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Biomedical subjects

R Siebenmann

Publications and source records attributed to R Siebenmann.

At least 19 recordsLinked to original sources

[Surgery of mitral valve insufficiency. Results of 10 years].

From 1987 to 1996 we operated on 263 patients for mitral insufficiency. Multiple valve operations were excluded, with the exception of tricuspid reconstruction for functional regurgitation. The perioperative mortality was 3%, while the late mortality rate during a mean follow-up period of 3.5 years amounted to 2% per patient year and 1.7% if only cardiac causes were considered. The prognosis for patients with rheumatic, endocarditic and ischemic valvular disease was much worse compared to that for a degenerative cause. The latter group consisted of 209 patients with an operative mortality of 1.4% and a late mortality rate per patient year of 1.4% and 0.9% for cardiac causes only. Further analysis showed a significant prognostic improvement for patients with a preoperative ejection fraction of more than 60% and a repairable valve.

Adult

[Cerebral insult in heart surgery].

The aim of the study was to identify causes for perioperative stroke in cardiac surgery in order to reduce its occurrence. From 1989 to 1994, 3593 open heart operations were performed in adult patients. In 59 patients carotid endarterectomy for high grade stenosis was combined with the cardiac operation. There were a total of 68 (2%) focal strokes, 41 of which were considered minor and 14 major; 13 were lethal. The etiology of the 27 major and lethal events was most probably an embolus from the ascending aorta (6), from the ascending aorta or a cardiac valve (5), a thrombus in the left heart (6), air (1), cardiac arrest and resuscitation (4), cerebral hemorrhage (1), preoperatively unknown but high grade internal carotid stenosis (3), and a 50% stenosis of both internal carotid arteries preoperatively known but not operated on (1). There were 2 minor but no major neurologic complications in patients undergoing a combined carotid and cardiac procedure. A wide indication for preoperative neuroangiologic examination, echocardiography and careful intraoperative management may help to identify sources of possible emboli. Endarterectomy of high grade carotid stenosis is recommended simultaneously with the cardiac procedure.

Adult

[Acquired heart diseases and pregnancy].

Understanding of the mechanisms of cardiovascular and hemodynamic adaptation during pregnancy helps to prevent or manage complications in cardiac patients during gestation. Manifestations of coronary heart disease are exceptional during pregnancy and delivery. The same is true of disorders of the pericardium. Peripartal cardiomyopathy is a myocardial disorder of undetermined cause occurring shortly before, during or after delivery, which may take a fatal course. Hypertrophic obstructive or non-obstructive cardiomyopathy is compatible with gestation and delivery without serious complications in most cases. Rheumatic mitral stenosis was the most common cardiac disorder until the 1950s. Nowadays it is rarely seen in this country. Surgical and other interventional therapies have greatly changed the outlook in pregnant women with valvular heart disease. A highly controversial issue is heart valve replacement in young women and management of anticoagulation during pregnancy. Like any other drug therapy, anticoagulation during gestation requires careful weighing of the benefit for the mother against toxic and teratogenic effects for the fetus. In women with heart disease the management of pregnancy should start, if possible, before conception. Thorough counseling and proper planning of pregnancy and of therapeutic measures is essential in order to avoid or manage complications.

Abnormalities, Drug-Induced

Development of nitrate tolerance in human arteries and veins: comparison of nitroglycerin and SPM 5185.

Nitrate tolerance is a clinical problem in patients with coronary artery disease and heart failure. Human internal mammary arteries and saphenous veins obtained intraoperatively were suspended in organ chambers, and isometric tension was measured. In the artery, nitroglycerin elicited a potent relaxation, which was significantly diminished after prolonged incubation with nitroglycerin (10(-6) M, 1 h). In contrast, no tolerance occurred in saphenous vein under the same conditions. However, incubation with 10(-5) M nitroglycerin also developed tolerance. Compared to nitroglycerin, the new cysteine-containing mononitrate SPM 5185 exhibited a lower sensitivity but comparable maximal relaxation in arteries and veins. In nitroglycerin-tolerant arteries and veins, SPM 5185 caused relaxations similar to those under control conditions. Our results show that in isolated blood vessels, vascular nitrate tolerance occurs more readily in the mammary artery than in the saphenous vein. SPM 5185 seems to be less prone to the development of tolerance, which may be advantageous during chronic nitrate therapy.

Acetylcysteine

Both ETA and ETB receptors mediate contraction to endothelin-1 in human blood vessels.

BACKGROUND: Endothelin (ET)-1 has potent vascular effects. Two endothelin receptors have been cloned, namely, the ETA receptor, which preferentially binds ET-1, and the ETB receptor, which equally binds ET-1 and ET-3 and preferentially sarafotoxin S6c. We characterized endothelin receptor subtypes on vascular smooth muscle and endothelium of isolated human internal mammary artery (IMA) and vein (IMV) and porcine coronary artery (PCA) using the ETA antagonists FR139317 and BQ-123, the ETB ligand sarafotoxin S6c, and the ETA/ETB antagonist Ro 47-0203 (bosentan). METHODS AND RESULTS: In endothelium-denuded IMA and PCA and less so in IMV, FR139317 and BQ-123 (in PCA only) shifted the concentration-contraction curves to ET-1 parallel to the right. However, even at 10(-5) mol/L, FR139317 did not inhibit a high-sensitivity portion of the concentration-contraction curve. Moreover, the ETB receptor agonist sarafotoxin S6c induced contraction in vessels preincubated with FR139317. IMV was significantly more sensitive to the contractile effect of ET-1 and sarafotoxin S6c than was IMA (P < .05). Prolonged incubation with sarafotoxin S6c (to downregulate ETB receptors) and FR139317 eliminated the contraction resistant to FR139317. The ETA/ETB receptor antagonist bosentan caused a parallel shift of the concentration-contraction curve to the right at all concentrations of endothelin. ETB receptor mRNA was detected by Northern blot analysis in IMA and aortic smooth muscle cells. In precontracted IMA and PCA with endothelium, sarafotoxin S6c did not cause endothelium-dependent relaxations, whereas transient responses occurred in IMV. CONCLUSIONS: Vascular smooth muscle cells of human IMA, IMV, and PCA contain both ETA and ETB receptors, whereas the endothelium of IMA and PCA does not express functional ETB receptors linked to nitric oxide and/or prostacyclin production. Hence, inhibition of endothelin-induced contraction in patients requires the use of combined ETA/ETB antagonists.

Animals

Thrombin-induced endothelium-dependent inhibition and direct activation of platelet-vessel wall interaction. Role of prostacyclin, nitric oxide, and thromboxane A2.

BACKGROUND: Platelet-vessel wall interaction plays an important role in acute cardiovascular disorders. Thrombin is a potent platelet activator but also has profound effects on the endothelium. Endothelial cells possess antithrombotic activity by releasing nitric oxide and prostacyclin, both potent vasodilators and platelet inhibitors. We studied the role of thrombin as a regulator of platelet-vessel wall interaction in isolated human arteries suspended in organ chambers for isometric tension recording. METHODS AND RESULTS: In arteries with endothelium, thrombin (0.01 to 1 U/mL) induced endothelium-dependent relaxations, which were reduced by the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 10(-4) mol/L) and/or indomethacin (10(-5) mol/L). Human platelets (75,000/microL) evoked only marginal contractions in arteries with endothelium (3 +/- 3% of the contraction to KCl 100 mmol/L; NS), which were markedly enhanced by endothelial removal (22 +/- 4%; P < .05). Thrombin (1 U/mL) did not affect the response to platelets in arteries with (6 +/- 5%; NS) but induced a huge contraction in rings without endothelium (53 +/- 6%; P < .01 versus control without endothelium). The potent contraction to thrombin-activated platelets (1000 to 75,000/microL) in arteries without endothelium was markedly inhibited by the thromboxane A2 synthetase/receptor antagonist ridogrel (10(-5) mol/L; P < .005 versus control) and the single-acting thromboxane receptor blocker SQ-30741 (10(-7) mol/L; P < .01 versus control). CONCLUSIONS: Thus, thrombin directly stimulates platelets to release thromboxane A2, inducing potent vasoconstriction, which is prevented by the simultaneous thrombin-induced release of prostacyclin and nitric oxide from endothelial cells. In arteries devoid of functional endothelial cells, as occurs in patients with coronary artery disease, a combined inhibition of thromboxane production and action provides a potent therapeutic tool to interfere with the thrombin-induced activation of platelet-vessel wall interaction.

Coronary Vessels

[Work load in occupations].

Fewer subjects return to work after acute myocardial infarction or a cardiac surgical procedure than one would expect from the results of their medical examinations and cardiac tests. To decide whether a patient is able to return to work, one has to assess his individual prognosis and measure his maximal physical working capacity without cardiac dysfunction. Psychological and socioeconomic aspects have also to be considered. Recommendations are presented for practical procedure in assessing the ability of a patient to return to work.

Adaptation, Psychological

The internal mammary artery 'string phenomenon'. Analysis of 10 cases.

The internal mammary artery (IMA) string sign has been described as a narrowing of IMA grafts in the late course after coronary artery bypass grafting. It has been assumed that this phenomenon was due to competitive flow in grafts connected to only mildly stenosed coronary arteries. We analyzed 10 cases of IMA string sign operated on between March 1988 and June 1991. Bilateral IMA was used in six cases and unilateral IMA in four. The mean interval between operation and reangiography was 14 +/- 11 months. String sign of the whole length of the IMA was detected in nine cases, and of the distal part between two sequential anastomoses in one. In all cases, the stenosis of the vessel bypassed with the narrowed graft proved to be only mild (50% or less) at reangiography. In all six cases with bilateral IMA grafts, the contralateral IMA was widely patent. These were all connected to highly stenosed or occluded coronary arteries. With respect to this observation, there is a high index of suspicion that the string phenomenon occurs due to competitive flow in only mildly stenosed coronary arteries. We decided, for our strategy in coronary artery surgery, still to aim at complete revascularization using IMAs as much as possible, but to avoid connecting IMA grafts to only mildly or moderately stenosed coronary arteries.

Coronary Angiography

Different effects of angiotensin-converting enzyme inhibition in human arteries and veins.

The renin-angiotensin system (RAS) participates in the regulation of vascular tone; its effects were studied in human internal mammary artery (IMA) and saphenous vein (SV) suspended in organ chambers for isometric tension recording. The angiotensin-converting enzyme (ACE) inhibitor enalaprilat (10(-7) M) markedly augmented endothelium-dependent relaxations to bradykinin in SV (concentration shift: 10-fold; n = 6; p < 0.005), but not in IMA; in both blood vessels, it had no effect on endothelium-dependent relaxations to acetylcholine. The contractions to angiotensin I (Ang I; 10(-7) M) were markedly inhibited by enalaprilat (10(-7) M) in SV (control: 34 +/- 6% of 100 mM KCl; treatment: 18 +/- 6%; n = 7; p < 0.05) but not in IMA (control: 33 +/- 4%; treatment: 30 +/- 6%; n = 7; NS) and abolished by the Ang II receptor antagonist DuP 753 (10(-7) M) in both blood vessels. Ang II (10(-7) M) induced more pronounced contractions than Ang I in IMA (63 +/- 4%) and SV (63 +/- 5%; n = 5-6; p < 0.05 vs. Ang I), which was markedly inhibited by DuP 753 (10(-7) M; IMA: 21 +/- 5%; SV: 32 +/- 5%; p < 0.05). Thus, in SV but not IMA, ACE inactivates bradykinin and thereby blunts endothelium-dependent relaxations to the peptide and converts Ang I to Ang II.

Acetylcholine

Similar endothelium-dependent relaxation, but enhanced contractility, of the right gastroepiploic artery as compared with the internal mammary artery.

The right gastroepiploic artery is an alternative coronary bypass graft. The excellent graft function of the internal mammary artery has been related to its physiologic properties, particularly to endothelial function. Isolated artery rings were suspended in organ chambers for recording of isometric tension. Norepinephrine and potassium chloride evoked threefold greater contractions in the gastroepiploic artery than in the mammary artery (p less than 0.01 to 0.05), whereas the sensitivity to the catecholamine was comparable. Acetylcholine induced endothelium-dependent relaxations, but the sensitivity (pD2: 6.7 +/- 0.3) and maximal relaxation (81% +/- 9%) were slightly less in the gastroepiploic artery than in the mammary artery (pD2: 7.6 +/- 0.2; 100% +/- 0%; p less than 0.05). Histamine induced endothelium-dependent relaxations with a similar sensitivity (pD2: 7.5 +/- 0.3 and 7.2 +/- 0.1), whereas the maximal relaxation was slightly enhanced in the gastroepiploic artery. The relaxation to the nitric oxide donor SIN-1 was identical in the two arteries. Thus the right gastroepiploic artery exhibits better contractility than the internal mammary artery but comparable endothelium-dependent and endothelium-independent relaxations. The good endothelial function of the gastroepiploic artery might be important for graft function and patency, whereas the enhanced contractility may facilitate vasospasm, especially in the presence of high circulating levels of catecholamines.

Acetylcholine

[Developments in mitral valve surgery].

Between 1987 and 1990 we operated on 104 patients for mitral valve disease. If possible the valve was reconstructed according to CARPENTIER's technique: 8 of 28 stenotic, 43 of 57 regurgitant and 2 of 7 mixed lesions were repaired. Twelve patients underwent re-replacement of a previously inserted mitral prosthesis. Six patients died early (7.8% after replacement, 8% after isolated replacement, 3.7% after repair and 2% after isolated repair). Five of these six patients were in NYHA class IV preoperatively. Seven patients died late after a mean observation period of 18 months (5 after replacement, 1 after double valve replacement and 1 after repair and multiple coronary bypass surgery). Prognosis is best for patients whose valve can be repaired and who are not already in NYHA class IV. The postoperative NYHA class for surviving patients is excellent (1.3 in the replacement group and 1.2 after repair).

Adult

[Use of the right gastroepiploic artery as a coronary bypass graft. Indications, technique and early results].

435 isolated coronary artery procedures have been performed between January and December 1989 at the HerzZentrum Hirslanden. In 93% of the cases, one or two internal mammary arteries (IMA) and in 7%, saphenous vein grafts only were used as a bypass conduit. In 12 patients, the right gastroepiploic artery (RGE) was used as a free (3) or pedicled (9) graft to the posterior surface of the heart. This group of 12 patients was analyzed in a retrospective study. Postoperative complications in this group included one myocardial infarction and reexploration for intraabdominal bleeding in the same patient. All patients were discharged from hospital after an average of 9.7 days. After a mean follow-up time of 5 months, all patients are in NYHA-functional class I without antiischemic drugs. Postoperative angiography in 7 patients (mean postoperative interval 4 months) showed all 13 IMA-grafts and 5 RGE-grafts patent, 1 RGE-conduit is occluded, 1 RGE-graft could not been assessed for technical reasons. The RGE is an viable additional arterial bypass conduit and an alternative to other grafts. Indications for use of the RGE are lack of sufficient other conduits, calcified ascending aorta, coronary reoperation after vein graft failure and probably young patients with severe hyperlipidemia.

Arteries

[Emergency surgery for PTCA complications: tactics and results].

Incidence, risk and results of emergency coronary bypass surgery after failed percutaneous transluminal coronary angioplasty (PTCA) have been analyzed in a retrospective study. Failed PTCA has been defined as visible pathology (dissection, occlusion) of the dilated vessel associated with acute chest pain and ECG changes. From 3-1-1987 to 11-30-1990, 23 patients of 433 (5%) underwent emergency surgery for failed PTCA (19 male, 4 female, mean age 55 +/- 8 years). PTCA was performed in 16 cases of one-vessel-disease, 3 cases of two-vessel-disease and 4 cases of three-vessel-disease. All had an ejection fraction beyond 40%. 19 patients remained in stable hemodynamic condition. In average 2.1 vessels have been bypassed; in 13 cases the internal mammary artery (IMA) has been used, in 10 cases the saphenous vein (VSM) only. No early nor late death occurred. The perioperative infarction rate is 30%. Comparing the group with IMA and the group with VSM only, no difference could be found regarding the number of unstable hemodynamics, the use of catecholamines nor the perioperative infarction rate. After a mean follow-up period of 14.3 months, 21 patients are in NYHA class I, 2 in NYHA class II. Emergency coronary bypass surgery can be performed with low risk and favorable results, if the operation is timed without delay after the onset of acute chest pain and ECG changes in failed PTCA. The infarction rate is remarkably higher than in elective coronary surgery. The use of the IMA seems to be no additional risk factor.

Angioplasty, Balloon, Coronary

Interaction between endothelin-1 and endothelium-derived relaxing factor in human arteries and veins.

Endothelin-1 is a 21-amino acid endothelial vasoconstrictor peptide that may be the physiological antagonist of endothelium-derived relaxing factor (EDRF). Endothelin-1 (10(-11)-3 x 10(-7) M) evoked potent contractions of isolated internal mammary arteries, internal mammary veins, and saphenous veins, which were enhanced in internal mammary veins as compared with internal mammary arteries (concentration shift, 6.3-fold; p less than 0.05) but not in the saphenous veins. Endothelial removal augmented the response to the peptide (at 3 x 10(-7) M) in internal mammary arteries (p less than 0.05) but not in veins. In the artery, EDRF released by acetylcholine or bradykinin reversed endothelin-1-induced contractions; in saphenous veins, both agonists were much less effective compared with the artery and veins contracted with norepinephrine (p less than 0.005-0.01). This inhibition of endothelium-dependent relaxations in veins occurred at half-maximal contractions but was most prominent at maximal contractions to the peptide. Nitric oxide similarly inhibited contractions to endothelin-1 and norepinephrine in internal mammary arteries, whereas in veins that were contracted with endothelin-1 but not with norepinephrine, the relaxations were blunted (p less than 0.005). The nitric oxide donor SIN-1 and sodium nitroprusside induced complete relaxations of internal mammary arteries but were less effective in veins contracted with endothelin-1 (p less than 0.005). Thus, in normal human arteries, EDRF inhibits endothelin-1-induced contractions, whereas the peptide specifically attenuates the effects of EDRF and nitrovasodilators in veins. This may be important in pathological conditions associated with increased levels of endothelin-1 and in veins used as coronary bypass grafts.

Acetylcholine

[Results of the initial 50 heart transplantations in Zurich].

During the first 40 months of the new Heart Transplantation Program (September 1985 until December 1988) a total of a 160 patients were evaluated for transplantation at the University Hospital in Zurich. 50 patients eventually came to heart transplantation, while one patient underwent a heart-lung transplant. In the same period 9 patients accepted for transplantation died on the waiting list before transplantation. All 50 hearts were transplanted orthotopically. Follow-up treatment, immunosuppression and diagnostics for rejection are described. There was no operative mortality in this group. Two patients died early and three died late. For the first consecutive 50 heart transplant patients, showing a total of 732 patient months, actuarial survival was calculated at 90.1% at one and two years, and at 79.5% at three years. "Enlarged Heart Transplantation Program" describes some of the secondary activities spurred by the new Heart Transplantation Program.

Actuarial Analysis

Late failure of systemic ventricle after atrial correction for transposition of great arteries.

The incidence of late systemic ventricular failure (SVF) was determined in 220 early survivors of atrial correction for transposition of great arteries (TGA), operated upon between 1964 and 1985. SVF was defined as either severe heart failure (NYHA class III or IV) or death due to the same cause, in the absence of other haemodynamic disturbances. The actuarial survival rate was 96% after 1, 94% after 5 and 87% after 10 years. SVF occurred in 16/220 patients (7.2%). SVF was more common in complex TGA (TGA + VSD or PS or both) with 11/99 patients (11%) than in simple TGA with 5/121 patients (4.1%), P less than 0.01. Actuarial freedom from SVF was 97% at 5, and 92.5% at 10 years. SVF caused 10/25 (40%) late deaths. SVF occurred from the 1st postoperative year up to 20 years after correction (average interval 6.3 years). In 1 of 2 patients a systemic atrioventricular (AV) valve annuloplasty did not improve SVF. Heart transplantation was performed in 2 patients and 1 is on the waiting list. SVF is a rare late complication of atrial correction for TGA with a constant incidence in the late course. SVF is more common in complex TGA.

Actuarial Analysis

Postinfarction ventricular septal defect--surgical strategies and results.

Twenty consecutive patients with postinfarction ventricular septal defect (VSD) were subjected to surgery: there were 8 females and 12 males with a mean age of 67 +/- 9 years. Nine acute patients developed cardiogenic shock, and intra-aortic balloon pump was started before surgery (with IABP). Eight acute patients showed preoperatively relatively stable hemodynamics, and surgery was feasible without previous use of the intra-aortic balloon pump (without IABP). The interval between myocardial infarction and surgery was 13 days for 17 acute cases. In the group with IABP the interval was 8 +/- 5 days versus 19 +/- 11 days in the group without IABP (p less than 0.025). VSD patch closure was performed in 20/20, resection of infarct in 10/20, transventricular approach without resection of infarct in 3/20, patch enlargement of the left ventricle in 2/20, plicature of an aneurysm in 3/20, aorto-coronary bypass in 10/20 (number of bypasses: 2.1 +/- 1.3) and mitral annuloplasty in 1/20. The perioperative 30 days mortality was 5/20 (25%) for the whole series. In the group with IABP mortality was 4/9 (44%) versus 1/8 (13%) in the group of acute patients without IABP (p less than 0.05). Mean follow-up for the 15 surviving patients was 1.7 +/- 1.0 years. Two patients died during the first year, one of them due to carcinoma. After 1 year, mean NYHA functional class was assessed 1.5 +/- 0.6. One patient showed a residual VSD which was closed surgically. Immediate closure of a postinfarction ventricular septal defect is the therapy of choice of this complication of acute myocardial infarct with a natural history showing an extremely high mortality.

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