Surgical and mechanical support of the failing heart

The surgical treatment of acute heart failure is limited to cases of pressure or volume overload. Acute valvular regurgitation due to active endocarditis or to prosthetic dysfunction is a classic example of failure which can be cured by restoring valvular competence. Acute pressure load is mostly caused by prosthetic dysfunction or pulmonary embolism; therapy is aimed at removal of the causative agent. Coronary heart disease can cause heart failure by volume overload: acute mitral incompetence or ventricular septal defect lend themselves to surgical correction. In the surgical treatment of acute heart failure maximal attention is devoted to optimal timing of surgery, anesthetic management and postoperative care. Careful attention to the function of the right and left ventricle and combination of catecholamines, afterload reducing agents and volume loading together with respirator support have considerably improved the surgical results. Acute pump failure due to coronary insufficiency and infarction is less amenable to surgical treatment, with rare exceptions of emergencies during coronary angiography and percutaneous dilatation. The intra-aortic balloon pump is the only method of mechanical circulatory assistance which has reached widespread clinical acceptance. The best results are achieved in conjunction with surgery: either as cardiac support in inherently reversible postoperative heart failure or as the means of circulatory stabilization prior to surgery. Ventricular assist devices are still in the experimental stage: their use has been sharply curtailed by the virtual disappearance of the postoperative low output syndrome. In selected cases of end-stage cardiomyopathy cardiac transplantation is nowadays performed with acceptable survival (7O% at one year after surgery). Both orthotopic and heterotopic transplantation (transplanted heart in parallel with the natural one) give comparable results, but the procedure is still very restricted due to the lack of donors, multiple contraindications and lack of suitable heart preservation technique

Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy

Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstructive cardiomyopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echocardiograms showed that postoperatively there was a significant reduction of septal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappearance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals > 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile parameters and little reduction of left ventricular hypertrophy. In 4of 12 patients evaluated > 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of leftventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavit

"Quantities, Units and Symbols in Physical Chemistry"; "Fundamentals of Thin Layer Chromatography (Planar Chromatography)"

A) I. Miles, T. Cvitaš, K. Homann, N. Kallay, K. Kuchitsu: Quantities, Units and Symbols in Physical Chemistry (Review by M. Brezinšćak) B) Friedrich Geiss: Fundamentals of Thin Layer Chromatography (Planar Chromatography) Osnove tankoslojne kromatografije (Plošna kromatografija) (Review by Srećko Turina

Valve replacement in octogenarians: increased early mortality but good long-term result

Between January 1983 and December 1990, 20 patients aged 80 years or older underwent valvular surgery. The patients' ages varied from 80 to 87 years (mean, 82 ± 1.5 years). The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective, two urgent, and three emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. Six patients (30%) had an uneventful hospital stay, and the other 14 (70%) experienced several post-operative complications. The operative mortality rate was 15± (three patients). All patients before operation were in NYHA (New York Heart Association) class III and IV and all survivors remained in NYHA class I or II. The survivors have been followed from 6 to 70 months (mean 20 ± 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement in octogenarians can be performed, despite the high rate of post-operative complications, with increased but acceptable mortality. Long-term results are goo

Isolated aortic valve replacement with the Björk-Shiley tilting disc prosthesis and the porcine bioprosthesis

Between 1977 and 1978, 239 patients underwent aortic valve replacement with either a bioprosthesis (100, BIO) or a Björk-Shiley tilling disc prosthesis (139, BS). Early mortality was 2%, late mortality 4%. There was no statistically significant difference between the two groups. Anticoagulation was maintained indefinitively in patients with a BS, after implantation of a BIO only for three months except in the presence of atrial fibrillation or a history ofeinboli. Thromboembolic complications and anticoagulant hemorrhages were almost twice as frequent in patients with BS than with BIO (5.3 versus 2.8 episodes/100 patient years). This difference however is statistically not significant. There were an equal number (two) of reoperations because of paravalvular leaks due to endocarditis or torn sutures in the two groups. A regurgitant murmur, though hemodynamically not significant, occurred more frequently in patients with BIO than with BS (10% versus 2%, P < 0.05). Its cause and importance cannot yet be determined. Postoperative results judged by the NYHA classification and reduction of heart size were similar in both groups. Of all patients, 13% with preoperative valvular incompetence and 15% with stenosis showed little or no reduction of the cardiothoracic ratio on X-ray indicating a worse long-term prognosis. The porcine BIO has become our preferred valvular substitute because of its low thromboembolic complication rate. The BS is mainly reserved for patients already on anticoagulants for other reaso

Long-term outcome after traumatic anterior dislocation of the hip

Introduction: Traumatic anterior dislocation of the hip joint is rare. Additional injuries to the hip due to dislocation are even more infrequent. Outcome is limited by osteoarthritic joint degeneration or the occurrence of avascular necrosis of the femoral head. Method: Anterior hip dislocation occurred in ten of 100 patients with traumatic hip dislocations (8 men, mean age: 43, 22-62years) at two major trauma centres, between January 2001 and December 2008. Four patients had impaction fractures of the femoral head and three patients had fractures of the anterior acetabular wall. One patient presented with an open dislocation. In three of the ten patients surgical treatment was necessary. Results: Nine patients were evaluated retrospectively at a follow-up of 4.8±2.3years (mean±SD). The mean scores were 88±19 (Harris Hip-Score), 15±23 (WOMAC-Score), level 6 (UCLA-Score). Four cases presented with only fair clinical or radiological results according to Epstein. AVN with collapse of the femoral head was observed in one. Conclusion: Traumatic anterior hip dislocations presented in six of the ten cases with additional injuries to the hip. Surgical treatment in cases with deep impaction fractures of the femoral head or with large fragments of the acetabulum may improve the outcom

Long-term follow-up of medical versus surgical therapy for hypertrophic cardiomyopathy: A retrospective study

In a retrospective analysis 139 patients with hypertrophic cardiomyopathy were followed up for 8.9 years (range 1 to 28 years). Patients were divided into two groups: Group 1 consisted of 60 patients with medical therapy and Group 2 of 79 patients with surgical therapy (septal myectomy). Groups 1 and 2 were subdivided according to the medical treatment. Group la received propranolol, 160 mg/day (n = 20); Group lb verapamil, 360 mg/day (n = 18); and Group 1c, no therapy (n = 22). Group 2a received verapamil, 120 to 360 mg/day, after septal myectomy (n = 17) and Group 2b had no medical therapy after surgery (n = 62).In Group 1, 19 patients died (annual mortality rate 3.6%) and in Group 2,17 patients died (mortality rate 2.4%, p = NS). Of the patients who died, approximately one half to two thirds in both Groups 1 and 2 died suddenly and the other one half to one third died because of congestive heart failure. The 10 year cumulative survival rate was 67% in Group 1, significantly smaller than that in Group 2 (84%, p < 0.05). In the subgroups, the 10 year survival rate was 67% in Group la, 80% in lb (p < 0.05 versus la) and 65% in lc (p < 0.05 versus 1b). The 10 year survival rate was 100% in Group 2a (p < 0.05 versus la, lb, 1c) and 78% in Group 2b (p < 0.05 versus 2a).It is concluded that cumulative survival rate is significantly better in surgically than in medically treated patients. However, the survival rate among medically treated patients was better in those treated with verapamil than in those treated with propranolol or in untreated patients. The 10 year survival rate was similar in the medically treated patients receiving verapamil (80%) and the entire surgically treated group (84%, p = NS). The most favorable outcome was observed in surgically treated patients receiving long-term therapy with verapamil, probably as a result of the reduction of systolic pressure overload by septal myectomy and improvement in left ventricular diastolic function mediated by verapamil

Evolution of antimicrobial prophylaxis in cardiovascular surgery

Objective: To examine the optimal duration of antibiotic prophylaxis in major cardiovascular surgery. Methods: In the past 15 years, four prospective randomized, controlled studies, conducted by the same group of authors, compared seven prophylactic antimicrobial regimens in 2970 patients undergoing major cardiovascular surgery. In 1980/81, a 4-day cefazolin (CFZ) prophylaxis was compared with a 2-day cefuroxime (CFX) administration (n=566). In 1982/83, a 2-day CFX prophylaxis was compared with a two shot ceftriaxone (CRO) prophylaxis (n=512). In 1984/87, a 1-day CFZ prophylaxis was compared with a single shot prophylaxis of CRO (n=883). In 1994/1995, a 4 day combination of amoxicillin (AM) and netilmicin (NET) prophylaxis was compared with a single shot prophylaxis of CFX (n=1009). Results: Total infection rate varied between 4.5 and 5.7%, despite different antimicrobial regimen used and their varying duration. Wound infection rate was 1.1% (range 0.4-2.5%), sepsis rate was 0.8% (range 0.4-1.6%), pneumonia rate 2% (0.7-2.9%), urinary tract infection rate 0.4% (range 0-1.4%), and central venous catheter-related infection rate was 0.4% (0-1%). The 30-day mortality rate was 1.3% (range 0.4-2%). All these differences were not statistically significant. Conclusions: A low infection rate (range 4.5-5.7%) occurred despite changes in duration of various prophylactic antibiotic regimen with cephalosporins of first, second or third generation. As a single shot prophylaxis could nowadays successfully be used in cardiovascular surgery, no postoperative antibiotics should be used, unless an intraoperative or a postoperative infection is documented or in presence of major perioperative complication