Paul W. Sanger

Congenital quadricuspid aortic valve with displacement of the left coronary orifice

Abstract A case of a 35 year old woman with quadricuspid aortic valve and displacement of the left coronary orifice is presented. The aortic regurgitation caused by maladaptation of the supernumerary cusps was corrected surgically.

Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

Abstract During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patients own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.

Transplantation of “live” hearts

Abstract A “stabilized” form of heart-lung preparation is presented, which enabled the authors to transplant hearts experimentally in a fully perfused, beating stage, without the assistance of parabiosis or extracorporeal circulation. This method proved to be most effective in maintaining the donor heart viable and functioning in the extracorporeal phase, as well as during the process of transplantation.

Pseudocoarctation associated with aneurysm of the aortic arch.

typical reverse E-shaped deformity of the descending thoracic aorta with &dquo;poststenotic&dquo; dilation. The hemodynamic difference between these two conditions is, however, distinct: true coarctation represents a severe obstruction to the aortic blood flow, whereas in pseudocoarctation the impediment of the flow is moderate or absent. This explains why the clinical diagnosis of these two anomalies is based mainly on functional rather than on morphologic findings. This report concerns a 42-year-old woman with pseudocoarctation and aneurysm of the aortic arch who underwent successful surgical repair.

Complete bypass of the right heart

Abstract The right ventricle is generally considered to be an organ that is indispensible to the circulation and essential in maintaining normal venous pressure and adequate pulmonary blood flow. This concept has been recently challenged by several investigators. These observations, even though very valuable, are still not adequate to prove that circulation could exist without any participation of the right ventricle. Such a proof could be obtained only by completely bypassing the right heart. We have presented our experiments in which the right heart was completely bypassed by an anastomosis of the superior vena cava to the right pulmonary artery and transplantation of the inferior vena cava into the left atrium. It is demonstrated that the entire right heart could be excluded from the circulation for a period as long as 7 days without significant changes in the arterial and venous pressure. However, the concept that a compensated circulation can be maintained for more prolonged periods without any participation of the right heart still awaits further experimental and clinical proof.

Aneurysm of the superior caval vein.

Aneurysms of the central venous system are extremely rare. Abbott (1-3) in his recent comprehensive monograph found only five such cases reported in the medical literature. Venous aneurysms practically never rupture and seldom cause symptoms of compression; however they may create a puzzling diagnostic problem. In this paper a case of a young woman is reported, who presented herself with an undiagnosed mediastinal mass, which proved to be an aneurysm of the superior caval vein at exploratory thorocotomy.

Atresia of the Pulmonary Valve With Normal Pulmonary Artery and Intact Ventricular Septum in a 21-Year-Old Woman* †:

a well-developed and nourished young woman whose lips and nails were cyanotic and who had clubbing of the fingers and toes. Pulse rate was 96 per min; blood pressure was 140/60 mm Hg. The liver exceeded the costal margin by two fingerbreadths and there was moderate pitting edema of the ankles. The heart was enlarged on percussion with the apical beat located in the fifth interspace. There was a systolic thrill palpable in the left third and fourth interspace parasternally. A harsh, grade IV, systolic-diastolic murmur was heard in the pulmonary area, and there was also a separate grade II to III systolic murmur in the left and right fourth and fifth interspace parasternally. Hemoglobin content of the blood was moderately elevated (15.5 gm. per cent). Other laboratory findings were noncontributory. Electrocardiogram showed right axis deviation, ~l’ segment depression in leads II to III, also in AVF, V2 to Vg . The T-wave was inverted in V2 to Vie. Prominent P-waves

Aortic Origin of the Right Pulmonary Artery with Patent Ductus Arteriosus

rigin of the right pulmonary artery from the ascending aorta is a peculiar anomaly which stands halfway between a true 0 aplasia and a ductus arteriosus. Fraentzel [6], who in 1867 first described this malformation, regarded it only as an anatomical curiosity; however, recent reports [2-5, 7, 8, 101 indicate that this condition is a distinct clinical entity with an extremely dim prognosis. In the following we present a case of a 2-year-old child who, besides suffering from this disease, also had a large patent ductus arteriosus. Our patient was a 2-year-old boy who was known to have had a heart murmur since birth. He had normal mental but retarded physical development. There was no history of cyanosis or congestive heart failure. Physical Examination. Physical examination revealed a somewhat underdeveloped child not in apparent distress. Pulse rate was 122 per minut,e; blood pressure, 115/55 mm. Hg on the left arm and 125/50 on the right arm. Peripheral pulses were all palpable. The heart appeared to be enlarged to the left, with the forceful apical beat located in the left fifth interspace in the anterior axillary line. Pulmonary second sound was accentuated and split. There was a Grade 1 systolic murmur audible over the entire precordium with a maximum point of intensity in the left third interspace parasternally. X-ray and ECG. X-ray examination of the chest showed both ventricles to be enlarged. The pulmonary conus was prominent, and the vascular markings were equally heavy on both sides. Electrocardiogram indicated biventricular hypertrophy antl strain. Laboratory findings were noncontributory. Catheterization. A right heart catheterization was done through the dissected right saphenous vein. The catheter entered the right atrium, right ventricle, and main and left pulmonary arteries. The right pulmonary artery could not be entered. From the left pulmonary artery the catheter passed repeatedly through a patent ductus arteriosus and appeared in the descending aorta. The pressure was 85/2mm.Hg in the right ventricle, 80/45 in the pulmonary artery, antl 98/62 in the aorta. The oxygen saturation was 33.8% in the right ventricle, 48% in the pulmonary artery, antl 84% in the aorta. Cineangiography. Cineangiography was clone in three different catheter positions: With the catheter tip at the base of the right ventricle (Fig. lA), 10ml. of Angio-Conray were injected manually. The dye filled the right ventricle, which

Long term complete circulatory exclusion of the right side of the heart: Hemodynamic observations☆

Abstract Long-term, complete circulatory exclusion of the right side of the heart was achieved in dogs by: (1) performing an end-to-side anastomosis between the left subclavian and left pulmonary artery as a preliminary procedure, (2) transplanting the inferior caval vein into the left atrium, (3) draining the superior vena cava into the pulmonary artery, and (4) ligating the previously established subclavian-pulmonary artery anastomosis. Sixteen out of 76 animals survived the third stage of the procedure; 9 dogs lived for two weeks or longer after the completion of the procedure. Five of the animals survived one year or longer following complete circulatory exclusion of the right heart. Except for some cyanosis of the mucous membranes and exertional dyspnea, the animals appeared to be and behaved like normal dogs. Hemodynamic observations one year after the completion of the experiment were characterized by the following findings: (1) Normal pressures in the left heart and systemic arteries. (2) Moderately increased pressure in the inferior caval area in some animals. (3) More pronounced pressure elevation in the superior caval area in most animals. (4) “Respiratory” characteristics of the pressure curve in the right pulmonary artery. (5) Desaturation of the arterial blood due to the right-to-left shunt. (6) Increase in the circulating blood volume.

Observations following four years of complete circulatory exclusion of the right heart.

ince the discovery of pulmonary circulation the physiological importance of the right ventricular function has always been S debated. According to the general view, the pumping action of the right ventricle is essential to life. Dissenting opinions have been expressed [l, 3, 6-8, 19, 24, 251; however, the view that the right heart can be excluded indeed without the collapse of the entire circulation remained but a theory waiting to be proved. In recent decades, developments in the surgical treatment of certain congenital anomalies, as well as advances in the design of artificial hearts, have aroused renewed interest in this problem. Following the initial experiments of Carlon et al. [23 in 1949, we [lo, 13, 14, 16, 20-221 as well as others [4, 5, 9, 17, 18, 231 demonstrated that partial bypass of the right heart is a possibility. Later we showed [15] that animals can live for a short time with their right heart completely excluded from the circulation. In the following year, this period of survival was extended to several months [l 1, 121. This paper presents an experimental protocol in which complete bypass of the right heart was accomplished for a period exceeding four years.