Stenotic Ring Research Articles

Extended Aortoplasty to Relieve Supravalvular Aortic Stenosis

An extended aortoplasty was used to relieve severe supravalvular aortic stenosis in 5 patients whose preoperative left ventricular-aortic gradient ranged from 85 to 140 mm Hg (median, 120 mm Hg). The stenotic ring above the commissures was divided in two places by an inverted U incision extending into the right and noncoronary sinuses. A distal vertical incision in the ascending aorta converted this into an inverted Y. The ridge above the left coronary sinus was excised. The aortic incision was repaired with an inverted Y-shaped Dacron gusset. The postoperative gradient ranged from 0 to 30 mm Hg (median, 15 mm Hg). The extended aortoplasty provides excellent relief of supravalvular aortic stenosis and, in addition, restores the aortic root geometry to a much more anatomical configuration than is achieved with the simple patch technique.

Endoscopic treatment of stenosis following stapler anastomosis.

The papillotomy knife, introduced by an endoscope, was employed to treat stenosis following stapler anastomosis, and to cut the stenotic ring in three points along its circumference.

Tracheal Stenosis: Conservative Surgery as a Primary Mode of Management

Tracheal and laryngeal stenosis has become increasingly common following prolonged intubation or tracheostomy for mechanical ventilation and is directly related to trauma. Tracheal resection up to 4 to 5 cm. with an end to end anastomosis is the generally accepted treatment. However, tracheal resection carries the danger of mortality and considerable morbidity. From 1974 to 1979 all patients in our series with tracheal stenosis, even with laryngeal involvement, regardless of etiology and age were intiially treated by conservative surgical management consisting of dilation, severance of the stenotic ring, intralesional injection of triamcinolone acetonide, and stenting with a silicone T tube for 90 days. Sixteen of 19 patients obtained good results and enjoy an adequate airway without a tracheostomy tube. The longest follow-up period was five years and the shortest, six months. Intralesional injection of triamcinolone acetonide is essential for successful treatment. No mortality or serious complications resulted from this treatment. Our experience indicates that patients with tracheal and laryngeal stenosis should undergo a primarily conservative surgical management. This technique appears worthy of trial prior to contemplating a more extensive procedure.

The genetics and pathology of discrete subaortic stenosis in the Newfoundland dog

Breeding experiments confirm that discrete subaortic stenosis (SAS) in Newfoundland dogs is a specific inherited trait. Specificity of the morphogenetic abnormality is not complete, however, since matings between Newfoundlands with SAS occasionally produced pups with valvular and subvalvular pulmonic stenosis as well as SAS. The spectrum of severity of SAS ranged from a subclinical forme fruste to a severe form causing death before maturity. Well-developed subvalvular stenotic rings consisted of a base of loosely arranged fibrous connective tissue and a subendocardial region of cartilagenous tissue. Severely affected dogs, some of which died suddenly, had foci of necrosis and fibrosis in the left ventricular myocardium, associated with thickening of the intramural coronary arteries. The lesions of SAS were not found in dogs before 3 weeks of age, and the mildest form was seen only in dogs between 3 and 12 weeks of age, suggesting that SAS is not a true congenital defect but develops postnatally. It is hypothesized that the fibrocartilagenous ring of SAS is derived from persistent embryonal endocardial tissue which retains its proliferative capacity and has chondrogenic potential for some time after birth. The results of breeding experiments were not consistent with any simple genetic hypothesis, and indicate that SAS is inherited as a polygenic trait or as an autosomal dominant trait with modifiers.

Management of acquired tracheal obstructions in infancy

Endoscopic resection of tracheal subglottic stenosis can be performed safely and effectively. With careful selection, some stenotic rings can be excised without the requirement for prior tracheostomy. Endoscopic resection does not supplant other methods of dilatation, injection, or stenting of subglottic scars, but early resection in appropriate cases may reduce the number of dilatations and obviate the need for a stent and systemic steroids.

Tracheostomy in children.

Tracheostomies were performed on 47 children, using the flap technique. Thirteen patients (28%) died of their basic disease and two (4%) died of complications resulting from the tracheostomy. Decannulation was difficult in four patients, and there was one case each of bleeding, infection, and tracheocutaneous fistula. Thus, the primary complication rate was 19%, including the two deaths. Clinical reexamination with tracheography was made on 20 patients after a follow-up period varying from four to ten years (average, eight years). One small stenotic ring in the area of the distal end of the cannula site and two slight depressions in the tracheal forewall were found. According to these results, the flap technique, if properly performed, is safe also in children.

Intracardiac irradiation of the valves from radium emanation, employing a two-stage operative technique.

In mitral stenosis there is indicated, on theoretical grounds, some form of intervention designed to dilate the narrowed orifice and thereby relieve the functional embarrassment of the heart. In advanced cases such relief must come through an intracardial approach. The operative dangers of such a course are necessarily great, but in hopeless cases of stenosis the chances of final success through opening-up of the constricted orifice, with the resulting advantages, may well outweigh the dangers. A single attempt in this direction has already been reported by Dr. Cutler, of Boston. An important characteristic of mitral stenosis from the standpoint of its ultimate relief is the slow progressive nature of the lesion as it normally occurs. This makes it impossible to predict whether surgical dilation will effect a permanent relief or will only alleviate the condition temporarily, after which there will occur a reformation of the old stenotic ring. The latter possibility makes it irrational, in the present state of our knowledge, to expose a patient to the dangers of this surgical operation. In view of these considerations we have been attempting in the past year to produce in dogs a real stenosis characterized by scar formation on valves and ring and presenting a progressive nature, as contrasted with the many previous attempts in this direction which have, for the most part, been in the nature of mechanical ligations of the orifice. With some reliable method of provoking a valvular lesion of this kind, it is our aim, then, to observe more fully the course of events following surgical intervention.