A technique to control bleeding from an inaccessible part of an aortic end-to-end anastomosis

A simple technique is presented for the control of bleeding from the posterior aspect of an aortic end-to-end anastomosis.

Risk factors for early mortality after valve surgery in Europe in the 1990s: lessons from the EuroSCORE pilot program

BACKGROUND AND AIM OF THE STUDY

The characteristics of valve surgery are evolving. The study aim was to explore its demographics and risk factors in Europe in the 1990s, using the EuroSCORE database.

METHODS

For the EuroSCORE program, information on 98 variables regarding risk factors, procedures and outcome were collected for 5,672 patients undergoing valve surgery under cardiopulmonary bypass in 128 European centers. Bivariate (i.e. Mann-Whitney test or chi-square when appropriate), then logistic regression analyses were carried out to identify risk factors for early mortality. The predictive value of EuroSCORE was analyzed using the Hosmer-Lemershow test and by computing the area under the receiver operating characteristic (ROC) curve.

RESULTS

Aortic valve stenosis was the most common diagnosis (47.6%), whilst mitral valve surgery accounted for 42% of procedures. Coronary surgery was performed concomitantly in 21% of cases. Hospital mortality was 6.1%. Predictive factors for early mortality were: age (p = 0.0001), preoperative serum creatinine >200 micromol/l (p = 0.014), previous heart surgery (p = 0.0001), poor left ventricular function (p = 0.008), chronic congestive heart failure (p = 0.0001), pulmonary hypertension (p = 0.0001), active acute endocarditis (p = 0.0001), emergency procedure (p = 0.05), critical preoperative status (p = 0.0001), tricuspid surgery (p = 0.015), aortic and mitral surgery (p = 0.002), combined thoracic surgery (p = 0.0001), and combined coronary surgery (p = 0.0001). The predictive value of EuroSCORE for mortality was good (area under the ROC curve = 0.75).

CONCLUSION

The 'valve' subset of the EuroSCORE database provides an instant picture of European valve surgery in the 1990s that can be used either for individual assessment, or for country- or institution-based epidemiological studies of risk factors and practices.

The relationship between predicted and actual cardiac surgical mortality: impact of risk grouping and individual surgeons

OBJECTIVE

To study the relationship between predicted and actual mortality in a cardiac surgical practice and to determine whether there is a consistent relationship across risk groups and surgeons.

METHODS

Risk information (Parsonnet score) was prospectively collected for 6213 consecutive adult patients undergoing cardiac surgery at one institution. The relationship between predicted mortality and actual mortality was analysed by risk group for all patients and for individual surgeons' practices.

RESULTS

Predicted mortality was 10.2%. Actual mortality was 4.2%, giving a mortality ratio of 41% of predicted. This ratio was not consistent across the five major risk groups, ranging from 32% in moderate risk to 67% in very low risk patients. When analysed by individual surgical practices, the results were even more disparate, with a mortality index range between 0% for one surgeon's low risk patients to 150% for another surgeon's very low risk patients.

CONCLUSION

The relationship between predicted and actual mortality at one institution may vary across the risk spectrum and between surgeons. This should be taken into account in preoperative risk assessment and informed patient consent. Individual surgeons may have strengths and weaknesses which are related to preoperative risk stratification.

Effect of surgical training on outcome and hospital costs in coronary surgery

BACKGROUND

There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs).

OBJECTIVE

To quantify the effect of training on outcome and costs.

DESIGN

Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs.

SETTING

Regional cardiothoracic surgery unit.

MAIN OUTCOME MEASURES

Postoperative mortality; hospital costs.

RESULTS

Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three different levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant differences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was pound6619, pound6572, pound6494, and pound6404 (NS).

CONCLUSIONS

Trainees performed 44.4% of all CABG operations. There was no detrimental effect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes.

Airway complications after lung transplantation: treatment and long-term outcome

BACKGROUND

Airway complications are a significant cause of morbidity after lung transplantation. Effective treatment reduces the impact of these complications.

METHODS

Data from 123 lung (99 single, 24 bilateral) transplants were reviewed. Potential risk factors for airway complications were analyzed. Stenoses were treated with expanding metal (Gianturco) stents.

RESULTS

Mean follow-up was 749 days. Thirty-five complications developed in 28 recipients (complication rate: 23.8%/anastomosis). Mean time to diagnosis was 47 days. Only Aspergillus infection and airway necrosis were significantly associated with development of complications (p < 0.00001 and p < 0.03, respectively). Stenosis was diagnosed an average of 42 days posttransplant. Average decline in forced expiratory volume in 1 second (FEV1) was 39%. Eighteen patients (13 single and 5 bilateral) required stent insertion. Mean increase in FEV1 poststenting was 87%. Two stent patients died from infectious complications. Six patients required further intervention. Long-term survival and FEV1 did not differ from nonstented patients.

CONCLUSIONS

Aspergillus and airway necrosis are associated with the development of airway complications. Expanding metal stents are an effective long-term treatment.

Does EuroSCORE work in individual European countries?

OBJECTIVE

Because of national epidemiological differences in adult heart surgery in Europe, the effectiveness and desirability of a pan-European score for the assessment of quality of surgical care remains controversial. We assessed the predictive value of EuroSCORE in national subsets of the EuroSCORE database.

METHODS

The EuroSCORE development data set was divided into national subsets of which those with 500 or more patients were selected for analysis. The Hosmer-Lemeshow goodness-of-fit test was applied to assess the calibration of the EuroSCORE model on individual national samples and the areas under the receiver operating characteristic (ROC) curve were measured to analyse the EuroSCORE discriminative power on individual death prediction.

RESULTS

There were 18676 patients in the six largest national samples: Germany, United Kingdom, Spain, Finland, France and Italy (mean: 3113 patients; range: Finland 1266 to France 4507). Major differences were observed in national distribution of procedures: coronary artery bypass grafting accounted for 77.7% of procedures in Finland but only 46.2% in Spain. The EuroSCORE model goodness-of-fit was satisfactory in all countries (P-value overall: 0.4; UK: 0.34; Finland: 0.87; no values less than 0.05). Areas under ROC curves were 0.81 in Germany, 0.79 in the UK, 0.74 in Spain, 0.87 in Finland, 0.82 in France and 0.82 in Italy.

CONCLUSION

Despite epidemiological differences between European countries, the discriminative power of EuroSCORE was good in Spain and excellent in all other countries. The system, developed from a merged European database, can therefore be used to assess improvement in quality of care achieved by surgeons and institutions as well as for international European comparison in adult heart surgery.

Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost

OBJECTIVE

Crash back on bypass (crash-BOB) is occasionally required in the resuscitation of patients developing life-threatening complications following cardiac surgery. This study aims to determine the incidence, aetiology and cost-effectiveness of such intervention.

METHODS

Retrospective review of all crash-BOB patients over 5.5 years at one hospital.

RESULTS

The incidence of crash-BOB was 0.8% and occurred at a mean of 7 h post-operatively (range 1 h-20 days). Pre-operative Parsonnet scores were similar to the overall population of patients undergoing surgery in our institution (mean score 10; range 0-45). The original cardiac operations were coronary revascularization (39), valve surgery (12) and others (4). Indications for crash-BOB were cardiac arrest (23), bleeding (20), hypotension (7), ischaemia (1) and others (4). Of the 55 patients, 20 died on the operating table. Of the remaining 35, a further 12 died in hospital. Overall survival was therefore 42%. Where crash-BOB was for bleeding, 17 of 20 patients (85%) survived to leave theatre, of whom 11 patients (55%) left hospital alive. In the 35 non-bleeders, only 18 (51%) survived crash-BOB and 12 (34%) left hospital alive. Sixteen patients required a second period of aortic cross-clamping of whom 13 (81%) survived to leave theatre, and 11 (69%) left hospital alive. Conversely, of nine patients in whom no specific diagnosis was found during crash-BOB, only two (22%) survived the procedure and none survived to hospital discharge. Multiple logistic regression identified pre-operative Parsonnet score (P=0.045) and the need for aortic cross-clamping to deal with an identified surgical problem (P=0.03) as significant predictors of hospital survival. Indication for crash-BOB (bleeder/non-bleeder) failed to reach significance (P=0.08). Age, sex, intra-aortic balloon pump use at the primary procedure, and time following the primary procedure to crash-BOB were not identified as predictors of hospital survival. Of the 23 hospital survivors, three patients suffered a stroke post-operatively and made a good functional recovery prior to discharge. Two patients developed sternal wound dehiscence requiring surgical rewiring. At follow-up (mean 3 years, range 1-6 years), 19 patients were in NYHA class I and four were in class II. Crash-BOB patients required an average of 8 extra intensive care days and 2 extra ward days. The total cost of these resources was pound164900 (including theatre time, cardiopulmonary bypass and intra-aortic balloon pump use). This was equivalent to pound7170 per life saved.

CONCLUSIONS

Crash-BOB occurred in 0.8% of cases and was associated with a survival to discharge of 42%, and a justifiable cost of only pound7170 per life saved. Establishing an accurate diagnosis for the cause of clinical deterioration resulting in crash-BOB intervention was important, and the need for a further period of aortic cross-clamping did not preclude a favourable outcome.

Aorto-atrial fistula after operated type A dissection

The development of a fistula between the aorta and right atrium is a rare complication of ascending aortic dissection and has a high mortality if not diagnosed and surgically treated. Clinical diagnosis is best supported by specialised imaging. In addition it may present technically very challenging problems. We report the first case which follows aortic root replacement for an acute type A dissection. Aorto-right atrial fistula (AoRAF) rarely complicates ascending aortic dissection. We report the first case to follow corrective surgery for aortic dissection.

Postinfarction acute aortic valve regurgitation and cardiac rupture

We report the case of a 71-year-old man who developed acute aortic regurgitation after a myocardial infarct. At operation he was also found to have a contained cardiac rupture.

Coronary surgery in Europe: comparison of the national subsets of the European system for cardiac operative risk evaluation database

OBJECTIVE

To compare the national samples of patients who underwent isolated coronary artery bypass grafting (CABG) during the European System for Cardiac Operative Risk Evaluation (EuroSCORE) trial in order to evaluate national differences in epidemiology, patient risk profile and surgical methods.

METHODS

From September to November 1995, 11731 patients had CABG in the six largest contributing nations to the EuroSCORE project: Germany, UK, Spain, Finland, France and Italy. The Chi-square and Kruskal-Wallis tests were applied to obtain an international comparison of patient general status, including pre-operative risk factors, cardiac status, critical pre-operative states, rare conditions, urgency of surgery, angina status, coronary lesions, procedures and EuroSCORE risk assessment.

RESULTS

Large national samples (from 984 patients in Finland to 3138 in Germany) identified significant differences in epidemiology, risk profile and surgical practice. Regarding epidemiology, CABG accounted for 62.8% of adult cardiac surgery, with a range of 46.2 in Spain to 77.7% in Finland (P<0.001). The mean age was 62.9 years (61.4 in Britain to 64.4 in France, P<0.001). The mean body mass index was 26.8 (26 in France to 27.5 in Finland, P<0.001). With regard to risk profile, diabetes was present in 20.3% of patients (11.8% in Britain to 27.7% in Spain, P<0.001). Chronic renal failure was present in 8.3% (6.8% in Germany to 10.6% in Spain, P<0.001). Chronic airway disease affected 3.8% (1.9% in Italy to 5. 1% in Germany, P<0.001). The mean ejection fraction was 0.56 (0.48 in Britain to 0.58 in Finland, P<0.001). The mean predicted mortality (according to EuroSCORE) was 3.3% (2.8% in Finland to 3.6% in France, P<0.001). The prevalence of chronic congestive heart failure, unstable angina and recent myocardial infarction also showed statistically significant differences. No differences were found for some critical preoperative states (such as immediate preoperative cardiac massage and pre-operative intubation), or for surgery for catheter laboratory complication. Regarding surgical practice, major differences were noted in preoperative intra-aortic balloon use (mean 1%, Finland 0%, Spain 2.3%, P<0.001), the number of mammary artery conduits used (mean 0.9, Spain 0.7, France 1.1, P=0.0001) and the number of distal anastomoses (mean 3, France 2.7, Finland 3.8, P=0.001).

CONCLUSION

There are important epidemiological differences in the national cohorts of CABG patients in the EuroSCORE database. Any international comparison of European surgical results must therefore take into account the risk profile of patients by using a compatible risk stratification system.

European system for cardiac operative risk evaluation (EuroSCORE)

OBJECTIVE

To construct a scoring system for the prediction of early mortality in cardiac surgical patients in Europe on the basis of objective risk factors.

METHODS

The EuroSCORE database was divided into developmental and validation subsets. In the former, risk factors deemed to be objective, credible, obtainable and difficult to falsify were weighted on the basis of regression analysis. An additive score of predicted mortality was constructed. Its calibration and discrimination characteristics were assessed in the validation dataset. Thresholds were defined to distinguish low, moderate and high risk groups.

RESULTS

The developmental dataset had 13,302 patients, calibration by Hosmer Lemeshow Chi square was (8) = 8.26 (P < 0.40) and discrimination by area under ROC curve was 0.79. The validation dataset had 1479 patients, calibration Chi square (10) = 7.5, P < 0.68 and the area under the ROC curve was 0.76. The scoring system identified three groups of risk factors with their weights (additive % predicted mortality) in brackets. Patient-related factors were age over 60 (one per 5 years or part thereof), female (1), chronic pulmonary disease (1), extracardiac arteriopathy (2), neurological dysfunction (2), previous cardiac surgery (3), serum creatinine >200 micromol/l (2), active endocarditis (3) and critical preoperative state (3). Cardiac factors were unstable angina on intravenous nitrates (2), reduced left ventricular ejection fraction (30-50%: 1, <30%: 3), recent (<90 days) myocardial infarction (2) and pulmonary systolic pressure >60 mmHg (2). Operation-related factors were emergency (2), other than isolated coronary surgery (2), thoracic aorta surgery (3) and surgery for postinfarct septal rupture (4). The scoring system was then applied to three risk groups. The low risk group (EuroSCORE 1-2) had 4529 patients with 36 deaths (0.8%), 95% confidence limits for observed mortality (0.56-1.10) and for expected mortality (1.27-1.29). The medium risk group (EuroSCORE 3-5) had 5977 patients with 182 deaths (3%), observed mortality (2.62-3.51), predicted (2.90-2.94). The high risk group (EuroSCORE 6 plus) had 4293 patients with 480 deaths (11.2%) observed mortality (10.25-12.16), predicted (10.93-11.54). Overall, there were 698 deaths in 14,799 patients (4.7%), observed mortality (4.37-5.06), predicted (4.72-4.95).

CONCLUSION

EuroSCORE is a simple, objective and up-to-date system for assessing heart surgery, soundly based on one of the largest, most complete and accurate databases in European cardiac surgical history. We recommend its widespread use.

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients

OBJECTIVE

To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE).

METHODS

From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis.

RESULTS

Mean age (+/- standard deviation) was 62.5+/-10.7 (range 17-94 years) and 28% were female. Mean body mass index was 26.3+/-3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P = 0.001), female gender (P = 0.001), serum creatinine (P = 0.001), extracardiac arteriopathy (P = 0.001), chronic airway disease (P = 0.006), severe neurological dysfunction (P = 0.001), previous cardiac surgery (P = 0.001), recent myocardial infarction (P = 0.001), left ventricular ejection fraction (P = 0.001), chronic congestive cardiac failure (P = 0.001), pulmonary hypertension (P = 0.001), active endocarditis (P = 0.001), unstable angina (P = 0.001), procedure urgency (P = 0.001), critical preoperative condition (P = 0.001) ventricular septal rupture (P = 0.002), noncoronary surgery (P = 0.001), thoracic aortic surgery (P = 0.001).

CONCLUSION

A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.

Successful thrombolysis for massive pulmonary embolism after pulmonary resection

We report the successful use of thrombolysis for acute massive pulmonary embolism 2 days after right lower lobectomy for bronchial adenocarcinoma. Pulmonary angiography revealed extensive clot unsuitable for surgical embolectomy. A bolus infusion of recombinant tissue plasminogen activator produced an immediate improvement in the patient's hemodynamic state. There was substantial blood loss requiring the transfusion of 21 units of blood over the postoperative period. The patient made a successful recovery and remained well at 1 year.

Modification to dissecting/ligature forceps

Images

Surgical angioplasty of the left main coronary artery: follow-up with magnetic resonance imaging

BACKGROUND

Ostial stenosis of the left main coronary artery is a serious condition with a dismal prognosis. The treatment is surgical, with the two viable options being coronary artery bypass grafting and surgical angioplasty of the left main coronary artery.

METHODS

We describe the use of surgical angioplasty to treat 3 patients (2 women and 1 man) with left main ostial stenosis using the posterior approach. Patency of the angioplasty was demonstrated subsequently with magnetic resonance imaging.

RESULTS

All 3 patients were free of angina 12, 18, and 24 months after operation. Magnetic resonance imaging scans in all 3 patients demonstrated the widely patent left main coronary artery.

CONCLUSIONS

Surgical angioplasty is an effective alternative to coronary artery bypass grafting in patients with left main ostial stenosis. Magnetic resonance imaging is an excellent noninvasive method for monitoring the patency of the left main coronary artery.

Bullous emphysema: the role of the surgeon

Emphysema is the permanent dilatation of the distal respiratory passages. Although the mainstay of treatment of emphysema is medical, there are certain groups of patients who obtain both symptomatic and prognostic benefits from certain surgical treatments, both old and new. This article discusses the indications for treatment and the different treatment options.

Excellent outcome of cardiac transplantation using domino donor hearts

OBJECTIVE

Domino cardiac transplantation affords flexible and optimal organ utilization, provides hearts unaffected by brain death, allows prospective tissue matching, and subsequent transplantation with short allograft ischemic times. A retrospective review of our experience with domino cardiac transplantation has been made.

METHODS

Seventy-two of 119 patients who underwent heart-lung transplantation from 1988 on served as domino cardiac donors (40 males, 32 females; mean age of 32 years; mean weight of 51 kg). The domino donor diagnoses were cystic fibrosis (n = 47), bronchiectasis (n = 9), primary pulmonary hypertension (n = 6), emphysema (n = 7), pulmonary fibrosis (n = 2) and Eisenmenger's syndrome (n = 1). Forty-seven domino hearts were transplanted at our institution and 25 were exported to other centres in the United Kingdom. The 72 domino cardiac recipients were 62 males and 10 females, mean age of 47 years, mean weight of 60 kg, with ischemic heart disease (n = 32), cardiomyopathy (n = 36) and other conditions (n = 4).

RESULTS

There were four deaths (5.6%) at less than 30 days (2 from multiple organ failure, 1 from primary allograft failure and 1 from acute rejection). Actuarial survival estimates and 1 and 5 years were 77 +/- 5.2% nd 69 +/- 6.3%, respectively. This compared favourably with survival data obtained in 234 non-domino cardiac recipients. In the patients transplanted at Papworth, there was no difference in the incidence of rejection (0.6 +/- 0.05 versus 0.7 +/- 0.03 events per 100 patient days for the first 12 months) or in the freedom from graft atherosclerosis (74 +/- 3% versus 70 +/- 3% at 5 years) between the domino and non-domino groups.

CONCLUSIONS

The use of domino hearts donated by recipients of heart-lung transplants is beneficial and is associated with an excellent early and longer-term outcome.

Audit of referral and explant diagnoses in lung transplantation: a pathologic study of lungs removed for parenchymal disease

BACKGROUND

Lung transplantation is performed for an increasing range of pulmonary conditions in which the diagnosis is often clinical or based on limited biopsy material. Diagnosis may be made late in the course of the disease where specific features are no longer present. Posttransplantation complications and disease recurrence may relate to the primary disease, and accurate diagnosis is therefore essential.

METHODS AND RESULTS

A pathologic review of 183 explanted lungs over a 10-year period (heart-lung = 109, single lung = 65, double lung = 9) showed 29 significant discrepancies or additional features likely to effect outcome. The final pathologic diagnosis was cystic fibrosis (n = 66), emphysema (59), bronchiectasis (17), pulmonary fibrosis (19), sarcoidosis (10), Langerhans cell histiocytosis (3), pulmonary veno-occlusive disease (3), posttransplantation obliterative bronchiolitis (2), primary hemosiderosis (1), rheumatoid obliterative bronchiolitis (1), extrinsic allergic alveolitis (1), pneumoconiosis (1). Unsuspected diagnoses included tuberculosis (8) (four cases of which were active and in single lung recipients requiring antituberculous chemotherapy), sarcoidosis (9), (of which, six were unsuspected primary diagnoses and three were additional diagnoses), veno-occlusive disease (3), carcinoma (1), pneumoconiosis (1), and pulmonary fibrosis (2). Aspergillus infection (2) and bronchocentric granulomatosis (3) were found in patients with cystic fibrosis. One active tuberculosis case also showed an aspergilloma. Unsuspected infections requiring therapy in immunosuppressed patients and previously unsuspected sarcoidosis, which is known to recur in the graft, were the major novel diagnoses. Discrepancy rate was 12 of 65 in single lungs (19%) and 17 of 109 in heart-lungs (16%).

CONCLUSIONS

These results emphasize the need for accurate preoperative diagnosis especially when the similarly diseased native lung remains in situ.

Single lung transplantation for end stage emphysema

BACKGROUND

The first successful single lung transplantation was carried out in 1983 for pulmonary fibrosis. Because of the inherent advantages of single lung transplantation, a transplantation programme has been started for patients with end stage lung disease due to emphysema.

METHODS

Between October 1990 and August 1993 25 patients with severe emphysema (15 men, mean age 51 years) received a single lung transplant at our institution. All patients were severely disabled with a mean (SD) 12 minute walking distance of 281 (165) metres. There were five deaths in the series, four in the first 20 days and one on day 503. Two patients suffered graft compression by air trapping in the native lung. Bronchial narrowing requiring insertion of endobronchial stenting occurred in four patients.

RESULTS

Mean (SD) FEV1 improved from a preoperative value of 17.8(13%) predicted to a six month value of 53.6(13)%, and FEV1/FVC from 23.8(12)% to 68.6(15)%. After the transplant 12 patients are in New York Heart Association (NYHA) class I and the rest of the survivors are in NYHA II. Actuarial survival was 82% at one year and 74% at three years.

CONCLUSIONS

Single lung transplantation is an effective treatment for end stage lung disease due to emphysema and carries an acceptable mortality and morbidity.

Aortic valve replacement for end-stage aortic valve disease

To evaluate the outcome of surgical intervention for end-stage aortic valve disease, we carried out a retrospective, longitudinal survey of 85 patients (65 males, 20 females; mean age 53 period. All the patients presented in New York Heart Association (NYHA) class IV in cardiac failure (3 had cardiogenic shock and 27 had bacterial endocarditis). In-hospital mortality was 9.4% (8/85) overall. Those with endocarditis had a significantly higher mortality, 6/27 (22%) vs 2/58 (3.4%), p < 0.01. In-hospital mortality was not significantly increased in those with renal failure, reoperation, simultaneous coronary artery surgery, age > 65 years nor was it related to the predominance of aortic regurgitation or stenosis. After a mean follow-up period of 5.9 years (range 0 to 12.5 years), the overall actuarial survival was 82% and 74% at 5 and 10 years respectively. For 66 late survivors, the NYHA status improved to class I in 51, to II in 10, to III in 4 patients, and one patient remained in class IV. The incidence of paraprosthetic leak, reoperation, thromboembolism, anticoagulant-related haemorrhage, and endocarditis were respectively 0.8, 0.8, 1.6, 1.4, and 0.2 per 100 patient-years. Aortic valve replacement in the patient with end-stage aortic valve disease is a high-risk procedure, the risk being higher in the presence of endocarditis. The favourable long-term survival, long-term improvement in functional class and the relatively low incidence of valve-related complications justify surgical intervention in such patients, who would otherwise have a very poor prognosis.

Airway stenoses after lung transplantation: management with expanding metal stents

Success in lung transplantation has been hindered by airway complications, usually as a result of anastomotic ischemia and stenosis. We report our experience with expanding metal stents in managing airway stenoses after lung transplantation. From April 1984 through November 1993, 46 single lung, 5 double lung, and 154 heart-lung transplantations were performed at Papworth Hospital. All patients received immunosuppression with azathioprine, cyclosporine, methylprednisolone, and induction antithymocyte globulin. Fourteen patients (nine single lung, two double lung, and three heart-lung) had an airway stenosis requiring a stent. The most common features were shortness of breath, wheezing or stridor, and a fall in pulmonary function tests (11 patients). Three patients had pneumonia. Airway stenosis was diagnosed on bronchoscopy an average of 61 days after transplantation (range 3 to 245 days). Stent placement occurred an average of 18 days after the diagnosis (range 2 to 84 days). One heart-lung transplant recipient received a silicone rubber stent. All other patients received expanding metal stents. Six patients required multiple stent placements. After stent placement the average increase in the forced expiratory volume in 1 second was 117%. Infection complicated the stenoses in 12 patients. Pseudomonas aeruginosa and Aspergillus fumigatus were the most common pathogens, each occurring in six cases. Multiple pathogens were isolated in seven cases. Three patients died as a direct consequence of their airway problems. Two died of pneumonia despite stenting, and a third died of acute occlusion of the silicone rubber stent. Expanding metal stents are an effective treatment of airway stenoses in lung transplant recipients. Patients with suspected airway problems should be referred for early bronchoscopy with the potential for stent placement.

Tuberculosis in transplanted lungs

Over a 4-year period in four of 61 patients (6.5%) who survived lung transplantation, pulmonary tuberculosis developed at a mean of 7.5 months (range 3 to 13 months) after operation. Clinical and radiologic features were atypical. Definitive bacteriologic diagnosis, which was established on bronchial, sputum, and pleural fluid samples, may be delayed by the concomitant presence of other infective organisms and the necessity for repeated sampling. All patients were treated successfully with antituberculous chemotherapy, but one patient also required lobectomy. At a mean follow-up of 2.25 years (range, 1 to 3 years), three patients are free of active disease, and one patient had a recurrence at 2 years. Tuberculosis in transplanted lungs is an uncommon but serious infection that may elude diagnosis but respond well to treatment.

Histological examination of peroperative frozen sections in suspected lung cancer

BACKGROUND

Despite extensive investigations some patients with suspected lung cancer may undergo thoracotomy without preoperative histological proof of malignancy. A questionnaire on the use of histological examination of peroperative frozen sections in such patients was sent to 50 thoracic surgeons. Replies were received from 41 surgeons and indicated an absence of consensus on the usefulness of histological examination of frozen sections in this context, confirming the need for this study.

METHODS

During one year 60 consecutive patients undergoing thoracotomy for suspected lung cancer without a prior histological diagnosis were studied prospectively. At thoracotomy the surgeon assessed the lesion macroscopically and a verdict on whether it was malignant was recorded. A biopsy specimen was then taken for examination of a frozen section and the result recorded. The appropriate operation was performed and the surgeon's verdict and the report on the frozen section were compared with the definitive histological diagnosis based on a paraffin section.

RESULTS

Of 50 malignant lesions, 43 were identified by the surgeon and 47 by examination of the frozen section (sensitivity 86% and 94% respectively). Of 10 benign lesions, four were identified by the surgeon and nine by examination of the frozen section (specificity 40% and 90% respectively).

CONCLUSIONS

Clinical and macroscopic assessment at thoracotomy are inferior to examination of frozen sections in suspected lung cancer, particularly where the lesion is benign. Lung resection should not be performed without examination of peroperative frozen sections when thoracotomy is performed for suspected but unproved lung cancer.

Expanding wire stents in benign tracheobronchial disease: indications and complications

Prosthetic tracheobronchial stents provide palliative treatment for narrowed airways where surgical resection is inadvisable. Over a 1-year period, 28 Gianturco expanding wire stents were used in 15 patients for nonneoplastic indications: pure fibrous airway stenosis (6), fibroinflammatory stenosis (4), and tracheobronchial malacia (5). Insertion was technically straightforward. A satisfactory airway lumen with immediate improvement in ventilatory function was obtained in all patients. After insertion all patients had an irritation-type cough that either subsided spontaneously (10 patients) or was successfully suppressed with inhaled corticosteroid therapy (5 patients). The most common complication (12 patients) was granuloma formation leading to stent removal in 3 patients with fibroinflammatory stenosis. Other complications were dysphagia (1), suction catheter entrapment (1), and fatal massive hemoptysis (1). At a mean follow-up of 13 months (range, 3 to 19 months) all remaining stents are functioning well with no displacement or infection. Overall results were satisfactory in pure fibrous stenoses and tracheobronchial malacia but poor in the presence of inflammation. Tracheobronchial wire stents can be successfully used in selected patients.

Foreign body perforation of the normal oesophagus

Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (> 48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesophagoscopy. A third of the perforations were cervical, the remainder intrathoracic. All patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment.

Classification of airway anastomotic healing

Airway complications remain a major problem after lung transplantation. There is no standardised method of assessment of airway healing. We propose a classification of airway healing based on the anastomotic appearances at endoscopy 15 days postoperatively. The system appears to correlate well with the subsequent development of anastomotic sequelae and can be used to assess the effectiveness of therapeutic modalities designed to reduce airway complications.

Lung transplantation with bronchial revascularisation. Surgical anatomy, operative technique and early results

Ischaemic anastomotic complications are an important cause of mortality and morbidity after lung transplantation. Anatomical studies have demonstrated that the pattern of bronchial arterial supply is relatively constant and therefore amenable to attempts at revascularisation. From May 1990, 10 patients who had a double lung transplantation (tracheal anastomosis) and 1 patient who had a right lung transplantation underwent concomitant bronchial revascularisation. There were two early and one late deaths. There were no anastomotic complications. Regular endoscopic examination showed satisfactory healing in all patients. Early angiography showed patent grafts in 7 of 9 patients. At a mean follow-up of 11 months (range 6-17 months) 8 patients are well and leading a normal life. This report describes the anatomical basis, technical aspects and early results of a promising operative procedure in the field of lung transplantation.

Preparation of the internal mammary artery

The internal mammary artery is the best currently available conduit in coronary artery bypass surgery. It is a living arterial graft with intact smooth muscle and its efficiency as a conduit therefore depends to a large extent on the way it is mobilized and prepared for grafting. This article discusses the anatomical, technical and pharmacological aspects of the surgical preparation of the internal mammary artery for coronary grafting.

Heart valve replacement with the Björk-Shiley monostrut valve in patients over 60 years of age

Over a period of five years (1983-88) 210 Björk-Shiley monostrut mechanical tilting disc prostheses were implanted in 176 patients over the age of 60. There were 61 aortic valve replacements, 86 mitral valve replacements and 29 multiple replacements. Patients were aged between 61 and 78 years (mean 65.5 years), 89% were in NYHA grades III and IV preoperatively and 34.6% had had previous cardiac surgery. Concomitant coronary surgery was performed in 15.9%. Early mortality was 9.1%. Follow-up is 100% complete. There were eight late deaths (3.1 per 100 patient years) of which three were valve-related (prosthetic endocarditis 2, periprosthetic leak 1). Actuarial survival at five years is 98% for aortic valve replacement and 93% for mitral valve replacement. There were no major embolic events and four possible minor embolic events. Overall freedom from anticoagulant complications was 88.9% at five years. No deaths occurred because of anticoagulant-related haemorrhage. There were no episodes of valve failure (thrombotic obstruction or mechanical disruption). Six patients were reoperated for complications: two for periprosthetic leak and three for prosthetic endocarditis. These results compare favourably with those of other valve substitutes and justify the continuing use of the Björk-Shiley monostrut tilting disc prosthesis in the elderly.

Does low-dose propranolol reduce the incidence of supraventricular tachyarrhythmias following myocardial revascularisation? A clinical study

During 1986, 343 consecutive patients who underwent isolated coronary bypass grafting were given 10 mg of propranolol three times daily for six postoperative weeks to help prevent supraventricular tachyarrhythmias. The incidence of these arrhythmias in this group was compared to that in a similar group of 337 consecutive patients who underwent coronary surgery in 1984 at the same institution and did not receive propranolol. There was no significant difference in the overall incidence of such arrhythmias between the propranolol group (10.8%) and the control group (10.4%). In preoperatively beta-blocked patients, the arrhythmia incidence in the propranolol group (9.9%) was lower than that in the control group (13.8%) but the difference did not achieve statistical significance. The two groups were also similar with respect to the ventricular response rates at the onset of the arrhythmia and the effectiveness of therapeutic intervention. These results suggest that propranolol in the above dosage does not significantly reduce the incidence of supraventricular tachyarrhythmias after myocardial revascularisation.

Endogenous digoxin-like immunoreactive substance in patients undergoing coronary surgery. Preliminary report

Perioperative digoxin concentrations were measured in 20 unselected adult patients undergoing coronary surgery. None of the patients were receiving treatment with digoxin. A digoxin-like immunoreactive substance was found in 16 patients postoperatively. This substance, if pharmacologically active, may have important clinical implications in the management of patients after open heart surgery.

Aortic origin of right pulmonary artery: successful surgical correction in three consecutive patients

Over a period of four years (1981 through 1984), 3 infants with aortic origin of the right pulmonary artery were seen in our surgical unit. Two infants had a persistent ductus arteriosus, which arose from the left subclavian artery in 1 of them who also had a right-sided aortic arch. There were no other associated abnormalities. Preoperative diagnosis was established by echocardiography in 2 infants. Anatomical surgical correction was undertaken in all 3 infants under cardiopulmonary bypass. There were no operative deaths. One child required reoperation at 15 months for anastomotic stenosis. All 3 children were well two to five years postoperatively with scintillographic evidence of normal ventilation and perfusion. Our experience indicates that this rare but severe congenital cardiac anomaly is easily diagnosed by echocardiography, and confirms that it is eminently amenable to surgical correction.

Instrumental perforation of the esophagus in benign disease

Over a period of seven years, a total of 1,831 endoscopic procedures were performed in patients with benign esophageal disease. These comprised flexible esophagoscopy (848), flexible esophagoscopy and dilation (924), pneumatic dilation (29), and rigid esophagoscopy (30). There were 14 episodes of perforation: 1 was cervical, 2 were abdominal, and 11 were perforations of the intrathoracic esophagus (7 occurred at or immediately above a stricture). The diagnosis was made immediately in 9 and within six hours in all but 1 patient. Treatment was emergency surgery in 12 patients, 2 of whom died. The major cause of death was respiratory failure. The overall incidence of perforation was 0.76%. The incidence of perforation was 0.35% (3/848) for flexible esophagoscopy alone, 0.38% (3/792) for dilation with Maloney mercury-weighted bougies, and 3.8% (5/132) for dilation with other bougies. Our experience indicates that instrumental perforation in benign esophageal disease carries a considerable mortality rate in spite of prompt recognition and surgical treatment. Successful dilation with mercury-weighted bougies can be achieved in 86% of benign strictures with an incidence of perforation similar to that for flexible esophagoscopy alone. Difficult strictures and the use of other bougies are associated with a tenfold higher incidence of perforation.

Valve-related events: a system of definitions

A system of definitions for valve-related complications is proposed for use in the assessment of the clinical performance of prosthetic heart valves.