Bibliothek

Notizen: 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.

Notizen: 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.

Notizen: 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.

Notizen: Abstract The experience of the German Heart Center with valve selection and choice of size of prostheses for aortic root endocarditis is hereby reported. This experience includes 37 cases of aortic root endocarditis between 1986 and 1989. Mechanical, bioprosthetic, and homograft valves were used depending on the size, annular pathology, and general conditions related to the patient's medical history. Operative techniques are presented. Regardless of the type of valve replacement device, extensive annular destruction indicates a difficult and complex operation with long-term early and late results inferior to those in patients without annular abscess.

Notizen: Abstract  Particularly in neonates, complex cardiac surgery employing cardiopulmonary bypass normally requires the transfusion of autologous blood components. This is predominately caused by the relatively high priming volume of the circuit with subsequent extreme hemodilution. We report on a synoptic approach to avoiding transfusions in a 2.2 kg neonate with scheduled for correction of an intracardiac total anomalous pulmonary venous connection to the coronary sinus and a persistent foramen ovale. In this patient with a preoperative hemoglobin value of 16.5 g/dL, minimization of the cardiopulmonary bypass circuit, adjustment of the perfusion technique and strict reduction of blood sampling resulted in complete avoidance of transfusions during the entire course of the operation while maintaining safe hemoglobin levels, which never fell below a concentration of 8 g/mL.

Notizen: 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.

Notizen: 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.

Notizen: 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.

Notizen: From July 1996 to March 2000, 391 patients with intraoperative cardiac lowoutput syndrome who underwent surgery with heart-lung bypass and had an intre-aortic balloon pump (IABP) Implanted were analyzed in a prospective study. Of these 391 patients, 153 (39%) were operated on in an emergency situation, and 238 (61%) patients had elective surgeries. The perioperative mortality was 34% (133 patients). Clinical parameters were analyzed 1 hour after IABP support began. Statistical multivariate analysis showed that patients with an adrenaline requirement higher than 0.5 μg/kg/min, a left mrial pressure higher then 15 mmHg, output of less than 100 mL/hour, and mixed venous saturation (SvO2) of less then 60% had poor outcomes. Using this data, we developed an IABP score to predict survival early after IABP implantation in cardiac surgery. We conclude that the success or failure of perioperative IABP support can be predicted early after implantation of the balloon pump. In patients with low-output syndrome despite IABP support, implantation of a vantricular assist system should be considered.

Notizen: 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)