[Modified bedside diagnosis in patients at risk for aortocoronary venous bypass surgery]. / Modifizierte Bed-side-Diagnostik bei Risikopatienten zur aortokoronaren Venenbypass-Operation.

Early detection of perioperative complications during cardiosurgical operations is of differential diagnostic and differential therapeutic importance. Various risk groups of aortocoronary venous bypass operations have been analysed under different aspects: age, (not significant), implemented bypass rate (aneurysm resection 1.75/p less than 0.01 compared with 2.65-2.9), death rate (= greater than 21 days) 4 to 6.3% (including patients with "bad ventricle", p less than 0.05), and the proportion of clinically relevant complications of 19 to 40% (aneurysm resection 40%/p less than 0.001). Monitoring the marker proteins is an appropriate method of judging the perioperative risk of perioperative myocardial damage in preoperatively defined high-risk patients (approximately 25% modified according to centre conditions). Patients who died always had early pathologic dynamics of marker proteins. Patients with perioperative risks (aneurysm resection and ejection fraction global less than = 30%), left main artery stenosis and unstable angina pectoris symptoms) were found to have pathologic dynamics of marker proteins to a significantly varying extent (compared to a test group). This modified approach of bedside diagnostics of risk patients confirms the preoperative selection of risk patients and forms the economically viable future basis for an individualized perioperative course control.

[The surgical risk in patients with cardiac diseases]. / Risiko chirurgischer Eingriffe bei Patienten mit kardialen Erkrankungen.

The increase in the number of patients with heart and circulatory diseases during selective surgical operations in the past decades is due to both the epidemiologic situation and the increase in the number of old and very old people. To ensure optimum perioperative care of these patients, the anaesthetist must know the degree of illness of each individual and the functioning state of the haemodynamic system. In this paper we show factors which increase the perioperative risk of cardiac complications. These factors are traceable on a semiquantitative basis by the remaining function of the myocardium or the risk of ischaemia of the cardiac muscle. Many clinical symptoms or diagnoses do not affect the perioperative risk. To judge preoperative risks and specific perioperative changes in medication, cooperation between the anaesthetist and cardiologist is required.

[Perioperative complications in at-risk patients undergoing heart valve surgery]. / Perioperative Komplikationen bei Risikopatienten mit Herzklappenersatzoperation.

The success of operations of the replacement of heart valves is disturbed by perioperative complications and early lethality. A valuation of the perioperative risk individually of patients with operations of the replacement of heart valves according to defined subgroups is controlled by the perioperative course. In order to achieve the registration of patients with perioperative lesion of the myocardium and/or low output syndrome, the bedside performance of a marker protein monitoring consisting of enzymes/isoenzymes (CK, CK-MB, ALAT) and the muscle protein myoglobin, respectively, is necessary. In 38% of the patients with operation of the replacement of heart valves the preoperative risk constellation was objectified early-postoperatively with the proof of complication and thus the strategy of the preoperative individual valuation of the risk confirmed. Altogether patients with replacement of the aortic valve showed the smallest rate of perioperative complications in comparison to patients with replacement of the mitral valve (re-operation in replacement of the mitral valve, double valve replacement, replacement of the mitral valve with restricted left-ventricular function).

[Therapy of perioperative myocardial damage in aortocoronary venous bypass surgery]. / Therapie des perioperativen Myokardschadens bei aortokoronarer Venenbypass-Operation.

The perioperative lesion of the myocardium in heart-lung machine operation can on principle not be prevented despite complex measures of the protection of the myocardium and the individual monitoring of the patients, this particularly by including patients with high risk of ischaemia of the myocardium (instable angina pectoris, stenosis of the trunc and greatly restricted left-ventricular function, respectively) in former years. In a proved perioperative lesion of the myocardium the limitation of the myocardial lesion stands in the centre of intensive-medical measures with vasodilators and positive inotropic substances.

[Perioperative risk of valve replacement surgery in the elderly]. / Perioperatives Risiko bei Klappenersatz-Operation im höheren Lebensalter.

The indication of surgical valva replacement also at older age (greater than 60 years) with chronically rheumatic valvular diseases requires both the assessment of the pre-operative constellation of findings and perioperative complications. From this combined point of view statements concerning the strategy of valve replacement at older age seem to be concludable. In the frame of a prospective study perioperative parameters were monitored in n = 90 patients with preoperative high-risk constellation out of a total of n = 300 patients for the quick recording of additional complications (such as perioperative myocardial damage, cardiac low output syndrome, and cases of death at the ICU). The average age of the whole group of patients was 52 years (25-68 years), that of the patients greater than 60 years was 63.6 years (61-68 years). In 72% of the older patients the preoperative high-risk constellation was confirmed by 50% deceased; 16% cLOS; 6% perioperative myocardial damage (PMD). On a total of 41% of the patients a combined operation was performed (valve replacement and bypass operation), there of 2/3 with aortic valve replacement and 1/3 with mitral valve replacement. The ejection fraction restricted heavily already before the operation (less than or equal to 30%) was the essential cause of perioperative complications (cases of death, cLOS) together with the combined operation. The immedicable pulmonary hypertension complicated the already preoperatively impaired left-ventricular function in a high percentage of patients with mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aortocoronary venous bypass operation in the elderly]. / Aortokoronare Venen-Bypass-Operation im höheren Lebensalter.

On the extended diagnosis for an aorto-coronary venous bypass operation, with a greater involvement of patients with instable angina pectoris symptomatik (inApS), left main artery disease (LAD), aneurysmal resection, and "bad" ventricle (ejection fraction global less than or equal to 30%), the preoperative risk was evaluated in n = 600 patients. In a total of n = 150 patients with preoperative high-risk constellation perioperative parameters were monitored to find complications (perioperative myocardial damage [PMD], cardiac low output syndrome [LOS]). Among them were n = 40 patients aged greater than 60 years (60-72), their average age being 62.9 years. In 30% of these older patients the preoperative high-risk constellation was confirmed: 15% PMD, 10% LOS, and 5% deceased. The further postoperative course (up to the 6th month) is objectified by the ejection fraction global (EFg) by multiple checks. As a whole, patients greater than 60 years with extended diagnosis for ACVB operation do not show any significant increase in hospital mortality, but an increase in PMD and LOS (p less than 0.001) compared to the age group less than 60 years. With corresponding individual intensive-therapeutic measures, however, both complications can be controlled in the majority of patients. Despite the demonstrated higher perioperative risk, the urgent ACVB operation proved to be strategically right (considering the results of EFg) for increasing the quality of life and improving the expectation of life also for patientes greater than 60 years, in particular with the operation indications of inApS and LAD.(ABSTRACT TRUNCATED AT 250 WORDS)