Excellent long-term results of cardiac valve replacement with the St Jude Medical valve prosthesis.

BACKGROUND: A retrospective review of the performance of the St Jude Medical valve prosthesis over a 12-year period was undertaken. METHODS AND RESULTS: Between 1978 and 1990, 696 St Jude Medical valve prostheses (351 isolated aortic, 191 isolated mitral, 64 double aortic/mitral) were implanted into 616 patients (mean age, 55 years). Concomitant coronary artery graft surgery was performed in 18%. During mid-1991, follow-up was conducted, yielding a 97% completion (16 lost), for a total of 3075 cumulative patient-years (mean, 5.0 years). Early (30-day) mortality rates were 3.1%, 5.2%, and 6.4% after aortic, mitral, and double valve replacements, respectively. The 5-year actuarial survival rates were 94.1 +/- 1.3%, 85.8 +/- 2.7%, and 86.3 +/- 4.6% and those for 10 years were 89.6 +/- 1.9%, 72.9 +/- 6.1%, and 83.0 +/- 5.4%, respectively. There were no structural valve failures. Anticoagulant-related hemorrhage was the most common valve-related complication (28 events, 0.9% per patient-year), with three being fatal. Thromboembolism (13 events) occurred at a rate of 0.5% per patient-year (0.6% aortic, 0.3% mitral, 0.3% double). All of the nonstructural deteriorations (10 events, 0.3% per patient-year) were paravalvular leaks, including 3 aortic valve replacements in patients who developed hemolytic anemia. There was 1 valve thrombosis (0.03% per patient-year). Patients undergoing coronary artery graft surgery had lower survival and higher complication rates than patients without coronary artery graft surgery. There was a significant improvement (P < .001) in New York Heart Association functional class for the entire patient population. CONCLUSIONS: The St Jude Medical valve prosthesis has performed well in all positions over a 12-year period, with an acceptably low incidence of valve-related complications.

Empyema thoracis: 14-year experience in a teaching center.

One hundred two patients with empyema thoracis were managed at the Royal Melbourne Hospital between 1976 and 1989. Fifty-five cases of empyema thoracis were postpneumonic, 8 followed esophageal rupture, and 5 were associated with thoracic trauma. Some form of systemic illness was a major contributing factor in the presentation of 29 patients. A single causal organism was found in 53 patients (the most common being Staphylococcus aureus), multiple organisms in 36, and no growth in 13. During the years 1983 to 1989 there was an increased incidence of empyemas caused by multiple or antibiotic-resistant organisms. Operative drainage was required in 90 patients and 12 were managed by thoracentesis or intercostal tube drainage alone. The in-hospital mortality rate for patients managed nonoperatively was 58% (7 of 12 patients); it was 16% (14 of 90 patients) for those receiving operative drainage. There were seven late deaths, four empyema related and three nonrelated. Early adequate operative drainage is recommended for patients with empyema thoracis.

Combined carotid and coronary surgery.

A retrospective review of 40 consecutive patients undergoing combined coronary artery bypass grafting (CABG) and unilateral carotid endarterectomy (CEA) was carried out to determine the stroke rate for the procedure. Patients presenting with severe coronary artery disease judged to be at risk of imminent myocardial infarction, who had signs of cerebral ischaemia (70%) or asymptomatic carotid bruits (30%), were investigated for extracranial carotid vascular disease. Patients with severe stenotic carotid lesions associated with high risk coronary artery disease underwent combined CEA/CABG. Three patients had a previous contralateral CEA. The average age of the patients was 62 years, and there were 31 males and nine females. CEA was completed prior to CABG under the same general anaesthetic. There were 24 CEAs on the left and 16 on the right. Six patients suffered a postoperative cerebral ischaemic event (15.4%): a reversible ischaemic neurological deficit in three (7.7%), a transient ischaemic cerebral event in two (5.1%), and a permanent stroke occurred in one (2.6%). Two deaths occurred and both were cardiac related. Combined CEA/CABG in patients with stenotic lesions of the coronary and extra-cranial carotid vascular systems who are at risk of cerebral or myocardial infarction, can be performed with a permanent stroke rate within the published range for either CEA or CABG alone and with a mortality of 5%.

Early clinical experience of a new heparinoid, Org 10172, in prevention of deep venous thrombosis.

The potential antithrombotic effect of a new low molecular weight heparinoid, Org 10172, was examined in a randomized, double-blind, placebo-controlled, dose-ranging pilot study of the prevention of deep venous thrombosis (DVT) in 45 high-risk patients having major thoracic or abdominal surgery for cancer. Org 10172 was given in doses of 500, 750 or 1000 U bd subcutaneously. DVT occurred in 9 of 14 patients given placebo and in 4 of 11 patients given 500 U bd but in none of the 20 patients given 750 or 1000 U bd. Operative blood loss and post-operative bleeding were not significantly different between the groups but one patient given 1000 U bd had major post-operative bleeding. Average mid-interval and trough plasma anti-Xa levels reached 0.26 and 0.20 U/ml respectively following the highest dose. It is concluded that Org 10172 is a potentially useful antithrombotic agent and that the effective and safe dose appears to be between 500 and 1000 U bd for prevention of DVT in high-risk patients.

Psychiatric aspects of coronary artery surgery. A prospective study.

A psychiatric assessment was carried out before operation, and at three months and 12 months after operation, in 77 men undergoing coronary artery bypass graft surgery. Neither psychiatric assessment before the operation nor perioperative surgical assessment could predict the physical outcome of surgery. The physical results of surgery were good, but there was a 20% decrease in the number of patients who were in employment after the operation. Abnormally high scores on measures of anxiety and depression were present in about 50% of patients before the operation, and in about one-third of patients after the operation. Impairment in various aspects of personality-functioning since surgery was reported by 7%-29% of patients. These complaints were not correlated with the surgical result. Attention is drawn to this area of persisting postoperative morbidity.

Prophylaxis of venous thrombosis after major thoracic surgery.

The high incidence (50-60%) of deep venous thrombosis of the legs (DVT) after major thoracic surgery is reduced only by about half with routine low-dose heparin prophylaxis. The present study compared the efficacy of a higher dose of heparin (7500 U twice daily) with the commonly used dose of 5000 U twice daily in preventing scan-detected DVT in 100 consecutive patients having thoracotomy for carcinoma of the lung or oesophagus. After the higher dose of heparin, postoperative DVT was not significantly less frequent (22% compared with 33% for total DVT) but was significantly less extensive (8% and 14%, respectively, for bilateral calf DVT, and 0% and 4% for popliteal DVT). Despite prophylaxis, DVT was especially common after oesophagogastrectomy (41% total DVT, 30% extensive DVT). No excessive postoperative bleeding was noted in either group. It is concluded that an increased dose of heparin safely offers increased prophylaxis against DVT in patients undergoing major thoracic surgery for cancer.

Cardiac valve replacement and coronary bypass grafts.

A retrospective, six-year survey of 72 patients who underwent combined cardiac valve replacement and coronary artery bypass grafting is presented. The average age was 58 years with a male to female ratio of 3.5:1. Eighteen patients were angina-free, their coronary disease being found by routine coronary arteriography. Fifty-eight patients (81%) had aortic valve replacements, 13 patients (18%) had mitral valve replacements, and one patient had a double valve replacement. Forty-one patients (58%) had a single coronary bypass graft. Total cardiopulmonary bypass times averaged two hours, and the average cold myocardial ischaemic time was 60 minutes. The operative mortality in the group was 8%, which did not differ significantly (chi 2 = 0.25; P greater than 0.6) from the operative mortality of 6% in 1400 operations either for single valve replacement or for isolated coronary grafts which were performed in the same six-year period.

Surgery for unstable angina.

A series of 84 patients with unstable angina, treated surgically by grafting procedures between October 1970 and September 1976, have been reviewed. The study indicates that extensive coronary artery disease is common in these patients, and suggests that operation may favourably influence mortality, both immediate and delayed, but does not reduce the risk of myocardial infarction. Eighty per cent of the patients were relieved of angina and able to lead a reasonably normal existence.

An evaluation of Potts' aortopulmonary shunt for palliation of cyanotic heart disease.

The results of 28 Potts' aortopulmonary shunts created for the relief of cyanotic heart disease are reviewed in this study. The shunt gave excellent symptomatic relief, but the incidence of immediate and late complications is high. Regular follow-up of patients is mandatory to detect evidence of increasing pulmonary vascular disease and to under take corrective surgery whenever feasible before its occurrence. Although Potts' anastomosis has been largely replaced by alternative shunt procedures, there may still be a place for its application in selected situations. Only a few problems were encountered at the time of closure of the shunt in 11 patients during corrective surgery using a transpulmonary technique and hypothermia with circulatory arrest.

Traumatic Arteriovenous Fistula between the Internal Thoracic Artery and Vein.

The case is presented of a young male with a traumatic arteriovenous fistula between the internal thoracic vessels following a penetrating injury. The nature of the resulting cardiac bruit and its direction of radiation seemed to differentiate the condition from a persistent ductus arteriosus. This was confirmed by emergency aortography and appropriate surgical treatment was performed. The literature is reviewed and a few similar reported cases are quoted. SUMMARY: A case of traumatic internal thoracic arteriovenous fistula is presented. The nature and site of the penetrating injury, the presence of a superficial continuous murmur conducted down-ward and to the right, and an awareness of the occurrence of this condition following chest trauma suggested the diagnosis, which was confirmed by an immediate thoracic aortogram. The condition was cured by immediate surgery. Only four other cases of post-traumatic fistulae between the internal thoracic artery and vein have been found in the literature.