Lung volume reduction surgery for a patient receiving mechanical ventilation after a complex cardiac operation.
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Aortic Dissection↗
Biomedical subjects
P Vogt
Publications and source records attributed to P Vogt.
Composite graft replacement of the aortic root in acute dissection.
OBJECTIVE: In acute type A dissection the indication for composite graft replacement of the aortic root and the optimal implantation technique are a matter of debate. In this study early and late results of root replacement in acute dissection are determined and compared with supracoronary graft replacement. Two implantation techniques (open vs. inclusion) are evaluated. METHODS: Between 1985 and 1995, 207 consecutive patients (mean age 58 +/- 12 years, 78% men) were operated for acute type A dissection of the aorta. Root replacement in 50 patients (inclusion technique in 34/50 patients with Cabrol shunt in 15/34 patients, open technique in 16/50 patients) was compared with more conservative procedures in 157 patients: supracoronary graft replacement in 143 patients (with aortic valve replacement in 23 patients) and local repair without graft interposition in 14 patients. Preoperative risk factors, like hemodynamic instability, renal failure, neurologic disorder and coronary artery disease did not differ in the two treatment groups. RESULTS: Early results, survival and reoperation-free survival after 5 years were insignificantly better after root replacement: mortality 10/50 (20%) vs. 38/157 (24%) P = n.s.; hemorrhage 10/50 (20%) vs. 39/157 (25%) P = n.s.; stroke 5/50 (10%) vs. 27/157 (17%) P = n.s.; survival 70 +/- 7% vs. 63 +/- 4%, reoperation free survival 92 +/- 6% vs. 78 +/- 5% P = 0.0815). For the open technique, early mortality was 18.8 vs. 20.6%, P = n.s. and reoperation free survival at 5 years was 80.7 vs. 65.2%, P = n.s. Perioperative complications did not differ in the two technical groups and a single pseudoaneurysm occurred in the Bentall group. CONCLUSION: In acute dissection composite graft replacement of the aortic root can be carried out with good early and late results not inferior to more conservative procedures. The open technique is the implantation method of choice and the modified Bentall technique is indicated in situations with increased risk of bleeding.
Acute Disease↗
Endothelial cell injury in cardiac surgery: salicylate may be protective by reducing expression of endothelial adhesion molecules.
OBJECTIVE: Cardiac surgery with cardiopulmonary bypass induces ischemia to the heart, hypoxemia to various tissues and release of endotoxins. The endothelial cell may suffer from hypoxia and trigger cascades of adverse reactions by activation of neutrophils through adhesion molecules. The authors measured expression of intercellular adhesion molecule-1 (ICAM-1), during hypoxia and normoxia and hypothesized that salicylate, which inhibits the nuclear factor-kappaB (NFkappaB), an hypoxia-dependent transmission factor, could reduce this expression. METHODS: Human umbilical vein endothelial cells were cultured and exposed to normoxia and hypoxia in the presence of lipopolysaccharide (LPS). The endothelial cells were thereafter treated with salicylate or indomethacin under the same conditions. The surface expression of ICAM-1 was measured by whole cell enzyme-linked immunosorbent assay (ELISA) and the NFkappaB expression by Western blotting. RESULTS: In the presence of LPS and under hypoxic conditions, the endothelial cells produced a 300 +/- 41% increased expression of ICAM-1 compared with normoxia. The addition of salicylate (0.02-20 mM) completely inhibited the enhanced expression of ICAM-1, the addition of indomethacin at equivalent concentrations did not reduce ICAM-1 expression under either condition. CONCLUSION: ICAM-1 expression is greatly enhanced by the hypoxic endothelial cell in the presence of circulating endotoxin. Pre-treatment with salicylate completely abolishes the enhanced expression. The study suggests that salicylate administered before cardiopulmonary bypass might protect the heart against ischemic/reperfusion injuries and reduce the load of the overall inflammatory reaction.
Blotting, Western↗
Endoluminal vessel reconstruction by stent placement in patients with obstructive coronary artery disease who are poor surgical candidates.
OBJECTIVE: To investigate the safety and efficacy of endoluminal vessel reconstruction by intracoronary stenting in patients with single or multivessel disease who have been turned down for surgical revascularisation. DESIGN: An observational, single centre trial of consecutive patients being followed up clinically. SETTING: Tertiary referral centre. PATIENTS: 43 patients treated between 1995 and 1996 with a clinical follow up period of at least six months. MAIN OUTCOME MEASURES: Acute procedural success following intervention (defined as a residual stenosis of < 30% with normal antegrade flow and without acute clinical complications); major adverse clinical events (death, myocardial infarction, repeat intervention, clinical restenosis); and functional status during follow up. RESULTS: Acute procedural success was achieved in 39 patients. Failures resulted from a refractory no reflow phenomenon with Q wave myocardial infarction (two patients), and from subacute stent thrombosis (one patient) and saphenous vein graft rupture at stent site (one patient), both manifesting by non-Q wave myocardial infarction. During a follow up period of 17 (8) months (mean (SD)), three of these patients died. Clinical restenosis was treated by repeat percutaneous intervention in 11 patients, while 28 patients remained asymptomatic. On a Kaplan-Meier estimate, the proportion of patients without adverse clinical events at two years was 65%. CONCLUSIONS: Percutaneous reconstruction of diseased coronary arteries in patients with single or multivessel disease turned down for surgical revascularisation may be considered as a valuable treatment option. On follow up, more events seem to be encountered than after elective de novo stenting of discrete coronary lesions. This is probably related to higher clinical restenosis rates.
Aged↗
CT appearances of hepatic involvement in systemic varicella-zoster.
In a patient suffering from T-cell non-Hodgkin's lymphoma and systemic varicella-zoster, contrast enhanced CT showed multiple hypodense nodular lesions in the liver which corresponded to areas of focal liver necrosis. This appearance on CT may be characteristic of varicella-zoster involvement of the liver.
Female↗
Endobronchial lipomatous hamartoma: a rare cause of bronchial occlusion.
A 74-year-old man presented with shortness of breath and vague chest pain. A chest roentgenogram showed subtotal atelectasis of the upper lobe of the left lung and a CT scan revealed an occlusion of the bronchus of the upper lobe of the left lung by an intraluminal tumor. A well-circumscribed yellow tumor obstructing the bronchus of the upper lobe of the left lung was seen by fiberoptic bronchoscopy. Biopsies revealed mature fat tissue and small areas with bone consistent with the diagnosis of an endobronchial predominantly lipomatous hamartoma.
Aged↗
[How to do: initial experiences with a new device in minimally invasive heart surgery].
A special surgical technique is required for minimal-invasive cardiac surgery. The view for the coronary artery anastomosis under beating heart conditions is important and coronary artery blood might prevent a clear view of the opened coronary artery vessel. A new system called VisoFlo promises to improve visualisation at the surgical site. VisoFlo delivers a column of air to help provide a clear view of anastomosis site and in addition has a controllable mist to help prevent desiccation of the graft and surrounding tissue. This system was tested on 45 patients with coronary-artery-bypass graft surgery under beating heart conditions and at 65 patients with standard coronary-artery-bypass graft surgery. Our conclusions are, that the VisoFlo system is easy to use, guarantees a clear view of the anastomosis site and the surgical work will not be impaired.
Anastomosis, Surgical↗
Tissue engineering: a new approach in cardiovascular surgery--seeding of human fibroblasts on resorbable mesh.
INTRODUCTION: In tissue engineering the material properties of synthetic compounds are manipulated to enable delivery of dissociated cells onto a scaffold in a manner that will result in in vitro formation of new functional tissue. The seeding of human fibroblasts on resorbable mesh is a precondition of a successful creation of human tissue such as autologous cardiac valves. MATERIAL AND METHODS: Polymeric scaffolds (n = 12) composed of polyglycolic acid (PGA) with a fiber diameter of 12-15 mm and a polymer density of 70 mg/ml were used as square sheets of 0.3 x 1 x 1 cm. Fibroblasts (passage 5), harvested from human foreskin, were seeded (3.4 x 10(6)) and cultured over a 3 week period on a PGA mesh. RESULTS: Microscopic examination of the seeded mesh demonstrated that the human fibroblasts were attached to the polymeric fibers and had begun to spread out and to divide. Electron microscopy showed a continuous distribution and formation of the cells throughout the "polymeric architecture". Spotlike hydrolysis of PGA fibers was observed. After 3 weeks the seeded scaffolds resembled a solid sheet of tissue. CONCLUSION: These preliminary results, successful seeding of human fibroblasts on a PGA mesh, represent a first basic step on the way to construct human tissue such as autologous cardiac valves and demonstrate that tissue engineering might be a promising new device in therapy of cardiovascular disease.
Cells, Cultured↗
[The significance of endothelial adhesion molecules in heart surgery].
Myocardial ischemia and reperfusion is a common event in cardiovascular surgery patients. The endothelium has been shown to play a key role in the injury suffered after ischemia and reperfusion. When endothelial cells became hypoxic followed by reoxygenation they become activated to express endothelial adhesion molecules followed by the migration of neutrophils into the tissue. These changes may contribute to the early postoperatively myocardial dysfunction. An increased understanding of the interaction between leukocytes and endothelium may allow to develop new therapies in future.
Animals↗
[Long-term follow-up after implantation of a coronary endoprosthesis].
UNLABELLED: The authors analysed the long-term clinical and angiographic follow-up of patients after coronary stenting for the treatment of coronary stenosis of a native artery or vein graft. BACKGROUND: The need for revascularization at 6 months and the restenosis rate were decreased after coronary stenting, compared to the conventional percutaneous angioplasty. This benefit appears to persist in the longer term. METHOD: The incidence of major clinical and angiographic complications was evaluated in 129 patients with a minimum follow-up of 3 years. RESULTS: At 6 months, 20% of patients presented a major clinical complication and restenosis was documented in 20% of cases. In the long-term, a major cardiac event was observed in 49% of cases (death: 16%, infarction: 5%, coronary artery bypass graft: 12% and another angioplasty: 16%). Patients treated by stenting during coronary artery bypass graft had a significantly lower survival (60% versus 88%), and a higher incidence of major clinical complications (55% versus 18%), and a higher stent revascularization rate (41% versus 16%). CONCLUSION: The late stent revascularization rate was low. Overall survival was significantly higher in patients treated for a native vessel than in those treated for a coronary artery bypass graft. The complication rate and stent revascularization rate were also significantly lower.
Aged↗
[Percutaneous versus surgical revascularization of isolated lesions of the proximal anterior interventricular artery. Five-year follow-up of a prospective randomized study].
The authors report the results of 5 years follow-up of 134 patients who benefited from percutaneous transluminal coronary angioplasty 5PTCA) or surgical intervention with implantation of the internal mammary artery as treatment of an isolated lesions of the proximal left anterior descending artery with normal left ventricular function. Sixty-eight patients underwent PTCA (group 1) and 66 had surgical bypass (group 2). The demographic data of the two groups was comparable. The incidence of the following events was analysed: death, myocardial infarction, indication for further revascularisation and functional class. At 5 years, the global mortality was 6% (8% in group 1 and 2% in group 2) but cardiac mortality was only 1% (1 patient in each group). The cumulative incidence of myocardial infarction was higher after angioplasty (15% vs 5%) but was mainly related to acute occlusions or acute coronary syndromes during angioplasty. However, the incidence of Q wave infarction was similar in the two groups. During follow-up, 32 patients (26 in group 1 and 6 in group 2) required one or more additional revascularisation procedures of the left anterior descending or of another artery. The proportion of asymptomatic patients at 5 years was high and similar in both groups. Finally, the proportion of patients without events during follow-up was 56% in group 1 and 86% in group 2. Despite the risk of restenosis and reoperation associated with angioplasty, this technique is an acceptable therapeutic alternative to surgical revascularisation in patients with isolated stenosis of the left anterior descending artery. Therefore, the therapeutic decision depends on the individual case, the availability of treatment and the patient's preference during consultation.
Angioplasty, Balloon, Coronary↗
Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction: application of magnetic resonance imaging.
BACKGROUND: There are conflicting reports on the effects of training on the remodeling process in post-myocardial infarction patients with ventricular damage. METHODS AND RESULTS: Twenty-five patients with reduced ventricular function (mean ejection fraction, 32.3+/-6%) after an anteroseptal or inferolateral myocardial infarction were randomized to an exercise group (n=12) or a control group (n=13). Patients in the exercise group resided in a rehabilitation center for 2 months and underwent a training program consisting of two 1-hour sessions of walking daily, along with four monitored 45-minute sessions of stationary cycling weekly. Before and after the study period, maximal exercise testing and cardiac MRI were performed. Oxygen uptake increased 26% at maximal exercise (19.7+/-3 to 23.9+/-5, P<.05) and 39% at the lactate threshold (P<.01) in the exercise group, whereas control values did not change. No differences were observed within or between groups in MRI measures of end-diastolic (187+/-47 pre versus 196+/-35 mL post in the exercise group and 179+/-52 pre versus 180+/-51 mL post in the control group), end-systolic volume (118+/-41 pre versus 121+/-33 mL post in the exercise group and 119+/-54 pre versus 116+/-56 mL post in the control group), or ejection fraction (38.0+/-9 pre versus 38.2+/-10% post in the exercise group and 37.0+/-10 pre versus 38.3+/-13% post in the control group). Myocardial wall thickness measurements at end diastole and end systole and their difference in 80 myocardial segments determined by MRI yielded no significant interactions between groups. When myocardial wall thickness measurements were classified by infarct or noninfarct areas, no differences were observed between groups over the study period. CONCLUSIONS: A high-intensity, 2-month residential cardiac rehabilitation program resulted in substantial increases in exercise capacity among patients with reduced left ventricular function. In contrast to some recent reports, the training program had no deleterious effects on left ventricular volume, function, or wall thickness regardless of infarct area.
Exercise Test↗
[Early results in the surgical treatment of type B aortic dissection].
In contrast to type A aortic dissection, the indication for acute surgical repair as treatment of choice in type B aortic dissection is not the actual dissection, but the complications resulting from the dissection (rupture, potential rupture and ischemic syndromes of the aortic branches). Between 1978 and 1994, 92 patients underwent surgical repair of type B aortic dissection at our institution. Following diagnostic confirmation by echocardiography and/or CT scan, all patients received conservative antihypertensive therapy. 52% of the patients underwent emergency surgical repair. Symptoms prompting surgical repair were: visceral ischemia (23%), pleural effusion (19%), paraparesis (17%), refractory hypertension (12%), further aortic enlargement (12%), and rupture (10%). In chronic type B aortic dissection, the main symptom in 84% of the cases was further enlargement of the aorta. The early mortality decreased in the course of initial treatment from 33% to 16%, and to 8% after exclusion of patients operated on for ruptured aorta. Improved early mortality has led to an increase in acute surgical repair. In cases of chronic dissection, strict antihypertensive therapy is indicated and regular checks on the width of the aorta, as well expeditious diagnostic confirmation of its enlargement, are important.
Acute Disease↗
[Reconstructive plastic surgery of thoracic wall defects].
Full-thickness defects of the thoracic wall following tumor resection, irradiation damage or secondary wound healing in thoracic surgery require early interdisciplinary cooperation to achieve patient-specific treatment modalities. Plastic surgical differential therapy allowing for sufficient soft tissue coverage, stabilisation of the thoracic wall and space filling in intrathoracic cavities, is presented and critically discussed.
Adult↗
Stenting within a stent: treatment for repeat in-stent restenosis in a venous graft.
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Aged↗
Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective?
OBJECTIVE: In a prospective, randomized study, postoperatively prolonged antibiotic prophylaxis is evaluated in a high-risk group of patients undergoing cardiac operations. These patients had postoperative low cardiac output necessitating inotropic support and intraaortic balloon pumping. METHODS: Between January 1991 and 1994, 53 patients were enrolled in the study (42 men, mean age 65 years). All patients received the usual perioperative (24 hours) cefazolin prophylaxis. In the study group (n = 28) a prolonged regimen of prophylaxis with ticarcillin/clavulanate was performed for 2 days and vancomycin was added in a low dose until removal of the intraaortic balloon pump. The control group (n = 25) did not receive a prolonged regimen of prophylaxis. Follow-up ended at hospital discharge. RESULTS: Early mortality was 7 of 28 patients (25%) in the prophylaxis group and 8 of 25 patients (32%) in the control group (p = 0.397). Defined infections (pneumonia, n = 22; sepsis, n = 8; deep sternal wound infection, n = 2) occurred in 50% of the study group and 68% of the control group (p = 0.265). In all patients with septicemia, only coagulase-negative staphylococci could be isolated from the bloodstream (5 patients in the prophylaxis group vs 3 in the control group). Infectious parameters were controlled daily and did not differ significantly between groups. A total of 1158 bacteriologic tests were performed (blood cultures, n = 389; intravascular catheters, n = 208; bronchial aspirates, n = 411; intraaortic balloon pumps, n = 42; wound secretions, n = 108) showing bacterial growth in 322 (28%) without a significant difference between the groups. In the prophylaxis group, 13 intravascular catheters and intraaortic balloon pumps showed bacterial growth versus 11 in the control group. No side effects were seen. CONCLUSIONS: In a high-risk group of patients undergoing cardiac operations, infectious outcome could not be effectively influenced by an additional and prolonged postoperative prophylaxis regimen with low-dose vancomycin and ticarcillin/clavulanate. Low-dose vancomycin did not reduce the rate of infections or colonizations of intravascular catheters with gram-positive organisms.
Aged↗
New approach to patency and flow assessment after left internal thoracic artery hypoperfusion syndrome with additional saphenous vein graft to the left anterior descending artery with phase-contrast magnetic resonance angiography.
OBJECTIVE: Perioperative and early postoperative flow reduction of a left internal thoracic artery conduit is a rare complication of myocardial revascularization and may lead to the potentially fatal left internal thoracic artery hypoperfusion syndrome. It has been advocated that an additional vein graft be placed to the distal left anterior descending artery to provide sufficient myocardial perfusion. Some evidence exists, however, that this high-flow vein might lead to competing or even backward flow through the internal thoracic artery. METHODS: In the past 2 years, 21 patients received an additional vein graft to the distal left anterior descending artery for left internal thoracic artery hypoperfusion syndrome. Nineteen of these patients were available for magnetic resonance imaging. Early (< 6 months) and late (> 12 months) postoperative flow measurements, both in the left internal thoracic artery and in the saphenous vein grafts, were performed by means of conventional and a segmented k-space phase-contrast magnetic resonance angiography technique. RESULTS: Early magnetic resonance examinations indicated that all conduits had adapted to the coronary flow type with predominant diastolic perfusion. Patency rate both at the early and at the late study was 100%. No concurrent flow, flow reversal, or steal phenomena were observed. Mean flow rates were 49.2 ml/min for the left internal thoracic artery and 72.6 ml/min for the saphenous vein graft. CONCLUSION: On the basis of the flow data obtained with magnetic resonance angiography, the use of an additional saphenous vein graft as the treatment of choice in left internal thoracic artery hypoperfusion syndrome does not lead to occlusion of the artery. Conduit flow adaptation to the diastolic predominance occurs in the first 6 months after operation.
Coronary Vessels↗
Alveolar soft part sarcoma: report of a case occurring in the larynx.
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Diagnosis, Differential↗