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Biomedical subjects

J Hofmeister

Publications and source records attributed to J Hofmeister.

At least 19 recordsLinked to original sources
PubMed2000

Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess--11 year results.

AIMS: The aim of the study was to evaluate the long-term results of allograft and prosthetic valve replacement in the treatment of infective aortic valve endocarditis with periannular abscess. METHODS: Between March 1988 and March 1996, 65 patients underwent surgery for active aortic valve endocarditis and paravalvular abscess. The indications for surgery were congestive heart failure, systemic emboli and atrioventricular block III. The pre-operative evaluation was performed with transoesophageal echocardiography. Aortic valve replacement was performed with allografts in 47 cases, with mechanical valves in 15, and bioprosthetic valves in three cases. All patients with total ventricular-aortic dehiscence and prosthetic valve endocarditis were treated with allografts. RESULTS: The 30-day mortality rate was 23.5% in the prosthetic group, when compared with 8.5% in the patients treated with allografts. The rate of recurrent valve infections during the 11-year follow-up period was 27.1% in the prosthetic group and 3.2% in the allograft group. The actuarial 11-year survival rate was 82.1% in the allograft group and 64.7% in the prosthetic group. CONCLUSION: Aortic allografts are an effective treatment for infective aortic valve endocarditis with associated periannular abscess. The operative mortality and recurrent infection rates are lower than in the prosthetic group, resulting in a significantly higher survival rate. Diagnosis and surgical management of these cases should be based on pre-operative transoesophageal echocardiography.

Abscess↗
PubMed1997

[Primary leiomyosarcoma in the left atrium--a rarity. Case report and literature review].

The case presents a 61 year old woman which came into the hospital with left heart failure. After an unsuccessful trial to treat the heart failure in an habitual method the echocardiographic showed a mass lesion which had filled out mostly of the left atrium. Histological features demonstrated a leiomyosarcoma with an origin from the wall of the left atrium. Immunohistochemical preparations revealed a positivity for actin, desmin and vimentin. Despite an operative resection and an attach of polychemotherapy it developed a local relapse and multiple lymph node metastases. Within the scope of this case report apart from an detailed bibliography it ought to be discussed the origin of the tumor into the atrium and the differential diagnosis from other sarcoma.

Diagnosis, Differential↗
PubMed1997

Imaging of the orifice of the left ventricular outflow tract: technique and initial results.

The mechanism of left ventricular outflow tract (LVOT) obstruction in the patient after mitral valve replacement or repair was examined with the aid of 2D echocardiography. For the interpretation of the spatial relationship between the aortic root and mitral annulus, however, the 2D display is sometimes inadequate since it may not simultaneously capture these structures in each center. We developed a method to clarify this relationship in 3D based on magnetic resonance images. We defined the office of the left ventricular outflow tract (LVOT orifice), consisting of, in turn, a muscular region, i.e., edge of the interventricular septum, and an annular region, i.e., the annulus of the anterior mitral leaflet. In this paper we present image data obtained from one of eight normal subjects examined and compare this with data of one of two patients who preoperatively suffered degenerative mitral regurgitation and subsequently underwent chordal-preserving mitral valve replacement, in which anterior chordae were reattached to the anterior annulus. In the normal subject, the mitral annulus exhibited a flexible change in shape during the systole, maintaining sufficient LVOT orifice size. In the patient, the prosthetic valve exhibited translational motion during systole, resulting in dynamic LVOT obstruction. This phenomenon was also observed in one other case. Furthermore, the lateral view of the LVOT orifice revealed a projection of the prosthetic valve into the LVOT, causing mechanical LVOT obstruction. The finding that translational motion of the prosthetic valve with an inflexible mitral annulus results in dynamic LVOT obstruction may support the hypothesis that annular rigidity causes dynamic LVOT obstruction after mitral valve repair with a rigid prosthetic ring.

Adult↗
PubMed1997

[Surgical therapy of chronic atrial fibrillation with the "Cox/Maze-III-operation"].

UNLABELLED: We examined the results of simultaneous surgical treatment of chronic atrial fibrillation using a Cox/Maze III operation during mitral valve surgery (n = 12), atrial secundum defect closure (n = 1), combined operation (mitral valve and atrial secundum; n = 1) and thrombectomy from the left atrium (n = 1). Mean preoperative atrial fibrillation was 5.1 years (range 0.5-12 years). In the mean follow-up period of 13.1 months (1-24 months), 14 patients (93%) had sinus rhythm. CONCLUSION: (1) The surgical treatment of chronic atrial fibrillation using a Cox/Maze III operation can be performed without increased perioperative or postoperative risks; (2) Cox/Maze III operation represents an effective surgical treatment of chronic atrial fibrillation.

Aged↗
PubMed1996

Reduced atrial angiotensin receptor type 1 mRNA content in end-stage human heart failure: assessment by a novel quantitative PCR-ELISA technique.

The number of atrial angiotensin II binding sites is reduced in end-stage human heart failure. The goals of our study were the development of a quantitative polymerase chain reaction for angiotensin II receptor type 1 mRNA to determine the angiotensin receptor type 1 (AT1) mRNA content in the atria of patients with end-stage heart failure. We established a quantitative PCR based on coamplification of AT1 wild-type and an internal standard in the same PCR, followed by liquid-phase hybridization of PCR products in microtiter plates and quantitation by ELISA. Glyceraldehyde phosphate dehydrogenase mRNA in the same samples was used to relate the AT1 mRNA content to a stably expressed reference gene. Atrial samples from 11 patients with end-stage heart failure obtained at cardiac transplantation were compared with atrial samples from 11 patients with normal cardiac function undergoing routine cardiac surgery. A PCR/ELISA system with a variance of about 6% after reverse transcription and a linear measuring range was established. In the samples from 11 patients with end-stage heart failure a 58% decrease in AT1 mRNA content was found in comparison with 11 controls (heart failure: 185,680 +/- 196,912 AT1 mRNA copies/microgram RNA, controls: 440,555 +/- 268,456, P < 0.02). When AT1 mRNA content was related to glyceraldehyde phosphate dehydrogenase mRNA, a 65% decrease was detected (AT1/glyceraldehyde phosphate dehydrogenase: heart failure: 4.84 +/- 5.18; controls: 13.74 +/- 7.77; P < 0.005). Standardization of PCR resulting in a low coefficient of variance, high reproducibility, and large sample capacity is possible using optimal internal standardization and the liquid-phase hybridization/ELISA system for detection. The optimized PCR procedure indicated downregulation of atrial AT1 in end-stage human heart failure, suggesting a reduced capacity of the atria to respond to angiotensin II stimulation in end-stage heart failure.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1996

Impact of mechanical heart valve prosthesis sound on patients' quality of life.

BACKGROUND: The "click" sound of mechanical heart valve prostheses has been recognized as a disturbing factor for some patients after mechanical heart valve implantation. The factors determining the extent of disturbance remain controversial. METHODS: Ninety-five unmatched patients with six different valve types were examined (Duromedics-Edwards, Björk-Shiley, St. Jude Medical, Medtronic, CarboMedics, and Omnicarbon), including 12 patients with double-valve replacement. Three groups (Björk-Shiley, Duromedics-Edwards, and St. Jude Medical) were comparable in size. All patients were examined and interviewed, a hearing test was performed, and valve sounds were analyzed. Sound transmission was evaluated. RESULTS: The loudest valve was the Duromedics-Edwards prosthesis (mean, 84.2 dB[A] impulse) and the St. Jude Medical was the quietest (mean, 73.5 dB[A] impulse). This ranking was independent of patient variables and valve position. Discomfort level correlated with hearing loss and loudness of the valve. Patients desiring a quieter valve had better hearing, had louder valve sounds, felt disturbed by the sound, had partners who felt disturbed, and were receiving coumarin for anticoagulation. Sound was transmitted predominantly by air conduction. The frequency analysis to identify different valves was unsatisfactory, but louder frequencies did correspond with hearing-impaired patients' audiograms. CONCLUSIONS: Our results emphasize the need for valve design changes, preoperative education about the sound, and inclusion of routine hearing tests into the preoperative workup.

Adult↗
PubMed1996

Using aortic allograft material to treat mycotic aneurysms of the thoracic aorta.

BACKGROUND: Although mycotic aneurysms are rare in this age of antibiotics, they nevertheless represent life-threatening lesions of the aortic wall because of their high incidence of rupture and significantly high rate of recurrence. METHODS: Between March 1988 and August 1994, cryopreserved allograft material was used to treat 8 patients (mean age, 62.5 years; range, 47 to 80 years) with mycotic aneurysms of the thoracic aorta at our institution. Two patients had emergency operations; the other operations in 6 patients were elective. The aneurysms were located at the previous cannulation site of the aorta (n = 1) or at the donor/recipient aortic anastomosis (n = 1) in the patients who had heart transplantation, in the ascending aorta in 3 patients with aortic valve endocarditis, in the aortic arch in 2, and in the descending aorta in 1. The operative technique consisted of excision of the mycotic aneurysm followed by allograft patch reconstruction in 5 patients, an allograft composite graft replacement of the ascending aorta in 2 patients with endocarditis, and combined aortic allograft root replacement and allograft patch reconstruction of the ascending aorta in 1 patient. RESULTS: The underlying infections of the aorta were treated successfully in 6 patients. One heart transplant recipient had reoperation because of recurrent mycotic aneurysm after allograft patch reconstruction at the donor/recipient anastomosis. There was one early death involving a patient with Salmonella sp sepsis. CONCLUSIONS: The use of aortic allograft material for repairing mycotic aortic aneurysms is a promising and effective operative concept for managing thoracic aortic infections.

Aged↗
PubMed1996

Heart transplantation: a single-center experience.

BACKGROUND: The success of heart transplantation led to the extension of the criteria for both recipients and donors. The aim of the study was to evaluate the experience with this therapeutic approach for end-stage heart failure at a single center. METHODS: Between April 1986 and January 1996, 1,413 patients were accepted as candidates for heart transplantation. Ventricular assist devices were used as a bridge to transplantation in 173 patients (biventricular assist device in 141 patients and left ventricular assist device in 32 patients). The longest duration of support was 572 days (average, 46 days). RESULTS: Of the 1,413 patients, 891 underwent heart transplantation (65 children/adolescents and 826 adults; 522 (36%) patients died awaiting a donor heart. The average time spent on the waiting list was 107 days. The average recipient age was 44 years, and the age of donors was extended up to 69 years. Eighty-three patients with ventricular assist devices (48%) subsequently underwent heart transplantation. Twenty-five patients (2.7%) underwent retransplantation. The 30-day mortality rate was 14%, and the overall actual survival at 1, 5, and 10 years was 80%, 59%, and 50%, respectively. Ninety-four percent of patients were in New York Heart Association functional class I or II at 1 year, and 44% returned to work after transplantation. CONCLUSIONS: Despite the broadening of the selection criteria for both recipients and donors, heart transplantation remains an effective treatment for end-stage heart failure. Nevertheless, this therapeutic approach is severely limited by a considerable disparity between the need and availability of donor organs.

Adolescent↗
PubMed1996

Mycotic aortic aneurysms after orthotopic heart transplantation: a three-case report and review of the literature.

Mycotic aortic aneurysm is a rare yet life-threatening complication after orthotopic heart transplantation. This article reviews three cases of mycotic aortic aneurysm in heart transplant recipients developing in the first year after heart transplantation. Excision of the aneurysm and in situ reconstruction of the ascending aorta were performed with a patch of glutaraldehyde-fixed pericardium or cryopreserved aortic allograft material as a patch or conduit replacement. These cases show that early diagnosis by computed tomographic scanning, surgical treatment, high-dose parenteral antibiotics, and close follow-up are essential for successful treatment.

Adult↗
PubMed1996

Freehand subcoronary aortic valve and aortic root replacement with cryopreserved homografts: intermediate term results.

BACKGROUND AND AIMS OF THE STUDY: The traditional method of aortic valve replacement with a homograft has been free-hand insertion in the subcoronary position. Recently, total root replacement has become increasingly popular. We present our experiences with both methods in this study. MATERIAL AND METHODS: Between January 1, 1987 and March 31, 1996, 208 patients underwent homograft replacement of the aortic valve (free-hand subcoronary technique, n = 147 and root replacement, n = 61). The age of the patients ranged between 1.5 and 78 years with a mean age of 41 years. There were 55 females and 153 males. Ninety-four patients had infected aortic root (with 47 ring abscesses) and 114 patients had sterile aortic roots. In these series, patients with small aortic root, complicated endocarditis, dilated aortic annulus and aneurysm received aortic root replacement. RESULTS: The hospital mortality of patients with non-infected and infected roots was 2.6% and 8.5% respectively making an overall hospital mortality of 5.2%. In patients with free-hand subcoronary valve implantation (AVR) and root replacement (ARR) techniques the hospital mortality was 3.4% and 9.8% respectively. The major risk factor for death was New York Heart Association functional class IV with sepsis. Eight years patient survival in patients with AVR and ARR was 95% +/- 2% and 86% +/- 4% respectively. Freedom from structural deterioration in patients with AVR and ARR was 96.5% +/- 2% and 98% +/- 3% whereas freedom from reoperation was identical 94% +/- 2% and 93% +/- 4% respectively. However, the incidence of reoperation in patients under 40 years of age, particularly in children (< 16 years of age) during the eight years' follow up was 27%. The rate of recurrent endocarditis was 3.6% in ARR patients and development of postoperative pseudoaneurysm formation occurred in 1.4% of AVR patients with endocarditis. CONCLUSION: In conclusion, ARR technique provides low rate of reoperation in the early postoperative period. Cryopreserved homografts in the subcoronary position in adult patients < 40 years of age showed excellent medium term durability and hemodynamic performance providing evidence that long term outcome with a meticulous subcoronary implantation technique is comparable to that with the ARR technique.

Adolescent↗
PubMed1995

Preservation of papillary muscles and chordae during mitral valve replacement: possibilities and limitations.

The various techniques of preserving the chordal apparatus in mitral valve replacement applied in 1,453 cases at a single institution between 1986 and 1994 are described. The techniques include preservation of chordal attachment to the posterior mitral leaflet only and to both leaflets with five different technical variations. The specific advantages and risks of these techniques are demonstrated and discussed. It is concluded, that preservation of the entire subvalvular structures is feasible in almost all cases. Different procedures should be employed according to the variety of mitral disease, in particular with respect to mitral leaflet mobility.

Chordae Tendineae↗
PubMed1994

Spatial relations of flicker signals in the two rod pathways in man.

1. Flicker signals originating from the human rod photoreceptors seem to have access to two retinal pathways: one slow and sensitive, the other fast and insensitive. The phase lag between signals in the two pathways grows monotonically with frequency, reaching 180 deg near 15 Hz. 2. At 15 Hz, destructive interference between the slow and the fast signals can cause two related phenomena: (i) a suprathreshold intensity region--the perceptual null--within which the perception of flicker vanishes, and (ii) a double branching of the 15 Hz rod-detected flicker threshold versus intensity (TVI) curve. 3. Here we investigate the effect of changing target size on these phenomena in normal human observers. We find that the double-branched flicker TVI curve and the perceptual null are found for all targets larger than 2 deg in diameter. For smaller diameter targets, however, neither the lower branch of the double-branched flicker TVI curve nor the null are found. 4. While this might suggest that the slow rod signals are selectively disadvantaged by the use of small targets, phase measurements relative to a cone standard reveal that the slow signals are always present. For targets < or = 2 deg in diameter, however, they remain below detection threshold because of destructive interference with the fast rod signals. Thus, for small targets, the perceptual null is not absent, but has merged with (and therefore obliterated) the lower branch of the double-branched flicker TVI function. 5. This situation could arise if decreasing the target size causes a parallel reduction in the sensitivities of both pathways, rather than a selective reduction in the sensitivity of either one. Our findings are therefore consistent with a model in which the large-scale spatial organization of the two rod pathways is roughly similar.

Electrophysiology↗
PubMed1994

Coronary artery bypass grafting and heart transplantation in end-stage coronary artery disease: a comparison of hemodynamic improvement and ventricular function.

Heart transplantation has now become an accepted treatment for end-stage coronary heart disease (CAD). However, the limited supply of suitable donor organs imposes constraints upon the decision of whether patients are selected for transplantation or for coronary artery bypass grafting (CABG). From April 1986 until the end of March 1992, 265 patients with end-stage CAD involving left ventricular ejection fraction (LVEF) 10% to 30% and predominant angina pectoris underwent CABG. All patients received an average of 2.9 +/- 0.3 venous grafts. Intraaortic balloon pumps were implanted in 30 patients (11.3%) who began to develop low cardiac output syndrome intraoperatively. The actuarial survival rate was 87.8% after 2 years and 86.9% after 3 years. LVEF was measured in 35 patients via left heart catheterization 12 months after their operations and was found to have increased from a mean of 23.8% to 38.1%. Left ventricular end-diastolic pressure had decreased from 16.2 mmHg to an average of 12.1 mmHg. Swan-Ganz catheterization was performed on 120 patients 6 months postoperatively. The pulmonary wedge pressure had reduced significantly from 18.1 mmHg to a mean of 12.7 mmHg (p < 0.01). From 1990 until the end of March 1992, 55 patients with CAD and predominant heart failure received transplants. Their 2-year survival rate was 66.3%. Mean LVEF was 55.6% postoperatively. We conclude that CABG is adequate for patients who have end-stage CAD and angina pectoris symptoms, and that it significantly improves hemodynamic functions. Patients suffering predominantly from heart failure (NYHA Class IV) can be transplanted and subsequently regain normal heart function.

Actuarial Analysis↗
PubMedDate not supplied

The inflexible mitral annulus after valve prosthesis. Inherent risk of dynamic left ventricular outflow tract obstruction.

Although chordal preserving mitral valve replacement is beneficial to cardiac function, the loss of flexibility of the annulus and consequent translational motion of the valve prosthesis during systole may cause potential left ventricular outflow tract (LVOT) obstruction after surgery. The extent of the flexibility of the mitral valve annulus (MVA) necessary for the prosthetic valve to prevent potential LVOT obstruction was determined. The three dimensional images of the MVA at 0, 100, 200, and 300 msec delay from the electrocardiogram R wave were reconstructed from cine-mode magnetic resonance images in eight normal subjects. In the lateral view of the MVA, the dorsal flexion angle (DFA) was defined. This angle implies the extent of the flexion of the anterior half of the MVA in relation to the posterior half. The data (mean +/- SD) for the DFA were 31.7 +/- 5.4 degrees (0 msec), 36.4 +/- 4.5 degrees (100 msec), 39.0 +/- 3.8 degrees (200 msec), and 43.6 +/- 2.6 degrees (300 msec), whereas the systolic increase in DFA was 11.9 +/- 3.2 degrees. The flexibility observed in normal mitral annuli is relevant to prosthetic mitral valves.

Adult↗
PubMedDate not supplied

The relationship between the mitral annulus and left ventricular outflow tract.

Mitral annular inflexibility due to rigid prostheses (ring or valve) has long been considered to contribute to the mechanism of dynamic left ventricular outflow tract (LVOT) obstruction after mitral repair or replacement. In clarifying the geometric relationship between LVOT orifice and mitral valve annulus (MVA) in eight normal subjects, the authors have endeavored to show how that a rigid mitral prosthesis might obstruct the LVOT based on the assumption that any rigid prosthesis necessarily follows the motion of the posterior half of the MVA (MVApost) in the course of every heart beat. During systole, the relationship between the MVApost and the approximated plane of the LVOT orifice was constant. However, with the respect to the relationship between the LVOT orifice and the approximated plane of the MVApost (PI-MVApost), the intersection between the two shifted toward the apex during systole. Assuming the prosthesis is aligned on the MVApost with the same orientation as the PI-MvApost, this shift implies a reduction in the effective size of the LVOT orifice due to the prosthesis. The calculated obstruction rate was 24.9% (0 ms), 30.9% (100 ms), 35.5% (200 ms), and 45.4% (300 ms). These results indicate the importance of maintaining the flexibility of the MVA after mitral valve surgery.

Adult↗
PubMedDate not supplied

Mitral valve reconstruction and mitral valve replacement for ischemic mitral insufficiency.

BACKGROUND: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this group of patients. METHODS: Between April 1986 and December 1994, 232 patients underwent surgery for ischemic mitral valve insufficiency; mitral valve replacement was performed in 98 of them. Operative mortality was 13.3%. The actuarial survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operative mortality 50.0%) was higher than in those whose LVEF was greater than 30%. Valve reconstruction was performed in 102 patients. Operative mortality in this patient group was 14.7%. The surgical risk in patients whose LVEF was < or = 30% was higher (operative mortality 42.9%). RESULTS: The total actuarial survival rate of all patients was 64.4% after 5 years. Mortality during follow-up was higher in patients with residual mitral valve insufficiency greater than grade I after mitral valve reconstruction. Twenty-four patients with severely impaired left ventricular function underwent heart transplantation. Operative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. CONCLUSIONS: We conclude that patients with highly impaired left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardiac transplantation should be considered for this patient group. However, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replacement with an acceptable prognosis. The goal of mitral valve reconstruction should be reducing mitral valve insufficiency to at least grade I. If this is not achieved, the prognosis after repair is worse than after valve replacement, therefore, the surgeon should replace the valve without delay.

Aged↗
PubMedDate not supplied

Mitral annular flexibility.

An analysis of three-dimensional movement of the mitral valve annulus (MVA) may address the question of geometrical change after mitral valve repair to preserve mitral annular function. Conventionally, annular contraction has been studied for this purpose. We investigated this geometrical change occurring in the anterior half of the MVA and discuss its clinical significance. Three-dimensional images of the MVA during systole were reconstructed from magnetic resonance images of eight normal subjects. The posterior half of the MVA exhibited translational motion. We assume that this portion, exhibiting translational motion as well as contraction, purely follows the motion of the left ventricular contraction. Compensating for the discrepancy between the motion of the aortic root and that of the posterior half of the MVA, the anterior half exhibited a flexible change in shape during systole, thus maintaining a sufficient left ventricular outflow tract (LVOT). The increase in the extent of displacement of the anterior MVA from the posterior half of the MVA during systole, which was 3.6 +/- 1.0 mm (mean +/- SD), indicates the annular flexibility. The preservation of annular flexibility may prevent LVOT obstruction. Further geometrical analysis of patients after mitral repair will clarify annular function as presented in this article.

Adult↗