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Two patients with Ebstein's anomaly and severe cardiac impairment underwent surgical repair with tricuspid valve replacement and closure of associated congenital septal defects. No attempt was made to plicate the atrialized right ventricle. Good cardiac function was obtained at the end of the procedure, with uniform contractions of the whole right ventricle. Both patients are leading normal and active lives 38 and 32 months after operation. We believe that successful repair is achieved chiefly by placing a competent tricuspid valve on its true anatomical position, leaving the underlying atrialized portion of the ventricular wall undisturbed. That portion will contract and work synchronously with the rest of the right ventricle.

Pulmonary function studies were performed in 10 patients undergoing surgery for heart transplantation. The study was repeated 6 to 12 months after surgery. The comparison between data before and after transplantation showed an overall improvement in lung function indices, except for the lung diffusing capacity (DLCO). A mean 14% reduction (p less than 0.01) of DLCO was observed. In the absence of evidence of other lung disease or rejection reaction in these patients, this finding may be related to a side effect of cyclosporine on the lung and deserves further investigation.

In neutralizing heparin with intravenous protamine sulfate, hypotension may be prevented by administering the drug intraarterially. Forty patients underwent cardiac surgery with extracorporeal circulation in our hospital; each received a rapid injection of nondiluted protamine sulfate in the aortic root to reverse the effects of heparin. To maintain the blood volume at a constant level, volume expanders and inotropic drugs were avoided. The intraaortic injections ranged in duration from 0.2 min to 2.8 min, with a mean of 1.1 min. The mean systolic pressure only dropped from 92 mm Hg (SD +/- 21) before protamine injection to 85 mm Hg (SD +/- 23) after injection (p < 0.0001). In seven patients (18%), no hypotension was evident; in the remaining patients, the systolic pressure returned to preinjection values within a mean of 2.2 min. Coagulation was observed within 3 to 4 min (mean = 2.2 min) after the initiation of injection. This study indicates that intraaortic administration of protamine is a rapid and safe technique for heparin reversal after cardiopulmonary bypass.

Transaortic intraluminal angioplasty of the left main coronary artery by Grüntzig's technique has been used intraoperatively in 4 patients who underwent multiple aortocoronary bypasses. Angiographic and clinical results were excellent in 3 of them. It is suggested that this combined technique be used to obtain more complete revascularization at the time of coronary artery bypass. The technique is easy to perform without x-ray facilities in the operating room, and it seems reasonable to assume that it may improve the myocardial blood supply of those areas irrigated by small arteries originating between the stenosed main trunk and other subsequent lesions.

A 62-year-old female with a history of progressive angina experienced an acute myocardial infarction. Seven days later, cardiac rupture ensued. She underwent surgical repair without the aid of extracorporeal circulation. A Teflon patch was glued over the myocardial tear with medical adhesive. She recovered and is leading a normal life, 15 months after surgery.

A newly designed temporary pacemaker wire has been tested in 20 patients who underwent open-heart operations. This new device has a small tip that stays securely buried in the myocardium, thus greatly reducing the risk of accidental dislodgment. In addition, the increase in thresholds during the postoperative period is slighter than with the standard electrode.

Four patients who underwent heart transplantation, in whom coronary obstruction was seen early after transplantation, are described. Repeated acute rejection episodes were detected within the first 2 months in each patient. Coronary obstruction or ischemia was shown through a combination of T1-201 isotopic study findings, evidence of vasculitis of a small coronary arteriole seen at endomyocardial biopsy, or coronary angiographic results. Vigorous treatment for rejection (antithymocyte globulin and bolus methylprednisolone) was given, and coronary artery lesions or myocardial ischemia resolved after treatment. Rejection-induced coronary obstruction should be considered in patients with repeated acute rejection episodes who are predisposed to the development of vascular rejection. Early after transplantation such obstruction is caused by diffuse vasculitis of small and medium-sized vessels and may be reversed with increased immunosuppression.

We report two patients with coarctation of the aorta who were admitted to the hospital with ruptured cerebral artery aneurysms. In both patients, we surgically treated the coarctation and later repaired the intracranial lesion. One patient, a 34-year-old woman, is alive and well after 3 years; whereas, the other, a 19-year-old man, did not survive. We discuss the sequence for surgery, which continues to be subjected to debate.

Between May, 1983, and November, 1984, the new integral monostrut Björk-Shiley prosthesis was used for aortic valve replacement in 62 patients. The prosthesis is machined from a solid piece of cobalt alloy and has no welded joints. The traditional U-shaped outlet strut has been replaced by a projecting metal finger that holds the disc in place. The disc opens to 70 degrees and is convexoconcave. Successful transseptal heart catheterization was performed in 23 patients an average of 6 months following operation to evaluate the hemodynamic performance of the prosthesis. The mean peak-to-peak gradient was 7.73 +/- 7.49 mm Hg (+/- standard deviation). In five valves it was 0, and in only three was it higher than 15 mm Hg. Significant peak gradients were directly related to the valve index (valve area/body surface area). Mean systolic gradient at rest was 12.7 +/- 6.27 mm Hg and did not increase after exercise. Effective orifice areas were adequate, and the discharge coefficient ranged from 0.77 for the 21-mm prosthesis to 0.48 for the 29-mm prosthesis. Minimal regurgitation, which was washed out on the next systole, was observed with all sizes of the prosthesis. Disc opening was maximal (70 degrees) in all but one of the observed instances. Longer clinical follow-up is required, but the new integral monostrut Björk-Shiley prosthesis, with its important design changes and excellent hemodynamic performance, appears to be a promising aortic valve substitute.

Mitral valve surgery was performed in 88 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure, 94.7 +/- 22 mm Hg; range, 70-180 mm Hg) over a 10-year period. Sixty-four patients (73%) were in New York Heart Association Functional Class III or IV. There were 64 valve replacements and 24 open mitral commissurotomies. Operative mortality was 5.6% (5 patients) and was not related to the degree of pulmonary hypertension, surgical procedure performed, or type of valve lesion. A 100% follow-up was obtained, ranging from nine months to 10 years, with a mean of 44 months. Six late cardiac deaths (7.2%) occurred, 5 in patients with valve replacement and 1 in a patient who underwent a commissurotomy. Actuarial survival was 86 +/- 3% at five years and 83 +/- 4% at 10 years. Fourteen patients underwent right ventricular catheterization a mean of 24 months following operation. Systolic pulmonary artery pressure had decreased from a mean preoperative value of 101 +/- 22 to 40.5 +/- 7 mm Hg (p less than 0.001). Cardiac index increased by 55% of the preoperative values. Functional status improved markedly; 71 survivors (93%) were in New York Heart Association Class I or II. These results indicate that, in patients with mitral valve lesions and severe pulmonary hypertension, (1) surgical procedures can be performed with an acceptable operative mortality; (2) excellent long-term survival and functional results can be obtained; and (3) pulmonary hypertension decreases significantly after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized, double-blind, placebo-controlled trial was performed in 209 patients to evaluate the efficacy of a low dose of aspirin plus dipyridamole or that of a new antiplatelet agent (triflusal) plus dipyridamole in the prevention of aortocoronary vein-graft occlusion. An angiographic control performed in 161 patients 9 days after surgery showed no significant differences between groups, but a new control on 138 of those patients 6 months later did show significant linear trends towards fewer distal anastomosis occlusions (P = 0.027) from the placebo (24%, 22/91) to the aspirin (16%, 17/106) and to the trifusal groups (12%, 10/86), and towards fewer new occlusions (P = 0.056) from 12% (9/78) to 10% (10/99) and to 2.6% (2/78), respectively, in the same groups. A multivariate logistic regression model, used to determine the effect of 33 variables on distal anastomosis occlusion at 6 months control, demonstrated that diameter of distal bed (P = 0.006), moderately to severely atherosclerotic distal bed (P = 0.003) and the interactions between poor distal bed and triflusal (P = 0.005) were independent predictors of occlusion. Thus, triflusal plus dipyridamole appeared superior to low-dose aspirin plus dipyridamole in the prevention of vein-graft occlusion, independently of coronary and vein-graft determinants of occlusion.

Iatrogenic coronary artery stenosis as a serious complication of aortic valve procedures is a difficult condition to solve. We present a case in which both ostia were involved. As the patient refused reoperation, percutaneous transluminal coronary angioplasty (PTCA) was used.

The changes in hematocrit during the intra and postoperative period were studied in 50 patients who underwent uncomplicated open-heart procedures and who did not receive blood or blood products during their hospital stay. Priming of the extracorporeal circuit and blood volume replacement postoperatively was done with crystalloid solutions exclusively. Mean preoperative hematocrit was 44% and dropped to 30.8% during the pump run. Lowest postoperative hematocrit was on the fourth day (mean: 29.3%) but it never went below 50% of the preoperative value. The percentage of the initial hematocrit was calculated for all patients at each time point and a median curve was constructed. Then, the curve of each patient was compared to this median curve. Patients with values below the median curve at one point at least had a larger amount of intra and postoperative fluid replacement than patients that stayed above the median at all times. We conclude that non-transfused open-heart surgical patients do not develop severe anemia and that changes in the hematocrit values can be predicted according to the median curve constructed and to the amount of crystalloid solution given during and after surgery.

A 23-year-old man who underwent surgical correction of a true pulmonary artery aneurysm is presented. Pathological features and the different surgical alternatives for treatment of this lesion are discussed.

A case of non-traumatic rupture of the ascending aorta in an hypertensive patient is presented. The clinical findings suggested acute aortic dissection but the typical angiographic features of this entity were not found.

One hundred patients who underwent elective cardiac operations were randomized into two groups. Group 1 had a 20 micron nylon screen filter in the arterial line. In Group 2 no filter was used in the arterial line. Neurologic and neuropsychologic examination of the patients was performed with seven psychometric tests of the Wechsler Memory Scale and the Wechsler Adult Intelligence Scale. These tests were conducted before and a mean of 10 days after the operation. Platelet counts and hemoglobin and total protein levels were measured at the onset and at the end of cardiopulmonary bypass. Two patients died during their hospital stay. Neurologic damage with focal signs was found in the postoperative examination in six patients (three in each group). Twenty-eight patients (28.5%) exhibited signs of mild cerebral dysfunction as assessed by the presence of archaic (primitive) reflexes. Fifteen were in Group 1 and 13 in Group 2 (no significant difference). Sixty patients (61%) had decrements greater than one standard deviation in at least one of the three tests that showed most decreased postoperative scores. There were 32 in Group 1 and 28 in Group 2 (no significant difference). When each test was analyzed individually, there were no significant differences between the two groups. Platelet counts decreased, during cardiopulmonary bypass, a mean of 33% in Group 1 and 34.5% in Group 2 (no significant difference). Both hemoglobin and total protein levels remained virtually unchanged. These results indicate that the addition of a small-pore filter in the arterial line does not prevent the neurologic and neuropsychologic disturbances frequently encountered after cardiopulmonary bypass. The filter itself does not appear to have a direct effect on the blood components. Routine use of an arterial line filter remains questionable.

Acute postperfusion right ventricular failure following mitral and aortic valve replacement in a patient with severe double-valve incompetence secondary to endocarditis is presented. The situation was reversed by creating an atrial septal defect that decompressed the right ventricle and increased left ventricular filling pressure.

The case of a 26-year-old woman with cardiac and pulmonary echinococcosis is presented. Surgical treatment of the intrathoracic disease was done in a one-stage operation. Under cardiopulmonary bypass, a left ventricular hydatid cyst and a lower lobe pulmonary cyst were removed. The patient is completely asymptomatic and is leading a normal life two years after operation.

Between May 1983 and April 1986, 318 patients underwent cardiac valve replacement with the Monostrut Björk-Shiley prosthesis. There were 136 aortic valve replacements, 128 mitral valve replacements, and 54 multiple replacements. A total of 373 valves were implanted. Associated procedures were done in 79 (25%) of the patients. Hospital (30-day) mortality rate was 5.6% (18 patients): 2.9% (n = 4) after aortic, 7.8% (n = 10) after mitrals and 7.4% (n = 4) after multiple valve replacement. Follow-up was obtained in all 300 operative survivors, for a total of 500 patient-years (mean 18 months). Actuarial survival rate, excluding operative deaths, at 4 years was 94.7% +/- 1.5% (mean +/- standard error of the mean). There were 16 thromboembolic episodes (3.2/100 patient-years). Freedom from all valve-related complications was 87% +/- 2.4% at 3 1/2 years. Neither valve thrombosis nor structural failure has been observed. Eighty percent of the patients are in New York Heart Association functional class I. Forty-two patients (26 with aortic and 16 with mitral valve replacement) underwent cardiac catheterization a mean of 6 1/2 months after the operation. In the aortic position, peak gradients were an average of 6.9 +/- 1.2 mm Hg. Mean systolic gradients were 12.4 +/- 6.3 mm Hg and did not increase with exercise. In the mitral position, end-diastolic gradients were an average of 2.1 +/- 2 mm Hg and mean gradients, 5.9 +/- 2 mm Hg. Discharge coefficient (estimated orifice area/geometric area) was 0.63 +/- 0.2 for the aortic and 0.53 +/- 0.2 for the mitral prostheses. Disc opening was maximal in most patients. These results indicate that the Monostrut prosthesis has a low rate of thromboembolic events, no structural failures or thrombotic obstructions and excellent hemodynamic performance, especially in the small aortic sizes (discharge coefficient for 19 and 21 mm valves, 0.77).

Between February 1986 and June 1987, 306 consecutive patients were included in a programme of non-invasive preoperative assessment of valvular heart disease using M-mode and cross-sectional echocardiography and Doppler ultrasound. In 285 cases (93%), echocardiography provided all the necessary preoperative information. Coronary angiography was performed in 74 patients because of angina and in 55 because of their age. Invasive investigation was needed in 21 cases because of discrepancies between clinical data and echo-Doppler results. The results were definitely misleading in six patients, mainly due to erroneous assessment of valvular regurgitation. One hundred and ninety one patients underwent valve surgery (179 evaluated exclusively by echocardiography, 79 with coronary angiography as the sole invasive procedure). No discrepancies were observed between echo-Doppler diagnosis and macroscopic evaluation of valvular heart disease at surgery. Operative mortality (3.6%) was not significantly different from that observed during the preceeding period when preoperative catheterisation was performed (3.3%). It is concluded that echo-Doppler techniques are perfectly satisfactory for the preoperative assessment of patients with valvular heart disease. Cardiac catheterisation is only infrequently required, although coronary angiography remains mandatory in a selected group of these patients.