Juliane Kilo

Malignancies of the colorectum and anus in solid organ recipients.

Patients undergoing solid organ transplantation (SOT) are at increased risk for developing malignancies due to the long term immunosuppression. Data on malignancies of the large intestine after various types of SOT are rare. A total of 3595 SOTs were performed between 1986 and 2005 at our center and retrospectively analyzed with regard to the incidence and course of malignancies of the colon, rectum, and anus. Standard immunosuppression consisted of calcineurin inhibitors in combination with azathioprine or mycophenolate mofetil and steroids with or without antithymocyte globulin or IL‐2 receptor antagonist induction. A total of 206 patients (5.7%) developed malignancies. Colorectal adenocarcinoma was diagnosed in nine patients (0.25%; mean age at diagnosis 65 years) at a mean of 5.3 years after transplantation. Five patients (55%) died 7.2 years post‐transplant due to cardiovascular disease (n = 4) and tumor progression (n = 1). Four patients developed anal neoplasia (0.11%) 7 years post‐transplant with 100% 1‐year survival. Five patients showed post‐transplant lymphoproliferative disorders (PTLD) with intestinal involvement. The incidence of anal but not of colorectal cancers in our transplant recipients differed from that of immunocompetent individuals of corresponding age (0.11% vs. 0.002% and 0.25% vs. 0.3%). PTLD may involve the colon.

Comparison of Anterolateral Minithoracotomy Versus Partial Upper Hemisternotomy in Aortic Valve Replacement

BACKGROUND In aortic valve replacement, a comparison between the anterolateral minithoracotomy and the partial upper hemisternotomy approach has not been reported to date. METHODS From 2006 to 2012, isolated aortic valve replacement was performed in 1,118 consecutive patients. Aortic valve replacement was performed through a anterolateral minithoracotomy in 166 patients (14.9%) and through a partial upper hemisternotomy in 245 patients (21.9%). A propensity score-matched analysis was performed in 160 matched pairs. RESULTS Conversion to median sternotomy was significantly higher in the anterolateral group (n = 22, 13.1%) than in the hemisternotomy group (n = 7, 4.4%) (p = 0.004). A second cross-clamp was significantly more often necessary in the anterolateral group (n = 14, 8.8%) than in the hemisternotomy group (n =2, 1.3%) (p = 0.003). The median cross-clamp time was significantly longer in the anterolateral group, 93 minutes (range, 43 to 231 minutes) than in the hemisternotomy group, 75 minutes (range, 46 to 137 minutes) (p < 0.0001). The median perfusion time was significantly longer in the anterolateral group, 137 minutes (range, 81 to 456 minutes) than in the hemisternotomy group, 113 minutes (range, 66 to 257 minutes) (p < 0.0001). Significantly more groin adverse events occurred in the anterolateral group (n = 17, 10.8%) than in the hemisternotomy group (n = 0, 0%) (p < 0.0001). No significant difference in 90-day mortality was seen in the anterolateral group (n = 6, 3.8%) than in the hemisternotomy group (n = 2, 1.3%) (p = 0.16). CONCLUSIONS The anterolateral minithoracotomy is associated with more perioperative adverse events. The partial upper hemisternotomy is an excellent surgical technique for minimally invasive aortic valve replacement in the daily routine for every staff surgeon.

How Mechanical Circulatory Support Helps Not to Need It—New Strategies in Pediatric Heart Failure

During the past 3 years, seven potential candidates for mechanical circulatory support (MCS) were treated at our center. Ultimately, only one of them needed MCS (extracorporeal membrane oxygenation [ECMO] for 16 days), although 5 years earlier, all would have been considered for MCS at our center. Seven consecutive patients were seen in this period: four toddlers (three suffering from fulminant myocarditis and one with dilated cardiomyopathy associated with spongy myocardium) and three adolescents (two with postmyocarditis cardiomyopathy and one with hypertrophic cardiomyopathy and severe restrictive dysfunction after an ischemic event with cardiopulmonary resuscitation [stunned heart]). All patients presented in acute cardiocirculatory decompensation. All were admitted to the intensive care unit (ICU); all but one were sedated and intubated. A combination of levosimendan, milrinone, and nesiritide was administered to all patients. Use of catecholamines was kept short (<48 h in six individuals). MCS (ECMO, Berlin Heart Excor Pediatric, and Heartware) was always available. MCS initiation was indicated in only one patient, who was developing progressive multiorgan failure (MOF). The three toddlers with myocarditis recovered with complete normalization of myocardial function within 6 months. The fourth toddler is still at the ICU while waiting for transplantation. The three adolescents were listed with high urgency for heart transplantation, and all received a graft within 3 weeks. The adolescent with the stunned heart developed progressive MOF and was successfully supported with ECMO until transplantation. All six patients with completed course were discharged home in New York Heart Association Heart Failure Functional Classification System I condition without neurological deficits. Combined use of levosimendan, milrinone, and nesiritide, avoidance of catecholamines as much as possible, and MCS as backup are the new strategies at our center. This cardioprotective approach gives excellent outcome at lower risk and better cost-effectiveness in our pediatric patients with acute heart failure. Pediatric trials are recommended to evaluate combined use of newer cardioprotective drugs.

Antithrombin III is associated with acute liver failure in patients with end-stage heart failure undergoing mechanical circulatory support

Objective: There are few data on the role of liver dysfunction in patients with end‐stage heart failure supported by mechanical circulatory support. The aim of our study was to investigate predictors for acute liver failure in patients with end‐stage heart failure undergoing mechanical circulatory support. Methods: A consecutive 164 patients with heart failure with New York Heart Association class IV undergoing mechanical circulatory support were investigated for acute liver failure using the Kings College criteria. Clinical characteristics of heart failure together with hemodynamic and laboratory values were analyzed by logistic regression. Results: A total of 45 patients (27.4%) with heart failure developed subsequent acute liver failure with a hospital mortality of 88.9%. Duration of heart failure, cause, cardiopulmonary resuscitation, use of vasopressors, central venous pressure, pulmonary capillary wedge pressure, pulmonary pulsatility index, cardiac index, and transaminases were not significantly associated with acute liver failure. Repeated decompensation, atrial fibrillation (P < .001) and the use of inotropes (P = .007), mean arterial (P = .005) and pulmonary pressures (P = .042), cholinesterase, international normalized ratio, bilirubin, lactate, and pH (P < .001) were predictive of acute liver failure in univariate analysis only. In multivariable analysis, decreased antithrombin III was the strongest single measurement indicating acute liver failure (relative risk per %, 0.84; 95% confidence interval, 0.77–0.93; P = .001) and remained an independent predictor when adjustment for the Model for End‐Stage Liver Disease score was performed (relative risk per %, 0.89; 95% confidence interval, 0.80–0.99; P = .031). Antithrombin III less than 59.5% was identified as a cutoff value to predict acute liver failure with a corresponding sensitivity of 81% and specificity of 87%. Conclusions: In addition to the Model for End‐Stage Liver Disease score, decreased antithrombin III activity tends to be superior in predicting acute liver failure compared with traditionally thought predictors. Antithrombin III measurement may help to identify patients more precisely who are developing acute liver failure during mechanical circulatory support.

Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement

BACKGROUND Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement. METHODS From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs. RESULTS In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group. CONCLUSIONS In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

The Eustachian Valve as a Pitfall in Persistent Foramen Ovale and Atrial Septum Defect Closure

a A b a n t i c r e b T s t r a A b c w THE EUSTACHIAN VALVE plays an important role during fetal life by directing oxygen-rich blood from the inferior vena cava (IVC) through the foramen ovale into the left atrium (LA) and the systemic circulation. After birth, the eustachian valve disappears or is reduced to a thin, nonfunctional ridge. Occasionally, it remains as an elongated and prominent structure within the right atrium (RA). If the eustachian valve is very prominent with undulating motion, it is called a giant eustachian valve.1 Otherwise, if t is very thin and small, it is called a Chiari network.2 Occasionally, it can be elongated and appears prominent with an undulating motion in echocardiography.1 It is best visualized by transesophageal echocardiography (TEE) in the midesophageal bicaval view, where it can be seen to originate from the junction of the RA and the IVC.2 A patent eustachian valve is not only a possible pitfall in echocardiography but also for the cardiac surgeon closing an atrial septum defect (ASD). There are several reports of the eustachian valve being mistaken for the lower rim of the ASD, thus causing inadvertent diversion of the IVC blood flow into the left atrium.3 Moreover, inflow obstruction of the IVC is reported to cause Budd-Chiari–like symptoms.4 TEE is superior to transthoracic echocardiography for the identification and characterization of ASDs in adults.5 Consequently, the authors resent 2 patients showing intraoperative TEE evidence of nintentional sewing of the eustachian valve into a surgical SD/PFO closure.

Minimally invasive mitral valve surgery in the old patient

ZusammenfassungGRUNDLAGEN: Die minimal invasive Operation der Mitralklappe ist heute eine bewährte Alternative zur konventionellen Operation durch mediane Sternotomie. Trotzdem bleibt unklar, inwieweit die objektiven Vorteile von Kosmetik, Blutverlust, Intensivstations- und Krankenhausaufenthalt sowie Wiederaufnahme der Arbeit auch bei älteren Patienten zum Tragen kommen oder vielleicht durch zusätzliche Komplikationen mit erhöhter Morbidität und Mortalität aufgewogen werden. Darüber hinaus bleibt die Frage ungeklärt, ob diejenigen Erkrankungen, welche bei älteren Menschen vorwiegend gefunden werden, mit der minimal invasiven Methode überhaupt angegangen werden können. METHODIK: Patienten über 75 Jahre, die in unserer Anteilung von 2001–2009 eine minimal invasive Mitralklappenoperation erhalten hatten, wurden hinsichtlich Operationsart (isolierte Mitralklappenoperation oder Kombination mit Trikuspidalklappenoperation oder Vorhofsablation bei Vorhofflimmern), perioperative Mortalität und intraoperativen Komplikationen untersucht. Die Ergebnisse werden der neueren Literatur gegenübergestellt. ERGEBNISSE: Von 2001 bis 2009 wurden von insgesamt 253 minimal invasiven Mitralklappenoperationen 30 % bei Patienten über 70, 14 % über 75 und 4 % über 80 Jahre durchgeführt. Die Mortalität betrug 1,3 % bei den älteren Patienten, gegenüber 0,8 % in der Gesamtpopulation. Der Anteil von Klappenersatzoperationen war bei den älteren Patienten gleich wie bei den jüngeren (11 % vs. 12,4 %). SCHLUSSFOLGERUNGEN: Anders als der Aortenklappenersatz werden minimal invasive Mitralklappenoperationen nur in einem relativ kleinen Prozentsatz bei älteren Patienten durchgeführt. Auf Grund unserer Ergebnisse können minimal invasive Operationen jedoch auch bei älteren Patienten mit ausgezeichneten Ergebissen durchgeführt werden. Daten aus der rezenten Literatur bestätigen diesen Schluss. Eine Verminderung des chirurgischen Traumas führt auch bei älteren Patienten nicht nur zu verbesserten kosmetischen Ergebnissen, sondern ist auch sicher.SummaryBACKGROUND: Minimally invasive (MICS) mitral valve surgery has become a valid alternative to the conventional approach by full median sternotomy; nevertheless, it remains unclear if the benefits, which comprehend mainly cosmesis, blood loss, ICU time, hospital stay and return to work also are true for the elderly population and may not be offset by additional complications resulting in an increased morbidity and mortality. Moreover the question remains if the diseases prevailing in the elderly population can be approached by the minimally invasive technique. METHODS: Patients 75 years or older treated in our institution from 2001 to 2009 by MICS mitral valve surgery are analyzed in respect to type of surgery (isolated mitral valve surgery or combined with tricuspid or atrial fibrillation surgery), perioperative mortality and intraoperative complications. The results are related to recent literature. RESULTS: Out of 253 MICS mitral valve procedures 30% were performed in patients >70 years, 14% in patients >75 years and 4% in patients of 80 years or older. Mortality was 1.3% in the older age group as compared to 0.8% in the total population. Valve replacement compared to valve repair was not different in the older patients (11% vs. 12.4%). CONCLUSIONS: In contrast to aortic valve surgery minimally invasive mitral operations are performed only in a relatively small percentage of elderly patients. According to our results, however, the technique can also be offered to these patients with excellent results. Results from recent literature support this finding. Reduction of surgical trauma not only improves cosmesis, but also is safe in the elderly.

Surgery of a cyanotic heart defect in an 11-year-old boy with thrombocytopenic thrombocytopathy and severe anemia due to a GATA-1 defect: hemostatic therapy.

A child was admitted to our hospital for repair of a ventricular septal defect (VSD) characterized by a predominantly right-to-left shunt and a severe stenosis of the right ventricular outflow tract (Tetralogy of Fallot). Severe congenital anemia (hemoglobin 72 g/L), thrombocytopenia (42×G/L) and profound platelet dysfunction led a stem cell defect to be suspected. X-linked thrombocytopenia (GATA-1 mutation) was diagnosed. GATA-1 defect may complicate medical interventions due to excessive bleeding and partial or complete bone marrow failure. Maintaining a platelet count of 100 G/L and a maximal clot firmness (EXTEM-MCF) >50 mm allowed repair of the congenital heart defect without bleeding or hematological complications. Anemia and thrombocytopenia persisted after cardiac surgery, while the spontaneous bleeding tendency improved.