Dual-Source computed tomography of the chest in the surgical planning of repeated cardiac surgery.

AIM: When reoperative cardiac surgery is indicated, detailed, three-dimensional imaging of the thorax permits accurate depiction of cardiac anatomy and vascular structures potentially increasing the safety of the surgical procedure. We sought to evaluate the contribution of dual-source multidetector-row computed tomography (DSCT) of the heart and thorax in planning repeated open heart surgery. METHODS: Twenty-eight patients (mean age, 68 years) scheduled for repeated cardiac surgery who had undergone previous coronary artery bypass grafting (n=19) or cardiac valve replacement (8) or combined valvular and bypass surgery (1) underwent contrast-enhanced ECG-gated DSCT (Somatom Definition, Siemens Medical Solutions) of the whole thorax with a temporal resolution of 82 ms and a spatial resolution of 0.4 mm³. The indication for repeated surgery was bypass surgery (N.=6), valve replacement (16), combined bypass and valvular surgery (5) or other reasons (1). Assessment of surgical risk based on DSCT data were performed in terms of the relation of the ascending aorta and cardiac structures to the expected median sternotomy line, graft patency and anatomic course, and the degree of calcification of the ascending aorta and coronary arteries. RESULTS: DSCT findings led to a change of surgical approach for 9/28 (32.1%) patients (non-midline incision, N.=3; surgery performed under circulatory arrest, N.=5; peripheral arterial cannulation before sternotomy, N.=1) and cancellation of surgery for 4/28 (14.3%) patients (heavy aortic and coronary calcifications impeding bypass surgery, N.=2; right heart or aortic aneurysm in close proximity to the sternum in high risk patients, N.=2). The planned surgical approach remained unchanged after DSCT for the remaining15/28 (53.6%) patients. Of 54 bypass graft conduits (20 arterial, 34 venous) visualized on DSCT in 20 patients after previous bypass grafting, 16 arterial and 24 venous grafts were patent, while 4 arterial and 10 venous grafts were occluded. CONCLUSION: DSCT of the heart and thorax is an effective, non-invasive tool for the preoperative planning of repeated cardiac surgery. The technique provides significant information to modify the surgical approach and may increase the safety of the procedure.

Indocyanine green clearance after cardiac surgery: the impact of cardiopulmonary bypass.

Plasma clearance of indocyanine green has recently been established as a tool to monitor hepatic function and perfusion non-invasively. Reduced indocyanine green clearance has been associated with adverse outcome in cardiac surgery patients, and cardiopulmonary bypass has been hypothesized to be one important triggering factor. We performed a prospective observational study comparing the influence of off-pump and on-pump coronary surgery on perioperative indocyanine green clearance. Twenty-five consecutive adult patients without known pre-existing hepatic diseases scheduled for off-pump coronary artery bypass grafting were evaluated for hepatic dysfunction pre- and postoperatively with serial measurements of indocyanine green plasma clearance, specific laboratory values and liver function scores. Twenty-five matched patients who underwent coronary artery bypass grafting surgery with cardiopulmonary bypass in the same period served as controls. Parameters of postoperative hepatic function, including measurements of indocyanine green plasma clearance and specific laboratory values and scores, did not differ significantly between patients undergoing off-pump coronary artery bypass grafting and patients undergoing coronary artery bypass grafting with extracorporeal circulation. In patients without pre-existing hepatic diseases, a significant influence of cardiopulmonary bypass on perioperative indocyanine green plasma clearance as well as on liver specific laboratory parameters and scores cannot be proven.

A haemodynamic study during OPCAB surgery using a new multi-suction cardiac positioner.

BACKGROUND: Displacement of the heart is necessary to expose the target vessel for distal anastomosis to achieve successful multivessel off-pump coronary artery bypass (OPCAB) grafting. In addition to complete revascularisation of the heart, a main challenge during the operation is to maintain haemodynamic stability during this procedure. A new heart positioner (Tentacles) was tested. METHODS: In a prospective clinical study we used the Tentacles device in 50 patients scheduled for multivessel OPCAB procedures and investigated the haemodynamic effects during displacement of the heart and while performing the anastomoses to the anterior, lateral and posterior wall. The following haemodynamic parameters were investigated: mean arterial blood pressure (MAP), cardiac index (CI) and stroke volume index (SVI). The incidence of myocardial ischaemia was monitored by transoesophageal echocardiography (TEE) and by ST-segment analysis in the electrocardiogram (ECG). RESULT: The Tentacles device permitted rapid, secure and excellent exposure of the lateral and posterior wall of the heart. During exposure of the anterior wall there was a small decrease in MAP (77 ± 10 vs.71 ± 9 mmHg, P = 0.02) in combination with an increase in the CI (3.0 ± 0.7 l vs. 3.1 ± 0.8 l/min/m2, P = 0.03). When the lateral and posterior walls of the heart were exposed, the SVI decreased significantly (36 ± 11 and 38 ± 8 mL/m2, P < 0.01 and P = 0.04, respectively) compared to baseline (44 ± 11 mL/m2) while CI and MAP remained stable. The amount of norepinephrine administered during displacement of the heart was significantly higher in all three positions (0.05 ± 0.05, 0.06 ± 0.05 and 0.04 ± 0.03 µg/kg/min, P < 0.01) compared to the physiological position (0.02 ± 0.02 µg/kg/min). Sinus rhythm was maintained throughout the operation. Neither significant changes of the ST-segment in the ECG nor incidences of wall motion abnormality in TEE were observed. Six hours postoperatively the troponin I concentration was 11.7 ± 4.3 ng/mL. CONCLUSION: The Tentacles device provided excellent access in multivessel OPCAB surgery. Haemodynamic stability was maintained in all patients; however additional catecholamine support was used when the heart was displaced. This was the case when carrying out an anastomosis on the anterior, lateral, or posterior wall.

Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery.

BACKGROUND: Unsuccessful surgical treatment of deep sternal wound infection (DSWI) and mediastinitis may lead to sepsis, multiorgan failure and death. Omental flap transposition (OFT) may, in this situation, be the only effective therapy. METHODS: Twenty-seven patients with DSWI and mediastinitis after one or more unsuccessful surgical attempts to cure the infection were treated by OFT. Forty-one interventions (1.5/patient) consisting of closed irrigation technique, bilateral pectoralis flap reconstruction and vacuum-assisted therapy were performed before carrying out OFT. RESULTS: Operative mortality was 0. Mean postoperative ventilation time was 1.38 days and mean time in the intensive care unit was 4.7 days. Hospital mortality was 7.4 % (n = 2). Mean follow-up time was 2 years. One patient (4 %) died one year after discharge. During follow-up, abdominal wall hernia occurred in one patient (4 %) and presternal fistula resection was necessary in another patient (4 %). CONCLUSION: OFT is, in our experience, the most effective procedure for the treatment of recurrent DSWI and mediastinitis after cardiac surgery. Early mortality is acceptable, morbidity is low and late results are very good.

Aberrant origin of the left main coronary artery arising from the right coronary artery associated with coronary artery disease: a case report.

Coronary artery anomalies are not frequent, nevertheless they are associated with increased and potentially lethal cardiac events. Recognition of these anomalies is fundamental in patients undergoing diagnostic or interventional coronary angiography. Most patients presenting with coronary anomalies are asymptomatic, but the risk of myocardial ischemia and sudden death requires the treatment of those patients. Different therapeutic options have been discussed, including surgery, conservative therapy, and interventional approaches. In this report, an aberrant origin of the left main coronary artery arising from the right coronary artery associated with coronary artery atherosclerosis and its surgical correction is described.

Contrast enhanced ultrasound and Dual Source CT of left atrial myxoma.

PURPOSE: Myxomas of the left atrial cavity of the heart are a rare occurrence. Incidental diagnosis is mostly based on transthoracic echocardiography. Contrast enhanced ultrasound (CEUS) seems to be a promising new diagnostic option for diagnosis and preoperative planning of treatment for patients with myxoma. It is an additional examination to baseline ultrasound and CT or MRT. MATERIALS AND METHODS: We report a case of a 63-year-old woman with myxoma of the left atrial cavity of the heart in which CEUS helped to define the location and its relation to the heart valve. RESULTS: In contrast enhanced ultrasound (CEUS), the oval mass in the left atrium was scanned in the 4-chamber view. Perfusion of the mass was examined by visualising gradual contrast enhancement. An involvement of the mitral valve could be excluded. The tumour base could be clearly depicted and differentiated from normal surrounding tissue. No thrombotic material was found in the left atrium (LA) or ventricle (LV). CONCLUSION: CEUS could detect the mass and offer additional information such as vascularity, mobility, attachment to the valve and possible thrombi. Dual Source CT (DSCT) confirmed the findings and provided a very clear morphological characterisation and dynamic evaluation of mobility and valve interference.

Arterial T-graft in coronary surgery: comparison of selective coronary angiography and multi-slice computed tomography.

BACKGROUND: The main aim of our study was to compare the results and value of angiography and multi-slice computed tomography (MSCT) after coronary artery bypass grafting using complex arterial conduit combinations. METHODS: Twenty-six patients underwent coronary surgery. In all patients, we utilized a T-graft (free arterial graft centrally implanted into the left internal thoracic artery IN SITU). Postoperative coronary angiography and MSCT were carried out prior to discharge. The results were interpreted separately by two different investigators. RESULTS: One hundred and thirteen distal anastomoses using 59 grafts for T-graft combinations were performed in 26 patients. A mean of 3.5 peripheral anastomoses was established per patient. Angiography showed a bypass graft patency rate of 94.6 % (56/59). In angiography, the patency rate of anastomoses was 96.5 % (109/113). All occlusions were identified in sequential anastomoses. The bypass patency rate measured by MSCT was 100 % and the patency rate of anastomoses 100 %. Based on these results, MSCT showed a sensitivity of 98.9 %. The specificity was 50.8 %, the positive predictive value was 94.6 % and the negative predictive value had a level of 99.9 %. CONCLUSION: MSCT is a simple, less invasive and useful method of monitoring results after coronary surgery including anastomosis and graft patency after complex arterial grafts. Its value may be restricted for sequential anastomoses and angiography should be preferentially used in these cases.

Minimally invasive off-pump pulmonary vein isolation to treat paroxysmal atrial fibrillation.

BACKGROUND: Minimally invasive off-pump pulmonary vein isolation to cure paroxysmal atrial fibrillation (PAF) may be an alternative to percutaneous catheter-based procedures. METHODS: Three patients with highly symptomatic lone PAF refractory to medical treatment and having undergone unsuccessful catheter-based ablation underwent pulmonary vein isolation using the Cardioblate BP device with a minimally invasive approach. RESULTS: There were no complications and all patients were discharged in sinus rhythm. Mean ablation time per lesion was 15.2 sec and mean operation time was 118 min. CONCLUSIONS: Irrigated bipolar radiofrequency ablation of the pulmonary veins is safe and can be performed off-pump in a minimally invasive manner.

Port-a-Cath complicated by right atrial thrombus. Minimally invasive thrombectomy without cardiopulmonary bypass.

Right atrial thrombosis during chemotherapy is commonly treated conservatively. We describe a minimally invasive surgical procedure to remove a right atrial thrombus in a patient with a history of recurrent lung embolism. Surgery was performed through a mini-thoracotomy without cardiopulmonary bypass during occlusion of both caval veins. Recovery was uneventful.

[ECG-gated bypass CT angiography--application in imaging arterial bypasses]. / EKG-gesteuerte Bypass-CT-Angiographie--Einsatz in der Darstellung arterieller Bypässe.

Nowadays coronary artery bypass grafting is increasingly performed using arterial grafts. Purpose of the study was the evaluation of a appropriate 16 detector-row CT angiography protocol in patients after predominantly arterial bypass grafting. Fourteen patients after bypass grafting were including into the study and CT angiography carried out in the early postoperative period using a 16 detector-row CT system. To reduce cardiac pulsation artifacts data acquisition was implemented using ECG-gating algorithms. Overall 43 grafts (37 arterial, 6 venous) were examined. In 13 patients surgery had been performed using composite grafts with T or TY configuration. The mean heart rate was 74.1 bpm and showed a negative correlation to the image quality (r=-0.65; p=0.01). However, all data sets were diagnostic. Contrast injection protocol allowed for a homogeneous opacification throughout the vessels of interest. All non-delineationable grafts (5) showed a close proximity to the heart (T or Y grafts). Cardiac surgery is increasingly focusing on arterial revascularisation in bypass grafting and therefore leading to new demands for non-invasive bypass graft imaging. 16 detector-row CT allows a reliable visualization of even composite arterial grafts. However, for detection of grafts in the proximity of the heart a reduction of the heart rate (<65-70) still seems to be necessary.

[Total arterial myocardial revascularization--strategy, early and midterm results]. / Die total arterielle Myokardrevaskularisation--Strategie, kurz- und mittelfristige Ergebnisse.

Total arterial myocardial revascularization (TAMR) represents a new alternative procedure to the classical aorto-coronary bypass operation with venous graft material. The early and midterm results with the use of the left and right internal thoracic artery (LITA and RITA) and radial artery (RA) for coronary artery bypass grafting are analyzed to assess the suitability of these conduits for myocardial revascularization. From June 1997 to June 2001, 234 patients suffering from a coronary artery disease underwent TAMR at our institution. The bypass material consisted of 234 LITAs, 160 RITAs and 84 RAs. The most frequently used conduit combination was a T-graft (n=213) consisting of a free arterial graft (RITA or RA) centrally implanted into LIMA "in situ" using an end-to-site grafting technique. The mean left ventricular ejection fraction was 0.59+/-0.4. In 150 patients (64.1%), the operation was performed on an urgent basis and in 24 cases (10.2%) it was a reoperation. A mean of 3.3+/-0.9 coronary anastomoses per patient was performed. The mean aortic cross-clamping time was 71+/-20 minutes. In 194 cases (83%), the postoperative course was uneventful. The early mortality was 0.8% (n=2). Complications included myocardial infarction in 4 patients (1.7%), sternal infection in 2 (0.8%), renal insufficiency in 2 (0.8%), prolonged respiratory ventilation in 28 (11.9%) and reoperation for bleeding in 6 (2.5%). At a mean follow-up of 25+/-1.3 months 197 patients (96.6%) were asymptomatic. Late mortality was 3.3% (n=7). TAMR is a safe and reliable procedure with very good early and midterm results. The results reported in this study support the widened use of this coronary artery grafting strategy.

Morphological and histopathological comparison of left and right internal thoracic artery with implications on their use for coronary surgery.

Goal of this study was the morphological comparison of the left (LITA) and right internal thoracic artery (RITA). Both ITAs were taken out in 20 autopsy cases. Sections over the entire length of vessel were cut and histomorphological examination was performed. There were no significant differences between the LITA and RITA concerning length, diameter, wall thickness and structure. The occurrence rates of atherosclerosis were equal. Four vessels showed luminal narrowing of more than 50%. There was a good correlation between the length of the sternum and the ITA. According to our findings the morphology of LITA and RITA is similar.

[Temporomandibular ankylosis. A treatment method using the interposition of a Dacron device]. / L'ankylose temporo-mandibulaire. Méthode de traitement par l'interposition d'une texture de Dracron.

BACKGROUND: Temporomandibular ankylosis with its multiple anatomo-clinical forms is a relatively rare disease. Its major morphopathological, therapeutical and psychological implications rank it among severe illnesses. Its treatment is exclusively surgical. The major therapeutical indication in ankylosis of type I and II Topazian is the neoarticular modelling osteotomy with interposition. MATERIAL AND METHODS: As a material for interposition, over the last 7 years, we have used in 15 patients with 18 ankylosis, concave rectangular Dacron fragments adequately shaped after being taken from a vascular prothesis. RESULTS: The qualities of this material are confirmed by the obtained results: quick resuming of the normal mobility of the mandible, lack of postoperative complications and recurrences. The material is cheap and easy to be obtained. The technique to be used is simple. DISCUSSION: The Dacron texture is soft, elastic in all respects, thick enough, resistant, with long lasting elasticity and integrity, physically and chemically sTable, well tolerated by the body and without foreign body rejection. It is easy to be cut, shaped, modelled and adapted to the bone stump. It is sterilized by autoclaving. It is also well integrated into the host tissue being penetrated by the connective tissue which fastens it to the surface of the neocondyle preventing a relapse. It plays the role of a joint cartilage.

[Percutaneous hydromechanical thrombectomy in acute and subacute lower limb ischemia]. / Perkutane hydromechanische Thrombektomie bei akuter und subakuter arterieller Beinischämie.

PURPOSE: A prospective study should evaluate the primary and 2-year results of treating acute and subacute lower-limb ischemia with hydromechanical thrombectomy (HTE). MATERIALS AND METHODS: Consecutively 64 patients, 12 with viable and 52 with threatening limb ischemia and onset of symptoms within 8 +/- 9 days, were treated and controlled for 24 months. An 8 F hydromechanical thrombectomy device (HTK), was used. It sucks and shreds the thrombi. The shredded particles are transported to the outside. RESULTS: In 8 patients a total, in the others a partial restoration of the vessel lumen up to 70-50% was achieved in a mean time of 34 minutes. Residual thrombi, underlying atherosclerotic vessel disease and occluded arteries with a small diameter made adjunctive interventions (balloon angioplasty, percutaneous aspiration thrombectomy, lysis) necessary. Clinical symptoms and the ankle-brachial index improved significantly (p < 0.01). Primary patency was 72%, 70%, 67%, and 65%; the limb salvage rates were 81%, 78%, 75%, and 73% for one, 3, 12, and 24 months respectively. Device-induced complications did not occur. CONCLUSIONS: The HTK allowed a rapid reduction of fresh thrombotic material without complications. In 78% of the cases adjunctive therapies are required for wall-adherent thrombi and when tibial vessels with smaller lumina are included. Long-term results are comparable to literature data for fibrinolytic or operative regimens. The advantage, however of the HTK seems to be the reduction of intervention time and intra-arterial dosage of fibrinolytic drugs.

Morphology and patency of Gore-Tex wrapped internal mammary artery bypass-evaluation with helical CT.

OBJECTIVE: To determine the patency of coronary internal mammary artery bypass (IMAB) with CT-angiography (CTA) and to evaluate the morphology of a covering Gore-tex IMAB-sleeve (PIMAS) used to protect the bypass at possible reoperation. MATERIALS AND METHODS: Sixty-five patients with IMAB wrapped with PIMAS (67 grafts) were prospectively investigated by CTA for bypass patency and sleeve morphology 6 months postoperatively with a standardised radiological and clinical protocol. RESULTS: All patent bypass arteries (62/62) were identified by CTA as open. In the remaining five cases, CTA revealed a bypass occlusion, which could be proven by coronary angiography in two cases (two patients refused angiography, one bypass was open angiographically). Morphology of the PIMAS could be imaged exactly in all cases. Sleeve implantation did not lead to adverse effects in terms of bypass occlusion or compression. In four patients, additional clinically relevant information were achieved. CONCLUSION: PIMAS implantation proved to be a safe procedure with good short-term results. CTA is a valuable method to exclude occlusion of sleeved IMA bypasses. Depiction of the wrapped IMAB by CTA supplies important information for preparing strategy in case of reoperation.

Shredding embolectomy thrombectomy catheter for treatment of acute lower-limb ischemia.

We undertook a prospective evaluation to prove a new mechanical thrombectomy device, the shredding embolectomy thrombectomy catheter (S.E.T. catheter), for the treatment of patients with acute lower-limb ischemia. The study evaluated the success, patency, mortality, limb salvage, and complication rates for 51 patients treated from January 1994 through June 1996, with this device, which was an 8-F three-lumen catheter. The onset of symptoms was 8.6 +/- 9 days. Thrombus length was 18 +/- 9 cm situated in 44 native vessels and in 7 bypasses, 42 limbs were graded as threatened. Hydromechanical thrombectomy with the S.E.T. catheter proved to be a quick and safe adjunct for therapy of acute femoropopliteal thromboembolic occlusions with a high initial success rate and an acceptable mid-term patency rate.

Linear repair versus ventricular reconstruction for treatment of left ventricular aneurysm: a 10-year experience.

OBJECTIVE: To describe a 10-year experience with surgical treatment of left ventricular aneurysm and compare the results of linear repair and ventricular reconstruction. DESIGN: A retrospective data analysis. SETTING: Department of cardiothoracic surgery. PATIENTS: All patients treated with concurrent coronary artery bypass revascularization and surgical repair of ventricular aneurysm from 1985 to 1995. METHODS: Patients underwent either linear repair after aneurysmectomy (group A; n=51) or reconstruction of the left ventricle using a patch (group B, n=10). Preoperative patient characteristics and postoperative mortality and symptomatic results in the two groups were compared with chi(2) and paired "t"-tests. RESULTS: The early mortality rates were 9.8% overall, 7.8%, in group A, and 20% in group B. During a mean follow-up of 58 months, the late mortality rates were 34.5%, 38.2%, and 12.5%. In comparison to patients in group A, those in group B had higher preoperative rates of seriously impaired left ventricular ejection fraction (p=0.01) and pathologic left ventricular end-diastolic pressure (p=0.03) and a prolonged operative aortic cross-clamp time (p=0.04). Early mortality in group B may have been influenced by the initially impaired hemodynamic function and the cross-clamp time. In the longterm, patients in group B had more symptomatic improvement than those in group A (p=0.02). CONCLUSIONS: Ventricular function in patients with left ventricular aneurysm improved after ventricular reconstruction using a patch. Further experience with this procedure should improve postoperative survival and long-term prognosis.

[Surgical treatment of acute pericardial tamponade in an infestation of the heart by Echinococcus]. / Chirurgische Behandlung der akuten Perikardtamponade bei Echinokokkusbefall des Herzens.

HISTORY AND CLINICAL FINDINGS: A 56-year-old turkish patient, previously in good health, was admitted because of pain suggesting myocardial infarction. Physical examination of the heart, lungs and abdomen was unremarkable. INVESTIGATIONS AND DIAGNOSIS: The concentrations of myocardium-specific enzymes were not elevated and the ECG showed no signs of ischaemia. Echocardiography and magnetic resonance imaging ruled out acute aortic dissection, but demonstrated a round cystic space-occupying mass over the anterior wall of the heart. Hydatid cyst was suspected from the imaging results and the patient's origin from area endemic for Echinococcus. The diagnosis was confirmed by a titre of 1:6,400 (normal: 1: < 100) for Echinococcus antibodies. TREATMENT AND COURSE: Albendazole administration was initiated. Planned elective surgical removal of the hysatid cyst had to be performed urgently because of acute pericardial tamponade. Cyst rupture was suspected but an actually undamaged cyst was subtotally removed under cardiopulmonary bypass. The postoperative course was uneventful and albendazole treatment was continued. CONCLUSION: Because of the high incidence of fatal complications urgent surgical removal under cardiopulmonary bypass is the treatment of choice for hydatid cyst involving the heart. Perioperative albendazole administration is also essential.

[Clinical, anatomical-pathological and therapeutic correlates of benign intracavitary heart tumors]. / Klinische, anatomopathologische und therapeutische Korrelate benigner intrakavitärer Herztumoren.

Benign intracavitary cardiac tumors lead to "malignant" complications, so early diagnosis and adequate treatment are of vital importance. Our investigation summarizes a 10-year experience after surgical treatment of 29 patients suffering from benign intracavitary cardiac tumors. The postoperative histological examination revealed a myxoma in 27 cases; in 2 cases a papillary fibroelastoma was diagnosed. The main symptom in 19 patients was dyspnea. In 8 cases an embolic event occurred. All patients underwent extirpation of the tumor. Early mortality was 10%, while late mortality was 4%. The treatment of choice of benign intracavitary cardiac tumors is extirpation, which, due to unpredictable embolic complications, is to be carried out immediately should the tumor have a lobulated tuberous surface. In such cases the descriptive function of echocardiography is of considerable importance.

[The quadri-cusp aortic valve: a congenital defect, responsible for pathologic changes?]. / Die quadricuspide Aortenklappe: Ein angeborenes Vitium, das pathologische Veränderungen hervorruft?

We report on a 61-year-old patient with considerable insufficiency of a quadricuspid aortic valve and coronary three vessel disease. The congenital quadricuspid aortic valve has become symptomatic due to the development of (post-endocarditic) insufficiency only in the advanced stage of life. It was treated by replacement of the aortic valve and bypass myocardial revascularization. The physiopathology of quadricuspid aortic valve will be discussed.