[Cardiogenic shock following yew needle poisoning : Digoxin immune fab, va-ECMO and albumin dialysis for the treatment of a suicidal yew leaf poisoning]. / Kardiogener Schock nach Eibennadelintoxikation : Digitalisantidot, va-ECMO und Albumindialyse in der Therapie der suizidalen Eibennadelintoxikation.

We present the case of a 46-year-old male who developed refractory bradycardia with cardiogenic shock after attempting suicide by ingestion of yew leaves. Due to delayed availability of the Digoxin immune fab, a va-ECMO was established to maintain sufficient circulation. Administration of the digoxin fab resulted in recovery of spontaneous circulation. Continuous venovenous hemodiafiltration with hemoadsorption and albumin dialysis were initiated with the intention to remove immune fab-toxin complexes and as organ support in acute kidney and liver failure. Within 5 days the patient was successfully weaned from ECMO, liver support and renal replacement and discharged without physical sequelae.

Surgery for acquired cardiovascular disease: antiseptic treatment of contaminated vein grafts.

AIM: Saphenous vein grafts harvested for use as bypass conduits can be contaminated intraoperatively, e.g. by being inadvertently dropped to the floor of the operating room (OR). This study was performed to investigate microorganisms most likely contaminating vein grafts and to assess the possible efficacy of measures to treat potentially contaminated vein grafts antiseptically for further use. METHODS: In a first step we determined the microbiological flora of the OR using surface cultures and cultures from intentionally dropped vein grafts. Several antiseptic agents (PVP-iodine 10%, octenidinhydrochloride 0.1%, polyhexanide 1%) were evaluated for their in vitro efficacy to disinfect artificially contaminated vein segments. The most promising antiseptic regimen was tested on veins contaminated in a real OR setting. Finally, we tested for possible alterations in mechanical properties of the veins caused by antiseptic treatment. RESULTS: Coagulase-negative staphylococci where the predominant bacteria recovered from the OR with 59.9%. Antiseptic treatment with a combination of octenidine and PVP-iodine resulted in a higher rate of negative cultures than any single agent. Treatment of 50 saphenous vein grafts contaminated in the OR with the combination regimen resulted in only 3 positive cultural results within 7 days. Mechanical tear-stress testing comparing antiseptically treated vein grafts with controls showed no difference in their resistance to tear stress. CONCLUSION: Antiseptic treatment of contaminated vein grafts was shown to be effective in a high percentage of cases without altering mechanical properties of grafts and may be an option for the surgeon in case of a contamination.

Anomalous origin and retropulmonary course of an atherosclerotic stenosed left circumflex coronary artery.

We here present the case of a rarely seen anomalous origin and retropulmonary course of the left circumflex artery from the proximal right coronary artery. The patient suffered from coronary ischemia due to stenotic lesions both in the aberrant circumflex coronary artery and in the first and second diagonal branches. Coronary bypass operation was performed.

Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic replacement and endovascular repair.

BACKGROUND: The aim of our study was to analyze the neurophysiological monitoring method with regard to its potential problems during thoracic and thoracoabdominal aortic open or endovascular repair. Furthermore, preventive strategies to the main pitfalls with this method were developed. METHODS: Between 11/2000 and 05/2007 in 97 cases open surgery or endovascular stentgraft-implantation was performed on the thoracic or thoracoabdominal aorta. Intraoperatively, neurophysiologic motor- and somatosensory-evoked potentials were monitored. RESULTS: Our cases were divided into four groups: event-free patients with normal potentials (A, 63 cases), with correlation of modified evoked potentials and neurological outcome (B, 14 cases), false-positive or false-negative results (C, 4 cases), and medication interaction or technical issues (D, 16 cases). We observed a sensitivity of 93 % and a specificity of 96 % for the neurophysiological monitoring. CONCLUSIONS: Monitoring spinal cord function during surgical and endovascular interventions on the thoracic and thoracoabdominal aorta is necessary. It can be made more effective by precisely analyzing the interference factors of the neurophysiological monitoring method itself. Successful strategies of immediate troubleshooting could be identified.

Reevaluation of two techniques of harvesting the skeletonized internal mammary artery.

BACKGROUND: Selective skeletonization of the internal mammary artery (IMA) without adjacent vasculo-muscular structures reduces trauma to the chest wall, results in elongated grafts, makes ideal graft positioning possible, and eliminates the need to implant a dissected or hypoplastic graft with direct visual control of the vessel. We compared two techniques of skeletonizing the IMA in a prospective randomized trial. METHODS: 51 IMAs were randomly harvested and divided into two groups according to the technique of skeletonization. In group I (n = 31), IMAs were harvested in a skeletonized fashion with the Harmonic Ultrasonic scalpel, and in group II (n = 20) using scissors and hemostatic clips. We compared arterial wall histology, harvesting time, spasm frequency, and the use of hemostatic clips between the two groups. RESULTS: There were no significant morphological differences in the arterial wall in the two groups. Use of an ultrasonically-activated scalpel reduced the IMA's harvesting time (p < 0.001), the frequency of spasm (p = 0.01), and the use of hemostatic clips (p < 0.001). CONCLUSIONS: Ultrasonic harvesting of a skeletonized IMA is a non-traumatic preparatory technique that reduces the costs of surgical clips and that can be performed safely and quickly.

Early detection of sternal dehiscence by conventional chest X-ray.

BACKGROUND: Diagnosis of sternal dehiscence after sternotomy for cardiac surgery is still made clinically. The aim of this study was to identify radiographic signs of sternal dehiscence by routine chest X-ray (CXR) in patients with and without clinically diagnosed sternal dehiscence. METHODS: 75 patients (group I: 65 +/- 9.3 years, f/m = 12/63) with clinically diagnosed sternal dehiscence, necessitating surgical revision and 75 patients with uneventful sternal healing (matched to group I by age, sex, preoperative risk factors and surgical procedures; group II: 66 +/- 9.0 years, f/m = 12/63) were included in this study. Serial CXRs immediately after surgery until re-intervention or discharge were analyzed by a radiologist, blind to the date of redo surgery. RESULTS: In 39 patients of group I (52%) vs. 8 (10.7%) in group II, abnormalities in the sternal wire and/or a midsternal stripe could be found (p < 0.0001): rotated wires (p = 0.003), shifted wires (p = 0.043), and ruptured wires (p = 0.312). Seven patients presented with combined wire abnormalities in group I vs. 0 in group II. Midsternal stripe sign could be detected in 26 patients of group I vs. 3 in group II (p < 0.0001). Sternal dehiscence was suspected based on the above mentioned abnormalities as early as three days postoperatively (Q1 = 2; Q3 = 8 days) in 39 patients, whereas clinical diagnosis of sternal dehiscence was delayed up to ten days postoperatively (Q1 = 7; Q3 = 13 days). CONCLUSIONS: Radiographic signs of sternal dehiscence could be detected before the clinical diagnosis was apparent and predicted sternal dehiscence in more than half of the patients.

Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications.

BACKGROUND: Median sternotomy is the most frequently used incision for cardiac procedures but carries a substantial risk for deep sternal wound infections and/or sternal dehiscence. In contrast to previous studies that examined risk factors for sternal infections this study evaluates factors that lead to poor outcome after surgical revision of the non healing sternum. METHODS: Between 1985 and 1999, 193 adults (mean age 64 +/- 9 years, m/f = 3/1) necessitated sternal revisions (incidence 1.93%). Pre-, intra- and post-operative risk factors were evaluated for their influence on the outcome after sternal revision. RESULTS: 65 of the 193 patients had a complicated course: ten (5.2%) died due to sepsis/multi organ failure (n = 6) or cardiac causes (n = 4). 32 patients (16.6%) needed several revisions, 17 (9%) were discharged with sternal instability, 5 (3%) with chronic fistula and one with persistent osteomyelitis. Univariate and multivariate analysis identified cardiopulmonary resuscitation (odds ratio (OR) = 11.188, p = 0.010), corticoid treatment (OR = 7.043, p = 0.0055), diabetes (OR = 4.130, p = 0.0128), smoking history (OR = 2.996, p = 0.0041), renal insufficiency (hazard ratio (HR) = 1.884), old age (OR = 1.108, p = 0.0266), high body mass (HR = 1.06), ECC time (p = 0.023), cross clamp time (p = 0.028), systemic hypothermia (p = 0.016), non-use of IMA (p = 0.042) or prolonged ventilation as risk factors for mortality or poor outcome. No correlation between sternal closure technique, mediastinal irrigation or antibiotic therapy and outcome after mediastinal revision could be found. CONCLUSIONS: To avoid disappointing results after sternal revision one should aim to preoperatively identify high-risk patients and aggressively address risk factors. This rather than modifications of the surgical and medical approach might improve the outcome of patients with mediastinal complications.

[Coronary revascularization: off-pump versus on-pump--a comparison of behavior of biochemical cardiac ischemia markers]. / Koronarrevaskularisation: Off-pump versus On-pump--Verhalten der biochemischen kardialen Ischämiemarker im Vergleich.

BACKGROUND: Recently, coronary artery bypass grafting (CABG) on the beating heart with avoidance of extracorporeal circulation (off-pump CABG technique) has been gaining increasing importance in modern cardiac surgery. The object of this prospective study was to compare postoperative kinetic and patterns of cardiac troponin I (cTnI), T (cTnT), and creatine kinase MB (CKMB) activities after off-pump CABG versus conventional on-pump CABG. METHODS: We studied 106 patients who underwent first-time elective on-pump (group I, n = 69, 56 male, 13 female, mean age: 64.3 +/- 9.9 years, mean ejection fraction: 56 +/- 15%) or off-pump (group II, n = 37, 24 male, 13 female, mean age: 68.4 +/- 9.1 years, mean ejection fraction: 57 +/- 13%) CABG surgery via median sternotomy. CTn I and cTnT levels, total creatine kinase (CK) and CK-MB activities in the serum were measured before operation, up on arrival at the ICU and 6, 12, 24, 48 and 120 hours later. Serial 12-lead ECGs were recorded preoperatively and on days 1, 2 and 5. RESULTS: Serum concentrations of cardiac troponins in all patients were preoperatively either not detectable or in the normal range and significantly increased after surgery. In group I, one patient developed a Q wave myocardial infarction, one patient a non-Q wave infarction and two patients a new left bundle branch block on the ECG. One patient of group II developed a new Q-wave myocardial infarction and another patient permanent atrial fibrillation associated with a continuous arrhythmia. All patients with a myocardial infarction in the ECG showed significant elevation of concentrations or activities of these biochemical markers. The median postoperative peak values for cTnI were measured at 24 h in both groups (2.7 micrograms/l, 95%-CI: [2.2, 3.2] in group I and 1.1 micrograms/l, 95%-CI: [0.5, 1.3] in group II). CTnT postoperatively presented an earlier median peak of 0.128 microgram/l at 12 h in group II (95%-CI: [0.041, 0.146]) than in group I at 48 h (0.298 microgram/l, 95%-CI: [0.254, 0.335]). CONCLUSIONS: All patients undergoing CABG surgery with or without extracorporeal circulation postoperatively showed an increase of cardiac troponin levels. After uncomplicated coronary revascularization, patients with the off-pump CABG technique continuously presented lower serum cardiac troponin concentrations than those with the on-pump CABG technique. CTnI showed the same patterns of release in both groups with different median postoperative peak values at 24 h. The patterns off cTnT release following CABC surgery with or without extracorporal circulation were different: CTnT reaches its postoperative peak value in patients with the off-pump CABG technique earlier than those with the on-pump CABG technique (12 h postoperatively versus 48 h).

Patterns and diagnostic value of cardiac troponin I vs. troponin T and CKMB after OPCAB surgery.

BACKGROUND: Cardiac troponin I (cTnI) has been shown to be a specific marker for myocardial injury in cardiac surgery. The object of this prospective study was to determine the patterns and kinetic and diagnostic value of cTnI, cardiac troponin T (cTnT), and creatine kinase MB (CKMB) activity after minimally invasive coronary revascularization using an octopus device on the beating heart (OPCAB). METHODS: 48 patients (33 male/15 female, mean age 68.3 +/- 8.7 years) underwent their first elective OPCAB surgery with median sternotomy without mortality. The mean number of grafts was 2.0 +/- 0.8 per patient. Preoperative mean ejection fraction was 56.6 % +/- 14.9%. CTnI and T levels, total creatine kinase (CK) and CK-MB activity in the serum were measured before operation, at arrival at the ICU, and 6, 12, 24, 48 and 120 hours afterward. Serial 12-lead ECGs were recorded preoperatively and at days 1, 2 and 5. The relationship between perioperative data and postoperative cTnI and cTnT levels and CKMB were statistically identified for all variables. RESULTS: The best cutoff value for cTnI was 8.35 micrograms/l. The patients were grouped by the ECG findings and maximal slopes of cTnI postoperatively (group I: unchanged ECG and cTnI < 8.35 micrograms/l, n = 38; group II: unchanged ECG and cTnI > 8.35 micrograms/l n = 6; group III: Q-wave in ECG and cTnI > 8.35 micrograms/l, n = 4). Baseline serum concentrations of cTnI were in the normal range, and significantly increased after surgery with a peak 24h after the operation. Maximal slopes of cTnI ranged in group II between 9.1 and 18.0 micrograms/l, and in group III between 35.9 and 88.8 micrograms/l. There was strong concordance between maximum cTnI, cTnT (p < 0.0001) and CK-MB levels (p = 0.003). First cTnI levels immediately post-op correlated with the maximum cTnI levels during the postoperative course (p = 0.009). CONCLUSIONS: CTnI after minimal invasive surgery shows a characteristic pattern with a maximum at 24h after the operation. The measurement of postoperative biochemical marker concentrations, specially cTnI, reflects myocardial injury incurred during the procedure. It is an accurate method for confirming or excluding a perioperative myocardial injury diagnosis after OPCAB surgery.

Comparison of diagnostic performance of cardiac troponin I on the IMMULITE system with other automated troponin I assays in minor myocardial damage.

An analytical and clinical evaluation of cardiac troponin I (cTnI) on the IMMULITE system is presented. The assay results were compared with those of the Stratus II and the Dimension RxL-HM. A between-run imprecision CV < 20% was found at a cTnI concentration of 0.23 microg/L (functional limit of detection). On the basis of a reference study including 215 patients without ischemic heart disease (97.5th percentile: 0.294 microg/L) and 36 patients clinically classified as having stable angina pectoris (<0.22 microg/L) a preliminary cutoff level of 0.3 microg/L was defined. Assay linearity, sample stability, influence of sample material and method comparison studies were performed. In patients with Duchenne's disease, chronic hemodialysis treatment, pulmonary embolism, coronary artery bypass surgery and minimally cardiac surgery the cTnI results of the IMMULITE agreed better with the Dimension RxL-HM than with the Stratus II data. Of 142 samples from patients with unstable angina 67 samples were classified as cTnI positive with the IMMULITE, 76 with the Dimension RxL-HM, and 62 with the Stratus II. In conclusion, the new assay is sensitive for the determination of cTnI and easy to perform within 45 min.

Postoperative patterns and kinetics of cTnI, cTnT, CK-MB-activity and CK-activity after elective aortic valve replacement.

OBJECTIVES: The aim of this prospective study was to evaluate postoperative kinetics of four different biochemical ischaemic markers after elective aortic valve replacement (AVR). Additionally, pre-, peri- and postoperative data were analysed in order to identify factors with possible impact on the postoperative release of the selected enzymes. DESIGN: Forty patients (14 males, 26 females, aged 70 +/- 11 years; EF = 54 +/- 18% [mean +/- SD]) undergoing elective AVR were prospectively included in this study. For all patients, serum concentrations of cTnI, cTnT, and serum activities of CK-MB and CK were measured preoperatively as well as 0, 6, 12, 24, 48 and 120 hours after removal of the aortic cross-clamp. Clinical data were assessed in all patients and correlated with postoperative enzyme patterns. RESULTS: There were no major complications. Preoperatively, all patients showed enzyme values in the normal range whereas the four ischaemic markers reached higher values postoperatively. cTnI reached its maximum values 24 hours (XMed = 2.35 micrograms/L, 95%-CI [2.0, 3.3]) and cTnT 48 hours after the operation (XMed = 0.239 microgram/L, 95%-CI [0.174, 0.283]). Typical biphasic release kinetics could be demonstrated for cTnT. There was a high linear correlation between cTnI and cTnT at all sampling times. In contrast, a high linear correlation between cTnI, cTnT, and CK-MB-activity was only found 48 hours after aortic unclamping. cTnI nearly was in normal range 120 h postoperatively (XMed = 0.5 microgram/L, 95%-CI [0.2, 0.6]), whereas cTnT still remained pathologically elevated (XMed = 0.223 microgram/L, 95%-CI [0.137, 0.299]). No linear correlation was found between maximum values of the ischaemic markers postoperatively and age, gender, body surface area, ejection fraction, LV-hypertrophy, operating time, ECC time, time of cardiac arrest, lowest body temperature, perfusion pressure, cardioplegia volume, reperfusion time, postoperative septiformic circulatory instability, or ventilation time. CONCLUSIONS: All four ischaemic markers showed individual peak characteristics and kinetics after uncomplicated AVR. In contrast to previous findings, aortic cross-clamping time had no detectable impact on postoperative peak patterns of any ischaemic marker.

Troponin I concentrations of shed blood might influence monitoring of myocardial injury after coronary operations.

In a prospective study we evaluated the concentration of cardiac troponin I (cTnI) and creatine kinase activities (CK) in shed mediastinal blood in the early postoperative period after coronary artery bypass grafting (CABG). Forty seven patients who underwent first time elective CABG were studied. CTnI levels and CK activities in arterial blood and shed mediastinal blood were measured after admission to the intensive care unit (ICU) and 6 h after unclamping the aorta. Mediastinal shed blood samples were drawn from 23 patients (group A) before the filter of the cardiotomy reservoir and from 24 patients (group B) behind. Additionally, both markers were measured in blood samples collected from the cell-saver. There were no significant differences between both groups (A and B) with regard to perioperative parameters. Mean loss of mediastinal shed blood in all patients was 207 +/- 127 ml within the first 6 h after operation. There was a positive correlation between CK activities and cTnI concentrations in serum and mediastinal shed blood, but shed blood contained significantly higher concentrations of cTnI as well as CK activities than the circulating blood after admission to the ICU and 6 h after unclamping the aorta. At both time points the cTnI-concentrations and CK activities in shed blood in group B were lower than those in group A but much higher than in serum. The effects of the use of a blood filter diminishes with time. Mediastinal shed blood contains extremely high cTnI concentrations and CK activities. Retransfusion of higher quantities of shed blood might lead to false-positive diagnosis of perioperative myocardial infarction.

Analytical and clinical evaluation of troponin I determination on dimension RXL-HM.

The evaluation of cardiac troponin I (cTnI) on the Dimension RxL-HM analyzer is presented. The one-step enzyme immunoassay is based on two cTnI specific monoclonal antibodies. Performed on a separate module of the analyzer, assay-time is 17 minutes. Using as criterion a between-run impression CV <20% the functional limit of detection was set at 0.1 microg/l. Cutoff level for minor myocardial damage of 0.1 microg/l was found. In Duchenne's dystrophy, patients showed increased cardiac Troponin T (cTnT) but no increased cTnI. In patients with a history of coronary heart disease undergoing chronic hemodialysis, cTnT and cTnI were increased. In different patients with submassive pulmonary embolism, increased cTnI was determined. In coronary artery bypass surgery without perioperative myocardial infarction, patients with extracorporeal circulation showed significantly higher cTnI at 24 h after surgery than those with minimal cardiac surgery. In patients with unstable angina, increased cTnI was found more often than on Stratus analyzer. In conclusion, the new assay is a very sensitive cTnI assay, fast and easy to perform in parallel to enzyme and substrate assays.

[Aneurysm of the ductus arteriosus Botalli]. / Aneurysma des Ductus arteriosus Botalli.

A congenital aneurysm of the ductus arteriosus Botalli was detected by chest X-ray as an intrathoracic mass in a 7-day-old infant. Following confirmation of the diagnosis by echocardiography and MRI the aneurysm was successfully resected via left lateral thoracotomy without cardiopulmonary bypass. The postoperative course was uneventful. Six years after operation the patient is asymptomatic and growing normally. An intrathoracic mass may be considered in the differential diagnosis especially in infants and children. Aneurysms of ductus arteriosus potentially are associated with serious complications. Timely diagnosis and early surgical intervention are decisive for prevention of serious complication and death.

[Surgical treatment of hypoplastic left heart syndrome: experience with staged palliative reconstruction]. / Chirurgische Behandlung des hypoplastischen Linksherzsyndroms. Erfahrungen und Ergebnisse mit der herzerhaltenden palliativen Rekonstruktion.

Hypoplastic left heart syndrome (HLHS) represents an anatomical spectrum of congenital disease with varying degrees of underdevelopment of the left-sided cardiac structures (Figure 1). The outlook for children born with HLHS, an otherwise highly lethal malformation, has improved with increasing experience with reconstructive techniques. This report represents a detailed analysis of the overall risk and mid-term results for a group of 39 consecutive neonates with HLHS referred to our hospital over a 5-year period between January 1994 and November 1998. Twenty-six patients were treated with a Norwood reconstructive procedure (Figure 2). One patient received a cardiac transplant at the request of the parents. Another patient with aortic atresia, ventricular septal defect and normal left ventricle underwent biventricular repair. Eleven patients were not eligible for surgical treatment due to a number of reasons (Table 1). In 26 neonates (9 girls, 17 boys; mean age 9.1 [4 to 42] days) staged reconstruction by Norwood's procedure was performed. The hospital mortality in the first stage of the Norwood procedure was 23% (6/26). Sixteen of the 20 long-term survivors underwent the bidirectional cavopulmonary anastomosis (hemi-Fontan; Figure 3) at a median age of 7.6 (3 to 14) months. All children survived. Up to now, 3 infants received the complete Fontan operation (Figure 4) at 2 years of age. No late death occurred. In 18 out of the 20 survivors neuro-developmental outcome and exercise performance were within the range of normals. Staged surgical palliation represents a realistic therapeutic option for neonates born with HLHS. At this intermediate stage of follow-up exercise performance and quality of life are satisfactory.