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Die hier vorliegende Studie stellt die Früh- und Langzeitergebnisse der chirurgischen Vorhofablation zur Behandlung des ischämischen Vorhofflimmerns (VHF) in Kombination mit einer aortokoronaren Bypass-Anlage vor. Dabei wurden die epikardiale Pulmonalvenenisolation mittels Radiofrequenzenergie (RF) und die endokardiale Kryoablation inklusive einer Box-Läsion und Mitralisthmuslinie miteinander verglichen. Im Zeitraum von 2002 bis 2009 wurden die prä- und postoperativen Daten von 262 Patienten mit paroxysmalem oder lang-persistierendem VHF prospektiv erhoben und anschließend eine Nachbeobachtung von durchschnittlich 2,30 Jahren durchgeführt. Die Kryoablation war im Vergleich zur RF-Ablation mit einer signifikant höheren perioperativen Invasivität und Morbidität verbunden. Die Operations- und Ischämiezeit sowie die postoperative intensivmedizinische Betreuung waren nach der Kryoablation signifikant länger. Die Rate an Schrittmacherimplantationen (4,8 % vs. 0,0 %), kardialen bzw. zerebralen Komplikationen (22,9 % vs. 12,3 %) und die Krankenhausmortalität (8,4 % vs. 2,2 %) lagen ebenfalls signifikant höher. Hingegen waren die Langzeitergebnisse ohne signifikante Unterschiede zwischen den Ablationsmethoden. Sowohl das Überleben (81,9 % vs. 86,0 %) als auch die Konversionsrate in den Sinusrhythmus (55,6 % vs. 61,5 %), die Lebensqualität der Patienten und die Komplikations- und Reinterventionsraten zeigten im Langzeitverlauf vergleichbare Ergebnisse. Auf der Basis der oben erhobenen Befunde kann die endokardiale Kryoablation nicht als Standardverfahren zur Therapie des paroxysmalen und lang-persistierenden ischämischen VHFs begleitend zu einer aortokoronaren Bypass-Anlage empfohlen werden. Die epikardiale RF-Ablation ist hier aufgrund der geringeren operativen Invasivität bei vergleichbaren Früh- und Langzeitergebnissen der endokardialen Ablation vorzuziehen.

Kawasaki disease (KD) is characterized by a systemic vasculitis of unknown etiology. More research indicates that KD is related to genetic. In 2003, Sekiya et al. studied the correlation of Th2-related genes and the KD in Japan. They found out that -431T allele would increase the concentration of Thymus and activation-regulated chemokine (TARC)/ CCL17 protein in serum by single nucleotide polymorphism (SNP) -431 C>T of chemokine TARC/ CCL17 operon 5¡¦-flanking region , which suggests that SNP has functionality. Therefore, this study explored the polymorphism and relationship between the regulation of chemokine of TARC/ CCL17 and KD. Firstly, we performed polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) to detect TARC/CCL17 -431 C>T genotype. Then enzyme immunoassay was used to detect TARC/CCL17 chemokine¡¦s expression. The results showed that the performance of TARC -431 C/T SNP, the alleles from KD patients with -431 T, were significantly less than the non-KD control group. It was observed that the -431 T alleles had a lower chance to occur in KD with aneurysms, but independent with coronary artery lesions (CAL). In addition, the acute stage of KD has a higher TARC protein expression, which gradually decreases during IVIG treatment period. However, the up-regulation of TARC protein may not be the direct consequence caused by the single nucleotide polymorphism of TARC -431 C>T.

Background: Kawasaki disease (KD) affects mainly children younger than five years of age, leading to coronary artery lesions, and even to life-threatening myocardial infarctions. Since 1976, Kawasaki disease has occurred among thousands of children in Taiwan. Evidence suggests that inflammation plays a key role in the pathogenesis of atherosclerosis. Significant determinants of high sensitivity C-reactive protein (hs-CRP), which is a sensitive indicator of inflammation, as well as white blood cell (WBC) count, and high-density lipoprotein cholesterol (HDLc) and coronary artery lesion were identified. The relationships between these factors¡¦ concentration and arterial lesion were likewise investigated and had reported. The aim of this study was to determine the serum levels of the hs-CRP, WBC count, and plasma HDLc levels in patients with later phase of KD. Methods and Materials: From July 2005 to June 2006, 97 children with Kawasaki disease at least 1 year after diagnosis were recruited in this study. These participated children had been diagnosed as KD and collected at the interval of 2001 to 2004. Diagnosis was based on the 1984 revised by the KD Research Committee in Japan. The participants were grouped into 45 patients with KD and coronary aneurysms (Group I), 52 patients with KD and normal coronary arteries (Group II), and 50 healthy age-matched children (Control Group III). Their WBC count, systemic and diastolic blood pressures, body mass index, age, sex, fasting total cholesterol concentrations, triglyceride, high-density lipoprotein cholesterol (HDLc), low-density lipoprotein cholesterol, serum hs-CRP levels, and coronary artery lesion by cardioechography were recorded and compared. The analytical differences between hs-CRP, WBC count, and plasma HDLc levels and the coronary artery events in KD were examined. Results: Serum hs-CRP levels of Group I patients (mean 0.264 mg/dl) was significantly greater than that of Group II (mean 0.155 mg/dl, p=0.006) and Group III patients (mean 0.116 mg/dl, p =0.017). Similarly, the WBC count of Group I patients (mean 6,543.11/mm3) was significantly greater than that of Group II (mean 5,720.19/mm3, p=0.029), and Group III patients (mean 5,611.27/mm3, p =0.012). However, plasma HDLc levels of Group I patients (mean 41.42 mg/dl) was significantly lesser than that of Group II (mean 44.79 mg/dl, p=0.035), and Control Group III patients (mean 46.58 mg/dl, p=0.027). There was a positive association between hs-CRP and WBC count levels (r = 0.641, p < 0.05), but none between hs-CRP and plasma HDLc levels. Conclusions: There is the possibility of ongoing low-grade inflammation late after the convalescent phase of Kawasaki disease in children with coronary aneurysms, which may have a role in increasing coronary artery dysfunction. These results also suggest that hs-CRP, WBC count, and plasma HDLc levels are useful parameters for predicting formation of coronary artery lesion even in children after onset of KD.

In finite elasticity, while developing representation for stress, it is customary to require the reference configuration to be stress free. This study relaxes this requirement and develops representations for stress from a stressed reference configuration. Using the fact that the value of Cauchy stress in the current configuration is independent of the choice of the reference configuration, even though the formula used to compute it depends on the choice of the reference configuration, the sought representation is obtained. It is then assumed that there exists a piecewise smooth mapping between a configuration with prestresses and a configuration that is stress free, and the representation obtained above is used to study the mechanical response of prestressed bodies. The prestress fields are obtained by directly integrating the balance of linear momentum along with the traction free boundary condition. Then, different classes of boundary value problems for the type of inhomogeneous and prestressed bodies of interest are formulated and studied. For the cases studied, it is found that even the global measures like axial-load required to engender a given stretch ratio for a prestressed body vary from the homogeneous stress free bodies, though not significantly. The local measures - stress and deformation - in a prestressed body differ considerably from their homogeneous stress free counterparts. The above gained knowledge is applied to understand the mechanics of circumflex arteries obtained from normotensive and hypertensive micro-mini pigs. It is found that the deformation of these arteries when subjected to inflation and axial extension is not of the form r = r(R), µ = £, z = Z. Comparison is also made between the response of an artery at various levels of smooth muscle activation and stretch ratio as well as normotensive and hypertensive specimens, using statistical methods.

Detection of coronary calcification from computed tomography scans is a noninvasive examination and has great potential for heart disease diagnosis. This study proposes new features to characterize calcium lesions. Different from the traditional calcium score features, these features are generated from the texture, shape, and gray level statistics of the calcium lesions. We study the correlation between these features and acute myocardial infarction and then compare the results with traditional calcium score features. According to the location of the lesions, patients are first divided into two groups. In one group, the myocardial infarction is located in segment of culprit lesion. For the second group, myocardial infarction is located in segment of non-culprit lesion. In comparing their means, the corresponding p-value of gray level statistics feature ¡§histogram relative smoothness¡¨ could reach 4.47E-07, which has fairly high significance. Furthermore, in studying the differences among patients, experiment on Hypercholesterolemia provide a good result. By comparing the means of patients which are classified into Hypercholesterolemia and non-Hypercholesterolemia groups, the corresponding p-value of texture feature ¡§inverse difference moment¡¨ could reach 3.74E-04. Initially, acute myocardial infarction do not have statistically significant result However, after adding the location weighting factor for the lesions, the corresponding p-value of texture feature ¡§average of information measures of correlation¡¨ could be reduced to 8.8921E-03, and p-value of gray level statistics feature ¡§Histogram relative Smoothness¡¨ could be improved to 2.4019E-02.

Numerous studies in North America, Europe and Australia have linked depression to increased risk of morbidity and mortality in coronary artery disease (CAD). Although the co-morbidity of depression and CAD is well documented in the western world, little work on the subject has been carried out in Asia. Differing depression presentations in Asia necessitate the use of culture-specific depression rating scales. This study sought to determine whether the correlation between CAD and depression documented in western countries also exists in an Asian nation: Thailand. It was hypothesized that rates of depressive symptoms were higher in Thai inpatients with either unstable angina or recent myocardial infarction than in Thai inpatients with non-cardiac (orthopedic) complications. A 15-question culturally-appropriate self-rating depression inventory was administered to 56 Thai inpatients33 cardiac and 23 orthopedicat two public and one private hospital in Bangkok. Subjects were asked to rate each of the fifteen items on a scale from 0-3 based on how they felt during the past week. Higher scores correlated with greater depressive symptoms. Five cardiac and two orthopedic patients were excluded from the final analysis because of past medical history of major depressive disorder. Of the remaining 49 patients, questionnaire scores ranged from 1 to 23, with a mean depression score of 9.00 (S.E.M.=.84). Cardiac patients showed significantly greater depressive symptoms than their orthopedic counterparts at one public and one private hospital: Ramathibodi Hospital (P=.01) and Bangkok General Hospital (P=.005), respectively. For cardiology patients, the three highest scoring items were early insomnia (Mean = 1.39), late insomnia (Mean = 1.25) and loss of appetite (Mean = 1.04). For orthopedic patients, the three highest scoring items were work inhibition (Mean = 1.05), anxiety (Mean = .86), and early insomnia (Mean = .86). On post-hoc analysis, it was shown that patients in hospital units with air-conditioning showed significantly fewer depressive symptoms than patients without air-conditioning (P=.003), where the daily temperature often reached 115[degrees]F. Rates of depressive symptoms did not differ in accordance with education level (P=.15), gender (P=.49) or age (P=.29). In conclusion, this study provides some evidence that Thai inpatients hospitalized for severe CAD have greater depressive experience than their orthopedic counterparts. This finding supports our hypothesis that depression and CAD are linked in Thailand as they are in western countries.

The purpose of this study was to investigate the presence of arterial insufficiency in patients undergoing CABG surgery and whether arterial insufficiency is a risk factor for postoperative wound infections in the harvesting leg. Patients who had CABG surgery were enrolled consecutively. A total of 144 patients participated in the study. During their hospital stay demographic data was recorded, as well as pre-, intra-, and postoperative tests and risk factors. The patients answered a questionnaire regarding postoperative wound infections 30 days after surgery patients answered a questionnaire regarding infections. The known and potential risk factors that were recorded were BMI, HB, tobacco usage, diagnosed diabetes, hyperglycemia, duration of surgery, the lowest temperature during surgery and clinical or subclinical arterial insufficiency. The result showed that 34% had postoperative wound infections in the harvesting leg and 26 patients had an ABI (Ankel Brachial Index) indicating arterial insufficiency. There was no significant relationship between ABI and postoperative wound infections in the lower extremity in the total study group (p = 0.36) nor among men (p = 0.92). There was a significant correlation between ABI and postoperative wound infections in the lower extremity (p = 0.02) among women. The conclusion is that arterial insufficiency is more prevalent in women. The relationship between postoperative infections of the lower limbs and arterial insufficiency was significant for the participating women, but not in the total group nor among the men.

Anxiety is a highly prevalent comorbidity in coronary artery disease (CAD) and confers increased risk of subsequent cardiac events and mortality. However, biological mechanisms of this relationship are not well understood. Ceramides are sphingolipids involved in inflammatory signaling and cell viability in the periphery and nervous system, and are implicated in pathophysiological mechanisms associated with anxiety. This study aimed to investigate relationships between plasma ceramide concentrations and anxiety symptomology as assessed by the Spielberger State-Trait Anxiety Inventory trait subscale (STAI-T) in CAD patients with linear regressions. High performance liquid chromatography coupled electrospray ionization tandem mass spectrometry was used to assay sphingolipid species. Plasma C22:0 ceramide (β=-0.232, p=0.018) concentrations and 8 other species of sphingolipids (SM18:0, SM20:1, C18:0, C20:0, C18:1, DHC22:0, LacC22:0, LacC24:1) were negatively correlated with STAI-T score when controlling for gender, BMI, and CES-D. Findings suggest specific sphingolipids to be potential markers for anxiety severity in CAD.

Pulmonary dysfunction following cardiopulmonary bypass surgery is a widely explored complication and a multitude of factors have been implicated, including but not limited to: operative trauma; the cardiopulmonary bypass circuit; cardioplegia; the type of donor grafts utilised; anaesthesia and fluid administered. There is a paucity of information regarding the effect of cardioplegia on the lungs. No studies have previously investigated whether allowing cold-blood cardioplegic solution to enter the lung parenchyma, during the period of cardioplegia delivery, has an effect on the clinical outcome of lung function following cardiopulmonary bypass surgery. For this reason an original study was done to determine the effect of preventing cardioplegia from entering the lungs, by evacuating overflow of cardioplegia not drained via the atriocaval cannula, by using a pulmonary artery vent. A total of 403 patients admitted to undergo full cardiopulmonary bypass were screened and 142 patients who fitted the criteria for inclusion and provided informed consent took part in this prospective double blind randomised clinical trial. The control group underwent routine cardiopulmonary bypass grafting. The study group had the intervention of a pulmonary artery vent sutured in position at the time the heart was cannulated for bypass. During cardioplegia delivery the cardioplegia was removed via the atriocaval cannula in the control group (A) and via the atriocaval cannula and the pulmonary artery vent in the study group (B). Aside from this difference, the two groups were managed identically intra- and post-operatively. Outcomes which were compared included eight time measures of arterial blood gases; electrolytes and shunt fraction; bedside lung spirometry measures over five time periods; radiographic measures of atelectasis and effusion over three time points; as well as physiotherapy and hospitalisation requirements. Numerous other potentially extraneous variables were measured and compared in order to monitor homogeneity of the study samples. The consistency of the results within each group throughout the study provides strong evidence that the measurements taken were accurate. The use of standardised equipment and vigilant adherence to the protocol ensured no extraneous deviation. The internal validity of this study was therefore good and accurate. The findings of the study however brought into question a previously accepted belief that the pulmonary artery vent prevents the overflow of cardioplegia, not drained from the right atrium, from entering the lungs. There was no literature or previous studies to confirm or dispute this accepted ‘observation’ by cardiac surgeons that the cardioplegia does enter the lung parenchyma. To therefore validate the findings of the study a further four original studies were designed and initiated. The objective of these studies was to establish the efficacy of the pulmonary artery vent and to determine whether cardioplegia indeed circulates through the lung parenchyma or merely accumulates and ‘pools’. Technetium (Tc-99m), a radio labelled isotope was added to the cold blood cardioplegia solution prior to delivery in order to determine this. In the four sub-studies it was confirmed that the pulmonary artery vent is 90-100% effective in retrieving any cardioplegic solution not drained by the atriocaval cannulae, thus confirming the effectiveness of the pulmonary artery vent in preventing cold blood cardioplegic solution from entering the lungs. The findings of the main study confirmed that respiratory impairment after uncomplicated cardiopulmonary bypass, even in low risk patients, is relatively common, as within each group there was a significant change in outcome measures over time. Inter-group comparisons however showed these changes were not significant, with both groups deteriorating by the same degree post-operatively, therefore establishing that these changes were independent of the intervention of the pulmonary artery vent. In the control group, the cold blood cardioplegia solution that did not drain from the atriocaval cannula entered the lungs and circulated the lung parenchyma during cardiopulmonary bypass. The study group made certain that none, or very little, of the cold blood cardioplegia solution entered the lungs. The main findings of this study are therefore that pulmonary function and gas exchange, although markedly reduced following cardiac surgery, are not affected by placement and suctioning via a pulmonary artery vent during the time of cardioplegia delivery intraoperatively. Furthermore, these studies strongly suggest that cold blood cardioplegia solution is innocuous to the lungs / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, 2006.