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Between 1982 and 1989, 145 patients underwent operations for persistent or recurrent primary hyperparathyroidism (HPT). At re-exploration, 15 patients (10.3%) were found to have locally recurrent parathyroid tumors (11 patients with adenoma and 4 with carcinoma). These 15 patients had 28 previous operations at outside institutions for HPT. Patients with locally recurrent HPT secondary to adenoma had a longer disease-free interval than patients with locally recurrent carcinoma. At the time of evaluation at the National Institutes of Health (NIH) for recurrent or persistent HPT, each patient was symptomatic and patients with carcinoma had significantly more symptoms and higher serum levels of calcium and parathyroid hormone than patients with adenoma. Locally recurrent parathyroid neoplasm was correctly localized by preoperative testing in 14 of 15 patients. These 15 patients underwent 18 reoperations at NIH for excision of locally recurrent parathyroid tumors. Following the final reoperation (two patients had more than one procedure), each patient had normal serum levels of calcium. In addition each patient remains biochemically cured (based on normal serum calcium level), with a median follow-up interval of 21 months. Local recurrence of parathyroid adenoma comprises a small but significant proportion of cases of recurrent or persistent HPT and can be indistinguishable from parathyroid carcinoma. Findings suggestive of carcinoma include shorter disease-free interval, higher serum levels of calcium and parathyroid hormone, and histologic appearance. Whether the locally recurrent parathyroid neoplasm is benign or malignant, aggressive surgery can control serum levels of calcium in these patients with acceptable rates of morbidity.

Two patients with aortic abdominal aneurysms in association with horseshoe kidney are presented, making a total of 34 cases recorded in the literature. In 29 patients, the aneurysm was resected and five patients were non-resectable. Because of the abnormalities in vascular supply to the abnormal kidney, it is important to diagnose the combination of aneurysm and horseshoe kidney preoperatively. An error in diagnosis should be unusual if an intravenous pyelogram is routinely obtained on all patients. This study may reveal abnormalities which will allow the diagnosis of horseshoe kidney to be made or suspected. If the intravenous pyelogram is abnormal, it should be followed by an aortogram. This may substantiate the diagnosis of aneurysm and horseshoe kidney and provide the necessary detailed information regarding the pattern of blood supply and its relationship to functioning tissue. The amount and disposition of functioning renal parenchyma may be further amplified by renal scan. If this sequence is followed, the unanticipated combination of abdominal aneurysm and horseshoe kidney should be rare.

Eleven patients seriously disabled by mitral regurgitation were re-evaluated 4 to 41 months following mitral annuloplasty (average 19.4 months). Preoperative and postoperative comparative data are presented. One patient was unimproved or worse. The rest were subjectively better. Mean changes were transverse cardiac diameter -17.8 mm. (median 15 mm.) ( p < .005); resting stroke index +9 ml./beat/M. 2 (median 9 ml./beat/M. 2 , p < .05); resting cardiac index +0.5 L./min./M. 2 ( p = .20); mean pulmonary artery pressure -7.2 mm. Hg, or 29 per cent (median 8 mm. Hg, p < .03); and arteriovenous oxygen difference -12 ml./L. (median 13 ml./L., p < .005). Abnormally prolonged mixing, as shown by indicator-dilution curves, was decreased in all patients ( p < .05). Exercise testing showed varying degrees of improvement in six of the nine so studied. In six patients mitral regurgitation by angiocardiographic measurements postoperatively represented 0, 0, 21, 24, 35, and 46 per cent of the total left ventricular stroke volume. Two patients had increased end-systolic left ventricular volume as evidence for postoperative left ventricular failure. The other four were probably normal. Ten of the 11 patients showed postoperative improvement that was felt to be significant in two or more of the above objective measures. Striking x-ray improvement in heart size occurred in two patients, eight others showed decreases in transverse diameter of up to 17 mm. One developed an increase in heart size. Although probably improved over their preoperative status, two patients had significant mitral stenosis at the time of re-evaluation. Another showed evidences of progressive mitral regurgitation after an initial period of improvement. Mitral annuloplasty is a palliative procedure with considerable potential for effecting a reduction in regurgitant volume and improving the clinical status of carefully selected patients.

The English surgical literature was reviewed for a 10-year period between 1950 and 1960. A total of 166 patients with anomalous pulmonary venous drainage treated surgically was found. Of this number, 65 patients had total anomalous pulmonary venous drainage (40 per cent). Ninety-five patients (57 per cent) had anomalous venous drainage via extracardiac channels. The over-all survival rate for 166 patients was 74 per cent. The single lesion with the lowest survival rate (35 per cent) was total anomalous pulmonary venous drainage via a persistent left anterior cardinal vein. Of the 34 patients in this category, only three (9 per cent) had a complete repair of the anomalous drainage with survival. A series of 10 patients with anomalous venous drainage via extracardiac channels operated on with the aid of extracorporeal circulation is reported. There were three deaths. Drainage occurred via the superior vena cava (six patients), the coronary sinus (two patients), and a persistent left anterior cardinal vein (two patients). Included in the series is a fourth instance of successful complete repair of total anomalous pulmonary venous drainage via a persistent left anterior cardinal vein. The clinical features, methods of repair, and perfusion data are reviewed. An important aspect of treatment for total anomalous pulmonary venous drainage is the realization that impedance of pulmonary venous outflow is extremely hazardous. It is suggested that pulmonary venous pressure be monitored when complete repair is contemplated. If complete occlusion of decompressive channels causes a significant increase in the pulmonary venous pressure, some avenue of decompression should be left; otherwise, venous infarction of the lungs with probable fatality will result.

Clinical and hemodynamic evaluation has been carried out one year after homograft aortic valve replacement in 15 patients. These studies have included an evaluation of pressure gradients across the aortic valve, supravalvular cineangiocardiography, and left atrial biplane angiocardiography for the measurement of left ventricular volume, left ventricular mass, and quantitation of aortic regurgitation. Eight patients had an excellent result, three patients a good result, and three patients a fair result. One patient had a poor result because of persistent, severe aortic regurgitation. A small systolic pressure gradient was present across the homograft valve in 2 of 13 patients. Significant aortic regurgitation, defined as more than 3 L/min, occurred in four patients. Patients with aortic regurgitation preoperatively had reduction in LV volume in proportion to the reduction in regurgitation after surgery. Left ventricular mass diminished postoperatively in proportion to the reduction in stroke work, as determined from the pressure-volume diagram.

Twenty-five patients with predominant aortic valvular disease have had replacement with a homograft aortic valve inserted after the fashion of Barratt-Boyes. Recently used valves have been stored at -80 C, allowing prolonged storage and rapid reconstitution. There were five early deaths (20%), none of which was directly attributable to the choice of valve. Of three late deaths (12%) in up to 18 months follow-up, two were found to be due to complications of the valve resulting in aortic regurgitation-one secondary to a peripheral leak, the other to a fungal endocarditis. All 17 survivors are greatly improved. All 11 patients who have survived over four months have returned to their former occupations. Five (29%) have no murmurs and 12 (71%) have no diastolic murmur. The five that have diastolic murmurs all show evidence of improvement. Tailoring the recipient annulus to fit the donor valve by means of "V" excision of the noncoronary sinus has been very important in minimizing the problem of valvular insufficiency. Recatheterization at one year has revealed no systolic gradient in four patients. Aortic regurgitation was minimal in one patient. There has been no thromboembolism, although anticoagulants are not used. These promising early results support continued use and evaluation of the homograft aortic valve.