Technique of implantation and removal of balloon catheters for the intra-aortic balloon counter pulsation.

During recent years, intra-aortic balloon counterpulsation has become the treatment of choice in patients suffering from left ventricular power failure following cardiac operations. In our clinic IABP became necessary in 55 patients out of 1873 patients operated with heart lung machine during the period under study. The patients were studied in two groups. In Group I the intra aortic balloon counter pulsation was started only after there was no response to pharmacological agents, which often included high doses of catecholamines and vasoconstrictors. The mortality in this group was 74%. The second group consisted of patients treated since 1975. In this group, the counter pulsation was started early before ventricular damage was irreversible. In this group the survival was 52%. In addition we have paid careful attention to the technique of implantation of the balloon catheter, thrombosis prophylaxis during the counter pulsation and removal of any possible thrombi in proximal and distal segments to the arteriotomy with the help of Fogarty catheters together with the closure of the arteriotomy with a vein patch. The technique described has resulted in almost no peripheral vascular complications.

[Surgical management of traumatic thoracic aortic aneurysms using the TDMAC-heparin shunt]. / Chirurgische Behandlung des traumatischen thorakalen Aortenaneurysmas mit dem TDMAC-Heparin-shunt.

Rupture of the aorta frequently occurs in major blunt trauma to the thorax, but few patients survive long enough to develop a chronic aneurysm. A TDMAC-heparin-coated shunt was used for operative procedures on the thoracic descending aorta in 5 patients aged 18--40 years. The lesions constituted in 4 recent ruptures and 1 chronic aneurysm. In 3 cases the aneurysm was resected and replaced with a prosthetic graft. End-to-end aorta sutures were performed in the other two cases. One patient died of renal and pulmonary insufficiency. There have been no complications attributable the shunt. The advantage of this shunt include elimination of the need for systemic heparin, avoidance of hypertension during crosslamping, and adequate perfusion of the distal circulation without an interposed pump. Because of the ease of handling and low risk we consider the use of this shunt the preferred method for operative procedures on the thoracic descending aorta.

[Postoperatives acute renal failure after operations with extracorporeal circulation (author's transl)]. / Postoperatives Nierenversagen nach Operation mit extrakorporalem Kreislauf

An acute renal failure was observed postoperatively in 3,45% of 929 patients operated with the heart lung machine during the years 1970-1972. Because of the bad results of any therapy in the case of acute postoperative renal failure, the diagnostic procedures of the preoperative renal function were intensified of the preoperative renal function were intensified in order to prevent an acute postoperative renal failure. Therefore additional measurements of the creatinine clearance and in few cases radioisotopic clearance tests were done.

[Results of electrical pacing in patients with hypertrophic obstruction cardiomyopathy (author's transl)]. / Erfahrungen mit der Schrittmacherdauerbehandlung bei Patienten mit obstruktiver Kardiomyopathie

In patients with hypertrophic obstructive cardiomyopathy, left ventricular outflow gradient decreased about 56 per cent by way of electrical stimulation of the apex of the right ventricle. In 4 patients a permanent pacemaker was implanted. P-wave triggered pacemakers with electronic conduction-time of approximately 0 sec showed to be preferable. The decrease of left ventricle outflow gradient as well as of subjective complaints inclusively cerebral syncopes were remarkable.

[Treatment of postoperative sternal osteomyelitis (author's transl)]. / Die Behandlung der postoperativen Sternum-Osteomyelitis

Report on 5 cases of postoperative sternal osteomyelitis after cardiac valve replacement. In 3 cases evaluation of Pseudomonas aeruginosa in probes taken of sternal wounds. Treatment of the osteomyelitis with continuous irrigation and suction supported by excochleation of the fistulae and application of pure spongiosa chips to the bone defect of the sternum. Uncomplicated postoperative course in 4 patients. In 1 patient postoperative time too short for a final decision.

[Survival of 51cr-tagged red blood cells in patients with artificial heart valves (author's transl)]. / Die Uberlebenszeit 51Cr-markierter Erythrozyten nach künstlichem Herzklappenersatz

Survival of 51Cr-tagged erythrocytes is determined in 10 patients approximately 1 week after insertion of an artificial heart valve ("early hemolysis") and in 9 patients approximately 2 years after heart valve replacement ("late hemolysis"). Red blood cell survival is found to be significantly reduced in all patients following insertion of an artificial heart valve as compared to a group of control patients. Hemolysis is significantly more pronounced in the early postoperative phase than two years postoperatively. LDH and plasma hemoglobin are relatively good indicators of hemolysis but less reliable than the determination of t/2 Cr.

[The Haemonetics cell saver in open heart surgery (author's transl)]. / Erfahrungen mit dem Haemonetics-Cell-Saver in der offenen Herzchirurgie.

A prospective study in 20 patients undergoing open heart surgery showed that up to 48 per cent of the required transfusion volume could be provided by autologous centrifuged blood. Re-transfusion of the washed packed red cells free of cell debris, heparin and aggregate significantly reduced blood loss both during and after the operation. The haemonetics cell saver is a valuable aid in the auto-transfusion technique.

[Significance of terminal deoxynucleotidyl transferase in patients with acute leukemia and malignant lymphoma: results obtained by immunofluorescence assay (author's transl)]. / Bedeutung der terminalen Desoxynucleotidyltransferase bei akuten Leukämien und bei malignen Lymphomen.

Deoxynucleotidyl transferase (TdT) is of diagnostic and therapeutic importance in acute leukaemia and malignant lymphoma. Previous methods for determining TdT activity by biochemical assay are complex and require the use of radioactive substances. There now is available a specific antibody for immunofluorescent demonstration of TdT. The two methods were compared on samples from 43 patients with leukemia or malignant lymphoma. There was very good agreement. High TdT activity was found in 12 of 14 patients with acute lymphatic leukemia and in one of two with acute undifferentiated leukaemia. TdT activity was absent with acute and chronic myeloid leukaemia, chronic lymphatic leukaemia and non-Hodgkin's lymphoma of low malignancy. Immunofluorescence assay, although its results are of similar significance to that obtained with the biochemical tests, is simpler to do. Furthermore, it can be done on normal bone-marrow smear or lymph-node preparations and can be correlated with the morphological findings.

[Results of prosthetic heart valve replacement. Primary, secondary and emergency operations]. / Ergebnisse des prothetischen Herzklappenersatzes. Erst-, Zweit- und Notoperationen.

From 1962 to 1984, 2460 prosthetic valve implantations in the heart were performed at the Department of Surgery of the University of Heidelberg. In addition to 2291 primary surgical interventions, 169 re-interventions were carried out. 153 emergency operations were necessary. The frequency rate of operations increased continuously; 52% of the operations were performed at the aortic valve and 37% at the mitral valve. In 9% of the cases, two valves had to be replaced, and in 2% even three valve prostheses were implanted. The indications for re-intervention included prosthetic thromboses, paravalvular leakages and prosthetic valve endocarditis. The situations requiring emergency intervention differed from case to case. Early mortality, which had been initially high, could be considerably reduced due to increased experience in surgical technique, anaesthesia, intensive care and improved myocardial protection. The extent and quality of medical postoperative care will determine the success of medical rehabilitation and hence the future professional activity of the patient.

[Indications for ligation of ductus arteriosus Botalli persistens in premature infants]. / Indikation zur Ligatur des Ductus arteriosus Botalli persistens beim Frühgeborenen.

Ligation of patent ductus arteriosus can be safely performed even in the smallest prematures and may be life-saving. Medical treatment with prostaglandin-inhibitors may be substituted in selected cases. From 1976-1985 a total of 215 prematures was treated. 52 of those experienced spontaneous closure. In 68 infants closure occurred following indomethacin-treatment. 48 had operation after failure of medical therapy and 53 with contraindications to indomethacin were primarily operated. The overall mortality reached 20% and was highest among those with combined medical and surgical treatment.

[Clinical findings on heart myxoma (authors' translation)]. / Zur Klinik der Herzmyxome.

Clinical findings, diagnosis, and pathology of heart myxoma are discussed on the basis of personal experience with nine patients. There was a striking variety of signs and symptoms caused by tumor embolization, hemodynamic obstruction, and autoimmunologic reactions. Echocardiography is the method of choice, although angiography may still be necessary in atypical or negative echocardiographic findings. The tumor should be removed as soon as possible after diagnosis. There is danger of tumor embolization in the course of the operation. Long-term results are good, if resection of the tumors is performed before catastrophic complications occur. Morphologically, myxomas are genuine tumors characterized by myxomatous stromata and cells.

[Clinical and experimental studies on pulsatile and continuous flow during extracorporeal circulation (author's transl)]. / Klinische und experimentelle Studie über den pulsatilen und kontinuierlichen Fluss whrend des extrakorporalen Kreislaufs.

In 20 patients who underwent open-heart surgery, the plasma concentrations of glucose, insulin, glucagon, growth hormone, free hemoglobin, and cholinesterase were measured before, during and after pulsatile and continuous perfusion. Pulsatile flow was achieved by modification of a roller pump to effect rapid acceleration and slowing. The driving motor was interfaced with a control module to enable ECG-triggered perfusion. In addition to the clinical studies, investigations were performed in 9 dogs to assess the effects of pulsatile and continuous perfusion on liver and pancreas flow during total bypass. During pulsatile perfusion there was a significant increase in insulin which, however, was clearly diminished in relation to glucose levels. The response of the beta-cells was markedly more compromised after continuous than pulsatile perfusion. The secondary postoperative increase in insulin can be accounted for by intravenous administration of glucose and, particularly, after pulsatile perfusion, indicates an almost completely normal response of pancreatic beta-cells. As opposed to the effects of continuous perfusion, the low glucose, glucagon, and growth hormone levels, the insulin increase during and after pulsatile perfusion as well as normal cholinesterase values observed in association with pulsatile perfusion appear to be the result of improved pancreatic and hepatic function. This contention is supported by the experimental finding of significantly increased pancreas and liver perfusion during pulsatile perfusion.

[Subdiaphragmatic pacemaker implantation of pacemakers - results of 1150 implantations]. / Subdiafragmalna implantacija pacemakera - rezultati kod 1150 implantacija.

Permanent pacemaker are presently used on patients with chronic disease of the cardiac conduction system, with recurrent Adams-Stokes attacks, and with bradycardia. 1865 pacemakers have so far been implanted in the unit for special thoracic surgery in the University of Heidelberg from 1965 to 1978. In 1.150 (or 61%) patients the pacemaker was implanted using the subdiaphragmatic method. A lower transverse pericardiotomy was performed and the battery was located in the rectus abdominis sheath. In the remaining 715 (or 39%) patients, the electrodes were introduced transvenously and implanted in the endocardium. The battery unit in this case was located beneath the pectoral muscle. The transvenous approach was the method of choice until 1971; from that time onward the subdiaphragmatic approach gradually replaced it as the method of choice. Between 1971 and 1978 80% of the pacemakers were implanted directly into the myocardium whereas only 20% were introduced transvenously. The subdiaphragmatic method completely eliminates the frequent complications of the transvenous approach, such as dislocation of electrodes and others so that it now is our method of choice.

[Haemochron--a simple method of monitoring heparin level during extracorporeal circulation]. / Hämochron - einfache Methode zur Kontrolle des Heparinspiegels während des extracorporalen Kreislaufes.

Tow forms of heparin management during cardiopulmonary bypass were compared in order to analyze the role of the heparin level in relation to postoperative blood loss. The study was divided in three groups: In group I, the control group, 3 mg/kg body weight heparin was given as an initial dose and maintained at a dose of 1.0 mg/kg every 60 min during cardiopulmonary bypass; group II received the same initial dose, but additional doses were based upon the activated clotting time measured with a Haemochron; in group III, the Haemochron time was measured at 10-min intervals to establish a base value. In group II we found a significant decrease in postoperative blood loss as well as a decrease in the amount of heparin administered during cardiopulmonary bypass. In addition, fewer transfusions were required in the immediately postoperative period. In group III, wide variations in the activated clotting time curve were observed. No patients was underheparinized, but some had markedly prolonged Haemochron times.

Efficiency of cardioplegia in the presence of coronary occlusion.

Myocardial tissue pH and temperatures (MT) were continuously measured in dogs on total cardio-pulmonary bypass (CPB) after acute distal coronary artery occlusion. Measurements were performed in a collateralized area with myocardial blood flow (MBF) ranging from 20 to 80 ml/100 g-min (microspheres). Immediately after coronary artery occlusion the aorta was clamped and the heart perfused with a cardioplegic solution (Bretschneider HP, 41 ml/kg, 4 degrees C). Prolonged regional fibrillation was observed and MT fell to 20 degrees C in 10 min in the low perfusion area (LPA) and in 2 min in the control area (CA). Whereas MTs were practically identical 15 min after termination of cardioplegic perfusion the magnitude of H+ accumulation continued to be greater in the LPA. During blood reperfusion with the coronary snare released MBF was significantly lower in the LPA as opposed to the CA indicating a microcirculatory derangement. Accordingly the bipolar ECG revealed signs of regional ischemia even after 30 min of reperfusion. We conclude that myocardial protection may be inadequate in areas located distal to coronary occlusion. This is true not only in cases of acute severe ischemia but also when collateral resistance is sufficiently high to impede the flow of cold viscous cardioplegic solutions. Results derived from intermittent MT measurements may be erroneous because intramyocardial heat equilibration may mask the inhomogeneous cardioplegic perfusion.

[Comparative studies on pulsatile and continuous flow during extracorporeal circulation. Effects on liver function and endocrine pancreas secretion]. / Vergleichende Studie über pulsatilen und kontinuierlichen Fluss während des extracorporalen Kreislaufs. Auswirkungen auf die Leberfunktion und endokrine Pankreassekretion.

The effects of pulsatile and nonpulsatile flow pattern on pancreas and liver blood flow were studied in nine dogs on cardiopulmonary bypass (CPB). Furthermore, plasma levels of glucose, insulin, glucagon, growth hormone, and cholinesterase were compared in 20 patients subjected to open heart surgery with either pulsatile or nonpulsatile perfusion. Impairment of liver and pancreas function was significantly greater at the end of CPB and 48 h afterwards with nonpulsatile flow as compared with the pulsatile flow pattern. A decrease of intestinal blood flow that was demonstrated in dogs subjected to nonpulsatile perfusion could at least in part be responsible for the difference in postoperative organ function observed in patients after CPB.

[Iatrogenic foreign bodies in heart (author's transl)]. / Iatrogene Fremdkörper im Herzen

Two cases are reported of migrating Kirschner wires, which had been inserted for stabilisation of bony defects of the thoracic cage. The wires migrated in both patients to the heart and caused life threatening complications like pericardial tamponade, arrhythmias and cardiac insufficiency. Indications for removal of foreign bodies from the heart are discussed. Attention is drawn to the fact that the ends of Kirschner wires must be bent in order to prevent migration.

Tissue glue for sealing plastic valves and bioprostheses in the canine aorta.

In experiments on seven dogs, a fibrin glue was used to seal plastic valves and bioprostheses in the thoracic aorta. Each valves was fixed in place with only four single sutures. Intraoperative and postoperative angiographic checks, with countercurrent aorta filling, gave no indication of perivalvular leak, even after eight weeks. Histologic studies confirmed the angiographic findings and showed only slight changes in the aortic wall. The results indicate that application of fibrin glue, supplementary to conventional suture procedure, may be useful when satisfactory fixation of aortic valves is hampered by pathologic circumstances.