William J. Kerth

Thrombosis and Degeneration of Hancock Valves: Clinical and Pathological Findings

Of 415 Hancock valves implanted in 370 patients, 26 valve specimens were recovered at postmortem examination and 8 at reoperation. In 9 of these 34, thrombosis had formed without apparent alteration of the heterograft tissue (Group A). All were mitral prostheses, and the thrombi were attached to the sewing ring. Six of the patients died in the early postoperative period following prolonged low cardiac output syndrome and coagulation disturbances. Three patients had late valve thrombosis 12 to 26 months after operation and were in chronic atrial fibrillation with a very large left atrium. Four valve specimens (Group B) demonstrated degenerative changes of the heterograft leaflets such as shrinkage, perforation, and calcification. The clinical courses and possible pathogenesis are discussed.

Ruptured aneurysms of the aortic sinuses of Valsalva

Abstract The basic defect of a congenital aneurysm of the aortic sinuses of Valsalva is a lack of continuity between the media of the aorta and the annulus fibrosus of the aortic valve ring. Most of the aneurysms arise in the right and noncoronary cusps and rupture into the right ventricle or right atrium. Rupture of the aneurysm leads to an aorticocardiac fistula which overloads the right heart leading to severe congestive failure. The murmur is usually continuous, loud and superficial and most frequently heard best in the third and fourth intercostal spaces to the left of the sternum. These fistulas and associated defects can be corrected with open heart surgery with a low mortality rate.

Immediate and long-term results of electrical conversion of arrhythmias

Summary A series of 240 electrical conversion of cardiac arrhythmias in 189 patients has been reviewed by comparing the immediate success of the procedure with long-term results. The material has been analyzed by considering the various forms of arrhythmia, the underlying heart condition and the factors influencing the proneness to the arrhythmia. The most consistently successful results of electrical conversion followed by permanent maintenance of sinus rhythm have been found in atrial flutter and atrial fibrillation developing in the immediate postoperative period following cardiac operations, in patients with valvular and congenital cardiac diseases. Similar success has been found in patients with idiopathic atrial flutter. Chronic arrhythmias in patients with mitral valve disease and in patients with hypertensive and ischemic heart diseases show a disappointingly small long-range yield of persistent sinus rhythm. On the basis of the results of this study, indications and contraindications for electrical conversion of arrhythmias have been defined by attempting to balance the risk of the procedure and the ensuing drug therapy against the risk of the effect of the continuing arrhythmia upon the circulatory system.

The surgical management of bacterial endocarditis: a review.

A total of 239 surgically treated patients with primary endocarditis were reviewed both from the literature and from our own experience. The age range was 10 to 74 years with a male to female ratio of 3:1. A wide variety of organisms was found. However, as a group, gram positive organisms predominate. The onset of congestive failure was the major indication for surgery. The aortic valve was predominantly involved with the mitral valve running a distant second. The hospital mortality rate was 20% and the late mortality rate was 6.7% with an overall mortality of 26.7%. The prognosis in infective endocarditis when congestive failure develops, even in the presence of antibiotic therapy, is poor (79–89% mortality). In view of this poor prognosis, an aggressive attitude with regard to early surgical intervention can greatly improve the outcome of valvular endocarditis.

Endocardial cushion defects.

Although there are at least fourteen possible combinations of endocardial cushion defects, their classification falls under two basic headings: simple or complete.[1,2,3] These include minor variations as well such as a cleft in the tricuspid valve confluent with the cleft to the mitral valve. A cleft mitral valve and no atrial septal defect as well as a very small secundum type of septal defect with a cleft mitral valve can also be listed as variations.

Treatment of Atrial Fibrillation After Surgical Repair of the Mitral Valve

Excerpt Atrial fibrillation, a common sequel to mitral valvular disease, profoundly affects the course of the disease. It adversely affects the performance of the heart; significant symptoms may fi...

Post-exercise thallium-201 myocardial scanning: A clinical appraisal*

Summary Post-exercise myocardial scanning with thallium-201 provides an additional, noninvasive technique for the detection of coronary artery disease which may be especially useful in situations where treadmill testing is likely to be nondiagnostic. Tl-201 scans are sensitive in the presence of severe, discrete single vessel coronary disease, or extensive, diffuse triple vessel disease. In addition, perfusion scanning provides an estimate of regional flow deficits in the myocardium complementary to the anatomic information derived from arteriography and supplementary to the functional information obtained from stress testing. However, our present inability to independently corroborate the status of myocardial perfusion in the clinical setting somewhat limits the value of this information. In this series, 20 of 42 treadmill tests were nondiagnostic, while 2 of 15 patients with severe coronary disease had false negative treadmill tests. Nine of nine patients with single vessel coronary disease had positive myocardial scans with good anatomic correlation between the location of the scan defect and the site of anatomic disease on angiogram. Eighty-three per cent of patients with double and triple vessel disease had positive scans, although anatomic correlation was poorer in these cases. Despite the theoretical advantages of performing both rest and exercise scans, such comparisons were found to be of limited value using this isotope in the clinical setting. The very differences in blood flow and, hence, isotope uptake which should account for rest vs. exercise changes in the presence of ischemic disease, and the low energy of emission of Tl-201, led to poor image clarity and resolution at rest. Underlying segmental wall motion abnormalities at rest could not always be excluded as the cause of a scan defect; exercise rarely altered such a defect recognizably. No false positive but one false negative scan was obtained among patients with severe coronary disease. The role of Tl-201 myocardial perfusion scanning in detecting mild coronary disease, and in evaluating postoperative graft status, remains uncertain. The effect on perfusion of mild coronary obstructive lesions cannot be accurately predicted. One patient, with minimal coronary disease and normal ventricular contraction, had a positive myocardial scan; this was considered to be a false positive. Among post-aortocoronary bypass patients, positive scans related to graft occlusion, significant unbypassed native coronary disease, segmental ventricular wall motion abnormalities, or a combination of these factors.

Bronchopulmonary precapillary blood flow during cardiopulmonary bypass.

Abstract A method of calculating the blood flow traversing bronchopulmonary anastomoses during cardiopulmonary bypass is presented, based on the CO 2 Fick principle. A total of 23 patients have been studied. Bronchial-alveolar flow varied with the type of cardiac lesion, and was often considerable, amounting to 11 per cent of the circulation in one patient with tetralogy of Fallot.

Congenital aortic stenosis

Excerpt Patients with congenital aortic stenosis are prone to sudden and unexpected death, in spite of their apparent well-being when first seen by the physician. The average reported mortality in ...

A new approach to the correction of pure mitral insufficiency by open-heart surgery☆

Abstract Four patients who had pure mitral insufficiency due to rheumatic heart disease are reported upon; in these patients, satisfactory surgical repair was accomplished by a simple suture technique. Clefts are often normally present in the posterior mitral leaflet. These clefts are particularly significant in the posterior half of this leaflet where there is a small reserve of tissue. Rheumatic valvulitis causes scarring and contracture of the leaflet tissue and contraction of the chordae tendineae attached to the edges of these clefts, which may cause the clefts to open. It is postulated that these initial areas of regurgitation may increase the left atrial pressure during early systole sufficiently to hinder the normal action of the aortic leaflet of the mitral valve and initiate a vicious cycle, causing significant mitral regurgitation. In the experimental laboratory and in 4 patients with pure mitral regurgitation, these clefts have been sutured together to reconstitute and shorten the arc of the posterior leaflet and thus restore competency of the mitral valve. This surgical approach appears to be applicable to a small but significant number of patients with pure mitral insufficiency.