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It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of the PFO in patients with paradoxical embolism.Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2 +/- 8.7 years; range, 37-74) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow-up at 99 +/- 30 months (range, 10-111 months) was 100% complete.All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97 +/- 3%, 97 +/- 5% and 94 +/- 8%, respectively. At long-term follow-up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery.Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.

Patients with severe heart failure due to valvular disease or coronary artery disease often benefit from conventional heart surgery even in the presence of severe left ventricular dysfunction. If a conventional procedure is not possible, left ventricular reconstructive surgery can be of value in selected cases. In cases of idiopathic dilated cardiomyopathy, the Batista procedure can improve left ventricular function, whereas in patients with ischemic cardiomyopathy, with or without left ventricular aneurysm, an endoventricular patch plasty with septal exclusion might be of value. Some patients with dilated cardiomyopathy and severe mitral regurgitation can benefit from a simplified mitral valvuloplasty.

Left ventricular wall perforation after acute myocardial infarction, without immediate rupture to fatal haemopericardium, is a rare complication that may result in a pseudoaneurysm. Transoesophageal echocardiography demonstrated a posterior wall perforation and the unique blood flow pattern at the neck of a pseudoaneurysm 6 days after acute myocardial infarction. In a second patient with angina and congestive heart failure 7 years after an acute myocardial infarction echocardiography demonstrated a huge pseudoaneurysm. Surgical repair was successful in both patients. Turbulence of blood at the neck of a pseudoaneurysm generates a murmur, and systolic regurgitation into a large aneurysm may cause symptoms of heart failure. Exact diagnosis, anatomical relations and size can be assessed with echocardiography. Angiography is required before surgery only to rule out coronary artery pathology. Occasionally a pseudoaneurysm may persist for many years but because of a high risk of rupture, prophylactic repair is indicated soon after diagnosis.

The results after 282 consecutive double (aortic & mitral) valve replacements (DVR) are compared with our previously reported experience after mitral (MVR, n = 810) and aortic valve replacement (AVR, n = 1753). All but one patient received Bjork-Shiley valves. The follow-up which closed on August 1, 1985 was 99.3% and covered 16,869 patient-years (mean 6.3 years/patient). Autopsies were performed in 74% of all fatalities. Early mortality rates were identical in the three patient groups, and late mortality did not differ between MVR and DVR patients. The fraction of valve-related mortality was similar in all groups. Anticoagulant-related bleeding was equally common in all patient groups. The incidences of thromboembolism, reoperation and valve failure did not differ between MVR and DVR patients, but were significantly higher than among AVR patients. With the exception of a slightly increased incidence of prosthetic valve endocarditis, the results after DVR equal those after MVR. In cases with severe mitral valve disease but borderline aortic valve disease, primary DVR is clearly justified and eliminates the need for, and risks of, a secondary AVR.

The present study attempted to determine the impact of alternative verdict choices on the decisions of mock jurors. Subjects used in this study as mock jurors were all college undergraduates. They were shown one of two versions of a videotaped simulated murder trial. Both films presented a defendant who appeared to be suffering emotional difficulties, but in one film the defendant had clearly committed the act while in the other film the defendant's actions were less certain. Subjects than gave their individual verdicts and, after deliberation with other subjects, a total jury verdict. The verdicts available to the subjects varied across three conditions such that the subjects in one condition were only allowed to find the defendant to be innocent or guilty. In another condition the subjects could find the defendant innocent, guilty or not guilty by reason of insanity (NGRI). In the third condition the subjects were allowed to choose between innocent, guilty, NGRI, and guilty but mentally ill (GBMI). The results indicated that the addition of the “mental health” verdicts had a significant impact on the decisions of the jurors. In particular, it appears that only defendants who would otherwise have been found innocent were likely to be found NGRI. This study also indicated that the GBMI verdict is very attractive to mock jurors. Indeed, even innocent defendants were found to be GBMI, a form of guilt, when this alternative was made available. These findings raise potentially important constitutional and practical issues for the trial of emotionally disturbed criminal defendants.

A 40-year-old man with Björk-Shiley valves implanted in the aortic and mitral positions nine months previously presented with central chest pain. Shortly after admission he developed clinical features consistent with left ventricular failure. Fracture of the mitral prosthesis was diagnosed by echocardiography. At emergency operation the outlet strut of the mitral valve was found to be fractured and the disc was in the left ventricle. The patient survived valve re-placement and is in good health four years later.

The results after 282 consecutive double (aorticmitral) valve replacements (DVR) are compared with our previously reported experience after mitral (MVR, n = 810) and aortic valve replacement (AVR, n = 1753). All but one patient received Björk-Shiley valves. The follow-up which closed on August 1, 1985 was 99.3% and covered 16,869 patient-years (mean 6.3 years/patient). Autopsies were performed in 74% of all fatalities. Early mortality rates were identical in the three patient groups, and late mortality did not differ between MVR and DVR patients. The fraction of valve-related mortality was similar in all groups. Anticoagulant-related bleeding was equally common in all patient groups. The incidences of thromboembolism, reoperation and valve failure did not differ between MVR and DVR patients, but were significantly higher than among AVR patients. With the exception of a slightly increased incidence of prosthetic valve endocarditis, the results after DVR equal those after MVR. In cases with severe mitral valve disease but borderline aortic valve disease, primary DVR is clearly justified and eliminates the need for, and risks of, a secondary AVR.

Clinical and experimental observations suggest that oestrogens may influence immune reactivity. The oestrogen-binding properties of the human thymus were studied by the use of an aqueous two-phase separation technique. A specific, high-affinity and low-capacity binding was found in 9 out of 10 thymic tissue samples obtained from children and adults of both sexes, their ages ranging from 1 to 42 years. The association constant (+/- SD) for the oestradiol binding in human thymus was 3.7 +/- 1.4 X 10(9) M-1 and was in the same range as the receptor binding in the human uterus. The steroid specificity was found to differ from the classical oestrogen receptor. The concentration of oestrogen-binding sites (+/- SD) was 182 +/- 181 fmol/mg protein and was higher than the receptor concentration of the uterus. According to histochemical analyses the binding is located in the reticulo-epithelial stroma rather than the thymocytes. Data suggest that the human thymus is a target organ for oestrogens which may influence lymphocyte function during therapy.

Between June 1980 and June 1983 4028 Björk-Shiley 70 degree convexo-concave prosthetic heart valves were distributed and implanted in Australia, Canada, Europe and South Africa. As of March 1986, a total of 52 outlet strut fractures (1.29%; 70% CL: 1.1%-1.5%) have been reported from 29 implant institutions in 12 countries. The majority (82.7%) occurred in Europe. Intervals between implantation and fracture were 13 days to 45.3 months (mean: 18.4 months; 70% CL: 16.6 months-20.1 months). The mortality rate after strut fracture was 78.7% (70% CL: 72.5%-84.9%). Upon stratification of the fracture by valve sizes and types it becomes evident that 75% (70% CL: 68.8%-81.2%) of all fractures are related to the sizes 29 mm to 33 mm (which virtually represent the same valve size) and predominantly to mitral valves (p less than 0.01). The large valves again have been stratified into two subsets, namely those fabricated from flanges originally machined as Björk-Shiley 60 degree convexo-concave valves (group I) and later produced valves machined initially to 70 degree specifications (group II). In group I the fracture rate was 5.2% (70% CL: 4.2%-6.2%) versus 1.6% (70% CL: 1.1%-2.1%) in group II (p less than 0.01), which identifies the group I 29 mm-33 mm Björk-Shiley 70 degree convexo-concave valves as the highest risk group for strut fracture. The rates are based upon all available information as of March 16, 1986.(ABSTRACT TRUNCATED AT 250 WORDS)

The experience after implantation of 3,334 Björk-Shiley valves over a 15 year period is described. With a 99.2% follow-up (covering 17,511 patient-years, mean follow-up time 6.3 years) and an autopsy rate of 75% among all fatalities, altogether 19 cases of mechanical failure were documented. There were no mechanical failures among the standard Delrin Björk-Shiley valve (n = 271), the aortic standard Pyrolyte Björk-Shiley (n = 739), or the Monostrut Björk-Shiley valve (n = 377). One of the mitral standard Pyrolyte valves (n = 430) fractured. Among the 1,461 convexo-concave valves, 18 fractured (6/884 with an opening angle of 60 degrees and 12/577 with an opening angle of 70 degrees). The actuarial incidence of mechanical failure at 5 years was 0.6% (with an upper 95% confidence limit of 1.2%) for the 60 degree convexo-concave valve and 2.8% (upper 95% confidence limit of 4.4%) for the 70 degree convexo-concave valve (p less than 0.01). Two groups of valves were especially affected by this complication; the 23 mm aortic 60 degree convexo-concave valve (5 year actuarial incidence 2.2%, upper 95% confidence limit 4.7%) and the 29 to 31 mm mitral 70 degree convexo-concave valve (8.3%, upper 95% confidence limit 14.2%). The hazard function presently indicates a constant (60 degree convexo-concave) or decreasing (70 degree convexo-concave) tendency for mechanical failure. The time interval between the first symptom of mechanical failure and circulatory collapse was significantly (p less than 0.01) shorter after aortic failure than after mitral failure, and no patient with a fractured aortic prosthesis survived long enough to undergo reoperation. The incidence of mechanical failure among patients dying suddenly (but with an autopsy) was 9.6% (95% confidence limits 4.9%-16.6%), and most cases of sudden death were unrelated to the prosthesis. The management of patients with suspected mechanical failure is described. Prophylactic re-replacements are discussed but cannot be generally recommended at present.

The early production series of the 29 to 31 mm 70-degree convexo-concave (CC70) Björk-Shiley heart valves constitutes a subgroup of CC70 values with an extra high risk of outlet strut fracture. The hazard function for mechanical failure among these valves has remained almost constant over a 7-year follow-up period, and the 7-year actuarial incidence of mechanical failure among these valves is 12.5%. Selected patients with these valves will be considered for prophylactic rereplacement.