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Objective: To evaluate the effectiveness of a motivation programme the motivation for lifestyle change in patients was measured before and after coronary artery bypass graft (CABG) surgery by comparing a usual care group with a group attending a motivation programme. Design: Prospective controlled study. Setting: University hospital cardiothoracic surgery department. Subjects: One hundred and forty patients (mean age 64.9; SD 8.5 years) who had an elective CABG surgery. Interventions: Each patient was evaluated regarding his or her motivation for lifestyle change two days before and 10 days after CABG surgery. Between January and May 2002 patients in usual care were investigated as a control group (n=70). From January to May 2003 patients had the opportunity to take part in a motivation programme that was provided by a trained clinical psychologist (n = 70). The programme consists of both personalized single sessions and group lectures. Measures: A 30-item questionnaire measuring the six factors Vulnerability, Intention, Social expectation, Outcome expectation, Self-efficacy expectation, and Perceived severity was developed. Results: ANOVA procedures with repeated measurements indicate significant effects in terms of higher motivation for lifestyle change in the treatment group in Vulnerability (F(1, 138) = 4.04; P=0.04), Intention (F(1, 138) = 19.81; P Conclusions: This motivation programme performed in a cardiac surgery hospital after CABG may increase the motivation for a positive lifestyle change.

Background: Health-related quality of life (HRQL) is one of the most important outcome criteria of nearly all medical procedures. Only the patients themselves can provide detailed and true information on their quality of life. The measurement of HRQL can be used to assess the expected benefit of coronary artery bypass graft (CABG) surgery. Methods: 142 patients were included in the study and completed the German version of the SF-36 health survey questionnaire (SF-36) [1]. The SF-36 was administered 2 days before, 10 days and one year after CABG surgery. Additionally, data produced by our patients was compared to the summary data of three populations displayed in the SF-36 handbook (standard population, patients with myocardial infarction and with angina pectoris). Results: While HRQL is slightly reduced 10 days after CABG surgery, the improvement one year later is highly significant compared to two days before CABG surgery. One year after CABG surgery, the HRQL of our patients is much closer to that of the standard population of the SF-36. Conclusions: According to HRQL, patients benefit from CABG surgery.

About 1,200 patients per year develop postoperative hypoparathyroidism alone in Germany. Many of those patients may be misdiagnosed as the symptoms of this disease may vary and can be atypical. As an example, we describe the first known case of an elderly patient with a long history of seizures as a complication of an undiagnosed chronic hypoparathyroidism after surgery of a pT4-esophageal carcinoma. The 63-year-old male patient underwent laryngo–hypopharyngo–esophagectomy with gastric transposition and partial thyroid resection for a proximal esophageal carcinoma in 1994. About half a year later, the patient developed for the first time a convulsive syncope. Misleading diagnoses were for years suspected metastasis formation and a dumping syndrome. The general physician of the patient called him the epilepsy man, while no cause of the seizures were found. More than a decade of years later, when the correct diagnosis was made, finally by determination of parathyroid hormone levels, the seizures of the patient were completely eliminated by calcium supplementation therapy. The patient’s quality of life improved clearly in the following time. It is essential to consider chronic hypoparathyroidism in the differential diagnosis of patients with hypocalcemia who have undergone extended neck and proximal esophageal surgery before. In addition to that, it is mandatory to autotransplant parathyroids during the initial procedure which might be accidentally removed during surgery and to monitor parathyroid function in each patient in the further course postoperatively.

Background Free radicals formed during ischemia and reperfusion can lead to lipid peroxidation (LPO) and the formation of 4-hydroxy-2-nonenal (4-HNE), one of the most toxic products of LPO. Using a heterotopic rat heart transplantation model we investigated endogenous 4-HNE formation as a response to cold storage of the transplant and warm blood reperfusion in the recipient. Methods Lewis rat hearts were subjected to 30, 240 or 480 minutes of 4°C cold ischemia in Bretschneider cardioplegic solution without or with transplantation and 240-minute reperfusion in F344 recipients. The amount of 4-HNE modified proteins was quantified in rat heart cryosections with an antibody recognizing cysteine-, histidine- and lysine-4-HNE Michael adducts and image analysis of immunostained tissue. Results We detected 4-HNE-modified proteins in ischemic rat hearts after transplantation and reperfusion. In hearts submitted to ischemia only, 4-HNE-protein adducts comprised 0.7 ± 0.3% (30 minutes), 0.7 ± 0.4% (240 minutes) and 0.2 ± 0.1% (480 minutes) (mean ± SEM) of the tissue area. Transplantation and reperfusion in the recipient significantly increased the amount of protein adducts to 6.8 ± 2.6% (p = 0.041), 5.2 ± 1.4% (p = 0.009) and 5.7 ± 0.9% (p = 0.002) in 30-, 240- and 480-minute ischemic hearts, respectively. Conclusions Under the conditions applied in the present study, cold ischemia for >30 minutes did not significantly alter the amount of 4-HNE protein adducts. However, because after transplantation and reperfusion, 6% of heart tissue consisted of 4-HNE-modified proteins, it can be assumed that this damage negatively affects long-term survival of the transplant

Background Tissue damage caused by reactive oxygen species (ROS) formed during ischemia/reperfusion seems to be an important risk factor in the failure of transplanted hearts. Although endogenous anti-oxidants protect the myocardium against free radical attack under physiologic conditions, their capacity may become limited during severe oxidative stress. Thus, we investigated the effect of 8-hour cold ischemia on the myocardial anti-oxidative defense system in a heterotopic rat heart transplantation model. Methods Lewis rat hearts were subjected to 30 or 480 minutes of 4°C cold ischemia in Bretschneider cardioplegic solution with or without transplantation and reperfusion (30 or 240 minutes) into F344 recipients. Activity levels of superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase and glutathione S -transferase (GST), and concentrations of glutathione (GSH), glutathione disulfide (GSSG) and lipid hydroperoxides (LOOH) were analyzed in heart homogenates. For histology, cross-sections of the ventricles were stained with hematoxylin-eosin. Results Except for GST, enzyme activities and GSSG concentration increased and the glutathione redox ratio (GSH/GSH + 2GSSG) significantly decreased in 480-minute ischemic hearts compared with those with 30-minute ischemia. Reperfusion dramatically decreased both GSH and GSSG and increased LOOH formation but without severe histopathologic findings in the transplants. Applying a tree-structured classifier technique, GSH and LOOH were identified as significant features indicative of transplantation-induced oxidative stress. Conclusions In the present study severe loss of glutathione and formation of LOOH indicated transplantation-induced oxidative stress in the rat heart; therefore, alterations of these parameters may hint at relevant deficits in the myocardial anti-oxidative defense and may also predict subsequent tissue damage.

Myasthenia gravis (MG) is the leading paraneoplastic manifestation of thymomas and is probably related to the capacity of thymomas to mature and export potentially autoreactive T cells. Why some thymomas are MG associated (MG+) and others are not (MG−) has been unclear. We addressed this question by comparing the percentages of intratumorous naive mature CD45RA+ thymocytes in 9 MG(+) and in 13 MG(−) thymomas by fluorescence-activated cell sorting analysis. Our results show that intratumorous naive CD4 T cells were present in all MG(+) thymomas and in one MG(−) thymoma with the development of MG only 2 months after surgery. By contrast, the percentage of naive CD4+ T cells was significantly reduced in all 13 MG(−) thymomas (P

BACKGROUND: The aim of this study was to explore patients' needs and changes to these needs during a hospital stay for coronary artery bypass graft (CABG) surgery. METHODS: 70 patients (60 males; mean age = 64.1; SD = 8.9) reported their needs two days before and ten days after CABG surgery using a specifically developed 15-item questionnaire. Student's T-test was used to detect significant differences. RESULTS: Before CABG, patients rated the need for “preparation for surgery”, and after CABG the need for “information about the correct handling of drugs”, as the most important. The rating of “information about the correct handling of drugs” showed a significant increase after CABG surgery ( T(69) = − 3.46; P < 0.001) and the need for a “letter with the latest scientific information on heart disease” was significantly reduced during this period ( T(69) = 2.07; P = 0.04). CONCLUSIONS: The results indicate that preparation for surgery should be conducted very carefully without time pressure. Patients should receive more detailed information on prescribed drugs.

The application of a centrifugal pump might lead to a reduced release of tissue factor (TF) due to less blood cell damage. This could result in a decrease in activation of the extrinsic pathway of coagulation and embolus formation. In the present study, 60 patients undergoing coronary artery bypass grafting were randomly assigned to a centrifugal or a roller pump. Plasma concentrations of TF, thrombin-antithrombin complex (TAT), and prothrombin fragments F1 + 2 were investigated before, during, and after cardiopulmonary bypass (CPB). Embolus detection was performed at the arterial line of CPB and transcranially by Doppler ultrasound. The centrifugal pump group revealed a lower TF release (area under the curve during CPB) when compared with the roller pump group [5661 (696-10359) vs 12681 (6383-17538) microg x min/l; median (lower - upper quartiles); P = 0.009]. In contrast, TAT and F1 + 2 formation did not differ between the groups, and neither did the total embolus count of both Doppler systems. Embolus counts did not correlate with TAT or F1 + 2 formation. In conclusion, the reduction in TF release by the application of a centrifugal pump seems to have little consequence on total thrombin formation. Since the applied Doppler systems seem to detect mainly microbubbles, conclusions regarding differences between the two pumps in the formation of thrombofibrinous clots cannot be drawn.

In a comparative study, we investigated whether or not removed and non-beating hearts could be preserved in vitro by continuous perfusion with oxygen-carrying solutions (blood, perfluoro-carbon emulsion) and simultaneous substitution with specific substrates. We used 18 mongrel dogs subdivided into 2 groups (1st group: perfluorocarbon emulsion; 2nd group: blood); the perfusion time was 9 h. In addition to parameters to control the medium of the perfusion solution, we measured parameters that would allow us to assess the success of the extended perfusion. These parameters were high-energy phosphates and, in particular, electron optical analysis. At the end of the perfusion period, electron optical analysis revealed a mild and reversible ischemic reaction by the myocardial cells in both groups. However, statistical analysis showed (1) a significant increase in the ischemic reaction for both groups over the perfusion period (P = 0.02), and (2) a significant, even more pronounced ischemic reaction in the subendocardial myocardium (P = 0.025). It should be noted that distinctly interstitial edema developed during the perfusion period and that this would appear to be a fairly critical problem with extended continuous isolated heart perfusion.

An important rehabilitation aim following coronary artery bypass graft (CABG) surgery is to modify cardiovascular risk factors positively. Among the most potent possibilities for improvement of these factors is a lifestyle change in terms of increasing sports exercise, changing diet patterns, stress reduction, etc. An indispensable condition for these changes is the motivation to implement the necessary changes. In our working group a patient education programme was developed aimed at enhancing the motivation for lifestyle change, which was already applied in a cardiac surgery hospital. In evaluating the programme, we could observe that various cognitive factors of motivation for lifestyle change had dropped in untreated patients and risen in patients participating in the programme. Based on these preliminary findings we examined the motivation for lifestyle change one year after CABG surgery.Each patient was evaluated for his/her value in motivation for lifestyle change using a 30-item questionnaire which measures the six factors Vulnerability, Intention, Social Expectations, Outcome Expectation, Self-Efficacy Expectation, and Perceived Severity two days before CABG surgery as well as ten days and one year after CABG surgery. Between January and May 2002 patients in usual care were investigated as control group (n=70). From January to May 2003, n=70 patients had the opportunity to take part in a comprehensive patient education programme that was provided by a specifically trained psychologist. Data from 108 patients could be evaluated one year after CABG surgery (response rate=77.1%). The programme had comprised individualized units, as well as a group lecture. If partners were available they were included in the process.One year after CABG surgery no significant differences between the control group and the intervention group could be found.The positive effects of the patient education programme measured ten days after surgery were found to have vanished one year after the operation. A possible reason is the short duration of the programme. Long-term, structured aftercare programmes should help stabilize the positive effects obtained in the short term.

Background One factor for the development of sternal wound infection (SWI) is bony instability after sternotomy. This study compares two surgical techniques with respect to the occurrence of SWI in patients with an increased risk. Methods In this multicenter study, 815 consecutive patients with an increased risk for SWI were prospectively randomly assigned to a conventional osteosynthesis (transsternal or peristernal wiring; n=440) or to an osteosynthesis with additional lateral reinforcement (Robicsek; n=375). Primary endpoints were the rate of sternal dehiscence as well as the occurrence of superficial sternal wound infections and deep sternal wound infections. Results Both groups were comparable concerning preoperative and intraoperative variables. The rate of sternal dehiscence, superficial sternal wound infections, and deep sternal wound infections (conventional technique 2.5%, 3.4%, 2.5%; and Robicsek 3.7%, 5.6%, 3.7%) did not differ between the groups. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass indes greater than 30 kg/m 2 (odds ratio [OR]: 2.9; p = 0.05), New York Heart Association class more than III (OR: 2.4; p = 0.07), impaired renal function (OR: 3.9; p = 0.01), peripheral arterial disease (OR: 3.6; p = 0.001), immunosuppressant state (OR: 3.3; p = 0.001), sternal closure performed by an assistant doctor (OR: 2.5, p = 0.004), postoperative bleeding (OR: 4.2; p = 0.03), transfusion of more than 5 red blood units (OR: 3.7, p = 0.01), reexploration for bleeding (OR: 6.9, p = 0.001), and postoperative delirium (OR: 3.5, p = 0.01). There was an inverse relation between the numbers of wires and DSWI in patients with conventional sternal closure ( p = 0.008). Conclusions In patients with an increased risk for sternal instability and wound infection after cardiac surgery, sternal reinforcement according to the technique described by Robicsek did not reduce this complication.

Background Scientific literature on depression and anxiety in patients with coronary heart disease (CHD) consistently reports data of elevated anxiety and depression scores indicating clinically relevant quantities of these psychopathological conditions. Depression is considered to be a risk factor for the development of CHD and deteriorates the outcome after cardiac rehabilitation efforts. The aim of our study was to evaluate the presence of clinically relevant anxiety and depression in patients before and after coronary artery bypass grafting (CABG). Additionally we evaluated their relationship to age because of the increasing number of elderly patients undergoing CABG surgery. Methods One hundred and forty-two consecutive patients who underwent CABG in our hospital were asked to fill in the "Hospital Anxiety and Depression Scale – German Version (HADS)" to measure depression and anxiety scores two days before and ten days after CABG surgery. Differences between these pre- and post-surgical scores were then calculated as means for changes, and the amount of elevated scores were appraised. In order to investigate the relationship between age and anxiety and depression, respectively, Spearman correlations between age and the difference scores were calculated. In addition, ANOVA procedures with the factor "age group" and McNemar tests were calculated. Therefore the sample was divided into four equally sized age groups. Results 25.8% of the patients were clinically depressed before and 17.5% after surgery; 34.0% of the patients were clinically anxious before and 24.7% after surgery. This overall change is not significant. We found a significant negative correlation between age and the difference between the two time points for anxiety (Spearman rho = -.218; p = 0.03), but not for depression (Spearman rho = -.128; p = 0.21). ANOVA and McNemar-Tests revealed that anxiety scores and the number of patients high in anxiety declined statistically meaningful only in the youngest patient group. Such a relationship could not be found for depression. Conclusion Our data show a relationship between age and anxiety. Younger patients are more anxious before CABG surgery than older ones and show a decline in symptoms while elderly patients show hardly any change.

The purpose of this study was to evaluate the influence of an in-hospital (stage I of rehabilitation) individualized motivation programme for life-style change on the cardiovascular risk factors of patients after coronary artery bypass grafting (CABG).142 consecutive patients undergoing CABG because of coronary heart disease were divided into two groups. Group I received the usual care; Group II received the intervention (individual motivation programme). Medical variables concerning all cardiovascular risk factors and the current medication plan were evaluated on admission and one year after surgery.After 12 months significant reductions in systolic blood pressure (p = 0.002), LDL-cholesterol (p = 0.023) and triglyceride (p = 0.046) were found in the intervention group on comparison of the two groups. The HDL cholesterol improved in the intervention group and decreased slightly in the control group. Both groups showed an improvement in diastolic blood pressure, Body Mass Index, blood cholesterol and blood glucose values. The intervention did not show a significant influence on smoking and medication habits.An individualized motivation programme starting in the acute hospital may positively influence cardiovascular risk factors with ongoing success.

Anticoagulation after implantation of a bioprosthetic heart valve has been suggested during a high-risk period of 3 months following surgery. There is little information available concerning the risk of thromboembolism during this period if anticoagulation is not carried out. However, this is of interest since 60-80% of all bleeding complications due to anticoagulation occur during the first year of treatment. Between 1983 and 1993, 57 of our patients did not receive oral anticoagulation after implantation of a bioprothesis in the aortic position (49 Hancock, 7 Mitroflow and one Edwards stentless). All patients were investigated retrospectively. A risk for thromboembolic complications of 1.75% is calculated for the first six months following surgery, being 3.5 per 100 patients/year. There seems to be no advantage in standard anticoagulation (INR 2.5-4) with its risk of serious bleeding complications of about 4% during this period of treatment. Low-dose anticoagulation (INR 2.0-2.3), however, preferably in combination with prothrombin estimation by the patients, seems to offer a relatively safe treatment for these patients.

Background . Cerebral oxygen saturation (ScO 2 ) can be assessed by near-infrared spectroscopy. We investigated the correlation between early postoperative cognitive performance and intraoperative ScO 2 in a prospective observational setting. Methods . Forty-seven patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass underwent preoperative and postoperative neuropsychological evaluation. Patients were classified according to the presence or absence of postoperative cognitive dysfunction. Cognitive dysfunction was defined as an individual test score decrease of more than one standard deviation in two or more of the five tests. During operation ScO 2 was continuously measured using an INVOS 4100 device. Cerebral oxygen saturation values were analyzed with reference to two cutoff points, which should reflect low cerebral oxygenation: an ScO 2 less than 40% and a drop of more than 25% from individual baseline values. The duration and extent of ScO 2 values below these two cutoff points was compared between the patients with and without cognitive dysfunction. Results . Sixteen patients (34%) showed postoperative cognitive dysfunction. Cerebral oxygen saturation values less than 40% occurred in 17 patients for a mean (± standard error of the mean) of 17.2 ± 6.5 minutes, whereas a decrease of more than 25% from baseline values occurred in 37 patients for 52.7 ± 7.8 minutes. The duration and extent below the two cutoff ScO 2 values was similar in patients with and without cognitive dysfunction. Conclusions . Intraoperative regional ScO 2 as assessed by near-infrared spectroscopy with the INVOS 4100 device is not predictive for postoperative cognitive performance in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

Fat emulsions can cause changes in blood-clotting and fibrinolysis. The aim of this study was to examine the relation between the use of the short-acting hypnotic propofol and alteration of the blood clotting system. In a double-blind randomized study, 36 patients with an aortocoronary bypass operation were given either midazolam/fentanyl or propofol/alfentanil. Eleven blood samples were taken at fixed times pre-, intra- and postoperatively to determine changes caused by the anesthetic agents on the hemostaseologic parameters during the whole operation. Perioperative blood pressures of both groups were measured at seven fixed points. From the beginning of the extracorporeal circulation (ECC) to the end of the operation, the measured values of the factor XIIa- and kallikrein-like activity in the propofol group were significantly higher than those of the midazolam group. Also the values of the kallikrein inhibition capacity and the indicators of fibrinolysis (t-PA and D-dimers) suggest a stronger activation of the contact phase at the start of the recirculation and as a result of it a stronger fibrinolysis within the propofol group. Besides, the hypotensive side-effect in the propofol group was evident in contrast to the midazolam group. With this investigation, a correlation between the application of propofol/alfentanil, contact phase activation with activation of the kallikrein-kinin-bradykinin system and the observed hypotension can be set up.

BACKGROUND Intraoperative thromboembolism and the systemic inflammatory reaction are thought to play a role in causing cerebral dysfunction following cardiopulmonary bypass (CPB). Increased levels of S100B, an astroglial protein, have been linked to neuropsychological deficits after CPB. The present study investigated whether S100B release correlates with intraoperative embolus formation, thrombin formation, or the release of inflammatory parameters. METHODS 40 patients undergoing coronary artery bypass grafting were included. Blood samples were taken before, during, and after CPB, and levels of S100B, thrombin-antithrombin complex (TAT), complement C5a, and interleukin 8 were analysed. Embolus formation was assessed by Doppler ultrasound at the arterial line of CPB. RESULTS The release of S100B correlated with embolus count (r = 0.42; p = 0.009) and TAT formation (r = 0.71; p = 0.0001). The correlation of S100B with interleukin 8 (r = 0.58; p = 0.0001) was due to the dependence of both parameters on bypass time (r = 0.29; p = 0.075, partial correlation). A correlation of S100B with C5a formation could not be observed. CONCLUSIONS S100B release is related to embolus and thrombin formation during CPB, indicating that thrombofibrinous embolism is involved in perioperative brain damage. Inflammatory parameters (i.e. interleukin 8 and C5a) seem to have no influence on S100B release.

In the present study the influence of different storage solutions on endothelial integrity or damage was investigated with direct methods particularly with transmission electron microscopy (TEM), scanning electron microscopy (SEM) and immunohistochemistry.Saphenous vein segments of 10 cm in length were taken surgically from 6 male CABG-patients (aged 60-70) under standardized conditions. Each vein segment was cut into rings, which were incubated at room temperature for 45 minutes in different storage solutions, particularly in 0.9% sodium chloride solution and in buffered solution (M 199) with 5% human serum albumin respectively. Then, the vein segments were fixed in 3.5% glutaraldehyde and prepared for scanning and transmission electron microscopy to evaluate the endothelial damage. In addition, immunohistochemical staining (CD34, PECAM and Factor VIII) was performed.When using 0.9% sodium chloride solution, the SEM-examination revealed that 55% of the cell population was destroyed. In comparison to these findings only 26% of the endothelial cell population was damaged when the venous segment was stored in buffered solution with 5% albumin (p0.01). In immunohistochemistry (CD34, PECAM, Factor VIII) these findings were supported.This study demonstrates the importance of storage solutions in regard to endothelial integrity. For best preservation of endothelium it is necessary to modify conventional storage methods. So, storage in buffered solution with albumin has shown much better endothelial cell preservation compared with physiological saline which might reduce the obliteration rate of CABG in future.

Cardiopulmonary bypass (CPB) is known to induce an inflammatory response. Previous studies reported an impairment of the cellular immune response with activation of neutrophils and changes in lymphocyte subpopulations. The objective of the present study was to investigate the effect of CPB on leukocyte activation in vivo. In 27 patients undergoing coronary artery bypass grafting, the quantitative and the qualitative response of leukocyte populations to CPB was analysed pre-, intra-, and postoperatively using flow cytometry. A significant increase in leukocyte counts was detected during CPB, resulting in a marked leukocytosis postoperatively. The total number of lymphocytes peaked in the early phase of CPB, followed by a significant decrease, mainly due to a loss in B and cytotoxic T lymphocytes. In contrast, the lymphocytopenia observed 8 h after protamin administration was mainly caused by a drop in the population of helper T lymphocytes. Activation of distinct cell populations could be detected during and following CPB. The results indicate an influence of CPB on the cellular immune system, however an immuno-suppression was detectable only transiently.

Of primary importance in the differential diagnosis of multiple circular foci in the lungs are the lung metastases. This study involves a patient with three circular foci, each of which could have been metastases. They proved, however, to be a rare coincidence of three benign lung affections, namely, an old tuberculoma, a chondrohamartoma, and a seldom encountered pulmonary cryptococcoma. Computerized tomography utilizing the spiral technique was valuable diagnostically, as it led to the discovery of the smallest of the three circular foci in the basodorsal left lower lobe. The form of the cryptococcosis among immunocompetent patients--only rarely localized in our experience--must be included in the differential diagnostical considerations of a circular focus in the lungs. In the event there are multiple circular foci with an unknown primary tumor, surgical intervention with a pathohistological clarification regarding a possible malignancy is absolutely necessary.

During cardiopulmonary bypass (CPB) mechanical stress and the contact of blood with artificial surfaces lead to the activation of pro- and anticoagulant systems and the complement cascade, and to changes in cellular components. This phenomenon causes the "postperfusion-syndrome", with leukocytosis, increased capillary permeability, accumulation of interstitial fluid, and organ dysfunction. In this study, we focused on the influence of the extracorporeal circulation, sternotomy, and heparin administration on the activation of coagulation and fibrinolysis. In 15 patients we investigated coagulation parameters before, during and post CPB, i.e., fibrinogen, antithrombin (AT) III, thrombin-antithrombin complex (TAT), prothrombin fragments F1 + 2 (F1 + 2), factor (F) XIIa, tissue factor (TF), and parameters of the fibrinolytic system, i.e., plasmin-antiplasmin-complex (PAP), D-dimer, tissue-plasminogen-activator (tPA), urokinase-type plasminogen activator (uPA), and plasminogen-activator inhibitor type 1 (PAI 1). The results demonstrate distinct alterations in the above mentioned parameters. Despite administration of a high dose of heparin (activated clotting time [ACT] > 450s) combined with a low dose of aprotinin, activation of the coagulation and fibrinolytic pathways was observed. We found this activation was mainly caused by CPB and not by sternotomy. The activation of coagulation was due to foreign surface contact (F XII => F XIIa) as well as to an effect of tissue factor release in the late phase of CPB. The enhanced fibrinolytic activity during CPB was, at least in part, caused by tPA and was followed by PAI 1 release.

Between 1986 and 1989 295 pacemaker (PM)-implantations were performed (mean age: 69.9 +/- 14.5 years; 54.9% male, 45.1% female).AV-Block II+III (36.6%), sick-sinus-syndrome (26.4%), bradyarrhythmia (18.0%). Concomitant disease: hypertension (40.6%), diabetes mellitus (19.3%), coronary artery disease (11.5%), malignant tumors (10.8%), renal failure (7.5%). We implanted in 72.9% VVI-PM, in 23.7% DDD-PM and in 3.4% AAI-PM. The median fluoroscopy-time as a measure for time of surgery was 6.2 minutes (DDD: 6.7; VVI: 5.4; AAI: 9.9). In 6.5% there were intraoperative complications: arrhythmias (3.4%), skeletal muscular stimulation (M.pect.; 1.4%), lead dislodgment (0.7%), missed puncture (A.subcl.; 0.7%). The early postoperative (14 days) complications rate was 9.5% (lead dislodgment 3.7%, development of high threshold 1.7%, bleeding 1.4%, bacteriaemia 1.0%, skeletal muscular stimulation 0.7%). The complication rate of AAI-PM (70.0%) was significantly higher compared to DDD-PM (29.8%; p less than 0.01) and VVI-PM (12.1%; p = 0.00025). In 17 patients (5.8%) reoperation was necessary (lead dislodgment n = 11, development of high threshold n = 3, arrhythmias n = 2, postoperative bleeding n = 1). The highest dislodgment rate was seen in atrial leads with active fixation (5.0%). In 2.6% of active fixation leads there was a development of high thresholds (passive fixation leads 0.5%). The selection of the PM-system to be implanted has to be considered in respect to the increased complication rate of DDD- and AAI-PM, especially in elderly patients.

In the years 1979 to 1985 (period I) 717 (102 per annum), in 1986 to 1989 (period II) 295 (73 per annum) pacemaker procedures had been performed at the cardiothoracic surgery division of Würzburg University. Indications for pacemaker therapy were in 35.4% vs. 36.6% (period I vs. period II) an atrioventricular block grade II or III, in 18.1% vs. 26.4% sick sinus syndrome, in 15.3% vs. 18.0% bradycardic rhythm disturbances, in 9.5% vs. 6.1% a sinuatrial block, in 6.5% vs. 2.4% a bradycardic sinus rhythm, in 12.4% vs. 3.7% others. While 41% of the procedures were performed under general anesthesia during the first period of observation, local anesthesia was predominant later on. Preferred venous access (79% vs. 74%) was the right cephalic vein followed by the subclavian vein (12% vs. 14%). The amount of the two chamber systems rose form 11% (period I) to 24% (period II). Intraoperative complications occurred in 2.5% vs. 5.8% and postoperative (within 14 days) complications occurred in 4% vs. 5.8%, respectively. No death was to be registered. The reasons for the increase of intra- and postoperative complications are discussed.

During open heart surgery, needle biopsy material was obtained in four patients, and electron microscopic preparations of the mitochondrial ATPases (coupling factors 1) in human myocardial cells were performed. The pre-ischemic, normal structure of the mitochondrial ATPases and the changes which occur during the ischemic interval were described. An increase in the center-to-center space was shown in the post-ischemic phase. This result was discussed for the pathogenesis of subcellular injuries due to ischemia.

Three biopsies were taken transmurally in different time intervals (before and after ischemia and during the reperfusion phase) from 20 patients undergoing open-heart operation for acquired valvular heart disease, and the myocardial cylinders were examined with the electron microscope. They were scrutinized to see if there is a relationship between the degree of hypertrophy and degeneration before ischemia and the extent of ischemic damage after a certain ischemia period, and between the damage before ischemia and the postoperative outcome of the patients. Our results show that the ischemic changes are not dependent on the preischemic extent of hypertrophy and degeneration. It seems that they are mainly dependent on the duration of ischemia because the degree of ischemic damage increases with prolongation of the ischemia interval. However, a good correlation was found between the preischemic changes and the postoperative outcome. Especially the combination of marked hypertrophy and the appearance of degenerative signs in the biopsy taken before ischemia seems to predestine a bad postoperative course. Therefore, it can be concluded that the total damage to the myocardial cells, which results from the sum of previous damage (hypertrophy and degeneration) and ischemic alterations, is responsible for the postoperative outcome.

Reconstruction of the carotid artery was performed in 41 patients (between 1967 and 1974). All had had signs of cerebrovascular insufficiency. There was angiographic evidence of obliterating arteriosclerotic lesions in the carotid artery of 32 patients, carotid aneurysm in two, kinking of the internal carotid artery in four, and acute thromboses of the carotid artery in three. Early and late results indicate that best chances of success exist for stage II and III a cases. The high mortality rate in stages III b and IV (five of twelve patients) clearly shows that in these reconstruction of the carotid artery should be embarked on with caution, especially in the early stages.

An experimental study about post-ischemic perfusion of muscles with a new stroma-free hemoglobin solution is presented. Compared to other storage and perfusion methods the solution has several advantages: 1. Oxygenation and metabolism of the skeletal muscles are preserved. 2. Excellent wash-out effect. 3. The rheologic characteristics are better than those of whole blood. 4. No incompatibility. 5. No thrombogenetic effect. 6. The method is easy to manage. Our ultrastructural investigations show less damage of the muscle cells after a post-ischemic perfusion with oxygenated hemoglobin solution than after a post-ischemic physiological perfusion with whole blood.

One hundred and two patients with epithelial thymoma (ET) and carcinoma have undergone surgical treatment since 1957. In this series thymomas were classified according to Masaoka's clinical staging criteria (encapsulated, invasive) and according to Muller-Hermelink's histological criteria of the resected specimens (medullary and cortical differentiation) and compared to clinical symptoms and survival rates (mean follow-up time 66.4 months). We found that it is not always possible to differentiate intraoperatively fibrous adhesions from infiltrations of the thymic capsule or to recognise thymus carcinoma as such macroscopically if they have not already infiltrated the organ's capsule. All ETs with cortical differentiation after thymectomy showed a malignant course; in contrary ETs with medullary differentiation we found without relapses of metastases. ETs with both histological types (hybrid typs) and cortical dominance took in only two out of 57 cases a malignant course though five of them showed an invasion into the capsule according to clinical staging criteria stage II. Therefore classifying ETs only into two categories, encapsulated and invasive, according to surgical and gross findings, seems to be not always possible and insufficient for the clinical assessment of the malignity and prognosis.

Nocardial sepsis occurred after aortic valve replacement in two patients. A septic suture aneurysm of the aortotomy was resected and the prosthesis exchanged in one of them. The other received conservative treatment for sternal osteomyelitis and local mediastinitis. Clinical cure was followed by relapse and death from cerebral infarction, and necropsy revealed a septic suture aneurysm of the aortotomy. Radical surgical revision seems to be necessary for lasting cure in such infections.

After-bleeding not due to surgery following extracorporeal circulation (ECC) in open heart surgery has its origin in disorders of platelet number and function as well as in changes of the haemostatic balance. Not only are the plasmatic factors of the coagulation and the fibrinolytic system of importance but also their inhibitors which tend to avoid dysfunctions and overshooting reactions. To detect early the danger of an excessive bleeding tendency assays of fibrinogen (factor I), prothrombin (factor II), antithrombin III (AT III) and of alpha 2-macroglobulin (A 2 M) are recommended. A substitution therapy can be oriented by the results of these coagulation parameters.

In order to evaluate the possible differences in response to two currently preferable inotropic-vasodilator drug combinations, the hemodynamic effects of automated infusions of nitroprusside-dobutamine and nitroprusside-dopamine were studied in two clinically similar groups of patients with low-output syndrome after aorto-coronary bypass surgery. Nitroprusside, when infused in combination with dopamine, was effective in lowering filling pressures of both ventricles and systemic and pulmonary arterial pressures reflecting the reversal of deleterious rise of these parameters including determinants of myocardial oxygen consumption (mean arterial pressure rate by +6%, heart rate by +20%) caused by dopamine (6 micrograms/kg/min) infused alone. The combination of the more cardioselective catecholamine dobutamine with nitroprusside brought about similar increase in cardiac output by 50%, but derived its hemodynamic efficiency from the sum of separate effects of components and produced less in the way of elevation of determinants of oxygen consumption. Dobutamine when infused alone (6 micrograms/kg/min) has not affected systemic and pulmonary arterial pressures and stroke index rose more markedly (+9%) as a result of more moderate heart rate increase (+13%). Nitroprusside contributed in an additive manner to the achieved overall reduction of SVR and PVR by 43% and 50%, resp., the automated infusion being helpful in maintaining these values within close tolerances.

We present a case of intraoperative dissection of the aortic root in a patient with non-calcified aortic valve incompetence. This complication led to life-threatening bleeding from the dissection line into the layers of the left ventricle as well as the aortic wall with formation of an increasing subadventitial hematoma. The only possible management was to remove the valve prosthesis and to close the entry site of the dissection when reinserting the valve implant. The mechanism of this complication is discussed.

Between 1972 and 1976, 24 patients have been treated by open pulmonary embolectomy with the aid of cardiopulmonary bypass (CPB). In 17 (71 percent) acute pulmonary embolism occurred 3 to 60 days after a surgical procedure. The remaining seven (29 percent) patients had chronic medical diseases. The interval between clinical manifestation of acute pulmonary embolism and the performance of open embolectomy ranged from 8 to 36 hours. The definitive diagnosis in all patients was made by pulmonary arteriography. Candidates for pulmonary embolectomy were selected by assessment of hemodynamic stuides: shock, arterial Po2 less than 65 mm. Hg, acidosis, pulmonary artery pressure higher than 20 to 30 mm. Hg, and central venous pressure elevated (patients in Class III or IV according to the Greenfield classification). The definitive indication for embolectomy was occlusion of the main pulmonary artery of more than 50 percent as well as occlusion of the right or left pulmonary artery. Of the seven patients operated upon between 1973 and 1974, three (43 percent) died in the early postoperative period. Between 1975 and 1976 the operative mortality rate in 17 patients was 23 percent (four patients). Our results show that prompt diagnosis of acute massive pulmonary embolism and better selection of patients may improve significantly the survival rate after open pulmonary embolectomy with CPB.

Congenital pulmonary arteriovenous fistula is a rare condition and, for this reason, is repeatedly misinterpreted despite the typical complaints it gives rise to. On the basis of seven cases diagnosed and treated surgically by the present authors, including follow-up, the clinical picture is discussed in detail. The diagnosis of pulmonary arteriovenous fistula can be established on the basis of pulmonary antiography or, more simply, with the aid of digital subtraction angiography with representation of multiple fistulas and accurate localisation. Employing segmentectomy, it usually proves possible successfully to treat even multiple arteriovenous fistulas in the lung, and to achieve lasting freedom from symptoms and recurrent disease. Even if it is asymptomatic, pulmonary arteriovenous fistula should always be resected, since life-threatening ruptures with followed by bleeding into the parenchyma and haemothorax (as was observed in one of our patients) can occur.