Dirk Fritzsche

Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures.

OBJECTIVE Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results. METHODS From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection. RESULTS There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%. CONCLUSION On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.

Elektromyostimulation (EMS) bei kardiologischen Patienten

ZusammenfassungHintergrund:Die Vorstellung, dass moderates Ausdauertraining im Rahmen der Sekundärprävention die Prognose der chronischen Herzinsuffizienz (CHI) verbessert, wurde inzwischen hinreichend validiert. In der klinischen Routine bleiben jedoch erfahrungsgemäß nur wenige, gut geführte, hoch motivierte und zumeist jüngere Patienten einer dauerhaften sportlichen Begleittherapie zugänglich. Die eigenen Erfahrungen mit Ganzkörper-Elektromyostimulation (EMS-Training) an herzinsuffizienten Patienten zeigen ein bislang nicht erahntes Potential bei der Regeneration neurohumoraler, inflammatorischer und skelettmuskulärer Krankheitssymptome im Rahmen der Systemerkrankung CHI.Die mittels Spiroergometrie dosierte, möglichst tägliche dynamische Belastung ist adjuvanter Bestandteil der leitliniengerechten Therapie von Patienten mit chronischer Herzinsuffizienz. Die positive Beeinflussung klinischer Symptome und der Prognose ist durch Ergebnisse prospektiver, randomisierter Studien evidenzbasiert belegt. In der klinischen Praxis zeigt sich jedoch, dass die Erfolge nur bei intensiver Betreuung und Führung dieser Patienten erreicht werden. Einmal in das häusliche Umfeld gänzlich entlassen, hält die Mehrzahl der Patienten die tägliche Herausforderung einer selbstständigen, aktiven Form der körperlichen Belastung aus mentalen, physischen oder sozialen Gründen nicht aufrecht, und der Circulus vitiosus Systemerkrankung CHI manifestiert sich erneut.Patienten und Methodik:Vor diesem Hintergrund haben die Autoren in einer prospektiven Pilotstudie die Wirkung und die Akzeptanz der Ganzkörper-EMS, einer Art passiven, von der mentalen Einstellung und dem physischen Leistungsvermögen weitgehend unabhängigen Trainingsform, bei herzinsuffizienten Patienten untersucht.Ergebnisse:Eine bis zu 96%ige Steigerung der Sauerstoffaufnahme an der anaeroben Schwelle konnte nachgewiesen werden (VO2at 19,39 [± 5,3] ml/kg Körpergewicht [KG] vor Trainingsbeginn; VO2at 24,25 [±6,34] ml/kg KG am Ende der Trainingsphase; p < 0,05). Der diastolische Blutdruck sank signifikant (psyst < 0,05; pdiast < 0,001), der Muskelzuwachs betrug bis 14% bei Gewichtskonstanz. Die Trainingsmethode wurde zu 100% akzeptiert (keine Abbrecher), die Patienten gaben eine deutlich gesteigerte subjektive Leistungsfähigkeit an.Schlussfolgerung:Die Ergebnisse lassen ein erhebliches Potential in der kardiologischen Primär- und Sekundärrehabilitation erahnen, wobei gerade schwer eingeschränkte Patienten mit CHI überproportional profitierten.AbstractBackground:Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease.Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50–70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%.It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.Patients and Methods:The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.Results:An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO2at 19.39 [± 5.3] ml/kg vs. 24.25 [± 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.Conclusion:The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.BACKGROUND Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers. PATIENTS AND METHODS The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude. RESULTS An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved. CONCLUSION The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Elektromyostimulation: Verbesserung von Lebensqualität, Sauerstoffaufnahme und linksventrikulärer Funktion bei chronischer Herzinsuffizienz

AIM OF THE STUDY Regular physical activity has found to be a strategy to increase exercise capacity in patients with chronic heart failure (CHF). Next to endurance training also electromyostimulation (EMS) of thigh and gluteal muscles results in an increased capacity in CHF patients. EMS therapy was either done by stimulating 8 major muscle groups involving also trunk and arm muscles (extended electromyostimulation (exEMS)) in comparison to EMS therapy limited to gluteal and leg muscles (limEMS). METHODS 31 individuals completed the EMS training program. Stable CHF patients (NYHA class II-III) received either exEMS (18 patients, 11 males, mean age 59.8±13.8 years) or limEMS (13 patients, 10 males, 63.6±9.4 years). Training was performed for 10 weeks twice weekly for 20 min, the level of daily activity remained unchanged. Effects on exercise capacity, left ventricular function (EF - ejection fraction) and QoL (quality of life) were evaluated. RESULTS QoL was found to be improved in all domains of the SF-36 questionnaire. In the exEMS group there was a significant improvement in the domain physical functioning (54.09±29.9 to 75.45±15.6, p=0.48) and emotional role (63.63±45.8 to 93.93±20.1 p=0.048). LimEMS group showed significant improvement in the domain vitality (37.5±6.9 to 52.8±12.5, p=0.02).There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: +29.6%, p<0.001; limEMS +17.5%, p<0.001). EF -increased from 36.94±8.6 to 42.36±9.1% (+14.7%, p=0.003) in the exEMS group (limEMS 37.7±3.6 to 40.3±5.9% [+6.9%, p=0.18]). CONCLUSION EMS contributes to an improved quality of life and can improve oxygen uptake and EF in CHF. It may be an alternative therapy in CHF patients who are otherwise unable to undertake conventional forms of exercise training.

Electromyostimulation (EMS) in cardiac patients. Will EMS training be helpful in secondary prevention

ZusammenfassungHintergrund:Die Vorstellung, dass moderates Ausdauertraining im Rahmen der Sekundärprävention die Prognose der chronischen Herzinsuffizienz (CHI) verbessert, wurde inzwischen hinreichend validiert. In der klinischen Routine bleiben jedoch erfahrungsgemäß nur wenige, gut geführte, hoch motivierte und zumeist jüngere Patienten einer dauerhaften sportlichen Begleittherapie zugänglich. Die eigenen Erfahrungen mit Ganzkörper-Elektromyostimulation (EMS-Training) an herzinsuffizienten Patienten zeigen ein bislang nicht erahntes Potential bei der Regeneration neurohumoraler, inflammatorischer und skelettmuskulärer Krankheitssymptome im Rahmen der Systemerkrankung CHI.Die mittels Spiroergometrie dosierte, möglichst tägliche dynamische Belastung ist adjuvanter Bestandteil der leitliniengerechten Therapie von Patienten mit chronischer Herzinsuffizienz. Die positive Beeinflussung klinischer Symptome und der Prognose ist durch Ergebnisse prospektiver, randomisierter Studien evidenzbasiert belegt. In der klinischen Praxis zeigt sich jedoch, dass die Erfolge nur bei intensiver Betreuung und Führung dieser Patienten erreicht werden. Einmal in das häusliche Umfeld gänzlich entlassen, hält die Mehrzahl der Patienten die tägliche Herausforderung einer selbstständigen, aktiven Form der körperlichen Belastung aus mentalen, physischen oder sozialen Gründen nicht aufrecht, und der Circulus vitiosus Systemerkrankung CHI manifestiert sich erneut.Patienten und Methodik:Vor diesem Hintergrund haben die Autoren in einer prospektiven Pilotstudie die Wirkung und die Akzeptanz der Ganzkörper-EMS, einer Art passiven, von der mentalen Einstellung und dem physischen Leistungsvermögen weitgehend unabhängigen Trainingsform, bei herzinsuffizienten Patienten untersucht.Ergebnisse:Eine bis zu 96%ige Steigerung der Sauerstoffaufnahme an der anaeroben Schwelle konnte nachgewiesen werden (VO2at 19,39 [± 5,3] ml/kg Körpergewicht [KG] vor Trainingsbeginn; VO2at 24,25 [±6,34] ml/kg KG am Ende der Trainingsphase; p < 0,05). Der diastolische Blutdruck sank signifikant (psyst < 0,05; pdiast < 0,001), der Muskelzuwachs betrug bis 14% bei Gewichtskonstanz. Die Trainingsmethode wurde zu 100% akzeptiert (keine Abbrecher), die Patienten gaben eine deutlich gesteigerte subjektive Leistungsfähigkeit an.Schlussfolgerung:Die Ergebnisse lassen ein erhebliches Potential in der kardiologischen Primär- und Sekundärrehabilitation erahnen, wobei gerade schwer eingeschränkte Patienten mit CHI überproportional profitierten.AbstractBackground:Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease.Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50–70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%.It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.Patients and Methods:The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.Results:An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO2at 19.39 [± 5.3] ml/kg vs. 24.25 [± 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.Conclusion:The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.BACKGROUND Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers. PATIENTS AND METHODS The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude. RESULTS An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved. CONCLUSION The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Surgical repair of an uncontrolled thrombus caused by the Watchman device

A device-related thrombus is a very common complication after the implantation of a Watchman device. Although anticoagulation therapy is the standard first choice therapy for a device-related thrombus, complications related to bleeding or existence of non-responders to the anticoagulation therapy are reported. Therefore, the possibility of another treatment, including surgical repair, needs to be discussed in the population unsuccessfully treated with anticoagulation therapy. We performed device-related thrombus removal and covered the orifice of the left atrial appendage with an autologous pericardial patch in 2 cases involving non-responders to anticoagulation therapy. Herein, we describe the technique and results of our experience with these 2 patients. The covering technique with an autologous pericardial patch is simple but highly efficient in preventing recurrent thrombus formation.

Elektromyostimulation (EMS) bei kardiologischen Patienten@@@Electromyostimulation (EMS) in Cardiac Patients. Will EMS Training Be Helpful in Secondary Prevention?: Wird das EMS-Training bedeutsam für die Sekundärprävention?

ZusammenfassungHintergrund:Die Vorstellung, dass moderates Ausdauertraining im Rahmen der Sekundärprävention die Prognose der chronischen Herzinsuffizienz (CHI) verbessert, wurde inzwischen hinreichend validiert. In der klinischen Routine bleiben jedoch erfahrungsgemäß nur wenige, gut geführte, hoch motivierte und zumeist jüngere Patienten einer dauerhaften sportlichen Begleittherapie zugänglich. Die eigenen Erfahrungen mit Ganzkörper-Elektromyostimulation (EMS-Training) an herzinsuffizienten Patienten zeigen ein bislang nicht erahntes Potential bei der Regeneration neurohumoraler, inflammatorischer und skelettmuskulärer Krankheitssymptome im Rahmen der Systemerkrankung CHI.Die mittels Spiroergometrie dosierte, möglichst tägliche dynamische Belastung ist adjuvanter Bestandteil der leitliniengerechten Therapie von Patienten mit chronischer Herzinsuffizienz. Die positive Beeinflussung klinischer Symptome und der Prognose ist durch Ergebnisse prospektiver, randomisierter Studien evidenzbasiert belegt. In der klinischen Praxis zeigt sich jedoch, dass die Erfolge nur bei intensiver Betreuung und Führung dieser Patienten erreicht werden. Einmal in das häusliche Umfeld gänzlich entlassen, hält die Mehrzahl der Patienten die tägliche Herausforderung einer selbstständigen, aktiven Form der körperlichen Belastung aus mentalen, physischen oder sozialen Gründen nicht aufrecht, und der Circulus vitiosus Systemerkrankung CHI manifestiert sich erneut.Patienten und Methodik:Vor diesem Hintergrund haben die Autoren in einer prospektiven Pilotstudie die Wirkung und die Akzeptanz der Ganzkörper-EMS, einer Art passiven, von der mentalen Einstellung und dem physischen Leistungsvermögen weitgehend unabhängigen Trainingsform, bei herzinsuffizienten Patienten untersucht.Ergebnisse:Eine bis zu 96%ige Steigerung der Sauerstoffaufnahme an der anaeroben Schwelle konnte nachgewiesen werden (VO2at 19,39 [± 5,3] ml/kg Körpergewicht [KG] vor Trainingsbeginn; VO2at 24,25 [±6,34] ml/kg KG am Ende der Trainingsphase; p < 0,05). Der diastolische Blutdruck sank signifikant (psyst < 0,05; pdiast < 0,001), der Muskelzuwachs betrug bis 14% bei Gewichtskonstanz. Die Trainingsmethode wurde zu 100% akzeptiert (keine Abbrecher), die Patienten gaben eine deutlich gesteigerte subjektive Leistungsfähigkeit an.Schlussfolgerung:Die Ergebnisse lassen ein erhebliches Potential in der kardiologischen Primär- und Sekundärrehabilitation erahnen, wobei gerade schwer eingeschränkte Patienten mit CHI überproportional profitierten.AbstractBackground:Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease.Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50–70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%.It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.Patients and Methods:The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.Results:An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO2at 19.39 [± 5.3] ml/kg vs. 24.25 [± 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.Conclusion:The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.BACKGROUND Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers. PATIENTS AND METHODS The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude. RESULTS An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved. CONCLUSION The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Prädiktoren für das Überleben nach Implantation einer intraaortalen Ballonpumpe

ZusammenfassungHintergrundIn letzter Zeit wurden verschiedene Risikofaktoren für die Frühsterblichkeit nach Implantation einer intraaortalen Ballonpumpe (IABP) beschrieben. Hierbei handelt es sich um den Katecholaminbedarf, hämodynamische Parameter, Blutlaktatspiegel, Blutdruck sowie die Urinausscheidung. Ziel unserer Studie war es, unabhängige Risikofaktoren für die In-Hospital-Lethalität in einem Patientenkollektiv mit IABP-Implantation zu erfassen, um einen Risiko-Score für die Überlebensprognose zu entwickeln.MethodenWir haben eine retrospektive Datenerhebung an unserem Herzzentrum durchgeführt, um Patienten mit intra- bzw. postoperativer IABP-Implantation zu erfassen. 120 Patienten erfüllten während eines Zeitraums von 2 Jahren die Ein- und Ausschlusskriterien. Wir haben univariate und multivariate statistische Analysen durchgeführt, um potentielle Einflussfaktoren auf die 30-Tage-Lethalität zu erfassen.ErgebnisseDie 4 Parameter mittlerer arterieller Druck, Adrenalindosis, zentralvenöser Druck und die Blutlaktatkonzentration 6 h nach IABP-Implantation waren unabhängige Prädiktoren der 30-Tage-Lethalität. Sie wurden benutzt, um einen IABP Risiko-Score zu entwickeln (0–4 Punkte). Bei diesem Score hatten Patienten mit 3 oder 4 Punkten keine Überlebenschance, während die Überlebenswahrscheinlichkeit bei Patienten mit 0 Punkten 84,4% betrug. Die Fläche unterhalb der Receiver operating characteristics (ROC)-Kurve war 0,82 (0,74–0,91). Ein prospektiv untersuchtes Kollektiv von 145 Patienten bestätigte die Vertrauenswürdigkeit unseres Scores.SchlussfolgerungDie Ergebnisse zeigen, dass unser Score in der Lage ist, bei Patienten mit IABP-Implantation die 30-Tage-Überlebenswahrscheinlichkeit vorauszusagen. Der Score kann hilfreich sein um herauszufinden, ob eine ECMO/VAD-Implantation notwendig ist.SummaryBackgroundSeveral risk factors for early mortality after intra- aortic balloon pump (IABP) implantation in cardiac surgery have recently been described. These factors include catecholamine requirement, hemodynamic parameters, blood lactate concentration, blood pressure, and urine output. It was the aim of our study to assess independent risk factors of in-hospital mortality in our cohort of patients with IABP implantation in order to develop an IABP risk score for prognosis of survival.MethodsWe performed a retrospective analysis at our heart centre to identify patients receiving peri- or post-operative IABP support. During a time interval of 2 years, the criteria were met by 120 patients. We performed univariate and multivariate analyses to assess variables potentially influencing in-hospital mortality of our study cohort.ResultsThe four parameters, mean arterial pressure, adrenaline dose, jugular venous pressure, and blood lactate concentrations at 6 h of IABP use were independently related to 30-day mortality. They were used to develop an IABP risk score (0–4 points). With this score, patients who scored 3 or 4 points had no probability of surviving, whereas patients with a score of 0 had a probability of 84.4%. The area under the receiver operator characteristics (ROC) curve was 0.82 (0.74–0.91). A prospectively screened cohort of 145 patients confirmed reliability of our risk score.ConclusionsOur data demonstrate that a score can predict 30-day mortality in patients with IABP implantation. Such a score can be useful to find out whether or not ECMO/VAD implantation is necessary.

Degeneration biologischer Aortenklappenprothesen im Senium

ZusammenfassungHintergrund:Aufgrund der gestiegenen Lebenserwartung von Patienten mit Herzklappenersatz sowie einer begrenzten Haltbarkeit biologischer Klappenprothesen wird bei einem signifikanten Prozentsatz der Patienten eine Reoperation im Alter von ≥80 Jahren notwendig. Es liegen jedoch nur wenige Daten zur Letalität nach Ersatz einer biologischen Prothese vor.Patienten und Methodik:Deshalb wurde bei 56 Patienten im Alter von ≥80 Jahren, die im Zeitraum von 1991 bis 2004 aufgrund einer Klappendegeneration am Zentrum der Autoren reoperiert wurden, eine retrospektive Datenanalyse vorgenommen. Mittels uniund multivariater Cox-Regressionsanalysen wurden Einflussfaktoren auf die Überlebensrate untersucht.Ergebnisse:Die mittlere Überlebensdauer der Patienten betrug 5 Jahre. Die 30-Tage-, 1-Jahres-, 3-Jahres- und 5-Jahres-Überlebensraten lagen bei 81,1%, 71,3%, 67,5% und 50,8%. Lediglich das Low-Output-Syndrom und Darmischämien erwiesen sich als unabhängige Prädiktoren sowohl der 30-Tage-Letalität als auch der 3-Jahres-Mortalität. Postoperativ kam es zu einer deutlichen Verbesserung des NYHA-Stadiums, und die Mehrzahl der Überlebenden war in der Lage, eigenständig zu Hause zu leben.Schlussfolgerung:Die Daten zeigen, dass es möglich ist, akzeptable Ergebnisse bei ≥80-Jährigen nach Ersatz der Klappenprothese zu erzielen. Sowohl die frühe als auch die mittlere Mortalitätsrate sind vorwiegend von unerwarteten postoperativen Komplikationen beeinflusst. Somit ist eine Reoperation der Aortenklappe selbst bei Patienten dieser Altersgruppe vertretbar.AbstractBackground:Due to increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, replacement of aortic valve prosthesis becomes necessary in a significant percentage of patients. However, reliable data on mortality and its risk factors in octogenarians after replacement of aortic bioprostheses are limited.Patients and Methods:56 patients aged ≥ 80 years who underwent cardiac reoperation of a bioprosthesis due to structural valve deterioration at the authors’ heart center between 1991 and 2004 were analyzed retrospectively. To assess predictors of 30-day and 3-year survival, uni- and multivariate Cox regression analyses were performed.Results:30-day, 1-year, 3-year, and 5-year survival rates were 81.1%, 71.3%, 67.5%, and 50.8%, respectively. Patients with reoperation had an estimated median survival of 5.0 years. Patients who survived their in-hospital stay had a very similar life expectancy compared with the general German population. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day and 3-year survival (p < 0.001). Postoperative New York Heart Association functional class improved markedly in the study cohort and the majority of survivors was able to live at home. As we cannot offer these patients an alternative effective medical therapy, octogenarians who need their aortic valve prosthesis to be replaced are left in a miserable condition with a poor prognosis, if surgery is denied. Therefore, considering that almost the same criteria are used for younger patients with the emphasis that surgery should not be delayed until they are highly symptomatic, reoperation of the aortic valve in this age group is justified.Conclusion:The data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who are in need of a replacement of their aortic valve prosthesis. Early as well as mid-term survival are predominantly influenced by unexpected postoperative complications.

Structural valve deterioration of aortic bioprostheses and reoperation in octogenarians. Results and risk factors for survival

ZusammenfassungHintergrund:Aufgrund der gestiegenen Lebenserwartung von Patienten mit Herzklappenersatz sowie einer begrenzten Haltbarkeit biologischer Klappenprothesen wird bei einem signifikanten Prozentsatz der Patienten eine Reoperation im Alter von ≥80 Jahren notwendig. Es liegen jedoch nur wenige Daten zur Letalität nach Ersatz einer biologischen Prothese vor.Patienten und Methodik:Deshalb wurde bei 56 Patienten im Alter von ≥80 Jahren, die im Zeitraum von 1991 bis 2004 aufgrund einer Klappendegeneration am Zentrum der Autoren reoperiert wurden, eine retrospektive Datenanalyse vorgenommen. Mittels uniund multivariater Cox-Regressionsanalysen wurden Einflussfaktoren auf die Überlebensrate untersucht.Ergebnisse:Die mittlere Überlebensdauer der Patienten betrug 5 Jahre. Die 30-Tage-, 1-Jahres-, 3-Jahres- und 5-Jahres-Überlebensraten lagen bei 81,1%, 71,3%, 67,5% und 50,8%. Lediglich das Low-Output-Syndrom und Darmischämien erwiesen sich als unabhängige Prädiktoren sowohl der 30-Tage-Letalität als auch der 3-Jahres-Mortalität. Postoperativ kam es zu einer deutlichen Verbesserung des NYHA-Stadiums, und die Mehrzahl der Überlebenden war in der Lage, eigenständig zu Hause zu leben.Schlussfolgerung:Die Daten zeigen, dass es möglich ist, akzeptable Ergebnisse bei ≥80-Jährigen nach Ersatz der Klappenprothese zu erzielen. Sowohl die frühe als auch die mittlere Mortalitätsrate sind vorwiegend von unerwarteten postoperativen Komplikationen beeinflusst. Somit ist eine Reoperation der Aortenklappe selbst bei Patienten dieser Altersgruppe vertretbar.AbstractBackground:Due to increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, replacement of aortic valve prosthesis becomes necessary in a significant percentage of patients. However, reliable data on mortality and its risk factors in octogenarians after replacement of aortic bioprostheses are limited.Patients and Methods:56 patients aged ≥ 80 years who underwent cardiac reoperation of a bioprosthesis due to structural valve deterioration at the authors’ heart center between 1991 and 2004 were analyzed retrospectively. To assess predictors of 30-day and 3-year survival, uni- and multivariate Cox regression analyses were performed.Results:30-day, 1-year, 3-year, and 5-year survival rates were 81.1%, 71.3%, 67.5%, and 50.8%, respectively. Patients with reoperation had an estimated median survival of 5.0 years. Patients who survived their in-hospital stay had a very similar life expectancy compared with the general German population. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day and 3-year survival (p < 0.001). Postoperative New York Heart Association functional class improved markedly in the study cohort and the majority of survivors was able to live at home. As we cannot offer these patients an alternative effective medical therapy, octogenarians who need their aortic valve prosthesis to be replaced are left in a miserable condition with a poor prognosis, if surgery is denied. Therefore, considering that almost the same criteria are used for younger patients with the emphasis that surgery should not be delayed until they are highly symptomatic, reoperation of the aortic valve in this age group is justified.Conclusion:The data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who are in need of a replacement of their aortic valve prosthesis. Early as well as mid-term survival are predominantly influenced by unexpected postoperative complications.

Degeneration biologischer Aortenklappenprothesen im Senium@@@Structural Valve Deterioration of Aortic Bioprostheses and Reoperation in Octogenarians. Results and Risk Factors for Survival: Ergebnisse und Risikofaktoren der operativen Therapie

ZusammenfassungHintergrund:Aufgrund der gestiegenen Lebenserwartung von Patienten mit Herzklappenersatz sowie einer begrenzten Haltbarkeit biologischer Klappenprothesen wird bei einem signifikanten Prozentsatz der Patienten eine Reoperation im Alter von ≥80 Jahren notwendig. Es liegen jedoch nur wenige Daten zur Letalität nach Ersatz einer biologischen Prothese vor.Patienten und Methodik:Deshalb wurde bei 56 Patienten im Alter von ≥80 Jahren, die im Zeitraum von 1991 bis 2004 aufgrund einer Klappendegeneration am Zentrum der Autoren reoperiert wurden, eine retrospektive Datenanalyse vorgenommen. Mittels uniund multivariater Cox-Regressionsanalysen wurden Einflussfaktoren auf die Überlebensrate untersucht.Ergebnisse:Die mittlere Überlebensdauer der Patienten betrug 5 Jahre. Die 30-Tage-, 1-Jahres-, 3-Jahres- und 5-Jahres-Überlebensraten lagen bei 81,1%, 71,3%, 67,5% und 50,8%. Lediglich das Low-Output-Syndrom und Darmischämien erwiesen sich als unabhängige Prädiktoren sowohl der 30-Tage-Letalität als auch der 3-Jahres-Mortalität. Postoperativ kam es zu einer deutlichen Verbesserung des NYHA-Stadiums, und die Mehrzahl der Überlebenden war in der Lage, eigenständig zu Hause zu leben.Schlussfolgerung:Die Daten zeigen, dass es möglich ist, akzeptable Ergebnisse bei ≥80-Jährigen nach Ersatz der Klappenprothese zu erzielen. Sowohl die frühe als auch die mittlere Mortalitätsrate sind vorwiegend von unerwarteten postoperativen Komplikationen beeinflusst. Somit ist eine Reoperation der Aortenklappe selbst bei Patienten dieser Altersgruppe vertretbar.AbstractBackground:Due to increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, replacement of aortic valve prosthesis becomes necessary in a significant percentage of patients. However, reliable data on mortality and its risk factors in octogenarians after replacement of aortic bioprostheses are limited.Patients and Methods:56 patients aged ≥ 80 years who underwent cardiac reoperation of a bioprosthesis due to structural valve deterioration at the authors’ heart center between 1991 and 2004 were analyzed retrospectively. To assess predictors of 30-day and 3-year survival, uni- and multivariate Cox regression analyses were performed.Results:30-day, 1-year, 3-year, and 5-year survival rates were 81.1%, 71.3%, 67.5%, and 50.8%, respectively. Patients with reoperation had an estimated median survival of 5.0 years. Patients who survived their in-hospital stay had a very similar life expectancy compared with the general German population. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day and 3-year survival (p < 0.001). Postoperative New York Heart Association functional class improved markedly in the study cohort and the majority of survivors was able to live at home. As we cannot offer these patients an alternative effective medical therapy, octogenarians who need their aortic valve prosthesis to be replaced are left in a miserable condition with a poor prognosis, if surgery is denied. Therefore, considering that almost the same criteria are used for younger patients with the emphasis that surgery should not be delayed until they are highly symptomatic, reoperation of the aortic valve in this age group is justified.Conclusion:The data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who are in need of a replacement of their aortic valve prosthesis. Early as well as mid-term survival are predominantly influenced by unexpected postoperative complications.