RESUMEN

BACKGROUND: Pulmonary paraganglioma is a very rare condition with 40 cases reported in the literature. In the vast majority of cases the correct diagnosis could not be yielded preoperatively. CASE PRESENTATION: We report a case of paraganglioma of the lung. Computed tomographic scan showed a solitary pulmonary nodule. Diagnostic thoracotomy was performed and a tumor in the left lower lobe was resected. Frozen section evaluation showed an epithelial tumor with neuroendocrine differentiation and low grade features. Accordingly, lobectomy was performed. The study of the paraffin-embedded specimen yielded furthermore a neuroendocrine differentiated tumor, but mitotic figures were rare. Immunhistochemically the final diagnosis paraganglioma was made. CONCLUSION: In patients with pulmonary paraganglioma, the correct preoperative diagnosis is in general not available. Solitary pulmonary nodules or minor tumors of unknown histology are resected by wedge resection and sent to frozen section evaluation. Frozen section evaluation results in the diagnosis neuroendocrine tumor with more or less mitoses and mostly specified as carcinoid tumor. According to the literature biologic behaviour of carcinoid tumor and pulmonary paraganglioma is similar and thus the incorrect result of frozen section evaluation leads to a correct resection mode. If frozen section evaluation shows low grade features, surgical overtreatment may occur.

Asunto(s)

Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Paraganglioma/patología , Paraganglioma/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Resultado del Tratamiento

RESUMEN

This retrospective study evaluates our experience with clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass. Twenty-three of 3,600 consecutive patients suffered from splanchnic malperfusion. Symptoms developed between day 2 and 6 postoperatively in 18 of 23 patients. Four of 23 patients had no abdominal symptoms. Laboratory evaluation revealed significantly higher serum lactate and creatine phosphokinase levels in the 18 symptomatic patients compared with those of a control group. Arteriography was performed in 20 cases and revealed nonocclusive splanchnic hypoperfusion. Risk factors for development of mesenteric ischemia include arrhythmias and low cardiac output. Patients with angiographically proven nonocclusive mesenteric ischemia were treated with intra-arterial bolus injection and subsequent intra-arterial infusion of tolazoline combined with heparin sodium. The overall mortality rate was 30% (7 of 23). Infusion therapy with tolazoline and heparin seems to be a successful treatment modality for clinically diagnosed mesenteric ischemia.

Asunto(s)

Puente Cardiopulmonar/efectos adversos , Isquemia/etiología , Mesenterio/irrigación sanguínea , Anciano , Puente Cardiopulmonar/métodos , Combinación de Medicamentos , Femenino , Hemodinámica , Heparina/uso terapéutico , Humanos , Isquemia/diagnóstico , Isquemia/tratamiento farmacológico , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Factores de Riesgo , Tolazolina/uso terapéutico , Vasodilatadores/uso terapéutico

RESUMEN

UNLABELLED: Patients with significant risk factors are at increased risk of higher mortality and morbidity (9-16%) after CABG-procedures with cardiopulmonary bypass (CPB). When catheter interventions are not applicable and conventional CABG with CPB are considered to have an unacceptable perioperative risk, these patients (n=35) were scheduled for minimally invasive coronary artery bypass grafting (MIDCAB). PATIENTS AND METHODS: The risks leading to exclusion of conventional CABG procedures were: extremely impaired LV-function (EF<20%), severe pulmonary diseases, malignant carcinoma, compromised coagulation system, age >80 years with impaired physical constitution, redo-procedures after complicated initial operation, symptomatic descending thoracic aortic aneurysm, ongoing long-term intensive care treatment with unclear prognosis. All patients received the LIMA as a single graft to the LAD. One year follow-up was performed using transthoracic Doppler echocardiography at rest and during exercise. RESULTS: In 20 patients incomplete revascularization was accepted. There was no mortality, while signs for myocardial infarction were seen in two patients. Twenty-nine patients (82%) showed clear improvement of clinical symptoms, one patient needed further conventional CABG. Nine to thirteen months postoperatively (mean 10.8+/-1.6 months), there were two deaths due to noncardiac reasons. Three of the survivors (n=33) had symptoms of angina pectoris. Exercise tests revealed an improved stress tolerance (NYHA class improved from preop. III-IV to postop. I-II). The IMA graft flow increased significantly with exercise in all patients. Flow patterns in both flow velocity and volume changed to diastolic-dominant, and the ratio of diastolic to systolic time-velocity integral of >1.5 excluded a graft stenosis. CONCLUSIONS: In high-risk patients, with an increased likelihood of perioperative morbidity and mortality, the MIDCAB procedure can be performed accurately and safely. Even after incomplete revascularization of some high-risk patients, exercise tolerance was improved. Transthoracic Doppler echocardiography proved to be a clinically useful noninvasive method of assessing IMA graft function at rest and during exercise. Despite the small patient population, our late follow-up results suggest the potential benefit of MIDCAB for patients with otherwise inoperable heart disease.

Asunto(s)

Anastomosis Interna Mamario-Coronaria/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Anciano , Anciano de 80 o más Años , Contraindicaciones , Puente de Arteria Coronaria , Ecocardiografía Doppler , Prueba de Esfuerzo , Tolerancia al Ejercicio , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Microvascular incompetence after ischemia and reperfusion may compromise the normal postischemic coronary perfusion and additionally jeopardize the recovery of the myocytes. We investigated whether such a form of acute endothelial dysfunction occurs in the routine operative setting despite the use of protective measures. For this purpose, we measured pressure-flow relations in the coronary vasculature during heart operations before and after ischemia and after reperfusion and their reaction to the nitric oxide donor nitroglycerin. METHODS: Forty-eight patients with a low risk profile scheduled for routine coronary artery bypass surgery were included. During normothermic extracorporeal circulation, the fibrillating heart was completely excluded from bypass by clamping of the ascending aorta and snaring of the caval veins. It was relieved of blood by opening the right atrium and venting the left atrium and ventricle to avoid distention. The coronary vessels were perfused under controlled flow, and the perfusion pressures were monitored. This protocol was performed in 24 patients before and immediately after ischemia and after a reperfusion period. RESULTS: Compared with the preischemic control, vascular resistance was decreased by 17% (P <.003) immediately after ischemia but increased again by 46% (P <.0001) during an average of 25 minutes of reperfusion and, even more important, by 23% (P <.028) in comparison with the preischemic values. In two groups of 12 patients, nitroglycerin was added to the perfusate either in a dosage of 3 microg. kg. min(-1) or as a bolus injection of 2 mg. Low-dose nitroglycerin did not reduce the elevated postreperfusion resistances significantly, but bolus injection did (P <.0002). Coronary vessel resistance increased during reperfusion in particular in patients with a history of hypertension. CONCLUSION: Coronary vasoconstriction during postischemic reperfusion is regularly present in the routine operative setting in cardiac surgery, despite myocardial protection measures. The amount of vasoconstriction varies considerably and is particularly increased in patients with hypertension. The nitric oxide donor nitroglycerin can normalize the elevated resistances, but only in high dosages. This demonstrates a preserved ability of vascular smooth muscle to relax. The phenomenon had no sequelae in our low-risk patients having elective operations. However, it may gain significance in the case of severe left heart hypertrophy and in patients at risk with both a postoperative low-output syndrome and reduced mean arterial pressures during reperfusion.

Asunto(s)

Vasos Coronarios/fisiopatología , Daño por Reperfusión Miocárdica/fisiopatología , Reperfusión Miocárdica , Donantes de Óxido Nítrico/uso terapéutico , Nitroglicerina/uso terapéutico , Resistencia Vascular/fisiología , Vasodilatadores/uso terapéutico , Anciano , Soluciones Cardiopléjicas , Estudios de Casos y Controles , Puente de Arteria Coronaria , Femenino , Hemodinámica/fisiología , Humanos , Masculino , Perfusión , Compuestos de Potasio , Estudios Prospectivos

RESUMEN

OBJECTIVE: The cytokine vascular endothelial growth factor (VEGF) is capable of triggering angiogenesis and at higher concentrations vasculogenesis. We report on a pilot study where VEGF-DNA as an additional therapy to coronary artery bypass grafting was injected into the myocardium in 24 patients (pts) with proximal coronary artery stenosis and diffuse peripheral disease. One region of the myocardium with proven ischemia remained unsupplied after surgery because the respective epicardial coronary artery was not graftable. METHODS AND RESULTS: Plasmid DNA encoding for the 165- and 167-amino acid isoform of the human VEGF genes was injected directly into the myocardium, not amenable to surgical revascularization at a dosage of 1000 microg each, using a standardized protocol. A (99m)Tc-sestamibi-SPECT at rest performed 7 days prior to the operation, had shown decreased marker activity in the region of interest. Controls were made 1 week and 80-100 days postoperatively. Transmural scarring was ruled out intraoperatively. Coronary and left ventricular angiographies were performed preoperatively and 3 months postsurgery, respectively. One or more of the following angiographic items were found in 16/24 patients postoperatively. (1) Improvement of regional left ventricular function at the VEGF treated myocardial sector (5/24 pts). (2) Newly visible vessels considered as collaterals (8/24 pts). (3) Earlier filling of parent vessels (6/24 pts). (4) An increase in diameter of preoperatively existing collateral vessels (7/24). An increased perfusion at rest in the region of gene application was detected in 3/24 patients by early postoperative (99m)Tc-sestamibi-SPECT investigation. In six additional cases, local perfusion increased markedly until the late examination. No perioperative myocardial infarctions and no signs of inflammation were observed. Newly developed abnormal vasculature was not detected in any patient. CONCLUSIONS: Direct intramyocardial administration of VEGF(165)-DNA and VEGF(167)-DNA may result occasionally in an enhancement of collateral vascularization in regions with diffuse peripheral coronary artery disease not surgically amenable. During midterm follow-up no adverse effects of VEGF-DNA application are observed so far. The very slight midterm improvements caused us to stop further VEGF-DNA application and, in our opinion, do not justify a prospective, and randomized study with a control group.

Asunto(s)

Enfermedad Coronaria/terapia , Factores de Crecimiento Endotelial/genética , Terapia Genética/métodos , Linfocinas/genética , Revascularización Miocárdica , Anciano , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , ADN/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Cintigrafía , Tecnecio Tc 99m Sestamibi , Resultado del Tratamiento , Factor A de Crecimiento Endotelial Vascular , Factores de Crecimiento Endotelial Vascular

RESUMEN

OBJECTIVE: A compromised blood flow after ischemia and reperfusion caused by an increased coronary artery resistance can additionally jeopardize the recovery of myocytes. During routine bypass operations, we investigated the effect of various nitroglycerin doses on elevated coronary resistance before and after ischemia and after a defined reperfusion period. METHODS: 46 patients with a low-risk profile scheduled for routine coronary artery bypass grafting were investigated. During normothermic total extracorporeal circulation, the completely relieved and fibrillating heart was completely isolated from the systemic circulation and the coronary artery system was perfused at 300 ml/min and flow-controlled. The perfusion pressures were monitored continuously. This protocol was performed at three time points: I. Control (ctr) = 10 minutes after institution of extracorporeal circulation, II. Early reperfusion (early rep) = immediately after an myocardial ischemia of 46 +/- 8 minutes, and III. Late reperfusion (late rep) = after a reperfusion period of 25 +/- 4.5 minutes. In 12 randomly chosen patients in a second step, 3 microg per kg heart weight per min of nitroglycerin (low-dose NTG) was added to the perfusate at time points I and III. In another 12 patients, we applied a bolus injection of 2 mg into the aortic root instead of low-dose NTG. RESULTS: Compared to ctr, vascular resistance had decreased at early rep by 17% (0 - 48%) (p < 0.005). At late rep, resistance had increased by 46% (5 - 94%) (p < 0.001) compared to early rep and by 23% (3 - 36%) (p < 0.005) compared to ctr. Resistances had risen in particular in patients with hypertension. Application of low-dose NTG lowered resistances by 5% (0-8%) (non-significant) at ctr, and by 6% (0 - 11%) (non-significant) at late rep. Bolus NTG decreased resistances at ctr by 11% (2 - 21%) (p < 0.05) and at late rep by 21% (6 - 48%) (p < 0.01). CONCLUSIONS: In routine heart surgery, coronary vascular constriction is regularly present during postischemic reperfusion despite myocardial protection measures. NTG abolishes this coronary vascular stunning only in part if systemically applicable dosages are given. High-dose intracoronary application of NTG relieves the coronary vasoconstriction completely, but the dosages needed cannot be applied systemically. In this study, vasoconstriction after reperfusion was markedly increased in patients with hypertension.

Asunto(s)

Puente de Arteria Coronaria/métodos , Reperfusión Miocárdica/métodos , Aturdimiento Miocárdico/prevención & control , Nitroglicerina/administración & dosificación , Anciano , Vasos Coronarios/efectos de los fármacos , Femenino , Humanos , Hipertensión/complicaciones , Masculino , Estudios Prospectivos , Resistencia Vascular/efectos de los fármacos , Vasoconstricción/efectos de los fármacos

RESUMEN

Here, we will report on a 63-year-old patient with a centrally located squamous cell carcinoma of the left lung with complete atelectasis and tumor infiltration into mediastinal pleura and fat. A known coronary two-vessel disease, which became highly symptomatic during the operation made a change of the planned surgical strategy necessary.

Asunto(s)

Carcinoma de Células Escamosas/cirugía , Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Neoplasias Pulmonares/patología , Neoplasias del Mediastino/cirugía , Neoplasias Pleurales/cirugía , Neumonectomía/métodos , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/secundario , Puente Cardiopulmonar , Terapia Combinada , Puente de Arteria Coronaria/instrumentación , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/diagnóstico , Humanos , Masculino , Neoplasias del Mediastino/complicaciones , Neoplasias del Mediastino/diagnóstico , Neoplasias del Mediastino/secundario , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Pleurales/complicaciones , Neoplasias Pleurales/diagnóstico , Neoplasias Pleurales/secundario , Neumonectomía/instrumentación , Atelectasia Pulmonar/etiología , Tomografía Computarizada por Rayos X

RESUMEN

OBJECTIVE: To assess the effects of lung oxygenation and ventilation vs. lung collapse on pulmonary markers of lung hypoxia. DESIGN: A prospective, nonrandomized, nonblinded comparative study. SETTING: University department of anesthesiology and cardiothoracic surgery. SUBJECTS: Twelve adult patients undergoing coronary bypass grafting requiring total cardiopulmonary bypass. INTERVENTIONS: Single lung ventilation during total cardiopulmonary bypass (tidal volume, 150 mL; respiratory rate, 6 breaths/min; inspiratory oxygen fraction, 0.5) while the contralateral lung was allowed to collapse completely without oxygenation. MEASUREMENTS AND MAIN RESULTS: At the beginning and at the end of total cardiopulmonary bypass (duration, 59-65 mins), blood was aspirated from the right and left pulmonary veins and the radial artery for measurement of blood gases and concentrations of endothelin-1, big-endothelin, thromboxane B2, lactate, and lactate dehydrogenase. Nonventilation during total cardiopulmonary bypass compared with ventilation resulted in lower pulmonary venous P(O2) values (57+/-15 torr [7.6+/-2.0 kPa] vs. 103+/-23 torr [13.7+/-3.1 kPa]) and higher thromboxane B2 concentrations (488+/-95 pg/mL vs. 434+/-92 pg/mL). The concentrations of endothelin-1, big-endothelin, lactate, and lactate dehydrogenase in the pulmonary veins did not differ significantly between nonventilated and ventilated lungs. CONCLUSIONS: Development of pulmonary tissue hypoxia during 1 hr of nonventilation and cardiopulmonary bypass with completely inhibited pulmonary arterial blood flow is unlikely, suggesting that enough oxygen is stored in or is provided to the collapsed lung. Thus, nonventilation during total cardiopulmonary bypass does not appear to contribute to postoperative respiratory dysfunction by causing pulmonary tissue hypoxia. These results, however, do not exclude that mechanical factors of ventilation might benefit the lung during cardiopulmonary bypass.

Asunto(s)

Dióxido de Carbono/sangre , Puente Cardiopulmonar , Puente de Arteria Coronaria , Cuidados Críticos , Hipoxia/terapia , Pulmón/irrigación sanguínea , Oxígeno/sangre , Respiración Artificial , Adulto , Anciano , Femenino , Humanos , Hipoxia/diagnóstico , Masculino , Persona de Mediana Edad , Venas Pulmonares

RESUMEN

BACKGROUND: Autoantibodies against nervous system structures have been proven to be a prognostic factor in small cell lung cancer. However, little is known about humoral autoimmunity in non-small cell lung cancer (NSCLC) and its prognostic significance. METHODS: We examined antineural antibodies (AnAb) and antinuclear antibodies (ANA) in the sera of 61 patients with NSCLC (histologically: 29 adenocarcinoma, 32 squamous cell carcinoma). Twenty-one patients had stage I NSCLC, 11 stage II, and 29 patients stage III. Autoantibody detection was done by immunofluorescence test; Western blotting was used as a confirmation test. RESULTS: Of the NSCLC patients, 27.8% were antineural antibody positive, and 32.7% had ANA. No differences were found between the histological groups. AnAb-positive patients showed a better survival in all patients (p = 0.005). There was also a higher survival of ANA-positive patients, but this was only significant in stage III (p = 0.0025). Cox regression analysis showed that antineural and antinuclear antibodies are a stage-independent prognostic factor in NSCLC. CONCLUSIONS: Antineural and antinuclear autoantibodies are a stage-independent prognostic factor in patients with NSCLC and may represent an effective immune response to the tumor.

Asunto(s)

Anticuerpos Antinucleares/sangre , Autoanticuerpos/sangre , Carcinoma de Pulmón de Células no Pequeñas/inmunología , Cerebelo/inmunología , Neoplasias Pulmonares/inmunología , Adenocarcinoma/inmunología , Anciano , Biomarcadores de Tumor/sangre , Western Blotting , Carcinoma de Células Escamosas/inmunología , Femenino , Técnica del Anticuerpo Fluorescente Indirecta , Estudios de Seguimiento , Humanos , Masculino , Estadificación de Neoplasias , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Tasa de Supervivencia

RESUMEN

Malignancy frequently is accompanied by activated coagulation and fibrinolysis indicating a hypercoagulable state. The purpose of our study was to estimate the contribution of local tumor-induced mechanisms to the activation of hemostasis and fibrinolysis. In a prospective study, we compared the plasma levels of thrombin-antithrombin complexes, prothrombin fragment 1+2, and D-dimers in blood samples that simultaneously were drawn from the superior vena cava and the pulmonary vein of a tumor-bearing pulmonary lobe. Samples from the superior vena cava were drawn before operation and served as controls. After thoracotomy, a second group of samples was simultaneously taken from the pulmonary veins of the tumor-bearing lobe and the superior vena cava. Forty-five patients with pulmonary malignancies were included (25 adenocarcinomas and 20 squamous cell carcinomas). There were no significant differences of thrombin-antithrombin complexes, prothrombin fragment 1+2, and D-dimers levels in patients suffering from adenocarcinoma and from squamous cell carcinoma. Intraoperatively, prothrombin fragment 1+2 and D-dimers levels were markedly increased when compared with the preoperative values (p<0.0001). There was no increase of thrombin-antithrombin complexes levels due to the operative traumatization. Prothrombin fragment 1+2, thrombin-antithrombin complexes, and D-dimers plasma levels were significantly higher in the pulmonary venous blood than in the blood simultaneously drawn from the superior vena cava (p<0.0001). Our findings indicate that malignant lung tumors directly contribute to the activation of hemostasis and fibrinolysis in these clinical settings.

Asunto(s)

Fibrinólisis/fisiología , Hemostasis/fisiología , Neoplasias Pulmonares/sangre , Anciano , Antifibrinolíticos/sangre , Antitrombina III/análisis , Biomarcadores/sangre , Coagulación Sanguínea , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Humanos , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Fragmentos de Péptidos/análisis , Péptido Hidrolasas/análisis , Neumonectomía , Precursores de Proteínas/análisis , Protrombina/análisis , Venas Pulmonares/química , Venas Pulmonares/fisiología , Tasa de Supervivencia , Trombofilia , Vena Cava Superior/química

Asunto(s)

Procedimientos Quirúrgicos Cardíacos/métodos , Circulación Extracorporea , Deficiencia del Factor VII/tratamiento farmacológico , Factor VII/administración & dosificación , Complicaciones Intraoperatorias/prevención & control , Adulto , Estenosis de la Válvula Aórtica/cirugía , Enfermedad Coronaria/etiología , Enfermedad Coronaria/cirugía , Deficiencia del Factor VII/complicaciones , Deficiencia del Factor VII/congénito , Humanos , Masculino , Resultado del Tratamiento

RESUMEN

BACKGROUND: In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant. METHODS: Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed. RESULTS: In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones. CONCLUSIONS: A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

Asunto(s)

Trasplante de Corazón/economía , Programas Nacionales de Salud/economía , Preservación de Órganos/economía , Programas Médicos Regionales/economía , Obtención de Tejidos y Órganos/economía , Análisis Costo-Beneficio , Alemania , Humanos

RESUMEN

Lung cancer patients have been reported to have generalized immune dysfunction of the cell-mediated immune response. In contrast, little is known about the humoral immune function in these patients. Therefore, we examined the IgG subclass distribution (IgG1-lgG4) in 67 lung cancer patients (23 adenocarcinoma, 29 squamous cell carcinoma, 15 small cell carcinoma), 13 patients with inflammatory lung diseases, seven patients with pulmonary metastasis and 23 healthy controls using a commercial available ELISA. We found a significant increase in the percentage of IgG1 in adenocarcinoma, compared with squamous cell and small cell lung carcinoma (P < 0.05). Small cell lung cancer patients showed an increase in IgG2, IgG3 and IgG4 compared with all other groups (P < 0.05, respectively). IgG1/lgG2, IgG1/lgG3 and IgG1/lgG4 ratios in adenocarcinoma were higher than in small cell lung cancer (P < 0.05). In the squamous cell carcinoma there was no difference in IgG subclass distribution compared to controls. Our study demonstrates that the different histological subtypes of lung carcinoma influence the IgG subclass distribution. Whether this phenomenon is the result of a direct influence on B-cell activity by the tumor needs further investigation.

Asunto(s)

Inmunoglobulina G/sangre , Neoplasias Pulmonares/inmunología , Adenocarcinoma/inmunología , Adenocarcinoma/mortalidad , Anciano , Carcinoma de Células Pequeñas/inmunología , Carcinoma de Células Pequeñas/mortalidad , Carcinoma de Células Escamosas/inmunología , Carcinoma de Células Escamosas/mortalidad , Ensayo de Inmunoadsorción Enzimática , Humanos , Neoplasias Pulmonares/mortalidad , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Tasa de Supervivencia

RESUMEN

BACKGROUND: The sympathoadrenal and the renin-angiotensin system (RAS) are involved in blood pressure regulation. They are known to be activated during cardiac surgery. We investigated the influence of preoperative RAS-blockade using angiotensin-converting-enzyme inhibitors (ACEI) on hemodynamic variables and on the perioperative need for exogenous catecholamines. METHODS: 240 patients undergoing coronary artery bypass grafting (CABG) or valve surgery were divided into three matched groups (group A: pre- and postoperative ACEI; group B: ACEI only pre-, not postoperatively; group C: no ACEI). In these three groups we analyzed hemodynamic variables, the need for catecholamines and the incidence of a "post-perfusion syndrome" or systemic inflammatory response syndrome (SIRS) with impaired microcirculation. RESULTS: There were significant differences in the intra- and postoperative need for catecholamines in groups A and B compared to C (intraop. A: 35%, B: 35%, C: 15%; postop. A: 21.2%, B: 16.2%, C: 10%) (p < 0.05). In the ACEI groups (A and B) there were 9 patients with a postoperative SIRS, only 2 cases in group C. Furthermore 4 patients of group B suffered from disturbances of the intestinal microcirculation postoperatively. CONCLUSIONS: Long-term ACEI treatment before cardiac surgery raises the perioperative need for catecholamines. Patients with preoperative long-term use of ACEI who do not receive ACEI postoperatively face an increased risk of impaired microcirculation. The inhibition of angiotensin-II (AT II) generation causes the vasodilatatory effects of ACEI, and could be one reason for a post-perfusion syndrome or a SIRS.

Asunto(s)

Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Síndrome de Respuesta Inflamatoria Sistémica/fisiopatología , Humanos , Microcirculación , Persona de Mediana Edad , Perfusión , Cuidados Posoperatorios , Cuidados Preoperatorios , Síndrome

RESUMEN

OBJECTIVE: C-Reactive protein (CRP) is known to be a sensitive indicator of infection. Since it is also involved in the acute phase reaction, it is of great interest, whether an isolated preoperative increase of CRP without further signs of infection is of any prognostic value for postoperative outcome after cardiac surgery with cardiopulmonary bypass (CPB), which itself is possibly causing a systemic inflammatory response syndrome (SIRS). METHODS: Fifty patients with an isolated CRP-elevation (>5 mg/l) (from 6.2 to 93.3 mg/l) were operated using CPB (group A). A control group (group B) consisted of 50 cardiac surgery patients, matched in the patterns of age, gender and kind of disease. No preoperative CRP-elevation (from 0 to 4.8 mg/l) occurred in this group. RESULTS: The postoperative course of both groups showed significant differences. Septic complications were seen more often in group A (20%) than in the controls (2%) (P < 0.01). Microbiology (blood culture, cultures from nose, tracheal aspirate and urine) was positive only in 10% of these patients. Catecholamine support (epinephrine, norepinephrine and/or doses of dopamine or dobutamine of more than 3 microg/kg per min) was needed in 26% of group A cases, whereas it was only needed in 10% of group B (P < 0.05). A significantly longer respiratory support was also necessary in patients with elevated CRP (25.2 +/- 6.4 h vs. 6.6 +/- 0.8 h) (P < 0.01). Furthermore there was a significant difference in the duration of intensive care (4.6 +/- 0.8 days vs. 2.6 +/- 0.3 days) (P < 0.05). CONCLUSIONS: These data show that patients without apparent infection or inflammation, who had elevated CRP-values preoperatively, face an increased risk of septic complications after extracorporeal circulation. As microbiology tests are negative in most cases, it may be speculated that the majority of septic complications are due to a SIRS.

Asunto(s)

Proteína C-Reactiva/análisis , Puente Cardiopulmonar , Complicaciones Posoperatorias/diagnóstico , Sepsis/diagnóstico , Procedimientos Quirúrgicos Cardíacos , Femenino , Humanos , Masculino , Cuidados Posoperatorios , Pronóstico , Estudios Retrospectivos , Sepsis/etiología

RESUMEN

BACKGROUND AND AIMS OF THE STUDY: To investigate the influence of different surgical techniques of chordal preservation in mitral valve replacement (MVR) on left ventricular size and function, we studied a series of 244 patients who underwent mitral valve replacement either with (n = 161) or without (n = 83) preservation of the subvalvular structures. RESULTS: Preoperatively there were no differences between the two patient groups. Three months postoperatively, echocardiography demonstrated that chordal preservation in MVR resulted in smaller left ventricular end-systolic diameter (LVESD) and end-diastolic diameter (LVEDD): preservation versus resection, LVESD: 43.4 +/- 7.8 mm versus 48.8 +/- 9.2 mm (p < 0.05), LVEDD: 57.3 +/- 7.8 mm versus 62.9 +/- 10.5 mm (p < 0.05) and a significantly decreased LV-L (long axis) (87.1 +/- 4.2 mm versus 97.5 +/- 5.7 mm; p < 0.05). There was no significant difference in cardiac dimensions between the three patient subgroups in whom chordal preservation was possible. In addition, left ventricular ejection fraction in the preservation groups was significantly improved compared with the resection group (54.2 +/- 11.2% versus 48.1 +/- 12.4%, p < 0.05); there were no differences between the preservation subgroups. Regional wall motion analysis revealed significantly improved segmental myocardial performance in all segments if both leaflets were preserved or the anterior mitral leaflet was reattached to the anterior mitral annulus.

Asunto(s)

Prótesis Valvulares Cardíacas/métodos , Válvula Mitral/cirugía , Función Ventricular Izquierda/fisiología , Adulto , Anciano , Análisis de Varianza , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía Doppler en Color , Estudios de Evaluación como Asunto , Femenino , Prótesis Valvulares Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/fisiopatología , Estenosis de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/mortalidad , Reoperación , Tasa de Supervivencia , Resultado del Tratamiento

RESUMEN

OBJECTIVE: A number of oncogenes and tumor suppressor genes participating in tumorigenesis have been identified, one of them being nm23. The expression of the candidate tumor suppressor gene nm23 depends on the cell type of tumors. Both, reduced expression as well as overexpression of nm23 is associated with a high potential of malignancy. In a variety of tumor cell lines secretion of the nm23 protein can be detected. In an earlier investigation we showed, that the nm23 expression in squamous cell lung carcinoma is considerably elevated. In order to establish the potential diagnostic value of this finding we investigated the nm23 expression in healthy and diseased lungs in patients with squamous cell lung cancers. METHODS: We examined bronchial lavage samples of 20 patients with bronchogenic squamous cell carcinoma. The lavage was separately performed in the bronchus of the tumor bearing lobe and in the corresponding bronchus of the unaffected contralateral lung. RESULTS: Using Western blot analysis we found 2-7 fold elevated amount of nm23 protein in bronchial lavage of the tumor bearing lung in comparison to the healthy side. This finding was neither related to tumor stage nor to tumor location. Thus we have a strong hint that the nm23 protein is secreted by the bronchogenic squamous cell carcinoma. CONCLUSIONS: With respect to these results the proof of nm23 protein in bronchial lavage fluid might be of relevance to establish the diagnosis when pulmonary nodules of unknown etiology are found.

Asunto(s)

Biomarcadores de Tumor/genética , Carcinoma Broncogénico/genética , Carcinoma de Células Escamosas/genética , Genes Supresores de Tumor/genética , Neoplasias Pulmonares/genética , Proteínas de Unión al GTP Monoméricas , Factores de Transcripción/genética , Bronquios/patología , Líquido del Lavado Bronquioalveolar/química , Carcinoma Broncogénico/patología , Carcinoma de Células Escamosas/patología , Regulación Enzimológica de la Expresión Génica/fisiología , Regulación Neoplásica de la Expresión Génica/fisiología , Humanos , Neoplasias Pulmonares/patología , Nucleósido Difosfato Quinasas NM23 , Nucleósido-Difosfato Quinasa/genética

RESUMEN

The purpose of this study was to determine the termination and acceleration rates for 1 to 6 attempts of antitachycardia pacing [ATP] delivered by ICD in order to terminate spontaneously occurring VTs. Twenty-four ICD recipients with active ATP programs, including a maximum of six ATP sequences and spontaneously occurring VTs during follow-up, were investigated. During a mean follow-up of 42 +/- 15 months (range, 17-63 months) 413 spontaneous VT episodes (17 +/- 14; range, 1-49 per patient) resulting in appropriate ATP delivery by the ICD occurred. ATP successfully terminated 328 episodes (80%) with a mean number of 1.6 +/- 1.1 pacing sequences. Eighty episodes (19%) were accelerated by ATP and 5 (1%) were unresponsive to ATP. The ATP success decreased until the third ATP sequence (59%-->31%-->24%), but increased again in the fourth to sixth attempt (46%-->46%-->29%). The acceleration rate increased from sequence one to sequence three (8%-->13%-->28%), but decreased significantly in further ATP attempts (19%-->0%-->0%). The mean time delays until redetection or termination after 4, 5, and 6 attempts of ATP were 22 +/- 5 seconds, 37 +/- 2 seconds, and 41 +/- 9 seconds, respectively. Nine patients (37%) used > or = 3 ATP attempts during follow-up and all of them had a therapeutic benefit from it. Five out of 13 VTs (38%) treated with > or = 4 attempts could ultimately be terminated by ATP. The results of this study demonstrate that the first ATP sequence is the most effective and that > 4 ATP attempts may be useful in a minority of patients. There seems to be a low risk of VT acceleration by the fourth to sixth ATP sequence. Because of the associated time delay, a high number of ATP attempts should only be programmed in patients with hemodynamically well-tolerated stable VTs.

Asunto(s)

Estimulación Cardíaca Artificial , Desfibriladores Implantables , Taquicardia Ventricular/terapia , Aceleración , Estimulación Cardíaca Artificial/clasificación , Estimulación Cardíaca Artificial/métodos , Cardiomiopatía Dilatada/complicaciones , Electrocardiografía , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Marcapaso Artificial , Factores de Riesgo , Volumen Sistólico , Factores de Tiempo , Fibrilación Ventricular/terapia , Función Ventricular Izquierda

RESUMEN

From 1976 to 1996 sixty patients with bronchopulmonary carcinoid were operated on at our institution. Post-operative histologic examination revealed typical carcinoid tumors in 50 cases and atypical carcinoid tumors in 10 cases. Preoperative diagnosis was correct in 32 cases (53%) and wrong in 11 cases (18%). In 17 cases (29%) we carried out a diagnostic thoracotomy. Resection was potentially for cure in 55/60 patients. Five-year-survival rates were 100% for patients with typical carcinoid tumors and 97% and 92% at 10 and 15 years, respectively. Regional lymphatic tissue was involved in typical (12%) as well as in atypical carcinoid tumors (20%). Furthermore distant metastasis occurred in both types of tumors, 4% in typical and 11% in atypical carcinoid tumors. There was no relationship between lymph node involvement and distant metastasis. Local recurrence was seen in 2/60 patients. Both patients suffered from atypical carcinoid tumors. Patients in whom only incomplete resection due to advanced tumor stage was possible showed no benefit from operative therapy.

Asunto(s)

Tumor Carcinoide/cirugía , Neoplasias Pulmonares/cirugía , Neumonectomía , Adolescente , Adulto , Anciano , Tumor Carcinoide/mortalidad , Tumor Carcinoide/patología , Femenino , Humanos , Pulmón/patología , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Tasa de Supervivencia

RESUMEN

Fibrosing mediastinitis is the most often observed benign cause of mediastinal compression syndromes, particularly the vena cava superior syndrome. We report 3 cases with such compression syndromes (2 x superior vena cava syndrome, 1 x symptomatic tracheal obstruction) due to fibrosing mediastinitis in which tumor resection led to a relief of symptoms. The operative procedures performed in our cases and in general as well as conservative treatment modalities reported for this rare disease are discussed with respect to our own experience and that of the recent publications in the European and American literature.

Asunto(s)

Mediastinitis/complicaciones , Síndrome de la Vena Cava Superior/etiología , Estenosis Traqueal/etiología , Adulto , Anciano , Prótesis Vascular , Femenino , Fibrosis , Humanos , Masculino , Mediastinitis/patología , Mediastinitis/cirugía