Percutaneous occlusion of post-myocardial infarction ventricular septum rupture.

AIMS: The aim of this systematic review is to gain insight into the published experience on percutaneous closure of a post-infarction ventricular septal rupture (VSR). METHOD: Relevant literature was obtained by MeSH-term searches in the online search-engine PubMed. Articles published in the last 10 years were included. Further filtering was done by using search limits and individual article selection based on the aims of this systematic review. CONCLUSION: Percutaneous closure is a potential technique in a select group of patients. The presence of cardiogenic shock and closure in the acute phase after VSR diagnosis are important risk factors of mortality. Device implantation is in general successful with few procedure-related complications. Reduction of the shunt fraction has been reported frequently. This technique is a less invasive alternative to surgical treatment and should be applied on a case-by-case basis.

Severe stomatitis complicating immune-suppressive switch after cardiac transplantation.

Everolimus is a recently developed immunosuppressive drug for patients following solid organ transplantation. Its mechanism of action, independent of calcineurin, is different from that of ciclosporin and tacrolimus and because of its lack of nephrotoxicity, it is a good alternative for calcineurin inhibitors in patients with renal dysfunction. In this paper we describe the case report of a 66-year-old caucasian female who underwent heart transplantation in December 2006. After induction with rabbit anti-thymocytic globulin, her immunosuppressive therapy comprised the combination of tacrolimus, mycophenolate mofetil (MMF) and steroids. Because of renal dysfunction, tacrolimus was changed for everolimus after 6 months. Unfortunately our patient developed severe stomatitis with aphthous ulcerations, shortly after the switch. Despite oral therapy (local anaesthetics), severe pain and malnourishment prompted interruption of everolimus and MMF and therapy was changed to ciclosporin and azathioprine. In addition, thalidomide was added. During the following weeks, there was progressive healing of the ulcerations. MMF was re-introduced and thalidomide was stopped after 6 weeks, without recurrent lesions after 4 months of follow-up.

Titanium transverse plate fixation: a new solution for old sternal problems.

OBJECTIVE: To evaluate our initial results with the titanium transverse plate fixation system of the sternum in four patients. METHODS: Two patients with late dehiscence and persistent instability of the sternum after cardiac surgery were treated with refixation by titanium transverse plates and screws. Two patients were treated with the same refixation method after pre-treatment with debridement, antibiotic therapy and vacuum-assisted closure therapy for extensive mediastinitis. RESULTS: All four patients healed without complications. The mean postoperative length of stay was 17,3 days (range 7-44). The instability and/or pain disappeared in all patients. The postoperative imaging showed good positioning of the osteosynthesis material. There was no re-infection in patients with mediastinitis. CONCLUSIONS: The titanium transverse plate fixation system is a very promising adjunct to the armamentarium of the cardio-thoracic surgeon for treatment of sternal problems, including dehiscence and fractures, even when mediastinitis is involved. It offers more stability compared to simple rewiring, without the need for extensive retrosternal dissection.

Guidelines for quality improvement in cardiac surgery. The College of Cardiac Surgery : results of the 2007 survey.

Optimal delivery of health care is a common goal of individual physicians, professional organizations, hospital structures and governmental authorities. A growing concern has emerged from the public, media and third payer organizations concerning the quality of care and the amount of resources spending. In the United States, large databases, guidelines and performance evaluation have been elaborated by medical societies, particularly in the area of cardiac surgery. These tools are useful for improvement of patients' care, resources distribution, pay for performance and public and practitioners' awareness. The evaluation of quality is based on composite models combining structure, process and outcome indices. However, pitfalls such as patients' selection, and risk avoidance in order to improve results must been prevented by adjustment of the treated populations' risk factors by specific scores. The Belgian Health authorities have built a structure directed at delivery of care improvement based on "Care Programs", monitored by Colleges formed by delegates of professional organizations. The College of Cardiac Surgery has promoted several studies aimed at data collection and evaluation. In 2007, a survey was addressed to all the Belgian Cardiac surgeons to define their opinion as to the best indicators of care in their specialty. These results will serve to define further avenues of research. By maintaining the responsibility of care evaluation in the hands of the involved professionals, this kind of cooperation between governmental and physicians' organizations seems to serve the best interests of the public and the practitioners.

Effects of phosphodiesterase III inhibition on length-dependent regulation of myocardial function in coronary surgery patients.

BACKGROUND: Phosphodiesterase III inhibitors increase myocardial contractility and decrease left ventricular (LV) afterload. We studied whether these effects altered LV response to an increase in cardiac load and affected length-dependent regulation of myocardial function. METHODS: Before the start of cardiopulmonary bypass, a high-fidelity pressure catheter was positioned in the left ventricle and the left atrium in 10 coronary surgery patients. LV response to an increased cardiac load, caused by leg elevation, was assessed during baseline conditions and after administration of milrinone at a dose of 20 micrograms kg-1 over 15 min. Effects on contraction were measured by changes in maximal rate of pressure development (dP/dtmax). Effects on relaxation were assessed by analysis of changes in maximum rate of pressure decrease and by analysis of the load dependency of myocardial relaxation (R = slope of the relation between the time constant of isovolumic relaxation and end systolic pressure). RESULTS: Milrinone increased dP/dtmax but measures of relaxation were unaltered. Leg elevation had more effect on measures of contraction and relaxation after milrinone than at baseline. The relationship between R and changes in dP/dtmax shifted downwards and to the right with milrinone, whereas the relationship between R and changes in end diastolic pressure (EDP) shifted downwards and to the left. CONCLUSIONS: This suggests that milrinone improved contraction, reduced the load dependency of LV pressure decrease, and reduced the change in EDP after leg elevation.

Antiproliferative effect of plant cytokinin analogues with an inhibitory activity on cyclin-dependent kinases.

In this study, analogues of olomoucine, a previously described plant cytokinin analogue with cyclin-dependent kinase (CDK) inhibitory activity, were investigated for effect on CDK1 and CDK2 and for effect on cell proliferation. Eight new compounds exhibit stronger inhibitory activity on CDK1 and CDK2 and on cell proliferation than olomoucine. Some active compounds showed low inhibition of proliferation of normal myeloid growth. Improvement of inhibitory activity of known compounds with a C6-benzylamino group was brought about by substitution with one hydroxyl. Also, new C2 substituents associated with inhibitory activity on CDK and on cell proliferation are described. There was a significant correlation between effect on CDK and antiproliferative effect on the KG1 and Molt3 cell lines and on primary human lymphocytes, strongly suggesting that at least part of the antiproliferative effect of cytokinin analogues was due to inhibition of CDK activity. Cytokinin analogues induced apoptosis in a time- and concentration-dependent manner and changes in cell cycle distribution. The antiproliferative and pro-apoptotic effects of plant cytokinin analogues suggest that they are a new class of cytostatic agents and that they may find an application in the chemotherapy of cancer.

Primary cardiac allograft failure after donor carbon monoxide poisoning treated with biventricular assist device.

Because of the current donor shortage, organ selection criteria are being progressively liberalized. We present a case of carbon monoxide poisoning in a multiorgan donor that led to primary cardiac allograft failure. A biventricular assist device was used as a bridge to recovery.

Should we use video-assisted endoscopic vein harvesting as a standard technique?

BACKGROUND: To investigate the feasability and results of endoscopic vein harvesting (EVH) using the Vasoview Uniport system (Guidant Corporation, Menlo Park,CA). Can this technique be used as a standard technique for vein harvesting in coronary artery bypass surgery (CABG) or is it too time consuming? Do smaller incisions result in less morbidity and discomfort? METHODS: From October 1998 to May 1999, 158 patients who underwent CABG with venous grafts, in addition to arterial grafts, formed the study population for EVH. In group A (n=131) the vein was harvested with the Vasoview Uniport System. In group B (n=27) the vein was harvested by a conventional open technique with interrupted incisions because of unavailability of the equipment. Recordings were made on vein length, harvest time, length of incision, and complications. RESULTS: In none of the patients in group A was a conversion to the open technique necessary. In 72/131, pure EVH was used. In 59/131 an additional incision below the knee was used for harvesting extra vein length. Mean harvested vein graft length (cm) was 35.9 (range 18-56) in group A and 30.6 (range 16-51) in group B, and mm of vein harvested/min was 77 and 71 in group A and B. Mean time for harvesting and closing (min) was 56.1 (range 14-120) SD 20.4 and 78.3 (range 37-129) SD 26 for a mean length of incision (cm) of six (range 2-19) and 27 (range 12-54). Wound complications at postoperative day three at discharge, and after six weeks were seen in 30 (23%), 27 (20%) and four (4%) patients of group A, and in five (18%), five (18%) and four (23%) of group B. CONCLUSIONS: Despite a learning curve in using endoscopic techniques, the total procedural time for EHV is acceptable and even shorter than open harvesting. Most of the time is gained in closure of the wound. Hematoma formation is the most common peroperative complication, but diminishes with experience. The absence of postoperative edema after EVH is striking. Despite the higher costs for disposable material, we have adopted EVH as a standard technique since patient and surgeon satisfaction have improved substantially.

Effects of desflurane and sevoflurane on length-dependent regulation of myocardial function in coronary surgery patients.

BACKGROUND: Desflurane and sevoflurane have negative inotropic effects. The current study investigated whether these effects resulted in an altered left ventricular response to increased cardiac load and affected length-dependent regulation of myocardial function. Length-dependent regulation of myocardial function refers to the ability of the heart to improve its performance when preload is increased. METHODS: A high-fidelity pressure catheter was positioned in the left ventricle and left atrium in 20 coronary surgery patients with a preoperative ejection fraction greater than 40%. Studies were performed before the initiation of cardiopulmonary bypass. Left ventricular response to increased cardiac load, obtained by leg elevation, was assessed during control conditions and during increasing concentrations of desflurane (2, 4, and 6% end tidal; n = 10) or sevoflurane (1, 2, and 3% end tidal; n = 10). Effects on contraction were evaluated by analysis of changes in maximal rate of pressure development. Effects on relaxation were assessed by analysis of changes in minimum rate of pressure development and by analysis of the load dependence of myocardial relaxation (R = slope of the relation between time constant tau of isovolumic relaxation and end-systolic pressure). Peak left atrial-left ventricular pressure gradients were analyzed during early left ventricular filling. RESULTS: With both desflurane and sevoflurane, maximal and minimum rates of pressure development decreased while tau increased. Peak left atrial-left ventricular pressure gradients remained unchanged. The hemodynamic effects of leg elevation were similar at the different concentrations. Changes in parameters of contraction and relaxation during leg elevation were coupled and were not altered by desflurane or sevoflurane. CONCLUSIONS: Despite their negative inotropic and lusitropic effects, neither desflurane nor sevoflurane adversely affect length-dependent regulation of left ventricular function. In the conditions of our study, the ability of the left ventricular to respond to increased cardiac load is not altered by the use of desflurane or sevoflurane.

The effects of the pericardium on length-dependent regulation of left ventricular function in coronary artery surgery patients.

OBJECTIVE: To analyze the effects of the pericardium on the length-dependent regulation of myocardial function in coronary artery surgery patients. DESIGN: Prospective. SETTING: University hospital. PARTICIPANTS: Patients scheduled for elective coronary artery surgery. INTERVENTIONS: In 10 patients, a combined micromanometer transducer conductance catheter was inserted into the left ventricle for measurement of left ventricular pressures and volumes. MEASUREMENTS AND MAIN RESULTS: Consecutive data were obtained during a progressive increase in left ventricular pressures and volumes obtained by leg elevation in closed chest-closed pericardium and open chest-open pericardium conditions. Pericardiotomy did not alter baseline left ventricular hemodynamics. The effects of leg elevation were different, however. In closed chest-closed pericardium conditions, stroke volume and stroke work remained unchanged, whereas these parameters increased in open chest-open pericardium conditions. This increase was related to the increase in end-diastolic volume that was observed in open chest-open pericardium conditions and not in closed chest-closed pericardium conditions. CONCLUSIONS: In coronary artery surgery patients, pericardiotomy does not alter baseline left ventricular function. When cardiac load is increased by leg elevation, however, use of the Frank-Starling mechanism is enhanced in open chest-open pericardium conditions.

Establishment of serum-free pre-colony forming unit assays for differentiation of primitive hematopoietic progenitors: serum induces early macrophage differentiation and inhibits early erythroid differentiation of CD34++CD38- cells.

In this report we show that serum has differentiation-inducing effects on primitive hematopoietic progenitor cells with the CD34++CD38- immunophenotype. Using the pre-colony forming unit (pre-CFU) assay as a model for early myelopoiesis, we compared the effects of serum-containing and serum-free media and evaluated different cytokine cocktails [interleukin (IL)-1, IL-3, IL-6, kit ligand with and without the Flt3/Flk2 ligand (FL)]. In this assay, pre-CFUs are defined as cells unable to form colonies when plated directly in semi-solid assays, but which can differentiate into CFUs when cultured in liquid medium containing early-acting cytokines. In one of the investigated serum-free media, the average myeloid expansion in liquid medium reached up to more than 50% of that obtained in serum-containing medium. In addition, our experiments revealed differences in the clonogenic output between cells cultured in serum-free medium and those cultured in serum-containing medium, demonstrating that serum has a monocyte differentiation-inducing effect on primitive hematopoietic progenitors. Also in serum-free medium, higher proportions of erythroid progenitors were generated. These differentiation-inducing effects of serum further emphasize the need for serum-free culture protocols for hematopoietic graft engineering. Addition of FL to the culture media ameliorated cellular expansion and resulted in a decrease in the proportion of erythroid and granulocyte progenitors and an increase in the proportion of monocyte progenitors. In conclusion, this study shows that good serum-free conditions are available for differentiation assays with primitive hematopoietic progenitors and demonstrates that serum and FL have biasing effects on the initial phase of hematopoietic differentiation, favoring the monocyte lineage.

Emergency ventricular assist device: better survival rates in non-post cardiotomy-related cardiogenic shock.

OBJECTIVE: The Abiomed BVS 5000 ventricular assist device (VAD) has been approved in Belgium for emergency cardiac support in patients with postcardiotomy failure with the aim of native heart function recovery. Other indications have emerged from world wide experience, but the indication and usefulness of emergency implantation of assist devices is often debated. METHODS: To decide which patients benefit most from emergency ventricular assist device implantation, we retrospectively reviewed our results of mechanical circulatory support with Abiomed in 20 patients over a 4-year period. Fifteen patients with mean age 58 +/- 6 years experienced postcardiotomy failure and underwent biventricular assist device (BVAD) implantation (group A), after elective (n = 9) or after emergency coronary artery bypass grafting (CABG) (n = 6). Five patients (group B), with mean age 35 +/- 19 years, had an implantation for other underlying conditions: hypertrophic cardiomyopathy (n = 3), myocarditis (n = 1) and primary cardiac allograft failure (n = 1). RESULTS: Of these two groups, eight and two patients respectively needed cardiopulmonary resuscitation before VAD implantation. The mean duration of support in both groups was 5.8 (range 12 h-13 days) and 4.4 days (range 2 h-9 days) respectively. Six and two patients could be weaned from the device and nine and one patients respectively, died on the device. Two patients in group B underwent successful heart transplantation and four patients in group A died after weaning. Two patients in the postcardiotomy group and four patients in group B survived (13% and 80%) with an overall survival and discharge rate of 30%. CONCLUSION: Although sample sizes are small, better survival rates with emergency Abiomed BVS 5000 implantation were obtained in the non postcardiotomy group (group B). For patients in the postcardiotomy group, outcome was negatively influenced by cardiac arrest and resuscitation before urgent CABG. Since death is the only alternative for these patients in cardiogenic shock and organ recovery cannot be predicted, we continue to consider emergency VAD implantation in this patient population.

Cardiac surgery in octogenarians.

OBJECTIVE: The elderly segment of the Western population is increasing rapidly, and cardiac surgeons are being asked to consider the very elderly for cardiac surgery. Our objective was to obtain data on the outcome of cardiac surgery in octogenarians in order to improve the indication for surgery and to give more accurate information to patients, family and general practitioners. METHODS AND RESULTS: From January 1990 through December 1998, 127 octo- and nonagenarians (age 80-94, mean 82.2 years) underwent cardiac surgery (coronary artery bypass grafting, valve surgery and aortic surgery) at the University Hospital of Antwerp. A retrospective review of the patients' medical records was performed. Follow-up information was obtained by mail or telephone from each patient's primary physician or cardiologist. Hospital mortality was 7.1% (9/127) and late mortality (mean follow-up 2 years) was 23% (30/127). Actuarial survival at 108 months was 70% (90/127). Eighty-three percent of the patients were having class III or IV anginal symptoms before operation. At follow-up 76% of the survivors were in NYHA class I or II. CONCLUSION: Cardiac surgery in the very old often permits survival with improved symptoms. Therefore surgery should not be refused solely because of old age.

Chronic osteomyelitis after sternotomy.

Two patients with chronic sternal osteomyelitis after an initially uncomplicated coronary artery bypass grafting (CABG) operation are described. Chronic osteomyelitis, caused in both cases by Pseudomonas aeruginosa, occurred six and four months after CABG respectively. Because chronic infection failed to respond to local wound care and medical therapy, more radical treatment was needed. Steel wires were removed and surgical debridement was performed. In one patient, an additional omental transposition was performed. In both cases radical debridement in combination with antibiotics successfully eradicated the infection.

Assessment of length-dependent regulation of myocardial function in coronary surgery patients using transmitral flow velocity patterns.

BACKGROUND: In a subset of coronary surgery patients, a transient increase in cardiac load by leg elevation resulted in a decrease in maximal rate of pressure development (dP/dtmax) and a major increase in end-diastolic pressure (EDP). This impairment of left ventricular (LV) function appeared to be related to a deficient length-dependent regulation of myocardial function. The present study investigated whether analysis of transmitral flow patterns with transesophageal echocardiography constituted a noninvasive method to identify these patients. METHODS: High-fidelity LV pressure tracings and transmitral flow signals were obtained in 50 coronary surgery patients during an increase in cardiac load by leg elevation. Using linear regression analysis, changes in transmitral E-wave velocity and deceleration time (DT) were related to changes in dP/dtmax and EDP. RESULTS: Changes in dP/dtmax with leg elevation were closely related to corresponding changes in E-wave velocity (r = 0.81; P < 0. 001) and to changes in DT (r = 0.78; P < 0.001). Similarly, changes in EDP were related to changes in E-wave velocity (r = 0.83; P < 0. 001) and to changes in DT (r = 0.84; P < 0.001). The decrease in dP/dtmax and the major increase in EDP in some patients was associated with an increase in E-wave velocity and a decrease in DT, indicating development of a restrictive LV filling pattern. CONCLUSIONS: Impairment of LV function with leg elevation was associated with the development of a restrictive transmitral filling pattern. Analysis of transmitral flow patterns by means of transesophageal echocardiography therefore allowed noninvasive identification of a subset of coronary surgery patients with impaired length-dependent regulation of LV function.

Generation of T cells from adult human hematopoietic stem cells and progenitors in a fetal thymic organ culture system: stimulation by tumor necrosis factor-alpha.

To investigate the T-lymphopoietic capacity of human adult bone marrow (ABM) hematopoietic progenitor cells, CD34+Lin-, CD34+CD38+, and CD34++CD38- cells were cultured in a severe combined immunodeficient (SCID) mouse fetal thymic organ culture (FTOC). Direct seeding of these progenitors resulted in a moderate to severe cell loss, particularly for the CD34++CD38- cell fraction, and T cells could only be generated from the CD34+Lin- fraction. Preincubation for 36 hours with interleukin-3 (IL-3) and stem cell factor (SCF) led to an improved cell survival and proliferation, although T-cell development was seen only in the CD34+Lin- fraction. Addition of tumor necrosis factor (TNF)-alpha to IL-3 + SCF-supplemented preincubation medium resulted in optimal cell survival, cell proliferation. and T-cell generation of all 3 cell fractions. The TNF-alpha effect resulted in an up-regulation of CD127 (ie, the IL-7 receptor alpha-chain) in a small subset of the CD34+ cells. No evidence could be generated to support the possibility that TNF-alpha inhibits a cell population that suppresses T-cell differentiation. A quantitatively different T-cell generation potency was still seen between the 3 subpopulations: CD34+Lin- (100% success rate) > CD34+CD38+ (66%) > CD34++CD38- (25%). These data contrast with our previous findings using fetal liver and cord blood progenitors, which readily differentiate into T-lymphocytes in FTOC, even without prestimulation with cytokines. Our results demonstrate that adult CD34++CD38- cells, known to contain hematopoietic stem cells, can differentiate into T-lymphocytes and that a significant difference exists in T-lymphopoietic activity of stem cells derived from ontogenetically different sources. (Blood. 2000;95:2806-2812)

Coronary artery bypass grafting on the beating heart using the Octopus method.

STUDY OBJECTIVE: To study the usefulness and effectiveness of off-pump coronary bypass grafting with the Octopus heart stabilizing device. METHOD: The files of thirty-one patients undergoing coronary artery bypass with the aid of the Octopus heart stabilizing device between April 1996 and October 1998 were studied retrospectively. Patients were divided into group A (n = 23), patients with single or double vessel disease and technically suitable coronary lesions for off-pump procedure and group B (n = 8), patients with multiple vessel disease considered to be with excessive risk for cardiopulmonary bypass due to poor general condition combined with renal failure and/or chronic obstructive pulmonary disease. Standard median sternotomy (n = 27), lateral thoracotomy (n = 1) or minithoracotomy (n = 3) were performed for access and for harvesting the left internal mammary artery (LIMA). MEASUREMENTS AND RESULTS: The mean number of bypasses was 1.2 and 1.1 in groups A and B, respectively. Thirty patients received a LIMA graft to the left anterior descending artery (LAD). Homologous blood transfusions were needed in five patients (21%) in group A and four (50%) in group B. There were no wound infections or neurologic complications. All patients in group A survived and are asymptomatic. One patient in group B died of septic shock, two have residual angina pectoris or dyspnea, and five are asymptomatic. CONCLUSION: Coronary artery bypass using the Octopus heart stabilizing device proved to be a safe and effective technique resulting in complete revascularization in group A patients with no mortality. Incomplete revascularization may offer a substantial benefit to patients who cannot tolerate cardiopulmonary bypass due to poor general condition. We prefer median sternotomy, allowing precise harvesting of the internal mammary artery and more precise anastomoses without increased morbidity.

GP130 and c-kit signalling, initiated by the sIL-6R/IL-6 complex, is insufficient to expand the primitive adult bone marrow CD34+CD38- pre-CFU cell.

It has previously been shown that gp130 and c-kit signalling synergize for the ex vivo expansion of human cord blood (CB) CD34+ haematopoietic progenitor cells. We were interested in evaluating this synergy within an ontogenetically different haematopoietic tissue [i.e. adult bone marrow (BM)] and on a more primitive progenitor subset (i.e. CD34+ CD38-cells), which are highly enriched for pre-colony forming unit (CFU) cells. These cells were plated out in a primary liquid culture supplemented with either interleukin (IL)-6+stem cell factor (SCF), IL-6+ SCF+soluble IL-6 receptor (sIL-6R), IL-6+SCF+sIL-6R+IL3+IL-1 or SCF+IL-3+IL-6+IL-1. Cell counting after liquid culture revealed an absolute expansion of 2.2-, 4.1-, 89.5- and 65.7-fold compared with initial cell input for the four-cytokine combinations, respectively. The secondary read-out assay revealed that this cell expansion in the liquid culture also resulted in CFU generation, with absolute cloning efficiencies of 0.002, 0.024, 12.13 and 7.73 (per cell initially present) for the respective cytokine combinations. These results indicate that gp130 and c-kit signalling alone (i.e. using IL6+SCF+sIL-6R), in terms of both cell number and CFU generation, insufficiently stimulate primitive adult BM CD34+CD38- haematopoietic cells in order to reach a CFU generation comparable with that obtained after multifactor stimulation. Adding sIL-6R to the multifactor stimulation and compared with this multifactor stimulation, a 1.7-fold synergy in terms of cell expansion and a 3.0-fold synergy in terms of CFU generation are obtained. The sIL-6R/IL-6 complex thus has a narrower spectrum of action on primitive adult BM CD34+CD38- cells than on CB CD34+ cells.

Spontaneous dissection of three major coronary arteries subsequent to cystic medial necrosis.

This case report describes the devastating consequences of spontaneous coronary dissection in a 36-year-old female patient. Surgical revascularization was attempted, but diffuse myocardial infarction developed. The patient was bridged to heart transplantation but died secondary to multiple organ failure. To our knowledge, this is the only reported case of spontaneous dissection of the three main coronary arteries due to severe cystic medial necrosis.