Clinical experience with the Björk-Shiley integral monostrut heart valve prosthesis in the aortic and mitral position.

From May 1982 to May 1985, 174 Björk-Shiley integral monostrut (BSIM) heart valve prostheses were implanted in 160 patients. Eighty-eight valves were placed in mitral and 86 in aortic position. There were 92 males and 78 females with a mean age of 54.1 years (140 patients were in NYHA class III or IV (87.5%]. Single valve replacement was performed in 116 (72%) patients, 30 (19%) underwent multiple valve procedures and in 14 (9%) valve replacement was combined with coronary artery bypass surgery. There were no intraoperative deaths. Six patients died within the first month after surgery. One hundred and fifty-two (98.7%) patients were followed for a total of 190 patient years (average 14.8 months per patient). There were 8 late deaths (4.2 per 100 patient-years), 5 of these were valve related. Valve related complications were observed in 9 patients (4.5 per 100 patient-years). The overall incidence of peripheral embolization was 2.6 per 100 patient years. At the time of the follow-up study 136 (94%) patients were in functional class I and II. Fourteen patients with isolated AVR and six with MVR underwent hemodynamic evaluation on an average of 12 and 10 months after surgery. The early results suggest that the BSIM prosthesis represents a promising alternative in heart valve replacement, because there were no mechanical failures, thromboembolic complications are rare and hemodynamic performance is good.

Changes in serum cyclic nucleotide concentration during open-heart surgery.

Changes in serum cyclic AMP and GMP concentrations were studied in 14 patients undergoing open-heart surgery with cold cardioplegia. Blood samples were taken on total bypass from the radial artery and from the coronary sinus before aortic cross-clamping and 1 and 9 min after declamping. The samples were analyzed for cyclic nucleotides. The cAMP levels showed no pronounced change in the arterial samples, but were significantly increased in the coronary sinus samples after declamping of the aorta. The cGMP values showed the same trend of change in the arterial and the coronary sinus samples, viz. significant fall after aortic release, and after 9 min an increase. The cAMP/cGMP ratio after clamp removal showed pronounced increase in the first minute and some reduction at 9 min. All the changes were statistically significant. Beating recommenced spontaneously in seven hearts. The cAMP levels were lower in this group than in the patients without spontaneous recovery. The outset cGMP levels and the cAMP/cGMP ratio were higher in the latter group. Absence of increase in the cGMP level may be due to effectiveness of cardioplegia in reducing the energy requirements of the ischemic myocardium. The study indicates that hearts without spontaneous recovery of beating react more sensitively to hypoxia and have to use up more of their energy resources for restoration of function.

Idiopathic dilatation of the right atrium. A case report.

Idiopathic dilatation of the right atrium in a young woman is reported. Thoracotomy was performed for suspected pericardial cyst. Intraoperative findings suggested idiopathic right atrial dilatation, which was histologically confirmed. Two years after partial resection of the dilated right atrial wall the patient is doing well. Management of asymptomatic idiopathic dilatation of the right atrium should be medical, surgery being reserved for patients with symptoms.

Iatrogenic aortocaval fistula secondary to intervertebral disc surgery. A case report.

A case of iatrogenic aortocaval fistula is presented. The fistula arose in association with lumbar disc surgery. Its presence was immediately suspected and was promptly confirmed by aortography. Sudden deterioration of the patient's condition necessitated surgical correction of the fistula before the elected date. The successful corrective operation is described and some preventive recommendations are made.

Ascending aortic aneurysms. Review of 100 consecutive cases.

Aneurysms of the ascending aorta, if undiagnosed or untreated, may result in left ventricular failure from aortic valvular insufficiency. Aortic rupture, dissection, or compression of adjacent vital structures may also occur. The application of refined cardiopulmonary bypass devices, prosthetic heart valves, and synthetic grafts now allows successful surgical management of this disorder. This report presents our current diagnostic methods, surgical techniques, and the early and late results of 100 consecutive patients undergoing surgical treatment of aneurysms of the ascending aorta. There were 72 males and 28 females, ranging in age from 25 to 72 (ave 51.2) years. All patients had angiographic studies to demonstrate precisely the location of the aneurysm and the presence or absence of aortic valvular insufficiency. Sixty-three patients required concomitant aortic valve replacement, and the remaining 37 patients had only aneurysm resection and replacement. Pathological studies revealed 69 aneurysms were atherosclerotic, 22 were secondary to cystic medial necrosis, with the remaining 9 considered to be possibly leutic in origin. Despite the magnitude of the surgery and the advanced ages of some of these patients, the overall operative and hospital mortality rates were 4% and 9%. Survival rates by actuarial representation in 82 patients at 2, 4, 6, and 8 years were 82.9%, 78%, 70%, and 69.5%, respectively.

Intraoperative arteriography during femoral-popliteal bypass.

Minor technical errors may jeopardize the patency of femoral-popliteal bypass grafts. In an attempt to detect such errors, intraoperative arteriography has been routinely employed. It allows immediate recognition and correction of the most common abnormal findings: intraluminal debris, intimal dissection, distal thrombosis, arterial spasm, and kinking of the graft.

Double prosthetic aortic valve. Case report.

A 55-year-old man underwent insection of a Hufnagel valve into his descending thoracic aorta for aortic valve insufficiency 18 years ago. He remained asymptomatic for 16 years. Because of progressive left ventricular failure his incompetent aortic valve was replaced with a De Bakey carbon ball aortic valve prosthesis 2 years later. Currently, 21 months after the operation, he is doing well with two aortic valves. Review of the literature suggests that he is the first patient reported with two aortic valves functioning concomitantly and one of the longest surviving patients with a Hufnagel valve.

Membrane vs bubble oxygenator: clinical comparison.

Numerous studies have demonstrated the superiority of membrane oxygenators (MO) over the bubble oxygenators (BO) when used for prolonged cardiopulmonary support. However, there is little information available evaluating the MO for routine, short-term cardiopulmonary bypass. In this study the 5MO314 Modulung-Teflo (MO) was compared to 5M30314 Miniprime Variflo (BO). The data of 91 patients (46 MO and 45 BO) were analyzed according to the duration of cardiopulmonary bypass (Group I less than 60 min., Group II 60-90 min. and Group III greater than 90 min.). Hemodynamic parameters, fluid and blood balance, as well as hematologic and blood gas studies were used for comparing the two oxygentors. The hemodynamic parameters were better, and the arterial blood gases were more physilogic with the MO. The postoperative blood loss was significantly less when using the MO. The other measurements documented the stability of the MO. All statements were based on statistical analysis with a DEC PDP-9 computer, using the MIIS language and operating system. Consequently, we are now using this MO for routine cardiopulmonary bypass.

Complete occlusion of the infrarenal abdominal aorta: management and results in 64 patients.

Sixty-four patients with complete occlusion of the infrarenal abdominal aorta were reviewed. The clinical findings, diagnostic procedures, and surgical management are described. Sixty-one patients underwent thromboendarterectomy and bypass grafts from the infrarenal abdominal aorta to the iliac or common femoral arteries. Because purulent material was found in the retroperitoneum of two patients, the proximal anastomosis was performed to the descending thoracic aorta in one patient and to the upper abdominal aorta in the other. One patient underwent thromboendarterectomy and patch graft angioplasty. The hospital mortality rate was 4.6 percent. Sixty-one patients discharged from the hospital were followed (average length of follow-up was 37 months). There were three late deaths (4.9 percent). Two patients have had occlusion of one limb of their bypass grafts and, along with four others, have developed recurrent symptoms of vascular insufficiency of the lower extremities. These symptoms were due to progressive atherosclerotic occlusive disease of the distal arterial tree for which additional distal procedures were required.

Inadvertent femoral artery "stripping": surgical management.

Following "vein stripping" for varicosities, two patients were referred to our service for evaluation of arterial insufficiency of the lower extremities. Both patients had had surgical interruption of the femoral arterial system which required reconstruction. This paper emphasizes the importance of understanding surgical anatomy and presents the techniques of successful surgical management of both cases.

Evaluation of myocardial revascularization utilizing Tc-99m pyrophosphate.

Early clinical application of technetium 99m labeled pyrophosphate for cardiac imaging has revealed a safe noninvasive method of determining areas of impaired myocardial perfusion in patients with atherosclerotic occlusive coronary artery disease. Using this method, we were able to demonstrate improvement in myocardial blood supply following coronary artery bypass surgery.