[A concept to improve wet-lab training in ENT surgery]. / Ein Konzept zur Verbesserung von Präparationskursen in der HNO-Heilkunde.

BACKGROUND: In literature and scientific societies no binding methodical-didactic recommendations or guidelines exist in order to design surgical training courses. The educating institutions plan, organise and evaluate the educational program on their own initiative. MATERIAL AND METHODS: Through a research project surgical training courses were investigated through structured surveys, expert discussions with course responsibles and trainers and analysis of participant's questionnaires. The investigation was performed by an pedagogical-psychological research institution. First implementations were installed and immediately included in the running process of evaluation. RESULTS: From the evaluation, specific alterations in the organisational and micro didactic process were implemented. In addition, changes in a long term process had to be implemented such as: (a) conception of the trainer role, (b) giving feedback and judge performance and (c) provide contents in a sophisticated manner. CONCLUSION: For advanced medical training providers a long term cooperation with a pedagogical institution seems to be highly advisable.

Pulmonary Palacos embolism: a case report.

Instrumentation with cement-augmented pedicle screws has expanded the therapeutic spectrum. This technique is useful for the palliation of bone metastases and in generalized osteoporosis. Serious complications such as pulmonary embolism have been described following percutaneous vertebroplasty, a frequently used technique. We report the case of a 55-year-old patient with a large central Palacos embolism of the right pulmonary artery after corporectomy of the lumbar vertebrae 3 and 4 and reconstruction using autologous pelvic bone. The large Palacos embolism was removed successfully from the right pulmonary artery with extracorporeal circulation.

Effect of pulsatile and non-pulsatile left ventricular assist devices on the renin-angiotensin system in patients with end-stage heart failure.

INTRODUCTION: Left ventricular assist devices have been successfully used as a bridge to cardiac transplantation. Because many patients exhibit marked clinical improvement of their heart failure after LVAD implantation, we studied the physiological effect of pulsatile and non-pulsatile devices on the neurohormonal axis and exercise capacity. METHODS: We prospectively included 20 patients (17 men, 3 women) undergoing LVAD implantation between November 2001 and January 2004. Ten patients (1 woman and 9 men) were treated with the non-pulsatile INCOR-LVAD (Berlin Heart(c)) and ten patients received the pulsatile EXCOR LVAD (Berlin Heart(c)). Blood samples for plasma renin activity (PRA) were taken once a week over a period of ten weeks. All blood samples were collected in the morning before mobilization. Blood pressure, body weight, fluid intake and urine production were measured once a day. All patients received standard hospital diet with no limitation in fluid intake. RESULTS: Body weight remained constant in both groups throughout the ten weeks' examination, and fluid intake and urine production were balanced in all patients. Although there was no significant difference in mean blood pressure (INCOR: 70 +/- 10 mmHg; EXCOR: 73 +/- 10 mmHg), plasma renin activity was substantially elevated in patients with non-pulsatile left ventricular support (INCOR: 94.68 +/- 33.97 microU/ml; EXCOR: 17.06 +/- 15.94 microU/ml; P < 0.05). Furthermore plasma aldosterone levels were significantly higher in patients supported by non-pulsatile INCOR LVAD (INCOR: 73.4 +/- 9.6 microg/ml; EXCOR: 20.6 +/- 4.6 microg/ml; P < 0.05). CONCLUSIONS: Our data suggest that pulsatile as well as non-pulsatile left ventricular assist devices are equally able to treat chronic heart failure. However pulsatile devices seem to have a greater impact on reversing the changes in plasma renin activity and might thus offer a greater advantage when recovery of left ventricular function is expected.

German disease management guidelines: surgical therapies for chronic heart failure.

The German Disease Management Guideline "Chronic Heart Failure" intends to guide physicians working in the field of diagnosis and treatment of heart failure. The guideline provides a tool on the background of evidence based medicine. The following short review wants to give insights into the role of some surgical treatment options to improve heart failure, such as revascularization, ventricular reconstruction and aneurysmectomy, mitral valve reconstruction, ventricular assist devices and heart transplantation.

Limitations of high urgency listing--ventricular assist device support in a neonate for 452 days.

The Eurotransplant International Foundation in Leiden, the Netherlands, is responsible for mediation and allocation of organ donation procedures to its member countries Austria, Belgium, Croatia, Germany, Luxembourg, the Netherlands and Slovenia. To provide organs for the patients who require urgent transplantation, the "high urgent (HU)" status was introduced in 2001 in Germany . This new HU allocation system is applicable to neonates as well as adults. However, waiting times on HU status exceed several weeks to months. Therefore an increasing number of pediatric patients has to undergo implantation of a ventricular assist device (VAD). In the present report we discuss the current Eurotransplant heart allocation system for pediatric heart transplantation in the light of a neonate with 452 days on mechanical support. We compare the average waiting time of patients on HU status at our center and their outcome in 2007 and 2008 (Data obtained from Eurotransplant International Foundation). Waiting time on HU status in our center increased significantly from 2007 to 2008. Therefore more patients require VAD support as bridging to transplantation. The case of a neonate under long-term VAD support is an outstanding example of the negative effects of this development.

Successful management of MRSA sepsis in a patient with left ventricular assist device.

Left ventricular assist devices (LVADs) offer the opportunity to substantially improve the clinical conditions and to interrupt hospitalization of patients suffering from end-stage heart failure awaiting heart transplantation. The authors report a case of a 66-year old patient suffering from end-stage idiopathic dilative cardiomyopathy who needed the implantation of a LVAD and later developed a sepsis with a methicillin resistant Staphylococcus aureus (MRSA) which could be recovered by a differentiated antibiotic regimen.

Switch from assist device to total artificial heart to improve cardiac output.

Left ventricular assist devices (LVADs) offer the opportunity to substantially improve the clinical condition and to interrupt the hospitalization of patients suffering from end-stage heart failure awaiting heart transplantation.We report a case of a 30-year-old patient (body surface area 2.49 m2) suffering from idiopathic dilative cardiomyopathy who was primarily given an LVAD with a free floating impeller pump and was finally switched to a total artificial heart due to the demand for a higher cardiac output.

[Off-label use in cardiac surgery]. / "Off-label use" in der Herzchirurgie.

In the view of off-label use, special concern should be granted to obtaining informed consent from the patient. It is important to point out the test character of the treatment. The patient has to be informed about the risks that exist with the treatment. The patient has to know that a drug not yet approved for this treatment is being used and the risks linked with its use have to be addressed. In addition, informed consent has to be documented and the differences compared with the standard treatment have to be pointed out.

Whole-heart coronary magnetic resonance angiography: value for the detection of coronary artery stenoses in comparison to multislice computed tomography angiography.

BACKGROUND: Coronary magnetic resonance imaging and computed tomography are being discussed as alternatives to catheter angiography in the detection of coronary artery disease. Yet, only few comparative validations have been performed. PURPOSE: To compare steady-state free precession whole heart coronary magnetic resonance imaging (MRI) with multidetector coronary computed tomography angiography (CTA) for the detection of coronary artery disease using catheter angiography as the standard of reference. MATERIAL AND METHODS: Twenty patients with known CAD were examined with navigator (NAV) gated and corrected free-breathing 3D balanced gradient echo whole heart coronary MRI and coronary CTA. Subjective overall image quality (4 point scale, 1 = excellent), visibility of vessel segments and accuracy for the detection of significant coronary stenoses (>50%) were compared to coronary x-ray angiography by two blinded readers. RESULTS: Median of subjective image quality was 3 for coronary MRI and 2 for coronary CTA. Of a total of 209 segments, 67 segments (32%) had to be excluded from the evaluation by coronary MRI (61 due to insufficient image quality and 6 due to stent artifacts). For coronary CTA, 31 segments (15%) had to be excluded from the evaluation (12 due to insufficient image quality, 15 due to severe calcifications superimposing the vessel lumen and 4 due to stent artifacts. Segment based values for the detection of >/=50% diameter coronary x-ray angiographic stenoses were: specificity: MRI 88%, CTA 95%; sensitivity: MRI 82%, CTA 84%; diagnostic accuracy: MRI 87%, CTA 93%; positive predictive value: MRI 68%, CTA 77% and negative predictive value: MRI 94%, CTA 95%. CONCLUSION: Coronary WH-MRI was inferior to coronary CTA regarding image quality and number of evaluable segments but both had similar diagnostic value for the detection and exclusion of CAD when only evaluable segments were included.

Heart transplantation for isolated noncompaction of the left ventricle in an infant.

Isolated noncompaction of the left ventricular myocardium is a rare cardiomyopathy typically showing a "spongy" myocardium on ultrasound. We report on the ultrasonic and pathomorphological characteristics of an infant who, at the age of 40 days, was treated by heart transplantation for isolated noncompaction. Noncompaction should be suspected in newborns with otherwise unexplained cardiomyopathy and a "spongy" left ventricle. However, ultrasonic and pathological findings may be much less pronounced at this age than later in life.

[Whole-heart coronary MR angiography -- initial results]. / Whole-Heart-MR-Koronarangiographie -- erste Ergebnisse.

PURPOSE: To evaluate a new coronary MR angiography technique covering the whole coronary artery tree in one data set acquisition. MATERIALS AND METHODS: Six healthy volunteers and 15 patients with known CAD were examined with a navigator gated and corrected (NAV) free-breathing 3D steady-state free precession sequence covering the whole heart (WH-MRA) (TR = 5.4, TE = 2.7, SENSE factor = 2, 160 slices, 0.75 mm reconstructed slice thickness, in-plane resolution = 0.99 x 0.99 mm(2), scan time 14 min [50 % NAV efficiency]) and a vessel targeted 3D SSFP MRA sequence (t-MRA) (TR = 5.6 ms, TE = 2.8 ms, 20 slices of 1.5 mm reconstructed slice thickness, in-plane resolution = 0.99 x 0.99 mm(2), scan time = 7 min [50 % NAV efficiency]). Subjective image quality (4-point scale) and objective image quality parameters including vessel sharpness, vessel diameter and CNR were calculated for WH-MRA and t-MRA. In patients, the accuracy for detection of stenosis larger than 50 % was compared to the accuracy of X-ray coronary angiography (XA), which was considered the standard. RESULTS: WH-MRA demonstrated good vessel visibility in healthy subjects (100 %) whereas vessel visibility in patients was limited (78 % in an 8 segment evaluation). Vessel sharpness was inferior to that of t-MRA in patients (37 vs. 42 %) but equal in healthy subjects (42 %). Vessel diameter did not differ significantly between WH-MRA and t-MRA. CNR was significantly reduced for WH-MRA (CNR 7.4 vs. 11.5). The diagnostic accuracy for the detection of CAD was comparable for both MRA approaches (85.5 vs. 86.2 %). CONCLUSION: WH-MRA allows good coronary artery visualization in healthy subjects and patients and provides a simplified scanning procedure and advantages in 3D post-processing. Regarding image parameters and the detection of CAD, the results are comparable to those acquired with t-MRA. The major disadvantage remains the high number of diagnostically insufficient images.

Mucinous cystadenocarcinoma--an extremely rare tumor in a young patient.

We report on an extremely rare case of pulmonary mucinous cystadenocarcinoma. A 29-year-old male patient was admitted because of progressive enlargement of a right lower lobe mass over a period of 10 years. Right lower lobectomy was performed after a malignant mucinous cystadenocarcinoma was diagnosed by intraoperative frozen section. PET and CT scans did not detect metastatic disease. This case is the youngest patient reported so far with a malignant pulmonary mucinous cystadenocarcinoma and highlights the importance of close follow-up of indeterminate pulmonary nodules in patients with unremarkable history.

[Caution in foregoing patient education]. / Vorsicht beim Aufklärungsverzicht.

A key part of the individual patient rights is the renunciation of explicit information on a planned surgical procedure. However, jurisdiction has assigned strict requirements for the validity of such a denial. To ensure legal validity of the denial, the surgeon has to obtain informed consent signed by the patient stating that the patient rejected detailed medical information, but did understand the nature of the planned procedure. The initiative to receive just limited medical information must be taken by the patient himself, not the surgeon. Thus, the patient may choose to receive either detailed or limited information on the surgical procedure. Important to know: A limited time schedule of the surgeon is not a valid justification for a limited informed consent.

Low weight in congenital heart surgery: is it the right way?

OBJECTIVE: There is ample evidence that premature and low birth weight children have a poor outcome after congenital heart surgery. The aim of the present study was to characterize the perioperative factors which significantly influence the outcome of these babies following cardiac surgery, and to clarify whether the RACHS-1 and the Aristotle score are compatible for this complex kind of heart surgery. METHODS: During the past 10 years, 108 children with a body weight of less than 3000 g were operated, including 43 premature babies. Mean weight at operation was 2.5 +/- 0.5 kg, mean age was 36.8 +/- 55 days. Fifty percent of the treatments were categorized into risk groups 4 and 6 and 54 % belonged to the complexity levels 3 and 4. Eighty-one operations (75 %) were performed using extracorporeal circulation. RESULTS: The 30 day mortality rate was 18 %, and the overall mortality rate was 30 %. The correlation between mortality rates and risk groups was significant ( p < 0.001). Other significant factors were preoperative acidosis ( p = 0.026), preoperative catecholamine support ( p < 0.001), prolonged ICU stay (> 7 days) after operation ( p < 0.001), and postoperative infection ( p = 0.019). In addition, X-clamp time ( p = 0.029) and palliative procedures ( p < 0.001) were significant factors for poor outcome. CONCLUSION: The results demonstrate that the mortality for correction of congenital heart defects in children weighing less than 3000 g depends on several factors. The risk groups of the RACHS-1 study and the complexity levels of the Aristotle score are useful tools to assess preoperative risk.

Harvest of the radial artery: technique of the skeletonization and pedicle preparation.

Nowadays, radial artery grafts play a significant role in coronary artery revascularization, however, harvesting techniques are not standardized. We developed various surgical techniques for radial artery harvesting considering the anatomic landmarks of the foramen, including conventional surgery (with scissors and clips) and procedures with ultrasonic scalpel and retrieving the radial artery graft in a pedicle or in a skeletonized manner.

Comparison of electrical velocimetry and transoesophageal Doppler echocardiography for measuring stroke volume and cardiac output.

BACKGROUND: Impedance cardiography (ICG) has been used extensively to estimate stroke volume (SV) and cardiac output (CO) from changes of thoracic electrical bioimpedance (TEB). However, studies comparing ICG with reference methods have questioned the reliability of this approach. Electrical velocimetry (EV) provides a new algorithm to calculate CO from variations in TEB. As the transoesophageal Doppler echocardiographic quantification of CO (TOE-CO) has emerged as a reliable method, the purpose of this study was to determine the limits of agreement between CO estimations using EV (EV-CO) and TOE-CO. METHODS: Standard ECG electrodes were used for non-invasive EV-CO measurements. These were placed on 37 patients scheduled for coronary artery surgery necessitating transoesophageal echocardiography monitoring. Simultaneous EV-CO and TOE-CO measurements were recorded after induction of anaesthesia. EV-CO was calculated using the Bernstein-Osypka equation. TOE-CO was measured across the aortic valve using continuous-wave Doppler echocardiography and a triangular orifice model. RESULTS: A significant high correlation was found between the TOE-CO and the EV-CO measurements (r2=0.86). Data were related linearly. The slope of the line (1.10 (se 0.07)) was not significantly different from unity, and the point at which it intersected the ordinate (-0.46 (0.32) litre min(-1)) was not significantly different from zero. Bland-Altman analysis revealed a bias of 0.18 litre min(-1) with narrow limits of agreement (-0.99 to 1.36 litre min(-1)). CONCLUSIONS: The agreement between EV-CO and TOE-CO is clinically acceptable, and these two techniques can be used interchangeably.

Effective systolic orifice area of the aortic valve: implications for Doppler echocardiographic cardiac output determinations.

BACKGROUND: Substantial research using echocardiography has established that stroke volume (SV) or cardiac output (CO) can be measured non-invasively at the level of the aortic valve (AV) with high accuracy. Stroke volume is the product of the velocity time integral occurring at the sampling site and the effective systolic AV orifice area (AVOAeff). Nevertheless, a generally accepted method for the determination of AVOAeff is still lacking. METHODS: Aortic valve OAeff was measured in 228 consecutive patients scheduled for coronary artery surgery. Two widely adopted methods were applied to approximate the constantly changing orifice area of the AV: (1) the circular orifice model (AVOA-CM), and (2) the triangular orifice model (AVOA-TM). Aortic valve OA-CM assumes the shape of a circle as an appropriately time averaged geometrical model, and AVOA-TM takes the shape of an equilateral triangle for granted. RESULTS: The AV was easily imaged by echocardiography in both short- and long-axis views in all patients. Relying on AVOA-CM, AVOAeff was 3.49+/-0.77 cm2. AVOA-TM estimates were 2.80+/-0.55 cm2 (mean+/-SD). The results did not agree (bias analysis). CONCLUSIONS: The echocardiographic measurement of SV or CO at the level of the AV has to be reconsidered.

Cardiothoracic surgery after heart and heart-lung transplantation.

OBJECTIVE: We sought to examine our management and the outcomes of cardiothoracic procedures after heart and heart lung transplantation. METHODS: We performed a retrospective review of cardiothoracic surgical procedures carried out between 1990 and 2004 in patients who had previously undergone heart or heart-lung transplantation at our institution. RESULTS: Twenty-one out of 340 patients (6.2 %) were identified. Cardiothoracic surgery was performed 44.4 +/- 33 months (range 1 - 115 months) after transplantation. Predominant types of surgery were coronary artery bypass grafting due to allograft vasculopathy (n = 5), aortic surgery due to acute dissection (n = 3), biventricular assist device implantation due to acute rejection (n = 1), tricuspid valve repair (n = 1), multiple cardiac surgical procedures including coronary artery bypass grafting, retransplantation, and tricuspid valve replacement (n = 2), explantation of a functionless heterotopic transplanted heart (n = 1). Lung surgery was performed in six patients due to pneumonia (n = 2), primary lung carcinoma (n = 3), lung torsion following heart-lung transplantation (n = 1). All patients underwent either lobectomy or segmental lung resection. Single lung retransplantation (n = 2) after prior heart-lung transplantation due to bronchiolitis obliterans was performed. In one patient a pneumonectomy (n = 1) due to severe chronic rejection of the contralateral lung was performed. Six subsequent deaths after cardiothoracic procedures were recorded after 1, 4, 78, 163, 205, and 730 days, respectively. Causes of death were advanced carcinoma (n = 1), multi-organ failure due to sepsis (n = 2), sudden heart death (n = 2), and advanced heart failure (n = 1). Fifteen out of 21 patients having undergone cardiothoracic procedures (71.4 %) survived the observation period of 56.6 +/- 34 months (range 1 - 114). CONCLUSIONS: Reasons for cardiothoracic procedures after prior heart or heart-lung transplantation were allograft vasculopathy, aortic dissections years after transplantation, chronic rejection, and either lung infections or malignancies. Surgical repair can be performed with an acceptable operative risk and good long-term survival rates.