Biomedical subjects
Publications and source records attributed to J S Wright.
We describe a patient in whom permanent endocardial pacing was accomplished by passage of the electrode through a porcine bioprosthetic tricuspid valve, thereby obviating the need for a second thoracotomy. After 8 years of follow-up, the patient continues to do well with satisfactory pacing and bioprosthetic valve function at the first change of pulse generator.
One hundred and twenty-two patients have been followed for five to eight years after cardiac revascularization. The over-all mortality of 2% compares closely with the expected mortality of a normal population. Seventy percent of patients remain essentially angina free at an average follow-up period of six years. Late infarction, assuming all "coronary" deaths were so caused, occurred at a rate of 3.7% yearly.
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Thirty-two children were reviewed following closure of ventricular septal defect in infancy. Fifteen had undergone continuous perfusion and 17 had been subjected to core cooling followed by deep hypothermic arrest. Parental and professional evaluations of intellectual and motor development, at periods between 7 and 72 months following operation, suggest that there is a higher incidence of developmental abnormality in the subgroup treated with deep hypothermic arrest.
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Staphylococcal endocarditis in a drug addict was controlled only after excision of the tricuspid valve. Total absence of the tricuspid valve was tolerated well for 18 months, at which time deteriorating liver function prompted the insertion of a bioprosthetic valve into the tricuspid ring. The haemodynamic and clinical results after two years of follow-up have been excellent.
Over a 10 year period, 185 patients have been treated for patent ductus, including nine premature infants with a respiratory distress syndrome. Thirty-five other infants have had duct obliteration during the neonatal period, the incidation for surgery being intractable heart failure. Six of 18 adults had calcification or aneurysm in the duct region. three of these required extracorporeal circulation for duct control and closure. The remaining patients were from 1 to 18 years of age and underwent elective duct obliteration. Double ligation of the duct is regarded as the simplest, safest, and quickest technique generally applicable. Special techniques are required for fragile, broad, calcified, hypertensive, and conical ducts.
Glutaraldehyde preservation of heterograft valves has increased their durability. Sixty-nine Hancock prostheses have been implanted, 30 in the mitral position and 39 in the aortic position. Anticoagulants have not been administered. There has been one important thromboembolic complication and periprosthetic mitral incompetence has occurred in three instances, but prosthetic incompetence has not developed. Two asymptomatic aortic diastolic murmurs have been noted. After a follow-up ranging between two and 19 months, it appears that the Hancock prosthesis offers a valuable alternative to mechanical valve replacement and anticoagulants are not required as a routine.
Dopamine hydrochloride (Intropin) has been used in the postoperative management of open-heart surgical patients, both children and adults. It has been associated with a very low incidence of undesirable responses and a high frequency of circulatory improvement associated with diuresis. Its administration requires careful control of infusion rate and measurement of response. In the dosages employed, it has been free of most of the undesirable side effects of other commonly used catecholamines.
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Experience has shown that successful cardio-pulmonary bypass depends upon an efficient oxygenator which causes minimum blood damage. Experience with 1,600 Lande'-Edwards membrane oxygenators in more than 1,000 patients has led to the development of a simple and safe routine for their use in open heart surgery. The circuitry, method of preparation for perfusion, and management of perfusion are described in detail.
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A series of 55 surgically treated cases of coarctation of the thoracic aorta is presented with an operative mortality of 5-4%. The problems encountered in infants are discussed and postoperative complications in adults and children detailed. The advantages of patch graft aortoplasty over resection and end-to-end anastomosis are described.
Myocardial revascularization surgery has proved most effective in relieving angina pectoris. Its influence on the survival of patients with coronary atherosclerosis, however, remains a contentious subject and one which may not be finally settled for years. The follow-up results of the first 196 patients to undergo direct coronary artery surgery at the Prince Henry Hospital support those who claim increased longevity as one of its benefits.
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In infants and piglets subjected to periods of circulatory arrest at 20 degrees C there was close correlation between duration of arrest and delay in return of electroencephalographic activity. Post mortem studies demonstrated histological evidence of brain damage in patients after circulatory arrest at 20 degrees C. Similar histological changes were demonstrated in piglets, including some who had complete E.E.G. and clinical recovery from circulatory arrest.
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Two patients sustained severe circulatory inadequacy before and during thoracotomy for coronary surgery. Both patients were promptly cote cooled to between 20 degrees and 25 degrees C. After coronary surgery, each patient was rewarmed and the operation was terminated uneventfully in each case, No important cerebral deficit was apparent despite periods of circulatory insufficiency and arrest which were well beyond the usually accepted limits. It is suggested that prompt core cooling may exert a protective effect in this context.