Ruptured aneurysm of sinus of Valsalva. Long-term postoperative follow-up.

Ruptured sinus Valsalva aneurysm was repaired in 13 patients (mean age c. 33 years). Dyspnea, chest pain, fatigue and palpitation were the most common symptoms and systodiastolic murmur, cardiomegaly and pulmonary congestion the most pertinent clinical findings. The pulmonary-to-systemic flow ratio averaged c. 2.5. Associated cardiac anomalies were ventricular septal defect, aortic or mitral regurgitation, aortic coarctation or subvalvular stenosis, tetralogy of Fallot (altogether 8 cases). The origin of the fistula was the noncoronary, right coronary or left coronary sinus (5, 4 and 3 cases) or was not identifiable (1 case). Rupture occurred into the right atrium (6 cases), right ventricle (6) or pulmonary artery (1 case). Repair was undertaken through aortotomy (6 cases), right ventriculotomy (2) or right atriotomy (1) or through aortotomy + right ventriculotomy or atriotomy (4). In one case aortic valve replacement was performed. All survived the operation. Follow-up averaged 9.6 years. Recurrent fistulation, though with small shunt, was found in two cases. Combined two-dimensional and Doppler echocardiography revealed minor cardiac abnormalities in most patients, particularly aortic regurgitation. All the patients were in NYHA function class I or II.

Sequential internal mammary artery (IMA) grafts in coronary artery bypass surgery.

Since 1972, double or triple left IMA bypasses have been made on 61 consecutive patients with a total of 123 distal anastomoses to the LAD or to the LD branches of the LAD. There were 54 additional vein grafts with 102 distal anastomoses. The number of single IMA grafts in the same period of time was 400. Hospital mortality was 2 patients (3.3%), with a late mortality of 7 patients (11.3%), 2 of them being heart-related, one of hypernephroma, one suicide, and of unknown cause in the remaining 3 patients. Five patients refused postoperative angiography. There were 50 patients with one or more postoperative angiograms available for the analysis after a mean follow-up time of 35.1 (0.5 to 128) months. The late patency of the left IMA anastomoses was 97% (98/101) and 82.4% (84/102) of the vein anastomoses. There were 2 anastomotic left IMA occlusions to the LD at 2 weeks and 10 months, respectively, and to LAD at 13 months. No left IMA graft had become completely occluded. According to the trend analysis, there was a 97.5% patency at 5 years, and 95.7% at 10 years with left IMA grafts compared to 78.4 and 67.9, respectively, with vein grafts. Ten left IMA grafts were dilated, 2 narrowed and 36 unchanged at the late angiography. Sequential left IMA graft, in appropriate cases seems to result in the most superior patency rate of all types of grafts.

The management of non-neoplastic esophageal perforation.

The clinical features, management and prognosis of non-neoplastic esophageal perforation are evaluated in a clinical series of 29 patients. Five of 12 spontaneous ruptures were caused by vomiting after alcoholic intake. There were 12 iatrogenic perforations, five of which were caused by esophageal dilatation, four by diagnostic endoscopy and three by endoscopic removal of foreign bodies. Most cases were diagnosed by esophagogram. The delay in reaching the right diagnosis was less than 12 hours in 11 cases and more than 48 hours in ten cases. Management was surgical in 25 cases and conservative in four cases. The operative procedures used were direct suture closure in 15 cases, drainage in eight cases and esophageal resection in two cases. The overall mortality rate was 24%. Ten out of 11 perforations treated surgically within 12 hours of the perforation were cured and seven of 15 patients treated by primary closure recovered without complications.

Bronchial rupture caused by blunt chest trauma.

Tracheobronchial rupture is a rare and serious complication of blunt chest trauma. The cause is often a traffic accident and the rupture may be associated with other, fatal injuries. Three cases were treated at our clinic in the period 1970-1982. In them, as in about 60% of all cases in the literature, the tracheobronchial injury was not recognized in the acute stage. The early clinical picture may vary, depending on the site and extent of the injury, from only minimal mediastinal emphysema to severe dyspnea with extensive subcutaneous and mediastinal emphysema or persistent pneumothorax. The correct diagnosis was confirmed in all three of the described cases by bronchoscopy, which was performed in the late course because of respiratory difficulties and roentgenographic evidence of pulmonary complications. Since early surgical repair is essential for a good functional result, the possibility of tracheobronchial rupture must be kept in mind in any case of severe thoracic trauma.

The effect of dipyridamole and warfarin on the patency rate of coronary artery bypass grafts.

Seventy consecutive patients who had undergone coronary artery bypass surgery were postoperatively treated with either dipyridamole or warfarin for 6 months. The dipyridamole series consisted of 28 patients given 150 mg dipyridamole 3 times daily and the warfarin series, of 42 patients who received the appropriate daily dose of warfarin needed to maintain the prothrombin time within the therapeutic range. The majority of patients in both series belonged to the NYHA class III. Sixty-one percent of the patients in the dipyridamole series and 66% of those of the warfarin series had triple vessel disease. In all, 70 and 105 coronary artery branches were bypassed in the dipyridamole and warfarin series, respectively. This resulted in 2.5 distal anastomoses per patient in each series. The patency of the grafts was confirmed angiographically. There was no mortality during the 23.6 +/- 2.4 months follow-up period in the dipyridamole series or the 12.8 +/- 2.7 months in the warfarin series. The patency rates were 95.7% and 88.6% in the dipyridamole and warfarin series, respectively. It is apparent that dipyridamole is not less effective than warfarin in preventing postoperative coronary graft occlusion.

The effect of sequential versus multiple single saphenous vein aortocoronary bypass surgery on exercise tolerance.

The effect of aortocoronary bypass surgery on exercise tolerance in 34 patients undergoing sequential saphenous vein bypass grafts (seq. SVBG) was compared with that in 38 patients who had undergone single SVBGs. Postoperative exercise testing was carried out on average 23 months after surgery in the seq. SVBG group and 27 months after surgery in the single SVBG group (range 10-62 months in both groups). At the time of follow-up complete revascularization was demonstrated in 59% of the patients in the seq. SVBG group and in 50% of the patients in the single SVBG group. The improvement in the maximal load (MaxL) at the follow-up was 90.0% (p less than 0.001) in the seq. SVBG and 41.3% (p less than 0.001) in the single SVBG group. The corresponding increase in maximal heart rate (MaxHR) was 12.5% (p less than 0.001) and 10.1% (p less than 0.001) and the maximal ST depression (MaxSTd) diminished by 70.4% (p less than 0.001) and 54.2% (p less than 0.001). There were no statistically significant differences between the groups with respect to changes in MaxL, MaxHR and MaxSTd postoperatively. The changes in MaxL, MaxHR and MaxSTd in the completely and incompletely revascularized subgroups did not differ statistically. The exercise tolerance in this study was at least as good in the seq. SVBG group as in the single SVBG group and fully justifies continuing bypass surgery with sequential vein grafts.

Management of arteriosclerotic aneurysms of the innominate and subclavian arteries.

Two patients with innominate artery aneurysm and four with subclavian artery aneurysm are presented. Resection of the aneurysm and reconstruction of the vascular continuity were performed in all cases. No patient died in association with surgery. The complications included paralysis of the recurrent laryngeal nerve in one patient and postoperative infection of the vascular prosthesis, necessitating removal of the graft, in another. Because of the absence of surgical mortality and the acceptable complication rate, surgical resection of these aneurysms is recommended.

Treatment of spontaneous rupture of the esophagus.

A series of 10 patients with spontaneous rupture of the esophagus is analysed. Early primary closure of the tear and good drainage of the mediastinum and pleural cavity give the best results in such cases. Correct diagnosis is difficult and is often missed in the acute phase. The time lapse between the rupture and diagnosis nevertheless seems to be the most important single factor in the outlook for treatment of spontaneous rupture of the esophagus.

Peroperative fine needle aspiration biopsy of lung tumors.

The feasibility and reliability of peroperative fine needle aspiration biopsy of lung tumors were studied in a series of 54 patients. The postoperative histologic examination confirmed that 47 of the lesions were malignant. The cytologic examination also showed malignancy in 45 of these cases. The accuracy of fine needle cytology thus was 96%. In the two false negative reports the classification was Papanicolaou grades II and III. The cytologic classification of the histologically benign lesions was only grades I or II. Thus there were no false positive cytologic results. No complications arose from the needle biopsies. Peroperative fine needle aspiration biopsy at thoracotomy is rapid, simple and safe, and has a high degree of accuracy. It is diagnostically useful in cases without preoperative confirmation of suspected lung tumor if excisional biopsy is judged to be hazardous or unlikely to yield a definite diagnosis. The method permits the surgeon to assess the extent of a malignancy and can specify the cell type of the tumor.

Chylothorax. Clinical experience in nine cases.

Clinical experience in nine cases of chylothorax is presented. In five cases the cause was iatrogenic, in two cases idiopathic and in two cases the chylothorax was secondary to an advanced malignant disease. Iatrogenic chylothorax occurred after mediastinoscopy, thoracic sympathectomy, pneumonectomy, resection of an aneurysm of the thoracic aorta and closure of a patent ductus arteriosus. Only one of these patients needed an operative closure of the thoracic duct. In one of the two cases of a neoplastic origin the chylothorax was caused by a malignant mesothelioma and thoracic duct ligation was needed while in the other case it was due to an inoperable pancreatic carcinoma and was treated by thoracocentesis. In one of the idiopathic cases supradiaphragmatic ligation of the thoracic duct was necessary. It is concluded that in most iatrogenic or traumatic cases chylothorax can be cured by conservative therapy (diet, thoracocentesis); in other cases the operative therapy should be adjusted to the primary disease, and the ligation of the thoracic duct should be performed at a level where it is able to prevent the chylous leak without unnecessarily interfering with the collateral lymphatic circulation. Abundant and prolonged chylous leakage should be always treated operatively to prevent disastrous nutritional and immunological deficiencies.

Is chronic brain damage in boxing a hazard of the past?

Of fourteen boxers with a mean age of 31 years who had been Finnish, Scandinavian, or European champions, only one showed deficits in neurological status and he and one other had had episodes of inappropriate behaviour which were attributed to boxing. However, computed tomography revealed pathological findings attributable to brain injury in four of six professional and one of eight amateur boxers. Two of the professionals and four of the amateurs had electroencephalographic abnormalities which may have been caused by brain injury. Twelve of the boxers had psychological test results which suggested brain injury, although only two professionals had definite deviation from normal. The results indicate that modern medical control of boxing cannot prevent chronic brain injuries but may create a dangerous illusion of safety. The only way to prevent brain injuries is to disqualify blows to the head.

Patency of sequential versus single vein grafts in coronary bypass surgery.

The patency and graft flow of sequential (seq. SVBG) and single saphenous vein bypass grafts (single SVBG) in coronary bypass surgery were compared angiographically (mean follow-up 26 months) in 76 patients with 36 seq. SVBG (75 distal anastomoses) and 85 single SVBGs. The late patency of all seq. SVBGs anastomoses (94.7%) was higher than that of single SVBGs (80.0%). No early or late graft occlusions were seen in the side-to-side (SSA) anastomoses of the seq. SVBGs. The cine-angiographically determined mean volume flow in the proximal segments of the seq. SVBGs was significantly higher (p less than 0.001) than that in the distal segments of the seq. SVBGs or in the single SVBGs at both early and late follow-up. Despite the higher late patency rate (88.9% vs 80.0%) in the end-to-side anastomoses (ESA) of the seq SVBGs, the mean graft flow was significantly lower in the distal segments of seq SVBGs than in the single SVBGs (71 ml/min vs. 109 ml/min, p less than 0.05).

The effect of sequential versus single vein aortocoronary bypass surgery on resting left ventricular function.

To study the effectiveness of sequential vein grafts in coronary bypass surgery, left ventricular (LV) function was serially estimated in 28 patients with sequential grafts and compared with that in 24 patients with multiple single vein grafts. Early patency of sequential grafts was 98% vs. 94% for single veins. Late patency (mean 28 months after operation) of sequential veins was 97% vs. 85% for single vein grafts (mean 32 months after operation). Various parameters of resting LV function (pressure, volumes, ejection fraction, regional contraction score, mean velocity of fiber shortening) showed only slight and non-significant changes during the angiographic follow-up in the sequential vein graft group, with the exception of LVEDP, which was significantly lower at the late follow-up (p less than 0.05). There was an apparently spurious highly significant decline in fiber shortening velocity in the sequential graft group (p less than 0.001). Division of the series into subgroups of complete or incomplete revascularization did not improve the predictive power of resting LV function. The data reveal that sequential vein grafts are comparable to multiple single vein grafts as far as the influence on LV function at rest is concerned.

Surgical support of collapsing intrathoracic tracheomalacia after thyroidectomy.

Invalidating tracheal collapse occurred in a 55-year-old male farmer after extirpation of an intrathoracic goitre. The collapse was successfully treated by a new modification of supportive surgery developed by us, viz. circumferential application of heavy Marles mesh (Davol Inc., Box 8500, Cranston, R. I. 02920, USA) around the trachea.

Pulmonary arteriovenous fistulas.

During the 20-year-period 1959-78, 7 patients with pulmonary arteriovenous fistula were treated at the Department of Thoracic and Cardiovascular Surgery. There were 5 men and 2 women, with a mean age of 26 (14-47) years. Cyanosis with elevated haematocrit was present in 4, dyspnoea in 4, neurological signs in 3 (including one brain abscess and one hemiplegia). Systolic hum was audible in 3 cases. Three patients had the hereditary type of the disease (Rendu-Osler-Weber) with telangiectasiae also elsewhere in the body. The calculated right-to-left shunt varied from 14 to 56 per cent of the cardiac output. The treatment was lobectomy in all cases (4 upper lobe, one middle lobe and 2 lower lobe resections). The patient with a brain abscess underwent craniotomy prior to lobectomy and developed epilepsy necessitating anticonvulsive treatment. The other patients had an uneventful recovery with relief of the symptoms. During the follow-up time (2-20 years), one patient (with hemiplegia) died of myocardial infarction 10 years after the operation. The others were doing well. It is concluded that the safest way to treat a pulmonary arteriovenous fistula is to operate as soon as it has been detected in order to prevent the complications so often associated with the disease.

Cinetracheobronchography and surgical correction of central airway collapse in an asthmatic patient.

The role of central airway collapse in asthma was demonstrated by cinetracheobronchography (CTBG) in a 45-year-old severely asthmatic woman, with total tracheal collapse during coughing. She was successfully treated by circumferential supportive tracheobronchial surgery, The contribution of CTBG in demonstrating tracheobronchial dynamics is stressed, not only in the pre-operative evaluation but also in the postoperative control.

Prevention of early reocclusion by dipyridamole and ASA in arterial reconstructive surgery.

In this prospective study 364 patients were subjected to different types of arterial reconstructive surgery. The patients were randomly divided into four groups according to the type of antithrombotic medication given. During the hospitalization period there were no reocclusions in the dipyridamole/ASA group of 93 patients compared with 12 reocclusions in the control group of 86 patients. The difference was statistically highly significant. The difference between the control group and the given dipyridamole or ASA was not statistically significant. Dipyridamole and ASA were tolerated well by the patients in this clinical trial. This was the first clinical investigation to prove the effectiveness of dipyridamole and ASA medication in the prevention of reocclusions in arterial reconstructive bypass surgery.