EDITORIALS
cc
Correction” of Congenital Heart Disease
I
n the early days of intracardiac surgery the term correction came into use to distinguish intracardiac attempts at reparative operations from the then more common indirect palliative operations. Correction is a powerful word. It indicates the act of setting right, of removing faults, defects, or errors, and this is what we imply when we use it. The term has been grossly misapplied. I have read of correction (or even “total correction,” which is a still more wonderful phrase we surgeons have introduced) of Ebstein’s anomaly, transposition of the great arteries, tricuspid atresia, Fallot’s anomaly, and complete endocardia1 cushion defects. The point does not need to be overworked, but some of these socalled corrections involve prosthetic valve replacement and some valve excision; in others the right ventricle is hypoplastic or hyperplastic, supporting systemic pressure after the repair. The list could easily be extended. The point of this communication is not to quibble about semantics but to counteract the complacent state of mind that the use of the term correction brings about. We actually correct relatively few congenital cardiac anomalies if we take correction to mean normal hemodynamics, normal conduction, and normal myocardial function, size, and perfusion. Nor can we forget the associated anomalies. How often do we “totally repair” a coarctation of the aorta, for example? Patients followed for many years after coarctation repair demonstrate a high incidence of residual hypertension, premature cardiovascular disease, and premature death [ 11. Patients with ventricular septal defect usually show bundle-branch block and many have left anterior hemiblock with right bundle-branch block; in some, these progress to complete block many years later [2]. Pulmonary vascular resistance that is elevated before operation may remain so or even increase in the ensuing years. Less subtle are the ventricular septal defects that persist even following repair and the tricuspid insufficiency that may have been produced during the operation. Regrettably, even atrial
VOI..
19,
NO. 1, JANUARY,
1975
103
Editorial
septa1 defects may recur following intracardiac closure, and we now learn that patients with such defects may have depressed left ventricular function and a floppy mitral valve. It is only by thorough late postoperative evaluation that we will learn how often intracardiac operations are corrective. One of the key factors will likely be the patient’s age at the time of operation. Younger patients will have fewer secondary manifestations of the abnormality, which may then more properly be considered along purely anatomical lines; but here the reconstruction must be compatible with growth. Meanwhile, what gross term should be used to distinguish intracardiac from palliative operations? I would offer the term intracardiac repair, which has been widely used in the surgical literature. T h e word repair might also seem an overstatement, but my dictionary says it signifies “to restore to a sound or good state,” and this we usually do.
ANTHONY R. C. DOBELL, M.D. T h e Montreal Children’s Hospital 2300 Tupper St. Montreal 108, P.Q., Canada
References 1. Maron, B. J., Humphries, J. O., Rowe, R. D., and Mellits, E. D.
Prognosis of surgically corrected coarctation of the aorta: A 20-year post-operative appraisal. Circulation 47: 119, 1973. 2. Wolff, G. S., Rowland, T. W., and Ellison, R. C. Surgically induced right bundle-branch block with left anterior hemiblock: An ominous sign in postoperative tetralogy of Fallot. Circulation 46:587, 1972.
104
THE ANNALS OF THORACIC SURGERY
cc
Correction” of Congenital Heart Disease
I
n the early days of intracardiac surgery the term correction came into use to distinguish intracardiac attempts at reparative operations from the then more common indirect palliative operations. Correction is a powerful word. It indicates the act of setting right, of removing faults, defects, or errors, and this is what we imply when we use it. The term has been grossly misapplied. I have read of correction (or even “total correction,” which is a still more wonderful phrase we surgeons have introduced) of Ebstein’s anomaly, transposition of the great arteries, tricuspid atresia, Fallot’s anomaly, and complete endocardia1 cushion defects. The point does not need to be overworked, but some of these socalled corrections involve prosthetic valve replacement and some valve excision; in others the right ventricle is hypoplastic or hyperplastic, supporting systemic pressure after the repair. The list could easily be extended. The point of this communication is not to quibble about semantics but to counteract the complacent state of mind that the use of the term correction brings about. We actually correct relatively few congenital cardiac anomalies if we take correction to mean normal hemodynamics, normal conduction, and normal myocardial function, size, and perfusion. Nor can we forget the associated anomalies. How often do we “totally repair” a coarctation of the aorta, for example? Patients followed for many years after coarctation repair demonstrate a high incidence of residual hypertension, premature cardiovascular disease, and premature death [ 11. Patients with ventricular septal defect usually show bundle-branch block and many have left anterior hemiblock with right bundle-branch block; in some, these progress to complete block many years later [2]. Pulmonary vascular resistance that is elevated before operation may remain so or even increase in the ensuing years. Less subtle are the ventricular septal defects that persist even following repair and the tricuspid insufficiency that may have been produced during the operation. Regrettably, even atrial
VOI..
19,
NO. 1, JANUARY,
1975
103
Editorial
septa1 defects may recur following intracardiac closure, and we now learn that patients with such defects may have depressed left ventricular function and a floppy mitral valve. It is only by thorough late postoperative evaluation that we will learn how often intracardiac operations are corrective. One of the key factors will likely be the patient’s age at the time of operation. Younger patients will have fewer secondary manifestations of the abnormality, which may then more properly be considered along purely anatomical lines; but here the reconstruction must be compatible with growth. Meanwhile, what gross term should be used to distinguish intracardiac from palliative operations? I would offer the term intracardiac repair, which has been widely used in the surgical literature. T h e word repair might also seem an overstatement, but my dictionary says it signifies “to restore to a sound or good state,” and this we usually do.
ANTHONY R. C. DOBELL, M.D. T h e Montreal Children’s Hospital 2300 Tupper St. Montreal 108, P.Q., Canada
References 1. Maron, B. J., Humphries, J. O., Rowe, R. D., and Mellits, E. D.
Prognosis of surgically corrected coarctation of the aorta: A 20-year post-operative appraisal. Circulation 47: 119, 1973. 2. Wolff, G. S., Rowland, T. W., and Ellison, R. C. Surgically induced right bundle-branch block with left anterior hemiblock: An ominous sign in postoperative tetralogy of Fallot. Circulation 46:587, 1972.
104
THE ANNALS OF THORACIC SURGERY
