Gregor Wollenek

Gender differences in clinical presentation and surgical outcome of aortic stenosis

Background Little is known about the gender differences of patients undergoing aortic valve replacement (AVR) for isolated severe aortic stenosis. Methods and Results 408 consecutive patients (215 women and 193 men; p=0.9) were analysed. At presentation, women were older (73.7±9.3u2005years vs men 66.5±11.5u2005years; p<0.001), more symptomatic (New York Heart Association (NYHA) class: women 2.3±0.7 vs men 2.0±0.65; p<0.001), and presented with smaller valve areas (women 0.6±0.2u2005cm2 vs men 0.7±0.2u2005cm2; p<0.001) and higher mean pressure gradients (women 67.3±19.2u2005mmu2002Hg vs men 62.2±20.0u2005mmu2002Hg, p=0.001). Despite older age and more advanced disease in women, operative mortality did not differ. Survival after AVR by Kaplan–Meier analysis tended to be even better in women (92.8%, 89.8%, 81.4% vs men 89.1%, 86.6%, 76.3% at 1, 2 and 5u2005years, p=0.31). After division into age quintiles, the outcome of women was significantly better in patients older than 79u2005years (p=0.005). After adjustment for clinical characteristics, gender did not predict operative mortality and late outcome. Despite physical improvement in both groups after surgery, women remained more symptomatic (NYHA class: women 1.6±0.7 vs men 1.3±0.4; p=0.001). Conclusion Although women referred to AVR are older and more symptomatic, operative and long-term mortality are not increased. In the oldest age group of 79u2005years and older, women even have a better outcome, presumably due to a longer mean life expectancy.

Role of amiodarone on the systemic inflammatory response induced by cardiac surgery : proinflammatory actions

Objectif nOn a demontre que l’amiodarone (AMIO), un medicament anti-arythmique tres utilise, reduit l’incidence de fibrillation auriculaire apres la chirurgie cardiaque et qu’il exerce une action immunomodulatrice in vitro ainsi que des effets pronflammatoires in vivo. Cette etude a observe les proprietes immunomodulatrices de l’AMIO dans la reaction inflammatoire provoquee par la chirurgie cardiaque avec circulation extracorporelle (CEC).PurposeAmiodarone (AMIO), a widely used anti-arrhythmic drug, has been shown to reduce the incidence of atrial fibrillation after cardiac surgery and also to exert immunomodulatory actionsin vitro and proinflammatory effectsin vivo. The present study investigated the immunomodulatory properties of AMIO in the inflammatory response induced by cardiac surgery with cardiopulmonary bypass (CPB).MethodsIn this double-blind, placebo-controlled trial, 20 patients undergoing elective coronary artery bypass graft were randomized to receive placebo or AMIO 600 mg·day-1 orally for seven days before surgery and 45 mg hr-1 intravenously for 48 hr postoperatively. Plasma levels of the proinflammatory markers Ceactive protein (CRP), fibrinogen (FBG), tumour necrosis factor (TNF)-α, interleukin (IL)-6 and monocyte chemoattractant protein (MCP)-1, and the antiinflammatory marker IL-10, were compared before and after surgery.ResultsNinety-six hours after start of surgery, plasma levels of FBG had more than doubled (2.2 ± 0.5-fold increase, P < 0.0001). Overall, FBG formation was significantly increased in the AMIO group (P = 0.048). Monocyte chemoattractant protein 1 secretion transiently increased four hours after start of surgery (6.6 ± 4.5-fold increase) but rapidly declined thereafter, (P < 0.0001). There was a trend toward higher MCP-1 plasma concentrations in the AMIO group (P = 0.13). The plasma levels of CRP, TNF-α, IL-6 and Il-10 changed significantly over time, but were not altered by AMIO treatment.ConclusionIn the inflammatory response induced by cardiac surgery with CPB, our data suggest that AMIO treatment is associated with a selective trend toward proinflammatory actions.RésuméObjectifOn a démontré que l’amiodarone (AMIO), un médicament anti-arythmique très utilisé, réduit l’incidence de fibrillation auriculaire après la chirurgie cardiaque et qu’il exerce une action immunomodulatrice in vitro ainsi que des effets pronflammatoires in vivo. Cette étude a observé les propriétés immunomodulatrices de l’AMIO dans la réaction inflammatoire provoquée par la chirurgie cardiaque avec circulation extracorporelle (CEC).MéthodeDans cette étude à double insu et contrôlée par placebo, vingt patients devant subir un pontage aortocoronarien ont été randomisés à recevoir oralement soit un placebo, soit de l’AMIO 600 mg·jour-1 les sept jours précédant la chirurgie et 45 mg·h-1 en intraveineux durant les 48 h suivant l’opération. Les niveaux plasmatiques des marqueurs pro-inflammatoires suivants ont été comparés avant et après l’opération: protéine C-réactive (CRP), fibrinogène (FBG), facteur nécrosant des tumeurs (TNF)- α, interleukine (IL)-6 et protéine chimioattractive monocytaire (MCP1), et le marqueur antinflammatoire IL-10.RésultatsLes niveaux plasmatiques de FBG avaient plus que doublé 96 h après le début de la chirurgie (augmentation par 2,2 ± 0,5 fois, P < 0,0001). De façon générale, la formation de FBG s’est accrue de façon significative dans le groupe AMIO (P = 0,048). La sécrétion de la MCP-1 a momentanément augmenté quatre heures après le début de la chirurgie (de 6,6 ± 4,5 fois), mais a rapidement diminué ensuite (P < 0,0001). Une tendance vers des concentrations plasmatiques de MCP-1 plus élevées a été observée dans le groupe AMIO (P = 0,13). Les niveaux plasmatiques de CRP, TNF-α, IL-6 et IL-10 se sont modifiés de façon significative durant le temps de l’étude, mais le traitement à l’AMIO ne les a pas influencés.ConclusionDans le cas de la réaction inflammatoire provoquée par une chirurgie cardiaque avec CEC, nos données suggèrent que le traitement à l’AMIO est associé à une tendance sélective vers des propriétés pronflammatoires.

Rôle de l’amiodarone sur la réaction inflammatoire systémique provoquée par la chirurgie cardiaque : Sactions pro-inflammatoires

Objectif nOn a demontre que l’amiodarone (AMIO), un medicament anti-arythmique tres utilise, reduit l’incidence de fibrillation auriculaire apres la chirurgie cardiaque et qu’il exerce une action immunomodulatrice in vitro ainsi que des effets pronflammatoires in vivo. Cette etude a observe les proprietes immunomodulatrices de l’AMIO dans la reaction inflammatoire provoquee par la chirurgie cardiaque avec circulation extracorporelle (CEC).PurposeAmiodarone (AMIO), a widely used anti-arrhythmic drug, has been shown to reduce the incidence of atrial fibrillation after cardiac surgery and also to exert immunomodulatory actionsin vitro and proinflammatory effectsin vivo. The present study investigated the immunomodulatory properties of AMIO in the inflammatory response induced by cardiac surgery with cardiopulmonary bypass (CPB).MethodsIn this double-blind, placebo-controlled trial, 20 patients undergoing elective coronary artery bypass graft were randomized to receive placebo or AMIO 600 mg·day-1 orally for seven days before surgery and 45 mg hr-1 intravenously for 48 hr postoperatively. Plasma levels of the proinflammatory markers Ceactive protein (CRP), fibrinogen (FBG), tumour necrosis factor (TNF)-α, interleukin (IL)-6 and monocyte chemoattractant protein (MCP)-1, and the antiinflammatory marker IL-10, were compared before and after surgery.ResultsNinety-six hours after start of surgery, plasma levels of FBG had more than doubled (2.2 ± 0.5-fold increase, P < 0.0001). Overall, FBG formation was significantly increased in the AMIO group (P = 0.048). Monocyte chemoattractant protein 1 secretion transiently increased four hours after start of surgery (6.6 ± 4.5-fold increase) but rapidly declined thereafter, (P < 0.0001). There was a trend toward higher MCP-1 plasma concentrations in the AMIO group (P = 0.13). The plasma levels of CRP, TNF-α, IL-6 and Il-10 changed significantly over time, but were not altered by AMIO treatment.ConclusionIn the inflammatory response induced by cardiac surgery with CPB, our data suggest that AMIO treatment is associated with a selective trend toward proinflammatory actions.RésuméObjectifOn a démontré que l’amiodarone (AMIO), un médicament anti-arythmique très utilisé, réduit l’incidence de fibrillation auriculaire après la chirurgie cardiaque et qu’il exerce une action immunomodulatrice in vitro ainsi que des effets pronflammatoires in vivo. Cette étude a observé les propriétés immunomodulatrices de l’AMIO dans la réaction inflammatoire provoquée par la chirurgie cardiaque avec circulation extracorporelle (CEC).MéthodeDans cette étude à double insu et contrôlée par placebo, vingt patients devant subir un pontage aortocoronarien ont été randomisés à recevoir oralement soit un placebo, soit de l’AMIO 600 mg·jour-1 les sept jours précédant la chirurgie et 45 mg·h-1 en intraveineux durant les 48 h suivant l’opération. Les niveaux plasmatiques des marqueurs pro-inflammatoires suivants ont été comparés avant et après l’opération: protéine C-réactive (CRP), fibrinogène (FBG), facteur nécrosant des tumeurs (TNF)- α, interleukine (IL)-6 et protéine chimioattractive monocytaire (MCP1), et le marqueur antinflammatoire IL-10.RésultatsLes niveaux plasmatiques de FBG avaient plus que doublé 96 h après le début de la chirurgie (augmentation par 2,2 ± 0,5 fois, P < 0,0001). De façon générale, la formation de FBG s’est accrue de façon significative dans le groupe AMIO (P = 0,048). La sécrétion de la MCP-1 a momentanément augmenté quatre heures après le début de la chirurgie (de 6,6 ± 4,5 fois), mais a rapidement diminué ensuite (P < 0,0001). Une tendance vers des concentrations plasmatiques de MCP-1 plus élevées a été observée dans le groupe AMIO (P = 0,13). Les niveaux plasmatiques de CRP, TNF-α, IL-6 et IL-10 se sont modifiés de façon significative durant le temps de l’étude, mais le traitement à l’AMIO ne les a pas influencés.ConclusionDans le cas de la réaction inflammatoire provoquée par une chirurgie cardiaque avec CEC, nos données suggèrent que le traitement à l’AMIO est associé à une tendance sélective vers des propriétés pronflammatoires.

Predictors of outcome of non-ischemic mitral valve surgery

BACKGROUNDnData on the risk stratification of patients undergoing mitral valve (MV) surgery for non-ischemic mitral disease are sparse. The present study seeks to define them in a contemporary cohort.nnnMETHODSn193 consecutive patients referred to non-ischemic MV surgery were prospectively studied. Baseline characteristics and the type of surgery were analyzed with regard to operative and late mortality as well as functional outcome.nnnRESULTSn129 patients underwent MV replacement and 64 MV repair. MV replacement patients presented with more symptoms (p = 0.010), higher EuroSCORE (6.1 versus 5.6; p=0.009), more frequently underwent additional valve surgery (7.8 versus 0%; p = 0.003) and were more frequently female (p=0.048). Operative mortality was 3.1%, two thirds of operative deaths had additional surgery of the tricuspid valve (p = 0.019). Patients were followed for 5.2 ± 2.7 years. 1-, 3-, 5- and 7-year survival rates were 93-, 91-, 82-, and 79% in MV replacement patients versus 100-, 98-, 96-, and 89% in patients with MV repair (p = 0.015). However, by multivariate logistic regression, overall mortality was determined by additional surgery of the tricuspid valve (p = 0.0103), multivessel coronary disease (p = 0.026), and age (p<0.0001), but not by the type of surgery (p=0.066). Furthermore, the type of surgery did not influence functional outcome (p = 0.515).nnnCONCLUSIONSnApart from age and coronary artery disease the need for additional tricuspid valve surgery significantly determines the outcome of non-ischemic MV surgery. The type of operation appears less important when the need for additional valve surgery and co-morbidities like coronary artery disease are taken into consideration.

Heart transplantation in Vienna: 25 years of experience

SummarySince the beginning of the University of Vienna Cardiac Transplant Program in 1984, 1113 heart transplant procedures have been performed through August of 2008. One- and five-year survival has increased steadily over time (82% and 76%). Ten-year survival is 65%. Over the past 25 years our program has seen dramatic changes in patient selection, accepting now patients with more risk factors (e.g. age, diabetes, elevated pulmonary resistance). Developments in immunosuppression have decreased incidence of infection, rejection and graftarteriosclerosis continuously. Our program continues to pursue novel strategies to improve the survival and quality of life of our heart transplant patients.