CT-derived left ventricular global strain in aortic valve stenosis patients: A comparative analysis pre and post transcatheter aortic valve implantation.

INTRODUCTION: We assessed the potential of CT strain to detect changes in myocardial function in patients referred for TAVI pre and post intervention. PATIENTS AND METHODS: 25 consecutive patients with symptomatic aortic valve stenosis in whom TAVI had been performed were included in this analysis. Functional CT data sets acquired before and 3 to 6 months after TAVI were available. Multiphase reconstructions in increments of 10% of the cardiac cycle were rendered and transferred to a dedicated workstation (Ziostation2, Ziosoft Inc., Tokyo, Japan). For quantification of left ventricular strain, multiplanar reconstructions of the left ventricle in standard 4 chamber, 2 chamber as well as apical 3 chamber views were rendered. The perimeter of the left ventricle was traced dynamically through the cardiac cycle. Peak strain was calculated for each patient pre and post intervention. Furthermore, for quantification of 3-dimensional maximum principal strain, 2 volumetric regions of interests (VOI) were placed per each basal, mid and apical segment of the previously mentioned MPRs and peak maximal principal strain was calculated. Maximum principal strain as well as perimeter-derived longitudinal strain values in the three standard windows were averaged to obtain global strain. RESULTS: 25 patients were included in this analysis (mean age 78 ±â€¯9 years, 13 males). Peak global maximum principal strain was significantly higher at follow-up compared to baseline (0.46 ±â€¯0.19 vs. 0.59 ±â€¯0.18, respectively, p = 0.001). Similarly global longitudinal strain derived by perimeter was significantly lower - implying better contraction - compared to baseline (-8.6% ±â€¯2.8% vs. -9.8% ±â€¯2.6%, respectively, p = 0.006). CONCLUSION: Using dedicated software, assessment of CT derived left ventricular strain is feasible. In patients treated with transcatheter aortic valve replacement, CT-derived parameters of global myocardial strain improve onshort-term follow-up.

Leaflet thrombosis following transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is increasingly being offered to high-risk patients with symptomatic aortic valve stenosis. Recent reports have suggested a high incidence of subclinical leaflet thrombosis following bioprosthestic aortic valve replacement. We report the frequency and clinical presentation of leaflet thrombosis identified by cardiac CT in patients referred for follow-up contrast enhanced CT angiography following TAVI. METHODS: 91 consecutive patients referred for follow-up contrast-enhanced CT angiography following TAVI were screened for inclusion in this analysis. Out of these, 13 patients were excluded. All CT examinations were performed using a 2nd or a 3rd generation dual-source system (Somatom Definition Flash/Force, Forchheim, Germany). In all patients, retrospectively ECG-gated spiral acquisition with tube modulation was performed to allow for assessment of leaflet motion. All prostheses were analyzed for presence of leaflet thrombosis defined as hypo-attenuated leaflet thickening with or without leaflet restriction. Post-procedural antithrombotic regimen as well as symptom status was documented in all patients. RESULTS: 78 consecutive patients (35 males, 81 ± 4 years) were analyzed. TAVI had been performed in all patients (76 transfemoral access, 2 transapical access) with either balloon-expandable prostheses (4 Sapien XT, 64 Sapien 3) or self-expandable prostheses (5 SJM Portico, 5 Symetis Acurate). Follow-up CT angiography was performed at a median of 4 months following index procedure (Interquartile range 1 month). Leaflet thrombosis was detected in 18 patients (23%, 14 Sapien 3, 1 Sapien XT, 2 SJM Portico, 1 Symetis Acurate). In patients with leaflet thickening on CT, only 11% were on either oral anticoagulation or new oral anticoagulants versus 50% for patients with no leaflet thickening (p 0.002). In patients with leaflet thrombosis, 3 leaflets were affected in 5 patients, 2 leaflets in 5 patients and in 8 patient only 1 leaflet was affected. Clinical symptoms (angina, dyspnea or both) were reported in 2/18 patients with leaflet thrombosis (11%) and in both patients a significant increase of the mean echocardiographic gradient over the prosthesis was documented. The peak and mean echocardiographic gradients obtained at the day of CT examination was significantly higher in symptomatic patients versus asymptomatic patients (peak 46 ± 7 vs. 23 ± 11 mmHg, mean 29 ± 7 vs. 12 ± 6 mmHg, p = 0.01 and 0.002, respectively). Follow-up CT was available for 4 patients with complete resolution of the hypo-attenuated leaflet thickening following treatment. CONCLUSION: Leaflet thrombosis following TAVI is a relatively frequent finding in patients referred for contrast enhanced CT angiography following TAVI. In the majority of patients it follows a subclinical course and is substantially more frequent in individuals who are not on oral anticoagulation. However, in patients with relevant increase in prosthetic gradients, symptomatic presentations are possible.

[Anticoagulation during pregnancy following an artificial heart valve replacement]. / Antikoagulation in der Schwangerschaft nach künstlichem Herzklappenersatz.

HISTORY AND CLINICAL FINDINGS: A 23-year-old woman had received a mechanical bileaflet mitral valve prosthesis because of severe mitral valve insufficiency caused by an acute bacterial endocarditis with vegetations. One year after the operation the patient suffered on two miscarriages under oral anticoagulation by phenprocoumon. Present, she was referred to our center with the question of conversion to low molecular weight heparine because of continued yearning for a baby. INVESTIGATIONS: At admission the woman was in good general and nutritional condition. Echocardiography showed a regular prosthetic function. Blood analysis, electrolyte parameters and enzyme values were normal, further laboratory investigations revealed a factor-V-Leiden-mutation. A chromosomal analysis detected no aberrations. TREATMENT AND COURSE: The oral anticoagulation by phenprocoumon was switched to subcutaneous low molecular weight heparine in therapeutical dosage. Anti-factor-Xa-activity was controlled at regular intervals. Further pregnancy was uneventful for both, mother and child. A healthy infant was born by caesarean section at 40 (th) week of gestation. CONCLUSIONS: Treatment with anticoagulation by phenprocoumon is indispensable for mechanical heart valve protheses. Conversion to low molecular weight heparine is possible in patients who insistent request to conceive. The anticoagulation by low molecular weight heparine avoids teratogenic effects during pregnancy because the placenta is impermeable to that heparin. Furthermore, prophylaxis of thromoses by low molecular weight heparine is probably in almost the same manner as by phenprocoumon.

[Computer-assisted process simulation: a suitable instrument for process optimization in hospitals]. / Computerunterstützte Prozesssimulation: Ein Beitrag zur Prozessoptimierung im OP.

The increasing financial pressure on hospitals resulting from changes in the health system demands detailed knowledge about the cost and earnings situation in the hospital. An essential part of strategic controlling now entails establishing structured cost-unit accounting. This can then be used for example through process optimization to ascertain savings potential and rationalization measures. This paper illustrates a possibility of using computer-assisted process simulation to find ways for prozess optimization. The simulation has been based on the treatment process "operative procedure" of a clinical pathway "CABG" developed in our hospital. The starting points for simulation possible prozess optimization consisted in the elimination of existing waiting times, respectively the parallel organization of certain partial processes. The software used for the simulation was Coral iGrafix Process 2003. The results of 1000 simulation processes reveal a clear reduction in the whole lead-time for the patient, both in avoiding waiting times and also in parallel process organization. In contrast to the initial situation (triangular distribution), the overall duration of the treatment section can be described approximately with normal distribution and a clear cluster of minimum overall durations. Computer-assisted process simulation is a suitable instrument for revealing and establishing possibilities for process optimization in hospitals, and therefore makes a valuable contribution to strategic controlling.

Cost unit accounting based on a clinical pathway: a practical tool for DRG implementation.

Setting up a reliable cost unit accounting system in a hospital is a fundamental necessity for economic survival, given the current general conditions in the healthcare system. Definition of a suitable cost unit is a crucial factor for success. We present here the development and use of a clinical pathway as a cost unit as an alternative to the DRG. Elective coronary artery bypass grafting was selected as an example. Development of the clinical pathway was conducted according to a modular concept that mirrored all the treatment processes across various levels and modules. Using service records and analyses the process algorithms of the clinical pathway were developed and visualized with CorelTM iGrafix Process 2003. A detailed process cost record constituted the basis of the pathway costing, in which financial evaluation of the treatment processes was performed. The result of this study was a structured clinical pathway for coronary artery bypass grafting together with a cost calculation in the form of cost unit accounting. The use of a clinical pathway as a cost unit offers considerable advantages compared to the DRG or clinical case. The variance in the diagnoses and procedures within a pathway is minimal, so the consumption of resources is homogeneous. This leads to a considerable improvement in the value of cost unit accounting as a strategic control instrument in hospitals.

Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications.

OBJECTIVE: Type and frequency of postoperative abnormalities were registered after cardiovascular surgery to evaluate the aetiology and diagnostic value of increased concentrations of procalcitonin (PCT) and C-reactive protein (CRP) during the early postoperative period. DESIGN: Prospective, observational study. PATIENTS: Two hundred and eight patients undergoing coronary artery bypass grafting or valve replacement requiring cardiopulmonary bypass were monitored for 7 days postoperatively for various types of infectious or non-infectious complications. Plasma PCT and CRP levels were measured on day 1 and day 2 after surgery and, when increased, until day 7. RESULTS: More patients with PCT above 2 ng/ml on day 1 or 2 (n=55) had postoperative abnormalities (95%) than patients with lower PCT (59%). Specifically, the incidence of three or more criteria of the "systemic inflammatory response syndrome" was 45% versus 4% (area under the curve of the receiver operating characteristic 0.866); positive inotropic support was needed in 65% versus 9% (0.870); respiratory insufficiency (PaO(2)/FIO(2)<200) 38% versus 12% (0.704); proven and suspected bacterial infection 9% versus 1% (0.900) and 24% versus 1% (0.897), respectively. For CRP, the respective areas under the curve were all below 0.63, while all patients had elevated CRP levels, whether they had a complication or not. CONCLUSIONS: Elevated PCT, but not CRP, correlates with evidence of systemic inflammation and other complications early postoperatively after cardiac surgery. Although the PCT levels do not rise as quickly as the criteria of the systemic inflammatory response syndrome appear, they do reflect systemic inflammation. Early identification and quantification of a systemic inflammatory response may help reduce postoperative complications.

Reducing the post-pump syndrome by using heparin-coated circuits, steroids, or aprotinin.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response called 'post-pump syndrome'. As a part of a complex interaction between white cells and vascular endothelium, proinflammatory cytokines IL-6 and IL-8 are part of a phased immune response that is also balanced by anti-inflammatory cytokines such as IL-10. We compared the influence of heparin-coated circuits, steroids, and aprotinin on these cytokines, looking for ways to reduce the syndrome. METHODS: 40 patients with coronary artery disease (CAD) undergoing elective CABG were prospectively studied in four randomized groups of 10. Group A received prednisolone pre- and postoperatively (2 x 250 mg), group B received aprotinin perioperatively (6 Mio. KIU). In group C, heparin-coated circuits ('Bioline' by Jostra) were used and in group D no special measures were taken (controls). Plasma levels of cytokines were measured before and during CPB and until 12 h after surgery using an ELISA technique. RESULTS: In group A IL-6 was significantly (p<0.05) suppressed in contrast to the control group (A: peak at 4 h, 155 pg/ml vs. control: peak at 8 h, 565 pg/ml). IL-8 was also suppressed (A: peak at 30', 22 pg/ml vs. control: peak at 30', 55 pg/ml). IL-10 level changed first and was markedly upregulated in contrast to the control (A: peak at 30', 1600 pg/ml vs. control: peak at 30', 130 pg/ml; p<0.05). In group B (aprotinin) the cytokine release was similar to group A. Using heparin-coated circuits (group C) also led to a significant (p<0.05) IL-10 upregulation (C: peak at 2 h, 1380 pg/ml) and IL-6 suppression (C: peak at 4 h, 290 pg/ml). IL-8 was not influenced significantly. CONCLUSIONS: The results show a similar reduction of the inflammatory cytokine release (IL-6 and IL-8 as markers) using early steroid application and aprotinin in high dosage. Heparin coating reduces IL-6 and increases IL-10 release, whereas IL-8 is not affected. Further studies should investigate the effects of a combined application for reducing inflammatory cytokine release and the post-pump syndrome.

High-risk mitral valve replacement in severe pulmonary hypertension--30 years experience.

OBJECTIVE: In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP) > 50 mmHg; pulmonary vascular resistance (PVR), 690 +/- 46 dyn/s per m2). We reviewed our early and late results in this high-risk subgroup. METHODS: We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4 +/- 0.2 years per patient. The overall early mortality rate was 10.5% (n = 40) and stayed at about the same level over the years, although patients characteristics have changed to much older patients and more reoperations. To clarify this fact we divided our data in results according to the decades in which the operations were carried out. The clinical preoperative status and results were as follows (*P < 0.05; **P < 0.01 compared with previous decade). In the decades between 1963 and 1973 (I), 1974 and 1983 (11) and 1984 and 1993 (III) we operated on n = 95 (I), n = 185 (II), and n = 102 (III) patients with a mean age of 43 +/- 1 (I), 50 +/- 1** (II), and 58 +/- 1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6%** (III). The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (III); late mortalities lowered from 5.77 (I), over 4.95 (II), and up to 3.39%** (III) patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0 +/- 0.1 (I), 3.2 +/- 0.1 (II) and 3.3 +/- 0.1 (III) to 2.4 +/- 0.2 (I), 2.4 +/- 0.1 (II) and 2.3 +/- 0.1 (III) postoperatively. RESULTS: Compared with routine elective MVR with a mortality rate of 3.6% (P < 0.01), early mortality is high. But once the patient survives the perioperative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as well are not significantly different. In spite of on average 15 years older multimorbid patients with therefore higher complication rates, early results improved slightly, which could be explained by better operative techniques, perioperative treatment and nursing (online monitoring with immediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes. CONCLUSION: According to our results, we recommend MVR in severe pulmonary hypertension even in the elderly, with a high but acceptable risk and good long-term results.

Results of a 1 to 31 years follow-up after aortic valve replacement in 2327 patients.

We studied the outcome of 2327 patients after aortic valve replacement from October 1962 to December 1993. 1840 mechanical (mostly STJ bi-leaflet and BS tilting disc valves) and 487 biological (IS and CE valves) prostheses were implanted. The mean follow-up period of 1458 surviving patients was 7.1 years. There were 688 non-survivors and 181 lost cases. The mean age was 50.1 years, 73% of the patients were male and 27% were female. Early mortality was about 20% in the 1960's and about 4.5% in the last years. Mortality following valve replacement was influenced by preoperative NYHA classification, cardiac index, pressure gradient and simultaneous CHD. The long term results of all valves showed a survival rate of 80% after 5 years, 73% after 10 and 60% after 15 years following operative treatment. There was no significant difference in survival rates between all mechanical and biological valves. Non-lethal complications of all mechanical valves showed no significant difference but there was a clearly lower rate of paraprosthetic leakages, haemolysis and thromboembolism in biografts. The biological valves showed a high rate of degeneration (2.7%/pty). Reoperation was performed in 170 patients. Most valve changes consisted of biological to mechanical and mechanical to mechanical valves. The main reason of reoperation was degeneration (biological), paraprosthetic leakage and haemolysis (mechanical). The cause of death of the 688 non-survivors was valve related in 17.9%. 37% of these were due to thromboembolism and 38% due to bleeding. 55.6% of survivors (group 2) could be ascribed to NYHA class III and 17.2% to class IV prior to operation. Postoperative outcome demonstrated an improvement in NYHA classification in about 80%. Of surviving patients 80% pronounced an increase of physical activity after operation.

[Rooming-in as a therapeutic possibility for a 6-year-old autistic girl]. / Rooming-in als Therapiechance für ein sechsjähriges autistisches Mädchen.

The possibilities of rooming-in as a form of therapy for the psychic abnormal child are demonstrated on the basis of the example of a mother-child-therapy, which lasted six weeks and happened during the stay of mother and child on our station. The patient was a six year old, intellectually retarded girl with autistic behavior disturbances. The points of main effort in our therapeutical interventions were set on reaching a higher selfreliance of the patient as far as every day life-routine was concerned, further more on increasing the child's social and intellectual capabilities and on eliminating the girl's sleeping troubles. In order to reach these aims we started a training in behavior modification (operant conditioning, modeling) for mother and child. The remarkable developmental progresses of our patient are attributed most of all to the thorough efforts that were made in order to improve the abilities of the girl by modifying the contact between mother and child. Besides, the possibility of being able to use the whole day for therapy, to discuss and,--if necessary--to correct immediately the learning experiences that have been made, seems to be a great chance for reaching the appropriate forms of action and interaction in a quicker way.