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Children with Autism often show difficulties in adapting to change. Previous studies of cortisol, a neurobiologic stress hormone reflecting hypothalamic–pituitary–adrenal (HPA) axis activity, in children with autism have demonstrated variable results. This study measured cortisol levels in children with and without Autism: (1) at rest; (2) in a novel environment; and (3) in response to a blood draw stressor. A significantly higher serum cortisol response was found in the group of children with autism. Analysis showed significantly higher peak cortisol levels and prolonged duration and recovery of cortisol elevation following the blood-stick stressor in children with autism. This study suggests increased reactivity of the HPA axis to stress and novel stimuli in children with autism.

Background— Coronary artery bypass graft (CABG) surgery has been performed frequently for symptomatic coronary atherosclerotic heart disease for more than 30 years. However, uncertainty exists regarding the relationship between long-term survival after CABG and readily available clinical correlates of mortality. Methods and Results— We studied outcome at 20 years by age, sex, and other variables in 3939 patients who had CABG surgery from 1973 to 1979 in the Emory University System of Healthcare. Twenty-year survival, freedom from myocardial infarction, and freedom from repeat CABG were 35.6% (95% confidence interval [CI], 33.9% to 37.3%), 66.6% (95% CI, 64.6% to 68.6%), and 59.1% (95% CI, 56.9% to 61.5%). Multivariate correlates of late mortality were age (hazard ratio [HR], 1.46 per 10 years), female sex (HR, 1.21), hypertension (HR, 1.44), angina class (HR, 1.07 per class increase of 1), prior CABG (HR, 1.72), ejection fraction (HR, 1.07 per 10-point decrease), number of vessels diseased (HR, 1.11 per 1-vessel increase), and weight (HR, 1.04 per 10 kg). Twenty-year survival by age was 55%, 38%, 22%, and 11% for age 70 years at the time of initial surgery. Survival at 20 years after surgery with and without hypertension was 27% and 41%, respectively. Similarly, 20-year survival was 37% and 29% for men and women. Conclusions— Symptomatic coronary atherosclerotic heart disease requiring surgical revascularization is progressive with continuing events and mortality. Clinical correlates of mortality significantly impact survival over time and may help identify long-term benefits after CABG.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

It is imperative that a chapter on medical-legal issues be included in this book, since all members of the cardiopulmonary bypass (CPB) team (surgeons, anesthesiologists, perfusionists, and nurses) have significant potential medical liability in caring for patients undergoing CPB. The complexity of CPB, even with all of the current safeguards, makes it inevitable that problems will occur. It is not a question of if, but a question of when.

Cardiology lost a giant on October 1, 2011, with the death of Dr. J. Willis Hurst in Atlanta, Georgia. Dr. Hurst died at Emory University Hospital from complications of a stroke. He was 91 years old. Willis will best be remembered as the long-term chairman of the Department of Medicine of the Emory University School of Medicine (30 years); as the editor or coeditor with Drs. Bruce Logue, Robert Schlant, and Nanette Wenger of The Heart; and as personal physician to Presient Lyndon Johnson. In addition to his wife, Nelie (61 years of happy arriage), and 3 sons, John, Jr., Stephen, and Philip, Dr. urst’s personal passions were teaching, writing, and atient care. Among his teaching awards, he received the aster Teacher Award twice from the American College f Cardiology, the Gifted Teacher Award from the Amercan College of Physicians, and the Pappageorge Award or Excellence in Teaching at Emory. Dr. Hurst created 8 medical books and published 461 scientific articles. urst’s The Heart continues to be the leading textbook in the eld of cardiology. One day at the White House to care for resident Johnson and the next caring for the poorest patients t Grady Memorial Hospital, Willis Hurst always provided xcellent patient care. Fortunately, he was recognized for his many contribuions to the medical profession during his lifetime. Dr. Hurst erved as president of the American Heart Association in 971 and 1972 and as president of the American Society of rofessors of Medicine 1985 and 1986. After becoming a ember of the Sub-Specialty Board of Cardiovascular Disases in 1965, he served as chairman of the board from 1967 o 1970. He was a Founder and President of the Paul Dudley hite Society in 1974 and was asked to give the memorial ddress when Dr. White died. I had the privilege of working with Willis Hurst for 49 ears and enjoyed his support and advice as chief of cariothoracic surgery, as director of the Emory Clinic (of hich Dr. Hurst was a founding member), and as vice resident for health affairs and director of the Robert W. oodruff Health Sciences Center. J. Willis Hurst was a remarkable and unique individual nd physician. He should be the ideal role model for all oung people who enter the medical profession.

Crystalloid cardioplegia with an extracellular fluid formulation is widely used for donor heart protection. A survey of 109 transplant programs yielded 62 replies with 42% of respondents using variations of extracellular solution and 45% using the dextrose and mannitol-based Stanford solution. These two commonly used clinical solutions and University of Wisconsin (UW) solution, which has had success in clinical hepatic and renal transplantation, were compared in a canine model of cardiac transplantation. After antegrade hypothermic cardioplegic arrest, the experimental hearts were excised and stored at 4 degrees C for 6 hours (n = 29). An oxygenated, blood-primed isolated heart preparation was used for reperfusion. After a rest of 45 minutes, cardiac output was increased against constant afterload until a left atrial pressure of 15 mm Hg was reached. The maximum cardiac performance measured by cardiac index, minute work, and stroke work was highly significantly better with Stanford or UW solution protection than with the extracellular solutions (p less than 0.0001). Assuming a cardiac index of 50 mL.kg-1.min-1 is necessary for successful separation from cardiopulmonary bypass, only 1 of 14 extracellular and 15 of 15 Stanford and UW animals would have survived (p less than 0.0001). This study strongly suggests that extracellular cardioplegia is inferior for cardiac transplantation and that programs using this solution should reevaluate their method of myocardial protection for donor hearts.

During a 12-month period, 11 patients underwent diagnostic thoracoscopy for previously undiagnosed thoracic disease. In all patients, the diagnosis had been unobtainable by the usual diagnostic modalities of bronchoscopy, scalene node biopsy, mediastinoscopy, thoracentesis, or closed pleural biopsy. Thoracoscopy was diagnostic in 10 of the 11 patients. There was no morbidity or mortality. In all patients the indication for thoracoscopy was suspected malignancy. The majority of patients had recurrent pleural effusions in which routine cytological studies and tissue biopsies had been nondiagnostic. Pathological findings were mesothelioma in 3 patients, primary carcinoma of the lung in 4, congestive heart failure with pleural effusion in 1, metastatic carcinoma in 2, and inflammatory disease in 1 patient. Indications, techniques, and results are discussed. Thoracoscopy is a valuable tool in the diagnosis of thoracic disease; with it, unnecessary thoracotomy can often be avoided.

This report details our experience with 300 sutureless epicardial electrode implantations performed in the past 6 years. Indications for pacing, surgical approaches, implantation sites and complications are presented. The subxiphoid approach was valuable in obtaining safe, reliable, and long-term impulse generation. Complications have been few and of short duration. In general, pacing thresholds have been lower and sensitivity thresholds higher with left ventricular implantation than with right ventricular implantation. Endocarcial pacing is reserved for the very aged and debilitated patients, patients requiring implantation within 4 to 6 weeks of acute myocardial infarction, and for atrial or atrioventricular sequential pacing.

We examined our practice of invasive therapy for one- and two-vessel coronary disease to assess the impact of the randomized trials of coronary surgery and the current use of angioplasty. We first reviewed our results with coronary artery bypass graft in equivalent patients in the Coronary Artery Surgery Study with one- and two-vessel disease between 1976 and 1981. Among 1376 patients, hospital mortality was 0.07%, and 5-year survival was 95.2% +/- 0.8%. To define trends in invasive therapy, which have since occurred, we compared 100 patients with one- and two-vessel disease in each of three groups: 1979 coronary artery bypass graft, 1984 coronary artery bypass graft, and 1984 percutaneous transluminal coronary angioplasty. Preoperative characteristics in the average 1979 and 1984 patients were similar; however, in 1984, patients who had a coronary artery bypass graft were older than patients who had percutaneous transluminal coronary angioplasty (61.5 versus 56.7 years, p less than 0.01), they required more heart medications (2.1 versus 1.5, p less than 0.01), had more previous infarctions (0.8 versus 0.5, p less than 0.01), and more patients had an ejection fraction of less than 50% (34% versus 7%, p less than 0.01). Patients who had angioplasty had a shorter postoperative stay (median number of days 7, 7, 2, p less than 0.01). Freedom from major complications was similar among the groups (91%, 87%, 85%). Unstable symptoms were the most frequent indication for invasive therapy (approximately 80%), whereas long-term symptoms, those considered in the randomized trials, occurred in relatively few patients. The number of patients without at least one definite indication for invasive therapy was 13%, 3%, and 11%, p less than 0.05, suggesting that the indications for the 1984 coronary artery bypass graft group have become more restrictive since the 1979 coronary artery bypass graft group. Indications for the 1984 percutaneous transluminal coronary angioplasty group remained less restrictive, being similar to those for the 1979 coronary artery bypass graft group. A continuing trend toward the use of percutaneous transluminal coronary angioplasty was evident, as 56% of the 1979 coronary artery bypass graft group of patients and 32% of the 1984 coronary bypass group of patients would be offered percutaneous transluminal coronary angioplasty rather than coronary artery bypass graft on the basis of 1986 percutaneous transluminal coronary angioplasty criteria. The p values were obtained with analysis of variance or chi 2 test.

The records of the patients with tracheoesophageal fistula from carcinoma of the esophagus treated from 1970 to 1983 were reviewed to assess the length and quality of their survival. Twenty-four patients with malignant tracheoesophageal fistula were treated during this period. The site of the carcinoma was the middle third of the esophagus in 18 patients, the lower third in 5, and the upper third in 1. Three patients received only supportive treatment, and 1 had only radiation therapy. Nine patients underwent insertion of a Mousseau-Barbin or Celestin tube with or without gastrostomy, and 7 patients had gastrostomy alone. Four patients had exclusion of the tracheoesophageal fistula, 3 with esophagogastrostomy and 1 with colon interposition. The 3 patients who received only supportive treatment survived 5 days, 1 week, and 2 weeks. The 7 patients who had gastrostomy lived 3 days to 18 weeks (mean, 6 weeks). The 9 patients with a Mousseau-Barbin or Celestin tube lived 1 week to 6 months (mean, 8 weeks). The 4 patients who had exclusion of the tracheoesophageal fistula survived 5 weeks, 4 months, 7 months, and 26 months following operation. This study suggests that the treatment for patients with tracheoesophageal fistula from carcinoma of the esophagus should be individualized and that in selected patients, exclusion of the fistula with esophagogastrostomy improves the quality of life and prolongs survival.

During the past 12 years, 13 patients with atrial (10 left and 3 right) myxoma have been treated. The tumors of the left atrium produced signs and symptoms of mitral valve obstruction and/or subacute bacterial endocarditis and those of the right atrium manifestations of tricuspid valve disease or of pulmonary embolus or hypertension. The diagnosis was established by angiocardiography in 8 patients, at surgery performed for suspected mitral stenosis in 3 patients, and at autopsy in 2 patients. Resection of the atrial myxoma alone in 5 patients or with atrial septum where the atrial myxoma was attached in 4 or with the whole right atrial wall where the atrial myxoma was attached in one patient was performed and all are doing well without evidence of recurrence. Studies of experimentally produced 1.5-3 cm in diameter left atrial thrombus in 30 dogs divided into 5 groups and followed cineangiocardiographically and sacrificed from 14 days to 6 months indicated that the implanted thrombus is absorbed over a 3 to 6 month period. These experimental and human left atrial thrombi were found to be histologically and histochemically different from human atrial myxomas. The electron microscopic studies performed on some of the resected atrial myxomas suggested that the atrial myxoma cells are active cells of endotheilial origin. These observations suggest that atrial myxoma is a primary tumor of the heart which can mimic other clinical entities, and the results of its surgical treatment are gratifying and long lasting.

Potassium-induced cardioplegia during anoxic arrest was utilized in a study of 190 consecutive patients undergoing revascularization (average 2.8 grafts per patient) from August, 1975, through August, 1976. Surgical technique, moderate systemic hypothermia with intermittent anoxic arrest, and the surgeon were the same for all patients. One hundred thirty-five patients (KCl-treated) received a bolus (150 ml.) of potassium solution injected into the proximal aortic root whenever the aortic cross-clamp was applied; 55 others served as control subjects. The mortality rate was 2.2 percent (three of 135) in the KCl-treated group and one of 55 in the control group. New Q waves appeared in 5.9 per cent (eight of 135) of the KCl-treated patients and 11 percent (6 of 55) of control subjects (p = N.S.). Catecholamine drips were required after bypass in 4.4 percent (six of 135) of patients given potassium and 18 percent (10 of 55) of control patients (p

A consecutive series of 121 patients 70 years of age and older who underwent aortocoronary artery saphenous vein bypass grafting without other cardiac procedures during a 5 year period was analyzed and follow-up status ascertained. This group was compared with a consecutive series of 2,850 patients under the age of 70 who underwent aortocoronary bypass during the same period. The patients aged 70 years or greater had a higher incidence of unstable angina pectoris, congestive heart fallure and cardlomegaly on roentgenography. They had more severe coronary obstruction with a 29 percent incidence rate of left main coronary disease versus a 15 percent incidence rate in the patients aged less than 70 years (P

Mediastinitis after cardiac valve replacement is a dreaded complication with consequent mortality estimated as high as 70%. We have reviewed 2,491 patients with cardiac valve operations to assess the impact of mediastinitis upon mortality in our institution in the past 10 years. Mediastinitis developed after valve replacement in 36 patients (1.4%). All patients required operative intervention for mediastinal infection with positive bacterial cultures. Twelve of these patients had other perioperative problems associated with a high mortality independent of mediastinitis: bacterial endocarditis not cured by valve replacement (three), recent preoperative myocardial infarction (four), triple valve disease with biventricular failure (one), and severe perioperative cerebral damage (four). Ten of these high-risk patients died (83.3 %). The impact of mediastinitis upon survival is best evaluated in the remaining 24 patients without high-risk perioperative problems. Eight of these patients were managed before 1980 with debridement and irrigation as the primary treatment, with two hospital deaths (25 %). Pectoral or rectus muscle flaps were frequently used after 1980 (flaps in 11 of 16 patients), leading to a significantly shorter time between diagnosis of infection and hospital discharge free of infection (62 versus 385 days p

This study retrospectively reviews the hospital records of 24 patients who developed ascending aortic dissection during or following 6,943 cardiac surgical procedures performed from January, 1971, through December, 1981. Group I consists of 15 patients with ascending aortic dissection presenting intraoperatively during myocardial revascularization. Group II consists of nine patients, seven who underwent myocardial revascularization and two who underwent aortic valve replacement, who developed ascending aortic dissection 30 minutes to 21 days after cardiac operation. Four of these patients had poorly controlled hypertension postoperatively. Surgical repair was attempted in all patients in Group I, with an operative mortality of 33%. The major cause of death was myocardial dysfunction secondary to ischemia. There were no operative deaths among six patients managed with closed plication techniques alone. Four of nine patients in Group II underwent ascending aortic dissection repair with an operative mortality of 50%. The overall mortality in Group II was 78%. The major factor in this high mortality was a delay in diagnosis and surgical therapy. Early diagnosis of the intraoperative or postoperative ascending aortic dissection process is essential to minimize the extent of dissection and prevent delay of definitive surgical therapy. Closed aortic plication of the intimal injury rather than more extensive aortic repair may reduce morbidity and mortality in selected patients.

In 1973 two physicians' assistants (P.A.'s) were employed on a cardiothoracic surgical service at Emory University Hospital. In 1974 our initial experience with these paramedical personnel was presented to this Association. Since that time eight additional P.A.'s have been added to our service. They are now employed in four hospitals of the Emory University Woodruff Medical Center. New guidelines and regulations have been imposed at both the state and federal levels regarding P.A.'s, and their role in our center has become rather well defined. With over 1,700 cardiac cases and 600 thoracic cases per year to cover on our service, the P.A. has assumed a position of increasing importance both in operating room assistance and in preoperative and postoperative care. Since the university has maintained a constant number of residents and fellows during this interval, P.A.'s have filled needs of expanded clinical service in the various hospitals. In the pediatric and community hospitals associated with a university, the P.A. now functions as a junior house officer. In our university center, with a large resident staff, their role has become narrowed with definite guidelines. A Credentials Committee now governs the hiring of all P.A.'s by the University. When properly utilized and supervised, the P.A. can be a vital member of the cardiothoracic team. This report details our experience with P.A.'s for the past 5 years—culminating in a staff of ten P.A.'s working on our service in four types of hospitals within our university medical center.

Nineteen patients with Hancock Modified Orifice prosthesis (HMO-250), size 19 to 23 mm, were recatheterized 6 to 16 months following aortic valve replacement (AVR). Although hemodynamic characteristics varied widely, HMO-250 compared favorably to the standard model 243 (less than 0.05). Mean peak resting gradient across HMO-250 was 14.8 torr at rest and rose to 26.8 torr with exercise. Systolic gradients for HMO-250, both resting and exercise, were improved for 21 mm (p less than 0.01), but not for 23 mm. Increasing the patient's body surface area (BSA) correlated with increasing gradients for 23 mm (p less than 0.05), but was unrelated to 21 mm. Effective orifice areas were similarly found to be improved with 21 mm HMO-250 but unchanged for 23 mm. Use of the 21 or 23 mm size HMO for AVR is supported only when the patient's body surface area is less than 1.8 m2. If the body surface area is greater than 1.8 m2, annulus enlargement and a larger size bioprosthesis should be employed. Use of 19 mm porcine xenograft for AVR is not supported.

The internal mammary artery is a dynamic coronary graft, whereas the saphenous vein graft is passive. Therefore, potential exists not only for beneficial vasodilation but also for catastrophic spasm of the artery. The purpose of this study was to examine blood flow in the internal mammary and saphenous vein grafts during infusion of drugs that are commonly used after cardiac operations. A canine right heart bypass preparation allowed precise control of cardiac output, blood pressure, and heart rate, which were maintained constant during drug infusion. Both the internal mammary and saphenous vein grafts were constructed so that they perfused the same coronary bed: They were anastomosed in a Y fashion to a ligated anterior descending coronary artery. Electromagnetic flow probes measured graft flow (with the other graft occluded) before and after 15 minutes of drug infusion. The order of drug infusion was randomized and changes were compared by tests for paired differences. Phenylephrine (2 micrograms/kg/min) decreased flow in both the internal mammary and saphenous vein grafts, whereas norepinephrine (0.1 microgram/kg/min) increased flow in both grafts. Epinephrine (0.05 microgram/kg/min) increased mammary artery flow 16% +/- 6% but decreased saphenous vein graft flow 9% +/- 7%. Nitroglycerin (1 microgram/kg/min) significantly increased internal mammary flow (36% +/- 13%), from 47 +/- 7 to 59 +/- 7 ml/min (p less than 0.01), whereas flow decreased significantly in the saphenous vein graft 14% +/- 3%, from 64 +/- 9 to 59 +/- 8 ml/min (p less than 0.01). Nitroprusside (1 microgram/kg/min) decreased mammary artery flow 12% +/- 2%, from 50 +/- 7 to 44 +/- 7 ml/min (p less than 0.01), but increased saphenous vein graft flow 25% +/- 8%, from 64 +/- 9 to 77 +/- 7 ml/min (p less than 0.01). All hemodynamic variables were unchanged, except for norepinephrine, which significantly increased the first derivative of left ventricular pressure. The results suggest that flow through the canine internal mammary artery is changed by the drugs commonly used in perioperative management. Epinephrine and nitroglycerin increased internal mammary artery flow and decreased saphenous vein graft flow, whereas nitroprusside had the opposite effect. The vascular reactivity of the internal mammary artery must be considered when these drugs are used after coronary revascularization.

We retrospectively analyzed the clinical data on 3479 consecutive patients having coronary bypass surgery. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% versus 3.8% and 4.2%; P less than 0.001). Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3040). Hospital mortality was significantly increased by history of myocardial infarction (P less than 0.001), hypertension (P less than 0.05), heart failure (P less than 0.01), extent of anatomic disease (P less than 0.005), presence of preoperative ST-T wave changes (P less than 0.001), and severe abnormalities of left ventricular function (P less than 0.001). Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure but not perioperative myocardial infarction significantly affected long-term survival. Patients with normal left ventricular function had excellent 42-month survival regardless of vessel disease. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced when left ventricular damage has occurred.

A palliative operation is described for the treatment of infants with all types of aortic arch interruption without regard to anatomic variation. It consists of establishment of continuity between the main pulmonary artery and descending thoracic aorta with a prosthetic graft, pulmonary artery banding distal to the graft, and ligation of the closing ductus arteriosus. Infant mortality rate in the past has been high, rega-dless of the type of operation used. The method of treatment described in this report is one in which an initial palliative operation is employed in the newborn period with total correction planned at a later date, when the risk of morbidity and death will be less.

Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, “early group,” were operated upon within 12 hours from the onset of their symptoms and five, “late group,” were operated upon between 20-76 hours (average 41) after rupture. All four patients in the “early group” had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the “late group” one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the “late group” were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.

We have favored treatment of moderate mitral regurgitation and coronary disease with coronary bypass alone because of the high operative mortality of combined mitral valve replacement and coronary bypass. Between 1977 and 1983, coronary bypass alone was performed on 58 patients (mean age 63 ± 8 years). Preoperatively, 90% had Canadian Cardiovascular Society class III or IV angina, and 10% had class III or IV congestive heart failure. In 72 % mitral regurgitation had been caused by coronary disease. Hospital mortality was 3.4% (2/58). At follow-up (100% complete, mean 43 years) 66% of survivors were functional classes I and II (compared with 7 % preoperatively, p

Possible enhancement of myocardial protection by oxygenation of a crystalloid cardioplegic solution was evaluated in a three-part study. In Part I, canine hearts underwent ischemia followed by heterogeneous cardioplegic arrest for 45 to 60 minutes. Oxygenation led to improved recovery in the left anterior descending region (47% versus 86% recovery, p ≤ 0.05) (15 minutes of ischemia) and in the circumflex region (9.5% versus 52% recovery, p ≤ 0.05) (30 minutes of ischemia). Part II was a blind prospective randomized study in 12 patients. It examined creatine kinase, myoglobin, and lactate as well as coronary sinus flow, oxygen consumption, and cardiac work 1 hour after aortic cross-clamping during atrial and during ventricular pacing. No significant difference was demonstrable between control and oxygenated solutions. In Part III, 57 coronary bypass patients were protected with a nonoxygenated solution while 94 patients received an identical oxygenated solution. Twelve-hour creatine kinase levels were similar in the nonoxygenated (9.5 ± 16 IU, ± standard deviation) and oxygenated (11 ± 22 IU) groups if the cross-clamp interval was 28 minutes or less. In patients subjected to longer than 28 minutes of arrest, the 12 hour creatine kinase MB levels were more than twice as high in the nonoxygenated group (26.5 ± 26 IU) compared to the oxygenated group (9.9 ± 14 IU, p ≤ 0.05). In this canine model of heterogeneous cardioplegia and in the routine conduct of coronary bypass operations, oxygenated crystalloid cardioplegia is superior to an identical nonoxygenated solution.

Thirty-seven patients with vein graft stenosis following coronary artery bypass underwent percutaneous transluminal vein graft angioplasty to avoid another operation. Location of the stenoses was at the aortic anastomosis in 3 patients, in the vein body in 12, and at the distal anastomosis in 22. All patients had disabling angina pectoris. Initial success (greater than 20% reduction of stenosis) was achieved in 35 patients. Vein graft angioplasty was performed within a year after bypass in 28 patients. The percent of stenosis and the pressure gradient across the obstruction were reduced from 84 to 24% and from 58 to 15 mm Hg, respectively. Complications of the procedure included emergency coronary artery bypass in 2 patients, myocardial infarction in 2, and ventricular fibrillation in 1. There were no deaths. Of 15 patients with stenosis at the aortic anastomosis or vein body, the dilation was initially successful in 14 but restenosis occurred in 7 within the first year after angioplasty. Only 2 of the remaining 7 were asymptomatic after vein graft angioplasty. However, for patients having vein graft angioplasty of the distal anastomosis, restenosis occurred in only 3, while 12 were asymptomatic at the end of the first year. The average hospital cost of a repeat coronary artery bypass operation was 2.8 times the cost of vein graft angioplasty.

The hemodynamic effects of positive end-expiratory pressure (PEEP) were studied in coronary artery bypass patients by recording intrapericardial and intracardiac pressures, measuring cardiac output by thermodilution, and determining left ventricular volumes by nuclear radiography. An elevation of PEEP to 5, 10, and 15 cm H2O led to a decrease in cardiac output (15% decrease at PEEP 15) as intrapericardial pressure increased and transmural left atrial pressure decreased. Modest volume loading (an increase in left atrial pressure of 3 mm Hg) greatly attenuated the deleterious effects of 15 cm H2O PEEP. There was an excellent correlation between pulmonary capillary wedge pressure and left atrial pressure at PEEP 0 and 5 (r = .85 and r = .83). This correlation was not nearly as reliable at PEEP 15 (r = .54). A predictable increase in intrapericardial pressure was observed as PEEP was applied in these patients. The magnitude of this increase can be estimated by multiplying the change in PEEP (in cm H2O) by 0.4 to estimate the change in intrapericardial pressure (in mm Hg). Using this estimation as a guide, modest volume loading can be used to maintain transmural filling pressures (and cardiac output) when PEEP is used after coronary artery bypass surgery.

The use of autologous blood transfusion to decrease blood bank requirements and improve coagulation parameters during cardiac surgery is still controversial. This study was undertaken to re-evaluate three methods of autologous blood transfusion. Before bypass, 13 to 15 percent of the patient's estimated blood volume was removed and stored with either CPD or heparin at room temperature and returned via a peripheral vein after bypass. All patients had significant abnormalities in their PTT, PT, and platelet counts after bypass. Heparinized autologous blood removed from the vena cava cannula was the only technique which significantly improved the PTT and platelet count. Total blood bank requirements were significantly less for the autologous blood groups than for controls. There was a saving of 18 percent in banked blood requirements. Fresh frozen plasma and platelets were not found to be routinely needed during cardiac surgery.

During a 3-year period, 45 patients with esophageal carcinoma (18 of the lower and 27 of the middle third) underwent esophagectomy and esophagogastrostomy. All patients were considered to be in Stage I and Stage II preoperatively, but at the time of operation, 66% were found to have Stage III disease. All patients underwent mobilization of the stomach through a laparotomy, and resection of the esophagus and reconstruction of the continuity of the gastrointestinal tract through a separate right lateral thoracotomy incision. Following operation, 22 patients (10, Stage I and II and 12, Stage III) received no radiotherapy and 23 patients (5, Stage I and II and 18, Stage III) received radiotherapy. Two patients died in the immediate postoperative period, for a surgical mortality of 4.8%. Because of the acceptable survival and enhancement of quality of life, esophagectomy and esophagogastrostomy should be offered not only to Stage I and II patients with esophageal carcinoma but also to selected patients with Stage III disease and those with lower and middle third esophageal lesions.

The hemodynamic interactions of verapamil and isoflurane were studied in eight dogs. Left ventricular function was analyzed using a right heart bypass preparation to permit rigid hemodynamic control. Hemodynamic studies were performed at 0.7, 1.05, and 1.40% isoflurane before and during the maintenance of two stable levels of verapamil, administered intravenously by combining a bolus dose (0.2 mg X kg-1) with an infusion (3.0 and 6.0 micrograms X kg-1 X min-1). Isoflurane produced a concentration-dependent depression of left ventricular function as indicated by dP/dt max, per cent systolic shortening, and left ventricular function curves. This depression was enhanced in a dose-plasma concentration-dependent manner by verapamil and was reversed by calcium chloride. Isoflurane alone and the combination of verapamil and isoflurane decreased systemic vascular resistance in a dose-dependent fashion that was antagonized partially by calcium chloride. Therefore, verapamil can enhance the hemodynamic effects of isoflurane in a dose-related manner that needs to be considered when both drugs are administered together.

One hundred twenty-nine consecutive patients underwent isolated aortic valve replacement with the Hancock porcine xenograft between July, 1974, and December, 1976. The hospital mortality rate was 3.9 percent. No patient was treated with anticoagulants, and valve-related complications were extremely rare. The smaller prosthetic sizes (19 and 21 mm. stent diameter) should be used with extreme caution, and the 19 mm. prosthesis should probably never be used in the adult patient. Two methods of managing the small aortic root are emphasized: one to avoid using the smaller prosthetic size in adults and the other to alter greatly the root size in children who have a hypoplastic aortic annulus. Acceptable calculated orifice sizes and left ventricular-aortic (LV-Ao) pressure gradients may be obtained with the 23 mm. or larger prostheses. Actuarial survival curves show 92 percent of patients alive and well at 24 months’ follow-up.

The case history of a 30-year-old man with severe mitral and aortic stenosis and slight aortic regurgitation who underwent replacement of both valves is presented. At the initial surgical procedure, because of the small-size annuli, a small Beall mitral prosthesis and a No. 19 Bjork-Shiley aortic prosthesis were used. The subsequent recurrence of severe symptoms and findings of an 80 mm. Hg gradient across the Bjork-Shiley aortic valve led to repeat exploration and corrective surgery. The operative procedure to relieve left ventricular outflow obstruction is described. It is felt that this procedure can be used not only for the relief of severe aortic annular stenosis but also for other forms of severe left ventricular outflow tract obstruction such as idiopathic hypertrophic subaortic stenosis and particularly in the patients who have experienced poor results with one of the known surgical procedures for this clinical entity.

Over a recent one-year period, 339 patients underwent percutaneous transluminal coronary angioplasty (PTCA) and were compared with 338 patients having isolated coronary artery bypass surgery. Patients undergoing PTCA had a shorter duration of angina, a lower number of prior myocardial infarctions, and better left ventricular function (p less than 0.01); PTCA was considered initially successful in 87% (295/339) of patients. Repeat angioplasty was performed in 18% of patients (34/339), with a successful outcome in all but 1. The most common finding at operation in those with failed angioplasty and urgent or emergency revascularization was dissection of an atheromatous plaque. There were 28 early failures (operation performed within 24 hours) and 24 late failures (operation at more than 24 hours), for early and late failure rates of 8.3% and 7.1%, respectively. Although the cumulative frequency of new Q-waves in the entire angioplasty series was low (2.7%), the incidence was high in those with angioplasty failure and subsequent operation (18%), and was significantly greater than in patients having elective coronary bypass (3.6%). Use of inotropic agents and lidocaine treatment for ventricular arrhythmias was also significantly higher in patients with unsuccessful PTCA who required operation than in those undergoing elective bypass (10% versus 3% and 10% versus 1.5%, respectively; p less than 0.01). Eleven of the 28 patients who were early failures were totally revascularized within 2 hours of angioplasty failure. Facilities and staff available for expedient revascularization accounted for the low morbidity and lack of mortality in PTCA failures.

Twenty-six consecutive patients underwent combined aortic valve replacement and myocardial revascularization at the Emory University Affiliated Hospitals between May, 1973 and March, 1976. Acute myocardial infarction resulted in two operative deaths (8%). There have been four late deaths, all Class IV preoperative. The age range was 37 to 79 years with an average age of 60. Preoperatively all patients were Class IV or late Class III. Twenty-three patients had symptoms of angina pectoris; congestive heart failure was evident in 56%. Postoperatively, 70% are now Class 1 or II. Single coronary bypass was performed in 16 patients, double in 6, and triple in three. Double bypass plus mitral valve replacement was required in two with aneurysmectomy in one. The rate of intraoperative infarction was 27% for the series but only 7% in the last year. The methods of intraoperative myocardial preservation and the technical approach for the operative procedures were variable. Results with each method are correlated, and currently preferred techniques are presented and discussed. Best results were obtained in patients who presented early in their symptomatic course with isolated proximal coronary lesions and good renoff vessels. Excellent results could be achieved despite advanced age of patients, requirement for multiple bypass grafts, and correction of other associated cardiac lesions. Poorest results were obtained when long-standing ventricular failure was combined with poor vessels distal to coronary stenoses.

The repair of many congenital heart anomalies would be facilitated by a tissue replacement for the atrial wall or pulmonary artery which would grow with the child. Such a tissue has not previously been identified. In 12 puppies a broadly based flap of pericardium was sutured over the right atrial free wall. The atrial wall was excised from beneath the flap. In four animals the flap was then cut away from its pericardial attachments superiorly, inferiorly, and along the phrenic nerve, leaving an autogenous pericardial patch. In the other eight animals the flap was left intact, allowing retention of neural and vascular supply. The animals were put to death 263 +/- 23 days later. In four animals having a pericardial patch, the area of the patch did not increase (94% of original size, NS) despite an increase in body surface area (BSA) to 169% (p less than 0.05) of original BSA. In eight animals with a pericardial flap, the area of the flap increased to 214% (p less than 0.01) of the original size with an increase in BSA to 199% (p less than 0.01) of original BSA. The flap size index (size/BSA) increased to 109% of the original index while the patch size index decreased to 54% of the original, a significant difference (p less than 0.01). The broadly based pericardial flap grew in a manner parallel to BSA increase in these puppies.

Pneumocystis carinii pneumonitis has increased in incidence within the population of patients receiving cytotoxic and immunosuppressive therapy. During the last seven years 12 patients with this fulminant disease have been encountered. Results of diagnosis and therapy are presented and discussed. Early open lung biopsy and the initiation of appropriate antimicrobial therapy are stressed.

Acute myocardial ischemia is a serious complication of percutaneous transluminal coronary angioplasty, often requiring emergency myocardial revascularization. Since our initial report of 17 such patients, we have encountered an additional 32 patients requiring emergency myocardial revascularization since September, 1981. The indication for emergency myocardial revascularization was ischemic chest pain in all 32 patients. Percutaneous transluminal coronary angioplasty resulted in injury to the right coronary artery in 11 patients, the left anterior descending artery in 19 patients, and the left main artery in two patients. The onset of ischemia was immediate in 26 patients but delayed up to 22 hours in six patients. Chest pain was associated with ST-segment elevation in 21 patients, hypotension in 7 patients, and cardiac arrest in 6 patients. Immediate intra-aortic balloon pumping was instituted in the angioplasty suite in 16 patients. The mean time from onset of ischemia to completed revascularization was 156 minutes with a mean of 1.6 grafts performed per patient. Seventeen patients (53%) had enzyme evidence of myocardial infarction postoperatively, with a significantly higher (p

From September, 1980, through August, 1981, 353 patients underwent attempted percutaneous transluminal coronary angioplasty (PTCA). Twenty-seven patients (7.6%) subsequently underwent elective myocardial revascularization without death or complicating PTCA. Surgical support in the first 2 months involved a fully-staffed operating room standing idle. During the last 10 months, patients requiring emergency revascularization were accommodated in the first operating room available. All 17 patients undergoing emergency revascularization had severe chest pain and 12 patients had ST-segment elevation on the electrocardiogram. The average time from onset of ischemia to revascularization was 135 minutes and did not change over the period of study. Improvement in the electrocardiogram and myocardial function were frequently noted with restoration of flow by the vein graft. Two patients (12%) required inotropic drug support following revascularization. All 12 patients with ST-segment elevation preoperatively had elevated myocardial enzyme levels postoperatively, including five patients (29%) with new Q waves on the electrocardiogram. Myocardial necrosis did not correlate with time to revascularization, number of diseased vessels, the artery being instrumented, the mechanism of ischemia, or the presence of collateral flow. There were no deaths. Because of the high incidence of myocardial infarction despite prompt revascularization, we now routinely insert the intra-aortic balloon pump in the catheterization laboratory in patients with refractory myocardial ischemia requiring emergency revascularization. Prompt safe revascularization for acute ischemia following PTCA can be achieved without expensive and inefficient standby of cardiac surgical facilities. Transmural myocardial ischemia following complicated PTCA is frequently associated with evidence of myocardial necrosis despite prompt surgical revascularization. Greater salvage of ischemic myocardium may be possible if the intra-aortic balloon pump is used in the interval between PTCA-induced injury and surgical revascularization.

From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease (CAD), thus possibly redefining candidates for coronary bypass surgery (CABS). Between October 1980 and June 1982, 777 patients having PTCA and 2068 patients having CABS were analyzed for differences in clinical presentation, complications, and early outcome. Patients having CABS were significantly older, had a higher incidence of hypertension (46% vs. 32%), more multivessel disease (80% vs. 12%), and poorer left ventricular function (nl. wall motion = 88% vs. 52%). The incidence of myocardial infarction in patients after PTCA was 1.0% (8/777). Emergency CAB was required in 5.3% of patients following PTCA. There were no deaths following the angioplasty procedure and 25 deaths in 2068 patients having CABS (hospital mortality rate = 1.2%). Since 1973, there has been a progressive decline in hospital mortality rate (now, less than 1%), postoperative infarction (now, 3%), requirement for inotropic drugs (now, 5%) and frequency of IABP (less than 1%). Increasing ability to achieve complete revascularization now means improved survival and freedom from angina with CAB surgery. PTCA and CAB are both procedures that may be used effectively for selected patients, depending on clinical presentation, extent of CAD, and left ventricular function (LVF). Careful patient selection affords the opportunity for use of PTCA in patients with single-vessel disease (SVD) and good LVF and CABS in patients with multivessel disease, regardless of LVF. Symptomatic patients with SVD and total vessel occlusion are not candidates for PTCA. Our data demonstrate that both PTCA and CABS may be accomplished with very low perioperative complications and hospital mortality.

In a 5 year interval 46 children with complete atrioventricular canal (CAVC) required 51 operations. Thirty-two children underwent correction; nine-received surgical palliation. The ages of the children undergoing correction ranged from 4 months to 14.6 years (mean 4.2 years); eight were less than 1 year old. Weights ranged from 4.1 kg to 39 kg (mean 13.5 kg); 15 weighed less than 10 kg. Ten had undergone previous palliation (seven by pulmonary artery band; three by shunt). There were no early deaths and two late deaths. One infant required mitral replacement at correction; two required subsequent mitral replacement. The ages of the children undergoing palliation ranged from 8 days to 1.34 years (mean 5.8 months); 16 were less than 1 year old. Weights ranged from 2.5 kg to 8.5 kg (mean 4.4 kg); 14 weighed less than 5 kg. Operations included pulmonary artery banding in 14, shunt creation in four, and pericardial enlargement of the right ventricular outflow tract in one. One death occurred 5 days after pulmonary artery banding in an infant with unrecognized coarctation. One late death occurred several months after the creation of a second shunt in a child with severe tetralogy of Fallot and hypoplastic pulmonary arteries. Forty-two (91%) of these children were alive at the time of this review. The outcome in these 46 patients supports individualized choice of initial operation (palliation versus correction) based upon clinical condition, weight, and associated anomalies. The pulmonary artery is banded in infants less than 4 to 5 kg; larger infants and children undergo correction primarily.

The Blalock-Taussig shunt has been used at our institution in 64 infants with cyanotic congenital heart disease who required palliation. Thirty-one of these children were less than 2 months of age at the time of operation. There were no early shunt closures. There were two hospital deaths (3%). There was only one hospital death in the 31 patients less than 60 days old. According to a life-table analysis, 87% ± 9% (± 95% confidence limits) of the shunts were functioning at I year and 78% ± 12% at 2 years. Results are similar in the subgroup of children less than 60 days of age at the time of operation or in the subgroup of children weighing less than 3,999 gm at operation. In infants with small pulmonary arteries, pulmonary arterial growth was excellent (ipsilateral pulmonary artery/descending aorta ratio 0.70 → 0.95 in 550 days, p

Between January, 1976, and April, 1980, 116 patients had urgent myocardial revascularization for clinical instability within 30 days of acute myocardial infarction (MI). Group 1 (8 patients) had coronary bypass grafting within 24 hours of acute MI; Group 2 (20 patients) had coronary bypass grafting 2 to 7 days after acute MI; and Group 3 (88 patients) had coronary bypass grafting 8 to 30 days after infarction. Indications for operation were persistent or recurrent pain (81%), pain plus ventricular arrhythmias (12%), and pain plus compelling anatomy. The incidence of single-vessel, triple-vessel, and left main coronary artery disease was 28%, 31%, and 12%, respectively. There were no hospital deaths in the series. The incidence of inotropic requirements, postoperative intraaortic balloon pumping, ventricular arrhythmias, and perioperative infarction was higher in patients operated on within 7 days of acute MI than for patients having coronary bypass grafting after this time. There have been 5 late deaths during a mean follow-up of 14 months. Actuarial survival was 97% at 18 months. Seventy-one percent of patients are presently pain free. Graft patency was 84% in 17 patients recatheterized after coronary bypass grafting and in 14 patients, grafts placed into the area of infarction were patent. This study suggests that the frequency of perioperative complications will be increased in patients operated on within one week of MI, but after this period, coronary bypass grafting can be accomplished with the same morbidity as the of elective operation.

Eventration of the diaphragm, although a relatively rare clinical entity, should be considered in all patients with respiratory distress during the neonatal period, particularly in babies born after difficult delivery by breech presentation or forceps extraction. The diagnosis can be made in the majority of spontaneously breathing patients by chest roentgenography or by fluoroscopy. The treatment initially should be supportive, including assisted ventilation if needed. If the infant cannot be weaned off the respirator after a week to ten days of respiratory support, surgical correction of the elevated diaphragm should be carried out. The results of surgical treatment in these desperately sick infants is usually most gratifying.

Thirty-five patients underwent revascularization within 30 days of myocardial infarction. Group I (10 patients) underwent revascularization within 24 hours of infarction; Group II (nine patients), 2 to 7 days following infarction; and Group III (16 patients), 8 to 30 days after infarction. Indications for operation were persistent or recurrent pain following infarction, refractory ventricular arrhythmias, or persistent or recurrent pain associated with objective signs of reduced cardiac output. (A patient was not considered a surgical candidate if pain-free following infarction or if mechanical circulatory assistance was required in the treatment of cardiogenic shock.) There was an almost equal incidence of transmural and subendocardial myocardial infarction among the patients. Although severity of coronary vascular disease was the same for each of the three groups, left ventricular dysfunction was significantly more prevalent in Group I and Group III. There were no operative or late deaths during a short follow-up period (mean 9.8 months). Low morbidity and mortality in this very unstable group of patients was attributed to precise prebypass monitoring of rate-pressure product, Lead V5 precordial electrocardiographic (ECG) changes, pulmonary capillary wedge pressure, and cardiac output. Pharmacologic intervention in the critical prebypass period included frequent use of intravenous propranolol and trinitroglycerin. Complications in the postoperative period (necessitating inotropic agents or intra-aortic balloon pumping) correlated with the degree of left ventricular dysfunction at the time of catheterization, rather than the infarction-revascularization interval. Satisfactory over-all graft patency (84 percent), patency of grafts into the infarcted area (82 percent), improvement in left ventricular function, and relief of angina pectoris were noted at the time of re-evaluation.

A total of 178 patients having a diagnosis of left main coronary artery stenosis were divided into three groups as follows: surgical, Group I (n = 135 patients); operable medically treated, Group II (n = 21 patients); and inoperable, Group III (n = 22 patients). Groups 1 and 2 were comparable with regard to clinical profile, extent of anatomic coronary disease, and left ventricular function. Inoperable patients had a much higher incidence of prior myocardial infarction (especially anterior), more severe distal coronary disease, and markedly depressed left ventricular function. The hospital mortality rate for surgical patients was 4% (6/135). The late mortality rate, (median follow-up = 23.4 months) was 7% (9/135). For operable patients, the late mortality rate was 43% (9/21) at 28 months. In the inoperable group, the late death rate at 20 months was 59% (13/22). Actuarial survival at 24 months for the three groups was: 88%, 66%, and 42%, respectively. Of the nine patients who died in the operable group, two had