Marian I. Ionescu

Atrial septal defect in adults: Clinical and hemodynamic results of surgery☆

Abstract Secundum type atrial septal defects were closed in 32 adults aged 30 to 57 years, with the use of cardiopulmonary bypass. Before operation, 12 had functional class II disease and 11 class III disease (New York Heart Association classification). Eight had a history of congestive cardiac failure, and 6 had atrial fibrillation. Cardiothoracic ratio ranged between 50 and 76 percent. Sixteen patients had moderate to severe pulmonary hypertension, but none had reversed shunt. There was 1 operative and 1 late death. Neither death was related to the complications usually associated with atrial septal defect in this age group. The remaining patients were followed up for 6 months to 12 years. All but 2 had functional class I disease after operation. Postoperatively a statistically significant reduction was noted in cardiothoracic ratio and pulmonary arterial pressures, and there was consistent rise in calculated pulmonary to systemic resistance ratio. A small residual shunt of 1.6:1 was present in 2 patients. It is concluded that irrespective of preoperative complications (pulmonary hypertension, atrial fibrillation and congestive heart failure), repair of atrial septal defect with left to right shunt in adults produces considerable clinical and hemodynamic improvement, and has low mortality and morbidity rates.

HEART-VALVE REPLACEMENT WITH AUTOLOGOUS FASCIA LATA

Abstract In a search for a better substitute for diseased heart-valves a technique of using autologous fascia-lata grafts mounted on to a support frame was developed. Since April, 1969, such grafts have been inserted into 70 patients in the mitral, aortic, or tricuspid area, with good immediate results. No systemic emboli have occurred, although anticoagulants have not been used.

Magnesium in patients undergoing open-heart surgery

Measurements of serum and urinary magnesium levels were made together with the other electrolytes, haematocrit, pH, and albumin in patients comprising two groups—one group of 50 patients undergoing heart valve replacement, and the other, 30 patients undergoing non-perfusion thoracic operations. Low serum magnesium levels were found in some patients admitted to hospital who were or had recently been in congestive heart failure. All patients were found to have low serum magnesium levels postoperatively, but to a greater degree and for a longer period following open-heart surgery. The latter group exhibited hypomagnesuria postoperatively. The literature is reviewed in an attempt to explain the reasons for the changes in the magnesium levels. It is concluded that the changes observed in this limited study warrant further detailed investigation including the use of a double blind trial for assessing the therapeutic value of administering magnesium salts of patients undergoing open-heart surgery.

Long-term results of DeVega tricuspid annuloplasty

DeVega tricuspid annuloplasty was performed in 74 patients undergoing mitral or mitral and aortic valve replacement between January, 1972, and December, 1985. Sixty-two hospital survivors have been followed up for a mean of 85.3 +/- 6.6 months. Actuarial survival at 14 years was 71.5 +/- 8.2%. None of the late deaths was related to the tricuspid annuloplasty. Three patients required tricuspid valve replacement for recurrence of tricuspid regurgitation (0.68% per annum). Eleven asymptomatic patients studied hemodynamically at a mean period of 53 months after the operation showed maintenance of the hemodynamic improvement. We recommend DeVega annuloplasty as the method of choice for moderate to severe tricuspid regurgitation in the absence of an organically diseased or deformed valve.

Frame-mounted tissue heart valves: technique of construction

Bartek, I. T., Holden, M. P., and Ionescu, M. I. (1974). Thorax, 29, 51-55. Frame-mounted tissue heart valves: technique of construction. The technical details for the construction and preservation of frame-mounted tissue heart valves are described. The results of clinical and experimental work which have prompted changes and improvements in valve construction are briefly discussed.

Mitral valve replacement with aortic heterografts in humans

The complications associated with the implantation of prosthetic valves and the experimental attempts to graft the mitral valve are described. Because of the disadvantages connected with the use of artificial valves and as the experimental methods of grafting the mitral valve did not prove satisfactory for clinical use, the authors developed a technique for mitral valve replacement using heterologous aortic valves—reinforced by a semirigid Teflon ring—placed above the mitral annulus inside the atrial cavity. The technique of collecting, preparing, and inserting these grafts is described in detail. Using this method, seven patients with mitral incompetence or mitral disease were operated upon between February and April, 1967. One patient died five weeks after the operation from bacterial endocarditis in a period of severe hospital infection with staphylococcus. The other six patients had a very good clinical result immediately after surgery. At the present time they are symptom-free and have normal heart sounds. Clinical and experimental data are discussed concerning the long-term fate of aortic heterografts in the mitral position.

Replacement of heart valves with frame-mounted tissue grafts

Ionescu, M. I., Pakrashi, B. C., Mary, D. A. S., Bartek, I. T., and Wooler, G. H. (1974). Thorax, 29, 56-67. Replacement of heart valves with frame-mounted tissue grafts. Between April 1969 and March 1973, 213 patients had heart valve replacement with frame-mounted autologous or homologous fascia lata or with heterologous pericardial grafts. There were 111 single aortic, 95 single mitral, and seven tricuspid valve replacements. The incidence of hospital and late mortality was each 10% for the entire series and the main causes were myocardial failure and infective endocarditis. The majority of patients obtained significant symptomatic improvement. In patients with aortic replacement there was a statistically significant reduction in cardiothoracic ratio and in the voltage of the electrocardiogram. Regurgitant murmurs developed in 11·6% of aortic patients and in 51·6% after mitral replacement (in 37·5% the murmur has not increased in intensity while in 14·1% it has gradually progressed). None of these mitral patients requires reoperation. Grafts in the tricuspid position have not shown signs of dysfunction or failure. Graft failure has not occurred in the aortic replacement series. From the mitral position six grafts have been removed due to failure. All six were made of autologous fascia and all showed varying degrees of thickening and retraction of cusps. There were six episodes of peripheral embolization (five transient) and one left atrial thrombosis. All seven patients are alive. Anticoagulants were not used. The results of haemodynamic studies and in vitro hydrodynamic experiments are discussed and an explanation for graft dysfunction in the mitral position is presented. The actuarial analysis of this series of patients over a period of up to 54 months post-operatively has shown encouraging results.

Serial C-reactive Protein Measurements in Infective Complications Following Cardiac Operation: Evaluation and Use in Monitoring Response to Therapy

Serum C-reactive protein (CRP) was studied serially in 100 patients who underwent cardiac operation and in another 17 patients in whom serious infections including prosthetic valve endocarditis developed in the early postoperative period. Eleven patients with late onset of prosthetic valve endocarditis and infective endocarditis were also investigated. The assay method used was radial immunodiffusion. Patients without postoperative infective complications showed a rapid increase in CRP levels, which reached a peak within 72 hours after operation followed by a progressive decline. The differences between the CRP levels in infected and uninfected patients were significant (p less than 0.01). Serial measurements were of prognostic value in evaluating the response to chemotherapy and in predicting the outcome of the disease.

Autologous fascia lata for heart valve replacement

To obviate the drawbacks of prosthetic devices and in search of a better substitute for diseased heart valves a technique of using autologous fascia lata grafts attached to a support frame was developed. The technique of preparing mounted fascia lata grafts is briefly outlined and their surgical implantation into the mitral, tricuspid, and aortic areas is described. Since April 1969, 83 fascial grafts have been inserted into 76 patients with very good immediate and short-term results. Ten patients succumbed within the operative period. None of these deaths was due to failure of the graft per se. Thromboembolic manifestations have been completely absent although anticoagulants were not used. All sixty-six survivors are very much improved. Data concerning the structure and function of fascia are presented and the experimental and clinical use of fascia lata in extracardiac and cardiac surgery is reviewed. The use of autologous, living, fascia lata valves is considered to be a better approach for heart valve replacement because autologous fascia maintains its structure unchanged after transplantation and, being under mechanical stimulation, it retains its functional properties.

Morbidity and mortality of oesophageal perforation

Thirty-three patients with oesophageal perforation seen within a 20-year period are reviewed. Endoscopic perforation in patients with neoplastic disease of the oesophagus carried a 100% mortality despite early diagnosis and immediate resection of the growth. Only two deaths occurred after instrumental perforation of the thoracic oesophagus for benign pathology in patients who were in the extremes of life. Twelve cases with spontaneous perforation were seen. Although the mortality figure of only 8% was encouraging, the morbidity in terms of postoperative complications was considerable, occurring in all but one of the survivors. The importance of early diagnosis and adequate treatment in relation to postoperative morbidity and mortality is discussed.