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BACKGROUND Medical malpractice claims against surgeons are increasing. In Germany, as in most other European countries, there is no central registry of medical malpractice claims. It is not known at which rate medical liability claims are decided in favor of the physician or the patient. METHODS All cases of reproaches of medical malpractice in which our clinic was involved within the 10-year period between 1989 to 1999 were reviewed. To compare our results with the general experience in the field of thoracic and cardiovascular surgery, we reviewed the data of the regional medical society in the same time period. RESULTS From 1989 to 1999, our Clinic was involved in 74 medical liability disputes. There were 28 reproaches of medical malpractice against our department (0.1% of cases performed). Malpractice was detected in only 7 of 74 claims (9.5%). Most reproaches were made for incorrectly performed operations (80%), but only 4 (6.8%) of 59 claims were regarded as medical malpractice. CONCLUSIONS Reliable data on reproaches of medical malpractice are virtually absent. Only 10% of all reproaches in our study were finally regarded as medical malpractice. A central registry of medical malpractice cases would allow analysis of the areas in which we have to improve performance, and how unjustified reproaches of medical malpractice can be avoided.

Background In patients undergoing left-ventricular assist system support, it has not been elucidated to which extent mechanical circulatory support itself as opposed to the underlying condition of endstage heart-failure contributes to perturbation of immune homeostasis. Methods In eleven heart transplant candidates who had to undergo Novacor left-ventricular assist device bridging, we prospectively sampled interleukin-6, T-cell and monocyte subsets and compared them to fifteen UNOS status II patients awaiting cardiac transplantation on medical heart failure treatment as outpatients at the time of LVAS implantation/listing decision as well as 2.0+/-1.2 months and 4.5+/-2.3 months later. In order to assess deviations in both groups from normal values, thirty-two healthy subjects served as reference group. Results Patients undergoing Novacor bridging had higher C-reactive protein, leukocyte, neutrophil, and monocyte levels at all three times, and exhibited lower CD3 +, CD4+, CD3+/CD45 RO T-cell and natural killer cell counts than medically treated patients awaiting transplantation 2 months after the LVAS implantation/listing decision. In comparison to controls, both groups had higher levels of inflammatory activation and lower levels of immunocompetence at all three times. Conclusions While both groups of endstage heart failure patients show immunological alterations compared to controls, patients who have to be bridged by the Novacor LVAS exhibit a more pronounced activation of inflammatory markers. This may be due to more advanced heart failure but the device itself also may contribute to more pronounced inflammation and a temporary suppression of immunocompetent cells.

Technological advances and growing expertise has lead to referral of much sicker patients with a greater incidence of heart failure prior to and after cardiac surgical procedures. The diversity of the heart failure patient cohort mandates a differentiated protocol for mechanical support adapted to the clinical requirements. It is desirable to have appropriate mechanical support available for different circumstances of heart failure. In this paper, we review the first decade of the Muenster University Hospital experience with the use of intra-aortic ballon pump, extracorporal membrane oxygenators, short term uni- and biventricular assist systems such as Thoratec and Medos devices, as well as long term left ventricular assist systems such as the TCI Heartmate and the Novacor system. The patient profiles, indications, contraindications, and future trends are reviewed within the framework of a contemporary university hospital Servive.

Implantable left-ventricular assist devices (LVAD) are successfully used as a bridge to transplant if the patient's condition is worsening and no donor organ is available. They allow recovery of compromised organ function. However, postoperative bleeding, thrombemboelism, and right-heart failure may jeopardize the important improvement of organ function and may even lead to death. We introduce our strategy for implantation of the Novacor LVAD system, which aims at minimal bleeding and maintained right-heart function. The Novacor LVAD was implanted with the heart beating during extracorporeal circulation in 8 patients, 3 of whom had previous cardiac surgery. Postoperatively, no patient developed right heart failure or had to undergo redo thoracotomy.

BACKGROUND Left-ventricular assist device implantation (LVAD) is still associated with thromboembolism as the optimal anticoagulation is still unclear. We report on the effects of adding platelet inhibitors to our anticoagulation regimen in our Novacor LVAD program. METHODS Oral platelet aggregation inhibitors (aspirin 330 mg + dipyridamole 75 mg, three times per day) were added to the heparin/phenprocoumon treatment in 9 patients starting on postoperative day 3 to 7 (group A). Of the previous 41 patients, the last 20 patients served as a control group (group B), to reduce any learning curve effect. RESULTS The mean interval of mechanical support between the two groups was comparable (group A vs B: 148 +/- 127 vs 104 +/- 61 days, n.s.). Accordingly, the cumulative support was much lower in group A (1051 days) as compared to group B (2091 days). In group B, 10 patients (50%) developed clinically evident thromboembolism. The number of events ranged from 1 to 10 (mean 1.4 +/- 2.3), with a total of 32. With addition of platelet inhibitors, the incidence of cerebral embolism dramatically dropped, as only one patient presented with transient ischemic attacks in group A (p < 0.05). Thoracic bleeding as defined by excessive drainage losses requiring redo thoracotomy did not increase (group A vs B: 22% vs 20%, n.s.). CONCLUSION Addition of platelet inhibitors to heparin/phenprocoumon effectively prevents thromboembolism. However, platelet inhibitors should be postponed until sufficient hemostasis is achieved, since too early administration is associated with an increased risk of bleeding.

We report on a 56-year-old patient who underwent coronary artery bypass grafting, tricuspid valve replacement, and pacemaker implantation within 49 months after heart transplantation. This case readily demonstrates that multiple cardiac procedures can be safely performed after heart transplantation and may thus serve as an alternative to retransplantation.

A now 14-year-old boy underwent orthotopic heart transplantation at the age of 13 for anthracycline cardiomyopathy which was a sequela of polychemotherapy for embryonal teratocarcinoma at the age of 1 year. Despite perioperative cerebellar infarction with signs of herniation which required emergency right cerebellar hemispherectomy the long-term course after 18 months turned out to be favorable with complete medical and psychosocial rehabilitation.

BACKGROUND The proportion of patients with left-ventricular dysfunction (LVD) undergoing high risk revascularization is increasing. In this patient group, the perioperative risk is elevated because of the pre-existing pathophysiology. Detailed evaluation and interdisciplinary differential therapeutic considerations on the basis of the comparative benefit rationale, with cardiac transplantation alternative, is mandatory. METHODS Among 7275 patients who underwent coronary artery bypass grafting between 1990 and 1998 in our institution, we found 51 patients who had had an ejection fraction

BACKGROUND Gene therapy promises to play an important role in the treatment of heart disease and in transplantation. The limited effectiveness of gene transfer, however, remains an unresolved problem. The aim of the study was to create a model for more effective gene transfer using adenovirus vectors carrying the lacZ-reporter gene (AdV-lacZ). METHODS Beating Lewis rat hearts perfused with oxygenated Krebs-Henseleit solution were harvested, after which an atrial septal defect (ASD) was created. All vessels were tied and AdV-lacZ was injected into the aortic root. The solution was recirculated through the ASD to the left side of the heart and pumped back to the coronary arteries by the left ventricle. Incubation was allowed for 20 min at 15 degrees C and the hearts were subsequently transplanted heterotopically in syngeneic rats. This method was compared to AdV-lacZ injection into cardioplegic hearts. The hearts were harvested after 2, 7, or 14 days and evaluated histologically for expression of the lacZ gene. RESULTS Maximal gene expression was achieved after 7 days by the recirculation model. There was less efficient gene expression at day 2 and at day 14. No evidence of ischemic injury of the myocardium was noticed histologically. Almost no successful gene expression was seen in the arrested hearts. CONCLUSION This novel recirculation method lets the vector be repeatedly exposed to the endothelium, resulting in an effective gene expression after 7 days incubation time rather than after 14, when a decline has set in presumably due to immunologic response.

During end-stage heart failure, plasma levels of interleukin-6 (IL6) are elevated. This cytokine exerts a negative inotropic influence on the myocardium. The production site of IL6 is unclear. We examined the hypothesis that IL6 in end-stage heart-failure patients is produced in the myocardium itself and is differentially regulated according to etiology. Cardiac tissue was obtained from 27 patients (idiopathic dilated cardiomyopathy, (DCM) 9/6 m/f, age 46 +/- 14 y; ischemic cardiomyopathy (ICM), 11/1 m/f, age 55 +/- 8 y) at the time of transplantation. The tissue was subjected to IL6 Northern-blot analysis. Signals were quantified by densitometric scanning after normalization to G3 PDH mRNA. Data were compared by Mann-Whitney test between DCM and ICM patients, divided by chamber origin. IL6 transcripts were found in all patients. In DCM, left-ventricular IL6 mRNA expression was higher than in ICM (p = 0.006). Median right-ventricular as well as left- and right-atrial IL6 mRNA expression was not significantly different in both groups. In summary, in end-stage heart failure, IL6 mRNA is consistently expressed in the myocardium. Left-ventricular expression is higher in DCM than in ICM. These data support the concept of a potentially reversible inflammatory component in the etiology of DCM which is more pronounced than in patients with ICM of comparable clinical severity.

Implantable left-ventricular assist devices have been remarkably free of mechanical failures. We describe an uncommon Novacor N100 PCq LVAS malfunction caused by an internal short circuit of the device due to urine aspiration via the vent line. Device replacement was managed via a subcostal approach without sternotomy. Patient recovery was uneventful and successful transplantation was performed one month after the device exchange.

Severe postoperative mitral regurgitation renders information on the underlying mechanism before reoperation very important, as a potential for mitral valve reconstruction may facilitate the decision whether to reoperate, especially in the very young. This study compares the efficacy of transthoracic echo-cardiography (TTE) and left-ventricular angiography with that of transesophageal echocardiography (TEE) for detection of the mechanism underlying mitral regurgitation and its quantitative assessment in children after repair of common atrioventricular septal defect. Five children aged 1.5 to 16 years were evaluated by TTE, TEE, and angiography for postoperative mitral regurgitation 1 to 21 months after initial repair. TEE showed septal detachment of the mitral leaflet in four patients and reopening of the mitral cleft in one patient as the cause of mitral regurgitation whereas TTE failed in four and angiography in all patients. TEE allows definite identification of morphologic characteristics of mitral regurgitation and reliable assessment of its severity. Thus redo surgery may be safety performed on the bases of TEE findings alone without confirmation by cardiac catheterization.