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Die Behandlungsfortschritte bei vielen Herzerkrankungen haben einerseits zu einer deutlichen Verlangerung der Lebenserwartung, andererseits aber auch zu einer Zunahme von Patienten mit einer progredienten und schlieslich terminalen Herzinsuffizienz gefuhrt. Die Herztransplantation hat sich als Standardtherapie etabliert und bietet heute unter einer verbesserten immunsuppressiven Therapie eine signifikante Lebensverlangerung bei hoher Lebensqualitat. Aufgrund eines zunehmenden Spendermangels verlangert sich die Wartezeit auf ein Organ stetig, und die demographische Entwicklung verscharft dieses Problem zusatzlich. So wurden in den letzten Jahren immer kleinere und funktionstuchtigere ventrikulare Assistenzsysteme entwickelt, die zunachst als Uberbruckung bis zu einer Transplantation eingesetzt wurden, heute aber auch als definitive Therapieoption fur nicht transplantable Patienten Verwendung finden und mit denen die Patienten auch in ihre hauslich Umgebung entlassen werden konnen.

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.

Lipidsenker vom Typ der HMG-CoA-Reduktasehemmer spielen eine wesentliche Rolle in der Prophylaxe der Koronararteriosklerose. Eine mogliche Nebenwirkung besteht in der Auslosung von Myopathien, die vorwiegend bei Interaktion mit anderen Pharmaka beschrieben sind.

Purpose: Over last two decades computational methods for the analysis of the biomechanics of the vascular system have been developed, aiming at a better understanding of its physiology and pathophysiology and at clinical use as a tool for diagnosis and risk prediction of vascular diseases such as aortic aneurysms or plaque rupture. However, the benefit of such studies is currently limited by the lack of information on the patient specific material properties. In this work we employ blood pressure measurements and 3D ultrasound speckle tracking imaging to acquire the time resolved 3D displacement field of the abdominal aortic wall during blood pressure induced deformation in healthy volunteers. An inverse Finite Element Updating Method is applied to these data to determine the anisotropic hyperelastic mechanical properties of the abdominal aorta in vivo. Material and methods: Time resolved 3D ultrasound image data of abdominal aortic segments were acquired by use of a customized commercial real time 3D-echocardiography system (Artida, Toshiba). 3D speckle tracking of the full 4D data sets was performed using the algorithm implemented in the ACP-software. The spatially and temporally resolved strain fields resulting from the measurements or from a simulation of systolic pressure loading are compared to identify the parameters of a material model for arterial walls. Results: Spatially and temporally resolved strain fields of the abdominal aorta of healthy volunteers were calculated from 3D ultrasound data. These data were successfully used to identify the material properties of arterial walls in vivo. Conclusion: Recently, several approaches of constitutive parameter identification based on full-field measurements of displacement and strain fields have been presented. In this paper we present the application of such a method to in vivo full field displacement data of human aortas. This can be used to develop new tools for the diagnosis of vascular pathologies.

Indications and timing of cardiac transplantation for children are more complex, because problems of rejection, graft atherosclerosis, and growth have been noted. On the basis of animal studies and of improvements in surgical techniques and neonatal cardiopulmonary bypass, we established an infant cardiac transplantation program

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.

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.

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.

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.

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.

In the sixties and early seventies several authors reported neurological complications following open-heart surgery. A primary matter of discussion was valid preoperative investigation aimed at preventing neurological complications among the increasing number of patients undergoing elective coronary artery bypass grafting (CABG). Controversy exists as to whether patients with asymptomatic carotid bruits have an increased risk of perioperative stroke at the time of cardiac surgery, especially when prolonged hypotension occurs. Moreover, perioperative strokes often occur in patients who were not suspected of having carotid disease. Furthermore, significant carotid occlusive disease may be present without signs or symptoms, and thus remain undiagnosed.

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.

Anastomoses or reconstructions at the trachea are known to be related to a high risk of complications. Simi larly, anastomoses at smaller vessels have often occasioned discussion con cerning new techniques and different suturing materials. Low-dose laser energy seems to offer a new chance of tissue welding in these areas. In 10 Beagle dogs tracheal anastomoses were performed with an argon laser system, stabilized only by three single sutures for readaptation of the stumps. In 5 dogs even these three su tures were removed immediately af ter the tissue welding was finished. The anastomoses were monitored by bronchoscopy after an interval of six weeks and were removed after twelve weeks for pathologic investigations. In another 5 dogs carotid arteries were transected and reanastomosed with a similar technique. Readapta tion was achieved by four single su tures at equal distance, which were left in situ. Patency was monitored by Doppler ultrasound and by angiogra phy, and again after an interval of four to six weeks the anastomotic seg ments were resected and examined pathologically. All animals showed an uneventful postoperative course. None of the tracheal anastomoses showed any signs of functional impairment, air leakage, or infection. Bronchoscopy revealed no significant luminal nar rowing. These findings were con firmed after resection. Histology showed regular wound healing and especially normal reconstruction of the ciliated endothelium of the tra chea. Similarly all carotid anasto moses were patent in Doppler ultrasound and angiographic con trols. Neither angiography nor direct inspection after resection revealed signs of aneurysm formation. Micro scopic investigations showed a smooth endothelial passage between the two anastomosed segments and regular wound healing of the arterial wall. There were no signs of excessive scar formation or intimal hyperpla sia. The results underline the applica bility of laser energy for the perform ance of anastomoses at the tracheobronchial tree, as well as at smaller vessels. Clinical application has to be preceded by further investi gations and some technical improve ments, but still the technique shall prove to be an alternative to conven tional suturing techniques for se lected cases in the near future.

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.

Diffuse multivessel disease can limit a complete revascularization in patients undergoing coronary bypass surgery. It is considered that coro nary endarterectomy (CEA) offers a reasonable chance for this special group of patients. Among 2415 patients undergoing coronary bypass surgery, a CEA of the right and/or left coronary system had to be performed in 397 patients with diffuse multivessel disease. Completeness of the procedure was controlled intraoperatively by dye perfusion and angioscopy. One hun dred one patients gave informed con sent to be reinvestigated clinically and by angiography at an average of forty-three months after surgery. The thirty days mortality after additional CEA was slightly in creased at 3.8%. Also the periopera tive infarction rate increased at 9.3 % . The long-term analysis re vealed a late mortality of 5.5%. Cor onary angiography showed a patency rate of the endarterectomized vessels of 81.2 %; 91% of the patients being reinvestigated showed an improved or asymptomatic clinical status. Despite a slightly increased risk, CEA proved to be a feasible therapy in this strictly limited group of pa tients, in whom conventional bypass surgery offers poor chances and who otherwise would even be candidates for transplantation.

This paper describes the results of treatment of 15 patients with inferior vena cava thrombosis. Thrombolysis using urokinase was the method of choice (12 patients) unless there were contraindications when thrombectomy (three patients) was performed. Thrombolytic therapy produced complete clearance of the inferior vena cava in eight of the 12 patients and partial clearance in the remaining four. Thrombolysis was terminated because of minor bleeding complications in four. Thrombectomy was done in three patients in whom there were contraindications to thrombolytic therapy. We believe that thrombolysis is a feasible method of treatment and possibly the method of choice when the thrombus is older than 3 days and the patient's general state is poor.

Whereas the resection of benign and semimalignant cardiac tumors is a procedure accepted worldwide, the surgical therapy of malignant tumors is still a matter under discussion. To evaluate the results of reconstructive procedures after removal of cardiac neoplasms, we investigated the follow-up of 40 patients with benign and 12 patients with malignant cardiac tumors, representing 0.65% of all open-heart surgery patients in our hospital from 1971 to 1987. We always tried to remove the tumor completely, however in four cases of malignant growth only a reduction of the tumor mass was possible. A vast myxoma of the left atrium was resected using the technique of autotransplantation. The created defects of wall or septum were replaced by autogenous or heterologous materials. Of the patients with benign cardiac tumors, one man died in the perioperative period. No recurrence of a tumor was noted. Six of the patients with malignant disease survived longer than 1 year, two of them longer than 48 months. In our opinion, removal of cardiac neoplasms should be done even in patients with a malignant tumor.

Tracheal anastomoses are known to be related to special surgical risks. We performed laser-assisted trachea anastomoses in 10 Beagle dogs, using an Argon-laser system and a handheld quarz fiber for energy transmission. All animals showed an uneventful postoperative course without signs of infection, air-leakage or respiratory impairment. Pathologic examination revealed no significant stenosis but a normal reconstruction of the tracheal endothelium and a normal woundhealing with only an increased connective tissue reaction. Because of the lower tensile strength of laser-assisted anastomoses in general, three adapting absorbable sutures should be left in situ to increase the resistance against mechanical stress. Under these circumstances laser-assisted anastomoses seem to be a promising additional method in the field of tracheal reconstruction and transplantation.