Life-threatening Mycoplasma hominis mediastinitis.

Mycoplasma hominis infections are easily missed because conventional methods for bacterial detection may fail. Here, 8 cases of septic mediastinitis due to M. hominis are reported and reviewed in the context of previously reported cases of mediastinitis, sternum wound infection, pleuritis, or pericarditis caused by M. hominis. All 8 patients had a predisposing initial condition related to poor cardiorespiratory function, aspiration, or complications related to coronary artery surgery or other thoracic surgeries. Mediastinitis was associated with purulent pleural effusion and acute septic symptoms requiring inotropic medication and ventilatory support. Later, the patients had a tendency for indolent chronic courses with pleuritis, pericarditis, or open sternal wounds that lasted for several months. M. hominis infections may also present as mild sternum wound infection or as chronic local pericarditis or pleuritis without septic mediastinitis. Treatment includes surgical drainage and debridement. Antibiotics effective against M. hominis should be considered when treating mediastinitis of unknown etiology.

Open distal anastomosis in conjunction with partial cardiopulmonary bypass and mild hypothermia for repair of descending thoracic aortic aneurysms.

The duration of spinal cord ischemia is probably the most important single factor in the pathogenesis of paraplegia after repair of descending thoracic aortic aneurysms. We describe a modification of open distal anastomosis technique originally presented by Dr. Cooley, in which we use partial cardiopulmonary bypass with femoral cannulation and mild hypothermia. Cardiopulmonary bypass is interrupted after lowering patient's temperature to 32 degrees C and the aorta is clamped using one proximal clamp. During the suturing of the distal anastomosis blood is sucked to reservoire and returned oxygenated to the patient via the venous line using a shunt which is installed between the arterial and venous lines. After completion of the distal anastomosis the graft is clamped and cardiopulmonary bypass reinstituted. Rewarming is started as bleeding intercostal arteries are sutured and proximal anastomosis performed. This modification shortens the distal ischemia time, but supports the circulation of the kidneys and splanchnic area immediately after the distal anastomosis is finished. Lowering the temperature should give additional protection for the spinal cord and the blood can be returned oxygenated to the patient. In our opinion, this combination of femoro-femoral perfusion, mild hypothermia, and open distal anastomosis offers several benefits and can be used in dissections and aneurysms, which extend up to aortic hiatus.

Heart transplantation in Finland 1985-1995.

BACKGROUND AND AIMS: Since improved immunosuppression in the 1980's, heart transplantation is a well established procedure to treat patients with end-stage heart failure. The first heart transplantation in Finland was performed in 1985. Since then the activity has gradually increased to a level of about 25 annual transplants. The aim of this report is to sum up the clinical experience during the first 11 years. MATERIALS AND METHODS: From February 1985 till the end of 1995, 190 heart transplantations were performed in our institution. There were 176 males and 14 females ranging from 15 to 62 (mean 42.2) years of age. End-stage preoperative cardiac disease was dilating cardiomyopathy in 108 cases, coronary artery disease in 65 cases, valvular disease in 12 cases and congenital heart disease in five cases. RESULTS: The 30-day hospital mortality was 29 out of 190 (15.2%). The actuarial survival was 77% at one year, 75% at two years and 73% at 10 years. The most common causes of death were rejection (11 cases), graft failure (11 cases), abdominal complications (six cases) and cytomegalovirus (CMV) infection (four cases). A total of 87 rejection episodes occurred in 53 patients consisting 28 per cent of patients. 44 rejections occurred within three months post transplantation. Significant infections were noted in 198 instances in 97 patients. These were of bacterial origin in 92, viral in 48, fungal in 12 and protozoal in 10 cases, and 36 such infections which responded to antibiotics favourably but in which the microbe remained unidentified. 138 infections (i.e. 80%) occurred within 6 months post transplantation. In viral infections cytomegalovirus (CMV) predominated (29 out of 48). The CMV infection was significantly milder in patients who were seropositive preoperatively than in preoperatively seronegative patients with seropositive donors. CMV infection was associated with increased risk of post-transplant coronary artery disease. Three years after transplantation some restoration of sympathetic nervous response was observed at orthostatic test in heart rate and blood pressure. CONCLUSIONS: It can be concluded that 1) if a patient survives the three immediate postoperative months, his prognosis is good for the forthcoming years, 2) clinically significant rejections occur in less than one third of the patients, 3) cytomegalovirus is the most harmful agent post transplantation and a risk factor for post-transplant coronary artery disease and that 4) some restoration of sympathetic nervous control of the heart occurs within three years after transplantation.

Prosthetic bifurcation grafting in occlusive and aneurysmal aortoiliac disease--a follow-up study.

A comparative clinical study was made of patients undergone prosthetic bifurcation grafting for non-ruptured abdominal aortic aneurysm n = 135 or aortoiliac occlusive disease n = 180 between January 1982 and December 1986. Patients in aneurysmal group were older, predominantly men, had hypertension more often and had better distal run-off at the time of operation. Smoking was over-presented among aortoiliac occlusive disease patients. Patients operated for abdominal aortic aneurysms had better early and late graft patency rates and lower late amputation rates. There were no significant differences in operative mortality rates and late survival rates between occlusive disease and aneurysmal patients. Cardiac mortality mainly reduced early and late survival rates in both patient groups. We should begin to use systematically a reliable and non-invasive method for screening the myocardial status in patients who are going to be operated for abdominal aortic aneurysm or aortoiliac occlusive disease.

Posterolateral diaphragmatic hernia in adults--acute symptoms, diagnosis and treatment. Case report.

Acute herniation through a posterolateral diaphragmatic defect is rare in adults. Two cases in which such herniation occurred by sudden inversion, a 29-year-old man and a 17-year-old girl, are presented. The symptoms, diagnosis and treatment are discussed.

Hematuria is an indication of rupture of an abdominal aortic aneurysm into the vena cava.

During a period of 13 years 11 patients were operated on because of a spontaneous aortocaval fistula caused by a ruptured abdominal aortic aneurysm. The classic diagnostic signs of an aortocaval fistula (pulsatile abdominal mass with bruit and high output heart failure) were present in approximately half of the patients, whereas hematuria was a constant finding in all patients. Six patients had macrohematuria, and five had microhematuria. Seven patients (64% survived, and four had postoperative complications: 1 ileus, 2 postoperative pneumonias, 2 deep venous thrombosis, 1 postoperative hemorrhage. The mean operative blood loss was 7 L. After operation the average follow-up time was 4 years. In four patients who died the perioperative (within 30 days) causes of death were renal failure, a bleeding duodenal carcinoma, myocardial infarction, and operative bleeding. It is concluded that hematuria is a more frequent finding than earlier assumed among patients whose abdominal aortic aneurysm has ruptured into the vena cava. The presence of hematuria in a patient suffering from an abdominal aortic aneurysm is an indication for aortography to rule out an aortocaval fistula.

Diagnosis and treatment of subclavian artery aneurysms.

The diagnostic features and operative results in 13 patients with subclavian artery aneurysms were analysed. Symptoms related to subclavian artery aneurysms were present in seven patients, whereas six patients were asymptomatic and the aneurysm was discovered incidentally on chest X-ray. Angiography was the most valuable diagnostic examination and was also necessary in planning the operation. A correct preoperative diagnosis was made in five of six patients with computed tomography. Resection of the aneurysm was performed in nine and aneurysmal exclusion in the latest four patients. Direct reconstruction was used in nine and in four cases an extra-anatomic carotico-subclavian bypass was performed. Postoperative complications arose in two symptomatic and in four asymptomatic patients (46%: two strokes, two wound infections demanding extirpation of the prosthesis in one patient, two pareses of the recurrent nerve and one postoperative haemorrhage). Operative mortality was one patient. Follow-up data was available for all patients for periods of 6 months to 14 years. The vascular graft was patent in all patients. The authors conclude that subclavian artery aneurysm must be included in the differential diagnosis of all obscure upper mediastinal masses as seen on the chest X-ray and examined with CT and angiography. Exclusion of the aneurysm with extra-anatomical reconstruction is technically easier and gives the same postoperative long-term results as resection of the aneurysm and direct reconstruction. A relatively high complication rate after operation on asymptomatic subclavian aneurysms indicates a need for re-evaluation of operative indications in asymptomatic patients.

Long-term follow-up of St. Jude Medical valve.

St. Jude Medical bileaflet valve replacement was performed on 182 patients--aortic in 90, mitral in 70, both sites in 20 and tricuspid in two. The 30-day mortality was 4.3%, and was related to poor preoperative condition (NYHA class III or IV). The late mortality during observation up to 8 years was 9.3%, with actuarial survival 87.4% at 5 years and 86.3% at 8 years. For aortic, mitral and double valve replacement the respective 8-year figures were 88, 87.3 and 76.2%. Late death was associated with high preoperative pulmonary vascular resistance in five cases, dysrhythmia in four, myocardial infarction in two, thromboembolism, paravalvular leakage, prosthetic endocarditis or bleeding, each in one case, and was accidental in two cases. Calculated per 100 patient years the incidence of late thromboembolic events was 1.0, of bleeding complications 0.9 and of prosthetic valve endocarditis and paravalvular leak 0.26 (8, 7, 2 and 2 cases). The NYHA class in the 144 cases available for follow-up was I in 63%, II in 27% and III in 10%. The St. Jude Medical prosthesis thus was reliable, with good long-term performance.

Indications for and risks in reoperation for coronary artery disease.

Seventy-one coronary artery bypass grafting (CABG) reoperations were performed during a 17-year period, comprising 2.7% of all CABG operations. The main indication (in 87%) was vein graft failure alone or combined with other causes. Progression of disease in native coronary arteries was the sole indication in only 4 of the 71 cases. There were seven perioperative deaths, mainly due to myocardial infarction. Significant perioperative complications arose in 36 cases, including intraoperative lesion of a previous left internal mammary graft (16.2%) or of the right ventricle or anterior descending branch of the left coronary artery (2.8%). Postoperative low output syndrome appeared in 13 patients (18.3%), in seven of whom myocardial infarction was verified. Postoperative bleeding required resternotomy in six cases (9.1%). Because of the heightened operative mortality and morbidity risks, indications for redo CABG should be individualized. A well functioning internal mammary artery graft may be a relative contraindication. Accurate knowledge of the previous operation is essential and, especially in young patients, the possibility of reoperation should be taken into consideration at initial CABG.

Primary cardiac tumours--operative treatment of 20 patients.

This report describes a series of 20 patients operated on for a primary cardiac tumour. The majority of the tumours (16) were benign myxomas; 12 of them were located in the left atrium, two in the right atrium and two were biatrial. Two lipomas were found; one was epicardial and the other was located in the left atrium. The only intraventricular tumour was a malignant left ventricular myosarcoma. The propensity of intracardiac tumours to embolize was distinctive. Nine of the 16 myxomas presented with peripheral embolization, and in two patients surgery was complicated by fatal perioperative cerebral embolization of myxomatous tissue. Furthermore, in one patient embolization of a left atrial lipoma necessitated amputation of her left arm before cardiac surgery. Late postoperative recurrences were found in two patients with atrial myxomas. In one of them, reoperation showed that the tumour had grown at that site in the interatrial septum where the original pedicle had been excised. One patient developed severe mitral valve regurgitation and underwent replacement with a prosthetic valve at reoperation. Otherwise our late follow-up study showed that the results of surgery were usually excellent even though mild echocardiographic abnormalities were not uncommon. Our experience emphasizes the embolic potential of intracardiac myxomas and suggests, furthermore, that to avoid recurrences excisions with wide margins should be preferred. Echocardiography is an optimal method for the follow-up of these patients.

Primary tumours of the sternum.

In 1966-1986, two men and four women (mean age 47.5 years) underwent surgery for primary sternal tumour. Three of the tumours were benign (two condromata, one osteochondroma) and three were malignant (two chrondrosarcomata, one reticulum cell sarcoma). Inflammatory or degenerative lesions impeded differential diagnosis in three additional cases (without tumour). The tumours were treated with radical resection of the affected part of the sternum, including the relevant attached structures. Marlex-mesh reconstruction of the defect was necessary in four cases. There was no operative mortality. One Marlex graft became infected. At follow-up (average 11.1 years, range 9.0-14.7 years), five patients were alive without recurrence of tumour and the sixth had died of unrelated cause.

Surgical technique and operative mortality in coronary artery bypass. A postmortem analysis with castangiography.

Post-mortem analysis with castangiography was performed on 54 patients who died within 30 days of coronary artery bypass surgery. Myocardial failure was the cause of 85% of the deaths. There were 215 coronary anastomoses (4.0 +/- 1.1/patient), 24% of which were non-functioning. Most of the occlusions were due to various technical failures. The most striking features were 1) high occlusion rate (25%) in sequential vein grafts and 2) disastrous complications of coronary endarterectomies. Compared with preoperative angiographic data, only 15 (28%) of the 54 patients were found to have 'complete' revascularization, with patent grafts and all stenosed coronary arteries bypassed. The need for recognition and avoidance of technical complications is stressed: Failures of surgical technique constitute a major risk factor in coronary artery surgery.

Results of reoperations for coronary artery disease.

Seventy-one patients undergoing reoperation for coronary artery disease were examined on average 2.5 years postoperatively. Operative mortality was 9.9% and late mortality 6.3%. 88% of the patients improved subjectively, and although only 7.8% were angina-free, 79.9% were in NYHA Class I or II. All patients who had been working before reoperation returned to work, and either patients who were on sick-leave before resumed their activities. A follow-up examination was performed in 21 patients with a follow-up time of more than three years. The mean peak work capacity did not change after reoperation and also the ST changes during the bicycle ergometer exercise test were the same after reoperation. The mean ejection fraction diminished from 54 +/- 15.5% to 44.7 +/- 15.2%. In thallium perfusion studies areas of hypoperfusion were observed in 14 cases (67%). Coronary angiograms showed 3.0 +/- 1.0 patent anastomoses at the follow-up examination; 76% of the anastomoses performed in the reoperations were patent. It can be concluded that although the objective results of repeat myocardial revascularisation in this material are not optimal, the subjective improvement of the patients was satisfactory, and in the majority of cases reoperation ensures an acceptable quality of life for years.

Management of vascular complications in thoracic outlet syndrome.

Arterial complications of thoracic outlet syndrome (TOS) were surgically treated in 11 patients (12 limbs) and venous complications in five (6 limbs). Arteriography showed total occlusion or significant stenosis of the subclavian artery in eight patients (bilateral in 1), with complicating peripheral thrombosis in three. Two patients had unilateral subclavian artery aneurysm: One was the patient with bilateral subclavian occlusion, and the other also had brachial artery embolism. Yet another patient had brachial thrombosis. Treatment included reconstructive surgery (3 limbs), thoracic sympathectomy (3) or decompression alone (6). Of the five patients with venous TOS complications, four were found at phlebography to have subclavian thrombosis and one had significant bilateral subclavian obstruction. Treatment was transaxillary first-rib resection (4 cases) or division of soft-tissue bands and hypertrophied anterior scalene muscle (1 case). After follow-up averaging 9 years, eight of the nine survivors in the arterial group were working and seven were asymptomatic. All five in the venous group were working and only two had slight, strain-related symptoms. Impaired arterial flow in TOS can usually be managed with decompression, but direct surgery (bypass or thrombectomy) or thoracic sympathectomy is required in cases with severe ischemia with proximal occlusion and after resection of a subclavian aneurysm or in cases with unilateral Raynaud's phenomenon or thrombosis of small arteries. For venous symptoms decompression alone suffices.

Primary tumours of the ribs.

Thirty-four primary rib tumours (24 benign, 10 malignant) were surgically treated in 1966-1985. The mean age was higher and the tumour diameter was greater in the patients with malignant, than in those with benign neoplasm. The benign tumours were excised without operative death. At follow-up after a mean of 12.3 years there was no recurrence of benign growth, but in two cases with initial diagnosis of chondroma a regrowth at the same site proved to be chondrosarcoma. Among the cases of malignant tumour there was one operative death from pulmonary embolism, after radical resection of sarcoma. None of the four patients with chondrosarcoma had recurrence 6-13 years after surgery. There was no long-term survival among the patients with other forms of sarcoma or malignant tumour of the reticuloendothelial system.