[Results from the German shoulder- and elbow arthroplasty register (SEPR) : Anatomic or reverse shoulder arthroplasty in B2-glenoids?] / Ergebnisse des deutschen Schulter- und Ellenbogenprothesenregisters (SEPR) : Anatomische oder inverse Prothese bei B2-Glenoid?

BACKGROUND: Anatomic shoulder arthroplasty in osteoarthritis with biconcave glenoid wear results in decreased functional results and a higher rate of early glenoid loosening. AIM: The aim of the data analysis of the German shoulder arthroplasty register was to clarify whether reverse shoulder arthroplasty can provide better functional results and a lower complication rate than anatomic arthroplasty in osteoarthritis with biconcave glenoid wear. METHODS: The analysis included 1052 completely documented primary implanted arthroplasties with a minimum follow-up of 2 years. In 119 cases, a B2-type glenoid was present. Out of these cases, 86 were treated with an anatomic shoulder arthroplasty, and in 33 cases a reverse shoulder arthroplasty was implanted. The mean follow-up was 47.6 months. RESULTS: The Constant score with its subcategories, as well as the active range of movement improved significantly after anatomic and after reverse shoulder arthroplasty. DISCUSSION: We observed no difference in functional results between both types of arthroplasty; however, reverse arthroplasty showed a significant higher revision rate (21.2%) (3% glenoid loosening, 6% prosthetic instability) than anatomic shoulder arthroplasty (12.8%) (11.6% glenoid loosening, 1.2% prosthetic instability), whereas anatomic shoulder arthroplasty showed a higher rate of glenoid loosening. Functional and radiographic results of both types of arthroplasty are comparable with the results reported in the literature, although our analysis represents results from an implant registry (data pertaining to medical care quality).

Mechanisms of Inactivation by High-Voltage Atmospheric Cold Plasma Differ for Escherichia coli and Staphylococcus aureus.

Atmospheric cold plasma (ACP) is a promising nonthermal technology effective against a wide range of pathogenic microorganisms. Reactive oxygen species (ROS) play a crucial inactivation role when air or other oxygen-containing gases are used. With strong oxidative stress, cells can be damaged by lipid peroxidation, enzyme inactivation, and DNA cleavage. Identification of ROS and an understanding of their role are important for advancing ACP applications for a range of complex microbiological issues. In this study, the inactivation efficacy of in-package high-voltage (80 kV [root mean square]) ACP (HVACP) and the role of intracellular ROS were investigated. Two mechanisms of inactivation were observed in which reactive species were found to either react primarily with the cell envelope or damage intracellular components. Escherichia coli was inactivated mainly by cell leakage and low-level DNA damage. Conversely, Staphylococcus aureus was mainly inactivated by intracellular damage, with significantly higher levels of intracellular ROS observed and little envelope damage. However, for both bacteria studied, increasing treatment time had a positive effect on the intracellular ROS levels generated.

Assessing stress responses to atmospheric cold plasma exposure using Escherichia coli knock-out mutants.

AIMS: This study investigated the effect of atmospheric cold plasma (ACP) exposure-induced stress on microbial inactivation patterns and the regulation of genes involved in the microbial stress response in conjunction with key processing parameters of exposure time and post-treatment storage time. METHODS AND RESULTS: Cell suspensions of Escherichia coli BW 25113 and its isogenic knock-out mutants in rpoS, soxR, soxS, oxyR and dnaK genes were treated with high-voltage ACP in a sealed package for 1, 3 and 5 min followed by 0-, 1- and 24-h post-treatment storage. Reactive oxygen species (ROS) densities and colony formation were determined. ΔrpoS strain showed higher microbial reduction and greater cell permeability than other mutants, while ΔoxyR only showed this effect after 5 min of treatment. With increased post-treatment storage time, ΔsoxS and ΔsoxR had increased sensitivity and resistance respectively. ΔdnaK cell suspensions had much higher ROS than other strains and showed increased sensitivity with 24 h post-treatment storage. CONCLUSIONS: RpoS and oxyR genes have both short-term and long-term regulatory effects under plasma stress. However, knocking out dnaK gene had an immediate response on ROS scavenging and long-term repairing mechanisms. ΔsoxR and ΔsoxS had different responses to ACP treatment with the increase in post-treatment time in relation to clearance of reactive species implying the different characteristics and functions as subunits. SIGNIFICANCE AND IMPACT OF THE STUDY: By comparing the response of mutants under ACP exposure to key processing parameters, the mechanism of microbial inactivation was partly revealed with respect to cellular regulation and repairing genes.

Tertiary individual prevention improves mental health in patients with severe occupational hand eczema.

BACKGROUND: Occupational hand eczema (OHE) is associated with impaired health-related quality of life (QoL) and mental distress. Interdisciplinary inpatient rehabilitation measures in the framework of tertiary individual prevention (TIP) offered by the German employers' liability insurance associations include dermatological treatment, education and psychological interventions. OBJECTIVE: To investigate the effects of interdisciplinary inpatient rehabilitation in the framework of TIP on mental health in patients with severe OHE and the relationships between recovery of OHE and improvement of mental health and QoL. METHODS: A total of 122 patients participated in the study. A test battery consisting of the German versions of the Hospital Anxiety and Depression Scale (HADS-D), the Dermatology Life Quality Index (DLQI), the Short Form Health Survey-36 (SF-36) and the Trier Inventory for the Assessment of Chronic Stress (TICS) was applied at the time of admission (T1) and 3 weeks after dismissal (T2). Severity of hand eczema was assessed with the Osnabrueck Hand Eczema Severity Index (OHSI). RESULTS: All parameters improved significantly from T1 to T2. A relationship was established between the improvement of QoL and recovery of OHE, while there was no such relationship between the improvement of mental distress and improvement of OHE. Nonresponders had significantly more cumulative days of sickness at T1. CONCLUSIONS: Our data underscore the importance of psychological interventions in addition to dermatological treatment in the framework of prevention measures for OHE. These measures should be applied at an early stage of OHE prior to the occurrence of sick leave.

Midterm results after revision rotator cuff reconstruction: Can ultrasound predict outcome of revision surgery?

PURPOSE: Structural failures after rotator cuff repair are well known, and despite advances and improved techniques in rotator cuff repair (RCR), retear rates remain high. The aim of this study was to (1) evaluate the midterm clinical and radiological outcomes after revision RCR and to (2) analyze whether preoperative ultrasound can predict outcome of open revision rotator cuff repair. METHODS: Twenty-five patients who underwent revision RCR in a single institution between 2010 and 2012 were retrospectively reviewed at a minimum follow-up of 2 years. The Constant Score (CS) and the Disabilities of the Arm, Shoulder and Hand score were collected. Ultrasound examination was used both before revision surgery and at follow-up to determine tendon integrity. RESULTS: At the final follow-up, 69.6% patients showed an intact rotator cuff and their CS had improved from 28.3 to 77. 30.4% patients had a persisting rotator cuff defect, and the CS had improved from 24 to 47.7. A preoperative tear size of more than 20 mm from an ultrasound examination could be identified as a factor that would risk structural failure of revision RCR. CONCLUSION: (1) Clinical outcomes after revision RCR improve in both patients with an intact RC and those with a retear at midterm follow-up. (2) Ultrasound seems to be a useful tool to predict whether reconstruction of recurrent rotator cuff tears is feasible. LEVEL OF EVIDENCE: IV, Case series.

A new algorithm for improving fetal weight estimation from ultrasound data at term.

OBJECTIVE: The purpose of this retrospective study was to find a method of improving the accuracy of fetal birth weight estimation on the basis of traditional ultrasonographic measurements of the head, thorax, and femur at term. In this context, we analyzed a novel regression method comparing to existing algorithms. METHODS: The delivery records of two hospitals were searched for women who delivered macrosomic infants, and the patients' medical records were retrospectively reviewed in order to derive clinical and ultrasonographic data at term. A total of 223 patients with macrosomic infants (birth weight > 4,000 g) were identified. These patients were complemented by data for 212 women who had ultrasound fetal assessments of less than 4,000 g. We used the method of isotonic regression to construct a birth weight prediction function that increases monotonically with each of the input variables and which minimizes the empirical quadratic loss. RESULTS: A suspicion of macrosomia was based on a history of macrosomia, fundal height, and sonographic weight estimation >4,000 g. The mean period between ultrasound weight estimation and delivery was 7.2 days. The ability of the biometric algorithms developed to predict fetal weight at term ranged between a mean absolute error of 312 and 344 g, given a confidence interval of 95%. We demonstrate that predictions of birth weight on the basis of ultrasound data can be improved significantly, if an isotonic regression model is used instead of a linear regression model. CONCLUSIONS: This study demonstrates that ultrasound detection of macrosomia can be improved using the isotonic regression method.

Certification testing as an acute naturalistic stressor for disaster dog handlers.

USA Federal Disaster Canine Teams, consisting of a handler and a dog, are essential for locating survivors following a disaster. Certification, required by the Federal Emergency Management Agency Urban Search and Rescue organization, requires two successful mock searches. Confirmation of the certification testing process as an acute stressor might offer further opportunities to consider stress effects on handlers and dogs in a controlled environment. This study used a pretest-posttest design to evaluate relationships between salivary hormone concentrations (cortisol and testosterone) and subjective stress ratings in handlers and controls, handler assessments of stress in their dogs, and posttest temperature and pulse rate in dogs. Posttest, both subjective stress ratings and salivary cortisol concentration were higher in handlers than controls with both correlated to handlers' assessment of stress in their dogs. Handlers' posttest salivary cortisol concentration was associated with posttest dog pulse and temperature. Posttest cortisol concentration was lower in handlers who were successfully certified compared with those who failed, and was also lower in handlers whose primary occupation was "firefighter". Salivary testosterone concentrations increased from pretest to posttest in handlers but decreased in controls, and higher posttest handler testosterone concentration was negatively associated with posttest dog pulse rate. These findings confirm certification testing as an acute stressor, suggest a relationship between stress and performance moderated by occupation, and demonstrate an interaction between handler stress and dog physiological responses. This certification testing offers a controlled environment for targeted evaluation of effects of an acute naturalistic stressor on disaster dog handlers and dogs.

Long-term outcome prediction by clinicopathological risk classification algorithms in node-negative breast cancer--comparison between Adjuvant!, St Gallen, and a novel risk algorithm used in the prospective randomized Node-Negative-Breast Cancer-3 (NNBC-3) trial.

BACKGROUND: Defining risk categories in breast cancer is of considerable clinical significance. We have developed a novel risk classification algorithm and compared its prognostic utility to the Web-based tool Adjuvant! and to the St Gallen risk classification. PATIENTS AND METHODS: After a median follow-up of 10 years, we retrospectively analyzed 410 consecutive node-negative breast cancer patients who had not received adjuvant systemic therapy. High risk was defined by any of the following criteria: (i) age <35 years, (ii) grade 3, (iii) human epithelial growth factor receptor-2 positivity, (iv) vascular invasion, (v) progesterone receptor negativity, (vi) grade 2 tumors >2 cm. All patients were also characterized using Adjuvant! and the St Gallen 2007 risk categories. We analyzed disease-free survival (DFS) and overall survival (OS). RESULTS: The Node-Negative-Breast Cancer-3 (NNBC-3) algorithm enlarged the low-risk group to 37% as compared with Adjuvant! (17%) and St Gallen (18%), respectively. In multivariate analysis, both Adjuvant! [P = 0.027, hazard ratio (HR) 3.81, 96% confidence interval (CI) 1.16-12.47] and the NNBC-3 risk classification (P = 0.049, HR 1.95, 95% CI 1.00-3.81) significantly predicted OS, but only the NNBC-3 algorithm retained its prognostic significance in multivariate analysis for DFS (P < 0.0005). CONCLUSION: The novel NNBC-3 risk algorithm is the only clinicopathological risk classification algorithm significantly predicting DFS as well as OS.

Targeted disruption of the mouse Npal3 gene leads to deficits in behavior, increased IgE levels, and impaired lung function.

The non-imprinted in Prader-Willi/Angelman syndrome (NIPA) proteins are highly conserved receptors or transporters. Translocation of NIPA genes were found in patients with Prader-Willi syndrome, and loss-of-function of the NIPA1 gene was identified in hereditary spastic paraplegia. The family of NIPA-like domain containing (NPAL) proteins is closely related to the NIPA proteins, but to date nothing is known about their function. Here, we could demonstrate that both human NPAL3 and mouse NPAL3 are ubiquitously expressed and encode highly conserved proteins. To further elucidate the function of the Npal3 gene, knockout (Npal3(-/-)) mice were generated. Intensive phenotypic analyses revealed that disruption of the Npal3 gene results in a pleiotropic phenotype. The function of the nervous system was impaired in both mutant males and females which could be demonstrated in behavioral tests. In addition, in NPAL3 mutants the number of NK cells was decreased and changes in IgM, IgG(2), and IgA were observed, indicating that the immune system is also affected. Interestingly, increased IgE levels as well as impaired lung functions were observed in mutant males but not in mutant females. It should be noted that the human Npal3 gene is located at 1p36.12-->p35.1, and atopic diseases were previously linked to this genomic region. Thus, the Npal3(-/-) mice could serve as a valuable model system for studying atopic diseases.

High voltage atmospheric cold air plasma control of bacterial biofilms on fresh produce.

Atmospheric cold plasma (ACP) offers great potential for decontamination of food borne pathogens. This study examined the antimicrobial efficacy of ACP against a range of pathogens of concern to fresh produce comparing planktonic cultures, monoculture biofilms (Escherichia coli, Salmonella enterica, Listeria monocytogenes, Pseudomonas fluorescens) and mixed culture biofilms (Listeria monocytogenes and Pseudomonas fluorescens). Biotic and abiotic surfaces commonly occurring in the fresh food industry were investigated. Microorganisms showed varying susceptibility to ACP treatment depending on target and process factors. Bacterial biofilm populations treated with high voltage (80 kV) ACP were reduced significantly (p < 0.05) in both mono- and mixed species biofilms after 60 s of treatment and yielded non-detectable levels after extending treatment time to 120 s. However, an extended time was required to reduce the challenge mixed culture biofilm of L. monocytogenes and P. fluorescens inoculated on lettuce, which was dependent on biofilm formation conditions and substrate. Contained treatment for 120 s reduced L. monocytogenes and P. fluorescens inoculated as mixed cultures on lettuce (p < 0.05) by 2.2 and 4.2 Log10 CFU/ml respectively. When biofilms were grown at 4 °C on lettuce, there was an increased resistance to ACP treatment by comparison with biofilm grown at temperature abuse conditions of 15 °C. Similarly, L. monocytogenes and P. fluorescens exposed to cold stress (4 °C) for 1 h demonstrated increased tolerance to ACP treatment compared to non-stressed cells. These finding demonstrates that bacterial form, mono versus mixed challenges as well as environmental stress conditions play an important role in ACP inactivation efficacy.

The influence of macrosomia on the duration of labor, the mode of delivery and intrapartum complications.

OBJECTIVE: This study assessed the perinatal outcome in a series of macrosomic fetuses with mothers from a general obstetric population in whom vaginal delivery was planned. METHODS: In all, 215 women with macrosomic infants were included from a total of 2,622 deliveries. The pattern of maternal weight gain in pregnancy, the influence of fetal macrosomia on the duration of labor and the delivery outcome were investigated in this group. The main issues studied were the impact of fetal weight on the mode of delivery, the duration of the two stages of delivery and the incidence of intrapartum complications in fetuses larger than 4,000 g in comparison with normal-weight fetuses. RESULTS: Complete data were obtained for 594 patients, including 215 macrosomic infants and 379 randomly assessed normal-weight infants. With regard to the mode of delivery, a direct correlation was observed between maternal weight gain and the incidence of secondary cesarean section (P<0.014) when vaginal delivery was initially planned. There was also a direct correlation between increasing birth weight and a higher incidence of secondary cesarean section and assisted vaginal delivery (P<0.002). In the first stage of labor, there was a statistically significant difference for obstructed labor between the two groups (P<0.03). The rate of perineal injuries and the incidence of postpartum hemorrhage were similar in the two groups. CONCLUSIONS: As some of the risk factors identified are known prior to delivery, every woman in whom there is a suspicion that the fetus may weigh up to 4,500 g should receive individual guidance regarding special intrapartum and perinatal conditions.

[The ECG-gated 4-row multidetector CT of the heart in preoperative imaging minimal invasive coronary artery bypass grafting]. / Die EKG-getriggerte 4-Zeilen-Spiral-CT des Herzens in der präoperativen Bildgebung vor minimalinvasiver koronarer Bypass-Operation.

PURPOSE: Minimal invasive direct coronary artery bypass grafting (MIDCAB) or off-pump coronary artery bypass grafting (OPCAB) on the beating heart with full or mini-sternotomy are becoming more common in coronary bypass surgery of the left anterior descending (LAD). In the decision, which surgical approach (MIDCAB, OPCAB or conventional surgery with cardiopulmonary bypass) will be best used, knowledge of the anatomical field is of major importance. The aim of the study was to evaluate retrospective ECG-gated 4-row multidetector CT (MDCT) in patients planned for MIDCAB as additional imaging to coronary angiography. MATERIAL AND METHODS: The study included 25 consecutive patients. MSCT was performed as unenhanced (collimation 4 x 2.5 mm) and contrast-enhanced examination (140-170 ml, 300 mg Iodine/ml, collimation 4 x 1 mm). The evaluation included presence of LAD calcifications, distance of LAD and left internal mammarian artery (LIMA), course of LAD and LIMA, the presence or absence of bridging through myocardium or epicardial fat and the presence of pleural fibrosis. The MDCT results were correlated with intra-operative findings. RESULTS: All MDCTs could be assessed with reference to the demands. In 20/25 operations, MDCT had direct influence as to the selection of the surgical approach (11 MIDCAB, 7 OPCAB with mini-sternotomy and 5 with full sternotomy, 2 conventional surgeries). The distance of LAD and LIMA varied from 0.9 to 4.5 cm in MDCT. As to calcifications, 3/25 correlated patients had calcifications and 10 patients had no calcifications in the middle LAD. Seven patients had intraoperative fibrosis of the vessel wall without calcification of the middle LAD, which could not be detected with MDCT. Another 5 patients had single calcified plaques in the middle LAD, 4 of these had a fibrosis of the vessel and 1 had a normal vessel at surgery. In these cases, the anastomosis was done between the calcified plaques. No myocardial bridging was detected by MDCT and at surgery. Bridging of epicardial fat was shown by MDCT and at surgery in 9/25 patients and was excluded in 15 patients. In 1 patient, the LAD seemed to run superficially in MDCT, but was covered with fat as seen during surgery. The course of the LIMA was inconspicuous in all cases, no pleural fibrosis was found. CONCLUSIONS: The 4-row MDCT has proven to be adequate in addition to coronary angiography for preoperative evaluation in patients scheduled for MIDCAB and provides the surgeon with relevant information for the selection of the operative approach.

Glycosylation patterns of the human colon cancer cell line HT-29 detected by Helix pomatia agglutinin and other lectins in culture, in primary tumours and in metastases in SCID mice.

Human colonic cancer cells (HT-29, 10(7) cells/dose) were injected subcutaneously between the scapulae of 19 severe combined immunodeficient (SCID) mice. After 19 days, large tumours had developed in 18 out of the 19 animals and the mice were then killed. Metastases were detected in the lungs of 16 animals but not in other organs investigated. Surgical removal of the primary tumour in another group of five animals led to a prolonged survival and further growth of metastases in the lungs. HT-29 injection into the tail vein (n = 5) resulted in colonization of the lungs. The tumours that developed in the animals were signet cell carcinomas; these forms are not seen in HT-29 cells in culture. Glycoconjugate expression of the tumours was assessed using several lectins. In many cases the results indicated a stability of lectin-binding patterns from cell culture conditions to implantation into the SCID mice. This was true for the lectin Helix pomatia agglutinin (HPA), the binding of which is associated with a high metastatic potential in some human tumours, including colon cancer. All the primary tumours and metastases were HPA positive. This xenograft tumour model seems to be a clinically relevant system for the study of glycoconjugate expression in human colon cancer cells and their metastases.

15-Deoxyspergualin for induction of graft nonreactivity after cardiac and renal allotransplantation in primates.

In order to assess the immunosuppressive potentials of 15-deoxyspergualin (15-DS) in a preclinical experiment, heterotopic cardiac (n = 27, group I) and classic renal (n = 25, group II) allotransplantations were performed in Chacma baboons. The following immunosuppressive regimens were applied: Groups IB and IIB were treated with 15-DS alone (4 mg/kg/day) for p.o. days 0-9. Groups IC and IIC were treated with cyclosporine A (10-40 mg/kg/day) for p.o. days 0-30. Groups ID and IID received a combination of 15-DS (for p.o. days 0-9) and CsA (for p.o. days 0-30). Groups IA and IIA served as control and received no medication. The mean graft survival was 11.0 days for group IA, 28.2 days for group IB (P less than 0.05; IB vs. IA), 32.4 days for group IC, and 43.1 days for group ID (P less than 0.025; ID vs. IA). After renal transplantation, the corresponding figures were 12.3 days for group IIA, 8.5 days for group IIB, 30.4 days for group IIC and 148.9 days for group IID (P less than 0.025; IID vs. IIA). After cardiac and renal transplantation, acute rejection was the main cause of graft failure. Treatment-related side effects, mainly gastrointestinal complications, were observed only in primates, who were treated with 15-DS alone. After cardiac transplantation, permanent graft non-reactivity was not achieved, but a delayed rejection occurred within a mean of 21.8 days after immunosuppression had been stopped. Following renal transplantation, graft nonreactivity was also not achieved in groups IIB and IIC. In group IID, however, 4 of 8 animals (50%) were graft-tolerant 340, 256, 244, and 164 days after treatment discontinuation. Thus, the combination of 15-DS and CsA led to a significant prolongation of graft survival in both groups. Long-term nonreactivity was achieved only after renal transplantation, when initially treated with 15-DS and CsA.

Variable platelet response to low-dose ASA and the risk of limb deterioration in patients submitted to peripheral arterial angioplasty.

A group of 100 patients with intermittent claudication (70 male, 30 female), treated with I00 mg ASA per day, were followed over 18 months after elective percutaneous balloon angioplasty. Platelet function was monitored over a period of 12 months by corrected whole blood aggregometry (CWBA). Upon stimulation by arachidonic acid (AA), adenosine diphosphate (ADP) and collagen, CWBA-results were obtained by an electronic acquisition and evaluation system correcting for hematocrit and platelet count of the blood sample. All patients showed a completely inhibited platelet response to AA stimulation. Comparison of the CWBA-results with clinical parameters revealed that reocclusions at the site of angioplasty occurred exclusively in male patients for which CWBA failed to prove an inhibition of aggregation upon both agonists, ADP and collagen, and for these patients the risk of complication is at least 87% higher (p = 0.0093). Only 40% of male patients show the expected effect of ASA on in vitro platelet aggregation at any given point in time and CWBA is capable of predicting those male patients which are at an elevated risk of reocclusion following peripheral angioplasty.

Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting.

OBJECTIVE: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. METHODS: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. PHASE I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. PHASE II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. PHASE III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. RESULTS: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. CONCLUSIONS: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.

Extended cardiopulmonary preservation: University of Wisconsin solution versus Bretschneider's cardioplegic solution.

Application of the University of Wisconsin cold storage solution has rapidly expanded to include medium-term to long-term preservation of virtually all intraabdominal organs. Its use in intrathoracic organ transplantation has also been suggested. We therefore examined the efficacy of the University of Wisconsin solution in a primate allotransplantation model for preservation of hearts, and as a simple single-solution system for static preservation of heart-lung blocks, for periods of ischemia ranging from 6 to 24 hours. For comparison, we employed the histidine-tryptophane-ketoglutarate cardioplegic solution of Bretschneider. University of Wisconsin solution provided superior results with regard to clinical outcome and hemodynamic recovery of hearts after ischemic periods of up to 16 hours. This was in contrast to Bretschneider's solution, which allowed storage of hearts for periods of only up to 10 hours. Heart-lung blocks were equally well preserved with either University of Wisconsin or Bretschneider's solution after 6 to 12 hours, although the University of Wisconsin solution group exhibited a more notable increase in pulmonary water content. This was in accordance with histological data, which suggested that, although hemodynamic recovery of hearts stored for periods longer than 10 hours was poor, preservation of pulmonary ultrastructure was far superior using Bretschneider's solution as compared with University of Wisconsin solution after an ischemic period of up to 16 hours.

Three-dimensional video and robot-assisted port-access mitral valve operation.

BACKGROUND: In order to minimize surgical trauma, video-assisted mitral valve operation has been started using the Port-Access technique with the addition of a three-dimensional visualization system (Vista Cardiothoracic Systems Inc, Westborough, MA) and a voice-controlled camera-holding robotic arm (Aesop; Computer Motion Inc, Goleta, CA). METHODS: Port-Access mitral valve replacement or repair (PAMVR) was undertaken using an endovascular cardiopulmonary bypass (CPB) system. Fifty patients underwent Port-Access mitral valve replacement or repair. A three-dimensional thoracoscope was inserted allowing complete three-dimensional projection of the mitral valve (Vista). In the last 20 patients, the camera was attached to a robotic arm (Aesop), which allowed stabilization and voice-activated movement of the camera. Mitral valve repair was performed in 26 patients, and the valve was replaced in 24 patients with a mechanical valve prosthesis. RESULTS: Median time of operation was 4.2 hours, aortic cross-clamp time 83 minutes, CPB time 125 minutes, intensive care unit stay 1.5 days and hospitalization 9.0 days. Three months follow-up was complete in 40 patients, with 34 patients (85%) in New York Heart Association class I and 6 patients in class II. Mortality was 0% and rate of reoperation was 2%, with a follow-up time up to 1.5 years postoperatively. CONCLUSIONS: Using three-dimensional video and robotic assistance, it was possible to minimize the length of skin incision, but at the same time to optimally visualize the whole mitral valve apparatus in order to perform true Port-Access mitral valve operation, including various repair techniques.

Minimally invasive coronary artery bypass grafting: port-access approach versus off-pump techniques.

BACKGROUND: Within the past 5 years several surgical techniques have been developed for less invasive surgical treatment of coronary artery disease. The aim of this study was to define specific indications for the various minimally invasive coronary artery surgical procedures. METHODS: Minimally invasive direct coronary artery bypass grafting through a minithoracotomy was performed in 67 patients. The left internal mammary artery was anastomosed on the beating heart with the use of a pressure or suction stabilizer without the use of extracorporeal circulation. In 58 other patients with multivessel disease, the off-pump coronary artery bypass grafting technique through a sternotomy was applied with a left internal mammary artery to left anterior descending artery and additional vein grafts without extracorporeal circulation. In a third group, Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting was performed through a left minithoracotomy with the use of an endovascular extracorporeal circulation system and cardioplegic arrest. Angiographic follow-up was complete in 64% of the patients. RESULTS: There was minimal perioperative or postoperative mortality (0.5%). The medium surgical procedure time for all minimally invasive and off-pump procedures was 2.5 hours; it was 4.5 hours for Port-Access procedures. The median postoperative intensive care unit stay was 1.0 days, and the median hospitalization was 5.0 days. Overall graft patency was 97.3%; in 8 patients (4.1%) a stenosis either at or distal to the graft anastomosis was dilated with coronary angioplasty. CONCLUSIONS: For single-vessel disease of the left anterior descending artery, the minimally invasive coronary artery bypass grafting procedure can be performed safely without the use of extracorporeal circulation. In case of hemodynamic instability or anatomic variation, the Port-Access procedure can be applied without additional necessity for sternotomy. For multivessel disease, the off-pump bypass grafting procedure with sternotomy can be recommended depending on the coronary arteries involved. In case of necessary grafts to the lateral marginal or circumflex branches, Port-Access grafting can be recommended and may play an important role in the future for the development of fully endoscopic robot-assisted coronary artery bypass grafting.