Clinical characteristics and risk profile of patients with elevated baseline serum tryptase.

BACKGROUND: The clinical relevance of elevated basal serum tryptase (eBST ≥ 11.4 ng/ml) often remains unclear. METHODS: BST was assessed in 15,298 patients attending our outpatient clinic. Frequency and severity of anaphylaxis was compared in 900 patients with eBST and 900 patients with normal BST. The prevalence of eBST was evaluated in patients with drug reactions, urticaria, gastrointestinal symptoms or venom allergy. Mast cell-associated symptoms were recorded prospectively in 100 patients with eBST and 100 controls using a standardised questionnaire. RESULTS: 5.9% (n=900) of 15,298 patients had eBST ≥11.4 ng/ml (mean 20 ± 21 ng/ml, 11.4-390 ng/ml). In 47% of them BST was <15.0 and in 78% <20.0 ng/ml. In patients with normal BST (4.5 ± 2.1 ng/ml), mean levels increased continuously with age (0.28 ng/ml per decade; p<0.001). Fatigue, meteorism, muscle/bone ache, vertigo, tachycardia, flush, palpitations, diarrhoea and oedema were associated with eBST (p<0.05 to <0.0001) without significant differences between slightly (11.4-20 ng/ml) or strongly (>20 ng/ml) eBST. eBST was significantly associated with adverse reactions to drugs (34%), radio contrast media (15%) and insect stings (24%) (p<0.05). Anaphylaxis was more common in patients with eBST (21% vs. 14%, p<0.001). The relative role of insect stings, drugs and food as the most important triggers was similar in patients with elevated and normal BST. Severe reactions (grade 3/4) occurred most often in subjects with BST >20 ng/ml (BST <11.4 mg/ml: 2.8%; 11.5-20 ng/ml: 5.9%; >20 ng/ml: 12.4%). CONCLUSIONS: In clinical practice it appears reasonable to assess BST, besides after anaphylactic reactions also in patients suffering repeatedly from vertigo, flush, tachycardia, palpitations, oedema and nausea. Even patients with slightly eBST have a higher risk of anaphylaxis and experience more severe reactions.

[GSTCVS certificate for cardiac pacemaker, ICD and CRT therapy]. / DGTHG-Zertifizierung zur Herzschrittmacher-, ICD- und CRT-Therapie.

Medical qualifications to perform operations with cardiac electronic implantable devices as well as for preoperative and postoperative therapy, including follow-up in this patient population are not well defined. Based on recommendations which have been worked out and published by an interdisciplinary consensus of cardiac surgeons, cardiologists and electrophysiologists, a certificate with three modules has been developed by the Working Group for Electrophysiologic Surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS, Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG). First examinations for this certificate will be held in 2013 and transitional regulations apply until 1st April 2014. Further details are available on the homepage of the GSTCVS.

Identification of Bet v 1-related allergens in fig and other Moraceae fruits.

BACKGROUND: Allergy to fig fruit (Ficus carica) has been described in patients allergic to Ficus benjamina or rubber latex but may occur also in pollen-allergic patients. OBJECTIVE: To study the potential cross-reactivity between fig and taxonomically related fruits with the major birch pollen allergen Bet v 1. METHODS: One hundred and eighty-eight patients with or without birch pollen allergy were prick-to-prick tested with fig (F. carica), mulberry (Morus alba), jackfruit (Artocarpus heterophyllus; all family Moraceae) and other pollen-associated foods. Moraceae fruit extracts were separated by SDS-PAGE and tested with patient sera and polyclonal antisera against Mal d 1. Western blot inhibition was performed with Moraceae fruit extracts, birch pollen and recombinant Bet v 1. Putative Bet v 1 homologs in Moraceae fruits were analysed by liquid chromatography-ion trap mass spectrometry. RESULTS: Among 85 patients with isolated birch pollen allergy, 78% had a positive skin test to fresh fig, 10% to dried fig, 91% to mulberry, 91% to jackfruit, 77% to Rosaceae fruits and 83% to hazelnut. Sixty-six per cent of birch pollen-allergic patients positive for fig, reported symptoms after consumption of fresh figs, whereas dried figs were mostly well tolerated. In 60 patients with isolated Ficus benjamina sensitization, the reactivity rates to the same foods were 83-40-0-0-0-0%. None of 32 mugwort pollen-allergic patients reacted to Moraceae fruits. Rabbit anti-Mal d 1 and patient sera reacted to a 17 kDa band in all Moraceae extracts. IgE binding to these proteins was completely inhibited by birch pollen and rBet v 1. Mass spectrometry identified several peptides from the 17 kDa fig, mulberry and jackfruit allergen with respectively 60%, 56% and 76% homology to Bet v 1. CONCLUSION: Fig and other Moraceae fruits contain allergens homologous to Bet v 1 and represent clinically relevant birch pollen-associated foods.

[Training requirements for transvenous implantation of pacemakers and cardioverter-defibrillators]. / Empfehlungen zur strukturierung der herzschrittmacher- und defibrillatortherapie.

Therapy with implantable pacemakers, cardioverter defibrillators (ICD), and devices for cardiac resynchronization (CRT) is performed by various medical and surgical specialists. With the change from implantation by thoracotomy to the transvenous approach, an increasing number of devices are implanted by cardiologists. The purpose of this paper is to establish training requirements for transvenous device therapy, implantation and follow-up examinations, regardless of the implanting person, an internist, cardiologist, general surgeon, or cardiothoracic surgeon. Epicardial lead placement should be performed only by surgeons. Two levels of training topics are defined, level 1 for pacemakers and level 2 for ICD and CRT devices. Surgery that involves the implantation of foreign material should demand the highest standards of operating rooms design and environment. Catheter laboratories used for implantations should meet operating room standards. Complications need to be documented carefully for quality control.

Intranasal mupirocin prophylaxis in elective surgery. A review of published studies.

BACKGROUND: Mupirocin is a natural antibiotic from Pseudomonas fluorescens which is available as a 2% ointment. The drug has been used mainly for topical treatment of the nasal vestibulum in patients carrying methicillin-resistant Staphylococcus aureus (MRSA). However, mupirocin is also active against methicillin-sensitive S. aureus. Nasal colonization with S. aureus has been identified as a significant risk factor for surgical site infection (SSI). METHODS: Randomized trials and sequential cohort studies investigating mupirocin nasal treatment for prophylaxis of SSI in elective surgery in comparison with placebo or no treatment were found by Medline review and additional manual search. Evaluable studies were analyzed regarding the influence of mupirocin on the rate of all SSIs and, specifically, of SSIs due to S. aureus. The effect in cardiosurgical patients was analyzed in detail. RESULTS: Four randomized and seven sequential open cohort studies were analyzed. Study design and mupirocin application schemes varied considerably. Three out of 5 studies carried out in cardiac surgery patients showed a significant reduction in sternotomy site infections. However, all three studies were open sequential cohort studies. By contrast, the only prospective, randomized, double-blind study in cardiosurgical patients showed no benefit of mupirocin. In other surgical disciplines, results were inconclusive or negative. Two studies specifically addressing the prevention of SSIs due to MRSA showed a significant effect of mupirocin on postsurgical infections due to this organism. CONCLUSIONS: Because of the heterogeneity of the studies and the variability of results, no recommendation can be given for the general use of mupirocin in elective surgical patients. Specifically, because of the negative result of a recently published high-quality study, no recommendation can be made for the use of mupirocin in cardiosurgical patients. By contrast, eradication of MRSA before surgery appears to lower SSI rates due to MRSA and is therefore recommended.

[New developments for surgical ablation of atrial fibrillation]. / Zukunftsvisionen und neue Technologien in der chirurgischen Behandlung des Vorhofflimmerns.

The Cox-Maze procedure and less complex modifications have gained widespread use as a treatment modality for patients with concomitant atrial fibrillation. Hypothermic or hyperthermic energy sources play a significant role in rapidly creating linear lesions. Endocardial ablation is easy to perform and effective with different energy sources. Epicardial techniques may simplify the procedure by allowing surgery on a beating heart. But epicardial fat and the heat sink effect of the flowing endocardial blood are obstacles to effective ablation. New devices using bipolar (irrigated) radiofrequency, microwave or laser energy, cryoablation or focused ultrasound are in clinical or pre-clinical stages and permit lesions to be created on a beating heart without cardiopulmonary bypass. Minimally invasive or video-assisted surgical techniques and effective devices for epicardial ablation will enable the treatment of patients suffering from lone atrial fibrillation. To facilitate the comparison between different techniques and devices, guidelines for reporting clinical results are necessary.

Sensitization to Ficus benjamina: relationship to natural rubber latex allergy and identification of foods implicated in the Ficus-fruit syndrome.

BACKGROUND: Ornamental Ficus benjamina (FB) has been recognized as a new indoor allergen. Little is known about the prevalence in moderately exposed subjects and the proposed association with fruit and Hevea latex hypersensitivity. OBJECTIVE: To study the prevalence of FB sensitization and the relationship with Hevea latex allergy, to identify cross-reacting fruits, and to characterize the responsible allergens. METHODS: A skin prick test solution prepared from FB latex (200 microg/mL) was included in our routine screening programme for suspect inhalant allergy. Patients reacting with the FB extract were further skin tested with exotic fruits by the prick-to-prick method. Inhibition of fig and FB CAP by FB latex, fig (Ficus carica), kiwi, the thiolproteases ficin and papain, Hevea latex and rHev b 6.02 (hevein) was performed in selected patients. RESULTS: Of 2662 patients with a positive skin test to any aeroallergen, 66 (2.5%) reacted with FB. Ten patients showed isolated sensitization to FB. Although FB-positive subjects were more often co-sensitized to Hevea latex than FB-negative (10.6% vs 3.8%, P< 0.01), nearly 90% tested negative for Hevea latex. Sensitization to FB was specifically associated with positive skin tests to fresh fig (83%), dried fig (37%), kiwi fruit (28%), papaya (22%), avocado (19%), banana (15%), and pineapple (10%) (n = 54). Clinical reactions were reported mainly from fresh and dried fig and kiwi (47%, 60%, and 64%, respectively, of skin test-positive patients), including seven patients with systemic reactions (urticaria, angiooedema, asthma). CAP to fig in 11 patients with clinical fruit allergy was inhibited on average by 87% by FB latex, 89% by fresh fig, 80% by dried fig, 38% by kiwi (100 microg/mL each), and by 59% and 44% by ficin and papain (50 microg/mL), respectively. No inhibition was obtained with Hevea latex and rHev b 6.02. CAP to FB was inhibited on average by 95% by FB, 60% by fresh fig, 41% by ficin, 29% by papain, and less than 7% by rubber latex allergens. CONCLUSIONS: Sensitization to FB latex is found in 2.5% of atopic individuals and mostly occurs independently of Hevea latex allergy. Sensitization is commonly associated with allergic reactions to figs and other tropical fruits ('Ficus-fruit syndrome'). This cross-reactivity is mediated at least in part by thiolproteases.

Identification of oilseed rape (Brassica napus) pollen profilin as a cross-reactive allergen.

BACKGROUND: Major allergens of oilseed rape (OSR) pollen with molecular weights of 6/8, 14 and between 27 and 69 kD have been described. The aim of the present study was to further characterize the 14-kD allergen. METHODS: The 14-kD protein was purified from OSR pollen extracts by poly-(L-proline) (PLP)-Sepharose affinity chromatography and characterized immunologically by means of allergic patients' IgE antibodies, profilin-specific rabbit antisera, Western blot and ELISA inhibition using recombinant birch profilin (rBet v 2), and skin prick testing. RESULTS: By PLP affinity chromatography, OSR pollen profilin was purified as a single protein of 14.5 kD and further identified as a profilin by three polyclonal rabbit antisera raised against ragweed and tobacco pollen profilin and the C-terminus of birch profilin. IgE binding of a human serum pool (n = 15) and four profilin-reactive sera to nitrocellulose-blotted OSR profilin was completely inhibited by 1 microg/ml rBet v 2 (birch profilin). Reciprocal ELISA inhibition using increasing concentrations of rBet v 2 and purified OSR profilin, respectively, showed that rBet v 2 strongly inhibits antibody binding to OSR profilin, whereas almost 100 times the amount of OSR profilin was needed to inhibit IgE binding to rBet v 2. Skin prick tests were positive (wheal >/=3 mm) with 5 microg/ml rBet v 2 in all three patients tested, and with OSR profilin in two patients at a concentration of 50 microg/ml. CONCLUSIONS: OSR pollen profilin shares IgE and IgG epitopes with Bet v 2 and other plant profilins and may represent a potentially relevant allergen for profilin-sensitized patients.

Results of a modified left atrial maze procedure as a combined procedure.

Starting in November 1999, we performed a left atrial radiofrequency ablation procedure concomitantly to a variety of cardiac surgical procedures. By January 2001, this ablation procedure had been performed on 100 patients (age 65.7 +/- 10.4 years, 53 % male, 47 % female, left atrium 51.0 +/- 7.5 mm) suffering either from chronic or paroxysmal atrial fibrillation. Primary cardiac pathology was mitral valve disease in most cases (43), aortic valve disease (28) or coronary heart disease (27). After bilateral pulmonary veins isolation, an additional ablation line was directed from the left pulmonary veins to the mitral valve annulus (Thermaline probe, Boston Scientific Corporation, USA). Finally, the left atrial appendage was resected. Surgical success was evaluated in the immediate postoperative course, 3 and 6 months postoperatively (ECG and echocardiography), and every year after that. Operative time was 229.7 +/- 56.5 min, ablation time 18.8 +/- 6.9 min. Follow-up is 95 % complete at the time of writing. Mean follow-up time was 7.3 months, ranging from 3 to 23 months. Success (sinus rhythm and atrial contraction) was proven in 72 out of 90 patients (80.0 %) (75.0 % mitral valve surgery, 84.0 % other cardiac surgery). The reported results support a broad spectrum of indications for this left atrial ablation procedure.

Fate of bypass grafts onto totally occluded coronary arteries.

BACKGROUND: Chronically occluded coronary arteries often develop good collateralisation, that leads to retrograde perfusion of these vessels, as regularly seen in coronary angiograms. Retrograde perfusion constitutes a form of competitive flow, which in turn is associated with an increased risk for early bypass graft failure. The aim of our study is to investigate the patency rate of bypass grafts onto totally occluded coronary arteries, in the presence of retrograde flow. METHODS: Two groups of patients were followed up by cardiac catheterisation. One month after undergoing coronary artery bypass grafting. Group 1 (n=33) had coronary three vessel disease, with one totally occluded coronary artery and evidence of retrograde flow in the preoperative coronary angiogram. Group 2 (n=30) was the control group, with coronary three vessel disease and without totally occluded coronaries. We used internal mammary arteries and saphenous vein grafts as conduits. RESULTS: Thirty-six point thirty-six per cent of bypass grafts onto totally occluded coronaries were occluded one month postoperatively (n=12). Graft failure in the control group was 13.3%. Significance p=0.03. CONCLUSIONS: In view of our findings we conclude, that there is a significantly increased incidence of early graft failure, when totally occluded coronary arteries are revascularised, that show retrograde flow in the preoperative coronary angiogram.

The Ross operation as a combined procedure and in complicated cases--is there an increased risk?

BACKGROUND: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures. METHODS: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2: mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95 % complete. RESULTS: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in 1 vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group. CONCLUSION: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.

Long term follow up of left ventricular function after repair of left ventricular aneurysm. A comparison of linear closure versus patch plasty.

OBJECTIVE: Suboptimal early and unsatisfactory late results after linear closure of left ventricular aneurysms, have focused attention on more physiologic concepts of aneurysmectomy, like endoventricular patch plasty. The aim of our study was to compare clinical results of linear closure and patch plasty 8 years after surgery. METHODS: From a total of 102 patients with postinfarctional left ventricular aneurysms, clinical outcomes and echocardiographic measurements of left ventricular function in 32 patients who underwent linear closure were compared to those of 20 patients who had endoventricular patch plasty. RESULTS: The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation and concomitant procedures. In the patch plasty group, ejection fraction increased from 33.1+/-12.2% to 34.4+/-9.7%. In the linear closure group, ejection fraction decreased from 44.3+/-10.9% to 40.1+/-7.9%. Perioperative mortality and complications, long term survival and functional class were similar in both groups with a total perioperative mortality of 1.9%, an 8-year survival rate of 85.6%, and a mean NYHA functional class of 2.51. CONCLUSION: Long-term follow up showed a decline in ejection fraction in the direct closure group and a slight increase in the patch plasty group. We suggest that linear closure should be limited to small ventricular aneurysms and that large ventricular aneurysms extending into the septum should be treated by patch plasty.

Background and early results of a modified left atrial radiofrequency procedure concomitant with cardiac surgery.

With the introduction of the maze operation Cox was able to show that the surgical treatment of atrial fibrillation (AF) is feasible. However, the maze operation remains surgically demanding and time-consuming as it requires multiple incisions in both atria. This has led to the development of various modifications. With new ablative technology and the acceptable results of an exclusively left atrial maze procedure in combination with mitral valve surgery, it has become possible to simplify the maze operation radically. Thirty-one patients ( mean age 62.3 years) with chronic or intermittent AF underwent a modified radiofrequency procedure in combination with some other cardiac surgical operation. Mitral valve disease coexisted in 17 patients, aortic valve disease in 9, coronary heart disease in 4 patients and 1 had an atrial septal defect (ASD). After left atriotomy and with the use of the Thermaline radiofrequency ablator probe, bilateral pulmonary vein isolation was carried out. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve annulus, and finally the left atrial appendage was resected. The complete procedure added an average of only 18.2 minutes to the operation. In the early postoperative course AF or atrial flutter recurred in 12 patients but at discharge only 8 patients (24%) still had an arrhythmia. We concentrated on the first 26 patients of our series who had received a follow-up examination 3 months postoperatively. At discharge 18 of the 26 patients were in sinus rhythm (69,2%), and at 3 months after surgery 23 of 26 patients were in sinus rhythm (88.5%), with recovery of atrial contraction confirmed echocardiographically. Only 4 patients still required medication for arrhythmias. The modified radiofrequency ablation procedure of the left atrium proved to be simple to perform, quick and reliable. It offers the possibility of a surgical cure for AF when performed together with another cardiac operation, and the early results indicate a high rate of success for this simple procedure.

The ross operation in 225 patients: a five-year experience in aortic root replacement.

BACKGROUND AND AIM OF THE STUDY: The Ross operation, introduced more than 30 years ago, has recently undergone several modifications to improve both technical feasibility and results. At the authors' institution, the Ross operation, performed as root replacement in all cases, was commenced in February 1995. METHODS: A total of 225 patients (177 males, 48 females; mean age 39+/-15 years; range: 2 to 67 years) were operated on up to December 2000. Aortic regurgitation was present in 80 patients, stenosis in 69, and combined disease in 73; prostheses were replaced in three patients. Combined procedures were performed in 51 patients. Nine patients had active endocarditis. Follow up was 98% complete and totaled 471 patient-years. RESULTS: There was no early mortality, and no thromboembolic or hemorrhagic events. Complications included prolonged ventilation in two patients, perioperative myocardial infarction in three, pacemaker implants in three and perioperative bleeding in six. One patient died at 25 months from hemoptysis, and one at five months of unknown cause. In the long term, four patients required reoperation due to autograft regurgitation (one autograft repair, three autograft replacements). Routine aortic annulus support, a lowered threshold in replacing all dilated ascending aorta and keeping the autograft short to the level of the sinotubular junction seems to have prevented further autograft failure. Pulmonary homograft stenosis led to reoperation in one patient. Six patients with elevated gradients are currently under observation. Echocardiography revealed autograft median peak gradients of 5.1+/-2.8 mmHg, pulmonary homograft gradients of 14.2+/-11.5 mmHg, and no significant regurgitation, except in one additional patient with recently diagnosed aortic insufficiency (grade >2). CONCLUSION: Mid-term excellent hemodynamic results, low morbidity and reoperation requirement support the evolved root replacement technique and justify its further utilization.

Surgical pacemaker lead extraction: 10 years of experience.

Due to the worldwide increasing number of patients with pacemaker implants, the problem of lead extraction with its potential difficulties and complications has gained enormous importance. Primarily lead extraction should be attempted percutaneously; however, in case of failure or contraindications for percutaneous extraction, such as vegetations with a high risk of embolization (size >10mm), a surgical approach is necessary. From 1991 until 2001 we performed surgical lead extraction in 16 patients (mean age 62.1±15.0 years, male 13, female 3). All patients presented with lead infection and clinical symptoms of septicemia at a rather advanced stage, in average 7.0±8.8 months after the onset of symptoms. In 13 cases we performed an open heart approach with the use of cardiopulmonary bypass, in 3 a closed heart approach. Perioperative mortality was 0%. Pacemaker leads were successfully removed in 100%. No reinfections were reported. Surgical pacemaker lead extraction is a highly effective tool and can be safely performed without significant mortality. If surgery is indicated it should be performed as early as possible.

Serine-53 at the tip of the glycine-rich loop of cAMP-dependent protein kinase: role in catalysis, P-site specificity, and interaction with inhibitors.

The glycine-rich loop, one of the most important motifs in the conserved protein kinase catalytic core, embraces the entire nucleotide, is very mobile, and is exquisitely sensitive to what occupies the active site cleft. Of the three conserved glycines [G(50)TG(52)SFG(55) in cAMP-dependent protein kinase (cAPK)], Gly(52) is the most important for catalysis because it allows the backbone amide of Ser(53) at the tip of the loop to hydrogen bond to the gamma-phosphate of ATP [Grant, B. D. et al. (1998) Biochemistry 37, 7708]. The structural model of the catalytic subunit:ATP:PKI((5)(-)(24)) (heat-stable protein kinase inhibitor) ternary complex in the closed conformation suggests that Ser(53) also might be essential for stabilization of the peptide substrate-enzyme complex via a hydrogen bond between the P-site carbonyl in PKI and the Ser(53) side-chain hydroxyl [Bossemeyer, D. et al. (1993) EMBO J. 12, 849]. To address the importance of the Ser(53) side chain in catalysis, inhibition, and P-site specificity, Ser(53) was replaced with threonine, glycine, and proline. Removal of the side chain (i.e., mutation to glycine) had no effect on the steady-state phosphorylation of a peptide substrate (LRRASLG) or on the interaction with physiological inhibitors, including the type-I and -II regulatory subunits and PKI. However, this mutation did affect the P-site specificity; the glycine mutant can more readily phosphorylate a P-site threonine in a peptide substrate (5-6-fold better than wild-type). The proline mutant is compromised catalytically with altered k(cat) and K(m) for both peptide and ATP and with altered sensitivity to both regulatory subunits and PKI. Steric constraints as well as restricted flexibility could account for these effects. These combined results demonstrate that while the backbone amide of Ser(53) may be required for efficient catalysis, the side chain is not.

[Pili trianguli et canaliculi. A case report of uncombable hair in relation to atopic eczema and tooth anomalies]. / Pili trianguli et canaliculi. Ein Fallbericht über unkämmbare Haare in Verbindung mit atopischem Ekzem und Zahnanomalien.

We report on a child with pili trianguli et canaliculi. This hair shaft abnormality belongs to a heterogeneous group of diseases which are included under the synonym uncombable hair. The diagnosis was confirmed by scanning electron microscopy, revealing hair shafts with a characteristic longitudinal groove. In addition the girl suffered from atopic eczema and tooth anomalies. Our findings suggest that this disorder could represent a tricho-odontal subtype of ectodermal dysplasia.

Leaflet escape in a TEKNA and an original duromedics bileaflet valve.

We report a case of leaflet escape in an Edwards-TEKNA bileaflet valve, in the mitral position. The examination findings of the explanted valve are compared with a similar case of leaflet escape in an original Edward-Duromedics prosthesis. Based on our findings alone, it is not certain whether the TEKNA valve continues to have a higher risk for fracture.

Exposure to formaldehyde and phenol during an anatomy dissecting course: sensitizing potency of formaldehyde in medical students.

BACKGROUND: The sensitizing potency of formaldehyde and phenol during anatomy dissecting was investigated. The objective was to determine whether exposure induces specific IgE or IgG against formaldehyde-albumin or phenol-albumin. METHODS: In 27 medical students, specific IgE against formaldehyde-albumin by RAST plus ELISA and specific IgE against phenol-albumin by ELISA were assessed. In addition, specific IgG against formaldehyde-albumin was assessed in 23 students. Symptoms before and during dissecting were assessed, and indoor formaldehyde and phenol were measured. RESULTS: Mean indoor formaldehyde was 0.265 +/- 0.07 mg/m3, and mean indoor phenol was 4.65 +/- 2.96 mg/m3. Specific IgE/IgG against formaldehyde-albumin was not found at the beginning. Four students developed specific IgE against formaldehyde-albumin (RAST classes of > or =2.0), and all four also had specific IgE in the ELISA, but IgG against formaldehyde-albumin was not found. Specific IgE against phenol-albumin was not seen. Itch and paresthesia of the hands (P<0.00001), dizziness (P<0.008), burning eyes (P<0.01), headache, sneezing, epistaxis, gingival bleeding, oral or pharyngeal itch, and shortness of breath were experienced. CONCLUSIONS: Formaldehyde exposure during dissecting may induce specific IgE, but not IgG, against formaldehyde-albumin. Sensitization did not correlate with symptoms.

Initial experience with a modified left atrial maze procedure concomitant to cardiac surgery.

BACKGROUND: The excellent results of the Cox-Maze-III operation showed that a surgical treatment of atrial fibrillation is possible. The maze operation is surgically demanding and time-consuming. This fact led to the development of simplified modifications. Due to the good results of an exclusive left atrial maze procedure in combination with mitral valve surgery and new technologies of ablation, it seems reasonable to perform these techniques concomitant to cardiac surgery on a large number of patients.¶ METHODS: From November 1999 until June 2000 a modified maze procedure concomitant to a cardiac surgical intervention was performed on 42 patients, with a mean age of 62.2 years, suffering from chronic or intermittent atrial fibrillation. Primary cardiac disease was mainly cardiac valve disease (mitral valve disease 19 patients, aortic valve disease 10 patients) or coronary heart disease (8 patients). After left atriotomy and with the use of the Thermaline probe (Boston Scientific, Corporation, San Jose, California, USA) a bilateral pulmonary veins isolation was carried out by radiofrequency ablation. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve anulus. Finally, the left atrial appendage was resected. An evaluation of the therapeutic success was carried out in the immediate postoperative course and 3 months after surgery, at that point of time operation-related influences on the refractory period of the atrial myocardium were negligible.¶ RESULTS: At the time of discharge 32 patients (76.2%) showed a regular supraventricular rhythm. Twenty-one patients have already undergone the 3-month follow-up examination. At the time of discharge 13 out of these 21 patients (61.9%) were in sinus rhythm and at 3 months after surgery 18 out of these 21 patients (85.7%) showed a sinus rhythm with a restoration of atrial transport function echocardiographically determined. Three patients were still receiving antiarrhythmic medication.¶ CONCLUSION: The modified maze procedure in combination with cardiac surgical interventions proved to be easy, quick and reliable to perform. The early results suggest a high success rate of this technique. The long-term results have to be verified with further, regular follow-up examinations of the patients.