Background. Aortic dissection still hasapoorprognosis despite progress intherapy. Therefore, this prospective follow-up study wasdesigned todetermine whether thedegree ofcommunication between true andfalse lumeninrelation tothetype of dissection, analyzed bytransesophageal echocardiography, influences therisk after initiation ofmedical orsurgical therapy. Methods andResults. Ineight centers, 168patients (124 menand44women)ofagerange of23-84years with proven aortic dissection wereexamined bytransesophageal echocardiography intheacute phase, after start ofmedical and/or surgical therapy, andduring follow-up (0-65months; mean,10months). Analyses were performed prospectively according toadetailed study protocol. Patients weresubdivided bytransesophageal echocardiography according toamodified DeBakey classification. TypeIaortic dissection wasfound in35%, type IIaortic dissection in17%,andtype m aortic dissection in48%o. Preoperative mortality was3%,7%,and 2%, andsurvival rates were52%,69%, and70%/o, respectively. Type m aortic dissection could besubdivided into those withcommunication andantegrade dissection (ca)(50%v), withcommunication andretrograde dissection limited tothedescending aorta(cr desc) (10%1), withdissection extended totheaortic archand ascending aorta (cr asc)(27%), andwith noncommunicating (nc) aortic dissection (13%). Anopenfalse lumen withnothrombus formation waspresent intypes I,II, m caandm crascaortic dissection in17%21%1, 39%7, and27%respectively, although itwasmostpronounced intypes m ncandm crdesc(75%and78%o). During follow-up inpatients whosurvived, thrombus wasdemonstrated inthefalse lumenin80%1 oftype Iaortic dissection and81%oftypes m caandm crasc. Openfalse lumenwasseen intype Haortic dissection in18%1. Spontaneous healing wasfound in4%withtype H and4%withtype m aortic dissection (mainly inpatients withtype m ncaortic dissection). Patients withfluid extravasation, pleural effusion, pericardial tamponade, andperiaortic effusion aswell asmediastinal hematoma hadamortality of52%. Reoperations werenecessary in12-29%, withthehighest rate inpatients withtype m caaortic dissection. Survival forpatients withtypes M ncandm crdescaortic dissection washigher thanthose withtypes I,II, m ca,andm crasc. Conclusions. Preoperative mortality appears tobereduced bytransesophageal echocardiography, allowing rapidinitiation oftreatment. Intraoperative andpostoperative mortality inaortic dissection remains high. Riskfactors arefluid extravasation andanopenfalse lumenwithhighcommunication. Thrombus formation inthefalse lumencanberegarded asagoodprognostic sign. Surgery appears tobe only afirst stepinthetreatment ofaortic dissection. Second surgery orclosure ofentry sites based on intraoperative echocardiography maybeconsidered toinduce thrombus formation andreduce aortic wall stress. (Circulation 1993;87:1604-1615)

To find out whether pulmonary thromboendarterectomy (PTE) can achieve lasting reduction of pulmonary vascular resistance in patients with pulmonary arterial hypertension due to chronic thromboembolism.45 patients (25 women, 20 men; mean age 45 +/- 24 [19-67] years) were re-investigated a mean of 21 (13-32) months after successful PTE. Two patients had then been in New York Heart Association (NYHA) stage II, 26 in stage III, and 17 in stage IV. In addition to clinical examination and chest radiogram 36 patients had right heart catheterization, 28 pulmonary angiography and 44 echocardiography.Definite improvement of symptoms had occurred in all. 34 were now in NYHA stage I, nine in stage II, and two in stage III. The pulmonary vascular resistance was significantly lower than before and immediately after PTE (pre-PTE: 1052 +/- 472 dyn.s.cm-5; post-PTE: 293 +/- 175 dyn.s.cm-5; at follow-up: 187 +/- 92 dyn.s.cm-5; P < 0.001 for follow-up vs pre-PTE; P < 0.05 for follow-up vs post-PTE). Correspondingly, cardiac index had significantly increased (3.0 +/- 0.5 vs 2.0 +/- 0.7 l/min.m2; P < 0.001). Radiological and echocardiographic examinations showed a definite decrease in right ventricular dimensions and improvement in right ventricular function.In patients with pulmonary arterial hypertension due to chronic pulmonary thromboembolism PTE can achieve a reduction in pulmonary vascular resistance with lasting improvement in right heart function and clinical symptoms.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

HISTORY AND CLINICAL FINDINGS:A 58-year-old man [correction of woman] without previous cardiac symptoms developed exertional dyspnoea and peripheral oedema which markedly increased within a two-week period. Auscultation revealed a 4/6-5/6 holosystolic and diastolic machinery murmur.EXAMINATIONS:Transthoracic and multiplane transoesophageal echocardiography established the diagnosis of a 3 cm aneurysm of the right coronary sinus of Valsalva with clearly demarcated rupture into the right atrium, with a large left to right shunt shown on colour-Doppler echocardiography. These findings were confirmed on cardiac catheterisation. There was no sign of coronary heart disease.TREATMENT AND COURSE:At open-heart surgery the aneurysm was resected, the defect closed with an autologous pericardial patch and the tricuspid valve reconstructed. On follow-up examination the result remained excellent and the patient was free of symptoms.CONCLUSION:In ruptured aneurysm of the coronary sinus of Valsalva, multiplane transoesophageal echocardiography provides exact diagnosis and optimal planning of the operative procedure.

Objectives: Visceral organ failure after CABG results in high morbidity and mortality. This study was designed to evaluate the effect on visceral perfusion and organ function following internal mammary to left anterior descending coronary artery bypass in a porcine model.

Objectives: Emboli generation during cardiac surgery contributes to neurocognitive outcome. Our aim was to determine the effects emboli formation on cerebral blood-flow and brain-water content after different surgical techniques for myocardial revascularisation.

vascular endothelium plays an important role in vasoconstriction, endothelial dysfunction, and vascular injury. Dilation procedures of grafts before coronary artery bypass graft surgery might lead to vascular injury and subsequent bypass graft disease.Methods. We analyzed in vitro the adherence of fluorescence-labeled polymorphonuclear neutrophils (PMNs) to endothelium of human saphenous vein grafts or internal mammary artery grafts after stimulation with thrombin (0.5 to 2 U/mL) or dilating procedures. Furthermore, we investigated endothelial function of prepared grafts.Results. Thrombin stimulation resulted in a dose-dependent increase of PMN adherence to the endothelium of saphenous vein and internal mammary artery, which was attenuated by the selectin-blocking carbohydrate fucoidin or anti-P-selectin monoclonal antibody. Mechanical dilation of saphenous vein or internal mammary artery led to a marked increase in PMN adherence (65 +/- 5 versus 5 +/- 3 PMN/mm(2); p<0.01), which was significantly attenuated by fucoidin or anti-P-selectin monoclonal antibodies. Treatment of internal mammary artery with the vasodilator papaverine led to a marked increase of PMN adherence (59 +/- 8 versus 12 +/- 4 PMN/mm(2); p<0.01) when papaverine was administered directly into the vessel. However, external treatment with papaverine did not affect PMN adhesion. Endothelial dysfunction was observed in dilated venous grafts and in arterial grafts internally treated with papaverine; in contrast, external treatment did not affect endothelial function.Conclusions. This study showed that mechanical or pharmacologic dilation of venous or arterial coronary grafts, usually performed before anastomosis of aortocoronary bypass grafts, led to increased selectin-mediated PMN adhesion on vascular endothelium and subsequent endothelial dysfunction.

Cardiac papillary fibroelastoma (CPF) is a rare primary benign cardiac tumor. Before the use of echocardiography, the lesion was identified at autopsy or incidentally during cardiac surgery. CPF is the third most common primary cardiac tumor after atrial myxoma and lipoma, and is the most common tumor of the valvular endothelium. Transthoracic echo cardiography (TTE) and transesophageal echocardiography (TEE) permit diagnosis of the tumor in living patients. CPF may be the cause of cerebrovascular or cardiac ischemia due to embolization or occlusion of the vascular ostia. Embolic material may arise from fragments of the tumor itself, or from surrounding thrombus. The case is reported of a patient with CPF of the aortic valve in whom TEE diagnosis was conducted and the tumor removed surgically.

BACKGROUND:During surgical coronary revascularisation hemodynamics and myocardial contractility can be affected. This in vivo study aimed to determine the effects of different operative techniques on hemodynamics and regional myocardial perfusion.METHODS:In 24 pigs IMA to LAD bypass was constructed using ECC (n = 8) and cardioplegic arrest, OPCAB techniques (n = 8), or the Impella elect 100 support device (n = 8). 8 animals received a sham operation. Mean arterial pressure (MAP), cardiac output (CO), and left ventricular pressure (LVP, LVdp/dt) were recorded. Regional myocardial perfusion (RMP) of both ventricles was assessed by fluorescent microspheres.RESULTS:MAP significantly decreased during revascularisation in all groups ( p < 0.05), staying below preoperative values thereafter ( p < 0.05). After ECC norepinephrine was administered to maintain MAP. CO and LVdp/dt were impaired more distinctly during OPCAB than with Impella ( p < 0.05) during subsequent recovery. RMP showed global reactive hyperemia during early reperfusion after ECC, remained unchanged in OPCAB, and showed low flow during and after Impella pump run ( p < 0.05).CONCLUSIONS:ECC led to hemodynamic impairment with post-ischemic reactive hyperemia. OPCAB created hemodynamic depression but left RMP unchanged. Hemodynamic depression can be reduced by the Impella pump, however regional myocardial blood flow is decreased.

Die Inzidenz tiefer Sternuminfektionen nach herzchirurgischen Eingriffen wird in der Literatur zwischen 0,25% und 7% angegeben. Diese Komplikation stellt einen schwerwiegenden Faktor für Morbidität und Mortalität im Rahmen herzchirurgischer Eingriffe dar. In der vorliegenden Studie berichten wir über das Ergebnis und die zugrundeliegenden Risikofaktoren von 249 Patienten, die eine, oder auch mehrfache Sternumdehiszenzen mit konsekutiver Reverdrahtung bedingten. Statistische Analysen ergaben, dass Alter, das Vorliegen einer chronisch obstruktiven Lungenerkrankung, Diabetes mellitus und ein erhöhter Body-Mass-Index signifikante Faktoren für die Entwicklung einer Sternumdehiszenz darstellen. Die am häufigsten nachgewiesenen Keime bei Sternuminfektionen waren: Staphylococcus aureus und epididermidis (73%), Enterokokken (8%) und Pseudomonas aeruginosa (7%). Darüber hinaus waren Diabetes mellitus und die Therapie mit Steroiden mit einer erhöhten Inzidenz von mehrfach notwendiger Sternum-Reverdrahtung verbunden. Zusammenfassend werden unterschiedliche präoperative Risikofaktoren für die Entwicklung einer Sternumdehiszenz ermittelt. Bei Patienten mit Diabetes mellitus könnte die kontinuierliche intravenöse Gabe von Insulin dazu betragen, die Inzidenz postoperativer Sternuminfektionen zu reduzieren.

Cardiac troponins have shown to be specific markers of myocardial injury. The aim of this prospective study was to compare patterns and kinetics of troponin I and T after coronary artery bypass grafting (CABG) with or without perioperative myocardial infarction (PMI).

Objectives: Ischemia-reperfusion injury is a major threat after lung transplantation and pulmonary thromboendarterectomy. There are recent investigations which describe the benefits of inhaled aerosolized Iloprost a analogue of prostacyclin on pulmonary hypertension and lung ischemia. The aim of this study was to examine the role of Iloprost given at the onset of ischemia in a model of isolated, buffer-perfused rabbit lungs.

Reoperation of aldehyde tanned bioprotheses due to calcific degeneration remains their major drawback. Based on experiments studying mechanisms and factors that influence the time phase, extent and progression of calcification and evaluating the efficiency of anticalcification treatments and the effects of surface seeding with vital cells a new concept to avoid calcification emerged: masking aldehyde-residues with a covalently bound polymer that supports surface cell seeding. Different covalently bound polymers were tested for their suitability to grow cells. Dense cell growth was achieved on some polymers but without correlation to physico-chemical properties. Ultrathin coating of biological materials appears a promising approach to achieve lining with vital cells.

Objectives: Hemodynamics, left ventricular contractility and regional myocardial perfusion following internal mammary artery bypass to left anterior descending coronary artery were investigated in an adult pig model.

INTRODUCTION Treatment of the ischemic diabetic foot syndrome still represents a medical and economic challenge. Contrary to the aims of the Saint Vincent declaration a dramatic reduction of major amputations in Germany was not noted, although in the diabetic patients the predominant type of tibial artery occlusion allows construction of pedal bypasses for limb salvage. METHOD In patients with ischemic diabetic foot syndrome following angiographic evaluation of the ischemic limb, the indication for surgical revascularisation of patent pedal arteries was established. The in-situ technique was preferred in the presence of a suitable ipsilateral greater saphenous vein whenever possible. Revascularisation was followed by treatment of foot ulcerations or, if necessary, minor amputations. Patients were followed by clinical examination and duplex scan investigation of the bypass in regular intervals. RESULTS From 01/89 to 12/01 in 79 patients (59 men and 20 women) with non healing ulcerations or established gangrene from a total of 175 pedal bypasses 84 pedal bypass operations in 84 limbs were performed using the in-situ technique. All patients were diabetic and in addition 13.9% were dependent on hemodialysis for end stage renal disease. 59.5% of the bypasses originated from the popliteal artery (distal origin bypass). The dorsalis pedis artery was chosen for the distal anastomosis in 83% and the posterior tibial artery in 17%. Two patients (2.4%) died postoperatively from cardiac events. Early bypass occlusion occurred in 8.4% resulting in a major amputation rate of 6%. After 60 months primary, primary assisted and secondary patency was 67.7%, 71.5% and 75.3% respectively with a limb salvage rate of 78%. CONCLUSION Pedal bypass using the in-situ technique provides excellent long term limb salvage rates in a disease with a generally unjustified bad prognosis with respect to limb salvage.

Factor V Leiden mutation has emerged as one of the leading abnormalities in inherited blood coagulation disorders, resulting in a markedly increased risk for deep leg vein thrombosis. A 24- year-old woman presented with acute onset of critical ischemia of her left thumb and index finger. Intraarterial angiography revealed an embolus in the distal radial artery and a thrombotic occlusion of the digital artery of the thumb and index finger. Immediate therapy encompassed a selective surgical embolectomy of the distal radial artery followed by a local intraarterial lysis that was continued for 3 days. Additionally, therapeutic anticoagulation and vasodilating drugs (prostaglandin E) were administered. Within 2 days, capillary refill reappeared and the initial loss of sensory function at the tip of the thumb and index finger diminished. A screening test for thrombophilic disorders led to the diagnosis of a heterozygous mutation of factor V (Leiden mutation). Arterial thromboembolic events of factor V Leiden mutation are rare and have to date been described only in the supraaortic and coronary circulation. Therefore, the arterial embolism to the left hand presented in this report constitutes a rarity that could be successfully salvaged by the combined use of a vascular surgical procedure and intensified medical management.

Background. In primary pulmonary hypertension, aerosolized prostanoids selectively reduce pulmonary vascular resistance and improve right ventricular function. In this study, hemodynamic effects of inhaled iloprost, a stable prostacyclin analogue, were evaluated in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and early after pulmonary thromboendarterctomy (PTE).Methods. Ten patients (mean age 49 years old [32 to 70 years old], New York Heart Association functional class III and IV) received a dose of 33 mug aerosolized iloprost immediately before surgery (T1), after intensive care unit admission (T2), and 12-hours postoperatively (T3). Effects on pulmonary and systemic hemodynamics and gas exchange were recorded and compared with preinhalation baseline values.Results. Preoperatively, inhaled iloprost did not significantly change mean pulmonary artery pressure (mPAP), cardiac index (CI), or pulmonary vascular resistance (PVR). Postoperatively, inhaled iloprost induced a significant reduction of mPAP and PVR and a significant increase of CI at T2 and T3. Preinhalation versus postinhalation PVR was as follows: at T1, 847 versus 729 dynes . s . cm(-5), p = 0.45; at T2, 502 versus 316 dynes.s . cm(-5), p = 0.008; and at T3, 299 versus 227 dynes . s . cm(-5), p = 0.004.Conclusions. In patients with CTEPH, inhalation of iloprost elicits no significant pulmonary vasodilation before surgery, and may have detrimental effects on systemic hemodynamics. Postoperatively, it significantly reduces mPAP and PVR, and enhances CI. Following PTE, inhalation of iloprost is useful to improve early postoperative hemodynamics. (C) 2003 by The Society of Thoracic Surgeons.