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We evaluated the potential usefulness of three-dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image "drop out" and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2+/- 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2+/- 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are

Background . Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management. Methods . An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H 2 O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H 2 O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. Results . There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV 1 /FVC) ( p = 0.005), increased age ( p = 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) ( p = 0.04), increased RV ( p = 0.02), and an increased functional residual capacity (FRC) ( p = 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients' ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. Conclusions . Most ALs after pulmonary resection are expiratory only. A low FEV 1 /FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment.

Background . Cardiac surgical patients consume a significant fraction of the annual volume of allogeneic blood transfused. Scavenged autologous blood may serve as a cost-effective means of conserving donated blood and avoiding transfusion-related complications. Methods . This study examines 834 patients after cardiac operations at the University of Alabama Hospital. Data were collected on patients receiving unwashed, filtered, autologous transfusions from shed mediastinal drainage and those receiving allogeneic transfusions. The data were incorporated into clinical decision models; confidence intervals for parameters were estimated by bootstrapping sample statistics. Costs were estimated for transfusing both allogeneic and autologous blood. Results . The study found a 54% reduction in transfusion risk or a mean reduction of 1.41 allogeneic units per case (95% confidence interval, 1.04 to 1.79 units). The process saved between $49 and $62 per case. Conclusions . The use of autologous blood has the potential to significantly reduce the costs and risks associated with transfusing allogeneic blood after cardiac operations.

Background: Intravascular perfluorochemical emulsions together with a high oxygen tension may increase the delivery of dissolved oxygen to useful levels. The hypothesis of this study is that increasing the dissolved oxygen content of blood with incremental doses of a perfluorochemical emulsion improves tissue oxygenation during cardiopulmonary bypass in a dose-related fashion. Methods and Results: Oxygen utilization was studied in a profoundly anemic canine model of hypothermic cardiopulmonary bypass. Forty-two dogs (mean ± standard error of the mean). Cardiopulmonary bypass was begun and resulted in a hematocrit of 9.4% + 0.6%. A standard primng solution was used in the control group (n = 12), and the test groups received 1.35 gm perfluorochemical · kg-1 (n = 10 dogs), or 5.4 gm perfluorochemical · kg-1 (n = 10 dogs), 2.7 gm perfluorochemical · kg-1(n = 10 dogs) through the venous return cannula. Each animal underwent a series of randomized pump flows (0.25,0.5, 1.0, 1.5, 2.0, and 3.0 L · min-1 · m-2 ) at 32° C. After the randomized flows were completed at 32° C, the temperature was raised to 38° C and cardiopulmonary bypass was discontinued. Mortality from cardiac failure on separation from cardiopulmonary bypass was 42% in the control group and 20% in perfluorochemical-treated groups. The mean perfluorochemical dose was higher in surviviors than in nonsurvivors (2.9 + 0.4 versus 1.3 + 0.5 gm perfluorochemical · kg-1; p < 0.05). No differences in oxygen consumption or transbody lactate gradient were found between groups during cardiopulmonary bypass. Analysis of mixed venous oxygen tension (a surrogate measure for tissue oxygenation) as a function of cardiopulmonary bypass flow normalized to body surface area showed that the control group had significantly lower mixed venous oxygen tension (p < 0.05) than the perfluorochemical emulsion-treated groups. Furthermore, the differences were related to the perfluorochemical emulsion dose. These differences in mixed venous oxygen tension continued after termination of cardiopulmonary bypass. The coronary sinus oxygen tension and cardiac arterial-venous oxygen content differences during and after cardiopulmonary bypass were similar among the control and perfluorochemical emulsion-treated animals. Dissolved oxygen consumption during and after cardiopulmonary bypass was calculated. Dissolved oxygen consumption increased in the perfluorochemical-treated animals in a perfluorochemical dose-related manner and was significantly higher in perfluoro-chemical-treated animals than in the control animals (p < 0.05). Conclusions: Graded increases in mixed venous oxygen tension during cardiopulmonary bypass were observed in response to graded increases in the dissolved oxygen delivery. These data suggest that enhancing oxygenation with perfluorochemical-dissolved oxygen is an effective temporary substitute for the use of hemoglobin-bound oxygen during cardiopulmonary bypass. Perfluorochemical-dissolved oxygen may be particularly beneficial in the setting of multiple hypoxic stresses. (J THORAC CARDIOVASC SURG 1995;110: 774-85)J THORAC CARDIOVASC SURG 1995;110:1-85.

Testou-se uma nova emulsão de perfluorocarbonos (OxygentMR, Alliance Pharmaceutical, San Diego, CA 92121, EUA) em circulação extracorpórea (CEC) com hipotermia de 32ºC e hematócrito de 12%. Estudaram-se 42 cães, 12 dos quais não receberam a droga e serviram de controle (Grupo 1), enquanto os demais constituíram 3 grupos de 10 animais cada, tratados com doses de Oxygent de 1,5 ml/kg (Grupo 2), 3 ml/kg (Grupo 3) e 6 ml/kg (Grupo 4) as quais geraram fluorocritos de, respectivamente, 1 %, 2% e 3%. Foram analisadas variáveis do metabolismo do oxigênio (O2) em 6 diferentes fluxos de perfusão (Q), ordenados ao acaso. Reaqueceram-se os cães, interrompeu-se a CEC e acompanharam-se os animais por 1 hora. Diferenças intergrupos foram analisadas pelo teste das médias dos quadrados mínimos e pelo teste de Duncan, considerando-se significantes os valores de p< 0,05. Embora algo maiores no Grupo 4, a pressão parcial bem como o conteúdo arterial de oxigênio (CaO2) foram estatisticamente semelhantes ao grupo controle. A pressão parcial de O2 no sangue venoso misto (PvO2) do Grupo 4, em função do Q, mostrou-se significativamente maior (p < 0,03) que a do grupo controle, conquanto isto não tenha se repetido ao ser analisada em função da oferta tecidual de O2 . Também não houve diferença quanto ao consumo de O2 total e dissolvido, nem quanto aos gradientes sistêmico e miocárdico de lactato, porém a maior dose da emulsão (Grupo 4) expressa efeito dose-dependente benéfico, ainda que de natureza especulativa, do Oxygent sobre o metabolismo do oxigênio.A novel perfluorocarbon emulsion (OxygentTM - Alliance Pharmaceutical Corp., San Diego, CA 92121, USA) was tested during hypothermic (32ºC) cardio pulmonary bypass (CPB) under severe hemodilution (Hto = 12%). Forty-two mongrel dogs were allocated to 4 groups. Group 1 (n=12) was not given Oxygent and served as control whereas Groups 2, 3, and 4 (10 animals each) were given a bolus dose of the emulsion (1.5,3.0, and 6.0 ml/kg, respectively) at the onset of CPB. O2 metabolism variables were then studied at 6 randomized pump flow rates (Q) ranging from 0.25 to 3.0 l/min/m². After rewarming CPB was discontinued and the animals were followed-up for one hour and then killed by IV KGI injection. Differences between groups were evaluated by the least squares means and Duncan's tests and considered significant for p

Background: This study compares oxyhemoglobin dissociation during the nonperfused periods of hypothermic cardioplegic arrest in two blood cardioplegic solutions with different hemoglobin concentrations. The hypothesis is that more oxygen will dissociate from hemoglobin in a blood cardioplegic solution with a higher hemoglobin content than from a cardioplegic solution with a lower hemoglobin content. However, the increment in the volume of oxygen that dissociates from hemoglobin will be less than anticipated by a ratio of hemoglobin concentrations in the cardioplegic solution. Methods and results: Pigs ( n = 22) were supported by bypass and subjected to 60 minutes of hypothermic cardioplegic arrest with either a high-hemoglobin ( n = 10) or low-hemoglobin ( n = 12) blood cardioplegic solution. Aortic root and coronary sinus blood samples were obtained before bypass and 5 seconds after the start of cardioplegic infusions at 20, 40, and 60 minutes of cardioplegic arrest. Oxyhemoglobin dissociation occurred in both experimental groups during the ischemic intervals of cardioplegic arrest. However, there were no significant differences between the high- and low-hemoglobin groups in the arterial-venous oxygen content differences for samples taken after each of the three ischemic intervals ( p values: control=0.78; cardioplegia interval 1=0.95; interval 2=0.56; and interval 3=0.12). Conclusions: The present study emphasizes the inherent limitations of unmodified erythrocyte hemoglobin as an oxygen source in hypothermic alkalotic cardioplegic solutions. These limitations may be obviated by methods that increase the dissolved oxygen content of the cardioplegic solution or methods that decrease the affinity of hemoglobin for oxygen under conditions of hypothermia and alkalosis. (J THORAC CARDIOVASC SURG 1994;108:664-71)

This study compared myocardial blood flow during postcardioplegia reperfusion asystole and ventricular fibrillation. Pigs (n = 20) were placed on cardiopulmonary bypass and blood cardioplegic solution at 38 degrees C was then infused. A preischemia microsphere injection was given in asystolic hearts. All animals then had 1 hour of hypothermic cardioplegic arrest and underwent reperfusion with high-dose (n = 10) or low-dose (n = 10) 38 degrees C blood cardioplegia. At 30 seconds after reperfusion, all hearts were asystolic. The second microsphere injection was then given. At 3 and 6 minutes after reperfusion, the animals' hearts were either in asystole (n = 10) or ventricular fibrillation (n = 10), and the third and fourth microsphere injections were then given. At 10 minutes after reperfusion, all hearts were beating and the final (fifth) microsphere injection was given. There was an initial increase in the global myocardial blood flow during reperfusion versus the preischemic control value. However, later, during reperfusion (ie, at the third and fourth injections), there was a significant (p0.05) decrease in the global myocardial blood flow. There was no discernible response in either the global myocardial blood flow or regional myocardial blood flow distribution to electromechanical activity (ie, ventricular fibrillation) for the third and fourth injections, suggesting that coronary autoregulation was abnormal. Postcardioplegia reperfusion ventricular fibrillation imposes metabolic demands that may cause reperfusion injury, especially in hearts affected by hypertrophy, ventricular distention, or coronary obstruction.

Cryopreserved aortic valve homografts have become an accepted aortic valve substitute, but long-term studies with echocardiographic assessment of valve function are largely unavailable. Between 1981 and January 1, 1991, a total of 178 patients aged 9 months to 80 years (median 46 years) underwent implantation of a cryopreserved aortic valve homograft. Serial two-dimensional Doppler echocardiographic studies were obtained in 149 patients. Overall survival was 91% at 1 year and 85% at 8 years. Survival of patients undergoing isolated primary infracoronary aortic valve replacement was 99% at 1 month and 94% at 8 years. Twelve patients underwent homograft explanation. Freedom from explantation for leaflet degeneration was 95% at 8 years. Freedom from presumed leaflet failure (valve degeneration at explantation or aortic insufficiency grade 3/4 or more without reoperation on echocardiography) was 94% at 5 years and 85% at 8 years. By multivariable analysis younger recipient age was the only risk factor identified for leaflet failure. Ninety-five percent of patients followed up for 4 or more years were in New York Heart Association class I or II.

The purpose of this study was to quantitate the uncertainty inherent in the electrophysiologic mapping of ventricular preexcitation as seen in Wolff-Parkinson-White syndrome. An ink-coated needle electrode was constructed to serve as a point source of unipolar stimulation along the atrioventricular junction. Activation times for 11 ventricular mapping sites at the atrioventricular junction were measured for each stimulation point. Maps were successfully completed for 18 right free wall and 14 posterior septal stimulation points. The activation time at the mapping site closest to the stimulation point was termed the index activation time. Activation times identical to the index activation time were noted at 1.3 +/- 0.5 mapping sites for each free wall stimulation point and 1.9 +/- 0.9 mapping sites for each septal stimulation point (p < 0.05, septal versus free wall stimulation points). Activation times falling within 5 msec of the index activation time were noted at 2.4 +/- 1.0 mapping sites for each free wall stimulation point and at 3.9 +/- 1.4 mapping sites for each septal stimulation point (p < 0.05, septal versus free wall stimulation points). The uncertainty of electrophysiologic mapping can be quantitated, and this error should be considered when making inferences regarding the anatomy of accessory pathways based on electrophysiologic data. A knowledge of the uncertainty inherent in the localization of accessory atrioventricular connections by electrophysiologic mapping can be used to plan borders of surgical dissection that will account for this uncertainty at a 95% confidence level.

Survival after entry and survival after repair (94%, 91%, and 91% at 1 month, 1 year, and 5 years, respectively) were similar in two institutions treating 196 consecutive patients, and there was no advantage (and a possible disadvantage) of a protocol of preliminary shunting and later repair in very young patients. Size and configuration of the right and left pulmonary arteries had no demonstrable effect on survival, prevalence of transannular patching, or postrepair right ventricular-left ventricular pressure ratio. Small size of the pulmonary “anulus” and trunk were risk factors for death, transannular patching, and high postrepair pressure ratio. High postrepair pressure ratio was a risk factor for death after repair. Very young age (less than about 3 months) was a risk factor for death after repair, particularly when other risk factors coexisted. The prevalence of transannular patching in patients with mild infundibular and pulmonary anulus and trunk hypoplasia decreased across the time of the study, without ill effect. The usefulness of measuring postrepair right ventricular-left ventricular pressure ratio is emphasized by the data. (J T horac C ardiovasc S urg 1992;103:706-23)

The purpose of this study is to present data comparing the penetration of cryolesions created by various sizes and shapes of cryoprobes in human cadaveric myocardium, fat, and tissue of the central fibrous body. Ten cryolesions were made for each combination of tissue and cryoprobe studied. All cryolesions enlarged most rapidly during the first minute of cryothermia (p less than 0.01). Maximal cryothermic penetration into nontrabeculated myocardium was 8.5 +/- 0.5 mm (15-mm flat probe) and 6.1 +/- 1.0 mm (5-mm small probe). Maximal cryothermic penetration into trabeculated myocardium was 9.4 +/- 1.0 mm (10-mm cone-tipped probe) and 7.4 +/- 0.5 mm (10-mm flat probe). Maximal cryothermic penetration into fat was 4.7 +/- 0.7 mm (15-mm flat probe) and 3.9 +/- 0.7 mm (5-mm flat probe). The deeper penetration of cryothermia into myocardium as compared with fat (p less than 0.05) is related to the lower thermal conductivity of fat. Maximal cryothermic penetration of the central fibrous body was similar to that of the myocardium with transmural freezing of the central fibrous body after 4.4 +/- 0.3 minutes of cryothermia. These data can be used when determining the optimal cryothermic exposure for ablation of arrhythmogenic tissue.

BACKGROUND The value of transesophageal echocardiography in the assessment of patients with aortic dissection was studied. METHODS AND RESULTS Group 1 (34 patients) represented all patients studied at our institution with this technique in whom aortic dissection was proven by aortography, surgery, or autopsy. Group 2 (27 patients) represented all patients studied with this technique at our institution in whom aortic dissection was excluded by aortography. Transesophageal echocardiography made a correct diagnosis of aortic dissection in 33 of 34 patients (sensitivity, 97%; specificity, 100%). It also correctly demonstrated the type of dissection in all 29 patients with aortographic or surgical proof. On the other hand, computed tomography scanning, performed in 24 of 34 patients in group 1, made a correct diagnosis in only 67% of patients and misclassified the type of dissection in 33%. Transesophageal echocardiography correctly identified involvement of the coronary arteries by aortic dissection in six of seven patients as well as absence of both left and right coronary artery involvement in 10 patients with aortic dissection. This technique was also useful in detecting communications between the true and false lumens, presence of thrombi in the false lumen, and, in two patients, localized dissection rupture with formation of a false aneurysm. In both groups 1 and 2, transesophageal echocardiography correctly identified patients with moderate to severe aortic regurgitation. CONCLUSIONS Transesophageal echocardiography is very useful in the assessment of aortic dissection.

ObjectiveIn 1990, Fontan, Kirklin, and colleagues published equations for survival after the so-called “Perfect Fontan” operation. After 1988, we evolved a protocol using an internal or external polytetraflouroethylene tube of 16 to 19 millimetres diameter placed from the inferior caval vein to either the right or left pulmonary artery along with a bidirectional cava-pulmonary connection. The objective of this study was to test the hypothesis that a “perfect” outcome is routinely achievable in the current era when using a standardized surgical procedure.MethodsBetween 1 January, 1988, and 12 December, 2005, 112 patients underwent the Fontan procedure using an internal or external polytetraflouroethylene tube plus a bidirectional cava-pulmonary connection, the latter usually having been constructed as a previous procedure. This constituted 45% of our overall experience in constructing the Fontan circulation between 1988 and 1996, and 96% of the experience between 1996 and 2005. Among all surviving patients, the median follow-up was 7.3 years. We calculated the expected survival for an optimal candidate, given from the initial equations, and compared this to our entire experience in constructing the Fontan circulation.ResultsAn internal tube was utilized in 61 patients, 97% of whom were operated prior to 1998, and an external tube in 51 patients, the latter accounting for 95% of all operations since 1999. At 1, 5, 10 and 15 years, survival of the entire cohort receiving polytetraflouroethylene tubes is superimposable on the curve calculated for a “perfect” outcome. Freedom from replacement or revision of the tube was 97% at 10 years.ConclusionUsing a standardized operative procedure, combining a bidirectional cavopulmonary connection with a polytetraflouroethylene tube placed from the inferior caval vein to the pulmonary arteries for nearly all patients with functionally univentricular hearts, early and late survival within the “perfect” outcome as predicted by the initial equations of Fontan and Kirklin is routinely achievable in the current era. The need for late revision or replacement of the tube is rare.

Pulmonary vasospasm and hypertension may occur after repair or palliation of congenital cardiac defects, and can be fatal in spite of conventional treatment. Nitric oxide has been shown to improve pulmonary hypertension unresponsive to conventional measures after a variety of repairs, but use has infrequently been reported after palliative systemic to pulmonary artery shunts. We report a case of pulmonary hypertension and life threatening desaturation after a modified Blalock-Taussig shunt that responded rapidly to inhaled nitric oxide. Clinical use, further study, and prospective analysis of prophylactic use of nitric oxide appear warranted.

Background . This report describes technical details of the right thoracotomy approach for mitral surgery, and analyzes our experience with this procedure for patients with a prior sternotomy. Three methods for myocardial management (hypothermic cardioplegic arrest, beating heart, and fibrillating heart) are compared. Methods . Records were abstracted of patients who had a right thoracotomy between January 1, 1992 and July 1, 1999 for mitral surgery after at least one prior sternotomy. Demographic, operative, and outcome data were collected for analysis. Telephone follow-up was used to measure postoperative New York Heart Association functional status. Results . Eighty-four patients (mean age 60 ± 15 years) had reoperative mitral surgery via a right thoracotomy. Myocardial management included ventricular fibrillation in 10 patients, operation on the beating heart in 58 patients, and hypothermic blood cardioplegia arrest in 16 patients. The mean time in the operating room was 185 ± 73 minutes, and the mean duration of cardiopulmonary bypass was 63 ± 56 minutes. There were no perioperative strokes and the prevalence of death for patients who received cardioplegic arrest was significantly higher than the prevalence of death for patients who had mitral surgery with perfused fibrillating or beating heart techniques ( p = 0.007; Fisher's exact test comparing risk- unadjusted mortality). Conclusions . Right thoracotomy provides efficient exposure for reoperative mitral surgery. Mitral valve procedures on the fibrillating or beating heart are feasible in most patients and are at least as safe as surgery using cardioplegic arrest.

Information describing outcome after myocardial revascularization and renal transplantation in patients with end-stage renal disease and coronary artery disease is limited in scope. There are several case reports that describe the results of cardiac operations in small numbers of renal transplant patients. 1–9 If these reports are considered together, there are 35 renal allograft patients who subsequently underwent cardiac operations. Of these 35 patients, 29 had isolated coronary artery bypass grafting (CABG). The aggregate immediate postoperative survival rate in these patients was 97%; however, intermediate- and long-term survival rates cannot be determined from the information contained in these reports. A larger study by Bolman et al published in 1984 included 14 patients who had cardiac operations. 10 Ten of the patients in this series had isolated CABG. There were two deaths; 12 patients were alive at 8 to 93 months after surgery. More recent studies of cardiac operations performed in renal transplant recipients 11,12 include more patients and a more complete outcome analysis. These studies, together with the earlier analysis of Bolman et al, indicate that surgical revascularization can be performed in renal transplant recipients without an unusually high incidence of postoperative infection despite immunosuppression, and with an acceptable short-term mortality rate relative to cardiac operations performed in patients without renal disease. In all three series, the short-term preservation of renal allograft function was good. Data have also been published that describe the outcome of patients who are maintained on dialysis and who receive either CABG or percutaneous transluminal coronary angioplasty (PTCA). 5,13–20 Several of these reports describe individual patients who had renal transplantation after revascularization; however, there is no report that describes long-term outcome and defines risk factors for patients with chronic renal failure who undergo a myocardial revascularization procedure and renal transplantation. The present report takes advantage of the large population of patients with renal disease treated at this institution. The goal was to generate a comprehensive review of myocardial revascularization in patients with chronic renal failure who also receive, at some point in their lives, a renal allograft. The specific aims of this analysis were to quantify the number of deaths in patients who had renal transplantation and myocardial revascularization at this institution, and to identify risk factors that influenced survival in these patients.

Estudaram-se a demanda metabólica e a distribuição do fluxo coronariano na presença de fibrilação ventricular (FV), durante a reperfusão pós-cardioplegia. Foram colocados 15 suínos em circulação extracorpórea e submetidos a parada cardíaca cardioplégica sangüínea anterógrada hipotérmica intermitente, durante uma hora, seguida por reperfusão miocárdica controlada. Os animais foram divididos em três grupos (n=5), conforme estivessem em assistolia (Grupo 1) ou em FV de curta (Grupo 2) ou longa duração (Grupo 3), durante os dez primeiros minutos de reperfusão. Os valores do consumo miocárdico de oxigênio (MVO2), em ml O2/min/g (média ± erro padrão) durante a reperfusão foram de 1,325 ± 0,144 (Grupo 1); 2,472 ± 0,208 (Grupo 2) e 2,469 ± 0,228 (Grupo 3). A diferença entre o MVO2 dos corações em assistolia e o dos corações em FV, quer de curta ou longa duração, foi significante (pMetabolic coronary blood flow recruitment and distribution were studied in the setting of ventricular fibrillation (VF) during post-cardioplegia reperfusion. Fifteen pigs were placed on cardiopulmonary bypass and subjected to one hour of intermittent cold blood antegrade cardioplegia, followed by controlled myocardial reperfusion. According to the electromechanical status during the first ten minutes of reperfusion, the animals were allocated into 3 groups (n=5). Whereas Group 1 remained asystolic, the other two groups developed short (Group 2) or long duration VF (Group 3). Myocardial oxygen consumption (MVO2), in m/O2 /min/g (mean ± standard error) during reperfusion was 1.325 ± 0.144 (Group 1); 2.472 ± 0.208 (Group 2) and, 2.469 ± 0.228 (Group 3). MVO2 difference between asystolic and both short and long duration VF hearts was significant (p

The success of methods that ablate atrioventricular (AV) node reentry demonstrates that extranodal tissue is part of the reentry circuit. The hypothesis of this study is that atrial tissue approaching the posterior AV node is part of the AV node reentry circuit and is especially suitable for complete division with sparing of AV conduction. This study measured AV node function after either an anterior or posterior perinodal incision. The only significant change noted in antegrade function was a lengthening of the Wenckebach point after the posterior incision. Retrograde AV conduction and ventricular echoes were abolished by the posterior incision, whereas the anterior incision had no discernible effect on retrograde AV node function. Anatomic analysis of the two incisions showed that the posterior incision completely interrupted the posterior atrial input to the AV node, whereas the anterior incision spared the medial input to the AV node. The atrial tissue posterior to the AV node is anatomically suited for complete interruption. Ablation of atrial tissue posterior to the AV node is proposed for abolishing AV node reentrant tachycardia.

Aortic valve endocarditis with an aortic root abscess cavity was treated by a modification of the standard technique of aortic homograft implantation in 3 patients. At a mean follow-up of 35 months, all 3 patients were well without reoperation or signs of aortic incompetence. This technique may, in some cases, be an alternative to the more complex procedure of homograft aortic root replacement with coronary reimplantation.

We speculated that prophylactic ligation of the ductus arteriosus would reduce mortality and morbidity in very-low-birth-weight infants. To test this hypothesis, we randomly assigned 84 babies who weighed 1000 g or less at birth and required supplemental oxygen either to receive standard treatment (n = 44) or to undergo prophylactic surgical ligation of the ductus arteriosus on the day of birth (n = 40). The ductus was ligated in babies in the control group only if the shunt was hemodynamically important. All the babies were followed for one year. The incidence of necrotizing enterocolitis was reduced in the group that underwent prophylactic ligation (3 of 40 [8 percent]) as compared with the control group (13 of 44 [30 percent]; P = 0.002). The frequency of death, bronchopulmonary dysplasia, retinopathy of prematurity, and intraventricular hemorrhage was similar in both groups. Because early enteral feeding may have increased the incidence of necrotizing enterocolitis, we analyzed separately the babies who were fed early. Among the infants who were fed within 14 days of birth, those who underwent prophylactic ligation had a lower incidence of necrotizing enterocolitis (1 of 11 [9 percent]) than those who did not (13 of 24 [54 percent]; P = 0.001). Within the control group, the infants who were fed within 14 days of birth and whose ductus was ligated for medical reasons within 5 days of birth had a lower incidence of necrotizing enterocolitis (2 of 10 [20 percent]) than those whose ductus was ligated later or not at all (11 of 14 [79 percent]; P = 0.004). We conclude that early surgical closure of the ductus arteriosus reduces the risk of necrotizing enterocolitis in infants of very low birth weight who require supplemental oxygen.

Four patients with tetralogy of Fallot, three of whom had congenital pulmonary atresia, were treated by initial palliative operations to enlarge left and right pulmonary arteries which were considered too small for complete repair. Two to four years later the right and left pulmonary arteries had enlarged sufficiently to allow complete repair.

Despite increasing experience with the surgical treatment of tricuspid atresia, controversy exists regarding the early and late results of the various surgical options. Between January 1, 1967, and September 1, 1982, 92 patients underwent 147 operations for tricuspid atresia. Eighty-five patients underwent 1 or more palliative operations (108 procedures), with 8 hospital deaths (9%; confidence limits [CL], 6 to 14%). Thirty-eight patients underwent 44 classic (Blalock-Taussig or Gore-Tex) shunts, with 3 early (7%; CL, 3 to 13%) and 3 late deaths. Actuarial survival at 5 years was 78%, but only 56% were alive and free from having to undergo further operation at 5 years. Thirty-seven patients underwent a Fontan procedure, with 5 hospital deaths (14%; CL, 8 to 22%). Of these 37 patients, 34 (92%) had a nonvalved connection between the right atrium and the right ventricular infundibulum or the pulmonary artery. Incremental risk factors for hospital mortality after the Fontan procedure in patients with tricuspid atresia as well as other cardiac anomalies include young age (p = 0.0003), diagnosis other than tricuspid atresia (p = 0.03), and complex associated procedures (p = 0.02). During the year 1983, hospital mortality was 7% (1 out of 14; CL, 1 to 22%) for the Fontan procedure without complex additional procedures. Actuarial survival after a Fontan procedure was 71% at 5 years, with 3 patients requiring late reoperation. Of the survivors, 96% are in New York Heart Association Functional Class I or II. The Fontan procedure without a valve offers good intermediate survival, good functional results, and few reoperations. In patients with diminished pulmonary blood flow, a classic shunt also provides good palliation and good intermediate survival, but there is a necessity for additional operations in many patients within 5 years.

Connection of an anomalous left superior vena cava to the left atrium is an uncommon lesion that is usually associated with other complex intracardiac malformations. A technique for diverting the anomalous caval return along the left atrial roof and into the right atrium is presented. This simple tunnel method avoids potential obstruction to systemic and pulmonary venous return and leaves viable atrial tissue comprising the majority of the new pathway. The technique and results in 7 patients are described.

A total of 312 patients with single or multiple ventricular septal defects (VSD) with or without major associated lesions underwent surgical repair between 1967 and 1979. In the overall experience in patients without major associated defects, six hospital deaths (3.6%) occurred among 166 patients undergoing primary repair of single large VSDs, but in the last 5 years, one death (1.1%) occurred among 94 patients. Among the 29 patients with multiple VSDs, nine deaths (31%) occurred, but only one (7%) among the 14 operated upon in the last 5 years. In both groups, young age was an incremental risk factor for hospital death overall, but not in the last 5 years. Neither the location of the VSD nor the surgical approach were risk factors. Among 58 patients with major associated lesions and either single or multiple VSDs, 14 (24%) died after operation. In this subset, risk of hospital death did not decline during the 12 year period, and young age remained a significant incremental risk factor throughout. Of 261 patients with a single VSD and without a straddling tricuspid valve, one (0.4%) developed complete heart block, as did two (4%) of 47 patients with multiple VSDs. The decrease in hospital mortality rate with time and the neutralization of young age and multiplicity of VSDs as important incremental risk factors resulted from improvements such as more precise preoperative diagnosis of location and number of VSDs and improved intraoperative and postoperative care. The incremental risk of major associated lesions, especially in the very young and in those with multiple VSDs, should be neutralized in the future by-further research and development. However, in the meantime, management in most subsets should be individualized.

Fifty-five infants less than 1 year of age underwent repair of coarctation of the aorta between 1967 and 1981. Sixteen (29%) died while in the hospital, with one death occurring from “pure” coarctation. Of the remaining patients, four among 20 with associated ventricular septal defect (VSD) and 11 among 19 with other major associated cardiac anomalies (p = 0.002) also died. Thirteen (62%) of 21 patients treated by resection and end-to-end anastomosis died in the hospital, while only two (7%) of 30 in whom the subclavian flap repair was used died (p

Fifty-five consecutive patients with the tetralogy of Fallot underwent intracardiac repair in a 12 month period. A standardized protocol for outflow tract enlargement was used. When the measured diameter of the pulmonary valve ring was at least the "minimum acceptable pulmonary valve ring diameter," primary patch-graft enlargement across the valve ring was not done (Group I, 34 patients); when it was less, primary patch-graft enlargement was done (Group II, 21 patients). The right ventricular-left ventricular systolic pressure ratio (PRV/LV) after repair without patch-graft enlargement across the ring was related to the size of the ring. Sixteen (94 percent) of 17 such patients with normal-sized or large pulmonary valve rings (according to the criteria of Rowlatt, Rimoldi, and Lev) had PRV/LV equal to or less than 0.65; four (80 percent) of five patients with smaller rings but within the 50 percent confidence limits had PRV/LV equal to or less than 0.65; five (56 percent) of nine with still smaller rings but within the 72.5 percent confidence limits had PRV/LV equal to or less than 0.65. In Group II, 15 patients had abnormally small rings, but after patch-graft enlargement the mean PRV/LV was 0.44 +/- 0.140. A surgical protocol based on these data has been developed.

The anatomic and functional characteristics of 310 consecutive patients undergoing repair of atrioventricular (AV) septal defects were studied. The characteristics of the six leaflets of the common (139 patients) or two-orifice (171 patients) AV valve are described. Interventricular communications were present in 156 patients and major associated cardiac anomalies in 73 (tetralogy of Fallot 20, double-outlet right ventricle nine, and others). Fifty-one patients (16%) died in hospital. The incremental risk of young age disappeared after 1976. Severity of preoperative AV valve incompetence and New York Heart Association (NYHA) functional class affected hospital mortality. Current risks for patients without major associated cardiac anomalies are 0.6% to 4% for patients in NYHA Class III without an interventricular communication, depending on the degree of preoperative AV valve incompetence, and 5% to 13% for such patients with an interventricular communication. Actuarial survival at 12 1/2 years postoperatively is 95% when preoperative AV valve incompetence is absent or mild and 88% when it is more severe (Grade 3, 4, or 5). Actually, 92% of hospital survivors are alive and in NYHA class I or II. Failure of the AV valve repair occurred in 32 (10%) of the 310 patients and occurred more frequently when AV valve incompetence was severe preoperatively. Its frequency is reduced by current repair techniques, except in patients without interventricular communication.

Surgical repair by ventricular septation was accomplished in 16 patients with univentricular heart of the left ventricular type, two atrioventricular (AV) valves, and a left anterior subaortic outlet chamber. There were seven hospital deaths (44%; CL 29% to 60%), six from low cardiac output, including each of five patients with outlet foramen obstruction (100%; CL 68% to 100%). In the subset of 11 patients with unobstructed outlet foramen, there were only two deaths (18%; CL 6% to 38%), both in patients with small ventricular size. Multivariate analysis in the group of 16 patients indicates that small ventricular size and again the presence of outlet foramen obstruction are incremental risk factors for hospital death. No late deaths occurred among nine survivors followed between 2 months and 4 years (median = 1.5 years). Only one patient was taking cardiac medication and each was in New York Heart Association Functional Class I. Late postoperative exercise testing in seven showed good exercise tolerance, although values were below normal for children of similar age. Planned initial palliation, appropriate timing of repair, appropriate patient selection, and improving surgical methods should reduce hospital mortality further. The late functional results are encouraging and support continuation of this surgical procedure in patients with suitable anatomy.

During the 13 year period from January 1967 to July 1980, the hospital mortality rate for open intracardiac operations in infants in the first 3 months of life was 43 percent (75 deaths among 194 patients), higher than the 22 percent mortality rate (35 deaths in 161 patients) for closed operations in the same age group. The mortality rate was lower late in the experience (p = 0.0001). Poor preoperative condition of the patient increased the mortality rate 87 percent in patients preoperatively acidotic or in shock [preoperative class V]and 22 percent in patients with moderate or severe symptoms but without recent hemodynamic deterioration (preoperative class II or III). The presence of major associated cardiac lesions increased hospital mortality (p

The original Senning technique of interatrial transposition of venous return was selectively employed for physiological correction in 24 patients with transposition of the great arteries (TGA) ranging in age from 74 days to 26 months (median 7 months). Twenty-three had intact ventricular septum and one had a large ventricular septal defect and diaphragmatic subpulmonary stenosis. There were no hospital or late deaths, and at follow-up examination 1.5 to 12 months postoperatively, each patient was asymptomatic, in normal sinus rhythm, and had no clinical evidence of caval or pulmonary venous obstruction. Nine patients underwent cardiac catheterization and angiocardiographic studies between 1.3 and 9 months postoperatively which demonstrated widely patent venous pathways and effective “left” and “right” atrial contraction. This experience lends support to the continued use of the Senning technique for interatrial transposition of venous return.

Twenty-nine patients with balanced forms of complete atrioventricular (AV) canal defects and tetralogy of Fallot in 12, double-outlet right ventricle (DORV) in 10, and additional anomalies associated with atrial isomerism in 7 underwent corrective repair. Age ranged from 39 days to 24 years (median, 3.7 years). Repair included reconstruction of the common AV valve in 25 patients and prosthetic valve replacement in 4. Construction of an intraventricular tunnel connecting the left ventricle with the aorta was accomplished in 23 of 25 patients with ventriculoarterial concordant or double-outlet connections. In 2 patients with situs inversus and associated DORV and in 4 patients in the isomerism group who had ventriculoarterial discordant connections, repair included intraatrial venous diversion by a modified Senning procedure in 2, a modified Mustard venous switch in 1, and a tailored atrial baffle in 3. A valved extracardiac conduit was required for repair in 4 patients. Partial anomalous systemic venous connection was repaired in 7 patients and total anomalous pulmonary venous connection, in 5. There was 1 hospital death (3%) and 3 late deaths (11%). There was 1 (3.6%) reoperation to replace an incompetent right (systemic) AV valve 17 months postoperatively, and each of the 25 surviving patients was in New York Heart Association Functional Class I (80%) or II (20%) at follow-up.

Double outlet right ventricle (DORV) may be divided into subsets according to the position and commitment of the ventricular septal defect (VSD) to the great arteries. In DORV with subaortic VSD, an intraventricular tunnel repair is the recommended operation. The current hospital mortality is 5% with an actuarial survival of 83% at 15 years. DORV with doubly committed VSD should also be repaired with an intraventricular tunnel, and the surgical results are similar to those for DORV and subaortic VSD. In DORV with subpulmonary VSD, an intraventricular tunnel repair is advisable when the distance from the tricuspid to the pulmonary valve exceeds the distance from tricuspid to aortic valve. Otherwise, a spiral intraventricular tunnel or an arterial switch procedure should be considered. In DORV with doubly committed VSD, the results of surgical treatment have been less good, and alternative forms of surgical treatment require further evaluation. The surgical treatment of DORV with pulmonary stenosis and the surgical details of the intraventricular tunnel repair are discussed.

Tetralogy of Fallot associated with atrioventricular (AV) canal is a well-recognized cardiac malformation; its surgical repair carries a high mortality, which is related partly to the complexity of the defect and partly to incomplete diagnosis. Hence an accurate preoperative diagnosis is essential. This communication describes the angiographic features observed in 17 patients with tetralogy of Fallot and AV canal with emphasis on the morphology of the right AV valve as seen during the right ventriculogram. A complete anatomic diagnosis can be consistently made from right and left ventriculograms performed in axial projections.

Classical tetralogy of Fallot was repaired by a transatrial-transpulmonary approach in 61 of 70 patients treated surgically on one surgical service between July 1981 and December 1985. Their ages ranged from 2.5 months to 57 years (mean 52.9 +/- 104.2 months). The ventricular septal defect was closed through the right atrium and tricuspid valve in 60 patients and via the pulmonary artery in one patient with a subpulmonary defect. A pulmonary arteriotomy was made in 38 patients to expose the stenotic pulmonary valve for valvotomy and to begin the infundibular mobilization and resection. It was extended through a small pulmonary anulus primarily in 15 patients and secondarily in one, a minimal distance upon the right ventricular infundibulum to enlarge the outflow tract to 2 standard deviations larger than the mean normal pulmonary valve anulus diameter. There were no hospital or late deaths or reoperations among the entire group. The mean postrepair peak right ventricular/left ventricular pressure measured in the operating room was 0.52 +/- 0.165 for the entire group of 61 patients which indicates similar relief of pulmonary stenosis to that obtained by the classical transventricular repair. At follow-up between 2.3 and 53.8 months (mean 22.6) each patient was in New York Heart Association Class I and without cardiac medication. Postoperative cardiac catheterization studies performed in nine patients between 4 and 28 months after operation showed no residual ventricular septal defects and a mean peak right/left ventricular pressure of 0.42 +/- 0.13. This series indicates that successful repair of tetralogy of Fallot can be accomplished in most patients by a transatrial-transpulmonary approach, which may provide improved right ventricular function over the long term.

Ten patients with complete atrioventricular (AV) canal and tetralogy of Fallot or double-outlet right ventricle (DORV) with subaortic ventricular septal defect and pulmonary stenosis underwent complete repair. Associated cardiac anomalies were frequent, and 3 patients had situs ambiguus and 1 had situs inversus. Two (40%) of the 5 patients with comple AV canal and tetralogy of Fallot died in hospital, as did 3 (60%) of the 5 with complete AV canal and DORV. No deaths occurred among the 4 patients in whom repair could be done without using a transannular patch across the pulmonary valve ring or a valved external conduit. Five (62%) of the 8 without major associated malformations survived. Preoperative study must define completely the malformation. The repair, done through the right atrium alone or in combination with a right ventriculotomy, is most easily accomplished with separate patches for the ventricular and atrial components of the septal defect.

Hemodynamic and metabolic data were obtained from 9 infants aged 4 months or younger early after repair of total anomalous pulmonary venous connection (TAPVC) in an effort to determine the cause of continuing mortality. A review by Barratt-Boyes [2] of recent experience from a number of centers shows that hospital mortality from repair of total anomalous pulmonary venous connection during the first 6 months of life is still 31% (16 of 51 patients). By contrast, in such centers the risk of repair of ventricular septal defect or tetralogy of Fallot, for example, is less than 10% in the same age group. Immediately after repair the stroke index in all infants was lower than the mean for the entire study, but a significant positive trend with increasing postoperative time was noted in all early survivors. The cardiac and stroke indexes in the 2 patients who died early were significantly below normal but were similar to values obtained early after repair in a variety of other congenital heart diseases in infants of similar age. Abnormal phasic fluctuations in the left atrial pressures of these patients undergoing TAPVC repair indicated that the left atrium was small in relation to ventricular stroke volume (inadequate reservoir function). Thus, ventricular filling and cardiac performance may have been impaired.

We evaluated 643 patients surviving aortic, mitral, and aortic and mitral (“double”) valve replacement with the Bjork-Shiley prosthesis from 1 to 72 months (median 38 months) postoperatively. Intermediate-term survival rate was similar to that reported for other prosthetic and bioprosthetic devices. Factors unrelated to the device, but related to preoperative patient characteristics or intraoperative or early postoperative events, had important association with late survival rate. These included previous valve replacement, concomitant ventricular aneurysm resection, black race, preoperative functional class, method of myocardial protection, duration of ischemic arrest, ventricular arrhythmias, and double valve replacement. Concomitant coronary artery bypass grafting and the type of valve lesion had no effect on survival prognosis. Freedom from thromboembolism was equal to or superior to other devices, but valve thrombosis occurred 16 times in 15 patients and caused 13 deaths. Improvement in New York Heart Association (NYHA) functional class occurred in the majority of patients. We conclude that the Bjork-Shiley valve is durable and effective, but, as with other devices, is associated with problems of thromboembolism and thrombosis. Intermediate-term survival is related also to non-device, patient-associated characteristics.

Repair of localized bilateral congenital pulmonary venous stenosis with living autologous atrial tissue was accomplished in two patients, 3 and 4 months of age. The tip of the left atrial appendage was opened and used as an onlay patch to widen the stenotic area of the left pulmonary veins, leaving a double pathway for venous return. A flap of interatrial septum was evaginated through an incision in the right side of the left atrium and used as an onlay patch to widen the stenotic area of the right pulmonary veins. Effective relief of obstruction was demonstrated by nearly normal postrepair pulmonary artery pressure in each and early postoperative angiography in one. Although we believe this method of repair will increase the probability of a lasting result, further experience and subsequent late reevaluation are needed to demonstrate its long-term effectiveness.

A 62-year-old man sustained an acute myocardial infarction complicated on the thirteenth hour by left ventricular rupture and acute pericardial tamponade. Echocardiography confirmed the suspicion of intrapericardial fluid, and immediate pericardiocentesis improved the hemodynamic state for a period sufficient to permit preparation for operation. Resection of ruptured and necrotic anteroapical left ventricular myocardium with primary reconstruction was successfully accomplished with the aid of temporary extracorporeal circulation. The patient has remained well for 1 year after the operation. Anatomic, clinical, and therapeutic features of acute cardiac rupture are discussed.

Two of 10 children with truncus arteriosus, Type I, II, less than 2 years of age, 6 of 7 between 2 and 5 years of age, and all 5 older than 5 years survived after complete repair. Five of the nine hospital deaths are believed related to inadequate intra- and postoperative management. One late death has occurred 42 months postoperatively. The low hospital mortality rates in those 2 years of age and older, good long-term results to date, and the poor prognosis of children not operated upon indicate the advisability of elective repair at age 2 to 3 years. Although results in infants less than 2 years old have not been good, current improvements of intra- and postoperative care and the lack of a better alternative suggest that prompt primary repair is indicated for infants with intractable heart failure or increasing pulmonary vascular resistance.

Twenty-six patients with atrioventricular discordance and a variety of ventriculo-arterial connections have had appropriate intracardiac repairs. Seven of 26 patients (26.9%) died early postoperatively, but only two (11.1%) of 18 patients operated upon since May 1972 have died. Ten patients (40%) developed permanent complete heart block. Two patients died late postoperatively; 16 (84.1% of those surviving the early postoperative period) were in NYHA Class I or II at late follow-up. Seventeen of the patients had "corrected transposition." Six developed tricuspid incompetence with regurgitation into the left atrium after repair. Two patients with atrioventricular discordance and double outlet right ventricle survived operation and are asymptomatic but have permanent pacemakers. One patient died after repair of double outlet left ventricle with atrioventricular discordance. Three of four patients with atrioventricular discordance and "pseudotruncus arteriosus" survived repair with valved external conduits and are well. One of two patients is well after repair of "isolated ventricular inversion" and ventricular septal defect.

Recent follow-up of 127 patients having repair of double-outlet right ventricle during an 18 year experience (1967 to July, 1984) indicated an overall actuarial survival rate at 12 years of 38%. However, multivariate analysis supported by contingency tables indicated that currently the early (2 week) survival rate after the intraventricular tunnel repair for double-outlet right ventricle with subaortic ventricular septal defect in 6-month-old infants is 99% and the 10 year survival rate 97%. Reoperation of the tunnel repair was rarely required (one of 56 patients), and the functional results were excellent. Results were similar in patients with doubly committed ventricular septal defect, except that two of 10 patients developed typical discrete localized subaortic stenosis late postoperatively. Early and late results in patients with double-outlet right ventricle and subpulmonary ventricular septal defect were poor when an atrial switch operation was part of the repair; when an intraventricular tunnel repair between the left ventricle and aorta was combined with a right ventricular-pulmonary arterial conduit, no early deaths occurred, but three patients died late postoperatively. Several techniques of repair of double-outlet right ventricle with noncommitted ventricular septal defect have provided only a 22% overall 10 year survival rate. These data are used to derive inferences as to optimal treatment protocols.

We examined the results of coronary artery bypass grafting (CABG) in patients with end-stage renal disease and symptomatic ischemic heart disease who had significant arteriosclerotic narrowing of one or more coronary vessels between 1970 and 1984. Twenty-four such patients underwent bypass grafting, 20 dialysis patients and four who had been transplanted. Bypass grafting completely or partially relieved symptoms in 83%. The hospital mortality associated with this surgery for the 20 dialysis patients was 20% compared with a lower overall hospital mortality for bypass grafting in nondialysis patients of 1.3%. Greater hospital mortality was noted for patients over age 60 undergoing bypass grafting, 33.3% v 1.9% in nondialysis patients. In this study, the most significant factor associated with mortality was older age. We conclude that bypass grafting has an acceptable mortality in younger end-stage renal disease patients anticipating or having had renal transplantation, but it is associated with a high hospital mortality in older dialysis patients.

One hundred two patients, aged 0.7 to 38 years, with a wide variety of cardiac malformations underwent the Fontan operation (1975 to April, 1985). Several different techniques were used. All but 17 had previously undergone one or more palliative operations. Follow-up information was obtained in all patients. Overall actuarial survival rate, with time zero being the time of the operation, was 63% at 6 years with no deaths after that in patients followed as long as out to 9.4 years; that for patients with tricuspid atresia was 81 %. The hazard function (instantaneous risk) for death was highest immediately after operation and merged after about 6 months with a constant hazard extending as long as the patients were followed. Elevated post-repair right atrial pressure was correlated (p = 0.002) with the probability of death in the early phase, with the risk rising rapidly with pressures above 14 mm Hg. Hypertrophy of the ventricular main chamber was a risk factor for death in both the early (p = 0.007) and late (p = 0.008) phases of hazard, which explained in part the lesser risk of the Fontan operation in patients with tricuspid atresia. Younger age, but not older age, was a risk factor for early postoperative death, but this risk was neutralized by recent date of operation. Thus currently there is not a predicted increased risk associated with younger age at operation. In general, the Fontan operation should be done at a young age (2 to 4 years) to avoid increasing ventricular hypertrophy, but older age per se is not a contraindication to the operation.

A total of 200 aortic vale re-replacements were performed between Jan. 1, 1975, and July 1, 1979. The re-replacements (RRP) were an isolated procedure or combined with coronary artery bypass grafting or resection of ascending aortic aneurysm. Ten patients (5%) died in hospital, compared with 24 (2.9%) among 842 patients undergoing isolated or combined initial aortic valve replacement (AVR) (p = 0.12). The mode of death was cardiac failure in six of the 10 patients, hemorrhage in two (from accidents at repeat sternotomy), and neurologic deficits in two (each with innominate vein transection at repeat sternotomy repaired by ligation). There were seven (3.9%) hospital deaths among 181 first RRP (p for difference from initial AVR = 0.5), but three (15%) of 19 died after the second or third RRP (p = 0.001). By simple contingency table analysis, preoperative New York Heart Association (NYHA) Class IV increased the risk of hospital death after RRP (p = 0.002), as did prosthetic valve endocarditis (p = 0.0005) and the use of cold ischemic arrest (p = 0.03). Logistic multivariate analysis showed advanced NYHA functional class (p = 0.02), use of cold ischemic arrest (p = 0.09), and increased aortic cross-clamps time (p = 0.03) to be incremental risk factors. Recommendations for reducing hospital deaths in the event of RRP are (1) reoperate before severe hemodynamic deterioration occurs, (2) plan and conduct the operation to minimize accidents from repeat sternotomy and dissection, (3) keep aortic cross-clamp time as short as possible, and (4) employ cold cardioplegia.

The long-term results of 414 patients who underwent repair of tetralogy of Fallot between 1967 and 1977 were studied and correlated with the results of others. There were nine late deaths (8-year actuarial survival 95.8%). Six of the deaths wee directly related to the malformation or its treatment. Eight patients (2.4%) required reoperation. Ten patients (4.8%) had arrhythmic symptoms. Eight (3.1%) had congestive heart failure that required treatment. The risk factors associated with late events of all types, including death, were: older age at repair, a high mean ratio of peak systolic right-to-left ventricular pressures (PLV/RV) immediately after repair, and the presence of a Potts anastomosis. Neither a transannular patch nor a previous Blalock-Taussig or Waterson anastomosis was an incremental risk factor. Bacterial endocarditis was not observed. Three hundred seven patients underwent repair primarily or after a single Blalock-Taussig or Waterston shunt and had a PRV/LV of 0.85 or less after repair. Among these selected patients, the actuarial survival was 98.1%, which is still lower than that for the general population (p = 0.12), and freedom from events was 95.9%. Late after repair, PRV/LV was lower by 6 +/- 28% (+/- SD) than PRV/LV immediately after repair (p = 0.03) in the 33 restudied patients with such data. The higher the PRV/LV immediately after repair, the greater the percent reduction.