Manuel J. Antunes

Primary cardiac leiomyosarcomas

Two patients with primary cardiac leiomyosarcoma, one of the rarest malignant tumors of the heart, are described. The first patient had a tumor of the pulmonary trunk and was admitted with symptoms suggestive of pulmonary thromboembolism. The second had a tumor of the left atrium and had signs and symptoms of mitral valve obstruction and regurgitation. The 2 patients were operated on and later underwent adjuvant chemotherapy. Both died more than 22 months after operation, having required multiple hospital admissions for treatment of complications related to the pathology or the treatment of the primary cardiac leiomyosarcoma. Nonetheless, aggressive surgical excision followed by chemotherapy appears to have improved survival in these patients with primary cardiac leiomyosarcoma, as they are among the longest survivors reported.

Tricuspid Annuloplasty: A Modified Technique

A modification of the de Vega semicircular annuloplasty for tricuspid regurgitation is presented. This technique has been used successfully in 48 patients since January, 1979.

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.

Performance of Glutaraldehyde-Preserved Porcine Bioprosthesis as a Mitral Valve Substitute in a Young Population Group

Porcine bioprostheses were implanted in the mitral position in 289 patients. The mean age was 25.8 +/- 13.7 years. One hundred thirty-five patients (47%) were 20 years old or younger. Most patients had chronic rheumatic valvulitis (74%). Mitral regurgitation and mixed mitral valve disease were the dominant lesions. Hancock, Angell-Shiley, and Carpentier-Edwards prostheses were implanted in 84, 14, and 191 patients, respectively. There were 19 early and 64 late deaths. Mean follow-up was 5.04 +/- 1.03 patient-years. Fifty-eight patients (6.71% per patient-year) were reoperated on for degenerated prostheses, with 13 deaths. Twelve patients died without reoperation, and 17 await reoperation for degenerated valves. The rate of structural failure (total, 87 patients) was 21.07% and 3.04% per patient-year for patients less than and older than 20 years, respectively (p less than 0.001). The 6-year actuarial survival for these two groups was 50% and 68%, respectively. However, for patients 20 years old or younger, survival free from degeneration was only 20% at 6 years (p less than 0.001). Bioprostheses have a high failure rate and should not be implanted in young patients or in patients with a life expectancy exceeding 10 years.

Acute traumatic rupture of the aorta: repair by simple aortic cross-clamping.

This report describes the techniques used in 16 patients for repair of acute traumatic rupture of the aorta. Direct aortic cross-clamping (13 to 27 minutes) was used without additional methods of spinal cord protection. Direct suture was possible in (56%) of the 9 patients with partial rupture of the aorta but in only 1 (14%) of the 7 patients with complete disruption. In the remaining patients, the repair was carried out by interposing Gore-Tex patches (4 patients) or open tubular grafts (6 patients) using a simplified method, which is described. The 2 deaths, 1 intraoperative and 1 postoperative, were unrelated to the technique. There were no additional perioperative complications. Direct aortic cross-clamping and repair by direct suture or open tubular graft, as described, greatly simplify the correction of acute traumatic rupture of the aorta, and their use is strongly recommended.

Isolated replacement of a prosthesis or a bioprosthesis in the mitral valve position

The operative results of 249 mitral valvular reoperations performed in 215 patients from 1974 through 1986 were reviewed to identify groups at greater risk. Two to 4 reoperations were performed in 28 patients. The mean interval between the first and second valve procedures was 47 +/- 40 months. The most common indications for reoperation were degeneration of bioprostheses (44%) and thrombosis of mechanical prostheses (26%). Thirty patients (12%) died. This rate was significantly higher (p less than 0.02) than that for primary valve procedures performed during the same period. The mortality rate for elective reoperations was 7%. Mortality rates were higher among patients with prosthetic valve endocarditis (6 of 17 cases, 35%), in those undergoing operation on an emergency basis (19 of 82, 23%) and when tricuspid valve replacement or anuloplasty was also performed (9 of 38, 24%) (p less than 0.02). No significant correlation was found between mortality rates and the age or sex of the patients and the types of prosthesis used originally.

Posterior D-transposition of the great arteries with an unusual form of aortic obstruction

SummaryAn unusual case of posterior transposition of the great arteries, with previously underscribed aortic obstruction is described. The patient, who underwent an arterial switch operation, was found at surgery to have a mass of myxomatous tissue arising from the tricuspid valve. This finding was responsible for the hemodynamically significant aortic stenosis.

Is the shunt patent

A novel technique for auscultating an aortopulmonary shunt murmur utilizing the principle of conduction of sounds through a closed air system is described.