Early detection of sternal dehiscence by conventional chest X-ray.

BACKGROUND: Diagnosis of sternal dehiscence after sternotomy for cardiac surgery is still made clinically. The aim of this study was to identify radiographic signs of sternal dehiscence by routine chest X-ray (CXR) in patients with and without clinically diagnosed sternal dehiscence. METHODS: 75 patients (group I: 65 +/- 9.3 years, f/m = 12/63) with clinically diagnosed sternal dehiscence, necessitating surgical revision and 75 patients with uneventful sternal healing (matched to group I by age, sex, preoperative risk factors and surgical procedures; group II: 66 +/- 9.0 years, f/m = 12/63) were included in this study. Serial CXRs immediately after surgery until re-intervention or discharge were analyzed by a radiologist, blind to the date of redo surgery. RESULTS: In 39 patients of group I (52%) vs. 8 (10.7%) in group II, abnormalities in the sternal wire and/or a midsternal stripe could be found (p < 0.0001): rotated wires (p = 0.003), shifted wires (p = 0.043), and ruptured wires (p = 0.312). Seven patients presented with combined wire abnormalities in group I vs. 0 in group II. Midsternal stripe sign could be detected in 26 patients of group I vs. 3 in group II (p < 0.0001). Sternal dehiscence was suspected based on the above mentioned abnormalities as early as three days postoperatively (Q1 = 2; Q3 = 8 days) in 39 patients, whereas clinical diagnosis of sternal dehiscence was delayed up to ten days postoperatively (Q1 = 7; Q3 = 13 days). CONCLUSIONS: Radiographic signs of sternal dehiscence could be detected before the clinical diagnosis was apparent and predicted sternal dehiscence in more than half of the patients.

The Fontan-operation: from intra- to extracardiac procedure.

PURPOSE: For treatment of univentricular heart, the Fontan operation has been established as the definitive palliation. The current controversy is mainly based on the high incidence of arrhythmias after an intra-atrial lateral tunnel Fontan operation. METHODS: From January 1995 until April 2002, 46 children underwent a Fontan-type operation with or without a small fenestration. In 33 patients (group I) an intracardiac tunnel and in 13 patients (group II) an extracardiac conduit procedure was performed. PRINCIPAL FINDINGS: There was no perioperative mortality. All patients showed postoperative a significant increase of arterial oxygen saturation, from 76 to 86% after surgery with fenestration, or to 90.5% without fenestration respectively. In patients with fenestration procedure, the saturation rose to 90% after closure of fenestrations 9 to 12 months after operation. CONCLUSIONS: Modified Fontan operations can be performed in normothermia on the beating heart with acceptable mortality. The extracardiac conduit Fontan procedure has the benefits of less surgical injury and a higher intraoperative flexibility.

[Transcatheter occlusion of the persisting arterial duct]. / Der Verschluss des persistierenden Ductus arteriosus Botalli mittels Herzkathetertechnik.

BACKGROUND: Transcatheter occlusion of the persisting arterial duct (PDA) is feasible using different techniques like coil-embolization (CE), Rashkind PDA occluder (Rash), Amplatzer Duct Occluder (ADO). Comparative studies with this devices in relation to the size of the PDA and the device are missing. Aim of this study was to evaluate the different systems at the own patient population. PATIENTS AND METHODS: From 1993 to 12/2001 transcatheter occlusion was attempted in 92 patients aged 4,13 years (range 0,07 to 14,39 years) using CE, Rash or ADO. All patients received echocardiographic examinations 24 hours before and after intervention, after 3, 6, and 12 months and than yearly. RESULTS: 91/92 PDAs could be successfully closed by 97 interventions. There were 63 CE, 25 Rash and 9 ADO performed. Primary closure rate was 75 % for Rash, 80 % for ADO and 80,8 % for CE (n. s.) and after 6 months 88 % for Rash, 92,3 % for CE and 100 % for ADO (p < 0,001), although the size of the PDA increased significantly from CE (2,14 + 1,1 min) to Rash (3,2 +/- 1,3 min) to ADO (4,9 +/- 1,9 min) (p < 0.05). In 6/7 pts with residual shunts complete occlusion could be achieved by second intervention. CONCLUSION: In dependency of the size of the PDA and the right choice of the occluder almost all PDAs are closable with transcatheter techniques.

Value of echocardiography in patient follow-up after surgically corrected type A aortic dissection.

BACKGROUND: To identify patients (pts) at risk of late complications, follow-up after surgery for type A aortic dissection is essential. We assessed the value of echocardiography to monitor patients after surgery for type A aortic dissection. METHODS: 80 out of 108 pts operated between 1989 and 1999 for type A aortic dissection survived surgery. 62 pts with at least one TEE, CT or MRI examinations during follow-up were included in this study. All pts had transthoracic echocardiography (TTE), 53 transesophageal echocardiography (TEE), 51 had CT, and 39 had MRI. RESULTS: At the first follow-up, 12 of 48 pts with aortic valve sparing surgery presented with aortic insufficiency >I degrees detected using echocardiography. 16 pts evolved a distal aortic aneurysm of over 5 cm, all seen in TEE, CT and MRI. A distal intimal flap was present in 39 pts and could be seen in TEE, CT and MRI in all patients. A new proximal aortic root dissection took place in 5 pts. Progressive aortic pathology led to reoperation in 9 pts. TEE was especially useful in 2 pts to confirm redissection, in 1 pt to rule out redissection assumed by CT, and in 1 with paraprosthetic blood flow after ascending aortic replacement. MRI led to additional information in 1 patient with false aneurysm of the distal anastomosis and 1 with redissection not seen in TEE 6 month before. CT and MRI were superior to TEE in demonstrating aortic arch pathology, whereas TEE was more effective in showing the flow pattern and residual entry sites. CONCLUSIONS: Echocardiography is an effective and cost-saving diagnostic tool to monitor pts after surgery for type A aortic dissection, and should be the method of choice to ascertain aortic pathology initially after surgery. Follow-up intervals and need for additional CT or MRI should be determined afterwards according to specific pathologies.

[Treatment of supravalvular pulmonary stenosis after arterial switch operations (ASO)]. / Die Behandlung supravalvulärer Pulmonalstenosen nach Arteriellen Switch-Operationen (ASO).

The aim of this study was to evaluate the incidence of postoperative pulmonary supravalvular stenosis in patients with d-TGA and to assess the rate of success or failure of balloon angioplasty. Out of 70 patients with d-TGA 67 patients underwent successful arterial switch operation. Twelve children developed severe supravalvular pulmonary stenosis with a peak gradient above 50 mmHg (range: 50-120 mmHg). In these patients 19 high pressure dilatations were performed up to a diameter of 130% of the native valve dimension. The mean age at angioplasty was 17 months (range: 3-36 months). Successful intervention was defined as a > 50% decrease of predilatation peak pressure gradient or right ventricular pressure < 50 mmHg. Dilatations were performed without complications. Complete resolution was primarily achieved in 1 patient. In 7 patients the pressure gradients could be reduced to 10-45 mmHg (mean: 25 mmHg). In another two patients a palliative stent-implantation into the pulmonary trunk was necessary to reduce the pressure gradient. Because unsuccessful intervention, two patients needed subsequent operation. During follow-up of 6-9 months after intervention severe restenosis occurred in 3 patients (2 after stent-implantation; 1 after re-re-dilatation) who then also needed operation. Balloon dilatation should be the first treatment in patients with pulmonary stenosis after ASO in TGA owing to the low complication rate and the potential benefit of this procedure. Recurrent and combined stenoses with narrow pulmonary valve annulus should be treated surgically.

Contrast-enhanced three-dimensional MR angiography of the thoracic aorta: experiences after 118 examinations with a standard dose contrast administration and different injection protocols.

The aim of this study was to test three injection protocols for contrast-enhanced magnetic resonance angiography (MRA) of the thoracic aorta with a standard-dose application. Ninety-three patients with a total of 118 examinations underwent MRA of the thoracic aorta at 1.5 T. There were three injection protocols: in 24 cases, no test bolus was performed and contrast was injected manually; in 14 cases, contrast was injected manually after a test bolus; and in 80 cases, a MR-compatible injector was used after a timing examination. All patients received 20 ml of Gd-DTPA. Quantitative signal-to-noise (SNR) measurements were obtained at different locations in the thoracic aorta, the pulmonary arteries, and the superior vena cava. Two readers in conference retrospectively evaluated each examination with respect to overall image quality and quality of bolus timing. Bolus timing was considered optimal in 70 cases, and either too early or too late in 11 cases. In 37 examinations the bolus was broadened. The SNR measurements of the thoracic aorta revealed that examinations after bolus testing were significantly superior to examinations without a test bolus (p < 0.001). Signal intensity ratios of the aorta and the pulmonary trunk were significantly higher in examinations with an optimal contrast timing (p < 0.001). Magnetic resonance angiograms of the thoracic aorta with a timing run are significantly superior to non-timed examinations with respect to image quality and SNRs. The administration of 20 ml of Gd-DTPA is sufficient for adult patients.

Aortic valve preservation in acute type A dissection: mid-term results.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term effectiveness of a strategy for managing the aortic valve, aortic root and ascending aorta according to the pathology in acute aortic type A dissection. Results after surgery for acute type A dissection with preservation of the aortic valve were reviewed. METHODS: The patient group included 57 hospital survivors operated on according to a surgical strategy of aortic valve resuspension and supracoronary ascending aortic graft implantation. Reinforcement of the aortic stumps with gelatin-resorcinol-formaldehyde glue was performed in all patients. Aortic valve function in all survivors was investigated by echocardiographic follow up at 30 days, 6 and 12 months after surgery, and yearly thereafter. RESULTS: During the follow up period, nine patients (16%) died without reoperation. Actuarial probability of freedom from reoperation for aortic valve failure in the complete series was estimated as 100% after both 30 days and 12 months. Postoperatively, one patient underwent reoperation 14 months for aortic regurgitation, and three patients for aortic regurgitation with sinus of Valsalva dilatation between 48 and 88 months. The hospital mortality rate at reoperation was 50% (n = 2). CONCLUSION: Valve-sparing surgery is possible and can be recommended for the majority of patients with acute type A aortic dissection.

Adjustable tourniquet to manipulate pulmonary blood flow after Norwood operations.

BACKGROUND: Survival after first-stage palliative Norwood operations for single ventricle with systemic outflow obstruction is mainly dependent on a balanced ratio of pulmonary blood flow to systemic blood flow. Here we report the clinical results using a modified technique that allows a controlled systemic-to-pulmonary shunt flow to prevent pulmonary overcirculation. METHODS: From 1995 to 1998, of 26 infants undergoing first-stage palliative Norwood operations, 7 had placement of an adjustable tourniquet around a modified right Blalock-Taussig shunt. RESULTS: Hospital survival was 20 of 26 patients (77%). All 7 patients in whom snaring of the shunt was indicated survived. Two patients underwent repeated adjustment, in 5 patients the tourniquet could be removed during delayed sternal closure, and 2 patients were discharged with the shunt partially snared. CONCLUSIONS: The snare-controlled systemic-to-pulmonary shunt allows improved hemodynamic stability after reconstructive surgery for hypoplastic left heart syndrome or other similar complex cardiac defects by reducing the risk of pulmonary overcirculation. It is simple and rapidly executed. The option of graded banding of the shunt depending on the hemodynamic situation increases flexibility and safety after cardiopulmonary bypass or at any time in the postoperative period.

[Follow up results of radical correction of Fallot's syndrome]. / Wyniki odlegle korekcji calkowitej zespolu Fallota.

In the years 1981-1989 in the Department of Cardiosurgery, Institute of Cardiology, Medical Academy in Lódz, 39 patients with Fallot's syndrome were subjected to radical correction of the congenital heart disease. In 18 cases the correction was preceded by a palliative operation carried out on the average four years before the radical correction of the congenital heart disease. During the early postoperative period seven patients died which accounted for 17%. Out of 39 patients treated surgically, 32 were in I or II haemodynamic grade according to NYHA.

[Surgical treatment of funnel chest]. / Chirurgiczne leczenie lejkowatej klatki piersiowej.

In 1976-1985, 39 patients were operated for the funnel chest. All patients were enrolled for the intensive rehabilitation program in the hospital, and correction exercises followed by swimming were recommended after release home. A favourable cosmetic effect was achieved in all patients in early postoperative period. However, a recurrence of the funnel chest has been noted in 10 patients (26%), later. Abnormality has been less advanced except 1 patient in whom subjective worsening has been noted.

[Results of the treatment of patent ductus arteriosus]. / Wyniki leczenia przetrwalego przewodu tetniczego.

Since the first effective surgical treatment of PAD, the indications for such a treatment have been more extensive and its results and methods have been changing. We present 123 patients who underwent surgery for PAD in the Clinic of Cardiosurgery, Institute of Cardiology, Medical Academy of Lódz within 1978-1987. In 101 cases PAD was dissected and both ends were sutured in two layers with continuous sutures, and in 22 cases PAD was ligated with 3 ligatures. In 30 patients PAD coincided with other congenital defects of the circulatory system. No cases of recanalization were observed in our patients. One death in the postoperative course was noted.

Distribution of mast cells in human heart auricles and correlation with tissue histamine.

The mast cell density, fixation and staining properties, as well as tissue histamine, were studied in the human heart right auricles of 28 patients with mild atrial or ventricular septal defect (ASD or VSD respectively). We have found that different modes of fixation did not change significantly the mast cell appearance and number as stained with pinacyanol erythrosinate. The mast cell density was 21294 +/- 2775 cells per mm3 tissue and the mean histamine content of the auricle was 900.7 +/- 63.9 ng/g wet tissue weight. A significant positive correlation was observed between mast cell counts and histamine content (r = 0.79, p = 0.001). Furthermore, our data suggest the existence of a non-mast cell pool of cardiac histamine in man.