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AIMS The relation between acute postoperative management of epicardial pacing and haemodynamic status in patients with poor left-ventricular function after coronary artery bypass grafting (CABG) demonstrates the importance of synchronous ventricular activation and contraction during the vulnerable early postoperative period. METHODS in 22 patients (mean age - 69.3 +/- 5.4 years) with poor left-ventricular function (ejection fraction 29.8 +/- 4.8), we compared the postoperative haemodynamic parameters between atrio-biventricular, atrio-monoventricular and atrial pacing 3 - 24 hours after elective coronary artery revascularisation. Temporary epicardial pacing electrodes were placed on the right atrium and the paraseptal region of the left and right ventricle. The ventricular pacing modus was confirmed by surface electrocardiogram (EGG). We used overdrive rate pacing. RESULTS In patients with left bundle branch block, atrio-left-ventricular and atrio-biventricular pacing increased cardiac index and decreased wedge pressure. Atrial pacing and atrio-right-ventricular pacing decreased cardiac index. In contrast, atrio-right-ventricular and atrio-biventricular pacing increased cardiac index in patients with right bundle brunch block. CONCLUSION Atrio-biventricular pacing increased cardiac index and decreased wedge pressure compared with AAI pacing. In patients with wall-motion abnormalities and impaired cardiac conduction, a site-specific pacing therapy can help to optimize postoperative haemodynamics and reduce the application of inotropic substances.

Objective The growing number of high-risk patients in cardiac surgery unavoidably leads to more complications, and therefore to a prolonged stay in an intensive care unit (ICU). The aim of our investigation was to elaborate on the fate of patents after long-term ICU treatment. Methods Out of 5055 patients, 232 had to be treated for longer than 5 days in ICU. These 232 patients were analyzed for in-hospital mortality and followed up for quality of life. The Barthel mobility index and geriatric depression scale by Sheikh and Yesavage were used to evaluate physical ability and mood disturbances. Follow-up time was 82 months, and could be completed for 99 % of the patents. Results In-hospital mortality was 34.6 %, with the majority of cases being coronary artery bypass grafting procedures (59.9 %). Average stay in ICU was 12.0 days for the survivors and 17 days for non-survivors. During follow-up time (6 - 82 months), another 56 patients (23 %) died. Survivors (n = 98) were predominantly in NYHA classes l-ll (83 %) with a Barthel index of more than 80, representing adequate mobilization during daily life in 78 % of the patients. Results according to the geriatric depression scale were normal in the vast majority of patients (91 %) with severe or life threatening depressions in only 6 patients (8 %). Conclusion Long-term treatment of critically ill patients is admittedly burdened with high in-hospital and follow-up mortality. However, the excellent physical and psychological recovery of survivors unequivocally supports the employment of all technical and personnel resources within modern intensive care medicine.

BACKGROUND: Intraoperative blood salvage is an important part of blood conservation efforts in cardiac surgery. The purpose of this study is to examine the effects of three different circuit blood-salvaging techniques: centrifugation, ultrafiltration and direct infusion. METHODS: Sixty patients undergoing elective coronary bypass graft procedures were randomly assigned in a prospective manner to one of the three blood-salvaging methods. RESULTS: Intra- and postoperative blood samples demonstrated increased hemoglobin values in the direct infusion group and higher platelet count in the ultrafiltration group. There were no significant differences in these results. The analysis of coagulation parameters revealed a similar prolongation of partial thromboplastin time and activated clotting time in all groups. The amount of blood loss was not significantly different between the three blood conservation methods. The effect of direct infusion method does not result in either major disturbance of coagulation parameters or in increased blood loss. CONCLUSION: In a sample of adult patients undergoing coronary artery bypass grafting, direct transfusion is, in consideration of the cost-effective factor, an appropriate approach for returning cardiopulmonary bypass circuit blood.

BACKGROUND Pathophysiology of extracorporeal circulation is multifactorial, and the link between newly developed "biomaterials" and clinical outcome is not easy to illustrate. MATERIAL AND METHODS We designed a randomized, double-blinded, prospective study in order to verify the impact of a new surface modification [SMAR(X)T] in combination with an optimized blood air interface, on the cerebral performance after cardiopulmonary bypass. 80 patients were randomly divided into two subgroups (SMAR(X)T vs. standard PVC control) and analyzed for the kinetic of cerebral ischemia markers neuronspecific enolase, protein S100 and neuropsychologically tested with the Mini-Mental-Status Test (MMST) before and after the operation. RESULTS We could not show significant differences of protein S100 and neuron-specific enolase (NSE) levels between SMAR(X)T patients and the controls, but the incidence of neurological complications was exceptionally low. Although no statistically significant differences could be obtained for the MMST, the different pointloss between both groups trends toward a better cerebral performance in SMAR(X)T patients. CONCLUSION The use of a biologically inert circuit in combination with an optimized perfusion management seems to be worthy of recommendation.

Background Introduction of innovative cardiac procedures mostly depends on extensive evaluation using laboratory animal models. Avoiding living creatures in the experimental setup where possible without loss of reliability would be progressive from a logistical as wells as an ethical perspective. Methods Hearts of meat-production animals (pigs) were removed without structural damage. Two tracheotomy tubes (length 35 mm, diameter 10 mm) were inserted into aortic and pulmonal positions. The atrial inflow had to be ligated. The ventilation tubes were joined to a respirator. The "ventilation" frequency was limited to a maximum of 100/min, "inspiration" volume at 100 ml and ventilation pressure at up to 60 mbar. Results "Air beats" triggered by the frequency of the respirator occurred in the ventilated heart. Insufflation and deflation generated movement that was almost the same as physiological action. Conclusions Air-animation of the heart using a standard respirator is an easily conducted alternative to extensive and expensive laboratory experiments for development and quality control of new devices or techniques without compromising the scientific value of results and without using living animals.

Objective: Aim of the study was the evaluation of the impact of lung recruitment maneuvers on the hemodynamics following cardiac surgery procedures. Methods: The prospective randomized study included 80 adult patients undergoing coronary artery bypass surgery from 01/2009 till 09/2009. Patients were randomized to two duration's of lung recruitment maneuvers (25 cmH2O airway pressure for 10s and 45cm H2O for 10s) immediately after arriving on ICU. Swan Ganz catheter measurement was used to calculate cardiac output, and arterial blood pressure were monitored continuously. Systemic and pulmonary arterial blood gases were sampled before and after each lung recruitment maneuver to determine the intrapulmonary shunt. Results: Left ventricular end-diastolic areas decreased significantly during both the 10-s and the 20-s lung recruitment maneuvers. Cardiac output was 5.6±0.8l/min at baseline, decreasing by 3.0±1.1l/min and 3.6±1.2l/min during lung recruitment maneuvers of 10 and 20s, respectively. Shunt decreased from 20±5% to 15±6% after the first lung recruitment maneuver and from 15±6% to 12±5% after the second. Conclusions: Lung recruitment maneuvers markedly reduced cardiac output and left ventricular end-diastolic areas in hemodynamically stable patients following cardiac surgery.

Objective: Gene polymorphisms of thrombolytic, lipoprotein and immological pathways are supposed to play a role in the pathogenesis of CAD (coronary artery disease). CAD accumulates in families, but does not segregate like a Mendelial single-gene disorder, indicating that atherosclerosis is basically a multifactorial disease. Method: We determined and compared 10 genetic mutations in homocygote or heterocygote occurrence in two cohorts: 314 patients with CAD following CABG operation and 500 healthy Caucasian. Factor V Leiden and Prothrombin are sensitive markers for venous thrombosis; Plasminogen-Activator-Inhibitor-1, Angiotensin Converting Enzyme, Methylentetrahydrofolatreductase, Cholesterinester-Transferprotein and Apolipoprotein E express risk for atherosclerosis; Glycoproteins (three polymorphisms) represent the risk for platelet induced thrombosis. Results: The analysis shows significant differences in two pathways. We found increased occurrence of FV Leiden (p=0.0034, OR 2.33) and PAI-1 (p=0.004, OR=1.34) in CABG patients compared to the control. There was also a higher mutation rate of GP Ia 807 in the CABG group. Discussion: With the identification of two polymorphisms involved in the metabolic path-ways of thrombus aggregation in CABG patients, there might be a future possibility in the screening, prediction and prevention of CAD in the population.

Objective: The predominant mechanism of early graft failure after coronary artery bypass grafting is associated with benefit of antiplatelet treatment of drugs like Acetyl-salicylic acid (ASA). The mechanisms for ASA resistance are multifactorial and can be screened by laboratory tests. Methods: We determined platelet function using whole blood impedance aggregometry (IA) induced by ADP, arachidon acid (AA) and collagen (Coll), plateled aggregation (PA), Platelet Function Analyzer-100 (PFA-100). ASA 300mg was administered intravenously by 40 patients on 7.–9. post day after CABG. Non compliance administration was eliminated. Blood was drawn immediately before, 60 minutes and 24 hours after ASA application. ASA Non-Responsiveness (NR) was defined as maximal AA-induced PA below 20mm, corresponding to at least 66% inhibition. Results: ASA NR was observed in 9 patients (22%) 1hr and 12 patients (30%) 24 hrs after ASA application. Before ASA injection, patients had significant greater IA values than 60 healthy controls (p

The myxoma complex is a very rare disease. We report on a 31-year-old woman who suffered a hyperthyreosis, which resolved spontaneously. A few months later she developed a Cushing's syndrome, caused by a primary adrenocortical nodular dysplasia. A bilateral adrenalectomy had to be performed. 15 months after this operation she developed a cerebral infarction caused by an embolus from a left atrial myxoma. Our patient is a further case of Carney's syndrome. The aspect of the hyperthyreosis is interesting: Perhaps disease of the thyroid represents a new element of Carney's syndrome.