[Show abstract][Hide abstract] ABSTRACT: Mechanical circulatory support (MCS) devices have been increasingly used for long-term support. We reviewed outcomes in all patients supported with a SynCardia total artificial heart (TAH) for more than one year to assess its safety in long term support.As of December 2011 all 47 patients who received the TAH from 10 centres worldwide were included in this retrospective study. Clinical data was collected on survival, infections, thromboembolic and hemorrhagic events, device failures, and antithrombotic therapy.The mean age of patients was 50 ± 1.57 year, the median support time was 554 days (range 365 - 1373 days). The primary diagnosis was dilated cardiomiopathy in 23 patients, ischemic in 15 and "other" in 9.After a minimum of one year of support, 34 patients (72%) were successfully transplanted, 12 patients (24%) died while on device support, and 1 patient (2%) is still supported. Five patients (10%) had a device failure reported. Major complications were as follows: systemic infections in 25 patients (53%), drive line infections in 13 patients (27%), thromboembolic events in 9 patients (19%) and hemorrhagic events in 7 patients (14%).SynCardia TAH has proven to be a reliable and effective device in replacing the entire heart. In patients who reached a minimum of one year of support, device failure rate is acceptable and only in two cases was the leading cause of death. Infections and hemorrhagic events were the major causes of death. Patients who remain supported beyond one year are still likely to survive to transplantation.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 08/2014; · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives CD133pos cells are currently evaluated for use in cardiac cell therapy. We hypothesized that they exert their beneficial effects in a paracrine manner and investigated this in a cell culture ischaemia model. Furthermore, we checked whether purified CD133pos cells perform better than non-fractionated mononuclear cells (MNC). Methods CD133pos cells were isolated from bone marrow MNC and conditioned medium was prepared from CD133pos and non-fractionated MNC. HL-1 cardiomyocytes were subjected to simulated ischaemia in the respective conditioned media or in control medium. After treatment, total remaining cells, apoptotic cells and nuclear shrinking were quantified using an automated imaging system. Furthermore, metabolic activity and phosphorylation of kinases Akt, Erk1/2, GSK3b and transcription factor Stat3 were investigated. Results After simulated ischaemia, the rate of detached dead cells was lowest in CD133pos conditioned medium (26 ± 6%) and highest in control medium (36 ± 6%). In CD133pos conditioned medium, the fraction of non-apoptotic cells was most enhanced and nuclear shrinking as a consequence of apoptosis was reduced. Cell viability was also highest in CD133pos conditioned medium (109.4 ± 8.8% in relation to control). In both conditioned media, phosphorylation of Akt, Erk1/2, and GSK3b was lower than in control medium. Stat3 phosphorylation was sustained on the level of control. Conclusions Factors released from purified CD133pos bone marrow cells exhibit more pronounced protective effects on HL-1 cardiomyocytes under simulated ischaemia than from non-fractionated MNC. These effects are not associated with the phosphorylation of cell survival promoting kinases Akt, Erk1/2, GSK3b and transcription factor Stat3. Although the molecular mechanism of cardioprotection by CD133pos cells requires further investigation, our results reinforce the advantage of enriching CD133pos cells for cardiac cell therapy. Conflict of interest and funding No conflict of interest declared. This work was supported by the German Ministry of Education and Research [BMBF FKZ 0312138A].
Interactive Cardiovascular and Thoracic Surgery 02/2013; 16(2):S227-S236. · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Heart transplantation is an established procedure with acceptable, predictable long-term results and good quality of life for more than 20 years. However, it is only available for a limited number of patients. The fate of the patients is determined by the side effects of immunosuppressive drugs, increased tumor incidence and chronic vascular transplant disease. Patients living 10 to 20 years after heart transplantation show physical status equal to that of patients with various chronic illnesses. They suffer from chronic side effects of long-term medication and mainly report fears of renal insufficiency followed by osteoporosis-associated pain, cortisone-induced myopathy and risk for tumors. Only moderate psychological impairment is reported despite somatic problems. In the period 10-20 years post-heart transplantation, there is even a surprising increase in emotional well-being. The 20-year survivors are active and satisfied with daily life. They experience their own life as meaningful and have good partner, family and social relations. Heart transplantation, the most ambitious project in medicine in the 20th century has been made a reality. Its development has the strongest impact on cardiac surgery, immunology, pharmacology, medical logistics, defining life and death, ethics in medicine, acceptance of medical progress by the public and by health care systems. It has provided a strong solidarity among politicians, sociologists, physicians and citizens. Ethical concerns will last and will make heart transplantation an important, yet temporary episode in human medicine. It has stimulated research and development of mechanical circulatory support systems as an alternative to treat end-stage heart failure.
HSR proceedings in intensive care & cardiovascular anesthesia. 01/2013; 5(2):76-80.
[Show abstract][Hide abstract] ABSTRACT: It is anticipated that as many as 10-20% of patients alive with anatomical congenital heart lesions may eventually develop heart failure. Most of these patients have undergone previous palliative or corrective surgeries. The Fontan procedure, although it has helped many patients with single-ventricle physiology to become hemodynamically functional, it is associated with protein-losing entropathy, intractable atrial arryhythmia and systemic ventricular dysfunction. In patients with transposition of the great arteries, physiological or intra-atrial repair techniques (Mustard and Senning) or anatomical correction (arterial switch) have been used. The majority of these patients are clinically well throughout their adult life but, as a consequence of the potential for right ventricular failure, some may develop cardiac insufficiency. Although long-term survival and quality of life in children and adults with complex congenital heart disease have remarkably improved due to advances in operative techniques and perioperative management, as well as the increasing experience of congenital heart surgeons, a growing number of these patients eventually develop end-stage heart failure and will require another treatment. Surgical options for treatment of these patients are limited. Heart transplantation has become a well-established treatment option for children as well as adults with end-stage congenital heart disease. Because of organ donor shortage, another option is mechanical circulatory assist device implantation, either as a bridge to transplantation, or as a permanent therapy.
HSR proceedings in intensive care & cardiovascular anesthesia. 01/2013; 5(2):81-4.
[Show abstract][Hide abstract] ABSTRACT: Patienten mit fortgeschrittener Herzinsuffizienz, vor orthotoper Herztransplantation, welchen aufgrund einer lebensbedrohlichen
ventrikulären Tachyaarrhythmie ein ICD implantiert wurde, erfahren frühzeitig eine adäquate antitachykarde ICD-Therapie. Durch
die Bewahrung dieser Untergruppe mit hohem Risiko vor dem plötzlichen Herztod durch die ICD-Therapie kann die Gesamtmortalität
auf das Niveau eines Vergleichskollektives ohne ICD verringert werden. Die Anwesenheit von Vorhoftachyarrhythmien korreliert
mit einer frühzeitigeren Abgabe einer adäquaten ICD Therapie Hämodynamische oder echokardiographische Messungen lassen sich
retrospektiv nicht zur Risikostratifizierung heranziehen. Es bedarf jedoch weiterer Studien zur Evaluierung der Assoziation
hämodynamischer Veränderungen und arrhythmischen Ereignisse in nicht selektierten Untersuchungsgruppen zur Definition von
Untergruppen, die vor Herztransplantation von einer prophylaktischen ICD Implantation profitieren könnten.
[Show abstract][Hide abstract] ABSTRACT: A 57-year-old female lung transplant recipient developed tuberculosis after quadruple maintenance immunosuppression for acute cellular rejection with respiratory compromise. Deteriorating neurological status led to cerebral imaging and lumbar puncture, which showed Mycobacterium tuberculosis. Tuberculous meningitis with elevated intracranial pressure was treated for 2 weeks on a neurosurgical ward, and intensive care therapy was necessary for another 2 weeks. Complete neurological recovery was achieved after 3 months.
[Show abstract][Hide abstract] ABSTRACT: Kinder mit progredienter dilatativer Kardiomyopathie können auf der Warteliste zur Herztransplantation versterben, da bei
ihnen das Krankheitsbild besonders rasch mit Kreislauf- und Multiorganversagen fortschreitet und ein passendes kindliches
Spenderangebot nicht schnell genug verfügbar ist.
Bei 15 Kindern im Alter von vier Monaten bis 15 Jahren führten wir im Stadium des nicht mehr medikamentös therapierbaren Herzversagens
und beginnendem Multiorganversagen eine Kreislaufunterstützung mittels Kunstherz (Ventrikuläres Assist Device, „Berlin Heart”)
durch. Alle Kinder befanden sich in progredientem Schock und waren mindestens einmal reanimiert worden, bevor wir uns zur
Das Kunstherz besteht aus zwei pneumatisch angetriebenen extrakorporalen Blutpumpen, vier Silikonkanülen zur venösen und arteriellen
Verbindung zwischen Patient und Pumpe und einem elektropneumatischen pulsatilen Antrieb.
Zwölf der 15 Kinder konnten wir mit dem System während 1 bis 98 Tagen (Mittel: 24 Tage) am Leben erhalten und die Wartezeit
bis zur Herztransplantation überbrücken. Neun Kinder waren während der Unterstützungszeit extubiert und mobilisiert. Drei
Kinder verstarben vor Erreichen einer Transplantation an Blutung, Sepsis und Lungenversagen, bei einem überlebenden Kind trat
ein Infarkt der arteria cerebri media auf. Sieben transplantierte Langzeitüberlebende sind beschwerdefrei und sozial vollintegriert.
Durch modifizierte Technik ist das Kunstherz auch im Säuglings- und Kleinkindalter einsetzbar. Dadurch können wir Kinder mit
terminaler Herzinsuffizienz bei dilatativer Kardiomyopathie für Wochen und Monate am Leben erhalten und die Zeit bis zur Transplantation
In children with dilated cardiomyopathy the disease may progress so rapidly that they die during the waiting period before
a suitable donor organ is found.
Fifteen children of 4 months to 15 years of age had been in congestive heart failure with multiorgan failure due to dilated
cardiomyopathy, where intensive medical treatment had failed. After resuscitation, a miniaturized pulsatile ventricular assist
device for the mechanical replacement of heart function was implanted. The biventricular assist device (“Berlin Heart”) consists
of two extracorporeal pneumatically driven polyurethane blood pumps, with a multi-layer flexible membrane that separates a
blood and an air chamber. Four silicon cannulae connect the blood pumps to the patient. A three-leaflet valve prevents blood
reflux. The pumps are driven by a pulsatile electropneumatic system.
In 12 of the 15 children the bridging to transplantation was successful with a support time of 1 to 98days (mean 24 days).
Nine of them were extubated and mobilized while assisted. Three children died during the support time due to hemorrhage, sepsis,
and pulmonary failure. In addition, there was one infarction of the arteria cerebri media. To date seven of the transplanted
children are in good condition on follow-up.
The beneficial effects of ventricular assist device use are well known in adult patients and with special devices it can be
transfered to infants and children in whom longer need for support is anticipated. Even in small infants it is an effective
method for bridging to cardiac transplantation.
Schlüsselwörter Kunstherz – Kinder – ventikuläres Assist Device – terminales Herzversagen – dilatative KardiomyopathieKey words Mechanical heart support – children – ventricular assist device – congestive heart failure – dilated cardiomyopathy
Zeitschrift für Kardiologie 04/2012; 89(11):1039-1045. · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Female gender is a risk factor for early mortality after coronary artery bypass graft surgery (CABG). Yet, the causes for this excess mortality in women have not been fully explained.
To analyse gender differences in early mortality (30 days post surgery) after CABG and to identify variables explaining the association between female gender and excess mortality, taking into account preoperative clinical and psychosocial, surgical and postoperative risk factors.
A total of 1,559 consecutive patients admitted to the German Heart Institute Berlin (2005-2008) for CABG were included in this prospective study. A comprehensive set of prespecified preoperative, surgical and postoperative risk factors were examined for their ability to explain the gender difference in early mortality.
Early mortality after CABG was higher in women than in men (6.9 vs. 2.4 %, HR 2.91, 95 % CI 1.70-4.96, P < 0.001). Women were older than men (+4.7 years, P < 0.001), had lower self-assessed preoperative physical functioning (-16 points on a scale from 0 to 100, P < 0.001), and had higher rates of postoperative low cardiac output syndromes (6.6 vs. 3.3 %, P = 0.01), respiratory insufficiency (9.4 vs. 5.3 %, P = 0.006) and resuscitation (5.2 vs. 1.8 %, P = 0.001). The combination of these factors explained 71 % of the gender difference in early mortality; age and physical functioning alone accounted for 61 %. Adjusting for these variables, HR for female gender was 1.36 (95 % CI 0.77-2.41, P = 0.29).
Age, physical function and postoperative complications are key mediators of the overmortality of women after aortocoronary bypass surgery. Self-assessed physical functioning should be more seriously considered in preoperative risk assessment particularly in women.
Clinical Research in Cardiology 04/2012; 101(9):745-51. · 3.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Die historische Entwicklung der extrakorporalen Zirkulation begann mit den isolierten Organperfusionen der Physiologen des
19. Jahrhunderts. Diese Experimente führten zur Entwicklung der Grundlagen der Perfusionstechnik, wie der Bubble- und Film-Oxygenation,
sowie pulsatilen Pumpensystemen und dem geschlossenen extrakorporalen Kreislauf. Die Vorstellung, dass die extrakorporale
Zirkulation im Zusammenhang mit herz- oder gefäßchirurgischen Eingriffen genutzt werden könnte, entstand schon zu Beginn des
Historic development of extracorporeal circulation began with the perfusion of isolated organs by physiologists in the 19th century. Those experiments led to the development of the basic principles of the perfusion technique, such as bubble-oxygenation
and film-oxygenation, systems for pulsatile pumping and the closed extracorporeal circuit. The idea for using extracorporeal
circulation for cardiovascular surgery was born at the beginning of the 20th century.
Zeitschrift für Herz- Thorax- und Gefäßchirurgie 04/2012; 14(3):93-99.
[Show abstract][Hide abstract] ABSTRACT: Patients receiving implantation of ventricular assist devices (VAD) suffer a high incidence of heparin induced thrombocytopenia (HIT); the occurrence of this condition is associated with increased complications and worse outcomes. We report our experience in the management of patients who were diagnosed with HIT either before (HITpre) or after (HITpost) implantation of VAD with argatroban, a direct thrombin inhibitor.
This retrospective analysis assessed data of VAD patients diagnosed with HIT at Deutsches Herzzentrum Berlin between November 2005 and April 2009. Argatroban dose requirements, anticoagulation efficacy and adverse events (death, thromboembolism, bleeding) were recorded. Procedural success (discharge from the hospital, heart transplantation, or recovery of the failing heart) was also assessed.
Twenty-seven patients were identified (11 HITpre, 16 HITpost). Argatroban was effective in obtaining adequate anticoagulation with a reduced dose regimen (0.02-0.42 mcg/Kg/min starting dose; 0.02-1.5 mcg/Kg/min maintenance dose). We noted 5 thromboembolic complications (18%), 6 cases of major bleeding (22%) and 5 deaths (18%), all cause composite adverse end point occurring in 40% of patients. Procedural success was obtained in 81% of patients (92% HITpre, 69% HITpost). As compared to historical controls of patients treated with lepirudin in the period 2000-2005, results were significantly improved.
Argatroban anticoagulation is feasible in patients with HIT after VAD implantation, without increasing bleeding risk. Its impact in terms of survival should be reviewed also in the light of the technological improvements of assist devices.
[Show abstract][Hide abstract] ABSTRACT: The development and improvement of cardiopulmonary bypass technology is an ongoing process. During the past decade, a number of publications on improvements and best practices have appeared, especially in the areas of biocompatibility, materials sciences, instrumentation, monitoring of physiological parameters and knowledge base (education and evidence-based medicine). Biocompatibility may be defined not only as an inherent property of a particular composition of matter, but also as a set of properties concerning shape, finish, fabrication techniques and choice of application. Materials in use for cardiopulmonary bypass have changed and coated components have been used frequently. Improvements in the area of instrumentation were achieved by adaptation of conventional cardiopulmonary bypass circuits. Miniaturization and re-design of cardiopulmonary bypass circuits (so-called minimized perfusion circuits or minimal extracorporeal circulation circuits) have made cardiopulmonary bypass technology less traumatic. A team approach, including the cardiac surgeon, the anesthesiologist and the cardiovascular perfusionist, was deemed beneficial in order to achieve further improvements. Next to choice of technology and material for a given operation, adjunct measures such as pharmaceutical treatment and blood conservation strategies need to be taken into consideration. Monitoring of variables during cardiopulmonary bypass has made some progress, while the knowledge base has expanded due to studies on best practices. For the immediate future, sound scientific knowledge and intelligent monitoring tools will allow cardiopulmonary bypass to be tailored to individual patients' needs.
HSR proceedings in intensive care & cardiovascular anesthesia. 01/2012; 4(4):211-6.
[Show abstract][Hide abstract] ABSTRACT: In recent years, ventricular assist devices (VAD) supporting the left (LVAD), the right (RVAD) or both ventricles (BVAD) have rapidly emerged as the standard of care for advanced heart failure patients. Both the numbers and ages of patients in which they are used are rising worldwide, especially when used as a permanent support (bridge to destination, BTD). Due to the continuing lack of donor organs, these devices now represent a viable alternative to bridge patients to transplantation (BTT), with a 1-year survival rate of 86%. BTD, especially in long-term support, might be a valid, and the sole, option for those patients in whom heart transplantation is contraindicated. Patient selection, pre- and intra-operative preparation, as well as the timing of VAD implantation are important factors critical to successful circulatory support. While BTT remains the goal in the majority of patients, the number of permanent VADs (i. e. BTD) is rising significantly. Although explantation of a VAD system as a bridge to recovery (BTR) can be considered in only a small number of patients, it represents a very special part of this therapy modality.
[Show abstract][Hide abstract] ABSTRACT: Chronic obstructive pulmonary disease (COPD) is an important risk factor for perioperative morbidity and mortality in patients undergoing cardiac surgery. Despite high clinical relevance, current guidelines lack clear recommendations on the optimal approach for patients with insufficiently treated COPD and urgent need for cardiac surgery. The aim of the present study was to analyze the efficacy of short-term pulmonary conditioning (PC) in this subset of cardiopulmonary patients.
Eighteen patients with urgent need for cardiac surgery were treated with 1 mg budenoside twice a day, 1.25 mg salbutamol four times a day and 15 mg ambroxol three times a day. On average, patients received pulmonary conditioning for 5.1 ± 2.1 days. Lung function was assessed before and after treatment.
Pulmonary conditioning improved forced expiratory volume in one second (FEV1) by 16% (P<0.001). Predicted FEV1 increased from 48.3 ± 13.6% at baseline to 55.4 ± 16.1% after treatment (P<0.001). Total resistance was reduced from 0.933 ± 0.418 kPa·s/L to 0.631 ± 0.344 kPa·s/L after PC (P=0.004). The percentage of patients in GOLD stages III-IV was reduced from 55.6% at baseline to 27.8% after treatment. After surgery, patients needed mechanical ventilation for 2 ± 3.4 days. One patient (5.6%) received a tracheostomy and four patients (22.2%) developed pneumonia; 30-day mortality was 5.6%.
Short-term treatment with budenoside, salbutamol and ambroxol significantly improved lung function parameters. If surgery can be delayed for several days, pulmonary conditioning should be considered for patients with insufficiently treated COPD.
The Journal of cardiovascular surgery 04/2011; 52(4):587-91. · 1.51 Impact Factor