[Initial follow-up results of aortic valve replacement with the CarboMedics bileaflet prosthesis].
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Actuarial Analysis↗
Biomedical subjects
A Laske
Publications and source records attributed to A Laske.
[Results of surgical revascularization of the kidney].
There are many different etiologies of renal artery disease (atherosclerosis, aneurysm, dissection, arteriovenous fistula, embolism, fibromuscular dysplasia) and also a lot of different therapies (conservative treatment, percutaneous transluminal angioplasty [PTA], endarterectomy, bypass grafting, patch plasty, nephrectomy). Recently conservative treatment and PTA have significantly improved. Patients who are referred to surgery today are of older age with severe and often bilateral disease of the renal arteries. Additional manifestations of general atherosclerosis like coronary artery disease, aortic aneurysm, peripheral occlusive vessel disease and cerebral vascular insufficiency are often present as well. The main goal of all forms of treatment is the preservation of general renal function. With our retrospective study the results after surgical revascularisation of kidneys are evaluated over a short period of time. Only graft revascularisations are included in the study and we were mainly interested in renal function and blood pressure.
Aged↗
Endocarditis in intravenous drug addicts and HIV infected patients: possibilities and limitations of surgical treatment.
The incidence of infective endocarditis in drug addicts is increasing with the spread of intravenous drug abuse. The tricuspid valve is involved most commonly, followed by the mitral. We evaluated 22 patients prospectively with a mean age of 23 years, presenting with addiction-associated endocarditis and referred to our institution during a three-year period. The tricuspid valve was involved in 13 instances, the mitral in four, mitral plus tricuspid valves in five patients and the aortic valve in one. Staphylococcus aureus was the most frequent infective organism (15 cases), followed by streptococci (4 cases), corynebacteria (2 cases) and one case with a mixed infection. Six patients were HIV positive and 17 had evidence of chronic viral hepatitis. Ten patients (three of them HIV positive) were treated surgically. Resection of the tricuspid valve with (one case) or without replacement (four cases), resection of vegetations and tricuspid repair (two cases), mitral valve replacement (2 cases) and aortic valve replacement (one case) were performed. Operative mortality (< 30 days) was high (2/10, 20%); one patient died from cerebral hemorrhage and another from multi-organ failure. Another three patients died after a mean follow up of 10 months. In 12 patients, surgery was not attempted because of still existing intravenous drug abuse or renal and liver failure. Five of these patients died after a mean follow up of 13 months, two from septicemia, two from AIDS-related complications and one from drug overdose. The prognosis of drug-associated endocarditis treated with antibiotics is generally good.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Effect of aortic clamping on heart function in elective operation of the abdominal aorta: immediate effects of coronary revascularization].
Infrarenal aortic cross-clamping required during surgical treatment of abdominal aortic aneurysm is generally well tolerated but can be occasionally associated with severe cardiac and haemodynamic disturbances, particularly in patients suffering from coronary artery disease. We compared the haemodynamic changes and the ECG-records before and shortly after infrarenal aortic clamping in three groups of 20 patients (group I: without coronary artery disease, group II: with overt coronary disease without indication for prior myocardial revascularization, and group III: patients undergoing combined procedure: coronary artery bypass immediately prior to aortic repair, during the same anesthesia). There was no significant difference in demographical characteristics between the three groups. Aortic cross-clamping lead to an increase in systemic arterial pressure in all patients. Group I demonstrated a decrease in pulmonary artery pressure, pulmonary capillary wedge pressure and central venous pressure, whereas patients of group II demonstrated an increase of each value when the aorta was clamped. 11 patients of this group developed either arrhythmia and/or ischemia during aortic cross-clamping. Haemodynamic and cardiac effects of aortic clamping seen in patients who had received coronary bypass immediately prior to aortic repair (group III) were surprisingly similar to those of patients without coronary disease, probably owing to systematic application of 2 vasodilators. Tolerance to infrarenal aortic cross-clamping differs in patients with and without coronary artery disease. Development of myocardial ischemia may be predicted by an increase in wedge pressure after clamping. Afterload reduction was the best treatment of ischemia occurring when the aorta was clamped.
Aged↗
Cytomegalovirus infection and prophylaxis in heart transplantation.
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Adult↗
[Immediate and long-term results of carotid endarterectomy: the Zurich experience].
Extracardial carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. The records of 485 patients who underwent carotid endarterectomy between 1978 and 1991 were reviewed, with special attention to both cardiac and neurological complications. 432 patients had symptomatic carotid disease whereas 53 were asymptomatic but presented with significant carotid stenosis or a large ulceration at doppler-duplex examination and/or angiography. These examinations showed the following lesions in symptomatic patients: unilateral stenosis > 75% (331; 68.5%), ulceration (41; 8.5%), bilateral stenosis (61; 12.5%) and unilateral stenosis with contralateral occlusion (51; 10.5%). Intraluminal shunt was used in nearly all patients whereas special management of cerebral metabolism (intraoperative electroencephalogram, somatosensory evoked potentials) were used in high-risk patients only. Overall early mortality was 1.8%. Three patients died from the sequelae of a neurologic injury, whereas six patients died from myocardial infarction or intractable arrhythmia. Mortality decreased from 2.4% between 1978 and 1984 to 0.8% between 1985 and 1991. At 6 and 8 years, actuarial survival rates of 88.1% and 76.1% and stroke-free survival rates of 86% and 81.5% were observed. Late mortality was essentially due to ischemic cardiac complications (38.5% of the actuarial late mortality at 8 years). Review of the literature shows that carotid endarterectomy is the treatment of choice for symptomatic high-grade extracranial carotid stenosis in patients who are not high-risk candidates.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
[Main coronary artery stenosis: a continuous challenge].
The pre- and postoperative course in 118 patients (104 males, mean age 62 +/- 8.1, 14 females, 60 +/- 10.7 years) who underwent coronary artery bypass surgery for significant left main coronary artery disease was studied to analyze the current management and risk factors of this lesion. Of these patients 32% (38/118) remained in hospital care from the date of diagnosis (coronary angiography) until the operation. The mean interval between diagnosis and operation was 39 days (range 0-166). Twelve patients (10%) had urgent procedures (< or = 48 hours after angiography), 25 (21%) accelerated (< or = 2 weeks), 52 (44%) anticipated (< or = 2 months) and 30 (25%) elective procedures (> 2 months). There was a significant negative correlation (p < 0.001) between the grade of stenosis and the time interval from diagnosis to operation. The operation technique did not differ from the usual procedure except for the less frequent use of the internal mammary artery as arterial conduit. Patients with stable angina received an internal mammary artery graft in 65% (80/118) as compared to 26% (6/23) of the patients with unstable angina. This differs significantly from the overall rate of 95% of the patients undergoing coronary artery bypass surgery at our institution. The rate of perioperative myocardial infarction was 18% (21/118). There was no significant relation between infarction and angina class, severity of the stenosis and the use of internal mammary artery as bypass graft. The hospital mortality was 4.2% (5/118) and thus was not different from the overall mortality of (2.5%).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Ganciclovir for cytomegalovirus after heart transplantation.
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Cytomegalovirus Infections↗
[Pericardectomy and acute infectious pericarditis].
Between 1980 and 1990 12 patients (5 male, 7 female) were operated on for acute infectious pericarditis at a mean age of 42 years. The infections were 6 bacterial (purulent 4, abscess 2), 4 tuberculous, 1 viral and 1 Candida. Pericarditis resulted from contiguous spread of infection from bilateral pneumonia in 3 patients, from subphrenic abscess in 2 and followed bacteremia in 1. Clinical signs were: tamponade/shock in 9, elevated jugular venous pressure in 11, edema in 6, hepatomegaly in 6, ascites in 1, and pericardial friction rub in 3. A preoperative pericardiocentesis in 9 patients allowed only 4 positive microbiological diagnoses and was an insufficient drainage in all cases. The preoperative mean NYHA class was 3.3. The pericardectomy was total in 9 patients and partial in 3. Total mortality was 1/12 patients (8%) with one late death due to recurrent tuberculous pericarditis. No patient with purulent pericarditis died. Another recurrence occurred 6 months after acute viral pericarditis. Atrial fibrillation in one patient was the only postoperative complication. After a mean follow-up period of 48.5 months no cardiac constriction had occurred in 11 surviving patients Actuarial survival after pericardectomy is 100% after 1 month and remains 91% after 5 years. The mean NYHA class has significantly improved to 1.2 (p less than 0.05) at the end of the follow-up. We conclude that pericardectomy combined with a specific antimicrobial therapy is a safe treatment for acute infectious and especially purulent pericarditis with low mortality and excellent longterm results. Early pericardectomy allows rapid decompression of the heart, removal of intrapericardial adhesions and infected tissue and prevents late constriction.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
Convulsions, hemiparesis and central retinal artery occlusion due to left atrial myxoma in child.
Multiple embolizations were the hallmark of the disease in an 8-year-old boy with a left atrial myxoma. Embolizations occurred initially in both hands and legs, later in the brain with generalized seizures and hemiparesis, and finally in the left eye with occlusion of the central retinal artery and consecutive severe visual impairment. Echocardiography demonstrated the tumour which was removed without complications.
Child↗
Surgical treatment of cardiovascular complications in Marfan syndrome: a 27-year experience.
Fifty-two patients with Marfan syndrome and ascending aortic pathology were treated surgically between 1964 and 1990. The indication for primary operation was true aneurysm of the ascending aorta with or without aortic insufficiency in 35 patients (67%) and dissection in 17 (33%). Composite grafts were used in 28 patients (54%; group I) and other procedures on the ascending aorta in 24 patients (46%; group II). The latter included supracoronary graft replacement with or without aortic valve replacement or reconstruction (n = 13), and reconstruction of the ascending aorta with or without aortic valve replacement (n = 11). Composite graft insertion was combined with mitral valve surgery at the same operation in 3 patients (6%). The early mortality after primary operations was 7.7% (4 deaths) and the late mortality was 27% (14 deaths). Eight late deaths were related to cardiovascular complications. The mean follow-up was 6.7 years (range 1-27 years). The actuarial 5-, 10-, and 15-year survival rates for all patients were 82%, 63%, and 44%, respectively; for group I (composite grafts) they were 87%, 76%, and 57%; and for group II (other types of operations) they were 73%, 53%, and 37%. The incidence of late complications was much higher in group II than in group I (50% vs. 16%). At 5 and 10 years, the actuarial rates of freedom from late complications related to the primary operation were 88% and 80%, respectively, in group I and 65% and 18% in group II. Composite graft insertion is the operation of choice when approaching the ascending aorta and/or aortic valve in Marfan syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Axillo-femoral bypass and simultaneous removal of the aorto-femoral vascular infection site: is the procedure safe?
In a retrospective analysis 12 patients treated for aorto-femoral vascular infections between 1984 and 1990 were evaluated. They were all male with a mean age of 63 years. Indications for treatment were: mycotic aneurysms-3, primary aorto-enteric fistula-2 and graft infection-7. Surgical treatment consisted of implantation of an extra-anatomic bypass, carefully avoiding the infected area, followed by removal of the infected graft and tissue at the same session. There was no early mortality (less than 30 days) but the first year mortality was 42% (n = 5). Causes of death were: aortic stump disruption (n = 1), recurrence of aorto-enteric fistula (n = 2), axillary anastomosis disruption (n = 1), cardiac failure (n = 1). Orthotopic reconstruction of the aorta after 12 months, as we advocate, was accomplished in two patients and is scheduled in another one. In two patients their poor condition precluded this second step, and in two further patients above-knee amputation with subsequent extra-anatomic graft removal was needed. Only one of the 12 extra-anatomic bypasses became infected. Reconstruction by axillo-femoral bypass combined with removal of the aorto-femoral graft at the same session is a practicable procedure with good early results. However, the rate of successful orthotopic reconstruction of the aorta after 12 months is low because of a high mortality rate, especially in the presence of aorto-enteric fistulas, and because some patients with well functioning axillo-femoral grafts are in too poor condition for another large operation.
Aged↗
Pulmonary atresia with intact ventricular septum: results and predictive factors of surgical treatment.
Between 1970 and 1989 26 children were operated for pulmonary atresia with intact ventricular septum (PA/IVS). According to the degree of right heart hypoplasia the patients were divided into 3 groups of mild (5), moderate (17) or severe (4) hypoplasia. Palliative operations were performed in 25 children (17 male, 8 female) at a mean age of 10 days: 13 valvotomies (valv.), 5 aortopulmonary shunts, and 7 valv. plus shunt. One patient had total correction as primary procedure. A total of 17 reoperations was necessary in 12 of 26 patients (10 palliations, 7 total corrections). Total corrections were: 2 conduits and 5 patches of the right-ventricular outflow tract (RVOT). Total mortality was 14/26 (54%) children (early 10/26 = 38%, late 4/26 = 16%). After total correction mortality was 3/7 (43%) patients. After a mean follow up of 10.8 years after palliation the 12 survivors are mostly in NYHA class I. Actuarial survival after palliation was 60% after 30 days and 44% after 5 and 10 years. We analyzed 9 clinical and hemodynamic variables by univariate and multivariate analysis to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed the degree of right-ventricular hypoplasia (p = 0.023) as an independent predictor for death whereas the age at palliation only approached significance (p = 0.065). We recommend the following surgical strategy, aiming in the first place at decompressing the right ventricle: in mild hypoplasia valvotomy alone or combined with a shunt for palliation, in moderate hypoplasia shunt plus patch of the RVOT and in severe hypoplasia shunting alone. In case of a restrictive foramen ovale initial balloon septostomy is performed.(ABSTRACT TRUNCATED AT 250 WORDS)
Analysis of Variance↗
Valve replacement in octogenarians: increased early mortality but good long-term result.
Between January 1983 and December 1990, 20 patients aged 80 years or older underwent valvular surgery. The patients' ages varied from 80 to 87 years (mean, 82 +/- 1.5 years). The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective, two urgent, and three emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. Six patients (30%) had an uneventful hospital stay, and the other 14 (70%) experienced several post-operative complications. The operative mortality rate was 15% (three patients). All patients before operation were in NYHA (New York Heart Association) class III and IV and all survivors remained in NYHA class I or II. The survivors have been followed from 6 to 70 months (mean 20 +/- 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement in octogenarians can be performed, despite the high rate of post-operative complications, with increased but acceptable mortality. Long-term results are good.
Aged↗
[Prevention of cytomegalovirus infection following heart transplantation].
Cytomegalovirus (CMV) infection after heart transplantation (HTx) is a severe complication, which leads to long treatment and hospital stay. Even if prophylactic therapy with anti-CMV IgG antibodies is performed, there is a high incidence of infection, especially when the heart from a CMV positive donor is transplanted to a CMV negative recipient (high risk constellation). This study evaluates the prophylactic antiviral therapy with ganciclovir in CMV high risk constellation at HTx. Out of 108 HTx, 29 CMV negative recipients (IgG and IgM) received a heart from a CMV positive donor (IgG pos., IgM neg.). The control group (CO) (n = 8) was treated with anti-CMV IgG antibodies (Cytotect 2 ml/kg at day 0, 1, 2, 7, 14, 21,), whereas the study group (GAN) (n = 13) was treated with ganciclovir (7.5 mg/kg single dose n = 8, or 5 mg/kg in twice daily doses n = 5 from day 1 to 14). Urea, creatinine, white blood cell count and platelet count was controlled daily. No side effects on renal and bone marrow function were noted. Therapy was well tolerated. Both groups had similar immunosuppressive protocol (prophylactic cytolysis, prednisone, azathioprine and cyclosporin A) and were similar in age, sex, preoperative diagnosis and NYHA class. Seroconversion for CMV (IgM and IgG) was observed in 75% of CO and 31% of GAN (p less than 0.05). Clinical manifestations of CMV infection started in the second month after HTx with fever in both groups CMV-organ manifestations developed in 50% (or 67% of infected) in CO (enterocolitis 2, pneumonitis 3, tonsillitis 1), and in 15% (or 50% of infected) in GAN (pneumonitis 2, epididymitis 1) NS.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Technique and organization of heart removal from the multi-organ donor].
The orthotopic heart transplantation is an accepted treatment for terminal cardiac disease. The technique of heart procurement and preservation is explained and the primary graft function in 108 subsequent heart transplantations is assessed. The mean ischemia time is 41 +/- 10 min in local, 98 +/- 19 min in distant (< 100 km) and 114 +/- 16 min in distant (> 100 km) organ procurement. Our method of preservation consists of cold cardioplegic arrest with potassium (30 mEq/L) cardioplegic solution. The incidence of the indication for high dose katecholamine-treatment after surgery and the maximal creatininekinase levels rose with ischemia time. All hearts recovered within a few days and the stay in the intensive care unit was not prolonged. We conclude that the heart preservation with cold cardioplegic arrest results in a good primary graft function. It is important to keep the ischemia time as short as possible.
Graft Survival↗
Are elderly organ donors acceptable for heart transplantation?
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Actuarial Analysis↗
[Valve replacement in patients over 80 years of age].
Between January 1983 and October 1990, 20 patients age 80 years or older (mean 82 +/- 1.5 year, range 80 to 87 years) underwent valvular surgery at Clinic for Cardiovascular Surgery Zurich. The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective operations, 2 urgent, and 3 emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. The operative mortality rate was 15% (3 patients). All patients were preoperative in NYHA classes III and IV. All survivors remained in NYHA classes I or II. The survivors have been followed from 6 to 70 months (mean 20 +/- 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement can be performed with increased but acceptable mortality and morbidity. Long-term results are encouraging.
Aged↗