes palliative shunting to relieve hypoxemia during infancy and to permit full development of the pulmonary arteries for eventual total correction at a more optimal age when a larger conduit may be used.

Surgical Treatment for Anomalous Origin of Left Coronary Artery from Pulmonary Artery

Anomalous origin of the left coronary artery from the pulmonary artery carries a poor prognosis; most patients die early in life from myocardial infarction and congestive heart failure. During a 12-year period at the Texas Heart Institute, 13 patients with this congenital malformation ranging in age from 1 to 24 years underwent operation. The anomalous coronary artery was sutured or ligated, or both, close to the pulmonary artery in 3 patients, 2 before 1965. Aortocoronary bypass was performed in the remaining 10 patients, using an autogenous saphenous vein graft in 9 and a Dacron tube in 1. More recently a distal end-to-side anastomosis has been employed and is not the preferred method. If necessary, a pump oxygenator may be used to complete the procedure. The only death was that of the first patient in the series who underwent ligation of the left coronary artery and mitral annuloplasty for severe mitral insufficiency; Of the 12 patients available for long-term follow-up study, all but 1 were asymptomatic. Follow-up angiographic studies showed the graft to be patent in 7 patients; the longest period of graft patency was 8 years. Definitive operative therapy is preferable to simple ligation because it eliminates the left-to-right shunt from the right coronary artery to the pulmonary artery and establishes a double coronary artery system.

Aneurysm of Pericardial Right Ventricular Outflow Tract Patches

Among 1,022 patients who underwent repair of tetralogy of Fallot, 252 received a pericardial patch of the right ventricular outflow tract; of these, 10 subsequently developed an aneurysm of the right ventricular outflow tract. Cardiac catheterization and angiography revealed moderate pulmonary insufficiency in all patients, a residual pressure gradient in the right ventricular outflow tract in 7, and a residual ventricular septal defect in 2 patients. Reoperation was indicated in 8 patients because of progressive distention of the aneurysm, residual infundibular or pulmonary artery stenosis, and recurrent ventricular septal defect. Reconstruction of the right ventricular outflow tract was accomplished by resection of the aneurysm and insertion of a woven Dacron patch in 5 patients, primary suture of the pulmonary artery in 2, and implantation of a woven Dacron conduit containing a Björk-Shiley cardiac valve prosthesis in 1 patient. There were no early or late deaths. When reconstruction of the right ventricular outflow tract is necessary, we recommend a woven Dacron patch because pericardium may form an aneurysm.

193. Bypass-Chirurgie der Coronararterien bei 95 Patienten über dem 70. Lebensjahr

SummaryFrom October 1969 through June 1974, 95 patients over 70 years of age underwent aortocoronary bypass at the Texas Heart Institute. The primary indication for surgery was severe angina, which was present in 88 patients. The mean coronary artery score was 9.51. Improvements in surgical technique are responsible for a reduction in the hospital mortality from 22.1 percent in all 95 patients to only 4.8 percent in the 21 patients operated upon during the first 6 months of 1974.ZusammenfassungVon den bis Juli 1974 am Texas Heart Institute durchgeführten 3780 aorto-coronaren Bypass-Operationen waren 95 Patienten 70 Jahre oder älter. Die anfänglich hohe Operationsmortalität in dieser Altersgruppe mit 27% stand in klarem Gegensatz zur Gesamtmortalität von 7,1% und konnte im letzten Jahr - hauptsächlich auf Grund von Verbesserungen in der Operationstechnik - von 27 % auf 4,8 % reduziert werden. Damit kann auch beim alten Patienten, im Einzelfall, eine coronare Bypass-Operation als Behandlungsmöglichkeit ins Auge gefaßt werden.

196. Aktive bakterielle Endokarditis und ihre Klappenkomplikationen -Chirurgische Ergebnisse bei 225 Patienten

SummaryBetween 1959 and 1973, 225 patients were operated on because of active bacterial endocarditis or its valvular complications. The hospital mortality was 12 percent and 60 patients died an average of 2 years after the operation. Seven early deaths occurred among 16 cases of acute dehiscence of the prosthetic valve-an indication for extensive resection of all diseased tissues. The average age was 43 years and there were 21 deaths due to myocardial infarction. The authors believe that the operative mortality can be further reduced through combined valvular and coronary artery surgery where this is indicated.Zusammenfassung225 Patienten wurden wegen aktiver bakterieller Endokarditis oder der Klappenkomplikationen operiert. Die Frühmortalität betrug 12%. Bei 16 Patienten kam es zur Prothesendehiszenz - davon überlebten 6 Patienten die notfall mäßige Reoperation und 7 Patienten verstarben -, eine Indikation zu ausgedehnter Resektion des erkrankten Gewebes. Das mittlere Operationsalter betrug 43 Jahre. Auf Grund der vorliegenden Daten darf angenommen werden, daß die Mortalität durch eine kombinierte klappenchirurgische- und Coronararterien-Operation - falls indiziert-weiter gesenkt werden kann.