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The Journal of thoracic and cardiovascular surgery 02/2011; 141(2):583-4. · 3.41 Impact Factor
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ABSTRACT: Surgical site infection (SSI) is a serious complication after cardiac surgery. This case-control study investigated the effect of a cyanoacrylate-based microbial skin sealant (InteguSeal) applied preoperatively on the SSI rate in patients undergoing coronary artery bypass graft (CABG) surgery. Of 676 patients who underwent CABG surgery with or without concomitant procedure(s) between March and November 2007, 545 received standard preoperative care and 131 also received pretreatment with the microbial sealant. Of these, 90 cases pretreated with microbial sealant and 90 controls were matched using established preoperative and intraoperative risk factors for SSI. Preoperative risk scores for SSI were 9.9+/-4.3 and 9.7+/-4.0 (P=0.747) for the microbial sealant and the control group, respectively, and combined preoperative-intraoperative risk scores were 9.7+/-4.1 and 8.7+/-3.5 (P=0.080), respectively. Carotid artery disease (P=0.019), congestive heart failure (P=0.019), acute myocardial infarction (P=0.001) and emergency surgery (P=0.026) were significantly more common in the microbial sealant group. Follow-up was 100% for both groups. Superficial or deep sternal infection 30 days post surgery developed in seven patients (7.8%) in the control group compared with one patient (1.1%) in the microbial sealant group (odds ratio 7.5). In summary, the inclusion of microbial sealant in preoperative patient preparation seems to reduce the incidence of SSI following CABG surgery; further larger studies are needed before firm conclusions can be drawn.
The Journal of hospital infection 04/2009; 72(2):119-26. · 3.01 Impact Factor
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ABSTRACT: Despite appropriate treatment, surgery for aortic dissection is frequently associated with bleeding problems. In these series we report on the employment of recombinant activated factor VII (rFVIIa) for refractory hemorrhage after emergency surgery for acute type A aortic dissection, used to face the problems of postoperative blood loss and transfusion requirements. Despite the good results of the therapy, a patient presented with thrombosis of the left cavernous sinus. Although a risk of thromboembolic complications has to be considered, rFVIIa is a reasonable rescue option in life-threatening hemorrhage and enlarges our hemostatic armamentarium in surgery for acute aortic dissection.
The Journal of cardiovascular surgery 11/2008; 50(4):531-4. · 1.56 Impact Factor
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ABSTRACT: The 3F equine aortic bioprosthesis is a new stentless valve which is currently undergoing evaluation in a multicenter clinical trial and is considered to have superior hemodynamic performance. Herein is reported the authors' initial experience with the 3F valve, focusing on the hemodynamic performance of the device.
Between March 2002 and October 2003, 35 patients (age range 61-86 years) underwent aortic valve replacement with the 3F valve implanted in the subcoronary position. Evaluation of valve hemodynamic performance was assessed at discharge (postoperative day 5 +/- 2), at 3-6 months, and at 11-14 months' follow up by means of transthoracic echocardiography. The mean preoperative transvalvular pressure gradient was 63 +/- 14 mmHg. Before surgery, all patients were in NYHA class III or IV, despite aggressive medical treatment. Five patients underwent concomitant coronary artery bypass grafting.
The implanted valve sizes ranged from 21 to 29 mm. There were no operative deaths and no major perioperative complications. After 12 months, mean pressure gradients for the 23-, 25-, 27- and 29-mm valves were 13, 13, 12 and 9 mmHg, respectively. Mean systolic pressure gradients and NYHA class were improved significantly after surgery. Mild signs of hemolysis and minimal central regurgitation were detected in some patients, but were of no clinical importance. Valve dysfunction or mechanical failure did not occur during the follow up period.
Because of its flexible structure, the 3F aortic bioprosthesis is simple to implant, and no major adverse effects have been associated with such valve implantation at the authors' center. Transprosthetic gradients appeared to regress at 6-12 months' follow up. The durability of the device is yet to be established in ongoing long-term trials.
The Journal of heart valve disease 08/2006; 15(4):545-8. · 0.81 Impact Factor
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ABSTRACT: A challenging issue is to create a heart valve with growth and remodeling potential, which would be of great interest for congenital heart valve surgery. This study was performed to evaluate the growth and remodeling potentials of a decellularized heart valve.
In 4 juvenile sheep (age 12 +/- 1 weeks) with a weight of 24.3 +/- 4.4 kg, a 17-mm diameter decellularized porcine valve was implanted as pulmonary valve replacement. Valve growth was evaluated by transthoracic echocardiography. At explantation, valves were evaluated by gross examination, light microscopy (hematoxylin and eosin, von Kossa, Sirius red, Weigert and Gomori staining), electron microscopy and immunohistochemistry. Atomic absorption spectrometry was performed to evaluate calcium content.
All animals showed fast recovery. The mean follow-up was 9.0 +/- 1.8 months. All sheep at least doubled their weight (54.3 +/- 9.2 kg). Echocardiography showed no regurgitation and a flow velocity of 0.7 +/- 0.1 m/s at the latest follow-up. The valve diameter increased from 17.6 +/- 0.5 to 27.5 +/- 2.1 mm (p < 0.018). Gross examination showed a similar wall thickness of the implanted valve and native pulmonary wall, with smooth and pliable leaflets. Histology showed a monolayer of endothelial cells, fibroblast ingrowth and production of new collagen. No calcification was seen at von Kossa staining, confirmed by low calcium content levels of the valve wall and leaflets at atomic absorption spectrometry.
This glutaraldehyde-free heart valve showed not only the absence of calcification, but also remodeling and growth potential.
European Surgical Research 01/2006; 38(1):54-61. · 0.93 Impact Factor
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ABSTRACT: The Pericarbon Freedom stentless valve has shown excellent hemodynamic results in the midterm course. However, there is no information as to whether a continuous or interrupted suture technique at the inflow site has an impact on postoperative hemodynamics.
139 patients were enrolled in a non-randomized, prospective matched trial. An interrupted suture line technique was used in 68 patients and a continuous suture line technique was used in 71 at the inflow site. Isolated valve replacement was performed in 70.4% of the continuous and 67.6% of the interrupted suture group. Pre- and postoperative hemodynamics and one-year follow-up were obtained by echocardiography and expressed as mean and peak gradients and grade of regurgitation.
No significant difference between continuous and interrupted suture techniques were noted with respect to mean (11.8 +/- 6.3 vs. 12.5 +/- 6.2 mm Hg, p = 0.251) and peak gradients (21.0 +/- 9.6 vs. 22.0 +/- 10.9 mm Hg, p = 0.292) as well as to the degree of regurgitation. Bypass and cross-clamping times decreased by 22.4 and 20.6 minutes, respectively, with the use of the continuous suture technique. One year follow-up showed a further, significant decrease of mean and peak gradients.
The Pericarbon Freedom stentless valve appears to offer excellent postoperative performance. The suture line technique at the inflow site does not result in any hemodynamic differences.
The Thoracic and Cardiovascular Surgeon 09/2005; 53(4):212-6. · 0.88 Impact Factor
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ABSTRACT: This study was performed to evaluate the possibility of creating a glutaraldehyde-free porcine xenograft to improve long-term durability.
A decellularized porcine pulmonary valve was implanted into the right ventricular outflow tract of 7 juvenile sheep. Valves were explanted after 3 months (n = 4) and 6 months (n = 3). Evaluation was performed by gross examination, radiography, histology (hematoxylin-eosin and Sirius red staining), and immunohistochemistry. Quantitative determination of calcium content was investigated by atomic absorption spectrometry.
All animals showed fast recovery without complications. At explantation, all decellularized valves showed smooth and pliable leaflets without evidence of thrombosis. The valve wall was also smooth and pliable without hardness. Light microscopy showed a monolayer of host endothelial cells covering the inner surface of the heart valves and repopulation of host fibroblasts into the deeper layers. Sirius red staining enabled visualization of the production of new collagen. Radiographic results showed an absence of calcification, confirmed by the low calcium levels (1.08 +/- 0.28 microg/g and 0.73 +/- 0.31 microg/g at 3 and 6 months, respectively) revealed by atomic absorption spectrometry.
The results with the juvenile sheep model showed that decellularized heart valves are recellularized in vivo. Host endothelial cells form a monolayer on the inner surface of the valve matrix. Furthermore, host fibroblasts repopulate the valve matrix and produce collagen; thus, a remodeling potential can be expected.
Heart Surgery Forum 02/2005; 8(2):E100-4; discussion E104. · 0.63 Impact Factor
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J P Braun,
T Schroeder,
S Buehner,
P Dohmen,
M Moshirzadeh,
J Grosse,
F Streit,
A Schlaefke,
V W Armstrong,
M Oellerich,
H Lochs, W Konertz,
W J Kox,
C Spies
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ABSTRACT: The effect of non-pulsatile, normothermic cardiopulmonary-bypass (CPB) on the splanchnic blood-flow and oxygen-transport, the hepatic function and the gastrointestinal barrier were observed in a prospective observational study in 31 adults undergoing cardiac valve replacement surgery.
The splanchnic (i.e. hepatic) blood-flow (HBF) was measured by the constant infusion of indocyanine-green (ICG) using a hepatic-venous catheter. Liver function was examined by calculation of lactate uptake, ICG extraction and the monoethylglycinexylidide (MEGX) test. A day before and after surgery the gastrioduodenal and intestinal permeability was measured by determination of sucrose and lactulose/mannitol excretion.
Splanchnic blood flow and oxygen delivery did not decrease during and after surgery while splanchnic oxygen consumption (P < 0.0125) and arterial lactate concentrations increased. The splanchnic lactate uptake paralleled the lactate concentration. After but not during CPB an increase of systemic oxygen consumption was observed. The MEGX test values decreased on the first day after surgery. The ICG extraction was attenuated during the operation. The gastroduodenal and the intestinal permeability increased significantly postoperatively (P < 0.002, respectively, P < 0.001). There was no correlation between these findings and the duration of CPB. There was a significant correlation of the intestinal permeability but not of the gastroduodenal permeability between the prior and after surgery values (P < 0.001).
Increased oxygen consumption during CPB may indicate an inflammatory reaction due to the pump beginning in the splanchnic area or a redistribution of the splanchinc blood flow during the CPB. Normothermic CPB does not lead to a significant or prolonged reduction of liver function. Normothermic CPB causes an increase of gastrointestinal permeability. The intestinal barrier function prior to surgery was accountable for the degree of loss of intestinal barrier function following surgery.
Acta Anaesthesiologica Scandinavica 07/2004; 48(6):697-703. · 2.19 Impact Factor
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ABSTRACT: To evaluate the efficacy of passive cardiomyoplasty with the determination of biventricular volumes, global systolic function as well as left-ventricular muscle mass.
In 19 patients with congestive heart failure of idiopathic or ischemic origin, a polyester mesh-graft was implanted around both ventricles for stabilization and functional support. Before and three months after surgery, 15 patients underwent EBCT and 4 patients with impaired renal function underwent MRI, for the evaluation of the volume and ejection fraction of both ventricles.
EBCT demonstrated a decrease from 385 to 310 ml in LV-EDV, from 312 to 242 ml in LV-ESV, from 209 to 160 ml in RV-EDV and from 149 to 87 ml in RV-ESV, and an increase from 20 to 26% in LV-EF and from 37 to 50% in RV-EF as well as a reduction of LV-MM from 300 to 274 g (p < 0.05 each). Similar results were obtained by MRI.
Following passive cardiomyoplasty, EBCT and MRI revealed an improvement of the global systolic function as well as a reduction of biventricular volumes and left-ventricular muscle mass.
RöFo - Fortschritte auf dem Gebiet der R 08/2003; 175(8):1086-92. · 2.76 Impact Factor
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ABSTRACT: During conventional cardiac surgery ischemia and reperfusion may cause excessive production of reactive oxygen species leading to tissue damage including early arrhythmias. We therefore assessed the kinetics of markers of radical stress including oxidized and reduced glutathione (GSSG/GSH), oxidized proteins (PCG) and malondialdehyde (MDA), and tested the hypothesis that different steroid treatments inhibit these markers and early reperfusion-associated supraventricular and ventricular extrasystolic beats.
In a randomized, controlled, blinded, prospective trial 36 patients received a preoperative infusion of methylprednisolone (MP, 15 mg kg-1, n = 12), tirilazad mesylate (TM, 10 mg kg-1, n = 12) or placebo (PL, NaCl, n = 12). Coronary sinus and arterial blood was drawn at baseline and 2, 5, 15, 30, 60 and 240 min after aortic declamping. Holter-ECG analysis was used to identify arrhythmias.
Cardiac GSSG release occurred very early (< 15 min) and was not significantly attenuated by either drug treatment. Cardiac PCG production showed biphasic increases, lasted > 4 h and was significantly reduced only by TM. Cardiac MDA release was short (< 30 min) and significantly reduced by MP and TM. Neither treatment had a significant influence on the early occurrence of ventricular or supraventricular arrhythmias. The number of patients needing cardioversions or defibrillations also were not different.
The results indicate that cardiac production of reactive oxygen species occurs after reperfusion in humans and is not inhibited by steroid treatment. Steroid treatment effectively reduces lipid peroxidation during cardiac surgery but has no influence on arrhythmias.
Acta Anaesthesiologica Scandinavica 07/2003; 47(6):667-74. · 2.19 Impact Factor
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ABSTRACT: A quality management system (QMS) will improve quality in health care units. This report describes the introduction of a QMS according to ISO 9001:2000 in a university cardiovascular surgery department.
First, a thorough analysis of all processes of patient treatment and clinical research was obtained. Multiple interfaces were defined to different departments as well as to administration units. We evaluated and optimized all necessary resources, evaluating customer satisfaction using patients' and referring physicians' surveys. We started quality rounds including surgeons, nurses and technicians. Based on this preparation, we redefined and explained all processes including their responsibilities and necessary resources in the quality manual.
After a process of 18 months, an independent, accredited organization recommended that our QMS be given certification according to ISO 9001:2000.
Certification of a university cardiovascular surgery department according to ISO 9001:2000 is possible, and may represent the first step towards total quality management (TQM). In complex health care units, certification of separate departments may help generate a consciousness of quality on the way to TQM.
The Thoracic and Cardiovascular Surgeon 07/2003; 51(3):167-73. · 0.88 Impact Factor
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ABSTRACT: In this study, the protective effect of piracetam on select aspects of cognitive function in patients undergoing bypass surgery was investigated. Male patients (n = 64) with an indication for a surgical revascularization using artificial extracorporal circuits were randomly assigned in a double-blind fashion to receive a single challenge of 12-g piracetam infusion or placebo (sterile saline) prior to the bypass surgery. A brief battery of neuropsychological tests for verbal and non-verbal short-term memory and attention was administered 1 day before and 3 days after the surgical intervention. There was a significant difference in short-term memory and attention, with the piracetam-treated patients producing a better level of performance 3 days after surgery compared to the placebo group. The overall postoperative cognitive function (z-transformation of all 6 test results) was more significantly (p < 0.001) reduced in the placebo group than in the piracetam group (z = -1.19 +/- 0.72 vs. -0.46 +/- 0.58, respectively). A single challenge of 12-g piracetam infusion prior to surgical intervention might offer a short-term neuroprotective effect for patients undergoing cardiac bypass surgery. Whether this effect persists for a longer period of time requires further investigation.
Pharmacopsychiatry 05/2003; 36(3):89-93. · 2.07 Impact Factor
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ABSTRACT: To evaluate the capability of bright-blood cine MR to directly visualize the leaflets of the valve replacement in pulmonary position following Ross operation.
Long and short axis views of the pulmonary valve were obtained in 10 normal subjects and 14 patients after Ross operation. Valve morphology and function were analyzed and signal-to-noise (SNR) and contrast-to-noise ratios (CNR) were calculated. Flow measurements were performed in the pulmonary trunk to assess pulmonary regurgitation.
In all subjects, tricuspid morphology of the pulmonary valve was visualized. SNR of the leaflets in normal subjects (9.8 +/- 3.0) and in patients after Ross operation (7.5 +/- 2.2) differed significantly from blood (12.6 +/- 3.2 and 11.3 +/- 2.5, respectively, p < 0.05). Valvular regurgitation was seen in 5 patients as an insufficient closure of the valve which was confirmed by flow measurements.
Cine MR enables in-plane visualization of the pulmonary valve and allows for functional and morphological evaluation in patients after pulmonary valve surgery.
Acta Radiologica 03/2003; 44(2):172-6. · 1.37 Impact Factor
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ABSTRACT: We report the case of a 29-year-old male Jehovah's Witness who presented with hemolysis and right heart failure as a consequence of extreme calcification of an aortic valve-containing allograft and Dacron prosthesis that had been placed 22 years earlier to repair tetralogy of Fallot. Reoperation had been denied by several other centers, because of the patient's refusal to undergo blood transfusion. For 2 weeks preoperatively, we raised the patient's hemoglobin level by treating him with recombinant erythropoietin, oral iron, and folic acid. At surgery, under normothermic cardiopulmonary bypass, we replaced the aortic allograft in the right ventricular outflow tract with a cryopreserved pulmonary allograft, also containing a valve. The postoperative course was uneventful, and the patient was released from the hospital on the 13th postoperative day in excellent condition.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 02/2003; 30(2):146-8. · 0.65 Impact Factor
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ABSTRACT: The mechanism of an indirect revascularization in ischemic myocardium by transmyocardial laser revascularization (TMLR) is not yet fully understood. An improvement of clinical symptoms caused by TMLR is reported in many clinical trials with patients in which a direct revascularization is not possible. An increase of myocardial perfusion through laser channels is doubtful, because the myocardial pressure in the wall is higher than in the cavum. Therefore we measured the local cardiac function (intramyocardial pressure, wall thickness, pressure-length curves) and acute metabolic changes (tissue lactate content, tissue pO2) in ischemic and nonischemic regions before and after TMLR in isolated hemoperfused pig hearts. An isolated heart was chosen because it enabled us to separate coronary flow from flow through ventricular channels. The ischemia was induced by coronary occlusion or microembolization (eight hearts each). It should be noted that microembolization leads to conditions which are more comparable with those found in patients selected for TMLR. In the isolated working heart, the coronary perfusion can be controlled independently from perfusion through the ventricular cavum. Under the ischemic conditions mentioned above, we observed that the intramyocardial pressure in the ischemic region decreased below the left ventricular pressure, so one premise for indirect perfusion was met. TMLR after microembolization led to a significant improvement of regional cardiac work and the tissue oxygen pressure. These acute effects demonstrate the possibility of functional and metabolic amelioration by TMLR after ischemia induced by microembolization in an isolated hemoperfused pig heart.
The International journal of artificial organs 12/2002; 25(11):1074-81. · 1.86 Impact Factor
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ABSTRACT: Hydrodynamic performance of a decellularized pulmonary porcine valve was evaluated with a computer versatile pulse duplicator and compared to glutaraldehyde fixated stentless porcine bioprosthesis and a polyurethane heart valve.
Decellularized pulmonary porcine matrices (Group I, n = 5) were treated chemically to become cell-free collagen matrices. The findings of this heart valve were compared with aortic glutaraldehyde treated porcine prostheses (Group II, n = 5) and polyurethane three leaflet valve prostheses (Group III, n = 1). Measurements were performed in 0.9% saline test fluid at room temperature. Measurements compared were closing time, closing volume, systemic pressure difference and energy losses. Each valve was measured 6 times with 70 beats/minute, a stroke volume of 70 ml corresponds to a cardiac output of 4.9 L/minute.
Group I and group III showed no significant differences between parameters. The measured closing time was significantly different (p < 0.001) between group I and II, respectively 24.333 and 53.600 ms and group II and III respectively 53.600 and 24.000. Difference in closing volume was significant (p < 0.05) between groups II and I respectively 3.67 and 0.68 ms and group II and III respectively 3.67 and 0.71. Systolic mean pressure gradient was 18.25 +/- 1.04 mm Hg in group II which was significantly different (p < 0.001) from groups I and III, respectively 10.65 +/- 0.29 mm Hg and 7.70 +/- 0.30 mm Hg.
Decellularized pulmonary porcine valves showed the same excellent performance as polyurethane valve prosthesis, which are superior to the investigated glutaraldehyde fixed xenograft.
The International journal of artificial organs 12/2002; 25(11):1089-94. · 1.86 Impact Factor
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Journal of Cardiothoracic and Vascular Anesthesia 11/2002; 16(5):615-6. · 1.64 Impact Factor
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ABSTRACT: Cardiac surgery in Jehovah's Witness patients remains a challenge in the presence of concomitant congenital or acquired coagulation disorders and anaemia. We report a case of a 66-year-old female Jehovah's Witness suffering from severe calcified aortic valve stenosis requiring aortic valve replacement. The anaemic patient suffered from concomitant platelet dysfunction and deficiency of factors V and VII due to gammopathy of immunoglobulin G. The patient was preoperatively treated with recombinant erythropoietin in combination with folic acid and iron, which resulted in an increase of the haematocrit from 0.335 to 0.416 after 22 days of treatment. Haemostasis was improved by high dose aprotinin and additional desmopressin, which could be demonstrated to be effective by a preoperative test. The patients intra- and postoperative course was uneventful, her total chest tube loss was 130 ml, and she was able to be discharged without the need of any blood transfusions. The beneficial properties of erythropoietin and desmopressin in Jehovah's Witness patients are discussed.
Perfusion 12/2001; 16(6):485-9. · 0.92 Impact Factor
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ABSTRACT: During cardiopulmonary bypass, inflammation and immunosuppression is present. We measured circulating mediators and monocyte-based functions and tested the hypothesis that these variables are influenced by methylprednisolone (MP) or tirilazad mesylate (TM) treatment.
Randomized, controlled, double-blind prospective trial.
A university hospital.
Thirty-nine patients scheduled for conventional coronary surgery with three-vessel disease.
Preoperative application of MP (15 mg/kg) or TM (10 mg/kg) compared with placebo (PL).
Circulating proinflammatory markers including interleukin (IL)-6, IL-8, monocyte chemoattractant protein 1, and C-reactive protein were all decreased by MP treatment but not by TM treatment. Whereas rapid increases in circulating anti-inflammatory IL-10 were superinduced by MP but not TM, plasma levels of IL-1RA and transforming growth factor beta were not altered by either treatment. Decreased ex vivo lipopolysaccharide-stimulated secretion of tumor necrosis factor alpha was prolonged after MP treatment but not after TM treatment. Perioperative stimulated secretion of IL-12 and interferon gamma was diminished in all groups, whereas ex vivo IL-1RA secretion tended to increase in all groups. Depression of monocyte surface expression of HLA-DR was significantly greater in patients treated with MP, whereas CD14 expression did not change.
These data confirm that, during cardiopulmonary bypass, pro- and anti-inflammatory systems are activated at the same time, whereas monocyte-based immune functions are depressed. Treatment with MP abrogates proinflammatory mediators and induces a shift toward anti-inflammation at the cost of further functional monocyte deficits, whereas treatment with TM apparently has neither anti-inflammatory nor immunosuppressive actions in this setting.
Critical Care Medicine 12/2001; 29(11):2137-42. · 6.33 Impact Factor
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ABSTRACT: The presence of viable endothelial cells may support longer durability and the absence of calcification in valve prostheses. This study shows the development of a tissue engineered heart valve, constructed from viable autologous endothelial cells on an acellular matrix and its evaluation in juvenile sheep. In 3-month-old sheep (n = 8) a piece of vein was harvested to culture autologous endothelial cells. A porcine acellular matrix was reendothelialized and implanted in juvenile sheep as pulmonary interposition. The valves were explanted after 1 week, 3 and 6 months. Examination was performed by X-ray, light microscopy, and atomic absorption spectrometry. Reendothelialization mean rate was 10.3 x 10(5) cells/cm(2) with a mean endothelial cell viability of 95.5% (0.98 x 10(5) cells/cm(2)). X-ray examination showed no cusp calcification at 1 week, 3 and 6 months, which was confirmed by light microscopy. Immunostaining for factor VIII demonstrated colonization of viable mature autologous endothelial cells on the heart valve after the seeding process. The atomic absorption spectrometry showed no significant increase of the calcium content after 3 (P value >.1) and 6 months (P value >.1) compared with nonimplanted tissue engineered heart valves. The tissue engineered valve showed no cusp calcification in the juvenile sheep after 3 and 6 months.
Seminars in Thoracic and Cardiovascular Surgery 11/2001; 13(4 Suppl 1):93-8.
