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Biomedical subjects

Ulf Herold

Publications and source records attributed to Ulf Herold.

At least 19 recordsLinked to original sources
PubMed2007

An electrophysiological endophenotype of hypomanic and hyperthymic personality.

BACKGROUND: Hyperthymic Temperament (HYT) and a closely related trait, Hypomanic Personality (HYP), have both been related to bipolar affective disorder (BAD). Intensity dependence of auditory evoked potentials (IAEP) is a suggested inverse indicator of serotonergic neurotransmission and has been found to be elevated in BAD. Therefore the present study explored for the first time whether subclinical variance of HYT/HYP is also associated with IAEP in a healthy sample. As several traits from biological personality research are correlated with HYT/HYP and also with BAD, the specificity of results against these traits was further analyzed by calculating multiple regression analyses. METHODS: Evoked potentials were recorded from a sample (N=87) homogenous for confounding variables influencing IAEP. For this reason, only 19 to 27-year-old non-smoker psychiatrically healthy male students were included. RESULTS: Significant correlations were found between IAEP and both HYP and HYT. Including Sensation or Novelty Seeking and Extraversion in Regression Analyses did not weaken the associations of HYP with IAEP much, but did affect those of HYT. However, these competing biological personality traits were hardly able to predict IAEP themselves. Impulsivity, though, was able to reduce the predictive power of HYP and HYT and to explain unique IAEP-variance. This was even more the case for Behavioral-Activation-System-Sensitivity (BAS) subscale Fun Seeking clearly dominating all regression analyses. LIMITATIONS: Homogeneity of sample. CONCLUSIONS: The impact of BAS is in agreement with the assumption that heightened BAS-sensitivity is an underlying biological cause for HYP/HYT and for BAD. Future studies on BAD should include BAS and Impulsivity besides HYP/HYT to further explore uniqueness of the latter and to develop questionnaires based on those items of a hyperthymic-hypomanic-impulsive-funseeking item pool, which possess the most external validity.

Adult↗
PubMed2006

Administration of C1-esterase inhibitor during emergency coronary artery bypass surgery in acute ST-elevation myocardial infarction.

OBJECTIVE: Myocardial inflammatory response including complement activation was demonstrated as an important mechanism of ischemia-reperfusion injury and complement inhibition by C1-esterase inhibitor (C1-INH) has recently shown to have cardioprotective effects in experimental and clinical settings. METHODS: The effects of C1-INH on complement activation, myocardial cell injury, and clinical outcome were studied in patients undergoing emergency CABG due to acute ST-elevation myocardial infarction (STEMI) with (group 1, CABG+STEMI+C1-INH, n=28) and without (group 2, CABG+STEMI, n=29) bolus administration of C1-INH (40 IU kg(-1)) during reperfusion and 6 h postoperatively (20 IU kg(-1)) besides the same study protocol. C1-INH activity, C3c and C4 complement activation fragments, and cardiac troponin I (cTnI) were measured preoperatively and up to 48 h postoperatively and compared to another elective set of CABG patients without STEMI as controls (group 3, CABG-STEMI, n=10). Clinical data, adverse events, and patient outcome were recorded prospectively. RESULTS: Patient characteristics were not different between groups 1 and 2. No drug-related adverse events were observed. Constant plasma levels of C1-INH were found in group 1, but not in groups 2 and 3. Plasma levels of C3c and C4 complement fragments were reduced in all three groups after surgery throughout the observation time, but tended to be lower in groups 1 and 2 compared with group 3. Preoperative cTnI levels were elevated but not different between the groups 1 and 2. The area under curve (AUC), as well as the postoperative cTnI serum levels, was significantly lower (P<0.05) in group 1 with a treatment delay < or = 6 h between reperfusion and symptom onset compared to group 2 at 36 h (47.9+/-11.1 ng/ml vs 97.7+/-17.2 ng/ml; mean+/-SEM), and 48 h (33.5+/-5.8 ng/ml vs 86.5+/-19.2 ng/ml) after surgery, but remained unchanged between groups among patients with a treatment delay of more than 6-24 h. In-hospital adverse events and postoperative complications, ICU and hospital stay, as well as in-hospital mortality (14.3% vs 13.8%; P=NS) were not different between groups 1 and 2. CONCLUSIONS: C1-INH administration in emergency CABG with acute STEMI is safe and effective to inhibit complement activation and may reduce myocardial ischemia-reperfusion injury as measured by cTnI.

Aged↗
PubMed2006

Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery.

BACKGROUND: A possible relationship between increased perioperative risk during coronary artery bypass grafting (CABG) and previous percutaneous coronary intervention (PCI) is debatable. We sought to determine the impact of previous PCI on patient outcome after elective CABG. METHODS AND RESULTS: Between January 2000 and January 2005, 2626 consecutive patients undergoing first-time isolated elective CABG as the primary revascularization procedure (group 1) were evaluated for in-hospital mortality and major adverse cardiac events (MACEs) and were compared with 360 patients after single PCI (group 2) and with 289 patients after multiple PCI sessions (group 3) before elective CABG. Unadjusted univariate and risk-adjusted multivariate logistic-regression analysis revealed previous multiple PCIs to be strongly associated with in-hospital mortality (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.52 to 3.21; P<0.001) and MACEs (OR, 2.28; 95% CI, 1.38 to 3.59; P<0.001). To control for selection bias, a computed propensity-score matching based on 13 patient characteristics and preoperative risk factors was performed separately comparing group 1 versus 2 and group 1 versus 3. After propensity matching, conditional logistic-regression analysis confirmed previous multiple PCIs to be strongly associated with in-hospital mortality (OR, 3.01; 95% CI, 1.51 to 5.98; P<0.0017) and MACEs (OR, 2.31; 95% CI, 1.45 to 3.67; P<0.0004). CONCLUSIONS: In patients with a history of multiple PCI sessions, perioperative risk for in-hospital mortality and MACEs during subsequent elective CABG is increased.

Aged↗
PubMed2006

Frequency and outcomes of acute renal failure following thoracic aortic stent-graft placement.

We assessed the incidence, correlates, and outcomes of acute renal failure (ARF) after thoracic aortic stent-graft placement. Postprocedural ARF is an inherent complication of catheter-based interventional procedures that use intra-arterial contrast agents and has adverse effects on short- and long-term outcomes. However, few data exist on the incidence, predictors, and outcomes of ARF after thoracic aortic stent-graft placement. We analyzed data of 97 patients (64.4 +/- 11.6 years of age; 73% men) who underwent thoracic aortic stent-graft placement from July 1999 to October 2005. Postprocedural ARF was defined as an increase > or = 25% and/or > or = 0.5 mg/dl in preprocedural serum creatinine at 48 hours after the procedure. Baseline estimated glomerular filtration rate was 65 +/- 24 ml/min/1.73 m2. Chronic kidney disease (glomerular filtration rate < or = 60 ml/min/1.73 m2) at baseline was present in 45% of patients. During the stent-graft procedure, patients received 307 +/- 188 ml of nonionic contrast medium. Postprocedural ARF occurred in 33 patients (34%), and 3 required dialysis. Multivariable analysis identified American Society of Anesthesiologists class > 3 (odds ratio 5.53, 95% confidence interval 1.71 to 17.85, p = 0.004) and duration of the stent-graft procedure (odds ratio 1.01, 95% confidence interval 1.001 to 1.014, p = 0.022) as independent predictors of postprocedural ARF. Compared with patients without ARF, those with ARF had markedly higher 30-day (18.2 +/- 6.7% vs 1.6 +/- 1.6%, p = 0.0022) and 1-year (35.2 +/- 8.6% vs 10.1 +/- 3.9%, p = 0.001) mortality. In conclusion, postprocedural ARF is a frequent complication of thoracic aortic stent-graft placement and has a significant adverse effect on 30-day and 1-year survival. Baseline factors identified in our study as associated with increased risk of ARF may facilitate a comprehensive informed consent process by way of patient education. In addition, identification of an at-risk subset may allow modification of reversible periprocedural factors that may help decrease postprocedural ARF.

Acute Kidney Injury↗
PubMed2006

Further evidence for an association of 5-HTTLPR with intensity dependence of auditory-evoked potentials.

Intensity dependence of auditory-evoked potentials (IAEP) has been suggested as an indicator of central serotonergic neurotransmission. Two recent studies investigated a possible association of IAEP with a functional polymorphism in the transcriptional control region of the serotonin transporter gene (5-HTTLPR) that has a short (s) and a long (l) variant. Although both studies found an association between 5-HTTLPR and IAEP, Gallinat et al found l/l individuals to exhibit lower IAEP, whereas Strobel et al observed stronger IAEP in l/l individuals. These conflicting results require further evaluation and more attention needs to be paid to variables that are known to be confounded with the effects of IAEP and 5-HTTLPR. Using a paradigm comparable to Strobel et al, the present study analyzes the effect of 5-HTTLPR on IAEP in a healthy male student sample (N=91; age=23 years, SD=1.9) that was homogenous for most significant confounding variables. A stronger IAEP was shown in l/l individuals, irrespective of the method of IAEP parametrization. This also held at retest after 3 weeks in a subsample (N=18). Given the successful replication of Strobel et al, several possible reasons for conflicting results with regard to Gallinat et al are discussed. It is argued that the most significant difference between Gallinat et al on the one hand, and Strobel et al and this study on the other, is that different intensity ranges are used which impact IAEP. Therefore, this study encourages further analysis of dose dependence of results.

Adult↗
PubMed2006

Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease.

Despite advances in medical and surgical treatment, acute as well as chronic diseases of the thoracic aorta are still associated with a high mortality. For the descending thoracic aorta, endovascular stent-graft placement competes with surgical therapy for clinical outcome. From July 1999 till December 2004, a total of 84 patients (64 +/- 14 years) with aortic disease of the descending thoracic aorta were treated. Nine patients had acute (AAD) and 35 chronic aortic dissection (AD), 16 had thoracic aortic aneurysms (TAA), 21 had penetrating aortic ulcer (PAU), and 3 patients had traumatic dissection (trans). Initial clinical status was assessed using the American Society of Anesthesiologists (ASA) classification. Fifty-three patients were in class 2, 16 in class 3, 8 in class 4, and 7 in class 5. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia. Technical success was obtained in 81/84 patients (96%). Within 30 days, seven patients (8%) died, four of them due to aortic rupture. In 14 patients, additional stent-grafts had to be implanted due to type I endovascular leakage (n = 5) or additional entry site adding up to a total of 107 implanted stent-grafts. During a follow-up period of 21 +/- 18 months, 17 additional patients died (22%). In 10 patients, death was disease- or procedure-related (13%). This long-term mortality depended on the underlying disease and was highest in the group with TAA (45%) followed by AAD (38%) and AD (18%). Patients in ASA class 4 and 5 had a significantly worse outcome. No aortic-related death occurred among patients with PAU or traumatic transsections. Overall, there was only one transient neurological deficit. Endovascular stent-graft placement has acceptable results in the treatment of patients with disease of the descending thoracic aorta. The outcome strongly depends on the underlying aortic pathology and the clinical health status of the patients. Randomized trials are necessary in order to establish the exact value of this new therapeutic option.

Adult↗
PubMed2006

Thoracic aorta endografts: variations in practice among medical specialists.

BACKGROUND: Endovascular stent-graft placement is emerging as a novel treatment option for patients with diseases of the descending thoracic aorta. However, currently no consensus guidelines exist to direct uniformity in stent-graft procedures as well as for pre- and postprocedural patient management, unlike that for the management of other cardiovascular disorder. Accordingly, the aim of the present survey was to assess variations in thoracic aortic stent-graft practice among different subspecialties in Germany. METHODS: An interdisciplinary questionnaire survey was conducted among 206 departments of vascular surgery, radiology, cardiology, and cardiothoracic surgery in Germany that actively performed aortic stent-graft placement. Data on preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized, self-administered questionnaire comprising 29 items. Responses were tabulated for analysis. RESULTS: Of a total of 206 questionnaires, 184 (89.3%) were returned with 71 (38.5%) centers reporting to have performed thoracic aortic stent-graft placement (total number of procedures 2,267) through 1997 and 2003. The average number of stent-graft procedures per year was 7.4 (25-75% percentile, 2.05-10.75) at participating sites, with 49% of the respondents reporting <5 procedures per year. Treatment of thoracic aortic aneurysms was the predominant indication for stent-graft placement, followed by type B-dissection. As anticipated, marked variability existed among the different medical specialties performing stent-graft procedures with respect to all aspects of the procedures including indication for treatment, choice of preoperative and intraoperative imaging modalities, technical equipment and perioperative management. The only consistent agreement was on the need for lifelong follow-up after stent-graft placement, with CT being the preferred imaging technique (90% of centers). CONCLUSION: The present survey documents an increasing adoption of endovascular stent-graft placement for patients with diseases of the descending thoracic aorta in Germany. Despite this, there is a lack of consensus among the different medical specialties performing stent-graft placement with respect to indications and technical execution of stent-grafting. Our data supports the need for consensus practice guidelines endorsed by medical professional societies for stent-graft procedure to standardize the growing number of thoracic stent graft procedures.

Angioplasty↗
PubMed2006

[Early single-center experience with the 3F-enable aortic valve bioprosthesis].

BACKGROUND AND PURPOSE: Patients with aortic valve (AV) pathology and severe comorbidities should benefit from reduced myocardial ischemic and extracorporeal circulation (ECC) time. Sutureless implantation of AV prosthesis may reduce myocardial ischemic and ECC time significantly. The authors report on their preliminary results with the first implants of the 3F-Enable sutureless AV prosthesis. MATERIAL AND METHODS: The 3F-Enable prosthesis was implanted in five patients. Prostheses sizes were 27 mm (n = 3), 23 mm (n = 1), and 21 mm (n = 1), respectively. Intraoperatively, at patient's discharge as well as 3 and 6 months postoperatively, the AV prosthesis was evaluated by echocardiography. RESULTS: ECC time was 87 +/- 36 min (range 49-141 min), myocardial ischemic time 55 +/- 27 min (range 32-97 min), and AV implant time 184 +/- 195 s (range 10-420 s). The latest postoperative echo (5.2 +/- 1 months postoperatively) revealed a fully competent AV in three patients, in two patient paravalvular leakage was detected at the severity of an aortic regurgitation (AR) II degrees , and AR II degrees -III degrees , respectively. The mean pressure gradients were 5.8 +/- 1.3 mmHg (range 4.2-7.1 mmHg), valve orifice area was 3.2 +/- 0.4 cm2 (range 2.6-3.6 cm2). CONCLUSION: The first clinical results of the 3F-Enable sutureless AV prosthesis are feasible; however, a paravalvular leakage was detected in two patients (40%). Thus, device and procedural enhancements are required to assure positioning and anchoring of the prosthesis.

Aged↗
PubMed2006

[Change of paradigms in the surgical treatment of complex thoracic aortic disease].

One of the main issues in complex thoracic aortic disease, requiring the replacement of the ascending aorta, the entire aortic arch and the descending aorta, is the vast amount of surgery necessary to cure the patient. Though one-stage repair is feasible by a clamshell thoracotomy, the associated surgical trauma and perioperative morbidity limit this approach to younger patients only. Classic surgical repair consist of a two-stage strategy, whereby, in the first step, the ascending aorta and the aortic arch are replaced via a midline sternotomy. In the second step, via a lateral thoracotomy, the descending aorta is replaced. The two stages may sum up to a mortality of 20%; furthermore, the waiting period between the stages is associated with a mortality rate of 10% of its own. Additionally, the two-stage strategy has an inherent limitation, due to the comorbidity and advanced age of the majority of patients. Therefore, the second stage cannot be offered to up to 30% of patients. New developments and improvements in aortic surgery were introduced to overcome these shortcomings and to simplify the surgical repair. The "elephant trunk" principle, introduced by Borst et al. in 1983, was an important step to facilitate surgical repair, but still required the second step. With the introduction of endovascular repair of thoracic aortic disease with stent grafts implanted retrograde via the femoral artery, new therapeutic concepts emerged. In the late 1990s, two Japanese groups reported first trials to stabilize the free-floating "elephant trunk" prosthesis by implantation of nitinol stent grafts into the vascular graft. The applied devices were purely custom-made and nonstandardized. The availability of industrially made and CE-marked stent-graft devices raised the possibility to apply them in open aortic arch surgery. The experience with stent-graft devices implanted antegrade into the descending aorta (Medtronic Talent) was reported first by the Essen and the Vienna group. The experience gained with these devices revealed the limitations of the devices designed for pure retrograde aortic delivery. This required a complete redesign and new construction of the stent graft itself as well as the introducer system. In a preliminary series of 14 patients the required stent-graft properties were presented in detail and resulted in the first industrially manufactured standardized and CE-marked Hybrid stent graft (Essen 1 prosthesis, E-vita Open, Jotec), especially made for antegrade open stent grafting of the descending aorta. This device consists of a stent graft with an integrated Dacron vascular prosthesis, enabling for direct and continuous aortic arch replacement after stent grafting of the descending aorta. From 01/2005 to 03/2006, this hybrid prosthesis was implanted in 16 patients (one aneurysm and 15 aortic dissections). In all cases, the underlying pathology within the thoracic aspect of the aorta could be excluded in a one-stage approach. In case of aortic dissection, thrombosis of the false lumen was detectable by transesophageal echocardiography already at the end of surgery. Though long-term results using this new method are not yet available, the initial promising results postoperatively are encouraging toward true one-stage repair by combining classic aortic surgery with open antegrade stent grafting utilizing the newly designed hybrid prosthesis. While surgical trauma is markedly reduced, this treatment option can be offered to elderly patients as well.

Adult↗
PubMed2006

Endovascular stent-graft treatment of penetrating aortic ulcer: results over a median follow-up of 27 months.

BACKGROUND: Penetrating aortic ulcer (PAU) is increasingly acknowledged as a pathological variant of classic false-lumen aortic dissection with a high incidence of bleeding complications and rupture in up to 40% of patients. The objective of this study was to investigate the results of endovascular stent-graft placement for the treatment of patients with PAUs. METHODS: Between July 1999 and December 2004, endovascular stent-graft repair of PAU was performed in 22 patients (69.1 +/- 7.8 years, 16 men), 3 (14%) of whom had contained aortic rupture. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia, using a surgical access. RESULTS: Procedural success was achieved in all but 1 patient (technical success rate 96%). Postoperatively, 1 (5%) patient had minor stroke with transient amentia. There were no other inhospital complications or deaths. During a median follow-up of 27 (range 1-62) months, 1 patient underwent adjunctive stent-graft placement for type I endoleak. Three patients died unrelated to the aortic disease late during follow-up. Overall survival rates were 100% at 30 days, 100% at 1 year, 82.5% +/- 11.3% at 2 years, and 61.9% +/- 20.0% at 5 years. CONCLUSIONS: Endovascular stent-graft treatment is an effective treatment for patients with PAU and is associated with low procedural morbidity. Both acute and midterm mortality of this novel treatment concept appear to be favorable compared with the natural course of the disease.

Aged↗
PubMed2005

Endovascular stent-graft placement in aortic dissection: a meta-analysis.

AIMS: This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS: We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION: Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.

Acute Disease↗
PubMed2005

Diagnostic discrimination between graft-related and non-graft-related perioperative myocardial infarction with cardiac troponin I after coronary artery bypass surgery.

AIMS: The rise of markers for myocardial injury indicates early graft-related or non-graft-related perioperative myocardial infarction (PMI) after coronary artery bypass grafting (CABG). A diagnostic discrimination between these two situations may enable adequate therapeutic measures, limiting myocardial damage, and improving outcome. METHODS AND RESULTS: In a prospective study, 94 among 3308 consecutive CABG patients underwent acute reangiography because of evidence of PMI. Of these 94 patients, 56 had graft-related PMI (group 1), 38 patients had non-graft-related PMI (group 2), and 95 patients without evidence of PMI and angiographically patent grafts served as control (group 3). Cardiac troponin I (cTnI), creatine kinase (CK), and its MB fraction were determined. CTnI, but not CK/CK-MB levels were significantly higher in group 1 than in groups 2 and 3 at 12 and 24 h after aortic unclamping (P<0.0001). Receiver operating characteristic and multivariable logistic regression analyses indicated cTnI as the best discriminator between PMI 'in general' and 'inherent' release of cTnI after CABG with a cut-off value of 10.5 ng/mL and between graft-related and non-graft-related PMI with a cut-off value of 35.5 ng/mL. CONCLUSION: Perioperative cTnI elevation after CABG separates among patients with graft-related, non-graft-related, and without PMI, however, not earlier than 12 h after surgery.

Aged↗
PubMed2005

Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome.

AIMS: To investigate the results of endovascular stent-graft placement for the treatment of patients with type B aortic dissection (B-AD). METHODS AND RESULTS: A total of 38 patients (62+/-10 years, 32 male) with acute (n=10) and chronic (n=28) type B-AD were treated with endovascular stent-grafts. The implantation procedure was successful in all patients. Peri-procedural non-fatal complications occurred in four (11%) patients. Overall, 4/38 (11%) patients died during the in-hospital period. Patients undergoing stent-graft placement for acute AD had a significantly higher in-hospital mortality than patients with chronic AD (40 vs. 0%, P=0.001). During a median follow-up of 18 (1-57) months, there were six additional deaths. Overall survival rates were 97.4+/-2.6% at 30 days, 80.4+/-6.7% at 1 year, 73.2+/-7.8% at 2 years, and 54.9+/-16.9% at 4 years. Patients with a poor clinical health status (ASA class > 3) had a significantly reduced life expectancy compared with patients with only moderate co-morbidities (ASA class </= 3) (1-year survival rate 28.6+/-17.1 vs. 92.6+/-6.7%, P=0.0001). Multivariable analysis revealed that a poor clinical health status (ASA>3) pre-operatively (HR=29.5, 95% CI 1.5-581.9, P=0.026) and increased age (HR=1.1, 95% CI 0.9-1.2, P=0.084) were independent determinants of post-interventional mortality. CONCLUSION: Endovascular stent-graft treatment is a safe alternative for patients with AD. The pre-operative clinical health status of the patient is the most important determinant of post-interventional outcome. Careful patient selection is thus of particular importance.

Acute Disease↗
PubMed2005

Endovascular stent-graft placement for acute and contained rupture of the descending thoracic aorta.

OBJECTIVES: To identify determinants of postinterventional death after endovascular stent-graft placement for acute rupture of the descending thoracic aorta, an emerging therapeutic modality for this highly life-threatening condition. METHODS: Between July 1999 and November 2004, 17 patients (14 males; mean age, 65+/-16 (25-83) years) underwent stent-graft repair of the descending thoracic aorta for acute rupture from a thoracic aneurysm (TAA, n=6), acute aortic dissection (AAD, n=6), penetrating aortic ulcer (PAU, n=3), or blunt chest trauma (n=2). Immediate, 30-day, 1-year, and 3-year mortality was assessed. Twenty-one clinical and procedural variables were evaluated in a post-hoc analysis regarding their influence on mortality. Of these, four preprocedural factors with the greatest impact were used to construct a rupture score with a scale from 0 (no adverse prognostic factors present) to 4 (all four adverse factors present). RESULTS: Stent-graft placement was technically feasible in all patients. Complete exclusion of the ruptured aortic pathology could be achieved in only 11 (65%) patients, despite implantation of 1.6+/-0.9 stent-grafts per patient, with a median length of 130 mm. There was one procedure-related early complication (bleeding at the access site). One patient died immediately following the procedure because of progressive mediastinal hematoma, although the rupture site was effectively sealed. Overall survival rates were (76.5+/-10.3)% at 30 days and (52.9+/-12.1)% at 1 year and remained at (52.9+/-12.1)% at 3 years. The four most important preprocedural denominators of death were (1) TAA or AAD as the underlying etiology of aortic rupture (P=0.024), (2) maximum aortic diameter>5 cm (P=0.024), (3) presence of mediastinal hematoma (P=0.056), and (4) an estimated lesion length requiring >1 stent-graft to be covered (P=0.009). Furthermore, residual leakage at the conclusion of the procedure (P=0.009), postprocedural need for dialysis (P=0.004), and prolonged ventilation (P=0.043) were significantly associated with postprocedural death. Using a threshold of >or=3, the rupture score constructed on the basis of the four preprocedural denominators of death was found to be well suited to discriminate postprocedural death (1-year survival: (20.0+/-12.7)% in patients with a rupture score>or=3 vs. 100% in patients with a rupture score<3, P=0.001). CONCLUSION: Endovascular stent-graft placement in patients with acute aortic rupture was technically feasible, albeit still associated with high mortality. A simple risk score constructed in retrospect, on the basis of preprocedural prognostic factors, appeared to provide a useful separation of candidates who are likely to benefit from a straightforward endovascular procedure and should be tested prospectively in future studies.

Acute Disease↗
PubMed2005

[Surgical treatment for massive pulmonary embolism].

Surgical embolectomy for massive pulmonary embolism (PE) has become a rare procedure. Often, it is viewed as a last-chance option for patients undergoing cardiopulmonary resuscitation after massive PE. Thus thrombolytic therapy has become the treatment of choice. However, a significant proportion of patients suffers from residual obstruction after thrombolytic therapy and faces the development of chronic pulmonary hypertension. Therefore, some centers have regained interest in surgical embolectomy after improved risk stratification and reported very good results. Perioperative survival rates up to 89% have been reported. This was accomplished by surgery on the ECC-(extracorporeal circulation-)supported, beating, normothermic heart and utilization of special instruments. These encouraging results have been confirmed by the authors and others in patients with stable systemic hemodynamics but moderate to severe right ventricular dysfunction. The more widespread use of surgical embolectomy seems warranted. A randomized, controlled trial is overdue to determine the benefits of this therapy in stable patients compared with thrombolytic therapy if "best-practice" therapy is to be achieved for the patients' benefit.

Embolectomy↗
PubMed2005

Endovascular stent-graft placement for complications of acute type B aortic dissection.

PURPOSE OF REVIEW: To review the concepts and current clinical results of endovascular stent-graft placement for acute complicated type B aortic dissection. RECENT FINDINGS: The optimal treatment for patients with dissections confined to the descending aorta (Stanford type B-AD) remains a matter of debate. Usually, antihypertensive medical therapy with strict blood pressure lowering below 135/80 mm Hg represents the first choice for patients with uncomplicated type B-AD. Patients with acute complicated type B-AD remain a major therapeutic challenge because surgery of the descending aorta is still associated with high morbidity and mortality. In 1999, endovascular stent-graft placement was introduced as a novel, less invasive treatment option for patients with type B aortic dissection. Current indications include acute (contained) aortic rupture, symptomatic ischemic branch vessel involvement, early aortic expansion, or unrelenting pain. So far, few studies on stent-graft placement in patients with acute complicated aortic dissection have been published reporting an early mortality between 0 and approximately 20%. SUMMARY: To date, there is limited experience with endovascular stent-graft placement for acute complicated type B aortic dissection demonstrating its feasibility and life-saving potential. The endovascular approach can avoid the major trauma of open surgery and should help to get patients out of the acute life-threatening phase of the disease; however, long-term results are needed to assess the durability of this treatment.

Aged↗