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Fourteen children had a permanent pacemaker implanted between May 1967 and July 1983. Postoperative complete heart block was the indication in nine cases, congenital complete heart block in three, and sick sinus syndrome in two. Two patients died, one suddenly and one after aortic valve replacement. A total of 48 pulse generators were implanted; five patients were given an isotopic pacemaker. Twelve patients had epicardial leads implanted initially, and two received a transvenous endocardial system. The lead system implanted initially remained without malfunction in only seven patients. In the other seven patients 20 lead malfunctions occurred. Psychological maturity and physical development seemed to be normal in all 14 children. Improvement in equipment and technique will improve the outlook for paced children in the future. [ABSTRACT FROM PUBLISHER]

A Caucasian female patient with repetitive attacks of ventricular tachycardia and fibrillation caused by annular submitral left ventricular aneurysm is reported. During a follow-up period of six years after aneurysmectomy, the patient remained symptom-free. [ABSTRACT FROM PUBLISHER]

A 23-year-old woman, who had suffered recurrent acute bronchitis, dyspnoea, and stridor, was found to have a tracheal stenosis and complete left main bronchus obstruction. Biopsy of the tumour showed an adenoid cystic carcinoma. After pneumonectomy the trachea was closed through tumour tissue. Two weeks later a right thoracotomy showed that a tumour had invaded the trachea from the carina up to 6 cm and the right stem bronchus for 1 cm. Under extracorporeal circulation 7.5 cm of the trachea and right bronchus were resected. A direct tracheal anastomosis was easy to perform. Spontaneous respiration with efficient coughing returned after five days. Unfortunately, one month later, high fever caused by a lung abscess developed, which provoked a massive haemoptysis with fatal outcome. [ABSTRACT FROM PUBLISHER]

Background: The selection of stage IIIA N2 non-small cell lung cancer patients for primary surgical treatment remains controversial., Methods: One hundred forty patients with resected non-small cell lung cancer who eventually proved to have pathologic N2 disease were studied with a univariate and multivariate analysis of prognostic factors., Results: Nineteen patients had a positive mediastinoscopy; the others had a preoperative N0 or N1 stage. Complete resection rate was 80.7%. Five-year survival was 20.8% (95% confidence interval, 17.2% to 24.4%), 32.2% in mediastinoscopy-negative patients. In the univariate analysis, clinical N stage at mediastinoscopy, complete resection, performance status, T stage, number of metastatic levels in adenocarcinoma, and nodal capsule rupture were important factors. In a multivariate model, survival was worse in case of higher T stage (relative risk = 1.43), lower performance status (relative risk = 1.37), involvement of more than one node level (relative risk = 1.68), nonsquamous histology (relative risk = 1.29) and clinical N2 stage (relative risk = 1.43). Long-term survival was unlikely when lactic dehydrogenase or carcinoembryonic antigen levels were elevated., Conclusions: In clinical N0 or N1 cancer, complete resection resulted in reasonable survival prospects. In patients with N2 disease discovered at mediastinoscopy, surgical treatment was only worthwhile in case of minimal N2. Several unfavorable prognostic factors could be identified in the univariate analysis and confirmed in a multivariate Cox model.

A prospective randomized study, comparing the clinical results between two groups of patients undergoing valve replacement with the Monostrut (MS) and Medtronic-Hall (MH) heart valve prosthesis was carried out between January 1985 and December 1988. A MS valve was implanted in 205, the MH in 198 patients selected randomly. Statistical analysis showed a perfect match between the two groups regarding preoperative and operative variables, including implantation site. All patients were given life-long anticoagulant therapy after operation. Follow up was 5.06 years (median) with a total of 1971.1 patient-years (pty) and 96.6% complete. The two groups showed no significant difference in the incidence of the following postoperative events: 30-day mortality, late mortality, reoperation, anticoagulant related bleeding, paravalvular leak, prosthetic valve endocarditis and thromboembolism (TE). Multivariate analysis indicated a borderline increased hazard of TE (2.1 +/- 0.4%/pty versus 0.7 +/- 0.2%/pty) (p = 0.0087, Bonferoni corrected significance) in the MS group. It is concluded that long term outcome is excellent with these two tilting disc valves. The marginally lower incidence of thromboembolism, however, favors the Medtronic Hall prosthesis.

A case is described, which presented the following combination of anomalies: An interatrial and interventricular septal defect, absence of a cleft in the aortic leaflet of the mitral valve and in the septal leaflet of the tricuspid valve. The latter leaflet was underdeveloped and presented several perforations. On the bases of the characteristic electrocardiographic, angiocardiographic and anatomical findings this anomaly was considered to be an intermediate form of a common atrioventricular canal. Total repair was successfully performed utilizing the technique of Rastelli and McGoon.

We report observations on ultrastructural and cytochemical changes in the myocardium after hypothermic protection in 21 patients who underwent cardiac operation. Two general categories of hypothermic protection were studied. (1) topical cooling during anoxic arrest and moderate general hypothermia (10 patients with aortic valve replacement, Group 1) and (2) intermittent perfusion during moderate general hypothermia combined with topical cooling (11 patients with multiple valve replacement, Group II). Transmural left ventricular biopsies were taken at the start of the cardiopulmonary bypass and shortly after the end of aortic cross-clamping. In Group I (cross-clamp time, 51 +/- 12 minutes) only minor pathologic changes of the myocardial fine structure were found, with no differences among the left ventricular layers. In most mitochondria, structure remained intact but the mitochondrial granules disappeared. Cytochrome-c-oxidase activity was unchanged. In Group II (total cross-clamp time, 83 +/- 16 minutes) the subendocardium was well preserved. Slight subcellular damage comparable with that of resulting from topical cooling was seen in all hearts even after a total cross-clamp period of 106 minutes. Cytochrome-c-oxidase activity was unchanged. In the subepicardium, however, a positive correlation was found between the severity of ultrastructural damage and total cross-clamp time (p less than 0.05). Matrix clearing, damage to the cristae and the mitochondrial membranes, and nuclear abnormalities occurred when the aorta was cross-clamped for morethan 60 minutes. Cytochrome-c-oxidase activities decreased in these samples. It is concluded that: (1) no significant subcellular injury was found in hearts cooled topically during 1 hour of anoxic arrest; and (2) in hearts protected by intermittent perfusion during moderate general hypothermia and additional external cooling, the subendocardium was well preserved for anoxic periods of up to 106 minutes. However, after 60 minutes of aortic cross-clamping subcellular damage increased progressively in the subepicardium.

The perioperative mortality rate in elective aneurysmectomy progressively declined to 2%; despite the fact that the percentage of patients with risk factors has increased. Important is that this perioperative mortality is not related to the age of the patients. In acute situations the perioperative mortality has increased to 30 à 50%. This can be explained by the increasing number of ruptured aneurysms and the influence of increasing age at the time of surgery. These results support the concept of elective resection of abdominal aortic aneurysms.

1. The overall operative risk for the palliative procedures for Tetralogy was 3,2% (93 cases). The Blalock-Taussig shunt remains the intervention of choice in older children. The Waterston shunt gives optimal results in the infants under six months of age but on long term the hasard of pulmonary hypertension still exists. 2. Before 1965, the mortality rate for the total repair was 43,7% (16 cases). During the last 8 years, the mortality rate decreased to 5,7% (36 cases). One operative death after total correction with a Potts shunt is not included in this figure. This type of shunt was replaced by the Waterston shunt after 1966, because of the high operative risk total correction and the high frequency of pulmonary hypertension on long term. 3. The long-term results were excellent in 85% of the survivors (mean follow-up of 4,1 years). A pulmonary insufficiency was found on clinical examination in 35% of the cases. This insufficiency was well tolerated by all patients. The long-term consequences, however, are uncertain. 4. It seams rational to proceed to an earlier total correction in these cases when well defined criteria are fullfilled, as the mortality figures of the palliative and corrective procedures have a tendency to reach each other: (3,2 versus 5,7%).

Ninety-one PTFE grafts (63 Gore-Tex and 28 Impragrafts) were used to bypass an occluded femoropopliteal artery in eighty-six patients. Ischemic rest-pain usually combined with ulcerative lesions or gangrene was the operative indication in 56 patients. In 58 percent the outflow was limited to at most 1 crural artery. The distal anastomosis was located to the distal popliteal artery in 38 reconstructions and to the tibioperoneal trunc or one of the crural arteries in 27 reconstructions. Postoperative angiography was performed in 18 patients. The incidence of early thrombosis is very high namely 47% within 3 months and 57% within 6 months. Limited outflow and thrombus apposition, as demonstrated by some angiograms, are the major reasons of the early occlusion.

During a 15-year period, the aortofemoral Dacron graft was used for revascularization of 615 limbs in 352 patients, with an overall operative mortality rate of 5.1% and a cumulative 10-year patency rate of 62%. The late complication rate was 27%, with late thrombosis being by far the most frequent complication (24%). Among several factors responsible for late occlusion, the presence of trifurcation disease and the site of the femoral anastomosis are by far the most important. Our procedure of choice for a thrombosed graft limb is thrombectomy and profundaplasty, which give a long-term patency rate of 68%.

The number of operated T3 lung cancers increases constantly. The absolute 5-year survival was 16.6% (9/54) and was only 9.5% (4/42) in resected N2 tumors.

Inflammatory aneurysms are not so frequent, etiology and pathogenesis are uncertain. Resection can be a problem because of the dense inflammatory fibrous reaction. Preoperative diagnosis may be possible with the aid of intravenous urography and CAT-scan. The treatment of choice is an aortic replacement followed by uni- or bilateral ureterolysis and omentoplasty to cover the entire vascular reconstruction and protect the ureters.

The late results of aortofemoral grafting for aortoiliac occlusive disease in 371 patients are presented. Late survival (30% after 15 years) was primarily dependent on age at the time of surgery and the presence of atherosclerotic heart disease on subinguinal atherosclerotic involvement. The majority of late deaths (42%) was due to atherosclerotic disease. With a mean follow-up period of 7 years the late complication rate was 29%. Late thrombosis was responsible for 66% of the late complications and a subsequent redo-operation was necessary in 24% of the patients. Age at the time of surgery and the presence of femoropopliteal occlusive disease were the most important factors. Regarding the late mortality rate of 45%, it is recommended that follow-up in these patients should be directed not only to late graft complications but also to other manifestations of generalized atherosclerosis.

Between January 1978 and March 1981, 100 anterior mediastinotomies were performed in patients with proven or suspected lung cancer. It was done 72 times in patients with a tumor of the left lung, all presenting with a normal mediastinum. Of those 72 patients, 59 had a tumor in the left upper lobe: 30.5% of the latter were found to have involved mediastinal lymphnodes (our yield in this location was 15.1% when using the cervical mediastinoscopy); 16 patients with a left upper lobe tumor had both an anterior negative cervical mediastinoscopy followed by an anterior approach: 4 became positive (25%). The anterior mediastinotomy was performed two times in patients with a suspect mediastinum: the mediastinoscopy was once positive, and once negative. It was done 26 times in patients with a radiologically manifest enlarged mediastinum (7 on the right side, 19 on the left side); in 24 patients the histological diagnosis was unknown. The anterior mediastinotomy was positive in all 26 cases. For the whole group we found positive nodes in 10 of 26, i.e. 38.5% of the patients despite normal findings at cervical mediastinoscopy. We would therefore recommend an anterior mediastinotomy in every patient with a suspect or an enlarged superior mediastinum in order to establish an histological diagnosis or exceptionally to check the operability. If the mediastinum is radiologically normal, the anterior approach has much more chance to yield a positive result than the cervical one when the tumor is located in the left upper lobe.

Between 1963 and 1979, limited pericardiectomy through left anterolateral thoracotomy was performed in 14 patients with uremic pericarditis. Two patients died after operation and one patient presented an early recurrence. Within a mean follow-up time of 3.3 years there were 7 late deaths but no recurrences or no cases of constrictive pericardidis. After reviewing the literature, it is concluded that the best early and late results in uremic pericarditis are obtained with pericardiectomy through an anterolateral thoractomy, the subxiphoid approach with creation of a pericardial window being a good alternative in critically ill patients.

Between 1970 and 1984 the diagnosis of acute, massive lung embolism was made 30 times in our department. In 29 patients the clinical diagnosis was correct and a Trendelenburg operation under extra-corporeal circulation was performed. In 18 cases there was an operation in the immediate preoperative course. In 1 case there was a combination of operation and the use of contraceptives. 3 cases were immobilized by a plaster of Paris cast. In 4 cases the use of oral contraceptives and in 3 patients the history of chronic recurrent lung embolism were evident. The mean immobilisation time was 15 days. In 24 cases the diagnosis was made only on the base of the clinical anamnesis, and examination, E.C.G. and chest radiography. In 4 cases angiography and in 1 patient the scintigraphy confirmed the diagnosis. Preoperatively 28 patients were in severe shock. One patient was operated electively. 14 patients needed external cardiac massage. In all cases clots were found in the left pulmonary artery, 28 in the right pulmonary artery, in 3 cases clots in the right atrium, 3 in the right ventricle and three in the inferior caval vein. Nine De Weese caval vein clips were inserted and one Mobin-Uddin filter. Postoperatively 18 patients were alive and well without sequelae. Two patients developed a cerebro-vascular accident (CVA) with one complete recovery. Ten patients died. Postoperative treatment consisted of I.V. heparin administration immediately after surgery and 6 months of oral anticoagulants. Except for chronic recurrent lung embolism the pulmonary function tests were excellent postoperatively without recurrence of the disease.

437 patients who underwent surgery for abdominal aortic aneurysm have been studied. Of these, 206 patients (medium age 63 years) had elective surgery, 231 patients (medium age 73 years) had acute surgery. The five-year survival rate was 65% for the elective group and 40% for the acute group, but these percentages are influenced by the perioperative mortality. When the survival curves of the 198 survivors of elective surgery and the 153 survivors of acute surgery were compared with these of a demographically similar population, we noted lower survival probabilities than for the standard population in the elective group, whereas the patients who underwent emergency surgery have similar survival probabilities as the standard population. The influence of age is especially related to the perioperative period and arteriosclerosis is the most determining factor for long time survival.

The diversity of conditions inducing an increase in CPK-MB, CPK, LDH and SGOT allows investigation of the quantitative evolution in cardiac patients during heart surgery. In nine patients submitted to valve replacement, three samples were taken respectively: one from the superior and the inferior caval veins and one another from the coronary sinus and immediately centrifuged. The sera were processed to quantitate the CPK, CPK-MB, LDH and SGOT through the three periods of observation. The three sites intended to explore the possible other sources of CPK-MB released at surgery: superior vena cava accounts for upper body regions, inferior vena cava for lower body regions and the coronary sinus for the heart itself. The three sites compared separately through the three periods did not show any significant differences. Only comparing the pre-CPK values to their homologous obtained during and after cardiopulmonary bypass, very evident differences could be registered (P less than 0,05 and less) for CPK, CPK-MB and LDH. While SGOT remained totally unchanged through the three periods. The evolutive CPK, CPK-MB and LDH increase accounted for high sensitivity of these enzymes to the variations of conditions during cardiac surgery. It is highly possible that other sources of CPK-MB could be dissiminated in the body and capable to produce valuable enzymatic amounts during and after cardiac surgery and that the heart is not exclusively alone in releasing this enzyme during cardiac ischemic arrest and in other circumstances. The real importance of CPK-MB principally and of CPK would be surestimated as conclusive parameters in diagnosis of myocardial damages during cardiac procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

A total of 1,001 patients with a confirmed diagnosis of lung cancer were treated at the University Hospital Pellenberg - Leuven in the five-year period 1970-1974. One hundred and sixty-four patients (16.4%) were operated and 152 underwent surgical resection of their pulmonary lung lesion. The influence of factors as histology, type of resection, age, staging, anatomic localization of the tumor on the five year survival are considered. The survival was 34.2% for all types of resected tumors, ranging from 42.0% for the lobectomies in squamous cell carcinoma to 0% in small cell carcinoma. The operative (30 days) mortality is included in the statistical follow-up. This mortality was 8.6% for the pneumonectomies and 4.3% for the lobectomies.

The early and late results of total pericardiectomy, performed over a 17 years period in 39 patients with chronic constrictive pericarditis, are presented. The overall operative mortality was 18%. With growing surgical experience and anesthesiological improvement, the operative morality of 26% during the first 12 years decreased to an acceptable 6.2% during the last 5 years. The cumulative 5 and 10 years survival rates were respectively 73% and 68%. Ninety-three percent of the surviving patients were classified in functional class I or II (NYHA classification), while preoperatively 90% of these cases belonged to class III or IV. Viewing these results it is concluded that the tendency towards early surgery should be encouraged, especially because the chronic state is accompanied by several deleterious effects.

In the period 1961--1971, 41 patients with a squamous-cell carcinoma were operated upon. The absolute 5-year survival is 47.6% for the lobectomy and 20% for the pneumonectomy. In the period 1971--1976 (6 years), 211 resections for carcinoma (all types) were performed including 19 cases of squamous cell carcinoma, operated in 1971 and also studied in the first part of the work. They represent only 15.2% of all the hospitalized lungcancer patients. The lobectomy/pneumonectomy ratio is 60/40. The postoperative mortality is respectively 4% and 9.5% and the major surgical complications (bleeding, broncho-pleural fistula, empyema) are 0.8% and 3.6%. The causes of postoperative death are examined. Remarkable is the low incidence of bronchial fistulisation: 1 in 211 resections for malignant tumors, i.e. 0.47%. These results are discussed and compared with the literature.

The cardioprotective effect of the addition of the slow calcium-channel blocker nifedipine to cardioplegic solution was tested in two double-blind placebo controlled randomized studies. The first study included 24 patients undergoing aortic-coronary bypass grafting, and the second included 24 patients undergoing aortic valve replacement. Nifedipine at a dose of 200 micrograms/L or placebo was added to St. Thomas' Hospital cardioplegic solution. The following markers of ischemia were used: adenosine triphosphate and its catabolites, creatine phosphate and inorganic phosphate, determined in transmural left ventricular biopsy specimens taken before, at the end of, and after aortic cross-clamping; hemodynamic recovery 15 minutes after cessation of cardiopulmonary bypass; clinical outcome in terms of the incidence of arrhythmias, low cardiac output, positive inotropic support immediately after operation, and follow-up at 15 months. The main difference between the two studies was that myocardial temperature during cross-clamping remained constant at 14 degrees C in coronary bypass grafting but increased to 25 degrees C in valve operations despite the application of the same amounts of cardioplegic solutions. This lower temperature resulted in better preservation of high-energy phosphates in coronary bypass operations as compared to the placebo group having valve replacement operations. According to analysis of variance, a drug effect could be demonstrated only in the aortic valve replacement study: Accumulation of breakdown products of the adenine nucleotide pool was less in the nifedipine group than in the placebo group (p less than 0.05). Adenosine triphosphate decreased only to 84% in the nifedipine group and to 72% in the placebo group. Despite this adenosine triphosphate-sparing effect, weaning from cardiopulmonary bypass was more difficult in the nifedipine group. Left ventricular stroke work index 15 minutes after bypass was decreased to 72% of the prebypass value in the nifedipine group (t test, p less than 0.01) and only to 86% in the placebo group (p = NS). In contrast, after the patients were admitted to the intensive care unit, the incidence of low cardiac output tended to be lower in the nifedipine group than in the placebo group: 33% versus 58% (p = NS). In conclusion, ischemia-induced degradation of nucleotides as it occurs when myocardial cooling is inadequate can be prevented by the addition of nifedipine to the St. Thomas' Hospital cardioplegic solution. This effect, however, is not associated with an improved clinical outcome.

Two uncommon cases of vein obstruction are presented. In the first case a syndrome of superior, caval vein obstruction was caused by idiopathic fibrous mediastinitis involving the vein wall, and creating a tumefaction in the lumen of the vein simulating the existence of a benign tumor (fibroma) of the wall. This tumefaction was removed by endvenectomy, and the venotomy was repaired by a pericardial patch. In the second case the obstruction of the right subclavian vein was caused by a stenosed valve without signs of inflammation nor consecutive thrombosis. Until the present day no other similar case of a stenosed valve in the right subclavian vein has been reported.