MIDCAB vs OPCAB for severe coronary artery disease: a comparative study

Background/Introduction

MIDCAB (minimally invasive direct coronary artery bypass surgery) ± PCI/DES was compared to classical “off pump” coronary artery bypass surgery (OPCAB) for the treatment of severe coronary artery disease.

Purpose

We hypothesized that MIDCAB is associated with reduced perioperative morbidity and mortality.

Methods

Preoperative and postoperative clinical data were collected prospectively in 329 consecutive patients with severe coronary artery disease undergoing either a MIDCAB procedure ± PCI/DES (MIDCAB group), n=118 patients, or classical OPCAB (OPCAB group), n=211 patients, at our institution from January 2017 to July 2019. A matched analysis using the EuroSCORE II (81 patients per group) was done.

Results

The median of EuroSCORE II was 1.05 in both groups, p=1. All MIDCAB patients underwent a left-sided mini-thoracotomy and received a single LIMA-LAD graft, OPCAB patients received median 3 distal anastomoses, p<0.001. Operative time was shorter in MIDCAB patients, 160min vs. 240min, p<0.001. Maximum postoperative Troponin levels were lower in MIDCAB compared to OPCAB, 105 μg/l vs. 260 μg/l, p<0.001. Intubation time was shorter in MIDCAB, 7.0 h vs. 9.3 h, p=0.04, as was ICU time, p=0.02. Chest tube drainage after 24 hours was lower in MIDCAB patients, 405 mL vs. 555 mL, p<0.001. Transfusions of blood, platelets and fresh frozen plasma were rarely needed. Transfusion of erythrocytes were more common in OPCAB, 19%, vs. MIDCAB, 2.5%, p=0.001. A transient neurological deficit showed one (1.2%) patient in the OPCAB group, non in MIDCAB, p=0.3. A hybrid procedure was performed in 18 MIDCAB patients (22%) and 5 OPCAB patients (6.2%). In-hospital mortality was 0% in the MIDCAB group, and 1.2% in OPCAB patients, p=0.3.

Conclusions

MIDCAB is a good and safe option to treat severe coronary artery disease. MIDCAB is not only less invasive, but associated with reduced perioperative risk compared to standard OPCAB surgery even if a hybrid procedure is needed.

Funding Acknowledgement

Type of funding source: None

Diastolic Filling Reserve Preservation Using a Semispherical Dacron Patch for Repair of Anteroapical Left Ventricular Aneurysm

In postinfarction left ventricular aneurysm, abnormal geometry and desynchronized wall motion may cause a highly inefficient pump function. The traditional endoventricular patch plasty according to the Dor technique might result in a truncated and restrictive left ventricular cavity in small adults. We report a modified technique of left ventricular anteroapical aneurysm repair by using a semispherical reshaping patch to restore the left ventricular geometry.

Full-root aortic valve replacement with stentless xenograft achieves superior regression of left ventricular hypertrophy compared to pericardial stented aortic valves

BACKGROUND

Full-root aortic valve replacement with stentless xenografts has potentially superior hemodynamic performance compared to stented valves. However, a number of cardiac surgeons are reluctant to transform a classical stented aortic valve replacement into a technically more demanding full-root stentless aortic valve replacement. Here we describe our technique of full-root stentless aortic xenograft implantation and compare the early clinical and midterm hemodynamic outcomes to those after aortic valve replacement with stented valves.

METHODS

We retrospectively compared the pre-operative characteristics of 180 consecutive patients who underwent full-root replacement with stentless aortic xenografts with those of 80 patients undergoing aortic valve replacement with stented valves. In subgroups presenting with aortic stenosis, we further analyzed the intra-operative data, early postoperative outcomes and mid-term regression of left ventricular mass index.

RESULTS

Patients in the stentless group were younger (62.6 ± 13 vs. 70.3 ± 11.8 years, p < 0.0001) but had a higher Euroscore (9.14 ± 3.39 vs.6.83 ± 2.54, p < 0.0001) than those in the stented group. In the subgroups operated for aortic stenosis, the ischemic (84.3 ± 9.8 vs. 62.3 ± 9.4 min, p < 0.0001) and operative times (246.3 ± 53.6 vs. 191.7 ± 53.2 min, p < 0.0001) were longer for stentless versus stented valve implantation. Nevertheless, early mortality (0% vs. 3%, p < 0.25), re-exploration for bleeding (0% vs. 3%, p < 0.25) and stroke (1.8% vs. 3%, p < 0.77) did not differ between stentless and stented groups. One year after the operation, the mean transvalvular gradient was lower in the stentless versus stented group (5.8 ± 2.9 vs. 13.9 ± 5.3 mmHg, p < 0.0001), associated with a significant regression of the left ventricular mass index in the stentless (p < 0.0001) but not in the stented group (p = 0.2).

CONCLUSION

Our data support that full-root stentless aortic valve replacement can be performed without adversely affecting the early morbidity or mortality in patients operated on for aortic valve stenosis provided that the coronary ostia are not heavily calcified. The additional time necessary for the full-root stentless compared to the classical stented aortic valve replacement is therefore not detrimental to the early clinical outcomes and is largely rewarded in patients with aortic stenosis by lower transvalvular gradients at mid-term and a better regression of their left ventricular mass index.

Multikinase inhibitor sorafenib prevents pressure overload-induced left ventricular hypertrophy in rats by blocking the c-Raf/ERK1/2 signaling pathway

Background

Left ventricular hypertrophy (LVH) is a potent risk factor for sudden death and congestive heart failure.

Methods

We tested the effect of sorafenib, a multikinase inhibitor (10 mg/kg, given orally, starting 2 days prior to banding, till sacrifice on day 14), on the development of LVH following aortic banding in rats.

Results

The latter resulted in significant LVH caused by both an increase in cardiomyocyte volume and interstitial collagen deposition. The observed LVH was entirely blocked by sorafenib downregulating both of these components. LVH was associated with PDGF-BB and TGFβ1 overexpression, as well as phosphorylation of c-raf and ERK1/2. Additionally, the transcription factors c-myc and c-fos leading to proliferation as well as the hypertrophy-inducing transcription factor GATA4 and its regulated gene ANP were all upregulated in response to aortic banding. All these overexpressions and upregulations were inhibited upon sorafenib treatment.

Conclusion

We show that sorafenib exhibits a regulatory role on the occurrence of LVH following AB in rats by blocking the rise in growth factors PDGF-BB and TGFβ1, activation of the corresponding c-Raf-ERK1/2 signaling pathway and effector mechanisms, including GATA4 and ANP. This effect of sorafenib may be of clinical importance in modulating the maladaptive hypertrophic response to pressure overload.

Familial unruptured sinus of Valsalva aneurysm obstructing the right ventricular outflow tract

A case demonstrating compression of the right ventricular outflow tract by an unruptured coronary sinus of Valsalva aneurysm in which repair resulted in symptomatic improvement is presented. The pathology report revealed that the patient's younger brother had died from a ruptured aneurysm of the coronary sinus of Valsalva. The present report is the first to describe a familial unruptured coronary sinus of Valsalva aneurysm raising questions regarding the screening of relatives of patients with sinus of Valsalva aneurysms of unknown etiology.

The development of cardiac surgery in an emerging country: a completed project

The necessity to develop cardiac surgery centers in the emerging world is widely accepted. Numerous groups and organizations from the developed world are involved in such work; however, the best method in which to develop a sustainable center in the emerging world is still debated. Herein, we present an approach that we have used in several such projects, which involves regular and frequent instructional visits with progressive reduction of our instructional support. Data to support our approach are presented.

Unusual Complications After Rewarming for Deep Accidental Hypothermia

Deep accidental hypothermia is an uncommon pathology. Successful management has been reported in isolated cases, but the majority of patients die from complications after rewarming. We report on a patient with deep accidental hypothermia after a mountaineering accident. He was successfully rewarmed with cardiopulmonary bypass, but presented several complications which led to death. These complications included the patient developing acute peritonitis and necrotizing fasciitis, which represent, to our knowledge, complications that have never been associated with deep accidental hypothermia before.

[The heart transplant in Lausanne from 1987 to 2003]

Since the availability of ciclosporine, the survival after heart transplantation has dramatically improved. We present our results since the beginning of our experience in 1987. We treated in the Lausanne University hospital, 150 patients for end-stage cardiac disease. Hundred and fifty-two transplantations were performed. The survival rate is comparable to the literature with 81% at one year, 70% at five year and 63 at ten year included the hospital mortality. We review the incidence of complications during the follow-up and report the modification in the management of these patients especially concerning the immunosuppression.

Success of thrombolysis as a predictor of outcome in acute thrombosis of popliteal aneurysms

PURPOSE

Acute limb ischemia after thrombosis of a popliteal aneurysm is a distinct and limb-threatening entity. Preoperative intra-arterial thrombolysis may improve the outcome in this challenging situation. This study retrospectively analyzed a consecutive series of patients treated with preoperative thrombolysis and subsequent revascularization.

METHODS

Thirteen patients with acute limb ischemia caused by thrombosis of a popliteal aneurysm underwent catheter-directed intra-arterial thrombolysis with urokinase and subsequent vascular reconstruction. The angiographic and clinical outcome was analyzed and compared with that in the literature.

RESULTS

Complete aneurysm thrombosis with absence of runoff was documented in 12 cases. Thrombolysis restored perfusion with patency of the popliteal artery and a one- or two-vessel runoff in 77% of cases (10/13). Early cumulative graft patency and limb salvage rates were 68% and 83%, respectively, with an ankle/brachial index of 0.8 +/- 0.2. Lytic failure followed by attempts at bypass grafting was present in three patients (23%) and resulted in above-knee amputation. Severe rhabdomyolysis and fatal pulmonary embolism were responsible for a 15% early mortality rate.

CONCLUSION

Preoperative thrombolysis followed by bypass grafting is a valid treatment option for patients who can withstand an additional period of ischemia that does not require immediate revascularization and intraoperative lysis. Lytic failure identifies patients with a highly compromised runoff who are probably best treated by means of subsequent amputation, without any attempts at bypass grafting.

[Long-term mechanical circulatory support for terminal cardiac insufficiency refractory to medical treatment]

Constant progress has been made over the years in order to improve the performance of mechanical circulatory support devices. After the introduction of portable blood pump systems into clinical practice, we now study the performance characteristics of totally implantable mechanical circulatory support systems which do not require percutaneous drive lines or percutaneous electrical wiring. As a matter of fact, transcutaneous energy transfer is now achieved by induction, and pump controller performance read-out and pump parameter adjustment is performed by telemetry. The indication for clinical use of such devices has to be evaluated carefully. Mainly patients in need of a heart transplant but having contraindications to move forward (advanced age, former neoplasm, persistent antibodies) have benefits from such devices as destination therapy.

A new expandable cannula to increase venous return during peripheral access cardiopulmonary bypass surgery

Peripheral cannulation for cardiopulmonary bypass (CPB) is of prime interest in minimally invasive open heart surgery. As CPB is initiated with percutaneous cannulae, venous drainage is impeded due to smaller vessel and cannula size. A new cannula was developed which can change shape in situ and therefore may improve venous drainage. An in vitro circuit was set-up with a penrose latex tubing placed between the preload reservoir and the cannula, encasing the cannula's inlet and simulating the vena cava. The preload (P) was stabilised at 2 and at 5 mmHg respectively. The maximum flow rate was determined for 4 conditions: passive venous drainage (PVD) and assisted venous drainage (AVD) using a centrifugal pump at the 2 preload settings. We compared the results of the prototype cannula to classical femoral venous cannulae: basket 28Fr, a thoracic 28Fr and a percutaneous 27Fr. Under PVD conditions and a CVP of 2 mmHg, the prototype cannula's flow rate outperformed the next best cannula by 14% (p=0.0002) and 13% under AVD conditions (p=0.0001). Under PVD conditions and a CVP of 5 mmHg, the prototype cannula outperformed the percutaneous cannula by 19% (p=0.0001) and 14% under AVD conditions (p=0.0002). The new cannula outperforms the classical percutaneous venous cannulae during all of the four conditions tested in vitro.

The GraftConnector experience. Long-term patency and histological work up in an animal model

BACKGROUND

A device to perform sutureless end-to-side coronary artery anastomosis has been developed by means of stent technology (GraftConnector). The present study assesses the long-term quality of the GraftConnector anastomosis in a sheep model.

METHODS

In 8 adult sheep, 40-55 kg in weight, through left anterior thoracotomy, the right internal mammary artery (RIMA) was prepared and connected to the left anterior descending artery (LAD) by means of GraftConnector, on beating heart, without using any stabilizer. Ticlopidine 250 mg/day for anticoagulation for 4 weeks and Aspirin 100 mg/day for 6 months were given. The animals were sacrificed after 6 months and histological examination of anastomoses was carried out after slicing with the connector in situ for morphological analysis.

RESULTS

All animals survived at 6 months. All anastomoses were patent and mean luminal width at histology was 1.8 +/- 0.2 mm; mean myotomia hyperplasia thickness was 0.21 +/- 0.1 mm.

CONCLUSIONS

Long-term results demonstrate that OPCABGs performed with GraftConnector had 100% patency rate. The mean anastomotic luminal width corresponds to mean LAD's adult sheep diameter. We may speculate that myotomia hyperplasia occurred as a result of local device oversizing.

Alternatives to unfractionated heparin for anticoagulation in cardiopulmonary bypass

Despite the progress made in the development of cardiopulmonary bypass (CPB) equipment, systemic anticoagulation with unfractionated heparin and post-bypass neutralization with protamine are still used in most perfusion procedures. However, there are a number of situations where unfractionated heparin, protamine or both cannot be used for various reasons. Intolerance of protamine can be addressed with extracorporeal heparin removal devices, perfusion with (no) low systemic heparinization and, to some degree, by perfusion with alternative anticoagulants. Various alternative anticoagulation regimens have been used in cases of intolerance to unfractionated heparin, including extreme hemodilution, low molecular weight heparins, danaparoid, ancrod, r-hirudin, abciximab, tirofiban, argatroban and others. In the presence of heparin-induced thrombocytopenia (HIT) and thrombosis, the use of r-hirudin appears to be an acceptable solution which has been well studied. The main issue with r-hirudin is the difficulty in monitoring its activity during CPB, despite the fact that ecarin coagulation time assessment is now available. A more recent approach is based on selective blockage of platelet aggregation by means of monoclonal antibodies directed to GPIIb/IIIa receptors (abciximab) or the use of a GPIIb/IIIa inhibitor (tirofiban). An 80% blockage of the GPIIb/IIIa receptors and suppression of platelet aggregation to less than 20% allows the giving of unfractionated heparin and running CPB in a standard fashion despite HIT and thrombosis. Likewise, at the end of the procedure, unfractionated heparin is neutralized with protamine as usual and donor platelets are transfused if necessary. GPIIb/IIIa inhibitors are frequently used in interventional cardiology and, therefore, are available in most hospitals.

Active cooling during open repair of thoraco-abdominal aortic aneurysms improves outcome

OBJECTIVE

Evaluate impact of active cooling with partial cardiopulmonary bypass (CPB) and low systemic heparinization during open repair of thoracoabdoninal aortic aneurysms.

METHODS

Prospective analysis of 100 consecutive patients undergoing surgical repair of thoracoabdominal aortic aneurysms. Partial CPB and normothermic (36 degrees C) or hypothermic (29 degrees C) perfusion was selected in accordance to the surgeons preference. In the hypothermic group, aortic cross clamp was applied when the target temperature of the venous blood was achieved and rewarming was started after declamping.

RESULTS

52/100 patients (62.2+/-10.9 years) received normothermic and 48/100 patients hypothermic perfusion (63.8+/-10.6 years: NS). Emergent procedures accounted for 18/52 (35%) with normothermia vs. 21/48 (44%: NS) with hypothermia. The number of aortic segments (eight = maximum including arch and bifurcation) replaced was 3.9+/-1.5 with normothermia vs. 4.1+/-1.5 with hypothermia (NS); Crawford type II aneurysms accounted for 21/52 patients (40%) for normothermia vs. 20/48 (42%:NS) for hypothermia. Total clamp time was 38+/-21 min with normothermia vs. 47+/-28 min with hypothermia (P=0.05). Pump time was 55+/-28 min with normothermia vs. 84+/-34 min with hypothermia (P=0.001). Mortality at 30 days was 8/52 patients (15%) with normothermia vs. 2/48 (4%) with hypothermia (P=0.06; odds ratio = 4.1). Parapareses/plegias occurred in 4/52 patients (8%) with normothermia vs. 4/48 (8%) with hypothermia (NS). Revisions for bleeding were required in 4/52 patients (8%) with normothermia vs. 2/48 patients (4%) with hypothermia (P=0.38). Revisions for distal vascular problems were necessary in 5/52 patients (10%) with normothermia vs. 2/48 (4%) with hypothermia (P=0.25). Freedom from death, paraplegia, and surgical revision was 89.9% with normothermia vs. 94.8% with hypothermia (P=0.04; odds ratio 2.0).

CONCLUSIONS

Active cooling during repair of thoracoabdominal aortic aneurysms allows for longer cross-clamp times, more complex repairs and improves outcome.

Intravascular ultrasound underestimates vessel dimensions

The information gathered with intravascular ultrasound (IVUS) are of great value in endovascular techniques. The aim of this study was to evaluate the reliability of IVUS when measuring vessel dimensions by comparison with an established reference method. The left carotid artery was exposed in 4 pigs (45-55 kg) and two piezoelectric crystals were sutured on the adventitia in the same cross-sectional plane. The distance between them was measured either by IVUS and by sonomicrometers. The mean distance between the two crystals calculated by the sonomicrometer was 4.7+/-0.4 mm (mean systolic distance was 4.9+/-0.2 mm, mean diastolic distance was 4.6+/-0.1 mm). The mean distance between the two targets calculated by IVUS was 4. 5+/-0.2 mm (mean systolic distance was 4.6+/-0.2 mm and mean diastolic 4.4+/-0.2 mm). Regression analysis of the two series of data shows a R(2)=0.9984. IVUS measurements are an average 5% smaller than sonomicrometer measurements (3.6% up to 8.3%) and the difference is statistically significant ( p <0.05). The underestimation of IVUS measurements will affect the accuracy, and probably the long-term outcome, of endovascular procedures.

Renal function one year after switching from Sandimmun to Neoral

BACKGROUND

The replacement of Sandimmun by Neoral in 1995 was thought to cause subsequent renal function deterioration due to the better bioavailability of the new drug. We prospectively analyzed the effect of a dose-to-dose drug replacement on renal function over 12 months.

METHODS AND RESULTS

The renal function of 47 consecutive heart transplanted patients was prospectively evaluated before (T0), at 1 (T1), 3 (T3), and 12 (T12) months after drug replacement. Mean serum creatinine was not significantly different at T0 and T12 (142 +/- 55 and 154 +/- 60 micromol/L, p = 0.1). We were able to reduce cyclosporine total and weight-indexed doses by, respectively, 11% and 14% between T0 and T12 (274 +/- 86 to 244 +/- 72 mg/d, p = 0.0003; and 3.7 +/- 1.4 to 3.2 +/- 1.2 mg/kg/d, respectively, p = 0.0005).

CONCLUSIONS

This study demonstrates that the dose-to-dose replacement of Sandimmun by Neoral is feasible, with no direct influence on renal function over a 1-yr follow-up.

Biomembrane mimicry provides improved thromboresistance for total artificial hearts

Thromboembolic events remain a significant issue in mechanical circulatory support. The aim of this study was to evaluate the potential benefit of surface modification in total artificial hearts (TAHs) using polymeric phospholipids (biomembrane mimicry). For this purpose, pneumatic TAHs (vacuum formed pellethane housing, hard double flap hinged inflow valves, soft trileaflet polyurethane outflow valves) had their blood-exposed surfaces either modified with polymeric phospholipids or unmodified before evaluation in bovine experiments. Orthotopic implantation of the TAHs was performed with cardiopulmonary bypass (CPB) using tip-to-tip heparin surface coated perfusion equipment and very low systemic heparinization (50 IU/kg bodyweight). After weaning from CPB and stabilizing hemodynamics, circulating heparin was neutralized with protamine (1:1). All animals were totally supported for 24 hours before elective sacrifice. No heparin was added at any time during support. Mean activated coagulation time (ACT) was 167+/-24 s at baseline before heparinization for CPB, 330+/-45 s at the end of CPB, 181+/-25 s after 1 hour of support, 180+/-31 s after 6 hours, and 185+/-28 s after 18 hours. After explantation, the TAHs perfused without anticoagulation were carefully analyzed. Atrial cuff coverage with red clot was 30+/-21% for artificial surfaces modified by biomembrane mimicry versus 100+/-0% for standard control surfaces (p<0.01). The number of macroscopic deposits found on the inflow valves was 1.33+/-0.47 for surfaces modified by biomembrane mimicry versus 3.83+/-1.86 for standard control surfaces (p<0.05). Likewise, on the outflow valves the number of macroscopic deposits was 0.00+/-0.00 for surfaces modified by biomembrane mimicry versus 1.00+/-0.81 for standard control surfaces (p<0.05). We conclude that presence and distribution of red clots and other macroscopic deposits are significantly different for artificial surfaces with biomembrane mimicry versus standard control surfaces. Application of the biomembrane mimicry concept has the potential to provide improved TAHs.

Incidence and prognostic value of electrocardiographic abnormalities after heart transplantation

BACKGROUND

The improvement of surgical techniques and the use of immunosuppressive drugs within the past 15 years has made heart transplantation an increasingly performed procedure and an accepted treatment for end-stage cardiac failure.

HYPOTHESIS

The aim of this study was to describe the changes of the 12-lead electrocardiogram (ECG) after heart transplantation and to determine their prognostic value on complications such as rejection or graft coronary artery disease during follow-up.

METHODS

The ECGs of 62 consecutive patients were analyzed for 5 years at follow-up periods of 1, 2, 3, 6 months and yearly after transplantation.

RESULTS

The most prevalent abnormality was the presence of complete or incomplete right bundle-branch block (RBBB). New RBBB appeared in 69% (43/62) of the patients, mainly during the first month (21/43). There was no left bundle-branch block. We detected nine episodes of supraventricular arrhythmias: one atrial fibrillation, six atrial flutter, one junctional tachycardia, one orthodromic tachycardia on a Wolff-Parkinson-White syndrome; all appearing during the first 3 months. Three of the six episodes of atrial flutter occurred during an episode of acute rejection. There was no relation between RBBB and the gender and age of recipients and donors, nor with the graft ischemic time and the pretransplantation hemodynamic values. Right bundle-branch block was not associated with acute rejection nor with graft coronary artery disease.

CONCLUSION

The ECG abnormalities after heart transplantation have no predictive value on the long-term evolution. Right bundle-branch block is very frequent and is not associated with adverse prognosis.

Factors predisposing to further hemorrhage and mortality after peptic ulcer bleeding

BACKGROUND

The mortality rate of peptic ulcer hemorrhage has remained unchanged, mainly attributable to rebleeding in an increasingly elderly population. It has been advocated that early identification of patients at high risk of rebleeding with subsequent prompt therapy may reduce the rebleeding and mortality rates. This study examines the value of clinical factors and endoscopic findings in the prediction of further hemorrhage and death.

STUDY DESIGN

One hundred fifty-seven patients admitted over a two year period with bleeding from peptic ulcer were reviewed. The predictive value of individual risk factors in identifying those patients at risk of further hemorrhage or dying was determined by the chi-square test with a Yates correction.

RESULTS

Nineteen patients died, 37 had further bleeding, and 31 had an early operation. Shock was the factor that best predicted further bleeding. Other significant factors were a transfusion requirement of more than four units of blood during the first 48 hours and endoscopic stigmata of recent hemorrhage. The number of coexisting illnesses per patient was strongly related to fatality rate. Other factors indicative of an increased mortality rate included steroid use, onset of bleeding during the period of hospitalization, alcohol use, further bleeding, and a need for more than four units of blood transfused during the first 48 hours.

CONCLUSIONS

Shock remains the most valuable sign in predicting further bleeding and is superior to endoscopic stigmata. The close relationship between the mortality rate and coexisting illness emphasizes the fact that the most deaths result from nonpeptic ulcer disease.

Early definitive operation for bleeding peptic ulcer

Thirty-one patients operated on for bleeding peptic ulcer were reviewed. The concept was to make an early decision to operate and proceed as soon as the patient was haemodynamically stable. In addition to haemostasis, a definitive operation was performed. Seventeen general surgeons performed the operations. Twenty-four patients (77%) were operated on within the first 24 h. During the hospital stay, two deaths (6%) occurred; four patients (13%) re-bled postoperatively, all of whom had a second operation. During a mean follow-up of 45 months, 12 deaths occurred unrelated to peptic ulcer disease and one patient had recurrent bleeding. Proximal gastric vagotomy (PGV) was used in 10 of the 14 duodenal ulcers (71%) without any hospital mortality; one patient re-bled after the operation and another during the follow-up. These results support the view that early surgery achieves a low hospital mortality and a PGV achieves good results even when carried out by several general surgeons.

Outcome of peptic ulcer hemorrhage treated according to a defined approach

The short- and long-term bleeding recurrence and mortality of 157 consecutive patients admitted emergently over a period of 2 years with an actively bleeding peptic ulcer were analyzed. They were treated uniformly according to a defined approach where suitable candidates for surgery were operated on early. The data of the 5-year follow-up were analyzed by constructing life tables. There were 94 men and 63 women with a median age of 72.3 years; 83 ulcers were gastric and 74 duodenal. Thirty-one patients underwent an operation. Eleven patients (7%) died within the first month, one in the surgical group. During the follow-up 13 patients rebled and 54 died, two of the deaths related to peptic ulcer disease. The life table for rebleeding and ulcer-related deaths showed a cumulative risk of 11.8% at 5 years, and the cumulative risk was not statistically different between patients according to their age (60 years and older versus younger), sex, the site of their ulcer (gastric versus duodenal), or the type of treatment (conservative versus surgical). With a well defined approach and early selective surgery, the short-term mortality compares favorably with the usual 10% or more reported. The high mortality rate during the follow-up reflects the advanced age of patients with coexisting disease. This long-term follow-up study could be used as a comparison against future studies evaluating new therapies.

[Risk factors of persistent or recurrent bleeding and mortality in peptic ulcer hemorrhage]

The mortality rate of peptic ulcer haemorrhage has remained unchanged, mainly attributed to rebleeding in an increasingly elderly population with more coexisting systemic diseases. The value of clinical factors and endoscopic findings in predicting in-hospital further haemorrhage and death are analysed. Over a 2-year period, 157 consecutive patients were admitted with bleeding from peptic ulcer, 19 died and 37 had further bleeding. The predictive value of each factor was determined by the chi 2 test with a Yates-correction (significant, p < 0.05). Significant predictive factors of further bleeding were shock, a transfusion requirement > 4 units during the first 48 hours and endoscopic stigmata of recent haemorrhage. The combination of these factors was not of better predictive value than shock alone. The number of coexisting illnesses per patient was strongly related to fatality rate. Other significant factors indicative of an increased mortality included steroid, onset of bleeding during a hospital stay, alcohol, further bleeding, and > 4 units transfused over the first 48 hours. Shock remains the most valuable sign in predicting further bleeding and is superior to endoscopic stigmata. The close relationship between the mortality rate and coexisting illnesses underlines the fact that the majority of deaths result from non peptic ulcer disease.

[Biopsy of occult lesions detected by mammography in a district hospital]

Most series of biopsies of mammographically identified breast lesions are performed in specialized units following mass screening and report an 11% to 36% rate of carcinoma. The results of such biopsies in a district hospital setting are analysed. Seventy-nine consecutive needle localisation biopsies were performed over a 2.5-year period by 15 surgeons and retrospectively reviewed. 13 lesions (16%) were referred by the National Breast Screening Programme. Carcinomas were found on 24 biopsies (30%): 8 were in situ and 16 were infiltrative, 5 of whom were less than 0.5 cm. Thus half of them met the criteria of "minimal" carcinoma as described by GALLAGHER. 40% of women 50 years and older and 13% of women less than 50 years had carcinoma. 6% of the lesions read on mammogram as "probably" benign and 47% of those considered as "probably" malignant were cancer. There was no significant correlation between the mammographic appearance and the occurrence of cancer but all "minimal" invasive carcinomas were associated with calcifications. Complete removal of the lesion failed in 3 cases. Localisation biopsy can be performed in a district hospital by general surgeons with a similar yield of malignancies as in specialized unit and with a high incidence of early detected cancers.

Bleeding Peptic Ulcer: An Audit of Conservative Management

One hundred and twenty-six of 157 consecutive patients (80%) admitted for a bleeding peptic ulcer were treated conservatively and retrospectively analysed. There were 52% duodenal, 41% gastric and 7% combined ulcers. The initial shock index (pulse/systolic blood pressure) was in excess of one in 10%. For 22% of the patients no transfusion was required but 10% had more than 6 units of blood during their hospital stay. Forty-nine per cent were on nonsteroidal anti-inflammatory drugs and 83% had at least one coexisting systemic disease. Six patients (5%) had a further haemorrhage, four of whom died. A total of 10 patients (8%) died. Five of them were related to the peptic ulcer disease but also had terminal or multiple systemic diseases precluding any surgery. Their poor short-term prognosis shows how difficult it will be to effectively reduce the mortality in this particular group of conservatively treated patients, even with the recent advent of endoscopic haemostasis, and stresses the importance of carefully identifying high risk patients in trials mounted to improve on the current mortality figures.

Biopsy of mammographically-detected breast lesions in a district hospital

Seventy-nine consecutive needle localization biopsies were performed for non-palpable breast lesions discovered on screening mammography over a two-and-a-half-year period in a district hospital by 15 surgeons. Malignant disease was found in 24 biopsies (30%). Eight were in situ and 16 were infiltrative carcinomas. Half the cancers met the criteria of 'minimal' carcinoma as described by Gallagher and Martin. Forty percent of women 50 years and older (20 of 50) but only 13% of women less than 50 years (4 of 29) had a carcinoma. Of thirty-two mammograms read as 'probably' benign, two (6%) were malignant pathologically. Of forty-seven mammograms considered 'probably' malignant, 22 (47%) were malignant pathologically. Abnormal calcification (38%), density (34%) or both (28%) were suspicious mammographic features. All 'minimal' invasive carcinomas were associated with calcification. Complete removal of the lesion was not achieved in three cases (3.7%) of which none showed invasive malignancy. Of the seven complications, two required treatment. Localization biopsy of non-palpable breast lesions, detected by screening mammography in a district hospital, performed by general surgeons, has produced a yield of malignancies similar to that seen in more specialized units.

[Surgery for bleeding peptic ulcer: short- and long-term results]

Thirty-one patients operated on for bleeding peptic ulcer were reviewed. The basic concept was to make an early decision to operate and proceed as soon as the patient was haemodynamically stable. In addition to haemostasis, a definitive operation was performed. The procedure was a proximal gastric vagotomy (PGV) for duodenal ulcers (DU), combined with an antrectomy for pre-pyloric ulcers, and either a PGV with ulcer excision or a Billroth I for gastric (GU) or combined (GU + DU) ulcers. Twenty-four patients (77%) were operated on within the first 24 hours. Nine patients could not be operated according to the basic protocol because of anatomical reason, additional ulcer complication or severe co-existing systemic disease. During the hospital stay, 2 deaths (6%) occurred and 4 patients (13%) rebled postoperatively, all of them were reoperated. During a mean follow-up of 44 months, 12 deaths unrelated to peptic disease and one recurrent bleeding occurred. PGV for DU could be used in 70% of cases without any hospital mortality; one patient rebled after the operation and another during the long-term follow-up. These results support the views that early surgery has a low hospital mortality and that PGV gives good results when performed as an emergency procedure.

[Sacrococcygeal cysts. Is Lord Millar's procedure an alternative to exeresis?]

The benignancy of sacrococcygeal cysts stands in contrast to their morbidity and rate of recurrence. Due to the differences in the results found in the literature and to the lack of recommendations as to the optimal surgical procedure, the authors have reviewed a series of 69 patients with a chronic inflammatory state. The procedure was either exeresis up to the sacrum (37 patients) or Lord Millar's procedure (32 patients). The latter consisted in a limited exeresis of the portals and in the extraction of the hairs with a brush, followed in principle by a weekly depilatory treatment until the wound was closed. The results in the 2 groups have been compared. Sixty-six patients (87%) were controlled after an average of 3.7 years. The shorter stay in hospital of the patients operated with Lord Millar's procedure (4.9 vs. 7.6 days) and the shorter period of inability to work (14 vs. 26 days) demonstrate the socioeconomical advantage of this procedure. Recurrence occurred in 5 of the 31 patients controlled after exeresis (16%) and in 7 of the 29 patients controlled after a Lord Millar's operation (24%), including one in the subgroup of 16 patients who submitted themselves to a regular postoperative epilatory treatment (6%) and 6 in the group of 13 who were not followed up in our clinic (46%). Thus Lord Millar's procedure represents an alternative to exeresis, provided the patient is motivated enough to submit himself to regular postoperative controls.

Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiography

Left ventricular ejection fraction (LVEF) is a measure of ventricular function with clinical and prognostic significance and can be reliably calculated with various M-mode and two-dimensional echocardiographic formulas in selected, good quality echocardiograms. Subjective visual echocardiographic estimate of LVEF is a potentially less time consuming and more widely applicable method. In order to test its reliability, we performed a prospective blind trial in 40 consecutive patients undergoing biplane contrast ventriculography (BCV), to compare the visual estimate of LVEF during a complete echocardiogram of three independent observers with (1) cubed M-mode formula, (2) Teichholz M-mode formula, (3) length-area method from the four-chamber view, and (4) Simpson's single plane formula. BCV was the reference method. The best correlation with BCV was obtained by visual estimate [r of the three observers, respectively = 0.75; 0.84; 0.81] and M-mode measurements [r (1) = 0.8; r (2) = 0.8], but the most sophisticated methods provided the poorest estimate [r (3) = 0.54; r (4) = 0.49]. All correlation coefficients improved when good studies, defined as a definition of the endocardial surface of more than 75%, were selected (n = 23), but the differences persisted. One observer systematically estimated higher values than the other two (Friedman's test, p less than 0.01) and this interobserver variability suggests that each echocardiographer should test himself against BCV in his lab in order to apply the visual estimate method reliably.

Complications after single versus dual chamber pacemaker implantation

To compare the complication rate in patients having a dual chamber versus a single chamber pacing system, 337 consecutive procedures performed during a 3-year period were analyzed prospectively. Two hundred fifty-eight patients (77%) received a VVI pacemaker and 75 (23%) a DDD unit. Thirteen VVI (5%) and 4 DDD (5.3%) needed reintervention. Lead displacement with reoperation was required for three ventricular leads (1%) and one atrial lead (1.3%). Infection occurred in two VVI units (0.77%) and one DDD (1.33%) unit. Muscular stimulation was noticed among three DDD (4%) and nine VVI systems (3.5%). Urgent reprogramming was needed for 23 VVI (9%) and six DDD units (8%). There was no increase in complications with dual chamber pacing compared to single chamber systems.