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A consecutive series of 4,522 patients who received aortocoronary bypass (ACB) from October 1969 through December 1974 has been analyzed with respect to cumulative (actuarial) survival, cause of late death, and late postoperative complications. Through December 1973, 2,676 patients received ACB alone. Cumulative survival was 85.9% for five years. Late cumulative mortality averaged 2.7% per year. Causes of death were myocardial in origin in only 60.4% of the patients. Late complications of nonfatal myocardial infarction occurred in 4.1% of the patients, and congestive heart failure occurred in 10.2%. However, preoperative congestive heart failure was present in 25% of these subjects. Mortality in 1974 was 3.4% in patients who underwent ACB only, and 4.2% for all patients who received ACB procedures (1,478 patients). Comparison to previous medical data makes it appear that this surgery increased the actuarial survival over long-term follow-up.

Use of the supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation.

In an attempt to answer the question as to whether or not aortocoronary bypass (ACB) does increase life expectancy of patients with coronary artery occlusive disease (CAOD), 4,766 consecutive patients undergoing ACB at the Texas Heart Institute from October, 1969 through June, 1975, were reviewed and followed for five and one half years. Overall early mortality was reduced from 9.7 percent during the first full year (1970) of the study to 3.3 percent during the last full year (1974). Early mortality in males (86.5 percent) was reduced to 3 percent during 1975, but in females only to 8.4 percent. However, late mortality in females was only 2.6 percent as compared to 3.4 percent in males. Long-term survival was similar for both males and females at five and one-half years when early mortality was considered. Males also experienced better symptomatic results than females with 90.3 percent of males remaining asymptomatic, while only 86.6 percent of females remained in this category. Early mortality increased as more vessels were bypassed, but late mortality decreased and symptomatic results improved as more complete revascularization was performed. Only 55 percent of late deaths were cardiac related. Actuarial comparison of this surgical series with the most comparable series in the literature of patients treated medically, demonstrated significant (P less than 0.001) increased survival in the surgical group as compared to medically treated patients at every year up to five and one-half years, for patients with double and triple vessel disease and for the entire series. In those patients with single vessel disease, the survival curves were similar to four years, following which survival was increased in the surgical patients at the end of the fifth and sixth reporting years. In summary, these data appear to suggest that surgical treatment of coronary artery occlusive disease does provide a favorable effect upon life expectancy.

With recent advances in all phases of coronary care and the increasing success of coronary arterial surgery, operative treatment of coronary artery disease is more readily recommended, even for patients over 70 years of age. In a series of 3,730 patients who underwent aortocoronary bypass from November 1969 through June 1974, there were 95 patients who were 70 years of age or older. The primary indication for surgery was severe angina, which was present in 88 patients. The mean coronary arterial score was 9.51. Associated valvular lesions were treated surgically in 21 patients, and a left ventricular aneurysm was resected in 7. Improvements in surgical technique and postoperative care are responsible for the hospital mortality rate of only 4.8 percent in the 21 patients operated upon during the first 6 months of 1974 compared with the overall mortality rate of 22.1 percent in all 95 patients. Long-term follow-up among the 95 patients includes data from 33 patients: 9 patients whose condition improved, 21 who were asymptomatic and 1 "coronary death".

Anoxic cardiac arrest, as opposed to induced ventricular fibrillation, greatly facilitates accurate distal anastomosis in aortocoronary bypass surgery. In order to diminish the anoxic insult, general and topical hypothermia may be used. In an attempt to establish the value of moderate hypothermia during anoxic cardiac arrest two groups of patients were compared. In group I coronary artery bypass procedures were performed under normothermic conditions with anoxic cardiac arrest. Patients in group II underwent similar procedures but under hypothermic conditions. General body hypothermia to an esophageal temperature of 30 degrees C and topical hypothermia with iced saline lavage were used. Using these techniques, the average intramyocardial temperature was 26 degrees C. Nonfatal cardiac complications did not occur more frequently in the hypothermic group. Operative mortality was decreased from 6.3% in the normothermic group to 1.5% in the hypothermic group. However, in group II, in addition to hypothermia, a second factor in the reduction of mortality was the completeness of the revascularization procedure: 58.5% of the patients had three or more bypass grafts in the hypothermic group. The mean anoxic arrest time was over 50 min for all patients--those who survived as well as those who died with postoperative low cardiac output or myocardial infarction. Therefore, anoxic arrest time should be kept as short as possible and certainly less than 50 min. Intermittent aortic occlusion and performance of the proximal anastomoses using a partial occluding clamp on the aorta are currently being used and, together with moderate hypothermia, provide a further reduction in postoperative myocardial complications.

Among 3,707 patients who underwent aortocoronary bypass, 302 had preinfarction angina. Coronary angiography revealed single-vessel disease in 43 patients, double-vessel disease in 81, and triple in 178 patients. Plane ventriculography showed contractility to be normal in 178 patients, fair in 88, and poor in 36 patients. Left ventricular end-diastolic pressure was normal in 203 patients, 13 to 23 mm Hg in 73, and larger than or equal to 24 mm Hg in 26 patients. Using cardiopulmonary bypass and moderate hypothermia, single coronary bypass was performed in 45 patients, double bypass in 120 patients, triple in 118 patients, quadruple in 15, and quintuple in 4 patients. Right coronary artery endarterectomy was necessary in 22 patients. The early mortality was 6.6% (20 patients) and was strongly related to poor contractility and congestive heart failure. One- to four-year follow-up data were obtained in 126 patients. Late myocardial infarction occurred in 11 patients and caused 4 late deaths; 3 unrelated deaths occurred. Ten patients experienced no benefit from their operations, 56 are completely asymptomatic, and 53 are significantly improved. Our results show that surgical intervention can improve the poor prognosis of preinfarction angina and appears to be superior to medical treatment.

Between July 1968 and December 1976, 9364 consecutive patients with coronary insufficiency underwent direct myocardial revascularisation using aortocoronary bypass (ACB). Among these patients 8017 had ACB alone, and the remaining 1347 had ACB in addition to correction of other cardiac and vascular lesions. In the series of patients having ACB alone the hospital (early) mortality was 3.9%, but for 2383 surgical patients in 1976 this figure was 2.2%. Operative mortality was higher for women (6.85%) than for men (3.5%), but late survival was about the same for both sexes. Among surviving patients 88% were improved or symptom-free after undergoing ACB. According to our data, at the end of eight years 80% of the patients will be survivors. These results, when compared with other series of patients treated medically, indicate the superiority of surgical treatment both in terms of symptomatic relief and also in increased life expectancy.

In the 20-year period ending December 31, 1973 we operated on 105 patients for palliation of tricuspid atresia (TA) with reduced pulmonary blood flow. Pott's anastomosis (85), Blalock-Taussig anastomosis (19), intrapericardial aorta (Ao)-to-right pulmonary artery (RPA) (18), Glenn procedure (3) and miscellaneous shunts (2) have been used. Of patients undergoing operation more than 15 years ago, 45% (9/20) are still alive. The over-all operative mortality was 9%. It was highest in patients less than one month of age (7/23, 30%). There were no operative deaths in patients older than 12 months. The median age at first operation for the entire series was five months. Our results indicate the Pott's anastomosis and Ao-to-RPA anastomosis are superior to the Blalock-Taussig anastomosis (BT) for palliation of TA. Of patients surviving BT, 69% (11/16) required reoperation, compared to 22% (17/78) surviving Pott's anastomosis and 13% (2/16) surviving Ao-to-RPA shunts. All three patients undergoing Glenn procedures (superior vena cava-to-RPA anastomosis) required reoperation or died without significant benefit. Ballon atrial septosomy and Pott's anastomosis appear to be indicated for infants less than six months of age, and Ao-to-RPA shunt with simultaneous atrial septectomy (if indicated) for older children.

Treatment of idiopathic hypertrophic subaortic stenosis (IHSS) remains a controversial problem and depending upon many factors, medical or surgical treatment may be elected. When medical therapy fails and surgery is recommended, choice of an appropriate surgical technique may be difficult. An analysis is given of 27 patients who have undergone only mitral valve replacement as definitive treatment. Twenty-six patients were dismissed from the hospital with good or excellent results and one died (3.7 percent mortality). Pressure gradients across the left ventricular outflow tract after operation were eliminated in every instance. The mean preoperative gradient was 74 mm Hg and postoperatively was 6.9 mm Hg. Advantages and disadvantages of mitral valve replacement as definitive treatment of IHSS are presented. This method of treatment should be reserved for patients with incapacitating symptoms, congestive heart failure, severe left ventricular hypertension, unusual electrocardiographic findings or in patients who have failed to respond favorably to previous septectomy.

Among the 5507 patients who underwent aortocoronary bypass between October 1969 and June 1975, 41 patients (0.007%) developed recurrent angina and required reoperation. The factors necessitating reoperation were graft thrombosis in 10 patients (24%), progression of disease in 12 (29%), graft thrombosis and critical unbypassed lesions in one (2.4%), graft failure and progression of disease in in 12 (29%), graft failure and critical unbypassed lesions in four (10%), and all three factors in two patients (4.8%). Among 10 patients with 50% lesions present but not bypassed at the initial operation, nine of these lesions progressed to significant stenosis and in five patients this was the sole reason for reoperation. At the second operation, total revascularization was achieved in 32 patients (78%). One patient (2%) experienced a perioperative myocardial infarction and one patient (2%) died. This study emphasizes the importance of "complete" revascularization at initial operation, the concept that arteries with 50% obstruction should be routinely bypassed, and the conclusion that risks of reoperation are comparable with those of initial aortocoronary bypass, but that long-term relief of angina is less favorable.

From 1969 through 1974, a total of 4,522 patients were operated on for coronary artery occlusive disease. This article is an in-depth analysis of a consecutive series of 275 of these patients, operated on during 1974. The mortality was 1.8% and perioperative myocardial infarction occurred in 3.6%. On analysis of risk factors, it was found that 24% of the patients were over the age of 60; 57% had some degree of left ventricular dysfunction; 9% had generalized hypokinesis; 24% were New York Heart Association functional class IV; 13% had left main coronary artery stenosis; and 11% had preinfarction angina. On analysis of the early mortality, the limiting factor was diffuse coronary arteriosclerosis combined with poor ventricular function. This resulted in inadequate or incomplete myocardial revascularization. Since these two risk factors are usually predictable, coronary artery bypass can be recommended not only for patients with intractable angina, but also for patients with impaired left ventricular function associated with angina, and in patients without angina who have a positive stress electrocardiogram.

The clinical course of 109 patients who underwent closure of a sinus venosus atrial septal defect is reviewed, with emphasis on the incidence, type, and severity of arrhythmias before and after operation. There were no operative deaths and only 1 late death. No instances of obstruction of the superior vena cava were detected clinically. One patient had a probable hemorrhagic pulmonary infarction that cleared; another may have a persistent left-to-right shunt. Excellent results were achieved in 72% of the patients, good results in 5%, and poor results in 3%. The type of arrhythmia, both before and after operation, varied with the age of the patient: younger patients had bradyarrhythmias, and older patients had tachyarrhythmias. Ten patients experienced persistent new arrhythmias postoperatively, but none were disabled, required a pacemaker, or died. The arrhythmias in all severely symptomatic patients were supraventricular tachycardias that had occurred before operation. Although functional classification after operation was clearly related to age at the time of the procedure (with younger patients having the best functional results), 19 of 21 patients over age 40 were noticeably improved after surgical closure of the sinus venosus atrial septal defect.

During the 5 year period 1969 to 1973, 403 patients underwent intracardiac repair of tetralogy of Fallot. The patients ranged in age from 3 months to 41 years. Before operation, 86 per cent were cyanotic and 14 per cent were acyanotic. Forty-nine per cent had had at least one palliative procedure before total correction. Mahor associated anomalies included atrial septal defect in 24 per cent, patent ductus arteriosus in 2.5 per cent, coronary anomalies in 4 per cent, and left superior vena cava in 4.5 per cent. Seven per cent of the patients had pulmonary atresia. Pulmonary valvotomy was performed in 111 patients and complete excision of the pulmonary valve in 151. Patch graft reconstruction of the right ventricular outflow tract was performed in 57 per cent of the patients. In 11 patients a conduit was used to connect the right ventricle to the pulmonary artery. The over-all hospital mortality rate was 9.5 per cent, with the lowest rate (3.5 per cent) in the age group 6 to 10 years and the highest in the infant and adult groups (16.5 and 14.5 per cent, respectively). Three known late deaths occurred. A residual ventricular septal defect (VSD) was found in 3 per cent of the patients and an aneurysm of the pericardial patch in the right ventricular outflow tract developed in 7 patients. Intracardiac repair of the tetralogy of Fallot can be performed with reasonable risk and low morbidity. In our experience the optimal age for elective surgery is between 6 and 10 years.

Stone heart or ischemic myocardial contracture is a complication of cardiopulmonary bypass characterized by contracture of the myocardium and inability to obtain cardiac output on manual massage. Stone heart has occurred only during aortic valve replacement and/or coronary artery bypass procedures. Predisposing factors are chronic congestive heart failure and myocardial hypertrophy with fibrosis secondary to longstanding aortic valve disease and/or coronary artery occlusive disease. Although the condition is rare, the outcome is usually fatal. Because of the biochemical and physiological implications of this syndrome, its prevention has been challenging. On the basis of our current concepts, prevention has been afforded by topical and general hypothermia and pretreatment with a small i.v. bolus of propranolol just prior to aortic occlusion. These measures have been utilized in potentially high-risk patients with the predisposition for stone heart and, thus far, the results have been satisfactory. The stone heart syndrome is an entity which should be recognized by all cardiac surgeons. Preventive measures must be aimed at protection of the myocardium during anoxic cardiac arrest.

From January 1970 to April 1975, 132 patients underwent surgical repair of aneurysms of the ascending aorta at this institution, 24 of whom had acute dissections. In almost all cases the ascending aorta was replaced with a Dacron tube graft. Aortic valve replacement was performed in 100 patients and 23 patients underwent coronary artery revision or bypass. Fifteen hospital deaths occurred. Although chronic or nondissecting aneurysms may be dealt with on an elective basis, acute dissections require prompt surgical intervention. Symptomatology and radiographic findings are such that angiography may not be necessary to establish the diagnosis. Clinical evidence of aortic regurgitation in an acute dissecting aneurysm is sufficient indication for immediate operation. Improvements in surgical techniques, fabric grafts, and valve prostheses have all contributed to the successful surgical treatment of aneurysms of the ascending aorta.

Aneurysms and fistulas of the sinus of Valsalva, although rare, present a challenging surgical problem. Forty-five patients with this lesion have undergone operative treatment during the last 17 years. The series includes 32 male and 13 female patients ranging in age from 2 to 68 years with a mean age of 35.3 years. Only 1 early death occurred in the series, a hospital mortality of 2.2%. Diagnosis of the aneurysm was made preoperatively in 30 patients and discovered at operation 15. The lesion involved the right coronary sinus in 28 patients, the noncoronary sinus in 19, and the left coronary sinus in 5. The aneurysm had not ruptured in 22 patients and had formed a fistulous communication between the right coronary sinus and the right ventricle in 13. Acute rupture occurred in 10 patients (22.2%). Long-term follow-up data were obtained in 38 patients after 1 to 15 years. Late mortality is low. A nonruptured aneurysm of the sinus of Valsalva should be managed conservatively when it occurs as an isolated lesion. Our experience supports the concept that perforated aneurysms and fistulas of the sinus of Valsalva, even if asymptomatic, should be treated operatively.

During a 12 year period 5,103 cardiac prosthetic valves in 4,193 patients have been evaluated for performance and incidence of complications. As a result of our experience, the advantages of fewer embolic phenomena, associated with epithelialization in completely cloth-covered valves and those with cloth-covered seating rings, are outweighed by the problems of cloth wear, hemolysis, and hemodynamic obstruction from tissue overgrowth. A valve has been designed which incorporates the desirable features of full-flow orifice, low-profile, self-washing principle, polished contact surfaces, durable materials, and a large eccentric sewing ring into a new mitral prosthesis. Clinical evaluation in 394 patients from Aug. 1, 1971, through Dec. 31, 1973, has demonstrated excellent hemodynamic function and a low incidence of thromboembolic phenomenon.

During a 10 year period, January, 1965, through January, 1975, 5 patients with interruption of the aortic arch (IAA) underwent operation at the Texas Heart Institute. The mortality rate was 60 per cent; 2 patients survived the operation. One 11-day-old infant with IAA, type A, a ventricular septal defect (VSD), and a patent ductus arteriosus (PDA) underwent successful two-stage treatment. A left subclavian-ductus anastomosis, closure of the PDA, and banding of the pulmonary artery were done initially. The VSD was closed later. The second survivor, a 3-year-old girl, had IAA, type B, with a PDA and VSD. Total correction was done with the aid of cardiopulmonary bypass and hypothermia. Considerations include palliative and staged procedures versus total correction with either conventional cardiopulmonary bypass or deep hypothermia and circulatory arrest. Survival rate is improved if associated lesions are totally repaired or palliated at the time of reconstruction of IAA.

To determine the frequency of morphologic abnormalities of the aorta, especially of the media, in patients with aneurysms of the ascending aorta, tissue specimens from surgically resected ascending aortic aneurysms of 339 patients were studied. Included were 232 men and 107 women; 53 (29 men, 23 women) had clinical signs of Marfan's disease. Features evaluated and graded included fragmentation of elastic fibers, cystic medial change, medial fibrosis, medial necrosis, atherosclerosis, periaortic fibrosis, and thickening of the vasa vasorum. Both elastic fragmentation and cystic medial change were present in a high percentage of patients. Cystic medial change was inversely correlated with increasing age of patients, especially in the group of patients without clinical evidence of Marfan's syndrome. Marked changes of these types in many younger patients without Marfan's syndrome could reflect a "tissue insufficiency" in early life that causes the aortic wall to weaken and dilate. Medial necrosis, fibrosis, and atherosclerosis were directly correlated with age. Hemodynamic events are considered to initiate injury and repair within the aortic wall. Dissection was more frequently seen with medial abnormalities than with atherosclerosis.

One hundred twenty-five patients undergoing surgical correction of total anomalous pulmonary venous return were studied. The overall mortality was 37% and was related to age at the time operation was required. Mortality was 57% during the first year of life, 29% in patients between 13 and 24 months, and 15% in those between 2 and 10 years; no deaths occurred in those over 10 years. Mortality was highest in patients with infracardiac lesions (62%), and lowest in those with cardiac defects (30%). The major cause of death was pulmonary edema, and survival was closely related to the degree of increased pulmonary vascular resistance. Surgical treatment should be delayed until at least 6 months of age, but the development of congestive heart failure may necessitate earlier operation.

Aberrant subclavian arteries, which form a type of vascular ring, elicit symptoms of dysphagia and chronic respiratory problems. Simple division of the encircling vessel has been the accepted treatment but has frequently led to various long-term complications. These include ischemia of the arm, which in turn results in claudication and the subclavian-vertebral "steal syndrome." Improved methods of reconstructive vascular surgery allow reestablishment of direct flow to the subclavian artery by means of graft insertion or reimplantation of the aberrant artery. With the use of these newer techniques, vascular continuity has been restored in two young patients.

In order to establish the anatomic criteria, the functional results, and the safety of complete myocardial revascularization for severe coronary artery disease, 100 consecutive patients who received four or five saphenous-vein grafts were analyzed. Ages ranged from 37 to 75 years (mean, 56 years). Men predominated by a ratio of 12:1. As an indication of the severity of multiple-vessel disease, 28 percent were in functional class 4, and left ventricular function was classified as good in 47 percent, as fair in 44 percent, and as poor in 8 percent. Coronary arterial scores ranged from 9 to 15 (average, 12.2). Fourteen patients had significant left main coronary arterial obstruction. All 100 patients had grafts to the left anterior descending coronary artery; 96 to the right coronary artery; 94 to the obtuse marginal branch of the circumflex; 78 to a diagonal branch of the left anterior descending; and 27 to the distal circumflex. Operative mortality was 5 percent. Nonfatal perioperative myocardial infarction occurred in 10 percent, and only one of these had low cardiac output. Follow-up from 5 to 23 months showed 95 percent of the patients to be improved, with 70 percent free of angina. Two late deaths occurred, for an overall mortality of 7 percent.

Dissecting aneurysm of the descending thoraic aorta (type iii) is a specific disease process whose pathogenesis, pathologic description, surgical treatment, and prognosis is different from dissections of the ascending arota (types l and ll). From 1964 through 1974, 91 patients underwent surgical correction of type iii dissection. The operative mortality was 21% and late mortality, up to ten years follow-up, was 13%. During the past four years, operative mortality has dropped to 6.5%. Mortality was determined by extent of the aneurysm and underlying cardiac disease. Antihypertensive and negative ionotropic drugs have not been used as definitive treatment but as adjuncts in perioperative support. Based on our present mortality of 6.5%, with no late mortality, we urge early surgical treatment of acute and chronic dissecting aneurysms of the descending thoracic aorta before extension, rupture, or massive enlargement of the aneurysm occurs.