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In this study, the effect of exogenous adenosine triphosphate (ATP) on the immature myocardium was evaluated. Isolated working neonatal rabbit hearts were perfused aerobically for 15 min with Krebs-Henseleit buffer (KHB) at 37 degrees C, and then arrested with St. Thomas solution (STS) in group 1 and STS containing 500 mumol/L of ATP in group 2 at 4 degrees to 6 degrees C and maintained at 10 degrees to 14 degrees C for 60 min. Hearts were reperfused with KHB aerobically at 37 degrees C for 15 min. Each heart served as its own control before and after arrest. Systolic function was significantly depressed in group 1 compared with group 2. There was a significant decrease in the peak left ventricular (LV) systolic pressure in group 1 (preischemia mean [PIM] 54 mm Hg to postischemia mean [PoIM] 42 mm Hg, Student's t test p = 0.007) than in group 2 (PIM 66 to PoIM 62 mm Hg, p = 0.5). The LV pulse pressure decreased in group 1 (PIM 72 to PoIM 54 mm Hg, p = 0.02) but not in group 2 (PIM 84 to PoIM 86 mm Hg, p = 0.9) and the rate of rise of LV pressure (dP/dT) in group 2 improved (PIM 5718 to PoIM 6926 mm Hg, p = 0.4) compared with group 1 (PIM 7021 to PoIM 4125 mm Hg, p = 0.008). The PoIM LV flow (LVF) was greater in group 2 than group 1 (LVF group 1 = 2.7 ml/min, group 2 = 4.5 ml/min). Diastolic pressures were not significantly different in the two groups. Our findings suggest that the incorporation of ATP in STS has a significant effect in improving postischemic LV systolic function in neonatal rabbit hearts.

The optimal orientation of the St. Jude Medical mechanical prosthesis in the mitral position has not yet been determined. While in the majority of cases the valve can perform satisfactorily regardless of valve orientation, certain circumstances can increase the risk of leaflet impingement. These valves are commonly implanted with their leaflets oriented parallel to the anatomic axis of the native leaflets (anatomic orientation) or with their prosthetic leaflets perpendicular to the axis of the native leaflets (antianatomic orientation). To determine the influence of valve orientation on the clearance from the prosthetic leaflet to the posterior ventricular wall, we calculated the clearances on all available models of the St. Jude Medical mitral valve. Clearances were computed from measurements of valve dimensions with use of an electronic caliper. In all cases the clearance in antianatomic orientation was at least 49.5% greater (mean 59%, range 49.5% to 77.5%) than in anatomic orientation.

This study was designed to evaluate the early phase events occurring in a stented pulmonary homograft valve implanted in the tricuspid position. A human pulmonary homograft was sterilized in antibiotic solution for 48 hours and cryopreserved in liquid nitrogen (-176 degrees C). Following thawing and trimming, the pulmonary valve was mounted on a Dacron cloth-covered Delrin stent and implanted into the tricuspid position in 3-month-old sheep, for a mean of 95 +/- 5 days. Seven animals were studied. Morphological assessment indicated good structural tissue preservation despite a decrease in viable fibroblasts noted in the distal part of the leaflets. The collagen fibers remained unchanged, and no tissue calcification was found. Viability of the mounted homograft was evaluated using an in vitro tissue culture method, and the viable cells underwent chromosomal analysis to identify whether they originated from the donor or host. Cells with 56 chromosomes, a number intrinsic to sheep cells, were cultured from the donor recipient junctional area. Hemodynamic and angiographic data, which were collected at the time of both implantation and explantation, revealed no functional deterioration of the implanted valve over 3 months. At the time of explantation, six of the seven valves were competent and no cusp retraction or thickening was noted. The seventh valve had deteriorated due to endocarditis. We conclude that stented cryopreserved pulmonary homografts may be useful as bioprostheses in the tricuspid position.

The purpose of this study was to evaluate alterations in adrenergic receptor density in patients with post-infarction left ventricular aneurysms. Resected specimens from 4 patients with left ventricular aneurysm were studied using standard techniques to evaluate beta receptors, alpha receptors, and muscarinic receptors in the border zone, perianeurysm tissue, and infarcted aneurysm tissue. Only the beta receptors demonstrated up-regulation around the aneurysm (p = 0.0003). This indicates that infarction with aneurysm formation can alter adrenergic receptor density, which may affect cellular response and predispose to arrhythmogenesis.

In an attempt to develop a new and better biological membrane for the pericardium, we evaluated the use of glutaraldehyde treated human amniotic membrane (AM) and compared it to polytetraflouroethylene (PTFE) membrane as a pericardial substitute. Four dogs underwent a right thoracotomy. Two 4 x 3-cm portions of pericardium, 3-4 cm apart, were excised in each animal and both sites replaced with a similar sized patch of 0.8% glutaraldehyde-treated AM and 0.2-mm PTFE membrane respectively. The AM was sutured to the pericardial defect with its smooth surface facing the epicardium. After 18 weeks, the materials were evaluated. The AM patches revealed minimal extrapericardial and no epicardial adhesion. The PTFE patches had moderate to severe epicardial adhesions and severe extrapericardial adhesions. Histopathological examination of AM patches revealed that the integrity of the AM was preserved, however, neovascularization and slight lymphocytic infiltration were observed. In the PTFE patches, there were severe inflammatory infiltration and fibroblast proliferation into both surfaces. AM patches by virtue of their low immunogenicity evoke very minimal host to graft reaction. These AM grafts, however, tear easily unless carefully sutured. Improved methods of treatment may improve suturing strength. We conclude that AM performs satisfactorily and is superior to PTFE as a pericardial substitute.

Subclavian artery stenosis is a rare cause of angina in patients who have undergone coronary revascularization using the internal mammary artery. The traditional approach to this problem is surgical revascularization of the subclavian artery with a bypass graft. We report the successful treatment of a patient with this condition using percutaneous transluminal subclavian artery angioplasty, obviating an additional surgical procedure.

In cardiac surgery, topical iced saline solution slush has become an important adjunct in maintaining myocardial hypothermia during cardioplegic arrest. One complication of this technique is phrenic nerve injury (PNI). In an attempt to reduce the incidence of PNI, a prospective study was undertaken to evaluate the impact of phrenic nerve insulation on PNI during cardiac surgery. Seventy-six consecutive patients who underwent coronary revascularization constituted the control group (CG) and were compared with 76 patients who underwent a similar procedure with the addition of phrenic nerve insulation. In the intervention group (IG), a foam insulation pad was placed between the heart and the pericardium in an effort to reduce exposure of the phrenic nerve to iced saline solution slush. There was no difference in major demographic descriptors or operative variables between the CG and the IG, except that the internal mammary artery was used more frequently in the IG (64 percent vs 36 percent, p = 0.0006). The in-hospital mortality was similar between the groups (CG, 0.0 percent; IG, 1.3 percent; p = 1.0); however, the incidence of roentgenographically diagnosed PNI was much greater in the CG (14/76 patients [18 percent] vs 0/76 patients [0 percent]; p = 0.0006). Patients with and without PNI were similar with regard to age, gender, aortic cross clamp time, cardiopulmonary bypass time, and number of grafts (p greater than 0.05). All unilateral PNI occurred on the left. Three patients with bilateral PNI required tracheostomy and prolonged mechanical ventilation. In-hospital mortality was similar for patients with and without PNI (0 percent vs 0.7 percent), but mean postoperative hospital stay for patients with clinically diagnosed PNI was longer than for those without PNI (32 vs 11 days, p = 0.04). This prospective study demonstrates that the incidence of PNI can be significantly reduced by the routine use of phrenic nerve insulation.

In certain patients with anomalies of systemic venous connection, traditional transvenous pacemaker lead insertion may not be technically feasible. We report the use of the femoral venous approach to insert a permanent pacemaker in a patient with congenital heart disease who had undergone two previous cardiac operations and had persistent anomalies of the superior systemic venous circulation. We recommend that the femoral venous approach be considered in select patients requiring permanent pacing.

Cellulose acetate was administered by way of a dietary admixture to Sprague-Dawley rats (20/sex/group) at dose levels of 0, 500, 2500 and 5000 mg/kg body weight/day for 94-96 days. Physical observations, body weight and food consumption measurements were made before testing and throughout the study. Ophthalmoscopic examinations were conducted on all animals before testing and just prior to study termination. Haematology, clinical chemistry and urinalysis were performed at 1.5 and 3 months on 10 animals/sex/group. After 3 months of treatment the animals were killed, terminal body weights and organ weights were measured and ratios calculated. Histopathological examination of tissues from the control and high-dose groups was conducted. The evaluation of physical observations, ophthalmology, body weight, food consumption, haematology, clinical chemistry, organ-to-body-weight ratios, gross pathology and histopathology revealed no evidence of an adverse effect related to treatment with cellulose acetate.

Right ventricular myocardium was assessed for cholinergic and adrenergic innervation, as well as alpha-adrenergic, beta-adrenergic, and muscarinic receptors, in 18 cyanotic patients with tetralogy of Fallot (TOF) and four acyanotic control patients with ventricular septal defect, each of whom underwent a cardiac repair from June through December 1987. Neurons containing acetylcholine (ACH), neuron-specific enolase (NSE), S-100 protein, neuropeptide-Y (NPY), dopamine-beta-hydroxylase (DBH), and calcitonin gene-related polypeptide (CGRP) were detected surrounding arterioles and myocytes in all specimens. NSE and S-100 immunoreactivities were also identified in the cytoplasm of TOF cardiocytes, possibly indicating a neuroendocrine origin of these cells. Cardiocyte size was increased in TOF (p = 0.05). Acetylcholine (cholinergic) (p = 0.04) and CGRP (cholinergic) positive neurons (p = 0.07) were decreased in the TOF as compared to controls. Adrenergic fiber content (p = 0.15) and beta receptors (p = 0.21) were similar in both groups. There was an increase in muscarinic receptors in the controls (p = 0.002), and a marked increase in alpha receptors in TOF (p = 0.019). There were no intragroup differences in the TOF patients according to degree of cyanosis. In conclusion, there were important differences in neuronal and amine receptor content between TOF and control patients. Increased alpha receptors in TOF could account for differences in clinical and hemodynamic events.

The smooth muscle cell invasion and macrophage stimulation within the intima during prolonged exposure to high blood levels of cholesterol esters contribute to increased production of connective tissue matrix. The thickened intima in turn immobilising more LDL derived lipid from the plasma. With damage to the internal elastic lamellae, from essential hypertension, the absorbed lipid can move down a concentration gradient into the medial tissue. This model was supported by our laboratory finding of a lipid gradient across the aorta wall. The gradient commenced shortly after completion of body growth, when the transmedial gradient became detectable. The slope of the gradient progressively increased during ageing. Association of the lipid medial gradient with the degree of atherosclerotic involvement suggested that the gradient influenced the development of intimal lesions. Accumulation of lipid within the medial tissue may then reduce the inward lipid transfer rate from the intima, promoting increased intimal retention and cause the formation of atherosclerotic plaques from the fat saturated intima.

A 53-year-old man who had previously undergone resection of a left ventricular aneurysm was admitted because of hemoptysis. Preoperative evaluation with computed tomographic scan and cardiac catheterization demonstrated a pseudoaneurysm of the inferior ventricular wall measuring 16 cm in diameter with protrusion into the left hemithorax. The neck of the pseudoaneurysm was a defect in the ventricular wall extending from the base of the mitral valve annulus to the insertion of the posterior papillary muscle. Operative repair was performed using an albumin-coated, low-porosity Dacron patch.

One hundred fifteen consecutive patients underwent repair of a variety of "isolated" simple ventricular septal defects (VSD), from February 1985 through December 1989. In no patient was a ventriculotomy required to accomplish the ventricular septal defect closure. There were no instances of permanent complete atrioventricular dissociation, and there have been no reoperations for residual or recurrent VSD. Postoperative echocardiographic and Doppler studies were performed in each patient and revealed good surgical results. There was one hospital death. The technical strategies used to accomplish the repair are described. These include methods for transatrial, transaortic, and transpulmonary approach to VSD closure. Enabling methodologies described include detaching the septal leaflet of the tricuspid valve to enhance VSD exposure in patients wherein the defect is obstructed by the tricuspid valve with "aneurysm of the membranous septum." Also, splitting of the VSD patch in order to manage tricuspid valve chordal straddling is outlined.

Percutaneous cardiopulmonary bypass (PCPB) has recently come to the forefront of medicine as a technique for resuscitating and supporting patients in various clinical situations. Current systems utilize small-diameter cannulas to aspirate blood under high suction into the cardiopulmonary bypass circuit. Aspiration-based systems have several disadvantages including risk of air embolism, blood hemolysis, and cavitation. Additionally, they are suboptimal for use during open-heart surgical procedures. A system with a venous cannula that employs gravity drainage has been evaluated. Once advanced into position over a guide-wire, the stylet is removed, causing the basket near the end of the cannula to expand. Blood flows into the cannula from side holes and the basket region, which prevents the vessel wall or atrium from collapsing around the catheter and impeding venous drainage. Hemodynamic, hematologic, and histologic examinations were performed on eight anesthetized mongrel dogs during 2 h of PCPB. All animals exhibited adequate tissue perfusion and right and left heart decompression. All animals were successfully weaned from PCPB and after 30 min exhibited normal myocardial function. No ischemic changes were observed in the heart, lung, kidney, or liver by light and electron microscopy. We conclude that full PCPB can be satisfactorily achieved by using a novel percutaneous venous cannula and gravity drainage.

Nineteen intra-aortic balloon (IAB) ruptures occurred in sixteen patients during a three-year period. Perforation occurred secondary to abrasion with material failure or mishandling of the device during insertion. To avoid serious sequelae, it is important to be aware of the possibility of IAB rupture and to remove any defective device immediately upon recognition of an event.

Of 530 patients undergoing tricuspid valve surgery from January 1, 1961 through December 31, 1987, those 362 patients having had preoperative right ventricular angiocardiography were studied. Mean age was 58.5 years. There were 71 males and 291 females. Tricuspid valve replacement (TVR) was performed in 126 (34.8%), and 236 underwent tricuspid valve repair (65.2%). The predominant pathology was combined tricuspid insufficiency and stenosis in 18 patients (4.9%), and isolated tricuspid insufficiency in 344 (95.1%). There were no complications related to the right ventriculogram. Preoperative angiographic severity of tricuspid valve incompetence was grade 1 in 23 patients (6.4%), grade 2 in 65 (17.9%), grade 3 in 109 (30.1%), and grade 4 in 165 (45.6%). Intraoperative assessment of the severity of tricuspid valve incompetence correlated 72% of the time with the preoperative angiographic assessment, in those patients with more severe degrees of incompetence (grade 3+ or 4+), p (X 2) less than 0.001. Increasing severity of preoperative angiographic triscuspid valve incompetence was associated with the requirement for TVR (vs. repair), p (X 2) = 0.0002. In conclusion, preoperative right ventricular angiography is a useful method for assessing tricuspid valve function and may predict the requirement for TVR in patients undergoing tricuspid valve surgery.

From January 1973 to December 1989, 54 patients over 80 years of age underwent an intracardiac repair which included a cardiac valve operation. There were 21 males and 33 females. Mean age at operation was 82 years, range 80-89 years. Fifty-two patients (96%) were in New York Heart Association functional class III or IV preoperatively. Six patients had undergone previous valve surgery (11%). There were eight hospital deaths (14.8%). Risk factors for hospital death included older age at repair (p = 0.008), increased total cardiopulmonary bypass time (p = 0.06), and, possibly, smaller aortic valve prosthesis (p = 0.10). All 46 hospital survivors were followed up at a mean of 28.8 months after hospital discharge. There were 11 late deaths (23.9%), occurring at a mean of 32.3 months postoperatively. Survival analysis indicated that increased age (p = 0.06) and increased pulmonary artery diastolic pressure preoperatively (p less than 0.07) were multivariate risk factors for overall mortality. Actuarial survival at 5 years was 44%, with no difference from survival in an age-, sex-, and race-matched population. We conclude that octogenarians in the modern era have good chance for survival following valvular surgery. As hazards for full anticoagulation were low in this series, if valve repair is not feasible, we presently recommend the use of mechanical valves in the elderly to reduce the requirement for late reoperation due to bioprosthesis degeneration.

Atrial natriuretic peptide (ANP) is synthesized and stored in the atria of the heart, but not or at very low concentrations in the ventricles. We investigated the occurrence of ANP and its messenger RNA (mRNA) in human ventricular aneurysm where the cardiocytes were physically over-stretched. The techniques of light and electron microscopic immunocytochemistry, and RNA-RNA tissue in situ hybridization were employed. A large amount of ANP immunoreactivity was found in the cytoplasm of the cardiocytes in and around the aneurysm, but not in fibrous scar tissue or in the normal ventricles. Immunoelectron microscopy localized the immunoreactivity mainly to specific secretory granules in the cytoplasm of the cardiocytes. ANP mRNA was also detected in these cardiocytes. The abundance of both was much higher than that found in the hypertrophic ventricles of other types. The highest concentration of ANP immunoreactivity and of ANP mRNA was found in the cardiocytes located at the border zone. The quantities of both ANP and its mRNA decreased in cardiocytes more distant from the lesion. Our findings suggest that human ventricular cardiocytes in and around aneurysm can convert to produce large amounts of the endocrine peptide ANP. This ventricular endocrine conversion was localized and was probably caused by physical over-stretch of the cardiocytes.

A case is presented of an 8-year-old child who had tension hemothorax after disruption of a modified Blalock-Taussig shunt 2 weeks postoperatively. A rapid deceleration mechanism was responsible for the injury.

From March 1978 through July 1985, 23 patients underwent implantation of 24 intraluminal ringed prostheses (IRP). There were 18 men and 5 women, with a mean age of 54.7 years, range 15-74 years. Eleven IRP were placed in the ascending aorta, two in the transverse arch, and 11 in the descending aorta. Pathology included acute aortic dissection in four patients, chronic dissection in four, and aortic aneurysm in 16. There were eight hospital deaths (35%). Causes of death included acute cardiac failure in seven patients, and ruptured abdominal aortic aneurysm in one. IRP complications requiring revision included right coronary artery occlusion in three of 11 patients (27%) with an IRP in the ascending aorta. Graft revision was also required in three of 11 IRP implanted in the descending aorta (27%), due to graft occlusion in one and graft stenosis in two. Of the six patients with IRP complications, there were three hospital deaths (50%). All 15 hospital survivors were followed for a mean of 68.5 months, range 5-112 months. There were four late deaths (26.7%). Causes of late death included hemoptysis in one, cardiomyopathy in one, and aortic redissection and rupture in two. We conclude that patients undergoing repair of aortic pathology with IRP have an important risk of early phase events, as technical problems can occur due to malposition and slippage of the securing rings.

A protocol for the analysis of the lipid profile of microsamples of aortic tissue was developed. Lipid extraction was from intact tissue using acetone and chloroform/methanol (2/1, v/v). The extract was analyzed for total lipid, esterified cholesterol, cholesterol, triacylglycerol, and phospholipid. The extract was then processed to separate cholesteryl esters, triacylglycerol, and phospholipid which were hydrolyzed and the fatty acid composition was determined by GLC of pentafluorobenzyl ester derivatives. A lipid profile could be obtained on samples with a wet weight of 5 mg.

Intraluminal balloon dilation of re-stenosis encountered after operative repair of coarctation of the aorta has been recently advocated. A case is presented that demonstrates a potential serious complication of this procedure: rupture of the aortic wall with pseudo-aneurysm formation. The operative repair and mechanism of injury are discussed. Balloon dilation of recurrent coarctation of the aorta can cause a significant morbidity and potential mortality.

Severe disruption of the aortic valve cusps in patients with aortic valve stenosis can occur during percutaneous aortic balloon valvoplasty. We report such a case treated successfully by aortic valve replacement.

From January 1982 through December 1985, 3,772 patients underwent a cardiac surgical procedure for coronary or acquired heart disease. Operative mortality increased from 4% in 1982 to 7% in 1985 (p less than 0.001 by chi 2 analysis). There was an increase over time of patients older than 70 years (p less than 0.001). Female patients increased from 31% in 1982 to 35% in 1985 (p less than 0.001). The percentage of patients having isolated coronary artery bypass grafting decreased from 69% in 1983 to 60% in 1985 (p less than 0.001), and hospital mortality after this procedure increased (p = 0.058). Patients requiring more complex procedures including multiple-valve operations or combined valve replacement or repair plus bypass grafting increased from 1982 through 1985 (p = 0.005). Reoperations for multiple-valve procedures or combined valve repair or replacement plus coronary artery bypass grafting also increased (p = 0.02), particularly for patients more than 70 years of age (p less than 0.001). Changing practice patterns have had a negative impact on surgical results. This evolution in cardiac surgical practice has important implications related to peer review and quality-assurance screening, diagnosis-related group reimbursement, and reporting of surgical outcomes to governmental agencies.

From November 24, 1964 through July 3, 1979, 81 patients underwent coarctation repair with resection and end-to-end anastomosis. Mean age at operation was 13.4 years, with a range of 4 months to 55 years. Thirty-two patients (39%) had associated cardiac defects. There were no hospital deaths. Eighty of the 81 hospital survivors were followed (99%) for a total of 10,780 months postoperatively, at a mean of 134.6 (+/- 7.1) months. There was one late death (1.3%) of a ruptured berry aneurysm at 120 months after repair. Actuarial survival was 100% at 10 years and 92.9 +/- 7% at 20 years. Five patients (6.3%) required late re-repair at a mean of 142.8 months postoperatively, range 85 months to 195 months. Actuarial freedom from reoperation was 97 +/- 2.0% at 5 years and 91.7 +/- 3.6% at 20 years. Earlier age at initial repair (P = 0.002), higher mean transrepair gradient (P = 0.005), and late hypertension (P = 0.08) were associated with re-coarctation. The hazard function for reoperation according to age at initial repair revealed a single early risk phase with a plateau starting at 7 years of age and zero hazard after 10 years of age. We conclude that correction of coarctation of the aorta using resection and end-to-end anastomosis permits a long history of event-free survival and continues to be an excellent method of repair.

From Jan. 1, 1961, through Dec. 31, 1987, 530 patients underwent an intracardiac operation that included a tricuspid valve procedure. The tricuspid valve was repaired in 351 patients (66%) and replaced in 179 (34%). Mean age was 56.9 years. Risk factors associated with tricuspid valve replacement included tricuspid stenosis (p = 0.02), jugular venous distention (p = 0.04), previous operation (p = 0.05), and angiographic severity of tricuspid valve incompetence (p less than 0.001). There were 78 hospital deaths (15%). Risk factors for hospital death included previous operation (p = 0.03), male gender (p = 0.03), hepatomegaly (p = 0.03), De Vega or Carpentier annuloplasty (repair group only), (p = 0.01), and older age at operation (p = 0.06). Ninety-eight percent of the patients were followed up. There were 185 late deaths (41%). The actuarial survival rate was 20% at 180 months. Risk factors for late death included male gender (p = 0.03), hepatomegaly (p = 0.04), and lack of postoperative warfarin therapy (p less than 0.001). Actuarial freedom from reoperation was 25.5% at 180 months. There was no difference in reoperation rates (p = 0.10) or survival (p = 0.42) whether the tricuspid valve had been repaired or replaced. We conclude that the requirement for surgical treatment of tricuspid valve insufficiency in patients with multivalvular disease constitutes a high risk group for cardiac surgery. Preoperative variables may predict the result of tricuspid valve replacement. Tricuspid valve replacement may be performed with the expectation of a low risk of valve-related events.

To assess the efficacy of intrapulmonary balloon counterpulsation in the management of right ventricular failure after right ventriculotomy, we undertook an experimental study in a swine model. To mimic the clinical settings more closely, (1) we left the automatic control of the heart intact (2) did not use cardiopulmonary bypass to support the left side of the heart, and (3) induced right ventricular failure by means of a generous surgical incision (50% to 70% of the anterior wall) of the right ventricle. The criteria set for right ventricular failure were (1) 50% increase in right ventricular end-diastolic pressure, (2) 30% decrease in mean arterial pressure, and (3) 30% decrease in cardiac output. Right ventricular failure was attained in all animals studied: A 230% increase in right ventricular end-diastolic pressure, a 43% decrease in cardiac output, and a 34% decrease in mean arterial pressure were evident after the right ventriculotomy. A specially designed intrapulmonary balloon catheter (Datascope Corp., Oakland, N.J.) was placed into the left pulmonary artery through the right ventricular outflow tract. A Datascope console was used for counterpulsation. Effects of counterpulsation for 40 minutes in a 1:1 mode were assessed after surgical induction of right ventricular failure in 14 swine. Each animal served as its own control. The mean hemodynamic changes are outlined: Right ventricular end-diastolic pressure decreased by 48.9% (p = 0.01). Mean arterial pressure increased by 68.8% (p = 0.01) and cardiac output by 44.2% (p = 0.01). Histologic studies disclosed no morphologic damage to the pulmonary artery or valve in the specimens analyzed. In addition, these results were compared with those in a second group of seven swine in which right ventricular failure was induced by right ventriculotomy and a balloon was placed into the left pulmonary artery but not activated. These results of short-term counterpulsation should be evaluated in a longer term model so as to mimic more closely the clinical setting. If the hemodynamic benefits are duplicated, intrapulmonary balloon counterpulsation should be considered as a simple, effective device when right ventricular failure develops after right ventriculotomy. It effectively improves right ventricular function without damaging the pulmonary artery or valve.

Minimizing the stress that nurses experience after a promotion requires an understanding of the dynamics of fledgling managers. Middle roles such as theirs are inherently difficult. We need to be aware of what can happen in moving up the ladder--factors such as loneliness, other unmet needs and unclear job descriptions evoke unique stresses. Knowing these factors, nursing administrators can plan their programs to better support their managers in transition.

Serial serum specimens from 149 patients with clinically diagnosed hepatitis were tested for five hepatitis B serological markers: hepatitis B surface antigen and its antibody (anti-HBs); hepatitis B e-antigen and its antibody (anti-HBe); and antibody to hepatitis B core antigen (anti-HBc). The times of appearance, disappearance, and persistence of these markers were used to differentiate various serological profiles obtained from the study. Four distinctive profiles were found to be associated with acute hepatitis B followed by recovery, and three with chronic hepatitis. These serologic profiles were assessed as diagnostic and prognostic guides for clinical management of the disease.

Seventeen consecutive patients with double-chambered right ventricles underwent intracardiac repair from February, 1985 through March, 1989. Nine patients had an associated ventricular septal defect. A transatrial approach to the repair was utilized in all patients. Early postoperative right ventricular-to-left ventricular pressure ratio was a mean of 0.29, range 0.21 to 0.37. There were no hospital or late deaths. We conclude that transatrial repair of a double-chambered right ventricle can be accomplished routinely with satisfactory results.

Repair of an atrioventricular septal defect was performed in 134 patients from 1973 to 1985. Interventricular communication was present in 54 (40%) and none was present in 80 (60%). There were 12 hospital deaths (9%; 70% confidence limits 6%-12%). Earlier date of operation (p = 0.03) and younger age at repair (p = 0.005) were incremental risk factors for hospital death after repair of partial atrioventricular septal defect. Smaller size (p = 0.003) and longer cross-clamp time (p = 0.002) were risk factors for hospital death in those patients with complete atrioventricular septal defect. Higher preoperative pulmonary vascular resistance was a risk factor for death in both groups (p = 0.007). The 10 year actuarial survival rate was 82% overall. Increasing preoperative severity of left atrioventricular valve incompetence was not a risk factor for early (p = 0.001) or late (p = 0.002) death. The 10 year actuarial freedom from reoperation after repair of partial atrioventricular defects was 85%, and it was 68% for complete atrioventricular defects (p = 0.06). We conclude that the intermediate term results after repair of atrioventricular septal defects are good. Incompetence of the left atrioventricular valve has apparently been neutralized as a risk factor for hospital death in this series. However, the durability of the repair has been disappointing. A policy of earlier repair has been adopted and should improve hospital mortality and permit better preservation of the atrioventricular valve structures with resultant improved late term functional status.

A total of 688 patients received 808 Björk-Shiley prostheses during a 5 year span. Cumulative duration of follow-up totaled 1175.4 patient-years (1368 valve-years). Linearized rates in percent per patient-year for valve-related events (95% confidence limits) were: strut fracture, 0.5 (0.00 to 1.03); infective endocarditis, 0.94 (0.39 to 1.49); thromboembolism, 2.2 (1.37 to 3.052); valve impingement, 0.3 (0.00 to 0.77); and anticoagulant-related hemorrhage, 3.1 (2.15 to 4.14). No valve thrombosis occurred. Actuarial patient survival, including in-hospital mortality, was: aortic valve replacement, 79.8 +/- 3.4%; mitral valve replacement, 71.7 +/- 4.9%; double valve replacement, 59.8 +/- 7.5%. Incremental risk factors for death were age over 65 (p = .001), preoperative infective endocarditis (p = .04), and associated procedures (p = .0002). Although this prosthesis carries a low risk of infective endocarditis and thromboembolism, concern has been raised regarding its structural integrity.

The pulmonary valve homograft (PH) has been reported to have potential advantages over the aortic valve homograft, including a larger diameter, a thinner wall, and decreased intrinsic calcification. From January 16, 1986, to July 14, 1987, eight consecutive patients underwent repair of congenital cardiac anomalies using a cryopreserved PH. Patients ranged in age from 18 months to 32 years. Diagnoses included tetralogy of Fallot with pulmonary atresia (3 patients); tetralogy with absent pulmonary valve (1 patient); corrected transposition with pulmonic stenosis (1 patient); transposition of the great arteries, ventricular septal defect, and pulmonic stenosis (2 patients); and double-outlet right ventricle with pulmonic stenosis (1 patient). The PH was implanted orthotopically in the patient with absent pulmonary valve, and in the other 7 it was placed as a valved extracardiac conduit. Two of the tetralogy patients with severe bifurcational pulmonary stenosis and another with nonconfluent pulmonary arteries and origin of the left pulmonary artery from a patent ductus arteriosus had their repairs facilitated using the branching pulmonary arterial portion of the PH. There were no hospital or posthospital deaths. Postrepair right ventricular to left ventricular systolic pressure ratios were a mean of 0.35 at 18 hours postoperatively (range, 0.21-0.61). All patients were studied with Doppler and echocardiography after repair. The mean gradient across the PH was 9 mm Hg (range, 2-27 mm Hg), and no pulmonary valve incompetence was present. One patient (12.5%) required reoperation seven months after repair for conduit revision due to compression by the sternum and is now well.(ABSTRACT TRUNCATED AT 250 WORDS)

Connection of an anomalous left superior vena cava to the left atrium is an uncommon lesion that is usually associated with other complex intracardiac malformations. A technique for diverting the anomalous caval return along the left atrial roof and into the right atrium is presented. This simple tunnel method avoids potential obstruction to systemic and pulmonary venous return and leaves viable atrial tissue comprising the majority of the new pathway. The technique and results in 7 patients are described.

In the April 1983 issue of JONA, the authors identified four major causes and the costs of promotion trauma. Nursing administrators can both minimize this trauma and its unnecessary cost by building awareness of the transition process, clarifying roles and expectations, and attending to the promoted employee's needs by developing a systematic program of manager care. Such support and encouragement can help promotees achieve the expected levels of competency in a shorter period of time, with less personal anguish. This article will help nursing administrators to develop a concept of manager care buttressed with programs for orientation of new managers, skills of mentoring, and systems of monitoring.

Patients undergoing operation for combined mitral and tricuspid valvular disease may have the repair performed through the right atrium and the interatrial septum. Although the transseptal method is an established procedure, recent reports have stressed the disadvantages of this operation and underscored the risk of the development of complete atrioventricular dissociation with this technique. A review of our results with this approach confirms the efficacy and safety of this method. The surgical protocols used are described.

To ascertain incremental risk factors for in-hospital and late mortality of patients undergoing AVR with the bovine pericardial valve, multiple variables were analyzed in a group of 240 patients undergoing AVR between 1977 and 1983. Follow-up totaled 12,023 patient-months (mean, 52.7 +/- 1.7 patient-months) and was 100 percent complete. Univariate analysis of incremental risk factors for in-hospital mortality identified the following: age over 60 years (p = 0.015); and advanced preoperative NYHA class (p = 0.003). Multivariate analysis of risk factors for in-hospital mortality identified the following: age (p = 0.038); NYHA class (p = 0.018); and year of operation (p = 0.049). Incremental risk factors for late mortality were identified as age (p = 0.003), year of operation (p = 0.003), concomitant procedure (p = 0.047), and valvular lesion (regurgitation) (p = 0.053). Actuarial survival of patients (+/- SE) was 87 +/- 2 percent, 75 +/- 3 percent, and 61 +/- 5 percent at 2, 5, and 8.7 years, respectively. The actuarial survival of patients experiencing valve-related events was 62.6 +/- 10.1 percent at 8.7 years, compared to 55.4 +/- 7 percent for those who did not (p = 0.38).

Actuarial curves and linearized rates of occurrence are statistical functions that traditionally have been used to evaluate freedom from, or incidence of, valve-related events that occur as a result of aortic valve replacement (AVR); however, the instantaneous risk of an event can be more precisely pinpointed by the use of a time-related hazard function. This function was used to analyze 240 cases involving patients who underwent AVR with the Ionescu-Shiley bovine pericardial valve. Follow-up was for 10 years. The period from 60 to 70 months after implantation was apparently critical, since specific and cumulative events (intrinsic tissue failure, thromboembolism, prosthetic valve endocarditis, cumulated events, and death due to valve-related events) peaked during this period. We suspect important degenerative bioprosthetic changes take place during this period and are the cause, in part, for this pattern. In an effort to reduce the incidence of thromboembolism, close observation, and probably antiplatelet drug administration, should be initiated 60 months after implantation of this valve.

The 1 month, 1 year, and 10 year actuarial survival rates after operation among 99 consecutive patients with discordant atrioventricular connection who underwent intracardiac repair are 86%, 75%, and 68%, respectively. The hazard function of death declines rapidly after operation to reach a low level 6 months postoperatively, and it becomes indistinguishable from that of a matched general population by 4 years. Risk factors for premature death include double-outlet right ventricle, complete heart block preoperatively or developing perioperatively, very young or older (greater than 25 years) age, a high hematocrit value, and earlier date of operation. The last indicates improvement in results in recent years. Eleven (11%) of 99 patients had complete heart block preoperatively, and 23 (26% of 88) developed it perioperatively. Patients with discordant ventriculoarterial connection (i.e., corrected transposition) had a lesser probability of developing heart block after repair than did those with other ventriculoarterial connections. Seventeen (17%) patients required tricuspid (pulmonary venous) valve replacement or repair at the original intracardiac operation, and eight additional patients developed important incompetence after repair. Among the risk factors for incompetence was an Ebstein-like anomaly of the tricuspid valve. Reoperations (three) for conduit obstruction have been no more common than in patients with concordant atrioventricular connection. Fifty-seven (81%) of 70 surviving patients are in New York Heart Association Class I and 12 (17%) in Class II. This, and the single-phase hazard function, indicate that the overall results of cardiac repair in patients with atrioventricular discordant connection could become excellent if the early risks were overcome.

To determine if anticoagulation therapy is necessary after valve replacement with the St. Jude Medical prosthesis in young subjects, 30 consecutive patients were studied. They ranged in age from 4 to 20 years, and each had undergone valve replacement some time between February, 1982, and June, 1984. There was 1 hospital death (3.3%; 70% confidence limits [CL] = 0.4% to 10.9%). The 29 hospital survivors were treated with aspirin and dipyridamole. All patients were followed up. There were 5 late deaths (17.2%; 70% CL = 9% to 27%), at a mean of 8 months postoperatively. Follow-up revealed that 7 thromboembolic events occurred in 7 of the hospital survivors (24.1%; 70% CL = 15% to 35%). Hemiparesis occurred in 1 patient, and documented valve thrombosis and death occurred in another. Transient sensorimotor deficits were found in the 5 other patients. Prosthetic valve endocarditis developed in 1 hospital survivor (3.5%; 70% CL = 0.4% to 11%) and resulted in late death. There were no reoperations in the hospital survivors. We conclude that the St. Jude Medical prosthesis is useful for valve replacement in the young because of its low profile, durability, and hemodynamic characteristics. However, we recommend that these patients receive full anticoagulation therapy.

Twenty-four consecutive patients with the tetralogy of Fallot underwent repair from March 25, 1985 to March 24, 1986. Correction was achieved without a ventriculotomy in 8 patients, necessitated a minimal ventriculotomy in 8, and a formal right ventriculotomy incision was required in the other 8. There were no early or late phase deaths-0% (70% C.L. 0%-7%). Post repair right ventricular to left ventricular pressure ratios were not significantly different between the three groups (p = 0.85). The 16 patients (66%) who underwent repair without a formal ventriculotomy were found to have severe hypertrophy of the infundibular septum as the primary etiology for right ventricular outflow tract obstruction. The other 8 patients (34%), who required a transventricular approach to the repair, were all found to have predominantly hypoplasia of the outflow tract and not hypertrophy. We conclude that repair of the tetralogy of Fallot can frequently be accomplished with no or a minimal ventriculotomy, and the results are satisfactory. Herein is described the operative approach to this procedure.

From January 1986 to January 1987, 116 Mitroflow pericardial valves were implanted in 98 patients at our center. Ages ranged from 10 to 83 years (mean, 64.9 years). Forty-three patients (44%) were in New York Heart Association Functional Class III or IV at the time of surgery. Twelve patients (12%) had undergone prior cardiac surgery. Ten hospital deaths (10%) (70% Confidence Limits, 7% to 14%) occurred. Incremental risk factors for hospital death included female gender (p = 0.08), higher functional class preoperatively (p = 0.04), and longer cardiopulmonary bypass time (p = 0.05). All 88 hospital survivors (100%) were followed for 6 to 13 months (mean, 9 months) after repair. Two late deaths (2.3%) occurred: 1 at 1.5 months from subacute cardiac failure, and another at 5 months from non-valve-related sepsis. Actuarial survival at 15 months was 87% +/- 5.5%. No late reoperations were performed. One patient who exhibited mild mitral incompetence 4 months postoperatively is being followed closely. Two patients (2.3%) who were not on anticoagulant therapy developed thromboembolic events in association with chronic atrial fibrillation. No patient has had hemolysis or infective endocarditis. All patients are now in Functional Class I or II. Our early-phase assessment of this valve reveals a low risk of valve-related events. Its low-profile frame and wide, flexible sewing ring make this prosthesis technically satisfactory for implantation. Continuing close follow-up will determine intermediate-and late-phase hazards.

Of 1,193 consecutive pediatric (less than 18 years) patients undergoing intracardiac repair from 1975 to 1984, 38 (3.2%) developed surgically induced complete heart block and were treated by permanent pacemaker implantation. Anomalies included complete atrioventricular septal defect = 9 (24%), simple ventricular septal defect = 9 (24%), atrioventricular discordant connection = 8 (212), tetralogy of Fallot = 7 (182), and other complex anomalies = 5 (13%). There were no hospital deaths. follow-up was 100% complete. There were six late deaths = 16%. Actuarial survival was 79 + 9% at 10 years. None of the late deaths were related to disturbance of cardiac rhythm or pacemaker system failure. Twelve patients (32%), required 27 reoperations for various types of pacemaker system failure. Indications for reoperation included: lead failure (44%). Pulse generator failure (44%), and wound sepsis (12%). Actuarial freedom from any pacemaker related reoperation was 50 + 16% at 48 months and 25 + 15% at 96 months. Only first reoperation was found to be an incremental risk factor for subsequent reoperation (p = 0.03). Surgical heart block has been neutralized as a risk factor for hospital death after repair of congenital cardiac defects. The risk of the development of surgical heart block now approaches zero, as indicated by a decreased incidence (1 of 401 = 0.25%) in our institution from 1985 to 1987, as compared to the era 1975 to 1984 (p = 0.001).