Hh Sievers

Association of Serology With the Endovascular Presence of Chlamydia pneumoniae and Cytomegalovirus in Coronary Artery and Vein Graft Disease

BACKGROUND Chemotherapeutic treatment for patients with symptomatic coronary artery disease to reduce cardiovascular events may be initiated in response to elevated antibody titers against Chlamydia pneumoniae or cytomegalovirus. How antibody titers are associated with the endovascular presence of these microorganisms is still unclear. METHODS AND RESULTS Antibody titers against C pneumoniae (microimmunofluorescence) and cytomegalovirus (ELISA) in patients undergoing primary (coronary desobliterates, n=80) or repeated CABG (occluded vein grafts, n=45) were correlated with the endovascular presence of the 2 microorganisms. C pneumoniae was detected by means of a nested polymerase chain reaction (PCR) and by culturing. Both conventional PCR and quantitative PCR were applied for detection of cytomegalovirus. C pneumoniae (PCR/culture) was detected in 19/9% (15/80 and 7/80) of coronary desobliterates and in 18/11% (8/45 and 5/45) of occluded vein grafts. There was no statistical evidence that IgG values differed between patients with or without C pneumoniae detection who were undergoing primary CABG. In contrast, repeated-CABG patients with a positive PCR (P=0.0027) or C pneumoniae culture (P=0.0018) had distinctly elevated IgG titers compared with patients in whom C pneumoniae was not detected. Cytomegalovirus could not be detected in the examined specimens. CONCLUSIONS Cytomegalovirus infection does not seem to be associated with advanced coronary artery lesions. C pneumoniae antibody titers are not associated with the endovascular presence of C pneumoniae in patients with coronary artery disease. The observed strong association between elevated IgG titers and the detection of C pneumoniae in occluded vein grafts warrants further investigation.

Rate of paraplegia and mortality in elective descending and thoracoabdominal aortic repair in the modern surgical era.

BACKGROUND The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. METHODS From July 1993 to April 2006, 56 patients (mean age 55+/-16 years, range 25 to 80 years, 62.5% males) underwent elective surgical repair of the descending (n=37, 66.1%) and thoracoabdominal aorta (n=19, 33.9%), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n=21), type B aortic dissection (n=24), and Marfans syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n=11), respectively. Most patients were operated using deep hypothermic circulatory arrest. RESULTS Thirty-day mortality was 5.4 % (n=3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6% (n=2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78%. CONCLUSIONS If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.

A Decision Tree for the Replacement of the Ascending Aorta in Patients Undergoing Aortic Valve Surgery: A Single Center Experience in 1362 Patients

Objective: The management of the ascending aorta (AA) of diameters between 40 and 50 mm in patients undergoing aortic valve surgery is controversial. We present our experience and factors that influence our decision to replace or repair the ascending aorta in 1362 patients undergoing aortic valve surgery. Methods: 1362 patients (1044 male) undergoing aortic valve surgery were retrospectively analyzed. Mean follow up was 5.4 ± 3.6 years (range: 0–14 years, 7334 patient-years) and 96.5% complete. The individualized AA management decision process included mainly the AA diameter, age, body surface area, presence and type of bicuspid aortic valve (BAV) as well as subjective factors such as the macroscopic AA configuration and the perceived tissue strength of the aortic wall. Three AA treatment groups were included in the analysis: no intervention, and intervention either by aortoplasty (AoP) or AA replacement (AAR). Recursive partitioning techniques using conditional inferences trees were used to investigate our AA decision process, how the effect of input variables (AA diameter, age, body surface area (BSA), BAV type) influenced this decision process, and the resulting patterns of AA intervention Results: In 66.5% of the patients (n = 906) no intervention was performed, in 12.6% (n = 172) an AoP and in 20.9 (n = 284) an AAR. Hospital mortality was 1.1% for no intervention, 0.6% for AoP and 0.4% for AAR (p = 0.4). 10 year survival was similar for all three groups and was comparable to that of the general population. Factors that exhibited a statistical significantly influence on our decision process to replace or repair the ascending aorta included: absolute ascending aorta diameter, BSA, presence of BAV and age (p < 0.01 for all). Conclusion: Our results indicate that the decision to repair or replace the ascending aorta of diameters between 40–50 mm is highly individualized and is influenced by patient related factors such as absolute ascending aorta diameter, body surface area, BAV type and age. Despite this being a retrospective analysis, our results point out that this individualized approach leads to excellent results in terms of durability, survival and morbidity. Longer-term follow-up in a prospective fashion is necessary to consolidate these conclusions.

Outcome of Mitral Valve Surgery in Patients with Chronic Mitral Regurgitation and Low Ejection Fraction: Repair or Replacement?

Objective: The amount of patients with functional mitral valve insufficiency and congestive heart failure with low ejection fraction (EF) is increasing. Whether mitral valve repair or replacement is superior regarding long-term outcome is this special patient group not yet clear and well studied. We analyzed the outcome data of all patients with mitral valve surgery and ejection fraction below 30%. Methods: We retrospectively analyzed data of 433 patients with chronic mitral regurgitation undergoing repair or replacement of the mitral valve either with a preoperative EF below 30% (n = 86, 19.9%) or between 30 and 50% (n = 347, 80.1%) between 2004 and 2012. Patients with endocarditis and other additional cardiac procedures except coronary artery bypass grafting (CABG) were excluded. Results: Patients with low EF were borderline significant more male (76.7 vs 66%, p = .070) but with a similar age (67.8 ± 9.4 vs 66.7 ± 11.5 years, p=.408) compared with patients with an EF of 30 to 50%. In the low EF group 79.1% of the mitral valves could reconstructed, in the EF30–50 group 66.9% (p = .036). All patients showed significant improvement in EF and reduction in MI grade measured by echocardiography and better NYHA class. These parameters were comparable between mitral valve reconstruction and replacement. CABG as an additional procedure was performed in 66.3% with low EF and 49% with moderate EF (p = .005). The figure shows the Kaplan-Meier Survival. All groups had significant different survivals, except replacement with moderate EF versus reconstruction in low EF (p = .113). Conclusion: Patients with low ejection fraction and mitral valve insufficiency have a worse long-term survival with mitral valve replacement. Reconstructive surgery should be attempted, especially in patients with low ejection fraction.