Robert G. Ellison

Influence of rhythm and anticoagulation upon the incidence of embolization associated with Starr-Edwards prostheses.

The incidence of embolism following aortic and mitral valve replacement with Starr-Edwards prostheses has been analyzed and correlated with cardiac rhythm and anticoagulation. No embolism occurred in the aortic valve replacement group, regardless of use or nonuse of Coumadin. In the mitral group, the incidence of embolism during atrial fibrillation was approximately 1.7 times that during sinus rhythm. Coumadin prophylaxis was extremely effective. The incidence during non-anticoagulation was 40 times that during adequate anticoagulation, and seven times that during inadequate anticoagulation. Embolism occurred as late as 21 months after surgery, often shortly after termination of anticoagulation. Three of the four patients with emboli associated with bacterial endocarditis died. All nine patients with emboli not associated with infection survived, half without permanent sequelae.

Two Decades of Experience with Modified Heller's Myotomy for Achalasia

We reviewed the hospital records of 36 patients who underwent modified Hellers myotomy for achalasia between January, 1961, and December, 1982. There were 18 male and 18 female patients ranging between 17 months and 75 years old. The most frequent symptom was dysphagia, followed by regurgitation of ingested food and weight loss. Modified Hellers myotomy was performed through a transthoracic incision in 35 patients and a transabdominal incision in 1. An antireflux procedure in addition to esophagomyotomy was performed in 20 patients. There was 1 postoperative death. Thirty-three patients were followed up for periods ranging from 9 months to 21 years. The results were considered good in 27, fair in 2, and poor in 4. One of the 4 underwent repeat esophagomyotomy 71/2 years after the initial operation with a good result. The remaining 3 had an antireflux procedure at the time of esophagomyotomy. Because of recurrence of symptoms, esophagogastrostomy was performed in 1 and colon interposition in 2. These results suggest that an antireflux procedure should not be added to modified Hellers operation in the treatment of achalasia.

Isolated Aneurysm of the Anterior Descending Coronary Artery Surgical Treatment

Abstract The case of an asymptomatic 30 year old man with an aneurysm in the proximal portion of the anterior descending branch of the left coronary artery is presented. The aneurysm was discovered because of an abnormal cardiac silhouette on a chest roentgenogram. Coronary angiograms demonstrated a localized fusiform aneurysm without shunt or fistula. After excision of the aneurysm, continuity of the artery was reestablished with a free saphenous vein graft. An associated anteroseptal myocardial infarction at the time of operation was an anticipated complication. Repeat coronary angiograms demonstrated patency of the graft and good distal flow 3 months postoperatively.

Thirteen year experience with aortic valve replacement

Abstract Two hundred forty-one patients (163 male, 78 female) underwent isolated aortic valve replacement at the Medical College of Georgia from 1963 to 1976. The mean age was 46 years (range 12 to 72). Thirty-seven percent had aortic stenosis, 39 percent aortic regurgitation and 24 percent mixed valve lesions. One hundred ninety-eight were in New York Heart Association functional class III or IV. Forty-three were in functional class I or II and underwent surgery for endocarditis, severe regurgitation with rapidly increasing heart size or appearance of angina or electrocardiographic signs of ischemia. The long-term clinical characteristics of five models of Starr-Edwards valves (1000, 1200, 2300, 2310 and 2320) and the Bjork-Shiley prosthesis were defined by rates of survival, complications and rehabilitation. In 212 patients who survived operation, the annual valve-related cardiac mortality rate calculated by the life table method was 4.8 percent for those with model 1000, 3.6 percent for those with model 1200, 7.1 percent for those with model 2300, 6.1 percent for those with model 2310, 3.7 percent for those with model 2320 and 4.0 percent for those with the Bjork-Shiley prosthesis. Complications were most frequent among patients with models 2300 and 2310. The model 2320 valves have posed the greatest embolism risk (7.1 episodes/100 patient years compared with 3.3/100 for the entire group). One hundred twelve current survivors (90 percent) are in functional class I or II. No patient in class IV preoperatively survived the full study period. Thirty-nine percent of those in class III and 91 percent of those in classes I and II preoperatively survived 13 years. Successful management of patients with an aortic valve prosthesis is based upon knowledge of the natural history of individual prostheses. Longevity and rehabilitation depend upon aortic valve replacement before severe myocardial decompensation occurs plus meticulous management to avoid lethal complications inherent in individual prostheses. Assessment of functional durability of hemodynamically adequate valve designs requires long-term evaluation.

Esophageal mucocele: a complication of blind loop esophagus

Mucocele of the bypassed esophagus is an unusual complication of esophageal replacement and has been described only in isolated references. This report is based on our experience with 6 patients in whom a mucocele developed following esophageal replacement. Esophageal replacement was performed on 37 patients over a 10-year period at the Medical College of Georgia Hospital. A symptomatic mucocele requiring excision developed in 3 patients with achalasia, 1 with congenital tracheoesophageal fistula, 1 with esophageal atresia, and 1 with inflammatory stricture. Conduits used included stomach (4), reversed gastric tube (1), and colon (1). Our experience indicates that conversion of a closed-loop esophagus into a symptomatic mucocele is more likely in the presence of functioning, chronically irritated mucosa. The clinical features were referable to the mucocele itself or respiratory embarrassment therefrom. Thoracic roentgenograms and computed tomographic scans were diagnostic in verifying the presence of the esophageal mucocele. All five mucoceles arose from squamous epithelium. One of 3 patients with achalasia in whom a mucocele developed following esophageal replacement had premalignant changes in the mucosa. Based on this experience, our treatment of choice is early, complete excision of the mucocele.

Disc Immobilization of Björk-Shiley and Medtronic Hall Valves during and Immediately after Valve Replacement

During the last fourteen years, 377 unileaflet tilting-disc prosthetic valves (Björk-Shiley and Medtronic Hall) have been used for single or multiple valve replacements with and without concomitant coronary artery by-pass grafting. In the past five years, five instances of disc immobilization (three in the mitral and two in the aortic position) occurred either at the time of weaning from cardiopulmonary bypass or immediately thereafter. When the implanted site of the prosthetic valve was the mitral position, reexploration in 2 patients revealed chordal remnants in the subannular area stuck between the disc occluder and the valve ring, thereby immobilizing the disc. In the third instance, the free movement of the disc was impeded by the left ventricular myocardium. In the aortic position, an unraveled suture impacted between the disc occluder and the valve ring immobilized the disc in 1 patient. In the other patient, the cause of the malfunction could not be determined at the time of reexploration. The 1 death among these 5 patients was directly related to the malfunction of the prosthesis. The mechanism, recognition, treatment, and prevention of this catastrophic malfunction of tilting-disc valves are discussed.

Traumatic superior mesenteric arteriovenous fistula: Report of a case and review of the literature

Penetrating arterial injuries can result in the formation of a traumatic false aneurysm or an arteriovenous fistula. Traumatic arteriovenous fistulas of the mesenteric circulation are extremely rare, with only 15 operated cases reported in the English language literature that involved the superior mesenteric artery and vein. Although surgical intervention has been considered the most successful method to treat traumatic mesenteric arteriovenous fistulas, percutaneous transcatheter embolization has been occasionally advocated in the management of small iatrogenic fistulas. We report a case of a gunshot wound patient who had an 8 cm abdominal aortic false aneurysm, as well as a high-flow arteriovenous communication between the superior mesenteric artery and vein, which were successfully treated by a combination of aorto-superior mesenteric bypass and postoperative percutaneous transcatheter embolization. A review of the literature is also included.

Surgically Induced Atrioventricular Block as Treatment for Recurrent Atrial Tachycardia in Wolff-Parkinson-White Syndrome

In a 60-year-old male with WPW syndrome and recurrent PAT refractory to cardiac drugs, surgical creation of complete A-V block without cardiopulmonary bypass has prevented recurrence of the PAT. The findings in this case support the accessory conduction tissue theory as being responsible for WPW conduction in some patients and a circus re-entry movement as responsible for the recurring PAT.

Pulmonary Compliance Following Open-Heart Surgery and Its Relationship to Ventilation and Gas Exchange

Pulmonary function was studied preoperatively and postoperatively in 71 patients undergoing 41 open-heart operations, ten thoracic operations not requiring cardiopulmonary bypass, ten intra-abdominal, and ten peripheral procedures. After operation total respiratory compliance was significantly reduced below the preoperative value for ten days in the open-heart group. Decreases of lesser degree and of shorter duration were noted in the thoracic and intra-abdominal patients with no significant reduction in the peripheral cases. Tidal volume decreased proportionately to the decrease in compliance, and respiratory rate increased, while total ventilation usually remained the same or was slightly increased. Oxygen uptake was significantly increased after open-heart operations, and there was a significant negative correlation between oxygen uptake and compliance. Abnormal venous admixture, not corrected by oxygen inhalation, was observed after cardiopulmonary bypass with a return to preoperative level coinciding with that of compliance. Cardiac output did not correlate with any other measurement.The data suggest that the postoperative breathing pattern after open-heart surgery is a compensatory adjustment to decreased compliance and that reduced compliance is one of the causes of the increased work of breathing and oxygen demands after open-heart surgery.

Experimental determination of optimum performance of counterpulsation assist pumping under computer control

Abstract Intra-aortic balloon pumping (IABP), a currently popular method for assisting a failing left ventricle, has a fundamental clinical problem that the effectiveness of the device is significantly affected by the method of controlling the timing settings. An experimental procedure is presented for the determination of the optimum control of a counterpulsation-type assist device such as IABP. Initial experiments with the method are reported with IABP under computer control. Determination of optimum heart assist pumping was considered based on performance indices defined as mean coronary artery flow, left ventricular stroke work, end-diastolic aortic pressure, cardiac output, and tension-time index. Weighting factors were chosen for each index. Data are presented in the form of computer-generated plots showing the effect of balloon pump timing (delay and duration) on each variable measured. The results show that the optimum setting of the timing settings is a compromise between several factors and that an on-line controller is indicated to continuously monitor and control the timing settings. In particular, inflation of the balloon earlier than the closing of the aortic valve and deflation of the balloon before the receipt of an ECG trigger may be beneficial.