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Notes: Due to its anatomical structure and physiological properties, omental tissue has proven to be beneficial when transposed to the thorax to treat severe mediastinal infections. Between April 1987 and July 1994, 17,005 open heart operations were performed at our institution. One hundred and forty patients who developed mediastinitis or serious wound infections postoperatively were treated by transposition of the greater omentum into the retrosternal space. These patients were compared with a control group of 100 patients operated in the same period, who did not develop infectious complications postoperatively. Significant differences were found in several risk factors, such as obesity, type, and duration of primary operation, ejection fraction 〈 30% (〈 0.01), as well as the incidence of low cardiac output syndrome treated by insertion of an intra-aortic balloon pump (p 〈 0.05) However, no significant differences were observed in factors such as diabetes mellitus, emergency operation, reoperation, degree of postoperative bleeding, and duration of aortic cross-clamp time. The mortality of mediastinitis largely depended on the type of primary operation. It was 19.2% in patients who underwent coronary surgery, and 52.2% in patients who underwent transplantation (overall mortality 35.7%). Only in 2% of the patients did we find complications related to the creation of the omental pedicle and its translocation. Today, serious disturbances in sternal wound healing, especially involving mediastinitis, are rare complications in cardiac surgery. Nevertheless, they continue to be associated with high mortality and prolonged hospitalization.

Notes: Transposition of the greater omentum to the thorax for treatment of severe mediastinal infections due to the anatomical structure and physiological properties of the omental tissue is a proven and safe procedure. From 1987 to 1993, thoracic omentoplasty was performed in 112 cases at our facility. In order to attempt to visualize the vascularization of an omental graft by the right or left gastroepiploic artery via the coeliac trunk, a small group of patients (n = 7) underwent left heart catheterization followed by angiography of the gastroepiploic arteries. Visualization of the gastroepiploic arteries was successful in six patients. Furthermore, anastomoses with adjacent vessels were observed in individual cases. The omental vessels remain open for a long period after transposition to the thorax, and additionally, appear to create anastomoses with surrounding vessels.

Notes: Between March 1986 and December 1994, four adult patients underwent surgery for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) at the German Heart Institute Berlin. The patients, aged 27, 35, 54, and 60, were all females. ALCAPA was diagnosed 3 to 8 months before surgery. The patients presented with cardiac murmur (two patients), abnormal ECG pattern (two patients), arrhythmia (one patient), and acute myocardial infarction (one patient). During surgery a two coronary system was established either by Takeuchi operation (one patient), interruption of the anomalous vessel and aortocoronary saphenous vein bypass (two patients), or internal mammary artery bypass (one patient). There were no postoperative deaths, however, one patient had to be reoperated because of a recurrent shunt. Clinical improvement was observed in all four patients with disappearance of fatigue, angina, dyspnea, and ischemic ECG changes. Despite having this long-standing congenital heart defect, adult and elderly patients with ALCAPA may benefit from surgical intervention to establish a two coronary system.

Notes: Heart transplantation has now become an accepted treatment for end-stage coronary heart disease (CAD). However, the limited supply of suitable donor organs imposes constraints upon the decision of whether patients are selected for transplantation or for coronary artery bypass grafting (CABG). From April 1986 until the end of March 1992, 265 patients with end-stage CAD involving left ventricular ejection fraction (LVEF) 10% to 30% and predominant angina pectoris underwent CABG. All patients received an average of 2.9 ± 0.3 venous grafts. Intraaortic balloon pumps were implanted in 30 patients (11.3%) who began to develop low cardiac output syndrome intraoperatively. The actuarial survival rate was 87.8% after 2 years and 86.9% after 3 years. LVEF was measured in 35 patients via left heart catheterization 12 months after their operations and was found to have increased from a mean of 23.8% to 38.1%. Left ventricular end-diastolic pressure had decreased from 16.2 mmHg to an average of 12.1 mmHg. Swan-Ganz catheterization was performed on 120 patients 6 months postoperatively. The pulmonary wedge pressure had reduced significantly from 18.1 mmHg to a mean of 12.7 mmHg (p 〈 0.01). From 1990 until the end of March 1992, 55 patients with CAD and predominant heart failure received transplants. Their 2-year survival rate was 66.3%. Mean LVEF was 55.6% postoperatively. We conclude that CABG is adequate for patients who have end-stage CAD and angina pectoris symptoms, and that it significantly improves hemodynamic functions. Patients suffering predominantly from heart failure (NYHA Class IV) can be transplanted and subsequently regain normal heart function. (J Card Surg 1994;9:77–84)

Notes: Abstract Background and Methods: In 21 patients intraoperatively receiving coronary revascularization, segments of the saphenous vein were prepared for aortocoronary bypass. Postoperatively, the endothelial intima was subjected to electron microscopy. Venous segments in which an intraluminal mean pressure of 263 mmHg ± 52 mmHg had been measured during preparation were compared with venous segments that had been explanted with the aid of a venous protection bulldog and with pharmacological treatment through papaverine. Results: Those segments of high-pressure distension that had not been protected showed intimal damage with erythrocytes and thrombocytes. On the other hand, venous segments with low-pressure distension that had been protected in the described way during harvesting appeared similar to native veins. Conclusion: We conclude that during the preparation of the saphenous vein for aortocoronary bypass surgery, the application of papaverine and the use of the venous protection bulldog clamp is effective in preventing pressure damage during preparation of the vein.

Notes: Abstract  Even in infants and small children, ventricular assist devices have an emerging role in the treatment of congenital and postcardiotomy heart failure. Extracorporeal pneumatic pulsatile devices are considered the strategy of choice if long-lasting bridge to recovery or transplantation is expected. However, complete explantation of the device may be complicated by hemorrhage and subsequent transfusions due to the establishment of CPB. The present case demonstrates successful weaning and complete removal of an apical venting pulsatile LVAD in a 4-kg infant without the employment of CPB.

Notes: Abstract In recent time, it has become more and more probable that patients with severe diffuse coronary artery disease, who are not candidates for aortocoronary bypass surgery or percutaneous transluminal coronary angioplasty procedures, can benefit from transmyo-cardial laser revascularization (TMR). But the underlying principle of TMR still remains unclear. This study reports on a histological analysis of eight patients, in whom a total of 250 channels had been created, who died after TMR. The TMR channels were created by a CO2 laser surrounded by a zone of necrosis with an extent of about 500 μm. In the hearts of patients who died in the early postoperative period (1 to 7 days postoperative), almost all channels were closed by fibrin clots, erythrocytes, and macrophages. There were no obvious connections between the channels and the ventricular cavity. In specimens from patients, who died 2 or more weeks after the procedure, a granular tissue with high macrophage and mono-cyte activity was observable. Within this tissue, we observed a developing network of capillaries. Otherwise, the tissue filling the channels did not substantially differ from scar tissue. We failed to observe connections between the ventricular cavity and the new capillaries. Whether these vessels within the closed channels have any impact on myocardial perfusion remains unclear, but it seems unlikely that the clinical effects of TMR are based on the principle of the amphibian heart.

Notes: Abstract  Background: The internal mammary artery (IMA) bypass graft provides a satisfactorily long-lasting blood supply to the myocardium. However, its initial flow capacity can be insufficient with subsequent regional myocardial ischemia. We evaluated a method to assess the IMA graft function intraoperatively. Methods: Twenty-five patients with three-vessel coronary artery disease underwent coronary artery bypass grafting on cardiopulmonary bypass. The in situ IMA was grafted to the left anterior descending coronary artery (LAD) in combination with two saphenous vein grafts to the left circumflex and right coronary artery. Distal anastomoses were performed during cold intermittent blood cardioplegia. After unclamping of the aorta and of the grafted IMA, the temperature at the cardiac anterior and posterior side was measured during the first 5 minutes of warm reperfusion. Results: A sufficient IMA graft function was expressed by a typical rise in temperature: the cardiac anterior and posterior sides showed a parabolic and exponential course, respectively. The rewarming velocity expressed as the first derivative of temperature over time led to a sharp and early peak for the anterior side, and a smaller and delayed peak for the posterior side. Insufficient IMA graft function could be recognized by an atypical temperature course. Conclusions: Temperature measurement of the heart during warm reperfusion after hypothermic cardioplegia can help to assess the effectiveness of the IMA-LAD graft function.

Notes: Transmyocardial laser revascularization (TMR) has received more acceptance within the last few years. The vast majority of TMR users report impressive clinical benefits. The underlying mechanism for benefit by TMR, however, remains somewhat unclear. Between July 1994 and September 1997, 165 patients underwent TMR at our institution. In three of our TMR patients after an initial angina-free interval of 1 to 2 years we decided to repeat the laser operation. This article focuses on the three re-TMR patients who underwent a second TMR operation 12 to 14 months after the first one. Two of the three patients are well and experience significantly less angina than preoperatively.

Notes: Abstract Background: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this group of patients. Methods: Between April 1986 and December 1994, 232 patients underwent surgery for ischemic mitral valve insufficiency; mitral valve replacement was performed in 98 of them. Operative mortality was 13.3%. The actuarial survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operative mortality 50.0%) was higher than in those whose LVEF was greater than 30%. Valve reconstruction was performed in 102 patients. Operative mortality in this patient group was 14.7%. The surgical risk in patients whose LVEF was 〈inlineGraphic alt="leqslant R: less-than-or-eq, slant" extraInfo="nonStandardEntity" href="urn:x-wiley:08860440:JOCS8:les" location="les.gif"/〉 30% was higher (operative mortality 42.9%). Results: The total actuarial survival rate of all patients was 64.4% after 5 years. Mortality during follow-up was higher in patients with residual mitral valve insufficiency greater than grade I after mitral valve reconstruction. Twenty-four patients with severly impaired left ventricular function underwent heart transplantation. Operative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. Conclusions: We conclude that patients with highly impaired left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardiac transplantation should be considered for this patient group. However, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replacement with an acceptable prognosis. The goal of mitral valve reconstruction should be reducing mitral valve insufficiency to at least grade I. If this is not achieved, the prognosis after repair is worse than after valve replacement, therefore, the surgeon should replace the valve without delay.