Showing papers by "Heinz Jakob published in 2010"

Silent and Apparent Cerebral Ischemia After Percutaneous Transfemoral Aortic Valve Implantation A Diffusion-Weighted Magnetic Resonance Imaging Study

Abstract: Background— The risk of stroke after transfemoral aortic valve implantation (TAVI) due to dislodgement and subsequent embolization of debris from aortic arch atheroma or from the calcified valve itself ranges between 2% and 10%. The rate of clinically silent cerebral ischemia is unknown but may be even higher. Methods and Results— Thirty-two patients who underwent TAVI with the use of a balloon-expandable (n=22) or self-expandable (n=10) stent valve prosthesis were included in this descriptive study and compared with a historical control group of 21 patients undergoing open surgical aortic valve replacement. Periprocedural apparent and silent cerebral ischemia was assessed by neurological testing and serial cerebral diffusion-weighted magnetic resonance imaging at baseline, at 3.4 (2.5 to 4.4) days after the procedure, and at 3 months. TAVI was successful in all patients. After the procedure, new foci of restricted diffusion on cerebral diffusion-weighted magnetic resonance imaging were found in 27 of 32 ...

Remote ischemic preconditioning reduces myocardial injury after coronary artery bypass surgery with crystalloid cardioplegic arrest

Abstract: Remote ischemic preconditioning (RIPC) with transient upper limb ischemia reduces myocardial injury in patients undergoing on-pump coronary artery bypass grafting (CABG) with cross-clamp fibrillation or blood cardioplegia for myocardial protection. Whether or not such protection is still operative when standard crystalloid cardioplegic arrest is used is uncertain. Fifty-three consecutive, non-diabetic patients with triple-vessel disease and 64 ± 12 years of age (mean ± SD), who underwent elective CABG surgery with crystalloid (Bretschneider) cardioplegic arrest, were allocated in a prospective, randomized, single-blinded protocol to receive either a RIPC protocol (3 cycles of 5 min transient left upper arm ischemia induced by inflating a blood pressure cuff to 200 mmHg with 5 min of reperfusion) or control, respectively, after induction of anesthesia. Cardiac troponin I (cTnI) concentration was measured preoperatively and over 72 h postoperatively, and the area under the curve (AUC) was calculated. Peak postoperative cTnI concentration was significantly reduced from 13.7 ± 7.7 ng/mL in controls to 8.9 ± 4.4 ng/mL in RIPC (P = 0.008). Mean cTnI concentration was significantly lower at 6, 12, 24, and 48 h after surgery (ANOVA; P < 0.0001) in the RIPC patients (N = 27) than in controls (N = 26), resulting in a 44.5% reduction of cTnI (AUC at 72 h). RIPC by repetitive inflation of a cuff around the left upper arm before surgery enhances myocardial protection in patients undergoing CABG surgery with antegrade cold crystalloid cardioplegia.

Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery.

Abstract: Objective: There are few data assessing factors, which identify patients with liver cirrhosis (LC) facing high risk for open-heart surgery. We sought tocomparetheModelfor End-StageLiverDisease(MELD)score,theChild—Turcotte—Pugh(CTP)classificationand theEuropeansystemfor cardiac operative risk evaluation (EuroSCORE) for risk prediction in cirrhotic patients. Methods: Fifty-seven consecutive patients with noncardiac LC, who underwent open-heart surgery with the use of cardiopulmonary bypass between 1998 and 2008, were studied at our institution. Potential preoperative predictors of outcome, as well as preoperative MELD score, CTP classification and EuroSCORE were calculated. The primarystudy endpoints were all-causein-hospitaland long-termmortality.Results:MELDscore and CTPclassification both differedsignificantly between survivors and non-survivors for in-hospital (P < 0.0001) and long-term mortality (P < 0.0001). Univariate predictors of in-hospital mortality were emergency surgery (odds ratio (OR), 4.9; 95% confidence interval (CI), 1.2—20.6; P = 0.03), ascites (OR, 7.2; 95% CI, 2.0—25.5; P = 0.002), total serum protein (OR, 0.4; 95% CI, 0.2—0.8; P = 0.01), CTP class (OR, 5.5; 95% CI, 1.4—21.5; P = 0.04) and MELD score (OR, 1.4; 95% CI, 1.1—1.6; P = 0.001). Multivariable exact logistic regression analyses revealed MELD score (OR, 1.3; 95% CI, 1.005—1.6; P = 0.04) as the only independent factor associated with in-hospital mortality. Receiver operating characteristic curve (ROC) analysis showed MELD score to be highly predictive with an optimal cut-off value of 13.5 (sensitivity: 82.0%, specificity: 78.5%) for postoperative in-hospital mortality (area under curve (AUC): 85.1 0.05%) and superior comparedto the CTP classification (AUC: 75.7 0.08%) and EuroSCORE(AUC: 65.9 0.08%).Conclusions:The mortality of patients with liver cirrhosis undergoing open-heart surgery progressively increases with the severity of liver dysfunction. Therefore, the MELD score most reliably identifies those cirrhotic patients who are at high risk for open-heart surgery. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Perioperative thrombocytopenia in cardiac surgical patients - incidence of heparin-induced thrombocytopenia, morbidities and mortality.

Abstract: Objectives: Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin therapy. At our institution, postoperative cardiac surgical patients are screened for HIT antibodies, when platelet counts persist to be less than 50% of the baseline level or less than 50 000 nl -1 . In the present study, we compared the outcomes in HIT-antibody-positive and HIT-antibody-negative patients. Methods: Patients who underwent a cardiac surgical procedure between 1999 and 2007 and in whom a clinical suspicion of HIT prompted a test for heparin-dependent platelet-activating antibodies, that is, the heparin-induced platelet activation (HIPA) test, were retrieved from the database. Patients were divided in group 1 (antibodies present) and group 2 (no antibodies present). Results: In 153 of more than 10 000 patients (1.5%), a HIPA test was performed, Of those, 21 patients tested positive (group 1) and 132 tested negative (group 2). Central venous and pulmonary thrombo-embolism was more frequent in group 1 (10% vs 2%, p = 0.04). Intestinal, microvascular thrombo-embolism was more frequent in group 2 (15% as opposed to 0%, p = 0.03). By multivariate analysis, only patient age ( p = 0.04, confidence interval (CI): 1.04 (1.00-1.08)), female sex (p = 0.03 Cl 3.45 (1.51-7.86)) and perioperative sepsis (p < 0.001 CI 6.88 (2.96-16.02)) were associated with mortality. Conclusion: Patients in whom a low platelet count prompted testing for HITantibodies, had a high mortality (59%), independent of whether heparin-dependent antibodies were present, indicating that a persistently lowered platelet count is a bad prognostic sign after cardiac surgery. Interestingly, the HIPA-positive patients had more central venous and pulmonary embolisms. Patient age, female sex and perioperative sepsis were risk factors for perioperative mortality.

Lung transplantation using donors 55 years and older: is it safe or just a way out of organ shortage?

Abstract: Objectives: Lung organ scarcity has led to more generous acceptance of organs under the idea of extended-donor criteria. However, long-term effects have to be monitored to redefine present practice. In this study, we investigated the impact of donor age over 55 years in lung transplantation. Methods: In this retrospective study, 186 consecutive double-lung transplantation procedures from January 2000 to December 2008 were evaluated. A total of 19 recipients received lungs from donors aged 55 years or older (range 55—69 years) (group A) and 167 received lungs from younger donors (range 8—54) (group B). In-hospital mortality, intensive care unit (ICU) stay, rejection episodes, lung function and survivalupto5yearswereevaluated.Results:In-hospitalmortalitywassimilarinbothgroups(groupA:10.5%;groupB:13.7%).PostoperativeICU stay was 19 33 days versus 17 34 days (Avs B). Rejection episodes as well as postoperative lung function up to 5 years, and overall cumulative 5-year survival (group A: 52.4%; group B: 50.9%) did not reach statistical significance. However, a trend of increased bronchiolitis obliterans syndrome (BOS) prevalence and reduced lung function was noted. Cause of death showed no differences in both groups. Conclusions: Donor age 55 yearsdoesnot compromiseimmediateand long-termresultsafterlungtransplantation,althoughlong-termobservation ofpatientsreceiving such an organ suggests earlier lung dysfunction. Due to the rising need of organs, lungs from donors aged 55 or older have to be considered for transplantation. However, the acceptance should be based on donor lung evaluation and individual recipient needs. Long-term outcomes over 5 years need to be further investigated. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Angioscopy — a valuable tool in guiding hybrid stent grafting and decision making during type A aortic dissection surgery

Abstract: During hypothermic circulatory arrest (HCA), a briefly visible descending aorta is exposed, enabling direct vision to the surgeon. This study evaluated the impact of angioscopy on arch and descendingaortic surgery for type A aortic dissection (AD).From December 2007 to March 2009, a flexible bronchovideoscope was used in 21 patients to assure true lumen (TL) positioning of the arterial cannula during open vision aortic cannulation (OVAC; nine of 21 cases) and to inspect the arch and descending aorta for re-entries, guide wire position and target zone for hybrid stentgraft(SG)landing(20of21cases).In OVAC,angioscopysecuredpositioningofthearterialcannulawithintheTLrequiringadditional 10—15 s of cerebral ischaemia. In 10 of 21 cases, no additional re-entries were found, thus obviating arch replacement in 2 of 21 and stent grafting in 8 of 21. In 11 of 21 cases, SG deployment was guided to the target zone, in three cases incomplete unfolding initiated balloon dilatation. Angioscopy has become an indispensable tool for decision making in AD to apply OVAC, downstream stent grafting and landing zone control with the ability to indicate ballooning at neglectable time requirements during HCA. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement?

Abstract: BACKGROUND The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most prominent scores used for the evaluation of predicted mortality in cardiac surgery. The aim of our study was to analyze the logistic and additive EuroSCORE in view of its accuracy for patients undergoing isolated aortic valve replacement (AVR). METHODS A total of 652 patients underwent isolated AVR from January 1999 to June 2007. Emergency and redo operations were included. Acute endocarditis was excluded. Out of logistic regression analyses, receiver operating characteristic (ROC) curve statistics were calculated both for the logistic and additive EuroSCORE. RESULTS By using the identical variables used in the EuroSCORE, the area under curve was 70.7% for the logistic and 72.4% for the additive EuroSCORE, respectively. If age, which is by nature positively correlated with increasing cardiac and non-cardiac comorbidity, is calculated as a single parameter, the area under curve remains at 69.9% being very close to the result of the EuroSCORE. CONCLUSIONS For the subgroup of patients undergoing isolated AVR, the use of the EuroSCORE provides a comparable precision concerning the estimation of early mortality compared with the simple factor 'age'. The extended use of the EuroSCORE in view of percutaneous AVR, the insufficient accuracy of the score bears the risk of incorrect decision-making.

Impermeability to blood of the E-vita open plus hybrid stent-graft: experimental and clinical evaluation.

Abstract: Purpose To evaluate the impermeability to blood of the modified E-vita open plus hybrid stent-graft in animal experiments and initial clinical applications in the replacement of the ascending aorta and aortic arch combined with antegrade stent-grafting of the descending aorta Methods In 3 acute pig experiments, a tightly woven hybrid stent-graft (18 x 50-mm) was implanted in the descending aorta Blood loss was measured after clamp release in fully heparinized animals by wrapping the aortic segment in a polyethylene bag For histological examination, 12-mm-diameter stent-grafts were interposed in the abdominal aorta of 6 minipigs The animals were sacrificed and studied after 3, 6, and 9 weeks Between October 2008 and October 2009, 9 patients were treated for 6 type I dissections and 3 thoracic aortic aneurysms using the new prosthesis Blood loss and blood replacement were evaluated Results Mean blood loss under heparinization was 35+/-4 mL/min in the animal model Histological examination of the explanted grafts demonstrated buildup of neointima In the clinical cases, the mean blood loss within the first 24 hours was 489 mL; no re-exploration for bleeding was required During a 6-month follow-up, no thrombus formation was seen within the vascular graft and no embolic event occurred Conclusion The new low-porosity hybrid prosthesis proved to be absolutely tight in animal experiments; histological examination demonstrated endothelial cell ingrowth with a trend to hyperplasia in this small-diameter graft These results were confirmed in the clinical cases by the extremely minimal blood loss and an uneventful course

DeBakey type I dissection: when hybrid stent-grafting is indicated?

Abstract: Aim For avoidance of late downstream complications after classic DeBakey type I aortic dissection repair, replacement of the arch with simultaneous antegrade descending stent-grafting using a hybrid prosthesis was applied in acute and chronic aortic dissection. Indication and results were studied. Methods Between January 2001 and January 2010, 168 patients were operated for acute and chronic aortic dissection (AD). Forty-five patients received an E-vita open stent-graft prosthesis, 29 for acute aortic dissection (AAD) (28 for DeBakey type I, 1 for type III) and 16 for chronic aortic dissection (CAD) (13 type I, 3 type III). Indication was full circular arch dissection, an entry or re-entry tear distal to the left subclavian artery in AAD, and new abdominal malperfusion, rapid growth of the false lumen (FL), impending or contained rupture in CAD. Results Hospital mortality was 10% in AAD and 0 in CAD. Complications like new stroke occurred in 7% versus 6%, temporary dialysis in 55% versus 19%, and false lumen obliteration was observed in 93% versus 63% in AAD versus CAD, respectively. Follow-up was 100% at a mean of 19 months. Overall survival at four years was 72% in AAD versus 94% in CAD. FL thrombosis was stable in AAD (92%) and increased to 93% in CAD over time. Freedom from secondary aortic intervention was 90% in AAD and 75% in CAD. Conclusion This hybrid approach in patients with AAD and CAD type I is safe when indicated and renders stable results over time down to the stent-graft end. Secondary TEVAR can be easily performed downstream when necessary. The international E-vita open registry data supports this single center results.

Abstract 18122: Cerebral Embolization during Transcatheter Aortic Valve Implantation (TAVI): A Transcranial Doppler Study.

Abstract: Background: Recent MRI studies showed that TAVI is associated with a high incidence of cerebral embolization, our group having detected 115 new embolic lesions in 27/32 patients. The origin of the ...

Comparison of sequential left internal thoracic artery grafting and separate left internal thoracic artery and venous grafting : A 5-year follow-up.

Abstract: Objectives The superiority of left internal thoracic artery (LITA) grafting to the left anterior descending artery (LAD) is well established. Patency rates of 80%–90% have been reported at 10-year follow-up. However, the superiority of sequential LITA grafting has not been proven. Our aim was to compare patency rates after sequential LITA grafting to a diagonal branch and the LAD with patency rates of LITA grafting to the LAD and separate vein grafting to a diagonal branch.

Successful treatment of secondary aortoesophageal fistula after thoracic endovascular aortic repair

Abstract: UNLABELLED HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome. DIAGNOSTIC ASSESSMENT CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation. THERAPY AND OUTCOME Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient. CONCLUSION Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.

Complex acute dissection of the aortic arch--a novel hybrid concept for one stage surgical repair.

Abstract: Acute aortic dissection is a life threatening disease, which is occasionally limited to an ascending aorta only (DeBakey type II). In majority of patients it involves the aortic arch and entire rest of the aorta (DeBakey type I). The standardized cannulation and operation strategy can not be used in cases, when aortic arch branches are involved in dissection (complex aortic arch dissection) or in cases with malperfusion or severely compromised hemodynamics (tamponade or heart failure due to severe aortic valve insufficiency). The aim of this present review is to present the "Essen" treatment concept of complicated acute aortic arch dissection from diagnostics to operation strategy.

Aortic stenosis in the geriatric population: current perspectives and modern treatment options

Abstract: Current demographic trends in all modern industrial countries will result in an increase in life expectancy. As a result, the number of octogenarians, nonagenarians and even centenarians will increase considerably within the next 50 years. Accordingly, the incidence of degenerative and calcified aortic stenosis, which is the most common form of valvular heart disease in Europe, will rise significantly. Although current outcomes of conventional surgical aortic valve replacement are excellent, even in elderly patients, mortality rates increase with the occurrence of comorbidities. Recent evidence suggests that more than 30% of patients who have an indication for aortic valve replacement remain untreated because nearly half of them are deemed ‘too sick’ for surgery. Therefore, it is good news that minimally invasive alternatives to open heart surgery have recently been developed and offer new treatment options for these ‘high-risk’ patients.

Perioperatives Gerinnungsmanagement bei Patienten mit Kunstklappen

Abstract: Die lebenslange Antikoagulation mit oralen Vitamin-K-Antagonisten (VKA) ist bei Patienten mit mechanischem Herzklappenersatz die Therapie der Wahl, um thrombembolische Komplikationen zu vermeiden Dadurch bedingt konnen Eingriffe oder grosere Operationen zu einer vermehrten Blutungsneigung bei diesen Patienten fuhren Somit muss die Therapie mit VKA zeitgerecht vor dem geplanten Eingriff abgesetzt werden, was jedoch aufgrund der langen Halbwertszeit der meisten VKA zu einer antikoagulatorischen Lucke mit dem Risiko potentieller thrombembolischer Komplikationen fuhrt Daher muss diese Zeit durch eine adaquate Antikoagulationsform (z B Heparin) uberbruckt werden („Bridging“) Anhand der aktuellen Leitlinien des „American College of Chest Physicians“ und der „European Society of Cardiology“ soll eine Ubersicht und Empfehlung fur das perioperative Antikoagulationsmanagement bei Patienten mit Herzklappenersatz vor groseren chirurgischen Eingriffen gegeben werden