Management of primary aortic graft infection by extra-anatomic bypass reconstruction.

In this retrospective study, 21 patients requiring treatment for primary infection of an aortic prosthesis between 1981 and 1991 were identified from a prospective register. Ten of the 21 patients had had additional peripheral reconstructive vascular surgery before the diagnosis of aortic graft infection. The median interval between aortic graft insertion and diagnosis of graft infection was 16 months (range 1-84). Infected grafts were removed and an extra-anatomic bypass constructed in all patients. All but three patients had axillodistal reconstruction. Six patients had simultaneous operations, whilst the other 15 patients had a staged procedure with extra-anatomic reconstruction preceding graft removal. Two patients died before discharge from the hospital (9.5%). No patient required extremity amputation in the perioperative period. By life-table analysis patient survival (including perioperative deaths) was 80% at 1 year, 55% at 3 years and 40% at 5 years. Primary patency was 62% at 1 year, 51% at 3 years and 40% at 5 years. Limb salvage rate was 89% at 1 year, 63% at 3 years and 63% at 5 years. The median length of follow-up was 24 months. Extra-anatomic reconstruction in patients with aortic graft infection can be performed with low perioperative mortality. Limb salvage rates following extra-anatomic reconstruction are determined not only by the mode of reconstruction, but also by the primary disease.

Imaging in cardiac mass lesions.

In 26 patients with cardiac mass lesions confirmed by surgery, diagnostic imaging was performed preoperatively by means of two-dimensional echocardiography (26 patients), angiography (12 patients), correlative computed tomography (CT, 8 patients), and magnetic resonance imaging (MRI, 3 patients). Two-dimensional echocardiography correctly identified the cardiac masses in all patients. Angiography missed two of 12 cardiac masses; CT missed one of eight. MRI identified three of three cardiac masses. Although the sensitivity of two-dimensional echocardiography was high (100%), all methods lacked specificity. None of the methods allowed differentiation between myxoma (n = 13) and thrombus (n = 7). Malignancy of the lesions was successfully predicted by noninvasive imaging methods in all six patients. However, CT and MRI provided additional information concerning cardiac mural infiltration, pericardial involvement, and extracardiac tumor extension, and should be integrated within a preoperative imaging strategy. Thus two-dimensional echocardiography is the method of choice for primary assessment of patients with suspected cardiac masses. Further preoperative imaging by CT or MRI can be limited to patients with malignancies suspected on the grounds of pericardial effusion or other clinical results.

[Determination of the right ventricular ejection fraction from the exponential decrease in the thermodilution curve--a comparison with biplanar cineventriculography]. / Bestimmung der rechtsventrikulären Ejektionsfraktion aus dem exponentiellen Abfall der Thermodilutionskurve--ein Vergleich zur biplanen Cineventrikulographie.

Using the exponential downslope of the thermodilution curve right ventricular ejection fraction and volumes can be calculated. To evaluate the accuracy of this method for clinical application thermodilution measurements were compared to the results of biplane cineventriculography in 40 patients. Mean right ventricular ejection fraction was 52 +/- 9% determined by thermodilution (Th), and 53 +/- 8% determined by angiography (A). Mean enddiastolic volume was 189 +/- 74 ml (Th) and 162 +/- 42 ml (A) and mean endsystolic volume 92 +/- 42 ml (Th) and 75 +/- 20 ml (A). Ejection fraction of thermodilution measurements correlated with the results of angiography (r = 0.59; SEE = 7%; % SEE = 13 rel. %; p less than 0.001). The correlation for endsystolic volume was: r = 0.50; SEE = 36 ml; % SEE = 48%; p less than 0.001, and for enddiastolic volume: r = 0.36; SEE = 70 ml; % SEE = 43%; p less than 0.05. The differences in ejection fraction calculated by the two different methods were especially high (up to 25%) in patients (n = 10) with low (less than 110 ml) or high (greater than or equal to 200 ml) enddiastolic volume. For the other 30 patients the correlation for right ventricular ejection fraction was: r = 0.82; SEE = 5%; % SEE = 9 rel. %; p less than 0.001. Thus, the thermodilution method allows an approximative assessment of right ventricular ejection fraction only in patients with a normal right ventricle. Since right ventricular ejection fraction cannot be determined with sufficient accuracy in patients with right ventricular dilatation, the clinical application of this method is limited.

Determination of right ventricular ejection fraction by thermodilution technique--a comparison to biplane cineventriculography.

Determination of right ventricular ejection fraction (RVEF) provides information about global right ventricular function, which may be important for the management of patients with various heart diseases. Right ventricular ejection fraction can be determined by new thermodilution techniques using fast-response thermistors. To evaluate the validity of these methods, thermodilution measurements were compared with biplane cineventriculography in 22 patients undergoing cardiac catheterization. In all patients standard deviation of RVEF was below 5%. Mean RVEF, determined by thermodilution, was 52% +/- 9%, ranging from 32% to 71% and correlated significantly with the results of angiography (RVEF: 52% +/- 9%) (r = 0.80, SEE +/- 5%, n = 22, p less than 0.001). Correlation was good especially in patients with small right ventricles (less than 160 ml) (r = 0.91, SEE +/- 5%, n = 13, p less than 0.001), lower heart rates (less than 65/min) (r = 0.84, SEE = +/- 6%, n = 12, p less than 0.001) and cardiac output below 5.51/min (r = 0.88, SEE +/- 6%, n = 11, p less than 0.001). Thus, if valid catheter placement is possible, right ventricular ejection fraction can be determined by thermodilution technique with good reproducibility and sufficient accuracy compared to biplane angio. Validation of this method in larger patient populations with various heart diseases is necessary.