Giant coronary aneurysm obstructing the right heart.
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Adult↗
Biomedical subjects
N Augustin
Publications and source records attributed to N Augustin.
Diastolic unloading and improved LV pump efficiency early after repair of the insufficient mitral valve.
BACKGROUND: This study aimed to evaluate the acute effect of mitral valve repair (MVR) on LV hemodynamics and geometry in patients with normal ventricular function. METHODS: In 10 patients with severe mitral regurgitation undergoing MVR, pressure-volume relationships were recorded before annuloplasty prior to and after hemodilution and after MVR during stable circulatory condition, using the conductance catheter technique (CC). Analyses were done off-line; volume calibration was based on data obtained after completion of valve repair (mean +/- s.d.). RESULTS: CC showed that only 61 +/- 15 % of left ventricular output was ejected into the systemic circulation, regurgitation volume being 39 +/- 15 %. MVR led to a reduction in LV stroke work index from 4.7 +/- 1.8 mm Hg x l x m (-2) at before valve repair to 2.2 +/- 1.0 mm Hg x l x m (-2) after surgery at unchanged cardiac index. LV diastolic filling parameters improved: LV relaxation time constant tau decreased from 52 +/- 15 to 37 +/- 11 ms and dP/dt (min) increased from - 873 +/- 231 to - 1286 +/- 283 mm Hg x s (-1). CONCLUSIONS: Despite cardioplegic arrest, MVR leads to acute improvement of diastolic LV function early after the operation. This may explain why valve repair has an acute positive effect in patients with impaired LV function.
Blood Pressure↗
[Acute thrombosis of a mechanical heart valve caused by inadequate anticoagulation with low molecular weight heparin].
CASE REPORT: A 55-year-old woman with a mechanical aortic prosthesis was admitted with pulmonary edema and suspect of valvular malfunction. The patient had a anticoagulation therapy at the time with low-molecular-weight heparin only. Echocardiography confirmed a failing mobility of a prosthetic valve leaflet. Emergency aortic valve replacement was performed. CONCLUSION: According to international approved guidelines an adequate anticoagulation after mechanical prosthetic heart valve replacement is provided either by oral anticoagulants, or, in the case of pregnancy or surgical procedures, by unfractioned heparins. The use of low-molecular-weight heparin as sole anticoagulant remains a matter of controversy in the literature. In recent years low-molecular-weight heparins were mainly administered for prevention and treatment of deep vein thrombosis, pulmonary embolism, stroke, and instable angina.
Acute Disease↗
Ischemically compromised myocardium displays different time-courses of functional recovery: correlation with morphological alterations?
OBJECTIVE: It has been demonstrated that positron emission tomography (PET) predicts the functional recovery of viable but ischemically compromised myocardium. Reversible contractile dysfunction after revascularization has been reported for 'hibernating myocardium' and stunned myocardium, however, there are little data concerning the time-course and the extent of improvement of the two different pathophysiological conditions. METHODS: Twenty-nine patients with advanced coronary artery disease and severely reduced left ventricular function (EF 18--35%) who were referred for isolated coronary artery bypass grafting underwent preoperative PET viability assessment and were functionally assessed by two-dimensional echocardiography preoperatively at 11 days, 14 weeks, and more than 12 months after surgical revascularization. Intraoperative biopsies were taken from dysfunctional areas defined by PET as segments of normal perfusion and normal metabolism (stunned myocardium) and from areas with a 'mismatch' between perfusion and metabolism (hibernating myocardium). The degree of morphological alterations was evaluated by electron microscopy. RESULTS: In 70% of the 240 dysfunctional segments, 'stunned myocardium' was present whereas 'hibernating myocardium' could be detected in only 24% (P < 0.01). Hibernating myocardium was associated with more severe preoperative wall motion abnormalities and incomplete postoperative recovery. After 1 year, 31% of 'stunned' segments vs. only 18% of 'hibernating' segments showed complete functional restoration (P < 0.05). This incomplete improvement was associated with more severe morphological alterations including depletion of sarcomeres, accumulation of glycogen, loss of sarcoplasmatic reticulum, and cellular sequestration. CONCLUSIONS: These data indicate that in patients with severe ischemic left ventricular dysfunction 'stunned myocardium' is more prevalent than 'hibernation'. Functional normalization is more frequent in 'stunned' segments, whereas areas of 'hibernation' showed more severe tissue injury and protracted recovery. Different degrees of myocardial injury coexist in most patients, which determines the time-course and the extent of improvement after revascularization.
Aged↗
Extended resection of a chest wall desmoid tumour with concomitant coronary artery bypass grafting.
We report on the resection of a large desmoid tumour of the anterior chest wall in a 65-year-old male patient. The patient had a coronary artery bypass operation 2 years prior to the first detection of a tumour. Because the left internal mammary artery bypass to the left anterior descending coronary artery (LAD) was embedded in the tumour mass, it had to be resected together with the tumour. A saphenous vein aorto-coronary bypass to the LAD with an off-pump technique was then performed, and the chest was reconstructed with polypropylene mesh and a latissimus dorsi musculocutaneous flap.
Aged↗
Time course and extent of improvement of dysfunctioning myocardium in patients with coronary artery disease and severely depressed left ventricular function after revascularization: correlation with positron emission tomographic findings.
OBJECTIVES: This study was performed to evaluate the prevalence, time course of recovery and extent of improvement of segments with a positron emission tomographic (PET) flow-metabolism mismatch and match pattern, as well as of PET segments with normal perfusion but with impaired myocardial function. BACKGROUND: Previous studies have shown that scintigraphic techniques evaluating myocardial viability provide predictive information about the improvement of regional wall motion. However, there are little data concerning the time course and extent of improvement of segments according to preoperative scintigraphic patterns. METHODS: Twenty-nine patients with ischemic cardiomyopathy (ejection fraction 18% to 35%) underwent preoperative PET viability assessment and were functionally assessed by two-dimensional echocardiography preoperatively and at 11 days, 14 weeks and >12 months after coronary artery bypass graft surgery. RESULTS: In 168 (70%) of 240 dysfunctional segments, a "normal" scintigraphic pattern was present, whereas a "mismatch" pattern was observed in 24% (p<0.01). Mismatch areas were associated with more severe preoperative wall motion abnormalities and incomplete postoperative recovery. After one year, 31% of normal scintigraphic segments, compared with only 18% of mismatch segments, showed complete functional restoration (p<0.05). CONCLUSIONS: These data suggest that in patients with severe left ventricular dysfunction, a scintigraphic pattern of normal perfusion and normal metabolism is more prevalent than a flow-metabolism mismatch pattern. Functional recovery is more frequent in normal scintigraphic segments, whereas in mismatch segments, postoperative recovery remains incomplete even after one year.
Adult↗
High-dose aprotinin modulates the balance between proinflammatory and anti-inflammatory responses during coronary artery bypass graft surgery.
OBJECTIVE: To rule out the effect of high-dose aprotinin in respect to the balance of proinflammatory and anti-inflammatory mediators induced by cardiopulmonary bypass (CPB). DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: University-affiliated cardiac center. PARTICIPANTS: Twenty patients scheduled for coronary artery bypass graft surgery. INTERVENTIONS: In group A patients (n = 10), high-dose aprotinin was administered (2 x 106 KIU pre-CPB, 2 x 10(6) KIU in prime, 500,000 KIU/hr during CPB). In group C patients (n = 10), placebo was used instead. Proinflammatory interleukin (IL)-6, anti-inflammatory IL-1-receptor antagonist, and clinical parameters were measured 8 times perioperatively. The values are presented as mean +/- SEM. MEASUREMENTS AND MAIN RESULTS: Four hours after CPB, IL-6 concentration reached the maximum value, being significantly lower in group A patients as compared with group C patients (615 +/- 62 pg/mL v 1,409 +/- 253 pg/mL; p = 0.019). On the first postoperative day, the concentration of IL-6 in group A patients remained lower (219 +/- 24 pg/mL v 526 +/- 123 pg/mL; p = 0.015). In contrast, IL-1-receptor antagonist concentration was higher in group A patients as compared with group C patients after CPB (13,857 +/- 4,264 pg/mL v 5,675 +/- 1,832 pg/mL; p = 0.03). Total postoperative blood loss was lower in group A patients as compared with group C patients (648 +/- 64 mL v 1,284 +/- 183 mL; p = 0.002). CONCLUSIONS: High-dose aprotinin treatment reduced the inflammatory reaction and postoperative blood loss. The anti-inflammatory reaction was significantly enhanced in these patients, which suggests that the physiologic reaction of the organism to reduce the deleterious effects from CPB is more pronounced by using high-dose aprotinin.
Aprotinin↗
Valve preserving treatment of Ebstein's anomaly: perioperative and follow-up results.
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Cardiac Surgical Procedures↗
Morphologic spectrum of Ebstein's malformation: revisitation relative to surgical repair.
OBJECTIVE: Our aim was to elucidate the morphologic spectrum of Ebstein's malformation of the tricuspid valve with regard to diagnosis and the feasibility of surgical repair, in the light of the currently favored reconstructive techniques. METHODS: We examined 23 autopsied hearts. Taking the displacement of the septal and mural leaflets of the abnormal tricuspid valve as our diagnostic criterion, we focused subsequently on the location of the distorted valvular orifice and the attachment and formation of the anterosuperior leaflet. We also assessed the dimensions of the components of the right ventricle relative to the plane of the displaced valvular orifice. RESULTS: In all hearts, the septal and mural leaflets were hinged at various points within the inlet of the right ventricle. In many cases, however, these leaflets were virtually absent. The plane of the effective tricuspid valvular orifice was displaced anterosuperiorly to varying degrees. In the most severe forms, the valvular mechanism took the form of a 1-leaflet valve. The length of the functional right ventricle when compared with the left ventricle ranged proportionally from 0.6 to 1. 1 (mean, 0.9). CONCLUSIONS: Ebstein's malformation is much more than simple "downward displacement" of the leaflets. In essence, the valvular orifice is formed within the ventricular cavity at the junction of the atrialized inlet and functional ventricular components. When surgical intervention becomes necessary, it is essential to make a detailed assessment of both valvular and ventricular abnormalities.
Adolescent↗
[Ebstein's anomaly: when should a patient have operative treatment?].
Ebstein's anomaly is a complex malformation of the tricuspid valve where the hinges of the septal and/or posterior leaflets are displaced downward into the right ventricle. The leaflets show variable deformations. In general, the anterior leaflet is enlarged. For those patients who have only mild symptoms, medical management is recommended, but operative treatment is indicated if progressive deterioration is evident. The timing of the surgical intervention is still a matter of controversy, especially since the results of surgical treatment were substantially improved by further development of repair techniques. Between 1974 and August, 1997, 69 patients with Ebstein's anomaly underwent surgical repair. In 65 patients (94.2%) tricuspid valvuloplasty was feasible, mainly by creating a monocusp valve with the "single-stitch technique", developed in our clinic by F. Sebening. Four patients required primary valve replacement with a bioprosthesis. Ten reoperations (14.5%) were necessary: 6 repeat valvuloplasties, 4 valve replacements. There were 2 hospital deaths (2.9%), the late mortality was 8.7% (6 patients). Since 1992, our valvuloplasties have been evaluated by intraoperative transesophageal echocardiography (TEE). Follow-up was obtained in 58 patients (95%) over a period of 4 months to 21.0 years (median 5.3 years, mean 7.6 years). The actuarial survival rate (Kaplan-Meier) was 96.5% +/- 2.4% at 1 year and 83.3% +/- 5.6% at 21 years. Pre-operatively, the majority of patients were in New York Heart Association functional Class III. At follow-up evaluation, nearly all patients showed substantial improvement of their pre-operative status, 94.8% were in NYHA Class I or II. Doppler echocardiographic studies demonstrated good tricuspid valve function in most patients. The valvuloplasty developed in our hospital using a single-stitch technique is a rewarding operation, which yields good long-term results. An analysis of the postoperative deaths revealed that all patients but one suffered from endstage cardiac disease and had a cardio-thoracic ratio greater than 0.65. This supports the importance of surgical intervention in time. In our opinion, operation is even indicated for those patients in functional Class II who reveal clinical deterioration.
Adolescent↗
Results after surgical repair of Ebstein's anomaly.
BACKGROUND: Ebstein's anomaly of the tricuspid valve is a complex malformation. Various operations have been undertaken with varying results. Because valve replacement yielded poor results, surgical treatment has focused on valvuloplasties. METHODS: Between April 1974 and February 1995, 60 patients with Ebstein's anomaly underwent surgical repair. Age ranged from 5 months to 54 years. In 56 patients (93.3%), tricuspid valvuloplasty was feasible, mainly by creating a monocusp valve with the single-stitch technique. The other 4 patients had valve replacement with a bioprosthesis. Six reoperations were necessary (10.0%): four valve replacements and two repeat valvuloplasties. RESULTS: There were two hospital deaths (3.3%) and a late mortality rate of 10.0% (6 patients). Forty-nine (94.2%) of 52 survivors were followed for 5 months to 18.6 years (median follow-up, 5.0 years; mean follow-up, 6.9 years). The actuarial survival rate (Kaplan-Meier) was 96.5% +/- 2.4% at 1 year and 83.3% +/- 5.6% at 18 years. At follow-up evaluation, nearly all patients showed substantial improvement (93.9% were in functional class I or II) compared with their preoperative status. Doppler echocardiographic studies demonstrated good tricuspid valve function in most patients. CONCLUSIONS: Valvuloplasty using the single-stitch technique is a rewarding operation. It yields good long-term results with substantial improvement in functional performance and clinical status.
Actuarial Analysis↗
Operative correction of traumatic tricuspid insufficiency.
Between 1975 and 1991, 5 patients were operated for traumatic tricuspid insufficiency. The patients, all male, with the age at surgery of 15 to 61 years (mean 39 years), suffered previous nonpenetrating trauma to the chest 0.1 to 23 years (mean 13.2 years) earlier. Symptoms were known for 0 to 18 years (mean 10.5 years). The patients were in NYHA class II to IV (mean 2.9). Preoperative angiography showed moderate to severe tricuspid insufficiency. Mean right atrial pressure was 9.6 +/- 1.7 mm Hg and mean pulmonary artery pressure 14.0 +/- 2.4 mm Hg, the mean cardiothoracic ratio was 0.59 +/- 0.04, 4 patients were in sinus rhythm and 1 patient was in atrial fibrillation. Intraoperatively 4 patients showed rupture of the anterior chordae tendineae, 1 patient had multiple ruptures of the leaflets and the anterior papillary muscle, all tricuspid valves showed massive annular dilatation. A primary valvular reconstruction was undertaken in 3 patients of whom only 1 patient was successful in controlling tricuspid insufficiency. Finally, 4 tricuspid valves had to be replaced, 3 with a bioprosthetic and 1 with a mechanical valve. One patient died early, 2 patients died late during a total follow-up of 35.3 years after 7 and 9 years, 2 patients are alive 9 and 10 years after the operation and are presently in New York Heart Association class II to III and I. Traumatic tricuspid insufficiency is a rare event, but is not infrequently overlooked for a long period of time inspite of present symptoms. Results after operative correction seem to be comparable with the results in patients following tricuspid repair or replacement for functional and organic lesions.
Adolescent↗
Combined membranous obstruction and saccular aneurysm of the inferior vena cava.
The authors report the history of a 35-year-old man who was operated on because of an asymptomatic combined membranous obstruction and saccular aneurysm of the inferior vena cava (IVC) at diaphragmatic level. Using extracorporeal circulation as well as hypothermia, aneurysm and IVC obstruction were resected and the IVC reconstructed using pericardium. This case and the experience reported in the literature is discussed.
Adult↗
Surgery for tricuspid insufficiency: long-term follow-up after De Vega annuloplasty.
Between 1975 and 1991, 97 consecutive patients underwent De Vega tricuspid annuloplasty either isolated or in combination with mitral, aortic, or mitral and aortic valve procedures. Preoperatively 96.9% of the patients were in New York Heart Association functional class III or IV. Causes of tricuspid insufficiency were functional tricuspid ring dilatation and a combination of dilatation and different organic tricuspid valve lesions. There were 17 early deaths (17.5%), primarily due to cardiac failure, none was related to the tricuspid annuloplasty. 80 perioperative survivors have been followed up for a mean of 4.7 +/- 4.1 years with a total of 462 cumulative patient-years. Actuarial 5-, 10-, and 15-year survival rates, including early deaths, were 64% +/- 5%, 48 +/- 6%, and 26% +/- 10%. Recurrence of tricuspid regurgitation was rated as moderate in 15% and severe in 18.8%. Ten patients required reoperation (2.2%/patient-year), of whom 8 were associated with tricuspid regurgitation (1.7%/patient-year). Although in all patients but one the De Vega annuloplasty was intact, the tricuspid ring was dilated; 4 patients had additional tricuspid organic valve lesions. 6 of the 8 patients had concomitant mitral valve or mitral prosthesis dysfunction. 26 patients died late (5.6%/patient-year) due to chronic cardiac failure in 50% and after reoperation in 7% of the patients. 4 patients had implantation of a permanent pacemaker (0.9%/patient-year). 54 patients (67.5%) are still alive, with 43% having no and 17.5% having only mild residual tricuspid regurgitation. De Vega annuloplasty is indicated with tricuspid insufficiency due to functional ring dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Hemangiopericytoma of the lung--a rare differential diagnosis of lung tumors.
The authors report of a 50 year old woman who was operated on because of a rectum carcinoma 5 years ago. At a follow-up examination a 2 x 2 x 1 cm sized tumor was found in the lower lobe of the right lung. Under the diagnosis of lung metastasis after rectum carcinoma resection, operation (wedge resection) was carried out. The histological examination revealed the rare tumor hemangiopericytoma. Based on this case, frequency of the tumor, clinical symptoms, surgical treatment, prognosis as well as recurrence rate and formation of metastases are discussed.
Diagnosis, Differential↗
[Diagnostic value of sonography and computed tomography in liver metastases].
The diagnostic accuracy of sonography and computed tomography for detecting liver metastases was analysed in 526 patients with tumors and the findings were compared with those at laparotomy and at post mortem. The surgical protocols were analysed in respect of the primary tumour, the frequency of metastases and the number, localisation and size of metastases. A comparison of sonography and CT showed a higher sensitivity for CT (57.1%) compared with sonography (52.3%) although specificity was slightly higher for sonography. Liver metastases greater than 15 mm were detected by sonography (80.5%) and CT (92%), with much higher sensitivity. CT also proved superior, since the results depended less on the size, number and localisation of the deposits and on the primary tumor than did sonography.
Humans↗
[Pedicled jejunum transplant--a possibility for partial bile duct replacement].
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Adult↗
[Retrograde invagination by a Braun anastomosis as a cause of outflow obstruction following Billroth II resection].
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Adult↗