Propionibacterium acnes endocarditis: a case series.

OBJECTIVES: Propionibacterium acnes remains a rare cause of infective endocarditis (IE). It is challenging to diagnose due to the organism's fastidious nature and the indolent presentation of the disease. The purpose of this study was to describe the clinical presentation and management of P. acnes IE with an emphasis on the methods of diagnosis. METHODS: We identified patients from the Cleveland Clinic Infective Endocarditis Registry who were admitted from 2007 to 2015 with definite IE by Duke Criteria. Propionibacterium acnes was defined as the causative pathogen if it was identified in at least two culture specimens, or identified with at least two different modalities: blood culture, valve culture, valve sequencing or histopathological demonstration of microorganisms. RESULTS: We identified 24 cases of P. acnes IE, 23 (96%) of which were either prosthetic valve endocarditis or IE on an annuloplasty ring. Invasive disease (71%) and embolic complications (29%) were common. All but one patient underwent surgery. Propionibacterium acnes was identified in 12.5% of routine blood cultures, 75% of blood cultures with extended incubation, 55% of valve cultures, and 95% of valve sequencing specimens. In 11 of 24 patients (46%), no causative pathogen would have been identified without valve sequencing. CONCLUSIONS: Propionibacterium acnes almost exclusively causes prosthetic valve endocarditis and patients often present with advanced disease. The organism may not be readily cultured, and extended cultures appear to be necessary. In patients who have undergone surgery, valve sequencing is most reliable in establishing the diagnosis.

Mid-luteal progesterone concentrations are associated with live birth rates during ovulation induction.

This retrospective study investigated whether mid-luteal serum progesterone concentrations are associated with live birth rates in women with WHO group II anovulatory infertility undergoing ovulation induction. Data were from women (n=335) stimulated with gonadotrophins using a low-dose step-up protocol, of which women with presumptive ovulation (n=279), defined as a mid-luteal progesterone concentration ⩾7.9ng/ml (⩾25nmol/l; range 7.9-194ng/ml) were included. Of the women with presumptive ovulation, 57 (20.4%) had a live birth and their serum mid-luteal progesterone concentration was significantly (P=0.016) higher than that of the non-live birth group. There were significant associations between the number of large (⩾15mm) and medium-sized follicles (12-14mm) at human chorionic gonadotrophin administration and the mid-luteal progesterone concentration (P<0.001), while the total number of large and medium-sized follicles was not significantly associated with live birth rate. In conclusion, mid-luteal progesterone concentrations above the cut-off values currently used for defining ovulation were positively associated with live birth rates in normogonadotrophic anovulatory women undergoing ovulation induction with gonadotrophins. The mid-luteal progesterone concentration, apart from being a consequence of the number of corpora lutea, may also reflect the quality of the follicle/oocyte/corpus luteum. Measurement of blood concentration of the steroid hormone progesterone in the mid-postovulatory phase of the menstrual cycle is frequently used to determine ovulation. The aim of this study was to investigate whether increasing blood concentrations of progesterone in the mid-postovulatory phase was associated with higher chances of achieving a live birth in a group of 335 women with anovulatory infertility, who had undergone stimulation with gonadotrophin hormones for the purpose of inducing ovulation. Statistical analysis, performed on the 279 women with presumptive ovulation (defined as a mid-postovulatory progesterone concentration ⩾7.9ng/ml serum), showed that the mid-postovulatory progesterone concentration was significantly positively associated with live birth rate. There was also a significant association between follicular development at end of gonadotrophin stimulation and the mid-postovulatory progesterone concentration, but follicular development could not explain live birth rate as mid-postovulatory progesterone concentrations could. In conclusion, increased blood concentrations of progesterone in the mid-postovulatory phase of the menstrual cycle above the threshold values currently used for defining ovulation were associated with increased live birth rates in anovulatory women undergoing ovulation induction with gonadotrophin hormones. The mid-postovulatory progesterone concentration, apart from being a consequence of the quantity of follicular development, may therefore also reflect the quality of the ovarian follicles and eggs.

Challenges in the diagnosis and management of Nocardia infections in lung transplant recipients.

BACKGROUND: Nocardia infection occurs in 2.1-3.5% of lung transplant recipients, and may involve cavitary nodular pulmonary lesions, soft tissue infection, or other sites of dissemination. Nocardiosis can pose challenging clinical problems in the areas of diagnosis and treatment. Diagnostic delays may occur, and adverse reactions to therapy are common. This study reviews clinical and epidemiological aspects of nocardiosis in lung transplant recipients, with special attention to pitfalls in management. Clinicians should be alert for these possibilities in order to institute prompt therapy and to achieve successful outcomes. METHODS: A retrospective cohort study was conducted of 577 lung transplant recipients from January 1991 to May 2007. Demographics, reason for transplant, recent rejection, time from transplantation, site of infection, hypogammaglobulinemia, and/or neutropenia shortly before onset, Pneumocystis jiroveci prophylaxis, Nocardia species, radiographic findings, extrapulmonary lesions, nature and duration of treatment, adverse reactions, and outcomes were recorded. RESULT: Nocardia infection occurred in 1.9% (11/577). Mean onset was 14.3 months after transplant (range 1.5-39 months). N. asteroides was isolated in 55% (6/11). Emphysema was the most common reason for transplant (7/11, 64%). Six patients were receiving trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis at the time of diagnosis. Three patients had immune globulin G levels <400 mg/dL and 2 were neutropenic in the 3 months preceding diagnosis. Diagnosis was made by bronchoalveolar lavage (55%), skin abscess culture (18%), open lung biopsy (9%), pleural fluid (9%), and sputum culture (9%). Definitive diagnosis required a median of 9 days and a mean of 13.6 days (range 3-35 days) from the time of diagnostic sampling. Soft tissue lesions occurred in 3 and central nervous system involvement in 1 patient. Adverse reactions to therapy occurred in 9/10 (90%) of patients for whom information was available. Nocardia-related mortality occurred in 2/11 patients (18%). CONCLUSIONS: Nocardiosis occurred in 1.9% of lung transplant recipients and was associated with a mean of nearly 2 weeks to diagnosis and frequent adverse effects on therapy. TMP-SMX prophylaxis on a thrice weekly basis did not prevent all episodes of nocardiosis. Despite utilization of protocol bronchoscopies with cultures for Nocardia, this organism remains a source of clinical complexity in the lung transplant population.

Double valve endocarditis.

BACKGROUND: There are little data concerning surgical outcomes in patients with native valve endocarditis affecting both the aortic and mitral valves. METHODS: From 1977 to 1998, 54 patients had simultaneous aortic and mitral valve grafting for native valve endocarditis. In 78%, mitral valve involvement was limited to the anterior leaflet, suggesting a jet lesion from the aortic valve. Surgical strategies included 31 valve repairs and valve replacement with mechanical (34), bioprosthetic (34), or allograft (9) prostheses. Three hundred twenty-five patient-years of follow-up were available for analysis (mean 6.0 +/- 4.8 years). RESULTS: There were no hospital deaths. Ten-year survival was 73%. Ten-year freedom from recurrent endocarditis was 84%, with risk peaking at 3 months, followed by a constant risk of 1.3%/yr. Choice of valvar procedure did not influence mortality or reinfection risk. CONCLUSIONS: The most common pattern of double valve infection was a jet lesion on the anterior mitral leaflet. Surgical treatment has late survival and freedom from reinfection similar to those of patients with single heart valve infection.

Tracheal cancer in Denmark: a nationwide study.

OBJECTIVE: Most published series on tracheal cancer reflect single institution experiences. We used the nationwide Danish Cancer Registry to report on characteristics and treatment of tracheal cancers in Denmark. METHODS: One hundred and nine cases of primary tracheal cancers were extracted from the registry in the period 1978-1995. The clinical data, histological distribution and treatment modalities were analyzed. The cancers were staged in four groups (stage I-IV) according to size, location and spread. RESULTS: Seventeen cases were diagnosed at autopsy. Ninety-two cases were diagnosed in vivo and 84% of these within 3 months after the first consultation. Sixty-three percent of the cancers were squamous cell carcinomas and only 7% were adenoid cystic carcinomas. The disease was at stage I in 21%, stage II in 23%, stage III in 6% and stage IV in 50%. The majority of the patients received radiotherapy as single treatment. Only nine patients were offered surgery (six were resected and three were found inoperable). The overall survival rates for cases diagnosed in vivo were 1-year 32%, 2-year 20% and 5-year 13%. For the resected patients the 5- and 15-year survival rates were 50%. CONCLUSIONS: Tracheal cancers were rare and adenoid cystic carcinomas not as frequent as generally believed. Surgery was rarely offered. A resectability rate of only 10% is not adequately explained by selection bias and indicates a nihilistic attitude based on ignorance about surgical treatment of tracheal cancers. A more dedicated and aggressive approach with centralized workup and radical treatment is strongly recommended.

The control of haemolysis during transurethral resection of the prostate when water is used for irrigation: monitoring absorption by the ethanol method.

OBJECTIVE: To determine whether the addition of ethanol to water for irrigation during transurethral resection of the prostate (TURP) and monitoring breath ethanol could be used to detect irrigant absorption and to limit free plasma haemoglobin in cases of absorption. PATIENTS AND METHODS: One hundred patients (46 in Piteå, Sweden and 54 in Uong bi, Vietnam) underwent surgery for benign prostatic hyperplasia (BPH) under an intermittent irrigation technique using water containing 2% ethanol. An expired breath alcohol meter was used to monitor ethanol in the patients' breath every 5 min. Blood samples taken after TURP were assessed for free haemoglobin in 99 patients, and other markers of haemolysis were also evaluated in the Swedish group. RESULTS: Thirty-two patients had detectable ethanol in their breath. There was a close correlation between the maximum ethanol reading during surgery and the level of free plasma haemoglobin after TURP (r = 0.90, P < 0.001). There was no correlation between the duration of TURP and the free haemoglobin level. CONCLUSION: Monitoring breath ethanol during TURP assesses absorption and so can help to keep control of haemolysis. It is suggested that the value on the alcohol meter should not be allowed to exceed 0.15 (corresponding to a blood ethanol level of 0.15 per thousand), which should maintain the free plasma haemoglobin level at < 1.0 g/L after TURP. Restricting the operative duration per se is not a reliable safety measure.

The atherosclerotic aorta at aortic valve replacement: surgical strategies and results.

BACKGROUND: Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta poses technical challenges. The purpose of this study was to examine operative strategies and results of aortic valve replacement in patients with a severely atherosclerotic ascending aorta that could not be safely crossclamped. PATIENTS AND METHODS: From January 1990 to December 1998, 4983 patients had aortic valve surgery; of these, 62 (1.2%) patients had a severely atherosclerotic ascending aorta and required hypothermic circulatory arrest to facilitate aortic valve replacement. They form the study group. RESULTS: All patients had hypothermic circulatory arrest, but several different strategies were used to manage the ascending aorta. These techniques included aortic valve replacement with the use of hypothermic circulatory arrest (39%), ascending aortic endarterectomy (26%), ascending aortic replacement (19%), aortic inspection and crossclamping during hypothermic circulatory arrest (10%), and balloon occlusion of the ascending aorta (6%). Duration of hypothermic circulatory arrest was substantially longer for patients having aortic valve replacement with hypothermic circulatory arrest than for all other strategies. Hospital mortality was 14%, and 10% of patients had strokes. Increasing New York Heart Association functional class and impaired left ventricular function were risk factors for hospital mortality. Choice of operative technique did not influence patient outcome; however, no patient who underwent replacement of the ascending aorta had a stroke. CONCLUSIONS: Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta is associated with increased operative morbidity and mortality. Complete aortic valve replacement during hypothermic circulatory arrest, the "no-touch" technique, requires a prolonged period of circulatory arrest. Ascending aortic replacement is a preferred technique, as it requires a short period of hypothermic circulatory arrest and results in comparable mortality with a low risk of stroke.

Outcome of septal myectomy in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: To study the outcome of septal myectomy in patients with hypertrophic obstructive cardiomyopathy. DESIGN: Septal myectomy in patients with hypertrophic cardiomyopathy with obstruction of the left ventricular outflow tract (HOCM) is symptomatically effective, and complication rates have been found to be low in large centres performing the procedure routinely. Representing a small centre we studied the outcome after septal myectomy in 11 consecutive patients, aged 44 +/- 21 (mean +/- SD) years with HOCM myectomized at our institution from 1991 to 1998. The patients were evaluated preoperatively using echocardiography and left-sided heart catheterization. RESULTS: Eight patients were operated on after medical treatment had failed and three after sudden deterioration of cardiac function. A Morrow myectomy was performed in 10 patients and a modified Konno procedure in one. Significant reductions were observed in left ventricular outflow tract gradients (77 +/- 29 to 10 +/- 7 mmHg, p < 0.01; n = 11), the degree of mitral valve regurgitation (grades 0-3) (1.7 +/- 1.0 to 0.8 +/- 0.7, p < 0.01; n = 11), NYHA functional classification score (2.4 +/- 1.0 to 1.5 +/- 0.7, p < 0.01; n = 11) and all five patients with angina preoperatively had an improved CCS angina classification score. There were no operative or early postoperative (30 days) deaths. One patient operated on with the modified Konno procedure was reoperated for a septal patch suture leak. During follow-up (43 +/- 24 months, range 11-83), the linearized mortality rate was 3.6% per year. One patient died from a pancreas cancer, one probably from coronary artery disease and one suddenly of unknown cause. CONCLUSION: We conclude that septal myectomy efficiently relieves symptoms in HOCM patients, possibly reflecting the direct as well as secondary effects of left ventricular outflow tract gradient reduction. The present results, obtained at a smaller centre for this procedure, should be considered when choosing from available therapeutic alternatives when medical therapy fails: dual chamber pacemaker implantation, percutaneous transluminal septal myocardial ablation or myectomy.

Vacuum assisted venous drainage (VAVD).

Poor venous drainage is a common problem in cardiac surgery, causing trouble for the surgeon and adverse effects to the patient. Smaller incisions for minimally invasive cardiac surgery require smaller venous catheters. In this study the function, safety and possible benefits of a system for vacuum assisted venous drainage has been tested experimentally and applied clinically. A vacuum regulator ('The Hamlet box') and safety procedures were developed. The system was characterized in vitro in regard to the relationship between vacuum, catheter size, and blood temperature and flow. The clinical study included 54 adult patients, coronary artery bypass graft surgery and valve operations. Venous cannulation was bi-caval with two 24 Fr catheters. All the perfusions were essentially event free, and the system was easy to manage and regulate. Venous drainage was totally adequate, irrespective of the position of the heart, and less fluid was added during the perfusions (a median of 250 ml/patient compared to a median of 1000 ml/patient in the control group). There has been no evidence of increased haemolysis or other adverse effects. All patients were hospital survivors and had uneventful postoperative courses. Vacuum assisted venous drainage is now used routinely, and further studies are under way to develop the system and clarify the physiological effects.

Predictors of chest pain after coronary artery bypass grafting.

To identify preoperative biopsychosocial factors characterizing patients who will experience chest pain (self-reported) one year after coronary artery bypass grafting (CABG), 111 patients under 61 years of age were evaluated by questionnaire before CABG and 12 months postoperatively. A "Coronary Health Profile" was evolved to study quality-of-life indicators, e.g. "Sense of Coherence" (SOC), emotional state (loneliness, depressed mood, stress, anxiety) and social support as well as experience of chest pain, and the results were correlated to biomedical data. Chest pain was experienced in the first postoperative year by 34% of the patients. These patients, who were younger than those without chest pain, generally had a body mass index >25, as well as lower preoperative values for SOC, poorer emotional state and social support. Independent predictors in a multivariate stepwise logistic regression analysis were moderate/weak SOC, ejection fraction <50%, and moderate/severe mood depression. We conclude that biomedical as well as psychosocial factors have a significant impact as predictors of chest pain (of any origin) after CABG, and must be considered in preoperative evaluation. The findings indicate the need for biopsychosocial support/intervention before as well as after CABG.

Human bronchial artery blood flow after lung Tx with direct bronchial artery revascularization.

The inaccuracy of measuring human bronchial artery blood flow has previously been considerable. En bloc double-lung transplantation with bronchial artery revascularization (BAR) using a single conduit offers the unique opportunity of direct measurement of the total bronchial artery blood flow. In eight en bloc double-lung-transplanted patients with complete BAR, the basal blood flow was measured by using a 0.014-in. Doppler guide wire and arteriography. The average peak velocity in the conduit was 12-73 cm/s [+/-2.1 (SD) cm/s], and the conduit diameter was 1.7-3.1 mm [+/-0.10 (SD) mm], giving individual basal flow values between 19 and 67 ml/min [+/-5 (SD) ml/min], or 0.2-1.9% of estimated cardiac output. In three patients basal measurements were followed by injection of nitroglycerin and verapamil into the conduit. This increased the bronchial artery flow to 121-262% of basal values (31-89 ml/min). The measured values appear more physiologically plausible than previous bronchial artery blood flow measurements in humans.

Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot.

OBJECTIVE: To describe the long-term prognosis after repair of Tetralogy of Fallot with pulmonary stenosis beyond 20 years. METHODS: One hundred and eighty five patients underwent corrective repair of Tetralogy of Fallot at Rigshospitalet in Copenhagen between January 1960 and July 1977. Ninety seven patients had undergone a palliative operation prior to Tetralogy of Fallot repair. All the 125 patients who were discharged from the hospital were traced through the population register and the patients alive July 1997 were contacted by mail and/or telephone and questioned about use of medicine, professional status, family status and ability to perform sport activities. RESULTS: Sixty patients died in hospital and 125 patients, 78 males and 47 females, were discharged alive. Among operative survivors, median age at operation was 12.8 years (range 0.4-41 years). Thirteen patients required a reoperation, the main indication was failed VSD closure. There were 16 late cardiac deaths, out of which seven were sudden and unexpected and three were in immediate relation to reoperations. One hundred and nine patients were alive at follow-up. The mean follow-up time was 25.5 years (range 20-38 years). Sixteen percent used cardiac drugs, 89% were, or had been, working normally (all professions from academics to hard manual labors were represented), 53% (64% of women) had given birth after the repair and 51% performed sport activities regularly. No patients were lost to follow-up. CONCLUSIONS: The vast majority of the patients seemed to live normal lives 20-37 years after Tetralogy of Fallot repair. Late deaths were cardiac in origin, including sudden death from arrhythmias. The number of late reoperation has been low. Considering the natural history of the disease, Fallot repair has proven to be a beneficial procedure even including the very early experience short after introduction of open heart surgery.

Arterial switch with internal pulmonary artery banding. A new palliation for TGA and VSD in complex cases.

In most cases, one stage repair by arterial switch operation (ASO) is the optimal treatment for neonates with transposition of the great arteries (TGA). Nevertheless, a ventricular septal defect (VSD) associated with TGA remains a major risk factor for early death and reoperation after complete repair in neonates with complex anatomy. A new palliative approach for such specific cases is proposed. An internal pulmonary artery banding (IPAB), as that already used to palliate other cardiac malformations, is performed in association with ASO instead of VSD closure. At the end of ASO, a circular polytetrafluorethylene (PTFE) patch with a 4-mm central hole is oversewn into the neo-pulmonary trunk. We adopted this method in a 17-day-old boy with TGA, VSD, hypoplastic tricuspid valve and diminutive right ventricle. After the operation the child thrived and was doing well without medication. Satisfactory growth of the right ventricle and tricuspid valve was observed by echocardiography during the following months. The patient successfully underwent VSD closure and IPAB removal 2 years after the first procedure. ASO with IPAB could be appropriate in all forms of TGA and VSD in which VSD closure appears too challenging in the neonatal period and in patients with uncertain suitability for biventricular repair. We preferred to use IPAB instead of classic PAB in order to reduce the risk of pulmonary valve damage, pulmonary artery distortion, and above all pulmonary artery dilatation and related coronary compression. In the presented case the strategy as well as IPAB worked according to our expectations.

Recurrent endocarditis in silver-coated heart valve prosthesis.

BACKGROUND AND AIM OF THE STUDY: In order to prevent prosthetic valve endocarditis (PVE), the implantation of a new silver-coated sewing ring has been introduced to provide peri- and postoperative protection against microbial infection. METHODS: A 56-year-old woman with aortic stenosis had elective replacement with a St. Jude Medical mechanical valve fitted with a silver-coated sewing ring (Silzone). The patient developed early PVE, which necessitated reoperation after one month. Despite a second Silzone prosthesis being implanted, the endocarditis recurred. During a third operation an aortic homograft was implanted, and after six months a fourth operation was performed for a pseudoaneurysm at the base of the homograft, in proximity to the anterior mitral valve leaflet. RESULTS: The diagnosis of PVE was confirmed by the presence of continuous fever, transesophageal echocardiography and growth of penicillin-resistant Staphylococcus epidermidis from the valve prosthesis. CONCLUSION: The implantation of all prosthetic valves is encumbered with a risk of endocarditis. Although silver has bacteriostatic actions, the advantages of silver-coated prostheses in the treatment of this condition have yet to be assessed in clinical trials.

Airway epithelium of transplanted lungs with and without direct bronchial artery revascularization.

OBJECTIVE: Normal systemic blood flow to the airways and lung parenchyma of transplanted lungs can only be re-established by direct bronchial artery revascularization. The purpose of the present study was to investigate whether such direct bronchial artery revascularization would preserve ciliary function, previously shown to be reduced in lungs transplanted without revascularization. METHODS: Twenty-five single lung transplanted patients were included in this study. Complete direct bronchial artery revascularization was achieved in eight patients. In 16 patients the procedure had either failed (n = 10) or was not attempted (n = 6). In one patient the result of the revascularization was unknown. Airway epithelium samples were obtained from the native and the transplanted lungs during bronchoscopic examinations. Airway erythema and excessive secretion were registered. The epithelium samples underwent histological examination and ciliary beat frequency was measured in vitro by video recording. Transbronchial biopsies from the transplanted lungs were examined for signs of rejection and bronchitis. RESULTS: No differences in ciliary beat frequency nor in the distribution of ciliated/de-ciliated columnar epithelium cells between native lungs and transplanted lungs with or without successful direct bronchial artery revascularization could be demonstrated. In 38% of the transplanted lungs without successful revascularization metaplastic or squamous epithelium was present, while lungs with successful revascularization had only normal columnar epithelium. Ongoing rejection or airway erythema did not influence ciliary beat frequency. Excessive secretion in the airways was the only finding associated with significantly increased ciliary beat frequency. CONCLUSIONS: Ciliary beat frequency of epithelium cells of transplanted lungs did not differ from that of native lungs and consequently direct bronchial artery revascularization did not have any demonstrable important influence. Excessive secretion in the airways was associated with increased ciliary beat frequency. The histological findings also showed that the abundance of ciliated cells was preserved in transplanted bronchi irrespective of bronchial artery revascularization. However, epithelium metaplasia was only seen in transplanted bronchi without revascularization.

Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial.

OBJECTIVE: We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass. METHODS: Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated. RESULTS: In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%). CONCLUSIONS: In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

Does bronchial artery revascularization influence results concerning bronchiolitis obliterans syndrome and/or obliterative bronchiolitis after lung transplantation?

OBJECTIVE: To study the frequency of histological obliterative bronchiolitis and clinical bronchiolitis obliterans syndrome after en bloc double lung transplantation with bronchial artery revascularization and bilateral lung transplantation without bronchial artery revascularization. METHODS: Primary en bloc double lung transplantation with bronchial artery revascularization using the internal mammary artery as conduit was performed in 62 patients. The frequencies of obliterative bronchiolitis and bronchiolitis obliterans syndrome have been established from transbronchial biopsies and lung function measurements. Results have been analyzed in relation to the arteriographic success of bronchial artery revascularization and have been compared to results from Stanford University, obtained through personal communications. RESULTS: Survival after 1, 2, 3, 4 and 5 years was 85, 81, 69, 69, and 69%, respectively. Fifteen patients developed bronchiolitis obliterans syndrome while seven developed obliterative bronchiolitis. Survival was superior for patients with bronchial artery revascularization classified as complete or incomplete bilateral versus incomplete hemilateral, incomplete poor or failed (P = 0.016, log-rank test). For patients surviving > or = 3 months post-transplant, the post-operative baseline FEV1 was lower for patients who later developed bronchiolitis obliterans syndrome compared to patients who did not (P = 0.007). The development of bronchiolitis obliterans syndrome and obliterative bronchiolitis were both correlated to observation time post-transplant but not to the number of rejections or infections when corrected for observation time. CONCLUSIONS: In a subgroup of lung transplant patients, a process in the transplanted lungs, eventually leading to bronchiolitis obliterans syndrome diagnosis, seems to start in the donor during the transplantation and/or in the early post-operative cause. A comparison with results after bilateral lung transplantation without bronchial artery revascularization suggests that good direct bronchial artery revascularization may postpone the onset of bronchiolitis obliterans syndrome and obliterative bronchiolitis. The positive trend motivates further use of direct bronchial artery revascularization in lung transplantation.

Treatment of aortic valve endocarditis with the Ross operation.

OBJECTIVE: Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aortic valve disease is increasing, but use of the pulmonary autograft in the treatment of aortic valve endocarditis has been limited. The objective of this prospective study is to present the technique and results of our experience with aortic valve endocarditis treated with the Ross operation. MATERIALS AND METHODS: Since 1992 we have treated 35 patients (median age 41 years, range 6-71 years) having aortic valve endocarditis with a Ross operation. Twenty-four patients had advanced disease defined as pathology due to endocarditis extending beyond the valve cusps (13 patients) or prosthetic valve endocarditis (11 patients). Twenty-two patients had active disease at the time of surgery, and 12 had undergone one to four previous heart operations. RESULTS: There were two operative deaths (5.8%), both related to severe disease with very advanced pathology and heart failure. Intraoperative echocardiography demonstrated no or trivial autograft insufficiency in all patients. There have been no late deaths. There has been one (probable) recurrent right-sided endocarditis in a drug addict during a follow-up period of 3-56 months. One patient has been reoperated on for homograft stenosis. CONCLUSIONS: We are enthusiastic about the use of the Ross operation in aortic valve endocarditis and in younger patients with advanced pathology, it is our preferred treatment modality. Following removal of the autograft, unparalleled exposure of the left ventricular outflow tract is obtained. Even in patients with very advanced pathology the left ventricular outflow tract is usually intact, allowing autograft implantation in the standard fashion. For selected patients with simple endocarditis, the Ross operation is an attractive option on its usual merits.

Medium-term patency and anatomic changes after direct bronchial artery revascularization in lung and heart-lung transplantation with the internal thoracic artery conduit.

OBJECTIVE: Our purpose was to study the 2-year patency of direct bronchial artery revascularization in lung transplantation. We wanted to clarify whether the revascularized bronchial artery system is functional after 2 years, whether bronchial artery vascularity changes with time, and whether posttransplantation bronchial artery disease is arteriographically evident after 2 years. METHODS: Bronchial artery revascularization is performed by anastomosing the internal thoracic artery to as many bronchial artery orifices in the donor descending aorta as possible. Twenty-three patients surviving 2 years or more have had internal thoracic artery-bronchial arteriography performed 1 month and 2 years after transplantation. One-month and 2-year arteriograms have been compared. RESULTS: Two-year patency of the internal thoracic artery conduit was 100%. The appearance of the bronchial arteries was unchanged after 2 years in 11 patients. A unilateral or bilateral increase in vascularity was found in two and seven patients, respectively. In three patients new vessels, not visible on the first arteriogram, had appeared. In four patients one or more small vessels visible on the first arteriogram had disappeared on the second arteriogram. We have found no arteriographic signs of bronchial artery disease, such as stenosis of the bronchial arteries, and no arteriographic evidence of arteriosclerotic disease in the internal thoracic artery. CONCLUSION: The internal thoracic artery is an excellent conduit for bronchial artery revascularization, with a 2-year patency of 100% in 23 patients. Only minor changes in the bronchial arteriograms have been found.