Spinal cord protection using hypothermic cardiocirculatory arrest in extended repair of recoarctation and persistent hypoplastic aortic arch.

OBJECTIVE: In recurrent coarctation collateral circulation may not be sufficient to maintain adequate perfusion of the lower body during the period of surgical repair. Different techniques such as interposition of a Gott-shunt, use of left heart bypass or hypothermic cardiocirculatory arrest are used to prevent spinal cord injury. METHODS: Twenty-eight operations for recurrent coarctation were performed in 26 patients following end-to-end anastomosis (58%), patch plasty (21%), subclavian flap aortoplasty (14%) and graft interposition (7%). Associated cardiac defects were present in 77% of the patients. Eleven patients who had adequate (> 50 mmHg) distal perfusion pressure during a test occlusion were operated on using simple cross-clamping (group I, mean age 8.5 +/- 3.8 years). In group I, end-to-end anastomosis was performed in nine patients and graft interposition in two patients. In 17 cases (including two patients from group I) with insufficient collateral circulation and with persistent hypoplasia of the arch, hypothermic cardiocirculatory arrest was used (group II, mean age 12.8 +/- 9.6 years). In group II end-to-end anastomosis was performed in three patients and graft interposition in 14 patients. Mean bypass-time was 116 +/- 36 min and arrest-time 33 +/- 16 min. Hypothermic cardiocirculatory arrest was begun when nasopharyngeal temperature was below 20 degrees C, corresponding to a rectal temperature of 24 +/- 3 degrees C. RESULTS: Hypothermic cardiocirculatory arrest allowed open reconstruction of the arch and/or complete or partial replacement of the arch and the coarctation segment. In-hospital mortality was 0 and 5.9% in group I and II, respectively. The one patient who died in group II had simultaneous correction of an anomalous pulmonary venous connection and death was unrelated to the method of coarctation repair. Reversible laryngeal nerve paresis was observed in two patients in group II, no other neurologic complications were observed in either group. Postoperative gradients over the repair site were less than 20 mmHg by Doppler-echocardiography. Two patients of group I had to have a second, early reoperation because of stenosis at the anastomotic site. Reconstruction of the distal aortic arch was then performed during hypothermic cardiocirculatory arrest. CONCLUSIONS: The use of hypothermic cardiocirculatory arrest in this special indication is a safe method which allows open reconstruction of the coarctation site and the aortic arch and protection of the spinal cord. The need for early reoperation because of inadequate repair may be reduced.

[Results of prosthetic heart valve replacement. Primary, secondary and emergency operations]. / Ergebnisse des prothetischen Herzklappenersatzes. Erst-, Zweit- und Notoperationen.

From 1962 to 1984, 2460 prosthetic valve implantations in the heart were performed at the Department of Surgery of the University of Heidelberg. In addition to 2291 primary surgical interventions, 169 re-interventions were carried out. 153 emergency operations were necessary. The frequency rate of operations increased continuously; 52% of the operations were performed at the aortic valve and 37% at the mitral valve. In 9% of the cases, two valves had to be replaced, and in 2% even three valve prostheses were implanted. The indications for re-intervention included prosthetic thromboses, paravalvular leakages and prosthetic valve endocarditis. The situations requiring emergency intervention differed from case to case. Early mortality, which had been initially high, could be considerably reduced due to increased experience in surgical technique, anaesthesia, intensive care and improved myocardial protection. The extent and quality of medical postoperative care will determine the success of medical rehabilitation and hence the future professional activity of the patient.

[Partial anomalous right pulmonary venous return into the coronary sinus without atrial septal defect (author's transl)]. / Fehlmündung der rechten Lungenvenen in den Koronarsinus ohne Vorhofseptumdefekt.

Drainage of right pulmonary vein into the coronary sinus. A case of anomalous drainage of the right pulmonary vein into the coronary sinus in a boy of 6 years is presented. There was no associated atrial septal defect. Flow from the right pulmonary vein was directed into the left atrium by using a teflon patch, while maintaining coronary venous return to the right atrium.

[Treatment of postoperative sternal osteomyelitis (author's transl)]. / Die Behandlung der postoperativen Sternum-Osteomyelitis

Report on 5 cases of postoperative sternal osteomyelitis after cardiac valve replacement. In 3 cases evaluation of Pseudomonas aeruginosa in probes taken of sternal wounds. Treatment of the osteomyelitis with continuous irrigation and suction supported by excochleation of the fistulae and application of pure spongiosa chips to the bone defect of the sternum. Uncomplicated postoperative course in 4 patients. In 1 patient postoperative time too short for a final decision.

Penicillin-induced coagulation disorder.

A coagulation disorder was seen after penicillin-G administration (10 million units/day) in uraemic patients and after high-dose penicillin G (40 million units/day) in patients with a normal glomerular filtration-rate (5 patients after cardiac surgery). This disorder was characterised by: prolongation of bleeding-time, appearing immediately after penicillin-G administration and persisting until 4 days after withdrawal of therapy; disturbance of collagen-induced and ristocetin-induced platelet aggregation; increase of antithrombin-III activity; and inhibition of factor-xa activity. The inhibition of factor-xa activity corresponded to that seen after low-dose-heparin prophylaxis. The clinically latent coagulation disorder, when super-imposed upon pre-existing coagulation abnormalities (uraemia, treatment with anti-coagulants) may cause severe bleeding, as observed in 1 patient with acute renal failure on haemodialysis.

[Postoperatives acute renal failure after operations with extracorporeal circulation (author's transl)]. / Postoperatives Nierenversagen nach Operation mit extrakorporalem Kreislauf

An acute renal failure was observed postoperatively in 3,45% of 929 patients operated with the heart lung machine during the years 1970-1972. Because of the bad results of any therapy in the case of acute postoperative renal failure, the diagnostic procedures of the preoperative renal function were intensified of the preoperative renal function were intensified in order to prevent an acute postoperative renal failure. Therefore additional measurements of the creatinine clearance and in few cases radioisotopic clearance tests were done.