[Surgical treatment of carcinoid bronchial tumor]. / Kirurgisk behandling av karsinoid bronkialtumor.

During the period 1977-95, 20 patients underwent surgery for carcinoid tumour in the bronchus at the University Hospital of Trondheim (n = 16) and Innherred County Hospital (n = 4). All the tumours were typical carcinoid tumours. Median age of the patients was 41 years (range 16-78 years). The observation period averaged 7.5 years (0.5-18 years). The most common symptoms were cough, dyspnoea, wheezing and pneumonia. One patient had carcinoid syndrome. Chest X-ray were negative in three of the patients. Bronchoscopy was carried out in all the patients. Biopsies were taken in ten of them, and the diagnosis was conclusive in five cases. Lateral thoracotomy was performed in all the patients. The surgical procedures were lobectomy (15), segmental/wedge resection (3), bronchotomy with tumour resection (1) and sleeve resection (1). 19 patients were still alive at the time of follow-up, with no tumour recurrence. One patient died from cerebral stroke eight years after surgery. Good long-term results were found, and the study supports the use of limited lung resection or bronchoplasty operations to treat carcinoid tumour in the bronchus if the primary tumour is localised and there are no metastases.

[Mitral valve plasty. A 12-year material]. / Mitralklaffeplastikk. Et 12-årsmateriale.

46 patients underwent mitral valve repair at the Regional Hospital in Trondheim/St. Elisabeth Heart Clinic, during the period 1983-95. There were 20 female patients. The valve pathology was ischemic in 40%, rheumatic in 10% and other or unknown in 50%. The surgical technique included commissurotomy (n = 9), ring annuloplasty (n = 18), resection of posterior leaflet (n = 12), Kay annuloplasty (n = 10), shortening of chordae (n = 3) and other techniques (n = 2). Postoperative complications included wound infection (n = 1), pneumonia (n = 1), mediastinitis (n = 1), pleural effusion (n = 5), renal failure (n = 1) and multi-organ failure (n = 1). One patient required re-exploration for postoperative bleeding. Three (6.5%) patients died within 30 days of surgery due to low cardiac output (n = 2) and multi-organ failure (n = 1). Nine patients (21%) died later. At follow up, within one year of surgery, marked functional improvement was registered, with only one patient in NYHA class III and none in class IV.

Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery.

OBJECTIVE: A substantial reduction in lung volumes and pulmonary function follows cardiac surgery. Pain may prevent effective breathing and coughing, and as thoracic epidural analgesia may reduce postoperative pain, we investigated the effect of epidural analgesia on pulmonary function. METHODS: Fifty-four male patients, under 65 years and with an ejection fraction of more than 0.5, were randomized into two groups: a control group receiving high-dose fentanyl anaesthesia and an epidural group receiving low-dose fentanyl anaesthesia + thoracic epidural analgesia. Time to awakening and time to extubation were recorded. Further, spirometric data, arterial oxygenation, pulmonary shunt, haemodynamics, use of vasoactive drugs and fluid balance were followed for up to 6 days postoperatively. RESULTS: Patients with low-dose fentanyl and epidural analgesia awoke (1.6 vs 3.6 h) and were extubated (5.4 vs 10.8 h) significantly earlier than control group patients. A 50-70% reduction in forced vital capacity, forced expiratory volume in 1 s (FEV1.0) and peak expiratory flow rate (PEFR) was seen after surgery, but higher FEV1.0 and PEFR on days 2 and 3 were seen in the epidural group than in the control group. Pulmonary shunt and alveolo-arterial oxygen difference increased similarly in both groups, whereas oxygen delivery and mixed venous oxygen saturation were higher in the epidural group. Epidural analgesia gave better control of the postoperative hyperdynamic circulation. CONCLUSIONS: Thoracic epidural analgesia yields a slight, but significant, improvement in pulmonary function, most likely due to a more profound postoperative analgesia.

Procaine is effective for minimizing postischemic ventricular fibrillation in cardiac surgery.

Procaine hydrochloride was added to cardioplegia and studied for its efficacy in stabilizing the postischemic rhythm after aortic declamping in cardiac surgery. Fifty-six patients scheduled for coronary artery bypass grafting (CABG), were included in a randomized, double-blind study. The patients were anesthetized with isoflurane, low-dose fentanyl, diazepam, and pancuronium. In the study group (28 patients), St. Thomas' Hospital cardioplegic solution II (Plegisol) was prepared with 1 mM procaine. The control group (28 patients) was given the same cardioplegia with saline. Ventricular fibrillation (VF) occurring after declamping was treated with direct current (DC) shock (8-12-12-20 J). There were no significant differences with regard to demographic properties or anesthesiologic and surgical treatment. Two patients (7%) in the procaine group required DC shock for VF, compared to 28 (100%) in the control group (P < 0.001). The amount of lidocaine (mean +/- SEM) given for resistant dysrhythmias was 3.6 mg +/- 3.6 in the procaine group compared to 35.7 mg +/- 9.2 in the control group (P < 0.002). One patient in each group required temporary pacing. The number of synchronized DC shocks for conversion of atrial fibrillation was lower in the procaine group (P < 0.05). The enzyme release the first day after surgery was lower in the procaine group (P < 0.05). Procaine (1 mM) in cardioplegia stabilizes the postischemic rhythm in CABG surgery in humans without any observed adverse effects.

Effects of thoracic epidural analgesia on coronary hemodynamics and myocardial metabolism in coronary artery bypass surgery.

OBJECTIVE: A possible influence of thoracic epidural analgesia on coronary hemodynamics and myocardial metabolism in coronary artery bypass grafting was investigated. DESIGN: The study was prospective and randomized. SETTING: The study was performed in a university hospital. PARTICIPANTS: Thirty male patients less than 65 years of age and with ejection fraction greater than 0.5 participated. They were randomized into 3 groups: the high fentanyl (HF) group receiving high-dose fentanyl (55 micrograms/kg) anesthesia, the HF + thoracic epidural analgesia (TEA) group receiving the same general anesthesia plus thoracic epidural analgesia, and the low-fentanyl (LF) + TEA group receiving low-dose fentanyl (15 micrograms/kg) anesthesia plus thoracic epidural analgesia. INTERVENTIONS: A thoracic epidural catheter, a peripheral and central venous catheter, a radial artery catheter, a thermodilution pulmonary artery catheter, and a coronary sinus reverse thermodilution catheter were inserted. MEASUREMENTS AND MAIN RESULTS: Coronary circulatory parameters, myocardial oxygenation, and myocardial substrate utilization were investigated before bypass and for 9 hours after bypass. Before bypass, the most striking finding was a reduction in myocardial lactate extraction in all groups, but also coronary flow and myocardial oxygen consumption decreased compared with baseline. After bypass, the only significant finding was a lower coronary vascular resistance early postoperatively in the epidural groups, but coronary blood flow was adequate in all groups. Myocardial metabolism was essentially unchanged both with and without epidural analgesia after bypass. CONCLUSION: With regard to the coronary circulation and myocardial metabolism, no hard data supporting the use of thoracic epidural analgesia in coronary artery bypass grafting were found.

Thoracic epidural analgesia in aortocoronary bypass surgery. II: Effects on the endocrine metabolic response.

Thoracic epidural analgesia (TEA) may offer haemodynamic benefits for patients with coronary heart disease going through major surgery. This may-in part-be secondary to an effect on the endocrine and metabolic response to surgery. We therefore investigated the effect of TEA on the endocrine metabolic response to aortocoronary bypass surgery (ACBS). Thirty male patients (age < 65 years, ejection fraction > 0.5) were randomized into 3 groups; the HF group receiving a high dose fentanyl (55 micrograms.kg-1) anaesthesia, the HF+TEA group with the same fentanyl dose+TEA with 10 ml bupivacain 5 mg.ml-1, followed by 4 ml every hour, and the LF+TEA group receiving fentanyl 15 micrograms.kg-1 + TEA. Adrenalin, noradrenalin, systemic vascular resistance (SVR), glucose, cortisol, lactate and free fatty acids were followed during the operation and for 20 h postoperatively. A significant increase in adrenalin, noradrenalin and SVR was found in the HF group whereas this increase was blocked in both epidural groups. An increase in glucose and cortisol was noticed in all groups, but the increase was delayed in the epidural groups. Our results suggest that a more effective blockade of the stress response during ACBS is obtained when TEA is added to general anaesthesia than with high dose fentanyl anaesthesia alone.

Thoracic epidural analgesia in aortocoronary bypass surgery. I: Haemodynamic effects.

Tachycardia and hypertension may cause myocardial ischaemia in patients with coronary heart disease going through major surgery. Thoracic epidural analgesia (TEA) has been reported to be beneficial in this situation. The haemodynamic effects of TEA in aortocoronary bypass surgery were investigated in 30 male patients < 65 years old and with ejection fraction > 0.5. They were randomized into 3 groups: the high dose fentanyl (HF) group receiving high-dose fentanyl (55 micrograms.kg-1) anaesthesia, the HF+TEA group receiving the same fentanyl dose+TEA with 10 ml bupivacaine 5 mg.ml-1 followed by 4 ml every hour, and the low dose fentanyl (LF) + TEA group receiving low-dose fentanyl (15 micrograms.kg-1) anaesthesia+TEA. Haemodynamic parameters, the use of vasoactive and inotropic drugs and fluid balance were followed during the operation and for 20 h postoperatively. Before bypass the only significant difference between groups was a higher mean pulmonary arterial pressure in the HF+TEA group and a lower systemic vascular resistance (SVR) in the LF+TEA group, both compared to the HF group. 89% of epidural group patients needed small doses of ephedrine whereas more HF group patients were given nitroglycerine. During bypass SVR and mean arterial pressure (MAP) were significantly higher and pump flow lower in the HF group compared to the LF+TEA group. More ketanserin to HF group patients and methoxamine to epidural group patients were given. After bypass heart rate increased in all groups. Lower MAP 0.5 h after bypass and higher filling pressures in the early post bypass period in the epidural groups, most pronounced in the HF+TEA group, were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographic findings of silent ischaemia following aortocoronary bypass surgery.

Silent ischaemia, defined as ST-depression > or = 1 mm without chest pain, was found on exercise testing in 22 (10.7%) of 206 patients who underwent aortocoronary bypass surgery in the period from March 1983 to November 1985. Exercise testing was performed 4.9 (range 3.6-6.7) years after operation on an electrically braked bicycle. Sixteen of the 22 patients were free from chest pain, while the remaining six had slight to moderate angina pectoris on exercise. Coronary angiography was performed in 21 patients with silent ischaemia; one of the 22 patients died before this investigation. Some 13 patients had one or more occluded grafts, one a new stenosis in a native vessel and five incomplete myocardial revascularization. For the remaining two patients, no aetiology for the ischaemia was found, and revascularization appeared to be complete. Before surgery, 13 patients had three-vessel disease, six two-vessel disease and three one-vessel disease. At follow-up, two patients had three-vessel disease, ten two-vessel disease and seven one-vessel disease. The value of identifying patients with silent ischaemia after aortocoronary bypass surgery with regard to life expectancy and quality is controversial. Subsets of patients, namely, those with main-stem stenosis and three-vessel disease, may benefit from secondary operation. Identification of these patients may therefore be of clinical importance.

Heparin-coated circuit during cardiopulmonary bypass. A clinical study using closed circuit, centrifugal pump and reduced heparinization.

A prospective randomized study was performed to investigate the effect of surface coating with covalently endpoint-attached heparin (Carmeda Bio Active Surface) and reduced general heparinization on haematological indices and complement C5 activation. Care was taken to optimize the rheological design of the system using centrifugal pump and a closed system without venting or machine suction. Twenty patients scheduled for aortocoronary bypass grafting (EF > 0.5) participated in the study. Ten patients were randomized to be treated with heparin-coated equipment (CBAS) and reduced i.v. heparin (1.5 mg.kg-1) while 10 patients treated with identical but noncoated equipment and full heparinization (3 mg.kg-1) served in a Control group. A vacuum suction was used to collect the blood from the operating field and it was autotransfused at weaning from extracorporeal circulation (ECC). Blood samples were obtained from the venous (precircuit) and arterial (postcircuit) side. We used a new and very specific method for detection of C5a based on monoclonal antibodies. The concentration of C5a was low in both groups during the operation but a significant increase was seen on days 1 and 2. In the Control group there was an increase from 10.2 ng.ml-1 +/- 1.2 to 27.5 ng.ml-1 +/- 4.8 on day 2 and in the CBAS group from 10.7 ng.ml-1 +/- 1.2 to 35.6 ng.ml-1 +/- 11.6 on day 2 (NS between groups). The granulocytes and total leukocyte count increased at the end of ECC and was maintained at the elevated level throughout the study period. The amount of free haemoglobin was high in the autotransfused blood in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between preoperative coronary angiography and clinical outcome of aortocoronary bypass surgery.

Two hundred and fifty preoperative coronary cineangiograms were reviewed. All observed stenoses were evaluated with regard to location, severity and suitability for bypass grafting. The angiographic prediction for a successful surgical result was classified as "doubtful", "acceptable", "good" and "very good". This was compared with the clinical result following surgery. All patients were operated on during the period March 1983 and November 1985. The mean observation time with regard to subjective improvement was 2.7 years (range 1.6-4.3). In the group "doubtful", containing 7 patients, 6 became free of symptoms or much improved, whereas one patient was unchanged. This was better than expected. In the group which was estimated to be "very good", including altogether 54 patients, approximately the same degree of improvement was achieved as in the other groups. An exercise test was performed 4.9 years (range 3.6-6.7) postoperatively. The distribution of positive exercise stress tests indicating remaining coronary ischemia, was almost equally divided in the four groups, except for the group "very good" where the share of positive tests was less. It is concluded that predicting the result of the operation from preoperative angiograms may be difficult, and unreliable in the groups where the results are predicted to be "acceptable" or "doubtful".

The influence of thoracic epidural analgesia alone and in combination with general anesthesia on cardiovascular function and myocardial metabolism in patients receiving beta-adrenergic blockers.

Thoracic epidural analgesia combined with chronic beta-adrenergic blocker medication may cause cardiac depression. We investigated the cardiovascular and myocardial metabolic effects of a T1-T12 epidural block in 18 patients (age < 65 yr, ejection fraction > 0.5), receiving chronic beta-adrenergic blocker medication and scheduled for aortocoronary bypass surgery. After randomization into a light or deeper general anesthetic group, the cardiovascular and myocardial metabolic effects of a subsequent general anesthesia induction were investigated. Thoracic epidural analgesia induced a moderate decrease in mean arterial pressure, coronary perfusion pressure, free fatty acids, and myocardial consumption of free fatty acids. General anesthesia with thiopental (2-4 mg/kg) and a low fentanyl dose (5 micrograms/kg) increased heart rate, coronary perfusion pressure, and coronary vascular resistance, whereas mean pulmonary arterial pressure and pulmonary capillary wedge pressure decreased. After thiopental (2-4 mg/kg) and a high fentanyl dose (30 micrograms/kg), mean arterial pressure and left ventricular stroke work index decreased. We conclude that a T1-T12 epidural block in well sedated, beta-adrenergic blocked patients does not induce clinically significant cardiovascular effects. Induction of general anesthesia was well tolerated, but the light general anesthetic could not prevent an increase in heart rate and coronary vascular resistance, whereas the deeper anesthetic induced slight myocardial depression. No effect on the atrioventricular conduction, as measured by the PQ-time, was noted.

Exercise hemodynamics in small (< or = 21 mm) aortic valve prostheses assessed by Doppler echocardiography.

Exercise Doppler echocardiography was used to assess hemodynamics in 25 patients with a < or = 21 mm aortic valve prosthesis (14 with a Medtronic-Hall 21 mm valve, three with a Medtronic-Hall 20 mm valve, three with a Sorin 21 mm valve, one with a Duromedics 21 mm valve, and four with a Carpentier-Edwards 21 mm valve). A symptom-limited upright bicycle exercise test was performed, and Doppler gradients were recorded during exercise. Gradients increased with exercise from 30 +/- 8/16 +/- 4 mm Hg (peak/mean) at rest to 46 +/- 12/24 +/- 7 mm Hg during exercise; both p < 0.001. Mean exercise gradient exceeded 30 mm Hg in five patients, and the highest mean gradient recorded was 37 mm Hg. Within the group of mechanical valves, gradients at exercise were similar for different types of valves. A linear relationship was found between gradients at rest and during exercise (peak r = 0.75, mean r = 0.77; both p < 0.001). Additional findings were midventricular velocities exceeding 1.5 m/sec in late systole in 10 patients (40%) and intraventricular flow (> or = 0.2 m/sec) toward the apex during isovolumic relaxation in 11 patients (44%). The patients with these velocity patterns had significantly smaller left ventricular cavities (end-diastolic diameter 39.8 +/- 4.8 vs 46.5 +/- 4.2 mm, p < 0.01; end-systolic diameter 24.2 +/- 3.0 vs 28.5 +/- 4.5 mm, p = 0.013).(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiography for prediction of aortic valve prosthesis size. A comparative study of Medtronic-Hall and Carpentier-Edwards supra-annular valves.

To assess the value of two-dimensional echocardiography (2D ECHO) for predicting prosthetic aortic valve size, the diameter of the aortic annulus was measured before implantation of a Medtronic-Hall valve in 24 patients and a Carpentier-Edwards supra-annular valve in 34. In the Medtronic-Hall group, the average prosthesis size was similar to the average annulus diameter, i.e. 23.2 +/- 2.1 vs 23.0 +/- 3.4 mm (NS), 95% confidence interval for the difference -1.0-0.7 mm. In the Carpentier-Edwards group the corresponding figures were 23.5 +/- 2.1 and 22.0 +/- 2.3 mm (p < 0.001), with 95% confidence interval 0.9-2.0 mm. Correlation between annulus diameter indicated by preoperative 2D ECHO and prosthesis size was stronger in the Medtronic-Hall (r = 0.88, p < 0.001) than in the Carpentier-Edwards group (r = 0.73, p < 0.001). The authors conclude that prosthetic aortic valve size may be accurately predicted by 2D ECHO, with Medtronic-Hall valve size similar to, and Carpentier-Edwards prostheses on average 1-2 mm larger than the 2D ECHO-estimated annulus diameter.

Hemodynamic evaluation by Doppler echocardiography of small (less than or equal to 21 mm) prostheses and bioprostheses in the aortic valve position.

To assess resting hemodynamics of an unselected group of patients with prostheses or bioprostheses sized less than or equal to 21 mm implanted into the aortic valve position during a 7-year period, 46 of 50 eligible patients were examined by Doppler echocardiography. The valves were Carpentier-Edwards (CE) supraannular 21 mm (n = 8), Medtronic-Hall (MH) 20 mm (n = 8) and 21 mm (n = 21), and the rest (n = 9) were other valves with only 1 to 3 patients in each group. Gradients, valve areas and dimensionless obstruction indexes (ratio of subvalvular/valvular velocities and velocity time integrals) were compared. By analysis of variance, gradients did not differ significantly between the CE supraannular 21 mm, the MH 20 and 21 mm prostheses (peak/mean 25 +/- 8/14 +/- 5, 31 +/- 13/16 +/- 6 and 25 +/- 10/13 +/- 5 mm Hg; p = not significant). Only 2 patients had a mean gradient greater than 25 mm Hg. The valve area was slightly larger for the MH 21 mm group compared with the CE supraannular 21 mm group (1.34 +/- 0.15 vs 1.16 +/- 0.14 cm2, p less than 0.05). The dimensionless obstruction indexes did not differ (CE supraannular 21 mm 0.36 +/- 0.07/0.40 +/- 0.07 (velocities/velocity time integrals), MH 20 mm 0.40 +/- 0.12/0.47 +/- 0.12, MH 21 mm 0.38 +/- 0.05/0.44 +/- 0.06; p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing return to work after aortocoronary bypass surgery.

Factors influencing the effect on employment status were investigated in 250 patients (males: females 224:26) who underwent coronary artery bypass surgery between March 1983 and November 1985. The median age at operation was 57.9 (range 36.6-69.4) years and the median follow-up time 32 (19-52) months. Preoperatively 149 patients (59.6%) were receiving sick pay or disability pension because of their heart disease. Only 64 (25.6%) were gainfully employed, in contrast to 97 (38.8%) at follow-up. Of those who were working at the time of operation, all but eight returned to work postoperatively. At follow-up 183 (80.3%) were free from symptoms or much improved, with degree of improvement somewhat greater in those who were working postoperatively. The period of sick leave and the preoperative waiting time were significantly shorter for patients who were working postoperatively than for those who were awarded disability pension. Age, previous myocardial infarction, duration of preoperative angina and type of work were also found to influence postoperative employment status.

Thrombotic disc impediment in a Medtronic-Hall aortic valve prosthesis diagnosed by Doppler echocardiography followed by successful reoperation.

A case with impeded disc movement caused by thrombus formation in a Medtronic-Hall aortic valve prosthesis is reported. A correct diagnosis, including both mechanism and severity of the prosthesis failure, was established by Doppler echocardiography. The patient was promptly referred for surgery without invasive or other supplementary investigations.

MRI: a method to detect minor brain damage following coronary bypass surgery?

In order to assess the occurrence of minor focal brain lesions after coronary bypass surgery, magnetic resonance imaging (MRI) was used. Nine male patients (age 42-63) with angina pectoris were investigated at 0.5 Tesla. The investigation was performed one to seven weeks prior to the operation and one month after the operation. Before surgery, the images demonstrated more than five high intensity spots in the white matter of the brain in all but two patients. No additional spots were found after operation. This pilot study indicates that it might be difficult to use MRI to detect minor parenchymal lesions after cardiopulmonary bypass surgery.

[Cardiogenic cause of cerebral embolism]. / Kardiogen årsak til cerebral emboli.

Cerebral insults of cardiac origin are often of great functional importance. The most common cause is atrial fibrillation. Other sources of cerebral embolies, even if rare, such as cardiac tumors, must not be ignored. Many of these patients present neurologic symptoms. The diagnosis is established on ecco-cardiography. Surgical management is the treatment of choice. We discuss a young patient with multiple cerebral insults and a papillary cardiac tumor.