A prognostic model of recurrence and death in stage I non-small cell lung cancer utilizing presentation, histopathology, and oncoprotein expression.

In order to construct a multivariate model for predicting early recurrence and cancer death for patients with stage I non-small cell lung cancer, 271 consecutive patients (mean age, 63 +/- 8 years) who were diagnosed, treated, and followed at one institution were studied. All patients were clinical stage I with head and chest/abdominal computed tomograms and radionuclide bone scans without evidence of metastatic disease. Pathological material after resection was reviewed to verify histological staging. Follow-up documented the time and location of any recurrence, was a median 56 months in duration, and was complete in all cases. Data recorded included age, sex, smoking history, presenting symptoms, pathological description, and oncoprotein staining for erbB-2 (HER-2/neu), p53, and KI-67 proliferation protein. Immunohistochemistry of oncogene expression was performed on two separate archived paraffin tumor blocks for each patient, with normal lung as control. All analyses were blinded and included Kaplan-Meier survival estimates with Cox proportional hazards regression modeling. Data, including immunohistochemistry, were complete for all 271 patients. Actual 5-year survival was 63% and actuarial 10-year survival was 58%. Significant univariate predictors (P < 0.05) of early recurrence and cancer-death were: male sex; the presence of symptoms; chest pain; type of cough; hemoptysis; tumor size > 3 cm diameter (T2); poor differentiation; vascular invasion; erbB-2 expression; p53 expression; and a higher KI-67 proliferation index (> 5%). An additive oncogene expression curve demonstrated a 5-year survival of 72% for 136 patients without p53 or erbB-2, 58% for 108 patients who expressed either oncogene, and 38% for 27 who expressed both (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Subvalvular left ventricular pseudoaneurysm after mitral valve replacement: two-dimensional echocardiographic findings.

Disruption of the posterior mitral anulus is a rare complication of mitral valve replacement that may result in subvalvular left ventricular pseudoaneurysm formation. Such pseudoaneurysm formation was easily recognized by two-dimensional echocardiography in a 54 year old man 3 years after his second mitral valve replacement. The finding was confirmed by cineangiography and direct surgical inspection. Recognition of this rare complication of mitral valve replacement has therapeutic importance because surgical correction is necessary.

The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery.

To assess the value of intraoperative transesophageal echocardiography during cardiac valve surgery, 154 consecutive patients who had a valve operation in conjunction with pre- and postcardiopulmonary bypass transesophageal imaging were studied. Prebypass imaging yielded unsuspected findings that either assisted or changed the planned operation in 29 (19%) of the 154 patients. Imaging immediately after bypass revealed unsatisfactory operative results that necessitated immediate further surgery in 10 (6%) of the 154 patients. Postbypass left ventricular dysfunction, prompting administration of inotropic agents, was identified in 13 patients (8%). Transesophageal echocardiography proved most useful when both two-dimensional and Doppler color flow imaging were employed in patients undergoing a mitral valve operation, where surgical decisions based on echocardiographic results were made in 26 (41%) of 64 cases. Postbypass echocardiographic findings identified patients at risk for an adverse postoperative outcome. Of 123 patients whose postbypass valve function was judged to be satisfactory, 18 (15%) had a major postoperative complication and 6 (5%) died, whereas of 7 patients with moderate residual valve dysfunction, 6 (86%) had a postoperative complication and 3 (43%) died (p less than 0.05 for both). Likewise, of 131 patients with preserved postbypass left ventricular function, 12 (9%) had a major complication and 7 (5%) died, whereas of 23 patients with reduced ventricular function, 17 (73%) had a postoperative complication and 6 (26%) died (p less than 0.05 for both). These data indicate that intraoperative transesophageal echocardiography is useful in formulating the surgical plan, assessing immediate operative results and identifying patients with unsatisfactory results who are at increased risk for postoperative complications.

Barrett's esophagus and adenocarcinoma of the esophagus and gastroesophageal junction.

Since 1985, 57 patients with adenocarcinoma of the esophagus and gastroesophageal (GE) junction have undergone surgical resection. In this group, 16 of the tumors arose in a Barrett's esophagus. There was a significant predilection toward white men above the age of 55 (15/16; 94%) in this subgroup. The mean proximal extent of abnormal columnar involvement was 5.4 cm above the gastroesophageal junction (range 2.5 to 11 cm). The mean location of the neoplasm centered in the distal esophagus 1.8 +/- 0.5 cm above the gastroesophageal junction. During the same time period, 30 patients with Barrett's esophagus were seen without associated adenocarcinoma. There were no statistical differences in the proximal extent of columnar involvement or the presence of reflux symptoms between the two groups. There were no significant differences in age, smoking history, and alcohol consumption between patients with benign or malignant Barrett's esophagus as compared to those with adenocarcinoma of the gastroesophageal junction not associated with Barrett's mucosa. The marked male predominance seen in the group with malignant Barrett's esophagus was in contrast to the benign cases (16/30; 53%) but was similar to the adenocarcinoma group, without recognized Barrett's esophagus (38/41; 93%). The mean location of the tumor in the latter was 0.9 +/- 1.2 cm above the gastroesophageal junction and was comparable to the location in the group with Barrett's adenocarcinoma. The 4-year survival rate of patients in the non-Barrett's adenocarcinoma group is approximately 30%. Of those with Barrett's adenocarcinoma, the present 4-year survival rate is 60%. The demographic and morphometric similarities between the Barrett's and non-Barrett's adenocarcinoma groups may be of primary importance in determining the true clinical prevalence of Barrett's adenocarcinoma. Our findings suggest that the sensitivity of endoscopic surveillance may be improved if biopsy specimens are concentrated within the distal 3 cm of the esophagus and the esophagogastric junction. Finally, the reason for the current difference in survival between the Barrett's and non-Barrett's adenocarcinoma groups is uncertain but may be related to endoscopic surveillance permitting earlier diagnosis and treatment.

Management of benign and malignant lesions of the trachea and bronchi with the neodymium-yttrium-aluminum-garnet laser.

Fifty patients with lesions of the trachea or bronchi have been treated with the neodymium-yttrium-aluminum-garnet laser. Forty-three patients had advanced carcinoma of the lung with pulmonary infection or abscess distal to an obstructing bronchial lesion or else had hemoptysis. Benign lesions were seen in seven patients. A total of 72 laser treatments were administered for obstruction and/or hemoptysis. There was no significant morbidity and only one hospital death occurred, which was unrelated to the laser therapy. Among the 43 patients with malignant disease, obstructive complications and hemoptysis were controlled in 39. All those with benign lesions have been significantly improved. Presently 22 patients with malignant disease remain alive and are symptomatically improved. The longest survival after successful laser treatment has been 73 weeks, and 34 survived longer than eight weeks. This laser is a very effective means of managing patients with benign lesions and offers significant palliation for patients with hemoptysis and advanced obstructing carcinoma of the trachea or main-stem bronchus.

Pulmonary tuberculosis in children.

A major change has occurred in the incidence and management of pulmonary tuberculosis in patients of all ages. This review emphasizes the effectiveness of drug therapy and the declining role of surgical management of pulmonary tuberculosis in children. Surgical intervention was necessary in only two of 140 children (1.4%) with proved tuberculosis, one for a large tuberculoma and the other for refractory involvement of the chest wall. The remaining 138 children were treated successfully with anti-tuberculous drugs. Pulmonary tuberculosis in children is primarily a medical disease and only rarely is surgical intervention indicated.

Regional pulmonary function during experimental unilateral pneumothorax in the awake state.

This study examines changes in regional pulmonary function during unilateral pneumothorax, immediately after, and 2 hours following re-expansion in awake dogs. Respiratory rate, tidal volume, physiologic dead space, arterial blood gases, and pulmonary shunt fraction were determined at each stage. Cardiac output (thermodilution), vascular pressures, and regional ventilation and perfusion (133Xe scans) were also measured. Chest roentgenogram confirmed the presence of UP. Respiratory rate increased 124 percent (p less than 0.01) during UP while alveolar ventilation remained unchanged. Pulmonary shunt fraction rose 93 percent (p less than 0.01) during UP, causing PaO2 to fall from 86 to 51 mm. Hg (p less than 0.01). PaCO2, pH, and cardiac output were not altered by UP. UP caused a relative underventilation of the collapsed lung (V/Q = 0.73 (p less than 0.01)) and an overventilation of the contralateral lung (V/Q = 1.74) (p less than 0.01). Immediately after re-expansion of the collapsed lung, all the above changes reverted to the control values. All variables remained unchanged 2 hours following complete re-expansion.

The effect of altitude-induced hypoxia on regional myocardial blood flow.

Mechanical obstruction of the pulmonary artery causes an increase in right ventricular myocardial blood flow (MBF) proportional to the increased work load. This study was done to assess the response of MBF to hypoxia in the absence of mechanical obstruction of the right heart. The effects of hypoxia on cardiac performance and regional MBF were studied in ten awake, unanesthetized dogs at 4,600 m (15,000 feet). Intracardiac pressures and pulmonary artery (PA) and thoracic aorta blood gases were recorded daily, initially at sea level and subsequently at 3,000 m and 4,500 m altitude. Regional MBF was measured on days 1 (control), 3, and 5 by use of 8 to 10 mu radioactive tracer microspheres, followed by postmortem assessment of subepicardial and subendocardial flow patterns in the left ventricle (LV), septum, and right ventricle (RV) (4,600 m). The results indicate that: (1) RV and PA pressures increase linearly with increasing degrees of hypoxia, (2) MBF increases in both the RV and LV with increasing degrees of hypoxia and elevated right-sided pressures, without increased systemic pressure, and (3) the transmural distribution of MBF is unaltered in both the BV and LV with altitude-induced hypoxia. These findings are distinctly different from those in which right-sided pressures are elevated secondary to mechanical obstruction of the PA in the absence of hypoxia.

Analysis of 945 cases of pulmonary metastatic melanoma.

From 1970 to 1990, 7564 patients with melanoma were seen at Duke University Cancer Center. Complete follow-up data were available in all patients. The estimated probability of a pulmonary metastasis developing 5, 10, or 20 years after initial diagnosis was 0.13, 0.19, and 0.30, respectively. Pulmonary metastases were documented in 945 patients (12%), these having 1-, 3-, and 5-year survival rates of 30%, 9%, and 4%, respectively. The methods of diagnosis were chest radiograph (n = 544), computed tomography (n = 157), transthoracic needle biopsy (n = 121), bronchoscopy (n = 14), thoracotomy (n = 112), and autopsy (n = 7). Evidence of advanced pulmonic spread included bilateral disease in 543 and more than two nodules in 595. Univariate predictors for early formation of pulmonary metastases (p less than 0.001) were male sex, black race, increased primary thickness (millimeters), higher Clark's level, nodular or acral lentiginous histology, location on trunk or head and neck, and regional lymph nodes positive for metastasis. Multivariate predictors of improved survival (p less than 0.001) in order of importance were complete resection of pulmonary disease, longer time for formation of metastases, treatment with chemotherapy, one or two pulmonary nodules, lymph nodes negative for metastasis lymph nodes (p less than 0.005), and histologic type (p less than 0.04). Additionally, survival in patients with one nodule and resection (n = 84) was better than in those with similar disease and no resection (n = 142 months, p less than 0.001). These data comprise the largest series to date and emphasize the importance of long-term follow-up, as well as supporting the selective use of resection for isolated pulmonary metastases, increasing the 5-year survival rate from 4% to 20%.

The effect of positive end-expiratory pressure on regional ventilation and perfusion in the normal and injured primate lung.

Although positive end-expiratory pressure (PEEP) is being employed in the management of respiratory insufficiency, many of its physiological effects remain undetermined. The cardiopulmonary effects of PEEP as well as its effect on regional ventilation and perfusion were studied in 10 baboons before and after pulmonary injury with oleic acid. In the normal lung, there was significant improvement in oxygenation at a PEEP of 5 cm. of water secondary to improved ventilation and perfusion in all PEEP greater than 5 cm. of water produced increasing mismatch of ventilation and perfusion in all zones. After oleic acid was injected, hypoxemia was evident with a reversal of the normal ventilation-perfusion (V/Q) relationship between upper and lower lung zones. This mismatch of ventilation and perfusion was corrected at a PEEP of 15 cm. of water. It was reasonable to conclude that the use of PEEP in the injured lung exerts it beneficial effect by balancing regional ventilation and perfusion in addition to increasing functional residual capacity.

Paecilomyces varioti endocarditis on a prosthetic aortic valve.

Fungal endocarditis following prosthetic valve surgery has assumed increased importance as a cause of postoperative death. We present, to our knowledge, the first case of the fungus Paecilomyces varioti producing endocarditis on a prosthetic aortic valve. This seems to be an extremely indolent organism which exhibits an apparent response to antibiotic therapyl. In vitro evidence suggests that this fungus is sensitive to attainable serum levels of both 5-fluorocytosine and amphotericin B. However, after viewing the extracted valve and the devastating embolic phenomenon in our patient, we believe that medical therapy alone would not suffice. Thus we suggest that prompt valve replacement be performed in future cases.

Electron microscopy in selection of patients with small cell carcinoma of the lung for medical versus surgical therapy.

Fifty-one cases of small cell carcinoma of the lung were studied by electron microscopy in order to determine if ultrastructural subsets could be found and if these subsets predicted clinical behavior. All of these cases were considered bona fide small cell carcinoma of the lung by light microscopy. Tumors with ultrastructural features of epithelial differentiation were defined by the presence of well-formed, classic desmosomes joining adjacent cells and by additional features of squamous or glandular differentiation. Thirty-one tumors (60%) were considered "typical oat cell" by electron microscopy and 20 (40%) showed features of epithelial differentiation. Fifteen (75%) tumors with epithelial features were considered operable and nine (45%) were resected with curative intent. In contrast, 26 (84%) tumors considered typical oat cell by electron microscopy presented with extensive metastatic disease. The cancer-free 5-year actuarial survival rate of patients whose tumors showed features of epithelial differentiation was 25%. The actuarial survival rate of nine patients who underwent resection of tumors with epithelial features was 38% at 5 years. Only one patient whose tumor was considered typical of oat cell carcinoma by electron microscopy survived 5 years. Our current recommendation is to remove all clinically resectable pulmonary neoplasms with the expectation that these localized small cell tumors are likely to show epithelial features by electron microscopic analysis.

Survival of patients with carcinoma of the esophagus treated with combined-modality therapy.

Since 1985, 229 cases of carcinoma of the esophagus have been considered for entry into a protocol with the use of preoperative chemotherapy and radiation therapy followed by surgical intervention as the primary element of treatment. One hundred sixty-five patients (93 with adenocarcinoma and 72 with squamous cell carcinoma) had esophagogastrectomy. The 5-year survival of the protocol patients who underwent resection was 25% for both groups--squamous cell carcinoma and adenocarcinoma. Of the protocol patients with squamous cell carcinoma who underwent resection, 40% had a sterilized specimen, whereas of those with adenocarcinoma, 20% had a sterilized specimen. If the patient had a sterilized specimen, the 5-year survival was approximately 60% for adenocarcinoma and 40% for squamous cell carcinoma. Those patients with adenocarcinoma and Barrett's esophagus had a 5-year survival of 55%. Of the patients who underwent only esophagectomy and esophagogastrectomy and had not been entered into the protocol, none lived beyond 3 years. The operative mortality rate for those who had esophagogastrectomy was 5%. Sixty-four patients completed the radiation therapy and chemotherapy but did not undergo surgical procedures because of progressive disease or refusal. Of those patients who completed chemotherapy and radiation therapy without surgical intervention, 5-year survival was 18% in patients with squamous cell carcinoma, whereas no patients with adenocarcinoma survived beyond 3 years. The finding of a sterilized specimen after esophagectomy is a favorable prognostic factor in patients with adenocarcinoma or squamous cell carcinoma. The finding that patients with Barrett's esophagus and adenocarcinoma have an improved chance for survival is perhaps related to an earlier diagnosis. It is clear that some patients with squamous cell carcinoma who did not undergo surgical procedures did have a sterilized specimen, because the survival in this group approached 20% at 5 years.

Detection of primary and recurrent lung cancer by means of F-18 fluorodeoxyglucose positron emission tomography (FDG PET).

Positron emission tomography (PET), with the glucose analog F-18 fluoro-deoxyglucose (FDG), takes advantage of the enhanced glucose uptake observed in neoplastic cells. We examined whether the detection of preferential FDG uptake with PET permits differentiation between benign and malignant focal pulmonary lesions in patients with suspected primary or recurrent lung cancer. Between November 1991 and September 1993, 100 patients with indeterminate focal pulmonary abnormalities including 16 patients who had previous lung resections for cancer were prospectively studied. Tissue diagnosis was obtained by transbronchial or percutaneous biopsy (n = 49) and open biopsy or resection (n = 35). Three patients underwent extended observation (> 2 years) alone. Excluded were 13 patients lacking firm pathologic diagnoses and less than 2-year follow-up. FDG activity in the lesion was expressed as a calculated standardized uptake ratio. Mean standardized uptake ratio (+/- standard deviation) was 6.6 (+/- 3.1) in 59 patients with cancer versus 2.0 (+/- 1.6) in 28 with benign disease (p = 0.0001; unpaired t test, two-sided). With a standardized uptake ratio > or = 2.5 used for detecting malignancy, sensitivity, specificity, and accuracy were 97% (57/59), 82% (23/28), and 92% (80/87), respectively. Notably, in patients evaluated for pulmonary abnormalities after lung resection for cancer, all chest recurrences were correctly identified. The exceptional sensitivity of FDG PET demonstrates that malignant pulmonary lesions preferentially accumulate FDG, which results in a standardized uptake ratio > or = 2.5. PET may be useful for distinguishing recurrent tumor from postoperative, or postradiation, changes. If performed in all patients before open biopsy, PET increases the diagnostic yield by reducing the number of patients who have benign lesions at operation. Moreover, by lowering expenditures for hospitalization and other diagnostic procedures, FDG PET may significantly reduce health care costs.

In-hospital and long-term outcome after porcine tricuspid valve replacement.

Porcine bioprostheses are often used for tricuspid valve replacement, yet the long-term outcome after this procedure is not well documented. Therefore, the records of 129 patients undergoing tricuspid valve replacement with Carpentier-Edwards (n = 88) or Hancock (n = 41) prostheses between 1975 and 1993 were reviewed. The operation required a repeat median sternotomy in 66 of 129 (51%) patients, whereas 67 of 129 (52%) underwent double or triple valve replacement. Operative mortality was 14% (2/14) in patients undergoing first-time isolated tricuspid valve replacement and 27% (35/129) overall. Survival at 5, 10, and 14 years was 56% +/- 5%, 48% +/- 5%, and 31% +/- 9%, and freedom from tricuspid reoperation at 5, 10, and 14 years was 96% +/- 3%, 93% +/- 4%, and 49% +/- 17%. No valve thrombosis was observed. In this largest reported series of porcine bioprostheses in the tricuspid position, long-term freedom from valve-related events was excellent because of a low incidence of valve thrombosis and a valve durability of 13 to 15 years in a population with limited life expectancy.

Long-term outcome after biologic versus mechanical aortic valve replacement in 841 patients.

OBJECTIVE: The purpose of this study was to optimize selection criteria of biologic versus mechanical valve prostheses for aortic valve replacement. METHODS: Retrospective analysis was performed for 841 patients undergoing isolated, first-time aortic valve replacement with Carpentier-Edwards (n = 429) or St Jude Medical (n = 412) prostheses. RESULTS: Patients with Carpentier-Edwards and St Jude Medical valves had similar characteristics. Ten-year survival was similar in each group (Carpentier-Edwards 54% 3% versus St Jude Medical 50% 6%; P =.4). Independent predictors of worse survival were older age, renal or lung disease, ejection fraction less than 40%, diabetes, and coronary disease. Carpentier-Edwards versus St Jude Medical prostheses did not affect survival (P =.4). Independent predictors of aortic valve reoperation were younger age and Carpentier-Edwards prosthesis. The linearized rates of thromboembolism were similar, but the linearized rate of hemorrhage was lower with Carpentier-Edwards prostheses (P <.01). Perivalvular leak within 6 months of operation was more likely with St Jude Medical than with Carpentier-Edwards prostheses (P =.02). Estimated 10-year survival free from valve-related morbidity was better for the St Jude Medical valve in patients aged less than 65 years and was better for the Carpentier-Edwards valve in patients aged more than 65 years. Patients with renal disease, lung disease (in patients more than age 60 years), ejection fraction less than 40%, or coronary disease had a life expectancy of less than 10 years. CONCLUSIONS: For first-time, isolated aortic valve replacement, mechanical prostheses should be considered in patients under age 65 years with a life expectancy of at least 10 years. Bioprostheses should be considered in patients over age 65 years or with lung disease (in patients over age 60 years), renal disease, coronary disease, ejection fraction less than 40%, or a life expectancy less than 10 years.

Function of the secretory immune system in bronchogenic carcinoma. Immunoglobulin A levels in respiratory secretions.

This study was designed to investigate the association between bronchogenic carcinoma of the lung and elevated immunoglobulin A (IgA) levels in respiratory secretions. Sixty-nine patients underwent bronchoscopic examination for evaluation of benign and malignant pulmonary diseases. The concentration of IgA in bronchoscopic washings was determined by a radioimmunoassay (RIA) procedure. The average IgA concentration in 20 washings from patients with benign disease was 171 micrograms/ml and agreed with reported IgA values in normal human volunteers undergoing bronchoscopic examination. In contrast, the average IgA concentration from patients with non--oat cell bronchogenic carcinoma was greater than 1,000 micrograms/ml, and 80% of these patients had values exceeding 300 micrograms/ml. Furthermore, in 16 of these patients, selectively collected washings had been obtained from the tumor-bearing lung and contralateral normal lung. In this group, elevated levels localized to the tumor-bearing side. In contrast, eight patients with extrathoracic cancer metastatic to the chest had an average IgA value of 160 micrograms/ml, and seven of eight (87%) had concentrations below 300 micrograms/ml. Aside from the association of cigarette smoking and pulmonary cancer, we found no clear relationship between smoking history and the concentration of IgA measured in secretions. Finally, biochemical analysis established that the changes in immunoglobulin levels were specific to the secretory immune system. In conclusion, measurement of secretory immune system components may be useful in the early diagnosis of malignant bronchogenic disease. Biological mechanisms and suggested clinical application are discussed.

Comparison of survival after mitral valve replacement with biologic and mechanical valves in 1139 patients.

OBJECTIVE: We sought to compare 10-year survival in patients after mitral valve replacement with biologic or mechanical valve prostheses. METHODS: Retrospective survival analysis was performed on data from 1139 consecutive patients older than 18 years of age undergoing mitral valve replacement with Carpentier-Edwards (n = 495; Baxter Healthcare Corp, Irvine, Calif) or St Jude Medical (n = 644; St Jude Medical, Inc, St Paul, Minn) prostheses. RESULTS: The 10-year survival was not statistically different between the patients receiving Carpentier-Edwards valves and those receiving St Jude Medical valves (P =.16). Adjusted survival estimates at 2, 5, and 10 years were 82% +/- 2% (95% confidence intervals, 79%-85%), 69% +/- 2% (95% confidence intervals, 64%-73%), and 42% +/- 3% (95% confidence intervals, 37%-48%), respectively, for the Carpentier-Edwards group and 83% +/- 2% (95% confidence intervals, 80%-86%), 72% +/- 2% (95% confidence intervals, 69%-76%), and 51% +/- 3% (95% confidence intervals, 45%-58%), respectively, for the St Jude Medical group. Predictors of worse survival after mitral valve replacement are older age, lower ejection fraction, presence of class IV congestive heart failure, coronary artery disease, renal disease, smoking history, hypertension, concurrent other valve surgery, and redo heart surgery. CONCLUSION: Choice of biologic or mechanical prosthesis does not significantly affect long-term patient survival after mitral valve replacement.

Determinants of reoperation after 960 valve replacements with Carpentier-Edwards prostheses.

During the period of 1977 to 1990, 960 Carpentier-Edwards standard prostheses (Baxter Healthcare Corp., Santa Ana, Calif.) were placed in 875 operations. Freedom from reoperation at 10 years was 57% +/- 4%, 76% +/- 3%, and 95% +/- 5% for mitral, aortic, and tricuspid valve replacement, respectively. Age was the only independent determinant of reoperation for both aortic and mitral valves. Likelihood of reoperation decreased with age, with freedom from reoperation after 10 years in patients aged less than 60 years versus 60 or more years being 65% +/- 5% versus 90% +/- 4% after aortic valve replacement and 48% +/- 5% versus 75% +/- 6% after mitral valve replacement. For mitral valve replacement, larger valve size made reoperation more likely, with freedom from reoperation at 10 years being 71% +/- 6% for sizes median less than 31 mm and 57% +/- 5% for sizes 31 mm or larger. For aortic valve replacement, prior median sternotomy reduced freedom from reoperation at 10 years from 80% +/- 3% to 25% +/- 5%. The low prevalence of reoperation affirms the suitability of the Carpentier-Edwards prosthesis for selected elderly patients and for tricuspid valve replacement. Because of their influence on the probability of reoperation, valve size and prior cardiac procedures also merit consideration in the choice of valvular prosthesis.

Aortic dissection resulting from tear of transverse arch: is concomitant arch repair warranted?

Forty-seven patients with aortic dissection resulting from a primary tear located in the transverse aortic arch underwent surgical treatment. Twenty-six patients had acute type A, 7 had acute type B, 7 had chronic type A, and 7 had chronic type B aortic dissections. Of the 33 patients with acute dissections, 11 (7 acute type A and 4 acute type B) underwent concomitant arch repair with an operative (less than or equal to 30 days) mortality rate of 55% (35% to 73%, +/- 1 asymmetric 70% confidence limit) (2 of 7 acute type A and 4 of 4 acute type B). Concomitant arch repair was omitted in 22 patients with acute dissections (19 acute type A and 3 acute type B); the operative mortality rate was 41% (29% to 54%) (7 of 19 acute type A and 2 of 3 acute type B) (p = not significant versus arch repair). The overall survival rate for those with arch repair was 45% +/- 15% (+/- 1 standard error of the estimate) at 4 years, compared with 43% +/- 11% for patients without arch repair (p = not significant). Considering the type of dissection, the 4-year survival estimate for patients with acute type A dissections who underwent arch repair (5 hemiarch and 2 total arch) was 71% +/- 17% (versus 44% +/- 12% for acute type A patients without arch repair). There were no survivors among the 4 patients with acute type B dissections who had an arch repair (1 hemiarch and 3 total arch), whereas patients with acute type B dissections who did not undergo concomitant arch repair had a 4-year survival estimate of 33% +/- 27% (p = not significant versus arch repair). Four other patients with acute type B dissections resulting from an arch tear were managed medically and tended to have a slightly better prognosis (2-year survival estimate of 75% +/- 22% versus 14% +/- 13% for all surgically treated acute type B patients), but again this difference was not statistically significant. Multivariate analysis of the 47 surgical patients revealed that advanced age (p = 0.0008), preoperative dissection complications (p = 0.02), and other coexistent medical problems (p = 0.03) were the only significant, independent determinants of overall mortality. Initial arch repair was not a significant predictor. Nine percent (2/22) of patients with acute type A dissections who initially underwent isolated ascending aortic replacement required subsequent arch replacement; 1 died after reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)