Morris J. Levy

Left retrograde cardioangiography in acquired cardiac disease: Technic, indications and interpretations in 700 cases∗☆

Abstract Application of retrograde left cardioangiography to 700 patients, both adults and children, with acquired valvular diseases is described. The technic employed for the test is described. Pressures from the aorta and left ventricle are obtained during the same procedure as angiography to determine whether stenosis of the aortic valve is present. The method may be used to estimate the degree of aortic or mitral insufficiency or both. Mitral stenosis may be identified by a fixed filling defect of the left ventricular cavity. The value of this information in the surgical management of many forms of cardiac disease is emphasized. Complications have occurred infrequently and, in most instances, the patients have responded to appropriate therapy. Three deaths occurred. These were caused by ventricular fibrillation in 1 patient and cardiac tamponade in 2. The most common complication was thrombosis of the femoral artery at the site of arteriotomy. This complication occurred in about 4 per cent of cases; but in none did gangrene occur, and pulsatile flow was restored in all cases by immediate re-exploration of the femoral artery as soon as the diagnosis was made.

Percutaneous tracheostomy: a new method

A rapid method of definitive low tracheostomy utilizing an original instrument kit and percutaneous approach is described. Through a horizontal, shallow (1.5-cm) skin incision in the neck, a 12-ga needle is introduced into the tracheal lumen. A flexible metal guidewire is gently introduced through the needle, which is then removed. A specially designed percutaneous tracheostomy tool slides over the guidewire into the trachea; by squeezing its handles, the intercartilaginous space is enlarged, securing the placement of a cuffed tracheal cannula. After extensive and successful investigation in both cadaver and animal trials, the procedure was carried out in 80 patients who had a variety of underlying diseases, without serious complications. Of these 80 patients, 33 required airway control after neurosurgical interventions or after severe head trauma, 23 had percutaneous tracheostomy performed before radical excision for head and neck cancer, and the remaining 24 suffered from severe cardiorespiratory problems. Twenty-nine procedures were performed in the operating theater, and 51 procedures were carried out at the patients bedside in the ICU, ED, or in the ward. There was no infection at the stoma site, and late healing was remarkable. It should be strongly emphasized that in the majority of our patients the procedure was carried out safely at the bedside. This resolved the logistic problem of moving very sick ICU patients (who are sometimes on high PEEP levels) to the OR. Although our experience is totally restricted to elective situations, we do postulate that it could be as effective in a variety of urgent situations.

Aortico-Left Ventricular Tunnel

To be distinguished from aneurysm of an aortic sinus (Valsalva) is the rare condition in which an abnormal channel begins in the ascending aorta (above the right coronary artery), bypasses the aortic valve, and leads through the ventricular septum into the left ventricular cavity. This entity, which has not previously been diagnosed during life, to our knowledge, is herein named aortico-left ventricular tunnel. The cases of three patients (aged 3, 5, and 10 years) with this rare condition are described. The clinical, electrocardiographic, and radiological features were similar in each case and resembled those in aortic valvular insufficiency. The diagnosis may be established clinically through selective aortography. This reveals that the origin of the abnormal communication lies in the anterior wall of the ascending aorta above the levels of the coronary arterial origins. The abnormal communication leads to the left ventricle. The condition is distinguished from aortic sinus aneurysm by its origin above t...

Anatomy of mitral insufficiency

Summary The causes of mitral insufficiency are primarily considered from an anatomic point of view. Mitral insufficiency may result from anatomic alteration of the papillary muscles, the chordae tendineae, the valve leaflets and/or the commissures. Left ventricular enlargement may contribute to mitral insufficiency by (1) enlargement of the valvular orifice and (2) alteration of the relationships between the valve leaflets, on one hand, and the chordae and papillary muscles, on the other. Left atrial dilatation resulting from one of the foregoing reasons for mitral insufficiency may displace the posterior leaflet and accentuate the degree of mitral insufficiency. Specific problems concerned with persistent common atrioventricular canal are also considered.

Right aortic arch with mirror-image branching causing vascular ring. A new classification of the right aortic arch patterns

Abstract Three patients with right aortic arch and mirror-image branching of the major arteries are presented. In contrast to those reported in the literature, none had associated cardiac defects and all of them had severe symptoms resulting from vascular ring, which required surgical treatment. A new classification of the right aortic arch patterns, based on the site of interruption of the left arch,has been proposed.

Resection of Myocardial Aneurysms after Infarction during Temporary Cardiopulmonary Bypass

The report consists of five patients with chronic postinfarct left ventricular aneurysms. The age distribution was between 47 and 63 years. The time lapse between the initial infarct and the appearance of the left ventricular aneurysm was 2 weeks to 2 years. The time interval between the initial infarct and surgery was 5 months to 6 years. Less than adequate bedrest following the infarct, multiple infarcts, and systemic hypertension were other factors present in this group. Right heart catheterization was performed in two patients and showed reduced cardiac output and elevated pulmonary pressures in one. The electrocardiograms were consistent with extensive old myocardial infarction and ventricular aneurysm. The diagnosis was suggested by electrocardiograms and roentgenography, supported by kymography, and confirmed by angiography. The world literature on surgically treated patients with ventricular aneurysms is briefly reviewed with emphasis on the varied surgical approaches to the problem in the past. The method of complete excision with ventriculoplasty during cardiopulmonary bypass was used in all our patients during the past 4 years. The anatomic distribution of the ventricular aneurysm as well as the histopathology of the resected specimen is described. All patients survived the operation, and were observed from 6 months to 40 months after operation. There have been no late deaths to date, and all patients have been rehabilitated. Postoperative catheterization studies have confirmed the clinical improvements observed. More attention should be given to this relatively common complication after infarct because excision under temporary heart-lung bypass is a safe and feasible approach.

DIRECT WIRE ELECTRICAL STIMULATION FOR ACUTE POSTSURGICAL AND POSTINFARCTION COMPLETE HEART BLOCK

The use of a myocardial electrode and electronic pacemaker for the clinical management of acute postsurgical heart block was introduced at the University of Minnesota Medical Center in January, 1957. This has subsequently become the method of choice in the management of postsurgical heart block, and a myocardial electrode with an implantable pacemaker is now used in many cases of chronic complete heart block. In spite of the almost universal acceptance of the use of a myocardial electrode and pacemaker in postsurgical heart block there have been very few reports of the results of this treatment. There has also been little written on the late results and management of heart block following surgery or heart block associated with myocardial infarction, following infections, or resulting from drugs that affect the myocardium. This report will deal with three major aspects of this group of problems. First, our experience in the management of postsurgical complete heart block will be detailed. Second, the management of chronic postsurgical heart block will be discussed. Third, we will discuss the management of postsurgical heart block appearing during the postoperative period and acute heart block associated with myocardial infarction. As a part of the management of these latter cases the use of a percutaneously inserted myocardial electrode will be discussed.

Familial ebstein's anomaly with emphasis on the surgical treatment

Abstract Ebsteins anomaly has been reported in a family affecting a brother and a sister. The rest of the family members, including the nonidentical twin brother of the second patient, were free of symptoms. The clinical and hemodynamic data indicated Ebsteins anomaly in both. This was confirmed on necropsy of the first patient and at operation in the second, in whom a prosthetic valve replacing the tricuspid was inserted at the age of 13 years. This patient also died eight months following operation. Despite this outcome and from the experience of others, it is our belief that certain cases of Ebsteins anomaly may be amenable to surgical treatment. The available surgical procedures and the indications for operation are briefly discussed.

Accessory Valvular Tissue Causing Subpulmonary Stenosis in Corrected Transposition of Great Vessels

This study reveals three cases of corrected transposition (one with total situs inversus) where an accessory flap or umbrella-like formation of the venous atrioventricular valve presented into the outflow tract of the venous ventricle causing severe subpulmonary stenosis.In one case the ventricular septum was intact, while in each of the other two, a ventricular septal defect lay below the obstruction. The latter combination effected a right-to-left shunt at ventricular level.These cases are important because they portray anatomic details of a condition which, although uncommon, is potentially curable. Clinical identification of the subpulmonary stenosis appears best to be accomplished by selective angiocardiography at the level of the venous ventricle.

Congenital Atresia of the Left Main Coronary Artery Ostium

Three patients with the rare anomaly of congenital absence of the ostium of the left main coronary artery are presented. In two of the patients, aged 50 and 52 respectively, the diagnosis was established during selective coronary cineangiography for a severe anginal syndrome. The third patient, a 16-year-old-girl, underwent cardiac catheterization for investigation of a congenital heart malformation, when a single right coronary artery was demonstrated with absence of the main coronary artery ostium. Two patients underwent successful aortocoronary bypass grafting. In view of the occurrence of sudden death and massive myocardial infarction in adult patients shown to have severe or complete obstruction of the left main coronary artery, it is suggested that adult patients with this condition, who require open-heart surgery for any other cardiac disorder, should undergo aortocoronary bypass grafting concurrently even prior to the development of anginal symptoms. Children shown to have this anomaly should be subjected to long-term follow-up and have an aortocoronary bypass graft performed when symptoms of coronary insufficiency develop.