Late recurrence of a cardiac glomus tumor.

Glomus tumors, also known as paragangliomas or chemodectomas, arise from well-differentiated mesenchymal cells that are known to be benign. These tumors account for 2% of all soft tissue tumors. The first case of a cardiac glomus tumor was reported in 1924 by Masson.1 Glomus tumors located within the pericardial tissue are extremely rare. We present the case of a recurrent cardiac glomus tumor. The preoperative investigation, diagnostic problems and surgical treatment of this case will be highlighted. Moreover we wish to emphasize the importance of such an entity and to remind readers that it must be included in the differential diagnosis of a pericardial tumor.

Impact of quality of life parameters and coping strategies on postchemotherapy nausea and vomiting.

To assess whether prechemotherapy quality of life (QoL) factors and certain coping strategies are associated with postchemotherapy nausea and vomiting (PCNV). A total of 43 chemotherapy-naïve patients scheduled to receive anti-emetic prophylaxis were enrolled in this study. QoL parameters were measured by a modified EORTC Quality of Life Questionnaire (QLQ-30). In addition, questions regarding active or passive coping strategies were asked 1 day before chemotherapy. Prechemotherapy QoL factors, coping strategies as well as other patient, disease and treatment variables were compared between the groups of patients with or without PCNV. The univariate analysis identified four QoL parameters, 'tiredness', 'impairment of daily life by pain', 'sensation of abdominal pressure and fullness' and 'impairment of social activities' as associated with PCNV. No association was found between coping strategies and PCNV. In the multivariate analysis, the factors 'impairment of social activities' and 'sensation of abdominal pressure and fullness' remained significant. Specific pretreatment QoL parameters are associated with the risk to develop PCNV. Thus, in addition to other established risk factors for PCNV, patients should be screened for these QoL factors in order to improve the control of PCNV and facilitate the selection of appropriate, individualised anti-emetic prophylaxes.

[Unusual cause of Staphylococcus aureus septicemia in a 79-year-old male patient]. / Ungewöhnliche Ursache einer Staphylococcus-aureus-Septikämie bei einem 79-jährigen Patienten.

High grade fever in the context of Staphylococcus aureus bacteremia led to hospital admission of a 79 year old male patient. A covered perforation of the ascending aorta resulted in the formation of a pseudoaneurysm which was complicated by superinfection caused by hematogenic spread of Staphylococcus aureus. The infected pseudoaneurysm found per continuitatem contact to the pericardium and resulted in bacterial pericarditis. Antibiotic pretreatment was followed by operation with a complex procedure including resection of pseudoaneurysm and suture closure of the perforation site.

Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

Preischemic iloprost application for improvement of graft preservation: which route is superior in experimental pig lung transplantation: inhaled or intravenous?

BACKGROUND: Optimal allograft protection is essential in lung transplantation to reduce postoperative organ dysfunction. Although intravenous prostanoids are routinely used to ameliorate reperfusion injury, the latest evidence suggests a similar efficacy of inhaled prostacyclin. Therefore, we compared donor lung-pretreatment using inhaled lioprost (Ventavis) with the commonly used intravenous technique. METHODS: Five pig lungs were each preserved with Perfadex and stored for 27 hours without (group 1) or with (group-2, 100 prior aerosolized of iloprost were (group 3) or iloprost (IV). Following left lung transplantation, hemodynamics, Po(2)/F(i)o(2), compliance, and wet-to-dry ratio were monitored for 6 hours and compared to sham controls using ANOVA analysis with repeated measures. RESULTS: The mortality was 100% in group 3. All other animals survived (P < .001). Dynamic compliance and PVR were superior in the endobronchially pretreated iloprost group as compared with untreated organs (P < .05), whereas oxygenation was comparable overall W/D-ratio revealed significantly lower lung water in group 2 (P = .027) compared with group 3. CONCLUSION: Preischemic alveolar deposition of iloprost is superior to IV pretreatment as reflected by significantly improved allograft function. This strategy offers technique to optimize pulmonary preservation.

Neonatal screening for hearing disorders in infants at risk: incidence, risk factors, and follow-up.

OBJECTIVE: To determine the incidence and risk factors for hearing disorders in a selected group of neonates and the feasibility of selective hearing screening. SETTINGS: Multicenter prospective trial at five centers in Germany. METHODS: Enrollment criteria: in addition to previously defined risk factors by the Joint Committee on Infant Hearing (family history of hearing loss, in utero infections, craniofacial anomalies, birth weight <1500 g, critical hyperbilirubinemia, ototoxic medications, bacterial meningitis, postnatal asphyxia, mechanical ventilation >5 days, stigmata, or syndromes associated with hearing loss), the impact of maternal drug abuse, birth weight <10th percentile, persistent pulmonary hypertension, and intracranial hemorrhage more than or equal to grade III or periventricular leukomalacia on infant hearing were evaluated. The screening procedure was performed by automated auditory brainstem response (A-ABR; ALGO 1-plus; Natus Med Inc, San Carlos, CA). STATISTICS: univariate analyses of risk factors versus A-ABR results and a multivariate regression analysis were used; additionally, the total test time was recorded. RESULTS: Seven hundred seventy recordings from 777 infants enrolled consecutively constitute the basis of this analysis. Mean gestational age was 33.8 +/- 4.3 weeks, birth weight 2141 +/- 968 g; 431 infants being male and 339 female; 41 (5.3%) infants exhibited pathologic A-ABR results (16 bilateral and 25 unilateral). Meningitis or sepsis, craniofacial malformations, and familial hearing loss were independent significant risk factors. Median total test time was 25 minutes. Follow-up examinations in 31 infants revealed persistent hearing loss in 18 infants (13 infants sensorineural, 5 from mixed disorders), 7 requiring amplification. CONCLUSION: Hearing screening in high-risk neonates revealed a total of 5% of infants with pathologic A-ABR (bilateral 2%). Significant risk factors were familial hearing loss, bacterial infections, and craniofacial abnormalities. Other perinatal complications did not significantly influence screening results indicating improved perinatal handling in a neonatal population at risk for hearing disorders.

Impact of PAF antagonist BN 52021 (Ginkolide B) on post-ischemic graft function in clinical lung transplantation.

BACKGROUND: Platelet activating factor (PAF) is associated with ischemia/reperfusion injury (I/R) after lung transplantation. Following promising experimental results, this prospective trial investigated the potential effect of PAF antagonist BN 52021 (ginkolide B) on clinical Euro-Collins (EC)-based lung preservation. METHODS: We analyzed 8 double-lung transplant patients in each of 3 groups. In the low-dose group (LDG), donor lungs were perfused with EC containing 2 mg/kg BN 52021, whereas we used 10 mg/kg in the high-dose group (HDG) and placebo in the control group (CG). Before reperfusing the first lung, we administered intravenously 120 mg BN 52021 (LDG), 600 mg BN 52021 (HDG), or placebo (CG). Hemodynamics in terms of pulmonary arterial pressure, pulmonary vascular resistance and serial determinations of the alveolo-arterial oxygen difference (AaDO(2)) were recorded. We measured blood levels of PAF pre-operatively and post-operatively, after 10 minutes and after 3, 8, 24, 48, and 144 hours. RESULTS: Within 32 hours, we noted a tendency toward better AaDO(2) in the LDG and the HDG compared with the CG (p > 0.05). We observed a significant improvement of AaDO(2) after 3 hours (HDG, p = 0.033) and 8 hours (LDG, p = 0.024), with poorest values in the CG. The PAF concentrations were lowest in the HDG, with significant deterioration 10 minutes after reperfusion. In contrast, placebo led to higher PAF levels. We measured significantly lower PAF concentrations (HDG vs CG) at 10 minutes and at 6 days post-operatively. CONCLUSIONS: Use of high-dose PAF antagonist BN 52021 can easily be combined with clinical preservation methods and may help optimize pulmonary function with reduced PAF levels, in the early post-ischemic period.

In vivo morphology of woven, collagen-sealed Dacron prostheses in the thoracic aorta.

BACKGROUND: Long-term changes in knitted Dacron grafts inserted into the infrarenal aorta have been addressed by a number of studies indicating their potential for postoperative dilatation. In contrast, the behavior of woven, collagen-presealed, double-velour Dacron grafts used to replace the thoracic aorta is not known. METHODS: Forty-five patients were examined at a mean of 32.4 +/- 14.8 months after insertion of woven, collagen-coated, Dacron double-velour prostheses (Meadox woven with Hemashield, Meadox, Oakland, NJ) in the thoracic position under highly standardized conditions using spiral computed tomography. RESULTS: Compared with a manufactured diameter of 26 mm, all grafts showed an increase of 1 to 5 mm (mean, 3.0 +/- 1.2 mm [11.6% +/- 4.4%]; p < 0.0001) with greater enlargement of the ascending than of the descending aortic portions (p = not significant). A further statistically significant progressive dilatation failed to occur. Degenerative changes, including false aneurysm formation, could be excluded. CONCLUSIONS: Woven, collagen-coated Dacron prostheses are considered a safe replacement material for the thoracic aorta.

Aerosolized iloprost for severe pulmonary hypertension as a bridge to heart transplantation.

Preexisting pulmonary hypertension in pediatric patients is associated with poor outcome after cardiac transplantation because of donor right ventricular dysfunction. To avoid a combined heart-lung transplantation in a 17-year-old patient, we used an intensified pretreatment with intravenous prostacyclin and dobutamine combined with an inhalative therapy with the aerosolized prostacyclin-analog Iloprost. With this regimen, the patient was hemodynamically stabilized for the waiting period of 21 days after which an uneventful cardiac transplantation was performed.

Retrograde versus antegrade crystalloid cardioplegia in coronary surgery: value of troponin-I measurement.

BACKGROUND: The optimal route for delivery of cardioplegia is still in debate in patients with ischemic heart disease. Cardiac troponin-I is a new marker with the potential for detection of minor differences in myocardial ischemia. METHODS: In a prospective randomized trial 58 patients undergoing elective coronary artery bypass grafting for two- or three-vessel coronary artery disease were divided into groups with antegrade (group A, n = 29) and retrograde (group R, n = 29) application of crystalloid cardioplegia (St. Thomas II). Patients with major risk factors were excluded. In addition to routine electrocardiogram monitoring, cardiac troponin-I and creatine kinase-MB activity were measured in all patients preoperatively at 2, 5, 8, 24, and 48 hours after aortic cross-clamp release, and at hospital discharge. RESULTS: In both groups, there were no differences regarding operative parameters. A significantly higher cardiac troponin-I concentration was observed in the antegrade group at 24 hours after cross-clamp (8.2 +/- 8.5 microg/L vs 3.2 +/- 3.1 microg/L; p = 0.02). Patients with subtotal stenosis or occlusion of one or more main coronary arteries showed significantly lower cardiac troponin-I levels after retrograde application. CONCLUSIONS: Lower concentrations of the cardiac troponin-I marker after retrograde application of cardioplegia indicate advantages of myocardial protection in ischemic heart disease.

Ten year survival after heart transplantation: palliative procedure or successful long term treatment?

OBJECTIVE: To investigate the long term outcome and prognostic factors after heart transplantation. SETTING: University hospital. SUBJECTS: 120 heart transplant patients (98 male, 22 female; underlying disease: dilated cardiomyopathy in 69, coronary artery disease in 42, miscellaneous in nine) who had undergone heart transplantation between October 1984 and October 1987. Immunosuppressive treatment was comparable in all patients and rejection episodes were treated in a uniform manner. METHODS: Functional status, quality of life, and potential predictors for long term survival were investigated. RESULTS: Actuarial survival rates were 65% at five years and 48% at 10 years; 58 patients survived > 10 years. The major causes of death were cardiac allograft vasculopathy (39%), acute rejection (18%), infection (11%), and malignancy (11%). Long term survivors had good exercise tolerance assessed by the New York Heart Association classification: 47 (81%) in grade I/II; 11 (19%) in grade III/IV. Echocardiography showed good left ventricular function in 48 patients. On angiography, severe allograft vasculopathy was present in only 16 patients (28%). Renal function was only slightly impaired, with mean (SD) serum creatinine of 148.5 (84.9) micromol/l. Multiple potential predictors of long term survival were analysed but none was found useful. CONCLUSIONS: Heart transplantation represents a valuable form of treatment. Survival for more than 10 years with a good exercise tolerance and acceptable side effects from immunosuppression can be achieved in about 50% of patients.

Ionization constants and distribution coefficients of phenothiazines and calcium channel antagonists determined by a pH-metric method and correlation with calculated partition coefficients.

The pH-metric technique was used to determine the ionization constants and distribution coefficients of 10 phenothiazines and five ionizable calcium channel antagonists. Because the studied compounds were poorly water soluble and quite lipophilic with partition coefficients in the range of 3.5 to 5.5, organic cosolvents had to be added for the determination of the ionization constants to avoid precipitation of the free bases. The effect of the cosolvents dioxane and methanol on the extrapolation to pure water was compared. For both cosolvents a very good agreement with accessible published ionization constants was obtained, however the slope of the regression line was much smaller for dioxane, yielding more reliable estimates according to the standard deviation of the extrapolated values. Thus, dioxane might be preferable to methanol as a cosolvent for the determination of ionization constants of sparingly water soluble bases. Also the n-octanol/water partition coefficients were determined and compared with published data and values calculated with the ClogP, ACD, and HINT programs. Although the obtained values were approximate in conformity with the published data, the calculated partition coefficients differed from the experimental ones considerably for the majority of the investigated compounds. Furthermore, the ion pair partitioning and the distribution coefficients at physiological pH 7.4 were determined. The pH-dependent distribution profiles showed the strong influence of the ionization constants and of the distribution of the ion pairs on the overall distribution. This result strongly suggests that greater use should be made of measured distribution coefficients in quantitative structure-activity relationship studies. The potentiometric method is a convenient way to determine the distribution properties of drug molecules at pH values relevant for the biological system under investigation.

Temporary distal occlusion for non-pharmacological preconditioning of harvested internal mammary artery grafts.

Perioperative spasm of the internal mammary artery (IMA) may result in early restriction of bypass flow. Therefore, pharmacological pretreatment is usually suggested. We present a technique of temporary distal occlusion of the transsected IMA using a metal clip. After 1 hour of storage in normal saline (SAL) there were significantly better flow rates compared with proximal application of a bull-dog clamp. No further increase in flow was noticed after submersion of the IMA pedicle in verapamil (VER). This technique easily provides sufficient IMA flow at the time of anastomosis, probably due to continuous endoluminal dilatation of the IMA by blood pressure, and thus avoids pharmacological pretreatment with vasodilators.

Renal carcinoma with caval vein infiltration and triple coronary disease: one-stage surgical management.

We report the one-stage surgical management in a 68-year-old patient with a renal cell carcinoma with extended intravascular growth into the inferior vena cava combined with severe triple coronary artery disease. After nephrectomy the resection of the intravascular tumor and caval reconstruction were performed in deep hypothermic circulatory arrest. Coronary revascularization was accomplished while rewarming. The postoperative course was uneventful. Nine months after this operation there are no signs of reoccurrence.

Lung transplantation--10-year experience.

OBJECTIVE: The experience at our institution with various forms of lung transplantation (heart-lung, double lung and single lung) from December 1987 to September 1998 is reviewed and discussed. METHODS: During this decade, 282 procedures (46 heart-lungs (HLTx), 142 double lungs (DLTx) and 94 single lungs (SLTx)) have been performed in 258 patients (140 male, 118 female; age: 38 +/- 13 years). Major indications included pulmonary fibrosis (n = 73), obstructive lung disease (n = 55), cystic fibrosis (n = 48), primary pulmonary hypertension (n = 36), secondary pulmonary hypertension (majority Eisenmenger's syndrome) (n = 30), and retransplantation (n = 24). RESULTS: Early postoperative mortality (<90 days) was 13.9% (n = 36). The 1-, 3-, and 5-year survival rates in all recipients was 77, 70 and 63%, respectively. There was no significant difference in 1-year survival rates between the different procedures (HLTx: 78%, DLTx: 77%, SLTx: 77%). Significantly better 1-year survival was achieved in patients with cystic fibrosis (89%), pulmonary fibrosis (81%), obstructive lung disease (74%), and Eisenmenger's syndrome (83%) when compared to patients with primary pulmonary hypertension (55%). Survival rates remained unchanged during this period despite expanding indications during the last years. Causes of death in 90 recipients (HLTx: n = 19, DLTx: n = 37, SLTx: n = 34) included sepsis (n = 42), obliterative bronchiolitis (n = 28), cardiac failure (n = 5), and early allograft dysfunction (n = 2). Freedom from bronchiolitis obliterans syndrome (BOS) (>stage I ISHLT) was 80% at 1 year and 45% at 5 years. CONCLUSIONS: Lung transplantation offers a true therapeutic option with good early and midterm results. Yet, chronic graft dysfunction represents a major obstacle for long-term benefit of this procedure.

Ten years experience with lung and heart-lung transplantation in primary and secondary pulmonary hypertension.

OBJECTIVE: Patients with primary pulmonary hypertension (PPHT) have a worse natural outcome compared with those with secondary pulmonary hypertension in Eisenmenger's syndrome (ES) and chronic pulmonary embolism (CPE). Lung transplantation (SLTx, DLTx, HLTx) still remains the only therapeutical option for patients with this type of endstage lung disease. METHODS: From 1988 to 1998, 63 patients underwent lung transplantation for PPHT (n=29, 9 m, 20 f, 2 SLTx, 14 DLTx, 13 HLTx), ES (n=29, 13 m, 16 f, 2 SLTx, 3 DLTx, 24 HLTx) or CPE (n=5, 2 m, 3 f, 1 SLTx, 2 DLTx, 2 HLTx). Groups were comparable for NYHA functional class, preoperative pulmonary arterial pressure, recipient and donor age, ischemic time, necessity and duration of cardiopulmonary bypass and cross-match. RESULTS: The 1-, 3- and 5-year survival was 52, 40 and 35% for the PPHT-group, 83, 78 and 74% for the ES-group and 80, 60 and 60% for the CPE-group, respectively (P=0.026, P=0.033, P=0.082 for 1-, 3- and 5-year survival). Patients following DLTx showed a lower 1-year survival rate as compared with patients after HLTx both in PPHT patients (36 vs. 62%, P=0.091) and in ES patients (67 vs. 83%, P=0.213). The incidence of bronchiolitis obliterans syndrome was 29% at 1 year and 45% at 3 years for the PPHT-group vs. 17 and 65% for the ES-group (n. s. in between groups). Excluding postoperative ventilation time (PPHT-group: 26.8+/-24.0 days vs. ES-group: 16.1+/-30.8 days, P=0. 011) and a higher incidence of infectious causes of death (PPHT-group n=8 vs. ES-group n=1, P=0.017) groups were comparable with regard to their postoperative courses. CONCLUSIONS: It is concluded, that predominantly the underlying primary disease influences graft survival after lung transplantation in patients with pulmonary hypertension compared with all other patient and procedure dependent factors. Lung transplantation in patients with PPHT requires further investigations to achieve results comparable with other indications.

Coronary artery bypass grafting surgery without the routine application of blood products: Is it feasible?

OBJECTIVE: Fresh frozen plasma (FFP) substitution is currently standard practise in cardiac surgery. In this study we investigate whether elective coronary artery bypass grafting (CABG) surgery is feasible without the administration of blood products compared to the substitution of fresh frozen plasma. PATIENTS AND METHODS: From September 1997 to April 1998, 120 consecutive patients underwent CABG surgery at our institution. In the FFP group patients (n=60; men, n=43; women, n=17; mean age: 64+/-8.5 years) received 4 units of fresh frozen plasma (FFP) intraoperatively. In comparison, patients in the control group (n=60; men, n=44; women, n=16; mean age: 65+/-7.5 years) did not receive FFP. Main endpoints included perioperative hematologic parameters, blood loss, and the amount of blood products that were administered. RESULTS: Intraoperatively, the substitution of packed red blood cells (pRBC) in the FFP group was significantly higher compared with the control group (0.63+/-0.94 units/patient vs. 0.12+/-0.38 units/patient, P=0.001). Postoperatively, patients in the FFP group required significantly more pRBC products than patients in the control group (0.78+/-1.09 vs. 0.42+/-0.77, P=0.024). There were no significant differences in hemoglobin (FFP group: 99+/-11.1 g/dl; control group: 105+/-13.5 g/dl) and hematocrit levels (FFP group: 30+/-3.39%; control group: 32+/-4%). Also, no significant differences regarding the postoperative blood loss was observed between groups (FFP group: 588+/-224 vs. control group: 576+/-272 ml/24 h). CONCLUSIONS: This study clearly demonstrates that the avoidance of routine intraoperative FFP administration does not lead to an increase in blood loss postoperatively compared to patients that received FFPs. Furthermore, we did not observe increased requirements for postoperative FFP infusion in patients that did not receive FFPs intraoperatively.

Bland-White-Garland syndrome. Surgical treatment using a minimal-invasive approach.

We report the surgical treatment of a Bland-White-Garland syndrome (BWG-syndrome) of adult type in a 61-year old female patient. Coronary catheterization revealed an anomalous origin of the left coronary artery from the trunk of the pulmonary artery. Based on excellent collateral perfusion of the artery from the right coronary artery, ligation near its origin from the pulmonary artery was attempted via a minimally-invasive approach. No saphenous vein bypass was implanted, no reimplantation of the anomalous vessel in the aorta was performed. The patient recovered uneventfully without signs of ischemia. Appearance of BWG-syndrome in adults is very rare, especially without symptoms of myocardial ischemia. The different modalities of the treatment of these syndromes in adult patients are often debated. In this case, closure without revascularisation appeared to be appropriate.

[Aorto-iliac reconstruction after kidney transplantation with in situ transplant perfusion with HTK solution]. / Die aortoiliakale Rekonstruktion nach Nierentransplantation unter In-situ-Transplantatperfusion mit HTK-Lösung.

A case report of a 57 year old male is presented, who underwent kidney transplantation in 1987. Subsequently he developed arterial occlusive disease. A bifurcated prosthesis was implanted and the graft preserved by in-situ-perfusion with HTK-solution (Custodiol). The graft artery was anastomosed in an end to side fashion to the prosthesis. The postoperative course was uncomplicated with unimpaired renal function. We conclude that in-situ-perfusion with cold HTK-solution represents a simple method for kidney graft protection during reconstructive vascular procedures.