[Perioperative antocoagulation in patients with prosthetic heart valves: recommendations]. / Perioperatives Gerinnungsmanagement bei Patienten mit Kunstklappen : Empfehlungen.

Lifelong anticoagulation, mainly with oral Vitamin K antagonists, represents the treatment of choice in patients with prosthetic heart valves to prevent thrombembolic complications. As a result, anticoagulant-related complications like excessive bleeding during interventions or surgical procedures will occur. Therefore, timely stopping of vitamin K antagonists prior to elective surgery is mandatory. However, based on the long half-life of all common vitamin K antagonists, interruption of oral anticoagulation will definitively lead to an increase of thrombembolic events. Hence, adequate bridging anticoagulation by temporary substitution of this therapy with heparin is necessary. This article gives a recommendation on the basis of the American College of Chest Physician and European Society of Cardiology current.

Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW.

BACKGROUND: In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant. METHODS: Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed. RESULTS: In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones. CONCLUSIONS: A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

[Aortic rupture after blunt chest trauma. Rapid diagnosis using transesophageal echocardiography when radiographic and computed tomographic findings are unclear]. / Aortenruptur nach stumpfem Thoraxtrauma. Rasche Diagnose durch transösophageale Echokardiographie bei unklarem Röntgen- und CT-Befund.

HISTORY AND CLINICAL FINDINGS: A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. On arrival of the emergency physician she was awake and responsive but complained of pain with bruising over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg, heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lungs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. INVESTIGATIONS: The ECG showed sinus tachycardia (103 beats/min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/dl with normal white cell and platelet counts. Clotting tests, serum transaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. TREATMENT AND COURSE: Because the haemoglobin level had fallen to 7.7 g/dl within the first 4 hours erythrocytes concentrate was infused. The chest radiogram and subsequent computed tomography showed a mediastinal and paraaortic haematoma of unclear origin. Transoesophageal echocardiography (TEE) demonstrated rupture of the descending aorta with free floating intraluminal parts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler echocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed and part of the descending aorta was replaced by a 3 cm dacron tube during an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other injuries were treated. CONCLUSION: After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once provide details of extent and degree of injury to heart and/or aorta.

[Suppurative abscess-forming mediastinitis after tooth extraction. Consequences for therapeutic approach]. / Eitrig abszedierende Mediastinitis nach Zahnextraktion. Konsequenzen für das therapeutische Vorgehen.

Purulent mediastinitis is a rare but serious complication of a descending odontogenic infection with a high mortality. Diagnosis is difficult and frequently delayed. Physical examination is often nondiagnostic, but may include pronounced edema of the neck and chest. CT scan is the single most important tool for early diagnosis. The treatment is always is surgical, in combination with an extremely high dose of combined antibiotics. Ultimately, we only could save our patient with this therapy.