H. Gramsch-Zabel

Left Ventricular Assist Device in a Patient With a Concomitant Subcutaneous Implantable Cardioverter Defibrillator

A 51-year-old male, with prior coronary artery bypass grafts and a more recent history of recurrent hospital admissions for refractory heart failure, presented with advanced heart failure caused by ischemic cardiomyopathy. The patient was placed on the heart transplantation list. A subcutaneous-implantable cardioverter/defibrillator (S-ICD; Cameron Health, San Clemente, CA) was electively implanted 1 month later for primary prevention. At implant, sustained ventricular fibrillation was induced and successfully converted to normal sinus rhythm with a submaximal 65 J standard polarity shock with time to therapy of 13 s and impedance of 55 Ω. After an uneventful postoperative period, the patient was discharged home but readmitted a few weeks later with …

Long‐Term Follow‐Up of Left Ventricular Pacing via a Posterior Cardiac Vein After Mechanical Tricuspid Valve Replacement

WINTER, J., et al.: Long‐Term Follow‐Up of Left Ventricular Pacing via a Posterior Cardiac Vein After Mechanical Tricuspid Valve Replacement. Permanent cardiac pacing was recommended in a 66‐year‐old woman with mechanical prosthetic mitral and tricuspid valves. To avoid a thoracotomy, a conventional endocardial lead was inserted with a steerable stylet (Locator) into the posterior cardiac vein via the right cephalic vein. Four weeks later, lead dislodgement required reoperation. The lead position remained stable up to 29 months.

Isolated Tricuspid Valve Surgery: A Single Institutional Experience with the Technique of Minimally Invasive Surgery via Right Minithoracotomy.

Background Minimally invasive cardiac surgery via right lateral minithoracotomy is a well‐described approach. However, reports on isolated tricuspid valve surgery (TVS) in this technique are rare. Therefore, we like to give a contribution by reporting our experience. Methods We retrospectively reviewed 25 tricuspid valve operations via right lateral minithoracotomy with femoral cannulation between August 2009 and September 2013 (18 repairs, 7 replacements, and 72% repair rate). Three patients (12%) presented for a re‐do operation, and nine patients (36%) suffered from active endocarditis at admission. All patients underwent TVS as single valve procedure. Ten patients received additional procedures such as removal of infected leads, resection of atrial tumors, or closure of atrial septal defects. An annuloplasty ring was inserted in 12 cases. We investigated the short‐term morbidity and mortality with regard to the surgical procedure. Results Repair rate was 72%. Thirty‐day and 1‐year mortality were 4 and 20%, respectively. The only patient with early mortality received the surgical procedure on the tricuspid valve as fourth cardiac‐related surgery and postoperative mortality was due to intracranial air embolism. Perioperative morbidity included reoperation for bleeding (8%) and stroke (4%). No disturbance of wound healing occurred. Durations of intensive care unit stay and hospital stay were 2.3 ± 2.4 and 17.4 ± 13.1 days, respectively. Endocarditis‐caused surgery did not reveal any significant difference in the intra‐ or perioperative course compared with other indications. Conclusion Minimally invasive TVS via right lateral minithoracotomy is feasible with good results. Even in a cohort of patients suffering from elevated rate of active endocarditis, a high repair rate can be achieved.

The Incidence of Myocardial Contusion in 160 Patients with Blunt Chest Trauma Diagnostic Criteria and Outcome

The incidence of myocardial contusion after blunt chest trauma has been reported in 8.2 to 75% of trauma patients. We performed this study to report on the incidence of myocardial contusion in order to determine the frequency and to describe the type of complications in these patients.We conducted a retrospective analysis over a period of 4 years. There were 160 patients with a blunt chest trauma which were admitted to our hospital.Myocardial contusion occurred in 27 of our patients with blunt chest trauma (16.9%). In all these patients typical ECG-changes could be found during hospitalization (100%). The incidence of further pathological findings in the 27 patients was 30% for the auscultation, 37% for cardiac enzymes (MB-fraction), and 41% for the echocardiography. Cardiac complications like arrhythmias, cardiac failure and tamponade occurred in 20 patients (74%).Early diagnosis of myocardial contusion in patients with blunt chest trauma is important to prevent and to treat possible complications. ECG-controls have the highest sensitivity to detect a myocardial contusion, whereas cardiac enzymes and echocardiograms seem to be poor markers of blunt myocardial injury.

Single-centre experience of mitral valve surgery via right lateral mini-thoracotomy in octogenarians

OBJECTIVES According to demographic changes in the industrialized world, the average age of patients referred to cardiac surgery is increasing. These patients typically display numerous comorbidities, associated with increased perioperative risk. Therefore, the indication for a catheter-based therapy is progressively extended, including interventions on the mitral valve (MV). In this context, we evaluated a contemporary series of octogenarians undergoing minimally invasive MV surgery at our institution using right lateral minithoracotomy to elucidate the preoperative risk profile and the postoperative course in this particular cohort. METHODS Between October 2009 and October 2014, 34 patients aged 80 years and older (82.5 ± 2.0) undergoing minimally invasive MV surgery were identified with a subgroup of 15 patients (44.1%) receiving concomitant surgery on the tricuspid valve (TV). We analysed the preoperative profile, perioperative course and functional outcome. RESULTS Preoperative comorbidities included insulin-dependent diabetes mellitus (17.6%), COPD (17.6%), active endocarditis (2.9%) and previous neurological events (2.9%). The mean left ventricular ejection fraction was 59.7 ± 6.9%. Mean European System for Cardiac Outcome Risk Evaluation II was 5.2 ± 5.3%. The repair rate of all treated MVs and TVs in isolated and combined procedures was 81.6% (73.5% for MV and 100.0% for TV surgery). Postoperatively, 4 patients (11.8%) required new-onset intermittent haemodialysis. Prolonged ventilation (>12 h) was necessary in 9 patients (26.5%). The 30-day mortality rate was 5.9%. CONCLUSIONS Minimally invasive right lateral MV surgery in octogenarians results in favourable outcomes. Therefore, MV surgery represents a valid option in this cohort, providing established and durable concepts of valve reconstruction.

Hypertrophische Kardiomyopathie (HCM) Chirurgische versus medikamentöse Therapie

Die hypertrophe Kardiomyopathie (HCM) ist eine Erkrankung mit unterschiedlichen ätiologischen, morphologischen, funktionellen, klinischen und therapeutischen Aspekten. Neuere Erhebungen zeigen eine relativ große Verbreitung der HCM in der Bevölkerung auf (1:500). Die Ursachen sind größtenteils auf eine familiäre oder sporadisch auftretende genetische Mutation zurückzuführen. Nach dem klinischen Bild ergeben sich aufgrund molekulargenetischer, hämodynamischer und morphologischer Befunde hinsichtlich medikamentöser und chirurgischer Therapieansätze im wesentlichen zwei Patientengruppen: 1. Die hypertrophe nichtobstruktive Kardiomyopathie (HNCM) Auf dem Boden familiärer molekulargenetischer Untersuchungen können Patienten ohne klinische, hämodynamische und morphologische Abweichungen identifiziert werden. Andere entwickeln eine geringgradige Hypertrophie sowie verschiedene Formen von Rhythmusstörungen, die auf ein erhöhtes Risiko, einem plötzlichen Herztod zu erliegen, hinweisen und einer entsprechenden antiarrhythmischen Behandlung bedürfen. Bei einer zunehmenden symptomatischen Hypertrophie ist eine Behandlung mit β-Rezeptorenblockern, Kalziumantagonisten und antiarrhythmischen Medikamenten angezeigt. Mit beginnender Manifestation einer Myokardinsuffizienz sind zusätzlich Diuretika, Digitalis, ACE-Hemmer sowie Katecholamine erforderlich. Eine weitere klinische Verschlechterung kann zur Indikation einer Herztransplantation bei geeigneten Patienten führen. Als Überbrückungsmaßnahme, bis ein Spenderherz zur Verfügung steht, ist u. U. die Implantation eines Linksherz- oder biventrikulären Unterstützungssystems notwendig. 2. Hypertrophe obstruktive Kardiomyopathie (HOCM) Die Patienten weisen eine linksventrikuläre subvalvuläre septale Ausflußtrakt-Obstruktion (typ. Form) oder eine mittventrikuläre systolische Einengung (atyp. Form) auf. Der erste Behandlungsschritt ist die medikamentöse Therapie mit β-Blockern (Propanolol) und/oder Ca-Antagonisten (Verapamil), z. T. unterstützt durch Antiarrhythmika (Disopyramid, Amiodarone). Bei unter medikamentöser Therapie fortschreitender klinischer Verschlechterung zum klinischen Schweregrad III (NYHA) war bisher die transaortale subvalvuläre Myektomie (TSM) als alleinige weitere Behandlungsmöglichkeit generell akzeptiert. Durch neuere interventionelle Techniken: – Zwei-Kammer-Stimulation mit einem Herzschrittmacher (DCP) (atrial getriggerte ventrikuläre Stimulation), – transkoronare Ablation der septalen Hypertrophie (TASH) (selektive Injektion von 95%igem Alkohol in den 1. Septalast), kann die Ausflußbahnobstruktion deutlich reduziert bzw. sogar vollständig beseitigt werden. Insbesondere bei jüngeren Patienten nach Synkopen, lebensbedrohlichen Tachykardien sowie nach Kammerflimmern mit erfolgreicher Reanimation kann die Implantation eines Kardioverter-Defibrillators notwendig werden. Vergleichende prospektiv randomisierte Studien bei verschiedenen Therapiemaßnahmen gibt es weder für die HNCM noch für die HOCM. Retrospektive Studien für die HOCM-Patienten nach TSM zeigen klinisch eine deutliche Besserung. Ein reduziertes Risiko eines plötzlichen Herztodes bleibt allerdings weiterhin bestehen. Trotz in der Regel deutlich schlechterer Ausgangssituation vor TSM ist die Langzeitüberlebensrate deutlich besser als bei Patienten mit nur medikamentöser Behandlung. Langzeitresultate bei den interventionellen Verfahren stehen natürlich noch nicht zur Verfügung, so daß die Langzeitergebnisse nach TSM über mehr als 25 Jahre als Vergleichsstandard angesehen werden können, die die interventionellen Techniken mindestens erreichen müssen! Hypertrophic cardiomyopathy (HCM) is a disease with different etiological, morphological, functional, clinical and therapeutic aspects. Recent investigations indicate that HCM is considerably widespread in the population (1:500). The causes seem to generate from familial or sporadic abnormalities (mutations). Depending on the clinical aspect, the complaints, and on the basis of morphologic and hemodynamic investigational results, we mainly have to consider two types of medical and surgical management. 1. Hypertrophic nonobstructive cardiomyopathy (HNCM) Patients may have no hemodynamic or morphologic deviations, but may be identified by familial moleculargenetic investigations. Others may have different types of rhythm disturbances which may indicate a higher risk of sudden death. Depending on the degree of hypertrophy, the clinical impairment indicates medical therapy with β-blockers, Ca antagonists, and anti-arrhythmic drugs. In the case of clinical deterioration and manifestation of myocardial insufficiency diuretics, digitalis, ACE inhibitors, and catecholamines are indicated. Further impairment may lead to heart transplantation or as a bridging procedere to implantation of a left ventricular or biventricular assist device until a suitable donor heart is available. 2. Hypertrophic obstructive cardiomyopathy (HOCM) Symptomatic patients may have different localizations of the left ventricular outflow tract obstruction (LVOTO) in the subaortic area (typical form) and in midventricular position of the LV (atypical form). The first therapeutic step is always medical therapy with β-blockers, Ca antagonists, and anti-arrhythmic drugs. Further deterioration toward clinical class III (NYHA) despite long-term medication until recently was generally accepted as indication for transaortic subvalvular myectomy (TSM). Today mostly two other techniques are preferred – if possible – – Double chamber pacing (DCP) (atrial triggered ventricular pacing), – Transcoronary ablation of septal hypertrophy (TASH) (by selective injection of alcohol, 95%, into the first septal branch) Especially in younger patients, after syncope, life-threatening tachyarrhythmias, and after resuscitation, the implantation of a cardioverter defibrillator may be necessary. Comparative prospectively randomized studies between different therapeutic regimens for HOCM are not available. Retrospective analyses of patients after TSM show a considerable clinical improvement. The risk of sudden death is relatively low, but not excluded. Patients after TSM demonstrate advantages concerning the survival rate despite the more deteriorated condition against those after medical therapy only. According to the new interventional techniques, long-term results are not yet available, of course. However, the long-term results after TSM may serve as a comparative standard which have at least to be reached by DCP and/or TASH.