[Isolated lung transplantation. I. Indications and criteria for patient selection].
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Adult↗
Biomedical subjects
U Hake
Publications and source records attributed to U Hake.
[Surgical therapy of thoracic aortic dissection].
Considerable surgical progress of treating aortic dissection has been achieved during the past decade. The emergency indication for acute dissection of the ascending aorta (type A according to the Stanford classification) is unquestioned while surgical treatment for acute dissection of the descending aorta (type B dissection) is mainly reserved for complicated cases. The major complication of acute operations--fatal hemorrhage from the suture line and secondary multi-organ failure--have been successfully reduced by a progress of cardiopulmonary bypass techniques, the introduction of cold cardioplegic myocardial protection, the development of modern suture materials and glues and last not least by a continuous intensive monitoring. Especially the introduction of the so-called french glue safely enabled both the closure of the false lumen as well as the strong reinforcement of the diseased aortic wall and seems to offer a reliable alternative to the application of multi-layered teflon strips. Since the principle of all reconstructive approaches in case of dissection consists of closure of dissected layers and the limited replacement of the segment that is susceptible to a rupture the exact readaptation and reinforcement of the diseased aortic wall represents a fundamental operative step. In type A operations the supracoronary aortic prosthetic replacement or the combined replacement of ascending aorta plus aortic valve followed by the reattachment of coronary arteries has become the standard operative technique. In fact, independently from the location of the primary intimal tear the operation has been traditionally limited to replace the ascending aorta in order to remove an aortic segment that is most likely to rupture. Yet an increasing number of follow-up investigations has demonstrated recurrence of dissection or an aneurysmatical dilatation of the false lumen in about 20% of patients treated with ascending aortic replacement. Consequently, repair of the aortic transverse arch and the radical elimination of the intimal entry is now favoured by an increasing number of surgeons. In addition to these various perioperative and intraoperative adjuncts the introduction of new imaging techniques, especially computerized tomography, magnetic resonance imaging and transesophageal echocardiography allowed to establish adequate therapeutical concepts on a more rational basis. Transesophageal echocardiography as a mobile diagnostic device enables investigators to perform a bed-side dynamic visualization of both the location and extent of a dissection, the evaluation of ventricular performance and aortic competence. Treatment of acute type B dissection is mainly conservative unless complications like intractable pain, aneurysmatic enlargement of the false lumen, ischemia of visceral organs or even rupture occur.(ABSTRACT TRUNCATED AT 400 WORDS)
Anastomosis, Surgical↗
Evaluation of the healing of precoated vascular dacron prostheses.
Knitted and woven Dacron grafts commercially coated with bovine collagen, gelatin and human albumin were implanted end-to-side between the infrarenal aorta and the bifurcation in 35 growing pigs. Grafts were explanted after 4, 8 and 12 weeks and compared to 6 uncoated knitted prostheses preclotted with blood that served as a control. Uncoated grafts rapidly developed a firmly attached neointima lined with endothelium. Compared with coated grafts the thrombus-free area of uncoated grafts was significantly larger (P less than 0.05). The slow resorption of albumin resulted in a delayed and incomplete neointimal healing and failing graft incorporation. Although the bovine collagen was only minimally cross-linked by formaldehyde, healing of the neointima was compromised in a thin woven graft that demonstrated peeling of the inner capsule even after 12 weeks. The identical collagen as well as bovine gelatin were quickly degraded in knitted grafts and both types showed transprosthetic infiltration at 4 weeks. All knitted grafts coated with either collagen or gelatin, however, were occluded after 8 and 12 weeks. Light microscopy revealed hyperplasia of smooth-muscle cells within the thickened distal anastomotic region. These results demonstrate that a timely return of porosity is mandatory for the development and maintenance of an intact neointima. Both the structure of the fabric as well as the method of preparing the coating are crucial variables to determine the rate of biodegradation.
Animals↗
Resection of central primary pulmonary artery sarcoma.
Primary sarcomas of the pulmonary arteries are rare, and the diagnosis is in the majority of the reported cases established postmortem. Surgical resection of these centrally located tumors has been performed either by pneumonectomy and/or local tumor resection. We report on two patients with sarcomas of the central pulmonary arteries who underwent successful resection of the tumor and prosthetic replacement of the arteries under cardiopulmonary bypass. One patient required additional thromboendarterectomy of the right pulmonary artery branches because of secondary thrombus formation. As primary pulmonary artery sarcomas are refractory to both chemotherapy and radiation, surgical resection remains the only means of treatment. The prognosis depends entirely upon resectability, which, if necessary, should be performed with the aid of cardiopulmonary bypass. In this way, lung resection may be avoided.
Adult↗
Healing parameters of a new albumin-coated knitted Dacron graft.
Knitted dacron grafts commercially coated with human albumin were implanted end-to-side between the infrarenal aorta and the bifurcation in 9 growing pigs. Uncoated knitted dacron grafts implanted in 6 pigs served as a control. Grafts were explanted after 4, 8, and 12 weeks and evaluated for neointimal healing, peeling of the inner and outer capsule, extent of neoendothelialization, absorption of the sealant, interstitial infiltration, and perigraft inflammation. Toxicological in-vitro analysis included the evaluation of residual aldehydes and plasticizers. In contrast to the uncoated knitted prosthesis, which rapidly developed a layered neointima with complete neoendothelialization, only islands of neointima were found in albumin-coated grafts after 4 weeks. The neointima remained incomplete at 8 and 12 weeks with scanning electron microscopic evidence of sharply demarcated endothelial areas. No transprosthetic bridging was detectable even after 12 weeks and peeling of the inner and outer capsule was easily provocable. These results outline that the cellular and connective infiltration of the prosthetic wall is compromised unless degradation of the sealant is completed within four weeks: the neointimal development is delayed and graft incorporation fails, leaving the outer capsule unattached.
Albumins↗
Diagnosis of perioperative myocardial necrosis following coronary artery surgery--a reappraisal of isoenzyme analysis.
Although the routine determination of CK-MB activity is widely used after coronary artery bypass grafting (CABG), the diagnosis of a perioperative myocardial necrosis remains arbitrary. The intention of the present study was to develop discriminative enzymatic parameters of CK-MB activity in a collective of 710 patients following CABG. Patients were grouped according to their postoperative electrocardiogram (ECG). For each patient, the time activity curve of CK-MB was determined. The total amount of CK-MB was calculated by integrating the area beneath the CK-MB activity curve. Patients presenting with an unchanged postoperative ECG (group I) or a new bundle branch block with uncompromised haemodynamics (group IIa) had an uniform and low profile of CK-MB activity. Serial CK-MB activities as well as the integrated CK-MB area of these two collectives were significantly different (P less than 0.001) from values determined for patients with bundle branch block and low cardiac output (group II b) or patients with new Q waves (group III). After 24h, the 90th percentile of serial CK-MB activities of group I had declined to 18 U/l and was clearly exceeded by 90% of all patients that belonged to either group IIb or III. The 90th percentile of CK-MB areas for group I showed a value of 801 U/l x h. CK-MB areas above 801 U/l x h were seen in about 50% of all patients of group IIa.(ABSTRACT TRUNCATED AT 250 WORDS)
Coronary Artery Bypass↗
[Clinical experience with the Kensey catheter system--complications and results].
Fifteen procedures have been carried out in 14 patients using the Kensey rotation angioplasty system. Sixteen occlusions of the superficial femoral artery, with an average length of 10.2 cm (3 to 24 cm) and one artery with multiple stenoses were treated. The following results were obtained: creation of a lumen, with subsequent balloon dilatation in eight out of fifteen procedures; in two patients the vessels were occluded shortly after the procedure, due to complications (one obstructive plaque and one haematoma); five perforations, three dissections and one peripheral embolus. The total complication rate was 11 out of 15 cases, clinical improvement was obtained in six out of 15 cases.
Aged↗
New bundle branch block after coronary artery bypass grafting--evaluation by CK-MB isoenzyme analysis and transoesophageal echocardiography.
Twelve patients with a new complete bundle branch block after coronary artery bypass grafting underwent transoesophageal echocardiography (TEE). The results of TEE were compared with the pre-operative ventriculography, CK-MB isoenzyme time-release curves and clinical course. In eight patients with transient right bundle branch block or bifascicular block, low CK-MB activities and an uncomplicated postoperative course, transoesophageal echocardiography showed no new segmental wall motion abnormalities apart from a paradoxical septal movement in five. A persistent right or left bundle branch block was associated with either elevated isoenzyme activities, transoesophageal echocardiographic evidence of new segmental wall motion disturbance or both in four patients. One patient died because of fatal arrhythmia and one suffered from a prolonged low cardiac output syndrome. A transient bundle branch block is usually a benign electrocardiographic finding. In case of a persistent bundle branch block associated with elevated CK MB isoenzymes, new left ventricular wall motion disturbances indicating a peri-operative myocardial injury are easily detected by transoesophageal echocardiography.
Aged↗
[Angioplasty of the subclavian artery. The technic, early and late results].
Percutaneous transluminal angioplasty (PTA) was performed in 22 patients (13 women and nine men; mean age 57 years [44-74] ) with symptomatic obstruction of the subclavian artery which was due to arteriosclerotic stenosis in 14, occlusion in six patients, radiogenic multiple stenoses in one (after radiotherapy for breast cancer), and stenoses of the left and right subclavian artery in one patient with Takayasu's arteritis. Primary success occurred in 21 (91%). The only complication was a stenosis of the brachial artery after combined brachiofemoral recanalization of a subclavian artery occlusion, but it did not require treatment. No emboli were noted. A good long-term result was achieved in 19 of the 21 primarily successful PTAs, in two instances after repeat PTA. PTA has thus been shown to be a simple, well tolerated interventional treatment of symptomatic subclavian obstruction with a high success rate and low risk of complications. It is to be preferred as a primary procedure to surgical intervention.
Aged↗
Surgical closure of aorto-pulmonary window without cardiopulmonary bypass.
The surgical treatment of aorto-pulmonary window by a closed technique is described. This avoids the increased risks of extracorporeal circulation and deep hypothermia with or without total circulatory arrest in the neonate or very sick infant.
Aortopulmonary Septal Defect↗
Influence of incremental preoperative risk factors on the perioperative outcome of patients undergoing emergency versus urgent coronary artery bypass grafting.
A retrospective analysis of 127 patients with impending myocardial infarction undergoing coronary artery bypass grafting was performed to evaluate incremental risk factors associated with perioperative mortality and morbidity. Fifty-four patients (group 1) were operated upon as emergencies within 24 h and 73 patients underwent urgent coronary revascularization within a mean of 3.4 days (group II) after admission. The incidence of non-transmural myocardial infarctions (NTMI), haemodynamic parameters, the number of diseased vessels and the incidence of a preceding percutaneous coronary dilatation (PTCA) were not statistically different between the groups. The overall perioperative mortality was 8.7% (16.7% group I, 2.7% group II). Major non-fatal complications were frequent in the surviving collective including low cardiac output in 14 patients (12.1%) and transmural or subendocardial perioperative infarction in 12 patients (10.3%). Perioperative mortality was associated with reduced left ventricular myocardial function (P less than 0.001), operation within 24 hr after onset of anginal symptoms (P less than 0.001) or subendocardial infarction (P less than 0.025) in the 4 weeks before operation. Perioperative mortality was independent of the degree of coronary stenosis, number of distal anastomoses or performance of a coronary endarterectomy. Of the patients, 90.5% (87.5% of group I and 92.3% of group II) included in a mean follow-up of 16.8 months (range 5-27 months) were graded into Canadian Heart Functional Class I. Successful coronary surgery for acute myocardial ischaemia results in excellent late functional recovery. The major risk factors for fatal perioperative outcome are reduced left ventricular function and the necessity of every early surgical intervention.
Angioplasty, Balloon, Coronary↗
Emergency surgical revascularization following coronary angioplasty: evaluation of operative results by isoenzyme analysis and electrocardiography.
Seventeen patients underwent emergency coronary artery bypass grafting due to balloon catheter induced occlusion or dissection of a major coronary artery. Patients were revascularized within a maximum of 210 min from the onset of ischaemia and received an average of 1.6 distal anastomoses. A perioperative transmural or non-transmural myocardial infarction as diagnosed by CK-MB activity and electrocardiographic patterns occurred in 7 patients (41.2%). One early death resulted in an overall perioperative mortality of 5.9%. Successful preservation of myocardium was demonstrated in 10 patients by a rapid decline of CK-MB activity, no perioperative electrocardiographic changes and no requirement for inotropic support. The incidence of a perioperative myocardial infarction was independent of the anginal status before coronary angioplasty or the angiographic evidence of a complete occlusion versus a dissection. Major ischaemic myocardial complications associated with coronary angioplasty are rare but frequently catastrophic events. Fast surgical intervention is mandatory to prevent myocardial infarction or to limit the extent of injury. The operative outcome can be evaluated by careful analysis of time release curves and cumulative parameters of CK-MB activity.
Adult↗
[Percutaneous removal of a pacemaker electrode].
The large number of pace-makers introduced transvenously has resulted in increasing the number of complications, amongst which infections and dislocations are prominent. It is usually necessary to remove the electrode, which can be attempted percutaneously by using a Dormia basket, a loop or forceps. Amongst the complications of this procedure are tears to the myocardium, with the risk of pericardial tamponade, or tears of the tricuspid valve leading to tricuspid insufficiency. Consequently, thoracic surgical intervention should be available if necessary. Four successful procedures are described.
Aged↗
Urgent indications for surgery in primary or secondary cardiac neoplasm.
Ten patients underwent resection of primary or secondary cardiac tumor. Two-dimensional transthoracic echocardiography per se accurately located the endoluminal cardiac mass in nine patients, and transesophageal echocardiography demonstrated a right atrial tumor in the tenth case. The indications for urgent surgery included prior embolic events (3 cases), syncopal attacks (2) or echocardiographic evidence of a multilobulated mass (2 cases). The operative strategy was standardized for atrial tumors, but for malignant myocardial neoplasm both the anatomic site and the extent of tumor growth determined the surgical procedure. Histologic examination showed myxoma in seven cases, fibroma in one and metastases of malignant melanoma in two cases. The course after resection of endoluminal benign tumor was uneventful apart from transient atrial fibrillation in four cases. Follow-up echocardiography (after 4-28 months) showed no recurrent growth. In both cases of intracardiac metastases there was recurrence within 6 to 8 months after resection of the growth.
Adult↗
Initial clinical experience with an endoluminal spiral prosthesis for treating complicated venous thrombosis and preventing pulmonary embolism.
Fourteen patients with complicated venous thrombosis or recurrent pulmonary embolism were treated by implantation of an endoluminal spiral prosthesis subsequent to balloon angioplasty, surgical thrombectomy or embolectomy, a combination of these, or, in 2 cases, no other treatment. The patients were divided into 2 groups, based on their primary diagnosis and the purpose of the prosthesis. Group I included 8 patients with extensive iliofemoral or caval thrombosis, caused by congenital caval stenosis (1 case) or extravascular compression or retraction (7 cases); 7 of these patients had had previous operations, and the remaining patient had undergone thrombolysis, which failed. The current treatment consisted of balloon angioplasty and surgical thrombectomy or embolectomy, and implantation of an endoluminal spiral stent to prevent elastic recoil of the vessel. In 4 cases, an arteriovenous fistula was constructed and was taken down 3 months later; in 1 additional patient, a bilateral arteriovenous fistula was created. Group II comprised 6 patients with recurrent pulmonary embolism (4 cases), massive pulmonary embolism (1 case), or paradoxical bilateral carotid artery embolism (1 case). Four of these patients underwent surgical thrombectomy or embolectomy, while 2 had no treatment other than filter implantation. All 6 underwent transluminal implantation of a helix caval filter (a modification of the endoluminal spiral stent). All but 1 implantation was accomplished by means of either a transfemoral or a transjugular cutdown; the remaining implantation was performed transatrially after a pulmonary embolectomy. The only device-related complication was a retroperitoneal hematoma in Group I, resulting from perforation of the inferior vena cava by the guidewire during device implantation. This complication necessitated an emergency laparotomy and takedown of the arteriovenous fistula, which resulted in rethrombosis of the left iliofemoral vein. The other 7 stented veins were patent at early phlebographic follow-up, as were all 5 of those studied later. One Group-I patient died 4 months after surgery, due to tumor progression and without signs of caval restenosis. Twelve months postoperatively, 1 Group-II patient died of urosepsis without a recurrence of pulmonary embolism. Four of the 6 Group-II patients were studied late postoperatively, and all of their stented vessels were patent. There was no operative mortality or postoperative embolism. On the basis of these results, we conclude that endoluminal stenting with an expandable spiral prosthesis is a promising method for remote venous reconstruction. Moreover, it appears that the modified stent, or helix caval filter, compares favorably with commercially available filters.
Journal Article↗
[Surgical valve replacement].
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Bioprosthesis↗
[Vascular recanalization using an electric thermal cauterizing catheter--in vitro experiences with a new catheter system].
Recanalisation of arteriosclerotic occlusions by means of laser angioplasty, Kensey catheter and the "hot tip" catheter is undergoing early, successful clinical trials. The thermo-cautery catheter described in this paper uses the well known technique of cutting with high frequency electric currents in order to achieve vascular recanalisation. Seven attempts were made to recanalise occlusions at post mortem; four were successful, but perforation occurred in three. Histologically we found a narrow rim of carbonisation of tissues surrounded by a zone of homogenisation and a transitional zone.
Angioplasty, Balloon↗
Prerequisite coronary endarterectomy for coronary artery bypass grafting.
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Coronary Artery Bypass↗