- Email: [email protected]
Aortic Valve Endocarditis with Aortic Root Abscess Cavity: Surgical Treatment with Aortic Valve Homograft
Aortic Valve Endocarditis with Aortic Root Abscess Cavity: Surgical Treatment with Aortic Valve Homograft James K. Kirklin, M.D., John W. Kirklin, M.D., and Albert D. Pacifico, M.D. ABSTRACT Aortic valve endocarditis with an aortic root abscess cavity was treated by a modification of the standard technique of aortic homograft implantation in 3 patients. At a mean follow-up of 35 months, all 3 patients were well without reoperation or signs of aortic incompetence. This technique may, in some cases, be an alternative to the more complex procedure of homograft aortic root replacement with coronary reimplantation. The surgical treatment of native or prosthetic valve endocarditis of the aortic valve is occasionally complicated by abscess cavity formation in the aortic root [l-41. Although homograft aortic valve replacement has been advised for endocarditis of the aortic valve [5], its use in the presence of abscess cavities involving the aortic root generally has not been recommended because geometric distortion of the homograft valve may result. We report the intermediate-term follow-up of 3 patients who underwent homograft aortic valve replacement in the presence of abscess formation of the aortic root, using a variation of the classic technique of homograft valve insertion [6].
Patients and Methods Cryopreserved homograft valves for aortic valve replacement have been used at the University of Alabama at Birmingham since 1981. From 1981 to 1986, a total of 54 patients underwent homograft replacement of the aortic valve. Of these, 3 patients had native or prosthetic valve endocarditis that was complicated by important abscess cavities of the aortic root. These 3 patients are the subject of this report. The hospital records and operative notes were reviewed, and follow-up was performed at a mean of 35 months (range, 3 1 4 1 months) by direct telephone communication with the patient or his local physician, or both.
Patient 2 A 31-year-old man with a bicuspid aortic valve and prior repair of coarctation was seen with fever and chills. Blood cultures were positive for Staphylococcus uureus. Because of progressive aortic incompetence, operation was undertaken one month later. At operation, a bicuspid aortic valve was noted, with gross vegetations on the From the Division of CardiovasculariThoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL. Accepted for publication Dec 31, 1987. Address reprint requests to Dr. Kirklin, Department of Surgery, University of Alabama at Birmingham, 739 Zeigler Bldg, University Station, Birmingham, AL 35294.
noncoronary cusp. Two large abscess cavities excavated above the level of the annulus adjacent to the commissure separating the left and right sinuses of Valsalva. The annulus was elongated and redundant in this area, extending well below the level of the remaining annulus. The infected valve was excised, and a 26-mm homograft aortic valve was implanted, such that the abscess cavities were excluded from the circulation. The patient recovered uneventfully and was discharged after an additional 14-day course of intravenously administered antibiotics. He was readmitted to an outside hospital approximately six months later and underwent antibiotic therapy for enterococcal bacteremia. No diastolic murmur was noted. A subsequent cardiac catheterization revealed a small ventricular septal defect (possibly congenital) and no evidence of homograft valve incompetence. At last follow-up (34 months after operation), the patient was well, without clinical evidence of aortic incompetence, and in New York Heart Association (NYHA) Functional Class I.
Patient 2 A 26-year-old man with a congenitally bicuspid aortic valve was seen with native valve endocarditis, blood cultures positive for S. uuyeus, and progressive aortic insufficiency. After a brief course of antibiotic therapy, operation was performed. At operation, a bicuspid aortic valve was found with near obliteration of the leftsided commissure. An intramural abscess could be palpated from outside the heart. Within the aortic root, a localized abscess cavity or phlegmon burrowed into the aortic wall about 5 cm to the left of the left coronary ostium. The infected valve was excised, and a 23-mm homograft aortic valve was implanted, positioned so as to completely isolate the abscess cavity between the two suture lines. The patient was discharged from the hospital 15 days after operation on a regimen of orally administered antibiotics. The patient suffered no further sequelae, had no clinical evidence of aortic incompetence at last follow-up 41 months after operation, and was in NYHA Class I. Patient 3 A 44-year-old man underwent aortic valve replacement with a St. Jude prosthesis at an outside institution. Four months after operation, he was admitted to our institution with S. epidermidis prosthetic valve endocarditis, first degree atrioventricular block, and severe aortic incompetence. After brief initial therapy with intravenously administered antibiotics, the infected prosthetic valve was replaced with an aortic valve homograft. At
674 Ann Thorac Surg 45574-677, June 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
675 Kirklin et al: Aortic Homografts for Complex Endocarditis
Fig 1. The aortic valve has been excised, and the abscess cavity is visualized below the noncoronary sinus of Valsalva.
operation, an abscess cavity 2.5 cm wide and 1 cm deep was located at and below the annulus of the right sinus of Valsalva near the area of the His bundle. A second, smaller abscess cavity was located in the left sinus of Valsalva. The infected prosthesis was removed, and the abscess cavities were debrided. A 20-mm aortic valve homograft was implanted, excluding both abscess cavities from the circulation. His postoperative convalescence was normal. At the time of last follow-up (31 months after operation), he was in NYHA Class I, without recurrent endocarditis, and without evidence of aortic incompetence.
Operative Technique The operative technique consists of the following steps. The infected native or prosthetic valve is excised, and the location and extent of the abscess cavities are assessed (Fig 1). The annulus is sized, and a homograft 2 to 4 mm smaller than the annulus is selected. In the usual setting (without an abscess cavity), the scalloped portion of the homograft wall (in the sinuses of Valsalva) extends to within 3 mm of the annulus. In the presence of an abscess cavity, the distance (above and below the annulus) occupied by the cavity is used to determine the height of the homograft in the corresponding scalloped area (Fig 2). Three 4-0 polypropylene continuous sutures are used; the lower homograft suture line incorporates the lower edge of the abscess cavity and then follows the annulus and subcommissural area as usual (Figs 3, 4). The three posts of the homograft then are everted and properly positioned so that the abscess cavity is covered and the coronary ostia are unobstructed (Fig 5 ) . A 5-0 polypropylene mattress suture is placed through the superior aspect of each post and through the underlying aortic wall above the level of the native commissure. The upper (distal) suture line is constructed with three separate sutures of continuous 4-0 polypropylene, taking care to avoid impinging on the coronary ostium. If the upper edge of the abscess cavity lies above the level
Fig 2 . In preparing the homograft for standard aortic valve replacement, the scalloped portions of the homograft extend down into the sinuses of Valsalva to within approximately 3 mm of the aortic valve annulus. In the presence of an abscess cavity, the corresponding sinus of Valsalva is left with more aortic wall. The usual extent of scalloping is indicated by the dashed line. The nao height of the aortic wall in the scalloped area that will overlie (and exclude) the abscess cavity is determined by the overall extent of the abscess cavity below and above the native aortic value annulus.
Fig 3. In the areas of normal aortic annulus, initial sutures are passed through the midpoint of the annulus as usual. In the sinus of Valsalva containing the abscess cavity, the initial suture is placed through the lower extent of the abscess cavity if it lies below the annular level.
of the annulus, the distal homograft suture line will incorporate the upper edge of the abscess cavity (Fig 6), which is now totally covered (and excluded) by the homograft (Fig 7). If an extensive abscess cavity exists, encompassing much of the circumference of the aortic annulus, it may be advisable to place the entire proximal suture line below the annular level. If an extensive abscess cavity extends well below the annulus in one area, and if incorporation of the lower abscess rim in the proximal suture line would cause excessive angulation of the homograft, Barratt-Boyes (personal communication,
676 The Annals of Thoracic Surgery Vol 45 No 6 June 1988
Fig 4. The lower suture line follows the lower rim of the abscess cavity in the involved sinus of Valsalva.
Fig 6 . The upper suture lines are completed as usual in the two sinuses of Valsalva without abscess cavity formation. In the area of the abscess cavity, the upper suture line follows the upper rim of the abscess cavity if it extends above the level of the aortic annulus. Otherwise, it is placed as usual.
Fig 5. The posts of the homograft are everted in preparation for the upper suture line, which will exclude the abscess cavity.
1987) has used a pericardial patch to cover the abscess cavity, allowing the proximal homograft suture line to be placed at a more usual level [7]. This maneuver was not necessary in any of our 3 patients.
Comment Controversy exists as to the optimal method or type of valve substitute in the presence of native or prosthetic valve endocarditis [l-51. Data from our institution as well as from other sources [6] indicate that the risk of infection of a bioprosthesis or mechanical prosthesis is highest early after operation and then approaches a constant level of hazard after about six months. In contrast, the aortic valve homograft has a low constant level of hazard for infection from the time of operation, with no early increased risk of homograft infection [6]. This factor may relate to the absence of a cloth sewing ring in the homograft valve or to other as yet unidentified factors. Since the risk of developing prosthetic valve infection is increased perhaps fivefold when operating for endocarditis [7], we believe that the aortic valve homograft is the prosthesis of choice in that situation.
Fig 7. The completed insertion of the aortic valve homograft has now completely excluded the abscess cavity.
Since the first reported successful aortic valve replacement with a homograft aortic valve in the early 1960s [8, 91, the current standard method of insertion has become the continuous two-suture-line technique described by Kirklin and Barratt-Boyes [ 6 ] .In the presence of extensive abscess cavities of the aortic root, the geometry of the aortic root is less predictable. In this setting, Donaldson and Ross [2] have recommended replacing the aortic root with a homograft valve and ascending aorta, with reimplantation of the coronary ostia. Since the abscess cavity is usually below the levels of the coronary ostia, it seemed appropriate to simplify the technique of Donaldson and Ross [2] by contouring the homograft so that it could be placed below the level of the coronary ostia. The results in our 3 patients suggest that this simplified technique is an effective method of managing at least some cases of aortic valve endocarditis with abscess cavities of the aortic root.
677 Kirklin et al: Aortic Homografts for Complex Endocarditis
References 1. Bailey WW, Ivey TD, Miller DW Jr: Dacron patch closure of aortic annulus mycotic aneurysms. Circulation 66:Suppl 1:127, 1982 2. Donaldson Rh4, Ross DM: Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation 7O:Suppl 1:179, 1984 3. Franz PT, Murray GF, Wilcox BR: Surgical management of left ventricular-aortic discontinuity complicating bacterial endocarditis. Ann Thorac Surg 28:1, 1980 4. Reitz BA, Stinson EB, Watson DC, et al: Translocation of the
5. 6. 7. 8. 9.
aortic valve for prosthetic valve endocarditis. J Thorac Cardiovasc Surg 81:212, 1981 Kirklin JK, Kirklin JW, Pacific0 AD: Homograft replacement of the aortic valve. Cardiol Clin 3:329, 1985 Kirklin JW, Barratt-Boyes BG: Aortic valve disease. In Kirklin JW, Barratt-Boyes BG (eds): Cardiac Surgery. New York, Wiley, 1986, pp 373429 Ivert TSA, Dismukes WE, Cobbs GC, et al: Prosthetic valve endocarditis. Circulation 69:223, 1984 Ross DN: Homograft replacement of the aortic valve. Lancet 2:487, 1962 Barratt-Boyes BG: Homograft aortic valve replacement in aortic incompetence and stenosis. Thorax 19:131, 1964
REVIEW OF RECENT BOOKS
Decision Making in Cardiothoracic Surgery Lawrence H . Cohn, Donald B . Doty, and Richard B. McElvein St. Louis, Mosby, 1987 221 pp, illustrated, $46.64
Reviewed by Richard M . Peters, M . D This is an interesting book that alternates pages of tree-structured decision making with explanatory text for diagnosis and handling of cardiothoracic surgical problems. There is a short discussion of the reasons for the decision nodes and two or three references for each page of decisions. The section on acquired heart disease is by Dr. Cohn. There is a series of eleven decision trees on valvular disease, including chronic stenosis, regurgitation of mitral and aortic valves, tricuspid regurgitation, native and prosthetic endocarditis, the selection of mitral and aortic prostheses, bioprosthetic valve failure, and thrombosis of prosthetic discs. The coronary heart disease section contains fifteen decision trees covering postoperative low cardiac output, exercise testing, cardiac failure, various degrees of coronary disease, percutaneous transluminal coronary angioplasty, reoperation, and unstable angina. The third section contains five trees on aortic disease; the fourth has trees on left atrial myxoma, pulmonary embolism, and penetrating trauma of the heart. The section on diagnosis and treatment of congenital heart disease is by Donald Doty. It includes subsections on diagnosis in congenital defects, septa1 defects, anomalies of pulmonary veins, right heart valve lesions, left heart valve lesions, single ventricle, malposition of the great arteries, and thoracic arteries and veins. The final section is by Dr. McElvein and is on thoracic disease. It covers chest wall disorders, pleuromediastinal disease, tracheobronchial tree disease, lung disease, and esophageal disease.
The trees are informative and, as the authors state, provide “a method of approach” to decision making, though incomplete. The authors urge the readers to send them additional information to complete or provide alternatives. The decision trees are a reasonable start for protocols for workup of patients and decisions about surgery, but are not complete, nor are the references more than supportive of the positions taken. However, this format for decision making will be useful and, with modern computer technology, will become a significant part of appropriate patient evaluation. One can foresee this kind of decision tree being available for house officers or physicians in general to provide guides to the steps appropriate for the workup of a particular patient. The computer format would permit a much more versatile and active method of tree structure. For example, for those familiar with the Macintosh computer and the program, MORE’”, using the outliner it is possible with the press of a key or the mouse button to come up with tree structures. A book such as this provides the first steps toward automation and further sophistication. These authors are to be congratulated on following the methodology first started by Norton and Eiseman [l] for depicting tree-structure decision making. This kind of tree construction is conducive to orderly thinking. This book will be useful to general surgery house officers, medical students, and thoracic fellows who are reviewing for their boards, but has limited detail for somebody who is well versed on the subject.
Reference 1. Norton LW, Eiseman B (eds): Surgical Decision Making, second edition. Philadelphia, Saunders, 1986
Son Diego, C A
Patients and Methods Cryopreserved homograft valves for aortic valve replacement have been used at the University of Alabama at Birmingham since 1981. From 1981 to 1986, a total of 54 patients underwent homograft replacement of the aortic valve. Of these, 3 patients had native or prosthetic valve endocarditis that was complicated by important abscess cavities of the aortic root. These 3 patients are the subject of this report. The hospital records and operative notes were reviewed, and follow-up was performed at a mean of 35 months (range, 3 1 4 1 months) by direct telephone communication with the patient or his local physician, or both.
Patient 2 A 31-year-old man with a bicuspid aortic valve and prior repair of coarctation was seen with fever and chills. Blood cultures were positive for Staphylococcus uureus. Because of progressive aortic incompetence, operation was undertaken one month later. At operation, a bicuspid aortic valve was noted, with gross vegetations on the From the Division of CardiovasculariThoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL. Accepted for publication Dec 31, 1987. Address reprint requests to Dr. Kirklin, Department of Surgery, University of Alabama at Birmingham, 739 Zeigler Bldg, University Station, Birmingham, AL 35294.
noncoronary cusp. Two large abscess cavities excavated above the level of the annulus adjacent to the commissure separating the left and right sinuses of Valsalva. The annulus was elongated and redundant in this area, extending well below the level of the remaining annulus. The infected valve was excised, and a 26-mm homograft aortic valve was implanted, such that the abscess cavities were excluded from the circulation. The patient recovered uneventfully and was discharged after an additional 14-day course of intravenously administered antibiotics. He was readmitted to an outside hospital approximately six months later and underwent antibiotic therapy for enterococcal bacteremia. No diastolic murmur was noted. A subsequent cardiac catheterization revealed a small ventricular septal defect (possibly congenital) and no evidence of homograft valve incompetence. At last follow-up (34 months after operation), the patient was well, without clinical evidence of aortic incompetence, and in New York Heart Association (NYHA) Functional Class I.
Patient 2 A 26-year-old man with a congenitally bicuspid aortic valve was seen with native valve endocarditis, blood cultures positive for S. uuyeus, and progressive aortic insufficiency. After a brief course of antibiotic therapy, operation was performed. At operation, a bicuspid aortic valve was found with near obliteration of the leftsided commissure. An intramural abscess could be palpated from outside the heart. Within the aortic root, a localized abscess cavity or phlegmon burrowed into the aortic wall about 5 cm to the left of the left coronary ostium. The infected valve was excised, and a 23-mm homograft aortic valve was implanted, positioned so as to completely isolate the abscess cavity between the two suture lines. The patient was discharged from the hospital 15 days after operation on a regimen of orally administered antibiotics. The patient suffered no further sequelae, had no clinical evidence of aortic incompetence at last follow-up 41 months after operation, and was in NYHA Class I. Patient 3 A 44-year-old man underwent aortic valve replacement with a St. Jude prosthesis at an outside institution. Four months after operation, he was admitted to our institution with S. epidermidis prosthetic valve endocarditis, first degree atrioventricular block, and severe aortic incompetence. After brief initial therapy with intravenously administered antibiotics, the infected prosthetic valve was replaced with an aortic valve homograft. At
674 Ann Thorac Surg 45574-677, June 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
675 Kirklin et al: Aortic Homografts for Complex Endocarditis
Fig 1. The aortic valve has been excised, and the abscess cavity is visualized below the noncoronary sinus of Valsalva.
operation, an abscess cavity 2.5 cm wide and 1 cm deep was located at and below the annulus of the right sinus of Valsalva near the area of the His bundle. A second, smaller abscess cavity was located in the left sinus of Valsalva. The infected prosthesis was removed, and the abscess cavities were debrided. A 20-mm aortic valve homograft was implanted, excluding both abscess cavities from the circulation. His postoperative convalescence was normal. At the time of last follow-up (31 months after operation), he was in NYHA Class I, without recurrent endocarditis, and without evidence of aortic incompetence.
Operative Technique The operative technique consists of the following steps. The infected native or prosthetic valve is excised, and the location and extent of the abscess cavities are assessed (Fig 1). The annulus is sized, and a homograft 2 to 4 mm smaller than the annulus is selected. In the usual setting (without an abscess cavity), the scalloped portion of the homograft wall (in the sinuses of Valsalva) extends to within 3 mm of the annulus. In the presence of an abscess cavity, the distance (above and below the annulus) occupied by the cavity is used to determine the height of the homograft in the corresponding scalloped area (Fig 2). Three 4-0 polypropylene continuous sutures are used; the lower homograft suture line incorporates the lower edge of the abscess cavity and then follows the annulus and subcommissural area as usual (Figs 3, 4). The three posts of the homograft then are everted and properly positioned so that the abscess cavity is covered and the coronary ostia are unobstructed (Fig 5 ) . A 5-0 polypropylene mattress suture is placed through the superior aspect of each post and through the underlying aortic wall above the level of the native commissure. The upper (distal) suture line is constructed with three separate sutures of continuous 4-0 polypropylene, taking care to avoid impinging on the coronary ostium. If the upper edge of the abscess cavity lies above the level
Fig 2 . In preparing the homograft for standard aortic valve replacement, the scalloped portions of the homograft extend down into the sinuses of Valsalva to within approximately 3 mm of the aortic valve annulus. In the presence of an abscess cavity, the corresponding sinus of Valsalva is left with more aortic wall. The usual extent of scalloping is indicated by the dashed line. The nao height of the aortic wall in the scalloped area that will overlie (and exclude) the abscess cavity is determined by the overall extent of the abscess cavity below and above the native aortic value annulus.
Fig 3. In the areas of normal aortic annulus, initial sutures are passed through the midpoint of the annulus as usual. In the sinus of Valsalva containing the abscess cavity, the initial suture is placed through the lower extent of the abscess cavity if it lies below the annular level.
of the annulus, the distal homograft suture line will incorporate the upper edge of the abscess cavity (Fig 6), which is now totally covered (and excluded) by the homograft (Fig 7). If an extensive abscess cavity exists, encompassing much of the circumference of the aortic annulus, it may be advisable to place the entire proximal suture line below the annular level. If an extensive abscess cavity extends well below the annulus in one area, and if incorporation of the lower abscess rim in the proximal suture line would cause excessive angulation of the homograft, Barratt-Boyes (personal communication,
676 The Annals of Thoracic Surgery Vol 45 No 6 June 1988
Fig 4. The lower suture line follows the lower rim of the abscess cavity in the involved sinus of Valsalva.
Fig 6 . The upper suture lines are completed as usual in the two sinuses of Valsalva without abscess cavity formation. In the area of the abscess cavity, the upper suture line follows the upper rim of the abscess cavity if it extends above the level of the aortic annulus. Otherwise, it is placed as usual.
Fig 5. The posts of the homograft are everted in preparation for the upper suture line, which will exclude the abscess cavity.
1987) has used a pericardial patch to cover the abscess cavity, allowing the proximal homograft suture line to be placed at a more usual level [7]. This maneuver was not necessary in any of our 3 patients.
Comment Controversy exists as to the optimal method or type of valve substitute in the presence of native or prosthetic valve endocarditis [l-51. Data from our institution as well as from other sources [6] indicate that the risk of infection of a bioprosthesis or mechanical prosthesis is highest early after operation and then approaches a constant level of hazard after about six months. In contrast, the aortic valve homograft has a low constant level of hazard for infection from the time of operation, with no early increased risk of homograft infection [6]. This factor may relate to the absence of a cloth sewing ring in the homograft valve or to other as yet unidentified factors. Since the risk of developing prosthetic valve infection is increased perhaps fivefold when operating for endocarditis [7], we believe that the aortic valve homograft is the prosthesis of choice in that situation.
Fig 7. The completed insertion of the aortic valve homograft has now completely excluded the abscess cavity.
Since the first reported successful aortic valve replacement with a homograft aortic valve in the early 1960s [8, 91, the current standard method of insertion has become the continuous two-suture-line technique described by Kirklin and Barratt-Boyes [ 6 ] .In the presence of extensive abscess cavities of the aortic root, the geometry of the aortic root is less predictable. In this setting, Donaldson and Ross [2] have recommended replacing the aortic root with a homograft valve and ascending aorta, with reimplantation of the coronary ostia. Since the abscess cavity is usually below the levels of the coronary ostia, it seemed appropriate to simplify the technique of Donaldson and Ross [2] by contouring the homograft so that it could be placed below the level of the coronary ostia. The results in our 3 patients suggest that this simplified technique is an effective method of managing at least some cases of aortic valve endocarditis with abscess cavities of the aortic root.
677 Kirklin et al: Aortic Homografts for Complex Endocarditis
References 1. Bailey WW, Ivey TD, Miller DW Jr: Dacron patch closure of aortic annulus mycotic aneurysms. Circulation 66:Suppl 1:127, 1982 2. Donaldson Rh4, Ross DM: Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation 7O:Suppl 1:179, 1984 3. Franz PT, Murray GF, Wilcox BR: Surgical management of left ventricular-aortic discontinuity complicating bacterial endocarditis. Ann Thorac Surg 28:1, 1980 4. Reitz BA, Stinson EB, Watson DC, et al: Translocation of the
5. 6. 7. 8. 9.
aortic valve for prosthetic valve endocarditis. J Thorac Cardiovasc Surg 81:212, 1981 Kirklin JK, Kirklin JW, Pacific0 AD: Homograft replacement of the aortic valve. Cardiol Clin 3:329, 1985 Kirklin JW, Barratt-Boyes BG: Aortic valve disease. In Kirklin JW, Barratt-Boyes BG (eds): Cardiac Surgery. New York, Wiley, 1986, pp 373429 Ivert TSA, Dismukes WE, Cobbs GC, et al: Prosthetic valve endocarditis. Circulation 69:223, 1984 Ross DN: Homograft replacement of the aortic valve. Lancet 2:487, 1962 Barratt-Boyes BG: Homograft aortic valve replacement in aortic incompetence and stenosis. Thorax 19:131, 1964
REVIEW OF RECENT BOOKS
Decision Making in Cardiothoracic Surgery Lawrence H . Cohn, Donald B . Doty, and Richard B. McElvein St. Louis, Mosby, 1987 221 pp, illustrated, $46.64
Reviewed by Richard M . Peters, M . D This is an interesting book that alternates pages of tree-structured decision making with explanatory text for diagnosis and handling of cardiothoracic surgical problems. There is a short discussion of the reasons for the decision nodes and two or three references for each page of decisions. The section on acquired heart disease is by Dr. Cohn. There is a series of eleven decision trees on valvular disease, including chronic stenosis, regurgitation of mitral and aortic valves, tricuspid regurgitation, native and prosthetic endocarditis, the selection of mitral and aortic prostheses, bioprosthetic valve failure, and thrombosis of prosthetic discs. The coronary heart disease section contains fifteen decision trees covering postoperative low cardiac output, exercise testing, cardiac failure, various degrees of coronary disease, percutaneous transluminal coronary angioplasty, reoperation, and unstable angina. The third section contains five trees on aortic disease; the fourth has trees on left atrial myxoma, pulmonary embolism, and penetrating trauma of the heart. The section on diagnosis and treatment of congenital heart disease is by Donald Doty. It includes subsections on diagnosis in congenital defects, septa1 defects, anomalies of pulmonary veins, right heart valve lesions, left heart valve lesions, single ventricle, malposition of the great arteries, and thoracic arteries and veins. The final section is by Dr. McElvein and is on thoracic disease. It covers chest wall disorders, pleuromediastinal disease, tracheobronchial tree disease, lung disease, and esophageal disease.
The trees are informative and, as the authors state, provide “a method of approach” to decision making, though incomplete. The authors urge the readers to send them additional information to complete or provide alternatives. The decision trees are a reasonable start for protocols for workup of patients and decisions about surgery, but are not complete, nor are the references more than supportive of the positions taken. However, this format for decision making will be useful and, with modern computer technology, will become a significant part of appropriate patient evaluation. One can foresee this kind of decision tree being available for house officers or physicians in general to provide guides to the steps appropriate for the workup of a particular patient. The computer format would permit a much more versatile and active method of tree structure. For example, for those familiar with the Macintosh computer and the program, MORE’”, using the outliner it is possible with the press of a key or the mouse button to come up with tree structures. A book such as this provides the first steps toward automation and further sophistication. These authors are to be congratulated on following the methodology first started by Norton and Eiseman [l] for depicting tree-structure decision making. This kind of tree construction is conducive to orderly thinking. This book will be useful to general surgery house officers, medical students, and thoracic fellows who are reviewing for their boards, but has limited detail for somebody who is well versed on the subject.
Reference 1. Norton LW, Eiseman B (eds): Surgical Decision Making, second edition. Philadelphia, Saunders, 1986
Son Diego, C A