Gender differences during mechanical circulatory support

Long-term mechanical circulatory support (MCS) with ventricular assist devices (VADs) is now an acceptable option for patients with end-stage heart failure (HF). There are growing numbers of reports identifying sex-related differences in the development and prognosis of HF and cardiac surgery. With the experience of 1,607 VAD implantations in our institution we are the first to analyze our data to determine gender distribution in our patient populations and the effect of gender on outcomes. Of the total 1,456 patients with MCS, 1,225 were male and 231 female. The patients were divided into three age groups-below 13 years (group 1, n = 100), between 13 and 50 years (group 2, n = 540) and older than 50 years (group 3, n = 824). Five-year survival, HF etiology, and procedural success, defined as 30-day and 5-year survival were analyzed retrospectively. In group 1 the gender distribution was equal; the leading HF etiology was dilated cardiomyopathy (DCMP) with 17% in male (n = 17) and 19% in female (n = 19) patients, followed by congenital diseases (13% in male versus 9% in female) and postcardiotomy failure (13% in male versus 8% in female). No differences were seen in 5-year survival and procedural success. In group 2, significantly more men (n = 451, p < 0.0001) were supported by VADs. DCMP was the major cause for VAD implantation (54%) and was significantly more frequent in men (57.6%, p = <0.0001). Male patients were older (mean age = 37.1 years, p < 0.0001), with a longer median support time (151.6 days, p < 0.0001) and a higher median weight (78.2 kg, p < 0.0001). No difference was seen in procedural success whereas 5-year survival was better in men than in women (53% vs. 42%, p = 0.02).Group 3 consisted of 723 male patients and 101 female patients (p < 0.0001). Ischemic cardiomyopathy was the main HF etiology (37.9 %) and it was significantly more often the reason for left ventricular assist device support in men (p = 0.009). No differences were seen in procedural success; 5-year survival showed a better outcome in men (49% vs. 25%, p = 0.026). In patients supported by a VAD, gender has a significant impact on the distribution of diagnoses in the adult population. Women were underrepresented in the age group 13-50 years, and 50 years and older, and women had a higher risk for mortality on VAD support in the adult age groups (groups 2 and 3).     

Retrospective hemolysis comparison between patients with centrifugal biventricular assist and left ventricular assist devices

Little is known about the hemolysis rate in the case of concomitant implantation of two continuous flow pumps for the treatment of biventricular heart failure. We present a retrospective study comparing the hemolysis parameters in patients supported with one implantable centrifugal pump of the type HeartWare HVAD used as a left ventricular assist device (LVAD) and with two pumps as a biventricular assist device (BiVAD). A total of 20 consecutive patients who received HeartWare BiVAD (n = 10) and LVAD (n = 10) support at our institution between September 2009 and September 2010 were examined. Hemolysis- and anemia-related parameters were analyzed after 2 weeks, 5 weeks, 3 months, and 6 months of support. Preoperative levels of hemoglobin, lactate dehydrogenase (LDH), and total bilirubin were similar in both groups. There were no differences in LDH, plasma-free hemoglobin (fHB), or total bilirubin levels postoperatively for up to 6 months. Only the haptoglobin level was lower in BiVAD recipients up to 3 months after surgery: 2nd week (63.5 [range: 8-237] mg/dl vs. 151 [range: 11-263] mg/dl, p = 0.05), 5th week (67 [range: 8-196] mg/dl vs. 215 [range: 56-292] mg/dl, p = 0.046), and after 3rd month (42 [range: 8-205] mg/dl vs. 220 [range: 157-256] mg/dl, p = 0.048). Our retrospective analysis of BiVAD HeartWare and LVAD HeartWare recipients showed a lack of a clinically important degree of hemolysis when two centrifugal HeartWare pumps are used for biventricular support.     

Transapical aortic valve implantation and 'off-pump' arterial coronary bypass in a patient with a porcelain aorta

A simple hybrid procedure, namely transapical aortic valve implantation combined with 'off-pump' coronary artery bypass using an internal thoracic artery, was performed in a patient with porcelain aorta, aortic valve stenosis and coronary artery disease. This approach does not require cardiopulmonary bypass, and avoids aortic or peripheral arterial cannulation and clamping of the aorta. This hybrid approach can be regarded as a 'new technique' being applied to an 'old idea'.     

Different hemodynamic stress of the ascending aorta wall in patients with bicuspid and tricuspid aortic valve

It is unclear whether ascending aorta dilation in patients with bicuspid aortic valve is caused by abnormal hemodynamics or by a common developmental defect of the aortic valve and aortic wall. We performed an echocardiographic study to examine the differences in hemodynamic stress at the ascending aorta in patients with bicuspid and tricuspid aortic valve. We studied prospectively 58 consecutive patients referred for preoperative echocardiographic examination with aortic valve stenosis and either bicuspid or tricuspid valve and an ascending aortic diameter of 相似文献   

Implantation of MicroMed DeBakey VAD through left thoracotomy after previous median sternotomy operations

A left lateral thoracotomy was used for implantation of the continuous-flow MicroMed DeBakey left ventricular assist device in 12 patients with previous heart operations through a median sternotomy. This approach avoids reopening the chest through a median sternotomy and reduces the risk of bleeding and subsequent complications.     

Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess

BACKGROUND: The valve substitute of choice in active infective aortic valve endocarditis complicated by annulus abscess in our institution is the cryopreserved homograft. To avoid implantation of any prosthetic material, the Shelhigh No-React stentless valves and conduits may be considered an alternative when no suitable homograft is available. METHODS: Between March 1986 and January 2001, 452 homografts were implanted in the aortic position. From January 2000 to August 2001, 75 Shelhigh No-React prostheses were implanted at our institution. In 25 consecutive patients (study group) with aortic annulus abscess, urgent aortic valve replacement with the Shelhigh SuperStentless and Stentless Aortic Valve Conduit was undertaken. Patients (16 male, 9 female; age, 49 +/- 19 years) were studied with follow-up until March 2002. The control group comprised 68 consecutive historical patients (46 male, 22 female; age, 53 +/- 14.4 years) with similar disease treated between January 1997 and December 1999 in whom an aortic homograft was implanted. This group was also followed up until March 2002. Demographic data and preoperative characteristics of the patients were without significant differences. Patients were studied by echocardiography. RESULTS: Sixty-day mortality was 16% (11 patients) in the control group compared with 12% (3 patients) in the study group. Recurrent infection occurred in 4% in both groups. The instantaneous and mean Doppler gradients yielded no significant differences (19.4 +/- 10.4 mm Hg and 11.8 +/- 5.7 mm Hg versus 18.2 +/- 8.7 mm Hg and 10.9 +/- 5.3 mm Hg, respectively). The mean effective orifice area calculated from Doppler flow velocity for the stentless valve was 2.3 +/- 0.6 cm2. Preoperative evaluation of left ventricular dimensions and global left ventricular systolic function did not vary significantly between the two groups. However, postoperatively evaluated left ventricular end-diastolic diameter dimensions in the study group were significantly smaller than those in the control group (47.6 +/- 7.9 mm versus 56 +/- 9.5 mm; p = 0.05). Ejection fraction was similar in both groups (56.2% +/- 12.8% for the study [Shelhigh] and 52.6% +/- 16.8% for the control [homograft] group). CONCLUSIONS: Our experience with both the Shelhigh No-React SuperStentless and Stentless Aortic Valve Conduit in patients with native or prosthetic aortic valve endocarditis appears to demonstrate good results, similar to those of cryopreserved homografts. Ease of implantation and favorable effective orifice area and pressure gradients, as well as the No-React anticalcification treatment, are promising factors.     

Marfan-Syndrom und Herzklappenerkrankungen

Summary Marfan syndrome is a hereditary disease of the connective tissue with increased mortality mostly due to changes of the cardiovascular system. We describe our experience with the surgical treatment of 243 patients with Marfan syndrome and cardiovascular complications. We report the results of treatment of annulo-aortal ectasia using the classical surgical methods of Bentall DeBono and Cabrol and the method for preservation of the native aortic valve and concomitant surgery of the mitral valve. Reconstruction or replacement of the mitral valve is mainly based on the classical indications. Preservation of the native aortic valve and reconstruction of the mitral valve in patients with Marfan syndrome is possible but the long-term results are still unknown. Zusammenfassung Das Marfan-Syndrom ist eine erbliche Bindegewebserkrankung, die mit einer erhöhten Inzidenz von kardiovaskulären Komplikationen verbunden ist. Wir beschreiben unsere Erfahrungen bei der chirurgischen Behandlung von 243 Patienten mit Marfan-Syndrom. Bezüglich der Behandlung der anuloaortalen Ektasie zeigen wir unsere Ergebnisse bei der Verwendung der klassischen Operationsmethoden nach BentallDeBono und Cabrol. Neure Operationsmethoden wie die Verfahren nach David und Yacoub werden kritisch gewertet und eine eigene Modifikation zum Klappen erhaltenden Ersatz der Aorta ascendens wird vorgestellt. Bei einer großen Zahl von Patienten waren Operationen wegen der Manifestetion des Marfan-Syndroms im Bereich der distal der Aorta ascendens gelegenen Aortensegmente, der Mitralklappe und der Trikuspidalklappe erforderlich. Die Indikation zur Rekonstruktion bzw. zum Ersatz der Mitralklappe wird weitgehend entsprechend den klassischen Kriterien gestellt. Die Langzeitresultate des Erhalts der nativen Aortenklappe sowie der Mitralklappenrekonstruktion sind noch nicht vorhanden.