Citations

In the case of idiopathic fibrous retroperitonitis presented, the only symptoms were those of arterial insufficiency of the lower limbs and testicular and inguinal pain of uncertain origin. Relief of claudication and return of normal pulsations were achieved after surgical lysis of the common iliac arteries and the terminal segment of the aorta. Numerous reports in the literature indicate that idiopathic fibrous retroperitonitis is not rare but retroperitoneal arterial obstruction by the fibrous plaque is apparently unusual, and intermittent claudication without urinary symptoms is unique. Idiopathic fibrous retroperitonitis, therefore, should be included in the differential diagnosis of the causes of intermittent claudication. Although the aortogram may not permit differentiation of arteriosclerosis obliterans from external compression of the aorta by this fibrosing process, the excretory urogram should be helpful in making or excluding the diagnosis. Treatment is primarily surgical with thorough excision of the fibrous mass and with ureteral transplantation; vascular resection or bypass grafting is not necessary. Advisability of postoperative roentgen and adrenal corticoid therapy is not clearly established.

Cardiac output and related variables were measured in patients after open intracardiac surgery. Factors affecting cardiac performance during this period were the original anatomic lesions, the details of the operative procedure, ventricular-outflow resistance, transfusion of blood, the stage of convalescence, and digitalis. In postoperative patients, metabolic rate, level of hemoglobin, and level of oxygen in arterial blood varied more widely and acutely than in nonsurgical patients, resulting in a less predictable relation between cardiac output and oxygen saturation of mixed venous blood. Therapeutic applications of these observations were discussed.

Calcific emboli were observed in 38 of 62 patients (61 per cent) who died at varying intervals following aortic valvotomy for calcific aortic stenosis. Major coronary embolization occurred in 10 patients (16 per cent) and was considered to be a major cause of death of four patients. Minor coronary embolization occurred in 33 patients (53 per cent) and was not directly implicated as a cause of death in any patient. Calcific emboli occurred to other organs in eight patients (13 per cent). The technics instituted for reducing the incidence of embolization—occlusion of coronary ostia, diligence in detection and removal of any debris, and final aspiration of the left ventricle—appeared to have had a favorable effect.

The major parts of the atrioventricular conduction system of the human heart were traced in 21 instances of ventricular septal defect: 19 were examples of variously located uncomplicated ventricular septal defects and two of the tetralogy of Fallot. In the presence of a ventricular septal defect, the conduction system was found to have a normal course, except when the ventricular septal defect lay in a position normally occupied by the conduction system. In each specimen with a defect posterior and inferior to the crista supraventricularis, the conduction system occupied a position posterior and inferior to the defect. In no instance did the conduction system occupy a position superior to a defect of this type. Defects located in the posterobasal portion of the muscular part of the ventricular septum sometimes were posterior to the main parts of the conduction system, so that the conduction tissue was related to the anterior edge of the defect. No example of a defect lying superior to the crista supraventricularis was studied. In our two examples of tetralogy of Fallot, the position of the conduction system was essentially similar to that occurring in the usual variety of ventricular septal defect, that is, posterior and inferior to the crista supraventricularis.

Physiologic studies have been carried out during the first 3 days after intracardiac repair of tetralogy of Fallot. All patients survived. The ratio between systolic pressure in right ventricle and a systemic artery was 0.7 or less in all cases and did not vary significantly during the period of study. Residual left-to-right shunts of moderate degree were demonstrated in three patients (repaired with Teflon prostheses). In one of these three, no definite evidence of shunt could be found 2 weeks after operation. Additional abnormal circulatory pathways exist in these patients. Clear evidence was obtained of left-to-right shunting through aorticopulmonary collateral connections in one case. Systemic index was usually below normal or in the low normal range. It was usually lower on the second and third postoperative days than on the first postoperative day. Left atrial pressure was sometimes strikingly higher than right atrial pressure 30 minutes after repair, but not thereafter. Pulmonary vascular resistance was normal or slightly elevated. Gas exchange and management were adequate to maintain normal or near normal oxygen and carbon dioxide levels in arterial blood. Mild metabolic acidosis existed on the first 2 days, but had generally cleared by the third day. The implications of these data are discussed relative to ventricular function and performance, adequacy and technic of surgical repair, administration of blood after operation, and the state of preparedness in the lung and left ventricle in patients with tetralogy of Fallot.

Recently we have studied the role of surgical treatment of patients having occlusive cerebrovascular disease, particularly incipient stroke (or focal intermittent cerebrovascular insufficiency). This report concerns 35 pa-patients with incipient stroke in whom circulation was restored to normal by operation on an artery in an attempt to prevent transient ischemic episodes and cerebral infarction. Since all of the patients were neurologically normal at the time of the surgical procedure, we were concerned primarily with the risk of [see tablein the PDF file] the procedure, particularly in terms of cerebral infarction. The operative mortality rate was 8.5 per cent (three patients). Six patients (17 per cent) sustained cerebral infarcts. Four of these had mild neurologic deficits, usually consisting of clumsiness and mildly reduced discriminatory sensation in one hand; one had a severe neurologic deficit, and one died. Evidence shows that at least some of these infarcts resulted from emboli arising from the operative site at the time of or shortly after the operation. The results of long-term follow-up revealed that 66 per cent of the surgically treated patients were normal compared to 25 per cent of a contrast group; and 17 per cent of the treated patients had suffered cerebral infarcts compared to 40 per cent of the contrast group. The long-term results are thus similar to the immediate postoperative results. These findings simply indicate that an operated patient's prognosis was good over the long term if the cerebral ischemic episodes were relieved and if he sustained no complications from the surgical procedure.