Magnetic resonance imaging angiography in patency evaluation of bronchial artery revascularization grafts.

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.

Bronchial artery revascularization improves tracheal anastomotic healing after lung transplantation.

The study aimed to clarify the role of direct bronchial artery revascularization (BAR) after en bloc double-lung (DLT) and heart-lung transplantation (HLT). Group I comprised eight patients with en bloc DLT or HLT and successful BAR, while group II included 14 DLT or HLT cases without BAR or with failed BAR. From these groups, 2 subgroups were extracted: group III, including 6 cases of en bloc DLT with successful BAR and group IV 10 HLT cases without or with failed BAR. Airway healing was evaluated at bronchoscopy and patency of BAR with angiography. Pulmonary viral, bacterial and fungal infections, rejections and bronchiolitis obliterans syndrome (BOS) were registered. Tracheal healing at 2 weeks and 3 months was better in group I than in group 1 (p = 0.003 and p = 0.05, respectively). Compared with group IV, tracheal anastomotic healing at 2 weeks was better in group III (p = 0.007) and tended to be better also after 3 months (p = 0.07). The incidence of infections, rejection or BOS did not differ between groups I and II. BAR thus improved healing of tracheal anastomosis.

A comparison of remifentanil and alfentanil for use with propofol in patients undergoing minimally invasive coronary artery bypass surgery.

UNLABELLED: Most patients undergoing minimally invasive direct coronary artery bypass surgery can be awakened and tracheally extubated in the operating room. We have compared two techniques of total IV anesthesia in this patient population: 30 patients (aged 44 to 74 yr; 24 male) premedicated with temazepam were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 2 microg/kg or with alfentanil 40 microg/kg, with propofol, and maintained with remifentanil at 0.25 or 0.5 microg x kg(-1) x min(-1) or alfentanil at 0.5 or 1 microg x kg(-1) x min(-1). The stable maintenance infusion rate of propofol was adjusted for age. Times to awakening and tracheal extubation were recorded. Postoperatively, IV morphine provided by patient-controlled analgesia was used for 48 h. Times to awakening and tracheal extubation (mean +/- SD) were shorter (P < 0. 01) in patients receiving remifentanil, and interpatient variations in times to awakening and tracheal extubation smaller (awakening 25 +/- 7 vs 74 +/- 32 min, and extubation 27 +/- 7 vs 77 +/- 32 min). Analysis of variance revealed that postoperative consumption of morphine was dependent on both the intraoperative opioid and the time elapsed after surgery (P < 0.05): patient-controlled analgesia morphine use during the first 3 h after awakening was more in patients receiving remifentanil (P < 0.01). IMPLICATIONS: Recovery of patients undergoing Minimally Invasive Direct Coronary Artery Bypass Surgery is significantly shorter and more predictable after total IV anesthesia with remifentanil-propofol than with alfentanil-propofol, which may be important if the goal is that patients will be awakened and tracheally extubated in the operating room.

Ventricular Arrhythmia Suppression by Magnesium Treatment after Coronary Artery Bypass Surgery.

Ventricular arrhythmias occur frequently shortly after coronary artery bypass grafting (CABG), and their occurrence coincides with the postoperative decline in serum magnesium (Mg) levels. To examine if this decline causes ventricular arrhythmias and if their appearance could be reduced by intravenous Mg administration, 140 consecutive CABG patients were randomized to receive 70 mmol of Mg sulphate (N = 69) or placebo (N = 71) over two days. Serum Mg concentration fell to 0.77 mmol/l in the control group but rose to 1.09 mmol/l in the Mg group (p < 0.001). On 48 h Holter, the number of ventricular premature complexes (VPC) on the third postoperative day was reduced in the Mg group (4 +/- 5 vs 12 +/- 21 VPCs/h; p < 0.05) and the incidence of complex ventricular arrhythmias (Lown grade 2-5) was significantly diminished (19% vs 41% of the patients; p < 0.05). In multivariate analysis, high risk ventricular arrhythmias (repetitive polymorphic ventricular complexes, couplets, R-on-T complexes or operative tachycardia) were independently predicted by high number of bypassed vessels (p = 0.01), poor NYHA functional class (p = 0.06), preoperative diuretic use (p = 0.07), and low postoperative Mg levels (p = 0.08). In conclusion, correction of the postoperative decline in serum Mg concentration decreases the occurrence of early VPCs and complex ventricular arrhythmias. Patients with extensive underlying coronary artery disease and prior diuretic therapy appear to benefit greatest from Mg treatment.http://link.springer-ny.com/link/service/journals/00547/bibs/8n3p165.html

Donor lung pretreatment with prostaglandin E(1) does not improve lung graft preservation.

Prostaglandin E(1) (PGE(1)) is widely used to improve early graft function after lung transplantation, but some studies have questioned its benefits. Therefore we evaluated the effect of donor pretreatment with PGE(1) in our porcine model of single lung transplantation. Donors received PGE(1) or placebo intravenously before flushing the pulmonary artery with modified Euro-Collins solution. After cold storage, the excised left lung was transplanted. Ischemic time was 4 h. We used our right side heart bypass model to measure standardized pulmonary vascular resistance and to study blood flow distribution between recipient's native and transplanted lung. Systemic and pulmonary hemodynamics and gas exchange were also measured. After transplantation, pulmonary vascular resistance was significantly higher in the transplanted lung, which received only one fourth of the total pulmonary blood flow. PGE(1) pretreatment did not improve pulmonary hemodynamic parameters, or gas exchange.

Nitecapone as an additive to crystalloid cardioplegia in patients who had coronary artery bypass grafting.

BACKGROUND: Nitecapone has been shown to have a protective effect against ischemia-reperfusion injury in experimental heart transplantation and in Langendorff preparations. This prospective, randomized study assessed the effects of nitecapone in patients who had coronary artery bypass grafting. METHODS: Thirty patients with normal myocardial function were randomly divided into control patients (n = 15), who received crystalloid (Plegisol) cardioplegia, and nitecapone patients, who received nitecapone in a 50 microM solution (n = 15) in Plegisol. Cardioplegia was administered as an initial dose of 15 mL/kg of body mass after cross-clamping and 2 mL/kg every 15 minutes. Simultaneous coronary sinus and aortic blood samples, and myocardial biopsies were taken at 1, 5, and 10 minutes after unclamping. Hemodynamics were measured invasively for 24 hours and with transesophageal echocardiography for 3 hours after cardiopulmonary bypass. RESULTS: There were no adverse effects. The incidence of ventricular arrhythmias was significantly lower in the treatment group during the recovery period (p = 0.02). Cardiac output and stroke volume did not differ significantly between the groups. The conjugated dienes gradient between the aorta and the coronary sinus increased significantly during the first minute of reperfusion in the control group (p = 0.02) compared with the nitecapone group. Myeloperoxidase activity in myocardial biopsies was higher in the control group (2.3 times higher at 5 minutes and 3.2 times higher at 10 minutes) than in the nitecapone group (p = 0.13). CONCLUSIONS: Nitecapone did not exert any significant hemodynamic effects in patients with normal ejection fraction.

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.

Minimally invasive coronary artery bypass grafting: one-year follow-up.

BACKGROUND: Use of the minimally invasive direct coronary artery bypass grafting (MIDCAB) technique has been associated with excellent primary results, and sparing of resources has been assumed. There is, however, a limited amount of information available concerning the results of mid-term follow-up. The purpose of this study was to present 1-year follow-up results of our first 130 consecutive MIDCAB patients. METHODS: MIDCAB operations, defined as no sternotomy, no cardiopulmonary bypass, and no aortic manipulation were started in our clinic in February 1996. One hundred thirty patients requiring invasive treatment of coronary artery disease who were not suitable for percutaneous transluminal angioplasty were included in this series. The main outcome measures were mortality, the need for subsequent invasive treatment, and 1-year NYHA classification. RESULTS: There was one hospital death, but during the first-year follow-up, four additional deaths occurred and three patients were reoperated on with conventional techniques. Five percutaneous transluminal coronary angioplasties (PTCAs) had to be performed, two because of anastomosic stenosis. Additionally, cardiac- or operation-related symptoms caused a total of 27 hospital visits among 23 patients during the first-year follow-up. Angiographic left internal thoracic artery (LITA)-left anterior descending artery (LAD) patency was 97.4% (37/38) (confidence interval [CI] ranged from 86.2% to 99.9%) at 3 months. After 1 year, 86.9% (113/130) of the patients were without symptoms. A clear improvement of the follow-up results was observed to be associated with increased experience during the study period. CONCLUSIONS: MIDCAB operations, after some experience, can be performed with relatively good outcome. However, special attention should be directed to determination of correct anastomosic site and to avoiding anastomosic stenosis. We also recommend extended mobilization of the ITA and use of specific stabilizers.

The conventionally ventilated operating theatre and air contamination control during cardiac surgery--bacteriological and particulate matter control garment options for low level contamination.

OBJECTIVE: The purpose of the study was to compare the usefulness of a conventional bacteriological technique with that of particle counting under lower air contamination and better aseptic conditions achieved with special staff garments and covering for the patient. Contamination levels were estimated with continuous on line air particle counting measurement, volumetric intermittent short period aerobic bacteriological cultures and wound surface contact cultures. METHODS: In a series of 66 consecutive coronary artery bypass operations performed by the same team and in the same theatre using different types of patient and staff clothing, the impact of a reduced bacteriological and particulate contamination were assessed. The volumetric air contamination of particles > or =5 microm and bacteria-carrying particles were monitored 30 cm above the sternal wound. The bacterial contamination and bacterial wound infections in the sternal and leg wounds were assessed as well. RESULTS: With the alternative garment and textile system, the air counts fell from 25 colony-forming units (CFU)/m3 to 7 CFU/m3 (P < 0.0038). The contamination of the sternal wound was reduced by 46% and that of the leg wound by >90%. In order to give continuous contamination feedback during the whole operation to the theatre staff, particle counts > or =5 microm were monitored and visualized. Air particle counts decreased rapidly from 850 particles/m3 and stabilized to approximately 50 particles/m3 when the alternative clothing system was used (P < 0.001). Low particle counts > or =5 microm should offer the possibility to indirectly estimate air bacteria carrying particle counts during the entire operation. Less than 20% of the total count in this size group carries bacteria. The low air contamination was achieved even in an ordinary ventilated theatre when individual team members used clean air suits in combination with impermeable patient drapes. When air particle level < or =50 particles/m3 is reached, the bacterial air contamination is in the order of that of orthopaedic hip operations. The staff must during the entire operation adjust their activity to air asepsis. CONCLUSIONS: The use of clean air suits and impermeable patient clothing results in a low exogenous contamination of air and wound. Continuous air particle monitoring is a good intraoperative method to monitor the air contamination longitudinally in an operating theatre.

Effects of a new calcium sensitizer, levosimendan, on haemodynamics, coronary blood flow and myocardial substrate utilization early after coronary artery bypass grafting.

AIMS: The aim of the study was to evaluate the effects on systemic and coronary haemodynamics and myocardial substrate utilization of a new calcium sensitizer, levosimendan, after coronary artery bypass grafting. METHODS AND RESULTS: Twenty-three low-risk patients were included in this randomized and double-blind study. They received placebo (n = 8), 8 (n = 8) or 24 (n = 7) micrograms.kg-1 of levosimendan after coronary artery bypass operation. Systemic and coronary sinus haemodynamics with thermodilution and myocardial substrate utilization were measured. The heart rate increased 11 beats.min-1 after the higher dose (P < 0.05). Cardiac output increased by 0.7 and 1.61.min-1 (P < 0.05 for both) after 8 and 24 micrograms.kg-1 of levosimendan, respectively. Systemic and pulmonary vascular resistance decreased significantly after both doses. Coronary sinus blood flow increased by 28 and 42 ml/(P = 0.054 for the combined effect) after the lower and higher dose, respectively. Myocardial oxygen consumption or substrate extractions did not change statistically significantly. CONCLUSION: Despite improved cardiac performance, levosimendan did not increase myocardial oxygen consumption or change myocardial substrate utilization. Thus levosimendan has the potential to treat low cardiac output states after cardiopulmonary bypass surgery.

Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery.

BACKGROUND: Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA). METHODS: From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting. RESULTS: All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%. CONCLUSIONS: The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.

Surgical treatment of acute myocardial ischaemia related to coronary angioplasty with special reference to use of perfusion balloon catheter and long-term outcome.

Twenty of 569 consecutive patients (3.5%) undergoing percutaneous transluminal coronary angioplasty required emergency coronary artery bypass grafting for acute closure of the dilated vessel. In seven patients an intracoronary autoperfusion balloon catheter was inserted to ensure antegrade blood flow across the injured zone of the coronary artery. The time needed for completion of the bypass grafts ranged from 100 to 399 minutes (mean 180 minutes). An average of 1.9 coronary artery bypasses was inserted. In total, 11 of the 20 patients (55%) developed new Q waves and had elevated CK-MB levels. However, the myocardial infarction rate was only 14% in those with a perfusion balloon catheter as against 77% in those without one. The insertion of a ball-out catheter permitted greater utilization of the internal mammary artery as a bypass graft. Angiographic follow-up was conducted after a mean of 28 months (19 patients). The patency rate of the bypass grafts placed in the emergency setting was relatively good (91%). Thallium tomography revealed a scar of variable size in all 17 patients studied and a reversible exercise perfusion defect requiring coronary reangioplasty in three patients. In conclusion, the insertion of a perfusion balloon catheter after abrupt coronary occlusion during coronary angioplasty solved the problems of acute myocardial ischemia and markedly lowered the definite myocardial infarction rate. This technique ensures favourable haemodynamic conditions for emergency myocardial revascularization.

Heart transplantation in Finland 1985-1995.

BACKGROUND AND AIMS: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

En bloc heart and lung transplantation in Finland 1988-1996.

UNLABELLED: The purpose of the study was to review the first clinical experience in combined heart-lung transplantation in our institution. MATERIAL: From June 1988 to December 1996 15 en bloc heart and lung transplantations were performed. There were nine men and six women, aged 17-61 (mean 42.3) years. The indications for operation were primary pulmonary hypertension with right heart failure in five, Eisenmenger's syndrome in five, pulmonary embolism and right heart failure in three and emphysema with right heart failure in two cases. RESULTS: The hospital (30 day) mortality was four patients (26.6%). The causes of mortality were graft failure in two cases, infection and bleeding after transbronchial biopsy in one case and sepsis and aspergillosis in one case. Postoperative complications included eight cytomegalovirus (CMV), two Pneumocystis Carinii, five bacterial and five fungal (one Aspergillus and four Candida) infections. Rejection episodes (of the lungs) occurred in four patients (in 27%). During the follow-up to four years two patients developed diabetes mellitus (insulin therapy), one patient renal failure (dialysis), two patients tracheal stricture (laser resection), one patient fracture of the spine and one patient epilepsy. One patient died from prolonged CMV infection and chronic rejection eight months postoperatively. Four patients underwent bronchial artery revascularization (two with the internal thoracic artery and two with a vein graft). This was followed by improved airway healing and resistance towards infections. After a follow-up to four years 10 patients out of 15 (66.7%) were living an active life. CONCLUSION: Combined heart-lung transplantation offers a good mid-term outcome for patients with end-stage cardiopulmonary disease. The results compare favourably with the corresponding international statistics.

St. Jude versus CarboMedics: follow-up after prosthetic valve replacement.

BACKGROUND: The purpose of the present study was to evaluate the immediate and long-term outcome of patients with two types of mechanical bileaflet heart valves operated on in the same institution by the same group of surgeons. METHODS: A comparative analysis was made in 229 consecutive patients receiving either the St. Jude Medical (SJM) or CarboMedics (CMS) bileaflet mechanical valve in 1990-1991. There were no differences in the preoperative demographics between the two groups. At operations simultaneous coronary bypass operation was performed in 40 patients out of 134 (30%) in the SJM group and 95 (44%) in the CMS group (p=0.026). Sixteen patients in the SJM group underwent replacement of the ascending aorta with a composite graft and none in the CMS group. RESULTS: There was no difference in hospital mortality between the SJM (6.7%) and CMS (6.3%) groups or in other immediate postoperative complications. The patients were followed up to 32 months. There were more patients in the NYHA class I and II in the CMS group (88%) than in the SJM group (69%), p<0.002. Three were 11 thromboembolic events (0.051% per patient year) in the SJM group and one thromboembolic event (0.008% per patient year) in the CMS group. There were no other differences between the groups in long-term survival, rate of bleeding, infective endocarditis or perivalvular leakage. CONCLUSIONS: With the exception of a little more favourable exercise tolerance and fewer thromboembolic events in the CMS group there were no other differences in the outcome of patients with these two types of bileaflet mechanical valves.

Angiographic 5-year follow-up study of right gastroepiploic artery grafts.

BACKGROUND: The right gastroepiploic artery (RGEA) has been used from 1987 in coronary artery bypass grafting in several clinical studies. However, the published 1- to 5-year patency rates have been dependent on the selection of patients for angiography. METHODS: In our study, the RGEA was used from March 1987 to May 1990 for coronary artery bypass grafting in 31 consecutive patients, 25 male and 6 female. All but 1 patient had triple-vessel disease, and the mean number of distal anastomoses was 3.9 (range, 2 to 5). Internal thoracic artery grafts were used concomitantly in all patients. RESULTS: One early and two late deaths occurred. All but 1 of the 28 surviving patients underwent clinical and angiographic follow-up examinations 3 months and 5 years after the operation. The 5-year patency of RGEA grafts was 82.1%, with a 95% confidence interval of 63.1% to 93.9%. In 4 of the 5 nonvisualized cases, the recipient coronary artery showed proximal stenosis of up to 70%, allowing substantial competitive flow. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts. CONCLUSIONS: At 5-year follow-up, angiography of RGEA grafts showed good function and a smooth lumen, especially if the proximal stenosis was more than 70%.

Value of high-resolution computed tomography in routine evaluation of lung transplantation recipients during development of bronchiolitis obliterans syndrome.

BACKGROUND: Chronic rejection is a major long-term complication after lung transplantation. The purpose of our study was to evaluate the role of repeated high-resolution computed tomographic examinations in monitoring the development of bronchiolitis obliterans syndrome after lung transplantation. METHODS: A total of 126 high-resolution computed tomographic examination in 13 lung transplant recipients was analyzed. During a mean follow-up period of 23 months, bronchiolitis obliterans syndrome developed in eight of the patients. A scoring system from 0 to 10 based on the number of chronic changes on high-resolution computed tomography was developed, and the score of each patient was compared with decline in the forced expiratory volume in 1 second and maximal forced expiratory flow rate of 50% of the forced vital capacity. RESULTS: The score of chronic changes, measured at 1 year after transplantation, correlated inversely with the values of forced expiratory volume in 1 second and maximal forced expiratory flow rate at 50% of the forced vital capacity (p < 0.05). Stage I bronchiolitis obliterans syndrome was associated with scores of 4 to 6 (mean 5.0), stage 2 with scores of 6 to 9 (mean 7.0), and stage 3 with scores of 6 to 9 (mean 7.7). The sensitivity of high-resolution computed tomography was 93% and its specificity was 92% when five chronic changes were used as a cutoff level. CONCLUSIONS: The progress of chronic changes on high-resolution computed tomography occurs concurrently with the development of bronchiolitis obliterans syndrome. High-resolution computed tomography may provide additional morphologic information for noninvasive evaluation of chronic lung rejection.