0000000000010926
AUTHOR
S. Iversen
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…
Sarcoma of the pulmonary artery: Report of two cases and a review of the literature
Primary tumours of the pulmonary arteries are rare neoplasms seldom diagnosed during the patient's life time. We report on two cases of pulmonary artery sarcomas diagnosed during life time of the respective patients in intra-operative frozen sections by histopathological examination. Case 1 was of a 55-year-old man with a fibrosarcoma originating from the main pulmonary trunk. Case 2 was of a 43-year-old woman with a malignant fibrous histiocytoma originating from the right pulmonary artery. In both patients a radical tumour resection under cardiopulmonary bypass was attempted. Both patients, however, had a local tumour recurrence and died 18 months (patient 1) and 6 months (patient 2) afte…
Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism.
Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thro…
Value and limitations of transesophageal echocardiography in the evaluation of aortic prostheses.
Results of 34 transesophageal (TEE) studies in patients with suspected aortic prosthetic dysfunction were compared with transthoracic echocardiographic (TTE) results and to anatomic findings. Mass lesions noted at surgery (autopsy) were correctly described in 93% by TEE versus 43% by TTE. Abscesses were detected in 88% by TEE versus 18% by TTE. Bioprosthetic degeneration was visualized in 88% versus 38% and prosthetic obstruction correctly identified in 75% versus 50% by TEE and TTE, respectively. Anatomic aortic regurgitant lesions were identified in 96% by TEE versus 77% by TTE, whereas the correct origin was detected in 88% of cases by TEE versus 54% of cases by TTE. TEE provides valuabl…
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…
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…
Chronisches thromboembolisches Cor pulmonale bei schrittmacherassoziierten rechtsatrialen Thromben: Pulmonale Thrombendarteriektomie mit Elektrodenentfernung als lebensrettende Maßnahme
Life-threatening chronic cor pulmonale occurred in a 22-year-old woman with congenital 3 degrees atrioventricular block, 6 years after implantation of a pacemaker and 3 1/2 years after removal of the pacemaker (the electrodes were too firmly attached to be removed). The emboli originated from the right-atrial thrombi which had formed around the electrodes left in situ. The embolic source shrank during systemic administration of urokinase, initially 600,000 IU in 60 min, then 100,000 IU per hour, and pulmonary perfusion improved transiently. Nonetheless the patient became breathless on the slightest physical exertion. Recurrent syncopal attacks with marked increase of pulmonary artery pressu…
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…
Thoracic research scholarship 1988: pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension at the University of California, San Diego.
At the University of California, San Diego pulmonary thromboendarterectomy (PTE) has emerged as an effective measure in the treatment of chronic thromboembolic pulmonary hypertension. Unresolved emboli become organized by incorporation into the vascular wall and may form strictures, webs, bands and/or membranous occlusions and cause pulmonary hypertension refractory to medical treatment. When pulmonary vascular resistance exceeds 300 dyn.sec.cm-5 and the vascular wall changes are located to begin at or proximal to the lobar artery level, surgery is indicated. The operation is performed using cardiopulmonary bypass, deep hypothermia and periods of circulatory arrest. The dissection of each s…
Behandlung einer lebensbedrohlichen Hypoxie nach akutem kardiopulmonalem Versagen bei thromboembolisch bedingter pulmonaler Hypertonie mit dem „high-flow“ venovenösen extrakorporalen Bypass mit anschließender Thrombenarteriektomie der Pulmonalarterien
Die von Gattinoni und Kolobow (5) beschriebenen Erfolge in der Behandlung des schweren ARDS durch die extrakorporale CO2-Elimination in Verbindung mit niederfrequenter Uberdruckbeatmung wurden inzwischen auch von anderen Zentren bestatigt (4, 7). Bei diesem Verfahren steht die CO2-Elimination, d.h. der Ersatz der Ventilation durch die Membranlungen, im Vordergrund, wahrend die Oxygenierung als apnoische Oxygenierung uber die Lunge des Patienten erfolgt. Wegen der minder-perfusionsbedingten Hypoxie gehort die akute bzw. chronisch rezidivierende Lungenembolie nicht zu den primaren Indikationen fur die ECCO2-R-LFPPV. Bei der akuten Lungenembolie ist neben der akuten pulmonalen Embolektomie an …
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…
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…
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…
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.…
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…
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…
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…
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…
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…
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.