P Walter

Impaired left ventricular function in chronic aortic valve disease: survival and function after replacement by Björk-Shiley prosthesis.

Postoperative survival and left ventricular function were studied in 128 patients who underwent isolated aortic valve replacement by the Bj6rk-Shiley valve between 1973 and 1977. The average follow-up was 2.1 years. Patients with associated coronary artery disease or mitral valve disease were excluded. Preoperative ejection fraction ranged from 15-84%. Forty-two patients were restudied by cardiac catheterization 9.1 ± 1.1 months (mean ± SEM) after valve replacement. The hospital mortality was 11%. Preoperative type of valve lesion, functional class, cardiothoracic ratio, and ejection fraction (EF) had no significant effect on postoperative survival up to 4 years. After operation, left ventricular mass (LVMI) and peak systolic wall stress (PSWS) fell significantly, while EF and mean normalized systolic ejection rate (MNSER) increased in aortic stenosis and in aortic insufficiency. Neither in aortic stenosis nor in aortic insufficiency was there a significant relation between preoperative ejection fraction and postoperative LVMI, EF, MNSER and PSWS. We attributed this to a marked improvement of left ventricular function in patients with preoperative impaired ventricular function. Six patients with paravalvular leak at restudy had a significantly lower EF and MNSER, and a higher PSWS than patients without leak. Patients without leak had normal EF, MNSER and PSWS when compared with 10 normal persons, but LVMI remained moderately elevated. Postoperative transprosthetic gradient was 11.9 mm Hg (range 0-64 mm Hg).We conclude that impaired cardiac function is completely restored after aortic valve replacement by Bjork- Shiley valve, if valve function is good. Patients with impaired cardiac function preoperatively did not have a poorer prognosis after operation than patients with normal function.

Reduced volume fraction of myofibrils in myocardium of patients with decompensated pressure overload.

The relation between quantitative ultrastructural changes of the left ventricular (LV) myocardium and contractile function was studied in patients with chronic aortic stenosis (AS). The volume fractions of myofibrils, sarcoplasm and mitochondria in myocardial cells were determined by electron microscopic morphometry in small LV tissue samples of 19 patients with AS. Interstitial fibrosis was measured by light microscopic morphometry. Transmural biopsies of the LV free wall perfused by the anterior descending branch of the left anterior descending coronary artery (LAD) were obtained during aortic valve replacement. LV function was analyzed from preoperative right- and left-heart catheterization and angiography. Group 1 consisted of seven patients with ejection fractions (EFs) greater than 55% and mean left atrial pressure (LAP) less than 15 mm Hg. Group 2 consisted of 12 patients with EFs less than 55% and mean LAP greater than 15 mm Hg. Patients in group 1 had lower LV end-diastolic volume (91.9 vs 145.3 ml/m2, p < 0.05) and lower LV muscle mass (148.3 vs 199.8 g/m2, p < 0.05) than patients in group 2. The volume fraction of myofibrils was higher in group 1 than in group 2 (48.4 vs 42.1%, p < 0.05), while volume fractions of sarcoplasm (31.7 vs 36.0%) and mitochondria (20.9 vs 22.0%) were comparable (p > 0.05). Interstitial myocardial fibrosis did not differ between groups (16.3 vs 14.7%, p > 0.05). Biopsies from the area perfused by the LAD in 10 additional surgical patients who had coronary artery disease with moderate LAD stenosis and normal wall motion in the area of LV free wall perfused by the LAD were taken as controls for morphometric data. No significant difference of ultrastructural data was found between group 1 and controls. The volume fraction of myofibrils was lower in group 2 than in controls (42.1 vs 52.9%, p < 0.001), and the volume fraction of sarcoplasm was higher (36.0 vs 21.1%, p < 0.001). Mitochondria and interstitial fibrosis did not differ in group 2 and controls (p > 0.05).Thus, intracellular reduction in the volume fraction of myofibrils was the major morphologic finding in LV biopsy samples of patients with decompensated pressure overload.

Aneurysma spurium der A. hepatica

With the spread of laparoscopic cholecystectomy more and more complications are being reported. For the first time in this paper a pseudoaneurysm of the right hepatic artery as a complication of laparoscopic cholecystectomy in a 55 year old patient is described. During embolization the aneurysm ruptured and an emergency laparotomy was performed. The right hepatic artery was ligated. The postoperative course up to follow-up at 6 months was uncomplicated.With the spread of laparoscopic cholecystectomy more and more complications are being reported. For the first time in this paper a pseudoaneurysm of the right hepatic artery as a complication of laparoscopic cholecystectomy in a 55 year old patient is described. During embolization the aneurysm ruptured and an emergency laparotomy was performed. The right hepatic artery was ligated. The postoperative course up to follow-up at 6 months was uncomplicated.ZusammenfassungIm Rahmen der Verbreitung der laparoskopischen Cholezystektomie werden zunehmend postoperative Komplikationen beobachtet. Es wird erstmalig ein Aneurysma spurium der A. hepatic dextra nach laparoskopischer Cholezystektomie bei einer 55jährigen Patientin sowie dessen Therapie beschrieben. Im Rahmen des radiologischen Embolisationsversuches trat eine Aneurysmaruptur auf, so daß eine Notlaparotomie mit Ligatur der A. hepatica dextra erforderlich wurde. Der postoperative Verlauf über 6 Monate gestaltete sich komplikationslos.

362. Ein neues Modell der autologen Pankreastransplantation am Schwein. Induktion des Diabetes durch regionale Streptozotocinapplikation

SummaryA new model of pancreatic autotransplantation was developed in pigs. The left pancreatic segment was removed and used as an autograft. The head of the pancreas was left in place in order to maintain normal exocrine function. Its endocrine part, however, was ablated by regional streptozotocin infusion into the pancreaticoduodenal artery. The autograft was transplanted onto the right iliac vessels and its exocrine part either occluded using Ethibloc® or anastomosed with a jejunal Roux-en-y-loop. In this new model, all technical problems of pancreatic transplantation can be investigated in a diabetic animal without interference as a result of rejection.ZusammenfassungWir entwickelten ein neues Modell der autologen Pankreastransplantation am Schwein. Das linke Pankreassegment wird als Transplantat entnommen, während der Pankreaskopf verbleibt und die exokrine Funktion aufrechterhält. Sein endokriner Anteil wird über eine regionale Streptozotocinapplikation ausgeschaltet. Das Autotransplantat wird an die Iliacagefäße angeschlossen und je nach Protokoll mit einer Jejunostomie bzw. mit Ethibloc® versorgt. In diesem neuen Modell können alle technischen Fragen der Pankreastransplantation am diabetischen Tier unter Ausschluß von Abstoßungsvorgängen untersucht werden.

Behandlung traumatischer Blutungen mittels interventioneller radiologischer Verfahren

Early hemostasis in hemorrhagic shock after trauma is livesaving, but can be surgically difficult. In this report, 20 of 22 cases of profuse bleeding from trauma could be treated by embolisation.

283. Aggregationshemmung durch Ticlopidine

SummaryTo study the effects of Ticlopidine (Ticlid) as a platelet inhibiting drug, dacron grafts were implanted in arteries of 18 dogs. After different times of free blood-flow (10s to 7 weeks) pieces were taken out and observed by scanning electron microscopy. Those treated with the drug showed an inhibition of aggregation and pseudopods. The occlusion rate of the implanted grafts after 7 weeks had dropped from 76% to 11% under Ticlopidine.ZusammenfassungZur in vivo-Prüfung des Thrombocytenaggregationshemmers Ticlopidine (Ticlid) wurden bei 18 Hunden Dacron-Gefäßprothesen in beiden Aa. femorales implantiert. Nach verschiedenen Zeiten freien Blutdurchflusses (10s bis 7 Wochen) wurden Stücke derselben entnommen und rasterelektronenmikroskopisch untersucht. Die mit Ticlopidine behandelten Tiere zeigten eine Hemmung der Aggregation und der Pseudopodienbildung. Die Verschlußrate der implantierten Grafts nach 7 Wochen Versuchszeit war bei der mit Ticlopidine behandelten Gruppe (11%.) gegenüber der Kontrollgruppe (76%) signifikant niedriger.

203. Heterologer GefäBersatz der Vena cava inferior im Tierexperiment

SummaryA bovine collagen graft was implanted in 19 dogs to replace the inferior vena cava. During the observation period of 30 days (6 dogs) to 210 days (8 dogs), three thromboses and one partial thrombosis of the graft were observed. (Permeability rate = 78.9%.) The permeability was determined by phlebography. Histologic results after 30 days: Development of a neointima with collagen type III, originating from the anastomoses; after 90 days: continuous endothelial layer on the inner surface of the graft; after 150-210 days: continous endothelial layer of the graft, appearance of smooth muscle fibers in the neointima. Resorption of the bovine collagen from the graft-bed and replacement by new collagen type III fibers.ZusammenfaBungEine bovine Kollagenprothese wurde im Vena cava inferior-Segment des Hundes 19mal implantiert. Bei einer Nachbeobachtungszeit von 30 (6 Tiere) bis zu 210 Tagen (8 Tiere) zeigte sich 3mal eine Thrombose, und Imal eine Teilthrombose der Prothese (Durchgängigkeitsquote = 78,9%o). - Durchgängigkeitskontrolle mittels Phlebographie. - Histologischer Befund nach 30 Tagen: Aufbau einer Neointima mit Kollagen III, von den Anastomosen ausgehend. - 90 Tage: Durchgehende Abdeckung der Prothesenoberfläche = durchgehender Endothelbelag. -150–210 Tage: Durchgehende Endothelbedeckung des Interponats, Auftreten glatter Muskelfasern in der Neointima. - Abbau des Prothesenkollagens vom Implantatlager her und Ersatz durch neugebildete Kollagenfasern III.

Coronary and Contractile Reserve in the Dog Heart with Chronic Multiple Coronary Occlusions Before and After Aortocoronary Bypass

Peak isovolumetric left ventricular pressure and dp/dtmax before and after norepinephrine (N.E.) infusion and cross-clamping of the aorta was identical in normal dogs and in dogs with chronic coronary artery occlusion (C.C.O.) before and after aortocoronary bypass. In normal dogs, coronary reserve was 7.9 and 7.4 times control for the subendocardium and the subepicardium. After C.C.O., coronary reserve was 7.0 and 5.7 times control in the normal area and 2.4 and 3.5 times control in the collateral dependent area (endo vs. epi). After N.E. myocardial blood flow increased to 57% of the coronary reserve in normal dogs, and to 100% in dogs with C.C.O. After bypass, myocardial blood flow normalized. In dogs with C.C.O., N.E. stimulated the contractile reserve maximally and the coronary reserve is completely expended.

Programmierbare Schrittmacher und myokardiale Schraubelektroden. Zwei neue Gesichtspunkte in der Schrittmacherbehandlung

Das neue Omnicor-Schrittmacher-System (Fa. Cordis) ermoglicht such nach der Implantation jederzeit die Veranderung von Schrittmacherfrequenz und Impulsstromstarke. Seit Oktober 1972 wurden an der Giesener Chir. Univ.-Klinik 110 dieser Omnicor-Schrittmacher implantiert. In samtlichen Fallen konnte die Ausgangsleistung der Schrittmacher deutlich reduziert werden. Seit Juni 1973 wurden 50 Schrittmacher mit einer myokardialen Schraubelektrode (Fa. Medtronic) kombiniert. Die Implantation dieser Elektrode ist problemlos and zeitsparend, die Reizschwellenwerte sind sehr gunstig.