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Forty consecutive patients underwent intracardiac repair of acquired (15) and congenital (25) cardiac defects using a collagen sealed Dacron patch, baffle, or tube graft. Mean age at repair was 26.6 years (range, 1-74). Pediatric patients requiring valved extracardiac conduits were excluded from the study. Previous procedures had been done in 14 of the 40 patients (35%). There were three hospital deaths (7.5%), and two late deaths (5.4%), with an actuarial survival of 87 +/- 5.5% at 37 months after repair. Four patients required re-entry for bleeding (10%), but in no patient was bleeding related to leakage through the patch. There were no episodes of hemolysis. Mediastinitis occurred in one patient (2.7%) and resolved with usual treatment. There were no late reoperations, with actuarial freedom from reoperation 100% at 37 months after repair. The authors conclude that surgical implantation of collagen impregnated Dacron provides good early phase results. The collagen treated knitted Dacron has excellent handling characteristics and is impermeable. However, because of concerns regarding the potential for thick intimal peel formation due to variable collagen resorption rates, the authors continue to recommend pulmonary homografts when a valved extracardiac conduit is required in children.

The performance of a solid phase radioimmunoassay (ABBOTT-HBe) for the detection of hepatitis B e antigen (HBeAg) and its antibody anti-HBe was evaluated in clinical studies. The reagents and procedure were found to be reproducible by seven investigators, and lab-to-lab variations were minimal. In HBsAg positive sera, ABBOTT-HBe detected HBeAg or anti-HBe in 90% of the specimens compared to 50% tested by immunodiffusion. During the early acute stage of viral infection, serum HBeAg coincided with the rise and decline of HBsAg and seroconversion to anti-HBe occurred most often prior to loss of HBsAg. Patients with clinical evidence of chronic liver disease showed persistence of HBsAg and HBeAg. Vertical transmission studies of hepatitis B virus infection from mother to newborns, showed that mothers whose sera were positive for both HBsAg and HBeAg resulted in a greater incidence of transmission of hepatitis B virus to their offspring than mothers whose sera were HBsAg positive but HBeAg negative.

Repair of localized bilateral congenital pulmonary venous stenosis with living autologous atrial tissue was accomplished in two patients, 3 and 4 months of age. The tip of the left atrial appendage was opened and used as an onlay patch to widen the stenotic area of the left pulmonary veins, leaving a double pathway for venous return. A flap of interatrial septum was evaginated through an incision in the right side of the left atrium and used as an onlay patch to widen the stenotic area of the right pulmonary veins. Effective relief of obstruction was demonstrated by nearly normal postrepair pulmonary artery pressure in each and early postoperative angiography in one. Although we believe this method of repair will increase the probability of a lasting result, further experience and subsequent late reevaluation are needed to demonstrate its long-term effectiveness.

A needle modification is described that enables fibrin sealant to be applied as a fine spray to the operative site. The techniques for modification and use of the needle are presented.

Patients with atrioventricular septal defects are morphologically predisposed to subaortic obstruction. Some individuals require secondary left atrioventricular valve replacement for severe incompetence persisting after repair, and they are especially susceptible to left ventricular outflow tract obstruction. A surgical technique is described for replacement of the atrioventricular valve which seems to avoid the complication of left ventricular outflow tract obstruction by the prosthesis.

Fifty-two patients with tetralogy of Fallot underwent repair between March 1985 and July 1987. The repair was made without a ventriculotomy whenever feasible. There were no (0%) early or late-phase deaths (70% confidence limits 0% to 3.6%). Operative reports and preoperative angiocardiograms were retrospectively reviewed to delineate determinants for operative approach. Two distinct morphologic subgroups were observed angiographically and confirmed intraoperatively. Thirty-two patients (62%) had severe hypertrophy of the infundibular septal structures. Each of these 32 underwent transatrial and transpulmonary repair of the infundibular stenosis, and 12 of them also required a limited ventriculotomy to enlarge a hypoplastic pulmonary valve anulus. The other 20 patients (38%) were found to have hypoplasia and not hypertrophy of the infundibular septum. Each of these required a formal transventricular approach to the repair with an infundibular patch inserted to relieve the infundibular stenosis. Right ventricular/left ventricular systolic pressure ratios after repair were not different between the groups (p = 0.79). In conclusion, tetralogy of Fallot was satisfactorily repaired by means of a transatrial and transpulmonary approach in two thirds of these patients. The avoidance of a ventriculotomy to accomplish repair may be suggested preoperatively by selective angiocardiogram and confirmed by intraoperative assessment. These findings have important implications for the development of treatment protocols.

An experimental study was performed using C14 proline uptake in order to: (1) assess the effects of current sterilization and storage methods on fibroblast viability, and (2) establish a control tissue that could be used to determine viability of each homograft valve at the time of implantation in the clinical setting. The results were expressed as disintegrations per minute per milligram of tissue (DPM/mg). Swine aortic (AV), pulmonary (PV), and tricuspid leaflets (TV), and adjacent AV and PV arterial wall were procured sterile and subjected to routine sterilization and storage. Thirty samples of AV were analyzed for incorporation of labeled proline at procurement (208 +/- 7 DPM/mg), following 48-hour antibiotic exposure (87 +/- 6 DPM/mg, P less than .0001), and following controlled rate cryopreservation and storage for 12 days at -80 degrees C (78 +/- 8 DPM/mg, P = .42). Proline uptake of the other tissues at the same intervals disclosed that only the TV resulted in the same degree of viability at implantation (AV 78 +/- 8, PV 68 +/- 3, TV 75 +/- 2, P = NS). The homograft valves were obtained under sterile conditions from brain dead, multiorgan donors (homovital). It has been postulated that these valves are sterile and ready for implantation. Of 17 homovital valves cultured at procurement, 9 had positive cultures within 48 hours (53%). We conclude that: (1) the TV can be processed as a control tissue with each homograft and then utilized to predict viability at the time of implantation in the clinical setting; (2) antibiotic exposure is an essential step in the preparation of all homografts, however, modification of the antibiotic solution is necessary.

Studies of homograft valves in the past two decades have suggested that "viable" valves, i.e., those maintaining chemical and structural integrity of their leaflet intercellular matrix, have a better long-term function than nonviable valves. The most effective qualitative methods of assessing leaflet viability involve destruction of the valve leaflets; thus, these methods have been limited to random use in selected valves. A study was conducted in swine in an attempt to establish a control tissue which could be tested in place of the homograft leaflets, thereby determining viability levels of every valve clinically implanted and correlating the results with long-term clinical function. Thirty samples each of the aortic and pulmonary artery wall and tricuspid leaflet were compared with aortic and pulmonary leaflets. Utilizing the technique of C14-proline uptake, viability was assessed at procurement, following sterilization, and following cryopreservation and short-term storage. The tricuspid leaflet was found to retain the same level of viability as the aortic and pulmonary leaflets before and after the cryopreservation period. It was concluded that the tricuspid leaflet could be utilized as the control tissue.