Sture Larsson

Influence of aortic valve replacement, prosthesis type, and size on functional outcome and ventricular mass in patients with aortic stenosis

OBJECTIVESnTwo years after surgery for severe aortic stenosis, we prospectively evaluated the influence of aortic valve replacement, as well as valve type (mechanical or stented biologic) and size, on functional status, left ventricular function, and regression of mass.nnnMETHODSnPatients who received either a mechanical (n = 95) or a biologic valve (n = 42) were studied by echocardiography before the operation and after 2 years.nnnRESULTSnThe percentage of patients with severe dyspnea decreased from 53% to 13% (P =.001). The cardiac index increased from mean 2.6 L/min per square meter (95% CI: 2.48-2. 72 L/min per square meter) to 3.1 L/min per square meter (95% CI: 2. 94-3.26 L/min per square meter; P =.001). The percentage of the patients with mild-to-moderate diastolic dysfunction decreased from 43% to 18% (P =.001). The left ventricular mass index was reduced by 42.4 g (95% CI: 35-50 g; P =.001). In comparison with biologic valves of the same size, mechanical valves produced a more pronounced reduction in mass index (overall difference 21.7 g; 95% CI: 37.1-6.4 g; P =.007) and a lower mean Doppler gradient (overall difference 4 mm Hg; 95% CI: 2-6 mm Hg; P =.0002).nnnCONCLUSIONSnPatients undergoing aortic valve replacement had an improvement in functional status, as well as systolic and diastolic left ventricular function, and a reduction in left ventricular mass index, irrespective of prosthesis size and type. Mechanical valves are somewhat less obstructive than stented bioprosthetic valves of the same size. They are also associated with a concomitantly more pronounced reduction of left ventricular mass.

Gender differences in patients with severe aortic stenosis: impact on preoperative left ventricular geometry and function, as well as early postoperative morbidity and mortality

OBJECTIVEnIn patients with severe aortic stenosis, we studied the impact of gender on preoperative left ventricular geometry and function, as well as on early postoperative mortality and morbidity.nnnMETHODSnProspective Doppler echocardiographic evaluation was performed in 99 female patients and 96 males.nnnRESULTSnThe patients had severe aortic stenosis and the mean pressure gradients were similar in females and males. Left ventricular diastolic volume adjusted for body surface area (BSA) was larger in males, 55+/-17.4 ml/m2 versus 43+/-13.1 mL/m2 (mean+/-standard deviation; P = 0.0001). The ejection fraction was similar in females (55+/-14%) and males (55+/-13%), and patients of both sexes had significantly lower stroke volume and cardiac index than healthy controls. The relative wall thickness (wall thickness/diastolic diameter ratio) was higher (P = 0.03) in females (0.47+/-0.10) than in males (0.43+/-0.10) Consequently, the diastolic diameter/wall thickness ratio (a substitute for wall tension) was higher (P = 0.02) in males (4.2+/-0.99) than in females (3.9+/-0.80). Compared with survivors, patients who died within 30 days of the operation (n = 17, 11 females) had a smaller body surface area (1.70+/-0.19 vs. 1.82+/-0.19 m2, P = 0.012), smaller left ventricular outflow tract (20.8+/-0.21 vs. 22.0+/-0.22 mm, P = 0.023), higher incidence of abnormal intraventricular flow velocity (33 vs. 8%, P = 0.018) and increased relative wall thickness (0.52+/-0.17 vs. 0.45+/-0.09 P = 0.039). Gender was of no independent importance for early mortality when age and left ventricular outflow tract diameter were accounted for.nnnCONCLUSIONSnCardiac adaptation to aortic stenosis seems to be influenced by gender, males presenting larger left ventricular volumes and higher wall tension. The echocardiographic findings of a narrow left ventricular outflow tract, abnormally increased intraventricular velocity and increased relative wall thickness identified patients with increased risk of early postoperative mortality. However gender had no independent impact on early postoperative outcome.

Clinical usefulness of serum assays of neuron-specific enolase, carcinoembryonic antigen and CA-50 antigen in the diagnosis of lung cancer

Serum concentrations of neuron-specific enolase (NSE), carcinoembryonic antigen (CEA) and CA-50 antigen were determined in 168 consecutive patients with lung cancer. All three markers were significantly elevated compared with levels in 102 patients with non-malignant chest diseases. NSE and CEA varied significantly across histological lung cancer types, with most highly elevated serum levels in small cell lung cancer and adenocarcinomas, respectively. The overall diagnostic accuracy was 0.66 for NSE, 0.74 for CEA, and 0.62 for CA-50, implying that CEA best discriminated between lung cancer and benign chest diseases, while CA-50 was less efficient as a diagnostic marker. In multivariate analysis of the three markers combined, a positive predictive value of 95% for lung cancer could be achieved with a diagnostic sensitivity of 57%, with a cut-off level defined as 0.037.NSE + 0.052.CEA + 0.011.CA-50 > 1. In 22% of the cancer patients, the time from admission to histological or cytological lung cancer diagnosis exceeded 1 month. In 52% of these patients, the initial weighted tumour marker index was > 1, strongly implying the cancer diagnosis. The study lends support to the potential use of combined analysis of NSE, CEA and CA-50 as a complementary tool in the diagnosis of lung cancer.

Mechanical versus biological valve prosthesis: A ten-year comparison regarding function and quality of life

To determine the long-term outcome of biological and mechanical heart valve prostheses, we compared the Biocor, a new generation of porcine bioprosthesis, with the St. Jude Medical mechanical prosthesis. One hundred consecutive patients operated on between 1983 and 1985 with the Biocor in the aortic, mitral, or both positions (without concomitant cardiac procedures) were followed until January 1993, together with 100 matched patients implanted with the St. Jude valve. The mean age was 66 and 67 years, respectively. The follow-up was 100% complete. Valve-related mortality differed significantly, with a freedom rate of 80.7% +/- 9.0% for the St. Jude group and 97.7% +/- 1.6% for the Biocor group. There were few thromboembolic events, with no significant difference between the groups. Anticoagulant-related hemorrhage occurred almost exclusively in the St. Jude group (2.3%/patient-year), and reoperations were required almost exclusively in the Biocor group (1.8%/patient-year). The occurrence of all valve-related complications (mortality plus morbidity) differed markedly, with an actuarial freedom at 10 years of 55.8% +/- 9.8% for St. Jude and 80.0% +/- 4.4% for the Biocor. Quality of life and echocardiographic measurements did not differ significantly between the groups. We conclude from this study that the long-term performance of the Biocor and St. Jude are comparable, even though valve-related complications tended to be fewer in the Biocor group, with a significantly lower incidence of valve-related death.

Reference Doppler Echocardiographic Values for St. Jude Medical, Omnicarbon, and Biocor Prosthetic Valves in the Aortic Position

The objectives of the present investigation were (1) to describe Doppler echocardiographic findings for mechanical and biologic aortic valves at an early stage after operation and later in a stable phase and (2) to study the changes occurring between these investigations. Patients (n = 213) who received a mechanical (St. Jude Medical, Omnicarbon) or a biologic (Biocor) valve were studied by Doppler echocardiography within the first week (baseline, n = 203) and after 2 years (late, n = 172). The comparison of baseline with late investigation (mean +/- SD) showed an increase in systolic blood pressure (137 +/- 18.5 to 154 +/- 20.6 mm Hg, p = 0.0001, n = 112), reduction of heart rate (85 +/- 15.3 to 74 +/- 12.0 beats/min, p = 0.0001, n = 141) and increase in stroke volume (59 +/- 20.6 to 77 +/- 19.8 ml, p = 0.0001, n = 132). Prosthetic Doppler echocardiographic findings demonstrated a reduction in blood flow velocity in the left ventricular outflow tract (VLVOT, 1.10 +/- 0.25 to 0.96 +/- 0.23 m/sec, p = 0.0001, n = 146) reduction in peak velocity (Vmax 2.72 +/- 0.53 to 2.59 +/- 0.54 m/sec, p = 0.02, n = 150), reduction in mean pressure gradient (deltaPmean, 18.4 +/- 7.2 to 16.3 +/- 7.3 mm Hg, p = 0.004) and an increase in velocity index (Vmax/VLVOT, 2.56 +/- 0.62 to 2.67 +/- 0.60, p = 0.003, n = 144). The standard deviations of difference between baseline and late investigation expressed as percentage of mean were 25% for VLVOT, 20% for Vmax, 44% for deltaPmean, and 25% for velocity index. In conclusion, this large reference base provides data that should be useful for the clinician evaluating patients with prosthetic valves early after valve replacement as well as at a later stage. When valve dysfunction is suspected a previous investigation for comparison is helpful, and our data describe the changes that normally may be seen between an early baseline and a late investigation.

Coexpression of Ganglioside Antigen Fuc-GM1, Neural-Cell Adhesion Molecule, Carcinoembryonic Antigen, and Carbohydrate Tumor-Associated Antigen CA 50 in Lung Cancer

With the aid of specific monoclonal antibodies, tumor tissues from 68 patients with lung cancer were examined for their expression of two small cell lung carcinoma (SCLC) antigens, Fuc-GM1 (fucosyl GM1; IV2FucII3NeuAc GgOse4) and neural-cell adhesion molecule (NCAM), and two broader tumor antigens, carcinoembryonic antigen (CEA) and carbohydrate cancer-associated antigen CA 50. Expression of Fuc-GM1 was seen in 75% and NCAM in 78% of the SCLC specimens, but also in 12 and 20% of non-SCLC. Either or both of these antigens were expressed in more than 90% of SCLC and in 25% of non-SCLC. CEA was found in more than 80% of SCLC and non-SCLC. Expression of CA 50 was seen in 65-68% of non-SCLC and SCLC, showing preference for SCLC and lung adenocarcinoma. In SCLC, cellular expression of Fuc-GM1 was generally seen together with NCAM and CA 50, but rarely with CEA. There was considerable inter- and intratumor heterogeneity in the expression of all four antigens. The results suggest that CEA is the antigen of choice for the detection of lung cancer regardless of histotype. In combined analysis of CEA, CA 50, Fuc-GM1 and NCAM, two patterns of antigen expression were recognized that appear to discriminate between SCLC and non-SCLC tumors, respectively. A considerable fraction of SCLC and non-SCLC tumors, however, exhibited similar patterns of antigen expression. The biological and clinical significance of these observations remains to be investigated.

Long-term doppler echocardiographic results of aortic or mitral valve replacement with biocor porcine bioprosthesis

OBJECTIVESnOur objectives were to evaluate the long-term bioprosthetic and cardiac functional outcome after insertion (over a 10-year period) of a new-generation porcine zero pressure-fixed Biocor bioprosthesis, as well as to determine the echocardiographic accuracy for selection of patients requiring reoperation. The long-term systematic Doppler echocardiographic assessment after valve replacement with this bioprosthesis is lacking.nnnMETHODSnBetween January 1983 and January 1993, we inserted 756 Biocor prostheses in the aortic (619) or mitral (137) positions. All 51 patients who had a reoperation during the follow-up time were evaluated echocardiographically before reoperation. Additionally, 263 of 446 patients (59%) with aortic bioprostheses and 42 of 74 patients (57%) with mitral bioprostheses who were alive in January 1993 had long-term echocardiographic follow-up.nnnRESULTSnGroup A: Normally functioning bioprostheses were found in the aortic position in 242 of 263 patients and in the mitral position in 33 of 42 patients. Group B: Thirty patients had abnormal bioprosthetic function. Eleven patients had regurgitation, 3 had a combined lesion, and signs of calcification appeared in 16 patients with aortic valves, all with a peak gradient of above 60 mm Hg. Group C: Patients who had a reoperation (41 aortic and 10 mitral) within the follow-up period were followed up echocardiographically from the detection of a possible valve dysfunction until reoperation, and the findings accorded well with those at operation in 49 of 51 patients.nnnCONCLUSIONSnThese findings suggest that, during a long-term follow-up, most bioprostheses function normally, facilitating improved heart function. Abnormalities in a bioprosthesis usually develop gradually, enabling their detection by Doppler echocardiographic evaluations performed regularly or in case of any symptomatic deterioration.

Lung Cancer in West Sweden 1976-1985 A Study of trends and survival with special reference to surgical treatment

We reviewed 3 285 consecutive cases of lung cancer diagnosed in West Sweden during the period 1976-1985. Data were collected from the regional cancer registry, the Swedish National Population Registry, and medical records. During the study period, the annual female/male ratio increased from 0.29 to 0.42. In females, there was an increase primarily in the incidence of tobacco-related morphologic tumour types (i.e. squamous and small cell lung cancers). In males, a moderate increase of adenocarcinomas was seen, although squamous cell cancer remained the most common tumour type. The overall 5-year survival rate was 8.3%. In 641 patients (20%) a surgical tumour resection was carried out. The 5-year survival rate following resection was 38%, and the probability of 10-year survival was estimated at 25%. In a multifactorial model including gender, age, histology, pTNM stage and extent of resection, pTNM stage and, to a lesser degree, age were statistically significant independent predictors of postoperative survival. The five-year survival was 57% in stage 1, 21-27% in stage II and IIIa, and 10% in stage IIIb. Of all resected patients, 4.2% died within two months after resection. In males, early postoperative mortality was predicted by preoperative bicycle ergometry. The prognosis in non-resected patients was poor, with only 2% surviving 5 years or longer. In conclusion, the results indicate that some progress has been made with regard to surgical management of lung cancer, but they also point to the fact that the vast majority of patients are not amenable to curative treatments, and that the overall survival in lung cancer has improved only marginally during the last decades.

Immunohistochemical detection of two small cell lung carcinoma-associated antigens defined by MAbs F12 and 123C3 in bronchoscopy biopsy tissues

We have studied MAbs for their ability to detect SCLC and differentiate this tumor type from the other lung tumor histotypes in cryostat sections of biopsy specimens taken at bronchopscopy from patients with suspected primary lung tumor disease. MAb F12, specific for the ganglioside fucosyl‐GM1, reacted with 58% of the cases with SCLC (n= 19) and with less than 3% of those with non‐SCLC (n = 38). MAb 123C3, specifically reactive with NCAM, reacted with 78% of the SCLC cases (n = 23). With this MAb no positive staining was seen in the non‐SCLC cases (n = 41). None of the two MAbs reacted with tissue sections without tumor. In combined analysis with MAbs F12 and 123C3, all SCLC cases (n= 15) were positive with either and 47% with both of the MAbs. Our results show that both MAbs F12 and 123C3 are highly specific for SCLC in bronchoscopic biopsy tissue specimens, whereas the sensitivity for this histotype tends to be higher with MAb 123C3 than with F12 (P = 0.14). When used in combination, all SCLC cases could be identified. These MAbs may therefore be valuable as complements to current histopathologic characterization and differentiation of lung cancer.