Extending the use of Nuss procedure in patients older than 30 years

OBJECTIVE

The Nuss procedure was originally thought to be the method to correct pectus excavatum in children and teenagers. It is now a well-established technique, and is also used in older patients. The aim of this study was to investigate the results in patients ≥ 30 years of age.

METHODS

Since 2001, we have routinely used the Nuss procedure for correction of pectus excavatum in more than 700 patients. The indication for surgery has been disabling cosmetic appearance. All operations have been performed by the same surgeon. Patient records were retrospectively analyzed.

RESULTS

The study included fifty-two patients, who were ≥ 30 years or older (range 30-53 years), with median age 37 years; and 85% were males. There was no operative mortality. Nearly three-quarters (70%) needed two bars or more to obtain a satisfactory perioperative result. The median operating time was 60 min (range 18-104 min). The median postoperative stay was 4 days (range 3-29 days). Postoperative complications were few; one patient developed deep infection after re-operation caused by lateral dislocation of the bars.

CONCLUSION

The Nuss procedure can be used in older patients with excellent results. The operation time in their case is longer than in young patients because more patients need two bars; but the postoperative stay is equivalent to that in young patients.

Enforcing centralization for gastric cancer in Denmark

BACKGROUND

Population-based data on the early postoperative outcome after surgery for gastric cancer are very sparse. We examined the development in the quality of surgery and early postoperative outcomes in Denmark following centralization of gastric cancer surgery and implementation of national clinical guidelines.

METHODS

All patients in Denmark who underwent resection with curative intent for gastric cancer between 1st July 2003 and 31st December 2008 in one of five university hospitals were registered in a national database. Data on surgical quality and mortality were obtained from the database and compared with the results from the period before centralization (1999-2003).

RESULTS

A total of 416 patients underwent resection in the study period. The risk of anastomotic leakages for the whole period was 5.0% (95%CI; 3.2-7.7) compared to 6.1% (95%CI; 4.3-8.6) before centralization, whereas the 30-days hospital mortality was 2.4% (95%CI; 1.2-4.4) compared to 8.2% (95%CI; 6.0-10.4) before centralization. In addition, the percentage of patients with at least 15 lymph nodes removed increased during the study period from 19 in 2003 to 76 in 2008.

CONCLUSIONS

Centralization of gastric cancer surgery in Denmark and implementation of national clinical guidelines monitored by a national database was associated with improvements in surgical quality and substantially lower in-hospital mortality.

Health-related quality of life in children and adolescents undergoing surgery for pectus excavatum

INTRODUCTION

This study evaluated health-related quality of life (HRQoL) in children and adolescents undergoing cosmetic surgery for pectus excavatum (PE) compared to a group of healthy children.

METHODS

The Intervention Group consisted of 172 children and adolescents undergoing surgery for PE between 2003 and 2005, aged 8-20 years; 86% were males. A postoperative follow-up study was conducted one to three years after surgery. None of the children had had the metal bar removed when they answered the questionnaires. The Control Group consisted of healthy schoolchildren (n=387), 201 females and 186 males (9-20 years).The generic health-related quality of life questionnaires, the Child Health Questionnaire CHQ-CF87 (child version), and CHQ-PF50 (parent version) were used in both groups. A Nuss assessment questionnaire modified for Adults (NQ-mA) and a single-step questionnaire (SSQ) on quality of life and health status were only used in the Intervention Group; these questionnaires also included questions about the remembered preoperative status. The response rates in the Intervention and Control Groups were 69% and 70%, respectively.

RESULTS

The HRQol was significantly better in the Intervention Group compared to the Control Group in 9 out of 14 subscales (CHQ-CF 87): General Health (p<0.05), Physical Functioning, Self-Esteem, Emotional Role, Role Functioning-Physical (p<0.01) and Mental Health, Family Activities, Bodily Pain, Role Functioning-Behavioral (p<0.001). The scores of the children and the parents correlated well in all subscales (rho range from 0.19-0.55, p<0.05-0.001) except for the Role Functioning-Physical scale (rho=0.17). Significant differences between the parent and child scores were found in six scales. The children reported significantly lower scores in Global Behavior, Global Health, Behavior (p<0.05), Bodily Pain (p<0.01), and Mental Health (p<0.001). The parents reported significantly lower scores in the Self Esteem scale (p<0.01). Self-esteem and body concept scored significantly higher postoperatively (p<0.001) in NQ-mA and SSQ.

CONCLUSION

HRQol was significantly better in the Intervention Group compared to healthy controls at the same age. In five subscales Self-Esteem, Behavior, Emotional Role, Mental Health and Family Activities, the PE group had a better HRQoL.

Reconstruction of the thorax with Ley prosthesis after resection of the sternum

The Ley prosthesis is a titanium plate, which has been used in the past few years for sternum stabilization after postoperative mediastinitis and sternal dehiscence. There is no previous description of the use of this device in chest wall reconstruction after tumor resection. We describe the surgical technique for reconstruction of the skeletal defects with the Ley prosthesis in 3 patients operated on for a sternal chondrosarcoma. We propose the application of the Ley prosthesis for optimal reconstruction of skeletal tissue after sternal resection.

Can absorbable stabilizers be used routinely in the Nuss procedure?

OBJECTIVE

During minimal invasive surgical correction of pectus excavatum the metal bar is rotated 180 degrees and fixed by one or two stabilisers. Previously, all stabilisers were made from metal, but they often caused chronic pain and had to be removed. Recently, a slowly absorbable stabiliser made from Lactosorb has been introduced.

METHODS

From 2001 to 2008 a total of 507 patients underwent minimally invasive repair of pectus excavatum at Aarhus University Hospital. Since February 2007 we routinely used absorbable stabilisers made by Lactosorb. We always used shorter pectus bars than originally suggested and always placed one stabiliser close to the entry in the thoracic cavity on the left side. All operations were performed by the same surgeon and all patients were seen 6 weeks after surgery. Patient records were reviewed for retrospective analysis.

RESULTS

In 422 patients we used a metal stabiliser while 85 patients received a Lactosorb stabilizer. Seven patients received two stabilisers. During the follow-up period one metal stabiliser broke after 2(1/2) years (0.2%), but within 6 weeks after surgery three Lactosorb stabilizers broke (3.5%) and another three dislocated laterally (3.5%).

CONCLUSIONS

Absorbable stabilisers may be used for minimal invasive surgery for pectus excavatum but they are more vulnerable and break easier than metal stabilisers. This is likely a consequence of high stress forces that may be more pronounced in patients who receive a shorter pectus bar, but further research is needed.

Routine use of minimally invasive surgery for pectus excavatum in adults

BACKGROUND

The Nuss operation, a minimally invasive repair of pectus excavatum, is considered the treatment of choice in children. It is controversial in adults, but smaller series have been published. We have used the Nuss operation routinely in adults since 2003.

METHODS

The indication for operation was a patient-described disabling cosmetic appearance. We modified the operation by using a shorter pectus bar, which appears to be more stable. All patient records were available and analyzed retrospectively.

RESULTS

Operations for pectus excavatum were done in 475 patients (89% men) at Aarhus University Hospital. 180 patients (38%) were aged 18 years or older, median patient age was 22 years (range, 18 to 43 years). All but one patient achieved an excellent cosmetic result. Two pectus bars were required in 57 patients (32%), and 2 patients required 3 pectus bars. The median duration of the procedure was 41 minutes (range, 16 to 119 minutes), which was significantly longer compared with younger patients, but the difference was not clinically relevant (6 minutes). Pneumothorax occurred in 86 patients (48%), but only 4 (2%) required chest tube drainage. In 3 patients the pectus bar dislocated during follow-up.

CONCLUSIONS

Minimally invasive repair for pectus excavatum can be performed safely in adults, with excellent immediate cosmetic results. Adults often require more than 1 pectus bar. From the results of this large series, we conclude that patients aged younger than 50 years are eligible for minimally invasive surgical correction of pectus excavatum.

[Surgical correction of pectus carinatum]

INTRODUCTION

Pectus carinatum (PC) is a protrusion of the sternum due to overgrowth of the costal cartilages. It can have considerable psychological and somatic impact on the patient. Many physicians are unaware of the beneficial effects and low comorbidity related to surgical correction and therefore erroneously advise patients against the operation.

MATERIALS AND METHODS

We report the preliminary experience with 26 consecutive patients operated for PC at our Department between 1 April 2006 and 1 April 2007. Surgery was performed by a modified Ravitch and Welch technique. The mean age was 15 years (13-21), and 92% of the patients were boys.

RESULTS

We obtained excellent cosmetic results in the majority of patients (92%), no major complications, no major pain complaints and short hospital stays for all patients.

CONCLUSION

Patients who are psychologically or physically impaired by this deformity should be referred for surgical evaluation.

Management of facial blushing

Patients complaining of facial blushing should be investigated by a dermatologist or an internist to rule out serious underlying disorders. Patients with emotionally triggered blushing should be encouraged to try nonsurgical options as the first line of treatment. Provided there is still an indication for treatment, facial blushing may be treated effectively by thoracoscopic sympathectomy. The type of blushing likely to benefit from sympathectomy is mediated by the sympathetic nerves and is the uncontrollable, rapidly developing blush typically elicited when one receives attention from other people. Side effects are frequent, but most patients are satisfied with the operation. In the short term, the key to success in sympathetic surgery for facial blushing lies in a meticulous and critical patient selection and in ensuring that the patient is thoroughly informed about the high risk of side effects. In the long term, the key to success in sympathetic surgery for facial blushing lies in more quality research comparing surgical, pharmacologic, and psychotherapeutic treatments.

Thoracoscopic sympathectomy for axillary hyperhidrosis: the influence of T4

BACKGROUND

Recent data suggest that severe compensatory sweating after sympathectomy for hyperhidrosis is more common than previously reported. In particular, T2-T4 sympathectomy for axillary hyperhidrosis leads to significantly more disabling sweating compared with T2-T3 sympathectomy for palmar hyperhidrosis. However, it is not known whether this is a result of the additional transection of the T4 segment or if patients with primary axillary hyperhidrosis are more prone to experience disabling compensatory sweating.

METHODS

A follow-up study by questionnaire was made of 100 consecutive patients who underwent thoracoscopic sympathectomy for axillary hyperhidrosis at two university hospitals. Patients underwent T2-T3 sympathectomy (n = 35) or T2-T4 sympathectomy (n = 65) depending on the surgeon's preference.

RESULTS

The questionnaire was returned by 91% of patients after a median of 31 months. Compensatory sweating occurred in 90% of patients and was so severe in 61% that they often had to change clothes during the day. There were no significant differences in occurrence or severity of compensatory sweating between the two extents of sympathectomy. Surgical outcome, however, was significantly better after T2-T4 sympathectomy.

CONCLUSIONS

In contrast with previous reports, the incidence of compensatory sweating was not significantly related to the extent of sympathectomy for axillary hyperhidrosis. This result suggests that patients with primary axillary hyperhidrosis are more prone to experience compensatory sweating. Although the majority of patients with axillary hyperhidrosis were satisfied after thoracoscopic sympathectomy, many regret the operation. Patients should undergo surgery only if medical treatments fail; and provided there is an indication, we recommend T2-T4 sympathectomy.

Thoracoscopic Sympathectomy for Isolated Facial Blushing

BACKGROUND

Facial blushing is one of the most peculiar of human expressions and has become a cardinal symptom of social phobia. The pathophysiology is unclear and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom, but very few surgeons treat patients with isolated facial blushing. The literature is limited, and there are few long-term follow-up studies.

METHODS

A follow-up study by questionnaire in 180 consecutive patients who underwent thoracoscopic sympathectomy for isolated facial blushing at two Danish university hospitals during a 6-year period. Patients routinely underwent T2 sympathectomy at the university hospital in Aarhus (n = 101) and T2-T3 sympathectomy at the university hospital in Odense (n = 79).

RESULTS

The questionnaire was returned by 96% of the patients after a median follow-up time of 20 months. Overall, 90% of the patients had some effect from the operation, and the result was excellent or satisfactory in 75%. There was no significant difference between the two extents of sympathectomy. Compensatory sweating occurred in 88% of all patients and was significantly more frequent after T2-T3 sympathectomy (p = 0.02) Ten percent of our patients regretted the operation because of side effects or no effect of the operation.

CONCLUSIONS

This study demonstrates that thoracoscopic sympathectomy is an effective treatment for isolated facial blushing. The majority of patients achieve an excellent or satisfactory long-term result. Our results suggest that a T2 sympathectomy is superior for patients with isolated facial blushing because side effects are lower compared with a T2-T3 sympathectomy.

Intracellular smooth muscle [Ca2+] in acetylcholine and nitric oxide-mediated relaxation of human small arteries

In human resistance arteries the role of intracellular calcium during receptor agonist and nitric oxide (NO)-mediated vasorelaxation is almost unknown. We examined changes in smooth muscle calcium concentration ([Ca2+]i) caused by acetylcholine and the NO donor S-nitroso-N-acetylpenicillamine (SNAP) in isolated human subcutaneous small arteries. In arteries constricted with 50 mM KCl, acetylcholine and SNAP induced relaxation without any change in [Ca2+]i, whereas in noradrenaline constricted vessels, both acetylcholine and to a lesser degree also SNAP-mediated relaxation were associated with a decrease in [Ca2+]i. Furthermore incubation with SNAP (1 microM) induced a rightward shift in the [Ca2+]i-force relationship. These results suggest that relaxation mediated by endothelium derived hyperpolarizing factors (EDHF) is associated with reduction in [Ca2+]i, whereas NO-mediated relaxation can take place without changes in [Ca2+]i. This finding seems to be, at least partly, due to NO-mediated desensitization of the contractile apparatus to calcium.

Gustatory Side Effects After Thoracoscopic Sympathectomy

BACKGROUND

Compensatory sweating is a frequent side effect after thoracoscopic sympathectomy for primary hyperhidrosis. Gustatory sweating is less commonly reported. It is defined as facial sweating when eating certain foods (particularly spicy food or acidic fruits) and has no generally accepted pathophysiologic explanation. We decided to investigate this phenomenon in patients who underwent thoracoscopic sympathectomy for primary hyperhidrosis and analyze whether the occurrence was influenced by the extent of sympathectomy.

METHODS

During an 8-year period (1997 to 2005) a total of 238 patients were treated by thoracoscopic sympathectomy for primary hyperhidrosis or blushing. Sympathectomy was performed bilaterally at T2 for facial hyperhidrosis or blushing (n = 97), T2-T3 for palmar hyperhidrosis (n = 76), and T2-T4 for axillary hyperhidrosis (n = 65). All patients received the same questionnaire at follow-up.

RESULTS

The questionnaire was returned by 96% of patients after a median of 17 months. Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating.

CONCLUSIONS

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.

Severity of compensatory sweating after thoracoscopic sympathectomy

BACKGROUND

Compensatory sweating is a well-known side effect after sympathectomy for hyperhidrosis. It is often claimed to correlate with the extent of sympathectomy, but results from the literature are conflicting, and few have actually considered differences in the intensity of compensatory sweating.

METHODS

A total of 158 patients underwent thoracoscopic sympathectomy for primary hyperhidrosis or blushing, or both. Sympathectomy was performed bilaterally at Th2 for facial hyperhidrosis/blushing (n = 49), Th2-3 for palmar hyperhidrosis (n = 62), and Th2-4 for axillary hyperhidrosis (n = 47).

RESULTS

Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation.

CONCLUSIONS

Compensatory and gustatory sweating were remarkably frequent side effects after thoracoscopic sympathectomy for primary hyperhidrosis. We found no significant difference between the level of sympathectomy and the occurrence of compensatory sweating. However, it appears that this is the first study to demonstrate that severe sweating is significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis. We encourage informing patients thoroughly about these side effects before surgery.

[St Jude's bi-leaflet aortic valve prosthesis throughout two decades. Quality profile and risk factors]

INTRODUCTION

The St Jude standard aortic bi-leaflet disc valve is still the most widespread. With almost 20 years of follow-up, the present material may describe the quality profile of the valve and the relevant risk factors throughout the remainder of most patients' lives.

MATERIAL AND METHODS

A 100% complete follow-up was conducted of 694 adult patients who had an aortic valve replacement with the St Jude valve during 1980-1993. The Cox regression analysis was used to identify independent risk factors.

RESULTS

Survival was 79%, 58%, 39%, and 37% at 5, 10, 15, and 18 years, respectively. Only 12% of the deaths (0.60%/patient-year) were valve-related with a 15-year freedom of 91%. Embolism (1.18%/patient-year) and anticoagulant-related bleeding (2.24%/patient-year) were the dominant complications with 15-year freedoms of 80% and 72%. Valve thrombosis was noted in two patients (0.04%/patient-year) who were off anticoagulation. Mechanical failure was not observed. Endocarditis (0.42%/patient-year) had a 15-year freedom of 92% compared with 72% and 54%, respectively, for major valve (2.33%/patient-year) and all valve-related complications together (4.33%/patient-year) and 96% for aortic valve reoperation (0.36%/patient-year). Age of the patient and heart-related variables were identified as independent risk factors for mortality and valve-related complications.

CONCLUSION

With a follow-up of almost two decades showing a low incidence of valve-related deaths, acceptable thrombogenicity, and absence of mechanical failure, the St Jude bi-leaflet aortic disc valve sets the standard for contemporary mechanical valves.

Self-management of oral anticoagulant therapy for mechanical heart valve patients

OBJECTIVE

Self-management of oral anticoagulant therapy (OAT) has shown good results on a short-term basis. We hypothesize that self-management of OAT provides a better quality of treatment than conventional management also on a long-term basis. The aim of this study was to assess the quality of self-management of OAT in patients with mechanical heart valve prostheses on a 4-year perspective in a prospective, non-randomized study.

DESIGN

Twenty-four patients with mechanical heart valves and on self-managed OAT were followed for up to 4 years. A matched, retrospectively selected group of conventionally managed heart valve patients (control group) was used as reference.

RESULTS

The median observation time was 1175 days (range: 174-1428 days). The self-managed patients were within therapeutic INR target range for a mean of 78.0% (range: 36.1%-93.9%) of the time compared with 61.0% (range 37.4%-2.9%) for the control group.

CONCLUSION

Self-management of OAT is a feasible and safe concept for selected patients with mechanical heart valve prostheses also on a long-term basis. It provides at least as good and most likely better quality of anticoagulant therapy than conventional management assessed by time within the therapeutic International Normalized Ratio (INR) target range.

Standard aortic St. Jude valve at 18 years: performance profile and determinants of outcome

BACKGROUND

The standard St. Jude disc valve has been in use for 20 years and remains the dominant mechanical valve of today. With nearly 19 years of follow-up, the present large series could indicate the performance profile and its determinants in the very long term.

METHODS

A detailed follow-up was performed to a maximum of 18.6 years in 694 patients aged 15 to 83 years who undervent aortic valve replacement (AVR) with the standard St. Jude valve during 1980 to 1993. The Cox regression analysis was used to identify independent determinants of outcome in the aortic stenosis (n = 490) and regurgitation (n = 204) groups.

RESULTS

Overall survival was 58%, 39%, and 37% at 10, 15, and 18 years, respectively. Only 12% of deaths (0.60%/ patient-year) were related to the valve with a 15-year freedom of 91%. Embolism (1.18%/patient-year) and anticoagulant-related bleeding (2.24%/patient-year) were the dominant complications with 10-year/15-year freedoms of 90%/80% and 85%/72%, respectively. Only 24% of bleeding events were classified as major. Valve thrombosis occurred in 2 patients (0.04%/patient-year): 1 did not receive vitamin K antagonist treatment and International Normalized Ratio was below target level in the other. There were no mechanical failures. Endocarditis (0.42%/patient-year) and paravalvular leak (0.42%/ patient-year) occurred with 15-year freedoms of 92% and 96%, respectively, with a relation between the latter (but not the former) and preoperative endocarditis in the regurgitation group. Freedom from serious complications (2.33%/patient-year) and all complications joined (4.33%/ patient-year) were 72% and 54%, respectively, at 15 years with a 96% freedom from redo AVR (0.36%/patient-year). Age- and heart-related variables were independent risk factors for mortality, thromboembolism, bleeding, serious complications, and all complications joined. Small valve (19 and 21 mm) adversely affected serious and all complications in the regurgitation group.

CONCLUSIONS

With a follow-up approaching 2 decades and exhibiting a low rate of valve-related deaths, acceptable low thrombogenicity, and absence of mechanical failure, the standard aortic St. Jude disc valve sets the standard for contemporary mechanical valves.

Nitric oxide, prostanoid and non-NO, non-prostanoid involvement in acetylcholine relaxation of isolated human small arteries

The main purpose of the study was to clarify to which extent nitric oxide (NO) contributes to acetylcholine (ACh) induced relaxation of human subcutaneous small arteries. Arterial segments were mounted in myographs for recording of isometric tension, NO concentration and smooth muscle membrane potential. In noradrenaline-contracted arteries, ACh induced endothelium-dependent relaxations. The NO synthase inhibitor, N(G)-nitro-L-arginine (L-NOARG) had a small significant effect on the concentration-response curves for ACh, and in the presence of L-NOARG, indomethacin only caused a small additional rightward shift in the ACh relaxation. The NO scavenger, oxyhaemoglobin attenuated relaxations for ACh and for the NO donor S-nitroso-N-acetylpenicillamine (SNAP). Inhibition of guanylyl cyclase with 1H-[1,2,4]oxadiazolo[4,3-a]quinoxaline-1-one (ODQ), and inhibition of protein kinase G with beta-phenyl-1, N2-etheno-8-bromoguanosine- 3', 5'- cyclic monophosphorothioate, Rp-isomer, slightly attenuated ACh relaxation, but abolished SNAP induced relaxation. ACh induced relaxation without increases in the free NO concentration. In contrast, for equivalent relaxation, SNAP increased the NO concentration 32+/-8 nM. ACh hyperpolarized the arterial smooth muscle cells with 11.4+/-1.3 mV and 10.5+/-1.3 mV in the absence and presence of L-NOARG, respectively. SNAP only elicited a hyperpolarization of 1.6+/-0.9 mV. In the presence of indomethacin and L-NOARG, ACh relaxation was almost unaffected by lipoxygenase inhibition with nordihydroguaiaretic acid, or cytochrome P450 inhibition with 17-octadecynoic acid or econazole. ACh relaxation was strongly reduced by the combination of charybdotoxin and apamin, but small increments in the extracellular potassium concentration induced no relaxations. The study demonstrates that the NO/L-arginine pathway is present in human subcutaneous small arteries and to a limited extent is involved in ACh induced relaxation. The study also suggests a small contribution of arachidonic acid metabolites. However, ACh relaxation is mainly dependent on a non-NO, non-prostanoid endothelium dependent hyperpolarization. British Journal of Pharmacology (2000) 129, 184 - 192

Performance profile of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve

OBJECTIVE

The Starr-Edwards aortic ball valve has passed 30 years of clinical follow-up. A detailed account of the long-term performance from a large series could thus give valuable guidance in managing patients who are still alive, depict the total remaining life-span after aortic valve replacement (AVR) for the average patient, and set a record yet to be matched by modern disc valves.

METHODS

A detailed follow-up to a maximum of 31.1 years was performed for 717 patients who underwent their first AVR during 1965-1993 with a Starr-Edwards silastic ball valve (N = 355), a cloth covered valve (N = 164) or a track valve (N = 198) with a total of 7254 patient-years at risk.

RESULTS

Patients who received a silastic ball valve were older (average 60 vs. 58 years), had more endocarditis (9%) and more secondary kidney failure (24%) preoperatively than the other patients. The three valve types did not differ as regards long-term survival or freedom from complications and only 15% of late deaths were related to the valve. For the silastic ball valve cumulative freedoms at 10 and 25 years were 59 and 20% from all deaths (crude survival), 85 and 80% from thromboembolism, 87 and 70% from bleeding, 98 and 94% from endocarditis, 96 and 95% from redo AVR and 68 and 51% from all valve related complications joined. There were no instances of structural failure apart from wear of the cloth covering the cage struts of the cloth covered valves. Incidences of haemolysis (0.10%/patient-year) and valve thrombosis (0.06%/patient-year) were low for the silastic ball valve. Analysis of relative survival for the silastic ball valve indicated excess mortality relative to a matched background population only during 1st and 13th postoperative year. Apart from heart related factors and age, independent incremental risk factors for mortality and the various complications included, not valve type, but valve size index (valve size divided by body surface area) < or = 13 mm/m2.

CONCLUSIONS

The Starr-Edwards aortic ball valves, not least the currently available silastic ball valve, are durable through the remaining life time of the patients and able to secure near normal age and sex specific survival provided valve and patient size mismatch is avoided.

[Self management of peroral anticoagulant therapy in patients with artificial heart valves]

Twenty-one heart valve operated patients (age 19-70 years) were trained in self-managed oral anticoagulant therapy using a home coagulometer (CoaguChek). Twenty patients accomplished between eight and 29 (median 24) months of self management and were fully capable of self management after 30 weeks of training. No patients experienced major bleeds or thrombo-embolic events. A control group of 20 patients from our department was matched, retrospectively, to the study group. The self-managing patients were within the therapeutic INR range 78% of the study period compared to 54% for the control patients. All self-managing patients had their median INR-value within the therapeutic range, versus only 14 in the control group. Self-management of oral anticoagulant therapy seems feasible for selected patients.