[Acute jaw-thoracic pain and syncope in a 41-year-old man]. / Akuter Kiefer-Thorax-Schmerz und Synkope bei einem 41-jährigen Patienten.

A 41-year-old physically active man with no significant past medical history presented with sudden thoracic pain. The patient was referred to the next tertiary care hospital. A CT scan showed an ectasia of the ascending aorta with irregularities of the aortic wall without dissection. Despite initial refusal, the patient was referred to a university hospital with experience in aortic surgery. A triphase ECG-synchronized cardiothoracic flash protocol performed on a 256 line CT scanner confirmed an aortic intramural hematoma and a covered aortic perforation. Shortly afterwards the patient collapsed and had to be resuscitated.

Hypothermic circulatory arrest with "low flow" lower body perfusion: an experimental feasibility study of microcirculatory parameters.

BACKGROUND: To avoid extended cardiopulmonary bypass (CPB), moderate temperatures are commonly accepted for hypothermic circulatory arrest (HCA), thereby jeopardizing organ protection. Distal aortic perfusion may be an option, but supportive experimental data is missing. METHODS: Eight juvenile pigs (36 ± 2 kg) were cooled to 30 °C followed by 60 min of HCA with 50 min of low flow (LF) lower body perfusion. Multimodal monitoring was used to measure overall metabolism, hemodynamics and microcirculation of the terminal ileum. The animals were observed for four hours following reperfusion. Organs were harvested for histopathological evaluation. RESULTS: During LF perfusion, initially elevated l-lactate levels decreased subsequently ( P < 0.05). Capillary blood flow decreased during cooling to 50 % baseline levels ( P = 0.03), but remained stable under LF conditions. Parameters indicative of reduced liver and kidney function were slightly elevated at the end of the experiment, but still within normal ranges. CONCLUSION: Under moderate hypothermia, low flow perfusion seems to provide adequate protection for the lower body organs. Microcirculatory parameters during perfusion as well as lactate levels within normal ranges throughout the experiments further confirm the concept.

Treatment of acute aortic dissection type A (AADA): technical considerations.

Aortic dissection is one of the the most common and lethal catastrophes involving the aorta. Speedy diagnosis, as well as appropriate therapy are essential for survival of the patients. Because the clinical presentation in patients suffering AADA can differ substantially, discussion concerning specific surgical therapy remains controversial. This implies questions regarding the treatment of the aortic root as well as the aortic arch and the proximal descending aorta. The current manuscript raises important issues regarding surgical treatment of AADA patients which are discussed in the light of the institutional policy in the author's department.

Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study.

BACKGROUND: Bleeding diathesis after aortic valve operation and ascending aorta replacement (AV-AA) is managed with fresh-frozen plasma (FFP) and platelet concentrates. The aim was to compare haemostatic effects of conventional transfusion management and FIBTEM (thromboelastometry test)-guided fibrinogen concentrate administration. METHODS: A blood products transfusion algorithm was developed using retrospective data from 42 elective patients (Group A). Two units of platelet concentrate were transfused after cardiopulmonary bypass, followed by 4 u of FFP if bleeding persisted, if platelet count was < or =100 x 10(3) microl(-1) when removing the aortic clamp, and vice versa if platelet count was >100 x 10(3) microl(-1). The trigger for each therapy step was > or =60 g blood absorbed from the mediastinal wound area by dry swabs in 5 min. Assignment to two prospective groups was neither randomized nor blinded; Group B (n=5) was treated according to the algorithm, Group C (n=10) received fibrinogen concentrate (Haemocomplettan P/Riastap, CSL Behring, Marburg, Germany) before the algorithm-based therapy. RESULTS: A mean of 5.7 (0.7) g fibrinogen concentrate decreased blood loss to below the transfusion trigger level in all Group C patients. Group C had reduced transfusion [mean 0.7 (range 0-4) u vs 8.5 (5.3) in Group A and 8.2 (2.3) in Group B] and reduced postoperative bleeding [366 (199) ml vs 793 (560) in Group A and 716 (219) in Group B]. CONCLUSIONS: In this pilot study, FIBTEM-guided fibrinogen concentrate administration was associated with reduced transfusion requirements and 24 h postoperative bleeding in patients undergoing AV-AA.

Significance of infection markers and microbiological findings during tissue processing of cryopreserved arterial homografts for the early postoperative course.

BACKGROUND: To evaluate homograft implantation for the urgent treatment of vascular infections on the basis of the course of infection using microbiological findings in perioperatively obtained specimens and during homograft processing. PATIENTS AND METHODS: 85 patients were treated with cryopreserved homografts from 2004-2007. The microbiological findings of the decontamination process of homografts in the tissue bank were evaluated. The perioperative infection profile (microorganisms, CRP, leukocytes, body temperature) of the patients was analysed. RESULTS: Complete microbiological and clinical follow-up for the postoperative course was available for 35 patients, who were treated with homografts from the same tissue bank and finally included into this study. 55 cryopreserved homografts were implanted. 35/55 (64%) homografts were positive for microorganisms before decontamination. 3/35 (9%) homografts remained positive after the decontamination. 33 patients were operated for prosthetic graft infection and 2 for an infiltration of a large vessel from neighbouring malignant disease. The most common infection agent was Staphylococcus aureus. Thirty-day mortality was 20% (7/35). Only in 4/35 (11%) patients were the microorganisms of the intraoperative swabs also detected during the postoperative course. The microorganisms were ORSA, Enterococcus faecium, Enterobacter aerogenes and Burkholderia cepacia. The patient with ORSA infection died on POD 11 from multiple organ failure and all other patients recovered. None of the postoperative swabs showed the homograft predecontamination microorganisms. Interestingly, a significant association (P = 0.003) between C-reactive protein increase two weeks after surgery and donor-recipient ABO mismatch was found. CONCLUSIONS: The implantation of homografts following the established decontamination is an alternative urgent therapeutic option in vascular infections with encouraging outcomes. The absence of the predecontamination focus in the postoperative specimens of patients, suggests that the postoperative course and outcomes show no strong relation to potential homograft contamination prior to the decontamination process.

The role of cerebrospinal fluid S100 and lactate to predict clinically evident spinal cord ischaemia in thoraco-abdominal aortic surgery.

OBJECTIVE: Detecting spinal cord ischemia early during replacement of the thoracoabdominal aorta remains a challenge. In a high risk population, we have re-evaluated the potential impact of ischaemia/damage markers (S100, lactate) in the peripheral blood and CSF for perioperative patient management. PATIENTS AND METHODS: Thirteen patients undergoing replacement of the thoracoabdominal aorta (6 female, age 63 (27-71)) with continuous CSF pressure monitoring and drainage were entered into the study. A total of 485 CSF (C) and serum (S) samples were collected and analysed for S100, lactate and glucose. RESULTS: Two patients suffered from spinal cord injury (SCI) (15%). During and early after surgery, there was a strong correlation between C-S100 levels (r=0.79) and C-lactate levels (r=0.77) with time in patients with SCI. In patients with SCI C-lactate levels increased soon after aortic cross-clamping, whereas C-S100 levels did not become significantly elevated until 6 hours after cross-clamping. CONCLUSION: An increase of C-lactate occurs much earlier than the increase in C-S100 in patients with SCI. Both parameters may be used to adjust protective and therapeutic measures intra- and postoperatively.

Homograft patch repair in carotid artery rupture.

The case of a 24-year-old man with a rupture of the left common carotid artery and history of intravenous drug abuse is presented. Due to absence of a suitable autologous vein segment the carotid bulb was repaired with a human allograftpatch.

[Vascular interventions and reconstructive plastic surgery. Optimizing the treatment of chronic wounds]. / Gefässchirurgische Interventionen und plastisch-rekonstruktive Chirurgie. Ergebnisoptimierung in der Behandlung chronischer Wunden.

Despite the high prevalence of arterial occlusive disease, only a few studies have investigated the benefit of interventions to recanalize extremity arteries prior to plastic operations to close chronic wounds. The purpose of this study was to investigate the correlation of simple clinical examinations and apparative diagnostics of arterial occlusive disease of the lower extremity in patients with chronic wounds and to evaluate the benefit of vascular procedures to optimize wound perfusion before surgical closure. A total of 150 individuals with chronic wounds were included in this retrospective study. All patients underwent palpation of their foot pulses, Doppler sonography, and measurement of occlusive pressure. Positive results were tested by angiography. All patients with peripheral extremity vessel occlusion underwent vascular interventions prior to plastic operations for definitive wound closure. In all 34 patients with missing foot pulses, the clinical diagnosis of arterial occlusion could be confirmed by angiography. Peripheral recanalization and improved wound perfusion could be achieved in all patients. Arterial insufficiency could be diagnosed rapidly and safely using simple clinical examination such as palpation of foot pulses or measurement of occlusive pressures combined with Doppler sonography. Thus this simple and straightforward algorithm helped to secure the success of surgical therapy by shortening the time until wound-healing and reducing the psychosocial burden on the patient and financial costs to the health care system.

Severe obstructive calcifications affecting the descending and suprarenal abdominal aorta without coexisting peripheral atherosclerotic disease--coral reef aorta.

The case of a 58-year-old woman with leg claudication due to a very rare form of atherosclerosis affecting the descending thoracic and abdominal aorta--known as coral reef aorta--without involvement of the femoro-distal vessels is reported. The patient was treated with a polyester bifurcation graft from the proximal descending aorta to both common iliac arteries via a left dorsal mini-thoracotomy and a second left retroperitoneal approach. This unusual approach was chosen instead of direct aortic replacement in order to prevent paraplegia. In case of future visceral or left renal malperfusion the diseased artery can be connected to the prosthesis directly or by the use of an additional bypass graft. This would not be the case with a conventional axillo-bifemoral graft.

[Minimally invasive therapy options in aortic dissections]. / Minimal-invasive Therapieansätze bei der Aortendissektion.

Current day therapy for aortic dissection is aimed at the relief of branch vessel ischemia and the prevention of aortic rupture or aneurysm formation. Malperfusion complicating aortic dissection has historically been treated by surgery. Operations in patients with branch-vessel involvement may be technically difficult and the operative mortality is reported to be between 25% and 51%. This may rise to above 70% in patients with critical mesenteric or renal ischemia. Over the past decade, successful relief of such ischemia using the interventional radiological techniques of balloon fenestration, stent implantation and/or thrombolysis has been reported. In addition to being less invasive, this approach is associated with a lower mortality, ranging between 0% and 25%. Patency of the false lumen increases the probability of aortic rupture or aneurysm formation. Recent studies have reported successful closure of the proximal entry site with the help of stent grafts. The aim of the intervention is to initiate a thrombosis of the false lumen and thus stabilize the dissection. Based on a review of the literature and our own experience, we discuss the percutaneous management of branch vessel ischemia complicating aortic dissection as well as the role of stent graft implantation in patients with aortic dissection.

Effects of the ABO-mismatch between donor and recipient of cryopreserved arterial homografts.

AIM: Cryopreserved arterial homograft (CAH) is a well-established substitute material for in situ reconstruction of vascular infections. However, their degeneration remains serious complication. Although several studies propose ABO-mismatching between CAH-donor and -recipient as the main reason, the results are controversial. We compared the outcome between ABO-compatible and ABO-incompatible CAH recipients to evaluate the contribution of ABO-mismatching. METHODS: Between January 2004 and December 2007, a retrospective review in 32 patients who underwent CAH-implantation was performed. The patients were divided in ABO-incompatible (group A: 17/32 patients; 53%) and ABO-compatible (group B: 15/32 patients; 47%) to CAH donor. Leucocytes, platelets and C-reactive protein (CRP) levels were recorded during the in-hospital stay. These were correlated with the surface of implanted homograft (SIH). Mid-term survival- and freedom-from-reoperation (FFR) rates were also calculated. RESULTS: In both groups, peak of leucocytes and CRP was recorded on third postoperative day (POD3) and regarding platelets lowest values on POD1. Interestingly, a second CRP-peak was reported on POD8 in group A (A: 172±104mg/L vs. B: 75±55mg/L, P=0.01). No relationship between second CRP-peak and SIH was found. After 27 months median follow-up (range, 5-49 months), survival- (65% vs. 84%, P=0.28) and FFR-rates (94% vs. 93%, P=0.98) remained comparable. CONCLUSION: We consider that the second CRP-peak expresses an early cytoimmunologic response of ABO-incompatible recipients against CAH. However, we did not find any relationship between ABO-incompatibility and poor mid-term outcome in terms of reoperation or mortality. Longer surveillance of our patients is mandatory.

Carotid endarterectomy with or without concomitant aortocoronary bypass in elderly patients: an analysis of 599 procedures.

AIM: Carotid endarterectomy (CEA) has been established as an effective treatment of carotid artery disease. Controversial remains the performance of CEA in elderly patients. Aim of this study is to report the mid-term (30 days) neurological outcome in patients older than 75 years after CEA with or without simultaneous aortocoronary bypass (CABG). METHODS: 599 patients undergoing CEA from January 2000 to December 2007 were enrolled. Isolated CEA was performed in 398/599 (66%) patients (group A). In 201/599(34%) patients (group B) was performed a combined procedure (CEA/CABG). 90/398(23%) patients of group A (group A1) and 49/201(24%) patients of group B (group B1) were >75 years old. 308/398 (77%) patients of group A (group A2) and 152/201 (76%) patients of group B (group B2) were <75 years old. Mortality, TIA and stroke rates as well as pre- and postoperative Rankin scale (RS) were reported. RESULTS: In isolated CEAs, mortality was higher in group A1 (A1:1.1% vs A2:0%, P=0.51). We found no significant differences in rates of TIA (A1:4.4% versus A2:3.2%, P=0.79) or stroke (A1:2.2% versus A2:1.9%, P=0.98). In CEA/CABG, mortality was 0% in group B1 and 5.9% in group B2 (P=0.17). No significant differences in rates of TIA (B1:2% versus B2:3%, P=0.76) or stroke (B1:2% versus B2:5%, P=0.70) were reported. Preoperative RS was the only positive predictor for postoperative stroke in groups A1 (P=0.02) and B1 (P=0.001). CONCLUSION: CEA is an appropriate and safe procedure in elderly patients. Under consideration should be the performance of CEA in elderly patients with high preoperative RS.

[Thoracic aortic surgery with circulatory arrest and cold cerebral perfusion]. / Thorakale Aortenchirurgie unter moderater Hypothermie und kalter Gehirnperfusion.

BACKGROUND: This study was undertaken to identify pre- and perioperative risk factors to mortality and permanent neurological dysfunction (PND) and temporary neurological dysfunction (TND) in a large patient cohort, all operated under moderate hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SACP) in a single centre. PATIENT AND METHODS: Between November 1999 and March 2006, 319 patients at a median age of 65 years (range 21-86, 201 male) underwent elective aortic arch surgery with moderate HCA at 25 degrees C and additional SACP at 14 degrees C. Sixty-nine had additional coronary artery bypass grafts or valve procedures. Ninety-four (29%) had total arch repair. Statistical analysis was carried out to determine the risk factors for 30-day mortality as well as for TND and PND. RESULTS: Overall mortality was 7.8% (15% in cases with repeat surgery vs 4.8% in nonrepeats, P=0.002). Twenty-seven (8.5%) suffered from PND, and six (22%) died during hospital stay (P=0.004). There was TND detected in 32 patients (10%). Stepwise logistic regression revealed age (P=0.001, OR 1.09/year), repeat surgery (P=0.008, OR 5.04), preoperative neurological events (P=0.004, OR 3.44), CAD (P=0.051, OR 3.58), and cardiopulmonary bypass duration (P<0.001, OR 1.01/min) as risk factors for mortality. The PND was associated with preoperative renal insufficiency (P=0.026, OR 3.34) and operation duration (P<0.001, OR 1.01/min), whereas TND occurred in patients with coronary artery disease (P=0.04, OR 2.41), and prolonged cardiopulmonary bypass duration (P=0.05, OR 1.01/min). CONCLUSION: Thoracic aortic surgery including aortic arch using HCA and SACP can be performed with excellent results in elective patients, especially those without previous surgery. Nevertheless PND is associated with high hospital mortality. Neurological complications seem to be strongly associated with general atherosclerotic changes as well as the extent of surgery.

Effects of ivabradine on allograft function and exercise performance in heart transplant recipients with permanent sinus tachycardia.

Aim of this retrospective analysis was to evaluate the effects of ivabradine given primarily as a heart rate-lowering agent on allograft function and cardiopulmonary performance in heart transplant recipients with permanent sinus tachycardia. Starting May 2006, 26 heart transplant recipients with permanent sinus tachycardia received ivabradine (5 mg bid). It was discontinued early in 3 patients (11.5%) due to adverse events. In the remaining 23 patients, resting heart rate (HR) was significantly lowered from 106.3 +/- 9.1 to 82.2 +/- 6.3 bpm after 3 weeks of treatment. The effect remained constant during the remaining treatment period, whereas resting blood pressure was not affected. After 12 weeks of ivabradine treatment, the corrected QT interval was significantly reduced into the range seen in normal individuals. Left ventricular (LV) end-diastolic posterior wall thickness, LV mass and LV mass index were also found to have decreased significantly. There was a trend to improvement of cardiopulmonary performance and LV ejection fraction, both of which did not reach statistical significance, however. It may be concluded that ivabradine successfully reduced the resting HR of heart transplant recipients with sinus tachycardia without negatively influencing the blood pressure. The definitive impact of ivabradine on LV mass regression and cardiopulmonary performance require further prospective, randomized and controlled trials.