Pulmonary metastasectomy - A retrospective comparison of surgical outcomes after laser-assisted and conventional resection.

INTRODUCTION: Indications and surgical techniques for pulmonary metastasectomy (PME) are controversially discussed issues. Laser-assisted surgery (LAS) is a recent innovation that has been advocated especially in patients with multiple pulmonary metastases (PM). However, there are hardly any studies comparing surgical outcomes after laser-assisted and conventional resection. The aim of the current study was to evaluate the value of LAS in a larger study population. MATERIALS & METHODS: A retrospective analysis was completed on 178 consecutive patients undergoing 236 PMEs at a single center between 2010 and 2015. The main endpoint was survival. Statistical analysis was performed using the Kaplan-Meier method and survival rates were compared with the log rank test. Follow-up was done with special attention to the development of recurrent PM. Local relapse was defined as a recurrent metastasis in direct relation to the previously resected area according to CT scan comparisons. RESULTS: LAS was performed on 256 metastases in 99 patients, non-laser-assisted surgery (NLAS) on 127 metastases in 79 patients. 5-year-survival rates were 69.3% in all patients, 65.7% after LAS and 73.6% after NLAS. There was no statistically significant survival difference after LAS or NLAS (p = 0.41). The rate of local relapse was 0.8% after LAS vs 3.1% after NLAS (p = 0.073). CONCLUSION: Despite a larger number of negative predictors for survival in LAS patients, overall survival (OS) was similar in the compared groups. There was also a trend for a lower risk of local relapses after LAS. Therefore, LAS should be considered a promising method for PME.

A new era of thoracic oncology? Ex-vivo stereotactic ablative radiosurgery within Ex-vivo Lung Treatment System as a hybrid therapy for unresectable locally advanced pulmonary malignancies.

The concept of oligometastases is the medical rationale for a local treatment of a limited number of metastatic tumor manifestations. Patients with pulmonary oligometastases are candidates for surgery or radiotherapy, however there are a number of technical issues that limit treatment. Technical issues relating to radiotherapy include organs at risk of irradiation, chest wall toxicity and decreased precision of tumor targeting because of breathing movements. Technical issues relating to surgery include loss of lung parenchyma and unresectability. We propose the hypothesis that ex-vivo radiosurgery as new hybrid technique in thoracic oncology has the capability to overcome these technical issues and will expand the medical spectrum in thoracic oncology. The proposed - highly complex - technique consists of surgical lung explantation, followed by stereotactic radiotherapy during ex-vivo perfusion followed by surgical re-implantation.

A new era of ventricular assist device surgery: less invasive procedures.

As the number of patients suffering of congestive heart failure is rising worldwide, the use of mechanical circulatory support to treat these patients has also grown enormously, surpassing the number of annual heart transplants. Moreover latest generation of left ventricular assist devices (LVADs) is characterized by improved technologies. Moreover the size of new LVAD systems is considerably reduced when compared to older generation devices. Therefore, less invasive surgery is now possible for the implantation, explantation, and exchange of LVADs. Although experience with these new techniques is still limited, minimally invasive procedures are thought to improve surgical outcomes by declining the rates of operative complications such as bleeding or wound infection. The miniaturization of LVADs will continue, so that minimally invasive techniques will be used for most LVAD-related procedures in the future. In this article, we summarize and describe minimally invasive surgical techniques, with a focus on the most common LVAD systems in adults.

Outpatient management of intra-corporeal left ventricular assist device system in children: a multi-center experience.

Little is known about the outcomes of children supported on intracorporeal left ventricular assist device (HVAD), and the feasibility of outpatient management. All centers with pediatric patients discharged from the hospital on the device were identified using company database. A total of 14 centers were contacted, with 9 centers, contributing data retrospectively. From 2011 to 2013, 12 pediatric patients (7 females), mean aged 11.9 ± 2.3 years (range 8-15), mean weight 43 ± 19 kg (range 18-81), mean body surface area 1.3 ± 0.3 m(2) (range 0.76-1.96) were identified. Diagnosis included: dilated cardiomyopathy (CMP) (n = 5), noncompaction CMP (n = 4), toxic CMP (n = 2) and viral CMP (n = 1). Indications for support were permanent support (n = 1), bridge to recovery (n = 1) and bridge to transplantation (n = 10). Prior to HVAD implantation, all patients received intravenous inotropes and two patients were on temporary mechanical support. Overall mortality was 0%. Mean duration of inpatient and outpatient support were 56 (range: 19-95 days) and 290 days (range: 42-790), respectively. Mean readmission rate was 0.02 per patient month (2.1 per patient). No adverse events involving emergency department occurred. Eight children resumed local schooling. Home discharge of children supported on HVAD is feasible and safe. School integration can be achieved. There is wide center variability to discharge practice for children.

Optimal timing of pulmonary metastasectomy--is a delayed operation beneficial or counterproductive?

INTRODUCTION: Pulmonary metastasectomy represents an established approach in the treatment of lung metastases related to several solid malignant tumors, promising the chance of long term survival. Regarding the proper timing of metastasectomy both operation promptly after diagnosis and delayed operation after an interval of 3 months are common practice. MATERIALS AND METHODS: A systematic Medline search addressing the optimal timing of metastasectomy was performed. Since the search query "timing of metastasectomy" yields only a limited number of articles, the Medline search was expanded to include the main arguments for prompt metastasectomy ("metastases of metastasis", "growth rate of pulmonary metastases") and for delayed metastasectomy. RESULTS: Based on the data available to date, there is no necessity to expedite the timing of the operation. On the other hand, there is no evidence that a delayed operation, for example after re-staging following an interval of 3 months, provides a benefit. CONCLUSION: Therefore the timing of metastasectomy should only depend on the patient's requirements, such as general state of health and oncologic considerations, such as promising multimodal therapy concepts, extrathoracal tumor manifestations or oncologic type of the primary tumor. A delayed operation seems justified if the indication for resection is questionable due to a high risk of early multilocal recurrence.

[Ex situ tracheobronchoplastic operations using the organ care system]. / Broncho-/tracheoplastische Ex-situ-Operationen im "organ care system"

First clinical experiences with the organ care system (OCS) in lung transplantation showed that this device allows perfusion and ventilation of the lungs under practically physiological conditions. Some pulmonary pathologies necessitate ex situ operations, e.g. to avoid pneumonectomy. The objective of this work was to investigate the feasibility of ex situ pulmonary surgery within the OCS.In the first procedure a large tracheobronchial leakage was covered with a pericardial patch. The procedure was authorized by the local committee of animal welfare. In the second surgery a replacement of the distal trachea using an aortic graft was performed after removal of the heart-lung segment from a pig from the slaughterhouse. The postoperative ventilation of both lungs was free of problems. The mean pressure of the pulmonary artery remained steady during the whole experiment. The setup to prevent lung edema was basically successful.Performing thoracic surgery with the OCS is feasible; however, this approach is reserved for very special indications. Further investigations to optimize technical details of the OCS setup for this purpose are necessary.

Long-term maintenance therapy for post-cardiac transplant monoclonal lymphoproliferative disorder: caveat mammalian target of rapamycin.

A 53-year-old Caucasian male suffering from idiopathic dilated cardiomyopathy underwent cardiac transplantation. Fifty-seven days following transplant, he developed posttransplant lymphoproliferative disorder (PTLD), which was Epstein-Barr virus positive. The initial episode of PTLD was treated with a dose reduction in cyclosporine (CsA) and a 4-week course of rituximab. Subsequent biopsies showed resolution of PTLD. One year posttreatment, his evaluation revealed severe cardiac allograft vasculopathy (CAV). The patient was switched to sirolimus-based immunosuppression regimen with gradual up-titration of sirolimus in combination with complete withdrawal of previously administered Calcineurin-based immunosuppression approach. The switchover was carried out over a 6-week period. In the following 3 years, there was CAV regression as well as PTLD remission, without any significant episode of rejection. Despite frequent relapses with this form of PTLD, the patient remains in remission, 8 years posttransplantation. In summary, sirolimus has been demonstrated to attenuate the progression of CAV, and this case report illustrates that regression of CAV is possible. In addition to preventing rejection, mammalian target of rapamycin inhibitors directly suppress signaling pathways leading to PTLD and may be effective monotherapy for preventing rejection and suppressing PTLD.

[Meeting the needs of the European working time directive in german medical profession]. / Sollarbeitszeit und maximale Arbeitszeit bei angestellten Ärzten.

The legal obligation of the European Working Time Directive with its implementation into a German Working Hours Act requires German hospitals to give up old structures and requires the implementation of new working time models. The failure of the revision of the European Working Time Directive in April 2009 prevented that any changes of status quo might happen in the near future. Fundamental terms of the working law for the medical area have been elucidated and have been implemented into concrete calculation formulas. The planned working time has been clearly determined. Particularly, on-call duties and a signed "OptOut-declaration" have huge effects on the upper limit of the working time that is to be determined. Shift duty leads to the greatest limitations of the upper limit of the working time. The Working Hours Act defines the maximal, available, individual working time budget and thus the working time budget of a hospital and it limits the maximal availability of the service providers of a hospital as well as defining the maximal personnel costs. Transparency in this area lays the foundation for an effective time management and the creation of new working time models in accordance with the European Working Time Directive as well as the Working Hours Act and the "TVÄ" (labour contract for doctors at municipal hospitals). It is possible, with the knowledge of the maximal working time budget and the thereof resulting personnel costs, to calculate the economical revenues better. The reallocation of the working time of doctors enables efficiency enhancement. It is necessary to demand a clear definition of the tasks of doctors with the consequential discharge of tasks that should not/do not belong to the responsibilities of a doctor. This would lead to a more attractive working environment for doctors at hospitals and thus to an improvement of the care of the patients. The implementation of the European Time Directive is not to be seen as unrealizable, as has been generally heard; instead, it enables the urgently necessary structural reform at German hospitals.

Effects of different proton pump inhibitors on cardiac contractility in isolated human failing myocardium.

AIM: Proton pump inhibitors (PPI), e.g. pantoprazole (PP), esomeprazole (EP) and omeprazole (OP), work as anti-ulcer/gastrointestinal reflux drugs. Also, they are widely used in postoperative care of patients in cardiac surgery to prevent upper gastrointestinal bleeding. Therefore, in western industrial countries they play a major economic role, representing one of the most important drugs in open heart cardiac surgery. METHODS: Intact muscle strips (n=32) were isolated from the right ventricle wall of failing human hearts. In four different groups (PP, EP, OP, control group, each n=8), force amplitudes were recorded at a frequency of 60 beats per minute (bpm) with increasing PPI concentrations (0 to 320 µm/mL). RESULTS: In isometrically contracting muscle strips, significant negative inotropic effects were observed in the presence of all three PPI-groups (PP, EP and OP) with doses of 2.5 µg/mL and higher compared to the control group (p < 0.05 each). With high doses (320 µm/mL), force amplitudes could be almost completely depressed. The half maximal inhibitory concentration (IC50) for EP was 35.7 (confidence interval: 17.3-73.6) vs. OP 29.3 (6.8-126.6) vs. PP 25.1 (14.6-43.1) µg/mL (n.s.). No significant differences were found between the different proton pump inhibitors (PP, EP, OP) throughout the range of all concentrations. Relaxation was impaired in all PPI subgroups with prolonged time to 90% relaxation (RT90%) and maximum relaxation velocity (­df/dt) was reduced, too. These effects were partially reversible after wash-out of the drugs. CONCLUSION: We conclude that proton pump inhibitors show significant negative inotropic effects on isolated human failing myocardium. There is no apparent difference seen in the magnitude of the effects of each PPI-group. Further, in-vivo investigations are necessary to reveal the clinical evidence of PPI's negative inotropic effects, e.g. in cardio-surgical patients with heart failure.

Extracorporeal life support in pediatric patients with congenital heart diseases: outcome of a single centre.

AIM: In pediatric patients with congenital heart disease low cardiac output (LCO) is the principal complication after corrective heart surgery. In LCO refractory to all therapeutic options, mechanical circulatory support is the final method to keep these patients alive. In this present study the authors reviewed the outcome of pediatric patients who required mechanical circulatory support after corrective surgery with extracorporeal membrane oxygenation or ventricle assisted devices (VAD). METHODS: A retrospective single centre consecutive cohort study was carried out in children who required different mechanical circulatory support indicated by postcardiotomy low output syndrome between 1991 and 2004. A total of 20 patients received extracorporeal life support. The indications for surgery were: 12 transposition of great arteries, 1 Bland-White-Garland syndrome, 3 tetralogy of Fallot, 1 hypoplasia of aortic arch, 1 total anomalous pulmonary vein connection, and 2 ventricle septum defect. RESULTS: Mean age was 1.29 years. Mean duration of assist was 8.87 days. Seven patients out of 20 survived, six could be discharged after myocardial recovery from LCO and one could be discharged after successful heart transplantation. The overall mortality in patients with extracorporeal life support was 65%. The causes of death were multiorgan failure and bleeding in one case was a VAD related complication. CONCLUSION: The use of extracorporeal life support (ECLS) shows a high mortality rate. However, ECLS can still help to keep some of those patients alive. Mechanical support devices are the ultimate chance to save time, to increase survival and to bridge the time until heart transplantation.

Clinical relevance of eNOS T-786C polymorphism for hospital mortality and morbidity in cardiac surgical patients.

AIM: The endothelial nitric oxide (eNOS) gene T-786C polymorphism may influence as a genetic risk factor cardiovascular diseases and shows association with cardiovascular mortality. We hypothesized that this polymorphism may lead to increase mortality and morbidity after cardiac surgery with cardiopulmonary bypass (CPB). METHODS: In 500 patients who underwent cardiac surgery with CPB we investigated the eNOS T-786C polymorphism by DNA-sequencing. The patients were grouped according to their genotype in three groups (TT, TC, and CC). RESULTS: The overall genotype distribution of T-786C polymorphism was TT=41.6%, TC=51.2%, and CC=7.2% respectively. The groups did not differ in age and gender. No significance was shown in preoperative risk factors, excluding peripheral disease (P=0.03). No difference was shown in Euroscore, APACHE II, and SAPS II. The usage of norepinephrine (P=0.03) and nitroglycerine (P=0.01) was significant higher in TC allele carrier. The mortality was quite uniform across elective and urgent subgroup. However, we found a significant difference concerning mortality and emergency cardiac procedures in homozygous C-allele carrier (P=0.014). CONCLUSION: The present study demonstrates that this polymorphism contributes to a higher prevalence of postoperative mortality after emergency cardiac surgery. Thus, the eNOS T-786C polymorphism could serve as a possibility to differentiate high risk subgroups in heterogeneous population of individuals with cardiac diseases who need cardiac surgery with CPB.

Cardiac function during mild hypothermia in pigs: increased inotropy at the expense of diastolic dysfunction.

AIM: The induction of mild hypothermia (MH; 33 degrees C) has become the guideline therapy to attenuate hypoxic brain injury after out-of-hospital cardiopulmonary resuscitation. While MH exerts a positive inotropic effect in vitro, MH reduces cardiac output in vivo and is thus discussed critically when severe cardiac dysfunction is present in patients. We thus assessed the effect of MH on the function of the normal heart in an in vivo model closely mimicking the clinical setting. METHODS: Ten anaesthetized, female human-sized pigs were acutely catheterized for measurement of pressure-volume loops (conductance catheter), cardiac output (Swan-Ganz catheter) and for vena cava inferior occlusion. Controlled MH (from 37 to 33 degrees C) was induced by a vena cava inferior cooling catheter. RESULTS: With MH, heart rate (HR) and whole body oxygen consumption decreased, while lactate levels remained normal. Cardiac output, left ventricular (LV) volumes, peak systolic and end-diastolic pressure and dP/dt(max) did not change significantly. Changes in dP/dt(min) and the time constant of isovolumetric relaxation demonstrated impaired active relaxation. In addition, MH prolonged the systolic and shortened the diastolic time interval. Pressure-volume analysis revealed increased end-systolic and end-diastolic stiffness, indicating positive inotropy and reduced end-diastolic distensibility. Positive inotropy was preserved during pacing, while LV end-diastolic pressure increased and diastolic filling was substantially impaired due to delayed LV relaxation. CONCLUSION: MH negatively affects diastolic function, which, however, is compensated for by decreased spontaneous HR. Positive inotropy and a decrease in whole body oxygen consumption warrant further studies addressing the potential benefit of MH on the acutely failing heart.

Histological changes in a model of chronic heart failure induced by multiple sequential coronary microembolization in sheep.

AIM: Valuable models of chronic heart failure to perform histological studies are scarce. The authors aimed at investigating histological changes of the heart, lung, liver and kidneys in a stable and reproducible animal model of chronic heart failure in sheep. METHODS: In 8 sheep (N.=8, 77+/-2 kg) chronic heart failure was induced by multiple sequential microembolization through bolus injection of polysterol microspheres (90 microm, N=25 000) into the left main coronary artery. Microembolization (ME) was repeated up to three times in two to three week intervals until animals started to develop stable signs of heart failure. Therefore, clinical and hemodynamic parameters were measured (Troponin T, heart and respiratory rate, cardiac output) after each embolization. Clinical examination was carried out by a veterinarian. All animals were followed for 3 months after first microembolization and then euthanized for histological examination. Histological data of the heart, lung, liver and the kidneys were analyzed in hematoxylin-eosin (HE) stains (10x, 25x, 100x) at baseline (control group) and at 3 months after first ME. Additionally preparations of heart tissue were stained with Picro-Sirius-Red (PSR) for planimetric quantification. A score from 0 to 4 according to Rassler et al. (2005) was used to assess the degree of lung injury. RESULTS: All animals developed histological signs of heart failure as indicated by island-like, patchy fibrosis of the heart. Planimetric quantification (PSR stain) of the heart revealed a significant increase of the total amount of fibrosis from 8+/-2% (base) to 21+/-4% (3 months) (P<0.05), which was distributed homogeneously throughout the left ventricle (20+/-3% left ventricular [LV] anterior wall, 21+/-4% LV posterior wall, 20+/-4% septum). Histologic analysis of the lung demonstrated a moderate degree of interstitial edema and pronounced peribronchial processes of inflammation with beginning proliferation of fibrotic tissue. Liver tissue showed histological changes in terms of pericentral adiposis as sign of hypoxia in course of lacking perfusion. Signs of liver congestion could be detected histological in form of central-venous accumulation of erythrocytes and dissolution of liver tissue in proximity of the central veins. Kidney preparations illustrated loss of endothelial function and vascular occlusions, caused by microspheres, with decline of renal parenchyma particularly of the tubules. CONCLUSION: Multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with histological signs of chronic ischemic cardiomyopathy and pathological changes of lung, liver and kidney, which can directly be coursed by chronic heart failure. Thus, the present model may be suitable in experimental work on heart failure and LV assist devices, e.g. for studying the impact of mechanical unloading, mechanisms of recovery and reverse remodeling.

Chronic heart failure induced by multiple sequential coronary microembolization in sheep.

OBJECTIVE: Although a large variety of animal models for acute ischemia and acute heart failure exist, valuable models for studies on the effect of ventricular assist devices in chronic heart failure are scarce. We aimed to establish a stable and reproducible animal model of chronic heart failure in sheep. METHODS: Sheep (n=8, 77 +/- 4 kg) were anesthesized and a 5F sheath was implanted into the left carotid artery. The left main coronary artery was catheterized under flouroscopic guidance and bolus injection of polysterol microspheres (90 microm, n=25.000) was performed. Microembolization (ME) was repeated up to three times in two to three week intervals until animals started to develop stable clinical signs of heart failure. Clinical and echocardiographic data were analyzed at baseline (base) and at three months (3 mo) after first ME. All animals were followed for 3 months after first microembolization and then sacrificed for histological examination. Another four healthy sheep (79+/-6 kg) served as control animals. RESULTS: All animals developed clinical signs of heart failure as indicated by increased heart rate at rest (68+/-4 bpm (base) to 93 +/- 5 bpm (3 mo) (p<0.05)), increased respiratory rate at rest (28+/-5 (base) to 38 +/- 7 (3 mo) (p<0.05)) and increased body weight 77 +/- 2 kg to 81 +/- 2 kg (p<0.05) due to pleural effusion, peripheral edema and ascites. Echocardiographic evaluation revealed significantly an increase of left ventricular enddiastolic diameter from 46 +/- 3 mm (base) to 61 +/- 4 mm (3 mo) (p<0.05). Clinically and echocardiographically no significant changes were revealed in healthy control animals. CONCLUSIONS: We conclude that multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with clinical and echocardiographical signs of chronic ischemic cardiomyopathy. The present model may be suitable in experimental work on heart failure and left ventricular assist devices, e.g. for studying the impact of mechanical unloading, mechanisms of recovery and reverse remodeling.

Influence of angiotensin-I-converting-enzyme insertion/deletion gene polymorphism on perioperative hemodynamics after coronary bypass graft surgery.

AIM: The angiotensin I-converting enzyme insertion/ deletion polymorphism (ACE-I/D), including three genotypes (II, ID, DD), with a known impact on midterm mortality and morbidity in patients after coronary artery bypass graft surgery (CABG), was studied. Since this polymorphism has been linked with increased vascular response to phenylephrine during cardiopulmonary bypass (CPB), we investigated its possible effect on perioperative hemodynamics in patients undergoing CABG. METHODS: Genotyping for the ACE-I/D was performed by polymerase chain reaction (PRC) amplification in 110 patients who underwent elective CABG with CPB. Patients were assigned to two groups according to their genotype (group II [II genotype] and group ID/DD [ID and DD genotypes]). Systemic hemodynamics were measured directly before and at 4 h, 9 h, and 19 h after CPB. RESULTS: Genotype distribution of ACE-I/D was 18%, 57%, and 25% in genotypes II, ID, and DD, respectively. The two groups were similar in age (group II: 66+/-6 years, group ID/DD: 66+/-8 years), body-mass-index (BMI) (group II: 28+/-2, group ID/DD: 29+/-5 kg/m2), male: female ratio (group II: 16: 4, group ID/DD: 63: 27) and Euroscore (group II: 3.1+/-1.9, group ID/DD: 3.5+/-2.1). There were no differences in mortality rate or perioperative systemic hemodynamics. The pulmonary vascular resistance before cardiopulmonary bypass was higher in the ID/DD genotypes than in the II genotypes (227+/-121 vs 297+/-169 dyn.s(-1).m2.cm(-5)). Four hours after CPB no difference remained; at 9 h after cardiopulmonary bypass there was a slight difference in pulmonary vascular resistance between the two groups (247+/-134 vs 290+/-117 dyn.s(-1).m2.cm(-5)) and a significant difference in pulmonary arterial pressure (19+/-6 vs 23+/-8); at 19 h after CPB the differences were no longer detectable. CONCLUSION: ACE-I/D had no influence on perioperative systemic hemodynamics. However, transitory differences in pulmonary hemodynamic were observed after CPB. These differences may have been due to changes in serum ACE activity during CPB.

[Another case of "Lazarus phenomenon" during surgery? Spontaneous return of circulation in a patient with a pacemaker]. / Intraoperatives "Lazarus-Phänomen"? Spontane Kreislaufstabilisierung bei einem Patienten mit Herzschrittmacher.

A case is presented of spontaneous return of circulation after cardiac arrest in a patient with a pacemaker without intraoperative resuscitation. In the literature this kind of situation is called the Lazarus phenomenon. Cardiac arrest of the patient occurred during surgery and because of the poor prognosis no cardiopulmonary resuscitation was initiated. After 6 min of apnoea and cessation of circulation, the circulation restarted spontaneously and surgery was continued. Afterwards the patient was transferred to the intensive care unit but died 2 days later without regaining consciousness. The pathophysiological mechanisms for the Lazarus phenomenon are poorly understood but several mechanisms and multifactorial events are discussed in the literature.

[Anomaly of the vena cava inferior with paracaval venous aneurysm and renal collateralisation]. / Achsenanomalien der Vena cava inferior mit paracavalem venösen Aneurysma und renalem Kollateralkreislauf.

Aneurysms of the great venous vessels represent anatomical rarities. Most malformations of the venous system published so far concern mainly the inferior vena cava and arise in different formations. Reports of malformations of the renal veins are limited to a few case reports and may lead to diagnostic and therapeutic difficulties. We report on an case of a asymptomatic, aneurysmatic venous malformation of the vena cava inferior With consideration of the entire findings we preferred a conservative treatment of the patient.

[Josef Koncz (1916-1988)--pioneer of cardiac surgery]. / Josef Koncz (1916-1988)--Pionier der Herzchirurgie.

Josef Koncz (1916-1988) was until given emeritus status in 1982 director of the Department of Cardiothoracic and Vascular Surgery, which was specifically founded for him in Goettingen, Germany. By the fusion of three different surgical branches the University hospital of Goettingen took over the role of a pacemaker and initiated a standard in the development of this new specialty in Germany. The scientific and clinical work done by the Department of Cardiothoracic and Vascular Surgery was shaped by the personality of the surgeon and scientist Josef Koncz. He was a successful surgeon and innovative pioneer in one person. Already in 1956, he started open-heart surgery and proceeded this technique in an impressing series. In 1965 he was the first in Germany who operated upon the transposition of the great vessels by Mustard's method and developed together with his long-standing assistant, Huschang Rastan, an operation technique to extend the left-ventricular outflow tract combined with tunnel-shaped subvalvular aortic valve stenosis. Another essential element of his work is related to the establishment of the Cardiothoracic and Vascular Surgery as an independent specialty, ending in the foundation of the German Society for Thoracic and Cardiovascular Surgery in 1971.