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Biomedical subjects

Udo Sechtem

Publications and source records attributed to Udo Sechtem.

At least 19 recordsLinked to original sources
PubMed2007

Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score.

BACKGROUND: Surgical mortality for acute type A aortic dissection is frequently related to preoperative clinical conditions. We report a predictive score to identify risk of death that may be helpful to assist surgeons who are considering whether to proceed with surgical correction in the case of patients in extreme clinical risk. METHODS: Surgical outcome of 682 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2003 was analyzed. Two different models were used. The initial model included only preoperative variables such as demographics, history, symptoms, signs, and diagnostic methods (model 1). The second model also tested intraoperative hemodynamic and surgical variables (model 2). A bedside risk prediction tool to predict operative mortality in individual patients was developed. RESULTS: The overall in-hospital surgical mortality was 23.9%. Independent preoperative predictors of mortality in model 1 were age greater than 70 years, prior cardiac surgery, hypotension (systolic blood pressure less than 100 mm Hg) or shock at presentation, migrating pain, cardiac tamponade, any pulse deficit, and electrocardiogram with findings of myocardial ischemia or infarction. In model 2, other predictors of surgical death were intraoperative hypotension, a right ventricle dysfunction at surgery, and a necessity to perform coronary revascularization. An independent predictor for favorable surgical outcome was right hemiarch replacement. CONCLUSIONS: Surgery in unstable patients with acute type A aortic dissection can be highly unsuccessful. The International Registry of Acute Aortic Dissection risk models predict in-hospital mortality using a multivariable risk prediction tool, useful for surgeons and patients as they consider their surgical risk and the pros and cons of embarking on high-risk surgery.

Acute Disease↗
PubMed2006

Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection.

BACKGROUND: Follow-up survival studies in patients with acute type B aortic dissection have been restricted to a small number of patients in single centers. We used data from a contemporary registry of acute type B aortic dissection to better understand factors associated with adverse long-term survival. METHODS AND RESULTS: We examined 242 consecutive patients discharged alive with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. Three-year survival for patients treated medically, surgically, or with endovascular therapy was 77.6+/-6.6%, 82.8+/-18.9%, and 76.2+/-25.2%, respectively (median follow-up 2.3 years, log-rank P=0.61). Independent predictors of follow-up mortality included female gender (hazard ratio [HR],1.99; 95% confidence interval [CI], 1.07 to 3.71; P=0.03), a history of prior aortic aneurysm (HR, 2.17; 95% CI, 1.03 to 4.59; P=0.04), a history of atherosclerosis (HR, 2.48; 95% CI, 1.32 to 4.66; P<0.01), in-hospital renal failure (HR, 2.55; 95% CI, 1.15 to 5.63; P=0.02), pleural effusion on chest radiograph (HR, 2.56; 95% CI, 1.18 to 5.58; P=0.02), and in-hospital hypotension/shock (HR, 12.5; 95% CI, 3.24 to 48.21; P<0.01). CONCLUSIONS: Contemporary follow-up mortality in patients who survive to hospital discharge with acute type B aortic dissection is high, approaching 1 in every 4 patients at 3 years. Current treatment and follow-up surveillance require further study to better understand and optimize care for patients with this complex disease.

Acute Disease↗
PubMed2006

Presentation, patterns of myocardial damage, and clinical course of viral myocarditis.

BACKGROUND: Enteroviruses and adenoviruses have been considered the most common causes of viral myocarditis, but parvovirus B19 (PVB19) and human herpesvirus 6 (HHV6) are increasingly found in endomyocardial biopsy samples. METHODS AND RESULTS: Consequently, our aim was to evaluate the prevalence and clinical presentation of cardiac PVB19 and/or HHV6 infection in a cohort of myocarditis patients and to follow its clinical course. In addition, we sought to demonstrate patterns of myocardial damage and to determine predictors for chronic heart failure. Our study design consisted of a cardiovascular magnetic resonance protocol as well as endomyocardial biopsies in the myocardial region affected as indicated by cardiovascular magnetic resonance. One hundred twenty-eight patients were enrolled by clinical criteria. In the group of myocarditis patients (n=87), PVB19 (n=49), HHV6 (n=16), and combined PVB19/HHV6 infections (n=15) were detected most frequently. The remaining patients were diagnosed with healing myocarditis (n=15) or did not have myocarditis (n=26). Patients with PVB19 presented in a manner similar to that of myocardial infarction; most had typical subepicardial late gadolinium enhancement in the lateral wall and recovered within months. Conversely, patients with HHV6 and especially with HHV6/PVB19 myocarditis presented with new onset of heart failure, had septal late gadolinium enhancement, and frequently progressed toward chronic heart failure. CONCLUSIONS: Our data indicate that PVB19 and HHV6 are the most important causes for viral myocarditis in Germany and that the clinical presentation is related to the type of virus. Furthermore, clinical presentation, type of virus, and pattern of myocardial damage are related to the clinical course.

Adult↗
PubMed2006

Right ventricular involvement in Takotsubo cardiomyopathy.

AIMS: The aim of our study is to assess the incidence and clinical significance of right ventricular (RV) involvement in Takotsubo cardiomyopathy (TTC). METHODS AND RESULTS: Between February 2002 and December 2005, 47 patients with TTC underwent cardiovascular magnetic resonance (CMR) at our institutions. 13 patients with delayed initial CMR were excluded. In the remaining 34 patients (32 women), RV wall motion abnormalities (WMAs) were present in nine (26%). Left ventricular ejection fraction (LVEF) was significantly lower in patients with RV involvement (40 +/- 6 vs. 48 +/- 10%, P = 0.04). The most frequently affected RV segments were the apico-lateral (89%), the antero-lateral (67%), and the inferior segment (67%). All RV WMA improved or disappeared in eight of nine patients who underwent a follow-up CMR study. Pleural effusion was more common in patients with RV involvement (67 vs. 8%, P < 0.001) and was predictive of RV dysfunction (sensitivity 67% and specificity 92%). Significant or bilateral pleural effusions were seen exclusively in patients with RV involvement. CONCLUSION: RV involvement is common in TTC and seems to be associated with a more severe impairment in LV systolic function. It may be suspected by the presence of pleural effusion.

Aged↗
PubMed2006

Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival. METHODS AND RESULTS: We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P=0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P=0.01). Survival for patients treated with surgery was 96.1%+/-2.4% and 90.5%+/-3.9% at 1 and 3 years versus 88.6%+/-12.2% and 68.7%+/-19.8% without surgery (mean follow-up overall, 2.8 years, log rank P=0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P=0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P=0.02) as significant, independent predictors of follow-up mortality. CONCLUSIONS: Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

Acute Disease↗
PubMed2006

Effects of time, dose, and inversion time for acute myocardial infarct size measurements based on magnetic resonance imaging-delayed contrast enhancement.

OBJECTIVES: This study sought to investigate the influence of time, dose, and inversion time (TI) and their interactions on myocardial infarct size measurements to establish the foundation for a standardized protocol for multicenter trials. BACKGROUND: There is growing interest in using magnetic resonance imaging (MRI) infarct size measurements as an end point in clinical trials. However, no standardized protocol exists, and there are limited data concerning the effects of time, contrast agent dose, and TI. METHODS: First, we determined the influence of postcontrast imaging time (5 to 40 min), contrast agent dose (0.1 vs. 0.2 mmol/kg), TI, and their interactions in an animal model (n = 14). Second, we tested whether the findings of the animal study apply to patients and are generalizable. Therefore, we retested the diagnostic window in a multicenter study. A total of 48 patients with first acute myocardial infarction (AMI) from three centers were imaged twice (5 and 30 min) after injection of 0.15 mmol/kg gadolinium diethylenetriamine-pentaacetate using an adjusted TI. RESULTS: The animal study showed that the infarct size is independent of time and dose (p = 0.9 and p = 0.16, respectively) using an adjusted TI. Using a fixed TI, however, infarct size is a function of time and dose (p = 0.0001 and p = 0.01, respectively). The multicenter study showed that MRI 1 (16.9 +/- 12% of left ventricle) was not statistically different from MRI 2 (16.4 +/- 12% of left ventricle, p = NS) with no difference between sites (p = NS). CONCLUSIONS: The AMI size can be measured with MRI using a contrast dose between 0.1 and 0.2 mmol/kg and a time window of 5 to 30 min after contrast administration, provided that the TI is adjusted.

Adult↗
PubMed2006

Treatment decisions in stable coronary artery disease: insights from the Euro Heart Survey on Coronary Revascularization.

OBJECTIVE: We sought to assess determinants of clinical decision making in patients with stable coronary artery disease. METHODS: The 2936 patients with stable angina pectoris who enrolled in the Euro Heart Survey on Coronary Revascularization were the subject of this analysis. After the diagnosis has been confirmed, physicians decided on treatment: medical management or revascularization therapy by means of percutaneous coronary intervention or coronary bypass surgery. We applied logistic regression analyses to evaluate the relation between baseline characteristics and treatment decision: medical treatment versus percutaneous coronary intervention, medical treatment versus coronary bypass surgery, and percutaneous coronary intervention versus coronary bypass surgery. RESULTS: The median age was 64 years, 77% were men, and 20% had diabetes. Medical therapy was intended in 690 (24%) patients, percutaneous coronary intervention in 1503 (51%) patients, and coronary bypass surgery in the remaining 743 (25%) patients, respectively. Revascularization was generally preferred in patients with more severe anginal complaints, an intermediate-to-large area of myocardium at risk, and preserved left ventricular function who had not undergone prior coronary revascularization, provided lesions were suitable for treatment. Coronary bypass surgery was preferred over percutaneous coronary intervention in multivessel or left main disease, as well as in those with concomitant valvular heart disease, provided a sufficient number of lesions were suitable for coronary bypass surgery. In those with previous coronary bypass surgeries, more often percutaneous coronary intervention was preferred than redo coronary bypass surgery. Diabetes was not associated with more frequent preference for coronary bypass surgery. CONCLUSIONS: In the hospitals that participated in the Euro Heart Survey on Coronary Revascularization, treatment decisions in stable coronary artery disease were largely in agreement with professional guidelines and determined by multiple factors. Most important deviations between guideline recommendations and clinical practice were seen in patients with extensive coronary disease, impaired left ventricular function, and diabetes.

Aged↗
PubMed2006

Diabetes does not influence treatment decisions regarding revascularization in patients with stable coronary artery disease.

OBJECTIVE: To evaluate whether in stable angina preference for coronary revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is influenced by diabetes status and whether this has prognostic implications. RESEARCH DESIGN AND METHODS: A total of 2,928 consecutive patients with stable angina who were enrolled in the prospective Euro Heart Survey on Coronary Revascularization were studied. Multivariable analyses were applied to evaluate the relation between diabetes, treatment decision, and 1-year outcome. RESULTS: Diabetes was documented in 587 patients (20%) who had more extensive coronary disease. Revascularization was intended in 74% of patients with diabetes and in 77% of those without diabetes. In patients selected for revascularization, CABG was intended in 35% of diabetic and in 33% of nondiabetic patients. Multivariable analyses did not change these findings, but in some subgroups diabetes influenced treatment decisions. For example, diabetic subjects with mild heart failure had more often intended revascularization (91%) than those without diabetes (67%, P < 0.001). Treatment decisions in patients with more extensive (left main, multivessel, or proximal left anterior descending artery) disease were not influenced by diabetes status. Diabetes was not associated with an increased incidence of all-cause death, nonfatal cerebrovascular accident, or nonfatal myocardial infarction at 1 year, regardless of preferred treatment. The incidence of the combined end points was 7.3% in diabetic and 6.8% in nondiabetic patients (adjusted hazard ratio 1.0 [95% CI 0.7-1.4]). CONCLUSIONS: In stable angina, treatment decisions regarding revascularization or the choice for CABG or PCI were not influenced by the presence of diabetes. Diabetes was not associated with a poor prognosis.

Aged↗
PubMed2005

A vector-based, 5-electrode, 12-lead monitoring ECG (EASI) is equivalent to conventional 12-lead ECG for diagnosis of acute coronary syndromes.

AIMS: The conventional 12-lead electrocardiogram (cECG) derived from 10 electrodes using a cardiograph is the gold standard for diagnosing myocardial ischemia. This study tested the hypothesis that a new 5-electrode 12-lead vector-based ECG (EASI; Philips Medical Systems, formerly Hewlett Packard Co, Boeblingen, Germany) patient monitoring system is equivalent to cECG in diagnosing acute coronary syndromes (ACSs). METHODS: Electrocardiograms (EASI and cECG) were obtained in 203 patients with chest pain on admission and 4 to 8 hours later. Both types of ECGs were graded as ST-elevation myocardial infarction if at least 1 of the 2 consecutive recordings showed ST elevation more than 0.2 mV, as ACS if one or both showed ST elevation less than 0.2 mV, T-wave inversion, or ST depression. Otherwise, the ECG was graded negative. RESULTS: Final diagnosis was identical in 177 patients (87%; 95% confidence interval [CI], 82%-91%; kappa = 0.81; SE = 0.035). ST-elevation myocardial infarction was correctly identified or excluded by EASI with a specificity of 94% (95% CI, 89%-97%) and a sensitivity of 93% (95% CI, 86%-97%; using cECG as the gold standard). Of 118 patients with enzyme elevations, an almost identical number (72 [61% by EASI] and 73 [62% by cECG]) had ST elevations. Both techniques were equivalent in predicting subsequent enzyme elevation (identical, 108/143; 75% of ACS and ST-elevation myocardial infarction ECGs by EASI and cECG). Thus, both ECG methods had exactly the same specificity of 59% (95% CI, 48%-69%) and sensitivity of 91% (95% CI, 85%-96%) for detecting myocardial injury. CONCLUSION: EASI is equivalent to cECG for the diagnosis of myocardial ischemia.

Chest Pain↗
PubMed2005

Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection).

The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p <0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p = 0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes.

Acute Disease↗
PubMed2005

Left ventricular wall motion abnormalities as well as reduced wall thickness can cause false positive results of routine SPECT perfusion imaging for detection of myocardial infarction.

AIMS: The relationship between wall thickness, wall thickening, wall motion, and single-photon emission computed tomography (SPECT) results for detection of myocardial infarction has never been systematically evaluated in a clinical setting. In particular, the discussion whether non-ischaemic regional wall motion abnormalities and reduced wall thickness can cause SPECT to be false positive for infarct detection remains unsettled. METHODS AND RESULTS: We therefore evaluated patients presenting with left bundle branch block (LBBB) and only included them in the analysis if any coronary artery disease (CAD) had been ruled out by angiography. LBBB is known to cause septal wall motion abnormalities as well as to reduce systolic septal wall thickness. Thus, LBBB is a good non-ischaemic clinical model to evaluate the influence of wall thickness and wall motion on the homogeneity of tracer distribution in resting SPECT images. SPECT revealed fixed defects in all 139 patients initially identified for possible enrollment. CAD was found to be present by angiography in 120 patients. The remaining 19 patients without any CAD underwent cardiovascular magnetic resonance (CMR) and were included in the study. Evaluation of SPECT using a 72-segment model revealed septum-related fixed defects in all 19 patients. Every defect was interpreted as myocardial infarction by blinded observers. The comparison of nuclear results to the gold standard CMR demonstrated that none of the fixed SPECT defects did represent myocardial infarcts. Defects, however, exactly matched areas of wall motion abnormalities as well as regions with impaired wall thickness as demonstrated by CMR. On a segmental basis, we found a strong relationship between wall motion and reduced wall thickness on one hand and SPECT defects on the other hand. For example, only 5% of segments with normal wall motion were false positive by SPECT for myocardial infarction, whereas 93% of all dyskinetic segments were found to be false positive (P<0.01). Comparing wall thickness to SPECT results revealed that 58% of segment in which wall thickness was 1 SD below the mean and 93% of segments in which wall thickness was 2 SD below the mean showed fixed defects by SPECT. Conversely, only 0.5% of segments in which wall thickness was above the mean were affected by false positive SPECT results (P<0.01). CONCLUSION: Wall motion abnormalities as well as impaired myocardial wall thickening and wall thickness can cause false positive results of resting SPECT myocardial perfusion imaging for detection of myocardial infarction in the absence of myocardial infarct scars and CAD.

Aged↗