The matrix metalloproteinase inhibitor batimastat inhibits the lung colonisation of orthotopically implanted malignant pancreatic tumor cells in SCID mice.

AIM OF STUDY: In this study, we investigated the effect of the matrix metalloproteinase inhibitor batimastat on the lung colonisation of orthotopically implanted malignant pancreatic tumor cells in SCID mice. MATERIAL AND METHODS: Following intraperitoneal anaesthesia, 10(6) Panc-TU-1 cells were orthotopically implanted in the head of the pancreas in 20 SCID mice. Seven days later, treatment of 10 of these mice with an intraperitoneal injection of batimastat (30 mg/kg body weight) was begun and continued for 14 days. Of the mice in the untreated control group, 3 were sacrificed and examined after 7 days, a further 3 after 14 days and the remainder together with the group that had been treated after 21 days. RESULTS: Tumor growth was clearly visible between the 14th. and the 21st. postoperative day. The orthotopically implanted tumor cells metastasized between the 2nd. and 3rd. postoperative week in the lung. In the control group, a diffuse metastasis of the lung was observed, but in the group of treated mice no lung metastases were found. CONCLUSION: In this mouse model, a clear reduction and inhibition of lung metastases from orthotopically implanted pancreatic tumor cells was achieved by treatment with the matrix metalloproteinase inhibitor batimastat.

Clinical evaluation of defibrillation efficacy with a new single-capacitor biphasic waveform in patients undergoing implantation of an implantable cardioverter defibrillator.

AIMS: Improvements in the size and shape of implantable cardioverter defibrillators (ICDs) might be obtained by using one capacitor instead of the series connection of two capacitors traditionally used in ICDs. The aim of this study was to determine whether a biphasic waveform delivered from a single 336 microF capacitor had the same defibrillation efficacy as a standard biphasic waveform. METHODS AND RESULTS: Randomized, paired defibrillation threshold testing was acutely performed in 54 patients undergoing ICD implantation. A standard 140 microF 80% tilt biphasic waveform (two 280 microF capacitors connected in series) was compared with an experimental biphasic waveform delivered from a single 336 microF capacitor at either 60% tilt (33 patients) or 80% tilt (21 patients). All waveforms had a 60/40 phase1/phase2 duration ratio. Compared with the standard waveform, the 60% tilt experimental waveform had a lower delivered energy (6.7 +/- 2.8 vs 7.9 +/- 3.3 joules, P<0.02), lower peak voltage (218 +/- 43 vs 333 +/- 68 V, P<0.01), and a slightly longer pulse duration (13.4 +/- 1.4 vs 10.7 +/- 1.1 ms, P<0.01). Conversely, the 80% tilt experimental waveform had a higher delivered energy (9.1 +/- 3.5 vs 6.3 +/- 2.4 joules, P<0.01), a lower peak voltage (234 +/- 44 vs 302 +/- 51 V, P<0.01) and a much longer pulse duration (25.7 +/- 2.5 vs 1.13 +/- 1 ms, P<0.01). CONCLUSION: Waveforms delivered from a large capacitance are feasible but require a lower tilt. This technique may allow smaller, thinner ICDs without jeopardizing defibrillation success.

Giant primary cardiac liposarcoma vascularized via the circumflex coronary artery.

A 51-year-old patient presented with a history of chest pain and progressive dyspnea. CT scan demonstrated a lipomatous mass encircling the heart and compressing the left lung. After median sternotomy, an intrapericardial tumor of 3200 g with a vascular pedicle arising from the circumflex coronary artery was resected. A histologic diagnosis of a well-differentiated liposarcoma was made. The patient is alive and well 2 years postoperatively. This tumor with its unusual vascularization is the largest of the few primary cardiac liposarcomas that have been reported.

Septic endarteritis and fatal iliac wall rupture after endovascular stenting of the common iliac artery.

A 52-year-old female with arterial occlusive disease underwent an uneventful percutaneous transluminal angioplasty and placement of a vascular metallic stent in the left common iliac artery. Ten days later she presented with clinical symptoms of septic endarteritis. Shortly after re-admittance, an emergency laparotomy had to be performed because of an acute retroperitoneal bleeding. Rupture of the common iliac artery directly overlaying the penetrating stent was found but control of haemorrhage was of no avail. In this report of a case, septic endarteritis following placement of a vascular metallic stent preceded fatal rupture of the common iliac artery. This up to now unknown constellation requires surgical intervention without undue delay.

Short- and long-term performance of a tripolar down-sized single lead for implantable cardioverter defibrillator treatment: a randomized prospective European multicenter study. European Endotak DSP Investigator Group.

A new, thinner (10 Fr) and more flexible, single-pass transvenous endocardial ICD lead, Endotak DSP, was compared with a conventional lead, Endotak C, as a control in a prospective randomized multicenter study in combination with a nonactive can ICD. A total of 123 patients were enrolled, 55 of whom received a down-sized DSP lead. Lead-alone configuration was successfully implanted in 95% of the DSP patients vs 88% in the control group. The mean defibrillation threshold (DFT) was determined by means of a step-down protocol, and was identical in the two groups, 10.5 +/- 4.8 J in the DSP group versus 10.5 +/- 4.8 J in the control group. At implantation, the DSP mean pacing threshold was lower, 0.51 +/- 0.18 V versus 0.62 +/- 0.35 V (p < 0.05) in the control group, and the mean pacing impedance higher, 594 +/- 110 omega vs 523 +/- 135 omega (p < 0.05). During the follow-up period, the statistically significant difference in thresholds disappeared, while the difference in impedance remained. Tachyarrhythmia treatment by shock or antitachycardia pacing (ATP) was delivered in 53% and 41%, respectively, of the patients with a 100% success rate. In the DSP group, all 28 episodes of polymorphic ventricular tachycardia or ventricular fibrillation were converted by the first shock as compared to 57 of 69 episodes (83%) in the control group (p < 0.05). Monomorphic ventricular tachycardias were terminated by ATP alone in 96% versus 94%. Lead related problems were minor and observed in 5% and 7%, respectively. In summary, both leads were safe and efficacious in the detection and treatment of ventricular tachyarrhythmias. There were no differences between the DSP and control groups regarding short- or long-term lead related complications.

[Misplacement of a transvenous lead from an implantable cardioverter-defibrillator into the left ventricle via a patent foramen ovale]. / Fehlpositionierung der transvenösen Sonde des implantierbaren Cardioverter-Defibrillators im linken Ventrikel über das offene Foramen ovale.

HISTORY AND CLINICAL FINDINGS: 24-hour ECG monitoring in a 64-year-old man revealed self-limited (< 30 s) ventricular tachycardias (VT) of > 200/min. He had triple-vessel coronary artery disease with both anterior and posterior wall infarctions treated by three aortocoronary venous grafts. Physical examination was unremarkable except for a well healed thoracotomy scar. INVESTIGATIONS: Programmed ventricular stimulation induced prolonged monomorphic VT of 320 beats/min, despite aminodarone treatment. Left-heart catheterization demonstrated the three patent aortocoronary grafts and a left-ventricular ejection fraction of only 20%. TREATMENT AND COURSE: Because of the inducible and prolonged VT, despite antiarrhythmic treatment with amiodarone, a cardioverter-defibrillator was implanted (ICD). During threshold measurements of the pacemaker integrated into the ICD the pacemaker impulse was noted to produce a right bundle branch block pattern, the ICD lead having erroneously been placed in the left ventricle via a patent foramen ovale. The lead was left in place, because the ICD was functioning well and lead removal with the possible need of a thoracotomy carried a high risk. CONCLUSION: Extreme caution is needed to avoid malpositioning an implantable cardioverter-defibrillator. If the lead tip is unwittingly fixed in the left ventricle but functions well it should be left in place under prophylactic anticoagulation, because of the potentially high risk of its operative removal.

Pulmonary vein injury through repetitive clip friction: an unusual cause of hemothorax.

Massive hemothorax developed in a 58-year-old man 12 hours after a left pneumonectomy. The source of bleeding was a tear in the pulmonary vein stump caused by a titanium clip that had been used during mediastinal lymphadenectomy. Postoperatively, the clip progressively sawed through the vascular wall of the pulmonary vein due to friction during the cardiac cycle.

Empirical versus tested antitachycardia pacing in implantable cardioverter defibrillators: a prospective study including 200 patients.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death. The objective of this study was to evaluate whether testing of antitachycardia pacing (ATP) for induced ventricular tachycardias (VTs) at predischarge examination can predict ATP success during follow-up. METHODS AND RESULTS: The study covers 200 consecutive patients who received ICD implants from June 1991 through December 1995. All underwent electrophysiological testing. In 54 patients (ATP tested, group T), ATP terminated induced VTs successfully. In 146 patients (empirically programmed ATP, group E), only ventricular fibrillation could be induced, including 18 with unsuccessful ATP attempts for induced VTs. Disregarding the results of ATP testing, the same ATP scheme was programmed in all patients: three attempts of autodecremental ramp with 81% of the VT cycle length, with 8 to 10 pulses. During a follow-up of 20.4 +/- 10 months, 95% of 3819 spontaneous VTs were successfully terminated with ATP in 42 patients of group T. In group E, 90% of 1346 spontaneous VTs in 81 patients were terminated with ATP. Acceleration after ATP occurred in 2% in group T versus 5% in group E. The success for all episodes in individual patients was > or =90% in >60% of the ATP tested and empirically programmed patients. CONCLUSIONS: The results of this 200-patient prospective study comparing tested versus empirical ATP show high success (95% versus 90%) for VT termination, with low rates of acceleration. ATP is safe and very effective and should be programmed "on" in all patients regardless of the predischarge EP inducibility.

Induction combination chemotherapy with docetaxel and carboplatin in advanced non-small-cell lung cancer.

BACKGROUND: Results in the therapy of locally advanced non-small-cell lung cancer (NSCLC) by operation and/or irradiation only are poor. To improve the long-term prognosis a systemic induction chemotherapy may be successful in reducing local tumor burden and eliminating micrometastases. The efficacy of preoperative docetaxel-carboplatin combination chemotherapy was studied in a phase-II study for NSCLC stage IIIB. METHODS: 15 patients with functionally operable stage IIIB NSCLC (10 squamous-cell, 4 adeno, 1 large-cell) were enrolled to receive 4 cycles of docetaxel (100 mg/m2, day 1) and carboplatin (AUC 7.5, day 2) on an outpatient basis with G-CSF support after cycle 1 and were subsequently evaluated for surgery. Postoperatively the patients were irradiated with 50 Gy (R0-resection) or 60 Gy (R1-resection). RESULTS: Acceptable hematologic and non-hematologic toxicity was observed. On an intent-to-treat basis, 14 patients were evaluable for radiological response after 4 cycles of chemotherapy (1 patient still on therapy): 11/14 patients had radiological response of > or = 50%, 1/14 progressive disease, 2 exclusions because of toxic death (1 patient) and capillary leak (1 patient). Of 11 patients evaluated for surgery, 9 patients were resected, 1 patient is awaiting operation, 1 patient received radiotherapy because of an esophageal fistula. By histological findings a downstaging was achieved in 6/9 resected patients: histological complete response (CR) in 4 patients, partial response (PR) in 2, and no response in 3. With a mean follow-up of 8.1 months (excluding 1 patient in early postop course), 5/5 R0 and histological responders are alive and disease-free. Of the 3 histological non-responders, 1 patient (R1/2 resection) died of respiratory failure, 2 patients (1 R1 and 1 R0) of distant metastases. CONCLUSION: Outpatient therapy with docetaxel/carboplatin chemotherapy is effective in downstaging patients with NSCLC, toxicity is acceptable. Histological response may be the most important prognostic factor. The early results of this phase II study encourage evaluation of the long-term benefit within a prospective randomized phase III study.

Admission to an intensive care unit after transvenous implantable cardioverter defibrillator implantation: analysis of risk factors.

A retrospective review was undertaken of 90 patients admitted to the cardiothoracic intensive care unit and who comprised 47% of all transvenous implantable cardioverter defibrillator operations performed between March 1991 and August 1995. The review aimed to evaluate the necessity for routine postoperative intensive care unit (ICU) admission after implantable cardioverter defibrillator operation. Pre-, intra- and postoperative data were analysed. Eight of 90 patients (9%) subsequently required care unique to the ICU. None of the variables examined, including the Acute Physiology Score (APACHE II system), was helpful in identifying patients who required unique ICU services. Patients undergoing transvenous implantable cardioverter defibrillator surgery are identified as a low risk group requiring in over 90% of cases monitoring services rather than active therapy in an ICU. As no reliable predictors seem to exist to identify the necessity for postoperative ICU admission, cardioverter defibrillator implantations should only be performed in hospitals where adequate facilities are readily available.

Neurogenic lesions after posterolateral thoracotomy in young children.

In follow-up examinations of young patients we often noticed upward displacement of the left shoulder in cases where left-sided posterolateral thoracotomy had been carried out. Finding little discussion of this side-effect in the literature, we undertook the present study. The shoulder girdle of 69 patients who had undergone surgery for coarctation of the aorta between 1964 and 1984 was carefully examined to assess displacements and dysfunctions. In addition, in 24 of the patients electrodiagnostic examination was carried out of the associated muscles and nerves which were affected by the operation. We found disturbances of the muscular apparatus of the shoulder girdle in 80% of the cases: upward displacement of the shoulder (55%), downward displacement of the shoulder (8.7%), deviation of the scapula at rest (72.5%) and maximal elevated arms (40.6%), scapula alata (56.5%), and alterations of the posterior axillary line (39.1%). When considering only the cases of distinct upward or downward displacement of the shoulder, at least 25% of the operated children were affected. Children operated early (surgery during the first year of life) had more distinct alterations (47.6%) than those with later surgery (14.6%). Electromyographic examinations indicate that mainly disorders of the peripheral nerves caused by the operation led to these alterations of the shoulder girdle musculature. Although, except for one patient, no functional disorders were found, there were several cases in which the alteration caused quite severe cosmetic problems. One should pay more attention to positioning for surgery and do careful preparation to reduce these sequelae.

Successful surgery after complete disruption of the right bronchial system.

A case of successful surgical repair of a complex rupture of the right bronchial system in a twenty-nine-year-old man is presented. Complete primary bronchial reconstruction and intensive postoperative care was required to provide bronchial continuity and to avoid major pulmonary resection. Problems concerning diagnosis, surgical technique, and postoperative management are discussed. The good postoperative outcome may encourage bronchial repair instead of resection in complex bronchial disruptions.

[Bacterial endocarditis of the transvenous lead of an implantable cardioverter/defibrillator]. / Bakterielle Endokarditis der transvenösen Sonde eines implantierbaren Kardioverters/Defibrillators.

A 27-year-old patient carrying a transvenous ICD developed infective endocarditis more than 1 year after surgery. Staphylococcus aureus was isolated from blood cultures. A transesophageal echocardiogram revealed a mobile vegetation on a thrombus attached to the ICD lead in the right atrium. The ICD lead was removed by right anterolateral thoracotomy. This raises the issue of the risk of thrombus formation in patients with intravenous ICD leads and the associated susceptibility to infective endocarditis.

[Bronchial rupture and lung contusion in multiple trauma]. / Bronchusruptur und Lungencontusion beim Polytrauma.

Tracheobronchial ruptures resulting from blunt chest trauma are rare events. Depending on their anatomical location and extension they may be nearly asymptomatic and escape early diagnosis, on the other hand they may induce an acute life-threatening situation with dramatic symptoms. The awareness of the different clinical and radiological findings may point to this lesion, the definite diagnosis, however, is made by bronchoscopy. A rapid surgical reconstruction intends to avoid severe late complications and to protect all uninjured lung areas for an adequate gas exchange in case of associated lung contusion. In patients with thoracoabdominal injuries, whether to perform thoracotomy or celiotomy first must be decided for each individual case depending on the urgency. The clinical course of a patient, who after a traffic accident suffered from main bronchus rupture, bilateral lung contusion, liver rupture and multiple fractures of the upper extremities illustrates these problems.

[Spontaneous pneumothorax as the initial symptom of bronchial cancer]. / Spontanpneumothorax als Erstsymptom eines Bronchialkarzinoms.

Spontaneous pneumothorax is caused by benign lung diseases in more than 95 percent. Mainly presenting in younger male patients between 20 and 40 years of age its prognosis is generally good.--On the other hand, pneumothorax as initial manifestation of bronchial carcinoma is a rare complication with poor prognosis. We report such a case of a 70 year-old man, review the literature and describe characteristical problems in diagnosis and therapy of very small bronchogenic tumors. Estimating that only 2 percent of all spontaneous pneumothoraces are coexisted with malignant lung diseases--either primary or secondary--this tumor-complication especially must be considered in older patients. Their prognosis may be improved entirely by rapid diagnosis and therapy.

Fractured strut of Björk-Shiley 70 degrees convexo-concave mitral valve prosthesis found in left coronary artery. Use of a portable transcutaneous cardiopulmonary bypass system for successful valve replacement.

Strut fractures followed by disk escape of Björk-Shiley convexo-concave valve prostheses are a well-known problem. This article discusses the case of a successfully treated patient who was admitted to our institution with extreme and prolonged cardiogenic shock. The strut was dislodged into the main stem of the left coronary artery and the disk into the iuxtarenal abdominal aorta. The intent of this report is, in particular, to illustrate the management problems. Immediately after diagnosis, circulation and oxygenation were ensured by use of a portable cardiopulmonary bypass support (CPS) system whose circulation lines were introduced subcutaneously. Thus the transfer to the operating room and the surgical intervention were able to start under controlled conditions. The disk was removed by Fogarty catheter manoevre without any problems during the same operation, using a transpericardial access to the descending thoracic aorta. In our opinion, the primary insertion of the CPS and the avoidance of an additional laparotomy in disk removal help promote the survival of such critically ill patients.

Different ways of application of the implantable cardioverter defibrillator (ICD)--which is the current approach?

The implantable cardioverter defibrillator (ICD) has proved to be effective in patients at risk of sudden cardiac death (SCD). Because of the development of more effective lead- and defibrillator systems the surgical implantation modes have changed from extensive operative interventions (sternotomy, lateral thoracotomy) to less traumatical (subxiphoidal/subcostal approach) and less invasive (transvenous) techniques. Procedures with less operative damage may be offered to patients with reduced cardiac function. However, the kind of operative procedure to be performed must be decided individually. The different system configurations, their advantages and disadvantages as well as their complications are surveyed and discussed in the light of our patient population, 102 cases between 1984 and 1991, and the literature. Even when the "non thoracotomy" implantations will become the favoured method, the standard incisions by thoracotomy will still be of importance. Considering that major complications occur also in transvenous implant procedures and that cardiac operations have to be performed in 20-30% of the patients simultaneously, we suggest--following the recommendations of the North American Society of Pacing and Electrophysiology (NASPE)--that the devices be implanted exclusively in units for cardiac surgery in cooperation with rhythmologically well-trained cardiologists.

[Perforation of an automatic implantable cardioverter-defibrillator into the peritoneal cavity]. / Perforation eines automatischen implantierbaren Kardioverter-Defibrillators in die Peritonealhöhle.

The automatic, implantable cardioverter-defibrillator is a new therapy for life-threatening ventricular tachyarrhythmias that are resistant to other therapy. Only a few complications, such as infections, lead defects, and interactions with pacemakers have been reported. We report on a patient whose AICD-generator perforated into the peritoneal cavity.