Minimized perfusion circuits: an alternative in the surgical treatment of Jehovah's Witnesses.

OBJECTIVES: Jehovah's Witnesses present a challenge to cardiac surgeons, as quality of care is not only defined by mortality and morbidity, but also by the avoidance of blood transfusions. Over the last years, minimized perfusion circuits (MPC) have contributed substantially to the achievement of this goal in our clinic. Presented is a retrospective analysis of our experience. METHODS: Twenty-nine Jehovah's Witnesses, aged 69 ± 10 years, have undergone cardiac surgery with a MPC in our institution since 2005. The ROCsafe (reservoir optional circuit) MPC was used in most of these patients (n=27) as it offers the unique possibility of a speedy integration of a reservoir in the event of a major air leak, thereby, negligating any safety concerns. RESULTS: There was no in-hospital or 30-day postoperative mortality. Mean ICU stay was 1.6 ± 2 days with a mean intubation time of 11.3 ± 9.1 hrs. Postoperative complications included one myocardial infarction with accompanying low cardiac output, one stroke, one transient delirium, one idiopathic thrombocytopenia and three re-operations (one sternal infection, one postoperative bleeding and one delayed tamponade). The mean postoperative hospital stay was 9.9 ± 2.3 days. Mean decrease in hemoglobin was 2.1 ± 1.3 g/dl during cardiopulmonary bypass and 3.4 ±1.4 g/dl at discharge. The lowest postoperative hemoglobin level was 9.3 ±1.8 (Range 6-12.9). CONCLUSIONS: These encouraging results emphasize the role MPCs can play in optimizing the quality of patient care. We hope that this report can serve as a stimulus for similar experiences.

Flush perfusion with low potassium dextran solution improves early graft function in clinical lung transplantation.

OBJECTIVES: We have previously demonstrated experimentally an amelioration of reperfusion injury of the lung after preservation using low potassium dextran (LPD) solution compared to Euro-Collins (EC) solution. Now we report on early graft function in 106 lung transplant recipients of LPD or EC preserved grafts. METHODS: Initial graft function was assessed by measurement of lung compliance and oxygenation index 2 h after transplantation. Length of stay on the intensive care unit and hours of mechanical ventilation were compared. Correlation of donor oxygenation, ischemic time, type of transplant, recipient age and sex as well as initial lung compliance and oxygenation with early postoperative course were calculated. RESULTS: Dynamic lung compliance was significantly (P<0.05) improved in the LPD group. PO(2)/fiO(2) was comparable in both groups (303+/-122 mmHg LPD, 282+/-118 mmHg EC). Mechanical ventilation was used for 321+/-500 h in the EC group and 189+/-365 h in the LPD group (P=0.006). Intensive care therapy was required for 17.2+/-23.7 days in the EC group and 10.4+/-16 days in the LPD group (P=0.012). Significantly higher lung function parameters were obtained in extubated recipients of LPD preserved grafts 2 weeks after TX. Thirty day graft survival was improved in the LPD group (P=0.045). In the EC group, 30 day mortality was 14.2 and 8% in the LPD group. CONCLUSIONS: A reduction of perioperative mortality and morbidity suggests that LPD solution has superior early graft function compared to lung preservation using EC solution.

Minimally invasive coronary artery revascularization on the beating heart.

BACKGROUND: The quality of surgical beating heart revascularization is frequently questioned, especially when the surgical access is limited. Nevertheless, the number of off-pump coronary procedures is expanding worldwide. METHODS: Since getting started with minimally invasive direct coronary artery bypass to anterior myocardial vessels in June 1996, 306 patients received left internal mammary artery grafting through an anterior minithoracotomy. Risk increasing comorbidities were present in 168 of them. Particular attention was paid to early postoperative angiographic results and complications. RESULTS: The 30-day mortality summed up at 1.0% and was limited to patients with additional risks for conventional bypass grafting. Early postoperative control angiographies in 232 patients confirmed a global patency rate of 97.8%, revealing in addition four unexpected malinsertions to diagonal branches. In surviving patients major complications like myocardial infarction, stroke, or multiorgan failure were completely absent. CONCLUSIONS: Minimally invasive direct coronary artery bypass grafting appears to allow for a safe and effective revascularization of the left anterior descending artery by use of the left internal mammary artery. Especially patients with risk increasing comorbidities should benefit from this approach, provided the surgical indication based on a dominating left anterior descending artery lesion. Angiographic minimally invasive direct coronary artery bypass results seem to fulfill the expectations generated by results obtained in conventional left internal mammary artery grafting and appear to be superior to interventional means.

Different approaches for minimally invasive closure of atrial septal defects.

BACKGROUND: To improve the acceptance of cosmetic results after closure of atrial septal defects, anterior or lateral thoracotomies are preferred rather than median sternotomies. Along with the availability of minimally invasive techniques, a further reduction in incision length appeared feasible while preserving thoracic stability. METHODS: Various minimally invasive approaches differing in the type of incision and mode of cannulation have been applied under conditions of normothermic ventricular fibrillation. In technique 1 (n = 5), a right parasternal mini-incision was combined with a central aortic and bicaval cannulation. Technique 2 (n = 2) was composed of an anterior submammary mini-incision with femoral arterial and central bicaval cannulation. To optimize the surgical access, the transincisional cannulation of the superior vena cava was replaced by a percutaneous cervical cannulation (technique 3, n = 17). RESULTS: Effective atrial septal defect closure assessed by intraoperative echocardiography was achieved in all patients. Central neurologic complications were completely absent. Besides temporary atrial fibrillation in one case, no other cardiac complications occurred. There were no cases with complicated wound healing. CONCLUSIONS: Along with modified cannulation techniques and intraoperative echocardiography, minimally invasive techniques can be safely applied for atrial septal defect closure. Submammary incisions were highly accepted and allowed for adequate surgical exposure.

Porcine endogenous retrovirus (PERV) was not transmitted from transplanted porcine endothelial cells to baboons in vivo.

The discussion about the clinical risk of zoonoses in xenotransplantation has recently culminated in the demand for a moratorium on clinical organ transplantation using pig donors. The basis for this discussion was a recent report showing a possible trans-species transmission of pig endogenous retrovirus (PERV) by in vitro transfer to human cell lines. At present, it remains unclear if this could also happen in vivo or in the setting of xenotransplantation. Potential in vivo transfer of PERV after xenotransplantation was investigated in an experimental pig-to-baboon cell transplantation model. Baboons were immunosuppressed with high-dose cyclophosphamide (total 45-150 mg/kg) and transplanted with primary porcine aortic endothelial cells (PAEC). Tissue samples (skin, lymph nodes, lung) and peripheral blood leukocytes of 15 baboons, taken about 12-24 months after transplantation of PAEC, were then analyzed by PCR and showed no PERV infection. PERV expression in PAEC was also analyzed: PERV mRNA and reverse transcriptase in the culture supernatant could be detected. In spite of the release of retroviral particles from cultured PAEC, transplantation of these cells into baboon recipients did not result in virus transmission, not even under heavy immunosuppression.