Mid-term results after Epic xenograft implantation for aortic, mitral, and double valve replacement

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the mid-term results after implantation of the stented porcine xenograft (Epic valve with Linx anticalcification treatment) in elderly patients. METHODS: A total of 1,368 patients undergoing aortic valve replacement (AVR; n = 1,168), mitral valve replacement (MVR; n = 101) or double valve replacement (DVR; n = 105) between November 2001 and November 2006, was evaluated. The indication for Epic implantation was patient age > or = 70 years, with pathology not amenable to valve repair. Outcome was assessed by reviewing a prospectively acquired hospital database, in addition to annual clinical follow up. RESULTS: The mean patient age was 76 +/- 6 years (AVR), 73.7 +/- 6 years (MVR), and 73.1 +/- 7 years (DVR); among these patient subgroups, 50.3%, 65.3% and 57.7%, respectively, were female, and 16.4%, 25.5% and 40.0% presented with endocarditis. The logistic EuroSCORE predicted risk for mortality was 14.1 +/- 14%, 19.3 +/- 18%, and 20.3 +/- 20%, respectively. Additional surgical procedures included mitral valve repair in 103 patients (all AVR), CABG in 587 patients (515 AVR, 29 MVR, 43 DVR), left atrial ablation therapy in 70, 16 and nine patients respectively, and surgery on the thoracic aorta in 54, zero and 12 patients, respectively. The mean aortic cross-clamp time was 72 +/- 28, 84 +/- 44 and 133 +/- 48 min after AVR, MVR and DVR, respectively. Freedom from stroke events after five years was 99.0 +/- 0.3%, 97.3 +/- 1.9% and 100%, respectively; freedom from bleeding events after five years was 99.5 +/- 0.2%, 100% and 99.0 +/- 1.0%, and actuarial freedom from reoperation due to prosthetic valve endocarditis 98.9 +/- 0.7%, 96.7 +/- 1.9% and 92.4 +/- 3.4%. Among these patients groups, early mortality was 8.0 +/- 0.8%, 17.8 +/- 3.8% and 21.9 +/- 4.0%, and five-year survival 77.0 +/- 4.1%, 71.7 +/- 4.5% and 55.5 +/- 6.3%. Perioperative survival in non-endocarditis patients undergoing isolated valve surgery was 95.8 +/- 0.9%, 96.4 +/- 3.5% and 90.0 +/- 6.7% after AVR, MVR or DVR, respectively, while the five-year survival was 90.6 +/- 1.5%, 89.3 +/- 5.8% and 90.0 +/- 6.7%. CONCLUSION: Clinical outcome at five years after porcine valve replacement using the Epic xenograft was satisfactory in elderly patients. The clinical effectiveness of the Linx anticalcification treatment remains to be proven during longer-term follow up.     

Chirurgische Koronarrevaskularisation am schlagenden Herzen

Since the introduction of off-pump coronary artery bypass grafting (OPCAB) for coronary multivessel disease there was growing interest to evaluate the impact of OPCAB surgery compared to conventional coronary artery bypass grafting (CCAB) with cardiopulmonary bypass and cardioplegic arrest. However, subsequent prospective randomized studies and meta-analyses comparing OPCAB and CCAB surgery were performed on low-risk patients or mixed-risk populations. They usually failed to demonstrate a significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events. In recent years, efforts were made to analyze the meaning of beating-heart concepts for patients with specific cardiac and extracardiac risks like ischemic cardiomyopathy, older age, renal failure, acute coronary syndrome, left main stenosis and others. For these subsets of patients several mono- and multicenter studies are available today. Even if most of them were nonrandomized and thus failed to reach evidence level A according to the AHA/ACC (American Heart Association/American College of Cardiology) definition, they still allow analyzing interim results for each specific perioperative risk factor. Particularly multi-risk patients and patients with severely reduced left ventricular function seem to benefit in terms of perioperative mortality and major morbidity by avoiding cardiopulmonary bypass and cardioplegic arrest. Analyzing early results and long-term follow-up of 364 patients with severely reduced ejection fraction<20%, the authors found a long-term benefit for patients when using OPCAB strategies particularly due to reduced perioperative mortality. Moreover, for most subsets of patients with significant extracardiac risk factors the incidence or perioperative stroke was reduced. In patients with preoperative renal and pulmonary dysfunction a decrease of corresponding organ failure was found for OPCAB strategy. For most risk populations transfusion requirements were significantly lower in OPCAB compared to CCAB surgery. In none of the patients an unfavorable outcome of beating-heart surgery compared to CCAB was shown. For emergency patients with an acute coronary syndrome presenting stable and unstable hemodynamics the authors found a clinical benefit by using beating-heart strategies. Particularly in patients with cardiogenic shock, cardiopulmonary bypass was often required to guarantee adequate perioperative organ perfusion. However, these patients seemed to benefit from avoiding global cardiac ischemia and maintaining native coronary blood flow. Follow-up results were comparable for these patients. In conclusion, beating-heart coronary artery bypass grafting seems to be advantageous in various risk populations and should be considered for patients with more than average risks for cardiopulmonary bypass and cardioplegic arrest.     

Beating heart aortic valve replacement after previous coronary artery bypass surgery with a patent internal mammary artery graft

Re-sternotomy for aortic valve replacement (AVR) in patients with a patent internal mammary artery (IMA) graft may present a challenging surgical problem. Thus, strategies to prevent IMA graft injury include avoiding its dissection and leaving the graft open. However, when aortic cross clamping and cardioplegia are required, this approach may be associated with cardioplegia washout, suboptimal myocardial protection, and anterior myocardial wall injury. We herein describe an alternative technique for AVR on the beating heart in 4 patients with patent IMA grafts. The IMA was left unclamped and continuous retrograde coronary sinus perfusion (RCSP) was administered. Additional simultaneous antegrade venous bypass graft perfusion was established according to the extent of native coronary artery disease as well as patency and level of aortic proximal anastomoses. Using additional coronary ostia backflow control, the aortic valve was successfully replaced on the beating heart in all four cases without perivalvular leak. Postoperatively, low creatine kinase-MB fraction levels and preserved or improved ventricular function suggested very good myocardial protection. No myocardial infarction occurred in any patient. In our experience, aortic valve replacement on the beating heart using simultaneous antegrade-retrograde blood perfusion is a safe and effective method in this challenging subset of patients to prevent myocardial injury and to minimize the risk of patent IMA injury.     

Exercise training but not rosiglitazone improves endothelial function in prediabetic patients with coronary disease

BACKGROUND: Impaired glucose tolerance (IGT) is associated with endothelial dysfunction and upregulation of inflammatory markers, which is potentially reversible by adequate treatment. It was our aim to compare the impact of exercise training with that of rosiglitazone on endothelial function and inflammatory markers in patients with IGT and coronary artery disease (CAD). METHODS: Patients with IGT and CAD were randomly assigned to either exercise training (n=13), rosiglitazone (8 mg; n=11), or a control group (n=10). During the first week, exercise training consisted of 6 x 15 min/d followed by three weeks of 30 min/d submaximal ergometer exercise. In addition, group exercise training of 1 h was performed twice per week. RESULTS: After 4 weeks, triglycerides and uric acid were significantly lower in the exercise group whereas fasting glucose, HbA1c, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, C-reactive protein, fibrinogen, and body mass index did not differ between groups. In the exercise group, exercise capacity (123+/-33 vs. 144+/-31 W; P=0.006) and endothelium-dependent, flow-mediated vasodilatation (P<0.01) increased significantly, whereas in the rosiglitazone group and in the control group (P=n.s.) no changes were seen. CONCLUSION: In patients with IGT and CAD, 4 weeks of exercise training exert significant and superior improvement of endothelium-dependent vasodilatation as compared with rosiglitazone therapy or usual care. This finding should be seen as an even further encouragement to recommend and, where available, prescribe exercise training to our patients.     

Tempor?re Herz- und Lungenunterstützung

Since the invention of the first heart?Clung machine in the 1950s, there has been tremendous progress towards smaller and more efficient devices for extracorporeal circulation (ECC). Today, various types and models of assist devices for temporary support of cardiac and pulmonary function are available. These systems can be active (with a pump) or passive using arterial pressure to transport the blood through the extracorporeal components. Within this extracorporeal circulation, the blood is oxygenated and/or only CO₂ is eliminated from the blood. Finally, the blood is transported back into the venous or arterial system. This article explains the different modes of temporary extracorporeal life systems (ECLS) as well as their indications, risk and management.     

Impact of carbon coating on the restenosis rate after stenting of atherosclerotic renal artery stenosis.

PURPOSE: To investigate the impact of carbofilm coating and low-profile rapid exchange stent devices on the restenosis rate after stent-angioplasty of atherosclerotic renal artery stenosis (RAS). METHODS: During a 2-year period (7/2002-7/2004), 143 consecutive patients with 179 primary ostial atherosclerotic RAS>or=70% diameter stenosis were treated with stents selected at the discretion of the operator. Eighteen patients (32 lesions) treated with 9 different types of stents were excluded from the analysis, leaving 125 patients (69 men; mean age 67 years, range 42 to 90) with 147 lesions who received either a Radix carbofilm-coated stent in 78 (53%) lesions (68 [54%] patients) or a Palmaz Genesis bare stainless steel stent in 69 (47%) lesions (57 [46%] patients). The target vessel diameter ranged from 5 to 7 mm. RESULTS: Baseline characteristics were similar in both groups except the mean stent diameter, which was larger in the bare stent cohort (6.4+/-0.7 versus 5.9+/-0.5 mm, p<0.001). Primary success was 100% in both groups; the initial mean diameter stenosis was reduced from 79%+/-14% and 80%+/-14% in the coated versus bare stent groups to 3+/-5% and 2+/-6%, respectively. After a mean follow-up of 22+/-5 months, the restenosis rate was 6.4% for the coated stent and 5.8% for the bare stent (p=0.87). For the entire cohort, restenosis rates varied significantly (p<0.05) according to stent diameter: 19% (5/26) for 5 mm, 4% (3/81) for 6 mm, and 2.5% (1/40) for 7 mm. In a binary logistic regression analysis including carbofilm coating, stent diameter, gender, diabetes, smoking status, and body mass index, stent diameter was the only independent predictor of restenosis (odds ratio 0.12, 95% CI 0.03 to 0.48 [p=0.003] for a 1-mm increase in vessel diameter). CONCLUSIONS: Using modern low-profile stent devices, carbofilm coating does not significantly reduce the restenosis rate compared to a bare metal stent. With contemporary stent devices, the restenosis rate has been decreasing compared to earlier reports in the literature.     

Whose consent matters? Controlled donation after cardiac death and premortem organ-preserving measures

The goal of this overview is to discuss the ethics of premortem organ-protective measures with the aim of improving donation outcome for the recipient. A literature review was undertaken to find out which such measures were implemented in published articles on controlled donation after cardiac death. We reviewed studies on controlled human organ donation after cardiac death that were published in PUBMED and EMBASE between 2000 and 2010. To fit the inclusion criteria, studies had to describe the procedures that took place before the donor's death. We found 35 studies that were undertaken in six countries. Twenty-one of these studies mentioned the use of premortem measures on the donor that had the aim to improve the outcome of donation for the recipient. These measures illustrated a wide spectrum of invasiveness. The authors conclude that premortem measures have the potential to instrumentalize the organ donor and that they should be restricted to cases in which the donor wish is known-directly, through a donor card, or through a surrogate decision maker-and specific consent to premortem procedures has been given. This specific consent should be required at least until the general public is aware that premortem measures may be performed. If potential donors were informed about premortem measures as part of a community information effort, for example, school curricula, and again when they signed their donor card, one might consider their consent to be truly informed and valid.