Impaired Poststenotic Aortic Pulsatility After Hemodynamically Ideal Coarctation Repair in Children

Using echocardiographic quantification of aortic pulsatility distal to the site of the surgical anastomosis, we evaluated whether the preoperatively impaired poststenotic aortic pulsatility returned to normal after repair of coarctation with a hemodynamically ideal result. Patients who underwent repair of aortic coarctation without residual obstruction were compared to a matched group of normal children. A standardized M-mode echocardiographic evaluation of the aorta at the diaphragmatic level was performed for all patients. Measurements consisted of maximum and minimum aortic diameters, time intervals, and a calculated pulsatility index. Compared to normal children (n = 19), 20 children with operated coarctation and with a hemodynamically ideal result showed a significantly smaller increase in aortic diameter in systole (mean of 29 ± 7% in patients versus 37 ± 7% in normals; p < 0.01). In contrast to patients with coarctation in whom the maximum aortic distension is reached much later during the cardiac cycle, hemodynamically normalized, operated patients in our study had no such delay (maximum aortic pulsation at 28% of cardiac cycle time compared to 27% in normals; p = not significant). The pulsatility index of the poststenotic aorta was clearly lower in operated children (mean, 130 ± 50%/sec) compared to a normal mean value of 202 ± 33%/sec but was still significantly higher than that in patients with unoperated coarctation, who showed a low mean value of 51 ± 24%/sec (p < 0.01). After correction of aortic coarctation with a hemodynamically ideal result, the pulsatility of the poststenotic aorta, severely impaired prior to repair, did not return to normal during the observation period in the patients studie

Poplitealaneurysma

Zusammenfassung: Das Poplitealaneurisma (PA) ist eine typische Erkrankung von Männern über 65 Jahren, bei denen häufig Aneurysmen der Aorta, der iliacalen, femoralen und kontralateralen Poplitealarterie vorkommen. Als Ursache des Poplitealaneurysmas (PA) werden prioritär die Degradation durch Matrixmetalloproteinasen, eine entzündliche Reaktion mit Bildung von reaktiven Sauerstoffradikalen sowie der oxidative Stress in der Arterienwand postuliert. Zwei Drittel der Patienten kommen wegen Symptomen zum Chirurgen, die übrigen wegen eines Zufallsbefundes oder weil bereits die Gegenseite operiert wurde. Die akute und chronische Ischämie mit ihrer hohen Morbidität stehen im Vordergrund. Asymptomatische PA sollten ab einem Durchmesser von 2cm therapeutisch angegangen werden, besonders wenn sie partiell thrombosiert sind. Zur Diagnostik reicht eine Duplexuntersuchung. Die digitale Subtraktionsangiographie ist die wichtigste Untersuchung für die Operationsplanung. Lokalisierte Befunde, die auf die Kniekehle begrenzt sind, können von dorsal, langstreckige PA müssen durch einen Zugang von medial mit einem Interponat überbrückt werden. Dabei ist eine autologe Vene dem Kunststoffinterponat vorzuziehen. Im Fall eines Veneninterponates oder -bypasses kann mit einer Offenheitsrate von 85% nach 5Jahren gerechnet werden. Endografts sollen nur ausnahmsweise oder im Rahmen von Studien eingesetzt werde

Die endovaskuläre Ausbildung für Gefäßchirurgen an der Universitätsklinik Bern

Zusammenfassung: Die technische Entwicklung im Bereich von Katheterinterventionen hat auch zunehmenden Einfluss auf das Tätigkeitsfeld der Gefäßchirurgen. Im Operationssaal werden häufiger additive Katheterinterventionen oder Kombinationsverfahren, auch Hybrideingriffe genannt, durchgeführt. Dies setzt zwingend kathetertechnische Fertigkeiten voraus. Deshalb werden an der Klinik und Poliklinik für Herz- und Gefäßchirurgie in Bern in Zusammenarbeit mit interventionell tätigen Angiologen und Radiologen die Gefäßchirurgen in kathetertechnischen Interventionen trainiert. Katheterinterventionen zwingen dazu, die technische Ausrüstung des Operationssaals laufend anzupassen und die Schulung des Assistenzpersonals zu förder

Rat Heterotopic Heart Transplantation Model to Investigate Unloading-Induced Myocardial Remodeling

Unloading of the failing left ventricle in order to achieve myocardial reverse remodeling and improvement of contractile function has been developed as a strategy with the increasing frequency of implantation of left ventricular assist devices (LVADs) in clinical practice. But, reverse remodeling remains an elusive target, with high variability and exact mechanisms still largely unclear. The small animal model of heterotopic heart transplantation in rodents has been widely implemented to study the effects of complete and partial unloading on cardiac failing and non-failing tissue to better understand the structural and molecular changes that underlie myocardial recovery not only of contractile function.We herein review the current knowledge on the effects of volume-unloading the left ventricle via different methods of heterotopic heart transplantation in rats, differentiating between changes that contribute to functional recovery and adverse effects observed in unloaded myocardium. We focus on methodological aspects of heterotopic transplantation, which increase the correlation between the animal model and the setting of the failing unloaded human heart. Last, but not least, we describe the late use of sophisticated techniques to acquire data, such as small animal MRI and catheterization, as well as ways to assess unloaded hearts under reloaded conditions.While giving regard to certain limitations, heterotopic rat heart transplantation certainly represents the crucial model to mimic unloading-induced remodeling of the heart and as such the intricacies and challenges deserve highest consideration. Careful translational research will further our knowledge of the reverse remodeling process and how to potentiate its effect in order to achieve recovery of contractile function in more patients

Administration of Steroids in Pediatric Cardiac Surgery: Impact on Clinical Outcome and Systemic Inflammatory Response

Cardiopulmonary bypass (CPB) is associated with a systemic inflammatory response. Pre-bypass steroid administration may modulate the inflammatory response, resulting in improved postoperative recovery. We performed a prospective study in the departments of cardiovascular surgery and pediatric intensive care medicine of two university hospitals that included 50 infants who underwent heart surgery. Patients received either prednisolone (30 mg/kg) added to the priming solution of the cardiopulmonary bypass circuit (steroid group) or no steroids (nonsteroid group). Clinical outcome parameters include therapy with inotropic drugs, oxygenation, blood lactate, glucose, and creatinine, and laboratory parameters of inflammation include leukocytes, C-reactive protein, and interleukin-8. Postoperative recovery (e.g., the number, dosage, and duration of inotropic drugs as well as oxygenation) was similar in patients treated with or without steroids when corrected for the type of cardiac surgery performed. After CPB, there was an inflammatory reaction, especially in patients with a long CPB time. Postoperative plasma levels of interleukin-8 were correlated with the duration of CPB time (r = 0.62, p < 0.001). Administration of steroids had no significant impact on the laboratory parameters of inflammation. Administration of prednisolone into the priming solution of the CPB circuit had no measurable influence on postoperative recovery and did not suppress the inflammatory respons

Different techniques of distal aortic repair in acute type A dissection: impact on late aortic morphology and reoperation

Objective: To compare three different techniques of distal aortic repair in acute type A (de Bakey type I) aortic dissection and to evaluate their impact on the late morphology of the aortic arch and descending aorta and on the incidence of reoperation. Methods: From 65 patients operated on due to an acute type A aortic dissection between 1989 and 1993, 54 long-term survivors underwent clinical and radiologic follow-up examination after a mean postoperative interval of 62±16 months. The surgical techniques of distal aortic reconstruction included closed repair using Teflon felt reinforcement under moderate hypothermic cardiopulmonary bypass (n=20) and open repair in deep hypothermic circulatory arrest using either Teflon felt reinforcement (n=16) or gelatin-resorcin-formaldehyde (GRF) glue (n=18) to readapt the dissected aortic layers. In all patients, MR imaging was performed on a 1.5-T whole body imaging system for the evaluation of the morphology and function of the heart, aorta and supraaortic branches. Results: Overall hospital mortality following surgical repair of type A aortic dissection was 15.4% during this time period. The highest rate of persistent false lumen perfusion (17/20, 85%) and presence of an intimal flap in the aortic arch (13/20, 65%) was observed in patients following closed repair of acute ascending aortic dissection, whereas the lowest rate of such findings was demonstrated in patients who had undergone open distal aortic repair using biological glue (false lumen perfusion 10/18, 55% and intimal flap in the arch 2/18, 11%). Redo-surgery was significantly reduced in the open repair group using GRF glue (1/18, 5.5%) as compared with the Teflon felt repair group (3/16, 18%) and the closed repair group (6/20, 30%). Conclusions: In patients with acute type A dissection, open distal aortic repair using GRF-glue favourably influences both (1) the severity of late morphologic alterations in the downstream aorta and (2) the incidence of reoperatio