Daniel Höfer

Neurological Outcome of Septic Cardioembolic Stroke After Infective Endocarditis

Background and Purpose— The aim of this study was to evaluate mortality and neurological outcomes of cardioembolic cerebral stroke in infective endocarditis (IE) patients requiring cardiac surgery. Methods— A consecutive series of 214 patients undergoing cardiac surgery for IE was followed up for 20 years. In 65 patients (mean age, 52 years), IE was complicated by computed tomography– or magnetic resonance imaging–verified stroke (n=61) or transient ischemic attack (n=4). Perioperative (30-day) and long-term mortality was assessed with regression models adjusting for age. Complete neurological recovery of IE survivors was defined by a modified Rankin score of ≤1 and a Barthel index of 20 points. Results— Fifty of 61 stroke patients (81.9%) survived surgery. In comparison with nonstroke patients, the age-adjusted perioperative mortality risk was 1.70-fold (95% CI, 0.73 to 3.96, P=0.22) higher and long-term mortality risk was 1.23-fold (95% CI, 0.72 to 2.11, P=0.45) higher in stroke patients. Patients with complicated stroke (meningitis, hemorrhage, or brain abscess) showed a higher perioperative mortality rate (38.9% vs 8.5%, P=0.007) but no higher neurological complication rate than patients with uncomplicated ischemic stroke. Complete neurological recovery was achieved in 35 IE survivors (70%, 95% CI, 55% to 82%). However, in the case of middle cerebral artery stroke, recovery was only 50% and was significantly lower compared with non—middle cerebral artery stroke (P=0.012). Conclusion— Uncomplicated IE-related stroke showed a favorable prognosis with regard to both long-term survival and neurological recovery. The formidable risk of secondary cerebral hemorrhage due to cardiac surgery seems to be much lower than previously thought.

Mitochondrial respiratory control and early defects of oxidative phosphorylation in the failing human heart.

Heart failure is a consequence of progressive deterioration of cardiac performance. Little is known about the role of impaired oxidative phosphorylation in the progression of the disease, since previous studies of mitochondrial injuries are restricted to end-stage chronic heart failure. The present study aimed at evaluating the involvement of mitochondrial dysfunction in the development of human heart failure. We measured the control of oxidative phosphorylation with high-resolution respirometry in permeabilized myocardial fibres from donor hearts (controls), and patients with no or mild heart failure but presenting with heart disease, or chronic heart failure due to dilated or ischemic cardiomyopathy. The capacity of the phosphorylation system exerted a strong limitation on oxidative phosphorylation in the human heart, estimated at 121 pmol O(2)s(-1)mg(-1) in the healthy left ventricle. In heart disease, a specific defect of the phosphorylation system, Complex I-linked respiration, and mass-specific fatty acid oxidation were identified. These early defects were also significant in chronic heart failure, where the capacities of the oxidative phosphorylation and electron transfer systems per cardiac tissue mass were decreased with all tested substrate combinations, suggesting a decline of mitochondrial density. Oxidative phosphorylation and electron transfer system capacities were higher in ventricles compared to atria, but the impaired mitochondrial quality was identical in the four cardiac chambers of chronic heart failure patients. Coupling was preserved in heart disease and chronic heart failure, in contrast to the mitochondrial dysfunction observed after prolonged cold storage of cardiac tissue. Mitochondrial defects in the phosphorylation system, Complex I respiration and mass-specific fatty acid oxidation occurred early in the development of heart failure. Targeting these mitochondrial injuries with metabolic therapy may offer a promising approach to delay the progression of heart disease.

Combined CMV prophylaxis improves outcome and reduces the risk for bronchiolitis obliterans syndrome (BOS) after lung transplantation.

Background. The benefit of cytomegalovirus (CMV) hyperimmune globuline in preventing CMV infection after lung transplantation still remains unclear. The aim of this study was to investigate the effect of combined prophylaxis using ganciclovir (GAN) and CMV hyperimmune globulin (CMV-IG) on CMV infection, CMV disease, survival and its role in preventing Bronchiolitis obliterans syndrome (BOS). Methods. A consecutive series of 68 CMV high-risk lung transplant recipients (D+/R−, D+/R+), who had a minimum follow-up of 1 year posttransplant were analyzed. Thirty patients (44.1%) received single GAN prophylaxis for 3 months (control group) and 38 recipients (55.9%) received GAN together with CMV-IG 7 times during the first postoperative month (study group). Median follow-up was 16.5 months in the control and 23.8 months in the study group (P=0.54). Results. Five CMV-related deaths (16.7%) occurred in the control group (P=0.014). Fifteen recipients suffered from CMV pneumonitis and three patients had CMV syndrome. In the control group, 13 recipients (43.3%) suffered from clinically manifested CMV disease compared to 5 (13.2%) in the study group (P=0.007). Additionally, recipient survival was significantly better in the study group (P=0.01). One year freedom from CMV affection was 52.1% in the control and 71.5% in the study group (P=0.027). Three-year freedom from BOS was significantly higher in the study group (54.3% vs. 82%, P=0.024). Conclusions. In CMV high risk patients, additional CMV-IG administration seems to be effective to reduce CMV-related morbidity and to avoid CMV-related mortality. Reduced incidence of BOS may result from improved CMV prevention, although randomized trials are warranted.

Transvenous Pacemaker Lead Removal Is Safe and Effective Even in Large Vegetations: An Analysis of 53 Cases of Pacemaker Lead Endocarditis

Background: The aim of this study was to investigate whether transvenous lead removal is safe and effective in patients with lead vegetations greater than 1 cm in size.

Können CMV-Infekte nach Herztransplantation durch dreimonatige antivirale Prophylaxe reduziert werden? 7 Jahre Erfahrung mit Ganciclovir

BACKGROUND In the early phase after heart transplantation (HTX) patients are at high risk for infection because of intensified immunosuppression. This retrospective study evaluates the efficacy of a three-month antiviral cytomegalovirus (CMV) prophylaxis. PATIENTS AND METHODS 133 patients received a three-month combined intravenous and oral CMV prophylaxis with Ganciclovir (Cymevene after HTX between 1997 and April 2003 (group II). They were compared to a historical group consisting of 40 patients, who had undergone HTX between 1995 and 1996 (group I; CMV-prophylaxis: hyperimmune globuline (Cytotect) for the first post-operative month in combination with orally administered aciclovir (Zovirax) for 6 months). Demographic data of organ recipients and donors in both groups were comparable, except for underlying cardiac diseases (p = 0.016). All patients had identical postoperative immunosuppressive regimes. RESULTS Group II had a significantly lower mortality rate (GI: 37.5%, GII: 9.8%; p < 0.001); one year survival (p = 0.001) and overall survival (p = 0.001) were significantly better than in group I. Patients of group II had fewer rejection episodes > or = grade II ISHLT requiring treatment (p < 0.001). Group II presented significantly fewer positive CMV blood samples (p = 0.005) and CMV infections (26% versus 47,5% in GI; p = 0.008), and a later onset of infections after HTX than group I (group I with a mean interval of 5.8 weeks after HTX, group II: 24.8 weeks after HTX; p < 0.001). CONCLUSION Incidence of CMV infection was significantly lowered under ganciclovir prophylaxis, infections occurred at a later time point after HTX, when patients were immunologically more competent. The proportion of higher grade rejection episodes was markedly reduced and survival was improved.SummaryBackgroundIn the early phase after heart transplantation (HTX) patients are at high risk for infection because of intensified immunosuppression. This retrospective study evaluates the efficacy of a three-month antiviral cytomegalovirus (CMV) prophylaxis.Patients and methods133 patients received a three-month combined intravenous and oral CMV prophylaxis with Ganciclovir (Cymevene®) after HTX between 1997 and April 2003 (group II). They were compared to a historical group consisting of 40 patients, who had undergone HTX between 1995 and 1996 (group I; CMV-prophylaxis: hyperimmune globuline (Cytotect®) for the first post-operative month in combination with orally administered aciclovir (Zovirax®) for 6 months).Demographic data of organ recipients and donors in both groups were comparable, except for underlying cardiac diseases (p=0.016). All patients had identical postoperative immunosuppressive regimes.ResultsGroup II had a significantly lower mortality rate (GI: 37.5%, GII: 9.8%; p<0.001); one year survival (p=0.001) and overall survival (p=0.001) were significantly better than in group I. Patients of group II had fewer rejection episodes ≥ grade II ISHLT requiring treatment (p<0.001).Group II presented significantly fewer positive CMV blood samples (p=0.005) and CMV infections (26% versus 47,5% in GI; p=0.008), and a later onset of infections after HTX than group I (group I with a mean interval of 5.8 weeks after HTX, group II: 24.8 weeks after HTX; p<0.001).ConclusionIncidence of CMV infection was significantly lowered under ganciclovir prophylaxis, infections occurred at a later time point after HTX, when patients were immunologically more competent. The proportion of higher grade rejection episodes was markedly reduced and survival was improved.ZusammenfassungHintergrund und FragestellungIn der frühen Phase nach Herztransplantation (HTX), der Zeit intensivster Immunsuppression, haben Patienten ein hohes Infektionsrisiko. Diese retrospektive Kohortenstudie evaluiert die Wirksamkeit einer dreimonatigen antiviralen Cytomegalievirus (CMV)-Prophylaxe.Patienten und Methodik133 Patienten (Gruppe II: HTX 1997 — April 2003) erhielten eine dreimonatige kombiniert intravenös-orale CMV-Prophylaxe (Ganciclovir-Cymevene®) und wurden mit einer historischen Gruppe I (40 Patienten, HTX 1995-1996; CMV-Prophylaxe: CMV-Hyperimmunglobulin [Cytotect®] im 1. postoperativen Monat; Aciclovir [Zovirax®] oral über 6 Monate) verglichen.Demographische Daten der Spender und Ernpfänqer beider Gruppen zeigten keine relevanten Unterschiede (ausgenommen cardiale Grunderkrankungen; p=0,016). In beiden Gruppen wurde ein identes immunsuppressives Regime verwendet.ErgebnisseIn Gruppe II war die Mortalität hochsignifikant geringer (GI: 37,5%, GIl: 9,8%, p<0,001), das Einjahresüberleben (p=0,001) und das Gesamtüberleben (p 0,001) hochsignifikant besser als in Gruppe I. Patienten der Gruppe II hatten hochsignifikant weniger höhergradige, therapiewürdige Abstoßungen (≥ Grad II nach ISHLT) (p<0,001).In Gruppe II fanden sich signifikant weniger positive CMV-Bluttests (p=0,005) und CMV-Infektionen (25,6% vs. 47,5% in GI; p=0,008), diese traten hochsignifikant später nach der HTX auf als in Gruppe I (GI: im Mittel 5,8 Wochen nach HTX, GII: 23,6 Wochen, p<0,001).FolgerungenUnter Ganciclovirprophylaxe war die Inzidenz der CMV-Infekte nicht nur signifikant reduziert, sie wurden zudem in eine spätere Phase nach HTX, in der Patienten immunologisch wiederum kompetenter sind, verschoben. Höhergradige Abstoßungen waren in der Ganciclovirgruppe hochsignifikant seltener, die zudem ein verbessertes Einjahres- und Langzeitüberleben aufweist.

Guillain-Barré Syndrome due to CMV Reactivation after Cardiac Transplantation

A 40-year-old male patient suffered from end-stage heart failure due to ischemic cardiomyopathy and received orthotopic cardiac transplantation in June 2005. The instantaneous postoperative course was uneventful, but, seven months later, he suffered from paralysis in the lower extremities finally resulting in quadriplegia and was admitted to hospital. After laboratory testings the diagnosis of a Guillain-Barré syndrome due to cytomegalovirus reactivation was confirmed.

Training models for coronary surgery.

This paper reviews currently used training models for coronary artery bypass grafting (CABG). Training models for CABG are extremely helpful not only for training surgical techniques, but also for the evaluation of new technologies and for research on bypass graft pathophysiology. Wet-lab models serve as training platforms for surgical residents and allow the evaluation of new technology (e.g., robotically enhanced CABG). The right coronary artery to left anterior descending artery model on the slaughterhouse pig heart is easily available, cheap, and effective. In vivo animal models for CABG are much more sophisticated and cost intensive. Pigs and dogs are the most commonly used animals for CABG training. Offpump CABG techniques, totally endoscopic CABG, endoscopic gastroepiploic artery harvesting, and axillocoronary bypass grafting have been evaluated in animal models.

Cardiac manifestation in muscular dystrophies leading to heart transplantation

SummaryBackgroundMuscular dystrophy (MD) is a group of inherited progressive muscle disorders characterized by defects in muscle proteins and the death of muscle cells and tissue. Most types of MD are multisystem disorders with low incidence and low affection of the heart, gastrointestinal system, nervous system, endocrine glands, eyes, and brain. In several forms of MDs, the cardiac disease may even be the predominant manifestation of the underlying genetic myopathy. Cardiac symptoms include arrhythmias, conduction defects, and cardiomyopathies. Heart transplantation is the treatment of choice in patients suffering from end-stage heart failure.MethodsFour (1.19 %) of 335 patients who underwent heart transplantation at the Innsbruck Medical University between January 1994 and December 2011 suffered from end-stage cardiomyopathies related to inherited myopathies. Three male patients had Becker MD, and one female patient had limb-girdle dystrophy. Mean age was 38.5 years, ranging from 16 to 56 years. Postoperative follow-up periods ranged from 16 months to 139 months, with a mean of 68.5 months. All four patients received triple-drug immunosuppression, consisting of azathioprine, cyclosporine, and steroids.ResultsAll four patients had an uneventful immediate postoperative course. One male patient died 16 months after cardiac transplantation because of pulmonary embolism and right heart failure, and another one died 11 years after cardiac transplantation because of myocardial and cerebral infarction after tricuspid valve replacement. The other two patients are currently in good general condition without progression of the muscle disease.ConclusionsHeart transplantation may increase life expectancy and quality of life in patients suffering from end-stage heart failure due to inherited MD. However, such patients are a challenging group and require special care and consideration during the perioperative and postoperative period to avoid life-threatening complications and progression of their primary disease.

Cardiac sarcoidosis mimicking arrhythmogenic right ventricular dysplasia

Isolated manifestation of sarcoidosis in the heart is very rare. The present work describes the case of a 41-year-old woman with ventricular tachycardia and severe symptoms of heart failure in June 2006. Clinical, MRI and echocardiographic findings revealed the diagnosis of an arrhythmogenic right ventricular dysplasia. Due to the severe progression of the disease, cardiac transplantation was performed in August 2007. Histopathological examination of the explanted heart, however, revealed numerous non-necrotising granulomas with giant cells, lymphocytic infiltration and interstitial fibrosis, finally confirming the diagnosis of a myocardial sarcoidosis.

Das komplett künstliche Herz

BACKGROUND To date the CardioWest™ total artificial heart is the only clinically available implantable biventricular mechanical replacement for irreversible cardiac failure. OBJECTIVES This article presents the indications, contraindications, implantation procedere and postoperative treatment. MATERIAL AND METHODS In addition to a overview of the applications of the total artificial heart this article gives a brief presentation of the two patients treated in our department with the CardioWest™. RESULTS The clinical course, postoperative rehabilitation, device-related complications and control mechanisms are presented. CONCLUSION The total artificial heart is a reliable implant for treating critically ill patients with irreversible cardiogenic shock. A bridge to transplantation is feasible with excellent results.ZusammenfassungHintergrundDas komplett künstliche Herz [„total artificial heart“ (TAH)] CardioWest™ ist derzeit der einzige, klinisch verfügbare mechanische Herzersatz bei irreversiblem, biventrikulärem Herzversagen.FragestellungWie lauten die Indikationen und Kontraindikationen für das TAH? Wie gestalten sich die Implantation und postoperative Betreuung?Material und MethodenNeben einer Übersicht über die Anwendung des TAH beinhaltet der vorliegende Beitrag eine kurze Vorstellung der zwei Patienten mit TAH-Implantation an unserer Klinik.ErgebnisseDer klinische Verlauf, die postoperative Rehabilitation, Komplikationen im System sowie Steuermöglichkeiten werden vorgestellt.SchlussfolgerungenDas TAH ist ein Implantat zur effektiven Behandlung von Patienten im irreversiblen kardiogenen Schock als Überbrückung zur Transplantation.AbstractBackgroundTo date the CardioWest™ total artificial heart is the only clinically available implantable biventricular mechanical replacement for irreversible cardiac failure.ObjectivesThis article presents the indications, contraindications, implantation procedere and postoperative treatment.Material and methodsIn addition to a overview of the applications of the total artificial heart this article gives a brief presentation of the two patients treated in our department with the CardioWest™.ResultsThe clinical course, postoperative rehabilitation, device-related complications and control mechanisms are presented.ConclusionThe total artificial heart is a reliable implant for treating critically ill patients with irreversible cardiogenic shock. A bridge to transplantation is feasible with excellent results.