A role for the extended amygdala in the fear-enhancing effects of acute selective serotonin reuptake inhibitor treatment

Selective serotonin reuptake inhibitors (SSRIs) are reported to exacerbate symptoms of anxiety when treatment is initiated. These clinical findings have been extended to animal models wherein SSRIs also potentiate anxiety and fear learning, which depend on the amygdala. Yet, little is known about the role of specific amygdalar circuits in these acute effects of SSRIs. Here, we first confirmed that a single injection of fluoxetine 1 h before auditory fear conditioning potentiated fear memory in rats. To probe the neural substrates underlying this enhancement, we analyzed the expression patterns of the immediate early gene, Arc (activity-regulated cytoskeleton-associated protein). Consistent with previous reports, fear conditioning induced Arc protein expression in the lateral and basal amygdala. However, this was not enhanced further by pre-treatment with fluoxetine. Instead, fluoxetine significantly enhanced expression of Arc in the central amygdala (CeA) and the bed nucleus of the stria terminalis (BNST). Next, we tested whether direct targeted infusions of fluoxetine into the CeA, or BNST, leads to the same fear-potentiating effect. Strikingly, direct infusion of fluoxetine into the BNST, but not the CeA, was sufficient to enhance fear memory. Moreover, this behavioral effect was also accompanied by robust Arc expression in the CeA, similar to the systemic injection. Our results identify a novel role for the BNST in the acute fear-enhancing effects of SSRIs. These findings highlight the need to look beyond the traditional focus on input nuclei of the amygdala and add to accumulating evidence implicating these microcircuits in gating fear and anxiety.

Pre- and postoperative assessment of left ventricular function by magnetic resonance imaging and 2-D-echocardiography in patients undergoing left ventricular aneurysmectomy

BACKGROUND

Left ventricular (LV) aneurysms may complicate myocardial infarctions. Reliable quantification of LV functional parameters is mandatory to predict clinical outcome in patients undergoing LV aneurysmectomy. We compared global LV function measured by magnetic resonance (MR) and 2-D-echocardiography in patients before and after aneurysmectomy.

METHODS

31 patients (23 male), mean age 64 (range 35 - 85) years with an LV aneurysm (25/31 anterior MI, 5/31 inferior MI, 1/31 both) were enrolled. MR and echocardiography were performed directly before and 3 - 65 (median 8) days after surgery. MR studies were performed on a 1.5 Tesla scanner. End-diastolic and end-systolic volumes and diameters (EDV/ESV, EDD/ESD), ejection fraction (EF) and stroke volume (SV) were determined. Echocardiography was performed to determine EF, EDD and ESD. NYHA class was assessed before and 3 months after surgery.

RESULTS

After aneurysmectomy MR analysis showed a decrease in EDV (255 +/- 68 ml to 202 +/- 59 ml) ( p < 0.001) and ESV (186 +/- 71 ml to 134 +/- 53 ml; p < 0.001); EF increased (28 +/- 10 % to 35 +/- 12 %; p < 0.001); EDD/ESD decreased ( p < 0.01). Compared to echocardiography, a low correlation was found in EF before/after surgery r = 0.76/r = 0.69 and ESD r = 0.43/r = 0.60, respectively. In EDD a good correlation was found before surgery (r = 0.81), and a lower correlation after surgery (r = 0.72). NYHA class improved from 3.0 +/- 0.5 before to 1.8 +/- 0.8 after operation ( p < 0.001).

CONCLUSION

Resection of an LV aneurysm results in a mean improvement of 25 % in LV function, and improved clinical outcome. In asymmetric ventricles with aneurysms MR proved to be superior as a sensitive and non-invasive tool compared to conventional 2-D-echocardiography.

Leukocyte-depleted Secondary Blood Cardioplegia Attenuates Reperfusion Injury after Myocardial Ischemia

BACKGROUND

Activated neutrophils have been implicated in reperfusion injury of the myocardium; leukocyte depletion at the time of reperfusion may contribute to better myocardial protection after cardiac surgery. In the present study, we examined whether leukocyte depletion as an adjunct to terminal blood cardioplegia attenuates reperfusion injury.

METHODS

Porcine hearts that had undergone 60 minutes of normothermic ischemia with cardioplegia and 60 minutes of reperfusion under cardiopulmonary bypass were divided into four groups according to the methods of 15 min of controlled initial reperfusion: whole blood reperfusion (n = 6), leukocyte-depleted reperfusion (n = 6), secondary blood cardioplegia (n = 6) and leukocyte-depleted secondary blood cardioplegia (n = 6). At 60 min of reperfusion, hemodynamic recovery, release of malondialdehyde (MDA) as a marker for free oxygen radicals, CK-MB-isoenzyme from the coronary sinus, recovery of adenosine triphosphate, and myocardial water content were evaluated.

RESULTS

The group with leukocyte-depleted secondary blood cardioplegia showed the best hemodynamic recovery (Emax and total dp/dt), lowest levels of MDA, CK-MB and myocardial water content, and highest adenosine triphosphate recovery.

CONCLUSIONS

These results suggest that controlled reperfusion with leukocyte-depleted secondary blood cardioplegia attenuated severe damage of the myocardium as compared to whole blood reperfusion.

Novadaq Spy Intraoperative Imaging System--current status

The Novadaq Spy Intraoperative Imaging System is able to depict a fluorescent contrast agent emitting light at 830 nm when passing through the vascular tree or through myocardial chambers. The passage of the contrast agent can be observed in real time, allowing quality control in adult and congenital cardiovascular surgery.

Contrast-echocardiography: confirmation of patency of laser channels after transmyocardial laser revascularization

AIMS

Apart from casuistic autopsy results there is no long-term evidence for channel perfusion after transmyocardial laser revascularization in humans.

METHODS AND RESULTS

Fifteen consecutive patients aged 63+/-17 years were investigated 71+/-15 days after coronary artery bypass surgery and/or transmyocardial revascularization with 13-37 (20+/-5) channels (CO(2) laser, 40 J/pulse). Echocardiography was performed after injection of 6 ml echo contrast medium into left ventricular cavity and after injection of 3 ml contrast medium into the left main coronary artery. In five patients with additional bypass surgery to the same region, we also injected 3 ml contrast medium into bypass graft. We could prove in 10 of 15 patients (67%) one or two laser channels in the apical left ventricular myocardium. Channels were perfused exclusively during systole. During following heart cycles myocardium was opacified up to a mean width of 1.4+/-0.4 cm, a mean depth of 0.71+/-0.1cm, and a mean area of 1.0+/-0.6 cm(2). Contrast medium was washed out via coronary venous system in 9+/-8 systoles.

CONCLUSION

This is the first clinical evidence of long-term laser-channel patency in humans showing perfused myocardium via left ventricular cavity.

Predictors for atrial transport function after mini-maze operation

BACKGROUND

Restoration of atrial transport function (ATF) is a major goal of the maze procedure. This prospective study was undertaken to evaluate predictors of left atrial transport function in patients undergoing a mini-variant of the maze III procedure 3 and 12 months postoperatively.

METHODS

Mini-maze operation was performed in 72 patients with a mean age of 64 +/- 8.7 years during a 5-year period. Seventy of 72 (97%) had combined procedures. Clinical and electrophysiologic examination was carried out before surgery, and 3 and 12 months postoperatively.

RESULTS

Early mortality was 1.4% (1 of 72 patients) and late death occurred in 5.6% (4 of 71 patients). After 3 months, 54 of 68 (80%) patients showed sinus rhythm, and 48 of 60 (80%) after 12 months. ATF was restored in 87% (echocardiography) and 82% (magnetic resonance imaging) after 3 months, and in 86% (echocardiography) and 78% (magnetic resonance imaging) after 12 months. Independent predictors for ATF restoration after 12 months were better preoperative left ventricular function (p = 0.02), and smaller preoperative left atrial diameter (p = 0.005). Correlation between echocardiography and magnetic resonance imaging was 80% after 12 months.

CONCLUSIONS

Restoration of ATF after mini-maze procedure is achieved in over 80%. Independent predictors for ATF restoration are smaller preoperative left atrial diameter and better preoperative left ventricular ejection fraction.

Ruptured papillary muscle after mitral valve replacement with preservation of chordae tendineae

Many cardiac surgeons believe strongly that every effort should be made to preserve the continuity of the mitral anulus, chordae tendineae, and papillary muscles during mitral valve replacement in order to maximize ventricular function and maintain normal ventricular geometry. We treated a patient with spontaneous papillary muscle rupture after mitral valve replacement in whom efforts had been made to preserve continuity of the mitral mechanism.

Synaptic plasticity in the lateral amygdala: a cellular hypothesis of fear conditioning

Fear conditioning is a form of associative learning in which subjects come to express defense responses to a neutral conditioned stimulus (CS) that is paired with an aversive unconditioned stimulus (US). Considerable evidence suggests that critical neural changes mediating the CS-US association occur in the lateral nucleus of the amygdala (LA). Further, recent studies show that associative long-term potentiation (LTP) occurs in pathways that transmit the CS to LA, and that drugs that interfere with this LTP also disrupt behavioral fear conditioning when infused into the LA, suggesting that associative LTP in LA might be a mechanism for storing memories of the CS-US association. Here, we develop a detailed cellular hypothesis to explain how neural responses to the CS and US in LA could induce LTP-like changes that store memories during fear conditioning. Specifically, we propose that the CS evokes EPSPs at sensory input synapses onto LA pyramidal neurons, and that the US strongly depolarizes these same LA neurons. This depolarization, in turn, causes calcium influx through NMDA receptors (NMDARs) and also causes the LA neuron to fire action potentials. The action potentials then back-propagate into the dendrites, where they collide with CS-evoked EPSPs, resulting in calcium entry through voltage-gated calcium channels (VGCCs). Although calcium entry through NMDARs is sufficient to induce synaptic changes that support short-term fear memory, calcium entry through both NMDARs and VGCCs is required to initiate the molecular processes that consolidate synaptic changes into a long-term memory.

Symptomatic aneurysm of a saphenous vein graft with compression of the right atrium

A symptomatic aneurysm of a saphenous vein bypass to the right coronary artery in a 77-year-old female patient is presented. Surgical therapy included resection of the aneurysmal saphenous vein graft, reconstruction of the right atrium, and coronary artery bypass grafting (CABG) to the right coronary artery.

Epidemiology of occupational injuries and illnesses in a university population: a focus on age and gender differences

BACKGROUND

Occupational injuries and illnesses are a major preventable public health problem.

METHODS

This study evaluated the incidence, nature, and cause of awarded workers' compensation claims for a large state university and teaching hospital. Rates and types of injury were compared across age and gender.

RESULTS

Rates of injury varied over twofold with age, with those 16-25 having the lowest rates of injury and those 36-45 having the highest rates. Claims rates were 1.36-fold higher for women than men. Women had higher rates for injury resulting from lifting, falling, noxious exposures, repetitive motion, and carpal tunnel syndrome. Similarly women had significantly higher rates of claims for pain, sprains, bruises, burns, concussion, and inhalation injury; with lower rates of cuts, ligament injury, and jammed joints.

CONCLUSIONS

These group differences suggest the need to examine age and gender job distributions and relevant ergonomic and environmental causative factors.

[Papillary muscle rupture after mitral valve replacement with preservation of subvalvular structures]

We report a female patient with mitral valve replacement and preservation of subvalvular apparatus in which parts of the papillary muscle ruptured postoperatively. During systole the ruptured papillary muscle prolapsed through the native aortic valve. Echocardiographic documentation and operative procedure were demonstrated.

Peripheral arterial embolism originating from a thrombus in the ascending aorta

A 45-year-old man experienced arterial thromboembolism to the right leg requiring surgical restoration of blood flow. Transesophageal echocardiography (TEE) was performed to determine the source of embolism and identified a localized atherosclerotic lesion in the distal ascending aorta with an adherent, highly mobile thrombus. The patient underwent surgery with removal of the atherosclerotic plaque and attached thrombus, and resection of the adjacent aortic wall. This case illustrates an unusual location for a complex atherosclerotic lesion in the ascending aorta, and points out the opportunity for remedial surgery once a symptomatic embolus has occurred.

Thrombotic formations within the aortic arch as source of embolization in patients with coagulopathia

Thrombotic formations on atherosclerotic lesions of the thoracic aorta are potential sources of cerebral and systemic embolization. Especially younger patients without calcifications of atherosclerotic plaques or coagulation disorders have a higher risk for embolization. Magnetic resonance imaging and transesophageal echocardiography are the diagnostic methods of choice. As an alternative to anticoagulation surgical therapy is indicated to prevent severe brain damage or multiorgan failure in patients with mobile thrombotic formations. Herein we describe two patients in whom successful surgical treatment was performed in deep hypothermic circulatory arrest by excision of the aortic arch atheroma.

[The maze operation--surgical therapy of chronic atrial fibrillation: modification to mini-maze operation]

OBJECTIVE

Atrial fibrillation (AF) is the most common arrhythmia. However, its precise electrophysiologic mechanism is still not well understood. Chronic symptomatic atrial fibrillation resistant to medical therapy can successfully be treated by the Maze III procedure (M III). Several publications are dealing with alternative surgical techniques. This study describes technique and midterm results of a Mini-variant (Mini) of the Maze III procedure.

METHODS

During a 48-month period we performed either a M III (group I = 7 patients) or a Mini-Maze operation (group II = 65 patients) in 33 males and 39 females with chronic symptomatic atrial fibrillation and additional cardiac pathology. Patients were controlled 4.0 +/- 1.8 months (group I) respectively 3.6 +/- 0.8 months (group II) (NS) and 16.75 +/- 2.5 months (group I) respectively 13.2 +/- 1.9 months (group II) (NS) after operation by means of thorough electrophysiological assessment, right heart catheterization, MRI, echocardiography, stress-ECG and 24 h-ECG.

RESULTS

There was no significant difference between the two groups with regard to sex, age and duration of AF. Echocardiographic left atrial diameter (LAD) was 75 +/- 11 mm in group I and 65 +/- 8 mm in group II (p = 0.002). Whereas right atrial diameter was 62 +/- 8 mm in group I and 57 +/- 7 mm in group II (NS). Perioperative data (n = 72): Aortic cross clamp time was 127 +/- 40 min in group I and 87 +/- 22 min in group II (p = 0.0002). Cardiopulmonary bypass time was 185 +/- 71 min in group I and 137 +/- 42 min in group II (p = 0.01). Postoperative data I (first follow-up: n = 66): sinus rhythm (yes): 4/7 vs. 47/59 (NS); pacemaker (PM) in AAI mode (yes): 1/7 vs. 3/59 (NS); inducible atrial fibrillation (yes): 2/7 vs. 5/59 (NS); Bradycardie Tachycardie Syndrome with the need of PM implantation 0/7 vs. 4/59 (NS). Postoperative data II (second follow-up: n = 55): sinus rhythm (yes): 5/7 vs. 34/48 (NS); PM in AAI mode (yes): 0/7 vs. 4/48 (NS); Inducible atrial fibrillation (yes): 2/7 vs. 5/48 (NS); Bradycardia Tachycardia Syndrome with the need of PM Implantation 0/7 vs. 5/48.

CONCLUSION

Midterm results are identical after M III and Mini. The Mini-Maze procedure is less complex compared to the Maze III procedure and there is a significant reduction of crossclamp and ECC times. We recommend the Mini especially for polymorbid patients and for those with poor left ventricular function.

Activation of ERK/MAP kinase in the amygdala is required for memory consolidation of pavlovian fear conditioning

Although much has been learned about the neurobiological mechanisms underlying Pavlovian fear conditioning at the systems and cellular levels, relatively little is known about the molecular mechanisms underlying fear memory consolidation. The present experiments evaluated the role of the extracellular signal-regulated kinase/mitogen-activated protein kinase (ERK/MAPK) signaling cascade in the amygdala during Pavlovian fear conditioning. We first show that ERK/MAPK is transiently activated-phosphorylated in the amygdala, specifically the lateral nucleus (LA), at 60 min, but not 15, 30, or 180 min, after conditioning, and that this activation is attributable to paired presentations of tone and shock rather than to nonassociative auditory stimulation, foot shock sensitization, or unpaired tone-shock presentations. We next show that infusions of U0126, an inhibitor of ERK/MAPK activation, aimed at the LA, dose-dependently impair long-term memory of Pavlovian fear conditioning but leaves short-term memory intact. Finally, we show that bath application of U0126 impairs long-term potentiation in the LA in vitro. Collectively, these results demonstrate that ERK/MAPK activation is necessary for both memory consolidation of Pavlovian fear conditioning and synaptic plasticity in the amygdala.

The effect of leukocyte-depleted blood cardioplegia in patients with severe left ventricular dysfunction: a randomized, double-blind study

BACKGROUND

The propensity for leukocytes to cause reperfusion injury in patients undergoing heart surgery is widely accepted. Reperfusion injury may result in myocardial damage and unfavorable operative outcome, especially in patients with severely reduced ejection fractions. This study was performed to evaluate the impact of leukocyte filtration on the postoperative course of patients undergoing coronary bypass surgery.

METHODS

Thirty-two patients with coronary artery disease and left ventricular ejection fraction less than 35% were included in this double-blind, randomized study. Two serial leukocyte removal filters (Pall BC1B filter [Pall Biomedical, Portsmouth, England], group F, 15 patients) or two dummy filters (group C, 17 patients) were connected to the blood cardioplegia line. Leukocyte count, hemodynamic measurement, and transesophageal echocardiography were performed before and after cardiopulmonary bypass. Cardiac-specific enzymes were analyzed from arterial blood during the first 72 hours and from coronary sinus blood 30 and 60 minutes after aortic unclamping.

RESULTS

Patient characteristics were similar in the two groups (ejection fraction 20.9% +/- 4.3% in group C and 21.1% +/- 4.8% in group F; P =.773). No early death or perioperative myocardial infarction occurred. Leukocyte count, hemodynamic parameters, cardiac troponin T, cardiac troponin I, and creatine kinase MB mass levels in arterial blood were similar in the two groups. Group F showed lower release of cardiac troponin T from the coronary sinus 30 minutes after unclamping of the aorta (group F, 0.263 +/- 0.12 ng/mL; group C, 0.6 +/- 0.32 ng/mL; P =.005). Lower doses of dopamine were necessary after cardiopulmonary bypass (group F, 0.36 +/- 0.11 mg x kg(-1) x min(-1); group C, 0.49 +/- 0.14 mg x kg(-1) x min(-1); P =.003). A moderate increase in ejection fraction was observed at 30 minutes in both groups (group F, 30.3% +/- 6.2%; group C, 28.0% +/- 6.3%; P =.239) and a significant increase at 60 minutes in group F (group F, 32.5% +/- 6.0%; group C, 27.4% +/- 7.5%; P =.012).

CONCLUSIONS

These results indicate that serial leukocyte filters connected to the blood cardioplegia line decrease myocardial cell injury and may therefore help to improve outcome of patients with severely depressed ejection fractions undergoing coronary artery bypass grafting.

Do patients want minimally invasive aortic valve replacement?

OBJECTIVE

Access to aortic valve can be performed through small incisions. However, a considerable advantage of this approach has not been proven by randomized studies so far. We wanted to elucidate the opinion of patients when they are informed objectively about advantages and disadvantages of minimally invasive approach prior to operation.

METHODS

This prospective study was performed with 27 patients undergoing isolated aortic valve replacement. These patients were informed prior to operation by the same resident concerning objective data. A photograph was shown illustrating a patient with postoperative wound after a standard- and a mini-incision, respectively. After the interview the patient could decide between full and partial sternotomy.

RESULTS

After the interview 21/27 (78%) patients preferred to have a full sternotomy (group F) and 6/27 (22%) patients (group P) decided to have a partial sternotomy. Comments of group F: surgeon should have best exposure (n=15); cosmetics aspects unimportant (n=14); operation time as short as possible (n=7). Group P: cosmetic aspects important (n=6). Significant differences between groups (group F vs. group P): age (years), 69.1+/-1.5 vs. 49.2+/-7.3 (P=0.024); operation time (min), 142+/-7 vs. 189+/-15 (P=0.002); CK (IU/l), 111+/-11 vs. 374+/-114 (P=0.0007); CKMB (IU/l), 17+/-2 vs. 45+/-17 (P=0.006); ICU-stay (days), 2.6+/-0.2 vs. 3.2+/-0.2 (P=0.044). Pericardial effusion requiring drainage was observed in two patients of group P. One patient of group P suffered myocardial infarction.

CONCLUSION

When patients are informed objectively about advantages and disadvantages of minimal invasive aortic valve surgery only a smaller number decides to have a mini incision. The patients preferring short incisions are significantly younger since cosmetic aspects are more important. Longer duration of operation may be due to longer hemostasis based on limited exposure. Air bubbles due to inadequate de-airing might be responsible for higher CK and CK-MB levels in group P.

Simvastatin attenuates vascular hypercoagulability in cardiac transplant recipients

BACKGROUND

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to reduce cardiac allograft failure and to lower the incidence of transplant coronary artery disease. These effects result from as yet unknown mechanisms not clearly attributable to lipid lowering. We here report that low-dose simvastatin treatment inhibits excessive expression of monocyte tissue factor (TF) and reduces the persistent hypercoagulability state seen in cardiac transplant recipients.

METHODS

Fifteen consecutive heart transplant recipients receiving standard oral immunosuppression were newly assigned to a 10 mg daily simvastatin therapy. Levels of TF activity in both unstimulated and lipopolysaccharide-stimulated peripheral blood mononuclear cells drawn from transplant recipients before and under simvastatin therapy were evaluated by one-stage clotting assay.

RESULTS

Monocyte TF activity was found to be significantly increased in cardiac transplant recipients when compared with healthy controls. Excessive monocyte procoagulant activity was reduced in cardiac transplant recipients during simvastatin treatment. This effect occurred independently of the reduction of serum low-density lipoprotein cholesterol. As demonstrated by reverse transcriptase-polymerase chain reaction, monocyte TF reduction by simvastatin, observed in 13 of the 15 transplant recipients investigated, could be ascribed to an inhibition of monocyte TF gene transcription. The reduction of monocyte TF activity during treatment with simvastatin paralleled with the normalization of elevated levels of thrombin-antithrombin complex, prothrombin fragment F1+2, and D-dimer, which are markers of thrombin and fibrin formation indicating coagulation activation after cardiac transplantation.

CONCLUSION

Inhibition of monocyte TF expression and attenuation of the persistent hypercoagulable state observed in cardiac transplant recipients during treatment with simvastatin may represent an important mechanism by which HMG-CoA reductase inhibitors protect against the development of transplant coronary artery disease.

[Symptomatic true aneurysm of a venous bypass with compression of the right atrium]

A symptomatic true aneurysm of a saphenous vein graft to the right coronary artery in a female patient twelve years after bypass surgery is presented. Beating heart surgery included resection of the aneurysmatic saphenous vein graft, reconstruction of the right atrium and coronary artery bypass grafting to the right coronary artery. The symptoms of aneurysms of vein grafts, the diagnostic procedures and the surgical treatment are discussed.

L-type voltage-gated calcium channels mediate NMDA-independent associative long-term potentiation at thalamic input synapses to the amygdala

Long-term potentiation (LTP) in the amygdala is a leading candidate mechanism to explain fear conditioning, a prominent model of emotional memory. LTP occurs in the pathway from the auditory thalamus to the lateral amygdala, and during fear conditioning LTP-like changes occur in the synapses of this pathway. Nevertheless, LTP has not been investigated in the thalamoamygdala pathway using in vitro recordings; hence little is known about the underlying mechanisms. We therefore examined thalamoamygdala LTP in vitro using visualized whole-cell patch recording. LTP at these synapses was dependent on postsynaptic calcium entry, similar to synaptic plasticity in other regions of the brain. However, unlike many forms of synaptic plasticity, thalamoamygdala LTP was independent of NMDA receptors, despite their presence at these synapses, and instead was dependent on L-type voltage-gated calcium channels. This was true when LTP was induced by pairing presynaptic activity with either action potentials or constant depolarization in the postsynaptic cell. In addition, the LTP was associative, in that it required concurrent pre- and postsynaptic activity, and it was synapse specific. Thus, although this LTP is different from that described at other synapses in the brain, it is nonetheless well suited to mediate classical fear conditioning.

Evaluation of reports of periconceptual occupational exposure: maternal-assessed versus industrial hygienist-assessed exposure

BACKGROUND

While the number of women entering the work force has grown, so has the importance of investigating occupational reproductive hazards. The objective of this study was to examine the concordance between maternal-assessed and industrial hygienist-assessed exposure to four classes of occupational agents - video display terminals, paints, solvents, and agricultural chemicals.

METHODS

Case (n=87) and control (n=102) mothers who participated in a population-based study of orofacial clefts provided occupational histories and exposure (yes/no) to selected classes of agents for the one-year period prior to their child's delivery. Two industrial hygienists reviewed the occupational histories and assigned mothers an exposure status for each class of agent. Using industrial hygienist-assessed exposure as the "gold standard", sensitivity and specificity of maternal reports were calculated for each class of agent. Kappa statistics were calculated for the study population to account for chance agreement between the two exposure assessment methods.

RESULTS

Sensitivity estimates for cases were the highest for video display terminals (77%) and lowest for agricultural chemicals (14%). Respective estimates for controls were 74% and 14%. Specificity estimates tended to be high for both groups. Kappa values ranged from 0.16-0.45.

CONCLUSIONS

With regard to the classes of agents examined, these data suggest screening questions alone may not be the preferred method of obtaining occupational exposure histories, even when the time period of interest is fairly short and recent.

Midterm results after the Mini-Maze procedure

OBJECTIVE

Atrial fibrillation (AF) is the most common arrhythmia. However, its precise electrophysiologic mechanism is still not well understood. Chronic symptomatic AF resistant to medical therapy, can successfully be treated by the Maze III procedure (M III). However, there are several publications dealing with alternative surgical techniques. This study describes technique and midterm results of a Mini-variant of the M III procedure.

METHODS

During a 38-month period we performed either an M III (seven patients) (group I) or a MINI-operation (45 patients) (group II) with chronic symptomatic AF and additional cardiac pathology. Patients were controlled 3.6 +/- 0.9 and 14.9 +/- 2.2 months after operation by means of thorough electrophysiological assessment, right heart catheterization, magnetic resonance imaging (MRI), echocardiography, stress-EGG and 24-h-ECG.

RESULTS

There was no significant differences between the two groups with regard to sex, age and duration of AF. Echocardiographic left atrial diameter (LAD) was 75 +/- 11 mm in group I and 67 +/- 8 mm in group II (P = 0.01). Whereas right atrial diameter was 62 +/- 8 mm in group I and 56 +/- 7 mm in group II (NS). Perioperative data (n = 52): aortic cross clamp time was 127 +/- 40 mm in group I and 87 +/- 21 mm in group II, (P = 0.0002). Cardiopulmonary bypass time was 185 +/- 71 mm in group I and 137 +/- 46 mm in group II, (P = 0.02). Postoperative data: there was no difference between the two groups with regard to sinus rhythm, prolonged sinus node recovery time, pacemaker (PM) in AAI-mode, inducible atrial fibrillation, reduction of left and right atrial size after a follow-up interval of 3.6 months and 1 year, respectively.

CONCLUSION

Midterm results are identical after M III and MINI. MINI is less complex compared to the M III procedure and there is a significant reduction of crossclamp- and ECC-time. We recommend the MINI especially for polymorbid patients, and for those with poor left ventricular function.

Transmyocardial laser revascularisation has no beneficial effect on high energy phosphates and lactate content during acute myocardial ischaemia in pigs

OBJECTIVE

Transmyocardial laser revascularisation (TMLR) is used to treat endstage coronary heart disease. There is evidence that angina is significantly reduced after TMLR. However, the precise mechanism by which symptoms disappear remains unknown. The objective of the present study was to examine the potential effects of TMLR on high-energy phosphates and myocardial perfusion in an acute ischaemic model.

METHOD

Five male landrace pigs (42 +/- 1.8 kg) had TMLR of the anterolateral wall of the left ventricle using a 1000 W CO2 laser (PLC, USA). Thereafter the anterior descending coronary artery was occluded with a tourniquet. After 90 min of ischaemia, drill-biopsies were taken from ischaemic and non-ischaemic areas as well as from laser channels. The specimens were snap-frozen in liquid nitrogen. Subsequently, methylene blue was injected into the left atrium to study tissue distribution. The hearts were excised and the patency of channels was examined visually.

RESULTS

Coronary artery occlusion resulted in immediate blue discoloration in both TMLR and control areas. There was no subendocardial methylene blue staining around laser channels. Inspection of hearts showed occlusion of laser channels due to thrombus formation at both endo- and epicardial levels. ATP-metabolites significantly increased in ischaemic areas compared to non-ischaemic areas. Furthermore there was significant upregulation of purine-content in ischaemic regions even in areas with laser channels.

CONCLUSIONS

In our acute model there was early occlusion of the channels after TMLR. We suggest that clinical improvement after this procedure is not due to increased myocardial oxygen delivery, since high energy phosphate levels and lactate content remained unchanged.

Spatiotemporal development and distribution of intercellular junctions in adult rat cardiomyocytes in culture

The mode of development of the intercalated disk (ID) is largely unknown, and the hypothesis was tested that the assembly of cell adhesion junctions may precede the formation of gap junctions (GJ) in developing ID in adult rat cardiomyocyte (ARC) in long-term culture. Immunostaining for connexin 43 (Cx43) and for cell adhesion junction proteins (N-cadherin, catenins, and desmoplakin) in single- and double-label techniques was analyzed and quantified by confocal and electron microscopy. All proteins investigated disappeared 48 hours after ARC isolation and reappeared parallel to redifferentiation of ARC. The newly formed ID, observed after 5 days, showed the presence of N-cadherin, catenins, and desmoplakin, low levels of Cx43, and absence of ultrastructurally discernible gap junctions. A progressive incorporation of Cx43 within ID was observed after 6 days, when cell adhesion junction proteins were already organized as zipper-like structures. Quantitative confocal analysis revealed a progressive augmentation of the fluorescence intensity of Cx43, associated with an increase in both the number and size of GJ, resulting in a substantial increase in the percentage of total GJ length per reassembled ID from 1.67% (day 6) to 15.58% (day 12). In the present study, we show that (1) the formation of the ID can be followed in ARC in culture and (2) the assembly of the adhering type of junction is the prerequisite for subsequent GJ formation within the ID. These findings may have clinical relevance in elaborating strategies for using myocardial grafts and for the potential restoration of GJ communication in cardiac diseases.

Cardioscopy: potential applications and benefit in cardiac surgery

OBJECTIVE

Cardioscopy in open heart surgery is still not routine in most units. However, since our first report in 1996 we use this device more frequently, because we think that safety and accuracy of different surgical procedures is increased.

METHODS

Between 1/96 and 12/97 we performed cardioscopy in 100 patients. Indications (IND) for cardioscopy were as follows: IND (1) resection of hypertrophied septum (N = 15); IND (2) evaluation of aortic valve with low grade stenosis or insufficiency (N = 12); IND (3) removal of intracardiac foreign bodies/tumors (N = 13); IND (4) inspection of VSD prior and after repair (N = 8); IND (5) identification of paravalvular leakage (N = 8); IND (6) diagnostic purposes (N = 4); IND (7) education of surgeons and operating room staff (N = 40). During cardioplegic arrest the 5 mm rigid or flexible cardioscope (Storz, Tuttlingen, Germany) was inserted through ascending aorta, aortic valve or tricuspid valve depending on indication.

RESULTS

No complication occurred during cardioscopy. IND (1): there was an excellent view of all intracardiac structures. Thorough resection of hypertrophied septum was possible and there was no injury of adjacent structures or aortic valve. IND (2): all valves were inspected through a 1 cm aortic incision and the pathology of the valves was documented. In case of severe calcification, the valve was replaced although transvalvular gradient was less than 50 mm Hg. IND (3): intraventricular foreign bodies, such as felt pledges (N = 2), debris (N = 5), thrombi (N = 4) and tumors (N = 2) were entirely removed through the aortic valve with a special forceps. IND (4): anatomy of VSD was documented in all cases. It was possible to test accuracy of all patch-sutures. IND (5): all paravalvular leakages were identified even though there was heavy immobility of the mechanical valve. IND (6): a papillary muscle (N = 2) and a thrombus formation (N = 2) were diagnosed. IND (7): the surgeons and operating room staff could follow the entire procedure in all cases.

CONCLUSIONS

Cardioscopy is a supporting technique to clearly identify intracardiac structures, to control several surgical procedures, to document valve pathology, and to educate surgeons and operating room staff. Handling is easy and does not increase operative risk. Some procedures will be performed with minimal invasivity in future.

An assessment of exposure to mercury and mercuric chloride from handling treated herbarium plants

A curator at a university herbarium reported headache, nausea and mucosal irritation after initiating a project to remount plant specimens treated with mercuric chloride. Workplace exposure assessment indicated potential for mercury compound ingestion through hand-to-mouth contact. Blood, hair and urine assays were negative.

Repair of an aneurysm of the pulmonary trunk in a 65-year-old patient

The case of a 65-year-old patient with asymptomaticaneurysm of the pulmonary trunk associated with severe insufficiency of the pulmonary valve and symptomatic coronary artery disease is presented. The surgical procedure included coronary artery bypass grafting, aneurysmectomy, and pulmonary artery replacement with implantation of a stentless bioprosthesis and lengthening of the root of the bioprosthesis with a reversed vascular Y prosthesis, which was anastomosed to the left and right pulmonary artery.

Upregulated and downregulated transcription of myocardial genes after pulmonary artery banding in pigs

BACKGROUND

Acute or chronic pressure overload may occur during or after cardiac surgical procedures. Typical examples are aortic cross-clamping and pulmonary artery banding. It is well known that mechanical stress induces transcription of different myocardial genes. However, these results were mainly obtained from in vitro studies and experiments with rodents. This experiment was carried out to investigate molecular alterations after pressure overload in porcine hearts.

METHODS

The study was performed with 35 Landrace pigs with a mean weight of 32+/-1.2 kg. The five groups consisted of 7 pigs each, 3 sham-operated pigs and 4 banded pigs. The hearts were exised after different time intervals. We investigated messenger RNA expression of sarcoplasmic reticulum adenosine triphosphatase, phospholamban, alpha-/beta-myosin heavy chain, and atrial natriuretic factor by Northern blot analysis.

RESULTS

The ratio of right ventricular weight to body weight increased significantly after 7 and 24 days in banded pigs (p < 0.05). Atrial natriuretic factor messenger RNA was significantly upregulated in banded pigs versus sham-operated pigs after 1 day (240%+/-7% versus 100%+/-6%; p < 0.01) and 3 days (520%+/-8% versus 100%+/-8%; p < 0.01). There was insignificant downregulation of sarcoplasmic reticulum adenosine triphosphatase and phospholamban after 1, 3, and 7 days. Myosin heavy chain messenger RNA expression remained unchanged.

CONCLUSIONS

Pulmonary artery banding results in hypertrophic response of the porcine right ventricle; however, the weight increase is not the result of myosin heavy chain messenger RNA upregulation. Atrial natriuretic factor messenger RNA is locally expressed in mechanically stressed myocytes. Furthermore, pressure overload downregulates transcription of calcium-binding proteins that can influence ventricular contractility. These results may have an impact on cardiac surgical procedures.

Reoperations after dacron patch aortoplasty with heparinized femoro-femoral bypass

Dacron patch aortoplasty used to be a standard therapy in some surgical units. Occurrence of aneurysm formation after this procedure is well known. The incidence of aneurysms is reported to be 0-35% with a high risk of lethal rupture. We report three cases of aneurysm repair of the descending thoracic aorta after dacron patch aortoplasty using femoro-femoral extracorporeal system. Heparin-coated system was used primarily to prevent ischemic spinal cord injury through hypotension of the distal aorta and secondarily to reduce the risk of intraoperative hemorrhage.

Increased growth factor transcription after pulmonary artery banding

OBJECTIVE

Several mechanisms are known to produce mechanical stress during and after cardiac surgery, e.g. aortic cross-clamping and pulmonary artery banding (PAB). However, little is known about the transcription of myocardial genes which are changed during mechanical overload. This study was performed to investigate growth factor mRNA expression after PAB in porcine hearts.

METHODS

The experiment was performed in 35 pigs (five groups). Each group consisted of three sham-pigs (S-pigs) and four banding-pigs (B-pigs). The mean transbanding gradient in B-pigs was 29 +/- 2.5 mm Hg. The hearts were excised after different time intervals. The probes were snap-frozen in liquid nitrogen and stored at -80 degrees C. Analysis was performed by Northern blot.

RESULTS

Right ventricular weight increased significantly after 7 and 24 days (P < 0.05). There was an upregulation of transcriptional and growth factors in B-pigs: c-jun mRNA: 412 +/- 12.1% after 2 h (P < 0.001); c-fos mRNA: 303 +/- 18.5% after 2 h (P < 0.001); vascular endothelial growth factor (VEGF) mRNA: 203 +/- 18.2% after 2 h (P < 0.001); Flk-1 mRNA: 156 +/- 16% after 2 h (P < 0.05), 253 +/- 5% after 24 h (P < 0.01) and 184 +/- 12% after 3 days (P < 0.01); transforming growth factor-beta1 (TGF-beta1) mRNA: 255 +/- 21.5% after 24 h (P < 0.002). Fibroblast growth factors 1 and 2 (FGF-1 and FGF-2) were constitutively expressed in B- and S-pigs and did not change their expression.

CONCLUSIONS

Pulmonary artery banding results in significant right ventricular hypertrophy and upregulation of different growth factors. However, growth factors known to induce hypertrophy in vitro, like the FGFs, showed unchanged expression. We think that myocardial growth factors may have trophic functions in the heart which may be useful for cardiac surgery in future.

Video-assisted resection of hypertrophied and fibrous intraventricular tissue

There is increasing interest in endoscopic techniques in cardiac surgery. However, use of the endoscope during open heart operations is still not routine. Cardioscopy has been used in patients with hypertrophied obstructive cardiomyopathy, asymmetric septal hypertrophy, or membranous subaortic stenosis. We demonstrate the resection of this pathologic tissue under direct visualization. With this technique we could increase the safety and accuracy of this surgical procedure. Beside this advantage, the entire operating room staff could follow the surgical intervention, which increases its educational side-effect.

Diagnostic transaortic cardioscopy of the left ventricle

Preoperative diagnosis of pathologic intracardiac structures by noninvasive techniques is sometimes difficult or even impossible. In these cases a heart operation is required with opening of one or more cardiac chambers. We demonstrate direct visualization of the left ventricular cavity by transaortic cardioscopy in a patient with a pathologic intraventricular structure. With this technique we could avoid ventriculotomy.

Valve surgery combined with coronary artery operation: is the use of internal mammary artery a predictor for early complications?

The internal mammary artery (IMA) provides better early and long-term patency than venous grafts do. Although IMA is the conduit of choice in isolated coronary artery bypass grafting (CABG), its use in combined procedures is not routine in some cardiovascular units. During a 16-month period, 188 patients underwent valve surgery combined with CABG. Internal mammary grafts were used in 68/188 (36%) patients (group 1) and vein grafts without arterial grafts (group 2) in 120/188 (64%). Left IMA was implanted in 67/68 (99%) and right IMA in 1/68 1%) cases. Surgeon A used IMA in 28/44 (64%), surgeon B in 20/32 (63%), surgeon C in 18/44 (41%), surgeon D in 1/4 (25%) and surgeon E in 1/63 (2%) patients. The final decision to use IMA in a combined procedure was left up to the surgeon. Statistically, the preoperative- and perioperative data were identical in the two groups, although the frequency of IMA grafting in patients with double valve replacement and reoperation was lower (1/68 vs 11/120, ns, and 3/68 vs 9/120, ns). Ten of 188 (5.3%) patients died within 30 days after operation. Longer cross-clamp time (P = 0.008) and mitral valve replacement (P = 0.05) were independent risk factors for early death. The use of IMA did not increase the risk of early mortality. The postoperative variables were similar in the IMA and vein groups, in particular data suggesting perioperative myocardial infarction (CK-MB, catecholamine support). Postoperative mechanical ventilation was longer in the IMA group, although not significantly (P = 0.06). Early mortality and morbidity were identical in the two groups in combined procedures. We did not find any hints for an increased risk of using IMA in this type of surgery. Internal mammary artery implantation is safe in selected patients undergoing combined valve and CABG surgery. Beside the better long-term patency of IMA, its use may have several technical advantages.

Coronary arteriovenous fistula: surgical correction of a rare form

In a 60-year-old woman with long-standing angina left heart catheterisation revealed peripheral and central coronary arteriovenous fistulae connected to the left and right coronary system and opening into the pulmonary artery. The fistulae connected to terminal coronary artery branches were corrected by ligation of these feeding arteries while the electrocardiogram was continuously monitored. The central fistulae were closed via a transcoronary approach of the left anterior descending artery. Knowledge of different surgical techniques helps to prevent perioperative myocardial infarction and late fistula recurrence.

Ruptured abdominal aortic aneurysms: predictors for early complications and death

BACKGROUND

Urgent operation for ruptured aneurysm is still associated with a high operative mortality rate. The purpose of the study was to determine the risk factors that truly influence early complications and death.

METHODS

Between 1979 and 1991, 314 consecutive patients with a mean age of 69 years were treated surgically for a ruptured infrarenal abdominal aortic aneurysm. Twenty-two preoperative, perioperative, and intraoperative variables were subjected to a multivariate analysis to identify the independent predictors.

RESULTS

Early death occurred in 92 (29%) of 340 patients. Significant primary predictors for early death were duration of cross-clamp (p < 0.0001), preoperative shock (p = 0.0005), suprarenal cross clamp (p = 0.002), and a history of coronary artery disease (CAD) (p = 0.004). The following postoperative complications were risk factors for death: myocardial failure (p < 0.0001), renal failure (p < 0.0001), sepsis (p = 0.01), and colon ischemia (p = 0.03). Predictors for postoperative myocardial insufficiency were a history of CAD (p < 0.0001), amount of intraoperative volume substitution (p < 0.0001), suprarenal cross clamp (p = 0.0007), and preoperative shock (p = 0.05).

CONCLUSIONS

Preoperative and perioperative risk factors that result in fatal postoperative complications can be partially influenced by the surgeon. Short clamping time and infrarenal position of aortic clamp may lower overall early mortality rates. A history of CAD is a highly significant predictor for postoperative complications and early death.

Valvotomy for isolated congenital aortic stenosis in children: prognostic factors for outcome

Early and late results after surgery for isolated congenital valvar aortic stenosis were evaluated in a total of 86 children under 16 years of age (mean 7.4 years). Primary procedure was always conservative. There were 7/86 (8.1%) early deaths. All infants who died after the operation were younger than 4 months of age. Among the clinical variables tested by the univariate analysis only age and duration of cardiopulmonary bypass were significant prognostic factors for early death. There were 6/67 (7.7%) valve-related late deaths. Multivariate analysis could not identify any risk factors for early and late mortality. Actuarial survival was 97% (95% CL 93-101%) after 5 years, 94% (88-100%) after 10 years, 90% (82-98%) after 15 years, and 87% (77-97%) after 20 years. A total of 22/79 (28%) early survivors had a first reoperation and 5 had a second reoperation. Long follow-up interval was the only significant factor for reoperation. Actuarial reoperation-free interval was 91% (85-98%) after 5 years, 70% (58-81%) after 10 years, and 50% (34-64%) after 15 years. Significant factors for poor valve function were long duration of follow-up, endocarditis, and young age at operation. The probability of normal valve function was 91% (84-98%) after 5 years, 67% (55-79%) after 10 years, and 54% (40-68%) after 15 years.

[Single cusp homograft implantation in the reconstruction of right ventricular outflow tract in the correction of tetralogy of Fallot]

From 1987 to 1990, 37 children underwent surgical correction for tetralogy of Fallot. The mean age was 38.2 months (2-156 months). The indication for right ventricular outflow tract (RVOT) obstruction in 19/37 (51%) children was: hypoplastic pulmonary valve (n = 10), annular hypoplasia (n = 12), RVOT obstruction and hypoplastic pulmonary artery (n = 10). In 18/37 (49%) children, the repair of the RVOT was done without homograft. The RVOT morphology was the only indication for reconstruction with homograft. All other pre-, intra- and postoperative data were identical for both groups. There was no operative or late death. After a mean follow-up of 4.4 months, all 19 children with homograft were in NYHA class I and echocardiographic evaluation showed mild and moderate pulmonary regurgitation in 8 and 4 children respectively. Out of the 18 children without homograft, 16 were in NYHA class I and 2 in NYHA class II. Two children had early postoperative right heart failure. The mean follow-up time in this group was 5.5 months. Echocardiography revealed residual pulmonary regurgitation in 4 children, pulmonary stenosis in 6 and combined residual pulmonary valve defect in 6. If severe malformation of the RVOT or the pulmonary artery is present, a valved homograft is recommended for repair of tetralogy of Fallot. Good morphological and functional results may be achieved.

Pulmonary atresia with intact ventricular septum: results and predictive factors of surgical treatment

Between 1970 and 1989 26 children were operated for pulmonary atresia with intact ventricular septum (PA/IVS). According to the degree of right heart hypoplasia the patients were divided into 3 groups of mild (5), moderate (17) or severe (4) hypoplasia. Palliative operations were performed in 25 children (17 male, 8 female) at a mean age of 10 days: 13 valvotomies (valv.), 5 aortopulmonary shunts, and 7 valv. plus shunt. One patient had total correction as primary procedure. A total of 17 reoperations was necessary in 12 of 26 patients (10 palliations, 7 total corrections). Total corrections were: 2 conduits and 5 patches of the right-ventricular outflow tract (RVOT). Total mortality was 14/26 (54%) children (early 10/26 = 38%, late 4/26 = 16%). After total correction mortality was 3/7 (43%) patients. After a mean follow up of 10.8 years after palliation the 12 survivors are mostly in NYHA class I. Actuarial survival after palliation was 60% after 30 days and 44% after 5 and 10 years. We analyzed 9 clinical and hemodynamic variables by univariate and multivariate analysis to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed the degree of right-ventricular hypoplasia (p = 0.023) as an independent predictor for death whereas the age at palliation only approached significance (p = 0.065). We recommend the following surgical strategy, aiming in the first place at decompressing the right ventricle: in mild hypoplasia valvotomy alone or combined with a shunt for palliation, in moderate hypoplasia shunt plus patch of the RVOT and in severe hypoplasia shunting alone. In case of a restrictive foramen ovale initial balloon septostomy is performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylactic cytolytic therapy in heart transplantation: monoclonal versus polyclonal antibody therapy

The value of immunoprophylaxis with monoclonal anti-CD3 antibodies (OKT3) was evaluated in 44 consecutive, nonrandomized heart transplant patients. The control group (n = 22) was treated with polyclonal rabbit antithymocyte globulin (RATG) for 5 days. The study group (n = 22) was treated with OKT3 for 14 days. All patients had identical perioperative immunosuppressive therapy and similar maintenance therapy, with cyclosporine, azathioprine, and low-dose prednisone (starting prednisone: OKT3 group immediately, RATG group 3 weeks [n = 11] or greater than 3 months [n = 11] after transplantation). The mean histologic rejection grade (Texas classification) in the RATG and the OKT3 groups was 2.5 +/- 1.9 and 0.6 +/- 0.8 (p less than 0.005) after 1 week and 4.3 +/- 1.6 and 2.0 +/- 1.5 (p less than 0.001) after 2 weeks, but there was no difference in the first year. The linearized rejection rate (rejections per 100 patient days) was higher in the RATG group in the first 2 weeks (2.6 vs 0, p less than 0.05 respectively, 7.8 vs 0.7, p less than 0.001) and higher in the OKT3 group in the second month (1.4 vs 2.8, p less than 0.01). In the RATG group the rejection rate fell continuously, to 0.1 at the end of the first year, whereas in the OKT3 group it remained 0.4 (NS). The cumulative first-year incidence was similar for persistent rejections (RATG 0.38 +/- 0.29 vs OKT3 0.48 +/- 1.13, NS) and insignificantly higher for severe rejections in the OKT3 group (RATG 0.21 +/- 0.32 vs OKT3 0.49 +/- 1.10). Rejection-related mortality in the first year was 0% (RATG) and 9% (OKT3).(ABSTRACT TRUNCATED AT 250 WORDS)

Pericarditis constrictiva after aortic valve replacement simulating tricuspid stenosis

Pericarditis constrictiva after cardiac surgery is rare and may occasionally lead to congestive heart failure. The case of a 29-year-old patient is described who presented with pericarditis constrictiva after aortic valve replacement with localized tamponade, causing functional tricuspid stenosis. Pericardiectomy as the treatment of choice was curative.

Early and late results after surgery for massive pulmonary embolism

Between 1978 and 1990 emergency pulmonary embolectomy with the aid of extracorporeal circulation (ECC) was performed for massive pulmonary embolism (PE) in 44 patients (19-73 yrs; 49 +/- 15 yrs). Cardiopulmonary circulation was stable in 16/44 patients but unstable in 28/44; of the latter, 15 had undergone previous cardiopulmonary resuscitation due to cardiac arrest. Diagnosis of PE was obtained clinically in 15/44 patients, by angiography in 13/44, by echocardiography in 10/44, and by perfusion scintigraphy of the lung in 6/44 patients. There were 9/44 (20%) postoperative deaths. Early mortality was significantly higher in previously resuscitated patients (p less than 0.05). There were 2/36 (6%) late deaths. Actuarial survival was 75% after 4 yrs and 71% after 8 yrs. 77% or 35 survivors were in NYHA-class I and 23% in NYHA-class II after a mean follow-up of 4.6 yrs. Pulmonary embolectomy is indicated in patients with central PE and shock; it is advisable in patients with embolism of the main pulmonary artery or its major branches or in patients with contraindication to thrombolysis. Intraoperative insertion of a vena cava filter is recommended for prevention of recurrent embolism. Preoperative resuscitation and duration of ECC are predictors for early death.