Nils B. Fjeld

Effect of dietary supplementation with n-3 fatty acids on coronary artery bypass graft patency

Epidemiologic and experimental data suggest that a high dietary intake of long-chain polyunsaturated n-3 fatty acids may reduce the risk of atherothrombotic disease. In a randomized, controlled study, 610 patients undergoing coronary artery bypass grafting were assigned either to a fish oil group, receiving 4 g/day of fish oil concentrate, or to a control group. All patients received antithrombotic treatment, either aspirin or warfarin. Their diet and serum phospholipid fatty acid profiles were monitored. The primary end point was 1-year graft patency, which was assessed by angiography in 95% of patients. Vein graft occlusion rates per distal anastomoses were 27% in the fish oil group and 33% in the control group (odds ratio 0.77, 95% confidence interval, 0.60 to 0.99, p = 0.034). In the fish oil group, 43% of the patients had > or = 1 occluded vein graft(s) compared with 51% in the control group (odds ratio 0.72, 95% confidence interval, 0.51 to 1.01, p = 0.05). Moreover, in the entire patient group, there was a significant trend to fewer patients with vein graft occlusions with increasing relative change in serum phospholipid n-3 fatty acids during the study period (p for linear trend = 0.0037). Thus, in patients undergoing coronary artery bypass grafting, dietary supplementation with n-3 fatty acids reduced the incidence of vein graft occlusion, and an inverse relation between relative change in serum phospholipid n-3 fatty acids and vein graft occlusions was observed.

Pulmonary Endometriosis Causing Haemoptysis: Report of a Case Treated with Lobectomy

A 24-year-old woman with catamenial haemoptysis was treated with the antioestrogenic drug danazol for suspected pulmonary endometriosis. The haemoptysis then ceased, but rapidly recurred when the patient discontinued the medication 3 months later because of severe side effects. Lobectomy was performed, and the diagnosis histologically confirmed, 14 months after the onset of symptoms. Thereafter the patient was free from haemoptysis.A 24-year-old woman with catamenial haemoptysis was treated with the antioestrogenic drug danazol for suspected pulmonary endometriosis. The haemoptysis then ceased, but rapidly recurred when the patient discontinued the medication 3 months later because of severe side effects. Lobectomy was performed, and the diagnosis histologically confirmed, 14 months after the onset of symptoms. Thereafter the patient was free from haemoptysis.

Risk factors for graft occlusion after coronary artery bypass grafting.

A cohort of 610 well-characterized patients undergoing coronary artery bypass grafting were followed through the first postoperative year. Graft patency was angiographically assessed in 578 (94.8%) of the patients on average 12.1 (SD 1.5) months postoperatively and was related to characteristics of grafts and patients. For internal mammary artery grafts the incidence of graft occlusion was higher in women than in men and was inversely related to body surface area. In multivariate analysis the influence of gender was no longer significant when adjusted for body surface area. With vein grafts the incidence of occlusion was inversely related to body surface area and was positively associated with ejection fraction. Occlusion of vein grafts was less common in patients treated with beta-blockers pre- and peroperatively.

Risk factors of septicemia and perioperative myocardial infarction in a cohort of patients supported with intra-aortic balloon pump (IABP) in the course of open heart surgery.

In 1325 open heart operated (OHO) patients with a perioperative mortality of 5.8% the incidence of septicemia and perioperative myocardial infarction (PMI) were much higher in a cohort of 110 patients given intra-aortic balloon pump (IABP) support during the operative course. Analysis of this cohort showed that peri/postoperative insertion of the pump, the presence of disease in the descending branch of left coronary artery (LAD) and the need of more than one saphenous vein graft were risk factors for PMI. The presence of LAD disease was the only independent risk factor for PMI with an odds ratio (OR) of 4.62. Well known risk factors such as NYHA functional class, emergency, low left ventricular ejection fraction (EF) or elevated end diastolic pressure (EDP) were not prognostic of PMI. Thus, the intraoperative seemed to be more important than the preoperative risk profile for the development of PMI. Independent risk factors for the development of septicemia were the duration of IABP with an OR of 1.5 for each pump day and implantation of a valve prosthesis with an OR of 6.3. To avoid septic complications, this study suggests pump removal as soon as possible.

Injuries to the heart

During a 12-year period, 36 patients with cardiac injuries were recorded. Nine suffered penetrating injuries, nine blunt ruptures and 18 contusions. Only two patients with blunt rupture survived, in contrast to six out of seven patients with stab wounds to the heart. This reflects that heart stabs are easier to diagnose than blunt ruptures, and that the associated injuries are the most important factor for survival in patients with blunt injuries. All clinical manifestations of the heart injuries were present within the first 12 h. Cardiac monitoring of haemodynamically stable patients beyond this period may not be necessary.

Mortality in patients supported by intra-aortic balloon pump in the course of cardiac surgery was related to perioperative myocardial infarction.

OBJECTIVE To search for predictors of mortality for patients in need of intra-aortic balloon pump (IABP) support in the course of cardiac surgery. METHODS A retrospective study of possible pre- and perioperative risk factors in 110 patients with mean age of 62 years (38-79). The IABP was inserted preoperatively in 19 (17%) and perioperatively in 91 (83%). RESULTS Well known risk factors as advanced age (63.2/61.0; P = 0.25), NYHA functional class (OR = 1.59; 95% CI 0.23 to 13.31), female sex (OR = 2.40; 95% CI 0.81 to 6.73), emergency surgery (OR = 0.63; 95% CI 0.21 to 1.80), low left ventricular ejection fraction (62.9/60.7; P = 0.53), or elevated end diastolic pressure (19.4/21.0; P = 0.48), were not prognostic of death. Perioperative insertion of the balloon pump (OR = 3.83; 95% CI 1.07 to 14.95), perioperative myocardial infarction (OR = 23.3; 95% CI 7.62 to 81.8), low cardiac output (OR = 7.53; 95% CI 2.43 to 24.11), and renal failure (OR = 20.00; 95% CI 3.63 to 145), were strong predictors of death. CONCLUSIONS Outcome seemed to be determined by perioperative events rather than preoperative risk factors. This could possibly explain the favourable mortality rates seen in patients on IABP support prior to surgery compared to patients who had IABP installed perioperatively.

Early use of corticosteroids in severe closed chest injuries: a 10-year experience

Because of the controversy about the treatment of injured patients with steroids, each doctor treating closed chest injuries at Ullevål Hospital, Oslo, has been free to decide whether to use steroids. However, if steroids were to be used, early administration was recommended. Thus, on admission methylprednisolone 30 mg/kg body weight was given to 107 patients having at least four rib fractures or a flail chest. The dose was repeated after 8 and 16 hours. The patients treated with steroids were compared with 159 patients not receiving steroids, but who otherwise were treated identically. Three-quarters of the patients had multiple injuries and 219 patients (82 per cent) had intrathoracic injuries such as pneumothorax (39 per cent), haemothorax (37 per cent) or contusion of the lung (59 per cent). Forty-six patients (17 per cent) were in shock on admission. Most patients could be managed with intravenous infusion, oxygen, relief of pain and chest drains. Early thoracotomy was performed in 10 patients and 91 patients needed artificial ventilation. Analysis of the two groups of patients revealed a significantly lower hospital mortality of 11.2 per cent for those treated with steroids as against 23.3 per cent for those without. Comparison of the two groups demonstrated no differences which could explain the difference in mortality. The mean Injury Severity Score (ISS) was 24.0 for the steroid treated group and 21.4 for the control group. The steroid treatment was not associated with any increase in the incidence of infection. The present analysis indicates that steroids, when given early, may improve the clinical course of patients sustaining severe closed injuries of the chest.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical Treatment of Left Ventricular Aneurysm: Analysis of Risk Factors, Morbidity and Mortality in 205 Cases

Left ventricular aneurysm was surgically treated in 205 patients during the decade 1975-1984. The patients had had one to five myocardial infarctions, the latest days to years (mean 32 months) preoperatively and 92% were in NYHA functional class III or IV. The main indications for surgery were angina (47%), congestive heart failure (38%) and arrhythmia (15%). The 176 anterior, 23 posterior and six combined aneurysms were treated with resection (130 cases) or plication (75). The early mortality was 5%. Univariate analysis identified arrhythmia, concomitant valve replacement and need for intra-aortic balloon pumping (IABP) as significant risk factors, and multivariate analysis revealed the indication for surgery and need for IABP as the only independent predictors of total mortality. The survival rates 5 and 10 years postoperatively were respectively, 74% and 60%. At follow-up after 1/2-10 years, almost 90% of the surviving patients had improved functional status. Left ventricular aneurysm thus can be surgically treated with low mortality rate and good functional result.

Risk factors for morbidity and mortality in mitral valve replacement

Risk factors of operative mortality and long term survival were identified in 219 patients who underwent mitral valve replacement (MVR) using Bjørk-Shiley mechanical prostheses. Early mortality was 7.3%. The accumulated follow-up time was 1134 patient-years, and the 5-year survival for the total cohort was 78 +/- 3%. Independent prognostic factors of early mortality were poor NYHA class, which carried a relative risk (RR) of 3.2, and ischaemic aetiology, with a RR of 2.2. Ischaemic aetiology was the sole predictor of heart pump failure requiring intra-aortic balloon pump support (RR = 2.7). Independent risk factors of total mortality (early and late) were male sex (RR = 2.3), NYHA class III-IV (RR = 2.4), presence of mitral regurgitation (RR = 3.2) and relative heart volume (RR = 1.6 for a 800 ml/m2 size compared to a heart of 550 ml/m2). Our results underline the importance of patient-related factors in MVR, and indicate that care is needed in comparing the quality of MVR from different institutions with respect to mortality and morbidity. The results of MVR are palliative rather than curative except in female patients with NYHA class II function and mitral stenosis, in whom cure was attained.

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.