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ABSTRACT: BACKGROUND: Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair. METHODS: In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used. RESULTS: The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia. CONCLUSIONS: The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster.
The Annals of thoracic surgery 05/2013; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: An important number of patients are considered unsuitable for transcatheter aortic valve implantation because of a large native aortic valve. A new 29-mm balloon-expandable transcatheter valve offers the option to gain a maximal effective orifice area without paravalvular leakage. This study sought to define ranges of safe applicability in terms of device landing zone geometry. A second purpose was to determine performance of the prosthesis and clinical outcome. METHODS: Between April 2011 and July 2012, the new 29-mm SAPIEN XT prosthesis was implanted by means of transapical access in 78 patients with large aortic annuli. The study group represents 32.9% of all transapical transcatheter aortic valve implantations performed at our institution during the observation period; 82 patients receiving 26-mm prosthesis served as a control group. Device landing zone morphology was analyzed by echocardiography and computed tomography. RESULTS: The postimplant effective orifice area (study versus control group) was 2.7 cm(2) (interquartile range, 2.3 to 3.0 cm(2)) and 2.1 cm(2) (interquartile range, 1.7 to 2.4 cm(2)), respectively (p < 0.001), without any severe patient-prosthesis mismatch. Postprocedural regurgitation was similar in both groups (p = 0.892): absent in 56 (71.8%) and 54 (65.9%) patients, trace or mild in 21 (26.9%) and 27 (32.9%), and moderate in 1 (1.3%) and 1 (1.2%), respectively. Including patients in cardiogenic shock, the overall 30-day mortality rate of the study and control groups was 5.1% and 1.2%, respectively. One-year survival was 76.7% ± 8.6% with no difference from control patients (p = 0.743). CONCLUSIONS: The new 29-mm balloon-expandable prosthesis broadens the indication for transcatheter aortic valve implantation to include patients with large annuli. The outcome is very favorable.
The Annals of thoracic surgery 04/2013; · 3.74 Impact Factor
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ABSTRACT: Objectives We investigated early, midterm, and long-term results following valve replacement with the "No-React" bioprosthesis in patients with active infective endocarditis (AIE).Patients and Methods Between February 2000 and February 2011, a total of 402 patients (median 61 years, 17 to 91 years) received "No-React" bioprostheses due to single valve AIE in 315 (aortic valve replacement n = 158, aortic conduit n = 30, mitral valve replacement n = 116, tricuspid valve replacement n = 11) and double valve AIE in 87 cases. Prosthetic AIE was found in 105 patients (26.1%). Mean follow-up was 2.8 ± 3.2 years (1 month to 11.4 years) with 1,124 patient years, completed in 97.1%. This retrospective study analyzes both prospectively updated data (n = 255) and patients recently operated upon (n = 147).Results There was a highly significant difference in the survival between patients operated on urgently and patients operated on in an emergency (30-day, 1-, 5-, and 10-year survival were 80.9 ± 2.3%, 63.8 ± 2.9%, 48.3 ± 3.3%, and 39.7 ± 4.1% vs. 61.3 ± 4.5%, 45.0 ± 4.7%, 33.1 ± 4.6%, and 14.0 ± 5.1%, respectively, p < 0.001), due to native versus prosthetic AIE (p = 0.032), single versus double valve replacement (p = 0.005), and with or without abscess formation (p < 0.001). Thirty-day, 1-, 5-, and 10-year freedom from reoperation due to recurrent endocarditis were 100%, 95.1 ± 1.4%, 86.4 ± 2.6%, and 82.1 ± 3.6% and due to structural valve deterioration (SVD) were 100%, 100%, 98.9 ± 0.8%, and 91.4 ± 4.0%, respectively. There was no difference in prosthesis durability between the older (> 60 years) and the younger patients.Conclusions Our experience in the use of "No-React" bioprostheses in patients with native and prosthetic AIE shows satisfactory early, midterm, and long-term results, in particular low rates of reoperation due to recurrent endocarditis and SVD. Because these prostheses are readily available and their implantation straightforward, we strongly recommend their use in patients with AIE. Patients' survival differed significantly depending on their surgical urgency. Early mortality was independently predicted by septic shock, abscess formation, and number of implanted valves besides age per 10 years.
The Thoracic and Cardiovascular Surgeon 04/2013; · 0.88 Impact Factor
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Antonio Loforte,
Alexander Stepanenko,
Evgenij V Potapov,
Francesco Musumeci,
Nikolay Dranishnikov,
Martin Schweiger,
Andrea Montalto,
Miralem Pasic,
Yuguo Weng,
Michael Dandel,
Henryk Siniawski,
Marian Kukucka,
Thomas Krabatsch, Roland Hetzer
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ABSTRACT: Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25-70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty-six patients (38 men; median age 54.5 years, range: 25-70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28-68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90-day and 6-month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1-year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction.
Artificial Organs 04/2013; · 2.00 Impact Factor
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ABSTRACT: BACKGROUND: We analyzed risks for severe morbidity in the early period after extracardiac Fontan operation. METHODS: Between November 1995 and May 2011, 140 patients (median age, 3.8 years) underwent extracardiac Fontan operation. We assumed as preoperative risk factors systemic right ventricle (n = 51), heterotaxia (n = 25), arterial oxygen saturation less than 75% (n = 22), and adult age (>16 years, n = 20) at time of surgery. Prolonged cardiopulmonary bypass time of longer than 120 minutes (n = 30) and use of cardioplegia (n = 26) were analyzed as intraoperative risks. RESULTS: Heterotaxia was revealed as a risk factor for postoperative prolonged inotropic support, acute renal failure, prolonged mechanical ventilation, prolonged pleural effusions, and tachyarrhythmias. With the exception of pleural effusions, the same held true for right ventricle morphology. Low preoperative arterial oxygen saturation was found to be associated with an increased risk of prolonged inotropic support, acute renal failure, and prolonged mechanical ventilation. Adult age was identified as a risk factor for acute renal failure. Of the intraoperative factors, prolonged cardiopulmonary bypass time longer than 120 minutes was a risk factor for acute renal failure and prolonged pleural effusions, whereas use of cardioplegia was associated with an increased risk of prolonged inotropic support, prolonged mechanical ventilation, acute renal failure, and tachyarrhythmias. Multivariate analysis demonstrated heterotaxia, right ventricular morphology, and low preoperative arterial oxygen saturation to be independent risk factors for postoperative prolonged inotropic support and prolonged mechanical ventilation. CONCLUSIONS: Patients with heterotaxia, systemic right ventricle, and low preoperative arterial oxygen saturation are still at high risk for early Fontan failure after extracardiac Fontan operation and require special management for optimal outcome.
The Annals of thoracic surgery 02/2013; · 3.74 Impact Factor
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ABSTRACT: Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta.
The Annals of thoracic surgery 02/2013; 95(2):723-5. · 3.74 Impact Factor
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ABSTRACT: OBJECTIVES: Introduction of a new procedure has a typical learning curve with the "learning phase" at the beginning, characterized by an increased mortality or complication rate. We developed our institutional structured training program for transcatheter aortic valve implantation (TAVI) with the aim of eliminating these negative effects. METHODS: The program regulated the introduction of TAVI and building and training of the team. It combines cumulative knowledge from the field with the institutional and individual background experience. It includes stepwise acquisition of the tools necessary for the preoperative strategic planning, perioperative team communication, technical aspects of the procedure, and postoperative management. The program establishes a basis for interaction and feedback between the members of the team ("teach and learn"; "be proctor and proctored"). RESULTS: The program consists of 4 main parts: general principles, team building, team education and training, and the institutional clinical and procedural policies. The program possesses several control mechanisms, eg, occasional external proctoring. Additionally, a chain of steps spontaneously generates further procedural improvements and optimizes the overall outcome. The program has also had a global positive effect on the local institutional environment, awaking awareness of existing latent conditions and active failures, identifying them and inducing their correction, which has led to general clinical improvement. CONCLUSIONS: A structured educational training program enables implementation of a new procedure (TAVI) into clinical practice without increased morbidity and mortality rate during the learning curve. The program may also be used as a basis for any new device introduction into clinical practice.
The Journal of thoracic and cardiovascular surgery 02/2013; · 3.41 Impact Factor
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Anna Baumgarten,
Claudia Bang,
Anika Tschirner,
Anke Engelmann,
Volker Adams,
Stephan von Haehling,
Wolfram Doehner,
Reinhard Pregla,
Markus Anker,
Kinga Blecharz,
Rudolf Meyer, Roland Hetzer,
Stefan D Anker,
Thomas Thum,
Jochen Springer
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ABSTRACT: BACKGROUND: The transcription factor TWIST1 has been described to regulate the microRNA (miR)-199/214 cluster. Genetic disruption of TWIST1 resulted in a cachectic phenotype and early death of the knock-out mice. This might be connected to the activity of the ubiquitin-proteasome-system (UPS), as miR-199a has been suggested to regulate the ubiquitin E2 ligases Ube2i and Ube2g1. METHODS: Cardiac tissue from explanted hearts of 42 patients with dilated cardiomyopathy and 20 healthy donor hearts were analysed for protein expression of TWIST1 and its inhibitors Id-1, MuRF-1 and MAFbx, the expression of miR-199a, -199b and -214, as well as the activity of the UPS by using specific fluorogenic substrates. RESULTS: TWIST1 was repressed in patients with dilated cardiomyopathy by 43% (p=0.003), while Id1 expression was unchanged. This was paralleled by a reduced expression of miR-199a by 38±9% (p=0.053), miR-199b by 36±13% (p=0.019) and miR-214 by 41±11% (p=0.0158) compared to donor hearts. An increased peptidylglutamyl-peptide-hydrolysing activity (p<0.0001) was observed in the UPS, while the chymotrypsin-like and trypsin-like activities were unchanged (both p>0.2). The protein levels of the rate limiting ubiquitin E3-ligases MuRF-1 and MAFbx were up-regulated (p=0.006 and 0.038, respectively). Mechanistically silencing of TWIST1 using siRNA in primary rat cardiomyocytes led to a down-regulation of the miR-199/214 cluster and to a subsequent up-regulation of Ube2i. CONCLUSION: The TWIST1/miR-199/214 axis is down-regulated in dilated cardiomyopathy, which is likely to play a role in the increased activity of the UPS. This may contribute to the loss of cardiac mass during dilatation of the heart.
International journal of cardiology 01/2013; · 7.08 Impact Factor
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ABSTRACT: OBJECTIVES: The purpose of the present study was to test whether the cumulative knowledge from the field of transapical transcatheter aortic valve implantation, when incorporated into a structured training and then gradually dispersed by internal proctoring, might eliminate the negative effect of the learning curve on the clinical outcomes. METHODS: The present study was a retrospective, single-center, observational cohort study of prospectively collected data from all 500 consecutive high-risk patients undergoing transapical transcatheter aortic valve implantation at our institution from April 2008 to December 2011. Of the 500 patients, 28 were in cardiogenic shock. Differences during the study period in baseline characteristics, procedural and postprocedural variables, and survival were analyzed using different statistical methods, including cumulative sum charts. RESULTS: The overall 30-day mortality was 4.6% (95% confidence interval, 3.1%-6.8%) and was 4.0% (95% confidence interval, 2.6%-6.2%) for patients without cardiogenic shock. Throughout the study period, no significant change was seen in the 30-day mortality (Mann-Whitney U test, P = .23; logistic regression analysis, odds ratio, 0.83 per 100 patients; 95% confidence interval, 0.62-1.12; P = .23). Also, no difference was seen in survival when stratified by surgeon (30-day mortality, P = .92). An insignificant change was seen toward improved overall survival (hazard ratio, 0.90 per 100 patients; 95% confidence interval, 0.77-1.04; P = .15). CONCLUSIONS: The structured training program can be used to introduce transapical transcatheter aortic valve implantation and then gradually dispersed by internal proctoring to other members of the team with no concomitant detriment to patients.
The Journal of thoracic and cardiovascular surgery 01/2013; · 3.41 Impact Factor
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ABSTRACT: Dilated cardiomyopathy (DCM) which is a common cause of heart failure is often related to elevated levels of autoantibodies (AABs) against cardiac structural or functional proteins. Among several AABs which react against cardiac cellular proteins that have been detected in sera from DCM patients, those against β(1)-adreno-receptors (β(1)-ARs) appeared particularly relevant from a pathophysiological point of view. During the last 15 years several studies evaluating the short-term efficacy of imunoadsorption (IA) in idiopathic DCM have shown improvement in cardiac function and patient outcome. However, the invasive and complicated aspects of the IA, which is also costly, have limited its broad clinical application as long as only its short-term efficacy has been definitely proved. Autoimmunity is also suspected to play a key role in the pathogenesis of pulmonary arterial hypertension (PAH). Recently we identified functional AABs against the α(1)-AR and/or the endothelin-A-receptor (ETA) in sera of patients with PAH. These AABs activate the receptors like corresponding agonists but, unlike the agonists, the AABs induce long-lasting stimulatory effects and do not desensitize the receptors. The AABs against the α(1)-AR and the ETA-receptor belong to IgG3 and IGg2 subclass, respectively, and can be removed by IA. The first 5 potential transplant candidates with idiopathic PAH who underwent IA showed good results after this therapy. This update aims to summarize the present knowledge about the role of AABs in the etiopathogenesis of DCM and PAH and the potential therapeutic benefits of AAB removal by IA. Special attention is focused on the therapeutic benefits of IA for patients with life-threatening end-stage disease where all pharmacological therapeutic options are exhausted.
Atherosclerosis. Supplements 01/2013; 14(1):203-11. · 4.94 Impact Factor
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ABSTRACT: Background Viral infection and anti-cardiac immunity are involved in the pathogenesis of dilated cardiomyopathy (DCM). Immunity targeting particular antigens may evoke expansion of reactive T-cell clones. Material and Methods Myocardial tissues from explanted hearts were investigated for clonal T-cell-receptor- (TCR-) ß rearrangements by an established semi-nested polymerase chain reaction (PCR), followed by high-resolution GeneScan analysis and direct sequencing. From 17 explanted DCM hearts, 3 myocardial samples each were obtained from the right ventricle, the septum, and the left ventricle (total: 9 myocardial samples per case). Six explanted hearts with non-DCM cardiomyopathy entities served as controls. Results GeneScan analysis revealed polyclonal TCR-ß rearrangements in all controls. In contrast, at least 1 myocardial sample in 9 out of 17 DCM hearts (total: 20 of the 81 DCM specimens) displayed single dominant TCR-ß PCR products consistent with the presence of clonal T-cell populations. Direct sequencing of the clonal TCR-ß PCR-products disclosed an involvement of Vß 19.01 segments in 14 of the dominant amplificates (70%). Further TCR-Vß segments involved in clonal TCR-ß rearrangements of DCM hearts were Vß 6-1.01 (n=1), Vß 6-3.01 (n=2), Vß 6-5.01 (n=1), Vß 10-3.02 (n=1), and Vß 19.03 (n=1). Conclusions The detectability of clonal TCR-ß rearrangements indicates a pathogenic relevance of this finding in DCM. The predominance of Vß 19.01 segments suggests that the immune response in DCM patients targets particular epitopes. However, the partly heterogenic TCR-ß populations in various myocardial samples from the respective cases support the notion that T-cell immunity may target multiple epitopes in human DCM.
Medical science monitor basic research. 01/2013; 19:111-7.
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ABSTRACT: Exchange of the HeartWare HVAD made necessary by thrombosis or cable damage is rare, but it is a complex procedure associated with morbidity. Less invasive exchange procedures may contribute to faster postoperative recovery and early mobilization. Between September 2009 and April 2012, 225 patients (median age 55.4 years, range 7-82 years, 40 of them women) were supported with the HeartWare HVAD at our institution. Cumulative follow-up in all 225 patients was 151.9 patient/years. In six patients, early pump thrombosis (<30 days) requiring pump exchange occurred after a median time of 7 (2-9) days. In six patients, late pump thrombosis requiring pump exchange occurred after a median of 380 (84-705) days. The overall incidence was 5.3% with 0.079 thromboses per year. In two instances of accidental cable damage as a result of massive external mechanical impact, pump exchange was necessary. We describe a safe and less invasive technique for the explantation and exchange of the HeartWare HVAD through a left thoracotomy. Pump thrombosis of the HeartWare HVAD is a very rare condition caused mostly by new onset of heparin-induced thrombocytopenia type II, mismanagement of anticoagulation, or hypercoagulability in the case of severe sepsis. Since the introduction of the sintered inflow cannula no early thrombosis has occurred. Pump exchange in the case of hemolysis should not be delayed. The cable of the HeartWare HVAD is very reliable and breaks only after excessive external impact. A minimally invasive approach for pump exchange on cardiopulmonary bypass for pump thrombosis and off-pump for cable damage or pump explantation is recommended.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 12/2012; · 1.39 Impact Factor
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ABSTRACT: Treatment of endoleaks after thoracic endovascular repair remains challenging, particularly when the proximal landing zone is small and partly includes the origin of the neck vessels. We report a Type Ia endoleak, occurring after thoracic endovascular aneurysm repair, which was successfully treated with a novel uncovered nitinol stent. With this success, we were able to avoid a conventional surgery to treat the endoleak.
Interactive cardiovascular and thoracic surgery 12/2012;
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ABSTRACT: A patient with massive perioperative bleeding after repeat aortic surgery for proximal aortic redissection, anastomotic disruption, and prosthetic infection after recent surgery for acute type A aortic dissection was managed with, in total, 176 units of blood products during a 25-hour operating room session. The postoperative course was completely uneventful. Enduring and continuous hemostasis with mediastinal gauze packing, volume replacement, and timely blood product substitution may overcome temporary coagulopathy in desperate surgical circumstances.
The Thoracic and Cardiovascular Surgeon 12/2012; · 0.88 Impact Factor
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European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 12/2012; 42(6):918-9. · 2.40 Impact Factor
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ABSTRACT: BACKGROUND: The degree of involvement of left ventricular inflow tract obstruction is the predominant factor determining outcome in Shone's anomaly. In this series of patients with Shone's anomaly, we evaluated the impact of mitral valve (MV) repair strategies performed to correct the components of this anomaly on growth of the valve and long-term functional outcome in children. METHODS: In the last 25 years, 45 children, mean age 5.16 ± 5.0 years (median, 3.9; range, 2 months-16.8 years), underwent surgical correction of Shone's anomaly. Coarctation of the aorta was found in 40%, subaortic stenosis due to fibromuscular hypertrophy was found in 55%, and subvalvar membrane was found in 66% of these patients. Left ventricular inflow tract obstruction was brought about by commissures with dysplastic and shortened chordae in 53.3%, valve hypoplasia in 11.1%, supravalvar mitral ring in 100%, and parachute valve in 17.8 of patients%. RESULTS: Various repair strategies were performed according to the presenting morphologic characteristics in patients with either previously corrected or concomitant correction of the left-sided obstructive lesions. Mean duration of follow-up was 17.5 ± 1.5 years. Freedom from reoperation was 52.8% ± 11.8%, wherein 23 patients underwent repeated MV repair and 1 patient underwent MV replacement after failed attempts at repair. The cumulative survival rate was 70.3% ± 8.9% at 15 years. Severity and type of mitral abnormalities, left ventricular outflow tract lesions, and pulmonary hypertension are risk factors for reoperation and mortality (p < 0.05). CONCLUSIONS: Repair allowed growth of the MV. Long-term outcome of MV repair in Shone's anomaly is related to the degree that the obstructive lesions can be relieved.
The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
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ABSTRACT: To the Editor: The selection of controls in observational studies is challenging. The propensity-score methods use baseline variables as predictors and group assignment as the outcome.(1) The resulting model is applied to identify controls whose probability of receiving the intervention is close to that of patients who do receive the intervention. In theory, this approach allows apple-to-apple comparison of groups.(1) This goal is not adequately accomplished in the analysis by Fraser et al. (Aug. 9 issue).(2) The authors compared outcomes in U.S. children receiving mechanical circulatory support from a ventricular assist device (Berlin Heart) with outcomes reported for a registry-based . . .
New England Journal of Medicine 11/2012; 367(22):2159-61. · 53.30 Impact Factor
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ABSTRACT: Enormous progress has been made in paediatric heart transplantation since the first unsuccessful effort by Kantrowitz in 1967. Early reports of children undergoing heart transplantation showed alarmingly high perioperative mortality rates of 25-60%, with the diagnosis of congenital heart disease (CHD) representing a particularly high-risk subset compared with cardiomyopathy. Many of these early failures were related to poor patient selection, suboptimal immunosuppression and technical problems. We learned a great deal from these earlier difficulties. Presently, with more refined techniques, better-defined patient selection criteria, excellent graft rejection monitoring and optimal immunosuppression, the ISHLT 2011 registry reported a 10-year survival rate of 60% for patients transplanted for end-stage CHD and >70% for those transplanted for cardiomyopathy. The technical dilemmas in complex CHD were overcome by surgical ingenuity and creativity, innovative solutions and careful surgical planning, adapting the complex recipient anatomy to the normal donor anatomy. The miniaturized Berlin Heart pulsatile ventricular assist devices in children as a bridge to transplantation have revolutionized treatment and become a significant contribution in heart-failure therapy. The intramyocardial electrogram and echocardiographic strain rate imaging have been employed as non-invasive techniques of rejection monitoring. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy, the main cause of cardiac allograft loss and a leading cause of mortality after the first year post-transplantation. The questions of whether a transplanted heart in a newborn grows to adult size along with the child and whether the dimensional cardiac growth allows adequate function over time have been largely answered in our previous investigations. As more transplanted children reach adulthood, concerns about their life expectancy when they have reached 10 years of life post-transplant are raised, particularly with respect to establishing partnerships and families, their ability to earn a living and the fulfilment of personal life perspectives. Some heart-transplanted patients require retransplantation to remain alive. The disparity between the demand for and supply of donor hearts makes retransplantation an ethical issue. We 'do not refuse' any patient who needs retransplantation. Mechanical circulatory support devices for long-term use are now largely available to accommodate such cases.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 11/2012; · 2.40 Impact Factor
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ABSTRACT: BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of high-risk patients with aortic valve stenosis. Although a logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of more than 40% has been considered a contraindication for this new procedure, we routinely perform this procedure in this very high-risk patient group. We analyzed the results of TAVI patients with a EuroSCORE of over 40%. METHODS: Between April 2008 and January 2012, 514 consecutive patients underwent TAVI. In the study group (group I, EuroSCORE > 40%) of 186 patients the EuroSCORE was 63% ± 16% (range 40 to 98) and the Society of Thoracic Surgeons predicted risk of mortality score was 23% ±14% (range 4 to 90); there were 26 (14%) patients in cardiogenic shock. The mean age was 81 ± 8 (range 36 to 99) years and there were 122 women and 64 men. Group II (the control group, EuroSCORE < 40%) consisted of 328 patients. In this group the EuroSCORE was significantly lower (23% ± 9%, range 2% to 40%). The STS mortality score was 11% ± 8% (1% to 48%). In this group were 196 men and 132 women with a mean age of 78 ± 8 (range 29 to 97) years. RESULTS: Technically, in group I the valve was successfully implanted in 99.5% (185 of 186). In 25 (13%) patients the procedure was performed on the heart-lung machine and in 25 (13%) patients an elective percutaneous coronary intervention was performed in the same session. Postoperative echocardiography showed a low transvalvular gradient (mean 4.5% ± 2.5%, range 2 to 15) and a low rate of paravalvular regurgitation (grade 0 in 97, less than grade I in 49, less than grade II in 38 patients, and grade II in 2 patients). The overall 30-day mortality, including that in patients in cardiogenic shock, was 6.5%, and in patients without cardiogenic shock it was 5.7%; the 1-year survival was 67% and 71%, respectively, and the 2-year survival was 54% and 56%, respectively. CONCLUSIONS: Patients with comorbidities, as mirrored by a EuroSCORE of more than 40% should not be refused for TAVI. On the contrary, this is a supreme indication for the TAVI procedure.
The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
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The Journal of thoracic and cardiovascular surgery 11/2012; 144(5):1272. · 3.41 Impact Factor
