[Differential diagnosis of saccular aneurysms of the isthmus aortae: example of a penetrating atherosclerotic ulcer. Case-report and review of the literature]. / Sakkiforme Aneurysmen des Isthmus aortae. Differenzialdiagnose am Beispiel eines penetrierten atherosklerotischen Ulkus.

Most aneurysms of the isthmus aortae, particularly those following thoracic trauma, are most likely to be diagnosed as acute dissecting or post-traumatic pseudoaneurysms. Furthermore, penetrating atherosclerotic ulcers in patients with atherosclerosis, congenital aneurysms such as ductus diverticulum and Kommerell's diverticulum, luetic aneurysms, and saccular aneurysms associated with Marfan's syndrome have to be included in the list of differential diagnoses. In view of the severe effect of any open thoracic surgical intervention, exact preoperative diagnosis is crucial. We report the case of a 73-year-old male patient who was accidentally diagnosed with an aneurysm of the atherosclerotic isthmus aortae. The aneurysm extended from the aorta to the dorsal site. The sacciform aneurysm (4.5 cm) was resected electively. Based upon localisation and pathomorphological findings, a penetrating ulcer was diagnosed. We also present a review of the current literature and give a survey of the differential diagnoses of aneurysms of the aortic isthmus: penetrating atherosclerotic ulcus, acute (traumatic) dissecting aneurysm, post-traumatic pseudoaneurysm, ductus diverticulum, Kommerell's diverticulum, syphilitic aneurysm, and sacciform aneurysm due to Marfan's syndrome.

A multicenter initial clinical experience with right heart support and beating heart coronary surgery.

BACKGROUND: During coronary surgery without CPB, exposure of posterior vessel via sternotomy can cause deterioration of cardiac hemodynamics requiring inotrope drugs support. Recent animal experiments demonstrate hemodynamic benefit of right heart support (RHS) with the AMED system. The purpose of this study was to evaluate the hemodynamic effects during cardiac manipulation to expose the posterior coronary arteries, and determine the effect of RHS in restoring hemodynamics, increasing anastomotic exposure and reducing inotropic requirements. MATERIAL AND METHODS: From July 28 to December 29, 32 patients (25 men/7 women), mean age of 63.4 (+/- 6.2 years, ages: 49-78) received coronary revascularization with the A-Med RHS device. They were divided into two groups of 16 patients, A and B. Group A patients had at least one circumflex branch bypassed. The anterior wall was systematically bypassed off-pump without RHS. The right coronary artery (RCA) and the obtuse coronary artery (OM) were completed utilizing RHS. In group B patients, all vessels including anterior vessels were bypassed with the RHS. Mean arterial pressure (MAP), mean pulmonary arterial pressure (PAP), cardiac output (CO) and the average pump flow (APF) were recorded during the OM and RCA bypass for group A, and for group B LAD data was also recorded. RESULTS: Elective beating heart coronary artery bypass graft (CABG) was successfully accomplished in 32 patients with RHS. Data measurements recorded in Group A showed the improved hemodynamic recovery for OM and RCA bypass with RHS. The MAP increased from 44 to 68 mmHg (OM) and from 63 to 81 mmHg (RCA); the CO from 2.1 to 4.4 L/min (OM) and from 3.3 to 4.7 L/min (RCA). In group B, the data recorded showed the stability of the MAP in all vessels bypassed (LAD, OM and RCA). No device-related patient incidents occurred. All 32 patients were discharged to their homes. CONCLUSIONS: The AMED system, as RHS support, facilitated coronary bypass without CPB to posterior vessels, restoring hemodynamics, providing better exposure to anastomotic sites and apparently reducing inotropes need. Prospective randomize trials are necessary to confirm this initial experience.

Aortic valve replacement: better myocardial protection by cold or warm retrograde blood cardioplegia?

BACKGROUND AND AIMS OF THE STUDY: To determine whether warm blood cardioplegia (BCP) is superior to cold BCP in terms of myocardial protection, we compared warm (37 degrees C) and cold (4 degrees C) continuous retrograde administration of BCP in 40 patients undergoing aortic valve replacement (AVR) in a prospective, randomized study. MATERIALS AND METHODS: The main subjects of investigation were the myocardial oxygen consumption and the maintenance of the ultrastructure of the tissue. In addition, we looked at intraoperative recordings of time, heart rhythm disturbances, CK/MB serum levels, and inotropic support. RESULTS: We found, that oxygen consumption is significantly higher during warm BCP (7.95-10.38 ml/min) than during cold BCP (2.11-3.47 ml/min). Mild, reversible myocardial damage occurs during cold and warm BCP. The intraoperative serum potassium level was significantly higher after warm (7.25 mmol/l) than after cold (6.55 mmol/l) BCP. There was no statistically significant difference in the duration of extracorporeal circulation and of cardiac arrest, the CK/MB serum level or the recorded right and left ventricular performance data in the two groups. CONCLUSIONS: We conclude that continuous retrograde warm BCP is not superior to continuous retrograde cold BCP as far as myocardial protection is concerned. The administration of cold BCP prolongs the tolerated ischemic time of the myocardium and provides a higher safety margin.

Prophylactic use of hyperimmunoglobulin for cytomegalovirus infection in heart transplantation.

Cytomegalovirus (CMV) infection in solid organ recipients can endanger the immunosuppressed patient and increase vulnerability to secondary infections and the high risk of rejection triggered by the viral disease. The effect of passive immunization against CMV was examined in 69 heart transplant patients. The patients received weekly administrations of 1 ml/kg of CMV hyperimmunoglobulin from the day of transplantation until the 30th postoperative day. Forty-four of the patients were monitored clinically and serologically up to the 120th postoperative day. Nine patients showed clinical and serologic signs of CMV infection; in 15 the only evidence of CMV infection was a rise in antibody titers. The remaining 20 patients showed no clinical or serologic signs of CMV infection. Three patients who were seronegative preoperatively remained seronegative until the end of the observation period. The results indicate a potential therapeutic benefit of hyperimmunoglobulin prophylaxis to prevent infectious complications due to CMV in heart transplant patients.