[Atrial myxoma with clinical signs of systemic inflammatory disease]. / Vorhofmyxom mit klinischem Bild einer entzündlichen Systemerkrankung.

Atrial myxomas are detectable in 0.3 % of all autopsies and women are affected three times more often than men. The overall incidence of myxoma is relatively rare with 0.5 per one million inhabitants per year. Clinical signs, such as palpitations, dyspnea, dizziness and syncope or thromboembolic events may be found. Microembolic infarction or a higher expression of interleukin 6 may lead to misdiagnosis, such as vasculitis. This article presents the case of a 25-year-old woman with arthralgia, dysesthesia, staggering vertigo, cutaneous nodules and disturbed vision. Diagnostic procedures did not reveal a reason for these complaints. A therapeutic test with prednisolone did not improve the symptoms. Finally echocardiography showed a large space-occupying lesion in the left atrium which oscillated into the left ventricle during diastole. The patient was transferred to the department of cardiac surgery where the atrial myxoma could be removed without any complications and the patient ultimately made a complete recovery.

Transmyocardial laser revascularization combined with intramyocardial endothelial progenitor cell transplantation in patients with intractable ischemic heart disease ineligible for conventional revascularization: preliminary results in a highly selected small patient cohort.

OBJECTIVE: Transmyocardial laser revascularization for angina relief and intramyocardial autologous endothelial progenitor cell injection for neoangiogenesis may offer a new treatment strategy for patients with intractable ischemic heart disease. METHODS: Transmyocardial laser revascularization and intramyocardial injection of bone marrow-derived CD133+ cells was performed in six highly symptomatic patients. Transmyocardial laser channels were created and isolated CD133+ cells were injected intramyocardially. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: One patient died shortly after the operation due to refractory heart failure. In the five survivors, CCS class improved as well as left ventricular ejection fraction. Left ventricular end-diastolic volume and myocardial perfusion varied between the patients. All patients described a considerable improvement in quality of life postoperatively. Repeated 24-hour Holter monitoring revealed no significant arrhythmias. CONCLUSIONS: In this small patient cohort, intramyocardial CD 133+ cell injection combined with transmyocardial laser revascularization led to an improvement in clinical symptomatology in all patients and in left ventricular function in 4 out of 5 patients, with an unclear effect on myocardial perfusion. Caution is advised when employing this therapy in patients with severely depressed left ventricular function.

The extent of akinesis is predictive of the in-hospital mortality from endoaneurysmorrhaphy.

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62+/-9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality.Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30 degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the LV ejection fraction (p=0.001), the number of stenosed coronary arteries (p=0.004), and the extent of akinesis (p=0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.

Norepinephrine release is reduced in cardiac tissue of Type 2 diabetic patients.

AIMS/HYPOTHESIS: The aim of this study was to assess whether cardiac catecholamine release is affected in patients with Type 2 diabetes mellitus. METHODS: A trial tissue was obtained from 19 diabetic (Type 2) and 43 non-diabetic patients undergoing coronary surgery. Endogenous norepinephrine release was examined under baseline conditions as well as during electrical field stimulation (effective voltage 5 V, stimulation frequency 4 Hz, pulse width 2 msec) by high performance liquid chromatography and electrochemical detection. Cardiac function and arterial blood pressure was assessed from coronary angiography. RESULTS: In atrial tissue from diabetic patients, stimulation-induced norepinephrine release was reduced by 25% compared with non-diabetic patients, while baseline norepinephrine release did not differ between both groups. Preoperative plasma glucose and haemoglobin A(1C) concentrations were increased in patients with diabetes, however, no relation was found to catecholamine release. Diabetic and non-diabetic patients did not differ regarding left ventricular ejection fraction and arterial blood pressure. CONCLUSION/INTERPRETATION: Cardiac norepinephrine release is suppressed in patients with Type 2 diabetes which could contribute to sympathetic neuropathy. The difference of norepinephrine release in diabetic and non-diabetic patients was independent of cardiac function and arterial blood pressure.

Survival after transmyocardial laser revascularization in relation to nonlasered perfused myocardial zones.

BACKGROUND: Transmyocardial laser revascularization for severe diffuse coronary artery disease reduces angina significantly. The effect on survival, however, is questionable, and risk factors are not adequately addressed. Considering that transmyocardial laser revascularization channels do not remain patent for improving direct myocardial blood supply, other variables such as perfusion through open native or grafted vessels in remote non-transmyocardial laser revascularization areas are probably more important for survival. This hypothesis is the subject of the study. METHODS: Transmyocardial laser revascularization was performed with a CO2 laser system in 63 patients between October 1995 and December 1997. Patients received transmyocardial laser revascularization alone or in combination with coronary artery bypass grafting. The heart was divided into three perfusion zones as determined by the three major coronary arteries. Patients were divided into three groups according to the number of zones that were perfused by either a native coronary artery or a patent bypass graft: group 1 (n = 9), none; group 2 (n = 24), one; and group 3 (n = 30), two. Follow-up was performed at 3, 6, 12, 24, and 36 months and was 100% complete. Mean latest follow-up was 26.2 months, minimal follow-up of survivors was at least 12 months. RESULTS: Overall mortality was remarkably higher in group 1 (77.8%) compared with group 2 (20.8%, p = 0.005) and group 3 (13.3%, p = 0.001). Hospital mortality was 22.2% in group 1, 0% in group 2, and 3.3% in group 3. Late mortality was also higher in group 1 (55.5% versus 20.8%, and versus 9.9%, respectively). Cardiac deaths were more frequent in group 1 (55.5% versus 12.5% in group 2, p = 0.02, and versus 9.9% in group 3, p = 0.009). The number of perfused myocardial zones showed a significant influence for survival (p = 0.002). CONCLUSIONS: These data give some directional evidence that survival seems to be beneficially affected by the number of nonlasered perfused myocardial zones through native vessels or grafts in patients undergoing transmyocardial laser revascularization.

Electron-microscopic findings after transmyocardial laser revascularization in an acute ischemic pig model.

OBJECTIVE: The clinical benefit in terms of angina reduction after transmyocardial laser revascularization (TMLR) in patients with diffuse coronary artery disease who are not candidates for conventional procedures has been proved. The exact mechanisms of TMLR however, are still unknown. The aim of this study was to investigate the cellular changes in relation to intramyocardial partial oxygen pressure (ptiO2) after TMLR in a model of acute ischemia in pigs by electron microscopical methods (TEM). METHODS: Seven pigs were included in this study (five animals with acute myocardial ischemia and additional TMLR and two animals with acute myocardial ischemia and without TMLR for control). Acute ischemia was induced by ligation of diagonal branches of the left anterior descending artery (LAD). Intramyocardial partial oxygen pressure was measured before induction of ischemia and thereafter continuously for up to 6 h in all animals. Biopsies of all animals were taken before induction of ischemia and thereafter at 30 min, 3 and 6 h. Analysis of the myocardial ultrastructure was focused on mitochondria, cell nucleus, T-tubules and myofibrils. RESULTS: Ultrastructural changes were seen in all animals. At 6 h after induction of ischemia, mitochondria showed a destruction of the internal as well as the external membrane and of the cristae. The nuclei showed margination of the chromatin. Myofibrils were characterized by ruptures in the Z-stripes. Lipid droplets as an indicator of ischemia could be identified. PtiO2 between 40 and 80 mmHg before intervention decreased down to 0-2 mmHg within the first 9 min after diagonal branch ligation and did not increase even after TMLR. CONCLUSIONS: In this acute ischemic model using pigs, TEM evaluation following TMLR proves irreversible changes of the myocardial ultrastructure. Furthermore, TMLR was not able to increase ischemically induced decrease of ptiO2. These data provide some evidence that TMLR thus, may not be able to ameliorate acute ischemia at least in the pig model. Further investigations are needed to investigate the effect of TMLR in chronic myocardial ischemia.

Continuous venovenous haemofiltration in neonates with renal insufficiency resulting from low cardiac output syndrome after cardiac surgery.

Acute renal insufficiency is a common complication after surgery for congenital cardiovascular defects in neonates and is associated with a high incidence of morbidity and mortality. The authors reviewed their experience with continuous venovenous haemofiltration in neonates and infants with acute renal insufficiency resulting from low cardiac output following cardiovascular surgery. Twelve critically ill patients with pharmacologically intractable fluid overload were treated with continuous venovenous haemofiltration over a period of 42 months. All patients were mechanically ventilated and dependent on high doses of catecholamines. Continuous venovenous haemofiltration was started 64.2(28.2) h postoperatively and maintained for a period of 8 to 195 h. A negative fluid balance was achieved in all patients (2.1(0.5) ml/kg per h). No complications relating to continuous venovenous haemofiltration were evident during the treatment. The survival rate was 59% (seven of 12). Continuous venovenous haemofiltration is a valid and simple method for controlling fluid overload in neonates and infants with low cardiac output.

A new experimental model and formula for flow determination and possible application in sizing of interatrial communication.

The concept of an artificial interatrial communication in application of the Fontan procedure in high risk patients has raised the problem to exactly determine the shunt amount. This experimental study shows that in vitro flow studies of interatrial communications can be performed without animal blood and PTFE membranes respectively. Furthermore the simulation of an pulmonary vascular venous flow is not necessary. Additionally a new formula with acceptable accuracy for flow estimation is derived from the presented data obtained by this study.

Cardiovascular dynamics and dimensions after bicaval and standard cardiac transplantation.

Bicaval orthotopic cardiac transplantation leaving the right atrium intact has been introduced recently into clinical practice as an alternative to the standard method. To determine the effect of the surgical technique, 27 patients were studied at rest and supine exercise 19 +/- 5 months after bicaval orthotopic cardiac transplantation (group A, n = 15) and 22 +/- 7 months after standard orthotopic cardiac transplantation (group B, n = 12). Resting hemodynamics showed no difference between groups. With exercise, a significantly higher right atrial pressure was noted in group B. Echocardiographic analysis showed asynchronous right atrial contraction in 83% of group B patients versus none in group A. Resting right ventricular dimensions were significantly greater in group B (right ventricular end-diastolic diameter, 3.27 +/- 0.44 cm versus 2.88 +/- 0.35 cm [p < 0.05]; right ventricular end-diastolic area, 21.3 +/- 2.85 cm2 versus 17.1 +/- 2.01 cm2 [p < 0.005]). A higher incidence and significantly higher grade of tricuspid regurgitation were found throughout exercise in group B. The exercise duration (17.34 +/- 3.53 minutes versus 14.04 +/- 4.11 minutes [p < 0.05]) and the exercise capacity (1.17 +/- 0.25 W/kg versus 0.93 +/- 0.34 W/kg [p < 0.05]) were increased in group A. These data provide some evidence that the bicaval technique of cardiac transplantation improves cardiovascular dynamics and dimensions as well as exercise capacity.

Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation.

Conventional cardiac transplantation with atrial anastomoses alters atrial integrity, geometry, and possibly function. Theoretically, this may also contribute to the development of tricuspid insufficiency that is frequently observed after the operation. Thus more anatomic transplantation techniques using bicaval anastomoses were recently introduced into clinical practice. Knowledge of their efficacy, however, is scarce. Therefore right atrial size and tricuspid valve function were compared in patients with bicaval (group A) and standard atrial (group B) anastomoses in a randomized, prospective study. The results of this echocardiographic study at rest and exercise in 18 patients (bicaval n = 8; atrial n = 10) on the average 28 months after transplantation are presented. The right atrial dimension was comparable between group A patients and control subjects and larger in group B patients (p < 0.05). The incidence of tricuspid regurgitation was not different between the two groups at rest, but it was at exercise (50 watts of workload) (p < 0.05). This study suggests that up to 36 months after cardiac transplantation the technique of bicaval in contrast to atrial anastomoses preserves right atrial size and reduces tricuspid regurgitation during exercise. Whether this leads to improved hemodynamics and increased exercise capacity remains to be evaluated in a larger series of patients.

Rapidly growing Epstein-Barr virus-associated pulmonary lymphoma after heart transplantation.

There is strong evidence to show an association of Epstein-Barr virus (EBV) infection with the development of post-transplant lymphoproliferative disease. We report the rapid development of a malignant lymphoma in a heart transplant recipient, which occurred within less than eight weeks. The diagnosis of this malignant high grade B-cell lymphoma was established by open lung biopsy, and classified as centroblastic lymphoma of polymorphic subtype. Immunohistochemically, the lymphoma showed reactivity with the B-cell markers L-26 (CD20) and Ki-B5 and with the activation marker Ber-H2 (CD30). Furthermore, an expression of the bcl-2 oncoprotein was detected. Monoclonal JH gene rearrangement was demonstrated by polymerase chain reaction (PCR), indicating monoclonal proliferation of B-blasts. Although serum EBV immunoglobulin M (IgM) antibodies were negative, the association to an EBV infection could be demonstrated by EBV immunostaining pattern which revealed an expression of the latent membrane protein (LMP) of EBV in the atypical blasts. The results give clear evidence of an EBV association of this rapidly growing lymphoma developed after heart transplantation.

An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium.

The standard technique for orthotopic cardiac transplantation implies large atrial anastomoses which do not preserve the anatomical integrity of the donor atria. This may become a potential source of electrophysiological and mechanical atrial dysfunction, especially in the right atrium with the sinus node and the sensitive low-pressure atrioventricular valve. As an improvement we suggest an alternative technique which we have recently developed for orthotopic cardiac transplantation; it combines the simple, convenient left atrial connection of the standard technique with individual anastomoses of the superior and inferior venae cavae, preserving the right atrium of the donated heart intact. This technique and our first results in two cases are described. Postoperatively, no arrhythmias and no signs of tricuspid insufficiency were observed.

[Traumatic aortic rupture: immediate surgery--interval operation?]. / Traumatische Aortenruptur: Sofortoperation--Intervalloperation?

On the basis of our own patient population of the last 12 years which involved 17 traumatic ruptures of the descending thoracic aorta in the isthmus area (preoperative hospital mortality at the time of diagnosis: 5.8%; surgical mortality: 27%; postoperative hospital mortality: 18.7%) the problems of assessing indications for surgical intervention in polytraumatized patients with aortic damage are discussed. The indications for "immediate surgery", for "surgery with delayed urgency", and for "surgery in the interval" are clearly defined.

Assessment of different preservation and storage conditions on aortic valves: introduction of a quantitative measuring method of the integrity of endothelial cells.

The fate of human allogeneic aortic valves depends mainly on their histological and immunological condition at the time of transplantation. A screening test making novel use of Alcian Blue was used to determine the integrity of endothelial cells as a prerequisite to their function. The dye uptake into the nucleus was measured quantitatively. The test was used to compare the effect of different storage mediums and temperatures (+4 degrees C, -30 degrees C, -80 degrees C, DMSO, FCS, RPMI, antibiotic solution) on aortic valves of rats. The cell integrity decreased with increasing storage time and higher storage temperature. The cryoprotective agent DMSO had no essential effect on the maintenance of cell integrity.

A "semi-supported" porcine xenograft--description and first clinical use.

The anatomy of valsalva's sinus is such that it decreases the mechanical stress on the leaflets of the aortic valve. Artificial stents impair the hemodynamic performance of an aortic bioprosthesis and lead to unphysiological functional stresses and may also shorten their durability. Therefore a semi-supported xenograft was developed which can be attached with an one-suture row in subcoronary position. This facilitates surgery considerably. Moreover, the commissures can be attached directly to the patient's aortic wall. The semi-supported valve was successfully implanted in a 69 years old patient with a combined aortic valve lesion. Postoperative invasive investigations, including angiography and videodensitometry, showed a normal performance of the valve and a normal anatomy of the aortic root.