RESUMEN
There are several publications on the history of surgery at the University of Vienna. None of these publications, however, sought to group the rich history of surgery in Vienna into distinct "surgical schools" of which, upon closer inspection, only 3 have emerged over the last 250 years. The oldest school dates back to Ferdinand Joseph von Leber and Vinzenz von Kern in the eighteenth and nineteenth centuries, the second school was founded by Theodor Billroth in 1867 and his student Anton Eiselsberg in 1900. The third school dates back to Jan Navratil, who was called to Vienna from Brno in 1967. Each of these schools is unique in that it maintained a degree of coherence, as knowledge, methodology and scientific focus were passed down in a chain of succession. These three schools also significantly influenced the rest of surgery in Vienna because most of the department chairs at the Vienna city hospitals or private hospitals were trained in one of these three schools.
Asunto(s)
Proteínas Represoras , Humanos , AustriaRESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option in high-risk patients with severe aortic stenosis. AIMS: PARTNER EU is the first study to evaluate prospectively the procedural and mid-term outcomes of transfemoral (TF) or transapical (TA) implantation of the Edwards SAPIEN® valve involving a multi-disciplinary approach. METHODS AND RESULTS: Primary safety endpoints were 30 days and 6 months mortality. Primary efficacy endpoints were haemodynamic and functional improvement at 12 months. One hundred and thirty patients (61 TF, 69 TA), aged 82.1 ± 5.5 years were included. TA patients had higher logistic EuroSCORE (33.8 vs. 25.7%, P = 0.0005) and more peripheral disease (49.3 vs. 16.4%, P< 0.0001). Procedures were aborted in four TA (5.8%) and six TF cases (9.8%). Valve implantation was successful in the remaining patients in 95.4 and 96.4%, respectively. Thirty days and 6 months survival were 81.2 and 58.0% (TA) and 91.8 and 90.2% (TF). In both groups, mean aortic gradient decreased from 46.9 ± 18.1 to 10.9 ± 5.4 mmHg 6 months post-TAVI. In total, 78.1 and 84.8% of patients experienced significant improvement in New York Heart Association (NYHA) class, whereas 73.9 and 72.7% had improved Kansas City Cardiomyopathy Questionnaire (KCCQ) scores in TA and TF cohorts, respectively. CONCLUSION: This first team-based multi-centre European TAVI registry shows promising results in high-risk patients treated by TF or TA delivery. Survival rates differ significantly between TF and TA groups and probably reflect the higher risk profile of the TA cohort. Optimal patient screening, approach selection, and device refinement may improve outcomes.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Cateterismo Cardíaco/mortalidad , Causas de Muerte , Ecocardiografía , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Estimación de Kaplan-Meier , Masculino , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n=4, Class IIa n=4, Class IIb n=5, and Class IIIa n=3, IIIb n=2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n=5, pharmacologic remission n=4, minimal manifestations n=5, unchanged n=1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.
Asunto(s)
Miastenia Gravis/cirugía , Robótica , Timectomía/métodos , Cirugía Asistida por Video , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Austria , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Timectomía/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Cirugía Asistida por Video/efectos adversos , Adulto JovenRESUMEN
BACKGROUND: Renal dysfunction as a risk factor with the use of left ventricular assist devices (LVAD) is controversial. We determined the effect of renal function on outcomes after continuous flow LVAD implantation. METHODS: Eighty-six patients with advanced heart failure undergoing continuous flow LVAD implantation as bridge to transplantation from November 1998 to July 2007 were retrospectively analyzed. Renal function was assessed using the Modification of Diet in Renal Disease study-derived glomerular filtration rates (GFR [mL x min(-1) x 1.73 m(-2)]). Patients were categorized into two groups based on pre-LVAD GFR: those with normal renal function (GFR > 60, n = 46), and those with renal dysfunction (GFR < 60, n = 40). RESULTS: Post-LVAD survival at 1, 3, and 6 months for GFR greater than 60 was 91.3%, 79.9%, 72.6%, respectively, and for GFR less than 60, it was 92.5%, 66.5%, 47.9%, respectively (p = 0.038). Bridge-to-transplant rate was lower for GFR less than 60 than for GFR greater than 60 (40.0% versus 63.0%, p = 0.033). For GFR less than 60, GFR improved on LVAD support: implant to month 6, 41.7 +/- 11.5 to 62.7 +/- 25.0 (p = 0.021). Post-LVAD survival was improved in GFR less than 60 patients who after LVAD implantation recovered renal function to GFR greater than 60 (p < 0.001). Patients with post-LVAD renal failure had significantly lower post-LVAD survival regardless of pre-LVAD renal function (p < 0.001). CONCLUSIONS: Patients with renal dysfunction have poorer outcomes after continuous flow LVAD implantation. However, renal function improves after LVAD implantation and is associated with improved survival. Our data underscore the importance of end-organ function in patient selection for LVAD therapy.
Asunto(s)
Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Enfermedades Renales/cirugía , Riñón/fisiología , Adulto , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Enfermedades Renales/complicaciones , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Direct application of low-energy unfocused shock waves induces angiogenesis in ischemic soft tissue. The potential effects of epicardial shock wave therapy applied in direct contact to ischemic myocardium are uncertain. METHODS: For induction of ischemic heart failure in a rodent model, a left anterior descending artery ligation was performed in adult Sprague-Dawley rats. After 4 weeks, reoperation with (treatment group, n = 60) or without (control group, n = 60) epicardial shock wave therapy was performed. Low-energy shock waves were applied in direct contact with the infarcted myocardium (300 impulses at 0.38 mJ/m(2)). Additionally, healthy animals (n = 30) with normal myocardium were studied. Angiogenesis, ventricular function upregulation of growth factors, and brain natriuretic peptide levels were analyzed. RESULTS: Histologic analysis revealed significant angiogenesis 6 weeks (treatment group: 8.2 +/- 3.7 vs control group: 2.9 +/- 1.9 vessels per field, P = .016) and 14 weeks (treatment group: 7.1 +/- 3.1 vs control group: 3.2 +/- 1.8 vessels per field, P = .011) after shock wave treatment. In the treatment group ventricular function improved throughout the follow-up period (6 weeks: 37.4% +/- 9% [P < .001] and 14 weeks: 39.5% +/- 9% [P < .001]). No improvement of ventricular function was observed in the control group (6 weeks: 28.6% +/- 5% and 14 weeks: 21.4% +/- 5%). Rat brain natriuretic peptide 45 levels were lower in the treatment group compared with those in the control group 6 and 14 weeks after treatment. Vascular endothelial growth factor, Fms-related tyrosine kinase 1, and placental growth factor levels were upregulated after 24 and 48 hours and 7 days in the treatment group. No effects on healthy myocardium were observed. CONCLUSION: Direct epicardial low-energy shock wave therapy induces angiogenesis and improves ventricular function in a rodent model of ischemic heart failure.
Asunto(s)
Insuficiencia Cardíaca/terapia , Isquemia Miocárdica/terapia , Neovascularización Fisiológica/fisiología , Terapia por Ultrasonido , Función Ventricular Izquierda/fisiología , Animales , Modelos Animales de Enfermedad , Insuficiencia Cardíaca/etiología , Infarto del Miocardio/complicaciones , Isquemia Miocárdica/etiología , Pericardio , Ratas , Ratas Sprague-Dawley , UltrasonidoRESUMEN
OBJECTIVE: Ischemia/reperfusion injury caused by cardioplegic arrest is still a major challenge in patients with reduced left ventricular function. We investigated the effect of chronic versus acute administration of the selective endothelin-A receptor antagonist (ERA) TBC-3214Na during ischemia/reperfusion in failing hearts. METHODS: Male Sprague-Dawley rats underwent coronary ligation. Three days after myocardial infarction (MI), 19 randomly assigned animals (ERA chronic) were administered TBC-3214Na continuously with their drinking water, 29 MI rats received placebo, and 3 rats died during the observation period. Six weeks after infarction, hearts were evaluated in a blood-perfused working heart model during 60 minutes of ischemia and 30 minutes of reperfusion. In 14 MI rats, TBC-3214Na (ERA acute) was added to the cardioplegic solution during ischemia. Thirteen MI rats served as control. RESULTS: At a similar infarct size, postischemic recovery of cardiac output (ERA chronic: 91% +/- 10%, ERA acute: 86% +/- 11% vs control: 52% +/- 15%; P < .05) and external heart work (ERA chronic: 90% +/- 10%, ERA acute: 85% +/- 13% vs control: 51% +/- 17%; P < .05) was significantly enhanced in both TBC-3214Na-treated groups whereas recovery of coronary flow was only improved in ERA acute rats (ERA acute: 121% +/- 23% vs ERA chronic: 75% +/- 13%; control: 64% +/- 15%; P < .05). Blood gas measurements showed enhanced myocardial oxygen delivery and consumption with acute TBC-3214Na therapy. Additionally, high-energy phosphates (phosphocreatine) were significantly higher and transmission electron microscopy revealed less ultrastructural damage under acute TBC-3214Na administration. CONCLUSION: Acute endothelin-A receptor blockade is superior to chronic blockade in attenuating ischemia/reperfusion injury in failing hearts. Therefore, acute endothelin-A receptor blockade might be an interesting option for patients with heart failure undergoing cardiac surgery.
Asunto(s)
Fármacos Cardiovasculares/farmacología , Antagonistas de los Receptores de la Endotelina A , Insuficiencia Cardíaca/tratamiento farmacológico , Corazón/efectos de los fármacos , Isoxazoles/farmacología , Daño por Reperfusión Miocárdica/tratamiento farmacológico , Sulfonamidas/farmacología , Animales , Fármacos Cardiovasculares/uso terapéutico , Modelos Animales de Enfermedad , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/fisiopatología , Isoxazoles/uso terapéutico , Masculino , Infarto del Miocardio/complicaciones , Miocardio , Ratas , Ratas Sprague-Dawley , Sulfonamidas/uso terapéuticoRESUMEN
BACKGROUND: Thromboembolic and bleeding complications in outpatients with a left ventricular assist device are common and can be detrimental. A meticulous balance between anticoagulant and procoagulant factors is therefore crucial. However, in contrast to routinely performed plasmatic coagulation tests, platelet function is hardly ever monitored although recent reports indicated platelet dysfunction. We therefore differentially evaluated platelet function with four commonly used point-of-care devices. METHODS: In a cross-sectional design platelet function was assessed in 12 outpatients and 12 healthy matched volunteers using thrombelastography platelet mapping, thromboelastometry, platelet function analyzer, and a new whole blood aggregometer (Multiplate). RESULTS: Phenprocoumon produced an international normalized ratio of 3.5. It was associated with a twofold prolongation in the thromboelastometry clotting time (p < 0.001). Platelet function under high shear was severely compromised: collagen adenosine diphosphate closure times were 2.5-fold longer in patients than in volunteers (p < 0.001), and 50% of patients had maximal collagen adenosine diphosphate closure time values. Although antigen levels of von Willebrand factor were 80% higher in patients (p < 0.001), von Willebrand factor-ristocetin was subnormal in 5 of 12 patients. Ristocetin-induced aggregation was also threefold higher in volunteers (p < 0.001), indicating an additional functional defect of platelets affecting the glycoprotein Ib-von Willebrand factor axis. The von Willebrand factor multimer pattern in patients also appeared abnormal. CONCLUSIONS: Multimodal antiplatelet monitoring showed markedly impaired platelet function in patients with a left ventricular assist device. Platelet dysfunction under high shear rates and abnormal ristocetin-induced aggregation is only partly attributable to low von Willebrand factor activity. These findings resemble the acquired von Willebrand syndrome that is associated with microaggregate formation and enhanced bleeding.
Asunto(s)
Trastornos de las Plaquetas Sanguíneas/diagnóstico , Trastornos de las Plaquetas Sanguíneas/etiología , Corazón Auxiliar/efectos adversos , Hemorragia Posoperatoria/etiología , Factor de von Willebrand/metabolismo , Adulto , Atención Ambulatoria , Pruebas de Coagulación Sanguínea , Trastornos de las Plaquetas Sanguíneas/epidemiología , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Relación Normalizada Internacional , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Pacientes Ambulatorios/estadística & datos numéricos , Recuento de Plaquetas , Pruebas de Función Plaquetaria , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/epidemiología , Probabilidad , Valores de Referencia , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Tromboelastografía/métodos , Tiempo de Coagulación de la Sangre TotalRESUMEN
INTRODUCTION: Statins are an established therapy after cardiac transplantation. Sirolimus (Srl) has been used successfully in cardiac transplant patients. However, potential side effects are hyperlipidemia and interactions with statins. The aim of the study was to evaluate the safety and efficacy of statin therapy after switch to a Srl-based immunosuppression. PATIENTS AND METHODS: Ninety-eight long-term patients were switched from Cyclosporine A to Srl. Also all patients received mycophenolate mofetil alone or mycophenolate mofetil plus steroid therapy. Reasons for switch were renal dysfunction, graftvasculopathy, or skin cancer. Patients were switched 7.8+/-4.7 years after transplant. Total observation period was 12 months before and after switch, respectively. Safety evaluation consisted of regular measurements of CPK and liver enzymes to evaluate the incidence myopathy and hepatoxicity. Efficacy analysis was performed by serial blood lipid assessments (low-density lipoprotein, high-density lipoprotein, total cholesterol, and triglycerides). RESULTS: Forty-three percentage of patients received atorvastatin, 38% pravastatin, and 18% other drugs or therapy changes. Most lipid blood levels increased significantly after switch (cholesterol: 192.9+/-38.6 mg/dL vs. 221.8+/-49.2 mg/dL, P<0.0001; low-density lipoprotein: 108.0+/-35.6 mg/dL vs. 123.8+/-37.9 mg/dL, P<0.0001; and triglycerides: 178.3+/-88.2 mg/dL vs. 225.5+/-139.1 mg/dL, P<0.0001). Blood lipid levels after switch were not associated with statin type. Overall safety was acceptable, although incidence of myopathy doubled after switch (n=20 vs. 40; P<0.01). However, most cases were asymptomatic CPK elevations in the pravastatin group. Hepatotoxicity rate was 4% and only temporary. CONCLUSION: Statin therapy after switch from cyclosporine A to Srl in long-term cardiac transplant patients is safe. However, regular testing of blood lipids and CPK should be mandatory.
Asunto(s)
Ciclosporina/uso terapéutico , Trasplante de Corazón/inmunología , Trasplante de Corazón/fisiología , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Sirolimus/uso terapéutico , Corticoesteroides/uso terapéutico , Anciano , Atorvastatina , Colesterol/sangre , Dislipidemias/epidemiología , Dislipidemias/prevención & control , Femenino , Ácidos Heptanoicos/uso terapéutico , Humanos , Lipoproteínas LDL/sangre , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Pravastatina/uso terapéutico , Pirroles/uso terapéutico , Seguridad , Resultado del Tratamiento , Triglicéridos/sangreRESUMEN
BACKGROUND: Wound healing disorders after vein harvesting for coronary artery bypass graft surgery increase morbidity and lower patient satisfaction. Low-energy shock wave therapy (SWT) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor kappaB. In this study, we investigate whether prophylactic low-energy SWT improves wound healing after vein harvesting for coronary artery bypass graft surgery. METHODS: One hundred consecutive patients undergoing coronary artery bypass graft surgery were randomly assigned to either prophylactic low-energy SWT (n = 50) or control (n = 50). Low-energy SWT was applied to the site of vein harvesting after wound closure under sterile conditions using a commercially available SWT system (Dermagold; Tissue Regeneration Technologies, Woodstock, GA). A total of 25 impulses (0.1 mJ/mm(2); 5 Hz) were applied per centimeter wound length. Wound healing was evaluated and quantified using the ASEPSIS score. (ASEPSIS stands for Additional treatment, presence of Serous discharge, Erythema, Purulent exudate, Separation of the deep tissue, Isolation of bacteria, and duration of inpatient Stay). Patient demographics, operative data, and postoperative adverse events were monitored. RESULTS: Patient characteristics and operative data including wound length (SWT 39 +/- 13 cm versus control 37 +/- 11 cm, p = 0.342) were comparable between the two groups. We observed lower ASEPSIS scores indicating improved wound healing in the SWT group (4.4 +/- 5.3) compared with the control group (11.6 +/- 8.3, p = 0.0001). Interestingly, we observed a higher incidence of wound healing disorders necessitating antibiotic treatment in the control group (22%) as compared with the SWT group (4%, p = 0.015). No SWT-associated adverse events were observed in the treatment group. CONCLUSIONS: As shown in this prospective randomized study, prophylactic application of low-energy SWT improves wound healing after vein harvesting for coronary artery bypass graft surgery.
Asunto(s)
Puente de Arteria Coronaria/métodos , Ondas de Choque de Alta Energía , Infección de la Herida Quirúrgica/prevención & control , Cicatrización de Heridas/efectos de la radiación , Anciano , Análisis de Varianza , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Probabilidad , Estudios Prospectivos , Valores de Referencia , Vena Safena/efectos de la radiación , Vena Safena/trasplante , Sensibilidad y Especificidad , Recolección de Tejidos y Órganos/métodos , Resultado del Tratamiento , Cicatrización de Heridas/fisiologíaRESUMEN
We present a regimen for anticoagulation in the immediate postoperative period after left ventricular assist device (LVAD) implantation using low molecular weight heparin (LMWH) as an alternative to unfractionated heparin. Between May and September 2007, eight consecutive patients undergoing LVAD implantation for advanced heart failure received the LMWH nadroparin. Nadroparin was given twice daily to achieve anti-Factor Xa activity target peak levels of 0.4 +/- 0.1 U/mL. The antiplatelet therapy consisted of aspirin (100 mg/day) and dipyridamole (3 x 75 mg/day). One patient underwent heart transplantation, three patients died, and four patients continued to receive device support. The median duration of support was 78 days (range, 46 to 174). No major bleeding was observed; minor bleeding occurred in three patients. In two patients, pump thrombosis was suspected. There were two ischemic and no hemorrhagic strokes. The use of LMWH may provide a new anticoagulation treatment option in the immediate postoperative period after LVAD implantation.
Asunto(s)
Heparina de Bajo-Peso-Molecular/administración & dosificación , Anciano , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Aspirina/administración & dosificación , Dipiridamol/administración & dosificación , Insuficiencia Cardíaca/cirugía , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Heparina/química , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Persona de Mediana Edad , Nadroparina/administración & dosificación , Nadroparina/uso terapéutico , Evaluación de Resultado en la Atención de Salud , Periodo Posoperatorio , Prótesis e Implantes/efectos adversos , Trombosis/prevención & controlRESUMEN
The management of open chest with the vacuum assisted closure (VAC) system was evaluated in terms of impact on cardiac hemodynamics, respiratory parameters, complications, incidence of wound infection, overall handling and outcome in 22 patients during 2005 and 2008 after cardiac surgery. The decision to leave the sternum open was made electively in all patients at the time of primary operation or reexploration. In four patients the VAC was implanted during the primary operation. In the remainder the VAC was implanted after a mean of five days after the primary operation. The overall mortality rate was 45% (10/22). None of the patients developed a sternal wound infection, nor were there any VAC related complications. Management of open chest with the VAC system can be considered as an alternative to sterile draping. The VAC has no negative impact on cardiac hemodynamics as well as respiratory mechanics. The feared complication of right ventricular rupture and massive bleeding can be effectively prevented. Through the stabilizing of the thoracic cage, the patient can be easily moved and mobilized for nursing reasons and pneumonia prevention. Furthermore, the VAC effectively prevents the contamination of the wound and the mediastinum with potential subsequent infection.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Terapia de Presión Negativa para Heridas , Esternón/cirugía , Cicatrización de Heridas , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Niño , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Terapia de Presión Negativa para Heridas/efectos adversos , Terapia de Presión Negativa para Heridas/mortalidad , Proyectos Piloto , Mecánica Respiratoria , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard CarboMedics mechanical aortic valve or a Top Hat CarboMedics valve (CarboMedics, Austin, TX), specifically designed for the small aortic root. METHODS: Between 1986 and 2006, 316 consecutive patients underwent 19- or 21-mm mechanical aortic valve replacement, receiving either a CarboMedics Top Hat bileaflet valve (n = 56; mean age, 66 +/- 14 years) or a standard CarboMedics aortic valve replacement (n = 260; mean age, 60 +/- 13 years) at our institution based on institutional indications for the choice of type of valve prostheses. Median follow-up time was 83.5 months. We studied survival, valve-related and non-valve-related events, and hemodynamic performance by serial echocardiographic follow-up studies. RESULTS: In-hospital mortality was 8.9% in the Top Hat group and 10.0% in the standard group (p = 0.354). Five- and ten-year survival in patients in the Top Hat group was 83% and 67%, respectively. Five- and ten-year survival in the standard group was 73% and 59%, respectively (log-rank = 0.331). There were no differences in regard to valve-related and non-valve-related events. Cox regression analysis revealed age (hazard ratio, 1.045; 95% confidence interval, 1.026 to 1.066), previous cardiac surgery (hazard ratio, 1.812; 95% confidence interval, 1.101 to 2.982), additional procedures at the time of valve replacement (hazard ratio, 2.604; 95% confidence interval, 1.651 to 4.108), New York Heart Association class IV (hazard ratio, 3.645; 95% confidence interval, 1.214 to 10.945), and severely impaired left ventricular ejection fraction (hazard ratio, 2.253; 95% confidence interval, 1.289 to 3.941) to be independent predictors of survival. CONCLUSIONS: Mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality, in particular in the subset of patients requiring additional cardiac surgical procedures. Nevertheless, long-term outcome is satisfying. Because the type of prosthesis does not predict outcome in the multivariate Cox model, we conclude that use of the smaller Top Hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root.
Asunto(s)
Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/terapia , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estudios de Cohortes , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria/tendencias , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Modelos de Riesgos Proporcionales , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Estadísticas no Paramétricas , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Idiopathic dilated cardiomyopathy (DCM) is characterized by ventricular wall remodeling and an increased frequency of cardiac cell apoptosis. Apollon is a 528kD cell membrane-anchored protein that inhibits apoptosis by ubiquitinylation facilitating the degradation of Smac/Diablo and caspase-9. The present study tested the hypothesis that the Apollon/Smac system may mediate programmed cell death in DCM. METHODS: Apollon and caspase-9 protein expression was assessed in left ventricular biopsies of explanted failing hearts using Western blotting in 36 DCM patients undergoing cardiac transplantation and in 10 controls. Human cardiac cells were transfected with a plasmid containing the human Apollon complementary DNA or control vector and were subsequently stressed by hypoxia. Apollon, Smac/Diablo, and caspase-9 expression were then examined in cell lysates by real-time polymerase chain reaction and a transferase-mediated dUTP nick-end labeling assay was used to determine the apoptotic index. RESULTS: In DCM myocardial tissue, Apollon messenger (m)RNA and protein expression was down-regulated compared with control hearts (p < 0.001 and p < 0.005, respectively) concomitant with an increase in activated caspase-9 protein levels (p < 0.001). Cell stress resulted in increased apoptosis in cardiac cells in vitro and down-regulation of Apollon mRNA expression compared with control cells (p < 0.001). Transfection increased Apollon mRNA expression in cell lysates (p < 0.001) and completely prevented hypoxia-induced apoptosis associated with reduced expression of Smac/Diablo and activated caspase-9. CONCLUSIONS: These results suggest that Apollon down-regulation plays a role in programmed cell death associated with DCM. Up-regulation of Apollon might therefore represent a novel therapeutic strategy in the treatment of DCM.
Asunto(s)
Cardiomiopatía Dilatada/patología , Caspasa 8/metabolismo , Muerte Celular/fisiología , Proteínas Inhibidoras de la Apoptosis/metabolismo , Miocitos Cardíacos/efectos de los fármacos , Proteína Inhibidora de la Apoptosis Ligada a X/farmacología , Adulto , Biopsia con Aguja , Western Blotting , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/cirugía , Estudios de Casos y Controles , Muerte Celular/efectos de los fármacos , Células Cultivadas , ADN Complementario/análisis , Regulación hacia Abajo , Femenino , Trasplante de Corazón , Humanos , Etiquetado Corte-Fin in Situ , Proteínas Inhibidoras de la Apoptosis/efectos de los fármacos , Masculino , Persona de Mediana Edad , Miocitos Cardíacos/citología , Probabilidad , Estudios Prospectivos , Valores de Referencia , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Sensibilidad y Especificidad , TransfecciónRESUMEN
We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan.
Asunto(s)
Angioplastia , Aorta Abdominal , Aorta Torácica , Enfermedades de la Aorta/cirugía , Aterosclerosis/cirugía , Implantación de Prótesis Vascular , Stents , Anciano , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Aterosclerosis/diagnóstico por imagen , Estudios de Seguimiento , Humanos , Masculino , Diseño de Prótesis , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: This study was designed to determine the effect of continuous vs pulsatile flow devices on renal function after left ventricular assist device (LVAD) implantation. METHODS: Ninety-two patients undergoing LVAD implantation as bridge-to-transplant therapy were retrospectively analyzed. Patients receiving continuous flow devices (n = 63, 68.5%) were compared with patients receiving pulsatile flow devices (n = 29, 31.5%). Renal function was assessed by 2 calculated glomerular filtration rates (GFR) using the Modification of Diet in Renal Disease (MDRD)-derived GFR (ml/min/1.73 m(2)) and the Cockcroft-Gault-derived creatinine clearance (CrCl, ml/min). RESULTS: Mean GFR/CrCl was comparable between the groups at LVAD implantation, in the post-implantation period, and at transplantation. Both groups had a significant increase in mean GFR at Week 1 post-implantation (continuous, 59.4 +/- 22.8 to 76.4 +/- 38.6, p = 0.001; pulsatile, 52.5 +/- 21.1 to 69.2 +/- 34.7; p = 0.007), Week 4 (continuous, 59.9 +/- 23.0 to 84.3 +/- 32.9; p < 0.001; pulsatile, 50.3 +/- 21.1 to 79.9 +/- 38.7, p = 0.007), and Week 12 (continuous, 60.3 +/- 23.1 to 75.3 +/- 30.2, p = 0.004; pulsatile, 55.5 +/- 23.1 to 74.2 +/- 27.2, p = 0.037) that was also seen with the Cockcroft-Gault-calculated CrCl. No significant increase occurred in mean GFR/CrCl to transplantation. Incidence of post-implantation renal failure was comparable between the groups (continuous, 38.1%; pulsatile, 31.0%; p = 0.512). CONCLUSIONS: After LVAD implantation, patients with continuous flow devices and patients with pulsatile flow devices have comparable renal function.
Asunto(s)
Creatinina/sangre , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Riñón/fisiología , Femenino , Tasa de Filtración Glomerular , Insuficiencia Cardíaca/complicaciones , Humanos , Enfermedades Renales/etiología , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: To determine mid-term durability of endovascular stent-graft placement in patients with penetrating atherosclerotic ulcers (PAU) involving the thoracic aorta and to identify risk factors for death as well as early and late cardiovascular events. METHODS: From 1997 to 2006, 27 patients (mean age 66 yrs) presented with PAU (rupture n=7). Mean numeric EuroScore was 11 and mean logistic EuroScore was 35. Median follow-up was 42 (10-86) months, being complete in all patients. Outcome variables included death and occurrence of early and late cardiovascular events. RESULTS: In-hospital mortality was 11%. Primary success rate was 100%. Actuarial survival rates at 1, 3 and 5 years were 93%, 78% and 70%, respectively. Hemodynamic instability (HR 2.5, 2.1-3.9; p=0.034) as well as logistic EuroScore (HR 2.8, 2.4-4.3; p=0.019) was identified as independent predictor of early and late cardiovascular events. CONCLUSIONS: Endovascular stent-graft placement in patients with PAU is an effective palliation for a life-threatening sign of a severe systemic process. Hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. During mid-term follow-up, patients are mainly limited by sequelae of their underlying disease.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Aterosclerosis/cirugía , Implantación de Prótesis Vascular/métodos , Úlcera/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/patología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/patología , Aterosclerosis/diagnóstico por imagen , Aterosclerosis/patología , Implantación de Prótesis Vascular/efectos adversos , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Úlcera/diagnóstico por imagen , Úlcera/patologíaRESUMEN
BACKGROUND: This study assessed the feasibility of stent graft treatment of ascending aortic dissections in a porcine in vitro model. METHODS: The entire thoracic aortic aorta including the supraaortic branches was harvested from 12 adult pigs and an intimal tear was artificially created. The aortic annulus was then sewn into a silicon ring of a driving chamber. The distal aorta was connected to tubing with adjustable resistance elements. The circulation was driven by a hydraulic motor piston pump to mimic aortic flow and pressure. After creating a dissection by elevating the systolic aortic pressure to 180 mm Hg, a 2- x 2.6-cm covered stent graft was inserted through the brachiocephalic trunk using a specially designed delivery system. Stent graft placement was performed under continuous ultrasound control. RESULTS: The longitudinal length of the created ascending aortic dissection was 1.8 +/- 0.39 cm. Ultrasound studies revealed successful deployment of the stent graft and closure of the false lumen in all 12 cases. Diameter and area of the true lumen increased from 0.52 +/- 0.15 cm to 2.54 +/- 0.36 cm (p < 0.05) and from 0.78 +/- 0.27 cm2 to 5.13 +/- 1.35 cm2 (p < 0.05), respectively. The circumference of the true lumen increased from 4.50 +/- 0.52 cm to 7.96 +/- 1.2 cm (p < 0.05). Ultrasound studies also revealed uncompromised function of the aortic valve in all cases. No dislodging of stent grafts was observed. CONCLUSIONS: Given ideal anatomy, experimental stent graft placement for ascending aortic dissection is feasible and achieves complete closure of the false lumen.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Stents , Disección Aórtica/diagnóstico por imagen , Animales , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Prótesis Vascular , Modelos Animales de Enfermedad , Ecocardiografía Doppler , Estudios de Factibilidad , Probabilidad , Sensibilidad y Especificidad , PorcinosRESUMEN
BACKGROUND: The secretion of heat shock protein (HSP) 27, HSP60, HSP70, HSP90alpha, 20S proteasome, and their correlations to proinflammatory cytokine interleukin-6 is unknown in patients undergoing on-pump versus off-pump coronary artery bypass graft (CABG) operation. METHODS: Forty patients were included in this explorative study (on- versus off-pump CABG, each n = 20). Serum samples were obtained before and 30 minutes, 60 minutes, and 24 hours after CABG operation. Enzyme-linked immunosorbent assay technique was utilized to determine soluble HSP27, 60, 70, and 90alpha, 20S proteasome, and levels of interleukin-6. RESULTS: Serum levels of HSP are increased in patients undergoing on-pump CABG operation as compared with off-pump CABG technique. These differences were highly significant for HSP27, 70, and 90alpha at 60 minutes after initiation of cardiopulmonary bypass (all, p < 0.001). Concentrations of soluble 20S proteasome were increased 24 hours after operation in on- and off-pump CABG patients (p < 0.001) and correlated significantly with the serum content of HSP 27, 70, and 90alpha at 60 minutes after initiation of cardiopulmonary bypass (p < 0.001). No correlation was found when comparing interleukin-6 levels with intravascular leakage of HSP and 20S proteasome after CABG operation. CONCLUSIONS: We conclude from our data that the innate immune system is activated owing to spillage of known immune modulatory and apoptosis-associated proteins after CABG operation.
Asunto(s)
Puente Cardiopulmonar/métodos , Puente de Arteria Coronaria Off-Pump/métodos , Enfermedad Coronaria/sangre , Proteínas de Choque Térmico/sangre , Inmunidad Innata/fisiología , Complejo de la Endopetidasa Proteasomal/sangre , Biomarcadores/sangre , Estudios de Cohortes , Enfermedad Coronaria/diagnóstico , Femenino , Estudios de Seguimiento , Proteínas HSP70 de Choque Térmico/sangre , Proteínas HSP90 de Choque Térmico/sangre , Humanos , Interleucina-6/sangre , Masculino , Persona de Mediana Edad , Análisis Multivariante , Periodo Posoperatorio , Probabilidad , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND: Surgical methods for treatment of tricuspid valve (TV) endocarditis include complete TV excision, TV replacement, and the use of various reconstructive techniques even in cases of severe TV destruction and incompetence. This study summarizes our experience with TV reconstruction and replacement in patients with severe TV endocarditis. METHODS: Between October 1997 and July 2004, TV reconstruction was performed in 18 patients (mean age, 38 +/- 17 years; 7 women, 11 men), and TV replacement in 4 patients (mean age, 48 +/- 22 years; 2 women, 2 men). All patients presented with active endocarditis and severe TV incompetence. Reconstructive techniques included debridement of vegetations, complete resection of infected or destroyed leaflet tissue, leaflet reconstruction with pericardial tissue, sliding plasty of residual valve tissue and bicuspid valve formation with construction of a new commissure, and consecutive ring annuloplasty in all patients. RESULTS: There were no perioperative deaths. Late mortality was 0% for patients with TV reconstruction and 25% (n = 1) in the TV replacement group. At the latest follow-up (78% complete; mean, 53 +/- 18 months), 11 patients had no recurrent TV incompetence. Three patients presented with TV incompetence grade I or II. Two patients with TV reconstruction had recurrent TV endocarditis between 3 and 18 month postoperatively, including new vegetations in both patients and an additional pleural empyema in one. In all cases, conservative treatment was successful and no reoperation was required. CONCLUSIONS: The results of our study clearly demonstrate that in patients with severe TV endocarditis, complex reconstructive techniques yield excellent midterm results with regard to freedom of recurrence of endocarditis and valvular competence and should be considered as the primary surgical option in these patients. Tricuspid valve replacement should only be performed in cases of severe TV destruction that renders reconstructive techniques impossible.