William S. Dye

Left Ventricular Hemorrhagic Necrosis

ince the introduction of total cardiopulmonary bypass and the utilization of prosthetic heart valves, numerous reports have apS peared in the literature describing the clinical and hemodynamic results of their application in patients with valvular heart disease. It seems of paramount importance to review the inherent complications associated with this type of surgical intervention in hopes of determining their pathogenesis and prevention. This report is based on the review of the cardiac findings at necropsy in 31 patients who died in the early postoperative period following single or multiple valve replacement at the Presbyterian-&. Luke’s Hospital in Chicago. CLINICAL MATERIALS

Mitral valve replacement. Review of seven years' experience.

Abstract The clinical experience with mitral valve replacement at the Presbyterian-St. Lukes Hospital in Chicago since August 1961 is reviewed. The over-all operative mortality was 20 per cent with an additional 11 per cent late deaths during a mean follow-up period of 20 months. In reviewing the factors influencing the results of surgery, a direct correlation was found between the operative mortality and the level of pulmonary vascular resistance, the preoperative functional classification of the patients and whether or not a previous mitral operation had been performed. Sixty-nine per cent of the patients are still alive; of these, 90 per cent have benefited greatly from the operation. Disabling late complications have been rare. It is concluded that this modality of treatment should be utilized only in patients whose progressive cardiac decompensation indicates poor prognosis without surgery. Likewise, patients in New York Heart Association functional classification III should not be permitted to progress into class IV before valve replacement is offered since cumulative mortality doubles when this occurs.

Permanent transvenous balloon occlusion of the inferior vena cava: experience with 60 patients.

Traditional operations to obstruct the IVC are often unsatisfactory because the morbidity and mortality is appreciable; poor risk patients do not tolerate surgical and anesthetic trauma. Furthermore, if the patient is anticoagulated, an operation requires that such desirable treatment be stopped. Ten years ago a study was begun to develop a transvenous method of IVC occlusion in the awake anticoagulated patient. Animal studies were done prior to patient application. A technique was evolved wherein IVC interruption could be accomplished with a balloon bearing catheter inserted through the jugular vein. The balloon was positioned with venography and after inflation held in place by lateral pressure in the distensible IVC. The catheter was then removed, leaving the balloon in position. Balloon occlusion has been used in the management of 60 selected patients since 1970. Twenty-nine patients were simultaneously anticoagulated without complication. Very sick patients tolerated the procedure well. No patient experienced further pulmonary emboli. Nine hospital deaths occurred from a variety of causes, none related to the balloon catheter. Late follow-up shows that the occluding balloon gradually deflates in about 12 months. The remnant has remained stable in all patients, contained in a scar that permanently interrupts the IVC.

Apical Left Ventriculotomy in Subaortic Stenosis due to a Fibromuscular Hypertrophy

A total of five patients were operated upon for subaortic stenosis due to fibromuscular hypertrophy, using a generous left ventriculotomy centered on the apex. There were no deaths or serious complications, and all patients showed a completely satisfactory functional result in the postoperative periods of 19, 17, 11, 8, and 7 months. Three patients recatheterized 16, 11, and 7 months after surgery were found to have a virtual abolition of the gradient. Pressure measurements made at the completion of surgery in all patients, indicated satisfactory removal of the obstruction. The excellent exposure afforded by this ventriculotomy and the absence of complications arising from its use, recommend it for continued trial. It must, however, stand comparison with other techniques on the basis of the durability of the relief of obstruction.

Hypertension in a child relieved by bilateral renal arterioplasty

Abstract Hypertensive diseases are of two general types: essential or idiopathic, and secondary. Although not common during childhood, abnormal blood pressure has a special significance when it does occur because it is invariably of the secondary type. Among the causes of secondary hypertension are renovascular lesions with the associated Goldblatt phenomenon. Approximately seventeen cases are recorded in the literature of such renal artery abnormality in children associated with hypertension. An instance of bilateral renal artery stenosis resulting in extreme hypertension in a five year old girl is presented. The hypertension was relieved in this patient by surgical restoration of normal renal blood flow.

[The segmental nature of peripheral arteriosclerosis; surgical application].

1 Presented at the first meeting of the North American Chapter of The International Society of Angiology, June 7, 1952, Chicago, Ill. Arteriosclerosis obliterans produces a deficiency in the arterial supply of the part involved through several mechanisms. The major factors are those of mechanical obstruction and of reflex vaso-spasm. The latter factor has been the principle object of therapeutic intervention for a long time. Recent advances in techniques of blood vessel anastomosis, vessel grafting, and the utilization of anticoagulants are encouraging more direct and definitive methods of treatment. These methods have as their purpose reestablishment of the arterial flow through the main channel rather than improvement of collateral circulation as is the case with sympathectomy. The methods with which we are concerned consist of surgical removal of the diseased inner coats of the arteriosclerotic artery, thromboendarterectomy, and with the complete resection of obstructed arterial segments and their replacement by a vein or artery graft. Both techniques may be applied in either acute or chronic arterial occlusion in arteriosclerosis. Although most of our experience to this point is concerned with chronic occlusion there are certain features of the acute cases which are

Further Considerations on the Indications for and Limitations of Direct Surgery in Arteriosclerosis

Segmental obstruction due to arteriosclerosis may occur in peripheral arteries. Further experience in resection of these obstructed segments and their replacement by vein grafts is reported. Replacement of segments of the femoral artery has been accomplished in 30 patients. The proper selection of patients is essential for success. The various causes of failure and the limitations of the procedure are emphasized.