Patch enlargement of the aortic and the mitral valve rings with aortic-mitral double-valve replacement.

In 1 patient, patch enlargement of the aortic valve ring was accomplished by extending the aortic incision into the anterior mitral leaflet. The pericardial patch broke from the aortic leaflet of the mitral valve on the fourth postoperative day. The resultant acute mitral incompetence necessitated mitral valve replacement also. An aortic-mitral double-valve replacement with attendent enlargement of both the aortic and mitral valve rings ensued. To our knowledge, enlargement of the aortic and mitral valve rings with aortic-mitral double-valve replacement has not been described in the literature.

Echocardiographic profile of the normally functioning Omnicarbon valve.

Transthoracic echocardiography was performed in 141 patients with 90 Omnicarbon valves in the aortic and 66 in the mitral position. Additionally, 53 of them were investigated by transesophageal echocardiography comparing monoplane and multiplane facilities. The opening direction of the disc and the location of the pivot axis could be correctly determined by transthoracic, monoplane, and multiplane transesophageal echocardiography, respectively, in 100%, 80%, and 100% of the mitral and in 53%, 21%, and 82% of the aortic prostheses. Small regurgitation jets were detected in 90% of the aortic valves (1.6 +/- 0.4 cm2) by transthoracic and in all mitral prostheses (2.3 +/- 0.8 cm2) by transesophageal echocardiography. Based on morphological identification of the pivot points structures, origins of leakage jets were clearly identified as "design-related" in 12% (transthoracic echocardiography of aortic valves) to 100% (multiplane transesophageal echocardiography of mitral valves). In the aortic position, values obtained for transprosthetic forward flow velocity measurements exhibited wide scatter which did not allow a firm separation between valve sizes. No better differentiation was possible by using the calculated Doppler gradients or the velocity time integrals, either. Mean gradients and velocity time integrals showed even smaller differences between groups in the mitral valve patients. It is concluded that the Omnicarbon valve has a suitable design for morphological echocardiographic examination, and multiplane transesophageal technique expands the diagnostic capability. Forward flow measurements do not appear to be suited for detecting a beginning obstruction of this mechanical prosthesis.

IMA-graft patency control by thermal coronary angiography during coronary bypass surgery.

Thermal coronary angiography (TCA) was evaluated for the intraoperative assessment of graft patency and flow in internal mammary artery (IMA) bypass grafts. TCA was performed in 210 patients undergoing 460 vein and 153 IMA bypass grafts after completion of the distal anastomoses. The IMA grafts and the recipient coronary arteries were delineated by the temperature differential between a cold epimyocardium and the perfusing warm blood after bulldog clamp release. TCA provided information about graft and anastomosis patency, initial flow patterns, and native coronary stenoses. TCA was performed in all studied IMA bypass grafts: 142 grafts were patent. Low flow but patency was observed in 24 IMA grafts and 11 IMA grafts showed no flow. Subsequently, 8 anastomotic failures and 3 proximal IMA graft occlusions were encountered. Based on these findings, 8 anastomoses were successfully revised and 7 additional vein grafts were added. One low flow IMA graft was not revised leading to postoperative ST elevation. Thirty-one distal native coronary stenoses were detected in the recipient LADs, 3 of which were not seen in the preoperative cineangiogram. In 20 instances, TCAs were obscured by an excess of fat or myocardium impeding image analysis. In 8 cases, TCA results were confirmed by conventional angiography postoperatively showing an excellent correlation in all cases. We conclude that intraoperative TCA demonstrates early IMA graft function and initial flow patterns. During our study, TCA documented a 7.2% IMA graft early failure rate. Intraoperative decision making was aided by TCA in 9.2% of all IMA grafts; this confirmed the clinical relevance of TCA.

[Computer tomography of aorto-coronary bypass (author's transl)]. / Der aortokoronare Bypass im Computertomogramm.

Computer tomography is a non-invasive method for demonstrating occlusion or patency of an aorto-coronary bypass. The early results of computer tomographic investigations of 77 bypasses in 51 patients are described. CT diagnosis of bypass patency is well established, but further work will be required to determine the accuracy of computer tomographic diagnosis of bypass occlusion.

[The prognosis of the transitory disturbances of av-conduction following cardiac surgery (author's transl)]. / Zur Prognose der passageren AV-Uberleitungsstörungen nach korrektiven Eingriffen am Herzen

Out of 2250 cases with open heart surgery 106 patients were examined because of disturbances of av-conduction in the Department for Cardiology of the Childrens Hospital of the University of Göttingen. 38, 7 percent of all av-conduction disturbances have persisted, whereas 61, 3 percent were reversible. Especially the ventricular septal defects, the tetralogy of Fallot and the endocardial cushion defects are discussed. These lesions are predisposed for postsurgical av-disturbances because they are near to the av-conduction tissue. In this paper it has been demonstrated that the av-conduction disturbances, which last for more than one week, have only a little chance to return to sinus rhythm. Those which endure more than four weeks, will persist. The longer the av-conduction disturbances are lasting, the less is the possibility for restitution of sinus rhythm.

[Antitachycardia pacing therapy in supraventricular tachycardia using the microcomputer-guided Tachylog 651 pacemaker]. / Antitachykarde Schrittmachertherapie mit dem mikroprozessorgesteuerten "Tachylog 651" bei supraventrikulärer Tachykardie.

Microprocessor-controlled antitachycardia pacemaker expand the automatic detection of the tachycardia and incorporate multiple, different termination modes. We report our results in the long-term therapy of paroxysmal supraventricular tachycardia with the antitachycardia pacemaker "Tachylog 651". The system was implanted in 10 patients with a mean age of 48 years (from 20 to 68 years): Wolff-Parkinson-White syndrome 4 patients, paroxysmal AV nodal reentrant tachycardia 6 cases. The rate of the reentrant tachycardia was 162 +/- 23/min. The system reliably differentiated between paroxysmal supraventricular tachycardia and sinus tachycardia, including 4 patients with a tachycardia rate of less than 150/min. Burst overdrive pacing was effective in 6 patients and the "self-search system" in 3 patients. During follow-up of 9 +/- 4 months 104 +/- 93 successful interventions per patient were observed; change of the termination mode became necessary in 4 patients and of the detection mode in 3 patients. The incorporation of programmable detection and multiple termination modes in the microprocessor-controlled antitachycardia systems allows the effective long-term antitachycardia pacing. The multiprogrammable "Tachylog 651" pacemaker is an advancement in the electrotherapeutic treatment of paroxysmal supraventricular tachycardias, including the automatic treatment of tachycardias with low rates.

[Coarctation of the aorta: surgical management in infancy--results in 72 patients (author's transl)]. / Chirurgische Behandlung der Aortenisthmusstenose im Säuglingsalter - Ergebnisse von 72 Patienten.

Early and late results of a total of 72 infants operated for coarctation of the aorta are reported. Operative repair included various methods (End-to-End, Vossschulte, Clagett, Shumaker, Waldhausen, Blalock). Isolated coarctation was present in 6 infants, 17 also had patent ductus arteriosus, 39 patients had additional associated cardiac anomalies, part of which were combined with PDA. Out of the 72 infants 17 died (early mortality: 11, late mortality: 6). The highest mortality rate was found among the 0 to 3 months age group (11 patients). Fourteen out of the 17 deceased patients had additional cardiac anomalies. Out of the 55 survivals, 37 patients showed good results, restenosis was found in 13 patients, 5 patients had to be reoperated due to severe restenosis.

Budd-Chiari syndrome in a child with post-traumatic obstruction of the inferior vena cava.

An obstruction of the suprahepatic inferior vena cava was diagnosed by using ultrasound combined with Doppler flow analysis. Complete noninvasive diagnosis could only be done by adding the Doppler flow analysis to the displayed morphological information. After surgery complete morphological and functional relief were achieved.

Aortico-left ventricular tunnel.

Aortico-left ventricular tunnel (ALVT) is a very rare cardiac malformation with only 25 cases having been reported in the literature. This paper describes another 5 cases with surgical repair at the ages of 4, 5, 6, and 14 years, respectively. (A fifth case in an 11-year-old boy was operated upon just recently and is described separately in the addendum). The anatomical and clinical findings and diagnostic procedures including angiocardiography are reviewed. The surgical management is discussed, and the late results after follow-up periods of 5, 11, 13, and 16 years are presented. Three patients are doing well although showing clinical signs of mild aortic valve insufficiency, and one patient required aortic valve replacement 13 years after operation because of massive aortic regurgitation. Early surgical repair is recommended as soon as the diagnosis is established by angiocardiography in order to prevent secondary aortic valve lesion by dilatation of the aortic ring and aneurysmatic dilatation of the ventricular septum.

[A rare pacemaker complication of a perforation by a ventricular screw electrode causing hemothorax]. / Seltene Schrittmacherkomplikation durch Perforation einer ventrikulären Schraubelektrode mit Hämatothorax.

The myocardial perforation of a pacemaker electrode is an extremely rare complication associated with the danger of cardiac tamponade. We report on a perforation of a ventricular screw-in electrode with migration through the pericardium and bleeding in the left thoracic cavity. Two-dimensional echocardiography in combination with clinical, electrocardiographic and X-ray examination permits a reliable non-invasive diagnosis.

[Complications in pacemaker treatment caused by electrodes (author's transl)]. / Elektrodenbedingte Komplikationen bei Herzschrittmachertherapie

A total of 531 transvenous and 240 thoraco-abdominal electrodes were implanted into 624 patients, the latter as part of a thoracotomy. The complication rate was 35% for transvenous and 33% for epicardial implantations. The most common complication with transvenous electrodes was dislocation (17%), followed by myocardial (5%) and skin perforation (2%). With epicardial electrodes the complications were exit blocks (9%), disconnections (5.5%) and wire breaks (14%). These complication occurred in 1.5%, 2% and 4.5%, respectively, with transvenous electrodes. Electrode dislocations were particularly common in the first year after implantation, while wire breaks became more common as the interval sinceimplantation increased. Overall there was, therefore, no significant difference in complication rate between the two types of electrodes. But the surgical and early mortality ratewas higher after epicardial implanation (with thoracotomy)than transvenous implantation (11% and 6%, respectively). Transvenous implantation is recommended not only for old but also foryoung patients (with a long life expectancy), in combination with long-life pacemakers.

[Rastelli operation for complete transposition of the great vessels, ventricle septum defect and pulmonary atresis]. / Rastelli-Operation bei kompletter Transposition der grobeta Gefäbeta mit Ventrikelseptumdefekt und Pulmonalatresie. Bericht über einen Fall

We report about a 6 year old patient with complete transpositon of the great arteries, a ventiricle septum defect, and pulmonary atresia, who was operated using Rastellis technique. A Hancock-prothesis of of 20 mm diameter was used for reconstruction of the outflow tract of the right ventricle and anastomosed distal with the pulmonary artery on the left side of the aorta. The proximal anastomosis was performed with the right ventricle after a longitudinal ventriculotomy. The intraoperative pressure recordings and the post-operative studies revealed a very good early result.

[Early postoperative diagnostic management by arterial-reobstruction after vascular operations using the ultrasonic flowmeter (author's transl)]. / Frühdiagnose arterieller Verschlüsse nach Gefässeingriffen mit dem Doppler-Ultraschall-Gerät

The Doppler ultrasonic method can confirm the success of the operation in the early post-operative phase after reconstructive vascular operations as an essential non-invasive technique or clear a doubtful improvement of the blood flow. Thus an arteriography can be indicated in good time. On the basis of reconstructive cases the usefulness and the advantageous application of the Doppler ultrasonic flowmeter in the operating theater is demonstrated.

Cardiac myxoma. Clinical and pathologic features in 15 cases.

Neoplasms are rare cardiac findings of which myxomas comprise about 75%. We report of 15 patients, predominantly female (60%) with a mean age of 58.8 years. Male patients (40%) were 20 years younger on average. 80% of these tumors developed in the left atrium fixed to the atrial septum. In 2 patients the right ventricle and in 1 patient the right atrium was involved. No left ventricular or bilateral tumors were found. Clinical findings showed a great variety of symptoms. Often misdiagnosis was established until echocardiography was performed. Major symptoms were dyspnea (80%), elevated erythrocyte sedimentation rate (73%), arrhythmias (53%), lung edema (47%), embolization (40%) and anemia (40%). Pathological examination and tumor genesis are still in discussion. Several theories are reported in literature: a true thrombus, thrombus organization with malignant potential, true neoplasms as well as a familiar myxoma complex may explain clinical and histological features. Our findings did not confirm only one theory but emphasize different possibilities.

[Automatic implantable cardioverter-defibrillator (AICD) and antitachycardia pacemaker (Tachylog 651) in the treatment of ventricular tachyarrhythmias]. / Automatischer implantierbarer Kardioverter-Defibrillator (AICD) und antitachykarder Schrittmacher (Tachylog 651) zur Behandlung ventrikulärer Tachyarrhythmien.

For the electrotherapy of refractory ventricular tachycardia the automatic implantable cardioverter-defibrillator (AICD) and antitachycardia pacemaker are available. The long-term use of antitachycardia pacing is still limited by the potential risk of acceleration to ventricular fibrillation. To combine the advantages of antitachycardia pacing with back-up defibrillation, we evaluated the use of an antitachycardia pacemaker with the automatic defibrillator. The AICD was implanted in 13 patients with a mean age of 62 years (from 46 to 75 years); six of them with recurrent ventricular tachycardia (170 +/- 16 per minute) which could reliably be terminated by overdrive pacing, received also an antitachycardia pacemaker (Tachylog 651). The underlying cardiac disease was coronary heart disease in 11 patients and cardiomyopathy in 2 cases. All patients had survived 1 to 6 cardiac arrests and had not responded to 6 +/- 1.5 antiarrhythmic drugs. For antitachycardia pacing we used burst stimulation with 4 to 6 stimuli and coupling intervals from 260 to 300 ms. During the follow-up period of 12 +/- 2 months, 83% of 744 tachycardias could be terminated by burst stimulation, according to the diagnostic data of the pulse generator. If the pacemaker failed to terminate or in case of acceleration (three patients), the automatic countershock of the AICD (5-42 per patient) restored sinus rhythm. In seven patients with high rate tachycardia, 2 to 69 AICD discharges occurred. No patient died suddenly, but three died due to underlying disease and one because of a pneumonia postoperatively. Future antitachycardia devices should be flexible with regard to detection and termination modes, combining antitachycardia pacing with back-up defibrillation.

[Myxoma of the heart: symptoms masked by an atrial septal defect]. / Myxom des Herzens. Maskierte Symptomatik bei Vorhofseptumdefekt.

A 68-year-old woman, known to have a secundum atrial septal defect which had been asymptomatic, reported dyspnea and occasional chest pain for two years. Admission examination revealed orthopnea, cyanosis, polycythemia and inflow congestion of the upper part of the body. After some blood-letting, nifedipine and nitrates brought immediate relief of symptoms. Physical examination, chest x-ray and ECG were not different from previously known findings. All laboratory tests were normal. The findings on cross-sectional echocardiography raised the suspicion of a right ventricular tumor, which was then demonstrated by computed tomography. There were no metastases. Under extracorporeal circulation a right-ventricular benign myxoma, attached to the apical septum and the size of a tennis-ball, was removed. The postoperative course was without complications and the patient was discharged symptom-free.