Aortic Valve Replacement with the Labcor TLPB Supra™ Porcine Bioprosthesis: Intermediate Clinical and Echocardiographic Outcomes.

BACKGROUND: The Labcor TBLP Supra™ prosthesis is a second-generation tissue valve that has evolved from the Labcor TBLP™ prosthesis, first introduced in 1984. The Supra prosthesis is a triple-composite porcine valve, with no specific anticalcification treatment being used in its production other than standard tissue fixation with 0.4% glutaraldehyde. To date, more than 100,000 Supra valves have been implanted, mainly in South America. Despite this remarkably high number of implants, only marginal data exist concerning durability and safety issues. Hence, the study aim was to analyze short-term and intermediate outcomes relating to the clinical and hemodynamic performance of the Supra valve, as well as complication rates METHODS: A follow up study was initiated to evaluate outcomes and durability of the Labcor Supra prosthesis. Between September 2004 and October 2010, a total of 331 patients (mean age 75.8 ± 7.2 years; mean logistic EuroSCORE 8.5 ± 2.3%) underwent aortic valve replacement using the Supra porcine bioprosthesis. RESULTS: The 30-day mortality rate was 4.8% (n = 16). The overall actuarial five-year survival was 72.3 ± 4.9%, and eight-year survival was 60.4 ± 5.6%. Actuarial freedom from reoperation was 96.3 ± 2.4% after five years, and 92.5 ± 3.5% after eight years. Actuarial freedom from structural valve deterioration (SVD) was 99.7 ± 0.3% at five years, and 97.2 ± 0.8% at eight years; actuarial freedom from thromboembolism was 97.5 ± 1.0% and 95.7 ± 1.6% at these times. Actuarial freedom from event rates for endocarditis were 99.5 ± 0.3% and 96.8 ± 0.6%, and 96.1 ± 0.9% and 93.0 ± 1.4% for reoperation CONCLUSIONS: No evidence was found of increased rates of SVD. All parameters studied were comparable to those examined for other second-generation porcine prostheses. Further long-term follow up investigations are required however, for the final judgment of this prosthesis.

Beating-heart coronary artery bypass grafting with miniaturized cardiopulmonary bypass results in a more complete revascularization when compared to off-pump grafting.

The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed.

Long-term sinus rhythm stability after intraoperative ablation of permanent atrial fibrillation.

INTRODUCTION: Short- and medium-term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long-term follow-up? METHODS AND RESULTS: A total of 130 patients who had undergone intraoperative radiofrequency cooled-tip endocardial ablation (SICTRA) of permanent AF (mean AF duration 6+/-5 years) concomitant to open heart surgery more than 3 years ago were followed up using electrocardiogram (ECG), Holter-ECG, and echocardiography and compared with 12-month follow-up data. In 55% of patients, only the left atrium and in 45%, both atria were treated using SICTRA. Mitral valve replacement was performed in 21, mitral valve reconstruction in 25, aortic valve replacement in 13, CABG procedures in 51 (including 11 patients with additional mitral valve surgery), and complex procedures in 20 patients. Sixty-nine percent of patients (90/130) were in stable SR after a median period of 48 months, whereas 28% (36/130) were in AF and 3% (4/130) were in atrial flutter. In between the 12-month follow-up and the long-term follow-up, seven patients converted to AF after having documented SR, two patients converted to typical right atrial flutter after being in SR, and two patients from AF to left atrial macroreentry. After left and biatrial SICTRA, SR rates were comparable (73% vs 66%, P = 0.45). Echocardiography revealed 73% of patients in SR to have effective left atrial contraction. CONCLUSIONS: SICTRA restores long-term stable SR in 69% of all patients. Nine percent of patients reconverted back to atrial arrhythmia after having documented SR at 12 months.

Beating-heart coronary artery bypass grafting using a miniaturized extracorporeal circulation system.

BACKGROUND: Experience with miniaturized coronary artery bypass (CAB) systems in coronary artery bypass graft (CABG) surgery on the beating heart is limited. We used a relatively new miniaturized cardiopulmonary bypass (CPB) system, which we termed assisted CAB (ACAB), to perform CABG on the beating heart in 110 patients, and we analyzed clinical outcomes in this patient group. METHODS: Between January 2004 and September 2006, we used ACAB to perform CABG on the beating heart in 110 patients. The mean patient age was 73 +/- 8.1 years. The ACAB system uses a small prime volume of only 500 mL, and the circuit is shorter than that used in conventional CPB. In addition, the tubing and oxygenator systems were surface-coated with phosphorylcholine. The initial heparin dose was 150 IU/kg, with a target activated clotting time of >250 seconds. With this management, none of the patients experienced system thrombosis. We did not use cardioplegia or aortic crossclamping and did not routinely retransfuse cardiotomy blood. Observational data for the 110 patients were analyzed. RESULTS: The mean number of anastomoses performed was 2.67. The rate of perioperative infarction was 1.8% (2 patients). Perioperative mortality was 7% (8 patients). The mean EuroSCORE for all patients was 6.4 +/- 4, whereas it was 13.75 +/- 6.18 for the patients who died. Mean CPB time was 64.96 +/- 16.66 minutes. CONCLUSION: In our experience, beating heart CABG supported by a miniaturized CPB is a safe procedure with acceptable perioperative results.

Autologous platelet gel fails to show beneficial effects on wound healing after saphenectomy in CABG patients.

Wound healing impairment in the leg after removal of the saphenous vein within the framework of a coronary artery bypass graft (CABG) operation represents a clinically significant problem. Patients suffer from this complication, and treatment of the wounds is costly in terms of both time and money. No method is known to date that reliably prevents postoperative wound healing disturbances. The effect of autologous platelet gel to stimulate wound healing is known from various medical disciplines. Within a prospective randomized study, we wanted to determine whether intraoperative use of autologous platelet gel on the leg during a CABG operation could reduce the incidence of postoperative wound healing disturbances. The application group (AG) included 35 patients and was compared to a control group (CG) that also had 35 patients. The platelet gel, as well as the thrombin required to activate the platelets, was prepared from autologous patient blood during the operation. Validation of the platelet gel comprised measurement of the growth factors platelet-derived growth factor AB (PDGF AB) and epidermal growth factor (EGF), as well as the thrombocyte and leukocyte counts. Wound healing was photographically documented after surgery, and the patients were contacted by telephone on day 50 after surgery to obtain information on wound healing status. After cell separation, the platelet count was 1616 +/- 845/microL, which is higher than in whole blood by a factor of 7.1 +/- 2.0, with a platelet yield of 47.0% +/- 13.2%. The PDGF AB concentration after activation of the platelets was raised by a median factor of 158 and EGF by a median factor of 64 compared with whole blood. During the primary clinical stay, no statistically significant differences were recorded in the number of hematomas, postoperative leg swelling, or pain level. Large-area hematomas were less frequent in the application group (AG, 29.4% vs. CG, 60%, p = .007). In the follow-up 51 +/- 9 days after surgery, 17.6% (6/34) of the patients from the AG and 31.4% (11/35) of the patients from the CG showed leg wound healing disturbances (p = .184). Using the cell separation system, a biological product that contains high concentrations of platelets, leukocytes, and growth factors can be prepared reproducibly. Despite optimum application of the autologous platelet gel to the wound, no clinically relevant differences were found between the groups, either during the primary clinic stay or in the follow-up period.

Single-center experience with the On-X prosthetic heart valve between 1996 and 2005.

BACKGROUND AND AIM OF THE STUDY: Herein are presented long-term results for the On-X mechanical heart valve. All On-X heart valve recipients since the first implantation worldwide at the University of Bochum in September 1996 were followed retrospectively; the present authors' single-center experience over a period of almost 10 years is reported. METHODS: A total of 428 patients (255 males, 173 females; mean age 62.7 years) underwent either aortic valve replacement (AVR; n = 264) or mitral valve replacement (MVR; n = 164) using the On-X prosthesis. Preoperatively, 329 patients (76.8%) were in NYHA class III or IV. Approximately 5% of AVR and 23% of MVR patients had undergone previous cardiac surgery. Concomitant surgery was performed in 189 patients (44.2%). The mean follow up was 3.9 years, and cumulative follow up 1,625 patient-years (pt-yr); the overall follow up rate was 98.7%. RESULTS: Early mortality (< or = 30 days) was 3.7% after AVR and 14.0% after MVR, with valve-related mortality rates of 0.4% and 1.2%, respectively. At autopsy (n = 12) all implants were intact. Freedom from valve-related death at nine years was 85.0 +/- 3.9% after AVR and 87.6 +/- 3.2% after MVR. The overall survival rate was 67.9 +/- 4.3% after AVR and 52.7 +/- 8.1% after MVR. The linearized rate of thromboembolism for AVR and MVR was 1.49%/pt-yr and 1.61%/pt-yr; of thrombosis 0%/pt-yr and 0.35%/pt-yr; of hemorrhage 0.93%/pt-yr and 1.43%/pt-yr; of endocarditis 0.37%/pt-yr and 0.17%/pt-yr; of non-structural failure 0.18%/pt-yr and 1.43%/pt-yr; and of reoperation 0.28%/pt-yr and 0.53%/pt-yr. There were no cases of structural valve failure. CONCLUSION: After almost one decade of clinical experience in a single center, the On-X heart valve continues to be reliable and effective.

Severity of mitral regurgitation may be underestimated in the presence of a left atrial myxoma.

It is well known that mobile or large left atrial myxoma may lead to valve obstruction and insufficiency, and affect transmitral valve flow. The case is reported of a 47-year-old woman with severe mitral regurgitation (MR) and huge left atrial myxoma (6?4?3 cm). Preoperatively, the MR appeared related to the myxoma and was classified as moderate. Following extirpation of the myxoma, intraoperative transesophageal echocardiography (TEE) revealed a severe mitral regurgitant jet. After mitral valve repair by ring implantation, the MR was reduced to minor insufficiency. Hence, a large atrial tumor may mask the severity of concomitant unrelated MR in routine echocardiography. Intraoperative TEE helped in assessing correct mitral valve function after tumor extirpation. Preoperative echocardiography should focus on mitral valve dysfunction in order to separate tumor-related and -unrelated valvular pathologies.

Left atrial versus bi-atrial Maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery: safety and efficacy.

OBJECTIVES: We sought to determine whether limited left atrial Maze surgery encircling each of the pulmonary veins, using cooled-tip radiofrequency (RF) ablation, is as effective as the bi-atrial approach? BACKGROUND: The original Cox/Maze operation effectively restores sinus rhythm (SR) in patients with atrial fibrillation (AF). Ablation procedures aimed at eliminating pulmonary vein foci have produced promising short-term success. METHODS: This was a prospective analysis of patients with chronic AF undergoing open-heart surgery in addition to the Maze operation, using intraoperatively cooled-tip RF ablation either in the left atrium alone (group A) or in both atria (group B). RESULTS: Patients in group A (n = 21) and group B (n = 49) did not differ in terms of their baseline characteristics. Concomitant open-heart surgical procedures included mitral valve replacement (3 vs. 25), mitral valve plasty (0 vs. 2), mitral and aortic valve replacement (1 vs. 1), aortic valve replacement (4 vs. 6) and coronary artery bypass grafting (13 vs. 15) in groups A and B, respectively. Follow-up ranged from 1 to 50 months. The overall cumulative rates of SR were 82% in group A and 75% in group B, without a statistically significant difference (p = 0.571). Bi-atrial contraction was revealed in 92.3% of patients in SR in group A and in 79.2% in group B. The cumulative survival rates were 90.5% in group A and 77.9% in group B (p = 0.880). CONCLUSIONS: A left or bi-atrial Maze operation using intraoperatively cooled-tip RF ablation can safely be combined with open-heart surgery. A left atrial Maze procedure seems to be as effective as the bi-atrial procedure and restores SR in 82% of patients.

Optimizing revascularization strategies in patients with multivessel coronary disease: impact of intracoronary pressure measurements.

OBJECTIVES: In patients with multivessel coronary disease, the functional significance of each lesion is often unclear, and preinterventional stress tests may be inconclusive. In this setting, intracoronary pressure measurements may be helpful to define the optimal revascularization strategy. METHODS: Twenty-five consecutive patients (aged 64 +/- 11 years) with multivessel disease, inconclusive stress tests or not performed stress tests, and an angiographically intermediate coronary artery stenosis in at least 1 major vessel underwent intracoronary pressure measurements. Myocardial fractional flow reserve was measured for the intermediate lesions under the condition of maximum hyperemia induced by intravenous adenosine (140 microg x kg(-1) x min(-1). Revascularization strategies based on angiographic information alone were compared with treatment strategies based on fractional flow reserve results. RESULTS: The original recommendation of the revascularization procedure of choice (bypass operation or angioplasty) was changed in 9 patients (36%) on the basis of the results of fractional flow reserve measurements. In 6 more patients, pressure measurements led to a change in the recommended number of anastomoses to be aimed for during the operation. Within diffusely diseased vessels, fractional flow reserve provided an exact segmental resolution of pathologic vessel resistance for optimal graft placement. Significant left main disease was confirmed in 3 of 6 patients and was detected in 3 angiographically unsuspected cases. CONCLUSIONS: In patients with multivessel disease, coronary pressure-derived fractional flow reserve is a valuable tool to guide clinical decision making and support cardiologists and cardiovascular surgeons in the composition of optimal revascularization strategies.

Digital frequency analysis of valve sound phenomena in patients after prosthetic valve surgery: its capability as a true home monitoring of valve function.

BACKGROUND AND AIM OF THE STUDY: Depending on the individual risk profile of a patient, disturbances of the functional integrity of mechanical heart valve prostheses occur in up to 2.5% of patients each year. The early phase of prosthetic dysfunction (due to thrombus formation, tissue ingrowth or endocarditis) usually remains undiagnosed, as patients do not present with symptoms in this situation, and imaging techniques (echocardiography, fluoroscopy) demonstrate normal occluder motion. The delay between the onset of prosthetic valve dysfunction and its clinical manifestation may result in complications (e.g. thromboembolism) or extended therapeutic options (e.g. reoperation rather than more intensive anticoagulation). METHODS: A total of 291 patients with mechanical heart valves was allocated to four different sub-groups, and each measured their valve sounds regularly with the 'ThromboCheck' device. Depending on the subgroup, the signals were compared with different reference signals. Patients in whom a suspicious signal was detected were immediately contacted and examined meticulously. RESULTS: Fourteen patients were found to have suspicious signals. In 13 patients, valve dysfunction was confirmed by fluoroscopy, but in four cases neither transthoracic nor transesophageal echocardiography detected abnormal occluder motion or 'musses' adjacent to the prosthesis. Normal valve sounds returned in four patients who underwent thrombolytic therapy. All patients regularly recorded and passed on their signals. Surveys revealed high acceptance and easy handling of the Thrombocheck device. CONCLUSION: Home monitoring of sound pressure measurements of prosthetic valves by digital frequency analysis via a Fast Fourier transformation may detect even very mild alterations of prosthetic valve function. The next evolution of control systems, allowing for registration of flow, frequency spectrum and electrocardiography, opens potential applications for Internet-based, remote monitoring of cardiac patients.

Determinants of health-related quality of life after aortic valve replacement in six-month survivors of intervention.

BACKGROUND AND AIM OF THE STUDY: Although several determinants of survival after aortic valve replacement (AVR) have been identified, current knowledge regarding factors influencing the postoperative quality of life (QoL) is poor. The study aim was to evaluate health-related QoL (using Medical Outcome Study Short Form-36) in six-month survivors after AVR, and to determine predictors of outcome. METHODS: All patients undergoing heart valve surgery at the authors' hospital between 1992 and May 1999 were included. Data from 201 patients (119 males, 82 females; mean age 66.6 years) after AVR were obtained. The mean observation period was 42.5 months. RESULTS: Patients in preoperative NYHA classes I and II had a postoperative QoL comparable to that of the general population, while subjects in NYHA classes III and IV scored significantly lower. Multivariate analysis identified four independent predictors (preoperative NYHA class, diabetes mellitus, prosthetic valve type, sternal complications) for the Physical component score. NYHA class, atrial fibrillation, sternal complications and type of valvular heart disease were predictors for the Mental component score. No correlation was found between preoperative left ventricular function or size, pre-existing coronary artery disease or prior myocardial infarction and the postoperative QoL. CONCLUSION: Notably, preoperative aortic stenosis was identified as a strong and independent predictor of the postoperative QoL in six-month survivors after AVR. This effect was independent of left ventricular size and function. These findings support the proposal that patients with aortic stenosis should be operated on at an earlier stage, if possible before they develop symptoms.

Concomitant anti-arrhythmic surgery, using irrigated cooled-tip radiofrequency ablation, to treat permanent atrial fibrillation in CABG patients: expansion of the indication?

OBJECTIVES: The effectiveness of a concomitant anti-arrhythmic surgical procedure in coronary artery bypass grafting (CABG) patients with permanent atrial fibrillation (AF) was evaluated. METHODS: This prospective study included 36 CABG patients, who had a concomitant anti-arrhythmic procedure using irrigated cooled-tip radiofrequency ablation. Follow-up included a 24 h EKG and ultrasound examination at 3, 6, 12 months. RESULTS: Mean (SD) age was 68.7 years (8.0), left atrial diameter 44.9 mm (6.7), preoperative duration of AF 67 months (73), left ventricular ejection fraction 54% (14), euroscore 5.5 (2.6), number of distal anastomoses 3.3 (1.2), aortic cross-clamp time 90 (19)min, extracorporeal bypass time 156 (38)min. Thirty-day mortality was 2.8% (1/36). Mean (SD) follow-up was 25.3 months (17.9). Cumulative survival rates (SE) at 12 and 24 months were 0.94 (0.04) and 0.90 (0.06). Cumulative postoperative sinus rhythm (SR) rates (SE) at 6 and 12 months were 0.60 (0.08) and 0.75 (0.08). Restored bi-atrial contraction occurred in 73% (19/26) of all SR patients. As a consequence coumadine was stopped, after the 6th postoperative month, in 76% (16/21) in this subset of patients, corresponding with 44% (16/36) of all study group patients. One patient experienced a sick sinus syndrome 12 months postoperatively, for which a DDD pacemaker was implanted. Three out of five patients with a preexistent VVI pacemaker regained a stable postoperative SR with bi-atrial contraction, obviating the need of any pacemaker support.

[Acute postoperative confusion in heart surgery patients]. / Akute postoperative Verwirrtheit kardiochirurgischer Patienten.

Unlike other countries, Germany does not have data about the incidence of acute confusion following heart surgery. However, the occurrence of acute confusion does extend the hospitalization length by up to 13 days. Thus, this phenomenon is of high relevance for the health profession. This incidence study was performed with the goal to obtain exact information on the incidence rate of acute postoperative confusion after heart surgery (bypass and valve operations) through a multi-center evaluation. The data evaluation took place in the form of a convenient sample survey in three different German clinics specialized in heart surgery. The observation period lasted from the day of surgery up to the fifth postoperative day. In the context of this prospective cohort study, suitable study participants were all patients aged 18 or older who underwent heart surgery between February 1st and April 30th, 2000. At the end, 860 patients were included in the study. A total of 152 patients showed symptoms of acute confusion, meaning a total incidence of 17.4% (confidence interval 14-20%). The occurrence of this phenomenon was not symmetrical. A wide-spread occurrence could be observed particularly at night. Patients aged 81-91 were mainly affected, with an incidence of confusion of 43.5% in this group. The results confirm the clinical importance of this issue and require interdisciplinary approaches for solution.

One-year results of transcatheter aortic valve implantation in severe symptomatic aortic valve stenosis.

Transcatheter aortic valve implantation (TAVI) is an alternative therapy for symptomatic severe aortic valve stenosis in high-risk patients with several co-morbidities. We evaluated the 1-year effects of TAVI on quality of life, exercise capacity, neurohormonal activation, and myocardial hypertrophy. From June 2008 to October 2009, consecutive patients aged ≥75 years with symptomatic severe aortic valve stenosis (area <1 cm(2)) and a logistic euroSCORE ≥15% or aged >60 years with additional specified risk factors underwent TAVI. An aortic valve prosthesis (CoreValve) was inserted in a retrograde fashion. Examinations were performed before and 30 days and 1 year after TAVI. An assessment of the quality of life (Minnesota Living with Heart Failure Questionnaire), a 6-minute walking test, measurement of B-type natriuretic peptide, and echocardiography were performed. In 51 patients (mean age 78 ± 6.6 years, mean left ventricular ejection fraction 58.4 ± 12.2%), the follow-up examinations were performed after TAVI. The 1-year follow-up visit after TAVI revealed significantly improved quality of life (baseline Minnesota Living with Heart Failure Questionnaire score 39.6 ± 19 vs 26.1 ± 18, p <0.001) and more distance covered in the 6-minute walking test (baseline 185 ± 106 vs 266 ± 118 m, p <0.001). The B-type natriuretic peptide level had decreased (baseline 642 ± 634 vs 323 ± 266 pg/ml, p <0.001), and the left ventricular mass index had decreased (156 ± 45 vs 130 ± 42 g/m(2), p <0.001). The left ventricular diameter and ejection fraction remained unchanged. In conclusion, TAVI leads to significantly reduced neurohormonal activation, regression of myocardial hypertrophy, and lasting enhancement of quality of life and exercise capacity in patients with symptomatic and severe aortic stenosis 1 year after intervention.

Short-term effects of transcatheter aortic valve implantation on neurohormonal activation, quality of life and 6-minute walk test in severe and symptomatic aortic stenosis.

OBJECTIVE: This prospective study aimed to determine to what extent clinical symptoms and neurohumoral activation are improved in patients with severe aortic valve stenosis after transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis. METHODS: From June 2008 to June 2009 consecutive patients with symptomatic severe aortic valve stenosis (area<1 cm(2)), age>or=75 years with a logistic EuroSCORE >or=15% or age>60 years plus additional specified risk factors were evaluated for TAVI. Examinations of study patients were performed before and 30 days after TAVI and comprised assessment of quality of life (Minnesota living with heart failure questionnaire, [MLHFQ]) 6-minute walk test, measurement of B-type natriuretic peptide and echocardiography. Aortic valve prosthesis was inserted retrograde using a femoral arterial or a subclavian artery approach. RESULTS: In 44 consecutive patients (mean age 79.1+/-7 years, 50% women, mean left ventricular ejection fraction 55.8+/-8.5%) TAVI was successfully performed. Follow-up 30 days after TAVI showed a significantly improved quality of life (baseline 44+/-19.1 vs 28+/-17.5 MLHFQ Score, p<0.001) and an enhanced distance in the 6-minute walk test (baseline 204+/-103 vs 266+/-123 m, p<0.001). B-type natriuretic peptide levels were reduced (baseline 725+/-837 vs 423+/-320 pg/ml, p=0.005). CONCLUSIONS: Our preliminary results show a significant clinical benefit and a reduction of neurohormonal activation in patients with severe and symptomatic aortic valve stenosis early after TAVI.

Differential diagnosis of non-atherosclerotic left main coronary artery stenosis.

A left main coronary artery (LMCA) stenosis without any atherosclerotic changes elsewhere in the coronary artery tree is a rare finding, and some uncommon reasons for luminal narrowing should be considered. An unusual case of non-atherosclerotic LMCA stenosis is reported.A middle-aged patient presented with acute myocardial infarction. An immediate coronary angiography was ordered and revealed a subtotal mid LMCA stenosis. A drug-eluting stent was successfully implanted in the LMCA.Operative revascularisation was recommended. Routine surgery was performed and surprisingly revealed an extended mass of a mediastinal tumour surrounding the aortic root. Histopathological examination of the tumour revealed a poorly differentiated squamous cell carcinoma.Postoperatively, the patient was treated with chemotherapy (carboplatin and docetaxel). Five years after the first admission to our hospital, the patient died as a result of ventricular fibrillation.The differential diagnosis of non-atherosclerotic LMCA stenoses is discussed.

Early outcome after off-pump coronary artery bypass grafting: effect on mortality and stroke.

OBJECTIVE: One of the major and devastating complications of the coronary artery bypass grafting (CABG) is the stroke. Avoiding cardiopulmonary bypass (CPB) may reduce this neurological complication. In the past years there was an increased interest in the off-pump coronary artery grafting (OPCAB). The benefit of this method of revascularization in term of stroke and mortality is controversially discussed. METHODS: A retrospective analysis of collected data from 252 patients were operated without cardiopulmonary bypass out of 1516 CABG procedures from January 2004 through May 2006. The mean age of the patient population was 70+/-11 years, within a range of 27-88 years. Forty-eight (19%) patients were older than 80 years and there were 172 (69%) males. Mean graft per patient was 1.78+/-0.79. The internal mammary artery (IMA) graft was used in 95% of the patients. For eight (3.17%) patients this was the second procedure. RESULTS: Hospital mortality was 3.17%; Mean EuroSCORE in these patients was 10.36+/-6.67. No neurological complications occurred, six (2.38%) patients had temporary psycho syndrome. Postoperative myocardial infarction occurred in three (1.19%) patients. Two patients required rethoracotomy as a result of bleeding. Thirty-eight (15%) patients needed postoperative therapy for atrial fibrillation. CONCLUSION: CABG with OPCAB technique has the benefit of low mortality and morbidity in terms of stroke. The advantages of this technique depends on the patient's general condition at the time of the operation, the sufficiency of pump function and coronary morphology, as well as on the surgeon's experience.

Early detection of mechanical valve dysfunction using a new home monitoring device.

BACKGROUND: After heart valve replacement, patients are at risk of complications that are linked to irregular oral anticoagulation therapy. Depending on the type and position of the valve, the complication rate is 3% to 6% per patient-year. This study presents clinical results of a device enabling early detection of prosthetic dysfunction by frequency measurements. METHODS: Between November 2003 and March 2006, ThromboCheck devices were handed out to 483 patients after mechanical heart valve replacement from six heart centers. In each case, the devices were calibrated for individual patients early postoperatively. Taking control measurements, the device calculated deviations from calibrated frequency and amplitude ranges using a fast Fourier transform and sent a warning message to the display if any relevant changes occurred. This message was taken as cause to determine morphologic correlations of the disturbance using imaging techniques, for example, echocardiography or fluoroscopy (observation period, 550.7 patient-years; median application period, 15.1 months). RESULTS: Twenty-five true positive, 1 false positive, and no false negative measurements occurred. Eleven patients (44%) received thrombolytic therapy with streptokinase or recombinant tissue-type plasminogen activator, resulting in normalization of the digital frequency analysis. In 4 patients (16%), international normalized ratio levels were adjusted under temporary heparinization therapy. Normalization of the valve sounds were achieved within 3 to 7 days. Seven patients (28%) required reoperation despite lysis therapy. Sensitivity was 100% during the observation period; specificity was 99.8%. CONCLUSIONS: Digital frequency analysis represents a reasonable addition to the monitoring of patients after artificial heart valve replacement to detect prosthesis-related complications early on.

Multicentered European study on safety and effectiveness of the On-X prosthetic heart valve: intermediate follow-up.

BACKGROUND: This study was performed to determine the safety and effectiveness of the On-X valve, a novel mechanical valve substitute. METHODS: Eleven centers participated in a European, multicentered, longitudinal, nonrandomized study of the On-X valve performance. Isolated aortic or mitral valve replacement with an On-X valve was studied in 301 patients. Aortic valve replacement was performed in 184 patients (average follow-up, 5.0 years), whereas mitral valve replacement was performed in 117 patients (average follow-up, 4.4 years). RESULTS: In patients with aortic valve replacement, mean transvalvular pressure gradients ranged from 8.3 to 4.7 mm Hg and effective orifice areas from 1.5 to 2.7 cm2, for 19-mm through 25-mm valves, respectively. After mitral valve replacement, mean gradient was 4.2 mm Hg and effective orifice area by pressure half-time was 2.6 cm2 regardless of valve size. Hemolysis was low, with postoperative serum lactate dehydrogenase at 225 +/- 41 IU (mean +/- standard deviation) or 253 +/- 65 IU, after aortic valve replacement or mitral valve replacement, respectively (upper normal value, 250 IU). At 1 year or greater postoperatively, 91.6% of patients after aortic valve replacement and 84.6% after mitral valve replacement were in New York Heart Association functional class I or II. Adverse event rates in percent per patient-year after aortic valve replacement or mitral valve replacement were thromboembolism, 0.88 or 1.76; thrombosis, 0.11 or 0.20; bleeding, 0.77 or 1.96, respectively. Late mortality was 1.97% or 2.55%, respectively. CONCLUSIONS: At the intermediate follow-up, the On-X valve exhibited improved hemodynamics, low hemolysis with in-range lactate dehydrogenase, and low adverse event rates, particularly in the aortic position.