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A study of the effect of additional oral potassium on the low body potassium of seven patients with severe valvular heart disease showed that the potassium supplements were retained. After one month's treatment the exchangeable potassium was significantly increased, but the predicted value was not reached in any of the patients. There was no significant change in plasma potassium. These results suggest that it is of benefit to increase the dose of oral potassium for at least one month preoperatively in patients undergoing cardiac surgery.

The complexity of operation upon the heart and great vessels and the difficulties of physiological postoperative management make it desirable to have an operative exposure which is simple, rapid, and least disturbing to respiration. Having employed the median sternotomy in over 30 patients requiring total heart-lung by-pass, we are convinced that it has advantages over bilateral thoracotomy. It is the purpose of this paper to advocate its use for most intracardiac procedures. Milton 1 was among the first to suggest median sternotomy, and those interested in the subject would profit by reading his excellent paper. It was also recommended by Lilienthal, 2 Roberts and Wilson, 3 and, more latterly, Holman, for pericardiectomy 4 ; Shumacker, for pulmonary stenosis, 5 and Julian, for various intracardiac procedures. 6 Initially we used the conventional transverse incision through the fourth interspace on the right and the third interspace on the left, with a V-shaped transection

As considerable and widespread interest in open cardiac surgery has developed, many papers have appeared describing the various techniques and results with use of extracorporeal circulatory systems. However, the important aspects of pre and postoperative care of the open heart patients have received much less attention. This omission is indeed significant for given a group of cardiac patients with a good total body perfusion and a good surgical repair of their cardiac lesions, the difference between a very low operative risk and a higher mortality is often made by the attention given to details of management in the immediate pre and postoperative intervals. Therefore, it may be of value to others to examine suggestions based on experiences gained at the University of Minnesota Hospitals during the past five years in which period more than 700 open cardiac operations were performed.

In a previous report we demonstrated that, by making a simple modification in the method of recording the ear oximeter, one is able to obtain, in addition, a record of blood flow in the ear which is closely related to cardiac output. In this paper, we report our observations on the relationship between this measure of cardiac output and the actions of vasoconstrictor drugs during cardiac surgery. In some instances, we have seen a rise in cardiac output with a rise in blood pressure; while in others, there has been an accompanying fall in cardiac output. The method offers itself as a very convenient way of assessing the actions of the various vasopressor drugs on cardiac output. In instances where a rise in blood pressure produced by the vasopressor is not accompanied by an increase in cardiac output, all vasopressor therapy is abandoned or a change is made to a more suitable drug.

Summary This paper describes the role of digitalis in cardiac surgical patients as viewed in our hospital. Routine preoperative digitalis is given to almost all patients who are to have intracardiac surgery, whether or not cardiopulmonary bypass is to be used. The positive inotropic effect of digitalis and its action on atrioventricular conduction are discussed in relation to cardiac surgery. The use of digitalis and the means of its administration before, during and after surgery are described. Postoperative digitalis intoxication and its treatment are outlined.

The surgical treatment of acquired and congenital cardiac lesions has undergone great development in the past decade. The steadily increasing number of operations performed upon the heart and adjacent great vessels has given rise to occasional complications involving the nervous system. Some of these complications have already been called to the attention of the neurologist. Thus, the problems of cerebral embolization from cardiac surgery 1 and the resulting pathologic changes 2 have been discussed. Neurologic complications following mitral commissurotomy, 3 aortic surgery, 4 and open heart surgery 5,6, also have been reported. The purpose of this paper is to describe the incidence and nature of the neurologic complications associated with all types of cardiac surgery. To accomplish this, detailed neurologic examinations were performed on all patients who underwent operations on the heart and adjacent great vessels at the Mount Sinai Hospital, New York, during 1958. Methods and Materials Preoperative neurologic

Criteria for the selection of patients for surgery for mitral stenosis and for mitral insufficiency are presented with regard to the place of such surgery in the life cycle of these diseases. A brief discussion has been given of the clinical differentiation between mitral stenosis and mitral incompetence, as well as the place of hemodynamic and other laboratory procedures in the evaluation of patients for surgery and of the results of operation. Closed mitral valvuloplasty is the operation of choice in group iii patients without significant valvular calcification or incompetency. This conclusion is based on statistically valid figures which are cited, the low operative mortality of less than 2 per cent, the sustained good results and the excellent life expectancy of these patients. Other patients must be carefully evaluated, and in many, open operations utilizing cardiopulmonary bypass may be preferred. The problems attendant on open cardiac surgery are discussed, and it is concluded that the place of such surgery cannot be definitely defined until long term results are available. The problem of “restenosis” is considered. Although in many patients deterioration after initial improvement is apparently due to an inadequate operation, mitral insufficiency, rheumatic fever or myocardial failure, in others no obvious iactors explain the restenosis. Reoperations for mitral stenosis are required in increasing numbers as the follow-up period increases. After nine years, in our series, 22 per cent of patients have had reoperation. The technic and results from reoperation are briefly mentioned. Patients with predominant mitral stenosis should be offered surgery when their symptoms are becoming progressively worse, or if they have clear-cut evidence of well marked pulmonary hypertension, or if they have had peripheral embolization. Mitral insufficiency is a condition requiring open surgery. The problems in the selection of patients, in evaluating the valve pathology and in the surgery itself are briefly discussed. Because there is no agreement as to the type of patient to be selected for surgery, because the surgical procedures are still in the developmental phase, because operative mortality in symptomatic patients is high, and because long term results are not yet available, surgery for this lesion must be considered to be still in the experimental stage. It should be offered only to those patients with rheumatic mitral incompetence who are symptomatic and whose disease is obviously progressing. Since operative mortality, and probably long term results as well, are directly related to the severity of the illness, the degree of disability and the valvular pathology, it is important that these be clearly set forth in any papers published on this subject; this has often not been done. Finally, the role of primary myocardial failure in the course of rheumatic heart disease, particularly with mitral incompetence, is discussed.

Fungal endocarditis is an uncommon complication of cardiac surgery. Candida endocarditis following open heart surgery was first reported by Koelle and Pastor (1956) and since then 24 cases have been recorded. Nineteen cases were reviewed by McConnell and Roberts (1967) and three cases of their own were added. Two more cases have been reported since, one by Newsome, Lea and Russell Rees (1967) and the other by Kahn, Kane and Dean (1968). The fungi isolated from these 24 cases were Candida albicans in 14, other Candida species in seven, Aspergillus in two and Paecilomyces in one (Uys et al., 1963). The first case of Aspergillus endocarditis following open heart surgery was reported by Newman and Cordell (1964). This paper presents a case of Aspergillus fumigatus endocarditis on an aortic valve homograft.

PEN-HEART SURGERY is the greatest single predisposing factor in the development of Candida endocarditis. It provides both access routes for invading Candida and suitable endocardial foci on which the circulating Candida can implant. There are many possible sources of this ubiquitous organism, which may gain access to the heart during or after surgery. Rarely, suture or implant materials may be contaminated. Infections associated with intravenous catheters may provide the nidus for ultimate spread to the endocardium. Tracheal traumatization or spread from an infected tracheostomy wound or from a bronchopulmonary infection may be implicated in the candidemia of the open-heart-surgery patient. Whether the Candida will then be eliminated by the host or cause disseminated disease or endocarditis seems to depend on iatrogenic factors and general host defenses. The recently traumatized heart apparently provides suitable conditions for the growth of Candida ‘Ihe time lapse before the disease becomes manifest, then depends upon the magnitude of the invasion, whether it is recurrent or persistent, and on the host’s ability to handle the organism. This paper analyzes the patterns of infection in 91 patients who developed Candida endocarditis after cardiac surgery.* The risk of disregarding postoperative candidemia, and of waiting for re

The purpose of this paper is to present an anesthetic technique for cardiac surgery in which no inhalation agent is used other than 100% oxygen. It should be pointed out that the evolution of the method entailed no predetermined ideas about producing an analgesic state in the absence of an anesthetic inhalant this property, but, rather, was the outcome of clinical observations on various patients during cardiac surgery dating back to the latter part of 1952. 1 It is believed that this technique accomplishes an analgesic state similar to that which has been attributed to ether and oxygen, but avoids the necessity of giving ether. 2 The Preoperative Visit The anesthesiologist's visit to the patient the evening before surgery is an important part of the procedure, since at that time he must always do a thorough chest examination whether or not the patient has had such an examination prior to

Recent advances in cardiac surgery have made necessary the development of more accurate diagnostic tests for certain acquired and complex congenital heart lesions. We have found left retrograde cardioangiography the most reliable means of diagnosis for both aortic and mitral valvular disease. It has proved useful also in certain cases of congenital heart disease, particularly intracardiac and extracardiac left-to-right shunts. In this paper details of the technic employed at the University of Minnesota Hospitals will be given. In addition, the observations will be correlated with surgical data for patients who have been operated upon to date. Information concerning the relative diagnostic accuracy of conventional roentgenography will be included. History In 1933 Reboul and Racine (1) reported a technic for direct needle puncture of the left ventricle and injection of contrast material. In 1936 Nuvoli (2) opacified an aneurysm of the ascending aorta in a patient by this procedure. Ponsdomenech and Nunez (3...

IN RECENT years the antemortem diagnosis of perforation of the ventricular septum following myocardial infarction has become more common. Most of these patients die due to either a sudden arrhythmia or intractable congestive failure. Surgical intervention in this acquired defect has become possible since the development of open cardiac surgery. A brief review of the English literature shows 14 attempts at surgical closure of the septal defect. There are, however, no clear cut indications for surgical intervention. The time of intervention and the condition of the myocardium at that time are clearly the factors which determine the results. The purpose of this paper is to describe the successful repair of a ruptured ventricular septum following myocardial infarction in a patient who could not be gotten out of intractable congestive failure by more conservative means. Report of Case On or about March 1, 1965, a 55-year-old man experienced sudden pain in

The value of the electroencephalogram as an anesthetic and clinical tool in cardiac surgery is established. The electroencephalogram is a dependable and sensitive monitor of brain oxygen supply. This paper describes electroencephalographic alterations due to cardiac manipulation (without heart-lung bypass), heart-lung bypass and hypothermia. The diagnostic and prognostic role of the electroencephalogram in cardiac surgery are presented.

Extracorporeal circulation was designed to provide the surgeon with a « dry heart », while oxygen supply to the tissues was maintained. However, even « total bypass » does not answer th is purpose because several normal and pathologie pathways shunt blood from the systemic circulation to the heart and lungs. Therefore, « coronary suction » is necessary to remove blood from the operating field (a more adequate name is « field suction »). In addition, measures have to be taken to prevent dangerous accumulation of blood in the heart and lungs. Our paper deals with this problem.

DURING the past three years a voluminous literature has accumulated on the use of hypothermia in prolonging the safe period of circulatory occlusion during cardiac surgery, but little has been written on the use of hypothermia in general surgery. The purpose of this paper is to summarize our experience with the use of hypothermia in general surgery and to give the physiologic rationale for its employment. Clinical Material During this period from July, 1953, to May, 1956, we employed hypothermia for 41 noncardiac operative procedures. Of these, 11 were for neurosurgical operations and are not further considered in this . . .

Extracorporeal circulation was designed to provide the surgeon with a « dry heart », while oxygen supply to the tissues was maintained. However, even « total bypass » does not answer th is purpose because several normal and pathologie pathways shunt blood from the systemic circulation to the heart and lungs. Therefore, « coronary suction » is necessary to remove blood from the operating field (a more adequate name is « field suction »). In addition, measures have to be taken to prevent dangerous accumulation of blood in the heart and lungs. Our paper deals with this problem.