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In order to describe subclinical brain injury in conjunction with cardiac operations 94 patients were prospectively studied with three brain injury assessment methods: CSF analyses 24 hours after bypass, psychometry, and computed tomography of the brain. Adenylate kinase (AK), a marker of ischemic brain cell injury, was measured in cerebrospinal fluid (CSF) and in serum. In 13% of the patients, a considerable increase in CSF-AK was seen, in 46% there was a moderate increase, and in 41% no or trivial increase. Psychometry measured as change between preoperative scores in a test battery (SS3) revealed a moderate decrease in intellectual function after operation. There was a significant inverse correlation between CSF-AK and SS3 (r = -0.46, p less than 0.001, r2 = 0.21, n = 71). Computed tomography (CT) of the brain was performed preoperatively and postoperatively in 54 patients. Two of these had cerebral infarctions visible on the CT, despite an essentially normal postoperative state. There was no correlation between indices of brain injury and patient diagnosis and length of perfusion. It is concluded that subclinical brain injury is often seen after cardiac operations. Most often the injury appears trivial and/or reversible, but in a minority of cases there is evidence that the brain injury is irreversible. Factor analysis favors the view that the microembolism theory might no longer be a valid concept in modern cardiopulmonary bypass (CPB). Instead, circumstances in the operative field seem more likely to be important causative factors. This interpretation calls for new principles in the search for an improved cerebral protection during cardiac operations.

Thirty rats were subjected to a standardized critical aortic injury and divided into six groups. In addition to controls, the animals were treated with a pneumatic antishock garment (PASG), massive intravenous or intra-aortic saline infusion, or PASG in combination with either massive intravenous or intra-aortic saline infusion. Twenty-six rats were subjected to a standardized hepatic injury and divided into four groups. In addition to controls, the animals were treated with PASG, massive intravenous saline infusion, or PASG in combination with massive intravenous saline infusion. These animals were allowed to bleed for 5 minutes before the treatment was started. The treatment with PASG alone prolonged the median survival time significantly from 7 min in the control group to greater than 120 min in the PASG group in rats with an aortic injury and from 33 to greater than 120 min in rats with a hepatic injury. Intravenous infusion of saline did not prolong the median survival time. Intravenous infusion in combination with PASG did not have any positive effects on median survival time or median mean aortic pressure and failed to prolong the median survival time significantly in rats with a liver injury, as six out of eight animals developed a lethal pulmonary edema.

Twenty-nine rats were subjected to a severe standardized hepatic injury and divided into four groups. In addition to controls, the animals were treated with PASG inflated to 40 mm Hg, PASG and infusion of Ringer's acetate, or PASG and infusion of Ringer's acetate and Dextran 70 in combination. The aim of the infusion therapy was to stabilize the mean aortic blood pressure at 60 mm Hg. PASG significantly prolonged the survival time and the time during which a sensory evoked response could be observed. The PASG also prolonged the time before the EEG amplitude began to decrease or a burst-suppression pattern appeared in the EEG. Intravenous infusion of Ringer's acetate did not prolong these times compared to when PASG was used alone; when Dextran 70 was added to the infusion therapy these times were reduced. Changes in the EEG were recorded at a mean aortic pressure of 60 mm Hg when infusions were given, whereas the aortic pressure had to fall to 40 mm Hg before any changes could be observed when no infusions were used.

A case of malignant leiomyosarcoma presenting as a left atrial cardiac tumor is described and its echocardiographic features are discussed. Tumor masses invading the atrial walls were extensively resected and the atrial wall was reconstructed with two patches of bovine pericardium.

The incidence and extent of cerebral damage following open-heart surgery were prospectively investigated in 103 patients, using clinical assessment, psychometry, adenylate kinase analysis in cerebrospinal fluid (CSF-AK) and computed tomography (CT) of the brain. The surgical mortality was 1.9%. Clinically there was obvious cerebral dysfunction in four cases, subtle evidence of brain damage (mainly undue fatigue) in 16 and no evidence in 81 cases. In the 16 patients the mean CSF-AK was substantially increased (0.122 U/l) and the psychometric performance distinctly impaired (-12 points) postoperatively; in the 81 patients the figures were 0.55 U/l and -3.4. Psychometrically, 60% of the patients showed cerebral dysfunction, which was pronounced in 16%. CSF-AK analysis indicated cerebral damage as absent or trival in 45%, moderate in 33% and marked in 22%. CT revealed postoperative cerebral infarction in two cases. Results from the various methods showed reasonable correlation, but also considerable overlap. Open-heart surgery thus can cause brain damage additional to that neurologically discernible. Fatigue is an important sign in this context. In research on postoperative brain damage, the relative insensitivity of routine neurologic investigation calls for supplementary, refined methods.

A five-year material of splenectomies (1970-74) is presented. The material was divided according to the indications for splenectomy as follows: radicality (Group I), iatrogenic hemorrhage Group II), traumatic ruptures (Group III), hematological cases (Group IV) and miscellaneous cases (Group V). There was a large increase in the hematological group over the period due to the addition of splenectomy in the staging procedure for Hodgkin's disease. The mortality was highest in group I and lowest in group IV, as also was the incidence of complications. No patient with Hodgkin's disease died of the operation and the staging laparotomy for this disease, which gives valuable information, thus seems sufficiently safe to warrant routine use.

One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71% early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.

Forty-nine patients with lung tumors initially diagnosed as carcinoids from their cellular appearance and arrangement were originally included in the study. The tumors of 46 of these patients showed an argyrophil reaction with the Grimelius silver stain. The three nonargyrophil tumors were reclassified as noncarcinoid tumors at further examination. The use of the argyrophil technique in characterization of the lung carcinoid tumors is discussed. The incidence of lung carcinoid tumors in the County of Uppsala was 0.7 patients per 100,000 inhabitants per year. Eleven patients with detected disease were symptom-free. The doctor's delay in 9 patients was 3 to 13.8 years. Yet, the prognosis was good, with 5-year survival in 91 percent, 10-year survival in 91 percent, and 15-year survival in 86 percent of the 46 surgically-treated patients. It is concluded that the surgical treatment should at least comprise a lobectomy.