Bronchoplastic procedures in the treatment of endobronchial carcinoid tumors

Pulmonary carcinoid tumor was surgically treated in 33 patients during a 22-year period. The tumor was polypoid and endobronchial in 19 (58%) of the patients. Conventional operation was required in 12 (63%) of the 19, viz. pneumonectomy (1), bilobectomy (1), lobectomy (9) or lingulectomy (1). In one of these 12 patients, metastasis to a salivary gland was found 15 years postoperatively, and to the mediastinum after 16 years. The other seven patients (5 female, 2 male) were treated with bronchoplasty, or with lobectomy and bronchial resection including bronchoplasty, to avoid more extensive pulmonary resection. All seven were recalled for follow-up examination 5 months to 10 years postoperatively. No recurrence or metastasis of the tumor was found, and spirometry and radiospirometry showed that the saved pulmonary tissue was functional.

Surgery after heart transplantation

Of 17 patients who underwent heart transplantation in 1985-1988, three were later operated for reasons unrelated to the transplant. Two of them had acute cholecystitis and one haemothorax, due to rupture of the internal mammary artery during endomyocardial biopsy. Cholecystectomy was performed in the first two cases and thoracotomy in the third, with uneventful recovery in all cases. Early diagnosis and adequate surgical treatment are necessary in these cases. Consideration of the immunosuppressive medication is important during and after operation.

Primary cardiac tumours--operative treatment of 20 patients

This report describes a series of 20 patients operated on for a primary cardiac tumour. The majority of the tumours (16) were benign myxomas; 12 of them were located in the left atrium, two in the right atrium and two were biatrial. Two lipomas were found; one was epicardial and the other was located in the left atrium. The only intraventricular tumour was a malignant left ventricular myosarcoma. The propensity of intracardiac tumours to embolize was distinctive. Nine of the 16 myxomas presented with peripheral embolization, and in two patients surgery was complicated by fatal perioperative cerebral embolization of myxomatous tissue. Furthermore, in one patient embolization of a left atrial lipoma necessitated amputation of her left arm before cardiac surgery. Late postoperative recurrences were found in two patients with atrial myxomas. In one of them, reoperation showed that the tumour had grown at that site in the interatrial septum where the original pedicle had been excised. One patient developed severe mitral valve regurgitation and underwent replacement with a prosthetic valve at reoperation. Otherwise our late follow-up study showed that the results of surgery were usually excellent even though mild echocardiographic abnormalities were not uncommon. Our experience emphasizes the embolic potential of intracardiac myxomas and suggests, furthermore, that to avoid recurrences excisions with wide margins should be preferred. Echocardiography is an optimal method for the follow-up of these patients.

Angiographic findings in patients exhibiting ischemia after oral dipyridamole

We have assessed the angiographic features of a group of 37 patients given oral dipyridamole and 37 patients given matching placebo. Both groups represented severe coronary arterial disease and were studied prior to bypass surgery. Six patients (16%) had angina and 13 patients (35%) had electrocardiographic changes after dipyridamole. All the patients in the control group were nonresponders. In the group given dipyridamole the patients responding with angina had significantly more compromised collaterals than the patients without chest pain (P = 0.021). The same applied to the patients with electrocardiographic changes versus those with no electrocardiographic changes (P = 0.034). No differences between responders and nonresponders could be found in terms of the severity of coronary arterial disease, severity of anginal symptoms, exercise tolerance, antianginal medication, number of past myocardial infarctions, and left ventricular ejection fraction. In conclusion, the data strongly suggest that ischaemic responses to dipyridamole originate from myocardial steal accentuated by compromised flow in collateral vessels.

Intracellular-type solution flush for preservation of myocardium and coronary and pulmonary artery flow surface

Modified Euro-Collins solution (ECS), which has been successfully used in kidney, liver and lung transplantation, was tested concerning myocardial and endothelial preservation in nine piglets. In six (group I), 1-hour cardiac arrest was induced with cold modified ECS, and in three (group II) heart-lung transplantation was performed, using modified ECS for graft preservation. In group I myocardial energy preservation was determined with biochemical assays for adenosine triphosphate, creatine phosphate, lactate and creatine 5, 15, 30 and 60 minutes after aortic clamping, and preservation of endothelium in the aorta and coronary arteries was studied with scanning electron microscopy. In group II electron microscopy was performed on endothelial samples from the ascending aorta and coronary and pulmonary arteries of the heart-lung block after excision, after 2 hours of ischemia, and after 1-2 hours of reperfusion. High-energy phosphates decreased progressively during the ECS cardioplegia in group I, and circulatory support was required during the post-transplantation reperfusion period in group II. The endothelial lining in all specimens was remarkably well preserved, however. Modified ECS flush thus was ideal for vascular endothelium but, because of its poor energy-preserving capacity, unsuitable for cardioplegia.

Single-lung allotransplantation in pigs following donor pretreatment with intravenous prostaglandin E-1. Morphologic changes after preservation and reperfusion

Single left lung allotransplantation with ligation of the right pulmonary artery was performed on 11 pigs after donor pretreatment with prostaglandin E-1 and pulmonary artery flush with modified Euro-Collins solution. Sequential morphologic changes in pulmonary artery flow surface and lung structure were studied after 6-hour storage and after 4-hour reperfusion, using light microscopy and scanning and transmission electron microscopy. Morphologic observations were compared with functional changes. After 6-hour preservation slight degenerative changes were found in the pulmonary artery flow surface and changes in lung tissue suggestive of increased vascular permeability and edema. During 4-hour reperfusion the changes progressed. Preservation was in general moderate. Lung tissue showed vascular congestion and slight inflammation. Localized areas of reperfusion damage could adjoin near-normal looking alveoli. Oxygenation and gas exchange, though low in the beginning of reperfusion, tended to improve during the reperfusion period. The method was concluded to afford good morphologic preservation of the graft after 6-hour storage, and moderately good morphologic and functional preservation after 4-hour reperfusion.

Polydioxanone and polypropylene suture material in free internal mammary artery graft anastomoses

An experimental study with six beagle dogs was conducted to evaluate a new monofilamentous absorbable suturing material--polydioxanone. Free internal mammary artery grafts, 3 cm long, were harvested via a median sternotomy and were implanted as arterial bypasses in femoral arteries (12 end-to-end anastomoses) and as arteriovenous shunts in the carotid artery-contralateral jugular vein position (12 end-to-side anastomoses). Twenty-four anastomoses were made with monofilamentous nonabsorbable suturing material, polypropylene (12 arterial, 12 shunts), to serve as control grafts. At 6 months the grafts and anastomoses were explanted and studied with light and scanning electron microscopes. Macroscopically, the polydioxanone sutures had disappeared. The major histologic finding was the foreign body reaction around the polypropylene sutures. In the electron microscopic study the endothelial line covered the anastomotic site and in the polypropylene anastomoses the suture material was bulging up from the anastomoses. No aneurysms or dilatations were seen. According to this study, polydioxanone is a suitable suturing material for small luminal arterial anastomoses and is superior to polypropylene suturing material because it causes no tissue or other late changes on the flow surfaces.

Early and late results of surgery for atrial septal defect in patients aged over 60 years

To assess the risks and benefits attending the surgical repair of atrial septal defect in the elderly the case histories of all patients operated on at the age of 60 years or more were reviewed and follow-up study, including cardiac catheterization, was performed. A total of 17 patients (12 females and 5 males) were identified. The left-to-right shunt ratio averaged 2.7. Fifteen patients had abnormally high systolic (greater than 30 mmHg) or mean (greater than 20 mmHg) pulmonary artery pressure and the pulmonary arterial resistance was elevated (greater than 1.5 units) in eight. One patient died shortly after surgery (operative mortality, 6%) and major postoperative complications were found in four additional patients (24%). Three months after surgery the effort capacity had improved by at least one class in all survivors. After an average of 8.2 years follow-up 12 patients were alive. Ten of them felt better than preoperatively. Eight agreed to cardiac catheterization. The pulmonary blood flow was markedly decreased in all (means, 5.6 l/min postoperatively, vs 11.2 l/min preoperatively) even though a hemodynamically significant shunt persisted in two patients. The mean pulmonary artery pressure had decreased in all who were hypertensive before operation (mean, 25 mmHg vs 33 mmHg). It had slightly increased in patients who had normal pulmonary pressure preoperatively (mean, 27 mmHg vs 19 mmHg). The pulmonary arterial resistance was higher than before surgery in all except one patient (mean, 2.2 units vs 1.5 units).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of addition of magnesium to potassium-containing fluorocarbon cardioplegic preparations. An experimental study

The effect of magnesium on potassium fluorocarbon cardioplegia was studied in 20 rabbits. Isolated hearts with ascending aortas were perfused with oxygenated and cooled (+4 degrees C) fluorocarbon solutions. In 10 experiments, the solution contained 20 mmol/l of potassium, in 10 further experiments, 20 mmol/l of potassium and 15 mmol/l of magnesium. Ultrastructural preservation of the myocardium was studied using transmission electron microscopy. In addition, the cation contents of the myocardium were studied by flame atomic absorption spectrophotometry (calcium, magnesium) or electrothermal atomic absorption spectrophotometry (copper). After 120 minutes of ischaemia, areas of moderate or severe ultrastructural myocardial cell damage were observed in both groups but severe damage was more extensive and commoner in the group with no access to magnesium. Preservation of the capillary endothelium was also worse in that group. There was a highly significant increase in magnesium content, a decrease in calcium content and an increase in the magnesium/calcium ratio following magnesium-potassium fluorocarbon infusion. The copper content remained unchanged. A protective effect of magnesium was observed. The electrolyte content of cardioplegic solutions also alters the electrolyte content of the myocardium. This may be important in reperfusion.

Hypothermia and circulatory arrest in reconstruction of aortic arch. A report of nine cases

From 1982 until October 1985 we operated 9 cases of aortic aneurysm involving the transverse aortic arch (5 male and 4 female, from 26 to 69 years). Two patients had an acute dissecting aortic aneurysm, the others had an aneurysm of the aortic arch involving also the ascending aorta in 5 cases and the descending aorta in 1. Three patients underwent aortic valve replacement and implantation of coronary orifices. Two patients had previously had AVR. The operation was carried out under cardiopulmonary by-pass. After obtaining 25 degrees C hypothermia the bypass was discontinued and the cerebral vessels were cannulated from inside of the opened aneurysm and perfused at a flow rate of 250 ml/min. The myocardium was protected by cold cardioplegia and topical cooling. During total circulatory arrest the distal aortic arch anastomoses were completed in 28-56 minutes. Then the by-pass was restarted and the rest of the operation was carried out as usual. One patient with an acute dissecting aortic aneurysm died on the 2 post-operative day due to brain damage and rupture of abdominal aorta. The other patients recovered well. There were no permanent neurological or myocardial complications. Three patients had a transient renal failure, one needing dialysis. The 8 survivors have done well 4-46 months after the operation.

Correlation of NYHA classification, bicycle ergometry and right heart haemodynamics after total correction of tetralogy of Fallot in adults

Thirty-two patients who had undergone correction of Fallot's tetralogy in adult life were examined on average 6.3 years postoperatively, at mean age 25.8 years. Palliative shunt operation had been performed in childhood in 28 cases. The clinical condition was good in 25 patients (78%). 13 of whom had mean gradient between right ventricle and pulmonary artery 16.0 +/- 4.2 mmHg and systolic right ventricular pressure 39.0 +/- 10.0 mmHg, while 12 had right ventricular pressure 62.6 +/- 16.3 mmHg. In these groups the maximum exercise capacity was, respectively, 136.7 +/- 36.1 and 106.1 +/- 30.8 W/min. Three other patients were in satisfactory, and four in poor clinical condition, with right ventricular systolic pressure, respectively, 74.3 +/- 10.9 and 91.5 +/- 60.0 mmHg. The gradient from right ventricle to pulmonary artery averaged 58.5 +/- 10.4 mmHg in the latter group but, despite the obstructed pulmonary outflow tract, the exercise capacity (116.7 +/- 28.9 W/min) was similar to that in the groups with better clinical results. It is concluded that in most patients with palliative surgery in childhood, tetralogy of Fallot can be successfully corrected in adult life. The causes of right ventricular impairment do not significantly reduce the exercise capacity.

Cardiorespiratory function after correction of tetralogy of Fallot. Modifying effect of previous shunt operation

Of 28 patients with total surgical correction of tetralogy of Fallot in adult life, 22 had previously undergone Blalock-Taussig shunt operation. Possible modifying effects of the shunt on pulmonary ventilation and perfusion and on exercise tolerance were investigated with spirometry, radiospirometry and bicycle ergometry. The observed ventilatory volumes and capacities and diffusing capacity were significantly lower than the predicted values. Vital capacity was significantly reduced in patients with adverse NYHA or haemodynamic classification. Between the various NYHA or haemodynamic groups no statistically significant difference was demonstrable in pulmonary function or diffusing capacity or in airway resistance. Ventilatory obstruction was found also in patients without previous shunt. Other lung function tests showed no significant difference between the shunt and the non-shunt group. Nor was distribution of lung perfusion significantly affected by shunt. No correlation was seen between lung function and bicycle ergometric findings. However, in non-shunt patients who had ventilatory obstruction or impaired diffusing capacity, exercise tolerance was significantly higher than in patients who had had palliative shunt.

Reappearance of Hering-Breuer reflex after bilateral autotransplantation of the lungs

In combined heart-lung transplantation the afferent nerve pathways inevitably are transsected. In previous studies with en bloc heart-lung transplantation in dogs, we found altered regulation of breathing-abolition of Hering-Breuer reflex and response to hypercapnia inhalation stimulus consisting of augmented tidal volume with no change in respiratory rate-shortly after the operation. The long-term effects of pulmonary denervation on breathing regulation were now studied in dogs after staged bilateral pulmonary autotransplantation. Mechanical and electrical activities of the respiratory muscles were recorded during spontaneous breathing and after deflation and inflation with varying volumes of air. Five months postoperatively the duration of the respiratory cycle increased 2.5 times on inflation with 600 ml of air and occlusion of the airways, compared with tenfold prolongation in intact control dogs, indicating a partial return of the Hering-Breuer reflex after the autotransplantation. The duration of the EMG bursts in respiratory muscles increased in intact dogs and in those with bilateral lung autotransplants. In impulse frequency the response to stretching was less evident after autotransplantation. The mechanism mediating reappearance of Hering-Breuer reflex warrants further study.

Prolonged survival with a thrombotically occluded tricuspid valve prosthesis

A 49-year-old man who had undergone tricuspid valve replacement with a Björk-Shiley prosthesis in November 1974 was reoperated on in January 1985 due to prosthesis malfunction. The operation revealed a totally occluded prosthetic valve and a paravalvular defect which had served as the channel for atrioventricular blood flow. In retrospect, all evidence indicated that the valve had stuck as early as six months after the primary operation, when the patient had first noticed the loss of audible valve clicks and the reappearance of effort intolerance. Due to the gradual progression of the patient's symptoms and misinterpretation of the significance of absent valve clicks, the correct diagnosis was not made until a follow-up study 10 years after the first operation when contrast echocardiography showed the absence of both disc movements and transvalvular contrast flow. Our experience indicates that thrombosis of a tricuspid valve prosthesis may present highly insidiously and that the loss of audible valve clicks should be relied on as a sign of prosthesis malfunction.

Constrictive pericarditis following coronary bypass reoperation. Fibrotic pericardium and a foreign body reaction

A 65-year-old male patient underwent two bypass operations because of coronary artery disease. After the second operation he developed congestive heart failure with breathlessness, ankle swelling, hepatomegaly and poor exercise tolerance. Echocardiographic and haemodynamic findings were characteristic of constrictive pericarditis. Pericardiectomy was performed three months after the second operation. The retrosternal space was replaced with fibrotic, patchy hyalinic tissue, and the pericardium was thick and rigid. Histologically, the thickened pericardium showed dense fibrosis and foreign-body granulomas with large multinuclear giant cells and irregular crystals. This report indicates that foreign body reaction following coronary artery bypass operation may result in constrictive pericarditis with severe heart failure.

The effect of inhaled carbon dioxide and hypoxia mixtures on the electrical and mechanical activities of respiratory muscles in dogs

The effects of hypercapnia and hypoxia on the regulation of breathing was studied in six mongrel dogs during pentobarbital anaesthesia with special reference to their action on the respiratory muscles. Carbon dioxide (5.5% in air) inhalation produced an increase of minute volume due to augmentation of respiratory frequency and tidal volume. The number of electrical impulses per breath remained unaffected despite the increase tidal volume. Therefore the mechanical ventilation increased more than the electrical output to the respiratory muscles indicating that the efficiency of the muscles increased. The tidal volume increased more than the pressure impulse (mechanical work by the respiratory muscles) suggesting that the airway conductance was increased during hypercapnia. During hypoxic stimulus (11% oxygen in nitrogen) the increase of minute volume was due to increase in respiratory frequency. The ratio of tidal volume to the number of electrical impulses in the respiratory muscles remained unaltered. During combined carbon dioxide and hypoxia stimulus the responses were similar to those of carbon dioxide stimulus alone. However, the increase of minute volume and the increase in the ratio of tidal volume and pressure impulse to the number of electrical impulses in the respiratory muscles were more pronounced. These findings suggest that carbon dioxide affects the regulation of breathing above the respiratory muscles and in the muscles themselves. Hypoxic stimulus seems not to have any direct effect on the respiratory muscles in dogs during pentobarbital anaesthesia.

Failure of mechanical valves in Ebstein's malformation

Five patients with Ebstein's malformation were operated on with closure of the atrial septal defect and implantation of a mechanical prosthesis at the right atrioventricular junction. The 4 patients who survived showed an excellent early recovery. Three of the patients noticed the disappearance of the valve clicks 6 months after the operation. At re-examination using echophonocardiography, peripheral dye dilution curves and catheterization, these valves were found to be stuck in the open position in 2 patients and in the closed position in 1 patient. The last patient had a paravalvar channel supplying blood into the right ventricle. One patient who had a St. Jude prosthesis was doing excellently 4 years postoperatively and the valve was functioning well. Two years after the operation, the other patient with a St. Jude valve again noticed valve clicks after over 1 year of silence. Examination revealed the prosthesis to be functioning normally. The totally occluded Björk-Shiley prosthesis (10 years postoperatively) was excised at re-operation and replaced by an Ionescu-Shiley bioprosthesis. The patient with a jammed Björk-Shiley prosthesis (10 years postoperatively) declined a re-operation and is doing well, albeit under close observation.

Auscultatory characteristics of normally functioning Lillehei-Kaster, Björk-Shiley, and St Jude heart valve prostheses

Auscultatory and echocardiographic and phonocardiographic studies were performed on 26 patients who had a total of 11 Lillehei-Kaster, 16 Björk-Shiley, and 18 St Jude heart valve prostheses functioning normally in the aortic or mitral positions or both. With all types and positions of prostheses a distinct closing sound was always detected. It was frequently heard in two parts which, according to echocardiographic and phonocardiographic studies, resulted from the onset and completion of the valve closure. An opening sound could be heard from all Björk-Shiley and St Jude valves but from only four of the 11 Lillehei-Kaster valves. The opening sounds due to mitral prostheses consisted of two to three closely spaced clicks detected as a faint early diastolic crackle on auscultation. Echocardiography with phonocardiography indicated that they were related to the onset and termination of the disc opening excursion. In the aortic position the valves always produced early to mid-systolic murmurs, and a soft early diastolic murmur was also heard in seven of 23 patients. A mid-diastolic rumble was heard in 12 of 22 patients with mitral prostheses. Normally functioning tilting disc valve prostheses produce characteristic auscultatory findings, and familiarity with these findings will be useful in clinical evaluation of patients with these prostheses.

Substance P- and leu-enkephalin-immunoreactive nerves before and after myocardial ischaemia, hypothermic chemical cardioplegia and reperfusion injury during open-heart surgery

During open-heart surgery, myocardial biopsies were obtained before the start of extracorporeal circulation (from the right auricular appendage) and after weaning from the pump (from the right atrium), and processed for immunocytochemical demonstration of substance P- and leu-enkephalin-immunoreactive nerve fibres and for electron microscopy. Substance P-immunoreactive nerves were seen around blood vessels, between myocardial cells and forming large glomerulus-like loops, but were not numerous. Leu-enkephalin-immunoreactive nerves were very sparse. We therefore believe that both nerve types primarily are modulatory axons. In the post-weaning specimens, nerves of both types were more numerous (attributable to the different site of biopsy), and no change was seen in the immunofluorescence reaction. The ultrastructure (all types) of nerve terminals was well preserved, although myocardial damage was obvious in many specimens. Cardiac nerves, including peptidergic nerves, thus seem to be relatively resistant to ischaemia, hypothermic chemical cardioplegia and reperfusion injury.

Effects of synthetic blood combined with contrast medium on coronary endothelium: an experimental study

The study described was carried out to evaluate endothelial injury following incubation of coronary material in contrast medium and in contrast medium diluted with fluorocarbon solution. Six porcine hearts were excised and isolated. Immediately thereafter, pieces of the main coronary arteries and ascending aortas were incubated in four different solutions: 1) blood, 2) contrast medium, 3) fluorocarbon solution, 4) fluorocarbon--contrast medium (1:1). Flow surfaces and coronary endothelial morphology were evaluated by scanning electron microscopy (SEM). Porcine blood (at room temperature) preserved endothelial structures intact but, in two samples, small patchy areas of denuded surface were found. Four minutes' immersion in contrast medium resulted in easily visible changes in the endothelial lining and individual cells. Denuded flow surface areas were common, the intact surface morphology was flattened. After 7 minutes, destruction was total. The addition of fluorocarbon solution to contrast medium (1:1) diminished the changes, which also occurred later than after incubation in pure contrast medium. After 7 minutes, separate endothelial cells were still identifiable but the microvilli had disappeared. Fluorocarbon solution preserved the endothelial lining well during a 10-minute follow-up period. The experimental protocol described confirmed the deleterious effect of contrast medium on coronary endothelial lining, which could be reduced to some extent by adding fluorocarbon solution to contrast medium.

Mediastinal neurogenic tumours. Early and late results of surgical treatment

Early and late results of surgery for neurogenic mediastinal tumour were evaluated in 66 cases with a mean follow-up of 12 years. The series comprised 48 neurilemmomas, 8 neurofibromas, 7 ganglioneuromas, and neurinoma, neurofibrosarcoma and ganglioneuroblastoma each in one case. There were two early deaths (3%), one due to peroperative bleeding from the left subclavian artery and the other to acute myocardial infarction. Operative complications arose in 12 cases (18%), the most common being wound infection (3 cases). There were 17 late deaths (26.6%). In the neurilemmoma group, 3 of the 13 late deaths were related to the tumour or its treatment, and both deaths in the neurofibroma group were related to malignant transformation. Recurrence of tumour appeared in 3 of the 48 patients with neurilemmoma and also in the single patient with neurinoma as tumour classification. One neurilemmoma was a dumb-bell tumour, and operation in this case resulted in paraplegia. Malignant transformation appeared in 2 of the 8 neurofibromas 5 and 13 years postoperatively. Because of the risks of malignant degeneration and of recurrence, patients operated on for neurogenic mediastinal tumour should be carefully followed up for many years.

Plasma cell granuloma of lung and pleura

A report is presented of seven patients with plasma cell granuloma of the lung or pleura. Two were operated on in 1970, three in 1971, one in 1973 and one in 1984. None of the patients had smoked cigarettes. Five had a history of infection. Most of the patients were young, healthy and working. The surgical treatment was lobectomy in four cases, bilobectomy in one case and resection of tumour in two cases. The histology of the tumours was re-evaluated, and was similar in all cases. They were composed mainly of plasma cells, lymphocytes and granulocytes, and small foci of calcification were also seen. No recurrence of tumour was found in observation up to 13 years postoperatively. One patient died of pancreatic carcinoma after 6 years. The others are doing well.

Comparative analysis of tilting disc and ball valve prosthesis in aortic position

In a retrospective analysis, comparison was made between the Cutter-Smeloff ball valve (n = 63) and the Lillehei-Kaster tilting disc valve (n = 256) in the aortic position. No significant intergroup difference was found as regards rate of thromboembolism (0.6/100 patient years for both valve types), endocarditis (0.2 for Cutter-Smeloff and 0.5 for Lillehei-Kaster/100 patient years) and paraprosthetic leak (0.9 and 0.5, respectively/100 patient years). The actuarial curve of cumulative survival was similar for both valves until 6 years postoperatively. Thereafter the outcome was less favourable for the patients with Cutter-Smeloff valve (actuarial survival 79 +/- 5% than for those with Lillehei-Kaster valve (91.2 +/- 2%). The reason for this, statistically significant, difference may be associated with the difference in valve profiles.

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

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