Derzeit beträgt die perioperative Letalität in der Koronar- und Herzklappenchirurgie etwa 3 %. Diese deutliche Verbesserung wird zum einen durch eine Optimierung der operativen Technik und des Myokardschutzes sowie die Fortschritte in der Anästhesiologie erreicht. Dieses Kapitel gibt einen Überblick über die Besonderheiten kardiochirurgischer Patienten, wichtige Aspekte in der präoperativen Betreuung sowie die Anästhesieführung per se, wobei auf die Besonderheiten unterschiedlicher kardiochirurgischer Eingriffe eingegangen wird.

BACKGROUND:There is no doubt today about the existence of the endothelial glycocalyx (EG) and its decisive role in maintaining vascular homeostasis in adult humans. Shedding of the EG has been demonstrated in adults with sepsis or trauma, in patients undergoing major operations, and after ischemia/reperfusion. The aim of the present study was to demonstrate whether shedding of the EG also occurs in infants undergoing heart operations. METHODS:Two major constituents of the EG (syndecan-1 and hyaluronan) were measured in the arterial serum of 42 infants during cardiac operations in a prospective observational study. The groups were defined according to the ischemic impact: cardiac operations with cardiopulmonary bypass under beating heart conditions (CPB group, regional ischemia of lungs, n = 10), operations with cardiopulmonary bypass and aortic clamping (CPB+AC group, regional ischemia of heart and lungs, n = 24), and cardiac operations with deep hypothermic circulatory arrest (CPB+AC+DHCA group, whole-body ischemia, n = 8). RESULTS:Syndecan-1 and hyaluronan were detected in all infants, providing an indication for the presence of a glycocalyx. During the operations, no significant difference in syndecan-1 concentration was observed in the CPB group, but levels increased significantly in both other groups (maximum increases: CPB+AC 3.0-fold, CPB+AC+DHCA 3.7-fold, p < 0.05). Hyaluronan increased significantly in the course of the operation in all groups (maximum increases: CPB 1.2-fold, CPB+AC 1.4-fold, CPB+AC+DHCA 1.7-fold, p < 0.05). CONCLUSIONS:The present data provides the first evidence for basal turnover of vascular EG in infants. Similarly to the process in adults, the shedding of this structure increases with ischemia/reperfusion, the extent being dependent on the degree of ischemic challenge.

Purpose: Assessment of contractile function is a major challenge in patients with left ventricular dysfunction, especially during cardiac surgery. The initial tangent of the femoral arterial pressure increase (tanin) has recently been described to be an estimate of left ventricular (LV) contractility. To confirm these findings tanin was compared to various indices of LV performance in patients undergoing cardiac surgery. Methods: Data from 17 patients were evaluated retrospectively. Myocardial performance was estimated by the echocardiographic indices ejection fraction (EF), shortening fraction (FS), circumferential fiber shortening velocity (Vcf), the parameters of pulse contour analysis area under the curve (AUC) and tanin. Measurements were taken before and after cardiopulmonary bypass (CPB). Results: Tanin increased significantly (813 ± 216 mmHg/s vs. 1490 ± 450 mmHg/s, p in and Vcf correlated strongly (r = 0.70, p in showed only weak correlation with EF (r = 0.36, p = 0.037). There was no significant correlation with FS (r = 0.31, p = 0.079). Tanin and AUC correlated inversely (r = -0.62, p in correlated well with the less preload-dependent parameter Vcf, thus suggesting that tanin may be used as an easily accessible estimate of LV contractility during cardiac surgery.

Complications of pacemaker implantation include myocardial perforation, venous thrombosis, vegetations of the tricuspid valve or pacing lead, and tricuspid regurgitation. We report a patient presenting with a case of delayed ventricular lead perforation through the right ventricle. The lead was uneventfully extracted under transesophageal echocardiographic observation in the operating room with cardiac surgery backup.

Development of a paravalvular leak after prosthetic valve replacement is a rare but hard to treat complication. In many cases, it requires reoperation. Reoperation is associated with higher mortality and excess risk of recurrent paravalvular insufficiency. During the last couple of years, several hybrid procedures have been developed to decrease operative risk and trauma.1Schmitz C. Esmailzadeh B. Herberg U. Lang N. Sodian R. Kozlik-Feldmann R. et al.Hybrid procedures can reduce the risk of congenital cardiovascular surgery.Eur J Cardiothorac Surg. 2008; 34: 718-725Crossref PubMed Scopus (30) Google Scholar We describe the case of a 66-year old man after replacement of the aortic and mitral valves (Medtronic Hall; Medtronic, Inc, Minneapolis, Minn) in 1989. In 2000, the ascending aorta was replaced, and a DDD pacer was implanted. In 2008, the patient had acute hemolysis, which necessitated periodic blood transfusions. Transthoracic echocardiography revealed a new paravalvular leak of the mitral valve (Figure 1). Because of multiple comorbidities (renal insufficiency, hypertension, previous hemicolectomy), we discussed with the patient the option of implanting an Amplatzer Septal Occluder in a hybrid fashion. With the patient under general anesthesia, the chest was opened through a small (8 cm) left anterolateral thoracotomy to present the left ventricular apex. The pericardium was incised just above the apex, and two Teflon-armed purse-string sutures (Ethicon, Johnson & Johnson, Norder Stedt, Germany) were placed on the left ventricular apex. A short 8F sheath (Cordis, Johnson & Johnson, Warren, NJ) was inserted through a stab wound incision into the left ventricle. A Terumo 0.025–inch guidewire (Termumo Medical Corporation, Somerset, NJ) was introduced under transesophageal echocardiographic and fluoroscopic guidance and pushed forward through the annular dehiscence into the left atrium. The sheath was advanced into the left atrium, and a 6-mm Membranous Amplatzer Septal Occluder (AGA Medical, Golden Valley, Minn) was implanted. After sheath removal, the purse-string sutures were tied, and the chest was closed in layers. Overall skin-to-skin operative time was 140 minutes. The patient was weaned from the ventilator on postoperative day 1, was transferred from the intensive care unit on postoperative day 2, and was discharged home on postoperative day published 23. During the hospital stay, the pacemaker was replaced. Transthoracic echocardiography showed no residual leakage. Function of both valve prostheses was normal. There have been several reports on closing paravalvular leaks with different umbrella-type devices.2Sivakumar K. Shahani J. Transcatheter closure of paravalvular mitral prosthetic leak with resultant hemolysis.Int J Cardiol. 2007; 115: e39-e40Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 3Webb J.G. Pate G.E. Munt B.I. Percutaneous closure of an aortic prosthetic paravalvular leak with an Amplatzer duct occluder.Catheter Cardiovasc Interv. 2005; 65: 69-72Crossref PubMed Scopus (64) Google Scholar In all reports published to date, a percutaneous approach was used. In our case, such an approach was not possible because the patient had two mechanical valves. Passing a mechanical aortic prosthesis with a big, stiff sheath leads to significant aortic insufficiency. Furthermore, no valve company guarantees that the leaflets of the valves will stay in place when passing them with a stiff sheath. Another option, the antegrade approach to the mitral valve through a puncture in the atrial septum, is also extremely difficult, because the antegrade pathway to the mitral valve is very curvy. In our case we discussed the options: a standard reoperation with median sternotomy, right lateral thoracotomy with cardiopulmonary bypass, or an off-pump hybrid procedure. As there was no need to exchange the well-functioning mitral prosthesis itself, we decided to go for the last option. Approaching the paravalvular leak from the left ventricular apex turned out to be much easier than expected. The guidewire, which was approached first, fell more or less by itself into the dehiscence between the sewing ring and annulus. However, there was one delicate situation. During the pushing of the Amplatzer device out of the sheath, one leaflet of the mitral valve was blocked. It was hard to determine whether the umbrella itself or the sheath was responsible was responsible for this blockade. We pulled the introducer sheath back without detaching the umbrella. Fortunately, valve function returned to normal, proving that the sheath did indeed compromise function. We believe that in this particular situation, a hybrid procedure, reduced the risk of the operative procedure significantly.

The appearance of re-stenosis after repair of an interrupted aortic arch may be a surgical challenge due to adhesions. Here, we describe an approach using off-pump coronary artery bypass grafting techniques to reach the descending aorta through a median sternotomy in a patient with aortic arch stenosis after conduit repair. The 17-year-old patient with diagnoses of interrupted aortic arch and ventricular septal defect presented after two previous operations (one left lateral thoracotomy and one median sternotomy) with a stenosed vascular graft between ascending and descending aorta. Surgery was done via re-sternotomy without cardio-pulmonary bypass. An extraanatomic graft was used to connect ascending and descending aorta. When performing the distal anastomosis, the heart was exposed using a standard suction device. This case demonstrates that the use of modern techniques may facilitate surgical approaches dramatically. In our opinion the above-described technique is the first choice for all patients requiring arch repair following multiple previous operations, performed via sternotomy and thoracotomy.

Right (systemic) ventricular (RV) failure in patients with transposition of the great arteries (TGA) after the Senning operation is a well-known late complication. Although double switch operations have been advocated by some groups,(1) orthotopic heart transplantation (HTx) remains the only definitive option to treat these patients.(2) However, there is a high mortality rate for patients on transplant waiting lists, and the use of ventricular assist devices (VADs) is often required as a bridge to HTx.(3)

Iatrogenic nerve lesions affecting the long thoracic nerve are very rare after a median sternotomy. Here we report on a patient who developed clinical signs of a so-called "winged scapula" after an uneventful aortic valve replacement for infective endocarditis.

Introduction: Donor shortage is a major problem in pediatric heart transplantation (HTx). However, due to AB0-incompatibilities the number of unused organs in this age group is greater than the number of children dying on the waiting list. ABO-incompatible heart transplantation may be an option to increase donor availability, because of the immaturity of the immune system of infants.

In the first two yr of life blood-group incompatible (ABO-incompatible) heart transplantation can be performed leading to immune tolerance to donor blood group. Antibody titers should be below 1:4. VAD use is correlated with sensitization toward blood-group antigens. A boy was diagnosed with dilated cardiomyopathy at nine months of age and listed for 0-compatible transplantation. Progressive heart failure required implantation of a left VAD. His listing was extended for ABO-incompatible transplantation despite antibody titers of 1:32 anti-A and 1:8 anti-B. After 26 days on VAD, he was transplanted with a B donor heart. No hyperacute or acute rejection occurred in 12 months post-transplant. Anti-B antibodies rose to a maximum of 1:2. No use of rituximab or plasmapheresis was required. There are no signs of graft vasculopathy. This indicates that inclusion criteria for ABO-incompatible transplantation may be extended to immediate cases. This is the first case with a healthy immune system to show signs of tolerance development after ABO-incompatible heart transplantation with increased prior antibody titers and without specific treatment.

In the pediatric age group shortage of donor hearts leads to mortality rates of 30-50% on the waiting list. Because of the immaturity of the immune system of infants, ABO-incompatible heart transplantation may be an option to increase donor availability. We transplanted two infants with blood type O at the age of 7 and 5 months, respectively, with complex congenital heart disease. Intraoperative plasma exchange was performed during cardiopulmonary bypass followed by standard immunosuppression. Both recipients received a blood type A donor organ. Plasma was exchanged up to six times until anti-A antibodies were eliminated. No hyperacute rejection occurred, ventricular function is excellent and there have been no acute rejection episodes up to 4 months after transplantation. Anti-A antibody titers remained low and eventually disappeared. ABO-incompatible cardiac transplantation shows good short-term results in young infants and appears to be a safe procedure to reduce mortality on the waiting list.

Effects of microspheres (5 μm or 10 μm diameter) and polymorphonuclear leucocytes (PMN) on coronary resistance were compared in beating, non-working isolated guinea-pig hearts (Langendorff preparation). The hearts were buffer perfused (5 ml/min, constant flow) and particles or cells were infused into the coronary system as a bolus (1 ml, 1 min). Coronary perfusion pressure, coronary flow and formation of epicardial transudate were measured before and after bolus administration. Coronary resistance was estimated from these parameters. Retention of particles or cells was monitored by quantifying the numbers emerging in the coronary effluent in relation to the number administered. The effects of PMN were also studied after 15 min of global ischaemia. Coronary resistance correlated with the number of 10-μm particles infused, which were almost quantitatively retained. In contrast, 5-μm beads had no such effect and were not retained in the coronary system. Though considerable numbers of PMN were retained in the hearts (about 21% under control conditions and 35% after ischaemia), coronary resistance was not increased in either case. Blockage of the CD18 adhesion complex by monoclonal antibodies lowered basal retention to 11% and completely prevented the elevation of retention by ischaemia. We conclude that, in this experimental model, PMN, permanently retained in the hearts under normal flow conditions and especially after brief ischaemia, do not cause acute, haemodynamically relevant capillary plugging, but adhere to postcapillary venules via CD18.