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Jückstock J, Rothenburger M, Friese K, Traunmüller F. Passive Immunization against Congenital Cytomegalovirus Infection: Current State of Knowledge. Pharmacology 2015; 95:209-17. [PMID: 25924667 DOI: 10.1159/000381626] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/09/2015] [Indexed: 11/19/2022]
Abstract
Primary infection with the human cytomegalovirus (CMV) occurs in 1-4% of pregnancies. The rates of maternal-fetal CMV transmissions are around 25, 36, 41, and 66%, for infections occurring in the peri-conceptional weeks, first, second, and third trimester of pregnancy, respectively. On the other hand, the severity of fetal organ damage and dysfunction diminishes with increasing gestational age. Congenitally CMV-infected newborns may have neurosensory impairments like mental retardation, cerebral palsy, epilepsy, progressive hearing loss or visual defects, or even may have a fatal outcome. In in-vitro experiments, CMV specific neutralizing IgG antibodies - which are abundant in CMV specific hyperimmune globulin (HIG) products - inhibited the entry of the virus into target cells and hampered viral cell-to-cell spread. This article provides a brief overview on the epidemiology and diagnostic tools in congenital CMV infection. It also concisely summarizes the currently available study results on the safety and effectiveness of HIG treatment. Accordingly, in clinical studies HIG administration to expectant mothers following primary CMV infection (prophylactic use) was shown to lower the risk of maternal-fetal transmission of CMV compared to untreated controls. HIG was also able to ameliorate the disease sequelae in evidently infected fetuses (therapeutic use), as demonstrated by the regression or even resolution of sonographic pathologies including placental inflammation.
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Affiliation(s)
- Julia Jückstock
- Department of Gynecology and Obstetrics I, Ludwig-Maximilians-University, Munich, Germany
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Topp H, Hochfeld O, Bark S, Grossmann M, Joukhadar C, Westphal M, Straatsma H, Rothenburger M. Glycerophosphate is interchangeable with inorganic phosphate in terms of safety and serum pharmacokinetics. Pharmacology 2011; 88:193-200. [PMID: 21986180 DOI: 10.1159/000331341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 07/14/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The primary aim of the present investigation was to determine and compare the pharmacokinetic (PK) profiles of inorganic phosphate in serum and urine after intravenous administration of sodium glycerophosphate and inorganic sodium phosphate. Additionally, study product safety profiles were evaluated. SUBJECTS AND METHODS In total, 27 healthy, white volunteers (17 male/10 female) were enrolled in this double-blinded, randomized, 2-sequence, crossover study and were assigned to receive an organic test drug (sodium glycerophosphate) and an inorganic reference preparation (sodium phosphate) on 2 occasions. Validated analytical methods were used, and concentrations of total inorganic phosphate in serum and urine were determined over 24 h following a single 4-hour continuous intravenous infusion of test and reference drugs at a dose of 80 mmol. Study days were separated by washout periods of 7 days. An analysis of variance, based on population means and 90% confidence intervals (CIs), was used for testing bioequivalence (BE; range 0.8-1.25) between investigational products. RESULTS The geometric means of the ratio of the point estimates and corresponding 90% CIs for the area under the concentration-versus-time curve of inorganic serum phosphate from 0 to 24 h (AUC(0-24)), the phosphate's maximum concentration in serum (C(max)) and the total amount of inorganic phosphate excreted in urine over 24 h corrected for individual baseline values (Ae(0-24 bc)) were estimated. The test/reference ratios for inorganic phosphate were 1.04 (CI 1.00-1.07), 0.85 (CI 0.84-0.87) and 0.84 (CI 0.77-0.92) for AUC(0-24), C(max) in serum and Ae(0-24 bc) in urine, respectively. Hence, standard BE criteria were met for AUC(0-24) and C(max) in serum, while Ae(0-24 bc) marginally failed to demonstrate BE. After drug administration, a total of 15 subjects reported the occurrence of at least 1 treatment emergent adverse event (AE). All AEs were classified as mild to moderate in severity, and the two treatment groups were equally affected. No serious AEs occurred. CONCLUSION The serum PK profiles of inorganic phosphate were almost superimposable following intravenous administration of equimolar doses of test and reference drugs. Thus, we conclude that the two study drugs are essentially similar in terms of serum PK profiles, safety and tolerability.
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Topp H, Hochfeld O, Bark S, Grossmann M, Joukhadar C, Westphal M, Straatsma H, Rothenburger M. Glycerophosphate Does Not Interact with Components of Parenteral Nutrition. Pharmacology 2011; 88:114-20. [DOI: 10.1159/000330066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 05/18/2011] [Indexed: 11/19/2022]
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Stypmann J, Engelen MA, Troatz C, Rothenburger M, Eckardt L, Tiemann K. Echocardiographic assessment of global left ventricular function in mice. Lab Anim 2009; 43:127-37. [DOI: 10.1258/la.2007.06001e] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Doppler-echocardiographic assessment of cardiovascular structure and function in murine models has developed into one of the most commonly used non-invasive techniques during the last decades. Recent technical improvements even expanded the possibilities. In this review, we summarize the current options to assess global left ventricular (LV) function in mice using echocardiographic techniques. In detail, standard techniques as structural and functional assessment of the cardiovascular phenotype using one-dimensional M-mode echocardiography, two-dimensional B-mode echocardiography and spectral Doppler signals from mitral inflow respective aortal outflow are presented. Further pros and contras of recently implemented techniques as three-dimensional echocardiography and strain and strain rate measurements are discussed. Deduced measures of LV function as the myocardial performance index according to Tei, estimation of the mean velocity of circumferential fibre shortening, LV wall stress and different algorithms to estimate the LV mass are described in detail. Last but not least, specific features and limitations of murine echocardiography are presented. Future perspectives in respect to new examination techniques like targeted molecular imaging with advanced ultrasound contrast bubbles or improvement of equipment like new generation matrix transducers for murine echocardiography are discussed.
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Affiliation(s)
- Jörg Stypmann
- Department of Cardiology and Angiology, Hospital of the University of Münster, Albert-Schweitzer-Str. 33, D-48149 Münster, Germany
- Interdisciplinary Centre for Clinical Research, Central Project Group (ZPG 4a), Westfälische Wilhelms Universität, Münster, Germany
- Collaborative Research Centre (SFB) 656, Project C3, Münster, Germany
| | - Markus A Engelen
- Department of Cardiology and Angiology, Hospital of the University of Münster, Albert-Schweitzer-Str. 33, D-48149 Münster, Germany
- University Medical Center Utrecht, Department of Medical Physiology, Utrecht, The Netherlands
| | - Clemens Troatz
- Collaborative Research Centre (SFB) 656, Project C3, Münster, Germany
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, University of Bonn, Bonn, Germany
| | - Markus Rothenburger
- Department of Thoracic and Cardiovascular Surgery, University Hospital, Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology and Angiology, Hospital of the University of Münster, Albert-Schweitzer-Str. 33, D-48149 Münster, Germany
| | - Klaus Tiemann
- Collaborative Research Centre (SFB) 656, Project C3, Münster, Germany
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, University of Bonn, Bonn, Germany
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Lehmkuhl H, Hummel M, Kobashigawa J, Ladenburger S, Rothenburger M, Sack F, Dengler T, Hetzer R. Enteric-Coated Mycophenolate-Sodium in Heart Transplantation: Efficacy, Safety, and Pharmacokinetic Compared With Mycophenolate Mofetil. Transplant Proc 2008; 40:953-5. [DOI: 10.1016/j.transproceed.2008.03.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sauermann R, Rothenburger M, Graninger W, Joukhadar C. Daptomycin: A Review 4 Years after First Approval. Pharmacology 2007; 81:79-91. [DOI: 10.1159/000109868] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 06/11/2007] [Indexed: 01/27/2023]
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Thallinger C, Rothenburger M, Marsik C, Wuenscher S, Popovic M, Endler G, Wagner O, Joukhadar C. Daptomycin does not exert immunomodulatory effects in an experimental endotoxin model of human whole blood. Pharmacology 2007; 81:57-62. [PMID: 17851272 DOI: 10.1159/000108106] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 06/11/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent studies have shown that distinct classes of antimicrobial agents might exert immunomodulatory effects in experimental settings. Daptomycin is the first member of the class of cyclic lipopeptide antibiotics, which exert their antimicrobial activity via a unique mode of action on the bacterial cytoplasmic membrane. Thus, we tested its ability to influence pro-inflammatory cytokines by use of an established experimental model of human endotoxemia. METHODS A controlled experimental study design with 4 parallel groups was used. Whole blood from 10 healthy male volunteers was incubated either with saline (negative control), daptomycin (40 microg/ml, control), lipopolysaccharide (LPS; 50 pg/ml, positive control), or the combination of daptomycin plus LPS for 4 h. Real-time polymerase chain reaction was utilized for the measurement of selected pro-inflammatory cytokines, namely IL-1 beta, IL-6 (high sensitivity) and TNF-alpha on the mRNA level. Protein concentrations of these respective cytokines were measured in the supernatant using a commercially available ELISA. RESULTS Incubation of whole blood with LPS significantly increased protein and mRNA levels of cytokines compared to baseline (p < 0.05). However, the combination of daptomycin plus LPS did not exert any significant effect on mRNA and protein levels of IL-1 beta, IL-6 (high sensitivity) and TNF-alpha after 2 and 4 h of incubation compared to LPS incubation alone. CONCLUSION Daptomycin does not affect pro-inflammatory cytokines in the early phase of endotoxemia. This is most likely due to the unique mode of action of daptomycin, its low potential to penetrate into human cells and its high affinity to bacterial cytoplasmic membranes.
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Affiliation(s)
- Christiane Thallinger
- Division of Clinical Pharmacokinetics, Department of Clinical Pharmacology, University of Vienna, Vienna, Austria
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Stypmann J, Engelen MA, Orwat S, Bilbilis K, Rothenburger M, Eckardt L, Haverkamp W, Horst J, Dworniczak B, Pennekamp P. Cardiovascular characterization of Pkd2+/LacZ mice, an animal model for the autosomal dominant polycystic kidney disease type 2 (ADPKD2). Int J Cardiol 2007; 120:158-66. [PMID: 17182135 DOI: 10.1016/j.ijcard.2006.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 08/27/2006] [Accepted: 09/20/2006] [Indexed: 01/15/2023]
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is caused by mutations in PKD1 or PKD2. Patients with ADPKD have an increased incidence of cardiac valve abnormalities and left ventricular hypertrophy. Systematic analyses of cardiovascular involvement have so far been performed only on genetically unclassified patients or on ADPKD1 patients, but not on genetically defined ADPKD2 patients. Even existing Pkd1 or Pkd2 mouse models were not thoroughly analyzed in this respect. Therefore, the aim of this project was the noninvasive functional cardiovascular characterization of a mouse model for ADPKD2. METHODS Pkd2(+/LacZ) mice and wildtype controls were classified into 8 groups with respect to gender, age and genotype. In addition, two subgroups of female mice were analyzed for cardiac function before and during advanced pregnancy. Doppler-echocardiographic as well as histological studies were performed. RESULTS Doppler-echocardiography did not reveal significant cardiovascular changes. Heart rate and left ventricular (LV) length, LV mass, LV enddiastolic and LV endsystolic diameters did not differ significantly among the various groups when comparing wildtype and knockout mice. There were no significant differences except for a tendency towards higher maximal early and late flow velocities over the mitral valve in old wildtype mice. CONCLUSIONS Non-invasive phenotyping using ultrasound did not reveal significant cardiovascular difference between adult Pkd2(+/LacZ) and WT mice. Due to the lack of an obvious renal phenotype in heterozygous mice, it is likely that in conventional ADPKD knock out mouse models severe cardiac problems appear too late to be identified during the reduced lifespan of the animals.
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Affiliation(s)
- Jörg Stypmann
- Department of Cardiology and Angiology, Hospital of the University of Münster, Germany
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Bruch C, Reinecke H, Rothenburger M, Scheld HH, Whalley GA, Stypmann J, Breithardt G, Wichter T, Gradaus R. Transmitral Flow Patterns and the Presence of Chronic Kidney Disease Provide Independent and Incremental Prognostic Information in Patients with Heart Failure and Systolic Dysfunction. J Am Soc Echocardiogr 2007; 20:989-97. [DOI: 10.1016/j.echo.2007.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Indexed: 11/30/2022]
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Lehmkuhl HB, Mai D, Dandel M, Knosalla C, Hiemann NE, Grauhan O, Huebler M, Pasic M, Weng Y, Meyer R, Rothenburger M, Hummel M, Hetzer R. Observational Study With Everolimus (Certican) in Combination With Low-dose Cyclosporine in De Novo Heart Transplant Recipients. J Heart Lung Transplant 2007; 26:700-4. [PMID: 17613400 DOI: 10.1016/j.healun.2007.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 12/21/2006] [Accepted: 02/03/2007] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/METHODS This observational study reports on immunosuppression with cyclosporine (CsA) in 38 de novo heart transplant recipients receiving everolimus compared with 14 patients receiving mycophenolate mofetil (MMF). RESULTS Mean (+/- SD) everolimus C0 blood levels remained stable within 5 to 7 ng/ml. Mean CsA C0 blood levels were reduced by 47%, from 240 +/- 57 ng/ml at 2 weeks post-transplant to 128 +/- 38 ng/ml at Month 6 and by 58% to 101 +/- 26 ng/ml at Month 12 in the everolimus group, compared to 18% from 246 +/- 54 ng/ml at 2 weeks post-transplant to 201 +/- 48 ng/ml at Month 6 and by 35% to 160 +/- 41 ng/ml in MMF patients. Efficacy was high with a rejection rate of 23.6% (everolimus) vs 28.5% (MMF) by Month 12. Mean pre-transplant serum creatinine levels of 1.67 +/- 0.59 mg/dl decreased to 1.53 +/- 0.57 mg/dl under everolimus and increased from 1.22 +/- 0.36 to 1.99 +/- 0.75 mg/dl in the MMF group by Month 12 post-transplant. However, calculated GFR declined in both groups by Month 12 (everolimus: from 71 +/- 29 to 57 +/- 27 ml/min/1.73 m2; MMF: from 73 +/- 22 to 44 +/- 24 ml/min/1.73 m2), with stabilization after 3 to 6 months in everolimus-treated patients and after 6 to 9 months in MMF-treated patients. CONCLUSIONS Everolimus allows marked reduction of CsA exposure without significant loss of efficacy and also provides early protection of renal function.
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Affiliation(s)
- Hans B Lehmkuhl
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
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Hülsken G, Rothenburger M, Etz C, Löher A, Schmid C, Scheld HH. Telematics in Medicine: A Network Infrastructure to Optimize Processes in Cardiology and Heart Surgery. Thorac Cardiovasc Surg 2007; 55:264-7. [PMID: 17546561 DOI: 10.1055/s-2006-924698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES During the past 2 decades, cardiac surgery has developed into a high-tech field. Increasing numbers of urgent surgical procedures mean that the time interval from diagnosis to surgical treatment must become ever shorter. Optimizing inconvenient and slow processes such as postal correspondence by using internet services is therefore mandatory in current cardiosurgical practice, and this includes the electronic transfer of patient data and diagnostic imaging material [12]. This study focuses on the internet connection of several cardiac referral centers to a cardiosurgical institution. METHODS Eleven cath lab centers were connected to a cardiosurgical center by internet. Auser program was especially developed to optimize connecting processes with the department. Data conversion was based on HL7 codes and angiograms were based on CD-ROM mediums and the DICOM standard. An online registration based on the HL7 communications standard was provided. RESULTS All cath lab centers were successfully connected to the cardiosurgical institution. Angiography data were transmitted within 30 +/- 15minutes. The time interval from diagnosis to decision for surgery decreased from 36 +/- 13 hours to 1 +/- 0.5 hours (p = 0.01). Urgent or emergent surgery could be provided after 18 +/- 19 hours, compared to 56 +/- 35 hours before (p = 0.02). CONCLUSION Special programs transmitting data via the internet significantly reduces the time interval from diagnosis to surgical treatment. Standardizing data transmitting processes from referral centers markedly optimizes cardiological and cardiosurgical treatments and could thereby improve survival rates and reduce costs.
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Affiliation(s)
- G Hülsken
- Department of Thoracic and Cardiocascular Surgery, University Hospital Muenster, Muenster, Germany.
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Rothenburger M, Zuckermann A, Bara C, Hummel M, Strüber M, Hirt S, Lehmkuhl H. Recommendations for the use of everolimus (Certican) in heart transplantation: results from the second German-Austrian Certican Consensus Conference. J Heart Lung Transplant 2007; 26:305-11. [PMID: 17403469 DOI: 10.1016/j.healun.2007.01.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Revised: 11/08/2006] [Accepted: 01/07/2007] [Indexed: 01/10/2023] Open
Abstract
Everolimus (Certican; Novartis Pharma AG, Basel, Switzerland) represents the latest generation of proliferation signal inhibitors (PSIs). Everolimus is indicated for use as an immunosuppressive drug in renal and heart transplantation. This report reflects the recommendations of the second German-Austrian Certican Consensus Conference, held in January 2006, for the clinical use of everolimus.
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Affiliation(s)
- Markus Rothenburger
- Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Muenster, Germany.
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Rothenburger M, Teerling E, Bruch C, Lehmkuhl H, Suwelack B, Bara C, Wichter T, Hinder F, Schmid C, Stypmann J. Calcineurin inhibitor-free immunosuppression using everolimus (Certican) in maintenance heart transplant recipients: 6 months' follow-up. J Heart Lung Transplant 2007; 26:250-7. [PMID: 17346627 DOI: 10.1016/j.healun.2007.01.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 11/09/2006] [Accepted: 01/08/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Everolimus is a proliferation signal-inhibitor recently introduced in heart transplant recipients. To date, little is known about calcineurin inhibitor (CNI)-free immunosuppression using everolimus. This study reports the results of CNI-free immunosuppression using everolimus. METHODS During a continuous 9-month period, 60 heart transplant recipients were enrolled. Reasons for switching to everolimus were side effects associated with prior CNI immunosuppression. All patients underwent standardized switching protocols and completed 6 months of follow-up. Blood was obtained for lipid status, renal function, routine controls, and levels of immunosuppressive agents. Echocardiography and a physical examination were performed on Days 0, 14, 28, and then every 3 months. RESULTS After switching to everolimus, most patients recovered from the side effects associated with CNIs. Renal function improved significantly after 6 months (creatinine, 2.1 +/- 0.6 vs 1.5 +/- 0.9 mg/dl, p = 0.001; creatinine clearance, 42.2 +/- 21.6 vs 61.8 +/- 23.4 ml/[min x 1.73 m2], p = 0.018). Arterial hypertension improved after 3 months and remained decreased during the observation period. Tremor, peripheral edema, hirsutism, and gingival hyperplasia markedly improved. Adverse events occurred in 8 patients (13.3%), including interstitial pneumonia (n = 2), skin disorders (n = 2), reactivated hepatitis B (n = 1), and fever of unknown origin (n = 3). CONCLUSION Preliminary data suggest that CNI-free immunosuppression using everolimus is safe, with excellent efficacy in maintenance heart transplant recipients. Arterial hypertension and renal function improved significantly. CNI-induced side effects such as tremor, peripheral edema, hirsutism, and gingival hyperplasia markedly improved in most patients.
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Affiliation(s)
- Markus Rothenburger
- Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Berlin, Germany.
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Bruch C, Kauling D, Reinecke H, Rothenburger M, Scheld HH, Breithardt G, Wichter T. Prevalence and prognostic impact of comorbidities in patients with severe aortic valve stenosis. Clin Res Cardiol 2006; 96:23-9. [PMID: 17066348 DOI: 10.1007/s00392-006-0452-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 08/28/2006] [Indexed: 11/25/2022]
Abstract
In patients with severe aortic valve stenosis (valve area <or= 1 cm(2), AS), the prevalence and the prognostic impact of comorbidities is unknown. Fifty-eight patients with severe AS (mean aortic valve area 0.8 +/- 0.2 cm(2)), who underwent cardiac catheterization and 2-D/Doppler echocardiography, were prospectively enrolled. The glomerular filtration rate (eGFR) was estimated using the abbreviated Modification of Diet in Renal Disease Study equation. Death from a cardiac cause was defined as study end point. Coronary artery disease was present in 33 patients (57%). Subsequently, 43 patients (77%) underwent aortic valve replacement. During a follow-up of 485 +/- 336 days, 11 patients suffered a cardiac death. Survivors and non-survivors did not differ with respect the prevalence of coronary artery disease, invasive hemodynamic measurements or echocardiographic variables of systolic/diastolic function. Non-survivors were in a poorer NYHA functional class (3.2 +/- 0.3 vs 2.4+/-0.8, p = 0.002), had a lower eGFR (33.4 +/- 15.5 ml/min/1.73 m(2) vs 49.1 +/- 15.6 ml/min/1.73m(2), p = 0.004), a higher prevalence of diabetes mellitus (73% vs. 22%, p = 0.0001) and a lower serum hemoglobin level (11.6 +/- 2.1 vs 13.0 +/- 1.5 g/dL, p = 0.017). By multivariate Cox analysis, NYHA class (hazard ratio: 6.17, p = 0.013) and eGFR (hazard ratio 0.95, p = 0.04) were independent prognostic predictors. In patients with eGFR < 41.8 ml/min/1.73 m(2) (cut-off value derived from ROC analysis, area under the curve: 0.78 +/- 0.08), outcome was markedly poorer as compared to patients with eGFR > 41.8 ml/min/1.73 m(2) (event-free survival rate of 38% vs 93%, p = 0.004). Thus, in patients with severe AS, comorbidities are frequent, and particularly kidney disease significantly impacts longterm outcome.
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Affiliation(s)
- Christian Bruch
- Universitätsklinikum Münster, Medizinische Klinik und Poliklinik C (Kardiologie und Angiologie), Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
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Bruch C, Reinecke H, Stypmann J, Rothenburger M, Schmid C, Breithardt G, Wichter T, Gradaus R. N-terminal pro-brain natriuretic peptide, kidney disease and outcome in patients with chronic heart failure. J Heart Lung Transplant 2006; 25:1135-41. [PMID: 16962477 DOI: 10.1016/j.healun.2006.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Revised: 04/30/2006] [Accepted: 05/15/2006] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In patients with chronic heart failure (CHF), N-terminal pro-brain natriuretic peptide (NT-proBNP) provides relevant prognostic information, but its usefulness in the presence of kidney disease has been questioned. METHODS We prospectively enrolled 142 patients with stable CHF and a wide spectrum of renal function (estimated glomerular filtration rates [eGFRs] ranging from 17.1 to 100.3 ml/min/1.73 m2). Chronic kidney disease, defined as eGFR < 60 ml/min/1.73 m2, was present in 63 patients (44%). NT-proBNP measurements were carried out on a bench-top analyzer (Elecsys 2010). Cardiac death or urgent cardiac transplantation were considered as a combined study end-point. RESULTS During a follow-up of 383 +/- 237 days, 19 patients underwent a cardiac event (cardiac death, n = 17; urgent cardiac transplantation, n = 2). By multivariate Cox analysis, including clinical and laboratory variables, NT-proBNP and serum hemoglobin were independent prognostic predictors. In patients with NT-proBNP > 1,129 pg/ml, outcome was significantly worse compared to patients with NT-proBNP < 1,129 pg/ml (event-free survival rate 67% vs 94% in those with NT-proBNP < 1,129 pg/ml, p = 0.001). By linear regression analysis, NT-proBNP levels were related to New York Heart Association (NYHA) functional class (R = 0.41, p < 0.001), and inversely related to eGFR (R = -0.29, p = 0.001) and to left ventricular ejection fraction (R = -0.43, p < 0.001). CONCLUSIONS In CHF patients with and without kidney disease, NT-proBNP provides independent prognostic information. In such patients, NT-proBNP levels are not only reflective of a reduced clearance (i.e., a lower eGFR) but also of the severity of the underlying structural heart disease.
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Affiliation(s)
- Christian Bruch
- Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany.
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Stypmann J, Engelen MA, Breithardt AK, Milberg P, Rothenburger M, Breithardt OA, Breithardt G, Eckardt L, Cordula PN. Doppler echocardiography and tissue Doppler imaging in the healthy rabbit: differences of cardiac function during awake and anaesthetised examination. Int J Cardiol 2006; 115:164-70. [PMID: 16806537 DOI: 10.1016/j.ijcard.2006.03.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Revised: 01/07/2006] [Accepted: 03/11/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In the past years, Doppler echocardiography has evolved into a commonly used technique. More recent sophisticated advances in imaging quality have substantially improved spatial and temporal resolution allowing the adaptation of this technique to small animal models, particularly in rabbits but even in mice. Recently, parameters obtained by Tissue Doppler Imaging (TDI) have been shown to be more independent of pre- and afterload than classic hemodynamic Doppler measurements. Exploration of animal models may require anaesthesia but there is only very little information on the effect of anaesthesia on echocardiographic parameters in rabbits. METHODS We therefore performed Doppler-echocardiographic examinations of 20 wild-type New Zealand White rabbits in awake state and under light ketamine-xylazine anaesthesia. Special focus was put on the evaluation of global and regional left ventricular systolic and diastolic function using TDI and the myocardial performance index (Tei-index). RESULTS Doppler-echocardiographic measurements including TDI in rabbits were feasible to assess cardiac morphology and function within a short examination time. There were some distinct changes of functional parameters during anaesthesia. Exemplary for systolic function, fractional shortening, cardiac output and systolic TDI velocity of the lateral wall decreased distinctly. Global left ventricular function measured by the Tei-index deteriorated. CONCLUSIONS Doppler echocardiography and TDI can be performed easily, quickly and safely in the rabbit. Anaesthesia with the cardiodepressive ketamine-xylazine shows some distinct Doppler-echocardiographically measurable negative effects on cardiac function. Thus, echocardiography with less cardiodepressive anaesthetic regimes or even without anaesthesia after training of the animals should be considered as alternatives whenever possible.
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Affiliation(s)
- Jörg Stypmann
- Department of Cardiology and Angiology, University Hospital Münster, Germany.
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Schmid C, Tjan TDT, Etz C, Schmidt C, Wenzelburger F, Wilhelm M, Rothenburger M, Drees G, Scheld HH. First clinical experience with the Incor left ventricular assist device. J Heart Lung Transplant 2006; 24:1188-94. [PMID: 16143232 DOI: 10.1016/j.healun.2004.08.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Revised: 08/26/2004] [Accepted: 08/31/2004] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Incor (Berlin Heart AG, Germany) is a small (200 g), implantable, magnetically accentuated axial flow pump (non-pulsatile flow) designed to support the left ventricle for extended periods of time. We report on the first single-center clinical experience with this device. METHODS The Incor was studied in 15 consecutive patients (10 men, 5 women), 24 to 59 years of age. Underlying heart disease was end-stage ischemic heart disease (n = 5), acute myocardial infarction (n = 4), dilated cardiomyopathy (n = 3), acute myocarditis (n = 2) and Chagas disease (n = 1). All patients were in New York Heart Association (NYHA) Class IV heart failure. Four patients had prior open heart surgery. Implantation via cannulation of the left ventricular apex and the ascending aorta was elective in 6 patients and on an emergency basis in 9. RESULTS No early bleeding complications were seen, but late bleeding occurred in 4 patients. Minor cerebral thromboembolic events with transient neurologic symptoms occurred in 3 patients; severe stroke had to be treated in 1 patient. Systemic emboli were seen in 2 patients. Thrombus-related pump dysfunction was suspected in 3 patients, and managed by intensifying anti-coagulation. Five patients were successfully transplanted after a support interval of 90 to 156 days; 1 patient could be weaned from the system after 171 days. Six patients died during support, 9 to 63 days after device implantation. The remaining 3 patients are still under support, with excellent quality of life. CONCLUSIONS The Incor is a left ventricular assist device (LVAD) with transplant and adverse event rates comparable to those of other modern ventricular support devices. Its advantages include the small pump chamber, the virtual absence of device-related infections, and the extraordinary convenience during implantation and explantation.
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Affiliation(s)
- Christof Schmid
- Department of Thoracic and Cardiovascular Surgery, University Hospital, Muenster, Germany.
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Bruch C, Rothenburger M, Gotzmann M, Sindermann J, Scheld HH, Breithardt G, Wichter T. Risk Stratification in Chronic Heart Failure: Independent and Incremental Prognostic Value of Echocardiography and Brain Natriuretic Peptide and its N-terminal Fragment. J Am Soc Echocardiogr 2006; 19:522-8. [PMID: 16644435 DOI: 10.1016/j.echo.2005.12.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Indexed: 11/27/2022]
Abstract
BACKGROUND It was the aim of this study to compare the prognostic impact of echocardiography and brain natriuretic peptide and its N-terminal fragment (NT-proBNP) in patients with chronic heart failure (CHF). METHODS In all, 73 patients with CHF underwent conventional 2-dimensional/Doppler echocardiography and Doppler tissue analysis of systolic, early and late diastolic mitral annular velocities. The mitral filling pattern was classified as restrictive or nonrestrictive. NT-proBNP measurements were carried out on a bench-top analyzer. A cardiac event (rehospitalization caused by worsening CHF, cardiac death, urgent cardiac transplantation) was defined as combined study end point. RESULTS During follow-up of 226 +/- 169 days, 27 patients had an event (rehospitalization because of CHF, n = 18; cardiac death, n = 7; urgent transplantation, n = 2). On multivariate Cox regression analysis, a restrictive filling pattern, NT-proBNP, the ratio of peak early diastolic mitral flow to mitral annular E' velocity were independent prognostic predictors. A risk stratification model based on the 3 strongest independent predictors separated groups into those with good, intermediate, and poor outcome (event-free survival of 78%, 46%, and 0%, respectively). CONCLUSIONS In patients with CHF, Doppler echocardiography, Doppler tissue imaging, and NT-proBNP provide independent and incremental prognostic information. A combined use of echocardiography and NT-proBNP may help to improve risk stratification in this patient population.
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Affiliation(s)
- Christian Bruch
- Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany.
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Rothenburger M, Stypmann J, Bruch C, Wichter T, Hoppe M, Drees G, Berendes E, Huelsken G, Loeher A, Welp H, Röttger C, Schmid C, Scheld HH, Tjan TDT. Aminoterminal B-type pro-natriuretic peptide as a marker of recovery after high-risk coronary artery bypass grafting in patients with ischemic heart disease and severe impaired left ventricular function. J Heart Lung Transplant 2006; 25:596-602. [PMID: 16678040 DOI: 10.1016/j.healun.2005.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Revised: 06/01/2005] [Accepted: 12/27/2005] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Aminoterminal B-type pro-natriuretic peptide (NT-proBNP) is a reliable indicator of heart failure severity. Levels of NT-proBNP are markedly increased in patients with coronary artery disease (CAD) and severely impaired left ventricular (LV) function. The aim of our study was to assess the impact of NT-proBNP levels after high-risk coronary artery bypass grafting (CABG) with regard to recovery potential. METHODS Between 1998 and 2004, 121 patients with CAD and severely impaired LV function, who were undergoing CABG, were investigated. Their mean age was 64 +/- 11 years. All patients were in New York Heart Association (NYHA) Class III/IV status; LV ejection fraction (EF) was 20 +/- 6%. All survivors underwent follow-up (59 +/- 34 months) spiroergometric, electrocardiographic (ECG) and echocardiographic assessment and were tested for routine blood controls and NT-proBNP levels (Roche, Mannheim, Germany). RESULTS The survival rate after 8 years was 70%. All survivors received follow-up assessment. Among survivors the median NT-proBNP level at follow-up was 896 (521 to 1,687) pg/ml. The maximum oxygen uptake was 14.6 +/- 4.9 ml/min/kg, and EF increased to 42% at follow-up among all survivors. On dichotomizing survivors into two groups with NT-proBNP levels above and below the median, the post-operative body mass index was significantly higher in the high NT-proBNP group (p = 0.036). EF (p = 0.028) and NYHA classification (p < 0.05) improved significantly in both groups, with a tendency toward higher EF in the low NT-proBNP group. CONCLUSIONS Patients undergoing a high-risk CABG procedure have a survival rate comparable to heart transplantation patients and show a potential for clinical and myocardial recovery. NT-proBNP use a useful marker for recovery after a high-risk CABG procedure, with significant correlation with clinical parameters.
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Affiliation(s)
- M Rothenburger
- Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Muenster, Germany.
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Wenzelburger F, Welp H, Rothenburger M, Klotz S, Schmid C, Stypmann J, Drees G, Scheld HH. Kidney function in heart transplant patients after LVAD bridging. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rothenburger M, Stypmann J, Welp H, Sezer Ö, Röttger C, Wichter T, Wenzelburger F, Schmid C, Scheld HH. CNI-free immunosupression using everolimus in long term heart transplant recipients -procedures of switching protocols and side effects. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Deiters S, Zahn P, Rothenburger M, Soeparwata R, Sindermann JR, Scheld HH, Hoffmeier A. Surgical treatment of cardiac myxomas: 16 years experience of 78 patients. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Löher A, Rothenburger M, Gradaus R, Vahlhaus C, Welp H, Drees G, Hoffmeier A, Hülsken G, Scheld HH. NT-proBNP for risk stratification after biventricular pacing in heart failure patients. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Welp H, Etz C, Klotz S, Tjan T, Rothenburger M, Hoffmeier A, Scheld H, Schmid C. 292. J Heart Lung Transplant 2006. [DOI: 10.1016/j.healun.2005.11.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wilhelm MJ, Hammel D, Schmid C, Rhode A, Kaan T, Rothenburger M, Stypmann J, Schäfers M, Schmidt C, Baba HA, Scheld HH. Long-term support of 9 patients with the DeBakey VAD for more than 200 days. J Thorac Cardiovasc Surg 2005; 130:1122-9. [PMID: 16214529 DOI: 10.1016/j.jtcvs.2004.10.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Revised: 09/23/2004] [Accepted: 10/22/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pulsatile left ventricular assist devices serving as mechanical circulatory support for patients with end-stage heart failure are associated with complications, including bleeding, thromboembolism, and infection. Axial-flow pumps might overcome some of these shortcomings. Here we report our experience with long-term application of the DeBakey VAD (MicroMed Technology, Inc, Houston, Tex). METHODS Nine male transplant candidates (37 +/- 14 years) with severe hemodynamic compromise (cardiac index, 1.6 +/- 0.5 L . min(-1) x m(-2); pulmonary capillary wedge pressure, 27 +/- 6 mm Hg) and beginning end-organ failure despite inotropic and intra-aortic balloon pump support received the DeBakey VAD. Clinical outcome was evaluated. RESULTS Cumulative support was 7.8 years, and the mean duration of support was 314 +/- 75 days (range, 229-438 days). Eight patients were transplanted, and one died from intracerebral bleeding. Peripheral circulation and end-organ function recovered rapidly after implantation. Continuous flow was able to maintain adequate organ perfusion over the long term. Eight patients were discharged during support, with good quality of life. There were no early bleedings, but there were late bleedings in 3 patients caused by excessive anticoagulation and platelet inhibition. Neurologic events occurred in 4 patients. Three patients recovered completely from symptoms, and one had lethal intracerebral bleeding. Because of thrombus formation, the device was exchanged in 4 patients. With increasing experience, thrombolysis was performed in similar situations. All such patients underwent successful transplantation. Hemolysis occurred, with events indicating thrombus formation. Device-related infection was found in one patient. CONCLUSIONS The DeBakey VAD demonstrated its potential for long-term bridge to transplantation. The risk for thrombus formation needs to be addressed by improvement of pump technology and new strategies for platelet inhibition.
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Affiliation(s)
- Markus J Wilhelm
- Department of Thoracic and Cardiovascular Surgery, Westfalian Wilhelms-University, Muenster, Germany.
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Rothenburger M, Schmid C, Huelksen G, Loeher A, Scheld HH. Thrombolytic therapy due to thrombus formation associated with left ventricular assist devices. J Heart Lung Transplant 2005; 24:2305. [PMID: 16364888 DOI: 10.1016/j.healun.2005.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 04/04/2005] [Accepted: 04/11/2005] [Indexed: 11/29/2022] Open
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Welp H, Etz C, Klotz S, Rothenburger M, Scheld HH, Schmid C. Effect of pulsatile and nonpulsatile left ventricular assist devices on the neuroendocrine system. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-922365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Hoffmeier A, Etz C, Schmid C, Debus V, Kehl HG, Ozgun M, Maintz D, Spieker T, Franzius C, Drees G, Rothenburger M, Tjan TDT, Löher A, Scheld HH. Cardiac Transplantation for Giant Sarcoma of the Left Ventricle. Circulation 2005; 112:e247-9. [PMID: 16203918 DOI: 10.1161/circulationaha.104.500264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A Hoffmeier
- Department of Thoracic and Cardiovascular Surgery, Hospital Münster, Westfalian Wilhelms-University Münster, Germany.
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Rukosujew A, Hoffmeier A, Rothenburger M, Löher A, Etz C, Ghezelbash F, Scheld HH, Schmid C. Harvest of the radial artery: technique of the skeletonization and pedicle preparation. J Cardiovasc Surg (Torino) 2005; 46:509-14. [PMID: 16278643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Nowadays, radial artery grafts play a significant role in coronary artery revascularization, however, harvesting techniques are not standardized. We developed various surgical techniques for radial artery harvesting considering the anatomic landmarks of the foramen, including conventional surgery (with scissors and clips) and procedures with ultrasonic scalpel and retrieving the radial artery graft in a pedicle or in a skeletonized manner.
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Affiliation(s)
- A Rukosujew
- Department of Thoracic and Cardiovascular Surgery,University Hospital, Muenster, Muenster, Germany.
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Wilhelm MJ, Hammel D, Schmid C, Kröner N, Stypmann J, Rothenburger M, Wenzelburger F, Schäfers M, Schmidt C, Baba HA, Breithardt G, Scheld HH. Partial left ventriculectomy and mitral valve repair: favorable short-term results in carefully selected patients with advanced heart failure due to dilated cardiomyopathy. J Heart Lung Transplant 2005; 24:1957-64. [PMID: 16297804 DOI: 10.1016/j.healun.2005.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2004] [Revised: 07/25/2004] [Accepted: 03/08/2005] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Because of the scarcity of donor hearts, surgical alternatives to heart transplantation, such as partial left ventriculectomy (PLV), were introduced for treatment of advanced heart failure. Here, we report our experience with this procedure performed in combination with mitral valve repair. METHODS Twelve patients with dilated cardiomyopathy (DCM), New York Heart Association (NYHA) class exceeding III on maximal medical therapy, cardiac index of 2.5 liter/min/m2 or less, VO2max of 14 ml/kg/min or less, left ventricular end-diastolic diameter (LVEDD) of 7.0 cm or more, and grade II or greater mitral incompetence, were selected for PLV and mitral valve reconstruction (MVR). Echocardiography, hemodynamics, spiroergometry, and clinical assessment were performed before and 1 year after the operation. RESULTS One-year survival was 83.3%. All 10 surviving patients were free from failure of the procedure 1 year post-operatively. From pre-operatively to 1 year post-operatively, NYHA functional class improved from 3.3 +/- 0.3 to 1.9 +/- 0.2 (p < 0.001), cardiac index increased from 2.0 +/- 0.2 liter/min/m2 to 2.9 +/- 0.2 liter/min/m2 (p < 0.001), stroke volume index from 25.9 +/- 4.8 ml/m2 to 40.3 +/- 7.3 ml/m2 (p = 0.008), and VO2max from 10.9 +/- 2.4 ml/kg/min to 16.0 +/- 3.6 ml/kg/min (p = 0.016), whereas LVEDD decreased from 8.4 +/- 0.6 cm to 6.6 +/- 0.3 cm (p < 0.001), left ventricular end-systolic diameter from 6.8 +/- 0.8 cm to 5.3 +/- 0.5 cm (p < 0.001), and mitral incompetence from 2.4 +/- 0.6 to 0.9 +/- 0.6 (p < 0.001). Pulmonary pressures and fractional shortening did not change significantly (p > 0.05). Four patients received an implantable cardioverter/defibrillator as a result of their pathologic electrophysiologic examination. CONCLUSIONS In carefully selected patients, PLV combined with MVR achieves short-term results comparable to that after heart transplantation. However, long-term results and multicenter evaluation will be needed to define its place in the treatment of advanced heart failure.
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Affiliation(s)
- Markus J Wilhelm
- Department of Thoracic and Cardiovascular Surgery, Westfalian Wilhelms-University, Muenster, Germany.
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Schmidt C, Hinder F, Van Aken H, Theilmeier G, Bruch C, Wirtz SP, Bürkle H, Gühs T, Rothenburger M, Berendes E. The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. Anesth Analg 2005; 100:1561-1569. [PMID: 15920175 DOI: 10.1213/01.ane.0000154963.29271.36] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients with coronary artery disease, vasoconstriction is induced through activation of the sympathetic nervous system. Both alpha1- and alpha2-adrenergic epicardial and microvascular constriction are potent initiators of myocardial ischemia. Attenuation of ischemia has been observed when sympathetic nervous system activity is inhibited by high thoracic epidural anesthesia (HTEA). However, it is still a matter of controversy whether establishing HTEA may correspondingly translate into an improvement of left ventricular (LV) function. To clarify this issue, LV function was quantified serially before and after HTEA using a new combined systolic/diastolic variable of global LV function (myocardial performance index [MPI]) and additional variables that more specifically address systolic (e.g., fractional area change) or diastolic function (e.g., intraventricular flow propagation velocity [Vp]). High thoracic epidural catheters were inserted in 37 patients scheduled for coronary artery surgery, and HTEA was administered in the awake patients. Echocardiographic and hemodynamic measures were recorded before and after institution of HTEA. HTEA induced a significant improvement in diastolic LV function (e.g., Vp changed from 45.1 +/- 16.1 to 53.8 +/- 18.8 cm/s; P < 0.001), whereas indices of systolic function did not change. The change in the diastolic characteristics caused the MPI to improve from 0.51 +/- 0.13 to 0.35 +/- 0.13 (P < 0.001). We conclude that an improvement in cardiac function was due to improved diastolic characteristics.
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Affiliation(s)
- Christoph Schmidt
- Departments of *Anesthesiology and Surgical Intensive-Care Medicine, †Cardiology, and ‡Chest, Heart, and Vascular Surgery, University of Münster Hospital, Germany
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Bruch C, Gotzmann M, Stypmann J, Wenzelburger F, Rothenburger M, Grude M, Scheld HH, Eckardt L, Breithardt G, Wichter T. Electrocardiography and Doppler echocardiography for risk stratification in patients with chronic heart failure. J Am Coll Cardiol 2005; 45:1072-5. [PMID: 15808766 DOI: 10.1016/j.jacc.2004.12.064] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2004] [Revised: 12/08/2004] [Accepted: 12/21/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This prospective study tested whether Doppler echocardiographic variables add incremental value to QRS duration in determining the prognosis of patients with chronic heart failure (CHF) and systolic dysfunction. BACKGROUND Diastolic dysfunction frequently is observed in patients with CHF, but its prognostic impact relative to that of QRS duration is unknown. METHODS A total of 193 patients with CHF and an ejection fraction <45% were enrolled prospectively. Echo measurements included left ventricular dimensions/volumes, ejection fraction, mitral early/late diastolic velocity ratio, deceleration time, and tissue Doppler mitral annular velocities. The mitral filling pattern was classified as either restrictive (RFP) or nonrestrictive. A cardiac event (cardiac death or urgent cardiac transplantation) was defined as combined study end point. RESULTS During a follow-up of 385 +/- 270 days, 24 patients suffered an event (cardiac death, n = 21; urgent transplantation, n = 3). The RFP, QRS duration, left ventricular systolic diameter, and mitral annular early diastolic velocity were independent predictors of an event. In patients with QRS duration >144 ms, the outcome was markedly poorer in the presence of RFPs as compared with their absence. Similarly, despite a QRS duration <or =144 ms, the outcome was worse in the presence of a RFP. A risk-stratification model based on the three strongest independent predictors separated groups into those with good prognosis and those with high, intermediate, and low event-free survival rates. CONCLUSIONS In subjects with CHF and systolic dysfunction, transmitral flow patterns add incremental value to QRS duration in determining the prognosis.
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Affiliation(s)
- Christian Bruch
- Department of Cardiology and Angiology, University Hospital of Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany.
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Rothenburger M, Hülsken G, Stypmann J, Wichter T, Tjan TDT, Löher A, Hoffmeier A, Drees G, Etz C, Semik M, Schmidt C, Reinecke H, Schmid C, Scheld HH. Cardiothoracic Surgery after Heart and Heart-Lung Transplantation. Thorac Cardiovasc Surg 2005; 53:85-92. [PMID: 15786006 DOI: 10.1055/s-2004-830472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to examine our management and the outcomes of cardiothoracic procedures after heart and heart lung transplantation. METHODS We performed a retrospective review of cardiothoracic surgical procedures carried out between 1990 and 2004 in patients who had previously undergone heart or heart-lung transplantation at our institution. RESULTS Twenty-one out of 340 patients (6.2 %) were identified. Cardiothoracic surgery was performed 44.4 +/- 33 months (range 1 - 115 months) after transplantation. Predominant types of surgery were coronary artery bypass grafting due to allograft vasculopathy (n = 5), aortic surgery due to acute dissection (n = 3), biventricular assist device implantation due to acute rejection (n = 1), tricuspid valve repair (n = 1), multiple cardiac surgical procedures including coronary artery bypass grafting, retransplantation, and tricuspid valve replacement (n = 2), explantation of a functionless heterotopic transplanted heart (n = 1). Lung surgery was performed in six patients due to pneumonia (n = 2), primary lung carcinoma (n = 3), lung torsion following heart-lung transplantation (n = 1). All patients underwent either lobectomy or segmental lung resection. Single lung retransplantation (n = 2) after prior heart-lung transplantation due to bronchiolitis obliterans was performed. In one patient a pneumonectomy (n = 1) due to severe chronic rejection of the contralateral lung was performed. Six subsequent deaths after cardiothoracic procedures were recorded after 1, 4, 78, 163, 205, and 730 days, respectively. Causes of death were advanced carcinoma (n = 1), multi-organ failure due to sepsis (n = 2), sudden heart death (n = 2), and advanced heart failure (n = 1). Fifteen out of 21 patients having undergone cardiothoracic procedures (71.4 %) survived the observation period of 56.6 +/- 34 months (range 1 - 114). CONCLUSIONS Reasons for cardiothoracic procedures after prior heart or heart-lung transplantation were allograft vasculopathy, aortic dissections years after transplantation, chronic rejection, and either lung infections or malignancies. Surgical repair can be performed with an acceptable operative risk and good long-term survival rates.
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Affiliation(s)
- M Rothenburger
- Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Münster, Germany.
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Hoffmeier A, Schmid C, Deiters S, Drees G, Rothenburger M, Tjan TDT, Schmidt C, Löher A, Maintz D, Spieker T, Mesters RM, Scheld HH. Neoplastic Heart Disease - The Muenster Experience With 108 Patients. Thorac Cardiovasc Surg 2005; 53:1-8. [PMID: 15692911 DOI: 10.1055/s-2004-830389] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Tumours of the heart are rare. Different histological subtypes are known. The most common tumour entity is benign cardiac myxoma. Malignant heart tumours are less common. Tumours originating in other organs such as the kidney may also affect the heart by tumour progression via the inferior caval vein. A large experience with surgical treatment of different types of heart tumours is presented. METHODS Between January 1989 and April 2004, 108 patients with a heart tumour were included in a database. All patients underwent radical surgical resection, except for 2 patients who had malignant lymphoma of the heart. RESULTS Histological findings included 78 myxomas (72.2 %), and 6 other benign cardiac tumours in 5.6 % of the patients. Primary malignant heart tumours were seen in 10 (9.2 %) and renal cell carcinoma with cardiac involvement in 6 (5.6 %) patients. Eight patients presented with tumour metastases inside the heart (7.4 %). Mean overall survival was 12.7 years for myxoma patients and 5.6 years for patients with other benign heart tumours. Patients with primary malignant heart tumours survived 5.5 years on average. CONCLUSIONS Heart tumours are rare, but usually life-threatening. Radical surgical resection is the therapy of choice and may offer excellent long-term survival, even in cases with malignant heart tumours.
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Affiliation(s)
- A Hoffmeier
- Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Westfälische Wilhelms-University Münster, Münster, Germany.
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Rothenburger M, Stypmann J, Wichter T, Löher A, Berendes E, Röttger C, Etz C, Schmid C, Scheld H. The role of NT-proBNP in chronic heart failure and renal insufficiency. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-862012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Etz C, Welp H, Rothenburger M, Hoffmeier A, Schmid C, Scheld H. Analysis of platelet function during ventricular assist device support with a platelet aggregation profiler. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-862015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Etz C, Welp H, Rothenburger M, Wenzelburger F, Tjan T, Schmid C, Scheld H. Reversibility of medically unresponsive pulmonary hypertension during mechanical pulsatile and non-pulsatile left ventricular unloading in cardiac transplant candidates. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-861954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Welp H, Etz C, Rothenburger M, Stypmann J, Schmid C, Scheld H. Calcineurin inhibitor-induced chronic nephrotoxicity in heart transplant patients is reversible using rapamycin as the primary immunosuppressive agent. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-861891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Welp H, Etz C, Wenzelburger F, Rothenburger M, Schmid C, Scheld H. Long-term mechanical circulatory support for cardiogenic shock following acute myocardial infarction: single-center 10-year experience. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-861951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Klotz S, Wenzelburger F, Rothenburger M, Welp H, Schmid C, Scheld H. Effectiveness of Prostaglandin E1 versus Prostacyclin in evaluation of transplant candidates with elevated pulmonary vascular resistance. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-862154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Röttger C, Rothenburger M, Hoppe M, Stypmann J, Löher A, Schmid C, Scheld H. NT-proBNP as a marker of recovery after high-risk coronary artery bypass grafting in patients with severely impaired LV-function. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-861957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Schmid C, Etz C, Welp H, Rothenburger M, Reinecke H, Schäfers M, Schmidt C, Scheld HH. Clinical situations demanding weaning from long-term ventricular assist devices. Eur J Cardiothorac Surg 2004; 26:730-5. [PMID: 15450564 DOI: 10.1016/j.ejcts.2004.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 07/07/2004] [Accepted: 07/08/2004] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Ventricular assist devices are increasingly used to treat patients with acute or chronic end-stage heart failure. We report on circumstances, exemplified on four cases, where a surprisingly favorable clinical course of the patients ultimately demanded early explantation of the device, which was not anticipated prior to its implantation. METHODS The four patients were provided with implantable (Micromed BeBakey trade mark, Incor trade mark ) and external pneumatically driven (Thoratec trade mark, Excor trade mark ) devices under emergency conditions and were listed for heart transplantation. RESULTS All four patients had an unexpected recovery of myocardial pump function. After careful diagnostic evaluation, all device components were completely removed without extracorporeal circulation. No stepwise weaning protocol was employed. CONCLUSIONS Weaning patients from ventricular assist devices after recovery of myocardial pump function can become necessary. Diagnostic evaluation and the implementation of a weaning protocol is still a matter of debate, while complete surgical removal of all device components without extracorporeal circulation is possible with a low risk.
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Affiliation(s)
- C Schmid
- Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Albert-Schweitzer-Str. 33, 48149 Münster, Germany.
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Etz C, Welp H, Rothenburger M, Tjan TDT, Wenzelburger F, Schmidt C, Scheld HH, Schmid C. Analysis of Platelet Function during Left Ventricular Support with the Incor and Excor System. Heart Surg Forum 2004; 7:E423-7. [PMID: 15799917 DOI: 10.1532/hsf98.20041073] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Improvements in pump technology and the scarcity of donor organs have led to an increased use of mechanical assist devices, but the problem of thromboembolism has still not been solved. We report on our initial experience with sequentially analyzing platelet function in patients provided with the Incor left ventricular assist device (LVAD) and the Excor LVAD system. Thirteen patients 5 to 61 years old with acute or end-stage heart failure were included in a pilot study. Five of the 10 Incor patients underwent LVAD placement under emergency conditions, and 5 were electively scheduled for surgery. All 3 patients with an Excor device had been connected to an extracorporeal membrane oxygenation system prior to insertion of the device. An anticoagulation protocol including heparin, aspirin, and clopidogrel was employed, and the patients were closely monitored with a special platelet analyzing system that allows dose optimization for antiplatelet drugs. Initial platelet function was normal in only 2 patients (15%). During a follow-up period of 1770 days (cumulative >4.8 years), no early (<30 days) bleeding complications related to device implantation occurred. Late cerebral thromboembolic events were noted in 3 patients. One patient experienced severe stroke mandating neurosurgery during mechanical assist, and 1 patient experienced systemic embolism. The PAP platelet analyzer offers a cheap and reliable alternative to the more expensive thromboelastography method for adequately surveying the efficacy of aspirin and clopidogrel treatment, even if late thromboembolic events cannot be prevented.
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Affiliation(s)
- Christian Etz
- Department of Thoracic, University Hospital, Münster, Germany
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Rothenburger M, Wichter T, Schmid C, Stypmann J, Tjan TDT, Berendes E, Etz C, Pioux A, Löher A, Wenzelburger F, Drees G, Hoffmeier A, Breithardt G, Scheld HH. Aminoterminal pro type B natriuretic peptide as a predictive and prognostic marker in patients with chronic heart failure. J Heart Lung Transplant 2004; 23:1189-97. [PMID: 15477114 DOI: 10.1016/j.healun.2004.07.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 07/08/2004] [Accepted: 07/19/2004] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND B-type natriuretic peptide (BNP) is released from the cardiac ventricles in response to increased wall tension. We studied the relation of NT-proBNP to Heart Failure Survival Score (HFSS) and New York Heart Association (NYHA) class in patients with chronic heart failure (CHF). We also studied the impact for recipient selection for cardiac transplant and assessed it as a predictive and prognostic marker of CHF. METHODS A total of 550 patients with dilative cardiomyopathy (n = 323), and coronary artery disease (n = 227) were prospectively examined. All patients underwent spiroergometry, echocardiography, right heart catheterization, and electrocardiogram. Routine blood levels and NT-proBNP were measured. The clinical selection for cardiac transplant candidates was adjudicated by 2 independent cardiologists who were blinded to the results of NT-proBNP assays. Clinical outcome and predictive power of NT-proBNP were analyzed. RESULTS NT-proBNP levels in patients clinically considered for cardiac transplantation were significantly higher (2293 ng/ml vs 493 ng/ml; p < 0.001). The receiver operating characteristic (ROC) analysis regarding transplant candidacy showed an area under the ROC curve (AUC) of 0.84 +/- 0.01 for HFSS, 0.86 +/- 0.001 for NYHA, and 0.96 +/- 0.01 for NT-proBNP. Patients with increasing NT-proBNP levels or remaining elevated levels despite adequate heart insufficiency treatment were maintained with left ventricular assist device implantation (n = 10) or urgent heart transplantation (n = 2). Patients with NT-proBNP levels above 5000 pg/ml had a mortality rate of 28.4% per year. Twenty-eight patients died during the observation period; all these patients were within NYHA Classes 3 and 4 (NT-proBNP 5423 +/- 423 ng/ml). CONCLUSIONS NT-proBNP discriminates patients at high likelihood of being a candidate for transplantation and provides prognostic informations in patients with CHF. NT-proBNP levels above 5000 pg/ml at admission were associated with death, and these levels markedly discriminated candidates for left ventricular assist devices or urgent transplantation.
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Affiliation(s)
- Markus Rothenburger
- Department of Thoracic Surgery, University Hospital Muenster, Muenster, Germany.
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Schmid C, Rothenburger M, Rukosujew A, Scheld HH. ICD implantation -- between necessity and tragedy. Thorac Cardiovasc Surg 2004; 52:249-51. [PMID: 15293164 DOI: 10.1055/s-2004-817810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report on a 42-year-old patient with known dilative cardiomyopathy who underwent placement of a multiple transvenous pacemaker and ICD electrodes, and required removal of all leads via median sternotomy, followed by placement of epicardial electrodes. This experience has led us to question the necessity of the current implantation policies for these systems.
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Affiliation(s)
- C Schmid
- Klinik und Poliklinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum Münster, Münster, Germany.
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Trösch F, Rothenburger M, Schneider M, Welp H, Etz C, Wilhelm MJ, Scheld HH, Schmid C. First Experience with Rapamycin-Based Immunosuppression to Improve Kidney Function After Heart Transplantation. Thorac Cardiovasc Surg 2004; 52:163-8. [PMID: 15192777 DOI: 10.1055/s-2004-820880] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED This study was designed to gain initial experience with rapamycin in thoracic organ transplant recipients with severely compromised kidney function, i.e. to see whether and how kidney function will improve with a rapamycin-based immunosuppressive protocol. METHODS Twelve heart transplant patients were included into the study (serum creatinine > 2.5 mg/dL), with an average time after transplantation of more than 4 years. The calcineurin inhibitor (cyclosporine A = 9, tacrolimus = 3) was reduced by 50 %, and rapamycin added to reach a target level of 8 - 12 ng/dL. Azathioprine was halted, corticosteroid treatment remained unchanged. RESULTS After implementing the rapamycin-based immunosuppression kidney function improved in all patients within one week. Serum creatinine dropped from 3.1 +/- 0.6 mg/dL to 2.7 +/- 0.5 mg/dL ( p = 0.0004), creatinine clearance increased from 30.4 +/- 11 mL/min to 40.8 +/- 10.5 mL/min ( p = 0.003). This improvement continued until 3 months after the conversion ( p = 0.032). Thereafter, no statistically significant changes were noted up to 6 months posttransplant ( p = 0.41). Serum cyclosporine levels dropped from 180 +/- 40 ng/mL to 132 +/- 46 ng/mL on average ( p = 0.002). Side-effects occurred in 4 patients and were all related to a rapamycin level exceeding 12 ng/mL. CONCLUSIONS We conclude that transplant patients with impaired kidney function will have an immediate benefit from partially replacing calcineurin inhibitors by rapamycin.
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Affiliation(s)
- F Trösch
- Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Münster, Germany
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Rukosujew A, Reichelt R, Fabricius AM, Drees G, Tjan TDT, Rothenburger M, Hoffmeier A, Scheld HH, Schmid C. Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel. Ann Thorac Surg 2004; 77:120-5. [PMID: 14726047 DOI: 10.1016/s0003-4975(03)01488-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The radial artery (RA) is increasingly used for myocardial revascularization because of its presumed advantageous long-term patency rates. The vessel can be harvested as a pedicle or skeletonized. The aim of this study was to compare the skeletonization technique with pedicle preparation using either an ultrasonic scalpel or scissors. METHODS Forty consecutive patients with coronary artery disease undergoing complete arterial revascularization were included in the study. In 20 patients the RAs were prepared using scissors and clips (group 1: skeletonization; group 2: pedicle). In another 20 patients the arteries harvested were prepared using an ultrasonic scalpel (group 3: skeletonization; group 4: pedicle). The RA was treated with papaverine to prevent spasm of the vessel during and after harvesting. Tissue specimens of each RA were taken to analyze endothelial morphology by scanning electron microscopy. After implantation of the RA, graft perfusion was measured with a flow probe. RESULTS Harvesting the RA as a skeletonized vessel took more time as compared with pedicle preparation (group 1 vs group 2: 37.1 +/- 3.5 minutes vs 24.4 +/- 3.9 minutes; p < 0.001 and group 3 vs group 4: 31.1 +/- 3.5 minutes vs 25.6 +/- 3.7 minutes; p < 0.01). The number of hemostatic titanium clips was similarly higher in group 1 as opposed to group 2 (58.7 +/- 7.1 vs 38.7 +/- 7.1; p < 0.01). However, there was no difference between groups 3 and 4 (p = 0.086). The length of the RA after skeletonization with scissors and clips was 20.8 +/- 1.5 cm in contrast with 19.1 +/- 0.9 cm (p < 0.01) after dissection as a pedicle. In the groups using the ultrasonic scalpel, there was no difference in graft length (p = 0.062). Mean blood flow through the graft after establishing the proximal anastomosis was similar among all groups (groups 1, 2, 3, and 4: 50 +/- 20.1 mL/min, 53.8 +/- 24.3 mL/min, 56.3 +/- 25.1 mL/min, and 51.8 +/- 23 mL/min, respectively). Scanning electron microscopy demonstrated endothelial damage in all patients in groups 1, 2, and 3 and in 7 patients of group 4. Most endothelial lesions were minor except in group 3 in which 1 of 5 endothelial lesions were severe. Statistically significant differences was found between groups 1 and 2, and 3 and 4 with respect to the degree of endothelial damage (p < 0.01). CONCLUSIONS Skeletonization using scissors and clips is more time consuming and technically more difficult, but yield significantly longer grafts. Skeletonization with an ultrasonic scalpel did not result in additional length and was more frequently associated with severe endothelial damage. Pedicle preparation using scissors or an ultrasonic scalpel is much simpler and faster, and does not jeopardize endothelial integrity.
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Affiliation(s)
- Andreas Rukosujew
- Department of Thoracic and Cardiovascular Surgery, University Hospital, and, Muenster, Germany.
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Schmid C, Tjan T, Etz C, Schmidt C, Janssen F, Rothenburger M, Scheld H. First clinical experience with the incor lvad. J Heart Lung Transplant 2004. [DOI: 10.1016/j.healun.2003.11.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Rothenburger M, Stypmann J, Hoffmeier A, Berendes E, Etz C, Pioux A, Rukosujew A, Löher A, Scheld H, Schmid C. B-type natriuretic peptide, a marker for selection of heart transplant candidates. J Heart Lung Transplant 2004. [DOI: 10.1016/j.healun.2003.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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