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

BACKGROUND Different primary treatment modalities have been utilized to treat poststernotomy mediastinitis (PM) following cardiac surgery. METHODS A literature survey using the key phrases "treatment of deep sternal wound infection" and "poststernotomy-mediastinitis" was performed. Furthermore, a questionnaire regarding the primary treatment of PM was distributed to all 79 German heart surgery centers. RESULTS The review of the literature shows that the current understanding is based purely on retrospective studies, not on evidence-based medicine. All 79 German heart centers replied to the questionnaire. Vacuum-assisted closure therapy (V. A. C.(R)) is used in 28/79 (35 %) heart centers as the "first-line" treatment, 22/79 (28 %) perform primary reclosure in conjunction with a double-tube irrigation/suction system, and in 29/79 (37 %) German heart centers both treatment options were used according to the intraoperative conditions. CONCLUSIONS As a primary treatment for PM two treatment modalities are currently in use: primary reclosure coupled with a double-tube suction/irrigation system versus V. A. C.(R) therapy. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing both treatment modalities are pivotal to define the evidence for patients presenting with PM.

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

Entscheidend fur den Erfolg medizinischer Interventionen ist neben der Verbesserung der Uberlebensrate auch die gesundheitsbezogene Lebensqualitat. Gerade bei alten Patienten stellt die Verbesserung der Lebensqualitat haufig das primare Ziel eines medizinischen Eingriffes dar. Ist zusatzlich zur korperlichen Funktion eine Verbesserung der gesundheitsbezogenen Lebensqualitat nachweisbar, ist sowohl ein subjektiver als auch ein objektiver Nutzen der Behandlung erreicht. Der Gewinn, der sich durch eine Behandlung einstellt, wird haufig gerade bei der Behandlung alterer Patienten diskutiert und in Frage gestellt. Mit der durchgefuhrten Untersuchung sollte die Frage moglicher Alterseffekte bezuglich der gesundheitsbezogenen Lebensqualitat bei herzbypassoperierten Patienten beantwortet werden. Dazu wurden 142 Patienten zwei Tage vor, zehn Tage nach und ein Jahr nach einer Herzbypassoperation untersucht. Zur Messung der gesundheitsbezogenen Lebensqualitat wurde der Fragebogen zum Gesundheitszustand SF-36 verwendet. Mit Hilfe dieses Fragebogens werden acht Subtests des subjektiv eingeschatzten Gesundheitszustands erfasst. Zur Berechnung der Alterseffekte wurde die Gesamtpopulation durch Quartilbildung in vier gleich grose Altersgruppen unterteilt. Die Auswertung erfolgte mittels einer Varianzanalyse mit Messwiederholung. Es zeigte sich ein Jahr nach der Herzbypassoperation unabhangig vom Alter der Patienten eine hochsignifikante und klinisch bedeutsame Verbesserung der gesundheitsbezogenen Lebensqualitat. Aus den Ergebnissen kann geschlussfolgert werden, dass durch eine Herzbypassoperation die gesundheitsbezogene Lebensqualitat unabhangig vom Alter des Patienten langfristig verbessert wird.

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

Postoperative sternale Wundkomplikationen, wie Sternuminstabilitaten, oberflachliche und/oder tiefe Wundinfektionen sind selten, aber mit signifikantem Einfluss auf Morbiditat und Mortalitat. Insbesondere die steigende Anzahl an alteren Patienten, die mehrere Risikofaktoren aufweisen sind gefahrdet sternale Wundkomplikationen zu entwickeln. In der vorliegenden Studie fuhren wir zwei Arbeiten zusammen, um den Einfluss des Alters bezuglich postoperativer sternaler Wundkomplikationen zu untersuchen. (1) Aus einem konsekutiven Kollektiv von 339 herzchirurgischen Patienten wurden 86 altere Patienten (≥75 Jahre) entweder dem konventionellen Sternumverschluss oder der Verschlusstechnik nach Robicsek prospektiv randomisiert. Primare Endpunkte waren oberflachliche und/oder tiefe sternale Wundinfekte und Sternuminstablilitat; sekundare Endpunkte beinhalteten eine Zusammenfassung klinischer Parameter. (2) Zusatzlich untersuchten wir in einer retrospektiven Arbeit bei 54/5273 Patienten mit Mediastinitis den Einfluss des Alters auf deren weiteren Verlauf. (1) Einen statistisch signifikanten Vorteil der Robicsek Verschlusstechnik auf primare Endpunkte wurde nicht festgestellt, allerdings konnten signifikante Vorteile auf sekundare Endpunkte gezeigt werden: Nachbeatmung (p=0,03), thorakales Schmerzempfinden >3 Tage (p=0,04) und Krankenhausaufenthaltsdauer (p=0,05). (2) 54/5273 (1,02%) Patienten entwickelten eine Mediastinitis. 12/54 (22%) Patienten verstarben innerhalb 6 Monaten nach der initialer Operation. Risikofaktoren fur Mortalitat waren Insulin-abhangiger Diabetes mellitus (p=0,05), Niereninsuffizienz (p=0,01), verzogerter Sternumverschluss (p=0,05), Intensivaufenthalt >10 Tage (p=0,01) und Methicillin-resistenter Staphylococcus aureus (p=0,03) oder Pilzinfektion (p=0,02). In der alteren Bevolkerung bietet der Sternumverschluss nach Robicsek keinen Vorteil bezuglich postoperativer sternalerWundkomplikationen, allerdings sind eindeutige Vorteile bezuglich der Nachbeatmungsdauer, dem thorakalen Schmerzempfinden und der Krankenhausaufenthaltsdauer festzustellen.

BACKGROUND: Permanent postoperative hypoparathyroidism is a rare, but complex endocrinological disease. A classification system for this disease does not exist until now. We propose a novel classification based on our clinical experience and own extensive studies. METHODS: A validated, specific questionnaire tool was used to determine the signs, symptoms and sequels of the disease in 3 study groups in Germany und the Ukraine. As basic scoring systems we calculated a "total symptom score" (=TSS) and a "distress level score" (=DLS). The levels of parathyroid hormone (= [PTH]i.s.) and calcium (= [Ca++]i.s.) were determined in all patients. Different statistical tools were used to establish the classification (Pearson's correlation coefficient, Spearman-rho test, Varimax rotation analysis). RESULTS: Due to our data, stage I corresponds to latent or subclinical chronic hypoparathyroidism, whereas stage II includes as the main clinical features increased neuromuscular excitability resulting from hypocalcemia. This stage is subdivided in IIa (paresthesias) and IIb (muscular symptoms, tetany). Stage III is comprised of changes of the integument (p < 0.05; varimax analysis). Stage IV patients suffer from long-term effects like basal ganglia calcification, kidney stones, cardiac insufficiency and cataracts. Their [Ca]i.s. is correlated significantly with these symptoms (p < 0.05), but no significant correlation could be found between [PTH]i.s. and the severity of disease in all stages. By determination of the clinical scores, which takes less than 5 min, the individual patient's stage can be easily arranged. CONCLUSIONS: The advantages of the so-called Wuerzburg classification are its immediate clinical relevance, comprehensibility and ease of application. Hereby we emphasize that hypoparathyroidism not only presents a surgical complication but also a complex illness demanding adequate treatment.

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

Background Sternal instability and mediastinitis are rare but serious complications following cardiac surgery with median sternotomy. Methods This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The conventional sternal closure technique, the parameters considered to be risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. In addition, a literature research with the key words "sternal closure technique" and "sternal dehiscence" was performed. Results Conventional closure of primary sternotomy is done using many different methods, most often with surgical steel sutures (87 %) passed trans/peristernally (64 %). An osteoporotic or fractured sternum (70 x), and obesity (31 x) were the most frequently cited risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method of Robicsek (48 x). Conclusion There is no uniform osteosynthetic method for primary sternal closure and there is substantial variation in the perception of risk factors for sternal instability and possible surgical consequences among the surgical heart centers in Germany.

We report about a MEDLINE research from 2000 to 2005 with the key words 'positron emission tomography AND/OR mediastinoscopy'. The search identified 448 potential studies. Out of the published data sensitivity, specificity, positive and negative predictive value, and accuracy for mediastinal lymph node staging by FDG-PET ranged from 58%-94%, 76%-96%, 43%-95%, 56%-98% to 74%-91%, respectively. With corresponding values of 80%-96%, 100%, 100%, 92%-97%, and 94%, respectively, for mediastinoscopy. FDG-PET improved the rate of detection of local and distant metastases in 12% to 62% and changed the management of treatment in 8% to 60% of patients with NSCLC. Our study shows that in the diagnostic strategy of patients with NSCLC, additional FDG-PET can prevent non-therapeutic thoracotomy in a significant number of cases. If FDG-PET imaging and CT scan is negative for mediastinal lymph node involvement routinely mediastinoscopy can be omitted and thoracotomy can immediately be performed. In patients with negative FDG-PET scan, but positive CT scan, histologic verification by invasive methods can individually be considered. Patients with positive FDG-PET scan mediastinoscopy still remain a reliable standard for exact lymph node staging. By incorporating FDG-PET in clinical staging unnecessary exploratory thoracotomies, and mediastinoscopy, can be omitted.

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

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

Myasthenia gravis (MG) is the prime autoimmune manifestation of thymomas. We investigated the generation of T cells with a regulatory phenotype (T(R)) in thymomas with and without associated MG. In patients with MG(+) thymomas, maturation and export of T(R) cells but not of other T-cell subsets was significantly reduced. We conclude that imbalance between effector and regulatory T cells in thymomas may be involved in modulation of onset and/or severity of MG.

Trotz bedeutender Fortschritte in Diagnostik und Therapie ist die infektiose Endokarditis nach wie vor eine schwere Erkrankung mit einer durchschnittlichen Letalitat von 30%. Aufgrund einer steigenden Anzahl von Herzklappenoperationen und endoskopischer Untersuchungen, sowie durch wachsenden Drogenmissbrauch sind neue Risikofaktoren fur infektiose Endokarditiden entstanden. Fur die Entwicklung einer infektiosen Endokarditis sind entweder Erkrankungen der Zahne, des Zahnhalteapparates und der Kieferknochen, aber auch zahnarztliche Eingriffe von unveranderter Bedeutung. In der vorliegenden Arbeit werden die Ergebnisse einer Fragebogenaktion vorgestellt. Es wurden alle deutschen herzchirurgischen Kliniken bezuglich der Fokussuche und Sanierung—insbesondere im Dentalbereich—als Endokarditisprophylaxe vor Herzklappenoperationen befragt. Des Weiteren wurde untersucht, ob und inwieweit Zahnerkrankungen bzw. zahnarztliche Masnahmen nach dem gegenwartigen Stand der Wissenschaft noch als potentielle Ursache einer infektiosen Endokarditis aufzufassen sind. Ferner wurde erarbeitet, welche Zahnerkrankungen als Risikofaktoren fur eine Herzklappenendokarditis einzustufen sind. Zur Erganzung der erarbeiteten Ergebnisse und der Literaturangaben werden die Leitlinien der Deutschen Gesellschaft fur Zahn-, Mund- und Kieferheilkunde zur Endokarditisprophylaxe vorgestellt.

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

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

Aims In the past most of the investigations regarding the influence of valve size on outcome after heart valve replacements were done retrospectively. The present study is the first to investigate prospectively the influence of the implanted valve size on morbidity and mortality, using a close follow-up technique. Method and results The findings in the present study were obtained prospectively in a multicentre study (the German Experience in Low Intensity Anticoagulation [GELIA] study) conducted from 1993 to 1999. In the subgroup analysis we sought to determine whether a smaller valve size influenced morbidity or mortality after heart valve replacement. Data from 2244 patients (1765 aortic and 479 mitral valve replacements) were analyzed for morbidity. For mortality, a t otal of 2557 patients were eligible. Patient data were compared for all valve diameters, and for valve area index (VAI) below and above the median (median VAI for aortic valves was 1·6 cm2 .m ‐2 and for mitral valves it was 2·44 cm2 .m ‐2 ). Only three patients fell into the categories of small VAI (aortic valves VAI < 0·9 cm2 .m ‐2 ; mitral valves VAI

Die steigende Lebenserwartung der Bevolkerung fuhrt dazu, dass sich zunehmend Patienten im fortgeschrittenen Lebensalter einer Herzoperation unterziehen. Es stellt sich nun die Frage, inwieweit fortgeschrittenes Alter und Multimorbiditat das Fruh- und Langzeitergebnis nach Herzoperationen beeinflussen. Die vorliegende Studie ist eine retrospektive Untersuchung. Sie erfasst zwei Kollektive (je 96 Patienten). Gruppe I sind Patienten mit 75 Jahren und alter. Gruppe II sind Patienten im Alter von hochstens 65 Jahren. Um die Aussagefahigkeit zu verbessern, wurde das Vergleichskollektiv so ausgewahlt, dass es mit Gruppe I bzgl. der Geschlechtsverteilung und Therapieart identisch ist. Der mittlere Beobachtunszeitraum betrug zwischen 12 und 71 Monaten. Die perioperative Mortalitat der alteren Patienten betrug 2,1% (n=2) und die der jungeren 0% (n=0). Innerhalb des funfjahrigen Beobachtungszeitraumes sind 13,54% (n=13) der uber 75-jahrigen und 6,25% (n=6) des Vergleichskollektives verstorben. Eine kardiale Todesursache wiesen 53,85% (n=7) der alteren und 66,66% (n=4) der jungeren auf. Postoperative Komplikationen, wie Herzrhythmusstorungen, neurologisches Defizit, Nachblutung und Infarkt, traten bei den alteren Patienten mit einer Haufigkeit von 17,71% und bei den Jungeren mit 14,58% auf. Praeoperativ befanden sich 81% der alteren und 63% der jungeren Patienten im NYHA-Stadium III und IV. Postoperativ waren es in beiden Kollektiven jeweils nur noch 20%. Die Befragung unserer Patienten ergab, dass sich die Selbstandigkeit und Mobilitat durch die Operation entschieden gebessert hatte, lediglich 6,02% (n=5) der alteren und 4,44% (n=4) der jungeren Patienten konnten sich aufgrund der Herzerkrankung nicht mehr selbstandig versorgen. Insgesamt gesehen beurteilten die alteren Patienten ihr Allgemeinbefinden subjektiv besser als die jungeren. 92% der alteren und 84% der jungeren Patienten waren der Meinung, dass ihnen die Herzoperation eine wesentliche Besserung gebracht hat. Die Patienten im Alter von 75 Jahren und alter sprachen sich einstimmig fur die Operation aus, bei den Jungeren wurden sich nur 96,66% erneut fur die Operation entscheiden. Ziel der operativen Therapie der koronaren Herzerkrankung ist die Reduktion der Beschwerdesymptomatik, die Verbesserung der Lebensqualitat und die Erhaltung der Selbstandigkeit. Anhand unserer Ergebnisse ist ersichtlich, dass uns dies vorallem auch bei den alteren Patienten gelungen ist. Trotz eines erhohten prae- und perioperativ Risikoprofils und eines vermehrten pflegerischen Aufwandes bei alteren Patienten werden gute Ergebnisse erreicht.

Paragangliome sind sehr seltene Tumore, die von sympathoadrenalen und parasympathischen Paraganglien ausgehen. Die Inzidenz wird mit 0,001 bis 0,002% angegeben. Klinisch bleiben Paragangliome entweder unauffallig oder treten durch lokale Verdrangung aufgrund der Tumormasse in Erscheinung. Ferner konnen Paragangliome durch Katecholaminproduktion symptomatisch werden, wobei das klinische Bild dem des Phaochromozytoms entspricht. Problematisch ist die Dignitat, die sich aufgrund der histologischen oder immunhistochemischen Untersuchungen nicht klaren bzw. voraussagen lasst.¶ Anhand einer Kasuistik wird ein Uberblick uber die aktuelle Klassifikation, Klinik, Histopathologie mit historischem Ruckblick gegeben. Vorgestellt wird der Fall eines 67jahrigen Patienten, der zunachst mit instabiler AP und kleinem Myokardinfarkt stationar aufgenommen wurde. Bei klinisch ansonsten unauffalligem Patienten zeigte sich im Herzkatheter neben einer koronaren Dreigefaserkrankung ein atypisches Gefaskonvolut im Bereich der aufsteigenden Aorta, welches durch die rechte Koronararterie gespeist wurde. Bei konservativ nicht weiter beherrschbarer Angina pectoris erfolgte der operative Eingriff ohne weitere diagnostische Abklarung des Tumorbefundes. Intraoperativ zeigte sich ein kraftig vaskularisierter Tumor (3,5×3×1,5cm) auf der Aorta ascendens, der bereits bei leichter Beruhrung starke Blutungstendenzen zeigte. Die Schnellschnittdiagnose eines Paraganglioms konnte in der histologischen und immunhistochemischen Aufarbeitung bestatigt werden. Eine Resektion des Tumors im Gesunden unter Mitnahme der Aortenadventitia war moglich. Der postoperative Verlauf gestaltete sich komplikationslos. Metastasen konnten mittels In-111-Oxin-Octreotid- und I-123-MIBG-Szintigrafie nicht nachgewiesen werden.

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

Im Zeitraum von 1983 bis einschlieslich Dezember 1996 wurden 112 erwachsene Patienten (17 bis 67 Jahre, im Durchschnitt 41 Jahre) an einem Vorhofseptumsdefekt in der Klinik und Poliklinik fur Herz- und Thoraxchirurgie der Universitat Wurzburg operiert. Es wurde bei 73 Frauen (65%) und 39 Manner (35%) in einer retrospektiven Studie der pra-, intra-, peri-, und postoperative Verlauf nach chirurgischer Therapie beobachtet. Die weitaus haufigste Form stellte der Vorhofseptumdefekt vom Secundum-Typ (ASDII) mit 79% (89/112 Patienten) dar. 18% (20/112 Patienten) wurden wegen eines Sinus-venosus-Defektes (SVD) und lediglich 3% (3/112 Patienten) aufgrund eines Vorhofseptumdefektes vom Primum-Typ (ASDI) operiert. Angaben uber den postoperativen Verlauf konnte bei 110/112 Patienten (98%) erhoben werden. Der Nachbeobachtungszeitraum erstreckte sich von 8 Monaten bis zu 14 Jahren, im Durchschnitt 8 Jahre. Es konnte gezeigt werden, das die praoperativen Druckwerte im rechten Herzen und der Schweregrad der pulmonalen Hypertonie einen deutlichen Anstieg mit zunehmendem Alter aufwiesen (p

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

Polymorphisms in the CYP2C9 gene can have a significant impact on drug therapy by affecting the pharmacokinetics of frequently prescribed drugs, such as phenprocoumon and warfarin. It is essential therefore that genetic CYP2C9 variants are excluded in patients with a suspected intolerance of anticoagulant therapy. Here we present the first report of a case of left ventricular non-compaction syndrome associated with a genetic variant of the CYP2C9 gene in a 45-year-old woman with myocardial insufficiency who was scheduled for implantation of a cardioverter defibrillator.

Wahrend der extrakorporalen Zirkulation (EKZ) besteht durch die mechanische Oxygenierung des Blutes stets das Risiko von Gas-Embolien fur den Patienten. Die Detektion von Microbubbles ist wahrend der EKZ mit verschiedenartigen Methoden moglich. Doppler-Ultraschall kann als eine nicht invasive Methode eingesetzt werden um freie Gas-Embolien in der arteriellen Linie der Herz-Lungen-Maschine zu verifizieren.

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

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

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

Our 18-year old female patient suffered from microscopic polyangiitis. After invasive diagnostics, a diffuse alveolar hemorrhage occurred, leading to acute lung failure. In spite of differential ventilation, respiratory insufficiency and lactate-acidosis increased quickly. Due to the massive hemorrhage, a pumpless extracorporeal lung assist was implanted and, after six hours, low-dose heparinization was started. In response to this therapy, hypercapnia and acidosis improved quickly and were completely eliminated within 24 hours. Simultaneously, treatment with prednisolon and cyclophosphamid was started. After 7 days, the patient's conditions allowed weaning from the pumpless extracorporeal lung assist and after 9 days she was extubated. In conclusion, the pumpless lung assist was shown to be a very practical option to treat the most serious forms of hypercapnia, especially for patients disposed to diffuse bleeding.

Objectives: Invasive staging by mediastinoscopy provides the gold standard for histological proof of mediastinal lymph node involvement in patients with newly diagnosed NSCLC. This review assess the value of 18-FDG-PET and of mediastinoscopy in lymph node staging (LNS) in patients with NSCLC on the basis of published studies. Methods: We report about a MEDLINE research from 2000–2006 with the key words „18-FDG-PET AND NSCLC“ and „mediastinoscopy AND NSCLC“. Results: The search identified 63 hits for „18-FDG-PET AND NSCLC“ and 101 hits for „mediastinoscopy AND NSCLC“. We selected 28 compareable studies (3 meta-analysis, 17 prospective, and 8 retrospective articles). All other studies were excluded after scanning their abstracts. Out of the published data sensitivity, specificity, positive and negative predictive value, and accuracy for LNS by FDG-PET ranged from 58%–94%, 76%–96%, 43%–95%, 56%–98%, and 74%–91%, respectively. With corresponding values of 80%–96%, 100%, 100%, 92%–97%, and 94%, respectively for mediastinoscopy. 18-FDG-PET improves the rate of detection of local and distant metastases in 12%–62% and changed the management of treatment in 8%–60% of patients with NSCLC. Conclusion: We conclude that in the diagnostic strategy of patients with NSCLC additional 18-FDG-PET prevents non-therapeutic thoracotomy in a significant number of cases. If 18-FDG-PET imaging and CT is negative for medaistinal lymph node involvement routinely mediastinoscopy can be omitted and thoracotomy can immediately be performed. In patients with negative 18-FDG-PET, but positive CT, histological verification by invasive methods can individually be considered. In patients with positive 18-FDG-PET mediastinoscopy still remains the definitive method for exact LNS.

Objectives: The management of sternal dehiscence associated with or without deep sternal wound infection (DSWI) constitutes in every single cases a challenging and controversial problem for a cardiothoracic surgeon. Over the years, quite an impressing array of various methods, materials and surgical techniques have been proposed to adress this complication of cardiac surgery, which occurs with an incidence of 1–8%. Methods: We report about our experience with transverse plate fixation of the sternum halves (TPF) with simplified bilateral pectoralis flap advancement in a series of 9 patients with DSWI, not in a one-step procedure, but after control of infection was achieved by V.A.C.® therapy. Results: All patients went on to complete bony union and wound healing was initially uneventful. The course in the follow-up period of 5 to 17 months was without pathological findings in seven patients. Two patients suffered from major complications, requiring repeat surgery. One thoracic wall hematoma (related to excessive anticoagulation), and one late wound infection occured 9 weeks after reconstruction, which made it necessary to remove the complete fixation system. Conclusion: The clear advantage of the method described are that it provides a very stsable reconstruction of the sternum after DSWI, even in the presence of a reduced or multi-fractured bone matrix, and, moreover, avoids complete mobilization of substernal adhesions and foreign material penetrating to the anterior mediastinum. Based on our experience, we will continue the use of TPF of the sternum combinded with bilateral pectoralis advancement in a selected group of patients.

Background Primary graft dysfunction is a still poorly understood complication after cardiac transplantation. Ischemia/reperfusion injury contributes to different disorders resulting in impaired graft function. Methods In a heterotopic rat heart transplantation model we extended graft ischemic time up to 8 hours. Results Using immunohistochemistry we detected an up to 4-fold increase in intracellular adhesion molecule-1 (ICAM-1) expression during 4 hours of reperfusion, independent of ischemic time (30-minute ischemia: 7.65 ± 2.15 without reperfusion, 19.46 ± 4.6 after 4-hour reperfusion; 240-minute ischemia: 5.6 ± 1.99 and 22.3 ± 3.77; 480-minute ischemia: 3.7 ± 1.56 and 13.1 ± 2.2). Eight-hour ischemic allografts had an increase in CD8-positive cells (1.37 ± 0.5 and 2.3 ± 0.77) and a significant increase in MHC II expression (11.48 ± 2.1 and 18.27 ± 1.34) during 4 hours of reperfusion. Conclusions We hypothesize that these findings reflect an early inflammatory reaction in the allograft possibly triggered by oxidative stress. During therapeutic interventions, both of these pathways must be considered.

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

Long-term survival after surgical treatment is possible in patients with renal cell carcinoma (RCC) extending in the right atrium. Different surgical techniques for the treatment of patients with RCC extending into the vena cava have been advocated, depending on the proximal extent of the tumor. We present and propose an algorithm regarding the operative strategy depending on the extent of tumor growth.

Background There is a great deal of controversy surrounding the issue of hormone replacement therapy after transplantation. The question whether or not this therapy has effects in cardiac allograft vasculopathy (CAV), the Achilles heel of cardiac transplantation or other unique aspects of allograft function is still unknown. Methods We investigated the long-term effect of 17beta-estradiol as well as phytoestrogen Coumestrol, a synthetically produced phytoestrogen, on the development of CAV and the degree of fibrosis in an ovariectomized female heterotopic chronic allograft model (LEW-F344). Results We found that, 150 days after transplantation, no significant effect of estrogen application on intimal thickening of coronary arteries was observed. 17beta-estradiol and phytoestrogen Coumestrol did significantly reduce the perivascular immune reaction. However, the immune effect had no consequence on the intensity of CAV. Although neither 17beta-estradiol nor phytoestrogen Coumestrol revealed a positive effect on CAV, the group of animals treated with 17beta-estradiol showed the highest decline in heart function and the most distinct fibrosis. Conclusions 17beta-estradiol does not affect CAV positively, but worsens cardiac allograft function and leads to increased fibrosis. This is the first study showing a negative effect of 17-beta-estradiol after heart transplantation in the long term.

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

Mometasone furoate (MF) is a topically used glucocorticoid with high anti-inflammatory potency. In contrast to the wealth of data derived from clinical studies, information about the molecular pharmacology of the compound is lacking or contradictory. Thus, we elucidated the characteristics of receptor binding kinetics and receptor affinity in a bioassay. Metabolite formation was determined in human plasma and lung tissue as well as binding affinity to human lung tissue. Fast and extensive association of MF to the human glucocorticoid receptor was observed while the dissociation of the MF-receptor complex was faster compared to fluticasone propionate (FP). The relative receptor affinity of MF was calculated as 2200 (dexamethasone = 100, FP = 1800) and confirmed in a bioassay measuring the induction of the glucocorticoid regulated protein CD163 in human monocytes. In plasma and human lung tissue MF formed a 9,11-epoxy degradation product. The binding affinity of MF to human lung tissue was low compared to FP due to fast redistribution from tissue into plasma. These molecular pharmacological properties are in accordance with clinical data.

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

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

Postoperative infections are a dreaded complication in pulmonal surgery. Besides the optimal preparation of the patients and careful operative technique, perioperative antibiotic prophylaxis represents an important factor in avoiding infectious consequences. Owing particularly to the high proportion of patients with malignant, consumptious illnesses in thorax surgery, immune deficiencies must be reckoned with in this group of patients. The spectrum of germs to be expected within the framework of pulmonal surgery determines to some extent which antibiotic shall be used. We have investigated the efficacy of a standardized antibiotic prophylaxis using cefotaxime (Claforan) in 200 pulmonal patients. Pleural empyema is a rare, but nonetheless important infectious illness, as a consequence of pulmonal operations, or also following pneumonia. Whilst the early stages of an empyema can often be successfully treated using only drainage treatment, chronic empyema usually requires a thoracotomy with empyema dissection and excortication, as well as subsequent irrigation-suction drainage treatment. In spite of specific surgical sanitation and irrigation-suction drainage treatment, therapy is often complicated by persistent germs in the thoracic cavity. Instillation therapy with taurolidine can lead to faster healing of the infection in such cases. Purulent mediastinitis is an extremely rare illness, but dreaded owing to its high mortality. The causes of the illness lie in injuries of the trachea, of the bronchial tubes, and of the oesophagus. With the introduction of medial sternotomy as operative entry, mediastinitis as a postoperative complication has increased noticeably in frequency. Mediastinitis occurs as a descending infection as a consequence of odontogenic affections. Owing to frequently late diagnosis, infection is usually advanced, so that simple drainage treatment of the mediastinum no longer suffices in many cases. We introduce our concept of treatment using our own patient collective.