Severe late complications after operative correction of aortic coarctation by interposition of prosthesis.

Out of 198 patients with aortic coarctation who were operated on with the implantation of an orthotopic bypass vascular prosthesis, 7 developed severe late complications 9-20 years postoperatively with late anastomosis dehiscence which resulted either in acute rupture and sudden death from massive hemorrhage (2 patients) or in false aneurysms with or without delayed rupture. Reoperation was done in 4 patients. After elective reoperation 2 of 3 patients survived, one elective and one emergency case died. The only evident reason for the late suture disruption was complete absorption of polyamide suture material in 6 cases. Therefore all patients with polyamide-sutured anastomosis should be followed-up thoroughly even in the late postoperative period in order to detect indications for elective reoperation. Suture material for anastomosis with any prosthesis must be nonabsorbable for lifetime.

Relationship between design and control of artificial heart for protection of the right/left balance.

Right/left matching in the total artificial heart (TAH) is essential to prevent fatal volume displacement into the pulmonary circuit. Measurements were made with three different sized Rostock pneumatic artificial ventricles incorporated in the Donovan mock circulatory system together with the heart driver AKT 86. First for each ventricle we determined the dependence of the maximum effective stroke volume on the systolic driving pressure and the afterload. The right ventricle (RV) is about 10% more effective than the left ventricle (LV). Control of the TAH permits different or equal frequencies for the RV and LV. For control with equal frequencies and full-to-empty regimen of one ventricle (RV-Master or LV-Master) the ratio of designed stroke volumes between RV and LV is important. This follows from the smaller efficiency of the LV and the left-to-left shunt. Otherwise a control mode with different heart rates must be used.

[Rare complications with multiple hereditary cartilaginous exostosis (author's transl)]. / Seltene Komplikationen durch multiple hereditäre kartilaginäre Exostosen.

A case of hereditary multiple cartilaginous exostosis is reported and the clinical symptoms are discussed. An exostosis of the distal femur was followed by an aneurysma spurium of the left femoral artery. Osteochondromas of the left ribs caused a hematothorax. Thoracotomy was necessary for treatment.

[Thoracic gunshot-injury with penetration of the pericardium in a 15-year-old student]. / Thoraxsteckschussverletzung mit Durchschuss des Perikards bei einem 15jährigen Schüler

On account of the exceptionality is reported on a 15-year-old adolescent who suffered a gunshot into the thorax by a device which was built by himself. More than 12 hours after the accident for the first time a physician was consulted. Then the patient was transported to Leipzig for operation. The missile had penetrated the anterior wall of the pericardium, had passed through the cleft between exterior layer of the myocardium and the pericardium and lodged at the trangression into the adjacent lung. The postoperative course was without complications. The patient could be dismissed without any complaints.

[Long-term results in electric pacemaker therapy]. / Langzeitergebnisse in der Therapie mit elektrischen Herzschrittmachern

It is reported on experiences and results in 317 patients with altogether 690 implantations of pacemakers from 1963 to 1974 and under comparison and with reference to the up to now existing long-term results published in literature state and tendency of the medical and technical development of the electric heart stimulation are discussed. The average age of outpatients was 62.9 years with a peak of age of 46% in the 7th decade of life. 60% were male patients, 40% female ones. With about 50% the constant total atrioventricular block was the most frequent indication. 63% of the familiar types of pacemakers were biotronic apparatuses, 36% of them with fixed frequency. The average duration of the function of all apparatuses was calculated with 20.1 months. Hereby the biotronic types had the longest average function times of 26.7 months (frequency fixed) or 26.3 months (regulated). In 373 reimplantations is shown that 2.17 apparatuses were implanted in each patient. The total number of complications was 21.2% related to the total number of implantations. With 8.9% breaks of the cable were in the first place in myocardial electrodes. Dislocations of transvenous electrodes were observed only in 4.5% of our cases. With 5.8% pressure necroses and infections were the cause of complications stood in the second place concerning frequency. The total lethality was 23.7% with an age peak of 38% in the 8th decade of life. 13.4% of the cases of death belong to an early lethality with a prevailing part of epicardial implantations. In our patients the cumulative survival rate was after 1 year 89.3%, after 5 years 62.3% and after 8 years 47.7%. The 50% survival rate was ca. 7.3 years. In comparison to the population of the same age the average expectance of life is transgressed by about 6 years. The prolongation of the survival time by electrostimulation compared with the conservative treatment of the total atrioventricular block with Adams-Stokes-syndrome is the essential result of the pacemaker therapy.

[Enoximone--clinical experiences in heart surgery]. / Enoximon--klinische Erfahrungen in der Herzchirurgie.

In 1991 and 1992, we introduced the new phosphodiesterase-III-inhibitor, enoximone, in the treatment of cardiac low-output-syndromes in the early phase after valve replacement or coronary bypass grafting. We introduced enoximone in cases which met the following criteria: cardiac index < or = 2.4 l/min/m2; systolic arterial pressure < or = 90 mmHg; left ventricular filling pressure > or = 20 mmHg despite the use of dopamine (> or = 12 micrograms/kg/ min); epinephrine (> or = 0.12 microgram/kg/min) and glyceroltrinitrate (1 microgram/kg/min). After clarification of preoperative risk factors and postoperative complications, retrospective evaluation of complete haemodynamic monitoring in patients after valve replacement (14 out of 86) and patients after coronary bypass grafting (22 out of 228) led to the following conclusions. Enoximone is of essential importance for the treatment of cardiac low-output at the end of extracorporeal circulation, particularly in cases complicated by preoperative myocardial deterioration. The use of enoximone is especially effective combined with beta-sympathomimetics as a result of elevation of cAMP-levels in two ways: by stimulation of beta-adrenoceptors directly and by inhibition of phosphodiesterase. Cardiac indices early after bypass, compared with measurements taken before bypass, reveal a clear rise indeed caused by increase in heart rate. Only in patients who underwent coronary bypass grafting did we observe a moderate increase in stroke volume indices. The therapeutic principle of using vasodilators--to lower peripheral resistance for improving stroke volume --appears to be effective immediately after extracorporeal circulation only in part. The vasodilating effect of enoximone has to be constantly compensated for by volume supplementation and alpha-mimetic stimulation, especially after valve replacement surgery. In contrast to this, we continued the application of glyceroltrinitrate in about 25% of the cases. Coronary surgery patients tolerated the vasodilating action particularly well; consequently, despite inotropic stimulation to a high degree, these patients showed no additional signs of ischaemia. Based on our therapeutic measures, the therapy led to very good short-term results. However, this therapeutic regime failed in patients suffering from extended myocardial infarction or irreversible pulmonary hypertension.

[A successful prolonged resuscitation following mitral valve replacement--a case report]. / Erfolgreiche verlängerte Reanimation nach Mitralklappenersatz--Ein kasuistischer Beitrag.

Based on a case report a successful resuscitation lasting 2 hours and 28 minutes is described and discussed. This case report demonstrates that particularly with cardiosurgical patients the recently fixed "Do not resuscitate order" is hardly to be taken into account. If the absolute criteria for breaking off the resuscitative measures are not present, resuscitation should be continued regardless of its duration.

[Current status of the use of the artificial heart and ventricular assist systems]. / Zum gegenwärtigen Stand der Anwendung des künstlichen Herzens und ventrikulärer Assistsysteme.

The state of the technical development of the mechanical assist systems and the artificial heart, respectively, guarantees a sufficient support of the circulatory system up to the improvement of the own heart function or to the possible heart transplantation. There is the necessity for the temporarily limited support of the heart, but also for the long-term one. Independent of the underlying etiology in acute conditions of cardiac failure in many cases the external supporting system may be sufficiently helpful. The antithrombotic therapy and the prophylaxis of infections demands particular carefulness. There is still no representable release for the long-term use of the hitherto available cardiovascular supporting systems. The question is controversial, whether then an experiment on patients or an already accepted therapeutic intervention is still taken into consideration. Essential prerequisites for the long-term use would be a full implantability of the systems in transcutaneous energy transmission, a further biologization of the blood-contacting materials, a clarification of the immune phenomena, a possibly automatic mode of action adapted to the need as well as a reliable strategy of antithrombotic therapy. The increased risk of infection should be taken into consideration.

[Results of the differentiated use of catecholamines and vasodilators in the early post-bypass phase]. / Ergebnisse des differenzierten Einsatzes von Katecholaminen und Vasodilatatoren in der frühen Postbypassphase.

Presented are the results of a procedure to characterize the haemodynamic situation and the required therapy in the early post-bypass period by including haemodynamic parameters (Part, CVP, PLA, TPR, PVR, f, Cl) in a system of seven parameter constellations although directly measured values must be supplemented by clinical data. In this way situations with increased or normal cardiac output and pathological peripheral resistance can be more easily distinguished from situations with reduced cardiac output. The investigations were performed in 300 patients who underwent cardiac surgery in 1985 and 1986. In more than 80% of the patients increased volume alone was not able to end the bypass, and so therapy including catecholamines and/or vasodilatators was instituted. Due to a relatively intensive but specific treatment, a favourable result with a 3% mortality was achieved. The frequency of patients after coronary surgery, valve replacement or correction of congenital heart defects in the seven situations of parameters corresponded to the expected haemodynamic peculiarities. In the group treated with catecholamines only, including 34% of the coronary patients, no increased mortality occurred compared with the total number. In patients in whom the constellation of parameters required a treatment with catecholamines combined with vasodilators, a higher mortality of 8.6% occurred compared with the total result. Here patients are concentrated with whom a good surgical result could not be obtained or the changes of myocardial stimulation were exhausted. Our findings emphasize the importance of the following points for further practice: improvement of invasive monitoring to apply vasodilators more intensively especially in infancy, careful selection of patients for coronary surgery, reduction of negative inotropic drugs preoperatively in high risk patients for improving postoperative stimulation of the myocardium.

[Subclavian steal syndrome in childhood (author's transl)]. / Subclavian-Steal-Syndrom im Kindesalter.

The authors report on four children with subclavian steal associated with coarctation or interrupted aortic arch. All children showed a stenotic origin of the left subclavian; in addition three of them had an extreme hypoplasia of the proximal segment of this artery. Two children had typical symptoms of insufficiency of the vertebral and basilar circulation (headache, dizziness, syncopal attacks, vision and hearing disorders) since the age of 7 and 8 years, respectively. The clinical findings, such as reduced pulses and blood pressure of the respective arm, may suggest the provisional diagnosis. The principles of congenital subclavian steal are discussed.

[Diagnosis and therapy of arteriovenous lung fistulas]. / Diagnostik und Therapie der arteriovenösen Lungenfistel

On the basis of 6 own cases, 5 of which were observed during one year, the clinical picture, the diagnostics and the therapy of the arteriovenous pulmonary fistula are described. Of decisive diagnostic importance is the angiography of the pulmonary artery which should always be used for the clarification of unclear pulmonary foci as well as clinically unclear cyanosis. For the removal of this shunt connection in the lesser circulatory system therapeutically only the operation comes into question. On account of the threatening complications and the inclination to the dilation of the fistula with growing age it is indicated also in cases with only slight haemodynamic effect. Dependent on the anatomical position of the fistula the ligature of the afferent artery is recommended.

[Central venous long-term catheter in the treatment of acute leukemia: implantation of a modified Hickman technic]. / Zentralvenöse Langzeitkatheter in der Behandlung akuter Leukämien: Einführung einer Modifikation der Hickman-Technik.

Central venous catheters are an essential prerequisite for the supportive ascertainment of highly aggressive cytoreductive therapy programmes in patients with acute leukaemia. From the indications (parenteral nutrition, transfusions, blood taking a. o.) and the particular conditions of the patient with acute leukaemia (granulo- and thrombocytopenia) results the superiority of a subcutaneously tunnelled central venous catheter with a particular occlusion of the place of entry into the skin in contrast to usual techniques.

Long-term results of anastomotic operations in 120 children with cyanotic congenital heart disease operated on the the first two years of life.

The author analyse results of anastomosis in 120 children with cyanotic heart disease operated on in the first two years of life. At the age up to 3 months of life 21 infants were operated on, 11 (52.4%) of whom died in connection with the procedure. Between the 3rd and 24th month of life 99 children were operated on with a death rate of 11.1%. In 94 children hypoxic spells disappeared, cyanosis and hypoxia were relieved. In the majority of patients, however, the duration of an improved general condition was limited to five years. Both immediate and long-term results depended first of all on the age of the child and on the type of heart lesion. Patients with tetralogy of Fallot had the lowest operative mortality (7.1%) and the best long-term results. In pulmonary atresia, which has poor prognosis without operation, the results of anastomosis were the least gratifying. The authors consider an anastomotic operation, especially the Blalock and Waterston shunt, to be an important life-saving procedure in infants with cyanotic congenital heart disease with hypoxic spells and critical hypoxia.

[Significance of modern therapeutic procedures in long-term treatment of supraventricular tachyarrhythmias]. / Zur Bedeutung der modernen Therapieverfahren bei der Langzeitbehandlung supraventrikulärer Tacharrhythmien.

To get a quantitative statement concerning the significance of modern therapy in supraventricular tachyarrhythmias 200 consecutive patients who were admitted to a coronary unit were analysed retrospectively. Finally accepted treatment were empirical drug therapy in 85 per cent, electrophysiologically controlled medical treatment in 12.5 per cent, pacemaker therapy in 1 per cent, and ablative procedures (catheter ablation and surgical Kent bundle dissection) in 2.5 per cent. As strictly atrial tachyarrhythmias are prevailing and advantages of electrophysiologically controlled drug therapy are not proven, in the majority of cases of supraventricular tachyarrhythmias empirical medical treatment is sufficient. Only in very few cases it is surpassed by the modern procedures. But, nevertheless these modern methods should be known to find the best treatment in problematical cases.

Results of total repair of tetralogy of Fallot after previous subclaviopulmonary or aortopulmonary anastomosis.

Total repair of tetralogy of Fallot was performed in 69 patients after the primary construction of a Blalock (28 patients) or a Waterston (41 patients) anastomosis. A total of 7 patients (10.1%) died. One to 5 yrs after correction, 62 patients (89.9%) survive: 52 (75.4%) are in a very good condition, 7 (10.1%) are in a good condition and the condition of 3 (4.4%) is unsatisfactory. 8 (11.6%) patients have serious late complications. The result of correction is not much influenced by the previous Blalock anastomosis (mortality rate 6.9%). After the Waterston anastomosis, however, there are frequent serious complications (pulmonary hypertension in 25.0% of patients), which adversely affect the result and increase mortality (12.5%) of the subsequent correction. The authors prefer two-stage repair of tetralogy of Fallot in the first two years of life. By administration of beta-blockers and prostaglandins they endeavour to postpone the construction of a Blalock anastomosis or an anastomosis performed by means of a polytetrafluoroethylene vascular prosthesis up to the age when the pulmonary artery branches are at least 4 mm in diameter. They plan the subsequent correction to be performed between the 2nd and the 5th year of age.

[Coronary artery fistula--surgical or percutaneous embolization treatment?]. / Koronararterienfistel--chirurgische oder perkutane Embolisationsbehandlung?

Three children aged 4 months, 2.7 and 7 years with the unusual fistula of the left coronary artery to the right atrium were observed over a 2-year period. The two younger children underwent emergency surgery although they showed no clinical symptoms. The reasons for surgical intervention were an aneurysm in the right atrium with obstruction of the vena cava superior and a considerably enlarged fistula, respectively. In the older child, we percutaneously embolized a terminate fistula of the ramus circumflexus with two platinum microcoils without complications. Two-dimensional-echocardiography and color flow mapping were used to confirm the diagnosis. After such diagnosis we recommend a coronary angiography in every case. The transcatheter-coil-embolization is an alternative method to surgical closure in selected cases. We recommend an early onset intervention in case of congenital coronary artery fistula.