Aortopexy in severe tracheal instability: short-term and long-term outcome in 29 infants and children.

BACKGROUND: Tracheal instability is a hazardous situation after operation for esophageal atresia. In cases with life-threatening apneas, aortopexy is a therapeutic option. To assess efficacy, short-term and long-term outcome was analyzed retrospectively. METHODS: Between 1985 and 2000, 29 patients (age, 1.5 months to 5.2 years) were operated on. A flaccid trachea after operation for esophageal atresia was the cause for life-threatening apneas in 27, and there was external vascular compression in 2 patients. The operative procedure consisted of ventropexy of the aortic arch to the sternum and ventral thoracic wall. RESULTS: There was neither early nor late mortality. A reversible lesion of the phrenic nerve was observed in 2 patients, a pneumothorax in 3, and secondary wound healing in 1. In all but 1 patient symptoms improved markedly or disappeared within days or within the first 3 months postoperatively. An increased susceptibility to respiratory infections was observed in long-term follow-up. CONCLUSIONS: Aortopexy can be performed with no mortality and low morbidity. Aortopexy is effective to prevent further life-threatening apneas, but does not prevent an increased susceptibility to respiratory infections.

Intracoronary Doppler flow velocity measurements in two patients with solitary coronary ostium: is there true obstruction?

BACKGROUND: Coronary anomalies in the absence of other major cardiac malformations are rare, with an incidence of less than 1-1.5%. Although most have been incidental findings without clinical relevance, a subgroup of anomalies has been identified that are associated with cardiac symptoms or even sudden cardiac death. This subgroup includes an ectopic origin and abnormal course of the left coronary artery from the right sinus of Valsalva. RESULTS: We examined two patients with this anomaly. In patient I the left main coronary artery took a deep intramural course anterior to the pulmonary trunk, and in patient II the left anterior descending coronary artery took its course between the pulmonary trunk and ascending aorta. Both anomalies were identified by coronary angiography and that in patient I was confirmed by surgery. Intracoronary Doppler flow velocity measurements during cardiac catheterization, including atrial pacing in patient II, demonstrated significant flow acceleration in both patients. This occurred within the intramural segment (in patient I) and in the segment between the pulmonary artery and ascending aorta (in patient II). CONCLUSIONS: These findings indicate that external vessel compression is one pathophysiological mechanism that leads to ischaemia and a longstanding history of cardiac symptoms in these patients. Invasive haemodynamic measurements such as these have not previously been available.

[Superior vena cava occlusion. Demonstration of surgical therapeutic possibilities]. / Der Vena cava superior-Verschluss. Darstellung der chirurgischen Therapiemöglichkeiten.

Surgical problems in treatment of superior vena cava syndrome are discussed by our population of 15 patients and the literature. Nine patients which suffered from caval thrombosis were managed by thrombectomy. In four cases superior vena cava was bypassed or replaced by PTFE (Gore-Tex) tubular grafts successfully. Whereas autologous vein as spiral composite graft or complete venous conduit might be preferred by reason of excellent longtime patency rates, the every time available PTFE vascular prosthesis appears to be an efficient synthetic material for replacement of superior vena cava.

[Hemodynamics and differentiated CO transfer following fulminant lung embolism and pulmonary artery embolectomy and following recurrent lung embolism]. / Hämodynamik und differenzierter CO-Transfer nach fulminanter Lungenembolie und Pulmonalisembolektomie sowie nach rezidivierenden Lungenembolien.

Pulmonary embolectomy as an emergent surgical treatment after massive pulmonary embolism often is necessary in cardiogenic shock (CS) and even without previous diagnostic. If complete dissolution of the thromboembolus is possible or spreading of microemboli may occur is unknown. Therefore we studied 21 patients surgically treated by embolectomy, ten of these with consecutive cardiogenic shock (CS) and twelve patients after repetitive microembolism and cava-blocking. Besides lung-functional parameters for special CO-diffusion capacity (DLCO), differentiated in membrane (DM) and vascular (VC) component (Roughton and Forster), we measured mean pulmonary artery pressure (PAP) at rest and at exercise. Patients after repetitive embolism showed considerably more diminution of DLCO (-31%) than those after single massive embolic event (-15%) even concomitant by CS (-10%). Repetitive microembolism lowered VC by 21%. Slight decrease of DM was found after CS. Mean pulmonary artery pressure was elevated at rest (26 mm Hg) and exercise (33 mm Hg) after repetitive microembolism and normal after massive embolism or CS. Pulmonary embolectomy may prevent disturbances of DLCO or PAP even after CS. Damage of vascular integrity (VC) was found after microembolism. Pulmonary embolectomy seems to remove total embolic material and therefore seems to be optimal.

[Surgical treatment of congenital heart malformations. Indications and surgical management (author's transl)]. / Chirurgische Behandlung angeborener Herzfehler. Indikation, Operationszeitpunkt und chirurgische Möglichkeiten.

Congenital malformations of the heart have to be expected in approximately 0,8% of all newborns. The majority of them needs surgical treatment and can be corrected anatomically with a low operative risk (atrial and ventricular septal defects, patent ductus arteriosus, coarctation, valvular aortic and pulmonary stenosis etc.). Surgical repair of complex anomalies includes either palliative or functionally corrective procedures and has a much higher operative and early postoperative mortality (transposition of the great arteries, tetralogy of Fallot, tricuspid atresia etc.). Surgery becomes urgent in babies suffering from congestive heart failure and/or progressive severe hypoxia during the first months of life. Early total surgical repair or primary palliation and two-stage correction depends on the kind of anomaly and has to be selected individually. Hemodynamical classification, general distribution and surgical considerations of the most common congenital malformations of the heart are described.

[Aortic aneurysm and aortic injury--surgical treatment and follow-up]. / Aortenaneurysmen und Aortenverletzungen--Chirurgische Behandlung und Verläufe.

This study summarizes our experience with 90 patients (68 male and 22 female, mean age 57.2 years). From Jan. 1980 to Feb. 1990, 51.1% underwent surgery for dissection of the aorta; the rest for acute aortic ruptures, false and true aneurysms. Procedures with reconstruction of the aortic arch were performed in cases of deep hypothermia and circulatory arrest (no fatal courses). The overall death rate was 18.8% (emergency 29.5%, elective 8.7%). Acute dissections Type I had the highest perioperative mortality with 29.4%. The leading causes of early death were myocardial infarction (23.5%) and cerebral injury (23.5%). Therefore coronary angiograms should be performed preoperatively in older patients. A major problem in our experience is the long-term followup examination which should remain the surgeon's responsibility.

[Vectorcardiographic study on the right hypertrophy diagnosis in complete right bundle branch block]. / Vektorkardiographische Untersuchung zur Rechtshypertrophie-diagnostik bei komplettem Rechtsschenkelblock

Vectorocardiograms were led and interpreted by means of quantitative and qualititive criteria in 100 children with a complete block of the right bundle-branch occurring after correcting surgery of tetralogy of Fallot or isolated defect or the ventricular septum. The results are discussed after demonstrating the pathophysiological patterns of excitation associated with right ventricular hypertrophy and complete block of the right bundle-branch. After a survey of the literature a precise summary of the results is given in order to distinguish clearly by differential diagnosis necessary for postoperative observation of the vitiae cordis mentioned above, between complete block of the right bundle-branch and right ventricular hypertrophy. 4 vetorcardiograms were selected out of the total number of loops for demonstration of the defined criteria for right ventricular hypertrophy associated with complete block of the right bundle-branch.

[Myocardial metabolic status in various methods of inducing a reversible heart arrest]. / Myokardialer Stoffwechselstatus bei verschiedenen Verfahren zur Einleitung eines reversiblen Herzstillstandes.

In experiments with dogs, three different methods of inducing a reversible cardiac arrest were compared: (A) the ischemic arrest for 45 min, (B) the cardiac arrest for 90 min due to injection of Cardioplegin according to KIRSCH, and (C) the cardiac arrest for 90 min due to infusion of solution LK 352 according to BRETSCHNEIDER. The body temperature was reduced to 30 degrees C during the period of cardiac arrest. From the alterations in the adenylic acid system of the left ventricular myocardium at the end of the period of myocardial standstill and after 60 min of recovery, it can be deduced that the best myocardial protection is given by method C. Method A has the least effect.

Comparison of three methods of myocardial protection.

Ischemic arrest (45 minutes), injection cardioplegia (2-3 ml/kg body weight within 1 minute) using Cardioplegin (magnesium-aspartate-procaine-sorbitol) according to Kirsch (90 minutes), and infusion cardioplegia (30 ml/kg body weight within 5 to 7 minutes) employing solution LK 352 (sodium-potassium-magnesium-aspartate-sorbitol) according to Bretschneider (90 minutes) were investigated in dogs in order to evaluate their efficacy of protection during myocardial ischemia and their effects on post-ischemic cardiac function. Parameters studied were myocardial tissue levels of adenine nucleotides, creatine phosphate, total creatine and glycogen as well as heart rate, systemic pressure, cardiac output, LVEDP, left ventricular pressure-volume-work, dp/dtmax, t-dp/dtmax, (dp/dtmax)/IP, and Vpm. According to biochemical data corrected for differences in myocardial temperature during arrest, myocardial protection during aortic cross-clamping at a core temperature of 30 degrees C was increased 1.8-fold by Cardioplegin and 3.4-fold by LK 352 administration respectively when compared to ischemic arrest. Functional recovery was poor after ischemic arrest and better after Cardiplegin arrest. Infusion cardioplegia with LK 352 did not result in a post-arrest depression of functional parameters.

Biochemical monitoring of the lung during and after extracorporeal circulation.

The activity of NAG, lysozyme and PMN-elastase has been investigated in the superior vena caval and left atrium blood collected from patients who underwent open heart surgery. The effect of various types of respiration on the enzyme release has been also documented. Concentration gradients between v. cava sup. and left atrium has been used as an index for pulmonary damage post operatively. We found a time dependent increase of all enzymes during extracorporeal circulation. However, only the release of NAG and lysozyme is characteristic for pulmonary damage. We observed significant higher enzyme release from the lung after Apnea ventilation compared with the PEEP and low frequency ventilation group. Also significant higher NAG and lysozyme activity was found in patients who needed longer respiration post-operatively. PMN-elastase seems to be not suitable for diagnosis of post perfusion lung because the main amount of elastase released by mechanical destroy of the granulocytes.

The hemodynamics and contractility of the right ventricle in the early postoperative phase following correction of tetralogy of Fallot.

The hemodynamics, contractility and compliance of the right ventricle were examined during the early postoperative phase in 9 children operated for correction of tetralogy of Fallot. The same assessments were made in 5 patients after the transventricular closure of ventricular septal defects (control group). A further reduction of the PRV/LV quotient was observed in the Fallot group during the first 3 hours postoperatively. The contractility of the right ventricle (dp/dt max) was greatly reduced in all cases. The pressure/volume relationship of the right ventricle showed severe disturbance in compliance. The type of correction (with/without outflow tract patch or monocusp) did not appreciably affect the results. The hemodynamic changes observed in the control group (VSD) were considerably less pronounced. Apparently it is not the ventriculotomy but the infundibulectomy which is the traumatic factor of corrections in the area of the right ventricular outflow tract.

[Tracheal instability in tracheo-esophageal abnormalities]. / Trachealinstabilität bei tracheo-ösophagealen Fehlbildungen.

The clinical pattern of signs and symptoms of respiratory complications due to flaccid trachea has been analysed in 83 children treated in our hospital between 1983 and 1988 for tracheo-oesophageal malformations. These signs and symptoms are classified according to endoscopic findings, and are thus arranged according to various degrees of severity. Of the surviving children who were followed up and who were suffering from oesophageal atresia Vogt III B, only 5 of 57 were without a pointer towards flaccid trachea, whereas in oesophageal atresia Vogt II there were two of three. The two children with an isolated tracheo-oesophageal fistula showed abnormal findings both clinically and via endoscopy. 16 of the 20 children with very severely pronounced flaccid trachea--defined by the occurrence of life-threating apnoeas and an endoscopically identifiable tracheal collapse of more than two-thirds of the lumen--were subjected to surgery via aortosternopexy. A marked and identifiable improvement was obtained in 15 cases. Complications caused by surgery consisted of temporary phrenicus lesions in two cases.

Coronary angioscopy during cardiac catheterization and cardiac surgery.

Coronary angioscopy (CA) was performed in 30 patients (pts) during cardiac catheterization (Group 1) and in 11 pts during coronary bypass surgery (Group 2) using ultrathin fiberoptic angioscopes (phi 1.2-1.8 mm). For percutaneous CA (Group 1) the angioscope was introduced through a 9F guiding catheter from the femoral artery. The viewing field was cleared by flushing Ringer's solution and short-time occlusion of the coronary ostium by the guiding catheter. In Group 2 CA was performed retrogradely from the distal arteriotomy and through the bypass vein during flushing with cardioplegic solution. In Group 1 in 17/30 pts the coronary artery could be successfully examined by CA. In 13 pts the obstruction was eccentric and irregular shaped. In 2/5 pts, in whom CA was performed successfully pre and post balloon dilatation, CA after PTCA revealed an intimal rupture without clinical or angiographical signs of the intimal dissection. In Group 2 in 9/11 pts good visualization of stenoses could be achieved. At the obstruction site CA revealed thrombi in 3 pts and ulcer in 1 pts. In contrast to angiography, which estimates the lumen diameter of a segmental lesion, CA gives information about the luminal shape and the underlying substance of the obstruction (e.g. atheroma, thrombus, ulceration). The main problems in percutaneous CA are the insufficient intraluminal guidance, the insufficient depth of view of the angioscopes, and the limited examination time.

[In vivo reactivation of reduced T cell activity following polytransfusion caused by immune aggregates in immunoglobulin preparations]. / In-vivo-Reaktivierung reduzierter T-Zellaktivität nach Polytransfusion durch Immunaggregate in Immunglobulinpräparationen.

Surgery leads to an activation of peripheral blood lymphocytes, which is inhibited by polytransfusion. This effect could be eliminated by application of immunoglobulins. We think that immune aggregates in immunoglobulin preparations can stimulate T-lymphocytes.

[Global and regional left ventricular function following acute coronary artery occlusion and emergency aortocoronary venous bypass operation]. / Globale und regionale linksventrikuläre Funktion nach akutem Koronararterienverschluss und notfallmässiger aortokoronarer Venebypassoperation.

Complications following percutaneous transluminal coronary angioplasty (PTCA), such as coronary artery occlusion, spasm, or dissection, frequently require urgent surgical intervention. Out of 26 patients from our hospital, 12 who underwent emergency coronary bypass grafting because of balloon catheter complications with a total ischemic time of 100-255 min, were restudied in the late postoperative period by clinical examination and by coronary and left ventricular angiography. Left ventricular angiograms were evaluated quantitatively for global and regional function using the AVD system (Siemens Elema, Erlangen). Electronmicroscopic results from myocardial biopsy samples, taken intraoperatively from the presumed center of the ischemic zone, were compared with the clinical results. An improvement of left ventricular function parameters could be seen in patients with reperfusion intervals within 130 min. In the case of intermittent perfusion of the occluded vessel (catheter perfusion with arterial blood, intermittent spasm) operative revascularization proved to salvage jeopardized myocardium. There was a close correlation between the degree of left ventricular dysfunction and histological results, coronary morphology and clinical staging. In conclusion, the efficacy of myocardial protection by emergency bypass surgery depends mainly on coronary morphology and above all on reperfusion intervals.

[Para-aortic pseudoaneurysm following aortic valve replacement. Its diagnosis by magnetic resonance tomography]. / Paraaortales Pseudoaneurysma nach Aortenklappenersatz. Diagnose mit Magnetresonanztomographie.

Para-aortic pseudoaneurysms after prosthetic replacement of an aortic valve was diagnosed by magnetic resonance imaging (MRI) in two patients and confirmed at surgery. The abscesses had not been visualized in either case by computed tomography and echocardiography, but in one it had been demonstrated by angiography. MRI can thus precisely define site and extent of a para-aortic pseudoaneurysm after aortic valve replacement without any interference by artefact, noninvasively and without use of contrast media.

Lysosomal enzyme activity influenced by various types of respiration during extracorporeal circulation.

The hypoxic damage of the lung as seen after extracorporeal circulation (ECC) is in correlation to lysosomal hydrolase and protease activation. In the recent study the effect of various types of respiration during ECC on lysosomal enzyme release were studied. 53 patients undergoing open heart surgery were divided into 4 groups: Apnoea, low frequency, continuous positive airway pressure, combination of low frequency and continuous positive airway pressure. Paired blood samples were withdrawn from the superior vena cava (SVC) and the left atrium (LA) throughout the cardiopulmonary bypass. A continuous increase of N-azetyl-beta-D-Glucosaminidase (NAG) in venous plasma and significant differences (SVC-LA) with higher activities in the LA in the apnoea group were detectable (p less than or equal to 0.05-p less than or equal to 0.01). In the other groups a time dependent course could also be evaluated, but the changes of the activities were not significant. The different types of respiration during ECC influenced the clinical course and outcome of the patients in correlation to the release of lysosomal enzymes from the lung. It is concluded that concentration gradients of lysosomal enzymes are an index for pulmonary damage due to the extracorporeal perfusion in open heart surgery. The activation of lysosomal enzymes in the lung circulation are positively influenced by "ventilation" during ECC.

[Myocardial stress of different surgically induced types of cardiac arrest in dogs evaluated by myocardial potassium and acid-base balance (author's transl)]. / Die Herzmuskelbelastung unterschiedlicher kardiochirurgisch induzierter Herzstillstandsformen, gemessen am myokardialen Kaliumverlust und Säure-Basen-Verhalten im Tierexperiment.

In mongrel dogs myocardial stress of the following types of artificial cardiac arrest in moderate hypothermia and cardiopulmonary bypass was compared: 1. Ischemic arrest after aortic occlusion lasting 30 or 45 minutes. 2. Injection-cardioplegia according to Kirsch lasting 90 minutes. 3. infusion-cardioplegia according to Bretschneider lasting 90 minutes. The following parameters were compared: extracellular potassium activity ([K+]e) during cardiac arrest and [K+] in arterial and coronary venous blood during reflow, total [K+] and acid-base balance during reflow, time course of [K+] and lactic acid release and uptake during reflow after cardiac arrest. In our experimental conditions the lowest alterations of myocardial [K+] and acid-base balance were observed after infusion-cardioplegia according to Bretschneider. Injection-cardioplegia according to Kirsch was less protective for the heart as evidenced by more intensive acidosis, enlarged [K+] loss and prolongation of [K+] uptake during reflow. Ischemic cardiac arrest in moderate hypothermia was the worst type of artificial standstill indicated by development of fatal myocardial acidosis.