Klaus Matschke

Protection against acute porcine lung ischemia/reperfusion injury by systemic preconditioning via hind limb ischemia

Previous work on various organs and tissues has shown that ischemic preconditioning protects against reperfusion injury in these organs and also against secondary effects in the lung. In contrast, the purpose of this study was to investigate the effects of preconditioning in a remote organ (hind limb ischemia) on an ischemia/reperfusion (I/R) treatment of the lung itself. A porcine model of in situ left lung ischemia (90 min) and reperfusion (5 h) was used. Systemic preconditioning was induced by clamping the left common femoral artery (3 × 5 min). Lung injury was assessed in terms of pulmonary vascular resistance, pulmonary artery pressure, pulmonary venous and arterial pO2, and tissue macrophage counts. The zymosan‐stimulated release of reactive oxygen species (ROS) in whole blood was determined by a chemiluminometric procedure. Inflammatory cytokines (interleukin‐1β and interleukin‐6) were measured in arterial plasma as indicators of a systemic inflammatory reaction. Preconditioning by hind limb ischemia completely prevented the I/R‐induced functional impairment of the lung, the pulmonary hypertension and the reduced oxygenation capacity. The plasma levels of interleukin‐1β and the macrophage counts in preconditioned animals were reduced to control values, whereas the levels of interleukin‐6 and the release of ROS were not affected by preconditioning. In conclusion, systemic preconditioning by repeated hind limb ischemia protects against acute I/R injury of the lung but not against all indices of reperfusion‐associated systemic inflammation.

Clozapine-induced myocarditis after long-term treatment: case presentation and clinical perspectives

Clozapine is the drug of choice for treatment-resistant schizophrenia. Prompted by a patient who developed reversible clozapine-induced myocarditis after long-term treatment with clozapine for several years for chronic-resistant schizophrenia, we undertook a review of the relevant literature. Concerning the myocarditis, the patient recovered rapidly by withdrawal of clozapine and with supportive management. Psychiatric stabilisation of the patient was at least possible with a combination of quetiapine (600 mg) and amisulpride (800 mg). Well-designed studies with the aim to specifically investigate treatment options after clozapine are limited and clinical possibilities are discussed in this paper. Olanzapine and combinations using non-clozapine atypical neuroleptics have partly shown improvement, whereas evidence for successful augmentation with mood stabilisers, anticonvulsants or electroconvulsive therapy in treatment-resistant schizophrenia is limited.

Minimally invasive surgical treatment of coronary artery multivessel disease

BACKGROUND If coronary artery multivessel disease is the target of a minimally invasive procedure, either median sternotomy or cardiopulmonary bypass can be avoided. METHODS We used an alternate technique instead of minithoracotomy and cardiopulmonary bypass to treat 102 patients (82 men, 20 women; age range, 39 to 82 years; median, 61.0 +/- 8.9 years) for coronary artery single-vessel, double-vessel, or multivessel disease between November 1996 and January 1998. Twenty-nine patients (22 men, 7 women; age range, 46 to 78 years; median, 69.0 +/- 8.4 years), who were in a high-risk group for the development of perioperative complications because of the use of cardiopulmonary bypass, received median sternotomy and a beating heart procedure using the Octopus stabilizing technique. The left anterior descending coronary artery was the target vessel in all patients except for 1, in whom the left internal mammary artery was used. RESULTS There was no intraoperative death in either series. In the beating heart group (Octopus) 2 patients died on postoperative day 31 and 35, respectively, of postoperative pneumonia. CONCLUSIONS Both techniques present safe alternative procedures to conventional coronary artery bypass grafting in patients with coronary artery multivessel disease.

Three‐Year Follow‐Up After Port‐Access Mitral Valve Surgery

Abstract Introduction: After the promising early results with Port‐Access mitral valve (MV) surgery, the mid‐term results were evaluated. Methods: Among 31 patients receiving this surgery, there were two subgroups (A and B). The 14 patients in group A (7 men, 7 women, 64.0 ± 12.8 years, LVEF 0.62 ± 0.118) received the procedure exactly as proposed by Heartport. The 17 patients in group B (6 men, 11 women, 63.0 ± 11.48 years, LVEF 0.61 ± 0.117) received a modified technique for a low complex procedure. The underlying diseases were MV insufficiency (n = 14), MV stenosis (n = 9), and combined MV disease (n = 8). One female patient had a partial atrial ventricular canal. Results: Perioperative mortality was 3.2%. Survival at 39.0 ± 6.3 months (median ± SEM) was 93.5%. Two patients required intraoperative inotropic and mechanical support (intro‐aortic balloon pump [IABP]). One of these two patients died on postoperative day 3 due to low cardiac output syndrome. All ther patients survived the procedure. Twenty‐four patients underwent MV replacement, 7 patients recalved MV repair, and 1 patient received, in addition, ASD repair. In group B, operative time, ICU stay, and hospitalization was shorter. Conclusions: Good early results after Port‐Access MV surgery were confirmed by equal mid‐term results. The patients are satisfied with the surgical and the cosmetic results, however, Port‐Access MV surgery still has to prove superior outcome compared to conventional MV surgery. In selected cases a true reduction of the surgical trauma is possible.

Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients.

OBJECTIVE The treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique. METHODS Using this technique 100 patients (80 male, 20 female, median age 61.0+/-8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6-9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia. RESULTS No death or intraoperative complications were observed in this series. The median hospital stay was 6.0+/-1.4 days (median+/-SEM). Postoperative complications were reexplored for bleeding (n = 1), delayed wound healing (n = 2), wound infections (n = 4), lymphatic fistulas (n = 4), and a chest wall hernia (n = 1). CONCLUSIONS This minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.

Koronarchirurgie im akuten Koronarsyndrom

ZusammenfasungHintergrund:Im Rahmen einer retrospektiven Studie wurde analysiert, inwieweit Patienten im akuten Koronarsyndrom (ACS) von einer chirurgischen Therapie profitieren.Patienten und Methoden:Zwischen Januar 2003 und Mai 2005 unterzogen sich im Herzzentrum Dresden 3127 Patienten einer isolierten koronaren Bypassoperation. 220 dieser Patienten befanden sich im ACS; 88 Patienten hiervon im Stadium der instabilen Angina pectoris (IAP) (Gruppe I), 97 Patienten ohne ST-Elevationsinfarkt (NSTEMI) (Gruppe II) und 35 Patienten mit ST-Elevationsinfarkt (STEMI) (Gruppe III).Ergebnisse:Die durchschnittliche Gesamtsterblichkeit lag bei 6,4 % (n = 14); 2,2 % innerhalb der Gruppe I, 9,2 % in Gruppe II und 8,5 % in Gruppe III. Die logistische Regressionsanalyse ergab folgende signifikante Mortalitätsfaktoren: Alter, NYHA, EF, Katecholamine, kardiogener Schock, Rhythmusstörungen, COPD, Niereninsuffizienz, und EuroSCORE (p < 0.0001). Die Zeit zwischen Symptomauftritt und Operation war in Gruppe III bei Überlebenden (5,1 ± 2,7 h) und Verstorbenen (11,4 ± 3,2 h) signifikant unterschiedlich (p < 0.0007). Präoperatives TnT zeigte keine prognostische Relevanz.Fazit:Die koronarchirurgische Therapie im ACS kann mit akzeptablen Ergebnissen durchgeführt werden, wobei das klinische Ergebnis in den einzelnen Gruppen unterschiedlich ist und zwingend eine individuelle Risikostratifikation notwendig macht. Prognostisch scheint insbesondere in der STEMIGruppe eine frühe Revaskularisation bedeutend zu sein.AbstractBackground:The objective of the present study was to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS).Patients and methods:Between January 2003 and May 2005, a total of 3127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. UAP was present in 88 pts (group I), 97 pts (group II) had NSTEMI, whereas 35 pts (group III) had STEMI. Clinical data, inhospital mortality was studied, retrospectively.Results:Overall in-hospital mortality was 6.4 % (n = 14), being 2.2 % in group I (n = 2), 9.2 % in group II (n = 9) and 8.5 % (n = 3) in group III (p < 0.05). Logistic regression identified age, NYHA, EF, catecholamine support, cardiogenic shock, COPD, renal disease and EuroSCORE (p < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 ± 2.7 h) and no survivors (11.4 ± 3.2 h) (p < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information.Conclusion:CABG in pts with ACS can be performed with good clinical results. The clinical outcome is dependent on the ACS group. Therefore an individual risk stratification of each pt in ACS is necessary. The time interval of 6 h seems to be crucial as a prognostic variable in the STEMI group.