["Necessary" diagnostic procedures in traumatic aortic rupture, acute dissecting and chronic aortic aneurysms].
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Acute Disease↗
Biomedical subjects
S Hagl
Publications and source records attributed to S Hagl.
[Surgical treatment of acute endocarditis--which preoperative diagnosis does the surgeon need?].
In a group of 140 patients undergoing operation for acute infectious endocarditis in an 8-year period, the value of preoperative diagnostic procedures was analyzed in a retrospective study. Echocardiography was sufficient to establish the diagnosis in each case, angiography did not add any information about the endocarditis, but detected severe coronary heart disease in 19 patients. Abdominal sonography is mandatory to exclude intestinal foci, while CT scan of the brain only has to be performed in patients with neurologic deficits.
Acute Disease↗
Tricuspid valve reconstruction, a treatment option in acute endocarditis.
Tricuspid valve endocardititis is treated surgically by total valve excision or valve replacement. Both procedures are controversial with regard to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated on for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n = 4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in six and hemodynamically relevant tricuspid insufficiency in one out of seven patients. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In eight patients the tricuspid valve endocarditis was treated as follows: debridement, vegectomy, patch reconstruction of the cusps, reducing the cusps to two. In three patients reconstruction was not possible because of extensive involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients primary valve replacement (n = 1) or valve excision with secondary replacement (n = 2) was performed. In four patients tricuspid reconstruction was combined with mitral (n = 1), aortic (n = 1) or double valve replacement (n = 2). Postoperatively, signs of infection vanished in all surviving patients (n = 10) and tricuspid valve endocarditis healed without recurrences. Implanted prosthetic material did not lead to recurrent infection. One patient died early postoperatively after valve excision, in septic shock and multi-organ failure. In seven patients late echocardiographic follow-up showed tricuspid regurgitation grade 0 in three patients, I in two, II in one and III in one. Our results suggest that valve repair is a reasonable treatment option for tricuspid valve endocarditis in all cases with localized infection of the valve. Only if extensive valve destruction excludes valve repair, would we now favor primary valve replacement over simple valvulectomy. In all other cases primary valve reconstruction is the treatment of choice for tricuspid valve endocarditis, if surgery is indicated.
Acute Disease↗
Surgical treatment of acute endocarditis of the aortic valve with paravalvular abscess: considerations justifying the use of mechanical replacement devices.
OBJECTIVE: Early recurrency after surgery for acute endocarditis is a life-threatening complication. Allograft valves are supposed to have a higher resistance to recurrent infection, thus several authors claim them to be the replacement device of choice in cases of aortic endocarditis. However, allografts have two major drawbacks: their availability is limited, and most of the patients require reoperation for graft calcification of degeneration. Until now there has been no prospective study analysing whether early recurrency after surgery of acute endocarditis is associated with the mechanical valve per se or with factors related to the surgical technique or postoperative care. PATIENTS AND METHODS: We present a prospective study on 36 consecutive patients with acute endocarditis of the aortic valve with paravalvular abscesses. In this series, there were 5 women and 31 men with a mean age of 50.3 years. All patients were operated before a course of antibiotic therapy was completed. Abscesses were radically resected and the cavities closed either with direct suture or, if not possible, with Dacron patches. For aortic valve replacement, a mechanical valve was used in every patient. RESULTS: The early mortality in this series was 14%, only one patient experienced recurrent endocarditis and underwent reoperation. The results compare well with those achieved after valve replacements with allograft valves. CONCLUSION: We conclude that, even in cases of acute endocarditis, replacement of the aortic valve with a mechanical device is an acceptable alternative to the allograft, if radical surgical debridement and adequate antibiotic therapy are performed.
Abscess↗
[Biomechanical heart and cardiovascular support].
A surgical association between skeletal muscle and heart muscle dates back to experiments at the beginning of this century. Initially, the use of skeletal muscles aimed at plastic reconstructions of myocardial defects and enhancement of myocardial blood flow. The application of the contractile force of the skeletal muscle failed because of skeletal muscle fatigue. In the late sixties, investigations in muscle physiology demonstrated the "functional plasticity" of muscle tissue: Chronic electrical stimulation induces a transformational process of the cellular organelles, the metabolism, the fiber proteins and the calcium regulatory systems which results in "fatigue resistance" of the muscle. This was is a prerequisite for the application of skeletal muscles for continuous support of the circulation. Biomechanical support of the heart and the circulation is experimentally performed as skeletal muscle ventricles, chronic extraaortic counterpulsation and ventricular and atrial cardiomyoplasty. The electrical stimulation is performed with "burst" impulses, in order to increase the force and the length of contraction. The first clinical application of ventricular cardiomyoplasty is attributed to the French surgeon Alain Carpentier. Clinical investigations show that cardiomyoplasty results in an impressive symptomatic improvement of the patients clinical condition with only moderate changes of objective hemodynamic parameters. Further research will investigate the clinical applicability of the other, thus far only experimental techniques of biomechanical support. The introduction of cardiomyoplasty has induced great scientific interest in all forms of skeletal muscle circulatory support. Close collaboration between basic researchers and clinical investigators is of utmost importance for further developments in this field. The combined international research effort can be expected to yield considerable progress within the forthcoming years.
Animals↗
[Value of dynamic cardiomyoplasty].
The value of dynamic cardiomyopathy in the treatment of end-stage heart failure is controversial. After more than 500 patients have been operated worldwide, the indication and the surgical technique have become more uniform, which makes results from different centers eligible for comparison. We performed cardiomyopathy in patients with contraindications for heart transplantation. Between 8.90-2.94, 8 isolated cardiomyopathy-procedures in patients with cardiomyopathy (EF 14-32%, NYHA III) were performed. One patient died in 2 months after surgery. Reported are the results of 7 patients after a mean follow-up of 41.1 +/- 14.1 months. Considerable symptomatic improvement was found in 6 of 7 patients, 3 of whom went back to work. One patient with severe pulmonary hypertension exhibited no improvement. Mean NYHA-class decreased from 3.0 to 1.9 (p < 0.001). Echocardiography showed an increase in fractional shortening in all patients. LV-EF increased from 21.2 +/- 5.2% to 38.1 +/- 15.9% (n = 7, p < 0.015) at 1 year, to 36.6 +/- 17.6% (n = 6, p < 0.05) at two years and to 36.4 +/- 18.9% (n = 5, NS) at three years. Pulmonary artery pressure tended to decrease at rest over time. No significant change in exercise level and maximal O2-consumption upon treadmill testing was observed. One patient died 34 months after the operation from sudden death. Our preliminary results show, that patients after cardiomyopathy may exhibit an impressive clinical improvement with less striking changes of objective hemodynamic parameters. This data is in mutual agreement with all other investigators. According to the current state of experience with cardiomyopathy, the place for this procedure lies in the treatment of patients with end-stage heart failure and contraindications for heart transplantation. We do not consider cardiomyopathy an alternative to heart transplantation, however, it may receive further importance as a bridge to Htx.
Adult↗
[Dynamic cardiomyoplasty: current status and concepts of the mechanism of action].
Surgical treatment of end-stage heart failure offers heart transplantation as a well established and effective treatment option. In addition, the permanent implantation of left-heart assist-devices is now gaining increasing importance. Yet, both methods also have inherent drawbacks and may not be available to all patients, so that new methods are constantly evaluated. Cardiomyoplasty was introduced into clinical practice 10 years ago, but still lacks general acceptance as a routine method. Worldwide results show a considerable symptomatic improvement with only small effects on systolic cardiac function. Survival rate was significantly improved by careful patient selection. As a mechanism of action the skeletal muscle wrap exerts some active improvement of systolic wall motion of the heart/skeletal muscle-complex. However, probably more important is an acute and chronically persisting shift of the pressure-volume relation to the left. This process results in a "reverse remodeling" of the insufficient heart with an improvement of the "contractility reserve". Cardiomyoplasty is indicated in patients with contraindications to heart transplantation and as a bridge-to-transplantation in patients with ventricular arrhythmia and severely impaired left ventricular function, concomitant with ICD implantation.
Animals↗
[Quality assurance in heart surgery: 8 years experience with a "feedback-control" system in Heidelberg].
An important aspect of quality assurance in cardiac surgery covers the epidemiological analysis of patient data. After an 8 year period of clinical experience with quality assurance, we summarize and evaluate current concepts and actual experiences regarding a special type of database application and organisation ("feedback-control-system") for quality assurance. It had been developed to meet and solve the problems related to the data acquisition process, that are typically present in the clinical routine of quality assurance. In 1988 the "feedback-control-system" was designed and implemented in the Department of Cardiac Surgery at Heidelberg University. Since then it had been continuously improved and adapted to satisfy current needs in cardiac surgery. More than 1500 items are now recorded routinely per patient. At present, detailed information of more than 10,000 patients is available for the specific methods of analysis in the field of quality assurance. The basic concept included 1. the integration of the data acquisition in the daily clinical routine, 2. the evaluation and improvement of collected data material by means of "output-functions", that require previously recorded reliable data (that is automatically computer generated operation reports, letters, statistics, accounting etc.), and 3. to ensure that the medical and non-medical staff members participate in the advantages and the responsibilities of the data-base system for quality assurance. Analyses of perioperative risks and results, early discovery of trends, identification of special subpopulations receiving special types of treatment in cardiac surgery etc. have now become a regularly performed tool in clinical routine. This includes the availability of "problem profiles", "trend analysis", the use of simple concluding statistics as well as the calculation of multivariable models. This internal quality assurance is completed by "multicentric" comparisons with further hospitals already using the same data-base system (external quality assurance). Within 8 years, the feedback-control-system has become a reliable and valuable tool for quality assurance in daily routine. The high acceptance of the database system is related to the advantages it provides for every participant. We conclude that the concept of data evaluation and improvement by means of "output functions" and "integration of data acquisition in clinical routines" has proved to be efficient in everyday practice. The sensitivity and specifity to such a feedback controlled system as a tool for measuring surgical quality, however, still remains a matter requiring further research.
Cardiac Surgical Procedures↗
Residual 201Tl activity in irreversible defects as a marker of myocardial viability. Clinicopathological study.
BACKGROUND: The objective of the present study was to characterize the relation between the residual 201Tl activity in irreversible perfusion defects and the extent of irreversible myocardial damage indicated by the volume fraction of myocardial interstitial fibrosis in patients with chronic coronary artery disease. METHODS AND RESULTS: Stress planar 201Tl scintigraphy with tracer reinjection at rest was performed in 37 patients with > or = 75% stenosis of the left anterior descending coronary artery, and anteroseptal 201Tl activity was quantified by computer-assisted placement of regions of interest from the serial myocardial images. During coronary artery bypass grafting (performed within 6 +/- 3 weeks after scintigraphy), two transmural biopsy specimens were taken from the anterior wall of the left ventricle and the amount of interstitial fibrosis was assessed by use of light microscopic morphometry. A wide spectrum of interstitial fibrosis was obtained, ranging from 15 vol% to 60 vol%. Interstitial fibrosis was similar in patients with reversible (n = 11) or irreversible (n = 15) tracer defects in conventional stress-redistribution images. However, interstitial fibrosis was significantly lower in patients who had enhanced regional 201Tl activity after tracer reinjection compared with those who did not have enhancement of tracer activity after reinjection (28 +/- 8 vol%, n = 7, versus 41 +/- 12 vol%, n = 8; P = .031). The correlation between relative poststenotic 201Tl activity and interstitial fibrosis after tracer reinjection was significantly improved compared with conventional redistribution images (r = -.622 versus r = -.851, n = 15; P < .01). CONCLUSIONS: The present data demonstrate that the level of regional 201Tl activity in redistribution and, in particular, reinjection images is significantly related to the mass of preserved viable myocytes in poststenotic left ventricular myocardium. Therefore, the residual 201Tl activity provides information about viability within irreversible perfusion defects and may itself serve as marker of myocardial viability.
Biopsy↗
Treatment of dilated cardiomyopathy with dynamic cardiomyoplasty: the Heidelberg experience.
BACKGROUND: Data concerning the efficacy of dynamic cardiomyoplasty are still inconsistent, especially in terms of improvement of left ventricular function. METHODS: Between August 1990 and February 1994, eight isolated cardiomyoplasty procedures were performed in patients with cardiomyopathy (ejection fraction, 0.14 to 0.32; New York Heart Association class III) and contraindications to heart transplantation. RESULTS: Follow-up was 41.1 +/- 14.1 months. One patient died 2 months and another 3 years after operation. Considerable symptomatic improvement was found in 6 of 7 patients, 3 of whom went back to work. One patient with severe pulmonary hypertension exhibited no improvement. Mean New York Heart Association-class decreased from 3.0 to 1.9 (p < 0.001). Echocardiography showed an increase in fractional shortening and in peak aortic flow velocity in all patients. Left ventricular ejection fraction increased from 0.21 +/- 0.05 to 0.38 +/- 0.16 (n = 7, p < 0.015) at 1 year, to 0.37 +/- 0.18 (n = 6, p < 0.05) at 2 years, and to 0.36 +/- 0.19 (n = 5, not significant) at 3 years. Pulmonary artery pressure tended to decrease over time. No significant change in exercise level or maximal oxygen consumption during treadmill testing was observed. CONCLUSIONS: Our preliminary results show that patients may exhibit an impressive clinical improvement after cardiomyoplasty, with only moderate changes in objective hemodynamic indices. We do not consider cardiomyoplasty an alternative to heart transplantation, but reserve it for patients with contraindications to heart transplantation.
Cardiomyopathy, Dilated↗
Atrioventricular valve insufficiency and atrial geometry after orthotopic heart transplantation.
BACKGROUND: The etiology of tricuspid and mitral valve regurgitation (TR and MR) after heart transplantation is still controversial. METHODS: We studied 25 patients undergoing transplantation and intraoperative transesophageal echocardiography to evaluate the incidence, the degree, and the cause of TR and MR. The degree of valve regurgitation was assessed by color Doppler echocardiography. Cross-sectional areas of the recipient (R) and donor (D) portions of the atria and their ratio (R/D) were measured to assess the distortion of atrial geometry. Tricuspid and mitral valve annuli, their systolic shortening, and hemodynamic indices were measured preoperatively and perioperatively. RESULTS: Tricuspid valve regurgitation was found in 21 of 25 patients (84%) and MR in 12 of 25 (48%). The degree of MR was mild, whereas TR was mild to moderate. Mitral valve regurgitation did not show any correlation with the studied indices; TR showed no correlation with the hemodynamic indices but a significant correlation with R/D ratio (r = 0.90; standard error of the estimate = 0.2). An inverse correlation was found between the degree of TR and systolic shortening of tricuspid annulus (r = -0.88; standard error of the estimate = 0.03) and between R/D ratio and systolic shortening of tricuspid annulus (r = -0.85; standard error of the estimate = 0.04). CONCLUSIONS: Tricuspid valve regurgitation has a higher incidence than MR and occurs immediately after transplantation; MR is mild and correlates with neither hemodynamic indices nor atrial distortion. An increased R/D ratio, and hence distortion of right atrial geometry, may lead to a reduction in systolic annulus shortening, which in turn causes TR. Surgical attempts to reduce the R/D ratio may decrease the incidence and the degree of TR after heart transplantation.
Echocardiography, Doppler, Color↗
Adjustable De Vega tricuspid valve annuloplasty guided by transesophageal echocardiography.
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Echocardiography, Transesophageal↗
Two different mechanisms of noradrenaline release during normoxia and simulated ischemia in human cardiac tissue.
Species-related differences in the mechanisms of noradrenaline release during normoxia and myocardial ischemia emphasize the need for studies on human hearts. Therefore, the mechanisms of noradrenaline release were investigated during normoxia and energy depletion in incubated human atrial tissue and compared to the release characteristics in normoxic and ischemic rat heart. Potential differences of atrial versus ventricular myocardium were assessed by comparing catecholamine release during electrical stimulation and ischemia in isolated rat atrium with release characteristics in the intact perfused heart. The overflow of endogenous noradrenaline and its deaminated metabolite dihydroxyphenylethyleneglycol (DOPEG) were determined by high pressure liquid chromatography and electrochemical detection. During normoxia noradrenaline release was evoked by electrical field stimulation. Stimulation-induced noradrenaline release depended on the extracellular calcium concentration in both species and was almost completely suppressed under calcium-free conditions. The release was significantly inhibited by neuronal (N-type) calcium channel blockers such as omega-conotoxin (100 nmol/l) and cadmium chloride (100 mumol/l), indicating a predominant role of N-type calcium channels in exocytotic noradrenaline release from sympathetic neurons in human and rat heart. Desipramine (100 nmol/l) enhanced the overflow of noradrenaline evoked by electrical stimulation in both species by blocking neuronal catecholamine uptake (uptake1). Myocardial ischemia was caused by interruption of perfusion flow in rat heart and simulated by anoxic and glucose-free incubation in human and rat atrial tissue. Ischemia- and anoxia-induced noradrenaline release in rat heart and human atrial tissue was unaffected by varying extracellular calcium concentrations and occurred even after omission of calcium and addition of EGTA (1 mmol/l). In both species neither omega-conotoxin (100 nmol/l) nor cadmium chloride (100 mumol/l) affected ischemia-induced noradrenaline overflow in both rat heart and atrium as well as in human atrium. In human and rat atrial tissue, blockade of energy metabolism in the presence of oxygen (cyanide model) resulted in a desipramine-sensitive release of noradrenaline, which was accompanied by DOPEG overflow, indicating increased axoplasmic noradrenaline concentration. The data imply a dual mechanism of noradrenaline release in the human heart. During normoxia noradrenaline release is modulated by neuronal calcium influx indicating exocytotic release. Ischemia-induced noradrenaline release, however, is independent of calcium and inhibited by uptake1 blockade suggesting nonexocytotic release mechanism. The characteristics of noradrenaline release in human atrial tissue provide evidence for carrier-mediated release of noradrenaline from sympathetic neurons operative in the ischemic human myocardium.
Adrenergic Uptake Inhibitors↗
Modified surgical concept for fulminant pulmonary embolism.
Surgical intervention in fulminant pulmonary embolism (PE) is still associated with an overall 30% fatal outcome which increases to about 60% when cardiopulmonary resuscitation (CPR) is necessary. Despite unfavorable conditions like hemodynamic instability, failed lysis or CPR, the surgical strategy might have a certain impact on the patient's outcome since 30-40% of the surgical mortality is related to persistent right heart failure and early thromboembolic recurrence. From 1/88 to 8/94 a total of 25 patients (15 females, 10 men, mean age 57 [25-78]) years underwent emergency pulmonary embolectomy with the use of the heart-lung machine. Seventeen patients were operated upon between 1988 and 1992. A standard approach by central pulmonary artery incision with extraction of adjacent pulmonary emboli using forceps, suction of Fogarty catheters was used. Six of these patients (35%) died, with four out of six operated upon under CPR. Since 1993 we have used a modified surgical strategy in eight patients. Five patients (63%) were operated on after or under CPR. In these cases, left and right pulmonary arteries were incised peripherally and all segmental arteries were desobliterated selectively using small suction devices. Thereafter the right atrium was opened and inspected. After removal of the inferior caval vein cannula all inferior body blood was taken with cardiotomy suction while both legs and the abdomen were massaged centripetally to mobilize additional fresh thrombotic material. In three cases up to 50 cm long thrombi could be delivered. All patients have survived to date with two patients receiving a LGM caval filter placed percutaneously after bilateral postoperative phlebography had revealed ongoing thrombotic disease. We conclude that selective desobliteration of every segmental pulmonary artery in combination with simultaneous clearance of major body veins from additional thrombotic material will probably lower surgical mortality in these critically ill patients.
Adult↗
Cardiocirculatory effects of acutely increased intracranial pressure and subsequent brain death.
Hemodynamic instability and functional impairment of the donor heart are currently reported problems in organ transplantation. Actual shortage of potential donor hearts continues to raise controversial discussion about adequate donor management with regard to graft quality. In an experimental open chest model, physiopathologic effects of acutely induced, irreversible intracranial hypertension (AIIHT) were investigated in situ with respect to hemodynamics, cardiac pump and muscle function, and hormonal parameters. Acutely induced irreversible intracranial hypertension was induced by rapid inflation of a subdural balloon catheter in 10 anesthetized dogs, four animals serving as controls. The observation period in both groups was 300 min. Cardiocirculatory stability was maintained by continuous crystalloid volume substitution without the use of inotropic or pressor agents. After AIIHT, three characteristic hemodynamic response phases have been observed: 1) The "acute hyperdynamic phase" lasting up to 15 min with marked increases of heart rate (HR), left ventricular pressure (LVP), cardiac output (CO) and myocardial contractility indices, 2) At the end of the "early restabilization phase", (60 min), these parameters returned close to control levels, except HR (+50%) and systemic vascular resistance (SVR) (-40%), 3) During the "late restabilization phase", filling pressures, LVP and CO remained within control limits at low SVR, contractility indices showed a decreasing tendency. All assessed plasmatic hormones (Catecholamines, triiodothyronine (T3), thyroxine (T4), adrenocorticotropic hormone (ACTH), cortisol and anti-diuretic hormone (ADH) showed a continuous fall to levels significantly below control over the phases of restabilization. Acutely induced irreversible intracranial hypertension leads to multifactorial hemodynamic and hormonal changes. At low SVR, cardiac pump function was preserved exclusively by continuous volume substitution, while myocardial contractility indicated a slight decrease. From this observed hemodynamic and functional state within the donor organism, no reliable prediction on graft functional capacity can be made.
Animals↗
"Cardioplegia on the contractile apparatus level": evaluation of a new concept for myocardial preservation in perfused pig hearts.
UNLABELLED: The concept of a reversible desensitization of the myocardial contractile apparatus for calcium by 2,3 Butanedione Monoxime (BDM) as a method to improve the myocardium's tolerance to cold ischemia was evaluated in normal pig hearts (n = 14). The results were compared to those obtained after application of Bretschneider's HTK cardioplegic solution. METHODS: Series I) After BDM treatment (concentrations: 0-30 mmol/L) the isometric force output and the intracellular calcium transients (measured using the FURA-2 ratio method) of electrically driven (1 Hz) isolated left-ventricular muscle strips excised from beating pig hearts (n = 14) were recorded simultaneously in order to analyse the mode of action of BDM; Series II) The cardioprotective effects of BDM (30 mmol/L) and Bretschneider's cardioplegic solution (HTK) were compared in a large-animal model: after "in situ perfusion" of pig hearts with either 2000 ml ice-cold BDM solution (30 mmol/L) (n = 7) or 2000 ml HTK (n = 7) the hearts were explanted and stored at 4 degrees C in the same solutions for up to 42 h. The contractile properties of muscle fibres, excised after storage periods of 8, 24, and 42 h from these hearts were analyzed in terms of isometric force development and isotonic shortening. 280 muscle fibres from 14 pigs were used for measurements. RESULTS: Series I) In pig myocardium a dose-dependent reduction of isometric force development was found after BDM application. The shape and the amplitude of the intracellular calcium transient were also affected by BDM. At 30 mmol/L BDM no force development could be elicited despite the presence of an intracellular calcium transient (amplitude < 70% of the control). Series II) Shortening, calcium transient, and force of left-ventricular muscle strips of pig myocardium excised after storage periods for up to 42 h showed complete recovery when BDM was applied. In contrast HTK perfusion allowed complete recovery of these parameters when the storage period did not exceed 6 hours. CONCLUSION: Under the given experimental conditions reversible desensitization of the contractile apparatus for calcium results in a considerable prolongation of the tolerance to cold ischemia in explanted pig hearts. The present study shows that the protective effects of BDM are not only present when isolate muscle fibres were stored (and the extracellular space is large) but also after storage of complete hearts in a solution in a solution containing BDM. Thus BDM may become a useful agent to enlarge the storage period of donor hearts in heart transplatation considerably.
Animals↗
Dynamic cardiomyoplasty: indication, surgical technique, and results.
The efficacy of dynamic cardiomyoplasty is still controversial. To date more than 400 patients have been operated worldwide. In recent years the indication and the surgical technique have become more uniform, which makes results from different centers eligible for comparison. We performed cardiomyoplasty exclusively in patients with contraindications for heart transplantation, such as chronic and recurrent infections or severe, irreversible sequelae of diabetes. Between August 1990 and October 1994, 8 isolated cardiomyoplasty procedures were performed in patients with cardiomyopathy (EF 14-32%, all in NYHA III). One patient died 2 months after surgery. Reported are the results of 7 patients after a mean follow-up of 41.1 +/- 14.1 months. Considerable symptomatic improvement was found in 6 or 7 patients, 3 of whom went back to work. One patient with severe pulmonary hypertension exhibited no improvement. In the others NYHA class improved by at least one. Echocardiography showed an increase in fractional shortening in all patients. LVEF increased from 21.2 +/- 5.2% to 38.1 +/- 15.9% (n = 7, p < 0.015) at 1 year, to 36.6 +/- 17.6% (n = 6, p < 0.05) at two years, and to 36.4 +/- 18.9% (n = 5, NS) at three years. Pulmonary artery pressure tended to decrease at rest over time. Resting lung function showed no change of vital capacity and FEV1. No significant change in exercise level and maximal O2-consumption during treadmill testing was observed. One patient died 34 months after the operation from sudden death. Our preliminary results show that patients after cardiomyoplasty may exhibit an impressive clinical improvement with less striking changes of objective hemodynamic parameters. This data is in agreement with the results of all other investigators. Some possible mechanisms of action are discussed and a risk profile suggested. According to the current state of experience with cardiomyoplasty, we do not consider this method an alternative to heart transplantation, but reserve it for patients with contraindications for heart transplantation.
Cardiomyopathies↗
[Surgical therapy of acute tricuspid valve endocarditis: indications, technique and results].
Tricuspid valve endocarditis is treated by antibiotics alone in the majority of the cases. However, intractable infection or hemodynamic compromise may warrant surgery. In those cases total valve-excision or valve-replacement had been the most common surgical procedures. Both are controversial in regards to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n = 4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in 6 and hemodynamically relevant tricuspid-insufficiency in 1 out of 7 patients, respectively. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In 8 patients the tricuspid valve endocarditis was treated as follows: Debridement, vegectomy, patch-reconstruction of the cusps, bicuspidalization. In 3 patients reconstruction was not possible because of extended involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients, primary valve-replacement (n = 1) or valve-excision with secondary replacement (n = 2) was performed. In 4 patients tricuspid-reconstruction was combined with mitral- (n = 1), aortic- (n = 1) or double-valve replacement (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗