The hypothesis that replacement of the aortic root with a valved composite graft is a safe and effective therapy for aneurysms involving the sino-tubular segment of the aorta was tested by a retrospective review. From September 1978 to January 1995, 335 consecutive patients underwent prosthetic aortic root replacement as the primary operation for aneurysm (222) or dissection (acute 59, chronic 54). There were 248 men (74%) and 87 women (26%) with a mean age of 50 +/- 14 years. 22 patients (6.6%) experienced hospital death primarily due to cardiac causes. Mortality was significantly higher in patients with acute dissection versus those with non-dissecting aneurysms and chronic dissection. Sex, Marfan syndrome (20.3% of patients), mitral regurgitation, coronary artery disease, and era of operation had no effect on early outcome. Mortality was significantly increased in patients aged over 50 years, in those with circulatory compromise, and in patients requiring emergency operation. Follow-up was complete in 313 survivors (97%) at a mean of 61.3 +/- 44 months. Actuarial survival was 80% at 5 and 67% at 10 years. There were no complications involving the coronary anastomoses, other than infection-related, regardless of the mode of ostial reattachment.

Despite omental wrap and avoidance of prophylactic administration of corticosteroids in the early postoperative phase, ischemic bronchial complications still represent an important source of early morbidity and mortality following lung transplantation. In a retrospective analysis, the effect of pharmacological enhancement of pulmonary collateral flow on bronchial healing was investigated. Thirty-nine consecutive unilateral or bilateral transplant procedures (Tx) were analyzed. Immunosuppression consisted of rabbit antithymocyte globulin (RATG), cyclosporine A, and azathioprine. In group 1 (10 Tx, 12 anastomoses) routine immunosuppression was employed and the anastomoses wrapped with an omental or pericardial pedicle. In group 2 (29 Tx, 41 anastomoses) PGI2 (4 ng/kg per min x 48 h), heparin (200 U/kg per day), and prednisolone (0.5 mg/kg per day) were added to the therapeutic regimen. The 2 groups were comparable with respect to age and sex of the patients, primary diagnosis, type of transplant, intraoperative use of extracorporeal circulation, graft ischemia, duration of mechanical ventilation, and mortality. Bronchoscopic evidence of a significant bronchial ischemia (extending more than 1 cartilaginous ring beyond the anastomosis) was seen in 8 of 12 anastomoses in group 1 vs 14 of 53 anastomoses in group 2 (P = NS). In group 1, significant bronchial stenosis required implantation of an endobronchial silicone stent in 6 of 12 anastomoses, whereas in group 2, no significant bronchial stenosis occurred (P less than 0.01). No negative effects possibly related to the prophylactic administration of corticosteroids could be observed.(ABSTRACT TRUNCATED AT 250 WORDS)

A new method of treating acute type-A dissection of the aorta is described and illustrated. It involves the reconstruction of both the valve and the ascending aorta. This procedure was employed in 17 patients, 2 of whom succumbed early of complications unrelated to the method while one committed suicide at a later date. One of the surviving patients required reoperation due to breakdown of a resuspended aortic commissure. Two patients show minor non-progressive valve regurgitation in the absence of annulo-aortic ectasia. Two patients have developed dilatation of the aortic root--one will require reoperation in the foreseeable future. In our hands, this method has served to make emergency operation for acute aortic dissection both simpler and safer. The limitations of its use are discussed.

Extracoronary blood flow to the myocardium was studied in 54 patients during cold cardioplegic arrest. Coronary venous return was measured with the aorta and the pulmonary artery cross-clamped, both venae cavae occlusively snared, and the heart completely drained. Cold St. Thomas' cardioplegic solution was infused into either the aortic root or the coronary ostia. Myocardial septal temperature was continuously monitored. The amount of blood in the right atrial effluent was determined by means of the hematocrit and was considered to be the extracoronary collateral myocardial blood flow (QE), originating from the systemic circulation. QE ranged from 0 to 1470 ml-100 min-1 (x = 241.1 ml-100min-1). The myocardial spontaneous rewarming rate was not significantly correlated to QE. QE was lowest in pure mitral valve stenosis (x = 39.9 ml-100 min-1) and higher in aortic valve disease (x = 165.5 ml-100 min-1). Very high QE values (greater than 800 ml-100 min-1) were only observed in patients with severe three vessel coronary artery disease. Patients with angina at rest appear to have lower QE values than patients with equally severe coronary artery disease suffering from angina under excise only. It is concluded that extracoronary collateral blood flow may unpredictably influence the efficacy of clinical cardioplegia and may to some extent compensate for severe coronary artery disease.

The authors' method for uniting the dissected aortic wall layers with the help of gelatine-resorcinol adhesive is described focusing on special instruments used in this conjunction.

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Functional results and data concerning the incidence and severity of graft atherosclerosis (GASC) and tricuspid incompetence (TI) in the intermediate term after orthotopic heart transplantation (HTX) are still striking. We examined 92 patients 1, 2, and 3 years after HTX by right and left heart catheterization in order to evaluate pump function, the status of the coronary arteries and the extend of TI, using a double indicator thermodilation technique. Mean left ventricular volumes and ejection fraction were normal 1 and 2 years post-transplant. The incidence of GASC was 8/87 (9.2%) at 1, and 11/92 (12%) at 2 years. It was more frequent (16%) in patients with preexisting coronary artery disease (IHD) than in patients with underlying dilative cardiomyopathy (DCM) (11%). At the end of the 1st postoperative year, 62% of patients were free of TI, whereas only 38% had normal valve function 2 years posttransplant. In 9/14 (64%) of patients, consecutively assessed at 1 and 2 years, TI had increased between both investigations. Preoperative haemodynamics, the number of endomyocardial biopsies and rejection episodes as well as preoperative cardiac size did not correlate with TI. Left ventricular volumes and ejection fraction are normal in the intermediate term after HTX. The incidence of GASC was less than 10% at 1 year and did not significantly increase thereafter. TI is a frequent and yet unexplained finding after HTX showing a considerable tendency to increase with time, but with little or not haemodynamic consequence.

This report concerns our clinical experience with fibrin glue for local bleeding control and for sealing of vascular prostheses. Hemostasis could be achieved in 90% of 124 applications of the glue under different indications. Local application of fibrin adhesive is recommended in all types of bleeding difficult either to approach or control by conventional surgical technique. Complete sealing of low pore vascular grafts could be obtained in all operations under extracorporeal circulation and full heparinization. Highly porous grafts sealed with fibrin glue also were explored under conditions thus far requiring tightly woven grafts.