Showing papers in "Texas Heart Institute Journal in 1993"

Immunochemical identification of human endothelial cells on the lining of a ventricular assist device.

Abstract: We are studying the biologic (pseudointimal) lining that forms in the HeartMate (Thermo Cardiosystems, Inc.; Woburn, Massachusetts, USA), a left ventricular assist device with a pusher-plate blood pump, housed in solid titanium with uniquely textured blood-contacting surfaces. Sintered titanium microspheres cover the rigid surface, and integrally textured polyurethane lines the flexing diaphragm. The texture of the blood-contacting surfaces is designed to encourage formation of a biologic pseudointimal lining, which greatly reduces the risk of thromboembolic complications. We performed immunochemical analyses to characterize precisely the pseudointimal lining. Samples were taken from 2 explanted pumps; 1 had supported a patient for 132 days and the other, 189 days. The samples were cultured to detect factor-VIII-related antigen (von Willebrand factor), acetyl low-density lipoprotein receptors, smooth-muscle-cell actin, and surface adhesion molecules specific for monocytes/macrophages. Macrophage cells were predominant in both pumps, but in the 2nd pump, cultures from the center of the diaphragm were positive for acetyl low-density lipoprotein receptor and von Willebrand factor, indicating the presence of endothelial cells. We believe that blood-borne endothelial cells or endothelial cell precursors were deposited on the blood-contacting surfaces, which is an important clinical finding with regard to lowering the risk of thromboembolic complications and reducing the need for systemic anticoagulation in long-term left ventricular assist device patients.

Brain-heart interactions. The neurocardiology of arrhythmia and sudden cardiac death.

Abstract: Neuroanatomic connections between the brain and the heart provide links that allow cardiac arrhythmias to occur in response to brain activation. Recognition and analysis of such links in the pathogenesis of malignant cardiac arrhythmia are emphasized in this review. Neurocardiac links have been shown to produce arrhythmia both experimentally and clinically; specific examples, including stroke, epilepsy, and environmental stress are presented. We hypothesize that the individual with a diseased heart has a greater likelihood of experiencing cardiac arrhythmia and sudden cardiac death when the neurocardiac axis is activated. Reviewing possible mechanisms of brain-related arrhythmias, we suggest that the nervous system directs the events leading to cardiac damage by raising catecholamine levels and potentially inducing arrhythmia.

Aortic valve replacement through right thoracotomy.

Abstract: There has never, to our knowledge, been a report of aortic valve replacement via a right thoracotomy. However, we recently used this approach in 2 young women with severe aortic stenosis. Exposure of the aortic valve was excellent, and we encountered neither technical difficulties nor sequelae related to the right thoracotomy. We believe that right thoracotomy provides adequate access for safe aortic valve replacement and yields cosmetically more appealing results than does median sternotomy.

Primary cardiac tumors. A clinical experience of 12 years.

Abstract: From January 1980 through December 1992, we performed operations on 31 patients with primary cardiac tumors. There were 12 male and 19 female patients; the ages ranged from 7 to 71 years (mean, 47.7 +/- 18.3 years); 29 were adults and 2 were children. Twenty-six (83.9%) of the tumors were benign, and 5 were malignant. The most frequently encountered benign tumor was myxoma (22), and the most frequently encountered malignant tumor was fibrosarcoma (4). The most common symptoms at clinical presentation were those associated with cardiac insufficiency or embolization. Definition of the tumor was accomplished in all patients by echocardiography; cardiac angiography was performed in only 4 patients. All patients survived the operative procedure and were discharged from the hospital, but 4 patients with malignant disease died within 30 days. Follow-up for myxoma patients ranged from 16 to 151 months (mean, 68.5 +/- 36 months). Among the 26 patients with benign tumors, there was 1 death, 72 months after the surgical procedure, of right-heart failure due to recurrence of the myxoma.

Use of polytetrafluoroethylene surgical membrane as a pericardial substitute in the correction of congenital heart defects.

Abstract: Patients who undergo repair of congenital heart defects have a high probability of eventually needing a repeat operation. In such cases, use of a pericardial substitute can preclude adhesion formation, thereby helping to avert the complications of a repeat sternotomy. This report describes our use of the GORE-TEX polytetrafluoroethylene surgical membrane in 321 patients who underwent repair of congenital heart disease at our hospital between May of 1989 and December of 1992 (these cases account for 37.1% of all such repairs performed during this period). The patients' ages ranged from 2 days to 31 years (mean, 5.9 years). Eighty-eight patients (27.4%) had at least 1 previous median sternotomy, and 234 (73.0%) had a moderate to high probability of reoperation. Seventy-eight patients (24.3%) received a homograft, which was positioned extracardially in 63 cases. During a maximum follow-up period of 43 months (mean, 26 +/- 5.6 months), 11 patients died, for an overall mortality of 3.4%. In no case was death attributable to membrane-related complications. Postoperative complications were encountered in 12 patients (3.7%), 10 of whom required an early repeat thoracotomy. One patient had mediastinitis, for an incidence of 0.3% (in contrast to 0.2% in 864 patients who underwent similar repair without the use of a surgical membrane). No complications were encountered in the 27 patients in whom the membrane was implanted during delayed sternal closure. Seventeen patients (5.5% of the survivors) underwent a repeat sternotomy, for further correction of congenital heart defects, a mean of 20 months after the original repair. At reoperation, major complications were encountered. Although the number of reoperations was low, we conclude that use of the polytetrafluoroethylene surgical membrane for pericardial closure in children is a safe procedure that helps prevent complications at reoperation.

Pheochromocytoma-induced myocardial infarction in pregnancy. A case report and literature review.

Abstract: We present the case of a 30-year-old woman, 33 weeks pregnant, whose pregnancy was complicated with the rare condition of pheochromocytoma-induced myocardial infarction. Alpha- and beta-adrenergic blockade was instituted immediately for control of hypertension and arrhythmias. Two weeks after myocardial infarction, fetal maturity was documented, and the patient underwent cesarean section delivery of a 6-lb, 6-oz baby girl. The delivery was followed immediately by excision of a 7- x 6- x 4.5-cm tumor, which was confirmed to be a pheochromocytoma by histologic examination. Her post-operative course was uneventful. Our case study and a review of the literature show that the key to successful fetal and maternal outcome is early diagnosis, which can be confirmed by 24-hour urine testing of catecholamine and metanephrine levels. If the tumor is diagnosed before 20 weeks' gestation, we recommend immediate surgical removal of the tumor and continuation of the pregnancy to term. The management of the patient who presents between 20 and 24 weeks' gestation will depend on the uterine size in terms of tumor access. After 24 weeks, the pregnancy should be carried to term, at which time delivery by cesarean section will be followed by tumor excision. Postoperative care should include appropriate cardiovascular investigation and ongoing serial measurements of urinary catecholamines.

Coronary angioplasty for acute myocardial infarction in a hospital without cardiac surgery.

Abstract: We evaluated, retrospectively, the hospital records of 100 consecutive patients with acute myocardial infarction who underwent emergency coronary angiography and percutaneous transluminal coronary angioplasty between January 1984 and August 1990. Intracoronary streptokinase (250,000 to 1 million units) was administered to 46 of these patients. Reperfusion was achieved in 82 patients, 8 of whom died in the hospital within 30 days. Angioplasty failed in 18 patients. Six were managed medically and survived, 7 survived emergency coronary bypass surgery at a nearby facility, and 5 died. The overall mortality rate was 13%. No facilities for open-heart surgery were available at our hospital; however, surgical back-up was available at another hospital, 0.5 miles away. No death was related to the transfer of a patient or to the unavailability of an in-house cardiac surgery facility. The American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures has written guidelines for cardiac surgical back-up for percutaneous transluminal coronary angioplasty. These guidelines strongly recommended that an experienced cardiovascular surgical team be available for emergency surgery in the institution as a back-up for all angioplasty procedures. Our study shows, however, that with careful case selection, emergency angioplasty for acute myocardial infarction can be performed safely with good results in a setting without on-site cardiac surgery facilities.

Balloon dilation of tricuspid and pulmonary valves in carcinoid heart disease.

Abstract: Heart involvement is usually the cause of death in patients with carcinoid syndrome, who may survive a long time even after the disease has entered an advanced stage. For this reason, carcinoid heart disease patients have undergone surgical replacement of affected valves. Two of our patients were not good candidates for surgery, due to the extent of hepatic metastasis. Alternatively, we performed percutaneous balloon valvuloplasty on both the tricuspid and pulmonary valves in both patients. To our knowledge, there has been only 1 previous report of successful tricuspid valvuloplasty in a case of carcinoid heart disease, and this did not involve concomitant pulmonary valvuloplasty. Before the procedure, both of our patients had low cardiac output with restriction in the right ventricle, pulmonary and tricuspid stenosis, and moderate tricuspid regurgitation. In the 1st patient, valvuloplasty reduced tricuspid and pulmonary gradients without change in cardiac output. This patient experienced initial clinical improvement but died 8 months after the procedure, of portal hypertension and extensive hepatic metastasis. The 2nd patient showed notably diminished gradients and a very significant increase in cardiac output. She advanced from New York Heart Association functional class IV to class I, and is now maintained with diuretic therapy. In our judgment, balloon valvuloplasty is a sound alternative to surgery for patients with carcinoid heart disease, especially when stenosis is the dominant symptom. Valvuloplasty is contraindicated in cases of severe tricuspid regurgitation.

The paleopathology of the cardiovascular system.

Abstract: Paleopathology, the study of disease in ancient remains, adds the dimension of time to our study of health and disease The oldest preserved heart is from a mummified rabbit of the Pleistocene epoch, over 20,000 years old Cardiovascular disease has been identified in human mummies from Alaska and Egypt, covering a time span ranging from approximately 3,000 to 300 years ago An experimental study suggests that the potential exists for identifying a wide range of cardiovascular pathologic conditions in mummified remains The antiquity and ubiquity of arteriosclerotic heart disease is considered in terms of pathogenesis

Coronary-prone behavior. Type A behavior revisited.

Abstract: On the basis of prospective population studies that found a relationship between Type A behavior and cardiac morbidity and mortality independent of traditional risk factors, Type A behavior was declared a risk factor for the development of coronary heart disease. However, subsequent studies of individuals with multiple risk factors or established cardiovascular disease failed to support this association consistently. Attempts to identify toxic subcomponents of Type A behavior have supported an association between hostility and cardiac morbidity and mortality. There is evidence that Type A men are physiologically reactive in challenging situations and that behavioral programs, in combination with cardiac counseling, can reduce recurrent morbidity and mortality.

Emergency surgical treatment for total left main coronary artery occlusion. A report of 2 cases.

Abstract: Treatment of total left main coronary artery occlusion is rarely reported (84 chronic and acute cases in the world literature), due to the high mortality rate from massive myocardial infarction. Acute occlusions have been treated with intracoronary streptokinase, with percutaneous transluminal coronary angioplasty, or with both. To date, there has been no report of successful surgical revascularization in an acute case. We present 2 cases of surgically treated patients who survived total left main coronary artery occlusion that appears to have been acute, or acutely evolving. Both patients had an 80% or greater stenosis of the right coronary artery, yet have remained in New York Heart Association functional class I or II postoperatively. We attribute this not only to the aggressive surgical approach, which enabled reperfusion to be achieved within 2 hours of total occlusion, but to the protective effect in these patients of right coronary-to-left anterior descending collaterals.

Right thoracotomy revisited.

Abstract: From September 1991 through August 1992, 38 patients (34 female and 4 male) underwent mitral valve surgery through a limited right anterior thoracotomy. The ascending aorta was easily cannulated for arterial return in all patients. Although there was no operative mortality, 8 patients required reoperation for bleeding, usually associated with the site of chest-wall puncture for the left atrial pressure line and epicardial pacing wires, a problem that we were able to correct. Right lower lobe collapse occurred in 2 patients, but the lungs were fully expanded in all patients before hospital discharge. We believe that a return to this older surgical approach is particularly suited to young patients and provides the important advantages over median sternotomy of superior mitral valve exposure and a cosmetically acceptable scar.

Papillary fibroelastoma. A right atrial presentation.

Abstract: Papillary fibroelastoma is a rare cardiac tumor arising most frequently from valvular endocardium. These tumors are clinically important because of their tendency to embolize. Emphasis is therefore placed on early detection and surgical excision. We describe a case of a papillary fibroelastoma arising from the right atrium. To our knowledge, only 2 such cases have been reported in the English literature. Our case illustrates the discovery of a rare, but potentially fatal cardiac tumor, successfully removed by surgery.

Cardiac metastasis of rectal adenocarcinoma. Surgical treatment.

Abstract: The authors report a case of cardiac metastasis of a rectal adenocarcinoma that infiltrated the right ventricle and partially obstructed its outflow tract. Surgical treatment was performed because of syncopal attacks. The differential diagnosis between organized thrombi and intracardiac tumor is considered.

Psychiatric complications in the critically ill cardiac patient.

Abstract: Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. A description of delirium associated with the use of the intraaortic balloon pump and its treatment with high doses of intravenous haloperidol is also included. After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion.

Iliac arteriovenous fistula due to spinal disk surgery. Causes severe hemodynamic repercussion with pulmonary hypertension.

Abstract: We present a case of a 46-year-old man with a pulsatile mass in the left inferior abdominal quadrant that irradiated a continuous murmur extending to the left lumbar region. Despite an 8-year history of cardiomegaly, he appeared to be asymptomatic except for the mass and could recollect no traumatic injury or surgery that might have caused it. Near the vertebral column, we found a small scar, the result of spinal disk surgery 11 years before. Following chest radiography and electrocardiography, we located the suspected arteriovenous fistula by selective angiography of the aorta and its branches: a communication of the left iliac artery with the left iliac vein had resulted in a very large left-to-right shunt and a severely dilated inferior vena cava. We then divided and isolated the arterial segment containing the fistula, but left this segment in continuity with the left iliac vein by over-sewing both ends. To avoid injury to surrounding structures, dissection was limited to the area of maximal thrill. Hemodynamic improvement was immediate, and the postoperative course was uneventful. At the present time, almost 3 years postoperatively, the patient is asymptomatic.

Use of the activated clotting time in anticoagulation monitoring of intravascular procedures

Abstract: The activated clotting time first came into clinical use in the mid-1970s to guide the administration and reversal of heparin during cardiopulmonary bypass procedures. The explosive growth of cardiopulmonary bypass led to the development of automated techniques for measuring activated clotting times. Recent advances in the field of interventional cardiology have emphasized the importance of the coagulation cascade and the need for the prevention of thrombosis with anticoagulant drugs. The activated clotting time has emerged as an important means of monitoring and guiding heparin therapy during invasive intravascular procedures. This review focuses on the following topics: 1) the development of anticoagulation monitoring techniques; 2) current alternatives in bedside anticoagulation monitoring; and 3) the clinical application of activated clotting times outside surgery. Until prospective studies can establish appropriate "target" activated-clotting-time values for interventional procedures, procedural anticoagulation must be guided empirically. Nevertheless, the activated clotting time is extremely useful in the catheterization laboratory, for monitoring heparin therapy and the adequacy of anticoagulation.

High-risk angioplasty. Coarctation of the aorta after Norwood Stage 1.

Abstract: This report describes 2 patients with hypoplastic left heart syndrome who developed severe coarctations of the aorta after Norwood Stage I procedures and subsequently survived recurrent ventricular fibrillation during successful percutaneous angioplasty. Although ventricular fibrillation has not been associated with hypoplastic left heart syndrome, postoperative Norwood Stage I, or angioplasty of isolated coarctations of the aorta, we believe that the complex physiology of our patients created conditions that precipitated ventricular tachycardia and ventricular fibrillation. We strongly recommend that follow-up of infants with hypoplastic left heart syndrome after Norwood Stage I operations be meticulous; that even mild coarctation be treated aggressively, to avoid progression to high-risk situations; and that interventionalists be prepared to manage malignant ventricular dysrhythmias whenever postoperative Norwood Stage I patients undergo percutaneous angioplasty for coarctation of the aorta.

Surgical management of intracardiac myxomas. A 16-year experience.

Abstract: Twenty-six patients with an intracardiac myxoma underwent surgical resection at our institution from 1977 through 1992. Left atrial myxoma was diagnosed in 22 patients, left ventricular in 1, right atrial in 2, and right ventricular in 1. Six patients were asymptomatic; preoperative symptoms included dyspnea, arrhythmias, embolic episodes, and syncope. The diagnosis was established with transthoracic echocardiography in all cases but one. Surgery was performed in all cases with the aid of cardiopulmonary bypass with moderate hypothermia and cold crystalloid cardioplegia. One patient with a left ventricular myxoma died in a comatose state during the immediate postoperative period. Long-term clinical and echocardiographic evaluation was performed in 19 patients; results were excellent (all the patients were in New York Heart Association functional class I or II), and no recurrences were documented. The clinical characteristics, diagnostic methods, and surgical approach are presented and discussed.

Esophageal-aortic erosion associated with double aortic arch and tracheomalacia: Experience with 2 infants

Abstract: Patients with double aortic arch may require lengthy intubation for ventilatory support. The need for endotracheal and nasogastric intubation may be prolonged in such patients because of associated tracheomalacia. Iatrogenic tracheal or esophageal erosion with subsequent aortic fistulization is an unusual but catastrophic complication that may result from such intubation. We report the cases of 2 infants with double aortic arch and tracheomalacia who developed iatrogenic esophageal-aortic erosion. This complication was successfully managed in 1 of the infants. We conclude from our experience that the important steps in preventing this complication include 1) expediting the exclusion of upper-airway compromise in intubated infants who have a presentation characteristic of bronchospastic airway disease (hyperinflation and hypercapnia) that seems unresponsive to usual therapeutic measures; and 2) expediting the diagnosis of vascular ring in order to minimize the duration of dual tracheal and esophageal intubation. Effective management of this problem, once established, requires primary closure of the esophageal perforation, removal of the nasogastric tube, interposition of thick viable tissue between the esophagus and the aorta, and decompressive gastrostomy and feeding jejunostomy. Concomitant aortopexy may be appropriate.

Mental stress and myocardial ischemia. Correlates and potential interventions

Abstract: In past years, indirect evidence has suggested a link between mental stress and coronary artery disease. Recent research in coronary artery disease patients has confirmed the observation that mental stress is a potent trigger of myocardial ischemia in both the laboratory and the field. The pathophysiologic effects of mental stress appear to operate via alterations in both myocardial oxygen demand and supply. Intense negative emotion, such as hostility, and heightened cardiovascular reactivity are positively associated with this ischemia, suggesting that recognition of these factors may help identify patient subgroups at highest risk. Preliminary studies evaluating pharmacologic intervention suggest that traditional anti-ischemia therapy, such as beta-blockers and vasodilators, can reduce mental-stress-triggered ischemia in coronary artery disease patients. Behavioral and psychosocial interventions, such as reducing environmental stress through social support, altering stress perception through behavioral training, and altering the physiologic reaction to stress through physical training, also show promise as therapeutic options. Further work is needed in this fertile biobehavioral area.

Chest pain and angiographically normal coronary arteries. Implications for treatment

Abstract: Approximately 20% to 30% of patients who undergo coronary arteriography for the evaluation of chest pain are found to have normal coronary arteries. These patients have a survival rate comparable to that of the normal population, yet they continue to complain of symptoms on extended follow-up, and about half of this group are disabled on account of chest pain. Once other clinically obvious disorders have been ruled out, common diagnostic considerations include microvascular angina, esophageal dysfunction, and perhaps fibromyalgia. Panic disorder, however, is the most common condition affecting these patients and can be diagnosed in at least one third of the group, with or without the presence of the other conditions mentioned. Appropriate diagnosis and treatment can reduce the psychosocial morbidity so frequently seen in these patients.

Progressive visual deterioration leading to blindness after pediatric heart transplantation.

Abstract: We present the case of a 10-year-old girl who developed visual loss progressing to blindness after orthotopic heart transplantation and an immunosuppressive regimen of cyclosporine, azathioprine, and prednisone. Headaches and visual deterioration began 2 months after transplantation, and a diagnosis of pseudotumor cerebri was made. The patient's visual loss continued despite aggressive medical and surgical therapy, which included bilateral optic nerve sheath fenestration. To our knowledge, permanent visual loss as a late sequela following pediatric heart transplantation and immunosuppressive therapy has not been reported previously in the English literature. Although the cause of visual loss after transplantation in our patient is poorly understood, we conclude that permanent visual loss, although rare, should be considered as a possible late neurologic sequela after pediatric heart transplantation.

Why referred potential heart donors aren't used

Abstract: Heart donor demand far exceeds supply We evaluated donor referrals to 1 organ procurement agency in an attempt to determine why many potential cardiac donors are not used Of 430 referrals between September 1989 and August 1991, 169 hearts (39%) were harvested In potential donors ultimately not yielding a heart, 387% were unavailable because the family refused to consent to organ donation, 36% were medically unsuitable, and 161% did not meet standard brain death criteria Of the 94 donors not used for medical reasons, 436% had cardiac arrest, 17% had hypotension, 128% were drug abusers, 64% had sepsis, 53% had hepatitis, 53% had an acute myocardial infarction, 32% had low ejection fraction levels, and 21% tested positive for human immunodeficiency virus or syphilis (43% were not specified) A significant difference (p = 0001) in racial distribution surfaced; Blacks and Hispanics constituted 272% of the donor group but 463% of the non-donor group These data confirm that strategies must be created to continue educating the public and physicians in order to increase consent rates, optimize donor selection, and improve physician awareness of brain death criteria

Pulmonary embolism due to compression of the inferior vena cava by a hepatic hemangioma.

Abstract: We describe a 35-year-old man who had a pulmonary embolism with thrombosis of the inferior vena cava, apparently resulting from compression by a hepatic hemangioma. The diagnosis of pulmonary embolism was confirmed by pulmonary angiography; however, the hemangioma was detected only incidentally, as a hyperechoic mass, during an echocardiogram for intracardiac thrombosis. Abdominal sonography, computed tomography, celiac angiography, technetium 99m-labeled red blood cell scintigraphy, and ultrasound-guided liver biopsy all assisted in the diagnosis of hepatic hemangioma and its compression of the inferior vena cava. Because of the multisegmental and perihilar involvement of the tumor, surgery was not performed. For dissolution of the clots, the patient was given thrombolytic therapy followed by heparin administration. He was then placed on long-term warfarin therapy and is well after 5 years; the size of the hemangioma is unchanged. Cases of pulmonary embolism due to diseases of the upper abdominal organs are rare and probably underestimated. This case stresses the need for a systematic investigation of the abdomen when a pulmonary embolism is present without evidence of deep vein thrombosis.

Fungal infection in a dissecting aneurysm of the thoracic aorta.

Abstract: We describe a 54-year-old man who had an ascending aortic prosthetic graft and a porcine aortic valve prosthesis that were infected by Candida albicans. This infection led to the formation of a dissecting false aneurysm of the remaining transverse and entire descending thoracic aorta, and the man was admitted to our hospital for surgical treatment in February of 1991. Staged in situ graft replacement was performed using Borst's "elephant trunk" repair for the proximal aortic reconstruction and an open distal anastomosis technique for the distal repair. Candida albicans in the residual prosthetic graft was identified, and therapy with high-dose liposomal amphotericin B was initiated. The use of liposomal amphotericin B reduces the incidence of adverse effects and allows administration of higher doses than those possible with conventional amphotericin B therapy. Lifelong antifungal therapy is recommended for patients with C. albicans infection of prosthetic aortic grafts.

Depression and its treatment in cardiac patients.

Abstract: In general medical-surgical hospital services, depression is the most common reason for seeking psychiatric consultation in behalf of patients with cardiovascular disease. The nontreatment of depression or the use of a psychotropic agent mismatched to a patient's particular cardiac condition or individual sensitivities has considerable negative impact. Therefore, a systematic approach should be used in the differential diagnosis of depression in cardiac patients, to eliminate other psychiatric disorders and to assure the correct treatment strategy. Physicians can develop an appropriate rationale for the use of a psychopharmacologic regimen in cardiovascular settings through recognition of the diagnostic criteria for depression and through comprehensive knowledge of the pharmacologic properties and possible cardiovascular effects of these vital treatments. Standard and alternative pharmacotherapies for depression in cardiac patients are reviewed.

Anterior translocation of the pulmonary confluence in the surgical treatment of truncus arteriosus.

Abstract: A surgical technique is described for correction of truncus arteriosus type II, in which the confluence of the pulmonary arteries is translocated anteriorly to the divided truncal root. In this technique, the truncal root is reconstructed, and the ventricular septal defect is closed through a right ventriculotomy. The outflow tract of the right ventricle is reconstructed by using a cryopreserved aortic homograft, with the pulmonary artery confluence lying anteriorly to the aorta. This positioning may facilitate future reoperation in patients with this anomaly by obviating dissection around the truncal artery.

Standard and alternative adjunctive treatments in cardiac rehabilitation

Abstract: Cardiovascular rehabilitation is the process of restoring functional abilities degraded by a serious cardiovascular event or by a surgical procedure to preempt such an event. Cardiovascular rehabilitation also includes attempts to reverse risk factors that have contributed initially to the disease process. Rehabilitation programs generally comprise disease-related educational components, supervised prescriptive physical exercise, diet counseling and modification, cessation of tobacco use, psychoeducational interventions aimed at adjustment and coping, and relaxation and stress management to lower nonexertion-related sympathetic drive. The presence of so-called coronary-prone behavior patterns can be detected, and special behavioral modifications may be indicated to mitigate these putative risk factors. This paper reviews the roles of these behavioral adjuncts in treating cardiovascular disease and its aftermath, and notes new and unusual approaches to these components of treatment, such as alternative exercises, biofeedback, yoga, and other relaxation methods. Barriers to compliance are acknowledged, and enhancement of compliance is discussed briefly.