Alexander M. Fabricius

Intraoperative left atrial ablation (for atrial fibrillation) using a new argon cryocatheter: early clinical experience

PURPOSE Recently surgical treatment of atrial fibrillation has gained more popularity and presently is being performed in large numbers of patients. This report describes our early experience in treatment of patients with chronic or paroxysmal atrial fibrillation with a new tool for left atrial cryoablation. DESCRIPTION From July 2002 through January 2003, 28 patients underwent left atrial cryoablation with the Surgifrost CryoCath. Patients underwent cryotherapy as an isolated procedure (n = 1), in combination with mitral valve surgery (n = 13), or with other surgical procedures (n = 14). In all patients contiguous lesion lines to the orifices of the pulmonary veins connected to the mitral annulus and the atriotomy were created. Surgery was performed through a conventional sternotomy in 8 patients (29%) and a right lateral minithoracotomy using video-assistance in 20 patients (71%). EVALUATION Postoperatively sinus rhythm was restored in 27 patients (96%). At discharge 82% (23/28) of patients were in sinus rhythm and 18% (5/28) were in atrial fibrillation. Four patients (14%) required pacemaker implantation. There was no in-hospital mortality. At 6-months follow-up (19/28 patients) all were alive and 74% were in stable sinus rhythm, New York Heart Association functional class was 1.2 +/- 0.4. CONCLUSIONS As indicated by our small and early patient cohort left atrial cryoablation with the Surgifrost argon cryocatheter is effective for the treatment of atrial fibrillation. This new device is technically easy to handle, it can be applied through a median sternotomy or lateral minithoracotomy. Long-term follow-up is necessary to evaluate further rhythm outcome.

Minimally invasive saphenous vein harvesting techniques: morphology and postoperative outcome

BACKGROUND Conventional saphenous vein harvest is associated with numerous complications, which may be reduced by minimally invasive vein-harvesting techniques. The integrity of the venous endothelium must be guaranteed before using new saphenous vein harvesting techniques. This short-term study compared the clinical outcome of two minimally invasive techniques with the conventional technique, and compared morphology as documented by light and electron microscopy. METHODS Ninety-two patients were prospectively randomized into three groups. Two different minimally invasive techniques of greater saphenous vein harvesting were used in sixty-two patients. One used a video-assisted dissector (group A, n = 31), and one used a light-coupled retractor (group B, n = 31). Thirty patients were treated by the conventional technique (group C). RESULTS Incision lengths were 7.6+/-2.1 cm in group A and 9.3+/-3.2 cm in group B, as compared with 38.9+/-8.7 cm in the conventional group. Harvesting time was prolonged by a mean of 26% when using a minimally invasive technique. Conversion rate to the open technique was 3 of 31 (9.3%) in group A and 2 of 31 (6.2%) in group B. No wound complications were noted in group A, but one wound inflammation was seen in group B; only a mild hematoma was seen in both groups. Edge necrosis, wound separation and inflammation were noted in the conventional group. Light and electron microscopy revealed no significant denudation of the endothelial layer in groups A and B as compared with group C. CONCLUSIONS These data show an excellent postoperative result when using the minimally invasive technique as compared with the conventional group. The safety of the technique is demonstrated by the preservation of endothelial integrity.

Temporary Extracorporeal Membrane Oxygenation in Patients with Refractory Postoperative Cardiogenic Shock—A Single Center Experience

Abstract  Background: Approximately 1% of patients require temporary circulatory support due to refractory cardiogenic shock following cardiac surgery. Such patients are at very high risk for subsequent morbidity and mortality. We evaluated the results of temporary extracorporeal membrane oxygenation (ECMO) support in patients with postcardiotomy cardiogenic shock. Methods: From November 1997 to February 2000, 7900 patients underwent cardiac surgery in our institution. Ninety‐five patients (1.2%) (CABG, n = 63; AVR, n = 16; CABG and AVR, n = 8; other procedures, n = 8) required temporary postoperative ECMO support. ECMO implantation was performed via the femoral vessels or via the right atrium and ascending aorta. Intraaortic balloon counterpulsation was employed in all patients. Results: Mean duration of ECMO support was 2.8 ± 2.1 days. Forty‐five patients (47%) were successfully weaned from ECMO. Of these, 28 patients were discharged from hospital 35.8 ± 20.8 days post‐ECMO support. Overall hospital mortality for all ECMO patients was considerable at 71%. Mortality rate in the combined CABG and AVR group was 100% (P < 0.05 versus the other surgical groups). ECMO support was complicated by renal failure in 64% of patients, bleeding requiring mediastinal reexploration in 62%, ischemia of the lower limbs in 16%, cerebral edema in 6%, and cerebral hemorrhage in 3%. Conclusions: ECMO is a suitable technique for short‐term treatment of refractory postoperative low cardiac output. Mortality rates are comparable to other cardiac assist devices, with approximately 30% of patients able to be discharged from hospital. (J Card Surg 2003;18:512‐518)

Skeletonization Versus Pedicle Preparation of the Radial Artery With and Without the Ultrasonic Scalpel

BACKGROUND The radial artery (RA) is increasingly used for myocardial revascularization because of its presumed advantageous long-term patency rates. The vessel can be harvested as a pedicle or skeletonized. The aim of this study was to compare the skeletonization technique with pedicle preparation using either an ultrasonic scalpel or scissors. METHODS Forty consecutive patients with coronary artery disease undergoing complete arterial revascularization were included in the study. In 20 patients the RAs were prepared using scissors and clips (group 1: skeletonization; group 2: pedicle). In another 20 patients the arteries harvested were prepared using an ultrasonic scalpel (group 3: skeletonization; group 4: pedicle). The RA was treated with papaverine to prevent spasm of the vessel during and after harvesting. Tissue specimens of each RA were taken to analyze endothelial morphology by scanning electron microscopy. After implantation of the RA, graft perfusion was measured with a flow probe. RESULTS Harvesting the RA as a skeletonized vessel took more time as compared with pedicle preparation (group 1 vs group 2: 37.1 +/- 3.5 minutes vs 24.4 +/- 3.9 minutes; p < 0.001 and group 3 vs group 4: 31.1 +/- 3.5 minutes vs 25.6 +/- 3.7 minutes; p < 0.01). The number of hemostatic titanium clips was similarly higher in group 1 as opposed to group 2 (58.7 +/- 7.1 vs 38.7 +/- 7.1; p < 0.01). However, there was no difference between groups 3 and 4 (p = 0.086). The length of the RA after skeletonization with scissors and clips was 20.8 +/- 1.5 cm in contrast with 19.1 +/- 0.9 cm (p < 0.01) after dissection as a pedicle. In the groups using the ultrasonic scalpel, there was no difference in graft length (p = 0.062). Mean blood flow through the graft after establishing the proximal anastomosis was similar among all groups (groups 1, 2, 3, and 4: 50 +/- 20.1 mL/min, 53.8 +/- 24.3 mL/min, 56.3 +/- 25.1 mL/min, and 51.8 +/- 23 mL/min, respectively). Scanning electron microscopy demonstrated endothelial damage in all patients in groups 1, 2, and 3 and in 7 patients of group 4. Most endothelial lesions were minor except in group 3 in which 1 of 5 endothelial lesions were severe. Statistically significant differences was found between groups 1 and 2, and 3 and 4 with respect to the degree of endothelial damage (p < 0.01). CONCLUSIONS Skeletonization using scissors and clips is more time consuming and technically more difficult, but yield significantly longer grafts. Skeletonization with an ultrasonic scalpel did not result in additional length and was more frequently associated with severe endothelial damage. Pedicle preparation using scissors or an ultrasonic scalpel is much simpler and faster, and does not jeopardize endothelial integrity.

Die chirurgische Behandlung des therapierefraktären Vorhofflimmerns

Atrial fibrillation in patients with isolated, therapy resistant, chronic or paroxysmal atrial fibrillation (AF) or AF in combination with additional valvular and non-valvular cardiac pathology can be surgically treated by different techniques. Unipolar high frequency, cryotherapy and microwave energy is a curative approach for the treatment of the left atrium for AF. The postoperative mortality and morbidity rate is comparable to other cardiac surgery procedures. It is a technically less challenging procedure as compared to the MAZE procedure and can be applied using a minimally invasive approach. Alternative techniques such as new cryotechnologies, laser application and bipolar high frequency energy need to be evaluated for effectiveness and safety. Patienten mit alleinigem therapierefraktärem chronischen oder paroxysmalen Vorhofflimmern, oder mit begleitenden kardialen Erkrankungen, wie Herzklappendegenerationen, können mit verschiedenen Techniken chirurgisch behandelt werden. Mit der unipolare Hochfrequenzenergie, der Kryoapplikation und der Mikrowellenenergie ist eine erfolgreiche Behandlung des Vorhofflimmerns im Bereich des linken Vorhofes möglich. Die postoperative Mortalität und Morbidität ist vergleichbar mit anderen kardiochirurgischen Eingriffen. Der operative Eingriff ist weniger aufwendig als die MAZE-Operation und kann in einer minimalinvasiven Technik, auch in Zusammenhang mit Mitralklappeneingriffen, durchgeführt werden. Alternative Techniken, wie die neue Kryotechnologien, die Laserapplikation und die bipolare Hochfrequenzenergie werden im Rahmen von Studien auf ihre Effektivität und Sicherheit geprüft.

Surgical treatment of therapy resistant atrial fibrillation

Atrial fibrillation in patients with isolated, therapy resistant, chronic or paroxysmal atrial fibrillation (AF) or AF in combination with additional valvular and non-valvular cardiac pathology can be surgically treated by different techniques. Unipolar high frequency, cryotherapy and microwave energy is a curative approach for the treatment of the left atrium for AF. The postoperative mortality and morbidity rate is comparable to other cardiac surgery procedures. It is a technically less challenging procedure as compared to the MAZE procedure and can be applied using a minimally invasive approach. Alternative techniques such as new cryotechnologies, laser application and bipolar high frequency energy need to be evaluated for effectiveness and safety. Patienten mit alleinigem therapierefraktärem chronischen oder paroxysmalen Vorhofflimmern, oder mit begleitenden kardialen Erkrankungen, wie Herzklappendegenerationen, können mit verschiedenen Techniken chirurgisch behandelt werden. Mit der unipolare Hochfrequenzenergie, der Kryoapplikation und der Mikrowellenenergie ist eine erfolgreiche Behandlung des Vorhofflimmerns im Bereich des linken Vorhofes möglich. Die postoperative Mortalität und Morbidität ist vergleichbar mit anderen kardiochirurgischen Eingriffen. Der operative Eingriff ist weniger aufwendig als die MAZE-Operation und kann in einer minimalinvasiven Technik, auch in Zusammenhang mit Mitralklappeneingriffen, durchgeführt werden. Alternative Techniken, wie die neue Kryotechnologien, die Laserapplikation und die bipolare Hochfrequenzenergie werden im Rahmen von Studien auf ihre Effektivität und Sicherheit geprüft.

Successful coronary artery bypass grafting with the aid of a portable minimized extracorporeal life support system.

Extracorporeal life support system has been successfully used in patients with cardiac failure after open heart surgery, as a bridge to transplantation, and in patients with prolonged cardiogenic shock or cardiopulmonary arrest. This report presents our early experience with the new system Cardiohelp in coronary artery bypass grafting (CABG). Between August 2010 and June 2011, 50 patients underwent CABG with the aid of Cardiohelp. This subgroup was matched for sex and logistic EuroSCORE with 100 patients, who underwent CABG using two different extracorporeal circulation systems, a minimized (MECC) (n = 50) and a conventional (CECC) (n = 50) during the same period. Because of less hemodilution, the intraoperative blood transfusion was significantly lower in the Cardiohelp group (36%) and MECC group (40%) compared with the CECC group (64%). Postoperative release of creatinine kinase and lactate was lower in the Cardiohelp and MECC groups (p < 0.001). Furthermore, these patients had shorter duration of ventilation and lengths of stay at the intensive care unit (p < 0.05). Device-related complications were not observed. A conversion to CECC was not necessary. In conclusion, the Cardiohelp is a safe alternative for CABG surgery. Valid technical innovations and limited number of side effects support its employment as a highly effective device for coronary surgery.

Die chirurgische Behandlung des therapierefraktren Vorhofflimmerns@@@Surgical treatment of therapy resistant atrial fibrillation

Atrial fibrillation in patients with isolated, therapy resistant, chronic or paroxysmal atrial fibrillation (AF) or AF in combination with additional valvular and non-valvular cardiac pathology can be surgically treated by different techniques. Unipolar high frequency, cryotherapy and microwave energy is a curative approach for the treatment of the left atrium for AF. The postoperative mortality and morbidity rate is comparable to other cardiac surgery procedures. It is a technically less challenging procedure as compared to the MAZE procedure and can be applied using a minimally invasive approach. Alternative techniques such as new cryotechnologies, laser application and bipolar high frequency energy need to be evaluated for effectiveness and safety. Patienten mit alleinigem therapierefraktärem chronischen oder paroxysmalen Vorhofflimmern, oder mit begleitenden kardialen Erkrankungen, wie Herzklappendegenerationen, können mit verschiedenen Techniken chirurgisch behandelt werden. Mit der unipolare Hochfrequenzenergie, der Kryoapplikation und der Mikrowellenenergie ist eine erfolgreiche Behandlung des Vorhofflimmerns im Bereich des linken Vorhofes möglich. Die postoperative Mortalität und Morbidität ist vergleichbar mit anderen kardiochirurgischen Eingriffen. Der operative Eingriff ist weniger aufwendig als die MAZE-Operation und kann in einer minimalinvasiven Technik, auch in Zusammenhang mit Mitralklappeneingriffen, durchgeführt werden. Alternative Techniken, wie die neue Kryotechnologien, die Laserapplikation und die bipolare Hochfrequenzenergie werden im Rahmen von Studien auf ihre Effektivität und Sicherheit geprüft.