A central venous catheter with a subcutaneous infusion port was implanted for chemotherapy into a 64-year-old woman with gastric lymphoma. Six weeks later, two weeks after a trivial trauma with hyperextension of the shoulder joint, it was found that the catheter had broken and its tip portion had embolized into the pulmonary artery: it was retrieved without difficulty via the femoral vein. This event suggests that pressure between clavicle and first rib can cause material fatigue in a silicon catheter. Such catheters should therefore not be implanted via the subclavian vein.

The amount of particulate matter present in Bretschneider's cardioplegic solution (HTK) was assessed by laser-mediated particle counting. Permissible levels of contaminant particles with a distribution of diameters between 0.2 and 20 microns were found. A significant further increase in the particle count was observed when the fluid was administered for clinical use, which resulted in the additional release of particles from, for example, the infusion kit, which included an in-line filter with pores of 270 microns. Filtration of the HTK solution by a terminal inline filter (0.2 micron) significantly reduced the number of particles. In order to determine the chemical composition and the potential hazards of the particulate material we used scanning electron microscopy in combination with energy dispersive X-ray analysis and transmission electron microscopy to examine specimens taken from heart tissue obtained from Göttinger minipigs after cardioplegia and from humans undergoing mitral valve replacement after cardioplegia and reperfusion. Particles of various diameters were found either to be plugging coronary capillaries, to be adherent to the endothelial layer, or to be engulfed by polymorphonuclear (PMN) granulocytes, which appeared to be activated. Some of the PMN granulocytes were apparent in the endothelial layer. It is recommended, therefore, that a terminal in-line filter (0.2 micron) should be routinely used.

Objective: In patent ductus arteriosus, critical coarctation or aortic stenosis and atrial septal defect of secundum type the necessity of invasive diagnostic procedures is under debate. We checked whether clinical and echocardiographic findings - independent of hemodynamics - would allow a clear indication for operation. Methods: Retrospectively we compared pre- and intraoperative findings in 98 non-invasively investigated children (21 % of all children operated) and looked, how often the diagnosis had to be corrected so that operative procedures had to be changed, how often diagnoses had to be completed or made more precise. For comparison the same procedure was applied to 37 catherized children with atrial septal defect. Results: While all ducts were diagnosed correctly, diagnoses concerning coarctation had to be completed in 25 % (= 3 patent ducts), and slightly modified in 77 % (localization, description of aortic arch). In critical aortic stenosis patent ducts were overlooked and bicuspid valves (43 %) not recognized. In atrial septal defects the most relevant corrections were unrecognized partially abnormal pulmonary venous drainage (11 %), which had been missed by heart catheterization in 5.4 % of our patients. Both groups did not differ regarding further completions and modifications. Conclusion: In all patients presented the diagnosis could be established non-invasively without the risk and X-ray exposure of heart catheterization. They had been operated without additional morbidity or mortality.

Pacing and sensing failure in apical right ventricular coil electrode PCD implantation due to ventricular scars or aneurysma may force the implanting surgeon to switch to more invasive procedures such as subxyphoidal pericardiotomy or thoracotomy for epimyocardial corkscrew electrode and for epicardial patch application. In order to avoid this more invasive operation in the most severely impaired patients, right ventricular outflow tract positioning of the RV electrode is suggested as an alternative RV electrode site for implantation. A study of four cases shows that this occasional procedure is a practicable method to avoid more invasive techniques. Excellent pacing, sensing, and defibrillation characteristics were obtained and application is relatively simple.

Under the suspicion of a malignant renal tumour a nephrectomy was performed in a female patient. During the operation she developed an acute hemodynamic instability. A fulminant pulmonary embolism was diagnosed by means of angiography, and with extracorporeal circulation a thrombectomy was performed. The histological examination showed that the thrombotic material was from an angiomyolipoma of the kidney. Although there were also vital tumour cells in the thrombotic material we could not find any proliferation during the following eleven months but even a resolving of the residual embolized tumour material in the small pulmonary arteries.

A significant proportion of early graft occlusions after aortocoronary revascularization using autologous saphenous vein grafts (SVG) are due to mechanical and/or metabolic or biochemical endothelial lesions. The morphological examination of the endothelium, usually carried out using light microscopy or by various types of scanning electron microscopy (SEM), does not give any indication of the functioning of the endothelium (E). Functionally intact E is capable of producing endothelium-derived relaxing factor (EDRF); a practicable in vitro test is the relaxation of pre-contracted vein segments (VS) in response to acetylcholine (ACh) application. To study the effect of the solution used to rinse and store the SVG between removal and implantation on the functional characteristics of the E, we performed in vitro tests on macroscopically intact VS removed from the saphenous vein of 30 male patients who underwent elective CABG surgery. Isolated VS rings were incubated for 60 min in heparinized whole blood (HWB), Bretschneider's cardioplegic solution (HTK), human albumin solution (HAS), or Ringer's solution (RS) and compared with the results obtained immediately after the removal of untreated control samples (C) taken from the same patients. After equilibration in carbogen aerated Krebs-Henseleit solution and precontraction by 3 x 10(-7) M noradrenaline (NE), relaxation induced by 10(-6) M ACh was measured. Only the samples stored in HWB (13.4 +/- 0.4 mN) showed similar maximal contractions with NE to those in the control group (14.4 +/- 0.5 mN), i.e. all those segments which showed both contractions with NE and relaxation with ACh.(ABSTRACT TRUNCATED AT 250 WORDS)

Krebsleiden bedingen in ihrem Verlaufe eine Vielzahl von Sekundärproblemen, wovon einige deshalb besondere thoraxchirurgische Bedeutung erlangt haben, da sie entweder im therapeutischen Gesamtkonzept kurativ beseitigt oder unter palliative Gesichtspunkten zur Verbesserung der Lebensqualität des Kranken gelindert werden können.

Lung transplantation has been successfully used in the treatment of patients with end-stage pulmonary disease and adequate cardiac function. We report about a 32-year-old man with pulmonary alveolar microlithiasis who underwent sequential bilateral lung transplantation. Preoperative hemodynamic studies revealed severe pulmonary hypertension; the right ventricular ejection fraction was 0.27. Eighteen months postoperatively, he continues to do well with normalized pulmonary and cardiac function and without clinical or histopathologic signs of graft rejection.

In order to determine whether the primary use of a phosphodiesterase-III (PDE) inhibitor as monotherapy for severe cardiac low-output states (LOS) is in fact practicable, we investigated the haemodynamic effects of amrinone and enoximone in a prospective randomized study. After elective CABG, AVR, or MVR, patients with cardiac LOS were given amrinone (n = 10) or enoximone (n = 9). Following bolus saturation (1.0-2.0 mg/kg [XA = 1.4] or 0.5-1 mg/kg [XE = 0.9] in total), a dose of 5-10 microgram/kg/min was given by infusion. The standard monitoring program included discontinuous haemodynamic measurements (Swan-Ganz) over a maximum time period of 48 hours, arterial and venous blood-gas analyses, and clinical chemistry. The preoperative clinical and haemodynamic status of the enoximone (E) group (55% CABG patients; MPAP 27 +/- 2.5 mmHg, PCWP 20 +/- 2.9 mmHg, PVR 201 +/- 35 dyn.s.cm-5) was considerably worse than that of the amrinone (A) group (70% CABG patients; MPAP 23 +/- 2.3 mmHg, PCWP 16 +/- 3.5 mmHg, PVR 153 +/- 28 dyn.s.cm-5). Both PDE inhibitor preparations led to a significant increase in cardiac index (from 1.9 +/- 0.1 to 2.5 +/- 0.12 L/min/m2 (A) and from 1.98 +/- 0.1 to 2.6 +/- 0.18 L/min/m2 (E) within 30 minutes, accompanied by a simultaneous decrease in filling pressures and vascular resistances. For up to 2 hours, 3/10 (A) and 2/9 (E) patients required additional positive inotropic support with adrenaline. There were no significant differences between the two groups at any time.(ABSTRACT TRUNCATED AT 250 WORDS)

Die Lungenpraservation ist ein noch weitgehend ungelöstes Problem, das die Ischämie-/Transportzeit und somit die Ausschöpfung von Spenderresourcen limitiert. Das derzeit am häufigsten angewendete Verfahren beruht auf Flush-Perfusion des pulmonalen Funktionskreislaufes. Weitere Verfahren sind autolog arbeitende Herz-Lungenpräparation oder tiefe Spenderganzkörperhypothermie. Die vorgestellte Konzeption verbindet Ganzkörperhypothermie mit Aquilibrierung des Extrazellularraumes mit dem Ziel intrazellulärer Adaptation und ist modifiziert auf die Anforderungen der Multiorganentnahme. Durch Anschluß des Spenders an eine für these Zwecke entwickelte transportable Herz-Lungenmaschine wird das Kühlverfahren eingeleitet und parallel zur Temperaturabsenkung eine Hämodilution durch Inkorporation der protektiven HTK-Lösung nach Bretschneider induziert. Die schrittweise Äquilibrierung zielt auf eine extrazelluläre Senkung des Na+-Gehaltes, Anhebung des K+-Gehaltes and Ca++-Absenkung. Gleichzeitig wird die Kapazität der bluteigenen Puffersysteme durch das inkorporierte Histidin-Puffersystem verstärkt. Zur Vermeidung von Ödembildung wird eine möglichst kurze Phase der extrakorporalen Zirkulation angestrebt; die tiefe Hypothermie his unter 10°C Organtemperatur wird durch parallelgeschaltete Wärmeaustauscher mit Hochdrucküberflutung eines Tieftemperaturcisblockes in weniger als 30 min erreicht. Zusätzlich wird zur weiteren Oberflächenorgankühlung arterielle Blutüberströmung der Lungen eingesetzt. Die Vorteile erstrecken sich nicht allein auf die Lungenpräservation, sondern auch auf die Vorbehandlung aller weiteren zur Multiorganentnahme vorgesehenen Organe.

Increasing knowledge about immunological [6, 18], oncological [4, 5. 17], and infectious [2, 12, 19] risks when transfusing blood have altered attitudes and indications of blood-transfusions as well as the effort to reduce the loss of blood intraoperatively and postaperatively [1]. Recently, attention has been particularly focussed on the potential risk of HIV-infection. The high risk of hepatitis infection after transfusion is well-known; it amounts to 4 %, corresponding to 25. 000 infected patients in the Federal Republic of Germany annually [13, 15].

Preservation of the lung is still one of the most challenging problems, because due to limited procurement time not all organs available can be used. The most common procurement technique is flush perfusion of the pulmonary artery system. Alternative methods in clinical use are either the autologous working heart-lung preparation or donor core-cooling (DCC). The own concept presented here, modified to the special demands of multiorgan-procurement, combines DCC and interstitial equilibration adapted to intracellular ion concentration. DCC is induced by extracorporeal circulation (ECC) using a transportable heart lung machine including a highly effective cooling system: cooling circuit based on two parallel heat exchangers with ice-water cooling produced by an high-pressure overflow of an low-temperatured ice block (-40-degrees-C). While cooling by ECC stepwise hemodilution is achieved by priming volume and incorporation of the cardioplegic solution (Bretschneider-HTK). The aim of equilibration is to lower the extracellular levels of sodium and calcium, and to increase the level of potassium. Additionally, the buffer capacity of donor blood is increased by the incorporated histidine-buffer system (alpha-stat). To avoid donor organ edema the time of ECC should be as short as possible. Using our system donor organ temperatures below 10-degrees-C are reached within less than 30 min. In addition to ECC, lung surface cooling is achieved by external overflow with cold arterial blood (internal mammary artery). Besides lung preservation the main advantage of this concept is the profound precooling of all visceral organs before their individual flush perfusion.

Preservation of the lung is still one of the most challenging problems, because due to limited procurement time not all organs available can be used. The most common procurement technique is flush perfusion of the pulmonary artery system. Alternative methods in clinical use are either the autologous working heart-lung preparation or donor core-cooling (DCC). The own concept presented here, modified to the special demands of multi-organ-procurement, combines DCC and interstitial equilibration adapted to intracellular ion concentration. DCC is induced by extracorporeal circulation (ECC) using a transportable heart lung machine including a highly effective cooling system: cooling circuit based on two parallel heat exchangers with ice-water cooling produced by a high-pressure overflow of a low-temperature ice block (-40 degrees C). While cooling by ECC stepwise hemodilution is achieved by priming volume and incorporation of the cardioplegic solution (Bretschneider-HTK). The aim of equilibration is to lower the extracellular levels of sodium and calcium, and to increase the level of potassium. Additionally, the buffer capacity of donor blood is increased by the incorporated histidine-buffer system (alpha-stat). To avoid donor organ edema the time of ECC should be as short as possible. Using our system donor organ temperatures below 10 degrees C are reached within less than 30 min. In addition to ECC, lung surface cooling is achieved by external overflow with cold arterial blood (internal mammary artery). Besides lung preservation the main advantage of this concept is the profound precooling of all visceral organs before their individual flush perfusion.

Binding of [3H]-NMS to human atrial and ventricular membranes was rapid, reversible and saturable (KD-values: 0.5–1.0 nmol/l). The maximal number of [3H]-NMS binding sites, however, was approximately 2.5-fold higher in right and left atrial membranes (200–250 fmol[3H]-NMS specifically bound/mg protein) than in right and left ventricular membranes (80–100 fmol/mg protein).