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Incidence, aetiology, diagnosis and treatment of round lesions in the lungs were analysed in 64 patients after lung transplantation (33 men, 31 women; mean age 45 [21-68] years; postoperative survival > 2 weeks). These lesions were found in 8 patients 1-10 months (median of 5.8 months) after the transplantation, singly in two, multiple in six. In six patients it was an incidental finding, further elucidated by computed tomography or fine-needle biopsy. The aetiology varied from B-cell "lymphoma" (posttransplant lymphoproliferative disorder-PTLD) in three patients, aspergilloma in two, and bacterial abscess in one. Two patients died of septicaemia (Aspergillus; Pseudomonas aeruginosa/Staphylococcus aureus), while four had a full remission. The solitary lesions disappeared without specific treatment in 2-3 weeks. If round lesions are noted after lung transplantation, rapid histological and microbiological diagnosis and aggressive treatment are necessary to combat an otherwise high death-rate. PTLD and infection (bacterial or mycotic) are the most frequent causes.

Sternal wound infection after heart transplantation is a feared and potentially life threatening complication with reported incidences between 2.5 % and 3.6 %. However, optimal therapy of sternal wound infections in heart transplant recipients remains a matter of controversy, particularly the effect of immunosuppression in those patients is still unclear. We examined 5 heart transplanted patients (4 men and 1 woman with a median age of 46 +/- 21.4 years (ranging from 14 to 59 years) in terms of inflammation and treatment response during VAC therapy. Infection begin was median 18.2 days (+/- 10 days, ranging from 5 to 28 days) after transplantation. VAC therapy lasted on average 12.2 +/- 2 days, ranging from 10 to 19 days. A median of 3 changes (range from 3 to 5) were necessary until the definitive closure. We examined C-reactive protein, leucocyte count and fibrinogen 2 days pre VAC, during VAC treatment and 2 days after definitive closure. All five patients showed an increase of leucocytes at every VAC change. Furthermore, we saw an adequate reaction to the VAC in terms of granulation tissue growth and resolution of infection. Transplanted patients had an increase of leucocytes at every VAC change. Furthermore all patients showed an adequate response of VAC treatment in terms of granulation tissue in growth and infection decline. Therefore a reduction of immunosuppressive therapy is not necessary, which in turn would increase the risk of rejection.

The expression of the intercellular adhesion molecule 1 (ICAM-1) on the surface of endothelial cells plays an important role in immune-mediated processes. The induction by the proinflammatory cytokine interleukin (IL)-1beta is regulated by nuclear transcription factor kappaB (NF-kappaB). We studied the effect of an inosine-5'-monophosphate dehydrogenase (IMPDH) inhibitor, mycophenolic acid (MPA), on constitutive and IL-1beta-induced expression of ICAM-1 in human umbilical vein endothelial cells (HUVECs). Unexpectedly, pretreatment with MPA enhanced the constitutive expression and potentiated the induction of ICAM-1 by IL-1beta, as detected by flow cytometry. Northern blot analysis revealed an increase in ICAM-1 mRNA levels in cells treated with MPA. This was associated with an increase in phosphorylation of IkappaB-alpha (an inhibitor of NF-kappaB), nuclear translocation of the NF-kappaB subunits p50 and p65 and their binding to DNA as detected by Western blotting, confocal microscopy, and electrophoretic mobility shift assay. The up-regulation of ICAM-1 by MPA was prevented by high doses (100 microM) of guanine or guanosine but not by physiological doses (0.1 microM), indicating that guanylates are involved in endothelial responses to IL-1beta. Cultivation of HUVECs in the absence of guanine enhanced further ICAM-1 expression during IMPDH inhibition. These results demonstrate that cytokine-mediated endothelial ICAM-1 expression can be modulated by IMPDH inhibition. We believe this represents a novel interaction between endothelial guanylate metabolism, NF-kappaB activation, and adhesion molecule expression.

Grundlagen: Die chirurgische Behandlung des diffusen, nichtbullosen Lungenemphysems wurde erstmals 1957 von Brantigan et al. beschrieben und 1995 von Cooper et al. als Lungenvolumenreduktion (LVRS) wiedereingefuhrt. Sie ist mittlerweile ein weltweit etabliertes Verfahren in der Therapie des Lungenemphysems. Wir berichten uber unsere Erfahrungen und Ergebnisse nach LVRS bei 91 Patienten. Methodik: Zwischen September 1994 und August 1998 wurde bei 91 Patienten (Alter: 33–-80 Jahre; Mittel: 56,4 Jahre) uber eine mediane Sternofissur (n = 15), videoendoskopisch (n = 49), uber eine Thoracotomie (n = 18) oder kombiniert auf einer Seite videoendoskopisch, auf der anderen uber eine Thoracotomie (n = 9) eine LVRS durchgefuhrt. Alle Patienten hatten praoperativ trotz maximaler medikamentoser und physikalischer Therapie eine ausgepragte Dyspnoesymptomatik. Ergebnisse: Die perioperative Mortalitat betrug 5,5 % (5 Patienten). Bei 75 % der Patienten kam es zu einer signifikanten funktionellen Verbesserung (forcierte expiratorische Vitalkapazitat nach einer Sekunde (FeV1) postoperativ mehr als 120 % des Ausgangswerts). Im Mittel stieg die FeV1 um 28,6 % von 25,5 ± 1,2 des Sollwerts (% S ) praoperativ auf 32,8 ± 1,9 % S innerhalb der ersten 6 Monate (p < 0,005). Weiterhin kam es zu einer signifikanten Reduktion des mittleren Residualvolumens von 320,3 ± 7,9 % S praoperativ auf 248,4 ± 7,5 % S 6 Monate postoperativ sowie der totalen Lungenkapazitat (TLC) von 140,2 ± 2,4 % S praoperativ auf 126,1 ± 2,1 % S postoperativ (p < 0,005). Der intrinsische PEEP sank von 5,1 ± 0,4 cm H2O praoperativ auf 2,3 ± 0,3 cm H2O postoperativ (p < 0,05). Schlusfolgerungen: Die LVRS stellt ein mittlerweile etabliertes Therapieverfahren beim fortgeschrittenen Lungenemphysem dar, mit dem bei entsprechender Patientenselektion eine deutliche funktionelle Verbesserung erzielt werden kann. Uber die Langzeitresultate kann derzeit jedoch keine definitive Aussage getroffen werden.

Zwischen September 1994 und Dezember 1996 wurde bei 70 Patienten (Alter 33–80 Jahre, Mittel 57,1 Jahre) uber eine mediane Sternofissur (n=15), videoendoskopisch (n=33), uber eine Thorakotomie (n=14) oder kombiniert auf einer Seite videoendoskopisch, auf der anderen uber eine Thorakotomie (n=8) eine Lungenvolumenreduktion (LVRS) durchgefuhrt. Bei allen Patienten bestand trotz maximaler medikamentoser und physikalischer Therapie eine hochgradige Dyspnoesymptomatik.

The aim of this paper was to evaluate the results in patients from the religious community of Jehovah's Witnesses (JW) undergoing open heart surgery.Between January 1998 and November 2007, 35 patients with a religious background of JW church underwent open heart surgery at the Department of Cardiothoracic Surgery, Medical University of Vienna (Austria). Eighteen patients underwent coronary artery bypass graft (CABG), 11 patients underwent valve surgery and 5 patients underwent combined procedures. One patient underwent isolated ascending aortic replacement. Five patients undergoing CABG were operated without cardiopulmonary bypass (CBP).Mean baseline hematocrit serum levels were 35.8+/-6.3%. The mean decrease of hematocrit serum levels was 20.0+/-21.1% after surgery. The mean decrease of hematocrit serum levels in patients undergoing CABG without CPB was 12.5+/-5.4% and 12.0+/-20.0% in patients after isolated valve replacement. One patient died during the operation. Four patients died in the postoperative period due to anemia. During follow-up, being 34.6+/-34.8 months to date, no cardiovascular related adverse event has been observed.The decrease of hematocrit serum levels is significantly characterizing the postoperative period of open heart surgery in JW. In patients undergoing CABG without CPB and in patients undergoing isolated valve replacement, decrease of hematocrit serum levels was lowest. Therefore, these techniques should be considered for first choice when appropriate. Furthermore, highly normal preoperative hematocrit serum levels and a meticulous surgical technique remain the mainstay of therapy in these patients.

In 63 patients undergoing heart operations with extracorporeal circulation (47 males, 16 females, mean age 54 years; coronary artery bypass in 38 cases, valvular surgery in the rest) postoperative neurological and psychiatric complications were evaluated. 18 patients (29%) had no complications, whereas 35 patients (56%) showed minor or transient neurological symptoms, and 9 patients (14%) exhibited severe symptoms. Nine of the patients had slight psychiatric disturbances (affective disturbances, desorientation). No correlation was found between risk factors (age, nicotine abuse, hypertension, hypercholesteremia, neurologic and cardiac history), intraoperative parameters (duration of extracorporeal bypass, aortic clamp time, deviation of mean arterial pressure), postoperative parameters (internal complications) and the complication rate. Therefore no predisposing factors could be identified.

OBESITY is a well-described and significant risk factor for postoperative medical complications in surgery. High incidences of wound infection and dehiscence, thrombophlebitis, and pulmonary insufficiency have been reported. Obese surgical patients have abnormalities in cardiac, pulmonary, endocrine, and gastrointestinal function, as well as abnormalities in pharmacokinetics and pharmacodynamics. Obesity is also associated with the development of some of the most prevalent diseases of modern society: Cardiovascular as well as cerebrovascular disease, diabetes, and hypertension. More postoperative complications and the same comorbidities might also be expected in obese transplant recipients, which could lead to increased postoperative morbidity and mortality. In fact, reports on solid organ transplantation, including kidney, liver, and pancreas indicated in agreement a poorer outcome in obese organ recipients in terms of graft and patient survival. There is little information, however, on the impact of obesity on outcome after cardiac transplantation. Organ donor shortages mandate careful assessment of preoperative risk for heart transplantation to enable appropriate patient selection for this procedure. Therefore the purpose of the present study was to determine the impact of preoperative overweight and obesity as defined by body mass index (BMI 5 kg/m) on outcome after heart transplantation with regard to patient survival, surgical complications, incidence of infection, acute rejection and development of transplant coronary artery disease.

Sternal wound infection after heart transplantation is a feared and potentially life threatening complication with reported incidences between 2.5 % and 3.6 %. However, optimal therapy of sternal wound infections in heart transplant recipients remains a matter of controversy, particularly the effect of immunosuppression in those patients is still unclear. We examined 5 heart transplanted patients (4 men and 1 woman with a median age of 46 +/- 21.4 years (ranging from 14 to 59 years) in terms of inflammation and treatment response during VAC therapy. Infection begin was median 18.2 days (+/- 10 days, ranging from 5 to 28 days) after transplantation. VAC therapy lasted on average 12.2 +/- 2 days, ranging from 10 to 19 days. A median of 3 changes (range from 3 to 5) were necessary until the definitive closure. We examined C-reactive protein, leucocyte count and fibrinogen 2 days pre VAC, during VAC treatment and 2 days after definitive closure. All five patients showed an increase of leucocytes at every VAC change. Furthermore, we saw an adequate reaction to the VAC in terms of granulation tissue growth and resolution of infection. Transplanted patients had an increase of leucocytes at every VAC change. Furthermore all patients showed an adequate response of VAC treatment in terms of granulation tissue in growth and infection decline. Therefore a reduction of immunosuppressive therapy is not necessary, which in turn would increase the risk of rejection.

Since November 2001 all patients with postoperative sternum bone infections were treated with V.A.C. therapy. The mean length of stay at intensive care unit was reduced from 9 to 1 day and reduces costs for 33 714.- USD per patient. Additionally patients who had to be closed with pectoralis muscle flap had significant reduced length of stay at ICU (1 vs 4 days, cost effectiveness 14 984.- USD per patient). The V.A.C. therapy after post-sternotomy mediastinitis significantly reduces morbidity and mortalità and is cost effective.

The coronary vasculature of the Icft ventricle of thc heart is represented in a lumped parameter modcl, consisting of an arterial, a microcirculatory and a venous compartment. The differential equations are solved for the boundary conditions of coronary sinus interventions both during normal arterial perfusion and coronary artery obsuuction. representation of the venous compartment, in particular of iB volume dependent compliance [9]. In this scnsc, thc prcscnt modcl is an advantagc as compared to previous approaches [lo]. Based on adcquate reproduction of venous hemodynamics, we found for coronary sinus occlusion in thc undiscased statc that oscillating flow between microcirculatory and venous compartment is able to renew in each cardiac cyclcabout two thirds of the blood stored in the microcirculation [91.

Summary Haemodialysis is a widespread option for end-stage renal disease (ESRD). Long-term success of dialysis is, however, limited by a high rate of serious bacterial and viral infections. We compared T cell functions in ESRD patients undergoing haemodialysis (n = 20), or were not dialysed and received conventional medical treatment (n = 20). Healthy volunteers (n = 15) served as controls. The T cell phenotype was examined by immunofluorescence using fluorochrome-labelled monoclonal antibodies and FACS analysis. The concentration of soluble CD95/Fas and of tumour necrosis factor-α receptor type 1 (sTNFR1) in the sera was quantified by ELISA. Activation-induced programmed T cell death was triggered by anti-CD3/CD28 antibodies and measured by 7-AAD staining. All immunological tests were performed at least 1 month after dialysis initiation. T cell proliferation in response to phytohaemagglutinin or anti-CD3 monoclonal antibodies was moderately diminished in non-dialysed patients and markedly reduced in haemodialysis patients compared to healthy controls (P

The study was designed to investigate the clinical performance of the On-X prosthetic heart valve in a multicenter experience.Between September 1996 and September 1999, 301 patients (56% males) underwent isolated On-X valve replacement (184 isolated aortic (AVR), 117 isolated mitral (MVR)) at 11 European centers under a standardized protocol. Average age at implant was 60.2 years. Office or hospital follow up was required by the protocol; average follow up on all patients was 11 months.Thirty-day mortality in the study was 2.2% for AVR and 6.0% for MVR, with valve-related mortality of 0.5% for AVR. There were eight late deaths (0.7%/pt-yr AVR and 2.3%/pt-yr MVR). Two of these deaths were sudden, and thus possibly valve-related (one AVR, one MVR). Early total valve-related morbidity was 3.5% for AVR and 2.6% for MVR. In total, 13 thromboembolic events occurred; one early event in AVR resulted in death (0.5%), and one transient early event occurred in MVR (0.9%). There were 11 late events (seven AVR (1.7%/pt-yr) and four MVR (1.8%/pt-yr)), for a two-year freedom from thromboembolism of 96.6% after AVR and 97.1% after MVR. Three late bleeding events occurred, all after AVR (0.7%/pt-yr and 98.9% free at two years). Major paravalvular leaks requiring reoperation occurred on two occasions early (one AVR (0.5%), one MVR (0.8%)) and once late in MVR (0.5%/pt-yr). Late minor, untreated paravalvular leaks occurred in three AVR patients (0.7%/pt-yr) and in one MVR patient (0.5%/pt-yr). Prosthetic endocarditis occurred four times (two AVR (0.5%/pt-yr), two MVR (0.9%/pt-yr)), all within the first 12 months of surgery. Actuarial freedom from all valve-related events at two years was 88.7% for AVR and 88.1% for MVR. NYHA class was improved in 75.8% of AVR patients and 70.6% of MVR patients at two years after surgery.These early results indicate that the On-X valve provides satisfactory clinical outcome in the immediate postoperative period, and that the valve is both safe and effective.

The revised Edwards-Duromedics valve was introduced onto the market in June 1990. In September 1993, the producer changed the name of the valve to TEKNA, which is a low profile, bileaflet, mechanical prosthesis with a self-irrigating hinge mechanism. The results of a prospective follow-up study after valve replacement with this prosthesis are presented.From November 1990 to December 1996, 173 TEKNA prostheses were implanted in 161 patients (73 men, 88 women), either in the aortic (AVR; 48.4%), mitral (MVR; 44.1%), or aortic and mitral positions (DVR; 7.5%). Patient ages ranged from 17 to 83 years (mean age 59.2 +/- 8.7 years). Follow-up was 97.5% complete, comprising 433.15 patient-years for a mean follow-up of 34.8 +/- 23 months.Overall operative (30-day) mortality was 4.97%. Fifteen patients died in the late period, corresponding to a linearized late mortality rate of 3.5%/pt-yr. Actuarial survival at six years was 75.3% +/- 6.2% overall. The actuarial freedom from complications was calculated as follows (linearized rates in parentheses): valve-related mortality 91.3% +/- 5.1% (0.92%/pt-yr); thromboembolism 94.2% +/- 2.5% (1.62%/pt-yr); valve thrombosis 98.6 +/- 1.0% (0.46%/pt-yr); bleeding events 85.9% +/- 4.7% (2.77%/pt-yr); prosthetic valve endocarditis 98.6 +/- 0.9% (0.46%/pt-yr); nonstructural dysfunction 93.2 +/- 3.2% (1.38%/pt-yr); reoperation 87.1 +/- 5.3% (2.08%/pt-yr). Functional class according to NYHA was improved from preoperatively 72.05% in III or IV to 6-year postoperative 94.2% in I or II.The clinical performance of the TEKNA valve is quite satisfactory, with low incidence of valve-related complications. No structural deterioration has been observed. Further, the patients physical ability and quality of life were significantly improved.

We sought to analyze the experience with bronchoplastic procedures over a 7-year period and to determine putative prognostic factors for survival.From 1991 to 1997, 144 bronchoplastic procedures were performed for non-small cell lung cancer (n = 123), small cell lung cancer (n = 5), carcinoid tumor (n = 10), and metastases of extrathoracic malignant tumors (n = 6). There were 111 sleeve lobectomies, 17 bilobectomies, 4 lobectomies with carinal resection, 8 sleeve pneumonectomies, and 4 bronchotomies without parenchymal resection. Multivariable analysis included risk factors, such as age, sex, type of bronchoplastic procedure (bronchotomy, lobectomy, bilobectomy, or pneumonectomy), additional angioplasty, TNM staging, histology, radicality of resection, respiratory risk (forced expiratory volume in 1 second, percent predicted60), cardiovascular risk, and adjuvant therapy.Overall 1- and 3-year survival was 72% and 52%, respectively. The overall 30-day mortality was 8.3% (5.4% for single sleeve lobectomies). Multivariable analysis demonstrated 4 risk factors for survival. High tumor stage, type of bronchoplastic procedure, impaired lung function, and presence of cardiovascular risk were associated with a poor outcome. Univariate analysis showed reduced survival in patients with sleeve pneumonectomies (1-year survival, 25%).Bronchoplastic procedures for central tumors and sleeve pneumonectomies are associated with poor survival. Careful selection of these patients, as well as of patients with impaired lung function and cardiovascular risk factors, is mandatory.

Because of the high frequency of acute hemodynamic deterioration in patients awaiting cardiac transplantation, mechanical techniques of circulatory support to bridge the period until transplantation have become a standard clinical procedure. Continuous-flow rotary blood pumps offer exciting new perspectives in terms of ventricular assistance and/or as a total cardiac substitute. A DeBakey VAD axial flow pump was implanted in two male patients (aged 44 and 65 years, respectively) suffering from end-stage left heart failure. In the initial postoperative period the mean flow rate of the pump was 3.9 +/- 0.5 l/min. In both patients, the early postoperative phase was characterised by a completely non-pulsatile flow profile. Two weeks after implantation and partial recovery of the natural left ventricle, increasing pulse pressures became evident and net flow increased to 4.5 +/- 0.6 l/min. Patients were mobilised and made to under-go regular physical training. Hemolysis produced by the pump was low while free haemoglobin stayed in physiological ranges, increasing only slightly from 2.1 +/- 0.8 mg/dl preoperatively to 3.0 +/- 1.5 mg/dl ten weeks after implantation. One patient was successfully transplanted on day 74 after implantation of the DeBakey VAD while the second patient is, after 110 days of pumping, still waiting for transplantation. This first experience concerning clinical implantation of the DeBakey VAD axial flow pump showed that the device is promising as a means of providing mechanical support to bridge the period until cardiac transplantation.

A brief period of ischemia was used to evaluate an erythrocyte-enriched Krebs-Henseleit (KH) buffer (n=8) compared to KH only (n=8) in an isolated working rabbit heart. Experimental protocol was as follows: preischemic baseline, 5 min of global ischemia followed by 45 min of reperfusion. Preischemic heart rate was identical, coronary flow was significantly lower (2.7 versus 5.6 mL/min/g wet wt, p0.01), the other hemodynamic and biochemical values were significantly higher in erythrocyte-perfused hearts: aortic flow 23.5 versus 12.0, p0.01; cardiac output 26.2 versus 17.6, p0.01; all in mL/min/g wet wt; dp/dt max 1286 versus 997 mmHg/s, p0.01; myocardial oxygen consumption 3.5 versus 2.3 micromol/min/g wet wt, p0.05. During early reperfusion, in the erythrocyte-perfused hearts, coronary flow further increased (p0.003), the other hemodynamic parameters returned to baseline values in both groups. High-energy phosphates showed significantly higher values (ATP 2.0+/-0.1 versus 1.3+/-0.1, p0.05; CrP 2.0+/-0.2 versus 1.6+/-0.1, p0.05 all in micromol/g wct wt), water content was significantly lower (81% versus 74%, p0.05) in erythrocyte-perfused hearts. It can be concluded that the erythrocyte-perfused working heart model provides excellent oxygenation, leading to superior hemodynamic and metabolic performance. Additionally, in the erythrocyte-perfused hearts preservation of coronary flow reserve underlines the physiological competency of this preparation.

Surgical treatment of diffuse, nonbullous emphysema was first described by Brantigan et al. in 1957 and was reintroduced by Cooper et al. in 1995 as lung-volume reduction surgery (LVRS). Meanwhile it has become an internationally established procedure in the treatment of lung emphysema. We report our results after LVRS in 91 patients.Between September 1994 and August 1998 LVRS was performed through median sternotomy (n = 15), videoendoscopy (n = 49), thoracotomy (n = 18) or combined video endoscopy on one side and thoracotomy on the other (n = 9) in 91 patients (aged 33-80 years; mean 56,4 years). All patients showed progression of severe dyspnea despite maximum medical and physical therapy.Perioperative mortality was 5.5 % (5 patients). Seventy-five percent of the patients showed significant functional improvement [postoperatively above 120 % of the preoperative forced expiratory volume in 1 s (FeV1)]. Mean FeV1 significantly increased by 28.6 % from 25.5 +/- 1.2 % predicted (% p) preoperatively to 32.8 +/- 1.9 % p during the first 6 months postoperatively (p0.005). Furthermore, the mean RV was reduced from 320.3 +/- 7.9 % p preoperatively to 248.4 +/- 7.5 % p 6 months postoperatively and mean TLC from 140.2 +/- 2.4 % p to 126.1 +/- 2.1 % p (p0.005). Intrinsic PEEP decreased significantly from 5.1 +/- 0.4 cm H(2)O preoperatively to 2.3 +/- 0.3 cm H(2)O postoperatively (p0.05).LVRS is an excellent therapeutic option for selected patients with severe emphysema and additional signs of severe hyperinflation. It results in significant postoperative functional improvement and marked increase in quality of life. The long-term benefit of LVRS remains to be defined.

SUMMARYStudies performed in mice together with the demonstration of increased levels of heart-specific autoantibodies, cytokines and cytokine receptors in sera from cardiomyopathy (CMP) patients argued for a pathogenic role of autoimmune mechanisms in CMP. This study was designed to analyse the presence of IgG anti-heart antibodies in sera from patients suffering from hypertrophic and dilatative forms of CMP as well as from patients with ischaemic heart disease and healthy individuals. Patients' sera were analysed for IgG reactivity to Western-blotted extracts prepared from human epithelial and endothelial cells, heart and skeletal muscle specimens as well as from Streptococcus pyogenes. The IgG subclass (IgG1–4) reactivity to purified human cardiac myosin was analysed by ELISA. While sera from CMP patients and healthy individuals displayed comparable IgG reactivity to a variety of human proteins, cardiac myosin represented the prominent antigen detected strongly and preferentially by sera from CMP patients. Pronounced IgG anti-cardiac myosin reactivity was frequently found in sera from patients with dilatative CMP and reduced ventricular function. ELISA analyses revealed a prominent IgG2/IgG3 anti-cardiac myosin reactivity in CMP sera, indicating a preferential Th1-like immune response. Elevated anti-cytomegalovirus, anti-enterovirus IgG titres as well as IgG reactivity to nitrocellulose-blotted S. pyogenes proteins were also frequently observed in the group of CMP patients. If further work can support the hypothesis that autoreactivity to cardiac myosin represents a pathogenic factor in CMP, specific immunomodulation of this Th1- towards a Th2-like immune response may represent a promising therapeutic strategy for CMP.

Simultaneous double-organ transplants comprising various organ combinations have become frequent. The purpose of this article is to report on a single center's experience of simultaneous heart and kidney transplantation (HNTX) with particular emphasis on selection criteria and patient outcome.From September 1990 to January 1997, nine patients underwent HNTX, receiving both grafts from a single donor selected on ABO blood group compatibility and a negative lymphocytotoxic crossmatch, but without regard to HLA-antigen matching.One patient died of acute humoral rejection of the cardiac graft shortly after surgery. Eight patients are alive and well and have normal cardiac and renal function at a mean follow-up of 44+/-28 months.HNTX offers a compelling therapeutic solution in the treatment of advanced cardiac and renal failure in carefully selected patients. Because the heart and kidney rejection episodes were independent of each other, rejection surveillance should be carried out separately for each transplanted organ.

Patients with acute type A aortic dissection are associated with a high mortality rate and postoperative complications. This study was designed to explore perioperative risk factors for death in patients with acute type A aortic dissection.One hundred nine consecutive surgical patients with acute type A aortic dissection were included in the present study. Thirty-five perioperative risk factors were used in the statistical analysis for mortality prediction. The 30-day mortality rate for all patients was 30% (33 of 109). Univariate analysis revealed 5 preoperative and intraoperative risk factors that were found to be statistically significant predictors for death: older age, renal failure, preoperative hemodynamic instability, preoperative cardiopulmonary resuscitation, and lack of retrograde cerebral perfusion (P0.05). Rupture of aneurysm, hypothermic circulatory arrest time, and operation date were not found to be risk factors for death. Stepwise multiple logistic regression confirmed that older age and lack of retrograde cerebral perfusion were statistically significant independent risk factors for death (P0.05). Four postoperative complications were found to be statistically significant prognostic indicators for death: liver failure, stroke, sepsis, and reoperation after the initial surgery (P0.05).Perioperative risk factors for death after the operation for acute type A aortic dissection were identified. This will allow physicians and surgeons to better assess the patient's risk, which will lead to better outcome.

Chronic hypercapnia is still considered to increase the risk for perioperative mortality and therefore to be a contraindication for lung volume reduction surgery (LVRS). The aim of this study was to analyse the influences of hypercapnia upon postoperative outcome.The functional improvement (preop vs. 3 months postop) and clinical outcome was studied in 22 patients with chronic hypercapnia (preoperative arterial pCO2or = 45 mmHg) who underwent LVRS between 9/94 and 2/97 and were compared to all other patients (n = 58) without hypercapnia. Data are expressed as the mean +/- SEM.The 30-day mortality was 9.1% (2/22) in patients with chronic hypercapnia (HC) and 5.2% (3/58) in patients with normal arterial pCO2 levels (control) (P = n.s). The stay on the ICU (3.5 +/- 0.8 vs. 2.1 +/- 0.3 days) and duration of chest drainage (7.3 +/- 1.2 vs. 7.2 +/- 0.8 days) was similar between both groups (HC vs. control) (P = n.s). The preoperative lung function (% of predicted) and blood gas (mmHg) parameters were significantly worse in HC patients compared to control patients. In both groups significant functional improvements were observed: FeV1 in the control group increased by 37% within the first 3 months (29.1 +/- 1.7% of predicted vs. 39.9 +/- 3.1% of predicted, P = 0.0198). In the HC group, FeV1 increased by 73% which was even higher than in the controls (19.5 +/- 1.5% of predicted vs. 33.7 +/- 4.7% of predicted, P = 0.0385). All patients of both groups who died perioperatively had a significantly higher severity of parenchymal destruction than those who survived (P = 0.0277 and 0.0380, respectively).Patients with chronic hypercapnia alone, had no significantly higher mortality and morbidity, and therefore should not be excluded from LVRS. However, the presence of additional risk factors, such as homogeneity of disease, high degree of parenchymal destruction or pulmonary hypertension should be considered as contraindications for the procedure.

This study was performed to evaluate the role of collagen fibrils, cellular elements and matrix proteins in calcification of glutaraldehyde (GA)-fixed bioprosthetic material.Lyoplant (lyophilized bovine pericardium, type I collagen) was processed according to three protocols. DF-group (double fixation): after conventional fixation in GA (0.5% for 72 h; storage 0.25%) Lyoplant was implanted subcutaneously into rats for 5 days. Specimens were explanted and re-fixed (conventional fixation), followed by autologous or homologous reimplantation in rats for 21 or 63 days. CF-group (conventional fixation): Lyoplant patches were conventionally fixed (as DF-group), kept in 0.9% saline for one week, and then autologously and homologously reimplanted. GF-group (high-concentration GA): Lyoplant patches were processed (as GF-group) but 0.5% GA was used for tissue storage. Explanted specimens were studied by light microscopic histochemistry; calcium contents were measured by atomic absorption spectroscopy.Severe calcification occurred in the DF-group without differences between autologous and homologous reimplantation. In CF- and GF-groups, calcification was negligible, but immunologic response against homologous implants was accompanied by increased calcium content. Histologic characterization of matrix material in calcified areas revealed oxyphilic glycoproteins, identified as sialoglycans.Modification of extracellular matrix by GA is assumed as essential to cause calcification of bioprosthetic material. Calcium deposition and accumulation of sialoglycans are simultaneous events. A specific role of this glycoprotein for calcification has to be considered.

The study aim was to collect intermediate clinical data on the TEKNA bileaflet valve.This nine-center clinical study involved 884 patients implanted between June 1990 and October 1993. The population consisted of 522 (59.0%) males and 362 (41.0%) females. Mean age at implant was 59.1 +/- 11.8 years (range: 14.7 to 88.4 years). Indication for valve replacement was dependent on the position: stenosis was the predominant reason in the aortic position; regurgitation was more pronounced for the mitral position. A total of 261 (29.5%) patients underwent concomitant procedures. Mean follow up is 2.7 +/- 1.2 years; total follow up is 2386.1 patient-years (pt-yr).Total operative (or = 30 days postoperative) mortality rate was 3.7%; seven patients (0.8%) died due to valve-related causes. Total postoperative (30 days postoperative) mortality rate was 2.5%/pt-yr and included a valve-related mortality rate of 1.1%/pt-yr. The following valve-related complication rates (%/pt-yr) were reported for the long-term postoperative period: thromboembolism 0.6; valve thrombosis 0.3; bleeding events 1.5; non-structural deterioration 0.6; and endocarditis 0.4. No structural valve deterioration was reported. Actuarial freedom at four years was: overall survival rate 86.9 +/- 1.4%; valve-related survival rate 94.7 +/- 1.0%; freedom from thromboembolism 96.8 +/- 0.9%; valve thrombosis 99.3 +/- 0.3%; endocarditis 98.5 +/- 0.5%; bleeding events 94.3 +/- 1.0%; and non-structural deterioration 98.2 +/- 0.6%.The data indicate that observed mortality is due mainly to non-valve-related disorders. Risk of thromboembolic and bleeding events was low (0.9%/pt-yr and 1.5%/pt-yr, respectively). We conclude that this valve is safe and efficacious for use.

Pulmonary hypertension (PH) signifies elevated blood pressure in the pulmonary circulation either due to clearly defined causes (cardiac, pulmonary-parenchymatous, systemic) or of idiopathic origin (primary PH, PPH). While conservative treatment is beneficial only for a small number of patients, lung transplantation represents a curative measure. The optimal form of transplantation [i.e. single lung (SLTX), bilateral lung (BLTX) or combined heart-lung transplantation (HLTX)] is still under discussion. This study is a retrospective analysis of 16 patients with different forms of PH who underwent BLTX from 1992 to 1996 in Vienna. Four patients had Eisenmenger's disease due to atrial septum defect, 3 had chronic thromboembolic PH and 9 had PPH. BLTX with cardiopulmonary bypass was the standard procedure in all patients. Acute retransplantation had to be performed in 3 patients. Mean pulmonary arterial pressure was reduced from 63 +/- 11 mmHg preoperatively to 23 +/- 5 mmHg on the second day postoperatively (p0.0001), while the cardiac index concomitantly improved from 2.1 +/- 0.5 to 3.9 +/- 1.2 l/min/m2 (p0.05). Echocardiography proved normalisation of right ventricular wall thickness and end-diastolic diameter within 12 months, while tricuspid insufficiency, present in all patients before transplantation, resolved completely. Perioperatively 4 patients (25%) died due to septic complications (n = 3) or therapy refractory rejection (n = 1). Follow-up of the remaining patients ranged from 6 to 51 months (mean 33 +/- 17). One patient died at 8 months due to fungal sepsis. Eleven patients (68%) are currently alive. Only 2 of them show functional signs of chronic allograft rejection (bronchiolitis obliterans syndrome). All patients are at present in NYHA functional class I or II. In conclusion, BLTX results in complete recovery of right ventricular function and morphology and offers good functional long-term results. Because SLTX correlates with a high incidence of reperfusion edema, and HLTX is seriously limited by the scarcity of donor organs, BLTX should be the method of choice for treating end stage PH.

Das Prinzip der Gegenpulsation wurde erstmalig 1958 von Harken als Methode zur Behandlung des Linksherzversagens vorgestellt. Man dachte an raschen Volumenentzug uber Zugang durch die A. femoralis wahrend der Systole, um gleichzeitig die Nachlast des insuffizienten Herzens zu unterstutzen. Wahrend der Diastole sollte das Blut wieder rasch rucktransfundiert werden, um eine diastolische Augmentation, zwecks erhohter koronarer Perfusion, zu erreichen. Realisiert wurde diese Technik mittels einer externen Pumpkammer mit angeschlossenem Reservoir.

Since November 2001 all patients with postoperative sternum bone infections were treated with V.A.C. therapy. The mean length of stay at intensive care unit was reduced from 9 to 1 day and reduces costs for 33 714.- USD per patient. Additionally patients who had to be closed with pectoralis muscle flap had significant reduced length of stay at ICU (1 vs 4 days, cost effectiveness 14 984.- USD per patient). The V.A.C. therapy after post-sternotomy mediastinitis significantly reduces morbidity and mortalita and is cost effective.

Lung cancer claimed about 153,000 lives in 1994 in the United States. Despite research overall lung cancer survival has still not improved during the last 20 years, with 5-year relative survival remaining about 13%. In addition several epidemiologic and molecular studies showed a difference in the incidence of lung cancer in the three major races. The aim of our study was to investigate the variations of race in lung cancer patients, in order to identify potential risk factors linked to the different racial status. In this light we compared a 10 years lung cancer data of black population from Howard University Hospital, Washington D.C., U.S.A. and a 20 years data of white population from the Vienna University Hospital, Austria. Our results did not show any significant difference in mean age or tumor localization in both groups, but highlighted a remarkable difference in the incidence of the lung cancer histological types also according to the sex. In this respect it could be more successful to consider carcinogenesis like a protracted process of gene function deregulation in response to cell injury from exposure to genotoxic substances with individual specificity.

Cancer of the lung is the most frequent cancer in the world, but with wide geographical variation in risk. It is most spread among males of all races worldwide, the only exception being its incidence among Chinese women aged 70 years and older. When comparing the different ethnic groups we have to consider that besides inhaling cigarette smoke actively or as a passive smoker the exposure to occupational carcinogens varies considerably according to different work places. In our study we compared 10 years of data from African-Americans in Howard University Hospital, Washington D.C. with 20 years of data from the white population in the University Hospital of Vienna, Austria. Ethnic patterns are generally consistent within each group in terms of both incidence and mortality. The difference in susceptibility between the sexes, the three major racial groups and already proven differences in genetic variations indicate the difference between individuals concerning the initiation and progression of lung cancer.

To demonstrate that emergency aortic valve replacement can be successfully performed in patients with critical aortic stenosis and reduced left ventricular function even in cardiogenic shock with associated severe multiple organ failure.Retrospective, consecutive case series.Multidisciplinary intensive care unit of a tertiary care university hospital.Five patients admitted to the intensive care unit with critical aortic stenosis (aortic valve area 0.56 +/- 0.13 cm2) and greatly reduced left ventricular ejection fraction (20 +/- 3%) in prolonged cardiogenic shock and associated multiple organ failure (Multiple organ failure score 6.8 +/- 0.5; Acute Physiology, Age, and Chronic Health Evaluation III score 91 +/- 27).Emergency aortic valve replacement.All patients survived with full recovery of organ function. At follow-up (18 +/- 10 months) all patients were in New York Heart Association functional class I or II with improvement of left ventricular ejection fraction to 48 +/- 25%.This excellent outcome suggests that emergency aortic valve replacement should be strongly considered in patients with critical aortic stenosis even in cardiogenic shock and multiple organ failure.

Functional electrical stimulation of the latissimus dorsi muscle flap for circulatory assistance extends the traditional concept of using this flap for reconstructive procedures into the field of cardiac surgery. It requires a transformed muscle which is able to contract for long periods of time without fatigue. Two main groups of experiments have been carried out in sheep. In six sheep the latissimus dorsi muscle (MLD) was transformed into a fatigue-resistant muscle by the means of multichannel stimulation of the supplying motor nerve. After that, stimulation of MLD at a frequency of 70 contractions per minute could be performed continuously without significant muscle fatigue. The loss of maximal force caused by the conditioning procedure was about one third of the initial force. In a second series of acute experiments the MLD was used for cardiomyoplasty. The muscle was divided into two parts which were wrapped around the heart in two different forms. The resting tension of the muscle was preserved. EKG-synchronous stimulation resulted in an increase in left ventricular pressure between 12 and 53%. The increase in arterial pressure was between 10,6 and 58%.

Between 1986 and 1995, 124 isolated lung and 29 combined heart-lung transplantations were performed at our institution. Twenty of these procedures were retransplantations. Four different types of reoperations were performed: ipsilateral single lung retransplantation (n = 3), single lung retransplantation after bilateral or heart-lung transplantation (n = 7), bilateral retransplantation after bilateral lung transplantation (n = 5), and bilateral retransplantation after single lung transplantation (n = 5). Nine patients underwent retransplantation while still in the intensive care unit after the primary transplantation. Indications for retransplantation in these patients were primary graft failure in seven and bronchial complications in two patients. In 11 patients a late retransplantation (3 to 30 months after the first transplantation) was performed. The indication was obliterative bronchiolitis in nine and late bronchial complications in two patients. Overall, 13 patients were ventilator-dependent before retransplantations.Overall survival was 52.8% and 36.2% at 1 and 12 months, respectively. For early retransplantation the survival rate at 1 month was only 22.2% with 2 patients alive 5 and 22 months after the retransplantation. For late retransplantation survival at 1 and 12 months was 70.7% and 50.5%, respectively (p = 0.07), and the longest surviving patient was at 47 months after retransplantation at the time this article was written. Patients who were ventilator-dependent before retransplantation had a significantly worse outcome (survival at 1 and 12 months: 33.8% and 25.4% versus 85.7% and 57.1% for all others, p = 0.055). Of those surviving to date, all were in New York Heart Association class I or II.We conclude that late and elective lung retransplantation achieves acceptable results when offered to patients with chronic pulmonary dysfunction but with otherwise stable conditions. In view of the poor results, early acute retransplantation should be performed much more restrictively.

Between September 1994 and August 1996 Lung Volume Reduction Surgery (LVRS) was performed through median sternotomy, videoendoscopically or by thoracotomy in 60 patients (age 33 to 80 years, mean 56.7 years). All these patients had severe emphysema despite maximal conservative and physical therapy. The areas with the most destroyed lung parenchyma were resected by means of linear stapling devices, 3 patients (20%) out of 15 who were operated via sternotomy died postoperatively due to aspiration pneumonia, multiorgan failure and acute hepatic failure. In the videoendoscopic group with 45 patients, 2 patients (4.4%) died due to multiorgan failure and cardiorespiratory failure. 72.7% of the remaining patients showed a significant functional improvement (postoperative FEV1130% of the preoperative value) with a marked decrease of dyspnea. There was no significant improvement in 23.7% of the patients (postoperative FEV1 = 90 to 110% of the preoperative value) and 3.6% of the patients had a functional deterioration. Residual volume decreased from 317.0 +/- 12.4% of predicted (%p) preoperatively to 226.2 +/- 8.8 %p within the first month (p = 0.0001). FEV1 significantly increased from 23.7 +/- 1.3 %p preoperatively to 36.6 +/- 4.1 %p during the first 6 months postoperatively (p = 0.0016). Radiological signs of hyperinflation and distention of the thorax preoperatively improved to narrowed intercostal spaces and a more shaped diaphragm. These morphological changes resulted in better ventilatory muscle function. The intrinsic PEEP significantly decreased from 5.92 +/- 0.64 cm H2O preoperatively to 1.70 +/- 0.25 cm H2O postoperatively (p = 0.0001). The work of breathing decreased from 1.58 +/- 0.09 J/l preoperatively to 0.99 +/- 0.07 J/l postoperatively (p = 0.0001). In conclusion, LVRS is an excellent therapeutic option for patients with severe emphysema and additional signs of severe hyperinflation with significant postoperative functional improvement and marked increase in quality of life.

Between 9/94 and 3/96 volume reduction was performed on 29 patients by a median sternotomy or videoendoscopic approach. Perioperative mortality occurred in three patients. The residual volume decreased within the first month from preoperative 308.8 +/- 13.4% of predicted (%p) to 217.9 +/- 12.7%p (p0.05). FeV1 significantly improved to 37.9 +/- 4.6%p after 3 months, versus 23.5 +/- 1.8%p preoperatively (p0.05). Intrinsic PEEP substantially decreased from 6.69 +/- 0.91 cm H2O preop to 0.93 +/- 0.28 cm H2O initially after surgery (p0.005). This was paralleled by the work of breathing: 1.78 +/- 0.2 J/l preoperatively versus 0.77 +/- 0.04 J/l postoperatively (p0.005). In conclusion, VR is a safe and successful option for patients with pulmonary emphysema, who show signs of marked hyperinflation.