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Mycotic pseudoaneurysm of the aorta is a rare disease in childhood. We report on two cases which were diagnosed in an unselected general pediatric population within an 8-month period. The first case was a 16-month-old toddler with a normal cardiac history who presented with purulent pericarditis due to group A steptococcus and subsequent pseudoaneurysm formation of the ascending aorta while convalescing from varicella infection. The second case was a 14-year-old girl with a previously undiagnosed coarctation of the aorta who developed a Staphylococcus aureus aortitis in the dilatated poststenotic segment with pseudoaneurysm formation and infiltration into the adjacent lung tissue. In both cases parenteral antibiotic therapy was administered over 10 and 4 days, respectively, followed by emergency surgery consisting of aneurysmectomy, coarctectomy (case 2), and in situ homograft implantation. Recovery was uneventful. In both cases early institution of a femorofemoral cardiopulmonary bypass prevented a fatal outcome despite intraoperative rupture of the pseudoaneurysm.

The advances in the treatment of many different heart diseases have on the one side led to a significant prolongation of life expectancy but have also contributed to an increase of patients with heart failure. This tendency is supported even more so by the demographic development of our population. The replacement of insufficient organs has always been in the focus of medical research. In the 1960's Shumway and Lower developed the technique of cardiac transplantation and also worked intensively on the treatment and diagnosis of rejection. However, it was Barnard who, in 1967 performed the first human cardiac transplantation. Other centers followed worldwide but the mortality was high and the new therapy was controversially discussed in many journals. By the introduction of cyclosporin as a new immunosuppressive agent in 1978, results improved rapidly and cardiac transplantation became an accepted therapeutic option for patients with end stage heart failure and also for children and newborns with congenital heart defects. Today, with newer immunosuppressive regimens and improved techniques, cardiac transplantation offers excellent results with a long-term survival of nearly 50% of patients after 15 years and among the pediatric population even after 20 years. However, the donor organ shortage as well as the increasing number of elderly patients with end stage heart failure has necessitated work on other alternatives. Neither stem cell transplantation nor xenotransplantation of animal organs are yet an option and there are still some obstacles to be overcome. In contrast, the development of so-called artificial hearts has made significant progress. While the first implants of totally artificial hearts were associated with many comorbidities and patients were seriously debilitated, new devices today offer a reasonable quality of life and long-term survival. Most of these systems are no longer replacing but mainly assisting the heart, which remains in place. These ventricular assist devices have been used as a bridge to transplantation for a long time and are now also offered as a destination therapy for patients who for a variety of reasons are no longer amenable to heart transplantation. Further miniaturization and a decrease of the costs will make these devices a realistic alternative to a sole medical therapy and studies have already proven the superiority in terms of survival as well as rehospitalization rates. However, at present they are still not an alternative to heart transplantation.

Since the first description of coronary magnetic angiography (MRA) in the early of 1990, this method seems to be shaped us a promising noninvasive modality to view the coronary arteries. Since several years dedicated high-field MR systems up to 4T are available for human use. The aim of the study was the evaluation of an in vitro vessel model with defined stenoses on 1.5T and 3T. For imaging at 3T, we used a 3d gradient-echo-sequence (fast SPGR). Furthermore, we examined the influence of the flow velocity and the contrast medium concentration on the spatial resolution. The accurate detection of in vitro stenoses was possible in segments up to 0.6 mm at 3T, the best results were obtained at a flow velocity of 40 ml/min and a contrast medium concentration of 0.2 mmol/l. The influence of the contrast medium concentration was statistically not significant. These results show that the spatial resolution can be increased by the use of a high-field MR scanner. Further in vivo studies are necessary to eliminate the method's limitation in visualizing small distal vessel segments.

Results of aortic arch repair for interrupted aortic arch or aortic coarctation have considerably improved. However, re-stenosis or aneurysm formation is a common complication requiring complex re-interventions or even extra-anatomic bypass grafting. In two patients with recurrent coarctation, the use of cardiopulmonary bypass was mandatory, in one due to the concomitant repair of the intra-cardiac defect, in the other due to the small aortic arch, the long segment aortic coarctation and the small diameter of the supra-aortic vessels. In both patients a segment of the ascending aorta was interposed between the distal aortic arch and the proximal descending aorta with uneventful postoperative courses and freedom from pathological findings at 1 year and 6 months follow-up. In patients undergoing complex congenital heart surgery involving the ascending aorta, a segment of the autologous ascending aorta may be used to repair recurrent isthmic stenosis, avoiding the use of any foreign material.

Background— The Early Self Controlled Anticoagulation Trial (ESCAT I) showed that anticoagulation self-management after mechanical heart valve replacement decreased complication rates by maintaining INR levels closer to the target range than International Normalized Ratio (INR) home doctor management. The therapeutic range for the INR in that study was between 2.5 and 4.5 for all positions of prosthetic valves. ESCAT II should find out whether lowering the target range for INR self-management would further reduce complication rates. Methods— ESCAT II is a prospective controlled randomized (valves: St. Jude Medical Standard or Medtronic Hall, treatment: conventional/low-dose) multicenter study with 3 300 patients. We present interim results of 1 818 patients. 908 were categorized as having a low-dose target range, which was INR 1.8 to 2.8 for prostheses in aortic position and 2.5 to 3.5 for prostheses in mitral position or in combined valve replacement. The control group (conventional group) with 910 patients aimed at an INR of 2.5 to 4.5 for all valve positions. Results— In the conventional group, 74% of INR values measured were within the therapeutic range. In the low-dose group, 72% of the values were within that range. The linearized thromboembolism rate (% per patient year) was 0.21% for both groups. The bleeding complication rate was 0.56% in the low-dose regimen group versus 0.91% in the conventional group. Conclusions— Early onset INR self-management under oral anticoagulation after mechanical heart valve replacement enables patients to keep within a lower and smaller INR target range. The reduced anticoagulation level resulted in fewer grade III bleeding complications without increasing thromboembolic event rates.

Currently, no reliable minimally invasive method of measuring cardiac output continuously in neonates and children undergoing cardiac surgery is available. An extravascular Doppler probe was used to measure cardiac output in 15 New Zealand White rabbits (average weight 3.5 kg, range 2.5-4.5 kg). The results obtained were compared with cardiac outputs determined using the aortic thermodilution principle. The mean cardiac outputs measured with the extravascular Doppler probe was 0.37 +/- 0.01 l/min as compared with 0.39 +/- 0.01 l/min with aortic thermodilution. Regression analysis revealed a close correlation (r = 0.973) between the two techniques. The extravascular Doppler techniques is an option for continuous and reliable cardiac output measurement in small animals used in surgical experiments (open chest models) and in neonates or children during surgical repair of complicated congenital heart conditions.

Pericardiectomy today is an accepted therapeutic concept in patients with different pericardial disorders. The postoperative outcome of patients is mainly influenced by two factors. First, diagnosis has to be established early to avoid myocardial deterioration and secondary organ failure, especially of liver and kidneys. Second, the whole accessible surface of atria and ventricles has to be freed from diseased and calcified pericardium. To achieve this, we prefer a total median sternotomy for the surgical approach. In selected cases of acute pericardial effusion or as a palliative procedure, a small infrasternal incision or anterolateral thoracotomy is used for pericardiocentesis and creation of a pericardio-pulmonary window. Between January 1969 and March 1990 we treated 187 patients with different pericardial disorders. Mortality was 4.8% overall, and was especially low (2.8%) among the 106 patients with acute and chronic pericardial effusion. Out of 67 patients with constrictive pericarditis, four died during hospital stay (5.9%). The prognosis is still poor for patients with primary or secondary malignant pericardial tumours, in whom surgery is mostly restricted to palliative resection, and a special group with constrictive and mostly calcified epicarditis, for whom no surgical option is available.

Of 54 cardiac tumors operated upon in our clinic, 42 were classified as benign and only 12 as malignant. The major part of the benign tumors were myxoma, mainly located in the left atrium. While smaller tumors could be treated by local resections, extensive resections were necessary in 14 patients with greater tumors followed by reconstructions of the pulmonary and caval vein, mitral and tricuspid valve, and major parts of the right and left ventricular wall. In one patient with a huge benign myxoma, tumor exposition and total resection could only be achieved by an autotransplantation of the heart. While mortality after surgical therapy of benign tumors was only 1.4% (1/42) within a mean follow-up time of 48 months, the prognosis of malignant tumors is still fatal with a mortality of 50% (6/12) within a mean follow-up time of 24 months, despite additional chemotherapy or radiation.

Mimicking the physiological characteristics of the circulatory system, pulsatile bloodflow has also been introduced into extracorporeal perfusion to avoid known postoperative complications. In a mathematical consideration of the situation bloodflow is seen as a function of time F(t) for approximately constant vessel diameter over a given time. The kinetic energy of a column of blood produced by the heart-lung machine is transmitted directly to the arterial circulation via the aorta. The nature of the energy release can give rise to both positive (organ perfusion) and negative (damage to endothelium) effects. This study investigates how this energy release can be optimised, using the following experimental approach. A Doppler flow-measuring probe is placed on the ascending aorta to monitor the extracorporeal circulation. At the same time, the blood pressure is measured and converted to a pressure-flow curve via an A/D converter. On the basis of the parameters thus obtained, the energy released by the heart-lung machine is calculated. By regulating the functional parameters of a new generation of heart-lung machines, the bloodflow can then be adapted to the physiological requirements. Within the pulse period (cycle) a 20% rise phase ending in a slightly increasing plateau is established. The energy increase within a cycle should not exceed 150 joules. To optimize the mode of functioning of the heart-lung machine, we introduced the "energy-equivalent pressure" (EEP). Adaptation of the EEP to the physiological conditions required a basic flow of 60% at a pulse rate of 60/min and a pulse duration of 35% within the pulsatile flow interval.

CT angiography was performed in 12 patients with insufficient autologous graft situations to evaluate postoperative patency and situation of the proximal, distal and coronary artery anastomoses of synthetic Perma-Flow coronary artery bypass grafts.Bypass grafts were evaluated postoperatively with spiral CT of the mediastinum. At a flow rate of 3 ml/s, 120 ml of contrast material were applied over a cubital vein. Slice thickness was 3 mm, maximum pitch factor 2 and image reconstruction was performed at 2 mm increment. Shaded surface displays were analysed together with axial scans for bypass evaluation.8 out of 12 synthetic bypasses proved to be patent. One bypass was completely occluded and in three patients the distal portions of the grafts were occluded. Coronary angiography performed in one case confirmed complete bypass occlusion. Due to the occlusions, 8 distal and 12 proximal anastomoses were visible. Only 8 out of 19 side-to-side coronary artery anastomoses could be sufficiently well imaged with this technique.CT angiography is suitable for postoperative screening of synthetic coronary bypasses to determine the patency and anastomotic situations. Coronary artery anastomoses however are not sufficiently imaged and coronary angiography continues to be required.

Endstage coronary artery disease still remains a therapeutic challenge. An increasing number of patients is no longer amenable for direct revascularization by PTCA or coronary bypass surgery and does also no longer respond to maximum medical therapy. This fact has directed the interest again towards surgical techniques of indirect revascularization, which had been introduced by Beck and other surgeons more than 60 years ago. Among these attempts we can also find transmyocardial needle punctures, firstly performed by Sen in Bombay. In the early eighties it was Mirhoseini, who used a laser for creating these transmural channels, primarily in combination with coronary bypass surgery at the arrested heart and later on together with Crew as a sole therapy at the beating heart. The idea behind this transmyocardial laser revascularization (TMLR) was a "reptilization" of the human heart, which meant a direct blood supply from the ventricle into the ischemic myocardium. Whereas this theory has not proven to be true, as the surface area of these channels is not sufficient for the nutrition of the surrounding myocardial tissue by diffusion or convection, different models have been developed by anatomical, experimental and clinical studies, such as the connection between the laser channels and intramyocardial vessels or capillaries, analogous to ventriculo-coronary connections in human anatomy or pathology as for example those connections described in children with pulmonary atresia and intact ventricular septum or the Thebesian veins. Moreover the laser trauma may also simply contribute to the induction of neoangiogenesis. While the function of TMLR is still not clearly defined, clinical studies in the United States and also in other countries have proven the clinical efficacy in a cohort of severely diseased patients undergoing this procedure. Accordingly more than 2/3 of all patients after TMLR showed a significant improvement of more than 2 angina classes (CCS) as well as a decrease in medication and hospitalization. Moreover there was also a reduction of ischemic areas demonstrated by szintigraphy and, in one study from Houston, also by positron emission tomography. While the overall mortality in all those studies is still considerably high, a reduction could be achieved by a stricter selection of patients excluding especially those with a severely impaired left ventricular function. As demonstrated by preliminary data from the last phase III FDA-study, TMLR may even reduce long-term mortality compared to maximum medical therapy in a randomized group of patients. Our own experiences in 134 patients also confirmed a significant reduction of angina after TMLR alone (n = 67) or in combination with bypass surgery (n = 67) with the majority of patients being in angina class 1 and 2 (CCS) 6 months after surgery. All of these patients were in angina class 3 and 4 before surgery. Nuclear scans could demonstrate an improved perfusion in more than 40%. Further studies as well as other clinical and also experimental investigations have still to be awaited, before the definitive role of TMLR within the armamentarium against coronary artery disease can be determined. However, it is already a therapeutic option for those highly symptomatic patients, who cannot be offered a different treatment modality.

Transmyocardial laser revascularization (TMLR) is a new technique for patients with CAD or heart attack to revascularize ischemic areas of the myocardium in which the localisation or the condition of the vessels does not allow bypass grafting. This study shows the results in observation of patients before and during the first 3 months after TMLR. Of 110 patients operated on from 1994 to 1996, 86 were evaluated for well being (quality of life), using NYHA- and CCS-classification, stress test and nitril-scintigraphy at rest and under stress conditions. 51 patients, of whom 11 were females, underwent TMLR combined with coronary artery bypass graft (CABG). 35 male patients were treated singularly with TMLR. The average age in both groups was 59 years (+/- 23). All patients were subject to phase I rehabilitation in specialised institutions after being mobilised in the operating hospital. The evaluations took place on the day of admission to the hospital prior to surgery, within 10 days after surgery and 3 months following. The average stay in the rehabilitation-institution was between 4 and 6 weeks. Our findings demonstrate that both groups profited from the procedures, while the TMLR/CABG group showed a faster recovery and a better outcome. In comparison to 57% of the TMLR group, 85% of the patients in the TMLR/CABG group reported an improvement ranging from good to significant in quality of life assessments. The TMLR/CABG rated from an average of initially 3.4 (+/- 0.6) to 2.1 (+/- 0.8) after 3 months at NYHA- and 3.3 (+/- 0.7) to 1.7 (+/- 0.8) at CCS-classification. The TMLR group rated from 3.6 (+/- 0.5) to 2.4 (+/- 0.8) in NHYA- and from 3.4 (+/- 0.5) to 1.9 (+/- 0.7) on the CSS-scales. A remarkable improvement was noted in the stress test with an increase in power and endurance from 21 to 89 watts for the combined group and 8 to 81 watts for the TMLR treated patients, who generally recovered more slowly. The perfusion scan showed the same tendencies as previously reported but in some cases the results were not congruent with other findings. Overall, our findings indicate that there is a benefit for terminally symptomatic CAD patients after TMLR, but an observation period of 3 months does not allow for final conclusions on this matter. Rehabilitation seems to be of value for TMLR-patients since they have shown a markedly better performance following 3-month treatment, but further data from clinical randomised trials are needed to determine the influence of TMLR with short- and long-term rehabilitation on the prognosis of the disease.

In many cases blunt chest trauma involves cardiac lesions, such as pericardial effusion, aneurysma dissecans, or valvular rupture. Early diagnosis with routine transthoracic and/or transesophageal echocardiography is essential to prevent a fatal outcome. In the case reported, a previously healthy 68-year-old woman fell 7 meters from the roof of a barn and sustained blunt injury to the chest as well as fractures of the face. Physical examination revealed a systolic murmur at the cardiac apex, and chest x-ray film showed a severe pulmonary edema. Transesophageal echocardiography demonstrated a ruptured anterolateral papillary muscle with fourth degree mitral insufficiency. An immediate mitral valve replacement was necessary.

Under normal conditions the coronary system of the human heart is not hermetically isolated from the surrounding structures nor the ventricles, but is in various ways connected to the adjacent arteries and the cardiac chambers. These natural connections have been models for most surgical efforts to revascularize the myocardium. Numerous anastomoses between the aorta and the coronary branches functionally resemble aorto-coronary bypass grafts. Coronaro-ventricular anastomoses do also exist in the myocardium and therefore transmyocardial laser revascularization should allow blood to penetrate from the ventricle into the myocardium. This process should not be called "reptilization" of the human heart, as in large reptilian hearts the nutrition of an extensive amount of myocardium only by diffusion is highly unlikely. Transmyocardial laser revascularization results in a relevant reduction of clinical symptoms and an increase of exercise capacity in approximately two thirds of the patients treated. Objective data of enhanced myocardial perfusion as assessed by positron emission tomography and stress echocardiography has up to now only been presented by smaller studies. Open laser channels are rarely visualized by conventional ventriculography for the limited resolution of the technique. Possibly contrast-echocardiography may offer a more appropriate option to proof the systolic filling of the laser channels, as recently reported in patients. This would allow a correlation between clinically successful revascularization and functioning channels in contrast to an early or late failure due to the closure of the channels. As to the current opinion, transmyocardial laser revascularization is no alternative to established medical, interventional or surgical therapies but may in conjunction with bypass surgery or as a sole procedure offer a new option for those patients, who were recently considered to be refractory to conventional treatment. Experimental studies in particular should contribute to the understanding of therapeutic mechanisms and lead to standardized indications in the surgical treatment of end-stage coronary heart disease. Even though in transmyocardial laser revascularization the perioperative risk depends mainly on the degree of cardiac disease and the overall state of the patient, and impaired left ventricular function is per se no exclusion criterium, if viable myocardium is detectable. Many questions concerning indications, long-term prognosis and pathophysiological mechanisms are still open to discussion and have to be answered in order to find standardized applications for treatment of end-stage coronary artery disease.

Transmyocardial laser revascularization refers to the perfusion of the reptilian heart with its large ventriculo-myocardial channels and to well-known ventriculo-coronary connections in congenital heart defects. By a high energy CO2-laser transmural channels can be created at a beating heart and may, by connecting to the intramyocardial capillary network or by inducing a neocapillarization, improve the blood supply to the ischemic myocardium. This indirect method of revascularization is indicated in symptomatic patients with diffuse coronary heart disease, not accessible by conventional methods like PTCA or coronary bypass surgery. Worldwide, this new kind of operation has already been performed in some 100 intractable patients. In our hospital 79 patients have been treated with this new technique, 37 of them in conjunction with conventional bypass surgery. The majority of those patients had already undergone one or two bypass operations. The perioperative mortality was 11.4% including three non cardiac events. Postoperative follow-up after 3 and 6 months showed among the reinvestigated patients a significant improvement concerning angina- (CCS) and clinical classification (NYHA). Scintigraphy after the same time period revealed an improvement of myocardial perfusion in 50% of the reinvestigated patients. These results as well as the international reports demonstrate a clinical efficacy of this new therapeutic approach in a selected group of severely diseased patients. Further objective data and also experimental studies have to confirm the role of this new method in the treatment of diffuse coronary heart disease.

The number of published cases of adolescents surviving thoracic aortic injuries with accompanying severe thoracic injuries is small. Only 20-30% of all these patients reach the trauma center alive. In the present case we demonstrate the diagnostic, operative and intensive care management in a 15-year-old girl. The exact interpretation of the AP thoracic X-ray in connection with a typical mechanism of injury led to the detection of a haemomediastinum. This is very important in the further development of diagnostics, because the conventional X-ray picture does not show significant signs in the case of an incomplete aortic rupture. Diagnostic hints have to be derived from the detection of the haemomediastinum. The girl was operated on under left heart bypass. Spinal ischaemia was absent after surgery, and renal failure also did not occur. The adjacent severe lung confusion healed under kinetic therapy with a kinetic treatment table without pulmonary complications.

Indications for interventional catheter techniques and bypass surgery have been extended to more complex lesions and also the number of reoperations after primary successful interventions has increased due to progression of the underlying disease. Finally a number of patients remains still symptomatic but, as a consequence of a very diffuse distribution of atherosclerotic lesions, is no longer accessible with conventional techniques of direct revascularization. This has drawn the attention again to indirect techniques of myocardial revascularization. Transmyocardial laserrevascularization offers a new option in reperfusing the ischemic myocardium via transmural channels from the ventricular cavity. As to the function of the channels, it is not quiet clear, wether they may connect to intramyocardial capillaries or may themselves induce a neoangiogenesis. However the clinical follow up in patients with intractable angina pectoris shows a significant improvement. At our hospital a number of 117 patients have been treated with this new method, 53 of them in conjunction with conventional bypass surgery. Clinical follow up after three and six months postoperatively showed a significant improvement concerning angina (CCS) and exercise tolerance (NYHA). This could also objectively be demonstrated by scintigraphy with an increased myocardial perfusion in 50% of the reinvestigated patients. Ischemic areas can still be seen, but occur at a significantly higher exercise level, demonstrating an improved but not normalized myocardial blood supply. The transmyocardial laserrevascularization is no alternative to well established procedures like PTCA or bypass surgery, but can be seen as a therapeutic option for those symptomatic patients recently being intractable. Further longterm studies and also experimental investigations have to evaluate the definitive role of this new treatment for endstage coronary heart disease.

In symptomatic endstage coronary artery disease after full medical therapy (antianginal drugs, betablockers and ACE-inhibitors) further therapeutical options both for the interventional cardiologist with little hope for improvement by PTCA, stent, rotablation and atherectomy and for the cardiac surgeon with bypass surgery and endarterectomy are not available by definition due to the diffuse arteriosclerotic vessel morphology. In those patients one can therefore consider transmyocardial laser therapy (TMR) as the ultimate treatment option. It then is primarily a palliative measure to reduce the patient's symptoms. Improving perfusion and prognosis remains the most important goals, however. TMR can be utilized as the only revascularizing treatment measure or in combination with CABG or PTCA. According to data from international registries, few controlled and several non controlled studies and our own registry in Marburg with now 101 patients improvement of angina and/or dyspnoea can be expected in more than 60% of patients with end stage coronary artery disease (CAD). The patient cohort comprises symptomatic individuals after CABG or multiple PTCAs or with diffuse CAD in diabetes mellitus or with most severe hypercholesterinemia. We consider these above mentioned criteria as the only validated criteria to enter patients with endstage CAD in our controlled study. Hypothetical options for treatment by TMR such as vasculopathies after heart transplantation, cardiomyopathies under the notion of a possible but not proven microangiopathy are not accepted in our institution at present. Before TMR all patients are assessed for their angina class according to the Canadian Cardiac Society (CCS I-IV)) and their exercise capacity according to the New York Heart Association classification (NYHA I-IV) and reassessed regularly after 3, 6 and 12 months. Thallium/Te MIBI scans at rest- and whenever possible at exercise as well as stress echocardiography are carried in the patients to assess symptomatic improvement, alterations in myocardial perfusion and functional efficacy by TMR. By intermediate analysis the 101 patients of our registry more than 60% of the patients had improved their angina class by at least one classe, some patients have improved perfusion as assessed by scintigraphy, which makes at present a trend but not yet a significant difference, whereas central hemodynamics and ejection fraction remained virtually unchanged in most patients reassessed after TMR. In our analysis mortality of the 101 TMR patients was assessed and plotted on Kaplan Meier survival curves. Mortality at 6 months was 11%. When compared to a historical group of patients with identical CCS and comparable NYHA classes, who were worked up in the manner of a case control study, the TMR mortality was marginally but not yet significantly lower than one would expect from these control patients with terminal CAD treated purely by medication: Their 6 months mortality was 14%. Remarkably but not unexpectedly patients with comparable CCS classes, who could still be treated by PTCA and/or CABG had a significantly lower 6 months mortality than TMR patients or patients on antianginal drugs only. The pathophysiological mechanisms for the symptomatic improvement by laser therapy are not yet fully understood. The 1 mm transmyocardial channels created by the CO2 laser have been postulated to permit perfusion from the ventricular cavity and to seek connection to capillaries and vessels present in the malperfused myocardium thus improving the perfusion by newly created connections and sinusoids from the ventricular cavity. Although there is clear evidence for the presence of open channels acutely and within a few days after TMR therapy little evidence in man is as yet available on the question whether the channels remain open in the long run and, if so, whether they can actually improve perfusion to a substantial degree...

Orthotopic heart transplantation has become an accepted therapy for adult patients with end-stage heart disease. In newborns and infants, this procedure is still controversial because of the unknown long-term results and the lack of donor organs. Since March 1988, we have performed orthotopic heart transplantation in 11 infants and children with hypoplastic left heart syndrome (n = 6), cardiomyopathy (n = 4), or congenital endocardial fibroelastosis (n = 1). The smallest infant was 3 days old and weighed 2,650 g. Four of 15 potential donors had to be refused for various medical reasons, and 4 were transferred to our hospital for organ retrieval. Seven hearts were procured remotely. We accepted weight mismatches up to 105% between donor and recipient. There were three perioperative deaths, two in patients 5 and 17 days old with hypoplastic left heart syndrome and 1 in a 2-year-old patient with a dilated cardiomyopathy. All 3 patients had drug-resistant right heart failure. A 2-year-old girl with a dilated cardiomyopathy died 2 months after transplantation owing to severe pulmonary embolism originating from the superior vena cava. The remaining 7 patients are alive and well between 1 month and 31 months after transplantation. Angiographic follow-up has not revealed signs of graft atherosclerosis at 2 years.

Nowadays orthotopic heart transplantation is world wide accepted as a therapeutic concept in endstage congestive heart failure. Concerning infants, there are still major objections against this kind of therapy and especially in our country exists only very limited experience. Since march 1988 we have performed an orthotopic heart transplantation in 10 pediatric patients: 5 infants (2-16 years of age) with congestive cardiomyopathy, 1 newborn with endocardial fibroelastosis, 3 newborns with hypoplastic left heart syndrome, and finally 1 infant at the age of 2 years with AV-canal and hypoplastic left ventricle. Until now 6 infants survived and are all at home and in good clinical condition. There have been no signs for chronic rejection or graft atherosclerosis up till now. As demonstrated in the example of the newborn, in whom we performed the first successfully orthotopic heart transplantation in Germany, the clinical course and quality of life are superior to those after other palliative procedures in complex cardiac malformations.

Enoximone belongs to a new class of noncatecholamine-positive inotropes, which selectively inhibit phosphodiesterase type III and increase cyclic AMP (cAMP). This study was performed in 30 coronary artery surgery patients with impaired myocardial function (ejection fraction [EF] less than 50%). The study's two purposes were to investigate the hemodynamic effects of enoximone, 0.5 mg/kg, administered following induction of anesthesia (phase I), and to assess whether enoximone can potentiate the actions of sympathomimetic agents during weaning from cardiopulmonary bypass (CPB) (phase II). Starting with already reduced hemodynamics, induction of anesthesia led to a further deterioration of blood pressure and cardiac output (CO). Administration of enoximone produced a significant increase in cardiac index (CI) (+47%), whereas pulmonary capillary wedge pressure (PCWP) (-37%), pulmonary artery pressure (PAP) (-17%), and systemic vascular resistance (SVR) (-17%) were significantly reduced. Heart rate (HR) was not increased, and no dysrhythmias occurred during the investigation. The hemodynamic effects were maintained for 30 minutes until the start of the operation. In phase II, where weaning from CPB was not possible without pharmacological support, either enoximone (0.5 mg/kg) + epinephrine (0.1 micrograms/kg/min) or only epinephrine (same dosage) was randomly selected. Weaning was successful in both groups, but the combined therapy produced a larger increase in cl and a more pronounced decrease of the elevated filling pressure (PCWP). PAP was not changed in the combined therapy group, but increased in the patients receiving epinephrine alone. It is concluded that enoximone has beneficial hemodynamic effects in the perioperative period, and that potentiation of the effects of epinephrine in severe heart failure may be one of the drug's most useful features.

A large atrial myxoma, attached in an atypical location, was identified in the left atrium of a 70 year old patient. Although the tumour occupied a large part of the left atrium the patient remained in sinus rhythm and displayed no symptoms.

The use of laser in bronchology plays a major role in the therapy of benign and malignant tumours. By flexible delivery systems, lasers can be used in combination with flexible bronchoscopes. By this benign tumours, especially in young children, can be ablated successfully without major surgical intervention. In malignant tumours laser ablation can only be used as a palliative procedure in cases untreatable by conventional surgery or prior to radiation or chemotherapy, in which the symptoms of hemopthysis or significant obstruction are indications for an urgent treatment. Especially in elder patients a quick relief of symptoms can be reached avoiding the high risks of an operation. A new and experimental field of laser application in bronchology is the tracheal reconstruction with laser assistance. In 10 Beagle dogs laser assisted tracheal anastomoses revealed good functional results with an uneventful postoperative course. Histology showed a normal healing and a good reconstruction of the ciliated endothelium without metaplastic changes. So this new technique may in future become an additional tool in the reconstructive surgery of the trachea and main bronchi.

Diltiazem is a calcium channel blocker whose effects lie between those of the two other important calcium antagonists nifedipine and verapamil. In addition to vasodilation, it has a negative dromotropic effect with prolongation of the A-V interval. In animal experiments and human investigations, diltiazem improves the function of ischemic myocardium due to a direct dilating effect on coronary vessels. The purpose of the present study was to investigate the hemodynamic effects of diltiazem in patients before and during coronary revascularization. METHODS. The study included 60 consenting male patients with coronary heart disease. Twenty premedicated patients randomly received 0.3 mg/kg diltiazem or placebo within 3 min before induction of anesthesia. Hemodynamic measurements (arterial pressure, heart rate, mean pulmonary arterial pressure, pulmonary capillary pressure, right atrial pressure and cardiac output) were taken during the following 21 min. Before cannulation of the great vessels for institution of extracorporeal circulation (ECC), 20 other patients received 0.014 mg diltiazem or placebo/kg per min over 20 min. In addition to the above mentioned hemodynamic measurements, left ventricular parameters (LVP, LVEDP, dp/dt) were directly registered, and 5 min after the end of ECC the measurements were repeated with the same preload as before the ECC. Twenty additional patients received 0.014 mg diltiazem or placebo/kg per min within 21 min during ECC observing arterial perfusion pressure and oxygenator volume. RESULTS. Pre- and intraoperatively diltiazem caused a decrease in mean arterial pressure; cardiac index increased only during the preoperative investigation period (Tables 1, 2), whereas stroke volume index increased pre- and intraoperatively; heart rate decreased in all patients as well as dp/dt (Fig. 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Myxomas are predominantly located in the right on left atrium. We report an unusual case of a myxoma adherent to the aortic valve. The child presented with symptoms of subaortic stenosis. By invasive methods a tumor was diagnosed located at the aortic valve. After surgical removal the child recovered soon and is doing well. According to our knowledge this is the first report of a myxoma of the aortic valve.

The hemodynamic effects of the intravenous application of nisoldipine (0.2 microgram/kg bw per minute and 0.1 microgram/kg bw per minute) were studied in 70 patients with coronary artery disease. Measurements were performed before the induction of anesthesia, during anesthesia (prior to the cannulation of the great vessels) and 5 min after the end of extracorporeal circulation (ECC) (with the same preload as before ECC) as well as during ECC. Each group was compared to a group of patients who received a placebo injection. The preoperative and intraoperative application of nisoldipine produced a decrease in the mean arterial pressure and total systemic resistance, whereas the cardiac index and the stroke-volume index increased. Only during preoperative measurement did the heart-rate increase. The central venous pressure, pulmonary artery pressure and pulmonary capillary wedge pressure remained unchanged. There was no change in the dp/dtmax after 0.2 microgram/kg bw per minute of nisoldipine. There was no difference in hemodynamic outcome between the three groups 5 min after the end of ECC. During ECC, nisoldipine did not reduce the vascular resistance, possibly because of the hypothermic conditions. The principal effect of nisoldipine is to increase the cardiac index by decreasing the total systemic resistance without influencing the myocardial contractility.

A prospective study was undertaken to determine the prognostic value of somatosensory evoked potentials during carotid artery surgery in patients where an intraluminal shunt was not used. During a three-year period 167 patients underwent 193 consecutive carotid endarterectomies under general anaesthesia. The somatosensory evoked potential after median nerve stimulation including calculation of central conduction time was used to assess cerebral function intraoperatively. Early postoperative neurologic morbidity was 3.6%, mortality 0.6%. Evoked potential changes in these patients were uniform and consisted of an increase in central conduction time of more than 20% from control (anaesthetic baseline), a decrease of the amplitude of the primary cortical response exceeding 50% and a loss of middle latency components. In subsequent recordings complete loss of the entire cortical evoked potential was observed in 5 of 7 patients. Sensitivity of CCT prolongation was 100%, specificity 89% (18 false positives). For amplitude reduction sensitivity was 86% (1 false negative), specificity 96% (7 false positives). For loss of the entire cortical response sensitivity was 71% (2 false negatives), specificity 99% (2 false positives). The above mentioned parameters correlated with postoperative neurologic state (Chi-square, p = 0.0001). Since the effects of potentially confounding variables (anaesthetics, temperature) are well known, the somatosensory evoked response, especially central conduction time, can be used as a reliable guide for brain supporting procedures.

In ten of 3031 patients undergoing coronary surgery, we used a PTFE graft for bypass to the right coronary artery following endarterectomy. Diffuse calcification was the reason for endarterectomy of the right coronary artery in all cases. We chose a PTFE graft only in those cases where autologous grafts were not available in a sufficient number. After a mean follow-up period of twelve months nine of the ten grafts were patent.--This study demonstrates that under selected circumstances PTFE grafts can be successfully used in coronary surgery if autologous grafts are lacking.

Nimodipine, a new calcium channel blocker, seems to be effective in the treatment of vasospasm in cerebral vasculature. Typical cardiovascular side effects have limited the dose in neurology and neurosurgery to 0.03 mg/kg X h. This study was designed to examine the influence of an infusion of high dose nimodipine (0.09 mg/kg X h) on haemodynamics. 52 patients undergoing aorto-coronary bypass surgery and prospectively randomised in a nimodipine group and a control group having received 0.9% saline solution as placebo were investigated at 3 different times: 1. before induction of anaesthesia (n = 6) 2. during anaesthesia (n = 10) 3. during extracorporeal circulation (ECC n = 10). Predominant effect of high-dose nimodipine was a decrease in total systemic resistance (TSR), followed by a decrease in mean arterial pressure (MAP) and a significant increase in cardiac output. Haemodynamic effects were much more pronounced during anaesthesia in comparison to patients before induction of anaesthesia, thus demonstrating an interaction between anaesthetics and calcium channel blocker. Heart rate (HR -9.3%) and dp/dtmax (-17%) showed a decrease, too. The decrease in MAP and HR in connection with a decrease in left ventricular pressure (-21.9%) and left ventricular end diastolic pressure (-42.8%) indicate a reduction in myocardial oxygen demand. An increasing dosage of nimodipine is accompanied by increasing cardiovascular effects. From the haemodynamic point of view high dosage of nimodipine seems to be of advantage in patients with hypertension and/or coronary heart disease suffering simultaneously from cerebral vasospasm.

The influence of 3 different, preoperatively given glucocorticoids (30 mg/kg bw methylprednisolone, 3 mg/kg bw dexamethasone, 30 mg/kg hydrocortisone) on extravascular lung water (EVLW) was investigated in a randomised study consisting of 60 patients undergoing elective aortocoronary bypass surgery and compared to a control group having received 0.9% NaCl as placebo. EVLW-measurements were performed by using the double indicator dilution technique with indocyanine green and a microprocessed lung water computer. Besides EVLW-measurements haemodynamics and various laboratory data were studied before as well as after (15 min, 45 min, 5 h) extracorporeal circulation (ECC). ECC was followed by an increase in EVLW, which was less pronounced in the dexamethasone-group without being statistically significant (p = 0.1), however. Pulmonary gas exchange, too, did not differ statistically, in spite of a less pronounced (p = 0.1) deterioration of paO2 in the dexamethasone-group. Haemodynamics and laboratory data in the corticoid-group did not show any significant difference compared to the non-treated control group. It was concluded, that pretreatment with corticoids in pharmacological doses in cardiac surgery had no beneficial effects on extravascular lung water and pulmonary function.

Out of a great number of hearts investigated post-mortem by coronary arteriography and quantitative histology, 437 coronary arteries of 202 hearts had severe stenoses with a lumen reduction to less than 50 per cent. Mainly these most severe obstructions lay between 2 and 5 cm behind the aortic ostium. In the right coronary artery the frequency curve showed a smaller peak, a smaller decrease, and an inconsiderable second peak in the periphery. Perhaps the slow calibre reduction of the right coronary artery is significant for these findings. The narrowed lumen mostly lay a little eccentric and had an oval shape. A slit-like shape was a rare finding. Only in 20 per cent of the severe stenoses a normal intima was preserved in parts of the circumference of the coronary artery. Among 113 patients the following risk factors were known: hypertony, diabetes mellitus, cigarette smoking and hypercholesterinemia. Significant differences in the localisation of the most severe stenoses were not recognizable under the influence of these risk factors.

The influence of different vasopressors (Akrinor, etilefrine, ephedrine, norfenefrine, ameziniummetilsulfate) on arterial perfusion pressure and oxygenator volume during extracorporeal circulation was compared to a control group. All substances led to an increase in perfusion pressure, thus demonstrating a direct influence on arterial vessels. The rise in arterial pressure after injection of ameziniummetilsulfate persisted during the investigation period, whereas norfenefrine led to a short-lasting, but massive increase. No rise in venous tone was noticed during the investigation period.

In order to investigate whether the increases in mean arterial pressure (MAP) and HR during carotid endarterectomy are due to a systemic, sympathicotonic stress response and to compare two anesthetic regimens for this operation, 20 patients were randomly allocated to the following groups: (1) modified neuroleptanesthesia with midazolam, fentanyl, and vecuronium: and (2) isoflurane anesthesia with vecuronium relaxation. Premedication (pethidine, promethazine) and induction of anesthesia were similar in both groups. The plasma levels of epinephrine and norepinephrine (by HPLC/ECD), ADH, ACTH, and cortisol (by RIA), glucose, lactate, and free glycerol were determined before and after induction of anesthesia, 7 times during the operation, and 30 min after extubation. MAP and HR were measured continuously. Statistical evaluation was undertaken by analysis of variance with repeated measures on 1 factor, considering P values of less than 0.05 as significant. The endocrine parameters failed to show any remarkable increase during the entire operation period. After the end of the operation all hormones rose significantly (P less than 0.001). No correlation was found between plasma catecholamines and increases in MAP and HR. Group levels of norepinephrine and ADH were higher in the isoflurane group (P less than 0.04). It is concluded that cardiovascular reactions during carotid endarterectomy are not caused by systemic stress. Neuroleptanesthesia leads to better stress protection in the postoperative period, while isoflurane anesthesia has some advantages for the intraoperative control of arterial pressure.

Summarizing our data we can say, that some hematologic disorders during extracorporeal circulation can be diminished by the use of new oxygenator types like the membrane and the Hollowfiber oxygenator. This correlates to the results of other research teams. In contrast to that the activation of the complement cascade is caused by the three systems in a similar way. Although we know, that the activation of the complement systems is only one of numerous reasons for postoperative pulmonary complications, we still must regard this as an important factor, so that the aim of further investigations should be to reduce complement activation during long term ECC.