P. S. Jairaj

Pulmonary hypertension in isolated secundum atrial septal defect: High frequency in young patients

Out of 709 consecutive patients with isolated secundum atrial septal defect, the pulmonary artery systolic pressure was greater than 50 mm Hg in 118 patients (17%). Pulmonary hypertension was present in 13% of patients under 10 years and in 14% aged 11 to 20 years. The Eisenmenger reaction was present in 9% of the 709 patients. The frequency of the Eisenmenger reaction was high in young patients and was not significantly different in patients in the first and second decades as compared to older patients. None of our patients with pulmonary hypertension resided at high altitude. The high frequency of pulmonary hypertension in our young patients cannot be satisfactorily explained. Autopsy studies suggest that in some, pulmonary hypertension is due to the persistence of the fetal pulmonary vascular pattern.

Surgical Treatment of Ruptured Aneurysms of the Sinus of Valsalva

Aneurysms of the sinus of Valsalva are usually congenital in origin. When they rupture, it is generally into the right atrium or the right ventricle. Signs of a left-to-right shunt, aortic runoff, and cardiac decompensation are the cardinal features. Early diagnosis and surgical correction result in cure. We report our experience with 28 patients. In all patients, we used a combined aortocameral approach, and we recommend a sandwich patch for the repair. Aortic valve replacement is needed only in patients with severe degenerative changes. The overall operative mortality was 21.4%, but in the last 10 years, mortality was only 11.7%. The causes of operative and late mortality are discussed.

Restenosis of the Mitral Valve: Surgical Considerations and Results of Operation

Our experience over an eight-year period with 63 consecutive patients with mitral restenosis who underwent operation forms the basis for this report. Striking clinical disability was a notable finding. A majority of the patients were less than 30 years old. Embolic phenomena were rare. Closed transventricular valvotomy offers excellent low-risk palliation and good long-term results. Follow-up showed excellent or good results in 90.5% of the patients and poor results in 9.5%. Hemodynamic study of 6 patients demonstrated a pronounced decrease in the pulmonary artery pressure. Open valvotomy was performed in 6 subjects. The presence of intracardiac calcification together with mild mitral incompetence in 2 patients made valve replacement mandatory. The problem of restenosis of the mitral valve is complex, and only after further long-term results are available will the superiority of any one method be demonstrated.

Coexistent mitral valve disease with left-to-right shunt at the atrial level: Clinical profile, hemodynamics, and surgical considerations in 67 consecutive patients

Between January, 1963, and June, 1985, 67 patients underwent corrective surgery for this complex anomaly. Symptoms and signs of atrial septal defect were dominant in the majority of subjects. History of rheumatic fever (46%), paroxysmal nocturnal dyspnea (33%), presence of an opening snap, mitral diastolic murmur, or pansystolic murmur provided clinical clues to document associated mitral valve disease. Open mitral valvotomy was accomplished in 39 subjects, while in the remainder (28 subjects) the valve required replacement. Partial anomalous venous connection was encountered in 12 subjects. Recognition and attention to the associated tricuspid incompetence is a high priority, and 21 subjects underwent concomitant annuloplasty. The overall hospital mortality was 13.4%, with no deaths in the last 22 consecutive patients. The period of follow-up ranged from 1 year to 22 years, with a mean +/- SD of 9.34 +/- 6.61 years. We believe, with other authors, that since the hemodynamic and therapeutic considerations are very similar, both the stenotic and regurgitant lesions should be included in the same syndrome.

Massive Left Atrial Thrombus Complicating Mitral Stenosis with Atrial Fibrillation: Results of Surgical Treatment

Thirty-five patients with massive atrial thrombus complicating mitral stenosis and atrial fibrillation were treated surgically. The mean age in this series is lower than that reported in the West. Furthermore, the incidence of preoperative embolic manifestations has been less frequent in our experience. We believe it is desirable to document the presence of a thrombus by selective left atrial cineangiography. Surgical treatment was accomplished with an acceptable mortality. The vital role played by the use of low-molecular-weight dextran and early anticoagulation in decreasing the incidence of postoperative cerebral embolism is emphasized. Follow-up data in the survivors has shown excellent functional status with no late embolic phenomena in any subject.

Intracardiac Repair of Tetralogy of Fallot in the Adult

Two hundred patients over 14 years of age underwent intracardiac repair of tetralogy of Fallot malformation. This number forms part of a total of 536 patients who had corrective surgery for this anomaly at our center during the period 1967–1984. Our experience with these adult patients forms the basis of this review.

Omental pedicle flap for the management of postoperative bronchopleural fistulae

Nine patients, who had previously undergone pneumonectomy (3) or lobctomy (6), were treated for bronchopleural fistulae using a pedicled omental flap. After adequate evacuation of the pleural space and control of infection, the omentum was harvested with an intact gastroepiploic arch and through an upper midline laparotomy and then transferred to the affected hemithorax. Successful closure was achieved in all the cases. The empyema spaces got completely obliterated without any recurrences, leaving no cosmetic defect.

Closed commissurotomy for mitral stenosis: Obsolete or relevant?

Between 1956 and 1989, 5326 patients with rheumatic mitral stenosis were treated with closed mitral commissurotomy. Two-thousand one-hundred and fourteen (39.7%) were in New York Heart Association functional Class IV. The overall hospital mortality was 3.1 per cent and during the last ten years only 1.55 per cent. Five-thousand two-hundred and twenty (98.0%) patients had a satisfactory surgical result. In the remaining patients the commissurotomy was inadequate, 16(0.3%) requiring emergency valve replacement. An actuarial analysis showed a 94.0, 89.4, 85.0 and 78.3 per cent survival at six, 12, 18 and 24 years respectively without requiring a second procedure. The incidence of restenosis varied from 4.2 per cent to 11.4 per cent per 1000 patients/year between the fifth and fifteenth yeart of follow-up. Closed transventricular re-commissurotomy was carried out in 200 patients. Based on this experience we prefer and recommend closed commissurotomy as the palliative procedure of choice in rheumatic mitral stenosis.

Benign fibrovascular polyp of the oesophagus

A case of fibrovascular polyp of the oesophagus is described. Endoscopy, ultrasonography and CT scan were useful to confirm the intraluminal location of the mass.

Oesophageal stenosis due to tracheo bronchial remnants

Dysphagia due to an intrinsic congenital malformation causing oesophageal stenosis is rarely seen in adults. Histopathology of the obstructive lesion revealed tracheo bronchial remnants. This unusual cause of dysphagia and its surgical treatment is discussed.