[RESULTS OF APPLICATION OF THE METHOD OF STERNAL INFECTION ELIMINATION IN CARDIOSURGICAL PATIENTS]

A retrospective analysis of cases of sternal infection development was made in 388 cardiovascular patients from 2006 to 2012. The standard preventive measures of wound infection development were applied in the first period from 2006 to 2009. The method of "elimination of sternal infection" was used in the second period from 2009 to 2012. The application of the method of "elimination of sternal infection" allowed reducing the rate of sternal infection from 7.7 to 0.5% (odds ratio 0.099, 95% CI: 0.013-0.747; p = 0.025). According to results of statistical analysis the most significant factors were: body mass index (p = 0.002), resternotomy in early postoperative period (p < 0.001), risk according EuroSCORE Logistics (p < 0.001) and usage of the method of "elimination of sternal infection" (p = 0.006). The prevention of postoperative infectious complications shorthens the terms of hospital stay no less than 3 weeks, improves the quality of life for the patients and decreases treatment costs on 2.5 times.

Beneficial effects of intravenously administered N-3 fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a prospective randomized study

BACKGROUND

Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting operation (CABG). Experimental data have shown antiarrhythmic effects of n-3 polyunsaturated fatty acids (PUFA) on myocardial cells. Orally administered PUFA could significantly reduce the rate of postoperative AF. We assessed the efficacy of PUFA for the prevention of AF after CABG. PUFA were given intravenously to prevent variation in bioavailability.

METHODS AND RESULTS

52 patients were randomized to the interventional group, 50 served as controls. In the control group free fatty acids (100 mg soya oil/kg body weight/day) were infused via perfusion pump, starting on admission to hospital and ending at discharge from intensive care. In the interventional group PUFA were given at a dosage of 100 mg fish oil/kg body weight/day. Primary end point was the postoperative development of AF, documented by surface ECG. Secondary end point was the length of stay in the ICU. The demographic, clinical and surgical characteristics of the patients in the two groups were similar. Postoperative AF occurred in 15 patients (30.6 %) in the control and in 9 (17.3 %) in the PUFA group ( P < 0.05). After CABG, the PUFA patients had to be treated in the ICU for a shorter time than the control patients. No adverse effects were observed.

CONCLUSIONS

Perioperative intravenous infusion of PUFA reduces the incidence of AF after CABG and leads to a shorter stay in the ICU and in hospital. Our data suggest that perioperative intravenous infusion of PUFA should be recommended for patients undergoing CABG.

Impact of graft size and resuspension level of the commissures on aortic insufficiency after reimplantation of the aortic valve

BACKGROUND

In addition to the size of the graft, the resuspension of the commissures has been described as important for valve function in valve-sparing aortic root replacement procedures. This study describes the influence of a stepwise reduction of the fixation level of the commissures within the graft as well as a stepwise reduction of graft size on valve insufficiency.

METHOD

Porcine aortic valves were reimplanted into a tubular graft and the height of the commissures was reduced in a stepwise manner. In a second series of experiments, the diameter of the grafts was reduced by 30 % and 50 %.

RESULTS

A reduction of the commissure heights by 10 % and 20 % caused a significant increase in reflux water. Using the criteria of homograft preparation, a 10 %, but not a 20 %, reduction was tolerated. The coaptation level of the valve became increasingly lower, indicating a higher risk for late valve incompetence. A reduction of the prosthesis diameter by 30 % and 50 % did not result in insufficiency of the valve but it lowered the coaptation level.

CONCLUSION

Resuspension of the commissures within the graft has a more important impact on early failure rates than the choice of graft size.

Contrast echocardiography: a valid and sensitive imaging method in the investigation of transmyocardial laser-revascularization in an acute ischemia model

In an acute porcine myocardial ischemia model we examined the effect of transmyocardial laser-revascularization (TMLR) on the regional micro perfusion and oxygen supply. In clinical practice, contrast echocardiography is a reliable tool for the measurement of changes in regional blood flow in the ischemic myocardium. We compared contrast echocardiography with the laser Doppler measurement of micro perfusion and with the quantification of regional tissue oxygen tension using a Clark electrode. 22 pigs were randomised in the interventional group and 12 in the control group. Measurements with all three methods were performed before and after occlusion of the first diagonal branch of the left anterior descending coronary artery and, in the interventional group, after TMLR. We investigated not only the effects in the dependent ischemic myocardium, but also in two other myocardial areas, not involved in the coronary occlusion. There was a significant effect of TMLR on regional micro perfusion and local oxygen tension in the dependent ischemic myocardial area. Contrast echocardiography is a successful experimental tool to measure changes in regional myocardial perfusion which cannot be perceived using clinical imaging methods.

The dynamic air bubble trap reduces cerebral microembolism during cardiopulmonary bypass

OBJECTIVE

Neuropsychologic disorders are common after coronary artery bypass operations. Air microbubbles are identified as a contributing factor. A dynamic bubble trap might reduce the number of gaseous microemboli.

METHODS

A total of 50 patients undergoing coronary artery bypass operation were recruited for this study. In 26 patients a dynamic bubble trap was placed between the arterial filter and the aortic cannula (group 1), and in 24 patients a placebo dynamic bubble trap was used (group 2). The number of high-intensity transient signals within the proximal middle cerebral artery was continuously measured on both sides during bypass, which was separated into 4 periods: phase 1, start of bypass until aortic clamping; phase 2, aortic clamping until rewarming; phase 3, rewarming until clamp removal; and phase 4, clamp removal until end of bypass. S100 beta values were measured before, immediately after, and 6 and 48 hours after the operation and before hospital discharge.

RESULTS

The bubble elimination rate during bypass was 77% in group 1 and 28% in group 2 (P <.0001). The number of high-intensity signals was lower in group 1 during phase 1 (5.8 +/- 7.3 vs 16 +/- 15.4, P <.05 vs group 2) and phase 2 (6.9 +/- 7.3 vs 24.2 +/- 27.3, P <.05 vs group 2) but not during phases 3 and 4. Serum S100 beta values were equally increased in both groups immediately after the operation. Group 2 patients had higher S100 beta values 6 hours after the operation and significantly higher S100 beta values 48 hours after the operation (0.06 +/- 0.14 vs 0.18 +/- 0.24, P =.0133 vs group 2). Age and S100 beta values were correlated in group 2 but not in group 1.

CONCLUSION

Gaseous microemboli can be removed with a dynamic bubble trap. Subclinical cerebral injury detectable by increases of S100 beta disappears earlier after surgical intervention.

Aortic homograft endocarditis caused by Rhodotorula mucilaginosa

Serious infections caused by Rhodotorula spp. are rare and usually occur in immunocompromised people, especially in patients with tumors and long-time use of indwelling central venous catheters. We report a case of Rhodotorula mucilaginosa homograft endocarditis in an otherwise healthy man, which was successfully treated by surgery in combination with amphotericin B and subsequently intraconazole.

Intracellular adhesion molecule-1 in patients developing pulmonary insufficiency after cardiopulmonary bypass

OBJECTIVES

Cardiopulmonary bypass activates adhesion molecules, which are associated with systemic inflammation and organ dysfunction. The intracellular adhesion molecule-1 (ICAM-1) has been evaluated in patients presenting pulmonary dysfunction after cardiac surgery.

MATERIALS AND METHODS

Postoperative serum levels of the ICAM-1 were measured in 40 patients who underwent isolated coronary artery bypass grafting, in 28 with uneventful postoperative recovery (70 %) (Group 1), and in 12 (30 %) with postoperative respiratory insufficiency (Group 2), defined by the need for prolonged (> 24 hours) mechanical ventilation using a fractional oxygen concentration of > 40 %.

RESULTS

Patients in group 1 were ventilated for 12.21 +/- 4.86 hours and those in group 2 for 92.91 +/- 48.14 hours (p < 0.001). ICAM-1 decreased from 145.98 +/- 73.40 ng/ml to 81.15 +/- 114.82 ng/ml in group 1, while in group 2 ICAM-1 showed a significant higher level and increased to 435.01 +/- 130.02 ng/ml (p < 0.001). The leukocyte count increased in both groups as well as the C-reactive protein (CRP) during the postoperative course. The CRP behaves similar in both groups (p = 0.636) in contrast to the leukocyte count which was significantly higher in group 2 (p < 0.01). While none of the patients in group 1 died the mortality in group 2 was 50 % (p < 0.001).

CONCLUSION

Respiratory insufficiency after cardiopulmonary bypass is associated with a distinct increase in the ICAM-1. The reason for the increase of the ICAM-1 in this small subset of patients has not been clarified.

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.

[Septic endarteritis after angiography]

Infectious complications after angiography are rare. We treated a 72-year-old man who developed staphylococcus aureus endarteritis after angiography resulting in delayed rupture of the common iliac artery. Diagnostic problems, type of bacteria involved and therapeutic implications are discussed.

[Timing of reoperation of degenerated aortic and mitral bioprostheses]

Reoperative surgery for degenerated aortic and mitral valve bioprostheses has a considerable mortality. This study compares life expectancy, mode of failure and predictors for emergency reoperation and reoperative mortality between degenerated aortic and mitral bioprostheses. A total of 265 bioprosthetic valve patients, 172 aortic and 93 mitral patients, were followed to assess the time period between first and redo valve replacement. Mean life expectancy for aortic bioprostheses was 10.4 +/- 4.3 (2 to 28.6) years, whereas it was 10.0 +/- 3.7 (0.9 to 20) years for mitral bioprostheses (group M). Emergency reoperation had to be performed in 31/172 group A (18%) and 16/93 group M (17%) patients. In group A, the reoperative mortality was 5.2%; it was 1.4% for elective and 22.6% for emergency reoperation (p < 0.0001; OR = 20.3). Reoperative mortality in group M patients was 5.4% and did not differ between elective and emergency surgery. Group A patients who died at reoperation had higher transvalvular gradients before the first operation (p = 0.007), received smaller sized bioprostheses (p = 0.03) and had a higher incidence of coronary artery disease (p = 0.001) and pulmonary artery hypertension (p = 0.009) acquired during the interval. Endocarditis being the reason for primary surgery (p = 0.004), postoperative pneumonia after the first procedure (p = 0.005), pulmonary artery hypertension (p = 0.0004), later recurrence of symptoms of valve degeneration (p = 0.04), acute onset of bioprosthetic regurgitation (p = 0.00002) and a lower left ventricular ejection fraction (p = 0.03) were risk factor for emergency surgery. There were no predictors of reoperative mortality identified in mitral valve patients. The life expectancy of aortic and mitral bioprostheses is acceptable even in a relatively young patient population (mean age 46 +/- 13 in group A and 45 +/- 12 years in group M patients). Patients with degenerated aortic bioprostheses undergoing emergency reoperation have an extraordinary high reoperative mortality. They can be identified as patients who had a history of endocarditis and higher transvalvular gradients prior to the first operation, who received smaller sized bioprostheses and acquired coronary artery disease and pulmonary artery hypertension during the interval. Thus, emergency reoperation is preventable, increasing overall life expectancy of patients with bioprostheses. There were no risk factors for reoperative mortality identified in bioprosthetic mitral valve patients.

[Long-term results of the surgical treatment in acute aortic valve endocarditis]

Late results after surgery for acute infectious aortic endocarditis using allografts are compared with those achieved with bioprostheses or mechanical heart valves. Cryopreserved allografts were used in 74 (22%) and prosthetic heart valve in 262 out of 336 (78%) patients presenting acute aortic endocarditis. Prosthetic (p = 0.001) and destructive endocarditis (p = 0.001) were more frequent in patients receiving allografts. Mean follow-up time was 6.6 +/- 4 years (range, 3 to 28 years). The 30-day-mortality was 19% for allograft patients and 6% for those receiving prosthetic heart valves (p = 0.002). Early reoperation, postoperative renal failure and sepsis did not differ between groups. After 20 years, actuarial survival was 60% for mechanical heart valves, 44% for bioprosthesis and 38% for allografts (p = 0.003), reoperation was unnecessary in 52% of mechanical heart valves and 10% of bioprostheses and allografts (p = 0.0007). Acute infection at the time of operation (p = 0.0001), redo surgery (p = 0.0006), staphylococci (p = 0.0003), older age (p = 0.004) and mitral valve involvement (p = 0.004) were risk factors for late death, irrespective of preoperative antibiotic treatment and type of prosthesis used. A longer bypass and aortic cross-clamp time predicted early (p = 0.0001) and late survival (p = 0.0001), independently. Destructive aortic endocarditis has a poor long-term outcome irrespective of the use of allografts. Acute infection at the time of surgery predicted early and late death; however, surgery is indicated prior to secondary involvement of the mitral valve. The duration of preoperative antibiotic treatment did not affect outcome. A thorough surgical technique directly influences early and late survival.

Surgical management of severe common carotid artery injury after mediastinoscopy

Mediastinoscopy is a widely used method to achieve pathologic diagnosis of enlarged lymph nodes or undefined mediastinal solid mass. Aortic arch penetration and injury of the supraaortic arteries are rare but very dangerous complications of mediastinoscopy. We describe the hazardous transportation of a 57-year-old woman after mediastinoscopic injury of the right common carotid artery and its successful repair with cardiopulmonary bypass and deep hypothermia.

Preoperative administration of steroids: influence on adhesion molecules and cytokines after cardiopulmonary bypass

BACKGROUND

Cardiopulmonary bypass (CPB) is associated with tissue damage mediated by adhesion molecules and cytokines. Prebypass steroid administration may modulate the inflammatory response, resulting in improved postoperative recovery.

METHODS

Fifty patients undergoing elective coronary operations under normothermic CPB were randomized into two groups: group A (n = 24) received intravenous methylprednisolone (10 mg/kg) 4 hours preoperatively, and group B (n = 26) served as controls. Cytokines (tumor necrosis factor-alpha [TNF-alpha], interleukin-2R [IL-2R], IL-6, IL-8), soluble adhesion molecules (sE-selectin, sICAM-1), C-reactive protein, and leukocytes were measured before steroid application, then 24 and 48 hours, and 6 days postoperatively. Adhesion molecules were measured by enzyme-linked immunosorbent assay, cytokines by chemiluminescent immunoassay. Postoperatively, hemodynamic measurements, inotropic agent requirements, blood loss, duration of mechanical ventilation, and intensive care unit stay were compared.

RESULTS

Aortic cross-clamp and CPB time was similar in both groups. Prednisolone administration reduced postoperative levels of IL-6 (611 versus 92.7 pg/mL; p = 0.003), TNF-alpha (24.4 versus 11.0 pg/L, p = 0.02), and E-selectin (327 versus 107 ng/mL, p = 0.02). Postoperative recovery did not differ between groups.

CONCLUSIONS

Preoperative administration of methylprednisolone blunted the increase of IL-6, TNF-alpha, and E-selectin levels after CPB but had no measurable effect on postoperative recovery.

Modification of surgical aortoatrial shunts for inaccessible bleeding in aortic surgery -- modification of the Cabrol-shunt technique

Bleeding after complex ascending aortic, aortic root or transverse arch surgery which is inaccessible or difficult to control may present a major problem. Here, we describe a modified Cabrol-shunt technique using complete mediastinal coverage with decompression into the innominate vein where the classical technique is not suitable. The long-term fate of the classical aortoatrial and modified mediastinal to innominate shunts has been analyzed to assess their potential complications.

A primary cardiac sarcoma with unusual histology and clinical course

A left atrial tumor, in which radical resection was impossible, demonstrated two processes: An inflammatory pseudotumor and cellular atypia suggestive of a sarcoma. Immunohistochemistry (proliferating cell nuclear antigen [PCNA], MIB-1 [Ki-67 antibody], bcl-2 positive; p53 negative, focal loss of nm23) was supportive for a malignant tumor. Despite no further therapy because of uncertainty in tumor classification, the patient remained in remission for 28 months. Thereafter, spine metastases and local regrowth were found, and the patient died 15 months later, after temporary remission by radiotherapy. This case stresses the impact immunohistochemistry may have on diagnosis of malignancy and the difficulty in predicting the biological behavior of cardiac sarcomas.

Surgical management of retro-aortic left renal vein in combined abdominal aortic and coronary surgery

Although generally retro-aortic left renal vein is a rare anatomic finding, it occurs in 0.8% of the patients admitted for abdominal aortic aneurysm surgery. Surgeons fear fatal bleeding during clamping of the aorta, caused by a more caudal insertion of the retro-aortic left renal vein and a greater vulnerability of the anomalous tissue. Once such a complication occurs, a reconstruction of the retro-aortic left renal vein using a synthetic graft should be performed to obtain adequate renal venous flow and maintain renal function.

Symptomatic mechanical heart valve thrombosis: high morbidity and mortality despite successful treatment options

BACKGROUND

Recommendations for treatment of mechanical prosthetic heart valve thrombosis (PVT) include systemic thrombolysis and/or reoperation. Data on complications and outcome are limited.

METHODS

Clinical and echocardiographic findings of 17 patients with mechanical PVT were reviewed. Complications and outcome of surgery and/or thrombolysis were analysed. Prospective follow-up was obtained.

RESULTS

Symptomatic PVT occurred 8.4 +/- 7.2 years after mechanical valve replacement at mean age 55 +/- 15 years. Thrombosis involved the mitral valve in 12 patients (71%), the aortic valve in 4 (24%) and the tricuspid valve in one (6%). The reason for PVT was inadequate anticoagulation in 11 patients (65%), endomyocardial fibrosis in 2 (12%) and unknown in 4 (24%). Prior to diagnosis, systemic emboli occurred in 6 patients (35%). Thirteen patients (76%) presented in functional class NYHA IV. Haemodynamic valve obstruction was documented by echocardiography in 15 patients (88%). Treatment included primary reoperation in 12 patients (71%), thrombolysis with urokinase in 3 (18%) (with reoperation in 1), reinstitution of adequate anticoagulation in one (6%); death occurred before treatment in one (6%). Intraoperatively, both pannus and thrombus were found in 5 of 13 patients (38%). Treatment-related emboli occurred in 5 patients (29%), to the brain in 3, to the legs in one and to a coronary artery in one. Five patients died (mortality 29%) within 30 days due to multiorgan failure/septicaemia (3 patients), congestive heart failure (1), or cerebral emboli (1). Follow-up after 28 +/- 28 months in the 12 surviving patients was unremarkable.

CONCLUSIONS

The most common aetiology for obstructive PVT is thrombus formation due to inadequate anticoagulation. PVT remains a serious complication with high morbidity and mortality despite aggressive treatment by thrombolysis and/or surgery. Surgery is often needed due to the frequent presence of pannus and/or large thrombi. However, long-term prognosis after successful treatment of PVT is excellent.

Symptomatic mechanical heart valve thrombosis: high morbidity and mortality despite successful treatment options

BACKGROUND

Recommendations for treatment of mechanical prosthetic heart valve thrombosis (PVT) include systemic thrombolysis and/or reoperation. Data on complications and outcome are limited.

METHODS

Clinical and echocardiographic findings of 17 patients with mechanical PVT were reviewed. Complications and outcome of surgery and/or thrombolysis were analysed. Prospective follow-up was obtained.

RESULTS

Symptomatic PVT occurred 8.4 +/- 7.2 years after mechanical valve replacement at mean age 55 +/- 15 years. Thrombosis involved the mitral valve in 12 patients (71%), the aortic valve in 4 (24%) and the tricuspid valve in one (6%). The reason for PVT was inadequate anticoagulation in 11 patients (65%), endomyocardial fibrosis in 2 (12%) and unknown in 4 (24%). Prior to diagnosis, systemic emboli occurred in 6 patients (35%). Thirteen patients (76%) presented in functional class NYHA IV. Haemodynamic valve obstruction was documented by echocardiography in 15 patients (88%). Treatment included primary reoperation in 12 patients (71%), thrombolysis with urokinase in 3 (18%) (with reoperation in 1), reinstitution of adequate anticoagulation in one (6%); death occurred before treatment in one (6%). Intraoperatively, both pannus and thrombus were found in 5 of 13 patients (38%). Treatment-related emboli occurred in 5 patients (29%), to the brain in 3, to the legs in one and to a coronary artery in one. Five patients died (mortality 29%) within 30 days due to multiorgan failure/septicaemia (3 patients), congestive heart failure (1), or cerebral emboli (1). Follow-up after 28 +/- 28 months in the 12 surviving patients was unremarkable.

CONCLUSIONS

The most common aetiology for obstructive PVT is thrombus formation due to inadequate anticoagulation. PVT remains a serious complication with high morbidity and mortality despite aggressive treatment by thrombolysis and/or surgery. Surgery is often needed due to the frequent presence of pannus and/or large thrombi. However, long-term prognosis after successful treatment of PVT is excellent.

[Double aortic arch: clinical aspects, diagnosis and therapy in children and adults]

Double aortic arch is a rare vascular anomaly which usually causes tracheal and esophageal compression in the first few months of life. During the last 30 years, 7 children, 2 to 24 months old, and one 29-year-old woman with double aortic arches have been treatedatour institution. Symptoms, diagnosis and treatment of these patients were evaluated. Dyspnoe, stridor, recurrent pulmonary infections, feeding problems and failure to thrive were the leading symptoms. Despite typical symptoms from early childhood, the diagnosis was missed in our adult patient. Typical compression of the esophageus and the trachea was visualized by esophagography by 7 and bronchoscopy/-graphy by 6 patients. Angiography was performed in all children, whereas magnetic resonance angiography and computed tomography were done in the adult patient. Resection of the smaller aortic arch, left in 3 and right in 5, through a right or a left posterolateral thoracotomy was uncomplicated and fully resolved the symptoms in all patients. Typical symptoms in early childhood should lead to prompt diagnosis and surgical treatment of double aortic arch. Surgical resection of the smaller aortic arch should also be performed in oligosymptomatic patients to prevent complications later. Preoperative angiography can be replaced by the less invasive magnetic resonance imaging and computed tomography.

Inhaled nitric oxide for pulmonary hemorrhage due to acute pulmonary vein trauma

A 57-year-old man with a history of prosthetic aortic valve and supracoronary ascending aortic replacement presented with a 9.8 cm Sinuses of Valsalvae aneurysm ruptured into the left upper pulmonary vein leading to massive pulmonary hemorrhage due to acute rupture of small pulmonary veins. Prosthetic graft replacement of the aneurysm and reconstruction of the atrial roof and left upper pulmonary vein was performed. Inhaled nitric oxide reversed treatment-refractory hypoxemia following massive small pulmonary vein trauma.

A 20-year follow-up of internal carotid artery endarterectomy with bifurcation advancement

BACKGROUND

Carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. For two last decades, we have been performing endarterectomy of the internal carotid artery with bifurcation advancement.

METHODS

From January 1977 until December 1997, all records of patients who underwent internal carotid artery endarterectomy with bifurcation advancement were reviewed. Data were collected from patients charts and by a questionnaire. 160 patients (80.6% men, 19.4% women, average lifetime 65.1 year) underwent a total of 181 endarterectomies with bifurcation advancement.

RESULTS

The 30-day mortality was 1.9% and the postoperative stroke plus death rate 3.1%. The incidence of reoperations was 0.6% with an average follow up of 64 months. In one patient (0.6%), a significant restenosis of the repaired carotid artery was observed. The 1, 5 and 10 years neurological death free survival (including early mortality) was 99.3%, 97.2% and 92.5% and the overall survival (including early mortality) was 96.3%, 78.9% and 59.3% (Kaplan-Meier).

CONCLUSIONS

The technique of the internal carotid artery endarterectomy by bifurcation advancement is a safe and reliable method for improvement of cerebral blood supply. Or foreign material or autologous vein can thus be avoided. This method offers excellent long term patency and has a notable lack of late restenosis.

Left ventricular pressure-area relations as assessed by transoesophageal echocardiographic automated border detection: comparison with conductance catheter technique in cardiac surgical patients

The aim of this study was to validate measurements of intraoperative left ventricular (LV) area by transoesophageal echocardiography against simultaneous measurements of LV volume by conductance catheter (CC) in cardiac surgical patients with normal systolic LV function. Echo area was compared with CC volume during steady state and during acute changes of pre- and afterload by partial clamping of the inferior vena cava and the ascending aorta in eight patients scheduled for coronary artery bypass grafting. At steady state, Bland-Altman analysis of 32 recordings revealed a bias (SD) of 0.6% (2.5%) between echo area and CC volume, related to the initial values of end-diastolic area (100% area) and volume (100% volume), respectively. During loading interventions, bias between the two methods, as assessed by 112 measurement sequences, was 0.5% (3.7%) during aortic occlusion and -3.9% (4.4%) during cava occlusion at end-systole (P < 0.0001); at end-diastole, this bias was 1.3% (4%) during aortic occlusion and 0.2% (5.7%) during cava occlusion (P < 0.0001). Intraoperative area measurements with transoesophageal echocardiography in cardiac surgical patients with normal systolic LV function show good correlation with CC volume measurements under steady-state conditions. During acute unloading by vena cava occlusion, the resulting small end-systolic echo area measurements differ significantly more from CC volume measurements than during acute increase in afterload by aortic occlusion.

Incidence, progression and functional significance of cardiac allograft vasculopathy after heart transplantation

BACKGROUND

Cardiac allograft vasculopathy after heart transplantation leads to an accelerated form of atherosclerosis with marked and often diffuse vessel wall changes that limit long-term survival. Previous studies showed contradictory results relating vessel wall changes to endothelial vasodilator response.

METHODS

A total of 30 cardiac transplant recipients were studied 3, 12, and 24 months after heart transplantation. Coronary angiography was performed at rest, during supine bicycle ergometry, and after 1.6 mg sublingual nitroglycerin. Coronary cross-sectional area (biplane coronary angiography) and coronary artery wall changes (intravascular ultrasound) were assessed and extent of intimal changes correlated to vasodilator responses to nitroglycerine and bicycle ergometry.

RESULTS

Intravascular ultrasound showed significant intimal thickening in 43, 64, and 58% of patients at 3, 12, and 24 months. Intimal thickening 3 months after transplantation was related to donor age (r=0.70, P<0.01) but did not predict progression of disease that manifested itself angiographically as a decrease in coronary cross-sectional area at 12 and 24 months (P<0.005) and significant coronary stenosis in 12% of patients after 24 months. Endothelium-independent vasodilatation after nitroglycerin (33+/-15, 44+/-20, and 43+/-24%) was normal. Endothelium-dependent, flow-induced vasodilatation during exercise was decreased (14+/-11, 18+/-14, and 16+/-17%) but did not correlate to intimal changes assessed by ultrasound.

CONCLUSIONS

The study confirms the high incidence of intimal thickening after heart transplantation as assessed by intravascular ultrasound. Impaired exercise-induced vasodilatation suggests diminished bioavailability of endothelium-derived nitric oxide to physiological stimulation but the lack of relationship between coronary wall changes and this functional impairment suggests intermittent and presumably reversible endothelial injury in graft atherosclerosis.

Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality

OBJECTIVE

The long-term outcome of patients with aortic bioprosthetic valves could be improved by decreasing the reoperative mortality rate.

METHODS

Predictors of emergency reoperation and reoperative mortality were identified retrospectively in 172 patients who had the first bioprosthetic aortic valve replacement between 1975 and 1988 (mean age 46+/-13 years) and were subjected to replacement of the degenerated bioprostheses between 1978 and 1997 (mean age 56+/-14 years). Emergency reoperation had to be performed in 31 patients (18%).

RESULTS

The operative mortality was 5.2% (9/172), 22.6% for emergency (odds ratio 11.17; 95%-confidence limit 4.33-28.85) and 1.4% for elective replacement of the degenerated aortic bioprosthesis (P<0.0001; OR=20.3). Patients who died at reoperation had higher transvalvular gradients before the primary aortic valve replacement (P=0.007), received smaller bioprostheses at the first operation (P=0.03), had later recurrence of symptoms after the first aortic valve replacement (P=0.04), a higher pre-reoperative New York Heart Association (NYHA) class (P=0.02), and a higher incidence of coronary artery disease (P=0.001) and pulmonary artery hypertension (P=0.009). Endocarditis before the primary aortic valve replacement (P=0.004), postoperative pneumonia at the first operation (P=0.005), pulmonary hypertension (P=0.0004) acquired during the interval, later recurrence of symptoms (P=0.04) after the first operation, a lower ejection fraction at the time of reoperation (P=0.03) and acute onset of bioprosthetic regurgitation (P=0.00002) were predictors for emergency surgery. Higher transvalvular gradients at the primary aortic valve replacement (P=0. 006), coronary artery disease (P=0.003) acquired during the interval, the need for concomitant coronary artery revascularization (P=0. 001), sex (P=0.02) and size (P=0.05) and type of the bioprostheses used (P=0.007) were incremental predictors for reoperative mortality which were independent of emergency surgery.

CONCLUSIONS

Elective replacement of failed aortic bioprostheses is safe. Patients undergoing emergency reoperation have a considerably higher mortality. They can be identified by a history of native aortic valve endocarditis, higher transvalvular gradients at primary aortic valve replacement, smaller bioprostheses, and pulmonary hypertension or coronary artery disease acquired during the interval. A failing bioprosthesis must be replaced at its first sign of dysfunction.

Double aortic arch: diagnosis missed for 29 years

Double aortic arch is a rare vascular anomaly which causes tracheal and esophageal compression usually in the first months of life. Typical symptoms in the early childhood should lead to prompt diagnosis and surgical treatment of this malformation. In adults this anomaly is extremely rare. A case of a severely 29-year-old symptomatic woman is presented. Despite characteristic symptoms, the diagnosis was missed during childhood. The importance of different diagnostic procedures and operative therapy is discussed. Preoperative angiography can be replaced by the less invasive magnetic imaging and computed tomography. Surgical operation should also be performed in oligosymptomatic patients to prevent late complications.

Long term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone?

OBJECTIVE

To identify predictors for the safe use of antibiotic treatment without reoperation in patients with prosthetic valve endocarditis.

SETTING

Retrospective study in a tertiary care centre.

SUBJECTS AND DESIGN

All 49 episodes of definite prosthetic valve endocarditis (Duke criteria) diagnosed at one institution between 1980 to 1997 were analysed. Ten episodes (20%) were treated with antibiotics only (antibiotic group) and 39 episodes (80%) with combined antibiotic and surgical treatment (surgery group). The analysis included detailed study of hospital records and data on long term follow up which were obtained in all patients by a questionnaire or telephone contact with physician or patient. The length of follow up (mean (SD)) was 41 (32) months in the antibiotic group and 45 (24) months in the surgery group (NS). Long term survival was estimated by the Kaplan-Meier method and compared by the log-rank test.

RESULTS

There was no significant difference in age, history of previous endocarditis, number of previous heart operations, vegetations, emboli, type of prosthesis, or percentage of early prosthetic valve endocarditis and positive blood cultures between the two groups. In the antibiotic group, there were more enterococcal (50%; p = 0.005) and in the surgery group more staphylococcal infections (55%; p = 0.048). Annular abscesses (p < 0. 0001) and aortoventricular dehiscence (p = 0.02) were more common in the surgery group. No patient in the antibiotic group had heart failure. Long term follow up showed no significant difference between the surgery and antibiotic groups regarding late mortality (14% v 18%) and five year rates of recurrent endocarditis (14% v 16%), event related mortality (14% v 3%, log-rank test), and the need for reoperation (14% v 19%; log-rank test). The only patient with conservatively treated staphylococcal prosthetic valve endocarditis died after reoperation for recurrence.

CONCLUSIONS

Haemodynamically stable patients with non-staphylococcal prosthetic valve endocarditis who are carefully supervised can be treated with antibiotics alone without an increased rate of reinfection, reoperation, or death.

Operative results of "repair" of ventricular septal rupture after acute myocardial infraction

Fifty-four consecutive patients with postinfarction ventricular septal defect were reviewed. The rupture was closed with a patch and the left ventricle remodeled in all patients. Coronary artery bypass surgery was performed in 28 patients (52%). Fourteen patients (26%) died after operation and 19 during follow-up (mean 42 months). Cumulative survival (including operative deaths) was 78%, 65%, and 40% at 1, 5, and 10 years, respectively. A short interval between septal rupture and operation was a risk factor for early mortality (p = 0.03). Treated associated coronary artery disease had no effect. A residual septal shunt, detected in 10 patients (18%), warranted reoperation in 7 and contributed to 2 early and 1 late death. The location and morphology of the septal rupture were not associated with increased risk of residual shunt. Thus, patch closure of the ventricular septal rupture, remodeling of the left ventricle to improve stroke volume and reduce wall stress, and selective myocardial revascularization provided acceptable results.

Treatment of left atrial dissection after mitral repair: internal drainage

Two patients with intraoperative dissection of the entire left atrium after mitral valve repair are presented. Intraoperative transesophageal echocardiography detected left atrial dissection with formation of a large cavity compressing the left atrium. The false lumen was opened and widely connected to the right atrium to perform the decompression. This technique permits the runoff into the low pressure system in case of persisting hemorrhage from the unknown entry, and eliminates the risk of systemic embolization from the cavity.

Less invasive surgical treatment of renal cell carcinomas extending into the right heart and pulmonary arteries: surgery for renal cell carcinoma

BACKGROUND

Radical resection using deep hypothermic circulatory arrest improves the survival of patients with transvenous intracardiac tumor extension of renal cell carcinomas. A less invasive surgical approach avoiding deep hypothermia, circulatory arrest, and cross-clamping of the aorta is presented.

METHODS

Between 1987 and 1999, 12 patients (mean age 57+/-8 years) underwent resection of a renal cell carcinoma extending into the right atrium, right ventricle, or pulmonary arteries. After median sterno-laparotomy, normothermic cardiopulmonary bypass is used cannulating the ascending aorta, superior caval vein, and inferior caval vein below the renal veins. The tumor and the corresponding kidney are radically excised, including the renal vein. Tumor fragments from the inferior caval vein, the right heart, and pulmonary arteries are removed either on the fibrillating or beating heart.

RESULTS

Operative mortality was 0%. Mean cardiopulmonary bypass time was 53+/-27 minutes (median 36; range 32-110 minutes). Mean blood loss per patient was 1200 mL. Mean duration of postoperative mechanical ventilation was 36+/-12 hours (median 36; range 30-77 hours), mean intensive care stay 5.5+/-5 days (median 3; range 1-48 days), and mean duration of hospitalization 22+/-12 days (median 21; range 10-58 days). All patients were discharged home. Patients with multiple tumor manifestations outside the cardiovascular systems died within 9 months after the operation.

CONCLUSIONS

The use of normothermic cardiopulmonary bypass is a less invasive method for radical resection of renal cell carcinoma with intracardiac tumor extension. Radical resection does not improve survival in patients with multiple distant metastases.

Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts

BACKGROUND

Aortic graft infection is associated with significant mortality and morbidity. Total graft replacement with homografts provides an effective treatment. Partial graft replacement at the site of infection may simplify the surgical procedure.

METHODS

Between January 1991 and December 1996, homografts were used in 18 patients (mean age, 61+/-12 years; range 41-85) with thoracic (4/18; 22%) or abdominal (14/18; 78%) aortic graft infection. Sepsis was present in 14 patients (78%); 6 (33%) had various aortic fistulae. Total graft replacement using homografts was performed in 14 (78%), and partial graft replacement at the site of infection in 4 patients (22%).

RESULTS

Hospital mortality was 11%. During the follow-up period of 22+/-15 months (range, 12-65) there was 1 infection and 1 homograft-related late death after complete homograft replacement, and 1 percutaneous vascular stent placement after partial graft replacement. No other instances of reinfection, suture line rupture or anastomotic aneurysms were observed.

CONCLUSION

Total graft replacement with homografts provides an effective treatment for infected aortic grafts. Partial graft replacement at the site of infection is feasible and safe.