Long-term follow-up of Björk-Shiley mitral valve replacement. 10 years' experience.

Retrospective analysis was made of 176 patients who received a Björk-Shiley mitral valve replacement in the period 1973 through 1982. Actuarial cumulative curves showed the 10-year and 5-year survival rates to be 79 +/- 3.4%. The functional status at follow-up was better than preoperatively in 77.1% of the patients. The hospital mortality was 9.1% and the late mortality was 3.6/100 patient years. Early complications included disc entrapment against the ventricular wall in three cases, wedging of chorda between disc and valve rim in two and posterior perforation of the left ventricle in three patients. There was no structural valve damage. Calculated per 100 patient years, the incidence of thromboembolism was 2.5, endocarditis 1.4 and prosthetic leak 1.8. One thrombosed valve was successfully replaced by a new prosthesis 11 years after the initial implantation. Jamming of the disc by tissue over-growth necessitated a new valve implantation in one case. The incidence of early valve-related complications was high, but the long-term results were comparable with those from other mechanical valves. One early complication--disc entrapment against the ventricular wall--may be avoided by use of a sufficiently small valve if the ventricle is small and thickened.

Repair of ventricular septal defect in adults.

To evaluate the outcome of ventricular septal defect (VSD) with long duration of haemodynamic derangement, a retrospective study was made of 42 consecutive patients who underwent closure of VSD as adults (age range 15-48, mean 27 years). The mean systolic pulmonary arterial pressure was 53 mmHg, mean pulmonary vascular resistance 2.5 Wood units and mean pulmonary/systemic flow ratio 2.4. VSD was complicated by aortic regurgitation in 12 cases, mitral regurgitation in 4, and sinus of Valsalva fistula in 6 cases. There were 15 supracristal, 24 infracristal and 3 muscular VSDs. In addition to VSD closure, surgery included aortic valve replacement (7 cases), mitral valve replacement (2), valve repair by suture (7) and repair of Valsalva sinus fistula (6 cases). Two patients died in the early postoperative period and two during follow-up (1-10, mean 4.5 years). The early and the late mortality were related to large infracristal VSD, pulmonary hypertension and irreversible pulmonary vascular changes which could not be anticipated on the basis of high calculated shunt flow at preoperative catheterization. No patient with supracristal VSD died. Recurrent VSD was diagnosed in five patients, three of whom needed reoperation and recovered uneventfully. Reduction of heart size and improved exercise tolerance were the most pertinent follow-up findings. The results suggest that large supracristal VSD with aortic valve involvement can be successfully closed in adults, but that the prospect for large infracristal VSD is less favourable if correction is postponed until adulthood.

Combined valve replacement and myocardial revascularization. Factors influencing early and late results.

The risk factors involved in simultaneous valve replacement and coronary artery bypass grafting were evaluated in 54 consecutive patients, 42 men and 12 women, aged 22 to 73 years. The predominant valve anomalies were aortic stenosis (30 patients), aortic regurgitation (9), mitral regurgitation (10) and mitral stenosis (5). All the patients had angina. Myocardial infarction had occurred in 22 cases and was impending at the time of operation in 10. The diseased valves were replaced with mechanical prostheses, and on average 2.5 coronary arteries per patient were bypassed with vein or with internal mammary artery grafts. Four of the 54 patients died in association with surgery, and four more during follow-up (0.5-6 years). The operative mortality was 2/39 in the aortic valve group and 2/14 in the mitral valve group. The late mortality was equal in both groups. A relatively small ejection fraction and long aortic cross-clamping were the only factors which attained statistical significance as surgical risks, but mitral regurgitation due to ischaemic papillary muscle dysfunction, advanced rheumatic mitral regurgitation and tight aortic stenosis combined with coronary artery disease also seemed to be indicators of poor prognosis.

The effects of a centrifugal pump as a left-ventricular-assist device in myocardial infarction.

Cardiogenic shock after acute myocardial infarction and open heart surgery having cardiopulmonary bypass may present a difficult clinical problem with high mortality. The present study was carried out to evaluate a newly developed laminar flow centrifugal pump as a left-ventricular-assist device to support the circulation and prevent myocardial damage in such situations. Experimentally induced acute myocardial infarction in dogs was used as the model. Cardiogenic shock was effected by ligating enough branches of the left coronary artery. In addition to recording the haemodynamic parameters, samples of myocardium were taken with a biopsy needle from the infarcted area, transitional zone and intact myocardium for determination of adenosine triphosphate, creatine phosphate and lactate. In the first phase of the work the effects of acute myocardial infarction on haemodynamics and high-energy compounds were defined, to form a basis for the evaluation of the pump as left-ventricular-assist device. Ligation of the branches of the left coronary artery produced a rapid fall in aortic pressure, cardiac output and cardiac performance, elevation of ST-segment in the ECG and fall in high-energy compounds. However, there was a marked spontaneous recovery in the transitional zone within 120 min, despite the haemodynamic deterioration. The laminar flow pump produced a significant improvement in the haemodynamic and metabolic parameters which exceeded the spontaneous changes noted previously.

Surgical intervention in cases of Ebstein's anomaly. Abnormal origin and structure of the tricuspid valve.

During the ten-year period 1972-81 four patients, two men and two women, with Ebstein's disease underwent operation at our institution. Their average age was 34. Central cyanosis at rest, clubbing and polycythaemia were the most common clinical features of the patients. Enlarged heart, a small pulmonary arterial arch and transluminal lung fields were seen in chest X-ray. Operative findings were a grossly enlarged right atrium and ventricle, the latter having a segment that was typically atrialized and thin-walled but was contracting synchronously with the true right ventricle, and a wide variation in the leaflets of the tricuspid valve and their origins. The atrial septal defect was small in all cases. Artificial heart valves (1 Cutter-Smeloff, 2 Björk-Shiley, 1 St. Jude) were used in the tricuspid reconstruction in addition to closure of the ASDs. One of the patients died postoperatively, the other three are doing well.

Valve replacement for bacterial endocarditis.

During the 10-year period 1970-79, 88 patients underwent valve replacement for complications of bacterial endocarditis. The mean age of the patients was 42 (15-60) years. There were 64 men and 22 women. Thirty-three patients had a history of rheumatic fever. In 11 cases the murmur was heard already in childhood. In 44 cases (50%) no heart disease was diagnosed before the onset of symptoms of bacterial endocarditis. Strepto- and staphylococci were the most common organisms found in culture. In 12 cases a dental and in 12 a respiratory tract infection preceded the endocarditis. In 51 cases, however, the origin of the infection remained unestablished. Intractable heart failure and embolizations were most common indications for operation. Only 9 patients underwent operation in the acute phase. Aortic valve replacement (AVR) was performed in 58 cases, mitral valve replacement (MVR) in 19, both AVR and MVR in 6, AVR and aneurysm of sinus Valsalva repair in 3 cases, AVR and repair of VSD in one and AVR combined with myocardial revascularization and replacement of the ascending aorta for aneurysm in one case. The early mortality was 9 patients (10%) and late mortality 9 patients. During follow-up times of up to 10 years, 7 patients experienced embolic complications. They recovered uneventfully. One valve prosthesis was replaced because of thrombosis and another due to paraprosthetic leak. Two patients had a late recurrent bacterial endocarditis 5 and 8 years postoperatively. They were treated conservatively and recovered. It was concluded that after valve replacement for bacterial endocarditis, the risk of recurrent infection is relatively low and that results approaching those for elective valve replacement can be achieved.

Penetrating and perforating thoracic injuries.

Five hundred and eleven patients with penetrating or perforating chest injuries were admitted to the Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki, during the 25-year-period 1952-77. There were 433 stab wounds, 59 gunshot wounds and 19 other penetrating injuries. The organs most often involved were lungs (major haemo- or pneumothorax in 385 patients), heart (63 patients) and liver (61 patients). About one third of the patients were in profound shock on admission. The treatment was immediate thoracotomy in 176 (35%) and laparotomy in 123 cases (24%). Tube thoracostomy was applied in 117 patients and needle aspiration performed in 88 patients. Nine patients died (mortality of 1.8%). Two patients required later open-heart procedure. One of them had an aortopulmonary fistula and the other a traumatic VSD combined with aortic valve lesion. One of the traumatic VSDs closed spontaneously during the follow-up time. An active operative approach in the early phase seems to guarantee the best final results, especially in the most critically ill patients.

Ischaemic cardiac aneurysms and ventricular septal defects. Surgical treatment with and without revascularization.

During the period 1968--78, 35 patients with left ventricular aneurysm after acute myocardial infarction were operated on at the Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki. Twenty patients underwent resection of the left ventricular aneurysm and had coronary bypass grafting (Group I) and 15 patients had aneurysmectomy without revascularization procedures (Group II). Most of the patients (21) had the operation within one year after acute myocardial infarction. The aneurysm was located in the anterior wall in 31 cases and in the posterior wall in 4 cases. Three patients in Group II had a concomitant ventricular septal rupture, which was repaired simultaneously with the aneurysmal resection. In average, the patients in Group I had bypass grafting in 1.8 coronary branches. There were no intra-operative deaths. Three patients in the revascularization group died and 2 patients in the non-revascularization group died during hospitalization (15% hospital mortality). Two patients in the revascularization group and one in the non-revascularization group died during the average follow-up time of 3.4 and 6.4 years for the respective groups (late mortality 10 and 7%). The rest of the patients were doing well, including those with repaired VSDs. Follow-up coronary angiography was carried out of 12 patients; in 10 all the grafts were patent and in 2 one revascularized coronary branch had a patent graft. Revascularization produced apparent relief of anginal symptoms. Its beneficial effects on longevity remained unestablished.

Surgical treatment of pulmonary metastases.

Pulmonary metastases from many primary sources were treated by surgery in 42 patients. The seven-year survival rate was 10%. A long time interval between the operation on the primary tumor and the metastatic lung lesion was associated with a better prognosis. The survival rates for patients with carcinomas and sarcomas were nearly equal equal after removal of pulmonary metastases. The patients with melanoma died soon after lung resections. The location of the metastases in the lower lung lobes had a better prognosis than that of metastases in the upper lobes. In this material there was a patient who, after treatment of the primary tumor, needed three thoracotomies to remove eight pulmonary metastases from both lungs. The patient was alive and free from all signs of recurrence 20 years after the first removal of pulmonary metastases.

ASD in patients over 40 years of age.

To evaluate the benefits of operative treatment of congenital heart disease in older age groups, a clinical study on patients over 40 years of age with atrial septal defect was carried out. The series consisted of 125 consecutive patients operated on between 1966 and 1974. There were 8 cases with a primum, 12 cases with a sinus venosus type of secundum and 105 cases with a simple secundum defect. The operative mortality was 2 patients (1.6%). It was due to myocardial infarction in one case and high pulmonary vascular resistance in the other. On re-examination 3-6 months postoperatively, 107 patients were improved, 13 patients unchanged and 3 patients were worse than before operation. On re-evaluation after an average period of 6 years, 88 patients were still improved. 32 patients unchanged and 3 patients were worse compared with their pre-operative status. On the basis of the results and the previous reports on atrial septal defect without operation, the surgical correction of ASD even in older age groups can be recommended. The problem of deterioration of some patients, despite a good immediate postoperative result, is discussed.

The effect of digoxin on the contractility of transplanted heart.

The effects of digoxin on the contractility of orthotopically transplanted heart was studied in dogs. Intravenously administered digoxin produced a fall in the rate and output of the transplanted heart without any change in stroke volume, whereas the output of the intact heart was slightly improved due to a small increase of stroke volume. This difference was thought to be due to the action of digitalis which is mediated via the nervous pathways, which are interrupted in the transplanted heart.

Surgical treatment of carcinoma of the oesophagus and cardia.

A clinical series of 216 patients with carcinoma of the oesophagus or cardia, who underwent surgical resection of the oesophagus, is presented. There were 104 patients with oesophageal carcinoma and 112 patients with carcinoma of the cardia. Histologically, there were 102 squamous cell carcinomas, 98 adenocarcinomas, 11 anaplastic carcinomas and 7 non-differentiated carcinomas. Oesophago-gastrotomy was the procedure mostly used; colon interposition was done in only 13 cases. The hospital mortality was 21%. The 5-year survival rate for the whole series after oesophageal resection was 23%. The duration of symptoms, location of the tumour, age and sex of the patients, pre- or postoperative radiotherapy and the histological type of the tumour had only a minor bearing on survival. The two most important prognostic factors were the spread of the tumour at time of operation and a preceding lye stricture. The 5-year survival rate was 34% for the patients with a local tumour at operation and 44% for those in whom the carcinoma developed at the site of a previous lye stricture. The variance of the results in the literature is discussed. Surgical approach to the carcinoma of the oesophagus and cardia is recommended in all the cases in which the patient and tumour seem to be eligible for resection.

Atrial myxoma in a family.

A family is described in which the mother and three of seven children had atrial myxoma. The mother had biatrial myxoma; surgical treatment resulted in massive intraoperative embolization and death. Surgery was sucessful in two sons with left atrial myxoma and systemic arterial embolization. A third son had calcified right atrial myxoma with destruction of the tricuspid valve and episodes of syncope and pulmonary embolism; surgery including valve replacement, was successful. The mother's father and a brother had died suddenly without a definite diagnosis. The family data are consistent with dominant transmission. The possibility of finding affected relatives should be borne in mind when studying patients with atrial myxoma.

Donor-circulation as cardiopulmonary bypass in experimental heart transplantation.

Heart transplantation was performed on 21 mongrel dogs using donor-circulation of another, bigger dog, instead of the heart-lung machine. All the dogs survived the operation. They showed a moderate metabolic acidosis, which was more related to a reduced blood flow of the recipient than to inadequate oxygenation capacity of the pump dog during transplantation, and which was corrected by administration of bicarbonate after the procedure. The technique was superior to disposable oxygenators in reducing the expense of the operation and providing a more gentle perfusion.

Operative treatment of carotid artery occlusion. A follow-up study.

One hundred consecutive patients have been subjectes to 134 carotid artery reconstructive procedures. 81 patients had TIA syndrome, 2 had acutely progressing stroke and 17 had symptomless stenosis at the carotid artery bifurcation. In 121 instances a bifurcation endarterectomy was performed, in 6 cases the internal or common carotid artery was resected and reconstructed, in 5 cases allograft- and in 2 cases autologous vein was used for the reconstruction. An intraluminal shunt was used in 93 operations. Operative mortality occurred in 4 patients, one was a case of acutely progressing stroke. Late mortality occurred in 16 patients. A follow-up study was carried out in the remaining 80 patients. According to the patients' own judgement symptomatic relief was good in 52.5 %, satisfactory in 40 % and unchanged in 7.5 %.

Operative treatment of atherosclerotic lesions in innominate, subclavian and vertebral arteries. A follow-up study.

The follow-up study consists of 121 surgically treated atherosclerotic patients. The average age was 49 years and the male: female ratio 7:5. There were 165 obstructions or occlusions in this series. 59 of them suffered from a subclavian steal syndrome. Altogether 146 reconstructive procedures were perdormed. 78 of them were endarterectomies, 51 bypass graft operations, 15 transpositions of the subclavian artery to the common carotid artery and 2 were other procedures. Operative mortality occurred in 3 patients (2.5 %). Non fatal complications occurred in 26 patients, the most frequent of which was thrombosis ot the reconstructed artery (12 cases). In the follow-up study (mean follow-up time 3.5 years) data on 118 patients was available. During the follow-up time 15 patients had died of other reasons than cerebral ischaemia. 42 % of the patients considered the operative result good and 51 % satisfactory. 25 % of the patients were ar work before operation and 50 % after.

Mitral valve replacement with ball and tilting disc valve prosthesis. A clinical and haemodynamic study.

A survey is presented on the results of 100 consecutive patients who underwent mitral valve (78 patients) or mitral and aortic and/or tricuspid valve replacement (22 patients) with ball or disc valve prosthesis. The patients were followed-up from 6 to 54 months postoperatively. The mortality for mitral valve replacement was 13 (17%) early deaths (up to one month from operation) and 5 (6%) late deaths. The corresponding figures for multiple valve replacements were 9 (41%) and 3 (14%). A direct correlation was found between early mortality and preoperative functional class IV of the New York Heart Association (30% dead). Pulmonary hypertension combined with multiple valve disease resulted in an early mortality of 42%. No significant differences in early mortality figures after MVR were found between ball and disc valve prostheses. Predominant complications were respiratory infection and atelectasis (13%), acute myocardial infarction (11%) and haemorrhage (9%). Haemolysis was found in 9 patients and three other patients had haemolytic anaemia attributable to paravalvular leak which in two indicated the reapplication of the prosthesis. The main causes of death were heart failure, 8 early and 4 late deaths, and myocardial infarction, 5 and 4 respectively.

The effects of beta-adrenergic agents on the contractility of transplanted canine heart.

The effects of isoprenaline and adrenalin on the myocardial contractility of transplanted heart were studied in 6 mongrel dogs which had undergone orthotopic cardiac transplantation. Isoprenaline and adrenaline produced a fall in end-diastolic and end-systolic volumes, and an increase in stroke volume, cardiac output and velocity of contraction when the heart rate was increased. Similar changes were observed in 4 mongrel dogs tested as controls, with the exception of a less pronounced increase of cardiac output after administration of isoprenaline and adrenalin and a fall in stroke volume associated with a higher acceleration of heart rate after administration of isoprenaline. These minor differences between the transplanted and intact heart were thought to be a reflexion of the increased blood volume following heart transplantation.