Åke Senning

Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty.

In percutaneous transluminal coronary angioplasty, a catheter system is introduced through a systemic artery under local anesthesia to dilate a stenotic artery by controlled inflation of a distensible balloon. Over the past 18 months, we have used this technic in 50 patients. The technic was successful in 32 patients, reducing the stenosis from a mean of 84 to 34 per cent (P less than 0.001) and the coronary-pressure gradient from a mean of 58 to 19 mm Hg (P less than 0.001). Twenty-nine patients showed improvement in cardiac function during follow-up examination. Because of acute deterioration in clinical status, emergency bypass was later necessary in five patients; three showed electrocardiographic evidence of infarcts. Patients with single-vessel disease appear to be most suitable for the procedure, and a short history of pain indicates the presence of a soft (distensible) atheroma likely to respond to dilatation. We estimate that only about 10 to 15 per cent of candidates for bypass surgery have lesions suitable for this procedure. A prospective randomized trial will be necessary to evaluate its usefulness in comparison with surgical and medical management.

Transcaval posterocranial resection of the liver as treatment of the Budd-Chiari syndrome.

In 3 patients with a Budd-Chiari syndrome the suprahepatic caval vein was incised during extracorporeal circulation and the suprahepatic hindrance for the hepatic venous runoff abolished. By resection of the juxta caval hepatic tissue the thrombotically occluded parts of the main vein stems were removed and a free hepatic venous flow to the caval vein was established in 2 patients. In the third patient, who had a caval stenosis at the diaphragmatic level (web) and thrombosis of even smaller hepatic veins and a retrograde flow to the portal vein, the resection resulted in an abundant blood flow from the resected liver area. It is assumed that this flow originates not only from the smaller hepatic veins, but to a great extent from arterio- and portovenous shunting. Angiography has shown that such shunting can take place after resection.The first 2 patients are healthy and working full-time at 2 1/2 and 2 years postoperatively, respectively. Nine months postoperatively, the third patient is in good condition, jaundice has disappeared, and bleeding from esophageal varices has not occurred.RésuméChez 3 malades accusant un syndrome de Budd Chiari, le segment sus-hépatique de la veine cave fut abordé sous circulation extra-corporelle et lobstacle sus-hépatique sopposant au flux veineux fut supprimé. Par exérèse du tissu hépatique précave, la partie occluse des pédoncules veineux fut réséquée et le retour veineux vers la veine cave rétabli chez 2 de ces malades. Chez le troisième, qui présentait une sténose au niveau du diaphragme et une thrombose des plus petites veines hépatiques avec retour par voie rétrograde du sang à la veine porte, lexérèse du parenchyme hépatique se traduisit par un saignement abondant. Il est probable quil trouvait son origine non seulement au niveau des petits veines hépatiques elles-mêmes mais aussi en grande partie au niveau de shunts artério- et portoveineux. Langiographie a montré quun tel système de shunts peut se développer après la résection.2 ans et 2 ans 1/2 après lopération, respectivement, les 2 premiers malades sont en bonne santé et ont repris leur activité; 9 mois après lintervention, le 3ème opéré est en bon état, na pas présenté dhémorragie et son ictère sest effacé.ResumenEn 3 pacientes con sindrome de Budd-Chiari fué posible incidir la vena cava suprahepática bajo circulación extracorpórea para vencer el impedimento al drenaje venoso suprahepático. Mediante la resectión de tejido hepático yuxta-cava se logró remover los segmentos de las venas principales ocluidos por trombosis, y en dos pacientes se pudo establecer flujo venoso hepático libre en dirección de la vena cava. En el tercer paciente, que tenia estenosis de la cava al nivel diafragmático (membrana o “web”) y trombosis de pequeñas venas hepáticas con flujo retrógrado hacia la vena porta, la resección résultó en flujo sanguineo abundante a partir del área de resección hepática. Se asume que este flujo se origina no sólo en las pequenas venas hepáticas, sino, en gran parte, en comunicaciones arterio y portovenosas. La angiografia ha mostrado que este tipo de comunicaciones puede presentarse después de la resección.Los primeros dos pacientes operados se encuentran sanos y trabajan tiempo completo a los 2 1/2 y 2 años postoperatorios respectivamente. El tercer paciente está en buena condición 9 meses después de la operación; la ictericia ha desaparecido y no se ha presentado sangrado de várices esofágicas.

The Ascending Aortic Aneurysm: Replacement or Repair?

Between 1971 and 1980, 100 patients underwent operation for ascending aortic aneurysm. Acute dissection was present in 29, chronic dissection in 11; 56 had dilatation only, and 4 had inflammatory disease of the ascending aorta. Four different operative procedures were applied independent of the type of disease: repair and reduction aortoplasty (21), reduction aortoplasty reinforced by nylon net (17), supracoronary graft replacement (42), and composite graft replacement with reimplantation of both coronary ostia (20). Early mortality was 10%, and late mortality was 12% after a mean follow-up of 45 months. Retrospective comparative analysis of the four operative methods led to the following conclusion: reduction aortoplasty supported by a tightly wrapped synthetic net is a suitable method in patients with a normal sinus of Valsalva and without dissection or inflammatory disease. Particular attention needs to be drawn to the proximal anchor stitches to avoid late net displacement. Compared with supracoronary or composite graft replacement, this method carried a lower complication rate, particularly in regard to cerebrovascular accidents and myocardial infarction. For patients with acute and chronic dissection with intact aortic root, supracoronary graft replacement is preferred, whereas in those with annuloaortic ectasia with dilated sinus of Valsalva and in all patients with Marfans syndrome, composite graft replacement has become the procedure of choice.

The Role of the Surgeon in Percutaneous Transluminal Dilation of Coronary Stenosis

Percutaneous transluminal dilation (PTD) of coronary artery stenosis is performed by means of a balloon-tipped catheter introduced from a peripheral artery. It was attempted in 45 patients; stenosis was passed in 33 and was successfully dilated in 28 patients (62%). The method failed in 17 patients: in 6 of them an abrupt closure of a stenosed artery or a beginning infarction necessitated an emergency revascularization. There were no deaths or serious complications, but an infarction developed in 1 patient despite immediate bypass grafting. PTD was successful in 5 out of 7 patients who had recurrent angina after previous coronary bypass grafting: in 2 of them stenosis of a distal coronary artery and in 3 a stenosed bypass graft were dilated. PTD is a new method of treatment of coronary artery disease and is an addition rather than an alternative to coronary bypass grafting. The best results can be expected in patients with single-vessel disease, with a short history of angina (less than 1 year), and with narrow, noncalcified proximal stenosis. Some late complications of bypass grafting are also amenable to this method of treatment.

Treatment of budd-chiari syndrome by dorsocranial liver resection and direct hepatoatrial anastomosis

Since 1980 an operation which reestablishes the blood outflow from occluded hepatic veins was performed in 7 patients with Budd-Chiari syndrome by one of us (A. Senning). Using extracorporeal circulation a dorsocranial cylindrical resection of the liver including the confluence of the occluded hepatic veins was performed by transcaval approach. The incised right atrium was sutured around the resected liver area. There was one intraoperative death. In 6 patients with a mean postoperative follow-up of 19.2 months (4-42 months), the patency of hepatoatrial anastomosis was documented by angiography or Doppler-2d-echocardiography. Four patients are free of symptoms and signs of Budd-Chiari syndrome. In one of two patients with associated cirrhosis compression of inferior vena cava reoccurred and in another patient esophageal varices persist. We conclude, that the hepatoatrial anastomosis is an effective treatment of Budd-Chiari syndrome.

Huge left coronary artery aneurysm associated with multiple arterial aneurysms

Natural history of an aneurysm at the bifurcation of the left coronary artery is reported. A gradual increase in its size occurred over an 18-year period until it was a huge and partially thrombosed sac. It was associated with ectasia of the right coronary artery, aneurysms of the left subclavian artery and thoracic aorta, and calcified dilatations of the branches of the celiac trunk.

Reconstruction of the Mitral Valve

Abstract Isolated mitral valve reconstruction was performed in 100 consecutive patients for either mitral regurgitation or combined mitral valve disease. Early mortality was 8% for the total series but has decreased to 2% since 1965. Eight late deaths occurred between 2 and 99 months after operation. Preoperatively all but 2 patients were in Functional Class III or IV according to the New York Heart Association classification. One to two years after operation 72 patients were ameliorated by one to three functional classes and 7 were unchanged. Four to nine years postoperatively 28 were still improved by one to three functional classes while 3 were the same as preoperatively, and 5 patients had died during this late follow-up period. Objective assessment of postoperative mitral valve function by apnea curves and dye-dilution curves yielded good long-term results. Postoperative cardiac catheterization studies demonstrated a marked decrease in pulmonary artery and pulmonary capillary wedge pressures. Six patients had to be reoperated upon because of either progressing rheumatic disease or unsatisfactory repair. Analysis of actuarial survival curves demonstrates more favorable results with mitral valve reconstruction than with mitral valve replacement in comparable series, primarily because of the low embolus rate after reconstruction.

Left anterior thoracotomy for pulmonary embolectomy with 29-year follow-up

Pulmonary embolectomy is usually performed in cardiopulmonary bypass. In acute situations too much time can be lost in setting up and connecting the pump oxygenator; this delay can cause cerebral damage in a patient with circulatory arrest. In such a situation left anterior thoracotomy can provide an ideal approach. An emergency thoracotomy can be performed in a few seconds. The lung automatically retracts. The phrenic nerve, pulmonary artery, and pericardium are clearly seen, and they outline the area for embolectomy. A case in which such an approach was successfully used is described.

Correction of common bile duct stricture by onlay patch of duodenum.

A simple method to correct iatrogenic common bile duct strictures is presented. The stenotic bile duct is incised longitudinally and a large T-tube inserted, the ends extending proximal and distal to the incision. The rim of the incision is sutured to the posterior duodenal wall, and this is used as a serosal patch for roofing. The T-tube is removed after 3–6 months. Use of this technique in 2 patients was successful.RésuméPrésentation dune méthode simple de correction des sténoses iatrogènes du cholédoque. Le canal sténosé est incisé longitudinalement et un drain de Kehr de large diamètre y est introduit, dont les branches proximale et distale dépassent les limites de lincision. Les bords de lincision sont suturés à la paroi postérieure du duodénum qui sert de patch séreux de recouvrement. Le drain de Kehr est enlevé après 3–6 mois. La technique a été utilisée avec succès dans 2 cas.

Die Transposition der großen Arterien

Als Transposition der grosen Gefase wird eine angeborene Misbildung des Herzens angesprochen, welche dadurch charakterisiert ist, das die Aorta dem anatomisch rechten, die Pulmonalarterie dem anatomisch linken Ventrikel entspringt. Diese ursprungliche Definition entspricht den Befunden, wie sie erstmals von Steno (1672) und spater von Morgagni (1761) sowie Baillie (1797) erhoben wurden (Keith et al., 1958). Auch Farre (1814) versteht in seiner Beschreibung aus dem Jahre 1814 unter Transposition einen gegenseitigen Austausch von Aorta und Arteria pulmonalis am Ursprung aus dem normalerweise zugehorigen Ventrikel. Erfolgt die Entwicklung der ubrigen Herzabschnitte, insbesondere diejenige der atrio-ventrikularen Kontinuitat regelrecht, so bilden sich unter diesen Umstanden zwei in sich geschlossene Kreislaufe, wobei die Lungenarterie oxygeniertes Lungenvenenblut aus dem linken Ventrikel wiederum zur Lunge, die Aorta hingegen das Systemvenenblut aus dem rechten Ventrikel wiederum in den Systemkreislauf fordert.