Prolapsing left atrial myxoma: preoperative diagnosis using a multimodal imaging approach with magnetic resonance imaging and real-time three-dimensional echocardiography.

Real-time three-dimensional echocardiography (RT3DE) is a new promising technique for the evaluation of intracardiac masses. We present the diagnostic work-up using a multimodal-imaging approach in a 74-year-old patient with a prolapsing tumour in the left atrium suggestive of a myxoma, causing severe congestive heart failure attributable to dynamic left ventricular inflow obstruction, and mimicking severe mitral valve stenosis. Real-time three-dimensional echocardiography allowed to accurately image the entire volume of the myxoma, and to analyse the dynamic left ventricular inflow obstruction. The size of the lobulated mass as assessed by RT3DE was 65 x 25 x 22 mm. The mass was surgically removed, histology was diagnostic for myxoma, and the patient had an uneventful recovery. Real-time three-dimensional echocardiography images the entire volume of a mass allowing for accurate measurements in multiple planes, and allowing for real-time evaluation of obstructive effects on ventricular in- or outflow. This case shows how RT3DE and other non-invasive imaging modalities may be used as complementary techniques for evaluation of intracardiac masses.

Early and late results after resection and end-to-end anastomosis of coarctation of the thoracic aorta in early infancy.

Over a 9 year period, 55 infants underwent resection and end-to-end anastomosis for symptomatic coarctation of the thoracic aorta during their first 120 days of life (mean age 47 days; mean weight 3.7 kg). Forty-two had preductal coarctation and 13, postductal. Additional cardiac lesions were found in 48 patients. Ventricular septal defect, either isolated or associated with other malformations, was the most frequent finding (37 patients). Simultaneous banding of the pulmonary artery was performed in 14 infants because of nonrestrictive ventricular septal defects. The hospital mortality was 3.6% (two patients). There were no late deaths. All survivors have been reinvestigated, and 27 have been recatheterized. In the group as a whole, after an average follow-up of 4.5 years, the mean pressure gradient (arm/leg) was 7 mm Hg (range 0 to 45 mm Hg). In the recatheterized infants, the average systolic pressure gradient at the anastomotic site was 16 mm Hg (range 2 to 62 mm Hg), whereas the mean pressure gradient in this group was 7 mm Hg (range 0 to 33); only three of them had systolic pressure gradients of more than 20 mm Hg. One reoperation is scheduled. Our data suggest, that resection and end-to-end anastomosis for symptomatic coarctation in the first 3 months of life can be performed with very low operative mortality and excellent long-term results.

Tricuspid valve regurgitation following blunt thoracic trauma.

Valvular lesions following blunt thoracic trauma are uncommon. Tricuspid valve regurgitation occurs very rarely. We report a successful tricuspid valve reconstruction for rupture of the chordae tendineae in a young man nine years after a motor vehicle accident. The value of echocardiography and transesophageal echocardiography for the diagnosis and quantification of this valve lesion is stressed.

Stentless xenograft valve in a truncus arteriosus communis.

We report the use of a recently developed stentless porcine valve in a 2-year-old child with truncus arteriosus communis (type I). The child had received no previous surgical palliation. Despite a markedly increased pulmonary arteriolar resistance the right ventricle was connected to the pulmonary artery with a homograft. The postoperative course was complicated at first by right ventricular failure due to pulmonary hypertension and secondarily by left ventricular failure caused by rapidly increasing truncal valve incompetence. Because we did not have a suitable homograft at hand we replaced the truncal valve with a stentless porcine xenograft valve.

Aortic valve surgery following previous coronary artery bypass grafting. Impact of calcification and leaflet movement.

We reviewed the reports of 27 patients who had an aortic valve replacement after previous coronary artery bypass grafting. The aortic valve disease -- mainly aortic stenosis -- showed a rapid rate of progression. In the time interval between coronary artery bypass grafting and aortic valve replacement of 4.6+/-2.2 years the peak-to-peak pressure gradient of the aortic valve rose from 20.2+/-14.3 to 63.0+/-22.7 mmHg. As there is a great interest to identify the patients with a high risk of a rapid progression because of a high mortality of an aortic valve replacement as the second cardiac operation following a coronary artery bypass grafting we also reviewed the cardiac catheterisation films and found a high incidence of calcification and impaired aortic valve motion (81.5% of the patients had already calcified aortic valves and 81.5% had a impaired valve motion) at the time of coronary artery bypass grafting. We concluded that if a patient has to be operated for coronary artery disease an aortic valve replacement should be considered not only according to hemodynamic criteria but also when the aortic valve is calcified or its leaflets' motion is impaired.

Moraxella catarrhalis endocarditis: report of a case and literature review.

A 53-year-old man developed severe acute systemic illness three weeks after an upper respiratory tract infection. Serial blood cultures grew Moraxella catarrhalis. During antibiotic treatment, fever and infectious parameters disappeared, but severe aortic regurgitation developed. Aortic valve replacement was performed, during which extensive destruction of the aortic valve was noted. Endocarditis due to M. catarrhalis is very rare with, to our knowledge, only six cases having been reported to date. M. catarrhalis is a normal commensal of the upper respiratory tract, but in unpredictable circumstances can become an important pathogen. Bacteremia due to this organism therefore requires prompt treatment, as serious organ complications, including endocarditis, can occur.

Mitroflow pericardial valve prosthesis in the aortic position: an analysis of long-term outcome and prognostic factors.

BACKGROUND AND AIM OF THE STUDY: Pericardial valves combine optimal hemodynamic properties with limited durability. To describe the long-term performance of Mitroflow pericardial valves in the aortic position, outcome and risk factors up to 12 years after implantation were analyzed. METHODS: A retrospective study, based on follow up of 1,029 patients who received 1,044 Mitroflow pericardial valves in the aortic position between February 1985 and December 1996, was performed. Follow up was 98.2% complete. Average follow up was 3.79 years. Mean patient age was 75.2+/-6.5 years (range: 27.9-90.9 years). At surgery, 86.3% of patients were aged over 70 years. Among patients, 482 (46.8%) had concomitant operations. RESULTS: Results (+/- SE) are given for evident and possible (in parentheses) valve-related events; the latter included all reported postoperative strokes and sudden deaths. Actuarial event-free rates after 5 and 10 years respectively were: structural valve deterioration: 99.2+/-0.5% and 77.6+/-4.4%; non-structural valve deterioration: 99.7+/-0.2% and 99.7+/-1.2%; valve-related complications: 95.7+/-0.9% and 73.5+/-4.0% (5 years 90.1+/-1.2%, 10 years 57.0+/-4.3%); endocarditis: 96.6+/-0.8% and 92.6+/-1.6%; explantation: 98.6+/-0.5% and 80.1+/-3.9%; cerebrovascular accident 95.2+/-0.9% and 82.5+/-3.5%; embolism 99.9+/-0.1% and 99.9+/-0.5%; bleeding 99.8+/-0.2% and 99.8+/-1.3%; overall mortality 69.9+/-1.8% and 35.3+/-3.0%; valve-related death 97.5 +/-1.1% and 95.1+/-4.2% (5 years 91.9+/-1.4%, 10 years 76.1+/-3.2%). The 30-day mortality rate was 4.1%. Patients aged 70 years or more with valve diameters of < or =23 mm showed 10-year freedom rates of 85.8+/-4.6% for structural valve degeneration and 95.1+/-1.2% for evident valve-related death. The detailed risk factor analysis showed results that were in accordance with clinical experience. CONCLUSION: Long-term results with Mitroflow pericardial valves in the aortic position compare well with those for other widely used bioprostheses, especially in patients aged > or =70 years and with small aortic root diameters (< or =23 mm).

Aortic valve replacement in octogenarians.

In a consecutive series of 1109 patients undergoing aortic valve replacement (AVR) between January 1988 and December 1990, there were 48 patients (33 female, 15 male) over 80 years of age (mean age 83.5 years, median 82.9 years). Of those, 33 had aortic stenosis and 15 combined aortic valve disease, with additional coronary artery disease being present in 36. Isolated AVR was performed in 25 patients, and it was combined with coronary venous bypass grafting, with 1-4 (mean 1.8) peripheral anastomoses in 23. Two patients died within 30 days (early mortality 4.2%). Non-fatal complications included one hemiparesis, four transient cerebral disorders, two cases of pneumonia which led to ventilatory assistance, three rethoracotomies because of postoperative bleeding, 15 tachycardias and one transient AV block. Late results were obtained after a median follow up time of 22 months. There were eight late deaths (four cardiac related, four not related) and a low incidence of non-fatal complications (two episodes of gastrointestinal bleeding while on oral anticoagulation, one cerebral transient ischemic attack and one acute left ventricular failure). Nine patients are in NYHA Class I, 12 in Class I-II, 11 in Class II, three in Class II-III and three in Class III. Of the surviving 38 patients, four are currently living in a home for the aged or a nursing home, while all the others are living in their own homes and are able to sustain a relatively independent life-style. We conclude that in very old patients with aortic valve disease, AVR can be performed with low mortality and few non-fatal complications.

Ischemic cardiomyopathy--revascularization vs. transplantation.

Advanced coronary artery disease (CAD) and ischemic cardiomyopathy with elevated pulmonary artery pressures are criteria of a severe illness. In selected cases surgical revascularization has proved beneficial in terms of survival, reduction of morbidity and lowering the frequency of angina pectoris [6] in numerous studies over the past 25 years. But most of the earlier publications concentrated on patients with angina pectoris (AP) as a dominant symptom. Patients without AP but with predominant signs of congestive heart failure were largely excluded. This has changed recently [1-3,7,8,10,12,16,18] with the advent of the concept of hibernating myocardium. This term is defined as the presence of persistent myocardial and left ventricular dysfunction at rest due to reduced regional coronary blood flow that can be partially or completely restored to normal by myocardial revascularization [5,19]. Salvage of viable myocardium by successful revascularization improves left ventricular dysfunction. Diagnosis of hibernating myocardium is crucial because it does not leave the patient with chronic heart failure a candidate only for cardiac transplantation. Instead, these patients' left ventricular dysfunction is potentially reversible following revascularization by coronary bypass surgery. Furthermore we face a critical shortage of donor organs and extending waiting lists for possible transplant candidates. Following the start of the heart transplantation (HTX) program at our institution more than 690 operations were performed until September 1995. We screened more than 1600 patients for their eligibility as cardiac transplant recipients or for other forms of treatment. In this group of patients it has always been our policy to revascularize rather than transplant whenever possible.

Long-term results after myectomy in 64 patients with hypertrophic obstructive cardiomyopathy (HOCM). Morphological and hemodynamic aspects.

BACKGROUND: The aim of this study was to observe the changes in left-ventricular morphology, the improvement in hemodynamics and the survival curves (according to Kaplan-Meier) of patients following transaortic myectomy. METHODS: From November 1985 to August 1997, transaortic myectomy according to Morrow's proposal was carried out at the Heart Center NRW in Bad Oeynhausen in 64 patients with isolated HOCM. At the time of operation, the patient group included 33 women and 31 men aged between 14 and 76 years (mean 52.56 years). A hemodynamically relevant aortic stenosis was excluded in all patients. Sixty-three patients (98.4%) were evaluated in total over a mean observation period of 4.6 years (4 months to 12 years). One patient lost touch with our hospital RESULTS: The clinical symptoms according to NYHA grade could be improved postoperatively from 3.4 +/- 0.33 to 1.36 +/- 0.6 (p < 0.001). The echocardiographic preoperative pressure gradient between the left ventricle and the aorta was 73.2 +/- 14.8 mmHg at rest and 139.6 +/- 21.2 mmHg after provocation by ventricular premature beats (VPBs). Postoperatively, the gradient was reduced significantly: 13.56 +/- 2.7 mmHg at rest and 23.3 +/- 10.7 mmHg after VPBs, respectively (p < 0.001). Perioperative complications occurred in 12 patients including 1 early death due to low-output syndrome, corresponding to an early mortality rate of 1.6%. Four patients died within a postoperative period of 1 year to 9.5 years, none of them due to cardiac causes, 2 due to non-cardiac causes and 1 of unknown causes. In 2 patients a recurrent HOCM occurred at 7 and 10 years after the myectomy and they were treated by catheter intervention with the alcohol induced septal infarction. CONCLUSIONS: Based on the 12-year survival rate of 76.640% in our study, transaortal myectomy according to Morrow represents a safe and reliable form of therapy, with relatively low perioperative mortality and complication rates, also in the long-term

Recovery of organ dysfunction during bridging to heart transplantation in children and adolescents.

The beneficial effects of ventricular assist devices on organ dysfunction during bridging to heart transplantation have been widely reported in the adult population. In contrast, the use of ventricular assist devices used as bridge-to-transplant in children is limited. To evaluate organ recovery during ventricular support in pediatric transplant candidate, respiratory, renal and hepatic function were reviewed retrospectively. The Thoratec device (stroke volume 65 ml) and the HIA-Medos-system (stroke volume 25/10 ml) were used as bridge-to transplant in 11 children and adolescents who were in low-output-syndrome despite maximal pharmacological support. Prior to implantation five patients were mechanically ventilated, six patients underwent cardiopulmonary resuscitation, eight patients had anuria (one treated by hemofiltration), three patients had liver dysfunction and four patients had signs of severe infection. At the time of implantation one patient was supported by the intraaortic balloon pump and one by the femorofemoral bypass for rapid hemodynamic stabilization. Eight patients were treated using the Thoratec device (one of these by Nova cor on the left side), three by the HIA-Medos system. The support time ranged between seven and 140 days. Seven patients could be extubated within three days. Renal function recovered in all pts. Liver enzymes decreased in all pts without reaching normal values. Bilirubin values also decreased in survivors but increased to 9.3 mg/dL in non-survivors. At least seven patients underwent successful heart transplantation, three patients died because of multiorgan failure after extended transfusion and one patient because of technical failure. In our experience the hemodynamic situation was sufficient in all bridging to transplant candidates. In all patients who underwent successful transplantation, transplantability was associated with rapid organ recovery within seven days after initiating mechanical assistance. Extended blood tranfusions, combined failure of three organs and increasing bilirubin values during support seem to be predictors of poor outcome.

[Endosonography in preoperative assessment of rectal tumors]. / Die Endosonographie in der präoperativen Beurteilung rectaler Tumoren.

Together with digital examination and rectoscopy, the endorectal ultrasound is of great value in the preoperative diagnostics of rectal carcinoma. In 90% of these patients it is possible to determine the depth of infiltration preoperatively. At the same time assessment of lymph node involvement can be made with a sensitivity and specificity of 78%. Thus, endorectal ultrasound gives decisive criteria for the therapeutic plan. Furthermore, endorectal ultrasound represents a fitting instrument for the postoperative follow-up of patients with anterior resection of the rectum. Intramural as well as extrarectal sited recurrences of the tumor can be detected. Whether endosonography will have an influence on the prognosis of rectal carcinoma, remains to be seen.

Initial experience with the medtronic ADVANTAGE valve prosthesis in the mitral position--clinical outcome and analysis of complications.

OBJECTIVE: The Medtronic ADVANTAGE prosthetic heart valve is a bileaflet mechanical heart valve which has two main design modifications. The prosthesis has an enlarged central orifice to improve blood flow characteristics and an asymmetric butterfly pivot recess with expanded outflow component designed to enhance the blood flow washing through the pivot region. This report summarizes the initial experience with 55 patients who underwent isolated mitral valve replacement. METHODS: We prospectively followed 55 patients undergoing mitral valve replacement with the Medtronic ADVANTAGE prosthesis in a single center study. All patients were operated on via a median sternotomy and a left atrial approach. RESULTS: The age of the patients at implant ranged from 42 years to 77 years with a mean of 61.8 years. Forty-five percent of the patients were male. Seventy-five percent of the patients were in NYHA functional class III or IV prior to valve replacement. The diameters of the implanted prostheses were as follows: 25 mm in 2 patients, 27 mm in 12 patients, 29 mm in 20 patients, and 31 mm in 21 patients. Coronary artery bypass grafting was performed with valve replacement in 16.4 % of patients and additional tricuspid repair in 10.9 %. After one year, 97.6 % and after two years 100 % of the included patients were in NYHA functional class I or II. All patients had Coumadin (warfarin) therapy postoperatively with a target INR range of 2.5 to 3.5, or 3.0 to 4.0. There were 4 thromboembolic events (7.3 %) in the early period and 2 late events (2.6 %). Episodes of valve thrombosis were not seen during the follow-up, which consisted of 76.5 patient years. The hemodynamic performance was favorable and within clinically acceptable ranges. The incidence of valve-related mortality and morbidity in this preliminary study was extremely low, indicating good clinical results comparable to those reported for other bileaflet valves. CONCLUSION: The ADVANTAGE valve is a safe and effective option for mitral valve replacement with a very low incidence of valve-related complications.

Giant coronary arteriovenous fistula. A case report and review of the literature.

Coronary artery fistulas are rare congenital anomalies. Although they constitute the most common form of hemodynamically significant coronary malformation, the incidence is around 0.002% in the general population. We report the successful surgical closure of a very large coronary artery fistula, originating from the left coronary artery and draining into the right atrium with left-to-right shunt of more than 50% and a review of the literature.

[Diagnosis and therapy of inflammatory cecal diverticula]. / Diagnose und Therapie entzündlicher Zökaldivertikel.

Caecal diverticular are rare, and so are their inflammatory complications. The clinical symptoms of caecal diverticulitis are hard to distinguish from those of acute appendicitis. Caecal diverticulitis, therefore, is usually diagnosed intraoperatively. Reported in this paper is experience obtained by the authors from seven patients who had received treatment, in recent years, at the Surgical Department of the University Hospital of Heidelberg, FRG. An account is given of incidence, possible diagnostic approaches, and potential complications. Surgical management of caecal diverticulitis should be restricted to the smallest possible intervention.

[What treatment expectations does the elderly patient have from surgery and what can surgery achieve--from the viewpoint of heart surgery]. / Welchen Behandlungswunsch hat der Patient im höheren Lebensalter an die Chirurgie und was kann die Chirurgie leisten--aus Sicht der Herzchirurgie.

In the west the elderly population is constantly increasing. Consequently, the percentage of old and very old patients is also increasing among cardiac surgical cases. Almost all cardiac diseases which can be treated surgically can be corrected nowadays with good results even in very old patients. Prerequisites are the correct judgement of individual risk and possible individual gain for the patient. This has to be weighted against the surgeon's and the institution's results. Today, no patient requiring a cardiac operation should be refused on the grounds of age.

[Prevention and management of dysfunction of prosthetic heart valves]. / Prävention und Management von Fehlfunktionen von Herzklappenprothesen.

The ideal heart valve prosthesis has not been developed. The today available mechanical and biological prostheses are far from perfect concerning thrombogenesis, mechanical durability and hemodynamic performance. Failure of an implanted valve is possible due to inadequate indication, inadequate surgical technique and inadequate medical follow-up. The patient with a heart valve prosthesis must be seen as a life-long challenge for the cooperation between cardiologists and cardiac surgeons. This article describes the main causes of prosthetic heart valve dysfunction and the surgical treatment, including structural dysfunction, thrombosis, paravalvular leakage, tissue ingrowth and prosthetic valve endocarditis.

Coronary artery and aortic valve disease as a long-term sequel of mediastinal and thoracic irradiation.

Mediastinal and thoracic irradiation has been identified as a risk factor for the development of among other things, coronary artery disease (CAD) and valvular disease. We screened all patients for a history of mediastinal or thoracic radiotherapy. Between 01.07.1989 and 31.12.1995 we identified 33/16,364 patients with such a history. In 19 cases (0.12%) the cardiac disease was considered radiation-induced, nine patients were female, ten were male. Mean age was 51.7 years (range 38-73). All 19 patients displayed proximal coronary artery stenoses. Mean age in the CAD group was significantly lower (48.5, range 38-63) than in the valvular group (mean age 64.0, range 55-73). The mean interval since radiotherapy in the valvular group was significantly longer (22.25 years, range 13-32) than the one in the CAD group (12.2 years, range 7-24). All patients were treated surgically and made an uneventful recovery. Some form of mediastinal fibrosis or pericardial adhesions was present in all patients. We conclude from these findings that radiation-induced cardiac disease is infrequently encountered in patients from a large surgical center. However, especially the radiation-induced coronary artery disease displays a specific pattern of stenosis location.

[Coronary artery stenoses close to the ostia after mediastinal irradiation]. / Ostiennahe Koronararterienstenosen nach mediastinaler Bestrahlung.

A 42-year-old man who 16 years previously had had mediastinal radiotherapy (total focal dosage of 52 Gy) for a malignant lymphoma, developed chest pain on mild exertion. Coronary arteriography during a diagnostic cardiological work-up revealed a 50-70% stenosis of the right coronary artery near its origin and a 90% stenosis in the main left coronary artery. Except for being slightly over-weight (85 kg at a height of 181 cm) there were no risk factors for coronary heart disease and there was no evidence for arterial disease elsewhere. A double aortocoronary vein graft was placed to the right coronary artery and the interventricular branch of the left coronary artery. The postoperative course was unremarkable and the patient has resumed his occupation. This report emphasizes that, in case of atypical chest pain after mediastinal radiotherapy, coronary heart disease as a late complication should be considered.