[show abstract][hide abstract] ABSTRACT: OBJECTIVES: Endoaortic balloon occlusion (EBO) and aortic transthoracic clamping (TTC) are the dominant methods of remote access perfusion (RAP) in minimally invasive cardiac surgery. The aim of the study was to compare the two methods in terms of feasibility, success and complications. METHODS: From June 2001 to November 2011, 307 (median age; range) (57; 16-77 years) and 460 (62; 11-88 years) patients underwent minimally invasive CABG, ASD and mitral valve surgery using EBO and TTC, respectively. Perioperative procedure feasibility, success and postoperative complications were recorded. RESULTS: Overall 30-day mortality was 0 and 2 (0.43%) for the EBO and TTC groups, respectively (P = 0.52). Overall and RAP-associated conversions were noted in 21 (6.8%) and 4 (1.3%) patients in the EBO and in 9 (2%) and 6 (1.3%) patients in the TTC groups (P < 0.001, P = 1.00, respectively). Incidence of major complications, including aortic dissection, major vessel perforation, injury of intrapericardial structures, limb ischaemia, myocardial infarction and neurologic events, was similar [EBO: 12 (4%); TTC: 11 (2.4%); P = 0.23]. Minor complications such as minor vessel injury, groin bleeding or lymphatic fistula were noted in 31 (10.1%) and 35 (7.6%), respectively (P = 0.23). Successful RAP procedures defined as absence of RAP-associated conversions and major complications were equal [EBO: 295 (96%); TTC: 449 (97.6%); P = 0.23]. Complications detected during follow-up included pain: 30 of 249 (12%) and 13 of 279 (4.7%) (P = 0.002); sensational disturbances: 60 of 249 (24.1%) and 40 of 278 (14.4%) (P = 0.005) and wound-healing complications: 49 of 249 (19.7%) and 42 of 277 (15.2%) (P = 0.172) for EBO and TTC, respectively. CONCLUSIONS: RAP can be successfully and safely implemented in minimally invasive cardiac surgery. EBO and transthoracic clamping of the ascending aorta are performing equally in terms of feasibility and procedural success.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2013; · 2.40 Impact Factor
[show abstract][hide abstract] ABSTRACT: A 63-year old male with prior bioprosthetic mitral valve replacement and coronary artery bypass graft surgery presented with dyspnea. C-reactive protein and white blood cells were elevated and serial blood cultures were negative. Transesophageal echocardiography showed a paravalvular leak and a thickened anterior leaflet of unclear either infective or degenerative origin. For differential diagnosis, cardiac 128-dual source computed tomography (CT) was performed. The CT image showed a thickened anterior leaflet and further revealed that the paravalvular leak was draining into a large wall thickened pseudoaneurysm with dense tissue adjacent suggestive for an abscess. Therefore, (18)fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) was appended and fused with the CT images. There was no tracer-uptake surrounding the leak excluding an abscess. However, an increased (18)FDG-tracer uptake at the thickened anterior leaflet indicated active inflammation. During the subsequent cardiac surgery, vegetations were identified on the anterior cusp of the bioprosthetic valve. Intraoperative biopsy was taken and the cell culture was positive for Staphylococcus aureus. The pseudoaneurysm was repaired and the valve was replaced with a bioprosthesis. The patient was discharged uneventfully from hospital on day 12 and antibiotic treatment was continued for 4 weeks. In conclusion, our case indicates that (18)FDG-PET with cardiac CT image fusion may be a useful tool in patients with unclear focus of inflammation and possible bioprosthesis infection.
Interactive Cardiovascular and Thoracic Surgery 12/2011; 14(3):364-6. · 1.11 Impact Factor
[show abstract][hide abstract] ABSTRACT: Occlusion of coronary arteries during off-pump coronary bypass operations bears the potential for endothelial injury. The aim of this study was to elucidate the effects of hemostatic devices on the beating heart in human coronaries by means of scanning electron microscopy.
The coronary arteries of 9 patients with dilated cardiomyopathy and 13 with ischemic heart disease undergoing heart transplantation were handled with intracoronary shunts as well as external snaring techniques on a beating heart, after cannulation but before starting cardiopulmonary bypass. Adjacent noninstrumented coronary artery segments served as controls. Integrity of endothelial lining was observed with scanning electron microscopy.
Nearly all coronary artery segments manipulated with a shunt exhibited a severe injury with extensive endothelial denudation. Endothelial injury was significantly higher after manipulation with intracoronary shunts compared with external occlusion devices (p < 0.001) or control specimens (p < 0.001). Plaque rupture was apparent in 3 samples.
Manipulation of human coronary arteries during off-pump operations leads to endothelial denudation and plaque rupture. From this investigation we conclude that insertion of intracoronary shunts during beating heart operations leads to severe endothelial denudation in human coronary arteries. We therefore recommend using shunts selectively in cases where critical ischemia or technical difficulties due to anatomic conditions are expected during anastomosis. The clinical significance of these structural damages has to be further investigated with clinical trials.
The Annals of thoracic surgery 01/2009; 86(6):1873-7. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: The long-term effects of high impedance vs. standard impedance pacing leads on actual generator longevity were studied.
In 40 patients (21 females, age 73 +/- 13 years) with standard dual-chamber pacemaker indication, bipolar standard impedance ventricular leads and high-impedance leads were implanted in a randomized fashion. Identical pacemaker generators and atrial pacing leads were implanted in all patients. Patients were observed during a mean follow-up of 89.8 +/- 8.8 months before pacemaker replacement. Initially, the patients who received the high-impedance leads had a lower current drain as compared with standard pacing impedance leads, and the estimated pacemaker longevity was significantly prolonged, too. But this pattern disappeared after 6 years of follow-up, and finally the actual pacemaker generators' replacement time was 86.7 +/- 6.8 months in standard impedance lead group vs. 91.2 +/- 10.3 months in high-impedance lead group (P = 0.17).
Implantation of high pacing impedance leads for ventricular stimulation does not result in a benefit with respect to pacemaker longevity as compared with standard impedance leads.
[show abstract][hide abstract] ABSTRACT: The use of venoarterial extracorporal membrane oxygenation and ventricular assist-devices in children with end stage heart failure is well established. The use of a bridge-to-bridge strategy leads to excellent survival rates in pediatric patients. We present an adolescent, who acquired acute respiratory failure, due to possible transfusion related lung injury, and who was successfully treated with venovenous extracorporal membrane oxygenation while on ventricular assist-device support.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 01/2008; 54(5):551-3. · 1.39 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The axillocoronary bypass graft is an extraanatomical coronary bypass graft variation that is indicated when sternal
reentry or proximal graft connection to the ascending aorta need to be avoided. METHODS: Usually a saphenous vein graft is
taken but for the axillary artery to left anterior descending artery position the radial artery is also an option. Special
attention should be paid to a tension free course in the infraclavicular region, a wide opening of the intercostal transition,
and placement of the graft in the pleural space that avoids entrapment or compression by the lung. RESULTS: Graft flows and
profiles seem to be adequate and hospital mortality as well as early graft patency in the literature are acceptable. Single
cases with promising graft patency in the 5–8 year range are currently available. CONCLUSIONS: More information on longterm
patency needs to be accumulated in order to assess the durability of the axillocoronary bypass graft.
GRUNDLAGEN: Der axillokoronare Bypass ist eine extraanatomische Bypassgraft-Variante, welche dann indiziert ist, wenn eine
Resternotomie oder ein Bypass-Anschluss an die Aorta ascendens vermieden werden sollen. METHODIK: Üblicherweise wird ein Vena
saphena magna graft verwendet, die Arteria radialis stellt aber auch eine mögliche Option dar. Speziell sollte auf einen spannungsfreien
Verlauf in der Regio infraclavicularis, auf eine weite Öffnung des interkostalen Durchtritts sowie auf eine Platzierung in
der Pleurahöhle, welche eine Einklemmung oder Kompression durch die Lunge verhindert, geachtet werden. ERGEBNISSE: Bypass
flows und Flow Profile scheinen adäquat zu sein. Ebenso sind die in der Literatur berichtete perioperative Letalität und frühe
Bypass-Offenheitsrate zufriedenstellend. Einzelfälle von durchgängigen axillokoronaren Bypassgrafts nach 5 bis 8 Jahren sind
bekannt. SCHLUSSFOLGERUNGEN: Mehr Information über die Bypassdurchgängikeit muss angesammelt werden um die Langzeit-haltbarkeit
European Surgery 03/2007; 39(2):91-95. · 0.15 Impact Factor
[show abstract][hide abstract] ABSTRACT: The two h post-dose cyclosporine (CsA) concentration has been advocated as the optimal time point measurement for CsA area under the curve (AUC) estimation after solid organ transplantation. The aim of the study was to investigate whether intensified CsA monitoring is necessary, or if a single time point measurement is accurate to estimate the AUC in the very early period following lung transplantation (LuTX).
Within the first two wk following transplantation, daily AUCs were calculated by serial CsA measurements at zero, one, two, three, four, and six h (C0-C6) in 12 consecutive lung transplant recipients. Correlation of single CsA measurements and AUC as well as linear regression analysis was performed to evaluate the most predictive single CsA blood level regarding the AUC.
A total of 606 CsA concentration measurements were performed and the 101 corresponding AUCs were calculated for each patient. Mean AUC was 3443 +/- 1451 microg/L. C0: 361 +/- 118 microg/L, C1: 481 +/- 231 microg/L, C2: 682 +/- 314 microg/L, C3: 715 +/- 347 microg/L, C4: 658 +/- 271 microg/L, C6: 571 +/- 260 microg/L. The correlation of CsA serum levels with AUC was the lowest at trough levels (C0) with a correlation coefficient (r = 0.31) and highest at three h (C3: r = 0.89) and two h (C2: r = 0.88).
Similar to a stable post-transplant period, CsA trough levels turned out to have poor correlation with the corresponding AUC early after LuTX. The highest correlation of C3 with the AUC may be explained by delayed intestinal resorption immediately post-operative, however C2 is a peer parameter. Optimum AUCs and corresponding C2 or C3 levels in the immediate post-operative phase however remain to be determined.
[show abstract][hide abstract] ABSTRACT: The benefit of cytomegalovirus (CMV) hyperimmune globuline in preventing CMV infection after lung transplantation still remains unclear. The aim of this study was to investigate the effect of combined prophylaxis using ganciclovir (GAN) and CMV hyperimmune globulin (CMV-IG) on CMV infection, CMV disease, survival and its role in preventing Bronchiolitis obliterans syndrome (BOS).
A consecutive series of 68 CMV high-risk lung transplant recipients (D+/R-, D+/R+), who had a minimum follow-up of 1 year posttransplant were analyzed. Thirty patients (44.1%) received single GAN prophylaxis for 3 months (control group) and 38 recipients (55.9%) received GAN together with CMV-IG 7 times during the first postoperative month (study group). Median follow-up was 16.5 months in the control and 23.8 months in the study group (P = 0.54).
Five CMV-related deaths (16.7%) occurred in the control group (P = 0.014). Fifteen recipients suffered from CMV pneumonitis and three patients had CMV syndrome. In the control group, 13 recipients (43.3%) suffered from clinically manifested CMV disease compared to 5 (13.2%) in the study group (P = 0.007). Additionally, recipient survival was significantly better in the study group (P = 0.01). One year freedom from CMV affection was 52.1% in the control and 71.5% in the study group (P = 0.027). Three-year freedom from BOS was significantly higher in the study group (54.3% vs. 82%, P = 0.024).
In CMV high risk patients, additional CMV-IG administration seems to be effective to reduce CMV-related morbidity and to avoid CMV-related mortality. Reduced incidence of BOS may result from improved CMV prevention, although randomized trials are warranted.
[show abstract][hide abstract] ABSTRACT: After heterotopic heart transplantation, a 59-year-old woman presented with remarkable symptoms of breathlessness and fatigue, despite excellent donor heart function. Asynchrony of donor and native heart provoked haemodynamic instability. Dual atrial pacemaker implantation lead to linkage and synchronization of atrial and ventricular contraction in both the donor and native heart with the faster organ executing the synchronization. Remarkable relief of symptoms has been evident during the long-term follow-up.
[show abstract][hide abstract] ABSTRACT: The aim of this study was to investigate whether transvenous lead removal is safe and effective in patients with lead vegetations greater than 1 cm in size.
From 1991 to 2005, a total of 53 patients underwent pacemaker or ICD lead removal for vegetations. Transvenous lead removal using locking stylets and sheaths was performed in 30 patients (56.6%) and was found to be effective in 29 of those patients. In 1 patient, due to rupture of the lead, open heart removal of the ventricular lead remnant and tricuspid valve repair had to be performed due to persistent infection. In 23 of these patients, transesophageal echocardiography (TEE) verified vegetations greater than 1 cm in size. The remaining patients underwent primary lead removal using sternotomy and extracorporeal circulation (ECC). Pacemaker pocket infection was found in 16 patients (55.2%) of the transvenous study group and in 11 patients (45.8%) of the ECC group (P = 0.72).
Perioperative mortality was 5.7% (3 patients); all of them underwent primary ECC removal and had severe endocarditis of the tricuspid valve. None of the patients who underwent transvenous lead removal died and there were no further complications such as pericardial tamponade or major pulmonary embolism requiring further interventions, even in patients demonstrating large vegetations.
This study demonstrates that transvenous lead removal is a safe and highly effective procedure for the removal of infected pacemaker and ICD leads, even in patients with large vegetations. Embolism to the lung proceeds mainly without further complications; however, patients with vegetations that might obstruct a main stem of the pulmonary artery should undergo ECC removal.
Pacing and Clinical Electrophysiology 04/2006; 29(3):231-6. · 1.75 Impact Factor
[show abstract][hide abstract] ABSTRACT: Ascending aortic atherosclerosis is a risk factor for perioperative morbidity and mortality in coronary surgery. It was the aim of our study to determine the role of atherosclerosis of the ascending aorta and other factors for the survival rate during long-term follow-up after CABG.
From 500 out of 580 CABG patients (aged 67 (33-85) years, 77% male), who underwent intraoperative epiaortic ultrasound for assessment of ascending aortic wall thickness, a complete follow up regarding long-term survival was achieved. The median follow-up time was 55 (1-78) months.
53/500 (11%) patients died within the follow-up period, and the cumulative survival rate was 95, 90, and 84% after 1, 3, and 5 years, respectively (including hospital deaths). A significantly lower long-term survival was present in patients with: an age of 70 years or more (P<0.001), COPD (P=0.005), preoperative elevated serum creatinine of >1.2mg/dl (P=0.007), preoperative LVEF <40% (P=0.033), ascending aortic wall thickness of 4mm or more (P=0.001), carotid artery disease (P<0.001), peripheral vascular disease (P<0.001), and acute operation (P=0.009). Multivariate analysis revealed carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age to be independent risk factors.
Patients with ascending aortic atherosclerosis are at risk for a decreased long-term survival after CABG. Besides, preoperative elevated serum creatinine, COPD, carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age are risk factors for a decreased long-term survival after CABG.
European Journal of Cardio-Thoracic Surgery 11/2005; 28(4):558-62. · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: B-type natriuretic peptide (BNP) concentrations, a cardiac hormone released upon cardiac stress, was monitored in patients after heart transplantation. Rejection was assessed by the International Society for Heart and Lung Transplantation (ISHLT) criteria. BNP was assessed by a cross-sectional approach. We found significantly (p = 0.024) increased concentrations during rejection episodes of ISHLT grade 2 and higher. BNP yielded only a moderate diagnostic accuracy (area under the receiving characteristic curve: mean = 0.76, 95% confidence interval 0.53-0.92) to detect clinically significant episodes of rejection, which was too low to replace endomyocardial biopsies. Acute rejection episodes were associated with marked BNP increases and a significant decrease in case of successful treatment in the individual long-term monitoring in the majority of patients. BNP monitoring seems to be a useful addition in the individual follow-up of heart transplant recipients to rule out significant rejection.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 10/2005; 24(9):1444. · 3.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: In the early phase after heart transplantation (HTX) patients are at high risk for infection because of intensified immunosuppression. This retrospective study evaluates the efficacy of a three-month antiviral cytomegalovirus (CMV) prophylaxis. Patients and methods: 133 patients received a three-month combined intravenous and oral CMV prophylaxis with Ganciclovir (Cymevene after HTX between 1997 and April 2003 (group II). They were compared to a historical group consisting of 40 patients, who had undergone HTX between 1995 and 1996 (group I; CMV-prophylaxis: hyperimmune globuline (Cytotect) for the first post-operative month in combination with orally administered aciclovir (Zovirax) for 6 months). Demographic data of organ recipients and donors in both groups were comparable, except for underlying cardiac diseases (p = 0.016). All patients had identical postoperative immunosuppressive regimes.
Group II had a significantly lower mortality rate (GI: 37.5%, GII: 9.8%; p < 0.001); one year survival (p = 0.001) and overall survival (p = 0.001) were significantly better than in group I. Patients of group II had fewer rejection episodes > or = grade II ISHLT requiring treatment (p < 0.001). Group II presented significantly fewer positive CMV blood samples (p = 0.005) and CMV infections (26% versus 47,5% in GI; p = 0.008), and a later onset of infections after HTX than group I (group I with a mean interval of 5.8 weeks after HTX, group II: 24.8 weeks after HTX; p < 0.001).
Incidence of CMV infection was significantly lowered under ganciclovir prophylaxis, infections occurred at a later time point after HTX, when patients were immunologically more competent. The proportion of higher grade rejection episodes was markedly reduced and survival was improved.
Wiener klinische Wochenschrift 08/2004; 116(15-16):542-51. · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Implantation of a cytomegalovirus (CMV)-positive graft (D+) into a CMV-negative recipient (R–) is a high-risk
constellation after heart transplantation (HTX). CMV infection after HTX is associated with increased morbidity, mortality,
raised incidence of acute rejection and possibly the development of transplant vasculopathy. In order to further reduce the
incidence of CMV infections, a new, antiviral prohylaxis was established in 1997. METHODS: We retrospectively reviewed all
mismatched cardiac transplant recipients (D+/R–) who were treated with oral acyclovir combined with CMV-hyperimmune globulin
(group I, n = 8, 1995/1996) and compared them with CMV-mismatched (D+/R–) recipients who had postoperatively intravenous ganciclovir
and subsequent oral ganciclovir for 90 days (group II, n = 18, 1997–2001). Demographic data of both groups were comparable.
The same immunosuppressive regimen was used for the entire study period. RESULTS: Five patients (62.5%) of group I died after
a mean of 6.7 ± 7.6 months, 3 patients (37.5%) remain alive for a mean of 80.7 ± 5.2 months after transplantation. In contrast,
two patients of group II died (11.1%), whereas 16 patients (88.9%) remain alive for a mean of 41.6 ± 13.0 months (p = 0.004).
CMV seroconversion occurred in 6 patients of group I (75%) 7.8 ± 1.9 weeks after HTX and in 9 patients of group II (50%) 44.5
± 22.7 weeks after HTX (p = 0.01). There were more positive antigenemia tests in group I compared with group II (13.8% vs.
9%, p = NS). Significantly less rejection episodes grade IB or more (ISHLT classification) were noticed in group II (18 of
195 biopsies, 9.2%) than in group I (16 of 89 biopsies, 18.0%) (p = 0.036). CONCLUSIONS: Mortality was significantly lower
in the ganciclovir group. Antiviral prophylaxis is able to reduce the incidence and to delay the onset of CMV infection in
the high-risk CMV-mismatched population after HTX.
GRUNDLAGEN: Die Implantation eines Zytomegalievirus-(CMV-)IgG-positiven Spenderorganes (D+) in einen CMV-IgG-negativen Empfänger
(R–) stellt eine Hochrisikokonstellation nach Herztransplantation (HTX) dar. Jede CMV-Infektion nach Transplantation ist nicht
nur mit erhöhter Morbidität und Mortalität assoziiert, sondern steigert auch die Inzidenz akuter Abstoßungen und ist zudem
ein Kofaktor in der Entwicklung der Transplantatvaskulopathie. Um Infektionen postoperativ weiter zu reduzieren, wurde ab
1997 eine neue, antivirale CMV-Prophylaxe etabliert. METHODIK: Retrospektiv wurde die CMV-Hochrisikopopulation (D+/R–) ausgewertet,
die mit oralem Acyclovir und CMV-Hyperimmunglobulin prophylaktisch behandelt worden war (Gruppe I, n = 8, 1995/1996) und mit
dem D+/R–-Kollektiv verglichen, welches postoperativ Ganciclovir initial intravenös, anschließend oral über insgesamt 90Tage
erhalten hatte (Gruppe II, n = 18, 1997–2001). Die demographischen Daten beider Gruppen unterschieden sich nicht. Über den
gesamten Beobachtungszeitraum wurde in beiden Gruppen eine idente Immunsuppression verabreicht. ERGEBNISSE: Fünf Patienten
(62,5 %) der Gruppe I starben im Mittel 6,7 ± 7,6Monate nach HTX, die verbleibenden 3 Patienten (37,5 %) leben im Mittel
80,7 ± 5,2Monate nach der Transplantation. Nur zwei Patienten der Gruppe II verstarben (11,1 %), 16 Patienten (88,9 %) leben
im Mittel 41,6 ± 13,0Monate nach der HTX (p = 0,004). In Gruppe I kam es bei 6 Patienten (75 %) im Mittel 7,8 ± 1,9Wochen
nach der HTX zur CMV Serokonversion, in Gruppe II bei 9 Patienten (50 %) erst 44,5 ± 22,7Wochen nach HTX (p = 0,01). In Gruppe
I fanden sich mehr positive Antigenämietests als in Gruppe II (13,8 % vs. 9 %, p = NS). Signifikant weniger Abstoßungsepisoden
Grad IB oder höher (ISHLT-Klassifikation) traten in Gruppe II (18 von 195 Biopsien, 9,2 %) als in Gruppe I (16 von 89 Biopsien,
18,0 %)(p = 0,036) auf. SCHLUSSFOLGERUNGEN: In der Gruppe mit Ganciclovir-Prophylaxe war die Mortalität signifikant niedriger.
Die 90-tägige antivirale Ganciclovirprophylaxe reduzierte die Inzidenz der CMV-Infektionen im Hochrisikokollektiv, das Auftreten
der Infektionen konnte signifikant in eine spätere Phase nach HTX verschoben werden.
European Surgery 03/2004; 36(2):113-120. · 0.15 Impact Factor