Aneurysma des Ductus arteriosus Botalli

A congenital aneurysm of the ductus arteriosus Botalli was detected by chest X-ray as an intrathoracic mass in a 7-day-old infant. Following confirmation of the diagnosis by echocardiography and MRI the aneurysm was successfully resected via left lateral thoracotomy without cardiopulmonary bypass. The postoperative course was uneventful. Six years after operation the patient is asymptomatic and growing normally. An intrathoracic mass may be considered in the differential diagnosis especially in infants and children. Aneurysms of ductus arteriosus potentially are associated with serious complications. Timely diagnosis and early surgical intervention are decisive for prevention of serious com…

Regurgitant flow in apparently normal valve prostheses: improved detection and semiquantitative analysis by transesophageal two-dimensional color-coded Doppler echocardiography.

In 128 patients with apparently normally functioning prosthetic valves ( n = 136) in the aortic position ( n = 79) and the mitral position ( n = 57), the prevalence of transprosthetic regurgitant flow was studied by use of transthoracic and transesophageal two-dimensional color-coded Doppler echocardiography. With the transthoracic approach, regurgitant flow was detected in early systole or diastole for 28% of the mitral prostheses and for 29% of the aortic prostheses. With transesophageal color-coded Doppler echocardiography, regurgitant jets were visualized for 95% of the mitral prostheses and for 44% of the aortic prostheses. In 40% of the Bjork-Shiley prostheses and 88% of the St. Jude …

Endoventricular patch plasty improves results of LV aneurysmectomy.

From May 1985 to December 1991 52 patients were operated upon for postischemic left ventricular aneurysm (LV-A). Between May 1985 and July 1989 25 patients (group I) with a mean age of 59 (46-72) years underwent conventional aneurysmectomy with direct closure of the left ventricle (LV) and a mean of 1.9 (0-3) additional bypass grafts (54% triple-vessel disease). The hospital mortality was 8% (2/25) and the late mortality during a median follow-up time of 34 months was 28% (7/25) with a 4-year survival of 66%. Improvement in the quality of life (NYHA from 2.6 to 2.1, P = 0.078) and global left ventricular ejection fraction (EF) (from 35 to 38%) proved to be unsatisfactory in conjunction with…

Reversibilität von Veränderungen der links- und rechtsventrikulären Geometrie und Hämodynamik bei pulmonaler Hypertonie. Echokardiographische Charakterisierung bei Patienten vor und nach pulmonaler Thrombendarteriektomie (Reversibility of changes in left- and right ventricular geometry and hemodynamics in patients with pulmonary hypertension. Echocardiographic characteristics before and after pulmonary thrombendarterectomy)

Durch pulmonale Thrombendarteriektomie kann bei Patienten mit chronischer embolisch bedingter pulmonaler Hypertonie eine akute rechtsventrikulare Nachlastsenkung erzielt werden. Der Einflus auf die rechts- und linksventrikulare Geometrie und Hamodynamik wurde prospektiv mit Hilfe der transthorakalen Echokardiographie an einem Kollektiv von 14 Patienten (8 Frauen, 6 Manner; Alter 55 ± 20 Jahre) vor und nach 18 ± 12 Tagen postoperativ untersucht. Nach operativer Desobliteration der Pulmonalarterien fand sich eine Abnahme des invasiv bestimmten totalen pulmonalen Gefaswiderstands von 986 ± 318 auf 323 ± 280 dyn x s/cm5; p < 0,05. Der echokardiographisch erfaste systolische pulmonalarterielle D…

Klappenerhaltende Resektion eines Fibroelastoms

Papillare Fibroelastome sind seltene und gutartige Tumore des Herzens mit bevorzugter Lokalisation im Bereich der Klappen, die mit schwersten Komplikationen oder fatalen und malignem Verlaufen einhergehen konnen. In diesem Fallbericht wird uber eine modifizierte, klappenerhaltende Operationstechnik eines symptomatischen Fibroelastoms an der Aortenklappen berichtet.

Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula.

Objective: Herein we report our experience in placement of endovascular stentgrafts in the descending aorta in patients with acute bleeding complications due to traumatic rupture or aortobronchial fistula. Methods: Six patients (one woman, five men, mean age 47 ^ 19 years) were treated from September 1995 to February 2000 by implantation of endovascular stentgrafts in the descending aorta. Indications included traumatic ruptures of the aortic isthmus (na 3) and aortobronchial fistulas (na 3). All procedures were performed under general anaesthesia. The implants were introduced under fluoroscopic guidance via the aorta (na 1), the iliac (na 4) or femoral (na 2) artery, respectively. Results:…

Identification of abscess formation in native-valve infective endocarditis using transesophageal echocardiography: implications for surgical treatment.

The object of the study was to follow patients with endocarditis-associated abscesses in order to evaluate the clinical outcome with and without surgical intervention. Transesophageal echocardiography successfully displayed the location and extent of abscess cavities in 14 patients (group A) with aortic valve endocarditis. The infective process was limited to the perivalvular tissue in two, extended into the ascending aorta in six, and included the interventricular septum, the right ventricular outflow tract, interatrial septum, and/or mitral valve annulus in six patients. The complication rate was significantly higher in group A than in group B, which consisted of 27 patients with proven s…

Arterial Embolism to the Upper Extremity in a Patient with Factor V Leiden Mutation (APC Resistance)

Factor V Leiden mutation has emerged as one of the leading abnormalities in inherited blood coagulation disorders, resulting in a markedly increased risk for deep leg vein thrombosis. A 24- year-old woman presented with acute onset of critical ischemia of her left thumb and index finger. Intraarterial angiography revealed an embolus in the distal radial artery and a thrombotic occlusion of the digital artery of the thumb and index finger. Immediate therapy encompassed a selective surgical embolectomy of the distal radial artery followed by a local intraarterial lysis that was continued for 3 days. Additionally, therapeutic anticoagulation and vasodilating drugs (prostaglandin E) were admin…

Extremitätenerhalt durch pedalen In-situ-Bypass beim diabetischen Fußsyndrom

INTRODUCTION: Treatment of the ischemic diabetic foot syndrome still represents a medical and economic challenge. Contrary to the aims of the Saint Vincent declaration a dramatic reduction of major amputations in Germany was not noted, although in the diabetic patients the predominant type of tibial artery occlusion allows construction of pedal bypasses for limb salvage. METHOD: In patients with ischemic diabetic foot syndrome following angiographic evaluation of the ischemic limb, the indication for surgical revascularisation of patent pedal arteries was established. The in-situ technique was preferred in the presence of a suitable ipsilateral greater saphenous vein whenever possible. Reva…

Klebereinsatz in der Chirurgie der Aortendissektion

Im Gegensatz zur chronischen Dissektion der Aorta, die meist mit einer Dilatation des Aortenanulus und der Aorta ascendens sowie Aortenklappeninsuffizienz einhergeht und daher vorzugsweise durch Implantation einer klappentragenden Gefasprothese behandelt wird, sind bei akuter Dissektion mit normalkalibrigen Gefasverhaltnissen zumeist rekonstruktive Verfahren moglich.

Das Mitralklappenprolaps-Syndrom

Effects of Tolazoline and Prostacyclin on Pulmonary Hypertension in Infants After Cardiac Surgery

Objective To evaluate the hemodynamic effects of tolazoline and prostacyclin in infants with pulmonary vasospasm after cardiac surgery. Design Prospective cohort study. Setting Pediatric ICU. Patients The cohort consisted of 42 infants and children with congenital heart disease and pulmonary hypertension who underwent corrective surgery and were monitored postoperatively using pulmonary artery catheters. Fourteen infants (2 to 12 months old) in this group required postoperative treatment with tolazoline or prostacyclin. Interventions Tolazoline was administered as a bolus of 0.5 mg/kg for treatment of persistent pulmonary hypertension or acute pulmonary hypertensive crisis. If its effective…

Schwere sternale Wundkomplikationen nach kardiochirurgischen Eingriffen im Erwachsenenalter

Schwere postoperative Wundheilungsstorungen bis hin zur kompletten Sternumdehiszenz sind gravierende Komplikationen nach medianer Sternotomie in der Herz-Thoraxchirurgie. Sie fuhren zu einer erhohten Morbiditat- und Mortalitatsrate und verursachen eine sehr viel langere Hospitalisation der Patienten als bei normaler Wundheilung. Fur das Krankenhaus entstehen daraus zusatzliche Kosten. Die vorliegende Ubersichtsarbeit beschaftigt sich mit den schweren sternalen Wundheilungsstorungen und ihrer Atiologie, Symptomen, Diagnose, pradisponierenden Risikofaktoren und Behandlungsstrategien und berucksichtigt dabei die weltweit jungste Literatur.

Mediastinal lymph node staging with transesophageal echography in cancer of the lung.

Transesophageal echography (TEE) was used prospectively to study mediastinal lymph node enlargement in 23 patients with cancer of the lung. The findings were validated blindly by comparison with computed tomography (CT, n = 23) and pathological N classification after curative surgery (n = 9). Lymph nodes larger than 1 cm were defined as pathologically enlarged. In the upper mediastinum, 22% (8 vs 36), in the lower mediastinum including the subaortic region 112% (37 vs 33) and in the hilar region 67% (6 vs 9) of enlarged lymph nodes diagnosed by CT were detected by TEE. A pathological study in 9 patients demonstrated true positive findings in 2 vs 1, true negatives in 4 vs 5, false positives…

Continuous monitoring of mixed venous oxygen saturation in infants after cardiac surgery

Continuous mixed venous oxygen saturation (SvO2c) was measured in 16 infants immediately after cardiac surgery. A polyurethane 4F, dual channel catheter (Opticath, Modell U440, Oximetrix) with fiberoptic filaments was introduced into the pulmonary artery during cardiothoracic surgery. The catheters were left in place for an average of 67.5 h (range 27 h -125 h) and there were no catheter-related complications. Correlation between continuous in vivo SvO2 values and in vitro values was satisfactory (r = 0.85), whereas a correlation between SvO2c and arterial oxygen saturation (SaO2) was not found (r = 0.07). The sampled arterial lactate values were inversely correlated to the simultaneously m…

Three-Dimensional Contrast-Enhanced Magnetic Resonance Angiography in a Patient With Chronic Thromboembolic Pulmonary Hypertension Before and After Thromboendarterectomy

The patient was a 69-year-old man with progressive dyspnea during the previous 5 years and no history of thromboembolic events. By means of spiral CT scanning and multiplanar digital subtraction angiography of the pulmonary arteries, chronic thromboembolic pulmonary hypertension was diagnosed. Mean pulmonary artery pressure and pulmonary vascular resistance were elevated to 46 mm Hg and 890 …

Diagnosis of aortic dissection: the value of transesophageal echocardiography.

Using the transesophageal approach the descending part of the aorta can be imaged by two-dimensional enchocardiography in cross sections comparable to computer tomograms. The value of combined transesophageal and transthoracic echocardiography was evaluated in 53 patients who were studied consecutively from 1983 to 1986 with symptoms of aortic dissection and compared with computed tomography, angiography, surgery and/or autopsy. In all patients the transthoracic aorta could be visualized and the dissection could be classified according to DeBakey: in 9 of 29 patients (34%) type I dissection, in 4 (14%) type II dissection and in 16 (55%) type III dissection was found. Operation was carried o…

Aortenisthmusstenose bei Erwachsenen: operative Korrektur - mittel- und langfristige Ergebnisse

Fragestellung Ziel dieser retrospektiven Untersuchung war es, die Mittel- und Langzeitergebnisse der operativen Korrektur von Aortenisthmusstenosen (ISTHA) bei Erwachsenen zu erfassen. Patienten und Methodik Zwischen August 1985 und Januar 1999 wurden 20 Patienten (8 Frauen, 12 Manner) wegen ISTHA im Alter 19–60 Jahren (im Mittel 33 Jahre) operiert. Alle Patienten fielen klinisch durch Bluthochdruck der oberen Extremitaten auf (im Mittel 177/92 mmHg). Bei 9 Patienten von 16 (56%) handelte es sich um einen Zufallsbefund (bei 4 konnte dies nicht eruiert werden). Eine eingeschrankte praoperative Belastbarkeit wiesen 13 Patienten (65%) auf. Herzrhythmusstorungen zeigten sich bei 3 Patienten (15…

Reoperation and the centrifugal pump?

Postperfusion syndrome is still a problem in long cardiac operations using extracorporeal circulation (ECC). To evaluate whether or not centrifugal blood pumping during open heart surgery is beneficial, a randomized, prospective study was undertaken of 50 consecutive patients undergoing elective coronary artery bypass grafting. The patients were divided into two groups of 25 each. In group 1 a centrifugal pump (Biomedicus) was used as arterial blood pump, while in group 2 a roller pump (Stockert) was used. The two groups did not differ significantly and the number of variables during surgery was kept low (identical perfusion set, two surgeons, minimal cardiotomy suction). The parameters stu…

Zur Chirurgie des insuffizienten linken Ventrikels

PTCA of the left main stem following protective coronary artery bypass grafting.

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. R…

Aktuelle Frühergebnisse nach pulmonaler Thrombendarteriektomie bei chronischer thromboembolischer pulmonaler Hypertonie (Early results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension)

Die pulmonale Thrombendarteriektomie ist ein potentiell kuratives Operationsverfahren bei Patienten mit chronischer thromboembolischer pulmonaler Hypertonie. Von Juni 1989 bis Dezember 1994 wurden in unserer Klinik 109 Patienten einer pulmonalen Thrombendarteriektomie unterzogen. Seit Januar 1995 wurden vielfaltige Veranderungen des operativen und postoperativen Therapiekonzepts vorgenommen. Wir berichten uber die Fruhergebnisse von 32 Thrombendarteriektomien, die von Januar 1995 bis Januar 1997 durchgefuhrt worden sind.

Rapamycin vermindert die Neointimaausbildung nach vaskulärer Schädigung

Background: Proliferation and migration of vascular smooth muscle cells (SMCs) mark the key processes in the development of bypass graft disease and during neointima formation in restenosis after angioplasty. Growth factors are potent SMC mitogens as they are involved in SMC proliferation and in extracellular matrix (ECM) synthesis. Based on these premises, we examined the effect of the proliferation inhibitor rapamycin in human SMC culture and in a rabbit vascular injury model. Materials and methods: Injection of rapamycin or its vehicle was performed with an infusion-balloon catheter directly into the vessel wall during vascular injury. The intima/media ratio was determined histologicall…

Proliferative activity in stenotic human aortocoronary bypass grafts

Abstract Background: Aortocoronary bypass graft disease is responsible for long-term failure of autologous vein grafts. The analyses of proliferation and cell type characterisation in human bypass grafts harvested during re-do surgery make it possible to investigate the cellular processes leading to bypass graft failure. Methods: 30 stenotic vein grafts and 25 control veins were explantated during re-do heart surgery procedures. The total area and cell count of the neointima, media and adventitia were calculated computer-assisted. Actively proliferating cells were identified using antibody to Ki-67 and positive cells were determined by double-label immunocytochemistry with SMC α-actin, CD 3…

Nitric oxide and prostacyclin lower suprasystemic pulmonary hypertension after cardiopulmonary bypass

In a 3-week-old male newborn persistent suprasystemic pulmonary hypertension developed after surgical valvulotomy for a critical aortic valve stenosis. Because of a residual transvalvular pressure gradient of 35 mmHg and postoperative left as well as right ventricular dysfunction, treatment with inhaled nitric oxide (NO) and intravenously infused prostacyclin (PGI2) was attempted. Low-dose inhaled NO and low dose PGI2 corrected severe pulmonary hypertension and led to an increase in cardiac output. Treatment with NO but not PGI2 was accompanied by a rise in PaO2 and systemic blood pressure. Interruption of NO administration led to a rapid increase in pulmonary arterial pressure to suprasyst…

Patterns and diagnostic value of cardiac troponin I vs. troponin T and CKMB after OPCAB surgery.

Cardiac troponin I (cTnI) has been shown to be a specific marker for myocardial injury in cardiac surgery. The object of this prospective study was to determine the patterns and kinetic and diagnostic value of cTnI, cardiac troponin T (cTnT), and creatine kinase MB (CKMB) activity after minimally invasive coronary revascularization using an octopus device on the beating heart (OPCAB).48 patients (33 male/15 female, mean age 68.3 +/- 8.7 years) underwent their first elective OPCAB surgery with median sternotomy without mortality. The mean number of grafts was 2.0 +/- 0.8 per patient. Preoperative mean ejection fraction was 56.6 % +/- 14.9%. CTnI and T levels, total creatine kinase (CK) and C…

Gene expression profiling of human stenotic aorto-coronary bypass grafts by cDNA array analysis

Objective: Aorto-coronary bypass graft disease with its increasing clinical signification represents an unsolved problem in cardiological and heart surgery practice. Late occlusion of autologous saphenous vein grafts is due to medial and neointimal thickening secondary to migration and proliferation of smooth muscle cells (SMCs) and the subsequent formation of atherosclerotic plaques. This study is aimed at identifying differentially expressed genes in human stenotic bypass grafts to detect unknown pathomechanism and to identify novel targets for prophylactic treatment options. Methods: Stenotic saphenous aorto-coronary bypass grafts ðn ¼ 5Þ were retrieved during re-do aortocoronary bypass …

Der kurze popliteodistale Venenbypass beim diabetischen Fußsyndrom DFS

Purpose: World wide increase of diabetes compound with diabetic foot syndrome becomes a challenge in vascular surgery to avoid limb loss. In diabetics a special pattern of atherosclerosis is prevalent with disease limited to the infrageniculate arteries but sparing inflow vessels and distal tibial and pedal arteries. This provides short bypass grafting from popliteal to tibial and pedal arteries, a concept first described by F. Veith in 1981. Methods: Diabetics with severe atherosclerotic disease and limb-threatening ischemia got general evaluation and vascular imaging. Falling in this special category the patients underwent short vein bypass grafting originating at the first or third popli…

Reduced inotropic support after aprotinin therapy during pediatric cardiac operations

Several reports indicate that aprotinin treatment before and during cardiopulmonary bypass (CPB) might have a protective effect on the myocardium. We evaluated the hemodynamic effects of perioperative aprotinin treatment.We conducted a randomized, double-blind, placebo-controlled trial in 34 infants (mean age, 2.5 years) who had cardiac operations. Half of the patients received high-dose aprotinin therapy. There were no significant differences between the aprotinin and placebo groups with respect to age, weight, sex, aortic cross-clamp time, and CPB time. The following data were recorded at arrival in the intensive care unit 6, 12, 24, and 48 hours after termination of CPB: heart rate, bloo…

External reinforcement of varicose veins with PTFE prosthesis in infrainguinal bypass surgery -- clinical results.

OBJECTIVE Segmental varicose degeneration of the autogenous greater saphenous vein may limit its use in infrainguinal bypass surgery. Wrapping a PTFE prosthesis around dilated veins has emerged as an option to create externally reinforced vein bypasses. Results regarding graft patency and limb salvage were analyzed. METHODS Between September 1995 and January 2001, 35 infrainguinal bypass operations in 33 patients were performed with greater saphenous veins exhibiting segmental varicose dilatation. Grafts were followed by duplex scan and retrospective analysis of graft patency and limb salvage was performed. RESULTS One bypass prompted successful revision for early occlusion. Four bypasses r…

Autogenous Reconstruction of Infected Arterial Prosthetic Grafts Utilizing the Superficial Femoral Vein1

BACKGROUND Prosthetic infection after reconstructive vascular surgery is a most serious complication, associated with high mortality and amputation rates. Following excision of the infected graft, several methods of reconstruction are available. We present here our experience with autogenous reconstruction of infected prosthetic arterial grafts using the superficial femoral vein (SFV). METHODS From November 1995 to December 1999, we used the SFV in seven patients (mean age 70 years) for reconstruction of an infected aortobifemoral (n = 2), aortoiliac (n = 1), femorofemoral bypass (n = 1), femorotibial (n = 2) and carotid crossover bypass (n = 1). Treatment encompassed complete prosthetic ex…

113. Beurteilung klappenrekonstruktiver Massnahmen mittels intraoperativer transoesophagealer Kontrastechokardiographie

Bei 30 Patienten mit Mitral- bzw. Tricuspidalklappenfehlem (6 Mitralstenosen bzw. 13 -insuffizienzen, 12 Tricuspidalinsuffizienzen) wurde intraoperativ am schlagenden Herzen mittels transoesophagealer Echokardiographie (TEE) der Erfolg einer operativen Rekonstruktion uberpruft. 1 ml eines Echokontrastmittels wurde nach Bypassende in den jeweiligen Ventrikel injiziert. Anhand des Ausmasses der Regurgitation des Kontrastmittels in den betreffenden Vorhof konnte das Rekonstruktionsergebnis beurteilt werden. Bei allen Tricuspidalklappen sowie bei 16/19 Mitralklappen konnte eine erfolgreiche Rekonstruktion belegt werden. Die Aufdeckung einer massiven Mitralinsuffizienz bei 3/19 Patienten durch d…

Remodeling der Aorta als rekonstruktive Maßnahme für Aneurysmen der Aorta aszendens

Eine weniger haufig gebrauchte Methode zur operativen Therapie des Aszendens-Aneurysmas ist die plastische Rekonstruktion im Sinne einer Reduktionsplastik mit anschliesender Ummantelung der nativen Aorta. Der Vorteil liegt in der vollstandigen Erhaltung der Endothelzellschicht der Aorta und der Beibehaltung der dynamischen Funktion der Sinus Valsalvae.¶ Von 1987–1998 wurden 20 Patienten mit einem Aneurysma verum nach der o.g. Methode operiert. In 9 Fallen (Gruppe I – mittleres Patientenalter 72 Jahre; Spannweite 64–78 Jahre) beschrankte sich der Eingriff auf die plastische Rekonstruktion der Aorta und konsekutive Ummantelung. Bei 11 Patienten (Gruppe II – mittleres Patientenalter 45 Jahre; …

Diagnose eines intramyokardialen Hämatoms nach traumatischem Myokardinfarkt durch Magnetresonanztomographie

Thoraxverletzungen treten bei etwa 30% aller traumatisierten Patienten auf, wobei in den meisten Fallen Verkehrsunfalle die Ursache sind. Wir berichten uber den Fall eines Patienten, der nach einem Skiunfall einen traumatischen Vorderwandinfarkt erlitt. Im weiteren Verlauf kam es zu einer ausgedehnten intramyokardialen Einblutung. Differentialdiagnostisch kam zunachst ein linksventrikulares Pseudo- bzw. Pseudopseudoaneurysma in Frage, kernspintomographisch konnte jedoch durch den Nachweis eines schmalen Myokardsaums sowohl ventral als auch dorsal der Raumforderung die Diagnose eines intramyokardialen Hamatoms gestellt werden. Bei dem Patienten wurde daraufhin eine aortokoronare Bypass-Opera…

Solitäre fibröse Pleuratumoren - Seltene Tumoren mit unvorhersehbarem klinischen Verhalten

Solitary fibrous tumors of the pleura are rare tumors with unpredictable clinical behaviour. We report about two patients with an incidental finding of an intrathoracic tumor. Preoperative diagnosis was uncertain. In both patients, a solid tumor of the pleura was resected en bloc in combination with a wedge resection of the lung following anterolateral thoracotomy. The postoperative course was eventful. Six months after primary complete resection there were no signs of tumor recurrence.

Ventrikuläre Assistenz mit Zentrifugalpumpen beim Postkardiotomie-Low-output-Syndrom

Im Juli 1986 wurde an der Klinik fur Herz-, Thorax- und Gefaschirurgie der Universitat Mainz erstmalig in der Bundesrepublik Deutschland erfolgreich die extrakorporale Kreislaufassistenz mit Zentrifugalpumpe bei einem Patienten mit therapierefraktarem Postkardiotomie-Low-output-Syndrom eingesetzt. Von 7/86 bis 12/90 wurde dieses Verfahren bei insgesamt 12 Patienten — oder 0,52% von insgesamt 2321 — mit Hilfe der Herz-Lungemaschine (HLM) am offenen Herzen operierten Patienten angewandt. Wahrend dieses Zeitraums wurde die intraaortale Ballongegenpulsation als ausschliesliche oder primare mechanische Kreislaufhilfe bei 60 Patienten — oder 2,6% — eingesetzt, so das die Gesamtinzidenz des postop…

Clinical and morphological characteristics in Streptococcus bovis endocarditis: a comparison with other causative microorganisms in 177 cases

Aim—To compare the clinical and morphological characteristics of patients with Streptococcus bovis endocarditis with those of patients with endocarditis caused by other microorganisms. Methods—177 consecutive patients (Streptococcus bovis, 22; other streptococci, 94; staphylococci, 44; other, 17) with definite infective endocarditis according to the Duke criteria were included. All patients underwent transthoracic and transoesophageal echocardiography. In 88 patients, findings from surgery/necropsy were obtained. Results—S bovis endocarditis was associated with older patients, with a higher mortality (p = 0.04), and with a higher rate of cardiac surgery (p < 0.001) than other microorganisms…

Schwere sternale Wundkomplikationen nach heizchirurgischen Eingriffen — Inzidenzen, Morbidität, Mortalität, Risikoanalyse und Resultate

Sternumdehiszenz oder ausgedehnte sternale Wundheilungsstorungen sind schwerwiegende Komplikationen nach medianer Sternotomie in der Herzchirurgie. Ziel der vorliegenden Studie war die Ermittlung und Erfassung von Haufigkeit, Spektrum, Risikofaktoren und Behandlungsergebnissen bei Pat. mit Sternumdehiszenz bzw. mit schweren sternalen Wundkomplikationen.

Troponin T — a reliable marker of perioperative myocardial infarction?

Following cardiac surgery, electrocardiography and creatine kinase isoenzyme MB (CK-MB) activities are of limited value in diagnosing a non-transmural infarction. With the recent availability of an assay to detect serial levels of the specific cardiocyte contractile protein troponin T the possibility has been increased of closing a diagnostic gap among cardiosurgical patients. Ninety patients with severe diffuse three-vessel disease undergoing myocardial revascularization were grouped by their postoperative electrocardiographic (ECG) findings (group I--unchanged ECG; group II--new Q-waves representing perioperative myocardial infarction (PMI)). Serial levels of troponin T and the activity o…

Die Eversions-Endarterektomie der A. carotis interna als Simultanoperation in der Koronarchirurgie

Im Zeitraum von Oktober 1993 bis Oktober 1996 wurde bei 27 Patienten simultan zur Koronaroperation eine Eversions-Endarterektomie (EEA) der A. carotis interna durchgefuhrt. Praoperativ hatten 2 Patienten eine Hemiparese erlitten, 3 Patienten hatten uber transitorisch ischamische Attacken (TIA) berichtet. Bei den ubrigen Patienten mit asymptomatischer Karotis-Interna-Stenose wurde die Operationsindikation aufgrund einer hochgradigen, wenn auch klinisch asymptomatischen Stenosierung (>90%) gestellt. Bei 23 Patienten lag eine einseitige Karotisstenose vor, bei 4 Patienten war auch die Gegenseite bis maximal 70% stenosiert, wobei sich die Wahl der Operationsseite nach der klinischen Symptomatik…

Mitral Valve Repair Without Using Rings or Slings

Reconstructive surgery of the mitral valve is still deemed superior to prosthetic replacement because of the lower operative risk as well as the fewer thromboembolic complications [1, 2]. Whereas closed or open commissurotomy of a stenosed mitral valve has been routine in the past and present [3], reconstructive measures for incompetent valves have been among those least often performed. The use of rigid or semi-flexible annular rings [4–9] has significantly contributed to progress in this field. However, these are not suitable for repair of all valvular lesions and undoubtedly have at least some of the negative features of prosthetic substitutes. We have therefore started a program of mitr…

Trainierte Skelettmuskulatur als Herzmuskelersatz: Ein neues Therapiekonzept

‘Soft’ Snaring of the Coronary Artery in Minimally-Invasive Coronary Surgery

A technique is described that allows a simple and safe temporary occlusion of the coronary artery in beating heart procedures using monofilament stay sutures underlaid with small pericardial pads. Postoperative serial levels of Troponin I remained low (<4 ng/L) and control angiography revealed no stenosis in the distal coronary artery.

Expression of the proto-oncogene c-myc in human stenotic aortocoronary bypass grafts.

Summary Proliferation and differentiation of vascular smooth muscle cells (VSMC) are central events in vascular pathobiology and play a major role in the development of stenotic and restenotic lesions [ 15, 27 ] . The proto-oncogene c-myc and other early cell cycle-regulating genes have been implicated in the induction of cell proliferation and differentiation under diverse pathophysiological conditions [ 11, 13 ] . In the present study we analyzed c-myc mRNAexpression by indirect nonradioactive in situ hybridization technique (NISH) in human stenotic venous bypass grafts (n = 32) retrieved during re-do operations of coronary artery disease and compared the results with 28 native veins (ven…

Revaskularisation mit der A. gastroepiploica dextra — Bewertung der Indikation und des perioperativen Risikos

Bei 35 Patienten (mittleres Alter 64,0 Jahre (±10,4 Jahre) wurde bei fehlender oder unbrauchbarer V. saphena magna neben der einoder beidseitigen A. thoracica interna (ITA) die rechte A. gastroepiploica (GEA) zur Revaskularisation der rechten Koronararterie (RCA) verwendet. Ausgeschlossen wurden Patienten mit erheblicher Adipositas (Broca-Index >20%) sowie Patienten mit abdominellen Voroperationen. In einem Fall konnte die GEA wegen Plaquebildung nicht verwendet werden. Bei 23 Patienten wurde die GEA mit dem R. interventricularis posterior (RIVP), bei 11 Patienten mit der RCA vor bzw. in Hohe der Crux anastomosiert.

Intraoperative Evaluation of Reconstruction of the Atrio ventricular Valves by Transesophageal Echocardiography

In a total of 30 operations the mitral valve was reconstructed in 18, the tricuspid valve in 11, and both AV-valves in one patient. The result of reconstruction was tested first in the open arrested heart by injection of crystalloid solution into the appropriate ventricle either through the reconstructed valve or one of the great arteries. Upon termination of cardiopulmonary bypass the valve function was examined in the beating heart by means of transesophageal contrast echocardiography (TEE). For visualization 0.5-1.0 cc of agitated Gelifundol was injected into the ventricle. In 22 patients open testing as well as echocardiographic visualization showed identical and good operative results.…

Endovaskuläre Therapie aortaler Aneurysmen: erste klinische Ergebnisse

PURPOSE A clinical study aiming at examining the implantation technique and the clinical results of a new vascular prosthesis in endovascular therapy of aneurysms of the aorta. MATERIAL AND METHODS In 21 patients (20 men of 55 to 87 years of age, average age 70 years) with aneurysms of the infrarenal abdominal aorta (AAA n = 19) and the thoracic aorta (n = 2), a self-expanding nitinol stent with outer Dacron sheath (tubular prosthesis n = 4; bifurcation prosthesis n = 17) was implanted by means of an F-18 introductory set after surgical opening of the inguinal artery. RESULTS By means of the 4 tubular prostheses and 13 of the 17 bifurcation prostheses the aneurysm was bypassed completely. I…

Diagnosis of perioperative myocardial necrosis following coronary artery surgery — a reappraisal of isoenzyme analysis

Although the routine determination of CK-MB activity is widely used after coronary artery bypass grafting (CABG), the diagnosis of a perioperative myocardial necrosis remains arbitrary. The intention of the present study was to develop discriminative enzymatic parameters of CK-MB activity in a collective of 710 patients following CABG. Patients were grouped according to their postoperative electrocardiogram (ECG). For each patient, the time activity curve of CK-MB was determined. The total amount of CK-MB was calculated by integrating the area beneath the CK-MB activity curve. Patients presenting with an unchanged postoperative ECG (group I) or a new bundle branch block with uncompromised h…

Transvaskuläre Fensterung eines dissektierenden Aortenaneurysmas

A review of 507 off-pump coronary bypass patients: a single center experience.

This retrospective study evaluates perioperative results of 'Off-pump' coronary artery bypass surgery (OPCAB) experience in a single center. Five hundred and seven patients were operated (median sternotomy) from 1998 to 2002 using OPCAB. Patient data were registered and risk prediction calculated using the full logistic version of EuroSCORE. Overall, 1091 distal anastomoses were performed and only five (1%) patients required conversion to cardiopulmonary bypass. The predicted mortality was 3.8+/-4.5%, the observed mortality was 2.37%. OPCAB technique has become a standard approach in our department with low mortality and morbidity rates even in treatment of multivessel disease or high-risk …

Intraoperative Evaluation of the Reconstruction of the Atrioventricular Valves by Means of Transesophageal Echocardiography

In 44 operations, the mitral valve was reconstructed in 28 patients, the tricuspid valve in 12, and both atrioventricular (AV) valves in four. The results of reconstruction were tested first in the open arrested heart by injection of a crystalloid solution into the left or right ventricle, either through the reconstructed valve or via one of the great arteries. Upon termination of cardiopulmonary bypass the valve function was examined in the beating heart by transesophageal contrast echocardiography (TEE). For purposes of visualization, 0.5–1.0 cc of agitated Gelifundol was injected into the ventricle. In 31 patients, open testing and echocardiographic visualization showed identical, good o…

Pulmonale Thrombendarteriektomie bei thromboembolischer pulmonaler Hypertonie: Indikationen und Frühergebnisse

Pulmonary thrombendarterectomy was performed in 32 patients (14 men and 18 women; mean age 38 +/- 15 years) with thromboembolic pulmonary hypertension (New York Heart Association stage III: n = 22; stage IV: n = 10). The preoperative arterial pO2 averaged 59 +/- 11 mm Hg; pulmonary vascular resistance (PVR) and mean pressure (MPAP) were increased to 1,045 +/- 430 dyn.s.cm-5 and 53 +/- 12 mm Hg, respectively. The perioperative death rate was 22% (7 of 32). In the 25 survivors the pulmonary hypertension was reduced to a PVR of 194 +/- 75 dys.s.cm-5, MPAP of 28 +/- 6 mm Hg. Subsequent re-examination in 15 patients (NYHA stage I: n = 14, stage II: n = 1) after a mean of 17 +/- 5 months demonstr…

New bundle branch block after coronary artery bypass grafting— evaluation by CK-MB isoenzyme analysis and transoesophageal echocardiography

Twelve patients with a new complete bundle branch block after coronary artery bypass grafting underwent transoesophageal echocardiography (TEE). The results of TEE were compared with the pre-operative ventriculography, CK-MB isoenzyme time-release curves and clinical course. In eight patients with transient right bundle branch block or bifascicular block, low CK-MB activities and an uncomplicated postoperative course, transoesophageal echocardiography showed no new segmental wall motion abnormalities apart from a paradoxical septal movement in five. A persistent right or left bundle branch block was associated with either elevated isoenzyme activities, transoesophageal echocardiographic evi…

Long-term results after thromboendarterectomy for chronic pulmonary embolism1

Objective: In patients with chronic thromboembolic pulmonary hypertension, pulmonary vascular resistance (PVR) can be reduced by pulmonary thromboendarterectomy (PTE). In this study, long-term symptomatic and hemodynamic effects were investigated. Methods: Twenty-two patients (12 female, 10 male, mean age 40 years, preoperative NYHA functional class II/III/IV: n = 1/12/9) were re-evaluated 48‐72 months (mean 60 months) after surgery. In addition to clinical assessment, radiologic, hemodynamic and echocardiographic investigations were performed. Results: All patients reported a marked improvement of their clinical condition. At follow-up, 11 patients were identified as NYHA class I, 10 as NY…

EDV-gestützte Leistungserfassung und Dokumentation in der Herz-, Thorax- und Gefäßchirurgie

Angesichts des steigenden Patientenaufkommens und der Verscharfung des wirtschaftlichen Wettbewerbs der letzten Jahre ist eine exakte Leistungs- und Kostenerfassung nicht erst durch das Gesundheitsstrukturgesetz zu einer unabdingbaren Notwendigkeit geworden. Vorgestellt wird ein Datenbanksystem mit dem Namen “TOPAS”, das fur die Datenerhebung im OP konzipiert wurde und nicht als allgemeines Klinikinformations- und Verwaltungssystem dient.

Operationen und Reinterventionen an Herzklappen bei bakterieller Endokarditis

Erst seit den fruhen 60er Jahren ist eine Klappenchirurgie am offenen Herzen durch den Einsatz der Herz-Lungen-Maschine moglich geworden. Dennoch waren bis 1970 nur etwa 40 Berichte uber Herzklappenoperationen bei Endokarditis veroffentlicht. Zweifellos basierte diese Zuruckhaltung auf dem Grundsatz, keine Operation oder Fremdmaterialimplantation bei floriden entzundlichen Prozessen wegen der Gefahr der Implantatabstosung und intraktablen Infektion vorzunehmen. Die aus der Not geborene Erfahrung lehrte erst spater, das eine solche Infektion oft erst und nur durch die Operation zur Abheilung kam und mit etwa 10% relativ selten eine Prothesenendokarditis resultierte. Umgekehrt als zunachst an…

Chirurgische Behandlung des hypoplastischen Linksherzsyndroms

Kinder mit dem angeborenen Herzfehler eines hypoplastischen Linksherzsyndroms haben ohne fruhzeitige chirurgische Behandlung eine extrem ungunstige Prognose. Anhand einer retrospektiven Funf-Jahres-Analyse werden die Moglichkeiten und Ergebnisse der herzerhaltenden palliativen Rekonstruktion dargestellt.

Thrombendarteriektomie bei chronischer thromboembolischer pulmonaler Hypertonie: Hämodynamik und Rechtsherzfunktion im Langzeitverlauf

OBJECTIVE To find out whether pulmonary thromboendarterectomy (PTE) can achieve lasting reduction of pulmonary vascular resistance in patients with pulmonary arterial hypertension due to chronic thromboembolism. PATIENTS AND METHODS 45 patients (25 women, 20 men; mean age 45 +/- 24 [19-67] years) were re-investigated a mean of 21 (13-32) months after successful PTE. Two patients had then been in New York Heart Association (NYHA) stage II, 26 in stage III, and 17 in stage IV. In addition to clinical examination and chest radiogram 36 patients had right heart catheterization, 28 pulmonary angiography and 44 echocardiography. RESULTS Definite improvement of symptoms had occurred in all. 34 wer…

Extrathoracic Arteriosclerotic Vascular Changes Preclude the Use of the Internal Thoracic Artery for Coronary Artery Bypass Grafting

During a two-years period we have treated 6 patients where use of the internal thoracic artery for coronary artery grafting was precluded because of extrathoracic arteriosclerotic vascular lesions. In four patients with severe aorto-iliac occlusive disease preoperative digital angiography demonstrated collateralisation of the lower extremity by either the left, right, or both internal thoracic arteries (ITA). In these cases use of the ITA was excluded in order to preserve the collateral supply and coronary bypass grafting was performed using only saphenous vein. In two patients with proximal occlusion of the left subclavian artery the right ITA was used as in-situ bypass to graft the left a…

Laser Welding - Suitable for Vascular Anastomosis?

Carotid arteries of 21 piglets were transsected and reanastomosed either by laser welding (Neodym:YAG laser) or by conventional suture anastomosis. Histological specimens of the anastomoses obtained 2 to 32 days after the operation showed less foreign body reaction and intimal hyperplasia after laser welding than after suturing. There was, however, no significant difference when comparing occurrence of thrombosis, patency rate, or growth of the anastomosis in growing animals. Neither our study nor a review of the literature of laser-assisted vascular anastomosis in microvessels and large arteries up to 5 mm diameter could establish a definite clinical application for laser welding in vascul…

The Fontan-Operation: From Intra- to Extracardiac Procedure

Purpose For treatment of univentricular heart, the Fontan operation has been established as the definitive palliation. The current controversy is mainly based on the high incidence of arrhythmias after an intra-atrial lateral tunnel Fontan operation. Methods From January 1995 until April 2002. 46 children underwent a Fontan-type operation with or without a small fenestration. In 33 patients (group I) an Intracardiac tunnel and in 13 patients (group II) an extracardiac conduit procedure was performed. Principal findings There was no perioperative mortality. All patients showed postoperative a significant increase of arterial oxygen saturation, from 76 to 86% after surgery with fenestration, …

Analgosedierung mit Fentanyl/Midazolam nach Korrektur angeborener Herzfehler

Abstract There is no standard therapy in the management of postoperative pain control following corrective cardiac surgery of congenital heart disease. Assessment in the preverbal age is difficult. In a randomized study we compared a combined treatment of fentanyl and midazolam, given as continuous infusion versus single dose application. A pain assessment score was used to measure the effectiveness of analgosedation in addition to recording nurseries observations. Fentanyl and midazolam are an appropriate combination for postoperative pain treatment. Continuous application is considered to be more effective concerning basic anxiety, cumulative dosage and to avoid volume overload in infants…

Evaluation of the healing of precoated vascular dacron prostheses.

Knitted and woven Dacron grafts commercially coated with bovine collagen, gelatin and human albumin were implanted end-to-side between the infrarenal aorta and the bifurcation in 35 growing pigs. Grafts were explanted after 4, 8 and 12 weeks and compared to 6 uncoated knitted prostheses preclotted with blood that served as a control. Uncoated grafts rapidly developed a firmly attached neointima lined with endothelium. Compared with coated grafts the thrombus-free area of uncoated grafts was significantly larger (P less than 0.05). The slow resorption of albumin resulted in a delayed and incomplete neointimal healing and failing graft incorporation. Although the bovine collagen was only mini…

Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography.

Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen c…

Acetylcholine in isolated airways of rat, guinea pig, and human: species differences in role of airway mucosa

Stored endogenous acetylcholine (ACh) and in vitro synthesis of [3H]ACh were measured in isolated, mucosa-intact and mucosa-denuded airways of rat, guinea pig, and humans. In addition, choline acetyltransferase (ChAT) activity and ACh content were measured in freshly isolated airway mucosa as well as in cultured epithelial cells of rat tracheas. Rat tracheas stored 25 nmol/g ACh, whereas guinea pig tracheas and human bronchi contained only 2-3 nmol/g ACh. When incubated with [3H]choline, the isolated airways of rat, guinea pig, and human synthesized significant amounts of [3H]ACh. In guinea pig and human airways, removal of the mucosa affected neither stored ACh nor in vitro synthesis of […

Assistierte Zirkulation bei einem 7 Tage alten Neugeborenen wegen Postkardiotomie-low-output-syndrom

Bei einem 7 Tage alten Saugling wurde ein nach anatomischer Korrektur einer d-Transposition der grosen Arterien aufgetretenes Postkardiotomie-low-output-Syndrom mittels assistierter Zirkulation behandelt. Unter Einsatz eines Zentrifu-galpumpensystems konnte die linksventrikulare Kreislaufunterstutzung bis zur Durchfuhrung eines erfolgreichen Entwohnungsverfahrens nach insgesamt 20 Stunden der Kreislaufassistenz aufrechterhalten werden. Zum Entlassungszeitpunkt war bei dem neurologisch unauffalligen Neugeborenen echokardiographisch eine komplette Erholung der linksventrikularen Funktion nachweisbar.

Primäres Leiomyosarkom der Pulmonalarterie: Inzidenz, Diagnostik und Therapie

Leiomyosarkome des Herzens und der grosen Gefase sind sehr seltene hochmaligne Tumoren, die meist rasch zum Tode fuhren.¶ Wir berichten uber einen 31-jahrigen Patienten mit einem von der Pulmonalklappe ausgehenden Leiomyosarkom, das beide Pulmonalarterien und den Ausflusstrakt des rechten Ventrikels miteinbezog. Infolge der raschen Diagnosestellung und nachfolgenden radikalen Resektion ist der Patient nach mehr als 5 Jahren weiterhin tumorfrei. Nur die fruhzeitige Diagnose und komplette chirurgische Excision konnen die Uberlebenschance fur Patienten mit Pulmonalissarkomen erhohen.

In-vitro-Untersuchung von biologischen und technischen Herzklappenprothesen im MRT: Beurteilung möglicher Anziehung und Erhitzung der Implantate

PURPOSE In vitro evaluation of possible deflection and heating of present-day prosthetic heart valves during MR imaging at 1.5 T. METHODS 17 prosthetic heart valves, 12 technical and 5 biological, were investigated using a 1.5 Tesla Siemens Vision system. Deflection was measured at the edge of a 1.5 Tesla superconducting magnet. Each valve was then submerged in a vial of a 1/1 electrolyte solution and temperature was measured before and after imaging with a turbo-spin-echo sequence (TR 5200 ms, TE 138 ms, Flip angle 180 degrees, acquisition time 10.5 minutes, length of echo train 29). MR imaging was performed with phase encoding parallel and perpendicular to the plane of the valves. RESULTS…

Assessment of successful valve reconstruction by intraoperative transesophageal echocardiography (TEE)

In 17 patients (10 patients with mitral insufficiency, 5 patients with tricuspid regurgitation, 2 patients with mitral stenosis) the result of valve reconstruction was evaluated by intraoperative two-dimensional transesophageal contrast-echocardiography (TEE). Therefore, 1–2 cc of an agitated contrast-medium (GelifundolR) were injected into the left or right ventricle. The result of reconstruction was assessed by the extent of regurgitant microbubbles into the left or right atrium. A successful valve repair could be demonstrated in 15 patients without or with only minimal regurgitation of contrast-fluid. In one patient residual severe mitral insufficiency after valve reconstruction could on…

Chirurgische Therapie des Pulmonalarteriensarkoms

BACKGROUND AND OBJECTIVES Pulmonary artery sarcoma is a rare neoplasm and possibly unnoticed cause of pulmonary hypertension. The presentation is one of central pulmonary artery obstruction and progressive right-heart failure. In most cases, the diagnosis of malignancy is confirmed post mortem. We report the outcome of eight patients with primary pulmonary artery sarcomas. METHODS Eight patients (four female, four male, mean age 48,2 years, preop. NYHA functional class III/IV: n = 5/3) were referred for further evaluation of pulmonary hypertension. Malignancy was suspected in six of these patients by means of computed tomography (CT) and magnetic resonance tomography (MRT). In two patients …

Value of echocardiography in patient follow-up after surgically corrected type A aortic dissection.

Background To identify patients (pts) at risk of late complications, follow-up after surgery for type A aortic dissection is essential. We assessed the value of echocardiography to monitor patients after surgery for type A aortic dissection. Methods 80 out of 108 pts operated between 1989 and 1999 for type A aortic dissection survived surgery. 62 pts with at least one TEE, CT or MRI examinations during follow-up were included in this study. All pts had transthoracic echocardiography (TTE), 53 transesophageal echocardiography (TEE), 51 had CT, and 39 had MRI. Results At the first follow-up, 12 of 48 pts with aortic valve sparing surgery presented with aortic insufficiency >I degrees detected…

Anti-inflammatory properties of simvastatin on leukocyte-endothelial cell interactions following hemorrhagic shock

Background Hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have been shown to lower serum cholesterol levels. Recent studies reported that statins have vasculoprotective effects independent of their cholesterol-lowering properties. We studied simvastatin for its ability to modulate leukocyte-endothelial cell interactions under acute inflammation following hemorrhage and reperfusion. Methods The effects of simvastatin on leukocyte-endothelial cell interactions were observed by intravital microscopy in the rat mesenteric microcirculation and by immunohistochemical analyzes. Simvastatin (50 μg/kg or 100 μg/kg) was administrated intraperitoneally 18 h before study. Inf…

Congenital mitral regurgitation caused by a perforation in the anterior leaflet: Perioperative evaluation by color-coded Doppler echocardiography

Color-coded two-dimensional (2D) echocardiography confirmed the presence of severe congenital mitral regurgitation in an 8-month-old infant. Intraoperative inspection revealed an isolated perforation in the anterior leaflet.