The critical role of aprotinin in controlling haemostasis in conjunction with non-pharmacological blood-saving strategies during routine coronary artery bypass surgery.

OBJECTIVE: Aprotinin, a non-specific serine protease inhibitor, has been confirmed to be safe and effective in reducing intra- and postoperative blood drainage, transfusion requirements, and perioperative morbidity and mortality during coronary artery bypass surgery. It is the only one of the currently available haemo-static agents that is approved by the U.S. Food and Drug Administration (FDA) for use in cardiac surgery. However, one major weakness of currently available trials is the lack of information regarding the concomitant usage of aprotinin with blood-saving strategies that have been used more frequently in recent years. METHODS: Patients undergoing elective first-time coronary artery bypass grafting (n = 172) who were given systemic high-dose aprotinin (n = 85), combined systemic high-dose aprotinin and topical aprotinin (n = 27), or no aprotinin (n = 60) were reviewed retrospectively. The use of all blood-saving procedures was systematically taken in account. RESULTS: Postoperative blood drainage was significantly less in patients treated with aprotinin than controls (P < 0.0001). Concomitant use of topical aprotinin was accompanied by a postoperative blood loss reduction of 35% compared to systemic aprotinin use alone (P < 0.003). The intra- and postoperative donor blood requirements were dramatically reduced in both aprotinin-treated groups compared to controls, although patients received different blood saving strategies as appropriate (P < 0.0001). A trend of up to 20% lower postoperative blood drainage was noted in patients in whom intraoperative haemodilution and autologuos blood transfusions were used (P > 0.05). CONCLUSIONS: The present analysis demonstrates that the local and systemic administration of aprotinin is safe and effective in reducing intra- and postoperative blood drainage and transfusion requirements. In elective CABG procedures, aprotinin should still be used even if blood-saving strategies are employed.

Transesophageal two-dimensional echocardiography in the diagnosis of cor triatriatum in the adult.

Two adult patients with left ventricular inflow obstruction are presented. Conventional two-dimensional echocardiography had failed to yield a definite diagnosis, whereas transesophageal two-dimensional echocardiography clearly documented a membraneous echo structure within the left atrium, diagnostic of cor triatriatum. On the basis of the transesophageal echocardiographic findings, left heart catheterization and angiocardiography were not performed and both patients successfully underwent cardiac surgery.

Intracoronary thallium 201 scintigraphy as an immediate predictor of salvaged myocardium following intracoronary lysis.

Since February of 1980, 157 patients who had had symptoms of acute myocardial infarction for less than 3 hours underwent intracoronary lysis. Forty-six patients required early aorta-coronary revascularization. However, operation was believed to be indicated only when intracoronary lysis was successful and myocardium was salvaged. Since left ventricular angiography proved unreliable in assessing the viability of the myocardium in the acute stage, starting in March of 1981 we obtained intracoronary thallium 201 scintiscans in 23 patients before and after intracoronary lysis. Patients in whom there was a significant reduction (greater than 50%) in the initial 201Th defect (n = 12) were considered ideal candidates for operation (Group 3). Patients with poor or unimproved 201Th uptake after successful intracoronary lysis (n = 6) were treated medically (Group 2), as were patients in whom intracoronary lysis was unsuccessful (n = 5, Group 1). In order to validate this new approach, we compared the change in the regional wall motion of the "infarcted area," as shown in the early and follow-up left ventricular angiograms in all three groups. In the acute stage, the mean regional ejection fraction was 19.9% in Group 1, 19.1% in Group 2, and 20.1% in Group 3. Only in Group 3 was there a significant increase in regional ejection fraction to a mean of 51%. The mean ejection fraction obtained at follow-up in Groups 1 and 2 was 16.5% and 17.3%, respectively. From our findings, we conclude that 201Th scintigraphy is a valuable predictor of the salvageability of myocardium immediately following intracoronary lysis. To date, it has been the most valuable tool in assessing those patients suitable for early coronary revascularization.

Long-term hemodynamic benefit of atrial synchronization with A2A2D or A2A2T pacing in sinus node syndrome after orthotopic heart transplantation.

BACKGROUND: Exercise capacity after heart transplantation (HTx) may be limited by sinus node disease of the donor heart and atrioatrial dissociation. The role of pacemaker therapy in this setting is not well defined. The purpose of this study was to compare clinical and hemodynamic data of heart transplant recipients with acquired sinus node disease treated with atrial synchronized pacing and patients with other pacing modes or without pacemakers 1 year after operation. METHODS: Our cohort comprises a total of 112 HTx recipients from the years 1984 to 1996. Atrial synchronized pacing was performed in 21 patients with donor sinus node disease and recipient sinus rhythm. There was no associated morbidity or death for the pacemaker implantation. Fourteen patients received a dual-chamber pacemaker programmed with a short atrioventricular-Delay in A2A2D mode (donor atrial pacing triggered by recipient atrial sensing or both atria stimulated on demand); in the last 6 consecutive patients a single-chamber pacemaker was implanted with two unipolar leads to the atria connected with a Y adapter programmed in A2A2T mode (both atria were sensed and stimulated by triggering each other). RESULTS: Signals and thresholds remain stable over time. When clinical and hemodynamic data of 12 A2A2D/T patients with complete 1 year follow-up were compared to age- and sex-matched control HTx recipients with other pacing modes or without pacemakers, a significant benefit of atrial synchronization could be shown regarding rise in heart rate response to exercise (+38% vs 30% vs 16% at 50 watt), New York Heart Association classification (1.6 vs 1.8 vs 2.2), Roskamm staging (1.3 vs 2.5 vs 1.5), cardiac index at rest (3.2 vs 2.78 vs 3.1 L/min x m2), cardiac index at 50 watt (5.5 vs 4.5 vs 5.2 L/min x m2), stroke work at rest (51 vs 38 vs 42 pondmeter [PM]), stroke work at 50 watt (66 vs 48 vs 51 PM), pulmonary wedge pressure at rest (7 vs 13 vs 8 mm Hg) and pulmonary wedge pressure at 50 watt (14 vs 24 vs 18 mm Hg). CONCLUSION: It is concluded that electromechanical synchronization of the atria was of long-term benefit in heart transplant recipients with recipient sinus rhythm and donor sinus node disease.

Epidemiology of invasive mycosis in ICU patients: a prospective multicenter study in 435 non-neutropenic patients. Paul-Ehrlich Society for Chemotherapy, Divisions of Mycology and Pneumonia Research.

OBJECTIVE: To determine the epidemiological and clinical significance of invasive fungal infections in non-neutropenic patients in intensive care who stay longer than 10 days on the intensive care unit (ICU). DESIGN: Prospective epidemiological multicenter study over a period of 11 months, based on strict clinical, bacteriological, serological and histological criteria. SETTING: Six surgical and two medical ICUs units in five university and two municipal hospitals. PATIENTS: 435 non-neutropenic patients from medical and surgical ICUs with an ICU stay of more than 10 days. MEASUREMENTS AND MAIN RESULTS: A new occurrence of invasive mycosis (3 sepsis/4 peritonitis/1 disseminated candidiasis), corresponding to the protocol conditions with onset after day 10 in the ICU, was detectable in 2.0% (95% confidence interval 0.85 to 3.8%) of the 409 patients who could be assessed. Candida species were identified as an infection-relevant pathogen in all cases. The most important risk factor for the development of an invasive mycosis was the onset of peritonitis by the day 11 in the ICU (odds ratio 11.3; p = 0.003). A fungal colonization was detected in 64% of patients (Candida species 56%, Aspergillus 4%, and other fungi). Six of 8 patients with an invasive mycosis died on the ICU; ICU mortality in patients with fungal colonization was 31% and in noncolonized patients 26%. Serological tests were not helpful clinically. The sensitivity was 88% for the Candida HAT (haemagglutination test) (threshold titer > 1:160), 100% for the Candida IFT (immunofluorescence test) (threshold titer > 1:80), and 50% for the Candida Antigen Test (Candtec Ramco, threshold titer > or = 1:8), and the specificity was 26, 6, and 73%, respectively. The specificity for the Aspergillus HAT (threshold titer > 1:10) was 29%. CONCLUSIONS: Invasive mycoses are rare in non-neutropenic ICU patients, even after a longer stay in the intensive care unit; fungal colonization, on the other hand, is frequently detectable. The mortality of invasive mycosis--even with systemic antimycotic therapy--was high; the mortality in patients with fungal colonization was not significantly increased compared to that in noncolonized patients. The serological test procedures, Candida HAT, Candida IFT, and the Candida Ramco Antigen Test, had a low specificity and were not helpful in diagnosing relevant invasive mycosis.

Pharmacokinetic behavior of ciprofloxacin both in native cardiac and porcine valves treated in glutaraldehyde.

When judging a probable therapeutic success for antibiotic management of bioprosthetic endocarditis, sufficient drug levels in heterologous valve tissues play a very important role. The pharmacokinetic behavior of ciprofloxacin was investigated in native and porcine valvular tissues and compared with plasma levels during a 90- to 120-min period of surgery. Analysis was carried out by HPLC using excised valvular tissues (Hancock T 505). In all, 15-20 patients were investigated in each group. The antibiotics were administered intravenously or per os. Tissue concentrations after onset of the procedures showed ciprofloxacin plasma concentrations of 2.09-0.47 micrograms g in the native and 3.98-1.99 micrograms/g in the heterologous valvular tissues.

Results of aortic valve replacement with pulmonary and aortic homografts.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement with cryopreserved human pulmonary or aortic valves (homografts) is an attractive alternative to the implantation of mechanical valves or bioprostheses, as anticoagulation can be avoided and a near-normal anatomy restored. However, few reports exist on the long-term follow up of patients with this type of valve. METHODS: Between 1990 and 1997, a total of 64 homografts were implanted in 62 adults (mean age 42 +/- 12 years) with non-endocarditic valve lesions (insufficiency, n = 16; stenosis, n = 20; combined lesions, n = 12; redo, n = 16). In total, 23 pulmonary grafts (PG) and 41 aortic grafts (AG) were used. Valves were obtained from the European Homograft Bank in Brussels. Two patients with aortic homografts were lost to follow up; the others were examined clinically and echocardiographically at yearly intervals (mean 3.6 +/- 2.0 years). Children aged less than 16 years (n = 21), and patients receiving a homograft due to endocarditis (n = 28) or during a Ross procedure (n = 16) were excluded from the study. RESULTS: Three patients (5%) died due to early postoperative complications (two with AG, one with PG). Three PG had to be explanted due to primary malfunction, and five (total 35%) during further follow up due to severe aortic insufficiency (at a mean of 3.3 +/- 1.8 years). In contrast, all AG were functioning at the end of the observation period (log rank test, p = 0.0001, chi-square test 13.9). The mean echocardiographic degree of regurgitation for PG was significantly higher than for AG (2.2 +/- 1 vs. 0.75 +/- 0.7, p <0.0001). The peak transvalvular gradient did not differ between groups (PG 12.3 +/- 9 mmHg vs. AG 16.7 +/- 10 mmHg, p = NS). In respect of perioperative parameters, patients with PG showed a significantly higher body temperature during the first seven postoperative days (37.3 +/- 0.6 degrees C vs. 36.8 +/- 0.3 degrees C, p = 0.003). All three patients with acute graft malfunction in long-term follow up had a perioperative febrile response without overt bacterial infection. CONCLUSION: In contrast to grafts of aortic origin, pulmonary homograft valves should not be used for aortic valve replacement because of their high rate of malfunction, both acutely and chronically. Higher postoperative body temperatures should lead to further investigations of possible enhanced immunoreactions against pulmonary homografts.

Banking of cryopreserved heart valves in Europe: assessment of a 10-year operation in the European Homograft Bank (EHB).

BACKGROUND AND AIM OF THE STUDY: The preparation, banking and distribution of cryopreserved heart valves has been carried out at the European Homograft Bank (EHB) in Brussels without interruption since January 1989. We present an assessment of the Bank's activities during this 10-year period. METHODS: Heart valve donors aged <62 years form three categories: multiorgan donors with non-transplantable hearts; recipients of cardiac transplantation; and non-beating heart cadavers with a warm ischemia time of less than 6 h. Past history and biology are checked for transmissible diseases. Dissection, incubation in antibiotics and cryopreservation in 10% dimethylsulfoxide with storage in liquid nitrogen vapors (about -150 degrees C), and quality control are according to the standards of the Belgian Ministry of Health. Cryopreserved valves are shipped to the implantation centers in a dry shipper at about -150 degrees C. RESULTS: Between January 30th 1989 and December 31st 1998, 1,817 non-transplantable hearts and 12 excised semilunar valves were obtained. In total, 2,077 valves (1,032 pulmonary, 931 aortic and 13 mitral) were decontaminated, cryopreserved and stored in liquid nitrogen vapor (six more valves were refrigerated). In total, 1,515 valves were discarded at different stages of the protocol, the main causes of rejection being significant macroscopic lesions (68.2% aortic and 26.67% pulmonary). Inadequate excision at procurement (10.37% pulmonary), persistent contamination after antibiotics (5.6%) and positive serology for hepatitis B and C and Q fever (5.4%) were other frequent causes for rejection. Among the 2,117 accepted valves, 1,398 were graded first and 719 second choice, mainly on the basis of morphology. In total, 2,090 cryopreserved valves and one refrigerated valve were implanted in 39 institutions between May 1989 and December 1998. Of requests, 10.02% could not be satisfied. In total, 967 pulmonary valves were implanted in the right ventricular outflow tract (RVOT); 424 during a Ross procedure, and 76 in the left ventricular outflow tract (LVOT). Of the aortic valves, 732 were implanted in the LVOT and 266 in the RVOT. Mitral homografts were used for tricuspid valve replacement in two cases, and in the mitral position in seven. Complications at distribution and thawing included 10 bag ruptures and 16 transversal conduit wall fractures. Of the valves shipped, 317 (13.16%) were not used and were returned safely in the dry shipper. Comparison of distribution rates in the first 5.5 and last 4.5 years of EHB activity shows: (i) a significant increase in pulmonary valve implantations in the RVOT (from 71.95% to 81.95%); and (ii) a marked increase (265%) in pulmonary homograft implantations as part of a Ross operation, and a significant decrease (28%) in aortic homograft implantation in the LVOT. CONCLUSION: While macroscopic lesions of procured aortic valves remain the most frequent and unavoidable cause of homograft rejection during quality control, the high percentage of inadequate surgical heart valve excision should be corrected. The rates of bacterial contamination and positive serology seem acceptable. Storage and shipping of cryopreserved homografts in liquid nitrogen vapor permits them to be spared very efficiently. The increasing use of pulmonary valves for RVOT reconstruction either in congenital heart disease or as part of the Ross procedure compensates for the limited availability of good quality aortic valves.

New nomenclature and computerized programme of graphics for the description and recording of aortocoronary bypasses.

In the process of drawing up a computerized operation reporting system, a nomenclature for the precise description of recently fitted or existing aortocoronary bypasses has been developed. This is based on a sequence of letters showing in one line which type of bypass has been fitted, the graft material used, the central anastomosis (source) as well as the peripheral anastomoses on the coronary arteries (objective). For this purpose, abbreviations of the customary terms in use in cardiac surgery have been used. A computer graphics programme has been created in parallel, enabling all bypasses (existing and/or new) to be sketched into the diagram of a heart with the aid of a mouse. The bypass nomenclature is automatically generated from the diagram, which can also be printed out as a sketch of the operation. The complete diagram of the heart plus data input forms enable the operation report to be compiled automatically. The nomenclature and the graphics programme are easily learnt, simplify work, can readily be incorporated into a computerized hospital organization and enhance documentation quality.

Smoking after heart transplantation: an underestimated hazard?

OBJECTIVE: Risk factors for the development of vasculopathy and malignancies as the most important causes of morbidity and mortality after heart transplantation are not well defined. METHODS: Univariate and multivariate Cox regression analysis of the data derived from our 84 survivors of more than 3 months after orthotopic heart transplantation between 1984 and 1996. Measurement of carbonmonoxide-hemoglobin blood levels with an ABL 520 analyzer. RESULTS: Recipient or donor age, the mode of immunosuppression, total-, LDL- and HDL-cholesterol, the HDL/LDL-ratio, triglycerides, hypertension, diabetes mellitus, CMV status and rejection episodes had no independent influence on total mortality or the occurrence of graft vasculopathy or cancer. By means of an intensive questionnaire (in case of deceased patients, by their relatives) and measurement of CO-Hb blood levels we detected a high rate of patients who smoked after transplantation (22/84 = 26%). Four patients confessed smoking after undergoing the blood test. Non-smokers were defined as denying it in the questionnaire and having CO-Mb levels < 2.5% in repeated measurements. All but one were smokers before heart transplantation. Mean consumption was 11 cigarettes per day. Five and 10 years survival was significantly reduced in smokers vs. non-smokers (37 vs. 80% and 10 vs. 74%, respectively, P < 0.0001). Survival curves diverged dramatically after 4 years of observation. Smokers had a higher prevalence of transplant vasculopathy as revealed by coronary angiography and/or autopsy (10/22 smokers vs. 2/62 non-smokers, P < 0.00001) and a higher rate of malignancies (7/22 smokers developed cancer, as compared to 4 cancers in 62 non-smokers, P = 0.0001). The primary site of cancer was the lung in 5/6 smoking and lymphoma in all non-smoking cancer patients. CONCLUSIONS: Our data show that the prevalence of smoking after heart transplantation may be relatively high, especially in former smokers. Repeated measurements of CO-Hb could be helpful in its detection. Despite a relatively low cigarette count, smoking is a major risk factor of morbidity and mortality after heart transplantation (HTx). Approximately 4 years of exposure time is needed to uncover its negative influence. These findings should lead to aggressive smoking screening and weaning programs in every HTx center.

Are pulmonary homografts subjected to pulmonary hypertension more appropriate for aortic valve replacement than normal pulmonary homografts? Results of echocardiography in a multicentric study.

OBJECTIVE: To compare the function in aortic position of cryopreserved pulmonary homografts subjected to pulmonary hypertension with that of normal cryopreserved pulmonary homografts. METHODS: Pulmonary valves (52) were implanted in aortic position in different cardiothoracic centres. The valves were classified as follows: Group I-pulmonary hypertension (procured from recipients of heart/heart-lung transplantation, 31 valves), Group II-normal pulmonary pressure (procured from cadavers and multiorgan donors, 21 valves). Regular echocardiographic follow-up was obtained by the implanting centers. Significant echo changes were defined as insufficiency > 2+ and/or stenosis producing a delta P > 30 mm Hg. RESULTS: Pulmonary homografts showed the following significant echo changes: in the Pulmonary Hypertension Group, 7, 27 and 33% at 12, 24 and 36 months, respectively; in the normal PA Group 10, 37.5 and 80% at 12, 24 and 36 months, respectively. In both groups the most common echocardiographic alteration was homograft insufficiency rather than stenosis. Thus, pulmonary homografts subjected to long-term pulmonary hypertension have significantly less echo changes than normal pulmonary homografts, especially after 12 months (chi 2: P < 0.036). CONCLUSIONS: These findings suggest that pulmonary valves subjected to pulmonary hypertension might be more appropriate than normal pulmonary homograft for aortic valve replacement, constituting a possible alternative in case of lack of aortic valve homografts. However, the failure of two out of five valves in the longer term must dictate caution while waiting further long-term results.

Are pulmonary homografts which were subjected to pulmonary hypertension more appropriate for aortic valve replacement than normal pulmonary homografts? A long-term multicentric echography study.

OBJECTIVE: To compare long-term results of the European Homograft Bank (LHB) cryopreserved pulmonary homograft in left ventricular outflow tract (LVOT) subjected to pulmonary hypertension with those subjected to normal pulmonary pressure. The mid-term study of this material published in 1997 showed different results. METHODS: Statistical analysis is calculated by the Kaplan-Meier survival curves, while differences in prevalence by the Log-Rank test. RESULTS: Follow-up (FU) was available in 69 cases (76.7%): 46 in group 1 and 23 in group 2. Five patients have been excluded from the study because of early homograft explantation (technical problems or early valve incompetence). Fourteen out of 43 cases of group 1 (32. 6%) and seven out of 21 cases of group 2 (33.3%) have been explanted after 2.5-88 months and 7-88 months, respectively. Significant echography changes have been found in 19 of 43 (44.18%) of group 1 and 11 of 21 cases (52.38%) of group 2 during the follow-up. Histology showed essentially wear and tear induced lesions. Mean FU was 36.9 (range, 6-88) and 41.3 months (range, 4-88) for group 1 and 2, respectively. No significant difference in the long-term outcome have been found between the two groups (P=0.38). CONCLUSION: Contrary to our previous echocardiography study of mid-term implants the long-term follow up of the PHGs implanted in the LVOT did not show better function of the pulmonary homografts subjected to pulmonary hypertension than those with normal pulmonary pressure. The high failure rate of the PHGs should discourage their use for LVOT reconstruction. Further echocardiography studies of remaining PHGs implanted in the LVOT, and gross and microscopic explant studies are required to judge on the definitive outcome of these grafts.

[Arterial digital subtraction angiography for demonstrating aortocoronary venous bypasses]. / Arterielle DSA zur Darstellung des aortokoronaren Venenbypass (ACVB).

We examined the patency of aortocoronary venous bypasses in 51 patients during the early postoperative phase by using non-selective contrast injection into the aorta with digital subtraction angiography. In all patients it was possible to evaluate the degree of patency by this method. The accuracy and value of this examination, as compared with other invasive and non-invasive methods, is discussed.

Induced ischemic cardiac arrest. Clinical and experimental results with magnesium-aspartate-procaine solution (Cardioplegin).

The risk of open heart surgery can be lowered by combination of different methods of myocardial protection. 1. Cardioplegia with a potassium free Mg-1-aspartate and Procaine-solution (Cardioplegin). 2. Coronary perfusion after ischemia longer than 35-40 minutes in case of excessive left ventricular hypertrophy or failure. 3. Hypothermia. Surface cooling gives an additional safety if coronary perfusion is not ideal possible in case of multiple coronary stenoses. For patients with this dispositions a continuous coronary perfusion with cardioplegic solution might be advisable, as it was presented by Gercken in his paper. This method was used three times already in human, but is still in an experimental stage.

[Surgical hand disinfection using alcoholic rubbing disinfectants]. / Chirurgische Händedesinfektion mit alkoholischen Einreibepräparaten. Eine Standortbestimmung.

Since 1965, besides the use of scrubbing disinfectants, a number of alcoholic handrub methods are employed in the surgical skin disinfection of the hands. These contain, in addition to the alcohols, substances such as phenols and among others, cation-active substances. The efficacy of the substances is examined by means of in vitro-tests and through investigations conducted under conditions approximating those in the practice in accordance with the guidelines set down by the German Society of Hygiene and Microbiology. The comparison between the alcohol-containing handrub disinfectants and the scrubbing methods indicates clearly that the latter achieve only a low germ-reduction effect. The investigation on 4 alcoholic handrub disinfectants showed an initial potent germ-reducing and a good long-term effect. When mechanical scrubbing of the hands is carried out in a timely relationship to the application of the handrub -method, it is found to be able to produce extensive dermal damages. The reduction in the transient microbial flora by means of the mechanical hand scrubbing is minimal. The study on the germ-reduction after surgical disinfection of the hands using alcoholic handrub disinfectants in combination with and without initial soap-scrubbing demonstrated no differences, neither in the number of sterile hands nor in the averages of germ-reduction. The investigations conducted confirmed the excellent efficacy of the alcoholic handrub disinfectants and pointed out that it is unnecessary to combine mechanical hand scrubbing and the employment of alcoholic disinfectants in the same process.

[Successful operation of a symptomatic aneurysm of the superior mesenteric artery in a child with Ehlers-Danlos syndrome]. / Erfolgreiche Operation eines symptomatischen Aneurysmas der Arteria mesenterica superior bei einem Kind mit Ehlers-Danlos-Syndrom.

Bleeding of an aneurysm--especially of a great vessel--represents a complication of Ehlers-Danlos syndrome that is often lethal. A successful operation of a symptomatic aneurysm of the superior mesenteric artery in a 12-year old girl with an Ehlers-Danlos syndrome type VI is reported. The aneurysm was resected and replaced by a venous graft. Four years postoperatively the artery is perfectly patent; a new aneurysm did not develop.

Alteration in thyroid hormone concentration during and after coronary bypass operation.

The effect of a surgical stress on serum TSH, T4, free T4, T3, rT3 and TBG was measured before, during and after a coronary bypass operation. Precautions were taken to age, sex, pre-operative nutritional state, anamnestic illness, pre- and post-operative medication. Compared to the pre-operative period TSH increased during operation and normalized at the first post-operative day, while only minor alterations for total and free serum T4 were observed. T3 and rT3 declined at the start of extracorporal circulation, T3 remained reduced during the post-operative period, while rT3 reached its pre-operative value at the first post-operative day. It is concluded that the coronary bypass operation evokes a rapid decline in T3, which is not normalized by the TSH induced response of the thyroid gland, while the post-operative period is characterized by a "low T3 state". The clinical relevance of this finding is discussed with respect to the cardiovascular and the nutritional state of the patients in the post-operative period.

Primary epiploic appendagitis and fructose malabsorption.

Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made when computed tomography (CT) reveals a characteristic lesion. We report on contrast-enhanced CT images of a patient with PEA and regression of inflammation and the reduction in size of the inflamed appendage over the time period of 4 months. Patients with PEA usually recover without medication or surgical treatment within a few weeks. However, due to continuing bloating and irregular bowel movements we investigated carbohydrate malabsorption and diagnosed a fructose malabsorption. Bloating and irregular bowel movements in this patient with PEA were correlated to carbohydrate malabsorption and were treated successfully with a diet free of culprit carbohydrates.