BACKGROUND:Coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CBP) is associated with significant morbidity and mortality. In high-risk patients, doomed for reoperation the adverse effects of CBP may be more striking. We evaluated the results of reoperative CABG (redo-CABG) by either off-pump (OPCAB) or on-pump (ONCAB). Clinical endpoints were perioperative myocardial infarction, mortality, survival and as the most striking difference between prior studies the quality of life (QoL).METHODS:We performed a prospective, non-randomized assessment for patients who underwent redo-CABG by redo-OPCAB (n=40) or redo-ONCAB (n=40) at our institution between January 2007 and December 2010. For evaluation of QoL the SF-36 health survey was used with self-administered assessment.RESULTS:During follow-up 37 of 40 patients were alive in the redo-OPCAB group versus 32 of 40 patients in the redo-ONCAB group (p<0.05). The shorter operation time, less blood loss, fewer perioperative myocardial infarctions, the higher rate of totally arterial revascularisation and shorter intensive care stay were the significantly beneficial differences for patients in the redo-OPCAB group (p<0.05). The 3-year survival rate was higher in the redo-OPCAB group with 81 ± 12% versus 63 ± 9%in the redo-ONCAB group. The quality of life survey did not reveal any significant differences between both groups.CONCLUSION:In conclusion, with our present retrospective study, we could demonstrate the safety and efficacy of the redo-OPCAB technique with even higher 3-year survival rate. Both techniques seem to have similar impact on the outcome of patients.

Background: Plasma concentrations of natriuretic peptides are often elevated in chronic hemodialysis patients and difficult to interpret due to accumulation, high incidence of cardiac disease and changes in volume status. Mid-regional pro-ANP is a newly developed assay whereas BNP and its fragment NT-pro-BNP are available for a longer time. In this cross-sectional study, we compared the plasma concentration of MR-pro-ANP, BNP and NT-pro-BNP in stable ambulatory hemodialysis patients (n = 239) and investigated their associations with clinical factors such as residual diuresis, cardiac status and interdialytic weight gain and with mortality. Methods and Results: In all patients enrolled, the plasma concentration of all natriuretic peptides were largely elevated with a median concentration of 337 pg/ml (interquartile range 146-684) for BNP, 4435 pg/ml (1687-16228) for NT-proBNP and 907 pmol/L (650-1298) for MR-pro-ANP. Plasma concentration of all natriuretic peptides correlated independently with age, degree of systolic dysfunction and negatively with residual diuresis. Dependency on residual renal clearance was strongest for the fragments MR-pro-ANP and NT-pro-BNP. The plasma concentration of all natriuretic peptides was associated with mortality within 2 years of follow-up. Receiver-operated curves revealed a low sensitivity (32-45%), but high specificity for all natriuretic peptides (85-93%) resulting in a high negative predictive (82-87%). Best cut-off values obtained from were 18 611 pg/ml for NT-pro-BNP, 958 pg/ml for BNP and 1684 pmol/L for MR-pro-ANP. Conclusions: In hemodialysis patients, the fragments NTproBNP and MR-pro-ANP are largely elevated compared to BNP which is explained by accumulation. The prognostic performance of MR-pro-ANP is similar to that of NT-pro-BNP or BNP.

Background For patients with end-stage renal failure hemodialysis with an autogenous arteriovenous fistula (AVF) has proven to be the ideal vascular access. Objective The aim of this study is to discover potential predictors of a well-functioning hemodialysis fistula. Methods From December 2009 to March 2011, 80 patients undergoing first time AVF creation were enrolled in our retrospective study. We analyzed pre- and postoperative vessel diameters and flow characteristics gained by duplex ultrasonography (DUS) and intraoperative ultrasound transit-time flow measurements regarding intraoperative blood flow and pulsatility index (PI). Follow-up was defined until the end of the first month with regular hemodialysis, 10 weeks after AVF creation. We performed statistical analyses by employing Spearman correlation, t test, analysis of variance, (2) test, and receiver operating characteristics (ROC). Results At the end of the follow-up, 62 patients (78%) featured functioning AVFs and 18 patients (22%) featured nonfunctioning AVFs. Factors influencing AVF function were radial artery diameter ((2) = 5.23, p = 0.02), intraoperative flow ((2) = 7.09, p = 0.01), intraoperative PI ((2) = 6.5, p = 0.01), and postoperative flow ((2) = 16.29, p = 0.01). According to the ROC analyses, we could develop cut-off values for predicting an ideal AVF function: radial artery diameter more than 2.3 mm, cephalic vein diameter more than 2.7 mm, intraoperative mean flow more than 113 mL/min, PI less than 1.4, and postoperative mean flow more than 160 mL/min. Conclusion Intraoperative ultrasound transit-time flow measurements gained at surgery and postoperative follow-up with DUS can help identify AVFs that are unlikely to function and therefore need early intervention.

AIM:After cardioplegia and subsequent reperfusion of the myocardium as employed in cardiac surgery, ischemia/reperfusion injury of the myocardium can induce apoptosis. The aim of this study was to evaluate the anti-apoptotic properties of resveratrol, a phenolic phytoalexin present in grape skins and especially red wines during simulated cardioplegia (cp) and reperfusion (rep) in an in-vitro microperfusion model on human myocardium, which to our knowledge has not been investigated yet.METHODS:Cardiac specimens were retrieved from the right auricle of patients undergoing elective coronary artery bypass graft before induction of cardiopulmonary bypass. Cardiac specimens, with resveratrol (10 µM) (N.=15) and w/o resveratrol (control, N.=15) were exposed in vitro to varying periods of cp/rep (30/10, 60/20, 120/40 min) in a microperfusion chamber. For detection of apoptosis anti-activated-caspase-3, PARP-1 cleavage immunostaining and real-time PCR for gene expression of cardiac cytokines like BNP, NF-κB1, NF-κB2, E-Selectin, Troponin and TNF-α were employed.RESULTS:CONTROL GROUP:the longer the cp/rep period lasted the higher were the rate of anti-activated-caspase-3 positive cardiomyocytes (21.26±2.07% ‑ 46.56±3.2%) and of PARP1-cleavage positive cardiomyocytes (23.29±2.16% ‑ 36.86±2.11%). Resveratrol group: apoptosis was suppressed significantly (P<0.05). Anti-activated-caspase-3 positive cardiomyocytes (13.45±4.35% ‑ 15.3±2.97%) and PARP1-cleavage positive cardiomyocytes (9.87±2.04% ‑ 11.77±3.42%). Resveratrol significantly suppressed the expression of BNP, NF-κB2, E-Selectin, Troponin and TNF-α in vitro (P<0.05).CONCLUSION:Resveratrol significantly suppresses apoptosis under our applied in vitro conditions. This finding warrants further studies aiming suppression of ischemia/reperfusion injury in clinical settings.

History and admission findings: We report on two patients with cardiorenal and renocardiac syndrome, respectively, who were treated with peritoneal dialysis.Investigations: Patients 1 suffered from dilated cardiomyopathy with an ejection fraction of 20%. There was no hint for an intrinsic renal disease, urialysis showed microalbuminuria at the most. Due to progressive cardiac forward failure kidney dysfunction and diuretic-refactory volume retention developed. Patient 2 was admitted with an uremic syndrome and newly developed atrial fibrilation. Echocardiography revealed a hitherto unknown dilated cardiomyopathy.Diagnosis, treatment and course: Both patients were treated with continuous ambulatory peritoneal dialysis. This led to regression of the uremic complications. Sinus rhythm was restored in patient 2 after two weeks and cardiomyopathy was reversed after another 9 months.Conclusions: End-stage heart failure results in kidney dysfunction which can progress to a dialysis-dependent state. End-stage renal failure is often accompanied by cardiac dysfunction and failure.

BACKGROUND:Cardioplegia and reperfusion of the myocardium may be associated with cardiomyocyte apoptosis and subsequent myocardial injury. In order to establish a pharmacological strategy for the prevention of these events, this study aimed to verify the reliability of our human cardiac model and to evaluate the pro-apoptotic properties of the sphingolipid second messenger ceramide and the anti-apoptotic properties of the acid sphingomyelinase inhibitor amitryptiline during simulated cardioplegia and reperfusion ex vivo.METHODS:Cardiac biopsies were retrieved from the right auricle of patients undergoing elective CABG before induction of cardiopulmonary bypass. Biopsies were exposed to ex vivo conditions of varying periods of cp/rep (30/10, 60/20, 120/40 min). Groups: I (untreated control, n = 10), II (treated control cp/rep, n = 10), III (cp/rep + ceramide, n = 10), IV (cp/rep + amitryptiline, n = 10) and V (cp/rep + ceramide + amitryptiline, n = 10). For detection of apoptosis anti-activated-caspase-3 and PARP-1 cleavage immunostaining were employed.RESULTS:In group I the percentage of apoptotic cardiomyocytes was significantly (p < 0.05) low if compared to group II revealing a time-dependent increase. In group III ceramid increased and in group IV amitryptiline inhibited apoptosis significantly (p < 0.05). In contrast in group V, under the influence of ceramide and amitryptiline the induction of apoptosis was partially suppressed.CONCLUSION:Ceramid induces and amitryptiline suppresses apoptosis significantly in our ex vivo setting. This finding warrants further studies aiming to evaluate potential beneficial effects of selective inhibition of apoptosis inducing mediators on the suppression of ischemia/reperfusion injury in clinical settings.

Coronary artery aneurysms (CAA) in adults are rare. However, the natural history of CAA is unknown since in adults it is predominantly atherosclerotic in origin. The clinical presentation, prognosis and management of giant CAA are not well defined due to limited experience and the low incidence of CAA. We present a case of successful exclusion of multiple giant CAA with an interposed reversed saphenous vein graft.

Glomus tumors, also known as paragangliomas or chemodectomas, arise from well-differentiated mesenchymal cells that are known to be benign. These tumors account for 2% of all soft tissue tumors. The first case of a cardiac glomus tumor was reported in 1924 by Masson. 1 Glomus tumors located within the pericardial tissue are extremely rare. We present the case of a recurrent cardiac glomus tumor. The preoperative investigation, diagnostic problems and surgical treatment of this case will be highlighted. Moreover we wish to emphasize the importance of such an entity and to remind readers that it must be included in the differential diagnosis of a pericardial tumor.

After coronary artery bypass grafting ischemia/reperfusion injury inducing cardiomyocyte apoptosis may occur. This surgery-related inflammatory reaction appears to be of extreme complexity with regard to its molecular, cellular and tissue mechanisms and many studies have been performed on animal models. However, finding retrieved from animal studies were only partially confirmed in humans. To investigate this phenomenon and to evaluate possible therapies in vitro, adequate human cardiomyocyte models are required. We established a tissue model of human cardiomyocytes preserving the complex tissue environment. To our knowledge human cardiac tissue has not been investigated in an experimental setup mimicking extracorporeal circulation just in accordance to clinical routine, yet.

BACKGROUND:After cardioplegia, ischemia/reperfusion injury can induce apoptosis. The aim of this study was to evaluate our ex vivo microperfusion model on human myocardium during simulated cardioplegia (cp) and reperfusion (rep). In addition, the aim was to verify the anti-apoptotic properties of the phosphodiesterase 3 inhibitor milrinone.METHODS:Cardiac biopsies were retrieved from the right auricle of patients undergoing elective CABG prior to induction of cardiopulmonary bypass. Biopsies were exposed to ex vivo conditions with varying periods of cp/rep (30/10, 60/20, 120/40 min). Group I consisted of untreated controls (n=15), Group II of treated controls who had cp/rep (n=15) while Group III had cp/rep+milrinone (n=15). For the detection of apoptosis, anti-activated caspase-3 and PARP-1 cleavage immunostaining were used.RESULTS:The percentage of apoptotic cardiomyocytes in Group I was significantly (P<0.05) lower compared to Group II, revealing a time-dependent increase. In Group III with milrinone treatment, apoptosis was significantly suppressed (P<0.05).CONCLUSIONS:Milrinone significantly suppressed apoptosis in our ex vivo setting. This finding warrants further study aiming to evaluate the potential beneficial effects of milrinone on the suppression of ischemia/reperfusion injury in a clinical setting.

Background: Cardioplegia and reperfusion of the myocardium may be associated with cardiomyocyte apoptosis and subsequent myocardial injury. To establish a pharmacologic strategy for the prevention of these events, this study aimed to verify the reliability of our human cardiac model and to evaluate the antiapoptotic properties of the nonselective beta-blocker carvedilol during simulated cardioplegia and reperfusion ex vivo.Methods: Cardiac biopsies were retrieved before induction of cardiopulmonary bypass from the auricle of the right atrium of patients undergoing elective coronary artery bypass grafting. Biopsies were exposed to ex vivo conditions of varying periods of cardioplegia/reperfusion (30/10 minutes, 60/20 minutes, 120/40 minutes). Group I was the untreated control (n = 15), group II was the treated control (cardioplegia/reperfusion, n = 15), and group III was the experimental group (cardioplegia/reperfusion plus carvedilol, n = 15). Immunostaining for antibodies to activated caspase 3 and poly(ADP-ribose) polymerase 1 (PARP-1) cleavage was used to detect apoptosis.Results: The percentage of apoptotic cardiomyocytes was significantly lower (P < .05) in group I than in group II, revealing a time-dependent increase. In group III, carvedilol treatment suppressed apoptosis significantly (P < .05).Conclusion: Carvedilol significantly suppresses apoptosis in our ex vivo setting. This finding warrants further studies to evaluate the potential beneficial effects of carvedilol in suppressing ischemia/reperfusion injury in clinical settings.

BACKGROUND:Cardiac allograft rejection and vasculopathy are the main factors limiting long-term survival after heart transplantation.In this pilot study we investigated whether non-invasive methods are beneficial to detect cardiac allograft rejection (Grade 03 R) and cardiac allograft vasculopathy. Thus we compared multi-slice computed tomography and magnetic resonance imaging with invasive methods like coronary angiography and left endomyocardial biopsy.METHODS:10 asymptomatic long-term survivors after heart transplantation (8 male, 2 female, mean age 52.1 +/- 12 years, 73 +/- 11 months after transplantation) were included. In a blinded fashion, coronary angiography and multi-slice computed tomography and ventricular endomyocardial biopsy and magnetic resonance imaging were compared against each other.RESULTS:Cardiac allograft vasculopathy and atherosclerosis were correctly detected by multi-slice computed tomography and coronary angiography with positive correlation (r = 1). Late contrast enchancement found by magnetic resonance imaging correlated positively (r = 0.92, r2 = 0.85, p < 0.05) with the histological diagnosis of transplant rejection revealed by myocardial biopsy. None of the examined endomyocardial specimen revealed cardiac allograft rejection greater than Grade 1 R.CONCLUSION:A combined non-invasive approach using multi-slice computed tomography and magnetic resonance imaging may help to assess cardiac allograft vasculopathy and cardiac allograft rejection after heart transplantation before applying more invasive methods.

Cardiac fibromas are rare lesions which occur predominantly in infants and children. In a 2-week-old premature infant with progressive exertional dyspnea, a huge cardiac tumor (5.0 x 4.5 x 5.0 cm) obstructing the right ventricle was diagnosed. Due to tumor progression with resulting obstruction of the right ventricular outflow tract (RVOT), surgery became necessary at 6 months. The tumor was partially resected, creating a crater-like defect, and the resection margins were subsequently plicated. Histological examination confirmed infantile fibroma. The combination of early diagnosis, the time and opportunity for cardiac development and immediate excision once symptoms occur is supposed to improve survival.

The aim of this study was to establish a practical simplified formula to facilitate the management of a frequently occurring postoperative complication, pleural effusion. Chest ultrasonography with better sensitivity and reliability in the diagnosis of pleural effusions than chest X-ray can be repeated serially at the bedside without any radiation risk. One hundred and fifty patients after cardiac surgery with basal pleural opacity on chest X-ray have been included in our prospective observational study during a two-year period. Effusion was confirmed on postoperative day (POD) 5.9+/-3.2 per chest ultrasound sonography. Inclusion criteria for subsequent thoracentesis based on clinical grounds alone and were not protocol-driven. Major inclusion criteria were: dyspnea and peripheral oxygen saturation (SpO(2)) levels < or = 92% and the maximal distance between mid-height of the diaphragm and visceral pleura (D > or = 30 mm). One hundred and thirty-five patients (90%) were drained with a 14-G needle if according to the simplified formula: V (ml)=[16 x D (mm)] the volume of the pleural effusion was around 500 ml. The success rate of obtaining fluid was 100% without any complications. There is a high accuracy between the estimated and drained pleural effusion. Simple quantification of pleural effusion enables time and cost-effective decision-making for thoracentesis in postoperative patients.

Introduction: Cardiac ischemia-reperfusion injury (IRI) is known to induce apoptosis in on-pump cardiac surgery. Our objective is to determine the impact of drugs on IRI using a novell in-vitro model of human cardiomyocytes.

The development of systemic collateral veins after palliative surgery in children with univentricular circulation is a common complication, however, manifestation as late as 10 years postoperatively is rare. Massive systemic to hepatic venous collaterals developed in a 14-year-old girl with univentricular heart, situs inversus atriovisceralis and hemiazygos continuity to the left-sided superior vena cava, 10 years after Kawashima operation. The resulting azygoportal shunt had led to a progressive systemic desaturation and reduction in ventricular function. Interventional occlusion was supposed to be risky for renal failure due to potential closure of the renal vein so that surgical closure was performed. The saturation persistently increased from 65% to more than 85% postoperatively.

We report a simple valve repair for severe pulmonary incompetence in a 25-year-old patient. The patient had been operated on twice before for ventricular septal defect and coarctation of the aorta. The first operation consisted of pulmonary artery banding and coarctectomy and end-to-end anastomosis at 4 months, followed by debanding and transinfundibular ventricular septal defect closure at 6 years of age. Massive pulmonary incompetence was due to destruction of one valve cusp with the right ventricular outflow tract and pulmonary artery dilated secondarily. Repair consisted of pulmonary valve bicuspidization and right ventricular remodelling.

Aims: Cardiac ischemia followed by reperfusion may induce apoptosis in on-pump cardiac surgery. We established a new in vitro model of human cardiomyocytes preserving the natural cellular environment to investigate apoptosis and furthermore by adding aprotinine and carvedilol, a selective ß-blocker.

A.G., a 63-year-old man with the history of a colorectal carcinoma, which had been treated by sigmoidectomy and chemotherapy 4 years ago, presented to another hospital with progressively increasing dyspnea on exertion, leg edema, palpitations, and weight loss. A large central liver metastases, infiltrating the liver segments IV, V, VII, and VIII without any other tumor recurrence was diagnosed. A second turn of chemotherapy was initiated with palliative intent. The effect was a minimal decrease in size of the liver metastases without preventing progressive tumor thrombosis of the inferior vena cava (IVC) extending into the right atrium in the next months (Fig. 1). Recurrent embolization of thrombus masses adherent to the caval tumor caused dyspnea so that the patient was anticoagulated with phenprocoumon. At the time of his transfer to our institution the residual left liver lobe was too small. First of all percutaneous embolization of the right portal vein branches should induce hypertrophy of the future remnant left liver lobe [2]. Two months later the size of the left liver lobe was sufficient for an extended right hemihepatectomy. After sternotomy and midline abdominal incision the ascending aorta and right atrium were exposed for immediate cannulation in case of tumor embolization into the lungs during further abdominal preparations. The diaphragm was incised down to the IVC. Then the infiltrated liver segments were devascularized and the right liver lobe carefully partially mobilized. Due to tumor thrombi extending into the atrium cross-clamping of the IVC was impossible. The ascending aorta, the superior vena cava, and the left femoral vein were cannulated. Cannulation of right atrium was avoided to reduce the risk of tumor embolization by touching the tumor or ensuing rhythm disturbances. CBP was instituted and circulatory arrest was induced after the patient was cooled to 198 tympanic temperature [3]. The incision extended from the right atrium to the IVC caudally of the liver veins (Fig. 2). A massive circumferential invasion of the liver metastases into almost 2/3 of the IVC could be identified. Then the liver metastases were resected en bloc by extended right hemihepatectomy with 2/3 circumferential resection of the IVC. After that the distal IVC and SVC were clamped and CBP was resumed and rewarming of the patient was started. Simultaneously, the IVC was reconstructed with a pericardial patch pretreated with glutaraldehyde (Fig. 3). Reperfusion and warming of the patient was followed by weaning from CBP. The whole operation required 10 hr, CBP time was 146 min and circulatory arrest duration was 6 min. The patient remained ventilated for 12 hr. After 48 hr on the surgical intensive care unit the patient was discharged home on the 14th postoperative day.

Objectives: After heart transplantation (HTX) regular monitoring of recipients for transplant rejection and coronary vasculopathy is required. We compared the ability of multi-slice computed tomography (MSCT) and MRI to coronary angiography (CA) and myocardial biopsy to detect rejection including fibrosis and coronary artery disease (CAD) in long term survivors of HTX.