Early and late results of aortic valve replacement. A series of 510 patients.

Aortic valve replacement was performed in 510 patients (Björk-Shiley valves in 93%), with concomitant surgical procedures in 146 cases. The patients were grouped according to technique of myocardial protection: Group I (n = 98) selective coronary perfusion, group II (n = 82) topical cooling, and group III (n = 330) cold crystalloid cardioplegia and topical cooling. The early mortality rate was 5.7% overall: Among patients with isolated aortic valve replacement in groups I, II and III it was 8.4, 1.7 and 1.3%, respectively, and among those with additional surgery 40.0, 12.5 and 8.4%. Myocardial infarction and low cardiac output were responsible for 65.5% of the early deaths. Follow-up ranged from 2 months to 16 11/12 years, totalling 2,859 patient years. In patients with isolated aortic valve replacement and Björk-Shiley prosthesis, the incidence of valve-related late complications/100 patient years was 0.49 for thromboembolism, 0.82 for anticoagulant-related haemorrhage and 0.49 for prosthetic valve endocarditis. There was no thrombotic encapsulation in aortic position. Survival at 5 and 10 years was 83% and 72%. Aortic valve replacement is a safe procedure and concomitant operations do not unreasonably increase risks.

Prosthetic valve endocarditis.

Prosthetic valve endocarditis is an infrequent but serious complication of valve surgery. It occurred in 25 (3.2%) of 772 patients who received aortic, mitral or double valve replacement in 1971-1987. The total follow-up time was 3,976 patient years, giving an incidence of 0.63/100 patient years. Staphylococci were the most common of the cultured organisms in early and late infections-60% and 64%, respectively. The endocarditis was disclosed at autopsy in two cases. Treatment was antibiotics alone in 11 cases, and surgery was required in 12, the indication always being congestive heart failure. C-reactive protein level fell more rapidly than erythrocyte sedimentation rate in response to antibiotic or surgical management. The mortality rate was 73% in the antibiotic group and 33% in the surgical group. The findings demonstrated that an infected valve prosthesis should be replaced without delay if complications develop.

Results of multiple valve repair. A clinical study of 81 patients.

A report is presented of 50 men and 31 women, mean age 50.3 years, who underwent surgery for multivalvular cardiac disease in 1973-1987. NYHA function class was III-IV in 88% of the patients. The most common procedures were aortic + mitral valve replacement (81%), aortic + mitral valve replacement + coronary artery bypass grafting (5%), aortic valve replacement + tricuspid valvuloplasty (5%) and mitral valve replacement + tricuspid valvuloplasty (5%); 95% of the implanted valves were of Björk-Shiley disc type. Nine patients died perioperatively, six due to myocardial infarction and/or low cardiac output. Postoperative bleeding necessitated resternotomy in three cases. Follow-up was complete, with a mean observation time of 4.5 years (a total of 323 patient years). The incidence of thrombotic valve encapsulation was 0.6/100 patient years. Corresponding figures for anticoagulant-related haemorrhage, prosthetic valve endocarditis and paraprosthetic leakage were 0.9, 1.2 and 1.2. In our experience, the rate of late complications after multivalvular reconstruction using Björk-Shiley prosthesis is acceptable if anticoagulant therapy is correctly employed.

Surgical treatment of active native valve endocarditis.

A report is presented of 24 patients (23 male), mean age 38 years, who underwent surgery for active native valve endocarditis of the left heart in 1975-1988. The aortic valve was affected in all patients, and also the mitral valve in five. Pre-existing aortic valve disorder was present in 17 cases (13 congenitally bicuspid 4 rheumatic affection). There were five hospital deaths (20.8%). Staphylococci as causal organism and extensive infection predicted the highest mortality and morbidity. The mean follow-up time was 39.7 (range 2-114) months. Two reoperations because of prosthetic valve dehiscence revealed endocarditis of the implanted valve. Strong correlation was found between favourable postoperative course and rapid normalization of C-reactive protein levels, which did not fall in patients with persistent infection. Early surgery is recommended if the course of bacterial endocarditis is severely complicated.

Mesocaval shunt for bleeding oesophageal varices.

A total of 43 patients underwent end to side mesocaval (25 patients) or interposition shunts (18 patients) for bleeding oesophageal varices in 1970-1985. Alcoholic cirrhosis was the aetiology in 30 patients. The operation was elective in 26 and urgent or as emergencies in 17 instances. Operative mortality in elective operations was 19%. In emergency operations the bleeding was controlled in all but one patient, but the mortality was 56%. In Child's group C the mortality was also high, about 50%. During the follow-up of 18 months to 16 years there were five episodes of gastrointestinal bleeding, two of which might have been variceal. Out of the 43 patients 22 survived at least 2 years. Most of the late deaths were caused by hepatic coma; no patient died of recurrent variceal bleeding. - The two types of shunt were equally effective in lowering portal venous pressure. Two venous leg ulcers occurred after an end to side shunt. During the period under study the end to side mesocaval shunt was abandoned and from 1980 only interposition shunts have been performed in our clinic.

Clinical results after mitral valve replacement with the Björk-Shiley disc prosthesis.

Between September 1971 and June 1985, 230 Björk-Shiley valves were implanted for mitral valve disease at the Department of Surgery, University of Turku. Concomitant cardiac surgical procedures were performed in 35.2% of the cases. The follow-up period was between 1 month-13 years 4 months, with a total follow-up of 986 patient years. The early mortality was 4% in patients with isolated MVR and 10% where concomitant procedures had to be performed. Since the use of cold cardioplegia there has been no mortality for isolated MVR and the mortality rate for patients with concomitant procedures has been 3.9%. During the follow-up the rate of thromboembolism was 0.4 per 100 patient years, that of thrombolic encapsulation 0.4 and anticoagulant-related haemorrhage 0.7. Ninety-five per cent of the patients were free from thrombotic or embolic complications at 5 and 10 years after surgery. The survival rate was 79% at 5 years and 72% at 10 years. Considering these results we still prefer the Björk-Shiley valve in mitral valve replacement.

Results of five standard operations for elective surgery of duodenal ulcer.

459 patients who were operated on electively for duodenal ulcer in the Surgical Department, University of Turku, in 1965-1976 are reviewed. The operations were: Billroth II resection (B II) 95, truncal vagotomy and antral resection (TV-A) 61, selective gastric vagotomy and antral resection (SV-A) 159, vagotomy and pyloroplasty (V-P) 70, and parietal cell vagotomy (PCV) 110 patients. Operative mortality was 0 in B II, 4.9% in TV-A, 0.6% in SV-A, 1.4% in V-P, and 0 in PCV. About 80% of patients were interviewed 3-12 (mean 5-7) years after operation. Dumping, diarrhea and vomiting occurred less frequently after PCV, but dyspepsia was as common as after B II, TV-A, SV-A, or V-P. Recurrence rates were: after B II 2.7%, TV-A 0, SV-A 0.7%, V-P 9.7% and PCV 8.5%. The incidence of good overall results (Visick grades I + II) was similar after PCV and B II (70% and 69%) which was significantly better than after V-P (41%) and compared favorably with TV-A or SV-A (56% and 54%).

Parietal cell vagotomy for duodenal and pyloric ulcer: clinical and secretory results.

UNLABELLED: In the Department of Surgery, University of Turku, 310 patients underwent parietal cell vagotomy for duodenal (268 patients) or pyloric-prepyloric ulcer (42 patients) in the years 1973-82. The male/female ratio was 4/1 and mean age 43 years. There was no mortality. Splenic injury led to splenectomy in 2.6%. A relaparotomy for intraabdominal bleeding was done in 1%. No case of minor curve necrosis occurred. During the follow-up of 3-9 (mean 5) years 9 patients had died of unrelated causes and 29 could not be traced leaving 272 patients for study. Late symptoms occurred as follows: Dyspepsia 20% (recurrences excluded), heartburn 17%, regurgitation 8%, vomiting 4%, epigastric fullness 12%, dumping 5% and diarrhoea 6%. There were 17 proven recurrences of ulcer (6.3%), 11 after original duodenal ulcer (4.7%) and 6 after pyloric-prepyloric ulcer (16.7%). In addition, 4 patients were reoperated for other reasons (1 for dyspepsia, 1 for stenosis and 2 for oesophagitis). The overall results according to the Visick classification were as follows: Grade I 49%, grade II 18%, grade III 15%, grade IV 18%. CONCLUSION: the method is safe and when used for duodenal ulcer will give satisfactory results, but after pyloric or prepyloric ulcer the recurrence rate may be higher.

Early results and complications of coronary artery bypass surgery. A consecutive series of 441 patients.

The mortality rate and early complications of coronary artery bypass surgery were assessed for the first 441 consecutive patients operated on at Turku University Hospital. The overall hospital mortality rate was 2.5%. Perioperative myocardial infarction (PMI) accounted for more than half of the deaths, cerebral thromboembolism and sudden coronary death each for one-fifth and left ventricular failure for one-tenth. Postoperative complications occurred in 17.7% of the patients. Bleeding and postpericardiotomy syndrome were the most common complications (in 5.2 and 3.6% of the patients). Sternal resuture was needed in 3.2% of the patients, and PMI occurred in 2.9%. PMI had a 46% mortality rate, with two-thirds of the deaths occurring in the operating theatre. Only PMI reached statistical significance as sole cause of death. Mode of myocardial protection, completeness of revascularization and severity of coronary disease did not influence the PMI rate. Graft patency overall was 92.8% on average 3 months after surgery. The respective patency rates for internal mammary artery grafts and vein grafts were 90.3 and 92.9%.

Surgical repair of annulo-aortic ectasia in children.

Results of total repair of annulo-aortic ectasia in three children are presented. The operations were performed on vital indications. All the children survived. In one of them a total AV-block developed and required permanent pacemaker treatment. There were no late complications in the follow-up period of 22 to 41 months.

Myocardial oxygen balance during hemodilution in patients undergoing coronary artery bypass grafting.

The myocardial (arterial-coronary sinus) balance of oxygen and lactate was studied before a cardiopulmonary bypass and during the first 5 min of a normothermic bypass in two patient groups undergoing coronary revascularization for multiple coronary artery disease. The hemodilution (HD) group was hemodiluted before the bypass with dextran 70 (15 ml/kg; resulting mean hematocrit 32%) and further at the beginning of the bypass due to nonhemic priming of the oxygenator (mean hematocrit 15%). The control (C) group was not diluted before the bypass, and four units of red blood cells were included in the oxygenator priming (mean hematocrit 27% after the beginning of the bypass). The preoperative dilution produced a decline in the coronary sinus blood oxygen tension and oxygen saturation, but no change in the arterial-coronary sinus lactate balance. After the first 5 min of the bypass, the heart produced lactate in both the HD group and the C group, but the lactate production was more pronounced in the HD group. At the same time, the coronary sinus blood oxygen saturation was lower in the HD group than in the C group. Hypotension frequently accompanied the beginning of the bypass in both groups. It is concluded that the hemodilution to a hematocrit level of 32% in patients undergoing coronary revascularization for multiple stable coronary artery disease produces compensatory changes in myocardial oxygen extraction, but no changes of a generalized ischemia can be demonstrated. The hemodilution to a hematocrit level of 15% produces myocardial ischemia in patients with a normothermic unloaded heart, adding to the effect of hypotension at the beginning of the bypass.

Use of activated clotting time to monitor anticoagulation during cardiac surgery.

The use of a fixed dosage schedule was compared with the use of activated clotting time (ACT) for monitoring heparin anticoagulation and its neutralization during and after extracorporeal circulation in patients undergoing coronary artery bypass grafting. Use of ACT resulted in a statistically significant decrease in heparin and protamine dosages and statistically significant reductions in postoperative blood loss and blood transfusion needs. Postoperative levels of blood hemoglobin concentration were significantly higher and the activated partial thromboplastin time was significantly shorter with ACT monitoring than with use of a fixed dosage schedule. The results confirmed the superiority of the ACT method for monitoring anticoagulation during cardiac surgery.

Effects of extreme haemodilution on the immediate post-operative course of coronary artery bypass patients.

The immediate post-operative course was investigated in 70 patients who had undergone coronary artery bypass grafting under normovolaemic moderate and subsequent extreme haemodilution, and in 70 control patients who underwent a similar operation with a haemic prime in the heart-lung machine. Altogether 8 patients (5.7%), 4 from the haemodilution group and 4 from the controls required re-exploration for excessive post-operative bleeding and were examined as their own group. There were no marked differences in bleeding through chest tubes or in blood haemoglobin concentration between patients who had undergone intra-operative haemodilution and controls. Post-operatively both patient groups required approximately analogous amounts of infused blood, colloids and crystalloids. Central venous pressure was consistently lower in haemodiluted patients. Opening of peripheral circulation as indicated by a rise in skin temperature occurred significantly faster in haemodiluted patients than in controls. Before and after weaning from the respirator, arterial blood oxygen tension was slightly lower in patients who had undergone intra-operative haemodilution. Serum creatinine levels were lower and blood platelet counts significantly higher in haemodiluted patients than in controls. Rates of peri-operative myocardial infarctions showed no essential difference between the groups.

Abdominal aortic aneurysms: a clinical and autopsy study of 408 patients.

The material consisted of 408 patients with abdominal aortic aneurysms between 1959-1969 (Period I) and 1970-1979 (Period II). Of the aneurysms 135 were ruptured of which 65 were operated on and 70 revealed at autopsy. Autopsy revealed that in Period I an incorrect diagnosis had been made in 12/24 (50%) of those cases in which rupture was the cause of death; in Period II an incorrect diagnosis was made in 6/46 (13.3%) of similar cases. During Period I, 16/26 (62%) of those operated on for aneurysms were rupture cases; during Period II rupture cases were 49/129 (38%). The mean age of patients operated on for rupture was 66 years (mean age of elective patients 64 years). The operative mortality rate in rupture cases was 63% (41/65): eleven of these patients died during the operation and 30 died during the postoperative period most often on account of late sequelae of the primary shock period or some type of cardiovascular complication. Among patients older than 70 years the mortality rate was 89%; in the younger age group 49%. All patients with free peritoneal rupture died. Preoperative shock, massive bleeding during the operation and duration of operation correlated with the high operative mortality rate. In elective cases the hospital mortality rate was 7%. Myocardial infarction was the most important cause of death. The mortality rate did not correlate with age, perioperative bleeding or the duration of the operation.

Annulo-aortic ectasia involving the aortic arch. Total replacement using a composite graft. A case report.

A case of annulo-aortic ectasia involving the aortic arch and the proximal part of the left subclavian artery is reported. The aorta was replaced with a composite graft (Björk-shiley tilting disc valve and very soft Cooley low-porosity prosthesis) and the coronary ostia and the innominate and left common carotid arteries were implanted directly into the prosthetic tube. The patient recovered without complications.