Comparison of Two High-End Ultrasound Systems for Contrast-Enhanced Ultrasound Quantification of Mural Microvascularity in Crohn's Disease.

PURPOSE: To verify the reproducibility of contrast-enhanced ultrasound (CEUS) quantification results of two different high-end ultrasound systems and to evaluate the clinical utility of the method in patients with Crohn's disease (CD). MATERIALS AND METHODS: 18 patients with histologically confirmed CD (36.8 % women, 63.2 % men; mean age 43.7 ±â€Š14.1 years) and wall segments thicker than 5 mm were recruited. CEUS quantification and conventional ultrasound investigation were performed under standardized settings using Toshiba Aplio500 and Siemens Acuson S3000 high-end ultrasound systems. CEUS was performed at a low mechanical index of 0.1 after bolus application of 4.8 ml of SonoVue(®) contrast medium. The recorded DICOM clips were quantified using VueBox(®) (version 4.3) calculating 11 quantitative parameters. Subsequently, CEUS quantification and conventional ultrasound results were analyzed. RESULTS: Correlation of quantitative parameters between the Aplio500 and AcusonS3000 systems for peak enhancement (PE), rise time (RT), wash-in-rate (WiR) and quality of fit (QOF) yielded significance levels of p < 0.05 and p < 0.0001 for wash-in-wash-out area under the curve (WiWoAUC). Spearman rank test showed moderate levels of correlation for PE, RT, WiR and QOF (r = 0.5, 0.49, 0.49 and 0.5 respectively), and high correlation for WiWoAUC (r = 0.89) between the two ultrasound systems. CONCLUSION: Due to multiple uncontrollable affecting factors, the method of CEUS quantification by VueBox in the intestine cannot be recommended for device-independent multicenter studies. Therefore we suggest to use identical ultrasound systems and probes as well as to establish adequate reference ROIS, like a AIF-ROI.

[Pulmonary Metastases of Colorectal Carcinoma]. / Pulmonale Metastasenchirurgie des kolorektalen Karzinoms.

Treatment strategies for patients with pulmonary metastases of colorectal carcinoma are continuously evolving. This applies mostly to new systemic therapeutic approaches. For carefully selected patients surgical removal of pulmonary metastases remains an important interdisciplinary therapeutic option and is recommended as first treatment option by the guidelines. Five-year survival rates of up to 60 % are reported following pulmonary metastasectomy. Parenchyma sparing resection has been well established in this setting with low morbidity and mortality. Prognostic factors are, among others, complete resection, thoracic lymph node involvement, the number of metastases and the disease free interval. Although data result mostly from retrospective studies, these factors currently help in patient selection.

Influence of plasma cortisol and other laboratory parameters on nonalcoholic Fatty liver disease.

The objective of the present study was to analyse the association between the plasma cortisol concentration and nonalcoholic fatty liver disease (NAFLD). A total of 1 326 subjects (age 18-65 years) were examined in the context of an epidemiological study of a population-based random sample. Medical history and anthropometric data of 662 women and 664 men were documented. In addition, laboratory examinations were performed and the fat concentration of the liver was estimated by ultrasound examination. Mean cortisol concentration in plasma was 260.4±156.8 nmol/l for women and 295.8±161.2 nmol/l for men. NAFLD was identified in 17.7% in women and 35.1% in men. Plasma cortisol concentration showed no association with the existence of NAFLD. NAFLD correlated positive with age, body-mass index (BMI), waist-to-hip-ratio (WHR), alanine aminotransferase (ALT), and triglycerides. The present study failed to establish any association of plasma cortisol concentrations and NAFLD.

[Infiltration of the superior vena cava in NSCLC: results of surgical intervention]. / Ergebnisse des chirurgischen Vorgehens bei NSCLC und Infiltration der Vena cava superior.

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed.

Associations of fatty liver disease and other factors affecting serum SHBG concentrations: a population based study on 1657 subjects.

Sex hormone binding globulin (SHBG) is a glycoprotein expressed predominantly in the hepatocytes. It regulates the transport of sex steroid hormones in the blood stream to their target tissues. The expression of the SHBG gene is subject to multifactorial regulation including hormonal, metabolic, and nutritional aspects. Against this background, we investigated the effect of fatty liver and metabolic syndrome, together with other parameters, on serum SHBG concentrations in a population-based cohort in Germany. This cross-sectional study included 870 women and 787 men (average age 42.3±12.8 years), who underwent ultrasound screening for fatty liver in addition to providing a complete medical history and undergoing physical and laboratory examination. Fatty liver was diagnosed on ultrasound criteria in 159 women (18.3%) and 287 men (36.5%). Fatty liver was shown to exert a significant influence on serum SHBG concentrations in men and in premenopausal women. Men with grade 1 fatty liver had a 1.96-fold increased risk (95%-confidence interval=1.28-3.02; p=0.0022) and postmenopausal women with grade 1 fatty liver a 2.4-fold risk (95%-confidence interval=1.11-5.27; p=0.0267) for low SHBG concentrations. Among metabolic parameters, HDL-C represented as affecting factor in men (p=0.0058) and premenopausal women (p=0.0002), while cholesterol only showed an association in premenopausal women (p=0.0439) and triglyceride in postmenopausal women (p=0.0436). No association of concentrations of SHBG and metabolic syndrome was observed. Age, BMI and waist-to-hip ratio also influence the SHBG concentration. Based on these findings, we conclude that fat accumulation in the liver influences SHBG concentrations in men and premenopausal women.

Randomized phase 2 trial on refinement of early-stage NSCLC adjuvant chemotherapy with cisplatin and pemetrexed versus cisplatin and vinorelbine: the TREAT study.

BACKGROUND: Adjuvant chemotherapy is beneficial in non-small-cell lung cancer (NSCLC). However, balancing toxicity and efficacy mandates improvement. PATIENTS AND METHODS: Patients with completely resected stages IB-pT3N1 NSCLC were randomly assigned to either four cycles cisplatin (C: 50 mg/m(2) day (d)1 + 8) and vinorelbine (V: 25 mg/m(2) d1, 8, 15, 22) q4 weeks or four cycles cisplatin (75 mg/m(2) d1) and pemetrexed (Px: 500 mg/m(2) d1) q3 weeks. Primary objective was the clinical feasibility rate (no grade (G)4 neutropenia/thrombocytopenia or thrombocytopenia with bleeding, no G3/4 febrile neutropenia or non-hematological toxicity; no premature withdrawal/death). Secondary objectives were drug delivery and efficacy. RESULTS: One hundred and thirty two patients were randomized (stages: 38% IB, 10% IIA, 47% IIB, 5% pT3pN1; histology: 43% squamous, 57% non-squamous). The feasibility rates were 95.5% (cisplatin and pemetrexed, CPx) and 75.4% (cisplatin and vinorelbine, CVb) (P = 0.001); hematological G3/4 toxic effects were 10% (CPx) and 74% (CVb) (P < 0.001), non-hematological toxic effects were comparable (33% and 31%, P = 0.798). Delivery of total mean doses was 90% of planned with CPx, but 66% (cisplatin) and 64% (vinorelbine) with CVb (P < 0.0001). The median number of cycles [treatment time (weeks)] was 4 for CPx (11.2) and 3 for CVb (9.9). Time to withdrawal from therapy differed significantly between arms favoring CPx (P < 0.001). CONCLUSION: Adjuvant chemotherapy with CPx is safe and feasible with less toxicity and superior dose delivery compared with CVb.

Thyroid dysfunction and hepatic steatosis in overweight children and adolescents.

BACKGROUND: Overt or subclinical hypothyroidism is a common finding in adult populations affected by non-alcoholic fatty liver disease (NAFLD). Currently, there are only sparse data available on the association of thyroid dysfunction and NAFLD in obese children and adolescents. OBJECTIVE: The study aims to investigate the association of thyroid function test values with NAFLD and metabolic risk factors in a population of obese children and adolescents. METHODS: A total of 332 overweight and obese children and adolescents (170 girls) aged between 10 and 19 years were analysed. Subjects underwent ultrasound examination of the liver. Thyroid function was evaluated by laboratory determination of thyroid-stimulating hormone (TSH), total triiodothyronine (T3) and total thyroxine levels. All included subjects were either euthyroid or had subclinical hypothyroidism (TSH > 4 µU mL-1 , normal thyroxine). Further metabolic profiling included the determination of lipid status, insulin and liver function tests. Anthropometric parameters body mass index, waist and hip circumference were documented. RESULTS: The prevalence of hepatic steatosis was 29.8%. Subjects with NAFLD had significantly higher TSH levels than those without (p = 0.0007). After dividing TSH values into quartiles, both univariate and multivariate analyses (adjusted for age, body mass index-standard deviation scores and stage of puberty) showed a significant association with hepatic steatosis (p < 0.05). CONCLUSION: Taking possible variables into consideration, our results show that there is a significant association between hepatic steatosis and the TSH levels in obese children and adolescents. Mild thyroid dysfunction may therefore have a role in determining an unfavourable metabolic profile in obese children and adolescents.

[Cystic lesion of the dorsal mediastinum]. / Zystische Raumforderung im hinteren Mediastinum.

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

Complications in CT-Guided, Semi-Automatic Coaxial Core Biopsy of Potentially Malignant Pulmonary Lesions.

PURPOSE: Histological verification of pulmonary lesions is important to ensure correct treatment. Computed tomographic (CT) transthoracic core biopsy is a well-established procedure for this. Comparison of available studies is difficult though, as technical and patient characteristics vary. Using a standardized biopsy technique, we evaluated our results for CT-guided coaxial core biopsy in a semi-automatic technique. MATERIALS AND METHODS: Within 2 years, 664 consecutive transpulmonary biopsies were analyzed retrospectively. All interventions were performed using a 17/18G semi-automatic core biopsy system (4 to 8 specimens). The incidence of complications and technical and patient-dependent risk factors were evaluated. RESULTS: Comparing the histology with the final diagnosis, the sensitivity was 96.3%, and the specificity was 100%. 24 procedures were not diagnostic. In all others immunohistological staining was possible. The main complication was pneumothorax (PT, 21.7%), with chest tube insertion in 6% of the procedures (n = 40). Bleeding without therapeutic consequences was seen in 43 patients. There was no patient mortality. The rate of PT with chest tube insertion was 9.6% in emphysema patients and 2.8% without emphysema (p = 0.001). Smokers with emphysema had a 5 times higher risk of developing PT (p = 0.001). Correlation of tumor size or biopsy angle and the risk of PT was not significant. The risk of developing a PT was associated with an increasing intrapulmonary depth of the lesion (p = 0.001). CONCLUSION: CT-guided, semiautomatic coaxial core biopsy of the lung is a safe diagnostic procedure. The rate of major complications is low, and the sensitivity and specificity of the procedure are high. Smokers with emphysema are at a significantly higher risk of developing pneumothorax and should be monitored accordingly. KEY POINTS: Using an 18G core biopsy system with 6 specimens will allow immunohistological staining with high sensitivity and specificity. Smokers with emphysema are at a significantly higher risk of developing a pneumothorax.

Determination of vitality of liver lesions by alveolar echinococcosis. Comparison of parametric contrast enhanced ultrasound (SonoVue®) with quantified 18F-FDG-PET-CT.

UNLABELLED: Objective of our study is qualitative and quantitative comparison of contrast enhanced ultrasound (CEUS) and 18F-FDG PET-CT in monitoring hepatic alveolar echinococcosis (HAE). Parasitic liver lesions were examined regarding number, size, morphology, vascularization and metabolic activity. PATIENTS, METHODS: 36 patients with medically-treated HAE were included in this prospective clinical study. Abdominal ultrasound and CEUS were carried out using ultrasound contrast amplifier SonoVue®. As part of monitoring, patients were examined by 18F-FDG-PET-CT. Quantitative analysis of CEUS was performed using the Software VueBox™ Quantification Toolbox. Maximum contrast enhancement in lesions peak enhancement (PE) was used as parameter. For quantification of 18F-FDG PET-CT, maximum Standardized Uptake Value (SUVmax) of lesions was specified and statistically compared with PE. RESULTS: 18F-FDG uptake in parasitic liver lesions was diagnosed by 18F-FDG PET-CT in 32 of 36 patients. Vascularization of liver lesions was detected by CEUS in 22 of 32 FDG-positive patients with sensitivity of 69% and specificity of 100%. Mean maximum diameter of lesions was 69.5mm in CEUS and 63.7mm in B-scan ultrasound (p < 0.0001). No significant correlation was found between SUVmax and PE (p = 0.8879). CONCLUSION: In comparison to FDG PET-CT, the gold standard for detecting viable lesions by depicting metabolism, CEUS detects viable lesions with high specificity and moderate sensitivity by showing vascularization. CEUS must be regarded as an important tool in monitoring HAE. Dimensions of parasitic lesions are displayed more precisely through CEUS than in B-scan. With currently available methods, CEUS quantification has no benefit in monitoring HAE lesions in daily clinical practice.

Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation.

OBJECTIVE: Aortic valve regurgitation in combination with dilatation of the ascending aorta and root requires a combined procedure to restore valve function and eliminate pathologic dilatation of the proximal aorta. Two techniques have been proposed for this purpose; the aortic root may be either remodeled with an especially configured vascular graft or replaced with reimplantation of the aortic valve within the graft. We have used both techniques depending on the individual pathologic condition of the aortic root. METHODS: Of 107 patients undergoing operation for proximal aortic disease between October 1995 and November 1997, 40 patients had morphologically intact aortic valve leaflets in conjunction with dilatation of the aortic root. Of these, 15 patients underwent an operation as a surgical emergency for acute aortic dissection type A. In 29 instances, root remodeling in conjunction with ascending aortic replacement was performed; 11 patients underwent radical replacement of the proximal aorta with reimplantation of the aortic valve. Partial or total arch replacement was performed additionally in 27 of these patients. Other concomitant procedures were coronary artery bypass grafts (n = 11) and mitral reconstruction (n = 1). RESULTS: Two patients died after repair of acute aortic dissection, for a total operative mortality rate of 5%. No patient died after elective surgery. Aortic valve function could be effectively restored with both techniques. No patient underwent reoperation on the proximal aorta; freedom from aortic regurgitation of grade II or more at 1 year is 88% with both techniques. CONCLUSIONS: Depending on individual root pathologic condition, both the remodeling and the reimplantation techniques appeared to have their individual merits. Both result in adequate restoration of aortic valve function and elimination of pathologic aortic dilatation.

Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results?

OBJECTIVE: Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS: Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS: Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION: Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.

Comparison of aortic valve gradient during exercise after aortic valve reconstruction.

PURPOSE: Aortic valve preservation is a promising alternative to conventional composite replacement of aortic valve and ascending aorta. This approach may have a physiologic benefit compared with valve replacement similar to that seen in mitral valve reconstruction. We investigated aortic valve gradients at rest and during exercise in patients who had undergone valve-preserving aortic replacement and compared them with composite replacement of valve and aorta. METHODS: Four groups were studied: nine patients underwent composite valve replacement (group A: valve diameter, 23 to 27 mm), eight patients underwent remodeling of the aortic root (group B), and another nine patients had reimplantation of the aortic valve (group C). Healthy volunteers were studied as a control group (group D). Using continuous-wave Doppler echocardiography, all patients were examined on a bicycle ergometer for aortic valve gradients (0 to 75 W). RESULTS: There were no differences among the groups with respect to age, body surface, left ventricular end-diastolic diameter, fractional shortening, or left ventricular mass. Maximum resting gradients were significantly elevated in group A compared with groups B, C, and D (group A: 21.3 +/- 7.1 mm Hg; group B: 9.0 +/- 4.5 mm Hg; group C: 8.6 +/- 3.7 mm Hg; group D: 4.9 +/- 1.6 mm Hg; p < 0.05). At 75 W, group A exhibited significantly higher gradients than all other groups (group A: 31.3 +/- 7.5 mm Hg; group B: 13.9 +/- 6.6 mm Hg; group C: 12.8 +/- 3.5 mm Hg; group D: 9. 2 +/- 1.9 mm Hg; p < 0.05). There was no significant difference among the other groups. Both valve-preserving groups had only insignificantly higher gradients than the control group. CONCLUSION: Our data strongly support the suggestion that preserving the aortic valve restores nearly normal hemodynamic function of the aortic valve. Long-term observations will have to prove the clinical relevance of restoring physiologic aortic valve hemodynamics.

Lung transplantation in Kartagener's syndrome.

Kartagener's syndrome is associated with bronchiectasis and situs inversus and may offer an indication for lung transplantation. One case of heart and lung transplantation has been published that stresses the necessity for a modified surgical procedure creating a large single atrium to manage the situs inversus. We performed a double lung transplantation in a 46-year-old patient with this disease. No technical modifications for the different anatomic relationship were necessary; discrepancies of the bronchial lumina were easily overcome.

Allogeneic lymphocyte chimerism after clinical lung transplantation.

Donor lungs contain large amounts of passenger leukocytes which are transferred to the recipient by organ transplantation. In this study we have analysed the fate of these cells and have studied the populations of donor leucocytes detectable in the blood circulation of ten lung transplanted patients during the first postoperative weeks. To this aim we have applied immunocytological as well as flow cytometric analyses using monoclonal antibodies against polymorphic HLA class I antigens that differed between donor and recipient as well as antibodies against cell differentiation markers. The results demonstrate that donor cells can be detected in the circulation of all lung transplanted patients but there is a considerable interindividual variability between 0.9% and 17.5% (mean 5.1%) on postoperative day 3. Cells were usually detectable for 2-4 weeks and had disappeared in all patients after 1 month. The circulating donor cells consisted exclusively of lymphocytes. T cells were the predominant population, most of which seemed to be CD45R0+, but B and NK (natural killer) cells were also present. Probably due to the small numbers of patients studied no correlation between clinical parameters and the extent of donor lymphocyte persistence; there were no clinical graft-versus-host reactions. The findings demonstrate the regular existence of a transient (macro)chimerism due to passenger lymphocytes in the early phase after lung transplantation. The immunological function and the relation between this phenomenon and the long-term microchimerism which frequently develops after solid organ transplantation remain unclear.

Left ventricular-right atrial fistula complicating redo mitral valve replacement.

We describe the case of a 58-year-old female patient who underwent redo mitral valve replacement and remained in heart failure. The diagnosis of a left ventricular-right atrial fistula was made. The fistula was closed surgically with a patch of autologous pericardium. The patient improved immediately after the operation and has been asymptomatic since.

Bronchial and bronchovascular sleeve resection for treatment of central lung tumors.

BACKGROUND: To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively. METHODS: From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III). RESULTS: Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS). CONCLUSIONS: Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Remodeling of the aortic root and reconstruction of the bicuspid aortic valve.

BACKGROUND: Currently, isolated reconstruction of a regurgitant bicuspid aortic valve can be performed with adequate early results. Dilatation of the proximal aorta is known to be associated with this valve anomaly and may be partially responsible for the development of primary regurgitation or secondary failure of valve repair. We have used repair of the bicuspid valve with remodeling of the aortic root as an alternative to insertion of a composite graft. METHODS: Between October 1995 and May 1999, 16 patients (12 men, 4 women, aged 35 to 73 years) were seen with a regurgitant bicuspid aortic valve and dilatation of the proximal aorta of more than 50 mm. All patients underwent repair of the valve using either coapting sutures alone (n = 12) or in combination with triangular resection of a median raphe (n = 4). Using a Dacron graft, the aortic root was remodeled and the ascending aorta (n = 16) and proximal arch (n = 4) replaced. RESULTS: No patient died. The postoperative degree of aortic regurgitation was less than grade II in all patients. Valve function has remained stable in all patients between 2 and 43 months postoperatively. CONCLUSIONS: Reconstruction of the regurgitant bicuspid valve in the presence of proximal aortic dilatation is feasible with good results by combining the root remodeling technique with valve repair.

Valve-preserving operation in acute aortic dissection type A.

BACKGROUND: The standard treatment in patients with acute aortic dissection type A (AADA) and aortic regurgitation is either supracommissural aortic or composite replacement of ascending aorta and valve. Valve-preserving surgical procedures provide a promising alternative. We retrospectively analyzed midterm results after these different approaches. METHODS: From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5). RESULTS: All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B. CONCLUSIONS: In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.

Progression of steroid-associated osteoporosis after heart transplantation.

BACKGROUND: Osteoporosis has been recognized as an important side effect of long-term and of pulsed steroid application after heart transplantation. METHODS: In June 1989 a prospective clinical trial was started to study bone demineralization by quantitative computed tomographic scan. All patients received vitamin D and calcium. In group I (n = 30) synthetic calcitonin (40 Medical Research Council Standard Units subcutaneously per day was administered in 14-day cycles, whereas group II patients (n = 31) received a placebo preparation. Repeat trabecular and cortical quantitative computed tomographic scans of the thoracic (T12) and lumbar spine (L1, L2, L3) were obtained within 48 weeks after heart transplantation. RESULTS: Expressed as the means of T12, L1, L2, and L3, trabecular bone density decreased significantly from 100+/-24 to 79+/-29 mg/mL within 3 weeks after heart transplantation, followed by a further reduction to 67+/-29 mg/mL after 3 months in the calcitonin group. The values for cortical bone density decreased significantly from 229+/-37 to 202+/-40 mg/mL (calcitonin) 3 weeks after heart transplantation. Comparable results were obtained in the placebo group. In both groups bone density remained stable thereafter. Intergroup differences were not of statistical significance. CONCLUSIONS: In heart transplant recipients progressive trabecular bone demineralization is limited to the first 3 postoperative months. Thereafter, bone density remained stable. A positive effect of synthetic calcitonin in addition to prophylactic calcium and vitamin D application could not be proved by repeat quantitative computed tomography.