Munich Oktoberfest experience: remarkable impact of sex and age in ethanol intoxication.

Approximately 5,000 of 6 million annual visitors of the Oktoberfest in Munich have to undergo medical treatment. Patients with alcohol intoxication without trauma or further complications are all treated in a specialized medical camp. We studied these patients in order to identify risk factors and to assess the relevance of the Glasgow Coma Score (GCS) and of ethanol blood concentrations for patient management. In 2004 totally 405 patients suffering from ethanol intoxication without trauma were treated in the medical camp. A complete set of the following data was obtained from all 405 patients: GCS, ethanol blood concentration, age, sex, blood pressure (mean, systolic and diastolic), body temperature, heart rate, blood sugar, GOT, gamma-GT, and CK. A multivariate logistic regression model was applied to identify risk factors predicting patients at increased risk of hospitalization. Low GCS (< or =8 vs. >8, OR: 4.18, CI: 1.96-8.65) low age (20-29 vs. > or =30 years, OR: 2.35, CI: 1.05-5.65) and male gender (male vs. female, OR: 3.58, CI: 1.36-9.34) independently predicted patients that had to be hospitalized. All other parameters including ethanol blood concentrations were not explanatory. Patients with GCS < or = 8 (n = 66) had a lower median blood pressure (P = 0.0312) and showed a smaller increase in blood pressure during the observation period compared to patients with GCS > 8 (P < 0.001), suggesting that this subgroup may require longer recovery periods. Men aged 20-29 years were at highest risk for hospital admission. Increased risk could not be explained by higher ethanol blood concentrations in this subgroup. Importantly, GCS < 6 does not justify endotracheal intubation in ethanol intoxicated patients, when further complications, such as trauma, can be excluded.

Reducing ischemia-reperfusion injury in clinical lung transplantation.

OBJECTIVE: Acute graft dysfunction secondary to ischemia-reperfusion injury (IRI) continues to be the most common cause of early mortality after lung transplantation. The perioperative management with aprotinin could decrease the incidence of severe IRI. METHODS: A retrospective analysis was conducted of the data from 180 patients who underwent either single lung (56%) or bilateral sequential lung transplantation for similar end-stage lung disease between 1997 and 2005. The most recent 68 patients were managed perioperatively with the high-dose aprotinin infusion regimen (aprotinin group). The ISHLT grade III injury score was used for the diagnosis of severe IRI, which is based on a Pao(2)-FIo(2) ratio of less than 200 mmHg. RESULTS: Grade III injury was observed in 18% of the patients who were not managed with aprotinin (control group, 152 grafts, 64% single transplants, 68% male, 54 +/- 8 years of age). Early ECMO support was required in 25% of these patients. The associated mortality rate was 40%. Despite significantly longer cold ischemic times (290 +/- 14 minutes vs 231 +/- 14 minutes), older donors (42 +/- 12 years of age), and more frequently observed severely elevated systolic PAP of greater than 60 mmHg (60% vs 48%) as well as more frequently required extracorporeal circulatory support (24%* vs 12%) in the aprotinin group, the incidence of severe IRI (8%) and associated mortality (9%) was markedly reduced. CONCLUSIONS: The use of aprotinin in LTX surgery, which had strong beneficial effects on patient outcomes, significantly decreased the incidence of severe posttransplant IRI.

Regression of left ventricular hypertrophy after surgical therapy for aortic stenosis is associated with changes in extracellular matrix gene expression.

BACKGROUND: Regression of left ventricular hypertrophy (LVH) after surgical correction for aortic stenosis is not fully understood on the molecular level. The aim of this study was to examine whether there is an association between LVH regression and extracellular matrix (ECM) gene expression. METHODS AND RESULTS: A standard model of controlled LVH induction by supracoronary banding (A=baseline) was applied in 44 growing sheep (age, 6 to 8 months). Surgical correction to release the pressure gradient was performed 8.3+/-1 months later (B). The animals were killed after another 10.1+/-2 months (C). At all time points, hemodynamic evaluations and quantitative analysis of mRNA and protein expression for matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP) was performed. Left ventricular mass index was 82+/-21 (A) versus 150+/-33 (B), P<0.01, and 78+/-18 g/m(2) (C), P<0.01. Left ventricular function and cardiac index remained stable. Myocardial fiber diameter index was 9.1+/-1.2 (A) versus 12.3+/-1.4 (B), P<0.01, and 8.4+/-1.3 micrometer/m(2) (C), P<0.01. In parallel to the development of LVH at B, gene expression was increased significantly for MMP-1, MMP-2, MMP-3, and MMP-9 and for TIMP-1 and TIMP-2 and decreased significantly for TIMP-3. After surgical correction (C), there was a complete regression of gene expression to baseline measures. CONCLUSIONS: Controlled induction of compensated LVH leads to significant increase in ECM gene expression. The regression of LVH after surgical therapy is associated with complete regression of ECM gene expression. However, no cause-and-effect relation could be demonstrated.

Extracellular matrix gene expression correlates to left ventricular mass index after surgical induction of left ventricular hypertrophy.

The cardiac extracellular matrix (ECM) is a dynamic entity maintaining the structural and functional properties of the myocardium. Little is known about alterations in ECM regulation during controlled induction of compensated left ventricular hypertrophy (LVH) using experimental aortic stenosis. Fifteen growing sheep received supra-coronary banding at an age of 7 +/- 1 months whereas 10 age-matched sheep served as the control group (C). Explantation of the hearts was performed 8.3 +/- 1 months after banding. Gene sequences for sheep matrix metalloproteinase (MMP)-1,-2,-3,-9 and tissue inhibitors (TIMP)-1,-2,-3 were isolated and cloned. Then mRNA and protein gene expression analyses were performed. Concentric LVH with no evidence of heart failure was diagnosed at explantation. Left ventricular mass index (LVMI) was 150 +/- 33 g/m2 (LVH) versus 88 +/- 23 (C) and 82 +/- 21 (baseline) (p < 0.01 versus LVH). Parallel to LVH there was a significant increase in mRNA and protein expression for MMP-1,-2,-3, -9 and for TIMP-1,-2 whereas there was a significant decrease in TIMP-3 gene expression. A close correlation between changes in LVMI and ECM gene expression was found. Compensated LVH goes along with a significant modification of MMP and TIMP gene expression. Alterations in ECM gene expression may be part of the adaptive process during left ventricular remodeling.

Three-dimensional visualization of coronary arteries in excised hearts.

OBJECTIVE: We sought to image coronary arteries in excised hearts. METHODS: Twelve excised pigs' hearts were imaged in a water bath. The aortic valve was closed surgically. A contrast agent (Echovist) was injected into the aortic root and selectively into single coronary arteries. Three-dimensional (3D) imaging was performed with TomTec Echoscan equipment. Mechanical rotations were performed at 1 degrees intervals. The hearts were visualized by InVivo software. Selective coloring of coronary arteries in 3D data sets was obtained by using color superpositioning, which differentiates information before and after injection of contrast. Distance measurements were performed in conventional 3D echocardiograms of coronary arteries and color-superimposed echocardiograms and compared with those from angiograms and casts. RESULTS: After a learning curve, during which optimal conditions for the visualization of coronary arteries were determined, a quick display of all major parts of the coronary tree was obtained. Distance measurements (n >400) revealed that fundamental contrast echocardiography overestimated angiography by 25% +/- 5% and casts by 28% +/- 6%. However, distances in color-superimposed echocardiograms (flow mode 4) were not significantly different from those obtained from angiograms and casts. In harmonic contrast echocardiograms, color super-positioning gave smaller distances compared with those from fundamental contrast echocardiograms, though they were still significantly larger than the reference diameters. CONCLUSIONS: The 3D imaging of epicardial coronary arteries under ideal conditions in a water bath seems feasible and provides insight into coronary visualization with the use of ultrasonography.

Experimental aortic stenosis and corresponding left ventricular hypertrophy in sheep.

Left ventricular hypertrophy (LVH) is an independent cardiac risk factor. A simple standard experimental model of inducing LVH for further studies using experimental aortic stenosis in sheep was performed. The aim of this study is to describe animal-specific requirements as well as perioperative therapy, postoperative care, and the use of echocardiography for routine follow-up examinations. Supracoronary aortic banding was performed in 55 female sheep at an age of 6 to 8 months. General anesthesia and an antero-lateral thoracotomy were used. The objective was to achieve pressure gradients of 20 to 30 mm Hg. In addition a 4th intercostal space rib window was created to improve echocardiographic vision. The operations were completed successfully in all animals. Intraoperatively, little severe arrhythmia occurred. During the follow-up interval of 8 +/- 1.3 months, 8 animals died, due to incomplete perforation of the ascending aorta (3), chronic heart failure (2), pericardial cyst (1), and respiratory failure and infection (2). All remaining animals were amenable for further studies. Severe LVH was diagnosed with routine echocardiography on follow-up. Thus, experimental aortic stenosis in sheep is a safe and relatively simple technique to generate stable LVH. Echocardiography is an easy tool for follow-up evaluations. Due to low complication rates, the sheep model is well suited for further research in LVH.

Quality assessment in minimally invasive coronary artery bypass grafting.

OBJECTIVES: The most important determinant for the success of minimally invasive coronary artery bypass grafting (MIDCAB) is the quality and long-term patency of the graft and anastomosis. Intra and postoperative quality assessment is important to confirm the safety and effectiveness of minimally invasive techniques. METHODS: From January to December 1998 MIDCAB was performed in 246 patients using a limited minithoracotomy for single left anterior descending artery (LAD) revascularization. According to our standard protocol quality assessment of the graft and anastomosis consisted of intraoperative flow measurement, early postoperative angiography and follow-up angiography after 6 months. RESULTS: Intraoperative flow measurement was performed in patients with anastomoses unsuitable for coronary probing (75/246, mean flow of 34.3 +/- 17.7 ml/min). Early patency was confirmed by intraoperative monoplane angiogram in 37/246 (15.0%) patients and by postoperative multiplan angiography in 205/246 (83.3%). Early patency rate was 98.0%. Six months follow-up showed a patency rate of 97.5% (one occluded graft, two severe and two moderate stenoses at the anastomotic site). Eighty-nine percent of the patients were in a CCS angina class I, 11% in class II, respectively. Six months mortality was 0.8%. Re-intervention had to be performed in 5/116 (4.3%). CONCLUSIONS: A standardized protocol for quality assessment is mandatory for MIDCAB surgery. The proposed algorithm serves to ensure the safety and effectiveness of this new technique. Our recent series document an excellent outcome of the MIDCAB approach. Postoperative multiplan angiography is the only technique to achieve valid information about the quality of graft and anastomosis.

Indication and patient selection in minimally invasive and òff-pump' coronary artery bypass grafting.

BACKGROUND: The selection criteria to perform 'off-pump' coronary bypass (OPCAB) grafting are not well defined. The aim of this presentation is to outline the indications and the patient selection on the basis of 2 years experience with 572 OPCAB procedures. MATERIALS AND METHODS: From November 1996 minimally invasive coronary bypass grafting was performed in 406 patients using a limited minithoracotomy for single left anterior descending artery (LAD) revascularization (group A). In 166 patients full sternotomy and OPCAB grafting for single or multiple vessel revascularization was performed (group B). RESULTS: In group A the procedure could be performed 'off-pump' together with a limited thoracotomy in 406 out of 457 patients (88.8%) who were scheduled for single graft revascularization to LAD. Exposure and quality of the LAD was good in 308/406 (76.0%) of the patients. The decision for sternotomy was made for different preoperative characteristics of these patients: Obese female patients 16/457 (3.5%), angiographic evidence of an intramyocardial running LAD 6/457% (1.4%), diffusely diseased and small LAD 11/457 (2.4%) severe COPD 3/457 (0.7%), unstable angina 11/457 (2.4%), emergency revascularization after failed PTCA 4/457 (0.8%). In 315/406 (77.8%) of the minimally invasive direct coronary artery bypass (MIDCAB)-patients exposure and quality of the LAD was good, in 97/406 (22.2%) moderate or even bad. In the latter subgroup stenosis free anastomosis was reduced (86.5%) compared to the subgroup of good exposure and quality with 98.3%. In group B selection for sternotomy and 'off-pump' procedure was made in 117/166 (70.4%) patients with a normal preoperative status (stable angina, ejection fraction > 35%) and with coronary lesions amenable for beating heart surgery (proximal RCA lesion > 80%, not calcified and well defined POD and marginal branches). In 49/166 (29.5%) decision for 'off-pump' procedure was made on the basis of a potential risk for cardiopulmonary bypass (CPB) such as acute myocardial infarction in 10/166 (6.0%), reduced ventricular function with EF < 35 in 28/166 (16.9%), calcified ascending aorta 4/166 (2.4%) or concomitant diseases 7/166 (2.5). CONCLUSION: To maintain excellent results after single LAD revascularization using the MIDCAB-approach, appropriate patient selection is crucial. Indication for sternotomy and 'off-pump' single LAD revascularization should made in those patients excluded for MIDCAB and in patients scheduled for multiple vessel-CABG who are at high risk for CPB (concomitant pulmonary, renal, neurological diseases or severely impaired left ventricular dysfunction) and have suitable target coronary arteries in term of location and quality.

[Primary hemangiosarcoma of the heart]. / Primäres Hämangiosarkom des Herzens.

Primary cardiac sarcomas are malignant neoplasmas of mesenchymal cells. Angiosarcomas, unlike all other primary cardiac sarcomas, are typically found in the right atrium. We present the case of a 52-year-old patient in whom through echocardiography, computed tomography and angiography the precise diagnosis and extent of the tumor was revealed. Surgical treatment consisted of excision of the tumor with right atrium patch-plasty under cardiopulmonary bypass. Despite the successful operation the patient died 6 months later because of metastasis. Very early and precise diagnosis is essential to improve patient survival and prevent the development of metastases.

Aortic valve debridement by ultrasonic surgical aspirator in degenerative, aortic valve stenosis: follow-up with Doppler echocardiography.

OBJECTIVE: Recently there has been an emphasis on reconstructing diseases native valves as an alternative to prosthetic valve replacement. Whereas; the surgical repair of aortic valve stenosis has been always problematic. This study was performed to estimate the clinical results after aortic valve debridement using ultrasonic energy. METHODS: Between 1990-1994 26 patients underwent ultrasonic aortic valve decalcification. There were 15 females and 11 males, the age was in average 74 years. As a concomitant diagnosis 88% patients (23) had mostly mild, aortic valve insufficiency, 16 (61%) had coronary artery disease and 11 (42%) had mild mitral valve incompetence. All of the patients were operated with cardiopulmonary bypass using moderate hypothermia, cardioplegical arrest and topical cooling for myocardial protection. The calcifications were removed tangentially using Cavitron Ultrasonic Surgical Aspirator. (CUSA), CAVITRON, USA. Leaflet perforation and/or unsatisfactory valve closure have been indications for aortic valve replacement. RESULTS: Two operative death (8%) have occurred and six patients have died in the further course (follow-up mean 17 months ranging from 4 to 61 months). Postoperative Doppler-Echocardiography results taken directly after surgery and then again 17 months later (n = 18) showed a decrease of peak and mean gradients across the aortic valve three and two times respectively (p < 0.001). 17 months after debridement we observed a mild rise in both gradients (by peak gradient p < 0.05). Directly postoperative, the aortic valve area increased doubly and decreased 17 months later slight, but it was still statistically significant in comparison with our preoperative data (p < 0.001). Follow-up echocardiography demonstrated late onset of moderate aortic valve insufficiency in 6 patients. The classification of New York Heart Association was improved in 13 (72%) survivors after 17 months. CONCLUSIONS: Ultrasonic debridement of aortic valve stenosis allows precise and energy-controlled removal of calcium, increased doubly the valve area and decreased of peak and mean gradients statistically significant. The advantages of preserving the native aortic valve in elderly patients are relative good arguments; although a longer follow-up is necessary to establish this procedure.