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Background Locally advanced (T4) non-small cell lung cancer (NSCLC) is principally amenable to surgery. For radical resection of cardiovascular structures, extracorporeal circulation (ECC) may be required. Tumor dissemination is a concern in this situation. In this study, we evaluate the long-term results of T4 NSCLC surgery with ECC and compare them with combined cardiopulmonary surgery for early-stage NSCLC and heart disease. Methods We retrospectively analyzed 16 patients undergoing surgery on ECC over a 13-year period. Eight patients suffered from T4 NSCLC (group A), and another eight patients suffered from coincidental T1–T2 NSCLC and heart disease (group B). Results In group A, five patients received neoadjuvant radiochemotherapy. Complete resection was achieved in all patients. Thirty-day mortality was one patient (12.5%) in each group. Six patients died from recurrent cancer with a median survival of 13.6 months in group A. Prognosis in patients with direct tumor invasion of the aortopulmonary window was a lot worse compared to those with atrial infiltration. One T4 patient who had only received surgery survived for 155 months without relapse. In group B, no NSCLC relapse occurred, and median survival was 21.6 months. All but one death in group B occurred due to cardiovascular incidents. Conclusions Surgery on ECC for T4 NSCLC gives satisfactory results. The site of infiltration appears to be most important for local tumor relapse. Long-term survival is possible in some cases. Simultaneous cardiac and pulmonary surgery resulted in good early and midterm outcomes without surgery-induced tumor propagation.

Objective: Protection of the myocardium against ischemia/reperfusion injury is a major challenge in cardiac surgery and cardiology. A cardioprotective role of heat shock proteins (Hsp), in particular Hsp 70, against ischemia has been demonstrated. A prerequisite for clinical exploitation of high Hsp 70 levels in the heart during ischemia is the determination of the efficacy and the kinetics of cardiac Hsp synthesis in vivo. Methods: We examined Hsp 70 and other immediate early genes, that are induced by cardioplegia and reperfusion, in right atrial biopsies taken from 15 patients during coronary artery bypass grafting. Specimens were obtained before cardioplegia and after ending of reperfusion and subsequently studied by immunohistochemistry and Western blot analyses. Results: Overall Hsp 70 increased 2.0 ^ 1.1-fold (P , 0:01) in the nucleus as well as in the cytosol of myocytes and endothelial cells during open-heart surgery. As determined by comparison to a dilution series of recombinant protein, Hsp 70 levels amounted up to 6‰ of total cellular protein. The increase of Hsp 70 correlated well with the duration of cardioplegia and reperfusion (P , 0:005) showing a markedly accelerated increase at periods longer than 2 h. Further, the immediate early gene c-Fos also increased 2.4 ^ 2.2-fold during open-heart surgery (P , 0:05), whereas other members of the Hsp family, like Hsp 27 and Hsp 90, showed no significant changes in protein levels during cardioplegia and reperfusion. Conclusions: These findings demonstrate that protein levels of Hsp 70 in the myocardium increase to significant amounts within few hours after induction. The optimum time point for induction of Hsp 70 appears to be at least 2 h before open-heart surgery. q 2002 Elsevier Science B.V. All rights reserved.

OBJECTIVE To evaluate and compare two fast gradient-echo sequences (GRE) concerning the visualization of solitary pulmonary nodules with an open low-field MRI system in comparison to computed tomography. MATERIALS AND METHODS Fourteen patients with solitary pulmonary nodules detected by spiral CT ranging in size from 6 mm to 42 mm (mean 20 mm) underwent MRI on an open 0.2 T scanner using a spoiled 2D GRE (2D FLASH; TR/ TE/Flip = 100 ms/7.5 ms/30 degrees ) and a totally refocused 2D steady-state GRE (True-FISP; TR/TE/FA = 7.3 ms/3.5 ms/80 degrees ). The image quality concerning artifacts (by flow, breathing and susceptibility) and the morphologic characteristics of the nodules were scored and compared with CT by two independent radiologists. The diameters of the nodules measured by MRI were compared with CT measurements. The sequences were also evaluated with regard to the signal-to-noise ratio (SNR) of the lesion. RESULTS All lesions were detected with the 2D FLASH sequence. True-FISP failed to find a granuloma with a size of 6 mm. The 2D FLASH was rated significantly superior to true FISP concerning image quality artifacts by susceptibility as well as concerning to CT the presentation of nodule characteristics. In MR images, the size of lesions was significantly smaller than in CT images for both sequences: for 2D FLASH the mean difference was 0.9 mm and for true FISP 2.6 mm. The SNR of the nodules was significantly higher for the 2D FLASH than for the true FISP. CONCLUSION In low field MRI, the 2D FLASH sequence is superior to the 2D true FISP sequence in imaging of pulmonary nodules. With the 2D FLASH sequence nodules of 6 mm or larger in size can be visualized.

Purpose To evaluate the effectiveness and safety of endovascular treatment of various descending thoracic aortic pathologies with covered stent-grafts as an alternative to open surgery. Methods Among 16 patients (5 type B dissections, 5 contained ruptures, 3 aneurysms of the descending aorta, 1 thoraco-abdominal aneurysm, 1 mural thrombosis, 1 patch aneurysm) treated between November 1997 and November 2000, eight patients received Talent stent-grafts and another 8 patients underwent a Gore-TAG stent-graft implantation. A clinical follow-up and control CT scans were obtained after the procedure and then at six-month intervals. Results Deployment of the stent-grafts was technically successful in all cases. Sufficient aortic reconstruction was achieved in all but one patient who needed surgical treatment. One patient died two days after the procedure from aortic rupture due to retrograde type A dissection. Another patient died 19 months after the procedure from an unknown cause. There was no occurrence of distal embolization, paralysis or infection. During follow-up, all patients remained free from recurrence or late complications of their disease. Conclusion Endoluminal treatment of thoracic aortic pathologies with covered stent-grafts appears to be a safe and feasible method with at least mid-term efficacy.

Myocardial preservation during open heart surgery is a subject of intense investigation. A prerequisite for further improvement is a better understanding of the underlying pathophysiologic mechanisms responsible for postoperative myocardial stunning. In this report, we analyzed the role of apoptosis in myocardial stunning.Myocardial samples were obtained from 11 patients undergoing elective coronary artery bypass grafting before (control) and after cardioplegic arrest and reperfusion. Specimens were examined for apoptosis by electron microscopy, in situ end-labeling of DNA fragments, and biochemically for mitochondrial cytochrome c release.Electron microscopy revealed condensation and margination of nuclear chromatin after surgery, as well as swelling and membrane rupture in mitochondria of single myocytes surrounded by healthy cells. TUNEL-positive cells were also found. Cytochrome c release, an initial step in apoptosis, revealed a 3.4 +/- 0.4-fold increase during surgery (p0.0001). Furthermore, cytochrome c release from otherwise intact mitochondria showed a negative correlation with left ventricular function and a positive correlation with the duration of cardioplegic arrest and reperfusion (p0.05).Our data demonstrate that programmed cell death is evident early after open heart surgery and correlates with declining cardiac contractility. We conclude that apoptosis may be an important mechanism in postoperative myocardial stunning.

Tumors of the inferior vena cava are rarely complicated by pulmonary tumor embolism. We report a patient with a leiomyosarcoma of the inferior vena cava complicated by an embolus in the left pulmonary artery. We describe the successful treatment of this condition, which consisted of cavoplasty and pulmonary endarterectomy conducted under hypothermic circulatory arrest. Different aspects of the surgical strategy are discussed.

Purpose: To obtain morphologic and functional information in patients with dissection of the descending aorta using contrast-enhanced MR angiography (MRA) and MR blood flow quantification of the true and false lumina. Material and Methods: Fourteen patients were studied prospectively using a 1.5 T unit. MRA was performed with a 3D FISP sequence (TR/TE/flip angle 4.7/1.9 ms/30°) after injection of 0.2 mmol Gd-DTPA per kg b.w. Flow quantification with phase velocity mapping was done at the level of the diaphragm using a 2D FLASH technique (TR/TE/flip angle 28/6.5 ms/30°) with an average temporal resolution of 23 frames per cardiac cycle (34 ms). A spectral broadening index was applied to quantify the amount of flow irregularity within both channels of the aorta. Extension of the dissection and involvement of the major branch vessels were analyzed. Results: The mean flow volume per minute was 1982 ml (SD 1083 ml) in the true and 1052 ml (SD 763 ml) in the false lumen. Average peak-velocities were 98 cm/s (SD 33 cm/s) in the true channel and 47 cm/s (SD 26 cm/s) in the false channel. Ten patients had bidirectional flow in the false lumen with a reflux volume ranging between 6.8% and 98%. Only 1 patient presented with bidirectional flow in the true lumen (reflux volume 15%). A significantly higher degree of flow irregularity was found in the false lumen compared with the true channel. Conclusion: Different hemodynamic patterns were found in aortic dissection. Their prognostic value and the impact on therapy, specifically percutaneous interventional procedures, have to be further studied.

Objective: Increased serum levels of a multitude of mediators like interleukins, tumor necrosis factor, elastase, adhesion molecules, and endotoxin have been described following cardiopulmonary bypass (CPB). The biological consequences of this complex response are unclear. Methods: Serum samples of nine patients scheduled for elective coronary artery bypass grafting were obtained preoperatively and 1, 6, and 12 h after weaning from CPB. Additional serum samples were obtained perioperatively from four patients undergoing major lung resection and from four healthy volunteers. The apoptosis-inducing activity of serum samples on endothelial cells was examined using a tissue culture assay system. Endothelial cells were derived from human umbilical cords and incubated for 48 h with serum samples in various dilutions during their second passage. The culture plates were fixed with methanol/acetone and stained with the DNA dye diamidinophenylindole. Apoptotic and normal cells were identified and counted using phase contrast and fluorescence microscopy. Results: The proportion of apoptotic endothelial cells was 5.6-fold higher in culture plates incubated with diluted (30%) serum samples obtained at 6 h after weaning from CPB when compared to plates incubated with preoperative samples (Pa 0:0077). A smaller effect occurred already at 1 h in some patients, whereas at 12 h after weaning from CPB no increased endothelial apoptosis was observed. No proapoptotic activity was found in preoperative as well as in control samples from patients undergoing lung resection or from healthy volunteers. Conclusions: Serum of patients after CPB exerts a strong apoptosis inducing activity on human endothelial cells. Apoptotic death of endothelial cells following CPB may be responsible for postoperative vascular and bypass dysfunction including phenomena like increased capillary permeability. q 2000 Elsevier Science B.V. All rights reserved.

Bei einem 69 jahrigen Patienten mit eingeschrankter Lungenfunktion wurde ein zentrales Plattenepithelcarcinom der linken Lunge mit Infiltration von Hauptbrochus, Pulmonalarterie und linkem Vorhof diagnostiziert. Staging-Untersuchungen erbrachten keinen Hinweis fur Metastasen. Mit Hilfe der extracorporalen Zirkulation wurde eine erweiterte Pneumonektomie links mit Teilresektion des linken Vorhofs durchgefuhrt. Nach Verschlus des Vorhofdefekts mit einem Perikardflicken wurde der Unterlappen ex situ vom Operationspraparat abgesetzt und reimplantiert, wobei der Stumpf der unteren Lungenvene mit dem linken Herzohr anastomosiert wurde. Nach vollig ungestortem Verlauf ist der Patient 2 1/2 Jahre postoperativ rezidivfrei und gut belastbar.

Somatostatin receptor scintigraphy with 111In-[DTPA-D-Phe1]-octreotide has the potential for visualizing primary and recurrent thymomas in patients with myasthenia gravis, whereas thymic hyperplasias fail to accumulate somatostatin analog peptides. We demonstrate somatostatin receptor imaging findings in a patient with a mixed encapsulated thymoma which exhibited intense 111In-[DTPA-D-Phe1]-octreotide uptake in early and late scans. In another patient with a history of malignant thymoma 111In-[DTPA-D-Phe1]-octreotide accumulation was clearly seen in a mass suspected to be a recurrence. This paper describes the imaging protocol including Single Photon Emission Computed Tomography (SPECT) and discusses the clinical applications of this feasible functional imaging method in patients with thymomas.

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

HISTORY AND CLINICAL FINDINGS For some months a 57-year-old woman had noted increasing shortness of breath, associated in the last few weeks with undirected vertigo and several brief periods of lost consciousness. She was finally admitted because of additional central facial paresis. On auscultation a high-frequency systolic murmur was heard over the apex and a discrete diastolic murmur over Erb's point. There were numerous facial freckles and three cutaneous myxomas. INVESTIGATIONS Echocardiography revealed irregular tumours throughout the left atrium and a large broad-based one prolapsing through the mitrale valve in diastole. Computed tomography demonstrated a 6 x 6 cm tumour in the left lower abdomen, probably arising from the left ovary, and a second 3 x 3 cm presacral tumour. TREATMENT AND COURSE At cardiac surgery four tumours were found in the left atrium and resected: histologically they were benign myxomas. Removal required extensive resection in the area of the interatrial septum and the atrial wall, resulting in 2 degrees AV block for which a VDD pacemaker was implanted. CONCLUSION Atrial myxomas may be the cardinal sign of the Carney Complex, an autosomal dominant syndrome with cutaneous myxomas, myxoid abdominal tumours, hormone-producing tumours in the testicles, adrenal cortex or hypophysis, schwannoma as well as lentigines. For this reason, further tumours should be looked for if freckles and/or cutaneous tumours are found in association with an atrial myxoma. The patient and family should be informed about the genetic aspects.

Objective: Under experimental conditions cardiac stress may induce early immediate genes. Of these, heat shock proteins like hsp 70 have been linked to preconditioning and cellular salvage. Protooncogenes like c-fos and c-jun act as transcription factors for other genes and may be involved in the regulation of programmed cell death. Methods: Patients, 30, undergoing elective coronary artery bypass grafting, received either cold antegrade St. Thomas II or Bretschneider or Hamburg cardioplegic solutions with ten patients in each group. Tissue from right atria was removed before cardiopulmonary bypass and following cardioplegic arrest and reperfusion. Tissues were examined by Northern blots, immunohistochemistry, and in situ nick-end labeling of fragmented DNA as evidence for programmed cell death. Results: There were no significant preoperative or operative differences between groups. Following cardioplegia and reperfusion, a significant induction of both protooncogene and heat shock protein 70 mRNA was observed. Whereas levels of hsp 70 were increased about two-fold in all groups (PB 0.05), induction of c-fos and c-jun was most pronounced following the Hamburg cardioplegic solution (PB 0.05 versus baseline and for differences to other groups). Induction on the protein level was confirmed using immunohistochemistry that furthermore, identified cardiac myocytes and endothelial cells being the cell types that expressed these genes. In contrast to prebypass samples, in situ nick-end labeling of fragmented DNA following cardioplegic arrest and reperfusion was positive, preponderately in subendocardial myocytes and endothelial cells. Conclusions: Cold cardioplegia is a potent stimulus for induction of the early immediate genes examined in human hearts. Increased expression of protooncogenes may be deleterious to cardiac myocytes as indicated by in situ nick-end labeling of DNA fragments. Differences in gene induction may add additional information for the evaluation of different cardioplegic strategies. © 1997 Elsevier Science B.V.

Auf den Operationstisch wird eine Gelmatte gelegt, um Druckstellen vorzubeugen. Falls intraoperativ gerontgt werden muss, kommt unter die Gelmatte eine Bleischutzmatte fur das Becken. Die Schutzmatte wird wahrend der Operation vor dem Korper mit Klettverschlussen geschlossen. Der Kopf wird auf ein kleines Schaumstoffkissen oder einem Gelring gelagert. Huft- und Kniegelenke werden leicht angebeugt und die Fersen entlastet durch Unterlegen von Schaumstoffrollen im Bereich der Kniekehlen und Achillessehnen. Wenigstens ein Arm des Patienten wird fur intravenose Zugange auf einer Armstutze ausgelagert. Man verwendet dafur den Arm auf der dem Operateur abgewandten Seite. Der andere Arm wird am Korper angelagert. Rasiert werden nur stark behaarte Korperregionen. Die Neutralelektrode wird dort aufgeklebt, wo sie breitflachig haften kann, also an den Flanken oder Oberschenkeln. Dabei soll der Stromfluss nicht uber die Herzachse geleitet werden. Wegen der Gefahr von Kriechstromen darf der Patient nirgendwo Kontakt mit Metallteilen des Tischs oder von Stutzen bekommen und er darf nicht im Nassen liegen. Deshalb werden bei der Hautdesinfektion Tucher unterlegt, die uberschussiges Desinfektionsmittel aufsaugen konnen und nach dem Abwaschen wieder entfernt werden (Abb. 21.1).

Introduction: Cardiac ischemia-reperfusion injury (IRI) is known to induce apoptosis in on-pump cardiac surgery. Our objective is to determine the impact of drugs on IRI using a novell in-vitro model of human cardiomyocytes. Methods: Human right atrial myocardium was obtained during CABG prior to cardiopulmonary-bypass (CPB). Samples were perfused with 32°C Krebs-Henseleit buffer (KH). CPB simulated by exposing the samples to standard cardioplegia-ischemia (cp-isch) and reperfusion (rep) in microperfusion-chambers using 4°C BUCKBERG-cardioplegia. Beside the control-group subgroups were perfused with resveratrol, carvedilol or milrinone. Reperfusion consisted of 35°C KH. Cp-isch/rep-periods were 35/12, 65/22, 120/40min (n=36). Apoptosis was analysed after cp-isch by anti-activated-caspase-3 and parp-1 cleavage-immunostaining on cryosections counterstained with DAPI. Results: see table 1. Resveratrol, carvedilol and milrinone could reduce apoptosis significantly (p

Methods RF ablations of ten pulmonary malignancies in eight patients were performed under computed tomography (CT) guidance. The primary tumors were adenocarcinoma of the lung, rectal and colonic carcinoma, sarcoma, melanoma and adrenocortical carcinoma. Three days after RF ablation, surgical resection was performed followed by pathologic examination. Specimens were evaluated macroscopically and histologically by hematoxylin and eosin (HE) staining, immunohistochemically for cleaved caspase 3 expression, and terminal deoxy-nucleotidyl transferase-mediated nick end-labeling (TUNEL). In addition, electron microscopic investigations were performed. The pathological extent of coagulation was correlated to the helical CT immediately after the ablation procedure.

BACKGROUND After aortic valve-sparing procedures patients should be evaluated regularly because of the risk for further disease progression in the remaining aorta as well as recurrent aortic insufficiency. The purpose of this study was to evaluate the potential of functional MRI as a single examination for complete follow-up of these patients. METHODS Twenty-two patients with a mean age of 54 years (range 30 - 66) were prospectively examined at 1, 12, 24, 36, and 74 months postoperatively, following a Yacoub aortic root remodeling operation, using a 1.5 T MRI. The original disease was chronic aneurysm of the ascending aorta or root in 17, chronic dissection in 3, and acute dissection in 2 patients. Transverse graft diameters, regurgitant fraction, LVEDV, and cardiac index were measured using cine MRI. Results were compared to spiral computed tomography and transthoracic color Doppler echocardiography. Mean time of follow-up was 24.9 months and ranged from 1 to 74 months. RESULTS There were 2 re-operations, 2 years after primary surgery, due to high aortic insufficiency. CT and MRI measurements of graft diameters correlated well (p = 0.4544). Mean graft diameter (mean +/- SD) was 30 +/- 3.7, 33 +/- 3.4, 36.5 +/- 1.5, 37 +/- 2.8, and 38.3 +/- 2.8 mm at 1, 12, 24, 36, and 74 months, respectively, indicating a significant increase of graft diameter (p < 0.0001). Mean regurgitant fraction as determined by MRI was 14 +/- 7, 12 +/- 9, 13 +/- 9, 15 +/- 7, and 14 +/- 9 % at 1, 12, 24, 36, and 74 months, respectively. Flow based grading of aortic insufficiency by MR imaging correlated well with color Doppler echocardiography (p < 0.0001). CONCLUSIONS MRI provides an excellent, noninvasive, comprehensive tool for follow-up after valve-sparing aortic root reconstruction. The determination of regurgitant fraction, ventricular dimensions and functions, and graft diameters allows standardized imaging protocols with a high reproducibility, which may lead to this technique being favored for the follow-up of patients after aortic root remodeling.

Malposition of a cardiac pacemaker lead within the left ventricle represents a source of early and late thromboembolic complications. We report a case of cerebral embolism, caused by an inadvertently misplaced left ventricular electrode, occurring 3 years after implantation. The lead was removed via a transaortic approach with extracorporeal circulation.

To evaluate and compare two fast gradient-echo sequences (GRE) concerning the visualization of solitary pulmonary nodules with an open low-field MRI system in comparison to computed tomography.Fourteen patients with solitary pulmonary nodules detected by spiral CT ranging in size from 6 mm to 42 mm (mean 20 mm) underwent MRI on an open 0.2 T scanner using a spoiled 2D GRE (2D FLASH; TR/ TE/Flip = 100 ms/7.5 ms/30 degrees ) and a totally refocused 2D steady-state GRE (True-FISP; TR/TE/FA = 7.3 ms/3.5 ms/80 degrees ). The image quality concerning artifacts (by flow, breathing and susceptibility) and the morphologic characteristics of the nodules were scored and compared with CT by two independent radiologists. The diameters of the nodules measured by MRI were compared with CT measurements. The sequences were also evaluated with regard to the signal-to-noise ratio (SNR) of the lesion.All lesions were detected with the 2D FLASH sequence. True-FISP failed to find a granuloma with a size of 6 mm. The 2D FLASH was rated significantly superior to true FISP concerning image quality artifacts by susceptibility as well as concerning to CT the presentation of nodule characteristics. In MR images, the size of lesions was significantly smaller than in CT images for both sequences: for 2D FLASH the mean difference was 0.9 mm and for true FISP 2.6 mm. The SNR of the nodules was significantly higher for the 2D FLASH than for the true FISP.In low field MRI, the 2D FLASH sequence is superior to the 2D true FISP sequence in imaging of pulmonary nodules. With the 2D FLASH sequence nodules of 6 mm or larger in size can be visualized.

To evaluate the effectiveness and safety of endovascular treatment of various descending thoracic aortic pathologies with covered stent-grafts as an alternative to open surgery.Among 16 patients (5 type B dissections, 5 contained ruptures, 3 aneurysms of the descending aorta, 1 thoraco-abdominal aneurysm, 1 mural thrombosis, 1 patch aneurysm) treated between November 1997 and November 2000, eight patients received Talent stent-grafts and another 8 patients underwent a Gore-TAG stent-graft implantation. A clinical follow-up and control CT scans were obtained after the procedure and then at six-month intervals.Deployment of the stent-grafts was technically successful in all cases. Sufficient aortic reconstruction was achieved in all but one patient who needed surgical treatment. One patient died two days after the procedure from aortic rupture due to retrograde type A dissection. Another patient died 19 months after the procedure from an unknown cause. There was no occurrence of distal embolization, paralysis or infection. During follow-up, all patients remained free from recurrence or late complications of their disease.Endoluminal treatment of thoracic aortic pathologies with covered stent-grafts appears to be a safe and feasible method with at least mid-term efficacy.

Background Surgery of the aortic arch avoiding profound systemic hypothermia and using antegrade or retrograde cerebral perfusion has recently been popularized. This usually renders the CPB and surgical field set-up more complex. We propose a simple method achieving a similar effect. Methods During a 6-month period, 7 patients (median age 72 years) underwent surgery involving the aortic arch with cannulation of the right subclavian artery for arterial return. There were 6 acute type A dissections and one ascending aorta and arch aneurysm. After commencing CPB, the ascending aorta was clamped and reconstruction of aortic valve and root were initiated. Patients were cooled to a tympanic temperature of 25 - 27 degrees C. CPB was then stopped, and the arch was opened and inspected from inside. While resuming arterial perfusion via the right subclavian artery, the arch branches were clamped sequentially from right to left under observation for back flow. Bilateral radial artery pressure and temporal transcutaneous oxygen saturation were always monitored. Results In all cases, the aortic valve was spared using remodeling and resuspension techniques. 2 complete arch, 2 partial arch and 3 proximal arch replacements were performed. Mean times were 183 (113 - 321) minutes for CPB and 120 (67 - 213) minutes for aortic cross-clamping. Maximal systemic circulatory arrest time was 82 min. One patient died in the hospital due to MRSA sepsis with a normal CCT scan. All others were discharged in good condition. Conclusion The initial experience with this simple technique of antegrade cerebral perfusion avoiding profound systemic hypothermia and the possible disadvantages of femoral artery cannulation appears promising.

A 69-year-old patient with reduced pulmonary function was diagnosed as suffering from non-small cell lung cancer of the left lung invading the main bronchus, pulmonary artery and left atrium. Staging examinations were negative. Using cardiopulmonary bypass, an extended pneumonectomy with partial resection of the left atrium was performed. The cardiac defect was closed with a pericardial patch. The lower lobe was divided ex situ from the upper lobe and reimplanted with anastomosis of the lower pulmonary vein to the left auricle. After a totally uneventful course the patient is in good condition and free of tumor recurrence 2.5 years postoperatively.

To describe principles and results of percutaneous treatment of ischemic complications of aortic dissection.In five cases (four patients) aortic dissection was clinically complicated by renal (n = 4), iliofemoral (n = 2) or mesenterial ischemia (n = 1). After evaluation by means of computed tomography, angiography, and manometry, treatment consisted of balloon fenestration of the intimal flap, stent placement or both.Eleven of 25 vascular beds were classified as ischemic. Treatment consisted of 11 balloon fenestration procedures in 3 patients, in one case supported by stent placement across the dissection membrane. Stents were placed in five renal arteries, one stent was placed in the true lumen of the aorta. One iliac artery was treated with balloon dilatation. One renal artery dissection became symptomatic after balloon fenestration and was treated successfully by stent placement. In all cases ischemia was resolved by endovascular treatment. All patients had persistent relief of symptoms. Mean follow-up time is 5.8 months.Ischemic complications of aortic dissection can be effectively and safely treated with stent placement and balloon fenestration.

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

Background . Induction of protooncogenes such as c- fos , c- jun , and EGR-1 has been implicated in cellular growth and differentiation. Heat-shock proteins (HSPs) such as hsp 70 may mediate resistance to ischemia after heat shock and ischemic preconditioning. The effects of cardioplegia on the regulation of these immediate early genes are unclear. Methods . Isolated rat hearts were subjected to different cold (5°C) or normothermic (35°C) cardioplegic solutions and reperfused with normothermic Krebs-Henseleit buffer. Right atrial biopsy specimens from patients undergoing coronary artery bypass grafting with cold cardioplegic arrest were taken before and after cardiopulmonary bypass. Analysis of immediate early gene messenger RNAs was performed using Northern blots. Related proteins were localized by immunohistochemistry. Results . In rat hearts, cold cardioplegia for 40 minutes with Bretschneider or St. Thomas' II solution followed by 40 minutes' reperfusion resulted in a significant increase in left ventricular c- fos , EGR-1 , and c- jun messenger RNA levels (4.0-, 3.1-, and 3.0-fold, respectively, with Bretschneider solution and 3.7-, 2.8-, and 2.1-fold, respectively, with St. Thomas' II solution) compared with control hearts perfused at 35°C with Krebs-Henseleit buffer. Normothermic cardioplegia with St. Thomas' II solution was without effect, whereas sequential perfusion with Krebs-Henseleit buffer at 5°C and 35°C resulted in a similar increase in protooncogene messenger RNA levels. Only cold Bretschneider solution was related to a 5.2-fold induction of hsp 70 messenger RNA levels. Likewise, rat atrial tissues and samples from patients after cardiopulmonary bypass displayed a significant induction of these immediate early genes. Monoclonal antibodies against c-FOS and HSP 70 proteins stained nuclei and perinuclear spaces of endothelial cells and cardiac myocytes. Conclusions . Cold cardioplegic arrest and normothermic reperfusion are potent triggers for immediate early gene induction. Hypothermia emerged as the prime stimulus for the examined protooncogenes. In contrast, hsp 70 induction was dependent on the cardioplegic solution. (Ann Thorac Surg 1997;63:1669–75)

Objective: For patients with atrioventricular block single lead atrial synchronous ventricular pacing (VDD) may have advantages compared to conventional dual chamber pacing (DDD) since it eliminates the need for an atrial lead. The purpose of this study was to investigate the clinical performance of a novel VDD pacemaker and the reliability of atrial sensing via the ‘floating’ atrial electrode. Methods: 31 patients (10 females; age 649 13 years) underwent an implantation of a VDD pacemaker system (Intermedics UNITY). The patients were analyzed with regard to implantation parameters, complications and postoperative atrial sensing performance using the diagnostic data of the pacemaker memory. The mean follow-up was 6.3 (1‐18) months. Results: The implantation procedure did not differ from that of conventional single chamber pacemakers. Dislocation of a ventricular electrode was the only complication observed. The P wave at implantation was 1.69 0.9 mV and dropped to 0.990.4 mV at predischarge. During follow-up the atrial sensing threshold remained stable. The atrial sensing performance (percentage of atrial synchronous ventricular complexes) after reprogramming the highest atrial sensitivity was 99.7%. Two patients (6%) developed atrial fibrillation. 29 patients (94%) remained in VDD mode as primarily intended. Conclusions: From these results it is concluded that VDD pacing represents an excellent alternative in patients with atrioventricular block and intact sinus node function. The atrial sensing was found to be reliable. © 1997 Elsevier Science B.V.

A case of pulmonary artery rupture due to Swan-Ganz catheterization is reported. A 73-year old women undergoing coronary artery bypass grafting developed massive endotracheal bleeding during weaning from the cardiopulmonary bypass and inflation of the balloon of the Swan-Ganz catheter. As bleeding could not be controlled by endobronchial Fogerty catheter blockade, resection of the lateral segment of the middle lobe was necessary before bypass could be terminated. The postoperative course was complicated by an abscess formation in the right middle lobe of the lung which required operative revision.

With the increasing experience in percutaneous transluminal angioplasty (PTCA) for unstable angina surgical revascularization versus interventional angioplasty treatment has been controversial. From 1991 to 1993, 162 patients underwent coronary artery bypass grafting (CABG) for unstable angina. While 126 patients received primary surgery (group I), 36 had a PTCA first which was followed by emergency operation for complications (group II). In group II there were more cases of single-or double-vessel disease (p < 0.001) and none had left main stem stenosis (p < 0.0001), but there was no difference in ventricular function between the groups. The number of distal anastomoses, mean cross-clamp time, and usage of the internal mammary artery (IMA) were significantly lower in group II. The peri-operative mortality rate was comparable between groups (5.5% versus 8.3%; n.s.). Myocardial infarction occurred more frequently in patients after PTCA (8.3% versus 4.0%; p < 0.05) without increasing the rate of low output syndrome. In conclusion, emergency CABG after failed PTCA in patients with unstable angina carries an acceptable perioperative risk. Since the perioperative rate of myocardial infarction is higher and the IMA is used less frequently in this setting long-term results may be better with the direct surgical approach.

A total of 164 patients with a mean age of 78.6 +/- 2.7 years and often critical preoperative conditions [New York Heart Association (NYHA) class III + IV, 78.7%] underwent cardiac operations [coronary artery bypass grafting (CABG) 97; valve replacement, 33; CABG + valve replacement, 18; replacement of ascending aorta and others, 18] with an in-hospital mortality of 8.5% (n = 14). Follow-up was completed for 147 patients (98%) after 16.5 +/- 10.8 months. Most patients were in a good clinical condition (NYHA I + II, 79.6%; late deaths, 8 patients, 5.4%) and more than 95% of patients lived at home or with relatives. Charges for hospital treatment dropped to one third after the hospitalization period for surgery in the first postoperative year compared to the year immediately preceding the cardiac operation.

A total of 164 patients with a mean age of 78.6±2.7 years and often critical preoperative conditions [New York Heart Association (NYHA) class III + IV, 78.7%] underwent cardiac operations [coronary artery bypass grafting (CABG) 97; valve replacement, 33; CABG + valve replacement, 18; replacement of ascending aorta and others, 18] with an in-hospital mortality of 8.5% (n=14). Follow-up was completed for 147 patients (98%) after 16.5±10.8 months. Most patients were in a good clinical condition (NYHA I + II, 79.6%; late deaths, 8 patients, 5.4%) and more than 95% of patients lived at home or with relatives. Charges for hospital treatment dropped to one third after the hospitalization period for surgery in the first postoperative year compared to the year immediately preceding the cardiac operation.

Tuberbculous aneurysms of the aorta are supposed to be exceedingly uncommon. In a recent review of the English literature from 1945 to 1999, 41 cases were counted, with only 2 aneurysms located at the aortic arch.1 Incidence and presentation of tuberculosis change rapidly because of migration, traveling, and immunosuppression. Multiresistant strains and comorbidity impair the effects of medical therapy and might result in surgical complications.2 Here we report on 2 patients on whom we have operated for tuberculous pseudoaneurysms of the aortic arch.

Von 1977 bis 1989 wurden bei 54 Patienten (Pt) 61 Operationen wegen eines rezidivierenden Spontanpneumothorax (SP) oder eines persistierenden Luftlecks nach SP durchgefuhrt. Die Nachbeobachtungszeit bei 43 Pt betrug im Mittel 58 Monate. Neben der Versorgung von Bullae, die in 10 Fallen auch auserhalb des Oberlappens lokalisiert waren, wurde 20mal eine rein apikale und 26mal eine subtotale scharfe Pleurektomie vorgenommen; 15mal erfolgte eine totale stumpfe Abrasio der parietalen Pleura mit einer Burste. 3 Pt (alle nach Pleurektomie) wurden bei einer Nachblutung rethorakotomiert. 4 Pt (alle nach apikaler Pleurektomie) erlitten ein ipsilaterales SP-Rezidiv. Bei 23% der nachbeobachteten Pt kam es im Gesamtverlauf zu einem kontralateralen SP-Rezidiv. Wir empfehlen daher eine komplette stumpfe Abrasio der parietalen Pleura, ggf. simultan beidseits uber eine Sternotomie.