Noel H. Fishman

Models of congenital heart disease in fetal lambs.

SUMMARY Intracardiac flow patterns were chronically altered by partially obstructing left ventricular (LV) inflow or outflow in midgestational fetal lambs. Physiological measurements of the fetal circulation were made serially through indwelling catheters and the use of radioactive microspheres.With LV inflow obstruction, mean LV output (LVO) decreased to 30% of control (P < 0.01). Within seven days, the LV/right ventricular (RV) weight ratio decreased to 70% of control (P < 0.01), and the mean LV/RV chamber volume decreased to less than one-half of control (P < 0.001), simulating an early form of the hypoplastic left heart syndrome.With LV outflow obstruction, mean LVO decreased to 64% of control (P < 0.05). Mean LV/RV wall thickness doubled (P < 0.0001) and mean LV/RV chamber volume decreased to less than one-half of control (P < 0.0001). Within four to ten days after increasing LV afterload, a large increase in LV mass occurred, which was demonstrated by morphometric analysis to be due to hyperplasia of ventricular myocytes. LV chamber volume decreased somewhat, simulating moderately severe congenital aortic stenosis. Over the long term (30-36 days), the mean LV/RV weight ratio decreased and the LV chamber was nearly obliterated, simulating very severe congenital aortic stenosis.The results suggest that by varying preload and afterload in both ventricles of the fetus, various forms of congenital heart disease may be simulated.

Formalin Infiltration of the Ductus Arteriosus: A Method for Palliation of Infants with Selected Congenital Cardiac Lesions

To circumvent the decreased pulmonary blood flow associated with closure of the ductus arteriosus in newborns with heart defects, we infiltrated buffered formalin solution into the wall of that structure to delay its closure. In four infants with pulmonary atresia in whom shunts had been unsuccessful or were technically not feasible, this procedure produced rapid improvement of arterial oxygen tension that was maintained in three infants for one to nine months. The other died of complications of attempted shunt procedures. In an infant with interrupted aortic arch and a large ventricular septal defect, formalin infiltration of the ductus and pulmonary arterial banding alleviated cardiac failure and improved lower-body perfusion. Formalin infiltration of the ductus is an effective palliative technic for treating certain congenital cardiac defects. No adverse effects have been noted.

Mechanical injury to the coronary arteries during operative cannulation

Abstract An extensive review of 18 patients who died after aortic valve surgery indicated that operative cannulation caused fatal mechanical injury in 10 of these patients. Underlying coronary arterial anomalies and atherosclerosis were present in most of these cases. It is probable that many operative deaths which have formerly been attributed to the patients heart disease are really due to iatrogenic coronary artery obstruction. Disease coronary arteries and the technical problems of cannulation present hazards which may offset those of intermittent ischemia.

Infant Coarctation: A Spectrum in Clinical Presentation and Treatment

Between 1975 and 1985, 125 infants 2 to 365 days old (majority, 30 days old or less) with coarctation of the aorta underwent surgical repair. Forty-seven patients (38%) had severe congestive heart failure (CHF), metabolic acidosis, and poor systemic perfusion. The predominant operative technique was synthetic patch aortoplasty (100 patients); the remaining 25 had an end-to-end anastomosis. There were no operative deaths. Perioperative complications were minimized with the synthetic patch technique (less than 15%). For patients surviving at least 3 months after repair, the arm-leg systolic blood pressure gradient was relieved in 82% (71/87) of the patients having patch aortoplasty versus 65% (15/23) of the patients with end-to-end anastomosis. Although the rate of reoperation between the two groups was similar (patch, 5 [6%]; end-to-end, 3 [13%], two of the reoperations in the patch group were for preexisting hypoplastic transverse aortic arch. Late deaths (20 patients, 16%) were due to other major associated cardiac anomalies. Patch aneurysms have not occurred. Expedient use of synthetic patch aortoplasty has decreased perioperative complications, relieved coarctation gradients for CHF, increased early survival even in the presence of complex or associated cardiac anomalies, and has an acceptable rate of recurrent coarctation (6 to 13%).

The application of radionuclide infarct scintigraphy to diagnose perioperative myocardial infarction following revascularization.

To evaluate the application of radionuclide infarct scintigraphy to diagnose myocardial infarction after revascularization, we obtained postoperative technetium 99m pyrophosphate myocardial scintigrams, serial electrocardiograms and CPK-MB isoenzymes in ten control and 51 revascularized patients. All control patients had negative electrocardiograms and scintigrams, but eight had positive isoenzymes. Eight revascularized patients had positive electrocardiograms, images and enzymes and two had positive scinti- grams and enzymes with negative electrocardiograms. Thirty-four patients with negative electrocardiograms and scintigrams had positive isoenzymes; in only seven patients were all tests negative. Our data suggest radionuclide infarct scintigraphy is a useful adjunct to the electrocardiogram in diagnosing perioperative infarction. The frequent presence of CPK-MB in postoperative patients without other evidence of infarction suggests that further studies are required to identify all factors responsible for its release.

Open mitral valvulotomy.

Abstract A five-year experience with routine open visualization of the mitral valve in 95 patients with mitral stenosis resulted in salvage of 53 valves and replacement of 42. The subvalvular structures were often thickened and fused, and meticulous dissection was necessary to produce adequate mobilization of the valve leaflets. An operative mortality of 1 death among the 53 patients undergoing commissurotomy attests to the safety of the procedure, but immediate functional results were not significantly better than with the closed method. Sufficient mobilization to produce a wide-open orifice in the relaxed state may be an important factor in the functional result.

Postintubation Tracheal Stenosis

uring the past three years, 12 patients have been treated at the University of California Medical Center, San Francisco, for D severe tracheal stenosis that followed prolonged mechanical ventilation. A retrospective analysis of the clinical material was made to determine the role of techniques, underlying disease, and coincident contributory factors in the production of this previously rare complication. The results of treatment were also evaluated.

Myocardial temperature differences as a guide to the order of coronary artery bypass anastomoses in high-risk patients☆

Abstract A technique for increasing the effectiveness of hypothermic, hyperkalemic cardioplegia for myocardial protection during ischemic arrest is described. The essence of the technique is delivery of cold cardioplegic solution directly to areas of the myocardium inadequately perfused through the root of the aorta. The solution is delivered through grafts placed preferentially to the areas identified by temperature measurements as being incompletely cooled. The sequence of all distal anastomoses is determined by the differences in temperature, in order of the warmest to coldest regions. Favorable results were obtained in 200 consecutive high-risk patients through application of this technique. The mortality rate was 3.0 percent. Only three of the six deaths were related to low output failure, and they occurred relatively early in the series. The perioperative myocardial infarction rate was 3.5 percent. No single factor previously reported to increase operative mortality influenced the rate of death or infarction in this series. There were no deaths or infarctions in 41 patients who had only one risk factor. Only when a constellation existed, which consisted of (1) three or more risk factors, (2) the need for extensive surgery (five or more grafts or additional procedures), and (3) advanced age, did the mortality rate approach levels previously reported in patients with any single risk factor. The mortality rate was only 0.76 percent (one death) in 130 patients in this high-risk group in whom surgery was limited, by the extent of disease, to bypass of fewer than five vessels, regardless of age or the number of risk factors.

Combined Treatment Methods For Carcinoma of the Esophagus

From 1950 to 1973, 129 patients received irradiation for esophageal squamous-cell carcinoma at the University of California, San Francisco. From this group, 26 received surgical and irradiation treatment. Twelve did not receive irradiation until recurrence became evident and among them were no 5-year survivors. Among the other 14 were six 5-year survivors (43%). The authors believe that planned sequential irradiation and surgery offer the best chance for cure in squamous-cell carcinoma of the esophagus. Selection factors, treatment details, and therapeutic regimens are presented and a management plan proposed for this group of operable patients.

Anastomoses between Aorta and Right Pulmonary Artery (Waterston) in Neonates

Abstract An anastomosis between the aorta and right pulmonary artery (Waterston operation) was constructed in 10 infants with severe cyanosis within 10 days after birth. Diagnoses after cardiac catheterization and cineangiography were pulmonary atresia with intact ventricular septum (five cases), pulmonary atresia with ventricular septal defect (two), pulmonary atresia with ventricular septal defect and transposition of the great arteries (one), tetralogy of Fallot (one) and tricuspid atresia with intact ventricular septum (one). One infant died five hours after operation and did not have a patent anastomosis. Four infants died six to 14 weeks after operation (two, who had associated lesions, died from chronic congestive heart failure, and two, who were seemingly well, died unexpectedly at home). Five patients are alive five to 23 months after operation. Four are asymptomatic, and one has intermittent respiratory problems. The Waterston operation is a successful, palliative procedure in newborn infants wi...