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The physiopathologic results of mitral commissurotomy were studied at intervals of several months, one year, two years, and three years after the operation. Pericarditis occurred after the operation in 90 per cent of the cases; and postpericardiotomy syndrome (the so-called postcommissurotomy syndrome) in 12.5 per cent, with no correlation between this and the results of biopsy of the auricular appendage. The results of mitral commissurotomy were evaluated by preoperative and postoperative cardiac catheterization, phonocardiogram, electrocardiogram, vectorcardiogram, electrokymogram, ballistocardiogram, roentgenogram, pulmonary angiocardiogram, and pulmonary function tests. The physiopathologic data did not always correspond to the clinical results. Sometimes the clinical improvement was greatly superior to the results furnished by these tests. In this series of 200 patients, excellent or good clinical results were obtained in 67 to 70 per cent of the cases. There was a mortality of 6 per cent. Finally, some factors are present which condition the physiopathologic results of mitral commissurotomy: postoperative mitral insufficiency, valvular calcification, postoperative emboli, insufficiency of the myocardium, sub-valvular stenosis, insufficient commissurotomy, and recurrent rheumatic reactivation, which may cause rcstenosis.

Two cases of postpericardiotomy syndrome following percutaneous left ventricular puncture have been reported. Both had symptoms identical with the other “cardiotomy” syndromes and responded promptly to adrenal steroid therapy. The fact that one of the patients had a second episode of pericarditis four weeks following open heart surgery may mean that the development of this syndrome following left ventricular puncture may be associated with the development of the postpericardiotomy syndrome following cardiac surgery.

Widespread intracardiac surgery of rheumatic heart disease has brought to medical attention a puzzling postoperative complication, usually designated the "postcommissurotomy syndrome" and often considered to represent reactivation of rheumatic fever. Herein are reported instances of an identical complication following intrapericardial surgery of congenital heart disease. It is suggested that the delayed febrile pleuropericardial reaction represents a traumatic pericarditis and that a preferable name for it is the postpericardiotomy syndrome.

A patient is described in whom the postpericardiotomy syndrome developed secondary to a gunshot wound to the chest with the retained missile in close proximity to the pericardium. Steroid therapy produced a prompt and sustained clinical remission. The literature is reviewed, and it is suggested that retained foreign bodies in or near the pericardium are still another precipitating cause of the postpericardiotomy syndrome. Possible etiologic mechanisms, the role of corticosteroids in therapy, and indications for surgery are discussed.

Five patients with acute myocardial infarction developed pleuropericarditis during the first week of their illness. Angiocardiography was diagnostic for pericardial effusion in four patients and in the fifth patient the effusion was demonstrated by echocardiogram. Prednisone therapy resulted in dramatic relief of symptoms and signs in one patient in whom subsequent withdrawal of the drug was associated with prompt recurrence. The other four patients experienced spontaneous resolution of the pleuropericardial and pulmonary findings. The observations reported here suggest that a pericardial rub heard during the first days of acute myocardial infarction is sometimes a manifestation of the Dressier syndrome, and not always simply the reflection of transmural infarction.

The first case of bacterial endocarditis due toNeisseria perflavaafter placement of a graft in the ascending aorta and a prosthetic aortic valve is presented. Sudden death due to a suture ...

While the results of cardiac surgery have improved dramatically during the past 20 years, and operative mortality and morbidity have greatly declined, more early and late complications have evolved as the complexity of cardiac surgery has increased. The recognition of late complications may be greatly facilitated by an acquaintance with those observed most frequently.

Several of the more common problems affecting the postoperative cardiac surgical patient are discussed, along with their treatments.

From October 1969 through March 1972, 1,276 patients underwent coronary artery bypass at the Texas Heart Institute. Associated conditions included simultaneous valve replacement and resection or repair of ventricular aneurysms or ascending aortic aneurysms. Among the series were 1,105 patients who underwent bypass surgery alone, with or without endarterectomy. Factors affecting outcome were analyzed and revealed adverse influences including concomitant endarterectomy, female sex, age, evidence of left ventricular failure or serious ventricular dysfunction, and previous myocardial infarction within the month before surgery, but more importantly within the week prior to surgery. Functional class III and IV angina was significantly decreased or totally relieved in a high percentage of patients after bypass surgery, and remains the major indication at this time for myocardial revascularization. Progressive reduction in surgical risk and improvement in patient selection allow coronary artery bypass to be performed currently with an early mortality risk of only 3.7%.

Among a total of seventy-three patients operated upon for patent ductus arteriosus, thirtysix had adequate observation over a period of two to seven years following operation. Of the thirty-six patients, clinical evidence of rheumatic fever or a progressive valvular disease has developed in six. The study suggests a more frequent association between patent ductus arteriosus and rheumatic heart disease than has been previously suspected, and in some cases operation may have either precipitated or reactivated rheumatic fever. The possible significance of these findings in relation to the etiology of the "postcommissurotomy syndrome" is discussed. The suggestion is made that long term observation following operation for congenital heart defects should include special attention to the possibility of the occurrence of superimposed rheumatic fever.

A thin-walled Silverman needle has been used for 254 percutaneous punch biopsies of the left ventricle in 198 patients with closed chests at the Cleveland Clinic. The technic is described. The biopsy specimens were adequate for diagnosis in 192 patients. In all but three patients (who had lupus erythematosus, scleroderma, and chronic glomerulonephritis with congestive heart failure) cardiac catheterization and selective cardioangiographic studies were performed. There was angiographic evidence of primary myocardial disease, coronary atherosclerosis, or both, or rheumatic valvular disease in 175 patients. Cardiac catheterization and angiographic studies demonstrated no evidence of organic heart disease in 20 patients. Cardiac tamponade was a complication of myocardial biopsy in eight patients. Post-pericardiotomy syndrome occurred in four patients and ventricular fibrillation in one patient. Myocardium with no pathologic diagnosis and interstitial fibrosis or myocardial hypertrophy or both were the light microscopic findings in 165 patients. Representative sections of the biopsy in 27 patients demonstrated small-vessel disease, basophilic degeneration, focal interstitial myocarditis, amyloidosis, Aschoff's nodules, or vacuolar degeneration. The current experience suggests that myocardial biopsy combined with selective cardioangiography is of experimental value, improves the accuracy of diagnosis, and plays a role in the management of some patients.

Attention is drawn to the occurrence of a postcardiotomy syndrome after implantation of a cardiac pacemaker. The complication was observed in 2 out of 11 surviving patients in whom recurrent Adams-Stokes attacks necessitated this operation.