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A 74-year-old woman presented with progressive dyspnea on exertion. Transthoracic echocardiography (TTE) demonstrated significant left ventricular outflow tract (LVOT) obstruction with a pressure gradient of 100 mmHg caused by a sigmoid septum (SS). Mitral regurgitation (MR) of a mild to moderate degree occurred due to systolic anterior motion (SAM) of the anterior mitral leaflet (AML), with no intrinsic mitral valve (MV) abnormality. Myectomy of the hypertrophied septal bulge ameliorated the pressure gradient to 8 mmHg with similar MR. However, just before the sternal closure, hemodynamic status deteriorated drastically to ventricular fibrillation. MR exacerbated to a severe degree with an uncertain etiology; thus, a mechanical prosthetic valve was implanted. The postoperative course was complicated by prolonged mechanical ventilation due to massive pulmonary edema and complete atrioventricular block (CAVB) requiring permanent pacemaker implantation. One year postoperatively, the patient is asymptomatic and TTE revealed no residual pressure gradient with an iatrogenic ventricular septal defect (VSD). This case, the first published surgical experience of SS, may indicate that secondary MR, which is usually relieved by sufficient myectomy in hypertrophic cardiomyopathy (HCM), can exacerbate markedly, and that myectomy might not be advisable in SS. The therapeutic strategy must be considered carefully before embarking on surgical intervention.

A 50-year-old man underwent repeat surgery for a benign vagal schwannoma in the middle mediastinum. He had undergone tumor enucleation at another hospital 4 months before presentation. The tumor (99 × 88 × 76 mm) was located in the aortopulmonary window and arose from the left vagus nerve. It had been enucleated, leaving its sheath behind to preserve the nerve. Imaging studies showed tumor regrowth without distant metastasis, and the tumor was extirpated along with the involved nerve during cardiopulmonary bypass. There was no nerve dysfunction, recurrence, or metastasis 6 months after the operation. A benign vagal schwannoma can be excised with nerve transection or enucleated without nerve transection. The present case suggests that a vagal mediastinal schwannoma should be extirpated along with the nerve because insufficient enucleation might lead to tumor regrowth.

Aldosterone prevents norepinephrine uptake and promotes structural remodeling of the heart. Spironolactone is well known to have an anti-aldosteronergic effect, and this agent could improve cardiac sympathetic nerve activity (CSNA) in patients with chronic heart failure (CHF). On the other hand, we previously reported that the delta washout rate (WR) determined from serial (123)I-MIBG scintigraphic studies is the best currently available prognostic value in patients with CHF.In total 208 patients with CHF (left ventricular ejection fraction [LVEF]45%), but no cardiac events for at least 5 months, were identified on the basis of a history of decompensated acute heart failure requiring hospitalization. These patients underwent (123)I-MIBG scintigraphy and echocardiography just before leaving the hospital and after 6 months of treatment. The patients were retrospectively divided into a spironolactone (n=82) and a non-spironolactone (n=126) group.The extents of changes in (123)I-MIBG scintigraphic and echocardiographic parameters in the spironolactone group were significantly better than those in the non-spironolactone group. Of the 208 patients, 56 experienced fatal cardiac events during the study. The mean follow-up period was 4.45+/-1.82 years. On Kaplan-Meier analysis, the rate freedom from cardiac death was 81.7% (67/82) in the spironolactone group and 67.5% (85/126) in the non-spironolactone group (P0.05). Moreover, stepwise multivariate analyses showed spironolactone therapy to have the most independent and significant negative relationship with delta-WR, during the period from hospital discharge until 6 months after starting treatment, in patients with CHF (P0.001).Spironolactone treatment improves CSNA and prevents LV remodeling in patients with CHF. Furthermore, this agent is potentially effective for reducing the incidence of fatal cardiac events in CHF patients.

Aim: The goal of this study was to analyze differences in risk factors, including the level of brain natriuretic peptide (BNP) and the distribution of lesions, between cases of critical limb ischemia (CLI) and intermittent claudication (IC) among patients with peripheral arterial disease. Methods: Risk factors and clinical characteristics were prospectively investigated in 817 consecutive patients, including 185 patients with CLI and 632 patients with IC. Results: The patients in the CLI group were older than those in the IC group (p ＜0.001). The prevalence of diabetes and cerebral infarction and the proportion of women were higher in the CLI group (p＜0.05). The plasma BNP levels in the CLI group were higher than those observed in the IC group (333±538 vs. 136±354 pg/mL, p＜0.001). In contrast, the levels of homocysteine and fibrinogen were higher and the levels of albumin and the estimated glomerular filtration rate were lower in the CLI group (p＜0.05). According to a multiple logistic analysis, the BNP level, diabetes, female gender, the albumin level, body mass index (BMI) and ankle-brachial pressure index (ABI) were associated with CLI (p＜0.05). Aortoiliac artery lesions were less common, whereas femoropopliteal and below-the-knee (BK) lesions were more common, in the CLI group (p＜0.05). The number of affected BK arteries was also higher in the CLI group (p＜0.001). Correlations were found between the presence of aortoiliac lesions and smoking and a low HDL cholesterol level, while femoropopliteal lesions were found to correlate with age, BMI and hypertension and BK lesions were found to correlate with diabetes, age, female gender and BMI (p＜0.05). The plasma BNP level correlated with the number of affected BK arteries (p＜0.05). Conclusions: A high BNP level, diabetes, female gender, a low albumin level, ABI and BMI are risk factors for CLI. In this study, differences in the levels of anatomical lesions and correlated risk factors were found between the CLI and IC groups. J Atheroscler Thromb, 2013; 20:798-806.

Late ventricular potentials (LPs) are considered to be useful for identifying patients with heart failure at risk of developing ventricular arrhythmias. 123I-metaiodobenzylguanidine (MIBG) scintigraphy, which is used to evaluate cardiac sympathetic activity, has demonstrated cardiac sympathetic denervation in patients with malignant ventricular tachyarrhythmias. This study was undertaken to clarify the relationship between LPs and 123I-MIBG scintigraphy findings in patients with dilated cardiomyopathy (DCM). A total of 56 patients with DCM were divided into an LP-positive group (n = 24) and an LP-negative group (n = 32). During the compensated period, the delayed heart/mediastinum count (H/M) ratio, delayed total defect score (TDS), and washout rate (WR) were determined from 123I-MIBG images and plasma brain natriuretic peptide (BNP) concentrations were measured. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and left ventricular ejection fraction (LVEF) were simultaneously determined by echocardiography. LVEDV, LVESV, LVEF and plasma BNP concentrations were similar in the two groups. However, TDS was significantly higher (35 ± 8 vs. 28 ± 6, p

The goal of the study was to examine possible sex-related differences in the clinical characteristics and risk factors in Japanese patients with peripheral arterial disease (PAD).Sex-related differences in clinical profiles, risk factors and treatments were examined in 730 consecutive patients with PAD (148 women (20.3%) and 582 men (79.7%)).The mean age of the women was higher than that of the men (73.6 ± 11.2 vs. 70.9 ± 9.1 years old, p = 0.002) and the proportion of subjects aged ≥ 75 years old was also higher in women (P=0.005). Women more frequently had critical limb ischemia (P0.001) and diabetes mellitus (P = 0.026), but less frequent smoking and alcohol intake, compared to men (P0.001). Total cholesterol (P0.001) and LDL cholesterol (P = 0.014) were higher in women. Fontaine stages were correlated with age, diabetes, cerebral infarction and women (p0.001). The prevalence of iliac artery lesions was higher in men (p0.001), whereas that for below the knee lesions was higher in women (p0.001). The number of affected below the knee arteries was also higher in women than in men (p0.001). The prevalence of medical treatment was higher in women (P = 0.009) and major amputation tended to be higher in women (p = 0.056).Women had more severe symptomatic states and uncontrolled risk factors. The prevalence of iliac artery lesions was lower, but below the knee lesions were more severe in women.

Blood pressure increases in many women after menopause. Ovarian hormones, particularly estrogen, may be responsible, at least in part, for the lower blood pressure in premenopausal women. However, the mechanisms responsible for the increase in blood pressure in women after menopause are not yet fully known. In this article, we focused on estrogens and reviewed the effects of estrogen on the clinic blood pressure in women. Oral high-dose conjugated equine estrogen (CEE) administration and oral contraceptive use have been reported to increase the blood pressure in women. On the other hand, although oral common- and low-dose CEE administration had little effect on the blood pressure in younger postmenopausal women, oral common-dose CEE administration produced a slight increase of the blood pressure in older postmenopausal women with or without an established coronary heart disease. Transdermal 17β-estradiol had either no effect or produced a slight decrease in blood pressure in postmenopausal women. Raloxifene had no effect on blood pressure in postmenopausal women. In addition, concomitant administration of progestogens had little additional effect on the blood pressure in women receiving estrogen therapy. Oral high dose of CEE administration and oral contraceptive administration to post- and premenopausal women, respectively, and oral common-dose CEE administration to older postmenopausal women with or without established coronary heart disease should call for caution, particularly in individuals with uncontrolled hypertension. Further large, long-term, controlled, randomized studies are needed to confirm these findings.

Background We previously reported the development of a new surgical technique, called the "less invasive quick replacement" technique, for treating type A acute aortic dissection. This study examines the midterm outcome and postoperative quality of life of octogenarian patients who underwent less invasive quick replacement. Methods During the last 3 years, 27 patients underwent less invasive quick replacement. The average age of the patients at the time of onset was 81.7 years old. During open distal anastomosis with a rectal temperature of 28°C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40°C. As soon as the distal anastomosis was completed, rapid rewarming was initiated by 40°C blood perfusion. We assessed the midterm outcomes in terms of survival and cardiovascular event-free rates, patency of the distal false lumen, aortic regurgitation, and cognitive disorders. Results The durations of circulatory arrest, cardiopulmonary bypass, overall operation, postoperative mechanical ventilation, and hospital stay were 18.7 minutes, 82.8 minutes, 143.4 minutes, 13.0 hours, and 12.2 days, respectively. Hospital mortality rate was 3.7% (1 patient). There were no incidences of brain damage, renal failure, or respiratory failure. At the time of this study, 25 of the patients were doing well and visiting the outpatient clinic, and 22 of them scored more than 20 points on the Mini-Mental State Examination, indicating no development of dementia. Midterm computed tomography scans detected the patent false lumen in 11.5%. No aortic regurgitation was found in the echocardiography. Actuarial survival and cardiovascular event-free rates at 3 years were 96.2% and 83.0%, respectively. Conclusions The less invasive quick replacement technique is safe and effective. It is a very attractive option that can contribute to maintaining a long-term good quality of life for octogenarians with type A acute aortic dissection.

Background ATS Medical, Inc, developed a mechanical heart valve that has been in use since 1992. In this article, we present the results of 15 years of follow-up of patients who have undergone ATS heart valve replacement at our hospital. Methods and Results We performed ATS heart valve replacements on 231 patients between September 1993 and March 2008. Our operative mortality rate for the study period was 2.2%. The survival for postoperative thromboembolic events was 0.29%/pt-y for aortic valve replacement, 0.48%/pt-y for mitral, 0.80%/pt-y for double valve replacement, and overall 0.44%/pt-y. The survival after bleeding events was 0.29%/pt-y for aortic valve replacement, 0.16%/pt-y for mitral, 0%/pt-y for double valve replacement, and overall 0.19%/pt-y. Patient–prosthesis mismatch, as determined by echocardiography, was found in 83.3% of patients at 19 mm, but other sizes showed good valve function. Prosthetic valve noise was undetectable in 92.8% of patients, and quality of life was excellent. Conclusions Few prosthetic valve–related complications were seen with ATS heart valve replacements in this study, and the follow-up results were favorable. The international normalized ratio was maintained in the range 1.6 to 2.0 in patients with aortic valve replacement in sinus rhythm. Not only bleeding events, seen at a rate of 0.19%/pt-y, but also thromboembolic events, at 0.44%/pt-y, were low when compared with conventional mechanical valves. Prosthetic valve noise is low, and this appears to be an excellent mechanical valve from the quality of life standpoint. The ATS valve has an excellent safety profile when compared with other mechanical valves.

Objectives Continuous low-dose infusion of human atrial natriuretic peptide (hANP) in patients undergoing cardiac surgery on cardiopulmonary bypass (CPB) inhibits the renin-angiotensin-aldosterone system and compensates for the adverse effects of CPB. Background We examined the influence of hANP infusion on cardiac and renal function in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Methods The subjects were 133 patients who underwent CABG and had a pre-operative ejection fraction ≤35%. They were randomized to receive 0.02 μg/kg/min of hANP from the initiation of CPB (hANP group) or placebo (saline) infusion. Results Early post-operative mortality did not show a significant difference between the 2 groups, but perioperative complications were significantly less frequent in the hANP group (p = 0.015). Long-term all-cause mortality showed no difference, but the cardiac death-free rate at 5 or 8 years post-operatively was 98.5% in the hANP group and 85.5% in the placebo group (p = 0.0285). Post-operative ejection fraction was significantly larger and the post-operative brain natriuretic peptide level was significantly lower in the hANP group. Serum creatinine was significantly lower in the hANP group than the placebo group at 1 month, 6 months, and 1 year post-operatively, whereas the estimated glomerular filtration rate was significantly higher in the hANP group at these times. Conclusions In patients with left ventricular dysfunction undergoing CABG, hANP showed renal- and cardio-protective effects and reduced post-operative complications. It also improved the long-term prognosis. We suggest that hANP should be considered as part of perioperative management of patients with cardiac dysfunction undergoing cardiac surgery. (NU-HIT trial for LVD; UMIN000001652 )

Background We assessed the efficacy of aggressive lipid controlling therapy (ALCT), which maintains low-density lipoprotein cholesterol (LDL-C) below to 80 mg/dL and LDL/high-density lipoprotein cholesterol (HDL-C) ratio less than 1.5 for preventing postcoronary bypass (CABG) saphenous vein graft (SVG) diseases by using intracoronary angioscopy. Methods Twenty-one patients after CABG were divided into two groups: group I consisted of 10 patients whose serum LDL-C level and LDL/HDL could be controlled less than 80 mg/dL and 1.5, respectively, by rosuvastatin for about one year; group II consisted of 11 patients whose LDL-C level and LDL/HDL have been higher than 100 mg/dL and 2.5, respectively, regardless of having medication of pravastatin. Twenty-seven SVGs were assessed by intravascular ultrasound (IVUS) and angioscopy on postoperative 12 to 16 months. Results The serum LDL-C level (I: 64.1 vs II: 130.2 mg/dL) and LDL/HDL (I: 1.36 vs II: 2.64), and high sensitive C-reactive protein (I: 0.045 ± 0.100 vs II: 0.116 ± 0.020 mg/dL) were significantly lower in group I. In group II, IVUS detected eccentric plaques in 11 (78.6%) of 14 SVGs. Furthermore the angioscope showed yellow plaque in all 14 SVGs (100%) and 11 (78.6%) of them had thrombi. On the other hand, in group I, all 13 SVGs had no eccentric, yellow plaques or thrombi and the intima was entirely clear white. Conclusions Prophylactic treatment for yellow plaque and thrombus formation are extremely important in the development of early and late SVG disease. Aggressive lipid controlling therapy is quite attractive to avoid post CABG SVG disease and may be effective to maintain the long-term graft patency.

Objective Atrial fibrillation after cardiac surgery is a frequent complication. In this study we studied various factors in addition to trying to identify a marker that would predict the potential for atrial fibrillation before surgical intervention to prevent its occurrence. Methods We targeted 234 cases in which isolated coronary artery bypass grafting had been performed. The items for study included age, EuroSCORE, and maximum values of creatine phosphokinase–MB, troponin I, and angiotensin II after surgical intervention and preoperative values of atrial natriuretic peptide, brain natriuretic peptide, and C-reactive protein. As fibrotic markers, we measured levels of the sialylated carbohydrate antigen KL-6 in the blood, hyaluronic acid, and pyridinoline cross-linked carboxyterminal telepeptide of type I collagen C. At the time of surgical intervention, a section of the right atrium was extracted, and atrial natriuretic peptide, the sialylated carbohydrate antigen KL-6, hyaluronic acid, and pyridinoline cross-linked telopeptide of type I collagen levels were measured. Results Atrial fibrillation was observed in 73 (31.2%) cases, and preoperative factors that showed statistically significant differences in the occurrence of atrial fibrillation included age, EuroSCORE, and preoperative values of atrial natriuretic peptide, angiotensin II, the sialylated carbohydrate antigen KL-6, hyaluronic acid, and pyridinoline cross-linked telopeptide of type I collagen in the blood. As for intraoperative and postoperative factors, statistically significant differences were observed in the postoperative maximum of angiotensin II, atrial natriuretic peptide of the right atrium, the sialylated carbohydrate antigen KL-6, hyaluronic acid, and pyridinoline cross-linked telopeptide of type I collagen levels. Conclusion The fibrosis of tissue associated with age is believed to be closely related to the occurrence of atrial fibrillation after coronary artery bypass grafting. This study suggests that the preoperative values of atrial natriuretic peptide, angiotensin II, the sialylated carbohydrate antigen KL-6, hyaluronic acid, and pyridinoline cross-linked telopeptide of type I collagen in the blood are useful as a new index for the occurrence of atrial fibrillation after coronary artery bypass grafting.

The effectiveness of the ATS valves includes their durability and the quietness of the valve sound. However, a cine-fluoroscopic study revealed an incomplete opening of the valve leaflet. An overall evaluation of the ATS valve was conducted by transesophageal echocardiography.The patients were divided into two groups based on the opening angle (OA): Group A, with a maximum OA of 80 degrees or greater and Group B, with a maximum OA of under 80 degrees.In Group A, the peak pressure gradient (PPG) sites of the anterior, central and posterior mitral commissure were 8.17, 8.05, and 8.09 mmHg, respectively, with no significant differences among the three sites. Similar results were obtained for Group B; the PPG at the three respective measurement sites were 8.59, 8.43, and 8.51 mmHg, and the differences were not statistically significant. No statistically significant differences were observed in the mean pressure gradient or pressure half time among the three measurement sites or between the two patient groups.Although, in many cases, the ATS valves did not open completely, the incomplete valve opening did not pose any problems in the valve function itself or in the cardiac functions of the patients.

Background The mid-term outcome of quick proximal arch replacement with moderate hypothermia followed by aggressive rapid re-warming in emergency surgery for type A acute aortic dissection (AAD) was assessed. Methods and Results Eighty-five patients were divided into 2 groups: group I consisted of 43 patients undergoing surgery for deep hypothermic circulatory arrest and selective cerebral perfusion; and group II consisted of 42 patients who recently underwent aggressive rapid re-warming. During open distal anastomosis in group II patients with a rectal temperature of 28°C but who did not suffer any cerebral perfusion, circulating blood in the cardiopulmonary bypass (CPB) circuit was warmed to 40°C. As soon as distal anastomosis was completed, rapid re-warming was initiated by a 40°C blood perfusion. The duration of CPB (I: 182.1 vs II: 85.3 min), overall operation (305.0 vs 150.8 min), postoperative mechanical ventilation (44.3 vs 9.1 h), and hospital stay (31.4 vs 9.6 days) were significantly shorter in group II patients. The incidence of postoperative brain complication (I: 14.0 vs II: 2.4%), renal failure (14.0 vs 0%), pneumonia (18.6 vs 4.8%), and mortality (9.3 vs 0%) was significantly less in group II patients. Conclusions Moderate hypothermia followed by a rapid re-warming procedure was safe and effective in the proximal arch replacement for AAD. (Circ J 2009; 73: 69 - 72)

ObjectiveWe assessed the efficacy of our newly modified technique, namely, less invasive quick replacement with rapid rewarming, for octogenarians undergoing emergency surgery for type A acute aortic dissection.MethodsForty-two patients with acute aortic dissection, whose average age was 81.7 ± 2.3 years, were divided into two groups: group I consisted of 25 patients undergoing surgery with deep hypothermic circulatory arrest and selective cerebral perfusion; group II consisted of 17 recent patients who underwent less invasive quick replacement. In the latter technique, during open distal anastomosis with a rectal temperature of 28°C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40°C accompanied by warming of the patient's body by a heating mat. As soon as the distal anastomosis was completed, rapid rewarming was initiated by 40°C blood perfusion.ResultsThe durations of cerebral protection (group I, 75.8 minutes, vs group II, 18.8 minutes), cardiopulmonary bypass (I, 201.2, vs II, 84.4 minutes), and overall operation (I, 425.6, vs II, 148.6 minutes) were significantly shorter in group II. In group I, 5 patients had complications of cerebral damage and 5 required re-exploration for bleeding, 7 had pneumonia, 6 required hemodialysis for renal failure, and the hospital mortality rate was 24% (6 patients). On the other hand, no such complications or mortality were observed in group II (P < .0291). Postoperative hospital stay was significantly shorter for the patients in group II than in group I (13.2 days vs 33.7 days; P < .0001).ConclusionLess invasive quick replacement is safe and effective. It should be a standard surgical technique for octogenarians with type A acute aortic dissection.

Objective The number of octogenarians undergoing emergency surgery is increasing and may negate the impact of the beneficial advances. The aim of this study was to review octogenarians with type A acute aortic dissection and assess the prognosis. Methods Fifty-eight patients with acute aortic dissection, whose average age was 83.2 years, were divided into 2 groups: Group I comprised 30 patients who underwent emergency surgery, and group II comprised 28 patients who were treated conservatively. We compared the 2 groups in terms of mortality and morbidity. Results In group I, postoperative hospital mortality was 13.3% (4 patients). In group II, 17 patients (60.7%) died in the hospital. In group I, although emergency aortic replacement was successfully completed, 5 patients became bedridden after surgery and 2 patients died of pneumonia or stroke in the early stages of institutional care. Thirteen patients in group I died of malignancies, abdominal aortic rupture, traffic accident, heart failure, or late-stage senility in later phase. There was no difference in actuarial survivals at 5 years, which were 48.5% in group I and 35.4% in group II. Conclusion Emergency surgery for octogenarians with acute aortic dissection showed acceptable mortality. However, families had to take responsibility for patients who experienced unconsciousness, had dementia, or became bedridden. It is important to have consensus between the family and surgeons about emergency surgical treatment for octogenarians.

Cardiac retransplantation is controversial therapy because of a chronic shortage of donor hearts. We retrospectively reviewed short- and long-term outcomes after cardiac retransplantation. Between February 1989 and December 2004, 28 cases of cardiac retransplantation were performed. Indications for retransplantation were primary graft failure (PGF) in 11 patients (39.3%), intractable acute cardiac rejection (IACR) in 4 (14.3%), and coronary allograft vasculopathy (CAV) in 13 (46.4%). The patients had been supported with prolonged cardiopulmonary bypass (CPB) (n = 3), IABP (n = 1), intravenous inotropic support (n = 7), ECMO (n = 3), and VAD (n = 4). Ten patients had no inotropic support. Eight patients died within 30 days postoperatively. The causes of early death were acute rejection (n = 3 ; 37%), MOF (n = 3 ; 37%), PGF (n = 1 ; 13%), and right ventricular failure (n = 1 ; 13%). The causes of late death in 8 other patients were acute rejection (n = 4 ; 50%), CAV (n = 2 ; 25%), MOF (n = 1 ; 13%), and infection (n = 1 ; 13%). The 1-, 5-, 10-, and 15-year survivals were 78.5, 68.4, 54.5, and 38.3%, respectively, for primary cardiac transplantation, and 46.4, 40.6, 32.5, and 32.5% for cardiac retransplantation (P = 0.003). Acute cardiac rejection was the most common cause of death (43.8%). Thirty-day and 1-year survivals of IACR, PGF, and CAV were 50.0/0, 63.6/45.5, and 84.6/68.4%, respectively. Long-term survival after retransplantation was acceptable for patients with CAV and PGF, however, we should select patients carefully if the indication for retransplantation is IACR because of the poor outcome.

Summary Heart transplantation is the most effective therapy for end-stage heart failure in patients with diabetes mellitus (DM). However, diabetes-related complications (DRCs) are a relative contraindication for heart transplantation. Nevertheless, the increasing prevalence of both DM and congestive heart failure makes it necessary to perform heart transplantation even in those patients with advanced DM. We performed a retrospective analysis on long-term survival in 47 patients with insulin-treated DM and DRCs (group 1). Survival rate and causes of death were compared with data of a group of heart transplant recipients without DM (n = 1061, group 2). Mean follow-up time of all heart transplant recipients was 68.2 months (range: 0–204 months). Overall mortality during follow-up was 42.9%. Long-term survival did not differ significantly between study groups, but tended to be shorter in group 1 than in group 2 (P = 0.07). In group 1, steroid-free immunosuppressive therapy was associated with a higher percentage of long-term survivors compared with no steroid-free immunosuppression. Our data demonstrate that long-term survival is acceptable in heart transplant recipients with preoperatively diagnosed DM and DRCs. Consequently, advanced DM should no longer be a relative contraindication for heart transplantation.

Background Low-dose continuous human atrial natriuretic peptide (hANP) administration during cardiac surgery has been reported on previously. In the present study, the efficacy of the therapy during emergent coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) is investigated. Methods and Results One hundred and twenty-four patients patients undergoing emergent CABG for ACS were divided into 2 groups; a group receiving administration of hANP (hANP group) and a group not receiving hANP infusion (non-hANP group). The postoperative peak levels of creatine kinase-MB were significantly lower in the hANP group as compared with those in the non-hANP group. The incidence of postoperative arrhythmias was also significantly lower in the hANP group as compared with that in the non-hANP group. The postoperative brain natriuretic peptide was significantly lower in the hANP group as compared with that in the non-hANP group until 1 year after the operation. The free-rate of cardiac events after the operation was also significantly higher in the hANP group as compared with that in the non-hANP group. Conclusions It is therefore considered that hANP might not only be effective for overcoming some major shortcomings of cardiopulmonary bypass, but also might be effective to attenuate ischemia-reperfusion injury, protect the myocardium, have an anti-arrhythmic effect, and suppress left ventricular remodeling. (Circ J 2007; 71: 1401 - 1407)

Background The long-term outcome of medical treatment in patients with type B acute aortic dissection (BAD) was assessed and predictors of early in-hospital death were investigated, as well as the need for surgical intervention. Methods and Results In the past 11 years, 180 patients were admitted to hospital and medically treated at the time of onset. If the maximum diameter of the dissected aorta exceeded 60 mm, or rapid enlargement or vital organ ischemia were identified, early or elective surgery was performed. Emergency operation was required in 7 patients. Elective surgery was required for 31 patients (19.1%). The operation-free rate was 76.0% at 10 years. Actuarial survival rate was 89.4% at 5 years and 71.8% at 10 years. Multivariate analysis indicated that refractory hypertension (odds ratio (OR), 4.08, 95% confidence interval (CI), 3.06-21.44, p=0.0434) and rupture (OR 5.87, 95% CI, 2.21-9.12, p=0.0154) were predictors of early hospital mortality. The only significant predictor for elective surgery was a maximum diameter exceeding 40 mm at the time of onset (OR 13.4, 95% CI, 1.93-6.89, p=0.0003). Conclusions Medical treatment for BAD produced good results. Strict control of blood pressure is important for patients with a dissected aortic diameter exceeding 40 mm at the time of onset. (Circ J 2007; 71: 1279 - 1282)

Furthermore, it is difficult for individual cardiovascularsurgeons to gain sufficient experience outside high-volume centers because of the low incidence of surgicalcases. To perform this difficult surgical technique moreeasily,weusemade-to-ordersurgicalinstrumentsforresec-tionofthemembraneormuscleinpatientswithSAS.Thesesurgical instruments are custom-made for the depth andtargetangleinthetransaorticapproach.Wereporttheiruse-fulness in a sample surgical case of SAS.TECHNIQUE AND RESULTSInstrumentsHere we describe the special features of surgical instru-ments for resection of the subaortic region (Figure 1). Thescalpel has a total length of 22 cm and an angle of 140 at3 cm from the tip. It is used by attaching an edge to thetip. The scissors has a total length of 25 cm and an angleof160 rightinthemiddle.Theretractorshaveatotallengthof 30 cm and an angle of 120 at 5 cm from the tip with agroove.CaseAn 11-year-old girl had a diagnosis of discrete SAS withconstrictivepericarditis.Althoughshecouldnotreportsub-jective symptoms because of severe mental disability, weelectedtoperformpericardiotomywithresectionofthesub-aorticmembraneinlightofthehighpeakinstantaneous leftventricular outflow tract (LVOT) gradient of 80 mm Hg.Theoperationwasperformedthroughamediansternotomy.Afterpericardiotomy,thepatientwascooledto32 Cforce-rebral protection under cardiopulmonary bypass andsubsequentcardiacarrest.Afteraortotomy,thesubaorticre-gion was excellently exposed with angled retractors with agroove (Figure 2, A). The obstructive fibrous membrane,which appeared on the LVOT (Figure 2, B), and a part ofthe septal muscle were resected with a scalpel and scissorsangled to enter the septal muscle at a shallow angle(Figure 2, C and D). We confirmed passage of the diameterdilator(15mm).Afterweconfirmedthattherewasnoaorticregurgitation and no injury of the aortic valve, the incisionof the aorta was closed. The postoperative peak instanta-neous LVOT gradient was decreased, and this patient wasdischarged from the hospital on postoperative day 11.DISCUSSIONAlthoughearlysurgicalrepairofSASisassociatedwithasignificant recurrence risk and aortic regurgitation progres-sion,surgicalinterventionisrequiredinpatientswithahighLVOTgradient.

Tacrolimus (TAC) is a calcineurin inhibitor that is used for cardiac allograft rejection. Efficacy and safety data of a combined TAC/mycophenolate mofetil (MMF) therapy in comparison with a TAC/cortisone therapy in heart recipients are lacking. We analysed the clinical outcome of 41 patients who received TAC in combination with MMF (TMF group) and of 41 patients who received TAC in combination with cortisone (TCO group). Outcomes were serum creatinine levels, cardiac rejections, cytomegalovirus infections, graft vasculopathy, malignancy rates and two-yr survival. Baseline characteristics were comparable in the two study groups. During follow-up, serum creatinine levels decreased slightly in the TMF group (p=0.039) but not in the TCO group. Compared with the TMF group, more clinically proven cardiac rejections which needed a cortisone bolus and more severe rejections that needed lymphoablative therapy with OKT occurred in the TCO group (p=0.001 and 0.04, respectively). In contrast, significantly more cytomegalovirus (CMV) infections occurred in the TMF group compared with the TCO group (p=0.01). The number of patients with graft vasculopathy as well as malignancy rates and overall survival did not differ significantly between the two study groups. The introduction of MMF was associated with an improvement of renal function and a more efficient immunosuppressive therapy. However, this treatment strategy also had led to a higher CMV infection rate compared with cortisone. Consequently, no general recommendation can be given at present whether TAC should be combined with MMF or with cortisone in heart transplant recipients.

Background The aim of the present study was to evaluate the efficacy of α-human atrial natriuretic peptide (hANP) in cardiac surgery under cardiopulmonary bypass (CPB). Methods and Results A prospective randomized study was conducted with 150 patients who underwent scheduled coronary artery bypass grafting to compare a group of patients receiving 0.02 μg · kg-1 · min-1 of hANP from the initiation of CPB with a group not receiving hANP. Hemodynamics, levels of atrial and brain natriuretic peptides (BNP), angiotensin-II and aldosterone, renin activity, and left ventricular (LV) function were examined. The hANP group showed significantly lower renin activity and lower levels of angiotensin-II and aldosterone during the early postoperative period, compared with the non-hANP group. The incidence of postoperative ventricular arrhythmia and the postoperative peak level of creatine kinase-MB were significantly lower in the hANP group. BNP at 1 month after surgery and measures of LV function were also significantly lower in the hANP group. Conclusions Low-dose continuous infusion of hANP during cardiac surgery not only had a compensatory effect for the imperfections of CPB during the early postoperative period but also an inhibitory effect on postoperative LV remodeling and a reduction in ischemia/reperfusion injury. hANP should be part of the postoperative care for cardiac surgery. (Circ J 2006; 70: 1426 - 1431)

Aim The goal of the study was to investigate the relationships between coronary artery disease (CAD) and risk factors, including the serum levels of high-sensitivity C-reactive protein (hs-CRP), lipoprotein(a) (Lp(a)) and homocysteine, in Japanese patients with peripheral arterial disease (PAD). Methods Coronary angiography was performed in 451 patients with PAD, among whom the prevalence and clinical characteristics of CAD were analyzed. A multiple logistic analysis was used to evaluate the relationships between CAD and the risk factors. The relationships between the severity of coronary arterial lesions and the risk factors were evaluated using multiple regression analysis. Results The prevalence of CAD (≥70% luminal diameter narrowing or a history of CAD) and coronary artery stenosis (≥50%) was 55.9% and 74.1%, respectively, and the rate of CAD (≥70%) with single-, double- and triple-vessel disease was 25.9%, 13.5% and 10.6%, respectively. The prevalence of diabetes was higher among the patients with CAD than among those without. The serum levels of hs-CRP, Lp(a), and homocysteine were higher in the patients with CAD, whereas the estimated glomerular filtration rates and HDL-cholesterol levels were lower in these patients. According to the multiple logistic analysis, CAD was related to diabetes (hazard ratio [HR]: 2.253; 95% confidence interval [CI]: 1.137-4.464, p=0.020), hs-CRP (HR: 1.721; 95% CI: 1.030-2.875, p=0.038), Lp(a) (HR: 1.015; 95% CI: 1.001-1.029, p=0.041) and homocysteine (HR: 1.084; 95% CI: 1.012-1.162, p=0.021). Furthermore, diabetes and the D-dimer and LDL-cholesterol levels exhibited significant relationships with the number of stenotic coronary lesions in the stepwise multiple regression analysis (p＜0.05). Conclusions Diabetes, hs-CRP, Lp(a), homocysteine and lipid abnormalities are critical risk factors for CAD in Japanese patients with PAD.

Background International normalized ratio (INR) self-management can significantly reduce INR fluctuations, bleeding, and thromboembolic events compared with INR control managed by general practitioners. However, even patients with INR self-management may have an increased risk of bleeding if their INR value is above 3.5. This study evaluated the compliance, clinical complications, and survival of patients after mechanical heart valve replacement with low-dose INR self-management compared with conventional-dose anticoagulation. Methods Group 1 (n = 908) received low-dose anticoagulation with a target INR range of 1.8 to 2.8 for aortic valve replacement and 2.5 to 3.5 for mitral or double valve replacement. Group 2 (n = 910) received conventional-dose anticoagulation with a target INR range of 2.5 to 4.5 for all heart valve prostheses. Results In groups 1 and 2, 76% and 75% of INR values, respectively, were in the target range. Results did not differ according to schooling and age. The rate of thromboembolic events per patient year was 0.18% in group 1 and 0.40% in group 2 (p = 0.210). The rate of bleeding complications was 0.74% for group 1 and 1.20% for group 2 (p = 0.502). In most patients with clinically relevant bleeding, these complications occurred although their measured INR values were below 3.5. The survival rate did not differ between the study groups (p = 0.495). Conclusions Low-dose INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. INR self-management is applicable for all patients in whom permanent anticoagulation therapy is indicated. Even INR values below 3.5 can bear the risk of bleeding complications.

It is suggested that the vacuum technique is a promising new method for the therapy of mediastinitis, but reliable investigations are currently almost completely lacking. We therefore compared clinical outcome of patients whose sternal infection was managed with the vacuum-assisted closure system or with the conventional procedure of open packing.We performed a retrospective analysis in 68 cases of sternal wound infection that were identified at our Heart Center between September 1998 and September 2003. Thirty-five patients could be allocated to the vacuum group and 33 patients to the conventional group. We compared the time interval from sternal infection until freedom of microbiological cultures, in-hospital stay, the status at discharge (rewired or open sternum), the time interval until wound healing was achieved, and survival rates. Moreover, we compared serum levels of C-reactive protein and blood leukocyte counts on admission, at diagnosis of sternal infection, and at different points of time until discharge.Baseline characteristics and blood factors did not differ between the two study groups at diagnosis of sternal infection. Moreover, the number of prescribed antibiotics was similar, and the C-reactive protein level and blood leukocyte counts at discharge were comparable in both groups. However, freedom from mediastinal microbiological cultures was achieved earlier (p0.01), C-reactive protein levels declined more rapidly (p0.025), in-hospital stay was shorter (p0.01), rewiring was earlier (p0.01), and survival tended to be higher (p0.15) in the vacuum group compared to the conventional group.This retrospective analysis could demonstrate that the vacuum technique improves the medical outcome of patients with mediastinitis compared with the conventional technique of open packing.

Coronary artery fistulas are rare congenital anomalies. Although they constitute the most common form of hemodynamically significant coronary malformation, the incidence is around 0.002% in the general population. We report the successful surgical closure of a very large coronary artery fistula, originating from the left coronary artery and draining into the right atrium with left-to-right shunt of more than 50% and a review of the literature.

Background The phenomenon of malignancy transmission from donors with primary brain malignancy (PBM) which is relatively well documented in renal or liver transplant recipients, has not been analyzed in cardiac allograft recipients. Methods We reviewed the medical records of 32 cardiac allograft recipients who were transplanted with organs from donors suffering from primary brain malignancies from 1989 to 2003. Results No case of donor-transmitted malignancy has been reported with a mean follow-up of 80.6 months. Conclusions In our experience as well as according to a review of the literature, the risk of tumor transmission from donors with primary brain malignancy to cardiac allograft recipients seems to be extremely low. In the context of the increased donor shortage, we recommend to accept all suitable cardiac allografts harvested from donors with primary brain malignancy provided there are no detectable remote metastases.

Purpose The purpose of this study was to investigate whether: 1. sound phenomena may be used to detect prosthetic valve dysfunction; 2. clinical and experimental data permit conclusions about alterations in the functional state of mechanical valves; 3. patients can record and pass on signals via Internet. Methods 1. We implanted bi-leaflet valves in pigs. By gradually influencing the motion of the tilting discs prosthetic dysfunction could be generated. 2. Thrombosis and lysis of bi-leaflet valves was studied in sheep. This process was documented using echocardiography and acoustically by the Fast Fourier Transformation. 3. Thirty devices were set up and handed out to patients following mechanical valve replacement. All patients regularly sent data to the hospital via Internet, regardless of their location at the time. The data were evaluated by comparing them with the reference file. Results Animal experiments proved that changes in prosthetic function led to a significant change in sound phenomena. In contrast to echocardiography alterations at an early stage (onset of thrombosis) could be reliably verified. The sensitivity was greater than in echo-control analysis. All patients regularly recorded and passed on their signals. Surveys revealed high acceptance and easy handling of the devices. Conclusions Online registration of sound phenomena seems to be suitable for the detection of changes in prosthetic function. This led to the development of the first hand-held device for home monitoring of valve function. Registration of flow, frequency spectrum, and ECG envisaged at the next level opens up potential applications for Internet-based, remote monitoring of cardiac patients.

Background Operative outcome of simultaneous carotid endarterectomy and valvular surgery has not been clarified. We retrospectively reviewed short-term and long-term outcomes after carotid endarterectomy combined with valvular replacement. Methods Seventy-nine patients (50 men and 29 women. mean age, 68.9 ± 6.9 years; range, 53.3 to 78.7 years) underwent carotid endarterectomy combined with valve replacement from February 1985 to April 2002. Indication of carotid endarterectomy was more than 75% carotid stenosis with or without ulceration. Thirteen patients had history of stroke. Endarterectomy was performed under mild hypothermia with cardiopulmonary bypass in all cases. Positions of replaced valves were aortic in 64 patients, mitral in 10, and mitral and aortic in 5 patients. Results There were 8 early deaths (10.1%). Early neurologic complications occurred in 8 patients (10.1%); two late events were observed. Double valve replacement was an independent risk factor for early death (p = 0.039; odds ratio=25.6). For early stroke we found no statistically significant risk factor. Myocardial infarction (p = 0.022; odds ratio=3.0) and age more than 70 years (p = 0.03; odds ratio=2.5) were independent risk factors for premature death; we found no independent risk factor for late stroke. Permanent impairment or death as a stroke consequence was seen in 5 patients, 3 of them had ipsilateral strokes, 2 had contralateral strokes. Conclusions Endarterectomy can be safely performed combined with aortic valve surgery. Concomitant mitral or double valve replacement cannot be judged reliably because of the small number of patients, but they might be a high risk.

Specific problems of cardiosurgical implantation of biventricular devices for cardiac resynchronisation therapy are elucidated elaborately. In particular, the necessity and amount of intraoperative monitoring as well as the appropriate mode of anaesthesia are described. Furthermore, the sequence of lead placement, the technique of coronary sinus intubation using a guiding catheter as well as means to avoid thrombus formation in the coronary sinus are depicted. Biventricular ICD devices should be implanted from a left sided approach to integrate the device into the defibrillation field and to maintain the option of placing an additional subcutaneous array lead. It is of particular cardiosurgical interest that coronary vein leads are applicable for ventricular stimulation in patients after tricuspid valve replacement thus avoiding repeated surgical exposure of the heart.

Based on the recent experience of 464 patients with left ventricular pacing, we report on specific characteristics of various leads and lead types for left ventricular stimulation. In addition to describing the technique and indications for epicardial lead usage, commercially available coronary vein leads are introduced and discussed. Since there is no universally applicable coronary vein lead, the individually optimal lead choice and the sequelae of an erroneous lead selection are described in typical clinical examples.

Uberbruckungsmoglichkeiten. Lange Zeit standen fur die Uberbruckung bis zur Herztransplantation bei Kindern und Jugendlichen ausschlieslich die bei Erwachsenen etablierten Systeme zur Verfugung. Wir haben das Thoratec-System (Schlagvolumen 65 ml) bei 8 Kindern und Jugendlichen eingesetzt. 7 der 8 Patienten konnten letztendlich erfolgreich transplantiert werden. Fur kleinere Kinder wurde inzwischen ein Unterstutzungssystem vom Typ Medos mit einer Ventrikelgrose von 25 bzw. 10 ml entwickelt.

From March 1989 to December 1999, 1,013 heart transplantations were carried out in this center. Univariate analysis of potential risk factors for early death was followed by stepwise logistic regression to determine independent risk factors. Long-term results were assessed by the Kaplan-Meier method. Multivariate comparisons of long-term results were performed using Cox's proportional hazards model. Early mortality was 8.6%. Actuarial survival was 78.1%, 69.4%, and 53.1% at 1, 5, and 10 years, respectively. Mean total ischemic time was 194 minutes. Independent risk factors of early mortality were female recipient, donor age over 50 years, and ischemic heart disease in the recipient. The precise mechanism of the increased early mortality in female recipients should be studied in the future. Although older donor age was a predictor of early mortality, because of the donor shortage, older hearts should not be excluded from the donor pool. Survival was better in patients with dilative cardiomyopathy than in those with ischemic heart disease.

Our experience with 121 coronary vein (CV) leads in 116 patients shows that CV leads are the leads of choice for pacing the left ventricle (LV). The information gained from pre-operative venous angiography permits individual selection of the most appropriate lead model for each case. The use of steerable electrophysiology catheters facilitates guide catheter cannulation of the coronary sinus (CS) when the anatomy is difficult and reduces the risk of complications. By selecting the CV lead model most suitable for each individual patient, we achieved successful implantation in 99.1% of patients. In this day and age, epicardial electrodes should be restricted to cases with CS anomalies which make CS cannulation impossible, and to LV lead implantation during heart surgery.

A retrospective analysis was undertaken in 79 patients who underwent pericardiectomy for chronic constrictive pericarditis from January 1985 to February 1999. Most operations (77) were carried out with cardiopulmonary bypass, with subtotal pericardiectomy in 75 patients, and concomitant operations in 25. Postoperative complications occurred in 8 patients: cerebrovascular accident in 2, renal insufficiency in 5, bleeding in 2, low output syndrome in 4, and respiratory insufficiency in 2. The operative mortality was 5%; causes of death were cardiac-related in all cases. Actuarial survival at 1, 5, and 10 years was 89.9% ± 3.4%, 74.9% ± 5.7%, and 55.4% ± 13.5%, respectively. Regression analysis was performed using 53 clinical variables. Female gender, renal insufficiency, concomitant coronary artery bypass grafting, and preoperative right ventricular end-diastolic pressure > 20 mm Hg were found to be predictors of poor survival. At follow-up, improved functional status was noted in 88% of patients. Subtotal pericardiectomy can be performed on cardiopulmonary bypass with low mortality and good long-term survival.

Severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement essentially occur due to intense oral anticoagulation and fluctuating individual INR values around the target range. INR self-management can help to minimize these fluctuations. Beginning this therapeutic control immediately after mechanical heart valve replacement further reduces anticoagulant-induced complications. Included in the study were 1200 patients. The quality of oral anticoagulation also improved through INR self-management. Over an observation period of two years, nearly 80 % of INR values recorded by the patients themselves were within the target therapeutic range of 2.5-4.5. This corresponds to a high significance of p < = 0.001 in favor of INR self-management. Only 64.9 % of INR values monitored by family practitioners were within the desired range. The results differed slightly in quality between patient groups with different levels of training (comprehensive, secondary modern, grammar with or without university). Of patients trained in INR self-management following mechanical heart valve replacement, 91.7 % maintained their competence in this technique throughout the entire follow-up period. Only 8.3 % of those trained immediately after surgery were unable to continue with INR self-management.

Eine 32-jahrige Patientin, bei der als Kind eine Aortenisthmusstenose mittels Dacronpatchplastik korrigiert worden war, wurde wegen rezidivierender Hamoptysen stationar aufgenommen. Die radiologische Diagnostik zeigte eine aneurysmatische Erweiterung des distalen Aortenbogens. Bei der kurzfristig durchgefuhrten Operation fand sich ein groses Aortenbogenaneurysma, ausgehend von der Region der Patchplastik im Isthmusbereich, mit gedeckter Perforation in den linken oberen Lungenlappen. Nach Korrektur einer Aortenisthmusstenose mittels Patchplastik sollten Patienten lebenslang regelmasig im Hinblick auf die Moglichkeit einer Aneurysmabildung im Patchbereich untersucht werden.

Purpose: We describe our experience with ventricular assist devices (VAD) in patients with cardiogenic shock refractory to pharmacological therapy and support using intraaortic balloon pump after cardiac transplantation. Patients: Between July 1987 and August 1997, 848 patients underwent cardiac transplantation in our hospital. Interventions: Fifteen patients (1.8%) needed mechanical circulatory support for refractory cardiac failure due to right heart failure (six patients), primary graft failure (three patients), and acute rejection (six patients). Three pump systems were used: Biomedicus Centrifugal Pump, Abiomed BVS 500, and Thoratec VAD. The choice of system depended on the indication and quality of each device. Seven patients (47%) could be weaned from the mechanical circulatory support (MCS) system and three patients (20%) are long-term survivors. Results: All 15 patients developed at least one serious complication, such as multiorgan failure (MOF), liver failure, acute renal failure or sepsis. Twenty-five per cent had severe bleeding and 13% had neurological complication. Mortality was due mostly to MOF, MOF and sepsis or sepsis. The survivors had a CI greater than 2.2 l·min·m2, total bilirubin less than 1.0 U/1, and did not undergo resuscitation. Conclusions: Heart failure after cardiac transplantation severe enough to require MCS is currently associated with several major complications and high mortality (80%).

Clinical handling, risk and benefit of a heparin-coated cardiopulmonary bypass system combined with reduced systemic heparinization in coronary bypass surgery was investigated in a prospective, randomized clinical study. 243 patients (Pts.) were divided into 3 groups: group A (n = 83) had a standard uncoated extracorporeal circulation (ECC) set, and systemic heparin was administered in an initial dose of 400 IE/kg body weight. During ECC activated clotting time (ACT) was kept > or = 480 sec. Group B (n = 77) had the same ECC set completely coated with low-molecular-weight heparin; i.v. heparin was given in the same dose as in group A, ACT was kept at the same level. Group C (n = 83) had the same coated ECC set as group B, but i.v. heparin was reduced to 150 IE/kg, and was set to be > or = 240 sec during ECC ACT. The same circulatory components were used in all 3 groups including roller pumps, coronary suction and an open cardiotomy reservoir. In the postoperative clinical course, recovery was not significantly different between groups, especially with respect to organ dysfunction; but there was significantly reduced postoperative bleeding where heparin-coated ECC and low-dose systemic heparinization were both used. This circulatory technique was also associated with a distinctly lower need for postoperative blood replacement. We conclude that heparin-coated extracorporeal circulation combined with either full-dose or reduced systemic heparinization can be used effectively with the same standard equipment and procedures as in uncoated technology. Combination with low-dose i.v. heparin leads to significantly decreased blood loss and less need for blood replacement.

Seit Marz 1989 wurden im HZ-NRW1030orthotope Herztransplantationen (HTx) durchgefuhrt, darunter waren 159 Patienten (Pt.), die mittels mechanischer Kreislaufunterstutzung bis zur HTx uberbruckt wurden. Folgende Systeme kamen zum Einsatz: Biomedicus-Zentrifugalpumpe (n=10), Abiomed BVS 5000 (n=16), Thoratec (n=71), Novacor (n=38) und Heart Mate/TCI (n=24). Die kumulative Ein-Jahres-Uberlebensrate (UR) nach HTx lag je nach verwendetem Unterstutzungssystem zwischen 75 und 97%, im Mittel bei 92% gegenuber 79% UR nach HTx ohne vorhergehender Kreislaufunterstutzung. Die mittlere 3-Jahres-UR bei unterstutzten Pt. betrug 95% nach HTx versus 77% mit konventioneller HTx. Als system-assoziierte Komplikationen traten in 26% neurologische Storungen, in 18% schwere Blutungen, in 9% systemische Infektionen, in 6% Hernien und in 3% Tascheninfektionen sowie gastrointestinale Storungen auf. Trotz der bekannten Komplikationsraten haben Pt. mit erfolgreichem Bridging eine bessere Prognose nach HTx, insbesondere nach Langzeit-LV-Unterstutzung.

Background . A variety of sophisticated devices have been developed for mechanical circulatory support in patients bridged to cardiac transplantation. Based on 13 years' experience, we have developed specific protocols for patient selection and management for different devices. Methods . The principal systems applied in the bridge-to-transplant cohort are the Thoratec ventricular assist device (n = 144, mean duration of support 53 ± 57 days), the Novacor left ventricular assist system (LVAS) (n = 85, mean duration of support 154 ± 15 days), and the HeartMate LVAS (n = 54, mean duration of support 143 ± 142 days). The Thoratec device is used for biventricular assistance or if the duration of support is expected to be less than 6 months. For long-term support, either the Novacor or HeartMate LVAS are preferred. Results . Despite careful postoperative patient management, this group of patients is prone to a variety of complications. Bleeding occurred in 22% to 35%, right heart failure in 15% to 26%, neurologic disorders in 7% to 28%, infection in 7% to 30%, and liver failure in 11% to 20% of patients. Complications varied with the device applied and the patient's preoperative condition. A total of 73 patients were discharged from hospital for a mean period of 184 days; this cumulative experience amounted to 37.5 patient-years. Conclusions . The Novacor and the HeartMate systems offer the additional possibility of discharging patients during support if they fulfill certain criteria. The main reasons for rehospitalization were thromboembolic and infectious complications.

Aldosterone prevents the uptake of norepinephrine in the myocardium. Atrial natriuretic peptide (ANP), a circulating hormone of cardiac origin, inhibits aldosterone synthase gene expression in cultured cardiocytes. We evaluated the effects of intravenous ANP on cardiac sympathetic nerve activity (CSNA) and aldosterone suppression in patients with acute decompensated heart failure (ADHF). We studied 182 patients with moderate nonischemic ADHF requiring hospitalization and treated with standard therapy containing intravenous ANP and 10 age-matched normal control subjects. ANP was continuously infused for >96 h. In all subjects, delayed total defect score (TDS), heart to mediastinum ratio, and washout rate were determined by 123I-metaiodobenzylguanidine (MIBG) scintigraphy. Left ventricular (LV) end-diastolic volume, end-systolic volume, and ejection fraction were determined by echocardiography. All patients with acute heart failure (AHF) were examined once within 3 days and then 4 weeks after admission, while the control subjects were examined only once (when their hemodynamics were normal). Moreover, for 62 AHF patients, plasma aldosterone concentrations were measured at admission and 1 h before stopping ANP infusion. 123I-MIBG scintigraphic and echocardiographic parameters in normal subjects were more favorable than those in patients with AHF (all p

Objective: Long-term mechanical circulatory support as a bridge-to-transplantation procedure and bridge to recovery is of increasing importance. The implantable left ventricular assist devices, Novacor N100 left ventricular assist system (Baxter Healthcare Corporation, Berkeley, Calif) and TCI HeartMate vented electric left ventricular assist system (Thermo Cardiosystems Inc, Woburn, Mass), have proved to be efficient devices in bridge-to-transplantation settings and for prolonged support. The two systems were compared with regard to reliability and morbidity. Methods: Between October 1996 and March 1998, a prospective, single-center study was done that included 40 patients, 20 of whom were treated with the Novacor system and 20 of whom were treated with the HeartMate device. The diseases were mainly dilated cardiomyopathy (13/9) and ischemic cardiomyopathy (6/10). There were no statistically significant differences between the two groups regarding age, sex, preoperative clinical blood chemistry values, hemodynamic data, or risk factors. Results: There were no statistically significant differences between the two groups with regard to postoperative hemodynamics, organ recovery, out-of-hospital support, and survival to heart transplantation. Mean duration of support was 235.3 ± 210 days for the Novacor group and 174.6 ± 175 days for the HeartMate group and mean out-of-hospital support was 241 ± 179 days and 166 ± 152 days for the two groups, respectively. Neurologic complications occurred significantly more often among the Novacor group, whereas the HeartMate group had a higher prevalence of infections and technical problems, which was statistically significant. Survival to transplantation was 65% for the Novacor group and 60% for the HeartMate group. Conclusions: Most patients had organ recovery with left ventricular assist system support, and a considerable number of patients in both groups underwent transplantation. However, both devices need revision to address the current problems, that is, thromboembolism for the Novacor device and infection and reliability for the HeartMate device. (J Thorac Cardiovasc Surg 2000;119:581-7)

INR self-management can reduce severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement. Beginning anticoagulation therapy immediately in the postoperative period further reduces anticoagulant-induced complications. Data were collected from the first 600 surviving patients (from a total study sample of 1200 patients) who completed follow-up of at least 2 years. Patients were randomly divided into a self-management group and a control group. INR self-management reduced severe hemorrhagic and thromboembolic complications (P=0.018). Nearly 80% of INR values recorded by patients themselves, regardless of educational level, were within the target therapeutic range of INR 2.5-4.5, compared with 62% of INR values monitored by family practitioners. Only 8.3% of patients trained in self-management immediately after surgery were unable to continue with INR self-management. The results differed slightly between patient groups with different levels of education. We conclude that all patients for whom anticoagulation is indicated are candidates for INR self-management regardless of education level.

A 49-year-old man had sudden chest pain and paralysis of the lower right limb. An acute aortic dissection was diagnosed in a computed tomography scan and the patient underwent an emergency operation. After the operation, myonephropathic metabolic syndrome developed, and human atrial natriuretic peptide was administered for 11 days until the volume of daily urine output reached at least 10,000 mL, which would facilitate limb salvage and the preservation of life without hemodialysis. This report documents that postoperative myonephropathic metabolic syndrome improved due to the strong diuretic action of human atrial natriuretic peptide without hemodialysis.