[Intravenous leiomyomatosis]. / Die intravenöse Leiomyomatose.

Intravenous leiomyomatosis (IVLM) is an unusual neoplasm derived from uterine smooth muscle cells seen in patients with uterine leiomyomas. The typical histological features of IVLM consist of benign smooth muscle cells present within venous vascular spaces of the uterine wall. Increasing intravascular and intracardial spread of IVLM may lead to life-threatening clinical complications. Thorough pathological study of routine hysterectomy specimens may lead to the diagnosis of IVLM. Most affected patients will be cardiologically asymptomatic at the time of diagnosis. Herein, the relatively unknown clinical and morphological aspects of IVLM are presented and discussed.

Simple technique of repair for Barlow syndrome with posterior resection and chordal transfer via minimally invasive approach: primary experience in a consecutive series of 22 patients.

OBJECTIVE: Current techniques for mitral valve repair (MVR) in Barlow's disease require high level of surgical expertise due to a complex anatomy. A novel and simple standardized technique that particularly considers the pathological changes of the mitral valve in Barlow's disease has been developed. METHODS: Between 2009 and 2013, 22 patients underwent minimally invasive MVR for Barlow's disease and severe mitral regurgitation (MR). A simple, standardized technique was applied, including resection of P2 segment of posterior mitral leaflet (PML) with preservation of the shortest chordae, transfer of the preserved chordae to A2, and implantation of a semi-rigid open ring. In 2015, all patients were contacted for follow-up by transthoracic echocardiography (TTE) and interviewed for their clinical status. RESULTS: During follow-up (mean 2.8 ± 1.1 years; 100% complete), one patient died due to abdominal bleeding 4 months after the initial MVR and one patient with severe calcification of PML underwent valve replacement due to recurrence of MR. Among the remaining cohort (mean follow-up 3.0 ± 1.0 years), NYHA class I, II and III was present in 13, 6, and 1, respectively. TTE demonstrated MR grade 0, 1+, or 2+ in 40, 55, and 5%, respectively, with mean and maximum transvalvular gradients ranging at 1.9 ± 1.7 and 4.7 ± 3.3 mmHg, respectively. CONCLUSIONS: A simple and standardized technique facilitates the repair of MR in the presence of Barlow's, simultaneously addressing the height of PML and the position of the anterior leaflet. This technique has proven durable in the mid-term follow-up in our small series and warrants further validation in larger cohorts.

Perioperative and long-term development of anxiety and depression in CABG patients.

BACKGROUND: The high incidence of symptomatic anxiety and depression in coronary artery bypass graft (CABG) patients may lead to impaired quality of life and increased morbidity and mortality. This prospective longitudinal study on CABG patients should provide data for future preoperative and postoperative psychotherapeutic interventions. METHODS: From 2009 to 2010, 135 consecutive patients who were able and prepared were consulted by one interviewer immediately before 1 week (early) and 6 months (late) after surgery to complete the "Hospital Anxiety and Depression Scale" questionnaire. RESULTS: Compared with the standard population, anxiety scores (AS) were preoperatively elevated in 39.3% of the patients. Early and late after surgery, AS had decreased to 34.4% (not significant [n.s.]) and 28.9% (p < 0.01). Before surgery, depression scores (DS) were elevated in 20.7%. Early and late after surgery, DS further increased to 24.0% (n.s.) and 28.0% (n.s.).Preoperative elevated DS appeared to correlate with increased complications. Mortality was not associated with elevated AS or DS. Both scores were not affected by on- or off-pump surgery. CONCLUSION: Remarkably high AS and elevated DS late postoperatively require psychotherapeutic support even after seemingly successful CABG.

[Mitral regurgitation in heart failure. Surgical therapy]. / Mitralinsuffizienz bei Herzinsuffizienz. Chirurgische Therapie.

The optimal treatment of mitral regurgitation concomitant to heart failure remains controversial. A lack of consensus between cardiologists and cardiac surgeons, because of limited studies and heterogeneous data, has led to vaguely defined guidelines and different handling in the clinical routine in the past. However, progress in the operative management with excellent results of individual experienced centers suggests that a variety of patients might benefit from surgical therapy. Each patient should be evaluated individually regarding the benefits of surgical therapy which requires an interdisciplinary approach ("heart team") due to the complex pathophysiology and demanding diagnostics.

[Tissue engineering of heart valves]. / Tissue Engineering von Herzklappen.

With the introduction of heart valve prostheses cardiac valvular disease has become much more accessible to therapeutic options. However, currently available prostheses display significant limitations, such as limited long-term durability (biological prostheses) and a long-term necessity for anticoagulation therapy. Hence, alternative prosthesis types have been extensively explored in recent years particularly aiming at the development of vital and regenerative prostheses by means of tissue engineering. In the scientific field, different competing concepts have been introduced, including biological or synthetic scaffolds which can be further enhanced by cellular or extracellular components to promote further in vivo development of the prosthesis after implantation. Nowadays, decellularized donor heart valves are among the most advanced prosthesis types experiencing growing clinical attention and widespread use.

Vacuum-assisted wound closure is superior to primary rewiring in patients with deep sternal wound infection.

OBJECTIVE: Deep sternal wound infections are serious complications after cardiac surgery. The aim of the present study is to compare the outcome after vacuum-assisted wound closure to that after primary rewiring with disinfectant irrigation. The study additionally focuses on defining predictors for the failure of primary rewiring and its impact on postoperative outcome. METHODS: Retrospective analysis was performed in 5232 patients who underwent cardiac surgery with a median sternotomy. 192 patients postoperatively developed deep sternal wound infections and were distributed into 2 therapy groups: a vacuum-assisted wound closure (= VAC) group and a primary rewiring (= RW) group, which was subdivided into healing after rewiring (= RW-h) and failure of rewiring (= RW-f). These groups were compared statistically to reveal coincidental pre-, intra- and postoperative parameters. RESULTS: Compared to the VAC group, the RW group showed a poorer outcome, although RW baseline characteristics were apparently beneficial. Primary rewiring failed in 45.8 % of all cases, which led to even worse outcomes. Important predictors for failure of primary rewiring were morbid obesity, diabetes mellitus type II, chronic obstructive pulmonary disease, preoperatively impaired left ventricular function, postoperatively positive blood and wound cultures, bilateral harvesting of internal thoracic arteries and the need for surgical reexploration. CONCLUSIONS: In spite of patients being in a worse condition, vacuum-assisted wound closure therapy resulted in improved outcomes and thus should be preferred to primary rewiring. Moreover we report on predictors which may indicate whether there is a high risk of rewiring failure.

Heparin-induced thrombocytopenia type II after cardiac surgery: predictors and outcome.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a serious complication after cardiac surgery. The aim of the present study was to identify pre- and intraoperative predictors for the postoperative occurrence of HIT. The study additionally focused on the impact of HIT on postoperative outcome. METHODS: Retrospective analysis was performed for 5073 patients who had required extracorporeal circulation during cardiac surgery. Patients were divided into 3 groups: 1) patients who had postoperative HIT (HIT+); 2) patients with postoperative thrombocytopenia but without HIT (HIT-); and 3) patients with normal platelet count (C). The groups were statistically compared with regard to pre-, intra- and postoperative parameters. RESULTS: Statistically significant predictors were renal insufficiency, intravenous application of heparin for more than 3 days, previous percutaneous coronary intervention within the last 4 weeks, urgency/emergency operation, combined surgery, prolonged extracorporeal circulation or cross-clamping time, and low cardiac output syndrome. Postoperative HIT was associated with an enhanced risk of renal failure, infectious and thromboembolic complications and in-hospital mortality. CONCLUSION: Postoperative HIT increases morbidity and mortality. The predictors presented in this study can be used to identify patients at risk of developing HIT.

Early reintubation after cardiac operations: impact of nasal continuous positive airway pressure (nCPAP) and noninvasive positive pressure ventilation (NPPV).

BACKGROUND: Due to an increasing number of comorbidities there is still a significant incidence of respiratory failure after primary postoperative extubation in patients who undergo cardiosurgery. We wanted to study whether nCPAP could improve pulmonary oxygen transfer and avoid the necessity for reintubation after cardiac surgery. Additionally, we compared this protocol to noninvasive positive pressure ventilation (NPPV). PATIENTS AND METHODS: Over a period of 3 years we analyzed all patients who were extubated within 12 hours after cardiac surgery, and in whom pulmonary oxygen transfer (PaO2/FIO2) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation. There were three groups of patients: A = patients required immediate reintubation (n = 125); B = patients had nCPAP with intermittent mask CPAP (n = 264); and C = patients had NPPV (n = 36). RESULTS: 25.8 % of patients in Group B and 22.2 % of patients in Group C were also intubated after a period of CPAP or NPPV. All other patients of Groups B and C could be weaned from these devices (B: 33.4 ± 5.8 hours, C: 26.2 ± 4.2 h; P < 0.05) and were well oxygenated using a face mask at ambient pressures (PaO2/FIO2: B: 136 ± 12, C: 141 ± 12). In Group A, we found a higher mortality (8.8 %) than in Group B (4.2 %) and Group C (5.6 %). The ICU stay and in-hospital stay were significantly prolonged in Group A. The incidence of pulmonary infections (A: 24 %, B: 10.6 %, C: 13.8 %; P < 0.05) and the need for catecholamines were significantly increased in Group A, whereas nCPAP patients suffered significantly more often from impaired sternal wound healing (A: 4.8 %, B: 8.3 %; P < 0.05). CONCLUSIONS: We conclude that reintubation after cardiac operations should be avoided since nCPAP and NPPV are safe and effectively improve arterial oxygenation in the majority of patients with nonhypercapnic oxygenation failure. However, it is of great importance to pay special care to sternal wound complications in these patients.

Enhancement of ohmic and stochastic heating by resonance effects in capacitive radio frequency discharges: a theoretical approach.

In low-pressure capacitive radio frequency discharges, two mechanisms of electron heating are dominant: (i) Ohmic heating due to collisions of electrons with neutrals of the background gas and (ii) stochastic heating due to momentum transfer from the oscillating boundary sheath. In this work we show by means of a nonlinear global model that the self-excitation of the plasma series resonance which arises in asymmetric capacitive discharges due to nonlinear interaction of plasma bulk and sheath significantly affects both Ohmic heating and stochastic heating. We observe that the series resonance effect increases the dissipation by factors of 2-5. We conclude that the nonlinear plasma dynamics should be taken into account in order to describe quantitatively correct electron heating in asymmetric capacitive radio frequency discharges.

The prevalence of mental health problems in children 1(1/2) years of age - the Copenhagen Child Cohort 2000.

BACKGROUND: The Copenhagen Child Cohort, CCC 2000, was established to investigate developmental psychopathology prospectively from birth in a general population. METHODS: A random sample of 211 children from the CCC 2000 was investigated when the children were 1(1/2) years of age. The prevalence and associates of mental health problems and psychopathology were studied by clinical and standardised strategies, including videotape recordings, parent interviews and the following instruments: The Child Behavior Check List 1(1/2)-5 (CBCL 1(1/2)-5), The Infant Toddler Symptom Check List (ITSCL), Checklist for Autism in Toddlers (CHAT), Bayley Scales of Infant Development II (BSID II), The Parent Child Early Relationship Assessment (PC ERA) and Parent Infant Relationship Global Assessment Scale (PIR-GAS). RESULTS: Mental health problems according to International Classification of Diseases (ICD-10) and Diagnostic Classification Zero to Three (DC 0-3) diagnoses were found in 16-18% of 1(1/2)-year-old children. Most common were disturbances of emotion, behaviour and eating and the DC 0-3 diagnosis of regulatory disorder. Parent-child relationship disturbances were found in 8%. High psychosocial risk was significantly associated with emotional and behavioural disorders (OR 3.1 95% (1.2-8.1)) and disturbed parent-child relationship (OR 5.0 95% (1.6-16.0)). The strongest association of risk was found between relationship disorders and emotional and behavioural disorders (OR 11.6 95% (3.8-37.5)). CONCLUSIONS: The prevalence and distribution of psychopathology in 1(1/2)-year-old children seem to correspond to the distributions among older children. Disturbances in parent-child relationship have a key position in the risk mechanisms in early child psychopathology.

Microcirculation of the ankle after Cryo/Cuff application in healthy volunteers.

The aim of the study was to assess the combination of compression and cryotherapy (Cryo/Cuff ankle device) on parameters of ankle microcirculation in healthy volunteers over 30 min. In 21 volunteers (12 males, 29 +/- 10 years [incl. females], BMI 24 +/- 3) the Cryo/Cuff ankle device (AIRCAST, Summit, NJ, USA) was applied with continuous assessment of parameters of ankle microcirculation, such as tissue oxygen saturation (SO2), relative postcapillary venous filling pressures (rHb), and microcirculatory blood flow at 2- and 8-mm tissue depths during 30 min with the Oxygen-to-see System, a laser-Doppler-spectrophotometry-system (LEA Medizintechnik, Giessen, Germany). Superficial tissue oxygen saturation (SO2, 48 +/- 19 %) immediately dropped to 23 +/- 15 % (-52 %, p < 0.05) within the first 2 min after Cryo/Cuff activation with a consecutive slow decrease to 32 +/- 23 % (- 32 %, p < 0.05 vs. baseline) after 30 min. Deep SO2 (8 mm, 69 +/- 5 %) did not change within 30 min of Cryo/Cuff application (70 +/- 4 %, n.s.). Superficial postcapillary venous filling pressures (61 +/- 17 relative units) showed an immediate and sustained decrease after Cryo/Cuff application within four minutes to 37 +/- 18 relative units (-39 %, p < 0.05). Deep postcapillary venous filling pressures (85 +/- 20 relative units) dropped within the first four minutes of Cryo/Cuff application to 68 +/- 19 relative units (-20 %, p < 0.05). Superficial microcirculatory blood flow (21 +/- 36 relative units) decreased significantly to 7 +/- 5 relative units after 30 min (-69 %, p < 0.05 vs. baseline). Deep microcirculatory blood flow at 8 mm tissue depth (63 +/- 43 relative units) significantly decreased over the 30 min to 39 +/- 23 relative units (-47 %, p < 0.05 vs. baseline). Using the Oxygen-to-see system we could demonstrate significant effects of the Cryo/Cuff device on the ankle level in healthy volunteers with reduced superficial tissue oxygen saturation with preserved deep tissue oxygen saturation, reduced superficial and deep postcapillary venous filling pressures, and reduced superficial and deep microcirculatory blood flow as a function of time. Further clinical studies are mandatory to elucidate the effects of the Cryo/Cuff device on the microcirculatory environment in injured ankles.

[Rhabdomyolysis after administration of diclofenac]. / Rhabdomyolyse nach Diclofenacgabe.

Rhabdomyolysis may develop after various traumatic and nontraumatic circumstances. The use of lipid-lowering statins as well as the abuse of stimulants such as methylendioxymethamphetamine (ecstasy) can lead to fatal rhabdomyolysis with acute renal failure. We describe a case of diclofenac-induced rhabdomyolysis after a cumulative dose of 200 mg per os with consecutive critical increase of the creatine kinase and myoglobin. Prescription of diclofenac should therefore be done with caution. In cases of emergent myalgias, immediate testing of creatine kinase and myoglobin is mandatory to exclude fatal rhabdomyolysis with acute renal failure.

Microcirculation of the sternum following harvesting of the left internal mammary artery.

BACKGROUND: Internal thoracic arterial grafts (ITA) in coronary artery bypass surgery provide excellent long-term patency results. Due to the elevated incidence of sternal infections following pedicled ITA harvesting, blood supply to the sternum has gained the focus of attention. This study sought to evaluate real time parameters of sternal microcirculation prior and immediately after harvesting of the ITA by a novel laser Doppler flowmetry and remission spectroscopy system (Oxygen-To-See (O2C), LEA Medizintechnik, Giessen). METHODS: 21 patients (16 males, age 63 + 4 years, mean NYHA 2.3 +/- 0.3) scheduled for coronary artery bypass grafting (CABG) were enrolled into the study. After median sternotomy, the probe was placed sequentially pre- and retrosternally for measurements of tissue oxygen saturation (sO2), hemoglobin concentration (rHb), superficial (2 mm) und deep (8 mm) blood flow. Measurements were performed and analyzed before and after surgical harvesting of the ITA with a pedicle. RESULTS: Baseline pre- and retrosternal tissue oxygen saturation (sO2) were 90 +/- 3 % and 87 + 4 %, respectively (n. s.). After left ITA harvesting, presternal sO2 remained unchanged (90 + 4 %, n. s.), whereas retrosternal sO2 decreased significantly (54 + 4 %, p < 0.001). Simultaneously, retrosternal post-capillary venous filling (rHb) increased significantly after ITA harvesting (86 +/- 2 vs. 93 + 2, p < 0.05), whereas presternal rHb remained unchanged. Retrosternal superficial and deep blood flow also decreased significantly (75 +/- 5 vs. 41 +/- 4, and 94 +/- 5 vs. 52 +/- 6) in contrast to comparable presternal blood flow before and after ITA harvesting. There were neither superficial nor deep sternal wound infections occurred in the studied patient population. CONCLUSIONS: The pedicled harvesting of ITA leads to a significant decrease of microcirculatory blood flow, retrosternal tissue oxygen saturation, and an increase in post-capillary venous filling. Parameters of microcirculation in the presternal area after ITA harvesting remained unchanged compared to baseline values. Hence, the incidence of sternal infections after ITA harvesting in coronary surgery may well be explained by a significant decrease of sternal blood supply in the retrosternal area. Further prospective randomized studies are needed to elucidate the potential role of skeletonized ITA preparation in sternal microcirculation.

Minimally invasive removal of a dislocated stent from the right atrium after previous CABG.

Repeat sternotomy after previous open heart operations constitutes a serious risk factor for cardiac injury, particularly in the presence of a patent internal thoracic artery. We report a case of successful minimally invasive removal of a dislocated subclavian vein stent entangled in the tricuspid valve in a patient 5 years after coronary artery bypass surgery.

Studies on linkage and association of atopy with the chromosomal region 12q13-24.

BACKGROUND: Several studies have shown linkage of bronchial asthma, allergic rhinitis and total serum IgE concentration to the chromosomal region 12q13-24 in ethnical diverse populations. This region harbours a number of candidate genes for asthma and atopy, including stem cell factor (SCF), leukotriene A4 hydrolase (LTA4H), thyroid receptor 2 (TR2), and signal transducer and activator of transcription 6 (STAT6). However, the same region was shown as well to be linked to other diseases with inflammatory character. So far no variants in any of these genes have been published which would allow association studies and confirm the pathogenicity of any of these genes. OBJECTIVE: We wanted to test for linkage of the chromosomal region 12q13-24 with the atopic phenotype without regard to clinical manifestations. Furthermore we screened for common nucleotide polymorphisms in candidate genes to enable association studies. METHODS: We employed sib-pair linkage analysis and transmission disequilibrium testing with regard to four highly polymorphic microsatellite markers in 12q13-24 in atopic nuclear families. In addition, we looked for polymorphisms in the genes coding for SCF, LTA4H, TR2 and STAT6 performing SSCP-analysis and direct genomic sequencing. RESULTS: We found no evidence for linkage of the genomic region 12q13-24 to elevated total serum IgE levels, specific sensitization to common inhalant allergens or atopy. Furthermore we identified three nucleotide polymorphisms including one common variant in the gene coding for SCF. No association of this polymorphism and any of the atopic phenotypes was seen. CONCLUSION: We conclude from our data that genes in the chromosomal region 12q13-24 and in particular SCF are unlikely to exert a major effect on the induction of the atopic phenotype in our Caucasian population. However, we did not focus on the asthmatic and thereby inflammatory aspect of atopy which might explain these results in contradiction to previous studies.

Effects of minimal invasive coronary artery bypass on pulmonary function and postoperative pain.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) requires substantially smaller incisions than conventional coronary artery bypass grafting (CABG). We investigated whether this fact may lead to less postoperative pain and improved pulmonary function. METHODS: Preoperative and postoperative (days 1, 3, and 5) pulmonary function and postoperative pain were assessed in 15 patients undergoing MIDCAB (group A) by using a standardized score and were compared with 15 patients admitted for CABG (group B). RESULTS: Total operation time (140 minutes versus 189 minutes; p<0.001) and duration of mechanical ventilation (300 minutes versus 840 minutes; p<0.001) were significantly less in group A. Pulmonary function was comparable between the 2 groups on postoperative day 1 (POD 1). Vital capacity was significantly greater in group A on POD 3 (59.7% versus 40.6%; p<0.001) and on POD 5 (74.4% versus 53.9%; p<0.001). Similar results were found for forced expiratory volume in 1 second (group A versus B on POD 3: 56.3% versus 42.2%; p<0.05; and on POD 5: 68.4% versus 55.5%; p<0.01). Postoperative pain was significantly higher in group A (POD 1: score 5.5 versus 3.6; POD 3: 4.0 versus 2.9; p<0.01). CONCLUSIONS: MIDCAB procedures lead to better preservation of pulmonary function compared with conventional CABG despite greater postoperative pain.

Mini-sternotomy for off-pump coronary artery bypass grafting.

The number of off-pump coronary artery bypass grafting procedures without cardiopulmonary bypass is steadily increasing. We report on a new, minimally invasive surgical approach for off-pump coronary revascularization in multivessel disease. A distal sternotomy is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery, diagonal branches, and right coronary artery for off-pump revascularization.