P Ketonen’s research while affiliated with Helsinki University Central Hospital and other places

Since improved immunosuppression in the 1980's, heart transplantation is a well established procedure to treat patients with end-stage heart failure. The first heart transplantation in Finland was performed in 1985. Since then the activity has gradually increased to a level of about 25 annual transplants. The aim of this report is to sum up the clinical experience during the first 11 years. From February 1985 till the end of 1995, 190 heart transplantations were performed in our institution. There were 176 males and 14 females ranging from 15 to 62 (mean 42.2) years of age. End-stage preoperative cardiac disease was dilating cardiomyopathy in 108 cases, coronary artery disease in 65 cases, valvular disease in 12 cases and congenital heart disease in five cases. The 30-day hospital mortality was 29 out of 190 (15.2%). The actuarial survival was 77% at one year, 75% at two years and 73% at 10 years. The most common causes of death were rejection (11 cases), graft failure (11 cases), abdominal complications (six cases) and cytomegalovirus (CMV) infection (four cases). A total of 87 rejection episodes occurred in 53 patients consisting 28 per cent of patients. 44 rejections occurred within three months post transplantation. Significant infections were noted in 198 instances in 97 patients. These were of bacterial origin in 92, viral in 48, fungal in 12 and protozoal in 10 cases, and 36 such infections which responded to antibiotics favourably but in which the microbe remained unidentified. 138 infections (i.e. 80%) occurred within 6 months post transplantation. In viral infections cytomegalovirus (CMV) predominated (29 out of 48). The CMV infection was significantly milder in patients who were seropositive preoperatively than in preoperatively seronegative patients with seropositive donors. CMV infection was associated with increased risk of post-transplant coronary artery disease. Three years after transplantation some restoration of sympathetic nervous response was observed at orthostatic test in heart rate and blood pressure. It can be concluded that 1) if a patient survives the three immediate postoperative months, his prognosis is good for the forthcoming years, 2) clinically significant rejections occur in less than one third of the patients, 3) cytomegalovirus is the most harmful agent post transplantation and a risk factor for post-transplant coronary artery disease and that 4) some restoration of sympathetic nervous control of the heart occurs within three years after transplantation.

In a retrospective study, 210 autogenous femorotibial saphenous vein grafts inserted during the 15 years from 1967 to 1982 were followed-up for a mean period of 62.3 +/- 5.7 months. Seven patients, who had had eight grafts died in hospital. The remaining 202 grafts fell into three groups: (1) Sixty grafts in patients who received 325 mg of dipyridamole and 1.0 g of acetylsalicylic acid daily, starting on the second postoperative day and continuing for six months. (2) One hundred and two grafts in patients on no antithrombotic therapy. (3) Forty grafts in patients on warfarin therapy to maintain the prothrombin time (prothrombin-proconvertin method) within the therapeutic range (0.10 to 0.20). Medication was continued for six months. This group included more high-risk patients than the other two groups. The mean ages and the incidence of risk factors did not vary significantly between the groups. The patency rates in three groups at five years were 62.5%, 44.0% and 26.0% and at ten years 48.5%, 25.0% and 21.5% for the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups, respectively. The limb salvage rates were 100%, 96% and 85% in the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups respectively. Thus, the best results were seen in the aspirin/dipyridamole group.

The diagnostic features and operative results in 13 patients with subclavian artery aneurysms were analysed. Symptoms related to subclavian artery aneurysms were present in seven patients, whereas six patients were asymptomatic and the aneurysm was discovered incidentally on chest X-ray. Angiography was the most valuable diagnostic examination and was also necessary in planning the operation. A correct preoperative diagnosis was made in five of six patients with computed tomography. Resection of the aneurysm was performed in nine and aneurysmal exclusion in the latest four patients. Direct reconstruction was used in nine and in four cases an extra-anatomic carotico-subclavian bypass was performed. Postoperative complications arose in two symptomatic and in four asymptomatic patients (46%: two strokes, two wound infections demanding extirpation of the prosthesis in one patient, two pareses of the recurrent nerve and one postoperative haemorrhage). Operative mortality was one patient. Follow-up data was available for all patients for periods of 6 months to 14 years. The vascular graft was patent in all patients. The authors conclude that subclavian artery aneurysm must be included in the differential diagnosis of all obscure upper mediastinal masses as seen on the chest X-ray and examined with CT and angiography. Exclusion of the aneurysm with extra-anatomical reconstruction is technically easier and gives the same postoperative long-term results as resection of the aneurysm and direct reconstruction. A relatively high complication rate after operation on asymptomatic subclavian aneurysms indicates a need for re-evaluation of operative indications in asymptomatic patients.

Seventy-one coronary artery bypass grafting (CABG) reoperations were performed during a 17-year period, comprising 2.7% of all CABG operations. The main indication (in 87%) was vein graft failure alone or combined with other causes. Progression of disease in native coronary arteries was the sole indication in only 4 of the 71 cases. There were seven perioperative deaths, mainly due to myocardial infarction. Significant perioperative complications arose in 36 cases, including intraoperative lesion of a previous left internal mammary graft (16.2%) or of the right ventricle or anterior descending branch of the left coronary artery (2.8%). Postoperative low output syndrome appeared in 13 patients (18.3%), in seven of whom myocardial infarction was verified. Postoperative bleeding required resternotomy in six cases (9.1%). Because of the heightened operative mortality and morbidity risks, indications for redo CABG should be individualized. A well functioning internal mammary artery graft may be a relative contraindication. Accurate knowledge of the previous operation is essential and, especially in young patients, the possibility of reoperation should be taken into consideration at initial CABG.

We have used polydioxanone (PDS) in 50 patients who underwent coronary artery bypass grafting. The anastomoses consisted of suturing an autologous vein graft to the coronary artery (122 operations), a vein graft to the aorta (63 operations) and the internal mammary artery to the coronary artery (33 operations). The recipient coronary artery was subjected to endarterectomy in 28 instances. The anastomoses proved to be reliable in the early postsurgical period; no bleeding was attributed to the PDS suture. Clinical follow-up for a maximum of two-and-half years, completed using control coronary angiograms in selected cases, demonstrated good results. The practical properties of PDS were evaluated to be at least as good as those of polypropylene. Experiments have clearly shown that small artery anastomoses heal more favourably after the use of absorbable sutures than after the use of nonabsorbable sutures. Because of this finding and on the basis of our clinical experience, we believe the application of PDS in coronary surgery should be recommended as an alternative treatment.

The results of 305 femorotibial bypass grafts performed in 246 patients are presented. Of these operations 246 were primary and 58 secondary or tertiary. A total of 66 diabetic patients were in the series. An autogenous saphenous vein graft was employed in 196 primary operations, the other grafts used being PTFE, human umbilical cord vein graft, venous allograft and knitted dacron velour graft. Hospital mortality was 8 patients (2.6%), while late mortality was 73 patients, 39 of them having had patent grafts. There were 89 (29.2%) immediate or early hospital failures. Two-hundred-sixteen grafts were followed for a mean observation time of 62.3 +/- 5.7 months. The cumulative patencies were analyzed using the life-table method. One, five, and ten year overall patencies for saphenous vein grafts as indicated by claudication were 73%, 53% and 35%, respectively. In rest pain, the patency rates were 62%, 46% and 40% at similar intervals. In impending gangrene the patencies were 43%, 35% and 20%, respectively. The patencies for arterial substitutes were generally poor, i.e., 35% and 15% at one and five years. None of the graft substitutes were followed for up to ten years. Diabetic patients had a significantly lower patency rate than nondiabetics (p = 0.002). The impact was remarkable if impending gangrene co-existed. In all these situations the early graft failure ensued. Both the run-off and inflow status affected the patency rates. This was significantly lower (p = 0.001) when only one distal branch was visualized in angiography.

External compression of the popliteal artery is probably still underdiagnosed. Young patients with atypical claudication, with isolated popliteal changes, deserve thorough investigation. Subdividing the entrapment syndrome into three subgroups (I-III) highlights the clinically important characteristics of the different types. Delayed diagnosis leads to arterial occlusion with clinical and radiological resemblance to arteriosclerotic occlusive disease. At this stage a medial approach with reversed saphenous vein bypass is recommended. If the artery is still patent, a posterior S-shape approach offers good exposure for arterial decompression, rerouting and possible ancillary measures. In addition to reviewing the literature and outlining the classification criteria and surgical treatment, five cases of our own are presented including two rarities. In one both type I and type III existed simultaneously. In the other the popliteal artery entrapment was combined with cystic adventitial disease.

Post-mortem analysis with castangiography was performed on 54 patients who died within 30 days of coronary artery bypass surgery. Myocardial failure was the cause of 85% of the deaths. There were 215 coronary anastomoses (4.0 +/- 1.1/patient), 24% of which were non-functioning. Most of the occlusions were due to various technical failures. The most striking features were 1) high occlusion rate (25%) in sequential vein grafts and 2) disastrous complications of coronary endarterectomies. Compared with preoperative angiographic data, only 15 (28%) of the 54 patients were found to have 'complete' revascularization, with patent grafts and all stenosed coronary arteries bypassed. The need for recognition and avoidance of technical complications is stressed: Failures of surgical technique constitute a major risk factor in coronary artery surgery.

From 1967 to 1982, 305 femoral tibial bypasses were performed. Of these 180 (59%) were performed on limb salvage indication. A reversed autogenous saphenous vein was used in 134 instances, among 46 vein substitutes there were 15 vein allografts, 13 human umbilical cord vein grafts, 12 PTFE grafts and six dacron grafts. Hospital mortality was six patients. An additional 37 patients died during the follow-up period. The patency rates for saphenous vein bypass grafts were 62.5%, 48%, and 25% at one, five, and ten years, respectively, and 33% and 25% at one and five years, respectively, for the vascular substitutes. The mean +/- SD follow-up time was 62.27 +/- 5.7 months. During the early postoperative period 23 legs (12.7%) had to be amputated. During the follow-up period an additional 14 legs (7.8%) were lost giving a limb salvage rate of 79.5%.

In 1966-1986, two men and four women (mean age 47.5 years) underwent surgery for primary sternal tumour. Three of the tumours were benign (two condromata, one osteochondroma) and three were malignant (two chrondrosarcomata, one reticulum cell sarcoma). Inflammatory or degenerative lesions impeded differential diagnosis in three additional cases (without tumour). The tumours were treated with radical resection of the affected part of the sternum, including the relevant attached structures. Marlex-mesh reconstruction of the defect was necessary in four cases. There was no operative mortality. One Marlex graft became infected. At follow-up (average 11.1 years, range 9.0-14.7 years), five patients were alive without recurrence of tumour and the sixth had died of unrelated cause.