Leaflet fracture in Edwards-Duromedics bileaflet valves.

Two cases of leaflet fracture in the Edwards-Duromedics valve at 36 and 38 months after implantation are reported. Both patients were immediately reoperated on and recovered well. In one valve an older housing fracture with partial tissue ingrowth was noted beside a recent transverse leaflet fracture. In the other valve the leaflet was fractured near the pivot mechanism. All larger embolized parts were detected in the iliac artery region by computed tomographic scan and were subsequently removed. Problems in diagnosis and the importance of immediate reoperation, even without exact diagnosis, are discussed. Technical evaluation of the valve revealed crack growth and arrest, giving evidence of fatigue fracture. Scanning electron microscopic examination revealed several areas of pitting and erosion. Although the exact cause of mechanical disruption remains speculative, pyrolytic carbon seems to have the characteristic of fatigue fracture as well as erosion damage. A connection between the two might exist.

Breast development and areola sensitivity after submammary skin incision for median sternotomy.

Vertical incision for median sternotomy may result in unsightly scars. Therefore we have used a horizontal approach in women since the early 1980s. Of 36 women, 27 came for a follow-up examination. A tendency toward scar hypertrophy was found medially in 7 women. Four breast-fed their child after operation. Reduced areola sensitivity occurred in only 9 women. Horizontal submammary skin incision resulted in cosmetically acceptable scar formation and did not harm breast development and lactation.

Complete repair of PA-VSD with diminutive or discontinuous pulmonary arteries by transverse thoracosternotomy.

BACKGROUND: Optimal treatment and the optimal sequence of surgical and interventional steps to correct pulmonary atresia with ventricular septal defect and hypoplastic or discontinuous intrapericardial pulmonary arteries is still under discussion. Collateral arteries may be hardly accessible through median sternotomy at total correction. Bilateral transsternal thoracotomy gives wide access to the heart, both pleural spaces and hilar structures. METHODS: We used this incision for total correction of pulmonary atresia with ventricular septal defect in 6 patients. Three had Blalock-Taussig shunts placed previously, and intrapericardial pulmonary arteries were absent in all patients but 1, in whom they were hypoplastic. Central pulmonary arteries were enlarged with pericardial patches or replaced with tube grafts; the number of unifocalized collateral arteries varied between two and eight. RESULTS: One patient died of respiratory failure and sepsis (16.7%). Oxygen saturation increased from 76% (range, 65% to 88%) preoperatively to 96% (range 91% to 99%) postoperatively. Mean postoperative pulmonary artery pressure was 30 mm Hg (range, 28 to 34 mm Hg). One patient had to be reoperated on through the same incision due to scarring and shrinkage of the peripheral anastomoses. Six months after operation 2 patients are in New York Heart Association functional class I and 2 are in class II. CONCLUSIONS: Transverse thoracosternotomy gives excellent access to the anatomical structures necessary to correct complex cases of pulmonary atresia with ventricular septal defect and may reduce the number of surgical procedures.

Early prediction of deep sternal wound infection after heart operations by alpha-1 acid glycoprotein and C-reactive protein measurements.

Serum C-reactive protein (CRP) and alpha 1-acid glycoprotein (AAG) levels were studied in 188 patients undergoing heart operations with cardiopulmonary bypass. Mediastinitis or osteomyelitis of the sternum or both developed in 10 patients on postoperative day 4 to 13 (median, day 9). The mean CRP levels on day 2 were lower in patients with later deep sternal wound infection (9.1 +/- 1.5 mg/dl [mean +/- standard error]) compared with patients without major infections (14.0 +/- 0.8 mg/dl; p = 0.103 [univariate logistic regression]). AAG levels on day 2 reacted in a similar manner, yielding 78.2 +/- 5.5 mg/dl and 100.9 +/- 2.7 mg/dl, respectively (p = 0.0004). No correlation was found between CRP or AAG and duration of cardiopulmonary bypass, number of blood transfusions, or total protein levels on day 2. The white blood cell count (WBC) on day 2 was 13.1 +/- 1.7 X 10(3)/microliter for patients with infection and 9.7 +/- 0.3 for those without infection. Multivariate logistic regression analysis revealed that AAG, WBC, and CRP on day 2 were significant risk factors sufficiently predicting the probability of a deep sternal infection. After adjustment for these three variables, other variables (age, sex, total protein on day 2, diabetes mellitus, type of operation, duration of cardiopulmonary bypass, length of operation, repeat thoracotomy for bleeding, number of blood transfusions on the day of operation, intraaortic balloon pumping, reoperation, emergency operation, and surgeon's professional status) were not of additional significance. The goodness of fit of the statistical model was confirmed by a high correspondence between predicted and observed cases of deep sternal infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for severe bacterial infections after valve replacement and aortocoronary bypass operations: analysis of 246 cases by logistic regression.

Risk factors for severe bacterial infections, that is, deep sternal wound infection, pneumonia, septicemia, and prosthetic valve endocarditis, were evaluated in 246 consecutive patients undergoing valve replacement (N = 84) or aortocoronary bypass operation (N = 162). Multiple logistic regression analysis was applied to determine the ability of putative risk factors to predict infection. The risk factors considered were age, sex, diabetes mellitus, duration of cardiopulmonary bypass (CPB), duration of operation, amount of blood restored on the day of operation, repeat thoracotomy for bleeding, intraaortic balloon pumping, reoperation, emergency operation, and the professional status of the surgeon. Severe infections occurred in similar frequency after valve replacement (8/84; 9.5%) and aortocoronary bypass (11/162; 6.8%). For patients who had a bypass procedure, repeat thoracotomy was the only factor significantly associated with infection (p = 0.0004). However, the classification analysis revealed that this variable alone is too unspecific for a reliable prediction. Univariate analysis indicated that restoration of more than 2,500 ml of blood (p = 0.0001), reoperation (p = 0.0821), duration of operation (p = 0.0061), duration of CPB (p = 0.0318), and intraaortic balloon pumping (p = 0.0281) were associated with infection following valve replacement. A model with three variables emerged from the multiple logistic regression: after correction for blood restoration, reoperation, and duration of CPB, no other variable was of additional predictive value. For patients who underwent valve replacement, the model performed well in predicting complications. The classification analysis revealed a high correspondence between observed and predicted instances of infection: it correctly predicted 75% of the patients with infection and 96% of those without infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary autograft valve replacement in the dilated and asymmetric aortic root.

Pulmonary autograft aortic valve replacement is the only technique for implantation of a biologic, vital and thus nondegenerating valve. The technique of root replacement overcomes problems of asymmetric aortic roots and reduces the risk of malalignment, but bears the risk of dilatation. We have performed pulmonary autograft aortic root replacement in 20 patients (mean age 22 years, range 5-38). Twelve presented with aortic incompetence, 3 with stenosis and 5 with combined defects. Initially roots were implanted just supraannularly with two running suture lines. As the neo-aortic roots gradually dilated, we started to implant autografts intraannulary, but still one valve dilated and aortic incompetence (AI) increased from grade I to II. Consequently the remaining aortic wall was wrapped around the new root and the composite subsequently was reinforced by a circular absorbable mesh. In addition, the aorta and pulmonary valve were exactly sized and the aortic root was reduced by commissuroplasty stitches up to 6 mm in diameter in seven cases. The ventricular size decreased in all patients 10 days after surgery, the left ventricular end-diastolic diameters (LVEDD) from 58 +/- 12 to 52 +/- 10 mm (P = 0.0002; paired t-test) and left ventricular end-systolic diameter (LVESD) from 41 +/- 12 to 36 +/- 10 mm (P = 0.008), but the contractility did not change significantly (fractional shortening from 31 +/- 9% to 30 +/- 9%). The diameter of the new aortic ring increased for the supraannular position but size matching and the intraannular valve position reduced the new ring size significantly (P = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Anomalous origin of the left coronary artery: a review of surgical management in 13 patients.

Over the last decades, surgical management of anomalous left coronary artery originating from the pulmonary artery (ALCAPA) has seen a considerable evolution. Between 1965 and 1992, 13 children with age at operation ranging between 2 months and 11 years (mean 23 months) underwent one of 5 different surgical procedures: ligation (n = 3), direct aortic reimplantation (n = 7), subclavian (n = 1) or internal mammary (n = 1) artery anastomosis, or modified aortic implantation (Vigneswaran-procedure, n = 1). There were 3 early and one late deaths resulting in an overall mortality of 30.7%. Mortality was 66.7% in the ligation group, and 20% in the revascularization group (28.6% in the subgroup with direct aortic implantation). The one late death occurred 6 months after ligation. Follow-up ranges between 3 months and 21 years, mean 7.3 years. All but one survivors are in NYHA functional class I. Following operative correction, there was clear improvement in left ventricular performance. Our data give reason to suggest ALCAPA to be more frequent than considered so far. Early surgery is recommended in all patients with ALCAPA, regardless of age or symptomatic status. Reestablishment of a two-coronary system is considered the procedure of choice. All survivors require long-term follow-up controls of early recognition of residual or progressive cardiac problems.

[Experiences with surgical treatment of the complete form of atrioventricular septum defect]. / Erfahrungen mit der chirurgischen Behandlung der kompletten Form des atrioventrikulären Septumdefektes.

13 children whose ages ranged from 3 to 30 months, with complete atrioventricular septal defect underwent surgical correction. 1 patch was used in Rastelli Type A cases and 2 patches in Rastelli Type C patients, without incision of the AV valve tissue. In all cases the left superior and inferior valve leaves were approximated with 2 or 3 stitches. One child died postoperatively. A good result was attained in 7 children. 5 children still need digitalis and diuretics. Complete AV-block was not seen.

[Advances in the surgical treatment of congenital heart defects (author's transl)]. / Forschritte in der chirurgischen Behandlung angeborener Herzfehler.

One-stage correction of operable congenital cardiac defects in infancy, the operative treatment of transposition of the great arteries and the operative management of intracardial stenosis or atresia with a conduit are examples of the progress achieved in the treatment of congenital heart disease. The improvement in preoperative diagnosis, supporting medication, the technique of extracorporeal circulation and in surgical technique are the reasons why nowadays only a few, rare congenital malformations of the heart are inoperable.

[Surgical complications in pacemaker operations and their management]. / Chirurgische Komplikationen bei Schrittmacheroperationen und ihre Behandlung

A review is presented of the range of surgical complications encountered in 120 out of 749 patients (16%) receiving a pacemaker implantation over the period October 1974 to September 1975. These complications can be subdivided into those involving interruption or disturbance of the conduction of the pacemaker impulse and those associated with impaired wound-healing. The aetiology, the diagnosis and the surgical management are discussed.

[Surgical treatment of uraemic pericarditis (author's transl)]. / Zur chirurgischen Behandlung der urämischen Perikarditis.

Surgical therapy was undertaken in 8 patients with uraemic pericarditis. The clinical symptoms and signs, operative technique and results are presented and compared with the relevant literature. Extended pericardial resection after median sternotomy has proved to be the method of choice in the management of pericardial tamponade due to uraemic pericarditis with haemorrhagic effusion. Acute pericardial tamponade is thereby alleviated, relapse prevented and intra- and postoperative respiratory function maintained.

[Exit block: a postoperative complication of pacemaker implantation (author's transl)]. / Der Exit-Block als postoperatives Problem der Schrittmacherchirurgie.

Exit block occurs in 7% of cases following implantation of a pacemaker for the first time and appears to be a serious and unpredictable occurrence which cannot be prevented by the selection of a particular technique or type of electrode of pacemaker. Therapeutic measures in patients who are not dependent on a pacemaker consist primarily of exchanging the intracardial lead. In all patients, as well as in those cases with recurrence of exit block, a pulse width-adjustable pulse generator should be implanted without resorting to other methods of questionable efficacy. The implantation of such a pulse generator was successful in all our cases.

[Long-term results after isolated aortic and mitral valve replacement with a prosthesis (author's transl)]. / Spätresultate nach isoliertem Aorten- und Mitralklappenersatz mit einer Klappenprothese.

111 patients with aortic valve replacement (AVR) and 159 patients with mitral valve replacement (MVR) were studied after hospital discharge. The late mortality was 20% after AVR and 32% after MVR. Of the survivors, 93% were greatly improved after AVR and 83% after MVR (functional class I or II). The calculated 5-year survival rate of the patients with AVR is 76% and with MVR 64%. The general state of health of the survivors, the thromboembolic rate and the fatal complications are discussed. Further improvement in the results can only be expected if valve replacement is performed before irreversible myocardial damage has occurred.

[Surgery of the mitral valve (author's transl)]. / Die Chirurgie der Mitralklappe.

A report is given on the results of different forms of mitral valve operations in 866 patients. Closed mitral valvulotomy was performed in 519 patients and mitral valve replacement in 291 cases. Open mitral valve anuloplasty was performed as reconstructive surgical procedure in 15 patients. The overall mortality was 10.4%. Follow-up of the surviving patients showed that the long-term results of mitral valve replacement are significantly worse than those of mitral valve reconstruction.

[A cosmetically advantageous approach to median sternotomy]. / Ein kosmetisch vorteilhafter Zugang zur medianen Sternotomie.

A horizontal submammary skin incision was chosen as approach route to median sternotomy in 36 patients undergoing cardiac operations. The low complication rate in conjunction with a cosmetically acceptable result makes this procedure the method of choice for selected patients. The potentially higher risk of infection should not be overlooked when planning the operation.

[Surgical treatment of Bland-White-Garland syndrome in infants and children: experiences with revascularization techniques]. / Zur chirurgischen Behandlung des Bland-White-Garland-Syndroms bei Säuglingen und Kindern: Erfahrungen mit Revaskularisationstechniken.

In comparison with the older technique of ligation of the anomalous coronary artery in Bland-White-Garland syndrome, the various methods of revascularisation have in common the concept of a two coronary artery system. Between 1980 and 1992, 10 children from 6 weeks to 11 years of age (mean 2 years) underwent revascularisation: direct reimplantation of the coronary ostium from the pulmonary artery to the aorta (n = 7), modified implantation with coronary artery elongation (n = 1), bypasses using subclavian artery (n = 1) or the mammary artery (n = 1). Postoperatively, 2 infants died, both following direct reimplantation, resulting in an overall mortality of 20%. There was no late death. All children but one are asymptomatic and do not require medication on follow up for between 3 months and 12 years (mean 5 years) after the procedure. Echocardiography, cardiac catheterisation, and scintigraphy show a significant improvement of left ventricular function and, as a direct consequence, a decrease in preexisting mitral insufficiency. Hence any surgical manipulation at the mitral valve should be avoided at the initial operation. As a principle, the revascularisation procedure should be performed at the earliest possible time to avoid further ischemic myocardial damage. On long-term follow-up, ventricular function and prognosis of the residual low-degree mitral insufficiency remain unclear and require regular control examinations.

[Splenectomy in idiopathic thrombocytopenic purpura: short- and long-term results (author's transl)]. / Splenektomie bei idiopathischer thrombozytopenischer Purpura. Kurz- und Langzeitergebnisse.

The results of splenectomy in 25 patients with chronic idiopathic thrombocytopenic purpura (ITP) are reported. Splenectomy was performed when the platelet count was consistently less than 30,000/mm3 in spite of glucocorticoid therapy over an observation period of at least six months. Following splenectomy, 13 patients showed complete remission, 9 partial remission, whilst in 3 cases the condition was unaffected by splenectomy. It is not possible to predict a successful response to splenectomy on the basis of preoperative laboratory findings. A rise in thrombocyte count to over 400,000/mm3 during the first 2 weeks after splenectomy makes complete remission very likely.

[Diagnosis and therapy of supravalvular aortic dissection (type A)--an interdisciplinary challenge]. / Diagnostik und Therapie der supravalvulären Aortendissektion (Typ A)--Eine interdisziplinäre Herausforderung.

Acute dissection of the ascending aorta is a life-threatening disease. Successful management requires close teamwork of internal medical specialist, radiologist and cardiovascular surgeon. The diagnostic and therapeutic approach is reviewed on the basis of 18 of our own cases - 15 men and 3 women aged from 42 to 88 years. Peculiarities of history, pain and ECG give valuable clues to the differentiation of aortic dissection from myocardial infarction and massive pulmonary embolism. As a non-invasive rapidly available diagnostic method echocardiography may yield decisive information about the aortic root and the presence of pericardial effusion. Definite confirmation of diagnosis is accomplished by aortography and/or computed tomography. Blood pressure and aortic flow must be decreased to the lowest level tolerated by the patient to prevent pericardial tamponade or rupture into the mediastinum. The urgency of surgical repair is underlined by a median survival time of 12 hours from onset of symptoms to death with conservative treatment. 7 of our patients were operated on. In 6 cases surgery was performed by means of extracorporeal circulation and the ascending aorta was replaced by a graft. 3 patients survived the operation (2 for over 2 years and three died in the postoperative period due to cerebral and pulmonary complications). In one case with inoperable dissection an axillo-femoral bypass was performed for relief of complete ischaemia of the left lower limb. Postoperatively, maintainance of the patient's blood pressure at the low normal level ist mandatory.