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OBJECTIVE: Our aim was to chart the short-term results of the first 75 of our patients who had undergone first-time aortic valve replacement (AVR) with stentless xenografts. DESIGN: Our study included a complete follow-up (mean/max. 1.5/3.7 years) of the first 75 patients (42 males, 33 females; mean age 74, range 61-84 years) who underwent a first AVR with stentless xenografts. RESULTS: Forty-three percent of patients were in functional class II and 57% in classes III-IV preoperatively. Coronary artery bypass grafting (CABG) was performed in 33 patients. Early mortality (< or = 30 days) was 6.7%, with no significant relation to CABG or age. Crude survival was 81% (95% confidence interval, CI: 71-91 %) at 3 years. Using a multivariate analysis, we identified a low left ventricular ejection fraction as a predictor of early and late mortality. Late survival (early mortality excluded) was comparable with the survival of a matched Danish background population. There were six embolic events (all cerebral: 3 minor, 1 major, 2 fatal), while two patients underwent redo-AVR because of either endocarditis (fatal) or aortic regurgitation caused by malaligned commissures. There were no other valve-related complications. Cumulative freedom was 89% (95% CI: 79-99%) for embolism and 86% (95% CI: 76-96 %) for all complications at 3 years. At the end of the study, 64% of the survivors were in functional class I, 34% were in class II and 2% in class III. CONCLUSIONS: Considering the age composition of our patients, and compared with international results, our early mortality rates were acceptable. The absence of late excess mortality compared with the background population and the functional status at end-of-study may indicate the potential haemodynamic advantages of stentless aortic valves, at least in the short term.

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The five-year survival after surgery for non-small cell lung cancer is good with respect to Stage I and Stage II and poor with respect to higher stages. The aim of this retrospective study of 172 patients was to detect a connection between the intraoperative stage and the pre-operative delay. Concerning the intervals from first symptom to operation and from first contact with the healthcare system to operation, the delay was significantly shorter for the patients in Stage I and II compared to Stage III and IV. The fraction of lung cancers detected by coincidence was significantly higher in Stage I and II compared with Stage III and IV. In conclusion, a few months' delay before final treatment of a non small-cell lung cancer has an impact on the perioperative stage, and thereby on the patient's prognosis. Screening asymptomatic risk-group patients will result in recognition of early lung cancer.

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Seventy-five patients undergoing coronary artery bypass grafting were randomized to receive injections of papaverine solution or isotonic saline or no injection into the left internal mammary artery (LIMA) used as graft. Blood flow in the LIMA was measured twice-after dissection of the pedicle and before anastomosis to the coronary artery. Blood flow increased significantly in all three groups, but after papaverine injection it was twice as high as in the control groups, increasing by 285% (from 40 +/- 12 to 154 +/- 32 ml/min, p = < 0.0001). The pH of the papaverine solution was only 3, and we advise that surgeons check and correct pH in the papaverine solutions they use, in order to avoid endothelial damage to the LIMA. Based on these results we can recommend papaverine injection into the arterial graft only if the initial flow is low.

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The use of radionuclide transit (RT) as a screening test for chest pain of oesophageal origin has been debated. The aim of this study was to determine the value of RT as a screening test for oesophageal disorders in comparison with oesophageal manometry in patients admitted with acute chest pain but without acute myocardial infarction (non-AMI patients), and to assess the frequency of oesophageal disease present in these patients. A total of 222 non-AMI patients entered the study. An extensive examination programme comprised noninvasive cardiac studies, pulmonary studies, a careful physical examination of the musculoskeletal system, and oesophago-gastric examinations including endoscopy, pH monitoring of the oesophagus and a Bernstein test. In 91% of the patients one or more diagnoses were obtained. Based on clinical and laboratory data a 'consensus' diagnosis was made. With manometry as the reference RT had a poor sensitivity (35%) but an acceptable specificity (82%). With the consensus diagnosis as the gold standard the sensitivities of both manometry and RT were poor (29%), whereas the specificity of RT, but not of manometry, was very high (97%). Gastrointestinal diagnoses were found in 57% of the patients. In conclusion, none of the applied oesophageal examinations are valuable as single screening tests. Both RT and manometry have low sensitivities. RT may be used as a cheap, noninvasive and rapid supplementary examination. When positive, it strongly supports further invasive studies of the oesophagus in non-AMI patients with unexplained chest pain.

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OBJECTIVE: The purpose of this investigation was to study the correlation between diagnostic delay and the stage of the lung cancer at the time of operation. A second objective was to study differences in symptoms between the patients grouped according to stage. METHODS: A total of 172 patients consecutively admitted for surgery between 1 January 1994 and 1 June 1995 at the Department of Thoracic and Cardiovascular Surgery of Rigshospitalet National Hospital of Denmark were included in the retrospective study. Two groups of patients were compared, one group with good prognosis (patients in Stages I and II) and one group with poor prognosis (patients in Stages III and IV). The time-spans studied were: (1) interval from the patient's perception of the first symptom to operation; and (2) the time from first contact with the healthcare-system to operation. The median delay between the patient-groups was compared using the Mann-Whitney U-test. To compare the symptoms which brought the patients in contact with the healthcare-system, the chi2-test was used. RESULTS: In the time interval between appearance of the first symptom and operation, a significantly shorter median delay was found for patients with Stages I and II compared to Stages III and IV (P = 0.037). Concerning the interval from first contact with the healthcare system to operation a significantly shorter median delay was found for the group of patients in Stage I and II compared to the patients-group in Stage III and IV (P = 0.017). It was found that the cancer was an accidental finding, significantly more often in patients in Stages I or II compared to patients in Stages III or IV (P = 0.0002). CONCLUSIONS: A few months delay before final treatment of a non-small-cell lung cancer seems to have an impact on the perioperative stage of the cancer, and thereby on the patients prognosis. A screening of asymptomatic risk-group patients will result in recognition of early lung cancer.

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OBJECTIVE: The purpose of this study was to describe the frequencies of various diagnoses in patients admitted with acute chest pain, but without acute myocardial infarction, and to evaluate a non-invasive screening programme for these patients. PATIENTS: A total of 204 consecutive non-acute myocardial infarction patients were included. Fifty-six had a definite diagnosis within 48 h, whereas 148 patients underwent an examination programme including pulmonary scintigraphy, echocardiography, exercise electrocardiography, myocardial scintigraphy, Holter monitoring, hyperventilation test, oesophago-gastro-duodenoscopy, 3 h monitoring of oesophageal pH, oesophageal manometry, Bernstein test, physical examination of the chest wall and thoracic spine, bronchial histamine provocation test and ultrasonic examination of the abdomen. RESULTS: According to predefined criteria, 186 patients (91%) had at least one diagnosis, 144 had one, whereas 39 had two, and three patients had three diagnoses. In 18 patients no diagnosis was obtained. The diagnoses belonged mainly to three groups: (1) ischaemic heart disease (n = 64); (2) gastro-oesophageal diseases (n = 85); (3) chest-wall syndromes (n = 58). Less frequent diagnoses included pulmonary embolism, pleuritis/pneumonia, lung cancer, aortic stenosis, aortic aneurysm and herpes zoster. CONCLUSIONS: The high risk subset of a non-acute myocardial infarction population can be identified by means of a clinical evaluation and non-invasive cardiac examinations. Among the remainder, pulmonary embolism, gastro-oesophageal diseases and chest-wall syndromes should be paid special attention. A careful physical examination of the chest wall and upper endoscopy seems to be the most cost-beneficial examination to employ in this subset.

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OBJECTIVE: To test our standard dosing regimen in omeprazole treatment of gastro-oesophageal reflux disease (GORD) and to determine whether 'non-responders' could be pinpointed. DESIGN: A reverse dose-response examination using increasing doses of omeprazole. The study was conducted as an open consecutive clinical study. Response was measured by 24-h pH-metry, symptoms, endoscopy and histopathology. SETTING: All patients had been referred to one of the partaking departments for evaluation of oesophageal reflux symptoms. PATIENTS: A total of 62 patients were included, 29 with systemic sclerosis and 33 consecutively included patients suffering from idiopathic oesophageal reflux. RESULTS: Approximately one-third of the patients required doses higher than 40 mg of omeprazole/day (up to 140 mg/day) to abolish GOR. No cases of tachyphylaxia or bile-induced oesophagitis were seen in this study. In all patients subjected to dose titration we were able to achieve healing of oesophagitis assessed by symptom scoring, endoscopy and histopathology. No prediction of final dose of omeprazole could be made. CONCLUSION: Four weeks after reaching a dose level of omeprazole that ensured the abolition of GOR, healing of oesophagitis according to endoscopic/histological evaluation was obtained in all patients. Persistent oesophagitis, i.e. bile induced, was not found.

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BACKGROUND AND AIMS: When routinely checking patients receiving omeprazole treatment for gastro-oesophageal reflux, we have been finding patients with surprisingly low nocturnal gastric pH. The aim of this study was to evaluate the impact of timing of the 40 mg omeprazole once daily regimen. METHODS: We evaluated the difference in effect of 40 mg omeprazole, given as a morning or evening dose, in 17 patients with gastro-oesophageal reflux disease. Gastric and oesophageal pH was recorded by portable 24-h two-channel pH-metry in a cross-over design of 14 days of morning and 14 days of evening administration. RESULTS: In five patients pathological reflux was abolished by both regimens, four only during morning dosage, and three only during evening dosage. In the remaining five patients abolition of pathological reflux was not achieved. The therapeutic outcome and patient preference for morning or evening administration were closely related to the individual oesophageal pH curves. Patients with reflux induced by physical activity had a clear preference for morning dosage, patients with nocturnal reflux showed a clear preference for evening dosage. Gastric pH profiles showed a high inter-individual variation; paired statistics, however, revealed a significant impact of dosage timing on the gastric pH profile. After morning dosage the work-day part (the first 7 h) of the gastric pH profile is 0.72 +/- 0.91 (mean difference of pairs +/- s.d.) higher than after evening dosage (P < 0.01). After evening dosage the gastric pH during the supine period is 0.64 +/- 0.83 (mean difference of pairs +/- s.d.) higher than after morning dosage (P = 0.02). CONCLUSION: The timing of a 40 mg omeprazole dosage regimen has a clinically significant impact on the 24-h pH profile, and that--by relating to the patient 24-hour oesophageal pH-metry in combination with the patient symptomatology--the timing of this dosage is highly important for therapeutic efficacy.

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A left lower lobe of the lung was transplanted from a mother to her child, who had previously received a maternal bone marrow transplant for an immune defect. Following the bone marrow transplantation, the child had developed severe pulmonary fibrosis. Surgery and the early postoperative course have been uncomplicated. Immunosuppression with corticosteroids was administered for a short period, after which all immunosuppressive treatment was discontinued. The operation and the outcome are described both in the donor and recipient. Rehabilitation was slow, but one year later the patient is doing well.

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The lower lobe of the left lung was transplanted from a mother to her child, who previously had received a bone marrow transplant from the mother because of an immune defect. After the bone marrow transplant the child had developed progressive pulmonary fibrosis (obliterative bronchiolitis). The surgical procedure and the early postoperative period has been uncomplicated. Immunosuppression with corticosteroids was only given for a short period, after which no immunosuppressive treatment has been given. The operation and results for both donor and recipient are described. The early results are promising, but rehabilitation is progressing slowly.

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Thirty-six heart-lung and lung transplantations have been performed in Denmark from January 1992 to January 1994. Heart-lung transplantations was initially carried out in patients with pulmonary vascular diseases. Single lung, double lung and heart-lung transplantation have become therapeutical alternatives and the indications have been expanded to terminal patients with pulmonary diseases. Careful selection of patients and donors, careful surgical techniques and a stringent immunosuppressive treatment have minimized the perioperative mortality. Daily lung function measurements, transbronchial biopsies and bronchoalveolar lavage have created possibilities for an early and safe diagnosis of infections and rejections. A high frequency of obliterative bronchiolitis with loss of pulmonary function is still a serious and unsolved problem. Intensive investigations with the aim of understanding, preventing and treating obliterative bronchiolitis are going on.

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Microemboli in the brain may inhibit brain function during cardiopulmonary bypass, and in a previous study in pigs of normothermic nonpulsatile bypass we reported a significant decrease in cerebral glucose consumption secondary to interruption of the capillary flow, possibly caused by microemboli. In the present study we measured the regional cerebral glucose consumption and the regional capillary diffusion capacity (that is, the number of perfused capillaries) in 10 different brain regions in two separate groups of animals with and without an arterial filter during normothermic cardiopulmonary bypass. Inclusion of a 40 micron arterial filter in the bypass circuit increased the regional brain glucose consumption 27% (median; range -12% to 145%) and regional capillary diffusion capacity increased 123% (median; range 36% to 829%). No change in brain histologic features, the cerebrovascular permeability to serum proteins, or cerebral water content was observed. The arterial filter probably protects the cerebral microcirculation and prevents the decrease in cerebral glucose consumption otherwise seen during bypass.

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Reduction of pump flow during cardiopulmonary bypass (CPB) reduces the formation of microemboli and trauma to the blood components, reduces both rewarming of the heart and the noncoronary collateral flow, and improves surgical exposure. Recent studies indicate that a reduction in pump flow, even at normothermia, does not increase the incidence of postoperative cerebral dysfunction. We examined the cerebral consequences of 2 h of normothermic CPB in pigs carried out at pump flows of either 70 ml/kg per min or 50 ml/kg per min, and compared the results with those of a nonperfused control group. We measured the regional cerebral glucose metabolism and the regional capillary diffusion capacity simultaneously in ten different brain regions. Brain morphology, the blood-brain barrier permeability to serum proteins and the regional cerebral water content were also determined in the same animals. Glucose metabolism decreased significantly in both CPB groups (P < 0.001), and significant differences were found between the capillary diffusion capacities of the three groups (P < 0.05), with decreases in eight out of ten brain regions examined in the 50 ml/kg per min group. The results indicate that a reduction of pump flows from 70 ml/kg per min to 50 ml/kg per min is deleterious to the brain, and that a pump flow of 70 ml/kg per min itself has an injurious effect, when normothermic CPB is carried out for 2 h without the use of vasoactive drugs to maintain the blood pressure. Mean arterial blood pressure (MAP) rather than pump flow seemed to determine the adequacy of the cerebral perfusion.

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In a follow-up study of 147 patients with achalasia of the esophagus treated by myotomy, 146 patients were traced (58 female and 88 male patients aged 4 to 83 years; median 46 years). The living persons were contacted in writing or by telephone. The mean follow-up time after the operation was 23.2 years (range, six to 41 years). The cause of death was established for 71 patients. There were three postoperative deaths and two deaths following recurrence. In comparison with the Danish population, the 66 remaining patients were found to have a relatively higher cancer mortality (34.9% percent). Contrary to the expected less than one, ten of 23 patients who died of cancer had a malignant tumor in the esophagus. The mortality rate after 30 years was 66.1 percent, 11.9 percent of the deaths caused by esophageal cancer. It is concluded that there is a connection between achalasia and cancer of the esophagus that ought to be considered in the treatment and follow-up of patients with achalasia.

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