Biomedical subjects
Publications and source records attributed to S Khonsari.
A disruptive injury to the ascending aorta during a cardiac operation is a serious and often fatal event. Such an injury is described in which the aorta disrupted at the site of the proximal aortocoronary anastomoses. It was possible to repair the aorta using an intraluminal sutureless graft after other techniques of repair failed.
The indications for operation to correct acute mechanical defects after myocardial infarction are clearly established. Less clear is the use of surgical procedures for nonmechanical complications such as persistent ischemia or circulatory collapse. Between 1974 and 1981, 80 patients underwent coronary artery bypass grafting (CABG) within 2 weeks of infarction. Continued pain was the indication in 83% and cardiogenic shock in 17%. Seventeen patients were operated upon within 24 hours of infarction, 35 from 1 to 7 days, and 28 from 8 to 14 days. Eighty-one percent were men; mean age was 58 years. In 39% of patients the infarction was the premier symptom of coronary artery disease. Sixty-two percent had impaired left ventricular function as judged by left ventricular end-diastolic pressure greater than 15 mm Hg or abnormal wall motion seen on ventriculogram. Overall operative mortality was 5.0%; early mortality by indication was 3.0% for pain and 14.3% for shock. Operation for pain carried a 7.7% mortality if done within 48 hours of infarction and was 0% for those patients operated upon after that time. The status of 90% of all patients was known as of December, 1981, with a mean follow-up of 2.9 years. Life-table analysis demonstrates a 5 year survival rate of 85% +/- 6% in the group operated upon for pain. CABG in the immediate postinfarction period can be done safely with a 5 year survival in patients without hemodynamic compromise comparable to that of patients with chronic angina undergoing elective operation. These results should encourage the application of early postinfarction CABG in other high-risk subgroups of patients.
During the past 5 years all patients with complete atrioventricular (AV) were subjected to surgical correction regardless of age. Thus we were able to assess the ease and reliability of mitral repair in early infancy. Key features of operation include division of bridging leaflets when indicated, selection of a patch sufficiently small to prevent postoperative annular dilation, attachment of the leaflets to the patch with continuous nonpledget-supported sutures at a level determined by the chordal structure, and, based on the size of the mural leaflet, construction of a bicuspid or tricuspid mitral valve. Operative mortality and postoperative morbidity were no greater in patients under 6 months of age than in older patients. Reoperation for mitral regurgitation was required in three patients. In all of them, the primary reason for the failure of repair was that the mitral valve had been left tricuspid; in two of them, the mitral anulus was dilated, as well. Repair was uniformly accomplished by bicuspidization, combined in two instances with a Wooler-type annuloplasty and shortening of the free margin of the aortic leaflet. The absence of secondary scarring of the leaflets in the patients under 6 months of age facilitated repair in this age group. Early repair is possible, and preferable, provided that meticulous attention is paid to the technical features of the repair and a proper decision is made with regard to treatment of the mitral "cleft."
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Common pulmonary vein atresia is a rare congenital anomaly; all four pulmonary veins drain into a common dilated chamber with no direct connections to the heart or systemic venous system. Since its first description in 1962, 16 cases have been reported. Only four patients were surgically managed and none survived. This communication presents the seventeenth reported case of common pulmonary vein atresia and the only patient whose anomaly was suspected early enough to demand immediate surgical management, with gratifying long-term success. The literature on the subject is reviewed and common features of the anomaly are emphasized to facilitate precise diagnosis, so that a futile search for a nonexistent communicating vein is avoided at the time of operation. This approach has led to the first successful surgical management of this otherwise fatal lesion.
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A 5-year-old boy with clinical findings of pulmonic stenosis was found to have a large calcified mass in the right ventricular outflow region and a gradient of 120 mm Hg between the right ventricle and the pulmonary artery. At surgery, an ovalshaped tumor attached to the interventricular septum and obstructing the right ventricular outflow tract was removed. The child survived and is doing well. Histologically, the tumor had the characteristics of fibroma. A hemodynamic study three months after surgery showed almost complete abolishment of the gradient. To our knowledge this is the fifth reported case of calcified right ventricular fibroma with successful operation. In childhood intracardiac calcifications, together with obstruction, are highly suggestive of this lesion.
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A 14-year-old boy after a Mustard procedure for transposition of the great arteries developed pulmonary hypertension secondary to baffle obstruction. This occurred over several years without apparent significant symptomatology. Systemic-level pressure prevailed in the left (pulmonary) ventricle and provided an opportunity to perform a successful one-stage arterial switch.
BACKGROUND: Many studies have demonstrated the superior hemodynamics of stentless porcine aortic valves compared to stented valves. This article describes the operative techniques and reviews our 5-year experience with the Medtronic Freestyle stentless valve. METHODS: Between January 1993 and November 1997, 95 patients underwent implantation of the Medtronic Freestyle valve at a mean age of 76 years. All patients were seen at 6 months, 1 year, and annually thereafter for clinical assessment and Doppler echocardiography. RESULTS: There were three operative and ten late deaths (two cardiac and eight noncardiac). Three strokes and four transient ischemic attacks occurred in the follow-up period. Four patients had bacteremia that was treated successfully with antibiotics. No patient required reoperation for valve-related problems. Serial echocardiograms revealed a decrease in mean systolic gradients across the valve during the first year and an increase in effective orifice areas. Ninety-one percent of patients had no, or trace, aortic insufficiency at the time of discharge and this has not increased over time. CONCLUSION: The Medtronic Freestyle valve has excellent hemodynamics and good clinical results. In our experience, no patient has required reoperation in a 5-year follow-up.
Fifteen patients were operated upon for right-sided infective endocarditis after failing medical treatment. The infection was localized sufficiently to allow reconstruction without valve replacement in 9 patients (60%). Extensive annular and tri-leaflet infections (2 pts.) or significant residual regurgitation (2 pts.) prohibited reconstruction in four patients. In the remaining two patients, the relatively low intracardiac pressures allowed isolated tricuspid or pulmonary valvectomy (1 each). The single hospital mortality (6.7%) resulted from a missed secondary lesion during reparation. Late recurrence or replacement in the valvuloplasty group was 0 in 9 patients (0%) while late replacement or death from infection occurred in 2 of 5 patients (40%) in the valvectomy and replacement groups. Right-sided endocarditis is frequently amenable to reconstruction without late recurrence. Its advantage is in establishing satisfactory hemodynamics without prosthetic replacement. Alternatively, isolated valvectomy can be occasionally performed. Simultaneous or staged prosthetic replacement is frequently required for early (associated left-sided infection) and late (right-sided dilation) hemodynamic reasons.