Extra-anatomic management of homograft reinfection after thoracic aortic rupture.

Vascular graft infections involving the thoracic aorta have high morbidity and mortality rates. The management of homograft reinfection has not been discussed yet. A 23-year-old woman suffered a rupture of the descending thoracic aorta. Seven months after interposition of a Dacron graft she was readmitted for graft infection and a homograft was inserted. An esophageal lesion was oversewn. Follow-up CT showed several aneurysms around the homograft. She underwent implantation of an extra-anatomic ascending-descending aorta Dacron bypass with stump closure of the descending aorta. The patient is alive and free from reinfection seven years later.

Intra- and extravascular volume status in patients undergoing mitral valve replacement: crystalloid vs. colloid priming of cardiopulmonary bypass.

BACKGROUND AND OBJECTIVE: Cardiopulmonary bypass is associated with changes of intra- and extravascular volume status often resulting in cardiopulmonary dysfunction. The purpose of this prospective double-blind study was to evaluate the influence of different priming solutions of the extracorporeal circuit on intra- and extravascular volume status and haemodynamics in patients undergoing elective mitral valve replacement. METHODS: Twenty-two patients with mitral valve insufficiency were randomly allocated into two equal groups. In Group 1 cardiopulmonary bypass was primed with a nearly isooncotic solution consisting of 4% albumin. The second group received a pure crystalloid priming solution. The thermo-dye indicator dilution technique was used for the assessment of cardiac output, central and pulmonary blood volume, right ventricular end-diastolic volume and total blood volume. RESULTS: Patients in the crystalloid group showed increased intraoperative fluid requirements. Significantly more fluid was accumulated in the extravascular space whereas total blood volume was decreased after surgery. Stroke volume index (SVI) was significantly decreased in the immediate postoperative period when compared to baseline. As indicated by the increase in extravascular fluid content after surgery, both colloid and crystalloid priming volumes were transferred to the extravascular space. CONCLUSION: The use of colloid priming solutions in patients with mitral valve insufficiency leads to less fluid requirements and significantly reduced fluid shift in the interstitium. However, these changes are not associated with changes in haemodynamic parameters or short term outcome.

Effects of induction of anaesthesia with sufentanil and positive-pressure ventilation on the intra- to extrathoracic volume distribution.

BACKGROUND AND OBJECTIVE: Induction of general anaesthesia in combination with positive-pressure ventilation is often associated with a significant decrease of arterial pressure. A decreased preload may contribute to this phenomenon. The aim was to investigate whether a change in cardiac filling occurs following the induction of general anaesthesia with sufentanil under typical clinical conditions. METHODS: Fifteen patients scheduled for elective coronary bypass grafting were studied immediately before surgery. In addition to standard monitors, a transpulmonary double-indicator dilution technique measured in vivo intrathoracic blood volume, global end-diastolic volume and total circulating blood volume. For induction of anaesthesia 2 microg kg(-1) sufentanil was given. Measurements were performed awake and after the induction of anaesthesia, intubation and mechanical ventilation of the lungs. RESULTS: To maintain arterial pressure during the induction period within -20% of baseline pressure, on average 22 +/- 6mLkg(-1) crystalloids and 8 +/- 6mLkg(-1) colloids were given. Despite these amounts of fluid, cardiac filling was decreased, whereas circulating blood volume increased significantly. Both central venous pressure and pulmonary capillary wedge pressure increased. CONCLUSIONS: Induction of general anaesthesia with positive-pressure ventilation is regularly associated with a blood volume shift from intra- to extrathoracic compartments. Even in low-dose opioid monoanaesthesia with sufentanil--often regarded as relatively inert in haemodynamic terms--the phenomenon could be demonstrated as the primary cause of the often-observed decrease of arterial pressure. It seems, therefore, rationally justified to restore cardiac filling by generous administration of intravenous fluids, at least in patients with unaffected cardiac pump function. During induction of anaesthesia, central venous pressure and pulmonary capillary wedge pressure do not reliably indicate cardiac filling.

Efficacy of balloon valvuloplasty in patients with critical aortic stenosis and cardiogenic shock--the role of shock duration.

BACKGROUND: Because of limited long-term success, aortic balloon valvuloplasty is considered to be a palliative procedure, including patients at excessive risk for standard therapy-aortic valve replacement-that is, those in cardiogenic shock. HYPOTHESIS: The study was undertaken to evaluate the outcome of balloon valvuloplasty for critical aortic stenosis complicated by cardiogenic shock. METHODS: Over a 10-year-period, we followed 14 patients (age 74+/-11 years, range 50-91) presenting in cardiogenic shock and critical aortic stenosis, who underwent valvuloplasty, together with 19 patients with critical aortic stenosis requiring urgent major noncardiac surgery. RESULTS: In patients in shock, calculated aortic valve area could be increased successfully by at least 0.3 cm2, from 0.38+/-0.09 to 0.81+/-0.12 cm2, with an insignificant increase in cardiac index from 1.89+/-0.33 to 2.01+/-0.41 l/min * m2. In-hospital mortality was 71% (10 patients). Two patients underwent valve replacement within 16 days and survived after 1 year, as did two patients refusing surgery. By multivariate logistic regression analysis, only an interval between onset of shock symptoms and valvuloplasty of > 48 h was significantly associated with fatal outcome (p < 0.01). In those patients requiring noncardiac surgery, this was possible after valvuloplasty in 95% who survived 1 year after hospital discharge. One patient in this group died of pulmonary embolism the day after the procedure. CONCLUSION: These data support the concept of causal treatment in patients with cardiogenic shock, as well as in the setting of cardiogenic shock and critical aortic stenosis, at the earliest possible convenience.

Improvement of impaired renal function in heart transplant recipients treated with mycophenolate mofetil and low-dose cyclosporine.

BACKGROUND: Cyclosporine (CsA) nephrotoxicity is a common problem after cardiac transplantation. We have studied the impact of CsA dose reduction in association with mycophenolate mofetil (MMF) treatment on renal function in heart transplant recipients with suspected CsA nephrotoxicity (serum creatinine level >2 mg/dl). METHODS: Twelve heart transplant recipients (11 men, 1 woman; 111 to 1813 days after transplantation) with CsA-based immunosuppression (plus azathioprine and/or steroids) and a serum creatinine level >2.0 mg/dl were started on a daily dose of 2000 mg of MMF. Dilated cardiomyopathy was the underlying disease in nine patients, ischemic cardiomyopathy in three patients. Mean patient age was 57 years (range 44-69 years). Azathioprine was discontinued and CsA slowly tapered. Creatinine clearance, serum creatinine level, urea nitrogen, and uric acid were monitored. CsA levels were measured, and CsA dose was adjusted for whole blood levels of 70-120 microg/L. Ten patients still had endomyocardial biopsies, whereas one had echocardiographic controls only. RESULTS: One grade 1B rejection episode according to ISHLT (International Society for Heart and Lung Transplantation) was observed until 1 year after the switch to MMF. One patient was excluded due to gastrointestinal side effects. CONCLUSIONS: Conversion from azathioprine to MMF with consecutive reduction of CsA in heart transplant recipients with CsA-impaired renal function improves renal function as evidenced by lower serum creatinine, urea nitrogen, uric acid, and higher creatinine clearance.

[Deep leg and pelvic vein thrombosis in aplasia of the inferior vena cava]. / Tiefe Bein- und Beckenvenenthrombosen bei Aplasie der Vena cava inferior.

Deep phlebothromboses of iliacal vein and aplasia of the inferior vena cava Coincidence of deep phlebothromboses of iliacal vein and aplasia of the inferior vena cava is a rare condition but has significance for further therapy. Two cases of this anatomical malformation with complications are presented and the importance of therapeutical strategies are discussed. We report on our experiences with the operative procedures of venous thrombectomy and arteriovenous fistula, aimed at increasing the venous flow in the collaterals of the aplastic inferior vena cava.

Leiomyosarcoma of the diaphragm.

An asymptomatic, intrathoracic mass was found on imaging studies in a 53-year-old man. After excision it proved to be an extrapulmonary leiomyosarcoma, a rare malignancy of smooth muscle, originating from the right diaphragm. The location of this malignant tumor is rare in an adult. The tumor was resected, the diaphragm was reconstructed, and the patient should have a long-term cure and good quality of life.

Heart transplantation after successful donor postpartum pulmonary embolectomy.

A fulminant pulmonary embolism can be treated surgically if thrombolytic therapy is contraindicated. A 31-year-old woman developed a fulminant pulmonary embolism after right-sided deep venous thrombosis 1 day after undergoing a cesarean section. A pulmonary embolectomy with cardiopulmonary bypass was performed, but the patient was brain-dead. After 2 days of echocardiographic observation, her heart was explanted for a 61-year-old man with ischemic cardiomyopathy. His right heart data were unremarkable, and he remains well 16 months after transplantation. Despite the sudden strain on the right ventricle that occurs with a pulmonary embolism, such a heart may be transplanted successfully after a pulmonary embolectomy.

Changes in central venous pressure and pulmonary capillary wedge pressure do not indicate changes in right and left heart volume in patients undergoing coronary artery bypass surgery.

The value of pulmonary artery catheterization is a matter for discussion. Previous studies suggest that direct measurements of intravascular volume distribution and cardiac volume indices may be of greater relevance than central venous and pulmonary capillary wedge pressure. We therefore used a thermo-dye dilution technique for the quantification of central blood volume, right ventricular end-diastolic volume and left heart volume in patients undergoing coronary artery bypass surgery. Measurements were performed after the induction of anaesthesia as well as 1, 6 and 24 h after surgery. Central venous pressure was significantly increased at 1 and 6 h, whereas right ventricular end-diastolic volume was increased only at 6 h post-operatively. Pulmonary capillary wedge pressure showed a tendency to increase whereas left heart and central blood volume decreased significantly after surgery. The results of the present study suggest that changes in cardiac filling pressure do not indicate changes in indices of cardiac volume in patients after coronary bypass surgery.

Calcification tendency of various biological aortic valves in an experimental animal model.

The present study aimed at investigating the influence of fixation methods on the ultrastructure and calcium content of five different aortic biovalves. Biovalves subcutaneously implanted in Wistar rats for 12 weeks demonstrated significant differences in their calcium contents. Using Scheffe tests, two different groups of biovalves could be distinguished: (i) valves with high calcium content, such as Toronto-SPV (165 +/- 42 mg/g dry tissue) and Intact (193 +/- 36 mg/g dry tissue), and (ii) valves with low calcium content, such as Mosaic (2.7 +/- 1.8 mg/g dry tissue), Freestyle (2.3 +/- 1.1 mg/g dry tissue) and Hancock-II (3.6 +/- 1.2 mg/g dry tissue) (P < 0.05). All biovalves with an ultrastructurally preserved endothelium exhibited a low calcification tendency. The data suggest that if the endothelium is lost as a result of the fixation procedure, then calcification can only be prevented by appropriate anticalcification methods.

Resection for CMV ileitis in a patient supported by a left-ventricular assist device.

We describe a patient requiring a HeartMate 1000 IP left-ventricular assist device (LVAD) due to cardiogenic shock. After prolonged gastrointestinal bleeding without identifying the source of bleeding technetium scintigraphy pointed to the right lower abdomen. The patient underwent a laparotomy and inflamed ileum was resected. Pathologic examination revealed cytomegalovirus ileitis. This was treated with ganciclovir and acyclovir. The patient is now (14 months later) awaiting heart transplantation since she could not be weaned from LVAD. The diagnostic and management problems are discussed as well as the relevance for future transplantation.

Influence of arterial carbon dioxide tension on systemic vascular resistance in patients undergoing cardiopulmonary bypass.

BACKGROUND: The effects of induced hypothermia in cardiac surgical patients are not yet fully understood. Despite numerous studies on the effects of acid-base management on organ blood flow, only little information is available on the effects of alpha-stat versus pH-stat management on systemic haemodynamics. We therefore compared the effect of alpha-stat and pH-stat acid-base management on systemic haemodynamics in a prospective, controlled, cross-over study. METHODS: Twenty patients undergoing coronary artery bypass surgery were included in the study. Cardiac output was measured by thermodilution. Cardiac index and systemic vascular resistance were calculated according to standard formulae. Measurements were performed under hypo- and hypercapnia after induction of anaesthesia. Measurements were repeated at the end of two 30-min periods of pH-stat and alpha-stat acid-base management, respectively. RESULTS: Systemic vascular resistance at the lower PaCO2-levels (hypocapnia and alpha-stat, respectively) was significantly higher than those at the higher level (hypercania and pH-stat, respectively). The periods of different PaCO2-levels were comparable with respect to haematocrit, blood viscosity and temperature. Systemic vascular resistance was not significantly different from the control period. CONCLUSIONS: This study demonstrates that during hypothermic cardiopulmonary bypass, systemic vascular resistance under alpha-stat acid-base management is higher than under pH-stat management. As obvious from measurements during the control period, this finding can be completely explained by the difference in PaCO2.

Acute affect of mitral calve replacement on extravascular lung water in patients receiving colloid or crystalloid priming of cardiopulmonary bypass.

Despite numerous studies on extravascular lung water (EVLW) in patients undergoing coronary artery bypass surgery, few data are available on the perioperative time course of EVLW in patients undergoing mitral valve replacement for mitral valve insufficiency (MVI). We have investigated 26 patients undergoing elective mitral valve replacement in order to determine the influence of the preoperative degree of mitral valve insufficiency (degree III or IV) and the effect of different priming solutions for cardiopulmonary bypass. Crystalloid priming with Ringer's lactate was compared with human albumin priming solution. Measurement of EVLW was performed using the thermo-dye dilution technique, before and 1, 6 and 24 h after surgery. Before operation, EVLW is increased significantly in patients with MVI degree IV (MVI-degree IV) compared with patients with degree III (MVI-degree III) and patients undergoing coronary artery bypass surgery. During the postoperative time course a significant decrease in EVLW was observed in patients with MVI-degree IV whereas in patients with MVI-degree III the amount of EVLW did not change. However, compared with patients undergoing coronary artery bypass surgery, EVLW remained above normal in both groups. There was no interaction between the type of priming solution and the postoperative time course of EVLW, and no differences in respiratory variables or duration of mechanical ventilation were observed between groups.

Kidney salvage in a case of ruptured renal artery aneurysm: case report and literature review.

A 79-year-old woman presented with hypovolaemic shock caused by rupture of a left renal artery aneurysm. She was successfully treated by arterial reconstruction with functional salvage of the kidney. The frequency of renal artery aneurysms, their risk of rupture and the results of urgent surgery are discussed.

The influence of controlled mandatory ventilation (CMV), intermittent mandatory ventilation (IMV) and biphasic intermittent positive airway pressure (BIPAP) on duration of intubation and consumption of analgesics and sedatives. A prospective analysis in 596 patients following adult cardiac surgery.

The aim of the study was the determination of the influence of ventilation modes on the consumption of analgesics and sedatives, duration of intubation and pulmonary gas exchange. Assist/controlled mandatory ventilation (S-CMV, 123 patients), synchronized intermittent mandatory ventilation (S-IMV, 431 patients) and biphasic positive airway pressure ventilation (BIPAP, 42 patients) were compared in a prospective, controlled, open clinical trial over an 18-month period. Five hundred and ninety-six adult patients with normal pulmonary function before surgery and uneventful course following coronary artery bypass graft surgery were studied. Patients ventilated with BIPAP had a significantly shorter mean duration of intubation (10.1 h, P < 0.05) than patients treated with S-IMV (14.7 h) and S-CMV (13.2 h). In the S-CMV group, 39.9% of the patients required single or multiple doses of midazolam, but only 13.5% in the S-IMV group and 9.5% in the BIPAP group. The mean total amount of midazolam administered to these patients was significantly higher in the S-CMV group (8.8 mg) than in the S-IMV group (6.6 mg, P < 0.05) and in the BIPAP group (4.3 mg, P < 0.05). The consumption of pethidine and piritramide did not differ between S-CMV and S-IMV, but was significantly lower during BIPAP (P < 0.05). After extubation the patients' PaCO2 was highest in the S-CMV group. We conclude that ventilatory support with BIPAP reduces the consumption of analgesics and sedatives, and the duration of intubation. The possibility of unrestricted spontaneous breathing in all phases of the respiratory cycle is considered to be the reason. BIPAP seems to be an alternative to S-CMV and S-IMV in short-term ventilated patient.

Surgical treatment of abdominal aortic aneurysms of octogenarians.

The purpose of this study was to determine whether elective abdominal aortic aneurysmectomy in octogenarians is justified or may even be advisable. Between January 1986 and August 1993, 30 octogenarians of mean age 83.1 (range 80-93) years underwent abdominal aortic aneurysmectomy. Patients were divided into two groups: group 1 (n = 9) underwent elective surgical repair; group 2 (n = 21) underwent emergency procedure. In 28 patients location of the abdominal aortic aneurysm was infrarenal; two patients presented with a juxtarenal aneurysm. The average aneurysm diameter was similar in both groups (group 1, 68.8 mm; group 2, 83.5 mm, P = n.s.). In group 2, two patients had free peritoneal rupture, one presented with rupture into the duodenum and one with penetration into the vena cava. Rupture was confined to the retroperitoneum in another 15 patients. Two patients had an expanding aneurysm. Hospital mortality rate was zero in group 1 and 42.8% in group 2 (P = 0.011). Most early deaths were related to cardiac disease. The overall complication rate was 22% in group 1 and 62% in group 2. Mean intensive care unit time was 1.8 (range 1-3) days in group 1 and 3.6 (range 1-8) days in group 2 (P = 0.47). The 5-year survival rate was 67% in the electively managed group and 34% in the emergency group.

[Intraoperative coronary angioscopy after unsuccessful percutaneous dilatation angioplasty and the implantation of an intracoronary stent]. / Coronaroangioscopia intraoperatorie în urma angioplastiei dilatative percutane nereusite si implantarea de stent intracoronarian.

In all coronary arteries after failed PTCA with subsequent stent insertion the stenosed and dilated part of the vessels were inspected. We found dissections in 17/25 coronary lesions as well as thrombus adherent to the wall of the vessels in 8/25 cases. The morphology of the coronary stenosis was compared with the preoperative cine-angiogram. The angioscopic images after failed PTCA and subsequent stent-insertion showed severe wall dissections which were located beyond the inserted stent. In none of the cases was stent-implantation the sufficient treatment of coronary lesions. In all patients we performed coronary artery bypass grafting (CABG). Every coronary incision was used for peripheral anastomosis of the bypass grafts.

Successful surgery after complete disruption of the right bronchial system.

A case of successful surgical repair of a complex rupture of the right bronchial system in a twenty-nine-year-old man is presented. Complete primary bronchial reconstruction and intensive postoperative care was required to provide bronchial continuity and to avoid major pulmonary resection. Problems concerning diagnosis, surgical technique, and postoperative management are discussed. The good postoperative outcome may encourage bronchial repair instead of resection in complex bronchial disruptions.

True aneurysm of the superior gluteal artery: case report and review of the literature.

Aneurysms of the gluteal arteries are rare and mostly are caused by pelvic fractures or penetrating injuries. As such these aneurysms are pseudoaneurysms. As an absolute rarity we report the case of a 43-year-old man with a histologically verified 5 cm-diameter, true saccular aneurysm of the left superior gluteal artery. The patient was admitted with 6-weeks ongoing sciatic pain without previous trauma. He was scheduled for surgery because an initial attempt of transcatheter embolization failed. By dividing the origin of the gluteus maximus muscle from the iliac crest, the aneurysm was exposed at the pelvic outlet by an extrapelvic approach and was excluded by endoaneurysmorrhaphy. Uncontrolled bleeding was prevented by temporary occlusion of the left iliac artery by a percutaneously inserted balloon catheter, thus avoiding an additional retroperitoneal approach. The postoperative course was uneventful, and sciatic pain had resolved completely. The chosen strategy provides safe and successful surgical management of gluteal artery aneurysms.