Implantation of the liver during reperfusion of the heart in combined heart-liver transplantation: own experience and review of the literature.

BACKGROUND: There are only a few reports about combined heart-liver transplantations. The surgical techniques differ widely, ranging from sequential implantation of the organs to simultaneous transplantations. We report our experience with simultaneous, combined heart-liver transplantations without using a veno-venous bypass demonstrating that this is a feasible surgical technique. METHODS: Since 2005, we performed 4 combined heart-liver transplantations by implanting the liver during the reperfusion period of the newly implanted heart. We retrospectively reviewed patient clinical data and outcomes. RESULTS: The mean operative time was 534 ± 247 minutes and the ischemia times for heart and liver were 190 ± 72 minutes (cold ischemia time for the heart), 98 ± 96 minutes (warm ischemia time for the heart), 349 ± 101 minutes (cold ischemia time for the liver), and 36.25 ± 3.5 minutes (warm ischemia time for the liver). Three patients were discharged from the hospital after an uneventful clinical course. One patient died due to multi-organ failure during the intensive care unit stay on the 23rd postoperative day. CONCLUSION: We suggest that combined, simultaneous heart-liver transplantation without veno-venous bypass is a feasible surgical technique.

Prognostic value of daily cardiac surgery score (CASUS) and its derivatives in cardiac surgery patients.

BACKGROUND: We aimed to validate the usefulness of CASUS derivatives for cardiac surgery patients and their reliability for daily decision making. METHODS: We included, prospectively, the data of all adult cardiac surgery patients who had an ICU stay of at least 12 hours between 20 January 2003 and 14 October 2005 in the Department of Cardiothoracic Surgery of the University of Cologne, Germany. Data were collected until ICU discharge and included initial, maximum, mean, and total CASUS values. δ CASUS (difference from initial value) was calculated at 48 and 96 hours postoperatively. The predictive efficacy of the derivatives was tested with calibration and discrimination statistics. RESULTS: 2372 patients were included with a mean age of 66.2 ± 11.2 years. ICU mortality was 3.6 % (n =85). Mean ICU stay was 3.0 ± 6.1 days. The discrimination was very good for all derivatives (area under the curve ranged between 0.988 and 0.926). The calibration was also good except for the total CASUS, which showed a significant difference between the expected and observed mortality. Increased δ CASUS at 48 hours (1038 patients) and 96 hours (435 patients) correlated with an increase in mortality (23.1 % and 42.9 %, respectively), and conversely a decreased mortality rate was observed with decreasing values (1.9 % and 3.8 %, respectively). CONCLUSION: CASUS derivatives including δ CASUS have a good prognostic value for cardiac surgery patients with regard to the prediction of mortality and survival during ICU stay, with the exception of total CASUS which was not informative.

Foreign body in the airway: unusual cause of acute dyspnoe after cardiac surgery.

We report on a 68-year-old male who presented with acute onset of dyspnoea and cough. After coronary artery bypass grafting and mitral valve repair with an annuloplasty ring, postoperative recovery was initially uneventful. On the 6th postoperative day, he came back to intensive care unit due to acute dyspnoea. Fig. 1 demonstrates chest x-ray. We identified the foreign body as a dental prosthesis (Fig. 2). Removal from the right bronchial tree was successful using a flexible bronchoscope under local anesthesia; intubation was not required. This procedure was safe and well tolerated by the patient. Clinical presentation of adult foreign body aspiration are often nonspecific. Chest x-ray is very helpful for identification and localization of foreign bodies in the airway. Extraction can be performed with flexible or rigid bronchoscopy. For the removal, biopsy forceps, Fogarty balloon catheter, alligator forceps or wire baskets are effective.

Socks for the dilated heart. Does passive cardiomyoplasty have a role in long-term care for heart failure patients?

Dynamic cardiomyoplasty has been performed in over 1000 patients worldwide but due to limited success the procedure was never been adopted as an alternative approach for the surgical therapy of heart failure. However, observations in these patients showed that the nonstimulated or fibrotic transformed latissimus dorsi by itself led to an improvement of heart failure symptoms. These findings stimulated animal experiments with so-called passive cardiomyoplasty devices. In several animal models, the progression of heart failure could be stopped, and even reversed remodeling could be demonstrated. Several different devices have been developed and tested in animal models. The Acorn CorCap has already passed a successful clinical feasibility study. However, the final evaluation of two multicenter trials has to be awaited to assess the future role of this device in the treatment of heart failure.

[Right heart failure following pericarditis constrictiva tuberculosa--urgent surgical treatment]. / Pericarditis constrictiva tuberculosa als Ursache einer schweren Rechtsherzinsuffizienz--dringliche chirurgische Behandlung.

UNLABELLED: A 71-year-old male patient presented with a 4-month history of fever, dyspnoea, night sweat, ankle swelling and was admitted to our institution for further investigation due to heart failure (NHYA IV). A posterior-anterior chest radiograph showed an enlarged cardiac silhouette, the lung was without pathological findings; calcifications were not described. Echocardiography revealed a severe diastolic malfunction but no pericardial effusion. In computed tomography, pericardium was thickened. Patient was admitted for further investigations. Heart catheterization revealed a left ventricular ejection fraction of 56 %, a cardiac index of 1.3 ml/min/m2 leading to the diagnosis of severe constrictive pericarditis. The patient underwent an urgent pericardectomy via median sternotomy. Extracorporal circulation was not necessary. The postoperative course was uneventful, heart failure improved to NYHA II. The removed pericardium revealed severe granulomatous pericarditis resulting from infection with acid-resistant bacilli. The diagnosis was confirmed by a positive culture for mycobacterium tuberculosis. The patient was put on anti-TB chemotherapy for one year. 1 year after operation patient is graduated in NYHA class II. CONCLUSION: This rare extrapulmonary form of TB can have an insidious or sudden onset. The diagnosis is complicated by non-specific clinical and radiographic findings. Clinical presentation may be the result of the infectious process itself or the pericardial inflammation causing pain, effusion, and hemodynamic effects. In the absence of concurrent extracardiac TB, diagnosis of pericardial TB is difficult. Nevertheless, rapid diagnosis and treatment are crucial to reduce mortality.

Coronary artery bypass grafting in patients with systemic lupus erythematosus.

Cardiac involvement in patients with systemic lupus erythematosus (SLE) is common. The natural history of the cardiovascular manifestations has been altered by systemic corticosteroids used for the treatment of SLE; thus, young patients with SLE may suffer from angina and myocardial infarction. The surgical problems and special requirements in patients with SLE are discussed. CAD is one of the major complications limiting the prognosis of the patient with SLE. In the future, a large number of SLE patients may be candidates for myocardial revascularization. In our opinion, total autogenous arterial bypass grafting is advised and intraoperative biopsies of the LIMA are meaningful in patients with SLE.

Cardiac malformations associated with the Holt-Oram syndrome--report on a family and review of the literature.

The Holt-Oram syndrome (HOS) is characterized by mild-to-severe congenital cardiac defects and skeletal abnormalities of the upper limb. The most common cardiac disorder is an ostium secundum atrial septal defect (ASD), followed by ventricular septal defect (VSD) and ostium primum ASD. Electrocardiographic abnormalities, such as various degrees of atrioventricular block, have also been reported. In addition, hypoplastic peripheral vessels of the upper limbs have been observed. Here, we will report about a family with three sons having HOS, and we will detail the cardiac spectrum of HOS as reported in the literature.

[Primary synovial sarcoma of the lung - a rare tumor]. / Primäres Synovialsarkom der Lunge: ein sehr seltener Lungentumor.

We present a 26 year old patient with a primary malignant synovial sarcoma of the lung that was observed for more than one year by a general practitioner and a pulmologist. Finally, because of recurrent hemoptysis a central tumor of mesenchymal origin of the left lower lobe was diagnosed by bronchoscopy. The invasion of the left atrium as far as to the mitral valve was diagnosed by MRT. The patient was operated on by extended pneumonectomy with extracorporeal circulation. The partial excision of the left atrium required plastic reconstruction. In the postoperative course the patient underwent chemo-therapy, 6 cycles adriablastine/ifosfamid. 8 months after the first operation an extensive tumor recurrency occurred with infiltration of the chest wall. The patient refused further radio- or chemotherapy and died 14 months after the operation. Because of the small number of cases therapeutic strategy conceptions do not exist. The resection of the tumor is generally recommended. Chemo- and radiotherapy are accepted as an option for advanced tumor stage.

Papillary fibroelastoma of the aortic valve with temporary occlusion of the left coronary ostium.

We report a rare tumor of the aortic valve located at the commissure close to the left coronary ostium in a 71-year old female patient. Due to an intermittent obstruction of the left coronary ostium, the patient became symptomatic and presented with repeated angina and syncope. Diagnosis was made by echocardiography and confirmed by surgery. Complete surgical removal of the tumor was possible, without replacement of the aortic valve. Histology revealed the diagnosis of a papillary fibroelastoma.

Decentralization of health systems in Latin America.

Decentralization is often a major part of health reform policies. However, there have been few attempts to comparatively study the degree of decentralization and the effects of decentralization on equity of allocations to health, so we do not know how best to implement this reform. This article uses an innovative comparative analysis of the "decision space" that was allowed to local municipalities in the health reforms of Bolivia and Chile, two countries that have had several years of experience in implementing decentralization. The studies found that relatively little decision space was allowed to local authorities over key functions of health care systems. The studies also found that central authorities often reduce the decision space in order to direct more resources to health or to restrict local choice over human resources issues. The studies found that more equitable allocations of health funding were achieved through a common equalization fund for the municipalities in Chile and by forcing the assignment to health of a specific percentage of the central government transfers to municipalities in Bolivia.

Resection of a right atrial metastatic melanoma with unknown origin of primary tumor.

Cardiac involvement of malignant melanoma is generally part of a widespread tumor dissemination, which is mostly multifocal. Hence the disease is usually not amenable to surgical intervention. We report successful resection of a large intracavitary melanoma to the right atrium, the primary origin of which was unknown. The right atrium was reconstructed with an autologous pericardial patch. At 12-month follow-up the patient remains asymptomatic.

Surgical treatment of vascular ring including right cervical aortic arch.

Cervical aortic arch is a developmental entity consisting of persistence of the right or left third branchial arch and regression of the fourth branchial arches. In most cases, the aorta is redundant and crosses behind the esophagus to the opposite side. In the presence of an aberrant subclavian artery contralateral to the side of the aortic arch and a ligamentum arteriosum, a vascular ring is formed around the trachea and esophagus. Two young patients with right-sided cervical aortic arch, aberrant left subclavian artery, and ligamentum arteriosum presented with dysphagia and exertional dyspnea. In one patient, through a left thoracotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were dissected thoroughly above and below the level of the ring. In addition, the aberrant left subclavian artery was divided at its origin from a large diverticulum and implanted into the left common carotid artery; the aortic diverticulum was resected. In the other patient, who had associated 22q11 chromosomal deletion, in addition to left-sided compression of the trachea and esophagus, there was additional marked compression of the right anterolateral trachea by the redundant ascending aorta. Through a median sternotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were widely mobilized; an additional aortopexy of the ascending aorta to the right of the sternum resulted in the absence of tracheal compression. The cases of the two reported patients illustrate the clinical variability of vascular ring, including a right cervical aortic arch and the consequently versatile surgical approach that is needed to successfully address this combination of vascular anomalies.

Operative treatment of hypertrophic obstructive cardiomyopathy and aortic valve disease in infants.

BACKGROUND: The indications for operative intervention for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) in infancy and childhood are not well defined because of the rarity of the lesion. The traditional surgical procedure consists of septal myectomy. In an attempt to further improve the outcome of HOCM associated with concentric left ventricular hypertrophy and aortic valve disease in infancy, we have combined resection of the left ventricular septum and free wall with a Ross-Konno procedure. METHODS: Three infants (aged 3, 4, and 10 months) with HOCM (left ventricular aortic gradients of 75, 95, and 110 mmHg), associated concentric left ventricular hypertrophy, and valvar aortic stenosis (n = 1) or combined valvar aortic stenosis and regurgitation (n = 2) underwent extensive resection of fibroelastosis and subendocardial myocardium of the left ventricular septum and free wall in combination with a Ross-Konno operation. All three patients had marked systolic anterior motion of the mitral valve. The length of the incision into the ventricular septum was 1.8, 2.0, and 2.3 cm. RESULTS: In all three patients this procedure resulted in a marked reduction of width of the left ventricular septum (median 9 mm vs 14 mm preoperatively) and the left ventricular posterior free wall (median 8 mm vs 12 mm preoperatively) and an almost twofold increase of the left ventricular end-diastolic volume (median 13.5 cm3 vs 7.0 cm3 preoperatively). The neo-aortic valve functioned normally. Systolic anterior motion of the anterior leaflet of the mitral valve had completely resolved in two patients and had markedly regressed in the remaining patient. At follow-up of 15, 17, and 26 months, two patients had absence of a left ventricular outflow tract gradient and the third patient had a residual sub-valvar gradient of 15 mmHg. CONCLUSIONS: The reported procedure may be a valuable technique in severe forms of hypertrophic cardiomyopathy associated with aortic valve disease. The operation results in enlargement of the left ventricular stroke volume and improvement of the left ventricular diastolic function, restores aortic valve anatomy and function, and abolishes or decreases systolic anterior motion of the mitral valve.

Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.

Transformation of ministries of health in the era of health reform: the case of Colombia.

Ministries of health are being called upon to lead major health reforms; at the same time they must reform themselves to become more modern institutions and assume new and different functions and roles in the more dynamic reformed system. The literature on public administration and on health reform has recommended many processes of institutional reform and development, building on private sector management techniques, popularized by 'reinventing government' and 'total quality management'. More recently, thoughtful insights have emphasized improving public management through a focus on creating 'public value'; on political, as well as administrative, leadership; improving institutional performance through strengthening the 'task networks' of organizations needed to achieve strategic objectives; and creating a learning culture within the organization. This article applies these recent approaches to the specific needs of ministries of health in order to improve their capacity to lead major health reforms. This combined approach is then used to analyze and make recommendations to the Ministry of Health in Colombia where the authors were providing technical support for a major new health reform.

Chile's health sector reform: lessons from four reform periods.

This paper applies an interdisciplinary approach to analyze the process of health reform in four significant periods in Chilean history: (1) the consolidation of state responsibility for public health in the 1920s, (2) the creation of the state-run National Health Service in the 1950s, (3) the decentralization of primary care and privatization of health insurance in the 1980s, and (4) the strengthening of the mixed public-private market in the 1990s. Building on the authors' separate disciplines, the paper examines the epidemiological, political and economic contexts of these reforms to test simple hypotheses about how these factors shape reform adoption and implementation. The analysis underlines: (1) the importance of epidemiological data as an impetus to public policy; (2) the inhibiting role of economic recession in adoption and implementation of reforms: and (3) the importance of the congruence of reforms with underlying political ideology in civil society. The paper also tests several hypotheses about the reform processes themselves, exploring the role of antecedents, interest groups, and consensus-building in the policy process. It found that incremental processes building on antecedent trends characterize most reform efforts. However, interest group politics and consensus building were found to be complex processes that are not easily captured by the simple hypotheses that were tested. The interdisciplinary approach is found to be a promising form of analysis and suggests further theoretical and empirical issues to be explored.

Can they get along without us? Sustainability of donor-supported health projects in Central America and Africa.

This article presents a synthesis of five country studies of the sustainability of U.S. government-funded health projects in Central America and Africa. The studies reviewed health projects with a comparative framework to determine which project activities had continued after the donor funding ceased. This review found that health projects in Africa were less firmly sustained than those in Central America. The studies then evaluated context factors and project characteristics that were related to the sustainability of the projects. The weak economic and political context of the African cases was found to inhibit sustainability in those countries, suggesting that broader development issues be addressed before donors expect significant sustainability of health projects in Africa. Even in Central America it was found that the strength of the institution implementing the project was an important variable for sustainability, suggesting that donor attention also be shifted toward strengthening institutional development in order to assure sustainability. In addition to context factors, several project characteristics were related to sustainability in most cases and suggest sustainability guidelines for project design and implementation. The article concludes that projects should be designed and managed so as to: (1) demonstrate effectiveness in reaching clearly defined goals and objectives; (2) integrate their activities fully into established administrative structures; (3) gain significant levels of funding from national sources (budgetary and cost-recovery) during the life of the project; (4) negotiate project design with a mutually respectful process of give and take: and (5) include a strong training component.

The political and administrative context of primary health care in the Third World.

Despite increasing knowledge about technical aspects of Primary Health Care (PHC), there has been as yet only limited research into political and administrative influences on the effectiveness of PHC programs. A three-stage model of the policy process is developed as a framework for organizing the relationships between elements of (1) the national political setting and PHC policy formulation; (2) the implementing agency and program administration; and (3) the community setting and service delivery. Drawing upon the literature on PHC and related programs, hypotheses are proposed for each of these stages as a basis for future study and practical application. Possible output indicators are suggested for each stage of the model. Several basic methodological issues must be addressed in the design of empirical research on political-administrative factors, including variable selection, identification of data sources, and choice of analytical approach. It is hoped that this review will encourage more systematic investigation in this area.