Do biometric parameters improve the quality of optic nerve head measurements with spectral domain optical coherence tomography?

BACKGROUND: Spectral domain optical coherence tomography (SD-OCT) is a widely applied non-invasive technique for evaluating optic nerve head parameters. The aim of this study was to evaluate the impact of biometric parameters such as the spherical equivalent (SE) and the anterior corneal curvature (ACC) on the peripapillary retinal nerve fiber layer (pRNFL), Bruch's membrane opening (BMO), and the minimum rim width (MRW) measurements performed by spectral domain optical coherence tomography (SD-OCT) in glaucomatous and healthy eyes. METHODS: In this cross-sectional, case-control prospective pilot study, the glaucoma group consisted of 50 patients with previously diagnosed and treated glaucoma and one healthy group of 50 subjects. Two consecutive examinations of pRNFL, BMO, and MRW with SD-OCT for every patient were performed without ACC and objective refraction (imaging 1) and with them (imaging 2). RESULTS: The interclass correlation coefficient (ICC) reflected high agreement between imaging 1 and imaging 2 in both groups. The ICC in the glaucoma and healthy groups for pRNFL (0.99 vs. 0.98), BMO (0.95 vs. 0.97), and MRW (1.0 vs. 1.0) was comparable. CONCLUSIONS: Our preliminary data from a small number of eyes showed that the measurements of pRNFL, MRW, and BMO reflected high agreement between both imaging techniques with ACC and objective refraction and without these parameters in subjects with a refractive error up to ± 6.0 diopters. Further studies with participants with higher refractive error are necessary to evaluate the impact of biometric parameters such as SE and ACC on measurements with SD-OCT.

FUNCTIONAL AND STRUCTURAL EFFECTS OF NONDAMAGING RETINAL LASER THERAPY FOR MACULAR TELANGIECTASIA TYPE 2: A Randomized Sham-Controlled Clinical Trial.

PURPOSE: Macular telangiectasia (MacTel) Type 2 is a progressing neurovascular disease of the macula, currently lacking effective treatment. This study assessed the effect of nondamaging retinal laser therapy (NRT) compared with sham. METHODS: Twelve MacTel patients were enrolled in this double-masked, controlled, randomized clinical trial. For the nine patients with both eyes eligible, one eye was randomized to NRT or sham and the other received alternate treatment. For three patients with only one eye eligible, that eye was randomly assigned either NRT or sham. Ellipsoid zone disruption, best-corrected visual acuity, and macular automated perimetry at 12 months served as structural and functional measures. RESULTS: Eleven eyes were randomized to sham and 10 to NRT. Baseline best-corrected visual acuity was 66 letters (20/50) for sham and 72 letters (20/40) for NRT (P = 0.245). Ellipsoid zone disruption area was 298 µm2 in sham and 368 µm2 in NRT (P = 0.391). At 12 months, ellipsoid zone disruption increased by 24% in sham and decreased by 34% in NRT (P < 0.001). Best-corrected visual acuity measures remained stable during follow-up compared with baseline. At 1 year, the mean macular sensitivity was 28 dB in the NRT group, compared with 26 dB in sham. CONCLUSION: Nondamaging retinal laser therapy was safe and well tolerated in patients with MacTel and resulted in structural and functional improvements, which could represent a protective effect of laser-induced hyperthermia. Longer follow-up and larger number of patients should help corroborate these effects.

Publisher Correction: Groundwater Throughflow and Seawater Intrusion in High Quality Coastal Aquifers.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Groundwater Throughflow and Seawater Intrusion in High Quality Coastal Aquifers.

High quality coastal aquifer systems provide vast quantities of potable groundwater for millions of people worldwide. Managing this setting has economic and environmental consequences. Specific knowledge of the dynamic relationship between fresh terrestrial groundwater discharging to the ocean and seawater intrusion is necessary. We present multi- disciplinary research that assesses the relationships between groundwater throughflow and seawater intrusion. This combines numerical simulation, geophysics, and analysis of more than 30 years of data from a seawater intrusion monitoring site. The monitoring wells are set in a shallow karstic aquifer system located along the southwest coast of Western Australia, where hundreds of gigalitres of fresh groundwater flow into the ocean annually. There is clear evidence for seawater intrusion along this coastal margin. We demonstrate how hydraulic anisotropy will impact on the landward extent of seawater for a given groundwater throughflow. Our examples show how the distance between the ocean and the seawater interface toe can shrink by over 100% after increasing the rotation angle of hydraulic conductivity anisotropy when compared to a homogeneous aquifer. We observe extreme variability in the properties of the shallow aquifer from ground penetrating radar, hand samples, and hydraulic parameters estimated from field measurements. This motived us to complete numerical experiments with sets of spatially correlated random hydraulic conductivity fields, representative of karstic aquifers. The hydraulic conductivity proximal to the zone of submarine groundwater discharge is shown to be significant in determining the overall geometry and landward extent of the seawater interface. Electrical resistivity imaging (ERI) data was acquired and assessed for its ability to recover the seawater interface. Imaging outcomes from field ERI data are compared with simulated ERI outcomes derived from transport modelling with a range of hydraulic conductivity distributions. This process allows for interpretation of the approximate geometry of the seawater interface, however recovery of an accurate resistivity distribution across the wedge and mixing zone remains challenging. We reveal extremes in groundwater velocity, particularly where fresh terrestrial groundwater discharges to the ocean, and across the seawater recirculation cell. An overarching conclusion is that conventional seawater intrusion monitoring wells may not be suitable to constrain numerical simulation of the seawater intrusion. Based on these lessons, we present future options for groundwater monitoring that are specifically designed to quantify the distribution of; (i) high vertical and horizontal pressure gradients, (ii) sharp variations in subsurface flow velocity, (iii) extremes in hydraulic properties, and (iv) rapid changes in groundwater chemistry. These extremes in parameter distribution are common in karstic aquifer systems at the transition from land to ocean. Our research provides new insights into the behaviour of groundwater in dynamic, densely populated, and ecologically sensitive coastal environments found worldwide.

Analysis of Minimally Invasive Left Thoracotomy HVAD Implantation - A Single-Center Experience.

BACKGROUND: Minimally invasive left ventricular assist device (LVAD) implantation may reduce peri-/postoperative complications and risks associated with resternotomies. In this study, we describe our first results using a minimally invasive LVAD implantation technique (lateral thoracotomy [LT] group). These results were compared with LVAD implantations done via full median sternotomy (STX group). METHODS: HVAD (HeartWare, Framingham, Massachusetts, United States) implantations in 70 patients (LT group n = 22, 52 ± 15 years old; STX group n = 48, 59 ± 11 years old) were retrospectively analyzed. Minimally invasive access via left thoracotomy was feasible in 22 patients. Peri- and postoperative analyses of survival and adverse events were performed. RESULTS: No survival differences were observed between the LT and STX group (p = 0.43). LT patients without temporary right ventricular assist device (tRVAD) showed a significantly better survival rate compared to LT patients with concomitant tRVAD implantation (p = 0.02), which could not be demonstrated in the STX group (p = 0.11). Two LT and four STX patients were successfully bridged to heart transplantation and three STX patients were successfully weaned with subsequent LVAD explantations. LVAD-related infections (n = 4 LT group vs n = 20 STX group, p = 0.04) were less likely in the LT group. No wound dehiscence occurred in the LT group, whereas five were observed in the STX group (p = 0.17). The amount of perioperative blood transfusions (within the first 7 postoperative days) did not differ in both study groups (p = 0.48). CONCLUSION: The minimally invasive approach is a viable alternative with the possibility to reduce complications and should be particularly considered for bridge-to-transplant patients.

The effectiveness of the high-LET radiations from the boron neutron capture [10B(n,α) 7Li] reaction determined for induction of chromosome aberrations and apoptosis in lymphocytes of human blood samples.

Provided that a selective accumulation of (10)B-containing compounds is introduced in tumor cells, following irradiation by thermal neutrons produces high-LET alpha-particles ((4)He) and recoiling lithium-7 ((7)Li) nuclei emitted during the capture of thermalized neutrons (0.025 eV) from (10)B. To estimate the biological effectiveness of this boron neutron capture [(10)B(n,α)(7)Li] reaction, the chromosome aberration assay and the flow cytometry apoptosis assay were applied. At the presence of the clinically used compounds BSH (sodium borocaptate) and BPA (p-boronophenylalanine), human lymphocytes were irradiated by sub-thermal neutrons. For analyzing chromosome aberrations, human lymphocytes were exposed to thermally equivalent neutron fluences of 1.82 × 10(11) cm(-2) or 7.30 × 10(11) cm(-2) (corresponding to thermal neutron doses of 0.062 and 0.248 Gy, respectively) in the presence of 0, 10, 20, and 30 ppm of BSH or BPA. Since the kerma coefficient of blood increased by 0.864 × 10(-12) Gy cm(2) per 10 ppm of (10)B, the kerma coefficients in blood increase from 0.34 × 10(-12) cm(2) (blood without BSH or BPA) up to 2.93 × 10(-12) Gy cm(2) in the presence of 30 ppm of (10)B. For the (10)B(n, α)(7)Li reaction, linear dose-response relations for dicentrics with coefficients α = 0.0546 ± 0.0081 Gy(-1) for BSH and α = 0.0654 ± 0.0075 Gy(-1) for BPA were obtained at 0.062 Gy as well as α = 0.0985 ± 0.0284 Gy(-1) for BSH and α = 0.1293 ± 0.0419 Gy(-1) for BPA at 0.248 Gy. At both doses, the corresponding (10)B(n, α)(7)Li reactions from BSH and BPA are not significantly different. A linear dose-response relation for dicentrics also was obtained for the induction of apoptosis by the (10)B(n, α)(7)Li reaction at 0.248 Gy. The linear coefficients α = 0.0249 ± 0.0119 Gy(-1) for BSH and α = 0.0334 ± 0.0064 Gy(-1) for BPA are not significantly different. Independently of the applied thermal neutron doses of 0.062 Gy or 0.248 Gy, the (10)B(n, α)(7)Li reaction from 30 ppm BSH or BPA induced an apparent RBE of about 2.2 for the production of dicentrics as compared to exposure to thermal neutrons alone. Since the apparent RBE value is defined as the product of the RBE of a thermal neutron dose alone times a boron localization factor which depends on the concentration of a (10)B-containing compound, this localization factor determines the biological effectiveness of the (10)B(n, α)(7)Li reaction.

Experimental determination of the antineutrino spectrum of the fission products of U238.

An experiment was performed at the scientific neutron source FRM II in Garching to determine the cumulative antineutrino spectrum of the fission products of U238. Target foils of natural uranium were irradiated with a thermal and a fast neutron beam and the emitted ß spectra were recorded with a γ-suppressing electron telescope. The obtained ß spectrum of the fission products of U235 was normalized to the data of the magnetic spectrometer BILL. This method strongly reduces systematic errors in the U238 measurement. The ß spectrum of U238 was converted into the corresponding ν¯e spectrum. The final ν¯e spectrum is given in 250 keV bins in the range from 2.875 to 7.625 MeV with an energy-dependent error of 3.5% at 3 MeV, 7.6% at 6 MeV, and ≳14% at energies ≳7 MeV (68% confidence level). Furthermore, an energy-independent uncertainty of ∼3.3% due to the absolute normalization is added. Compared to the generally used summation calculations, the obtained spectrum reveals a spectral distortion of ∼10% but returns the same value for the mean cross section per fission for the inverse beta decay.

RBE of thermal neutrons for induction of chromosome aberrations in human lymphocytes.

The induction of chromosome aberrations in human lymphocytes irradiated in vitro with slow neutrons was examined to assess the maximum low-dose RBE (RBE(M)) relative to (60)Co γ-rays. For the blood irradiations, cold neutron beam available at the prompt gamma activation analysis facility at the Munich research reactor FRM II was used. The given flux of cold neutrons can be converted into a thermally equivalent one. Since blood was taken from the same donor whose blood had been used for previous irradiation experiments using widely varying neutron energies, the greatest possible accuracy was available for such an estimation of the RBE(M) avoiding the inter-individual variations or differences in methodology usually associated with inter-laboratory comparisons. The magnitude of the coefficient α of the linear dose-response relationship (α = 0.400 ± 0.018 Gy(-1)) and the derived RBE(M) of 36.4 ± 13.3 obtained for the production of dicentrics by thermal neutrons confirm our earlier observations of a strong decrease in α and RBE(M) with decreasing neutron energy lower than 0.385 MeV (RBE(M) = 94.4 ± 38.9). The magnitude of the presently estimated RBE(M) of thermal neutrons is-with some restrictions-not significantly different to previously reported RBE(M) values of two laboratories.

Minimally invasive resection of a right atrial mass in a cardiac transplant recipient: a case report.

Intracardiac thrombus formation usually occurs in the left-sided cavities of the heart, most frequently in the presence of atrial fibrillation or cardiomyopathy. We report the case of an initially unclear mass developing in the right atrium (RA) of a heart transplant recipient, which was subsequently resected via a minimally invasive surgical approach. Access via right anterior minithoracotomy using videoscopic assistance allowed for uncomplicated RA thrombectomy in the presented case, avoiding reentry sternotomy with the potential risk of cardiac injury and without aortic cross-clamping or cardioplegic arrest. The patient is doing fine with excellent graft function at the latest follow-up 4 months after minimally invasive thrombectomy and 30 months after cardiac transplantation. To the best of our knowledge, this is the first report describing minimally invasive resection of a right atrial thrombus in a heart transplant recipient.

Dose-response relationship of dicentric chromosomes in human lymphocytes obtained for the fission neutron therapy facility MEDAPP at the research reactor FRM II.

The biological effectiveness of neutrons from the neutron therapy facility MEDAPP (mean neutron energy 1.9 MeV) at the new research reactor FRM II at Garching, Germany, has been analyzed, at different depths in a polyethylene phantom. Whole blood samples were exposed to the MEDAPP beam in special irradiation chambers to total doses of 0.14-3.52 Gy at 2-cm depth, and 0.18-3.04 Gy at 6-cm depth of the phantom. The neutron and gamma-ray absorbed dose rates were measured to be 0.55 Gy min(-1) and 0.27 Gy min(-1) at 2-cm depth, while they were 0.28 and 0.25 Gy min(-1) at 6-cm depth. Although the irradiation conditions at the MEDAPP beam and the RENT beam of the former FRM I research reactor were not identical, neutrons from both facilities gave a similar linear-quadratic dose-response relationship for dicentric chromosomes at a depth of 2 cm. Different dose-response curves for dicentrics were obtained for the MEDAPP beam at 2 and 6 cm depth, suggesting a significantly lower biological effectiveness of the radiation with increasing depth. No obvious differences in the dose-response curves for dicentric chromosomes estimated under interactive or additive prediction between neutrons or gamma-rays and the experimentally obtained dose-response curves could be determined. Relative to (60)Co gamma-rays, the values for the relative biological effectiveness at the MEDAPP beam decrease from 5.9 at 0.14 Gy to 1.6 at 3.52 Gy at 2-cm depth, and from 4.1 at 0.18 Gy to 1.5 at 3.04 Gy at 6-cm depth. Using the best possible conditions of consistency, i.e., using blood samples from the same donor and the same measurement techniques for about two decades, avoiding the inter-individual variations in sensitivity or the differences in methodology usually associated with inter-laboratory comparisons, a linear-quadratic dose-response relationship for the mixed neutron and gamma-ray MEDAPP field as well as for its fission neutron part was obtained. Therefore, the debate on whether the fission-neutron induced yield of dicentric chromosomes increases linearly with dose remains open.

Heart transplantation in a patient with multiple sclerosis and mitoxantrone-induced cardiomyopathy.

We describe a 30-year-old man with end-stage heart failure after therapy with mitoxantrone for multiple sclerosis. A successful orthotopic heart transplantation was performed when intensified medical therapy failed to improve the patient's hemodynamics. In spite of the severe underlying disease he did well on dual immunosuppression with methylprednisone and cyclosporine. Neurologic symptoms remained stable throughout the procedure and, after 2 months, he resumed preoperative ambulatory status. Eight years after the operation, the patient is now in New York Heart Association (NYHA) Class I status. Using canes, he is able to walk short distances. Repeated urinary tract infections caused by Escherichia coli became a problem, but have been controlled by long-term oral antibiotic prophylaxis with trimethoprim.

Young Investigator's Prizewinner 2001. Direct visualization of the influence of normothermic as opposed to hypothermic cardiopulmonary bypass on the systemic microcirculation in neonatal piglets.

The direct visualization of systemic microcirculation using intravitalmicroscopy permits the classification of proinflammatory and ischemic microvascular alterations during normothermic and hypothermic cardiopulmonary bypass in neonates. We used seven newborn piglets, on average aged 9 days, and weighing 3200g, as a control group. In addition, we studied nine piglets subjected to 60 minutes of constant nonpulsatile flow using hypothermic extracorporeal circulation at 28 degrees C, and five piglets using normothermic conditions at 37 degrees C. The microvascular network of the greater omentum and the subcutaneous tissue was directly visualized using intravitalmicroscopy. We analysed interactions between leukocytes and endothelial cells, microvascular morphology, and microrheological conditions, focussing on signs of ischemic and proinflammatory alterations. During normothermic cardiopulmonary bypass, the numbers of activated leukocytes were elevated compared to hypothermic cardiopulmonary bypass (p > 0.05). Arteriolar diameter decreased during hypothermia. Capillaries were markedly dilated during normothermia. Patterns of microvascular perfusion, for both types of cardiopulmonary bypass, showed signs of ischemic damage, revealed by a reduced functional capillary density. Perfusion dependent levels of lactate were higher during normothermic cardiopulmonary bypass (p > 0.05). This new experimental approach revealed that non-pulsatile cardiopulmonary bypass, independent of temperature, induces a proinflammatory and ischemic response compared to an unaltered control group. The markedly elevated numbers of activated adherent leukocytes, the reduced capillary density, and the high lactate levels in those undergoing bypass in normothermic conditions indicate a more pronounced inflammatory stimulus and tissue hypoperfusion compared to the possible protective effect of hypothermia for children undergoing cardiopulmonary bypass.

Port Access surgery for congenital heart disease.

OBJECTIVES: Minimally invasive surgical techniques have been introduced into cardiac surgery in order to avoid median sternotomy related complications. Surgical trauma to the patient can be significantly reduced without compromising the safety. In addition, a small lateral chest incision results in improved cosmesis, especially in female patients. METHODS: Thirteen patients (median age 39 +/- 14 years, ranged from 17-61 years) with atrial septal defect were treated with a minimally invasive surgical method using a modified Port Access technique. In all patients access to the heart was achieved via a small (4-8 cm) right lateral chest incision in the 4th intercostal space. In these patients the selection of the Port Access system was used for cardiopulmonary bypass via the femoral vessel and for the application of cardioplegic solution. RESULTS: No deaths or intraoperative complications were observed in any of the patients. The postoperative course was uneventful and only minor complications were observed postoperatively. The median hospital stay was 8.0 +/- 1 days (median +/- SEM). CONCLUSION: This minimally invasive surgical technique for the treatment of atrial septal defects represent a safe alternative to conventional treatment of ASD using median sternotomy and standard cardiopulmonary bypass. The exposure of the right atrium via the 4th intercostal space is ideal and can be performed with excellent cosmetic results.

The Dresden approach for complete multivessel revascularization.

BACKGROUND: In a prospective clinical trial, a group of patients receiving less invasive surgical procedure, including minithoracotomy in combination with cardiopulmonary bypass (group 1), was compared to a group of patients receiving conventional bypass surgery (group 2) for the treatment of coronary artery disease. METHODS: Group 1 included 85 patients (71 men, 14 women, aged 39 to 82 years, median 61.1 +/- 9.0 years); group 2 included 53 patients (38 men, 15 women, aged 51 to 79 years, median 62.0 +/- 6.1 years). RESULTS: There were no perioperative deaths in the whole series of patients. Time of operation was 256 +/- 43 minutes in group 1 and 150.0 +/- 53.6 minutes in group 2. Hospitalization was 6.0 +/- 1.4 days and intensive care unit stay 1 day for both groups. Back pain assessment on postoperative day 3 showed less pain in group 1. Three-month follow-up revealed ischemia in stress electrocardiogram in 2 patients (2.5%) in group 1 and in 2 patients (4.1%) in group 2. Coronary angiograms confirmed the stress-electrocardiogram findings. CONCLUSIONS: Surgical results are equal for both techniques. Even though time of operation is longer in patients receiving less invasive procedures, intensive care unit stay and hospital stays are the same length. Early postoperative back pain is less in group 1 and combined with faster convalescence.

Oxygen tension in transplanted mouse osteosarcomas during fractionated high-LET- and low-LET radiotherapy--predictive aspects for choosing beam quality?

PURPOSE: The lower OER of high-LET radiations, compared to conventional (low-LET) radiations, has often been put forward as an argument for using high-LET radiotherapy in the management of hypoxic tumours. Among the different neutron beams used in therapy, the reactor fission neutrons have the lowest OER. The aim of the present study is to follow the variations of tumour oxygenation status during fractionated irradiation with different radiation qualities. Little information is available so far after fractionated high-LET irradiation. In addition, the RBE of reactor fission neutrons for effects on tumours and on normal tissues are compared. MATERIAL AND METHODS: Murine OTS 64-osteosarcomas were transplanted in 102 balb-C mice and irradiated by 36 Gy of photons in fractions of 3 Gy five times a week (group P-36/3) or by 12 Gy of reactor fission neutrons in fractions of 2 Gy two times a week (group N-12/2). Irradiations started at a tumor volume of 500 to 600 mm3. A third group received no radiotherapy, but all investigations (group CG). Tumor volume and tumor oxygenation were measured once a week under therapy and during three weeks after therapy. For in vivo-evaluation of oxygen status a computerized polarographic needle electrode system (KIMOC pO2 histograph, Eppendorf) was used. The median pO2 and the hypoxic fraction (pO2 values < 5 mm Hg) of single tumors and of total groups were calculated from pooled histograms and from row data as well. RESULTS: In correlation with the increase of tumor volume, from day 1 to day 42 of follow-up the median pO2 decreased from 20 mm to 8 mm Hg and the hypoxic fraction increased from 7% to 31%. After fractionated photon therapy a growth delay of three weeks was observed. Six weeks after beginning of the irradiation the median tumor volume had been doubled again. After fission neutron therapy growth delay continued until the end of the follow-up period. In both of the irradiated groups a significant decrease of median pO2 values and an increase of the hypoxic fraction were observed under radiotherapy. Hypoxia was more intensive after neutrons with a decrease of the median pO2 from 20 mm Hg to 1 mm Hg vs. 10 mm Hg after photon therapy and with an increase of the hypoxic fraction from 7% to 78% vs. 36% respectively. Two weeks after the end of therapy the median pO2 and the hypoxic fraction of both treated groups reached the levels prior to irradiation indicating a complete reoxygenation. CONCLUSION: During fractionated irradiation of murine osteosarcomas with photons and reactor fission neutrons, a marked hypoxia was observed for both radiation qualities, but hypoxia was more intense during fractionated neutron irradiation. After irradiation, a complete reoxygenation occurred in both groups independently of the degree of hypoxia observed during the treatment. The RBE of reactor fission neutrons, after fractionated irradiation, was much higher for effects on murine osteosarcomas compared to their RBE observed for normal tissues in previous experiments. Present data are in agreement with our clinical observations on more than 300 patients treated with reactor fission neutrons for advanced and hypoxic tumours with various histologies.

New minimally invasive surgical technique using arterial T-grafts for treatment of double-vessel coronary artery disease: experimental study.

Minimally invasive surgery has been used successfully in patients with single-vessel coronary artery disease (CAD), but there are no clinical reports of surgical techniques for the treatment of multivessel disease in this field using both internal mammary arteries (IMAs). Therefore a canine model has been established to demonstrate the feasibility of a minimally invasive surgical treatment of coronary artery double-vessel disease using both IMAs. Ten mongrel dogs underwent bilateral thoracoscopic preparation of both internal mammary arteries through small left lateral chest ports. Using the Port Access endovascular cardiopulmonary bypass system the right IMA (RIMA) was anastomosed as a free graft end-to-side to the left IMA (LIMA) as a T-graft. After induction of cardioplegic arrest the RIMA was anastomosed to the circumflex artery and the LIMA to the left anterior descending artery. All animals were weaned from cardiopulmonary bypass without inotropic support. The electrocardiogram showed sinus rhythm with no signs of ischemia. Intraoperative coronary angiography demonstrated patency of all anastomoses. The minimally invasive surgical treatment of double-vessel CAD using arterial T-grafts of both IMAs is thus feasible. Surgical trauma can be further reduced by harvesting the RIMA transmediastinally through the left lateral chest.

Clinical experience with minimally invasive coronary artery and mitral valve surgery with the advantage of cardiopulmonary bypass and cardioplegic arrest using the Port Access technique.

To minimize surgical trauma, the use of Port Access cardiac surgery was initiated in patients (pts) with coronary artery disease (CAD) (42 pts) or mitral valve disease (MVD) (24 pts) in March 1996 at our institution. Altogether 42 pts (36 men, 6 women; age 31-75 years, median 59.0 years) with isolated lesions of the left anterior descending (LAD) artery underwent Port Access coronary artery surgery (PACAS). A small (5-9 cm) incision was done parasternally on top on the fourth rib. The left internal mammary artery (LIMA) was dissected through the minithoracotomy or by using an additional thoracoscopic approach. A total of 24 pts (12 men, 12 women; age 30-75 years, median 62 years) underwent Port Access mitral valve surgery (PAMVS). In these pts the procedure was performed through a small right thoracotomy (6-8 cm). In all cases, endovascular cardiopulmonary bypass (CPB) was instituted through femoral cannulation, and an additional endoaortic balloon catheter was introduced into the ascending aorta for aortic occlusion. In pts with PACAS the survival was 98% (41/42) and in the PAMVS group 100%. All pts but one survived the PACAS and are well today. There were no deaths in the PAMVS group. The hospital stay was reduced by 1 day on average after PACAS and 3 days after PAMVS. Thus in well selected patients Port Access cardiac surgery represents a safe and feasible minimally invasive surgical approach that avoids the potential complications of a sternotomy while offering the advantages and safety of CPB and cardioplegic arrest. This minimally invasive approach offers a shortened hospital stay and earlier rehabilitation.

New telemetric system for daily pulmonary function surveillance of lung transplant recipients.

BACKGROUND: Following lung transplantation, prompt diagnosis and therapy of acute pulmonary rejection and infection episodes relies primarily upon changes in pulmonary function and determines long-term outcome. We tested a new system that allows daily monitoring of the patient's pulmonary status even after discharge from the hospital. METHODS: Seven lung transplant recipients from our center were equipped with a telemetric monitoring device consisting of a portable flowmeter and a special modem unit. The flowmeter measures forced vital capacity (FVC), forced expiratory volume per second (FEV1), and mid expiratory flows (MEFs), encodes information like fever, cough, and dyspnea in a binary code form, and stores all values in a 32 kB memory unit. After its use, the patient positions the flowmeter onto the modem unit which automatically connects to a central computer at our center to transfer all saved data. The whole set can be used via any regular phone jack. The patient's file in the computer can be checked every day. RESULTS: All patients learned to use the unit during their postoperative stay or during later follow-up, and were able to apply the system at home. In a mean follow-up period of 10.3+/-2.2 months, 15 episodes of significant deterioration in home pulmonary function tests (PFTs) (>10%) were registered in 6 patients, which were all confirmed by in-hospital body plethysmography. They resulted in diagnoses of 4 episodes of acute rejection, 6 cases of beginning bacterial pneumonia, and 5 cases of, most likely, viral tracheobronchitis. Only 1 patient had to be admitted to the hospital. All patients PFTs returned to previous values after treatment. CONCLUSIONS: Telemetric monitoring of graft function in lung transplant recipients allows reliable early diagnosis and treatment of infection or rejection, which might help to prevent exacerbation of the pathology and reduce quantity of amounting graft dysfunction.

Minimally invasive mitral valve surgery--clinical experiences with a PortAccess system.

OBJECTIVE: This is the initial experience with a new minimally invasive surgical technique for the treatment of mitral valve disease using a PortAccess system. METHODS: Between May 1996 and May 1997, 21 patients (nine male, 12 female, aged 30-75 years, median 64 years) underwent minimally invasive mitral valve surgery. The underlying diseases were: mitral valve insufficiency (n = 11), mitral valve stenosis (n = 5) and combined mitral valve disease (n = 5). Through a small right thoracotomy (6-8 cm) access to the pericardium and the heart was gained. Cardiopulmonary bypass was instituted through femoral cannulation and an intraaortic balloon-catheter (Heartport Inc., Redwood City, CA) was introduced for aortic occlusion, aortic root venting and delivery of cold crystalloid cardioplegia. Mitral valve repair (four patients) or replacement (15 patients) was performed. RESULTS: There was no death during the whole follow-up period. There was no perivalvular leak and only minor residual mitral valve regurgitation was observed on intraoperative or postoperative (3 months) transesophageal echocardiography. There was no postoperative study-related complication. Time of ventilation, intensive care unit and hospital-stay were comparable with the data of patients undergoing conventional mitral valve surgery. CONCLUSIONS: This technique of PortAccess mitral valve surgery combines the advantage of less invasive operative trauma with the safety of conventional mitral valve surgery.