[Marfan syndrome and valvular disease]

Marfan syndrome is a hereditary disease of the connective tissue with increased mortality mostly due to changes of the cardiovascular system. We describe our experience with the surgical treatment of 243 patients with Marfan syndrome and cardiovascular complications. We report the results of treatment of annulo-aortal ectasia using the classical surgical methods of Bentall DeBono and Cabrol and the method for preservation of the native aortic valve and concomitant surgery of the mitral valve. Reconstruction or replacement of the mitral valve is mainly based on the classical indications. Preservation of the native aortic valve and reconstruction of the mitral valve in patients with Marfan syndrome is possible but the long-term results are still unknown.

Idiopathic eosinophilic esophagitis is associated with a T(H)2-type allergic inflammatory response

BACKGROUND

Idiopathic eosinophilic esophagitis (IEE) is a chronic-inflammatory disorder of the esophagus of unknown origin. The established cornerstone of diagnosis is a dense infiltration of the esophagus with eosinophils, but neither the precise pattern of inflammatory cell infiltration nor the mechanisms that likely contribute to induction and maintenance of the inflammatory response have been described.

OBJECTIVE

The intention of this study was to characterize the esophageal inflammatory infiltrate and the expression of cytokines in the esophagus in this disease. In addition, we searched for immunologic abnormalities of blood leukocytes to exclude major primary hyporeactive and hyperreactive conditions of the immune system.

METHODS

Infiltration of inflammatory cells in the esophagus, stomach, and duodenum was analyzed by immunohistochemistry through use of mAbs against lineage-associated molecules. Cytokine expression was measured by ELISA and immunohistochemical analysis. Lymphocyte subpopulations in blood were determined by means of flow cytometry.

RESULTS

High eosinophil infiltration into the esophageal squamous epithelium was observed in patients with IEE but not in control subjects. Interestingly, increased T-cell and mast cell numbers were also found within the epithelium in these patients. In contrast, the numbers of inflammatory cells were not increased in the stomach and duodenum in patients with IEE, suggesting a specific inflammatory process within the esophagus. Moreover, increased expression of IL-5 and TNF-alpha was observed in esophageal epithelial biopsy specimens. The distribution of lymphocyte subsets in the peripheral blood and their capacity to generate cytokines did not reflect the changes observed at the inflammatory site.

CONCLUSIONS

IEE is a selective inflammatory response of the esophagus. T cells, IL-5, eosinophils, and IgE-mediated mechanisms appear to be involved, giving rise to the possibility that allergic reactions might play a role in the pathogenesis of the disease.

Wound-healing disturbances after vein harvesting for CABG: a randomized trial to compare the minimally invasive direct vision and traditional approaches

BACKGROUND

Harvesting the great saphenous vein for coronary artery bypass grafting is often associated with complications in wound healing, insufficient cosmetic results, and delay in mobilization of the patients. The aim of this study was to compare the results of our minimally invasive technique with the traditional method.

METHODS

We report our experience of minimally invasive direct vision harvesting the great saphenous vein with the Aesculap retractor system (Aesculap AG Co KG, Tutlingen, Germany) by performing 3 (to 5) small cutaneous incisions. We scheduled 255 patients for elective coronary artery bypass grafting prospectively randomized to undergo vein harvesting by either the minimally invasive technique (group A: n = 128; age range, 68.2 +/- 9.1 years; male, 53.1%) or by the traditional technique (group B; n = 127; age range, 66.1 +/- 8.3 years; male, 62.9%). We classified and defined leg-wound healing disorders in terms of mild, moderate, and severe wound-healing disturbances.

RESULTS

Between group A and B there were no differences with the risk stratification before operation, length of vein being harvested, or total operation time. The time for minimally invasive harvesting of the great saphenous vein was slightly increased. Severe leg-wound healing disorders occurred in 4 of 128 patients of group A (3.1%) versus 12 of 127 patients of group B (9.4%) with significant difference (p = 0.042).

CONCLUSIONS

Minimally invasive direct vision harvesting the great saphenous vein is an attractive alternative to the traditional open-harvesting technique. In our trial this procedure resulted in fewer wound complications and showed a much better cosmetic outcome. The total operation time was not increased by using the minimally invasive technique.

Benefits of surgical repair of coarctation of the aorta in patients older than 50 years

BACKGROUND

Most patients with unrepaired coarctation of the aorta die before the age of 50 years. In patients who present at an older age, the indications for surgical treatment are controversial because the benefits of operating are unclear.

METHODS

At follow-up investigation from 0.5 to 11.5 years (mean, 4 years) after primary surgical correction of coarctation in 15 patients aged 50 to 63 years (mean, 54 years), we analyzed the preoperative and postoperative complications, symptoms, need for antihypertensive drugs, and blood pressure at rest and during exercise.

RESULTS

Preoperatively no patient had normal blood pressure at rest despite combined antihypertensive medication. There was no significant mortality or morbidity after repair. At follow-up examination only 3 patients had at rest mild hypertension, the other 12 patients were normotensive. Of the 11 tested patients, 8 displayed systolic arterial hypertension during exercise.

CONCLUSIONS

Surgical correction of coarctation can be performed after the age of 50 years with low surgical risk. Operation reduces systolic hypertension at rest and permits more effective medical treatment. Despite persistence of the hypertension during exercise, symptomatic improvement occurs in most patients.

Collagen type XVIII/endostatin is differentially expressed in primary and metastatic colorectal cancers and ovarian carcinomas

Collagen type XVIII (C18) is a nonfibrillar collagen of basement membranes. Its C-terminal fragment, endostatin, has been identified as an inhibitor of angiogenesis. C18 is predominantly expressed by hepatocytes of normal, cirrhotic and neoplastic liver. We compared the patterns of C18 RNA-expression in colonic adenocarcinoma metastases, which represent the most frequently occurring liver tumours, to normal colon mucosa, to primary colon cancers and to ovarian cancers which are often morphologically similar to colonic cancer or metastasis. Two C18-specific RNA-probes were generated to perform in situ hybridization combined with immunohistochemistry for cytokeratin, vimentin and the endothelial marker CD31, in order to characterize the C18-expressing cells. C18/endostatin protein was localized by immunohistology. In colorectal carcinomas and their liver metastases high levels of C18 transcripts were observed in endothelial cells and fibroblasts/myofibroblasts, whereas C18 RNA was virtually absent from carcinoma cells. Ovarian carcinomas displayed high C18 RNA expression both in carcinoma and stromal cells, indicating that induction of C18 transcription in tumour stromal cells is independent of the ability of carcinoma cells to express C18. While the role of tumour cell derived C18 in cancer growth regulation remains unknown, stimulation of proteolysis of the locally strongly expressed C18 to endostatin could offer an attractive approach for a targeted antineoplastic therapy.

[Multiple organ failure. Mechanisms, clinical manifestations and treatment strategies]

Multiple organ failure (MOV) still represents the leading medical and economical problem in the care of the critically ill surgical patient. Although the incidence of MOF has tended to decrease over the last several years reflecting improved surgical and supportive therapy in the ICU, prognosis still remains serious when MOF develops. MOF seems to reflect a dysregulation of host-defence systems, such as innate immune, coagulation and complement systems, which are likely to reflect a more general dysregulation of cellular and subcellular functions, such as signal transduction and stress gene expression. Besides complexity and redundancy of the mediator systems involved, their beneficial local reparative as opposed to detrimental systemic effects may have contributed to the disappointing results of anti-mediator strategies in the treatment of MOF and sepsis. Although treatment of the underlying disease remains the cornerstone of the care of the critically ill patient to prevent MOF, recent results indicating a decreased mortality in severely septic patients receiving activated protein C as a supportive treatment suggest that modulation of the mediator cascades of sepsis and MOF remains a generally promising therapeutic strategy.

Does thyroid supplementation accelerate tricyclic antidepressant response? A review and meta-analysis of the literature

OBJECTIVE

The delayed onset of therapeutic response to antidepressants remains a major problem in the treatment of depression. Among the strategies to accelerate response to treatment, the early addition of thyroid hormone to antidepressants has been suggested as a viable method. The authors performed a meta-analysis of the literature on the use of thyroid hormone supplementation to accelerate the treatment of depression to determine whether there is sufficient evidence to support the clinical efficacy of this strategy.

METHOD

Both a computer-aided search of the National Library of Medicine MEDLINE and an intensive search by hand were conducted to identify all double-blind, placebo-controlled studies assessing the concomitant administration of thyroid hormone and antidepressant to accelerate clinical response in patients with nonrefractory depression.

RESULTS

Six studies were identified. All were conducted with triiodothyronine (T(3)) and a tricyclic antidepressant. Five of the six studies found T(3) to be significantly more effective than placebo in accelerating clinical response. The pooled, weighted effect size index was 0.58, and the average effect was highly significant. Further, the effects of T(3) acceleration were greater as the percentage of women participating in the study increased.

CONCLUSIONS

This meta-analysis supports the efficacy of T(3) in accelerating clinical response to tricyclic antidepressants in patients with nonrefractory depression. Furthermore, women may be more likely than men to benefit from this intervention.

Bone mineral density in pre-and post-menopausal women with affective disorder treated with long-term L-thyroxine augmentation

BACKGROUND

Augmentation with TSH-suppressive L-thyroxine (T4) has been shown to improve the course of illness in otherwise refractory affective disorders. This collaborative study investigates whether T4 augmentation for a minimum of 12 months decreases bone mineral density (BMD) in 26 pre- and post-menopausal women with affective disorder.

METHODS

We measured BMD at the femoral neck, Ward's triangle, trochanter and lumbar vertebrae (L1-L4) in 13 premenopausal and 13 postmenopausal women with affective disorder using dual energy X-ray absorptiometry. BMD was expressed as g/cm(2) and as a Z-score, calculated using bone density data from the international reference population standard.

RESULTS

The Z-scores for the pre- and post-menopausal women were within the reference range of the age and sex matched population standard. BMD for the composite group also did not differ either from the population standard. BMD in the lumbar spine and hip did not differ significantly between the pre- and post-menopausal groups. However, there were a relatively high number of postmenopausal patients with BMDs one S.D. lower than the population standard.

LIMITATIONS

This is a cross-sectional study with a relatively small sample size.

CONCLUSIONS

The study demonstrates that T4 augmentation treatment does not reduce BMD to a clinically significant degree in many women with affective disorder. However, the resilience of bone structure to T4 treatment may vary with site and menopausal status. This study underscores the need for regular assessment of BMD during adjunctive thyroid treatments for affective disorder, especially in postmenopausal women.

Differential activation pattern of redox-sensitive transcription factors and stress-inducible dilator systems heme oxygenase-1 and inducible nitric oxide synthase in hemorrhagic and endotoxic shock

OBJECTIVE

To investigate the role of redox-sensitive transcription factors nuclear factor kappa-B (NF-kappaB) or activator protein-1 (AP-1) for hepatic gene expression of heme oxygenase (HO)-1 and inducible nitric oxide synthase (iNOS) in models of hemorrhagic or endotoxic shock.

DESIGN

Prospective controlled laboratory study.

SETTING

Animal research laboratory at a university hospital.

SUBJECTS

Male Sprague-Dawley rats (250-350 g).

INTERVENTIONS

After anesthesia, animals were assigned to hemorrhagic shock (mean arterial pressure 35-40 mm Hg for 60 mins), sham operation, or endotoxemia (1 mg/kg intraperitoneally). To assess the role of reactive oxygen species for activation of NF-kappaB or AP-1, animals were treated with the antioxidant trolox (6 mg/kg body weight). In additional experiments, animals were pretreated with dexamethasone (10 mg/kg body weight), an inhibitor of the transactivating function of DNA-bound AP-1 or with actinomycin-D (2 mg/kg body weight), an inhibitor of DNA-directed RNA synthesis. Activation of NF-kappaB or AP-1 was assessed by electrophoretic mobility shift assay. HO-1 and iNOS gene expression were assessed by Northern and Western blot.

MEASUREMENTS AND MAIN RESULTS

Hemorrhage and resuscitation induced hepatic HO-1 transcripts 12-fold. Induction was abolished by actinomycin-D and was attenuated by dexamethasone and the antioxidant trolox. Activation of AP-1 was observed after hemorrhagic but not after endotoxic shock. AP-1 activation was inhibitable by trolox and correlated with accumulation of HO-1 transcripts. In contrast, a weak activation of NF-kappaB was observed after hemorrhage that was not affected by trolox. A profound activation of NF-kappaB after endotoxic shock correlated with induction of iNOS but failed to induce HO-1 transcripts.

CONCLUSIONS

These data suggest that AP-1 but not NF-kappaB activation is dependent on reactive oxygen intermediates in vivo and contributes to HO-1 gene expression. Thus, AP-1-dependent HO-1 induction under oxidative stress conditions may subserve a similar function as a stress-inducible vasodilator system as does NF-kappaB-dependent iNOS expression in liver inflammation.

Three-dimensional materials analysis by confocal Raman microspectroscopy

Two- and three-dimensional spatial analysis of various composite materials was performed with a scanning confocal Raman microspectrometer. Samples include TiO(2) microparticles, mixtures of polymers, and the surface of an older Eprom computer chip. In the last case both structural and compositional information was obtained by means of comparing the signal intensity of the Rayleigh line with that of the silicon Raman line at 520 cm(-1). The spatial compositions of a pain-relief medicine and a pharmaceutical salt mixture could be visualized from characteristic Raman lines of the components.

Oncogenic potential of c-erbB-2 and its association with c-K-ras in premalignant and malignant lesions of the human uterine endometrium

The aim of this study was to detect activated c-K-ras by gene point mutation and to find c-erbB-2 gene amplification with p185 expression in association with the c-K-ras gene product p21 in the human endometrium. Specimens obtained from 25 normal, 31 hyperplastic and 72 malignant samples of the human endometrium were examined for point mutation in codons 12, 13 and 61 of the c-K-ras by direct sequencing and c-erbB-2 gene amplification with p185 and p21 expression by differential polymerase chain reaction (DPCR) and immunohistochemistry. Neither the normal endometrium nor endometrial hyperplasias were found to have mutations in the c-K-ras gene, although a double mutation of codons 12 and 13 as a single-point mutation was observed in one case of endometrioid carcinoma (2.8%). In each of two other cases of endometrioid carcinoma (2/72), two single-point mutations of codon 13 (5.6%) were shown. Using DPCR, we found c-erbB-2 to be amplified in 15 premalignant (48%) and 45 malignant (63%) samples. We noticed that nonamplification of the c-erbB-2 gene was associated with the absence of immunoreactivity. Our data indicate that, while c-erbB-2 plays a role in the early development of endometrioid carcinomas, c-K-ras gene activation by point mutation does not.

Limitation of microwave treatment for double immunolabelling with antibodies of the same species and isotype

Microwave treatment (MW) involves completely blocking contaminating staining in the double-labelling technique, using primary monoclonal antibodies from the same species and the same isotype as well as the same secondary antibody (ab). However, we noticed some limitations when locating proliferating cell types in cryostat and paraffin sections using the advantages presented by MW. Control experiments have shown that MW does not diminish contaminating staining when cytoplasmic (desmin, ASM-1) or nuclear (Ki-67) antigens have been labelled with antibodies in the first round of immunolabelling. In contrast to the cell surface antigen, CD18, where the primary ab had to be crosslinked by a secondary ab to obtain contaminating staining, this was observed for the detection of cytoplasmic or nuclear antigens only labelled with a primary ab. In conclusion, for double immunolabelling with abs from the same species and the same isotype, MW is not able to completely abolish contaminating staining.

Sudden death due to pituitary apoplexy

A case of sudden, unexpected death due to hemorrhage into a large, previously undiagnosed pituitary adenoma (pituitary apoplexy) in a 41-year-old man is presented. Pituitary adenomas are frequent intracranial tumors with usually benign prognosis. Acute hemorrhage into the tumor is a severe and potentially fatal complication, if not diagnosed and treated early, and occurs in up to 10% of cases. Sudden tumor enlargement due to the hemorrhage with compression of vessels and neural tissue at the skull base may result in coma and death without preceding symptoms leading to forensic investigations as demonstrated by this case report.

Detection of maternal DNA in umbilical cord plasma by fluorescent PCR amplification of short tandem repeat sequences

Recently, maternal DNA was detected in umbilical cord blood using PCR amplification of minisatellite sequences. The presence of maternal DNA was demonstrated in 1% to 100% of umbilical cord blood samples. The objective of this study was to determine the frequency of cord blood contamination by maternal genetic material. We used fluorescent PCR amplification of highly polymorphic short tandem repeat (STR) markers to detect maternal DNA in umbilical cord plasma.

Hemorrhagic shock primes the hepatic portal circulation for the vasoconstrictive effects of endothelin-1

To test whether hemorrhagic shock and resuscitation (HSR) alters the vascular responsiveness of the portohepatic circulation to endothelins (ETs), we studied the macro- and microcirculatory effects of the preferential ET(A) receptor agonist ET-1 and of the selective ET(B) receptor agonist sarafotoxin 6c (S6c) after 1 h of hemorrhagic hypotension and 5 h of volume resuscitation in the isolated perfused rat liver ex vivo using portal pressure-flow relationships and epifluorescence microscopy. Although HSR did not cause major disturbances of hepatic perfusion per se, the response to ET-1 (0.5 x 10(-9) M) was enhanced, leading to greater increases in portal driving pressure, total portal resistance, and zero-flow pressures and more pronounced decreases in portal flow, sinusoidal diameters, and hepatic oxygen delivery compared with time-matched sham shock controls. In sharp contrast, the constrictive response to S6c (0.25 x 10(-9) M) remained unchanged. Thus HSR primes the portohepatic circulation for the vasoconstrictive effects of ET-1 but does not alter the effects of the ET(B) receptor agonist S6c. The enhanced sinusoidal response may contribute to the subsequent development of hepatic microcirculatory failure after secondary insults that are associated with increased generation of ET-1.

Mutations in the gene encoding epsilon-sarcoglycan cause myoclonus-dystonia syndrome

The dystonias are a common clinically and genetically heterogeneous group of movement disorders. More than ten loci for inherited forms of dystonia have been mapped, but only three mutated genes have been identified so far. These are DYT1, encoding torsin A and mutant in the early-onset generalized form, GCH1 (formerly known as DYT5), encoding GTP-cyclohydrolase I and mutant in dominant dopa-responsive dystonia, and TH, encoding tyrosine hydroxylase and mutant in the recessive form of the disease. Myoclonus-dystonia syndrome (MDS; DYT11) is an autosomal dominant disorder characterized by bilateral, alcohol-sensitive myoclonic jerks involving mainly the arms and axial muscles. Dystonia, usually torticollis and/or writer's cramp, occurs in most but not all affected patients and may occasionally be the only symptom of the disease. In addition, patients often show prominent psychiatric abnormalities, including panic attacks and obsessive-compulsive behavior. In most MDS families, the disease is linked to a locus on chromosome 7q21 (refs. 11-13). Using a positional cloning approach, we have identified five different heterozygous loss-of-function mutations in the gene for epsilon-sarcoglycan (SGCE), which we mapped to a refined critical region of about 3.2 Mb. SGCE is expressed in all brain regions examined. Pedigree analysis shows a marked difference in penetrance depending on the parental origin of the disease allele. This is indicative of a maternal imprinting mechanism, which has been demonstrated in the mouse epsilon-sarcoglycan gene.

Modulation of collagen XVIII/endostatin expression in lobular and biliary rat liver fibrogenesis

BACKGROUND/AIMS

The liver is the major source of collagen XVIII (C18), the precursor of the angiogenesis inhibitor endostatin. In human liver C18 is mainly expressed by hepatocytes. However, its quantitative and temporospatial expression patterns during liver fibrogenesis are unknown.

METHODS

We used RNA quantification and in situ hybridization combined with cell-specific markers to study C18 compared to procollagen alpha1(I) and tissue inhibitor of metalloproteinases-1 (TIMP-1) mRNA expression in acute (single dose of CCl4) and chronic (biliary) rat liver fibrogenesis.

RESULTS

C18 transcripts were only found in hepatocytes and bile duct epithelia of normal and fibrotic livers, and occasionally in arterial myocytes and hepatic stellate cells. 72 h after CCl4 injection, C18 mRNA levels remained unchanged, while procollagen alpha1(I) mRNA was increased at 72 h and TIMP-1 mRNA peaked at 12 h (P < 0.05). In biliary fibrosis C18 mRNA levels increased 1.8-fold, contrasting with 20- and 4-fold elevated procollagen alpha1(I) and TIMP-1 transcript levels, respectively.

CONCLUSIONS

Hepatocytes and bile duct epithelia are the predominant sources of C18 in normal and fibrotic rat liver. Contrary to procollagen alpha1(I) and TIMP-1, C18 expression remains constant in acute fibrogenesis and is upregulated in biliary fibrosis. Modulation of epithelial C18 expression and its processing to endostatin could allow a liver-specific anticancer therapy.

Antifibrotic effect of silymarin in rat secondary biliary fibrosis is mediated by downregulation of procollagen alpha1(I) and TIMP-1

BACKGROUND/AIMS

Silymarin reduces hepatic collagen accumulation by 35% in rats with secondary biliary cirrhosis. The aim of the present study was to explore its antifibrotic mechanism.

METHODS

Thirty female adult Wistar rats were allocated to (1) bile duct occlusion, (2) bile duct occlusion and oral silymarin at 50 mg/kg per day, and (3) sham operation and oral silymarin at 50 mg/kg per day. Steady-state mRNA levels for procollagen alpha1(I), tissue inhibitor of metalloproteinases-1 (TIMP-1), and transforming growth factor (TGF) beta1 were determined by multi-probe ribonuclease protection assay.

RESULTS

After 6 weeks of bile duct occlusion, liver collagen content was increased 12-fold, when compared with the sham-operated controls. These animals displayed 17-, 6.5- and 16-fold higher transcript levels for procollagen alpha1(I), TIMP-1 and TGFbeta1 (P < 0.01). Silymarin downregulated elevated procollagen alpha1(I), TIMP-1 and TGFbeta1 mRNA levels by 40-60% (P < 0.01). These lowered hepatic profibrogenic transcript levels correlated with decreased serum levels of the aminoterminal propeptide of procollagen type III.

CONCLUSIONS

Silymarin suppresses expression of profibrogenic procollagen alpha1(I) and TIMP-1 most likely via downregulation of TGFbeta1 mRNA in rats with biliary fibrosis. The serum procollagen type III propeptide level mirrors profibrogenic mRNA expression in the liver.

High-pressure bulk synthesis of crystalline C(6)N(9)H(3).HCl: a novel c(3)n(4) graphitic derivative

A novel carbon nitride compound, structurally related to the proposed graphitic phase of C(3)N(4), has been synthesized in a bulk well-crystallized form. The new material, with stoichiometry C(6)N(9)H(4)Cl, was prepared through a solid-state reaction of 2,4,6-triamino-1,3,5-triazine with 2,4,6-trichloro-1,3,5-triazine at 1.0-1.5 GPa and 500-550 degrees C and also through a self-reaction of 2-amino-4,6-dichloro-1,3,5-triazine at similar conditions. X-ray and electron diffraction measurements on the yellowish compound indicate a hexagonal space group (P6(3)/m) with cell parameters of a = 8.4379(10) A and c = 6.4296(2) A. This new compound possesses a two-dimensional C(6)N(9)H(3) framework that is structurally related to the hypothetical P6m2 graphitic phase of C(3)N(4), but with an ordered arrangement of C(3)N(3) voids. The large voids in the graphene sheets are occupied by chloride ions with an equivalent number of nitrogen atoms on the framework protonated for charge balance. The composition of the sample was determined by bulk chemical analysis and confirmed by electron energy loss (EELS) spectroscopy. The chemical and structural model is consistent with bulk density measurements and with the infrared and (13)C NMR spectra. This work represents the first bulk synthesis of a well-characterized and highly crystalline material containing a continuous network of alternating carbon and nitrogen atoms.

Liposome-mediated gene transfer to fetal human ventral mesencephalic explant cultures

The feasibility of non-viral gene transfer using liposomes is described for human fetal nigral tissue. Ventral mesencephalic explants from 6 to 12 week old fetuses were grown as free-floating roller tube cultures. For the transfection, a vector coding for beta-galactosidase driven by the Rous Sarcoma Virus promoter was used. The developmental stage of the human tissue, time in vitro and the amount of vector DNA used significantly influenced the transfection efficiency. Optimal transfection results were obtained with tissue from a 10 week old fetus, cultured for 4 days and transfected with mixtures containing 4 microg vector DNA. Histological analysis suggested that a specific population of ventral mesencephalic precursor cells were the target for the gene transfer. This finding might have implications for gene delivery and cell replacement strategies in Parkinson's disease.

[Congenital coronary fistulas: the most frequent congenital coronary anomaly]

Congenital arteriovenous coronary fistulae are a rare condition of a direct communication between a coronary artery and one of the cardiac chambers, the coronary sinus, the superior vena cava or the pulmonary artery. In most instances the diagnosis is made during heart catheterization for coronary or congenital heart disease. Whether congenital coronary artery fistulae should be treated by transcatheter intervention or surgery and in which patients fistula closure should be performed is controversial. This report summarizes our experience of the surgical treatment of congenital arteriovenous coronary fistulae in 14 patients at the Deutsches Herzzentrum Berlin between March 1988 and April 1997. There were seven females and seven males aged from 3 to 67 years (mean 47 years). We analyzed the symptomatic status (NYHA class) preoperatively and in the late outcome, the preoperative angiographic data and the surgical techniques. The right coronary artery was affected in six, the left in six, and both arteries in two cases. The fistulae drained into the pulmonary artery in eight cases, into the superior vena cava and into the right atrium in two cases, and into the right ventricle and into the coronary sinus once. Fistula closure was unsuccessfully attempted interventionally in two patients and surgically in one patient in another institution. Twelve of the patients exhibited additional cardiac disease requiring surgery: seven cases presented additional coronary artery disease, one mitral valve disease, one persistent ductus arteriosus, one an aneurysm of the right coronary artery, and two an atrial septal defect. We performed fistula closure either by ligating or transsecting the fistula as well as by closure of the fistula's drainage opening. Surgery and postoperative courses were uneventful in all patients. Most of the patients (93%) were in good clinical condition (NYHA I-II) after a mean follow-up period of 6.6 years (range 3-11). Fistula closure should be performed in patients who are symptomatic or who have a hemodynamic relevant shunt. In asymptomatic patients and small left-to-right shunt, fistula closure should also be performed to prevent later complications. Surgical fistula closure should be employed in patients with larger and more complex fistulae, especially if interventional therapy failed, and for patients with additional cardiac conditions that necessitate surgery.