Late results of mitral valve replacement using unstented antibiotic sterilised aortic homografts.

Three hundred and seventy nine patients who had undergone mitral valve replacement using unstented antibiotic sterilised aortic homografts were followed up for 52 to 138 months (mean 102 months). Patients requiring additional aortic valve replacement were excluded. The commonest cause was rheumatic heart disease (321 patients). There were 37 early deaths (9.8%) and 97 late deaths (28%). The actuarial survival of operative survivors was 83% at three years, 75% at five years, and 55% at nine years. Technical valve failure occurred in six patients (1.6%), infective endocarditis in 19 (5%), and degeneration of the valve in 43 (12.5%). The cumulative probability of freedom from endocarditis was 96% at three years, 94% at five years, and 91% at nine years, while that of freedom from valve degeneration was 97% at five years and 48% at 10 years. There were no early embolic episodes, but late embolism occurred in five patients (1.5%).

Early and late results of combined endarterectomy and coronary bypass grafting for diffuse coronary disease.

Between October 1969 and December 1979, a total of 440 patients who had diffuse coronary artery disease were treated with combined endarterectomy and coronary bypass grafting. This constitutes 42 percent of all patients operated on at the same institution during this period. Six hundred eight endarterectomies were performed, 329 on the right coronary artery, 227 on the left anterior descending coronary artery and 52 on the left circumflex coronary artery. The early mortality rate was 4.3 percent and the late mortality rate 9 percent during a mean follow-up period of 47 months. The perioperative infarction rate was 15 percent. Ninety-five percent of survivors were asymptomatic or in improved condition. Only 11 patients were lost to follow-up study. Three hundred fourteen patients (71 percent) were reinvestigated with coronary and graft arteriography 1 month to 8 years postoperatively. The early patency rate of grafts to the endarterectomized vessels was 85 percent and the late patency rate (1 year or more) was 77 percent. The runoff was good in 79 percent, fair in 14 percent and poor in 7 percent of grafts. Endarterectomy is a valuable additional procedure in the management of patients with diffuse coronary artery disease.

Angina, aortic stenosis and coronary heart disease.

The pre-operative clinical and haemodynamic findings of 139 consecutive patients with aortic stenosis were analysed in an attempt to determine the incidence and influence of coronary heart disease on the mode of presentation of patients with aortic stenosis. The overall incidence of coronary heart disease was 32%. 105 patients (76%) presented with angina and of these, 41 patients (39%) had significant coronary heart disease as compared to 4 (13%) of the remaining 34 patients who did not present with angina. Clinical parameters including age, sex, severity of angina together with the presence of associated symptoms and precipitating factors were unhelpful in distinguishing those patients with coronary heart disease. Evidence of previous transmural myocardial infarction or the presence of ST-T abnormalities in the absence of digitalis and the changes of left ventricular hypertrophy were reliable electrocardiographic signs of coronary heart disease. Although peak systolic aortic valve gradient tended to decrease with increasing severity of coronary heart disease, the severity of aortic stenosis was not a reliable indicator of the presence of coronary disease. Patients with coronary heart disease in the absence of angina all had a combination of moderate aortic stenosis and single vessel disease. It is concluded that coronary heart disease cannot be predicted in patients with angina and, in the absence of angina occurs with an incidence sufficiently high to advocate the use of coronary angiography as part of the investigation of all patients with aortic stenosis being considered for valve replacement.

Coronary angiography Review of 1500 consecutive cases.

Fifteen hundred coronary angiograms have been performed by the staff of Harefield Hospital since 1970. Only 2 deaths have occurred in the last 1000 consecutive cases though there were 5 in the first 500 cases. This drop in the mortality is ascribed to careful attention to detail and better training of the operators. It is concluded that the Fudkin's method of coronary angiography in trained hands is a safe method of investigation but that because of the very serious potential dangers it is unjustifiable for new units to start unless there is a fully experienced investigator in charge.