Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.     

Quantification of urinary TIMP-2 and IGFBP-7: an adequate diagnostic test to predict acute kidney injury after cardiac surgery?

IntroductionPostoperative acute kidney injury (AKI) is a frequently observed complication after on-pump cardiac surgery (CS) and is associated with adverse patient outcomes. Early identification of patients at risk is essential for the prevention of AKI after CS. In this study, we analysed whether urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) combined with urine insulin-like growth factor binding protein 7 (IGFBP-7) ([TIMP-2] × [IGFBP-7]) is an adequate diagnostic test to identify early AKI after on-pump CS.MethodsIn 42 patients undergoing coronary artery bypass graft surgery, we surveyed individual risk factors for AKI and defined AKI by applying the Kidney Disease: Improving Global Outcomes (KDIGO) classification during the day of surgery and the following 2 days after surgery. Concentrations of urinary TIMP-2 multiplied by IGFBP-7 were recorded at four time points: at baseline pre-surgery, at the end of surgery, 4 hours after cardiopulmonary bypass (CPB) and at 8:00 am on the first postoperative day.ResultsIn total, 38% of the patients experienced AKI. The results showed a median baseline [TIMP-2] × [IGFBP-7] concentration of 0.3 (ng/ml)²/1,000, decreasing at the end of surgery and then increasing at the next measurement point 4 hours after CPB and further on the first postoperative day. On the first postoperative day, patients with AKI had significantly higher concentrations of [TIMP-2] × [IGFBP-7]. On the day of surgery, the concentration did not significantly differ between patients classified as KDIGO 0 or KDIGO 1 or 2. Previously published cutoff points of 0.3 and 2 were not confirmed in our study cohort.Conclusion[TIMP-2] × [IGFBP-7] concentration can be used as a diagnostic test to identify patients at increased risk of AKI after CS on the first postoperative day. At earlier time points, no significant difference in [TIMP-2] × [IGFBP-7] concentration was found between patients classified as KDIGO 0 or KDIGO 1 or 2.

Trial registration

German Clinical Trials Register (DRKS) DRKS00005457. Registered 26 November 2013.     

Aortic root abscess and secondary infective mitral valve disease: results of surgical endocarditis treatment.

OBJECTIVE: Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women. METHODS: Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality. RESULTS: In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV. CONCLUSIONS: Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.     

Humoral rejection after heart transplantation: reliability of intramyocardial electrogram recordings (IMEG) and myocardial biopsy

In recent years, as the importance of humoral-mediated rejection has increasingly become recognized, the fact that endomyocardial biopsies (BX) evaluated according to the criteria of the International Society for Heart and Lung Transplantation often produce false-negative results has become a matter of concern. To evaluate the reliability of measuring intramyocardial ECG amplitude (IMEG) and immunofluorescence evaluation (FITC-labeled anti-IgG/IgM staining) of endomyocardial biopsies (IFM), heterotopic neck-heart transplantation (HTX) was performed on eight beagles previously sensitized through skin transplantations. After HTX, IMEG, echo, and donor-specific antibodies in serum (IgG, IgM) were determined daily and myocardial biopsies (IFM, BX) were performed once every 2 days. Accelerated (humoral) rejection occurred on the 5th (4th–5th) postoperative day and sensitivity of IMEG, IFM, and BX was 100 %, 75 %, and 12.5 %, respectively. In each case rejection was recognized so early that it was possible to initiate therapy with “restitutio ad integrum”. Our results show that, as opposed to endomyocardial biopsy (IFM, BX), IMEG diagnosis detected humoral-mediated rejection early and with high reliability. Received: 8 August 1996 Received after revision: 11 July 1997 Accepted: 21 August 1997     

Heart Transplantation: A Single-Center Experience

Background. The success of heart transplantation led to the extension of the criteria for both recipients and donors. The aim of the study was to evaluate the experience with this therapeutic approach for end-stage heart failure at a single center.

Methods. Between April 1986 and January 1996, 1,413 patients were accepted as candidates for heart transplantation. Ventricular assist devices were used as a bridge to transplantation in 173 patients (biventricular assist device in 141 patients and left ventricular assist device in 32 patients). The longest duration of support was 572 days (average, 46 days).

Results. Of the 1,413 patients, 891 underwent heart transplantation (65 children/adolescents and 826 adults; 522 (36%) patients died awaiting a donor heart. The average time spent on the waiting list was 107 days. The average recipient age was 44 years, and the age of donors was extended up to 69 years. Eighty-three patients with ventricular assist devices (48%) subsequently underwent heart transplantation. Twenty-five patients (2.7%) underwent retransplantation. The 30-day mortality rate was 14%, and the overall actual survival at 1, 5, and 10 years was 80%, 59%, and 50%, respectively. Ninty-four percent of patients were in New York Heart Association functional class I or II at 1 year, and 44% returned to work after transplantation.

Conclusions. Despite the broadening of the selection criteria for both recipients and donors, heart transplantation remains an effective treatment for end-stage heart failure. Nevertheless, this therapeutic approach is severely limited by a considerable disparity between the need and availability of donor organs.     

Non-specific, time-dependent desensitization of the vas deferens and anococcygeus preparations of the rat to alpha 1-adrenoceptor antagonists and atropine

Rat vas deferens preparations became desensitized to the alpha 1-adrenoceptor antagonist thymoxamine: after 6 h in vitro, the t 1/2 value (time to attain half the occupancy of receptors occupied at equilibrium) of the response to this drug was 1.50 fold greater in control strips (strips exposed to thymoxamine at 6 h) than in test strips (strips exposed to thymoxamine at 1 h). The rate of action of the alpha 1-adrenoceptor antagonist AR-C239 on the rat anococcygeus preparation was correlated with the rate of action of atropine. There was also a significant correlation between the t 1/2 ratios (1.37 and 1.30 for AR-C239 and atropine respectively) observed in the control muscles at 6 h. The in vitro slowing is thus due to some change in the longitudinal muscle and not to a change in the receptors. The in vitro slowing occurred when either phenylephrine or methoxamine was the alpha 1-adrenoceptor agonist used. The most likely mechanism of desensitization is a non-specific slowing of the access of drugs to receptors.