Tuberculous pericarditis in Birmingham.

Forty-one patients with acute tuberculous pericarditis were studied retrospectively. Anti-tuberculosis chemotherapy alone was effective in thirty. Five patients died, two from unrelated causes, two due to delayed diagnosis, and one after pericardiectomy. Constrictive pericarditis developed in seven patients, six of whom had successful pericardiectomy. Corticosteroids could not be shown to have reduced the risk of developing constriction. When constriction occurred it did so within the first six months of illness in all cases in contrast to a separate series of 15 patients who presented with constrictive pericarditis. These had had no previous history of tuberculosis, and in 10 cases where pericardiectomy was done, no histological evidence of tuberculosis was found. They were European with an average age of 49 years whereas in the group with acute tuberculous pericarditis 33 were Asian and the average age was 36 years.     

Asbestos induced pericardial effusion and constrictive pericarditis.

The number of disorders attributable to asbestos exposure has increased gradually over the years. The latest to be recorded is pericardial effusion and constrictive pericarditis, and three cases are reported here. A man with bilateral pleural thickening and plaques developed acute pericarditis and an effusion and was treated by pericardiectomy. Two men died from constrictive pericarditis associated with bilateral pleural effusions and diffusion pleural thickening. The pericardium showed nonspecific fibrous thickening. All had been occupationally exposed to asbestos. In the fatal cases the lungs contained amphibole fibres, in keeping with a modest degree of occupational exposure. Asbestos produces progressive fibrosis of the pericardium that is similar to diffuse pleural thickening and may be fatal. Both conditions may develop after relatively short or light exposure.     

The management of Hemophilus influenzae, Type B, pericarditis.

The incidence of Hemophilus influenzae, type B, infections in children has been increasing recently, so the number of cases of pericarditis is likely to rise also. We describe the clinical manifestations and treatment of H. influenzae, type B, pericarditis based on 4 patients and a review of the literature. The most common complication is cardiac tamponade, which requires drainage. All patients should be treated with antibiotics (chloramphenicol, ampicillin) and a drainage procedure. Because of several recently reported cases of subsequent constrictive pericarditis, we recomment anterior interphrenic pericardiectomy both for drainage and to prevent constrictive pericarditis. With appropriate therapy the survival rate should be very high.     

Profile of thoracic trauma–An analysis of 350 cases

The incidence of chest trauma is rising rapidly and opinion continues to differ on its management. Our experience with 350 consecutive patients of chest injuries between January, 1983 and June, 1986 was reviewed. There were 300 males and 50 females. The average age was 29 years. Two-hundred and seventy-five (80%) were under forty years of age. The commonest presenting features were pain (100%), and dyspnoea (58.57%). Features of peripheral circulatory failure were found in 20 per cent. Ninety (25.71%) had other associated injuries. Three hundred (85.71%) were treated conservatively with 20 (6.66%) deaths. Forty-eight (13.7%) patients underwent surgical exploration (thoracotomy in 34 and laparotomy in 14 patients) with 8 deaths. Remaining 2 patients died in the casualty soon after arrival. The overall mortality was 8.57 per cent. The average period of hospitalisation was 9.5 days.     

Management of unstable angina

One-hundred and seven patients with unstable angina were treated between 1981 and 1987. Platelet dysfunction and elevation of fibrinogen was observed. The efficacy of aspirin, dipyridamole and heparin on coagulation profile is compared. Left main disease was seen in 11.4 per cent. Left anterior descending was occluded in 90.7 per cent. Aortocoronary bypass graft using saphenous vein graft was carried out on all patients. On an average, each patients received 3.5 grafts. Emergency surgery was done in nineteen. Associated ventricular aneurysm was resected in nine. Thirteen patients died. Operative mortality decreased to nil in 1986–1987. Perioperative infarction was seen in five patients. Clinical improvement was seen in 80.3 per cent and 48.9 per cent were asymptomatic. Actuarial survival was 92 per cent after six years. Postoperative coronary angiography in 28 patients showed patency of grafts in 18, partial patency in six and occlusion in four. Aspirin was found useful after surgery to relieve angina. Spiroergometry and Thallium²⁰¹ scintigraphy was useful to assess medical and surgical treatment.     

Pericardiectomy: Current Indications,Concepts, and Results in a University Center

During a 7½-year period, 102 patients underwent pericardiectomy in the Emory University Affiliated Hospitals for a wide variety of pericardial disease. Seventy-six patients had predominantly effusive pericardial disease, and 26 patients had constrictive pericarditis. Nineteen cases of constrictive pericarditis developed in patients who had undergone previous open-heart operations. Hospital mortality at six weeks was 8.8%. The surgical approach was a left anterior thoracotomy in 72 patients; median sternotomy in 26 patients; and a subxiphoid approach in 4 patients. Only 2 patients required cardiopulmonary bypass. A detailed discussion of each subgroup of patients with pericardial disease requiring pericardiectomy is given.     

Rheumatoid pericarditis. Clinical significance and operative management.

The incidence of subclinical pericarditis associated with rheumatoid pericarditis may be as high as 50 percent, but significant impairment of cardiac performance owing to this type of pericarditis rarely occurs. In the past 7 years, we have encountered eight men with congestive heart failure owing to rheumatoid pericarditis. Cardiac catheterization and echocardiography were useful in establishing the diagnosis of pericardial constriction. Pericardiocentesis was unsuccessful in relieving symptoms in the three patients in whom the procedure was performed. Seven patients underwent pericardiectomy; six had constrictive pericarditis and one patient had an acute pericarditis with the sudden onset of cardiac tamponade. The other patient died of cardiac tamponade prior to operation. All patients improved after operation and have remained free of cardiac symptoms 3 months to 4 1/2 years later. The frequent occurrence of adhesive and obliterative pericarditis with loculated effusions suggests the need for pericardiectomy rather than pericardiocentesis in the patient with rheumatoid arthritis and symptomatic pericardial involvement. Immediate and lasting relief of this unusual nonarticular manifestation of rheumatoid arthritis can be expected after pericardiectomy.     

Traumatic Hemopericardium and Chronic Constrictive Pericarditis

Chronic constrictive pericarditis following traumatic hemopericardium has been reported in recent years, but it has not been reproduced experimentally in dogs. The present study attempted to produce posttraumatic constrictive pericarditis in 34 experimental animals.Hemopericardium by means of trauma to the epicardium or pericardium was produced by a sharp instrument or by the injection of autologous blood inside the pericardial sac. All animals were killed at intervals between 3 and 31 months.The animals in which hemopericardium was induced by injecting blood into the pericardial cavity showed no changes. The hemopericardium was completely resolved without noticeable residual trace. Animals having hemopericardium as a result of trauma evidenced a well-developed constrictive pericarditis that was documented clinically, hemo-dynamically, and histologically.These experimental findings indicate that chronic constrictive pericarditis may well be due to traumatic hemopericardium rather than to specific infection.     

慢性缩窄性心包炎的围术期处理

目的探讨慢性缩窄性心包炎的围术期处理方法. 方法 96例慢性缩窄性心包炎病人均行心包剥脱术. 结果全组死亡1例(1.04%).82例(85.41%)随访2个月～15年,其中80例心功能得到改善. 结论心包剥离术是治疗慢性缩窄性心包炎的有效方法,而良好的围术期处理至关重要.     

Early pericardiectomy of acute purulent pericarditis]

The results of early pericardiectomy in 15 cases of acute purulent pericarditis were reported. 13 cases were followed up from 2 to 8 years, none of them developed chronic constrictive pericarditis. The operation is simple and can shorten the time of hospitalization following thorough debridement of the infected foci.     

Combined surgical management of tuberculous constrictive pericarditis and coronary artery disease

The combination of constrictive pericarditis and coronary artery disease is rarely reported in medical literature. Constrictive pericarditis occurs after cardiac operations in 0.2–0.3 % of cases. Normal coronary vessels can be involved in the inflammatory process of constrictive pericarditis by scar tissue. The association between tuberculosis and coronary artery disease is rare. Obliteration of coronary vessels may occur in rare cases of tuberculous aortitis. We present a case of coronary artery disease associated with tuberculous constrictive pericarditis. Combined treatment by total pericardiectomy and coronary artery bypass surgery was successful.     

Peripheral lymph node tuberculosis: a review of 80 cases

One hundred and ninety-two patients with peripheral lymphadenopathy were screened and 80 patients with tubercular lymphadenitis were studied. Their ages ranged from 1 to 65 years; most were younger than 30 years and there was a slight female preponderance (1.2:1). Seventy per cent of patients were of low socioeconomic status. Of the 80 patients, 56 had affected cervical nodes, seven had inguinal nodes, five had axillary nodes and 12 had multiple sites of lymph node involvement. All had enlarged nodes which were matted in 44 cases and discrete in 18 cases, while the rest had either an abscess or a discharging sinus. Fifty-nine cases (74 per cent) showed a positive Mantoux test and four cases (5 per cent) had associated pulmonary tuberculosis. Fine needle aspiration cytology gave a positive diagnosis in 66 cases (83 per cent). Fifty-two cases showed a positive culture for Mycobacterium tuberculosis of human type in Lowenstein-Jensen medium. Short-term chemotherapy (9 months) consisting of rifampicin, isoniazid and ethambutol gave an excellent result. Surgery was not required in any of the cases.     

Sufentanil anaesthesia for major surgery: the multicentre Canadian clinical trial

One hundred and fortyone investigators from 45 institutions across Canada participated in the phase 4 clinical trial of sufentanil citrate involving 616 patients. All patients were ASA physical status class I, II, or III, undergoing elective, noncardiac, major surgical procedures. The average duration of surgery was 1.98 hr and mean dosage of sufentanil was 1.24 μg·kg^{? 1}· hr^{? 1}. Supplemental inhalational anaesthesia was administered to 266 patients (43 per cent). Eightysix patients required naloxone in the immediate postoperative period. Eighty per cent of these patients had received in excess of 1.0 μg· kg^{? 1}·hr^{? 1} of sufentanil. One hundred and twentynine adverse reactions were reported as disturbing and possibly drugrelated. Profound bradycardia or sinus arrest was reported in four cases and disturbing hypotension in 37. None of these events required termination of the procedure. The induction, maintenance and recovery phases were rated as good or satisfactory by the participating investigators in 94, 92 and 93 per cent of cases respectively.     

Pericardiectomy: A changing scene

The indications for pericardiectomy as well as the causal factors have changed in recent years. Sixty-eight patients operated on at the UCLA Medical Center between 1955 and 1982 have been described. There were 37 male patients and 31 female patients. The indication for operation was acute pericarditis in 37 patients, of whom 31 had recurrent effusion, and chronic constrictive pericarditis in 31 patients, of whom 8 were calcific. The most common cause of pericardial disease was tumor (20 patients), followed by idiopathic (13 patients), uremic (7 patients), viral (7 patients), tuberculous (6 patients), rheumatologic (6 patients), and miscellaneous (9 patients) causes. In most patients, pericardiectomy was performed through a left anterolateral thoracotomy without cardiopulmonary bypass. We recommend wide excision of the anterior pericardium (phrenic nerve to phrenic nerve) for effusive pericarditis. For chronic constrictive disease, we advocate a more extensive resection that includes the anterior as well as the posterior pericardium, thus freeing the left and right ventricles. Excellent long-term results were obtained with pericardiectomy in 90 percent of the patients who survived the operation.     

Intracardiac repair of tetralogy of fallot

One-hundred and twenty-two patients underwent intracardiac repair for tetralogy of Fallot between the ages of four and twenty-one. Isolated infundibular stenosis was seen in 63.6 per cent combined infundibular and valvular stenosis in 17.3 per cent, diffuse hypoplasia of outflow tract and main pulmonary artery in 10 per cent and isolated valvular stenosis in 9 per cent. Narrowing of right pulmonary artery was seen in two patients. Outflow patch was necessary in seventy-seven. Nineteen patients died. The causative factors were transannular patch for diffuse hypoplasia, infection and inadequate repair. Residual right ventricular hypertension was an important cause for mortality and morbidity. Myocardial blood flow was also found reduced, especially when residual right ventricular pressure was high.     

Surgical management of pericarditis in Zaria, Nigeria.

Over eight years, 58 rural Nigerians with pericarditis were treated surgically in Zaria using basic surgical facilities. Eighteen patients had purulent pericarditis, associated with staphylococcal pneumonia in children, or pneumococcal pneumonia in adults. Treatment with antibiotics and prompt pericardiectomy appeared to be superior to drainage, since a quarter of those initially treated with surgical drainage developed early constriction and required pericardiectomy soon after. Thirteen patients had chronic pericardial effusions, of whom one had epicardial constriction and two had cardiomyopathy. Twenty-seven patients had chronic constrictive pericarditis but tuberculosis was confirmed histologically in three only. Echocardiographic findings remained unchanged in five patients evaluated before and after pericardiectomy. Eight of the 13 patients who died had already developed myocardial or hepatic insufficiency before operation, because of late presentation or diagnosis. Greater awareness of the significance of precordial pain in this rural population where ischaemic heart disease is rare would help in making an earlier diagnosis.     

Long-term results following femoro-popliteal vascular reconstruction

All in all, 330 thromboendarterectomies (TEA) and 354 venous bypass operations (VBP) were performed on 550 patients. In 11.01 per cent of all cases in which VBP had been planned, veins were not in optimum condition. Repetitive interventions had to be applied to 111 patients. Successful reoperations could be performed on six cases with immediate TEA-closures (1.8 per cent) and another two after immediate VBP-closures (0.56 per cent). Postoperative lethality figures were 0.6 per cent after TEA and 0.28 per cent following VBP. Twenty-nine early TEA-closures (8.9 per cent) were corrected by secondary VBP in 16 cases (4.8 per cent). Three were corrected by femoral ablation and two by toe amputation in the border zone (1.7 per cent). Thirty-nine early VBP-closures (11.0 per cent) required repetitive VBP in two cases (0.5 per cent) and toe amputation in the border zone in another three instances (0.84 per cent). Eight patients each died within the first postoperative year from TEA (2.4 per cent) and after VBP (2.2 per cent). The following cumulative patency rates were recorded according to the life table method: after one year (TEA: 90.9 per cent, VBP: 88.9 per cent), after five years (TEA: 73.4 per cent, VBP: 84.6 per cent), after ten years (TEA: 38.2 per cent, VBP: 73.7 per cent), after 15 years (TEA: 9.8 per cent, VBP: 24.2 per cent). These differences were significant as early as five years from surgery. Late amputation rates were 2.1 per cent for TEA and 2.9 per cent for VBP. Late lethality rates were 28.8 per cent for TEA and 7.6 per cent for VBP.     

Early and late results of pericardiectomy in 118 cases of constrictive pericarditis

The medical records of 118 patients (86 male, 32 female, age 10-50 (mean 27) years) who underwent pericardiectomy for constrictive pericarditis at the Christian Medical College Hospital, Vellore, from 1954 to 1985 were reviewed. All had appreciable pericardial constriction. Preoperatively 97 of the 118 were in class III or IV of the New York Heart Association classification and 100 had peripheral oedema or ascites. Tuberculosis was proved as the cause in 72 patients. Pericardiectomy was accomplished through a standard anterolateral thoracotomy (107 cases), median sternotomy (3 cases), or bilateral thoracotomy (8 cases). Postoperatively an apparent low cardiac output state was seen in 34 patients, 12 of whom died. Hospital mortality in the last 12 years was 11%. Mortality was higher in NYHA class III and IV patients. The improved surgical results recently may be related to increased use of inotropic support and prolonged ventilation. At follow up there were 72 patients in whom functional capacity could be assessed; 63 were in class I or II. The poor results of pericardiectomy in some patients are likely to be related to advanced preoperative disability and early pericardiectomy is therefore recommended.     

Surgical experience with Aneurysm of the Sinus of Valsalva

During a three year period from July 1977 to July 1980, six cases of Aneurysm of the Sinus of Valsalva underwent surgical correction in our Institute. Three of them were males and three females. The constant symptoms were palpitations and fatigability and the constant signs were collapsing pulse and continuous murmur with thrill. In four cases the right coronary sinus had ruptured into the right ventricular outflow; in two patients, the non-coronary sinus was involved, one rupturing into the right atrium, the other one being unruptured. Four patients had associated aortic regurgitation and two had ventricular septal defect. All were corrected surgically; four patients with aortic regurgitation had aortic valve replacement; the ventricular septal defects were closed directly. One patient died on the operating table; one died at home suddenly, two months after surgery. The other four patients are doing well clinically, two to five years after surgery.     

The stomach after surgery--on the incidence of pathologic changes from the endoscopic viewpoint

The incidence of pathological changes in the wake of stomach surgery amounted to 483 of 550 patients who were endoscopically examined at the Outpatient Department of Surgery attached to the Medical Academy of Erfurt, between January 1st, 1975 and December 31st, 1985. These were 87.8 per cent. Similar findings were recorded from 67 vagotomised patients (12.2 per cent). These 550 cases represented 6.7 per cent of 8,155 patients whose upper digestive tract had been endoscopically examined throughout the above period of time. The first endoscopic check was applied to 49.9 per cent only five or more years, following surgery and to 44.8 per cent within two years from surgery. Pain was recorded as the major symptom and indication for the follow-up checks from 75 per cent of these patients. Pathological changes were endoscopico-macroscopically detectable from 75 per cent of the probands. Ulcers were observed in 20 per cent. Inflammatory changes accounted for 40 per cent in both groups. Tumours were established in ten per cent. Macroscopic findings were histologically verified in 208 cases (37.8 per cent), among them 41.2 per cent after stomach resection and 13.2 per cent following vagotomy. Suspicious diagnoses of inflammation was thus positively verified in 93.4 per cent of all cases and those of malignant tumours in 39 of 47 cases. Inflammatory processes were histologically detected in 31 cases in which it had been neither assumed nor formulated. In eight histologically established tumour cases that diagnosis had not been macroscopically made (inflammations in seven cases and no contributory findings in one). Macroscopic findings recorded from the above selected group of patients proved to be reliable for tumours in 85 per cent of all cases and for gastritis in 93 per cent. Endoscopic follow-up diagnosis should begin within the first year from stomach surgery and should be persistently continued on the basis of a systematic extended medical care programme. All the above findings were gained on the basis of high-continuity computer-adjusted data collection and evaluation.