Clinical course after surgical treatment of active isolated native mitral valve endocarditis.

AIM: Isolated mitral valve endocarditis (MVE) forms a particular subgroup within native infective valve endocarditis (NVE). We characterized this particular subgroup and analyzed the course of patients undergoing cardiac surgery. METHODS: Between 1997 and 2011, 474 patients underwent cardiac surgery at our institution for NVE treatment. Of these, 89 patients (18.8%) suffered from MVE. Valve replacement was undertaken in 84.2% and valve repair in 15.8%. Follow-up was completed with 267 patient years. RESULTS: A delay between the onset of first symptoms and surgery of 4.7±1.2 weeks was observed. Hence, most patients were in a critical preoperative state characterized by severe sepsis and destruction of the mitral valve. About 19.4% were emergency procedures. The MVE group presented with a higher prevalence of preoperative stroke, atrial fibrillation, coronary artery disease and chronic obstructive pulmonary disease in comparison with remaining NVE cases. MVE was more likely caused by Staphylococcus aureus; Staphylococcus epidermidis and Staphylococcus viridans were less frequent (P<0.01 each). Early mortality (6.7%) was caused by persistent sepsis. ICU stay >7 days and time on artificial ventilation >40 h led to a higher risk of in-hospital death. Five-year survival was 59.6% and affected by extracardiac comorbidities. CONCLUSION: Isolated MVE was characterized by a long delay before surgery, differences in microbiological findings and a higher prevalence of preoperative strokes in comparison to NVE. Surgery for MVE can be conducted with good clinical results, but mid-term outcome is limited by extracardiac comorbidities.

[Surgery of the ascending aorta and aortic arch]. / Chirurgie der Aorta ascendens und des Aortenbogens.

The surgical therapy of the ascending aorta and the aortic arch with its supraarotic branches has been, and still is, one of the major challenges in the therapy of the aorta. There have been major developments in the endovascular therapy field, which can be used as a complementary or even sometimes as an alternative to the standard surgery. Therefore, an interdisciplinary approach is a prerequisite for optimal therapy planning for such patients. The risk of operating under circulatory arrest has been markedly reduced due to the continued development of cardiosurgical techniques, especially selective cerebral perfusion and mild hypothermia. Further developments of the therapy of aortic diseases via alternative approaches are expected in the near future. However, the conventional surgical therapy for pathologies in the ascending aorta (with/out the aortic valve) and the aortic arch is still the gold standard.

Combined immunosuppressive therapy including a TNF-alpha blocker induces remission in a difficult to treat patient with Takayasu arteriitis and coronary involvement.

A 40 year old woman presented with symptoms of a systemic inflammatory disease and obstruction of the left subclavian artery. Takayasu arteriitis (TA) was clinically diagnosed and confirmed by MR angiography and FDG-PET scan showing inflammation of the aortic arch and the left subclavian artery. Immunosuppression with glucocorticoids and methotrexate resulted in immediate clinical improvement and normalization of systemic markers of inflammation. Despite that the patient developed chest pain on exertion suggesting coronary involvement, which was confirmed by dobutamine stress echocardiography. After adding the TNF-alpha blocker infliximab coronary symptoms gradually improved and a clinically stable situation could be achieved for more than 6 months. Coronary angiography and aortography showed an occluded main stem of the left coronary artery, an occluded left subclavian artery, and stenoses of the brachiocephalic trunk and the left common carotid artery. Revascularization of the coronary artery and the aortic arch and its branches was performed. The patient returned to work two months after the operation. Immunosuppressive therapy with infliximab and methotrexate is continued, glucocorticoids were stopped after one year of treatment. This case shows that vascular progress in TA patients may occur even when systemic inflammation is controlled, therefore patients have to be carefully observed for new vascular manifestations. TNF-alpha blockers may be an additional treatment option in otherwise difficult to treat TA patients allowing to perform revascularization after a stable disease state has been achieved.

Readmission to the intensive care unit after cardiac surgery: a single-center experience with 7105 patients.

AIM: Identification of patients at high risk for readmission to the Intensive Care Unit (ICU) after cardiac surgery is paramount. We evaluated the clinical characteristics of readmitted patients and identified perioperative prognostic variables for ICU readmission. METHODS: A total of 7105 patients who underwent cardiac surgery between 2007 and 2010 and discharged after a primary stay in the ICU were reviewed retrospectively. Of these, 7.8% (554) patients were readmitted. The reasons for readmission and postoperative course were analyzed. Perioperative risk factors for readmission were determined by multivariate regression analysis. RESULTS: Mortality of patients after readmission was 13.6% compared with 0.2% without recidivism (P<0.0001). Mean length of stay in hospital of patients requiring readmission was 24.9 ± 19.1 days and significantly longer compared to all other patients 12.3±8.4 days (P<0.0001). The main reasons for readmission were respiratory failure (39.0%) and cardiovascular instability (26.2%). Complex cardiac surgery, aortic surgery and extended stay in the ICU were the most powerful variables to predict ICU readmission. CONCLUSION: ICU readmission was related to complex surgery and associated with impaired outcome. Respiratory complications were the most common reasons for readmission. Predictive renal and pulmonary risk factors indicate the need of preoperative preconditioning and patient selection.

The C-Port xV® vascular anastomosis system: results from an animal trial.

BACKGROUND: In this study, facilitated anastomosis using an anastomotic device was compared to conventional hand-sewn (HS) vascular anastomosis in an animal model. METHODS: A pig carotid bypass model was employed. C-Port xV® (xV) and HS anastomoses were compared by evaluating intraoperative performance, midterm graft patency, and histology. RESULTS: All animals survived; none developed early/late neurological deficits. Mean graft blood flow was comparable between groups (HS group: 161 ± 61 ml/min; xV group: 143 ± 44 ml/min). All anastomoses were patent at necropsy (at 111 ± 6 postoperative days). Histologically, no significant inflammation was found around the fasteners or in the vessel wall. Neointimal overgrowth on the lumen surface appeared organized and covered with endothelium. There was no adherence of fibrin, platelets, or inflammatory cells to the surface. The neointimal tissue appeared normal without any inflammation, hemorrhage, calcification, or necrosis. CONCLUSION: Facilitated vascular anastomosis using the xV anastomotic device is safe and effective in the pig carotid bypass model. Further studies should evaluate the efficacy of this device when used in confined spaces to define its potential role in minimally invasive procedures.

Intra-aortic balloon pump implantation does not affect long-term survival after isolated CABG in patients with acute myocardial infarction.

BACKGROUND: Intra-aortic balloon pump (IABP) is an established therapy to support patients with heart failure during coronary artery bypass grafting (CABG). The impact of the timing of IABP on the hospital course and on follow-up is of particular clinical interest. The purpose of this study was to analyze the relationship between the time of IABP implantation and its impact on early, mid- and long-term survival in patients with acute myocardial infarction (AMI) who underwent emergent CABG for NSTEMI and STEMI. METHODS: A total of 472 patients with AMI (NSTEMI and STEMI) underwent emergency CABG at our institution; 158 of them additionally received IABP support. Fifty-seven (36 %) patients received preoperative and 101 (64 %) patients underwent intraoperative IABP implantation. Endpoints were in-hospital und follow-up (mean duration 37 ± 28 months) survival. RESULTS: Overall in-hospital mortality was 17.1 % (n = 27): 17.6 % (n = 10) in the preoperative group and 16.8 % (n = 17) in the intraoperative group ( P = ns). Mid- and long-term survival rates were comparable for both groups 78.6 % vs. 73.7 %, 71.4 % vs. 68.7 % and 64.3 % vs. 54.6 % at 1, 3 and 5 years, respectively ( P = ns). CONCLUSION: This study demonstrates that CABG with IABP support in high-risk patients with AMI can be performed with acceptable in-hospital and long-term survival rates. The decision for IABP placement should consider the preoperative clinical condition and the intraoperative course of each patient. IABP placement does not appear to affect the long-term outcome after isolated CABG in patients with AMI.

[Transapical aortic valve implantation--indications, risks and limitations]. / Transapikaler Aortenklappenersatz--Indikationen, Risiken und Grenzen.

Calcified aortic stenosis is the predominant valve disease in the western world. Currently, surgical aortic valve replacement is the gold standard procedure for symptomatic severe aortic stenosis that can be performed with low morbidity and mortality. The prevalence of aortic stenosis increases with age, and the incidence of several comorbidities also unavoidably elevates the risk of surgical treatment. Therefore, the most adequate and gentle treatment is needed especially for this population. Since the first transcatheter aortic valve implantation (TAVI) was performed in 2002, the main implanting routes are the transfemoral, retrograde access through the common femoral artery, and the antegrade, transapical approach via anterolateral minithoracotomy. Meanwhile, TAVI has become an alternative treatment for patients who are not suitable candidates for surgical therapy in some centers.The initial clinical results are promising and have confirmed the feasibility of this technique. Due to the restricted long-term data, conventional aortic valve replacement still remains the standard for the treatment of aortic stenosis. Selection of the suitable therapy approach (surgical replacement, transfemoral or transapical aortic valve implantation) must consider each patient's specific risk profile and individual indication. Prospective, randomized trials will be necessary to assess the individual survival benefit of TAVI for various risk populations and to extend the indication.

Coronary surgery for acute coronary syndrome: which determinants of outcome remain?

BACKGROUND: The mortality risk associated with coronary artery bypass grafting (CABG) after acute myocardial infarction remains controversial. The objective of the present study was therefore to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS). PATIENTS AND METHODS: Between January 2003 and May 2005, a total of 3,127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. Out of these, unstable angina pectoris was present in 88 pts (group I), 97 pts (group II) had non-ST-elevation infarction, whereas 35 pts (group III) had ST-elevation infarction. Clinical data, in-hospital morbidity and mortality were recorded and studied retrospectively. RESULTS: Overall in-hospital mortality was 6.4% (n = 14) in the complete cohort, being 2.2% in group I (n = 2), 9.2% in group II (n = 9) and 8.5% (n = 3) in group III (P < 0.05). Logistic regression and receiver operating characteristic analyses identified age, NYHA, ejection fraction < 45%, catecholamine support, cardiogenic shock, renal disease and the additive EuroSCORE > 10 (P < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 +/- 2.7 h) and no survivors (11.4 +/- 3.2 h) (P < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information. CONCLUSION: CABG in pts with ACS can be performed with good clinical results. The clinical outcome is particular depending on the different groups of ACS. Therefore an individual risk stratification of each pts in ACS is necessary. The time interval of 6 h seems to be crucial as prognostic variable in the STEMI-group.

Incidence of aortic valve regurgitation and outcome after percutaneous closure of atrial septal defects and patent foramen ovale.

BACKGROUND: In recent years percutaneous, transcatheter closure of atrial septal defects (ASD) or patent foramen ovale (PFO) was introduced into clinical practice. OBJECTIVE: To investigate the functional effects on heart valves caused by an interatrial closure device. METHODS AND RESULTS: Between 2001 and 2006, 240 consecutive patients underwent percutaneous closure of an ASD or a PFO. Heart valve functions were defined by transoesophageal echocardiography before implantation and 3, 6 and 12 months after defect closure. A successful implantation procedure was performed in 98% of patients. Sufficient closure without residual shunt was achieved in 89% of patients with ASD and in 92% of patients with PFO. An overall major complication rate of 0.8% was apparent during the observation time (mean (SD) 27 (15) months). Long-term follow-up disclosed newly developed or worsened aortic valve regurgitation (AR) in 9% of patients with ASD and in 10% of patients with PFO. A potential cause for developing AR may be overgrowth of the device by tissue, leading to changes in interatrial septal geometry and traction on the root of the non-coronary aortic cusp. CONCLUSION: AR occurred in 9% of patients with closed ASD and in 10% of patients with closed PFO. Indication for closure should consider this potential complication despite an otherwise safe interventional procedure.

Coronary artery bypass grafting in octogenarians--outcome with and without extracorporeal circulation.

Octogenarians are increasingly considered for coronary artery bypass grafting (CABG), but still represent a high-risk patient group with increased mortality and morbidity. In recent years off-pump surgery has been successfully established in CABG. The avoidance of extracorporeal circulation (ECC) seems to be of particular benefit for this patient group. We retrospectively analyzed our experience with CABG surgery with and without ECC in octogenarians to define the potential benefit of these different approaches in this high-risk group of patients. We analyzed the outcome after isolated CABG of 344 consecutive patients (219 male, 125 female, age: 82 +/- 2.4 years) who were aged 80 or older. Patients were divided into two groups according to the use of ECC. The on-pump group consisted of 237 patients (151 male, 86 female, 82 +/- 2.8 years) and the off-pump group consisted of 107 patients (68 male, 39 female, 82 +/- 1.9 years). The predicted EuroSCORE and EuroSCORE mortality risk were similar for both patient groups. The overall hospital mortality rate was 5.5 % (n = 17): 14 patients (5.9 %) in the on-pump group (n = 237, 100 %) and five patients (4.6 %) in the off-pump group (n = 107, 100 %). The average number of grafts in the on-pump group was 2.8 +/- 0.4 and it was 2.4 +/- 0.6 in the off-pump group ( P = 0.05). Morbidity was comparable in both groups. Significant variables in multivariate regression were preoperative atrial fibrillation ( P = 0.03; RR = 2.7), COPD ( P = 0.0001; RR = 6.5) and prolonged intubation ( P = 0.005; RR = 4.1). Isolated CABG in octogenarians can be performed with good clinical results, although a substantial mortality remains. The results of coronary surgery in this patient group with and without ECC are comparable with respect to mortality and morbidity.

Coronary surgery in dialysis-dependent patients with end-stage renal failure with and without extracorporeal circulation.

Coronary artery bypass grafting (CABG) in dialysis-dependent patients with end-stage renal failure (ESRF) has become the standard treatment for CAD in this patient group, but is still considered as a risk procedure due to the increased mortality and morbidity. The avoidance of extracorporeal circulation in dialysis-dependent patients seems to be an attractive alternative. This retrospective study analyzed and compared our experience with CABG surgery with and without extracorporeal circulation in dialysis-dependent patients with ESRF. We analyzed the clinical results of isolated CABG in 73 dialysis-dependent patients with ESRF with and without the use of extracorporeal circulation. The on-pump group consisted of 43 patients (7 female and 36 male, 65 +/- 7.3 years) and the off-pump group included 30 patients (4 female and 26 male, 67 +/- 7.2 years). Demographic and preoperative data were comparable in both groups. Overall hospital mortality rate was 4.2 % (n = 3), two patients (4.6 %) in the on-pump group and one patient (3.3 %) in the off-pump group died due to noncardiac reasons. Morbidity was comparable in both groups. The mean number of grafts was 3.1 +/- 0.9 in the on-pump group and 2.9 +/- 0.8 in the off-pump group. During follow-up, 13 patients (30.2 %) in the on-pump group died, nine of these patients (69.2 %) due to cardiac reasons; eight patients (26.7 %) in the off-pump group died, mostly due to cardiac reasons (n = 5, 62.5 %). CABG can be performed in patients with dialysis-dependent ESRF with good clinical results and low morbidity with two different surgical approaches. Midterm results are still affected by cardiac events.

Prosthetic valve endocarditis: importance of surgical treatment.

Surgical therapy of prosthetic valve endocarditis (PVE) is still associated with a high mortality of up to 80 %. Further risk analysis and characterization of clinical features are important for a further improvement of surgical results. The aim of this retrospective study was a risk analysis of clinical features of the pre-, intra-, and postoperative period. Between February 1998 and December 2004, 70 patients (52 male, 18 female, age 62 +/- 11 years) were referred to our institution for surgical therapy of PVE. This cohort included 16 patients with early PVE and 54 patients with late PVE. Preoperative, intraoperative and postoperative features were evaluated with respect to their influence on the early postoperative course and the midterm follow-up. The aortic valve was affected in 41 patients (58.6 %) and the mitral valve in 15 patients (21.4 %). Double valve infection was recorded in 14 patients (20.0 %). Staphylococci (n = 36, 51.4 %), Streptococci (n = 9, 12.9 %) and others (n = 24, 14.5 %) were identified as causative agents in blood cultures. The hospital mortality rate was 20.0 % (n = 14), during follow-up (mean follow up: 3.3 +/- 2.5 years), a further 11 patients (15.7 %) died, resulting in an overall mortality of 35.7 %. The main predictors for hospital mortality were preoperative heart failure ( P = 0.01) and Staphylococci infection ( P = 0.01). Predictors of overall mortality were Staphylococci infection ( P = 0.01), heart failure ( P = 0.02) and abscess formation ( P = 0.02). Surgical therapy of prosthetic valve endocarditis is still associated with quite a high mortality during the early and midterm follow-up. Predictors of outcome particularly include preoperative risk constellations (heart failure, Staphylococci infection).

Coronary reoperation with and without cardiopulmonary bypass.

Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB. From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66 +/- 9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67 +/- 8 years). Perioperative overall mortality rate was 3.6% (n = 7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p = 0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity. Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p < 0.01). The average number of grafts was significantly higher in the on pump group (2.8 +/- 0.78 versus 1.6 +/- 0.6; p = 0.04).Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50 +/- 16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44 +/- 13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p = 0.92). On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.

Perforation of the ascending aorta: a late complication of superior vena cava stenting.

Intravascular stenting of the superior vena cava (SVC) is an established therapy in patients with SVC syndrome. Late complications include re-occlusion, stent infection, migration, and perforation. Affection of the greater thoracic vessels is rare and life-threatening when it occurs. We present a case of ascending aorta laceration as a late complication of SVC stenting. Surgical therapy included excision of the aortic lesion and pericardial patch repair. This case illustrates successful management of a complication after palliative stenting of the SVC.

Lactatdehydrogenase (LDH) prior and post implantation of ATS heart valves.

Establishing guidelines towards an assessment of prostheses dysfunction using LDH as a marker is difficult as shown by [M. Suedkamp, A.J. Lercher, F. Mueller-Riemenschneider, K. LaRosee, P. Tossios, U. Mehlhorn, Hemolysis parameters of St Jude Medical hemodynamic valves in aortic position, Int. J. Cardiol (95) (2004) 89-93]. In response to their work we would like to add our data concerning ATS valves (AP) and say a word of caution in interpreting an increase of LDH values.

Coronary surgery in dialysis-dependent patients with end stage renal failure.

The number of patients with dialysis-dependent end stage renal failure (ESRF) and coronary heart disease (CAD) has increased in recent years. Coronary artery bypass grafting (CABG) has become the standard treatment for CAD in this patient group, but is still considered as a risk procedure due to increased mortality and morbidity. In a retrospective study we analyzed our clinical results of isolated CABG in 40 dialysis-dependent patients with ESRF (5 female and 35 male, mean age 65+/-8.4 years) and the use of extracorporeal circulation. The perioperative control group comprised 51 patients (10 female and 41 male, mean age 67+/-7.3 years) with normal renal function and isolated CABG. Demographic and preoperative data were comparable in both groups. Hospital mortality was 2.5% in patients with ESRF and 0% in patients with normal renal function. Morbidity was comparable in both groups. The mean number of grafts was 3.1+/-0.9 in the dialysis group and 2.9+/-0.8 in the control group. In the follow-up of the dialysis group (34+/-23 months) 8 patients died. CABG in patients with dialysis-dependent ESRF can be performed with good clinical results and morbidity comparable to patients with normal renal function.

[Surgical therapy of traumatic cardiologic intervention]. / Chirurgische Therapie nach traumatischen interventionellen Koronarläsionen.

Coronary perforation and entrapment of catheter materials are rare, but life-threatening complications, which often require emergency cardiosurgical treatment. Surgical options include tamponade drainage, coronary artery bypass grafting, perforation suturing, and removal of catheter materials. Surgical strategies are not standardized but mainly depend on the surgical anatomy. This is in particular true for the removal of the catheter remnants (stent, guidewire). Keeping this in mind, these patients can be treated with good clinical results.

[Space occupying lesion of unknown origin in the pulmonary trunk: targeted differential diagnosis and surgical therapy in a patient with B symptoms and thoracic pain]. / Unklare Raumforderung im Truncus pulmonalis: Gezielte Differenzialdiagnostik und chirurgische Therapie bei einem Patienten mit B-Symptomatik und Thoraxschmerzen.

Leiomyosarcomas are only rarely found in routine cardiac surgery. For the patient they hold, however, a very high-risk potential as only an early diagnosis, and immediate surgical therapy leads to long-term survival. Awareness, timely diagnosis, and immediate radical surgical therapy is imperative. This report describes the case of a 21-year old male with a strong suspicion of leiomyosarcoma of the pulmonary artery. Due to his clinical symptoms, the patient was transferred to operation immediately after completion of all diagnostic measurements. Postoperatively the diagnosis of a leiomyosarcoma proved to be false; instead a rare fibro-histologic tumor was found. Even in the case of a suspected leiomyosarcoma, rapid and radical surgical therapy is imperative due to the poor prognosis of leiomyosarcoma.