Lung transplantation in Norway 1999-2020. / Lungetransplantasjon i Norge 1999­2020.

BACKGROUND: Since 2009, patients with a rapidly progressing lung disease have been given a higher priority on the waiting list for a lung transplant. The purpose of our study was to examine diagnosis distribution, waiting list times, mortality and survival for patients on the waiting list in the period 1999-2020. MATERIAL AND METHOD: We conducted a descriptive, retrospective study of patients on the waiting list for a lung transplant in the periods 1999-2008 and 2009-2020. RESULTS: A total of 557 lung transplants were performed: 185 in 1999-2008 (median of 17.5 per year) and 372 in 2009-2020 (median of 32.5 per year). In the periods 1999-2008 and 2009-2020, the proportion of patients with chronic obstructive pulmonary disease (COPD)/emphysema was 67 % and 49 %, respectively. The corresponding figures for pulmonary fibrosis were 13 % and 23 %, and for cystic fibrosis 5 % and 11 %. Waiting list mortality was 27 % in 1999-2008 and 16 % in 2009-2020. Correspondingly for the two periods, waiting list mortality for patients with pulmonary fibrosis was 45 % and 22 %, and for cystic fibrosis 41 % and 2 %. Waiting times were shorter for all diagnoses in the period after the change in priority and longest for patients with COPD/emphysema (median of 381 days). Median survival after lung transplantation during the study period was ten years. INTERPRETATION: For patients with pulmonary fibrosis and cystic fibrosis, the change in transplant priority in 2009 may have played a role in reducing waiting list mortality.

[Extracorporeal membrane oxygenation for acute respiratory distress syndrome in patients with COVID-19]. / Ekstrakorporal membranoksygenering ved akutt lungesviktsyndrom hos covid-19-pasienter.

BACKGROUND: COVID-19 can lead to acute respiratory distress syndrome (ARDS). In some patients for whom conventional mechanical ventilation is insufficient, venovenous (VV) extracorporeal membrane oxygenation (ECMO) can be life-saving. MATERIAL AND METHOD: Retrospective analysis of data from patients with ARDS triggered by COVID-19 who received ECMO therapy between March 2020 and February 2022. Premorbid health condition, course of respiratory distress and respiratory support before, during and after ECMO therapy were registered. RESULTS: Thirty patients received ECMO therapy. Median age was 57 years, median body mass index 28 kg/m2, and 23 patients were men. Median duration of lung protective mechanical ventilation with tidal volume 5.8 mL/kg predicted body weight before initiation of ECMO therapy was 8 days. Treatment indication was primarily severe hypoxaemia, frequently combined with hypercapnia. Twenty-three patients developed at least one severe complication while receiving ECMO therapy. Sixteen patients died, 13 during ongoing ECMO therapy. Fourteen were discharged from hospital. Median duration of ECMO and mechanical ventilation was 27 and 37 days, respectively. INTERPRETATION: ECMO therapy for patients with ARDS triggered by COVID-19 can be life-saving, but the treatment is accompanied by severe complications and a high mortality rate.

Achievements in congenital heart defect surgery: a prospective, 40-year study of 7038 patients.

BACKGROUND: This article presents an update of the results achieved by modern surgery in congenital heart defects (CHDs) over the past 40 years regarding survival and the need for reoperations, especially focusing on the results from the past 2 decades. METHODS AND RESULTS: From 1971 to 2011, all 7038 patients <16 years of age undergoing surgical treatment for CHD at Rikshospitalet (Oslo, Norway) were enrolled prospectively. CHD diagnosis, date, and type of all operations were recorded, as was all-cause mortality until December 31, 2012. CHDs were classified as simple (3751/7038=53.2%), complex (2918/7038=41.5%), or miscellaneous (369/7037=5.2%). Parallel to a marked, sequential increase in operations for complex defects, median age at first operation decreased from 1.6 years in 1971 to 1979 to 0.19 years in 2000 to 2011. In total, 1033 died before January 1, 2013. Cumulative survival until 16 years of age in complex CHD operated on in 1971 to 1989 versus 1990 to 2011 was 62.4% versus 86.9% (P<0.0001). In the comparison of patients operated on in 2000 to 2004 versus 2005 to 2011, 1-year survival was 90.7% versus 96.5% (P=0.003), and 5-year cumulative survival was 88.8% versus 95.0% (P=0.0003). In simple versus complex defects, 434 (11.6%) versus 985 (33.8%) patients needed at least 1 reoperation before 16 years of age. In complex defects, 5-year cumulative freedom of reoperation among patients operated on in 1990 to 1999 versus 2000 to 2011 was 66% versus 73% (P=0.0001). CONCLUSIONS: Highly significant, sequential improvements in survival and reductions in reoperations after CHD surgery were seen. A future challenge is to find methods to reduce the need for reoperations and further reduce long-term mortality.

Extracorporeal driveline vibrations to detect left ventricular assist device thrombosis - A porcine model study.

BACKGROUND: Pump thrombosis (PT) and related adverse complications contributed to the HeartWare Ventricular Assist Device (HVAD) market withdrawal. Many patients still receive lifelong support, with deficient PT surveillance based on pump power trends. Analysis of pump vibrations is better for detecting PT. Here, we investigated the feasibility of an extracorporeal accelerometer to detect PT from pump vibrations propagated out on the driveline. METHODS: In a porcine HVAD model (n = 6), an accelerometer was attached to the pump as a reference and another to the driveline for comparisons of signals. In total, 59 thrombi were injected into the heart to induce PT, followed by intermittent thrombus washout maneuvers. Signals were compared visually in spectrograms and quantitatively in third harmonic saliences (S3H) by correlation analysis. Receiver operating characteristic curves expressed the method's outcome in sensitivity vs specificity, with the overall diagnostic performance in the area under the curve (AUC) score. RESULTS: Five experiments had good driveline signal strength, with clear spectrographic relationships between the 2 accelerometers. Third harmonic driveline vibrations were visible 20 vs 30 times in the reference. The comparison in S3H showed a strong correlation and yielded an AUC of 0.85. Notably, S3H proved robust regarding noise and false PT detections. CONCLUSIONS: An extracorporeal accelerometer on the driveline can be a readily available method for accurate HVAD PT detection before an accelerometer integration with left ventricular assist device is feasible.

Preoperative versus postoperative survival in patients with univentricular heart: a nationwide, retrospective study of patients born in 1990-2015.

OBJECTIVES: Few data exist on mortality among patients with univentricular heart (UVH) before surgery. Our aim was to explore the results of intention to perform surgery by estimating preoperative vs postoperative survival in different UVH subgroups. DESIGN: Retrospective. SETTING: Tertiary centre for congenital cardiology and congenital heart surgery. PARTICIPANTS: All 595 Norwegian children with UVH born alive from 1990 to 2015, followed until 31 December 2020. RESULTS: One quarter (151/595; 25.4%) were not operated. Among these, only two survived, and 125/149 (83.9%) died within 1 month. Reasons for not operating were that surgery was not feasible in 31.1%, preoperative complications in 25.2%, general health issues in 23.2% and parental decision in 20.5%. In total, 327/595 (55.0%) died; 283/327 (86.5%) already died during the first 2 years of life. Preoperative survival varied widely among the UVH subgroups, ranging from 40/65 (61.5%) among patients with unbalanced atrioventricular septal defect to 39/42 (92.9%) among patients with double inlet left ventricle. Postoperative survival followed a similar pattern. Postoperative survival among patients with hypoplastic left heart syndrome (HLHS) improved significantly (5-year survival, 42.5% vs 75.3% among patients born in 1990-2002 vs 2003-2015; p<0.0001), but not among non-HLHS patients (65.7% vs 72.6%; p=0.22)-among whom several subgroups had a poor prognosis similar to HLHS. A total of 291/595 patients (48.9%) had Fontan surgery CONCLUSIONS: Surgery was refrained in one quarter of the patients, among whom almost all died shortly after birth. Long-term prognosis was largely determined during the first 2 years. There was a strong concordance between preoperative and postoperative survival. HLHS survival was improved, but non-HLHS survival did not change significantly. This study demonstrates the complications and outcomes encountering newborns with UVH at all major stages of preoperative and operative treatment.

Long-term continuous flow mechanical biventricular support: 9 years and counting.

We report 2 continuous flow HeartWareTM left ventricular assist devices successfully used in a patient with advanced heart failure of giant cell myocarditis origin in a biventricular configuration. Despite technical challenges of adapting a left ventricular assist device engineered for systemic pressure to function as a right ventricular assist device, the addition of dynamic banding on the right ventricular assist device outflow graft allowed successful adaptation of afterload. This patient has now been on biventricular configuration support for 9 years, and remains stable to this day.

Operative survival in patients with acute aortic disease in the era of newer oral anticoagulants.

AIMS: The aim of this study was the analysis of the risk associated with direct oral anticoagulants (DOACs) in patients undergoing non-elective operations on the proximal aorta due to aortic disease. METHODS AND RESULTS: Data from the department's register of cardiac surgery was analysed retrospectively with emphasis on operative mortality. 135 non-elective operations for proximal aortic disease (October 2016 to 2018) were identified, of which 19 died during the first 90 days. DOAC use was the top-ranked risk factor in the univariate analysis with a HR of 9.6 (3.1 to 29), p=0.00007. Using a Cox proportional hazards model including the most relevant risk factors, the risk associated with DOAC use remained significant with a HR of 6.1 (1.4 to 26.3), p=0.015. We did not find increased risk associated with warfarin use. CONCLUSION: In patients undergoing non-elective operations on the proximal aorta due to aortic disease, the use of DOAC is associated with increased operative mortality.

Detection of Thromboembolic Events and Pump Thrombosis in HeartWare HVAD Using Accelerometer in a Porcine Model.

We have recently demonstrated that accelerometer-based pump thrombosis and thromboembolic events detection is feasible in vitro. This article focuses on detection of these conditions in vivo. In an open-chest porcine model (n = 7), an accelerometer was attached to the pump casing of an implanted HeartWare HVAD. Pump vibration was analyzed by Fast Fourier Transform of the accelerometer signals, and the spectrogram third harmonic amplitude quantified and compared with pump power. Interventions included injection of thrombi into the left atrium (sized 0.3-0.4 ml, total n = 35) and control interventions; pump speed change, graft obstruction, and saline bolus injections (total n = 47). Graft flow to cardiac output ratio was used to estimate the expected number of thrombi passing through the pump. Sensitivity/specificity was assessed by receiver operating characteristic curve. Graft flow to cardiac output ratio averaged 66%. Twenty-six of 35 (74%) thrombi caused notable accelerometer signal change. Accelerometer third harmonic amplitude was significantly increased in thromboembolic interventions compared with control interventions, 64.5 (interquartile range [IQR]: 18.8-107.1) and 5.45 (IQR: 4.2-6.6), respectively (p < 0.01). The corresponding difference in pump power was 3 W (IQR: 2.9-3.3) and 2.8 W (IQR: 2.4-2.9), respectively (p < 0.01). Sensitivity/specificity of the accelerometer and pump power to detect thromboembolic events was 0.74/1.00 (area under the curve [AUC]: 0.956) and 0.40/1.00 (AUC: 0.759), respectively. Persistent high third harmonic amplitude was evident at end of all experiments, and pump thrombosis was confirmed by visual inspection. The findings demonstrate that accelerometer-based detection of thromboembolic events and pump thrombosis is feasible in vivo and that the method is superior to detection based on pump power.

In vitro evaluation of PHISIO-coated sets for pediatric cardiac surgery.

OBJECTIVES: Phosphorylcholine coated cardiopulmonary bypass (CPB) circuits for children have been available for some years, but conflicting results regarding the inflammatory response have been reported. Accordingly, we aimed to investigate the effect of phosphorylcholine coating on the inflammatory response. DESIGN: Ten coated and nine uncoated pediatric CPB sets were tested in an in vitro CPB circuit model. The inflammatory response was assessed by serial assays of hemoglobin, hematocrit, leukocyte counts, platelet counts, activation of the complement system, activation of platelets measured as beta-thromboglobulin, activation of neutrophils measured as myeloperoxidase, activation of coagulation measured as prothrombin fragments 1+2, assessment of hemolysis measured as lactate dehydrogenase, and a panel of seven cytokines. Samples were obtained at baseline and after 15, 30, 60 and 120 minutes. RESULTS: There were no significant differences between the phosphorylcholine coated circuits and the uncoated circuits for any of the parameters during the observation period, although a potentially beneficial effect on platelets could not be ruled out. CONCLUSIONS: Phosphorylcholine coating of CPB equipment did not exert any beneficial effect on the inflammatory markers monitored.

[A six-year-old girl with dyspnea following tracheocutaneous repair]. / En seks år gammel jente med dyspné etter operasjon på halsen.

BACKGROUND: A few patients develop prominent scars combined with persistent fistula after the removal of a long-standing tracheostomy tube. The procedure needed to correct the condition is generally considered minor surgery, normally without any significant complications. We describe, however, a patient who developed a particularly complicated postoperative course. MATERIAL AND METHODS: The patient was a six-year-old girl who underwent surgery because of significant scar formation and a persistent small tracheocutaneous fistula eight months after removal of the tube. Postoperatively she had a cough attack and developed spontaneously subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax. She required intensive care, thoracic drainage and antibiotic prophylaxis. Over the next days her situation improved and she was discharged on the sixth day. INTERPRETATION: Operative treatment of scarring after tracheostomy in which the surgeon also confronts a tracheocutaneous fistula or an opening into the tracheal lumen requires postoperative observation so that any severe complications can be managed.

Pediatric coronary artery revascularization: a European multicenter study.

BACKGROUND: We sought to evaluate the hospital and midterm results of different surgical revascularization techniques in pediatric patients within the European Congenital Heart Surgeons Association. METHODS: From 1973 to 2011, 80 patients from 13 European Congenital Heart Surgeons Association centers underwent 65 pediatric coronary artery bypass grafting (PCABG) and 27 other coronary artery procedures (OCAP; 12 patients had combined PCABG and other coronary artery procedures). Excluded were patients with Kawasaki disease. Median age at the time of coronary procedure was 2.3 years (range, 2 days to 16.9 years); 33 patients (41.2%) were younger then 12 months. An emergency procedure was necessary in 34 patients (42.5%). RESULTS: Twelve patients (15%) died in the hospital; age at surgery (p=0.02) and the need for an emergent procedure (p=0.0004) were related to hospital mortality. Median follow-up time was 7.6 years (range, 0.9 to 23 years). There were 3 late cardiac deaths, all after a median time of 4 years (range, 9 months to 8.8 years) after PCABG. Fourteen patients (20.5%) presented with symptoms, including congestive heart failure (n=10) and angina (n=4), that were significantly associated with a low ejection fraction (p<0.001) and the presence of moderate or severe mitral valve regurgitation (p=0.0003). Six patients underwent a reintervention for impaired myocardial perfusion; all of them had a stenotic or atretic PCABG (p=0.001), and the majority were symptomatic (5 of 6 patients; 83.3%; p=0.001). CONCLUSIONS: Both PCABG and other coronary artery procedures are suitable surgical options in pediatric patients with impaired myocardial perfusion, which increases operative and midterm survival. Such population of patients needs to be followed for life to prevent and treat any possible cause of further myocardial ischemia.

Combined repair of upper sternal cleft and transposition of the great arteries in a newborn.

We report the case of a newborn with the unusual association of an upper sternal defect and transposition of the great arteries. Surgical correction of the cardiac disease consisted of the arterial switch procedure. The already less compliant bony thorax of the infant made direct approximation of the upper sternal defect only possible with adjuvant bilateral chondrotomy. Sternal cleft repair is advised during the very first weeks of life.

Correction of postpneumonectomy syndrome in infants with saline-filled expandable prosthesis.

We report two infants who underwent right pneumonectomy in infancy and developed postpneumonectomy syndrome with obstruction of the left main bronchus causing severe airway obstruction in one patient and gastrointestinal reflux due to a displaced and grossly dilated oesophagus in the other patient. Both patients were operated with implantation of an expandable breast prosthesis.

Single-center 50 years' experience with surgical management of tetralogy of Fallot.

OBJECTIVE: The aim of this study was to evaluate the long-term outcome of total repair for tetralogy of Fallot. We aimed to characterize late survival and the time-related risk of late reoperation. METHODS: Operative protocols, patient records, and the database of the department were evaluated from 1951 until 2008. The official death registry of Norway was used for follow-up. Of the patients identified, the follow-up was 99.6% complete. RESULTS: A total of 627 patients were studied. Of these, 570 could be identified for follow-up. There were a total of 41 early and 30 late deaths. The total early (including palliative procedures) mortality was 7.2% and total late mortality was 7.9%. However, during the last 10 years, no early mortality has been observed following repair. A total of 264 patients underwent some form of palliative procedure as their first treatment, and 541 patients had a reparative procedure performed, with an early mortality of 31 (5.7%). In patients subjected to a reparative procedure, there was no difference in freedom from death or reoperation following primary repair versus primary palliation. The use of transannular patch was associated with a highly significant risk of reoperation. CONCLUSIONS: Surgical treatment of the tetralogy of Fallot and related congenital cardiac malformations has good long-term prognosis. In this cohort of patients, more than one-third required additional procedures later on, and, in some cases, as many as four additional surgeries. Palliative procedures followed by repair do not influence survival or reoperation-free survival. There are no differences between transatrial versus transventricular repair on survival or re-repair. Any transannular incision increases the risk of re-repair, but does not influence long-time survival. There is an almost linear decrease in reoperation-free survival following any type of repair of tetralogy of Fallot, even for as long as 50 years since the first procedure.

Biomarker profile in off-pump and on-pump coronary artery bypass grafting surgery in low-risk patients.

BACKGROUND: The purpose of this study was to investigate the cytokine and chemokine profile in low-risk patients undergoing off-pump and on-pump coronary artery bypass grafting (CABG) surgery by use of a broad panel of cytokines and chemokines. METHODS: Eight consecutive blood samples were obtained from patients enrolled into a prospective, randomized study comparing off-pump and on-pump CABG in a low-risk population. Eleven patients from each group were randomly selected for analysis of 25 different cytokines and chemokines using multiplex technology. Data were compared using two-way repeated measures analysis of variance. RESULTS: Of the 25 biomarkers analyzed, 11 were not detected while 14 increased significantly in both groups. Only three mediators, eotaxin, macrophage inflammatory protein (MIP)-1beta, and interleukin (IL)-12 were significantly different between the two groups, increasing more in the on-pump than in the off-pump group (p < 0.001, p < 0.01, and p < 0.05, respectively). There was a marked, comparable increase in the concentrations of the cytokines IL-6, IL-10, IL-15, and IL-1Ra as well as the chemokines inducible protein (IP)-10, monokine induced by interferon gamma (MIG), monocyte chemoattractant protein 1 (MCP-1), and regulated on activation, normal T cell expressed and secreted (RANTES) in both groups (p < 0.001 for all). There was only a modest, but still statistically significant, increase in IL-8, tumor necrosis factors alpha, and IL-2R, without any intergroup differences. When corrected for hemodilution the production of the antiinflammatory biomarkers IL-1Ra and IL-10 were significantly higher in the on-pump group (p < 0.001 for both). CONCLUSIONS: The cytokine and chemokine production profile of the inflammatory response associated with CABG is largely similar using the off-pump and on-pump techniques in low-risk patients, but slightly higher concentrations of eotaxin, MIP-1beta, and IL-12 were found in the on-pump group.

Off-pump cardiac surgery abolishes complement activation.

BACKGROUND: This prospective randomized study compared the inflammatory response in patients undergoing elective on-pump and off-pump coronary artery bypass grafting. PATIENTS AND METHODS: Forty-four patients undergoing elective coronary artery bypass grafting were recruited with 22 patients randomized to on-pump heart surgery and 22 patients to off-pump coronary bypass surgery. Plasma levels of C3bc, the terminal SC5b-9 complement complex, myeloperoxidase, beta-thromboglobulin and prothrombin fragment F1 + 2 were measured before the operation, intraoperatively, at termination of the operation, and two hours post-operatively. RESULTS: Complement was markedly activated in the on-pump group as indicated by a significant increase in C3bc and SC5b-9 (p < 0.001 for both), whereas no complement activation was seen in the off-pump group (p = 0.001 between the groups). In contrast, both groups showed significant activation of neutrophils, platelets and coagulation, as indicated by an early increase in myeloperoxidase and a post-operative increase in beta-thromboglobulin and F1 + 2, respectively. Notably, there were no intergroup differences with regard to neutrophil and platelet activation, whereas coagulation activation was more pronounced in the off-pump group (p < 0.01). CONCLUSIONS: Off-pump surgery completely eliminated the heart-lung machine-induced complement activation. Neutrophils and platelets were equally activated in both groups, whereas coagulation was enhanced post-operatively in the off-pump group.

A life-threatening complication of the Nuss procedure for pectus excavatum.

We describe a delayed, life-threatening complication in a boy operated on using the Nuss-procedure 2 months earlier. On admittance he was in shock with cardiac tamponade. An immediate needle aspiration of blood from the pericardium was done before a median sternotomy. The Nuss-bar was removed, and we identified a 1.5-cm laceration in the adventitial layer of the ascending aorta as the source of bleeding. The tear was closed, and the patient had an uneventful recovery. Careful positioning of the bar is necessary to avoid complications. Measures must be taken postoperatively to confirm that the steel bar does not rotate.

Comparison of a Duraflo II-coated cardiopulmonary bypass circuit and a trillium-coated oxygenator during open-heart surgery.

BACKGROUND: Cardiopulmonary bypass (CPB) evokes a systemic inflammatory response. In attempting to improve the biocompatibility of the equipment, various methods to coat the inner surfaces of the CPB systems have been developed. The present study compares a Trillium Biopassive surface-coated Affinity oxygenator with a Duraflo II totally heparin-coated CPB system. METHODS: Low-risk patients admitted for primary coronary artery bypass grafting or aortic valve replacement were randomized to operation using the Trillium- or the Duraflo II-coated setups. Heparin concentration, complement activation (C3bc activation products and terminal complement complex (TCC)), platelet activation (platelet numbers and beta-thromboglobulin (BTG)), leukocyte activation (leukocyte numbers and myeloperoxidase (MPO)), coagulation (thrombin/antithrombin complexes (TAT)) and fibrinolytic activity (plasmin/alpha2-antiplasmin complexes (PAP)) were measured during CPB and two hours postoperatively. RESULTS: Platelet counts decreased during CPB, without significant intergroup differences. The median BTG concentration increased moderately in both groups and were slightly higher in the Trillium group during CPB (p < 0.05), but not postoperatively. Complement activation products (C3bc and TCC), leukocyte counts, MPO, TAT and PAP activity showed no differences between the two groups. CONCLUSIONS: There were small differences in the inflammatory response between the two extracorporeal circulation devices compared in this study.