Atrial septal defect in adults: cardiopulmonary exercise capacity before and 4 months and 10 years after defect closure.

OBJECTIVES: The purpose of the study was to evaluate the cardiopulmonary exercise capacity and ventilatory function in adults with atrial septal defect (ASD) preoperatively and 4 months and 10 years postoperatively. BACKGROUND: Only few data are available on cardiopulmonary exercise tolerance after ASD closure, but detailed knowledge might be helpful for indication for defect closure in certain patients. METHODS: The study was performed in adult patients (mean [+/-SD] age at operation 39.9 +/- 11.5 years; left-right shunt 9.6 +/- 5.6 liters/min; pulmonary/systemic flow ratio 2.8 +/- 1.2; mean pulmonary artery pressure 18.2 +/- 6.2 mm Hg). Cardiopulmonary exercise testing was performed with a bicycle ergometer. We determined peak oxygen uptake, anaerobic threshold, performance at anaerobic threshold and maximal performance in relation to these variables in a normal group. Ventilatory function at rest was expressed by vital capacity, maximal voluntary ventilation and forced expiratory volume in 1 s. RESULTS: Preoperatively, ventilatory function at rest was only moderately reduced to approximately 75% to 85%. Four months postoperatively we found no significant improvement, but 10 years postoperatively ventilatory function at rest was normalized. Preoperative cardiopulmonary exercise capacity was markedly reduced to 50% to 60%; early postoperatively it was only slightly higher, but late postoperatively exercise capacity significantly improved and was completely normalized. CONCLUSIONS: Although preoperative cardiopulmonary capacity in adult patients with nonrestrictive ASD was significantly decreased, some improvement was seen at 4 months postoperatively, with complete restitution to normal at 10 years after shunt closure.

[X-ray diagnosis of thoracic aorta ruptures]. / Röntgenologische Diagnostik thorakaler Aortenrupturen.

One hundred and twenty-two patients were examined in order to diagnose, or for follow-up of, acute or chronic traumatic rupture of the thoracic aorta; sixty-two had arterial angiography, thirty-three had intravenous digital subtraction angiography, thirty-one had computer tomograms and seventeen were examined by ultrasound. In addition, plain films were evaluated in forty-two cases. The value of these methods in diagnosing acute or chronic aneurysms is analysed and discussed. Arterial angiography was the best method for acute aneurysms, whereas in the sub-acute and chronic stages CT and DSA are indicated.

[Peripheral pulsed laser angioplasty--4-year clinical experience]. / Periphere gepulste Laserangioplastie--Erfahrungen nach 4jährigem klinischen Einsatz.

In 134 patients, 21 iliac, 91 femoropopliteal and 22 crural arterial occlusions were treated by percutaneous laser-assisted angioplasty and in 32 patients femoropopliteal occlusions by conventional balloon angioplasty. Laser angioplasty could be performed in 126 patients following initial guide wire recanalisation using 9.7 and 4.5-F multifiber catheters, respectively. In 72 patients a 308-nm excimer laser and in 54 patients a 504-nm pulsed day laser was used. Luminal opening by laser angioplasty was obtained in 102 of 126 (81%) procedures (9 incomplete catheter passages, 15 persistent occlusions). 95% of iliac, 90% of femoropopliteal and 77% of crural recanalizations including supplemental balloon dilatations (n = 105) and stent implantations (n = 24) succeeded technically. Clinical success rates at 1 (2) years after angioplasty were 95% (89%) for iliac, 66% (63%) for femoropopliteal and 57% (50%) for crural treatments. Technical and clinical results of laser-assisted femoropopliteal recanalizations showed no significant differences in comparison to the results of conventional balloon angioplasty. The use of pulsed lasers for the treatment of peripheral arterial occlusive disease would require further technical improvements.

[CT-guided percutaneous lumbar sympathicolysis in peripheral arterial occlusive diseases]. / CT-gestützte perkutane lumbale Sympathikolyse bei peripherer arterieller Verschlusskrankheit.

Between June 1991 and November 1992, 36 patients with peripheral arterial occlusive disease were treated by CT-guided percutaneous lumbar sympathicolysis. Three months after the procedure, 39% claimed subjective improvement, 53% were unchanged and 8% were worse. Walking distance increased significantly from 86 to 167 m (p = 0.02). There was a comparable increase in walking distance between diabetics and non-diabetics. Comparison of one and two level procedures (each 50%) also showed similar increase in walking distance. There were no serious complications. The results justify the use of CT-guided percutaneous lumbar sympathicolysis in patients with peripheral arterial occlusive disease who are unsuitable for treatment by revascularisation. The procedure can be carried out on an outpatient basis and on otherwise inoperable patients and therefore has significant advantages compared with surgical sympathectomy.

[Spiral CT and CT angiography after coronary bypass surgery]. / Spiral-CT und CT-Angiographie nach koronarer Bypassoperation.

AIM: Evaluation of spiral-CT and CT-angiography for imaging of venous and arterial coronary bypass grafts during the early postoperative period. PATIENTS AND METHODS: In 198 patients suffering from coronary heart disease, 583 aortocoronary venous grafts (ACVG), 70 arterial grafts and 24 jumped grafts were investigated 9-15 days following coronary surgery. In 57 patients the results were compared to arterial DSA and reconstructive CT-angiography. RESULTS: At arterial DSA 93% of ACVG and 100% of arterial grafts were patent. Spiral-CT demonstrated 104 of 105 ACVG (99%) and 20 of 29 arterial grafts (69%) correct patent. All occluded ACVG (n = 8) were detected. 90% of ACVG but only 32% of arterial grafts were visualised completely over long segments. Imaging of jumped grafts was insufficient. In CT-angiography artificial vessel stenoses impaired correct visualisation of graft morphology. CONCLUSIONS: Spiral-CT allows sufficient differentiation of patent and obstructed ACVG during the early postoperative period. Diagnostic of arterial grafts is of lower accuracy. For CT angiography of venous and arterial coronary grafts further improvements are necessary.

Temporary wound covering with a silicon sheet for the soft tissue defect following open fasciotomy. Technical note.

OBJECTIVE: Temporary covering of a defect of the soft tissues with a silicon sheet after fasciotomy in the treatment of compartment syndrome. DESIGN: Retrospective study. SETTING: University Hospital, Tübingen. PATIENTS: From January 1991 to June 1996, open fasciotomy was performed a total of 18 times on 17 patients with compartment syndrome. In 17 of the 18 cases acute vascular ischemia was the cause of the compartment syndrome. INTERVENTIONS: For the 18 necessary fasciotomies, a silicon sheet was temporarily used to cover the defect of the soft tissue temporarily a total of 9 times. The silicon sheet was gradually drawn together and the wound was finally closed with a secondary suture. RESULTS: In 6 of the 9 cases a secondary suture could be performed without any difficulties after the swelling had subsided, and a meshgraft covering was not necessary. Only one patient suffered from wound infection because the silicon sheet had not been sutured correctly. In the other cases there was no sign of infection. The wound dressing was changed painlessly and furthermore, an improved cosmetic result was observed. CONCLUSIONS: There are considerable advantages in the use of a silicon sheet as a temporary covering for the defect of the soft tissues in the treatment of compartment syndrome: lower costs because of shorter hospitalisation and the dressing change is practically painless. A reduced risk of infection and improved cosmetic results are further advantages of this method.

Repair of symptomatic aortic coarctation in the first three months of life. Early and late results after resection and end-to-end anastomosis and subclavian flap angioplasty.

During a 9 year period between January 1977 and December 1985, 98 consecutive infants under 3 months of age underwent surgical repair of symptomatic aortic coarctation. Resection and end-to-end anastomosis was performed in 73, subclavian flap angioplasty in 14, and other procedures in 11 patients. There were 20 (20.5%) early and 12 (12.5%) late deaths. No early deaths occurred in the isolated coarctation group. Associated complex cardiac malformations and age under 2 weeks at operation influenced significantly early and late outcome but not any particular surgical procedure. The survivors were followed from 6 months to 8 years and 8 months postoperatively. There were 16 (28%) re-coarctations among 56 survivors after end-to-end anastomosis requiring re-operation in 7 (12%) infants and 3 (30%) re-coarctations among 10 survivors after subclavian flap angioplasty requiring re-operation in 1 infant. After end-to-end anastomosis re-coarctation as well as re-operation rate was markedly lower when an interrupted suture line for the entire anastomosis was used as compared to the group with a continuous suture line of the posterior aortic wall (21% vs. 33% re-coarctation rate and 4% vs. 18% re-operation rate respectively). From our results it is concluded that subclavian flap angioplasty for relief of aortic coarctation in early infancy is not superior to resection and end-to-end anastomosis. In the end-to-end anastomosis group an interrupted suture line has a lower re-coarctation as well as re-operation rate as compared to a continuous suture line of the posterior aortic wall.

[Arterial dominance of the hand]. / Arterielle Dominanz der Hand.

Arterial dominance in the hand was studied in 164 hands using digital pulse electronic oscillography (DPEO) and the Allen test. It was seen that the radial artery more frequently delivered the main blood supply to the digits (radial-ulnar dominance 12.8: 4.2%). The situation where no collateral circulation is present deserves special attention (absolute dominance). This was observed in 3% of the cases for the radial and in 1.2% for the ulnar artery. The Allen test was found useful in detecting ulnar artery dominance for the radial artery, however, false negative results may be obtained. In addition, 29 hands with a thrombosed radial artery were studied. No collateral circulation other than from the ulnar artery could be demonstrated. Since dominance of the ulnar artery is less common and can be reliably assessed with the Allen test, a forearm flap based on the ulnar artery appears to be safer than a radial forearm flap.

[Asymptomatic carotid stenosis: is surgical prevention of infarct still justified?]. / Asymptomatische Karotisstenose: ist die operative Insultprophylaxe noch gerechtfertigt?

The present retrospective study compared the incidence of TIA, stroke, and death in patients with asymptomatic carotid stenosis (greater than 50%) during a follow-up period of 24 to 30 months. 65 patients were operated and 193 treated medically. The incidence of death was comparable in both groups. Death in most patients was due to cardiac disease or cancer. The annual incidence of TIA and stroke was not different between the two populations. Despite the low incidence of perioperative complications (%) surgery of asymptomatic carotid stenosis cannot be recommended at the present time.

[Conservative therapy of arterial occlusive diseases. Double-blind study on the effect of butalamine hydrochloride]. / Zur konservativen Therapie arterieller Verschlusskrankheiten. Doppelbind-Studie zur Wirkung von Butalaminhydrochlorid.

In a double blind placebo-controlled trial the influence of butalamine-hydrochloride (Adrevil forte) in a daily dosage of 3 x 2 tablets on the exercise tolerance of muscles with impaired blood flow in the lower limb was evaluated. The drug was tested versus placebo in a total of 32 patients suffering from peripheral arterial insufficiency stadium II according to Fontaine with occlusions in one or both extremities. Clinical parameters measured were muscle ergometry, plethysmography as well as the assessment of the painfree walking distance. During the whole trial the systemic blood pressure was monitored. The group receiving the active drug showed already after two weeks therapy a statistically significant improvement in the walking distance. After the end of 8 weeks therapy the walking distance in the group under active drug therapy was increased 4 times. Measurements of perfusion also showed significantly higher values under active therapy. The systemic blood pressure was not affected during the 8 weeks therapy with Adrevil forte.

[Long-term results following aorto-femoral Y bypass. Doppler ultrasound pressure measurement, real-time ultrasound, CT and i.v. DSA]. / Langzeitergebnisse nach aorto-femoralem Y-Bypass. Doppler-Ultraschall-Druckmessung, Real-time-Sonographie, CT und i.v. DSA.

Five to seven years after aortoiliac prosthetic reconstruction 29 patients were examined by sonography (Doppler and real-time), CT and intravenous DSA. Doppler-sonography showed findings due to occlusion, stenosis and severe arteriosclerotic changing. By DSA these changing could be shown and exactly localised. CT demonstrated marginal thrombosis of the bypass lumen, aneurysms and fine paravascular fibrosis. So Doppler-sonography and DSA both bring functional and morphological, real-time sonography and CT morphological informations. The methods are complementary.

Neuropsychological functions after carotid endarterectomy.

Psychological testing was performed on 23 patients (mean age 60.7 years) with unilateral or bilateral stenoses of the carotid arteries prior to and 10 months after carotid endarterectomy. Intellectual functions were slightly improved, mnemic functions impaired, psychomotor functions and dimension of personality remained unchanged. Carotid endarterectomy, although improving neuropsychological functions in a few cases, on average does not cause a significant improvement. This underscores the preventive character of the surgical intervention.

Ultrasonographic follow-up of subclavian stenosis and occlusion: natural history and surgical treatment.

Continuous-wave Doppler ultrasonography and clinical examination were used over a 2-year period to monitor the natural history of subclavian stenoses and occlusions in 67 patients. Thirty-nine presented with subclavian steal and 28 without. We also studied an additional group of 29 patients who had undergone surgery for subclavian steal syndrome and vertebrobasilar transient ischemic attacks. The results, in terms of both ultrasonographic and clinical criteria, demonstrate the benign nature of the subclavian steal syndrome: all neurologic signs and symptoms were of a transient character. Spontaneous remission of vertebrobasilar transient ischemic attacks occurred in approximately 50% of the initially symptomatic patients, and only 15% of the initially asymptomatic patients experienced vertebrobasilar transient ischemic attacks during follow-up. Doppler ultrasonography revealed progression during follow-up in only 17% of the subclavian stenoses, and in 13% a stenosis was no longer detectable. Still-ongoing brainstem transient ischemic attacks were reported in 24% of the operated patients. The most important factor for the lack of improvement was the occlusion of the bypass. Continuation of transient neurologic symptoms could be observed in only 14% of the patients with intact carotid-subclavian bypass. In conclusion, indications for surgical treatment of the subclavian steal syndrome should be restricted to cases in whom vertebrobasilar transient ischemic attacks occur frequently and are either debilitating or greatly frighten the patient.

[Carotid endarterectomy for prevention of stroke: comparison of surgical and conservative therapy]. / Karotisendarterektomie zur Insultprophylaxe: Vergleich der operativen mit konservativer Therapie.

The incidence of TIA, stroke and death among 689 patients with a narrowing of the internal carotid artery exceeding 50% was investigated in a follow-up study. Patients were assigned according to their initial status to one of the following groups: asymptomatic, transient ischemic attacks (TIA) and minor stroke. Patients subjected to carotid endarterectomy (n = 206) were compared to those treated by oral medication only. The follow-up time averaged 2.1 years. The incidence of stroke and death among the initially asymptomatic persons was not significantly different in those who underwent surgery (n = 46) and those who did not (n = 234). The incidence of TIA however was significantly higher in the operated patients. Among patients with TIA the incidence of repeated TIA, stroke and death was similar in those who were operated (n = 90) and those who were not (n = 61). The same was true for subsequent TIA and strokes in patients who had suffered from a first stroke prior to the initial examination. Patients who underwent surgery (n = 70) did not differ in this respect from the 188 patients who were not operated on. The death rate, however, was significantly higher in the non-operated patients (24.5% versus 7.2%). Due to the retrospective character of the study, operated and non-operated groups of patients were not directly comparable. We therefore selected comparable groups of patients by a stratification procedure. These subgroups showed no differences in the incidence of TIA and stroke between operated and non-operated patients. The result indicates, that the decision to perform carotid endarterectomy should be made with great caution.

The sternocleidomastoid flap for treatment of a septic sternum defect.

After sternotomy for prosthetic repair of the ascending aorta and replacement of the aortic valve with a bioprosthesis in a 70-year-old woman local wound infection developed. Preliminary conservative treatment did not succeed. Because of the high risk for the patient due to local infection and partial exposure of the aortic prosthesis there was an indication for local flap surgery. Both healing of the infection and covering the prosthesis was achieved using a sternocleidomastoideus muscle flap.