Modulating IL-6 and IL-10 levels by pharmacologic strategies and the impact of different extracorporeal circulation parameters during cardiac surgery.

Postoperative morbidity after coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) can be influenced by pro- and anti-inflammatory cytokines like interleukin 6 (IL-6) and IL-10 triggering and balancing the acute phase response. The extent of cytokine release can be modulated by different methods. This prospective randomized study examines the effect of treatment of patients with steroid (group 1, 250 mg of prednisolone)(Solu-Decortin H)), aprotinin (group 2, 6 Mio. KIU [kallikrein inhibitory units] aprotinin [Trasylol]), and heparine coating of the artificial surface (group 3, Bioline) on the systemic release of IL-6 and IL-10 in four groups of 40 patients with coronary artery disease (CAD) scheduled for CABG. Group 4 (standard medication) served as control. Twenty hemodynamic and biochemical parameters of the CPB were analyzed regarding correlation to cytokine levels measured by enzyme-linked immunosorbent assay (ELISA). In group 1, IL-6 was suppressed compared to the control (P< 0.01). IL-10 was upregulated (P< 0.01). In group 2, cytokine release was similar to group 1. Using heparin-coated circuits in group 3 led to IL-10 upregulation (P < 0.05) and IL-6 suppression (P < 0.05). We found an exponential relationship between IL-10 levels (IL-6 levels) and cardiac ischemia time, duration of CPB, and the extent of negative base excess. An inverse relationship was found for IL-10 (IL-6) levels and venous O2 saturation (SvO2), and mean arterial pressure (MAP). Hypothermia (<34 degrees C) reduced IL-10 and IL-6 release, whereas long duration of hypothermia correlated with higher IL-10 and IL-6 release. Cytokine release after extracorporeal circulation (ECC) can be modulated pharmacologically and by distinct perfusion regimen.

Posttraumatic aneurysm of the right atrium.

We report on an acquired right atrial false aneurysm, which was removed under extracorporeal circulation. The patient remembered three occasions of blunt chest trauma with rib fractures. Clinical symptoms were ongoing dyspnea, chest pain, and atrial fibrillation.

Monosomy 22q11 in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries.

OBJECTIVE: To describe the morphology of the pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries with and without monosomy 22q11. DESIGN: A retrospective analysis of all patients with this congenital heart defect who are being followed at the University Children's Hospital Erlangen. SETTING: A tertiary referral centre for paediatric cardiology and paediatric cardiac surgery. PATIENTS: 21 patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. Monosomy 22q11 was diagnosed by fluorescent in situ hybridisation using the D22S75 probe (Oncor). The morphology of the pulmonary arteries was assessed on the basis of selective angiograms. RESULTS: 10 patients (48%) were shown to have a microdeletion in 22q11 (group I). There was no difference with respect to the presence of confluent central pulmonary arteries between these patients (80%) and the remaining 11 patients (group II) without monosomy 22q11 (91%). Patients of group I, however, more often had arborisation anomalies of the pulmonary vascular bed (90% in group I v 27% in group II). Because of the more severe abnormalities of the pulmonary arteries, a biventricular repair had not been possible in any of the children with monosomy 22q11, though repair had been carried out in 64% of the children in group II. CONCLUSION: The developmental disturbance caused by the monosomy 22q11 seems to impair the connection of the peripheral pulmonary artery segments to the central pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries, resulting in a lower probability of biventricular repair.

Changes in pulmonary artery size before and after total cavopulmonary connection.

OBJECTIVE: To assess changes in size of the central pulmonary arteries following a total cavopulmonary connection (TCPC). DESIGN: A retrospective analysis of the angiographic diameters of the central pulmonary arteries, expressed as z scores, in infancy before the TCPC and 3.5 (0.9) years (mean (SD)) later. Analysis of the relation between the pulmonary arteriolar resistance and the z scores at follow up. SETTING: Tertiary referral centre. PATIENTS: 32 patients who had TCPC from February 1990 to July 1993. RESULTS: The patients were divided into two groups (n = 16) depending on their preoperative flow ratio: group I, Qp/Qs < or = 1; group II, Qp/Qs > 1. At the initial study in infancy the mean z scores in group I were -6.0 for the right pulmonary artery (RPA) and -9.6 for the left pulmonary artery (LPA); in group II the respective values were -2.7 and -3.0. Before the TCPC the values increased to 0.5 (RPA) and -0.5 (LPA) in group I, and to 8.8 (RPA) and 8.2 (LPA) in group II. At follow up the z scores decreased to -2.4 (RPA) and -4.9 (LPA) in group I, and to 2.2 (RPA) and -0.7 (LPA) in group II. The changes in pulmonary artery diameters were significant for both groups (p < 0.02). Following the TCPC, no significant difference in pulmonary arteriolar resistance index was found between patients with relatively small pulmonary arteries (z score RPA + LPA < or = 0) and those with relatively large pulmonary arteries (z score RPA + LPA > 0). CONCLUSIONS: Creation of a TCPC results in a significant reduction in size of the central pulmonary arteries. At a mean interval of 3.5 years following the TCPC, however, there was no significant difference in pulmonary arteriolar resistance index between patients with smaller and larger central pulmonary arteries.

Surgical removal of a lipoma of the heart.

In a 29-year-old woman echocardiography revealed a tumour originating from the anterior wall of the right ventricle. Noninvasive findings aroused suspicion of a lipoma. The tumour was removed under cardiopulmonary bypass, the resulting defect in the right ventricular wall being covered with a Goretex patch. Histological examination classified the tumour as a rhabdomyolipoma.

Electrocardiographic characteristics indicating a risk of irreversibly impaired myocardial function in chronic aortic regurgitation.

In order to define which of selected ECG variables could indicate irreversibly impaired myocardial function in chronic aortic regurgitation 54 patients were stratified according to normal (> or = 50%; Group A, n = 41) or subnormal radionuclide left ventricular ejection fraction (LVEF < 50%; Group B, n = 13) late after aortic valve replacement. Preoperatively, Group B patients had a significantly greater QRS duration, greater R-peak time (RPT) prolongation in I, V5 or V6, greater RPT relative to the S-peak time of the maximum S in V1, V2 or V3 (R-peak delay) and a greater negative T-wave in I or V6, as compared with Group A. These ECG variables together with preoperative angiocardiographic LVEF and end-systolic volume index were subjected to stepwise linear discriminant analysis. The maximum RPT, angio-LVEF and the maximum RPT relative to the S-peak time of the maximum S in V1, V2 or V3 emerged as the most promising variables. Of of Group A patients 82.9% and 84.6% of Group B patients were correctly classified by the three variables. If applied separately, APT prolongation or the presence of the R-peak delay in the left-sided leads, although less sensitive, have reasonably high specificity as risk indicators of irreversibly impaired chamber function, their positive predictive value being 60 and 62.5%, respectively. In conjunction with preoperative LVEF the diagnostic contribution of the two ECG variables amounts to the greatest overall separation of postoperatively preserved from irreversibly impaired systolic function.

Assessment of left ventricular function from the electrocardiogram in left bundle branch block.

The QRS duration, maximum right precordial S amplitude, sum of amplitudes of the maximum right precordial S and T wave and T wave polarity in lead I have been analyzed in order to identify electrocardiographic predictors of left ventricular end-diastolic volume index and ejection fraction in 165 patients with complete left bundle branch block and various forms of heart disease. Multivariate analysis selected the duration, maximal amplitude of the S wave and polarity of the T wave in decreasing order of discriminatory power, which correctly identify 76.6% of the patients with a normal end-diastolic volume index less than or equal to 90 ml/m2 and a normal ejection fraction greater than or equal to 60% (n = 64) and 73.3% of those with an end-diastolic volume index greater than 90 ml/m2 or an ejection fraction less than 60% (n = 101). The comparisons of the QRS duration with the end-diastolic volume index and the ejection fraction give the best single correlations: r = 0.57 and -0.63, respectively. Multiple correlations lead to no substantial improvement of the r values: 0.06 and -0.65, respectively. A QRS duration less than 140 msec is almost always predictive of the presence of a normal end-diastolic volume index and a normal ejection fraction (sensitivity 100%, specificity 91.9%, positive predictive value 73.3%). A QRS duration greater than 170 msec is most accurate in predicting depressed left ventricular ejection fraction less than 55% (sensitivity 36.5%, specificity 98%, positive predictive value 92%). Thus, only the QRS duration provides a useful reference and guide for the evaluation of left ventricular function in the presence of left bundle branch block.

Pericardectomy for chronic constrictive pericarditis: risks and outcome.

From 1970 to 1990, 71 consecutive patients (51 men and 20 women) had pericardectomy for chronic constrictive pericarditis. The mean age was 44.2 +/- 16.1 years. In the preoperative state 2.8% were in NYHA class I, 18.3% in II, 43.6% in III and 35.2% in IV. The operative approach was median sternotomy in 93% and left anterolateral thoracotomy in 7%. The early mortality rate (within 30 days after operation) was 5.6%. All four early deaths were female (P < 0.001), in the preoperative state the patients were classified as NYHA class IV (P < 0.01). These patients had a significantly higher preoperative mean right atrial pressure then survivors (21.5 +/- 8.5 mmHg vs 13.6 +/- 5.6 mmHg, P < 0.005). Follow-up was obtained for 65 patients (91.5%) and averaged 11 +/- 5.8 years (the longest period was 21.5 years). Actuarial survival at 5, 10, 15 and 20 years for all patients was 84.6% +/- 4.5%, 80.1% +/- 5.3%, 70.5% +/- 6.9% and 65.8% +/- 7.9%, respectively. In the preoperative state 10 of the 12 late deaths (83%) were classified NYHA class IV and the remaining ones class III. Of the 49 patients alive 23% belong to NYHA class I, 42% to II and 35% to III; none is in class IV. Negative predictors of survival were found to be preoperative NYHA class IV (P < 0.01), low-voltage electrocardiogram (ECG) (P < 0.01), ascites (P < 0.01), dyspnea at rest (P < 0.05) and hyperbilirubinemia (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Thromboembolic and bleeding complications after mitral valve replacement.

One thousand six hundred and sixty-eight consecutive patients who underwent isolated mitral valve replacement (MVR) from 1963 to 1984 were evaluated retrospectively. Thromboembolism occurred with a linearised rate of 2.5% +/- 0.2%/patient-year (PY) for Starr-Edwards disc prosthesis Model 6520, 2.4% +/- 0.3%/PY for Bjørk-Shiley plane prosthesis, 3.0% +/- 0.8%/PY for Bjørk-Shiley convexo-concave 60 degrees prosthesis, 3.0% +/- 0.8%/PY for St. Jude Medical prosthesis and 3.4% +/- 0.5%/PY for Carpentier-Edwards tissue valve without the differences reaching significance. In the SJM group, the incidence of thromboembolism was significantly higher (P less than 0.025) in smaller sizes (less than M29) probably due to a more turbulent flow. The linearised rate for major haemorrhage was 1.6% +/- 0.1%/PY. Twenty-three percent of the thromboembolic and 18% of the bleeding events were fatal. Sixty-eight percent of the emboli involved the central nervous system and bleeding apart from fatalities was predominantly non-cerebral (81%). Whereas thromboembolism was a time-related event with more than twice as high a risk in the first postoperative year (4.2% +/- 0.5% vs. 1.7% +/- 0.8%, P less than 0.01), bleeding occurred with a constant rate over time (0.9% +/- 0.4%). Adequacy of anticoagulation was an important risk factor for postoperative embolism with the prothrombin time (PT) exceeding the therapeutic range in 65% of all events. A preoperative history of embolism was the only additional patient-related risk factor for postoperative embolism (18.3% vs. 9.6%, P less than 0.001). In 30% of all haemorrhage, the PT was below 15%.(ABSTRACT TRUNCATED AT 250 WORDS)

High-risk mitral valve replacement in severe pulmonary hypertension--30 years experience.

OBJECTIVE: In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP) > 50 mmHg; pulmonary vascular resistance (PVR), 690 +/- 46 dyn/s per m2). We reviewed our early and late results in this high-risk subgroup. METHODS: We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4 +/- 0.2 years per patient. The overall early mortality rate was 10.5% (n = 40) and stayed at about the same level over the years, although patients characteristics have changed to much older patients and more reoperations. To clarify this fact we divided our data in results according to the decades in which the operations were carried out. The clinical preoperative status and results were as follows (*P < 0.05; **P < 0.01 compared with previous decade). In the decades between 1963 and 1973 (I), 1974 and 1983 (11) and 1984 and 1993 (III) we operated on n = 95 (I), n = 185 (II), and n = 102 (III) patients with a mean age of 43 +/- 1 (I), 50 +/- 1** (II), and 58 +/- 1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6%** (III). The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (III); late mortalities lowered from 5.77 (I), over 4.95 (II), and up to 3.39%** (III) patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0 +/- 0.1 (I), 3.2 +/- 0.1 (II) and 3.3 +/- 0.1 (III) to 2.4 +/- 0.2 (I), 2.4 +/- 0.1 (II) and 2.3 +/- 0.1 (III) postoperatively. RESULTS: Compared with routine elective MVR with a mortality rate of 3.6% (P < 0.01), early mortality is high. But once the patient survives the perioperative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as well are not significantly different. In spite of on average 15 years older multimorbid patients with therefore higher complication rates, early results improved slightly, which could be explained by better operative techniques, perioperative treatment and nursing (online monitoring with immediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes. CONCLUSION: According to our results, we recommend MVR in severe pulmonary hypertension even in the elderly, with a high but acceptable risk and good long-term results.

Results of a 1 to 31 years follow-up after aortic valve replacement in 2327 patients.

We studied the outcome of 2327 patients after aortic valve replacement from October 1962 to December 1993. 1840 mechanical (mostly STJ bi-leaflet and BS tilting disc valves) and 487 biological (IS and CE valves) prostheses were implanted. The mean follow-up period of 1458 surviving patients was 7.1 years. There were 688 non-survivors and 181 lost cases. The mean age was 50.1 years, 73% of the patients were male and 27% were female. Early mortality was about 20% in the 1960's and about 4.5% in the last years. Mortality following valve replacement was influenced by preoperative NYHA classification, cardiac index, pressure gradient and simultaneous CHD. The long term results of all valves showed a survival rate of 80% after 5 years, 73% after 10 and 60% after 15 years following operative treatment. There was no significant difference in survival rates between all mechanical and biological valves. Non-lethal complications of all mechanical valves showed no significant difference but there was a clearly lower rate of paraprosthetic leakages, haemolysis and thromboembolism in biografts. The biological valves showed a high rate of degeneration (2.7%/pty). Reoperation was performed in 170 patients. Most valve changes consisted of biological to mechanical and mechanical to mechanical valves. The main reason of reoperation was degeneration (biological), paraprosthetic leakage and haemolysis (mechanical). The cause of death of the 688 non-survivors was valve related in 17.9%. 37% of these were due to thromboembolism and 38% due to bleeding. 55.6% of survivors (group 2) could be ascribed to NYHA class III and 17.2% to class IV prior to operation. Postoperative outcome demonstrated an improvement in NYHA classification in about 80%. Of surviving patients 80% pronounced an increase of physical activity after operation.

Analysis of adhesion molecules in myocardial biopsies of cardiac allografts and coronary artery disease with CABG.

Interactions of leukocytes with vascular endothelium are important components of inflammation tissue reactions and have been implicated in cardiac transplant rejection and demonstrated to be mediated by cell adhesion molecules (CAM's). The expression of ICAM-1, VCAM-1 and E-selectin in human myocardium is variable and little is known about the expression of LFA-1 and Mac-1 during allograft rejection. This study investigated these CAM's in myocardial biopsies of transplanted hearts (HTX) and of coronary artery disease eligible for coronary artery bypass grafting (CABG) as non-inflammatory controls and explicitly examines vascular endothelium, cardiomyocytes and infiltrating cells. Immunohistochemistry was performed using the APAAP-method and directing specific mouse anti-human monoclonal antibodies against ICAM-1 (CD54), VCAM-1 (CD106), E-selectin (CD62E), alpha-LFA-1 (CD11a), alpha-Mac-1 (CD11b), alpha-p150/95 (CD11c) and the beta2-integrin chain (CD18). CD18, LFA-1 (CD11a), Mac-1 (CD11b) and p150/95 (CD11c) were markedly expressed on infiltrating immunocytes in HTX compared to CABG where no expression of beta2-integrins was observed. Cardiac allografts demonstrated a strong expression of ICAM-1 on vascular endothelium and on infiltrating cells. ICAM-1 was not detected on cardiomyocytes. In CABG a weak expression of ICAM-1 was observed on endothelial cells but not on myocytes. VCAM-1 was expressed on vascular endothelium and perivascular infiltrating cells in HTX but not in CABG. VCAM-1 was not found to be expressed on myocytes. There was no evidence for the presence of E-selectin in any of our biopsy specimens. Our study shows that the study of cell adhesion molecules adds to the pathophysiological understanding of inflammation after transplantation in cardiac disease. This offers a potential for the development of diagnostic tools and new therapeutic strategies.

Left ventricular false aneurysm.

False aneurysms of the left ventricle develop after rupture of the ventricular wall in an area of pericardial adhesions. This complication of myocardial infarction is uncommon. Images of a post-infarction false aneurysm are presented.

Asymptomatic strut fracture in DeBakey-Surgitool aortic valves: incidence, management, and metallurgic aspects.

From August 1971 through November 1972, we implanted 62 Model 2 DeBakey-Surgitool aortic valve prostheses in 62 patients, 4 of whom later had clinically asymptomatic strut fractures. In 1 case, the patient died suddenly, and autopsy revealed detachment of the ball-cage; in each of the other 3 cases, fractures of 2 struts close to the base of the prosthesis were diagnosed fluoroscopically, and the patients underwent successful reoperation. The interval between implantation and reoperation ranged from 11 months to 16 years, 9 months. In 1 patient, retrospective study of chest radiographs revealed that the fracture had been present for 2(1/2) years. Larger valves (>/= A6) were affected significantly more often than smaller ones. We performed metallurgic analysis of 1 prosthesis: results revealed strut wear from fatigue cracking and secondary abrasion. Strut fracture was also promoted by suspension of the cage at right angles to the prosthetic ring and by use of a pyrolytic carbon ball in a titanium cage (i.e., an occluder harder than its holder). Patients with DeBakey-Surgitool aortic valve prostheses should undergo annual radiologic examinations to enable early detection of strut fractures. Prophylactic valve replacement is not indicated.

[Indication margins for pulmonary embolectomy]. / Indikationsgrenzen der Pulmonalisembolektomie.

Pulmonary embolectomy is the most effective form of treatment in acute, massive pulmonary embolism. Persistent cardio-respiratory failure, in spite of intensive medical therapy, presents a clear indication for embolectomy. A relative indication is given with the occlusion of more than 50% of the pulmonary arterial tree, especially in the case of beginning circulatory failure and contraindications to fibrinolytic therapy. Preoperative angiography is essential and should be performed whenever possible. A dramatic deterioration of the patient's condition may, however, require a prior reestablishment of sufficient circulation with relief of the right ventricle. According to the clarity of symptoms, either immediate thoracotomy or peripheral canulation and partial cardio-pulmonary bypass with subsequent angiography on the operating table should be preferred. Even a long resuscitation with persistently dilated, non-reactive pupils does not exclude operative success, and justifies neither the ommission nor the premature discontinuance of a resolute and consistent therapy.

[Surgical treatment of aneurysm of the left ventricle. Prognostic considerations]. / Trattamento chirurgico dell'aneurisma del ventricolo sinistro. Considerazioni prognostiche.

174 cardiac aneurysms were resected between 1970 and 1977. In 49 patients the remaining contractile segment was revascularised at the same time. The hospital mortality was 10.3%, the late mortality was 14%. The uncorrected cumulative survival rate calculated by the actuarial method was 90% at 3 years (84--96), and 80% at 5 years (74--85). Results were excellent or good in two thirds of the survivors; 44% were free of angina pectoris, 40% were improved, 73% had no disturbances of cardiac rhythm, and in 15% they were improved. Comparison of the pre- and post-operative ejection fraction showed that the indication for surgery of a cardiac aneurysm exists when more than 20% of the musculature of the left ventricle is affected, when the total ejection fraction is larger than 10% when one vessel is affected, and more than 30% when more than one vessel is affected. Contraindications are diffuse coronary heart disease, when ejection fraction of the contractile segment is less than 30%, reduction in contractility of the ventricular septum, and the generally applicable surgical contraindications.