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Between October 1991 and March 1993, 281 consecutive patients underwent non-emergency isolated coronary artery surgery under the care of one surgeon (A.R.). They were prospectively randomised to receive either intermittent cold (Group I-144 patients) or continuous warm (Group II-137 patients) blood cardioplegia for myocardial protection. There were no significant differences in clinical outcome between the two groups, as judged by operative mortality, rates of peri-operative myocardial infarction, blood loss, need for circulatory support, post-operative neurological deficit, or duration of intensive care or hospital stay. However, sinus rhythm returned spontaneously with greater frequency (91.2% vs 45.8%, P < 0.001) in Group II patients. There was greater transmyocardial oxidative stress in Group I patients, as evidenced by a significant rise in oxidised glutathione in coronary sinus blood on myocardial reperfusion. Also, the serum CKMb isoenzyme level 2 h post-operatively was significantly raised in Group I patients, although this difference had disappeared by the day after surgery. In conclusion this preliminary report suggests that continuous warm blood cardioplegia provides comparable myocardial protection to that achieved with standard hypothermic techniques in patients undergoing coronary artery surgery.

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Since 1983 percutaneous balloon dilatation of the right ventricular outflow tract has been performed as an alternative to surgical palliation in selected cases of tetralogy of Fallot at the Royal Liverpool Children's Hospital. From 31 December 1984 to 31 December 1988, 27 of these patients underwent subsequent surgical correction. Age at operation ranged from 7 to 58 months (median 2.7 years). The mean interval between balloon dilatation and correction was 15.6 months (range 3-39 months). Two patients had a systemic pulmonary shunt operation performed before dilatation and a further five required one afterwards. Overall 20 (74%) patients had some anatomical alteration as the result of balloon dilatation, while in seven (26%) there was no discernible change in the right ventricular outflow tract. There was no consistent relation between the ratio of balloon size to pulmonary annulus diameter and the morphological findings. Balloon dilatation may obviate the need for systemic-pulmonary shunt at the expense of some structural damage, particularly to the posterior cusp. The present data suggest that dilatation does not bring about growth of the annulus to such an extent that transannular patch is no longer needed at intracardiac repair.

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Nineteen patients with double outlet right ventricle and discordant atrioventricular connexion were studied in order to analyze their angiographic anatomy. The discordant atrioventricular connexion was parallel in 18 patients and criss-cross in one. A ventricular septal defect, present in all cases, was perimembranous in ten (50%), muscular in seven (37%), and was part of an atrioventricular septal defect in two. The defect was related spatially to the subaortic outflow in six (29%), to the subpulmonary outflow in 11 (52%), was doubly committed in one and non-committed in two. Long axial and four-chamber views of the ventriculograms were most useful for the angiographic delineation of the basic anatomy of this entity. In patients with abnormally located hearts, variations of the axial views were necessary for proper delineation of the anatomy. It is concluded that modified axial views of ventriculograms are useful for diagnosis of double outlet right ventricle and discordant atrioventricular connexions.

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Truncus arteriosus (type II) with interrupted aortic arch (type B) was successfully repaired at 11 days of age using anterior translocation of the pulmonary arteries, resection of the ductus arteriosus, and direct anastomosis between the descending aorta and truncus. This technique permitted wide reconstruction of the aortic arch and minimized the number of suture lines. It also positioned the right ventricle-pulmonary artery conduit anteriorly, which may simplify its subsequent replacement.

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A technique to overcome acquired left ventricular outflow obstruction after previous Senning (Mustard) atrial redirection operations is described.

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An isolated defect in the membranous atrioventricular septum was found in a five-year-old girl who presented with a cystic lesion in the right atrium. This type of left ventricular-right atrial communication could result from a structural abnormality of the central fibrous body in combination with arrested maturation of the membranous ventricular septum.

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Dissection was performed in 41 hearts from patients with classic tricuspid atresia so as to demonstrate the major arteries supplying the right atrium and the sinus node. A right anterior atrial artery was identified in 85.4% of the hearts, a right lateral atrial artery was seen in 68.3%, a right posterior atrial artery in 41.5%, and a left anterior atrial artery in 78.0% of the specimens. The artery to the sinus node, identified in 34 hearts, originated from the right coronary artery in 38% of the cases, from the left coronary artery in 59%, and had a dual origin in 3% of cases. The relative importance of these arteries is discussed with regard to the atriopulmonary anastomosis of the Fontan procedure. Special consideration is given to the incisions employed in different variations of this operation and the arterial distribution is compared to that found in the normal heart.

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Twenty seven months after pulmonary artery banding a boy aged two and a half developed rapidly progressive cyanosis. A periarterial abscess was found at the site of the band. Repair of the pulmonary artery and closure of the ventricular septal defect were complicated by profoundly low cardiac output and prolonged dependence on a ventilator. This near fatal complication would have been avoided by primary closure of the ventricular septal defect.

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The occurrence of neurological sequelae following cardiopulmonary bypass (CBP) surgery has stimulated interest in refining the techniques of extracorporeal circulation. Air micro-emboli originating from the oxygenator have been postulated as one source of cerebral damage. Since controversy still exists regarding the merits of bubble versus membrane oxygenators, this has prompted investigators to devise methods to determine the amount of micro-emboli produced during CPB. In this study, 27 patients undergoing CPB surgery for coronary artery disease (21) or valve replacement (6) were examined. The surgical and anaesthetic techniques were standardised in all patients except for the type of oxygenator used. A bubble oxygenator was used in 17 patients (Bentley Bio-10, William Harvey or Dideco) and a membrane oxygenator with a 25 microns filter in the remaining 10 patients (Bentley BOS CM50). Transcranial pulsed Doppler ultrasound was used to obtain blood velocity signals from the middle cerebral artery throughout CPB. A flow disturbance index (FDI) was defined which provided a representative index of the number of micro-emboli passing the ultrasound transducer. The FDI indicated the presence of gaseous micro-emboli during insertion of the aortic cannula in 22 of the 27 patients. In the 17 patients with a bubble oxygenator, the FDI ranged from 4-39. In the 10 patients with a membrane oxygenator, the FDI was always 0. Variation of gas flow rates in 3 patients with bubble oxygenators showed a change in the FDI from 4 +/- 4 at a flow rate of 2 l/min to 17 +/- 9 at 5 l/min.(ABSTRACT TRUNCATED AT 250 WORDS)

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A patient with chronic postinfarction ventricular septal defect located posteriorly is described. The right atrial approach is suggested for these defects and the operative differences between chronic and acute defects are discussed.

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The safety of coronary bypass operations after coronary reperfusion with streptokinase for acute myocardial infarction is not well documented. Therefore we studied 23 consecutive patients (mean age, 59.5 years; 22 men) undergoing bypass operations a median of 5 days (range, 1 to 23 days) after thrombolysis (streptokinase). The control group consisted of 169 concurrent patients of similar mean age (58.8 years) having bypass operations for standard indications. The preoperative angiographic ejection fraction was 68 +/- 14% in the control patients and 61 +/- 14% in the streptokinase group (p less than 0.05). The number of diseased vessels (70% stenosis or greater) averaged 2.6 in control and 2.3 in streptokinase patients. A previous myocardial infarction had occurred in 42% of the controls and all of the streptokinase patients. Aortic cross-clamp times did not differ between the two groups (80 +/- 35 minutes for the controls and 68 +/- 25 minutes for the streptokinase group). Cardiopulmonary bypass times were similar: 108 +/- 45 minutes in the controls versus 109 +/- 28 minutes in the streptokinase group. Grafts per patient averaged 3.7 +/- 1.5 for the controls versus 2.8 +/- 1.1 for the streptokinase patients (p less than 0.01). Difficult operative hemostasis was noted in 4% of both groups. Inotropic support was given postoperatively to 11% of the control and 13% of the streptokinase patients (p = not significant). Measured blood loss during the first 48 hours postoperatively was similar, averaging 809 ml in controls and 776 ml in the streptokinase group. Blood product replacement was also comparable: mean, 713 ml in the control group versus 759 ml in the streptokinase group.(ABSTRACT TRUNCATED AT 250 WORDS)

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Se describe un caso de fistula de arteria coronaria derecha a tronco de arteria pulmonar, en un paciente de 59 anos con historia de angor estable que se hace progresivo de lesiones coronarias, tratado en el Instituto Nacional de Cirugia Cardiaca. Se discute brevemente la frecuencia de manifestaciones clinicas y de variedades anatomicas de esta patologia, finalmente se detallan los criterios aceptados hoy dia para el tratamiento de esta anomalia, concluyendo, en base a revision de la literatura que: 1 - La fistula debe ser obliterada una vez realizado el diagnostico debido a sus posibles complicaciones: 2 - La reparacion se rige por la forma anatomica de presentacion; 3 - El cierre intracavitario del ostium fistuloso es la forma de asegurar una obliteracion completa; 4 - El uso de CEC para esto ultimo y para aquellas de dificil asceso, debe tenerse en cuenta

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Se analiza la experiencia en el Instituto Nacional de Cirugia Cardiaca en cirugia de revascularizacion miocardica en el periodo de un ano - agosto de 1980 a julio de 1981 Se evaluan los resultados en relacion a la mortalidad operatoria - es decir, la mortalidad en el periodo de treinta dias del postoperatorio. La mortalidad operatoria registrada en dicho periodo fue del 2,85%.3 muertes en 105 pacientes - lo que resulta compatible con los resultados internacionalmente aceptados en 1981. Se analizan los distintos factores considerados predictores de mortalidad operatoria en cirugia coronaria

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Se presentan tres casos de operaciones correctivas para Tetralogia de Fallot, practicadas en pacientes portadores de una anastomosis paliativa tipo Blalock-Taussig Se analizan las caracteristicas clinicas y paraclinicas y se describen las metodologias quirurgicas empleadas en su tratamiento. Se expone la evolucion postoperatoria inmediata y alejada, enfatizando la mortalidad nula y la remision sintomatica obtenida en todos los casos. Se discuten diversas comunicaciones, especialmente en lo referente a: evolucion de los conceptos sobre el tratamiento quirurgico de la Tetralogia de Fallot; resultados; mortalidad pautas de indicacion de cirugia paliativa y correctiva. Se puntualizan los criterios utilizados por nuestro grupo de trabajo en la actualidad

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