Endoluminal stent-graft placement for acute rupture of the descending thoracic aorta.

AIMS: To investigate the results of endovascular stent-graft placement for the treatment of acute perforating lesions of the descending thoracic aorta. METHODS AND RESULTS: A total of 31 consecutive patients underwent interventional treatment for perforating lesions of the descending aorta. In 21 cases (group A), the aortic perforation was due to rupture of a descending thoracic aneurysm or dissection, whereas 10 patients (group B) were treated for traumatic transection of the descending aorta. A total of 42 endoprostheses were implanted. The implantation procedure was successful in all cases without peri-interventional complications. In one case, implantation of a second endoprosthesis became necessary due to type I endoleak. Overall, the 30-day mortality was 9.7%. As all three deaths occurred in group A, the mortality rate in this group was 14.3% versus 0% in group B. Similarly, postinterventional complications were more prevalent, with 28.6% in group A (renal failure n = 4; stroke n = 2) versus 10.0% in group B (renal failure n = 1). No paraplegia and no further deaths or ruptures occurred during follow-up (mean 17 months). CONCLUSION: Interventional stent-graft placement is an effective treatment option for the emergency repair of descending aortic perforations.

[Surgical treatment of therapy resistant atrial fibrillation]. / Die chirurgische Behandlung des therapierefraktären Vorhofflimmerns.

Atrial fibrillation in patients with isolated, therapy resistant, chronic or paroxysmal atrial fibrillation (AF) or AF in combination with additional valvular and non-valvular cardiac pathology can be surgically treated by different techniques. Unipolar high frequency, cryotherapy and microwave energy is a curative approach for the treatment of the left atrium for AF. The postoperative mortality and morbidity rate is comparable to other cardiac surgery procedures. It is a technically less challenging procedure as compared to the MAZE procedure and can be applied using a minimally invasive approach. Alternative techniques such as new cryotechnologies, laser application and bipolar high frequency energy need to be evaluated for effectiveness and safety.

Transmyocardial laser revascularization with the holmium:YAG laser: loss of symptomatic improvement after 2 years.

OBJECTIVE: Whether transmyocardial laser revascularization (TMLR) provides a long-term benefit in terms of relief of angina, improvement of exercise tolerance, left ventricular function, and myocardial perfusion. METHODS: Forty-one patients underwent TMLR using a holmium:YAG-laser, 14 as TMLR alone (group A), 27 with additional aortocoronary bypass grafting (group B). Follow-up was obtained at 6, 12, 18, 24, and 36 months in this prospective study. RESULTS: In group A patients CCS-class improved up to 18 months postoperatively, after 24 and 36 months postoperatively there was absence of a positive effect of TMLR: the CCS-class decreased to 2.4 as compared to 3.5 preoperatively After combined CABG and TMLR (group B) there was a significant decrease in angina at all times. The CCS-functional class in these patients was 1.7 at 36 months as compared to 3.5 preoperatively. There was no significant change in exercise tolerance as compared to preoperatively. Left ventricular ejection fraction did not improve in either of the groups. Thallium scintigraphy indicated no improvement in myocardial perfusion in laser treated areas. The perioperative mortality was 0%, the late mortality rate was 36% in group A and 11% in group B. CONCLUSIONS: In our experience, in the vast majority of patients who are subjected to TMLR alone the benefit of reduction or relief of angina and improvement in quality of life is only temporary. In addition there is no improvement in objective clinical parameters. We believe that TMLR should only be used in patients with severe angina refractory to medical treatment and requiring a symptomatic therapy.

Early clinical results after stentless mitral valve implantation and comparison with conventional valve repair or replacement.

BACKGROUND: A new quadricusp stentless mitral bioprosthetic valve (QMV) is evaluated and compared with current standards. METHODS AND RESULTS: Since August 1997, 67 patients were prospectively evaluated: 23 patients received a QMV, 23 had mitral valve repair (MVR), and 21 received conventional mitral valve replacement (MVP). Patient age was 69+/-8, 64+/-10, and 62+/-9 years for QMV, MVR, and MVP treatment, respectively. The underlying pathology was mitral stenosis, incompetence, and mixed disease in a corresponding 8, 9, and 6 patients for QMV, 1, 22, and 0 patients for MVR, and 2, 12, and 7 patients for MVP. The papillary muscles were sufficient in all QMV cases to suspend the valve. Cross-clamp time was 59+/-19 minutes for QMV implantation. In-hospital mortality for QMV, MVR, and MVP was 1, 0, and 0 patients, respectively, and thoracotomy had to be performed again in 1, 1, and 2 patients, respectively (these outcomes were not valve related). At baseline transthoracic echocardiography, respective maximum flow velocities were 1.6, 1.4, and 1.7 m/s, and valve orifice area was 2.6, 3.5, and 3.4 cm(2). Mild transvalvular reflux was seen in 8, 7, and 2 patients; moderate reflux, in 1, 1, and 1 patients. Left ventricular ejection fraction was 52%, 54%, and 51% in the respective treatment groups. At follow-up, hemodynamic parameters had further improved in all groups. CONCLUSIONS: One year after clinical implantation, the QMV appears to function well and has no additional risks compared with MVR or MVP. The subvalvular apparatus is preserved by suspending the QMV at the papillary muscles; this arrangement is hemodynamically advantageous. Echocardiography reveals an excellent valve performance that resembles native mitral valve morphology and hemodynamic function. The QMV is a promising alternative for biological mitral valve replacement.

Computer-enhanced mitral valve surgery: toward a total endoscopic procedure.

The aim of the study was to develop a computer-enhanced, video-assisted approach for mitral valve repair as a potential step toward a complete endoscopic procedure. In 10 patients with nonischemic mitral valve insufficiency, computer-enhanced telemetric mitral valve repair using the Intuitive surgical telemanipulation system was performed. A femorofemoral bypass was initiated using Port-Access (Heartport, Redwood City, CA) cannulation. A small minithoracotomy was made in the right 4th intercostal space, and a custom-made rib retractor was placed. The pericardium was opened manually, and four traction stay sutures were placed to enhance exposure. After endoaortic balloon clamping, the left atrium was opened and stabilized. The end-effectors were placed in the left atrium through two ports (3rd ICS and 6th ICS, midaxillary line). A 30 degrees three-dimensional (3D)-videoscope angled up was placed through the incision. Mitral valve repair was then performed remotely from the surgical console. This included inspection of the valve, leaflet resection, leaflet repair, and ring implantation. After completion of the repair and testing of the valve, the end effectors were withdrawn, and the left atrium was closed manually using standard endoscopic instruments (Heartport). In all but 1 patient, successful repair, including quadrangular resection, chordal shortening, Whooler-plasty, and Alfieri-plasty, could be accomplished using the computer-enhanced telemanipulation system. A partial ring was implanted in 6 patients and a complete ring was implanted in 3 patients, respectively. Time for surgery, CPB, and clamp time were 170 to 330 minutes (median, 185 minutes), 140 to 220 minutes (median, 149 minutes), and 78 to 133 minutes (median, 94 minutes), respectively. In one patient, intraoperative transesophageal echocardiography (TEE) showed insufficient repair, a second surgery was performed via an enlarged left thoracotomy. One patient with recurrent mitral insufficiency had to have a second surgery on postoperative day 3 for a torn-out ring. Median time of hospitalization was 8 days. At 3 months follow-up (completed in 7 patients), all patients had improved clinically. Computer-enhanced mitral valve repair is feasible and can be performed with good functional results. The telemanipulation system offers the potential for true endoscopic mitral valve repair. However, surgical time is prolonged, and a learning curve has to be overcome.

The evolution of minimally invasive valve surgery--2 year experience.

OBJECTIVES: The aim of the study was to evaluate the evolution of Port-Access minimally invasive mitral valve surgery to a robot assisted video assisted solo surgery approach. METHODS: One hundred and twenty-nine patients with non-ischemic mitral valve disease underwent 3D-video assisted mitral valve surgery via a 4 cm right lateral minithoracotomy using femoro-femoral bypass and endoaortic clamping. Transcranial Doppler and continuous transesophageal echocardiography were used to monitor placement and positional stability of the endoclamp. After the initial series (group I, n = 62), a simplified solo surgical technique using voice controlled robotic assistance for videoscope guidance was used in the last 67 patients (group II). RESULTS: After an initial learning curve and modifications of catheter design, the procedure could be steadily redefined and simplified. In the last 67 patients, the procedure was completed without the need for an additional assistant as 'solo surgery'. The mitral valve was repaired in 72 and replaced in all other patients. Duration of bypass and clamp time steadily improved during our study and in the most recent 67 patients average 107 +/- 34 and 48 +/- 16 min, respectively. The voice controlled robotic arm (AESOP 3000, Automated Endoscope System for Optimal Positioning) provided a stable and precise video image with excellent exposure of all valvular and subvalvular structures. Hospital mortality was high in the early series (mean survival 88.7% at 804 +/- 35 days; 95% CI: 735-873) and partially procedure related (aortic dissection in two patients). In group II, hospital mortality has declined to 3.0% (mean survival 97.0% at 568 +/- 12 days; 95% CI: 553-600). CONCLUSION: Port-Access minimally invasive mitral valve surgery has evolved to be a reliable video assisted technique with reproducible results. Surgery can now be performed almost in the same time as with conventional techniques. Robotic assistance has enabled a solo surgery approach.

Comparison of MIDCAP versus conventional CABG surgery regarding pain and quality of life.

BACKGROUND: This prospective clinical trial focuses on pain and quality of life (QOL) after minimally invasive direct coronary artery bypass (MIDCAB) grafting versus conventional coronary artery bypass grafting (CABG). METHODS: Group A consisted of 65 consecutive MIDCAB patients using an anterolateral mini-thoracotomy and the "off-pump" technique. Group B consisted of 95 computer-matched patients who underwent conventional CABG with cardiopulmonary bypass (CPB). Pain was graduated using the visual analog scale (VAS), and the verbal rating scale (VRS) [Troidl 1990]. QOL was evaluated at the time of discharge and three months after surgery using modified Nottingham Health Questionnaires that separate physical, social, activity, emotional, pain, and sleeping conditions. RESULTS: Postoperative pain was higher after MIDCAB on postoperative day (POD) 1 (p< 0.002). From POD 4 onwards MIDCAB patients had less pain compared with the conventional group (p<0.04). MIDCAB patients required less pain medication from POD 4 onwards (p<0.05). QOL was significantly better in the MIDCAB group on POD 7 for physical (p< 0.038), activity (p< 0.016), pain (p< 0.041), and sleep (p<0.038) conditions. The three-month questionnaire showed significantly better levels for MIDCAB patients regarding physical (p< 0.03) and pain (p< 0.001) conditions, and a trend for activity (p< 0.08) and emotional (p<0.08) conditions. CONCLUSION: Compared to patients undergoing conventional surgery, MIDCAB patients suffer more pain in the first three postoperative days, probably as a result of the lateral thoracotomy. From POD 4 onwards, MIDCAB patients are significantly better, experiencing less pain and showing better physical, activity, and sleeping conditions even three months after surgery. This can be attributed to the absence of median sternotomy and/or the avoidance of cardiopulmonary bypass.

Anabolic steroids (metenolone) improve muscle performance and hemodynamic characteristics in cardiomyoplasty.

The loss of force and mass in the conditioned latissimus dorsi muscle are principal reasons for the poor improvement in hemodynamic functioning attained by cardiomyoplasty. Using 24 sheep, we investigated the effect of anabolic steroids on the hemodynamic, histologic, and myophysiologic characteristics in the setting of cardiomyoplasty. In 12 of the animals (group A), the latissimus dorsi muscles were electrically conditioned with an Itrel pulse generator; in the remaining 12 animals (group B), the electrical conditioning was combined with the administration of an anabolic hormone (metenolone; 100 mg/week). The hemodynamic measurements were performed during isolated perfusion of the subclavian artery (maintenance of pressure in the muscles), while all other circulation variables were held at the exact and reproducible value of zero by inducing ventricular fibrillation. Maximum force and muscle mass showed a significant increase in group B (maximum force: group A, 4.23 +/- 0.55 kp, and group B, 6.0 +/- 3.14 kp; muscle mass: group A, +11.07% +/- 1.06%, and group B, +79.9% +/- 40.8%). The ratio of type I to type II fibers after 12 weeks was 65.2% to 34.8% in group A and 96.7% to 3.3% in group B, as opposed to 19.9% to 80.1% in the control group. No side effects of the anabolic steroids were observed during the experiment. In the hemodynamic studies, we were able to demonstrate a further significant increase in the left ventricular pressure, fractional fiber shortening value, ejection fraction, stroke volume, cardiac output, and stroke work when using conditioned latissimus dorsi muscles that were additionally treated with metenolone.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of an anabolic steroid (Metenolon) on contractile performance of the chronically stimulated latissimus dorsi in sheep.

In 12 sheep the left latissimus dorsi muscles (LD) were conditioned by chronic electrostimulation with a pulse generator (Itrel, Medtronic). Six animals (group B) received a weekly intramuscular injection of an anabolic steroid (Metenolon). After 14 weeks the contraction parameters of the left LDs (group A and B) and right LDs (control group) were investigated. The increase in weight of the conditioned LDs was 11.07% (+/- 1.06%) in group A and 79.97% (+/- 40.8; P < 0.05) in group B. The force capacity under stimulation patterns which were just tetanic was 1.15 kp in group A and 4.13 kp in group B (P < 0.05); under supramaximal stimulation patterns it was 4.23 kp (A) and 6.0 kp (B) (P = ns). The force time relation (dF/dt) was 6.7 kp/s for the left LDs in group A versus 16.4 kp/s for the right LDs (P < 0.01); in group B it was 5.13 kp/s for the left LDs versus 15.8 kp/s for the control muscles (P < 0.05). The maximal force (Fmax) per 100 g muscle weight did not differ significantly (A: 2.42 kp/100 g; B: 2.52 kp/100 g). In conclusion, the LD muscles which were subjected to both anabolic therapy and electrical stimulation showed a significant increase in their force capacity due to an enormous increase in mass. Fibre type transformation was complete only in group B. No fibre deterioration was observable in either group. No anabolic side effects were detected in the animals. With the use of anabolic steroids, therefore, a clearer direct increase in contractility on the left ventricle should be expected ("squeezing" theory), as well as a contribution to reduction in wall tension and myocardial oxygen consumption, respectively, according to Laplace's Law (via the considerable increase in thickness).

[The effect of timing of surgical intervention on fatality of acute endocarditis]. / Der Einfluss des Zeitpunktes der operativen Intervention auf die Letalität der akuten Endokarditis.

Between 1/1986 and 5/1992 a total of 5283 surgical procedures involving extracorporal circulation were performed at our clinic, including 44 patients who underwent a total of 54 operations for acute endocarditis. On the basis of a retrospective study, this paper presents the pre-operative findings and the results of surgery in relation to the duration of the case history. Pathogenic microorganisms were successfully grown from the blood cultures of 63.6% (n = 31) of the patients. Among these microorganisms were viridans streptococci (n = 12), coagulase-negative staphylococci (n = 5), staph. aureus (n = 5), beta-haemolytic streptococci (n = 2) as well as combined infections (n = 2) and miscellanea. Preoperatively, 38 patients were in NYHA stage III or IV. Surgery resulted in an average improvement of 1.6 NYHA classes from NYHA 3.3 to NYHA 1.7. The total-mortality rate was n = 13; early mortality was n = 3. The mean follow-up period was 3.9 years (minimum 5 weeks, maximum 6.4 years). The time elapsed between initial clinical manifestation of the disease and operation had a significant influence on mortality and on the prevalence of complications. Patients who died of endocarditis had a significantly longer case history (p < 0.05). The prognosis was poorer, according to our data, if the case history extended over more than 80 days. Our results demonstrate clearly the necessity for such patients to be referred to a heart surgeon without delay.

[Isolated florid pulmonary valve endocarditis]. / Isolierte floride Pulmonalklappenendokarditis.

We report on a case of isolated pulmonary valve endocarditis caused by coagulase-negative staphylococci 22 years after total correction of a pentalogy of Fallot. The M-mode and two-dimensional echocardiographic findings are presented, and the patient's clinical progress is described. An overview of the literature shows isolated endocarditis of the pulmonary valve to be an exceptionally rare occurrence. 6 months postoperatively, the patient has not been experiencing a relapse and is now in NYHA stage I.

[Clinical and hemodynamic results of surgical correction of hypertrophic obstructive cardiomyopathy]. / Klinische und hämodynamische Ergebnisse nach operativer Korrektur bei hypertroph obstruktiver Kardiomyopathie (HOCM).

The value of transaortal subvalvular myectomy after Morrow remains unclarified. We therefore analysed our results with HOCM with particular attention to the operation risk and the longterm results. 56 patients were treated at the Leipzig Heart Centre between January 1984 and August 1990 using the transaortic myectomy. In 16 patients an additional mitral valve replacement or -reconstruction was required. In 14 patients, other combined operations (aortic valve replacement, aortocoronary bypass) were indicated. In the postoperative observation period (up to 7 years; 141 patient-years; mean follow-up 4.2 yrs) detailed information was obtained at regular intervals about subjective complaints, ECG changes, left ventricular functional parameters and the weight of the heart muscle mass were recorded. The myectomy resulted in an alteration of the NYHA-class from 3.1 to 1.3 postoperatively (p < 0.05). The ventriculo-aortal pressure gradient reduced in the group myectomy (group I) from 69.2 +/- 5.2 to 23.3 +/- 2.7 mmHg postoperatively. In the myectomy+mitral valve repair group (group II) the intracavitary pressure gradient was even reduced to 11.7 +/- 2.2 Torr (p < 0.05). The Sokolov-Lyon-Index was 3.7 +/- 0.19 mV preoperatively and went down to 2.9 +/- 0.16 mV. The heart muscle mass decreased from 680 g to a postoperative value of 430 g (p < 0.05). The relation of BAR and calcium channel density of 0.5 +/- 0.1 in HOCM versus 0.9 +/- 0.08 in a control group (n = 6) proves the increased number of calcium channels in HOCM.

Comparison of myectomy alone or in combination with mitral valve repair for hypertrophic obstructive cardiomyopathy.

UNLABELLED: Between 1/84 and 6/91 56 patients were treated for hypertrophic obstructive cardiomyopathy (HOCM): the Morrow technique alone was performed on 40 patients (group 1), in 16 patients (group 2) an additional replacement (n = 13) or reconstruction (n = 3) of the mitral valve was indicated. In a total of 14 cases coronary artery bypass grafting and aortic valve replacement was performed in addition. Postoperatively (mean follow-up 4.2 yrs, 141 patient-years) left-ventricular diastolic and systolic function parameters, heart muscle mass, ECG findings, and symptomatology were recorded and the ratios of beta-adrenoreceptor density to density of the calcium channel were measured. RESULTS: Pressure gradient decreased from 69.2 +/- 5.2 (group 1) and 75.1 +/- 4.8 (group 2) to 23.3 +/- 2.7 and 11.7 +/- 2.2 mmHg postoperatively. Likewise Sokolow-Lyon index decreased from 3.5 +/- 0.2/3.7 +/- 0.2 to 2.9 +/- 0.2/2.8 +/- 0.3. The quotient time-to-peak-velocity/left-ventricular-ejection-time decreased significantly in group 2 from 58.6 +/- 6.3 to 41.9 +/- 5.8 (p less than 0.05). The heart muscle mass, determined echocardiographically, decreased from 680g to 430g (p less than 0.05). Isovolumetric tension time, isovolumetric relaxation time, and E/A ratio at rest and after stress showed typical characteristics. Ca(++)-channel density was clearly raised in all patients, with no differences between the two groups being observable. We conclude from our results: The most marked improvements in clinical and left-ventricular functional parameters were experienced by patients in group 2 (myectomy+MVR).(ABSTRACT TRUNCATED AT 250 WORDS)

[Candida infection after aortic valve replacement--a case report with special reference to the literature]. / Candidasepsis nach Aortenklappenersatz--ein Fallbericht unter besonderer Berücksichtigung der Literatur.

Candida-infections of the heart are rare and often combined with a difficult diagnostic and therapy as well as a high mortality rate. That's why we critically finished off diagnostic and therapeutic instructions are present valid by means of a case. To give a proof of a candida-infection is very difficult and demand to include all of clinical and paraclinical directions as well as the often echocardiographic control of implanted strange materials. In the present time the mostly used therapeutic regime is caused of the explantation of strange material already in the case of a suspicion of an infection with candida and the consequent and combined application of antimycotica with the favoured combination of amphotericin B and flucytosin.

[The incidence of wound healing disorders in heart surgery]. / Häufigkeit von Wundheilungsstörungen in der Herzchirurgie.

In a five-year retrospective study we investigated the wound infection rate after median sternotomy in 2805 adult patients on whom elective surgery had been performed with extracorporeal circulation. On the basis of 14,700 apparently relevant data from 101 patients with wound healing disturbances at the sternotomy site, both the significance of predisposing risk profiles and the prevalence of nosocomial pathogens were evaluated. The control group was formed by 100 patients selected at random. The results were checked for statistical significance using the X2 test for alternative characters; the significance level was set at alpha = 5%. The infection rate observed in our group was 3.6%, which was assigned to 5 internally defined degrees of severity. Cases of healing by second intention were caused to 93% by coagulase-negative staphylococci and staphylococcus aureus. Factors leading to a decrease in oxygenation of the wound area (low-output syndrome, rethoracotomy), diabetes, obesity and the duration of wound drainage were accompanied by a significantly more frequent occurrence of wound healing disturbances. On the other hand, perfusion-technical parameters, operation duration, revascularisation techniques (IMA/ACVB), pulmonary conditioned hypoxemias and the end-of-year desinfection usual in our clinic had no influence on wound healing. Seasonal fluctuation of the epidermal microclimate appear to be responsible for the prevalence and virulence of the pathogen strains in the clinic environment. The preventive measures used in cardiosurgical clinics do not yet represent a fully developed prophylaxis against exposure to nosocomial pathogens.

[Heart surgery interventions in patients with terminal renal failure]. / Herzchirurgische Eingriffe bei Patienten mit terminaler Niereninsuffizienz.

It is reported on first own experiences in the cardiosurgical treatment of patients with terminal renal insufficiency. Frequency of cardiovascular complications and their high lethality in this group of disease force into early and routine use of cardiological diagnostics and cardiosurgical therapy. The surgical indication should exclusively be based on the severity of the present heart disease. The permanent dialysis treatment is no contraindication. When the patients are carefully selected and with close cooperation of all specialties participating the operative risk of patients with terminal renal insufficiency does not essentially differ from that one of patients with healthy kidneys.

[Emergency coronary surgery in patients with unstable angina pectoris. Results and place in the total concept of the treatment of this group of patients]. / Die dringliche Koronarchirurgie bei Patienten mit instabiler Angina pectoris. Ergebnisse und Stellenwert im Gesamtkonzept der Behandlung dieser Patientengruppe.

The urgent coronary surgery performed in patients with high risk unstable angina (rest pain greater than 48 h) shows still different results. We found in 57 urgent operated patients the same functional and clinical results as after elective bypass grafting. A higher in hospital mortality after urgent coronary surgery based on a higher number of grafts are occluded in the early postoperative period. The better prognosis concluded that the use of urgent coronary surgery is the therapy of choice in patients with refractory unstable angina pectoris.