Thomas D. Bartley

Effect of Valvular Surgery on Antibody to the Group A Streptococcal Carbohydrate

Because previous studies revealed that high levels of antibody to the group A streptococcal carbohydrate (A-antibody) persist in the serum of patients with chronic rheumatic valvular disease, the effect of valvular surgery on the level of this antibody was examined in the present study. Streptococcal antibody titers (ASO, anti-DNAse B, and A-antibody) were determined on 73 patients admitted for cardiac surgery: 36 with chronic rheumatic valvular disease and 37 with nonrheumatic cardiac or coronary disease. While the ASO and anti-DNAse B presurgical titers were similar in rheumatic and nonrheumatic individuals, the levels of A-antibody were significantly higher in rheumatic patients. The effect of blood perfusion during cardiac surgery was reflected by reversion of antibody titers towards the mean value for a normal population. A trend toward a rise in all antibodies was seen in all patients two to seven weeks after surgery. However, after an interval of eight weeks or more following surgery, a significant decline in the A-antibody occurred in rheumatic patients who had undergone excision and replacement of the affected valve, but not in those who had experienced a simple commissurotomy. These findings provide additional evidence to support a relationship between valvular disease and A-antibody level in rheumatic patients.

Disturbances in Atrial Rhythm and Conduction Following the Surgical Creation of an Atrial Septal Defect by the Blalock-Hanlon Technique

Disturbances in atrial conduction or rhythm, or both, were found in 16 of 27 patients undergoing the surgical creation of an atrial septal defect by the Blalock-Hanlon technique. These included P-wave aberrations of intra-atrial block and ectopic atrial rhythm, A-V rhythm, A-V dissociation, sinus bradycardia, atrial flutter, escapecapture bigeminy, and atrial premature beats. Some of these were transient and occurred within 2 weeks after surgery. It seems likely that tissue trauma engendered by the clamp and resection of the atrial septum with possible injury to the internodal conducting pathways may be the genesis of these early postoperative disturbances. Of the eight cases with transient disturbances, six occurred in this period.Later changes, such as intra-atrial block, sinus bradycardia, and atrial flutter, may be atttributed to changes in atrial size secondary to the postoperative pathophysiology. Digitalis intoxication and congestive heart failure cannot be excluded as contributory factors in either the early or the late disturbances.It was not possible to correlate the incidence and nature of these disturbances with morbidity and mortality. In such severely ill, cyanotic infants, irregularities, however slight, may have altered cardiac function significantly and contributed to their deaths.

Persistent truncus arteriosus in infancy: A study of 14 cases

Abstract Infants with PTA (Types I and II) usually have growth retardation and the physical findings of a large left-to-right shunt. Cyanosis is almost always either absent or minimal. Characteristically, a loud systolic murmur along the left sternal border is present. It is preceded by a prominent constant ejection click and ends before the second sound. A diastolic flow murmur is frequently present at the apex. Continuous or truncal valve insufficiency murmurs are rare. “Splitting” of the second sound is not uncommon. This auscultatory finding may be explained because, in some patients, the second sound is “wide” being composed of several closely approximated, or indeed, 2 discrete components. The ECG usually shows atrial enlargement, a mean QRS axis between +55 and +110 degrees, combined ventricular hypertrophy, and abnormal T waves in V 6 . Isolated right or left ventricular hypertrophy is rare. A high incidence of extracardiac anomalies is found especially in patients with a left aortic arch. The typical roentgen findings are prominent vascular markings of the shunt type, in a patient with right aortic arch (50 per cent of our cases). The plain film findings in patients with left aortic arch are similar to those with complete transposition of the great vessels except that they have a straighter upper left heart border. Selective angiocardiography either with the catheter in the root of the trunk or in the right ventricle is the best diagnostic procedure to delineate the anatomic abnormalities. Absence of the right ventricular infundibulum with a single arterial trunk arising from both ventricles are the diagnostic features. At cardiac catheterization, the systemic arterial pulse pressure is generally wide reflecting the “aortic” run-off lesion. Systemic arterial oxygen saturation approaches normal in many of these infants. Differences in oxygen saturations between the pulmonary arteries and the “ascending aorta” are most likely due to preferential streaming.

Mitral Valve Replacement in a Patient with Mitral Regurgitation Secondary to Rupture of a Papillary Muscle

Excerpt Rupture of a papillary muscle of the heart is considered a rare complication of myocardial infarction (1-5). Cederquist and Soderstrom (1) recently reported an incidence of 0.9% in 578 case...

Correction of Ventricular Septal Defect in Childhood

Abstract One hundred and two consecutive patients underwent operative repair of ventricular septal defect with 9 operative deaths. Preoperative cardiac catheterization was performed in 100 patients. Severe pulmonary hypertension was present preoperatively in 8 of the 9 patients who died. Two patients had permanent heart block. Postoperative cardiac catheterization was performed in three-quarters of the surviving patients. Two patients had significant residual ventricular septal defect. The 92 surviving patients have been followed up to eleven years postoperatively and are asymptomatic.

Intractable Hemoptysis in Mitral Stenosis Treated by Emergency Mitral Commissurotomy

Excerpt The occurrence of hemoptysis in patients with mitral stenosis is not unusual. Various authors report a prevalence of from 17 to 20% (1-4). However, it is exceedingly uncommon for this pulmo...

Use of Superior Vena Cava-Right Pulmonary Artery Anastomosis in Congenital Heart Disease with Decreased Pulmonary Blood Flow

Clinical, hemodynamic, and angiocardiographic findings on eight long-term (more than 3 years) survivors of anastomosis of the superior vena cava (SVC) to the right pulmonary artery (RPA) are described. All patients had severe cyanotic congenital heart disease with decreased pulmonary blood flow. Postoperative cardiac catheterization and angiocardiography defined the physiology of the shunt. SVC pressure was elevated after the creation of the SVC-RPA shunt. This was without obvious clinical effect in six patients. Mild SVC syndrome developed in the immediate postoperative period but was associated with overall clinical improvement in two cases. A late, and more severe SVC syndrome associated with clinical deterioration developed in three patients with severe pulmonic stenosis as part of their cardiac malformation. Clinical improvement and relief of SVC syndrome followed systemic-pulmonary artery shunt or open heart repair of the underlying cardiac malformation, leaving the SVC-RPA anastomosis intact. Clinical improvement following open heart repair of tetralogy of Fallot has persisted in spite of severe postoperative pulmonic valve insufficiency and elevated mean pressure in the left pulmonary artery. This is believed to be a result of the SVC-RPA shunt, which reduced the venous return into the right heart.

Endocardial fibroelastosis of the right ventricle in the newborn: Presenting the clinical picture of the hypoplastic right heart syndrome☆

Abstract A 12 hour old infant with extensive right ventricular endocardial fibroelastosis presenting with cyanosis and all the clinical features of the hypoplastic right heart syndrome is reported. Anatomically, there were no other associated cardiac defects. Endocardial fibroelastosis of the right ventricle, therefore, must be recognized as another cause of cyanosis in the newborn which may present with all the clinical manifestations of the hypoplastic right heart syndrome. Although many different pathologic entities can produce the hypoplastic right heart syndrome, clinical and hemodynamic features are similar. Since the major physiologic derangement is inadequate blood flow to the lungs in all conditions included in this syndrome, a palliative shunt procedure to increase pulmonary blood flow is indicated in symptomatic patients, regardless of the exact anatomic diagnosis.