Palliative Care teaching in Germany - concepts and future developments.

BACKGROUND: Following recent modifications of the Medical Licensure Act (ÄApprO) in the year 2009, palliative care was introduced as a compulsory 13(th) cross-disciplinary subject (Q13) in the undergraduate curriculum. Its implementation must have taken place before the beginning of the final year ('practical year') in August 2013 and has to be substantiated for the medical exams taking place in October 2014. Very diverse structures pertaining to palliative care teaching were described in previous surveys at various medical faculties in Germany. As a result, the current and future plans and concepts related to content and exams of a mandatory Q13 course at the respective faculty sites should be ascertained. METHODS: Since 2006, the German Medical Students' Association (bvmd) has been carrying out a bi-annual survey at all medical faculties in Germany regarding the current situation of teaching in the field of palliative care. After designing and piloting an online survey in May 2010, a one-month online survey took place. The data was assessed using a descriptive approach. RESULTS: 31 of 36 medical faculties took part in the survey. At the time of questioning, 15 faculties already taught courses according to the requirements of the new ÄApprO; at three sites the Q13 is yet to be introduced commencing in 2012. A teaching curriculum for Q13 already existed at 15 faculty sites, partly based on the curricular requirements of the German Association for Palliative Medicine (DGP). Six sites described an implementation process as yet without an independent curriculum. Most of the faculties aim for 21-40 course hours, which will for the most part be provided as lectures, seminars or less often in more assisted and intense formats. The majority of the participating faculties intend an examination containing multiple choice questions. At 8 universities there is an independent Chair for palliative medicine (5 more are planned); this was linked with a higher degree of mandatory teaching in alignment with the requirements of the ÄApprO. A broad spectrum of educationally-involved occupational groups, specialist disciplines and external co-operating partners, were mentioned. CONCLUSION: The infrastructural prerequisites of the present curricular concepts and the degree of implementation of the Q13 according to the requirements of the new ÄApprO diverge significantly among the various medical faculties. The efforts made to produce a qualitatively high standard of teaching with regard to the multifaceted questions concerning the support for severely and terminally ill patients is as much reflected in the survey, as the special implications of an independent Chair for palliative medicine for the implementation of the requirements by law. The participation of various occupational groups in this survey as well as the broad spectrum of those involved highlights the interdisciplinary and multi-professional dimension of teaching in palliative care.

Age determines vascular reactivity as measured by optical rhinometry.

BACKGROUND: Endonasal blood volume depends on autonomous nervous system activation and ultimately vascular reactivity. It can be measured by optical rhinometry, a simple- to-use, subject-compliance independent method. We investigated endonasal perfusion following postural change to determine predictors of vascular response. MATERIALS AND METHODS: Optical rhinometry was performed in 52 healthy subjects (25 women) with an age range of 21-80 years. Subjects were placed in supine position after 5 min of standing. Optical density (OD) as marker of endonasal blood volume was continuously measured for 30 min after postural change. In addition to age, data on other risk factors for impaired vascular reactivity, such as gender, smoking, level of physical activity, resting heart rate and blood pressure were obtained. To evaluate raw-data curves, integrals over defined time-periods were calculated. RESULTS: The OD initially increased following the intervention (t(max) at 207 +/- 12 s, mean +/- SEM). Thereafter, a gradual return to baseline levels was observed in young but not in elderly subjects. In multivariate models, age was the most influential parameter for vascular response followed by body mass index. The defined integrals as indicators of curve structure were all significantly influenced by age (P < 0.01 for each interval). Other measured risk factors had no effect on curve characteristics. CONCLUSIONS: Age is an important predictor of endonasal perfusion. Evaluation of optical rhinometry needs to take age-dependency of results into account. Studies in patients with cardiovascular disease are needed to show if optical rhinometry can provide information about vascular responsiveness as a predictor of cardiovascular morbidity.

Coronary artery revascularization using both ITAs as free conduits in patients with three-vessel disease--the lambda graft.

BACKGROUND: There is little information on using internal thoracic arteries (ITA) as free conduits in coronary artery bypass grafting. This study examines the results using both ITAs as free grafts in a lambda configuration implanting the common trunk into the ascending aorta. METHODS: Over a 6-year period, 317 patients underwent coronary artery revascularization with both ITAs as free grafts in a lambda configuration. RESULTS: An average of 4.9 distal anastomoses per patient was performed. There were 4 deaths (three early and one late). The mean NYHA class improved from preoperatively 2.8 to 1.1 at the last check. All 16 patients with suspected recurrent angina or a pathologic exercise test were restudied by angiography. Segmental graft stenosis or occlusion was found in 13 (in only one at aortic anastomosis). Five patients underwent late PTCA, and two underwent coronary reoperation. The six-year actuarial survival was 98% (90 % CL+/- 2 %), intervention-free survival 96 % (90 % CL +/- 2 %). CONCLUSION: Revascularization using both ITAs as free grafts in a lambda configuration gives good early and mid-term results for up to 6 years. The aortic ITA anastomosis can be considered safe.

[Abdominal aortic aneurysms. Results of surgical treatment from 1987 to 1998]. / Das Bauchaortenaneurysma. Resultate der chirurgischen Behandlung von 1987 bis 1998.

Conventional open surgery for abdominal aortic aneurysm has recently been challenged by a closed transfemoral approach for repair (stent-graft). The presented data over the past eleven years after open surgery for graft implantation are intended to serve for comparison with future results after transfemoral graft placement. In addition, it is the purpose of this study to investigate the prognostic importance of treatment of concomitant coronary artery disease. Early mortality of all 195 consecutive patients with abdominal aortic aneurysm repair was 1.5%; it was 0.6% after elective repair for infrarenal aneurysm and not dependent on the presence of coronary artery disease if the latter was treated. Late outcome, however, related closely to coronary artery disease as a major risk factor. Late graft complications are extremely rare and occurred only once (graft thrombosis). Incisional hernias and impotence in male patients are non-lethal complications affecting quality of life. Open surgical repair of abdominal aneurysm is safe, and long-term, complication-free survival is good. Coronary artery disease is the most frequent concomitant disease and major risk factor requiring close observation and treatment. These results need to be matched by the new transfemoral graft implantation technique before broad application of the latter.

[Surgery of mitral valve insufficiency. Results of 10 years]. / Die Chirurgie der Mitralinsuffizienz. 10-Jahres-Resultate.

From 1987 to 1996 we operated on 263 patients for mitral insufficiency. Multiple valve operations were excluded, with the exception of tricuspid reconstruction for functional regurgitation. The perioperative mortality was 3%, while the late mortality rate during a mean follow-up period of 3.5 years amounted to 2% per patient year and 1.7% if only cardiac causes were considered. The prognosis for patients with rheumatic, endocarditic and ischemic valvular disease was much worse compared to that for a degenerative cause. The latter group consisted of 209 patients with an operative mortality of 1.4% and a late mortality rate per patient year of 1.4% and 0.9% for cardiac causes only. Further analysis showed a significant prognostic improvement for patients with a preoperative ejection fraction of more than 60% and a repairable valve.

[Cerebral insult in heart surgery]. / Der zerebrale Insult in der Herzchirurgie.

The aim of the study was to identify causes for perioperative stroke in cardiac surgery in order to reduce its occurrence. From 1989 to 1994, 3593 open heart operations were performed in adult patients. In 59 patients carotid endarterectomy for high grade stenosis was combined with the cardiac operation. There were a total of 68 (2%) focal strokes, 41 of which were considered minor and 14 major; 13 were lethal. The etiology of the 27 major and lethal events was most probably an embolus from the ascending aorta (6), from the ascending aorta or a cardiac valve (5), a thrombus in the left heart (6), air (1), cardiac arrest and resuscitation (4), cerebral hemorrhage (1), preoperatively unknown but high grade internal carotid stenosis (3), and a 50% stenosis of both internal carotid arteries preoperatively known but not operated on (1). There were 2 minor but no major neurologic complications in patients undergoing a combined carotid and cardiac procedure. A wide indication for preoperative neuroangiologic examination, echocardiography and careful intraoperative management may help to identify sources of possible emboli. Endarterectomy of high grade carotid stenosis is recommended simultaneously with the cardiac procedure.

Pressure gradients across bileaflet aortic valves by direct measurement and echocardiography.

BACKGROUND: Pressure gradients calculated from echo-cardiography after aortic valve replacement are commonly much higher than would be expected from in vitro measurements. METHODS: The mean, peak-to-peak, and maximal gradients across bileaflet aortic prostheses (St. Jude Medical) were measured invasively in 52 patients at high and low heart rate, cardiac index, and stroke volume. One week after operation the gradients were calculated from a standard transthoracic echocardiogram (delta p = 4v2(2)). In a second study 3 to 12 months later, gradients were calculated using the standard, simplified Bernoulli equation, and with the equation considering subvalvular flow velocities (delta p = 4(v2(2-)v1(2)). Invasive and echocardiographic measurements were matched and compared. RESULTS: Invasively measured mean gradients for 21 to 29-mm valves ranged from 7.4 +/- 4.9 to 4.3 +/- 1.6 mm Hg at systolic flow rates from 11.3 +/- 0.7 to 16.2 +/- 1.8 L.min-1.m-2. Mean echocardiographic gradients were 15.1 +/- 4.5 to 7.5 +/- 2.2 mm Hg (p < 0.001) with the standard method, and 10.5 +/- 1.9 to 5.6 +/- 1.5 mm Hg when considering the subvalvular flow velocity (p < 0.001). CONCLUSIONS: Mean gradients across bileaflet prostheses are generally low, even in small valves and with high systolic flow. The correlation of the invasive in vivo with in vitro gradients is good. Standard echocardiography overestimates gradients across bileaflet heart valves and high gradients are not due to valve dysfunction. Gradients obtained by echocardiography considering the subvalvular flow velocity correlate better to invasively measured and in vitro gradients.

Effect of residential cardiac rehabilitation following bypass surgery. Observations in Switzerland.

BACKGROUND: Cardiac rehabilitation in central Europe traditionally involves isolating patients in a residential idyllic setting where exercise is performed frequently but in a relatively unstructured fashion. Few studies have been performed on the effects of these programs among patients who have undergone bypass surgery. Recent data suggest that postbypass patients may enter these programs too soon after surgery or that exercise is not structured enough to distinguish the benefits of rehabilitation from those experienced by a control group. METHODS: Forty-two male patients (mean age, 58 +/- 7 years) were divided into exercise and control groups approximately 1 month after undergoing bypass surgery. Exercise training consisted of 1 h of group walking twice daily, with the intensity stratified into four levels based on initial exercise capacity. Using a crossover design, patients in the exercise group participated in rehabilitation for 1 month, followed by 1 month of usual care, while control patients underwent the opposite sequence. At 1, 2, and 3 months, patients in both groups underwent pulmonary function testing and maximal ramp exercise testing using lactate and gas exchange analysis. RESULTS: A main effect for maximal oxygen uptake was observed; significant improvements within each group occurred across each testing period (range, 5 to 13%; p < 0.05). However, there was no significant interaction between groups. Mean lactate levels throughout exercise were reduced within both groups (p < 0.01). A reduction in oxygen uptake for test 2 at the lactate threshold in the exercise group resulted in differences between groups in lactate, heart rate, and other gas exchange variables at this point. CONCLUSION: Similar changes occur in the functional status of postbypass surgery patients regardless of their participation in the short but concentrated programs common in central Europe. This suggests that a significant spontaneous effect of healing occurs in the recovery phase after surgery. These programs may have greater efficacy if they began later after surgery, lasted longer, or were more structured, and studies are needed to determine their effect on psychosocial factors and return to work.

Influence of coronary artery bypass grafting on ventricular late potentials as a predictive factor for ventricular arrhythmias during short- and long-term follow-up.

UNLABELLED: Ventricular late potentials have been identified as a prognostic factor in the prediction of ventricular arrhythmias in patients after myocardial infarction. In this prospective study the possible impact of late potentials on the prediction of ventricular arrhythmias in the short- and long-term follow-up after coronary artery bypass grafting was evaluated. In 188 patients (165 men, 23 women, age 57 +/- 8 years) with chronic coronary heart disease 48 (26%) had late potentials before bypass grafting; after the procedure this was reduced to 39 (21%) (ns). In 16 (33%) of the 48 patients with late potentials before bypass grafting, late potentials were no longer present in the short-term follow-up (9 +/- 6 days). Conversely, seven (5%) of the 140 patients without late potentials before bypass grafting had late potentials in the short-term follow-up after grafting. Nine (19%) of the 48 patients with late potentials before bypass grafting had ventricular arrhythmias in the peri-operative phase, which had to be treated with antiarrhythmic agents. In contrast, only three (2%) of the 140 patients without late potentials before bypass grafting had to be treated for ventricular arrhythmias (P < 0.001). In the long-term follow-up of 29 +/- 3 months, there were no events in the group of 149 patients without late potentials after grafting. In the 39 patients with late potentials after grafting, there were two (5%) events (two patients with arrhythmic syncope). CONCLUSIONS: (1) Patients with late potentials before bypass grafting have a markedly higher risk of developing serious ventricular arrhythmias in the peri-operative period than patients without late potentials. (2) Patients without late potentials have a very low risk of developing serious ventricular arrhythmias in the peri-operative period. (3) During long-term follow-up there was only a low probability of developing symptomatic ventricular arrhythmias in patients with or without late potentials.

[Surgical therapy in unstable angina pectoris]. / Chirurgische Therapie bei instabiler Angina pectoris.

In order to assess the value of surgical revascularization of coronary arteries in patients with unstable angina pectoris, a series of 551/3397 consecutive patients belonging to New York Heart Association (NYHA) class IV was investigated. Fulfillment of at least two of the following criteria is mandatory for diagnosis unstable angina pectoris: slightly increased CK (< 300 IU/l), modified ECG at rest (decreased ST-T, increased ST), therapy-resistant post-infarction angina, therapy-resistant angina at rest, increased severity, duration or frequency of angina attacks within the last three months, insufficient therapeutic response. Patients with acute myocardial infarction were excluded from analysis. 362/551 patients out of the investigated cohort fulfilled criteria of unstable angina pectoris NYHA class IV; in 189/551 patients, criteria of stable angina pectoris NYHA class IV were fulfilled (controls). The mean follow-up period for these patients was 72 +/- 33 months (24 +/- 144 months). There were no differences regarding age, percentage of patients with three vessel disease, ejection fraction of the left ventricle and of cardiogenic shock. The mean number of aortocoronary grafts was 3.8 +/- 1.3 in patients with unstable angina, compared to 3.4 +/- 1.5 in patients with stable angina pectoris (p < 0.05). An intra-aortic balloon pump had to be applied in 8% of patients with unstable angina compared to 3% in stable angina. A mortality of 2% within 30 days of surgery was registered in unstable compared to 3% in stable angina pectoris (n.s).(ABSTRACT TRUNCATED AT 250 WORDS)

Modified operation technique for orthotopic heart transplantation.

Atrioventricular (AV) valve dysfunction with tricuspid regurgitation is a common finding after orthotopic heart transplantation (HTx). In 20 patients the heart transplantation was performed with bicaval anastomoses and the results were compared to the precedent 20 patients operated with the standard technique. The right atrium of the recipient was completely removed and the caval anastomoses were performed on the beating heart during reperfusion. Using an interrupted suture line, no stenoses at the venous anastomoses were seen as known from the early implantation technique in heart-lung transplantation. Due to a more stable sinus rhythm only 15% of the patients in the bicaval group needed prolonged pacing (> 30 min) versus 55% (P < 0.01) in the group with standard operation. One to 3 months after surgery the transthoracic echocardiographic evaluation of the AV valve function showed tricuspid valve regurgitation (TVR) in 20% of the patients with bicaval anastomoses versus 75% with a right atrial anastomosis (P < 0.001). Tricuspid valve regurgitation during the first 2 weeks (in 31% of recipients with bicaval and in 70% with atrial anastomoses) improved in all recipients with bicaval anastomoses and in 14% of the recipients with atrial anastomosis. The modification of the operation technique did not result in significantly longer bypass time (75 +/- 14 versus 68 +/- 14 min) and ischemia time (44 +/- 12 versus 41 +/- 9 min with local organ procurement and 111 +/- 24 versus 101 +/- 19 min with distant organ procurement). The AV valve function and the postoperative rhythm after orthotopic HTx can be improved by implanting the heart with bicaval anastomoses.

[Occlusion of the distal aorta]. / Verschluss der distalen Aorta.

Between 1984 and 1992, 79 patients were operated for occlusion of the infrarenal abdominal aorta. 12/79 (15%) of the patients underwent emergency procedure for an acute Leriche syndrome. 67/79 (85%) of the patients with a chronic occlusion were treated electively. The surgical management includes in our series in 57/79 (72%) cases aortoiliac or aortofemoral prosthetic bypass, in 11/79 (14%) cases aortoiliac endarterectomy, in 6/79 (8%) cases embolectomy and in 5/79 (6%) extraanatomical axillofemoral bypass. For chronic total occlusion of the aorta the most common procedure was prosthetic bypass in anatomical position. For emergency cases embolectomy was performed in 42%. Early morbidity rate was 26% (21/79). The most frequent complications were thromboembolic events in 7 patients, myocardial infarction in 4 patients and renal insufficiency in 4 cases. The 30-day mortality 2.5% (2/79); the cause in both cases myocardial infarction. For atherosclerotic occlusive disease of the infrarenal abdominal aorta the prosthetic bypass is the first-choice surgical procedure. For embolic occlusions and for risk patients other less burdening procedures are available.

[Cardiovascular interventions in elderly patients]. / Kardiovaskuläre Eingriffe bei älteren Patienten.

From January 1981 to December 1990, 204 patients between 70 and 81 years of age underwent aortocoronary bypass-surgery, and 20 patients age 80 years or older underwent valvular surgery. The operative mortality rate (30-day mortality) of aortocoronary bypass-surgery was 6.8%; actuarial survival rate at 1 and 5 years was 92% and 86%, respectively. The operative mortality rate of valvular surgery was 15%; actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. The mean follow-up was 25 months. Most patients undergoing myocardial revascularization (71%) and all the patients undergoing valvular surgery were preoperatively in New York Heart Association (NYHA) functional class III or IV, at the end of the follow-up in NYHA functional class I or II (95%). A rapid rise in the number of heart operations in the elderly is evident. It is associated with increased but acceptable operative risk. Longterm results and postoperative improvement of functional status are satisfactory.

Should cardiac transplantation for congenital heart disease be delayed until adult age?

The number of pediatric heart transplantations for complex congenital heart disease has increased over the last years, but little experience has been reported in adolescent and adult populations. Between 1987 and 1992, 14 patients (mean age 33.2 years, range 14 to 51 years) were transplanted in our institution because of structural congenital heart disease (n = 9) or other rare disorders of the endomyocardial morphogenesis (n = 5). The main diagnosis included transposition of the great arteries, congenitally corrected transposition of the great vessels, left superior vena cava, tricuspid atresia with right ventricular hypoplasia, double outlet right ventricle with transposition, left ventricular sinusoidal malformation and right ventricular dysplasia. In several cases there were additional intracardiac malformations, including ventricular septum defect, atrial septum defect as well as different forms of pulmonary stenosis. Seven patients had undergone one or more palliative repairs that consisted of modified Blalock-Taussig shunts, Glenn's cavopulmonary anastomosis, Waterstone shunt, Blalock-Hanlon atrioseptectomy and Brock pulmonary valvotomy. Two patients had undergone Senning procedure for transposition of the great arteries. The donor cardiectomy was modified in order to include complete inflow and outflow tissue in the explant and transplantation could be performed without prosthetic material in all patients; deep hypothermic cardiac arrest was never necessary in this series. There was no early or late mortality after a mean follow-up of 37 months (range 4 to 74 months); postoperative echocardiography and cardiac catheterization demonstrated perfect anatomical and functional results in all patients. Adolescent and adult patients with complex congenital cardiac diseases can be transplanted with a very low perioperative risk, even after several prior operative procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Infectious complications in 100 consecutive heart transplant recipients.

Clinical and laboratory data on infectious complications in 100 consecutive heart transplant recipients were analyzed retrospectively. The mean length of follow-up was 651 +/- 466 days. All patients received a basic immunosuppressive regimen including cyclosporine (whole blood target trough level 400-600 micrograms/l), azathioprine (1 mg/kg/day) and prednisone (0.15 mg/kg/day). Early rejection prophylaxis consisted of polyclonal rabbit antithymocyte globulin (ATG) (4 mg/kg/day for 4 days) in the first 57 patients and monoclonal murine OKT-3 (5 mg/day for 14 days) in the remaining patients. The primary cause of death was infection in three patients and rejection in 16 (p < 0.001). The incidence of infection was 0.96/patient/year (n = 179); 95 infections were nosocomial (53%), 47 community-acquired (26%) and 37 opportunistic (21%). The number of hospitalizations due to infections was fewer than that due to rejection (53 versus 246 respectively, p < 0.0001), but the mean length of hospital stay was longer in the first group (13.85 +/- 10.92 days versus 3.48 +/- 2.28 days, p < 0.001). Previous early rejection prophylaxis with OKT-3 was associated with a greater number of opportunistic and nosocomial infections compared to prophylaxis with ATG (p < 0.05), as was treatment with ATG and steroid pulses compared to steroid pulses alone in cases of opportunistic infection (p < 0.05).

[Extra-anatomic ascending-supraceliac aortic bypass in treatment of complex or recurrent aortic isthmus stenosis]. / Der extra-anatomische aszendens-suprazöliakale Aortenbypass in der Behandlung der komplexen oder rezidivierenden Aortenisthmusstenosen.

Several surgical approaches have been reported for operative correction of complex or recurrent form of aortic coarctation. In this study we report our experience with extra-anatomic ascending-supraceliac abdominal bypass grafting for complicated form of aortic coarctation in 12 patients. All patients survived the operations, without late mortality. This type of surgical correction of complex or recurrent form of coarctation is a safe and effective procedure.

[Surgery of endocarditis in the drug dependent and HIV patient. A prospective comparison with conservative treatment]. / Chirurgie der Endokarditis beim Drogensüchtigen und HIV-Patient. Ein prospektiver Vergleich mit der konservativen Behandlung.

The incidence of infective endocarditis in drug addicts is increasing with the spreading of intravenous drug abuse. The tricuspid valve is the most commonly involved valve followed by the mitral valve. We evaluated prospectively 22 patients with a mean age of 23 years, presenting with addiction-associated endocarditis endocarditis and referred to our institution during a three-year period. The tricuspid valve was involved in 13 instances, mitral valve in 4, mitral plus tricuspid valve in 5 patients and aortic valve in 1 case. Staphylococcus aureus was the most frequent infective organism (15x), followed by Streptococci (4x), Corynebacteria (2x) and one case with a mixed infection. Six patients were positive for an HIV-infection and 17 had evidence for a chronic viral hepatitis. Ten patients (3 of them HIV-seropositive) were treated surgically. Resection of the tricuspid valve with (1x) or without replacement (4x), resection of vegetations and valve repair (2x), mitral valve replacement (2x), aortic valve replacement (1x) were performed. In case of tricuspid endocarditis, the decision whether to proceed with resection, repair or replacement with a bioprosthesis was taken according to valve pathology and the psycho-social situation of the patient. When the vegetations involved only one leaflet and could be removed easily, vegetectomy with annuloplasty or with repair using autologous pericardium was performed. Valvulectomy without replacement was the chosen method for those where persistent or recurrent drug abuse could not be excluded. A bioprosthesis was inserted when the tricuspid valve was completely destroyed and there was a proven abstinence from drugs over a period of several weeks preoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of surgical revascularization of the kidney]. / Resultate der chirurgischen Nierenrevaskularisation.

There are many different etiologies of renal artery disease (atherosclerosis, aneurysm, dissection, arteriovenous fistula, embolism, fibromuscular dysplasia) and also a lot of different therapies (conservative treatment, percutaneous transluminal angioplasty [PTA], endarterectomy, bypass grafting, patch plasty, nephrectomy). Recently conservative treatment and PTA have significantly improved. Patients who are referred to surgery today are of older age with severe and often bilateral disease of the renal arteries. Additional manifestations of general atherosclerosis like coronary artery disease, aortic aneurysm, peripheral occlusive vessel disease and cerebral vascular insufficiency are often present as well. The main goal of all forms of treatment is the preservation of general renal function. With our retrospective study the results after surgical revascularisation of kidneys are evaluated over a short period of time. Only graft revascularisations are included in the study and we were mainly interested in renal function and blood pressure.

[Effect of aortic clamping on heart function in elective operation of the abdominal aorta: immediate effects of coronary revascularization]. / Influence du clampage aortique sur la fonction cardiaque lors de chirurgie élective de l'aorte abdominale: effets immédiats de la revascularisation coronarienne.

Infrarenal aortic cross-clamping required during surgical treatment of abdominal aortic aneurysm is generally well tolerated but can be occasionally associated with severe cardiac and haemodynamic disturbances, particularly in patients suffering from coronary artery disease. We compared the haemodynamic changes and the ECG-records before and shortly after infrarenal aortic clamping in three groups of 20 patients (group I: without coronary artery disease, group II: with overt coronary disease without indication for prior myocardial revascularization, and group III: patients undergoing combined procedure: coronary artery bypass immediately prior to aortic repair, during the same anesthesia). There was no significant difference in demographical characteristics between the three groups. Aortic cross-clamping lead to an increase in systemic arterial pressure in all patients. Group I demonstrated a decrease in pulmonary artery pressure, pulmonary capillary wedge pressure and central venous pressure, whereas patients of group II demonstrated an increase of each value when the aorta was clamped. 11 patients of this group developed either arrhythmia and/or ischemia during aortic cross-clamping. Haemodynamic and cardiac effects of aortic clamping seen in patients who had received coronary bypass immediately prior to aortic repair (group III) were surprisingly similar to those of patients without coronary disease, probably owing to systematic application of 2 vasodilators. Tolerance to infrarenal aortic cross-clamping differs in patients with and without coronary artery disease. Development of myocardial ischemia may be predicted by an increase in wedge pressure after clamping. Afterload reduction was the best treatment of ischemia occurring when the aorta was clamped.