Thyroid dysfunction and hepatic steatosis in overweight children and adolescents.

BACKGROUND: Overt or subclinical hypothyroidism is a common finding in adult populations affected by non-alcoholic fatty liver disease (NAFLD). Currently, there are only sparse data available on the association of thyroid dysfunction and NAFLD in obese children and adolescents. OBJECTIVE: The study aims to investigate the association of thyroid function test values with NAFLD and metabolic risk factors in a population of obese children and adolescents. METHODS: A total of 332 overweight and obese children and adolescents (170 girls) aged between 10 and 19 years were analysed. Subjects underwent ultrasound examination of the liver. Thyroid function was evaluated by laboratory determination of thyroid-stimulating hormone (TSH), total triiodothyronine (T3) and total thyroxine levels. All included subjects were either euthyroid or had subclinical hypothyroidism (TSH > 4 µU mL-1 , normal thyroxine). Further metabolic profiling included the determination of lipid status, insulin and liver function tests. Anthropometric parameters body mass index, waist and hip circumference were documented. RESULTS: The prevalence of hepatic steatosis was 29.8%. Subjects with NAFLD had significantly higher TSH levels than those without (p = 0.0007). After dividing TSH values into quartiles, both univariate and multivariate analyses (adjusted for age, body mass index-standard deviation scores and stage of puberty) showed a significant association with hepatic steatosis (p < 0.05). CONCLUSION: Taking possible variables into consideration, our results show that there is a significant association between hepatic steatosis and the TSH levels in obese children and adolescents. Mild thyroid dysfunction may therefore have a role in determining an unfavourable metabolic profile in obese children and adolescents.

[Pulmonary Metastases of Colorectal Carcinoma]. / Pulmonale Metastasenchirurgie des kolorektalen Karzinoms.

Treatment strategies for patients with pulmonary metastases of colorectal carcinoma are continuously evolving. This applies mostly to new systemic therapeutic approaches. For carefully selected patients surgical removal of pulmonary metastases remains an important interdisciplinary therapeutic option and is recommended as first treatment option by the guidelines. Five-year survival rates of up to 60 % are reported following pulmonary metastasectomy. Parenchyma sparing resection has been well established in this setting with low morbidity and mortality. Prognostic factors are, among others, complete resection, thoracic lymph node involvement, the number of metastases and the disease free interval. Although data result mostly from retrospective studies, these factors currently help in patient selection.

Comparison of Two High-End Ultrasound Systems for Contrast-Enhanced Ultrasound Quantification of Mural Microvascularity in Crohn's Disease.

PURPOSE: To verify the reproducibility of contrast-enhanced ultrasound (CEUS) quantification results of two different high-end ultrasound systems and to evaluate the clinical utility of the method in patients with Crohn's disease (CD). MATERIALS AND METHODS: 18 patients with histologically confirmed CD (36.8 % women, 63.2 % men; mean age 43.7 ±â€Š14.1 years) and wall segments thicker than 5 mm were recruited. CEUS quantification and conventional ultrasound investigation were performed under standardized settings using Toshiba Aplio500 and Siemens Acuson S3000 high-end ultrasound systems. CEUS was performed at a low mechanical index of 0.1 after bolus application of 4.8 ml of SonoVue(®) contrast medium. The recorded DICOM clips were quantified using VueBox(®) (version 4.3) calculating 11 quantitative parameters. Subsequently, CEUS quantification and conventional ultrasound results were analyzed. RESULTS: Correlation of quantitative parameters between the Aplio500 and AcusonS3000 systems for peak enhancement (PE), rise time (RT), wash-in-rate (WiR) and quality of fit (QOF) yielded significance levels of p < 0.05 and p < 0.0001 for wash-in-wash-out area under the curve (WiWoAUC). Spearman rank test showed moderate levels of correlation for PE, RT, WiR and QOF (r = 0.5, 0.49, 0.49 and 0.5 respectively), and high correlation for WiWoAUC (r = 0.89) between the two ultrasound systems. CONCLUSION: Due to multiple uncontrollable affecting factors, the method of CEUS quantification by VueBox in the intestine cannot be recommended for device-independent multicenter studies. Therefore we suggest to use identical ultrasound systems and probes as well as to establish adequate reference ROIS, like a AIF-ROI.

Complications in CT-Guided, Semi-Automatic Coaxial Core Biopsy of Potentially Malignant Pulmonary Lesions.

PURPOSE: Histological verification of pulmonary lesions is important to ensure correct treatment. Computed tomographic (CT) transthoracic core biopsy is a well-established procedure for this. Comparison of available studies is difficult though, as technical and patient characteristics vary. Using a standardized biopsy technique, we evaluated our results for CT-guided coaxial core biopsy in a semi-automatic technique. MATERIALS AND METHODS: Within 2 years, 664 consecutive transpulmonary biopsies were analyzed retrospectively. All interventions were performed using a 17/18G semi-automatic core biopsy system (4 to 8 specimens). The incidence of complications and technical and patient-dependent risk factors were evaluated. RESULTS: Comparing the histology with the final diagnosis, the sensitivity was 96.3%, and the specificity was 100%. 24 procedures were not diagnostic. In all others immunohistological staining was possible. The main complication was pneumothorax (PT, 21.7%), with chest tube insertion in 6% of the procedures (n = 40). Bleeding without therapeutic consequences was seen in 43 patients. There was no patient mortality. The rate of PT with chest tube insertion was 9.6% in emphysema patients and 2.8% without emphysema (p = 0.001). Smokers with emphysema had a 5 times higher risk of developing PT (p = 0.001). Correlation of tumor size or biopsy angle and the risk of PT was not significant. The risk of developing a PT was associated with an increasing intrapulmonary depth of the lesion (p = 0.001). CONCLUSION: CT-guided, semiautomatic coaxial core biopsy of the lung is a safe diagnostic procedure. The rate of major complications is low, and the sensitivity and specificity of the procedure are high. Smokers with emphysema are at a significantly higher risk of developing pneumothorax and should be monitored accordingly. KEY POINTS: Using an 18G core biopsy system with 6 specimens will allow immunohistological staining with high sensitivity and specificity. Smokers with emphysema are at a significantly higher risk of developing a pneumothorax.

Determination of vitality of liver lesions by alveolar echinococcosis. Comparison of parametric contrast enhanced ultrasound (SonoVue®) with quantified 18F-FDG-PET-CT.

UNLABELLED: Objective of our study is qualitative and quantitative comparison of contrast enhanced ultrasound (CEUS) and 18F-FDG PET-CT in monitoring hepatic alveolar echinococcosis (HAE). Parasitic liver lesions were examined regarding number, size, morphology, vascularization and metabolic activity. PATIENTS, METHODS: 36 patients with medically-treated HAE were included in this prospective clinical study. Abdominal ultrasound and CEUS were carried out using ultrasound contrast amplifier SonoVue®. As part of monitoring, patients were examined by 18F-FDG-PET-CT. Quantitative analysis of CEUS was performed using the Software VueBox™ Quantification Toolbox. Maximum contrast enhancement in lesions peak enhancement (PE) was used as parameter. For quantification of 18F-FDG PET-CT, maximum Standardized Uptake Value (SUVmax) of lesions was specified and statistically compared with PE. RESULTS: 18F-FDG uptake in parasitic liver lesions was diagnosed by 18F-FDG PET-CT in 32 of 36 patients. Vascularization of liver lesions was detected by CEUS in 22 of 32 FDG-positive patients with sensitivity of 69% and specificity of 100%. Mean maximum diameter of lesions was 69.5mm in CEUS and 63.7mm in B-scan ultrasound (p < 0.0001). No significant correlation was found between SUVmax and PE (p = 0.8879). CONCLUSION: In comparison to FDG PET-CT, the gold standard for detecting viable lesions by depicting metabolism, CEUS detects viable lesions with high specificity and moderate sensitivity by showing vascularization. CEUS must be regarded as an important tool in monitoring HAE. Dimensions of parasitic lesions are displayed more precisely through CEUS than in B-scan. With currently available methods, CEUS quantification has no benefit in monitoring HAE lesions in daily clinical practice.

Influence of plasma cortisol and other laboratory parameters on nonalcoholic Fatty liver disease.

The objective of the present study was to analyse the association between the plasma cortisol concentration and nonalcoholic fatty liver disease (NAFLD). A total of 1 326 subjects (age 18-65 years) were examined in the context of an epidemiological study of a population-based random sample. Medical history and anthropometric data of 662 women and 664 men were documented. In addition, laboratory examinations were performed and the fat concentration of the liver was estimated by ultrasound examination. Mean cortisol concentration in plasma was 260.4±156.8 nmol/l for women and 295.8±161.2 nmol/l for men. NAFLD was identified in 17.7% in women and 35.1% in men. Plasma cortisol concentration showed no association with the existence of NAFLD. NAFLD correlated positive with age, body-mass index (BMI), waist-to-hip-ratio (WHR), alanine aminotransferase (ALT), and triglycerides. The present study failed to establish any association of plasma cortisol concentrations and NAFLD.

[Infiltration of the superior vena cava in NSCLC: results of surgical intervention]. / Ergebnisse des chirurgischen Vorgehens bei NSCLC und Infiltration der Vena cava superior.

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed.

[Chronic thromboembolic pulmonary hypertension: Time delay from onset of symtoms to diagnosis and clinical condition at diagnosis]. / Chronisch thromboembolische pulmonale Hypertonie: Latenz bis zur Diagnosesicherung und klinischer Zustand bei Diagnosestellung.

BACKGROUND AND AIM: Chronic-thromboembolic pulmonary hypertension (CTEPH) is a serious complication of acute pulmonary embolism (PE). In untreated patients prognosis is poor. It depends on WHO-functional class. A delay from onset of symptoms and diagnosis can lead to a further worsening of prognosis. A pulmonary endarterectomy is the treatment of choice. We aimed to evaluate the time delay from onset of symptoms to diagnosis and the WHO-functional class at primary diagnosis in patients with CTEPH. PATIENTS AND METHODS: Retrospective analysis of data from 70 monocentrically registered patients (48 women, 22 men, mean age 66,2 years  ± â€Š13,8 years) with confirmed CTEPH from the pulmonary hypertension expert center Missionsärztliche Klinik. Diagnostic work-up was performed according to the current guidelines. RESULTS: Mean delay from onset of symptoms to diagnosis of CTEPH was 18 ±â€Š26 months. Time delay was only slightly shorter in patients with a history of PE (n = 56; 81 %) than in patients without a history of PE (n = 13; 19 %): 16,9  ± â€Š23,8 vs. 23,5 â€Š± â€Š36,9 months. Time delay was higher in patients who received vasoactive medication before the first contact with a PH expert center and in patients who were classified as technically not suitable for a thrombendarterectomy. 38 patients with a history of acute PE did not have a period without symptoms. In 18 patients symptoms had transiently gone after PE. More than 70 % presented in WHO functional class III or IV. CONCLUSION: Time delay between onset of symptoms and diagnosis of CTEPH and referral to a PH expert center is long and the majority of patients presented in WHO-functional class III or IV. Prognosis is poor in untreated patients and getting worse with a higher WHO-functional class. For this reason, and because CTEPH can be cured by a pulmonary endarterectomy, each patient with suspected PH should be referred to a PH expert center to exclude CTEPH.

Associations of fatty liver disease and other factors affecting serum SHBG concentrations: a population based study on 1657 subjects.

Sex hormone binding globulin (SHBG) is a glycoprotein expressed predominantly in the hepatocytes. It regulates the transport of sex steroid hormones in the blood stream to their target tissues. The expression of the SHBG gene is subject to multifactorial regulation including hormonal, metabolic, and nutritional aspects. Against this background, we investigated the effect of fatty liver and metabolic syndrome, together with other parameters, on serum SHBG concentrations in a population-based cohort in Germany. This cross-sectional study included 870 women and 787 men (average age 42.3±12.8 years), who underwent ultrasound screening for fatty liver in addition to providing a complete medical history and undergoing physical and laboratory examination. Fatty liver was diagnosed on ultrasound criteria in 159 women (18.3%) and 287 men (36.5%). Fatty liver was shown to exert a significant influence on serum SHBG concentrations in men and in premenopausal women. Men with grade 1 fatty liver had a 1.96-fold increased risk (95%-confidence interval=1.28-3.02; p=0.0022) and postmenopausal women with grade 1 fatty liver a 2.4-fold risk (95%-confidence interval=1.11-5.27; p=0.0267) for low SHBG concentrations. Among metabolic parameters, HDL-C represented as affecting factor in men (p=0.0058) and premenopausal women (p=0.0002), while cholesterol only showed an association in premenopausal women (p=0.0439) and triglyceride in postmenopausal women (p=0.0436). No association of concentrations of SHBG and metabolic syndrome was observed. Age, BMI and waist-to-hip ratio also influence the SHBG concentration. Based on these findings, we conclude that fat accumulation in the liver influences SHBG concentrations in men and premenopausal women.

[Sleeve lobectomy: perioperative risks and functional results]. / Bronchusmanschettenresektion: Perioperatives Risiko und funktionelles Ergebnis.

Sleeve lobectomy is an established surgical procedure in patients with lung cancer. Usually the only surgical alternative would be a pneumonectomy. This article describes the perioperative risks and functional results in patients after sleeve lobectomy compared to pneumonectomy and typical lobectomy.There were only minor differences with respect to postoperative morbidity comparing the different procedures but the mortality rate was higher following pneumonectomy. Bronchopleural fistula rates were also similar comparing lobectomy and sleeve lobectomy but elevated following pneumonectomy. Bronchovascular fistulas after sleeve lobectomy are potentially life-threatening. Postoperative pulmonary function tests showed similar values for lobectomy and sleeve lobectomy patients and were considerably better than following pneumonectomy.Whenever possible sleeve lobectomy should take preference over pneumonectomy.

Randomized phase 2 trial on refinement of early-stage NSCLC adjuvant chemotherapy with cisplatin and pemetrexed versus cisplatin and vinorelbine: the TREAT study.

BACKGROUND: Adjuvant chemotherapy is beneficial in non-small-cell lung cancer (NSCLC). However, balancing toxicity and efficacy mandates improvement. PATIENTS AND METHODS: Patients with completely resected stages IB-pT3N1 NSCLC were randomly assigned to either four cycles cisplatin (C: 50 mg/m(2) day (d)1 + 8) and vinorelbine (V: 25 mg/m(2) d1, 8, 15, 22) q4 weeks or four cycles cisplatin (75 mg/m(2) d1) and pemetrexed (Px: 500 mg/m(2) d1) q3 weeks. Primary objective was the clinical feasibility rate (no grade (G)4 neutropenia/thrombocytopenia or thrombocytopenia with bleeding, no G3/4 febrile neutropenia or non-hematological toxicity; no premature withdrawal/death). Secondary objectives were drug delivery and efficacy. RESULTS: One hundred and thirty two patients were randomized (stages: 38% IB, 10% IIA, 47% IIB, 5% pT3pN1; histology: 43% squamous, 57% non-squamous). The feasibility rates were 95.5% (cisplatin and pemetrexed, CPx) and 75.4% (cisplatin and vinorelbine, CVb) (P = 0.001); hematological G3/4 toxic effects were 10% (CPx) and 74% (CVb) (P < 0.001), non-hematological toxic effects were comparable (33% and 31%, P = 0.798). Delivery of total mean doses was 90% of planned with CPx, but 66% (cisplatin) and 64% (vinorelbine) with CVb (P < 0.0001). The median number of cycles [treatment time (weeks)] was 4 for CPx (11.2) and 3 for CVb (9.9). Time to withdrawal from therapy differed significantly between arms favoring CPx (P < 0.001). CONCLUSION: Adjuvant chemotherapy with CPx is safe and feasible with less toxicity and superior dose delivery compared with CVb.

[Cystic lesion of the dorsal mediastinum]. / Zystische Raumforderung im hinteren Mediastinum.

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction. Microcirculation-dependent alteration of the gut mucosal barrier with subsequent translocation of endotoxins is a postulated mechanism for this inflammatory response. This study was designed to elucidate whether two different approaches to modulate splanchnic perfusion may influence systemic inflammation to CPB. METHODS: We examined 40 patients scheduled for elective coronary bypass surgery in a prospective, randomized study. One group (DPX) received dopexamine (1 micro g. kg-1. min-1) continuously after induction of anesthesia until 18 h after CPB. The control group (CON) received equal volumes of NaCl 0.9% in a time-matched fashion. In a third group (EPI) a continuous epidural infusion of bupivacaine 0.25% [(body height (cm) - 100). 10-1=ml.h-1] was administered for the whole study period. Procalcitonin (PCT), tumor necrosis factor (TNF-alpha), soluble TNF receptor, human soluble intercellular adhesion molecule-1, C-reactive protein (CRP) and leukocyte count were measured as parameters of inflammation. RESULTS: All parameters significantly increased following CPB. Increases of PCT, TNF-alpha and leukocyte count were significantly attenuated in the DPX and EPI groups at different time points. However, neither splanchnic blood flow nor oxygen delivery and consumption were different when compared with the CON-group. CONCLUSION: These results do suggest that mechanisms other than an improved splanchnic blood flow by DPX and EPI treatment have to be considered for the anti-inflammatory effects.

Mid-term results of aortic valve preservation: remodelling vs. reimplantation.

OBJECTIVE: Valve-preserving root replacement has become an accepted alternative to composite replacement both in dissection and in aneurysmal disease. We retrospectively analysed 5-year results comparing root remodelling and reimplantation procedures. METHODS: From October 1995 to January 2001, 119 patients underwent either root remodelling (group A; n = 98; age: 61 +/- 14 years) or valve reimplantation within a vascular graft (group B; n = 21; age: 47 +/- 17 years). In group A, 26 patients were operated for aortic dissection type A and 72 for aortic valve regurgitation and aneurysmal disease. In group B, 8 patients were operated for aortic dissection type A, 13 for aortic valve regurgitation and aneurysm. Concomitant arch surgery was performed in 65 patients (group A: 57; group B: 8). RESULTS: Time on cardiopulmonary bypass was 121 +/- 30 min in group A, 143 +/- 24 min in group B, and aortic cross-clamp time was 87 +/- 19 min in group A and 113 +/- 24 min in group B. Average duration was therefore longer in group B (p = n.s.) Hospital mortality was 3.1 % in group A and 0 % in group B. Following elective procedures, hospital mortality was 1.1 % in group A. Freedom from aortic regurgitation over grade 2 at 4 years was 86 % in group A and 94.7 % in group B. At 4 years, freedom from proximal reoperation was 97.8 % in group A and 100 % in group B. There was no deterioration of valve function or need for reoperation observed after 1 year in either group. CONCLUSION: Five-year results are comparable and encouraging for remodelling and reimplantation procedures. If the initial valve function and geometry is adequate, the chance of secondary failure beyond the first year is minimal.

Complete arterial revascularisation in patients older than 70 years.

BACKGROUND: Coronary artery bypass grafting (CABG) using left internal thoracic artery and vein grafts is standard in patients of advanced age. A number of these patients, however, present without suitable vein grafting material and thus require the use of arterial conduits. In order to investigate the safety and efficacy of complete arterial revascularisation, we have compared the perioperative results of patients older than 70 years with conventional CABG and complete arterial revascularisation. PATIENTS AND METHODS: Group I (n = 172) with conventional CABG in 1999 was compared with 152 patients (group II) with complete arterial CABG between 1996 and July 2000. There were no significant differences regarding age, gender, left ventricular ejection fraction or incidence of three-vessel disease or left main stenosis. The proportion of reoperations was significantly higher in group II (16 %) vs. group I (4 %). RESULTS: A mean of 3.7 +/- 0.7 anastomoses (I) versus 4.0 +/- 0.9 (II) were performed per patient (p = n. s.). Mean operating time (I: 210 +/- 46 min; II: 194 +/- 46 min) and bypass time (I: 87 +/- 25 min; II: 78 +/- 29 min) were significantly lower in group II. Ischemic time (I: 46 +/- 22 min; II: 49 +/- 21 min) was not significantly different. The incidence of sternal dehiscence was 2.9 % (I: n = 5) vs. 1.3 % (II: n = 2). Hospital mortality was 4.6 % in group I vs. 3.9 % (II). CONCLUSION: Complete arterial revascularisation is a safe option in patients aged over 70. It remains to be shown whether it may also have advantage in the long term.

Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results?

OBJECTIVE: Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS: Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS: Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION: Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.

Complete arterial revascularization in the diabetic patient--early postoperative results.

BACKGROUND: The prognostic benefit of arterial grafts appears to be particularly high in patients with diabetes mellitus, but has been limited by availability of grafts and sternal complications. Complete arterial coronary artery bypass grafting (caCABG) using skeletonized grafts, radial arteries (RA) and the T-graft approach may reduce the perioperative risk particularly in the diabetic patient. METHODS: The perioperative data of 174 diabetic (group I) and 402 non-diabetic patients (group II) who underwent caCABG were studied retrospectively. The operations were performed using bilateral internal thoracic arteries (ITA) (I: 20%; II: 21%; ns) or ITA and RA (I: 80%; II: 79%; ns). Diabetic patients presented with a higher incidence of 3-vessel disease (I: 93%; II: 83%; p<0.05) and a lower left ventricular ejection fraction (I: 55+/-16%; 11:60+/-16%; p<0.05). RESULTS: No differences were found regarding need of intraaortic balloon pump (I: 1.7%; II: 2.7%; ns), incidence of myocardial infarction (I: 1.2%; II: 1.7%; ns) and sternal complications (I: 2.3%; II: 1.0%; ns). In-hospital mortality was 1.7%(I) versus 2.2% (II) (p = ns). CONCLUSIONS: Using skeletonized arterial grafts and the T-graft approach, caCABG in diabetic patients is as safe as in non-diabetics. With the RA as a second graft, bilateral ITA harvesting is avoidable.

Left ventricular-right atrial fistula complicating redo mitral valve replacement.

We describe the case of a 58-year-old female patient who underwent redo mitral valve replacement and remained in heart failure. The diagnosis of a left ventricular-right atrial fistula was made. The fistula was closed surgically with a patch of autologous pericardium. The patient improved immediately after the operation and has been asymptomatic since.

[Reconstruction of the bicuspid aortic valve]. / Rekonstruktion der bikuspiden Aortenklappe.

Reconstruction of a regurgitant bicuspid aortic valve is a new alternative to aortic valve replacement. With concomitant aortic root dilatation adequate reconstruction is feasible by valve-sparing aortic replacement. Between 10/95 and 02/00, 30 patients underwent reconstruction of a regurgitant bicuspid aortic valve. Additional aortic replacement was performed in 23 cases. Valve reconstruction was performed by plication of the prolapsing leaflet. No patient died peri- or postoperatively. Freedom from aortic valve regurgitation > or = II as well as freedom from reoperation were 100% after 48 months. Reconstruction of a regurgitant bicuspid aortic valve is feasible with encouraging mid-term results. With concomitant dilatation of the ascending aorta, a combination of aortic replacement and valve reconstruction can achieve stable results even in bicuspid valve anatomy.

[Progression of an intramural hematoma to dissection]. / Progression eines intramuralen Hämatoms zur Dissektion.

Intramural hematoma is a spontaneous, localized bleeding in the wall of the thoracic aorta without evidence of intimal tear. Clinically, intramural hematoma manifests itself as an acute thoracical pain in patients with hypertension and therefore shows parallels with the classical aortic dissection. In the literature there is controversial discussion whether intramural hematoma can be regarded as its own aortic pathology or a precursor in the development of classical aortic dissection. We present the case of a 66 year old male who showed an intramural hematoma of the descending aorta which rapidly progressed to classical dissection within 3 months. This finding was secondarily accompanied by a dilatation of the descending aorta which leads to operative treatment with replacement of the proximal aorta descendens. This case supports the hypothesis that intramural hematoma is a potential early manifestation of aortic dissection and at the same time stresses the necessity for frequent follow-up investigations and, if necessary, early operative therapy.