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Background: This study aims to evaluate the early and late outcome of patients treated by surgery for myasthenia gravis and the diagnostic value of the Besinger Score, which is based on a correlation of severity of symptoms with specific antibodies to acetylcholine receptors, in the follow-up investigation after surgical therapy., Methods: Between June 1984 and April 1992 thoracotomy was performed in 51 myasthenia gravis cases at our department. The retrospective analysis considered patients with (n = 13) or without thymoma (n = 38). The Besinger score was used to describe the severity of disease preoperatively and up to 5 years postoperatively., Results: The Besinger score fell continually post surgery. Changes in relative serum concentrations of antibodies were similar to the Besinger score. Five years after thymectomy complete remission was diagnosed in 40% of the patients. The required dosage of pyridostigmine had fallen by two thirds after 5 years. Patients with follicular hyperplasia had significantly higher remission rates than those with thymoma., Conclusions: Surgery for myasthenia gravis is successful. The Besinger score well quantifies the severity of the disease.

The incidence of prosthetic valve thrombosis (PVT) has been reported to be < 0.1-0.25%/year following isolated aortic valve replacement and < 0.1-2.5%/year after mitral valve implantation. In a consecutive series 10.3% of PVT occurred after an interruption of oral anticoagulant therapy for weeks or months, in 20.7% with inadequate low anticoagulation while in 34.5% of PVT cases intensity of the oral anticoagulant therapy showed significant ups and downs. There was an obvious increase of PVT incidences during the winter months, concomitant with increasing fibrinogen levels and plasma viscosity. The diagnosis of PVT can be made with a high specificity and sensitivity by analysis of the typical opening and closing clicks of the valve occluder. Parameters indicating chronic intravascular hemolysis, fluoroscopy and echocardiography are additionally helpful to confirm the diagnosis. The therapy of choice is prosthetic valve re-replacement. Systemic thrombolytic therapy may be an alternative in selected patient groups.

Introduction: In this study systolic and diastolic function in patients with hypertrophic obstructive cardiomyopathy (HOCM) and intractable complaints to medication were investigated before and after a mean of 7 months after myectomy., Methods: Investigations in 19 patients with HOCM included echocardiography, Swan-Ganz-thermodilution-catheter and radionuclide-angiography., Results: Myectomy resulted in a reduction of the intraventricular gradient at rest (40.1 +/- 43.3 versus 7.6 +/- 12.0 mm Hg, p < or = 0.005) and under provocation (92.4 +/- 67.1 versus 21.3 +/- 26.5 mm Hg, p < or = 0.001). Echocardiographically determined basal septal thickness was reduced (24.9 +/- 6.3 versus 20.1 +/- 6.8 mm; p < or = 0.05) and diastolic diameter increased (40.4 +/- 5.2 versus 44.8 +/- 7.1; p < or = 0.05). Exercise tolerance increased from the maximally achieved 64.5 +/- 19.2 to 89.5 +/- 24.0 W (p < or = 0.001). Symptomatic status (NYHA) improved (1.7 +/- 1.4 versus 2.8 +/- 0.3 (p < or = 0.001). Systolic parameters showed at rest an increase in isovolumetric contraction time (65 +/- 39 versus 112 +/- 50 ms, p < or = 0.01), in time to peak ejection (109 +/- 40 versus 188 +/- 42 ms, p < or = 0.001), and a reduced left ventricular ejection fraction (72 +/- 12 versus 64 +/- 11%, p < or = 0.01). Analysis of regional ejection fraction revealed a significant reduction of ejection fraction in the basal septal region (p < or = 0.05). Increase of global and regional ejection fraction under exercise was still preserved. Mean pulmonary capillary wedge pressure was significantly reduced at rest (11.8 +/- 3.8 versus 8.6 +/- 2.4 mm Hg, p < or = 0.05) as well as under exercise (27.0 +/- 7.1 versus 20.4 +/- 6.8 mm Hg, p < or = 0.01), whereas left ventricular enddiastolic volume index (63 +/- 19 versus 72 +/- 17 ml*m-2, p < or = 0.05) was significantly increased., Conclusions: In patients with HOCM, myectomy reduces intraventricular gradient, increases exercise capacity, and is accompanied by improved diastolic function parameters, while systolic function parameters are generally reduced.

Six hundred consecutive patients were operated on between September 1978 and October 1982 for isolated aortic (n = 298), mitral (n = 215), or multiple valve replacement (n = 87) with the St. Jude Medical bileaflet prosthesis. Mean age of the 303 female and 297 male patients was 50.7 +/- 9.6 (range 12 to 83) years. All patients were followed up prospectively; follow-up was complete and averaged 122.2 +/- 1.1 months for operative survivors. Total follow-up for aortic patients was 2904.1 patient-years, for mitral replacement 1859.5 patient-years, and for multiple valve replacement 736 patient-years. When the prothrombin times measured with different thromboplastins were converted into an international normalized ratio, four patient groups could be separated; that is, the groups comprised patients whose anticoagulation was maintained during the follow-up within an international normalized ratio corridor of 4.0 to 6.0, 3.0 to 4.5, 2.5 to 3.5, or 1.75 to 2.75. Less intensive anticoagulation in terms of the international normalized ratio values caused only a mild increase in the incidence of thromboembolic complications but a highly significant decrease in the rate of bleeding. Severe bleeding complications in the aortic valve group were highest with an international normalized ratio of 4.0 to 6.0 (1.15 per patient-year) and lowest with an international normalized ratio of 1.75 to 2.75 (0.24 per patient-year). The same held true for patients with single St. Jude Medical mitral valve replacement (2.09 per patient-year versus 0.72 per patient-year) and multiple valve replacements (4.45 per patient-year versus 1.20 per patient-year). These results suggest that the generally recommended international normalized ratio of 3.0 to 4.5 may be too high for patients with St. Jude Medical aortic valve replacement and also for patients with St. Jude Medical prostheses in the mitral position if, with respect to the thromboembolic hazard, there is not a predominating patient-related comorbidity. A large multicenter prospective randomized study is therefore proposed to establish the safe international normalized ratio levels accompanied by the lowest complication rates for both bleeding and thromboembolic events after St. Jude Medical prosthesis implantation (German experience with low intensity anticoagulation study).

Exercise capacity following heart-valve replacement is dependent on how close to normal the artificial device can restore valve function, to what degree a preoperative impaired myocardial function and/or an increased pulmonary vascular resistance is normalized. The postoperative functional result can be determined by the subjective improvement of the patient, his functional capacity, exercise capacity, the central hemodynamics at rest and during exercise, and the systolic and diastolic function of the left and right ventricular myocardium. The subjective improvement of individual symptoms is obviously dependent on the degree of postoperative normalization of hemodynamics, especially of pressures in the pulmonary circulation. Subjective improvement can be objectified by comparing the functional capacities before and after surgery. Post-operative normalization of central hemodynamics and myocardial function does not happen immediately but within 3 to more than 12 months. A 12-month period can generally be expected in patients with mitral stenosis and increased pulmonary vascular resistance (> 400 dyn.sec.cm-5) prior to surgery. In patients with mitral and aortic regurgitation as well as with aortic stenosis and preoperative decrease of their left ventricular ejection fraction during exercise, continuous improvement of left ventricular pump function also may need up to 12 months. Physiological hemodynamic conditions generally are not restored by valve replacement. All prostheses are stenotic to forward blood flow because of the obstruction created by the narrowing of the valve area by sewing cuff and valve poppet. This may result in a hemodynamically important stenosis, especially after atrio-ventricular valve implantation, and may limit subjective and functional improvement. Exercise capacity after aortic valve replacement depends mainly on whether or not myocardial damage persists postoperatively. A workload of 1.5 w/kg body weight (BW) has been performed by 100% of patients aged 45 to 55 years with prostheses implanted for aortic stenosis. The significant lower exercise capacity all patients with valve replacement for aortic regurgitation have experienced (0.4 w/kg BW) indicates that a substantial number of these patients has irreversible myocardial damage prior to surgery. The workload experienced by patients with mitral valve prostheses varies between 0.4 and 2.0 w/kg BW (mitral stenosis) and 0.3-2.3 w/kg BW (mitral regurgitation), respectively. To objectify the functional result of heart-valve replacement, hemodynamic-metabolic measurements of functional improvement, determination of left, eventually also of right-ventricular function by echocardiography and additional invasive measurements of the central hemodynamics and myocardial pump function parameters at rest and during exercise might be necessary.

As early as 1964, Lillehei et al. published the technique of preservation of the posterior mitral leaflet (PML) and chordae tendineae in combination with mitral prosthesis implantation (MPI). In a limited randomized number of 95 patients with MPI the influence of preservation of PML on hemodynamics and physical capacity at least 46 months after surgery without (group A) and with preservation of PML (group B) was investigated. Statistically significant differences in favor of group B were found for cardiac index, pulmonary artery pressure after stress, end-diastolic volume index (EDVI), physical capacity and survival rate after a complication-free course. Basing on these results at rest and after exertion (30 W), patients with preservation of PML and MPI are long-term in a better clinical condition.

Thoracic aneurysms are classified according to the nomenclature of De Bakey (1-3b) or Daily (Stanford A-B). Our early and late results refer to dissections of the ascending aorta with and without aneurysms as well as with and without aortic valve involvement. The distal extension of the dissections was different. Since 1979 45 patients (mean age 48 years, range 23-70 years) were operated, the acute dissections mostly as emergencies after secured diagnosis. The preferred technique was reconstruction of the ascending aorta. However, also other techniques as prosthetic replacement or implantation of an conduit were used. The hospital lethality was 12.5% (n = 6); the late letality 24% (n = 7). The cumulative survival rate after 8 years was 74%.

In spite of intensive efforts to reduce the risk of hepatitis B after heart operations, this complication is observed in 40 % or more of the cases. Over a period of three years (1974--1976) we examined 588 patients who had undergone open heart surgery. The following results were found: In 1974 the hepatitis frequency was 2.0 %, while in 1975 and 1976 it was 0.6 % hepatitis B and 0.6 % non-B hepatitis. We believe the reason for this improvement is a more careful selection of blood donors and their continuous control according to the following parameters: regular clinical observation; regular chest x-ray; determination of BSR, hemoglobin and aminotransferase; TPHA test; and search for antibodies. In 1974 hepatitis-B-surface-antigen (HBsAg) was detected by means of reverse hemagglutination tests. Since 1975 a modified radioimmunoassay has been used for this purpose. No donor blood with abnormal results was transfused, except for a very small number of extreme emergencies. The good results demonstrated can only be obtained by following the described program and by strictly avoiding pool preparations.

In 342 patients undergoing open heart surgery we determined the serum enzyme levels of GOT, GPT, LDH, alpha-HBDH, LAP, CK and CK-MB from the beginning of the operation up to the 14 th postoperative day. There was an elevation of serum enzymes depending on the type of operation, the duration of extracorporal circulation and the postoperative course. A pattern of enzyme changes for uncomplicated cases is described. The investigations demonstrate a statistically significant correlation between the elevation of "liver specific enzymes" and right heart failure on one hand and of "heart specific enzymes" and myocardial ischemia on the other hand. It is concluded that only repeated determinations beginning with the operation enable to evaluate serum enzyme levels.

Following correction of a partial atrioventricular canal and closure of the atrial septum defect with a Dacron patch a severe hemolytic anemia developed caused by moderate mitral insufficiency. The clinical postoperative course and the successful treatment by reoperation is described in detail. The Dacron patch was excised, the mitral cleft was closed by four single sutures, and the septal defect was covered with a pericardial patch. In the literature ten other communications were gathered reporting hemolytic anemias following correction of endocardial cushion defects with Dacron, Teflon, or Ivalon patches. Three of six reoperated patients died postoperatively. A woman died after correction with renal failure caused by severe hemolysis. In four patients hemolytic anemia was compensated and there was no need for reoperation. In consideration of our own experience and those reported in the literature we recommend pericardium instead of synthetics for closure of atrial septum defects of Foramen-primum-type.

Between 1966 and 1973 145 palliative procedures were carried out on 110 infants with transposition of the great arteries. There were 23 early deaths (20.9 per cent). 85 per cent of the survivors were controlled till the end of 1974. Five late deaths and four cases of peripheral artery embolism were regarded. These complications, however, took place several years after palliation. The development of pulmonary hypertension doesn't seem to be as high as it is suspected sometimes. These results justify our conception, not to perform the Mustard-operation during the first two years of life.

From 1973 to 1985 2394 mechanical valve prostheses (MVP) (follow-up time 110,653 months) and 186 biological valve prostheses (BVP) (follow-up time 5887 months) were implanted. There were only small differences according to the cumulative incidence of prosthetic malfunctions, for reoperations after 10 years: MVP 5.4 +/- 0.4%; BVP 7.7 +/- 0.9%. The total reoperation incidence/100 patient-years was for MVP 1.14, for BVP 2.65. Further complications resulted from anticoagulation therapy (thrombemboli, bleeding), and prosthetic valve endocarditis. The cumulative freedom of any complications after 10 years was 73.1% for Björk-Shiley-AVR, 54.2% for BS-MVR, and only 31.2% for BS AVR + MVR. These results indicate regular controls for all patients postoperatively.

The results of intra-aortic balloon pumping in 7 patients with cardiogenic shock after cardiac surgery are reported. 2 patients were unresponsive to IABP, 4 patients showed initial stabilization of the circulation, but became IABP-dependent and died. One patient could be weaned from IABP, but died of uncontrollable cardiac arrhythmias. These results are discussed.

The natural history of hypertrophic obstructive cardiomyopathy (HOCM) is usually characterized by development of mitral insufficiency, congestive heart failure (CHF) and sudden death. In patients (pts) belonging to at least clinical class III (NYHA) after failed medical therapy (beta-blocking agents and calcium-antagonists) surgery should be considered (by means of transaortic subvalvular myectomy). The history and development of different surgical techniques and procedures has been described in detail since 1958, when Cleland performed the first transaortic subvalvular myotomy. Our surgical series (1963-May 31, 1986) consists of 212 pts (mean age 40 years, range 6-73 years) with typical and atypical HOCM. The total hospital mortality rate was 6.6% (n = 14), which was reduced to 3.8% (n = 6), if only transaortic subvalvular myectomy (TSM) was performed (n = 160). In the group of 52 pts with additional surgical procedures the mortality rate was 15.4% (n = 8). The main problems occurred in pts with additional mitral valve replacement (MVR) (n = 15, three deaths). The rate of HOCM-related complications (secondary VSD, total AV-block, cerebral embolism, intraoperative re-myectomy) and those related to surgery (bleeding, pulmonary embolism, wound dehiscence, septicemia) was low. Therefore TSM for HOCM is a low-risk surgical procedure with a good long-term prognosis. However, in pts with a need for additional surgical procedures, the risk is considerably increased. Subjective impression of the pts and hemodynamic data indicate a clear clinical improvement postoperatively. Concerning long-term survival and reduction of the sudden death rate, our data do not allow a final judgement at the moment.

Following the increasing number of patients with heart valve replacement and an extended indication (older age groups, acute infective endocarditis, multivalvular procedures) the indicence of malfunction of valve prostheses is continuously growing. The prognosis of patients with a malfunctioning prosthesis mainly depends on early diagnosis and adequate therapy. In a retrospective study (1970 to 1984) 3,533 implanted heart valve prostheses were followed up and the cases with malfunction (n = 150; 4.2%) were analyzed. During the follow-up period after 1963 mitral valve replacements (MVR) there were 78 cases of malfunction (4.6%), after 1806 aortic valve replacements (AVR) 73 (4.1%), and after 34 tricuspid valve replacements (TVR) 4 malfunctions (11.8%). These malfunctions concerned periprosthetic leakages (n = 65), prosthetic endocarditis (n = 42), prosthetic valve thrombosis (n = 13), mechanical dysfunction including bioprosthetic degeneration (n = 17), valve related hemolysis (n = 3), and unsatisfactory hemodynamics (n = 10). Special attention was turned to the problem of prosthetic endocarditis (1963-1984) found in a total of 71 patients following 3,878 prosthetic valve replacements (1.9%). In 42 reoperated cases (1970-1984) the causing microorganisms were analyzed, demonstrating staphylococci in a leading position. Secondary complications and additional risk factors are discussed. There has been no change concerning the basis and the strategy of management for prosthetic endocarditis for many years: After a short time of conservative management with tested antibiotics, early reoperation and exchange of the prosthesis seems to be the optimal therapy, despite a distinctly high postoperative mortality (17%).(ABSTRACT TRUNCATED AT 250 WORDS)