Evaluation Of The Effectiveness Of Endovascular Treatment Of Type 2 Endoleaks

INTRODUCTION

Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment.

MATERIAL AND METHODS

A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. CT scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival.

RESULTS

Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76 years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6 months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5 mm since last procedure in 4 patients (24%).

CONCLUSION

Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.

Long-term prognosis following vascular graft infection: a 10-year cohort study

Background

Vascular graft infection (VGI) remains a severe disease with high mortality and relapse rates. We performed a retrospective single-center cohort study to highlight factors associated with long-term all-cause mortality in patients with vascular graft infection.

Methods

All patients hospitalized in our facility over 10 years for VGI were included. VGI was defined by the presence of a vascular graft or an aortic stent graft (stent or fabric), associated with 2 criteria among clinical, biological, imaging, or microbiological elements in favor of VGI. The primary outcome was all-cause mortality. Empirical antibiotic therapy was considered as appropriate when all involved pathogens were susceptible in vitro to the antibiotics used. The surgical strategy was defined as nonoptimal when the graft was not removed in a late-onset surgery (>3 months) or no surgery was performed.

Results

One hundred forty-six patients were included. Empirical antibiotic therapy was administered in 98 (67%) patients and considered appropriate in 55 (56%) patients. Surgery was performed in 136 patients (96%) and considered as optimal in 106 (73%) patients. In multivariable analysis, appropriate empirical antibiotic therapy was associated with a lower probability of mortality (hazard ratio, 0.47 [95% confidence interval, .30–.79]; P = .002). Long-term survival did not differ according to whether the surgical strategy was considered optimal or not (log-rank = 0.66).

Conclusions

Appropriate empirical antibiotic therapy is a cornerstone of the management of VGI. Whenever possible, antibiotics must be associated with optimal surgical management. However, surgery could potentially be avoided in comorbid patients who are treated with appropriate antibiotics.

Enhancer analysis of the Drosophila zinc finger transcription factor Earmuff by gene targeting

BACKGROUND

Many transcription factors are involved in the formation of the brain during the development of Drosophila melanogaster. The transcription factor Earmuff (Erm), a member of the forebrain embryonic zinc finger family (Fezf), is one of these important factors for brain development. One major function of Earmuff is the regulation of proliferation within type II neuroblast lineages in the brain; here, Earmuff is expressed in intermediate neural progenitor cells (INPs) and balances neuronal differentiation versus stem cell maintenance. Erm expression during development is regulated by several enhancers.

RESULTS

In this work we show a functional analysis of erm and some of its enhancers. We generated a new erm mutant allele by gene targeting and reintegrated Gal4 to make an erm enhancer trap strain that could also be used on an erm mutant background. The deletion of three of the previously analysed enhancers showing the most prominent expression patterns of erm by gene targeting resulted in specific temporal and spatial defects in defined brain structures. These defects were already known but here could be assigned to specific enhancer regions.

CONCLUSION

This analysis is to our knowledge the first systematic analysis of several large enhancer deletions of a Drosophila gene by gene targeting and will enable deeper analysis of erm enhancer functions in the future.

Editor's choice--hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: a multicenter retrospective study

OBJECTIVES

The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature.

METHODS

The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases.

RESULTS

There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients.

CONCLUSIONS

Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Analysis of outcome after using high-risk criteria selection to surgery versus endovascular repair in the modern era of abdominal aortic aneurysm treatment

INTRODUCTION

The concept of high-risk patients suggests that such patients will experience a higher rate of postoperative complications and worse short- and long-term outcomes, and should therefore benefit from the use of endovascular techniques for aortic abdominal aneurysm (AAA) repair. The primary goal of this study was to assess the relevance of the different high-risk criteria, defined by the French health agency Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSAPS) in a single-centre continuous series. Secondary goals were to retrospectively compare the incidence of postoperative complications and short- and long-term survival in three groups of patients.

MATERIALS AND METHODS

Between January 1999 and December 2006, details of all the patients undergoing elective surgery for AAA in our hospital were recorded into a prospective registry (n=626). Three groups were considered according to the level of risk and type of repair defined by the AFSSAPS: endovascular aortic aneurysm repair (EVAR) high-risk (HR) (at least one high-risk factor and EVAR, n=138), open HR (at least one high-risk factor and open repair, n=134) and open low-risk (LR) (no high-risk factors and open repair, n=344). None of the low-risk patients were treated using an endovascular approach. The demographics, preoperative risk factors, intra-, postoperative data and short- and long-term survival were compared between the groups. Interrelations among the set of high-risk criteria for mortality were calculated using multiple correspondence analysis (MCA).

RESULTS

The distribution of high-risk criteria was similar in both high-risk groups, except for age, heart failure and hostile abdomen, which were significantly more frequent in EVAR HR. Operation time, blood loss and length of stay in an intensive care unit and hospital were significantly lower in the EVAR HR group. The 30-day mortality and survival rates at 5 years were 5.4 and 59.4% for EVAR HR, 3.7 and 70.4% for open HR and 2.3 and 83.7% for open LR, respectively, with no significant difference between the three groups for the mortality, but a significant higher survival at 5 years for the open LR versus both high-risk groups.

CONCLUSION

The high-risk AFSSAPS criteria were not predictive of postoperative mortality and should not be used to determine the choice of treatment technique. Other criteria therefore need to be established to determine whether open or EVAR repair should be used.

High circulating levels of 7beta- and 7alpha-hydroxycholesterol and presence of apoptotic and oxidative markers in arterial lesions of normocholesterolemic atherosclerotic patients undergoing endarterectomy

In previous investigations, we found that 7beta-hydroxycholesterol had potent pro-apoptotic, and pro-oxidative properties. So, we asked whether the circulating level of this oxysterol was enhanced in atherosclerotic patients undergoing endarterectomy of the superficial femoral artery. To this end, 7beta-hydroxycholesterol serum concentrations were determined and compared with common lipid parameters in atherosclerotic patients, and in healthy subjects. 7alpha-hydroxycholesterol was simultaneously measured to evaluate the reliability of the method used for oxysterol analysis. On normal and atherosclerotic arterial fragments from patients, markers of oxidation (4-hydroxynonenal (4-HNE) adducts), and apoptosis (activated caspase-3; condensed/fragmented nuclei) were studied. Interestingly, high serum concentrations of 7beta- and 7alpha-hydroxycholesterol were found in normocholesterolemic atherosclerotic patients. However, in statin-treated patients, the circulating levels of 7beta- and 7alpha-hydroxycholesterol tend towards normal values. Therefore, 7beta- as well as 7alpha-hydroxycholesterol could be more appropriate markers of lipid metabolism disorders than cholesterol or LDL in normocholesterolemic patients with atherosclerosis of the lower limbs, and statins could normalize their serum concentrations. At the arterial level, apoptotic cells were mainly identified in low grade lesions and no statin effects were found on oxidation and apoptosis.

Endovascular treatment as first choice in chronic intestinal ischemia

The purpose of this study was to define the place of endovascular treatment in chronic intestinal ischemia (CII). We report here a series of 19 consecutive patients treated with percutaneous angioplasty of the intestinal arteries. We excluded patients with acute ischemia, from the study. From January 1, 1989 to December 31, 2001, 19 patients with symptomatic CII were treated by endovascular techniques. This study group included 11 men and 8 women with a mean age of 59 years (range 30 to 90 years). The clinical presentation included postprandial pain in 16 patients, weight loss in 14 patients, with a mean weight loss of 7.4 kg (range 0 to 30 kg); and gastroparesis in 2 patients. Stenoses were significant in the single superior mesenteric artery (SMA) in 2 patients and in two arteries in 17 patients, including the celiac artery (CA) and SMA (n = 13), CA and inferior mesenteric artery (IMA) (n = 1), and SMA and IMA (n = 3). Balloon angioplasty was performed in only one of the arteries in each patient, 15 times in the SMA and 4 times in the CA. In 7 patients, angioplasty required stenting because of recoil (n = 5) or dissection (n = 1). In one patient the lesion was stented primarily, because of adjacent thrombus on the stenosis. Our results showed that initial treatment of CII can be endovascular. Focus on one artery only, seems to be reasonable and efficient in the short and long term.

[Four years followup of complicated Cockett syndrome treated by iliac vein endoprosthesis]

The purpose of this study was to check the long-term patency of the left common iliac vein endoprosthesis in Cockett syndrome and to confirm this appropriate etiological treatment in complicated cases. Three patients had respectively a pulmonary embolism, left common iliac vein occlusion with protein S deficiency, and venous claudication (Paget-von Schroetter syndrome) as complications of the Cockett syndrome. Treatment with endoprosthesis was performed. A mean follow-up of 48.6 months (31-61 months) revealed a clinical improvement without any recurrence of complications. The patency of the left common iliac vein flow was maintained. Indications on this treatment are being discussed.

Preoperative intraarterial thrombolysis before surgical revascularization for popliteal artery aneurysm with acute ischemia

Because a popliteal artery aneurysm (PAA) generates emboli that progressively deteriorate the distal arterial network, they can constitute limb-threatening lesions. In 20 to 40% of cases, discovery of PAA coincides with sudden occlusion and resulting acute ischemia. In 40 to 60% of these patients, surgical revascularization fails and amputation is required. The objective of this prospective study was to assess the value of intraarterial thrombolysis to restore distal runoff before surgical revascularization. Between January 1, 1992 and December 31, 1996, we treated 15 PAA causing acute ischemia in 15 male patients with a mean age of 66.7 years (range, 44 to 87 years). Diagnosis was documented by clinical examination and ultrasound imaging. Intraarterial thrombolysis was performed under arteriographic control through a multiperforated catheter inserted by the anterograde femoral route to the thrombus. After an initial bolus of 100,000 U of urokinase, 600,000 to 1,600,000 U was continuously infused over a period of 6 to 18 hr. Heparin sodium was administered throughout thrombolysis. Surgical revascularization was performed within 1 to 4 days (mean, 2 days) after thrombolysis by exclusion and bypass in 14 cases and percutaneous transluminal angioplasty with stenting in 1 case. The ensuing results showed that, if performed carefully, intraarterial thrombolysis can safely prepare patients presenting with occluded PAA with acute ischemia for surgical revascularization to restore distal runoff. We use this combined technique routinely in our department. Morbidity is low in comparison with the risks of amputation.

Surgical outcome of traumatic rupture of the thoracic aorta

BACKGROUND

The aim of this study was to point out the results of different techniques of spinal cord protection in surgically-treated patients with traumatic thoracic aorta (TTA).

METHODS

A multicentric study was carried out involving 182 patients with TTA. Four patients died before surgery. Two patients were operated on without any investigation and 2 had no aortic tear at thoracotomy. The remaining 174 patients had aortic isthmus disruption and were included in the study. The mean age was 32.3+/-14.29 years with 126 men (72.4%) and 48 women (27.6%). Road accidents were causal in 163 patients (93.66%); polytraumatism was frequent. A standard chest roentgenogram led to a diagnosis which was confirmed with aortography in 94.8% of cases. Surgical repair of visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. Thirty-three patients (19%) died and 9 (5.2%) had paraplegia. Sixty-nine patients had clamp and sew technique (group 1). Ninety-three patients had different types of extracorporeal circulation (group 2), and 12 patients had Gott shunt (group 3). No difference appeared between the 3 groups according to mortality and paraplegia. But the sex ratio, age, visceral lesions, craniocerebral lesions, the type of aortic repair, and cross-clamp time were discriminative.

RESULTS

The univariate analysis point out age, cross-clamp time, hemothorax, and anatomical type of aortic injury as the risk factors of death. This was confirmed by a multivariable test which retained age, cross-clamp time, and hemothorax as risk factors. When not diagnosed in time, TTA is serious and has a bad prognosis. In spite of a high mortality and morbidity, the surgical management has improved. Immediate operation and medullar protection are the stumbling block in this operation.

CONCLUSIONS

Operation can be delayed in some cases, but one must take care of hemodynamic instability. This calls for a repair of the serious associated lesions first, or of a quick performing of a thoracotomy for ruptured aorta. The question remains, is it better to protect the spinal cord with the lower aortic perfusion and avoid the simple cross-clamp? Clinical studies give few answers to this question, and the best answer has not yet been given, as we lack prospective studies in this field.

The interest of surgical closure of patent foramen ovale after stroke: a preliminary open study of 8 cases

The risk of stroke and the risk of recurrent strokes in patients with patent foramen ovale (PFO) need a prevention that still remains a therapeutic problem. There are 4 preventive treatments: anti-agregants, anti-coagulants, transcatheter closure, and surgical closure of PFO. The aim of this study was to demonstrate that surgical closure of PFO is safe and useful for prevention of strokes. Eight patients with stroke and PFO diagnosed by transesophageal echography (TEE) were prospectively selected for surgical closure. It was necessary to be younger than 70 years, not to have another cause of stroke, and to have either recurrent strokes or several ischemic lesions on MRI, isolated for PFO associated with an atrial septal aneurysm, and to have a Valsalva maneuver or cough inducing the stroke. For these reasons, these patients were considered to be an homogenous group with a strong relationship between the PFO and the stroke, and with a high risk of recurrence of stroke. The 8 patients had a direct suture of the PFO with a cardiopulmonary bypass. All patients were followed-up with clinical, MRI and TEE examinations during 12 months after surgery. No surgical complications were observed. After one year, without any anticoagulant treatment, no recurrent stroke or transient ischemic attack, no new ischemic lesions on MRI, nor neuropsychological disturbance were noted. No post-surgical inter-atrial right-to-left shunting was observed. In the absence of controlled studies to guide therapeutic options, our data suggest that surgical closure of PFO in patients with stroke, is safe and efficacious to prevent recurrent stroke without any anticoagulants in the first year of follow-up. Further studies are needed to evaluate the long-term role of surgical closure of PFO as an alternative to prolonged anti-thrombotic treatment.

[Carotid endarterectomy by eversion and reimplantation. Techniques and results]

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

[Extra-popliteal localizations of adventitial cysts. Review of the literature]

Cystic adventitial disease is an uncommon vascular anomaly first described in 1947 in the external iliac artery. The preferential localization is the popliteal artery although other arteries and veins may also be involved though not always recognized. There have been 45 extra-popliteal localizations of adventitial cysts reported in the literature. Thirty cases involved an artery an 15 a vein. The iliofemoral axis, with 33 reported cases, is the preferential localization of these extra-popliteal adventitial cysts (including 22 arteries and 11 veins). All the other cases also involved a vessel near an articulation (knee, ankle, elbow, wrist). Despite a preferential popliteal arterial localization only one case involved the popliteal vein. The diagnosis is rarely made before surgery, probably because of the nonspecific clinical presentation. Ultrasonography should allow better recognition of these adventitial cysts, eliminating an aneurysm or a synovial cyst, and evidencing the localization of the cyst within the vessel wall.

[Advances in surgery for carotid stenosis. 900 operations (1983-1994)]

OBJECTIVES

To evaluate morbidity and mortality in carotid endarterectomy in a personal series.

METHODS

Nine hundred endartectomies were performed from 1983 to 1994. All patients had > 70% carotid narrowing. Five hundred five patients underwent without preoperative angiography.

RESULTS

Outcome was analyzed for 3 periods showing decreasing mortality from 4.56% in 1983-86 to 0.67% in 1990-1994.

CONCLUSION

The reduction in morbidity and mortality resulted from the combined effects of pre-, per-, and post-operative care including noninvasive preoperative diagnosis of internal carotid artery stenosis using ultrasound duplex and surgery without previous angiography, delayed surgery in case of recent prolonged hemispheric deficit or of ischemic defect detected on computed tomography (CT) or magnetic resonance imaging (MRI), cerebral evaluation with CT-scan or MRI the day before operation, surgery under locoregional anesthesia, monitoring of arm arterial blood pressure during the first 24 hours following surgery.

Effect of verapamil on the prognosis of patients with early postinfarction electrical or mechanical complications. The Danish Verapamil Infarction Trial II (DAVIT II)

The Danish Verapamil Infarction Trial II (DAVIT II) demonstrated from the second postinfarction week, that long term treatment with verapamil significantly improved reinfarction free survival after an acute myocardial infarction (AMI). The present post hoc analysis of DAVIT II was undertaken with the purpose of evaluating the effect of treatment with verapamil in patients with early electrical complications, i.e. ventricular or atrial fibrillation, ventricular tachycardia, or second or third degree atrioventricular block, with or without mechanical complication, i.e. heart failure, during the first post-AMI week. In the placebo group, the 18-month mortality rate was lowest (9.5%) in patients without electrical or mechanical complications, highest (24.6%) in patients with electrical events only, and in-between (17.5%) in patients with mechanical problems regardless of presence of electrical complications. Verapamil significantly reduced the 18-month mortality rate in patients with early electrical without mechanical complications (60% reduction, P = 0.02), and in patients without mechanical complications (35% reduction, P = 0.02). Verapamil did not change the mortality rate in patients with mechanical complications.

Short- and long-term prognostic implications of in-hospital postinfarction arrhythmias. DAVIT II Study Group

The purpose of the present study was to evaluate, in patients surviving the first postinfarction week, the short- and long-term prognostic implications of arrhythmias, and their relation to easily obtained anamnestic and clinical parameters presented during hospitalisation. The study consisted of 897 placebo-treated patients of the Danish Verapamil Infarction Trial II (DAVIT II). In patients with and without supraventricular tachycardia mortality within 2 months was 9.2 and 3.7% (p = 0.004), respectively. By multivariate analysis supraventricular tachycardia independently predicted mortality within 2 months. Mortality within 5 years was predicted by the presence of supraventricular tachycardia, atrial fibrillation, advanced atrioventricular block, sinoatrial block, and of the combined arrhythmic parameter, i.e. ventricular and/or atrial fibrillation and/or advanced atrioventricular block. When easily obtained and assessed anamnestic and clinical parameters were included in a multivariate analysis, the presence of supraventricular tachycardia alone gave independent prognostic information on long-term mortality.

Does exercise-induced ST-segment depression predict benefit of medical intervention in patients recovering from acute myocardial infarction? The Danish Study Group on Verapamil in Myocardial Infarction

The present study tested the hypothesis that the increased risk in patients with exercise-provoked ST-segment depression recovering from acute myocardial infarction could by abolished by anti-ischaemic medical intervention. Prior to discharge a symptom-limited exercise test was carried out. Patients were then double-blindly randomized to treatment with either verapamil 120 mg t.i.d. or placebo, and observed for up to 18 months (mean 17 months). End-point was first major event; i.e. non-fatal reinfarction or death. Two-hundred-and-ninety-eight patients were included. Forty-four patients with and 111 without exercise-induced ischaemia were randomized to verapamil and 39 and 104 respectively, to placebo. The overall number of events was 12.5%. In patients without ST-segment depression, 12.5% in the placebo group (hazard = 1) and 12.6% in the verapamil group (hazard = 1.13) had an event (NS). In patients with ST-segment depression 15.4% in the placebo group (hazard = 1.20) and 9.1% in the verapamil group (hazard = 0.85) had an event (NS). The latter reduction (41%) supports the hypothesis that patients with ST-segment depression, i.e. residual myocardial ischaemia, are those who benefit from anti-ischaemic intervention after myocardial infarction.

Exercise-provoked ST-segment depression and prognosis in patients recovering from acute myocardial infarction. Significance and pitfalls

The importance of maximal versus submaximal exercise testing and the significance of heart failure on the prognostic value of exercise-provoked ST-segment depression > or = 0.1 mV was studied in 143 patients recovering from acute myocardial infarction. Patients were exercise tested prior to discharge and follow up lasted for up to 18 months (mean 17 months). End-point was first major event (i.e. first non-fatal reinfarction or death). A symptom-limited exercise test was superior to a heart-rate-limited test in detecting ST-segment depressions (27% vs. 20%: P < 0.5), and patients with ST-segment depression at lower heart rates did not have an increased risk of subsequent events compared with patients with ST-segment depression at higher heart rates (14% vs. 27%; NS). Heart failure surpassed ST-segment depression as a risk predictor (34% vs. 18%). Based on a meta-analysis including 13 studies (1987 patients) exercise-provoked ST-segment depression possessed an increased risk of subsequent major events (P < 0.0001; risk ratio = 1.90; 95% confidence limits 1.43,2.51). Thus, ST-segment depression provoked by a symptom-limited test selects patients with an increased risk of subsequent major events. In patients with a history of heart failure exercise-provoked ST-segment depression is of limited value.

Incidence and prognostic significance of intraventricular block in acute myocardial infarction

In 404 consecutively admitted patients with their first myocardial infarction (MI), intraventricular block (IV) was a complication in 124 (31%). The following types of block were encountered: 21 (5%) had left bundle-branch block (LBBB), 73 (18%) left anterior hemiblock (LAH), 13 (3%) left posterior hemiblock (LPH); 7 (2%) right bundle-branch block (RBBB); 9 (2%) RBBB + LAH, and 1 (0.3%) RBBB + LPH. Patients with IV block at the time of admission did not develop total atrioventricular block more frequently in the acute phase of MI (0-30 days) or in the follow-up period (3-5 years) than patients without IV block. During the acute phase, only patients with RBBB with or without hemiblock showed significantly higher mortality than patients without IV blocks. The other types of IV block did not influence the short-term prognosis. Among patients who survived the acute phase, significantly lower long-term survival rates were found in patients with LBBB compared to patients without IV block, whereas the presence of LAH did not affect the long-term prognosis.

Long-term survival after myocardial infarction as related to early complications

The material consists of 404 hospitalized patients with their first AMI. After an observation time of 1 and 5 yr, respectively, the mortality was 27% and 45%, against an expected mortality of 3% and 17% in a corresponding normal population. The annual mortality rate was 5.5% from 1 to 3 yr after the acute infarction, against an expected 3.5%. 3-5 yr after occurrence of the infarction, both the observed and expected annual mortality rates were 3.5%. In patients alive 1 mth after the acute attack, congestive heart failure (CHF) or left bundle branch block (LBBB) or secondary ventricular fibrillation (VF) during the acute phase gave a lower long-term survival, as compared to patients without CHF, intraventricular block or VF, respectively. Left anterior hemiblock, complete atrioventricular block following inferior infarction, or primary VF had no influence on the long-term prognosis.

Histopathology of the conduction system in patients with atrioventricular or intraventricular conduction disturbances

In 9 lethal cases where clinical signs gave rise to the suspicion of acute myocardial infarct (AMI) where well-characterized e.c.g.-changes, permanent or intermittent, were found by monitoring, a very careful autopsy of the heart was carried out, combined with a meticulous histological investigation of the conduction system. Acute changes of mild degree in the conduction system were found only in one case, possibly explaining the left bundle branch block found in this case. In the remaining cases, nothing but chronic changes were found and they did not exceed significantly the changes otherwise to be found in the agegroups concerned in a "control series" of violent deaths not preceded by symptoms of heart disease. According to an estimate there was good correlation between the conduction disturbances demonstrated and the localization of histopathological changes in seven of nine patients; in one of the latter correlation was relatively good; correlation was dubious only in one case. On this basis the authors conclude that present changes in the conduction system which are assumed mainly to be age-related, are the factors to determine the type of conduction disturbances from which the patient will suffer if acute heart ischaemia sets in, for instance due to an AMI, in fact, changes by which he will be predisposed to such disturbances.

Pulmonary congestion in chronic heart disease. Radiologic, clinical and hemodynamic relationships

Pulmonary congestion in chronic heart disease was evaluated by lung auscultation and roentgen examination of the chest and compared with pressure recording of the pulmonary circulation in 49 cases. Whereas auscultation appeared not to be correlated to the pressures, the radiologic findings proved to be a reliable measure of increased pressures. The radiologic assessment was based on isolated flow shift to the upper lobes of the lungs, indicating slight pulmonary venous hypertension, and flow shift in association with blurring of the lower lobe vessels, indicating pulmonary interstitial oedema. In distinction to the results from acute cardiac failure interlobular septa were often demonstrated in association with pulmonary interstitial oedema, and pulmonary alveolar oedema rarely demonstrated in spite of marked pulmonary venous hypertension.