L. C. Müller

Neurological Outcome of Septic Cardioembolic Stroke After Infective Endocarditis

Background and Purpose— The aim of this study was to evaluate mortality and neurological outcomes of cardioembolic cerebral stroke in infective endocarditis (IE) patients requiring cardiac surgery. Methods— A consecutive series of 214 patients undergoing cardiac surgery for IE was followed up for 20 years. In 65 patients (mean age, 52 years), IE was complicated by computed tomography– or magnetic resonance imaging–verified stroke (n=61) or transient ischemic attack (n=4). Perioperative (30-day) and long-term mortality was assessed with regression models adjusting for age. Complete neurological recovery of IE survivors was defined by a modified Rankin score of ≤1 and a Barthel index of 20 points. Results— Fifty of 61 stroke patients (81.9%) survived surgery. In comparison with nonstroke patients, the age-adjusted perioperative mortality risk was 1.70-fold (95% CI, 0.73 to 3.96, P=0.22) higher and long-term mortality risk was 1.23-fold (95% CI, 0.72 to 2.11, P=0.45) higher in stroke patients. Patients with complicated stroke (meningitis, hemorrhage, or brain abscess) showed a higher perioperative mortality rate (38.9% vs 8.5%, P=0.007) but no higher neurological complication rate than patients with uncomplicated ischemic stroke. Complete neurological recovery was achieved in 35 IE survivors (70%, 95% CI, 55% to 82%). However, in the case of middle cerebral artery stroke, recovery was only 50% and was significantly lower compared with non—middle cerebral artery stroke (P=0.012). Conclusion— Uncomplicated IE-related stroke showed a favorable prognosis with regard to both long-term survival and neurological recovery. The formidable risk of secondary cerebral hemorrhage due to cardiac surgery seems to be much lower than previously thought.

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.

Primary mediastinal synovial sarcoma: a case report and review of the literature.

Primary mediastinal synovial sarcoma is a rare malignancy with only a few cases reported so far. A 56-year-old woman was admitted to our hospital for an investigation of a nodule in the left middle lung on chest radiography. Computed tomography revealed a mediastinal mass first described as a solitary fibrous tumor. The diagnosis of synovial sarcoma was established by computed tomography-guided percutaneous needle biopsy. Work up showed no metastasis to distant organs or contralateral pleural cavity. The mass was surgically resected; pathological and immunohistochemical analyses confirmed the diagnosis of a monophasic spindle cell synovial sarcoma probably originating from phrenic nerve. The patient received adjuvant chemotherapy and radiation and is free of recurrence after a follow up of 16 months.

Development of a minimally invasive mitral valve surgery program – The Innsbruck experience

ZusammenfassungGRUNDLAGEN: Die minimal-invasive Mitralklappenrekonstruktion zeigt zunehmende Beliebtheit in wenigen selektierten herzchirurgischen Zentren weltweit. Diese Studie fasst die initialen Ergebnisse in der Entwicklungsphase eines derartigen Operationsprogramms an der Medizinischen Universität Innsbruck zusammen. METHODIK: Von 2001 bis 2005 wurden insgesamt 42 Patienten für eine minimal-invasive Mitralklappenoperation (miniMV) ausgewählt. Im gleichen Zeitraum wurden 64 konventionelle isolierte Mitralklappenrekonstruktionen (conMV) aufgrund einer isolierten nicht-ischämischen, nicht-infektiösen Mitralklappenerkrankung bei 64 Patienten durch eine mediane Sternotomie durchgeführt. ERGEBNISSE: In beiden Gruppen waren keine perioperativen Todesfälle zu verzeichnen. Das mittlere Alter betrug 54,1 ± 11,8 Jahre in der miniMV-Gruppe und 63,7 ± 11,3 Jahre in der conMV-Gruppe (p < 0,001). Die portaccess-Technik mit endovaskulärer Aortenklemmung wurde in den initialen 3 Fällen angewendet (7,3%) und aufgrund von technischen Problemen zugunsten der transthorakalen Aortenquerklemmung (Chitwood-Klemme) verlassen. Die Konversionsrate zur medianen Sternotomie betrug 2,4% (1 Patient) in der frühen Entwicklungsphase dieses Programms. Eine Reexploration aufgrund einer Blutung in der conMV-Gruppe (1,6%) und 1 in der miniMV-Gruppe (2,4%, thorakoskopisch) mussten durchgeführt werden. In der conMV-Gruppe erfolgten 2 valvuläre Reoperationen (3,1%), jedoch keine in der miniMV-Gruppe (0%). Im follow-up zeigte sich eine asymptomatische Lungenherniation bei 1 Patienten (2,4%) und unkomplizierte Lymphfisteln im Bereich der Leiste in 7 Patienten (17,1%). Die funktionellen Ergebnisse hinsichtlich restlicher Mitralinsuffizienz waren vergleichbar gut in beiden Gruppen. SCHLUSSFOLGERUNGEN: Die minimal-invasive Mitralklappenchirurgie ist zur Behandlung isolierter degenerativer Mitralklappenerkrankungen ideal geeignet und zeigt gleich gute funktionelle Ergebnisse bei deutlich besseren kosmetischen Ergebnissen und kürzerer Rehabilitationsdauer. Diese Technik sollte jedoch nicht bei Patienten mit schwerer Aortensklerose und pleuralen oder parenchymatösen Lungenerkrankungen angewendet werden.SummaryBACKGROUND: Minimally invasive mitral valve surgery has become popular in a few selected cardiac surgery centers worldwide. This article summarizes the initial experience of a minimally invasive mitral valve surgery program at the Medical University Innsbruck. METHODS: From 2001 to 2005 a total of 42 patients were selected for minimally invasive mitral valve surgery (miniMV) at our department. During the same period, another 64 patients underwent isolated mitral valve repair for non-ischemic and non-infective disease using conventional surgical technique (conMV). RESULTS: There were no perioperative deaths within both groups. Mean age was 54.1 ± 11.8 years in the miniMV group and 63.7 ± 11.3 years in the conMV group (p < 0.001). Port-access technique with endovascular aortic clamping was performed in the initial 3 procedures (7.3%) and left in favour of transthoracic clamping (Chitwood clamp). Conversion rate to sternotomy was 2.4% (1 patient) in the early phase of this program. One reexploration for bleeding in the conMV group (1.6%) and 1 in the miniMV group (2.4%, thoracoscopic) had to be performed. There were 2 valvular reoperations in the conMV group (3.1%) and none in the miniMV group (0%). In the follow-up, asymptomatic lung herniation occurred in one patient (2.4%) and lymph fistulation in 7 patients (17.1%). Functional results of mitral valve repair were similar in both groups. CONCLUSIONS: Minimally invasive mitral valve surgery has evolved to be a reliable method with reproducible results and excellent cosmetic and functional results. This technique, however, should not be applied in patients with severe aortic atherosclerosis or pleural/parenchymatous pulmonary disease.

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.

Simultaneous mitral valve and lung surgery for complicated endocarditis

A 48-year-old man developed severe sepsis after a chest trauma. The patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right lung lower lobe and severe infective endocarditis of the mitral valve. After subcutaneous and mediastinal abscess-drainage, hemodynamic stabilization, and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower lobe were performed. Restoration of the shoulder could be performed 22 days later. The patient was discharged after 4 weeks and is well 1 year after surgery.

The Bentall procedure – an attractive option for the aortic root

SummaryBACKGROUND: The Bentall operation is a favorable technique of aortic root replacement and can be applied to most cases in adult aortic root pathology. The operative procedure is highly standardized. METHODS: We present the main indications, general and special technical aspects of the procedure, and results according to literature data and own experience. RESULTS: Perioperative mortality of the Bentall operation, especially as an elective treatment, is comparable to elective isolated aortic valve replacement. CONCLUSIONS: It is the low rate of adverse events during long-term follow-up which makes Bentall operations highly attractive as a replacement of pathologic aortic roots.ZusammenfassungGRUNDLAGEN: Die Bentall-Operation stellt eine attraktive Variante des Aortenwurzelersatzes dar und kann in den meisten Fällen von Aortenwurzel-Pathologie beim Erwachsenen indiziert werden. Das operative Vorgehen ist hochstandardisiert. METHODIK: Anhand von Literatur und eigenen Erfahrungen werden Hauptindikationen, allgemeine und spezielle technische Aspekte der Operation und Ergebnisse dargestellt. ERGEBNISSE: Die perioperative Mortalität ist besonders bei der elektiv durchgeführten Bentall-Operation vergleichbar mit jener des elektiven, isolierten Aortenklappenersatzes. SCHLUSSFOLGERUNGEN: Niedrige Raten von Komplikationen im Langzeitverlauf machen die Bentall-Operation zu einer sehr attraktiven Option für die pathologisch veränderte Aortenwurzel.

Extracorporeal circulation in adult thoracic aortic surgery

SummaryBACKGROUND: In thoracic aortic surgery, optimum organ protection and the cannulation sites for extracorporeal circulation are a critical issue, especially if deep hypothermic circulatory arrest is necessary. METHODS: Standard cannulation sites for surgery of the thoracic aorta are the ascending aorta, femoral artery, or axillary artery. Specific organ protection is performed as cardioplegia and antegrade or retrograde cerebral perfusion. RESULTS: The hospital mortality of 277 patients (50% acute cases) undergoing surgery of the thoracic aorta was 13%. 8 out of 135 (5.9%) patients undergoing deep hypothermic circulatory arrest (DHCA) had a postoperative new stroke. Of 25 patients undergoing retrograde cerebral perfusion, 4% had a new postoperative stroke, whereas of 110 patients undergoing DHCA without cerebral perfusion, 6.4% had a new postoperative stroke (p = n.s.). In 6 patients undergoing antegrade cerebral perfusion and DHCA, no stroke was observed postoperatively. Axillary artery cannulation was increasingly used for cardiopulmonary bypass, especially in acute aortic dissection type A. The postoperative length of ICU stay was 3 (1–72) days in the whole series. CONCLUSIONS: With adequate perfusion techniques including perfusion of the central nervous system and the myocardium, surgery of the thoracic aorta can be carried out with an acceptable risk. The perfusion via the axillary artery is advantageous especially in patients with acute aortic dissection.ZusammenfassungGRUNDLAGEN: In der Chirurgie der thorakalen Aorta sind eine optimale Organprotektion und die Wahl der Kanülierungsstelle für den kardiopulmonalen Bypass von großer Bedeutung, insbesondere wenn ein tief hypothermer Kreislaufstillstand (DHCA) notwendig ist. METHODIK: Standard für die extrakorporale Zirkulation bei Operationen an der thorakalen Aorta ist die Kanülierung der Aorta ascendens, Arteria femoralis oder Arteria axillaris. Neben der Kardioplegie wird zur speziellen Organprotektion die antegrade oder retrograde zerebrale Perfusion durchgeführt. ERGEBNISSE: Bei 277 Patienten mit Operationen an der thorakalen Aorta (50 % akute Fälle) war die Hospitalmortalität 13 %. Die Schlaganfallsrate bei Patienten mit DHCA war 8 von 135 (5,9 %). Eine signifikante Reduktion der Schlaganfallsrate durch retrograde zerebrale Perfusion (4 % mit RCP vs. 6.4 % ohne RCP) konnte nicht nachgewiesen werden. Bei 6 Patienten mit DHCA und antegrader zerebraler Perfusion wurden keine Schlaganfälle beobachtet. Die Kanülierung der A. axillaris erfolgte in den letzten Jahren in zunehmendem Maße, sie ist zurzeit die erste Wahl bei akuten Aortendissektionen Typ A. Die postoperative Aufenthaltsdauer auf der Intensivstation war 3 (1–72) Tage. SCHLUSSFOLGERUNGEN: Mit Hilfe geeigneter Perfusionstechniken zur Hirn-, Rückenmarks- und Herzprotektion sind Operationen an der thorakalen Aorta mit akzeptablem Risiko möglich. Die axilläre Kanülierung gewährleistet eine sichere Perfusion aller gefährdeten Organe. Bei tief hypothermem Kreislaufstillstand ist damit auch eine antegrade zerebrale Perfusion möglich mit weiterer Reduktion des Risikos neurologischer Komplikationen.

Transcatheter aortic valve implantation via transaortic access: a bail-out strategy in unexpectedly inoperable patients

SummaryBackgroundTranscatheter aortic valve implantation is a procedure reserved for patients with severe aortic stenosis and high operative risk. Minimization of surgical trauma and avoidance of cardiopulmonary bypass makes this procedure interesting for bail-out situations of unexpectedly inoperable patients.MethodsWe describe two cases of transcatheter aortic valve implantation via transaortic access in patients with intraoperatively diagnosed contraindications to conventional aortic valve replacement.ResultsIn the first case, the procedure was performed via median sternotomy in order to allow central cannulation for extracorporeal circulation in a patient without access vessels for peripheral cannulation. In the second patient, the procedure was performed in a minimally invasive fashion via upper partial sternotomy. Both procedures were performed using a transapical sheath and an upside down mounted transcatheter aortic valve prosthesis.ConclusionsTransaortic valve implantation can be successfully used for unexpectedly inoperable patients even without previous evaluation for transcatheter valve implantation.

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.