Quality of life after cardiac surgery in the elderly.

BACKGROUND: Cardiac surgery in the elderly is performed with increasing frequency. Beside low mortality an evident gain in quality of life is the most important aim of therapy. To investigate the medium term outcome of cardiac surgery, we evaluated patients over 75 years of age who were operated on within a 1.5-year period. METHODS: Between 01/98 and 06/99, 124 patients (76 male, 48 female), mean age of 76.6 (range 75-86) years were operated on. Eighty-four per cent had isolated coronary or valve procedures and 16% had combined procedures. Pre- and postoperative NYHA classification, follow-up period, perioperative mortality and the subjective satisfaction were recorded. RESULTS: Total perioperative mortality was 6.4%. After a mean follow-up time of 15.2 (range 6-24) months, patient satisfaction with the operative results was excellent in 73%, good in 26% and low (unsatisfied) in 1%. CONCLUSIONS: Cardiac surgery in the elderly can be performed with an acceptable morbidity and mortality. The fact that 99.1% of the patients are satisfied with their operation and the dramatic improvement in functional status (96.5% NYHA I and II) justify cardiac surgery in this age.

Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting.

OBJECTIVES: Cannulation and clamping of a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) can lead to cerebral embolization of atheromatous debris and should therefore be avoided whenever possible. A variety of surgical techniques including performance of extraanatomical coronary bypass conduits has been described to solve this problem. We report on a preliminary series of four patients in whom the axillary artery was used as an inflow vessel for venous coronary artery bypass grafts which were performed on the beating heart in order to achieve an aortic no touch concept. METHODS: The axillary artery was exposed between the pectoralis major muscle and the deltoid muscle via an infraclavicular incision. A saphenous vein graft of at least 40 cm in length was sutured to the axillary artery and then brought into the pericardial cavity following an intercostal and transpleural route. The graft was anastomosed to the target vessel using local coronary occlusion. The procedure was carried out via sternotomy in three patients who also received additional internal mammary artery in situ grafts for adequate coronary revascularization. In one high risk patient an isolated axillocoronary bypass was performed in a minimally invasive fashion via anterolateral minithoracotomy. RESULTS: The procedure was completed without major technical difficulties in all four patients. The mean graft length required was 33.2 +/- 1.6 cm, postoperative ultrasonic duplex scans of the axillocoronary grafts revealed a mean flow of 62.5 +/- 23.6 ml/min. No stroke or brachial plexus injury occurred. Three patients are in angina class I (Canadian Cardiovascular Society Classification), one patient is in class II postoperatively. After a mean follow-up of 11.5 +/- 6.6 months postoperatively all grafts remain patent. CONCLUSION: Axillocoronary bypass grafting can be easily performed for management of the untouchable ascending aorta. Straightforward surgical technique and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass grafts.

Isolated right ventricular assist for postcardiotomy myocardial infarction.

Due to myocardial infarction, profound postcardiotomy right heart failure developed in a 57-year-old man after implantation of an aortic homograft for infective aortic valve endocarditis. Despite maximum medical therapy and intraaortic balloon counterpulsation, signs of endorgan injury developed, and therefore a Thoratec (Pleasanton, CA) right ventricular assist device was implanted. After 17 days of support, myocardial and endorgan function had recovered and the fully mobilized patient was successfully weaned from support and discharged from the hospital.

[A new cardiac pacemaker stimulation technology (autocapture) allows, with unchanged life expectancy, reduction of generator size by half]. / Eine neue Herzschrittmacher-Stimulationstechnologie (Autocapture) ermöglicht bei unveränderter Lebensdauer die Reduktion der Generatorgrösse auf die Hälfte.

Energy delivery (stimulation amplitude) of a pacemaker should be adjusted to the depolarisation threshold of the heart, which is a nonconstant magnitude. As programming of the stimulation amplitude is time-consuming, many pacemakers are never adjusted to the measured threshold referring to energy delivery. The unnecessary energy loss subsequently reduces the longevity of the implanted devices and remains the weak point of modern pacemakers. Autocapture function (automatic stimulation threshold search, subsequently automatic amplitude regulation 0.3 V above measured threshold, evoked response detection to verify the efficacy of every stimulus and back up pulse in case of loss of capture) is for the first time realized in an extremely small, rate adaptive, multiprogrammable single chamber pacemaker (Microny SR+ 2425T). The pulse generator was tested in a multicentric, european clinical investigation study. These pacemakers were implanted in 8 patients (5 male, 3 female) between December 1994 and April 1995. Automatic measurement of Autocapture threshold revealed 0.7 +/- 0.15 V at implantation, 1.5 +/- 0.3 V after 1 month, 1.3 +/- 0.14 V after 6 months and 1.3 +/- 0.14 V 1 year after implantation. A safety margin of 0.3 V is added to the threshold value to secure capture, therefore mean stimulation amplitude is 1.6 V after 12 months implantation time. The Autocapture feature minimizes current drain and that means that this extremely small generator provides a comparable life as the twice as large common generators used at present time.

[Successful resuscitation in severe hypothermia following near-drowning]. / Erfolgreiche Reanimation bei ausgeprägter Hypothermie nach Beinahe-Ertrinken.

A six-year-old boy fell into an ice-cold mountain stream and was immediately washed away. He was rescued 65 min later, 6 1/2 km downstream, seemingly lifeless with a rectal temperature of 16.4 degrees C. He was flown by helicopter to the surgical clinic of Innsbruck University, while resuscitation measures were undertaken by an accompanying doctor. After cannulation of the femoral artery and vein, extracorporeal circulation (ECC) with a child-size oxygenator was started and the blood rewarmed over 96 min in steps of 3 degrees C. Once circulatory stability and adequate cardiac output had been achieved ECC was gradually discontinued while the patient was still slightly hypothermic. Ten months after the accident the boy is restored to health, except for minimal residual neurological signs. There is a high chance for full neurological recovery.

Progesterone receptors in routinely paraffin-embedded primary breast carcinomas and lymph node metastases.

Described here is an immunohistochemical technique using the commercially available monoclonal progesterone receptor (PR) antibody KD 68 in routinely fixed and paraffin-embedded breast carcinomas and lymph node metastases. The authors' technique is compared with several incubation variations. The method applying the primary antibody in a dilution of 1:10 overnight followed by a biotinylated second antibody showed the best results when Triton X-100 was added to the buffer. Using this method, comparison with the results on frozen sections of 34 breast carcinomas yielded a significant concordance of 94%. Correlation between the results on paraffin sections and those obtained by the standard dextran-coated charcoal cytosol assay was 80%. The value of the method for predicting endocrine therapy response was shown in 20 patients. Thus the reliability of the method has been demonstrated and was applied on 151 lymph node metastases and the corresponding primary breast carcinomas from 50 patients. Generally PR content in the metastases was lower than in the primary tumors (p < 0.001). This finding indicates that evaluation of PR in lymph node metastases should be included in the decision for endocrine therapy of breast cancer.

Use of the greater omentum for treatment and prophylaxis of anastomotic and stump dehiscence in major airway surgery.

In 6 patients suffering from anastomotic dehiscence following bronchoplastic procedures of the central airways or from acute bronchial stump fistula following pneumonectomy, the therapeutic efficiency of omentopexy in the management of the fistula was investigated. In 5 other patients with an increased risk of anastomotic leakage after sleeve pneumonectomy or pneumonectomy with carinal resection the omentum was effectfully used to prevent such complication. 4 out of 5 evaluable patients had successful treatment of the anastomosis and stump fistula. Complications arising from the additional laparotomy were not observed.

Multimodal therapy of small cell lung cancer in TNM stages I through IIIa.

Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.

Critical checking of the radiological diagnosis of "complete remission" and "partial remission" following induction chemotherapy of small-cell lung cancer in the light of postoperative histological examination.

A multimodal therapy concept for small-cell lung cancer, which for patients with established pretherapeutic homolateral lymph-node metastases (N2) prescribes induction chemotherapy with subsequent resection as well as supplemental chemo- and radiotherapy, provided the opportunity to evaluate histologically the radiological diagnoses "complete remission" and "partial remission" using resection specimens. In 17 patients a 75% to 100% reduction in tumor size was achieved according to radiological diagnosis. Predictions of "no evidence of disease" or "evidence of disease" were only correct in ten cases. In the remaining seven cases, histology showed the radiological findings to be incorrect. This gives a 77% sensitivity for radiological diagnosis with no specificity. Moreover, differentiation between therapy effect on the primary tumor and on the N2 metastases gives similar results: sensitivity 64% and 67% respectively, specificity 33% and 25% respectively. It is concluded that, particularly after the tumor responds well to therapy, radiological techniques are unsuitable for establishing a diagnosis of "no evidence of disease" or "evidence of disease" in small-cell lung cancer. This is because on the one hand the radiological methods available do not permit clear differentiation between vital tumor tissue and necrosis or fibrosis, while on the other hand groups of vital tumor cells beyond the resolution power of X-ray technology will escape detection.

Immunohistochemical demonstration of chromogranins A and B in neuroendocrine tumors of the lung.

Fifty neuroendocrine tumors of the lung (16 carcinoids, two atypical carcinoids/well-differentiated neuroendocrine carcinomas [WDNCs], 13 neuroendocrine carcinomas of intermediate cell type [SCNCs], and 19 neuroendocrine carcinomas of small cell type [SCNs]) were immunohistochemically investigated with antibodies against chromogranins A and B. All carcinoids and WDNCs were positive for both chromogranins A and B, whereas in cases of ICNC and SCNC both markers were only expressed in six and five cases, respectively. One ICNC was only positive for chromogranin A. In cases of SCNC five tumors were exclusively positive for chromogranin A and six were positive only for chromogranin B. Chromogranins are therefore excellent markers for the immunohistochemical demonstration of carcinoids and WDNCs. It may be speculated that expression of chromogranins in cases of ICNC and SCNC represents a higher degree of differentiation in these tumors.

Operation for N2 small cell lung carcinoma.

Of 48 patients with limited small cell lung carcinoma treated by different modes, but always including radical operation, a series of 25 patients with N2 lymph node metastases is reported. In a first period (1970 to 1977) treatment consisted solely of radical resection in 3 patients; chemotherapy was added to operation in 6, and local radiotherapy was added in 2. Since 1977, 14 patients were treated according to a comprehensive therapy protocol including radical resection (six pneumonectomies, one bilobectomy, seven lobectomies), chemotherapy, local radiotherapy, and prophylactic cranial irradiation. Eleven patients, in whom N2 disease was confirmed preoperatively, received chemotherapy as the first step, followed by "adjuvant" resection. Projected 5-year survival rate is 25% for the entire N2 group and 47% for the comprehensively treated group. Seven patients of this latter group are alive 12, 19, 30, 48, 66, 73, and 74 months after comprehensive therapy, equivalent to an observed 2-year survival rate of 38%. This is the largest reported series of patients with resected small cell lung carcinoma in the N2 stage treated at a single institution; the results are so encouraging that we can no longer advocate general refusal of radical lung resection for small cell lung carcinoma in the N2 stage if it is part of a multimodal therapeutic protocol.

Transesophageal sonography in central bronchial carcinoma.

A new application of transesophageal sonography was tested in eight patients suffering from central bronchial carcinoma. Due to ultrasound technology, a real time investigation is feasible which enhances the diagnostic method of computed tomography (CT) by discriminating between tumour and mediastinal organs which cannot be delineated by CT only. Different sonographic densities and the movement between organ and tumour contribute to the diagnostic accuracy of sonography if operability is questionable due to possible organ infiltration by tumour. The method is limited by the air filled organs (trachea, bronchi), as ultrasound does not penetrate adequately.

Intraoperative cryoanalgesia for postthoracotomy pain relief.

In a randomized study, 63 patients were investigated for the benefits of cryoanalgesia after thoracotomy. Analgesia and its dependent effects such as enhancement of mobility, respiratory function, and reduced need of narcotics were evaluated. No significant differences in these variables were observed between the cryoanalgesia group and the control group. However, moderate to severe neuralgia was found in a number of patients in the cryoanalgesia group in the late postoperative period. Cryoanalgesia for pain relief after thoracotomy is not recommended.

Endoscopic removal of a pedunculated bronchial lipoma by means of the hot snare.

The complete endoscopic removal by means of the hot snare of a pedunculated bronchial lipoma with a carcinoma in situ in its covering bronchial epithelium is reported. To our knowledge, the endoscopic removal of peripheral polypoid bronchial lesions has not been reported to date. The advantage of this technique lies in its ability to permit an exact histologic examination of the lesion, in contrast to laser vaporisation.