[Transcardiac Access Routes for Endovascular Treatment of Ascending Aortic Pathologies]. / Transkardiale Zugangswege zur endovaskulären Versorgung der Aorta ascendens.

Gold standard for treatment of pathologies of the ascending aorta is still open surgery with extracorporal circulation in moderate to deep hypothermia. These procedures are associated with high morbidity and mortality, especially if performed in older patients or after previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment option for thoracic aortic pathologies of the descending aorta even in high-risk patients with severe comorbidities resulting in reduced morbidity and mortality compared to open repair. Despite the continuous development of endograft technology an adequate arterial access still poses a relevant limitation of this treatment option accentuated in the proximal segments of the aorta. The transfemoral access may be limited due to severe kinking or arteriosclerotic plaque stenosis of femoral or iliac vessels. Furthermore, the long distance between femoral access vessels and the aortic lesion impairs device torsibility and exact deployment of the stent graft. To provide a practical alternative endovascular access to the ascending aorta, antegrade transcardiac access routes including transapical or transseptal techniques have recently gained increasing interest.

Analysis of phenotype and genotype information for the diagnosis of Marfan syndrome.

Marfan syndrome is considered a clinical diagnosis. Three diagnostic classifications comprising first, Marfan genotype with a causative FBN1 gene mutation; second, Marfan phenotype with clinical criteria of the original Ghent nosology (Ghent-1); and third, phenotype with clinical criteria of its current revision (Ghent-2) in 300 consecutive persons referred for confirmation or exclusion of Marfan syndrome (150 men, 150 women aged 35 ± 13 years) were used. Sequencing of TGBR1/2 genes was performed in 128 persons without FBN1 mutation. Marfan genotype was present in 140, Ghent-1 phenotype in 139, and Ghent-2 phenotype in 124 of 300 study patients. Marfan syndrome was confirmed in 94 and excluded in 129 persons consistently by all classifications, but classifications were discordant in 77 persons. With combined genotype and phenotype information confirmation of Marfan syndrome was finally achieved in 126 persons by Ghent-1 and in 125 persons by Ghent-2 among 140 persons with Marfan genotype, and exclusion was accomplished in 139 persons by Ghent-1 and in 141 persons by Ghent-2 among 160 persons without Marfan genotype. In total, genotype information changed final diagnoses in 22 persons with Ghent-1, and in 32 persons with Ghent-2. It is concluded that genotype information is essential for diagnosis or exclusion of Marfan syndrome.

I-SWOT as instrument to individually optimize therapy of thoracoabdominal aortic aneurysms: Effective, norm-compliant and meeting the needs.

BACKGROUND: Guidelines summarize medical evidence, they identify the most efficient therapy under study conditions and recommend this therapy for use. The physician now has the challenge to translate a therapy that is efficient under laboratory conditions to a patient who is an individual person. To accomplish this task the physician has to make sure that (I) the ideal typical therapy is applicable and effective in this individual patient taking the special features into consideration, that (II) therapy is compliant with the norm including guidelines, laws and ethical requirements (conformity) and that (III) the therapy meets the patient's needs. OBJECTIVE: How can physicians together with the patients translate the medical evidence into an individually optimized therapy? MATERIAL AND METHODS: At the German Aortic Center in Hamburg we use I­SWOT as an instrument to identify such individually optimized therapy. With I­SWOT, we present an instrument with which we have developed an (I) efficient, (II) conform and (III) needs-oriented therapeutic strategy for individual patients. RESULTS: I-SWOT cross-tabulates strengths (S) and weaknesses (W) related to therapy with opportunities (O) and threats (T) related to individual patients. This I­SWOT matrix identifies four fundamental types of strategy, which comprise "SO" maximizing strengths and opportunities, "WT" minimizing weaknesses and threats, "WO" minimizing weaknesses and maximizing opportunities and "ST" maximizing strengths and minimizing threats. We discuss the case of a patient with asymptomatic thoracoabdominal aneurysm to show how I­SWOT is used to identify an individually optimized therapy strategy.

Tracheal allograft transplantation in rats: the role of different immunosuppressants on preservation of respiratory epithelium.

BACKGROUND: Bronchiolitis obliterans is the most significant complication adversely affecting the survival of lung allograft recipients. Injury and loss of epithelium are associated with obliteration of the airway lumen. The aim of this study was to examine the effects of various immunosuppressants on airway epithelium. METHODS: Tracheae from Brown Norway donors were heterotopically transplanted into the greater omentum of Lewis (allografts) or Brown Norway (isografts) animals. Recipients were treated for 28 days with FK778 (20 mg/kg), tacrolimus (4 mg/kg), or sirolimus (2 mg/kg). Tracheal segments were evaluated for the degree of luminal occlusion as well as the type and percent of luminal epithelial cell coverage. RESULTS: All agents inhibited peritracheal infiltration and luminal obliteration. Tacrolimus- more than sirolimus-treated recipients showed partial preservation of the luminal epithelial coverage, whereas animals that received FK778 showed no respiratory epithelium. The epithelial loss was accompanied by the appearance of fibrous tissue, which replaced the mucosa. CONCLUSIONS: Tacrolimus as well as sirolimus effectively prevented the development of obliterative airway disease whereas tacrolimus and, to a lesser degree, sirolimus preserved epithelial cells as a source of protective cytokines. With FK778 significant airway obliteration was suppressed despite complete epithelial loss. Thus, FK778-treated animals displayed an epithelial-independent inhibitory effect on myofibroblast proliferation.

FK778: new cellular and molecular mechanisms of action.

PURPOSE: The new malononitrilamide FK778 is currently being evaluated as an immunosuppressant for organ transplantation. Its main mechanism is inhibition of a pivotal enzyme of pyrimidine biosynthesis. This report revealed new mechanisms of action on different cell types involved in acute and chronic allograft rejection. METHODS: Purified Brown-Norway rat aortic endothelial cell (EC) cultures were pretreated with several concentrations of FK778. Endothelial adhesion molecule expression (ICAM-1/VCAM-1) stimulated with TNF-alpha was quantified by immunofluorescence. Purified Lewis rat lymphocytes (LC) incubated with FK778 were stimulated via TCR/CD28 signals, and CD25 expression was quantified using FACS analysis. Uridine addition was used in all assays to reverse the pyrimidine synthesis blockade. Lymphocyte-EC interaction was assessed by micromanipulator-assisted single-cell adhesion assays. Finally, smooth muscle cell (SMC) proliferation and migration was analyzed. Uridine addition was used in all assays to reverse the pyrimidine synthesis blockade. RESULTS: TNF-alpha stimulation and TCR/CD28 co-stimulation significantly increased EC ICAM-1/VCAM-1-expression and LC CD25 surface expression, respectively. These effects were dose-dependently inhibited by FK778 and were not reversed by the addition of uridine. FK778 dose-dependently attenuated LC adhesion to allogeneic EC. The dose-dependent inhibition of SMC proliferation by FK778 was abolished by uridine addition, whereas the inhibitory effect on SMC migration was not affected by uridine supplementation. CONCLUSIONS: FK778 directly reduced endothelial adhesion molecule up-regulation, inhibited lymphocyte activation, and attenuated lymphocyte-endothelium interactions, critical early steps in graft rejection. These effects were separate from the blockade of pyrimidine synthesis. The antiproliferative potency of FK778 on SMC may be an important mechanism to inhibit the fibroproliferative lesions of chronic organ rejection.

[The ECG-gated 4-row multidetector CT of the heart in preoperative imaging minimal invasive coronary artery bypass grafting]. / Die EKG-getriggerte 4-Zeilen-Spiral-CT des Herzens in der präoperativen Bildgebung vor minimalinvasiver koronarer Bypass-Operation.

PURPOSE: Minimal invasive direct coronary artery bypass grafting (MIDCAB) or off-pump coronary artery bypass grafting (OPCAB) on the beating heart with full or mini-sternotomy are becoming more common in coronary bypass surgery of the left anterior descending (LAD). In the decision, which surgical approach (MIDCAB, OPCAB or conventional surgery with cardiopulmonary bypass) will be best used, knowledge of the anatomical field is of major importance. The aim of the study was to evaluate retrospective ECG-gated 4-row multidetector CT (MDCT) in patients planned for MIDCAB as additional imaging to coronary angiography. MATERIAL AND METHODS: The study included 25 consecutive patients. MSCT was performed as unenhanced (collimation 4 x 2.5 mm) and contrast-enhanced examination (140-170 ml, 300 mg Iodine/ml, collimation 4 x 1 mm). The evaluation included presence of LAD calcifications, distance of LAD and left internal mammarian artery (LIMA), course of LAD and LIMA, the presence or absence of bridging through myocardium or epicardial fat and the presence of pleural fibrosis. The MDCT results were correlated with intra-operative findings. RESULTS: All MDCTs could be assessed with reference to the demands. In 20/25 operations, MDCT had direct influence as to the selection of the surgical approach (11 MIDCAB, 7 OPCAB with mini-sternotomy and 5 with full sternotomy, 2 conventional surgeries). The distance of LAD and LIMA varied from 0.9 to 4.5 cm in MDCT. As to calcifications, 3/25 correlated patients had calcifications and 10 patients had no calcifications in the middle LAD. Seven patients had intraoperative fibrosis of the vessel wall without calcification of the middle LAD, which could not be detected with MDCT. Another 5 patients had single calcified plaques in the middle LAD, 4 of these had a fibrosis of the vessel and 1 had a normal vessel at surgery. In these cases, the anastomosis was done between the calcified plaques. No myocardial bridging was detected by MDCT and at surgery. Bridging of epicardial fat was shown by MDCT and at surgery in 9/25 patients and was excluded in 15 patients. In 1 patient, the LAD seemed to run superficially in MDCT, but was covered with fat as seen during surgery. The course of the LIMA was inconspicuous in all cases, no pleural fibrosis was found. CONCLUSIONS: The 4-row MDCT has proven to be adequate in addition to coronary angiography for preoperative evaluation in patients scheduled for MIDCAB and provides the surgeon with relevant information for the selection of the operative approach.

Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting.

OBJECTIVE: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. METHODS: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. PHASE I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. PHASE II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. PHASE III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. RESULTS: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. CONCLUSIONS: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.

Aortic valvotomy for congenital valvular aortic stenosis: a 37-year experience.

BACKGROUND: The purpose of the study was to analyze the long-term results of aortic valvotomy and the risk factors associated with reoperation and survival. METHODS: From 1960 to 1977, 116 patients with congenital valvular aortic stenosis underwent isolated aortic valvotomy at a mean age of 13.7 +/- 7.8 years with a mean aortic gradient of 78 +/- 33 mm Hg. Fifteen patients had additional aortic regurgitation, and leaflet calcification was present in another 15 patients. RESULTS: Postoperatively the mean aortic gradient decreased to 19.4 +/- 11.3 mm Hg (p < 0.0001). Early mortality was 2.6%. At a mean follow-up of 23.8 years, 26 late deaths (22.4%) occurred among the 113 early survivors. Actuarial 10-, 20-, 30-, and 37-year survival rates were 94.6%, 79.7%, 76.2%, and 72.5%, respectively. According to multivariate Cox regression analysis, survival was influenced by preoperative New York Heart Association class (p = 0.0418), leaflet calcification (p = 0.0339), date of operation (p = 0.0253), and postoperative endocarditis (p < 0.0001). At a mean interval of 18.3 years, 37 patients required reoperation (31.9%) mainly because of recurrent aortic stenosis. The reoperation rate increased significantly 15 years postoperatively from 0.73%/year to 2.31%/ year (p < 0.0001). In a multivariate risk model, reoperation was influenced by older patient age (p = 0.0032) and the presence of leaflet calcification (p = 0.0289). CONCLUSIONS: AORTIC valvotomy is a simple and effective procedure for congenital aortic stenosis with excellent long-term results. However, the rate of reoperation increases 15 years postoperatively, and clinical follow-up should be intensified. Our results suggest that early repair should be performed and that adequate patient selection is the most important determinant of the longterm results.

Immunologic reaction and viability of cryopreserved homografts.

Homograft cell viability after cryopreservation was investigated and cytoimmunologic monitoring was performed during the early postoperative course to research possible immunologic reactions after allograft aortic valve replacement. After cryopreservation, morphologic observations were made, a nonradioactive cell proliferation assay was used, and prostaglandin I2 secretion of the remaining endothelial cells was determined. Cytoimmunologic monitoring was performed daily within the first 3 weeks postoperatively. An increase of the activation index greater than 1 was rated as an immunologic reaction. Maintained metabolic activity of graft endothelial cells after cryopreservation was confirmed by prostaglandin I2 release (9.24 +/- 3.48 ng/cm2 basic release and 20.1 +/- 5.76 ng/cm2 when stimulated with 25 mumol/L Na arachidonic acid). Cell proliferation was indicated after graft incubation with the nonradioactive viability kit (0.27 +/- 0.9 at 450 nm). Cytoimmunologic examinations (n = 861) after homograft implantation showed a more intense activation in patients with ABO-incompatible grafts (activation index 2.1 +/- 1.6, n = 16) than in those with ABO-compatible grafts (activation index 1.3 +/- 0.8, n = 17). In these groups, the duration of activation by cytoimmunologic monitoring was 2.8 +/- 1.5 days and 1.3 +/- 0.6 days, respectively (p < 0.041). No activation was observed in 8 patients after xenograft valve replacement (p < 0.01). Our data indicate that cryopreservation of homograft valves represents a cell- and tissue-protective preservation method. Postoperatively, all homograft valves caused immunologic reactions, which were reversible without immunosuppression treatment.

Mitral commissurotomy, a technique outdated? Long-term follow-up over a period of 35 years.

BACKGROUND: The objective of this study was to evaluate long-term survival, valve-related complications as well as prognostic factors for early and late outcome after open and closed mitral commissurotomy covering a follow-up period of 35 years. METHODS: From 1955 to 1977, 183 patients with mitral stenosis underwent mitral commissurotomy at our institution. Closed valvotomy was performed on 143 patients (group A) and open valvotomy on 40 patients (group B). RESULTS: Survival rates after 10, 20, and 30 years were 89%, 67.8%, and 49.1% in group A and 91.7%, 66.7%, and 45.9% in group B (p = not significant). The risk of late death increased significantly with an advanced preoperative New York Heart Association functional class, atrial fibrillation, higher age at operation, pre- or postoperative mitral regurgitation, and leaflet calcification. Forty-four patients in group A and 5 patients in group B required reoperation (p < 0.05). Independent predictors for reoperation in a multivariate analysis were a remaining postoperative mitral stenosis or regurgitation. A total of 68 patients showed valve-related complications. The linearized rate of valve-related morbidity and mortality was 2.1% per patient-years in group A versus 1.1% per patient-years in B (p < 0.01). CONCLUSIONS: Long-term survival for open and closed commissurotomy are excellent, showing no difference between the groups. However, both the incidence of reoperation as well as valve-related morbidity and mortality were significantly lower after open commissurotomy. In well-selected patients with pure mitral stenosis and no leaflet calcification, open commissurotomy still remains a valid surgical option.

Three-dimensional video and robot-assisted port-access mitral valve operation.

BACKGROUND: In order to minimize surgical trauma, video-assisted mitral valve operation has been started using the Port-Access technique with the addition of a three-dimensional visualization system (Vista Cardiothoracic Systems Inc, Westborough, MA) and a voice-controlled camera-holding robotic arm (Aesop; Computer Motion Inc, Goleta, CA). METHODS: Port-Access mitral valve replacement or repair (PAMVR) was undertaken using an endovascular cardiopulmonary bypass (CPB) system. Fifty patients underwent Port-Access mitral valve replacement or repair. A three-dimensional thoracoscope was inserted allowing complete three-dimensional projection of the mitral valve (Vista). In the last 20 patients, the camera was attached to a robotic arm (Aesop), which allowed stabilization and voice-activated movement of the camera. Mitral valve repair was performed in 26 patients, and the valve was replaced in 24 patients with a mechanical valve prosthesis. RESULTS: Median time of operation was 4.2 hours, aortic cross-clamp time 83 minutes, CPB time 125 minutes, intensive care unit stay 1.5 days and hospitalization 9.0 days. Three months follow-up was complete in 40 patients, with 34 patients (85%) in New York Heart Association class I and 6 patients in class II. Mortality was 0% and rate of reoperation was 2%, with a follow-up time up to 1.5 years postoperatively. CONCLUSIONS: Using three-dimensional video and robotic assistance, it was possible to minimize the length of skin incision, but at the same time to optimally visualize the whole mitral valve apparatus in order to perform true Port-Access mitral valve operation, including various repair techniques.

Early experience with robotic technology for coronary artery surgery.

BACKGROUND: To achieve an endoscopic coronary bypass anastomoses we performed a study with endoscopic robotic instrumentation and camera guidance using three-dimensional (3-D) visualization. METHODS: The surgical robotic system ZEUS (Computer Motion Inc, Goleta, CA) consists of three interactive robotic arms and a control unit allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion Inc, Goleta, CA) positions the endoscope via voice control. The study had three phases. Phase I: In a phantom model, end-to-side anastomoses between vein grafts and the left anterior descending coronary artery (LAD) of 109 pig hearts were performed. Phase II: In 6 dogs (FBI, 20-25 kg) the left internal mammary artery (LIMA) was harvested endoscopically. During Port-Access (Heartport Inc, Redwood City, CA) cardiopulmonary bypass (CPB), LIMA and LAD were then anastomosed endoscopically with the help of telemetric ZEUS instruments (Computer Motion Inc). Phase III: A total of seven patients were operated on with help of the ZEUS system (Computer Motion Inc). After endoscopic LIMA harvesting and CPB using the Port-Access (Heartport Inc) system, the bypass graft (LIMA to LAD) was anastomosed endoscopically through three thoracic ports in 2 patients. Another 3 patients were operated on off-pump with regional stabilization and 2 patients with sternotomy and routine CPB. RESULTS: The practice with the phantom model and the subsequent animal experiments allowed the surgeons to gain sufficient experience for the clinical setting. In the clinical cases, times for anastomoses ranged from 20 to 42 minutes. Median internal mammary artery flow rate was 74 mL per minute (range 36-110 mL per minute). One patient in the off-pump group was converted to CPB and routine anastomosis. All patients had an uneventful angiographic control and postoperative course. CONCLUSIONS: Using telemetic technology, a completely endoscopic anastomosis of LIMA to LAD is possible on the arrested heart, as well as on the beating heart.

Mitral valve annuloplasty: comparison of the mural annulus shortening suture (MASS) with the Carpentier-Edwards prosthetic ring.

BACKGROUND AND AIM OF THE STUDY: Although mitral annuloplasty is an important element of mitral valve repair, the technique employed remains controversial. In this prospective study, we compared two different annuloplasty techniques with regard to hemodynamic performance. METHODS: Between October 1995 and December 1998, 109 consecutive patients underwent mitral valve repair for mitral regurgitation. One group of patients (n = 55) received a Carpentier-Edwards (CE) ring for annuloplasty, and a second group (n = 54) underwent the mural annulus shortening suture (MASS) to reinforce the posterior circumference of the annulus. All patients were investigated prospectively by Doppler echocardiography before discharge and annually thereafter. The mean follow up was 22.7+/-11.6 months. RESULTS: The early mortality rate was 3.7%, with four early deaths in the CE group, and no early death in the MASS group. There was one late death in each group. One patient in each group required reoperation for severe mitral regurgitation after 19 and 30 months, respectively. Postoperative (12 months) Doppler echocardiography showed mean mitral valve gradients to be significantly lower (1.7+/-0.7 versus 2.7+/-1.7 mmHg; p <0.01) and mitral valve areas significantly larger (3.3+/-1.0 versus 2.6+/-0.7 cm2; p <0.01) in MASS patients compared with CE patients. There was no significant difference in mean postoperative mitral regurgitation between the two groups (0.5+/-0.2 versus 0.4+/-0.2). CONCLUSION: Both annuloplasty techniques showed excellent results; however, hemodynamic performance of MASS was superior to that of the rigid CE ring, while not increasing postoperative mitral regurgitation. Therefore, MASS may be recommended as an alternative to annuloplasty rings, if future long-term follow up studies confirm the durability of the technique.

Economic evaluation of different minimally invasive procedures for the treatment of coronary artery disease.

OBJECTIVE: Several different techniques exist within the field of minimally invasive coronary artery surgery. In this study the impact of all these techniques on the total costs and economics has been evaluated. METHODS: Since May 1997, 121 minimally invasive direct coronary artery bypass (MIDCAB) procedures, 125 off-pump coronary artery bypass (OPCAB), ten Port-Access coronary artery bypass (PA-CABG) and 10 endoscopic coronary artery bypass grafting (ENDO-CABG) procedures were performed at our institution. A relative cost analysis of the different procedures was carried out in addition to a thorough evaluation done in five patients of each group dividing the costs into staff-related costs, material-related costs and general hospital costs. The costs were set in relation to regular CABG procedures. RESULTS: Specific less invasive coronary artery surgical techniques, such as the MIDCAB or OPCAB technique already are able to reduce the total costs when compared to regular CABG procedures. Within the Port-Access group as well as the ENDO-CABG group, increased material- and general costs are present when compared to regular CABG leading to increased total hospital costs for PA-CABG and Endo-CABG in Germany. CONCLUSION: At present, MIDCAB and OPCAB procedures are able to reduce total hospital charges, when compared to regular CABG procedures. Increased costs for Port-Access, as well as Endo-CABG surgeries may be compensated in the future by decreased costs due to a shorter phase of rehabilitation and faster return to regular professional activities.

Long-term prognosis of surgically-treated aortic aneurysms and dissections in patients with and without Marfan syndrome.

OBJECTIVE: Aortic aneurysms and dissections are the leading causes of premature death in Marfan syndrome (MfS). This study aims to compare long-term results of surgically treated aortic aneurysms and dissections in patients with and without MfS in respect to early and late prognosis. METHODS: From March 1975 to August 1994, 33 patients with classic MfS (group A, age 34.2 +/- 9 years) and 298 patients with non-fibrillinopathic aortic disease (group B, age 54 +/- 13 years) underwent aortic surgery. Acute dissections occurred in 57.6 (A) versus 37.9% (B). A total of 54.6% of patients in group A were treated with a composite graft versus 16.4% in B. The aortic arch and the descending aorta was replaced in 30.4% of MfS patients and 24.9% of patients without MfS. RESULTS: We observed 7 (25.0%, A) versus 35 (14.2%, B) late deaths among the 28 (A) versus 247 (B) early survivors. In 5 patients (17.9%) of A and 8 patients (3.2%) of B, late death was caused by redissection or recurrent aneurysm (P < 0.001). Long-term survival after 5, 10 and 15 years in group A was 82 +/- 7, 60 +/- 11 and 30 +/- 22%, and 75 +/- 3, 69 +/- 3 and 64 +/- 4% in group B. A total of 22 reoperations were performed in 11 MfS patients, 17 reoperations were due to recurrent aortic diseases. Three of the 8 patients underwent reoperation after Wheat procedure because of sinus valsalva aneurysm. None of the patients with composite graft replacement needed reoperation in this segment, but 3 patients suffered from redissection at the proximal aortic arch. In group B, reoperations were significantly less frequent (10.7%) compared to MfS patients (66.7%; P < 0.001). CONCLUSIONS: Surgical treatment of aortic disease in MfS patients is associated with a high risk of redissection and recurrent aneurysm. If the ascending aorta needs to be replaced, we recommend the composite graft technique and a more aggressive approach to reduce the frequency of distal reoperations. In order to reduce the high reoperation rate in MfS patients, frequent clinical follow-up may contribute to improve life expectancy in MfS patients.

Single vessel revascularization with beating heart techniques -- minithoracotomy or sternotomy?

OBJECTIVE: The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization of the left anterior descending coronary artery (LAD). METHODS: In 256 patients a single left internal mammary artery (LIMA) to LAD bypass was performed with beating heart techniques through a left anterior minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB), n=129) or a full sternotomy (off-pump coronary artery bypass (OPCAB), n=127). RESULTS: In the OPCAB group, significantly more severe comorbidities (P=0.001) and redo-operations were noted (P<0.001). Conversion to sternotomy or CPB was necessary in five MIDCAB patients and one OPCAB patient. No cerebrovascular accident was seen in both groups. There was no hospital death in MIDCAB- and two deaths in OPCAB procedures (P=ns). There was a significant reduction in time of surgery (P=0.028) and coronary occlusion (P=0.009) in the OPCAB group. No differences in postoperative ventilation time, ICU stay and length of hospital stay were recorded between groups. Wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Early postoperative reoperation due to graft failure was necessary in three patients after MIDCAB and two patients after OPCAB (P=ns). Confirmed by angiography, the early graft patency rate was 96 and 98%, respectively (P=ns). CONCLUSIONS: Both beating heart techniques showed good results with low hospital mortality, low early complications and comparable angiographic results. Nevertheless, MIDCAB is a challenging technique as demonstrated by the longer times of surgery and coronary occlusion with a tendency towards a higher risk of conversion and wound infection. Thus, this technique should only be performed in selected patients with favourable coronary anatomy. Through a sternotomy approach, single vessel revascularization can be performed safely off-pump even in high-risk patients.

Cytoimmunological monitoring after homograft valve replacement.

Examination results concerning immunological reactions in cryopreserved allograft valves during the early postoperative course are so far not available. Cytoimmunological monitoring (CIM) is a well established method to prove rejection reaction after allograft transplantation and was used in this study. Allograft valves were harvested from patients who underwent heart transplantation, and did not require sterilizing in antibiotic solutions. The valves were dissected, conserved and subsequently frozen to -40 degrees C and stored in a freezing system at -196 degrees C. During the first 3 weeks following allograft implantation, CIM was performed daily. An activation index (AI) was determined from the cytological evaluation of the mononuclear concentrate in the peripheral blood. An increase of the AI > 1 was defined as an immunological reaction. As control we performed 98 CIM examinations in eight patients who underwent bioprosthetic valve replacement in the aortic position. Echocardiography (TTE and TEE) was used postoperatively as function control. Out of 16 patients who underwent cryopreserved aortic valve implantation in the aortic position, 336 CIM-results were obtained. An immunological reaction could be detected in all patients, starting on the 5th day on average. Comparing ABO-compatible (group I, n = 9) with ABO-incompatible (group II, n = 7) allografts, the AI-maximum in group I was 1.4 with a mean duration of 1.5 days. Group II was characterized by more intensive immunoreactions (mean = 2.3) which proved to be even more prolonged (mean = 3.3 days, P < 0.05). Nevertheless it became apparent that all observed immunological events were completely reversible without the need for immunosuppressive drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Homograft aortic root replacement for destructive valve endocarditis. The benefit of an in-house homograft bank.

This report concerns the surgical treatment of a 45-year old patient with active staphylococcus-endocarditis of the aortic valve which resulted in an aortic root abscess and consequently in a ventricular aortic discontinuity. A technique of homograft aortic root replacement after removal of all infected and necrotic areas is described. After a six month follow-up, the patient is asymptomatic (New York Heart Association functional class I) and shows no signs of recurrence of endocarditis. This case report makes the benefit of an in-house homograft-bank system obvious.

Indirect coronary angiography: a feasibility study.

The diagnostic method of choice to proof coronary artery disease and to localize stenoses and to judge the stage of the disease is coronary angiography. A new angiographic technique invented by. Wolffgram and Krieter that works without cannulation of the coronary arteries could simplify the interventional procedure. In addition, a technique like this could be used for angiography after CABG surgery directly on the table for quality assurance reasons. This angiography could be performed by the cardiac surgeon without necessarily involving a cardiologist. A feasibility study was successfully done in a cooperation of the Departments. for Cardiology and Cardiac Surgery, Munich University, Steinbeis Transfer Centre for rHealthcare Technologies, Tuebingen and Fraunhofer Technology Development Group (TEG), Stuttgart.