Ziele: Darstellung der prä- und postoperativen multimodalen Bildgebung bei Patienten mit Trichterbrust (pectus excavatum) inklusive der häufigsten Komplikationen. Methode: Seit 1994 unterzogen sich 143 PatientInnen (113m., 29 w.; mittleres Alter 16,8J.) an der Kinderchirurgie des Donauspitals einer Trichterbrustoperation. Von 1994 bis 2005 wurde die Operation nach dem Verfahren nach Nuss durchgeführt, seit Ende des Jahres 2005 wurde eine Variante („Hofer-Implantat“) verwendet.

The aim of our study was to further improve the preoperative diagnosis of acute appendicitis in children and adolescents. All diagnostic parameters from the patients' medical history (duration and quality of abdominal pain, stool behaviour), the laboratory (leukocytes, C-reactive protein), the clinic (defense, tenderness on percussion, nausea, vomiting, dry tongue) and repeated ultrasound investigations (visualisation of the appendix, indirect signs of an inflammatory process in the appendix region) were documented prospectively and were re-assessed with regard to their diagnostic value. As an additional parameter, procalcitonin was determined. 1156 patients (593 male/563 female) with a mean age of 9.51 years (+/- 1.2 yrs) (max. 15 yrs/min. 2.3 yrs), referred to the department with acute abdominal pain, were examined. 233 (141 male/92 female; 20.1 %) of these patients with a mean age of 10.47 years (+/- 1.1 yr) had appendicitis. Based on the patients' medical history, laboratory findings, the initial clinical investigation and the initial ultrasound investigation, 173 patients (74.3 % of the later operated 233 children with appendicitis) were diagnosed with certainty. The diagnosis of 60 patients (25.7 %) of this group remained uncertain. These patients received a saline enema (Clysmol, Pharmacia & Upjohn Company) and were subjected to a second clinical and sonographic investigation after approximately four hours of parenteral fluid substitution (Ringer's lactate, Mayrhofer Pharmazeutika Company, 4 ml/kg/h). The other 923 patients (79.83 %) were discharged and were followed up as outpatients in the following days. Based on this stepwise procedure, the percentage of correctly diagnosed appendicitis could be increased to 97.4 %. The measurement of procalcitonin proved to be of no value in the diagnosis of acute appendicitis. It may be concluded that in children with abdominal pain, high diagnostic accuracy can only be achieved by a carefully combined evaluation of all individual diagnostic parameters and repeated investigations.

A new method for radiation-free management of infantile clavicular fractures is presented. Forty-nine infants with clavicular fractures were examined radiologically and sonographically by independent examiners. The two imaging techniques were compared with regard to practicability, diagnostic results, and assessment of the healing process. The paired t-test showed no significant difference between X-ray and ultrasound (US) for the criteria of practicability and primary diagnostic results. With regard to assessment of the healing process, a highly significant advantage in favor of US. was registered. One week before radiographs revealed any sign of bone healing, stress-resistant, stable healing of tissue is seen on US. Even consolidation disorders such as early signs of pseudarthrosis are detected very early by US. This enormous diagnostic advantage reduces the duration of immobilization, the frequency and number of follow-up examinations, and last but not least, provides a cost-effective method of treatment without exposure to ionizing radiation.

See also: ERCP and Balloon Dilation is a Valuable Alternative to Surgical Biliodigestive Anastomosis in the Long Common Channel Syndrome in ChildhoodEndoscopy 1996; 28(08): 724-724DOI: 10.1055/s-2007-1005585

Phrenic nerve lesions as a result of birth trauma have been reported as a cause of acute respiratory distress infrequently. We report recent diagnostic and therapeutic experiences in four newborns with birth-traumatic phrenic nerve injury: one bilaterally, and three unilaterally, all right-sided. In each case, mechanical ventilation was required for at least 16 days. Ultrasound examination of the diaphragm and phrenic nerve conduction studies turned out to be the diagnostic methods of choice. Spontaneous recovery occurred in two children and two became asymptomatic after operative treatment. One improved after plication of diaphragm and one after autologous nerve transplantation.

In nine patients with meconium peritonitis prenatal ultrasonographic findings were correlated with the clinical course and outcome. Ultrasound findings included polyhydramnion (n = 4), ascites (n = 4), disseminated (n = 3) and solitary echogenic areas (n = 1), echopoor cystic areas (n = 3) and echogenic-echopoor solitary areas (n = 1). Intra-abdominal calcifications were found in five patients before delivery. Eight neonates survived and were subsequently followed up, one fetus died in utero. Four of the eight survivors required surgery, namely for meconium ileus (n = 1), perforation secondary to intestinal volvulus (n = 2) and inguinal hernia associated with prenatal rubella infection (n = 1). Three patients were healthy, one patient required drainage of pleural effusion and respiratory therapy but recovered without further problems. Cystic fibrosis was diagnosed in the patient with meconium ileus. Postnatal outcome could not be predicted from the prenatal sonographic findings.

In nine patients with meconium peritonitis prenatal ultrasonographic findings were correlated with the clinical course and outcome. Ultrasound findings included polyhydramnion (n = 4), ascites (n = 4), disseminated (n = 3) and solitary echogenic areas (n = 1), echopoor cystic areas (n = 3) and echogenic-echopoor solitary areas (n = 1). Intra-abdominal calcifications were found in five patients before delivery. Eight neonates survived and were subsequently followed up, one fetus died in utero. Four of the eight survivors required surgery, namely for meconium ileus (n = 1), perforation secondary to intestinal volvulus (n = 2) and inguinal hernia associated with prenatal rubella infection (n = 1). Three patients were healthy, one patient required drainage of pleural effusion and respirator therapy but recovered without further problems. Cystic fibrosis was diagnosed in the patient with meconium ileus. Postnatal outcome could not be predicted from the prenatal sonographic findings.

Three hundred nine cases of esophageal atresia were retrospectively investigated. One hundred and sixty-two (52.4%) had associated congenital malformations. The total number of malformations was 357. The eight groups of malformations in decreasing order of frequency were as follows; cardiac, 72 cases (23.3%); musculoskeletal, 55 cases (17.8%); anointestinal, 50 cases (16.2%); genitourinary, 45 cases (14.6%); head and neck, 31 cases (10.0%); mediastinal, 26 cases (8.4%); chromosomal, 17 cases (5.5%); pulmonary, 6 cases (1.9%). Of the 162 cases with associated malformations, 83 (51.2%) had a single group of malformations, 41 (25.3%) had two groups of malformations, and 38 (23.5%) had three or more groups of malformations. More than 50% of pulmonary (83.3%), head and neck (77.4%), chromosomal (58.8%), and mediastinal malformations (53.8%) were found in association with cardiac malformations. The frequency of associated malformations in esophageal atresia cases was found to be increased significantly during the investigated interval. Early gestational age and lower birthweights were significantly correlated with higher rates of malformations. The survival rates of patients with esophageal atresia was also found to be significantly increasing over time. The mean survival rates over 32 years for groups with and without malformations were 38.3% and 70.7%, respectively, and were statistically significant. The mean survival rates of the same groups in the last 5 years were found to have changed dramatically, rising to 62.9 in the group with malformations and to 100% in the group without malformations; again, the difference is significant.

We sonographically investigated the internal jugular veins of 40 children who had undergone catheterization of the vein (group A: silastic catheter, n = 24; group B: polyurethane catheter, n = 16) in the neonatal period. The average age at catheter implantation was 43+/-73 days, the average birthweight 2414+/-1145 g, and the average gestational age 34.8+/-5.0 weeks. We performed follow-up longitudinal and transverse high resolution sonographic scans including routine examination of the contralateral jugular vein at a mean age of 3.7+/-1.5 years. In group A thrombotic alterations were detected in 8 aut of 24 patients. In three of these patients we found mild clinical symptoms. In group B thrombotic alterations were detected in 1 aut of 16 patients without clinical symptoms, Mean birthweight (1815 versus 3313 g) and mean gestational age (32.3 versus 38 weeks) were significantly lower and indwelling time of the catheters (18 versus 11 days) was significantly longer in group A, Our results indicate that jugular vein thrombosis is a frequent long-term complication in neonates after jugular vein catheterization, High resolution ultrasonography is an adequate method for detecting jugular vein thrombosis and should therefore routinely be performed for long-term follow-up.

Glomerular basement membrane thickening and mesangial expansion are the main pathological features in diabetic nephropathy - glomerulosclerosis with the biochemical correlate of increased collagen accumulation. We studied a new principle to reduce collagen accumulation in the glomerulus:thiaproline, known to inhibit protein synthesis by blocking the elongation, led in our studies to a morphological reduction of the glomerular basement membrane thickening and to a decreased collagen content. As the thiaproline analogue is incorporated into collagen, the mechanism of increased degradation of the modified collagen is being discussed.

The Vienna heart uses a vacuum formed, pellethane pulsatile ventricle and is available in left ventricular assist (LVAD) and total artificial heart (TAH) configurations. This device was used as mechanical support of the failing heart in nine patients intended for heart transplantation. In two patients with cardiomyopathy an orthotopic TAH was implanted; one survived despite severe preoperative ischemic liver damage, and the other died of sepsis. In seven patients an atrio-aortic LVAD was implanted; six had suffered an acute myocardial infarction with cardiogenic shock, and one could not be weaned off bypass. Three patients survived. These included one 65-year-old with incipient ARDS at operation, and a 40-year-old with preoperative liver and kidney insufficiency who was transplanted in septicemia. In this patient the septic focus, natural and artificial heart, were removed at transplantation. Four patients died. In one we were unable to establish satisfactory circulation, one died after failure of the transplanted heart, one suffered a lethal cerebral embolism and one developed multi-organ failure after repeated attacks of ventricular fibrillation. With the Vienna heart sufficient circulatory support could be established with cardiac outputs between 6 and 8 l/min for the TAH and 3.5 to 4.5 l/min for the LVAD. With this type of support an overall survival rate of 44% could be achieved. Mechanical hemolysis was not a clinical problem and no device failure occurred.

Pregnancies following cardiac valve surgery represent a considerable maternal and fetal risk. The present paper is a report of 163 women in child-bearing age who underwent cardiac valve surgery. Congenital (14.7%) and acquired (85.3%) cardiac defects required a total of 72 alloplastic and 16 bioprosthetic valve implantations. In 69 patients, purely instrumental correction was performed, in 6 patients conduits were placed. Thirty-four pregnancies were observed and led to the delivery of 18 healthy infants. The birth weight was always in the 2-sigma normal range or slightly above. Three cesarean sections were performed due to the cardiac defect, in 6 patients vacuum extraction or forceps delivery was done, and in 9 patients delivery was spontaneous. We observed 4 cases of spontaneous abortion, and in 12 cases interruption of pregnancy. 75.1% women never became pregnant. Potential risks in terms of endocarditis, repeated valve implantation and anticoagulation are emphasized, methods to decrease the physical strain during delivery are discussed.

The Vienna Heart, a pulsatile artificial ventricle, vacuum-formed from Pellethane has been used successfully as total artificial heart (TAH) and left ventricular assist device (LVAD) to bridge over patients in terminal heart failure.A 50 year-old patient with cardiomyopathy had to be rescuscitated and was transferred in cardiogenic shock, with impaired renal and liver function, 6 days after orthotopic implantation of a Vienna TAH a suitable donor organ was found and the patient was transplanted. 7 weeks later he was discharged and is alive and well now.A 40-year-old patient was transferred in cardiogenic shock 22 days after recurrent anterior infarction. Due to renal failure he was on haemofiltration. Congestive liver failure caused a severe coagulation disorder so a Vienna LVAD was implanted without the use of extracorporeal circulation. Despite development of septicaemia he was transplanted 24 days later. It was thought that either the ventricular thrombus or the LVAD was the septic focus. All consecutive blood cultures have been negative and he was discharged 6 weeks later.To our knowledge, case 1 represents the first successful bridging with a non-Jarvic TAH. The second case shows that sepsis is not necessarily a contraindication to heart transplantation.

The implantation of a mechanical blood pump in a deteriorating candidate for heart transplantation is indicated in general if the cardiac index is less than 1.9 L/min/m2 despite maximal inotropic support. Deterioration of end organ function may be taken as a second factor indicating the need for mechanical support as patients with acute onset of shock may react differently from patients with chronic deterioration. Preoperative need for dialysis largely reduces the chances of long-term survival. The time on support should be long enough to normalize or at least improve secondarily damaged organ systems, but with time infectious and thromboembolic complications will increase. So optimal periods for artificial heart support range between two days and four weeks. Age less than 40 years is a positive predictor for outcome in TAH bridging. The general guidelines, however, do not preclude a favourable outcome in complicated cases, as we show in our own series.

An 111 Patientinnen, die wegen eines hämodynamisch wirksamen Herzklappenvitiums operiert wurden, wird der Hinfluß des Eingriffes auf die Fertilität untersucht. Nur 24 Frauen (21,6 %) wurden schwanger. Von insgesamt 34 Graviditäten endeten vier durch Frühabortus bis zur 12. Woche, zwölf Schwangerschaftsabbrüche waren zu verzeichnen, wobei für acht eine medizinische Indikation gestellt wurde. 18 Kinder wurden lebend geboren. Der überwiegende Teil der untersuchten Frauen, nämlich 87 (78,4 %), waren niemals schwanger, obwohl nur 29 Patientinnen von einer Schwangerschaft abgeraten worden war. 27 Frauen entschlossen sich bewußt zur Empfängnisverhütung (zehnmal Tubenligatur, viermal orale Kontrazeptiva, dreimal IUD, zehnmal andere Methoden wie spermizide Substanzen, Coitus interruptus, Zeitwahlmethode).

Today, thanks to cardiosurgical, medical and diagnostic progress, patients suffering from end-stage heart diseases can often be successfully treated. One important factor in this progress is the clinical availability of the total artificial heart or mechanical monoventricular cardiac assist devices. Adequate, quick hemodynamic restoration with a mechanical cardiac support system enables us to perform a successful surgical treatment, sometimes combined with human heart transplantation. About 30 years of mechanical heart development have passed, many designs have been developed and many of them have been used with clinical success. In principle, hemodynamic restoration can be achieved mechanically by pulsatile (membrane or sack pumps) or nonpulsatile (centrifugal or screw pumps) working pumps. Until 1985 clinical use of artificial blood pumps was a single event. In 1965, Spencer described the first clinical use of a left ventricular assist device (IVAD) (1). In April 1969, Cooley performed the first clinical total artificial heart (TAH) implantation for bridging to transplantation (2). In 1985 Copeland bridged a patient who was discharged from hospital and returned to work (3). Alternatively, a biological cardiac support is possible, using a skeletal muscle to reinforce, augment or replace diseased myocardium. In 1933, Leriche and Fontaine first experimentally demonstrated the feasibility of using the pectoralis muscle to reinforce a myocardial scar after ligation of a coronary artery (4). In 1958, Kantrowitz used a pedicled graft of diaphragm around the mobilized aorta for counterpulsation (5). In 1985, Carpentier performed the first successful myocardial reconstruction after resection of a large myocardial fibroma (6). Another approach is to use the conditioned autologous muscle to power an artificial ventricular assist device, which is then completely implantable. These biomechanical systems are still under experimental investigation. In 1986 and 1987 Chiu and Acker experimentally achieved sufficient aortic counterpulsation with such muscle-powered single or doublechamber balloon assists (7, 8).

We report on 111 patients, who were operated for heart valve failure. The influence of the operation on fertility was examined. Only 24 women became pregnant. From 34 pregnancies, 4 resulted in early abortion; in 12 cases abortion was performed (8 times for medical reasons), therefore 18 children were born. The remaining 87 operated patients (78.4%) never became pregnant, although only 29 patients were advised against pregnancy. 27 patients decided on various contraceptive methods by themselves.

Transesophageal echocardiography (TEE) has assumed an increasing importance in cardiothoracic surgery, but its use in patients with mechanically assisted circulation is unclear. We performed TEE in 11 patients: total artificial heart (TAH) 2, right ventricular assist device (RVAD) 2, left ventricular assist device (LVAD) 6, biventricular assist device (BVAD) 1. TEE was helpful in three areas. (1) selection of the assist device (AD): evaluation of left and right ventricular function allows differentiation of left, right or biventricular failure. (2) management of patient and optimization of pump performance: in all patients, correct cannula position and pump flow could be identified. Right ventricular failure in the presence of LVAD was found to cause hemodynamic instability in 4 patients. In 1 patient with repeated RV dilation and hypotension despite RVAD, TEE allowed optimal pump settings to be determined. (3) weaning from AD: Recovery of ventricular function can be assessed prior to weaning and repeatedly monitored during weaning. TEE in TAH is limited to problems such as identification of atrial thrombus or inflow valve dysfunction. We conclude that TEE is useful in the setting of mechanically assisted circulation for AD selection, improvement of patient management, optimization of pump performance and during weaning from AD.