Aneurysmatic disease in patients with Takayasu disease: a case review.

Takayasu disease is a non-specific inflammatory disease of the arterial system. Although various etiopathogenetic hypotheses have been formulated, its etiology remains unknown. The aorta and its main branches are predominantly involved in the disease, which is a form of panarteritis, starting with inflammation of the adventitia followed by involvement of the media and intima. It has been more frequently described in young oriental female patients. However, a worldwide distribution is being recognized. Arterial stenosis represents the most frequently diagnosed manifestation. Progression of the flogistic process may lead to stenosis of the aorta and supraaortic vessels, compromising arterial circulation to the brain and upper limbs. Aneurysm presentation may also rarely occur. Based on a recently treated case, the authors report on the clinical presentation, concomitant inflammatory diseases, current diagnostic methods, and management of this disease.

Serotypes and clinical manifestations of invasive group B streptococcal infections in western Sweden 1998-2001.

This study monitored the serotypes of Streptococcus agalactiae (group B streptococcus; GBS) isolated from invasive infections in western Sweden and investigated possible relationships between serotype, age and clinical manifestations. Invasive GBS isolates were collected prospectively during 1998-2001 at six laboratories, covering two counties with a population of 1.8 million, and were serotyped by coagglutination. Clinical data were obtained from hospital notes. In total, 161 invasive strains (50 from neonates and infants aged < 3 months, and 111 from adults) were serotyped. The commonest serotypes from neonates and infants were serotypes III (60%), V (22%) and Ia (10%), and from adults were serotypes V (42%) and III (25%). Serotype V had doubled in frequency among both children and adults compared to a previous study from the same area in 1988-1997. Most (80%) of the adults had an underlying medical condition. No relationship was found between serotype and clinical manifestations. However, the study demonstrated the importance of active surveillance of GBS serotypes and the difficulties of formulating a multivalent polysaccharide conjugate vaccine against GBS.

Treatment of descending thoracic aneurysms by endovascular stent grafting.

PURPOSE: Endovascular stent-graft treatment for true aneurysms of the descending thoracic aorta is a valid and effective alternative to conventional surgery. A review of our experience with 21 consecutive patients is reported and technical considerations are discussed. METHODS: Twenty-one patients (mean age 73 years) with true aneurysms of the descending thoracic aorta (n = 14) or contained rupture (n = 7) were treated between October 1999 and July 2001. Seven patients (33%) underwent emergency endovascular procedure. Postoperatively, the patients were followed with CT scans at 1, 3, 6, and 12 months. Follow-up, which averaged 17 months, was 100% complete. THIRTY-DAY RESULTS: No conversions to open repair were necessary. Two patients died (10%), one of acute intestinal ischemia and the other because of multiorgan failure. Four patients showed endoleaks immediately after stenting. Two patients required new endovascular stentgrafts, while the remaining two were treated conservatively. Besides endoleaks, eight major complications occurred in six patients (two stroke, two paraplegia, two respiratory insufficiency, and one renal failure). MID-TERM RESULTS: Three more patients died during the follow-up period. One patient died of heart failure after a complicated postoperative course, 91 days after stenting. The second patient died because of aortic rupture, 139 days after stenting. The third patient died of heart failure, 15 months after the endovascular procedure. The remaining 16 patients are alive and have been regularly controlled by CT scans. No late migration or endoleaks have been detected. In all the survivors, the size of the aneurysm was unchanged or diminished. CONCLUSIONS: Treatment of descending thoracic aortic aneurysms by endovascular stentgraft devices has good early and mid-term results. More accurate selection of patients may further reduce mortality and morbidity.

Aortic surgery in patients with marfan syndrome: long-term survival, morbidity and function.

BACKGROUND AND AIM OF THE STUDY: The natural history of patients with Marfan syndrome is depressing, but surgical intervention on the aorta can improve the prognosis. Study results were analyzed with reference to long-term survival, morbidity and function. METHODS: Seventy-four Marfan patients (51 males, 23 females; mean age 41+/-14 years), underwent first-time aortic surgery between 1977 and 1998. Follow up information regarding mortality, morbidity and functional status was obtained from patient records and by questionnaire. The mean follow up was 5 years (range: 0-19 years). Forty-seven patients (64%) had a dissection, 27 (36%) an aneurysm, and 45 (61%) patients underwent emergency operations (<4 h from arrival at hospital). In 72 patients (97%) the disease affected the ascending aorta, and implantation of a composite graft was the most frequent operation. RESULTS: Overall 30-day mortality was 12% (3% in elective cases, 18% in emergency cases, p <0.05). Emergency operations and surgery extended to the aortic arch were risk factors for early mortality. Overall actuarial survival was 63.4+/-8% at 10 years. Age was the only risk factor for late mortality. Seventeen patients were reoperated on due to pathologies of the remaining aorta (n = 12), pseudoaneurysms (n = 4) and aortic valve endocarditis (n = 1). A total of five patients had endocarditis; one patient with a homograft required surgery, and medical treatment was successful in the other four patients. Five patients had neurological thromboembolic episodes without permanent damage, and six had minor bleeding complications. Freedom from early and late mortality, reoperation on the aorta and major cardiovascular events (endocarditis episodes, thromboembolic/hemorrhagic strokes and other major bleeding/embolic episodes) was 33.3 +/- 8.1% at 10 years. At follow up, 98% of patients were in NYHA functional class I or II, and 80% were working. CONCLUSION: Elective aortic surgery in Marfan patients can be performed with good results. Close follow up of patients undergoing surgery is important. The long-term functional status of surviving patients is satisfactory.

Management of extensive lesions of the aortic arch: review of 42 consecutive cases.

This retrospective study reviews the long-term results in aortic arch surgery. Forty-two consecutive patients (44-74 years) were operated on between 1980 and 1995. Nineteen patients had acute dissections of the aortic arch, 11 had chronic dissections and 12 had aneurysms. Twenty patients were given emergency surgery and 22 were operated on electively. Reconstruction of the aortic arch alone (31%) or with other aortic segments (69%) was performed during antegrade cerebral perfusion (81%) or circulatory arrest (17%). Sixteen patients died during the first 30 days (38%). Early mortality rates were 60% in emergencies and 18% in elective cases. Early mortality in the group with aneurysms was 33% and 40% in patients in the dissection group. Long-term follow-up to July 1998 is now complete. Twelve patients (28%) died during the follow-up period; 4 of these deaths were due to a rupture of the descending aorta. Three patients (11.5%) underwent late reoperations on the remaining aorta, without operative mortality. We recommend careful follow-up of patients with aortic arch disease and, when indicated, surgery to avoid the rupture of the remaining aorta.

Off-pump bypass surgery--experience of 250 cases.

From April 1996 to October 1998, 250 patients with a mean age of 63 years (31-86 years) underwent coronary artery bypass grafting using the off-pump technique. The prime reason for using this technique was the need to minimize the surgical trauma by avoiding extracorporeal circulation. Fifty-seven percent of the patients had 1-vessel disease, 39% had 2-vessel disease and 4% 3-vessel disease. Sternotomy was performed in 196 patients and an anterior mini-thoracotomy in 54 patients. The mean number of coronary anastomoses was 1.5. Perioperative mortality was 0.4%. The first consecutive 87 patients underwent an early postoperative coronary angiography (days 1-5) revealing a graft patency of 96.5%. Five out of the 7 patients with occluded grafts subsequently underwent another intervention (surgical revascularization in 4 patients and percutaneous transluminal coronary angioplasty in one); 1.2% developed transmural myocardial infarction and 2.8% were reoperated upon for bleeding. The mean time of ventilatory support was 2.5+/-0.5 h. The mean ICU time for all patients was 12 h (0-10 days). The mean in-hospital time was 7 days (2-30 days). Coronary artery bypass surgery without the use of extracorporeal circulation is a safe procedure that can be performed with limited need for intensive care resources. However, long-term results remain to be investigated.

Difficulties in the interpretation of coronary angiogram early after coronary artery bypass surgery on the beating heart.

OBJECTIVE: The major objective of this study was to evaluate the findings in early postoperative coronary angiography in patients who underwent coronary revascularization on the beating heart without cardiopulmonary bypass. METHODS: Eighty-four consecutive patients receiving 113 grafts were studied. A coronary angiography was performed 0 to 5 days postoperatively. All the grafts were reviewed and classified in the following way: grade A (unimpaired run-off); grade B1 (<50 stenosis); grade B2 (>50% stenosis); grade O (occlusion). A second coronary angiography was performed in patients with a stenosis grade B2, 4 to 30 months postoperatively. An exercise test was performed by patients with B1 stenosis. RESULTS: Overall graft patency was 96% in the 113 grafts. None of the 14 patients with B1 stenosis in the early coronary angiography had any clinical signs of ischemia. Eight of the 12 patients who exhibited B2 stenosis either at the anastomotic site, in the graft or in the distal coronary artery at the first coronary angiography had a normal angiogram at the re-angiography. CONCLUSION: A majority of stenoses visualized at the early coronary angiography could not be seen at a later coronary angiography, which makes the interpretation of the angiogram unreliable as a tool for the decision as to redo-procedure in the early postoperative period.

[Bypass surgery on beating heart without heart-lung machine. A new technique revitalises an old method]. / Bypass-kirurgi på slående hjärta utan hjärt-lungmaskin. Ny teknik medför renässans för gammal metod.

Recently, new methodology entailing limited anterior thoracotomy or median sternotomy has rendered coronary surgery on the beating heart without extracorporeal circulation safe. Since a program for CABG on beating heart was initiated at Sahlgrenska University Hospital three years ago, 350 operations have been performed, 287 via sternotomy and 63 via limited thoracotomy. Mortality was 1.4% while graft patency in the first 84 patients was 94%. About 20% of all CABG's are performed on a beating heart, and signs are that this percentage is on the rise.

Easy pleurectomy with winding up of pleural flaps.

The authors describe an effective method of performing apical pleurectomy by winding up large pleural flaps on the thoracoscopic forceps after delineating the borders of the pleurectomy with electrocautery. The method is preferred by the authors compared to abrasio of the parietal pleura or stripping the pleura in small pieces and is in their hands easier and quicker than the other methods.

Long-term effect of endoscopic transthoracic sympathicotomy on heart rate variability and QT dispersion in severe angina pectoris.

UNLABELLED: We evaluated short and long-term effects on QT dispersion and autonomic balance after endoscopic transthoracic sympathicotomy (ETS). Heart rate variability (HRV) reflects autonomic balance of the heart. QT dispersion is a marker of cardiac electrical instability in patients with ischemic heart disease. Holter recordings for 24 h and a twelve-lead ECG were made prior to, 1 month, 1 year and 2 years after ETS. HRV was analysed in time domain and spectral analysis was performed during controlled respiration in supine position and during head up tilt. Dispersion of QT time and QTc were calculated. Of 88 patients, 62 (60) were eligible for HRV (QT-dispersion) analysis after 1 month, 39 (38) patients after 1 year and 23 (24) patients after 2 years. The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later. CONCLUSION: ETS changed HRV and QT dispersion which could imply reduced risk for malignant arrhythmias and death after ETS.

Intraoperative assessement of coronary flow and coronary vascular resistance during coronary bypass surgery.

The measurement of coronary graft flow rates is a well-established method of assessing graft function intraoperatively. In order further to understand the dynamics of graft function, the resistance to the flow was considered a desirable measurement intraoperatively. The coronary vascular resistance (CVR) was estimated by applying the Poiseuille-Hagen equation. The CVR was estimated at zero cardiac work (during cardioplegic arrest) using fixed perfusion flow rates and estimating the pressures produced. After going off cardiopulmonary bypass (CPB), the bypass graft flow (F) was estimated by a standard ultrasound Doppler technique. The perfusion pressure over the perfused coronary graft was then determined and the CVR in the working heart ascertained. The CVR was studied in 178 vein grafts in 59 patients undergoing coronary bypass surgery. The mean CVR in the cardioplegic heart (c-CVR) varied from 0.81 to 2.3 mmHg/ml/min for various coronary artery diameters and was significantly higher in small diameter arteries compared with larger arteries (p < 0.0002). Consequently significant high flows were found in the large vessels compared with the smaller ones (p < 0.0001). The mean c-CVR during cardioplegia of 1.57 +/- 0.06 increased significantly to 1.75 +/- 0.07 mmHg/ml/min after the procedure (p-CVR) and was attributed to the dynamic resistance of the working heart. The post-CPB graft flow was significantly and negatively correlated to the c-CVR of the arrested heart. The measurement of coronary vascular resistance reveals coronary beds at potential high risk for inadequate perfusion. Such areas are usually fed by small vessels with low flows. The working heart, in turn, increases the coronary resistance following cardioplegia during the surgical procedure.

Effect of endoscopic transthoracic sympathicotomy on heart rate variability in severe angina pectoris.

Endoscopic transthoracic sympathicotomy (ETS) is a recently developed technique to divide sympathetic nerves. ETS has been shown to improve symptoms and reduce ischemia in patients with severe angina pectoris. Low heart rate variability (HRV) in patients with ischemic heart disease carries an adverse prognosis. HRV reflects autonomic response of the heart and a shift in the sympathovagal balance towards parasympathetic dominance could be a marker of improved prognosis. HRV might also be used as an indicator of surgical success in sympathetic heart denervation. Heart rate was recorded in 57 patients before and after ETS. Registration was recorded during controlled respiration in the supine position and at tilt test over 10 minutes and spectral analysis was performed. Twenty-four hour Holter recordings were analyzed in the time domain. During the controlled setting, the high-frequency (HF) component (0.15 to 0.40 Hz) increased significantly whereas the low-frequency (LF) component (0.04 to 0.15 Hz) did not change significantly. The LF/HF ratio at tilt test was reduced from 1.3 to 0.8 (p <0.01). The time-domain analysis showed a significant increase of the mean RR interval (923 to 1,006 ms, p <0.001) and indexes reflecting parasympathetic tone also increased significantly (the root-mean square of difference measured from 24.3 to 29.5 ms, p <0.001 and the proportion of adjacent RR intervals >50% measured from 5.5% to 8.2%, p <0.01), whereas measurements reflecting global HRV did not change. In addition to relief of symptoms and reduced ischemia in severe angina pectoris, ETS caused a shift of sympathovagal balance toward parasympathetic tone. This might explain the anti-ischemic effect and have prognostic implications.

Angina pectoris treated by thoracoscopic sympathecotomy.

Open surgical sympathectomy has previously been shown effective in relieving severe angina pectoris. The method was hampered by high morbidity and mortality. The authors have developed a minimally invasive technique of dividing only the sympathetic chain endoscopically and obtained good results with no serious complications in patients operated on for severe palmar hyperhidrosis. This method was used in 43 patients with severe angina pectoris who were not eligible for coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. There was no mortality or any severe complications. Some 19 patients became symptom-free while 22 were improved and two unchanged after surgery. The frequency of anginal attacks was significantly reduced, as was the consumption of nitroglycerine tablets. The maximum exercise capacity was significantly increased and ST-segment depression reduced.

Half-dose aprotinin does not affect haemorheological properties in patients undergoing bypass surgery.

OBJECTIVE: To investigate haemorheological changes in patients undergoing coronary artery bypass grafting and to determine whether the protective effect on haemorheology of high-dose aprotinin also exists under a half-dose regimen. METHODS: Forty patients were studied in a double-blind, placebo-controlled study design. Patients in the aprotinin group received half of the standard high dose of aprotinin during surgery. Erythrocyte and white-cell clogging rates as well as whole blood and plasma viscosity were measured. Viscosity results were expressed as a ratio to the viscosity of saline. RESULTS: Erythrocyte and white-cell clogging rates were increased significantly, whereas whole blood and plasma viscosity were decreased significantly during cardiopulmonary bypass. The reduction in viscosity had a strong correlation to haemodilution. There was no significant difference in any of the measured variables between the aprotinin and the placebo groups. CONCLUSION: This study showed that blood cell damage occurred during cardiopulmonary bypass surgery, as measured by a raised clogging rate. This tendency was the same in both groups and therefore no increased potential for microthrombi could be attributed to aprotinin haemorheologically. However, half-dose aprotinin did not show any preserving effect in haemorheology when the blood-cell clogging rate and blood viscosity were studied.

A simple way to indicate pulmonary nodules at thoracoscopic wedge resections.

PURPOSE: Small pulmonary subpleural nodules are sometimes difficult to localise at thoracotomy. With the advent of minimal invasive surgery, thoracoscopic resection avoiding anterolateral thoracotomy is an attractive procedure. Since this technique does not allow manual palpation, preoperative indication of lesions is mandatory. A simple and cost-effective system for preoperative CT-guided localisation of small subpleural nodules before thoracoscopic resection is described. MATERIAL AND METHODS: The system consists of a 0.2 mm steel wire 30-40 cm in length and a 0.9-mm biopsy needle. The tip of the wire is bent to a hook, and, guided by CT, it is placed in the vicinity of the lesion. The technique was tested in 8 cases. RESULTS: The procedure was possible to perform in 7 patients. In all instances the wire remained in place when the lung was collapsed during the thoracoscopic procedure. The staple resected part of the lung also contained the lesion when examined extracorporeally. CONCLUSION: This simple and inexpensive system was found to be useful for indication of pulmonary lesions at thoracoscopic wedge resections.

A comparative retrospective study of thoracoscopy versus thoracotomy for the treatment of spontaneous pneumothorax.

Thoracoscopic surgery has been claimed to reduce patient disability, recovery time, and hospital costs compared with open surgery. We analyzed 25 patients who had undergone thoracoscopic surgery and compared the outcome to 24 patients who had undergone conventional surgery for spontaneous pneumothorax. The thoracoscopic group was able to return to work and daily activities earlier and had less impairment of shoulder movement. There was a loss of sensation corresponding to the dermatomes where the thoracoscopic ports were placed, which could have resulted from compression of the intercostal nerves by the instruments. However, a similar loss of sensation was found in the thoracotomy group. We conclude that thoracoscopy may be the method of choice for the treatment of spontaneous pneumothorax, although further methodological development should be done.

Endoscopic transthoracic sympathicotomy for severe angina.

We evaluated the antianginal effects of endoscopic transthoracic sympathicotomy (ETS) in 24 patients not eligible for coronary bypass surgery or angioplasty. In this procedure, the sympathetic chain is electrocoagulated under general anaesthesia. No major surgical complications occurred. The frequency of anginal attacks was significantly reduced (p = 0.001). The mean increase in maximum exercise capacity was 13 (SD 21) W (p = 0.009). ST depression at maximum comparable workload was reduced by 0.052 (0.10) mV (p = 0.005). Global ejection fraction during exercise and metaiodobenzylguanidine uptake were unchanged. Heart rate variability analysis showed a reduction of the ratio between low and high frequencies at tilt test (-1.00 [0.96]; p < 0.001). We conclude that ETS can be done without major complications, alleviates angina, and increases maximum working capacity in patients with advanced coronary disease.

In vivo regulation of mucosal transport of H+ and HCO3- in the feline gall bladder.

In the gall bladder of a fasting subject, a decline in the pH of the contents occurs due to secretion of H+ from the mucosa. In this study in anaesthetized cats, the gall bladder lumen was perfused with a bicarbonate buffer bubbled with 4% CO2 in air. During basal conditions, the PCO2 always rose while the pH and [HCO3-] fell in the buffer when passing through the gall bladder lumen, indicating a continuous secretion of H+ by the mucosa. This H+ secretion was enhanced by stimulation of the respective sympathetic nerves and was blocked by intraluminal amiloride. Intravenous infusion of vasoactive intestinal peptide (VIP) raised the pH and [HCO3-] in the buffer during the passage through the gall bladder lumen, indicating a secretion of bicarbonate from the mucosa. In view of the presence of sympathetic and VIP immunoreactive nerve fibres in the gall bladder wall and VIP receptors on the luminal epithelial cells, the study demonstrates that there are functional grounds for physiological variations in the secretion of H+ and HCO3- by the gall bladder mucosa. These variations may be important for the solubility of calcium salts in the gall bladder contents.

Contraction and evacuation of the gallbladder studied simultaneously by ultrasonography and 99mTc-labeled diethyl-iminodiacetic acid scintigraphy.

Emptying of the gallbladder was studied by the simultaneous use of 99mTc-labeled diethyl-iminodiacetic acid [HIDA] scanning and real-time ultrasonography. In response to a liquid test meal the gallbladder volume was reduced for 80 min and then increased again, but the radionuclide evacuation continued and was more complete than could be explained by the reduction of gallbladder volume. In response to intravenous infusion of cholecystokinin, a maximal contraction of the gallbladder to 35% of the basal volume was obtained at 40 min, and 36% of the HIDA then remained in the gallbladder. In a separate series repeated intravenous injections of 99mTc-HIDA were given after the test meal, and the isotope was found to enter the gallbladder even when the gallbladder contracted. The results support the view that the gallbladder acts like a 'bellows' when contracting and that postprandial fluid secretion by the gallbladder mucosa may help to evacuate its contents.