[Coronary artery bypass grafting without extracorporeal circulation]. / Koszorúérmútétek extrakorporális keringés alkalmazása nélkül.

At the Department of Cardiovascular Surgery of Semmelweis University, Budapest we have performed 57 coronary bypass operations without using cardiopulmonary bypass between 1996 and September 2001. Due to the learning phase we preferred cases of 1-2 wessel diseases, and revascularisation necessary on the anterior surface of the heart. In the beginning the stabilization of the operative field was ensured by manual methods, then by applying mechanical stabilization devices (Octopus 2, Genzyme). As to the type of operative indication overwhelmingly elective operations were performed. REDO procedure, i.e. repeated coronary bypass operation was carried out in 2 cases. Forty-eight patients recovered without complication. Two patients died, one of them suffered perioperative infarction, the other died due to cerebral complication. Total mortality was 3.5%. As a consequence of cardiac ischaemia in the direct postoperative period, we performed emergent coronary ballon dilatation (PTCA) in two cases. In three cases we experienced perioperative infarction. We followed up our patients by way of interview and telephone interview. The follow-up is 95%, the average follow-up time is 15 months. Significant cardiac event (infarction, PTCA or REDO coronary operation) took place in the case of 7 patients. In the majority of our patients the operation resulted in an improvement of condition, 43 patients are free from angina.

[Traumatic rupture of the descending aorta]. / Az aorta descendens traumás eredetü rupturája.

During a ten-year period 16 patients were seen with aortic rupture and false aneurysm secondary to blunt trauma. One patient underwent an acute operation, 4 patients had operative therapy elective delayed and 11 patients were operated on for chronic traumatic false aneurysm. Operative delay was done in case of simultaneous multisystem injury (e.g. shock caused by abdominal injuries, cerebral contusion or pulmonary contusion on the right side). The shunt bypass method of repair was used in the case of 3 patients, cardiopulmonary bypass in 6 cases and simple aortic cross-clamping in 6 patients. One operation was performed without aortic cross-clamping. Primary repair was achieved in three patient, in 3 more cases a patch was inserted and in 9 cases interposition Dacron grafting was accomplished. One "wrapping" operation was performed. In 2 cases, reoperation was necessary because of postoperative bleeding. One patient died in the perioperative period. Right sided hemiparesis occurred in one patient postoperatively. Rupture does not affect the whole aortic wall, especially in young people because of the natural elasticity of vessel. The appearing shock and hypotension might protect the mediastinal pleura against bursting. This could provide a chance to survive. Our experience indicate: Elective delay of operation in patients with multiple system injuries can be achieved with antihypertensive therapy.

[Clinical importance of monophasic action potential registration in long QT syndrome]. / Monofázisos akciós potenciál regisztrálás klinikai jelentösége hosszú QT-szindrómában.

For more than 30 years, the monophasic action potential has been used as an experimental tool for the study of myocardial repolarisation. With recent improvements in catheter design, the utility of the tool as a means to identify the bases for ventricular arrhythmias in humans has been greatly improved. Abnormalities of repolarisation leading to ventricular arrhythmia formation can be identified and specific pharmacological therapies may be evaluated. The pathomechanism of major arrhythmias (ventricular tachycardia, ventricular fibrillation) occurring in long QT syndrome (LQTS) is not yet fully elucidated. The authors have recorded the monophasic action potentials (MAP) of the right ventricle in three patients with LQTS and with previous episodes of major ventricular arrhythmias. The changes in MAP duration and after depolarisation in response to spontaneous arrhythmias, programmed electrostimulation, atrial pacing and isoproterenol treatment were studied. In all of the three patients the early afterdepolarisation was present, which in two cases exhibited pause-dependent features. Thus in these patients dual chamber pacemaker implantatious were performed. These were the first permanent recordings of MAP during electrophysiological examination in Hungary and also the first evidences that the early afterdepolarisation does play a pathogenic role in the development of idiopathic LQTS. Further evaluation of the technique by cardiac electro-physiologists may improve both the diagnosis and the treatment of ventricular arrhythmias dependent upon afterdepolarisation formation.

[Echocardiographic diagnosis of intermittent failure of a mitral valve prosthesis]. / Intermittáló mitralis mübillentyü "beragadás" echocardiographiás diagnózisa.

Three cases are reported who had intermittent diastolic jamming of a mitral tilting disc valve. The clinical presentation of this unfrequent but catastrophic early postoperative complication was different in all cases: the first patient presented with heart failure, the third patient had loss of consciousness with enuresis and the second patient was asymptomatic at the time of the diagnosis. Electromechanical dissociation was first suspected by clinical examination in 2 cases but it was confirmed in all 3 cases by 2 dimensional and Doppler echocardiography. Transesophageal echocardiography did not provide any additional information. Besides opening failure of the valve Doppler echocardiography also demonstrated incomplete or delayed opening in the asymptomatic period. Survival is dependent on correct diagnosis and urgent surgical treatment of this type of prosthetic valve dysfunction.

[Experience with a transvenous pacemaker-cardioconverter-defibrillator without subcutaneous patch]. / Transzvénás, subcutan patch nélküli pacemaker-cardioverter-defibrillátorokkal szerzett tapasztalataink.

Sudden cardiac death caused by malignant ventricular arrhythmias is one of the main causes of cardiovascular mortality. Implantation of cardioverter-defibrillators has resulted in the reduction of the incidence of sudden cardiac death caused by malignant ventricular arrhythmias from the yearly 10-30% to 1%. For the very first time in Hungary, the authors applied only transvenous lead configuration for automatic cardioverter defibrillators in three patients. The indications of the implantation were ventricular fibrillation in one case, ventricular tachycardias refractory to drug treatment in two cases. Ventricular arrhythmias were secondary to coronary heart disease in two patients, dilatative cardiomyopathy in one patient. Preoperative, intraoperative and postoperative electrophysiological studies were regularly taken. Using Biotronik Phylax 03 device with a right ventricular electrode and a superior vena cava electrode and without subcutaneous patch the intraoperative defibrillation thresholds were 6, 11 and 12 J respectively. The fractally iridium coating increases the surface of the electrodes that has a very good effect on defibrillation threshold. During a mean follow-up of six months the occurring spontaneous ventricular arrhythmias (1 ventricular fibrillation and 5 ventricular tachycardias) were terminated by Phylax 03 with cardioversion-defibrillation or overdrive stimulation. The authors' results of intraoperative testing and clinical experiences show that the Phylax 03 biphasic system due to low defibrillation thresholds without subcutaneous patch can safely be applied with only transvenous implant technique in patients with major ventricular arrhythmias to prevent sudden cardiac death and to terminate ventricular tachycardia.

[Iatrogenic sinus node disease and iatrogenic AV block]. / Az iatrogén színuszcsomó betegség és az iatrogén AV block.

The appearance of long lasting bradycardia due to damage of the sinus node (iatrogen sick sinus syndrome; or the atrioventricular conduction system, iatrogen AV block) is not a rare event after open heart surgery. In the course of 5093 heart operations the development of iatrogen sick sinus syndrome was observed in 234 patients (4.6%) and iatrogen AV block in 91 cases (1.8%). The incidence rate of iatrogen sick sinus syndrome or iatrogen AV block was quite divergent depending mostly on the type of operation. Comparing the data of our earlier (1977-1982) and later (1983-1991) cardiac surgical interventions, the prevalence of iatrogen sinus node disease and iatrogen AV block seems to decrease, mainly due to the progress in techniques of cardiac surgery. With the appearance of iatrogen sick sinus syndrome or AV block, urgent temporary pacing is indicated to prevent the deleterious hemodynamic effect of bradycardia. In the cases of persistent iatrogen sick sinus syndrome and iatrogen AV block, permanent pacemaker implantation is needed. It is remarkable that although the incidence rate of iatrogen sick sinus syndrome is greater than that of iatrogen AV block, in iatrogen sick sinus syndrome the regression is quite frequent, while in iatrogen AV block the 2nd or 3rd degree AV block is usually permanent. We performed pacemaker implantation in 56 cases of iatrogen sick sinus syndrome (24%) and in 57 patients of iatrogen AV block (63%). With pacemaker therapy the outcome of iatrogen sick sinus syndrome and iatrogen AV block is very favourable.

[Importance of carotid artery studies prior to coronary surgery]. / Carotis vizsgálat jelentösége coronaria mütétek kapcsán.

The incidence of cerebral complications following extracorporal cardiac operations is reported to be approximately 2%. One of the possible reasons behind these complications is the presence of significant carotid stenosis as coexistent disease to the cardiac illness requiring surgery. Because of the common etiology carotid stenosis coexists mainly with a coronary artery disease. The authors make known their own screening methods based on the correct exploration of medical history and on the proper physical examinations. Coexistent significant carotid stenosis was revealed in 3.6% of 1056 patients who underwent coronary surgery within the period of 41 months. In all of these cases prophylactic carotid endarterectomy was performed. In twenty cases within this group the carotid reconstructions were performed simultaneously with myocardium revascularization. Staged endprocedures were performed in the other 18 cases. There was no surgical mortality and only one patient suffered major stroke. The authors emphasize the importance of carotid screening among patients awaiting coronary surgery especially in patients who previously sustained cerebral ischemic attacks, the presence of carotid bruits or any other known localization of obliterate arterial disease and finally in all patients over 60 years of age.

[Coronary surgery at the Cardiovascular Surgical Clinic (1976-1990)]. / Coronariasebészet az Er- és Szívsebészeti Klinikán (1976-1990).

In the Cardiovascular Surgical Clinic of the Semmelweis Medical University of Budapest the first coronary artery bypass grafting (CABG) procedure was performed in 1975. Since that time coronary artery surgery has become a routine everyday practice representing more than half of the total workload of adult cardiac surgery. The analysis of 1347 operations performed between 1976-1990 on patients with coronary heart disease showed the followings: the first few years--so called learning curve of CABG operations is characterised by high mortality. With passing time the number of cases performed each year increased rapidly and the surgical technique has improved too. At the same time the operative mortality figures showed decreasing tendency--it was 2.1% for the last 609 cases. All observed parameters showed some progress: in 1990 the average number of grafts per patient was 3.09, internal mammary artery usage 15 percent and the mean aortic cross clamp time per anastomosis 24.5 minutes. Complete myocardial revascularisation is the key point of coronary artery surgery. In order to achieve this target in all operated cases further technical improvement is necessary.

[Development and results of valve replacement surgery at the Városmajor Clinic 1976-1990 (retorospective clinical analysis)]. / A szívbillentyü-sebészet fejlödése és eredményei a Városmajori Klinikán 1976-1990 (retrospektív klinikai analízis).

In Hungary valve replacement is still a major indication for heart surgery in adults. In the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest from 1976 to 1990 2435 patients were operated for valve disease. Majority of the cases had single (aortic n = 856, mitral n = 912) or double (aortic + mitral n = 513) valve replacement. Over this 15 years period there have been many alterations in patients characteristics and surgical technique as well. In spite of the increasing mean age of patients the operative mortality has decreased (in the last 5 years period it was 2.7%, 5.5% and 7.9% in the three groups respectively). At the same time the number of patients requiring valve re-replacement or combined valve + coronary procedure has increased. The use of bioprosthetic valves has fallen below 10 percent from the 60--80 percent observed between 1976--1980. The analysis showes excellent surgical results in the field of valve replacement in Hungary.

Atrial standstill: an indication for rate responsive pacing.

Atrial standstill (atrial paralysis) is a rare reason for permanent bradycardia. A case of atrial standstill is presented. A 35-year-old man had suffered from bradycardia since his childhood. For 2 years he had complaints (diminishment of his working capacity, and dyspnea occurred with effort) as well. On admission, a slow (38/min) junctional escape rhythm could be detected. There were no signs of atrial mechanical activity (atrial contraction) according to chest x ray, echocardiography, and the atrial pressure curve. The electrophysiological study revealed that the atria could not be electrically stimulated, and no P wave (A wave) could be recorded on right atrial electrograms. The patient received a rate responsive pacemaker. After pacemaker implantation, he became symptom-free; his working capacity improved markedly and his heart size decreased. Owing to the permanent bradycardia and the lack of atrial stimulation, the atrial standstill represents an indication for ventricular rate responsive pacing. Atrial standstill, permanent bradycardia, and the inability to stimulate the atrium are indications for ventricular rate responsive pacing.

[Successful surgical management of rupture of the papillary muscle diagnosed by ultrasound]. / Ultrahanggal felismert papillaris izomruptura sikeres mütéti megoldása.

The rupture of the papillary muscle is an infrequent complication of myocardial infarction. Survival of the acute phase depends on the severity of the rupture and the remaining function of the left ventricle. Permanent survival may be ensured however only by surgical intervention. The authors present the case record of a patients whose disease in connection with a myocardial infarction was revealed by echocardiography and was operated on successfully. No such data were found in the Hungarian literature.

[Pleuropericardial mesothelial cysts]. / Pleurokardiale Mesothelzysten.

Experience gained in connection with the diagnosis and removal of 33 pleuropericardial mesothelial cysts is described and compared with the pertaining data in the literature. The incidence, pathology, symptomatology, diagnostics and differential diagnostics of these cysts and the chances of conservative and surgical therapy are discussed.