The present study extends previous observations by the finding that carriers of the N5,N10-methylenetetrahydrofolate reductase C677T TT genotype with various coronary high risk profiles had clearly higher coronary heart disease scores than individuals with at least one C677T C allele.
A 38 year old male patient presented with a cardiac tumor. Echocardiography and visualization of the left atrium revealed a large myxoma. Surgical resection of the tumor was performed with the aid of cardiopulmonary bypass. The extensive size of the tumor base and its localisation at the posterior left atrial wall made a conventional approach impossible. Therefore radical resection of the tumor was undertaken using autotransplantation. After a routine postoperative course, the patient was discharged on the twenty seventh hospital day.
Of 54 cardiac tumors operated upon in our clinic, 42 were classified as benign and only 12 as malignant. The major part of the benign tumors were myxoma, mainly located in the left atrium. While smaller tumors could be treated by local resections, extensive resections were necessary in 14 patients with greater tumors followed by reconstructions of the pulmonary and caval vein, mitral and tricuspid valve, and major parts of the right and left ventricular wall. In one patient with a huge benign myxoma, tumor exposition and total resection could only be achieved by an autotransplantation of the heart. While mortality after surgical therapy of benign tumors was only 1.4% (1/42) within a mean follow-up time of 48 months, the prognosis of malignant tumors is still fatal with a mortality of 50% (6/12) within a mean follow-up time of 24 months, despite additional chemotherapy or radiation.
The introduction of fixed reimbursement rates in Germany for cardiac surgery of adults, mainly coronary artery bypass grafting (CABG) and valve surgery, has shifted the financial risk from insurers to providers of medical care, namely hospitals. Costs in turn are closely related to the preoperative condition of a patient, implicating that surgery in high-risk patients may result in financial losses for the operating institution. Furthermore, reports from the Society of Thoracic Surgeons national database indicate a trend over time towards a higher proportion of patients with adverse risk factors for the United States. To determine whether these trends are holding true for Germany, we conducted an analysis of the data from two institutions with the following questions: 1. Is there a trend over time towards unfavourable risk factors, and 2. Is there a relation between preoperative risk factors and postoperative length of stay? From 1987 to 1995, 3872 patients underwent CABG at the Departments of Cardiovascular Surgery of Justus-Liebig University Giessen and German Heart Center Munich. Medical history, preoperative condition, intra-, and postoperative course were recorded for these patients according to the protocol of the German quality assurance program. Preoperative condition of the patient was summarized with an additive risk score. The correlation between postoperative length of stay in the intensive care unit (ICU) and preoperative risk was investigated. For a subgroup of 30 patients, detailed cost analysis was performed and the relationship to preoperative risk examined. For all risk factors examined, a significant increase in prevalence between 1987 and 1995 was observed. A close correlation between preoperative risk and postoperative length of stay in the ICU was found. A similar correlation existed between preoperative risk and actual costs of treatment. In addition, high-risk patients had a significantly higher likelihood of being discharged directly from our ICU to the ICU of other hospitals. Postoperatively, high-risk patients suffer more often from morbidity with subsequent prolonged intensive care and are, therefore, a financial burden for the operating institution in a reimbursement system with fixed rates. This is aggravated by the fact that a trend towards adverse risk profiles among patients undergoing cardiac surgery can be observed. Both factors combined may result in a scenario where those who would benefit most are denied surgical treatment.
Somatosensory evoked cervical and cortical potentials (SEP) were analyzed under general anesthesia in 106 patients undergoing carotid endarterectomy. Cortical electrical silence occurred in 5 patients without an inlying shunt; all developed a new neurologic deficit postoperatively. Analysis of the SEP in these patients revealed progredient cerebral ischemia as indicated by an increase in central conduction time (CCT) and a decrease in amplitude of the primary cortical response N20P25 resulting in a complete loss of cortical SEP later on during the clamping period. In 6 patients the insertion of a shunt restored the deteriorated SEP, these patients and those with unchanged SEP after carotid clamping showed an uneventful postoperative recovery. Taking the presence or absence of N20P25 as the sole parameter, the sensitivity of this technique was 83%, specificity 99% and predictability 83%. A normal range for CCT and amplitude of N20P25 during anesthesia and criteria for shunt insertion were developed. The presented monitoring regimen appears to be rational and is based on current concepts of cerebrovascular physiology and pathophysiology.
During open-heart surgery, myocardial biopsies were taken from 31 patients undergoing aortic valve replacement on total cardiopulmonary bypass. The first needle biopsy was taken before the induction of cardiac arrest (Kirsch cardioplegia), the second at the end of global ischemia, and the third during the reperfusion period. The tissue was investigated by electron microscopy using a semiquantitative scoring system for changes in both myocytes and blood vessels. Mitochondrial volume and surface density were determined by morphometry. Reversible ischemic injury of moderate to severe degree occurred in cardiac cells and in small blood vessels. On reperfusion, signs of damage regressed earlier in myocardial than in vascular tissue. Morphometry revealed significant mitochondrial swelling during the reperfusion phase, but this was not present after ischemia alone. It is concluded that Kirsch cardioplegia as applied here, is unable to protect the heart from ischemic cellular damage.
Penetrating cardiac injuries provide the surgeon until nowadays with a challenging problem due to a high mortality rate. Depending on the mechanism of trauma and the time interval less than 20% of the patients with severe wounds of the heart reach the hospital alive. Methods of managing these wounds are controversial. Pericardiocentesis has more a diagnostic than a therapeutic value. Emergency thoracotomy will help reduce the mortality even in agonal and decompensation patients. With respect to the literature and 31 own cases the diagnosis, the operative management and the results will be discussed.
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