Bjarne K. H. Semb: The contriver of the first implantation of a total artificial heart in Europe.

In 1985, the surgical team led by Bjarne Semb implanted the first total artificial heart (TAH) in Europe, and the following year the first successful bridge to transplant in Europe using the Symbion J-7/100 TAH. Together with the clinical experiences of colleagues in the United States, these early cases preceded the subsequent development of scores of mechanical assist devices to treat advanced heart failure. Semb proved to have the pioneering spirit needed to use the early generation of a TAH, but these early implants also generated much controversy in the medical community as well as the general public.

Radical pericardiectomy for chronic constrictive pericarditis.

BACKGROUND: We studied the impact of radical pericardiectomy on early and long-term patient survival, postoperative New York Heart Association (NYHA) functional class, and left ventricular ejection fraction in patients with chronic constrictive pericarditis compared to a sub-total pericardiectomy. METHODS: From 1991 to 2016, 41 patients underwent pericardiectomy for chronic constrictive pericarditis. Sub-total pericardiectomy was performed in 17 (41%) and radical pericardiectomy in 24 (59%) patients. Patients in the two study groups had statistically similar NYHA functional class, left ventricular ejection fraction, and cardiac catheterization data. Follow-up was 100% complete with a median time of 4 years. RESULTS: Radical pericardiectomy resulted in increased survival rates at 10 years (94%) compared to sub-total pericardiectomy (55%) (P = 0.014). In the idiopathic chronic constrictive pericarditis sub-group, long-term survival rates were also increased after a radical pericardiectomy (P = 0.001). Eighty-five percent of patients after a radical pericardiectomy were in NYHA functional class I or II after 5 years and 94% up to 25 years versus 53% and 63%, respectively, for the sub-total pericardiectomy group. CONCLUSIONS: Radical pericardiectomy provided superior 10-year survival and clinical functional improvement in patients with chronic constrictive pericarditis compared to sub-total pericaridectomy.

Double lung, unlike single lung transplantation might provide a protective effect on mortality and bronchiolitis obliterans syndrome.

BACKGROUND: Survival after lung transplantation (LTx) is often limited by bronchiolitis obliterans syndrome (BOS). METHOD: Survey of 278 recipients who underwent LTx. The endpoint used was BOS (BOS grade ≥ 2), death or Re-lung transplantation (Re-LTx) assessed by competing risk regression analyses. RESULTS: The incidence of BOS grade ≥ 2 among double LTx (DLTx) recipients was 16 ± 3% at 5 years, 30 ± 4% at 10 years, and 37 ± 5% at 20 years, compared to single LTx (SLTx) recipients whose corresponding incidence of BOS grade ≥ 2 was 11 ± 3%, 20 ± 4%, and 24 ± 5% at 5, 10, and 20 years, respectively (p > 0. 05). The incidence of BOS grade ≥ 2 by major indications ranked in descending order: other, PF, CF, COPD, PH and AAT1 (p < 0. 05). The mortality rate by major indication ranked in descending order: COPD, PH, AAT1, PF, Other and CF (p < 0. 05). CONCLUSION: No differences were seen in the incidence of BOS grade ≥ 2 regarding type of transplant, however, DLTx recipients showed a better chance of survival despite developing BOS compared to SLTx recipients. The highest incidence of BOS was seen among CF, PF, COPD, PH, and AAT1 recipients in descending order, however, CF and PF recipients showed a better chance of survival despite developing BOS compared to COPD, PH, and AAT1 recipients.

25-year follow-up after lung transplantation at Lund University Hospital in Sweden: superior results obtained for patients with cystic fibrosis.

OBJECTIVES: In Sweden, two centres perform lung transplantation for a population of about 9 million and the entire population is covered for lung transplantation by government health insurance. Lund University Hospital is one of these centres. This retrospective report reviews the 25-year experience of the Skåne University Hospital Lung Transplant Program with particular emphasis on short-term outcome and long-term survival but also between different subgroups of patients and types of transplant [single-lung transplantation (SLTx) versus double-lung transplantation (DLTx)] procedure performed. METHODS: Between January 1990 and June 2014, 278 patients underwent lung transplantation at the Skåne University Hospital Sweden. DLTx was performed in 172 patients, SLTx was performed in 97 patients and heart-lung transplantation was performed in 9 patients. In addition, 15 patients required retransplantation (7 DLTx and 8 SLTx). RESULTS: Overall 1-, 5-, 10-, 15- and 20-year survival rates were 88, 65, 49, 37 and 19% for the whole cohort. DLTx recipients showed 1-, 5-, 10- and 20-year survival rates of 90, 71, 60 and 30%, compared with SLTx recipients with 1-, 5-, 10- and 20-year survival rates of 83, 57, 34 and 6% (P < 0.05), respectively. Comparing the use of intraoperative extracorporeal membrane oxygenation, extracorporeal circulation (ECC) and no circulatory support in the aspect of survival, a significant difference in favour of intraoperative ECC was seen. CONCLUSIONS: Superior long-term survival rates were seen in recipients diagnosed with cystic fibrosis, α1-antitrypsin deficiency and pulmonary hypertension. DLTx showed better results compared with SLTx especially at 10 years post-transplant. In the present study, we present cumulative incidence rates of bronchiolitis obliterans syndrome of 15% at 5 years, 26% at 10 years and 32% at 20 years post-transplant; these figures are in line with the lowest rates presented internationally.

Pulmonary collapse alone provides effective de-airing in cardiac surgery: a prospective randomized study.

OBJECTIVES: We previously described and showed that the method for cardiac de-airing involving: (1) bilateral, induced pulmonary collapse by opening both pleurae and disconnecting the ventilator before cardioplegic arrest and (2) gradual pulmonary perfusion and ventilation after cardioplegic arrest is superior to conventional de-airing methods, including carbon dioxide insufflation of the open mediastinum. This study investigated whether one or both components of this method are responsible for the effective de-airing of the heart. METHODS: Twenty patients scheduled for open, left heart surgery were randomized to two de-airing techniques: (1) open pleurae, collapsed lungs and conventional pulmonary perfusion and ventilation; and (2) intact pleurae, expanded lungs and gradual pulmonary perfusion and ventilation. RESULTS: The number of cerebral microemboli measured by transcranial Doppler sonography was lower in patients with open pleurae 9 (6-36) vs 65 (36-210), p = 0.004. Residual intra-cardiac air grade I or higher as monitored by transesophageal echocardiography 4-6 minutes after weaning from cardiopulmonary bypass was seen in few patients with open pleurae 0 (0%) vs 7 (70%), p = 0.002. CONCLUSIONS: Bilateral, induced pulmonary collapse alone is the key factor for quick and effective de-airing of the heart. Gradual pulmonary perfusion and ventilation, on the other hand, appears to be less important.

The International Heart Transplant Survival Algorithm (IHTSA): a new model to improve organ sharing and survival.

BACKGROUND: Heart transplantation is life saving for patients with end-stage heart disease. However, a number of factors influence how well recipients and donor organs tolerate this procedure. The main objective of this study was to develop and validate a flexible risk model for prediction of survival after heart transplantation using the largest transplant registry in the world. METHODS AND FINDINGS: We developed a flexible, non-linear artificial neural networks model (IHTSA) and classification and regression tree to comprehensively evaluate the impact of recipient-donor variables on survival over time. We analyzed 56,625 heart-transplanted adult patients, corresponding to 294,719 patient-years. We compared the discrimination power with three existing scoring models, donor risk index (DRI), risk-stratification score (RSS) and index for mortality prediction after cardiac transplantation (IMPACT). The accuracy of the model was excellent (C-index 0.600 [95% CI: 0.595-0.604]) with predicted versus actual 1-year, 5-year and 10-year survival rates of 83.7% versus 82.6%, 71.4%-70.8%, and 54.8%-54.3% in the derivation cohort; 83.7% versus 82.8%, 71.5%-71.1%, and 54.9%-53.8% in the internal validation cohort; and 84.5% versus 84.4%, 72.9%-75.6%, and 57.5%-57.5% in the external validation cohort. The IHTSA model showed superior or similar discrimination in all of the cohorts. The receiver operating characteristic area under the curve to predict one-year mortality was for the IHTSA: 0.650 (95% CI: 0.640-0.655), DRI 0.56 (95% CI: 0.56-0.57), RSS 0.61 (95% CI: 0.60-0.61), and IMPACT 0.61 (0.61-0.62), respectively. The decision-tree showed that recipients matched to a donor younger than 38 years had additional expected median survival time of 2.8 years. Furthermore, the number of suitable donors could be increased by up to 22%. CONCLUSIONS: We show that the IHTSA model can be used to predict both short-term and long-term mortality with high accuracy globally. The model also estimates the expected benefit to the individual patient.

Systemic effects of carbon dioxide insufflation technique for de-airing in left-sided cardiac surgery.

OBJECTIVE: Systemic effects of carbon dioxide (CO2) insufflation during left-sided cardiac surgery were evaluated in a prospective randomized study, with regard to acid-base status, gas exchange, cerebral hemodynamics, and red blood cell morphology. METHODS: Twenty patients undergoing elective left-sided cardiac surgery were randomized to de-airing procedure either by CO2 insufflation technique (CO2 group, n = 10) or by Lund technique without CO2 insufflation (Lund group, n = 10). Groups underwent assessment of acid-base status by intermittent arterial blood gases and in-line blood gas monitoring. Capnography was used to determine volume of CO2 produced. Cerebral hemodynamics was measured by transcranial Doppler sonography and near-infrared spectroscopy. Red cell morphology from cardiotomy suction and vent tubing was studied by scanning electron microscopy. RESULTS: Patients in the CO2 group consequently developed significantly higher levels of hypercapnia with a concomitant increase in the volume of CO2 produced despite significantly higher oxygenator gas flows compared with the Lund group. Effects on cerebral hemodynamics were observed in the CO2 group with significantly higher blood flow velocities in the middle cerebral artery and higher regional cerebral saturation. Red blood cell damage was observed in the CO2 group by scanning electron microscopy (97% in CO2 group vs 18% in Lund group). CONCLUSIONS: Insufflation of CO2 into the cardiothoracic wound cavity during left-sided cardiac surgery can induce hypercapnic acidosis and increased cerebral blood flow and local blood cell damage. These systemic effects should be monitored by in-line capnography and acid-base measurements for early and effective correction by increase in gas flows to the oxygenator.

Giant aneurysm in the sinus of Valsalva presenting as an acute coronary symptom.

We describe an 85-year old male who was admitted to the hospital with acute coronary symptoms. Bedside echocardiography revealed a structure in the aortic root, and a computed tomography scan verified the diagnosis of an aneurysm in the sinus of Valsalva below the left coronary ostium. A coronary angiography also depicted the aneurysm clearly and clearly showed how the aneurysm compressed and dislocated the left main coronary artery, explaining his initial symptoms. The patient was operated on with an aortic root replacement procedure, and recovered quickly.

Three decades of heart transplantation in Scandinavia: long-term follow-up.

AIM: Heart transplantation (HTx) has become a standard treatment for patients with end-stage heart disease. The aim of this study was to report the long-term outcome after HTx in Scandinavia. METHODS AND RESULTS: During the period, 1983-2009, 2333 HTxs were performed in 2293 patients (mean age 45 ± 16 years, range 0-70, 78% male). The main indications for HTx were non-ischaemic cardiomyopathy (50%), ischaemic cardiomyopathy (34%), valvular cardiomyopathy (3%), congenital heart disease (7%), retransplantation (2%), and miscellaneous (4%). The registry consists of pre-operative data from recipients and donors, data from pre-operative procedures, and long-term follow-up data. Mean follow-up was 7.8 ± 6.6 years (median 6.9, interquartile range 2.5-12.3, interval 0-27) and no patients were lost to follow-up. Long-term survival for HTx patients was 85, 76, 61, 43, and 30% at 1, 5, 10, 15, and 20 years of follow-up, respectively. Ten-year survival in patients bridged with mechanical circulatory support, in children, after retransplantation, and after concomitant other organ transplantation was 56, 74, 38, and 43%, respectively. Older patients (age > 55 years) had a significantly worse survival (P < 0.001). Patients transplanted more recently had a significantly better survival (P < 0.001). In a multivariate Cox regression analysis, independent predictors of long-term survival were recipient age (P < 0.001), donor age (P < 0.001), diagnosis (P = 0.001), and era of transplantation (P < 0.001). CONCLUSIONS: HTx in Scandinavia proves to have a significantly better survival among patients transplanted in the last decade. HTxs from mechanical circulatory support, in children, after retransplantation, and with concomitant other organ transplantation were performed with acceptable results.

How to recondition ex vivo initially rejected donor lungs for clinical transplantation: clinical experience from lund university hospital.

A major problem in clinical lung transplantation is the shortage of donor lungs. Only about 20% of donor lungs are accepted for transplantation. We have recently reported the results of the first six double lung transplantations performed with donor lungs reconditioned ex vivo that had been deemed unsuitable for transplantation by the Scandiatransplant, Eurotransplant, and UK Transplant organizations because the arterial oxygen pressure was less than 40 kPa. The three-month survival of patients undergoing transplant with these lungs was 100%. One patient died due to sepsis after 95 days, and one due to rejection after 9 months. Four recipients are still alive and well 24 months after transplantation, with no signs of bronchiolitis obliterans syndrome. The donor lungs were reconditioned ex vivo in an extracorporeal membrane oxygenation circuit using STEEN solution mixed with erythrocytes, to dehydrate edematous lung tissue. Functional evaluation was performed with deoxygenated perfusate at different inspired fractions of oxygen. The arterial oxygen pressure was significantly improved in this model. This ex vivo evaluation model is thus a valuable addition to the armamentarium in increasing the number of acceptable lungs in a donor population with inferior arterial oxygen pressure values, thereby, increasing the lung donor pool for transplantation. In the following paper we present our clinical experience from the first six patients in the world. We also present the technique we used in detail with flowchart.

Comparison of the effectiveness and safety of a new de-airing technique with a standardized carbon dioxide insufflation technique in open left heart surgery: a randomized clinical trial.

OBJECTIVE: We have compared the effectiveness, time required for de-airing, and safety of a newly developed de-airing technique for open left heart surgery (Lund technique) with a standardized carbon dioxide insufflation technique. METHODS: Twenty patients undergoing elective open aortic valve surgery were randomized prospectively to the Lund technique (Lund group, n = 10) or the carbon dioxide insufflation technique (carbon dioxide group, n = 10). Both groups were monitored intraoperatively during de-airing and for 10 minutes after weaning from cardiopulmonary bypass by transesophageal echocardiography and online transcranial Doppler for the severity and the number of gas emboli, respectively. The systemic arterial partial pressure of carbon dioxide and pH were also monitored in both groups before, during, and after cardiopulmonary bypass. RESULTS: The severity of gas emboli observed on transesophageal echocardiography and the number of microembolic signals recorded by transcranial Doppler were significantly lower in the Lund group during the de-airing procedure (P = .00634) and in the first 10 minutes after weaning from cardiopulmonary bypass (P = .000377). Furthermore, the de-airing time was significantly shorter in the Lund group (9 vs 15 minutes, P = .001). The arterial pH during the cooling phase of cardiopulmonary bypass was significantly lower in the carbon dioxide group (P = .00351), corresponding to significantly higher arterial partial pressure of carbon dioxide (P = .005196) despite significantly higher gas flows (P = .0398) in the oxygenator throughout the entire period of cardiopulmonary bypass. CONCLUSIONS: The Lund de-airing technique is safer, simpler, and more effective compared with the carbon dioxide insufflation technique. The technique is also more cost-effective because the de-airing time is shorter and no extra expenses are incurred.

Comparative outcome of double lung transplantation using conventional donor lungs and non-acceptable donor lungs reconditioned ex vivo.

A method to evaluate and recondition lungs ex vivo has been tested on donor lungs that have been rejected for transplantation. In the present paper, we compare early postoperative course between the six patients who received reconditioned lungs and the patients who received conventional donor lungs during the same period of time. During 2006 and 2007, a total of 21 patients underwent double sequential lung transplantation at the University Hospital of Lund. Six of those patients received reconditioned lungs. The other 15 patients received conventional donor lungs for transplantation without reconditioning ex vivo. The results are presented as median and interquartile range. Time in intensive care unit (days) between recipients of reconditioned lungs [13 (5-24) days], and recipients of conventional donor lungs [7 (5-12) days], P=0.44. Total hospital stay after transplantation (days) between recipients of reconditioned lungs [52 (47-60) days] and recipients of conventional donor lungs [44 (37-48) days], P=0.9. Ex vivo lung evaluation and reconditioning might not prolong early postoperative course in double lung transplantation. However, given the small number of patients, there might be a failure to detect a difference between the two groups.

Heart transplantation with ABO-identical versus ABO-compatible cardiac grafts: influence on long-term survival.

OBJECTIVES: To compare identical versus compatible, ABO blood group matching effects on rejection and long-term survival after heart transplantation (HT). DESIGN: Data were collected from 196 patients who underwent HT at Lund University Hospital between 1988 and 2008. Cox proportion hazard regression analysis was used to identify factors associated with reduced long-term survival. RESULTS: One hundred and sixty six patients (85%) had an identical ABO blood group match and 30 patients (15%) had a compatible, ABO blood group match. Four non-pharmacological variables reducing overall survival were identified: recipient blood group AB, age >55 years, ischemic time, and year of transplantation. Two pharmacological variables improved overall survival: glucocorticoids and cyclosporine. There was no significant difference in long-term survival between patients with identical blood groups compared to compatible ABO blood group matching. However, there was a trend towards graft failure as cause of death being more common in the compatible ABO group match compared identical blood group match (13% versus 5%, p=0.118). CONCLUSIONS: Six factors associated with overall survival were identified. One of these was related to blood group AB. No significant difference in survival following identical, versus compatible, ABO matching was demonstrated.

Desensitization and heart transplantation of a patient with high levels of donor-reactive anti-human leukocyte antigen antibodies.

BACKGROUND: To prepare a highly immunized recipient for heart transplantation, reduction of high levels of cytotoxic antibodies against human leukocyte antigen (HLA) was deemed essential to prevent antibody-mediated graft failure. METHODS: Antibodies were analyzed by lymphocytotoxic and solid-phase assays. The pretransplant desensitization treatment protocol included daily tacrolimus and mycophenolate mofetil, weekly protein-A immunoadsorption (IA), intravenous immunoglobulin, and daclizumab. Posttransplant treatment consisted of tacrolimus, mycophenolate mofetil, prednisolone, IA, and daclizumab. RESULTS: During pretransplant desensitization, each of the weekly immunoadsorption treatments reduced anti-HLA antibody levels by 50% to 70%, but they returned to the pretreatment level within 1 week as measured by flow cytometry. Cytotoxic antibodies remained reduced. After perioperative immunoadsorption, the donor-reactive antibodies (DRAs) were reduced to low levels. The patient underwent successful heart transplantation after 6 weeks on a waiting list. During the first week posttransplant, DRAs remained low. However, after the first week, anti-HLA DRAs reappeared and increased slightly over a 3-week period and then decreased slowly. Cytotoxic crossmatches were negative before and 3 week after transplantation. No clinical rejection was encountered. The patient was doing well 3 years after transplantation, and yearly clinical cardiac investigations were all normal. Three hyperimmunized patients have now undergone successful heart transplantation at our center using this desensitization protocol. CONCLUSIONS: IA in combination with pretransplant immunosuppressive drug treatment temporarily reduces antibody levels. The therapeutic levels of drug treatment at the time of transplantation may be of crucial importance. The treatment protocol resulted in freedom from rejection and other clinical adverse events.

The modified Ross operation using a Dacron prosthetic vascular jacket does prevent pulmonary autograft dilatation at 4.5-year follow-up.

OBJECTIVE: Following the Ross operation, pulmonary autografts tend to dilate over time. This study researches the fate of the pulmonary autograft - at 4.5 years following the modified Ross operation - with special reference to the impact of the modification on (a) pulmonary autograft dilatation, (b) the neo-aortic root geometry, (c) neo-aortic valve function and (d) the coronary artery reserve. METHODS: A total of 26 patients who underwent the Ross operation were included in this study; of these, 13 consecutive patients underwent a modified Ross operation in which the free-standing autograft root was supported externally by a Dacron vascular prosthetic jacket (DVPJ). These patients were compared to a cohort of 13 matched patients who were operated on using the conventional Ross technique; all patients were followed up prospectively by echocardiography studies. The patients who underwent the modified Ross operation were also subjected to bicycle ergometry. RESULTS: At the 47-month median follow-up, there was no significant increase in the size of the entire neo-aortic root in the patients who underwent the modified Ross operation; in addition, the geometry of the neo-aortic root was also preserved and the left ventricular function had improved significantly, whilst the aortic valve function and excursion remained satisfactory. All patients, with one exception, in the modified Ross operation group exhibited normal exercise capacity. By contrast, there were significant differences in diameters of the aortic root - between the two surgical techniques in favour of the modified Ross technique - following a median follow-up of 23 months in the patients subjected to the conventional Ross operation. CONCLUSIONS: Provision of external support to the entire pulmonary autograft with a DVPJ prevents its dilatation following free-standing pulmonary autograft Ross operation when evaluated at the 4.5-year follow-up. The function and the geometry of the neo-aortic root are not affected negatively by this modification and the patients demonstrated normal exercise capacity.

A new de-airing technique that reduces systemic microemboli during open surgery: a prospective controlled study.

OBJECTIVE: We have evaluated a new technique of cardiac de-airing that is aimed at a) minimizing air from entering into the pulmonary veins by opening both pleurae and allowing lungs to collapse and b) flushing out residual air from the lungs by staged cardiac filling and lung ventilation. These air emboli are usually trapped in the pulmonary veins and may lead to ventricular dysfunction, life-threatening arrhythmias, and transient or permanent neurologic deficits. METHODS: Twenty patients undergoing elective true left open surgery were prospectively and alternately enrolled in the study to the conventional de-airing technique (pleural cavities unopened, dead space ventilation during cardiopulmonary bypass [control group]) and the new de-airing technique (pleural cavities open, ventilator disconnected during cardiopulmonary bypass, staged perfusion, and ventilation of lungs during de-airing [study group]). Transesophageal echocardiography and transcranial Doppler continually monitored the air emboli during the de-airing period and for 10 minutes after termination of the cardiopulmonary bypass. RESULTS: The amount of air embolism as observed on echocardiography and the number of microembolic signals as recorded by transcranial Doppler were significantly less in the study group during the de-airing time (P < .001) and the first 10 minutes after termination of cardiopulmonary bypass (P < .001). Further, the de-airing time was significantly shorter in the study group (10 vs 17 minutes, P < .001). CONCLUSION: The de-airing technique evaluated in this study is simple, reproducible, controlled, safe, and effective. Moreover, it is cost-effective because the de-airing time is short and no extra expenses are involved.