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ABSTRACT: BACKGROUND: The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity. METHODS: Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete. RESULTS: Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up. CONCLUSIONS: Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe.
The Annals of thoracic surgery 05/2013; · 3.74 Impact Factor
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ABSTRACT: Although median sternotomy is the accepted approach to the heart for cardiac surgery, minimally invasive approaches including partial sternotomies have recently been developed. However, such strategies might lead to sternal overriding, instability, and fracture or division of the internal thoracic arteries. Furthermore, a full sternotomy would be required to address unpredictable intra- or postoperative complications. This article describes minimally invasive aortic valve replacement via full sternotomy and minimal skin incision using an endoscope.
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 03/2013;
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ABSTRACT: OBJECTIVES: The proper treatment of aneurysms of the ascending aorta is still under debate. Here, we describe the early and late outcomes after composite replacement (CR), supracommissural aortic replacement (SCR) and aortic valve-sparing (AVS) operations. METHODS: Five hundred and fourty-eight patients were operated on for ascending aortic aneurysm from 1994 until 2011. Two hundred and ninety-eight (54%) patients had CR, 154 (28%) underwent SCR, 96 (18%) received AVS using David's technique [83 (15%); after October 2006] and 13 (3%) using Yacoub's technique. The average size of the aneurysms was 5.8 ± 1.3 cm and differed between groups (P < 0.001). Patients in the SCR group were older (P < 0.001), and male gender was less frequent in the Yacoub group (P = 0.004). Marfan's syndrome was present more often in the AVS group (P < 0.001). RESULTS: Times for operation, extracorporeal circulation and aortic cross-clamping differed significantly (P < 0.001). In the SCR group, 40% of patients additionally underwent aortic valve replacement. Rethoracotomy for bleeding was required in 33 patients. Overall, 30-day mortality was 4.8% and did not differ between groups (SCR = 7.2%, CR = 4.8%, David's technique = 0% and Yacoub's technique = 8.3%; P = 0.12). Six patients experienced cerebral accidents. The follow-up was complete for 93%, and mean follow-up time was 3.9 ± 3.9 (0-17.8) years. Kaplan-Meier analysis revealed a significantly reduced long-term survival for women (log-rank P = 0.0052). Reoperation on the aortic root was necessary in only 6 patients from the Yacoub and SCR groups. No aortic dissection occurred. By uni- or multivariate regression analysis, age and preoperative creatinine were risk factors for 30-day mortality, and age, gender, creatinine, New York Heart Association class and chronic obstructive pulmonary disease, for long-term survival. CONCLUSIONS: All four applied techniques result in low mortality and low reoperation rate and prevent aortic dissection. The David procedure yields excellent mid-term results.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2013; · 2.40 Impact Factor
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ABSTRACT: OBJECTIVE: Fibrillin-1 hypomorphic mice (mgR/mgR) are accepted as a model of Marfan syndrome. Phenotypic investigations of this mouse have not previously included quantification of phenotypic features and detailed examinations of the histopathology other than in the ascending aorta. METHODS: We developed a quantitative polymerase chain reaction assay to genotype the mice. Necropsy was performed on 50 male mice after natural death. We then sacrificed 10 mgR/mgR and 10 wild-type mice at 14-19 weeks to perform in vivo computed tomographic scans (n = 3) and microscopic examinations (n = 7). Four aortic segments (ascending, descending, pararenal, and infrarenal aorta) were excised. Each segment was divided into four subsegments and analyzed with Van Gieson staining. The number of elastin breaks and internal aortic diameter were determined twice in randomized, blinded fashion. RESULTS: Computed tomographic scans of mgR/mgR mice revealed aneurysm formation in the ascending aorta and kyphoscoliosis. Elastolysis was present in all four aortic segments of mgR/mgR but was rarely observed in wild-type mice (P < .001). The diameter of the ascending aorta was larger in mgR/mgR than in wild-type mice (P = .01), but para- and infrarenal aortic diameter were even smaller in mgR/mgR mice (P < .001 and P = .01, respectively). Exploratory gene expression analysis showed a number of differentially expressed genes with overrepresentation of immune-related functions. Quantitative polymerase chain reaction analysis confirmed upregulation of selected genes in both the ascending aorta and the abdominal aorta. CONCLUSIONS: Our findings suggest that mgR/mgR mice could be a useful model to study aortic abnormalities in segments other than the ascending aorta in order to understand the molecular mechanisms of aortic disease in Marfan syndrome.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2013; · 3.52 Impact Factor
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Christof Karmonik,
Sasan Partovi,
Matthias Loebe,
Bastian Schmack,
Ali Ghodsizad,
Mark R Robbin,
George P Noon, Klaus Kallenbach,
Matthias Karck,
Mark G Davies,
Alan B Lumsden,
Arjang Ruhparwar
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ABSTRACT: To develop a better understanding of the hemodynamic alterations in the ascending aorta, induced by variation of the cannula outflow position of the left ventricular assist device (LVAD) device based on patient-specific geometries, transient computational fluid dynamics (CFD) simulations using the realizable k-ε turbulent model were conducted for two of the most common LVAD outflow geometries. Thoracic aortic flow patterns, pressures, wall shear stresses (WSSs), turbulent dissipation, and energy were quantified in the ascending aorta at the location of the cannula outflow. Streamlines for the lateral geometry showed a large region of disturbed flow surrounding the LVAD outflow with an impingement zone at the contralateral wall exhibiting increased WSSs and pressures. Flow disturbance was reduced for the anterior geometries with clearly reduced pressures and WSSs. Turbulent dissipation was higher for the lateral geometry and turbulent energy was lower. Variation in the position of the cannula outflow clearly affects hemodynamics in the ascending aorta favoring an anterior geometry for a more ordered flow pattern. The new patient-specific approach used in this study for LVAD patients emphasizes the potential use of CFD as a truly translational technique.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 09/2012; · 1.39 Impact Factor
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ABSTRACT: BACKGROUND: Empiric experiences suggest higher mortality and complication risk for patients with cirrhosis of the liver after cardiac surgery. However, cirrhosis is not considered a risk factor in either the EuroSCORE or The Society of Thoracic Surgeons score. We report a large single-center experience of patients with cirrhosis undergoing cardiac surgery with extracorporeal circulation and aimed to evaluate the severity of cirrhosis as a predictor of outcome. METHODS: During 2001 and 2011, we operated on 109 consecutive patients (average age, 64 years; 82 male) diagnosed for cirrhosis with cardiopulmonary bypass for different indications. Thirty-day mortality and long-term mortality were set as primary study end points. RESULTS: Thirty-day mortality was 26%, and 5-year survival was 19%. Patients categorized as Child-Turcotte-Pugh (CHILD) C (n = 6; 67% 30-day survival; 0% 5-year survival) and B (n = 30; 60%; 5%) had worse 30-day and 5-year survival compared with patients categorized as CHILD A (n = 73; 80%; 25%). For 30-day mortality, preoperative EuroSCORE (p = 0.015), model for end-stage liver disease (MELD) score (p = 0.006), albumin (p = 0.023), total protein (p = 0.01), and myocardial infarction (p = 0.049) revealed significant differences between survivors and nonsurvivors. Multivariate logistic regression identified only MELD score (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.03 to 1.23; p = 0.011) and total protein (OR, 0.97; 95% CI, 0.95 to 1; p = 0.049) were connected with increased 30-day mortality. Cox regression analysis revealed EuroSCORE (OR, 1.02; 95% CI, 1.01 to 1.03; p < 0.0001) and MELD (OR, 1.06; 95% CI, 1.01 to 1.12; p = 0.016) predicting the overall mortality. Receiver operating characteristic analysis indicated significant predictive power of MELD (p = 0.001) and EuroSCORE (p = 0.027) for 30-day mortality. CONCLUSIONS: Patients with cirrhosis undergoing heart surgery with extracorporeal circulation have a poor prognosis. Several preoperative factors are related to outcome. EuroSCORE and MELD score may help to evaluate operation risk and indication.
The Annals of thoracic surgery 08/2012; · 3.74 Impact Factor
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ABSTRACT: OBJECTIVE: Transcatheter aortic valve implantation (TAVI) is a therapeutic option for old and multimorbid patients with severe aortic stenosis. When applying the groin first approach by transfemoral implantation, patients in the transapical group are highly selected with even higher morbidity. We report outcome of the transapical group. METHODS: Between April 2008 and May 2011, 267 patients underwent TAVI through either a transfemoral (n = 201 CoreValve, n = 33 Edwards Sapien prostheses; mean age 81 ± 6 years, logistic EuroSCORE 19.5 ± 12.6 %; 4-76, STS score 7.2 ± 4 %; 1.5-28.9) or transapical approach (n = 33 Edwards Sapien prostheses; mean age 80 ± 1 years, logistic EuroSCORE 31.6 ± 17.1 %; 9.4-69.1, STS score 12.8 ± 7.1 %; 2.5-28.8). The transapical access was chosen only when transfemoral implantation was not possible. RESULTS: EuroSCORE and STS score were significantly higher in the transapical group (p = 0.001, respectively). A 30-day survival was comparable with 87.9 % in the transapical versus 92 % in the transfemoral group (p = 0.52). In the transapical group, female gender was predominant (n = 23; 70 %). Eight patients underwent previous cardiac surgery. All transapical implantations were successful. No bleeding or neurological complications occurred. Six patients required postoperative pacemaker implantation. Cardiac decompensation with concomitant pneumonia was the underlying cause for early mortality, except for one patient with abdominal malperfusion. Follow-up (0-37 months) was complete in 100 %, nine patients died after 30 days postoperatively (6 cardiac and 3 non-cardiac related). Echocardiography revealed good valve function with not more than mild paravalvular incompetence. CONCLUSIONS: Groin first approach is reasonable due to less invasive implantation technique. However, despite even higher predicted mortality, transapical aortic valve implantation is non-inferior to transfemoral approach.
Clinical Research in Cardiology 08/2012; · 2.95 Impact Factor
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ABSTRACT: OBJECTIVES Sternal dehiscence and mediastinitis are rare but serious complications following cardiac surgery. The aim of this study was to investigate the influence of the number of sternal wires used for chest closure on sternal complications. METHODS From May 2003 to April 2007, 4714 adult patients received cardiac surgery in our institute. X-ray images of all patients were reviewed and the used wires were counted. Patients who received another material or longitudinal wiring technique according to Robicsek for chest closure were excluded from this analysis; thus 4466 patients were included into the final analysis. Figure-of-eight wiring was counted as two wires. RESULTS Sternal complications occurred in 2.4%, and hospital mortality with or without sternal complications were 2.8 and 2.7%, respectively (P = 0.60). Mean numbers of sternal wires were 7.8 in both patient groups with or without sternal complications (P = 0.79). Multivariate analysis revealed diabetes mellitus [odds ratio (OR) 1.54, 95% CI 1.01-2.34, P = 0.04], chronic obstructive pulmonary disease (OR 1.85, 95% CI 1.12-2.79, P = 0.01) and renal insufficiency (OR 1.70, 95% CI 1.11-2.59, P = 0.001) as significant risk factors for sternal complications. In high-risk patients, the use of less than eight wires was significantly associated with postoperative sternal complications. CONCLUSIONS Particularly in high-risk patients, careful haemostasis should be done and eight or more wires should be used to avoid sternal complications.
Interactive cardiovascular and thoracic surgery 07/2012; 15(4):665-70.
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ABSTRACT: Transcatheter aortic valve implantation (TAVI) has become an established therapeutic option in high-risk patients with severe aortic valve stenosis. The potential threat of a postinterventional infection is one of several life-threatening complications. We have analyzed C-reactive protein levels in all patients who underwent successful transfemoral aortic valve implantation between July 2009 and January 2011. CRP and leukocyte counts were measured within 24 hours prior to implantation and daily up to 14 days after implantation. Patients with CRP levels above 109 mg/L (75th percentile; normal range <5 mg/L) were additionally analyzed. We performed 215 transfemoral aortic valve implantations (Edwards and CoreValve). The mean CRP increased after TAVI with a 7.5-fold peak on day 3, and was nearly normalized on day 14. Interestingly, mean leukocyte count remained within the normal range. To identify further independent predictors for post-TAVI elevation of CRP above the 75th percentile, multivariate logistic regression analysis was performed. This showed a significant relationship for patients with elevated baseline CRP values above 11.9 mg/L, for a body mass index above 25 kg/m², for a logistic EuroSCORE ≥22% and for signs of postinterventional infection. Elevated baseline (>6.4 mg/L) and elevated peak (>102 mg/L) CRP values were associated with higher 30-day mortality. In conclusion, CRP elevation after TAVI should be expected to peak on day 3. An infection should be taken into account if CRP increases above 110 mg/L and if patients show other signs of infection. Elevated CRP at baseline and at day 3 is associated with higher 30-day mortality.
The Journal of invasive cardiology 06/2012; 24(6):282-6. · 1.84 Impact Factor
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ABSTRACT: Considering the expanding technology of catheter-based aortic valve implantation, high-risk patients who would not be suitable for conventional aortic valve replacement (AVR) should be identified.
From 1997 to April 2007, 190 patients aged from 80 and 89 years old received isolated AVR. Patients between 80 and 84 years old were categorized as the early octogenarians (n = 148) and patients between 85 and 89 years old were categorized as the late octogenarians (n = 42).
Thirty days mortality in the early and late octogenarians were 6 and 21%, respectively (p = 0.003). The additive and logistic EuroSCORE were 8.0 ± 2.4 and 8.8 ± 1.8 in the early octogenarians and 13.2 ± 11.8 and 14.6 ± 8.7 in the late octogenarians. Multivariate analysis revealed the late octogenarians (OR 6.7, 95%CL 1.8-24.4, p = 0.004) and poor left ventricular function (OR 8.0, 95%CL 1.2-53.5, p = 0.032) as significant risk factors for 30 days mortality. Early octogenarians showed 1-year, 3-year, 5-year, and 8-year survival of 82.4, 67.6, 54.7, and 33%, respectively. Late octogenarians showed 1-year, 3-year, 5-year, and 8-year survivals of 69.0, 66.2, 41.6, 22.3%, respectively.
Mortality after AVR in the late octogenarians was very high, and was underestimated by EuroSCORE in this patients group. In late octogenarians, catheter-based aortic valve implantation despite relative low EuroSCORE level could be considered as a reasonable alternative.
The Thoracic and Cardiovascular Surgeon 05/2012; 60(5):343-50. · 0.88 Impact Factor
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ABSTRACT: Der Goldstandard zur Behandlung der hochgradigen Aortenklappenstenose ist die offene Herzoperation im künstlich induzierten
Herzstillstand (Kardioplegie) unter Nutzung der Herz-Lungen-Maschine. Mit dieser Technik können heute auch sehr alte Patienten
mit guten Ergebnissen behandelt werden. Dennoch kann bei sehr alten und/oder multimorbiden Patienten das Operationsrisiko
unverhältnismäßig hoch liegen und damit zur Inoperabilität führen. Durch Einführung der perkutanen Aortenklappenimplantation
(PAVI) können heute auch Patienten behandelt werden, die aufgrund der Komorbiditäten keine geeigneten Kandidaten für die offene
Herzoperation sind. Die PAVI wurde damit initial als Palliation für inoperable, symptomatische Patienten verstanden. Demzufolge
zeigten die ersten Ergebnisse mit dem neuen Verfahren eine hohe Morbidität und Mortalität bei diesen schwerkranken Patienten.
Während in dieser Initialphase die Kontraindikation zur offenen Operation, die zuvor gemeinsam von Kardiochirurgen und Kardiologen
festgestellt wurde, Voraussetzung für die Behandlung mit PAVI war, werden heute auch Patienten mit der neuen Methode behandelt,
die durchaus noch Kandidaten für eine Operation wären, allerdings unter erhöhtem Risiko. Das periprozedurale Risiko wird meist
mit dem logistischen Euroscore ermittelt und damit der Einsatz der PAVI gerechtfertigt, obwohl die Überschätzung des Operationsrisikos
mit dieser hier ungeeigneten Methode belegt ist. Mittlerweile sind die Komplikationsraten unter PAVI in erfahrenen Zentren
zurückgegangen. Trotzdem können die auftretenden Komplikationen, so z.B. die Dislokation der Prothese während der Freisetzung
des Stents, für den Patienten eine lebensbedrohliche Situation darstellen. Systemimmanente Komplikationen wie postoperative
paravalvuläre Leckage, AV-Blockierungen oder Gefäßverletzungen beim transfemoralen Zugang lassen sich wahrscheinlich mit zunehmender
Erfahrung zwar reduzieren, aber nicht ganz vermeiden. Auch deshalb ist der derzeitige Trend hin zu einer Erweiterung des Indikationsspektrums
auf Patienten, die gut für den konventionellen Aortenklappenersatz geeignet wären, ausgesprochen kritisch zu werten. Bevor
nicht randomisierte, prospektive Studien die Gleichwertigkeit der PAVI gegenüber dem offenen Aortenklappenersatz auch hinsichtlich
der Langzeitstabilität der Klappenprothese belegen, sollte dieses Verfahren ansonsten inoperablen Patienten vorbehalten bleiben.
Idealerweise sollte es zur höchstmöglichen Sicherheit der Patienten nur in Zentren zum Einsatz kommen, in denen ein Team aus
Herzchirurgen und Kardiologen gemeinsam die Indikation stellt, den Eingriff vornimmt und dann auch mögliche Komplikationen
beherrschen kann.
For symptomatic patients with severe aortic valve stenosis, open heart surgery for aortic valve replacement (AVR) with use
of cardioplegia under cardiopulmonary bypass remains the gold standard. Cumulative surgical experience and technical improvement
for more than 5 decades have led to excellent perioperative results with low mortality and morbidity. Long-term results are
convincing, long-term survival is close to the average population, and durability of biological prostheses is favorable in
the elderly. Even in octogenarians, AVR is feasible with acceptable results. However, in very old patients with many comorbidities,
the outcome is less favorable, and many of those patients may be inoperable or carry an inacceptably high perioperative risk.
Catheter-based balloon valvuloplasty (BAV) of the stenotic aortic valve was advocated 20 years ago, initially with high enthusiasm,
aimed to replace AVR in older patients. However, results were inacceptably poor, and isolated BAV is only used with palliative
intent today.
In 2002, Cribier et al. reported of percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic
stenosis: after BAV, they implanted a metal stent graft carrying a biological valve into the aortic annulus. Despite improvement
of hemodynamics, the patient died 17 weeks after implantation due to his comorbidities. Cribier and others applied percutaneous
aortic valve implantation (PAVI) to inoperable, symptomatic patients with severe aortic stenosis during the next years with
high early mortality and morbidity on a compassionate basis. However, with respect to the inoperable status of those patients,
a treatment strategy on top of AVR, and not as an alternative, was born for usually very old patients with many comorbidities,
applied as a palliation. In this early phase, cardiac surgeons were directly involved into selection of patients for PAVI,
since inoperability had to be documented.
Today, the indication for PAVI is about to be softened toward patients that may be candidates for open surgery as well. Not
only inoperable, but also “high-risk” candidates for open surgery are recruited for PAVI now. PAVI lost its compassionate
basis. Cardiac surgeons are not always involved into this decision tree anymore. For selection and justification, the perioperative
risk is usually calculated with the logistic Euroscore calculator preoperatively, although it has been evidenced that this
tool overestimates the operative risk by far, in contrast to the STS Score. The average Euroscore of patients selected for
PAVI also decreased by time.
PAVI carries the risk of several periprocedural complications, which may be life-threatening. Dislocation of the graft and
embolization of the aortic orifice, aortic rupture and dissection, obstruction of coronary ostia represent devastating complications.
The majority of patients after PAVI will suffer from perivalvular insufficiency; the incidence of complete AV blockade is
up to 25%. The retrograde approach via the femoral artery is associated with a relatively high incidence of vascular complications
to the downstream aorta, iliac and femoral arteries. The antegrade transapical approach requires intubation and thoracotomy,
with the risk of bleeding from the fragile apex of the heart. Furthermore, little is known about the durability of these valves.
Small catheter sizes, aimed to cross the groin vessels, do not allow the use of thick cusp tissue with high longevity.
Softening the indication for PAVI is ethically not acceptable yet. Randomized, prospective studies with long-term follow-up
are mandatory to evaluate the valvular longevity and the consequences of system-immanent complications of PAVI compared to
AVR. Selection of patients, conduction of the procedure and treatment of potentially life-threatening complications require
a team of cardiac surgeons, interventional cardiologists and anesthesiologists with a fully equipped hybrid operating room
including extracorporeal circulation.
Herz 04/2012; 34(2):130-139. · 0.92 Impact Factor
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ABSTRACT: Suggesting that bioartificial vascular scaffolds cannot but tissue-engineered vessels can withstand biomechanical stress, we developed in vitro methods for preclinical biological material testings. The aim of the study was to evaluate the influence of revitalization of xenogenous scaffolds on biomechanical stability of tissue-engineered vessels. For measurement of radial distensibility, a salt-solution inflation method was used. The longitudinal tensile strength test (DIN 50145) was applied on bone-shaped specimen: tensile/tear strength (SigmaB/R), elongation at maximum yield stress/rupture (DeltaB/R), and modulus of elasticity were determined of native (NAs; n = 6), decellularized (DAs; n = 6), and decellularized carotid arteries reseeded with human vascular smooth muscle cells and human vascular endothelial cells (RAs; n = 7). Radial distensibility of DAs was significantly lower (113%) than for NAs (135%) (P < 0.001) or RAs (127%) (P = 0.018). At levels of 120 mm Hg and more, decellularized matrices burst (120, 160 [n = 2] and 200 mm Hg). Although RAs withstood levels up to 300 mm Hg, ANOVA revealed a significant difference from NA (P = 0.018). Compared with native vessels (NAs), SigmaB/R values were lower in DAs (44%; 57%) (P = 0.014 and P = 0.002, respectively) and were significantly higher in RAs (71%; 83%) (both P < 0.001). Similarly, DeltaB/R values were much higher in DAs compared with NAs (94%; 88%) (P < 0.001) and RAs (87%; 103%) (P < 0.001), but equivalent in NAs and RAs. Modulus of elasticity (2.6/1.1/3.7 to 16.6 N/mm(2)) of NAs, DAs, RAs was comparable (P = 0.088). Using newly developed in vitro methods for small-caliber vascular graft testing, this study proved that revitalization of decellularized connective tissue scaffolds led to vascular graft stability able to withstand biomechanical stress mimicking the human circulation. This tissue engineering approach provides a sufficiently stable autologized graft.
Artificial Organs 07/2011; 35(10):930-40. · 2.00 Impact Factor
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ABSTRACT: Cardiac operation for severe aortic stenosis after previous mitral valve replacement is a surgical challenge in older patients with multiple morbidities. Transcatheter aortic valve implantation (TAVI) after previous mechanical mitral valve replacement has been considered a high-risk procedure, owing to possible interference with the mitral valve prosthesis.
Since August 2008, 5 female high-risk patients with severe aortic stenosis and previous mitral valve replacement (mean ± SD age, 80 ± 5.1 years; logistic EuroSCORE, 39.3% ± 20.5%) underwent TAVI with a pericardial xenograft valve that was fixed with a stainless steel, balloon-expandable stent (Edwards Lifesciences SAPIEN). We used a transapical approach in 4 patients and a transfemoral approach in 1 patient. Transesophageal echocardiography and multidetector computed tomography were used for preoperative planning and assessment of operation feasibility. The mean distance between the aortic annulus and the mitral valve prosthesis was 10 ± 1 mm (range, 9-11 mm).
TAVI was performed successfully in all 5 patients. There was no direct or functional interference with the mechanical mitral valve prostheses. Echocardiography revealed good valve function with no more than mild paravalvular incompetence early in the postoperative period and during routine follow-up. There were no neurologic events. After an initially uneventful course with good aortic valve function at the most recent echocardiography evaluation, however, 2 of the patients died from fulminant pneumonia on postoperative days 4 and 48.
TAVI is technically feasible in high-risk patients after previous mechanical mitral valve replacement; however, careful patient selection is mandatory with respect to preoperative clinical status and anatomic dimensions regarding the distance between aortic annulus and mitral valve prosthesis.
Heart Surgery Forum 06/2011; 14(3):E166-70. · 0.63 Impact Factor
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ABSTRACT: It has been demonstrated that transplantation of human cord blood-derived unrestricted somatic stem cells (USSC) in a porcine model of acute myocardial infarction (MI) significantly improved left ventricular (LV) function and prevented scar formation as well as LV dilation. Differentiation, apoptosis and macrophage mobilization at the infarct site could be excluded as the underlying mechanisms. The paracrine effect of the cells is most likely to be observed as the cause for the USSC treatment. The aim of our study was to examine the cardiomyocyte metabolism and the role of high-energy phosphates at the marginal infarct. Methods. USSC were transplanted into the myocardium of the LV, which was supplied by a ligated circumflex artery. Forty-eight hours later, the hearts were harvested and biopsies were performed from the marginal infarct zone surrounding the site of the cell injection. The concentrations of creatinine phosphate (CP), adenosine monophosphate (AMP), adenosine diphosphate (ADP) and adenosine triphosphate (ATP) were determined by chromatography.
The concentration of ADP, ATP and CP in the marginal zone of the infarction was significantly higher in the USSC group. The mean global left ventricular ejection fraction (LVEF) (SD) was 64% (8%) before MI; post-MI, LVEF decreased to 35% (9%).
Preservation of high-energy phosphates in the marginal infarct zone suggests that the preservation of energy reserves of surviving cardiomyocytes is a possible mechanism of action of transplanted stem cells in acutely ischemic myocardium.
Cytotherapy 03/2011; 13(8):956-61. · 3.63 Impact Factor
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ABSTRACT: Tissue-engineered arterial vessels (TEAV) offer substantial advantages in small-calibered human-bypass-grafting and vascularized scaffold applications. However, histological composition of TEAV must allow for functional properties, such as vasomotoricity. Aim of this study was to characterize human TEAVs regarding morphology and vasomotoricity.
Three groups containing segments of porcine carotid artery < 5 mm in diameter (native [NA, n = 6], decellularized [DA, n = 6], and decellularized/reseeded in a bioreactor [RA, n = 7] with human vascular endothelial [hvECs] and smooth muscle cells [hvSMCs]) were examined. Light and scanning electron microscopy were applied, and hvSMCs- and hvECs-associated Vasomotoricity Test conducted in Krebs-solution was used for characterization of revitalized TEAVs.
Morphologic examination showed cell-free extracellular matrix in DAs. Light microscopy demonstrated intact extracellular matrix components in circle-layered formation in cross sections of DAs. RAs showed small cells migrating along the remaining medial fiber structures and flat cell layers at the luminal site, identified as hvECs and hvSMCs with lower CD-31 and α-actin signaling than controls. Scanning electron microscopy showed intact flat cell layers on luminal surfaces of RAs and dense hvSMCs at their media site. DAs showed decreasing strain after stimulation. RAs retrieved vasomotoricity compared to DAs, but showed reduced contraction and incomplete relaxation compared to NAs.
This study shows that revitalization of DA with human vascular cells resembles NA-like morphology and can ensure vasomotoricity of TEAVs.
Tissue Engineering Part A 02/2011; 17(9-10):1253-61. · 4.64 Impact Factor
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Claus Eric Ott,
Johannes Grünhagen,
Marten Jäger,
Daniel Horbelt,
Simon Schwill, Klaus Kallenbach,
Gao Guo,
Thomas Manke,
Petra Knaus,
Stefan Mundlos,
Peter N Robinson
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ABSTRACT: Elastin production is characteristically turned off during the maturation of elastin-rich organs such as the aorta. MicroRNAs (miRNAs) are small regulatory RNAs that down-regulate target mRNAs by binding to miRNA regulatory elements (MREs) typically located in the 3' UTR. Here we show a striking up-regulation of miR-29 and miR-15 family miRNAs during murine aortic development with commensurate down-regulation of targets including elastin and other extracellular matrix (ECM) genes. There were a total of 14 MREs for miR-29 in the coding sequences (CDS) and 3' UTR of elastin, which was highly significant, and up to 22 miR-29 MREs were found in the CDS of multiple ECM genes including several collagens. This overrepresentation was conserved throughout mammalian evolution. Luciferase reporter assays showed synergistic effects of miR-29 and miR-15 family miRNAs on 3' UTR and coding-sequence elastin constructs. Our results demonstrate that multiple miR-29 and miR-15 family MREs are characteristic for some ECM genes and suggest that miR-29 and miR-15 family miRNAs are involved in the down-regulation of elastin in the adult aorta.
PLoS ONE 01/2011; 6(1):e16250. · 4.09 Impact Factor
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ABSTRACT: Acute aortic dissection type-A (AADA) is a life-threatening condition especially in patients with Marfan syndrome (MFS) simultaneously suffering from severe pectus excavatum (PE). We report on emergency surgery for combined treatment of PE and AADA in a patient with MFS using an alternative approach. It leads to excellent exposure of the dislocated heart and great vessels enabling Bentall procedure followed by funnel chest repair with modified technique of Adkins and Blades. We achieved favorable functional and cosmetic results. Therefore, we conclude the surgical approach presented is feasible for standard treatment of AADA and consecutive repair of PE.
Interactive cardiovascular and thoracic surgery 01/2011; 12(4):526-8.
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Victor Gertner,
Viktor Bordel,
Ursel Tochtermann, Klaus Kallenbach,
Markus Verch,
Matthias Ungerer,
Patricia Piontek,
Rawa Arif,
Mohammad Reza Mohammad Hasani,
Hiroaki Takahashi,
Mina Farag,
Arjang Ruhparwar,
Matthias Karck,
Ali Ghodsizad,
Amir Reza Mohammad Hasani
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ABSTRACT: This report describes the management of biventricular assist device (BIVAD) implantation in a patient with necrotic pancreatitis. BIVADs provide mechanical support for ventricular ejection in the failing heart and have become an accepted treatment for end-stage heart failure. They also have proved to be a successful bridge to heart transplantation. As their popularity has grown, the number of patients with BIVADs presenting for noncardiac surgery is increasing. We report the successful management of an implanted extracorporeal BIVAD in a patient with end-stage heart failure and with pancreatic stents in a case of necrotic pancreatitis. Historical, physical, laboratory, and imaging data allowed conservative management leading to a favorable outcome.
Heart Surgery Forum 12/2010; 13(6):E413-4. · 0.63 Impact Factor
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ABSTRACT: Older patients with aortic stenosis cannot always be offered conventional surgical aortic valve replacement at an acceptable risk. Transcatheter aortic valve implantation (TAVI) is currently considered an alternative treatment option with lower periprocedural risks. However, its effect on post-TAVI quality of life and clinical improvement has not been systematically and prospectively evaluated in those of advanced age. Thus, the aim of the present study was to assess the clinical improvement in geriatric patients after TAVI, with a special emphasis on quality of life. In the present study, we assessed the quality of life and brain natriuretic peptide in patients aged >80 years, before and 6 months after transfemoral CoreValve implantation. Of 87 prospectively studied patients with severe, symptomatic aortic stenosis at an age of ≥81 years, 80 survived for 6 months and were able to attend the follow-up visit with a quality of life assessment, using the Medical Outcomes Trust Short Form 36-Item Health Survey (average age 86 ± 2.9 years). The average scores of all 8 health components had improved significantly after TAVI. The greatest gain was seen in physical functioning (improvement from 23.4 ± 6.0 to 67.8 ± 13.7; p <0.001). The lowest gain was seen in bodily pain (improved from 37.5 ± 9.4 to 51.3 ± 11.5; p <0.05). Similarly, both the physical and the mental component summary scores improved significantly. This was consistent with significant improvement in brain natriuretic peptide levels (5,770 ± 8,016 to 1,641 ± 3,650 ng/L; p <0.0001). In conclusion, the results of the present study have shown a significant clinical benefit from TAVI in a patient population aged ≥81 years.
The American journal of cardiology 11/2010; 106(12):1777-81. · 3.58 Impact Factor
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Circulation Cardiovascular Interventions 06/2010; 3(3):e6-7. · 6.06 Impact Factor
