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Background: Radiofrequency (RF) ablation is an increasingly applied technique. Promising results of hepatic RF ablation raised expectations of its capabilities for treatment of primary and secondary lung tumors. Because of different thermal and electrical properties of lung tissue, compared with liver tissue, a simple analogy of tissue response is not possible. The authors aimed to evaluate the effectiveness of image-guided pulmonary RF ablation and to characterize pathomorphology of tissue response., Methods: RF ablations of 11 pulmonary malignancies in 9 patients were performed under computed tomography (CT)-guidance. Three days after RF ablation, surgical resection was performed followed by pathologic examination. Specimens were evaluated macroscopically, histologically by hematoxylin and eosin (H & E) staining, terminal deoxy-nucleotidyl transferase-mediated nick end-labeling (TUNEL), and electron microscopy., Results: Tumor tissues and adjacent lung tissues were characterized by double-strand fragmentation as determined by TUNEL. Ultrastructurally apoptotic bodies were found, indicating apoptotic cells. Criteria for tissue necrosis were not fulfilled by standard histological staining (H & E), showing preserved tissue architecture and only few microscopic cellular details suggestive of tumor regression. Because of DNA fragmentation, as determined by TUNEL and results from electron microscopy, the authors confirmed the tumor tissue to be completely ablated in 10 (90.9%) cases. However, in 2 cases, a safety margin was absent., Conclusions: CT-guided pulmonary RF ablation of pulmonary malignancies is a locally effective treatment. Three days after RF ablation, tumor tissue seemed to be thermally fixed still showing characteristics of vital tumor tissue in standard histological staining; however the tissue proved to be in regression toward coagulative necrosis verified ultrastructurally and by TUNEL., ((c) 2008 American Cancer Society)

Objective: Thrombotic events and immunoinflammatory processes take place next to each other during vascular remodeling in atherosclerotic lesions. In this study we investigated the interaction of platelets with dendritic cells (DCs)., Methods and Results: The rolling of DCs on platelets was mediated by PSGL-1. Firm adhesion of DCs was mediated through integrin alphaMbeta2 (Mac-1). In vivo, adhesion of DCs to injured carotid arteries in mice was mediated by platelets. Pretreatment with soluble GPVI, which inhibits platelet adhesion to collagen, substantially reduced recruitment of DCs to the injured vessel wall. In addition, preincubation of DCs with sJAM-C significantly reduced their adhesion to platelets. Coincubation of DCs with platelets induced maturation of DCs, as shown by enhanced expression of CD83. In the presence of platelets, DC-induced lymphocyte proliferation was significantly enhanced. Moreover, coincubation of DCs with platelets resulted in platelet phagocytosis by DCs, as verified by different cell phagocytosis assays. Finally, platelet/DC interaction resulted in apoptosis of DCs mediated by a JAM-C-dependent mechanism., Conclusions: Recruitment of DCs by platelets, which is mediated via CD11b/CD18 (Mac-1) and platelet JAM-C, leads to DC activation and platelet phagocytosis. This process may be of importance for progression of atherosclerotic lesions.

Aim: Heat shock proteins (HSP) act as chaperones and protect cellular homeostasis. They are induced by multiple forms of cell stress. Nothing is known about their rise in the drainage fluid after cardiac and thoracic operations., Methods: Forty-five patients undergoing open heart surgery or major lung resections were studied. Levels of inducible HSP70 were measured daily in thoracic wound fluid and blood with ELISA tests in addition to multiple conventional blood and wound fluid parameters. Data were analyzed using analysis of covariance and Spearman's rank-correlation coefficient., Results: Inducible HSP70 was detectable in all thoracic fluid samples. Mean HSP70-level after open heart surgery was 64 ng/mL and 40 ng/mL in patients without extracorporeal circulation (P=0.015). Drainage HSP70 levels were correlated with white blood cell counts in wound fluid (P<0.0001) and blood CK-MB levels (P<0.0001). Correlation coefficients between white blood cells in blood and local HSP-levels were explicitly lower (P=0.0023). There was a steady decrease in HSP levels in drainage fluid from day 1 to day 4 (P<0.0001)., Conclusions: Inducible HSP70 is present in postoperative thoracic drainage fluid. Drainage levels are higher in patients after open heart surgery and are correlated with blood CK-MB levels, indicating cardiomyocyte damage. Our data further suggest that extracellular HSP70 is released also by white blood cells. Additional studies are needed to examine the role of extracellular HSP70 in wound healing processes and myocardial damage.

Postoperative complications associated with cardiopulmonary bypass (CPB) surgery and extracorporeal circulation (ECC) procedures are still a major clinical issue. Improving the hemocompatibility of blood contacting devices used for ECC procedures may ameliorate various postpump syndromes. In a simulated CPB model using human blood, we investigated the hemocompatibility, fibrinogen adsorption, and platelet receptor (GPIIb-IIIa) binding capacity of surface-modified membrane oxygenators (Jostra Quadrox). Three groups were compared: (i) biopassive protein coatings (SafeLine), (ii) bioactive heparin coatings (BioLine), and (iii) noncoated controls. During the 2 h recirculation period, plasma concentrations of activation markers for platelets (beta-thromboglobulin), inflammation (elastase), complement (C5a), and coagulation (prothrombin fragment 1+2, thrombin-antithrombin III) were lower in the groups with biopassive and bioactive coatings compared to the noncoated group (p < 0.01). These parameters did not significantly differ between the two surface-coated groups, except for complement activation: C5a levels were higher in the biopassive group compared to the bioactive group (p < 0.01). Moreover, surface-coated oxygenators showed less fibrinogen adsorption, GPIIb-IIIa binding, and platelet/leukocyte adhesion (p < 0.01). We assume that fewer fibrinogen and platelet receptor molecules bound to the surface-coated oxygenator surfaces results in fewer platelet adhesion and activation, which will significantly contribute to the improved hemocompatibility of the biopassive and bioactive oxygenators. Our results suggest that the application of bioactive oxygenators (BioLine) during CPB surgery may reduce postoperative complications for the patient more effectively than biopassive oxygenators (SafeLine)., ((c) 2006 Wiley Periodicals, Inc.)

Purpose: To estimate the association between signal characteristic of dynamic enhanced MRI using curve types and angiogenesis in solitary pulmonary nodules., Materials and Methods: Thirty-six patients with a solitary pulmonary nodule (SPN) ranging in size from 6 to 37 mm (median 17 mm) underwent dynamic contrast enhanced MRI with a time interval of 10 s over a total period of 4 min. Resulting from the time-intensity curves four different enhancement curve profiles (A-D) were defined: type A with strong increase followed by early washout, type B with strong increase without washout, type C with slow increase and type D without relevant increase. Maximum peak (Pmax), slope of the first bolus transit (slope) and washout were calculated. Microvessel densities (MVD) were counted at the margins and at the center of the nodules. The mean MVD of each nodule was calculated. Enhancement characteristics were correlated with MVD grouped by diagnosis and by curve types. Curve types were correlated with the score of vascular endothelial growth factor (VEGF)., Results: The frequency of malignancy was 55% (20/36). Using curve types for differentiation between malignant and benign SPN, the sensitivity, specificity and accuracy were 100%, 75% and 89%, respectively. The correlation between Pmax and MVD(mean) for all nodules was moderate (r(s)=0.4, P=0.02). A relevant correlation was found between Pmax and MVD(margin) in curve type A (r(s)=0.63; P=0.04) and Pmax and MVD(mean) in curve type C (r(s)=0.86; P=0.006). No positive correlation was found between Pmax and MVD (mean, center and margin) in curve type B. No significant correlation was found for slope and washout. VEGF score correlated positively with curve types (r(s)=0.67; P<0.001)., Conclusion: A relevant association between perfusion curve profiles and angiogenesis was found in malignant nodules having early washout and in benign lesion with a slow increase of enhancement. In cases of strong signal increase without washout additional factors for enhancement must be considered. The use of curve profiles could allow for the estimation of the extent of VEGF.

Calcification is a common complication in cardiovascular disease and may affect both arteries and heart valves. Matrix gamma-carboxyglutamic acid (Gla) protein (MGP) is a potent inhibitor of vascular calcification, the activity of which is regulated by vitamin K. In animal models, vitamin K antagonists (oral anticoagulants [OACs]) were shown to induce arterial calcification. To investigate whether long-term OAC treatment may induce calcification in humans also, we have measured the grade of aortic valve calcification in patients with and without preoperative OAC treatment. OAC-treated subjects were matched with nontreated ones for age, sex, and disease. Calcifications in patients receiving preoperative OAC treatment were significantly (2-fold) larger than in nontreated patients. These observations suggest that OACs, which are widely used for antithrombotic therapy, may induce cardiovascular calcifications as an adverse side effect.

Study Design: We report on a 54-year-old man with chronic lower back pain after recent streptococcus pneumoniae pulmonary infection, resulting in a mycotic aortic aneurysm and spondylodiscitis of the eighth vertebrae 6 months later. Successful surgical treatment and recurrence-free survival after 4 years are described., Summary of Background Data: Osteomyelitis by Streptococcus pneumoniae of the spine combined with contained rupture of a mycotic aortic aneurysm into lung and spine has not been reported to date. Mycotic aneurysms with pulmonary fistulas are reported to carry a mortality rate of up to 100%. Few cases have been reported with different operative and conservative strategies., Methods: The mycotic aortic aneurysm was excised using extracorporeal circulation and replaced by a Dacron graft. The spondylitic section of the eighth thoracic vertebrae was radically resected, and a tricortical bone block from the iliac crest was inserted into the defect. To keep compartments separated, collagen sponges with antibiotic supplementation were used. A triple antibiotic therapy (Metronidazol 3 x 0.5 g/day, Cefotaxim 3 x 2 g/day, and Flucloxacillin 3 x 2 g/day) was prescribed for 6 weeks and changed to Clindamycin for 1 year thereafter., Results: The patient made a good recovery and is free of recurrence 4 years after surgery., Conclusions: Lower back pain might be a projected pain. Particularly in older patients or in the presence of comorbidities resulting in an immunocompromised status, an aggressive workup may be indicated. Radical resection of inflammatory tissues, sparse use of implant material, and prolonged administration of antibiotics proved a successful strategy in this patient.

Purpose: To determine whether dynamic contrast material-enhanced magnetic resonance (MR) imaging with use of kinetic and morphologic parameters reveals statistically significant differences between malignant and benign solitary pulmonary nodules., Materials and Methods: Fifty-eight patients met the inclusion criteria of a solitary 5-40-mm pulmonary nodule without calcification or fat at computed tomography. Fifty-one patients were examined successfully; 46 received a histologic diagnosis, and five received a diagnosis by means of observation over 2 years. Dynamic MR images were acquired every 10 seconds for a total of 4 minutes. Diagnostic characteristics for differentiation were examined by using threshold values for maximum peak enhancement, slope of enhancement, and washout. Receiver operating characteristic curves were calculated to test the usefulness of these parameters. The diagnostic performance of a combination of curve profiles and morphologic contrast material distribution were tested by using a decision tree., Results: Frequency of malignancy was 53% (27 of 51 nodules). Malignant nodules showed stronger enhancement with a higher maximum peak and a faster slope (P <.001). Significant washout (>0.1% increase in signal intensity per second) was found only in malignant lesions (14 of 27 lesions). Sensitivity, specificity, and accuracy were 96%, 88%, and 92%, respectively, for maximum peak; 96%, 75%, and 86% for slope; and 52%, 100%, and 75% for washout. When curve profiles and morphologic enhancement patterns were combined, sensitivity increased to 100%., Conclusion: Dynamic MR imaging delineates significant kinetic and morphologic differences in vascularity and perfusion between malignant and benign solitary pulmonary nodules. Washout seems to be highly specific for malignancy., (Copyright RSNA, 2004)

An inflammatory response to cardiopulmonary bypass (CPB) caused by bioincompatibility of extracorporeal circuits is one of the major clinical issues in cardiac surgery. Recently a new coating material, poly-2-methoxyethylacrylate (PMEA), was developed to improve the biocompatibility of blood contacting surfaces. In a simulated cardiopulmonary bypass model, using fresh human whole blood, 15 membrane oxygenators (Capiox SX18, Terumo Corp., Tokyo, Japan) were compared. Five of them had the PMEA coating, five had a heparin-coated surface, and five had no surface treatment. Blood samples were taken at several time-points during a 90 minute circulation period. Changes in coagulation, complement, and blood cell alteration factors were measured by ELISA methods, plasma bradykinin levels were measured by radioimmunoassay, and expression of genes encoding cytokines TNF-alpha, interleukin-1beta, interleukin-6, and interleukin-8 was determined by semiquantitative real time RT-PCR. Platelet adhesion was significantly reduced in both the PMEA and the heparin coated circuits. Release of platelet activation marker beta-thromboglobulin was significantly higher in the uncoated control group (p < 0.01). After 5 minutes of blood circulation bradykinin levels significantly increased in all three groups (p < 0.01); however, the group with the PMEA coated oxygenators showed the lowest values. Expression of genes encoding proinflammatory cytokines in monocytes was increased in all groups, with the lowest being in the PMEA coated group. PMEA coated CPB surfaces in an in vitro experimental model showed an improved thrombogenicity, reduced bradykinin release, less platelet activation and less proinflammatory cytokines gene expression in comparison with a noncoated group. The authors assume that PMEA coating may ameliorate some of intra- and postperfusion syndromes, particularly hypotension, unspecific inflammation, hyperfibrinolysis, and blood loss.

Follicular dendritic cell sarcomas (FDCSs) are very rare and usually originate in lymph nodes. We report an exceedingly rare case with localization in the dorsal mediastinum and, for the first time, provide positron emission tomography (PET) data for this tumor. This report describes the case of a 76-year-old man with a clinically aggressive tumor in the dorsal mediastinum. Computed tomography scan revealed displacement of soft tissue and lymph nodes. PET showed that the tumor had a high proliferation rate. Investigation of the successfully removed tumor mass revealed reactivity of the tumor cells for follicular dendritic cell markers and desmosomes linking adjacent tumor cells at the ultrastructural level. Marked atypia, a high mitotic rate, and areas of coagulative necrosis were found. The tumor in our case revealed the typical features and thus was classified as FDCS. In contrast to previous reports in the literature, preoperative imaging, histology, and immunohistochemistry studies indicated at least an intermediate degree of malignancy. Nevertheless, the patient made a good postoperative recovery and remained apparently disease-free 2 years later.

Objective: To evaluate and compare two fast gradient-echo sequences (GRE) concerning the visualization of solitary pulmonary nodules with an open low-field MRI system in comparison to computed tomography., Materials and Methods: Fourteen patients with solitary pulmonary nodules detected by spiral CT ranging in size from 6 mm to 42 mm (mean 20 mm) underwent MRI on an open 0.2 T scanner using a spoiled 2D GRE (2D FLASH; TR/ TE/Flip = 100 ms/7.5 ms/30 degrees ) and a totally refocused 2D steady-state GRE (True-FISP; TR/TE/FA = 7.3 ms/3.5 ms/80 degrees ). The image quality concerning artifacts (by flow, breathing and susceptibility) and the morphologic characteristics of the nodules were scored and compared with CT by two independent radiologists. The diameters of the nodules measured by MRI were compared with CT measurements. The sequences were also evaluated with regard to the signal-to-noise ratio (SNR) of the lesion., Results: All lesions were detected with the 2D FLASH sequence. True-FISP failed to find a granuloma with a size of 6 mm. The 2D FLASH was rated significantly superior to true FISP concerning image quality artifacts by susceptibility as well as concerning to CT the presentation of nodule characteristics. In MR images, the size of lesions was significantly smaller than in CT images for both sequences: for 2D FLASH the mean difference was 0.9 mm and for true FISP 2.6 mm. The SNR of the nodules was significantly higher for the 2D FLASH than for the true FISP., Conclusion: In low field MRI, the 2D FLASH sequence is superior to the 2D true FISP sequence in imaging of pulmonary nodules. With the 2D FLASH sequence nodules of 6 mm or larger in size can be visualized.

Case Report: A 75-year-old patient was hospitalized for angina pectoris and tachycardia. Neither ECG nor laboratory examinations were diagnostic for myocardial infarction. Because of an abdominal thrill and a history of an aortic aneurysm a thoracic and abdominal CT scan was performed. It revealed a rupture of the infrarenal aortic aneurysm into the inferior vena cava. In an emergency operation the aortocaval fistula was closed and the infrarenal aorta including both Aa. iliacae was replaced by a prosthesis. The patient recovered rapidly and was discharged home on the 11th postoperative day., Conclusion: Aortocaval fistulas are rare complications of abdominal aortic aneurysms. Due to altered hemodynamics they may become manifest by symptoms usually typical for other diseases. Computed tomography appears to be the most rapid and safe diagnostic measure. Particularly in patients with unstable hemodynamics, surgical transaneurysmatic closure of the fistula together with a prosthetic replacement of the diseased vessel is the therapy of choice.

Purpose: To evaluate the effectiveness and safety of endovascular treatment of various descending thoracic aortic pathologies with covered stent-grafts as an alternative to open surgery., Methods: Among 16 patients (5 type B dissections, 5 contained ruptures, 3 aneurysms of the descending aorta, 1 thoraco-abdominal aneurysm, 1 mural thrombosis, 1 patch aneurysm) treated between November 1997 and November 2000, eight patients received Talent stent-grafts and another 8 patients underwent a Gore-TAG stent-graft implantation. A clinical follow-up and control CT scans were obtained after the procedure and then at six-month intervals., Results: Deployment of the stent-grafts was technically successful in all cases. Sufficient aortic reconstruction was achieved in all but one patient who needed surgical treatment. One patient died two days after the procedure from aortic rupture due to retrograde type A dissection. Another patient died 19 months after the procedure from an unknown cause. There was no occurrence of distal embolization, paralysis or infection. During follow-up, all patients remained free from recurrence or late complications of their disease., Conclusion: Endoluminal treatment of thoracic aortic pathologies with covered stent-grafts appears to be a safe and feasible method with at least mid-term efficacy.

Background: Myocardial preservation during open heart surgery is a subject of intense investigation. A prerequisite for further improvement is a better understanding of the underlying pathophysiologic mechanisms responsible for postoperative myocardial stunning. In this report, we analyzed the role of apoptosis in myocardial stunning., Methods: Myocardial samples were obtained from 11 patients undergoing elective coronary artery bypass grafting before (control) and after cardioplegic arrest and reperfusion. Specimens were examined for apoptosis by electron microscopy, in situ end-labeling of DNA fragments, and biochemically for mitochondrial cytochrome c release., Results: Electron microscopy revealed condensation and margination of nuclear chromatin after surgery, as well as swelling and membrane rupture in mitochondria of single myocytes surrounded by healthy cells. TUNEL-positive cells were also found. Cytochrome c release, an initial step in apoptosis, revealed a 3.4 +/- 0.4-fold increase during surgery (p < 0.0001). Furthermore, cytochrome c release from otherwise intact mitochondria showed a negative correlation with left ventricular function and a positive correlation with the duration of cardioplegic arrest and reperfusion (p < 0.05)., Conclusions: Our data demonstrate that programmed cell death is evident early after open heart surgery and correlates with declining cardiac contractility. We conclude that apoptosis may be an important mechanism in postoperative myocardial stunning.

Purpose: To describe principles and results of percutaneous treatment of ischemic complications of aortic dissection., Materials and Methods: In five cases (four patients) aortic dissection was clinically complicated by renal (n = 4), iliofemoral (n = 2) or mesenterial ischemia (n = 1). After evaluation by means of computed tomography, angiography, and manometry, treatment consisted of balloon fenestration of the intimal flap, stent placement or both., Results: Eleven of 25 vascular beds were classified as ischemic. Treatment consisted of 11 balloon fenestration procedures in 3 patients, in one case supported by stent placement across the dissection membrane. Stents were placed in five renal arteries, one stent was placed in the true lumen of the aorta. One iliac artery was treated with balloon dilatation. One renal artery dissection became symptomatic after balloon fenestration and was treated successfully by stent placement. In all cases ischemia was resolved by endovascular treatment. All patients had persistent relief of symptoms. Mean follow-up time is 5.8 months., Conclusion: Ischemic complications of aortic dissection can be effectively and safely treated with stent placement and balloon fenestration.

Somatostatin receptor scintigraphy with 111In-[DTPA-D-Phe1]-octreotide has the potential for visualizing primary and recurrent thymomas in patients with myasthenia gravis, whereas thymic hyperplasias fail to accumulate somatostatin analog peptides. We demonstrate somatostatin receptor imaging findings in a patient with a mixed encapsulated thymoma which exhibited intense 111In-[DTPA-D-Phe1]-octreotide uptake in early and late scans. In another patient with a history of malignant thymoma 111In-[DTPA-D-Phe1]-octreotide accumulation was clearly seen in a mass suspected to be a recurrence. This paper describes the imaging protocol including Single Photon Emission Computed Tomography (SPECT) and discusses the clinical applications of this feasible functional imaging method in patients with thymomas.

History and Clinical Findings: For some months a 57-year-old woman had noted increasing shortness of breath, associated in the last few weeks with undirected vertigo and several brief periods of lost consciousness. She was finally admitted because of additional central facial paresis. On auscultation a high-frequency systolic murmur was heard over the apex and a discrete diastolic murmur over Erb's point. There were numerous facial freckles and three cutaneous myxomas., Investigations: Echocardiography revealed irregular tumours throughout the left atrium and a large broad-based one prolapsing through the mitrale valve in diastole. Computed tomography demonstrated a 6 x 6 cm tumour in the left lower abdomen, probably arising from the left ovary, and a second 3 x 3 cm presacral tumour., Treatment and Course: At cardiac surgery four tumours were found in the left atrium and resected: histologically they were benign myxomas. Removal required extensive resection in the area of the interatrial septum and the atrial wall, resulting in 2 degrees AV block for which a VDD pacemaker was implanted., Conclusion: Atrial myxomas may be the cardinal sign of the Carney Complex, an autosomal dominant syndrome with cutaneous myxomas, myxoid abdominal tumours, hormone-producing tumours in the testicles, adrenal cortex or hypophysis, schwannoma as well as lentigines. For this reason, further tumours should be looked for if freckles and/or cutaneous tumours are found in association with an atrial myxoma. The patient and family should be informed about the genetic aspects.

Background: Induction of protooncogenes such as c-fos, c-jun, and EGR-1 has been implicated in cellular growth and differentiation. Heat-shock proteins (HSPs) such as hsp 70 may mediate resistance to ischemia after heat shock and ischemic preconditioning. The effects of cardioplegia on the regulation of these immediate early genes are unclear., Methods: Isolated rat hearts were subjected to different cold (5 degrees C) or normothermic (35 degrees C) cardioplegic solutions and reperfused with normothermic Krebs-Henseleit buffer. Right atrial biopsy specimens from patients undergoing coronary artery bypass grafting with cold cardioplegic arrest were taken before and after cardiopulmonary bypass. Analysis of immediate early gene messenger RNAs was performed using Northern blots. Related proteins were localized by immunohistochemistry., Results: In rat hearts, cold cardioplegia for 40 minutes with Bretschneider or St. Thomas' II solution followed by 40 minutes' reperfusion resulted in a significant increase in left ventricular c-fos, EGR-1, and c-jun messenger RNA levels (4.0-, 3.1-, and 3.0-fold, respectively, with Bretschneider solution and 3.7-, 2.8-, and 2.1-fold, respectively, with St. Thomas' II solution) compared with control hearts perfused at 35 degrees C with Krebs-Henseleit buffer. Normothermic cardioplegia with St. Thomas' II solution was without effect, whereas sequential perfusion with Krebs-Henseleit buffer at 5 degrees C and 35 degrees C resulted in a similar increase in protooncogene messenger RNA levels. Only cold Bretschneider solution was related to a 5.2-fold induction of hsp 70 messenger RNA levels. Likewise, rat atrial tissues and samples from patients after cardiopulmonary bypass displayed a significant induction of these immediate early genes. Monoclonal antibodies against c-FOS and HSP 70 proteins stained nuclei and perinuclear spaces of endothelial cells and cardiac myocytes., Conclusions: Cold cardioplegic arrest and normothermic reperfusion are potent triggers for immediate early gene induction. Hypothermia emerged as the prime stimulus for the examined protooncogenes. In contrast, hsp 70 induction was dependent on the cardioplegic solution.

A case of pulmonary artery rupture due to Swan-Ganz catheterization is reported. A 73-year old women undergoing coronary artery bypass grafting developed massive endotracheal bleeding during weaning from the cardiopulmonary bypass and inflation of the balloon of the Swan-Ganz catheter. As bleeding could not be controlled by endobronchial Fogerty catheter blockade, resection of the lateral segment of the middle lobe was necessary before bypass could be terminated. The postoperative course was complicated by an abscess formation in the right middle lobe of the lung which required operative revision.

A total of 164 patients with a mean age of 78.6 +/- 2.7 years and often critical preoperative conditions [New York Heart Association (NYHA) class III + IV, 78.7%] underwent cardiac operations [coronary artery bypass grafting (CABG) 97; valve replacement, 33; CABG + valve replacement, 18; replacement of ascending aorta and others, 18] with an in-hospital mortality of 8.5% (n = 14). Follow-up was completed for 147 patients (98%) after 16.5 +/- 10.8 months. Most patients were in a good clinical condition (NYHA I + II, 79.6%; late deaths, 8 patients, 5.4%) and more than 95% of patients lived at home or with relatives. Charges for hospital treatment dropped to one third after the hospitalization period for surgery in the first postoperative year compared to the year immediately preceding the cardiac operation.

Malposition of a cardiac pacemaker lead within the left ventricle represents a source of early and late thromboembolic complications. We report a case of cerebral embolism, caused by an inadvertently misplaced left ventricular electrode, occurring 3 years after implantation. The lead was removed via a transaortic approach with extracorporeal circulation.

A 38-year-old woman suffered from syncopes due to torsades de pointes arrhythmias. Echocardiography showed a left ventricular mass that was resected. By immunohistochemical investigations, an organized thrombus was excluded and the diagnosis of a rare ventricular myxoma was confirmed. Postoperatively the arrhythmias resolved without recurrence. We conclude that left ventricular myxoma may cause life-threatening arrhythmias, possibly by irritation of cardiac mechanoreceptors. To our knowledge, this is the first case of a left ventricular myxoma associated with a torsades de pointes arrhythmia.

Emptying of the gastric substitute and small bowel transit time of a 99mTc-labeled solid test meal were measured in 20 tumor-free patients 13 to 63 (median, 35) months after total gastrectomy with Roux-y (n = 11) and jejunal interposition (n = 9) reconstruction. The emptying half-times ranged from 2 minutes to greater than 20 minutes. Rapid emptying was associated with dumping symptoms (p less than 0.03) and shorter orocoecal transit-time (p less than 0.05). Serum glucose concentrations rose more quickly in jejunal interposition, but the areas under the curve were identical in both groups. The median insulin-to-glucose ratio (areas under the curve) during the 20 minutes after the meal was 11.4 in jejunal interposition and 7.1 in Roux-y esophagojejunostomy (NS). Interposition cases had regained a significantly higher percentage (89%) of their premorbid weight than patients with Roux-y (78%; p less than 0.05). The weight/height2 ratio was above the 50th centile in 45% of interpositions, but below the 50th centile in all patients after the Roux-y mode of reconstruction (p less than 0.05). It is concluded that the emptying velocity of the gastric substitute has no impact on postoperative weight gain. The authors contend that the concept of a gastric substitute pouch is not supported by the findings of this study.

Calculated chemotherapy is based on the knowledge of the typical bacterial agents of a particular infection. From January 1983 to August 1985 bacteriological findings from surgical patients with peritonitis, septicemia or pneumonia treated in an intensive care unit were analysed. The study concentrated on those findings only which differed from previous bacteriological investigations. During the first three days 53 patients on assisted ventilation suffering from peritonitis exhibited mainly enterobacteria in their peritoneal secretions. At day 10 or later we also found bacteria from the pseudomonas group. At that time the bacterial spectrum of bronchial secretions was comparable to that of the peritoneal secretions of the same patient. After day 10, the bacterial spectrum was similar in 36 ventilated patients without peritonitis, in 56 patients suffering from post-operative pneumonia and in peritonitis patients. According to our findings, calculated chemotherapy may be based on the fact that patients with peritonitis who cannot be cured within a few days have a bacterial flora comparable to that of patients with septicemia or pneumonia. Patients with severe infections following surgery, such as potentially fatal pneumonia, generalised peritonitis or septicemia were treated with imipenem/cilastatin, according to the above definitions of calculated chemotherapy. 37 of 46 patients treated between May and December 1985, were clinically cured. Microorganisms persisted in five clinically cured patients. Development of resistance to imipenem was observed in one case. In one case treatment had to be stopped because of an allergic skin reaction. Monotherapy of peritonitis by imipenem/cilastatin appeared more satisfactory than treatment with combinations of other antibiotics.

A great variety of peptide hormones have been demonstrated by immunocytochemical means in endocrine cells of the digestive system. Usually the specificity immunostaining in these cells is checked by antigen-adsorption of the antisera. This kind of specificity control, however, examines only antibody non-specificity but not staining non-specificity. Indeed staining non-specificities caused by ionic binding mechanisms are of considerable significance, at least for the immunostaining of some endocrine cell types (e.g. pancreatic glucagon- and PP-cells, pyloric gastrin-cells, intestinal GLI-cells). Therefore immunoreactivities of these cell types should be investigated under various experimental conditions. According to our present findings the following investigations should be performed to exclude staining non-specificities in immunostained endocrine cells of the digestive system: 1. Running of ascending dilutions of primary and secondary antisera. 2. Comparative investigations using crude antisera and purified antibodies against the peptide in question. 3. Use of phosphate buffered saline (PBS) with a relatively high salt content as a dilution agent for the antisera.