[Comparative economic analysis of the new concept for veal calf fattening «outdoor veal calf¼ and the conventional IP-SUISSE label]. / Vergleichende Wirtschaftlichkeitsanalyse des Kälbermastsystems «Freiluftkalb¼ und der konventionellen IP-SUISSE-Labelmast.

INTRODUCTION: The evaluation of new animal husbandry concepts includes, beyond the exploration of chosen parameters, that the question is addressed whether economic benefits for producers and ethical benefits for society result of the new system when compared to traditional systems. In a previous study, a novel management and housing concept for veal production («outdoor veal calf¼, OVC) was tested from October 2016 to July 2018. The OVC concept was associated with distinctly lower antimicrobial use while average daily weight gain was similar and calf welfare better; furthermore mortality was lower compared to conventional label fattening. The aim of the present study was to compare economics between the OVC concept on intervention farms (IF) and the IP-SUISSE label concept on control farms (CF) by calculating contribution margins (CM). The CM indicates the difference between the performance of a production branch (e. g. slaughter return) and the allocable costs for this production branch (e. g. feed costs). In the present study, two different approaches were used for CM calculation to analyze the available data in detail. No substantial differences in CM between the OVC concept and the IP-SUISSE concept were found in either approach. However, the specific CM varied between the approaches as different calculation criteria for quantities and prices were applied (approach «real¼ with accurate costs and returns from the OVC study and approach «standardized¼ with costs and returns based on the CM catalogue). The CM varied slightly for the CM per man-hour (IF «real¼: 6.96 CHF/man-hour, «standardized¼: 4.49 CHF/man-hour; CF: 7.90 CHF/man-hour and 8.08 CHF/man-hour, respectively) and considerably for the CM per fattening space and year (IF «real¼: -380.36 CHF, «standardized¼: -559.50 CHF; CF: -244.70 CHF and -318.80 CHF, -respectively). Producing veal with the OVC concept -allowed for achieving comparable CM/man-hour as in conventional label production. Thus, the farmers' economic interests should be warranted when implementing the OVC concept.

INTRODUCTION: Lors du développement de nouveaux systèmes d'élevage, on s'efforce de les tester par rapport à des paramètres sélectionnés pour évaluer si un changement apporterait une valeur ajoutée économique ou sociétale par rapport aux systèmes déjà établis. Dans une étude précédente, un nouveau type de système d'engraissement des veaux (système «veau en plein air¼, VPA) a été testé d'octobre 2016 à juillet 2018. Par rapport à l'engraissement conventionnel labellisé, considérablement moins d'antibiotiques ont été utilisés avec ce système tout en conservant les mêmes performances de croissance quotidienne et en améliorant le bien-être des animaux; de plus, la mortalité des veaux d'engraissement était plus faible. Le but de la présente étude était de procéder à une analyse économique comparative des deux systèmes de détention, VPA et label IP-SUISSE (IPS), à l'aide du calcul des marges brutes (MB). La MB indique la différence entre les performances d'une branche de production (par exemple les revenus d'abattage) et les coûts imputables à cette branche de production (par exemple les coûts d'alimentation). Dans cette étude, deux variantes des marges brutes ont été calculées afin d'évaluer en détail les données disponibles. Les deux variantes sont arrivées à la conclusion qu'il n'y avait pas de différences majeures dans la MB entre le nouveau système VPA et le système du label IP-SUISSE. Cependant, la MB spécifique différait entre les variantes, en raison des bases de calcul différentes utilisées pour chaque variante pour les quantités et les prix (variante «réelle¼ aves des revenus et coûts concrets dérivés de l'étude VPA et variante «standardisée¼ avec des revenus et des prix basés sur le catalogue des MB). Les MB variaient légèrement en ce qui concerne la MB par heure de travail productive (VPA: variante «réelle¼: 6.96 CHF/heure, «standardisée¼: 4.49 CHF/heure; IPS: variante «réelle¼ 7.90 CHF/heure, «standardisée¼ 8.08 CHF/heure) et considérablement pour la MB par place d'engraissement et par année (VPA: variante «réelle¼: ­380.36 CHF, «standardisée¼: ­559.50 CHF; IPS: variante «réelle¼: ­244.70 CHF, «standardisée¼: ­318.80 CHF). La production de viande de veau selon le système VPA permet de générer une MB/heure de travail positive similaire à celle de l'engraissement conventionnel labellisé IP-SUISSE. En conséquence, les intérêts économiques des producteurs ne paraissent pas être prétérités dans ce nouveau système d'élevage.

[Efficacy of opioid analgesia at the superior cervical ganglion in neuropathic head and facial pain]. / Opioidwirksamkeit am Ganglion cervicale superius bei neuropathischen Schmerzen im Kopf- und Gesichtsbereich.

The efficacy of ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) was retrospectively investigated in 74 consecutive patients with neuropathic pain in the head and face region. It was possible to retrospectively analyze the short-term and medium-term treatment results in 64 of 74 patients. The long-term effect was subsequently determined using a standardized questionnaire. The short-term analgesic effect of the first blockade by GLOA was significant with a mean pain reduction of 52% (p < 0.001). Within a span of 20 min the mean pain intensity decreased from 65 to 28 on a visual analogue scale. A clinically relevant pain reduction (> or = 30%) was observed in 73% of the patients. The proportion of responders (pain reduction > or = 50%) was 59% after the first blockade. Patients with zoster or trigeminal neuralgia experienced greater pain relief than patients with atypical facial pain or longer lasting postzoster neuralgia. During the course of the blockade series with an average duration of 33 days, a significant medium-term pain reduction of 30% was noted. In the first 3 treatment days, the level of continuous pain declined from 6.3 to 4.3 on a numerical rating scale. Short-term responders reported a better medium-term pain reduction than nonresponders. After 3 years (range: 5 months to 6 years), 21% of 52 patients remained free of pain. The other patients reported often only minimal residual pain or a decrease of pain severity and duration. According to these results, GLOA at the SCG can represent a suitable and simple treatment option for neuropathic facial pain.

Clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass: retrospective study.

This retrospective study evaluates our experience with clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass. Twenty-three of 3,600 consecutive patients suffered from splanchnic malperfusion. Symptoms developed between day 2 and 6 postoperatively in 18 of 23 patients. Four of 23 patients had no abdominal symptoms. Laboratory evaluation revealed significantly higher serum lactate and creatine phosphokinase levels in the 18 symptomatic patients compared with those of a control group. Arteriography was performed in 20 cases and revealed nonocclusive splanchnic hypoperfusion. Risk factors for development of mesenteric ischemia include arrhythmias and low cardiac output. Patients with angiographically proven nonocclusive mesenteric ischemia were treated with intra-arterial bolus injection and subsequent intra-arterial infusion of tolazoline combined with heparin sodium. The overall mortality rate was 30% (7 of 23). Infusion therapy with tolazoline and heparin seems to be a successful treatment modality for clinically diagnosed mesenteric ischemia.

Simultaneous surgical revascularization and angiogenic gene therapy in diffuse coronary artery disease.

OBJECTIVE: The cytokine vascular endothelial growth factor (VEGF) is capable of triggering angiogenesis and at higher concentrations vasculogenesis. We report on a pilot study where VEGF-DNA as an additional therapy to coronary artery bypass grafting was injected into the myocardium in 24 patients (pts) with proximal coronary artery stenosis and diffuse peripheral disease. One region of the myocardium with proven ischemia remained unsupplied after surgery because the respective epicardial coronary artery was not graftable. METHODS AND RESULTS: Plasmid DNA encoding for the 165- and 167-amino acid isoform of the human VEGF genes was injected directly into the myocardium, not amenable to surgical revascularization at a dosage of 1000 microg each, using a standardized protocol. A (99m)Tc-sestamibi-SPECT at rest performed 7 days prior to the operation, had shown decreased marker activity in the region of interest. Controls were made 1 week and 80-100 days postoperatively. Transmural scarring was ruled out intraoperatively. Coronary and left ventricular angiographies were performed preoperatively and 3 months postsurgery, respectively. One or more of the following angiographic items were found in 16/24 patients postoperatively. (1) Improvement of regional left ventricular function at the VEGF treated myocardial sector (5/24 pts). (2) Newly visible vessels considered as collaterals (8/24 pts). (3) Earlier filling of parent vessels (6/24 pts). (4) An increase in diameter of preoperatively existing collateral vessels (7/24). An increased perfusion at rest in the region of gene application was detected in 3/24 patients by early postoperative (99m)Tc-sestamibi-SPECT investigation. In six additional cases, local perfusion increased markedly until the late examination. No perioperative myocardial infarctions and no signs of inflammation were observed. Newly developed abnormal vasculature was not detected in any patient. CONCLUSIONS: Direct intramyocardial administration of VEGF(165)-DNA and VEGF(167)-DNA may result occasionally in an enhancement of collateral vascularization in regions with diffuse peripheral coronary artery disease not surgically amenable. During midterm follow-up no adverse effects of VEGF-DNA application are observed so far. The very slight midterm improvements caused us to stop further VEGF-DNA application and, in our opinion, do not justify a prospective, and randomized study with a control group.

[Tube obstruction in operation of esophageal atresia. Brief review of intraoperative complications based on a case report]. / Tubusobstruktion bei der Operation einer Osophagusatresie. Kurzübersicht intraoperativer Komplikationen anhand einer Kasuistik.

In this case report we discuss the anaesthetic management of newborns with esophageal atresia classified as Vogt III b. This type is characterised by an upper esophageal pouch which ends blindly and a distal tracheoesophageal fistula. Commonly associated diseases are cardiac, renal, vertebral and anal anomalies. The most important intraoperative anaesthesiological complications are acidosis, hypoxaemia, gastric distension, endotracheal tube obstruction, tracheal compression, cardiac arrhythmias and atelectasis. In the presented case an endotracheal tube obstruction with hypercapnia occurred which required a change of the airway. After changing the endotracheal tube the newborn could be ventilated sufficiently. Further postoperative course was uneventful.

Antineural and antinuclear autoantibodies are of prognostic relevance in non-small cell lung cancer.

BACKGROUND: Autoantibodies against nervous system structures have been proven to be a prognostic factor in small cell lung cancer. However, little is known about humoral autoimmunity in non-small cell lung cancer (NSCLC) and its prognostic significance. METHODS: We examined antineural antibodies (AnAb) and antinuclear antibodies (ANA) in the sera of 61 patients with NSCLC (histologically: 29 adenocarcinoma, 32 squamous cell carcinoma). Twenty-one patients had stage I NSCLC, 11 stage II, and 29 patients stage III. Autoantibody detection was done by immunofluorescence test; Western blotting was used as a confirmation test. RESULTS: Of the NSCLC patients, 27.8% were antineural antibody positive, and 32.7% had ANA. No differences were found between the histological groups. AnAb-positive patients showed a better survival in all patients (p = 0.005). There was also a higher survival of ANA-positive patients, but this was only significant in stage III (p = 0.0025). Cox regression analysis showed that antineural and antinuclear antibodies are a stage-independent prognostic factor in NSCLC. CONCLUSIONS: Antineural and antinuclear autoantibodies are a stage-independent prognostic factor in patients with NSCLC and may represent an effective immune response to the tumor.

Improved regional left ventricular performance in mitral valve replacement with orthotopic refixation of the anterior mitral leaflet.

BACKGROUND AND AIMS OF THE STUDY: To investigate the influence of different surgical techniques of chordal preservation in mitral valve replacement (MVR) on left ventricular size and function, we studied a series of 244 patients who underwent mitral valve replacement either with (n = 161) or without (n = 83) preservation of the subvalvular structures. RESULTS: Preoperatively there were no differences between the two patient groups. Three months postoperatively, echocardiography demonstrated that chordal preservation in MVR resulted in smaller left ventricular end-systolic diameter (LVESD) and end-diastolic diameter (LVEDD): preservation versus resection, LVESD: 43.4 +/- 7.8 mm versus 48.8 +/- 9.2 mm (p < 0.05), LVEDD: 57.3 +/- 7.8 mm versus 62.9 +/- 10.5 mm (p < 0.05) and a significantly decreased LV-L (long axis) (87.1 +/- 4.2 mm versus 97.5 +/- 5.7 mm; p < 0.05). There was no significant difference in cardiac dimensions between the three patient subgroups in whom chordal preservation was possible. In addition, left ventricular ejection fraction in the preservation groups was significantly improved compared with the resection group (54.2 +/- 11.2% versus 48.1 +/- 12.4%, p < 0.05); there were no differences between the preservation subgroups. Regional wall motion analysis revealed significantly improved segmental myocardial performance in all segments if both leaflets were preserved or the anterior mitral leaflet was reattached to the anterior mitral annulus.

[Bronchopulmonary carcinoids: surgical therapy and prognosis]. / Bronchopulmonale Karzinoide: Operative Therapie und Prognose.

From 1976 to 1996 sixty patients with bronchopulmonary carcinoid were operated on at our institution. Post-operative histologic examination revealed typical carcinoid tumors in 50 cases and atypical carcinoid tumors in 10 cases. Preoperative diagnosis was correct in 32 cases (53%) and wrong in 11 cases (18%). In 17 cases (29%) we carried out a diagnostic thoracotomy. Resection was potentially for cure in 55/60 patients. Five-year-survival rates were 100% for patients with typical carcinoid tumors and 97% and 92% at 10 and 15 years, respectively. Regional lymphatic tissue was involved in typical (12%) as well as in atypical carcinoid tumors (20%). Furthermore distant metastasis occurred in both types of tumors, 4% in typical and 11% in atypical carcinoid tumors. There was no relationship between lymph node involvement and distant metastasis. Local recurrence was seen in 2/60 patients. Both patients suffered from atypical carcinoid tumors. Patients in whom only incomplete resection due to advanced tumor stage was possible showed no benefit from operative therapy.

Mediastinal compression syndromes due to idiopathic fibrosing mediastinitis--report of three cases and review of the literature.

Fibrosing mediastinitis is the most often observed benign cause of mediastinal compression syndromes, particularly the vena cava superior syndrome. We report 3 cases with such compression syndromes (2 x superior vena cava syndrome, 1 x symptomatic tracheal obstruction) due to fibrosing mediastinitis in which tumor resection led to a relief of symptoms. The operative procedures performed in our cases and in general as well as conservative treatment modalities reported for this rare disease are discussed with respect to our own experience and that of the recent publications in the European and American literature.

Pulmonary carcinosarcoma: diagnostic problems and determinants of the prognosis.

OBJECTIVE: Bronchopulmonary carcinosarcoma is a very rare tumor and the prognosis of patients with carcinosarcoma is assessed as unfavourable. The problems concerning diagnosis, therapy, and prognosis after resection treatment are discussed with reference to our seven cases and with consideration of the pertinent literature. METHODS: The retrospective data of seven patients with pulmonary carcinosarcoma were analysed. All were staged postoperatively according to the international TNM staging system. The diagnosis was verified by immunohistochemical investigation. The prognosis of the patients with carcinosarcoma was compared with the prognosis of patients with non-small cell carcinoma of the lung. RESULTS: Whether lung resection is the treatment of choice for these patients is of no relevance, because in most cases the preoperative diagnosis is incomplete, as only one component of the tumor, namely the epithelial one, is found in the biopsy specimen. The complete and correct diagnosis in five of the seven cases was not made before the resection had been performed and in the remaining two patients it was only made when tumor recurrence or metastases occurred. The prognosis of patients with carcinosarcoma of the lung is assessed to be comparable to that of patients with other pulmonary carcinoma: in this study survival times ranged from only 3 months (T2N3) to 4 years 6 months (T3N1). The causes of death of the patients with carcinosarcoma were local recurrence in four patients and metastases at distant sites in two. Two recurrent tumors as well as the metastases consisted only of the sarcoma component of the primary tumor histologically. CONCLUSION: One may suggest that the prognosis of carcinosarcoma might be determined by the sarcoma component of the tumor. Therefore the generally accepted therapies of soft tissue sarcomas should be adopted for the follow-up treatment of patients with pulmonary carcinosarcoma.

Postoperative assessment of chordal preservation and changes in cardiac geometry following mitral valve replacement.

Mitral valve replacement (MVR) is still associated with a relatively high mortality. To investigate the influence of chordal preservation in MVR on left ventricular size and function, we studied a series of 82 patients who underwent MVR either with (group A n = 50) or without (group B n = 32) preservation of the subvalvular structures and compared the two groups. Echocardiography was performed preoperatively, and 7 days and 3 months postoperatively. Echocardiographic investigations included left atrial and ventricular diameters, right ventricular diameters and left ventricular length. Preoperatively there were no difference between the two groups of patients. Intraoperative and postoperative management was similar in the groups. Three months postoperatively echocardiographic examinations demonstrated that chordal preservation in MVR resulted in smaller left ventricular systolic and diastolic diameters (LVESD: gr. A 43.4 +/- 7.8 mm vs gr. B 48.8 +/- 9.2 mm P < 0.05, LVEDD: 57.3 +/- 7.8 mm vs 62.9 +/- 10.5 mm P < 0.05) and a significantly decreased left ventricular length (87.1 +/- 4.2 mm in gr. A vs 97.5 +/- 5.7 mm in gr. B P < 0.05). In addition, left ventricular ejection fraction in group A was significantly improved compared to group B (54.2 +/- 11.2% vs 48.1 +/- 12.4%, P < 0.05). We conclude that chordal preservation in MVR improves left ventricular function and reduces left ventricular diameters and volumes compared to resection of the mitral subvalvular appartus and that these beneficial effects can be maintained in the postoperative course.

[The effect of puncture needle on the subarachnoid catheter position in continuous spinal ansthesia]. / Einfluss der Punktionsnadel auf die subarachnoidale Katheterposition bei kontinuierlicher Spinalanästhesie.

The subarachnoid position of the microcatheter has an impact on the outcome of continuous spinal anaesthesia (CSA). The present prospective, randomised study investigated the influence of two different spinal needles on the radiographically documented subarachnoid positions of microcatheters in CSA. In addition, the influence of the subarachnoid position of the microcatheter on onset time of analgesia, dose requirement of local anaesthetics, and level of analgesia was examined. METHODS. Forty orthopaedic patients received CSA using a 28-gauge spinal catheter inserted either through a non-directional 22-gauge Quincke needle (group 1) or a directional 22-gauge Sprotte needle (group 2). After initial injection of 2 ml to a maximum of 5 ml of supplemental doses of 0.5% plain bupivacaine, onset time of analgesia at the level of T 10, dose requirement of bupivacaine, and the achieved analgesic level were registered. After surgery, a dye-enhanced AP X-ray film of the lumbar spine was performed for radiological control of the subarachnoid catheter position. RESULTS. There was a higher number of cranial catheter positions in group 2 (60%) compared with group 1 (40%, P = 0.037). In contrast to group 1, with 35% caudally directed catheters, no catheter was seen in a caudal position in group 2. Onset time of analgesia (P = 0.0002) and anaesthetic dose requirement (P = 0.037) were lower in patients with cranially directed catheters compared to patients with the catheters situated at the level of the puncture site or in a caudal position. Maximal analgesic levels were higher in cranially directed catheters compared with other localisations (P = 0.022). CONCLUSIONS. Sprotte needles provide a higher number of cranially directed microcatheters, which are associated with faster onset of analgesia, lower dose requirement of local anaesthetics, and higher analgesic levels in CSA. The results suggest more effectiveness and probably more safety in microcatheter CSA using Sprotte needles for catheter insertion.

Effects of high-dose aprotinin on renal function in aortocoronary bypass grafting.

BACKGROUND: To reduce blood consumption in cardiac surgery, aprotinin has been widely used for years. Because aprotinin is metabolized in the kidney, damage of the renal system has been discussed. METHODS: To study these possibly unfavorable effects of aprotinin, a prospective, randomized, placebo-controlled study of 20 patients undergoing aortocoronary bypass operations was performed. A placebo group P was compared with group A, in which patients received high-dose aprotinin according to the "Hammersmith" regimen. Renal function was assessed for 5 postoperative days using sodium dodecyl sulfate gel electrophoresis and quantitative protein analysis of the urine. RESULTS: During and after the operation, temporary renal dysfunction was found in all patients, with a substantial increase of all investigated indices. The alpha 1-microglobulin level in the urine was significantly increased in the aprotinin group for 5 days in comparison with the placebo group, with a maximum on the third postoperative day (64.8 +/- 13.7 versus 21.0 +/- 6.5 mg/L; p < 0.05). Similarly, after sodium dodecyl sulfate-polyacrylamide gel electrophoresis, the bands of proteins filtrated in the renal tubular system were almost tripled in the aprotinin group 5 days postoperatively (5.0 +/- 0.8 versus 2.1 +/- 0.2; p < 0.05). Although urine production was significantly increased in group A (4789 +/- 580 versus 3653 +/- 492 mL/24 h postoperatively; p < 0.05), no relevant changes in serum or urine creatinine levels could be observed in either group. CONCLUSIONS: Patients undergoing aortocoronary bypass operations demonstrate a temporary renal dysfunction. Aprotinin impairs renal function in addition by overloading the tubular reabsorption mechanisms. Patients with normal renal function preoperatively--as were included in this study--are able to compensate for both the perioperative renal dysfunction caused by the extracorporeal circulation and the additional tubular damage due to aprotinin.

The concept of "direct mechanical ventricular assistance" in the treatment of left-ventricular failure. Part 2. Results of the new intrathoracic implantable multi-chamber pump system (IMPS) in an animal study.

An assist device was developed which is able to support the pumping function of the heart by direct application of pressure to the left ventricle. The goal of this animal study in pigs was to determine whether it is possible to maintain sufficient blood circulation with the aid of the new system when the heart is fibrillating or its capacity has been greatly reduced. Following sternotomy complete invasive monitoring was installed. The intrathoracic implantable mechanical multi-chamber pump system (IMPS) was placed around the left ventricle. By means of the beta-blocker carazolol, systolic left-ventricular pressure (LVPsys), cardiac output, heart rate, and left-ventricular dp/dtmax (LVdp/dtmax) were gradually lowered and the pump system was tested intermittently. Then the heart was fibrillated and the system was tested again. When cardiac output, LVdp/dtmax, and systolic blood pressure were reduced by approximately 50% IMPS was able to increase LVPsys by 83% (IMPS) on: 96 +/- 9 mmHg vs. IMPS off: 63 +/- 6 mmHg), and the blood pressure in the carotid artery by 86% (IMPS on: 95/40 +/-15 mmHg vs. IMPS off: 69/38 +/- 9 mmHg). The mean cardiac output was 64% (IMPS on: 4.3 L/min vs. IMPS off: 3.9L/min); in most cases a great variability could be observed depending on the preload, the heart rate, and the mode of pressure application. When the heart was fibrillating, IMPS was able to maintain adequate circulatory conditions with LVPsys = 88%, blood pressure in the carotid artery = 85%, and LVdp/dtmax = 57% of the control values measured before fibrillation and beta-blockade. The system presented here is able to support the impaired left ventricle and to replace its pumping function. The advantages of the system are its efficiency and the lack of contact of the circulating blood with foreign surfaces. Whether the system is suited for bridging and recovery support shall be clarified in further studies.

Preservation of the mitral subvalvular apparatus in multiple valve procedures.

The advantages of chordal preservation in mitral valve replacement have been demonstrated, but there is no detailed information available on the effect of chordal preservation in patients undergoing multiple valve operations. We assessed therefore a series of 61 patients who underwent multiple valvular procedures either with (Group A, n = 42) or without (Group B, n = 19) preservation of the subvalvular structures. Echocardiographic examinations were performed preoperatively, seven days and three months postoperatively. In addition clinical and electrocardiographic examinations were performed. Echocardiographic investigations included left atrial, left and right ventricular diameters and left ventricular length. Preoperatively there were no differences between the two groups. Intra- and postoperative management was similar in the two groups. Postoperative clinical and echocardiographic examinations demonstrated that, although beneficial effects were evident in both groups, improvement of left ventricular function and decrease in left ventricular size were more pronounced in patients in whom chordal preservation was possible.

The concept of "direct mechanical ventricular assistance" in the treatment of left-ventricular failure. Part 1: Idea, development and construction of an implantable multi-chamber pump system partially surrounding the heart.

In this paper we present a therapeutic concept for the treatment of heart failure due to muscular inability to pump properly. The basic principle of this concept triggered numerous studies, then with the aim of cardiopulmonary resuscitation, back in the 1970s. In general, it dealt with mechanical systems which led to an increase in stroke volume, systolic blood pressure, and cardiac output through the application of pressure directly to the left ventricle. After a critical appraisal of the relevant literature from technical, physical, and medical viewpoints, and our own preliminary studies on animal hearts within the framework of mock circulation experiments, we have conceived a new functional principle for direct mechanical ventricular assistance based on squeezing the left ventricle only. We have begun development of the system which has the advantages of ease of use, high biocompatibility due to lack of contact between blood and system components, the prevention of infection through complete intrathoracic implantation (long-range goal), and the fact that the patient's own heart can be supported by the system without being removed from the circulatory system (support of the residual myocardial function). Technical as well as medical prerequisites are indicated, and the materials selection and construction principles of the control, pressure generation, pressure transduction, and ventricular compression unit are described. It has proved possible to construct a prototype system to be used in animal experiments, which, through pneumatic inflation of a chamber system partially surrounding the left ventricle, should be able to augment or take over the pumping function of the left ventricle.

Celite and kaolin produce differing activated clotting times during cardiopulmonary bypass under aprotinin therapy.

Since the introduction of the proteinase inhibitor aprotinin in cardiac surgery, a strong increase of the activated clotting time (ACT) during the extracorporeal circulation phase (ECC) was reported in many clinical studies, but with a lack of correlation between ACT and heparin concentration. In searching for a cause of this inconsistency we investigated different surface activators of the ACT in a clinical study. During ECC ACT was measured in parallel, using a Hemochron device and corresponding tubes (nominally 12 mg celite activator) for celite ACT, and a HemoTec device with corresponding double tubes (nominally 0.1 ml kaolin activator) for kaolin ACT. Under the conditions of ECC, the kaolin ACT values (482 +/- 145 sec) were significantly lower than the celite ACT values (985 +/- 267 sec). These results were confirmed in ex-vivo experiments using an activated partial thromboplastin time (aPTT) model. With heparin alone, aPTT activated with celite and kaolin were similar. Including aprotinin in this model, the celite aPTT showed no correlation to the heparin concentration, whereas the kaolin aPTT remained well correlated to the heparin concentration and similar to the values without aprotinin. With aprotinin alone there were no changes of the aPTT times, whereas the celite ACT times were without any correlation. Our results indicate that using kaolin instead of celite the ACT measurements under aprotinin therapy stay in the same ranges as without application of aprotinin: aprotinin has no detectable influence on kaolin-activated ACT. In our opinion, kaolin should be used as the surface activator for ACT measurements under the conditions of ECC, heparinization, and aprotinin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve replacement with preservation of the subvalvular structures where possible: an echocardiographic and clinical comparison with cases where preservation was not possible. Surgical technique and early postoperative course.

Mitral valve replacement (MVR) is still associated with a relatively high mortality. To prove the benefits of chordal preservation at mitral valve replacement, we investigated its effects in a series of 65 consecutive MVR patients. Of those patients, in 42 preservation of the mitral subvalvular structures was possible whereas in the other 23 they had to be excised. Both groups showed no differences in age, sex, preoperative NYHA class, and valve pathology. Intra- and postoperative management was similar in both groups. The surgical techniques employed are described and the early postoperative course of both groups are analysed. Clinical, electrocardiographic and echocardiographic investigations, measuring left-atrial and -ventricular diameters, right-ventricular diameters and left-ventricular length, demonstrated that whereas beneficial effects were evident in both groups, the amount of benefits was higher in patients with chordal preservation. Chordal preservation also provided less arrhythmias than chordal resection.

Subacute thrombotic complications after intracoronary implantation of Palmaz-Schatz stents.

Despite excellent results as a bail-out procedure for the management of abrupt closure after balloon angioplasty and the potential beneficial effects on restenosis after angioplasty, intracoronary stenting is limited, especially by subacute stent thrombosis. In 100 consecutive patients with intracoronary implantation of 118 Palmaz-Schatz stents, 10 patients (10%) developed subacute stent thrombosis during their hospital course 3 to 9 days after implantation. Therapy included intravenous thrombolysis, mechanical recanalization by balloon angioplasty, and emergency bypass surgery. Although successful recanalization was maintained in eight of nine nonsurgically treated patients within 2 hours after the onset of symptoms, seven patients developed myocardial infarction, with two patients having Q wave myocardial infarction and five patients having non-Q wave myocardial infarction. By univariate analysis, several variables could be identified as risk factors for the development of subacute stent thrombosis: bail-out implantations (odds ratio: 6.42; 95% confidence interval: 1.53 to 26.38; p = 0.007), unstable angina (12.32; 1.50 to 101.37; p = 0.006), long (5.44; 1.31 to 22.65; p = 0.015) and complex (type C) lesions (8.17; 1.93 to 34.50; p = 0.002) with large plaque areas (9.85; 1.96 to 44.51; p = 0.002), symptomatic postangioplasty dissections (4.36; 1.10 to 16.90; p = 0.029), incomplete wrapping of the dissection after stenting (6.50; 1.10 to 42.30; p = 0.039), and vessel irregularities distal to the stented segment (21.70; 4.12 to 113.18; p < 0.001). These variables, except the variable large plaque area, were confirmed as independent predictors of subacute stent thrombosis by a stepwise multivariate logistic regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Collaterals do not prevent infarcts in subacute vascular stenosis following initially successful vascular stent implantation]. / Kollateralen verhindern nicht Infarkte bei subakuten Gefässverschulüssen nach initial erfolgreicher Gefässstützen-implantation.

UNLABELLED: Sufficient collateralization may prevent acute myocardial infarction despite complete obstruction of a coronary artery. Nevertheless, it is unclear if collaterals which regressed after restoration of antegrade flow may be recruited fast enough to prevent myocardial infarction in case of subacute coronary artery thrombosis. In 50 patients (pts) (48 males, two females, age 60 +/- 7.6 years) with high-grade coronary artery stenosis and collaterals from the contralateral non-diseased coronary artery, stenting devices (Palmaz-Schatz) were implanted. In seven patients subacute thrombosis of the stent occurred. Six patients developed myocardial infarcts with a CKmax greater than 100 U/l (mean 943 +/- 635 U/l). One patient was treated by intravenous thrombolysis, three pts with acute PTCA, one patient with both, and one patient had CABG after unsuccessful PTCA; no patient died. There was no statistical correlation to the degree of collateralization and time after, or location of stent implantation, most likely because of the small number of cases. CONCLUSION: This retrospective study shows that collaterals in humans with a high-grade coronary artery stenosis which has regressed after restoration of sufficient antegrade blood-flow cannot be recruited fast enough to prevent myocardial necrosis in case of subacute coronary artery occlusion. This is in contrast to earlier results obtained in animal studies.