Biomedical subjects

Ernst Wolner

Publications and source records attributed to Ernst Wolner.

At least 55 records · Page 3Linked to original sources

PubMed2004

Initial results after combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and consecutive endovascular stent-graft placement.

BACKGROUND: To evaluate safety and efficacy of a combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and endovascular stent-graft placement. METHODS: Between October 2002 and September 2003, 5 patients (mean age, 79.5 years) presented with aortic arch aneurysms involving the origin of the left carotid artery. Treatment was made by sequential transposition of the left carotid artery into the brachiocephalic trunk and transposition of the left subclavian artery into the already transposed left common carotid artery with consecutive endovascular stent-graft placement into the aortic arch. RESULTS: All patients survived both procedures. At completion angiography, a small type 1a endoleak was observed in 1 patient. After 1 week, the patient was readmitted for completion three-dimensional computed tomographic scan. The leak had already occluded spontaneously. Mean follow-up was 10 months (range, 4 to 16 months). At follow-up, all patients had normal computed tomographic scans with regular perfusion of the supra-aortic branches without any signs of endoleaks. CONCLUSIONS: Combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches with consecutive endovascular stent-graft placement is feasible. Extended application of this technique will enable safe and effective treatment of a highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.

Aged↗

PubMed2004

Extracorporeal membrane oxygenation is superior to right ventricular assist device for acute right ventricular failure after heart transplantation.

BACKGROUND: Acute right ventricular failure after heart transplantation is a life-threatening condition, and sometimes the use of mechanical circulatory support is inevitable. The aim of this retrospective study was to investigate the effectiveness of two different mechanical circulatory support systems for this indication. METHODS: From 1984 to 2003, 28 heart transplant recipients exhibited right ventricular failure resistant to drug therapy. Right ventricular assist device (n = 15) or extracorporeal membrane oxygenation (n = 13) was implanted to support the failing heart. RESULTS: Overall in-hospital survival was 43%. In the right ventricular assist device group, only 2 patients (13%) could be weaned from mechanical circulatory support compared with 10 patients (77%) in the extracorporeal membrane oxygenation group (p = 0.001). Retransplantation was necessary in 6 patients in the right ventricular assist device group and in 1 patient in the extracorporeal membrane oxygenation group (p = 0.049). There was no difference in patient survival between groups, but graft survival was significantly better in the extracorporeal membrane oxygenation group (p = 0.005). CONCLUSIONS: In view of these results, extracorporeal membrane oxygenation seems to be the better option as mechanical circulatory support for right ventricular failure in heart transplantation.

Aged↗

PubMed2004

Relation between size of prosthesis and valve gradient: comparison of two aortic bioprosthesis.

OBJECTIVES: The outcome of patients undergoing aortic valve replacement (AVR) may be affected by the influence of prosthesis-patient mismatch on left ventricular mass regression. However, due to the discrepancies in labeled valve size, size of sizer and actual valve dimension, it is difficult to compare different valve types. In order to perform an objective comparison, this study was designed to compare the hemodynamics of the Edwards Lifescience pericardial (ELP) and the Medtronic Mosaic porcine (MM) bioprosthesis between patients receiving the same valve size and between patients with the same aortic annulus diameter. METHODS: This prospective, randomized study was performed on 81 hospital survivors out of 86 patients undergoing AVR with either the ELP (n=39) or the MM (n=42) bioprosthesis. Intra-operative randomization was performed after the surgeon had excised the aortic valve, measured the size of the aortic annulus with three different sizers (ELP, MM and a set of metric sizers), and decided which size he would implant for either of the valve types. All valves were implanted in supra-annular position with the same implantation technique. Echocardiographic follow-up was performed early postoperatively and 6 months thereafter. RESULTS: In 12 (31%) of the patients receiving the ELP-valve, as compared to 3 (7.1%) of the patients receiving the MM-valve, the labeled valve size was smaller than the aortic annulus diameter (P<0.05). Early postoperatively, mean (17.4+/-3.1 vs 20.3+/-3.6 mmHg) and peak gradients (30.1+/-4.8 vs 37.6+/-9.6 mmHg) for the 21 mm ELP-valve were lower than for the 21 mm MM-valve (P<0.05). All other hemodynamic parameters did not show significant differences at any time point. When the same aortic annulus diameter was taken as a reference, there were no significant hemodynamic differences between either valve type at any time point, regardless of the valve size implanted. CONCLUSIONS: This study demonstrates that the hemodynamic performance of the ELP and the MM bioprosthesis are comparable when the same aortic annulus diameter is taken as a reference. The significant variabilities between different valve types with regard to labeled valve size, valve-sizer size and actual valve size have to be taken into account, when hemodynamic comparisons are performed.

Aged↗

PubMed2004

Microwave and radiofrequency ablation yield similar success rates for treatment of chronic atrial fibrillation.

OBJECTIVE: To evaluate the influence of two different ablation devices (microwave AFx and radiofrequency Medtronic), designed to create linear lesion lines, with respect to efficacy and restoration of sinus rhythm (SR). METHODS: Between February 2001 and December 2002, 42 patients with chronic, persistent atrial fibrillation (AF) >6 months were submitted to different combinations of valve surgery (mitral+/-tricuspid, n = 30; mitral and aortic+/-tricuspid reconstruction, n = 6 aortic+/-tricuspid, n = 8) and concomitant Maze procedure. The biatrial Maze followed the concept of the Cox III procedure, using either microwave energy (AFx Lynx) (group I: age 65.8+/-11.9 years, mean duration of AF 61.9+/-28.9 months, n = 23) or radiofrequency (Medtronic Cardioblate) (group II: age 64.1+/-11.1 years, mean duration of AF 53.5+/-49 months, n = 19). RESULTS: There was one death with group I (4%), due to liver failure. Both groups were comparable with regard to Euro Score, ejection fraction, cross clamp time, cardiopulmonary bypass time, ICU (median 1 day in both groups) and hospital stay, and type of indication. The preoperative diameter of the left atrium was 69.7+/-10.8 and 74.0+/-14.3 mm in groups I and II, respectively (P = 0.359). The Maze procedure resulted in 23+/-2 and 17+/-1 min additional cross clamp time in groups I and II, respectively (P = 0.013). At the 12-month follow up, freedom from AF was 81 and 80% in groups I and II, respectively. Twenty percent in group I and 21% in group II needed a pacemaker (PM), due to sick sinus syndrome (2 versus 2 cases), AV bloc (2 versus 1 case) and preoperative bradycardia (0 versus 1 case), respectively. CONCLUSIONS: The combination of complex valve surgery and Maze procedure was safe and reproducible. Following the Cox Maze III line concept, microwave and radiofrequency ablation gave similar results even in patients with more complex double or triple valve procedures.

Adult↗

PubMed2004

Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations.

OBJECTIVE: This retrospective study evaluates, if recent refinements in peri-operative management, have an impact on clinical outcome of patients undergoing elective repair of their ascending thoracic aorta. METHODS: One hundred sixty five (n = 165) consecutive patients were operated during a 7 year period at our department. The cohort was divided in an early group I (from Jan 1997 to Dec 1999, n = 75) and a late group II (from Jan 2000 to Jan 2003, n = 90). The mean age was 60.9+/-13.1 years in group I versus 58.1+/-13.6 years in group II. In group I 50 patients (66.6%) underwent replacement of the ascending thoracic aorta alone, 17 patients (22.6%) received a composite graft, 8 patients (10.6%) had an additional aortic valve replacement and 14 patients (18.6%) needed concomitant coronary artery bypass grafting. In group II the procedures were as follows: interposition graft alone in 58 patients (64.4%), composite graft in 26 patients (28.8%), aortic valve replacement in 6 (6.6%) and CABG in 11 patients (12.2%). RESULTS: Overall hospital mortality for the entire cohort was 6.6% (11/165) with no significant differences between the early and late group with 6.6% (5/75) and 6.6% (6/90), respectively, P = 0.985. Causes were multi organ failure in 63.3% (n = 7), stroke in 9% (n = 1) myocardial infarction in 18.1% (n = 2) and refractory bleeding in 9% (n = 1). Concomitant CABG, repair of the aortic valve and composite graft, emerged as independent risk factor for mortality in multivariate logistic regression analysis with P = 0.001. Differences, became apparent in ICU as well as hospital stay with a median ICU stay in group I of 7.1+/-12.9 days versus 4.4+/-6.8 days in group II, and median hospital stay of 16.7+/-5.3 days versus 9.5+/-8.4 days for group I and II, P < 0.05, respectively. Furthermore through the implementation of blood conservation techniques, a substantial reduction of transfusion requirements could be achieved (PRBC from 3.2+/-4 to 1.1+/-1.7 units, FFP 5.2+/-3 to 2.3+/-0.5 units, Platelets from 1.3+/-2 to 0.3+/-0.07 units). CONCLUSIONS: Even with the implementation of various refinements in surgical and anaesthetic techniques, the current risk of mortality for ascending aortic aneurysm repair has not changed in the last 7 years. However, shortened ICU and hospital stays as well as diminished usage of blood derivates are mainly the result of a more aggressive and improved peri- and post-operative management due to economic considerations.

Adult↗

PubMed2004

Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta.

OBJECTIVE: The objective of the study was to evaluate mid-term durability and need for reinterventions after endovascular stent-grafting (ESG) in descending aortic aneurysms and dissections. PATIENTS AND METHODS: Between November 1996 and February 2003 a total of 80 patients underwent ESG for the following indications: atherosclerotic aneurysms (50/80; 63%), type B dissections (20/80; 25%), penetrating ulcers (6/80; 8%), traumatic aneurysms (4/80; 5%). Two types of commercially available ESG (Talent, Medtronic, Santa Rosa, CA and Excluder, WL GORE, Flagstaff, AZ) were inserted via the femoral artery in 53 patients, via the iliac artery in 21 patients and via the abdominal aorta in 6 patients. RESULTS: In-hospital mortality was 3.8% (n=3). Type I endoleak formation requiring endovascular reintervention was observed in 3.8% (n=3). Surgical reintervention became necessary in 4 patients (4/80; 5%). One patient experienced a retrograde type A dissection, detected in the 3 month control after ESG of an acute type B dissection, consecutively undergoing frozen elephant trunc repair. Three patients with late type I endoleak formation (mean interval: 62 months) after ESG (two atherosclerotic aneurysms, one penetrating ulcer) underwent open thoraco-abdominal repair in deep hypothermia or left heart bypass technique. All patients had an uneventful postoperative course. CONCLUSIONS: Occurrence of late endoleak formation requiring surgical reintervention after ESG is acceptably low. In atherosclerotic aneurysms the development of endoleaks is assumed to be causative related to progression of the underlying aortic disease. A close follow-up of patients after ESG is crucial.

Aged↗

PubMed2004

Adenovirus-mediated overexpression of inhibitor kappa B-alpha attenuates postinfarct remodeling in the rat heart.

OBJECTIVE: The transcription factor nuclear factor kappa B (NF-kB) plays an important role in the inflammatory response following myocardial infarction. We hypothesized that NF-kB-blockade in an animal model of acute ischemia reduces the inflammatory response and therefore attenuates ventricular remodeling. METHODS: Myocardial infarcts (MI) were produced in male Sprague-Dawley rats by ligation of the LAD and followed by adenovirus-mediated intramyocardial delivery of inhibitor kappa Balpha-gene (n=10), the physiological inhibitor of the transcription factor nuclear factor kappa B, respectively, of a beta-gal reporter-gene (n=11). Sham-operated animals (n=10) received neither ligation nor gene transfer. Five days after MI IkB-expression levels were determined by western blotting. Seven weeks after MI in vivo cardiac function was evaluated by transthoracic echocardiography. Based on left ventricular endsystolic and enddiastolic diameters ejection fraction and fractional shortening were calculated. Only animals with MI involving more than 30% of the left ventricle were included. Data are given as mean+/-SD. RESULTS: In IkBalpha-transfected hearts IkBalpha-levels were six-fold higher (P<0.05) than in beta-gal transfected hearts. Concerning in vivo hemodynamics IkBalpha-treated hearts showed reduced systolic and diastolic left ventricular dimensions compared to the beta-gal MI-group (systolic 48+/-4 vs. 66+/-3 mm; diastolic 67+/-5 vs. 84+/-6 mm; P<0.01). Consequently fractional shortening (27.8+/-1.5 vs. 20.4+/-4.0%; P<0.01) and ejection fraction (63.4+/-3.6 vs. 49.1+/-8.3%; P<0.05) were preserved in IkBalpha hearts compared to beta-gal MI-hearts. CONCLUSION: It can be concluded that overexpression of IkBalpha leads to an improved cardiac function thereby attenuating postinfarct remodeling.

Adenoviridae↗

PubMed2004

Pre-emptive treatment with oral valganciclovir in management of CMV infection after cardiac transplantation.

BACKGROUND: Cytomegalovirus (CMV) has long been recognized as the most common opportunistic pathogen in transplant recipients. The use of post-detection antiviral treatment of CMV as a strategy to prevent disease in cardiac recipients is becoming the standard policy. Valganciclovir is an oral pro-drug of ganciclovir, with a 10-fold greater bioavailability than oral gancyclovir. PATIENTS AND METHODS: We reported our first experience with 8 patients (3 female, 45.0 +/- 10.5 years old, non-CMV mismatched) who underwent cardiac transplantation and had positive results of CMV polymerase chain reaction (PCR) within first 6 weeks after transplantation without concomitant CMV disease. These patients received valganciclovir in dosage 450 to 900 mg daily depending on renal function for 3 weeks. Standard immunosuppressive regimen consisted of cyclosporin A, MMF and corticosteroids, and was not changed after detection of CMV infection. In one patient we used sirolimus with respectively reduced dosage of cyclosporin A. Weekly measurements of CMV-PCR were performed to observe results of therapy. RESULTS: After 1 week of valganciclovir therapy CMV-PCR plasma concentration in all patients decreased significantly (2,105 copies/ml vs 400 copies/ml; p < 0.0001). No relapse of CMV infection has been detected after completing of valganciclovir therapy with follow up duration of 9.0 +/- 0.92 months. The drug was generally well tolerated, and we did not observe any severe drug related adverse events. CONCLUSION: Oral valganciclovir as pre-emptive antiviral therapy administrated after detection of CMV infection seems to be an effective and safe treatment in cardiac transplant recipients.

Administration, Oral↗

PubMed2004

Clinical results with an ePTFE inflow conduit for mechanical circulatory support.

BACKGROUND: Neurologic complication is an adverse event associated with mechanical circulatory support. To decrease the incidence of embolic cerebrovascular accidents (CVA) during support with the Novacor left ventricular assist system (LVAS), an expanded polytetrafluoroethylene (ePTFE) inflow conduit has been developed and introduced clinically. METHODS: Using clinical data from Europe and Canada, we conducted a retrospective analysis of the incidence of embolic CVA with the ePTFE inflow conduit (n=88) in comparison with the previously used polyester inflow conduits (n=310, including Vascutek n=155 and Cooley n=155). We calculated freedom from embolic CVA, risk reduction for embolic CVA, and linearized rates of embolic CVA. RESULTS: A significant decrease in the incidence of embolic CVA was demonstrated with the ePTFE conduit (ePTFE 10% vs polyester 23%, p=0.002). Kaplan-Meier analysis of freedom from embolic CVA at 180 days after implantation was 86% for the ePTFE group vs 72% for the polyester group (log-rank test, 0.0185). We also found an associated risk reduction of 55% in CVA occurrence in the ePTFE group when compared with the Polyester group (hazard ratio, 0.445; 95% confidence limit, 0.222-0.890; p=0.0221). Linearized CVA rates also were decreased at all time intervals after implantation in the ePTFE group. CONCLUSIONS: Preliminary clinical results with the newly introduced ePTFE inflow conduit provide compelling evidence that the ePTFE conduit material significantly decreases thromboembolic complications during mechanical circulatory support with the Novacor LVAS.

Adolescent↗

PubMed2004

Decellularization protocols of porcine heart valves differ importantly in efficiency of cell removal and susceptibility of the matrix to recellularization with human vascular cells.

OBJECTIVE: We compared 3 different decellularization protocols in porcine heart valves for efficiency of complete cell removal and potential for recellularization. METHODS: Porcine aortic and pulmonary roots were treated with trypsin, sodium-dodecyl-sulphate, or a new method using 0.25% tert-octylphenyl-polyoxyethylen in combination with sodium-deoxycholate. After a subsequent ribonuclease digestion, specimens were seeded with in vitro expanded human saphenous vein endothelial cells and myofibroblasts. RESULTS: After treatment with trypsin and subsequent ribonuclease digestion, endothelial attachment took place; however, xenogenic cells were still visible within the matrix. Unexpectedly, when human cells were seeded onto specimens that had been decellularized with sodium-dodecyl-sulphate, the matrices were surrounded by nonviable endothelial cell fragments, indicating a toxic influence of the ionic detergent; 0.25% tert-octylphenyl-polyoxyethylen together with sodium-deoxycholate completely removed porcine cells and enabled host recellularization. CONCLUSION: Compared with trypsin and sodium-dodecyl-sulphate involving decellularization procedures, reported to be effective in cell removal and susceptible to recellularization with human cells, only the porcine matrix treated with a new detergent-based decellularization method using 0.25% tert-octylphenyl-polyoxyethylen/sodium-deoxycholate followed by nuclease digestion presented an excellent scaffold for recellularization with human cells.

Aortic Valve↗

PubMed2004

Weaning of rotary blood pump recipients after myocardial recovery: a computer study of changes in cardiac energetics.

BACKGROUND: Weaning of patients from mechanical cardiac support after myocardial recovery has always involved multiple, interacting factors, particularly the training of the myocardium during reduction of pump flow. Rotary pumps offer training advantages when support flow is reduced, even to nearly zero. We report a computer analysis that evaluates the work required of the heart during partial unloading and removal of rotary pumps. METHODS AND RESULTS: A computer model of the assisted circulation, previously implemented in MATLAB (The MathWorks Inc, Natick, Mass), has been augmented with a model of the MicroMed DeBakey ventricular assist device (MicroMed Technology, Inc, Houston, Tex). Flow, pressure patterns, and external work (pressure-volume area, calculated as the area of the ventricular pressure-volume loop [external work] plus potential energy) were calculated for nonassisted and various continuously assisted patients. Under low-flow conditions, the heart imposes an oscillating forward-backward flow through the non-occlusive rotary pump, causing an increase in ventricular work. Thus, an assist flow of 1 to 1.5 L/min requires work equivalent to that of the unsupported heart. At 60% contractility, the nonassisted pressure-volume area is 1.10 Ws/beat, and the potential energy is 0.38 Ws/beat. At a Qpump of 1 L/min, the pressure-volume area is 1.21 Ws/beat, and the potential energy is 0.37 Ws/beat. At a Qpump of 3 L/min, the pressure-volume area is 0.93 Ws/beat, and the potential energy is 0.29 Ws/beat. These conditions cannot be achieved with pulsatile systems. CONCLUSION: During weaning and retraining, an implanted rotary pump can provide a workload to the heart like that in the nonassisted situation, thus increasing the predictability of weaning and reducing the risk of reiterating heart failure.

Cardiovascular System↗

PubMed2004

Primary or delayed closure for the treatment of poststernotomy wound infections?

OBJECTIVE: The methods of primary versus delayed wound closure for the treatment of sternal wound infections after cardiac surgery were retrospectively compared. METHODS: From January 2001 to March 2003, 132 patients (median age 66 years, male to female ratio 88:44) with sternal wound infection after cardiac surgery were treated at our department. After thorough debridement, 35 patients received preconditioning of the wound before implementation of definitive therapy; the remainder (97 patients) were treated with immediate closure. RESULTS: From the 35 patients with preconditioning, 19 patients proceeded to delayed primary closure, whereas the remaining 14 patients were referred to plastic reconstruction with a pectoralis muscle flap. Primary success rate in this group was 100%. In the immediate primary closure group, 33 patients experienced 1 or more therapy failures, resulting in a recurrence rate of 39%. Fifteen patients received a pectoralis muscle flap as definite treatment modality. CONCLUSIONS: Immediate primary closure is associated with a high rate of local infection recurrence. Surgical debridement and conditioning of the wound until resolution of infections with delayed primary closure or plastic reconstruction is suggested as the more appropriate treatment modality, with promising results.

Adult↗

PubMed2004

Elevated serum levels of epithelial cell apoptosis-specific cytokeratin 18 neoepitope m30 in critically ill patients.

Apoptosis of the epithelium is deemed to play a pivotal role in the pathogenesis of sepsis. A neoepitope in cytokeratin 18 (CK18), termed M30 neoantigen, becomes available at an early caspase cleavage event during apoptosis of epithelium-derived cells and is not detectable in vital or necrotic epithelial cells. A monoclonal antibody, M30, specifically recognizes a fragment of CK18 cleaved at Asp396 (M30 neoantigen). We used an enzyme-linked immunosorbent assay (ELISA) to measure M30 antigen levels in the sera of 15 septic patients. Healthy humans and critical ill patients suffering from severe trauma served as controls. Mann-Whitney U test was used to calculate significance, and a P value of <0.01 was considered to be statistically significant. Serum levels of the CK18 neoepitope M30 were significantly increased in septic patients (236.88 +/- 47.4 U/L) versus trauma (97.2 +/- 17.1 U/L) and healthy controls (66.9 +/- 9.2 U/L) (P < 0.01 and P < 0.008, respectively). The increased serum level of the CK18 neoepitope in septic patients indicates a heightened apoptotic turnover in epithelial cells as compared with trauma patients and healthy controls. Interestingly, nonsurviving trauma patients exhibited a significant increase in the M30 neoantigen as compared with survivors and healthy controls (P < 0.003 and P < 0.002, respectively). The detection of CK18 neoepitope M30 in the serum might be a useful marker in tracing apoptotic epithelium in septic patients.

Adult↗

PubMed2004

Stent-graft placement in atherosclerotic descending thoracic aortic aneurysms: midterm results.

PURPOSE: To determine midterm durability and need for reinterventions after stent-graft placement in atherosclerotic descending thoracic aortic aneurysms. METHODS: Fifty-four patients (38 men; mean age 68 years, range 33-87) underwent stent-graft repair of chronic atherosclerotic aneurysms of the descending thoracic aorta between November 1996 and December 2002. Acute aortic syndromes (type B aortic dissections, perforating ulcers, and traumatic dissections) were excluded from analysis. Two types of commercially available stent-grafts were used (Talent and Excluder). RESULTS: The primary technical success rate was 94.4%. In-hospital mortality was 3.7% (2/54). No adverse neurological events were encountered. Of 3 (5.6%) early type I endoleaks, 2 (3.7%) required reintervention; the other type I endoleak closed spontaneously. Mean follow-up was 38 months (range 1-72) in the 52 surviving patients. Four (7.7%) type I, 7 (13.5%) type II, and 4 (7.7%) type III endoleaks were seen. Three 3 patients had additional treatment for endoleaks (proximal stenting [type Ia], open thoracoabdominal repair [type Ib], and embolization [type II]). Two of the 3 reinterventions were performed in the first year of follow-up. One additional patient with a type Ia endoleak not suitable for reintervention is under close observation. There were no differences in the number of endoleaks between the 2 types of stent-grafts. Three-year event-free survival was 63%. CONCLUSIONS: Midterm durability of endovascular stent-graft placement in atherosclerotic descending aortic aneurysms seems promising, as the rate of endoleaks requiring reintervention is acceptably low. In our series, endoleak formation occurred during the first year after stent-graft placement, so close follow-up of patients after aortic aneurysm repair is crucial. Further studies are warranted to evaluate long-term durability of this new treatment modality.

Adult↗

PubMed2004

Complicated acute aortic dissection type B caused by femoral cannulation for endoscopic coronary artery bypass surgery.

PURPOSE: To report endovascular treatment of a patient with complicated acute aortic type B dissection caused by cannulation of the femoral artery for endoscopic coronary artery bypass (CAB) surgery. CASE REPORT: A 63-year-old man underwent single-vessel CAB surgery facilitated by the Da Vinci surgical system. After the procedure, acute lower limb ischemia led to the discovery of a type B dissection from the left subclavian artery to the iliac arteries. The subclavian artery was also dissected, with only minimal flow in the left mammary artery. The visceral and renal vessels originated from the false lumen and were not perfused. Emergent stent-graft placement was undertaken to close the entry tear and re-establish perfusion of the lower extremity as well as visceral and renal organs. Additional stent-grafts were placed in the dissected left subclavian artery to perfuse the left internal mammary bypass and in the inferior mesenteric artery, which arose from the false lumen. Six months after operation, the patient is well. CONCLUSIONS: Acute iatrogenic aortic dissection secondary to endoscopic CAB surgery can be treated emergently to restore distal perfusion to vital organs.

Aneurysm↗

PubMed2004

Reconstructed bicuspid aortic valve after 10 years: clinical and echocardiographic follow-up.

BACKGROUND: Sixteen patients (mean age, 30.9 +/- 12.9 years; range, 9-79 years) with incompetent bicuspid aortic valves underwent valve-sparing correction between 1992 and 1995. METHODS: All patients underwent triangular resection of the enlarged leaflet. In addition, 13 patients underwent commissuroplasty. In 3 patients leaflet perforations were corrected with glutaraldehyde-fixed autologous pericardial patch. All patients underwent annual echocardiographic and clinical examinations at our institution. RESULTS: During follow-up 1 patient died of heart failure, and 3 patients underwent reoperations because of valve incompetence or dilatation of the sinus. Two patients underwent reoperation perioperatively. At long-term follow-up (mean, 10.06 +/- 1.01 years) the remaining 10 patients were in New York Heart Association class I. No patient was receiving anticoagulation, and no thromboembolic, bleeding, or endocarditis events were observed in 107.2 cumulative patientyears of follow-up. Mean grade of regurgitation was 0.7 +/- 0.5; mean aortic flow velocity was 2.29 +/- 0.47 m/s. Optimal valvular function led to normal ventricular diameters (left ventricular end systolic diameter, 39.2 +/- 4.3 mm; left ventricular end diastolic diameter, 56.2 +/- 5.9 mm) and normal ventricular function (fractional shortening, 31.5% +/- 0.1%). The dimensions of the aortic root were stable from 1-year to late followup (mean aortic annulus, 27.1 +/- 6.8 mm; sinus of Valsalva, 33.0 +/- 7.1 mm; sinotubular junction, 34.1 +/- 7.7 mm; ascending aorta, 31.6 +/- 7.4 mm). CONCLUSION: In contrast to early follow-up results of 5 reoperations, clinical and echocardiographic results were excellent for 10 patients who had undergone reconstruction of bicuspid incompetent aortic valves, and the patients were in stable condition after 10 years. However, the mode of early failure is unknown. Reconstruction of bicuspid valves is possible in selected patients.

Adolescent↗

PubMed2004

EuroSCORE predicts mid-term outcome after combined valve and coronary bypass surgery.

BACKGROUND AND AIM OF THE STUDY: EuroSCORE is widely used to assess operative risk. Combined cardiac procedures carry increased perioperative mortality, but the influence of preoperative factors on mid-term outcome is not well known for these patients. The study aim was to determine if EuroSCORE risk influences mid-term survival after combined coronary artery bypass grafting (CABG) and valve surgery. METHODS: Follow up (mean 23.7 months) was obtained in 258 consecutive hospital survivors (148 males, 110 females; median age 72.29 years; mean EuroSCORE 7 points) operated on between January 1998 and March 2001. CABG + aortic valve replacement (AVR) was performed in 171 patients, CABG + mitral surgery in 72, and CABG + double valve surgery in 15. Kaplan-Meier estimates were calculated for survival and combined freedom from death and NYHA class III/IV. The Cox regression model was applied to prove the influence of EuroSCORE risk and a number of preoperative and operative variables on mid-term outcome. RESULTS: Thirty patients (11.63%) died during follow up, and 34 (13.17%) were in NYHA class III/IV. Freedom from death and NYHA class III/IV was 89.3%, 74.7% and 55.2% at 12, 24 and 36 months, respectively. The significant predictor for combined death and NYHA class III/IV was EuroSCORE risk (p = 0.0004). In the subgroup of patients with CABG + mitral valve surgery, age was identified as a significant risk factor for death (p = 0.0346), whereas in the subgroup of patients with CABG + AVR EuroSCORE was detected as significant risk factor for combined death and NYHA class III/IV. CONCLUSION: EuroSCORE is an important predictor for poor mid-term outcome after combined CABG and valve surgery.

Age Factors↗

PubMed2003

Predictors of adverse outcome and transient neurological dysfunction following surgical treatment of acute type A dissections.

Predictors of adverse outcome after replacement of the ascending aorta with resection of the intimal tear and open distal anastomosis were analyzed in 167 patients (109 male, median age 56). Median hypothermic circulatory arrest (HCA) time was 30 minutes (range 12 to 113). Eighty-six patients (pts) had surgery within 24 hours and 81 within 72 hours of symptom onset. Thirty-seven pts had only ascending aortic replacement, 128 had hemiarch repair, and in 2 the entire arch was replaced. The aortic valve was replaced in 37 pts, resuspended in 116, and untouched in 14. Either death or permanent neurological dysfunction was considered an adverse outcome (AO). AO occurred in 30.5% (51/167) of patients overall. Multivariate analysis revealed that the only significant (P<0.05) independent preoperative predictor of AO was hemodynamic instability (OR 6.0). Transient neurological dysfunction (TND) occurred in 19 of 116 patients (16.4%). Significant predictors of TND were increasing age >60 (OR 3.4 and 7.0 in the second and third tertile as compared with the lowest tertile) and coronary heart disease (OR 3.4). Cumulative survival of patients (median follow-up 34 months) was 55% at 1, 49% at 5, and 44% at 8 years, indicating an excessive in-hospital mortality, but excellent long term outcome. Surgical treatment of acute type A dissections is still associated with a high incidence of adverse outcome, but results in excellent long-term survival. Earlier diagnosis, before the development of cardiac tamponade and hemodynamic compromise, is critical to improve the operative salvage rate.

Adolescent↗