Severe pathological changes in the cardiac valves are often observed at an early age in children in the developing countries. Mitral stenosis is best managed by closed commissurotomy. However, mitral insufficiency, aortic insufficiency and tricuspid lesions may lead to life-threatening hemodynamic effects which necessitate valve replacement. This differs from experience in the developed countries where surgery for rheumatic valvular disease is limited to the adult. Our experience includes 33 children aged 5 to 16 years. Twenty-four children underwent single valve replacement, eight had two valves replaced and one had triple valve replacement. All were classified Grade IV or late Grade III (New York Heart Association). Four children had to be operated on despite known rheumatic activity. Two children in shock and pulmonary edema underwent emergency operation. There were two hospital deaths and eight late deaths. Patients have been followed for up to eight years. Twenty children are now classified as Grade I and lead completely normal lives and the remaining three are classified as Grade II. Postoperative catheterization studies have documented improvement from severe preoperative hemodynamic changes to near normal values at rest after operation. The cardiothoracic ratio has decreased impressively. We conclude that the natural history of rheumatic heart disease in children with severely damaged heart valves is favorably modified by valve replacement.

Adolescent↗

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Surgery for tricuspid valve disease.

Sixty patients underwent repair or replacement of the tricuspid valve, 58 for acquired and two for congenital lesions. In 59 of the cases, the tricuspid surgery formed part of multiple valve surgery. Preoperatively, 33 patients (55%) were in New York Heart Association class IV and 25 in class III functional capacity. The tricuspid valve was replaced in 42 patients and repaired in 18. Forty-seven patients (78%) survived operation, but 10 of these died during a follow-up period of two to seven years. Thirty-four of the 37 long-term survivors show marked improvement. Operative mortality was 26% for tricuspid valve replacement and 11% for repair; late mortality was 14% and 22%, respectively. It should be stressed that the tricuspid valve replacement group consisted of patients whose preoperative condition was worse and whose valvular pathology was more severe than that of those who had tricuspid repair. In view of this, and the better long-term results of tricuspid valve replacement, it is concluded that the procedure of choice for serious organic disease of the tricuspid valve is valve replacement.

Adolescent↗

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Blast injury of the chest. A review of the problem and its treatment.

Primary blast injury of the chest is a potentially lethal entity. Immersion blast is even more damaging than that incurred out of water. Illustrative cases of a group of patients injured by an underwater explosion are presented. The pathogenesis, clinical manifestations and diagnosis of the entity are described. Complications include arterial occlusion by air emboli, affecting the central nervous system and heart, and respiratory insufficiency and failure. Conventional management of respiratory failure with intermittent positive pressure breathing may further aggravate the air embolism. An attempt to circumvent this conflict with the aid of the membrane oxygenator and hyperbaric facilities is discussed. It is suggested that expeditious compression with oxygen in a one-man chamber might be the most favorable emergency measure, to be followed later by more extensive and definitive treatment in a major hospital equipped for such contingencies.

Blast Injuries↗

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Delayed sternal closure following cardiac operations.

In 13 patients, sternal closure was delayed at the end of open heart procedures. Seven patients underwent coronary artery bypass surgery (CAB), 5 valve replacements, and one left ventricular aneurysmectomy and closure of post myocardial infarction VSD. In all, primary closure of the sternum was considered impossible or inadvisable. The major indications for delaying sternal closure were: cardiac dilatation with tamponade-like behaviour upon attempted sternal closure (8 patients); intractable bleeding (2); intractable arrhythmia (1); insertion of mediastinal assist devices (3) and intraoperative non-cardiogenic pulmonary edema (1). In all, only the skin was closed. Delayed sternal closure (DSC) was performed 36-120 hours later on 10 of the patients, when their condition had stabilized. Nine patients are long term survivors. None of these patients has developed mediastinitis, wound infection, osteomyelitis or instability of the sternum. The judicious use of DSC in selected situations has several advantages: hemodynamic deterioration from pressure upon the heart may be prevented; a quick access to the heart in case of tamponade or intractable arrhythmia is obtained; insertion of mediastinal assist devices is facilitated. With careful technique the risk of infection is low.

Adult↗

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Improved functional results following myocardial revascularization in patients with left ventricular dysfunction.

Between February 1978 and October 1982, 40 patients with preoperative ejection fraction (EF) of 0.35 or less underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were seven late deaths (3 cardiac and 4 non-cardiac). The five-year cardiac actuarial survival rate was 74% +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.

Actuarial Analysis↗

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