Hemodynamic behavior of stentless aortic valves in long term follow-up

Objectives Stentless aortic valve replacements show improved hemodynamics due to larger orifice area and lower transvalvular gradients in short and mid-term follow-up. Hemodynamic long-term behavior and the adaptation of the left ventricle as well as valve-durability in patients aged ≤60 years remains unclear. Methods 7 to 16 years after aortic valve replacement, 54 patients (mean age at operation 53.1 ± years) received echocardiography and clinical examination. Mean follow-up time was 10.8 ± 2.2 years. Evaluated were NYHA class, transvalvular gradients, estimated aortic valve orifice area, degree of aortic valve insufficiency, left ventricular mass and function. Results At follow-up only one patient presented with NYHA class III. All other patients were in NYHA class I or II. Maximum and mean pressure gradients of the prostheses were 16.3 ± 7.4 mmHg and 9.1 ± 4.2 mmHg, respectively. Compared to echocardiography at discharge the mean pressure gradients dropped 18.0% (2.0 ± 0.9 mmHg) and stayed stable until 14 years after the operation. Only 5 patients showed relevant regurgitation (at 13–16 years after valve replacement), 49 showed no or trivial regurgitation. Left ventricular mass had decreased 26.5% (107.9 ± 18.5 g). Left ventricular ejection fraction (LVEF) had increased in most patients and decreased in only one. For patients with preoperatively impaired left ventricular function an increase of LVEF of 13.1 ± 3.1% was seen. Conclusion Porcine stentless aortic valves provide excellent hemodynamic long-term results without significant rise of transvalvular pressure gradients or relevant insufficiencies until 14 years after implantation, leading to sustained decrease of left ventricular mass and improvement of left ventricular function

Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients

INTRODUCTION: Monitoring of the cardiac output by continuous arterial pulse contour (CO(PiCCOpulse)) analysis is a clinically validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (CO(PACtherm)) in cardiac surgical patients. There is ongoing debate, however, of whether the CO(PiCCOpulse )is accurate after profound hemodynamic changes. The aim of this study was therefore to compare the CO(PiCCOpulse )after cardiopulmonary bypass (CPB) with a simultaneous measurement of the CO(PACtherm). METHODS: After ethical approval and written informed consent, data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (CO(PiCCOtherm)) and the CO(PACtherm )were determined in all patients. Prior to surgery, the CO(PiCCOpulse )was calibrated by triple transpulmonary thermodilution measurement of the CO(PiCCOtherm). After termination of CPB, the CO(PiCCOpulse )was documented. Both CO(PACtherm )and CO(PiCCOtherm )were also simultaneously determined and documented. RESULTS: Regression analysis between CO(PACtherm )and CO(PiCCOtherm )prior to CPB showed a correlation coefficient of 0.95 (P < 0.001), and after CPB showed a correlation coefficient of 0.82 (P < 0.001). Bland-Altman analysis showed a mean bias and limits of agreement of 0.0 l/minute and -1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and -1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of CO(PiCCOpulse )versus CO(PiCCOtherm )and of CO(PiCCOpulse )versus CO(PACtherm )after CPB showed a correlation coefficient of 0.67 (P < 0.001) and 0.63 (P < 0.001), respectively. Bland-Altman analysis showed a mean bias and limits of agreement of -1.1 l/minute and -1.9 to +4.1 l/minute versus -1.4 l/minute and -4.8 to +2.0 l/minute, respectively. CONCLUSION: We observed an excellent correlation of CO(PiCCOtherm )and CO(PACtherm )measurement prior to CPB. Pulse contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be re-calibrated as soon as possible, to prevent false therapeutic consequences

Impaired Relaxation and Reduced Lusitropic Reserve in Atrial Myocardium in the Obese Patients

Background: Obesity can influence the structure and function of the atrium, but most studies focused on the relationship of body mass index (BMI) and overt left atrium (LA) dysfunction as assessed by clinical imaging. We combined the assessment of right atrium (RA) function in vivo and in vitro in obese and non-obese patients scheduled for elective cardiac surgery. Methods: Atrial structure and function were quantified pre-operatively by echocardiography. RA tissue removed for the establishment of extracorporeal support was collected and RA trabeculae function was quantified in vitro at baseline and with adrenergic stimulation (isoproterenol). Fatty acid-binding protein 3 (FABP3) was quantified in RA tissue. Results were stratified according to the BMI of the patients. Results: About 76 patients were included pre-operatively for the echocardiographic analysis. RA trabeculae function at baseline was finally quantified from 46 patients and RA function in 28 patients was also assessed with isoproterenol. There was no significant correlation between BMI and the parameters of atrial function measured by the clinical echocardiography. However, in vitro measurements revealed a significant correlation between BMI and a prolonged relaxation of the atrial myocardium at baseline, which persisted after controlling for the atrial fibrillation and diabetes by the partial correlation analysis. Acceleration of relaxation with isoproterenol was significantly lower in the obese group (BMI ≥ 30 kg/m(2)). As a result, relaxation with adrenergic stimulation in the obese group remained significantly higher compared to the overweight group (25 kg/m(2) ≤ BMI < 30 kg/m(2), p = 0.027) and normal group (18.5 kg/m(2) ≤ BMI < 25 kg/m(2), p = 0.036). There were no differences on impacts of the isoproterenol on (systolic) developed force between groups. The expression of FABP3 in the obese group was significantly higher compared to the normal group (p = 0.049) and the correlation analysis showed the significant correlations between the level of FABP3 in the RA trabeculae function. Conclusion: A higher BMI is associated with the early subclinical changes of RA myocardial function with the slowed relaxation and reduced adrenergic lusitropy

The impact of an hematocrit of 20% during normothermic cardiopulmonary bypass for elective low risk coronary artery bypass graft surgery on oxygen delivery and clinical outcome – a randomized controlled study [ISRCTN35655335]

INTRODUCTION: Cardiopulmonary bypass (CPB) induces hemodilutional anemia, which frequently requires the transfusion of blood products. The objective of this study was to evaluate oxygen delivery and consumption and clinical outcome in low risk patients who were allocated to an hematocrit (Hct) of 20% versus 25% during normothermic CPB for elective coronary artery bypass graft (CABG) surgery. METHODS: This study was a prospective, randomized and controlled trial. Patients were subjected to normothermic CPB (35 to 36°C) and were observed until discharge from the intensive care unit (ICU). Outcome measures were calculated whole body oxygen delivery, oxygen consumption and clinical outcome. A nonparametric multivariate analysis of variance for repeated measurements and small sample sizes was performed. RESULTS: In a total of 54 patients (25% Hct, n = 28; 20% Hct, n = 26), calculated oxygen delivery (p = 0.11), oxygen consumption (p = 0.06) and blood lactate (p = 0.60) were not significantly different between groups. Clinical outcomes were not different between groups. CONCLUSION: These data indicate that an Hct of 20% during normothermic CPB maintained calculated whole body oxygen delivery above a critical level after elective CABG surgery in low risk patients. The question of whether a transfusion trigger in excess of 20% Hct during normothermic CPB is still supported requires a larger prospective and randomized trial

Concomitant ablation of atrial fibrillation in octogenarians: an observational study

<p>Abstract</p> <p>Background</p> <p>Cardiac surgery is increasingly required in octogenarians. These patients frequently present atrial fibrillation (AF), a significant factor for stroke and premature death. During the last decade, AF ablation has become an effective procedure in cardiac surgery. Because the results of concomitant AF ablation in octogenarians undergoing cardiac surgery are still not clear, we evaluated the outcome in these patients.</p> <p>Methods</p> <p>Among 200 patients undergoing concomitant AF ablation (87% persistent AF), 28 patients were ≥ 80 years (82 ± 2.4 years). The outcome was analysed by prospective follow up after 3, 6, 12 months and annually thereafter. Freedom from AF was calculated according to the Kaplan-Meier method.</p> <p>Results</p> <p>Octogenarians were similar to controls regarding AF duration (48 ± 63.2 versus 63 ± 86.3 months, n.s.) and left atrial diameter (49 ± 6.1 versus 49 ± 8.8 mm, n.s.), but differed in EuroSCORE (17.3 ± 10.93 versus 7.4 ± 7.31%, p < 0.001), prevalence of paroxysmal AF (25.0 versus 11.0%, p = 0.042) and aortic valve disease (67.8 versus 28.5%, p < 0.001). ICU stay (8 ± 16.9 versus 4 ± 7.2 days, p = 0.027), hospital stay (20 ± 23.9 versus 14 ± 30.8 days, p < 0.05), and 30-d-mortality (14.3 versus 4.6%, p = 0.046) were increased. After 12 ± 6.1 months of follow-up (95% complete), 14 octogenarians (82%) and 101 controls (68%, n.s.) were in sinus rhythm; 59% without antiarrhythmic drugs in either group (n.s.). Sinus rhythm restoration was associated with improved NYHA functional class and renormalization of left atrial size. Cumulative freedom from AF demonstrated no difference between groups. Late mortality was higher in octogenarians (16.7 versus 6.1%, p = 0.065).</p> <p>Conclusion</p> <p>Sinus rhythm restoration rate and functional improvement are satisfactory in octogenarians undergoing concomitant AF ablation. Hence, despite an increased perioperative risk, this procedure should be considered even in advanced age.</p

First clinical study during a safety and feasibility trial

Titelblatt und Inhaltsverzeichnis Einleitung Material und Methoden Ergebnisse Teil I Ergebnisse Teil II Ergebnisse Teil III Diskussion Literaturverzeichnis AnhangIn der Folge demographischer Veränderungen und besserer Behandlungsmethoden kardiologischer Grunderkrankungen nimmt die Inzidenz der chronischen Herzinsuffizienz immer mehr zu. Trotz beträchtlicher Fortschritte in der medikamentösen Herzinsuffizienztherapie besteht weiterhin ein großer Bedarf an herzchirurgischen Therapieoptionen, während gleichzeitig die Herztransplantation nur einer begrenzten Zahl der Patienten zur Verfügung steht. Angelpunkt der Krankheitsprogression ist die linksventrikuläre Dilatation und die sphärische Transformation der linken Herzkammer. Das hier vorgestellte CorCap Cardiac Support Device ist ein der Herzsilhouette entsprechend vorgeformtes Polyesternetz, welches im Rahmen einer Operation um beide Herzkammern gelegt wird und eine weitere Dilatation begrenzt. Das CorCap wurde im Rahmen einer Sicherheits- und Machbarkeitsstudie bei 29 Patienten implantiert. 26 der Patienten wurden in diese Auswertung aufgenommen, 3 mit simultaner Ventrikulotomie nicht berücksichtigt. Es wurden zwei Untergruppen gebildet eine mit ausschließlicher Implantation des Unterstützungsnetzes, die andere mit zusätzlicher Mitralklappenchirurgie. Die Patienten wurden über zwei Jahre regelmäßig zu Nachkontrollen einbestellt, wobei eine echokardiographische Untersuchung erfolgte und die kardiopulmonale Belastbarkeit nach der NYHA-Klassifikation, zum Teil auch mittels Spiroergometrie bestimmt wurde. Die 30-Tage-Letalität lag bei 7,7%, die Überlebenswahrscheinlichkeit nach 2 Jahren bei 77%. Die echokardiographischen Daten zeigten eine signifikante Abnahme der Ventrikeldurchmesser im Zeitverlauf, während sich die systolische Funktion relevant verbesserte. Die NYHA-Stufe als Maß der Leistungsfähigkeit wurde in den Nachkontrollen höher bewertet als präoperativ. Das Ausmaß dieser Effekte war in der Gruppe mit isolierter CSD-Implantation jeweils ausgeprägter. Der Schweregrad der Mitralinsuffizienz verbesserte sich nach der operativen Korrektur der höhergradigen Mitralvitien signifikant; es war aber auch in der Gruppe ohne zusätzliche Mitralchirurgie ein deutlicher Rückgang der begleitenden Mitralinsuffizienzen zu verzeichnen. Die passive Kardiomyoplastie mit dem CorCap führt bei den behandelten Patienten zu einer Verbesserung der Herzinsuffizienzsymptomatik. Kardiale Parameter wie die linksventrikuläre Größe und Funktion werden günstig beeinflußt, was auf eine Rückbildung myokardialstruktureller Umbauprozesse im Sinne eines reverse remodeling hindeutet.Following demographic changes and improved treatment options for cardiac diseases the incidence of congestive heart failure increases. Despite a remarkable progress in medical therapy there is still a need for surgical procedures, while heart transplantation is only available to a limited number of patients. A central issue of disease progression in heart failure is left ventricular dilation and transformation of ventricular shape to a more spherical one. The CorCap Cardiac Support Device, a preformed mesh-like polyester device, is surgically placed around the ventricles and prevents further dilation. As part of an initial safety and feasibility trial the CorCap was implanted in 29 patients. Three patients with concomitant ventriculotomy were excluded, the remaining 26 patients form the cohort for this study. The patients were divided into two subgroups, one with device placement as the only surgical measure, the other with concomitant mitral valve surgery, mainly mitral valve repair. Follow-up visits were scheduled over a period of two years, including echocardiography and assessment of cardiopulmonary functional performance. 30-day-mortality was 7,7%, the survival after 2 years was 77%. During the follow-up period a decrease of left ventricular size was observed, while the systolic function improved significantly. The functional performance increased in the majority of the patients by at least one NYHA-class. These findings were more marked in the subgroup without mitral valve surgery. The degree of mitral regurgitation improved significantly after surgical correction of moderate to severe mitral regurgitation, additionally the patients without concomitant mitral valve surgery also showed a decrease of mitral regurgitation on follow-up echocardiography. Implantation of the CorCap Cardiac Support Device in heart failure patients improves symptoms and functional performance and favourably influences left ventricular size and function, indicating reverse remodeling of left ventricle

Long-term results after the Ross procedure with the decellularized AutoTissue Matrix P® bioprosthesis used for pulmonary valve replacement

Objectives: Since 1967, the Ross procedure has been performed to treat aortic valve disease using homografts for pulmonary valve replacement. The decellularized Matrix P® prosthesis was developed to overcome (some) limitations of homografts. Until now, the long-term outcome data have been unavailable. Methods: Between 2002 and 2010, the Ross procedures using the Matrix P prosthesis were performed in 492 adult patients (mean age 57.2 ± 10.6 years, range 21–73 years) at our institution. Patient data were prospectively collected and analysed (3617.3 patient-years, mean follow-up 7.7  ±  4.3 years). Completeness of follow-up at 1, 5 and 10 years was 98.4%, 94.5% and 91.0%, respectively. Results: Hospital mortality was 3.9% (n  = 19). During follow-up, 121 patients died resulting in a survival rate at 5, 10 and 12.5 years of 82.8  ±  1.7%, 70.4  ±  2.3% and 62.4  ±  2.9%, respectively. Echocardiography revealed a high incidence of relevant dysfunction of the Matrix P prosthesis and subsequent right ventricular failure. Primary reoperation/reintervention was necessary for 150 Matrix P and 48 autografts. Freedom from pulmonary valve reoperation at 5, 10 and 12.5 years was 76.2  ±  2.1%, 58.6  ±  2.9% and 53.4  ±  3.4%, respectively. The autograft function and the left ventricular function showed similar results as previously reported with a freedom from autograft reoperation at 5, 10 and 12.5 years of 91.8  ±  1.4%, 86.1  ±  2.0% and 86.1  ±  2.0%, respectively. Conclusions: The Matrix P prosthesis used for the right ventricular outflow tract reconstruction in the Ross procedure showed unfavourable long-term echocardiographic results with a high rate of reoperation/reintervention for structural pulmonary valve failure. As a consequence, long-term survival of this patient cohort was impaired. Based on these findings, the use of the Matrix P prosthesis for pulmonary valve replacement for Ross procedures in adults should not be recommended.ISSN:1010-7940ISSN:1873-734

Concomitant ablation of atrial fibrillation in octogenarians: an observational study-1

Years.<p><b>Copyright information:</b></p><p>Taken from "Concomitant ablation of atrial fibrillation in octogenarians: an observational study"</p><p>http://www.cardiothoracicsurgery.org/content/3/1/21</p><p>Journal of Cardiothoracic Surgery 2008;3():21-21.</p><p>Published online 29 Apr 2008</p><p>PMCID:PMC2394520.</p><p></p