Friedrich Eckstein

Plicated Patch Repair for Acquired Gerbode Defect Involving the Tricuspid Valve

Gerbodes defect, a left ventricular-to-right atrial communication, with involvement of the tricuspid valve acquired after bacterial endocarditis can be challenging to repair. We report a modified technique for a shunt closure and reconstruction of the tricuspid valve using a plicated bovine pericardial patch. Combining such a repair with a left ventricular patch resulted in a complete defect closure and competent tricuspid valve without regurgitation.

Emergent Axillary Artery Stent-Graft Placement for Massive Hemorrhage from an Avulsed Subscapular Artery

Purpose: To report the successful endovascular repair of an acute axillary artery hemorrhage. Case Report: An 87-year-old woman with Charcot-Marie-Tooth ataxia presented with an enormous shoulder hematoma and clinical signs of exsanguination after a fall. Angiography demonstrated complete avulsion of the right subscapular artery from the axillary artery, and active bleeding into a hematoma of at least 1500 mL. Endovascular repair with a balloon-mounted covered stent-graft was performed percutaneously, which controlled the bleeding and averted surgery. The patient recovered uneventfully and was without signs of recurrent bleeding or ischemia on the 6-month ultrasound examination; she reports no symptoms referable to her upper extremity after 14 months. Conclusions: Endovascular repair with stent-grafts is effective in controlling arterial bleeding from supra-aortic vessels even under emergency conditions.

Total arterial off-pump versus on-pump coronary revascularization: comparison of early outcome.

Abstract  Background and aim: To assess differences in the early outcome after complete arterial myocardial revascularization with (ONCAB) or without cardiopulmonary bypass (OPCAB). Methods: Out of 870 consecutive CABG procedures 58 OPCAB and 91 ONCAB patients receiving exclusive arterial grafts were analyzed. OPCAB patients had more single‐vessel (p < 0.0001), less triple‐vessel (p < 0.0001) or left main disease (p = 0.0021), higher angina class (p = 0.003), unstable angina (p < 0.0001) or previous PTCAs (p < 0.0001). Results: ONCAB was associated with longer operations (182.5 ± 38 vs. 147 ± 56 min; p = 0.0001) and more anastomoses/patient (3.2 ± 1 vs. 2 ± 0.9; p < 0.0001), but incomplete revascularization was similar in both groups (11% vs. 17%; p = ns). ITA use was identical, whereas single left internal thoracic artery (LITA) use (25.9% vs.1%; p < 0.0001) and LITA jump anastomoses (10.3% vs. 7.7%; p < 0.0001) were more frequent in OPCAB. Radial artery (RA) use (89% vs. 46.6%; p < 0.0001) and RA jump anastomoses (57.1% vs. 12.1%; p < 0.0001) were more frequent in ONCAB. Mortality, arrhythmias, cerebro‐vascular accidents (CVA), and renal failure were similar, but ventilatory support shorter (8.8 ± 11.8 vs. 15.6 ± 9.4 h; p < 0.0001) and cardiac enzyme release smaller (p < 0.0001) after OPCAB with a trend toward less myocardial infarction (1.7% vs. 7.7%; p = 0.12) and low output (1.7% vs. 8.8%; p = 0.089), and more respiratory complications (10.3% vs. 2.2%; p = 0.056). Conclusions: Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or ICU and hospital stay, but with shorter ventilatory support and lower cardiac enzymes with a trend toward lower myocardial infarction and low output, but higher respiratory complication rates after OPCAB.

Totally arterial off-pump vs. on-pump coronary revascularization: comparison of early outcome.

Our objective was to assess differences in early outcome after completely arterial myocardial revascularization with (on-pump coronary artery bypass grafting or ONCAB) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting or OPCAB). Fifty-eight OPCAB and 91 ONCAB patients receiving exclusively arterial grafts were analyzed. OPCAB patients had more single-vessel (P<0.0001), less triple-vessel (P<0.0001) or left main disease (P=0.0021), higher angina class (P=0.003), more unstable angina (P<0.0001) and previous percutaneous transluminal coronary angioplasty (PTCA; P<0.0001), but similar EuroScores (P=n.s.). ONCAB was associated with longer operation time (P=0.0001) and more anastomoses/patient (P<0.0001). Internal thoracic artery (ITA) use was identical, whereas single left ITA use (P<0.0001) and left ITA jump anastomoses (P<0.0001) were more frequent in OPCAB. Radial artery (RA) use (P<0.0001) and RA jump anastomoses (P<0.0001) were more frequent in ONCAB. Complication rates were similar concerning mortality, arrhythmias, cerebro-vascular accidents (CVA), and renal failure with shorter ventilatory support (P<0.0001) and a trend towards less perioperative myocardial infarction (PMI) (P=0.12) and low output (P=0.089), and more respiratory complications (P=0.056) after OPCAB. Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or intensive care unit and hospital stay, but with shorter ventilatory support and a trend towards lower PMI and low output, and higher respiratory complication rates after OPCAB.

Effects of the Novel Polymer Gel LeGoo on Human Internal Thoracic Arteries

PURPOSE Established hemostatic devices can injure vessel wall integrity. LeGoo (Pluromed, Woburn, MA), a novel poloxamer gel with reverse thermosensitive properties, is a new device for temporary occlusion of blood vessels. The present study investigated the effects of LeGoo on vascular function and morphology. DESCRIPTION The distal end of the human internal thoracic artery was used to assess vascular function of LeGoo-applied segments in organ bath experiments and by scanning electron microscopy. EVALUATION After LeGoo application, both maximal contractile responses to noradrenaline and endothelium-dependent relaxant responses to acetylcholine were significantly reduced. Scanning electron microscopy showed areas of injured endothelium with exposure of subendothelial structures being in line with the functional changes. CONCLUSIONS Data suggested that application of LeGoo induced significant endothelial injury and deterioration of the smooth muscle in human internal thoracic arteries.

Chirurgie cardiaque et vasculaire thoracique: Revascularisation de la cardiopathie coronarienne chez les patients diabétiques – résultats de l’étude FREEDOM

La stratégie thérapeutique optimale pour patients diabétiques présentant une atteinte des trois vaisseaux coronaires a longtemps fait l’objet d’une controverse. L’objectif de l’étude FREEDOM était de répondre à la question suivante: un traitement médicamenteux agressif associé à des interventions percutanées au moyen de stents médicamenteux peut-il modifier la stratégie de traitement de patients diabétiques présentant une atteinte coronarienne multivasculaire? 1900 patients diabétiques ont été randomisés entre 2005 et 2010, 953 dans le groupe stent, 947 dans le groupe chirurgie [1]. L’étude a été conçue en tant que «superiority trial», avec une durée moyenne d’observation d’env. quatre ans. Tous les patients ont reçu un traitement optimal du taux de cholestérol, de la pression artérielle systolique et de la glycémie. Les facteurs suivants ont été analysés: cas de décès (toutes causes confondues) ainsi qu’infarctus myocardique et accident vasculaire cérébral sans létalité. La mortalité sur cinq ans était de 26,6% dans le groupe stent, contre 18,7% dans le groupe chirurgie (p = 0,049). L’avantage du pontage coronaire a été confirmé par le faible taux d’infarctus myocardiques (p <0,001). Au bout de cinq ans, les événements cérébrovasculaires étaient un peu plus fréquents chez les patients ayant suivi un pontage coronaire (5,2%) qu’après une intervention percutanée (2,4%). Ces résultats ont été confirmés pour tous les niveaux de complexité angiographique (selon le score Syntax), de fraction d’éjection du ventricule gauche et de fonction hépatique (fig. 1 x et 2 x). Les auteurs concluent que le pontage coronaire reste la meilleure option thérapeutique pour les patients diabétiques présentant une cardiopathie coronarienne avancée. De tels résultats avaient déjà été publiés au milieu des années 1990 (étude BARI) et confirmés plus tard par les études ARTS, CARDia et SYNTAX. Malgré ces résultats clairs, la pratique clinique n’a, dans l’ensemble, pas été fondamentalement modifiée. Ceci est dû au fait que le taux plus élevé d’événements cardiovasculaires avait été justifié par un besoin supérieur en revascularisations répétées dans le groupe traité à l’origine par stent [2]. Ceci est différent dans l’étude FREEDOM: l’avantage de la revascularisation chirurgicale s’explique principalement par une réduction du taux d’infarctus myocardiques et du nombre de décès (toutes causes confondues). Les résultats de cette étude sont en corrélation avec les observations cliniques selon lesquelles, après la pose de stent, les patients présentent souvent à long terme une diminution significative de la fonction ventriculaire gauche en raison de petits infarctus inapperçus et itératifs. Le traitement médicamenteux est essentiel pour tous les patients diabétiques présentant une cardiopathie coronarienne. A la différence de ceux de l’étude SYNTAX, les patients de l’étude FREEDOM ont reçu un traitement de suivi par des antiagrégants plaquettaires, comparable dans les deux groupes (ICP ou pontage). Pour conclure, l’éditorial du collègue Hlatky est mentionné comme une prise de position équilibrée émanant d’un cardiologue qui ne pratique pas d’interventions [3]. Ci-dessous se trouvent quelques-unes de ces affirmations les plus importantes: «As a cardiologist who does not perform either procedure, I find that the FREEDOM trial provides compelling evidence of the comparative effectiveness of CABG versus PCI in patients with diabetes and multivessel coronary artery disease.» «The results of the FREEDOM trial suggest that patients with diabetes ought to be informed about the potential survival benefit from CABG for the treatment of multivessel disease. These discussions should begin before

Integrity of mechanical aortic valve prostheses explanted after 27 and 23 years

We describe 2 cases of mechanical aortic valve endocarditis and the influence on clinical outcome and prostheses material integrity. One patient required extensive reconstruction due to active endocarditis leading to a “rocking valve”. The second case was caused by late aortic dissection following endocarditis. Both valve prostheses showed remarkable material quality and performance in functional assessment and high resolution scanning electron microscopic evaluation after 27 and 23 years of service.