Reiner Körfer

Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: A multicenter analysis

OBJECTIVESnDo prior percutaneous coronary interventions adversely affect the outcome of subsequent coronary artery bypass grafting? We investigated this effect on a multicenter basis.nnnMETHODSnEight cardiac surgical centers provided outcome data of 37,140 consecutive patients who underwent isolated first-time coronary bypass grafting between January 2000 and December 2005. Twenty-two patient characteristics and outcome variables were retrieved. Three groups of patients were analysed for in-hospital mortality and in-hospital major adverse cardiac events: patients without a previous percutaneous coronary intervention, with 1 previous intervention, and with 2 or more previous percutaneous coronary interventions before bypass grafting. A total of 29,928 patients with complete information for prior percutaneous coronary intervention underwent final analysis. Unadjusted univariate and risk-adjusted multivariate logistic regression analysis as well as computed propensity score matching were performed, based on 14 major risk factors to correct for and minimize selection bias.nnnRESULTSnA total of 10.3% of patients had 1 previous percutaneous coronary intervention, and 3.7% of patients had 2 or more previous interventions. Risk-adjusted multivariate logistic regression analysis revealed a significant association of 2 or more previous percutaneous coronary interventions with in-hospital mortality (odds ratio [OR], 2.0; confidence interval [CI], 1.4-3.0; P = .0005) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0013). After propensity score matching, conditional logistic regression analysis confirmed the results of adjusted analysis. A history of 2 or more previous percutaneous coronary interventions was significantly associated with in-hospital mortality (OR, 1.9; CI, 1.3-2.7; P = .0016) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0019).nnnCONCLUSIONSnMulticenter analysis confirms that a history of multiple previous percutaneous coronary interventions increases in-hospital mortality and the incidence of major adverse cardiac events after subsequent coronary artery bypass grafting. Critical discussion of the treatment strategy in these patients is warranted.

Risk Factor Analysis in Pediatric Heart Transplantation

BACKGROUNDnSteady assessment of risk factors will enable identification of patients at higher risk for post-transplant death, and may thus improve organ utilization and outcomes. In this study we aimed to identify the risk factors of mortality in pediatric heart transplantation.nnnMETHODSnBetween November 1989 and February 2004, there were 116 orthotopic heart transplantations performed in patients <18 years of age at our institution.nnnRESULTSnThe 30-day mortality risk was 12% (dilated cardiomyopathy 7%, congenital heart disease 26%; univariate analysis: p = 0.023). The main cause of 30-day mortality was primary graft failure (36%). The late mortality rate was 31 per 1,000 person-years. The main causes of late mortality were acute rejection (44%) and cardiac allograft vasculopathy (26%). The 1-, 5-, 10- and 15-year survival rates were 85%, 77%, 65% and 53%, respectively. Male donor (odds ratio [OR] 6.33, 95% confidence interval [CI] 1.11 to 36.01) and cardiopulmonary bypass >210 minutes (OR 43.05, 95% CI 1.11 to 1,669) were risk factors for 30-day mortality. Risk factors for 1- and 5-year mortality were body weight ratio <0.8 (OR 40.36, 95% CI 3.04 to 536.47) and male donor (OR 3.36, 95% CI 1.05 to 10.75), respectively. Recipient age <1 year (OR 64.65, 95% CI 1.69 to 2,466.77) and donor-recipient body surface area mismatch of <0.9 (OR 10.58, 95% CI 1.03 to 108.25) were risk factors for 10-year mortality.nnnCONCLUSIONSnPediatric heart transplantation can be performed with an expectation of excellent results. Certain risk factors suggest poorer outcomes.

Total artificial heart-implantation technique using the CardioWest or the Thoratec system

Total artificial heart is a safe and efficient bridge for patients with terminal congestive heart failure awaiting cardiac transplantation. The implantation of the CardioWest total artificial heart has become an accepted therapeutic option in critically ill patients who have irreversible biventricular failure and are candidates for cardiac transplantation. Because of anatomical limitations in smaller patients (women, adolescents) implantation of the CardioWest system might be impossible. In these cases we have implanted the paracorporeal Thoratec device in a modified technique as a total artificial heart.

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.

Prolapsing left atrial myxoma: preoperative diagnosis using a multimodal imaging approach with magnetic resonance imaging and real-time three-dimensional echocardiography

Real-time three-dimensional echocardiography (RT3DE) is a new promising technique for the evaluation of intracardiac masses. We present the diagnostic work-up using a multimodal-imaging approach in a 74-year-old patient with a prolapsing tumour in the left atrium suggestive of a myxoma, causing severe congestive heart failure attributable to dynamic left ventricular inflow obstruction, and mimicking severe mitral valve stenosis. Real-time three-dimensional echocardiography allowed to accurately image the entire volume of the myxoma, and to analyse the dynamic left ventricular inflow obstruction. The size of the lobulated mass as assessed by RT3DE was 65 x 25 x 22 mm. The mass was surgically removed, histology was diagnostic for myxoma, and the patient had an uneventful recovery. Real-time three-dimensional echocardiography images the entire volume of a mass allowing for accurate measurements in multiple planes, and allowing for real-time evaluation of obstructive effects on ventricular in- or outflow. This case shows how RT3DE and other non-invasive imaging modalities may be used as complementary techniques for evaluation of intracardiac masses.

Surgical Treatment of Left Ventricular Aneurysm

When a left ventricular aneurysm leads to pulmonary congestive symptoms, aneurysmectomy may provide relief. This retrospective study included 269 patients who underwent aneurysmectomy between 1993 and 2002, by the classic Cooley operation in 164 and by Dor ventriculoplasty in 105. There were no significant differences in early and late survival between groups, although the frequency of extended anteroseptal infarction was higher in patients undergoing the Dor procedure. Postoperative echocardiographic findings showed significant improvements in left ventricular function in both groups, in terms of end-diastolic and end-systolic dimensions and ejection fraction. Left ventricular aneurysmectomy significantly improved the clinical status and hemodynamic parameters of symptomatic patients. The choice of surgical technique depends on the extent of the scar segment, especially the presence of an anteroseptal scarred area. The Dor procedure is more suitable for restoring normal left ventricular geometry in patients with extensive septal infarction.

Successful Correction of a Total Anomalous Venous Connection in a 63-year-old Male—Case Report and Review of the Literature

Total anomalous pulmonary venous connection is a rare variant of cyanotic congenital heart disease and usually requires surgical correction within the first few months of life. We report midterm results of a 63-year-old male with intracardiac total anomalous venous return into the coronary sinus who presented with congestive predominantly right heart failure and underwent corrective surgery with unroofing of the coronary sinus and patch closure of the secundum atrial septal defect.

Single Center - Erfahrungen mit der klinischen Anwendung implantierbarer Blutpumpen

Epidemiologische Studien belegen eine jahrliche Inzidenz der Herzinsuffizienz von 0,3-1,0 % in den USA und in Europa (3). In Amerika erkranken ca. 400.000 Menschen pro Jahr neu an einer Herzinsuffizienz. Gerade die Inzidenz der fortxadgeschrittenen Herzinsuffizienz steigt weiter deutlich an, bedingt u. a. durch die zunehmende Uberalterung der Gesellschaft. Patienten mit fortgeschrittener Herzinsuffizienz, NYHA-Klasse IV, haben eine 1-Jahres-Mortalitatsrate von ca. 35% (1). Die 5-Jahres-Mortalitatsrate liegt laut der Framingham-Studie bei 75 % fur Manner und bei 62 % fur Frauen. Goldstandard der Therapie der terminalen Herzinsuffizienz ist die Herztransplantation, aufgrund eines persistierenden Mangels an Spenderorganen ist diese Therapieoption in ihrer Anwendung jedoch limitiert. Die Suche nach geeigneten anderen Therapieoptionen hat seit Mitte der 80er Jahre vermehrt zur Entwicklung verschiedener mechanischer Kreislaufunterstutzungssysteme gefuhrt. Seit den 90er Jahren wurde insbesonxaddere an der Entwicklung implantierbarer Systeme gearbeitet.

Bosentan in pulmonary hypertension secondary to left heart failure

ABSTRACT Background: Pulmonary hypertension (PH) secondary to left ventricular failure not only predicts a poor clinical outcome, but also excludes patients from orthotopic heart transplantation (HTX). Recent clinical and laboratory findings indicate comparable pathophysiological mechanisms in PH secondary to left ventricular dysfunction and pulmonary arterial hypertension (PAH), a clinical situation in which endothelin (ET)-1 is an established key pathogenetic mediator. In addition to ET-1-mediated constriction and remodelling of the pulmonary vasculature, ET-1 further contributes to cardiac hypertrophy and aldosterone secretion in left heart failure (HF). Results: Initial results with the oral, dual ET receptor antagonist bosentan in patients with advanced left HF and secondary PH (presented herein as two case studies of patients with Class III and IV HF and a case series of 19 patients with PH secondary to left HF of different aetiologies) has shown promising results: cardiopulmonary haemodynamics improved significantly with a concomitant clinical stabilization. Conclusion: As illustrated by these initial results, bosentan may expand the therapeutic arsenal in PH secondary to left ventricular dysfunction and may not only help to bridge the time to HTX, but may also allow the improvement of cardiopulmonary haemodynamics and thus listing of patients that would be otherwise excluded from HTX.