[Therapy of cardiogenic shock : A success story of German cardiology]. / Therapie des kardiogenen Schocks : Eine Erfolgsgeschichte der deutschen Kardiologie.

In contrast to the situation in the 1960s and 1970s, the mortality risk for patients with myocardial infarction has been clearly reduced, particularly for those with myocardial infarction with cardiogenic shock (MICS). Approximately 5­10 % of patients with a myocardial infarction are affected by a MICS and the mortality risk is between 30 % and 50 %. The primary percutaneous coronary intervention with stent implantation should be carried out as quickly as possible in order to reduce the mortality to around 20 %. This article gives an overview of the currently available options for conservative and fibrinolytic treatment of MICS, of the interventional treatment of cardiogenic shock in the era of intravenous and intracoronary infarct treatment as well as without thrombolysis. In addition, the currently available mechanical support systems and the possibilities for surveillance and monitoring of patients are presented.

Effect of different operative techniques for myocardial revascularisation on hemodynamics and myocardial perfusion in a porcine model.

BACKGROUND: During surgical coronary revascularisation hemodynamics and myocardial contractility can be affected. This in vivo study aimed to determine the effects of different operative techniques on hemodynamics and regional myocardial perfusion. METHODS: In 24 pigs IMA to LAD bypass was constructed using ECC (n = 8) and cardioplegic arrest, OPCAB techniques (n = 8), or the Impella elect 100 support device (n = 8). 8 animals received a sham operation. Mean arterial pressure (MAP), cardiac output (CO), and left ventricular pressure (LVP, LVdp/dt) were recorded. Regional myocardial perfusion (RMP) of both ventricles was assessed by fluorescent microspheres. RESULTS: MAP significantly decreased during revascularisation in all groups ( p < 0.05), staying below preoperative values thereafter ( p < 0.05). After ECC norepinephrine was administered to maintain MAP. CO and LVdp/dt were impaired more distinctly during OPCAB than with Impella ( p < 0.05) during subsequent recovery. RMP showed global reactive hyperemia during early reperfusion after ECC, remained unchanged in OPCAB, and showed low flow during and after Impella pump run ( p < 0.05). CONCLUSIONS: ECC led to hemodynamic impairment with post-ischemic reactive hyperemia. OPCAB created hemodynamic depression but left RMP unchanged. Hemodynamic depression can be reduced by the Impella pump, however regional myocardial blood flow is decreased.

[Limb salvage in diabetic foot syndrome with pedal bypass using the in-situ technique]. / Extremitätenerhalt durch pedalen In-situ-Bypass beim diabetischen Fusssyndrom.

INTRODUCTION: Treatment of the ischemic diabetic foot syndrome still represents a medical and economic challenge. Contrary to the aims of the Saint Vincent declaration a dramatic reduction of major amputations in Germany was not noted, although in the diabetic patients the predominant type of tibial artery occlusion allows construction of pedal bypasses for limb salvage. METHOD: In patients with ischemic diabetic foot syndrome following angiographic evaluation of the ischemic limb, the indication for surgical revascularisation of patent pedal arteries was established. The in-situ technique was preferred in the presence of a suitable ipsilateral greater saphenous vein whenever possible. Revascularisation was followed by treatment of foot ulcerations or, if necessary, minor amputations. Patients were followed by clinical examination and duplex scan investigation of the bypass in regular intervals. RESULTS: From 01/89 to 12/01 in 79 patients (59 men and 20 women) with non healing ulcerations or established gangrene from a total of 175 pedal bypasses 84 pedal bypass operations in 84 limbs were performed using the in-situ technique. All patients were diabetic and in addition 13.9% were dependent on hemodialysis for end stage renal disease. 59.5% of the bypasses originated from the popliteal artery (distal origin bypass). The dorsalis pedis artery was chosen for the distal anastomosis in 83% and the posterior tibial artery in 17%. Two patients (2.4%) died postoperatively from cardiac events. Early bypass occlusion occurred in 8.4% resulting in a major amputation rate of 6%. After 60 months primary, primary assisted and secondary patency was 67.7%, 71.5% and 75.3% respectively with a limb salvage rate of 78%. CONCLUSION: Pedal bypass using the in-situ technique provides excellent long term limb salvage rates in a disease with a generally unjustified bad prognosis with respect to limb salvage.

[Short distal origin vein graft in diabetic foot syndrome]. / Der kurze popliteodistale Venenbypass beim diabetischen Fusssyndrom DFS.

PURPOSE: World wide increase of diabetes compound with diabetic foot syndrome becomes a challenge in vascular surgery to avoid limb loss. In diabetics a special pattern of atherosclerosis is prevalent with disease limited to the infrageniculate arteries but sparing inflow vessels and distal tibial and pedal arteries. This provides short bypass grafting from popliteal to tibial and pedal arteries, a concept first described by F. Veith in 1981. METHODS: Diabetics with severe atherosclerotic disease and limb-threatening ischemia got general evaluation and vascular imaging. Falling in this special category the patients underwent short vein bypass grafting originating at the first or third popliteal segment extending to the tibial or pedal arteries. Follow up of patency and limb salvage was nearly complete. RESULTS: From 1988 to 2001 124 diabetics received 140 vein bypass grafts for limb salvage, 95.7% already preoperatively with foot necrosis. Operative mortality rate was 1.4%, major morbidity rate was 9.3%, early graft failure rate 8.5% and early amputation rate was 3.8%. 2 year primary patency, primary assisted patency, secondary patency rates and limb salvage were 73.3%, 75.7%, 76.4% and 87.2%. 5 years results were 63.6%, 69.2%, 70.0% and 81.9% respectively. DISCUSSION: This series revealed exceptionally good results in patients with diabetes mellitus after short vein bypass grafting in concert with earlier studies since 1981. Compared to long femorodistal grafts there was no difference in longterm patency. Bypass grafting in diabetic foot syndrome is still regarded to have a poor prognosis. Just the contrary is the case. This study in concert with former studies revealed distal origin bypass grafting a durable and effective procedure to fight limb loss in diabetic foot syndrome. CONCLUSION: Distal origin vein bypass grafting is an excellent method just for patients with diabetes. Looking at limb salvage rates over 80 % in 5 years, this procedure should be offered more often suitable patients with diabetic foot syndrome.

External reinforcement of varicose veins with PTFE prosthesis in infrainguinal bypass surgery -- clinical results.

OBJECTIVE: Segmental varicose degeneration of the autogenous greater saphenous vein may limit its use in infrainguinal bypass surgery. Wrapping a PTFE prosthesis around dilated veins has emerged as an option to create externally reinforced vein bypasses. Results regarding graft patency and limb salvage were analyzed. METHODS: Between September 1995 and January 2001, 35 infrainguinal bypass operations in 33 patients were performed with greater saphenous veins exhibiting segmental varicose dilatation. Grafts were followed by duplex scan and retrospective analysis of graft patency and limb salvage was performed. RESULTS: One bypass prompted successful revision for early occlusion. Four bypasses required additional reintervention during follow-up. 48 months primary, primary assisted and secondary patency rates were 66%, 82% and 82%, respectively, with a limb salvage rate of 97%. Duplex scan failed to demonstrate stenosis of the reinforced vein segments or aneurysmal degeneration of the residual vein. CONCLUSION: External reinforcement with a PTFE prosthesis allows the use of autogenous greater saphenous veins with varicose dilatation and enables the construction of all autogenous bypasses with promising graft patency and limb salvage.

Limb trauma with arterial injury: long-term performance of venous interposition grafts.

BACKGROUND: In contrast to arterial occlusive disease, data on long-term outcomes after vein grafts in limb trauma with arterial injury are sparse. PATIENTS: From 1991 through 2001, 22 trauma victims received 23 interposition vein grafts performed by an interdisciplinary team of trauma and vascular surgeons. Indications included both blunt and penetrating injuries with critical limb ischemia in the majority of cases. RESULTS: Operative treatment of the injured vessels (brachial n = 5, radial/ulnar n = 7, popliteal n = 6, tibial n = 3, pedal n = 2) encompassed venous interposition graft of either saphenous (n = 15) or cephalic vein (n = 8). All patients survived the operative procedure. 4 graft occlusions were noted and 3 major amputations had to be performed (one despite patent graft). 13 patients (76%) were available for duplex ultrasound examination after a mean follow-up of 59 months where patent grafts could be detected in all cases. CONCLUSION: A multidisciplinary approach ensures optimal treatment strategy of arterial injury in extremity trauma. Interposition vein grafts provide durable long-term results and should be attempted even in single-vessel injuries of forearm and lower leg.

Rapamycin reduces neointima formation during vascular injury.

BACKGROUND: Proliferation and migration of vascular smooth muscle cells (SMCs) mark the key processes in the development of bypass graft disease and during neointima formation in restenosis after angioplasty. Growth factors are potent SMC mitogens as they are involved in SMC proliferation and in extracellular matrix (ECM) synthesis. Based on these premises, we examined the effect of the proliferation inhibitor rapamycin in human SMC culture and in a rabbit vascular injury model. MATERIALS AND METHODS: Injection of rapamycin or its vehicle was performed with an infusion-balloon catheter directly into the vessel wall during vascular injury. The intima/media ratio was determined histologically whereas the protein expression was analysed using the powerful two-dimensional gel electrophoresis (2D page) technique. Inhibition of proliferation after rapamycin application was estimated in a human SMC culture for time and dose dependent effects. RESULTS: Rapamycin treatment resulted in a significant reduction of intima media ratio compared to vehicle treated animals after three weeks (0.65 +/- 0.1 vs. 1.2 +/- 0.2 intima-media-ratio, p < 0.05). 2D electrophoresis analysis proved increased ECM synthesis following angioplasty (i.e., lamin, vimentin) in vehicle treated animals. Local rapamycin administration resulted in profound reduction of ECM synthesis after vascular injury. In in-vitro experiments exposure of cultured human SMCs to rapamycin resulted in a significant and dose-dependent (1 nm-100 nm) reduction of human smooth muscle cell proliferation measured by cell counting. CONCLUSION: These above mentioned results suggest that protein synthesis in addition to reduction of cellular proliferation plays an important role following vascular injury, since application of rapamycin resulted in the reduction of SMC proliferation and ECM-synthesis.

Arterial embolism to the upper extremity in a patient with factor V Leiden mutation (APC resistance)--a case report and review of the literature.

Factor V Leiden mutation has emerged as one of the leading abnormalities in inherited blood coagulation disorders, resulting in a markedly increased risk for deep leg vein thrombosis. A 24-year-old woman presented with acute onset of critical ischemia of her left thumb and index finger. Intraarterial angiography revealed an embolus in the distal radial artery and a thrombotic occlusion of the digital artery of the thumb and index finger. Immediate therapy encompassed a selective surgical embolectomy of the distal radial artery followed by a local intraarterial lysis that was continued for 3 days. Additionally, therapeutic anticoagulation and vasodilating drugs (prostaglandin E) were administered. Within 2 days, capillary refill reappeared and the initial loss of sensory function at the tip of the thumb and index finger diminished. A screening test for thrombophilic disorders led to the diagnosis of a heterozygous mutation of factor V (Leiden mutation). Arterial thromboembolic events of factor V Leiden mutation are rare and have to date been described only in the supraaortic and coronary circulation. Therefore, the arterial embolism to the left hand presented in this report constitutes a rarity that could be successfully salvaged by the combined use of a vascular surgical procedure and intensified medical management.

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.

A review of 507 off-pump coronary bypass patients: a single center experience.

This retrospective study evaluates perioperative results of 'Off-pump' coronary artery bypass surgery (OPCAB) experience in a single center. Five hundred and seven patients were operated (median sternotomy) from 1998 to 2002 using OPCAB. Patient data were registered and risk prediction calculated using the full logistic version of EuroSCORE. Overall, 1091 distal anastomoses were performed and only five (1%) patients required conversion to cardiopulmonary bypass. The predicted mortality was 3.8+/-4.5%, the observed mortality was 2.37%. OPCAB technique has become a standard approach in our department with low mortality and morbidity rates even in treatment of multivessel disease or high-risk patients.

Pedal arterial bypass for limb salvage in patients with diabetes mellitus.

OBJECTIVE: to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD: from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS: one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION: Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.

[Coronary revascularization: off-pump versus on-pump--a comparison of behavior of biochemical cardiac ischemia markers]. / Koronarrevaskularisation: Off-pump versus On-pump--Verhalten der biochemischen kardialen Ischämiemarker im Vergleich.

BACKGROUND: Recently, coronary artery bypass grafting (CABG) on the beating heart with avoidance of extracorporeal circulation (off-pump CABG technique) has been gaining increasing importance in modern cardiac surgery. The object of this prospective study was to compare postoperative kinetic and patterns of cardiac troponin I (cTnI), T (cTnT), and creatine kinase MB (CKMB) activities after off-pump CABG versus conventional on-pump CABG. METHODS: We studied 106 patients who underwent first-time elective on-pump (group I, n = 69, 56 male, 13 female, mean age: 64.3 +/- 9.9 years, mean ejection fraction: 56 +/- 15%) or off-pump (group II, n = 37, 24 male, 13 female, mean age: 68.4 +/- 9.1 years, mean ejection fraction: 57 +/- 13%) CABG surgery via median sternotomy. CTn I and cTnT levels, total creatine kinase (CK) and CK-MB activities in the serum were measured before operation, up on arrival at the ICU and 6, 12, 24, 48 and 120 hours later. Serial 12-lead ECGs were recorded preoperatively and on days 1, 2 and 5. RESULTS: Serum concentrations of cardiac troponins in all patients were preoperatively either not detectable or in the normal range and significantly increased after surgery. In group I, one patient developed a Q wave myocardial infarction, one patient a non-Q wave infarction and two patients a new left bundle branch block on the ECG. One patient of group II developed a new Q-wave myocardial infarction and another patient permanent atrial fibrillation associated with a continuous arrhythmia. All patients with a myocardial infarction in the ECG showed significant elevation of concentrations or activities of these biochemical markers. The median postoperative peak values for cTnI were measured at 24 h in both groups (2.7 micrograms/l, 95%-CI: [2.2, 3.2] in group I and 1.1 micrograms/l, 95%-CI: [0.5, 1.3] in group II). CTnT postoperatively presented an earlier median peak of 0.128 microgram/l at 12 h in group II (95%-CI: [0.041, 0.146]) than in group I at 48 h (0.298 microgram/l, 95%-CI: [0.254, 0.335]). CONCLUSIONS: All patients undergoing CABG surgery with or without extracorporeal circulation postoperatively showed an increase of cardiac troponin levels. After uncomplicated coronary revascularization, patients with the off-pump CABG technique continuously presented lower serum cardiac troponin concentrations than those with the on-pump CABG technique. CTnI showed the same patterns of release in both groups with different median postoperative peak values at 24 h. The patterns off cTnT release following CABC surgery with or without extracorporal circulation were different: CTnT reaches its postoperative peak value in patients with the off-pump CABG technique earlier than those with the on-pump CABG technique (12 h postoperatively versus 48 h).

Transfection of E-cadherin cDNA in human lung tumor cells reduces invasive potential of tumors.

Lung cancer is a major health-care problem in industrialized countries. With reference to its therapeutic consequences and major histological variations, it is divided into two subgroups - SCLC (small-cell lung cancer) and NSCLC (non-small-cell lung cancer). As an important factor of cell-cell and cell-substratum interaction, cell adhesion molecules (CAMs) seem to play a key role in tumor-cell migration and invasion that lead to metastases. We investigated human lung tumor cell lines established from histologically documented neoplastic lesions taken in our operating theater. Immunohistological screening showed differences in E-cadherin expression with no clear predominance of SCLC or NSCLC cell lines. Using an invasion model with Matrigel Matrix and a migration assay, we could demonstrate a more aggressive behavior pattern in E-cadherin-negative cell lines. We transfected E-cadherin cDNA into a formerly negative cell line showing strong invasive behavior in the initial tests in order to investigate the role of E-cadherin in this process. In this study, we examined E-cadherin cDNA transfection in human bronchial carcinoma cells. At present, transfection is stable with a follow-up time of one year. We could demonstrate that cell lines were remarkably less invasive after transfection of E-cadherin in the invasion model with Matrigel Matrix. These results indicate that the E-cadherin CAM plays an important role in lung tumor invasion and metastasis. Further studies are in progress to confirm these findings and to describe a possible role of this CAM in tumor therapy.

Bypass graft disease: analysis of proliferative activity in human aorto-coronary bypass grafts.

BACKGROUND: Aortocoronary bypass graft disease with its increasing clinical signification represents an unsolved problem in cardiological and heart surgery practice. Late occlusion of autologous saphenous vein grafts occurs against a background of medial and neointimal thickening due to migration and proliferation of smooth muscle cells and the later appearance of atherosclerotic plaques. To clarify the role of cellular proliferation in humans we characterized the cellular composition and proliferative index in 30 stenotic saphenous vein grafts. METHODS: 30 stenotic vein grafts and 25 control veins were explantated during redo heart surgery procedures. Time between initial surgical intervention and explantation was 3-168 month (mean 94,8 month). The total area and cell count of the neointima, media and adventitia was calculated computer assisted. Actively proliferating cells were identified using antibody to Ki-67 and by double-lable immuncytochemistry with alpha SMC actin, CD 31 (endothelial cells), CD 68 lpar;makrophages) and CD 45 (T-lymphocytes). RESULTS: Active proliferation was detected in different cell typs with a mean proliferation index of 0.15%,0.18% and 0.086% for the neointima, media and adventita. Only 9% of the proliferating cells in the neointima were SMC (not identified cells 40%); corresponding 14% SMC (not identified cells 33%) were detected in the media. Endothelial cells were the predominante proliferating cell type in all sites of the vessel wall. CONCLUSION: 1. Proliferation occured at low level. While proliferation may play an important role in early lesions our data imply low proliferation activity in advanced graft lesions. Other mechanism like production and deposition of extracellular matrix (ECM) in the neointima are responsible for the lumen reduction of bypass grafts. 2. The high portion of unidentified cells may represent SMC or other cell types at different stages of differentiation; this requires further investigation. 3. The identification of proliferating macrophages and T-lymphocytes implicate an inflammatory component in the development of human bypass graft lesions.

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.

[Surgical management of pulmonary artery sarcoma]. / Chirurgische Therapie des Pulmonalarteriensarkoms.

BACKGROUND AND OBJECTIVES: Pulmonary artery sarcoma is a rare neoplasm and possibly unnoticed cause of pulmonary hypertension. The presentation is one of central pulmonary artery obstruction and progressive right-heart failure. In most cases, the diagnosis of malignancy is confirmed post mortem. We report the outcome of eight patients with primary pulmonary artery sarcomas. METHODS: Eight patients (four female, four male, mean age 48,2 years, preop. NYHA functional class III/IV: n = 5/3) were referred for further evaluation of pulmonary hypertension. Malignancy was suspected in six of these patients by means of computed tomography (CT) and magnetic resonance tomography (MRT). In two patients diagnosis was established during pulmonary thromboendarterectomy based on histological examination of frozen sections. Operative procedures consisted of gross tumor resection with prosthetic replacement (n = 3) or reconstruction (n = 5) of central parts of the pulmonary vessels. Additional pneumonectomy was necessary in two patients, resection of metastases in one patient. Seven patients received adjuvant radio- and/or chemotherapy. RESULTS: There were no postoperative deaths. 3 months after surgery, all patients demonstrated improvement in hemodynamics and exercise tolerance. Four patients died 7, 9, 18 and 19 months after surgery, respectively. Two patients are alive 3 and 39 months after primary surgery with evidence of pulmonary metastases. Two patients are alive in complete remission 25 and 65 months postoperatively. CONCLUSIONS: In patients with primary pulmonary artery sarcoma, emphasis must be placed on early identification which can be achieved by CT and MRT. Radical surgical resection currently offers the best chance for survival. Adjuvant therapy might bring additional benefit.

[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.

Patterns and diagnostic value of cardiac troponin I vs. troponin T and CKMB after OPCAB surgery.

BACKGROUND: Cardiac troponin I (cTnI) has been shown to be a specific marker for myocardial injury in cardiac surgery. The object of this prospective study was to determine the patterns and kinetic and diagnostic value of cTnI, cardiac troponin T (cTnT), and creatine kinase MB (CKMB) activity after minimally invasive coronary revascularization using an octopus device on the beating heart (OPCAB). METHODS: 48 patients (33 male/15 female, mean age 68.3 +/- 8.7 years) underwent their first elective OPCAB surgery with median sternotomy without mortality. The mean number of grafts was 2.0 +/- 0.8 per patient. Preoperative mean ejection fraction was 56.6 % +/- 14.9%. CTnI and T levels, total creatine kinase (CK) and CK-MB activity in the serum were measured before operation, at arrival at the ICU, and 6, 12, 24, 48 and 120 hours afterward. Serial 12-lead ECGs were recorded preoperatively and at days 1, 2 and 5. The relationship between perioperative data and postoperative cTnI and cTnT levels and CKMB were statistically identified for all variables. RESULTS: The best cutoff value for cTnI was 8.35 micrograms/l. The patients were grouped by the ECG findings and maximal slopes of cTnI postoperatively (group I: unchanged ECG and cTnI < 8.35 micrograms/l, n = 38; group II: unchanged ECG and cTnI > 8.35 micrograms/l n = 6; group III: Q-wave in ECG and cTnI > 8.35 micrograms/l, n = 4). Baseline serum concentrations of cTnI were in the normal range, and significantly increased after surgery with a peak 24h after the operation. Maximal slopes of cTnI ranged in group II between 9.1 and 18.0 micrograms/l, and in group III between 35.9 and 88.8 micrograms/l. There was strong concordance between maximum cTnI, cTnT (p < 0.0001) and CK-MB levels (p = 0.003). First cTnI levels immediately post-op correlated with the maximum cTnI levels during the postoperative course (p = 0.009). CONCLUSIONS: CTnI after minimal invasive surgery shows a characteristic pattern with a maximum at 24h after the operation. The measurement of postoperative biochemical marker concentrations, specially cTnI, reflects myocardial injury incurred during the procedure. It is an accurate method for confirming or excluding a perioperative myocardial injury diagnosis after OPCAB surgery.

Surface attached ultrathin polymer monolayers for control of cell adhesion.

BACKGROUND: Calcific degeneration is the major drawback of bioprostheses. None of the numerous preventive approaches omitted calcification. Previous studies showed that cellular surface seeding decreases calcium uptake in vitro but achievement of coverage remains problematic. A new approach is presented masking glutaraldehyde residues with a polymer layer allowing cell seeding. The aim of this study was to evaluate different polymers for suitability. METHODS: Ten polymers--covalently bound to glass--were tested for their ability to seed animal and human cells. Quality of coverage was evaluated by light and scanning electron microscopy, and polymers were characterized physicochemically. RESULTS: Quality of cellular growth was similar for canine and human cells. Five polymers allowed excellent surface coverage, two led to a decrease of cell adherence, and four to poor cellular growth. No correlation between molecular weight, thickness, hydrophilicity, or charge of the polymer and cell growth was found. CONCLUSIONS: Polymer monolayers can promote cellular growth but without correlation to physicochemical characteristics. Polymers covalently bound to biologic tissue appear to be a promising approach for achieving cellular coverage of biomaterials.