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Thirty-nine patients have undergone operation for relief of tracheoesophageal compression resulting from vascular rings and related entities at the Mayo Clinic. Nineteen patients had a double aortic arch, 11 patients had a right aortic arch with an aberrant left subclavian artery, 5 patients had a left aortic arch with an aberrant right subclavian artery, 2 patients had a pulmonary artery sling, 1 patient had a right aortic arch with mirror-image branching and a left ligamentum arteriosum, and 1 patient had a left aortic arch, a right descending aorta, and a right ductus arteriosus. Diagnostic examinations included chest radiography, barium esophagography, angiography, and, more recently, transthoracic echocardiography, computed tomography, and magnetic resonance imaging. A comparison among the various diagnostic techniques used in 12 patients during the last 12 years showed that angiography (n = 7), magnetic resonance imaging (n = 5), and computed tomography (n = 3) were the most reliable, as they always accurately delineated the anatomy. However, in the 6 patients who underwent transthoracic echocardiography, 1 of whom was an older child and 2 of whom were adults, the vascular abnormality was described correctly only once; in the other 5 patients, the results were false-negative or the technique failed to visualize the relevant vascular structures sufficiently. Currently, magnetic resonance imaging is our imaging technique of choice for the delineation of the vascular and tracheal anatomy in patients suspected of having a vascular ring.

Three patients with dextro-transposition of the great arteries and an aortic intramural left coronary artery are described. A review of our patients with dextro-transposition of the great arteries and those reported in the literature suggests that an aortic intramural course of the left coronary artery or left anterior descending coronary artery must be assumed when the artery arises from the right (posterior) sinus of Valsalva, distal to the right sinotubular junction, or at the commissure between the right and left (anterior) sinuses and courses between the great arteries.

Background: Preoperative diagnosis of the coronary artery pattern in dextrotransposition of the great arteries is important because deviation from the usual pattern may influence the surgical strategy., Methods: For assessment of the value of angiography and echocardiography in this setting, we analyzed the preoperative echocardiographic and angiographic findings in 74 patients with dextrotransposition of the great arteries in whom an arterial switch operation was performed., Results: Two-dimensional echocardiography established a diagnosis of the coronary artery pattern in 40 of the 74 patients; that diagnosis was correct in 38-30 of 32 (94%) with the usual coronary artery pattern and 8 (100%) with an atypical pattern. Angiography established a diagnosis of the coronary artery pattern in 52 patients; that diagnosis was correct in 50-41 of 42 (98%) with the usual coronary artery pattern and 9 of 10 (90%) with an atypical pattern. The accuracy of echocardiography in diagnosing the coronary artery pattern in dextrotransposition of the great arteries in this series was 95% and that of angiography was 96%., Conclusion: Both echocardiography and angiography can establish the diagnosis of the coronary artery anatomy in most patients. Echocardiography is routinely performed in infants with dextrotransposition of the great arteries and is proving to be increasingly sensitive for diagnosing the coronary artery anatomy; the role of angiography may evolve to be supplementary, especially in cases in which the coronary artery anatomy is not clearly demonstrated by echocardiography.

To determine long-term outcome after operation for supravalvular aortic stenosis, we reviewed the case histories of 80 patients who had repair of the localized form (group A) (n = 67) or diffuse form (group B) (n = 13) from 1956 to 1992, including 31 patients with the Williams-Beuren syndrome. Ages ranged from 7 months to 54 years (mean = 12.6 years). Forty-six patients had one or more associated cardiovascular anomalies; the most common was aortic valve stenosis (33.8%). Eighteen patients had 22 previous cardiovascular operations, and 28 patients had one or more additional anomalies repaired during their initial procedure at our institution. In group A, the aortic root was enlarged with a teardrop-shaped patch (n = 61) or a pantaloon-shaped patch (n = 6). In group B, patch enlargement of the aorta was confined to the root (n = 4) or extended into the ascending aorta or aortic arch (n = 7); one patient had a graft placed between the ascending and descending thoracic aorta and one patient had a left ventricular-aortic conduit. There were no deaths in group A; two patients in group B in whom patch enlargement was confined to the aortic root died during the operation (2.5%). Follow-up extended to 33.4 years (mean = 14.2 years); there were five late deaths in group A and one in group B. Survival excluding operative mortality was 94% at 10 years and 91% at 20 years. All patients were in functional class I or II. There was no significant difference between patients with a teardrop-shaped or pantaloon-shaped patch in terms of late gradient, survival, or aortic insufficiency. By Cox multivariate model, the only independent predictor of late death for all patients was associated aortic valve disease (p = 0.02), which was also a risk factor for late reoperation (p = 0.02). In group B, overall survival was better in patients who received an extended patch versus aortic root patch only (p = 0.02). We reached the following conclusions: (1) Associated aortic valve disease was strongly correlated with late death and need for reoperation. (2) Both the teardrop-shaped and pantaloon-shaped patch techniques provide excellent long-term relief of localized supravalvular gradients and preservation of aortic valve competence. (3) In diffuse supravalvular aortic stenosis, aortic enlargement should be extended into the ascending aorta or beyond as required to relieve the gradient; some patients may require a graft or conduit.(ABSTRACT TRUNCATED AT 400 WORDS)

This report describes a patient with congenital absence of the left pericardium with displacement of the heart into the left pleural space and associated tricuspid insufficiency. Excision of the ruptured chordae, plication of the flail anterior leaflet, and tricuspid annuloplasty rendered a competent tricuspid valve.

Myocardial protection is the cornerstone of cardiac surgery especially in coronary reoperation, where the most striking problem is perioperative myocardial infarction. Use of retrograde delivery of cardioplegic solution may be preferable in coronary reoperation. Experience is described with retrograde cardioplegia in 48 reoperations for myocardial revascularization, and the advantages and limitations of this technique discussed.

From 1947 through 1992, 37 Mayo Clinic patients underwent operation for the relief of tracheoesophageal obstruction that resulted from vascular rings and related entities. Of the 37 patients, 18 had a double aortic arch, 11 had a right aortic arch with an aberrant left subclavian artery, 4 had a left aortic arch with an aberrant right subclavian artery, 2 had a pulmonary artery sling, 1 had a right aortic arch with mirror-image branching and a left ligamentum arteriosum, and 1 had a left aortic arch, a right descending aorta, and a right ductus arteriosus. Symptoms consisted of stridor, recurrent respiratory infections, and dysphagia. The anomaly was approached through a left thoracotomy in 31 patients, through a right thoracotomy in 4, and through a median sternotomy in 2. Only one early postoperative death (3%) and no late deaths occurred. At long-term follow-up (maximal duration, 45 years), three patients had residual symptomatic tracheomalacia, one of whom required right middle and lower lobectomy for recurrent pneumonia. Magnetic resonance imaging is the imaging technique of choice for accurate delineation of the vascular and tracheal anatomy. When patients are symptomatic, vascular ring should be repaired. The surgical risk is minimal, and the long-term results are excellent.

Background: Although membranectomy, with or without septal myotomy or myectomy, has been the accepted method for treatment of fixed subaortic stenosis, controversies remain regarding operative methods and uncertainties regarding recurrence of subaortic obstruction and development of aortic insufficiency after repair., Methods and Results: To determine late survival and risk of reoperation, we reviewed 169 patients who, between 1957 and 1992, had repair of discrete (n = 108) and tunnel (n = 61) subaortic stenosis. One hundred fifty-four patients had their primary operation for subaortic stenosis at the Mayo Clinic, and 15 patients had their primary operation elsewhere. Among patients having initial repair at our institution, membranectomy was performed in 52 patients (33.8%), membranectomy plus myotomy in 24 patients (15.6%), membranectomy plus myectomy in 71 patients (46.1%), myectomy plus a Konno-Rastan procedure in 5 patients (3.2%), and myectomy plus a modified Konno-Rastan procedure in 2 patients (1.3%). For all patients, early mortality was 4.7% (2.7% since 1961), and during follow-up extending to 29 years, there have been 16 late deaths. Twenty-six patients underwent a second or third operation for recurrent left ventricular outflow obstruction, including 11 of the 154 who had their primary operation at the Mayo Clinic (7.1%). Among the 21 patients who had a discrete lesion at initial repair and required reoperation, 19 (92%) were noted to have tunnel obstruction at reoperation. At late follow-up, the left ventricular outflow tract gradient was higher in patients with tunnel versus discrete obstruction (33 +/- 5 versus 24 +/- 17 mm Hg, P < .04), and 10-year survival was poorer (79% versus 91%, P < .02). Ten-year survival was worse in patients with tunnel lesions and associated cardiac anomalies versus those with isolated tunnel subaortic stenosis (64% versus 92%, P < .005). Some degree of aortic valve insufficiency was seen at late follow-up in 26% of patients, but in most cases this was mild. For patients with discrete subaortic stenosis, risk of late aortic insufficiency was 38.6% after isolated membranectomy, 27.8% after membranectomy and myotomy, and only 7.3% after membranectomy and myectomy (P < .004). Progression of aortic insufficiency requiring aortic valve replacement occurred in only 6 patients., Conclusions: Our results support the use of myectomy in conjunction with membranectomy for discrete subaortic stenosis. For restenosis and tunnel obstruction, more complete relief of subaortic stenosis by extended resection or a modified or classical Konno-Rastan procedure may improve late survival and reduce the incidence of recurrent subaortic stenosis and late aortic valve insufficiency.

To assess potential suitability of the intercostal artery as a conduit in myocardial revascularization a histomorphometric study of the fifth intercostal artery (n = 11) and intercostal arteries other than the fifth (n = 9) was conducted. All arteries were harvested at autopsy in 11 individuals (mean age, 75 years). The length of the intercostal arteries varied from 22 to 35 cm (mean, 29.4 cm). Three combinations of histologic patterns were seen along the course of the intercostal artery: a proximal elastic segment followed by subsequent elastomuscular and muscular segments (n = 3), a proximal elastomuscular segment with the remainder of the artery being muscular (n = 6), and a completely muscular pattern (n = 2). The mean luminal diameter of the fifth intercostal arteries varied from 1.4 +/- 0.3 mm at the origin to 0.9 +/- 0.2 mm at 30 cm (30% to 40% decrease in diameter due to the flaccid state and rigor mortis). The mean intimal thickness at these locations was 54 +/- 38 microns and 25 +/- 16 microns and the mean thickness of the media was 205 +/- 38 microns and 70 +/- 45 microns. The histologic findings, mean luminal diameter, and mean diameter of the intima and the media were similar in the intercostal arteries other than the fifth. Our study demonstrates that the intercostal artery has a relatively thin intima and media, the latter being elastic or elastomuscular in the proximal segment in the majority of the investigated arteries, which are favorable properties with regard to its potential suitability as a coronary bypass conduit.

A total of 44 patients undergoing isolated aortic valve replacement received either anterograde (20 patients) or retrograde (24 patients), cold St Thomas's Hospital cardioplegia. The patients were similar with respect to age, sex, left ventricular ejection fraction, left ventricular-aortic pressure gradient, cross-clamping time and mean dose of cardioplegia. After surgery, there were no differences in enzyme release, low cardiac output syndrome, rhythm disturbances or clinical outcome between the two groups. Analysis of the postoperative haemodynamic data, however, suggests better preservation of left ventricular contractility with retrograde delivery of cardioplegic solution.

The hydrodynamic performance of four currently used bileaflet heart valve prostheses (St. Jude Medical, CarboMedics, modified Edwards-Duromedics, and Sorin-Bicarbon) with a nominal tissue anulus diameter of 27 mm were measured in the aortic position. All experiments were performed in nonpulsatile flow and in an electrohydraulic, computer-controlled pulse duplicator simulating the left side of the human circulatory system. Testing conditions were set at cardiac outputs of 3.0, 4.5, 6.5, and 8.0 L/min at a constant heart rate of 70 beats/min. The Sorin-Bicarbon valve had the lowest pressure difference with regard to nonpulsatile (mean 5.4 mm Hg at 30 L/min) and pulsatile (mean 2.2 mm Hg at 8 L/min) flow, followed by the St. Jude Medical, CarboMedics, and modified Edwards-Duromedics valves. The leakage volumes under static and pulsatile flow conditions were lowest for the modified Edwards-Duromedics and Sorin-Bicarbon valves. The energy loss in pulsatile flow was lowest for the Sorin-Bicarbon valve, mainly because its systolic, closure, and leakage energy losses were low. Systolic sequential velocity profiles showed the most even flow distribution pattern for the St. Jude Medical and Sorin-Bicarbon valves. These findings correspond with lower overall Reynolds shear stress levels for the St. Jude Medical and the Sorin-Bicarbon valves than for the modified Edwards-Duromedics and CarboMedics valves.

From May 1960 to January 1992, 13 patients with cor triatriatum underwent surgical correction at the Mayo Clinic. Their ages ranged from 7 months to 57 years. Four patients had isolated cor triatriatum; three others had an associated patent foramen ovale or atrial septal defect. Six patients had major associated cardiac anomalies. In patients who had isolated cor triatriatum or associated anomalies with high pulmonary blood flow, the mean gradient across the left atrial diaphragm was 24.4 mm Hg, in comparison with 11.6 mm Hg in patients who had cor triatriatum and a connection between the common pulmonary venous chamber and the right atrium or associated cardiac anomalies that restricted pulmonary blood flow. In all 11 patients who underwent angiography, echocardiography, or both at our institution, the correct diagnosis was established preoperatively. Currently, echocardiography is the procedure of choice for diagnosing cor triatriatum. The diaphragm was excised through a left atrial approach in seven patients and through a right atriotomy in six. All associated anomalies were corrected. One critically ill patient who underwent an emergency operation in 1963 died early postoperatively, and one patient with chromosomal abnormalities and multiple cardiac defects died 2 months after an uneventful postoperative course. At the time of follow-up of the 11 long-term survivors, 9 were in New York Heart Association functional class I, and 2 (both of whom had major associated cardiac anomalies) were in class II. Postoperative angiography or echocardiography (in nine patients) showed no residual interatrial shunt or recurrent left atrial diaphragm.

Between 1952 and 1991, 15 Mayo patients were found to have partial or complete absence of the pericardium at the time of a cardiovascular surgical procedure. One patient with complete absence of the left pericardium had symptoms possibly related to the pericardial abnormality. This 42-year-old man had severe insufficiency of the tricuspid valve attributable to chordal rupture of the anterior leaflet, possibly precipitated by complete displacement of the heart into the left pleural space. Excision of the ruptured chordae and plication of the anterior flail leaflet rendered a competent tricuspid valve. In two patients, a small defect in the pericardium was repaired. Three patients who underwent operation for complex congenital heart disease died: two early postoperatively and one late after a reoperation. In the other 12 patients, no early or late postoperative complications were encountered. Although rare and usually asymptomatic, complete and partial deficiency of the pericardium may lead to serious complications such as cardiac valvular insufficiency or incarceration of cardiac tissue.

The effects of retrograde and antegrade delivery of cardioplegic solution on myocardial function were evaluated and compared in 60 patients who underwent myocardial revascularization. All patients had three-vessel coronary artery disease, and the revascularization was done with extensive use of the internal mammary artery. Seventy-five percent of the distal anastomoses were performed with the internal mammary artery. Myocardial protection consisted of St. Thomas' Hospital cardioplegic solution, topical slushed ice, and systemic hypothermia (28 degrees C). The patients were randomly separated into two groups: group A (n = 30), who received antegrade cardioplegia, and group B (n = 30), who received retrograde cardioplegia. With the exception of the total dose of cardioplegic solution (p = 0.02), there was no significant difference between the two groups that concerned septal myocardial temperature at the moment of asystole and after infusion of the total dose of cardioplegic solution. Cardiac function was assessed before and after the patient was weaned from cardiopulmonary bypass. In the immediate postoperative period there was a significant increase in right atrial pressure of the patients who underwent antegrade cardioplegia. For the other registered parameters there was no significant difference either in the immediate postoperative period or 6 hours later. Release of creatine kinase MB isoenzyme was the same in the two groups. Clinical outcome in terms of mortality, prevalence of perioperative infarction, prevalence of low cardiac output, and rhythm and conduction disturbances was similar in both groups. Technical problems related to cannulation and decannulation of the coronary sinus were not encountered. Multivariate analysis showed that occlusion of the left anterior descending coronary artery (p = 0.012) is an essential contraindication of antegrade delivery of cardioplegic solution. Analysis of the patients with an occlusion of the left anterior descending coronary artery who underwent antegrade (n = 9) and retrograde (n = 10) cardioplegia showed a significant difference in the total dose of cardioplegic solution (p = 0.02) and septal myocardial temperature at the moment of asystole (p = 0.008) and after infusion of the total dose of cardioplegic solution (p = 0.015). The mean arterial systolic blood pressure in the antegrade group was significantly lower than in the retrograde group (p = 0.003). Preservation of the left ventricular stroke work index was significantly better in the retrograde group (namely, 85% of its initial value versus 71% in the antegrade group, p = 0.0116).(ABSTRACT TRUNCATED AT 400 WORDS)

The treatment of superior pulmonary sulcus (Pancoast) tumor is not uniform and is still discussed. Literature data and our retrospective study are presented. Fourteen patients were operated for a Pancoast tumor. Nine patients underwent mediastinoscopy followed by preoperative radiotherapy. Five patients received adjuvant radiotherapy after incomplete resection. Five patients who did not have preoperative radiotherapy, received postoperative irradiation. All three patients who survived five years or more, had preoperative radiotherapy and two of them underwent a complete resection. Literature data are discussed and emphasis is laid on the importance of preoperative staging, including mediastinoscopy, preoperative radiotherapy and complete "en bloc" resection.

Background: Severity of coronary artery stenosis has been defined in terms of geometric dimensions, pressure gradient-flow relations, resistance to flow and coronary flow reserve, or maximum flow capacity after maximum arteriolar vasodilation. A direct relation between coronary pressure and flow, however, may only be presumed if the resistances in the coronary circulation are constant (and minimal) as theoretically is the case during maximum arteriolar vasodilation. In that case, pressure measurements theoretically can be used to predict maximum flow and assess functional stenosis severity., Methods and Results: A theoretical model was developed for the different components of the coronary circulation, and a set of equations was derived by which the relative maximum flow or fractional flow reserve in both the stenotic epicardial artery and the myocardial vascular bed and the proportional contribution of coronary arterial and collateral flow to myocardial blood flow are calculated from measurements of arterial, distal coronary, and central venous pressures during maximum arteriolar vasodilation. To test this model, five dogs were acutely instrumented with an epicardial, coronary Doppler flow velocity transducer. Distal coronary pressures were measured by an ultrathin pressure-monitoring guide wire (0.015 in.) with minimal influence on transstenotic pressure gradient. Fractional flow reserve was calculated from the pressure measurements and compared with relative maximum coronary artery flow measured directly by the Doppler flowmeter at three different levels of arterial pressure for each of 12 different severities of stenosis at each pressure level. Relative maximum blood flow through the stenotic artery (Qs) measured directly by the Doppler flowmeter showed an excellent correlation with the pressure-derived values of Qs (r = 0.98 +/- 0.01, intercept = 0.02 +/- 0.03, slope = 0.98 +/- 0.04), of the relative maximum myocardial flow (r = 0.98 +/- 0.02, intercept = 0.26 +/- 0.07, slope = 0.73 +/- 0.08), and of the collateral blood flow (r = 0.96 +/- 0.04, intercept = 0.24 +/- 0.07, slope = -0.24 +/- 0.06). Moreover, the theoretically predicted constant relation between mean arterial pressure and coronary wedge pressure, both corrected for venous pressure, was confirmed experimentally (r = 0.97 +/- 0.03, intercept = 9.5 +/- 13.3, slope = 4.4 +/- 1.2)., Conclusions: These results provide the experimental basis for determining relative maximum flow or fractional flow reserve of both the epicardial coronary artery and the myocardium, including collateral flow, from pressure measurements during maximum arteriolar vasodilation. With a suitable guide wire for reliably measuring distal coronary pressure clinically, this method may have potential applications during percutaneous transluminal coronary angioplasty for assessing changes in the functional severity of coronary artery stenoses and for estimating collateral flow achievable during occlusion of the coronary artery.

Between 1953 and 1990, 19 patients, who were from 7 weeks to 27 years old, underwent surgical correction of aortopulmonary window at the Mayo Clinic. Associated cardiac anomalies were present in nine patients (47%). At operation, extracorporeal circulation was used in all except one patient. In seven patients, division and primary closure were done. In four patients, the defect was closed by direct suture through a transpulmonary approach. In eight patients, the defect was closed with a patch through a transpulmonary or transaortic approach. Four deaths (21%) occurred intraoperatively or immediately postoperatively. All four patients had undergone division of the aortopulmonary window before 1962, and three of them had a pulmonary vascular resistance (Rp) that was 7.3 U.m2 or more and a ratio of Rp to systemic vascular resistance (Rp/Rs) that exceeded 0.6. One patient with an Rp of 11.8 U.m2 and an Rp/Rs of 0.72 died 16 years postoperatively. Statistical analysis of risk factors indicated that early year of operation (P = 0.022), division of the aortopulmonary window versus transaortic or transpulmonary closure (P = 0.009), and a high Rp/Rs (P = 0.021) were significantly associated with perioperative death. All patients with a preoperative Rp of 8 U.m2 or less, an Rp/Rs of less than 0.4, and no major associated cardiac anomalies were in functional class I (New York Heart Association) postoperatively. Our study confirms that infants with aortopulmonary window should undergo operation early, before irreversible pulmonary vascular changes have developed. Patients with an Rp/Rs that exceeds 0.4 should be thoroughly assessed to determine their operability.

Using transthoracic B-mode imaging and Doppler spectrum analysis it was found that the luminal diameter of the internal mammary artery and its hemodynamics were not significantly different among 15 preoperative patients (64 +/- 10 years) who underwent myocardial revascularization using the left internal mammary artery and young and older control groups (25 +/- 3 years and 61 +/- 9 years, respectively). These data indicate that older age does not significantly adversely influence the degree of intimal thickening and compliance in the internal mammary artery. Doppler spectrum analysis of the internal mammary artery in the patients who were operated on revealed conversion from a triphasic systolic waveform preoperatively to a unidirectional combined systolic/diastolic waveform at 1 week and 2 and 6 months postoperatively, characterized by a significant increase in the diastolic blood flow velocity and a significant decrease in the systolic blood flow velocity and the pulsatility and resistance indices. This study indicates that transthoracic B-mode imaging and Doppler spectrum analysis are promising noninvasive techniques in the preoperative assessment of internal mammary artery morphology and physiology. In addition, Doppler spectrum analysis can also be used in the long-term serial assessment of the internal mammary artery conduit after myocardial revascularization.

The internal mammary, musculophrenic, and superior epigastric arteries were unilaterally harvested from 11 individuals (aged 49 to 83 years; mean age, 67 years) and were examined histologically at 1-cm intervals. In 2 individuals the media of the entire internal mammary artery was elastic, whereas in the other 9 individuals we observed an alternating histological pattern in the media of the internal mammary artery, that of the proximal and distal segments being elastomuscular and that of the mid segment being elastic. In 4 of the latter 9 individuals the distal 10% to 20% of the media of the internal mammary artery was muscular with rare elastic lamellae. The media of the first 1 to 2 cm of the musculophrenic and superior epigastric arteries was elastomuscular or muscular with rare elastic lamellae, whereas more distally the media was purely muscular. The degree of intimal hyperplasia was significantly greater in arterial segments with a purely muscular media (25.6%) than in those with elastic (16.7%), elastomuscular (15.3%), and muscular (with rare elastic lamellae) (17.5%) types of media (p < 0.01). The mean cross-sectional luminal area of the elastic segment (1.9 mm2) and proximal and distal elastomuscular segments (1.9 and 1.2 mm2, respectively) of the internal mammary artery was significantly greater than that of the muscular segments of the musculophrenic artery (0.9 mm2) and the superior epigastric artery (0.7 mm2) (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

We studied the effect of hydrostatic dilation of the internal mammary artery used for coronary revascularization in 10 patients (aged 45 to 79 years, median 63 years). Diluted papaverine solution was injected in the lumen of distal segments of the internal mammary artery, the musculophrenic artery, or the superior epigastric artery that had been obtained at operation; injection was followed by hydrostatic dilation not exceeding a sheer force of 50 gm. In 12 control patients (aged 42 to 76 years, median 64 years) in whom the internal mammary artery had also been harvested for elective myocardial revascularization, similar arterial segments were wrapped in sponges soaked in papaverine solution of the same dilution. In the nondilated group the median (with interquartile range) number of fenestrations in the internal elastic lamina increased from the elastic (21, 7) to the elastomuscular (41, 11) and muscular segments (89, 12) (elastic-elastomuscular: p = 0.006; elastic-muscular: p = 0.006; elastomuscular-muscular: p = 0.003) (Wilcoxon signed-rank test). In none of the three histologic segments were full-thickness disruptions of the intima and disruptions of the internal elastic lamina seen. Similarly, in the dilated group the number of fenestrations in the internal elastic lamina increased from the elastic (25, 18) to the elastomuscular (43, 9) and muscular (100, 13) segments (p values 0.01, 0.01, and 0.006, respectively). In addition, in 20% of the elastic sections, in 17% of the elastomuscular sections, and in 35% of the muscular sections of the dilated group, disruptions of the intima and internal elastic lamina were seen. Comparison of the number of fenestrations in internal elastic lamina in the three histologic segments between the nondilated and dilated groups revealed a significantly greater value in the muscular segments of the latter group (p = 0.01) (Mann-Whitney U test). We concluded that (1) hydrostatic dilation of the internal mammary, musculophrenic, and superior epigastric arteries may have detrimental effects on the histologic characteristics of the intima and the internal elastic lamina and (2) the number of fenestrations in the internal elastic lamina of these arteries is related to the presence or absence of elastic lamellae in the media.

The problem of the efficacy of right-ventricular protection with retrograde coronary sinus cardioplegia is studied. Sixty patients undergoing myocardial revascularization were prospectively assigned to receive cold St. Thomas' Hospital cardioplegia into the aortic root (30 patients) or retrogradely in the coronary sinus (30 patients). The two groups were similar concerning preoperative and operative data. The hemodynamic recovery postoperatively was good in both groups, the increase of the heart rate, the decrease of the mean aortic pressure and the right-ventricular stroke-work index were not significantly different in the two groups. However, right atrial pressure increased significantly (p less than 0.001) in patients who received cardioplegia anterogradely and decreased, but not significantly, in the retrograde group. The data suggest that the decrease of the right-ventricular stroke-work index in the anterograde group is related to a depressed contractility and in the group with retrograde delivery of cardioplegia to a decreased preload. There were no differences between the groups with respect to clinical outcome. We conclude that retrograde delivery of cardioplegia results in an excellent protection of the right-ventricular function in elective myocardial revascularization.

Doppler spectrum analysis was performed in the nonused internal mammary artery in a group of patients who underwent myocardial revascularization using the contralateral internal mammary artery and in both internal mammary arteries in a group of patients who underwent median sternotomy for cardiac surgical procedures in which the internal mammary artery was not used. In all nonused internal mammary arteries the preoperatively triphasic systolic flow pattern had postoperatively converted into a unidirectional systolic flow pattern with a large diastolic flow component, characterized by a significant increase in the diastolic flow parameters and a significant decrease in the resistance and pulsatility indices. This effect had almost subsided at 6 months postoperatively. This study indicates that the reactive hyperemia observed in the nonused internal mammary artery in the early postoperative period is mainly caused by the temporarily increased metabolic demand of the anterior thoracic wall and mediastinum, rather than by the metabolic demand of the anterior diaphragm and the contralateral rectus abdominis muscle after deprivation of their main nutritional vessel.

To maximize use of the right gastroepiploic artery in myocardial revascularization 11 cadavers were studied to determine the shortest route (retrogastric versus antegastric) of the right gastroepiploic artery from its origin to the recipient coronary artery. Any coronary artery could be reached with an in situ right gastroepiploic artery. There was no significant difference between the retrogastric and antegastric routes for any coronary artery, although the former generally is slightly shorter to the vessels on the posterior surface of the heart and the latter to vessels on the anterior surface of the heart. Histological examination of the right gastroepiploic artery in its proximal, mid, and distal segments showed a similar width of intima and media and invariably an almost purely muscular media. Based on the histological similarity of the right gastroepiploic artery to the coronary artery, some scepticism toward liberal use of the right gastroepiploic artery, especially if used as a free graft, is warranted until clinical studies on its long-term patency have been performed.

The aim of this study was to relate the working style of general practitioners to the health status of a sample of their patients. From a large regional sick fund forming part of the national health insurance system in the Netherlands a stratified sample was taken of general practitioners with at least 1000 patients on their list, taking into account the degree or urbanization of the area in which they practised and their annual referral rates to specialists. These 75 general practitioners were observed for two days in their surgeries by trained doctors and rated according to criteria defined beforehand. Taking into account these ratings and the annual figures from the sick fund for prescribing selected drugs and referrals to specialists, the general practitioners were classified into styles of practice - integrated, interventionist or minimal diagnostic. Twenty randomly selected women, aged 50-65 years, from each general practitioner's list, were interviewed and examined by independent doctors. The patients of general practitioners with the integrated practice style appeared to feel more healthy and to have more realistic expectations about the possibilities of professional help for common ailments. They tended to visit their doctor less frequently and to have fewer symptoms. The results showed an association between the quality of general practitioners and patients' health, and it may therefore be concluded that good general practitioners can further the health and well being of their patients.

Myocardial protection is the corner stone of cardiac surgery. In recent years there has been a renewed interest in the retrograde delivery of cardioplegia in coronary artery surgery and also in aortic valve replacement several reports have suggested the advantages of this technique. We describe our experience with retrograde cardioplegia in 25 patients undergoing aortic valve surgery, and discuss the advantages and limitations of this technique.

This article describes a retrospective investigation concerning the occurrence of hypertension in 65 patients who, between 1975 and 1990, underwent surgical repair of coarctation of the aorta. The objective of the study was to investigate the incidence of hypertension after operative correction of coarctation of the aorta. In addition an attempt was made to find a correlation between recoarctation, age at surgery, surgical technique and associated intracardiac malformations, and the presence of persistent postoperative or late occurring hypertension. Eighteen of the 65 patients (27.7%) appeared to be hypertensive 3 to 13 years (mean 5.2 years) after the operation. In only 3 patients hypertension could be explained by restenosis at the coarctation repair site. In 60% and 34.3% of the patients a correlation existed with the presence of a hypoplastic aortic arch and serious additional intracardiac anomalies, respectively. On the basis of these findings early operative treatment of coarctation of the aorta seems to be indicated, especially when the coarctation is associated with hypoplasia of the aortic arch or with complex intracardiac anomalies. Because of the relative small number of patients that underwent operative correction of coarctation of the aorta beyond the first year of life a correlation between the postoperative occurrence of hypertension and the age at operation was not found.

A modification of the technique described by Robicsek and associates for treatment of sternum separation after open heart operation is described. The technique consists of placing four interlocking steel wires parasternally on both sides and then including them in the usual transverse peristernal wires.

Cardiac myxoma is the most common primary tumor of the heart. A high suspicion of this potentially lethal disease is warranted because it may mimick a large variety of diseases. Two patients with different symptoms and signs are presented, in whom resection of the tumor was successful. Complete resection of the tumor is the only effective method of treatment.

This study deals with a replication of a previous research project on the correlation between medical and behavioural skills of general practitioners. The PREVARA observation schedule was used to assess these skills of 75 general practitioners. Fifteen surgery contacts were tape-recorded for each GP and were rated by trained observers. The study shows that fundamental dimension underlies the surgery behaviour of the GP: the various skills appear to be equally developed. More specifically, a positive correlation was found between performing obligatory physical examination and paying attention to psychosocial aspects. The results are discussed in the context of the evaluation of the vocational training and medical audit of GPs.