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Es wird über systematische Untersuchungen der Gerinnungsverhältnisse von 28 Patienten berichtet, bei denen eine Herzoperation mit Hilfe der extrakorporalen Zirkulation durchgeführt wurde. Von diesen 28 Patienten erhielten 14 Patienten zusätzlich vor der Inaktivierung des Heparins mit Protaminchlorid 10 000 Einheiten Trasylol/kg Körpergewicht. Ein überzeugender positiver Effekt wurde nach den Ergebnissen der Blutgerinnungsuntersuchungen mit diesem Medikament nicht nachgewiesen. Nach einer anfänglichen Steigerung der fibrinolytischen Aktivität unmittelbar nach der Thorakotomie, die durch die Euglobulinlysezeit erfaßt wurde, kam es während der extrakorporalen Zirkulation zu einer Verbrauchskoagulopathie mit Abfall der Thrombozytenzahl, des Fibrinogens, des Quick-Wertes, der Faktoren II, V, und VII, zu einer Verlängerung der PTT und zum Anstieg der Fibrinmonomere. Die Verbrauchskoagulopathie bestand auch nach Beendigung der extrakorporalen Zirkulation einige Zeit fort. 2-5 Stunden nach der Gabe von Protaminchlorid fand sich eine abermalige Verlängerung der Thrombinzeit, die durch Protamintitration zu normalisieren war. Dieser Befund war als Heparin-Rebound-Phänome zu deuten. Die therapeutischen Möglichkeiten und Konsequenzen werden ausführlich diskutiert. Studies on changes in blood coagulation during and after operations with the help of the heart lung machine.

A new therapeutic concept of enlarging the outflow tracts of both ventricles with a patch and inserting an aortic prosthesis has been developed for the treatment of tunnel subaortic stenosis. This operation has been applied clinically since June 1974 on several types of obstruction in the outflow tract of the left ventricle. Twenty-one operations have been performed on 20 patients under the age of 18 years, with an overall mortality of 24% and no late deaths. Seven patients developed complete right bundle branch block or left anterior hemiblock or both as a result of this operation; transient atrioventricular block and complete left bundle branch block occurred in one patient each. In no case, however, did rhythm disturbances contribute to death. In one patient, the septal incision injured a septal coronary artery, with fatal result. Fourteen patients had catheterization studies postoperatively. Although previous conventional surgery had been unsuccessful, aortoventriculoplasty (AoVPI) reduced the mean gradient across the left ventricular outflow tract significantly (p less than or equal to 0.01), from 94.7 +/- 25.5 mm Hg to 14.4 +/- 17.2 mm Hg, leaving the end-diastolic pressure practically unchanged. No significant defect remained in the patch-covered septal incision. Thus, we consider AoVPI to be the operation of choice for tunnel subaortic stenosis, for valvular aortic stenosis with a narrow annulus and in cases where an artificial aortic valve has become too small because of the patient's growth.

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Nineteen patients with tricuspid atresia and reduced lung perfusion (valvular-and/or subvalvular pulmonary stenosis, transposition of the great arteries and/or single atrium) were operated in the period 1975--1979. The surgical procedures employed varied according to the additional cardiac defects. The age of the patients was between 2 and 18 years. Eleven children received a contuit with a Hancock valve, 8 children a valveless conduit. In 9 patients it was possible to connect the conduit to the right ventricle using the pumping action of the right ventricle with an anatomically intact pulmonary valve. Six patients died (4 early deaths, 2 late deaths, early mortality rate 21%). In this study, the postoperative courses, which were complicated in several cases, are related to the hemodynamical findings. Thirteen children were examined between 1 and 38 months following the operation. Cardiac catheterization was performed in 10 patients. Of the 13, 10 had fully saturated arterial blood. A remnant atrial defect was demonstrated in one child, and 2 displayed intrapulmonary shunts attendant to Glenn anastomoses which had been in place for 10 to 12 years. Among the patients the right atrial pressure ranged from 10 to 20 mmHg with a mean value of 14.5 +/- 0.9 mmHg. An increase in size of the right ventricle was demonstrated angiographically in the case of 2 patients who had valve-bearing conduits to the right ventricle.