Thoraxchirurgie, vaskulare Chirurgie最新文献

Supravalvular aortic stenosis is either a syndrome combined with typical face characteristics mental retardation and peripheral pulmonary artery stenosis or it occurs as an isolated congenital heart defect. The diagnosis was confirmed in 137 patients by means of catheterization and angiocardiography; 35 pediatric and 10 adult patients were considered to be candidates for corrective surgery because of the severity of their disease. Age varied from 3 to 32 years. 7 patients (15,5%) died. Recatheterization was performed in 12 children 5,6 +/- 4,1 years after surgery. Left ventricular pressures were decreased from 184,1 +/- 28,4 to 155,5 +/- 32,1 mm Hg, and the pressure gradients between left ventricle and the aorta fell from 101,2 +/- 19,7 to 29,1 +/- 23,1 mm Hg. The postoperative values varied between 0 and 80 mm Hg. Operative results are discussed in relation to the anatomical type malformation and the operative technique.

In order to determine the incidence of subendocardial ischemia after open heart surgery, subendocardial blood flow was monitored in 171 patients subjected to mitral and/or aortic valve replacement or coronary revascularization by on-line calculation of Diastolic (DPTI) and Systolic Pressure Time Index (TTI). Body hypothermia with an esophageal temperature of 25 degrees C and magnesium-aspartate-procaine cardioplegia were applied for myocardial protection. Ten patients developed low cardiac output state with two early deaths. In the two patients with fatal low cardiac output DPTI/TTI remained below 0.8. In the remaining 8 patients DPTI/TTI rose to 1.4 after a mean recovery time of 36 hours. In 161 patients (94%) no low cardiac output state evolved and DPTI/TTI rose to 1.3 within 60 min. after termination of cardiopulmonary bypass. Our results indicate that body hypothermia of 25 degrees C combined with magnesium-aspartate-procaine cardioplegia can reduce the incidence of subendocardial ischemia, but does not prevent this complication completely after anoxic times beyond 60-70 minutes.

218 benign tumors of the lung and pleura, 190 of which were operated, are discussed. Little doubt exists about the necessity of operative removal in cases of benign pleuro-pulmonary tumors. Therapeutic management depends on histology, localisation and the extent of growth. The majority of untreated benign tumors have a poor prognosis even if malignant degeneration does not occur. Postoperative prognosis of rehabilitation and resocialization is good.

At the time of preoperative coronary angiography in 44 patients left ventricular angiograms immediately after high frequency stimulation and after administration of nitroglycerin were performed. For interpretation we used the shortening (in percentage) of 8 vertical semi-diameters and of longitudinal axis in biplane angiograms. The data found in 15 healthy persons were used for comparison. Looking at the rate of shortening after high frequency stimulation myocardial areas endangered by hypoxia could be unmasked. By giving nitroglycerin thereafter we were able to differentiate between reversibly and irreversibly damaged areas. In 7 patients this has already been proven by postoperative examination. In preoperatively reversibly damaged myocardial areas no hypokinesis could be observed any more after successful revascularization. In contrast there was no improvement seen in preoperatively irreversibly damaged areas in spite of graft patency. The described preoperative angiography-test allows: 1. to unmask myocardial areas endangered by hypoxia. 2. to differentiate preoperatively between reversibly and irreversibly damaged areas. 3. more precise indication as well as better control of the results of revascularization.

There is still controversy of the validity of elevated CK-MB serum activity in the diagnosis of perioperative myocardial infarction after open heart surgery. CK-MB activity was investigated using myocardial and skeletal muscle biopsies and in sera postoperatively in 192 patients. In biopsies CK-MB fraction of total myocardial CPK was 37%, the total-CPK activity of human skeletal muscles still shows a 5% fraction of CK-MB. There has to be more than 8% CK-MB fraction of total CPK-serum-activity to take this as evidence of myocardial damage. 3 h postoperatively enzymatic-immunologic CK-MB test is no longer interfered by enzymes derived from hemolyzed erythrocytes. In patients without signs of myocardial lesions postoperatively mean CK-MB-activity is 11 to 27 U/1 depending on the operative procedure performed. Activity levels exceeding 50 U/1 are almost evident of myocardial infarction. Elevated CK-MB-serum activity is a sensitive parameter for myocardial lesions overestimating an event of infarction. It is a helpful tool diagnosing perioperative myocardial infarction.

In 342 patients undergoing open heart surgery we determined the serum enzyme levels of GOT, GPT, LDH, alpha-HBDH, LAP, CK and CK-MB from the beginning of the operation up to the 14 th postoperative day. There was an elevation of serum enzymes depending on the type of operation, the duration of extracorporal circulation and the postoperative course. A pattern of enzyme changes for uncomplicated cases is described. The investigations demonstrate a statistically significant correlation between the elevation of "liver specific enzymes" and right heart failure on one hand and of "heart specific enzymes" and myocardial ischemia on the other hand. It is concluded that only repeated determinations beginning with the operation enable to evaluate serum enzyme levels.

A pneumatically driven artificial heart with tubular silicone rubber membrane and disc valves was used in four patients with intractable postoperative cardiac failure. The operation was performed through a median sternotomy: large cannulas were placed in both atria and blood was returned to aorta and pulmonary artery. In three patients the natural heart recovered and the artificial ventricles were removed. One patient died 6 weeks after the operation, the other two left the hospital in good condition. Profound postoperative heart failure can be reversed by the use of the paracorporeal artificial heart; the advantage of the system lies in the simplicity of its implantation and removal.

Early and late results of a total of 72 infants operated for coarctation of the aorta are reported. Operative repair included various methods (End-to-End, Vossschulte, Clagett, Shumaker, Waldhausen, Blalock). Isolated coarctation was present in 6 infants, 17 also had patent ductus arteriosus, 39 patients had additional associated cardiac anomalies, part of which were combined with PDA. Out of the 72 infants 17 died (early mortality: 11, late mortality: 6). The highest mortality rate was found among the 0 to 3 months age group (11 patients). Fourteen out of the 17 deceased patients had additional cardiac anomalies. Out of the 55 survivals, 37 patients showed good results, restenosis was found in 13 patients, 5 patients had to be reoperated due to severe restenosis.

Between 1965 and 1976 40 patients underwent valve replacement for active, infective endocarditis. The overall mortality rate was 32,5 per cent. Six patients died early (within 30 days) and 7 within the following 8 years. 11 patients developed paravalvular leckage. Eight of these 11 patients required reoperation. We suggest that all patients with active infective endocarditis who develop progressive heart failure, intractable sepsis or recurrent embolization should be subject to immediate valve replacement despite higher operative risk.

The different pathophysiological mechanisms involved in producing airflow obstruction at different sites in the tracheobronchial tree enable their differentiation by means of pulmonary function tests. These tests include volume-time measurements at forced in- and expiration, flow-volume measurements forced in- and expiration and flow-pressure measurements in the bodyplethysmograph during quiet breathing. In 23 patients with localized stenosis of the central tracheobronchial tree (12 with extra-thoracic tracheal stenosis, 4 with intrathoracic tracheal stenosis and 7 with main bronchus stenosis) the following parameters proved to be of diagnostic value: In the differential diagnosis of intra-extra-thoracic tracheal stenosis the forced in-expiratory flow-volume curve, in main bronchus stenosis the plethysmographically obtained flow-pressure curve with a large phase lag at zero flow ("trapped air"). In extreme cases the qualitative analysis of the spirogram in connection with the static lung volumes can be diagnostic.