Karl Victor Hall

In situ vein bypass in the treatment of femoropopliteal atherosclerotic disease: A ten year study

Abstract The in situ vein bypass technic for femoropopliteal atherosclerotic disease is described. Several factors influence the long-term results, the most important being a history of myocardial disease, the size of the vein graft, and sufficient runoff.

Postoperative Blood Flow Measurements In Man By The Use Of Implanted Electromagnetic Probes

Intra- as well as postoperatively the blood flow through in situ bypass vein grafts in the thigh were studied by the use of implanted electromagnetic flow probes. The quantities of blood flow found at intra-operative measurements was a good indication on the postoperative blood flow within the individual case. The effect of exercise, papaverine injection and postural changes were also studied.

Clinical and Haemodynamic Results Following Mitral Valve Replacement with the New Lillehei-Kaster Pivoting Disc Valve Prosthesis

Thirty-four patients were re-examined 12-24 months after mitral valve replacement with the Lillehei-Kaster pivoting disc valve prosthesis. There was an improvement of the kinetics with a significant decrease in arteriovenous oxygen difference compared with oxygen consumption. Cardiac output and stroke volume remained abnormally low, not differing significantly from pre-operative values. Resting pulmonary wedge pressure, pulmonary arterial pressure and pulmonary vascular resistance decreased significantly after operation. Mean values for these parameters remained slightly above normal. Exercise produced a rise in pulmonary wedge pressure, which could be explained partly by a simultaneous deterioration of the left ventricular function, as indicated by high end-diastolic pressures, and partly by a degree of obstruction to the foreward flow at the mitral valve itself. The rise in pulmonary wedge pressures led in turn to increased pulmonary arterial pressure, the latter being aggravated in some patients by a rise in pulmonary vascular resistance. Cardiac output increased during exercise, but usually to a lesser extent than was anticipated from the increase in oxygen consumption. The changes in cardiac output during exercise were due to an increase in heart rate, while stroke volume remained unchanged. The mean diastolic pressure difference across the prosthesis was 8.6 mmHg at rest and 12.7 mmHg during exercise. Subjective improvement and reduction in heart volume, as noted in the present series, corroborated the benificial effect of the operative procedure. The valve were all competent, as judged by cinéangiography, except in a few patients, in whom a small valvular or paravalvular leakage was seen. No thrombo-embolic episodes were recorded during the follow-up period.

Postoperative Aortic Regurgitation Related to Peroperative Blood Flowmetry in Ball Valve Replacement

It is most important to leave a completely competent aortic valve after prosthetic replacement. In an attempt to ensure this, peroperative electromagnetic flowmetry on the ascending aorta has been performed in a series of 38 Magovern and 37 Starr-Edwards replacements. With a follow-up time from 1 to 4 years post-operatively, these studies strongly suggest that residual insufficiency dates from the time of the operation, and routine flowmetric control after aortic replacement should be made. Residual insufficiency, valvular or perivalvular, ought to be corrected immediately, as this will otherwise often cause serious complications and markedly reduce the prognosis for a successful result.

Experiences with Various Types of Mitral Valve Prostheses

During the period 1967-1973, four different types of mitral valve prostheses were used by the same surgical group. Altogether 139 patients are included in this study. With the exception of the surgical approach, the operative technique was the same in all groups. The total mortality varied from 17% in the group receiving the Björk-Shiley valve to 40% in the Beall valve group. Thrombo-embolic complications were responsible for three deaths in the Beall and one death in the Lillehei-Nakib group. All patients had been on the adequate anticoagulant therapy. At follow-up, 40 to 77% of the patients had improved functional class, the best results being obtained in the Björk-Shiley group. The diastolic gradients across the prosthetic valves varied from 9 to 4 mmHg at rest. Again, the Björk-Shiley valve gave the most favourable result. The results and significance of the various parameters are briefly discussed.

Intra-Aortic Balloon Pumping in the Treatment of Cardiogenic Shock Following Open-Heart Surgery

Intra-aortic balloon pumping (IABP) was used in the treatment of 29 patients in cardiogenic shock refractory to pressor drugs subsequent to open-heart surgery. Nineteen patients recovered from the shock primarily, but four died later in hospital. The remaining 15 were discharged alive. Peroperative electromagnetic flow measurements in one patient showed a 23% increase in aortic flow and a 26% increase in aortocoronary bypass flow when pumping was started.

Mitral Insufficiency Following Myocardial Infarction

Severe mitral insufficiency following myocardial infarction in 15 patients is reported. The mean interval from infarction to surgery was 2.8 years. All patients were operated on with mitral valve replacement and in 14 aortocoronary bypass and/or resection of left ventricular aneurysm was necessary as well. Rupture of one or more heads of the papillary muscle was found in 5 patients. In another 5 the papillary muscles were discoloured, fibrosed and shortened, and in the last 5 patients the mitral incompetence was caused by a marked dilatation of the atrioventricular ring. Five patients (33%) died, 3 early and 2 late after surgery. All the patients who died had a markedly imparied left ventricular function pre-operatively with end-diastolic pressures from 15 to 26 mmHg.

Bypass to the tibial and peroneal arteries using the great saphenous vein in situ

In 22 patients with extensive atherosclerotic disease of the lower extremities 24 long bypasses have been performed. The main indications for surgery were rest pain and imminent or manifest gangrene. The semiclosed in situ vein technique was used in all except one case. Five grafts thrombosed within 2 weeks postoperatively, one of them was successfully reopened. At discharge 20 grafts were patent, and most of the patients had relief of their ischemic symptoms. After 5 years 26% of the long vein grafts were patent. In comparison, almost 70% of in situ femoro-popliteal vein grafts were patent. One patient is still living with an open long vein graft 14 years after surgery. The in situ vein technique is especially suited for long bypasses. The poorer results in the present series is probably due to an extremely advanced atherosclerotic disease and a high percent of small fibrotic veins with a diameter of 3 mm or less.

Surgery in acute and chronic pericarditis. Pathophysiology and management.

Forty-two cases of surgically treated pericarditis are presented, with comments on the management and pathophysiology of the acute, recurrent, and chronic stages of the disease. The spectrum of aetiological factors has changed within the last few decades in that tuberculosis is now rare, whereas uraemic pericarditis is referred to surgery with increasing frequency. With the advent of haemodialysis and renal transplantation, these cases should be treated vigorously, since they are amenable to surgical cure. Rapid surgical intervention is advocated in impending tamponade, and in all other acute cases which do not respond promptly to conservative management. In recurrent and chronic pericarditis, surgery is also preferable to long-term medical treatment with steroids and diuretics. Chronic pericarditis should not be allowed to progress to an advanced stage of disease with myocardial involvement and impairment of liver function. Early operation carries little hazard and gives lasting relief in the majority of cases. Microscopical examinations and laboratory analyses point towards an abnormal permeability of capillaries and visceral pericardium as an early and major event in the development of pericardial effusions. Destruction or preservation of the mesothelial cell lining is probably an important factor in determining the progression of acute disease towards adhesions and constriction.

Pervenous Atrial Electrode

“Atricor” P-synchronous pacemakers have been installed in 11 patients by the use of pervenous electrodes. At the follow-up, 8 patients still had P-synchronous pacemakers working, whereas in 2 cases “Ectocar” (“demand”) had been installed on account of non-functioning atrial electrodes. One patient received a temporary “demand” pacemaker because of cardiac surgery. In 1 patient, a pervenous atrial electrode has been used for atrial pacing as treatment for sinus bradycardia. This pacemaker has now functioned for 1 year. In 5 patients, surgical replacement of displaced atrial electrodes has been necessary. Proper fixation of the atrial electrode in the subclavian fossa is vital for successful P-synchronous pacing of longer duration.