591 Correspondence

outflow tracts. The right ventricular bypasses to the left pulmonary artery were successful at Bethesda. In Dr. Francis Moore's laboratory at Harvard, the successful bypass to the main pulmonary artery with ligation and occlusion of the pulmonary valve was accomplished as an outgrowth of the work performed at Bethesda. Dr. Hufnagel's contribution was the descending aortic ball valve to which a tube was added before insertion into the ventricular apex to bypass the aortic valve. This valve promptly wore out but was redesigned (before it was used in humans), and up to two-year studies in dogs were done in laboratories at Harvard and Hartford Hospital. The high incidence of thromboembolism in dogs dissuaded us from publishing some of these data, which are now being reevaluated. It is gratifying to see the successful human application of these shunts to decompress the right and left ventricles, whatever the name affixed to the operative procedure. The endocardia1 anastomosis still seems of primary importance in avoiding stenosis and thromboembolism.

with each instance successfully, we thought no more of them. Of course, we have taken special care not to allow recurrence. However, at a recent meeting it was brought to our attention that similar occurrences have been noted by other surgeons. We therefore thought we should write this letter to bring this matter to the attention of surgeons who may not have encountered the problem and who may be using this prosthesis under circumstances in which left atrial lines may interfere with its function.

Thomas: J. Donovan, M . D .

Although puncture of the internal jugular vein, either high or low, has a relatively small incidence of serious complications, it was timely of Dr. McEnany and Dr. Austen ("Life-threatening hemorrhage from inadvertent cervical arteriotomy," Ann Thorac Surg 24:233, 1977) to highlight the serious consequences of arterial puncture in the neck immediately prior to open-heart operations. We also have had a fatality, due in major part to hemorrhage in the right chest, from this cause. May we recommend that all central venous lines, whether for drug administration, pressure measurement, or cardiac output determination, be inserted at operation through a separate small stab incision into the innominate vein. This technique, which is in no way original, avoids arterial trauma, is quick, and allows exact positioning of the catheter tip. In addition, the catheter is held rigidly in situ, reducing the chances of kinking and of introducing infection at the puncture site. A technique very similar to this one was reported last year by Gosalbez, Magilligan, and Davila (Ann Thorac Surg 22:378, 1976).

100 Retreat A v e Hartford, CT 06106

Poppet Jamming during Mitral Valve Replacement To the Editor: This letter is to bring a potential technical misadventure to the attention of the readers of The Annals. On two separate occasions while performing mitral valve replacement using the Lillehei-Kaster tiltingdisc prosthesis, we encountered poppet jamming due to impaction of thin polypropylene tubing utilized for left atrial pressure monitoring. Subsequently, we demonstrated to our satisfaction that the close clearance of the tilting disc within its housing in the closed position of this prosthesis design lends itself to this complication. The problem occurs when the small polypropylene tubing is used if this tubing is allowed to pass through the valve orifice and the poppet is then forcefully closed, as with ventricular contraction. Similarly, testing a Bjork-Shiley mitral prosthesis in vitro demonstrated that the clearance in this prosthesis is such that the jamming did not occur. Although we noted these occurrences and dealt

D . A. Browdie, M.D. li. F . A g n e w , M . D . C . 5. Hamilton, J r . , M . D . Fargo Clinic

Box 2067

737 Broadway Fargo, N D 58102

Central Venous Line Insertion To the Editor:

J. R . W. Keates, F.1i.C.S. A.

M . Macarthur, F.K.C.S.

Department of Cardio-Thoracic surgery King's College Hospital Denmark Hill London S E 5 9RS, England

Central venous line insertion.

591 Correspondence outflow tracts. The right ventricular bypasses to the left pulmonary artery were successful at Bethesda. In Dr. Francis Moore's la...
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