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The operation of combined heart-lung transplantation results in acute denervation of the heart, lungs, and airways below the level of the trachea. The bronchoconstrictor response to inhaled methacholine of 12 recipients of heart-lung transplants was compared with that of 12 recipients of heart transplants having similar medication and 12 normal subjects. The median dose of methacholine that produced a reduction of at least 20% in the FEV1 (PC20) for the recipients of heart-lung transplants (8 mg/ml) was significantly lower than that for the recipients of heart transplants (64 mg/ml) and normal subjects (greater than 64 mg/ml). The increased airway reactivity may be related to the effects of chronic pulmonary denervation or subclinical inflammation in the airways. The effect of denervation on the response to full inspiration during bronchoconstriction was studied in six patients with heart-lung transplants by means of partial and maximal forced expiratory manoeuvres. Four showed bronchodilation after a deep breath, indicating that this response can occur after extrinsic pulmonary denervation in man. The patients with heart-lung transplants described a "tight" sensation in the anterior chest during bronchoconstriction, indicating that this sensation is not dependent on pulmonary innervation. [ABSTRACT FROM AUTHOR]

For the success of anatomical correction of transposition of the great arteries (TGA) it is essential to transfer the coronary ostia to the posterior vessel without undue tension, torsion, or kinking of the proximal coronary arteries or their early branches. This requires thorough understanding of the different modes of origin and early branching of the coronary arteries in TGA. Based on observations made during anatomical correction, a classification of the coronary arteries in TGA is suggested. In type A the right and left coronary ostia arise from the middle of the right and left posterior aortic sinuses and curve forwards to reach the right atrioventricular groove or anterior interventricular groove respectively. In type B both coronary arteries arise by a single ostium, while in type C the two coronary ostia are situated posteriorly, very close to each other, in a position similar to that in type B. The origin of the coronary arteries in type D is similar to that of type A. However, the right coronary artery gives origin to the circumflex coronary artery that curves round the posterior (pulmonary) vessel to reach the atrioventricular groove. In type E the right coronary artery arises in common with the left anterior descending artery from the left posterior sinus, while the circumflex artery arises separately from the right posterior sinus. Three techniques for the transfer of the different types of coronary arteries during anatomical correction are described. [ABSTRACT FROM PUBLISHER]

A rare case of anomalous origin of the right pulmonary artery from the ascending aorta associated with an aortopulmonary window and severe pulmonary hypertension in a 13-year-old girl is reported. The window was closed using a Dacron patch and the continuity between the anomalous vessel and the main pulmonary artery was restored with a tubular Dacron graft. After operation the pulmonary pressure dropped to about one-half of the systemic pressure, and equal perfusion and ventilation of both lungs was demonstrated. Although early recognition and surgical treatment of this condition are mandatory to prevent the onset of irreversible pulmonary vascular disease, the presence of severe pulmonary hypertension did not contraindicate surgical correction in our patient. [ABSTRACT FROM PUBLISHER]

The long-term follow-up of a 30-year-old patient who had a correction of the syndrome of left ventricular diverticulum and thoraco-abdominal defects is presented. The main features of the syndrome include a diverticulum of the left ventricle, a ventricular septal defect, and sometimes other cardiac anomalies. The thoraco-abdominal defects consist of foreshortened sternum, pericardial and diaphragmatic defects, and umbilical hernia. The association of these anomalies is thought to be due to a developmental failure of the primitive paramidline mesoderm. The diagnosis can be made clinically by the presence of a pulsatile, epigastric mass associated with signs of cardiac septal defects and dextrocardia. The prognosis of patients with this syndrome depends mainly on the associated abnormalities although rupture of the diverticulum can be a fatal complication. The treatment of choice is resection of the diverticulum combined with repair of associated anomalies which can give good early and late results. [ABSTRACT FROM PUBLISHER]

Postoperative septicaemia with infective endocarditis is a recognized complication of open-heart surgery, in particular homograft or prosthetic replacement of cardiac valves. Several infective organisms, both bacterial and fungal, have been incriminated but infection due to tubercle bacilli has not, to our knowledge, been reported. The clinicopathological features of this condition are discussed. During a five-year period, over 800 homograft replacements in the aortic and/or mitral positions have been performed at Harefield Hospital. Seven cases of miliary tuberculosis following homograft valve replacement are descrbied here. In three, there was a past history suggestive of tuberculosis infections but necropsy failed to reveal any caseous or other tuberculous lesion apart from recent miliary tuberculosis. Vegetations on the homograft valves contained microcolonies of acid-fast bacilli in most cases. Tubercle bacilli of the human type were recovered by culture or guinea-pig inoculation in six of the seven cases, and in three the diagnosis was established during life; two of these survived on antituberculosis chemotherapy. The onset of symptoms varied from a few weeks to 12 months after operation. The main presenting symptom was intermittent pyrexia. In two patients the diagnosis was made on radiological and clinical grounds and in both, tubercle bacilli were grown from drill biopsy specimens of lung tissue. The source of infection was presumed to be the homograft valves contaminated in the postmorten room. The antibiotic mixture used in the sterilization of the homografts was not effective against tubercle bacilli. [ABSTRACT FROM PUBLISHER]

Mitral regurgitation due to 'floppy' valves is frequently associated with areas of medical necrosis in the ascending aorta. Application of the aortic clamp to such an area during valve replacement may produce an intimal tear followed by acute dissection. This complication occurred in three patients and was treated successfully by repair of the tear in the two cases where the dissection was observed at the time of operation. Is is suggested that infrequent clamping of the aorta and careful control of the pefusion pressure may decrease the risk of intimal trauma and acute dissection. [ABSTRACT FROM PUBLISHER]

Idiopathic pulmonary hilar fibrosis is a condition related to mediastinal fibrosis, characterized by localization of the fibrosing process to one or both pulmonary hila. This results in pulmonary hypertension and bronchial narrowing. Three patients suffering from this disease, in whom the diagnosis has been confirmed by thoracotomy, are reported. The clinical and pathological features are described and previously reported cases are reviewed. The syndrome is classified into two types, according to whether the obstruction affects mainly the pulmonary artery or veins. The disease is a self-limiting one but may lead to organic changes in the lungs causing severe disability. [ABSTRACT FROM PUBLISHER]

Red cell survival was studied in 21 patients following homograft replacement of the aortic valve. Autologous cells labelled with Cr were used. The T½ Cr varied between 24 and 34 days, with only one patient below the normal limit of normal variations. The absence of haemolysis was confirmed by other haematological studies, including estimation of reticulocytes, serum lactic dehydrogenase, and urinary haemosiderin. Haptoglobin levels were low in most of the patients studied. In contrast to prosthetic valves there was no haemolysis in patients with regurgitation around or through the homograft valve. [ABSTRACT FROM PUBLISHER]

Four cases of congenital defect of the pericardium are described; three had complete absence of the left pericardium and one had a partial defect. One of the patients developed acute pulmonary oedema in the immediate post-operative period following repair of a sinus venosus defect. This complication was thought to be directly related to the pericardial defect. The functions of the pericardium are discussed. The clinical features of the different types of pericardial defect are described. The diagnosis is usually made from the radiographic appearances. Electrical alternans has been noticed in one patient. This is probably due to the increased mobility of the heart. These defects are not completely benign, as has been suggested before. They can cause disabling symptoms, as in case 3, and may be directly responsible for death. [ABSTRACT FROM PUBLISHER]

Two cases of strangulation of the heart following left intrapericardial pneumonectomy are described. The condition presents in the immediate post-operative period by sudden fall of blood pressure associated with a high central venous pressure. The diagnosis is usually made by the characteristic radiographic appearances. Actual strangulation of the ventricles is more common on the left side and can lead to irreversible damage in a short time. The predisposing and precipitating factors are discussed with special reference to prevention. Treatment of the established case is by emergency thoracotomy and reduction of the herniated heart. Recurrence is prevented by repairing the defect or wide excision of the pericardium. [ABSTRACT FROM PUBLISHER]

Three cases of pulmonary osteoarthropathy secondary to pulmonary metastases from extrathoracic tumours are described. Analysis of the reported cases shows that most of them were secondary to osteosarcoma, nasopharyngeal tumour, fibrosarcoma, and uterine tumour. Fibrous tumours and tumours with a predominantly fibrous stroma tend to be associated with osteoarthropathy more than others. This suggests that the fibrous stroma may be a factor in the stimulation of the reflex mechanism responsible for osteoarthropathy. [ABSTRACT FROM PUBLISHER]

A rare case of anomalous origin of the right coronary artery from the pulmonary artery associated with a large aortopulmonary window in a 4-month-old boy is reported. The right coronary artery is exposed to systemic pressure and carries fairly well-oxygenated blood to the myocardium. Angiographic diagnosis could be difficult because of the simultaneous filling of both great arteries which obscures the origin of the anomalous vessel. Closure of the aortopulmonary window alone could result in acute myocardial ischaemia. A plastic procedure for correction of this association of defects, which should allow normal growth, is described. [ABSTRACT FROM AUTHOR]

Four new cases of Candida endocarditis after heart surgery are described and predisposing factors are discussed. Details are given of the one patient diagnosed in life and treated successfully with amphotericin B. [ABSTRACT FROM PUBLISHER]