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A 72-year-old patient with heparin-induced thrombocytopenia (HIT) and global cardiac decompensation underwent cardiac surgery using an extracorporeal circuit (ECC). For systemic anticoagulation r-Hirudin (lepirudin, Refludan) was administered as a heparin substitute during extracorporeal circuit. During cardiopulmonary bypass (100 min) the concentration of r-Hirudin was between 2.9 and 4.6 mcg/ml under continuous infusion of r-Hirudin at between 1.5 and 4.5 mcg/kg/min. The operation was successful and during its course no abnormal bleeding or fibrin formation in the extracorporeal circuit was observed. One hour after operation haemorrhage occurred and rethoracotomy was performed without discovering the cause of the surgical bleeding. After substitution with fresh frozen plasma, thrombocytes and Prothromblex the bleeding stopped on the operation day. The further postoperative course was uncomplicated. After 3 days the patient came to nursing station and was discharged from hospital to a rehabilitation centre after 13 days. After a further 3 weeks he went home in a good general condition.

In contrast to type A aortic dissection, the indication for acute surgical repair as treatment of choice in type B aortic dissection is not the actual dissection, but the complications resulting from the dissection (rupture, potential rupture and ischemic syndromes of the aortic branches). Between 1978 and 1994, 92 patients underwent surgical repair of type B aortic dissection at our institution. Following diagnostic confirmation by echocardiography and/or CT scan, all patients received conservative antihypertensive therapy. 52% of the patients underwent emergency surgical repair. Symptoms prompting surgical repair were: visceral ischemia (23%), pleural effusion (19%), paraparesis (17%), refractory hypertension (12%), further aortic enlargement (12%), and rupture (10%). In chronic type B aortic dissection, the main symptom in 84% of the cases was further enlargement of the aorta. The early mortality decreased in the course of initial treatment from 33% to 16%, and to 8% after exclusion of patients operated on for ruptured aorta. Improved early mortality has led to an increase in acute surgical repair. In cases of chronic dissection, strict antihypertensive therapy is indicated and regular checks on the width of the aorta, as well expeditious diagnostic confirmation of its enlargement, are important.

The therapy of acute myocardial infarction has made major advances in the last 10 years. Cardiac surgeons have to adapt their strategies to the more aggressive management of acute myocardial infarction. Only in mechanical complications of acute myocardial infarction is cardiac surgery nowadays the therapy of choice. In cardiac rupture and ventricular septal defect, surgery is the only therapeutic option. In ischemic mitral regurgitation, cardiac surgery is required in the event of concomitant cardiogenic shock and pulmonary edema after intra-aortic balloon pump placement. Coronary artery bypass surgery my be indicated at low risk in patients with unstable angina pectoris when PTCA is not feasible or has failed, or in catheter emergencies.

Refinement in surgical technique and perioperative management have considerably improved morbidity and mortality rates of carotid endarterectomy and abdominal aortic surgery, thus allowing a more aggressive approach in the treatment of carotid stenosis, abdominal aortic aneurysm and aorto-iliac occlusive disease in the elderly population (> 70 years). We review our experience with 446 consecutive patients undergoing surgery of the abdominal aorta: 295 patients (mean age 75.5 years) underwent resection of an abdominal aortic aneurysm (asymptomatic but > 5-6 cm, (n = 193), symptomatic (n = 67) or ruptured (n = 35). Additionally, 198 patients were treated surgically for aorto-iliac occlusive disease. A small group of 13 patients was deferred for combined operation, including prior myocardial revascularization and subsequent vascular surgery during the same anesthesia. The majority of patients had several cardiovascular risk factors and/or significant associated diseases. Mortality (< 30 days) was 3.5% following aorto-iliac bypass in the treatment of arterial occlusive disease and 8.4% after aneurysm repair (asymptomatic, symptomatic and ruptured aneurysms all included). 5-year survival was 74% and 64% after repair of aortic aneurysm and treatment of aorto-iliac occlusive disease respectively. On the basis of these results, we believe that major vascular surgery is still justified in elderly patients and can be achieved with reasonable mortality and morbidity. Main goals of the surgery, e.g. to relieve suffering, restore function so as to limit disability and dependency, and prolongation of life expectancy in a dignified and meaningful life-style, are realized the majority of operative survivors.

Severe late complications after reconstruction of the abdominal aorta are unusual; when they occur, they demand a different strategy to treat the patient with success and to achieve a durably favourable long term outcome. These complications include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for the lower extremities. In patients who survived graft removal and extra-anatomic bypass, a source of major arterial inflow should be at least considered in order to secure a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypass and as a valid alternative to avoid dense adhesions in the abdomen or retroperitoneum. We present our experience with 8 patients in whom the aorta had been previously oversewn below the renal arteries (resection of infected graft [n = 4], repair of aorto-enteric fistula [n = 3]) or avoided because of dense adhesions after radiotherapy (n = 1). Temporary extra-anatomic reconstruction consists of an axillo-femoral (-popliteal) bypass on the right side with femoro-femoral cross-over graft. This method avoids surgery in the left thoraco-abdominal region, thus facilitating the definitive repair. Proper preoperative radiographic evaluation with inflow and outflow details is essential before conversion into thoraco-bifemoral bypass. Posterolateral thoracotomy is performed and the chest entered in the 7th interspace. The thoracic aorta is clamped tangentially and a bifurcated graft is anastomosed to the aorta. The bypass is passed through a retroperitoneal tunnel and anastomosed end-to-end with the distal portion of the previously inserted grafts; this technique avoids a second dissection of the vessel itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Vague abdominal pain after cardiac surgery was caused by ectopic ossification in the distal part of sternotomy. The rarity of this complication (one case seen in recent years, operation volume: 1200 cases/year) prompted us to review the literature, where only 6 cases are described. Diagnostic problems and therapy are discussed.

Reoperative coronary bypass surgery has been encountered with increasing frequency over the last few years. It is associated with several major problems: difficulties with myocardial protection secondary to progression of arterial disease and occluded saphenous vein grafts, left ventricular dysfunction, and concomitant medical and vascular disease. We present our experience with 194 consecutive patients operated on between 1980 and 1992. They represent 4.0% of the overall number of isolated coronary revascularizations performed during the same period. There were 178 men and 16 women, mean age 58.6 +/- 7.4 years. The interval between primary coronary bypass grafting operation and redo-operation extended from 4 to 12 years, mean 8.2 years. At reoperation, 91.7% (178/194) of the patients received at least one arterial conduit, whereas revascularization with arterial conduits only was performed in 16 patients. Perioperative mortality amounted to 4.6% and was significantly higher than mortality of primary isolated coronary operations (1.6%) during the same period; the following significant morbidity was encountered: perioperative myocardial infarction (8.2%), postoperative low output requiring intraaortic counterpulsation (8.7%), postoperative bleeding (8.2%) and infectious complications (9.2%). First postoperative follow-up showed a significant improvement of symptomatology with a decrease of 1.5 point in NYHA functional class. Mid term survival is promising with a 5-year survival rate of 88.5%. Improved myocardial preservation and a trend towards complete revascularization should become routine and will probably reduce perioperative mortality and morbidity.

Extracardial carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. The records of 485 patients who underwent carotid endarterectomy between 1978 and 1991 were reviewed, with special attention to both cardiac and neurological complications. 432 patients had symptomatic carotid disease whereas 53 were asymptomatic but presented with significant carotid stenosis or a large ulceration at doppler-duplex examination and/or angiography. These examinations showed the following lesions in symptomatic patients: unilateral stenosis > 75% (331; 68.5%), ulceration (41; 8.5%), bilateral stenosis (61; 12.5%) and unilateral stenosis with contralateral occlusion (51; 10.5%). Intraluminal shunt was used in nearly all patients whereas special management of cerebral metabolism (intraoperative electroencephalogram, somatosensory evoked potentials) were used in high-risk patients only. Overall early mortality was 1.8%. Three patients died from the sequelae of a neurologic injury, whereas six patients died from myocardial infarction or intractable arrhythmia. Mortality decreased from 2.4% between 1978 and 1984 to 0.8% between 1985 and 1991. At 6 and 8 years, actuarial survival rates of 88.1% and 76.1% and stroke-free survival rates of 86% and 81.5% were observed. Late mortality was essentially due to ischemic cardiac complications (38.5% of the actuarial late mortality at 8 years). Review of the literature shows that carotid endarterectomy is the treatment of choice for symptomatic high-grade extracranial carotid stenosis in patients who are not high-risk candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

The pre- and postoperative course in 118 patients (104 males, mean age 62 +/- 8.1, 14 females, 60 +/- 10.7 years) who underwent coronary artery bypass surgery for significant left main coronary artery disease was studied to analyze the current management and risk factors of this lesion. Of these patients 32% (38/118) remained in hospital care from the date of diagnosis (coronary angiography) until the operation. The mean interval between diagnosis and operation was 39 days (range 0-166). Twelve patients (10%) had urgent procedures (< or = 48 hours after angiography), 25 (21%) accelerated (< or = 2 weeks), 52 (44%) anticipated (< or = 2 months) and 30 (25%) elective procedures (> 2 months). There was a significant negative correlation (p < 0.001) between the grade of stenosis and the time interval from diagnosis to operation. The operation technique did not differ from the usual procedure except for the less frequent use of the internal mammary artery as arterial conduit. Patients with stable angina received an internal mammary artery graft in 65% (80/118) as compared to 26% (6/23) of the patients with unstable angina. This differs significantly from the overall rate of 95% of the patients undergoing coronary artery bypass surgery at our institution. The rate of perioperative myocardial infarction was 18% (21/118). There was no significant relation between infarction and angina class, severity of the stenosis and the use of internal mammary artery as bypass graft. The hospital mortality was 4.2% (5/118) and thus was not different from the overall mortality of (2.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1980 and 1990 12 patients (5 male, 7 female) were operated on for acute infectious pericarditis at a mean age of 42 years. The infections were 6 bacterial (purulent 4, abscess 2), 4 tuberculous, 1 viral and 1 Candida. Pericarditis resulted from contiguous spread of infection from bilateral pneumonia in 3 patients, from subphrenic abscess in 2 and followed bacteremia in 1. Clinical signs were: tamponade/shock in 9, elevated jugular venous pressure in 11, edema in 6, hepatomegaly in 6, ascites in 1, and pericardial friction rub in 3. A preoperative pericardiocentesis in 9 patients allowed only 4 positive microbiological diagnoses and was an insufficient drainage in all cases. The preoperative mean NYHA class was 3.3. The pericardectomy was total in 9 patients and partial in 3. Total mortality was 1/12 patients (8%) with one late death due to recurrent tuberculous pericarditis. No patient with purulent pericarditis died. Another recurrence occurred 6 months after acute viral pericarditis. Atrial fibrillation in one patient was the only postoperative complication. After a mean follow-up period of 48.5 months no cardiac constriction had occurred in 11 surviving patients Actuarial survival after pericardectomy is 100% after 1 month and remains 91% after 5 years. The mean NYHA class has significantly improved to 1.2 (p less than 0.05) at the end of the follow-up. We conclude that pericardectomy combined with a specific antimicrobial therapy is a safe treatment for acute infectious and especially purulent pericarditis with low mortality and excellent longterm results. Early pericardectomy allows rapid decompression of the heart, removal of intrapericardial adhesions and infected tissue and prevents late constriction.(ABSTRACT TRUNCATED AT 250 WORDS)

A consecutive series of 74 patients was analyzed after repair of descending thoracic and thoracoabdominal aortic aneurysms. After hospital discharge there were 13/71 deaths (18%) during a mean follow-up of 60 +/- 20 months (range: 28-107). Actuarial analysis showed a mean survival rate of 89% after 1 year, 78% after 5 years and 71% after 9 years. During the same time period there were reoperations of the aorta in 10/71 patients (14%). Actuarial analysis showed freedom of reoperation in 97% after 1 year and in 80% after 5 years. Elective repair of these aneurysmal lesions can be recommended.

Aortic branch occlusion may constitute the mode of presentation or become an important focus of treatment in patients sustaining acute aortic dissection. The optimal therapeutic approach in patients with acute aortic dissection complicated by cerebral, visceral and peripheral vascular problems, and the implications of such complications, are not well established. We review the outcome in 187 consecutive patients (149 males and 38 females, mean age 58 years) with acute dissection of the thoracic aorta who were admitted and operated on in our department over a 13-year period. We assess the incidence, consequences and specific management of significant stenotic and obstructive lesions of the aorta and its branches. Noncardiac vascular complications occurred in 59 patients (32%); of these complications, 38 were associated with type A dissection (incidence 28%) and 21 with type B dissection (incidence 48%). A trend towards decreasing overall surgical mortality was observed in the second part of the study (1983-1989) compared with the first part (1977-1982) i.e. 28% versus 12%. Although aortic rupture and cardiac tamponade were the strongest correlate of morbidity and mortality, death specifically related to vascular complication was more common when such malperfusion occurred in the carotid, celio-mesenteric and renal circulation. Proximal aortic repair at the site of the intimal tear with obliteration of the false lumen may have restored adequate distal circulation in 27 patients in whom improvement of the visceral or peripheral ischemia was observed after the thoracic aortic repair. Additional procedures (immediately after the thoracic repair or later) were necessary in 15 patients to restore adequate perfusion in the compromised area.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1975 to 1980, 112 patients with an ejection fraction below 45% underwent coronary artery bypass grafting (CABG) in the Cardiovascular Surgery Unit, University Hospital Zürich. The mean age was 35 years and the mean ejection fraction 32% (21-44%). The vast majority of patients had severe symptoms (angina pectoris or congestive heart failure). Elective surgery was performed in 62 patients (55%) and emergent or urgent in 50 (45%). All were operated on in mild hypothermia (26-30 degrees C). An average of 2.9 bypasses per patient were performed; in 57, internal mammary artery bypass was carried out for revascularization of the left anterior descending branch. - Early postoperative mortality (within 30 days of operation) was 3.6%; all deaths were of cardiac origin. Perioperative myocardial infarction occurred in 7.5% of all patients. Cumulative survival was 83% at 5 years and 68% at 9 years. Mean mortality rate/year was 3.8% with a maximum of 6.5% in the first year after operation. The incidence of angina pectoris and congestive heart failure was significantly lower after revascularization. Cumulative survival was significantly enhanced in patients with complete revascularization (91% at 5 years vs 71% for incomplete revascularization). Early postoperative mortality was especially high in urgent and emergent cases, and was higher after revascularization with internal mammary artery bypass than with venous graft. Postoperative ejection fraction was assessed in 20 patients (12 with 2- or 3-vessel disease and 8 with left main coronary artery stenosis). Ejection fraction was significantly increased only in the patient group with left main coronary artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)