Serial evaluation of the thoracic aorta in patients with a bicuspid aortic valve: a magnetic resonance angiography study.

BACKGROUND: Bicuspid aortic valve (BAV) is associated with an arteriopathy leading to a progressive dilatation of the aortic root. Recent studies have shown that the whole thoracic aorta is affected by this arteriopathy. Longitudinal data regarding the progression of this arteriopathy in the whole thoracic aorta has not been reported before. PATIENTS AND METHODS: In this retrospective study 40 patients (mean age 28.5 +/- 9.1 years) had 2 MR-angiographies (mean interval 37.1 +/- 15.2 months). In 23 patients the aortic valve was regurgitant, in 1 stenotic, in 4 combined aortic stenosis / regurgitation was found, while in 12 the valve function was normal. Aortic diameters were measured at 6 different, standardized anatomical points. The influence of demographic and clinical parameters was assessed. RESULTS: A significant increase of the diameter was observed at the aortic root (35.4 +/- 5.6 mm --> 39.1 +/- 6.5 mm, p < 0.001), the ascending aorta (37.3 +/- 8.0 mm --> 39.5 +/- 8.5 mm, p = 0.001), proximal to the innominate artery (29.4 +/- 6.1 mm --> 31.6 +/- 6.8 mm, p = 0.008), and the descending aorta (20.2 +/- 2.4 mm --> 21.6 +/- 4.2 mm, p = 0.03). There was no significant increase proximal (24.0 +/- 5.7 mm --> 24.6 +/- 5.3 mm, p = 0.44) and distal to the left subclavian artery (21.4 +/- 4.6 mm --> 21.9 +/- 4.5 mm, p = 0.19). These observations were independent of the presence of arterial hypertension, a previous operation, gender, and functional status of the aortic valve. CONCLUSIONS: The progressive dilatation of the aortic root and ascending aorta that can be observed in patients with BAV was not found in the more distal parts of the thoracic aorta with the exception of the descending aorta in this study. If the dilatation of the descending aorta bears any clinical significance can't be answered with the current data. A prospective study should be performed to confirm these results.

[The current view of surgical treatment of diverticular disease]. / Soucasný pohled na chirurgickou lécbu divertikulární choroby.

AIM: The aim of our prospective dynamic cohort trial is the evaluation of indication for surgery for diverticular disease and the evaluation of morbidity and mortality. MATERIAL AND METHOD: All patients operated for diverticular disease and its complications were involved in the study. The conservatively treated patients were not involved. 104 patients with diverticular disease and its complication were operated from August 2007 till July 2008.46 men and 58 women at average age of 63.9 (31-85) years were in this group. 78 patients were electively operated in noninflammatory stage of diverticular disease. 3 patients of them had colovesical or enterocolical fistulas. An elective laparoscopic colon sigmoid resection was performed by 74 patients and a laparoscopic left hemicolectomy was performed by 4 patients. An end-to-end stapled colorectal suture was performed by all patients. An excision of fistula from urinary bladder and a segment resection of small bowel were performed in the case of fistula presence. In connection with previously repeated diverticulitis attacks or after previous surgeries, adhesiolysis was performed by 23 patients. 26 patients were operated for acute complication of diverticular disease. 24 patients of this group were operated for acute diverticulitis and 2 patients for diverticular bleeding. 23 colon sigmoideum resections, 2 left hemicolectomies, and once ileocecal resection were performed. The primary bowel suture was performed by 20 patients and Hartmaruts operation was performed by 4 patients. RESULTS: The indication for surgery follows the classification according to Hansen and Stock. The abdominal postoperative complications (wound infection, anastomotic leak, prolongated bowel atonia, and others) occurred by elective operated group in 9% and by acute operated group in 26.9%. The overall abdominal postoperative complications occurred in all the involved patients in 13.4%. The extraabdominal postoperative complications (urinary infection or retention, cardiopulmonary complications, trombosis/embolia, postoperative qualitative conscious disorder, renal insufficiency, and others) occurred by elective group in 19.6% and by acute operated group in 50%. Overall extraabdominal postoperative complications occurred in all involved patients in 26.90%. The mortality was 0%. The conversion rate in elective group was 3.8% (3 pts.). An anastomosis leak occurred once (1%) by elective operated patient. An acute reoperation with resection according to Hartmann was performed. A small bowel loop perforation by coincidental adhesiolysis occurred once. A small bowel defect was identified and sutured by early laparoscopic reoperation. The conversion rate in acute group was 23.1% (6 pts.). The colonoscopy was necessary on 3rd day by 1 patient after left hemicolectomy for splenic flexure bleeding. This examination revealed bleeding from diverticulum in hepatic flexure. An endoscopic treatment was performed. An abscess in small pelvis occurred by this patient (12th postoperative day) and open drainage was performed. There was no anastomosis leak in group with acutely operated patients. CONCLUSION: The usage of standard classification is suitable for operation's indication for diverticular disease and its complications. It helps to determine the type and operation's strategy. The acute complicated diveticulitis has high morbidity and mortality. The early indication of selected patients with diverticular disease for elective colon sigmoideum resection protects against possible complication in the case of next attack of diverticulitis. It concerns the patients with recidivated uncomplicated and complicated forms of disease as well. The primary conservative treatment with percutaneous CT navigated drainage allows a postponed elective surgery. The primary resection with suture is better than the two stage surgery. The primary laparoscopic resection is safe procedure in almost all the cases. The primary suture can be safely performed in all elective cases for uncomplicated diverticulitis, chronic fistulas, obstruction, for primarily conservatively treated stages Hinchey I and II and possibly for all the selected patients with Hinchey III and IV stages with MPI lower as 21.

Endothelial microparticles as a diagnostic aid in Churg-Strauss vasculitis-induced cardiomyopathy.

Churg-Strauss Syndrome (CSS) is characterized by allergic rhinitis, asthma and prominent blood and tissue eosinophilia. Although CSS can affect any organ system, isolated cardiac manifestation is a rare feature that is often characterized by rapidly progressive congestive heart failure. We present the case of a 48-year-old woman with acute dyspnoea and chest pain. Her past medical history was significant for asthma and frequently relapsing minimal-change glomerulonephritis. Echocardiogram and coronary angiography revealed cardiomyopathy and coronary small-vessel vasculitis in the presence of blood eosinophilia and elevated IgE. In the absence of infective agents, neoplastic diseases and further vasculitic manifestations, a flow cytometry-based analysis of markedly elevated endothelial microparticles supported the diagnosis of CSS. Cardiomyopathy resolved completely after initiation of immunosuppressive treatment with corticosteroids and cyclophosphamide pulses. Elevated endothelial, leukocytic and platelet-derived microparticles decreased during follow-up and closely paralleled vasculitic activity. Endothelial microparticles might be an additional tool to diagnose and monitor cases of suspected vasculitic cardiac involvement in CSS.

Good manufacturing practice-compliant validation and preparation of BM cells for the therapy of acute myocardial infarction.

BACKGROUND: Intracoronary application of BM-derived cells for the treatment of acute myocardial infarction (AMI) is currently being studied intensively. Simultaneously, strict legal requirements surround the production of cells for clinical studies. Thus good manufacturing practice (GMP)-compliant collection and preparation of BM for patients with AMI was established by the Cytonet group. METHODS: As well as fulfillment of standard GMP requirements, including a manufacturing license, validation of the preparation process and the final product was performed. Whole blood (n=6) and BM (n=3) validation samples were processed under GMP conditions by gelafundin or hydroxyethylstarch sedimentation in order to reduce erythrocytes/platelets and volume and to achieve specifications defined in advance. Special attention was paid to the free potassium (<6 mmol/L), some rheologically relevant cellular characteristics (hematocrit <0.45, platelets <450 x 10(6)/mL) and the sterility of the final product. RESULTS: The data were reviewed and GMP compliance was confirmed by the German authorities (Paul-Ehrlich Institute). Forty-five BM cell preparations for clinical use were carried out following the validated methodology and standards. Additionally three selections of CD34+ BM cells for infusion were performed. All specification limits were met. Discussion In conclusion, preparation of BM cells for intracoronary application is feasible under GMP conditions. As the results of sterility testing may not be available at the time of intracoronary application, the highest possible standards to avoid bacterial and other contaminations have to be applied. The increased expense of the GMP-compliant process can be justified by higher safety for patients and better control of the final product.

Stem cell therapy: a new perspective in the treatment of patients with acute myocardial infarction.

Experimental studies suggest that cardiac transfer of stem and progenitor cells can have a favorable impact on tissue perfusion and contractile performance after acute myocardial infarction (AMI). While the mechanistic background of stem cell therapy is still intensely debated, the concept of cell therapy has already been introduced into the clinical setting, where small, mostly uncontrolled trials indicate that stem cell therapy may be feasible in patients. The overall clinical experience also suggests that stem cell therapy can be safely performed, if the right cell type is used in the right clinical setting. Preliminary efficacy data indicate that stem cells have the potential to enhance myocardial perfusion and/or contractile performance in patients with AMI. The field now is rapidly moving towards intermediate-size, double-blinded trials to gather more safety and efficacy data. Ultimately, large outcome trials will have to be conducted. At the same time, continued basic research to elucidate the underlying mechanism of stem cell therapy is needed.

[Partial k-space sampling with zero filling used with phase-contrast flow measurements: in vivo and in vitro validation]. / Partielle k-Raum-Auslesung mit Null-Interpolation bei Phasenkontrast-Flussmessungen: In-vivo- und In-vitro-Validierung.

PURPOSE: To validate the technique of partial k-space sampling and zero filling with phase-contrast flow measurements as compared to measurements with full k-space sampling. MATERIALS AND METHODS: In vitro: A laminar flow phantom was utilized to evaluate the effect of partial k-space sampling on the accuracy, precision and signal-to-noise ratio of phase-contrast flow measurements. In vivo: The effect of partial k-space sampling on the quantification of cardiac output (n = 40 patients) and the duration of the scan were evaluated in the ascending aorta (n = 37) and pulmonary trunk (n = 34) in a prospective study. RESULTS: Partial k-space sampling resulted in an increase in the SNR by 2 % in vitro. The precision was altered by less than 1 %. Flow volumes were systematically overestimated by 3.5 %. No significant differences were found in the in vivo measurements of cardiac output. The scan duration was reduced by 34 % by utilizing partial k-space sampling. CONCLUSION: Partial k-space sampling can be used to reduce scan time without a significant decrease in the accuracy or precision of phase-contrast flow measurements in large arteries.

Dilatation of the entire thoracic aorta in patients with bicuspid aortic valve: a magnetic resonance angiography study.

BACKGROUND: The presence of a bicuspid aortic valve (BAV) might be associated with a progressive dilatation of the aortic root and ascending aorta. However, involvement of the aortic arch and descending aorta has not yet been elucidated. PATIENTS AND METHODS: Magnetic resonance angiography (MRA) was used to assess the diameter of the ascending aorta, aortic arch, and descending aorta in 28 patients with bicuspid aortic valves (mean age 30 +/- 9 years). RESULTS: Patients with BAV, but without significant aortic stenosis or regurgitation (n = 10, mean age 27 +/- 8 years, n.s. versus control) were compared with controls (n = 13, mean age 33 +/- 10 years). In the BAV-patients, aortic root diameter was 35.1 +/- 4.9 mm versus 28.9 +/- 4.8 mm in the control group (p < 0.01). The diameter of the ascending aorta was also significantly increased at the level of the pulmonary artery (35.5 +/-5.6 mm versus 27.0 +/- 4.8 mm, p < 0.001). BAV-patients with moderate or severe aortic regurgitation (n = 18, mean age 32 +/- 9 years, n.s. versus control) had a significant dilatation of the aortic root, ascending aorta at the level of the pulmonary artery (41.7 +/- 4.8 mm versus 27.0 +/- 4.8 mm in control patients, p < 0.001) and, furthermore, significantly increased diameters of the aortic arch (27.1 +/- 5.6 mm versus 21.5 +/- 1.8 mm, p < 0.01) and descending aorta (21.8 +/- 5.6 mm versus 17.0 +/- 5.6 mm, p < 0.01). CONCLUSIONS: The whole thoracic aorta is abnormally dilated in patients with BAV, particularly in patients with moderate/severe aortic regurgitation. The maximum dilatation occurs in the ascending aorta at the level of the pulmonary artery. Thus, we suggest evaluation of the entire thoracic aorta in patients with BAV.

[Intracoronary ultrasound]. / Intrakoronarer Ultraschall.

IVUS imaging provides a 2-dimensional, cross-sectional view into the lumen and vessel wall structure of coronary arteries; it is superior to angiography with regard to visualization about several aspects of coronary artery disease. IVUS has given important information on the development and progression of coronary atherosclerosis. Moreover, IVUS has improved our understanding of the mechanisms of percutaneous interventions and restenosis. IVUS-guided balloon sizing during PTCA may increase acute lumen gain as compared to conventional angiographic guidance. Optimization of stent implantation by IVUS guidance also results in larger initial lumen gain than with angiographic control; this approach, however, does not reduce restenosis rates. In summary, IVUS is an optional imaging modality that provides clinically useful information in selected patients.

Ascending aortic replacement with aortic valve reimplantation.

BACKGROUND: Reimplantation of the native, structurally intact aortic valve within a Dacron tube graft in patients with aortic root aneurysms corrects annular ectasia and dilatation of the sinotubular junction. The durability of this valve repair with respect to the increased mechanical stress on valve cusps has been discussed, is quite controversial, and is yet unknown. METHODS AND RESULTS: From July 1993 to November 1998, a replacement of the ascending aorta with a repair of the aortic valve was performed in 75 patients (53 men and 22 women aged 50+/-19 years). Twenty-one patients (28%) had Marfan syndrome, and 11 patients (15%) had an aortic dissection, type Stanford A (6 acute, 5 chronic). In 17 patients (23%), concomitant replacement of the aortic arch was necessary. Clinical and echocardiographic follow-up was performed in 6- to 12-month intervals for a cumulative study period of 137 patient-years. No operative deaths occurred. Two patients (3%) died 5 and 20 months postoperatively. One additional patient experienced a transient ischemic attack within the first postoperative week. Three patients (4%) with progressive aortic insufficiency required aortic valve replacement after 9, 11, and 14 months. All other patients had no or mild aortic insufficiency. The repairs have now remained stable for

Arterial hypertension in adults after surgical treatment of aortic coarctation.

Despite primarily successful surgical repair of aortic coarctation (CoA), postoperative persistent, recurring, or newly developing hypertension is regarded as a risk factor of earlier mortality compared with a normal population. The present study shows that even after surgical correction of CoA many patients have hypertension at rest or during exercise. Out of 44 patients, 72% had a pathological profile at rest, 20% during exercise, and 53% during ambulatory blood pressure measurement. Regular checks on blood pressure are therefore necessary, including measurements at rest, during exercise, and under ambulatory conditions. Since these processes yield very different answers they should be combined and evaluated critically for a proper assessment of the blood pressure situation and effective treatment. Ambulatory blood pressure measurement allows the recognition of round-the-clock behavior of blood pressure and of patients with 'occult' or 'white-coat' hypertension, and furthermore it helps to control the effectiveness of the treatment. It thus makes an essential contribution to the postoperative care of patients after surgical treatment of CoA.

Validity of SEP monitoring in carotid surgery. Review and own results.

OBJECTIVE: The sensitivity of intraoperative monitoring by means of somatosensory evoked potentials (SEP) in carotid surgery is to be examined. EXPERIMENTAL DESIGN: Prospective clinical investigation. In addition, the influence of circulatory parameters on SEP curves will also be tested. SETTING: Department of Surgery of a university clinic. MATERIALS AND METHODS: A total of 200 patients underwent intraoperative monitoring by means of somatosensory evoked potentials (SEP) during carotid endarterectomy between March 1, 1991 and August 1, 1994. MEASURES: In order to exclude blood pressure variations as a cause for amplitude changes the blood pressure and pulse were documented during the entire phase of preparation and clamping. RESULTS: A significant correlation could not be established between parameters of circulation and amplitude changes (r = 0.0026; p = 0.62). In seven cases of intraoperative amplitude reduction of more than 50% a stroke has been avoided by inserting a shunt. Despite the lack of an amplitude reduction, a watershed stroke of A.cerebri media and A.cerebri posterior occurred in two instances. Taking this into consideration the sensitivity of monitoring is 99.0% at a specificity of 100%. CONCLUSIONS: SEP-monitoring in carotid endarterectomy is simple to execute and is superior in sensitivity to EEG analysis. To avoid artefaction by anesthesia, a standard injection anesthesia is recommended. Farfield potentials should also be derived to avoid watershed infarctions.

[Atresia of the left-sided atrioventricular connection with single ventricle and transposition of great vessels in a adult patients]. / Atresie der linksseitigen atrioventrikulären Verbindung mit singulärem Ventrikel und Transposition der grossen Arterien bei einer erwachsenen Patientin.

Mitral atresia is an extremely rare congenital anomaly in which survival into adulthood is an exception. Without treatment most patients with this anomaly will die in early childhood and only few reach adolescence or early adulthood. The here described patient with mitral atresia, atrial septal defect, single ventricle and transposition of the great arteries survived to age 24 years. She died as consequence of massive cerebral embolism of a thrombus in her left atrium.

[Evaluation of the aorta and supra-aortic vessels with spiral CT and 3-dimensional vascular reconstruction after operation of aortic isthmus stenosis]. / Beurteilung von Aorta und supraaortalen Gefässen mittels Spiral-CT und dreidimensionaler Gefässrekonstruktion nach Operation einer Aortenisthmusstenose.

Aneurysm formation, restenosis, and hypertension are well known complications after surgery for coarctation of the aorta (CoA). In order to assess long-term results, 46 patients were studied by spiral computed tomography and three-dimensional reconstruction after an interval ranging from 1 to 21 years (median 10 years) after surgery for coarctation. Spiral computed tomography showed pathological changes of the aorta in the majority of patients. Typical findings were ectasy or aneurysm formation of the ascending aorta, hypoplastic aortic arch, ectasy or aneurysm formation of the supraaortic vessels, circumscript aneurysm of the descending aorta at the side of surgery, restenosis of the descending aorta and malformations and anomalies of arterial vessels. In order to initiate adequate treatment of such specific complications as restenosis, aneurysm and/or arterial hypertension, regular controls are necessary in patients after surgery for aortic coarctation. In addition to clinical examination and besides magnetic resonance imaging and angiography, spiral computed tomography is an effective non-invasive imaging method for follow-up.

Islet isolation and autotransplantation in pigs.

Despite recent considerable progress in the isolation and purification of porcine pancreatic islets the final proof of functional integrity has not yet been performed. In the present study the feasibility, technical problems and posttransplant metabolic function of islet transplantation in the pig were investigated. Intraductal collagenase perfusion technique for islet preparation was used in 27 landrace pigs and eight minipigs followed by intraportal or intrasplenic transplantation of the islets. Islet purification was performed by dextran gradient in six preparations. Islet quantification, portal vein pressure measurements, intra- and postoperative complications and postoperative graft function were monitored. Between 1.73 x 10(5) and 11.4 x 10(5) islet containing fragments (8.23 x 10(3)-54.28 x 10(3) islet containing fragments/kg recipient body weight) were transplanted. Portal vein thrombosis occurred in 4 animals with significantly elevated portal pressure (p = 0.0001). 11 of 27 landrace pigs died due to postoperative complications. None of the minipigs was lost due to perioperative mortality (p = 0.031). Four of eight landrace pigs with intrasplenic grafts (50%) were normoglycemic and two of eight landrace pigs with intrahepatic transplants (25%) were normoglycemic. In minipigs two out of four (50%) with intrasplenic transplants and two of four (50%) with intraportal transplants were normoglycemic. The results in glucose metabolism as measured with intravenous glucose tolerance tests and calculated by K-values were statistically significantly different between normoglycemic and hyperglycemic animals (landrace pigs p = 0.0002 and minipigs p = 0.0005). Longevity was prolonged in normoglycemic animals as compared to hyperglycemic and apancreatic animals. It is concluded that successful islet isolation and transplantation is feasible in the landrace pig and the minipig while the landrace pig appears to be more susceptable to perioperative mortality.

[Adverse effects of a new non-ionic contrast medium in heart catheterization]. / Verträglichkeit eines neuen nichtionischen Kontrastmittels bei Herzkatheteruntersuchungen.

Tolerance of a New Non-ionic Contrast Medium during Heart Catheterization The new non-ionic contrast medium iomeprol (CAS 78649-41-9) was investigated for adverse reactions and diagnostic quality in 75 patients undergoing heart catheterization. Blood pressure and ECG were continuously registered. The patients were asked for subjective complaints by using a standardized questionnaire. Experienced cardiologists assessed the diagnostic quality of the angiograms. With iomeprol neither fatal nor severe reactions were observed. The dye had only little influence on diastolic and systolic blood pressure; heart rate was not significantly influenced. Minor and partly moderate adverse reactions all being completely reversible were observed in 14 patients (18.7%). One patient complained of strong heat sensation after dye injection into the left ventricle. The diagnostic quality of the angiograms allowed to make a definitive diagnosis in all cases. Thus, iomeprol proved to be a suitable and safe contrast medium for heart catheterization.

Pharmacokinetics of ciprofloxacin in elderly patients.

For perioperative prophylaxis 200 mg ciprofloxacin were administered as a short intravenous infusion to 17 patients aged 57-84 years before transurethral resection (TUR-P) or transvesicular enucleation (TVP) of the prostate. 13 patients were injected simultaneously with 2.5 g ioxitalamic acid i.v. to determine the kidney function. In 11 patients the plasma concentrations were assayed and the pharmacokinetic parameters calculated. At the end of infusion the concentrations of ciprofloxacin in plasma reached 4.2 +/- 0.8 microgram/ml and decreased after a fast distribution period (plasma half-life 0.20 +/- 0.09 h) with a terminal half-life of 4.2 +/- 1.3 h to 0.2 +/- 0.09 microgram/ml after 10 h. The apparent volume of distribution in steady state was 183 +/- 45% of body weight, the plasma clearance 457 +/- 146 ml/min/70 kg. The average concentrations in prostatic adenoma tissue were at all sampling times higher (2fold) than in plasma. The mean concentrations in prostatic secretion were about half of the respective plasma concentrations. High concentrations of the concomitantly administered ioxitalamic acid in prostatic secretion are considered as an indicator of urinary contamination. In those patients high ciprofloxacin concentrations in prostatic secretion are not reliable.