Mitroflow pericardial bioprosthesis: clinical performance to ten years.

The Mitroflow pericardial bioprothesis, a second generation pericardial prosthesis, has clinical performance assessment to 10 years. This bioprosthesis was used in 445 operations in 445 patients between 1982 and 1992 inclusive (mean age, 59.1 years; age range, 19 to 94 years). There were 253 aortic valve replacements (AVR), 155 mitral valve replacements (MVR), 31 multiple valve replacements (MR), and 6 tricuspid valve replacements. Concomitant procedures were performed in 40 patients (14.2%). The age group distributions (years) were less than or equal to 35 years, 28 patients; 36 to 50 years, 79; 51 to 64 years, 167; 65 to 69 years, 70; and 70 years or more, 101 patients. The total follow-up was 1,524 patient-years (mean, 5.4 years), 96% complete. The early mortality was 6.3%/patient-year (28 patients) and the late mortality was 4.1%/patient-year (96 patients). Concomitant procedures did not influence either early or late mortality (p = not significant [NS]). The overall patient survival at 10 years was 58% +/- 5% (p = NS by valve position). The overall freedom from structural valve deterioration (SVD) at 8 years was 69% +/- 3% and at 10 years, 45% +/- 7%; and at 8 years AVR 80% +/- 4%, MVR 58% +/- 6%, and MR 38% +/- 11% (p < 0.05, AVR > MVR > MR). The freedom from thromboembolism (TE) was 87% +/- 2%, overall at 10 years, and was not different by valve position (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

The Mitroflow pericardial bioprosthesis. Comparison of early clinical performance in aortic and mitral positions.

Between 1983 and 1987 the Mitroflow pericardial prosthesis was implanted in 354 patients, ranging in age from 14 to 94 years (mean 60.1 years). The early mortality was 5.7% and the late mortality 2.9% per patient-year. The total cumulative follow-up was 853 years (mean 2.4 years). Patient survival at 4 years for aortic valve replacement (AVR) was 81.5% and for mitral valve replacement (MVR) 74.8%. The overall rate of valve-related complications was 4.8% per patient-year (41 complications): thromboembolism, 15; hemorrhage related to antithromboembolic therapy, 1; prosthetic valve endocarditis, 15; nonstructural dysfunction, 3; and structural valve deterioration, 7. At 4 years the freedom from thromboembolism was 91.5% +/- 2.7% for AVR and 91.1% +/- 4.0% for MVR, from prosthetic valve endocarditis 93.5% +/- 2.3% for AVR and 94.0% +/- 2.9% for MVR, from structural valve deterioration 97.3% +/- 2.1% for AVR and 92.6% +/- 3.2% for MVR, from valve-related mortality 96.9% +/- 1.4% for AVR and 97.5% +/- 1.8% for MVR, and from reoperation 93.5% +/- 2.8% for AVR and 83.1% +/- 5.1% for MVR. The freedom from the composite of all valve-related complications at 4 years was 81.1% +/- 4.2% for AVR and 75.3% +/- 2.8% for MVR. The Mitroflow valve has provided satisfactory clinical performance at the 4-year evaluation. Structural valve deterioration is greater in the mitral position than in the aortic position. Long-term evaluation of the Mitroflow valve is necessary to determine the impact of structural valve deterioration on its clinical performance.

The Carpentier-Edwards standard porcine bioprosthesis: clinical performance to 15 years.

The Carpentier-Edwards standard porcine bioprosthesis was implanted in 1,195 patients in 1,213 operative procedures between 1975 and 1987, with the majority of implants performed prior to 1982 at the University of British Columbia. The mean age of the patient population was 57.2 years (range 8 to 85 years). The mean follow-up was 7.4 years per patient. The freedom from the combination of thromboembolism and antithromboembolic therapy-related hemorrhage at 15 years was 79.5% for aortic valve replacement (AVR), 72% for mitral valve replacement (MVR), and 84% for multiple valve replacement (MR) (p less than 0.05, AVR greater than MR greater than MVR). The freedom from structural valve deterioration at 15 years was 71% for AVR, 41% for MVR, and 41% for MR (14 years) (p less than 0.05, AVR greater than MVR greater than MR). The freedom from nonstructural dysfunction and prosthetic valve endocarditis did not distinguish the valve positions (p = NS). The freedom from valve-related mortality from all causes including reoperation was 92% for AVR, 78% for MVR, and 77% for MR at 15 years (p less than 0.05, AVR greater than MVR greater than MR). The freedom from residual morbidity was not significantly different between valve positions (p = NS). The freedom from treatment failure (valve-related mortality and residual morbidity) at 15 years was 87% for AVR, 72% for MVR, and 75% for MR (p less than 0.05, AVR greater than MR greater than MVR). The freedom from all complications at 14 years was 50% for AVR, 25% for MVR, and 27% for MR (p less than 0.05, AVR greater than MR greater than MVR).(ABSTRACT TRUNCATED AT 250 WORDS)

The Carpentier-Edwards supra-annular porcine bioprosthesis: clinical performance to 8 years of a new generation porcine bioprosthesis.

The Carpentier-Edwards supra-annular porcine bioprosthesis has been utilized at the University of British Columbia since its introduction in 1982. The prosthesis was designed to improve hemodynamics with the supra-annular configuration and to reduce tissue failure with low-pressure glutaraldehyde preservation of the porcine aortic tissue. The prosthesis was inserted in 1,956 patients with 2,129 prostheses between 1982 and 1989. The mean age of the patient population was 62.7 years (range 13 to 87 years). The mean follow-up was 3.7 years per patient. The freedom from thromboembolism and antithromboembolic therapy-related hemorrhage at 8 years was 92% for aortic valve replacement (AVR), 83% for mitral valve replacement (MVR), and 92% for multiple valve replacement (MR) (p less than 0.05, AVR greater than MR greater than MVR). The freedom from structural valve deterioration was 86% for AVR, 73% for MVR, and 96% for MR at 8 years (p less than 0.05, AVR greater than MR greater than MVR). The freedom from nonstructural valve dysfunction and prosthetic valve endocarditis was not different between positions (p = NS). The freedom from valve-related mortality at 8 years was 98% for AVR, 94% for MVR, and 98% for MR (p less than 0.05, AVR greater than MR greater than MVR). The freedom from residual morbidity was not different at 8 years (p = NS). The freedom from treatment failure (valve-related mortality and residual morbidity) was 96% for AVR, 89% for MVR, and 94% for MR (p less than 0.05, AVR greater than MVR greater than MR).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of pneumothorax in patients with acquired immunodeficiency syndrome.

Pneumocystis carinii pneumonia in a patient with acquired immunodeficiency syndrome may cause severe alveolar damage, resulting in pneumothoraces that are often bilateral, recurrent, and refractory to accepted methods of treatment. The clinical features, management, and follow-up results were assessed in 22 consecutive patients who presented with a pneumothorax and acquired immunodeficiency syndrome. Seventeen patients died within the time frame of this study. Their average survival time was 147 days. Five surviving patients have lived an average of 366 days. We proposed an algorithm to assist in the management of pneumothoraces in these patients. We concluded that pneumothorax in patients with acquired immunodeficiency syndrome is prognostic of short-term survival. The results in the treatment of pneumothorax in the patient with acquired immunodeficiency syndrome are related to the pathologic lesions of the lung that are associated with Pneumocystis pneumonia and not to the surgical treatment that is employed.

Pregnancy and childbearing in a population with biologic valvular prostheses.

Long-term performance of biological prostheses and course of pregnancy, labor, and delivery were evaluated in women less than 35 years of age. Between 1975 and 1987, 87 female patients received a porcine (n = 86) or pericardial valve (n = 1); the mean patient age was 26.8 years, with a range of 8 to 35 years. A total of 17 of these patients experienced 37 pregnancies. A total of 25 babies were delivered, of which 19 were babies of normal birth weight born at term and six were born prematurely (two of these were stillborn). There were six spontaneous abortions and five therapeutic abortions. The mean time from primary operation to first delivery was 29 months. Of the 17 pregnant patients, 14 were in normal sinus rhythm and three were in atrial fibrillation. One of those in fibrillation had a therapeutic abortion while receiving warfarin therapy, and another was successfully delivered of her neonate after 7 months of warfarin therapy. The remaining 15 patients were treated through 35 pregnancies without anticoagulants or antiplatelet agents. Of the total population of 87 patients, 32 (36.8%) were treated for valve-related complications. Structural valve deterioration occurred in eight patients (47.1%) of the pregnancy group and 10 patients (14.3%) of the nonpregnancy group (p less than 0.05). The freedom from structural valve deterioration at 10 years was 23.3% +/- 14% for the pregnancy group and 74.2% +/- 8.5% for the nonpregnancy group (p less than 0.05, age as a determinant, p not significant). There were eight valve-related deaths (1.5%/patient-year). Reoperation was performed in 59% of the pregnancy group and 19% of the nonpregnancy group, primarily for structural valve deterioration manifested as valvular obstruction from aggressive calcification (p less than 0.05). The freedom from reoperation at 10 years parallels freedom from structural valve deterioration (20.3% +/- 12.4% and 64.3 +/- 9.1% for the pregnancy and nonpregnancy groups, respectively, with p less than 0.05; with age added as a determinant, p not significant). The overall reoperative mortality was 8.7% (two patients). The biologic prostheses afforded successful pregnancy without fetal wastage or congenital anomalies and without significant maternal morbidity or mortality.

The Carpentier-Edwards standard porcine bioprosthesis. A first-generation tissue valve with excellent long-term clinical performance.

The Carpentier-Edwards standard porcine bioprosthesis was implanted in 1190 patients (1201 operations, 1303 valves) between January 1975 and June 1986; most implants were before 1982. The mean age of the patients was 57.2 years (range 8 to 85 years). The early mortality was 7.6% (aortic valve replacement 5.1%, mitral valve replacement 8.8%, and multiple valve replacement 15.3%). Late mortality was 3.9% per patient-year (aortic valve replacement 3.6%, mitral valve replacement 4.2%, and multiple valve replacement 3.8%). The total cumulative follow-up period was 6737 years. Thromboembolism was 1.5% per patient-year (fatal 0.4% per patient-year) (minor 0.6%, major 0.9%); antithromboembolic therapy-related hemorrhage was 0.5% (fatal 0.1%); prosthetic valve endocarditis was 0.6% (fatal 0.2%); nonstructural dysfunction was 0.5% (fatal 0.2%); and structural valve deterioration and/or primary tissue failure was 1.5% per patient-year (fatal, 0.2% per patient-year). Thromboembolism and structural valve deterioration were the significant complications, structural valve deterioration occurring primarily between the sixth and 10th year of evaluation. The overall patient survival was 65.0% for aortic valve replacement and 54.8% for mitral valve replacement (p less than 0.05) at 10 years. The patients were classified as 92.9% New York Heart Association functional classes III and IV preoperatively and 92.3% classes I and II postoperatively. Freedom at 10 years from thromboembolism was 84.3% for aortic valve replacement and 76.5% for mitral valve replacement (p = 0.05); structural valve deterioration was 78.6% for aortic valve replacement and 71.6% for mitral valve replacement (p less than 0.05); reoperation was 74.4% for aortic valve replacement and 67.1% for mitral valve replacement (p less than 0.05). Freedom from all valve-related complications at 10 years was 58.9% for aortic valve replacement and 46.8% for mitral valve replacement (p less than 0.05); valve-related mortality was 89.5% for aortic valve replacement and 82.6% for mitral valve replacement (p = not significant); mortality and reoperation was 58.9% for aortic valve replacement and 46.8% for mitral valve replacement (p less than 0.05); mortality and residual morbidity (treatment failure) was 87.2% for aortic valve replacement and 75.1% for mitral valve replacement (p = not significant); mortality, residual morbidity, and reoperation were 66.3% for aortic valve replacement and 54.9% for mitral valve replacement (p less than 0.05). The standard Carpentier-Edwards porcine bioprosthesis has provided satisfactory clinical performance and has afforded patients excellent quality of life.

Cardiac valve replacement in the elderly: clinical performance of biological prostheses.

From 1975 to 1987, 1,127 elderly patients underwent 1,223 valve replacements with the Carpentier-Edwards standard or supraannular porcine bioprostheses in 1,147 operations. Of the total patient population seen during these years, 33.5% receiving a standard porcine bioprosthesis and 48.6% receiving a supraannular bioprosthesis were 65 years of age or older. Of this elderly patient population, 465 patients were between 65 and 69 years old; 618 patients, 70 and 79 years old; and 52 patients, 80 years old and older. Aortic valve replacement was performed in 635 patients, mitral valve replacement in 417 patients, tricuspid valve replacement in 2 patients, and multiple-valve replacement in 80 patients. The cumulative follow-up was 3,957 patient-years. Early mortality was 9.5%: 7.3% for the 65- to 69-year-old group, 10.7% for the 70- to 79-year-old group, and 15.4% for the group 80 years old and older. Late mortality was 5.5% per patient-year: 4.2% per patient-year for the 65- to 69-year-old group, 6.3% per patient-year for the 70- to 79-year-old group, and 14.1% per patient-year for the group 80 years old and older. Valve-related causes contributed to 7 early deaths and 33 late deaths. The overall patient survival, including operative deaths, was 70.7% +/- 1.6% at 5 years and 47.8% +/- 3.7% at 10 and 12 years. The freedom from all valve-related complications was 52.1% +/- 6.1% at 10 and 12 years. The overall rate of valve-related complications was 5.0% per patient-year (fatal complications, 1.13% per patient-year). The overall rate of thromboembolism was 2.3% per patient-year and the freedom from thromboembolism, 69.6% +/- 5.2% at 10 and 12 years. The freedom from structural valve deterioration was 80.8% +/- 8.1% at 10 and 12 years: 71.7% +/- 11.0% at 10 and 12 years for the 65- to 69-year-old group, 97.9% +/- 1.2% at 10 years for the 70- to 79-year-old group, and 100% at 12 years for the group 80 years old and older. At 10 and 12 years, the freedom from valve-related death was 83.7% +/- 4.3% and the freedom from reoperation, 73.3% +/- 8.6%. The freedom from valve-related death, residual morbidity from thromboembolism and anticoagulant-related hemorrhage, and reoperation was 61.7% +/- 7.0% at 10 and 12 years. The clinical performance of porcine bioprostheses in the elderly patient population has been excellent. The early mortality increases in patients 70 years old or older.(ABSTRACT TRUNCATED AT 400 WORDS)

The Carpentier-Edwards supra-annular porcine bioprosthesis: new generation low pressure glutaraldehyde fixed prosthesis.

The Carpentier-Edwards supra-annular porcine bioprosthesis was implanted in 1,576 operations (1,536 patients with 1,704 valves) between 1981 and 1987. The mean age of the patients was 61.9 years (range 13 to 87 years). During the years 1981 and 1987, approximately 90% of the total valvular surgery population received the prosthesis. The early mortality was 7.0% (included patients with concomitant procedures including coronary artery bypass and ascending aortic aneurysm resection). Late mortality was 4.0% per patient-year. The total cumulative follow-up was 4,237 years. Thromboembolism (TE) was 2.4% per patient-year (fatal 0.4% per patient-year) (minor 1.2%; major 1.3%); antithromboembolic therapy-related hemorrhage (ATH) 0.5% (fatal 0.07%); prosthetic valve endocarditis (PVE) 0.5% (fatal 0.2%); periprosthetic leak (PPL) 0.3% (fatal 0%); clinical valve dysfunction (CVD) 0.3% (fatal 0.02%); and structural valve deterioration/primary tissue failure (SVD) 0.2%/patient-year (fatal 0%). Thromboembolism and structural valve deterioration were the significant complications, SVD occurring primarily between the fourth and fifth year of evaluation. The overall patient survival was 77.1% +/- 1.4% at five years. The patients were classified as 89.6% NYHA functional Class III and IV preoperatively and 96.1% Class I and II postoperatively. The freedom at five years from TE was 90.6% +/- 1.0%; SVD 98.9% +/- 0.5%; and reoperation 95.9% +/- 0.9%. Freedom from all valve-related complications at five years was 84.1% +/- 1.3%; valve-related mortality 96.8% +/- 0.7%; mortality and reoperation (valve failure) 92.9% +/- 1.1%; mortality and residual morbidity (treatment failure) 93.7% +/- 0.9%; and mortality, residual morbidity, and reoperation (valve failure and dysfunction) 90.0% +/- 1.2%. There were 28 valve-related deaths of a total 280 deaths (early 4, late 24) (TE 17; ATH 3; CVD 1; PVE 7; PPL 0; and SVD 0). Valve-related reoperations were performed in 32 patients (TE 2; CVD 4; PVE 7; PPL 11; and SVD 8). The supra-annular Carpentier-Edwards porcine bioprosthesis has provided very satisfactory clinical performance and afforded patients an excellent quality of life. The long-term durability of this low pressure glutaraldehyde fixed prosthesis will be determined by observation over the next five to seven years.

The Carpentier-Edwards supraannular porcine bioprosthesis. A new generation tissue valve with excellent intermediate clinical performance.

The Carpentier-Edwards supraannular porcine bioprosthesis, an investigational valve, was implanted in 1167 patients (1174 operations, 1274 valves) between November 1981 and December 1985 (age range 13 to 85 years, mean 61 years). The early mortality rate was 7.2% (with concomitant procedures 10.9%, without 4.8%; with previous operation 10.5%, without 6.6%). The late mortality rate was 4.5% per patient-year (aortic valve replacement, 4.0%; mitral valve replacement, 4.8%; multiple valve replacement, 5.6%). Total cumulative follow-up was 2272.3 years. The prevalence of thromboembolism was 2.6% per patient-year (fatal 0.4% per patient-year, major 1.4%, minor 1.2%); hemorrhage related to antithromboembolic therapy, 0.7% (fatal 0.1%); prosthetic valve endocarditis, 0.4% (fatal 0.2%); periprosthetic leak, 0.4% (fatal 0%); structural valve deterioration (primary tissue failure/structural failure), 0.1% per patient-year; and clinical valve dysfunction, 0.4%. The reoperation rate was 0.8% per patient-year (thromboembolism, 0.1%; clinical valve dysfunction, 0.1%; prosthetic valve endocarditis, 0.1%; periprosthetic leak, 0.4%; structural valve deterioration, 0.1%). Thromboembolism occurred throughout the observation period but with decreasing frequency, hemorrhage throughout the period in no predictable fashion, prosthetic valve endocarditis within 2 years, periprosthetic leak within 2 years, and structural valve deterioration occurred during the fourth year of assessment. The overall survival rate was 79.8% +/- 1.7% (4 years). Freedom (at 4 years) from thromboembolism was 92.2% +/- 1.2%; from structural valve deterioration, 98.8% +/- 0.8%; and from reoperation, 95.8% +/- 1.3%. Freedom from all complications (4 years) was 85.9% +/- 1.7%; from complication mortality, 98.4% +/- 0.4%; and from valve failure (mortality and reoperation), 94.3% +/- 1.3%. This investigational Carpentier-Edwards supraannular porcine bioprosthetic valve has provided excellent clinical performance and remains our overall prosthesis of choice.

The Carpentier-Edwards standard porcine bioprosthesis: long-term evaluation of the high pressure glutaraldehyde fixed prosthesis.

The Carpentier-Edwards standard porcine bioprosthesis was implanted in 1,000 operations (988 patients with 1,092 valves) between 1975 and 1981. The mean age of the patients was 56.8 years (range 8 to 85 years). During the years 1975 and 1981, approximately 97% of the total valvular surgery population received the prosthesis. The early mortality was 7.8% (including patients with concomitant procedures including coronary artery bypass and ascending aortic aneurysm resection). Late mortality was 3.8% per patient-year. The total cumulative follow-up was 5,937 years. Thromboembolism (TE) was 1.3% per patient-year (fatal 0.4%/patient-year) (minor 0.4%; major 0.9%); antithromboembolic therapy-related hemorrhage (ATH) 0.5% (fatal 0.1%); prosthetic valve endocarditis (PVE) 0.5% (fatal 0.2%); periprosthetic leak (PPL) 0.4% (fatal 0.2%); clinical valve dysfunction (CVD) 0.2% (fatal 0.02%); and structural valve deterioration (SVD)/primary tissue failure 1.6% per patient-year (fatal 0.2%/pt-yr). Thromboembolism and SVD occurring primarily between the sixth and tenth year of evaluation, were the significant complications. The overall patient survival was 60.5% +/- 2.4% at 10 years. The patients were classified as 93.5% NYHA functional Class III and IV, preoperatively and 93.1% Class I and II, postoperatively. The freedom at 10 years from TE was 82.9% +/- 2.7%; SVD 76.9% +/- 2.9%; and reoperation 70.8% +/- 3.1%. Freedom from all valve-related complications at 10 years was 54.3% +/- 3.1%; valve-related mortality 86.4% +/- 2.3%; mortality and reoperation (valve failure) 64.0% +/- 3.2%; mortality and residual morbidity (treatment failure) 82.3% +/- 2.6%; and mortality, residual morbidity, and reoperation (valve failure and dysfunction) 60.6% +/- 3.2%. There were 61 valve-related deaths of a total 352 deaths (early 7, late 54) (TE 21; ATH 7; CVD 1; PVE 12; PPL 9; and SVD 11). Valve-related reoperations were performed in 128 patients (TE 3; CVD 4; PVE 14; PPL 17; and SVD 90). The standard Carpentier-Edwards porcine bioprosthesis has provided very satisfactory clinical performance and afforded patients excellent quality of life. Primary tissue failure is the significant long-term complication.

The mitral medical pericardial bioprosthesis: new generation bovine pericardial prosthesis.

The Mitral Medical Mitroflow pericardial bioprosthesis was implanted in 99 operations (99 patients with 104 valves) between 1984 and 1987. The mean age of the patients was 62.8 years (range 28 to 94 years). The early mortality was 6.1% (including patients with concomitant procedures--coronary artery bypass and ascending aortic aneurysm resection). Late mortality was 2.3% per patient-year. The total cumulative follow-up was 172 years. Thromboembolism (TE) was 4.1% per patient-year (fatal 1.2% per patient-year) (minor 2.3%; major 1.8%); antithromboembolic therapy-related hemorrhage (ATH) 0.6% (fatal 0.6%); prosthetic valve endocarditis (PVE) 0.6% (fatal 0%); periprosthetic leak (PPL) 0.6% (fatal 0%); clinical valve dysfunction (CVD) 1.2% (fatal 0%); and structural valve deterioration/primary tissue failure (SVD) 1.2% per patient-year (fatal 0% per patient-year). Thromboembolism was the significant complication. SVD occurred in two patients during the third year of evaluation. The overall patient survival was 89.2 +/- 3.3% at four years. The patients were classified as 91.9% NYHA functional Class III and IV preoperatively and 97.7% Class I and II postoperatively. The freedom at four years from TE was 88.5% +/- 4.9%; SVD 92.5 +/- 5.1%; and reoperation 89.8% +/- 5.3%. Freedom from all valve-related complications at four years was 76.8% +/- 6.6%; valve-related mortality 97.2 +/- 2.0%; mortality and reoperation (valve failure) 87.3% +/- 5.5%; mortality and residual morbidity (treatment failure) 95.5% +/- 2.6%; and mortality, residual morbidity, and reoperation (valve failure and dysfunction) 85.6% +/- 5.7%. There were three valve-related deaths of a total of ten deaths (early 2; late 1) (TE 2; ATH 1; CVD 0; PVE 0; PPL 0; and SVD 0). Valve-related reoperation was performed in four patients (TE 0; CVD 0; PVE 1; PPL 1; and SVD 2). The Mitral Medical Mitroflow pericardial bioprosthesis has provided very satisfactory clinical performance and afforded patients excellent quality of life.

Iliac artery aneurysms arising in patients having had resections of abdominal aneurysms.

We report the angiographic, computed tomographic, and ultrasonographic findings in two patients with iliac artery aneurysms detected several years after undergoing vascular graft surgery to the aorta. These lesions are often silent until serious complications occur, and they should be treated even when asymptomatic. Radiologists should be familiar with this complication so that it may be more readily diagnosed.

Carpentier-Edwards porcine bioprostheses: assessment of clinical performance.

Carpentier-Edwards porcine bioprostheses have been implanted since 1975, commencing with the previous generation standard prosthesis in that year and the new generation supra-annular prosthesis in 1981. The first 700 operations with each prosthesis were evaluated: Carpentier-Edwards standard porcine bioprosthesis (CE-S), 692 patients (772 valves) and Carpentier-Edwards supra-annular porcine bioprosthesis (CE-SA), 698 patients (756 valves). The incidence of thromboembolism was CE-S 1.4% per patient-year and CE-SA 2.1% per patient-year (hazard interval rates not considered). The rate of structural valve deterioration was CE-S 1.8% per patient-year (79 prostheses) and CE-SA 0.2% (four prostheses). The reoperation rate was 2.5% per patient-year (110 prostheses) for CE-S and for CE-SA it was 0.9% (six prostheses). The late mortality rate was 3.7% per patient-year and 4.2%, respectively. The 10-year freedom rates for CE-S were thromboembolism, 82.7 +/- 2.8%; prosthetic valve endocarditis, 93.5 +/- 1.6%; structural valve deterioration, 77.1 +/- 2.9%; reoperation, 69.9 +/- 3.1%; valve related mortality, 85.9 +/- 2.4%; valve failure, 62.8 +/- 3.2%; treatment failure, 82.0 +/- 2.7%; mortality, reoperation and residual morbidity, 59.5 +/- 3.2%; and all complications, 53.4 +/- 3.1%. The four-year freedom rates for CE-SA were thromboembolism, 93.0 +/- 1.3%; prosthetic valve endocarditis, 98.7 +/- 0.5%; structural valve deterioration, 98.3 +/- 1.0%; reoperation, 95.6 +/- 1.3%; mortality, 97.9 +/- 0.6%; valve failure, 93.6 +/- 1.4%; treatment failure, 94.6 +/- 1.1%; mortality, reoperation and residual morbidity, 90.9 +/- 1.6%; and all complications, 85.6 +/- 1.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Carpentier-Edwards standard porcine bioprosthesis: primary tissue failure (structural valve deterioration) by age groups.

Primary tissue failure (structural valve deterioration) has been documented as the most prominent complication of porcine bioprostheses. The influence of age on primary tissue failure has received limited consideration. From 1975 to 1986, 1,301 Carpentier-Edwards standard porcine bioprostheses were implanted in 1,183 patients in 1,201 operations. Of the total number of prostheses, 97.7% were implanted prior to 1983. The mean follow-up was 5.6 years and was 97.5% complete. Primary tissue failure was identified in 96 patients (98 operations) at reoperation (95) or autopsy (3). One hundred four (104) prostheses were involved. Thirty-one failed after aortic valve replacement (AVR), 49 after mitral valve replacement (MVR), and 24 after multiple-valve replacement (18 patients). There were 47 male and 49 female patients. The mean age at implantation was 47 years (range, 8 to 72 years). The mean implantation time was 74.0 months. The freedom from primary tissue failure at 10 years is 77.0 +/- 2.9% overall; for AVR, 83.1 +/- 3.7%; for MVR, 72.1 +/- 4.9%; and for multiple-valve replacement, 65.5 +/- 7.8%. The freedom from deterioration for patients less than 20 years of age is significantly less than that for other age groups. The freedom from deterioration increased by decades; the greatest freedom was noted in patients 70 to 80 years old and 80 years old or older. The freedom from deterioration at 10 years for patients less than 30 years of age is 26.8 +/- 17.2%; 30 to 59 years, 77.4 +/- 3.0%; and 60 years and older, 83.1 +/- 4.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperation within 2 years of aortofemoral bypass.

The authors analysed 267 consecutive primary aortofemoral grafts to identify the reasons for reoperation within the first 2 years postoperatively. Forty-one (8%) of the 521 limbs required a second operation. Precursors to reoperation were: occlusion of a superficial femoral artery (12%), gangrene (27%) and severe acute ischemia (35%). The rationale for reoperation was classified as technical 11, questionable selection (candidates for percutaneous transluminal angioplasty or inappropriate operation) 9, disease progress 11, residual symptoms 9, contralateral symptoms 1. The commonest technical problem was blind endarterectomy which preceded seven reoperations, five for thrombosis of the graft or a superficial femoral artery which was patent initially. Although 218 limbs had an occluded or severely stenosed superficial femoral artery, only 26 (12%) required reoperation within the first 2 years. The authors believe that the incidence of reoperation after aortofemoral bypass can be reduced by identifying the limbs at risk, by appropriate selection for percutaneous transluminal angioplasty, avoiding blind outflow endarterectomy and considering concomitant femoropopliteal bypass when gangrene is present.

Surgical management of spontaneous pneumothorax in patients with acquired immunodeficiency syndrome.

Spontaneous pneumothorax has been reported with increasing frequency in patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia. In the past year, we treated 4 patients with spontaneous pneumothorax. All of them were treated with closed tube thoracostomy, and 1 patient with bilateral apical cysts eventually required bilateral thoracotomies and pleurectomies. Only 1 patient had an uncomplicated hospital course. The remaining patients had prolonged air leaks, and 2 had synchronous pneumothoraces. Pneumothorax appears to be associated with P. carinii pneumonia. We recommend closed tube thoracostomy as the initial treatment in symptomatic patients. Pleurectomy for air leaks persisting longer than seven days can be safely performed in patients fit for thoractomy.

Late rupture of prosthetic aortic grafts. Presentation and management.

Eight patients were treated for complications arising from actual holes in prosthetic aortofemoral or aortoiliac grafts. All occurred more than 8 years after implantation. Presentations varied and included shock from a graft-to-enteric fistula, a rapidly expanding painful femoral aneurysm, an acutely ischemic limb, and rest pain. The whole graft is suspect and must be assessed by aortography, but graft deterioration can be localized, which simplifies management. In our patients, holes in the body of the graft or near the bifurcation were approached transabdominally. We replaced as much of the graft as was reasonable under the circumstances. Two of the four patients died. Five patients had graft holes in the inguinal region which we believe were related to tethering in that area. For this reason, we recommend cutting the inguinal ligament and prosthetic limbs no more than 8 mm in diameter. Partial retroperitoneal resection with external sleeve support has been a durable alternative to a complete redo operation in patients with degeneration isolated to the inguinal area.

Surgical treatment of lung cancer: promise and problems of early diagnosis.

Recent studies have shown that the survival of patients with lung cancer is improved if the tumour is resected before it becomes larger than 3 cm in diameter and before it spreads to lymph nodes. While this suggests a positive benefit from early detection, recent mass-screening studies have claimed that the benefit obtained from this procedure is illusory because it relates to a lead-time bias. This study reports the results of surgical resection of 143 primary lung cancers. The data confirmed that the predicted 5-year survival was greatest (74%) following resection of lesions that were less than 3 cm in diameter without node involvement. Analysis showed that the age of these patients was 63 +/- 8 years, the same as in patients with larger tumours and more extensive node involvement. This suggests that tumours progress rapidly from a stage at which resection is beneficial to stages at which it is not. Although it is desirable that tests predict the presence of small tumours, the high requirements for sensitivity and specificity at current prevalence rates for lung cancer make this goal impractical.

Carpentier-Edwards supra-annular porcine bioprosthesis. Clinical experience and implantation characteristics.

The investigational Carpentier-Edwards supra-annular valve was implanted in 592 patients from November, 1981, to February, 1984 (aortic valve replacement in 286, mitral valve replacement in 259, and multiple valve replacement in 47, for a total of 638 prostheses). A previous cardiac operation had been performed in 77 patients (13%). Concomitant procedures were performed in 202 patients (34.1%), including coronary artery bypass in 163 patients. The patient evaluation was 98.6% complete. The early mortality was 7.4% (44 patients) and the late mortality was 6.2% per patient-year (41 patients). The valve-related causes of late mortality were thromboembolism (five), anticoagulant-related hemorrhage (one), and prosthetic valve endocarditis (one). The overall patient survival, including operative death, was 85% at 2 years. The linearized occurrence rate for valve-related complications was 5.6% per patient-year (37 events)--thromboembolism 2.7% per patient-year (18) anticoagulant-related hemorrhage 1.2% (eight), prosthetic valve endocarditis 0.8% (five), and periprosthetic leak 0.9% per patient-year (six). There were no cases of primary tissue failure or structural failure. At 2 years, the freedom from valve-related complications was 86.9%, from valve-related mortality, 98.7%, and from valve-related mortality and reoperation, 97.7%. This valve is fixed in glutaraldehyde at low pressure and is designed to improve durability. It has provided a low incidence of valve-related complications without structural failure. The structural design of the prosthesis does not always conform to the anatomy of bicuspid aortic valves.