Acute dissection of ascending aortic aneurysm in a patient with previous coronary artery bypass grafting.

Six years after coronary artery bypass grafting, a 61-year-old man underwent emergency surgery for annulo-aortic ectasia and acute dissection. The aneurysmal tissue and aortic valve were excised and reconstruction was achieved with a composite graft. The patent vein grafts were attached to the composite graft and the original coronary orifices were closed.

Composite graft in annulo-aortic ectasia. Nineteen years' experience without graft inclusion.

OBJECTIVE: The original Bentall procedure for the surgery of annulo-aortic ectasia (AAE) includes the risk of leakage and pseudo-aneurysm formation in the coronary anastomosis. To avoid the complications mentioned above we have used the open technique without the graft inclusion. In this study we evaluate our early and late results. MATERIAL AND METHODS: One hundred consecutive patients with annuloaortic ectasia underwent surgical repair with composite graft between December 1975 and February 1994. In all cases the aneurysmal tissue was radically resected and the origins of the coronary arteries were directly reimplanted to the tube prosthesis. No wrapping was used. Twenty-two patients met the clinical criteria of Marfan syndrome. Thirteen of the patients underwent an emergency operation, because of a rupture of aneurysm in 2 cases and an acute dissection in 11 cases. Additional procedures were performed in 16 patients: mitral valve replacement in 2, coronary artery bypass grafting in 12 patients and in 2 cases the tube prosthesis included aortic arch, too. RESULTS: The overall hospital mortality was 3.0% (3/100). In the elective group there was one hospital death (1/87; 1.1%). In the emergency group two patients died in the operation room (2/13; 16.7%). There have been 13 late deaths among the 97 hospital survivors (13.4%). Four of the late deaths were surgery related. Routine control angiography was performed in all patients 6 months after surgery. Sixty patients who had lived at least 3 years after surgery were called to reangiography and 53 of them came. No pseudo-aneurysm or leakage at distal anastomosis or coronary anastomosis could be seen. A slight dilatation of one or both coronary origins was observed on 15 patients; 9 of whom had Marfan syndrome. CONCLUSIONS: The open technique is simple and can be used in all anatomical variations of the annulo-aortic ectasia. The early and late results are at least comparable with those achieved by other techniques.

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.

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.

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%.

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.

Contrast enhancement of the pancreas in computed tomography.

Contrast enhancement of pancreas, liver, kidney, muscle, and blood was measured from computed tomography scans of 46 patients, including patients with normal pancreas (20), pancreatitis (20), and pancreatic carcinoma (6). A bolus injection of contrast agent was given intravenously. Contrast enhancement and contrast distribution volume in a single scan of the pancreas were measured at 40 sec and at 2, 5, and 15 min after the injection. There was a slight delay in the uptake of contrast material by pancreatic tissue if the disease was severe. In all other aspects, the pattern of contrast enhancement was equal in various patient groups and included great individual variations. Visually, the contrast agent distribution in severe pancreatitis was uneven. In severe pancreatitis, edema was seen both in the pancreas and surrounding tissues. It is concluded that gross anatomic changes and visual estimation are the only means of studying pancreatic pathology with an 18 sec scan time, and that contrast enhancement in such a study provides little additional diagnostic information.

Clear cell sarcoma of tendons and aponeuroses: malignant melanoma of soft tissues? Report of four cases.

In a survey of 246 soft tissue sarcomas in the extremities and limb girdles reported to the Finnish Cancer Registry in 1960-1969, two clear cell sarcomas of tendons and aponeurones were diagnosed. We subsequently diagnosed two more examples. Three tumors were located in the foot and one in the wrist. The histology of the tumors was characteristic, and three of them were shown to contain brown pigment tinctorially indistinguishable from melanin. The pigment could be bleached with potassium permanganate. Ultrastructural studies performed in the most recent case revealed premelanosomes in the cytoplasm of tumor cells. Increasing evidence in the literature and results of the present study seem to suggest that clear cell sarcoma of tendons and aponeuroses represents a soft tissue malignant melanoma.

Computerised tomography of the pancreas with acute pancreatitis.

Twenty patients with clinically diagnosed or suspected pancreatitis were examined with computerised tomography. Five pseudocysts and one pancreatic abscess were found as a complication of the disease. Computerised tomography is a non-invasive method of diagnosis in acute pancreatitis and is especially valuable in diagnosing the complications of the disease. Slight swelling of the inflamed part of pancreas and occlusion of the peripancreatic fat were found in mild pancreatitis. Swelling of the perinephric fat and the mesenteric fat were found in five cases of severe pancreatitis. This is a new sign, as well as uneven distribution of the contrast agent in the pancreatic parenchyma.

Alveolar soft part sarcoma: a report of two cases with some histochemical and ultrastructural observations.

In a survey of all malignant soft tissue tumors in the extremities and limb girdles in Finland between 1960 and 1969, only one alveolar soft part sarcoma was found among 246 tumors (0.4%). Another alveolar soft part sarcoma, diagnosed in 1976, was more thoroughly studied. There was evidence that the characteristic crystals of alveolar soft part sarcoma are formed from the dense granules. Both were PASM-positive at ultrastructural level. No monoamines were detected in the cells by formaldehyde-induced fluorescence. This is a further fact to nullify the theory of the paraganglionic origin of alveolar soft part sarcoma, but the question of the histogenesis of the tumor still remains open.

An analysis of 38 malignant fibrous histiocytomas in the extremities.

All the malignant soft tissue tumours in the extremities and limb girdles reported to the Finnish Cancer Registry between 1960-1969 were reviewed. From a total of 246 sarcomas, 38 were diagnosed as malignant fibrous histiocytoma. There was an equal number of male and female patients with the median age of 67 years. The thigh was the most frequent site, and the majority of the tumours originated in the deep soft tissues. The predominant treatment was excision followed by radiation therapy. In 17 patients there were one or more recurrences and in 21 patients there was a metastatic spread ascertained by biopsy, autopsy or clinical or radiographic evidence. There were 11 survivors with a minimum of 5 years' follow-up; seven patients died of an intercurrent disease and the remaining 20 patients were considered victims of their tumour. The findings that seemed to favour a poor prognosis were higher age and female sex of the patient as well as deep location, large size, necrotic areas, and high mitotic activity of the tumour.