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Biomedical subjects

H H Scheld

Publications and source records attributed to H H Scheld.

At least 37 records · Page 2Linked to original sources
PubMed2004

Vascular anastomosing by gluing--an experimental study.

BACKGROUND: Performing anastomoses by stitching is very time-consuming. We therefore looked for an alternative technique and used a relatively new surgical adhesive. METHODS: Ten anastomoses between the aorta and a prosthesis were performed on five pigs (Deutsche Landrasse) using surgical glue (BioGlue). The proximal anastomoses between the abdominal aorta and the prostheses were performed end-to-side just below the renal arteries, the distal anastomoses in an end-to-end fashion just above the iliac bifurcation. The aorta between the anastomoses was ligated and resected. The animals were sacrificed between one week and up to four months after operation and anastomoses were analysed by angiography, CT angiography, angioscopy, and histology. RESULTS: Angiography and CT angiography revealed that all anastomoses were patent. No aneurysms were found at the site of anastomoses. No haematomas were detected. Angioscopy revealed well-healed connections between the original aorta and the prosthesis. CONCLUSIONS: We could demonstrate that anastomoses between the aorta and a prosthesis can be performed safely using a surgical adhesive. Further investigations of these anastomoses, especially over the long term, using calcified aortas, are necessary.

Adhesives↗
PubMed2004

The place of research and the role of academic surgeons in cardiac surgery.

The development of the discipline of cardiac surgery was, to a large extent, guided by the vision and research of its pioneers. On the basis of their efforts, all the different areas of cardiac surgery were able to evolve including coronary artery bypass grafting, heart valve surgery, surgery of the aorta, congenital heart surgery, surgery for rhythm disorders including the implantation of pacemakers and defibrillators, and surgical treatment of advanced heart failure (for example, heart transplantations and mechanical circulatory support). The continued existence of cardiac surgery and its role in medicine in general will depend, to a significant extent, on the future research activities of its protagonists. Cardiac surgeon-scientists will play a pivotal role since they combine clinical experience with scientific knowledge and intuition which make them able to direct research to topics which will matter in the future. However, research costs money, and state or national funds will be not sufficient to support research as much as is necessary. Funding from third parties such as industry will increasingly be required. Due to this, however, the cardiac surgeon-scientist faces various challenges such as the evaluation of his skill in acquiring funds, conflicts with current ethical standards, conflicts of interest when receiving money from industry, and, as a result of the tough competition in this field, the temptation to commit fraud. The head of a department of cardiac surgery holds an important function as his initiative is decisive for the development of visions for the future and for the employment of surgeon-scientists who pursue visionary research. It will take the combined efforts of surgeon-scientists and departmental heads not only to maintain but to extend the position of cardiac surgery in medicine and society even further.

Biomedical Research↗
PubMed2004

Radical resection of cardiac sarcoma.

We report on our experience with six patients with malignant sarcoma of the heart and show that long-term survival is possible after radical resection. At presentation, the 6 patients (3 male, 3 female) were 45.8 +/- 20 years old. Three patients are alive without evidence of metastases since 29.6 +/- 36.8 months, three patients died after 38 +/- 50.2 months due to distant metastases. Precise preoperative localization of the tumor by means of imaging techniques is very important. In some cases, radical surgery requires an ex situ procedure (autotransplantation). If necessary, the right heart can be resected almost completely, and reconstructed in the form of a Fontan-type circulation. A heart transplantation, as suggested by others, is not justified from our point of view, since prognosis is not better and donor organs are too rare. The results of radical resection are promising, but new concepts for treatment--in particular chemotherapy concepts--for these mostly middle-aged or young patients are required.

Adolescent↗
PubMed2004

ICD implantation -- between necessity and tragedy.

We report on a 42-year-old patient with known dilative cardiomyopathy who underwent placement of a multiple transvenous pacemaker and ICD electrodes, and required removal of all leads via median sternotomy, followed by placement of epicardial electrodes. This experience has led us to question the necessity of the current implantation policies for these systems.

Adult↗
PubMed2004

First experience with rapamycin-based immunosuppression to improve kidney function after heart transplantation.

UNLABELLED: This study was designed to gain initial experience with rapamycin in thoracic organ transplant recipients with severely compromised kidney function, i.e. to see whether and how kidney function will improve with a rapamycin-based immunosuppressive protocol. METHODS: Twelve heart transplant patients were included into the study (serum creatinine > 2.5 mg/dL), with an average time after transplantation of more than 4 years. The calcineurin inhibitor (cyclosporine A = 9, tacrolimus = 3) was reduced by 50 %, and rapamycin added to reach a target level of 8 - 12 ng/dL. Azathioprine was halted, corticosteroid treatment remained unchanged. RESULTS: After implementing the rapamycin-based immunosuppression kidney function improved in all patients within one week. Serum creatinine dropped from 3.1 +/- 0.6 mg/dL to 2.7 +/- 0.5 mg/dL ( p = 0.0004), creatinine clearance increased from 30.4 +/- 11 mL/min to 40.8 +/- 10.5 mL/min ( p = 0.003). This improvement continued until 3 months after the conversion ( p = 0.032). Thereafter, no statistically significant changes were noted up to 6 months posttransplant ( p = 0.41). Serum cyclosporine levels dropped from 180 +/- 40 ng/mL to 132 +/- 46 ng/mL on average ( p = 0.002). Side-effects occurred in 4 patients and were all related to a rapamycin level exceeding 12 ng/mL. CONCLUSIONS: We conclude that transplant patients with impaired kidney function will have an immediate benefit from partially replacing calcineurin inhibitors by rapamycin.

Aged↗
PubMed2004

Successful long-term bridge to transplant in a 5-year-old boy with the EXCOR left ventricular assist device.

We report on a 5-year-old boy who presented with postcardiotomy failure after aortic valve replacement and had to undergo implantation of a Berlin Heart-Excor system since treatment with ECMO did not improve myocardial pump function. After a stormy postoperative course with delayed sternal closure after 9 days, the young boy finally recovered and could be fully mobilized. Until successful heart transplantation after a support interval of 77 days, he experienced no device-related infectious or thromboembolic complications.

Aortic Valve Insufficiency↗
PubMed2004

[Left ventricular assist devices (LVAD): optional treatment alternative to cardiac transplantation?].

Left ventricular assist devices (LVAD) are used to "bridge" patients with end-stage heart failure until transplantation of a donor heart can be performed ("bridge to transplantation"). However, LVAD support sporadically results in improved cardiac function, and heart transplantation is not necessary even after removal of LVAD in a subset of patients ("bridge to recovery"). Additionally, LVAD appears to be an optional treatment alternative to heart transplantation in patients with contraindication for organ replacement ("destination therapy"). The underlying process has descriptively been termed "reverse remodeling". The molecular basis remains incompletely understood at present, however, some mechanisms have been identified in the past. Alterations of several molecular pathways are involved in the development of chronic heart failure. Some of the pathways appear to be reversible and have been shown to be regulated by LVAD treatment. LVAD lead to lowered cardiac pressure and volume overload followed by decreased ventricular wall tension, reduction of cardiomyocyte hypertrophy, improved coronary perfusion and a decrease of chronic ischemia in the myocardium. Improved coronary flow and myocardial perfusion as well as decreased ventricular wall tension may serve as a possible explanation for changes of the molecular systems involved in the development of chronic cardiac insuffiency. This review focuses on the roles of apoptosis, heme-oxygenase-1 (HO-1), Metallothionein (MT) and the transcription factor NFkkappaB in chronic heart failure after mechanical circulatory support.

Apoptosis↗
PubMed2003

Mortality rates after heart transplantation: how to compare center-specific outcome data?

BACKGROUND: Studies of outcome in cardiac transplantation have focused primarily on identifying patient- and donor-related factors associated with patient mortality. Less consideration has been given to the impact of the transplant center. This study was undertaken to assess variability in heart transplantation outcome in Eurotransplant centers to provide a framework for auditing. METHODS AND RESULTS: In a 2-year period, 1,401 adult patients underwent heart transplantation in 45 centers. The 1-year patient survival rate was 76% (95% CI, 74%-78%) with a range of 0% to 100% at the center level. The risk-adjusted center effect on mortality was estimated by calculating a standardized difference between the observed number of deaths 1 year after transplantation and the expected number of deaths based on the case mix. By assessing within- and between-center variations with empirical Bayes (EB) methods, after adjustment for all registered prognostic factors, an improved estimate of the true center effect was obtained. Compared with the standard risk-adjusted center effect method, fewer outlying centers were identified with the EB method. CONCLUSION: EB methods, because they are known to incorporate more information from the data, enable a more precise and realistic portrayal of heart transplant centers' performances, compared with other risk-adjusted center effect methods. In the context of auditing procedures, EB methods should preferably be used for the identification of centers that deviate significantly from quality standards.

Adolescent↗
PubMed2003

[Evaluating the first German diagnosis-related groups (G-DRG) in cardiological patients: problems in the correct medical and economic grouping].

About three years ago, the German Government initiated a complete change in the reimbursement system for costs of the in-hospital treatment of patients. A commission of representatives from every component of the German health system decided to adapt the Australian refined Diagnosis Related Groups (AR-DRG system). The AR-DRG system was selected as it would fit best to the German system and because of its high flexibility and preciseness reflecting severity of diseases and treatments. In October 2002, the first German Diagnosis Related Groups (G-DRGs) were calculated from the data of about 116 hospitals. These data now allow first analyses in how far a correct and precise grouping of patients in specific hospital settings is indeed performed and corresponds to the actual costs. Thus, we thoroughly calculated all costs for material and personnel during the in-hospital stay for each patient discharged during the first 4 months of 2002 from our cardiological department. After performing the grouping procedure for each patient, we analyzed in how far inhomogeneous patient distribution in the DRGs occurred and which impact this had on costs and potential reimbursements. Several different problems were identified which should be outlined in this work regarding three G-DRGs: costs of patients who received an implantable cardioverter defibrillator (F01Z) were markedly influenced by multimorbidity and additional expensive interventions which were not reflected by this G-DRG. Use of numerous catheters and expensive drugs represented a major factor for costs in patients with coronary angioplasty in acute myocardial infarction (F10Z) but seemed to be not sufficiently included in the cost weight. A specific area of patient management in our department is high frequency ablation of tachyarrhythmias which is included in other percutaneous interventions (F19Z). Complex procedures such as ablation of ventricular tachycardia or new innovative procedures as ablation of atrial fibrillation were associated with high costs leading to inadequate reimbursement. Furthermore, problems in the associated codes for diseases and procedures became apparent. Opportunities for future optimization such as specific new DRGs, splitting of DRGs, or the impact of changes in reimbursement for high-outliers were discussed.

Angioplasty, Balloon↗
PubMed2003

Ex situ resection of primary cardiac tumors.

The prognosis of malignant heart tumors is pessimistic; 50% of patients die within 6 months. No optimal therapy has been established, and standardized therapeutic concepts have not been developed due to the low incidence of this disease. In most cases, chemotherapy and radiotherapy have not shown any survival benefit compared to surgical treatment. Obviously, radical resection of the tumor is the most important determinant for long-term survival. Here, we report on two patients in whom radical resection of heart tumors could be accomplished only after explantation of the heart.

Adult↗
PubMed2003

Arterial revascularization--advantages and pitfalls.

Arterial revascularization is still subject to debate, even though numerous publications have reported presumed advantages of arterial over venous grafts. This brief review summarizes current knowledge on arterial revascularization on a practical basis.

Coronary Artery Bypass↗
PubMed2002

[Myocardial alterations with mechanical left ventricular assist devices].

Left ventricular assist devices (LVAD) have been used to "bridge" patients with end-stage heart failure to transplantation. Although several reports have suggested that the native ventricular function recovers after long-term LVAD support, a process called "reverse remodeling", the underlying biological mechanisms are still unclear. Various molecular pathways of the human myocardium associated with apoptosis, response to stress, or matrix changes are known to be altered under conditions of heart failure, and some have been shown to be reversibly regulated during left ventricular mechanical support, suggesting that the descriptive term "reverse remodeling" is, at least in parts, a reversible mechanism. The reduction of volume and pressure overload with a decrease of ventricular wall stress leading to an improvement of myocardial blood supply under mechanical circulatory assistance, may be one explanation for the molecular myocardial changes and may reflect one possible cause for the phenomenon of "reverse remodeling".

Animals↗
PubMed2002

[Secondary prevention of coronary heart disease. Results from EuroASPIRE I and II in the region of Münster, Germany].

BACKGROUND: EuroASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events) is a European multicenter study on secondary prevention in patients with coronary heart disease (CHD). The first cross-sectional survey was undertaken in 1995/96 among 3569 patients from nine countries. A second cross-sectional survey (EuroASPIRE II) was conducted in 1999/2000 among 5556 patients from 15 countries to evaluate among others whether coronary prevention had improved since the first. METHODS: The present study was conducted in the region of Münster, Germany, as part of the EuroASPIRE study. Consecutive patients, men and women up to 70 years of age with established CHD, were identified retrospectively. A total of 392 (EuroASPIRE I) and 402 (EuroASPIRE II) patients participated. Information on cardiovascular risk factors, lifestyle and medication were obtained through medical records, interviews and examinations. RESULTS: Both studies demonstrate a high prevalence of risk factors among CHD patients. At the time of the interview more than 60% of the patients in both surveys had two or more risk factors. The comparison of EuroASPIRE I and II reveals a substantial decrease of 20% in the prevalence of hypercholesterolemia, but an increase in the prevalence of hypertension and obesity. ACE-inhibitors, betablockers and lipid lowering drugs, especially statins, were used more frequently in EuroASPIRE II. CONCLUSIONS: We conclude that secondary prevention of CHD in the region of Münster like in the other European study regions is less than optimal and has not substantially improved between 1996 and 2000. Potential reasons are discussed.

Adult↗
PubMed2002

[Malignomas following heart transplantation].

Up to 30% of patients with an organ transplantation develop precancerous lesions and malignant tumors, especially of the skin. All 241 patients who underwent heart transplantation from 1990 to 2000 were evaluated with regard to the development of neoplasias. Those alive in September 1999 were referred for a standardized dermatological exam (n=156) which detected malignancy in 28 patients being transplanted for 4.98 years on average. The skin was the organ most frequently involved (64%, n=18). 18% (n=5) of tumors were found in the urinary and genital tract, 7% (n=2) each in the respiratory and gastrointestinal tract, and 4% (n=1 ) in the breasts. The average age of patients who developed tumors was significantly higher as compared to the overall mean age (59.5+/-5 vs 49.8+/-14.7 years, p=0.00027). There was no correlation between development of malignancy and HLA matching, immunosuppressive drugs used, dosage and serum levels of immunosuppressive medication, and episodes of transplant rejection. Our study shows that the risk to develop tumors is at least doubled after heart transplantation. Due to the high incidence of skin tumors, transplant patients should undergo dermatological examinations on a regular basis.

Age Factors↗
PubMed2002

Mycotic cerebral vasculitis in a paediatric cardiac transplant patient excludes misadventure.

We present the case of a 10-year-old girl with cardiomyopathy who received a heart transplant. Due to organ rejection, the dosage of immunosuppressive agents was increased postoperatively. The patient complained of intermittent headaches in the following days and developed a haemorrhagic necrosis of the left thalamus. A week later, an oral dose of cyclosporin A was accidentally given intravenously, and 2 weeks later a recurrent subarachnoid haemorrhage of unknown origin was diagnosed. The clinical course was then characterised by progressive deterioration resulting in coma, fluctuating brain stem symptoms and the development of a massive cerebral oedema with subsequent brain death. A coroner's autopsy was instigated to investigate a claim of medical misadventure. Neuropathological investigations found a focal infiltration of fungal hyphae in the left posterior cerebral artery resulting in necrosis of the vascular wall and thus explaining the source of the recurrent subarachnoid haemorrhage which eventually resulted in the girl's death. Medical misadventure due to the administration of cyclosporin was not directly responsible for the death of this patient. This case illustrates that it is of paramount importance to copiously sample and investigate the basal cerebral arteries in cases of subarachnoid haemorrhage of unknown origin, in particular in a medico-legal context.

Aspergillosis↗