Cost-saving single-shot prophylaxis in cardiovascular surgery.
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Cardiac Surgical Procedures↗
Biomedical subjects
M Turina
Publications and source records attributed to M Turina.
[Acute ischemia syndrome: analysis of 144 cases].
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Acute Disease↗
[Endomyocardial biopsy following heart transplantation: results and complications].
Heart transplantation (HTPL) has worldwide become a well established therapy of terminal heart failure. Besides non-invasive parameters the endomyocardial biopsy (EMB) is proved to be the goldstandard method for early detection of graft rejection. At the University Hospital of Zurich 31 HTPL have been performed between September 1985 and December 1987. 100 out of 460 EMB's showed moderate or severe rejection and needed additional immunosuppressive treatment. 1.5% of all EMB's caused further treatment due to local or systemic complications.
Biopsy↗
Cardiopulmonary bypass without systemic heparinization. Performance of heparin-coated oxygenators in comparison with classic membrane and bubble oxygenators.
Performance characteristics of heparin-coated hollow-fiber membrane oxygenators (COATED HFMO, n = 5) were evaluated in an open-chest dog model without systemic heparinization. Four other oxygenators were evaluated with standard systemic heparinization (300 IU/kg, activated clotting time more than 400 seconds): a standard hollow-fiber membrane oxygenator (HFMO, n = 5), an inversed hollow-fiber membrane oxygenator (IHFMO, n = 5), a plate membrane oxygenator (PLATE MO, n = 5) and a bubble oxygenator (BUBBLE O, n = 5). The 25 dogs (36 +/- 12 kg) were perfused after cavo-aortic cannulation for 6 hours with a mean flow of 100 ml/kg body weight. At the end of perfusion without systemic heparin, heparin-coated equipment was replaced in three animals with standard uncoated equipment for control studies. Besides continuous hemodynamic evaluation with Mikro-Tip pressure transducers (Millar Instruments, Inc., Houston, Texas), a standard battery of analyses was performed before, after mixing, and every 30 minutes during bypass. All animals could be perfused in accordance with the protocol. Blood-gas values (pH, arterial oxygen tension, and arterial carbon dioxide tension) were maintained within physiologic ranges for all groups. After 6 hours of perfusion, plasma hemoglobin levels were as follows: 0.57 +/- 0.51 gm/L for COATED HFMO without systemic heparinization versus 2.65 +/- 1.02 gm/L for HFMO (p less than 0.05), 1.77 +/- 0.48 gm/L for IHFMO (p less than 0.05), 1.96 +/- 0.41 gm/L for PLATE O (p less than 0.05), and 1.5 +/- 0.40 gm/L for BUBBLE O (p less than 0.05) with systemic heparinization. Platelet levels were highest for COATED HFMO with 47% +/- 36% without systemic heparinization versus 33% +/- 9% for HFMO, 12% +/- 2% for IHFMO, 36% +/- 17% for PLATE O, and 19% +/- 12% for BUBBLE O with systemic heparinization. Activated clotting time for COATED HFMO without systemic heparinization was 135 +/- 75 seconds before bypass, 207 +/- 21 seconds after mixing, and 131 +/- 20 seconds after 4 hours of perfusion. There was no statistically significant increase of plasma heparin levels in the group perfused without systemic heparin. Determination of fibrin split products during perfusion without systemic heparinization did not show a significant increase. At the end of perfusion all devices were disconnected and gently rinsed with saline: There were no macroscopic clots in the COATED HFMO group perfused without systemic heparin. However, uncoated equipment introduced for control in animals perfused without systemic heparin showed major clotting.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
[Surgery of retroperitoneal pheochromocytoma].
Retroperitoneal pheochromocytomas are very uncommon tumors. During the last 10 years only 3 cases have been operated on in our clinic. Two of them were primary retroperitoneal paragangliomas. These two patients are now well and without recurrence 1 and 10 years respectively after operation. The third patient had retroperitoneal metastases of an adrenal pheochromocytoma. Now, after 1 year he has disseminated metastases without response to therapy with (131I)metaiodobenzylguanidine (MIBG). The surgical procedure includes often extended resection and replacement of retroperitoneal blood vessels and requires therefore an experienced surgical team and optimal anesthetic management (Swan-Ganz-katheter). In two cases the aorta was resected and replaced with a Dacron-graft. Reimplantation of both renal arteries into the graft was necessary in one case. Further interventions were: nephrectomy (2x), resection and ligation of the inferior vena cava (1x), resection and replacement of the left renal vein (1x).
Adrenal Gland Neoplasms↗
[Isolated rupture of an iliacus aneurysm].
A retrospective analysis of 23 patients with isolated iliac aneurysms is presented. The age of the 23 men ranged from 49 to 89 years (mean +/- SE: 72.2 +/- 8.4 y). All patients had pain, nineteen (83%) were in shock, in only 11 (48%) an abdominal mass was palpable. Fifteen (65%) of the aneurysms were located in the common iliac artery, 5 (22%) in the internal and 3 (13%) in the external iliac artery. Their diameter ranged from 3 to 12 cm (mean +/- SE: 7.8 +/- 2.6 cm). Resection with an unilateral graft interposition was done in 12 (52%), a Y-graft implanted in 8 (35%) and an endoaneurysmorrhaphy of the internal aneurysm performed in 2 patients. Early mortality was 22% and was not statistically different from the 28.6% mortality in ruptured abdominal aneurysm resections performed in the same time. Because of the substantial risk of rupture with high mortality elective operative intervention should be considered for isolated iliac aneurysms with a diameter more than 3 cm.
Aged↗
[Development of a small-lumen vascular prosthesis coated with autologous endothelial cells].
A new compliant prosthesis with a monolayer of autologous endothelial cells (ENC) has been developed. It consists of a porous polyurethane-siloxane-copolymer reinforced by a polyester network to prevent excessive dilatation. On the inner surface an ENC monolayer is established before implantation by a cell culture procedure. The prosthesis displays compliance (13.2 +/- 3.0 x 10(-4) mmHg-1) comparable to native arteries. It is non-kinkable (minimal radius of curvature less than 5 mm). Burst resistance, remaining deformation, cut out force and tensile strength are superior to standard values. ENC-coverage in excess of 95% of the inner surface was produced in vitro using a lining procedure. The monolayer of confluent cells was demonstrated to consist of endothelial cells by their characteristic cobblestone morphology, the expression of factor VIII related antigen and the specific uptake of Dil-Ac-LDL. The unstimulated prostacyclin production was similar both in native veins as well as in lined prostheses. Antithrombogenicity of the endothelial cell lining was demonstrated in 24 h animal implants.
Animals↗
[Surgery of traumatic aortic rupture].
This report describes the clinical presentation, diagnosis, surgery and results of patients with acute traumatic rupture of the aorta in a series of 21 consecutive patients. Direct cross-clamping without additional methods of spinal cord protection was used in 18/21 patients (86%). Direct suture was possible in 12/21 patients (60%). In the remaining patients, the repair was carried out by interposition of a Dacron graft. Overall mortality was 7/21 patients (33%). However, in 3 patients with severe polytrauma irreversible brain damage was the cause of death whereas 2 patients died from septicemia and myocardial infarction, respectively. No paraplegia nor paraparesis occurred in the surviving patients which were operated by direct cross-clamping of the aorta and rapid reanastomosis without additional methods of spinal cord protection.
Adolescent↗
[Anti-tachycardia pacemakers: welcome alternative in the therapy of paroxysmal supraventricular tachycardia].
Antitachycardia pacemakers can detect paroxysmal supraventricular tachycardias (PSVT) and interrupt them automatically by atrial overdrive pacing. In patients with PSVT, antitachycardia pacing offers a therapeutic alternative to drug treatment. The authors present the long term follow-up in their patients and explain the indication for implantation.
Adult↗
Difference between endothelium-dependent relaxation in arterial and in venous coronary bypass grafts.
Both the internal mammary artery and the saphenous vein are used to construct coronary-artery bypass grafts. We hypothesized that the release or production of endothelium-derived relaxing factor, which regulates blood flow and inhibits platelet function, may differ in venous and arterial grafts. We therefore studied endothelium-dependent relaxation in internal mammary arteries, internal mammary veins, and saphenous veins obtained from 58 patients undergoing coronary bypass surgery. Vascular rings with and without endothelium were suspended in organ chambers, and isometric tension was recorded. Acetylcholine (10(-8) to 10(-4) M), thrombin (1 U per milliliter), and adenosine diphosphate (10(-7) to 10(-4) M) evoked potent endothelium-dependent relaxation in the mammary artery but weak response in the saphenous vein (P less than 0.005; n = 6 to 27). In the mammary artery, relaxation was greatest in response to acetylcholine (86 +/- 4 percent reduction in norepinephrine-induced tension), followed by thrombin (44 +/- 7 percent) and adenosine diphosphate (39 +/- 8 percent). In the saphenous and mammary veins, relaxation was less than 25 percent. Relaxation was unaffected by indomethacin but was inhibited by methylene blue and hemoglobin (P less than 0.005 and 0.01, respectively), which suggests that endothelium-derived relaxing factor was the mediator. Endothelium-independent relaxation in response to sodium nitroprusside was similar in arteries and veins. We conclude that endothelium-dependent relaxation is greater in the mammary artery than in the saphenous vein. The possibility that this contributes to the higher patency rate among arterial grafts than among venous grafts will require further study.
Acetylcholine↗
[Inflammatory abdominal aortic aneurysm].
348 cases of abdominal aortic aneurysm were reviewed for typical features of inflammatory aneurysm (IAAA) (marked thickening of aneurysm wall, retroperitoneal fibrosis and rigid adherence of adjacent structures). IAAA was present in 15 cases (14 male, 1 female). When compared with patients who had ordinary aneurysms, significantly more patients complained of back or abdominal pain (p less than 0.01). Erythrocyte sedimentation rate was highly elevated. Diagnosis was established in 7 of 10 computed tomographies. 2 patients underwent emergency repair for ruptured aneurysm. Unilateral ureteral obstruction was present in 4 cases and bilateral in 1. Repair of IAAA was performed by a modified technique. Histological examination revealed thickening of the aortic wall, mainly of the adventitial layer, infiltrated by plasma cells and lymphocytes. One 71-year-old patient operated on for rupture of IAAA died early, and another 78-year-old patient after 5 1/2 months. Control computed tomographies revealed spontaneous regression of inflammatory infiltration after repair. Equally, hydronephrosis due to ureteral obstruction could be shown to disappear or at least to decrease. IAAA can be diagnosed by computed tomography with high sensitivity. Repair involves low risk, but modification of technique is necessary. The etiology of IAAA remains unclear.
Aneurysm, Infected↗
[Prolonged course in patients with symptomatic ventricular tachycardia].
In a retrospective study we analyzed the long-term course in 77 patients (71 males and 6 females) with symptomatic ventricular tachycardias. Initially all patients had undergone an electrophysiological examination. 56/77 patients received drug therapy and 19/77 underwent surgery (implantation of an automatic defibrillator in 2 patients). Two patients received no therapy. After an observation period of 30 (5-81) months, 60% of the patients who had received drug therapy and 77% who had undergone surgery were free of tachycardia. 16/56 (29%) of the patients under drug management and 6/19 (32%) of the surgically treated had died in the meantime. In the whole group the mortality rate was 9.6 times higher than in an age and sex matched control group. In younger subjects (16-50 years) the mortality rate was 4 times greater than in those aged 51-81 years. The highest mortality was observed in the first year. The most important prognostic parameter was the left ventricular ejection fraction, which was significantly higher in survivors. We conclude that ventricular arrhythmias can be effectively controlled, and quality of life enhanced, with drug therapy or surgery.
Adolescent↗
[Regression of myocardial hypertrophy in aortic valve disease following aortic valve replacement].
In patients with aortic valve disease successful valve replacement leads to a significant decrease in left ventricular angiographic mass, which 14-15 months postoperatively ranges between 31 and 37% of the preoperative value. Postoperative normalization of angiographic mass occurs in 2/3 of the patients with aortic stenosis and in 1/3 of the patients with aortic insufficiency. The degree of preoperative hypertrophy determines whether angiographic mass does or does not normalize after valve replacement. In patients with aortic stenosis and combined lesions, left ventricular end-diastolic wall thickness decreases postoperatively and remains unchanged in the patients with aortic insufficiency. Muscle fiber diameter decreases significantly in the first two years after valve replacement and thereafter remains unchanged. The upper limit of normal (20 mu) is not reached. Relative interstitial fibrosis increases early after surgery whereas left ventricular fibrous content remains unchanged during the first two years after valve replacement. Five years postoperatively there was a significant decrease in left ventricular fibrous content both in patients with aortic stenosis and with aortic insufficiency. Hence there appears to be no longer any validity in the earlier concept that a once established interstitial fibrosis in patients with concentric and eccentric hypertrophy is irreversible after removal of the abnormal hemodynamic burden.
Aortic Valve Insufficiency↗
[Indications and contra-indications for heart transplantation].
Indication and contraindications for selection of patients for cardiac transplantation are given on the basis of 2 years' experience in evaluating a total of 65 patients, 30 of whom received heart transplant. Heart transplant must be considered in patients with: 1. Severe heart failure without response to maximal medical treatment. 2. End stage coronary artery disease where clinical heart surgery is no longer feasible. 3. Intractable malignant arrhythmia associated with pump failure. Heart transplant is contraindicated in: 1. Patients with extracardiac polymorbidity. 2. Cardiac low output with renal and hepatic impairment. 3. Compliance failure. 4. Increased pulmonary artery resistance. 5. Age over 60 years.
Adult↗
[Replacement of the aortic valve with a bioprosthesis: 5-year surgical results].
To evaluate the clinical course after replacement of the aortic valve with a porcine heart-valve, 87 patients (mean age 52 years [5-70] at time of surgery) were followed up for a five-year period. Operative mortality was 1% and late mortality 8%. The actuarial probability of survival at five years for all patients was 91%. Embolic events occurred in two patients and endocarditis in six. Valve dysfunctions requiring reoperation resulted from bacterial endocarditis in three patients, from primary valve dysfunction in three patients and from paravalvular leak in another three patients. Echocardiographic cross examination of the bioprostheses showed degenerative processes in eight asymptomatic patients. Patients who underwent reoperation or showed valve degeneration were significantly younger (41 +/- 19 years and 42 +/- 9 years respectively) than patients without valve degeneration (52 +/- 9 years) [p less than 0.05]. We conclude that there is an increased risk of primary valve degeneration for patients under age 35. Echo-Doppler sonographic cross examinations of the heart are a highly sensitive means of detecting early degeneration of the bioprostheses.
Actuarial Analysis↗
[Ruptured aneurysm of the abdominal aorta and iliac arteries. An analysis of 132 cases].
A series of 132 consecutive patients with ruptured aneurysms of the abdominal aorta or iliac arteries treated between 1979 and 1984 is retrospectively reviewed. 13% had a known abdominal aneurysm before rupture. Workup consisted of clinical assessment alone in 69%, assisted by ultrasound in 23%. Perioperative mortality was 35% (70%-confidence limits (CL) 30%-39%). Preoperative factors associated with increased mortality were age over 80 years, shock and evidence of coronary artery disease. In addition, intraoperative blood transfusion over 10 liters, suprarenal site of rupture, presence of free intraperitoneal blood, suprarenal aortic clamping and operation lasting longer than 3.5 hours were related to death, though higher mortality was statistically significant only for operating time and site of clamping. Cardiac morbidity was the most common and most critical factor affecting 52% of patients with a mortality of 59% (CL: 52%-65%). Development of oligo-anuric renal failure in postoperative course was almost uniformly associated with death (91%, CL: 83%-96%) even with use of dialysis, usually from multiple systems failure. Actuarial five-year survival, including perioperative mortality, was 38% (CL: 33%-43%). After a mean follow up of 3.3 years 82% (CL: 76%-87%) of surviving patients are in good health comparable to the pre-rupture state. Although many risk factors exist there are few contraindications to surgery, and results can be improved if workup and operation are rapid and simple. Minimizing blood loss is essential, while supportive measures in postoperative multiple systems failure still remain a serious problem. Prevention of rupture by resection of the intact aneurysm remains the ultimate goal.
Acute Kidney Injury↗
[Treatment and follow-up care after heart transplantation].
Today survival rates after heart transplantation of around 80% at 1 year and around 65% at 5 years are realistic. Most patients attain NYHA functional class I. Due to progress in donor and recipient selection, in immunotherapy, and in a systematic follow-up program post transplant, heart transplantation today has become an accepted treatment in special forms of terminal heart disease. Between September 23, 1985, and May 15, 1987, 19 patients were transplanted in Zurich. After an average of 7 months (1-20), 18 patients are alive with NYHA functional class I. The follow-up program checks systematically for the three main problems post transplant (rejection, infection, and drug-induced side-effects). Regular endomyocardial biopsy is the gold standard for diagnosis of rejection. Non-invasive methods, such as cyto-immunological monitoring, neopterin, or beta 2-microglobulin, are not a substitute but valuable adjunctive diagnostic methods.
Adult↗
Outcome and risk factors in surgery of descending thoracic aneurysms.
In a series of 100 consecutive patients operated upon for aneurysmatic lesions of the descending thoracic aorta, the mean age was 52 +/- 16 years (male = 81, female = 19). There were 31 dissections (acute 10, chronic 21); 28 post-traumatic aneurysms (ruptured 5, acute 7, chronic 16); 22 arteriosclerotic aneurysms (ruptured 1, chronic 21); 11 thoracoabdominal aneurysms, 5 anastomotic aneurysms and 3 mycotic aneurysms. No symptomatic patient was refused. Preoperative risk factors were graded on a scale of 6 by counting 1 point for each of the following elements: central nervous system disease; heart, pulmonary, and renal disease; arterial hypertension, age greater than 60. In-hospital mortality and paraplegia for the whole series were 25% and 7% respectively. In acute dissection, the mortality was 6/10 patients versus 2/21 in chronic events. In post-traumatic aneurysms, mortality was 2/5 in ruptured, 2/7 in acute and 0/16 in chronic events. In arteriosclerotic aneurysms, mortality was 1/2 in ruptured and 6/20 in chronic events. In thoracoabdominal aneurysms, mortality was 5/11, in anastomotic 1/5 and in mycotic 0/3 patients. The mean number of risk factors in non-survivors versus survivors was significantly higher in acute dissection, chronic dissection, chronic arteriosclerotic aneurysms and thoracoabdominal aneurysms. Rupture and acute events are related to a high surgical mortality. Non-survivors appear to have significantly more preoperative risk factors.
Adolescent↗