Stanley John

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.

The clinical profile and surgical treatment of tetralogy of Fallot in the adult: results of repair in 200 patients

This report describes our 17-year experience with intracardiac repair in 200 patients older than 14 years with tetralogy of Fallot. Congestive failure, hemoptysis, and cerebral abscess were present in 15, 10, and 3% of patients, respectively. Prior palliative shunts had been performed in 24.5% only. Polycythemia with a hematocrit greater than 60% was noted in 100 patients but was not considered an incremental risk factor (p greater than 0.05). A transannular gusset was utilized in 74% of patients in the last 5 years of the study. Hospital mortality was 1.3% in the last 5 years. Ninety-seven percent of survivors at follow-up are asymptomatic and leading an active life. Recatheterization data from 86 patients revealed excellent or good results in 88%. The incidence of residual ventricular defect was 1% overall, with a zero incidence in the last 12 years. On the basis of this review, we consider that easier and hemodynamically satisfactory repair has been achieved in the adolescent and older patient compared with the child. The ultimate longevity, however, must await the results of long-term functional and serial hemodynamic evaluation.

25-year experience with 456 combined mitral and aortic valve replacement for rheumatic heart disease

BACKGROUND Valvular heart disease in developing countries resulting from rheumatic fever is disabling and if untreated leads to congestive heart failure and death. Valve replacement has remained the procedure of choice for advanced valve disease. METHODS Between 1973 and 1997, 456 patients underwent combined mitral and aortic valve replacement. In light of our favorable earlier experience the Starr-Edwards ball valve prostheses were implanted in 90% and 72.8% of mitral and aortic positions, respectively. Follow-up ranged from 1 to 24 years with a median of 8.5 years. RESULTS The 30-day hospital death rate was 9.2% and late death occurred in 10.1%. A low-intensity anticoagulant regimen was followed to maintain the target prothrombin time at 1.5 times the control value. The actuarial survival at 5, 10, 20, and 24 years was 90.4%, 85.6%, 84.4%, and 82.4% per year, respectively. CONCLUSIONS In view of the acknowledged advantage of superior durability, increased thromboresistance in our patient population, and its cost effectiveness the Starr-Edwards ball valve is the mechanical prosthesis of choice for advanced combined valvular disease. The low-intensity anticoagulant regimen has offered sufficient protection against thromboembolism as well as hemorrhage.

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.

Prosthetic valve replacement in ebstein’s malformation: 30-year follow-up

This report addresses a 42-year-old asymptomatic patient who underwent prosthetic replacement of his tricuspid valve 31 years previously for Ebsteins malformation. A ball valve prosthesis was implanted to replace the abnormal valve. Furthermore, he had concomitant closure of a large atrial septal defect with a perforated patch together with plication of the atrialized ventricular segment. The patient is asymptomatic, and it remains noteworthy that he has not been on coumadin for about 30 years.

Tetralogy of Fallot: Intracardiac Repair in 840 Subjects

Since 1967. when the first intracardiac repair was performed in this centre, until 1991, 840 symptomatic subjects with tetralogy of Fallot have undergone corrective surgery. Cardiac catheterization and angiocardiography were carried out in all patients. Cardinal findings on the clinical status of these subjects are outlined. A substantial number of patients (244; 29.0%) were >15 years of age. Historically, a transannular pericardial gusset has been utilized in 578 (68.8%). and in 423 (93.0%) during the past decade. The incidence of residual interventricular septal defects has been 0.68% and occurrence of complete heart block after surgery 0.4%. Death occurred in 86 patients (10.2%) within 30 days of operation and later in 40 subjects (4.8%). Long-term results have been excellent with good haemodynamic status In >90% of subjects in the follow-up period. Associated features including absent pulmonary valve, absent left pulmonary artery, and previous palliative shunts did not alter the outcome: however, a raised haematocrit (>0.65) was associated with an increased mortality rate.

Empyema caused by an unusual retained pleural foreign body

We report a rare case of post-traumatic chronic empyema in an 18-year-old boy, caused by a piece of wood retained in the pleura. This unusual foreign body initially remained undetected on account of its radiolucency and was discovered during rib-resection for open drainage.