Asymptomatic fatal post-lobectomy hemopericardium.

We report a case of an asymptomatic post-lobectomy hemopericardium in a female who died suddenly at day two post surgery. Autopsy revealed no pathologic findings, but 250 ml of blood and clots in the pericardium and a non-significant injury to the epicardial fat overlying the circumflex artery territory.

Good outcomes from cardiac surgery in the over 70s.

OBJECTIVE: To determine the early mortality and major morbidity associated with cardiac surgery in the elderly. DESIGN: Retrospective case record review study of 575 patients >/= 70 years old who underwent cardiac surgery at the Manchester Heart Centre between January 1990 and December 1996. SETTING: Regional cardiothoracic centre. SUBJECTS: Patients >/= 70 years old who underwent cardiac surgery. MAIN OUTCOME MEASURES: Comparison of 30 day mortality and incidence of major morbidity between patients >/= 70 years old and patients < 70 years old. RESULTS: Of 4395 cardiac surgical operations, 575 operations (13.1%) were in patients aged >/= 70 years (mean (SD) 73.1 (3.2) years). The proportion of elderly patients rose progressively from 7.9% in 1990 to 16.5% in 1996. 334 patients (58.1%) had coronary artery bypass grafting alone, 91 patients (15.8%) had valve surgery alone, and 129 patients (22.4%) had combined valve surgery and bypass grafting. For isolated coronary artery bypass grafting, 30 day mortality in patients >/= 70 years was 3.9% compared with 1.3% in patients < 70 years (p < 0.001). 30 day mortality for isolated valve surgery in patients >/= 70 years was 7.7%. Isolated aortic valve replacement was the most common valvar procedure in patients >/= 70 years and carried the lowest mortality (4.3%). Additional coronary artery bypass grafting increased the mortality rate in patients >/= 70 years to 9.3% for all valve surgery and to 8.0% for aortic valve replacement. Major morbidity in patients >/= 70 years was low for all procedure types (stroke 1.9%, acute renal failure requiring dialysis 1.6%, perioperative myocardial infarction 0.5%). CONCLUSIONS: Early mortality and major morbidity is low for cardiac surgery in elderly patients. Concerns over the risk of cardiac surgery in the elderly should not prevent referral, and elderly patients usually do well. However, unconscious rationing of health care may affect referral patterns, and studies that assess the cost effectiveness of cardiac surgery versus conservative management in such patients are lacking.

Comparison of saccharides as osmotic impermeants during hypothermic lung graft preservation.

We have previously shown that the trisaccharide raffinose is largely responsible for the superior lung graft performance seen after storage in University of Wisconsin solution. To investigate the use of osmotic agents in perfusates for hypothermic lung graft storage, we compared saccharides of various molecular weights in an isolated rat lung model. Grafts were flushed with 1 of 6 preservation solutions (n=5 each group) containing either a monosaccharide (glucose [G] or fructose [F]), disaccharide (trehalose [T] or sucrose [S]), or trisaccharide (raffinose [R] or melezitose [M]. Grafts were stored for 6 hours at 4 degrees C, reperfused by a veno-venous circuit from an anesthetized support animal for 60 min, and ventilated with room air. The best graft function was seen when trisaccharides were used (PO2; R 126 +/- 3 mm Hg, M 129 +/- 3 mm Hg, blood flows: R 10.2 +/- 0.42 ml/min, M 10.3 +/- 0.22 ml/min). Disaccharides produced similar oxygenation (T 133 +/- 3 mm Hg, S 129 +/- 3 mm Hg) and flows (T 10.3 +/- 0.29 ml/min, S 9.7 +/- 0.4 ml/min) at 60 min, but initial flows were reduced. Monosaccharides produced the least satisfactory graft function, with impaired oxygenation (F 110 +/- 14 mm Hg, P<0.05; G 69 +/- 10 mm Hg, P<0.01) and blood flows (G 6.5 +/- 0.6 ml/min, F 9.1 +/- 0.6 ml/min, P<0.01 each). Only glucose-stored lungs demonstrated a significant decrease in compliance (P<0.01) and weight gain (P<0.01). The worst results were seen with glucose, which is the osmotic agent most commonly used for clinical lung storage. A solution containing a trisaccharide or disaccharide may be more appropriate for this purpose.

Controlled pressure reperfusion of rat pulmonary grafts yields improved function after twenty-four-hours' cold storage in University of Wisconsin solution.

BACKGROUND: Pulmonary graft recipients commonly have a degree of pulmonary hypertension. Immediate reperfusion of stored pulmonary grafts at supraphysiologic or even physiologic pressures may be detrimental to subsequent function. We wished to test the hypothesis that initial reperfusion of pulmonary grafts at low pressures may be beneficial. METHODS: We used an isolated, ventilated rat lung model, perfused by an extracorporeal veno-venous circuit from a support animal. Three groups of donor lungs (n = 5 each) were flushed with cold University of Wisconsin solution. Group I was reperfused immediately at physiologic pressure to provide control values. Group II grafts were stored at 4 degrees C for 24 hours and reperfused at physiologic pressure. Group III grafts were also stored at 4 degrees C for 24 hours but reperfused according to a protocol of reduced pressure initially, with increments every 15 minutes up to physiologic levels by 60 minutes. Grafts and support animals were ventilated with room air. Graft function was assessed over a 2-hour period with regard to oxygenation, vascular resistance, peak airway pressure, and the wet/dry weight ratio. RESULTS: Grafts in group II functioned poorly at 2 hours compared with control values: group II: oxygen tension 68 +/- 4 mm Hg; pulmonary vascular resistance 2488 +/- 675 x 10(3) dyne.sec/cm5; peak airway pressure 32 +/- 1 mm Hg wet/dry wright ratio 9.1 +/- Group I: oxygen tension 136 +/- 2 mm Hg; pulmonary vascular resistance 120 +/- 3 x 10(3) dyne.sec/cm5; peak airway pressure 13 +/- 1 mm Hg and wet/dry weight ratio 3.6 +/- 0.3; p < 0.001 all parameters except pulmonary vascular resistance: p < 0.05. In contrast, grafts undergoing controlled pressure reperfusion (group III) achieved function comparable with baseline values at 2 hours: oxygen tension 137 +/- 3 mm Hg; pulmonary vascular resistance 132 +/- 7 x 10(3) dyne. sec/cm5; peak airway pressure 13 +/- 1 mm Hg; wet/dry weight ratio 4.1 +/- 0.3 (p = Not significant). CONCLUSIONS: The pressure at which pulmonary grafts are initially reperfused appears to be critical to their subsequent integrity. A protocol of controlled reperfusion may reduce reperfusion injury and improve graft function in clinical practice.

A technique for studying the function of an isolated, perfused and ventilated lung in a rat model.

We describe a technique which allows perfusion of an isolated, ventilated rat lung with an extracorporeal veno-venous circuit from a support animal. This model provides stable and reliable function of the isolated lung for up to 3 h, thus overcoming some of the disadvantages of previous models. It may prove a potentially useful model for assessing ischaemic lung injury.

Comparison of propafenone to atenolol for the prophylaxis of postcardiotomy supraventricular tachyarrhythmias: a prospective trial.

To compare the efficacy of propafenone to atenolol in the prevention of supraventricular tachyarrhythmias (SVT) following cardiac surgery, 207 consecutive patients were randomly allocated to receive either propafenone 300 mg twice daily (105 patients) or atenolol 50 mg once daily (102 patients) orally for 7 days after operation. Double blinding was achieved using placebos. The end point was the development of a SVT which was symptomatic, recurrent, or lasting over 2 minutes, or the occurrence of adverse effects possibly attributable to the drugs. The groups were well matched for age, sex, bypass- and cross-clamp times, and other data. Thirteen patients in the propafenone group and 11 in the atenolol group developed SVT during the first week after operation. (P = 0.89, non significant, chi-squared with Yates' correction). In our study propafenone and atenolol were of approximately equal efficacy in preventing post cardiotomy SVT. Propafenone may have an advantage in being less negatively inotropic than atenolol; it could therefore be used in patients with poor left ventricular function or marginal haemodynamics when a beta blocker is contraindicated.

University of Wisconsin solution for lung graft preservation: which components are important?

Rat lung grafts were perfused with either Euro-Collins solution, University of Wisconsin solution, or one of six modified University of Wisconsin solutions that had been sequentially depleted of specific components (n = 5 each group). After storage at 4 degrees C for 6 hours, the isolated, ventilated pulmonary graft was reperfused for 1 hour with recirculating venous blood from a support animal. In a further group, lungs were reperfused immediately after explanation to provide control values. Grafts flushed with University of Wisconsin solution functioned at control levels with regard to oxygen tension: University of Wisconsin solution 128 +/- 2.7 mm Hg, control 126 +/- 5 mm Hg; graft blood flow: University of Wisconsin solution 9.9 +/- 0.4 ml/min, control 10.2 +/- 0.8 ml/min; peak airway pressure: University of Wisconsin solution 17 +/- 0.5 mm Hg, control 16.5 +/- 0.6 mm Hg; and weight gain: University of Wisconsin solution 0.12 +2- 0.1 gm, control 0.19 +/- 0.13 gm. In contrast, lungs treated with Euro-Collins solution functioned less well: oxygen tension 54 +/- 6 mm Hg, graft blood flow 3.5 +/- 0.42 ml/min, peak airway pressure 35 +/- 4 mm Hg, and weight gain 4.15 +/- 0.5 gm (p < 0.0001 all parameters). Sequential removal of hydroxyethyl starch, magnesium, allopurinol, adenosine, glutathione, and lactobionate from University of Wisconsin solution did not impair the efficacy of the solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung graft preservation. Comparison of phosphate-buffered sucrose, modified EuroCollins, and University of Wisconsin solutions.

Phosphate-buffered sucrose (PBS) has been shown to be highly effective for renal graft storage. It may, therefore, be useful for lung graft storage. Recent studies have suggested a possible role for University of Wisconsin (UW) solution in lung preservation. The object of this study was to evaluate these two solutions in comparison with EuroCollins (EC) solution for lung graft preservation in an isolated rat lung model. Lungs were stored for 6 hr at 4 degrees C after a single pulmonary artery flush with either PBS with prostacyclin (n = 10), EC with prostacyclin (n = 5), or UW (n = 5) solution. Reperfusion of the isolated lung was carried out for 1 hr using a venovenous extracorporeal circulation from a ventilated support rat. The support animals and isolated lungs were ventilated with room air. Control values were obtained from lungs reperfused immediately after harvesting (n = 5). At 1 hr, PBS provided a similar level of protection to EC: pO2, 45 +/- 10 mmHg and 54 +/- 6 mmHg; graft blood flow, 4.1 +/- 1.2 ml/min and 3.5 +/- 0.42 ml/min; peak airway pressure, 32 +/- 2.5 mmHg and 36 +/- 3.6 mmHg; weight gain, 4.1 +/- 0.6 g and 4.2 +/- 0.6 g, respectively (P = NS). However, the UW group provided superior function, which was similar to the control group: pO2, 128 +/- 2.7 mmHg and 126 +/- 5 mmHg; graft blood flow, 9.9 +/- 0.4 ml/min and 10.2 +/- 0.8 ml/min; peak airway pressure, 17.6 +/- 0.4 mmHg and 16.5 +/- 0.6 mmHg; weight gain, 0.12 +/- 0.1 g and 0.19 +/- 0.13 g, respectively (P = NS). UW was superior in all parameters to PBS and EC (P < 0.001). This suggests that the renal solutions PBS and EC are inappropriate for lung graft preservation, and that the requirements of the lung during hypothermic storage differ from those of the kidney.

Prevention of a phrenic nerve palsy following left anterior mediastinotomy.

A left phrenic nerve palsy was observed following left anterior mediastinotomy performed for staging of a left upper lobe tumour. Since no evidence of mediastinal spread of the tumour was found, a left upper lobectomy was subsequently performed. Oedema (but no evidence of tumour) was seen around the phrenic nerve in the region of the previous mediastinotomy. As a result of this experience we have altered our technique of left anterior mediastinotomy.

Surgical factors affecting growth potential of the immature rat lung.

The transplanted immature rat lung has been shown capable of fulfilling its growth potential after left lung transplantation (LLTx) and concomitant right cardiac lobe resection (RCLR). However, unexpected findings in these studies included an abnormal rise in lung volume in the contralateral lung due to alveolar multiplication, and significant dilatation of the bronchi in the transplanted left lung. In the present study, the influence of surgical factors that could have contributed to these changes, i.e. RCLR, denervation, and anastomotic stenosis, were studied individually. Immature Lewis rats aged 4 and 6 weeks were used and (a) RCLR, (b) RCLR and right hilar stripping, and (c) RCLR and left pulmonary artery (PA) banding were performed in groups 1 (n = 12), 2 (n = 5) and 3 (n = 6), respectively. Animals were killed after 6 months and the lungs studied using quantitative morphometric techniques. In groups 1 and 2, right lungs did not show any significant increase in volume. Alveolar number and airway diameter in both lungs in all groups were not significantly different from controls. In group 3 both right and left lungs presented an increase in alveolar size (p less than 0.02 on the right and p less than 0.01 on the left). Changes seen after LLTx in the rat, such as alveolar multiplication, cannot be explained by compensatory growth (RCLR), denervation (RCLR and hilar stripping), or arterial stenosis at the anastomotic site (RCLR and left PA banding), but must be regarded as a consequence of transplantation per se. A role for neuropeptides in lung growth following transplantation is suggested.

Successful use of mechanical assist device for right ventricular failure after orthotopic heart transplantation.

A 22-year-old woman underwent orthotopic heart transplantation, resulting in acute failure of the donor right ventricle caused by a raised pulmonary vascular resistance. This was successfully managed by mechanical assistance of the right ventricle, with use of a centrifugal pump. After a complicated early postoperative course, the patient made a complete recovery.

Growth potential of the immature transplanted lung. An experimental study.

Syngeneic (Lewis to Lewis) and allogeneic (Brown Norway to Lewis) unilateral left lung transplants were performed on immature rats at 6 weeks of age at a time when alveoli are still multiplying after birth. Left lung denervation without transplantation was performed in a further group of rats (Lewis) by stripping the hilum, at 4 and 6 weeks of age. Animals were killed at either 2 weeks or 6 months after operation. Right and left lungs were analyzed separately by light microscopic quantitative techniques and findings were compared with findings from control animals matched for age and strain. The transplanted left lung in both syngeneic and allogeneic animals continued to grow to a normal size by formation of new alveoli, despite the presence of low-grade rejection activity in the immunosuppressed allogeneic group. The airways showed an increase in diameter for age at the hilum and periphery (p less than 0.01 and less than 0.001, respectively). The volume of the contralateral right lung was greater than normal because of an increase in number (p less than 0.01) and size of alveoli for age. Denervation alone was associated with normal growth of both lungs. Thus it appears that, in rats, the transplanted immature lung can fulfill its growth potential.

Opportunist pulmonary infection with Legionella bozemanii.

Three cases of pulmonary Legionella bozemanii infection in immunocompromised patients are described. The diagnosis was made by culture in each case and would not otherwise have been made, and it is recommended that a culture specific for Legionella species should be included in the investigation of patients with suspected opportunist pulmonary infections.