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Objective: To compare volume therapy with HES 130/0.4, a new hydroxyethylstarch (HES) solution with a gelatin-based fluid replacement strategy., Design: Prospective, randomized, safety study., Setting: Urban, university-affiliated hospital (single institution)., Participants: Forty-two patients undergoing elective cardiac surgery., Interventions: Patients were prospectively randomized into 2 groups: In group 1 (n = 21), gelatin was given perioperatively for volume support until the 1st postoperative day to keep the central venous pressure (CVP) between 10 and 14 mmHg; in group 2 (n = 21) HES 130/0.4 was administered using the same protocol as in group 1., Measurements and Main Results: Standard coagulation variables and modified thromboelastography (TEG) were used. Using different activators for extrinsic and intrinsic activation and heparin inactivation by heparinase, the onset of coagulation (coagulation time), kinetics of clot formation (clot formation time), and maximum clot firmness were measured. Measurements were performed after induction of anesthesia (T0), at the end of surgery (T1), 4 hours after surgery (T2), and on the morning of the 1st postoperative day (T3). A total of 3310 +/- 810 mL of gelatin and 3070 +/- 570 mL of HES 130/0.4 were used in the 2 groups during the study period. The 2 groups did not differ with regard to postoperative bleeding or in use of packed red blood cells or fresh frozen plasma. Standard coagulation variables were similar between the 2 groups. All TEG variables were within the normal range at baseline. Coagulation time and clot formation time data were significantly elevated after surgery and in the intensive care unit, without showing specific differences between the 2 volume replacement groups. Intrinsic TEG and heparinase TEG clot formation times remained significantly higher until the end of the study period. No differences were seen between HES-treated and gelatin-treated patients., Conclusions: Volume replacement with the new HES preparation was as safe as gelatin-based volume replacement with regard to coagulation in cardiac surgical patients. HES 130/0.4 is an alternative plasma substitute to treat volume deficits., (Copyright 2001 by W.B. Saunders Company.)

Background: Inflammation plays a pivotal role in the pathogenesis of organ injury after cardiopulmonary bypass (CPB). Elderly patients appear to be especially prone to develop general inflammation. Use of pentoxifylline (PTX) before surgery may be a promising approach to minimize the negative effects of CPB in these patients., Methods: In a prospective, randomized study, patients more than 80 years old undergoing aortocoronary artery bypass grafting received either PTX (n = 15) after induction of anesthesia (initial bolus of 300 mg followed by a continuous infusion of 1.5 mg.kg(-1).h(-1) during the next 2 days) or saline as placebo (control group; n = 15). Polymorphonuclear neutrophil (PMN) elastase, C-reactive protein (CRP), and interleukins (IL-6, IL-8, IL-10) were measured from arterial blood samples before surgery (T0), at the end of surgery (T1), 5 hours after surgery (T2), and at the morning of the first (T3) and second (T4) postoperative day., Results: Postoperatively, PTX-treated patients less often needed catecholamines and were extubated earlier than the control patients (p < 0.05). On the intensive care unit, cardiac index inceased more in the PTX-treated (from 1.95 +/- 0.3 to 3.26 +/- 0.4 L.min(-1).m(-2)) than in the control patients (from 1.89 +/- 0.2 to 2.78 +/- 0.3 L.min(-1).m(-2)). Increase in CRP and PMN-elastase was significantly higher in the untreated control than in the PTX patients. After CPB, IL-6, IL-8, and IL-10 increased in both groups showing a significantly higher increase in the untreated control patients (IL-8 control: from 11.3 +/- 2.6 to 154.4 +/- 57 pg/mL [T1]); IL-8 PTX: from 10.9 +/- 2.7 to 71.8 +/- 23 pg/mL [T1])., Conclusions: In elderly cardiac surgery patients, use of PTX before surgery and continued after CPB resulted in less inflammatory response than in an untreated control group. The value of attenuating the inflammatory process by PTX on outcome in this patient population needs to be evaluated in further controlled studies.

Objective: To compare intraoperative hemodynamics and depth of anesthesia using sufentanil-midazolam (SM) versus remifentanil-propofol (RP) anesthesia., Design: Prospective, randomized study., Setting: Clinical investigation in an urban, university-affiliated hospital., Participants: Forty patients undergoing elective first-time coronary artery bypass graft surgery., Interventions: Twenty patients were anesthetized using SM and 20 patients using RP., Measurements and Main Results: Hemodynamic monitoring included a 5-lead electrocardiogram, a radial artery catheter, and a pulmonary artery catheter. Depth of anesthesia was assessed using bispectral index (BIS). Data were obtained after induction of anesthesia (T1), after sternotomy (T2), after pericardiotomy (T3), 5 minutes after cardiopulmonary bypass (CPB) (T4), after closure of thorax (T5), and at the end of surgery (T6). The 2 groups were comparable with regard to demographic and perioperative data. There were no significant differences of any hemodynamic parameter at any time between the 2 groups. In both groups, systemic vascular resistance increased at T2 and decreased at T4 from baseline value (p < 0.05). Cardiac index increased at T4 in both groups from baseline value (p < 0.05); 55% of the patients of both groups needed low-dose dobutamine after CPB. During CPB, 40% of the RP patients needed norepinephrine versus 35% of the SM patients. BIS was lower in the RP than in the SM group at T2 and T3 (p < 0.05). BIS values indicating intraoperative awareness were not noted., Conclusion: Both anesthesia regimens provided stable hemodynamics and adequate anesthesia in patients undergoing coronary artery bypass graft surgery.

Objective: To compare the hemodynamic efficacy of a new hydroxyethyl starch (HES) preparation (130/0.4) with an HES 200/0.5 solution., Design: Prospective, randomized, double-blind, phase II study., Setting: An urban, university-affiliated hospital., Participants: Twenty patients undergoing elective first-time cardiac surgery., Interventions: After induction of anesthesia and before the start of surgery, a new HES 130/0.4 (molecular weight, 130,000 d; degree of substitution, 0.4) (n = 10) or HES 200/0.5 (molecular weight, 200,000 d; degree of substitution, 0.5) (n = 10) was infused (10 mL/kg) within 30 minutes when pulmonary capillary wedge pressure was less than 10 mmHg., Measurements and Main Results: Extensive hemodynamic monitoring was performed 30 and 60 minutes after the end of infusion. Then surgery was started. Standard laboratory parameters were measured before surgery and on the 1st postoperative day. A similar amount of HES was given in both groups (HES 130, 795+/-75 mL; HES 200, 820+/-90 mL). Filling pressures (central venous pressure, pulmonary capillary wedge pressure) and cardiac index increased similarly in both groups and remained significantly elevated 60 minutes after the end of infusion. All other hemodynamic parameters were similar between the two volume groups. Renal (creatinine) and hepatic function (aspartate aminotransferase, alanine aminotransferase) and hemostasis (platelet count, activated partial thromboplastin time, blood loss) were without group differences until the morning of the 1st postoperative day., Conclusions: The new 6% HES 130/0.4 was as effective as a 6% HES 200/0.5 preparation in regard to hemodynamic efficacy. No negative side effects on organ function were seen. The 6% HES 130/0.4 solution may become an alternative strategy for volume therapy in cardiac surgery.

Objective: To compare standard nurse-based pain therapy with a patient-controlled analgesia (PCA) regimen., Design: Prospective, randomized study., Setting: Single-institutional, clinical investigation in an urban, university-affiliated hospital., Participants: Sixty patients undergoing elective first-time cardiac surgery were included., Interventions: In 30 patients, a standard analgesic regimen was used, and in 30 patients, a PCA regimen was used. The perioperative and postoperative management was similar for all patients., Measurements and Main Results: Degree of sedation, satisfaction, and pain (by visual analog scale [VAS]) was assessed within the first 3 postoperative days. Vital capacity (VC) and forced expiratory volume in 1 second (FEV1) were measured using a portable spirometry system. Cortisol and troponin T (TnT) plasma levels were also measured. The expectation of pain was similar in both groups, and the postoperative pain score was significantly lower in the PCA than in the standard group throughout the study period. Significantly more piritramid was used in the PCA (total, 75.6 +/- 33.4 mg) than in the standard group (total, 20.1 +/- 31.9 mg). VC and FEV1 were significantly lower in the standard group compared with the PCA patients. Cortisol and TnT plasma levels were similar in both groups. Frequency of side effects were similar for both groups., Conclusion: Because of the beneficial effects with regard to degree of pain and satisfaction, pain management using PCA systems can be recommended for cardiac surgery patients. It appears to be superior to standard nurse-based pain therapy.

In this case report a 65-year-old patient came into the emergency ward with acute chest pain after coronary artery bypass graft operation in 1985. On routine chest X-ray in 1995 a mediastinal widening was diagnosed. The chest X-ray in 1997 (Figure 1) showed an increase of the diameter of the known mediastinal widening. Therefore a CT-scan was performed (Figures 2a and 2b). This showed an enhancement of contrast material in a contained structure, without identifying its origin. Therefore a coronary angiography was done. Here, we diagnosed a contained disruption of the aorta at the insertion site of the bypass graft at the right coronary artery. Figure 3a shows leakage of contrast material out of the aorta into the pseudoaneurysm and in Figure 3b this is demonstrated in a schematic drawing. Figure 4a shows supraselective imaging of the pseudoaneurysm, demonstrated in a schematic drawing in Figure 4b. As the chest pain could only be handled by i.v.-medication, betablocker and bed rest we decided to operate. Intra-operatively the diagnosis was confirmed (Figure 5a and 5b). Postoperatively the patient died due to cerebral ischemia. Despite the lethal outcome an operative revision appears even retrospectively justified because of the increasing size of the pseudoaneurysm in addition to new symptoms that were difficult to treat. On the other hand there are no data available in order to estimate the risk of a spontaneous course.

The myxoma complex is a very rare disease. We report on a 31-year-old woman who suffered a hyperthyreosis, which resolved spontaneously. A few months later she developed a Cushing's syndrome, caused by a primary adrenocortical nodular dysplasia. A bilateral adrenalectomy had to be performed. 15 months after this operation she developed a cerebral infarction caused by an embolus from a left atrial myxoma. Our patient is a further case of Carney's syndrome. The aspect of the hyperthyreosis is interesting: Perhaps disease of the thyroid represents a new element of Carney's syndrome.

Background: Endocarditis of the tricuspid valve is a rare form of valvular endocarditis and occurs mainly in patients with special risk factors., Case Reports: The three case reports demonstrate 3 young patients (age 30 to 37 years, 2 female and 1 male) with a typical history of those risk factors. The two women were intravenous drug addicts and one of them had suffered already an episode of tricuspid valve endocarditis several years ago. The man developed his infection after implantation of a pacemaker. In all of the three patients the endocarditis was due to infection with staphylococci twice staphylococcus epidermidis and once staphylococcus aureus. In two of the three patients the endocarditis could not be cured by intravenous antibiotics alone and these patients had to undergo cardiac valvular surgery. All patients left the hospital after several weeks without signs of infection., Conclusion: In clinical praxis the introduction of a special endocarditis service, a small team which has to be consulted in every suspected case of endocarditis, seems to be beneficial as well as the use of the Duke criteria for diagnosis in those cases.