Will C. Sealy

Traumatic ventricular septal defect secondary to nonpenetrating chest trauma

Abstract A patient with a nonpenetrating traumatic ventricular septal defect is described and the literature reviewed. In view of the high mortality associated with large defects and the ease of successful surgical correction, immediate and follow-up clinical evaluation for this specific entity is mandatory in all cases of blunt chest trauma.

Hypertension and renal dynamics in aortic coarctation

Abstract Examination of the changes in blood pressure in both human and experimental aortic coarctation indicates that these alterations cannot be explained solely as a result of the mechanical effects of the lesion. Studies of the renal dynamics before and after operation in human coarctation fail to show a correlation with the blood pressure changes. It is concluded that other mechanisms, besides the increased resistance imposed by the constriction and collaterals, are necessary to explain the hypertension of aortic coarctation. These mechanisms apparently do not involve renal ischemia.

Supraventricular tachycardia dependent upon accessory pathways in the absence of ventricular preexcitation

Abstract Paroxysmal supraventricular tachycardia is a common disorder of cardiac rhythm, generally thought to be due to reentry within the atrioventrlcular (A-V) node. The possibility that this disorder may be a manifestation of the Wolff-Parkinson-White syndrome should always be considered, but this etiology is usually rejected if the electrocardiogram in sinus rhythm falls to demonstrate a delta wave (i.e., ventricular preexcitatlon). Several recent reports have demonstrated that an accessory A-V pathway may conduct impulses only in the retrograde or ventriculo-atrial direction. Hence, reentrant tachycardia based on a mechanism identical to that observed in patients with classic Wolff-Parkinson-White syndrome may occur, and the electrocardiogram in sinus rhythm fail to show a delta wave. This report describes 11 patients who presented with paroxysmal supraventricular tachycardia without QRS changes in sinus rhythm that suggested the Wolff-Parkinson-White syndrome. Electrophysiologic studies demonstrated that an accessory pathway participated in the mechanism of the tachycardia. Eight of these 11 patients were successfully treated by surgical interruption of either the accessory pathway or the bundle of His. Accessory pathways are not rare among patients with paroxysmal supraventricular tachycardia; and it follows that this variant of the Wolff-ParkinsonWhite syndrome is more common than would be suspected if the Wolff-Parkinson-White syndrome is considered only when delta waves are observed on the electrocardiogram.

The Wolff-Parkinson-White Syndrome and the Beginnings of Direct Arrhythmia Surgery

The bundle of Kent, one of the two pathways involved in the reentry tachycardia of the Wolff-Parkinson-White syndrome, was identified and then interrupted fifteen years ago. This marked the beginning of direct arrhythmia surgery. The patient was a 31-year-old man with a right free wall pathway and persistent tachycardia refractory to medical treatment. In the present report, the historical landmarks in the description of the morphology of the conduction system are reviewed. Current methods of interrupting the Kent bundle, based on experience with more than 200 surgical patients, are discussed. Included is the newer method of simplifying the surgical procedure with cryothermia. Speculation about the future of direct arrhythmia surgery is given in the concluding remarks.

Myxoma of the left atrium: Observations on two cases, with successful removal and review of diagnostic methods

Abstract Myxomas of the left atrium deserve consideration when evaluating patients with suspected mitral valve disease. Careful attention to any atypical features of the history, physical examination, roentgenologic or phonocardiographic study may prove rewarding. Routine right heart catheterization seldom arouses suspicion. Angiocardiographic study is the only definite way to confirm a suspicion of myxoma preoperatively. The pertinent literature is reviewed and observations on two new cases in which the tumor was successfully removed are discussed. In one, the diagnosis was made at operation for mitral valve repair; in the other the tumor was demonstrated on the cineangiocardiogram. The episodic development, in one case, of rather striking disparity in the degree of venous engorgement in the two lung fields, ascribed to selective pulmonary vein obstruction, is offered as an additional finding which may serve to initiate suspicion and aid in the diagnosis of tumor of the left atrium.

Effectiveness of surgical management of the Wolff-Parkinson-White syndrome☆

In this report, the surgical experience with the treatment of Wolff-Parkinson-White syndrome in 190 patients who had 210 Kent bundles has been summarized. The patients with reentry tachycardia caused by the Kent bundle were relieved by Kent division or by His division, the latter being used only in 10 percent of the patients. A malignant ventricular arrhythmia was found in 25 percent of the patients and was due to a Kent bundle that conducted an atrial flutter-fibrillation 1:1 to the ventricle. This arrhythmia was corrected by Kent interruption, since the Kent bundle alone participated in the arrhythmia. Other unusual manifestations of Kent bundles were found, such as multiple pathways, unidirectional conducting pathways, and pathways causing incessant junctional tachycardia. Other cardiac problems were frequently present, such as hypertrophic cardiomyopathy and Ebsteins anomaly. Even in such a multifaceted problem caused by a minute congenital abnormality, careful application of sophisticated electrophysiologic measurements followed by appropriate surgical methods have proved to be effective in correcting the two arrhythmias associated with Wolff-Parkinson-White syndrome.

When is surgery indicated for the control of supraventricular tachycardia

The surgical treatment of supraventricular tachycardias, if the experience with the ones caused by Kent bundles is excluded, is only now developing. Recent reports have described eight patients who had ablation, excision, or exclusion of an area of myocardium that contained an automatic focus. One instance of partial atrioventricular node interruption has been reported for correction of an atrioventricular nodal reentry tachycardia. The largest group of patients subjected to a direct operation had interruption of atrioventricular conduction. Twenty-seven patients, most of whom had enhanced atrioventricular nodal conduction, had either His bundle ablation or division. Experiments on the supraventricular conduction system have been outlined; they may point the way to extension of the indications for direct operations for supraventricular tachycardia.