Brandenburg, Robert O.

During pregnancy, when surgically reparable heart disease can no longer be medically manged, open- or closed-heart surgery is the procedure of choice without prior therapeutic abortion. Cyanotic congenital heart disease in a pregnant patient when completely correctable surgically may be an indication for surgery in itself. Available data suggest that pregnancy per se does not increase the maternal risk of heart surgery with use of extracorporeal circulation. Fetal mortality in our series was 33%.

Postoperative embolism occurred in 35 of 546 patients traced for 2 to 15 years after surgical repair of uncomplicated ASD. A total of 58 embolic episodes occurred, resulting in the death of 11 of these 35 patients. The incidence of embolism was not significantly related to the technique used for surgical repair. Six of the nine patients who had had a preoperative embolism also had an embolism in the postoperative period. The most significant factors associated with an increased risk of postoperative embolism were increased age of the patient, atrial fibrillation, and pulmonary hypertension, all of which are interrelated: seventy-seven per cent (27/35) of patients having a postoperative embolism had either atrial fibrillation or pulmonary hypertension, and 77% (27/35) of patients with postoperative embolism were more than 40 years old at the time of the first embolism. Because actuarial analysis suggests that 30% of patients more than 40 years of age who have atrial fibrillation after repair of ASD may have an embolism within 10 years postoperatively, continuation of anticoagulation therapy indefinitely in these patients is suggested. The highest risk of embolism occurs in the early postoperative period, suggesting the advisability of anticoagulation therapy for all adult patients during convalescence.

The incidence of thromboembolism after insertion of prosthetic cardiac valves is related to the type of prosthesis and in the cases reviewed here was highest for the ball-valve prosthesis. The risk of thromboembolism was studied by constructing actuarial curves showing the proportion of patients with embolism at increasing time intervals postoperatively. Such curves for the patients studied suggest that the risk of thromboembolism diminishes with time, particularly by the third postoperative year. The risk was remarkably similar for patients having aortic, mitral, and multiplevalve replacements, being 15% for the first 6 postoperative months, another 8% for the next 6 months, and another 20% for the next 2 years. Emboli lodged in cerebral, coronary, renal, and other sites in these patients in diminishing frequency. The risk of fatality averaged 15%. None of the nonfatal embolisms resulted in significant continuing disability, save for 7% of the cerebral embolisms. A beneficial effect of anticoagulation was demonstrated for patients having replacement of the aortic valve with a ball-valve prosthesis, particularly when this treatment was carefully controlled. In the latter group, the risk of thromboembolism was less than 5% 2 years postoperatively.

1. The results of closure of atrial septal defects in 155 patients over 45 years of age have been reviewed. 2. The over-all operative mortality rate was 6.5%; the operative mortality rate in the last 48 patients was 2.1%. 3. The late results of operation were considered excellent in 83% and good in 13% of the patients. 4. Long-term follow-up studies suggest that patients have significantly longer survival with closure of their defects. 5. It is concluded that operation for atrial septal defect in the older patient may be done at a low risk with an excellent prospect of a good, long-term result in almost all cases.

Of 128 children with anatomically confirmed interatrial communications 74 had ostium secundum, 37 had ostium primum defects, 5 had common atrium, and 12 had total anomalous pulmonary venous connection. Analysis of the medical history, physical examination, roentgenogram, and electrocardiogram resulted in accurate diagnosis in most instances. In 6 of the 128 patients the proper diagnosis was not made: 3 infants with total anomalous pulmonary venous connection died within a few hours after admission to the hospital and did not have proper diagnostic evaluation; the condition of 3 other patients with ostium secundum defects was misdiagnosed as ostium primum defect before surgical treatment. In patients with ostium secundum and ostium primum defects the symptoms, signs, roentgenologic data, and findings at cardiac catheterization are similar, but differences in respect to the electrocardiograms are striking when the latter are subjected to vectorial analysis. The QRS loop is clockwise in the presence of ostium secundum defect and counterclockwise when ostium primum defect is at hand. Clinical and roentgenologic manifestations also are noted among patients with common atrium and total anomalous pulmonary venous connection, and the findings at cardiac catheterization likewise may be similar, but the electrocardiographic differences are significant. The QRS loop is counterclockwise in patients with common atrium and clockwise in patients with total anomalous pulmonary venous connection.

Analysis of accumulated experience with the repair of atrial septal defect in 119 adults has revealed several factors determinable preoperatively that appear to have a strong influence on the operative risk. These factors are related to the presence of pulmonary vascular disease or heart failure and contribute importantly to the selection of patients for operation.