[Soft-tissue reconstruction of the dorsum of the hand and finger to cover the extender tendons]. / Weichteilrekonstruktion am hand- und fingerrücken über dem streckapparat.

Small defects of extensor tendons can mostly be covered by local flaps. For larger defects the groin flaps, pedicled flaps from the forearm and free flaps are indicated. Between January 2001 and December 2005, we performed the following pedicled and free flaps to reconstruct the soft tissue defects of the hand or distal forearm: 23 pedicled flaps: 15 posterior interosseus artery or perforator flaps, 8 radial forearm flaps; 26 free flaps: 4 radial forearm flaps, 12 lateral upper arm flaps, 10 latissimus, serratus fascia or scapula flaps. With this study we want to illustrate the different procedures, compare their surgical techniques and outcomes and finally to rate the results. In the context of security, morbidity of the donor site and functional outcomes, our favourite flap is the lateral upper arm flap.

Cardiac rupture in embolic myocardial infarction after implantation of a valved aortic conduit.

We report a case of an apical myocardial infarction complicated by left ventricular wall rupture due to coronary artery embolism four years after surgery of an acute type A dissection of an aortic aneurysm with implantation of a valved aortic conduit.

Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound.

This case report describes the devastating consequences of spontaneous coronary dissection in a 36 year old female patient who otherwise had a normal coronary arteriogram. Intravascular ultrasound showed coronary artery dissection and intramural haematoma at the left main stem coronary artery. Acute coronary syndrome developed and subsequently surgical revascularisation was performed successfully.

Increased serum concentrations of soluble CD95/Fas and caspase 1/ICE in patients with acute angina.

OBJECTIVES: To investigate the expression of death inducing receptors in the sera of patients with stable and unstable angina. DESIGN: 80 consecutive patients with stable (n = 40) or unstable (n = 40) angina pectoris were studied. Serum concentrations of soluble CD95 (sCD95), soluble CD95 ligand (sCD95L; CD178), tumour necrosis factor (TNF) alpha, soluble TNFalpha receptor type 1 (sTNFR1), and interleukin 1beta converting enzyme (ICE; caspase 1) were measured by enzyme linked immunosorbent assay (ELISA). RESULTS: Significant increases in the concentrations of sCD95 and ICE (p < 0.001 and p < 0.023, respectively) were found in the serum from patients with unstable angina relative to those with stable angina. There were no significant differences in the concentrations of sCD95L, TNF alpha, and sTNFR1 between the groups. CONCLUSIONS: These data provide the first evidence that sCD95 and ICE are important serological markers that may help to discriminate between stable and unstable angina. This observation may warrant further clinical study to elucidate the clinical impact of sCD95 and ICE in acute coronary syndromes.

[Coronary artery bypass graft dysfunction--clinical presentation, laboratory and electrocardiographic parameters]. / Aortokoronare Bypassdysfunktion--Wertigkeit klinischer, laborchemischer und elektrokardiographischer Parameter.

The recurrence of symptoms after coronary artery bypass surgery is often caused by bypass-dysfunction. In this study we tried to determine factors related to the long-term patency of arterial and venous bypass grafts. We evaluated all patients with bypass grafts undergoing coronary angiography in the year 1998 at our hospital (163 patients, mean age 67 years, mean interval since the operation 79 months, a total of 341 venous bypasses (VBP), 386 peripheral venous anastomoses and 85 arterial (LIMA = left internal mammarial artery) bypasses. The data were collected by a retrospective analysis of the hospital records. Statistics were performed using the Wilcoxon-Mann-Whitney-U test. After an interval of 53 months LIMA-bypasses were patent without stenosis in 92%. Symptoms were caused in only 2% by a dysfunction of the LIMA-graft. The patency of venous bypass grafts decreased with time (5 years after the operation 74% were patent without stenosis, 5-10 years 56%, more than 10 years 35%, p < 0.01). We found clear relations between the function of the venous grafts and the clinical presentation (patent grafts without stenosis in 43% with acute coronary syndromes, in 57% with stable angina [p = 0.08] and in 86% with atypical angina [p < 0.0001 for the difference between each of the first two and the last syndrome]), the resting-ECG (65% patent VBP without stenosis with normal ST-segments and 49% with abnormal ST-segments, p < 0.01), the body-mass-index (70% patent VBP without stenosis with a BMI < 25 and 56% with a BMI > 30, p = 0.05) and the erythrocyte sedimentation rate after 2 hours (79% patent VBP with an ESR < or = 20 mm vs. 64% with an ESR > 49 mm, p = 0.02). The function of VBP after coronary artery bypass graft (CABG)-procedure depends primarily upon the interval since the operation. In addition, we found correlations with clinical presentation, resting-ECG, body-mass-index and erythrocyte-sedimentation rate as a possible marker of inflammation in bypass-atherosclerosis. Therefore, inflammatory processes seem to play an important role in the development of venous graft dysfunction.

[Fracture and embolization of a central venous port catheter without prior compression between the clavicle and the 1st rib]. / Bruch und Embolisation eines zentralvenösen Portkatheters ohne vorherige Kompression zwischen Klavikula und erster Rippe.

A central venous port catheter inserted infraclavicularily via the subclavian route may be compressed by the clavicle and the adjacent first rib. It's appearance on chest x-ray has been previously described as the 'pinch-off phenomenon' and requires the removal of the catheter due to a significant risk of fracture. We report the case of a catheter fracture without prior evidence of pinch-off. The free catheter fragment was embolized into the right atrium and caused pericardial effusion. Percutaneous removal of the fragment was attempted but failed and thus open heart surgery with a cardiopulmonary bypass was required. The myocardial lesion caused by the catheter was sutured.

Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology.

BACKGROUND: Severe mitral regurgitation associated with complex mitral valve disease often precludes successful surgical repair. The feasibility and the results of valvuloplasty with glutaraldehyde-treated autologous pericardium remain largely unknown. METHODS: The cases of 63 patients who underwent operation within an 11-year period were studied. A pretreated autologous pericardial patch was used for leaflet extension plasty, for paracommissural plasty, as a substitute for part of the leaflet, and for reimplantation of ruptured papillary muscles to eliminate severe mitral regurgitation. Patients with a severely calcified annulus after en bloc decalcification had straddling endoventricular pericardial patch annuloplasty for reconstruction of the affected atrioventricular groove. Chordal replacement with a strip of pericardium was chosen if no suitable chordae were available. Pericardium-reinforced suture annuloplasty was used in patients with acute endocarditis resistant to medical therapy. Associated valvuloplasty procedures with Carpentier techniques were also employed. RESULTS: There were no operative deaths in this series. At a mean follow-up of 61.1 months (range, 4 to 132 months), mitral regurgitation was absent or trivial in 92.1% of patients by echocardiography. Freedom from reoperation was 95.2% at 1 year and 5 years. Thromboembolic events have not been detected. Thirty percent of patients returned to sinus rhythm. Two patients required valve replacement. CONCLUSIONS: Our beneficial results indicate that glutaraldehyde-treated autologous pericardium is suitable for valvuloplasty. It provides durable and predictable repair of valves that might otherwise need to be replaced because of the complex mitral valve disease. The technique is reliable, allows further efficacious repair possibilities, and improves postoperative outcomes. Whether it can prevent late deterioration and calcification requires more investigation.

Early investigation of silver-coated Silzone heart valves prosthesis in 126 patients.

BACKGROUND AND AIM OF THE STUDY: Permanent silver (Silzone) coating of the sewing cuff of St. Jude Medical prosthetic heart valves may reduce the rate of prosthetic valve endocarditis (PVE). However, the incidence of paravalvular leaks and stroke in patients after implantation of Silzone-coated heart valve prostheses is largely unknown. METHODS: Complications were analyzed among 126 consecutive patients (78 males, 48 females; mean age 64.7 years; range: 40-80 years) who received Silzone-coated prostheses at our institution between February 1998 and December 1999. Among patients, 94 had aortic valve replacement, 29 mitral valve replacement, and three had aortic and mitral valve replacement. Concomitant cardiac procedures (mainly coronary bypass) were performed in 47 patients (37.3%). RESULTS: Hospital mortality was 1.6% (2/126) and freedom from valve-related mortality 99.2+/-0.9%. Total follow up was 137.4 patient-years, and 98.4% complete. Strokes or transitory ischemic attacks (TIAs) occurred in four cases (two strokes, two TIAs; stroke rate 1.5%/year; 95% CI 0.4-2.6%/year; stroke+TIA rate 3%/year; 95% CI 0.4-5.25%/year). There was no case of prosthetic valve dysfunction or PVE. Freedom from reoperation due to procedure-associated complications was 97.6% (one aortic dissection, two major bleeds). Paravalvular leak was detected in 19 cases, and graded trivial or mild in 17 cases (11 grade 0-I, six grade I), and moderate in two cases (grade I-II in one, grade II in one). No patient needed reoperation due to paravalvular leak. Left ventricular (LV) function was normal in 80 cases, but was impaired mildly in 20 cases, moderately in 16, and severely in eight. Bicycle exercise testing in 92 patients (73%) showed median exercise performance (81.4+/-23.9% of normal) after correction for age and weight. Cerebral magnetic resonance imaging was performed in 64 patients (50.8%); median MRI score was 2.0+/-1.8 according to a 12-scaled score system. CONCLUSION: The overall incidence of echocardiographic paravalvular leak graded more than trivial or mild was low (1.6%) in patients followed for a mean of 1.1+/-0.5 years (range: 1-27 months) after valve replacement with Silzone-coated heart valve prostheses. No patient required reoperation due to paravalvular leak; moreover, the stroke rate (1.5%/year) was low in these patients. The present data indicated no significant disadvantages or higher rate of complications related to silver coating compared with other, non-silver-coated prostheses. Future investigation is needed to determine long-term outcome.

Valve repair in mitral regurgitation complicated by severe annulus calcification.

BACKGROUND: Valvuloplasty has significant advantages over valve replacement for mitral regurgitation, but the presence of severe calcification of the mitral valve apparatus has been thought to preclude successful valve reconstruction in general. The purpose of this report is to assess the results of valvuloplasty in patients with severe mitral regurgitation having extensive calcification extending from the mitral annulus to underlying myocardium and parts of the papillary muscles. METHODS: Thirty-seven adult patients with severe mitral regurgitation and calcification were operated on between April 1990 and January 1998. Twenty-six patients had degenerative disease, 4 had acute bacterial endocarditis, 6 had postrheumatic fever, and 1 patient had Marfan's disease. The valve repair comprised of en bloc decalcification with extensive leaflet debridement and reconstruction of the annulus. Autologous pericardium was used in patch-extended endocardial annuloplasty or leaflet repair. Valve competence was retained after correction of regurgitation by sliding atrioplasty, rotation paracommissural sliding plasty, cusp remodeling, or chordal repair. All patients required a prosthetic annuloplasty. RESULTS: Follow-up echocardiography at 47 months (range, 3 to 92 months) showed no or only trivial mitral regurgitation in 33 patients; 3 had grade I-II mitral regurgitation and 1 required valve replacement after 3 months. Freedom of reoperation at 1 and 5 years was 94.6%. At last examination, 33 patients were in New York Heart Association functional class I and 3 in class I-II; there has been no mortality and no thromboembolic events. CONCLUSIONS: Valvuloplasty can be safely and successfully carried out in patients suffering from regurgitation associated with severe calcification of the mitral apparatus. With encouraging beneficial midterm results, we suggest patients with calcified valves should not be excluded from mitral repair.

Cardiac tamponade following acupuncture.

We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects.

[Dosimetry of a blood irradiator]. / Dosimetrie eines Blutbestrahlungsgerätes.

BACKGROUND: Blood and blood products are irradiated to avoid the graft-versus-host disease (GVHD) in immunosuppressed patients and to destroy tumor cells during the intra-operative autotransfusion in tumor surgery. For that purpose more and more dedicated gamma irradiators are used. In most cases the equipment is supplied with a dose calibration factor for a totally filled irradiation canister. As users handle different blood product volumes, it is necessary to investigate the influence of the irradiated blood volume on the absolute dose in a reference point and the dose distribution in the irradiation volume. MATERIAL AND METHODS: The dose rate in the center of an empty irradiation canister of an IBL 437C blood irradiator (CIS Diagnostic) was investigated by means of Fricke solution dosimeters from the Physikalisch-Technische Bundesanstalt (PTB). Using thermoluminescence dosimetry (TLD) this value could be transferred to a situation with an empty or completely filled respectively with 2 blood samples (270 ml each) filled canister. Also essential for the irradiation of blood is the knowledge of the dose distribution in the irradiated volume. The distributions in the empty and the realistic filled canister were measured by positioning the TLD on the plexiglas holder in a regular pattern. The case of a completely filled container was investigated by means of the MR Fricke gel dosimetry. All distributions are presented as dose-volume-histograms (DVH). RESULTS: The TLD-measurement in the center of the completely filled canister yielded a 4.8% higher dose rate value as compared to the suppliers certificate. From the investigations using the Fricke solution dosimeters in air combined with TLD-measurements values for the complete bandwidth of different container fillings could be derived. So the dose rate in the centre of the canister in the boundary conditions empty and full canister as compared to the values for the realistic filling condition (2 bags) are 117.5% and 94% respectively. Axial dose distributions and DVH have been determined for the 3 filling conditions. CONCLUSIONS: We recommend a dose calibration measurement of a blood irradiator to determine the irradiation times for the chosen filling condition, which is typical for the hospital. The DVH presented in this work can be used to derive a value for the dose variance within the irradiated blood.

[Lambl's excrescence as tumorous heart valve mass]. / Die Lambl'sche Exkreszenz als tumoröse Herzklappenveränderung.

HISTORY AND CLINICAL FINDINGS: A 44 year old woman consulted a general physician because of weakness and fatigue. 5 months ago otitis media and a urinary tract infection had been treated successfully with antibiotics. The physical examination was unremarkable except for healed scars after an orthopedic operation about 35 years ago and a resection of a benign tumor of the left breast about 14 years ago. INVESTIGATIONS: Except for a slightly elevated antistreptolysin titer the laboratory tests were normal. The ECG showed sinus rhythm, left axis deviation and normal ST-segments. In the transthoracic echocardiogram an echogenic mass adherent on the ventricular side of the noncoronary cusp of the aortic valve in size of 2 x 1.5 cm could be demonstrated. The mass moved with the normally functioning valve and prolapsed into the aorta ascendens. The Doppler-echocardiogram was normal. TREATMENT AND COURSE: Because of the size of this echogenic mass with unknown origin and the risk of an embolic event its removal was indicated. This was done without destroying the aortic valve. Postoperative echocardiography demonstrated normal valve function. The histologic examination showed an endothelialized mass, rich in fibers and with only a few fibroblasts and histiocytes, without smooth muscle cells, according to a Lambl's excrescence. CONCLUSION: Cardiac valve tumors are rare. The differentiation between surface excrescences on the cardiac valve and neoplasia is only possible by histologic examination. Because of its possible malignancy and the potential risk of emboli surgical treatment is indicated.

[Conservative surgery in breast carcinoma]. / Záchovné operace u karcinomu prsu.

OBJECTIVE: The authors evaluate recent trends in the treatment of breast cancer, i.e. trends manifested in this country more markedly since the beginning of the nineties. METHOD: In 1993 the authors were able to perform local surgery of breast cancer in 36% of the operated patients, in 1994 in 38% and in 1995 in as many as 48%. During this period they operated 39 patients stereotactically for an non-palpable breast lesion. The ratio of non-palpable lesions which proved to be carcinomas was 5% in 1994 and 9% in 1995. The increasing number of local operations is due to earlier diagnosis and the fact that at the beginning of the nineties investigations were published which provided evidence that in selected indications local surgery along with further oncological treatment have after a five- to ten-year interval comparable results as patients after radical operations. CONCLUSION: In not advanced breast tumours in the 1st and 2nd clinical stage, i.e. tumours not larger than 2 to 4 cm, local extirpation of the tumour along with axillary lymphadenectomy and irradiation or possibly other oncological treatment achieves comparable patient survival as mastectomy.

Clinical presentation of rupture of the left-ventricular free wall after myocardial infarction: report of five cases with successful surgical repair.

Rupture of the left-ventricular free wall may not always result in immediate irreversible hemodynamic collapse. We report a series of five patients (4 male, 1 female; age 59-79 years) successfully operated for postinfarction free-wall rupture with good long-term results. Two patients presented with syncopy and acute tamponade three days after an acute myocardial infarction. In two patients with atypical chest pain and congestive heart failure, a large pericardial effusion and an extreme localized thinning of a myocardial scar region was seen several weeks after an uncomplicated myocardial infarct. In one patient a pseudoaneurysm was detected, which developed asymptomatically within three weeks after a posterior myocardial infarct. In all cases myocardial rupture was suspected after an echocardiographic examination. At surgery a hemopericardium and a localized rupture site were found. The surgical procedure included closure of the defect by direct suture or patch, CABG in 3 cases, and mitral valve replacement in one patient. The postoperative course was uneventful, only one patient needed IABP for 24 hours. Three patients returned to NYHA functional class I, one patient to class II, and one patient to class III. The latter patient died of heart failure 17 months postoperatively, and the other patients are still alive 4,18,24, and 26 months postoperatively. Thus clinical representation of left-ventricular free-wall rupture after myocardial infarction can be highly variable. But close cooperation between experienced echocardiographers and surgeons may allow successful corrections with good long term-results.

Modulation of L-selectin ligand expression during an immune response accompanying tumorigenesis in transgenic mice.

Immune surveillance depends on lymphocyte access to tissue. Lymphocytes emigrate from blood when adhesion receptors such as L-selectin and the alpha 4 beta 7 integrin on these cells bind to ligands expressed on venular endothelium. Among transgenic mouse lines expressing an oncoprotein (Tag) in islet beta cells, some recognize Tag as nonself. In these mice, Tag expression elicits both beta cell hyperplasia with subsequent progression to tumors and lymphocytic infiltration. Endothelial ligands for L-selectin and alpha 4 beta 7 were upregulated in infiltrated islets in these transgenic mice. These ligands were not expressed in tumors, which were devoid of lymphocytic infiltration. In contrast, the adhesion molecules PECAM-1, ICAM-1, and VCAM-1 were expressed on endothelium in both noninfiltrated tumors and infiltrated islets. Thus, upregulation of expression of endothelial ligands for L-selectin and alpha 4 beta 7 may contribute to autoimmune infiltration. Repression of expression of these same ligands may be involved in the failure of tumor immunity.

[Ostium stenosis of the left coronary artery after aortic valve replacement--2 case reports]. / Ostiumstenose der linken Koronararterie nach Aortenklappenersatz--2 Fallberichte.

The development of left main coronary artery stenosis is a rare complication arising after aortic valve replacement. We report the different clinical course of two cases. One patient developed typical exertional angina 3 months after uneventful aortica valve replacement. Coronary stenosis had been excluded on preoperative coronary angiography. One day before hospital admission for coronary angiography the patient died suddenly. The second patient reported symptoms typical of angina 6 months after aortic valve replacement. Coronary angiography revealed critical left coronary ostial stenosis, which was successfully treated by surgical revascularization. These cases demonstrate the rare, yet potentially fatal complication of left coronary ostial stenosis. Early coronary angiography seems warranted in the event of typical exertional angina, even after angiographic exclusion of relevant coronary artery stenosis before aortic valve replacement.

Videoendoscopic procedures in thoracic surgery: technical aspects and report of removal of a mediastinal cyst.

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracic surgery is the basis of this report. Video-assisted thoracic surgery was performed in 36 patients for the following indications: Raynaud's syndrome, undefined pulmonary nodule, persisting spontaneous pneumothorax, T1 bronchial carcinoma, and mediastinal cyst. Videoendoscopic surgical procedures were accomplished using double-lumen endotracheal anaesthesia and a percutaneous stapling device. Procedures performed using this technique include thoracic sympathectomy, wedge or keel excision, blebectomy, lung apex stapling, parietal pleurectomy, and dissection of the mediastinal cyst. Median operating time was 45 min (range, 15 to 90 min). Tissue diagnosis was obtained in all patients. Median diameter of excised nodules was 10 mm (range, 7 to 70 mm). There were no operative deaths. The single complication was a prolonged air leak. This new method of thoracic surgery appears to benefit the patients. For us it proved a secure way to perform thoracic surgery. Our case of removal of a benign cyst in the posterior mediastinum shows that video-assisted thoracic surgery has expanding applications in the field of general thoracic surgery.

Expression of synthetic cDNA sequences encoding human insulin-like growth factor-1 (IGF-1) in the mammary gland of transgenic rabbits.

We have developed an expression system where foreign proteins are synthesized specifically in the mammary gland of transgenic rabbits and secreted into the milk. Regulatory elements were isolated from the bovine alpha S1-casein-encoding gene and combined with a synthetic DNA coding for human IGF-1 and for [Gln58]IGF-1, an IGF-1 analogue. The resulting hybrid DNA constructs were used to generate transgenic rabbits. Females of seven transgenic lines tested were positive for synthesis of IGF-1. Transmission of the transgene to progeny and IGF-1 production in female offspring was observed in all transgenic lines analysed. As expected, expression of transgene mRNA could only be detected in the mammary gland. Production levels of transgenic protein were as high as 1 g IGF-1 per liter rabbit milk. IGF-1, as well as [Gln58]IGF-1, when secreted into rabbit milk, was correctly processed and biologically active. IGF-1 was purified from the milk of transgenic rabbits to a nearly homogenous active form.