Hemoglobin concentration and blood shift during dry static apnea in elite breath hold divers.

Introduction: Elite breath-hold divers (BHD) enduring apneas of more than 5 min are characterized by tolerance to arterial blood oxygen levels of 4.3 kPa and low oxygen-consumption in their hearts and skeletal muscles, similar to adult seals. Adult seals possess an adaptive higher hemoglobin-concentration and Bohr effect than pups, and when sedated, adult seals demonstrate a blood shift from the spleen towards the brain, lungs, and heart during apnea. We hypothesized these observations to be similar in human BHD. Therefore, we measured hemoglobin- and 2,3-biphosphoglycerate-concentrations in BHD (n = 11) and matched controls (n = 11) at rest, while myocardial mass, spleen and lower extremity volumes were assessed at rest and during apnea in BHD. Methods and results: After 4 min of apnea, left ventricular myocardial mass (LVMM) determined by 15O-H2O-PET/CT (n = 6) and cardiac MRI (n = 6), was unaltered compared to rest. During maximum apnea (∼6 min), lower extremity volume assessed by DXA-scan revealed a ∼268 mL decrease, and spleen volume, assessed by ultrasonography, decreased ∼102 mL. Compared to age, BMI and VO2max matched controls (n = 11), BHD had similar spleen sizes and 2,3- biphosphoglycerate-concentrations, but higher total hemoglobin-concentrations. Conclusion: Our results indicate: 1) Apnea training in BHD may increase hemoglobin concentration as an oxygen conserving adaptation similar to adult diving mammals. 2) The blood shift during dry apnea in BHD is 162% more from the lower extremities than from the spleen. 3) In contrast to the previous theory of the blood shift demonstrated in sedated adult seals, blood shift is not towards the heart during dry apnea in humans.

Extreme Hypoxia Causing Brady-Arrythmias During Apnea in Elite Breath-Hold Divers.

Introduction: The cardiac electrical conduction system is very sensitive to hypoglycemia and hypoxia, and the consequence may be brady-arrythmias. Weddell seals endure brady-arrythmias during their dives when desaturating to 3.2 kPa and elite breath-hold-divers (BHD), who share metabolic and cardiovascular adaptions including bradycardia with diving mammals, endure similar desaturation during maximum apnea. We hypothesized that hypoxia causes brady-arrythmias during maximum apnea in elite BHD. Hence, this study aimed to define the arterial blood glucose (Glu), peripheral saturation (SAT), heart rhythm (HR), and mean arterial blood pressure (MAP) of elite BHD during maximum apneas. Methods: HR was monitored with Direct-Current-Pads/ECG-lead-II and MAP and Glu from a radial arterial-catheter in nine BHD performing an immersed and head-down maximal static pool apnea after three warm-up apneas. SAT was monitored with a sensor on the neck of the subjects. On a separate day, a 12-lead-ECG-monitored maximum static apnea was repeated dry (n = 6). Results: During pool apnea of maximum duration (385 ± 70 s), SAT decreased from 99.6 ± 0.5 to 58.5 ± 5.5% (∼PaO2 4.8 ± 1.5 kPa, P < 0.001), while Glu increased from 5.8 ± 0.2 to 6.2 ± 0.2 mmol/l (P = 0.009). MAP increased from 103 ± 4 to 155 ± 6 mm Hg (P < 0.005). HR decreased to 46 ± 10 from 86 ± 14 beats/minute (P < 0.001). HR and MAP were unchanged after 3-4 min of apnea. During dry apnea (378 ± 31 s), HR decreased from 55 ± 4 to 40 ± 3 beats/minute (P = 0.031). Atrioventricular dissociation and junctional rhythm were observed both during pool and dry apneas. Conclusion: Our findings contrast with previous studies concluding that Glu decreases during apnea diving. We conclude during maximum apnea in elite BHD that (1) the diving reflex is maximized after 3-4 min, (2) increasing Glu may indicate lactate metabolism in accordance with our previous results, and (3) extreme hypoxia rather than hypoglycemia causes brady-arrythmias in elite BHD similar to diving mammals.

Cardiac hypoxic resistance and decreasing lactate during maximum apnea in elite breath hold divers.

Breath-hold divers (BHD) enduring apnea for more than 4 min are characterized by resistance to release of reactive oxygen species, reduced sensitivity to hypoxia, and low mitochondrial oxygen consumption in their skeletal muscles similar to northern elephant seals. The muscles and myocardium of harbor seals also exhibit metabolic adaptations including increased cardiac lactate-dehydrogenase-activity, exceeding their hypoxic limit. We hypothesized that the myocardium of BHD possesses similar adaptive mechanisms. During maximum apnea 15O-H2O-PET/CT (n = 6) revealed no myocardial perfusion deficits but increased myocardial blood flow (MBF). Cardiac MRI determined blood oxygen level dependence oxygenation (n = 8) after 4 min of apnea was unaltered compared to rest, whereas cine-MRI demonstrated increased left ventricular wall thickness (LVWT). Arterial blood gases were collected after warm-up and maximum apnea in a pool. At the end of the maximum pool apnea (5 min), arterial saturation decreased to 52%, and lactate decreased 20%. Our findings contrast with previous MR studies of BHD, that reported elevated cardiac troponins and decreased myocardial perfusion after 4 min of apnea. In conclusion, we demonstrated for the first time with 15O-H2O-PET/CT and MRI in elite BHD during maximum apnea, that MBF and LVWT increases while lactate decreases, indicating anaerobic/fat-based cardiac-metabolism similar to diving mammals.

Higher arterial pressure during cardiopulmonary bypass may not reduce the risk of acute kidney injury.

BACKGROUND: Acute kidney injury after cardiac surgery is common and associated with increased mortality. It is unknown whether an intended higher arterial pressure during cardiopulmonary bypass reduces the incidence of acute and chronic kidney injury. METHODS: Patients were randomised either to a control group or a high pressure group (arterial pressure > 60 mmHg). The inclusion criteria were age > 70 years, combined cardiac surgery and serum creatinine < 200 µmol/L. Glomerular filtration rate using the Cr-EDTA clearance method was measured the day before surgery and 4 months postoperatively. The RIFLE criteria were used to define the presence of acute kidney injury. In addition, the ratio between urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) and creatinine was measured. RESULTS: Ninety patients were included. Mean age was 76 ± 4 years and 76% were male. Mean arterial pressure was 47 ± 5 mmHg in the control group and 61 ± 4 mmHg in the high pressure group (p < 0.0001). The change in glomerular filtration rate at follow-up was - 9 ± 12 ml/min in the control group and - 5 ± 16 ml/min in the high pressure group (p = 0.288, 95% CI - 13 to 4). According to the RIFLE criteria 38% in the control group and 46% in the high pressure group developed acute kidney injury (p = 0.447). The postoperative urinary NGAL/creatinine ratio was comparable between the groups. CONCLUSIONS: An intended increase in arterial pressure during cardiopulmonary bypass to > 60 mmHg did not decrease the incidence of acute or chronic kidney injury after cardiac surgery. TRIAL REGISTRATION: Clinicaltrials.gov, identifier: NCT01408420 . Registered 3rd of August 2011.

Oxygen conserving mitochondrial adaptations in the skeletal muscles of breath hold divers.

BACKGROUND: The performance of elite breath hold divers (BHD) includes static breath hold for more than 11 minutes, swimming as far as 300 m, or going below 250 m in depth, all on a single breath of air. Diving mammals are adapted to sustain oxidative metabolism in hypoxic conditions through several metabolic adaptations, including improved capacity for oxygen transport and mitochondrial oxidative phosphorylation in skeletal muscle. It was hypothesized that similar adaptations characterized human BHD. Hence, the purpose of this study was to examine the capacity for oxidative metabolism in skeletal muscle of BHD compared to matched controls. METHODS: Biopsies were obtained from the lateral vastus of the femoral muscle from 8 Danish BHD and 8 non-diving controls (Judo athletes) matched for morphometry and whole body VO2max. High resolution respirometry was used to determine mitochondrial respiratory capacity and leak respiration with simultaneous measurement of mitochondrial H2O2 emission. Maximal citrate synthase (CS) and 3-hydroxyacyl CoA dehydrogenase (HAD) activity were measured in muscle tissue homogenates. Western Blotting was used to determine protein contents of respiratory complex I-V subunits and myoglobin in muscle tissue lysates. RESULTS: Muscle biopsies of BHD revealed lower mitochondrial leak respiration and electron transfer system (ETS) capacity and higher H2O2 emission during leak respiration than controls, with no differences in enzyme activities (CS and HAD) or protein content of mitochondrial complex subunits myoglobin, myosin heavy chain isoforms, markers of glucose metabolism and antioxidant enzymes. CONCLUSION: We demonstrated for the first time in humans, that the skeletal muscles of BHD are characterized by lower mitochondrial oxygen consumption both during low leak and high (ETS) respiration than matched controls. This supports previous observations of diving mammals demonstrating a lower aerobic mitochondrial capacity of the skeletal muscles as an oxygen conserving adaptation during prolonged dives.

Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature.

Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation. A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke. The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.

Are medical students being taught anatomy in a way that best prepares them to be a physician?

Reasoning in a clinical context is an attribute of medical expertise. Clinical reasoning in medical school can be encouraged by teaching basic science with a clinical emphasis. The aim of this study was to investigate whether anatomy is being taught in a way that facilitates the development of clinical reasoning. Two multiple-choice tests on thoracic anatomy were developed using a modified Delphi approach with groups of four clinical consultants and four teachers, respectively, expressing their opinions about knowledge relevant to thoracic anatomy. Validity was assessed by administering the tests to clinical consultants, anatomy teachers, and pre-course medical students. Post-course medical students took both tests to explore the focus of the course, i.e., whether it facilitated clinical reasoning. The pre-course students scored significantly lower than the teachers and post-course students on both tests and lower than the consultants on the consultants' test (P < 0.001 for all comparisons). The teachers significantly outperformed the consultants (P = 0.03 on the consultants' test, P < 0.001 on the teachers' test) and the medical students (P < 0.001 on both tests). The post-course students scored significantly lower on the consultants' test (P = 0.001) and significantly higher on the teachers' test (P = 0.02) than the consultants. This study demonstrates poor performances by medical students on a test containing clinically relevant anatomy, implying that the teaching they have received has not encouraged clinical reasoning.

Aortic valve bypass: experience from Denmark.

OBJECTIVES: In aortic valve bypass (AVB) a valve-containing conduit is connecting the apex of the left ventricle to the descending aorta. Candidates are patients with symptomatic aortic valve stenosis rejected for conventional aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI). During the last one and a half year, 10 patients otherwise left for medical therapy have been offered this procedure. We present the Danish experiences with the AVB procedure with a focus on patient selection, operative procedure and short-term results. METHODS: AVB is performed through a left thoracotomy. A 19-mm Freestyle(®) valve (Medtronic) is anastomosed to a vascular graft and an apex conduit. The anastomosis to the descending aorta is made prior to connecting the conduit to the apex. In 1 patient, we used an automated coring and apical connector insertion device (Correx(®)). The device results in a simultaneous coring and insertion of an 18-mm left ventricle connector in the apical myocardium. AVB is routinely performed without circulatory assistance. RESULTS: Ten patients have been operated on since April 2011: eight females and 2 males with a median age of 76 (65-91) years. Seven patients had a severely calcified ascending aorta. Three of these had previously had a sternotomy, but did not have an AVR because of porcelain aorta. Six patients had a very small left ventricle outflow tract (<18 mm). The median additive EuroSCORE was 12 (10-15). Seven patients were operated on without circulatory assistance. Two patients had a re-exploration for bleeding and 1 developed a ventricle septum defect 1 month postoperatively and was treated with surgical closure. The median follow-up was 7 (2-15) months and was without mortality. New York Heart Association class was reduced from 2.5 to 2 at the follow-up, but some patients were still in the recovery period. The total valve area (native plus conduit) was 2.2 (1.9-2.5) cm(2) and 1.34 (1.03-1.46) cm(2)/m(2), indexed to the body surface area. There was no AV block or stroke. CONCLUSIONS: AVB can be performed with low mortality and acceptable results in selected patients. The procedure can be offered to patients rejected for conventional aortic valve replacement and TAVI and results in a larger total valve area than by insertion of standard bioprosthesis.

Establishing pass/fail criteria for bronchoscopy performance.

BACKGROUND: Several tools have been created to assess competence in bronchoscopy. However, educational guidelines still use an arbitrary number of performed procedures to decide when basic competency is acquired. OBJECTIVES: The purpose of this study was to define pass/fail scores for two bronchoscopy assessment tools, and investigate how these scores relate to physicians' experience regarding the number of bronchoscopy procedures performed. METHODS: We studied two assessment tools and used two standard setting methods to create cut scores: the contrasting-groups method and the extended Angoff method. In the first we compared bronchoscopy performance scores of 14 novices with the scores of 14 experienced consultants to find the score that best discriminated between the two groups. In the second we asked an expert group of 7 experienced bronchoscopists to judge how a borderline trainee would perform on each item of the test. RESULTS: Using the contrasting-groups method we found a standard that would fail all novices and pass all consultants. A clear pass related to prior experience of 75 procedures. The consequences of using the extended Angoff method were also acceptable: all trainees who had performed less than 50 bronchoscopies failed the test and all consultants passed. A clear pass related to 80 procedures. CONCLUSIONS: Our proposed pass/fail scores for these two methods seem appropriate in terms of consequences. Prior experience with the performance of 75 and 80 bronchoscopies, respectively, seemed to ensure basic competency. In the future objective assessment tools could become an important aid in the certification of physicians performing bronchoscopies.

Reliable and valid assessment of clinical bronchoscopy performance.

BACKGROUND: There have been several attempts to systematically assess performance in bronchoscopy. Earlier validation studies have used bronchoscopy simulators, not real-life performance in patients. OBJECTIVES: The aim of this study was to explore the reliability and validity of an assessment tool aimed for the use in a clinical setting. METHODS: Five junior residents, 5 senior residents and 9 consultants performed 3 bronchoscopies each. All 57 bronchoscopies were video-recorded and assessed blindly and independently by two bronchoscopy experts using the new assessment tool. RESULTS: The interrater reliability was high, with Cronbach's α = 0.86. Assessment of 3 bronchoscopies by a single rater had a generalizability coefficient of 0.84. The correlation between experience and performance was good (Pearson correlation = 0.76). There were significant differences between the groups for all aspects of the assessment, but post hoc tests showed different discriminative abilities. CONCLUSIONS: This new tool for assessing clinical bronchoscopy performance has a high interrater reliability. One rater assessing performance of 3 bronchoscopies ensures sufficient reliability. The assessment tool demonstrated sufficient construct validity.

Using performance in multiple simulated scenarios to assess bronchoscopy skills.

BACKGROUND: International guidelines suggest that trainees should perform at least 100 flexible bronchoscopies in a supervised setting, but this number is not evidence based. An objective assessment method could provide educational feedback to trainees and help supervisors decide when basic competency is established. No former assessment instrument has been able to distinguish between trainees and experts. OBJECTIVES: The aim of this study was to explore the validity and reliability of a new assessment procedure relating to testing operators across multiple tasks with increasing difficulty using a standardized scoring form. METHODS: The test was administered on a virtual reality bronchoscopy simulator to a total of 42 test subjects (14 senior consultants, 14 trainees and 14 medical students). The inter-rater reliability of the test procedure was explored according to examination of test results from 10 subjects using 3 raters (2 blinded). RESULTS: We found a high inter-rater reliability (Cronbach's α = 0.90). The assessment procedure sufficiently differentiated the performance of the 3 groups (p < 0.001). Assessment of 6 procedures was necessary to secure a generalizability coefficient >0.80. CONCLUSIONS: The new assessment procedure proved both valid and reliable.

Virtual reality simulation of basic pulmonary procedures.

BACKGROUND: Virtual reality (VR) bronchoscopy simulators have been available for more than a decade, and have been recognized as an important aid in bronchoscopy training. The existing literature has only examined the role of VR simulators in diagnostic bronchoscopy. The aim of this study was to find out whether the simulations of both diagnostic bronchoscopies and more advanced procedures were realistic, and whether clinical experience in bronchoscopy was associated with better and faster performance of basic pulmonary procedures in the simulator. METHODS: Thirty physicians performed 8 procedures, each on a VR bronchoscopy simulator. They performed 3 diagnostic bronchoscopies, 2 bronchoalveolar lavages, and 3 procedures in which they used all the available biopsy tools (needle, brush, and forceps) that could be used for tumors of increasing procedural difficulty. After the procedures, the physicians answered a questionnaire regarding the realism of the simulator. RESULTS: The realism of the anatomy and the appearance of the scope were rated higher than the movement of the scope, feeling of resistance, and performances of bronchoalveolar lavages and biopsies. Overall, the simulator was judged to be realistic and all the physicians agreed that VR bronchoscopy simulation is a good way to learn bronchoscopy. The more experienced physicians performed faster than the less experienced physicians. The simulator feedback did not allow for an assessment of the quality of the performed biopsies. CONCLUSIONS: Simulation of performing the procedures was significantly less realistic than the simulation of the anatomy and the scope. It was impossible to use the simulator metrics to assess the quality of the biopsies. Despite these deficiencies, clinicians recommend the use of VR simulators in the teaching of pulmonary procedures.

When operable patients become inoperable: conversion of a surgical aortic valve replacement into transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a relatively new treatment option for inoperable patients with severe aortic stenosis (AS). This case describes how a planned conventional surgical aortic valve replacement (AVR) on a 73-year-old woman was successfully converted to a TAVI procedure. On extracorporal circulation it was reconized that the aortic annulus, the coronary ostiae and the proximal part of the ascending aorta were severely calcified making valve implantation impossible. Surgical closure without valve substitution was estimated to be associated with a high risk of mortality due to the imparied left ventricular function. Consequently, TAVI was performed with a CoreValve ReValving System prosthesis. The delivery of the valve prosthesis was made through the ascending part of aorta, proximal of the cannulation of aorta. Positioning of the valve prosthesis was made under visual guidance, and the prosthesis was sutured to the ascending aorta. With some manipulation of the prosthesis it was possible to suture the aorta circumferentially around the fully expanded upper part of the prosthesis. Post-procedurally the patient recovered successfully, with improved function capacity, aortic valve area and left ventricle function.

Revascularization compared to medical treatment in patients with silent vs. symptomatic residual ischemia after thrombolyzed myocardial infarction--the DANAMI study.

AIMS: The aim was to compare the effect of revascularization to conservative treatment in patients with residual silent and with residual symptomatic ischemia following acute myocardial infarction (AMI). The study was a subanalysis of the DANAMI (DANish AMI) randomized study of invasive vs. conservative treatment in patients with inducible ischemia after thrombolysis in AMI. METHODS AND RESULTS: One thousand and eight patients were randomized to invasive or conservative treatment, stratified by the type of ischemia: silent, i.e. ST depression during an exercise test prior to discharge in 56%, or symptomatic, i.e. chest pain occurring either spontaneously during admission or during the exercise test, with or without ST changes, in 44%. Compared to a conservative strategy, invasive treatment reduced the incidence of nonfatal reinfarction, after in median 2.4 years, in both symptomatic patients (13.3-7.2%, p < 0.006) and patients with silent ischemia (10.1 vs. 5.7%, p < 0.05), and of admissions with unstable angina in symptomatic (44.5-27.6%, p < 0.0001) and silent ischemia (21.6-13.3%, p < 0.0006). CONCLUSIONS: Compared to conservative strategy, invasive treatment reduces the risk of nonfatal reinfarction and hospital admissions for unstable angina in thrombolyzed post-AMI patients with silent as well as symptomatic exercise-induced ischemia.

Metabolism of perfused pig intercostal muscles evaluated by 31P-magnetic resonance spectroscopy.

This study presents a perfused preparation for evaluation of metabolism in pig intercostal muscle in vitro. Preserved vessels and nerves to an intercostal segment including two adjacent ribs allowed for tissue perfusion and electrical stimulation with measurement of contraction force, oxygen consumption and 31P-magnetic resonance spectroscopy (31P-MRS). When perfused at rest with Krebs-Ringer buffer, the preparation maintained physiological levels of phosphocreatine (PCr), inorganic phosphate (Pi), ATP and pH at a stable oxygen consumption of 0.51 +/- 0.01 micromol min(-1) g(-1) for more than 2 h. Tonic stimulation of the nerve caused anaerobic energy consumption as PCr and pH decreased, and both variables recovered after the contraction with half-time values of approximately 7 min. Force increased to 0.040 N g(-1) (range, 0.031-0.103 N g(-1)) and it gradually decreased by about 70% during the subsequent 5 min of stimulation. The calculated free ADP concentration increased from 7.4 +/- 2.1 nmol g(-1) at rest to 28 +/- 12 nmol g(-1) (mean +/- s.d.) by the end of the stimulation. Thus anaerobic ATP turnover was zero at rest, 6.1 +/- 2 micromol min(-1) g(-1) during the first minute of stimulation and 3.5 +/- 0.5 micromol min(-1) g(-1) during the two last minutes, corresponding to the drop in force. When the preparation was left unperfused, anaerobic ATP turnover averaged 0.40 +/- 0.15 micromol min(-1) g(-1) for the first 10 min. The preparation can also be applied to human intercostal muscles, as demonstrated in one preliminary experiment. The results demonstrate a stable and functional in vitro preparation of intact perfused intercostal muscles in the pig.

The incidence of acute cellular rejection after lung transplantation: a comparative study of anti-thymocyte globulin and daclizumab.

OBJECTIVE: This study examined the effects of anti-thymocyte globulin (ATG) and daclizumab immunosuppressive induction therapy on the frequency and severity of acute cellular rejection in lung transplantation patients. METHOD: A retrospective analysis was conducted of 335 lung transplantation patients from a single center in the period 1992 to 2003. Patients completed standard ATG (Merieux, 2.5 mg/kg/day, or ATGAM, 12.5 mg/kg/day, for 3 consecutive days) (n = 151) or daclizumab (5 fortnightly treatments at a dose of 1 mg/kg) (n = 151) induction therapy. End points included acute cellular rejection requiring treatment (> or = A2), and moderate/severe acute cellular rejection (A3/A4). RESULTS: The percentage of patients free of rejection requiring treatment (< A2) was 32% at 3 months and 26% at 2 years after transplantation in the ATG group and 9% and 0%, respectively, in the daclizumab group (p < 0.0001). Compared with the ATG group, a significantly higher proportion of patients in the daclizumab group experienced 3 or more episodes of acute cellular rejection > or = A2 during the first 3 months (p < 0.0001) and the entire 2-year follow-up (p < 0.0001). The daclizumab group also experienced more moderate/severe acute cellular rejection episodes compared with the ATG group during the first 3 months (p = 0.005). Cox regression analysis demonstrated ATG induction therapy was independently associated with a significantly longer duration of freedom from acute cellular rejection requiring treatment (> or = A2) (p < 0.001). CONCLUSION: After lung transplantation, ATG induction appears to be superior to daclizumab induction in the reduction in the incidence and severity of acute cellular rejection.

The Copenhagen National Lung Transplant Group: survival after single lung, double lung, and heart-lung transplantation.

OBJECTIVE: To review the 13-year clinical experience of a single center's adult lung transplantation program. METHODS: From January 1992 to December 2003, 369 lung transplantations were performed on 362 patients. Single lung transplantation was performed in 234 cases, double lung transplantation in 113 cases (comprising en-bloc double lung transplantation in 44 cases and bilateral sequential lung transplantation in 69 cases), heart-lung transplantation in 21 cases, and lobe of lung transplantation in 1 case. Recipient diagnoses included chronic obstructive pulmonary disease (COPD) (n = 175), alpha1 antitrypsin (alpha1AT) deficiency (n = 86), cystic fibrosis (n = 36), pulmonary fibrosis (n = 20), Eisenmenger syndrome and secondary pulmonary hypertension (n = 24), primary pulmonary hypertension (n = 8), sarcoidosis (n = 7), silicosis (n = 4), bronchiectasis (n = 1), and graft-vs-host disease (n = 1). RESULTS: For patients surviving to discharge, the median duration of the intensive care unit stay was 3 days (1-67), and the median duration of the post-operative hospital stay was 37 days (16-144). Mortality for the entire series was 6% at 30 days and 10% at 90 days. The main causes of post-operative inpatient death were primary graft failure (41%), sepsis (29%), cardiac (15%), and hemorrhage (9%). The 1-, 3-, 5-, and 10-year actuarial survival rates for the entire series was 81%, 68%, 63%, and 36%, respectively. There were no significant differences in survival between types of transplant. No significant differences in survival were seen between alpha(1)AT deficiency and COPD patients after stratifying for age. Cox regression analysis demonstrated that age 60 years or older, donor age 50 years or older, and a recipient pre-operative body mass index of 25 or higher were independent predictors of poor survival. CONCLUSIONS: This center has 1-, 3-, and 5-year survival rates comparable to other high volume centers. Recipient age, pre-operative body mass index, and donor age significantly influence outcome after lung transplantation.

[Radical surgical resection of leiomyosarcoma of the inferior vena cava with intracardial tumour growth]. / Kirurgisk radikal resektion af leiomyosarkom i retrohepatiske vena cava med intrakardial tumortrombosering.

Sarcoma of the inferior vena cava (IVC) is a rare clinical entity. Surgical treatment of IVC is associated with improved survival. This case report describes a 42-year-old woman with biopsy-proven leiomyosarcoma of the inferior vena cava with intracardial tumour growth. The primary tumour was only 1 x 1 cm in the wall of the vena cava while the intracaval tumour was 12 cm long with a diameter of 5 cm and 1.5 cm in the right atrium. Using venovenous bypass with circulatory support, the tumour was excised in toto and the caval vein closed with a pericardial patch. The patient was discharged in good condition after 19 days.