Markus Thalmann

Acute type A aortic dissection and pregnancy: a population-based study

OBJECTIVE Pregnancy has been reported to be an independent risk factor for 50% of acute aortic dissections recorded in women younger than 45 years of age. The present epidemiologic study aimed to identify whether this putative association of pregnancy and acute type A dissection could be an artifact of selective reporting. METHODS This population-based study was conducted in the City of Vienna, Austria, Europe, in an average female population of 34,1381 women in the age range of 15-45 years who were followed up between 1994 and 2004 (total of 3755.195 person-years of observation). During this study, the incidence, management, and outcome of acute type A dissection were determined. RESULTS Fifteen patients (mean age: 38.8 years, SD: 4.8) with acute aortic dissection were identified, and an overall incidence of 0.4 case per 100000 person-years was estimated. The prehospital mortality rate was recorded to be 53%. Six patients, including two women in late pregnancy (incidence: 0.05 cases per 100000 person-years), were treated successfully by surgical repair during deep hypothermic circulatory arrest (in-hospital mortality rate: 6.6%). Pregnancy and aortic dissection were identified as events that were not related (RR: 3.27; 95% confidence interval (CI): 0.82-12.95; P=0.14). Observation during long-term follow-up was uneventful. CONCLUSIONS Acute aortic dissection represents a rare pathology in women younger than 45 years of age; however, it is associated with a high rate of sudden death. Pregnancy may not be a risk factor for this life-threatening vascular emergency. Immediate referral to surgery, even during pregnancy, will result in a prognosis of favorable outcome.

A 246-km continuous running race causes significant changes in bone metabolism

BACKGROUND Regular physical exercise exerts a favorable effect on the skeleton. However, excessive physical exercise may have detrimental effects. A low bone mineral density (BMD) has been registered in highly trained runners. The aim of the present study was to evaluate potential effects of the Spartathlon, an annual ultramarathon race of 246 km, on bone metabolism. METHODS Venous blood samples were taken before and within 15 min after the end of the race as well as three days after the start of the race. The following variables of bone metabolism were studied: osteocalcin (Oc), cross-linked-C-telopeptide of type I collagen (CTX), osteoprotegerin (OPG), and its ligand, receptor activator of nuclear factor kappaB ligand (RANKL). RESULTS Blood samples were taken from 18 runners (16 men and 2 women) at the three time points. The median time taken by the runners to complete the race was 32 h and 52 min. Serum levels of CTX were significantly increased immediately after the race as well as three days after the start of the race compared with the time prior to the race. Oc was transiently suppressed after the race. Serum levels of RANKL and OPG were increased three days after the start of the race compared to the time before the start of the race. CONCLUSIONS This study showed that an ultra-distance run of nearly 250 km induced changes in RANK/RANKL/OPG interaction, which suggests a transient uncoupling of bone metabolism, increased bone resorption, and suppressed bone formation.

Fate of the False Lumen After Combined Surgical and Endovascular Repair Treating Stanford Type A Aortic Dissections

BACKGROUND The purpose of this study was to evaluate the alterations of the aorta by using a new combined surgical and endovascular technique for the treatment of aortic type A dissections. The diameter of the descending aorta, the implanted stent graft, and the false lumen were evaluated. METHODS Between August 2005 and February 2009, 14 patients (aged 49 +/- 13 years; 11 men, 3 women) with type A dissection in the aorta were operated on the thoracic aorta by the frozen elephant trunk technique. The size dynamics of the false lumen were analyzed by deducting the diameter of the stent graft obtained on computed tomography from the maximum dimension of the aorta. RESULTS The technical success rate was 100%. All patients survived during the follow-up period. The mean follow-up period was 21.4 months. No redisection or aortic rupture occurred during the follow-up period. Postoperative computed tomography scans showed complete thrombus formation of the false lumen in the perigraft space within the entire zone of the stented segment of the hybrid prosthesis during the first 2 weeks after surgery in 12 patients (86%), whereas all patients showed complete obliteration of the false lumen at the 3-month control. The follow-up computed tomography scan obtained after 12 months revealed shrinkage of the false lumen in 9 patients (64%). CONCLUSIONS The combined surgical and endovascular technique described in this report proved effective for the treatment of extended aortic lesions. The perigraft space thrombosed completely and had shrunken after successful placement of the stent graft.

Changes in Serum Levels of Myokines and Wnt-Antagonists after an Ultramarathon Race.

Background Regular physical activities have a positive effect on the muscular skeletal system but overstrenuous exercise may be different. Transiently suppressed bone formation and increased bone resorption after participation in a 246-km ultradistance race has been demonstrated. Purpose The aim of this study was to analyze effects of the Spartathlon race on novel musculoskeletal markers. Methods Venous blood samples were obtained before and immediately after the race from 19 participants of the Spartathlon. From 9 runners who were available 3 days after the start blood was drawn for a third time. Serum levels of myostatin, an inhibitor of myogenic differentiation, and its opponent follistatin as well as sclerostin and dickkopf-1, both of them inhibitors of the wnt signaling pathway, and markers of bone turnover were determined. Results Serum levels of myostatin were significantly higher after the race. Serum follistatin only showed a transient increase. Sclerostin levels did not significantly differ before and after the race, whereas dickkopf-1 levels were significantly decreased. At follow-up a decrement of sclerostin and dickkopf-1 levels was seen. Serum cathepsin K levels did not change. Conclusion The increase of serum levels of myostatin appears to reflect muscle catabolic processes induced by overstrenuous exercise. After the short-term uncoupling of bone turnover participation in an ultradistance race seems to initiate a long-term positive effect on bone indicated by the low-level inhibition of the Wnt/β-catenin signaling pathway.

A newly designed thorax support vest prevents sternum instability after median sternotomy

OBJECTIVE Sternum infection remains one of the primary causes of postoperative morbidity and mortality after median sternotomy. We report the clinical efficacy for primary reinforcement of the sternum with a new design of thorax support vest. METHODS A prospective randomized study including 455 patients was started in September 2007 to evaluate the effectiveness of the Posthorax sternum vest (Epple Inc., Vienna, Austria). One hundred and seventy five patients were treated with the sternum dressing postoperatively (group A), 227 patients did not receive the vest (group B) and 53 patients refused it (group C). Several clinical and operative data were evaluated. All patients were recorded using the STS risk scoring analysis for mediastinitis after cardiac surgery. RESULTS The median age and gender distribution were comparable in both groups. Preoperative data like renal failure, chronic obstructive pulmonary disease, peripheral artery disease, and myocardial infarction were not significant. There were more patients with diabetes in group A and C (A: 39.4%, B: 29.1%, C: 43.4%, p = 0.036). A total of 55.8% underwent coronary bypass grafting, 15.4% aortic valve replacement, 7.7% mitral valve repair and 21.1% concomitant cardiac procedures. The median risk factor analysis and body mass index were comparable. In the follow-up period up to 90 days, in group A we observed 0.6% sternum wound complications, in group B 4.9%, and in group C 9.4% (group A vs B: Fishers exact test p = 0.0152 and group A vs C: p = 0.0029). CONCLUSIONS The use of the Posthorax sternum vest shows a favourable outcome to prevent sternum instability after cardiac surgery. There was one reoperation in patients treated with this sternum vest compared to 16 in the control groups.

Pre-Operative N-Terminal Pro-Brain Natriuretic Peptide Predicts Outcome in Type A Aortic Dissection

BACKGROUND Acute Stanford type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. OBJECTIVE N-terminal pro-brain natriuretic peptide (NT-proBNP) is a prognostic biomarker of outcome in cardiovascular disease. Its predictive power in patients undergoing emergency surgery for acute type A aortic dissection is yet unknown. METHODS We prospectively measured pre-operative NT-proBNP in 104 patients (39 female, 35%; median age 61 years) undergoing emergency surgery for AAD during a 6-year study period. European System for Cardiac Operative Risk Evaluation risk scores were recorded and patients were followed for 30-day mortality and major adverse events (MAEs) as defined by the need for rethoracotomy, occurrence of postoperative heart failure, neurologic deficit, lung failure, renal failure, or sepsis. RESULTS Median logistic European System for Cardiac Operative Risk Evaluation in the cohort was 12 (interquartile range 7 to 19). During the first 30 days, 23 patients (22%) died, and 53 patients (51%) experienced MAEs. Median (interquartile range) NT-proBNP levels in survivors versus nonsurvivors were 328 pg/ml (157 to 569) versus 2,240 pg/ml (515 to 4,734; p < 0.001), and in patients without versus with MAEs, 227 pg/ml (107 to 328) and 719 pg/ml (442 to 2,287; p < 0.001), respectively. Adjusted odds ratios for increasing tertiles of NT-proBNP compared with the lowest tertile were 0.98 (95% confidence interval [CI] 0.18 to 5.33; p = 0.98) and 11.67 (95% CI 2.61 to 52.09; p = 0.001) for 30-day mortality and 9.07 (95% CI 2.58 to 31.83; p = 0.001) and 50.21 (95% CI 10.85 to 232.45; p < 0.001) for MAEs, respectively, indicating a significant association between pre-operative NT-proBNP levels and outcome. CONCLUSIONS Pre-operative NT-proBNP predicts outcome in patients undergoing surgery of AAD.

Clinical and haemodynamic outcomes in 804 patients receiving the Freedom SOLO stentless aortic valve: results from an international prospective multicentre study †

OBJECTIVES The Freedom SOLO™ valve (Sorin Group, Italy) is a stentless aortic bioprosthesis designed for simplified implantation. The present multicentre study is the largest prospective evaluation of this prosthesis. Herein, we report on outcomes at 3-year follow-up. METHODS From March 2009 to February 2013, a total of 804 consecutive patients (mean age 74.9 ± 6.3 years; 45.1% females) underwent aortic valve replacement with the Freedom SOLO™ valve at 33 centres. Concomitant procedures (70.2% coronary artery bypass grafting) were performed in 376 patients. The cumulative follow-up included 1100 patient-years (mean 16.5 ± 10.8 months; range: 0-40.5 months). RESULTS Sixty-four patients died (14 early, 50 late); 12 deaths (1 early, 11 late) were valve-related. Operative mortality (30 days) was 1.7%. At 3 years, overall survival was 82.6% [95% confidence interval (CI) 75.5-87.8%] and freedom from valve-related death was 95.5% (95% CI 89.2-98.2%). Linearized late event rates were 0.82%/patient-years for non-structural valve dysfunction, 0.55%/patient-years for structural valve deterioration, 1.55%/patient-years for endocarditis, 3.64%/patient-years for thromboembolism and 3.18%/patient-years for bleeding. In total, there were 22 reinterventions [19 valve explants, 2 refixations, 1 transcatheter aortic valve intervention (TAVI)] for endocarditis (11), non-structural dysfunction (9) and structural valve deterioration (2). Freedom from reintervention was 95.2% (95% CI 91.2-97.4%) at 3 years. There were no instances of valve thrombosis or haemolysis. At 1, 2 and 3 years, 97.0, 95.5 and 91.4% of patients were in NYHA class I or II. Between discharge and 3 years after surgery, mean transvalvular gradients exhibited a non-significant increase (6.5 ± 4.3 vs 8.7 ± 6.5 mmHg), whereas effective orifice area index remained stable (0.9 ± 0.2 vs 0.8 ± 0.3 cm(2)/m(2)). At 3 years, no patient presented with more than mild aortic regurgitation. Left ventricular mass index decreased significantly between discharge and 1 year after surgery (139.4 ± 40.9 vs 122.4 ± 35.3 g/m(2), P < 0.001) and remained unchanged thereafter. Left ventricular size and function did not change over time. CONCLUSIONS The Freedom SOLO™ valve is a unique stentless pericardial bioprosthesis whose design favours haemodynamic performance and thus facilitates left ventricular reverse remodelling. In terms of survival, morbidity and functional status, it is associated with beneficial outcomes up to 3 years after surgery. Ongoing follow-up will assess the valve at the long-term course.

A European Multicenter Study of 616 Patients Receiving the Freedom Solo Stentless Bioprosthesis

BACKGROUND The purpose of this study was to evaluate the safety and performance of the Freedom Solo valve in aortic valve replacement by clinical and hemodynamic outcomes. METHODS Six hundred sixteen patients underwent aortic valve replacement in 18 European centers; mean age was 74.5 ± 5.9 years, 54.1% of the patients were male, and concomitant procedures were performed in 43.2% of the patients. The majority (69%) of the implanted sizes were 23 mm and 25 mm. RESULTS At 1 year, overall survival was 94.0%, whereas freedom from valve-related death was 98.6%. There were 9 (1.5%) early (≤ 30 days) and 27 (4.4%) late (>30 days) deaths. Early and late valve-related mortality was 0.3% (n = 2) and 1.1% (n = 7), respectively. Freedom from explant was 97.6%; 10 valves were explanted for endocarditis and 4 for paravalvular leak. There were 10 (1.6%) early and 5 (0.8%) late strokes. Atrioventricular block requiring pacemaker implant occurred in 8 (1.3%) and 1 (0.2%) patients in the early and late postoperative period, respectively. Thrombocytopenia was seen in 27 cases (4.4%) in the early postoperative period. Preoperatively, 93.8% of patients were in New York Heart Association functional classes II through IV, whereas at 1 year 96.9% of patients were in New York Heart Association functional classes I and II. At 1-year follow-up, mean and peak pressure gradients were 7.2 and 14.6 mm Hg, respectively. Indexed left ventricular mass decreased by 12% from 138 g/m(2) at discharge to 122 g/m(2) at 1 year. CONCLUSIONS At 1-year follow-up after Freedom Solo implantation, we found acceptable clinical results with low mortality and morbidity and good hemodynamic performance, confirming safety and effectiveness in this multicenter experience.