Post-transfusion hepatitis and its association with pooled clotting factors.

A prospective study of post-transfusion hepatitis was conducted in 97 adult patients undergoing open heart surgery. Twelve patients developed presumed non-A, non-B hepatitis (five of these were hospitalized and three were jaundiced), and all 12 had received clotting factors from pooled plasma (fibrinogen, factor VIII, factor IX complex) from different manufacturers. Of the remaining 85 patients none received these high risk plasma derivatives and none developed hepatitis. Multiple peak ALT elevation seems to be an indication of development of chronic non-A, non-B hepatitis. In addition to the 12 cases of presumed non-A, non-B hepatitis, nine cases of serological changes related to hepatitis B virus were observed as follows: six early booster reactions of anti-HBs, but not anti-HBc, in anti-HBs and anti-HBc positive persons; one late immunization-like response for anti-HBs and two serological hepatitis B infections without transaminase elevation. Five of the nine cases were also associated with the administration of pooled clotting factors.

Clinical comparison between membrane and bubble oxygenators in cardiopulmonary bypass.

The clinical course of two similar patient groups was compared in whom, during cardiopulmonary bypass, a membrane or bubble oxygenator was employed. According to our results there is no significant functional difference between the two types of oxygenators as long as the perfusion time does not exceed 90 minutes. Beyond this time limit, the membrane oxygenator has distinct advantages, particularly with regard to hemolysis. We presently prefer the bubble oxygenator. The use of a membrane oxygenator is restricted to complex open heart procedures with suspected technical problems.

[Behaviour of ATP and lactate in human papillary muscle during profound hypothermia and injection cardioplegia with magnesium-asparatate-procaine (author's transl)]. / ATP- und Laktatgehalt des menschlichen Papillarmuskels bei tiefer Körperhypothermie und Injektionskardioplegie mit Magnesium-Aspartat-Procain.

In 53 patients with mitral- or aortic-mitral valve disease, the content of ATP and lactate of the papillary muscles resected at the time of valve replacement was investigated at the beginning of ischemic arrest and at the time of reperfusion. Profound body hypothermia (25 degrees C) and injection cardioplegia using magnesium-aspartate-procaine were applied for myocardial protection. In hypertrophic papillary muscles the myocardial ATP content decreased at a slower rate (ATP decay 12% of the initial value after 60 minutes of ischemia) than in normal papillary muscles obtained from patients with isolated mitral stenosis (ATP decay 33% of the initial value after 40 minutes of ischemia). 20% of the patients required temporary inotropic circulatory support postoperatively for 12 to 88 hours. The ATP content of the papillary muscles of these patients differed only little from those, in who no myocardial failure occurred. However the myocardial lactate levels were higher in patients in whom a low cardiac output state evolved.

[Monitoring myocardial performance after open heart surgery by calculation of diastolic and systolic pressure time index (author's transl)]. / Uberwachung der Myokardfunktion nach offenen Herzoperationen durch Messung des diastolischen und systolischen Druck-Zeit-Index.

In order to determine the incidence of subendocardial ischemia after open heart surgery, subendocardial blood flow was monitored in 171 patients subjected to mitral and/or aortic valve replacement or coronary revascularization by on-line calculation of Diastolic (DPTI) and Systolic Pressure Time Index (TTI). Body hypothermia with an esophageal temperature of 25 degrees C and magnesium-aspartate-procaine cardioplegia were applied for myocardial protection. Ten patients developed low cardiac output state with two early deaths. In the two patients with fatal low cardiac output DPTI/TTI remained below 0.8. In the remaining 8 patients DPTI/TTI rose to 1.4 after a mean recovery time of 36 hours. In 161 patients (94%) no low cardiac output state evolved and DPTI/TTI rose to 1.3 within 60 min. after termination of cardiopulmonary bypass. Our results indicate that body hypothermia of 25 degrees C combined with magnesium-aspartate-procaine cardioplegia can reduce the incidence of subendocardial ischemia, but does not prevent this complication completely after anoxic times beyond 60-70 minutes.

Estimation of adequate subendocardial blood flow by online computation of systolic pressure time index and diastolic pressure time index after cardiopulmonary bypass.

Subendocardial perfusion was monitored in 48 patients subjected to valve replacement by calculation of diastolic pressure time index (DPTI), systolic pressure time index (TTI) and DPTI/TTI. An on-line computer which derives these values from the systemic pressure and wave-form was applied. For myocardial protection general body hypothermia (esophageal temperature 25 degrees C) and hypothermic injection cardioplegia were employed. No low cardiac output state occurred and no inotropic drugs were required. In all patients DPTI/TTI rose above 1 within 60 minutes from termination of cardiopulmonary bypass so that the necessity to intraaortic balloon counterpulsation could be denied in all cases. We believe that the calculation of DPTI/TTI after extracorporeal circulation is a useful modality to predict the adequacy of subendocardial perfusion and monitor myocardial performance.

[Myocardial protection utilizing hypothermia and cardioplegin during surgical correction of congenital heart disease (author's transl)]. / Myokardschutz mit Hypothermie und Cardioplegin bei der Operation angeborener Herzfehler.

Our methods of myocardial protection are demonstrated in 846 patients subjected to open heart surgery for correction of congenital heart disease. They include body hypothermia and injection cardioplegia using magnesium-asparate-procaine. The spectrum of myocardial protection reaches from normothermia without cardioplegic arrest during short periods of extracorporeal circulation to profound body hypothermia with multiple injections of the cardioplegic solution in complex cardiac malformations. The results in 586 patients with left to right shunt, 140 patients with cyanotic cardiac malformations and 120 patients with congenital valve lesions are presented. Attention is directed to possible negative sequelae of overdosage of magnesium-asparate.

Combined application of metabolic myocardial arrest and general profound hypothermia in aortic valve replacement.

To determine the value of general hypothermia in combination with magnesium-aspartate-procaine induced metabolic myocardial arrest, the surgical results of 2 similar groups of patients subjected to aortic valve replacement were compared. Metabolic arrest of the myocardium was achieved under mild hypothermic conditions in group I (71 patients) and in profound hypothermia in group II (48 patients). The operative mortality was 5.6% in group I and 4.1% in group II. There was no cardiac related with in group II. In group I two deaths were due to a low cardiac output state. In addition, 3 patients required inotropic support during the early postoperative period. Our results indicate, that magnesium-aspartate-procaine induced cardioplegia in combination with general profound hypothermia can provide effective myocardial protection during aortic valve replacement.

[Pulmonary hypertension and histological findings before and years after surgical treatment of congenital heart disease (author's transl)]. / Pulmonaler Hochdruck und histologischer Befund vor und Jahre nach chirurgischer Behandlung angeborener Herzfehler.

The coincidence of pulmonary hypertension and pulmonary vascular disease was investigated in 186 infants and children with congenital heart disease and left to right shunts. The correlation between pulmonary hypertension and pulmonary vasculopathy was highly significant. Hemodynamic pulmonary hypertension is completely suppressed by early pulmonary artery banding or total correction. Even pulmonary vascular alterations can be reversed by these measures.

[Combined application of magnesium-aspartate-cardioplegia and general hypothermia in aortic valve replacement (author's transl)]. / Kombinierte Anwendung der Magnesium-Aspartat-Kardioplegie und allgemeinen Hypothermie beim Aortenklappenersatz.

The surgical results of two similar groups of patients are compared in whom aortic valve replacement was performed utilizing magnesium-aspartate-cardioplegia combined with mild (group A = 71 patients) and profound (group B = 69 patients) hypothermia, respectively. Mortality was 5.6% in group A and 4.3% in group B. Two deaths in group A were due to a severe low cardiac output syndrome, three patients required continuous inotropic circulatory support during the early postoperative course. There was no low cardiac output in group B, no patient required inotropic support. Profound body cooling (esophageal temperature 25 degrees C) and hypothermic injection cardioplegia with magnesium-aspartate provide efficient myocardial protection up to 60 minutes of anoxia.

[Determination of glycoside concentrations in human tissue by means of radioimmunoassay (author's transl)]. / Radioimmunologische Bestimmung der Glykosidkonzentration im menschlichen Gewebe

After extraction of myocardial and skeletal muscle biopsy and autopsy specimens tissue glycoside concentrations can be determined by radioimmunoassay. Total tissue extraction of digoxin and beta-methyl-digoxin varies between 87 and 95%, the variation coefficient for repeated determinations is 10.2%. Glycoside concentrations of left ventricular papillary muscle obtained after mitral valve replacement were 69.0 +/- 25.05 ng/g with a tissue to serum relation of 46.6 +/- 8.96:1 and a correlation coefficient of r = 0.8442. In autopsy left ventricular papillary muscle glycoside concentrations were 105.2 +/- 27.35 ng/g with an almost identical tissue to serum relation of 46.2 +/- 9.57:1 and a corresponding serum concentration of 2.3 +/- 0.63 ng/ml. In adults glycoside concentrations of autopsy specimens of the right ventricle were significantly lower by 28 to 30% than those of the left ventricle. Glycoside concentrations of skeletal muscle specimens (m. pectorialis major) were 14.7 +/- 10.35 ng/g with a tissue to serum relation of 9.7 +/- 3.00:1 (r = 0.8377), which corresponds to approximately 1/5 to 1/4 of the concentrations of the left ventricular myocardium.

[Two stage surgical treatment of large ventricular septal defects (author's transl)]. / Ergebnisse der chirurgischen Zweiphasenbehandlung grosser Ventrikelseptumdefekte

Since March 1971, 51 infants were subjected to pulmonary artery banding (PAB) for a large ventricular septal defect (VSD) with pulmonary hypertension. 41 infants (80%) were under six months of age. Additional defects were present in 41%. Twelve babies died (24%). The lowest mortality was achieved in isolated VSD (6,7%). 28 patients subsequently underwent VSD closure and pulmonary artery debanding. Catheterization data revealed normal or slightly elevated pressures and normal vascular resistance in the pulmonary circuit in 22 children. The operative mortality rate was 10,7%.

[Prospective study in posttransfusion hepatitis in patients with open heart surgery (author's transl)]. / Hepatitishäufigkeit nach Transfusion von HBS-Ag-negativem und Anti-HBS-positivem Blut. Eine prospektive Studie bei Herzoperierten

In a prospective study in posttransfusion hepatitis 54 patients with open heart surgery received 220 blood units which were negative for HBS Ag by radioimmunoassay. 15 of these units contained anti-HBS and were given to 13 antibody negative patients. In a half year follow up period neither clinical nor biochemical (SGOT, SGPT, gamma-GT) signs of hepatitis could be found in these patients and neither HBS Ag nor anti-HBS developed. At the same time a screening for HBS Ag of hospital staff in contact with these patients revealed no carrier of the antigen. Therefore, the lack of any hepatitis in our relatively small study group may be attributable to two facts: the relative safety of blood screened by highly sensitive methods for the detection of HBS Ag and the noninfectious environment of these patients in the hospital during the observation period.

[Risks and results of banding surgery (author's transl)]. / Risiko und Ergebnisse der Banding-Operation

A Muller-Dammann banding operation was performed in 64 infants and small children within 5 years. The diagnosis and the surgical risk (between 5.9% and 65% depending on the degree of intracardial malformation) were presented. Complications and cause of death were described and compared with data presented in the literature. Twenty-three patients were given a follow-up examination with special cardiac diagnostic methods. The hemodynamic results were compared with those from 9 children who were operated on late. As other authors, were also found a pronounced reduction in pulmonary flow in those children operated on early and not in those operated on late.

[Palliative and corrective cardiac surgery in Down's syndrome (author's transl)]. / Palliative und korrektive Herzchirurgie bei Morbus Down

Since 1970 46 infants and children with Down's Syndrome were subjected to palliation of congenital heart disease, and 54 mongoloid children underwent correction of their cardiac defects. The most common cardiac malformation was endocardial cushion defect (72%). Palliation consisted in pulmonary artery banding (PAB) with or without division of a patent ductus arteriosus (PDA) in 16 infants, and sole division of a PDA in another 16 infants with large left to right shunts due to common canalis atrioventricularis (avcanal) or ventricular septal defect (VSD). An aorto-pulmonary anastomosis was performed for relief of severe hypoxia due to right ventricular outflow tract obstruction (RVOTO) in 14 patients. Operative mortality was 41% for PAB, 21% for aortopulmonary anastomosis, anastomosis, and 0% for division of a PDA. In the group of corrective cardiac surgery the operative mortality rate was 0% in ostium primum defects and 4% in VSD closure. Correction of complete av-canal and of malformations with RVOTO had a high mortality rate of 20 and 40%, respectively. Similar results were obtained in nonmongoloid children operated upon for the same cardiac defects. The complications and causes of death were due to the complexity of the cardiac malformations and had no relation to the Down's Syndrome itself. Mongoloid children do not pose additional medical problems to management of congenital heart disease. Their results do not differ from those obtained in nonmongoloid children.

[Changes in 2,3-diphosphoglycerate Levels in Blood and Brain Tissue after Craniocerebral Trauma and Cardiac Surgery]. / Tierexperimentelle und klinische Untersuchungen zum Verhalten des 2,3-Diphosphoglycerat nach Schädel-Hirn-Trauma und bei herzchirurgischen Eingriffen

The response of the 2,3-diphosphoglycerate (DPG) levels in the blood and brain tissue to a craniocerebral trauma of varying severity was studied in anaesthetized rats. A trauma producing cerebral contusion was followed within two hours by a highly significant rise in DPG concentration in the blood as compared with the control animals or only mildly traumatized rats. The DPG levels in the brain tissue showed no significant differences. Similar changes in DPG concentration were observed in the blood of patients with craniocerebral injuries. The DPG-mediated increased release of oxygen to the tissues represents a compensatory mechanism and is pathognomic for craniocerebral trauma. Patients undergoing surgery with extracorporeal circulation lack this mechanism for counteracting hypoxaemia; already during thoracotomy the DPG concentration in the blood fell significantly and did not reach its original level until 72 hours after the operation. In stored, ACD stabilized, blood the DPG concentration gradually decreases. Estimations carried out over 28 days showed a continuous statistically significant loss of DPG. After 24 hours the DPG levels in stored blood had already dropped to the lower limits of normal - a fact that has to be taken into account in massive blood transfusions.

[Ventrale derotations-spondylodesis (author's transl)]. / Ventrale Derotationsspondylodese. Vorläufiger Ergebnisbericht über 26 operierte Fälle

Results about 26 cases operated with the new developed "Ventrale Derotations-Spondylodesis". The first results with this new method are better than the results of the Harrington and the Dwyer method as it allows the operative derotation and lordosation. The risk of the operation put in relation to the distraction method by Harrington seems less. The importance of the operation one can't put into relation to the rather simple postoperative treatment. The results of the first 19 cases give the impression that the advantages of the Ventral Derotations-Spondylodesis make this method prefer to other instruments in the operative treatment of scoliosis.