Holger Hotz

Ross operation with a tissue-engineered heart valve

BACKGROUND The Ross procedure has gained increasing acceptance due to excellent hemodynamic results by replacing the diseased aortic valve with the viable autologous pulmonary valve. Consequently, the right ventricular outflow tract (RVOT) has to be reconstructed. In this report a viable heart valve was created from decellularized cryopreserved pulmonary allograft that was seeded with viable autologous vascular endothelial cells (AVEC). METHODS A 43-year-old patient suffering from aortic valve stenosis underwent a Ross operation on May 20, 2000, using a tissue engineered (TE) pulmonary allograft to reconstruct the RVOT. Four weeks before the operation a piece of forearm vein was harvested to separate, culture, and characterize AVEC. Follow-up was completed at discharge, 3, 6, and 12 months postoperatively by clinical evaluation, transthoracic echocardiography (TTE), and magnetic resonance imaging (MRI). Additionally, at 1-year follow-up a multislice computed tomographic scan was performed. RESULTS After four weeks of culturing 8.34 x 10(6) AVEC were available to seed a 27-mm decellularized pulmonary allograft. Trypan blue staining confirmed 96.0% viability. Reendothelialization rate after seeding was 9.0 x 10(5) cells/cm2. TTE and MRI revealed excellent hemodynamic function of the TE heart valve and the neoaortic valve as well. Multislice computed tomography revealed no evidence of valvular calcification. CONCLUSIONS After 1 year of follow-up the patient is in excellent condition without limitation and exhibits normal aortic and pulmonary valve function.

Clinical Experience With the MEDOS HIA-VAD System in Infants and Children: A Preliminary Report

BACKGROUND The need of pediatric cardiac assist is growing because of the complexity of the congenital conditions operated on and the increasing number of pediatric transplantations. We evaluated the newly developed pediatric MEDOS HIA-VAD ventricular assist device. METHODS The pneumatic paracorporeal ventricular assist device has three left ventricular sizes (10-, 25-, and 60-mL maximum stroke volume) and three right ventricular sizes (9, 22.5, and 54 mL) and can be operated effectively with up to 180 cycles/min. We used this device in 6 consecutive pediatric patients. Intention of treatment was to bridge to transplantation in 3 patients and to aid in recovery from a cardiac operation in 3. Age ranged from 5 days to 8 years. RESULTS Two children died during assist, 2 were weaned from the system and discharged home, and 2 had successful transplantation. During assist, laboratory variables indicative of impaired renal, hepatic, or pulmonary function normalized or showed a trend toward normalization. Both deaths were related to infection. CONCLUSIONS With the new MEDOS HIA-VAD ventricular assist device system, pediatric mechanical cardiac assist can be performed successfully. It requires timely implantation, careful monitoring, and adequate size-matched devices.

Safety and feasibility of a cardiac support device

The Cardiac Support Device (CSD), a preformed‐knitted polyester device surgically placed over the cardiac ventricles, prevents left ventricular (LV) remodeling and improves LV ejection fraction (EF) in dogs with heart failure (HF). This study was designed to examine the safety of the CSD in patients with advanced HF. As of December 31, 1999, the CSD was implanted into 22 patients with myocardial disease. Ten patients had concomitant mitral valve repair, two patients had valve replacement (one patient aortic and one patient mitral), one patient had LV assist device (LVAD) placement, and eight patients received only the CSD. The CSD was placed while on bypass with the heart beating, attached to the epicardium groove, and tailored anteriorly to snugly fit the ventricles. There were no intraoperative deaths or complications. Two patients died early from non‐CSD‐related causes 4 and 23 days postoperatively; one late death occurred. Of the remaining 19 patients, none had any CSD‐related adverse events during an average 3.5 ± 0.4 month follow‐up. All patients had completed 3‐month follow‐up. No patients had evidence of constrictive and/or restrictive physiology. Mitral valve regurgitation (MVR) improved in all patients.

Treatment of severe pulmonary hemorrhage after cardiopulmonary bypass by selective, temporary balloon occlusion.

Severe pulmonary bleeding causes frequent mortality, particularly if this event occurs during separation from extracorporeal circulation during cardiac surgery. We present a new approach to treat this life-threatening complication: temporary balloon occlusion of the pulmonary artery feeding the involved lobe. On attempting to wean a 71-yr-old female patient from cardiopulmonary bypass after aortic valve replacement, she lost more than 2 L of blood through her trachea over approximately 15 min and severe gas embolism into the left atrium was visualized on transesophageal echocardiography. As the bleeding was too vigorous to be localized by fiberoptic bronchoscopy, an interventional cardiologist was consulted. After localizing the affected lobe using fluoroscopy, he inflated a balloon dilating catheter in the lower lobe artery. This effectively stopped the bleeding. Separation from extracorporeal circulation was uneventful using one-lung ventilation to prevent further gas embolism. Sixteen hours after the end of surgery the catheter could be deflated and removed without any further intervention. The patient made an excellent recovery.

Effects of passive cardiac containment on left ventricular structure and function: verification by volume and flow measurements☆

BACKGROUND The cardiac support device (CSD, Acorn) is a compliant, textile-mesh graft placed around the ventricles to prevent further dilatation and to improve function in congestive heart failure. The aim of this study was to verify post-operative changes in left ventricular volumes, ejection fraction, blood flow, and myocardial mass. METHODS Fourteen patients underwent contrast-enhanced, electrocardiography-triggered electron-beam computerized tomography before and 6 to 9 months after CSD implantation. We measured volume and flow using the slice-summation method and the indicator-dilution technique. RESULTS We found significant changes for the following parameters: end-diastolic volume decreased from 382.9 +/- 140.2 ml to 311.3 +/- 138.7 ml, end-systolic volume from 310.4 +/- 132.4 ml to 237.4 +/- 133.8 ml, end-diastolic diameter from 75.3 +/- 7.8 mm to 70.7 +/- 11.6 mm, end-systolic diameter from 65.8 +/- 7.8 mm to 60.0 +/- 14.0 mm, and myocardial mass from 298.6 +/- 79.6 g to 263.1 +/- 76.8 g. Ejection fraction increased from 20.3% +/- 6.4% to 27.8% +/- 13.1%. We found no significant differences for stroke volume (from 72.5 +/- 24.6 ml to 73.8 +/- 23.6 ml), heart rate (from 80.5 +/- 11.0 beats per minute to 76.5 +/- 6.8 beats per minute), and total cardiac output (from 5.8 +/- 1.9 liter/min to 5.6 +/- 1.8 liter/min). Mitral regurgitation fraction decreased from 30.5% +/- 15.5% to 15.6% +/- 12.8%, increasing antegrade cardiac output from 3.8 +/- 0.9 liter/min to 4.7+/-1.5 liter/min. For most parameters, pre- and post-operative values in these patients differed significantly from those in an age- and gender-matched control group. In each patient, we observed a small hyperdense stripe along the pericardium after surgery, but we observed no local complications. CONCLUSION Three-dimensional structural and functional data obtained by computerized tomography volume and flow measurements confirm the safety and efficacy of CSD implantation.

Images in cardiovascular medicine. Papillary fibroelastoma of the aortic valve: appearance in 64-slice spiral computed tomography, magnetic resonance imaging, and echocardiography.

A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …

Papillary Fibroelastoma of the Aortic Valve: Appearance in 64-Slice Spiral Computed Tomography, Magnetic Resonance Imaging, and Echocardiography

A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …

Results of Batista Procedure in Ischemic Dilated Cardiomyopathy

From March 1995 to April 1998, 24 men and 5 women (mean age, 62.2 ± 10 years) underwent the Batista procedure for end-stage cardiac dysfunction due to ischemic dilated cardiomyopathy. Preoperatively, mean cardiac index was 1.9 ± 0.3 L·min−1·m−2, stroke index was 25 ± 5 mL·beat−1·m−2, ejection fraction was 20% ± 6%, and 22 (79%) patients were in New York Heart Association functional class IV. Associated procedures were coronary bypass (25), mitral valvuloplasty (15), aortic or mitral valve replacement (5), dynamic cardiomyoplasty (2), and aneurysmectomy (1). One patient (3.4%) died early and 3 (10.3%) died later. The 1- and 2-year actuarial survival was 87%. A left ventricular assist device was required in 2 patients during the follow-up period. Postoperatively, cardiac index was 2.9 ± 0.3 L·min−1·m−2, stroke index was 36 ± 5 mL·beat−1·m−2, and ejection fraction was 38% ± 10%. Left ventricular end-diastolic diameter decreased from 71 ± 8 mm to 55 ± 8 mm. Currently, 88% of survivors are in functional class I or II. It was concluded that the Batista procedure significantly improved objective and subjective parameters of cardiac performance during early and intermediate follow-up.

Papillary Fibroelastoma of the Aortic Valve

A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …A 60-year-old man with an acute stroke of unknown origin was referred to our institution for further diagnostic evaluation. Contrast-enhanced ECG-gated 64-slice spiral computed tomography depicted a well-defined, pedunculated, mobile, spherical lesion (density 69±21 Hounsfield units) attached to the commissure of the left coronary and noncoronary aortic valve leaflet. The lesion showed a relatively homogenous inner structure with a slightly villous outer margin (Figure 1A through 1D). ECG-gated magnetic resonance imaging exhibited a solid lesion with intermediate signal intensity on both T1- and T2-weighted spin-echo sequences (Figure 2A and 2B). …

Biventricular assist device in extreme anorexia nervosa

Low body mass index is an independent risk factor in cardiac surgery. Cardiac function may be severely impaired in the case of extreme malnutrition and require cardiac assistance if cardiac surgery is necessary. We report a case of the successful use of a biventricular assist device in a patient with an extreme low body mass index (6.7) due to anorexia nervosa for recovery after mitral valve replacement due to endocarditis after infusion therapy for nutrition.