Giant aneurysm of the right coronary artery with fistula to right atrium.

Coronary artery aneurysms are rare entities with a prevalence of 0.15%-4.9%. Giant coronary artery aneurysms are known as more than 2 to 5 cm in size. We present a case of 74 year-old female who was admitted to our clinic with chest pain and dyspnea. Coronary angiography demonstrated a giant right coronary artery (RCA) aneurysm with a significant left-to-right shunt. The patient underwent an open heart surgery. During the exploration, an aneurysm of 40 mm in diameter of the RCA was seen. The aneurysmatic RCA was excluded and continuously closed with the support of intra-aortic balloon pump (IABP). The patient was discharged on the 13th postoperative day without any complication.

An unusual case of retained bullet in the heart since World War II: a case report.

Although bullets penetrating into the heart are usually known as fatal, retained cardiac bullets can have a silent course without causing any cardiovascular complications. An 89 year-old patient with myocardial infarction was admitted to our department hemodynamically stable and widely awake. His electrocardiogram didn't show any evidence of ischemia. Cardiac catheterization revealed a three-vessel coronary artery disease. In addition, a circular structure projected on the area of the marginal branch and the V. magna cordis. Removal of the bullet showed that three quarters of myocardium were involved without any perforation. The history of the patient revealed an injury under the heavy fire during World War II. Thus, this case demonstrates that bullets can remain asymptomatic within in the heart for decades. The patient was dis-charged home at the 10th postoperative day after having an uneventful clinical course.

Simultaneous carotid endarterectomy and coronary artery bypass grafting in 313 patients.

The coincidence of coronary and carotid artery disease (uni- or bilateral, with or without involvement of the supra-aortic branch) is still a problem with regards to surgical strategy. Since the opening of the Heart Centre Duisburg in 1989 the authors have favoured a simultaneous approach to lesions in both arterial systems in order to avoid myocardial infarction or stroke. The aim of this retrospective study was to review the early and late results of the combined procedures for the endpoints of death, myocardial infarction and stroke. During a 7-year period (1990-1997) a total of 18,050 patients underwent cardiac surgery and extracorporeal circulation. Simultaneous intervention in both arterial systems was performed in 313 patients (1.73%). All patients underwent preoperative ultrasonic diagnostics, digital subtraction angiography, neurological examination and cardiac catheterization. The principal indication was the need for myocardial revascularization, and symptomatic or asymptomatic carotid stenosis of 80% diameter reduction or more (with or without contralateral disease). The mean age was 66.4 +/- 6.9 years; 240 patients (76.7%) were male, 73 patients (23.3%) female; 243 patients (77.6%) had triple-vessel disease, 82 patients (26.2%) had left main stenosis and 94 patients (43.5%) had a reduced ejection fraction. A total of 171 patients (54.6%) had a previous myocardial infarction, 54 patients (17.3%) presented with unstable angina and nine patients (2.9%) had prior coronary artery bypass grafts. Eighty-seven patients (27.8%) had an internal carotid artery stenosis on the right side, 75 patients (24%) on the left side and 151 patients (48.2%) lesions in both carotid arteries. Prior carotid endarterectomy was performed in 14 patients (4.5%), and the contralateral carotid was occluded in 24 patients (7.7%). Fifty patients had a previous stroke (16%) and 185 patients (59.1%) were asymptomatic. During surgery, the the carotid artery was first exposed, followed by median sternotomy, systemic heparinization, cannulation and cardiopulmonary bypass. After achieving mild hypothermia (30 degrees C), endarterectomy was performed with a venous patch closure. An occluded contralateral carotid artery was always an indication for shunting. Coronary artery bypass grafting was carried out with intermittent cross-clamping under moderate hypothermia (22-27 degrees C). Ten patients suffered a myocardial infarction (3.2%), seven patients (2.2%) had an apoplectic insult perioperatively ( < 30 days) and one patient (0.3%) had an event during long-term follow-up. Early overall mortality was 28 (8.9%), of which 13 were cardiac related (4.2%). Overall late mortality was eight (2.6%), of which six were cardiac related (1.9%). Mean survival time was 6.18 years. Simultaneous carotid endarterectomy and myocardial revascularization can be justified as a routine surgical management of severe lesions in both arterial systems. The risk of myocardial infarction, apoplectic stroke or mortality was not significantly different than isolated procedures.

Tracheobronchial rupture after emergency intubation.

Iatrogenic injuries of the trachea are rare. We report a case of tracheobronchial rupture in a 77-year-old woman after emergency intubation. Early bronchoscopy showed a rupture of the posterior wall of the trachea into the right main bronchus with a total length of 9.5 cm. A right thoracotomy was performed and the tracheal rupture was managed successfully by primary suture. Surgical treatment and possible causes of this lesion are discussed with reference to the literature.

Reoperations for malfunction of heart valve prostheses, especially with endocarditis.

Following the increasing number of patients with heart valve replacement and an extended indication (older age groups, acute infective endocarditis, multivalvular procedures) the indicence of malfunction of valve prostheses is continuously growing. The prognosis of patients with a malfunctioning prosthesis mainly depends on early diagnosis and adequate therapy. In a retrospective study (1970 to 1984) 3,533 implanted heart valve prostheses were followed up and the cases with malfunction (n = 150; 4.2%) were analyzed. During the follow-up period after 1963 mitral valve replacements (MVR) there were 78 cases of malfunction (4.6%), after 1806 aortic valve replacements (AVR) 73 (4.1%), and after 34 tricuspid valve replacements (TVR) 4 malfunctions (11.8%). These malfunctions concerned periprosthetic leakages (n = 65), prosthetic endocarditis (n = 42), prosthetic valve thrombosis (n = 13), mechanical dysfunction including bioprosthetic degeneration (n = 17), valve related hemolysis (n = 3), and unsatisfactory hemodynamics (n = 10). Special attention was turned to the problem of prosthetic endocarditis (1963-1984) found in a total of 71 patients following 3,878 prosthetic valve replacements (1.9%). In 42 reoperated cases (1970-1984) the causing microorganisms were analyzed, demonstrating staphylococci in a leading position. Secondary complications and additional risk factors are discussed. There has been no change concerning the basis and the strategy of management for prosthetic endocarditis for many years: After a short time of conservative management with tested antibiotics, early reoperation and exchange of the prosthesis seems to be the optimal therapy, despite a distinctly high postoperative mortality (17%).(ABSTRACT TRUNCATED AT 250 WORDS)