Left ventricular outflow tract obstruction coexisting with ventricular septal defect.
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Aortic Stenosis, Subvalvular↗
Biomedical subjects
D F Shore
Publications and source records attributed to D F Shore.
Atypical tamponade after cardiac operation in infants and children.
A state clinically indistinguishable from cardiac tamponade can occur after operation for congenital heart disease in the absence of intrapericardial blood or clot. We have employed a method of splinting the sides of the sternum apart in nine patterns in whom low-output states developed postoperatively, unresponsive to either inotropic drugs or vasodilator therapy. Blood pressure, heart rate, central venous pressure, urine output, toe temperature, and arterial PO2 immediately before and 90 minutes after the procedure were compared. Significant increases in blood pressure (p less than 0.02), urine output (p less than 0.001), and toe temperature (p less than 0.001) and a significant fall in central venous pressure (p less than 0.001) resulted. The figures indicate a marked improvement in cardiac output which occurred without alteration in inotropic support or after load reduction. We conclude that mechanical restriction of ventricular relaxation can occur in the absence of intrapericardial blood or clot, may contribute to low-output states, and can be successfully managed by sternal splintage.
Cardiac Output, Low↗
The use of tolazoline hydrochloride as a pulmonary vasodilator in potentially fatal episodes of pulmonary vasoconstriction after cardiac surgery in children.
Infants and children with highly reactive pulmonary vasculature may die of an acutely increased pulmonary vascular resistance (PVR) during or after correction of congenital heart defects. Fifteen patients, 11 infants ages 2--12 months (mean 5.3 months) and 4 children ages 2--10 years (mean 5.8 years), were treated with tolazoline to reduce an acutely elevated PVR during or after operation. Five patients had total anomalous pulmonary venous drainage, six had ventricular septal defect and four had truncus arteriosus. Preoperatively, the ratio of systolic pulmonary artery pressure to systemic artery pressure (PAP/SAP) was 0.57--1.54 (mean 0.93), and PVR was 1.8--20 units/m2 (mean 6.2 units/m2). The pulmonary artery pressure was monitored postoperatively by pulmonary artery lines placed at surgery (12 patients) or by balloon flotation catheters (two patients). Acute elevations in PAP/SAP accompanied by clinical deterioration occurred during attempted withdrawal from cardiopulmonary bypass in three patients, during apparently optimal ventilation postoperatively in eight patients, and after withdrawal of ventilatory support in four patients. Administration of tolazoline as a bolus (1--2 mg/kg) followed by infusion of 1--2 mg/kg/hour resulted in a rapid and sustained decrease in PAP/SAP, from 1.00 +/- 0.18 (mean +/- SD) to 0.40 +/- 0.09 (p less than 0.001), and was effective management for all these clinical crises. The use of tolazoline may prevent a fatal outcome from acute elevation of PVR in the perioperative period.
Cardiac Surgical Procedures↗
Intrapleural BCG in operable lung cancer.
In a controlled randomised clinical trial of 92 patients with surgically resected lung cancer, intrapleural BCG had no clear effect on survival. Adverse effects were insignificant.
Adenocarcinoma↗
Survival after resection of small cell carcinoma of the bronchus.
Forty patients who underwent curative resection for oat cell carcinoma of the bronchus between 1959 and 1974 are reviewed. During the same period there were 24 patients who underwent thoracotomy but who were found to have inoperable lesions. Of the 40 patients who underwent curative resection, 11 patients remain alive and well with no evidence of recurrence. Ten of these patients have survived five years or more, an overall five-year survival rate of 25%. We consider that surgery should be considered as a possible first line of treatment in patients with small cell carcinoma of the bronchus.
Adult↗
Results of mitral valvuloplasty with a suture plication technique.
Between January, 1975, and October, 1978, a total of 243 patients underwent repair of the mitral valve with a suture plication technique. Mitral valve replacement (MVR) was performed in 36 cases in which significant residual regurgitation was apparent on testing the valve after repair. The hospital mortality rate was 5.7%. Five patients required MVR within 1 month of operation. A total of 190 patients were discharged from hospital with what was considered to be a satisfactorily functioning mitral valve. Excluding patients from overseas, detailed follow-up information is available in 80 cases. Of these 80 patients, 13 have subsequently undergone MVR. Factors favorably affecting survival and durability of repair are degenerative valve disease and age below 55 years. Clinical and echocardiographic assessment indicate that this method of repair initially produces good symptomatic improvement and a normal or nearly normal pattern of left ventricular filling. The good early results are only maintained in patients with degenerative valve disease. We therefore no longer use or recommend this technique for elderly patients with rheumatic valve disease.
Adult↗
Intrapleural BCG in operable lung cancer.
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BCG Vaccine↗
Urinary lithiasis in childhood in the Bristol clinical area.
A series of 59 consecutive cases of urinary calculi in childhood is presented, being acquired from one local area (Bristol). These children were treated from 1950 to 1973. The peak presentation was in the 2nd and 3rd year of life, with a secondary peak in the 10th year. Anatomical (39%), metabolic (8.5%) or primary infective abnormalities (29%) were demonstrable, but 22% had to be left in an unsatisfactory "idiopathic classification''. The overall recurrence rate of 7% was reduced to 3.5% when those patients with cystinuria were excluded. The local water supply areas have been studied and a tentative association is suggested between patients and their environment when they live in an area where the water is not only hard but also alkaline (pHgreater than 8).
Adolescent↗
Urinary lithiasis in childhood in the Bristol clinical area.
A series of 59 consecutive cases of urinary calculi in childhood is presented, being acquired from one local area (Bristol). These children were treated from 1950 to 1973. The peak presentation was in the 2nd and 3rd year of life, with a secondary peak in the 10th year. Anatomical (39%), metabolic (8.5%) or primary infective abnormalities (29%) were demonstrable, but 22% had to be left in an unsatisfactory "idiopathic classification". The overall recurrence rate of 7% was reduced to 3.5% when those patients with cystinuria were excluded. The local water supply areas have been studied and a tentative association is suggested between patients and their environment when they live in an area where the water is not only hard but also alkaline (pH greater than 8).
Adolescent↗
The chaning face of urinary lithiasis in childhood.
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Age Factors↗
Thirteen years evaluation of the Bjork-Shiley isolated mitral valve prosthesis. The Wessex experience.
Between 1973 and 1985, 349 patients had isolated mitral valve replacement by a Bjork-Shiley prosthesis with an overall early (30 day) mortality of 5.1%. Of the 331 survivors, 294 patients have been traced and their clinical outcome was followed for up to 13 years in order to define the long term performance of the mitral Bjork-Shiley models MBRP-standard, MBRC-convexo concave and MMSM-monostrut. Cumulative follow-up extends to 6620 patient years (mean 5.75 years). The MBRP valve was implanted in 236 patients, the MBRC valve used in 44 patients and the MMSM valve inserted in 14 patients. The late mortality and morbidity was 0.8% and 0.6% per patient year at 13 years respectively. Actuarial survival rate for the whole group excluding operative deaths was 85% at 5 years, 66% at 10 years and 58.5% at 13 years. The freedom from all valve related complications at 13 years was 70.75%. Bjork-Shiley models MBRP, MBRC and MMSM mitral valve prosthesis show excellent durability with only one case of mechanical failure over a 13 year period.
Actuarial Analysis↗
Degenerative changes in glutaraldehyde preserved pericardium used for the experimental replacement of anterior chordae of mitral valve.
Plastic repair of the mitral valve after rupture of the anterior chordae can only be performed when less that one third of the anterior leaflet has lost its chordal support. This experimental study was designed to examine a method for chordal replacement utilizing gluteraldehyde preserved pericardium (Bovine pericardium supplied by Hancock Laboratories). The correct length of the "new chorda" was determined by the use of anatomical rules. In applying these rules we adopted the hypothesis that the chordae were under tension throughout diastole. The anterior chordae were replaced in eight dogs. At the end of the procedure the valve was tested and found to be competent in every case. Two dogs died before restudy because of the development of bacterial endocarditis confirmed histologically. Five dogs were restudied four months to two years after chordal replacement. There was no evidence of mitral incompetence and the mean left atrial pressure was within the normal range in each of the five dogs restudied. Histological examination of the new chordae demonstrated both cartilage formation and calcification. Electron microscopy demonstrated excellent healing of both suture sites with ingrowth of native collagen fibres between the fibres of the preserved pericardium. We conclude that excellent haemodynamic results can be obtained after chordal replacement and are maintained in spite of degenerative changes. Early calcification is known to occur in biological materials implanted in dogs and the use of this technique in man will be determined by the specific biological environment.
Animals↗
Valve repair versus replacement in the surgical management of ruptured chordae. A post-operative echocardiographic assessment of mitral valve function.
Between January 1971 and December 1978, 74 patients (pts) underwent surgery for ruptured chordae (RC) of the mitral valve. Thirty-eight patients underwent mitral valve replacement and 36 patients underwent repair. The hospital mortality was 8.3% after repair and 7.9% after replacement. Repair was performed by trapezoidal excision of redundant leaflet, re-approximation of the leaflet edges and annuloplasty. At six years the incidence of re-operation after repair was 3% (1/33) and after mitral valve replacement was 14.7% (5/35). The five years survival was 68 +/- 8% after mitral valve replacement and 100% after repair. The incidence of major thrombo-embolic episodes was 0.67 per 100 patient years, without anticoagulation, after repair and 5.7 per 100 patient years, with anticoagulation, following mitral valve replacement. The peak rate of dimension change (PRDC) of the transverse dimension of the left ventricle was determined by echocardiography in 17 patients after repair. The PRDC was within normal range (10/20 cms/sec) in 15 patients, in the stenotic range (10 cms/sec) in 1 patient, and in the regurgitant range (20 cms/sec) in 1 patient. Mitral valve replacement invariably produces PRDC values in the stenotic range. Valve repair is the procedure of choice in ruptured chordae of the posterior leaflet.
Bioprosthesis↗
Continuous monitoring of pulmonary artery pressure after cardiac surgery in infants and children.
Increases in pulmonary vascular resistance in the post-operative period are becoming more widely recognised as a cause of sudden clinical deterioration and death after the correction of congenital heart disease. Therefore pulmonary artery pressure was continuously monitored in the post-operative period in 45 selected infants and children who had undergone surgery for congenital heart disease by inserting an 18 gauge intravenous catheter into the main pulmonary artery through the right ventricular infundibulum at the time of operation. Episodes of low cardiac output which were accompanied by significant increases in PAP/AOP ratio occurred in 20 patients and were managed by alteration in ventilation and/or administration of pulmonary vasodilators. There was a small but significant morbidity associated with the procedure. It should therefore be reserved for those cases considered to be at risk of developing episodes of increased pulmonary vascular resistance.
Blood Pressure↗