Sm Tugtekin

Coronary surgery for acute coronary syndrome: which determinants of outcome remain?

BackgroundThe mortality risk associated with coronary artery bypass grafting (CABG) after acute myocardial infarction remains controversial. The objective of the present study was therefore to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS).Patients and methodsBetween January 2003 and May 2005, a total of 3,127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. Out of these, unstable angina pectoris was present in 88 pts (group I), 97 pts (group II) had non-ST-elevation infarction, whereas 35 pts (group III) had ST-elevation infarction. Clinical data, in-hospital morbidity and mortality were recorded and studied retrospectively.ResultsOverall in-hospital mortality was 6.4% (n = 14) in the complete cohort, being 2.2% in group I (n = 2), 9.2% in group II (n = 9) and 8.5% (n = 3) in group III (P < 0.05). Logistic regression and receiver operating characteristic analyses identified age, NYHA, ejection fraction < 45%, catecholamine support, cardiogenic shock, renal disease and the additive EuroSCORE > 10 (P < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 ± 2.7 h) and no survivors (11.4 ± 3.2 h) (P < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information.ConclusionCABG in pts with ACS can be performed with good clinical results. The clinical outcome is particular depending on the different groups of ACS. Therefore an individual risk stratification of each pts in ACS is necessary. The time interval of 6 h seems to be crucial as prognostic variable in the STEMI-group.

Lactococcus garvieae causing zoonotic prosthetic valve endocarditis.

A 55-year-old amateur fish farmer with a history of mechanical tricuspid valve replacement was admitted to hospital due to progressive dyspnea. Additionally he suffered relapsing shivering attacks and fever of unknown origin of 2 weeks duration. The patient denied arthralgia, night perspiration or weight-loss. His family doctor started antibiotic treatment with cotrimoxazole. Physical examination showed loss of click/murmur of the mechanical valve prosthesis. Five years ago the patient underwent mechanical valve replacement because of seronegative tricuspide valve endocarditis in consequence of chronic parodontitis complicated by bacterial lung abscesses. Transesophageal echocardiography revealed a mobile vegetation of 7 9 9 mm diameter on the mechanical valve prosthesis (Fig. 1). Baseline laboratory tests showed a leukocyte count of 18.9 Gpt/l and increased C-reactive protein of 72.4 mg/l. An intravenous antibiotic therapy of gentamicin, vancomycin and rifampicin was initiated. Three consecutively taken blood cultures were positive for Lactococcus garvieae. Within 1 week fever and inflammation parameters declined to normal values. The patient then underwent prosthetic valve replacement (33 mm Carpentier Edwards SAV bioprosthesis). Intraand postoperative course were uneventful. The patient was released from hospital with an antibiotic therapy adapted to the antibiogram (levofloxacin, amoxicillin and clavulanic acid) for 8 weeks and an oral anticoagulative therapy for 3 months. The Lactococcus genus is different to other gram-positive cocci like Streptococci or Enterococci [1, 2]. The catalase-negative, facultatively anaerobic, serogroup N gram-positive Lactococcus garvieae is a distinct fishpathogen with a high virulence in fish with LD50 of 10 bacteria per fish. It is isolated in saltwater fish in Far East and also in European Rainbow Trout. In humans it is a rare pathogen and of low virulence—a review of literature reports 12 cases of infection in humans [3]. The case of native or prosthetic valve endocarditis caused by these bacteria is extremely unusual [4–6]. In the present case the M. Wilbring (&) H. Reichenspurner Department for Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany e-mail: manuel.wilbring@gmail.com

Coronary reoperation with and without cardiopulmonary bypass.

SummaryRedo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB.From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66±9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67±8 years).Perioperative overall mortality rate was 3.6% (n=7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p=0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity.Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p<0.01). The average number of grafts was significantly higher in the on pump group (2.8±0.78 versus 1.6±0.6; p=0.04).Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50±16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44±13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p=0.92).On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.

Right Ventricular Reduction as an Adjunct Procedure in Tricuspid Valve Repair

Functional tricuspid regurgitation secondary to mitral valve disease can not be attributed to the dilatation of the tricuspid annulus alone. Furthermore, geometrical changes of the right ventricle lead to tethering of the tricuspid valve leaflets and thereby to an incomplete leaflet coaptation. With this pathologic entity, conventional isolated tricuspid valve annuloplasty will presumably result in significant residual tricuspid regurgitation. The surgical goal should be the reduction of tricuspid annulus dilatation and annihilation of tethering forces on the tricuspid leaflets. In combination with conventional tricuspid valve annuloplasty, right ventricular reduction surgery, as demonstrated, may be effective in reaching these goals and hereby avoiding residual tricuspid regurgitation in this patient population.

Austrian syndrome in the context of a fulminant pneumococcal native valve endocarditis.

This is the case of a young male suffering from Austrian syndrome, which is the triad of endocarditis, meningitis, and pneumonia due to invasive S. pneumoniae infection. He reported recurrent fever for six months without any antibiotic treatment, which may have determined the further course of the syndrome. Echocardiography revealed massive native valve endocarditis, and the patient was considered for ultima-ratio cardiac surgery. Intraoperative aspect presented extensive affection of the aortic root with full destruction of aortic valve, mitral valve, and aortomitral continuity. The myocardium showed a phlegmon-like infiltration. Microbiologic testing of intraoperatively collected specimens identified penicillin-sensitive Streptococcus pneumoniae. S. pneumoniae is a very uncommon cause for infective infiltrative endocarditis and is associated with severe clinical courses. Austrian syndrome is even more rare, with only a few reported cases worldwide. In those patients, only early diagnosis, immediate antibiotic treatment, and emergent cardiac surgery can save lives.

Intra-aortic balloon pump implantation does not affect long-term survival after isolated CABG in patients with acute myocardial infarction.

BACKGROUND Intra-aortic balloon pump (IABP) is an established therapy to support patients with heart failure during coronary artery bypass grafting (CABG). The impact of the timing of IABP on the hospital course and on follow-up is of particular clinical interest. The purpose of this study was to analyze the relationship between the time of IABP implantation and its impact on early, mid- and long-term survival in patients with acute myocardial infarction (AMI) who underwent emergent CABG for NSTEMI and STEMI. METHODS A total of 472 patients with AMI (NSTEMI and STEMI) underwent emergency CABG at our institution; 158 of them additionally received IABP support. Fifty-seven (36 %) patients received preoperative and 101 (64 %) patients underwent intraoperative IABP implantation. Endpoints were in-hospital und follow-up (mean duration 37 ± 28 months) survival. RESULTS Overall in-hospital mortality was 17.1 % (n = 27): 17.6 % (n = 10) in the preoperative group and 16.8 % (n = 17) in the intraoperative group ( P = ns). Mid- and long-term survival rates were comparable for both groups 78.6 % vs. 73.7 %, 71.4 % vs. 68.7 % and 64.3 % vs. 54.6 % at 1, 3 and 5 years, respectively ( P = ns). CONCLUSION This study demonstrates that CABG with IABP support in high-risk patients with AMI can be performed with acceptable in-hospital and long-term survival rates. The decision for IABP placement should consider the preoperative clinical condition and the intraoperative course of each patient. IABP placement does not appear to affect the long-term outcome after isolated CABG in patients with AMI.

Chirurgische Therapie nach traumatischen interventionellen Koronarläsionen

Coronary perforation and entrapment of catheter materials are rare, but life-threatening complications, which often require emergency cardiosurgical treatment. Surgical options include tamponade drainage, coronary artery bypass grafting, perforation suturing, and removal of catheter materials. Surgical strategies are not standardized but mainly depend on the surgical anatomy. This is in particular true for the removal of the catheter remnants (stent, guidewire). Keeping this in mind, these patients can be treated with good clinical results. Koronarperforationen und Verbleiben von Katheterbestandteilen sind seltene aber oft lebensbedrohliche Komplikationen nach interventionellen Eingriffen, welche eine notfallmäßige kardiochirurgische Versorgung erfordern. Das chirurgische Spektrum umfasst die Tamponadeentlastung, Anlage von Bypässen, Versorgung der Perforationsstelle sowie Entfernung von Katheterbestandteilen. Das chirurgische Vorgehen ist dabei nicht vereinheitlicht und hängt maßgeblich von den anatomischen Verhältnissen ab. Dies gilt insbesondere für das Entfernen oder Belassen von Katheterbestandteilen (Stent, Führungsdraht). Unter individueller Therapiefestlegung lassen sich diese Patienten mit guten klinischen Ergebnissen behandeln.

A fatal consequence of acute myocardial infarction in a patient with APC-resistance at high altitude

tended an expedition in the Himalayan-mountains. There were neither cardiac risk factors, nor any other severe illness or former medication reported in his anamnesis. While ascending at an altitude of approx. 6,000 m with a presumed PaO2 of 38 mmHg, he suddenly developed angina pectoris in combination with distinct weakness. He never experienced episodes like this before. Due to this cardiac event, he was impelled to descent to the base camp (5.400 m). The hospitalization at the beginning of November 2006 resulted due to thoracic tightness. The patient underwent a coronary angiography, which demonstrated an occlusion of the proximal LAD distal the outlet of the first D-branch (Fig. 1) with absence of significant coronary artery disease (CAD). The first attempt of recanalisation was futile. During the second attempt of LAD recanalisation, an acute formation of thrombi with consecutive occlusion of the circumflex branch, the proximal LAD and RIM occurred. The aspiration of the thrombi in the same session was successful. The occlusion of the LAD remained. The further diagnostics showed a heterozygote factor V Leiden (APC-resistance) as a possible causation. Extensive further diagnostics ruled out other diseases as deep vein thrombosis or tumour-suffering. An accomplished NMR of the heart showed a global hypocinesia with moderate dilatation of the left ventricle and a parietal thrombus on the apicoseptal segment (Fig. 2). An anticoagulation with coumadine was initiated. In March 2007, the readmission to hospital took place due to progressive dyspnoea (NYHA III+) and occasional stenocardia. A repeated coronary angiography affirmed the former reported findings. NMR of the heart and transthoracic echocardiography showed a progressive biventricular dilatation with a severely reduced ventricular function and mitral regurgitation grade 2+. Ejection fraction was approx. 20% (from 48% U. Kappert M. Wilbring S. M. Tugtekin K. Alexiou K. Matschke A fatal consequence of acute myocardial infarction in a patient with APC-resistance at high altitude

Coronary surgery in dialysis-dependent patients with end stage renal failure

Der Anteil von Patienten mit dialysepflichtigen terminalen Nierenversagen und koronarer Herzerkrankung (KHK) hat in den letzten Jahren zugenommen. Die koronare Bypassoperation hat sich als Standardtherapie in dieser Patientengruppe etabliert, gilt jedoch als Risikoeingriff aufgrund erhöhter Mortalität und Morbidität. In einer retrospektiven Analyse wurden die klinischen Daten und Ergebnisse der isolierten koronaren Bypassoperation bei 40 dialysepflichtigen Patienten mit terminaler Niereninsuffizienz (5 Frauen, 35 Männer, Alter 65±7 Jahre) untersucht und der perioperative Verlauf mit einer Kontrollgruppe von 51 Patienten (10 Frauen, 41 Männer, Alter 67±7,3 Jahre) mit normaler Nierenfunktion und isolierten koronarchirurgischen Eingriff verglichen. Zusätzlich erfolgte ein Follow-up der Dialysegruppe (mittlere Beobachtungszeitraum 34±24 Monate). Demographische und klinische Daten der beiden Gruppen waren vergleichbar. Die Hospitalmortalität war 2,5% (n=1) in der Dialysegruppe und 0% in der Kontrollgruppe, bei vergleichbarer Morbidität. Die Anzahl der Bypässe lag bei 3,1±0,9 in der Dialysegruppe und 2,9 ±0,8 in der Kontrollgruppe. Im gesamten Beobachtungszeitraum verstarben 8 Patienten, dabei fand sich bei 4 Patienten eine kardiale Genese. Die isolierte Koronarchirurgie kann bei Patienten mit dialysepflichtigen Nierenversagen mit guten klinischen Ergebnissen und geringer Morbidität durchgeführt werden. The number of patients with dialysis-dependent end stage renal failure (ESRF) and coronary heart disease (CAD) has increased in recent years. Coronary artery bypass grafting (CABG) has become the standard treatment for CAD in this patient group, but is still considered as a risk procedure due to increased mortality and morbidity. In a retrospective study we analyzed our clinical results of isolated CABG in 40 dialysis-dependent patients with ESRF (5 female and 35 male, mean age 65±8.4 years) and the use of extracorporeal circulation. The perioperative control group comprised 51 patients (10 female and 41 male, mean age 67±7.3 years) with normal renal function and isolated CABG. Demographic and preoperative data were comparable in both groups. Hospital mortality was 2.5% in patients with ESRF and 0% in patients with normal renal function. Morbidity was comparable in both groups. The mean number of grafts was 3.1±0.9 in the dialysis group and 2.9±0.8 in the control group. In the follow-up of the dialysis group (34±23 months) 8 patients died. CABG in patients with dialysisdependent ESRF can be performed with good clinical results and morbidity comparable to patients with normal renal function.

Surgical therapy of traumatic cardiologic intervention

Coronary perforation and entrapment of catheter materials are rare, but life-threatening complications, which often require emergency cardiosurgical treatment. Surgical options include tamponade drainage, coronary artery bypass grafting, perforation suturing, and removal of catheter materials. Surgical strategies are not standardized but mainly depend on the surgical anatomy. This is in particular true for the removal of the catheter remnants (stent, guidewire). Keeping this in mind, these patients can be treated with good clinical results. Koronarperforationen und Verbleiben von Katheterbestandteilen sind seltene aber oft lebensbedrohliche Komplikationen nach interventionellen Eingriffen, welche eine notfallmäßige kardiochirurgische Versorgung erfordern. Das chirurgische Spektrum umfasst die Tamponadeentlastung, Anlage von Bypässen, Versorgung der Perforationsstelle sowie Entfernung von Katheterbestandteilen. Das chirurgische Vorgehen ist dabei nicht vereinheitlicht und hängt maßgeblich von den anatomischen Verhältnissen ab. Dies gilt insbesondere für das Entfernen oder Belassen von Katheterbestandteilen (Stent, Führungsdraht). Unter individueller Therapiefestlegung lassen sich diese Patienten mit guten klinischen Ergebnissen behandeln.