The effects on fluid balance, pulmonary tunctions and economics were evaluated in a randomized comparison of one colloid free and three colloid containing fluid regimens, for 48 hours during and after coronary artery‐bypass (CAB) surgery.A standard regimen for anaesthesia, extracorporeal circulation and monitoring was used. Only Ringer's acetate (RAc) was used as priming solution for extracorporeal circulation. Forty patients were randomized to receive either RAc, polygeline 35 mg‐ml‐1 (Haemaccel®), dextran 70 (Macrodex®) 60 mg ml‐14, or albumin 40 mg‐ml‐1 in saline whenever fluid volume was needed to stabilize haemodynamics.At the end of the operation, fluid retention was significantly lower in patients receiving polygeline and dextran 70, compared with patients receiving RAc. At 48 hours, however, there were no differences in cumulative fluid balance. Patients in the colloid groups postoperatively had a higher serum colloid osmotic pressure (s‐COP), bui a higher net lung capillary filtration pressure (AP) only on the second postoperative day than the RAc group. However, this did not adversely atfect intrapulmonary venous admixture, arterial oxygen tension, or time on respirator in the RAc group compared with the colloid groups. The most expensive colloid fluid regimen (albumin) cost about 230 USS more per patient than the RAc fluid regimen.We conclude that Ringer's acetate for volume replacement to stabilize haemodynamics during and after CAB surgery is associated with increased fluid retention only during the intraoperative period, compared with dextran 70 or polygeline, and with a lower serum colloid osmotic pressure and net lung capillary filtration pressure postoperatively, compared with all three colloid groups. This does not affect pulmonary functions adversely. Thus, the RAc regimen is clinically fully acceptable and economically more favourable than the polygeline, dextran 70, and albumin‐containing fluid regimens.

Seven single lung transplants are reported. The patients were severely disabled and oxygen dependent below sixty years of age with a poor prognosis. Diagnosis were alfa 1-antitrypsin deficiency (3), sarcoidosis (3) and idiopathic emphysema (1). Multiorgan-harvesting including six hearts, was performed in local or distant hospitals (3). Partial cardio-pulmonary bypass simplified transplantation. The surgical procedure was modified with a direct transpericardial approach. Soft tissue wrapping by a vascularized pedicle secured the bronchial anastomosis. The four drug immunosuppressive regimen included cyclosporin A, azathioprine, steroids and antithymocyte globulin. Primary graft function was excellent. Six patients survived the postoperative period and are alive 5-19 months post transplant. Transbronchial biopsies and lung function studies have been helpful in detecting pulmonary rejections. Patient rehabilitation is satisfactory in most patients with improvement in physiologic parameters.

Seven single lung transplants are reported. The patients were severely disabled and oxygen dependent below sixty years of age with a poor prognosis. Diagnosis were alfa 1-antitrypsin deficiency (3), sarcoidosis (3) and idiopathic emphysema (1). Multiorgan-harvesting including six hearts, was performed in local or distant hospitals (3). Partial cardiopulmonary bypass simplified transplantation. The surgical procedure was modified with a direct transpericardial approach. Soft tissue wrapping by a vascularized pedicle secured the bronchial anastomosis. The four drug immunosuppressive regimen included cyclosporin A, azathioprine, steroids and antithymocyte globulin. Primary graft function was excellent. Six patients survived the postoperative period and are alive 5-19 months post transplant. Transbronchial biopsies and lung function studies have been helpful in detecting pulmonary rejections. Patient rehabilitation is satisfactory in most patients with improvement in physiologic parameters.

Heparin has been suggested as an activator of the plasma kallikrein‐kinin system, with possible formation of bradykinin, a potent vasodilator. Haemodynamic effects and changes in the kallikrein‐kinin system were studied after heparin‐ and saline‐injections in ten patients undergoing coronary bypass surgery. A moderate decrease in mean arterial pressure was found in all patients in the observation period, but significantly more at 2 and 3 min after heparin‐injection compared with saline‐injection. None of the other haemodynamic variables measured were significantly different when comparing heparin‐ to saline‐injection. Heparin‐injection resulted in significant changes in the kallikrein‐kinin system, with a marked increase in spontaneous kallikrein‐like activity as the most prominent feature, while no changes were found after saline‐injection. Liberation of bradykinin would be expected to give a decrease in systemic vascular resistance with an increase in cardiac output. The results indicate that the plasma kallikrein‐kinin system, though apparently activated after heparin‐injection, does not contribute significantly to the decrease in arterial pressure in the patients studied.

The effect of positive end-expiratory pressure ventilation (PEEP) on angiotensin II and atrial natriuretic factor (ANF) was studied postoperatively following heart surgery. In nine patients pressures were recorded in the radial artery, pulmonary artery and the right atrium. PEEP of 5 cmH2O (0.5 kPa) and 10 cmH2O (1 kPa) increased angiotensin II from 38.8 +/- 20.3 (mean +/- s.e.mean) to 56.7 +/- 29.6 (n.s.) and 66.7 +/- 28.7 (P less than 0.05) pmol/l, respectively. Plasma-ANF showed no significant changes during PEEP. Pulmonary artery wedge pressure increased from 12.9 +/- 2.0 to 14.1 +/- 2.0 (n.s.) and 18.5 +/- 2.1 (P less than 0.01) mmHg, and right atrial pressure from 8.3 +/- 1.7 to 9.8 +/- 1.7 (n.s.) and 12.9 +/- 1.7 (P less than 0.01) mmHg with 5 and 10 cmH2O (0.5 and 1.0 kPa) of PEEP, respectively. Systemic blood pressure tended to decrease (n.s.) with PEEP. In conclusion, PEEP markedly increased angiotensin II. This may represent an important compensatory mechanism, helping to prevent reduction in aortic pressure during PEEP. ANF, however, did not change with PEEP of 5 or 10 cmH2O (0.5 and 1.0 kPa).

The article describes the first cases of single lung transplantation in Norway. The indication for surgery was end-stage pulmonary disease (1 sarcoidosis, 2 emphysema) in three severely disabled patients requiring administration of oxygen. The operation necessitated cardiopulmonary bypass in all patients. Primary graft function was excellent. Epidural analgesia, peripheral pulse oxymetry and continuous monitoring of mixed venous oxygen saturation aided early extubation. The initial postoperative course with a four drug immunosuppressive regimen has been encouraging. Rejection is monitored by clinical examination, chest x-ray, serial pulmonary function tests and transbronchial biopsies.

We discuss our experience from 6 1/2 years of orthotopic heart transplantation at Rikshospitalet (the National Hospital). 112 grafts were performed on 109 patients (19 women and 90 men), mean age 47 years (range 14-63). In the first nine patients the immunosuppressive regimen consisted of cyclosporine A and prednisolone, and in the last 100 azathioprine was added (triple medication). There was no operative mortality. 21 patients died, giving an 81% cumulative survival, with a significantly better prognosis among those who received triple immunosuppressive regimen. The main complications were rejection, infection and arrhythmia. Since our main problem was rejection it is concluded that careful supervision, concentrated on as few cardiologists as possible, and a liberal indication for myocardial biopsy, are decisive for the prognosis.

A variable pattern of organ flow distribution was observed during experimental hypo- and hypercarbia. Mainly two patterns of organ flow changes emerged in that hepatic, renal and skeletal muscle flow showed a decreasing tendency during hypercarbia while gastrointestinal, myocardial and cerebral flow increased during hypercarbia and decreased during hypocarbia. These changes were accompanied by typical central hemodynamic changes including a decrease in systemic and pulmonary vascular resistance during both hypocarbia and hypercarbia which was also accompanied by decreased myocardial contractility.

A new approach to the challenge of surgical treatment of aneurysms of the aortic arch is described. Former techniques have been dependent on separate cannulation of the cerebral arteries, but induction of deep total body hypothermia to 15 degrees C and circulatory arrest is considered to give sufficient time for resection of the aneurysms and completion of the anastomoses. This is made possible by excising the aneurysms in such a way that the orifices of the three arch vessels are trimmed to leave a small cuff of tissue around the vessels, thereby reducing the number of anastomoses to three. The successful treatment of three patients with this method, is reported.

During the open-heart surgery, haemodilution is performed before extracorporeal circulation is started by the sampling of autologous blood and substituting an electrolyte solution. Following extracorporeal circulation, first the machine-blood and then the autologous blood is reinfused. The haemodilution and reinfusion procedures lead to alterations in blood osmolality and tissue fluid distribution, initiating changes in arterial blood pressure, central venous pressure, intracranial and intraocular pressures. These changes were studied in pigs. It is believed that these potentially hazardous pressure alterations can be minimized through proper handling of the procedure. This study presents some of the mechanisms involved.