Is it really possible to support or replace a human heart with a mechanical pump--a human heart--with all its historical, philosophical, and emotional importance?
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Heart↗
Biomedical subjects
E Wolner
Publications and source records attributed to E Wolner.
Pharmacologically induced heart failure for the evaluation of circulatory assistance.
For the evaluation of the hemodynamic interaction between the natural heart and an assist device, a reversible pharmacological model based on the channel blocker Verapamil under hyperkalemia, was developed for deterioration of left ventricular function. Four calves weighing 70-90 kg underwent standard implantation for left atrioaortal assist (BioMedicus, BP-80), pump anesthesia (oxygen/isoflurane [1%]; 8 mg/kg of BW/h ketamine), and of ventricular demand pacing at 120 bpm. Left atrial pressure (LAP), ventricular pressure (LVP), aortic pressure (AoP), pulmonary arterial (Qpulm) pressures, and graft flow (Qgraft) were monitored. The hemodynamic effects of anesthetic overdose (2% Isoflurane) were compared with those of Verapamil (Isoptin: 0.2 mg/kg BW/h 5 mmol/kg of BW/h of KCl) medication. Both regimens caused a decreased in AoP to < or = 50%. For Isoflurane, a slight reduction in cardiac output (CO) of 10% at a nearly constant LAP and a strong decrease of the peripheral resistance (Rperi) of 35% could be seen where Isoptin caused a significant reduction in CO of 40% at an increased LAP (+25%) and changes in Rperi of < 10%. Because the vascular tonus remains nearly constant, the hemodynamic effects are controllable and reversible (antagonized with calcium chloride); thus we conclude that Verapamil administration under hyperkalemia conditions is a proper model for mimicking congestive heart failure with low systemic side effects.
Anesthetics, Inhalation↗
Acceptance of a pump-driven infusion therapy with prostaglandin E1 as a bridge to heart transplantation.
Ambulatory pump-driven intravenous infusions are a novel and - compared with hospitalization-cost-effective procedure to bridge refractory heart failure patients to cardiac transplantation. In the present study 13 patients received chronic infusions with prostaglandin E1 alone or in conjunction with catecholamines and the acceptance of this bridging therapy was investigated over a period of seven weeks. Prostaglandin E1 was uptitrated from 2.5 ng/kg/min to a maximum of 40 ng/kg/min, according to individual tolerance. 50% of the maximum tolerated dose of prostaglandin E1 was used for chronic infusion with a further dose reduction if side effects occurred. Altogether 8 patients who completed the therapy were analysed; of the remaining 5 three patients had a heart transplant, one patient died and one patient did not comply with the protocol. The drugs were administered by an automatic portable pump, which was connected to a subcutaneous tunneled catheter. During hospitalization patients and their relatives were instructed how to prepare drug solutions and to handle the infusion system. Patients' perceptions were investigated by visual analog scale questionnaires (rating scale zero to ten) before, and at weekly intervals during bridging therapy. Initial acceptance was documented as belief in therapy (9.4 +/- 1.2 SD), absence of fear of handling the pump (8.9 +/- 1.2 SD) and confidence of receiving help of close relatives (8.7 +/- 1.8 SD). During the observation period there were no statistically significant differences compared with this favorable starting position and no significant disruption of life style occurred. Pain in the joints-a prostaglandin E1-associated side effect-increased significantly (p < 0.05) at week 5, but returned to baseline levels during the following two weeks. At study end patients confirmed that they would repeat the experience (7.6 +/- 1.4 SD) and advise other patients to undergo this form of therapy (8.2 +/- 1.9 SD). Thus, this pilot study suggests that ambulatory pump-driven intravenous infusion therapy comprising prostaglandin E1 and catecholamines is acceptable to patients as a bridge to heart transplantation and that there should be no major difficulties regarding compliance.
Adult↗
Influence of human leukocyte antigen matching on long-term outcome after lung transplantation.
BACKGROUND AND METHODS: The importance of human leukocyte antigen matching for long-term outcome after lung transplantation is uncertain. We therefore analyzed retrospectively 78 consecutive primary, isolated lung transplantations (37 female, 41 male; 40 single, 38 bilateral) performed between October 1989 and October 1995 for which human leukocyte antigen typing of both donor and recipient was available. The follow-up ranged from 1 day to 60.3 months. Graft failure, defined as retransplantation or patient death, served as end point. RESULTS: Graft survival was significantly better with one mismatch at the B locus than with two mismatches (p = 0.046): 67% versus 51% and 61% versus 25% graft survival at 12 and 36 months, respectively. For the B and DR loci combined, a marked matching effect was also observed (p = 0.21 for zero to two mismatches versus three to four mismatches: 81% versus 62% and 51% versus 29% graft survival at 12 and 36 months, respectively. The sum of mismatches at the A, B, C, and DR loci combined showed a similar effect (p = 0.17 for zero to four mismatches versus five to eight mismatches: 83% versus 62% and 58% versus 29% graft survival at 12 and 36 months, respectively. Although no clear effect could be shown for the isolated DR locus, the outcome for the three patients with zero mismatches was notably good: one patient is alive at 27 months, two died 37 and 48 months after transplantation. The number of acute rejection episodes showed a clear but insignificant correlation to the number of mismatches. A similar trend was observed for the incidence of bronchiolitis obliterans syndrome. CONCLUSIONS: In summary, a strong influence of human leukocyte antigen matching on the long-term outcome after lung transplantation is suggested by our results. A clear trend toward improved graft survival with better human leukocyte antigen matching was observed, with the most significant effect occurring at the B locus.
Adolescent↗
[Lung volume reduction in emphysema--experience and results of the first 2 years].
Between September 1994 and August 1996 Lung Volume Reduction Surgery (LVRS) was performed through median sternotomy, videoendoscopically or by thoracotomy in 60 patients (age 33 to 80 years, mean 56.7 years). All these patients had severe emphysema despite maximal conservative and physical therapy. The areas with the most destroyed lung parenchyma were resected by means of linear stapling devices, 3 patients (20%) out of 15 who were operated via sternotomy died postoperatively due to aspiration pneumonia, multiorgan failure and acute hepatic failure. In the videoendoscopic group with 45 patients, 2 patients (4.4%) died due to multiorgan failure and cardiorespiratory failure. 72.7% of the remaining patients showed a significant functional improvement (postoperative FEV1 > 130% of the preoperative value) with a marked decrease of dyspnea. There was no significant improvement in 23.7% of the patients (postoperative FEV1 = 90 to 110% of the preoperative value) and 3.6% of the patients had a functional deterioration. Residual volume decreased from 317.0 +/- 12.4% of predicted (%p) preoperatively to 226.2 +/- 8.8 %p within the first month (p = 0.0001). FEV1 significantly increased from 23.7 +/- 1.3 %p preoperatively to 36.6 +/- 4.1 %p during the first 6 months postoperatively (p = 0.0016). Radiological signs of hyperinflation and distention of the thorax preoperatively improved to narrowed intercostal spaces and a more shaped diaphragm. These morphological changes resulted in better ventilatory muscle function. The intrinsic PEEP significantly decreased from 5.92 +/- 0.64 cm H2O preoperatively to 1.70 +/- 0.25 cm H2O postoperatively (p = 0.0001). The work of breathing decreased from 1.58 +/- 0.09 J/l preoperatively to 0.99 +/- 0.07 J/l postoperatively (p = 0.0001). In conclusion, LVRS is an excellent therapeutic option for patients with severe emphysema and additional signs of severe hyperinflation with significant postoperative functional improvement and marked increase in quality of life.
Female↗
[Surgical technique and results of bilateral volume reduction in patients with pulmonary emphysema].
Between 9/94 and 3/96 volume reduction was performed on 29 patients by a median sternotomy or videoendoscopic approach. Perioperative mortality occurred in three patients. The residual volume decreased within the first month from preoperative 308.8 +/- 13.4% of predicted (%p) to 217.9 +/- 12.7%p (p < 0.05). FeV1 significantly improved to 37.9 +/- 4.6%p after 3 months, versus 23.5 +/- 1.8%p preoperatively (p < 0.05). Intrinsic PEEP substantially decreased from 6.69 +/- 0.91 cm H2O preop to 0.93 +/- 0.28 cm H2O initially after surgery (p < 0.005). This was paralleled by the work of breathing: 1.78 +/- 0.2 J/l preoperatively versus 0.77 +/- 0.04 J/l postoperatively (p < 0.005). In conclusion, VR is a safe and successful option for patients with pulmonary emphysema, who show signs of marked hyperinflation.
Female↗
Phenotypic patterns of mononuclear cells in dilated cardiomyopathy.
BACKGROUND: Immunological factors in the pathogenesis of idiopathic dilated cardiomyopathy (IDC) were suggested previously on the basis of the demonstration of mononuclear cell infiltrates and autoantibodies against the myocardium. The present study investigated whether tissue leukocyte subpopulations isolated from hearts with IDC (n = 6) differ in phenotype from those of tissues without IDC (n = 7). METHODS AND RESULTS: Leukocytes were quantified as reactive cells per square millimeter in perivascular, interstitial, and parenchymal tissue sections. Freshly isolated heart-tissue T cells and peripheral-blood T cells from the same patients were analyzed by triple staining and flow cytometry to identify T-cell subpopulations as well as their states of differentiation (expression of CD45RA and Leu-8 versus CD45RO) and activation (IL-2R, IL-7R, very late antigen-1, HLA-DR). All types of infiltrating cells (T cells, B cells, macrophages, granulocytes) are increased in hearts with IDC compared with normal hearts, but only CD8+ T cells and macrophages are increased relative to the other leukocyte subpopulations. CD45RO+/CD45RA-/Leu-8- cells constitute the majority of heart-tissue T cells in both normal hearts and hearts with IDC. Strikingly, hearts with IDC are infiltrated by eightfold greater numbers of perivascularly located IL-2R(+)- (26% of all T cells) and CD45RO(+)-activated memory T cells; moreover, in contrast to normal heart, approximately 40% of both CD4+ and CD8+ heart-tissue T cells express activation markers. CONCLUSIONS: Both normal hearts and hearts with IDC are populated by leukocytes. The quantitative increase in IDC, associated with a dramatically altered activation status of heart-tissue T cells, suggests a direct role of infiltrating leukocytes in the pathogenesis of IDC.
Cardiomyopathy, Dilated↗
ICD therapy in survivors of sudden cardiac death awaiting heart transplantation.
The impact of implantable cardioverter defibrillator (ICD) therapy on survival of heart transplant candidates is of major socioeconomic and ethical interest. However, efficacy is even uncertain for patients at highest risk of tachyarrhythmic death on the waiting list. We studied 60 selected heart transplant candidates (mean age, 55.8 years; mean left ventricular ejection fraction, 0.15; functional class III and IV) with a history of successful resuscitation by external electric defibrillation for spontaneous, syncopal ventricular tachyarrhythmia during the study period from March 1992 through September 1994. At the time of registration for transplantation, 30 patients had ICD devices implanted, whereas 30 patients lacked ICD therapy for various nonmedical reasons. Both therapy groups were comparable in clinical and hemodynamic characteristics as well as in intention to transplant (median waiting time to transplantation, 5.7 and 6 months, respectively; not significant by log-rank method). Survival on the waiting list was significantly improved by ICD therapy; only 1 of the 30 ICD patients (19 transplanted) but 7 of the 30 non-ICD patients (14 transplanted) died on the waiting list (p < 0.05 by log-rank method). Implantable cardioverter defibrillator therapy did not affect survival after transplantation as compared with non-ICD patients (not significant by log-rank method). During the waiting time, 26 of the ICD patients (87%) experienced adequate ICD discharges, and 12 of the non-ICD patients were treated successfully by external electric defibrillation (40%).(ABSTRACT TRUNCATED AT 250 WORDS)
Death, Sudden, Cardiac↗
Echocardiographic results after repair of incompetent bicuspid aortic valves.
INTRODUCTION: Valve-related complications and the necessity of anticoagulation after aortic valve replacement have led to new operative techniques for correction of aortic insufficiency (AI). Fourteen patients with bicuspid aortic valves and significant AI underwent valve repair. METHODS: Transthoracic echocardiography was performed preoperatively and 1 week postoperatively and in 10 patients who have come to follow-up so far. Operative procedures were triangular resection of one leaflet in all patients. Five patients had pericardial patch plasty in addition. RESULTS: Mean AI decreased significantly from grade 3.5 +/- 0.1 preoperatively to 0.5 +/- 0.1 postoperatively (p < 0.001). Postoperatively, 10 patients had no or trivial AI (0 to 0.5), and 2 patients had mild AI (1 to 1.5). Within the first week, 2 patients were reoperated on after echocardiography established significant AI. Ventricular dimensions decreased from preoperative to postoperative and were normal after 1 year. At follow-up, 7 patients show no change of AI; in 3 patients AI increased to moderate because of dilatation of the sinus of Valsalva or the sinotubular junction. CONCLUSIONS: Reconstruction of bicuspid aortic valves is feasible with good early results. Echocardiography shows that asymmetric sinuses may lead to early perioperative failures and postoperative dilatation of the proximal aorta to increasing AI. Operative techniques may have to consider the pathology of the proximal aorta.
Adolescent↗
Influence of hematocrit and platelet count on impedance and reactivity of whole blood for electrical aggregometry.
Previous studies have shown that differing qualities of blood specimen seem to influence whole blood electrical aggregometry (WBEA), making it difficult to standardize the method. The aim of this study was to investigate the impact of hematocrit (HCT) and platelet count (PLC) on in vitro platelet aggregation in citrated whole blood (CWB) in order to compensate for their possible effects on impedance aggregometry. Red blood cells and blood platelets were isolated from fresh citrated whole blood taken from 15 healthy donors (mean age = 26 years) and recombined to 20 physiologically relevant combinations of hematocrit and platelet count (HCT: 20-50, PLC: 100-500). Platelet aggregability was measured using WBEA with three different triggers. A special-purpose software package was used in this study, ensuring proper calibration, acquisition, and evaluation of analogue to digital converted data, allowing the calculation of a set of characteristic parameters of each impedance curve. Most of the linear regressions showed that all parameters significantly depend on HCT and PLC. Furthermore, we found interactions of both variables, making it impossible to focus on the effects of one of the investigated variables only. The outcome of this study is a set of dependences, allowing the calculation of regressions for in vitro aggregation in whole blood, enabling a comparison of blood of any quality with each other, regardless of the variables HCT and PLC. Together with the previously defined dependence of sample age on WBEA data, this step should help to make this technique a more reliable and practicable clinical tool, making it suitable for daily routine investigations.
Adult↗
Prognostic factors in adenocarcinoma of the cardia.
BACKGROUND: The optimal extent of resection for adenocarcinomas of the gastroesophageal junction is controversial. This study was conducted to examine whether the extent of resection is an independent prognostic factor in cardia cancer. METHODS: The records and survival data of 125 patients who underwent resection for cancer of the cardia were retrospectively analyzed. Multiple regression was used to evaluate prognostic factors in patients who underwent proximal gastric resection (PR) or total gastrectomy (TG) for cancer of the cardia. RESULTS: Seventy-five patients underwent PR and 50 TG. The 5-year survival was 40% for tumors confined to the esophageal wall (T1, T2), and 13% in more advanced cases (T1, T2; P = 0.0001). Twenty-two percent of the patients with tumor-free margins, 10% of those with microscopic residual tumor, and none with macroscopic residual tumor survived longer than 5 years (P = 0.0001 for any residual tumor versus no residual tumor). Lymph node involvement (P = 0.002) and stage (P = 0.0001) were also significant in the univariate analysis. Five-year survival was 18% after TG, and 17% after PR (P = NS). CONCLUSION: Multiple regression identified residual tumor and penetration depth as independent predictors of survival (P = 0.0002, and P = 0.0001, respectively). After correction for these factors, none of the following variables were of additional significance: extent of resection (TG versus PR), lymph node involvement, age, or Lauren's classification. In 19 of 20 cases with microscopic incomplete resection, it was the oral margin that was positive. We conclude that the extent of resection (TG versus PR) does not influence survival in adenocarcinoma of the gastroesophageal junction.
Adenocarcinoma↗
Comparison of perioperative myocardial protection with nifedipine versus nifedipine and metoprolol in patients undergoing elective coronary artery bypass grafting.
A randomized study was performed on 70 patients undergoing elective coronary bypass grafting to examine whether the combined infusion of the calcium channel blocker nifedipine (10 micrograms/kg per hour) and the beta 1-blocker metopropol (12 micrograms/kg per hour, n = 34) reduces the prevalence of perioperative myocardial ischemia and arrhythmias. The control group received nifedipine alone (n = 36). In both groups the infusion was started from the onset of extracorporal circulation and maintained over a period of 24 hours. Repeated 12-lead electrocardiographic and 3-channel Holter monitor recordings for 48 hours were used to define perioperative myocardial ischemia (transient ischemic event, myocardial infarction) and arrhythmias (sinus tachycardia, supraventricular tachycardia, atrial flutter/fibrillation, ventricular tachycardia). Hemodynamic parameters were repeatedly assessed for 24 hours and serum enzyme levels (creatine kinase, MB isoenzyme of creatine kinase) for up to 36 hours after the operation. The two groups did not differ significantly with respect to preoperative anamnestic and surgical data. No signs of perioperative myocardial infarction were detected in either group. However, a significantly lower incidence of transient ischemic episodes was observed in the nifedipine-metoprolol group than in the nifedipine group (3% vs 11%; p < 0.05). In addition, there was a tendency toward lower creatine kinase MB levels and peak values of creatine kinase and creatine kinase MB in the nifedipine-metoprolol group. With regard to perioperative arrhythmias, there was a significantly lower incidence of sinus tachycardia and atrial flutter/fibrillation in the nifedipine-metoprolol group (9% and 6%) than in the nifedipine group (33% and 27%, p < 0.05). In addition, postoperative heart rate was lower in the nifedipine-metoprolol group starting from the sixth hour after release of the aortic crossclamp (p < 0.05 and p < 0.01, respectively). No other hemodynamic parameters showed significant differences between the two groups and all returned to preoperative levels within 24 hours. In conclusion, perioperative application of nifedipine and metoprolol in patients undergoing elective coronary bypass grafting reduces the prevalence of perioperative myocardial ischemia and arrhythmias without significant negative inotropic effects. The combined infusion of the two drugs appears superior to nifedipine alone in preventing perioperative myocardial ischemia and reducing reperfusion-induced arrhythmias.
Adrenergic beta-Antagonists↗
The impact of implantable cardioverter-defibrillators on mortality among patients on the waiting list for heart transplantation.
Implantable cardioverter-defibrillators were investigated for their impact on mortality in 228 consecutive heart transplant candidates on the waiting list for transplantation (207 patients without and 21 with implantable cardioverter-defibrillator therapy). The mortality rate in 207 patients without implantable cardioverter-defibrillator therapy was 23.2% and in 21 patients with implantable cardioverter-defibrillator therapy was 4.7%. In a Cox proportional hazards model for all 228 study patients (mortality while on the waiting list: 21.5%; transplantation rate: 54.8%), the absence of an implantable cardioverter-defibrillator was only a marginally significant predictor of mortality (p = 0.079). However, the absence of an implantable cardioverter-defibrillator was a powerful predictor of mortality for a subgroup of 134 patients with high-grade ventricular arrhythmias on Holter electrocardiography (mortality while on the waiting list: 26.1%; transplantation rate: 54.5%; p = 0.022) and for a subgroup of 58 survivors of sudden cardiac death (mortality while on the waiting list: 22.4%; transplantation rate: 56.9%; p = 0.018). Implantable cardioverter-defibrillator therapy can be strongly recommended in transplant candidates with a history of sudden cardiac death. Recommendations for an expanded, prophylactic use of implantable cardioverter-defibrillator therapy in heart transplant candidates cannot be given.
Arrhythmias, Cardiac↗
Transoesophageal echocardiographic follow-up of patients with surgically treated aortic aneurysms.
In the present study, biplane transoesophageal echocardiography (TEE) was scheduled as part of an aneurysm surveillance programme during routine ambulatory follow-up of 37 patients following aortic aneurysm surgery. Time from surgery ranged from 3-72 months. Twenty-two patients had had aortic dissection and 15 non-dissecting aneurysms. Nineteen patients received an interposition graft of the ascending aorta, 12 valved conduit and six an interposition graft of the descending thoracic aorta. TEE showed enlargement of the sinus of Valsalva > 45 mm in seven patients. Dilatation > 45 mm of one or more aortic segments was found in four patients. An intimal flap was present in all patients, with primary aortic dissection if the initial dissection extended beyond the replaced segment. This was the case in 17 of 22 patients with aortic dissection. One to four intimal tears were identified in 15 of these patients. In all patients with intimal tears, flow was detected by colour flow Doppler in the false lumen. Thrombus formation was nil or minimal in the false lumen in 12 patients. TEE significantly influenced further management in 14 of 37 patients (38%). More frequent follow-up was scheduled in eight patients. Aortic surgery was performed electively for the second or third time in six patients based on TEE findings. We conclude that after surgical repair of aortic aneurysm, the incidence of pathological findings by TEE is high. These may have significant influence on further patient management and emphasize the need for careful follow-up.
Adult↗
The CarboMedics "top hat" supraannular prosthesis in the small aortic root.
Twenty-three patients, 11 men and 12 women, with a mean age of 64 (range, 34 to 78) underwent aortic valve replacement (AVR) with a CarboMedics "Top Hat" supraannular prosthesis between March 1993 and August 1994. The top hat supraannular prosthesis, a standard bileaflet valve with the cuff transferred to the valve inflow level, allowed implantation of 21-mm, 23-mm, and 25-mm valves, where a standard 19-mm or 21-mm valve would have usually been placed. One patient who had been in preoperative cardiogenic shock died in the perioperative period. Another had an intraoperative cerebral embolism with permanent impairment. Follow-up on 22 of 23 patients over a mean period of 9 months revealed mean Doppler gradients of 18 +/- 6 mmHg, 15 +/- 2.8 mmHg, and 11 mmHg, for the 21-mm, 23-mm, and 25-mm valves, respectively. Functional improvement was noted, with 17 patients in New York Heart Association (NYHA) Class I and 6 in NYHA Class II, postoperatively, compared with 0 in Class I, 9 in Class II, 10 in Class III, and 4 in Class IV, preoperatively. One patient showed reduced postoperative ventricular function with fractional shortening below 25%. Pandiastolic regurgitation intrinsic to the valve graded as slight was noted in all patients. Other postoperative complications included one patient with anticoagulant-related gastrointestinal bleeding and one other with prosthetic valve endocarditis successfully treated with antibiotics. The CarboMedics top hat valve allows a gain in prosthesis size of 2 mm to 4 mm in the aortic position over standard prostheses, resulting in favorable postoperative hemodynamics.
Adult↗
Surgical treatment of type A aortic dissections. Results with profound hypothermia and circulatory arrest.
Type A aortic dissection still presents an emergency situation in cardiac surgery that is associated with high morbidity and mortality rates. There has been a significant improvement in the surgical outcome since the introduction of deep hypothermia and circulatory arrest. In this study, we discuss our results after operative repair of ascending aortic dissections, using deep hypothermia and circulatory arrest. This study presents the results of 67 patients (43 men, 24 women) from 18 through 81 years of age (mean, 54 years) who underwent surgery for type A dissecting aneurysm over a period of 4 years. Type A dissection (52 acute and 15 chronic cases) was due to Marfan syndrome in 12 patients, to atherosclerotic disease of the aorta in 27 patients, and to traumatic injury in 1 patient. Hypertension as the only pathologic finding was observed in 27 patients. Deep hypothermia (confirmed by isoelectric electroencephalogram) and circulatory arrest were induced in all patients. Two patients died intraoperatively due to massive bleeding (intraoperative mortality, 3%). The 30-day mortality rate was 30% (n = 20). Causes of perioperative deaths in order of frequency were multi-organ failure (n = 11), myocardial infarction (n = 2), postoperative bleeding (n = 2), cerebrovascular insult (n = 2), and sepsis (n = 1). The mean intensive care unit stay of the surviving 47 patients (72%) was 8 days, followed by a mean of 21 additional days in the hospital. Our experience with profound hypothermia and circulatory arrest, used in combination with coated grafts, supports our conviction that this is the method of choice for the treatment of type A dissecting aneurysm.
Adolescent↗
[Diagnostic and therapeutic video thoracoscopy: conversion rate and costs].
With the further development of new surgical techniques, that allow for the performance of a variety of standard diagnostic and therapeutic procedures in a less invasive fashion, it is instructive to look at the complications of these new techniques, in order to define their role for general thoracic surgery. 372 patients have been treated by means of video-assisted thoracic surgery (VATS) between 1/1992 and 12/1994. A total of 934 open thoracic procedures were performed in the same time frame, 399 out of them for the same chest disorders as treated by VATS alternatively. In 40 cases (10.7%) the endoscopic procedure had to be converted to an open thoracotomy. The main reasons for conversion were inability to locate or resect lesions due to a deep or central position (n = 13), requirement of further resection (n = 10), adhesions (n = 9), fibrinopurulent empyema (n = 5), bleeding (n = 2) and single-lung-ventilation failure (n = 1). The mean operation time was significantly shorter with VATS compared to open procedures, except for decortications. The mean hospital stay was 4.2 days in the endoscopic and 7.9 days in the thoracotomy group. Cost analysis for both techniques included expenses for disposable instruments, the operation room, anesthesia, and total hospital charges. Higher costs for instruments for VATS procedures were compensated by shorter chest drainage, less postoperative need for analgetics and a significantly shorter hospital stay.(ABSTRACT TRUNCATED AT 250 WORDS)
Cost-Benefit Analysis↗
[Results of valve-sparing correction of aortic valve insufficiency].
The risk of valve-related complications and the necessity of anticoagulation in patients with prosthetic valves, has led to new operative techniques in the correction of severe aortic insufficiency. In the last 2 years, 35 patients (mean age 41.3 years, range 10-80 years) with aortic insufficiency underwent reconstructive valves surgery. Eighteen patients had a commissuroplasty with or without triangular resection. In 5 patients with perforation, the valves could be reconstructed with a pericardial patch. In 12 patients with insufficiency due to aortic aneurysm, the valves were resuspended within the aortic prosthesis. In 2 patients the aortic valves were replaced intraoperatively because of unsatisfactory results. The perioperative mortality was 5.7%. The echocardiographic degree of aortic insufficiency decreased from 3.3 +/- 0.5 preoperatively to 0.45 +/- 0.53 postoperatively. Two patients were reoperated within the first week. Five of 23 patients at 1-year follow-up have mild to moderate aortic insufficiency. Mean ventricular dimensions and function at discharge and after 1-year follow-up are normal. With the new operative techniques described recently, valve-sparing corrections of aortic insufficiency are possible in an increasing number of patients, and autologous valve tissue can be saved. With more refinement of surgical technique, early postoperative results will further improve.
Adolescent↗