Temporary wound covering with a silicon sheet for the soft tissue defect following open fasciotomy. Technical note.

OBJECTIVE: Temporary covering of a defect of the soft tissues with a silicon sheet after fasciotomy in the treatment of compartment syndrome. DESIGN: Retrospective study. SETTING: University Hospital, Tübingen. PATIENTS: From January 1991 to June 1996, open fasciotomy was performed a total of 18 times on 17 patients with compartment syndrome. In 17 of the 18 cases acute vascular ischemia was the cause of the compartment syndrome. INTERVENTIONS: For the 18 necessary fasciotomies, a silicon sheet was temporarily used to cover the defect of the soft tissue temporarily a total of 9 times. The silicon sheet was gradually drawn together and the wound was finally closed with a secondary suture. RESULTS: In 6 of the 9 cases a secondary suture could be performed without any difficulties after the swelling had subsided, and a meshgraft covering was not necessary. Only one patient suffered from wound infection because the silicon sheet had not been sutured correctly. In the other cases there was no sign of infection. The wound dressing was changed painlessly and furthermore, an improved cosmetic result was observed. CONCLUSIONS: There are considerable advantages in the use of a silicon sheet as a temporary covering for the defect of the soft tissues in the treatment of compartment syndrome: lower costs because of shorter hospitalisation and the dressing change is practically painless. A reduced risk of infection and improved cosmetic results are further advantages of this method.

The quality of autotransfused chest-drainage blood after cardiac surgery: a study of coagulation factors.

A wide range of experience, dating back as far as 1978, has been gained with both the hard-shell cardiotomy reservoir of the heart-lung machine and the Sorensen autotransfusion system as retransfusion systems. Three remains, however, a lack of knowledge regarding the quality of retransfused blood in systems of less complex construction which are already available on the market and involve the use of a pouch (Sentinel-Seal autotransfusion system and Pleur-evac collecting system). The present study entailed the investigation of blood from the chest drainages of twenty patients after cardiac surgery by using a simple retransfusion system (Sentinel-Seal autotransfusion system). In two postoperative groups of patients with low and high blood loss from chest drainage, we determined, in addition to free plasma hemoglobin, the following: factor XII, kallikrein-like activity, thrombin-antithrombin III complex, tissue-plasminogen and d-dimers. In the collective with a low blood loss, we found remarkable cell alterations as well as highly activated and advanced coagulation and an extraordinary fibrinolytic activity. If done at all, retransfusion by the Sentinel-Seal autotransfusion system should be restricted to the first four postoperative hours in cases of high blood loss.

[Inadvertant suture fixation of a Swan-Ganz catheter to the pulmonary artery following heart surgery]. / Unbemerkte Nahtfixation eines Swan-Ganz-Katheters in der Arteria pulmonalis während Herzoperation.

We report a patient undergoing redo cardiac surgery for combined replacement of the aortic and mitral valves. During the course of the operation, a Swan-Ganz catheter - positioned preoperatively - was accidentally fixed to the wall of the pulmonary artery. As this did not interfere with cardiac output measurement or the pulmonary artery pressure wave form, the fixation was not noticed until an attempt was made to remove the catheter. Fluoroscopy revealed both the catheter's immobility and the location of the suture fixation. The patient required a sternotomy to remove the catheter. In order to avoid this complication, the indications for pulmonary artery catheters during cardiac surgery should be carefully considered. If catheters are inserted, their mobility should by all means be ensured before the chest is closed.

[Spiral CT and CT angiography after coronary bypass surgery]. / Spiral-CT und CT-Angiographie nach koronarer Bypassoperation.

AIM: Evaluation of spiral-CT and CT-angiography for imaging of venous and arterial coronary bypass grafts during the early postoperative period. PATIENTS AND METHODS: In 198 patients suffering from coronary heart disease, 583 aortocoronary venous grafts (ACVG), 70 arterial grafts and 24 jumped grafts were investigated 9-15 days following coronary surgery. In 57 patients the results were compared to arterial DSA and reconstructive CT-angiography. RESULTS: At arterial DSA 93% of ACVG and 100% of arterial grafts were patent. Spiral-CT demonstrated 104 of 105 ACVG (99%) and 20 of 29 arterial grafts (69%) correct patent. All occluded ACVG (n = 8) were detected. 90% of ACVG but only 32% of arterial grafts were visualised completely over long segments. Imaging of jumped grafts was insufficient. In CT-angiography artificial vessel stenoses impaired correct visualisation of graft morphology. CONCLUSIONS: Spiral-CT allows sufficient differentiation of patent and obstructed ACVG during the early postoperative period. Diagnostic of arterial grafts is of lower accuracy. For CT angiography of venous and arterial coronary grafts further improvements are necessary.

The sternocleidomastoid flap for treatment of a septic sternum defect.

After sternotomy for prosthetic repair of the ascending aorta and replacement of the aortic valve with a bioprosthesis in a 70-year-old woman local wound infection developed. Preliminary conservative treatment did not succeed. Because of the high risk for the patient due to local infection and partial exposure of the aortic prosthesis there was an indication for local flap surgery. Both healing of the infection and covering the prosthesis was achieved using a sternocleidomastoideus muscle flap.

[Anomalous origin of the left coronary artery from the pulmonary artery. Variability of clinical aspects, echocardiography and angiography findings]. / Fehlabgang der linken Koronararterie aus der Pulmonalarterie. Variabilität von Klinik, echokardiographischen und angiographischen Befunden.

OBJECTIVES: Analysis of symptoms, diagnostical difficulties and follow-up in infants and children with anomalous origin of the left coronary artery from the pulmonary artery. METHODS: Retrospective study; 12 children between 3 weeks and 2 years old; time period: 1980-1991. RESULTS: Three infants were detected on routine examination because of a new cardiac murmur, the others presented with signs of cardiac failure. Cross sectional echocardiography and color Doppler flow mapping allowed to verify the suspected diagnosis. However, in one infant a false-negative cross sectional echocardiographic result was obtained. In this case nuclear magnetic resonance imaging was able to delineate the exact anatomy. Mean preoperative left ventricular ejection fraction: 33 +/- 4%; percentage of infants below the age of 6 months: 92%; surgery related mortality: 66%; mean follow-up of the remaining 4 patients being in good clinical condition: 2.9 +/- 1 years. CONCLUSIONS: 1. An anomalous origin of the left coronary artery should be included into the differential diagnosis when a new cardiac murmur is detected. 2. Possibility of false-negative echocardiographic results is emphasized. 3. With early symptoms and highly reduced left ventricular function, the mortality is still high.

Intraoperative valvuloplasty in calcific aortic stenosis: a study comparing the mechanism of a novel expandable device with conventional balloon dilatation.

In selected patients with calcific aortic stenosis, balloon valvuloplasty is an intermediate alternative to surgery. The effect of balloon valvuloplasty to increase valve area, however, is limited and the restenosis rate is high during follow-up. To improve the results and reduce the complication rate, a new device for valvuloplasty of calcific aortic stenosis was developed. This system consists of three expandable prongs mounted on a freely movable catheter tip. To evaluate the efficacy of this new device, valvuloplasty was performed in 10 patients with severe aortic stenosis intraoperatively just prior to valve replacement. Comparison was made with the results of conventional balloon dilatation performed in an additional 20 patients during surgery. Using the new device, the relative orifice area increased from 10 +/- 3% before to 20 +/- 6% following intervention. However, in only one patient was a considerable increase of static valve area (greater than 15%) found. The results were comparable to the effect of conventional balloon dilatation, which led to an increase of orifice area from 12 +/- 7% to 24 +/- 10%. With both systems, the best results were achieved in patients with aortic stenosis and significant commissural fusion. In contrast, in bicuspid or tricuspid valves without fused commissures the effect of the intervention was limited. Because complete obstruction of the aortic valve does not occur during dilatation, this new device might be superior to conventional balloon dilatation. Preselection of patients according to the morphology of the valve seems mandatory to improve the success and reduce the complication rate of valvuloplasty in aortic stenosis.

Early and late results of the modified Waterston shunt with PTFE grafts for palliation of complex congenital cyanotic heart disease in neonates.

During a 12 year period from 1978 to 1989, 35 infants under 4 weeks of age underwent palliative surgery for complex congenital cyanotic heart disease with a short (1-1.5 cm) PTFE graft between the ascending aorta and the right pulmonary artery (modified Waterston shunt). Twenty-three infants had pulmonary atresia and 14 had severe pulmonary stenosis. Underlying cardiac lesions were tetralogy of Fallot (n = 11), single ventricle (n = 7), transposition complexes (n = 6), and intact ventricular septum and hypoplastic right heart syndrome (n = 13). There were 4 early deaths (10.7%) in the entire series, 2 of which were shunt related. Three of the 4 occurred during our initial experience with this shunt in 1978 and 1979. They led to the modified Waterston shunt being abandoned for 3 years in favor of other shunt procedures. Since 1983 one early death occurred in 28 infants (3.5% mortality) with no death in the latest 26 patients. All patients were followed up between 6 and 108 months. There were 4 late deaths, one of which was shunt related. We observed a significant difference in the shunt patency rate between 4 and 5 mm grafts: palliation was adequate after 2 years in 52% of the patients when a 4 mm graft was used and in 89% of the 5 mm graft group (p less than 0.005). Reshunting was necessary in 7 infants between 5 and 60 months after primary surgery. Recatheterization was performed in 17 infants for suspected shunt failure (n = 6) or diagnostic reasons (n = 11).(ABSTRACT TRUNCATED AT 250 WORDS)

[Peripheral excimer laser angioplasty. The indications, methods and clinical results]. / Periphere Excimer-Laserangioplastie. Indikationen, Methode und klinische Ergebnisse.

Between March 1989 and January 1990, percutaneous transluminal excimer laser angioplasty was performed in 61 patients (40 men and 21 females; mean age 66 [41-86] years) with 65 peripheral arterial occlusions (iliac: 11, femoropopliteal: 48, tibial: 5, left subclavian artery: 1). The average ankle-arm index before treatment was 0.45 (0.2-0.8) for iliac, 0.52 (0-0.7) for femoropopliteal and 0.3 (0.1-0.4) for tibial occlusion. Recanalization was successful in 58 occlusions, but additional balloon dilatation was necessary in 54. The mean residual stenosis degree after laser application was 54%, after balloon dilatation 22%. Postangioplasty thromboembolism occurred in five patients. Intravascular stents were implanted in 11 patients because of extensive dissection or high-grade restenosis. After four weeks the clinical findings were improved in 54 of the 58 patients, in 47 even after six months. At that point the average ankle-arm index was 0.88 (0.5-1.1) after iliac, 0.79 (0.6-1.15) after femoropopliteal and 0.6 (0.4-0.7) after tibial recanalization.

[Carotid endarterectomy for prevention of stroke: comparison of surgical and conservative therapy]. / Karotisendarterektomie zur Insultprophylaxe: Vergleich der operativen mit konservativer Therapie.

The incidence of TIA, stroke and death among 689 patients with a narrowing of the internal carotid artery exceeding 50% was investigated in a follow-up study. Patients were assigned according to their initial status to one of the following groups: asymptomatic, transient ischemic attacks (TIA) and minor stroke. Patients subjected to carotid endarterectomy (n = 206) were compared to those treated by oral medication only. The follow-up time averaged 2.1 years. The incidence of stroke and death among the initially asymptomatic persons was not significantly different in those who underwent surgery (n = 46) and those who did not (n = 234). The incidence of TIA however was significantly higher in the operated patients. Among patients with TIA the incidence of repeated TIA, stroke and death was similar in those who were operated (n = 90) and those who were not (n = 61). The same was true for subsequent TIA and strokes in patients who had suffered from a first stroke prior to the initial examination. Patients who underwent surgery (n = 70) did not differ in this respect from the 188 patients who were not operated on. The death rate, however, was significantly higher in the non-operated patients (24.5% versus 7.2%). Due to the retrospective character of the study, operated and non-operated groups of patients were not directly comparable. We therefore selected comparable groups of patients by a stratification procedure. These subgroups showed no differences in the incidence of TIA and stroke between operated and non-operated patients. The result indicates, that the decision to perform carotid endarterectomy should be made with great caution.

[Results of emergency aortocoronary venous bypass surgery after failed percutaneous transluminal coronary angioplasty in patients with unstable angina pectoris]. / Ergebnisse der notfallmässigen aorto-koronaren Venen-Bypass-Operation nach fehlgeschlagener perkutaner transluminaler Koronarangioplastie bei Patienten mit instabiler Angina pectoris.

During a 4-year period from January 1985 to December 1988 140 patients underwent percutaneous transluminal coronary angioplasty (PTCA) of the culprit-vessel for unstable angina. Seventeen patients (12%) needed emergency aorta coronary bypass surgery (ACVB) for failed angioplasty. In 15 cases the culprit-vessel was the LAD and in 2 cases a dominant right coronary artery. Only in 2 cases a history of myocardial infarction was present. Twelve patients were in hemodynamic stable condition after arriving in the operating-room. Five patients were hemodynamic unstable, 4 of them were in cardiogenic shock. Four patients died representing an operative mortality rate of 23%. Three patients died from pump failure despite intraaortic balloon counterpulsation in 2 cases. One patient died from cerebral damage 12 day after surgery. All patients who died were in cardiogenic shock preoperatively. Two patients who survived suffered an extensive myocardial infarction. Thus including the patients who died from pump failure the perioperative infarction rate was 30%. From these results it is concluded that emergency ACVB after failed PTCA of the culprit-vessel in patients with unstable angina results in a significant higher mortality and morbidity as compared with patients who had primary surgery for unstable angina. The prognosis of patients after failed PTCA for unstable angina depends on the hemodynamic situation thereafter and becomes worse in patients with cardiogenic shock.

[Asymptomatic carotid stenosis: is surgical prevention of infarct still justified?]. / Asymptomatische Karotisstenose: ist die operative Insultprophylaxe noch gerechtfertigt?

The present retrospective study compared the incidence of TIA, stroke, and death in patients with asymptomatic carotid stenosis (greater than 50%) during a follow-up period of 24 to 30 months. 65 patients were operated and 193 treated medically. The incidence of death was comparable in both groups. Death in most patients was due to cardiac disease or cancer. The annual incidence of TIA and stroke was not different between the two populations. Despite the low incidence of perioperative complications (%) surgery of asymptomatic carotid stenosis cannot be recommended at the present time.

Repair of symptomatic aortic coarctation in the first three months of life. Early and late results after resection and end-to-end anastomosis and subclavian flap angioplasty.

During a 9 year period between January 1977 and December 1985, 98 consecutive infants under 3 months of age underwent surgical repair of symptomatic aortic coarctation. Resection and end-to-end anastomosis was performed in 73, subclavian flap angioplasty in 14, and other procedures in 11 patients. There were 20 (20.5%) early and 12 (12.5%) late deaths. No early deaths occurred in the isolated coarctation group. Associated complex cardiac malformations and age under 2 weeks at operation influenced significantly early and late outcome but not any particular surgical procedure. The survivors were followed from 6 months to 8 years and 8 months postoperatively. There were 16 (28%) re-coarctations among 56 survivors after end-to-end anastomosis requiring re-operation in 7 (12%) infants and 3 (30%) re-coarctations among 10 survivors after subclavian flap angioplasty requiring re-operation in 1 infant. After end-to-end anastomosis re-coarctation as well as re-operation rate was markedly lower when an interrupted suture line for the entire anastomosis was used as compared to the group with a continuous suture line of the posterior aortic wall (21% vs. 33% re-coarctation rate and 4% vs. 18% re-operation rate respectively). From our results it is concluded that subclavian flap angioplasty for relief of aortic coarctation in early infancy is not superior to resection and end-to-end anastomosis. In the end-to-end anastomosis group an interrupted suture line has a lower re-coarctation as well as re-operation rate as compared to a continuous suture line of the posterior aortic wall.

[Effect of tricuspid annuloplasty in mitral/aortic valve replacement on the clinical aspects and global function of the right heart chamber]. / Einfluss der Trikuspidalklappenraffung beim Mitral-/Aortenklappenersatz auf Klinik und Globalfunktion der rechten Herzkammer.

The clinical improvement after mitral or aortic valve surgery is primarily due to the correction of the aortic/mitral valve function and the subsequent decrease of pulmonary artery pressure. The hemodynamic effect of an additional tricuspid annuloplasty, however, is still unclear. To assess the influence of a tricuspid annuloplasty using DeVega- or Carpentier-technique on the clinical outcome, hemodynamics, and right ventricular function in patients with moderate to severe tricuspid insufficiency, 38 patients were studied pre- and 11 +/- 4 months postoperatively. The clinical degree of left heart failure was graded according to the criteria of the NYHA. The extent of right heart failure (RHF) was determined using a clinical score from 0 (no signs) to 3 (severe RHF with pleural effusion/ascites). Mean pulmonary artery pressure (PAPm), end-diastolic volume index (RVEDVI), and ejection fraction (RVEF) of the right ventricle using biplane cineventriculography, as well as the angiographic and dopplerechocardiographic degree of tricuspid insufficiency were determined. The patients were assigned to three groups: gr.I (n = 12): preoperatively no tricuspid insufficiency (TI), gr. II (n = 12): with preop. TI and without tricuspid annuloplasty (TA), gr. III (n = 14): with preop. TI and TA. The patients of all three groups improved postoperatively from NYHA functional class III to class II (p less than 0.001). The clinical score of RHF decreased from 0.8 +/- 0.5 to 0.3 +/- 0.5 in gr. I, from 1.4 +/- 1.1 to 0.6 +/- 0.7 in gr. II, and from 1.7 +/- 1.0 to 0.8 +/- 0.8 in gr. III (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonographic follow-up of subclavian stenosis and occlusion: natural history and surgical treatment.

Continuous-wave Doppler ultrasonography and clinical examination were used over a 2-year period to monitor the natural history of subclavian stenoses and occlusions in 67 patients. Thirty-nine presented with subclavian steal and 28 without. We also studied an additional group of 29 patients who had undergone surgery for subclavian steal syndrome and vertebrobasilar transient ischemic attacks. The results, in terms of both ultrasonographic and clinical criteria, demonstrate the benign nature of the subclavian steal syndrome: all neurologic signs and symptoms were of a transient character. Spontaneous remission of vertebrobasilar transient ischemic attacks occurred in approximately 50% of the initially symptomatic patients, and only 15% of the initially asymptomatic patients experienced vertebrobasilar transient ischemic attacks during follow-up. Doppler ultrasonography revealed progression during follow-up in only 17% of the subclavian stenoses, and in 13% a stenosis was no longer detectable. Still-ongoing brainstem transient ischemic attacks were reported in 24% of the operated patients. The most important factor for the lack of improvement was the occlusion of the bypass. Continuation of transient neurologic symptoms could be observed in only 14% of the patients with intact carotid-subclavian bypass. In conclusion, indications for surgical treatment of the subclavian steal syndrome should be restricted to cases in whom vertebrobasilar transient ischemic attacks occur frequently and are either debilitating or greatly frighten the patient.

[Effect of tricuspid annuloplasty on the clinical course following mitral or aortic valve operation]. / Einfluss der Trikuspidalklappenraffung auf den klinischen Verlauf nach Mitral- oder Aortenklappenoperation.

To assess the effect of additional tricuspid annuloplasty during mitral/aortic valve surgery on the clinical postoperative course in patients with severe preoperative tricuspid insufficiency, 64 patients were investigated pre- and 11 +/- 4 months postoperatively. Extent of left-side heart failure was graded as well as severity of right-side heart failure using a defined clinical score. Using preoperative biplane angiography of the right ventricle the patients were assigned to three different groups: group I (n = 30) with no preoperative tricuspid insufficiency (TI), group II (n = 19) with preoperative TI and without tricuspid annuloplasty, group III (n = 15) with preoperative TI and with annuloplasty of the tricuspid valve. The patients of all three groups postoperatively improved from an average of NYHA class III to class II. The clinical score of right-side heart failure in gr. III and gr. II was 1.4 +/- 1.0 and 1.5 +/- 1.0, respectively, and was significantly (p less than 0.05) higher than in gr. I (0.8 +/- 0.8). In all three groups there was a postoperatively significant decrease: gr. I: 0.3 +/- 0.5 (p less than 0.01); gr. II: 0.6 +/- 0.9 (p less than 0.02); gr. III: 0.7 +/- 0.8 (p less than 0.05). Mortality was 3% in gr. I; 5% in gr. II and 6% in gr. III. 3% of patients in gr. I, 30% in gr. II and 6% in gr. III had early postoperative hemodynamic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transluminal coronary angioplasty and aortocoronary bypass surgery in unstable angina pectoris and coronary multivessel disease]. / Perkutane transluminale koronare Angioplastie und aorto-koronare Bypass-Operation bei instabiler Angina pectoris und koronarer Mehrgefässerkrankung.

In 113 patients demonstrating the clinical syndrome of unstable angina, acute-stage coronary angiography revealed multivessel disease. Acute PTCA of the ischaemia-related coronary artery or bypass grafting was performed depending on angiographic criteria. Of the total of 68 patients in whom PTCA was performed, 45 had two-vessel disease (2 vd) and 23 three-vessel disease (3 vd). 12 of the 45 patients with bypass operation had a left main stem stenosis, whereas 33 had three-vessel disease. The primary success rate of PTCA was 81%, 89% in patients with 2 vd and 70% in patients with 3 vd. Acute post-PTCA bypass grafting was necessary in 2 patients having 2 vd and in 5 patients suffering from 3 vd. 5 of the 68 patients treated with PTCA developed a transmural myocardial infarct and one patient died after PTCA and emergency bypass surgery. 8 of the 45 operated patients had a perioperative or postoperative myocardial infarct and 5 patients died intraoperatively or postoperatively. The overall morbidity was 11.5%, and the mortality of hospitalised patients was 5.3% (6/113). Combination of PTCA with emergency bypass grafting offers a new and effective treatment with an acceptable risk even in multivessel disease patients and in those having unstable angina pectoris. The additional use of PTCA definitely improves therapeutic management in this high-risk population.

[Pulmonary artery loop and dysplastic tracheal stenosis. Case report with pre- and postoperative spirometry and discussion of the value of diagnostic signs]. / Pulmonalarterienschlinge und dysplastische Trachealstenose. Fallbericht mit prä- und postoperativer Spirometrie und Diskussion der Wertigkeit der diagnostischen Zeichen.

Since his second week of life a boy, with pulmonary artery sling now 8 3/4 years old suffered from mainly expiratory stridor during exercise and dyspnoe during bronchopulmonary infections, twice in a life-threatening manner. The indirect diagnostic signs were all negative, bronchoscopy revealed a narrow distal trachea and a pulsating stenosis of high degree at the bifurcation. Bronchographic findings were characteristic. Angiocardiographically the retrotracheal run of the left pulmonary artery could only be proved by marking the trachea with a catheter. After operation at the age of 8 1/4 years, the boy had no relevant subjective complaints during a follow-up of 6 months. Spirometric lung function tests before and after corrective operation revealed a considerable obstruction of central intrathoracic airways that persisted after operation, only peak flow improved significantly. According to the bronchological findings the reason therefore is a dysplastic tracheobronchial stenosis, which is seen often in combination with PAS.

[Stenoses and occlusions of the extracranial arteries. A field study of unselected subjects and patients with intermittent claudication]. / Stenosen und Verschlüsse der extrakraniellen Arterien. Feldstudie an unausgewählten Personen und bei Patienten mit Claudicatio intermittens.

Doppler sonography of the extracranial arteries was done in 556 unselected patients (greater than 40 years) in a prophylactic study. 226 high risk patients with arterial occlusive leg disease (AOD) served as control group. Doppler sonography revealed stenoses or occlusions of the carotid, vertebral and (or) subclavian arteries in 9.17% of normal persons and in 38.05% of AOD patients. Medical treatment is available only for stenoses (not occlusions) of the carotid arteries. Thus the frequency of asymptomatic internal carotid stenoses--only stenoses of more than 50% lumen diminution can be detected--of 2.33% in the group of normal probands and of 17.2% in the patient group is the reference value and justification for use of Doppler sonography for prophylactic assessment. The atraumatic and safe method with a success rate of 2.33% is suitable particularly in increased risk factors (age, males, smoking, hypertension, diabetes). As a prophylactic investigation in patients with arterial occlusive disease Doppler sonography is mandatory before prospective operations.