Graft control by transit time flow measurement and intraoperative angiography in coronary artery bypass surgery.

BACKGROUND: The aim of this study was to compare the relationship between intraoperative transit time flow measurements and angiographic findings with long-term graft patency in 72 patients who underwent coronary artery bypass surgery. METHODS: Transit time flow measurements with recording of mean flow and pulsatility indexes were performed after completion of the anastomoses. Coronary angiography was performed on-table while the patients were still in general anesthesia, and then at follow-up three months and 12 months after surgery. Based on angiography, the grafts were graded as type A (fully patent), type B (having more than 50% diameter reduction), or type O (occluded). RESULTS: Of the 67 left internal mammary artery (LIMA) grafts, 51 (76%) were type A on-table, 14 (21%) were type B, and two (3%) were type O. Of the 57 saphenous vein grafts, 49 (86%) were type A, 7 (12%) were type B, and one (2%) was type O. For both LIMA and vein grafts, there were no differences in flow (p = 0.69 and 0.47, respectively) or pulsatility index (p = 0.79 and 0.83) between type A and B. There were also no differences in flow (p = 0.37 and 0.7) or pulsatility index (p = 0.37 and 0.24) between type B on-table that either normalized or persisted occluded at the follow-up. Transit time flow measurement failed to detect an occluded LIMA graft as shown by intraoperative angiography. CONCLUSIONS: Blood flow measurements performed intraoperatively could not identify significant lesions in arterial or vein grafts, and could not predict graft patency. We have become cautious in interpreting flow measurements alone and combine blood flow recordings with intraoperative angiography in the assessment of graft quality.

[Immunomodulating treatment in advanced heart failure--effect of intravenous immunoglobulin]. / Immunmodulerende behandling ved avansert hjertesvikt--effekt av intravenøs immunglobulin.

BACKGROUND: Congestive heart failure is characterised by enhanced immune activation. Immune-mediated mechanisms may play a pathogenic role, hence the growing interest in therapeutic regimens that could modulate the immune response in heart failure. MATERIAL AND METHODS: In the present report we discuss the pathogenic role of immunological and inflammatory mediators in the pathophysiology of heart failure and discuss different treatment modalities with focus on our recent study with intravenous immunoglobulin. In that study 40 patients with symptomatic chronic heart failure and left ventricular ejection fraction (LVEF) < 40% were randomised in a double-blind fashion to receive therapy with immunoglobulin or placebo for a total period of 26 weeks. RESULTS: We found that intravenous immunoglobulin, but not placebo, shifted the cytokine balance in an anti-inflammatory direction, and that such a shift was associated with improvement in LVEF by 5 EF units. Functional capacity and haemodynamic variables also improved. INTERPRETATION: Our study supports the hypothesis that immunological variables might be of significant importance in the pathogenesis of heart failure and it suggests a potential for immunomodulating therapy in addition to optimal conventional cardiovascular treatment regimens in such patients. These issues are further discussed in the present article.

Immunomodulating therapy with intravenous immunoglobulin in patients with chronic heart failure.

BACKGROUND: Congestive heart failure (CHF) is characterized by enhanced immune activation, and immune-mediated mechanisms may play a pathogenic role in this disorder. Based on the immunomodulatory effects of intravenous immunoglobulin (IVIG), we hypothesized that IVIG could downregulate inflammatory responses in CHF patients and have potential beneficial effects on the left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Forty patients with chronic symptomatic CHF and LVEF of <40%, stratified according to cause (ie, ischemic and idiopathic dilated cardiomyopathy), were randomized in a double-blind fashion to receive therapy with IVIG or placebo for a total period of 26 weeks. Our main findings were that (1) IVIG, but not placebo, induced a marked rise in plasma levels of the anti-inflammatory mediators interleukin (IL)-10, IL-1 receptor antagonist, and soluble tumor necrosis factor receptors; (2) significantly correlated with these anti-inflammatory effects, IVIG, but not placebo, induced a significant increase in LVEF from 26+/-2% to 31+/-3% (P:<0.01), and this was found independent of the cause of heart failure; and (3) N-terminal pro-atrial natriuretic peptide decreased significantly after induction therapy and continued to decrease toward the end of study during IVIG therapy (P:<0.001) but remained unchanged during placebo. CONCLUSIONS: We demonstrated an IVIG-induced change in the balance between inflammatory and anti-inflammatory cytokines that favored an anti-inflammatory net effect in CHF. This effect was significantly correlated with an improvement in LVEF, suggesting a potential for immunomodulating therapy in addition to optimal conventional cardiovascular treatment regimens in CHF patients.

Duration of preoperative electrocardiographic QRS complex and the incidence of heart arrest after aorto coronary bypass surgery.

Sudden heart arrest (HA) in the early phase after aorto coronary bypass surgery represents a serious event necessitating resuscitation, and for those who survive usually also an extra stay in the coronary care unit. Since such episodes of heart standstill may be related to conduction defects, a study was conducted to determine whether the duration of the QRS complex on the preoperative ECG is a marker for this morbid event. A cohort of 1011 consecutive patients operated on between 1982 and 1986 and followed to January 1st, 1993 were included in the study. Incidence of lethal or non-lethal HA during the first 4 weeks after surgery was considered as the primary endpoint and total mortality as the secondary endpoint. The incidence of HA was 40/1011 = 4%, with the majority of events (60%) being lethal. Independent risk factors of HA using the multivariate logistic model were previous coronary artery bypass surgery, presence of mitral regurgitation, left ventricular ejection fraction and the intraoperative cross-clamp time of aorta. Adjusting for the effect of confounder variables showed that the gradient effect of QRS complex duration on the endpoint HA was still present (p = 0.012). The duration of the QRS complex taken from the preoperative ECG had a gradient effect on the incidence of HA. With a baseline level of QRS <70 ms, the following odds ratios (OR) for HA were found: OR = 1.38 (95% CI 0.60-3.31) for QRS 70-80 ms; OR = 2.27 (95% CI 0.87-5.90) for QRS >90-120 ms; and OR = 3.38 (95% CI 1.06-11.50) for QRS > 120 ms, when adjusting for the risk factors. Cumulative survival at 5 years after surgery was 28+/-7.1% for patients experiencing HA versus 87+/-1.2% for patients free from this event. Our results underline the importance of the QRS complex duration as a preoperative marker for HA after aorta coronary bypass surgery, when adjusting for other risk factors. Although the one-year survival is poor for patients experiencing HA, there is no increase in mortality during the late follow-up.

[Coronary surgery at the Heart Center in Oslo 1989-98]. / Koronarkirurgi ved Hjertesenteret i Oslo 1989-98.

BACKGROUND: Coronary artery bypass grafting was performed in 5,658 consecutive patients during the period 1989-1998. Due to changes over time, both in patients' risk profile and surgical strategies, a review was undertaken to study trends and results after coronary artery bypass surgery. MATERIAL AND METHODS: Our database includes more than 160 variables per patient, covering preoperative risk factors, catheterization data, operative and postoperative results. These data form the basis for analysis over time. RESULTS: Median age increased for both genders, from 58 years to 64 years for males and 62.5 years to 69 years for females. The female proportion increased from 12.8% to 19.8%. A high operative risk profile was registered in 23.7% in 1989 compared to 61.8% in 1998. Heparin-coated extracorporeal equipment and blood cardioplegia were gradually introduced in routine practice. Despite higher age and operative risk profile the morbidity and hospital mortality (0.41% overall) remained nearly unchanged. INTERPRETATION: Due to continuous improvement of technical equipment and treatment strategies, coronary artery bypass surgery represents a safe option for both high and low risk patients.

Fasting blood glucose: an underestimated risk factor for cardiovascular death. Results from a 22-year follow-up of healthy nondiabetic men.

OBJECTIVE: Because of the available conflicting epidemiological data, we investigated the possible impact of fasting blood glucose as a risk factor for cardiovascular death in nondiabetic men. This study reports the results from a 22-year prospective study on fasting blood glucose as a predictor of cardiovascular death. RESEARCH DESIGN AND METHODS: Of the 1,998 apparently healthy nondiabetic men (aged 40-59 years), a total of 1,973 with fasting blood glucose < 110 mg/dl were included in the study in which also a number of conventional risk factors were measured at baseline. RESULTS: After 22 years of follow-up, 483 men had died, 53% from cardiovascular diseases. After dividing men into quartiles of fasting blood glucose level, it was found that men in the highest glucose quartile (fasting blood glucose > 85 mg/dl) had a significantly higher mortality rate from cardiovascular diseases compared with those in the three lowest quartiles. Even after adjusting for age, smoking habits, serum lipids, blood pressure, forced expiratory volume in 1 s, and physical fitness (Cox model), the relative risk of cardiovascular death for men with fasting blood glucose > 85 mg/dl remained 1.4 (95% CI 1.04-1.8). Noncardiovascular deaths were unrelated to fasting blood glucose level. CONCLUSIONS: Fasting blood glucose values in the upper normal range appears to be an important independent predictor of cardiovascular death in nondiabetic apparently healthy middle-aged men.

[Mortality, recurrent angina pectoris and late myocardial infarction in patients surgically treated for coronary heart disease]. / Dødelighet, tilbakefall av angina pectoris og seninfarkt hos pasienter operert for koronar hjertesykdom.

This cohort study includes 1,025 patients operated between 1982 and 1986 at Rikshospitalet, the National Hospital of Norway, 912 men and 113 women. The closing date was 1 January 1993. A total of 31 patients (3%) died within 30 days of operation. Independent risk factors were atrial fibrillation, previous heart surgery, mitral insufficiency, left main stem stenosis, unstable angina pectoris and elevated end-diastolic pressure. Among the 164 patients (16%) who died more than 30 days after operation, the independent risk factors of total mortality were atrial fibrillation, concomitant resection of left ventricular aneurysm, left main stem stenosis, NYHA functional class IV on admission, elevated end-diastolic pressure and prolonged cross-clamping time. Recurrent angina pectoris was experienced by 146 patients (14.2%) while 102 patients had non-fatal myocardial infarction. The cumulative incidence of these conditions was initially low, but began to increase four year after operation. The independent risk factor for these two end-points was hypertension. The study suggests that stratification of independent risk factors facilitates comparison of mortality in different centres and permits improved quality control.

[Mortality and morbidity after coronary bypass surgery in high-risk patients]. / Dødelighet og sykelighet etter koronar bypasskirurgi hos høyrisikopasienter.

A total of 113 women and 912 men were submitted to coronary artery bypass surgery at Surgical Department A, Rikshospitalet between August 1982 and December 1986 and followed till January 1993. We found no difference in early mortality, recurrent angina pectoris or non-fatal myocardial infarction in diabetic patients compared to nondiabetic patients. However, total mortality was 1.87 times higher in the diabetic group. For patients with ejection fraction < or = 40%, early mortality was 10.2 times higher than for the reference group. For total mortality we found a practically linear relationship between increased mortality and falling ejection fraction values. We found no relationship between ejection fraction and recurrent angina and non-fatal myocardial infarction, neither did we find any difference in mortality and morbidity between women and men. Although a somewhat higher mortality and morbidity rate must be expected for high-risk patients, they seem to profit to the same extent from the favourable effects of coronary bypass surgery as other patients.

Coronary artery bypass surgery in women and in men; early and long-term results. A study of the Norwegian population adjusted by age and sex.

OBJECTIVE: We wished to analyse early mortality, postoperative low-output syndrome needing intra-aortic balloon pumping support (IABP), total mortality, recurrent angina pectoris and total non-fatal myocardial infarction in women compared with men. Also, the standard mortality ratio (SMR) was estimated to compare the mortality data to the general Norwegian population of comparable sex and age. METHODS: A total of 1025 patients; 113 women and 912 men, were submitted to coronary artery bypass surgery at Rikshospitalet, Oslo between August 1982 and December 1986. The patients were followed up until the 1st of January 1993, representing a mean follow-up time of 7.4 years. An exposed/non-exposed cohort study design was used. A power study was carried out. The standardized mortality ratios for women and men were calculated after adjusting for age and sex. RESULTS: Crude odds ratio (ORC) of early mortality was 2.0 with a 95% confidence limit (CL95%) of 0.7-5.4. Odds ratio of low output syndrome needing intra-aortic balloon support was 1.7 (CL95% = 0.8-4.2). Statistical significance was not achieved for these end-points. Women did not run an increased hazard of total mortality (ORC = 0.9; CL95% = 0.5-1.5), recurrent angina pectoris (ORC = 1.4; CL95% = 0.8-2.4) or of total non-fatal myocardial infarction (ORC = 0.8; CL95% = 0.4-1.6) when compared with men. Adjusting for confounders did not significantly alter the results. When matched on sex and age and compared to the normal Norwegian population, we found an increased SMR in both men (2.5; CL95% = 2.2-2.9) and women (4.1; CL95% = 2.2-4.9). CONCLUSION: The risk of early mortality and low-output syndrome needing intra-aortic balloon support tended to be higher in women compared with men. Women did not run an increased risk of total mortality, recurrent angina or of total non-fatal myocardial infarction. The standard mortality ratio was increased in both men and women, but in particular higher in women, suggesting a more aggressive course of coronary artery disease in operated women than in operated men. However, this difference did not show in the long term follow-up, due to the beneficial effect of coronary artery bypass surgery in both men and women.

Fifteen-year experience with the medtronic-hall valve prosthesis. A follow-up study of 1104 consecutive patients.

BACKGROUND: The Medtronic-Hall valvular prosthesis was used for the first time in Oslo, Norway, in June 1977. During the 10-year period from 1977 through 1987, the valve was the valve of choice in Oslo and was implanted in a total of 1104 consecutive patients with mean age of 56 years. There were 816 aortic (AVR), 187 mitral (MVR), and 101 combined mitral and aortic (DVR) valve replacements. METHODS AND RESULTS: We report our 15-year experience with this prosthesis in a total of 1090 patients (98.7% complete follow-up). The observation time ranged from 7 to 17.8 years (mean, 9.2 years), with cumulative follow-up representing 10016 patient-years. Actuarial survival, including both early and late deaths, was 46% after AVR, 42% after MVR, and 28% after DVR. Thromboembolism occurred at linearized rates of 1.8%, 1.9%, and 1.9% per patient-year after AVR, MVR, and DVR, respectively. There were eight cases of valvular thrombosis, one fatal, resulting in linearized rates of 0.05%, 0.19%, and 0.13% per patient-year after AVR, MVR, and DVR, respectively. There were no instances of structural valve failure. Morbidity from anticoagulant-related hemorrhage was 1.19% per patient-year, with seven fatal events, all of cerebral origin. CONCLUSIONS: Excellent long-term outcomes were confirmed for patients, with 80% of survivors in New York Heart Association class I or II.

Mortality and morbidity after coronary artery bypass surgery related to pre-operative left ventricular ejection fraction: a follow-up study.

OBJECTIVE: To study the pre-operative level of left ventricular ejection fraction that may be indicative of an increased risk of early and late mortality and of recurrent angina pectoris and late non-fatal myocardial infarction. MATERIAL AND METHODS: A total of 934 patients with known left ventricular ejection fraction, 80 women and 854 men, were submitted to coronary artery bypass grafting at the Cardiovascular Unit of Rikshospitalet, Oslo, between August 1982 and December 1986. The closing date was the 1st of January 1993, with a mean follow-up of time of 7.4 years. The patients were divided in to four subgroups according to their level of left ventricular ejection fraction: < or = 40%, 41-60%, 61-80% and > 80%. The left ventricular ejection fraction varied from 13-98%. A chi-square test of linear trend was used to calculate the relative risk between the different subgroups. Cumulative survival was determined using survival curves. RESULTS: Early mortality. Twenty-five patients (2.7%) died within 30 days of operation. Patients with left ventricular ejection fraction < or = 40% had a relative risk of 10.2 (1.9-17.2), for left ventricular ejection fraction 41-60% the relative risk was 0.9 (0.1-8.9) and for left ventricular ejection fraction 61-80% the relative risk was 2.8 (0.6-17.2). Left ventricular ejection fraction > 80% was defined as relative risk = 1. Late mortality. Altogether, 174 patients died in the late phase (18.6%). For patients with left ventricular ejection fraction < or = 40% the relative risk was 3.6 (2.8-10.9), for left ventricular ejection fraction 41-60% the relative risk was 1.8 (1.1-3.6), and for left ventricular ejection fraction 61-80% the relative risk was 1.5 (0.9-2.8). Recurrent angina pectoris. A total of 138 patients developed recurrent angina pectoris during the follow-up period, giving an incidence of 14.8%. Here, for left ventricular ejection fraction < or = 40% the relative risk was 0.5 (0.2-1.3), for left ventricular ejection fraction 41-60% the relative risk was 1.0 (0.5-1.8) and for left ventricular ejection fraction 61-80% the relative risk was 1.2 (0.7-2.0). Late non-fatal myocardial infarction. Altogether, 90 patients (9.6%) experienced non-fatal myocardial infarction in the late phase. For left ventricular ejection fraction < or = 40% the relative risk was 0.6 (1.2-1.8), for left ventricular ejection fraction 41-60% the relative risk was 1.0 (0.5-2.0) and for left ventricular ejection fraction 61-80% the relative risk was 0.7 (0.41-1.3). Cumulative survival. When pooled together, the cumulative survival for patients with left ventricular ejection fraction > 40% was 95.9, 91.9 and 79% after 1, 5 and 10 years, respectively. For the patients with left ventricular ejection fraction < or = 40% cumulative survival was 87.5, 73.1 and 55.2%, respectively. CONCLUSION: When the left ventricular ejection fraction was 40% or lower, there was a substantial increase in the risk of early mortality in patients submitted to coronary artery bypass grafting. As for the risk of late mortality, there was a practically linear increase in risk with falling values of left ventricular ejection fraction. We found no difference in risk of developing recurrent angina pectoris or of late non-fatal myocardial infarction related to values of left ventricular ejection fraction.

[Cardiology education in Norway--does it keep up with the needs?]. / Kardiologutdanningen i Norge--holder den tritt med behovet?

Despite an increase in the number of education positions for cardiologists in Norway in the late 1980s, there is felt to be a marked lack of sub-specialists in cardiology in most types of hospitals. A working group under the Norwegian Society of Cardiology has used a questionnaire in 1993, membership data from the Norwegian Society of Cardiology in 1994, a telephone query to all hospitals in the country, and data from the Norwegian Medical Association in 1995 to examine this apparent lack of specialists and the potentials for educating them. We were able to confirm a current lack of approximately 60 cardiologists. In addition, the capacity for education has been reduced and will not compensate for the predicted retirement of specialists from approximately year 2000. The capacity for educating cardiologists must be increased.

Diabetes mellitus and morbidity and mortality risks after coronary artery bypass surgery.

Of 1025 patients (912 men, 113 women) who underwent coronary artery bypass grafting and were followed up for a mean of 7.4 years, 45 (4.4%) had diabetes mellitus. Norwegian population is 1.8-2%). Early mortality was not significantly greater among diabetics than in non-diabetics (2.2 vs. 3.1%, odds ratio--OR-0.44, confidence interval--CI- 0.05-3.56). Diabetic patients had no increased risk of perioperative myocardial infarction (OR = 0.87, CI 0.36-2.10) or of low-output syndrome necessitating intraortic balloon pumping (OR = 0.42, CI 0.55-3.05), and no excess incidence of late non-fatal myocardial infarction (relative risk = 0.69, CI 0.10-1.28) or late chronic heart failure (OR = 2.50, CI 0.5-11.0). Long-term mortality was increased in the diabetic patients (relative risk 1.87, CI 1.60-2.14). Thus diabetes did not entail heightened risk of early mortality, perioperative myocardial infarction or low-output syndrome. Nor was there excess risk of recurrent angina pectoris, late non-fatal myocardial infarction or chronic heart failure among the diabetic patients, but the late mortality risk was increased.

Risk factors of recurrent angina pectoris and of non-fatal myocardial infarction after coronary artery bypass surgery.

The long-term results of 1025 patients, 912 men and 113 women, undergoing coronary artery bypass grafting (CABG) at the Cardiovascular Unit of Rikshospitalet, Oslo, between 1982 and 1986, were analyzed on factors associated with the return of angina pectoris and of non-fatal post CABG myocardial infarction. The closing date was 1st January 1993, with a mean follow-up time of 7.4 years. Recurrent angina pectoris was experienced by 118 (11.6%) patients and 102 (10%) patients experienced non-fatal post CABG myocardial infarction during the observation period. Altogether 30 possible risk factors were analyzed. The cumulative incidence of recurrent angina was initially low after operation, followed by a rise after 4 years. One, 5 and 10 years after the operation, survival free from angina rates were 97.8%, 91.8% and 80.6%, respectively. The cumulative incidence of post CABG myocardial infarction was also low initially, followed by a rise after 4 years. The survival free of non-fatal post CABG myocardial infarction rate was 98.9%, 96% and 83.5%, at 1, 5 and 10 years after surgery, respectively. The incremental risk factor of recurrent angina pectoris was hypertension. The independent risk factors of non-fatal post CABG myocardial infarction were hypertension and preoperative stenosis of the left-sided, versus right-sided, coronary arteries. The study emphasizes the favorable effect of coronary bypass surgery on the functional outcome in patients with symptomatic coronary artery disease.

Risk factors for early and late mortality in surgical treatment of coronary artery disease.

A total of 1025 patients who had coronary bypass surgery at the Surgical Department A, Rikshospitalet, Oslo, between 1982 and 1986, were analysed for factors associated with early mortality and long-term survival. The cumulative follow-up time accounted for 6553 patient-years; the median follow-up was 6.45 years and ranged from the day of admission to 10 years. In total, 31 patients (3%) died within 30 days of surgery. Some 30 possible risk factors were analysed. Univariate analysis followed by a multivariate analysis defined six independent risk factors for early mortality. These were lack of sinus rhythm, previous heart surgery, mitral regurgitation, left main stem stenosis, unstable angina, and an elevated left ventricular end-diastolic pressure. Estimation of attributable risk showed that these factors could identify all patients who died early. Independent risk factors for late death were: lack of sinus rhythm, resection of a left ventricular aneurysm, left main stem stenosis, New York Heart Association (NYHA) class IV on admission, an elevated end-diastolic pressure, and prolonged cross-clamping time. The attributable risk analysis showed that independent risk factors for total mortality explained only about half of the patients who died. This appeared to be because of the competing effect of non-cardiac mortality. Results of the study show that risk factors for early mortality are good indicators for the outcome of coronary artery bypass surgery, identifying all deaths, whereas long-term mortality cannot be predicted. Stratification of independent risk factors allows a better comparison of mortality in different centres, and also better quality control of bypass surgery.

Cardiac manifestations in mid-gut carcinoid disease.

The extent of heart disease and its relationship to the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA), was studied with M-mode, 2D and Doppler echocardiography in 42 consecutive patients, 30 females and 12 males, median age 63 (range 23-75) years with histologically verified mid-gut tumour, liver metastases and 24-h urinary 5-HIAA excretion above 47 mumol.24 h-1. All patients had normal left ventricular ejection fractions, median 65% (interquartile range (IQR) 54-74%). Moderate to severe tricuspid regurgitation (TR) was diagnosed in 22 patients (59%); mitral or aortic regurgitation was found in nine (24%) and six (16%) patients, respectively. The mitral flow peak early (E) on late (A) velocity ratio was significantly decreased compared to age-matched normal subjects. The group of patients with 5-HIAA excretion exceeding 1000 mumol.24h-1 contained significantly more patients with severe TR than those with a lower excretion. The decrease in the E/A ratio may indicate reduced left ventricular compliance, possibly secondary to fibrous changes similar to those seen intra-abdominally and in the right side of the heart. As serotonin is degraded in the lung circulation, other mediators such as tachykinins and cytokines (PDGF) may be involved.

Increasing incidence of ventricular septal defects caused by improved detection rate.

In a population-based study in children born alive during the 10-year period from 1982 to 1991 (n = 22,810), ventricular septal defects (VSDs) were diagnosed in 127 cases, an incidence of 5.6 per 1000. The incidence was significantly higher in the cohort of children born during the 6-year period from 1986 to 1991 than among those born in the preceding 4-year period, 1982-1985 (6.5 and 4.0 per 1000 respectively; p < 0.05). The increase was caused entirely by an increased detection rate of small defects in the muscular part of the interventricular septum after introducing echocardiography as a standard method for investigating suspect congenital heart defects in the neonatal period. This also explained entirely an increase in the total incidence of congenital heart defects to 10.6 per 1000 in the last period from 8.4 per 1000 in the first, although this increase was not significant (p > 0.05). More children born in 1986-1991 had spontaneous closure of their VSDs (75.5%) than those born in 1982-1985 (51.5%) (p < 0.05). In 69.3% of patients the VSDs closed during the first year of life. For the cohort born in 1986-1991, 84.6% of the defects located in the muscular part of the septum closed spontaneously. Small defects in the muscular part of the interventricular septum with spontaneous closure in early life may represent the tail of a normal developmental process, and not defects in the sense of malformations.

Studies on the elimination of bilirubin pre-operatively in patients with mitral valve disease.

This study looked at the hypothesis that patients with mitral valve disease have a reduced capacity to eliminate bilirubin prior to surgery for valve implantation. Radiolabelled bilirubin was administered as a bolus and as a steady state i.v. infusion so that its incorporation into plasma bilirubin, and the latter's elimination after the load, could be measured. Patients with mitral valve disease (10) and aortic valve disease (10), in NYHA functional classes II-III, with total bilirubin concentration < 26 mumol.l-1, were studied. The plasma conjugated bilirubin increased significantly during infusion with radiolabelled bilirubin; radioactivity also increased after 3-5 min both in mitral and aortic valve diseased patients. After termination of the infusion the decrease in plasma-free bilirubin concentration followed an exponential decay curve with a rate constant of 0.0101 +/- 0.0013 (mean +/- SD) and 0.00419 +/- 0.00130 for patients with aortic valve disease and mitral valve disease (P < 0.05) respectively. The rate constant correlated significantly with cardiac index (r = 0.55) (P < 0.01), and inversely with bilirubin concentration (r = -0.57) (P < 0.01). Patients with advanced mitral valve disease and normal bilirubin concentration demonstrated normal uptake. However, conjugation of bilirubin in the liver, with a diminished ability to eliminate a bilirubin load, indicated a functional block in the elimination of conjugated bilirubin, most likely related to a reduced liver flow.

[Are the results of thallium scintigraphy and coronary angiography equivalent? An evaluation of thallium scintigraphies performed at Vestfold Central Hospital]. / Er det samsvar mellom resultatene av thalliumscintigrafi og koronar angiografi? En evaluering av thalliumscintigrafiundersøkelser utført ved Vestfold sentralsykehus.

The value of exercise-redistribution thallium-201 perfusion scintigraphy (SPECT; single photon emission computed tomography) in the diagnosis of coronary artery disease was evaluated in 23 patients (one patient tested twice) who were subsequently submitted to coronary angiography. Reversible perfusion defects indicating myocardial ischemia were found in 22 patients, of whom 18 had angiographically significant coronary artery stenoses. Two patients had negative thallium scans, one had a normal angiogram and one had single vessel disease. Thus 18 of 19 patients with angiographically verified coronary heart disease had a positive thallium scan. The majority of patients with left main stenosis and triple vessel disease had scintigraphic evidence of double or triple vessel disease. The scintigraphic method identified the correct anatomical localization in 73% of the angiographically verified coronary artery stenoses. In conclusion, a positive exercise-redistribution thallium scan had a high predictive value in the diagnosis of coronary artery disease, whereas its value in estimating the number and localization of stenoses was more limited.