A 63-year-old white man with hyperparathyroidism had symptoms suggestive of a dissecting aneurysm and superior vena cava obstruction. Urgent exploration revealed a large mediastinal hematoma caused by hemorrhage surrounding a parathyroid adenoma. This case is believed to represent the first one of such a presentation by a parathyroid tumor. The patient was successfully treated by emergency aortic angiography, prompt mediastinal and neck exploration, and resection of the adenoma.

Follow-up information to 1972 was obtained on 49 of 54 survivors of the Mustard operation performed at the Mayo Clinic between March, 1964 and December, 1970. Ten late deaths have occurred from six months to eight years after operation. Causes of late deaths were progressive pulmonary vascular disease (two deaths), cardiac dysrhythmia (three), reoperation (two), pulmonary venous obstruction (one), sepsis (one), and unknown (one). The ages of the 39 surviving patients two to eight years postoperatively ranged from 4 to 28 years. Present physical condition was rated excellent or good in 36 patients (92%) and fair or poor in 3 patients (8%).The substantial improvement in physical well-being shown by nearly all patients after the Mustard operation is gratifying. However, the frequency of late deaths and the morbidity secondary to serious dysrhythmias, caval or pulmonary venous obstruction, and tricuspid insufficiency in these patients are disturbing. Although the Mustard operation should continue to be performed on appropriate patients, the effort to develop a more nearly curative operation should be intensified.

Fifty patients underwent correction of one or two valvular lesions with concomitant insertion of one to three aortocoronary vein bypass grafts. Hospital mortality was 14% and late mortality was 10%. Factors influencing operative mortality were: (1) mitral valve replacement after myocardial infarction; (2) complete obstruction of a coronary artery preoperatively; (3) high left ventricular end-diastolic pressure at rest preoperatively in patients with mitral valve disease; and (4) use of a single aortocoronary graft in the presence of multiple-vessel disease. For patients with significant associated valvular and coronary artery disease, combined correction yields results that appear sufficiently encouraging, judged by mortality and follow-up, to warrant its continued use in selected cases.

From 1957 through 1971, 18 patients whose ages ranged from 10 months to 18 years underwent surgical correction of tetralogy of Fallot with absent pulmonary valve. All patients had associated pulmonary arterial aneurysms; in two the left pulmonary artery also was absent. Right middle lobectomy had been performed previously on one patient for lobar emphysema; seven other patients had recurrent pulmonary infections.The ventricular septal defect was closed with a patch in 12 patients and by direct suture in 6. Concomitant infundibular resection was done in all. In four the narrow pulmonary valve annulus was enlarged with an outflow patch, and multiple radial incisions were made in the valve annulus in seven others. The pulmonary arterial aneurysms were not resected in any patients.There were three hopsital deaths (17%) and two late deaths. Complete heart block developed intraoperatively in three patients, all operated on prior to 1963, contributing to the early death of one patient and to the late deaths of the other two.In a follow-up of all 13 survivors at 8 months to 15 years (median 6 years), results were excellent and equal to those of patients who have undergone repair of tetralogy of Fallot with pulmonary valve.

Twenty-six patients were operated on for mitral insufficiency after myocardial infarction. The mean time between infarction and operation was 13 months (range 2 months to 5 years). The mitral valve was replaced in 17 patients; 9 patients had valvuloplasty or annuloplasty. In 12 patients, coronary arterial revascularization was performed concomitantly. There were eight postoperative deaths and eight late deaths during a mean follow-up period of 30 months (range 9 to 108 months). Seven of 17 patients are long-term survivors after mitral valve replacement, and 3 of 9 patients are long-term survivors after mitral valve repair. The main cause of death after operation was recurrent myocardial infarction. The mode of valvular surgery performed and concomitant coronary arterial revascularization did not alter the operative mortality rate. Twenty-six patients were operated on for mitral insufficiency after myocardial infarction. The mean time between infarction and operation was 13 months (range 2 months to 5 years). The mitral valve was replaced in 17 patients; 9 patients had valvuloplasty or annuloplasty. In 12 patients, coronary arterial revascularization was performed concomitantly. There were eight postoperative deaths and eight late deaths during a mean follow-up period of 30 months (range 9 to 108 months). Seven of 17 patients are long-term survivors after mitral valve replacement, and 3 of 9 patients are long-term survivors after mitral valve repair. The main cause of death after operation was recurrent myocardial infarction. The mode of valvular surgery performed and concomitant coronary arterial revascularization did not alter the operative mortality rate.

Thirty-seven patients survived two days or longer after aortic valve replacement with a close-clearance Starr-Edwards cloth-covered prosthesis, model A2310; 16 patients subsequently died. In seven, the only pathologic finding at autopsy was an aortic poppet held at the apex of the cage by fibrin deposits. A stuck poppet was found at autopsy in another patient who also had an extensive subendocardial infarction dating to the time of operation. Three additional patients died suddenly in a manner suggesting an entrapped aortic poppet, but autopsies were not performed. Two other patients who received the diagnosis of intermittent entrapment of the ball valve were successfully operated upon a second time, and the aortic valve was replaced with another model of the prosthesis. In all, 35% of patients were known to have or were suspected of having a stuck valve poppet.

From 1958 through September, 1972, 25 Mayo Clinic patients underwent repair or palliation of one or more cardiac anomalies associated with corrected transposition. Their ages ranged from 7 months to 45 years (median 5 years). The most common associated anomalies were ventricular septal defect and insufficiency of the systemic atrioventricular valve. Four patients underwent cardiac operations without the use of extracorporeal circulation, and the anomalies in the remaining 21 patients were repaired by open-heart surgery. There were 11 deaths within 30 days after operation and 2 late deaths. Approximately half of the patients are alive with a satisfactory late result at the time of this report. Anatomical and technical considerations in the repair of anomalies associated with corrected transposition are discussed.

Between 1955 and 1970, 143 Mayo Clinic patients less than 2 years old (78 boys and 65 girls; ages 10 weeks to 24 months, median age 14 months) underwent total correction of a ventricular septal defect using extracorporeal circulation. The distribution of associated lesions was as follows: 66% had no other lesions, 11% had an atrial septal defect, 9% had pulmonary stenosis, 8% had a patent ductus arteriosus, and 6% had other lesions. Two patients were asymptomatic; clinical features in the remainder included congestive heart failure (76%), failure to thrive (55%), and repeated respiratory infections (32%). Operative mortality was inversely related to age and weight. Neither of the asymptomatic patients died. The overall mortality was 21% for the entire interval; for the most recent five-year period, the rate was 10% (22% for infants less than 12 months and 0% for those 12 to 24 months). These data compare favorably with our previous experience and that of others for palliative pulmonary artery banding in infancy followed by correction at a later age, and they support our current approach of closure of the ventricular septal defect using extracorporeal circulation in almost all infants who require surgical aid.