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Background: Sarcomas arising in the heart or the great vessels are rare entities. The prognosis of the patients is dismal., Methods: Between January 1993 and September 2006, of 1,429 patients registered to the Sarcoma Center, 14 had a primary sarcoma of the heart or large vessels., Results: Tumors were located in the left ventricle (n = 3), left/right atrium (n = 2/3), pulmonary artery (n = 2), and ventricular septum, aorta, pericardium, and inferior vena cava (n = 1 each). The most frequently encountered histologic subtypes were leiomyosarcoma and angiosarcoma. Six patients presented with distant metastases to the lungs (n = 5), lymph nodes (n = 2), and liver (n = 1). Eight patients had localized disease. Six of them underwent resection with curative intent. Of those, two developed local recurrence within 2 and 10 months from surgery. Eleven patients received palliative chemotherapy, seven of those as initial treatment. Eight patients attained a response to treatment, two had disease stabilization for 6 and 12 months. After a median follow-up of 14.5 months (range, 2-156), three patients were alive with no evidence of disease 11, 52, and 156 months after diagnosis. Two patients were alive with disease and nine patients had died., Conclusions: Patients with primary sarcomas of the heart and the large vessels were of a young age, and more than half of them presented with advanced disease. Given the promising response to chemotherapy, an optimized treatment approach including neoadjuvant chemo-/radiotherapy in patients with locally advanced disease should be pursued.

Objective: Protection of the myocardium against ischemia/reperfusion injury is a major challenge in cardiac surgery and cardiology. A cardioprotective role of heat shock proteins (Hsp), in particular Hsp 70, against ischemia has been demonstrated. A prerequisite for clinical exploitation of high Hsp 70 levels in the heart during ischemia is the determination of the efficacy and the kinetics of cardiac Hsp synthesis in vivo., Methods: We examined Hsp 70 and other immediate early genes, that are induced by cardioplegia and reperfusion, in right atrial biopsies taken from 15 patients during coronary artery bypass grafting. Specimens were obtained before cardioplegia and after ending of reperfusion and subsequently studied by immunohistochemistry and Western blot analyses., Results: Overall Hsp 70 increased 2.0+/-1.1-fold (P<0.01) in the nucleus as well as in the cytosol of myocytes and endothelial cells during open-heart surgery. As determined by comparison to a dilution series of recombinant protein, Hsp 70 levels amounted up to 6 per thousand of total cellular protein. The increase of Hsp 70 correlated well with the duration of cardioplegia and reperfusion (P<0.005) showing a markedly accelerated increase at periods longer than 2 h. Further, the immediate early gene c-Fos also increased 2.4+/-2.2-fold during open-heart surgery (P<0.05), whereas other members of the Hsp family, like Hsp 27 and Hsp 90, showed no significant changes in protein levels during cardioplegia and reperfusion., Conclusions: These findings demonstrate that protein levels of Hsp 70 in the myocardium increase to significant amounts within few hours after induction. The optimum time point for induction of Hsp 70 appears to be at least 2 h before open-heart surgery.

Objective: Increased serum levels of a multitude of mediators like interleukins, tumor necrosis factor, elastase, adhesion molecules, and endotoxin have been described following cardiopulmonary bypass (CPB). The biological consequences of this complex response are unclear., Methods: Serum samples of nine patients scheduled for elective coronary artery bypass grafting were obtained preoperatively and 1, 6, and 12 h after weaning from CPB. Additional serum samples were obtained perioperatively from four patients undergoing major lung resection and from four healthy volunteers. The apoptosis-inducing activity of serum samples on endothelial cells was examined using a tissue culture assay system. Endothelial cells were derived from human umbilical cords and incubated for 48 h with serum samples in various dilutions during their second passage. The culture plates were fixed with methanol/acetone and stained with the DNA dye diamidinophenylindole. Apoptotic and normal cells were identified and counted using phase contrast and fluorescence microscopy., Results: The proportion of apoptotic endothelial cells was 5.6-fold higher in culture plates incubated with diluted (30%) serum samples obtained at 6 h after weaning from CPB when compared to plates incubated with preoperative samples (P=0.0077). A smaller effect occurred already at 1 h in some patients, whereas at 12 h after weaning from CPB no increased endothelial apoptosis was observed. No proapoptotic activity was found in preoperative as well as in control samples from patients undergoing lung resection or from healthy volunteers., Conclusions: Serum of patients after CPB exerts a strong apoptosis inducing activity on human endothelial cells. Apoptotic death of endothelial cells following CPB may be responsible for postoperative vascular and bypass dysfunction including phenomena like increased capillary permeability.

We present two cases of malperfusion syndrome due to aortic dissection type-B. A supra-renal blind sac phenomenon resulted in renal failure and absent femoral pulses in both patients. Additionally, one patient suffered from spinal cord ischemia, the other from severe abdominal pain. By interventional techniques, catheter perforation of the blind sac was achieved. The resulting re-entries were enlarged with a balloon catheter. Distal perfusion without pressure gradients was restored by this technique in both patients and resulted in complete relief of symptoms. Percutaneous fenestration of the aortic dissection membrane may be an alternative to operative treatment in malperfusion syndrome.

Objective: Some intracranial aneurysms may not be operable by conventional neurosurgery due to their location or morphology. Cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest renders surgery of these complex aneurysms possible. Brain temperatures can be measured directly in this setting., Methods: Eight patients with complex intracranial aneurysms were operated on with the aid of CPB. Femoro-femoral bypass with heparin-coated circuit components was used in all cases. Venous drainage was augmented by a centrifugal pump in six patients and by a newly developed vacuum technique in two patients. Temperatures were monitored by probes in brain, tympanum, nasopharynx, bladder, rectum, arterial and venous blood. These measurements were recorded on-line together with those of cerebral oxygen saturation, AP, CVP and PAP. Blood gas analyses and an EEG were also performed continuously., Results: Outcome was excellent in seven patients, in one patient moderate neurological disability occurred. Mean time on cardiopulmonary bypass was 160 (117-215) min, for cooling to a brain temperature of 18 degrees C 33 (20-47) min, and for total circulatory arrest 27 (15-45) min. Additionally, terminal brain arteries were clamped for up to 68 min in four patients. No cardiac complications were observed. Actual brain temperatures were best reflected by the tympanum probes (max. deviation 2 degrees C), whereas temperatures measured in bladder or rectum exhibited deviations of up to 10 degrees C. EEG activities were arrested between brain temperatures of 19 and 26 degrees C., Conclusions: Complex intracranial aneurysms can be treated successfully using deep hypothermic circulatory arrest. Extensive monitoring adds to the speed and safety of the procedure. The resulting comparative measurements of temperatures at different body sites including brain, EEG, and other variables may be of general relevance for operations employing deep hypothermia and circulatory arrest.

Objective: Under experimental conditions cardiac stress may induce early immediate genes. Of these, heat shock proteins like hsp 70 have been linked to preconditioning and cellular salvage. Protooncogenes like c-fos and c-jun act as transcription factors for other genes and may be involved in the regulation of programmed cell death., Methods: Patients, 30, undergoing elective coronary artery bypass grafting, received either cold antegrade St. Thomas II or Bretschneider or Hamburg cardioplegic solutions with ten patients in each group. Tissue from right atria was removed before cardiopulmonary bypass and following cardioplegic arrest and reperfusion. Tissues were examined by Northern blots, immunohistochemistry, and in situ nick-end labeling of fragmented DNA as evidence for programmed cell death., Results: There were no significant preoperative or operative differences between groups. Following cardioplegia and reperfusion, a significant induction of both protooncogene and heat shock protein 70 mRNA was observed. Whereas levels of hsp 70 were increased about two-fold in all groups (P < 0.05), induction of c-fos and c-jun was most pronounced following the Hamburg cardioplegic solution (P < 0.05 versus baseline and for differences to other groups). Induction on the protein level was confirmed using immunohistochemistry that furthermore, identified cardiac myocytes and endothelial cells being the cell types that expressed these genes. In contrast to prebypass samples, in situ nick-end labeling of fragmented DNA following cardioplegic arrest and reperfusion was positive, preponderately in subendocardial myocytes and endothelial cells., Conclusions: Cold cardioplegia is a potent stimulus for induction of the early immediate genes examined in human hearts. Increased expression of protooncogenes may be deleterious to cardiac myocytes as indicated by in situ nick-end labeling of DNA fragments. Differences in gene induction may add additional information for the evaluation of different cardioplegic strategies.

Objective: For patients with atrioventricular block single lead atrial synchronous ventricular pacing (VDD) may have advantages compared to conventional dual chamber pacing (DDD) since it eliminates the need for an atrial lead. The purpose of this study was to investigate the clinical performance of a novel VDD pacemaker and the reliability of atrial sensing via the "floating' atrial electrode., Methods: 31 patients (10 females; age 64 +/- 13 years) underwent an implantation of a VDD pacemaker system (Intermedics UNITY). The patients were analyzed with regard to implantation parameters, complications and postoperative atrial sensing performance using the diagnostic data of the pacemaker memory. The mean follow-up was 6.3 (1-18) months., Results: The implantation procedure did not differ from that of conventional single chamber pacemakers. Dislocation of a ventricular electrode was the only complication observed. The P wave at implantation was 1.6 +/- 0.9 mV and dropped to 0.9 +/- 0.4 mV at predischarge. During follow-up the atrial sensing threshold remained stable. The atrial sensing performance (percentage of atrial synchronous ventricular complexes) after reprogramming the highest atrial sensitivity was 99.7%. Two patients (6%) developed atrial fibrillation. 29 patients (94%) remained in VDD mode as primarily intended., Conclusions: From these results it is concluded that VDD pacing represents an excellent alternative in patients with atrioventricular block and intact sinus node function. The atrial sensing was found to be reliable.

Repair of aortic coarctation was performed in 152 adolescent and adult patients (mean age 28.5 years, range 14-67 years). Ninety patients were treated with patch plasty, 33 with end-to-end anastomosis, 18 with interposition of a tubular graft, 6 with prosthetic bypass and 5 with direct plasty. There were two (1.3%) early and ten (6.6%) late deaths after 2.9 to 11.8 (mean 6.6) years. Of the remaining 140 patients, 129 (92.1%) were reexamined with computed tomography and angiography after 1.5 to 17.2 (mean 9.1) years postoperatively. In 27 patients (35.1%) of the patch plasty group significant dilatation at the operative site was observed and reoperation for aneurysm formation was required in 15 patients (19.5%). Resection of the intimal crest did not increase the probability of aneurysm formation, whereas Dacron as patch material and late hypertension had a significant influence. Six of the ten late deaths occurred in the patch plasty group. Rupture of an aneurysm at the operative site was proved in two of these patients, and three patients died suddenly for unknown reasons. In the other groups significant dilatation was observed in 13 patients and 3 local aneurysms required reoperation (2 after end-to-end anastomosis and 1 after direct plasty). We conclude that patch plasty repair of coarctation should be abandoned in adults. End-to-end anastomosis is advisable only if possible without excessive tension. Reoperation with interposition of a tubular graft on left heart bypass proved to be a safe method.