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1.
Clin Res Cardiol ; 95(1): 48-53, 2006 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-16598445

RESUMO

OBJECTIVE: Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or-in addition with cerebral symptoms-in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS). METHOD: We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks. RESULTS: A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case. Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery. CONCLUSION: The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.


Assuntos
Angina Pectoris/diagnóstico , Angina Pectoris/etiologia , Ponte de Artéria Coronária/efeitos adversos , Síndrome do Roubo Subclávio/diagnóstico , Síndrome do Roubo Subclávio/etiologia , Insuficiência Vertebrobasilar/diagnóstico , Insuficiência Vertebrobasilar/etiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva
3.
Z Kardiol ; 92(4): 339-46, 2003 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-12707794

RESUMO

We report of long-term follow-up of a combined fusiform aneurysm of the right subclavian artery extending to the thyreocervical trunk (3.2 x 2.8 x 2.2 cm (width x height x depth)) in a 33-year old patient. As a newborn, the clinical diagnosis of an aortic isthmus stenosis was made without need for intervention at this stage. Further development of the child remained unremarkable until the age of eleven years when he experienced dizziness after sporting activities. Due to clinically proven progress, cardiac catheterization was performed and confirmed the initial diagnosis of a juxtaductale stenosis of the aortic isthmus, which was operated thereafter with an end-to-end anastomosis. Furthermore, an aneurysm of the right subclavian artery was revealed. Since then, non-invasive routine follow-up showed no significant worsening of this aneurysm, which extends to the thyreocervical trunk. The patient has been event free and completely asymptomatic. This case report illustrates the more than twenty years of follow-up of an asymptomatic combined fusiform aneurysm of the subclavian artery and thyreocervical trunk and provides a review of the literature on this topic.


Assuntos
Aneurisma/diagnóstico , Coartação Aórtica/cirurgia , Complicações Pós-Operatórias/diagnóstico , Artéria Subclávia , Adolescente , Adulto , Coartação Aórtica/diagnóstico , Criança , Pré-Escolar , Ecocardiografia , Eletrocardiografia , Seguimentos , Humanos , Lactente , Recém-Nascido , Angiografia por Ressonância Magnética , Masculino
4.
Pediatr Cardiol ; 24(3): 304-6, 2003.
Artigo em Inglês | MEDLINE | ID: mdl-12522653

RESUMO

Congenital absence of aortic cusps leads to severe aortic regurgitation. We present a newborn with this rare entity with extreme mitral stenosis. Hemodynamic features were those of hypoplastic left heart syndrome. Surgical management consisted of initial modified Norwood procedure followed by orthotopic heart transplantation.


Assuntos
Insuficiência da Valva Aórtica/congênito , Insuficiência da Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Estenose da Valva Mitral/congênito , Estenose da Valva Mitral/cirurgia , Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/diagnóstico , Transplante de Coração , Humanos , Recém-Nascido , Masculino , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/diagnóstico , Reoperação , Resultado do Tratamento
5.
Thorac Cardiovasc Surg ; 50(6): 347-50, 2002 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-12457311

RESUMO

BACKGROUND: Gene therapy in cardiovascular disease promises to be of great impact. The ideal vector for the therapeutic gene transfection remains to be determined. The aim of the present study was to investigate the efficacy of gene transfer using adeno-associated virus vectors carrying the lacZ-reporter gene (AAV-lacZ) in a previously described coronary recirculation model. METHODS: Beating Lewis rat hearts perfused with oxygenated Krebs-Henseleit solution were harvested, after which an atrial septal defect (ASD) was created. All vessels were tied, and AAV-lacZ was injected into the aortic root. The solution was recirculated through the ASD to the left side of the heart and pumped back to the coronary arteries by the left ventricle. Incubation was allowed for 20 min at 15 degrees C, and the hearts were subsequently transplanted heterotopically in syngeneic rats. Three increasing doses (109, 1,010, 1,011 e. u.) of AAV-lacZ virus vectors were used to study the rate of gene transfer. All hearts were harvested after 7-60 days and evaluated histologically for expression of the lacZ-gene. RESULTS: Dose-dependent gene transfer was observed. Even after 60 days, there was no obvious decline in gene expression. CONCLUSION: Adeno-associated virus vectors offer effective and uniform gene transfer in the myocardium after transcoronary injection and recirculation. Due to the lack of immune response previously described, no decrease in gene expression can be observed up to 60 days after injection.


Assuntos
Dependovirus/genética , Expressão Gênica , Terapia Genética/métodos , Cardiopatias/terapia , Animais , Soluções Cardioplégicas/metabolismo , Modelos Animais de Doenças , Relação Dose-Resposta a Droga , Técnicas de Transferência de Genes , Genes Reporter , Cardiopatias/genética , Transplante de Coração , Óperon Lac , Masculino , Miocárdio/metabolismo , Ratos , Ratos Endogâmicos Lew
6.
Thorac Cardiovasc Surg ; 50(6): 351-4, 2002 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-12457312

RESUMO

BACKGROUND: Mitral valve surgery for the correction of secondary mitral valve regurgitation (MR) in cardiomyopathy is associated with a poor outcome. Numerous studies have identified a severe left ventricular dysfunction as an indicator for a poor prognosis. The aim of the study was to asses the follow-up after mitral valve surgery and severe left ventricular dysfunction. METHODS: Between 1994 and 2000, 31 patients with mitral regurgitation and a left ventricular ejection fraction of below thirty percent undergoing isolated repair (n = 16) or replacement (n = 15) were investigated. All patients received maximal drug therapy. Twenty-one patients were New York Heart Association (NYHA) class III and 10 were class IV. Follow-up with echocardiography, ECG, and chest x-ray was performed in 87 % of the survivors. The mean duration of follow-up was 39 +/- 16 months. RESULTS: The mean duration of ICU and hospital stay was 3.6 +/- 2.1 days and 8.1 +/- 5.4 days, respectively. The 1-, 2-, and 5-year survival rates were 91 %, 84 %, and 77 %, respectively. NYHA class improved from 3.3 +/- 0.8 to 2.1 +/- 0.7 at follow-up (p < 0.01). The ejection fraction improved from 23.1 +/- 6.6 % to 36 +/- 6.8 % at follow-up (p < 0.02). Freedom from readmission for heart failure was 85 %, 79 %, and 68 % at 1-, 2-, and 5 years, respectively. CONCLUSIONS: Mitral valve surgery improves left ventricular function and reduces heart failure severity in patients with MR and cardiomyopathy. High-risk mitral valve surgery may be an alternative to heart transplantation in selected patients.


Assuntos
Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/cirurgia , Disfunção Ventricular Esquerda/complicações , Fibrilação Atrial/etiologia , Ponte de Artéria Coronária , Feminino , Próteses Valvulares Cardíacas , Humanos , Balão Intra-Aórtico , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/fisiopatologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Fatores de Risco , Volume Sistólico/fisiologia , Taxa de Sobrevida , Disfunção Ventricular Esquerda/fisiopatologia
8.
J Cardiovasc Surg (Torino) ; 42(6): 769-71, 2001 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11698943

RESUMO

The anticoagulative management of patients tested positive for heparin-induced thrombocytopenia type II (HIT II) and requiring cardiac surgery has been difficult until now. A special challenge arises, when left ventricular assist devices have to be implanted for bridging to cardiac transplantation. We report on the anticoagulative management of such a patient, based on the consideration of HIT II-pathophysiology and using heparin for Novacor LVAD implantation and cardiac transplantation.


Assuntos
Anticoagulantes/efeitos adversos , Cardiomiopatia Dilatada , Transplante de Coração , Coração Auxiliar , Heparina/efeitos adversos , Trombocitopenia/induzido quimicamente , Adulto , Ensaio de Imunoadsorção Enzimática , Humanos , Masculino
9.
Thorac Cardiovasc Surg ; 49(5): 259-67, 2001 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11605134

RESUMO

Partial left ventriculectomy is a new surgical option quickly introduced into clinical use worldwide for treating end-stage heart failure in patients with dilated cardiomyopathy. Due to the overwhelming success of this new kind of surgical treatment for dilated cardiomyopathy, experimental research on the physiological and pathophysiological basis was initially not performed. Now, demands for an appropriate animal model have arisen more and more since the outcome of patients treated by partial left ventriculectomy has differed considerably. This review summarizes available experimental models for heart failure in large animals, and discusses their suitability for research on partial left ventriculectomy.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiomiopatia Dilatada/cirurgia , Modelos Animais de Doenças , Animais , Bovinos , Cães , Ventrículos do Coração/cirurgia , Ovinos , Suínos
11.
J Cardiovasc Electrophysiol ; 12(8): 921-7, 2001 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-11513444

RESUMO

INTRODUCTION: Placement of implantable cardioverter defibrillators (ICDs) has been simplified by using the shell of a pectorally implanted ICD as a defibrillation electrode in combination with an endocardial right ventricular defibrillation lead. However, a sufficiently low defibrillation threshold (DFT) cannot be obtained in a few patients. Therefore, alternative approaches were systematically tested in the Active Can versus Array Trial (ACAT). METHODS AND RESULTS: In the first of two prospective randomized studies, the DFT of a subcutaneous left dorsolateral array anode introduced from a pectoral incision was compared to that of a standard active can anode in 68 patients. Intraoperatively, the DFT was determined twice in each patient using either the active can or, in patients with a subcutaneous array lead, once with all three fingers and once omitting the middle finger of the array. The second prospective randomized study included 40 patients. DFT also was determined twice in each patient using an active can in a left pectoral position as anode alone and combined with a left dorsolateral array electrode with two fingers. In ACAT I, stored energy at DFT decreased from 13.1+/-7.7 J (active can) to 9.6+/-6.1 J (three-finger array lead) (P = 0.04), impedance decreased from 53+/-8 ohms to 40+/-6 ohms (P < 0.0001). Omitting the middle finger of the array lead, stored energy at DFT increased by 0.9 J (P = 0.47) and impedance by 2 ohm (P < 0.0001). In ACAT II, DFT and impedance using an active can device were significantly lower when a two-finger array lead was added that decreased stored energy at DFT from 10.1+/-5.2 J to 6.9+/-3.9 J (P = 0.001) and impedance from 56+/-5 1 to 42+/-5 l (P < 0.0001). CONCLUSION: In combination with a right ventricular defibrillation electrode, a left pectoral subcutaneous array lead improves defibrillation efficacy if used instead of, or in addition to, a left pectoral active can ICD device. Implantation of the array lead can be simplified by using two instead of three fingers, without a significant loss of defibrillation efficacy.


Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Eletrodos Implantados , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/terapia , Estudos Cross-Over , Técnicas Eletrofisiológicas Cardíacas , Segurança de Equipamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
13.
Thorac Cardiovasc Surg ; 49(2): 78-83, 2001 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11339456

RESUMO

BACKGROUND: Primary tissue failure, which is mainly caused by calcification, is still the limiting factor in the long-term outcome of heart valve bioprostheses. Even though the precise nature of this process is not fully understood, in vitro tests have been developed to reproduce and predict calcification for individual bioprostheses. METHODS: In vitro calcification testing was performed by using an accelerated pulsatile valve tester which was adapted for testing stented as well as stentless bioprostheses with physiological fluid dynamics. A total of 84 bioprostheses (porcine, pericardial and stentless porcine of different manufacturers) were cyclically loaded at a test rate of 300/min at 37 degrees C within a rapid calcification fluid with CaxP = 130(mg/dl)2 at pH 7.4. Calcification was assessed by microradiography after 12 x 10(6) cycles. In a previous step, holographic interferometry was performed to identify irregularities of valve leaflets in order to predict later calcification. Selected specimens of calcified bioprostheses underwent histology, transmission (TEM) and scanning (SEM) electron microscopy. Tissue mineralization was investigated by coupling SEM, electron microprobe analysis (EMPA) and X-ray powder diffraction (XRPD) methods. RESULTS: For all tested bioprostheses, a significant calcification was achieved within 4 to 6 weeks of ongoing testing, and the degree of calcification increased with time. A significant correlation between calcification and leaflet irregularities (detected by holographic interferometry) was found (r = 0.80, p = 0.001). Calcification varied between individual bioprostheses, and significant differences were detected for different groups (calculated as percentage of total leaflet area, mean +/- SD): porcine stented (37.3 +/- 12.0%), bovine stented (23.0 +/- 8.9%), porcine stentless (16.2 +/- 7.6%). Histological and ultrastructural investigation showed intrinsic calcification involving both the spongiosa and fibrosa with collagen fibrils, interfibrillar spaces and cells as early sites of calcification. There was clear evidence of apatite crystallization, and observations made with in vitro calcification were quite similar to those occurring with in vivo implanted bioprostheses. CONCLUSION: In vitro tests can reproduce intrinsic calcification of bioprostheses even in the absence of viable biologic host factors. Moreover, degree and sites of calcification have become predictable. This enables the development and evaluation of bioprostheses with reduction of animal experiments. From our results obtained with a broad range of available bioprostheses, stented bovine and stentless porcine valves seem to be superior to conventional stented porcine bioprostheses with regard to leaflet calcification.


Assuntos
Bioprótese/efeitos adversos , Calcinose/diagnóstico , Próteses Valvulares Cardíacas/efeitos adversos , Holografia/métodos , Falha de Prótese , Animais , Bioprótese/normas , Calcinose/etiologia , Qualidade de Produtos para o Consumidor , Humanos , Teste de Materiais , Controle de Qualidade , Medição de Risco , Sensibilidade e Especificidade
14.
Pacing Clin Electrophysiol ; 24(4 Pt 1): 416-23, 2001 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11341077

RESUMO

Dual-chamber ICDs are increasingly used to avoid inappropriate shocks due to supraventricular tachycardias. Additionally, many ICD patients will probably benefit from dual chamber pacing. The purpose of this pilot study was to evaluate the intraoperative performance and short-term follow-up of an innovative single pass right ventricular defibrillation lead capable of bipolar sensing and pacing in the right atrium and ventricle. Implantation of this single pass right ventricular defibrillation lead was successful in all 13 patients (age 63 +/- 8 years; LVEF 0.44 +/- 0.16; New York Heart Association [NYHA] 2.4 +/- 0.4, previous open heart surgery in all patients). The operation time was 79 +/- 29 minutes, the fluoroscopy time 4.7 +/- 3.1 minutes. No perioperative complications occurred. The intraoperative atrial sensing was 1.7 +/- 0.5 mV, the atrial pacing threshold product was 0.20 +/- 0.14 V/ms (range 0.03-0.50 V/ms). The defibrillation threshold was 8.8 +/- 2.7 J. At prehospital discharge and at 1-month and 3-month follow-up, atrial sensing was 1.9 +/- 0.9, 2.1 +/- 0.5, and 2.7 +/- 0.6 mV, respectively, (P = NS, P < 0.05, P < 0.05 to implant, respectively), the mean atrial threshold product 0.79, 1.65, and 1.29 V/ms, respectively. In two patients, an intermittent exit block occurred in different body postures. All spontaneous and induced ventricular arrhythmias were detected and terminated appropriately. Thus, in a highly selected patient group, atrial and ventricular sensing and pacing with a single lead is possible under consideration of an atrial pacing dysfunction in 17% of patients.


Assuntos
Desfibriladores Implantáveis , Eletrocardiografia/instrumentação , Eletrodos Implantados , Marca-Passo Artificial , Taquicardia Supraventricular/terapia , Fibrilação Ventricular/terapia , Idoso , Desenho de Equipamento , Feminino , Seguimentos , Átrios do Coração/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Taquicardia Supraventricular/fisiopatologia , Fibrilação Ventricular/fisiopatologia
15.
J Cardiovasc Electrophysiol ; 12(3): 356-60, 2001 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-11291811

RESUMO

INTRODUCTION: The need to access the right ventricle might preclude transvenous placement of a defibrillation lead at implantable cardioverter defibrillator (ICD) placement, especially in small children or children with complex congenital heart defects. We investigated a subcutaneous array lead in addition to an abdominally placed "active can" ICD device in two children to avoid a thoracotomy. METHODS AND RESULTS: The first child (age 12 years, 138 cm, 41 kg) had transposition of the great arteries with a subsequent surgical intra-atrial correction by the Mustard technique. The second child (age 14 years, 161 cm, 54 kg) had a single atrium and a single ventricle, d-transposition of the aorta, and atresia of the main pulmonary artery with a surgical anastomosis between the aorta and the right pulmonary artery by the Cooley technique. The defibrillation threshold was 18 J and <20 J at initial implantation and at generator replacement in the first patient and 20 J in the second patient. During follow-up of 6 years and 1 month, respectively, no ICD-related complications occurred. CONCLUSION: In children in whom endocardial, right ventricular placement of a defibrillation lead is precluded, defibrillation is possible and safe between an abdominally placed "active can" ICD device and a subcutaneous array lead. This approach may avoid a thoracotomy in children with no possibility for transvenous ICD placement.


Assuntos
Desfibriladores Implantáveis , Cardiopatias Congênitas/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Abdome/cirurgia , Adolescente , Criança , Procedimentos Cirúrgicos Dermatológicos , Humanos , Radiografia Torácica , Toracotomia
16.
Surgery ; 129(4): 440-4, 2001 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11283535

RESUMO

BACKGROUND: Noncardiac surgery, especially abdominal surgical procedures in patients with long-term mechanical circulatory support and strong anticoagulation, is difficult. METHODS: We report on 14 patients (aged 44 +/- 15 years) with a portable Novacor or HeartMate system, who underwent noncardiac surgical procedures while being supported by the device. RESULTS: The patients underwent 20 procedures for noncardiac reasons; most had an intestinal operation or cholecystectomy. Half of the procedures were performed within 30 days after placement of the device (mean interval, 53 +/- 57 days), only 6 interventions were necessary after 100 days of mechanical support. Complications occurred in 8 patients (57%), 5 of whom had undergone cholecystectomy and had unacceptably high sanguineous drainage losses. CONCLUSIONS: An elective surgical procedure can be performed with an acceptable risk if the operation is carefully managed. Postponing resumption of full anticoagulation is advisable as it may reduce bleeding complications without apparently increasing the risk for thromboembolism. Emergency interventions remain a difficult task.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Coração Auxiliar , Adulto , Idoso , Colecistectomia/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/cirurgia , Prognóstico , Reoperação
20.
Basic Res Cardiol ; 96(1): 98-105, 2001 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-11215538

RESUMO

BACKGROUND: To predict the outcome after myocardial revascularisation, a clear separation between hibernation and/or repetitive stunning on the one hand and myocardial scarring on the other hand is of importance. METHODS AND RESULTS: A total of 44 patients was included in this study. In 35 patients with chronic myocardial ischaemia and an indication for coronary bypass-surgery, epicardial mapping of local activation was performed. Nine patients with LV aneurysm and an indication for antitachycardia surgery were also included. For simultaneous recording of the local electrograms during sinus rhythm, a sock electrode with 102 bipolar leads was used. The regional myocardial contraction pattern was assessed from preoperative angiograms and regional myocardial metabolism (viability) from 18F-FDG PET, respectively. The results were projected on the grid of the intraoperative position of the sock electrode. This enabled regional comparison of electrogram characteristics to local contraction patterns and viability. For the characterisation of local electrograms, peak-to-peak amplitude and duration of activation were calculated using custom-made automated computer-algorithms. Dysfunctional but viable areas showed normal or almost normal electrographic signal characteristics. In contrast, dysfunctional and non-viable myocardium showed a distinct reduction of local amplitudes and prolongation of signal duration. These changes were even more intense in areas of LV aneurysms. CONCLUSIONS: In patients with chronic ischaemic myocardium, a mismatch between mechanical function and local electrogram characteristics was observed in areas with preserved metabolism. Thus, normal epicardial electrograms in regions of myocardial dysfunction may be an indicator for myocardial viability.


Assuntos
Cicatriz/fisiopatologia , Cardiopatias/fisiopatologia , Isquemia Miocárdica/fisiopatologia , Pericárdio/fisiopatologia , Adulto , Idoso , Doença Crônica , Eletrofisiologia/métodos , Feminino , Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade
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