Structural studies of the formation of lipoplexes between siRNA and selected bis-imidazolium gemini surfactants.

Dicationic (gemini) surfactants are agents that can be used for the preparation of stable complexes of nucleic acids, particularly siRNA for therapeutic purposes. In this study, we demonstrated that bis-imidazolium gemini surfactants with variable lengths of dioxyalkyl linker groups (from dioxyethyl to dioxydodecyl) and dodecyl side chains are excellent for the complexation of siRNA. All of these compounds effectively complexed siRNA in a charge ratio range (p/n) of 1.5-10. The low resolution structure of siRNA oligomers was characterised by small angle scattering of synchrotron radiation (SR-SAXS) and ab initio modelling. The structures of the formed complexes were also analysed using SR-SAXS, circular dichroism studies and electrophoretic mobility tests. The most promising agents for complexation with siRNA were the surfactants that contained dioxyethyl and dioxyhexyl spacer groups.

[Loco-regional lysis with thrombosis older than 10 days: experiences and outcome]. / Erfahrungen mit der lokoregionalen Fibrinolysetherapie bei Thrombosealter über 10 Tage.

Successful treatment of deep vein thrombosis by lysis therapy leads to recanalisation of the occluded vessel saving the venous flaps, thus limiting postthrombotic syndrome. Systemic lysis therapy carries an increased risk of fatal complications (1-2%). However, loco-regional lysis therapy with rtPA stands out as a method of recanalisation without increased complications compared to compression and anticoagulation therapy. According to the leading opinion about systemic lysis therapy it should only be performed if thrombotic age does not exceed 10 days. In this study we examined whether loco-regional lysis therapy is successful with older thrombosis, too. We showed that in thromboses older than 10 days lysis success was slightly decreased whereas postthrombotic syndrome doubled (up to 50%). These results point out loco-regional lysis as a method suitable for thromboses with age up to 10 days only.

Do vascular compartments differ in the development of chronic rejection? AT(1) blocker candesartan versus Ace blocker enalapril in an experimental heart transplant model.

BACKGROUND: Accelerated coronary artery disease (ACAD), a serious consequence after heart transplantation, is characterized by diffuse, concentric myointimal proliferation in the arteries. Increasing evidence supports the existence of a local renin-angiotensin system and the role of angiotensin-II in smooth muscle cell proliferation. We investigated the effect of angiotensin-II blocker candesartan and angiotensin-converting enzyme (ACE) inhibitor enalapril on experimental ACAD in a rat model. METHODS: After heterotopic cardiac transplantation (Fisher to Lewis), recipients received 20 mg/kg/day candesartan or 40 mg/kg/day enalapril per os. Two groups of animals received additional pre-treatment with candesartan or enalapril 7 days before transplantation, and treatment was continued after grafting. All study groups including the controls received 3 mg/kg/day of sub-cutaneous cyclosporine for immunosuppression. A syngeneic group (Lewis to Lewis), serving as extra control, did not receive any treatment. Eighty days after grafting, we assessed the extent of ACAD in large and small arteries, using digitizing morphometry and expressed as mean vascular occlusion (MVO). RESULTS: In enalapril and candesartan pre- and post-treated animals, we observed significant reduction of MVO of intramyocardial arteries compared with the cyclosporine group (p < 0.005), to levels similar to the syngeneic transplants. MVO of epicardial arteries in enalapril and candesartan pre- or posttreated animals did not significantly differ from cyclosporine controls (p > 0.05). CONCLUSION: Our results support the hypothesis of 2 proliferative compartments in the development of ACAD, with differing receptor or enzyme distribution: the compartment of small, intramyocardial arteries in which ACAD can be reduced by ACE or AT(1) blockade, and that of large, epicardial arteries in which inhibition fails.

Methylammonium groups at the solid walls of nanometer-sized, water-filled monolayer gaps as binding sites for a tetraanionic porphyrin.

Long-chain hydrosulfides containing two secondary amide functions and either electron-poor or electron-rich carbon-carbon double bonds were self-assembled on gold surfaces around a flat-lying, octaanionic porphyrin. Rigid and reactive surface monolayers with 2 nm-wide, porphyrin-based gaps were thus obtained. The gold electrodes were then immersed in water, and the double bonds on the gaps' surfaces reacted with methylamine. It was added to the double bonds either by Michael addition or by bromination with hypobromite followed by methylamine substitution. Only the double bonds at the border of the gaps were accessible to methylamine dissolved in the bulk water volume and could react. The walls of the rigid membrane gaps now contained methylammonium groups at the sites of the double bonds in defined heights. A tetracationic copper(II) porphyrinate could not diffuse any more into the gap and did not quench the fluorescence of the octaanionic porphyrin on the bottom of the gap. A tetraanionic porphyrin, on the other hand, was fixated by the ring of ammonium groups. The bound porphyrin then acted as molecular cover for the gap with respect to ferricyanide transport from bulk water to the electrode. It was removed by raising the pH to a value of 12, where the methylammonium groups were neutralized to amines. Lowering the pH to 7 again and addition of more of the anionic porphyrin reclosed the gap.The porphyrin "cover" should be localized at distances of 8-10 and 20 A from the bottom porphyrin by multiple charge interactions. The 8-10 A distance is ideal for studies of photoinduced electron transfer between two porphyrin monomers of different redox potential. Furthermore it was found, that redox-active tyrosine could be trapped in the water volume above the porphyrin on gold.

Extension of generator longevity by use of high impedance ventricular leads.

The resistance of a pacing lead negatively correlates to current consumption. A prospective, randomized trial was conducted to evaluate the effect of a high impedance ventricular lead (CapSure Z) on generator longevity compared to a conventional lead (CapSure SP) eighty-nine patients were included in the study (51 male, 37 female, age 70.0+/-10.3 years). Forty-six patients received a CapSure SP lead (5024 bipolar), and 43 patients received a CapSure Z lead (5034 bipolar) in a randomized fashion. Follow-up data collected at 5 days, 3, 6, and 12 months postimplant included: lead impedance, pacing and sensing thresholds, impulse energy, and estimated time to replacement. All parameters were collected via pacemaker telemetry; the time to replacement was calculated automatically by a programmed algorithm of the pacemaker. There was no difference in the performance of the atrial lead when a dual chamber device was indicated. The CapSure Z leads displayed statistically significant higher impedance values than the CapSure SP lead in all follow-up periods. There was no significant difference in lead related complications. No significant differences were observed between pacing and sensing thresholds in both groups. The CapSure Z leads provided a significant reduction in current drain, resulting in a reduction of mean energy consumption at the 12-month follow-up from 10.4+/-5.0 microJ in the CapSure SP group to 6.6+/-1.4 microJ in the CapSure Z group (median from 9.9 microJ to 6.9 microJ, respectively), providing an estimated increase in mean longevity of more than 1 year from 81.1+/-23.5 months in the CapSure SP group to 94.5+/-13.4 months in the CapSure Z group (median: 76.5 months to 95.0 months, respectively). The use of a high resistance lead for ventricular pacing appears to result in a clinically relevant extension of generator longevity.

New approach in the therapy of chronic rejection? ACE- and AT1-blocker reduce the development of chronic rejection after cardiac transplantation in a rat model.

BACKGROUND: Angiotensin II is one of the most potent mitogens of smooth muscle cell proliferation and plays a central role in the development of accelerated coronary artery disease (ACAD), which remains a serious consequence after heart transplantation and limits long-term survival. We investigated the effect of an angiotensin-II blocker, Losartan (angiotensin II Type 1 [AT(1)]-blocker), and an angiotensin-converting enzyme (ACE) inhibitor, Enalapril, on experimental ACAD in a rat cardiac transplant model (Fisher to Lewis). METHODS: After grafting, recipients were treated with 10 mg/kg/day per os Losartan or 40 mg/kg/day per os Enalapril. Two groups of animals received additional pre-treatment with Losartan or Enalapril 7 days before transplantation. All study groups, including the control group, received immunosuppression with cyclosporine (3 mg/kg/day sub-cutaneously). We assessed the extent of ACAD of large and small arteries 80 days after grafting using digitizing morphometry. RESULTS: We observed significant reduction of neointimal proliferation in small arteries in Losartan pre- and post-treated and in Enalapril pre-treated recipients compared with the cyclosporine-treated group (p < 0.05). In epicardial arteries, Enalapril pre- and post-treatment as well as Losartan post-treatment significantly reduced neointimal formation compared with the control group. Reduction of neointima by Enalapril post-treatment in small arteries and Losartan pre-treatment in large arteries trended toward but failed statistical significance. CONCLUSIONS: Our results suggest the important role of the renin-angiotensin system in neointimal proliferation, which can be reduced equally with ACE inhibitors or the angiotensin-II blocker. Therefore AT(1) blockade with Losartan is a useful therapeutic strategy for inhibition of ACAD after cardiac transplantation.

Intracardiac QRS electrogram width--an arrhythmia detection feature for implantable cardioverter defibrillators: exercise induced variation as a base for device programming.

Delivery of inappropriate therapy of implantable cardioverter defibrillators (ICD) due to inaccurate arrhythmia detection represents a major clinical problem. Different arrhythmia detection criteria such as the "stability" of the cycle length or the suddenness of "onset" of tachycardia have been implemented in ICD software to prevent inappropriate therapy. The new Medtronic model 7223Cx ICD offers an additional detection parameter (QRS width), which reflects changes in the duration of ventricular depolarization as a tool to distinguish supraventricular from ventricular tachycardias. Although this criterion can be programmed based on ECG parameters derived from resting ECGs, this may not be sufficient since QRS width is subject to considerable changes due to transient myocardial ischemia, changes in autonomic tone, or frequency dependent effects of antiarrhythmic drugs. The present study aimed to determine frequency dependent changes in QRS width in individual patients at rest and during symptom-limited exercise testing in 16 patients with documented ventricular tachycardia (N = 13) or ventricular fibrillation (N = 3). The optimal EGM slew threshold and the individual variation of QRS width were determined. Measurements obtained at the end of the implantation procedure were compared to those performed at hospital discharge. The majority of patients showed a wider variation in QRS duration as measured from 30 consecutive cycles during exercise as compared to rest. For example, the QRS range (i.e., the difference between the maximal and the minimal QRS width measured) averaged 7 +/- 3 ms at rest and increased to 11 +/- 3 ms during exercise (P = 0.004) with an increase of > or = 4 ms observed in 11 (69%) of 16 patients. In 13 (81%) of 16 patients a reprogramming of at least one QRS width parameter from its value at the time of implantation was necessary. Thus, the QRS width measured from the intracardiac EGM shows significant intraindividual variations in different physiological conditions. For optimal programming of the QRS width parameter, measurements obtained during exercise are important.

[Combined therapy with transvenous cardioverter/defibrillator and anti-bradycardia pacemaker systems]. / Kombinierte Therapie mit transvenösen Kardioverter/Defibrillator- und antibradykarden Schrittmachersystemen.

Implantable cardioverter/ defibrillators (ICD) represent in many patients with ventricular tachyarrhythmias the first line treatment. Up to 15% of the patients requiring an ICD need concomitant permanent cardiac pacing for bradyarrhythmias resulting in the need of simultaneous ICD- and antibradycardic pacemaker-therapy. We present four patients with successful implantation of a transvenous ICD-system (Medtronic Jewel 7220 and Micro Jewel 7221; electrode: Medtronic 6939), all of which had an antibradycardic pacemaker (2 unipolar, 2 bipolar) implanted prior to ICD-implantation. Meticulous intraoperative testing in order to avoid adverse interactions between the two systems has been carried out successfully in all cases. Possible adverse interactions comprise oversensing of pacemaker signals by the ICD with subsequent inadequate therapy, inhibition of defibrillation therapy during ventricular fibrillation caused by false detection of pacemaker spikes by the ICD as well as reprogramming of the pacemaker after shock delivery. A review of the published literature yielded 91 reported cases of combined ICD- and pacemaker-therapy. In 16% of the patients, one or more of the mentioned complications have been observed. Those occurred more frequently with unipolar than with bipolar pacemaker-systems. Thus, combined therapy with antibradycardic pacemaker and transvenous ICD-systems can be performed safely.

[Individual risk assessment in aortocoronary bypass operation]. / Individuelle Risikoabschätzung bei aorto-koronarer Bypassoperation.

The treatment of coronary heart disease in open heart surgery shows the most increase since Favolora established in 1967 the aorto coronary bypass. Last year in Germany there had been 47 480 operations by using extracorporeal circulation. The individual advantages and risks of the bypass surgery are well known and discussed. But its difficult to explain the individual prognosis of the operation to the patient. To examine the survival rate after an aorto coronary bypass operation we used the Probit analyzing technique. The single and combined influence of the different parameters were examined by the Maximum-Likelihood method to estimate the value of each parameter. With this estimated values we calculated the individual risk using the formula based on the transformed standard deviation. Our examination includes 6122 patients revascularized 1983 and 1994. The multivarious analyze of the individual risks shows significant statistic values in the following parameters: left main stenosis, proximal RCA, RCX, and RIA stenosis, stenosis of peripheral RIA, NYHA class IV, existing kidney disease, peripheral arteriosclerosis, cardiac arrhythmias, quantity and location of myocardial infarction, emergency situations (e.g. after PTCA) and the age of the patient which shows a high significant value by a strong linear correlation.

Early and long-term results of cardiac surgery in dialysis patients.

Cardiac surgery in patients receiving dialysis has a high mortality and morbidity. Early long-term results have been analysed following various cardiac operative procedures. Between 1981 and 1992, 40 patients, of mean age 55.7 (range 31-71) years underwent cardiac surgery. Procedures included coronary artery bypass grafting (20 patients), aortic valve replacement (six), mitral valve replacement (four), aortic valve or mitral valve plus coronary artery bypass grafting (one each), aortic plus mitral valves (two), heart and renal transplantation (one each), atrial septal defect closure (one) and pericardial decortication (three). Before surgery, patients were in the New York Heart Association (NYHA) classes II (5%), III (52.2%) and IV (42.5%). The operative mortality rate was 15%; survivors were in NYHA classes I (3%), II (88.2%) and III (8.8%). There were 11 late deaths. Follow-up at a mean of 35 (range 1-93) months showed actuarial survival rates of 91% (1 year) and 69% (5 years). After coronary artery bypass grafting, survival rates were 95% (1 year) and 72% (5 years). Survivors were in NYHA classes I (4.7%), II (85.5%) and III (9.5%). Cardiac surgery in dialysis patients is associated with an acceptable hospital mortality; quality of life in long-term survivors is increased. Hence, surgical treatment is advocated in patients with symptomatic heart disease. Early diagnosis and surgical intervention in NYHA class II patients may lead to a lower perioperative mortality.

Early and long term results of cardiac surgery in dialysis patients.

OBJECTIVES: The risk of cardiac surgery in dialysis patients is increased compared with other patient groups. We analyzed early and long term results following various cardiac procedures. METHODS: Between 1981 and 1992, 40 patients underwent cardiac surgery with a mean age of 55.7-years (range 31-71 years). Cardiac procedures: Coronary artery bypass grafting (CABG) n = 20, aortic valve replacement (AVR) n = 6, mitral valve replacement (MVR) n = 4, AVR+CABG n = 1, MVR+CABG n = 1, AVR+MVR n = 2, combined heart and renal transplantation n = 2, atrial septal defect-closure n = 1, pericardial decortication n = 3. The preoperative NYHA functional classes were: NYHA II 5%, III 52.2%, IV 42.5%. Operative mortality was 15% (6/40). Hospital survivors were in NYHA functional classes I (3%), II (88.2%) and III (8.8%). A follow-up study was performed at 35 months (mean, range 1-93 months) postoperatively. RESULTS: There were 11 late deaths. The actuarial survival of all patients was 91% (1 year) and 69% (5 years). Following CABG it was 95% (1 year) and 72% (5 years). Survivors were in NYHA functional classes I 4.7%, II 85.8%, III 9.5%. CONCLUSION: Cardiac surgery in dialysis patients is associated with an acceptable hospital mortality. The quality of life of long term survivors is increased significantly. Thus we advocate surgical treatment in patients with symptomatic heart disease. Early diagnosis and surgical intervention in the NYHA functional class II may lead to a lower perioperative mortality.

Left main coronary artery stenosis after aortic valve replacement: genetic disposition for accelerated arteriosclerosis after injury of the intact human coronary artery?

BACKGROUND: Left main coronary artery stenosis is a rare but life-threatening complication after aortic valve replacement because of coronary perfusion-related trauma to the vessel wall with cannulation of the coronary ostia. We investigated whether this complication still occurs in the 1990s despite the use of more advanced catheter materials and modern surgical preservation techniques. METHODS: Four years after identification of the first two cases in 1987, five further patients had developed left main coronary artery stenosis after aortic valve replacement (incidence, 0.9%) at the cardiothoracic clinic of the J.W. Goethe University and were studied for contributing factors. RESULTS: Severe coronary ostial stenosis developed within 1 to 6 months after aortic valve replacement. In one such case, intimal proliferation was seen in a biopsy specimen that was comparable to the restenosis induced by coronary angioplasty. The clinical characteristics of the patients developing the complication, the surgical technique, and the intraoperative course did not differ from the other patients. However, five of the seven patients (71%) had a common genetic trait concerning their apolipoprotein E genotype (the epsilon 4 allele) that is normally present in only 10% to 15% of patients screened (P < 0.01). CONCLUSIONS: These lesions seem to result from a uniform response of the vessel wall to injury. Their incidence is probably related in part to the degree of injury after trauma to the coronary ostia during cannulation for myocardial protection. Patients with the epsilon 4 allele might be genetically predisposed for a pathologically increased response of proliferative repair mechanisms after arterial injury. The complication can be avoided by not instrumenting the coronary ostia for direct antegrade cardioplegia but using retrograde delivery as an alternative method of myocardial protection.

[Results of surgical therapy of bronchial cancers with reference to adjuvant therapeutic measures in an advanced stage]. / Ergebnisse der chirurgischen Therapie von Bronchialkarzinomen unter Berücksichtigung adjuvanter Therapiemassnahmen im fortgeschrittenen Stadium.

UNLABELLED: The prognosis of bronchial carcinoma especially in advanced tumor stage is poor despite different methods of treatment. The 5-year survival rate after radical operation is about 25-40% for all stages, and between 17-20% in stage III. Without therapy it is 3.5-9.5%. T3-tumors and N2-lymphnodes represent the limit of surgical therapy. From 1980 to 1988 we operated 456 patients because of bronchial carcinoma, 80% men (mean age 59.2 y) and 20% women (mean age 56.9 y). 83.1% had been smokers, 16.9% had been exposed to contaminants. At admission to the hospital 36% were in stage I, 13% in stage II, 47% in stage III, and 4% in stage IV. HISTOLOGY: squamous cell carcinoma 40.9%, adenocarcinoma 26.1%, large cell carcinoma 21.9%, and small cell carcinoma 11.1%. Looking at all cases we mostly performed a lobectomy, in stage III tumors the most common operation was pneumonectomy. In this group only 57.5% of the patients were resectable. In 77 potentially curative operated patients in stage III with non-small cell carcinoma we performed an adjuvant radio-, chemo- or combined therapy. The cumulative survival rates for all patients in the 1st year were 85% in stage I, 67% in stage II, and 36% in stage III and IV. In the 3rd year 57%, 14% and 10%, and in the 5th year 41%, 7%, and 5%. In stage III the survival rates of the potentially curative operated vs. the exploratively operated patients were in the 1st year 50%/36%, in the 3rd year 16%/10%, and in the 5th year 11%/5%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Protection of the tunica intima during preservation of venous bypass grafts from harvesting to implantation]. / Protektion der Tunica intima während der Aufbewahrung von Venenbypasses von der Entnahme bis zur Implantation.

The patency-rate of venous bypasses depends--beside other important factors--upon the integrity of the transplanted vessel, especially on the condition of the tunica intima. We investigated two different methods of venous storage and their on the intima. We examined 24 segments of healthy human saphenous vein and 65 segments of the inferior vena cava in the rat which had been harvested using a minimal touch technique. The veins were stored in the patients own arterial heparinized blood vs. Euro Collins solution at 4 degrees C, 20 degrees C and 37 degrees C over 15, 30, 60, and 90 minutes. As a reference we examined 11 segments of human saphenous vein which had been fixed immediately after harvesting. The stainings were performed with PAS, HE, Domagk-Elastica, and Toluidine-blue. We examined 1,181 slices by light-microscopy and used a damage score table for the documentation of the vein-trauma. No significant differences were found between human and animals veins. In the control-group the endothelium, the subendothelial layer, and the intern elastic membrane were intact in 57%, 78%, and 38%. At 4 degrees C the endothelium was intact in 31% having been stored in blood, and in 44% at Euro Collins solution. For the subendothelial layer the ratio was 48%/66%, and for the intern elastic membrane 26%/42%. At 20 degrees C we found a ratio of 55%/47% vs. 65%/58% vs. 37%/39%, and at 37 degrees C 56%/37% vs. 64%/51%/32%/38%. The factor time could be neglected up to 90 minutes. The results show that veins should be used immediately after harvesting.(ABSTRACT TRUNCATED AT 250 WORDS)

[Risks of combined surgical treatment of acquired heart valve defects and coronary heart disease]. / Risiken der kombinierten chirurgischen Behandlung von erworbenen Klappenvitien und koronarer Herzerkrankung.

In the past years the number of patients with combined treatment of the heart valves and coronary arteries rised as well as the patients age did. In 1980-1987 the rate of patients with aortic valve replacement and simultaneous aorto-coronary bypass was 10.9% in those who underwent aortic valve replacement and 2.9% in those who had aorto-coronary bypass operation. Since 1988 the ratios changed to 18.2% and 4.9%. For the calculation of the operative risk of the combined operative treatment (AVR + CABG, MVR + CABG) we compared these groups with those patients with isolated operations (MVR, AVR, CABG). We studied all patients during 1980 and July 1989. The hospital mortality of combined procedures was significantly increased. The mortality among female patients was higher as compared to the male group. The age of patients treated by the combined procedures was higher as compared to the isolated procedures. The mean age of the patients which died was severely increased as compared to the isolated procedures. However, in the combined procedures this increase was not as pronounced as in the isolated groups. Patients with combined procedures had a higher NYHA class. The risk factors of the combined procedures were comparable to isolated CABG.

Adequate flow through the internal mammary artery graft achieved by a dilatation technique.

From Jan. 1984 to Dec. 1988 941 patients had internal mammary artery grafting alone or with vein grafts. There were 1705 associated vein grafts and 957 internal mammary grafts, for a total of 2 662 grafts (2.8 per patient). Use of the internal mammary artery was indicated in patients younger than 70 years with a significant stenosis of the main stem or the proximal left anterior descending artery in elective operations. The overall operative mortality was 3.4%, 2.9% for men and 6.2% for women. It rose to 9.6% in patients who were in New York Heart Association Class IV. Incidence of bleeding requiring reexploration was 5.5% and an intra-aortic balloon pump was implanted in 3% because of low cardiac output. At cardiac recatheterization (on average after 12 months) 88.3% of the internal mammary grafts and 63.3% of the vein grafts were patent. In investigation of, reasons for operative mortality, measuring the free flow of the internal mammary artery showed flow rates of 32-208 ml/min only slightly depending on the blood pressure. A technique of dilatation is described that significantly increases the flow rate up to 85%. The technique has been used regularly since Nov. 1987: from that date the IMA is only used if it has a flow rate of at least 60 ml/min.

Results of surgical repair for 110 thoracic aortic aneurysms.

Between 1974 and July 1989 110 operations for thoracic aortic aneurysms in 107 patients (69 males, 38 females) were performed, whose ages ranged from 14 to 74. 37 patients had an aortic valvular disease, 15 had Marfan's syndrome, 28 of these patients had a history of thoracic trauma or of previous aortic or cardiac surgery (14 posttraumatic aneurysms, 9 aneurysms after cardiac surgery, 5 after repair of aortic coarctation), 29 patients had hypertension. 63 patients underwent repair of dissecting aneurysms, 47 of non-dissecting (saccular or fusiform) thoracic aortic aneurysms. 67 repairs were emergency and 43 elective. The hospital mortality for the entire series was 34.5%. The analysis of multiple preoperative and intraoperative variables showed that mortality following thoracic aortic aneurysm repair is higher with increasing age (65.7% mortality for operations between the 60th and 70th year of age, 100% mortality beyond the 70th year of age) and emergency surgery (hospital mortality 52.2% compared with 6.9% for elective operations). A significant increase in mortality was noted related to the aneurysm type (poorer prognosis in DeBakey type I and II), to history of hypertension, to preoperative shock or to perforation of the aneurysm, including haemopericardium or haemothorax.

[Thoracic aneurysms: criteria for surgical indications and results]. / Thorakales Aneurysma: Chirurgische Indikationskriterien und Ergebnisse.

Elective operations of chronic thoracic aortic aneurysms (TAA) can be performed with low risk. In contrast, emergency repair of TAA in symptomatic patients including those with rupture is associated with a high mortality. The worst results were obtained (a) in patients who were in shock preoperatively, (b) with palliative procedures during acute dissection and (c) in patients older than 70. The results may be improved by early diagnosis and better operative technique and perioperative management.