Arch thrombus formation in an apparently normal aorta as a source for recurrent peripheral embolization.

A floating thrombus in an apparently normal aortic arch is a rare and often neglected source for systemic embolic events. When no other underlying pathology for systemic embolization can be found, transesophageal echo (TEE) and magnetic resonance imaging (MRI) are the diagnostic methods of choice and should be performed in order to detect thrombus formations in the thoracic aorta. We report a case in which a floating thrombus in the aortic arch was the source of emboli into both femoral arteries. Successful bilateral thrombectomy was performed. To prevent repeat embolization, we performed surgery under deep hypothermic circulatory arrest with removal of the thrombus and plication of the aortic wall at the site of thrombus adhesion.

Predictive value of perioperative cardiac troponin I for adverse outcome in coronary artery bypass surgery.

OBJECTIVES: Cardiac Troponin I (cTnI) is a well-known marker for myocardial damage in patients undergoing aorto-coronary bypass grafting (CABG) peaking 6-8 h after aortic declamping. The aim of this study was to evaluate cTnI release in the course of CABG procedures early, i.e. after the cessation of cardiopulmonary bypass (CPB) in order to recognize unstable cardiac function leading to hemodynamic deterioration and resulting in an adverse outcome (AO). AO is defined as the onset of myocardial infarction and/or death peri/postoperatively. METHODS: Five-hundred and forty consecutive patients who underwent CABG were evaluated for cTnI release immediately prior to the induction of anesthesia (IND) and after termination of CPB (END). Standard CPB with ante/retrograde cold blood cardioplegia was used. Patients with any of the following criteria were excluded: (1), CABG within 7 days of myocardial infarction; (2), emergency operation for both unstable angina and for coronary occlusion at angioplasty; (3), CABG with concomitant surgical cardiac procedures; (4), preoperative renal dysfunction requiring hemodialysis; (5), redos. Troponin I was measured with the Stratus CS fluorometric enzyme immunoassay analyzer (Dade-Behring) running on site in the operation room (OR), so values of cTnI could be obtained within 15 min. RESULTS: There were six deaths (1.1%) in the entire series, Q-wave myocardial infarction occurred in 19 patients (3.5%), AO was experienced by 21 patients (3.9%). The mean preoperative cTnI level was 0.04+/-0.17 ng/l (mean+/-standard deviation) for the entire group. The END cTnI level for the AO-group was 0.91+/-0.5 ng/l; for all other patients, this was 0.37+/-0.3 ng/l (P<0.001). Changes in intraoperative cTnI levels relative to time course showed a marked increase for the AO-group (0.0038+/-0.0035 ng/l*min) as compared with non-AO patients (0.0019+/-0.0015 ng/l*min; P=0.028). The receiver operating characteristic curve indicates a cTnI level at CPB-end of higher than 0.495 ng/l with an area under the curve of 0.83 as the optimal cut-off point for predicting AO with a sensitivity and specificity of 76.2%. Stepwise logistic regression analysis revealed END cTnI level (odds ratio, 17.24; P<0.001), CPB time (odds ratio, 1.03; P=0.001), female sex (odds ratio, 3.8; P=0.011) as significant independent predictors for AO. Age of over 70 years (P=0.8), Cleveland Clinic risk score (P=0.65), diabetes (P=0.26), elevated preoperative creatinine level (P=0.77), severe left ventricular dysfunction (P=0.51), the number of grafts performed (P=0.15), and change of intraoperative cTnI level relative to time course (P=0.94) did not reach statistical significance. CONCLUSIONS: cTnI release as determined at the end of CABG procedures represents a strong predictor of an AO after surgery. Analyzing blood samples for cTnI with an automated device on site in the OR provides for immediate results, so specific diagnostic and therapeutic interventions can be performed before hemodynamics deteriorate.

Rest and exercise hemodynamics before and after valve replacement--a combined Doppler/catheter study.

BACKGROUND: Hemodynamic improvement is a common finding following valve replacement. However, despite a normally functioning prosthesis and normal left ventricular ejection fraction, some patients may show an abnormal hemodynamic response to exercise. METHODS: In a combined catheter/Doppler study, rest and exercise hemodynamics were evaluated in 23 patients following aortic (n = 12) (Group 1) or mitral valve (n = 11) (Group 2) replacement and compared with preoperative findings. Patient selection was based on absence of coronary artery disease and left ventricular failure as shown by preoperative angiography. Cardiac output, pulmonary artery pressure, pulmonary capillary pressure, and pulmonary resistance were measured by right heart catheterization, whereas the gradient across the valve prosthesis was determined by Doppler echocardiography. Postoperative evaluation was done at rest and during exercise. The mean follow-up was 8.2 +/- 2.2 years in Group 1 and 4.2 +/- 1 years in Group 2. RESULTS: With exercise, there was a significant rise in cardiac output in both groups. In Group 1, mean pulmonary pressure/capillary pressure decreased from 24 +/- 9/18 +/- 9 mmHg preoperatively to 18 +/- 2/12 +/- 4 mmHg postoperatively (p < 0.05), and increased to 43 +/- 12/30 +/- 8 mmHg with exercise (p < 0.05). The corresponding values for Group 2 were 36 +/- 12/24 +/- 6 mmHg preoperatively, 24 +/- 7/17 +/- 6 mmHg postoperatively (p < 0.05), and 51 +/- 2/38 +/- 4 mmHg with exercise (p < 0.05). Pulmonary vascular resistance was 109 +/- 56 dyne.s.cm-5 preoperatively, 70 +/- 39 dyne.s.cm-5 postoperatively (p < 0.05), and 70 +/- 36 dyne.s.cm-5 with exercise in Group 1. The corresponding values for Group 2 were 241 +/- 155 dyne.s.cm-5, 116 +/- 39 dyne.s.cm-5 (p < 0.05), and 104 +/- 47 dyne.s.cm-5. There was a significant increase in the gradients across the valve prosthesis in both groups, showing a significant correlation between the gradient at rest and exercise. No correlation was found between valve prosthesis gradient and pulmonary pressures. CONCLUSION: Exercise-induced pulmonary hypertension and abnormal left ventricular filling pressures seem to be a frequent finding following aortic or mitral valve replacement. Both hemodynamic abnormalities seem not to be determined by obstruction to flow across the valve prosthesis and may be concealed, showing nearly normal values at rest but a pathologic response to physical stress.

Aortic bioprosthesis without early anticoagulation--risk of thromboembolism.

Anticoagulation after implantation of a bioprosthetic heart valve has been suggested during a high-risk period of 3 months following surgery. There is little information available concerning the risk of thromboembolism during this period if anticoagulation is not carried out. However, this is of interest since 60-80% of all bleeding complications due to anticoagulation occur during the first year of treatment. Between 1983 and 1993, 57 of our patients did not receive oral anticoagulation after implantation of a bioprothesis in the aortic position (49 Hancock, 7 Mitroflow and one Edwards stentless). All patients were investigated retrospectively. A risk for thromboembolic complications of 1.75% is calculated for the first six months following surgery, being 3.5 per 100 patients/year. There seems to be no advantage in standard anticoagulation (INR 2.5-4) with its risk of serious bleeding complications of about 4% during this period of treatment. Low-dose anticoagulation (INR 2.0-2.3), however, preferably in combination with prothrombin estimation by the patients, seems to offer a relatively safe treatment for these patients.

[Current intra- and early postoperative results of transvenous pacemaker implantation]. / Aktuelle intra- und frühpostoperative Ergebnisse der transvenösen Schrittmacherimplantation.

UNLABELLED: Between 1986 and 1989 295 pacemaker (PM)-implantations were performed (mean age: 69.9 +/- 14.5 years; 54.9% male, 45.1% female). INDICATIONS: AV-Block II+III (36.6%), sick-sinus-syndrome (26.4%), bradyarrhythmia (18.0%). Concomitant disease: hypertension (40.6%), diabetes mellitus (19.3%), coronary artery disease (11.5%), malignant tumors (10.8%), renal failure (7.5%). We implanted in 72.9% VVI-PM, in 23.7% DDD-PM and in 3.4% AAI-PM. The median fluoroscopy-time as a measure for time of surgery was 6.2 minutes (DDD: 6.7; VVI: 5.4; AAI: 9.9). In 6.5% there were intraoperative complications: arrhythmias (3.4%), skeletal muscular stimulation (M.pect.; 1.4%), lead dislodgment (0.7%), missed puncture (A.subcl.; 0.7%). The early postoperative (14 days) complications rate was 9.5% (lead dislodgment 3.7%, development of high threshold 1.7%, bleeding 1.4%, bacteriaemia 1.0%, skeletal muscular stimulation 0.7%). The complication rate of AAI-PM (70.0%) was significantly higher compared to DDD-PM (29.8%; p less than 0.01) and VVI-PM (12.1%; p = 0.00025). In 17 patients (5.8%) reoperation was necessary (lead dislodgment n = 11, development of high threshold n = 3, arrhythmias n = 2, postoperative bleeding n = 1). The highest dislodgment rate was seen in atrial leads with active fixation (5.0%). In 2.6% of active fixation leads there was a development of high thresholds (passive fixation leads 0.5%). The selection of the PM-system to be implanted has to be considered in respect to the increased complication rate of DDD- and AAI-PM, especially in elderly patients.

Electron microscopic changes and edema after nine hours' perfusion of isolated canine hearts.

In a comparative study, we investigated whether or not removed and non-beating hearts could be preserved in vitro by continuous perfusion with oxygen-carrying solutions (blood, perfluoro-carbon emulsion) and simultaneous substitution with specific substrates. We used 18 mongrel dogs subdivided into 2 groups (1st group: perfluorocarbon emulsion; 2nd group: blood); the perfusion time was 9 h. In addition to parameters to control the medium of the perfusion solution, we measured parameters that would allow us to assess the success of the extended perfusion. These parameters were high-energy phosphates and, in particular, electron optical analysis. At the end of the perfusion period, electron optical analysis revealed a mild and reversible ischemic reaction by the myocardial cells in both groups. However, statistical analysis showed (1) a significant increase in the ischemic reaction for both groups over the perfusion period (P = 0.02), and (2) a significant, even more pronounced ischemic reaction in the subendocardial myocardium (P = 0.025). It should be noted that distinctly interstitial edema developed during the perfusion period and that this would appear to be a fairly critical problem with extended continuous isolated heart perfusion.

[Perioperative complications in pacemaker surgeries]. / Perioperative Komplikationen bei Schrittmacheroperationen.

In the years 1979 to 1985 (period I) 717 (102 per annum), in 1986 to 1989 (period II) 295 (73 per annum) pacemaker procedures had been performed at the cardiothoracic surgery division of Würzburg University. Indications for pacemaker therapy were in 35.4% vs. 36.6% (period I vs. period II) an atrioventricular block grade II or III, in 18.1% vs. 26.4% sick sinus syndrome, in 15.3% vs. 18.0% bradycardic rhythm disturbances, in 9.5% vs. 6.1% a sinuatrial block, in 6.5% vs. 2.4% a bradycardic sinus rhythm, in 12.4% vs. 3.7% others. While 41% of the procedures were performed under general anesthesia during the first period of observation, local anesthesia was predominant later on. Preferred venous access (79% vs. 74%) was the right cephalic vein followed by the subclavian vein (12% vs. 14%). The amount of the two chamber systems rose form 11% (period I) to 24% (period II). Intraoperative complications occurred in 2.5% vs. 5.8% and postoperative (within 14 days) complications occurred in 4% vs. 5.8%, respectively. No death was to be registered. The reasons for the increase of intra- and postoperative complications are discussed.

[Peripheral round lesion of the lung: diagnosis, therapy, prognosis]. / Der periphere Lungenrundherd: Diagnostik, Therapie, Prognose.

A total of 407 patients were hospitalized on account of a peripheral round lesion in the lungs (PR); 176 of these patients were inoperable for a wide range of different reasons. In 32.9% of the cases, a peripheral bronchial carcinoma presented, in 26.9%, the lesions were metastases, and in 2% malignant growths that were not further classified. All the remaining PR were benign. The following surgical procedures were performed: 39.8% lobectomies, 19.2% wedge resections, 20.6% enucleations, 6.4% segmental resections, 5.1% bilobectomies, 2.2% pneumonectomies, 6.7% various other procedures. The surgical mortality rate was 1.7% (0% in the case of the benign lesions); the re-thoracotomy rate for complications was 4.5%. The five-year survival probability for all bronchial carcinoma patients was 36%, and for all meta patients 47%. The poorest prognosis was seen in patients with PR when a small cell carcinoma or adenocarcinoma presented, and also in T3 tumours.

Nocardial endocarditis after aortic valve replacement. Reports of two cases.

Nocardial sepsis occurred after aortic valve replacement in two patients. A septic suture aneurysm of the aortotomy was resected and the prosthesis exchanged in one of them. The other received conservative treatment for sternal osteomyelitis and local mediastinitis. Clinical cure was followed by relapse and death from cerebral infarction, and necropsy revealed a septic suture aneurysm of the aortotomy. Radical surgical revision seems to be necessary for lasting cure in such infections.

Successful management of dissection of the aortic root during aortic valve replacement.

We present a case of intraoperative dissection of the aortic root in a patient with non-calcified aortic valve incompetence. This complication led to life-threatening bleeding from the dissection line into the layers of the left ventricle as well as the aortic wall with formation of an increasing subadventitial hematoma. The only possible management was to remove the valve prosthesis and to close the entry site of the dissection when reinserting the valve implant. The mechanism of this complication is discussed.

Four years of experience in endomyocardial biopsy--an immunohistologic approach.

Left ventricular biopsies from 376 patients (including 78 patients undergoing bypass surgery) were analyzed by light microscopy (necrosis, infiltration with or without fibrosis) and by immunohistology (bound antibodies). Circulating antisarcolemmal antibodies (ASA) were determined at the time of biopsy using a double-sandwich technique. Circulating antimyolemmal antibodies were assessed in intact rat and human cardiocytes. Histologic findings, heart catheterization, and echocardiography together with the patient's history established the diagnosis of perimyocarditis, myocarditis, postmyocarditic dilated cardiomyopathy, healed myocarditis, and healed perimyocarditis. Both bound and circulating ASA were found in up to 100% of cases in acute inflammatory heart disease and postmyocarditic cardiomyopathy, indicating a secondary immunopathogenesis of the myocardial disease. Analysis of immunoglobulin subclasses revealed: IgG-binding does not discriminate between acute/healing/healed carditis and postmyocarditic dilated heart disease (61.1%-91.7% positive); IgM binding is diagnostic for acute or healing perimyocarditis but has a relatively low incidence (33.3%); IgA binding occurs in acute or healing myocarditis (45.5%), perimyocarditis (33.3%), and in postmyocarditic heart disease (39.4%), but not in controls; complement fixation was never seen in controls, but was seen in acute myocarditis (45.4%), perimyocarditis (25%), and postmyocarditic heart disease (46%). Pretreatment of cryostat sections with collagenase to avoid "nonspecific" binding of antibodies to collagen considerably reduced the sensitivity but increased the specificity. Thus, endomyocardial biopsy proved a safe and valuable method for the further analysis of patients with carditis and myocardial disease of unknown origin.

[Infection prophylaxis with cefamandole. Clinical evaluation in the open heart-surgery and the prosthetic vascular reconstruction (author's transl)]. / Infektionsprophylaxe mit Cefamandol. Ergebnisse einer klinischen Prüfung in der offenen Herz- und prothetischen Gefässersatzchirurgie.

The experience with the cefamandole prophylaxis in 244 patients with open heart-surgery, and another 84 patients operated upon on prosthetic vascular reconstruction was evaluated. No case of endocarditis, sepsis or massive wound infection with infected prosthesis was found in the reviewed patients. Considering the fact that patients undergoing open heart-surgery and prosthetic vascular reconstruction are subjected to much more bacterial contamination than patients undergoing any other surgical procedure, the cephalosporin treatment (in our study cefamandole) should be considered the antibiotic of choice in preventing of infection during and after such surgical intervention.

Assays of cephalosporin antibiotics administered prophylactically in open heart surgery. Determination of serum and tissue levels before, during and after cardiopulmonary bypass.

Twenty-eight patients who underwent open-heart surgery were divided into three groups, each of which received a different antibiotic from the cephalosporin series (cephalotin, cefazolin or cefamandole) in order to prevent infection. All antibiotics were given via intravenous infusion in a dosage of 2 g prior to surgery. To clarify the question of antibacterial activity under operative conditions with the cardiopulmonary bypass, the serum and tissue levels were determined before, during and after the surgical procedure. The effectiveness of the cephalosporins against bacteria most frequently encountered in open-heart surgery was demonstrated and substantiated by the serum and tissue concentrations. It became apparent that, in view of the favorable serum and tissue levels during and after the cardiopulmonary bypass, cefamandole should be considered the antibiotic of choice in preventing infections during open-heart surgery.

[Prevention using cephalothin in open-heart surgery]. / Die Cephalotin-Prophylaxe in der offenen Herzchirurgie.

To assay the efficiency of cephalothin prophylaxis in open-heart surgery, bacteriological examination of pressure-measurement units, intravenous catheter tips, and urine were made in 211 consecutive patients as well as blood cultures and sputum in suspected postoperative sepsis. Furthermore, cephalothin concentration in serum and tissue was determined in 12 consecutive adults with intact kidney function. Samples were taken before, during, and after the cardiopulmonary bypass, the tissue from the right atrium only before and after cardiopulmonary bypass. A high serum cephalothin level (80.04 +/- 23.35 microgram/ml) was measured 30 min after administration of 2 g cephalothin given as a 15-min-long i.v. infusion on induction of anesthesia. An antibiotic regimen - 4 X 2 g dose of cephalothin daily (first dose on induction of anesthesia) - provides a serum cephalothin level which is significantly higher than the cephalothin minimum inhibitory concentrations for most gram-positive organisms (0.475 microgram/ml) and so ensures an adequate antibiotic coverage throughout the surgical procedure and during the early postoperative phase of open-heart surgery.