The art of human anatomy: Renaissance to 21st century.

This session examines the relationship between the art and science of anatomy from the time of Vesalius to the present with particular emphasis on the role of the medical artist and the changing nature of anatomical illustration over the last five centuries. Pivotal changes in the art of anatomy will be examined including the evolution of media and brain imaging from Golgi to Geschwind.

You can love it so much. Heart shape.

Diagnostic imaging can sometimes reveal interesting shapes. In this case we describe a transoesophageal echocardiogram of a mitral valve prolapse in shape of a heart sign, which was successfully repaired.

Octogenarians undergoing cardiac surgery outlive their peers: a case for early referral.

OBJECTIVE: To examine short and long term outcomes of octogenarians having heart operations and to analyse the interaction between patient and treatment factors. METHODS: Multivariate analysis of prospectively collected data and a survival comparison with an age and sex matched national population. The outcomes were base in-hospital mortality, risk stratified by logistic EuroSCORE (European system for cardiac operative risk evaluation), and long term survival. RESULTS: 12,461 consecutive patients (706 over 80 years) operated on between 1996 and 2003 in a regional UK unit were studied. Octogenarians more often had impaired ventricular function, pulmonary hypertension, and valve operations. They also included a higher proportion of women, had a higher serum creatinine concentration, and had a trend towards more unstable angina. Younger patients had a higher prevalence of previous cardiac operation, previous myocardial infarction, and diabetes. The in-hospital mortality rate was 3.9% for all patients (EuroSCORE predicted 6.1%, p < 0.001) and 9.8% for octogenarians (predicted 14.1%, p = 0.002). Long bypass time and non-elective surgery increased the risk of death above EuroSCORE prediction in both groups. A greater proportion of octogenarians stayed in intensive care more than 24 hours (37% v 23%, p < 0.001). Long term survival was significantly better in the study patients than in a general population with the same age-sex distribution (survival rate at five years 82.1% v 55.9%, p < 0.001). CONCLUSIONS: Cardiac surgery in a UK population of octogenarians produced excellent results. Elective referrals should be encouraged in all age groups.

Relationship between pulmonary function and lung cancer surgical outcome.

The British Thoracic Society and American College of Chest Physician guidelines outline criteria for investigating patients for lung cancer surgery. However, the guidelines are based on relatively old studies. Therefore, the relationship between pulmonary function test results and surgical outcome were studied prospectively in a large cohort of lung cancer patients. From January 2001 to December 2003, 110 patients underwent surgery for lung cancer. All underwent full lung function testing in order to predict post-operative lung function. The hospital mortality rate was 3% and major complication rate 22%. There was poor overall outcome in 13%. Mean pre-operative lung function values were: forced expiratory volume in one second (FEV1) 2.0 L (79.4% of the predicted value), and carbon monoxide diffusing capacity of the lung (D(L,CO)) 73.6% pred. The mean post-operative lung function values were: FEV1 1.4 L (55.6% pred), and D(L,CO) 51.3% pred. All lung function values were better predictors of poor surgical outcome when expressed as a percentage of the predicted value. Using a threshold of pre-operative FEV1 of 47% pred resulted in the most useful positive and negative predictive probabilities, 0.90 and 0.67, respectively. Lung function values expressed as a percentage of the predicted value are more useful predictors of post-operative outcome than absolute values. The threshold of predicted forced expiratory volume in one second for surgical intervention could be lower (45-50% pred) than is currently accepted without increased mortality.

Vocal fold palsy due to plombage for tuberculosis.

A 67-year-old patient, who had previously undergone Lucite ball plombage for pulmonary tuberculosis, presented with a hoarse voice, intermittent stridor and breathlessness. Direct laryngoscopy confirmed a left vocal fold palsy. A left supraclavicular mass became apparent and a computerized tomograph (CT) scan showed that a Lucite ball had migrated into her supraclavicular fossa. Subsequently she developed left arm pain and weakness. The balls were removed surgically, following which her arm symptoms improved but her voice remained unchanged. Migration of implanted material should be considered when new symptoms appear in patients who have undergone plombage treatment.

Effect of lung cancer surgery on quality of life.

BACKGROUND: Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery. METHODS: The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively. RESULTS: On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (Tlco). CONCLUSION: Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted Tlco may be associated with worse postoperative HRQOL.

Lung cancer . 10: Delivering a lung cancer service in the 21st century.

Properly organised regional centres would involve teams of interested cardiothoracic surgeons working with, and possibly led by, specialist pure thoracic surgeons to common protocols. A great deal of time would be saved by specialist staff reducing travelling times to outlying units. Data collection and administration would be greatly enhanced and the potential for collaborative work significantly increased. Unfortunately, there has been little if any coherent planning for a national strategy for the delivery of such care in the United Kingdom.

Influence of atrial fibrillation on outcome following mitral valve repair.

BACKGROUND: To investigate the outcome of patients in atrial fibrillation (AF) following mitral valve repair, clinical and echocardiographic follow-up was undertaken in 400 consecutive patients who underwent mitral valvuloplasty from 1987 to 1999. METHODS AND RESULTS: The main indications for surgery were degenerative (81.4%), endocarditis (7.1%), rheumatic (6.6%), ischemic (4.6%), and traumatic (0.3%) mitral valve disease. After excluding 6 paced patients and 1 patient in nodal rhythm, we compared the outcomes of 152 patients in AF against 241 patients in sinus rhythm. For patients in AF versus those in sinus rhythm, more AF patients were older (mean age 67.2+/-8.8 versus 61.9+/-11.8 years, respectively; P<0.001), more were assigned to a poorer New York Heart Association (NYHA) class (77.6% versus 66.0% in NYHA III/IV, respectively; P=0.01), and more demonstrated impaired ventricular function (78.9% versus 46.2% with moderate or severe impairment, respectively; P<0.001). For patients in AF versus those in sinus rhythm, there was no difference in 30-day mortality (2.0% versus 2.1%, respectively; P=0.95), repair failure (5.4% versus 3.6%, respectively; P=0.41), stroke (5.4% versus 2.2%, respectively; P=0.11), or endocarditis (2.3% versus 0.9%, respectively; P=0.27) on follow-up at a median of 2.8 years (interquartile range 1.1 to 6.0). On echocardiography, the proportion of patients with mild regurgitation or worse was 13.3% (AF patients) versus 10.8% (patients in sinus rhythm) (P=0.70). Patients in AF versus those in sinus rhythm had lower survival at 3 years (83% versus 93%, respectively) and 5 years (73% versus 88%, respectively). Univariate analysis identified factors affecting survival as AF (P=0.002), age >70 years (P=0.041), and poor ventricular function (P<0.001). However, by use of a multivariate model, only poor ventricular function remained significant (P=0.01). CONCLUSIONS: AF does not affect early outcome or durability of mitral repair. The onset of AF may be indicative of disease progression because of its association with poor left ventricular function.

Surgical correction of postpneumonectomy stridor by saline breast implantation.

Postpneumonectomy syndrome is a rare complication of pneumonectomy and is characterized by progressive dyspnea, stridor, and repeated chest infections. It is caused by displacement and rotation of the mediastinal structures into the pneumonectomy space, producing compression and malacic changes in the trachea and remaining bronchus. We report the successful long-term results of mediastinal correction, cardiopexy and plombage with saline breast prostheses in a 59-year-old man after right pneumonectomy for carcinoma of the lung.

Conservative surgical treatment of valvular injury after blunt chest trauma.

BACKGROUND: Blunt injury to the cardiac valves leads to progressive ventricular failure often requiring surgical management. Most frequently, prosthetic replacement is the chosen management. METHODS: Three consecutive patients presenting to one surgeon with blunt traumatic valve lesions formed the study group. RESULTS: At operation, the valvular pathology was assessed, and reparative techniques were used to correct the defects. All the patients had an excellent outcome at follow-up periods of 2 to 3 years. CONCLUSIONS: Conservative operation to repair traumatic valve lesions is feasible and has potential advantages over replacement.

Recurrent bronchogenic cyst in a Jehovah's witness.

A 26-year-old female practising Jehovah's witness presented with a history of recurrent respiratory infections since childhood and more recently, recurrent cardiac dysrhythmias. A large bronchogenic cyst arising beneath the carina and compressing the bronchi was felt to be responsible. The cyst was adherent to the roof of the left atrium. She initially underwent a partial excision through the standard approach of left thoracotomy. Complete resection via this route was hazardous with real danger of laceration of the atrial wall. Repeat surgery was performed on cardiopulmonary bypass 3 years later for recurrence of symptoms. Complete excision was achieved.

Massive plexiform neurofibroma of the sympathetic trunk.

A case report of a massive plexiform neurofibroma of the sympathetic trunk is reported. Symptoms included dysphagia, shortness of breath and paraesthesia of the right hand. The nerve of origin and extent of the tumour were unusual. The tumour mass partially filled the right hemithorax, surrounded the right brachial plexus, extended to the base of skull and invaded the cervical vertebrae threatening to compromise the spinal cord. Surgical resection required combined cardiothoracic, neurosurgical and plastic and reconstructive surgical teams. Early outcome following surgery was excellent. This case illustrates the need for a combined surgical approach for such a lesion and we believe it is the first reported case of plexiform neurofibroma of the sympathetic trunk.

Conservative operation for infective endocarditis of the mitral valve.

BACKGROUND: Subvalvular preservation is necessary to maintain left ventricular function, but accidental retention of infected tissue could cause postoperative endocarditis. METHODS: We examined 71 consecutive patients who underwent operation for mitral endocarditis. Endocarditis was uncontrolled and active in 24 patients, partially treated (unfinished antibiotic course) in 17, and healed in 30. RESULTS: Valves were repaired in 17% versus 59% versus 63% and replaced with subvalvular preservation in 25% versus 6% versus 3% of the uncontrolled active, partially treated, and healed groups, respectively. Thirty-day mortality was 29% versus 0% versus 3.3% (p=0.003), total mortality was 46% versus 18% versus 17% (p=0.035), and complications-related mortality was 38% versus 11% versus 13% (p=0.054), respectively. There was a trend toward lower complications-related mortality with subvalvular preservation than without. Postoperative endocarditis occurred in 3 of 30 patients without and 1 of 41 patients with subvalvular preservation. CONCLUSIONS: Postoperative mortality in uncontrolled active mitral endocarditis remains high, but results are good with partially treated or healed endocarditis. Subvalvular preservation improves outcome, does not increase postoperative endocarditis rates, and should be performed whenever feasible.

Cost implications of mitral valve replacement versus repair in mitral regurgitation.

BACKGROUND: Mitral valve repair and replacement (MVR) with preservation of the tendinous chordae [MVR(p)], may have better results than MVR with valve excision [MVR(e)]. It is not known whether the type of surgery affects in-hospital stay and cost. METHODS AND RESULTS: We reviewed all patients who had mitral valve surgery for regurgitation over 5 years from January 1991. Patients were considered in three groups; MVR(e), MVR(p), and Repair. Cost was calculated using operating room, intensive care unit, and ward expenses, not hospital charges. There were a total of 253 patients; 84 MVR(e), 42 MVR(p), and 127 Repair. Mean ages and preoperative New York Heart Association (NYHA) classes were similar in the three groups. There were more male patients in the Repair (62%) and MVR(p) (67%) groups than in the MVR(e) (44%) group (P<.05), and more patients with degenerative etiology in the Repair group (P<.01). A majority of MVR(e) were in atrial fibrillation (63%), while 59% of Repair were in sinus rhythm (P<.01). Of 9 patients who died in the hospital; four had MVR(e), 3 had MVR(p), and 2 had Repair. In univariate analyses, in-hospital stay increased with patient age >70 years (P<.01), preoperative atrial fibrillation (P<.05), and NYHA class III or IV (P<.01). The median and interquartile ranges for postoperative stay was 10 (8 to 13) days for MVR(e), 8 (7 to 11) days for MVR(p), and 8 (7 to 10) days for Repair (P<.01 versus MVR(e); multivariate analysis adjusting for age, rhythm, and NYHA class). Cost per patient was US $14469 for MVR(e), $13151 for MVR(p), and $11606 for Repair. CONCLUSIONS: Repair and MVR(p) may predict shorter in-hospital stay and reduced cost, although there are important differences in the group of patients who have MVR(e).

Echocardiography in mitral valve repair for mitral regurgitation: the surgeon's needs.

Mitral valve repair has become the operation of choice for mitral regurgitation. It is often technically more demanding than valve replacement. The role of echocardiography has now extended beyond the identification of severe mitral regurgitation that would benefit from surgical correction. It helps the surgeon to assess valve reparability preoperatively, to assess the need for valve surgery in equivocal cases of ischemic mitral regurgitation, to plan the operation, and to assess valve function after repair. This article aims to discuss the role of echocardiography in providing the information needed by the surgeon for successful mitral valve repair. The echocardiographer must understand the surgeon's needs, while surgeons should understand both the benefits and limitations of echocardiography.