[Experiences with biological aortic valve at Ullevål hospital]. / Erfaringer med biologiske aortaklaffer ved Ullevål sykehus.

Biological valves have been used at Ullevål Hospital since 1993 in patients over the age of 70, and in younger patients when anticoagulation is contraindicated. We have used two different types of biological valves; Medtronic Freestyle, a non-stented valve made from pigs aortic root; and Carpentier-Edwards, made from calf pericardium. This valve is mounted in a metallic frame (stent), covered by dacron. Both valves are fixed in glutaraldehyde to diminish tissue antigenicity. 91 patients were operated with biological valves during the period 1993 till January 1998; 56 patients received the Carpentier-Edwards and 35 Freestyle. Postoperative complications have been few and time in the intensive care unit and total hospital stay is satisfactory despite the high age of this group of patients. The overall 30 days postoperative mortality was 4.4%. In conclusion, aortic stenosis and insufficiency can be operated with low mortality and short postoperative or intensive care stay. There was no significant difference between the two groups of patients.

[Bronchial ruptures are rare and should be surgically treated]. / Bronkialrupturer er sjeldne, og de skal opereres.

Bronchial rupture in blunt trauma is caused by sudden compression of the chest with dislocation of the lungs. The less pliant bronchi may thus rupture. Bronchial rupture is rare in patients admitted alive. Bronchial rupture has been diagnosed in two of the last 275 severe chest traumas admitted to Ullevål hospital since 1993 (0.7%). A 19-year-old male had total atelectasis of the lung 19 days after the trauma. A four-year-old boy experienced total collapse of the lung and became critically ill the fourth day after initial normalisation of the chest X-ray. Both patients were successfully operated on, with reconstruction of the left main bronchus in both cases, after 29 and seven days, respectively. In the child an upper lobectomy was necessary. These patients illustrate that with expectative treatment in bronchial rupture, serious complications may be experienced.

[Surgical treatment of infective endocarditis]. / Operativ behandling av infeksiøs endokarditt.

Patients operated on for infective endocarditis (n = 69) at two regional hospitals between 1988 and 1994 are reviewed. 70% had a known valvular heart disease and 16% had prosthetic valve endocarditis. In 28% the offending microorganism was Staphylococcus aureus; in 26% Streptococcus viridans. Therapy was intended to be a six-week antibiotic course before operating, but 55% of the patients had to be operated on earlier. The postoperative course was uncomplicated in 59%, mortality was 16% and one-year survival 81%. Increased risk of death was associated with operating before the six-week course of antibiotics was completed (p = 0.005), with preoperative renal failure (p = 0.006) or lung failure (p = 0.008), with the growth of microorganisms from tissue samples extirpated during the operation (p = 0.01), with additional surgical procedures concomitant to valvular replacement (p = 0.02), S. aureus endocarditis (p = 0.03), and with the presence of paravalvular abscesses or intracardial fistulas (p = 0.03). The study shows that infective endocarditis is a serious disease. Wherever clinically feasible, all patients should be given antibiotics for six weeks before evaluating surgery. However, close surveillance of infection and haemodynamics is necessary to allow for the possibility of acute surgery before the development of organ failure. Special attention must be paid to cases of S. aureus endocarditis.

[Infectious endocarditis at Ullevål hospital 1988-94. Echocardiographic investigation]. / Infeksiøs endokarditt ved Ullevål sykehus 1998-94. Utredning med ekkokardiografi.

During a seven-year period (1998-94) 68 patients with infectious endocarditis were diagnosed at a university hospital. Staphylococcus aureus was the most common etiological agent (38%), followed by Streptococcus viridans (21%). In seven patients the diagnosis infectious endocarditis was first made during autopsy, all seven of them had the clinical diagnosis septicaemia. Surgery was performed on 41% of the patients. Case fatality was 34%. Case fatality was significantly higher for S aureus endocarditis than for S viridans endocarditis, 48% vs. 7% (p = 0.01). The advantages of transthoracic and transoesophageal echocardiography in the diagnosis and follow up of patients with infectious endocarditis is emphasized. In spite of these new diagnostic tools a definitive clinical diagnosis of infectious endocarditis was not made for 23% of the patients.

[Long term results of the use of Björk-Shiley convex-concave heart valves. Ullevol hospital 1978-83]. / Langtidsresultater ved bruk av Björk-Shileys konveks-konkave hjerteventiler. Ullevål sykehus 1978-83.

In recent years, Björk-Shiley CC-valves have become the object of suspicion after several reports of strut fracture with embolization of the tilting disk and acute heart failure. At Ullevål Hospital Björk-Shiley CC-valves were used in 341 patients during the period October 1978 to March 1983. Strut fracture occurred in four cases, three of the patients died and one survived an emergency heart operation with replacement of the valve. In four patients, prophylactic replacement of the valves was performed. During the observation period concluded in September 1995 a total of 187 patients died. These included 26 operative deaths (7.6%). Of the late deaths, 40% were due to heart failure and 21% were sudden deaths. Strut fracture was the cause of death in 2% of the late deaths.

Mortality in patients supported by intra-aortic balloon pump in the course of cardiac surgery was related to perioperative myocardial infarction.

OBJECTIVE: To search for predictors of mortality for patients in need of intra-aortic balloon pump (IABP) support in the course of cardiac surgery. METHODS: A retrospective study of possible pre- and perioperative risk factors in 110 patients with mean age of 62 years (38-79). The IABP was inserted preoperatively in 19 (17%) and perioperatively in 91 (83%). RESULTS: Well known risk factors as advanced age (63.2/61.0; P = 0.25), NYHA functional class (OR = 1.59; 95% CI 0.23 to 13.31), female sex (OR = 2.40; 95% CI 0.81 to 6.73), emergency surgery (OR = 0.63; 95% CI 0.21 to 1.80), low left ventricular ejection fraction (62.9/60.7; P = 0.53), or elevated end diastolic pressure (19.4/21.0; P = 0.48), were not prognostic of death. Perioperative insertion of the balloon pump (OR = 3.83; 95% CI 1.07 to 14.95), perioperative myocardial infarction (OR = 23.3; 95% CI 7.62 to 81.8), low cardiac output (OR = 7.53; 95% CI 2.43 to 24.11), and renal failure (OR = 20.00; 95% CI 3.63 to 145), were strong predictors of death. CONCLUSIONS: Outcome seemed to be determined by perioperative events rather than preoperative risk factors. This could possibly explain the favourable mortality rates seen in patients on IABP support prior to surgery compared to patients who had IABP installed perioperatively.

Effect of dietary supplementation with n-3 fatty acids on coronary artery bypass graft patency.

Epidemiologic and experimental data suggest that a high dietary intake of long-chain polyunsaturated n-3 fatty acids may reduce the risk of atherothrombotic disease. In a randomized, controlled study, 610 patients undergoing coronary artery bypass grafting were assigned either to a fish oil group, receiving 4 g/day of fish oil concentrate, or to a control group. All patients received antithrombotic treatment, either aspirin or warfarin. Their diet and serum phospholipid fatty acid profiles were monitored. The primary end point was 1-year graft patency, which was assessed by angiography in 95% of patients. Vein graft occlusion rates per distal anastomoses were 27% in the fish oil group and 33% in the control group (odds ratio 0.77, 95% confidence interval, 0.60 to 0.99, p = 0.034). In the fish oil group, 43% of the patients had > or = 1 occluded vein graft(s) compared with 51% in the control group (odds ratio 0.72, 95% confidence interval, 0.51 to 1.01, p = 0.05). Moreover, in the entire patient group, there was a significant trend to fewer patients with vein graft occlusions with increasing relative change in serum phospholipid n-3 fatty acids during the study period (p for linear trend = 0.0037). Thus, in patients undergoing coronary artery bypass grafting, dietary supplementation with n-3 fatty acids reduced the incidence of vein graft occlusion, and an inverse relation between relative change in serum phospholipid n-3 fatty acids and vein graft occlusions was observed.

[Thoracoscopic surgery]. / Torakoskopisk kirurgi.

Thoracoscopic operations were performed on 91 patients. In 52 patients operated on by thoracoscopic pleurodesis for pneumothorax, the results were compared with the results in 41 patients previously operated on by transaxillary thoracotomy. The groups did not differ with respect to duration of stay in hospital or minor complications, but the duration of postoperative sick leave was significantly reduced after thoracoscopic operation. In nine cases lung metastasis or primary lung tumours were removed thoracoscopically. Thoracoscopic evacuation were performed in seven cases of empyema or pleural haematoma. Two of these patients were later operated on by open decortication. The main advantages of thoracoscopic surgery are less postoperative pain and a shorter time away from work after operation than with open procedures.

Risk factors for graft occlusion after coronary artery bypass grafting.

A cohort of 610 well-characterized patients undergoing coronary artery bypass grafting were followed through the first postoperative year. Graft patency was angiographically assessed in 578 (94.8%) of the patients on average 12.1 (SD 1.5) months postoperatively and was related to characteristics of grafts and patients. For internal mammary artery grafts the incidence of graft occlusion was higher in women than in men and was inversely related to body surface area. In multivariate analysis the influence of gender was no longer significant when adjusted for body surface area. With vein grafts the incidence of occlusion was inversely related to body surface area and was positively associated with ejection fraction. Occlusion of vein grafts was less common in patients treated with beta-blockers pre- and peroperatively.

Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study.

The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg.ml-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg.ml-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins-Henry pain scale. Morphine requirement was registered, there was no difference between the groups in pain scores or need for additional morphine.

[Rupture of the thoracic aorta and multiple injuries]. / Ruptur av torakalaorta og multiple skader.

Traumatic rupture of the thoracic aorta is an extremely severe injury, and is usually fatal. The injury is most often seen in forceful deceleration trauma. This complicates the priority of diagnosis and treatment in relation to other severe injuries in the same patient. During the period 1984-1991, nine patients underwent operation for this injury at the Department of Thoracic Surgery. Two patients succumbed, because of free rupture in the operating theatre. The others survived. Three of these were treated by directly suturing the rupture, and four by introducing a prosthesis. The prognosis in operated traumatic rupture of the thoracic aorta is good if the haematoma is contained. Relevant history of deceleration and suspicion of mediastinal widening should lead to arcography and prompt operation if the diagnosis is confirmed. Only significant intraabdominal or intracranial hemorrhage supersede aortic rupture in the initial priorities for treatment.

Pulmonary endometriosis causing haemoptysis. Report of a case treated with lobectomy.

A 24-year-old woman with catamenial haemoptysis was treated with the antioestrogenic drug danazol for suspected pulmonary endometriosis. The haemoptysis then ceased, but rapidly recurred when the patient discontinued the medication 3 months later because of severe side effects. Lobectomy was performed, and the diagnosis histologically confirmed, 14 months after the onset of symptoms. Thereafter the patient was free from haemoptysis.

Thoracoscopic pleurodesis.

Thoracoscopic pleurodesis for pneumothorax was performed on 23 patients (16 men, 7 women), including seven with chronic obstructive pulmonary disease, over a 12-month period. Single-lumen intubation with spontaneous ventilation were used making intrapleural insufflation unnecessary. Postoperatively the patients required chest drainage for 1-28 (mean 3) days and remained in hospital for 3-33 (mean 6) days. The 14 gainfully employed patients had 11-40 (mean 20) days' sick leave. Hydrothorax requiring pleurocentesis developed in one patient after thoracoscopy. Pneumothorax recurred in another immediately after removal of the chest drain, but resolved definitively after 2 more days of drainage. A patient with obstructive lung disease required ventilator management for a week after the operation, but otherwise no serious complications were observed.

Risk factors of septicemia and perioperative myocardial infarction in a cohort of patients supported with intra-aortic balloon pump (IABP) in the course of open heart surgery.

In 1325 open heart operated (OHO) patients with a perioperative mortality of 5.8% the incidence of septicemia and perioperative myocardial infarction (PMI) were much higher in a cohort of 110 patients given intra-aortic balloon pump (IABP) support during the operative course. Analysis of this cohort showed that peri/postoperative insertion of the pump, the presence of disease in the descending branch of left coronary artery (LAD) and the need of more than one saphenous vein graft were risk factors for PMI. The presence of LAD disease was the only independent risk factor for PMI with an odds ratio (OR) of 4.62. Well known risk factors such as NYHA functional class, emergency, low left ventricular ejection fraction (EF) or elevated end diastolic pressure (EDP) were not prognostic of PMI. Thus, the intraoperative seemed to be more important than the preoperative risk profile for the development of PMI. Independent risk factors for the development of septicemia were the duration of IABP with an OR of 1.5 for each pump day and implantation of a valve prosthesis with an OR of 6.3. To avoid septic complications, this study suggests pump removal as soon as possible.

[Decortication of the lung]. / Dekortikasjon av lungen.

During a six year period 18 patients were operated by decortication of the lung. Eight patients had empyema, five were decorticated for postoperative/posttraumatic formation of haematoma. Four patients had restrictive pleuritis and one patient was operated due to insufficient expansion of the lung after operation for emphysematous bullae. After the decortication, one patient developed empyema and one septicemia, but both these patients were treated successfully. The median postoperative stay in hospital was 13 (7-84) days. Decortication should be considered for patients with empyema or pleural haematoma if the pleural effusion persists after more than one week of adequate drainage.

[Accidental hypothermia. Risk factors in 29 patients with body temperature of 30 degrees C and below]. / Aksidentell hypotermi. Risikofaktorer hos 29 pasienter med kroppstemperatur under 30 C grader.

29 patients with a body temperature below 30 degrees C (mean 26.4 degrees C) were treated during the period 1982-88, both years inclusive. Eight patients were severely hypotensive (systolic blood pressure less than 60 mm Hg) and two had ventricular fibrillation on admission. Bradycardia (less than 60 beats per minute) was noted in ten patients. 12 patients were rewarmed by surface warming, 17 by extracorporeal circulation with femoral cannulation. 22 patients (76%) were discharged alive. Age, sex, body temperature, method and rate of rewarming, serum electrolytes, acidosis and the use of blood components did not influence the outcome. Renal failure was the only complication associated with a fatal outcome. Severe hypotension on admission tended to increase mortality, but logistic regression analysis identified the mode of cooling as the only independent risk factor for death. A patient cooled indoors had an odd risk of 10.6 of hospital mortality compared to one found outdoors. For the sake of convenience, in hospitals with the available resources rewarming by extracorporeal circulation may be used in patients with circulatory arrest, since this is the easiest way to control and support failing circulation. In all other cases carefully monitored surface rewarming should be used as this necessitates less use of hospital resources and produces equally good results.

[Surgical pleurodesis in spontaneous pneumothorax]. / Kirurgisk pleurodese ved spontanpneumothorax.

Over a five year period 41 operations for spontaneous pneumothorax were performed on 38 patients. In all cases a transaxillary thoracotomy was performed in the third, or in some cases the fourth, intercostal space. Bullae were resected and operative pleurodesis carried out by rubbing the parietal pleura with a dry sponge. The indications for operation were: 1) More than one episode of pneumothorax on the relevant side. 2) The first incidence of pneumothorax if the patient had pneumothorax on the contralateral side before. 3) Continuous leakage of air after a week of drainage. One patient had to be reoperated for recurrence of pneumothorax, and one was reoperated due to formation of a large postoperative haematoma. One patient developed paresis of the serratus anterior muscle due to lesion of the long thoracic nerve.

Risk factors for morbidity and mortality in mitral valve replacement.

Risk factors of operative mortality and long term survival were identified in 219 patients who underwent mitral valve replacement (MVR) using Bjørk-Shiley mechanical prostheses. Early mortality was 7.3%. The accumulated follow-up time was 1134 patient-years, and the 5-year survival for the total cohort was 78 +/- 3%. Independent prognostic factors of early mortality were poor NYHA class, which carried a relative risk (RR) of 3.2, and ischaemic aetiology, with a RR of 2.2. Ischaemic aetiology was the sole predictor of heart pump failure requiring intra-aortic balloon pump support (RR = 2.7). Independent risk factors of total mortality (early and late) were male sex (RR = 2.3), NYHA class III-IV (RR = 2.4), presence of mitral regurgitation (RR = 3.2) and relative heart volume (RR = 1.6 for a 800 ml/m2 size compared to a heart of 550 ml/m2). Our results underline the importance of patient-related factors in MVR, and indicate that care is needed in comparing the quality of MVR from different institutions with respect to mortality and morbidity. The results of MVR are palliative rather than curative except in female patients with NYHA class II function and mitral stenosis, in whom cure was attained.

Mediastinal fibrosis. A case report.

Mediastinal fibrosis may be part of a multifocal fibrotic disease, including retroperitoneal fibrosis, lung fibrosis and Riedel's struma. A case of mediastinal fibrosis, with a previous history of retroperitoneal fibrosis and lung fibrosis, is discussed. There are many known causes of retroperitoneal and mediastinal fibrosis, but as in the present case the etiology often remains unknown.