The Thoracic and cardiovascular surgeon
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Thorac Cardiovasc Surg · Jun 1996
Extrathoracic arteriosclerotic vascular changes preclude the use of the internal thoracic artery for coronary artery bypass grafting.
During a two-years period we have treated 6 patients where use of the internal thoracic artery for coronary artery grafting was precluded because of extrathoracic arteriosclerotic vascular lesions. In four patients with severe aorto-iliac occlusive disease preoperative digital angiography demonstrated collateralisation of the lower extremity by either the left, right, or both internal thoracic arteries (ITA). In these cases use of the ITA was excluded in order to preserve the collateral supply and coronary bypass grafting was performed using only saphenous vein. ⋯ All patients survived the operation without development of a perioperative myocardial infarction, neurological deficit, or peripheral ischemia. Although they rarely do, extrathoracic vascular disorders can exclude the use of the ITA for grafting. Especially in the case of aorto-iliac occlusive disease or proximal arteriosclerotic subclavian lesions angiographic evaluation is mandatory to prevent the development of life-threatening peripheral ischemia by harvesting an ITA and to avoid the use of an inadequate ITA graft with in-flow occlusion.
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Thorac Cardiovasc Surg · Apr 1996
Multicenter StudyImplications of the introduction of fixed reimbursement rates in Germany.
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. ⋯ 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.
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Thorac Cardiovasc Surg · Feb 1996
Cardiac efficiency during coronary occlusion and during reperfusion after emergency revascularization under cardioprotection.
Myocardial infarction in consequence of a coronary artery occlusion presents a serious problem. It is the aim of any emergency revascularization to minimize the ischemia-induced damage or to salvage reversibly injured myocardium. In experiments on 8 anesthetized pigs, myocardial protection by orthograde perfusion with a high-volume cardioplegic solution was studied under controlled conditions. ⋯ During the entire reperfusion the myocardium was stunned, i.e. cardiac work was decreased at maintained MVO2. Thus, external efficiency was decreased. From these results we conclude that in reperfused myocardium after cardioplegic arrest, the oxygen is only inefficiently converted to develop force.
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Thorac Cardiovasc Surg · Feb 1996
Case ReportsCarinal reconstruction under veno-venous bypass using a percutaneous cardiopulmonary bypass system.
We report two patients who underwent carinal resection and reconstruction for advanced lung cancer under veno-venous bypass. The bypass system consisted of a centrifugal pump and a hollow-fiber membrane oxygenator, and was established by percutaneous insertion of cannulas through the femoral veins using the Seldinger technique. This respiratory support system under veno-venous bypass was safe and useful for carinal reconstruction, providing a good visual field and adequate oxygenation. Although other standard accepted ventilation techniques can be used for carinal resection, veno-venous bypass is an alternative adjunct in cases involving difficult carinal reconstruction.
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Thorac Cardiovasc Surg · Feb 1996
25th annual meeting of the German Society for Thoracic and Cardiovascular Surgery, 2nd joint annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Austrian Society for Thoracic and Cardiac Surgery, and the Swiss Society for Thoracic and Cardiovascular Surgery. Vienna, Austria, February 28-March 2, 1996. Abstracts.