Markus Fritz

Implantation of the CoreValve self-expanding valve prosthesis via a subclavian artery approach: a case report

an alternative technique for treatment of aortic stenosis in patients with an excessive surgical risk [8]. In 2002, Cribier and coworkers [2] performed the first in man implantation of a bovine pericardial prosthesis in a 57-year-old man with calcified aortic stenosis and cardiogenic shock, using an antegrade transseptal approach. Recently, they summarized their experience in a small series of patients [3]. Of the 36 patients taken to the catheterization laboratory, 27 patients underwent successfully aortic valve implantation [3]. In 23 cases, Cribier’s group used an antegrade, transseptal approach, in four patients a retrograde approach. Although not specifically emphasized by the authors, the differences in their methods are relevant. The antegrade approach demands a transseptal puncture, and the stiff guiding wire that loops from the left atrium to the ascending aorta may cause severe intraprocedural mitral regurgitation. Webb and coworkers reported about their experience in 18 patients with this technique, however, they preferred a retrograde approach for delivery of the Cribier–Edwards valve [9]. They advanced 22 F and 24 F sheaths from the femoral artery to the aorta, and successfully delivered the prosthesis in 14 cases. Of note, iliac injury occurred in two patients requiring surgery. In Germany, a first series of patients was reported by a group from Siegburg [5]. They used a CoreValve self-expanding valve prosthesis, delivered by first (24 F) and second (21 F) generation sheaths via a retrograde approach. Device success and procedural success were achieved in 88% and 84%, respectively. Of note, they discussed the advantages of this approach on account of procedural simplicity, but they also addressed the technical problems tracking a relatively long and high-profile stent valve apparatus through small-diameter, tortuous or heavily atherosclerotic aortas. Most recently in this context, Jilaihawi and coworkers illustrated that Waldemar Bojara Achim Mumme Ulrich Gerckens Michael Lindstaedt Michael Gotzmann Alfried Germing Markus Fritz Werner Pennekamp Andreas Mügge Implantation of the CoreValve self-expanding valve prosthesis via a subclavian artery approach: a case report

Beating-Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off-Pump Grafting

The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed.

Long‐Term Sinus Rhythm Stability after Intraoperative Ablation of Permanent Atrial Fibrillation

Introduction: Short‐ and medium‐term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long‐term follow‐up?

[Off-pump versus on-pump coronary artery bypass surgery. Comparison of 270 case-matched elderly patients].

Ob sich durch die „Off Pump Coronary Artery Bypass“ – Chirurgie die perioperative Morbidität und Mortalität senken lässt, ist noch immer eine kontrovers geführte Diskussion. Die vorliegende Studie vergleicht die Ergebnisse von älteren Patienten, die mit bzw. ohne Herz–Lungen–Maschine (HLM) operiert wurden. Von 1998–2002 wurden alle Bypass-Patienten die 75 Jahre und älter waren, retrospektiv aufgearbeitet. Dabei wurde entsprechend dem Euroscore und der Zahl der befallenen Gefäße eine paarweise Zuordnung vorgenommen. Die statistische Analyse erfolgte mit Student’s t–Test und Chi–Quadrat–Test. 270 Bypass–Patienten wurden aufgenommen: 135 wurden ohne und 135 mit HLM operiert. Das mittlere Alter für die Off–pump– bzw. On–pump–Gruppe lag bei 78,4 ± 3,1 versus 77,5 ± 2,9 Jahren. Der EuroSCORE lag bei 7,11 ± 2,3 in beiden Gruppen; die Zahl distaler Anastomosen pro Patient bei 1,7 ± 0,74 versus 3,1 ± 0,63 (p < 0,001) und die Operationszeit bei 138 versus 177 Minuten (p < 0,001). Bei den postoperativen Komplikationen ergaben sich keine signifikanten Unterschiede: Die Krankenhaus–Mortalität lag bei 3 versus 3,7%. Ein neu aufgetretenes Nierenversagen zeigte sich in 8,9% versus 12,1%, ein akuter Myokardinfarkt in 1,5 versus 4,4% und zentralneurologische Ereignisse in 0 versus 1,5%. Die Zahl der transfundierten Blutkonserven lag bei 2,6 ± 2,8 versus 4,6 ± 5,3 (p < 0,001). Die Intubationszeit sowie der Aufenthalt auf der Intensivstation waren in beiden Gruppen gleich. Im untersuchten Patientenkollektiv (≥ 75 Jahre) konnte durch das OPCAB–Verfahren keine Reduktion der perioperativen Morbidität und Mortalität erzielt werden. Offpump versus on–pump coronary artery bypass surgery: it still remains a matter of debate which method results in a lower incidence of perioperative morbidity and mortality. This case–matched study evaluates the outcome of elderly patients in both groups. All patients aged 75 and older, who underwent CABG from 1998 to 2002, were examined retrospectively. They were matched according to Euroscore and the number of diseased vessels. The Student’s t–test and chi–square test were used where appropriate. 270 CABG patients were considered: 135 off–pump and 135 on–pump patients. Mean age was 78.4 ± 3.1 versus 77.5 ± 2.9 years, respectively. EuroSCORE was 7.11 ± 2.3 in both groups; number of distal anastomoses per patient 1.7 ± 0.74 versus 2.6 ± 0.63 (p < 0.001), operation time 138 versus 177 minutes (p < 0.001). There were no significant differences in postoperative complications including hospital mortality 3.0 versus 3.7%, renal failure 8.9 versus 12.1% (new onset), acute myocardial infarction 1.5 versus 4.4% and cerebral events 0 versus 1.5%, respectively. The number of transfused packed cells was 2.6 ± 2.8 versus 4.6 ± 5.3 (p < 0.001). Intubation time and ICU stay were similar in both groups. OPCAB is not associated with a reduction of perioperative mortality and morbidity in patients aged 75 and older.

Beating-heart coronary artery bypass grafting using a miniaturized extracorporeal circulation system.

BACKGROUND Experience with miniaturized coronary artery bypass (CAB) systems in coronary artery bypass graft (CABG) surgery on the beating heart is limited. We used a relatively new miniaturized cardiopulmonary bypass (CPB) system, which we termed assisted CAB (ACAB), to perform CABG on the beating heart in 110 patients, and we analyzed clinical outcomes in this patient group. METHODS Between January 2004 and September 2006, we used ACAB to perform CABG on the beating heart in 110 patients. The mean patient age was 73 +/- 8.1 years. The ACAB system uses a small prime volume of only 500 mL, and the circuit is shorter than that used in conventional CPB. In addition, the tubing and oxygenator systems were surface-coated with phosphorylcholine. The initial heparin dose was 150 IU/kg, with a target activated clotting time of >250 seconds. With this management, none of the patients experienced system thrombosis. We did not use cardioplegia or aortic crossclamping and did not routinely retransfuse cardiotomy blood. Observational data for the 110 patients were analyzed. RESULTS The mean number of anastomoses performed was 2.67. The rate of perioperative infarction was 1.8% (2 patients). Perioperative mortality was 7% (8 patients). The mean EuroSCORE for all patients was 6.4 +/- 4, whereas it was 13.75 +/- 6.18 for the patients who died. Mean CPB time was 64.96 +/- 16.66 minutes. CONCLUSION In our experience, beating heart CABG supported by a miniaturized CPB is a safe procedure with acceptable perioperative results.

Subaortic valvular vegetation mimicking severe aortic valve stenosis.

For reprint information contact: Delawer Reber, MD Tel: 49 234 302 3600 Fax: 49 234 302 6010 Email: delawer.reber@ruhr-uni-bochum.de Department of Cardiothoracic Surgery, Bergmannsheil, Ruhr University Hospital, Bochum, Buerkle-de-la-Camp-Platz-1, 44789 Bochum, Germany. A 47-year-old male patient with symptoms of severe heart failure was diagnosed with aortic stenosis. Echocardiography showed normal systolic left ventricular function and an aortic valve with a peak transvalvular pressure gradient of 85 mm Hg and a valve area of 0.8 cm2. Cardiac catheterization showed a systolic pressure gradient of 101 mm Hg over the valve (area 0.54 cm2). Thus, the stenotic lesion of the aortic valve was considered to be severe. Prior to planned aortic valve replacement coronary angiography was performed which was normal. There was no history of sepsis preoperatively. Surgery was performed using extracorporeal circulation under mild hypothermia. During prima vista surgical exploration, trileafl et aortic valve was normal. The leafl ets were not thickened, fused or calcifi ed. However, a mass was found below the aortic valve closing the left ventricular outfl ow tract and somewhat attached to the aortic valve. The mass could be completely removed and the aortic valve was replaced with a bileafl et prosthetic mechanical heart valve. The postoperative re-evaluation and inspection of the preoperative left ventriculogram lastly confi rmed the subaortic mass (Figure 1) mimicking severe Figure 1. Preoperative left ventriculography with right (A) and left anterior oblique (B) projection of the heart. Note the mass (arrows) protruding in the ascending aorta. In retrospect, this subaortic mass was mimicking severe aortic valve stenosis. Ao asc = ascending aorta; LV = left ventricle.

Aortokoronare Bypass–Operationen im Off– und On–pump–Verfahren: Vergleichende Studie mit 270 älteren Patienten

Ob sich durch die „Off Pump Coronary Artery Bypass“ – Chirurgie die perioperative Morbidität und Mortalität senken lässt, ist noch immer eine kontrovers geführte Diskussion. Die vorliegende Studie vergleicht die Ergebnisse von älteren Patienten, die mit bzw. ohne Herz–Lungen–Maschine (HLM) operiert wurden. Von 1998–2002 wurden alle Bypass-Patienten die 75 Jahre und älter waren, retrospektiv aufgearbeitet. Dabei wurde entsprechend dem Euroscore und der Zahl der befallenen Gefäße eine paarweise Zuordnung vorgenommen. Die statistische Analyse erfolgte mit Student’s t–Test und Chi–Quadrat–Test. 270 Bypass–Patienten wurden aufgenommen: 135 wurden ohne und 135 mit HLM operiert. Das mittlere Alter für die Off–pump– bzw. On–pump–Gruppe lag bei 78,4 ± 3,1 versus 77,5 ± 2,9 Jahren. Der EuroSCORE lag bei 7,11 ± 2,3 in beiden Gruppen; die Zahl distaler Anastomosen pro Patient bei 1,7 ± 0,74 versus 3,1 ± 0,63 (p < 0,001) und die Operationszeit bei 138 versus 177 Minuten (p < 0,001). Bei den postoperativen Komplikationen ergaben sich keine signifikanten Unterschiede: Die Krankenhaus–Mortalität lag bei 3 versus 3,7%. Ein neu aufgetretenes Nierenversagen zeigte sich in 8,9% versus 12,1%, ein akuter Myokardinfarkt in 1,5 versus 4,4% und zentralneurologische Ereignisse in 0 versus 1,5%. Die Zahl der transfundierten Blutkonserven lag bei 2,6 ± 2,8 versus 4,6 ± 5,3 (p < 0,001). Die Intubationszeit sowie der Aufenthalt auf der Intensivstation waren in beiden Gruppen gleich. Im untersuchten Patientenkollektiv (≥ 75 Jahre) konnte durch das OPCAB–Verfahren keine Reduktion der perioperativen Morbidität und Mortalität erzielt werden. Offpump versus on–pump coronary artery bypass surgery: it still remains a matter of debate which method results in a lower incidence of perioperative morbidity and mortality. This case–matched study evaluates the outcome of elderly patients in both groups. All patients aged 75 and older, who underwent CABG from 1998 to 2002, were examined retrospectively. They were matched according to Euroscore and the number of diseased vessels. The Student’s t–test and chi–square test were used where appropriate. 270 CABG patients were considered: 135 off–pump and 135 on–pump patients. Mean age was 78.4 ± 3.1 versus 77.5 ± 2.9 years, respectively. EuroSCORE was 7.11 ± 2.3 in both groups; number of distal anastomoses per patient 1.7 ± 0.74 versus 2.6 ± 0.63 (p < 0.001), operation time 138 versus 177 minutes (p < 0.001). There were no significant differences in postoperative complications including hospital mortality 3.0 versus 3.7%, renal failure 8.9 versus 12.1% (new onset), acute myocardial infarction 1.5 versus 4.4% and cerebral events 0 versus 1.5%, respectively. The number of transfused packed cells was 2.6 ± 2.8 versus 4.6 ± 5.3 (p < 0.001). Intubation time and ICU stay were similar in both groups. OPCAB is not associated with a reduction of perioperative mortality and morbidity in patients aged 75 and older.

Cardiac Surgery in Suriname: Cui bono?

SummaryBackground: Cardiac surgery and interventional cardiology, in the industrialized countries, is taken for granted. Less industrialized countries like Suriname are deprived of such specialized care, although stenotic coronary artery disease and rheumatic valve disease are the major causes of cardiac death. Especially middle-aged persons who still participate and contribute to the economic, social, and material welfare of Suriname, are affected. The need to treat these diseases was recognized. This report describes the assistance provided by the Bergbauberufsgenossenschaft University Hospital Bergmannsheil (BBG-BMH) in Bochum, Germany. Methods: A cardiac surgical program was initiated in the Academic Hospital Paramaribo (AZP), Suriname, in cooperation with the BBG-BMH and the University Hospital Maastricht, the Netherlands. The aims of this cooperation were: 1) surgical treatment of at least 300 cardiac patients; 2) transfer of medical and surgical knowledge; 3) strengthening of the local logistical and medical infrastructure. Results: Between November 1998 and February 2001, three German cardiac surgical missions were performed, treating 80 patients; 31 female and 49 male. Type of operations were CABG (n=53), mitral valve surgery (n=14) with CABG (n=1), aortic valve replacements (n=5) with CABG (n=1), double replacements (n=3), atrial septum corrections (n=2) with mitral valve surgery (n=1). The overall 30-day mortality was 6% (5/80). The cause of death was sepsis, ventricular fibrillation, an abdominal aortic thrombosis, and in two cases multiorgan failures. The operative mortality for CABG was 5.6% (3/53). Morbidity included bleeding (n=3), perioperative infarction (n=2), mediastinitis (n=1), anaphylaxis (n=3), pulmonary infection (n=1). Transfer of knowledge and skills to the local operation and anaesthesia nursing assistance was considered successful because elective CABG and valve replacement procedures could be performed without German support. Adequate training of the AZP intensive care nurses and medical doctors was not achieved, due to inconsistent presence of the local nursing staff and shortage of medical doctors. A small but distinct strengthening of the AZP logistical structure (intensive care, cardiology, general surgery, neurology, haematological and chemical laboratories, physiotherapy, radiology, and blood bank) was evident. Conclusions: Cardiac surgery was feasible in Suriname with an acceptable mortality and morbidity. A moderate improvement in the local nursing skills was achieved and the local medical infrastructure was beneficially influenced.ZusammenfassungGrundlagen: In den Industrienationen sind sowohl interventionelle Eingriffe als auch Operationen am Herzen zu einer Selbstverständlichkeit geworden. Demgegenüber stehen Länder der dritten Welt, wie z. B. Surinam, denen die Behandlungsvielfalt aus medikamentöser, kardiologisch-interventioneller und herzchirurgischer Therapie nicht zur Verfügung stehen, obwohl die koronare Herzkrankheit und rheumatische Klappenerkrankungen auch hier zu den Hauptursachen kardialer Todesfälle zählen. Gerade Menschen im mittleren Lebensalter, die überwiegend zum ökonomischen, sozialen und materiellen Wohlstand des Landes beitragen, sind betroffen. Der vorliegende Bericht beschreibt den Beitrag der Berufgenossenschaftlichen Kliniken Bergmannsheil, Bochum an einem Kooperationsprojekt. Methodik: Im Rahmen einer Kooperation zwischen dem Academic Ziekenhuis Paramaribo (AZP), Surinam, der Berufgenossenschaftlichen Kliniken Bergmannsheil (BBG-BMH) und dem Academic Ziekenhuis Maastricht (AZM) wurde ein kardiochirurgisches Programm aufgebaut. Ziel der Kooperation war die herzchirurgische Behandlung von mindestens 300 Patienten, daneben sollten medizinische und chirurgische Kenntnisse vermittelt und die lokale medizinische Infrastruktur und Logistik verbessert werden. Ergebnisse: Zwischen November 1998 und Februar 2001 wurden in drei Einsätzen bislang 80 Patienten durch Mitarbeiter unserer Klinik operiert. Es waren 31 Frauen und 49 Männer. Bei 53 Patienten führten wir eine Bypass-Operation durch, in 14 Fällen erfolgte ein Mitralklappeneingriff, in einem Fall zusätzlich mit aortokoronarem Bypass. In 5 Fällen erfolgte ein Aortenklappenersatz, bei einem Patienten mit zusätzlicher Bypass-Operation und in weiteren 3 Fällen ein Doppelklappenersatz. Die verbleibenden Patienten erhielten einen Vorhofseptumverschluss (n=2) und einen Mitralklappenersatz mit Vorhofseptumverschluß (n=1). Die 30-Tage-Mortalität lag bei 6% (5/80). Die Todesursachen waren Sepsis, Kammerflimmern, in einem Fall eine Thrombosierung der Aorta abdominalis und in zwei Fällen ein Multiorganversagen. Die operative Mortalität isoliert für aortokoronare Bypass-Operationen lag bei 5.6% (3/53). In 3 Fällen kam es zu relevanten Nachblutungen, in 2 Fällen zu einem perioperativen Infarkt. Eine Mediastinitis ereignete sich in einem, eine Anaphylaxie in drei Fällen, bei einem weiteren Patienten kam es zu einem pulmonalen Infekt. Die Schulung des surinamesischen Anästhesie-Pflegepersonals sowie der OP-Schwestern war erfolgreich — elektive Bypass- sowie Herzklappenoperationen konnten ohne unsere Unterstützung vorgenommen werden. Die Ausbildung des Intensivpflegepersonals sowie des ärztlichen Personals war dagegen weniger erfolgreich. Zumindest konnte eine Verbesserung der logistischen Strukturen (Intensivstation, Kardiologie, Allgemeinchirurgie, Neurologie, Labormedizin und Blutbank sowie Radiologie und Physiotherapie) im AZP erzielt werden. Schlußfolgerungen: Kardiochirurgische Eingriffe sind mit einer akzeptablen Morbidität und Mortalität in Surinam durchführbar. Es konnte eine leichte Verbesserung der pflegerischen Tätigkeiten erzielt und die lokale medizinische Infrastruktur günstig beeinflußt werden.