Latissimus dorsi cardiomyoplasty: a chronic experimental porcine model. Feasibility study of cardiomyoplasty in Danish Landrace pigs and Göttingen minipigs.

Cardiomyoplasty is an experimental treatment for end-stage heart failure. We hypothesized that the porcine latissimus dorsi muscle (LDM) in an experimental porcine model is a suitable surrogate for a clinically relevant evaluation of this concept. Fourteen Danish Landrace (DL) pigs and six Göttingen minipigs (GM) were studied. The LDM was evaluated immediately after surgical dissection and in various phases: phase 1 (n = 4)--outcome of a partial vascular isolation (vascular delay), 2 to 3 weeks prior to heart wrapping in DL pigs; phase 2 (n = 6)--long-term flap survival of nonstimulated LDM cardiomyoplasty in DL pigs; phase 3 (n = 6)--outcome of nonstimulated cardiomyoplasty in GM; phase 4--one DL pig had dynamic cardiomyoplasty performed and was subjected to low-intensity LDM stimulation for 8 months. Isolation of the LDM of DL pigs and GM as a pedicled graft had no acute deleterious impact on the global blood supply. In phase 1a, partial vascular isolation and in situ recovery of the LDM resulted in a muscle encapsulated in fibrotic tissue, which hampered a later heart wrap. In phase 1b, a less extensive dissection diminished fibrosis and allowed subsequent wrapping. In phase 2, after 6 weeks of nonstimulated LDM cardiomyoplasty, the LDM of DL pigs was viable, with excellent heart-muscle integration. In phase 3, the same procedure applied in GM yielded the same result as that in DL pigs, but with a higher success rate owing to the learning phase.

Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection.

OBJECTIVE: The association of atrial fibrillation with thoracic surgical procedures is well known, but nevertheless its cause is not well defined. Increased sympathetic activity may play a role in the development of atrial fibrillation, and reduced beta-receptor activity may be advantageous. The objective was to evaluate the effect of oral beta-blockade on the frequency of atrial fibrillation and to evaluate some possible causative factors. DESIGN AND SETTING: The study was prospective, randomized, and double-blind, and was conducted at Aarhus University Hospital. PARTICIPANTS: Thirty patients without previous or present cardiovascular history undergoing elective thoracotomy for lung resection. INTERVENTIONS: The patients received either 100 mg of metoprolol or placebo orally before surgery and once daily postoperatively. Anesthesia consisted of a thoracic epidural block combined with general intravenous anesthesia. Epidural morphine was continued postoperatively. MEASUREMENTS AND MAIN RESULTS: Patients were monitored with electrocardiograms (ECGs), capillary pulse oximetry, invasive hemodynamic monitoring, central venous oxygen saturation, arterial blood gases, serum electrolytes, and fluid balances. Atrial fibrillation developed in 23.3% of the patients, 6.7% after metoprolol compared with 40% in the placebo group. Atrial fibrillation developed a mean of 2.9 days postoperatively. The predominant hemodynamic findings were perioperative lower oxygen consumption and postoperative lower cardiac index after metoprolol. Patients developing atrial fibrillation had much higher oxygen consumption and postoperative cardiac index than other patients. CONCLUSION: Perioperative oral beta-blockade can reduce the frequency of atrial fibrillation without serious side effects. Increased sympathetic activity is one of the predominant factors in the cause of this complication.

Preoperative metoprolol improves cardiovascular stability and reduces oxygen consumption after thoracotomy.

BACKGROUND: Increased sympathetic activity perioperatively and associated cardiovascular effects play a central role in cardiovascular complications. High thoracic epidural blockade attenuates the sympathetic response, but even with complete pain relief, haemodynamic and endocrine responses are still present. Beta-adrenoceptor blockade is effective in situations with increased sympathetic activity. This study was designed to evaluate the perioperative haemodynamic effect of preoperative beta-blockade and its influence on the haemodynamic aspects of the surgical stress response. METHODS: Thirty-six otherwise healthy patients undergoing elective thoracotomy for lung resection were randomised double-blinded to receive either 100 mg metoprolol or placebo preoperatively. Anaesthesia was combined high thoracic epidural block and general anaesthesia. The epidural analgesia was continued during recovery. Patients were monitored with ECG, pulse oximetry, invasive haemodynamic monitoring, arterial blood gases and electrolytes. RESULTS: After induction of anaesthesia the mean arterial pressure (MAP) decreased in both groups, and decreased further in the placebo group after initiation of the epidural block. The heart rate (HR) was slightly less throughout the observation period after metoprolol. Peroperatively, the only difference in measured haemodynamics was a marginally higher MAP after metoprolol. Postoperative cardiac index (CI) was lower with a lower variability and cardiac filling pressures were slightly higher in the metoprolol group. The oxygen consumption index was higher after placebo throughout the observation period, with no difference in the oxygen delivery. CONCLUSION: We found that preoperative beta-blockade during combined general anaesthesia and high thoracic epidural blockade stabilised perioperative HR and CI and decreased total oxygen consumption.

[Esophageal perforations]. / Esophagusperforationer.

An oesophageal perforation is a serious condition with high morbidity and mortality. During the latest decades an increased number of traumatic perforations as well as wide use of endoscopic procedures have increased the incidence of oesophageal perforation. An early diagnosis and treatment is important for the prognosis. Cervical and selected thoracic perforations can be treated conservatively although the majority should be operated. Primary closure can be performed if done before 24 hours have elapsed, while later treatment is controversial. Drainage of the mediastinum and pleural space, as well as diversion of saliva and gastric content is important. The literature is reviewed in relation to etiology, diagnosis, treatment and prognosis.

[Benign esophageal perforations treated at a department of thoracic surgery]. / Benigne esophagusperforationer behandlet på en thoraxkirurgisk afdeling.

Between January 1, 1980 and December 31, 1994, 37 patients with benign oesophageal perforation underwent different kinds of treatment. The overall mortality was 30%. When diagnosed less than 12 hours after the perforation the mortality was 21%, between 12 and 24 hours. Reinforced primary repair gave the best results without any deaths in seven cases where it was performed. Oesophageal perforation is a serious condition, and it is important to know the symptoms. If there is any suspicion of the condition, an oesophageal X-ray with watersoluble contrast medium should be performed on liberal indication. When diagnosed the patient should be transferred to a Department of Thoracic Surgery immediately. Only few patients can be treated conservatively and most should be operated with reinforced primary suture and drainage.

[Characteristics of mortality among patients waiting for coronary arteriographic evaluation or heart surgery]. / En karakteristik af mortaliteten blandt patienter der ventede på koronararteriografisk undersøgelse eller hjerteoperation.

It was the aim to reduce deaths among future patients queuing for heart catheterization or surgery. All the patients who died, after they were referred for heart catheterization or surgery because of coronary heart and heart valve disease, were registered over a three year period (July 1, 1990 to June 30, 1993). The total number of deaths was 98. Ninety-two (94%) died of cardiac disease. Seventyfour (80%) only had symptoms of cardiac disease; ten (11%) had competitive disease and eight (9%) had received revascularizing treatment previously. The number of catheterizations increased from 968 to 1312 per year, while the number of operations remained constant at about 600 per year. The death-rate for patients referred to heart catheterization was 2.5% for patients with aortic valve disease and 1.7% for patients with coronary heart disease. For patients referred for coronary artery bypass grafting the death-rate was 2.6% and for heart valve surgery 3.9%. The survival-time for patients waiting for catheterization was 4.2 months (0.3-16) and 4 months (1-16) for patients waiting for surgery. Half of the deaths in patients queuing for cardiac catheterization occurred within one month of waiting while half of the deaths in patients waiting for heart surgery appeared within 1.3 months. In the early deaths among patients queuing for cardiac catheterization there was a tendency towards prolonged doctor's delay and a surplus of patients with aortic valve disease. Deaths among patients awaiting heart catheterization or surgery can hardly be avoided. However, in the present study the death-rates for patients referred to surgery was 1.8 to 7.7 times higher compared to the conditions in other Western countries. The waiting-time was long and cardiac deaths frequent, reflecting the low capacity for invasive procedures as well as operations during this period.

[Dynamic cardiomyoplasty. A possible surgical treatment of heart failure]. / Dynamisk kardiomyoplastik. En mulig kirurgisk behandling af hjerteinsufficiens.

Dynamic m. latissimus dorsi cardiomyoplasty was introduced in 1985 as a new surgical treatment of terminal heart failure. The latissimus dorsi muscle is wrapped around the heart and paced simultaneously with the heart beat in order to contribute to the systolic function of the failing heart. Although more than 200 patients have received this treatment, the results show a persistent high perioperative mortality (16-25%). However, some patients achieve a considerable improvement in both survival and function, despite the fact that only a minimal improvement of cardiac function can be shown. The advantage of dynamic cardiomyoplasty is that the patient can be operated on in a stable phase. Also, as opposed to heart transplantation, there is no need for immunosuppression. Until further experimental and clinical documentation is available, dynamic cardiomyoplasty is not a realistic alternative to the established surgical and medical treatment of heart failure in Denmark.

FGM in Cameroon.

PIP: In 1994, group discussions and individual interviews with 468 women and young girls were held in Cameroon's Extreme North Province, South West Province, and capital area to obtain data on female genital mutilation practices. Precise incidence data on this practice could not be obtained due to the refusal of hospitals and health centers to complete questionnaires. However, interviews suggested the incidence of this practice is about 40% in the South West Province and substantially higher in the Extreme North. All Moslem women, but only 63% of Christians, had undergone this procedure. Only 1.3% of procedures were performed in hospitals; the remainder were performed by traditional practitioners. Although circumcised women reported hemorrhage and infection as complications of the procedure, they minimized its health consequences. Most respondents reported they followed the practice out of respect for tradition. Young women were more receptive to abandonment of female genital mutilation than their older counterparts; however, most women expressed concerns about the potential loss of circumcision-associated rituals such as the decoration of their houses and the Monekim dance. Opinion makers were equally divided in their attitudes and generally unaware that several international agencies have condemned female circumcision.^ieng

[Femoropopliteal bypass in arteriosclerosis]. / Femoropopliteal bypass ved arteriosklerose.

Since Kunlin's report on femoropopliteal bypass operations, this procedure, with homologous vein or various prosthesis has been the principal treatment for serious arteriosclerosis in this anatomical area. During the years 1979-88 we performed 235 femoropopliteal bypasses. Reversed autologous vein was used in 60% and the distal anastomosis placed below the knee in 75%. Perioperative, 30 days mortality was 2.1%. 93% of the operations were successful. The overall five year patency rate was 50.6%, but with significantly better results with the distal anastomosis above the knee. There was no significant difference, however, between reversed homologous vein and human umbilical vein grafts in the below knee position. At present, the indications for femoropopliteal bypass are critical ischemia and seriously incapacitating claudication.

[Overlooked bronchial rupture after blunt thoracic injury]. / Overset bronkieruptur efter stumt thoraxtraume.

A 72-year-old man developed a total atelectasis of the right lung six weeks after a blunt trauma in a motor vehicle accident. Bronchoscopy demonstrated a total fibrotic occlusion of the right main bronchus. By re-examination of earlier case sheets and chest x-rays it was suspected that the patient had suffered a partiel bronchial rupture from the accident. One and a half centimetres of the bronchus were resected with a good result. Findings and treatment of this rare complication are discussed.

[Surgical treatment of pulmonary sarcoma metastases]. / Kirurgisk behandling af pulmonale sarkommetastaser.

During the ten-year period from 1.1.1980 to 31.12.1989, thoracotomy was found performed on 22 patients with malignant sarcoma on account of suspected pulmonary metastases. Fourteen patients were submitted to operation on one occasion, nine patients were submitted to operation twice and one patient was operated upon six times. The median age was 21 years (range 7-68 years). The median interval without illness from the primary treatment was 65 weeks (range 7 weeks to 5.8 years). At the first operation, 13 patients had one metastasis, seven had two metastases and one had five metastases. In one patient, a benign lesion was found. Six patients were submitted to renewed thoracotomy on account of pulmonary metastases from 16 to 75 weeks after the first recurrence. The median survival after the first operation was 1.4 years (range 0.4-5.7 years). Five patients (24%) are still free from recurrences from 0.9 to 5 years after the last operation. It is concluded that patients with malignant sarcoma should be followed-up regularly with radiography of the thorax and should be offered operation in cases of pulmonary metastases.

Arterial injuries. Review of 12 years experience with 32 patients.

Thirty-two patients with 41 injured arteries were operated upon during a period of 12 years. Three quarters were men, and the median age was 33 years. Accompanying lesions were seen in 87.5% of the patients. Nearly half the lesions were related to blunt trauma. Occupational accidents constituted the largest group. The diagnosis was made on clinical grounds in most cases. The median time lapse from trauma to operation was 5 hours. The principles of treatment were those that are generally accepted. No patients died, the amputation rate was 12.5%. Median follow-up was 8 months. A successful arterial reconstruction contributed to a good functional result. Postreconstruction thrombosis of arteries were found to occur within the first hours or days after reconstruction. Late thrombosis was rare and the overall long-time patency was 61.4%. Patency of repair of upper limb small vessels was 54.5%.

Profundaplasty as the only reconstructive procedure in patients with severe ischemia of the lower extremity.

Twenty-one profundaplasties were performed as the only reconstructive procedure. All of the patients had severe ischemia of the lower extremity with serious symptoms, such as rest pain or gangrene, or both. There was no postoperative mortality. Two patients had a crural amputation, and one patient, a femoral amputation performed during the first three months postoperatively. All of the other patients improved, and there was a significant rise in distal blood pressures after one week, further increasing after three months. At follow-up study, 15 of the patients had considerably less symptoms than preoperatively or were free of symptoms. There was a limb salvage rate of 83 per cent after 60 months. The operation is recommended whenever possible in patients with severe ischemia of the lower extremity when the possibilities of other reconstructive procedures are considered to be poor.

The ischaemic leg: a long-term follow-up with special reference to the predictive value of the systolic digital blood pressure. Part I: No arterial reconstruction.

The course of 53 patients presenting with 76 legs with ischaemia, defined by blood pressure on the big toe below 30 mmHg, were investigated. The series consists of those patients who after an angiography were considered non-candidates for arterial reconstructive surgery. There were 38 limbs with low pressure and severe ischaemic symptoms, i.e. rest pain and/or gangrene and 38 limbs with low pressures and only intermittent claudication or no leg symptoms at all. There were statistically significant differences in the fate of the limbs in the two groups, the first group suffering a 68 per cent risk of amputations compared to only 16 per cent in the second group. The corresponding risk of death was approximately 60 per cent and 10 per cent. The social fate was poor in the group with rest pain and/or gangrene due to the high number of amputations.

The ischaemic leg: a long-term follow-up with special reference to the predictive value of the systolic digital blood pressure. Part II: After arterial reconstruction.

Ninety-five patients with 122 legs with a systolic blood pressure on the big toe below 30 mmHg were the subject of arterial reconstructive surgery. Investigating the limb survival rate we found the systolic blood pressure on the big toe to be the most important predictor, whereas there was found no predictive value of the ankle pressure/index. Preoperative clinical symptoms, which are closely related to the digital blood pressure, were significant predictors of the limb survival rate: the low-pressure limb with no symptoms or intermittent claudication had a significantly higher survival rate than the limb with rest pain and/or gangrene. Following arterial reconstructive surgery the social fate of patients with threatened legs was fairly good as 83% became fully independent.

Major vascular injury during gynecologic laparoscopy. Report of a case and review of published cases.

Serious complications following gynecologic laparoscopy are rare. We report a case of a 24-year-old woman who had a common iliac artery and vein injured by the trocar, resulting in deep shock. The arterial lesion was repaired with an allograft and the vein sutured. The patient recovered with light sequelae. The literature was reviewed and we found 15 cases described in varying detail. In most cases the injury was caused by the pneumoperitoneum-needle and in only 2 by the trocar. Characteristically the terminal aorta and its major branches were injured. All the patients had a large retroperitoneal hematoma and only minimal free blood in the peritoneum. Signs of bleeding were nearly always acute. Most lesions could be treated by simple suture. Recovery is the rule, but 2 of the 15 died. Examiner's experience and correct technique are important to prevent this potentially lethal complication which is also probably underreported.

Transposition of the sartorius muscle in the treatment of infected vascular grafts in the groin.

Out of 15 consecutive deep graft-infections during a 5-year-period, 12 cases were treated by local debridement, disinfectants, graft replacement and sartorius muscle transposition. The treatment was successful in 10 cases, which have shown no sign of re-infection. Three grafts occluded during the observation period (2 weeks, 2 months and 15 months), resulting in amputation in one patient. The method is recommended as the treatment of choice in Szilagyi type III infections limited to the groin.

Assessment of a standard exercise test in peripheral arterial disease.

A recently proposed standard exercise procedure for the assessment of peripheral arterial disease has been tested in patients with unilateral intermittent claudication. The immediate post-exercise fall in systolic ankle pressure after a 1 minute walk at 4 km/h on a 10% slope has been compared with the results from the contralateral and control limbs. The test was acceptable to the patients and easy to perform but has not in this study proven sensitive enough, as described, to detect asymptomatic (but angiographically verified) arterial lesions. The test is found valuable, however, especially in patients with inconclusive resting pressure recordings i.e. with an ankle to brachial pressure index close to 0.9. A pressure drop of 30% or more in this group of patients seems to indicate functionally important arterial disease.

Vascular graft infection: an analysis of sixty-two graft infections in 2411 consecutively implanted synthetic vascular grafts.

Among 2411 consecutive arterial reconstructions performed with synthetic prosthetic material in Denmark during a 4-year period, 62 patients (2.6%) developed graft infection. Graft infection occurred only when the groin had been incised. The incidence of infection and the spread of infection along the graft did not relate to the graft material used (Dacron velour, Dacron woven, polytetrafluoroethylene, and umbilical vein). Retrospective analysis disclosed predisposing or precipitating factors in 50 of the 62 cases; the most important seemed to be unsatisfactory surgical technique. Fifty-three percent of the graft infections occurred within 30 days. Gram-positive cocci were the most common pathogen. The 62 patients had been in the hospital for a mean of 90 days and had undergone an average of 1.4 operations for graft infections. Of the patients, 25.8% died and 30.6% underwent amputations. Vascular graft infection is still one of the major problems in vascular surgery; greater care should be taken to improve antiseptics, improve surgical technique, and establish a rational prophylactic antibiotic regimen. A prophylactic antibiotic regimen of a combination of cephalosporin and ampicillin is recommended.