Objectives: Ongoing ischemia, or even ischemia in progress, is regularly encountered in today's patients amenable to cardiac surgery. We set out to assess the effect of `active resuscitation' during cardioplegia with warm continuous retrograde blood cardioplegia (WB) in a protocol simulating a clinical situation. Methods: After 60 min with a regional ischemic injury to the left ventricle, 21 pigs were randomized to receive no treatment (control), cold retrograde intermittent crystalloid cardioplegia (CC) or WB. All animals were put on cardiopulmonary bypass. After 1 h of cardioplegia and 1 h of reperfusion the perfused left ventricle was colored with methylene blue. After excision of the hearts a standard planimetri technique was used to determine the area at risk and amount of necrosis (triphenyltetrazolium). Heart rate, mean arterial pressure (MAP), cardiac output and myocardial blood flow were recorded as well as myocardial oxygen consumption, plasma levels of free fatty acids, glucose, lactate and Troponin T from the coronary sinus. Results: The area at risk of the left ventricle was 13.6 +/- 1.2%. We found 71 +/- 2, 61 +/- 3 and 30 +/- 2% necrosis of the area at risk in the controls, CC and WB, respectively (P < 0.001, CC versus control and P < 0.0001, WB against CC and control). Troponin T release was highest in the CC group in the reperfusion period. Glucose levels increased significantly after ischemia in the controls and WB. In accordance with the amount of saved myocardium in the WB group which also had a normal coronary sinus lactate level as opposed to the fourfold increase in the CC group after ischemia. After standstill cardiac output and MAP were significantly lower than baseline values in the WB group only (P < 0.05). Conclusions: CC did reduce the size of the infarction by about 10% compared to control animals, whereas WB reduced the infarction by more than 50% of that seen after CC. Both modalities are, however, associated with a functional reduction during the first 60 min of reperfusion, WB being the worst. (C) 2002 Elsevier Science B.V. All rights reserved.

Objective -- We wanted to assess the effect of glucose-insulin-potassium (GIK) and glutamine on the oxidative metabolism during and after prolonged warm continuous blood cardioplegia (WB). Design -- WB was given to 21 pigs divided into three equally sized groups: WB (control), WB and GIK, or WB and glutamine. Oxidation rates of radiolabeled glucose ( 14 C) and free fatty acid (FFA) ( 3 H) were assessed before, during, and at 30 and 60 min after 3 h of cardiac arrest with WB. Results -- During standstill the substrate oxidation dropped markedly (<60%), glucose oxidation was highest in the WB + GIK group ( p < 0.05) and FFA oxidation highest in the WB + glutamine group (NS). During recovery the GIK group had an elevated glucose oxidation (47 and 40% vs WB at 30 and 60 min recovery, respectively - p < 0.05). Following 30 min recovery the addition of GIK suppressed FFA oxidation some 60%. Glutamine increased the oxidation of both glucose (30%) and FFA (150%) following 60 min recovery ( p < 0.05). During the whole recovery phase the relative FFA oxidation was significantly lowered in the GIK group. There were no differences between the groups regarding arterial levels or uptake of substrates, except for a higher myocardial oxygen consumption (MVO 2 ) during cardioplegia in the glutamine group. All the hearts performed similarly. Conclusion -- Addition of GIK or glutamine to the well-perfused and oxygenated heart during WB led to a postcardioplegic increase in oxidative metabolism and MVO 2 . GIK resulted in a significant metabolic shift from FFA to glucose.

OBJECTIVE:To examine the psychometric properties of a global physical functioning scale (GPFS) developed as a self-report measure and constructed to scale physical functioning from very poor (1) to excellent (100).DATA SOURCES:Data collection took place between January 1997 and September 1999. It consisted of self-ratings of surgical patients and the ratings of clinicians. The setting was the surgical department at a university hospital.STUDY DESIGN:Test-retest reliability and the convergence of the scores of patients and clinicians were examined in 106 patients before elective coronary or gastrointestinal surgery. Inter-rater reliability was tested in 36 hospitalized patients with cardiologic or vascular surgical diseases who were rated by random selection from a pool of 91 clinicians. The patients also rated their physical functioning. Discriminative validity, sensitivity to change, ceiling and floor effects, and influence of emotional state upon the scores were tested in 127 patients in six diagnostic groups who scored the GPFS before and subsequent to surgery. The concurrent validity was examined in 101 patients who scored the GPFS and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) before elective coronary surgery.PRINCIPAL FINDINGS:The test-retest correlation (.90), correlation of the scores of the clinicians and patients (.87), and rater intraclass correlation coefficient (.82) were high. The GPFS discriminated among patients with different levels of physical functioning, and it was sensitive to change following coronary surgery. There were moderate ceiling and no floor effects. The correlation with the physical functioning scale of the SF-36 (PF-10) was .67. The GPFS differentiated patients with middle levels of physical functioning better than did the PF-10.CONCLUSIONS:The psychometric properties of the GPFS appeared adequate as a measure of general physical functioning. The scale is easy to use and also appears suitable for outcome studies following substantial changes in physical functioning as after coronary surgery.

Objective - In Norway ?Transmyocardial laser revascularization? as a routine method was prohibited by the Ministry of Health in 1995 due to lacking evidence of treatment effect and concerns about procedural morbidity and mortality. In 1999 Norwegian health authorities asked for a re-evaluation of the method based on a systematic review of literature. Methods - Medline and Embase were searched and a total of 267 articles were identified. Publications were classified by an expert panel according to type of study and importance for the project. Results - Based on the literature review the panel concluded that heart laser treatment does not have a life-saving effect, nor does it improve myocardial function. However, the method has a considerable short-term symptomatic effect, the mechanism of which is not understood. Neoangiogenesis, denervation and placebo may play a role. Based on the report the Norwegian health authorities recommended use of this method be restricted to scientific trials only. Conclusions - Based on a systematic literature review it was concluded that the only documented effect of heart laser treatment is symptom relief, the mechanism for which is unclear. It could partly or totally be a placebo effect. A conflict of interest may arise when new technologies are to be implemented in health care. The communication between professionals evaluating scientific results and decision makers is challenging. Quality assurance of this process may be obtained by use of expert panels working under the auspices of an official institution.

BACKGROUND:Spontaneous pneumothorax is a common disorder in which treatment strategies are changing. MATERIAL AND METHODS:220 patients treated at the University Hospital of Tromsø over a 10-year period from 1988 to 1997 were studied. There were 128 patients with primary spontaneous pneumothorax, 51 with secondary spontaneous pneumothorax, and 41 with traumatic pneumothorax. The patients with spontaneous pneumothorax were divided into two groups depending on whether drainage time was less than three days or more. 68 patients were treated with videoassisted thoracoscopic surgery (VATS) or thoracotomy. RESULTS:Recurrence rate for primary pneumothorax was 19%, for secondary 13% and for traumatic 3%. Recurrence rate for patients having drains for more than three days was lower than the rate for those having drains for a shorter period; 11% and 27% respectively (p < 0.025). Recurrence rates after videoassisted thoracoscopic surgery or thoracotomy were 11% and 4% respectively (p > 0.05). INTERPRETATION:Although the results are good, the study indicates room for improvement. Drainage time should perhaps be somewhat prolonged when the airleak stops early (< 3 days). VATS should be considered early when there is a persisting leak.

Using two different methods simultaneously, a surgical department assessed how former patients experienced the treatment they received. One method was based on a specifically designed questionnaire, while the other studied the patients negative experiences with regard to their treatment. The two approaches were compared in 610 respondents. The questionnaire yielded a more differentiated response pattern than did the other approach. While most of the respondents (88%) expressed overall satisfaction, the degree of satisfaction with information and supervision was not so high. The importance of the doctor's role was strongly emphasized, especially in the "negative experiences" approach. The use of this approach is dependent on the questions covering aspects of treatment actually experienced by the patient. The simultaneous use of both approaches will not only provide information about how patients experience essential aspects of their treatment but also what they consider to be the most problematic practical issues. This will encourage greater motivation among the staff to become involved in evaluation and improvement of treatment.

Background. Warm continuous blood cardioplegia (WCBCP) has been recommended during prolonged cardiac arrest to minimize functional deterioration. Myocardial metabolism and efficiency after this cardioplegic modality are not well described.Methods. Substrate oxidation, blood now, and myocardial function were measured before, during, and after 3 hours of WCBCP in 7 pigs.Results. Free fatty acid and glucose oxidation decreased by 60% +/- 3.8% and 94% +/- 1.2%, respectively, during cardioplegia (both p < 0.05) and increased to 62% +/- 28% and 122% +/- 62% of baseline during the early recovery phase (p < 0.05 for glucose). One hour after WCBCP oxidation rates were similar to baseline. The transient postcardioplegic increase in substrate oxidation was associated with a 43% +/- 23% elevation of oxygen consumption (MVO2) compared with baseline and a 62% +/- 18% increase in myocardial blood flow. Cardiac output and mean arterial pressure did not change significantly after WCBCP, although myocardial function (stroke work, left ventricular end-systolic pressure, end-diastolic pressure, contractility, and efficiency) was depressed (p < 0.05). End-diastolic pressure and contractility improved from early to late phase of recovery, whereas the other indicators of ventricular function remained depressed.Conclusions. Myocardial substrate oxidation was preserved after 3 hours of WCBCP, although ventricular function was moderately impaired. Thus, WCBCP with a seemingly normal substrate and oxygen supply was associated with a reduced cardiac efficiency. (C) 2000 by The Society of Thoracic Surgeons.

To investigate the focal myocytic and microvascular injury that develops during the first hour of reperfusion after hypothermic cardioplegic cardiac arrest, and to compare the influence of gentle versus more abrupt reperfusion, serial atrial biopsies were obtained from 14 patients undergoing uneventful coronary bypass surgery. The biopsies were taken before cardioplegia, at the start of reperfusion, and after 20 and 60 min of reperfusion. Transmission electron micrographs of biopsies examined by stereological techniques revealed endothelial injury. Following 20 min reperfusion there was accumulation of both red blood cells (p = 0.03) and polymorphonuclear leucocytes (p = 0.0004) were found. There was also intravascular accumulation of platelets (p = 0.008) and extravasation of red blood cells (p = 0.02), which increased throughout the observation period. If reperfusion was started with a gradual rise in temperature and pressure, the numbers of platelets in the microvessels were lower than following ordinary, abrupt reperfusion (p = 0.06). It is concluded that reperfusion injury is associated with microcirculatory disturbances with trapping of blood cells, changes which may be favourably modified by a gentle reperfusion technique.

A retrospective survey comprising 1198 randomly chosen former surgical patients was carried out on average ten months after treatment. The goal of the research project was to investigate the associations between global satisfaction with treatment and issues that might influence how the treatment was experienced. There were no significant differences between the 610 responders and the sample of 1198 patients with respect to age, sex, length of treatment and diagnosis. The following five variables explained together 36.2% of the variance in global treatment satisfaction: Subjective health at time of investigation, the personality dimension conscientiousness, the "degree of severity of the illness", "contact with doctors and nurses" and "conveyed information and supervision". "Contact with doctors and nurses" alone explained 25.1% of the variance.

OBJECTIVE: The cardioplegic solution is often given at high flow andpressure following aortic clamping clamping to ensure rapid diastolicarrest. With standard setup in clinical practice, it is easy to exceed 200mmHg in the aortic root. To investigate whether cardioplegic solutiondelivery pressure has an influence on myocardial protection, intermittentinfusions of crystalloid cardioplegia were given at two different pressuresusing an in vivo pig model. METHODS: Fourteen pigs (48-57 kg) were put oncardiopulmonary bypass, aorta-clamped (2 h) and 500 ml St. Thomas'cardioplegia (4 degrees C) was delivered antegradely at either 75 mmHg(group 1, n = 7) or 175 mmHg (group 2, n = 7) pressure via 9-F aortic rootcardioplegic needle. Every 20 min, 100 ml cardioplegic were delivered ateither one of the two pressures. After 2 h, the aorta was unclamped and thehearts reperfused. Attempts were made to wean pigs from bypass following 20min reperfusion or, if they were failing, after 40 min. If failing onceagain, the pigs were reperfused for the last 20 min on the heart-lungmachine. RESULTS: Hearts in group 1 (n = 7) needed significantly longertime to stop after aortic clamping (38 +/- 9 s) than did group 2 hearts (n= 7) (21 +/- 5 s) (P = 0.043). In group 1, all pigs were weaned frombypass, whereas in group 2 only 2 out of 7 pigs were able to sustaincirculation without cardiopulmonary bypass (P = 0.01), and then with lowerhemodynamic performances. At the end of cardiac arrest, group 1 hadsignificantly higher adenosine triphosphate (19.4 +/- 1.1 mumol/g dryweight and 15.05 +/- 1.8 mumol/g dry weight, respectively) (P = 0.05) andsignificantly lesser fall in energy charge than group 2 (0.02 +/- 0.01 and0.05 +/- 0.02, respectively) (P = 0.05). Also at the end of reperfusion,group 1 had significantly higher adenosine triphosphate (16.54 +/- 1.4mumol/g dry weight and 12.53 +/- 0.95 mumol/g dry weight, respectively) (P= 0.016) than group 2. CONCLUSIONS: Despite a swifter diastolic cardiacarrest, the high cardioplegic solution delivery pressure causedsignificantly poorer postischemic recovery than a moderate pressure withthe same amount of cardioplegic solution.

Background. Although long-chain fatty acids are a major energy substrate utilized by the myocardium, changes in the substrate balance toward a predominating fatty acid utilization could jeopardize the myocardium during cardiac operative procedures.Methods. In the present study myocardial substrate utilization was examined during warm continuous blood cardioplegia (4 hours, 37 degrees C), using pigs undergoing cardiopulmonary bypass. Hearts were perfused antegradely in a closed extracorporeal circuit in which cardioplegic donor blood (hematocrit, 22%) containing C-14-glucose and H-3-oleate was delivered to the heart. Arterial and coronary sinus blood samples were taken at intervals for determination of plasma concentrations of energy substrates, as well as glucose and oleate oxidation rates ((CO2)-C-14 and (HOH)-H-3 production).Results. The concentration of fatty acids in the cardioplegic perfusate did not change significantly during the cardiac arrest period. The mean concentration of glucose showed a 30% decline (not significant), whereas the lactate concentration increased from a starting value of 3.12 +/- 0.27 to 6.31 +/- 0.72 mmol/L at the end (mean +/- standard error of the mean; n = 8; p < 0.05). Only fatty acid levels showed a significant (positive) arterial-coronary sinus difference. Myocardial oxidation of oleate varied between 302 +/- 71 and 650 +/- 66 nmol . min(-1). heart(-1), whereas the range of variation for glucose oxidation was 144 +/- 64 to 355 +/- 107 nmol . min(-1). heart(-1). However, the changes in fatty acid levels and glucose oxidation rates during the cardiac arrest period were not statistically significant. We calculated that overall glucose oxidation accounted for less than 5% of the total aerobic energy production.Conclusions. The present results demonstrate overreliance on fatty acids as a source of energy during warm continuous blood cardioplegia, consistent with a condition of myocardial insulin resistance.

Warm, continuous blood cardioplegia should theoretically maintain cardiac arrest for hours without ischaemic or hypothermic injury. In the absence of in vivo studies of myocardial metabolism and ultrastructural and/or functional preservation during and after more than 2 hours of cardiac arrest and after weaning from bypass, we devised a porcine model with a closed extracorporeal circuit for the heart alone. Normothermic blood cardioplegia was administered antegrade and recirculated for 2 or 4 hours, each in seven pigs. After aortic declamping all were successfully weaned from bypass and reperfused for 1 hour. Thereafter we found no significant intergroup difference in haemodynamic characteristics (average fall in mean arterial pressure 31.7 +/- 3.2% and 26.9 +/- 2.6%) or blood analyses. After 5 and 60 minutes of cardiac arrest there was minimal lactate production (5.7 +/- 10.7 and 0.5 +/- 10.5 nmol/l, respectively), whereas in the remainder of the arrest period there was lactate uptake, indicating aerobic heart metabolism. Our setup avoids systemic hyperkalaemia, gives good cardiac protection with no deterioration between 2 and 4 hours and is well suited for studies on the quiescent, blood-perfused oxygenated heart.

We describe successful use of respectively an aortic and a pulmonary homograft as total root replacement in two patients with extensive aortic valve endocarditis. At follow-up 18 months after operation both patients were doing well and echocardiography demonstrated excellent graft function with only trivial aortic regurgitation.

In 14 patients undergoing coronary surgery, repeated atrial biopsies were obtained before and at the end of ischemia, and at 20 and 60 min of reperfusion. In half of the patients reperfusion was initiated with an abrupt rise in blood temperature and pressure, in the other half with a gradual rise. The biopsies were prepared for transmission electron microscopy and analyzed by stereological technique. In all biopsies, myocytic injury, as revealed by mitochondrial changes and intracellular edema, occurred following ischemia (P = 0.0003 and 0.007, respectively). The intracellular edema regressed following 20 min of reperfusion (P = 0.008). The myocytic mitochondrial changes persisted during reperfusion towards the end of the observation period (P = 0.0001). Interstitial edema increased following ischemia (P = 0.007) and persisted following 60 min of reperfusion (P = 0.009). The capillary part was significantly reduced after 20 min of reperfusion (P = 0.003), probably reflecting interstitial edema. Most changes were reversible in nature, although foci of irreversible changes were shown. In patients with a gradual start of reperfusion there was a significant regression of interstitial edema (P = 0.005) at 60 min reperfusion compared to the patients with an abrupt start, where the same changes seemed to persist or even increase. The study demonstrates that "reperfusion injury" occurs in human myocardium. It can be discerned from "ischemic" injury, and it may be reduced by a gentle mode of reperfusion.

The surgical mortality among 22 patients treated for thoracic or thoracoabdominal aneurysm was compared with the mortality in 47 patients managed without surgery. Surgical mortality ( < 30 days) was low (1/13) in ascending aortic aneurysm, but higher (3/8) in aneurysm of the descending or thoracoabdominal aorta (including both acute and elective operations). Of the 20 non-surgically managed patients in the latter group, 15 died after a mean of 1.1 year. The only patient operated on for aortic arch aneurysm died of cerebral ischaemia 2 days postoperatively. Most of the 19 non-operated patients with aneurysm of the arch or total aorta (mean age 76 years) were never considered for surgical treatment. The analysis supports aggressive management of patients with aneurysm of the ascending, descending or thoracoabdominal aorta. Many of our patients with aneurysm of the arch or involving most of the aorta were old and had other, concomitant diseases, and in such cases an aggressive treatment strategy does not seem justified.