[Hyperthyroidism, eosinophilia, and fever in a 64-year-old patient]. / Hyperthyreose, Eosinophilie und Fieber bei einem 64-jährigen Patienten.

We report on a male patient suffering from loss of weight, fatigue, fever, eosinophilia, and hyperthyreoidism. The echocardiogram revealed a left atrial mass originating from the posterior mitral leaflet. In combination with the constitutional symptoms a left atrial myxoma was diagnosed. The tumor was surgically removed. Postoperatively therapy with corticosteroids and thiamazole was stopped. During follow-up, eosinophilia and hyperthyreodism could no longer be detected.

Ross procedure.

INTRODUCTION: In 1967 Donald Ross introduced the subcoronary Ross procedure consisting of transplantation of the autologous pulmonary valve into aortic position. We describe our 15-year experience in Ross procedures. METHODS: 576 subcoronary operations have been performed (436 male and 140 female patients); the mean age was 45±11.9 years. (range, 13 to 70 years). The mean follow-up was 7±4.2 years (range, 0 to 16 years). There were 4597 patient years at follow-up with a clinical completeness of 95% and echo completeness of 91%. RESULTS: There were two operative deaths (0.3%) and 31 patients with reoperation. The survival is similar to that of the normal population and the freedom from allo- and autograft reoperation is 87% at 15 years. Autograft regurgitation at last examination was grade 0 in 40%, trace in 54%, grade I in 19%, grade II in 4% and grade III in 0.4%; the pressure gradient was smaller than 5 mmHg in 57% and between 5 and 10 mmHg in 24%. Only 6% had a transvalvular pressure gradient of more than 10 mmHg. DISCUSSION: After 15 years of experience it can be concluded that the subcoronary technique provides near normal survival in adult patients, with excellent hemodynamics and acceptable rate of reoperations.

[Surgical atrial fibrillation ablation therapy and postoperative monitoring]. / Rhythmuschirurgie des Vorhofflimmerns und postoperatives Monitoring.

Atrial fibrillation represents the most common atrial arrhythmia seen in clinical practice. The surgical treatment of atrial fibrillation is recommended in symptomatic patients as well as in asymptomatic patients at low postoperative risk. As a "stand alone" procedure, surgical ablation therapy is indicated after failed catheter ablation therapy, which occurs increasingly due to the high number of catheter-based ablation techniques. In order to gain acceptance among patients as well as referring cardiologists, the surgical ablation procedure ought to be performed in a minimally invasive fashion and with a very high success rate. When applied in an interdisciplinary approach by cardiologists/electrophysiologists and cardiothoracic surgeons, both ablative techniques have the potential to treat atrial fibrillation effectively and in the long-term. In order to document the true heart rhythm after ablation therapy, intermittent "snapshot" ECG documentation ought to be avoided. Small leadless devices that can be implanted subcutaneously enable full heart rhythm disclosure with documentation of atrial arrhythmias. The modern technique of implantable loop recorders permits individualized treatment for each patient.

[Diagnostic pathways and pitfalls in acute thoracic aortic dissection: practical recommendations and an awareness campaign]. / Diagnostische Wege und Irrwege der akuten thorakalen Aortendissektion: Praktische Empfehlungen und Aufklärungskampagne.

Despite significant improvements in the surgical therapy of acute aortic dissection (AAD), mortality rates in the initial phase remain unacceptably high. Early diagnosis and therapy are essential to improving prognosis in these patients. A prerequisite of prompt and correct diagnosis is"thinking of it". Delayed or incorrect diagnosis can often have catastrophic results.The reported acute chest and back pain of a tearing, stabbing nature combined with the physiognomy of Marfan syndrome often arouse the clinical suspicion of AAD, prompting immediate imaging of the thoracic aorta and therapy. For less clear cases, additional hints drawn from the patient history and special findings from the medical examination are presented schematically in a diagnostic pathway. As an innovative form of diagnosis, preventive echocardiographic screening in high risk groups is discussed.To heighten awareness of AAD and the importance of its correct diagnosis, the poster campaign "Thinking of it can save lives" has been initiated. The poster depicts AAD schematically, indicates Marfan syndrome as a risk factor for AAD in young people and illustrates a CT scan as the most frequently performed imaging technique with high sensitivity and specificity.

Inhibition of caspase-3 differentially affects vascular smooth muscle cell apoptosis in the concave versus convex aortic sites in ascending aneurysms with a bicuspid aortic valve.

Apoptosis of vascular smooth muscle cells (VSMCs) is involved in bicuspid aortic valve (BAV) ascending aorta aneurysms characteristically affecting the convex site. Caspase-3 is a pivotal effector of the apoptosis machinery. The aim of this study was to investigate the impact of an inhibited caspase-3 pathway on apoptosis in convex and concave sites VSMCs of ascending aortic tissue in vitro. Specimens from the convex and concave sites of ascending aortic aneurysm were collected from nine patients with BAV (mean age 58.7+/-14.8). Cultured VSMCs were characterized morphologically and immunohistochemically. Apoptosis activity was measured in VSMCs using Annexin V-APC with propidium iodide nuclear staining in flow cytometry. To investigate apoptotic modulation, caspase-3 was inhibited by N-acetyl-Asp-Glu-Val-Asp-CHO (Ac-DEVD-CHO). Apoptosis was initiated by calcium chloride. Inhibition of caspase-3 with Ac-DEVD-CHO protected VSMCs against calcium chloride apoptosis significantly more in the concave site than in the convex site (25.8+/-9.8 versus 38.5+/-8.0% apoptotic cells, p=0.01). Morphological scanning using light microscopy revealed typical VSMCs. We provide evidence that VSMCs show a different behavior with respect to apoptosis in the concave versus the convex sites in BAV ascending aortic aneurysm. Inhibition of caspase-3 resulted in a significantly increased protection of VSMCs against apoptosis in the concave site compared with the convex site in ascending aortic aneurysm in BAV. These findings may have some implications on understanding aneurysmal formation and its potential modulation.

Transmyocardial laser revascularization combined with intramyocardial endothelial progenitor cell transplantation in patients with intractable ischemic heart disease ineligible for conventional revascularization: preliminary results in a highly selected small patient cohort.

OBJECTIVE: Transmyocardial laser revascularization for angina relief and intramyocardial autologous endothelial progenitor cell injection for neoangiogenesis may offer a new treatment strategy for patients with intractable ischemic heart disease. METHODS: Transmyocardial laser revascularization and intramyocardial injection of bone marrow-derived CD133+ cells was performed in six highly symptomatic patients. Transmyocardial laser channels were created and isolated CD133+ cells were injected intramyocardially. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: One patient died shortly after the operation due to refractory heart failure. In the five survivors, CCS class improved as well as left ventricular ejection fraction. Left ventricular end-diastolic volume and myocardial perfusion varied between the patients. All patients described a considerable improvement in quality of life postoperatively. Repeated 24-hour Holter monitoring revealed no significant arrhythmias. CONCLUSIONS: In this small patient cohort, intramyocardial CD 133+ cell injection combined with transmyocardial laser revascularization led to an improvement in clinical symptomatology in all patients and in left ventricular function in 4 out of 5 patients, with an unclear effect on myocardial perfusion. Caution is advised when employing this therapy in patients with severely depressed left ventricular function.

Impact of graft size and commissural resuspension height on aortic valve competence in valve-sparing aortic replacement under physiological pressures.

BACKGROUND: Valve competence in valve-sparing aortic root replacement has been described as being influenced by commissural height as well as graft size. The aim of this study was to investigate the impact of a gradual reduction of commissural height and graft diameter on aortic insufficiency under physiological conditions in an IN VITRO model. METHODS: Porcine aortic valves were reimplanted into a tubular graft and a native commissural height was obtained. Subsequently the height was reduced by 10 % and 20 %, respectively. To investigate the impact of graft size, a 30 % reduction of the prosthesis diameter was carried out in valves with both native and reduced commissural heights. All conditions were investigated under pulsatile flow simulation and static pressure exposure. RESULTS: Reduction of commissural height caused regurgitation at both 10 % and 20 % lower heights, which was more pronounced in grafts with 20 % reduction. Graft undersizing resulted in significant reflux, with regurgitation even occurring with valves in a native commissural position. CONCLUSIONS: Valve competence is impaired both by the reduction of commissural height and by reduced graft size. In particular, reimplantation of aortic valves into undersized grafts promotes valve insufficiency even if commissural height is well adjusted.

Rate of paraplegia and mortality in elective descending and thoracoabdominal aortic repair in the modern surgical era.

BACKGROUND: The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. METHODS: From July 1993 to April 2006, 56 patients (mean age 55+/-16 years, range 25 to 80 years, 62.5% males) underwent elective surgical repair of the descending (n=37, 66.1%) and thoracoabdominal aorta (n=19, 33.9%), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n=21), type B aortic dissection (n=24), and Marfan's syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n=11), respectively. Most patients were operated using deep hypothermic circulatory arrest. RESULTS: Thirty-day mortality was 5.4 % (n=3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6% (n=2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78%. CONCLUSIONS: If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.

[Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): diagnosis of postoperative delirium in cardiac surgery]. / Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): diagnostik des postoperativen delirs bei kardiochirurgischen Patienten.

OBJECTIVE: Since 2001 the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a method for the diagnosis of delirium, has been available for the Anglo American area which can also be applied to mechanically ventilated patients. This study was conducted to answer the following questions: 1. Can a German version of the CAM-ICU be applied to patients after cardiac surgery? 2. What is the prevalence rate of postoperative delirium after cardiac surgery diagnosed by the CAM-ICU? 3. Do patients with and without the diagnosis delirium differ in the clinical variables usually associated with this disorder in cardiac surgery? METHODS: A total of 194 patients undergoing cardiac surgery served as the analysis sample (85.5% of the total group). The CAM-ICU was carried out every day for 5 days after the operation. Sociodemographic and clinical variables were collected to examine the validity of CAM-ICU. Postoperative complaints were assessed by the Anaesthesiological Questionnaire for Patients (ANP). RESULTS: Postoperatively, the CAM-ICU could be applied to almost all patients without any problems. The prevalence rate of delirium was 28.4% and 85.5% of the delirium diagnosed was a hypoactive subtype when diagnosed for the first time. Patients with delirium diagnosed by CAM-ICU were older (p<0.001), had a lower educational level (p<0.05), longer anaesthesia time and operation time (p<0.05), a longer postoperative ICU stay (p<0.001), were mechanically ventilated for a longer time postoperatively (p<0.001), more often reintubated (p<0.01) and had higher leucocytes postoperatively (p<0.10). More patients with delirium had the lowest postoperatively measured oxygen saturation below 95% (p<0.01). CONCLUSION: The CAM-ICU is an economic method for the assessment of delirium which can easily be learned. It can be applied to patients after cardiac surgery without any problems.

Preexisting atrial fibrillation as predictor for late-time mortality in patients with end-stage renal disease undergoing cardiac surgery--a multicenter study.

BACKGROUND: Although patients with end-stage renal disease (ESRD) are considered to be high-risk patients in cardiac surgery, the reported studies are rather small, resulting in unsatisfactory analyses of outcome determinants. Therefore, we aimed to identify possible risk factors, with a particular focus on the impact of pre-existing atrial fibrillation (AF) on the postoperative short-term and long-term mortality of ESRD patients undergoing cardiac surgery. METHODS: In a multicenter study 522 patients with ESRD undergoing CABG only (62.9 %), valve surgery only (17.2 %), or both (19.9 %) with comparable demographic and other cardiac risk factor characteristics were investigated retrospectively over a period of 10 years. The outcome was divided into perioperative (within 30 days) and late morbidity and mortality, and multivariate analysis was performed for both. RESULTS: The mean perioperative mortality was 11.5 % and the 5-year survival rate was 42 %. Emergency surgery, insulin-dependent diabetes mellitus, the number of vein grafts and age were identified as risk factors whereas complete revascularization, the use of an internal thoracic artery and the presence of sinus rhythm were identified as beneficial factors for long-term survival. 14.1 % of all patients had pre-existing AF. Although AF was not identified as an independent risk factor for perioperative mortality ( P = 0.59), it was identified as an independent predictor for late mortality ( P < 0.001). Median survival of patients without AF was 1816 days, while for patients with AF it was only 715 days. CONCLUSIONS: AF does represent an independent predictor for long-term but not perioperative mortality in patients with ESRD. However, effective treatment of AF is controversially discussed. Anticoagulation therapy or perioperative ablation of the arrhythmia should be considered in order to improve the survival of these patients.

Types of reconstructive surgery of the aortic valve.

The aortic valve is part of the aortic root which is wedged between the heart and the ascending aorta, maintaining a directional flow throughout life-span. Beside different types of aortic valve replacements, reconstructive techniques are increasingly performed to restore normal aortic valve function. To apply these operations, understanding of normal and pathological valve anatomy and physiology is of basic importance. In addition, a widely accepted uniform aortic valve and root terminology is desirable for a proper scientific communication. Reconstructive techniques themselves can be divided into isolated reconstruction of aortic valve/root structures and the isolated replacement of one or more structures. Examples for the former ones are commissurotomy, cusps plication, decalcification or extension as well as plications of other aortic root structures (i.e. the intercusp triangles or the basal annulus). Examples for the latter ones are the remodeling and reimplantation techniques and their modifications. Replacement of the ascending aorta at the sinotubular level for the adjustment of the commissures to restore aortic root geometry also belongs to this group of techniques for aortic valve reconstruction. In this review article a systematic description of the current reconstructive techniques to restore adequate aortic valve function as well as clinical data are presented.

Diabetes mellitus increases adverse neurocognitive outcome after coronary artery bypass grafting surgery.

BACKGROUND: Cognitive dysfunction is a well known problem in the postoperative period in cardiac surgery. We hypothesised that the incidence of postoperative cognitive dysfunction in patients with diabetes mellitus is higher than in the nondiabetic patient. METHODS: Thirty-four patients (11 females, 23 males) with a mean age of 62.44 +/- 7.52 undergoing on-pump CABG surgery were studied in a prospective manner. Fourteen patients had treated diabetes mellitus (Group I) and 20 were nondiabetic (Group II). All patients were operated upon by the same surgeon under standardised intra- and perioperative conditions. Patients with preoperative dementia (MMSE < 24) or advanced cerebrovascular disease were excluded. An extensive set of tests examining emotional and cognitive state, stress-coping and quality of life were performed preoperatively. Emotional and cognitive variables were assessed daily from day two to five postoperatively. RESULTS: All tests showed comparable results between the groups preoperatively. The perfusion lasted considerably longer in Group I (102.5 +/- 16.61 vs. 83.9 +/- 14.1 min) as did the cross clamping (64.21 +/- 18.31 vs. 51.75 +/- 10.88 min). Postoperative cognitive outcome was significantly worse in Group I with regard to the Stroop Test (29.46 +/- 8.6 vs. 24.01 +/- 6.23, P = 0.02), the Abbreviated Mental Test (8.04 +/- 0.71 vs. 8.68 +/- 0.78, P = 0.02) and the Trial Making Test (35.72 +/- 11.38 vs. 29.3 +/- 7.77 P = 0.04). These differences persisted even after adjustment for perfusion- and cross-clamping time. CONCLUSION: The cognitive outcome in the early postoperative period is worse in diabetic patients compared to nondiabetics. Speed-related cognitive functions are mainly affected. Probably, this reflects a different physiology of cerebral perfusion during extracorporeal circulation. Optimising perfusion strategies to improve the outcome of diabetic patients should be the next topic of study.

The Na+/H+ exchange inhibitor cariporide is washed out of the myocardium by crystalloid cardioplegia.

BACKGROUND: Inhibition of the Na (+)/H (+) exchanger (NHE) is cardioprotective, but dosage and timing of NHE-inhibitors are critical for their efficacy. We studied the effect of a new dosing regime of the NHE-inhibitor cariporide on myocardial function and damage after cardioplegic arrest (CPA) and determined its myocardial and serum concentrations. METHODS: 3 pigs received a bolus of 180 mg cariporide intravenously (i. v.) and were sacrificed shortly thereafter to allow measurement of the myocardial concentrations of cariporide. Subsequently, 10 pigs were randomized to receive either i. v. cariporide (bolus followed by an infusion of 40 mg/h) or placebo. Cardiopulmonary bypass was initiated, and the heart was arrested for 60 minutes by infusion of St. Thomas Hospital solution. Left ventricular (LV) function was studied using microsonometry. Myocardial damage was assessed by troponin T. Serum concentrations of cariporide were measured throughout the study, and myocardial concentrations were measured before the end of CPA and 180 minutes thereafter. RESULTS: Cariporide was present in all myocardial specimens (median: 1.4 ng/mg) studied previously. In the main study, LV function or myocardial damage did not differ significantly between the groups at any time point. Stable serum cariporide concentrations were achieved (3.4 +/- 0.5 microg/ml). Cariporide was detectable in only one of the myocardial biopsies obtained before the end of CPA, but 180 minutes thereafter, the myocardial cariporide concentration was 2.5 +/- 0.3 ng/mg. CONCLUSION: We observed no effect of i. v. cariporide on LV function or myocardial damage after cardioplegic arrest. Our data suggest that cariporide is washed out of the myocardium by repeated application of crystalloid cardioplegia. Thus, the mode of delivery also appears to be critical for cardioprotection with NHE-inhibitors.

Autonomously contracting human cardiomyocytes generated from adult pancreatic stem cells and enhanced in co-cultures with myocardial biopsies.

Myocardial regeneration with artificially applied cardiomyocytes is emerging as a promising issue of significant scientific and clinical impact. Nevertheless the source of cells for human cardiomyocyte differentiation especially from adult tissue is still unclear. We hypothesized that human pancreatic stem cells may differentiate into cardiomyocyte-like cells and may increase in number when co-cultured with myocardial tissue. Adult stem cells were harvested from pancreatic tissue of patients undergoing operative procedures including the pancreas. The cells were selected, cultured and passaged. To promote self-differentiation into cardiomyocytes, human pancreatic stem cells were co-cultered with biopsies of human myocardium. After co-culture and breeding, cells were phenotyped as well with respect to RNA, protein and cardiomyocyte specificity at the electron-microscopic level.Pancreatic stem cells have already differentiated spontaneously into cardiomyocyte-like cells performing netlike cell clusters with rare but distinct multilocular cellular autonomous contractions with a frequency of about 20 beats per minute. The number of contracting areas however could be enhanced by co-culture with human myocardial biopsies. On RNA and protein levels as well as in electron-microscopy, evidence for cardiomyocyte specificity is shown. To the best of our knowledge this is the first report demonstrating the feasibility of generating autonomously contracting cardiomyocyte-like cells from adult human pancreatic stem cells and their enhancement by myocardial co-culture. This procedure might prove to be an alternative source and method for myocardial regenerative medicine.

Echocardiographic and hemodynamic characteristics of reconstructed bicuspid aortic valves at rest and exercise.

Repair of diseased bicuspid aortic valves has gained increasing interest as an alternative to conventional valve replacement. Hemodynamic data at exercise have not been reported before. The aim of this study was to investigate the clinical and echocardiographic status of patients after bicuspid aortic valve repair at rest and exercise. Between 03/94 and 09/02 a reconstruction of an incompetent bicuspid aortic valve was performed in 25 patients (mean age 35+/-12.1 years, group A, mean insufficiency 2.8 preoperatively). Patients were investigated clinically and echocardiographically after 2.1+/-2.4 (0.1-8.9) years at rest and exercise and compared to 20 controls (group B). Clinical followup was complete. There were no deaths, reoperations, thromboembolic or bleeding complications. At last examination 21 patients were in NYHA class I, n=4 in NYHA class II and mean aortic valve insufficiency (AI) was 1.0 with one patient having an AI>II degrees. Maximum and mean pressure gradient (dPmax/mean) across the aortic valve at rest were 14+/-5.5/7+/-2.6 mmHg for patients of group A and 7+/-2.5/3.6+/-1.1 mmHg in group B. Mean AVA at rest was 2.6+/-0.8 (group A) vs 2.9+/-0.6 cm(2) (group B, p=0.025), valvular resistance 13.4+/-4.8 (group A) vs 13.6+/-2.9 dyn x s x cm(-5) (group B, p>0.05). All individuals were stressed up to 100 W (dPmax/mean 21+/-6.8/11+/-3.6, group A vs 11+/-2.9/6+/-1.3 mmHg, group B). 56% of group A and 85% of group B could be stressed up to 175 W with dPmax/mean 24.5+/-8.3/12+/-4.2 and 16+/-3.6/8+/-1.4 mmHg, respectively (p<0. 01). Heart rate and blood pressure behavior were comparable. Left ventricular mass regression (preoperatively 369.3+/-76.4 vs 277.3+/-80.7 g at last examination, p<0.01) was significant in group A but did not reach normal values (group B, 227.8+/-71.1; p<0.01). Bicuspid aortic valve reconstruction reduces left ventricular volume load significantly. Although residual mild subclinical obstruction and incompetence were observed, the behavior of hemodynamics at exercise was comparable to controls. The clinical relevance of these findings in long term follow-up has to be evaluated.

[Aortic valve operation in young adults]. / Aortenklappenoperationen bei jungen Erwachsenen.

Young adults who have to undergo aortic valve surgery will frequently have (relative) contraindications to oral anticoagulation therapy because either pregnancy is planned or their life-style is very active. This review focuses on the surgical options available and assesses the literature focusing on the experience with each option obtained in young adults. There are no randomized studies in this age group which compare mechanical aortic valve replacement with any alternative option with regard to survival, need for reoperation, or quality of life. Among the alternative techniques, the Ross-procedure (pulmonary autograft) and aortic valve repair are of special interest. With the Ross-procedure, there is a rather large experience in young adults, and the results up to 10 years postoperatively are excellent. Unfortunately, there is only limited experience with this technique beyond that time.

The extent of akinesis is predictive of the in-hospital mortality from endoaneurysmorrhaphy.

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62+/-9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality.Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30 degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the LV ejection fraction (p=0.001), the number of stenosed coronary arteries (p=0.004), and the extent of akinesis (p=0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.