Modulating IL-6 and IL-10 levels by pharmacologic strategies and the impact of different extracorporeal circulation parameters during cardiac surgery.

Postoperative morbidity after coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) can be influenced by pro- and anti-inflammatory cytokines like interleukin 6 (IL-6) and IL-10 triggering and balancing the acute phase response. The extent of cytokine release can be modulated by different methods. This prospective randomized study examines the effect of treatment of patients with steroid (group 1, 250 mg of prednisolone)(Solu-Decortin H)), aprotinin (group 2, 6 Mio. KIU [kallikrein inhibitory units] aprotinin [Trasylol]), and heparine coating of the artificial surface (group 3, Bioline) on the systemic release of IL-6 and IL-10 in four groups of 40 patients with coronary artery disease (CAD) scheduled for CABG. Group 4 (standard medication) served as control. Twenty hemodynamic and biochemical parameters of the CPB were analyzed regarding correlation to cytokine levels measured by enzyme-linked immunosorbent assay (ELISA). In group 1, IL-6 was suppressed compared to the control (P< 0.01). IL-10 was upregulated (P< 0.01). In group 2, cytokine release was similar to group 1. Using heparin-coated circuits in group 3 led to IL-10 upregulation (P < 0.05) and IL-6 suppression (P < 0.05). We found an exponential relationship between IL-10 levels (IL-6 levels) and cardiac ischemia time, duration of CPB, and the extent of negative base excess. An inverse relationship was found for IL-10 (IL-6) levels and venous O2 saturation (SvO2), and mean arterial pressure (MAP). Hypothermia (<34 degrees C) reduced IL-10 and IL-6 release, whereas long duration of hypothermia correlated with higher IL-10 and IL-6 release. Cytokine release after extracorporeal circulation (ECC) can be modulated pharmacologically and by distinct perfusion regimen.

Left ventricular false aneurysm.

False aneurysms of the left ventricle develop after rupture of the ventricular wall in an area of pericardial adhesions. This complication of myocardial infarction is uncommon. Images of a post-infarction false aneurysm are presented.

Changes in circulating blood volume after cardiac surgery measured by a novel method using hydroxyethyl starch.

OBJECTIVE: To determine the incidence and extent of postoperative blood volume (BV) changes in patients after elective cardiac surgery using a new method based on dilution of hydroxyethyl-starch. DESIGN: Prospective, clinical, and laboratory investigation. SETTING: University hospital intensive care unit. PATIENTS: A total of thirty-five patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). INTERVENTIONS: Perioperative measurements of circulating BV, systemic hemodynamics, lactate, and collection of clinical data. MEASUREMENTS AND MAIN RESULTS: Measurements were made before and 1 to 72 hrs after CPB. The majority of patients undergoing cardiac surgery showed postoperative BV deficits compared with preoperative BV despite marked positive fluid balances after CPB. At 1 hr and 5 hrs after CPB, 18% and 33% of the patients, respectively, had BV deficits in the range of 0.5 L and 1.5 L, and in 3% to 10% of the cases, postoperative BV deficits exceeded 1.5 L. Concomitantly, at 5 hrs after CPB, mean arterial pressure was maximally reduced, and heart rate and lactate levels were maximally elevated. Thereafter, BV began to normalize, and at 24 hrs after CPB, pre- and postoperative mean BV were no longer significantly different. At 48 hrs and 72 hrs, even a BV surplus of more than 1 L could be observed in 6% and 14% of the patients, respectively. CONCLUSIONS: During the first hours after CPB, a high percentage of patients had significantly reduced BV and, concomitantly, showed cardiovascular dysfunction and hyperlactemia. Because hypovolemia is associated with increases of perioperative morbidity and mortality, rapid determination of BV is warranted to guide fluid therapy and optimize treatment in patients undergoing cardiac surgery.

[The prognosis of total cavo-pulmonary anastomosis in relation to age at surgery]. / Die Prognose der totalen kavopulmonalen Anastomose in Abhängigkeit vom Operationsalter.

The purpose of this study was to evaluate the relations between the age of surgery and the postoperative results in children after a total cavopulmonary anastomosis (TCPA). Between February 1990 and August 1995, 53 patients underwent a TCPA in our institution. At the time of the operation 26 of the patients were younger than 4 years, 27 patients were more than 4 years old. The perioperative mortality for all patients was 9.4%. Among the young children the perioperative mortality was higher than in the older patients (15.4% vs 3.7%). The only 2 patients who died late after surgery (2.8 and 2.6 years postoperatively) had been 8.3 and 9.0 years old at the time of their TCPA and represent 7.7% of the initially surviving patients of that group. The follow-up was based on routine heart catheterizations in 25 of our patients carried out 3.6 +/- 0.7 (m +/- SD) years postoperatively. Sixteen patients underwent a bicycle exercise test 4.0 +/- 1.0 years postoperatively and in 32 patients a Holter-ECG was obtained 3.2 +/- 1.2 years postoperatively (Table 1). The systemic cardiac index (CI), obtained at the catheterization laboratory, was only slightly reduced with 3.0 +/- 1.0 l/min/m2 (normal 3.5-5.5 l/min/m2). We saw a weak but significant negative correlation between the CI and the age at the TCPA (r = -0.43; p = 0.03; Figure 1). The maximal work load at the exercise test also showed a weak negative correlation to the age of surgery (r = -0.50; p = 0.05; Figure 2). Only 43.75% of our patients had no arrhythmias at the Holter-ECG. Again the group of children with no arrhythmias had been operated on at a significant lower age than the group of patients with arrhythmias (3.9 vs 7.3 years; p = 0.02; Figure 3). At follow-up the patients were all in good condition. Patients who had the TCPA in a relatively young age showed a better cardiac output, a higher work load at exercise testing and less arrhythmias than patients who were operated on when they were older. Therefore in suitable patients we recommend to carry out the TCPA at the 3rd or 4th year of life. The higher intraoperative mortality in young children should be overcome by excluding patients with additional preoperative risk factors.

Reducing the post-pump syndrome by using heparin-coated circuits, steroids, or aprotinin.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response called 'post-pump syndrome'. As a part of a complex interaction between white cells and vascular endothelium, proinflammatory cytokines IL-6 and IL-8 are part of a phased immune response that is also balanced by anti-inflammatory cytokines such as IL-10. We compared the influence of heparin-coated circuits, steroids, and aprotinin on these cytokines, looking for ways to reduce the syndrome. METHODS: 40 patients with coronary artery disease (CAD) undergoing elective CABG were prospectively studied in four randomized groups of 10. Group A received prednisolone pre- and postoperatively (2 x 250 mg), group B received aprotinin perioperatively (6 Mio. KIU). In group C, heparin-coated circuits ('Bioline' by Jostra) were used and in group D no special measures were taken (controls). Plasma levels of cytokines were measured before and during CPB and until 12 h after surgery using an ELISA technique. RESULTS: In group A IL-6 was significantly (p<0.05) suppressed in contrast to the control group (A: peak at 4 h, 155 pg/ml vs. control: peak at 8 h, 565 pg/ml). IL-8 was also suppressed (A: peak at 30', 22 pg/ml vs. control: peak at 30', 55 pg/ml). IL-10 level changed first and was markedly upregulated in contrast to the control (A: peak at 30', 1600 pg/ml vs. control: peak at 30', 130 pg/ml; p<0.05). In group B (aprotinin) the cytokine release was similar to group A. Using heparin-coated circuits (group C) also led to a significant (p<0.05) IL-10 upregulation (C: peak at 2 h, 1380 pg/ml) and IL-6 suppression (C: peak at 4 h, 290 pg/ml). IL-8 was not influenced significantly. CONCLUSIONS: The results show a similar reduction of the inflammatory cytokine release (IL-6 and IL-8 as markers) using early steroid application and aprotinin in high dosage. Heparin coating reduces IL-6 and increases IL-10 release, whereas IL-8 is not affected. Further studies should investigate the effects of a combined application for reducing inflammatory cytokine release and the post-pump syndrome.

Perioperative factors influencing interleukin-10 release under cardiopulmonary bypass.

BACKGROUND: The cytokine response to cardiopulmonary bypass (CPB) is complex and can be modified. Among several mediators, the anti-inflammatory interleukin-10 (IL-10, 'cytokine-secretion inhibitory factor') is particularly interesting because of its ability to counteract pro-inflammatory cytokines triggering endothelial and leukocyte activation in the immediate immune response to CPB. On the other hand, during the delayed phase of the immune response, IL-10 may act as a promotor of immunodeficiency in complicated courses. Therefore, it is of interest to investigate special conditions of CPB that may influence the extent of perioperative release of IL-10. METHODS: We analyzed 20 continuously registered parameters during CPB, including an analysis of subgroups in the case of application of aprotinin or steroids. 30 consecutive adult patients with coronary artery disease (CAD) and normal left-ventricular function undergoing elective CABG were prospectively studied. Arterial blood was sampled perioperatively and levels of IL-10 were determined using ELISA tests. For analysis, the time point of maximum IL-10 release was selected (30 min after end of CPB). Simultaneously, CPB-registration protocols were analyzed concerning standard parameters. RESULTS: We could state an exponential relationship between IL-10 levels 30 min after end of CPB and the ischemia time (r = 0.76), duration of CPB (r = 0.73) and the extent of negative base excess (BE, r = 0.66) in all subgroups. An inverse relationship could be seen between IL-10 plasma levels and venous O2 saturation: low values for O2 saturation correlated with high IL-10 levels as did low mean arterial pressure (MAP). Hypothermia reduced IL-10 release (r = 0.80), whereas a long duration correlated with high IL-10 release (r = 0.67). In the case of longer duration of hypothermia, the protective effect vanished. CONCLUSIONS: The results show a significant rise for IL-10 early after starting CPB. Low values for venous O2 saturation and low MAP correlated with high IL-10 levels. A good correlation could be seen between IL-10 plasma levels and the duration of CPB, ischemia time, and negative base excess. Because of the ability of persisting IL-10 production to induce a higher incidence of septic complications, all actions for maintaining an optimum of perfusion and oxygenation play an important role.

High-risk mitral valve replacement in severe pulmonary hypertension--30 years experience.

OBJECTIVE: In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP) > 50 mmHg; pulmonary vascular resistance (PVR), 690 +/- 46 dyn/s per m2). We reviewed our early and late results in this high-risk subgroup. METHODS: We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4 +/- 0.2 years per patient. The overall early mortality rate was 10.5% (n = 40) and stayed at about the same level over the years, although patients characteristics have changed to much older patients and more reoperations. To clarify this fact we divided our data in results according to the decades in which the operations were carried out. The clinical preoperative status and results were as follows (*P < 0.05; **P < 0.01 compared with previous decade). In the decades between 1963 and 1973 (I), 1974 and 1983 (11) and 1984 and 1993 (III) we operated on n = 95 (I), n = 185 (II), and n = 102 (III) patients with a mean age of 43 +/- 1 (I), 50 +/- 1** (II), and 58 +/- 1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6%** (III). The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (III); late mortalities lowered from 5.77 (I), over 4.95 (II), and up to 3.39%** (III) patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0 +/- 0.1 (I), 3.2 +/- 0.1 (II) and 3.3 +/- 0.1 (III) to 2.4 +/- 0.2 (I), 2.4 +/- 0.1 (II) and 2.3 +/- 0.1 (III) postoperatively. RESULTS: Compared with routine elective MVR with a mortality rate of 3.6% (P < 0.01), early mortality is high. But once the patient survives the perioperative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as well are not significantly different. In spite of on average 15 years older multimorbid patients with therefore higher complication rates, early results improved slightly, which could be explained by better operative techniques, perioperative treatment and nursing (online monitoring with immediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes. CONCLUSION: According to our results, we recommend MVR in severe pulmonary hypertension even in the elderly, with a high but acceptable risk and good long-term results.

Monosomy 22q11 in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries.

OBJECTIVE: To describe the morphology of the pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries with and without monosomy 22q11. DESIGN: A retrospective analysis of all patients with this congenital heart defect who are being followed at the University Children's Hospital Erlangen. SETTING: A tertiary referral centre for paediatric cardiology and paediatric cardiac surgery. PATIENTS: 21 patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. Monosomy 22q11 was diagnosed by fluorescent in situ hybridisation using the D22S75 probe (Oncor). The morphology of the pulmonary arteries was assessed on the basis of selective angiograms. RESULTS: 10 patients (48%) were shown to have a microdeletion in 22q11 (group I). There was no difference with respect to the presence of confluent central pulmonary arteries between these patients (80%) and the remaining 11 patients (group II) without monosomy 22q11 (91%). Patients of group I, however, more often had arborisation anomalies of the pulmonary vascular bed (90% in group I v 27% in group II). Because of the more severe abnormalities of the pulmonary arteries, a biventricular repair had not been possible in any of the children with monosomy 22q11, though repair had been carried out in 64% of the children in group II. CONCLUSION: The developmental disturbance caused by the monosomy 22q11 seems to impair the connection of the peripheral pulmonary artery segments to the central pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries, resulting in a lower probability of biventricular repair.

[Interventional occlusion of systemicopulmonary collateral arteries using metal spirals]. / Interventioneller Verschluss von systemikopulmonalen Kollateralarterien mit Hilfe von Metallspiralen.

Major systemicopulmonary collateral arteries (spca) frequently contribute to collateral lung perfusion in patients with pulmonary atresia and ventricular septal defect or in children with tetralogy of Fallot. Since the surgical access to these vessels is difficult, corrective surgery may become impossible. We report our experience with interventional occlusion of spca in 10 patients. In these patients (age range 13 months-19.5 years) selective injections demonstrated a total of 27 spca. Sixteen of these were coil-occluded by interventional cardiac catheterization. Total occlusion was achieved in 15 cases, in one case we found a small residual shunt. Occlusion was performed using platinum coils (2 cases), Gianturco coils (11 cases) and detachable steel coils (4 cases, including 1 with prior incomplete occlusion by Gianturco coils). 4 patients required 2 interventional cardiac catheterizations. Complications occurred only in procedures that were performed with conventional coils (peripheral pulmonary embolizations of platinum coils in 2 patients, dislocation of the delivery catheter with a partially extruded coil to the descending aorta in 1 patient). Operative ligation had to be performed in 6 spca, since those vessels were not suitable for interventional occlusion. The remaining 5 spca were left unoccluded, since they were of minor hemodynamic relevance due to a subsequent decrease in size. At the end of the follow-up period corrective surgery had been completed in 8 of our 10 patients. In the remaining 2 patients corrective surgery is planned in the near future. According to our experience interventional occlusion of spca is a major improvement in the management of a selected cohort of patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot. The introduction of detachable steel coils facilitates the embolization of those vessels.

Changes in pulmonary artery size before and after total cavopulmonary connection.

OBJECTIVE: To assess changes in size of the central pulmonary arteries following a total cavopulmonary connection (TCPC). DESIGN: A retrospective analysis of the angiographic diameters of the central pulmonary arteries, expressed as z scores, in infancy before the TCPC and 3.5 (0.9) years (mean (SD)) later. Analysis of the relation between the pulmonary arteriolar resistance and the z scores at follow up. SETTING: Tertiary referral centre. PATIENTS: 32 patients who had TCPC from February 1990 to July 1993. RESULTS: The patients were divided into two groups (n = 16) depending on their preoperative flow ratio: group I, Qp/Qs < or = 1; group II, Qp/Qs > 1. At the initial study in infancy the mean z scores in group I were -6.0 for the right pulmonary artery (RPA) and -9.6 for the left pulmonary artery (LPA); in group II the respective values were -2.7 and -3.0. Before the TCPC the values increased to 0.5 (RPA) and -0.5 (LPA) in group I, and to 8.8 (RPA) and 8.2 (LPA) in group II. At follow up the z scores decreased to -2.4 (RPA) and -4.9 (LPA) in group I, and to 2.2 (RPA) and -0.7 (LPA) in group II. The changes in pulmonary artery diameters were significant for both groups (p < 0.02). Following the TCPC, no significant difference in pulmonary arteriolar resistance index was found between patients with relatively small pulmonary arteries (z score RPA + LPA < or = 0) and those with relatively large pulmonary arteries (z score RPA + LPA > 0). CONCLUSIONS: Creation of a TCPC results in a significant reduction in size of the central pulmonary arteries. At a mean interval of 3.5 years following the TCPC, however, there was no significant difference in pulmonary arteriolar resistance index between patients with smaller and larger central pulmonary arteries.

Results of a 1 to 31 years follow-up after aortic valve replacement in 2327 patients.

We studied the outcome of 2327 patients after aortic valve replacement from October 1962 to December 1993. 1840 mechanical (mostly STJ bi-leaflet and BS tilting disc valves) and 487 biological (IS and CE valves) prostheses were implanted. The mean follow-up period of 1458 surviving patients was 7.1 years. There were 688 non-survivors and 181 lost cases. The mean age was 50.1 years, 73% of the patients were male and 27% were female. Early mortality was about 20% in the 1960's and about 4.5% in the last years. Mortality following valve replacement was influenced by preoperative NYHA classification, cardiac index, pressure gradient and simultaneous CHD. The long term results of all valves showed a survival rate of 80% after 5 years, 73% after 10 and 60% after 15 years following operative treatment. There was no significant difference in survival rates between all mechanical and biological valves. Non-lethal complications of all mechanical valves showed no significant difference but there was a clearly lower rate of paraprosthetic leakages, haemolysis and thromboembolism in biografts. The biological valves showed a high rate of degeneration (2.7%/pty). Reoperation was performed in 170 patients. Most valve changes consisted of biological to mechanical and mechanical to mechanical valves. The main reason of reoperation was degeneration (biological), paraprosthetic leakage and haemolysis (mechanical). The cause of death of the 688 non-survivors was valve related in 17.9%. 37% of these were due to thromboembolism and 38% due to bleeding. 55.6% of survivors (group 2) could be ascribed to NYHA class III and 17.2% to class IV prior to operation. Postoperative outcome demonstrated an improvement in NYHA classification in about 80%. Of surviving patients 80% pronounced an increase of physical activity after operation.

Analysis of adhesion molecules in myocardial biopsies of cardiac allografts and coronary artery disease with CABG.

Interactions of leukocytes with vascular endothelium are important components of inflammation tissue reactions and have been implicated in cardiac transplant rejection and demonstrated to be mediated by cell adhesion molecules (CAM's). The expression of ICAM-1, VCAM-1 and E-selectin in human myocardium is variable and little is known about the expression of LFA-1 and Mac-1 during allograft rejection. This study investigated these CAM's in myocardial biopsies of transplanted hearts (HTX) and of coronary artery disease eligible for coronary artery bypass grafting (CABG) as non-inflammatory controls and explicitly examines vascular endothelium, cardiomyocytes and infiltrating cells. Immunohistochemistry was performed using the APAAP-method and directing specific mouse anti-human monoclonal antibodies against ICAM-1 (CD54), VCAM-1 (CD106), E-selectin (CD62E), alpha-LFA-1 (CD11a), alpha-Mac-1 (CD11b), alpha-p150/95 (CD11c) and the beta2-integrin chain (CD18). CD18, LFA-1 (CD11a), Mac-1 (CD11b) and p150/95 (CD11c) were markedly expressed on infiltrating immunocytes in HTX compared to CABG where no expression of beta2-integrins was observed. Cardiac allografts demonstrated a strong expression of ICAM-1 on vascular endothelium and on infiltrating cells. ICAM-1 was not detected on cardiomyocytes. In CABG a weak expression of ICAM-1 was observed on endothelial cells but not on myocytes. VCAM-1 was expressed on vascular endothelium and perivascular infiltrating cells in HTX but not in CABG. VCAM-1 was not found to be expressed on myocytes. There was no evidence for the presence of E-selectin in any of our biopsy specimens. Our study shows that the study of cell adhesion molecules adds to the pathophysiological understanding of inflammation after transplantation in cardiac disease. This offers a potential for the development of diagnostic tools and new therapeutic strategies.

Posttraumatic aneurysm of the right atrium.

We report on an acquired right atrial false aneurysm, which was removed under extracorporeal circulation. The patient remembered three occasions of blunt chest trauma with rib fractures. Clinical symptoms were ongoing dyspnea, chest pain, and atrial fibrillation.

[Post-traumatic aneurysma spurium of the right atrium]. / Posttraumatisches Aneurysma spurium des rechten Vorhofes.

In a 61 year old male with heart failure and pulmonary congestion the x-ray shows a right paracardial tumor. The patient suffered from a blunt chest trauma 6 years ago. Since that accident he complains about exercise related dyspnea and cardiac arrhythmia with atrial fibrillation. On echocardiography we found a echolucent cystic tumor with a solid center structure surrounded by a thin membrane. Doppler echocardiography revealed a heart cycle dependent flow at its margin. During dextrocardiography rapid opacification only of the peripheral structures of the tumor could be observed. These findings are consistent with a traumatic rupture of the right atrium, and the diagnosis of a posttraumatic aneurysma spurium of the right atrium was established. Surgery confirmed this diagnosis and the aneurysm was extirpated.

[Thrombolysis of modified Blalock-Taussig shunts in childhood with recombinant tissue-type plasminogen activator]. / Thrombolyse von modifizierten Blalock-Taussig-Shunts im Kindesalter mit rekombinantem Gewebeplasminogenaktivator.

Since 1983, when c-DNA was isolated, recombinant tissue plasminogen activator (rtPA), an endothelial-cell-produced activator of fibrinolysis is used, more increasingly often in therapy of thrombosis. Whereas some studies have been published regarding efficacy and safety rtPA in different thrombotic states of adults, only case reports exist in children. Doses vary widely (0.8-6 mg/kg/d), bleeding complications are reported in up to 50%. We report on four infants with complex cyanotic congenital heart disease who developed an early post-operative thrombosis of a modified Blalock-Taussig shunt. By local low dosage application of rtPA we could achieve a complete lysis of the thrombus in three of our four patients. In one patient we were unsuccessful due to a distal stenosis of the shunt. This infant required repeat surgery with creation of a central aortopulmonary shunt. We saw severe bleeding in one, requiring transfusion of packed cells, and formation of a perigraft reaction in another patient. In our experience local application of rtPA in low doses is a good therapeutical option in patients with thrombosis of aorto-pulmonary shunts, especially in the first postoperative days.

[Aorto-left ventricular tunnel with origin in the left sinus of Valsalva: a rare cause of congenital aortic insufficiency]. / Aorto-linksventrikulärer Tunnel mit Ursprung im linken Sinus Valsalvae: Seltene Ursache einer kongenitalen Aorteninsuffizienz.

Aortico-left-ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. Normally, the defect appears immediately above the right coronary sinus of Valsalva and consists of a tunnel-like connection between the aortic root and the left ventricle. The differential diagnosis to coronary artery fistulae and ruptured aneurysms of the sinus of Valsalva is often difficult. We describe a patient with an aortico-left-ventricular tunnel originating from the left aortic sinus. Similar findings have been described in only three case reports. Additionally, in our case there was a stenosis in the midportion of the tunnel which was connected to an intraseptal aneurysm communicating with the left ventricular chamber via a "septal" defect. The infant underwent successful surgical correction of this malformation at 1 year and 5 months of age.

R peak time prolongation and R peak delay in leads I, V5, or V6. Diagnostic values as signs of myocardial dysfunction in chronic mitral incompetence.

On the assumption that maximum R peak time prolongation in the left-sided leads I, V5, or V6 and its time relationship to the S peak time of the maximum S amplitude in leads V1, V2, or V3 (representing dorsally directed forces of ventricular depolarization) could indicate the extent of left ventricular volume overloading and possibly left ventricular systolic function, these variables and the preoperative findings of angiocardiography were compared between patients with chronic mitral incompetence who, late after corrective valve surgery, had either well-preserved radionuclide left ventricular ejection fraction (group 1, n = 36) or radionuclide left ventricular ejection fraction below 50% (group 2, n = 30). Before surgery, group 2 patients had a highly significant lower mean left ventricular ejection fraction, a highly significant greater mean end-systolic volume index, a significantly greater mean end-diastolic volume index, a significantly greater mean maximum R peak time in leads I, V5, or V6, and a significantly greater prolongation of the maximum R peak time above the S peak time in the right precordial leads, as compared with group 1. R peak times greater than 50 ms or the presence of R peak delay (maximum R peak time greater than the S peak time of the maximum right precordial S amplitude) yields less sensitive but highly reliable results in predicting radionuclide left ventricular ejection fraction below 50% with both specificity and positive predictive values of 100%. Thus, in chronic mitral regurgitation surgery should not be delayed if patients present these signs because they are specific markers of irreversibly impaired chamber function.

[Effect of intravenous glucose versus glucose-xylose (1:1) administration on carbohydrate and lipid metabolism after trauma and during infection]. / Einfluss intravenöser Zufuhr von Glucose versus Glucose-Xylit (1:1) auf den Kohlenhydrat- und Fettstoffwechsel nach Trauma und während Sepsis.

OBJECTIVE: To detect the effects of glucose-xylitol infusion versus glucose infusion alone on carbohydrate and lipid metabolism in postoperative stress and during sepsis. DESIGN: Prospective randomized study (study I after cardiac surgery) and intraindividual cross-over control study (study II in septic patients), respectively. SETTING: Intensive care unit of a university hospital. PATIENTS: 18 patients after aortocoronary bypass (ACVB) and 5 patients with sepsis. INTERVENTIONS: In study I during the first 24 postoperative hours one group (K I, n = 6) received glucose only (2 mg/kg BW/min), a second group (K II, n = 6) a mixture of glucose and xylitol (1:1; 2 mg/kg BW/min) and a third group (K III, n = 6) a glucose-containing electrolyte solution (0.8 mg/kg BW/min). Glucose, lactate, insulin and free fatty acid concentrations were measured pre- and postoperatively in 6-hour intervals over 36 h. In study II patients were firstly given 4 mg glucose/kg BW/min over 6 h, then infusion was changed to a 1:1 glucose-xylitol mixture (4 mg/kg BW/min) for another 6 h. Hepatic glucose production, palmitate oxidation rates and lactate concentrations were determined at the end of both infusion regimens. RESULTS: Glucose and insulin concentrations were significantly lower in K II and K III than in K I. The highest lactate values were observed 6 h postoperatively in K I. Concentrations of all fatty acids were lower in K I than in K II and K III during the infusion periods. In study II the glucose production and lactate values were significantly reduced during xylitol infusion, whereas palmitate oxidation rates were significantly increased when the infusion regimen changed from glucose to glucose-xylitol mixture. CONCLUSIONS: These data indicate that energetically ineffective high glucose concentrations were avoided and lactate production was diminished by infusion of glucose-xylitol in study I. In addition, xylitol achieved a higher endogenous release and oxidative utilisation of free fatty acids representing important fuel substrates after trauma and during sepsis.

Pericardectomy for chronic constrictive pericarditis: risks and outcome.

From 1970 to 1990, 71 consecutive patients (51 men and 20 women) had pericardectomy for chronic constrictive pericarditis. The mean age was 44.2 +/- 16.1 years. In the preoperative state 2.8% were in NYHA class I, 18.3% in II, 43.6% in III and 35.2% in IV. The operative approach was median sternotomy in 93% and left anterolateral thoracotomy in 7%. The early mortality rate (within 30 days after operation) was 5.6%. All four early deaths were female (P < 0.001), in the preoperative state the patients were classified as NYHA class IV (P < 0.01). These patients had a significantly higher preoperative mean right atrial pressure then survivors (21.5 +/- 8.5 mmHg vs 13.6 +/- 5.6 mmHg, P < 0.005). Follow-up was obtained for 65 patients (91.5%) and averaged 11 +/- 5.8 years (the longest period was 21.5 years). Actuarial survival at 5, 10, 15 and 20 years for all patients was 84.6% +/- 4.5%, 80.1% +/- 5.3%, 70.5% +/- 6.9% and 65.8% +/- 7.9%, respectively. In the preoperative state 10 of the 12 late deaths (83%) were classified NYHA class IV and the remaining ones class III. Of the 49 patients alive 23% belong to NYHA class I, 42% to II and 35% to III; none is in class IV. Negative predictors of survival were found to be preoperative NYHA class IV (P < 0.01), low-voltage electrocardiogram (ECG) (P < 0.01), ascites (P < 0.01), dyspnea at rest (P < 0.05) and hyperbilirubinemia (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiographic characteristics indicating a risk of irreversibly impaired myocardial function in chronic aortic regurgitation.

In order to define which of selected ECG variables could indicate irreversibly impaired myocardial function in chronic aortic regurgitation 54 patients were stratified according to normal (> or = 50%; Group A, n = 41) or subnormal radionuclide left ventricular ejection fraction (LVEF < 50%; Group B, n = 13) late after aortic valve replacement. Preoperatively, Group B patients had a significantly greater QRS duration, greater R-peak time (RPT) prolongation in I, V5 or V6, greater RPT relative to the S-peak time of the maximum S in V1, V2 or V3 (R-peak delay) and a greater negative T-wave in I or V6, as compared with Group A. These ECG variables together with preoperative angiocardiographic LVEF and end-systolic volume index were subjected to stepwise linear discriminant analysis. The maximum RPT, angio-LVEF and the maximum RPT relative to the S-peak time of the maximum S in V1, V2 or V3 emerged as the most promising variables. Of of Group A patients 82.9% and 84.6% of Group B patients were correctly classified by the three variables. If applied separately, APT prolongation or the presence of the R-peak delay in the left-sided leads, although less sensitive, have reasonably high specificity as risk indicators of irreversibly impaired chamber function, their positive predictive value being 60 and 62.5%, respectively. In conjunction with preoperative LVEF the diagnostic contribution of the two ECG variables amounts to the greatest overall separation of postoperatively preserved from irreversibly impaired systolic function.