Intraoperative flow measurement of native coronary artery can help decision making before CABG

We report the case of a patient with three-vessel coronary artery disease whose right coronary artery had been stented at the time of the diagnostic procedure. He had recurrent angina 12 days later and was transferred for urgent coronary artery bypass grafting. No repeat coronary angiography was performed. In the operating room, the flow on the native right coronary artery was determined with an ultrasonic flow probe.

Bi-directional cavopulmonary shunt: is accessory pulsatile flow, good or bad?

OBJECTIVE

Evaluation of the effect and long-term outcome of accessory pulsatile blood flow versus classical bi-directional cavopulmonary connection (BCPC).

METHODS

Retrospective review of the medical and surgical records.

RESULTS

Two-hundred and five patients (119 boys, 86 girls) underwent BCPC from 1990 to 1996. Accessory pulsatile flow was present in 68%, flow being maintained through the pulmonary trunc in 46%, systemic-to-pulmonary artery shunt in 13% and mixed in 7%, or patent ductus arteriosus in 2%. Patients with accessory pulsatile flow had lower hospital mortality (3% versus 5%), while mean pulmonary artery pressure (14.1 versus 12.6 mmHg P = 0.050) and increase of oxygen saturation (12.4 versus 8.7, P = 0.034) were significantly higher. The period of artificial ventilation (1.9 day) and ICU stay (6 days) did not differ for both groups. Late mortality was higher following accessory pulsatile flow (6% versus 1%). At late follow-up patients with accessory pulsatile flow had significantly higher oxygen saturation (mean 85 +/- 4%, versus 79 +/- 4%; P < or = 0.005). If subsequent completion of Fontan is considered the optimal palliation and subsequent systemic to pulmonary artery shunt, arteriovenous fistula and transplantation is considered a failure, patients with accessory pulsatile flow had significantly more and earlier completion of the Fontan procedure (mean 1.7 +/- 2.4 years, versus 2.7 +/- 4.4 years; P = 0.008). Survival is not influenced by age at bi-directional cavopulmonary shunt surgery, left or right functional ventricular anatomy or previous palliative surgery. One patient with accessory pulsatile flow developed systemic-to-pulmonary collateral's eventually requiring lobectomy.

CONCLUSION

Despite two different initial palliative techniques the outcome was not significantly different. Accessory pulsatile blood flow appeared not to be a contra-indication for a completion Fontan procedure. Moreover, the data suggest that after accessory pulsatile flow can safely be performed, at late follow-up oxygen saturation is higher, while, significantly more and earlier completion of Fontan occurred. Age at bi-directional cavopulmonary shunt, basic left or right ventricular anatomy or previous palliative surgery did not influence survival.

Pro- and anti-inflammatory cytokine patterns during and after cardiac surgery in young children

The systemic inflammatory response that occurs after cardiopulmonary bypass shows many changes similar to those seen in sepsis. The mechanisms for these changes have been attributed to cellular and humoral activation, such as increased secretion of cytokines and complement. The aim of our study was to investigate the cytokine pattern of pro- and anti-inflammatory cytokines in young children during and after bypass surgery. Nineteen children undergoing either septal defect correction (n = 12), or more complex surgery (n = 7), were prospectively included in this study. There were significant higher pre-operative levels of circulating cytokines in the latter group. Cardiopulmonary bypass surgery induced in both groups a rise in circulating cytokine levels and a sharp decline in the capacity of the leucocytes to secrete interleukines-6 and -8 in response to ex vivo stimulation with lipopolysaccharide. Ex vivo production of interleukine-1 receptor antagonist was slightly attenuated by the procedure.

CONCLUSIONS

The downregulation of ex vivo pro- and, to some extent, anti-inflammatory cytokine production may be a reflection of a cellular stress response, induced by anaesthesia, cardiopulmonary bypass and surgery.

Tetralogy of Fallot with absent pulmonary valve. A continuing challenge

Absent pulmonary valve syndrome (APVS); the combination of tetralogy of Fallot (TOF) with agenesis of the pulmonary valve, is a relatively rare cardiac malformation. Despite the anatomic similarity with classic TOF, the pathophysiology is strikingly different. Data on 10 patients (3 male, 7 female) with APVS, treated between January 1978 and December 1995, were retrospectively reviewed. During this period a total of 2920 children underwent correction of a variety of congenital cardiac anomalies, of which 246 patients (8%) had a correction for TOF. Two patients with APVS presented within the first four months of life with severe cardiorespiratory distress and required several operative procedures. The remaining eight patients had only mild to moderate respiratory and/or cardiac symptoms and elective intracardiac repair was performed on those between the ages of 10 months and 9.5 years. Associated cardiac anomalies seen in five patients included aberrant coronary artery, absent or interrupted left pulmonary artery, partial AVSD and aberrant azygos continuation. In those electively corrected, the strategies used were ventriculotomy (7), pulmonary homograft (3) and aneurysmorrhaphy (2). There were two deaths, one in each group of patients, as a result of progressive respiratory insufficiency and cardiac tamponade, respectively. The follow-up of the eight survivors ranged from 2 to 11 years (median 6.75). All have a normal effort tolerance; only one child is on digoxin therapy, and one child continues to suffer bronchospastis episodes. Our experience with infants with this lesion is limited but underlines the different approaches required, depending on the age of presentation.

Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery

OBJECTIVES

Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication.

METHODS

From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function.

RESULTS

Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1-17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1-60 days (mean 4 days) after plication. Mean follow-up was 19 +/- 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months.

CONCLUSION

Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay.

Cardiac surgery by transxiphoid approach without sternotomy

OBJECTIVE

In a attempt to avoid the potential drawbacks associated with sternotomy coupled with a desire for a smaller scar led us to investigate the transxiphoid approach without sternotomy. We present our preliminary experience and a comparison between the sternal and thoracic approaches.

METHODS

From June 1996, at the Institut Cardiovasculaire Paris Sud, Massy, France (ICPS) and the Heart Institute, Sao Paulo, Brazil (HI) the transxiphoid approach was adopted for the correction of selected congenital cardiac defects. The xiphoid was resected through a 6 cm long vertical skin incision. With a special retractor the sternum was elevated cephalad and anteriorly. Closure of the defect was performed in the conventional manner. Twenty-six patients; 17 boys and 9 girls were entered into the study from representing 19 atrial septal defects (ASDs), 4 ventricular septal defects (VSDs) and 3 partial atrio ventricular septal defect (AVSDs). In addition at ICPS the transxiphoid approach for correction of ASD was compared to the thoracic and sternal approaches performed in the same period.

RESULTS

Both the aortic cross clamp time as well as the duration of extracorporeal circulation were increased when compared to either standard sternotomy or thoracotomy approaches. There were no differences within the groups when comparing body surface area, amount of chest drainage or length of either ICU or hospital stay. However the patients in the transxiphoid group showed less pain and respiratory discomfort.

CONCLUSION

Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort and a potentially lower risk of infection. However cardiopulmonary bypass and cross clamp times are increased. There were no complications, and patient satisfaction was high.

Survival of a neonate after myocardial infarction complicated by late mitral regurgitation

A neonate born with a normal heart developed acute myocardial infarction at 12 days of age. Trivial mitral regurgitation secondary to fibrosis of posteromedial papillary muscle progressed to heart failure at 6 months of age. Mitral valve annuloplasty improved her condition.

Late re-interventions following arterial switch operations in transposition of the great arteries. Incidence and surgical treatment of postoperative pulmonary stenosis

Seventy-six patients were studied after arterial switch operation (ASO) between May 1977 and February 1992. Pulmonary artery reconstruction was initially performed by: conduit interposition in 5 patients, direct main pulmonary artery anastomosis and button patches in 60 patients, and pantaloon-like patch repair in 11 patients. Pulmonary stenosis developed in 17 patients (22%), requiring a total of 26 late re-interventions. Re-intervention was required in four out of five patients operated with pulmonary artery conduits, 11 out of 60 with a button patch repair and 2 out of 11 following pantaloon-type repair. In this series pulmonary artery stenosis (PS) involving the pulmonary valve occurred in 9/17 patients. Involvement of the pulmonary valve was related to the technique of pulmonary artery reconstruction. In these patients surgery is necessary. Balloon angioplasty can be a valuable tool when the stenosis is more distal. The incidence of PS was not influenced by the type of reconstruction or the use of Lecompte's maneuver.

The modified Senning operation for cavopulmonary connection with autologous tissue

A modified Senning technique was used for intraatrial channeling of the systemic venous blood into the pulmonary arteries to create a Fontan circulation in 26 children, six with tricuspid atresia and 20 with complex congenital heart disease. In this technique a flap of atrial free wall tissue is used to create an atrial tunnel without artificial material. Eight patients had subaortic stenosis and required a Damus-Kay-Stansel procedure, in addition. Early mortality was two of 26 and late mortality one of 26. Pleural effusion was encountered in 17 of 26 patients, of whom four had a pericardial effusion, in addition. One patient required pacemaker implantation for complete atrioventricular block. Follow-up ranged from 2 months to 5 years. In this period the ability level index rose by one level. No thrombi were encountered in the right atrium/cavopulmonary tunnel. One patient required antiarrhythmic medication. Protein-losing enteropathy was diagnosed in one patient.

CONCLUSION

This modified Senning technique has the advantage of avoiding the use of prosthetic material in the creation of a Fontan circulation and the potential for fewer long-term complications.

Multiple primary lung cancers

Between 1970 and 1990, of 1287 patients undergoing resection for primary lung cancer, we considered 55 (4.3%) to have a second primary lung cancer, being synchronous in 15 cases (1.2%) and metachronous in 40 (3.1%). Two patients had a third primary lung cancer. The 15 patients with synchronous cancers were all treated surgically: ten underwent a two-stage procedure and 5 patients a one-stage. In 6 patients the cancers were located bilaterally and in 4 patients both synchronous cancers had a different histology. There were 3 postoperative deaths (20%). The 3- and 5-year actuarial survival rates were 26% and 15%. Of the 40 patients with metachronous cancers the mean interval between treatment of their first and second cancer was 5 years and 11 months. It was longer for the 21 patients having a contralateral second localization (7 years) than for those having an ipsilateral localization (4 years). There was no dependence of the intervals on whether or not the second cancer had the same histology as the first cancer. In 7 patients the second cancer was treated by chemo- and/or radiotherapy and in 33 patients by surgery. There were 5 postoperative deaths in this group (15.2%). The 3- and 5-year actuarial survival rates were 33% and 18%. For 25 patients with a stage I or II second cancer these rates were 42% and 27%; all 8 patients with a stage III second cancer died within 14 months. Survival was positively affected by: histological type differing between both cancers, an interval of more than 3 years, a bilateral localization, and a stage I or II second cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary venous obstruction following correction for total anomalous pulmonary venous drainage: a challenge

Pulmonary venous obstruction after surgical correction of total anomalous pulmonary venous drainage (TAPVD) is a serious condition. Pulmonary venous obstruction can be the result of a primary developmental error or is due to post-operative anastomotic stricture and is usually manifest within 6 months of surgery. Prompt restudy is indicated and if a stricture is present, urgent surgical relief is indicated. However, the results are often disappointing with a high early mortality and a significant chance of restenosis.

Cardiac myxoma: the grand masquerader

Cardiac myxoma is the most common primary tumor of the heart. A high suspicion of this potentially lethal disease is warranted because it may mimick a large variety of diseases. Two patients with different symptoms and signs are presented, in whom resection of the tumor was successful. Complete resection of the tumor is the only effective method of treatment.

[Purulent pericarditis in children. A continuously life-threatening disease]

Acute purulent pericarditis in children is usually fatal, if not recognized and adequately treated. The history of three children with acute purulent pericarditis is presented. In every septic child who presents with signs of right heart decompensation, acute purulent pericarditis should be seriously considered. Echocardiography is essential for the diagnosis. If possible, diagnostic pericardiocenthesis should be performed. Experience of the last years suggests that excellent results can be obtained when adequate surgical drainage and antibiotic therapy are combined.

[Aortopulmonary window. The need for early surgical correction]

The diagnosis of aortopulmonary window may be problematical. In 7 patients who had undergone operative closure of an aortopulmonary window the diagnostic and operative techniques, the operative findings, and the postoperative course were retrospectively determined. It appeared that the diagnosis is difficult and that cardiac catheterization with angiocardiography is the most accurate diagnostic technique. Good results of operative correction depend on the timing of the operation (preferably before the first year of life), the operative technique, and the severity of additional anomalies of the heart and great vessels. Delay of surgical correction leads to pulmonary hypertension, caused by irreversible pulmonary vascular disease.

[2 successful treatments with extracorporeal membrane oxygenation in neonates with severe respiratory problems]

We report the successful treatment with extracorporeal membrane oxygenation of two Dutch neonates with severe respiratory insufficiency, due to meconium aspiration syndrome and persistent fetal circulation respectively. During this procedure part of the cardiac output is led outside the body via a venous cannula in the right atrium, oxygenated in a membrane oxygenator, rewarmed to the patient's body temperature in a heat exchanger and returned to the patient via a cannula in the carotid artery debouching into the aortic arch.

Postponing the limits. Multiple and repeated pulmonary metastasectomy by parenchym sparing electrocautery excision

Due to the continuous improvement and effectiveness of the chemotherapeutics, the role of the surgical resections of metastases is changing. In the period 1954-1975 we removed from 35 patients 48 metastases, in the period 1976-1985 from 45 patients 102 metastases, while in the period 1986-1989 from 47 patients 200 metastases were removed. The ratio of 1.3 metastasectomy per patient in the first group is corresponding to the 4.5 ratio metastasectomies in the last group. The number of classical lobectomies decreased in favour of the segmental and wedge resections. Based on the case histories of non seminomatous testis tumors, finally an extraanatomical resection of the metastases minimizing all unnecessary waste of functional lung parenchyma became an obvious consequence of this development. Since 1986 we adapted and used the technique of extraanatomical pulmonary resections by electrocautery 92 times. It appeared that appropriate use the cutting and coagulating modality of electrocautery offers a safe, easy, fast, highly efficient and selective tool to divide and distinguish the normal lung parenchyma from the bronchial, vascular and pathologic structures. The cautery condensed surface of the remaining parenchyma is not difficult to control for hemostasis and air leakage and can be easier sutured. In case of doubts or deep intrapulmonal defects the fibrin glue (Tissucol) offers an extra security by sealing the irregular of large defects. The microscopical examination can distinguish on the specimen a thin layer of intact lung parenchyma. The surface of this--similar of the surface of the remaining resection plane--shows a "sealed membrane" of cauterized alveoli, bronchioli or vessels.

Morphology of pulmonary atresia with intact ventricular septum in patients dying after operation

In 1976, we adopted staged surgical management of pulmonary atresia with intact ventricular septum: stage 1 = establishment of a systemic to pulmonary artery shunt; stage 2 = open reconstruction of the right ventricular outflow tract and pulmonary valve; and stage 3 = closure of the shunt and interatrial communication. The morphological features of nine specimens obtained from 10 patients who died were reviewed. Special attention was given to features that might have influenced the poor surgical outcome in these patients. Survival after stage 1 depends on adequate systemic to pulmonary artery blood flow, initially as a combination of ductus arteriosus and shunt flow, with subsequent modification if the ductus closes. After stage 2, survival is influenced by left ventricular function and mitral valve function. The success of final correction (stage 3) depends largely on the morphology of both ventricles and their atrioventricular valves. It appears that the behavior of the ductus arteriosus and the size of the shunt are of vital importance for the survival of the infant. In 3 of the specimens, no right ventricular outflow tract was present, and in 2 others, short chordal attachments of the mitral valve were observed. Staged surgical correction appears to be a satisfactory approach if these considerations are taken into account.

Rupture of the supradiaphragmatic inferior vena cava by blunt decelerating trauma: case report

Lacerations of the inferior vena cava resulting from blunt external trauma are relatively rare, but extremely serious. The high lethality is due to the difficulty in diagnosis and technical problems with repair, particularly if the injury is located above the renal veins. During a 12-month period seven patients with inferior vena cava laceration were seen, of whom two presented with laceration of the inferior vena cava above the diaphragm. Both had a deceleration injury while wearing seatbelts. The clinical presentation was similar. The etiology is discussed. Caval continuity should be repaired because acute sudden occlusion at the suprahepatic level is incompatible with survival. Median sternotomy is advised, moreover it provides good exposure for eventual cannulation.

Perioperative morbidity and mortality of coronary artery surgery after the age of 70 years

The aim of this study was to compare the actual perioperative (operative and hospital) morbidity and mortality of coronary bypass surgery in patients aged 70 years or older and patients aged 69 years of younger. From January 1987 to September 1988, 102 patients aged 70 years or older underwent isolated aortocoronary bypass surgery. They were compared with the younger patients operated in the same period. Preoperative, operative and postoperative data were analyzed. There was no significant difference between the mortality and morbidity of the two groups. Morbidity was evaluated according to several parameters, low cardiac output, prolonged ventilation, cerebrovascular accident, transient ischemic attacks, pulmonary problems, psychosis, renal failure, wound problems and reoperations. Because this is a limited experience it may be premature to conclude than older patients can be operated on as safely as their young counterparts, but this study shows that age is not in itself a risk factor.

Surgical treatment of multiple primary lung cancers

Multiple primary lung cancers are now being recognized more frequently. Out of 1004 patients with a resected lung cancer, 32 (3.2%) presented a second primary and two of them a third primary lung cancer. A synchronous (S) primary was present in 7 and a metachronous (M) primary was present in 25. The histology was different in 1/7 with a S. and in 6/25 with a M. cancer. In all cases the cancer was located in another segment, lobe or lung. Out of the 7 with a S. cancer, 3 had a one stage and 4 a staged resection; out of the 25 with a M. cancer, 3 were treated by chemotherapy, 22 had a 2nd and 1 a 3rd operation to remove a new cancer. The mean time interval in M. cancer was 4 years, 8 months and was longer for adeno- (8 years) than for squamous cell carcinomas (4 years), longer for a contralateral cancer (6 years, 7 months) and longer for mild smokers (5 years, 1 month). The early mortality (10.3%) was 0/7 for S. and 3/22 for M. cancers. The three and five years actuarial survival of operated patients was 67% and 25% for S. and 43% and 31% for M. cancers. Survival is positively affected by a resection interval of more than 3 years and by 3 instead of 2 remaining lobes after the second resection. In conclusion a close follow-up of operated lung cancer patients is necessary and aggressive surgical approach is indicated for a new primary cancer.

Diagnosis and management of the coronary-subclavian steal syndrome

A patient is presented with recurrent angina due to a coronary-subclavian steal syndrome 3 years after left internal mammary to left anterior descending coronary artery bypass grafting. Myocardial ischaemia could easily be provoked by selective exercise of the left upper limb. Coronary angiography showed reversal of flow in the left internal mammary artery. Suggestions are given for prevention of the coronary-subclavian steal syndrome by identification of patients who are at risk of developing subclavian artery occlusive disease. Performance of coronary and brachiocephalic angiography is indicated in recurrence of angina in patients with internal mammary artery bypass grafts. Doppler spectral analysis may be a valuable technique for detection of a haemodynamically significant stenosis of the left subclavian artery. Carotid-subclavian bypass grafting is the procedure of choice for management of the coronary-subclavian steal syndrome.

The effectiveness of ketanserin in patients with primary Raynaud's phenomenon. A randomized, double blind, placebo controlled study

In 41 patients with Primary Raynaud's Phenomenon (PRP) the effectiveness of the serotonin receptor blocker ketanserin has been studied in a double blind cross-over study. Subjective assessments included: frequency and duration of the attacks (both per se and combined to a severity score), cold sensation, numbness, paresthesia, pain, cold water and cold weather provocation and the appearance of spontaneous attacks. The objective measurements comprised Digital Skin Temperature (DST), Digital systolic Blood Pressure (DBP) and Doppler Spectral Analysis (DOSA) of the radial and ulnar arteries. All measurements were performed both at room temperature and after instant cold provocation. The severity score, the occurrence of numbness and paresthesia and cold weather provocation improved significantly on ketanserin treatment. All objective measurements with the exception of the end-diastolic blood flow velocity of DOSA did not show significant improvements. Neither blood chemistry nor systemic blood pressure showed any significant change during ketanserin treatment. However, in the 6 (15%) patients with hypertension both systolic and diastolic blood pressure normalized. Although in objective measurements hardly any significant effects of ketanserin could be demonstrated, the results of the study suggest that orally administered ketanserin is effective for minimizing subjective complaints in patients with PRP. Ketanserin did not show any side effects.

Noninvasive hemodynamic assessment of vasospasm in patients with primary Raynaud's phenomenon

In order to assess vasospastic ischemic disease objectively 41 patients with primary Raynaud's phenomenon and 21 normal volunteers were investigated noninvasively by digital systolic blood pressure and digital skin temperature measurements before and after instant cold provocation. Much care had been taken to be certain that all patients had primary Raynaud's phenomenon. The results of digital pressure measurements appeared to be affected by interindividual variations in systemic systolic blood pressure. By introducing a digit-to-brachial systolic blood pressure index (DBI), such variations could be eliminated. Instant cold provocation did not change DBI significantly. No pressure drop due to a closing phenomenon could be observed. Both digital skin temperature and DBI differed significantly between healthy males and females. In the patient group males and females did not show significant differences. The results in healthy females were hardly different from the results in patients. Healthy males could be well discriminated from patients with both techniques. Sex differentiation appeared to be essential for the objective assessment of primary Raynaud's phenomenon.

Quantitative assessment of vasospasm by Doppler spectrum analysis in patients with primary Raynaud's phenomenon

The aim of the study was to investigate whether increased peripheral resistance which is supposed to exist in patients with primary Raynaud's phenomenon, can be quantified by using parameters of Doppler spectra of flow in the ulnar and radial arteries. A group of 24 patients with this abnormality were compared with a matched group of 24 normal subjects. Doppler spectra were analysed according to the methods of Fronek, Gosling and by Fast Fourier Transform analysis. The Doppler spectra obtained from patients at room temperature were very different from those in normal subjects, showing characteristic wave-forms with multiple oscillations in 92% of the patients. All three analysing techniques demonstrated significant differences between the two groups, which can be attributed to increased peripheral vascular resistance in the patient group. The results of this study emphasize the value of analysis of Doppler spectra obtained from ulnar and radial arteries in the assessment of peripheral vascular resistance in vasospastic disease.

Surgery of pulmonary metastases

From 1954 to 1985, 150 metastases were removed in 80 patients (55 males, 25 females) with an age range from 8 to 82 years. The role of pulmonary resection for metastatic lesions of the period 1954 to 1975 (group I) was compared to the period 1976 to 1985 (group II). In group I, 48 metastases were resected in 35 patients and in group II, 102 metastases in 45 patients. The surgical mortality in the total population was 1%. The average interval from diagnosis of the primary neoplasm to diagnosis of thoracic metastases was 4 years in both groups. Primary neoplasm localization did not differ in the 2 groups. In both groups approximately 50% of the patients were without symptoms. Wedge resection and lobectomy were the most frequent procedures followed by segmentectomy and pneumonectomy. The median post thoracotomy survival was 21 months in group I and 36 months in group II. Although the tumor-free interval, presenting symptoms and surgery did not differ in the 2 groups, the actuarial 5-year survival in group I was 31%, and 53% for group II. Neither sex, age nor the lung resection type significantly affected the therapeutic results. Good prognostic factors were a non-seminomatous testicular tumor as the primary tumor, a tumor-free interval longer than 60 months and a tumor-doubling time longer than 136 days. Poorer results were obtained in the presence of N2 metastases, and of a large tumor volume. It seems that with the increased effectiveness of chemotherapy, especially in non-seminomatous testicular tumor, the role of surgery is changing. Surgery is now also indicated to resect metastases unresponsive to chemotherapy and to obtain histology of stabilized lesions after chemotherapy.

Digital blood pressure and flow measurements in patients with primary Raynaud's phenomenon

The value of digital systolic blood pressure (DBP) and flow (DBF) measurements for a quantitative diagnosis of Primary Raynaud's Phenomenon (PRP) was evaluated by comparing the results obtained in 10 patients and 20 normals. Digital skin temperature (DST), DBP and brachial systolic blood pressure (BBP) and DBF were measured at room temperature, at maximal vasodilatation and during cold provocation. At room temperature DST discriminates between normals and patients with an accuracy of 77%. On maximum vasodilatation no significant differences can be found in DBP and DBF between normals and patients. However, DBF was significantly different between male and females both in normals and in patients. During gradual cooling a decrease in DBF (a closing phenomenon) was observed both in normals and patients. In contrast DBP did not show a substantial pressure drop. Calculating digit to brachial systolic pressure indexes (DBI) a slight significant increase can be found during cold provocation both in normals and in patients. Only the DBI of digit IV during cold provocation showed a significant difference between normals and patients which resulted in an accuracy of 83%.

Dissecting ventricular septal aneurysm after open-heart surgery

Pseudoaneurysm of the muscular ventricular septum has been reported after myocardial infarction and after transaortic septal myotomy. In our case, surgical repair for infundibular pulmonary stenosis and membranous ventricular septal defect (VSD) was complicated by a dissecting ventricular septal aneurysm with VSD. Echocardiography was the only diagnostic procedure that could demonstrate the lesion. ECG and body surface mapping suggested a local septal infarction, its etiology most probably due to the closing sutures of the initial VSD.

Thoracic sympathectomy as a therapy for upper extremity ischemia. A long-term follow-up study

Fifty-seven patients who had 72 thoracic sympathectomies have been reviewed. Twenty-five patients were preoperatively diagnosed as having primary Raynaud's phenomenon, 14 as having Raynaud's phenomenon secondary to arterial occlusion, 17 as having ischemia secondary to arterial occlusion and one as having hyperhidrosis. Twenty percent of the patients initially diagnosed as having primary Raynaud's phenomenon at the time of operation developed a collagenosis during the follow-up period. Improvement after 8 years' follow-up did not depend on the primary indication. Up to the fifth year after surgery a relapse was seen in cases of primary Raynaud's phenomenon. In secondary Raynaud's phenomenon a gradual decrease in improvement of 2% a year was seen during follow-up. In ischemia secondary to arterial occlusion, after 2 years the percentage of improved patients remained constant at a level of 70%. The mean improvement after 8 years follow-up according to the survival test of Gehan was 70 +/- 10%.

En bloc resection for bronchogenic carcinoma with chest wall invasion

The incidence rate of chest wall invasion in operated bronchogenic carcinoma is about 3%. From 1973 to 1984, 12 patients in our hospital underwent en bloc lung and partial chest wall resection for bronchogenic carcinoma with local invasion of the thoracic wall. All were male, between 49 and 74 years of age. Chest wall or back pain was the most prominent complaint. The duration of symptoms varied from 2 to 20 months. In 10 the tumour was peripherally and in 2 centrally located. Mediastinoscopies, selectively performed were negative. In 11 patients there was a squamous cell and in 1 an adenocarcinoma. 10 lobectomies and 2 pneumonectomies were performed. Macroscopic size of the tumour ranged from 3 to 17 cm, the number of partially resected ribs ranged from 1 to 4. There was 1 operative death (8%). 3 patients died within 5 months and 3 other patients within 14 months. 5 patients are still alive, 2 more than 5 years (17%). The survival is unfavourably influenced by lymph node involvement. The majority of patients became free of pain one month after surgery.

False aneurysm of a left ventricular stab wound for left vent during extracorporeal circulation--case report

The left ventricular apical stab wound had been used for instrumentation and venting since 1923. Despite the frequent use of this myotomy, only a few complications and even fewer operative corrections have been reported. One of these complications is a false aneurysm, its reported etiology being infection or suture failure. In this case we describe a case of left ventricular false aneurysm formation most likely due to suddenly increased intrathoracic pressure, 6 months after coronary artery bypass grafting. Evidence for likely causes, such as infection, suture failure or poor myocardial quality, was not found. As etiology we suspect an acute elevation of ventricular pressure superimposed upon poorly regenerated myocardium.

Chest wall resection for bronchogenic carcinoma

The incidence rate of chest wall invasion in bronchogenic carcinoma is difficult to estimate, but is possibly as high as 5%. These cancers can be locally extensive without systemic dissemination. From 1973 to 1982, 9 patients in our hospital underwent en bloc pulmonary and partial chest wall resection for bronchogenic carcinoma with local invasion of the thoracic wall. All the patients were male, their ages ranging from 49 to 67 years. Pain was the most prominent symptom. Bronchoscopy examination revealed no tumors in 7 of the 9 patients, in one a tumor was seen in the apex of the right lower lobe and in another in the apex of the right upper lobe. Seven lobectomies and 2 pneumonectomies were performed. The macroscopic size of the tumour ranged from 3 to 17 cm, the number of partially resected ribs ranged from 1 to 4. In 8 cases squamous cell carcinoma was found, in one adenocarcinoma. After operation 7 patients were classified as T3N0M0 and 2 as T3N1M0. One T3N0M0 patient died shortly after operation due to a lung embolism. Two out of the 6 patients with T3N0M0 neoplasm survived more than 5 years, none of the patients with T3N1M0 neoplasm survived more than 3 months. Late deaths were due to recurrent carcinoma in the chest wall (2 cases), cerebral metastasis (1 case), cardiac failure (1 case) and unknown causes (2 cases). In cases where the lymph nodes are not involved, the survival rate is not unfavorably influenced by chest wall invasion. In the literature the mean operative mortality rate is 12%, the median survival time approximately one year and the mean 5-year survival rate 18%; resection is also of great importance in relieving pain.