Nils Reiss

Determinants of mid- and long-term results in patients after surgical revascularization for ischemic cardiomyopathy

BACKGROUND The revascularization of patients suffering from ischemic cardiomyopathy is possible with acceptable perioperative mortality and morbidity. Many publications have discussed the problem of predicting myocardial viability, whereas the quality of the peripheral coronary vessels has been focused on less frequently. METHODS We studied 908 consecutive patients with ischemic cardiomyopathy revascularized between January 1, 1988 and April 30, 2000. Death, recurrent heart failure, hospitalization due to cardiac causes, ventricular assist device implantation, heart transplantation, and ventricular arrhythmias were defined as adverse events. To analyze the importance of pre- and perioperative variables (state of the coronary arteries, myocardial viability, complete vs incomplete revascularization, urgency of the operation, previous operations, gender, diabetes, preoperative New York Heart Association class, age, number of grafts, and ischemic time), a proportional hazards model was used. RESULTS The most important predictors of short- and long-term event-free survival were the quality of the coronary arteries, followed by myocardial viability, complete revascularization, number of bypass grafts, and an elective operation. CONCLUSIONS The coronary vascular system can be described by means of a simple scoring system. A good or at least moderate coronary artery perfusing an area of dysfunctional yet viable myocardium is the main predictor of a successful perioperative course and an event-free survival. Patients with a poor coronary vasculature regardless of myocardial viability should not be considered suitable for revascularization.

Acute fulminant myocarditis in children and adolescents: the role of mechanical circulatory assist.

We report children and adolescents in fulminant myocarditis undergoing prolonged circulatory support with different assist devices. Between 1994 and 2004, seven children and adolescents (aged 7–18 years, mean age 13.5 years) were treated with VADs (5 Thoratec, 1 Medos, 1 Novacor) for circulatory support. Three patients underwent left ventricular support; biventricular support was necessary in four patients. Four patients (three left VADs, one bi-VAD) could be successfully bridged to heart transplantation after a mean support time of 163 days (56–258 days). One 7-year-old girl (Medos-BVAD) died after a support time of 11 days because of irreversible multiorgan failure. One 18-year-old patient was successfully weaned from Thoratec BVAD after 66 days with complete recovery of left ventricular function. As good markers, atrial and brain natriuretic peptides were found which reached normal values after recovery of myocardial function. A 15-year-old girl is still on the device. In children or adolescents with irreversible shock in fulminant myocarditis with an anticipated mortality of 100%, both successful bridging to heart transplantation and successful bridging to recovery are possible. Young patients with fulminant myocarditis should be rapidly transferred to a clinic with a mechanical circulatory support program to offer this life-saving option.

Mechanical valve replacement in congenital heart defects in the era of international normalized ratio self-management

As the number of patients with congenital heart defects requiring heart valve replacement increases, the need for durable valve substitutes with good hemodynamic performance and a low incidence of complications becomes more apparent. The use of porcine xenografts is burdened with early fibrocalcific degeneration, whereas the use of mechanical heart valves led to an increased number of thromboembolic events, especially when implanted in the right side of the heart. We report on our experiences implanting bileaflet heart valves in congenital heart defects since the introduction of international normalized ratio (INR) self-management. The data of 68 long-term survivors (33 males, 35 females) who underwent mechanical heart valve replacement in congenital heart defect were reviewed. Patient age at the time of valve replacement ranged from 5 months to 61 years (mean 21 years). Underlying diagnoses were tetralogy of Fallot (n = 33), morbus Ebstein (n = 4), atrioventricular canal (n = 13), truncus arteriosus communis (n = 5), transposition of the great arteries (n = 10), and congenitally corrected transposition of the great arteries (n = 3). In all patients, bileaflet valves were implanted (St. Jude Medical n = 40, Carbomedics n = 28). Anticoagulation was performed using dicumarol (Marcumar) and INR self-management in all cases. The mean follow-up was 72 months (range 6–132 months; 409 patient-years). Valve thrombosis developed in 3 of 68 patients (4.4%, all three had tetralogy of Fallot, mean age 9.8 years) after a mean follow-up of 3.5 years. In two of these three patients, re-pulmonary valve replacement was necessary, whereas the third patient was treated by thrombolysis. From our experience, we conclude that mechanical heart valve replacement is a good therapy option with a low complication rate for patients with congenital heart defects requiring valve replacement, especially when INR self-management is performed.

Implantation of Cardio West Total Artificial Heart for Irreversible Acute Myocardial Infarction Shock

Patients who develop cardiogenic shock after acute myocardial infarction have a very high mortality rate despite early reperfusion therapy. Hemodynamic stabilization can often only be achieved by implanting a mechanical circulatory support system. When, in cases representing expansive myocardial impairment without any chance of recovery, pharmacological therapy and the use of percutaneous assist devices have failed, the implantation of a total artificial heart is indicated. We report our first experiences with this extensive and innovative method of managing irreversible cardiogenic shock patients. The CardioWest total artificial heart was implanted in 5 patients (male; mean age, 50 years). All patients were in irreversible cardiogenic shock despite maximum dosages of catecholamines, an intra-aortic balloon pump and/or a femoro-femoral bypass. In all patients early reperfusion therapy was performed. After implantation of the Cardio West system, all dysfunctional organ systems rapidly recovered in all patients. Four of 5 patients underwent successful heart transplantation after a mean support time of 156 days. One patient died because of enterocolic necroses caused by an embolic event after termination of dicumarol therapy. In summary, our first experiences justify this extensive management in young patients who would otherwise have died within a few hours.

Mechanical valve replacement of the systemic atrioventricular valve in children.

In children with systemic atrioventricular valve disease (SAVVD), reconstructive surgery is the primary goal. However, in cases with severely dysplastic valves or failed repair, valve replacement is the only option. The purpose of this study was to assess the early and late outcome following mechanical valve replacement in SAVVD. Between 1989 and 2003, 31 children underwent mechanical valve replacement (19 St. Jude Medical, 12 Carbomedics) in SAVVD (27 mitral, 3 tricuspid in corrected transposition of the great arteries, 1 common in an univentricular heart) at our institution. The ages ranged from 3 months to 15 years (mean 4 years) and body weight varied between 4.2 and 57 kg (mean 13.3 kg). The size of prostheses ranged between 16 and 31 mm (mean 23.9 mm). The main indication for valve replacement was severe insufficiency of left atrioventricular valve (84%); 84% of the patients had had a previous cardiac operation. The overall hospital mortality was 6.5% The mean follow up was 7.7 years (range 2–13 years). Ninety percent of children represent sinus rhythm, 87% are in NYHA class I. All patients were placed on a regimen of Phenprocoumon aiming to maintain the international normalized ratio (INR) between 3.0 and 4.0. Since 1994, INR self-management of oral anticoagulation was performed either by the patient or his or her parents. There was no anticoagulation-related complication in this patient group. Mechanical valve replacement in left atrioventricular valve disease carries a low operative risk across the spectrum of pediatric age despite previous operations in most cases. Long-term survival and quality of life are good in nearly all cases. The rate of anticoagulation-related complications is very low, especially when INR self management is performed.

International normalized ratio patient self-management for mechanical valves: is it safe enough?

Purpose of review People with mechanical heart valve replacement depend on lifelong anticoagulation. Since a few years, patients can control this themselves with the assistance of a portable anticoagulation monitor. If the patient performs the complete self-testing and self-adjustment by himself, the method is called self-management. Recently completed studies concerning international normalized ratio (INR) self-management in mechanical heart valve patients are reviewed in this article. Recent findings Large randomized prospective studies have demonstrated that the INR self-management concept results in well-trained patients with a high percentage of their measured INR values lying within the predetermined therapeutic range, thus resulting in a low rate of complications such as bleeding and thromboembolism. The reduced anticoagulation level resulted in fewer grade III bleeding complications (which means there is a need for surgery or endoscopy, in-hospital treatment or permanent damage) without increasing thromboembolic event rates. Summary The concept of INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. Data of the Early Self-Controlled Anticoagulation Trial (ESCAT II) study demonstrate that low-dose INR self-management does not increase the risk of thromboembolic events compared with conventional-dose INR self-management.

[Diabetes mellitus and heart failure - incidence and surgical therapy options].

ZusammenfassungDer Anteil der Diabetiker unter den Patienten mit einer Herzinsuffizienz beträgt nahezu 20%, verglichen mit 4–6% in einer Kontrollpopulation. Epidemiologische Studien haben ein deutlich erhöhtes Risiko bei Diabetikern nachweisen können, an einer Herzinsuffizienz zu erkranken. Experimentelle und klinische Studien konnten die Existenz einer spezifischen diabetischen Kardiomyopathie stützen.Eine genaue Kenntnis des jeweiligen diabetischen Status mag helfen, eine auf den Patienten mit einer Herzinsuffizienz zugeschnittene optimale Therapie zu finden. Bei der ischämischen Kardiomyopathie sollte die Wahl der chirurgischen Therapie entsprechend dem augenblicklichen diabetischen Status, der Ausprägung der Koronarsklerose und der linksventrikulären Dysfunktion erfolgen.Zum gegenwärtigen Zeitpunkt scheinen chirurgische Revaskularisationsverfahren bei der ischämisch bedingten Kardiomyopathie gegenüber interventionellen Verfahren im Vorteil zu sein.In zunehmendem Umfang sind in den letzten Jahren Diabetiker mit einer terminalen Herzinsuffizienz einer Herztransplantation unterzogen worden. Dabei hat sich gezeigt, dass sich das Überleben nach der Transplantation bei Patienten mit einem unkomplizierten Diabetes mellitus nicht signifikant von dem der Nichtdiabetiker unterscheidet. Liegt jedoch eine schwere Verlaufsform des Diabetes mellitus vor, so gibt es zum Überleben der Patienten nach der Herztransplantation gegensätzliche Publikationen. Aus diesem Grund sollte – auch angesichts der Organknappheit – eine sorgfältige Evaluierung erfolgen, um das richtige Therapieregime inklusive einer „destination therapy“ mittels eines mechanischen Kreislaufunterstützungssystems für jeden einzelnen Patienten auszuwählen.AbstractThe prevalence of diabetes mellitus in heart failure populations is close to 20% compared with 4–6% in control populations. Epidemiologic studies have demonstrated an increased risk of heart failure in diabetics. Experimental and clinical studies support the existence of a specific diabetic cardiomyopathy related to microangiopathy, metabolic factors or myocardial fibrosis.The knowledge of the diabetes status may help to define the optimal therapeutic strategy for heart failure patients. In ischemic cardiomyopathy the choice of the surgical treatment may differ according to diabetes status, coronary atherosclerosis and left ventricular function.At present, surgical revascularization techniques seem to be superior to interventional revascularization procedures.In the last decade a growing part of diabetics presenting severe heart failure underwent heart transplantation. Thereby, it was found that the survival rates of patients with uncomplicated diabetes mellitus and of nondiabetics did not differ. The survival rates in patients with severe and progressive form of diabetes mellitus are discussed controversially in the literature. Because of donor organ shortage each diabetic patient presenting severe heart failure should be evaluated to find the best therapy including permanent mechanical circulatory support (“destination therapy”).

Diabetes mellitus und Herzinsuffizienz – Inzidenz und chirurgische Therapieoptionen

ZusammenfassungDer Anteil der Diabetiker unter den Patienten mit einer Herzinsuffizienz beträgt nahezu 20%, verglichen mit 4–6% in einer Kontrollpopulation. Epidemiologische Studien haben ein deutlich erhöhtes Risiko bei Diabetikern nachweisen können, an einer Herzinsuffizienz zu erkranken. Experimentelle und klinische Studien konnten die Existenz einer spezifischen diabetischen Kardiomyopathie stützen.Eine genaue Kenntnis des jeweiligen diabetischen Status mag helfen, eine auf den Patienten mit einer Herzinsuffizienz zugeschnittene optimale Therapie zu finden. Bei der ischämischen Kardiomyopathie sollte die Wahl der chirurgischen Therapie entsprechend dem augenblicklichen diabetischen Status, der Ausprägung der Koronarsklerose und der linksventrikulären Dysfunktion erfolgen.Zum gegenwärtigen Zeitpunkt scheinen chirurgische Revaskularisationsverfahren bei der ischämisch bedingten Kardiomyopathie gegenüber interventionellen Verfahren im Vorteil zu sein.In zunehmendem Umfang sind in den letzten Jahren Diabetiker mit einer terminalen Herzinsuffizienz einer Herztransplantation unterzogen worden. Dabei hat sich gezeigt, dass sich das Überleben nach der Transplantation bei Patienten mit einem unkomplizierten Diabetes mellitus nicht signifikant von dem der Nichtdiabetiker unterscheidet. Liegt jedoch eine schwere Verlaufsform des Diabetes mellitus vor, so gibt es zum Überleben der Patienten nach der Herztransplantation gegensätzliche Publikationen. Aus diesem Grund sollte – auch angesichts der Organknappheit – eine sorgfältige Evaluierung erfolgen, um das richtige Therapieregime inklusive einer „destination therapy“ mittels eines mechanischen Kreislaufunterstützungssystems für jeden einzelnen Patienten auszuwählen.AbstractThe prevalence of diabetes mellitus in heart failure populations is close to 20% compared with 4–6% in control populations. Epidemiologic studies have demonstrated an increased risk of heart failure in diabetics. Experimental and clinical studies support the existence of a specific diabetic cardiomyopathy related to microangiopathy, metabolic factors or myocardial fibrosis.The knowledge of the diabetes status may help to define the optimal therapeutic strategy for heart failure patients. In ischemic cardiomyopathy the choice of the surgical treatment may differ according to diabetes status, coronary atherosclerosis and left ventricular function.At present, surgical revascularization techniques seem to be superior to interventional revascularization procedures.In the last decade a growing part of diabetics presenting severe heart failure underwent heart transplantation. Thereby, it was found that the survival rates of patients with uncomplicated diabetes mellitus and of nondiabetics did not differ. The survival rates in patients with severe and progressive form of diabetes mellitus are discussed controversially in the literature. Because of donor organ shortage each diabetic patient presenting severe heart failure should be evaluated to find the best therapy including permanent mechanical circulatory support (“destination therapy”).

Der Einfluss des Diabetes mellitus auf koronarchirurgische Eingriffe unter besonderer Berücksichtigung der linksventrikulären Funktion

Hintergrund:Diabetes mellitus ist nicht nur ein bedeutender Risikofaktor für die Entwicklung einer Arteriosklerose, sondern auch ein Risikofaktor bei der chirurgischen und interventionellen Behandlung der stenosierenden koronaren Herzerkrankung (KHK).Patienten und Methodik:In Krankengut der Autoren aus dem Jahre 2003 fanden sich 2 142 Patienten, die sich einer isolierten operativen Myokardrevaskularisation unterziehen mussten. 567 dieser Patienten litten unter einem Diabetes mellitus.Ergebnisse:Eine Analyse der diabetischen versus der nichtdiabetischen Patientengruppe ergab ein deutlicher ausgeprägtes präoperatives Risikoprofil, eine signifikant schlechtere linksventrikuläre Funktion und einen deutlich schlechteren Zustand der Koronararterien in der diabetischen Gruppe. Die perioperative Letalität war nicht signifikant verschieden. Wundheilungsstörungen, perioperative Einschränkungen der Nierenfunktion und neurologische Komplikationen traten in der diabetischen Patientengruppe signifikant häufiger auf.Schlussfolgerung:Die Ergebnisse lassen den Schluss zu, dass in der heutigen Zeit das Risiko quoad vitam für einen diabetischen KHK-Patienten trotz der deutlich schlechteren Ausgangssituation nicht, das Risiko von Wundheilungsstörungen und perioperativem Organversagen bei entsprechendem Risikoprofil hingegen sehr deutlich erhöht ist.Background:Diabetes mellitus is not only an independent risk factor for the development of arteriosclerosis, but also a risk factor for the surgical and interventional treatment of coronary artery disease (CAD).Patients and Methods:In 2003, a consecutive series of 2,142 patients underwent isolated coronary bypass grafting at the authors’ institution, 567 of these suffering from diabetes mellitus.Results:An analysis of the diabetic and nondiabetic patients revealed a more pronounced risk profile, a significantly reduced left ventricular function and a significantly poorer quality of the coronary arteries in the diabetic group. Perioperative mortality in both groups was not different. The incidence of wound infections, renal failure and neurologic complications was much higher in diabetic patients.Conclusion:From these findings it can be concluded that coronary artery bypass grafting in the current era is not associated with a higher perioperative mortality in diabetic patients despite their risk profile at baseline. The risk of wound infections and perioperative renal and neurologic complications is much higher in diabetic patients.

Der Einfluss des Diabetes mellitus auf koronarchirurgische Eingriffe unter besonderer Bercksichtigung der linksventrikulren Funktion@@@The Impact of Diabetes Mellitus on the Results of Coronary Artery Bypass Grafting with Respect to Left Ventricular Function

Hintergrund:Diabetes mellitus ist nicht nur ein bedeutender Risikofaktor für die Entwicklung einer Arteriosklerose, sondern auch ein Risikofaktor bei der chirurgischen und interventionellen Behandlung der stenosierenden koronaren Herzerkrankung (KHK).Patienten und Methodik:In Krankengut der Autoren aus dem Jahre 2003 fanden sich 2 142 Patienten, die sich einer isolierten operativen Myokardrevaskularisation unterziehen mussten. 567 dieser Patienten litten unter einem Diabetes mellitus.Ergebnisse:Eine Analyse der diabetischen versus der nichtdiabetischen Patientengruppe ergab ein deutlicher ausgeprägtes präoperatives Risikoprofil, eine signifikant schlechtere linksventrikuläre Funktion und einen deutlich schlechteren Zustand der Koronararterien in der diabetischen Gruppe. Die perioperative Letalität war nicht signifikant verschieden. Wundheilungsstörungen, perioperative Einschränkungen der Nierenfunktion und neurologische Komplikationen traten in der diabetischen Patientengruppe signifikant häufiger auf.Schlussfolgerung:Die Ergebnisse lassen den Schluss zu, dass in der heutigen Zeit das Risiko quoad vitam für einen diabetischen KHK-Patienten trotz der deutlich schlechteren Ausgangssituation nicht, das Risiko von Wundheilungsstörungen und perioperativem Organversagen bei entsprechendem Risikoprofil hingegen sehr deutlich erhöht ist.Background:Diabetes mellitus is not only an independent risk factor for the development of arteriosclerosis, but also a risk factor for the surgical and interventional treatment of coronary artery disease (CAD).Patients and Methods:In 2003, a consecutive series of 2,142 patients underwent isolated coronary bypass grafting at the authors’ institution, 567 of these suffering from diabetes mellitus.Results:An analysis of the diabetic and nondiabetic patients revealed a more pronounced risk profile, a significantly reduced left ventricular function and a significantly poorer quality of the coronary arteries in the diabetic group. Perioperative mortality in both groups was not different. The incidence of wound infections, renal failure and neurologic complications was much higher in diabetic patients.Conclusion:From these findings it can be concluded that coronary artery bypass grafting in the current era is not associated with a higher perioperative mortality in diabetic patients despite their risk profile at baseline. The risk of wound infections and perioperative renal and neurologic complications is much higher in diabetic patients.