Löffler endocarditis without peripheral eosinophilia.
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Adrenal Cortex Hormones↗
Biomedical subjects
T Fischlein
Publications and source records attributed to T Fischlein.
The use of preoperative intra-aortic balloon pump in open heart surgery.
AIM: Intra-aortic balloon pump (IABP) therapy before open heart surgery has been suggested for ''high risk'' patients. METHODS: Records from patients undergoing open heart surgery at our institution between June 1999 and February 2002 were reviewed. Indication for IABP insertion was severely impaired left ventricular function, acute myocardial infarction (MI) or unstable angina. RESULTS: Fifty-five patients were included in the study: 41 male, 14 female, age 64+/-9 years. Fifty-one (92.7%) required coronary artery bypass brafting (CABG) alone or as a combined procedure, 2 (3.6%) required mitral valve surgery, and 2 (3.6%) needed more complex cardiac procedures. Thirty-two patients (58%) underwent emergency cardiac surgery and 11 patients (20%) suffered from acute preoperative MI. The overall 30 days mortality was 9%. Mean intensive care unit (ICU) stay was 6+/-8 days. Four patients (7.2%) developed postoperative renal failure requiring temporary hemodialysis. Three patients (5.4%) developed IABP related peripheral vascular complications. CONCLUSIONS: Perioperative morbidity and mortality is increased despite preoperative IABP, particularly in patients with acute MI. In contrast to studies not using this approach, preoperative IABP reduces morbidity and mortality of high risk patients. IABP related complications are low. Our data suggest that high risk patients profit from preoperative IABP therapy, however, prospective studies are needed to confirm these findings.
Cardiac Surgical Procedures↗
Late pulmonary valve replacement after correction of Fallot's tetralogy.
BACKGROUND: The aim of this study was to investigate necessity and outcome of late pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF). METHODS: Hospital records from patients operated on for TOF at our institution between 1960 and 2002 were reviewed and patients were interviewed by questionnaires. RESULTS: Out of 411 long-term survivors after TOF-repair, 47 (11.4 %) patients required reoperation after 13.2 +/- 7.4 years. Preoperative right ventricular (RV) dilatation was present in 36 (76.6 %) patients including 16 (34 %) with impaired RV function. Isolated PVR was performed in 12 patients (25.5 %). Additional procedures were necessary in 35 patients (74.5 %), including closure of residual defects (VSD, n = 11), tricuspid valve replacement (n = 1) and repair (n = 3). Obstructive right ventricular or pulmonary artery lesions (34 patients, 72.3 %) were all surgically addressed. RV pressure decreased from 61.1 +/- 27.7 to 42.9 +/- 13.3 mm Hg (p < 0.01) after PVR. RV size was reduced and RV function improved compared to preoperative values. Early mortality after reoperation was 2.1 % (n = 1) with one patient dying from biventricular failure. There was no late mortality. CONCLUSIONS: PVR after Fallot repair is frequently required because of progressive RV enlargement with dysfunction. It can be performed with relatively low risk, even in the setting of multiple reoperation. Obstructive lesions (RVOTO, PA stenosis) and residual defects are frequently observed in patients needing late PVR and may play a crucial role in the development of RV failure. Timely valve replacement with repair of all obstructive lesions proximal and distal to the implanted valve is the key to preserving RV function.
Adolescent↗
Impella Recover 100: successful perioperative support for off pump coronary artery bypass grafting surgery in a patient with end-stage ischemic cardiomyopathy.
The authors present the successful use of the Impella recover 100 intracardiac left ventricular assist device in a 55-year old man suffering from end-stage ischemic cardiomyopathy. The pump was implanted preoff pump coronary artery bypass grafting (OPCAB) and it was successfully weaned 5 days postoperatively. In addition, an intra-aortic balloon pump (IABP) was implanted to convert the non-pulsatile flow of the Impella into a pulsatile flow. In this paper benefits and risks of this technique are shown.
Cardiomyopathy, Dilated↗
Hormone therapy in men-increased risk of cardiac allograft rejection?
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Adenocarcinoma↗
[Emergency management of an acute rupture of a perforated thoracic aortic aneurysm].
The emergency medical service was called to a 60-year-old woman with intensive chest pain, signs of shock, dyspnoea, intermittent paraesthesia of the right leg and disturbance of consciousness. With the diagnosis of an acute rupture of an aneurysm of the thoracic aorta, the patient was stabilised with volume, catecholamines, intubation and mechanical ventilation before being rushed to the preinformed department of cardiovascular surgery. The diagnosis was verified by transesophageal echocardiography immediately and the patient underwent surgery 2 h after onset of symptoms. Despite the rupture of the aorta and a short period of cardiac arrest, the patient recovered totally and could be discharged without any residual problems. This case shows that a ruptured thoracic aortic aneurysm can be survived although the overall mortality of this incident is more than 97%. The essentials of a good outcome are: 1. perfectly coordinated rescue operation which means an emergency medical service which includes the rupture of an aortic aneurysm in the differential diagnosis of acute chest pain, 2. an early verification of the diagnosis by means of transesophageal echocardiography which should also be carried out by anaesthesiologists due to its importance in the differential diagnosis in haemodynamic unstable patients.
Acute Disease↗
Aortic valvotomy for congenital valvular aortic stenosis: a 37-year experience.
BACKGROUND: The purpose of the study was to analyze the long-term results of aortic valvotomy and the risk factors associated with reoperation and survival. METHODS: From 1960 to 1977, 116 patients with congenital valvular aortic stenosis underwent isolated aortic valvotomy at a mean age of 13.7 +/- 7.8 years with a mean aortic gradient of 78 +/- 33 mm Hg. Fifteen patients had additional aortic regurgitation, and leaflet calcification was present in another 15 patients. RESULTS: Postoperatively the mean aortic gradient decreased to 19.4 +/- 11.3 mm Hg (p < 0.0001). Early mortality was 2.6%. At a mean follow-up of 23.8 years, 26 late deaths (22.4%) occurred among the 113 early survivors. Actuarial 10-, 20-, 30-, and 37-year survival rates were 94.6%, 79.7%, 76.2%, and 72.5%, respectively. According to multivariate Cox regression analysis, survival was influenced by preoperative New York Heart Association class (p = 0.0418), leaflet calcification (p = 0.0339), date of operation (p = 0.0253), and postoperative endocarditis (p < 0.0001). At a mean interval of 18.3 years, 37 patients required reoperation (31.9%) mainly because of recurrent aortic stenosis. The reoperation rate increased significantly 15 years postoperatively from 0.73%/year to 2.31%/ year (p < 0.0001). In a multivariate risk model, reoperation was influenced by older patient age (p = 0.0032) and the presence of leaflet calcification (p = 0.0289). CONCLUSIONS: AORTIC valvotomy is a simple and effective procedure for congenital aortic stenosis with excellent long-term results. However, the rate of reoperation increases 15 years postoperatively, and clinical follow-up should be intensified. Our results suggest that early repair should be performed and that adequate patient selection is the most important determinant of the longterm results.
Actuarial Analysis↗
Clinical autologous in vitro endothelialization of 153 infrainguinal ePTFE grafts.
BACKGROUND: Over the past 17 years, our group has developed and clinically applied an in vitro endothelialization procedure whereby infrainguinal expanded polytetrafluoroethylene (ePTFE) prostheses are confluently lined with cultured autologous endothelial cells before implantation. After a successful randomized pilot study from 1989 to 1993, the procedure was adopted for routine operations. METHODS: Since June 1993, 153 endothelialized ePTFE grafts were implanted in the infrainguinal position in 136 patients (102 above knee (AK) and 51 below knee (BK), 89 men and 47 women, mean age 64.7+/-9.4 years). Seventeen patients received an endothelialized prosthesis bilaterally. Autologous endothelial cells were harvested from 4- to 5-cm segments of a subcutaneous vein (in 86% the cephalic vein), grown to first-passage mass cultures and confluently lined onto 6- (n = 113) or 7-mm (n = 40) inner diameter (ID) ePTFE grafts, precoated with fibrin glue. The observation period for 6-mm grafts was 7 years, and for 7-mm grafts was 4 years. Patency assessment for Kaplan-Meier survivorship analyses was based on duplex sonography and angiography. RESULTS: Kaplan-Meier survivorship function revealed a primary patency rate of 62.8% after 7 years (SE = 0.05) for all infrainguinal reconstructions (60% AK/70.8% BK). The primary patency for stage II and III patients was 64.4% after 7 years. The more recent group of 7-mm ID grafts showed a primary patency of 83.7% after 4 years. CONCLUSIONS: Our data provide strong evidence that autologous endothelial cell lining distinctly improves the patency of small diameter vascular grafts.
Aged↗
Mitral valve annuloplasty: comparison of the mural annulus shortening suture (MASS) with the Carpentier-Edwards prosthetic ring.
BACKGROUND AND AIM OF THE STUDY: Although mitral annuloplasty is an important element of mitral valve repair, the technique employed remains controversial. In this prospective study, we compared two different annuloplasty techniques with regard to hemodynamic performance. METHODS: Between October 1995 and December 1998, 109 consecutive patients underwent mitral valve repair for mitral regurgitation. One group of patients (n = 55) received a Carpentier-Edwards (CE) ring for annuloplasty, and a second group (n = 54) underwent the mural annulus shortening suture (MASS) to reinforce the posterior circumference of the annulus. All patients were investigated prospectively by Doppler echocardiography before discharge and annually thereafter. The mean follow up was 22.7+/-11.6 months. RESULTS: The early mortality rate was 3.7%, with four early deaths in the CE group, and no early death in the MASS group. There was one late death in each group. One patient in each group required reoperation for severe mitral regurgitation after 19 and 30 months, respectively. Postoperative (12 months) Doppler echocardiography showed mean mitral valve gradients to be significantly lower (1.7+/-0.7 versus 2.7+/-1.7 mmHg; p <0.01) and mitral valve areas significantly larger (3.3+/-1.0 versus 2.6+/-0.7 cm2; p <0.01) in MASS patients compared with CE patients. There was no significant difference in mean postoperative mitral regurgitation between the two groups (0.5+/-0.2 versus 0.4+/-0.2). CONCLUSION: Both annuloplasty techniques showed excellent results; however, hemodynamic performance of MASS was superior to that of the rigid CE ring, while not increasing postoperative mitral regurgitation. Therefore, MASS may be recommended as an alternative to annuloplasty rings, if future long-term follow up studies confirm the durability of the technique.
Echocardiography, Doppler↗
Mitral commissurotomy, a technique outdated? Long-term follow-up over a period of 35 years.
BACKGROUND: The objective of this study was to evaluate long-term survival, valve-related complications as well as prognostic factors for early and late outcome after open and closed mitral commissurotomy covering a follow-up period of 35 years. METHODS: From 1955 to 1977, 183 patients with mitral stenosis underwent mitral commissurotomy at our institution. Closed valvotomy was performed on 143 patients (group A) and open valvotomy on 40 patients (group B). RESULTS: Survival rates after 10, 20, and 30 years were 89%, 67.8%, and 49.1% in group A and 91.7%, 66.7%, and 45.9% in group B (p = not significant). The risk of late death increased significantly with an advanced preoperative New York Heart Association functional class, atrial fibrillation, higher age at operation, pre- or postoperative mitral regurgitation, and leaflet calcification. Forty-four patients in group A and 5 patients in group B required reoperation (p < 0.05). Independent predictors for reoperation in a multivariate analysis were a remaining postoperative mitral stenosis or regurgitation. A total of 68 patients showed valve-related complications. The linearized rate of valve-related morbidity and mortality was 2.1% per patient-years in group A versus 1.1% per patient-years in B (p < 0.01). CONCLUSIONS: Long-term survival for open and closed commissurotomy are excellent, showing no difference between the groups. However, both the incidence of reoperation as well as valve-related morbidity and mortality were significantly lower after open commissurotomy. In well-selected patients with pure mitral stenosis and no leaflet calcification, open commissurotomy still remains a valid surgical option.
Adult↗
Clinical autologous in vitro endothelialization of infrainguinal ePTFE grafts in 100 patients: a 9-year experience.
BACKGROUND: Clinical in vitro endothelialization was assessed for its ability to improve the long-term patency of prosthetic femoropopliteal bypass grafts. METHODS: Between June 1989 and May 1998, 100 patients received 113 in vitro endothelialized expanded polytetrafluoroethylene grafts (ePTFE). Bilateral implantations were performed in 13 patients. In phase 1 of the study, 24 patients received 27 endothelialized grafts and 16 patients received 17 untreated grafts. In phase 2, endothelialization was offered to all patients who did not have a suitable saphenous vein available. Phase 2 began in June 1993 and included 76 patients who received 86 endotheliazed ePTFE grafts. In all, 100 patients had autologous endothelial cells harvested from 4- to 5-cm segments of a subcutaneous vein. In phase 1, the external jugular vein was used. In phase 2, the cephalic vein was used. These cells were grown to first-passage mass cultures and were lined confluently onto 6-mm ePTFE grafts, pre-coated with fibrin glue. Patency assessment for Kaplan-Meier survivorship analysis was determined by using duplex sonography and angiography. RESULTS: In phase 1, the Kaplan-Meier method revealed a primary 9-year patency rate for 65% for the endothelialized group, versus 16% for the control group (log-rank test, P = .002; Wilcoxon test, P = .003). In phase 2, the 5-year primary patency rate for all in vitro endothelialized infrainguinal reconstructions was 68% (66% for above-the-knee grafts and 76% for below-the-knee grafts). CONCLUSIONS: Nine years of clinical in vitro endothelialization provided strong evidence that autologous endothelial cell lining improves the patency of small-diameter vascular grafts and that a cell culture-dependent procedure can be used in a clinical routine.
Aged↗
Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair.
OBJECTIVES: We sought to analyze risk factors for long-term survival (up to 36 years) after surgical repair of tetralogy of Fallot (TOF). BACKGROUND: Survival after repair is excellent, but data >20 years are rare. METHODS: From 1958 to 1977, 658 patients underwent correction of TOF at our institution and were analyzed for survival. Of this patient group (age 12.2 +/- 8.6 years [mean +/- SD], range 2 to 67), 39.7% had a previous palliation. Operative (n = 139) and 1-year (n = 29) deaths were excluded for long-term calculations, resulting in a study group of 490 patients. RESULTS: Actuarial 10-, 20-, 30- and 36-year survival rates were 97%, 94%, 89% and 85%, respectively. Mortality increased 25 years postoperatively from 0.24%/year to 0.94%/year (p = 0.003). The most common cause of death was sudden death (n = 13), followed by congestive heart failure (n = 6). Multivariate correlates of impaired long-term survival were date of operation (before 1970, p = 0.0104), preoperative polycythemia (p = 0.0487) and use of a right ventricular (RV) outflow patch (p = 0.0079). Postoperative systolic RV/left ventricular pressure ratio and age showed no influence. Patients without preoperative polycythemia and an RV outflow patch (n = 164) had a 36-year actuarial survival rate of 96% and normal life expectancy. CONCLUSIONS: Cyanosis, operative experience of the surgeon and an RV outflow tract patch influence long-term outcome after repair of TOF in older children. Early repair by experienced surgeons to avoid polycythemia and excessive RV hypertrophy is supported by this study. However, mortality risk increases 25 years postoperatively, and thus heart monitoring should be intensified.
Actuarial Analysis↗
[Transplantation of aortic and mitral valves: permanent valve replacement without anticoagulation?].
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Anticoagulants↗
Thirty-year results of Starr-Edwards prostheses in the aortic and mitral position.
BACKGROUND: Between 1963 and 1977 a total of 415 patients admitted to the University Hospital Munich underwent an isolated valve replacement with a Starr-Edwards prosthesis in the aortic or mitral position. METHODS: A retrospective follow-up of 87.1% of the patients representing 4,254 patient-years was completed. Surviving patients were examined by means of echocardiography. RESULTS: Survival rates after 10, 20, and 30 years were 62.3%, 39.4%, and 19.9% after aortic valve replacement and 75%, 36.5%, and 22.6% after mitral valve replacement (operative mortality excluded). Freedom from all valve-related complications, reoperations, and valve-related death was 66.4%, 43.3%, and 23.8% after aortic valve replacement and 73.4%, 35.4%, and 14.3% after mitral valve replacement. Of the surviving patients, 82% and 76% who received aortic or mitral valves, respectively, are in New York Heart Association class I or II. The pressure gradients of the aortic valves were between 20 and 73 mm Hg; those of the mitral valves were between 9 and 30 mm Hg. Fifty-two percent of aortic and 68% of mitral valves show no echocardiographic peculiarities. The left ventricular function in both groups is normal in 64%. CONCLUSIONS: The long-term results together with the echocardiographic results show that after 30 years the Starr-Edwards valve represents a standard that still needs to be achieved by newer prostheses.
Adult↗
In vitro endothelialization of expanded polytetrafluoroethylene grafts: a clinical case report after 41 months of implantation.
PURPOSE: Forty-one months after we performed bilateral implantation of in vitro endothelialized femoropopliteal bypass grafts in a 69-year-old patient, we obtained a central graft segment for histologic and ultrastructural investigation. METHODS: Before implantation the grafts were confluently lined with autologous first passage mass cultures of pure cephalic vein endothelial cells. The precoating of the expanded polytetrafluoroethylene prosthesis was done with fibrinolytically inhibited fibrin glue. Reoperation became necessary because of symptomatic unilateral atherosclerotic lesions located in the center of one of the two in vitro lined grafts. A 21 cm long graft segment was removed and replaced by a new in vitro endothelialized expanded polytetrafluoroethylene graft. RESULTS: On scanning electron microscopy a confluently covering mature endothelium was found throughout the whole length of the removed prosthesis. The endothelial identity was confirmed by a positive immunohistochemical CD 34, von Willebrand factor-staining, and the ultrastructural demonstration of Weibel Pallade bodies. The endothelium rested on a collagen IV positive basement membrane. Histologic cross sections revealed uniformly developed subintimal tissue of 1.21 +/- 0.19 mm thickness, which was separated from the intima by a distinct internal elastic membrane. The cells of this cell-rich matrix stained strongly positive for actin. Ultrastructurally, this matrix was dominated by highly contractile myofibroblasts loaded with peripherally located well-developed actin fillaments. A number of these cells also showed signs of secretory cells with a distinct endoplasmic reticulum and a Golgi complex. In areas of atherosclerotic lesions the subendothelial matrix was partially exposed, and the internal elastic membrane had to a certain extent disintegrated. Only in these areas KP-1 and MG-M1 positive foamy macrophages and CD 34 positive capillaries were found. The myofibroblasts of this diseased part of the subintimal tissue contained large lipid vacuoles. CONCLUSIONS: We conclude that the confluent in vitro lining of synthetic vascular grafts with pure autologous endothelial cells facilitates graft healing, which may result in a hybrid structure with features of a native vessel.
Actins↗
Thirty years survival after double valve replacement with Starr-Edwards prostheses in aortic and mitral position.
We report about a patient who underwent double valve replacement with two Starr-Edwards prostheses in aortic and mitral position 30 years ago. Under anticoagulation medication he survived 28 years without any valve-related events. In the 29th year he sustained a cerebral infarction from which he recovered, having only a residual left arm paresis. His NYHA functional class today is II-III. Chest X-ray shows a mildly enlarged configuration of the heart, echocardiography reveals no irregularities of the implanted prostheses. We conclude, that the Starr-Edwards valve presents an outstanding standard concerning durability in mechanical valve replacement.
Adult↗
Endothelialized biological heart valve prostheses in the non-human primate model.
OBJECTIVE: The main disadvantage of implanted cardiac valve bioprostheses remains primarily tissue failure due to calcification. Coating of bioprostheses with viable autologous endothelial cells may delay or even eliminate tissue calcification and subsequent cardiac dysfunction. METHODS: Glutaraldehyde-preserved Hancock bioprostheses (n = 5), pretreated with glutamic acid (8%) and cryopreserved allografts (n = 5) were lined, using endothelial cells harvested from the external jugular vein. Coated specimens were cultivated for 9 days in Medium 199 supplemented with 20% fetal calf serum and basic fibroblast growth factor. Endothelialized grafts were anastomosed into the descending thoracal aorta of adult Chacma baboons. Untreated valve bioprostheses (n = 4) served as controls. Forty days after implantation the prostheses were examined morphologically and immunohistochemically. RESULTS: After implantation endothelialized prostheses showed a positive Factor VIII related antigen reaction by immunohistochemistry on all valve surfaces. Scanning electron microscopy showed confluently lined leaflets with transplanted endothelial cells and displayed cobblestone morphology on all coated allografts. In contrast, the surface of pretreated xenograft valves revealed uncoated areas with platelet and leucocyte aggregates. No endothelium was observed on the leaflets of untreated controls 40 days after implantation. CONCLUSION: In vitro endothelialization of cardiac valve bioprostheses with autologous endothelial cells is possible. The newly created endothelium is shear stress resistant and the antithrombotic as well as the antiaggregatory capacity of the transplanted cells were retained. Lining with autologous endothelial cells could improve the durability and clinical outcome of biological valve prostheses.
Animals↗
Platelet morphology in patients with mechanical circulatory support.
OBJECTIVE: Mechanical circulatory support is a therapy for patients with end stage cardiac insufficiency. The thromboembolic events are feared complications during support, due to the surface thrombogenicity of the implanted device. Activated blood platelets play a major role in this context. Consequently the platelet morphology of patients was investigated. METHODS: Platelets of eight patients were observed by means of scanning electron microscopy during the period of support with the Novacor left ventricular assist system N100. Blood was collected preoperatively and daily during the first week as well as weekly during the first 3 months. Samples were fixed with cacodylic-acid buffered glutaraldehyde. Platelet alterations were classified as non-activated, activated and aggregated, based on the so-called 'shape change' morphology. In addition, blood coagulation parameters were evaluated (e.g. activated partial thromboplastin time, prothrombin time, antithrombin III). RESULTS: Preoperatively, 15.0 +/- 4.6% (overall mean values) of activated platelets were found. Within the first postoperative week, the mean level of activated platelets increased to 32.8 +/- 8.0% (P < 0.05). Comparing short- (< 30 days; n = 4) vs. long-period (> 30 days; n = 4) support, a significant difference of activated platelets was evaluated (24.3 +/- 3.3% vs. 34.8 +/- 3.4%, P = 0.004). A correlation was found between the values of activated clotting time and activated platelets. Specific platelet deformations and damages appeared during support, which could not be found preoperatively. CONCLUSIONS: The platelet morphology showed alterations in all patients probably most strongly induced by the surface activation of the implanted device. These observations should be taken into consideration in management of postoperative anticoagulation therapy.
Adult↗