Effect of LDL apheresis on oxygen tension in skeletal muscle in patients with cardiac allograft vasculopathy and severe lipid disorder

In this study, the extent to which intramuscular pO2 is influenced by a single HELP-apheresis (Heparin-induced Extracorporeal LDL Precipitation) was investigated in 10 patients with cardiac allograft vasculopathy (CAV) and severe lipid disorder. For this purpose, a sterile flexible pO2 microcatheter was inserted into the anterior tibial muscle and pO2 monitoring was begun 10 minutes before starting apheresis treatment. The intramuscular pO2 values were recorded continuously until the end of apheresis treatment and a subsequent 30-minute further observation phase. The patients with CAV and severe lipid disorder presented with 11.6+/-3.8 mmHg significantly and pathologically reduced intramuscular pO2 (p<0.001). LDL apheresis resulted in a significant increase in pO2 in the anterior tibial muscle. Thirty minutes after the end of HELP-apheresis, intramuscular partial oxygen pressure had increased by 162% and showed values at this point, 30.3+/-9.8 mmHg, similar to those found in healthy subjects.

Chirurgische Therapie nach traumatischen interventionellen Koronarl�sionen

Coronary perforation and entrapment of catheter materials are rare, but life-threatening complications, which often require emergency cardiosurgical treatment. Surgical options include tamponade drainage, coronary artery bypass grafting, perforation suturing, and removal of catheter materials. Surgical strategies are not standardized but mainly depend on the surgical anatomy. This is in particular true for the removal of the catheter remnants (stent, guidewire). Keeping this in mind, these patients can be treated with good clinical results.

Influence of radiographic contrast media on myocardial tissue oxygen tension: NaCl-controlled, randomised, comparative study of iohexol versus iopromide in an animal model

It was tested whether a bolus injection of 10 ml radiographic contrast medium (iopromide vs. iohexol), compared to a 10 ml NaCl bolus and administered into the left anterior descending artery (LAD) of farm pigs, influenced the tissue pO2 in the territory of this artery. The radiographic contrast media and the NaCl bolus were given in randomised order. The mean pO2 LAD fell from initially 40.3+/-10.9 mmHg to a minimal value of 22.5+/-8.9 mmHg 241+/-44 sec after injecting the iopromide bolus, with this result representing a mean decrease of 44.2% (p=0.0003). The initial pO2 (baseline) was reached again after approximately 10 minutes. The mean pO2 LAD fell from the initial value of 34.5+/-14.6 mmHg to a minimal value of 29.4+/-13.9 mmHg 171.7+/-11.9 sec after injection of the iohexol bolus, with this result representing a mean decrease of 14.8% (p=0.0003). The baseline pO2 was reached again after approx. 5 minutes. The drop in the pO2 after iopromide administration was significantly larger than that after iohexol (p=0.0001), and also the time after which the baseline pO2 is reached again was considerably shorter for iohexol (p=0.001). The two radiographic contrast media did not influence the tissue pO2 in either the territory of the right coronary artery or in skeletal muscle. Injection of a NaCl bolus into the LAD influenced neither the tissue pO2 of the territory of the LAD nor that of the RCA or of the skeletal muscle. The tissue temperature, heart rate and the systolic and diastolic blood pressure were not affected during the three injections. Injection of radiographic contrast media into a coronary artery can lead to a distinct, local microcirculatory impairment in the myocardial territory supplied by this artery. In this case, the extent of the microcirculation impairment seems to depend not only on the viscosity of the contrast media but rather also on its chemotoxicity.

Coronary artery bypass grafting supported with intracardiac microaxial pumps versus normothermic cardiopulmonary bypass: a prospective randomized trial

OBJECTIVE

To analyze the difference in coronary artery bypass grafting (CABG) performed with normothermic cardiopulmonary bypass (CPB) and CABG supported with the intracardiac microaxial pump (ICP, Impella, Aachen, Germany).

METHODS

A prospective randomized study was conducted in seven centers. The study population consists of 199 patients undergoing isolated primary CABG (CPB group 94 patients, ICP group 105 patients). Both groups are equal in demographic variables, number of bypasses performed, and Euroscore predicted mortality. We analyzed clinical outcome, myocardial enzymes and blood parameters of hemolysis, organ function and inflammatory response.

RESULTS

Seventeen patients (16%), randomized in the ICP group, were switched to the CPB group. This was due to the inability to position the right side catheter adequately (n=8), to a pump failure (n=1) or to the perioperative decision that beating heart surgery is technically not possible (n=8). There was no significant difference between the two study arms regarding the pump assistance time (CPB 67.1+/-22.9 min; ICP 67.7+/-30.3 min; P=0.88861), the number of grafts (CPB 2.4+/-0.7; ICP 2.3+/-0.8) and the number of grafts to the back wall (CFX; both groups n=37). There is no significant difference in clinical outcome, evolution of myocardial enzymes, indices of organ function and hemolysis. There is a reduced inflammatory response in the ICP group as indicated in the postoperative release of granulocyte elastase (CPB 259+/-195; ICP 150+/-126 microg/l; P<0.00001) and complement C3 (CPB 0.73+/-0.2; ICP 0.65+/-0.2g/l; P=0.008).

CONCLUSION

The intracardiac pump for the right heart is difficult to introduce. As a consequence the right side pump underwent design modifications. There were no differences in clinical outcome between both groups. The inflammatory response is significantly reduced in the ICP group.

[Space occupying lesion of unknown origin in the pulmonary trunk: targeted differential diagnosis and surgical therapy in a patient with B symptoms and thoracic pain]

Leiomyosarcomas are only rarely found in routine cardiac surgery. For the patient they hold, however, a very high-risk potential as only an early diagnosis, and immediate surgical therapy leads to long-term survival. Awareness, timely diagnosis, and immediate radical surgical therapy is imperative. This report describes the case of a 21-year old male with a strong suspicion of leiomyosarcoma of the pulmonary artery. Due to his clinical symptoms, the patient was transferred to operation immediately after completion of all diagnostic measurements. Postoperatively the diagnosis of a leiomyosarcoma proved to be false; instead a rare fibro-histologic tumor was found. Even in the case of a suspected leiomyosarcoma, rapid and radical surgical therapy is imperative due to the poor prognosis of leiomyosarcoma.

Development of robotic enhanced endoscopic surgery for the treatment of coronary artery disease

BACKGROUND

The introduction of robotic enhanced surgery demanded stepwise development of performed procedures on the basis of growing experience of the operating team.

METHODS AND RESULTS

Between May 1999 and January 2001, this new wrist-enhanced instrumentation was used in 201 patients (156 men and 45 women, median age 64+/-10.5 years, left ventricular ejection fraction 68+/-12.4%). During the development of robotic enhanced CABG, the patients were divided into 3 groups. Group A (n=156) consisted of patients in whom the robotic system was used to harvesting the left or right internal mammary artery, or both, whereas the anastomoses were performed directly through a small chest incision. In group B (n=37), the harvest of the internal mammary arteries and the coronary anastomoses were performed totally endoscopically. In a third early group C, patient (n=8) were treated with robotic enhanced CABG via a median sternotomy already preoperatively planned, whereas gradual step-by-step application of robotic instrumentation and its feasibility were assessed. The survival rate was 99.4%. One patient (0.6%) died due to pneumonia on postoperative day 16. Conversion rate to median sternotomy was 5%. The left and right internal mammary artery conduits could be successfully harvested in 98% and 100%, respectively. The time of dissection of the left internal mammary artery could be significantly reduced alone by increasing experience. All patients were discharged from the hospital after a mean of 7 days. In 9 patients (4.5%), bleeding required reexploration.

CONCLUSIONS

The introduction of this new surgical tool enables the development of new endoscopic procedures. Our results gained during the development of robotic enhanced CABG motivate us to establish a set standard for the totally endoscopic treatment of patients with 1-vessel coronary artery disease.

[Symptomatic coronary patient with pathological coronary angiogram requiring surgery]

Bypass surgery has become a routine procedure for the treatment of coronary artery disease. Due to increase numbers of high-risk patients minimally invasive techniques were introduced in cardiac surgery with excellent clinical results. In addition molecular methods have been applied for primary and secondary treatment of coronary artery disease.

Wrist-enhanced instrumentation: moving toward totally endoscopic coronary artery bypass grafting

BACKGROUND

With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac operations the outlook for performing coronary artery bypass operations "closed chest" became a reality.

METHODS

Between May 1999 and December 1999 this new wrist-enhanced instrumentation was used in 61 patients. Six patients suffering from single-vessel coronary artery disease and one female patient with double-vessel disease underwent totally endoscopic coronary artery bypass. Thirty-seven patients with single-vessel disease underwent a minimally invasive direct coronary artery bypass procedure. Seventeen patients with double-vessel disease were treated using the robotic-enhanced Dresden technique.

RESULTS

Perioperative survival was 100%. In all patients the internal mammary arteries were safely harvested endoscopically and had excellent quality. In both totally endoscopic coronary artery bypass groups all patients were operated on through three stab incisions.

CONCLUSIONS

Our preliminary experience with this new surgical technique using robotic-enhanced minimally invasive methods for coronary artery disease promotes optimism regarding further development of these procedures and application in patients with coronary artery disease.

Robotic coronary artery surgery--the evolution of a new minimally invasive approach in coronary artery surgery

BACKGROUND

With the introduction of a wrist-enhanced robotic surgical system into minimally invasive cardiac surgery, the outlook of performing closed chest coronary artery bypass operations became a reality.

METHODS

Since May, 1999, this new wrist-enhanced instrumentation has been used in 109 (79 male, 30 female, median age 63 +/- 9.9 years) patients. Seven suffering from single vessel coronary artery disease (SVD) and double vessel disease (DVD) were treated as totally endoscopic coronary artery bypass (TECAB). 60 with SVD underwent a wrist-enhanced, minimally invasive direct coronary artery bypass procedure. 25 with DVD were treated using the robotically enhanced Dresden Technique coronary artery bypass.

RESULTS

Survival was 100%. In all patients the IMAs were safely harvested totally endoscopically. In the TECAB group, all patients were operated via a three-point stab incision. Data were observed during and after the operation.

CONCLUSIONS

Our preliminary experiences with this new surgical technique for the robotically enhanced, minimally invasive treatment of coronary artery disease promote an optimistic way of thinking about the further development of these procedures.

Three-year follow-up after port-access mitral valve surgery

INTRODUCTION

After the promising early results with Port-Access mitral valve (MV) surgery, the mid-term results were evaluated.

METHODS

Among 31 patients receiving this surgery, there were two subgroups (A and B). The 14 patients in group A (7 men, 7 women, 64.0 +/- 12.8 years, LVEF 0.62 +/- 0.118) received the procedure exactly as proposed by Heartport. The 17 patients in group B (6 men, 11 women, 63.0 +/- 11.48 years, LVEF 0.61 +/- 0.117) received a modified technique for a less complex procedure. The underlying diseases were MV insufficiency (n = 14), MV stenosis (n = 9), and combined MV disease (n = 8). One female patient had a partial atrial ventricular canal.

RESULTS

Perioperative mortality was 3.2%. Survival at 39.0 +/- 6.3 months (median +/- SEM) was 93.5%. Two patients required intraoperative inotropic and mechanical support (intra-aortic balloon pump [IABP]). One of these two patients died on postoperative day 3 due to low cardiac output syndrome. All ther patients survived the procedure. Twenty-four patients underwent MV replacement, 7 patients received MV repair, and 1 patient received, in addition, ASD repair. In group B, operative time, ICU stay, and hospitalization was shorter.

CONCLUSIONS

Good early results after Port-Access MV surgery were confirmed by equal mid-term results. The patients are satisfied with the surgical and the cosmetic results, however, Port-Access MV surgery still has to prove superior outcome compared to conventional MV surgery. In selected cases a true reduction of the surgical trauma is possible.

Coronary artery bypass grafting via median sternotomy or lateral minithoracotomy

OBJECTIVES

In order to evaluate the benefit provided through less invasive surgical techniques for the treatment of multivessel coronary artery disease, a prospective clinical trial was started.

METHODS

Group 1 included 53 patients (38 males, 15 females, age 51-79 years, mean 62.8 +/- 6.1 years) receiving conventional bypass surgery, group 2 included 69 patients (59 male, 10 female, age 43-82 years, mean 61.9 +/- 8.6 years) receiving less invasive surgical procedure including minithoracotomy in combination with cardiopulmonary bypass.

RESULTS

No perioperative death occurred in the whole series of patients. Time of operation was 267 +/- 61 min in group 2 and 162.9 +/- 53.6 min in group 1. Intensive Care Unit stay was 1 day for both groups and Hospitalization 6.9 +/- 6.0 for group 1 and 7.5 +/- 2.6 days for group 2. Perioperative bleeding was less in group 2 (P > 0.01). Back and chest pain assessment on postoperative day 3 showed less pain in group 2 (P < 0.05). Three-month follow-up revealed ischemia in stress electrocardiogram in two patients (3.8%) in group 1 and in 2 patients (2.9%) in group 2. Coronary angiograms confirmed the stress ECG findings. There was one (1.4%) redo operation in group 2 and two (3.8%) in group 1.

CONCLUSIONS

Both techniques are equal efficient. Even though time of operation is longer in patients receiving less invasive procedure, intensive care unit stay and hospitalization is exactly as long. Patients receiving minimally invasive surgery bleed less and have less pain early postoperatively.

[Flow cytometry controlled induction therapy with ATG and noninvasive monitoring of rejection--a modern management concept after heart transplantation]

We introduce our concept of non-invasive transplant monitoring. The introduction of individualized immunosuppression by means of flow cytometry leads to a lower incidence of acute graft rejection and preserves immuncompetence. With the simultaneous use of echocardiography and intramyocardial electrogram (IMEG) acute graft rejections can be safely identified without using any invasive method.

Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients

OBJECTIVE

The treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique.

METHODS

Using this technique 100 patients (80 male, 20 female, median age 61.0+/-8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6-9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia.

RESULTS

No death or intraoperative complications were observed in this series. The median hospital stay was 6.0+/-1.4 days (median+/-SEM). Postoperative complications were reexplored for bleeding (n = 1), delayed wound healing (n = 2), wound infections (n = 4), lymphatic fistulas (n = 4), and a chest wall hernia (n = 1).

CONCLUSIONS

This minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.

Minimally invasive surgical treatment of coronary artery multivessel disease

BACKGROUND

If coronary artery multivessel disease is the target of a minimally invasive procedure, either median sternotomy or cardiopulmonary bypass can be avoided.

METHODS

We used an alternate technique instead of minithoracotomy and cardiopulmonary bypass to treat 102 patients (82 men, 20 women; age range, 39 to 82 years; median, 61.0 +/- 8.9 years) for coronary artery single-vessel, double-vessel, or multivessel disease between November 1996 and January 1998. Twenty-nine patients (22 men, 7 women; age range, 46 to 78 years; median, 69.0 +/- 8.4 years), who were in a high-risk group for the development of perioperative complications because of the use of cardiopulmonary bypass, received median sternotomy and a beating heart procedure using the Octopus stabilizing technique. The left anterior descending coronary artery was the target vessel in all patients except for 1, in whom the left internal mammary artery was used.

RESULTS

There was no intraoperative death in either series. In the beating heart group (Octopus) 2 patients died on postoperative day 31 and 35, respectively, of postoperative pneumonia.

CONCLUSIONS

Both techniques present safe alternative procedures to conventional coronary artery bypass grafting in patients with coronary artery multivessel disease.

Coronary artery disease in patients with hearts from older donors: morphologic features and therapeutic implications

Of 558 heart transplant recipients, 234 long-term survivors (more than 12 months) were studied by annual catheterization to evaluate the risk of postoperative coronary artery disease in hearts from older donors. No significant difference was found in graft function between hearts from younger and older donors (group I: n = 157, mean donor age 23 +/- 5 years, mean follow-up 45 +/- 22 months; group II: n = 77, mean donor age 43 +/- 5 years, mean follow-up 42 +/- 22 months) as indicated by left and right ventricular ejection fraction, pulmonary artery pressure, and pulmonary capillary wedge pressure. Two morphologic patterns of coronary artery disease were observed: a diffuse type of concentric narrowing of the arteries (type 1) and a focal type with proximal single-vessel stenosis (type 2). Type 1 occurred in eight patients (5%) in group I and in four patients in group II (5%) (p = not significant). Type 1 coronary artery disease led to graft failure in seven patients in group I and two patients in group II. Type 2 coronary artery disease occurred in seven patients (4%) in group I and in 14 (18%) in group II (p < 0.001). No death was related to graft failure in patients with type 2 coronary artery disease. Eight patients with type 2 coronary artery disease were successfully treated by percutaneous transluminal coronary angioplasty; one patient underwent coronary artery bypass grafting. Hearts from older donors provide normal graft function. The risk of diffuse coronary artery disease is not elevated in comparison to hearts from younger donors. The higher incidence of focal coronary artery disease suggests donor-transmitted disease that can successfully be treated by conventional therapy.