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HISTORY A 26-year-old man sustained a wasp bite 5 years ago which caused arterial embolism to the right brachial artery. Now he again had a wasp bite with allergic reaction and an arterial embolus to the left brachial artery. 2 days later, after embolectomy and heparinisation, he had a cerebrovascular accident due to an embolus to the left internal carotid artery. 15 days later, despite oral anticoagulation (Quick value 10%), he had an embolism to the left femoral artery. INVESTIGATIONS The source of the emboli was found by echocardiography to be a spherical floating thrombus on the aortic valve. The plasminogen level was only 45-61%. His mother and sister also had a low plasminogen level, i.e. he had congenital plasminogen deficiency. TREATMENT AND COURSE At surgery, when the thrombus had been removed, a slit-like defect was found on one of the aortic leaflets and covered with a pericardial patch. At first heparin then phenprocoumon were administered, plus 250 mg ticlopidine twice daily. There have been no further complications. CONCLUSION As the patient's fibrinolysis activity was normal, additional, probably allergic, factors must have been present to disturb the equilibrium between thrombogenesis and fibrinolysis thus causing thrombosis at a predisposed site.

A 27-year-old woman sustained a massive pulmonary embolism (cause unknown) with circulatory arrest. She was intubated and ventilated while external cardiac massage was performed and urokinase was infused (1.5 X 10(6) U/h). These resuscitative measures were continued while she was transferred by helicopter to the nearest cardiothoracic surgical centre, 40 km away. Thrombectomy was successfully accomplished under extracorporeal circulation after (from its onset) 90 minutes of external cardiac massage. No neurological or other sequelae occurred. This case demonstrates that early and continuous resuscitative measures in a general hospital, followed by rapid transfer to a cardiothoracic surgical centre with immediate operation, can achieve a successful outcome.

19 patients in whom cardiopulmonary bypass (cpb) was performed during different types of cardiac operations, developed myocardial failure which remained refractory to inotropic support with increasing doses of adrenaline, dopamine and dobutamine, so that it was impossible to discontinue cpb. After changing the therapeutic approach to a new regime consisting of adrenaline, dopamine and enoximone, low-output syndrome (LCOS) could be successfully reversed in 12 of the 19 patients. In the 7 remaining patients blood pressure dropped in a clinically relevant way under treatment with enoximone. 5 of these patients needed intraaortic balloon pumping (IABP) inspite of the application of enoximone, before cpb could be successfully discontinued. In three patients receiving enoximone, persisting ventricular tachyarrhythmia appeared under treatment, and disappeared after discontinuation of the drug. One patient needed IABP and left heart bypass by means of the centrifugal pump before cpb could be duly discontinued. One patient died intraoperatively due to untreatable right ventricular failure and inability to discontinue cpb. It is concluded that enoximone represents a useful drug in a significant number of patients developing heart failure refractory to inotropic support, on emerging from cpb during cardiac surgery.

The implantable defibrillator is a device to treat refractory ventricular tachyarrhythmias. This study was done to evaluate the determinants of defibrillator performance which are not known completely. Different defibrillation electrodes were attached to beating and non-beating isolated pig-hearts (n = 15) and the electric field resulting from defibrillation measured over a distance of 3 mm. From 5 to 20 J a non-linear relation was found between delivered shock energies and the amplitudes of the recorded voltage waveforms. Using two patch electrodes maximal amplitudes were monitored apical in the right (4.6 +/- 0.5 V) and left ventricle (2.1 +/- 0.3 V). The atria only showed 10-25% of the maximal amplitudes. The combination of a patch and a catheter electrode showed similar efficiency. Two catheter electrodes reduced the apical (1.2 +/- 0.1 V) and increased the atrial amplitude (0.75 +/- 0.06 V). The recorded amplitudes in myocardium were half as much compared with blood-/sodium chloride indicating the twofold higher resistance of myocardial tissue. These experiments quantify the dependence of the efficiency of automatic implantable defibrillator systems on the sort and localization of the defibrillation electrodes.

Early and late results of a total of 72 infants operated for coarctation of the aorta are reported. Operative repair included various methods (End-to-End, Vossschulte, Clagett, Shumaker, Waldhausen, Blalock). Isolated coarctation was present in 6 infants, 17 also had patent ductus arteriosus, 39 patients had additional associated cardiac anomalies, part of which were combined with PDA. Out of the 72 infants 17 died (early mortality: 11, late mortality: 6). The highest mortality rate was found among the 0 to 3 months age group (11 patients). Fourteen out of the 17 deceased patients had additional cardiac anomalies. Out of the 55 survivals, 37 patients showed good results, restenosis was found in 13 patients, 5 patients had to be reoperated due to severe restenosis.

Only 9 of more than 900 operated patients with ventricular septal defects suffered from this rare combination. The problems of the diagnosis are discussed. Only in one case this diagnosis was made praeoperatively, in 6 cases intraoperatively and in two cases only postoperatively. In the last two cases a reoperation was necessary. The surgical methods are described and the results of surgery are communicated.

Bei insgesamt 16 Patienten wurde intraoperativ und am isolierten Myokard der Gewebs-pH-Wert gemessen. Als Herzstillstandsverfahren kamen zur Anwendung die „hypotherme Infusionskardioplegie” und die „externe Kuhlung”. Im isolierten resezierten menschlichen Myokard wurden bei 15°C parallel zu dem fortlaufend gemessenen intramyokardialen pH-Wert Proben fur die Elektronenmikroskopie entnommen. Auf diese Weise konnte der sogenannte Sicherheits-pH-Grenzwert fur das menschliche Myokard durch morphologische Untersuchungen zusatzlich wahrscheinlich gemacht werden. Die Ergebnisse werden mit denen fur das Versuchstier verglichen. In a total of 16 patients the tissue pH was determined on myocardium both during surgery and on isolated samples. Cardiac arrest was induced by hypothermal infusion cardioplegia and external cooling. In the isolated human myocardium section pH values were continuously determined at 15°C. Parallel to these measurements samples were taken for electron microscopic examinations. In this way the pH limit under which the human myocardium cannot be revived could be visualized by additional morphologic examination. These results and those from the intrasurgical measurements with a fixed heart muscle surface probe were compared with each other and with results from animal experiments.

The Doppler ultrasonic method can confirm the success of the operation in the early post-operative phase after reconstructive vascular operations as an essential non-invasive technique or clear a doubtful improvement of the blood flow. Thus an arteriography can be indicated in good time. On the basis of reconstructive cases the usefulness and the advantageous application of the Doppler ultrasonic flowmeter in the operating theater is demonstrated.

A beneficial influence on the myocardial energy imbalance of the hypoxaemically damaged heart can be reached with either intraaortic balloon pumping (IABP) or external counterpulsation (ECP). In the realm of our acquired clinical experience with two groups of patients, the technical demands of these cardiac assist devices are discussed and distinguished from one another in relation to different indications.

Corrected transposition of the great arteries is often associated with other cardiac anomalies. We report our experience with the correction of the associated cardiac defects in 13 cases: ventricular septal defect with pulmonary hypertension (5 cases), ventricular septal defect with obstruction of pulmonary outflow tract (5 cases), obstruction of pulmonary outflow tract (2 cases), ostium primum defect (1 case). The possible surgical approaches for repair of the cardiac anomalies are described and the results of the operative correction are communicated. Precise diagnosis, the knowledge of the unusual disposition of the conducting tissues and new surgical approaches are prerequisite for successful correction.

The levo-atrial systemic vein is a special type of persistent left superior vena cava and is associated with other intracardiac lesions most often. Hemodynamically there is a right to left shunt. The operative procedure may consist in a ligature in relation to the anatomic situation. The intraatrial correction intends a drainage to the right atrium. Of 7 cases four times a intracardiac rerouting was achieved but two times a ligation was performed.

Complex forms of transposition of great vessels necessitate different approaches to correction. In a case of double outlet right ventricle with d-transposition and atrioventricular concordance and a subvalvular pulmonary stenosis an intraventricular conduit with a 16 mm Dacron vascular prosthesis was used. This was anastomosed in an acute angular manner with the muscular margins of the VSD and routed to the base of the aorta. Surgical and anatomic implications are discussed.

Nineteen patients with tricuspid atresia and reduced lung perfusion (valvular-and/or subvalvular pulmonary stenosis, transposition of the great arteries and/or single atrium) were operated in the period 1975--1979. The surgical procedures employed varied according to the additional cardiac defects. The age of the patients was between 2 and 18 years. Eleven children received a contuit with a Hancock valve, 8 children a valveless conduit. In 9 patients it was possible to connect the conduit to the right ventricle using the pumping action of the right ventricle with an anatomically intact pulmonary valve. Six patients died (4 early deaths, 2 late deaths, early mortality rate 21%). In this study, the postoperative courses, which were complicated in several cases, are related to the hemodynamical findings. Thirteen children were examined between 1 and 38 months following the operation. Cardiac catheterization was performed in 10 patients. Of the 13, 10 had fully saturated arterial blood. A remnant atrial defect was demonstrated in one child, and 2 displayed intrapulmonary shunts attendant to Glenn anastomoses which had been in place for 10 to 12 years. Among the patients the right atrial pressure ranged from 10 to 20 mmHg with a mean value of 14.5 +/- 0.9 mmHg. An increase in size of the right ventricle was demonstrated angiographically in the case of 2 patients who had valve-bearing conduits to the right ventricle.

A new indication for the External Conterpulsation (ECP) is demonstrated. Due to the venous augmentation a "pulse wave" is created in the V. cava inferior and in the right atrium and the ECP acts as a "peripheral pumpventricle", thus increasing pulmonary blood flow and left ventricular enddiastolic pressure. This new application of ECP is of valve in cases with low output syndrome after physiological repair of tricuspid atresia as demonstreated in a case report.

A total of 531 transvenous and 240 thoraco-abdominal electrodes were implanted into 624 patients, the latter as part of a thoracotomy. The complication rate was 35% for transvenous and 33% for epicardial implantations. The most common complication with transvenous electrodes was dislocation (17%), followed by myocardial (5%) and skin perforation (2%). With epicardial electrodes the complications were exit blocks (9%), disconnections (5.5%) and wire breaks (14%). These complication occurred in 1.5%, 2% and 4.5%, respectively, with transvenous electrodes. Electrode dislocations were particularly common in the first year after implantation, while wire breaks became more common as the interval sinceimplantation increased. Overall there was, therefore, no significant difference in complication rate between the two types of electrodes. But the surgical and early mortality ratewas higher after epicardial implanation (with thoracotomy)than transvenous implantation (11% and 6%, respectively). Transvenous implantation is recommended not only for old but also foryoung patients (with a long life expectancy), in combination with long-life pacemakers.

Pulmonary arteriovenous fistulas are seldom diagnosed in infancy because of few signs and symptoms in early life. The clinical picture is due to the right-to-left shunt and includes dyspnea, cyanosis, polycythemia, clubbing, and murmur over the fistula. The diagnosis can be suspected by demonstration of a typical density on chest X-ray. It can be established by angiocardiography. Because of the life-threatening complications resectional treatment is recommended already in infancy. A case is reported, diagnosed on the second day of life by angiocardiography and treated 3 months later by lobectomy.

We report about a 6 year old patient with complete transpositon of the great arteries, a ventiricle septum defect, and pulmonary atresia, who was operated using Rastellis technique. A Hancock-prothesis of of 20 mm diameter was used for reconstruction of the outflow tract of the right ventricle and anastomosed distal with the pulmonary artery on the left side of the aorta. The proximal anastomosis was performed with the right ventricle after a longitudinal ventriculotomy. The intraoperative pressure recordings and the post-operative studies revealed a very good early result.

Durch intraportale Injektion von SiO2Teilchen mit einem Durchmesser bis 50 mΜ gelingt es bei Kaninchen einen akuten abstufbaren Pfortaderhochdruck zu erzielen.

Die Haufigkeit zerebraler Storungen nach Operationen am offenen Herzen war in Gottingen von 1969–1971 mit 3,6 % eher geringer als in anderen Zentren. Einerseits war es moglich, hinsichtlich der Ursachen der zerebralen Storungen eine Klarung herbeizufuhren, auf der anderen Seite blieb bei einem Teil des Krankengutes die Atiologie im Dunkeln. Nach orthograder Kanulierung im Jahre 1970/71 fiel vergleichsweise eine hohere Komplikationsrate von 7,6 % bei den zerebralen Storungen auf, was auf die Anwendung unterschiedlicher Kanulierungstechniken und verschiedener Aortenkanulen zuruckgefuhrt wird. The frequency of cerebral disturbances after open heart surgery was 3.6 % in Gottingen between 1969 and 1971. This is somewhat less than in other centres. In some cases it was possible to discover the causes of the cerebral disturbances wheras in others the aetiology was unknown. In comparison, a higher complication rate of 7.6% in the cerebral disturbances was observed in 1970/1971. This was thought to be due to different cannulation techniques and varying aortic cannulas.

Die Spatresultate nach alloplastischem Klappenersatz mit der Starr-Edwards-Prothese werden zum einen beeinflust durch Komplikationen, die mit der Prothese selbst zusammenhangen: namlich physikalischen Veranderungen der Kugel und thrombembolischen, durch den Fremdkorper hervorgerufene Komplikationen und zum anderen durch Komplikationen, die in dem Zustand des Herzens begrundet liegen, d. h. also auf Veranderungen des Myokards und der Koronargefase zuruckgehen. The late results of alloplastic valve replacements with the Starr-Edwards prosthesis are influenced partly by complications connected with the prosthesis itself, namely physical changes of the sphere and trombo-embolic complications due to the foreign body and partly by complications due to the condition of the heart, i. e. changes in the myocardium and coronary vessels. Les resultats tardifs du remplacement d'une valvule alloplastique d'une prothese de Starr-Edwards sont influences par des complications provenant de la prothese elle-meme: en particulier les modifications physiques de la sphere, les complications de thrombo-embolies resultant de la presence du corps etranger et en outre par d'autres complications qui proviennent de l'etat du coeur, c. a d., par des modifications du myocarde et des coronaires.

Aortico-left ventricular tunnel (ALVT) is a very rare cardiac malformation with only 25 cases having been reported in the literature. This paper describes another 5 cases with surgical repair at the ages of 4, 5, 6, and 14 years, respectively. (A fifth case in an 11-year-old boy was operated upon just recently and is described separately in the addendum). The anatomical and clinical findings and diagnostic procedures including angiocardiography are reviewed. The surgical management is discussed, and the late results after follow-up periods of 5, 11, 13, and 16 years are presented. Three patients are doing well although showing clinical signs of mild aortic valve insufficiency, and one patient required aortic valve replacement 13 years after operation because of massive aortic regurgitation. Early surgical repair is recommended as soon as the diagnosis is established by angiocardiography in order to prevent secondary aortic valve lesion by dilatation of the aortic ring and aneurysmatic dilatation of the ventricular septum.