|
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|
|
 |
Abstracta | |
|
| 1996: |
|
| Bauernschmitt R, Vahl CF, Lange
R, Jakob H, Hagl S (1996):
|
 Surgical treatment of
acute endocarditis of the aortic valve with paravalvular abscess:
considerations justifying the use of mechanical replacement
devices
|
| Eur J Cardiothorac Surg.
1996; 10(9): 741-7
|
| Abstract:
Early recurrency after surgery for acute endocarditis is a
life-threatening complication. Allograft valves are supposed to have
a higher resistance to recurrent infection, thus several authors
claim them to be the replacement device of choice in cases of aortic
endocarditis. However, allografts have two major drawbacks: their
availability is limited, and most of the patients require
reoperation for graft calcification of degeneration. Until now there
has been no prospective study analysing whether early recurrency
after surgery of acute endocarditis is associated with the
mechanical valve per se or with factors related to the surgical
technique or postoperative care. PATIENTS AND METHODS: We present a
prospective study on 36 consecutive patients with acute endocarditis
of the aortic valve with paravalvular abscesses. In this series,
there were 5 women and 31 men with a mean age of 50.3 years. All
patients were operated before a course of antibiotic therapy was
completed. Abscesses were radically resected and the cavities closed
either with direct suture or, if not possible, with Dacron patches.
For aortic valve replacement, a mechanical valve was used in every
patient. RESULTS: The early mortality in this series was 14%, only
one patient experienced recurrent endocarditis and underwent
reoperation. The results compare well with those achieved after
valve replacements with allograft valves. CONCLUSION: We conclude
that, even in cases of acute endocarditis, replacement of the aortic
valve with a mechanical device is an acceptable alternative to the
allograft, if radical surgical debridement and adequate antibiotic
therapy are performed.
|
|
 |
|
| Lange R, Brachmann J, Hagl
S (1996):
|
| [Value of dynamic
cardiomyoplasty]
|
| Z Kardiol. 1996; 85 Suppl 4:
49-58; discussion 59
|
| Abstract:The
value of dynamic cardiomyopathy in the treatment of end-stage heart
failure is controversial. After more than 500 patients have been
operated worldwide, the indication and the surgical technique have
become more uniform, which makes results from different centers
eligible for comparison. We performed cardiomyopathy in patients
with contraindications for heart transplantation. Between 8.90-2.94,
8 isolated cardiomyopathy-procedures in patients with cardiomyopathy
(EF 14-32%, NYHA III) were performed. One patient died in 2 months
after surgery. Reported are the results of 7 patients after a mean
follow-up of 41.1 +/- 14.1 months. Considerable symptomatic
improvement was found in 6 of 7 patients, 3 of whom went back to
work. One patient with severe pulmonary hypertension exhibited no
improvement. Mean NYHA-class decreased from 3.0 to 1.9 (p <
0.001). Echocardiography showed an increase in fractional shortening
in all patients. LV-EF increased from 21.2 +/- 5.2% to 38.1 +/-
15.9% (n = 7, p < 0.015) at 1 year, to 36.6 +/- 17.6% (n = 6, p
< 0.05) at two years and to 36.4 +/- 18.9% (n = 5, NS) at three
years. Pulmonary artery pressure tended to decrease at rest over
time. No significant change in exercise level and maximal
O2-consumption upon treadmill testing was observed. One patient died
34 months after the operation from sudden death. Our preliminary
results show, that patients after cardiomyopathy may exhibit an
impressive clinical improvement with less striking changes of
objective hemodynamic parameters. This data is in mutual agreement
with all other investigators. According to the current state of
experience with cardiomyopathy, the place for this procedure lies in
the treatment of patients with end-stage heart failure and
contraindications for heart transplantation. We do not consider
cardiomyopathy an alternative to heart transplantation, however, it
may receive further importance as a bridge to Htx.
|
|
| |
|
| Lange R, De Simone R,
Bauernschmitt R, Tanzeem A, Schmidt C, Hagl S (1996):
|
| Tricuspid valve
reconstruction, a treatment option in acute endocarditis
|
| Eur J Cardiothorac Surg.
1996; 10(5): 320-6
|
| Abstract:Tricuspid valve
endocardititis is treated surgically by total valve excision or
valve replacement. Both procedures are controversial with regard to
the hemodynamic consequences and to the long term prognosis. In the
following, results of tricuspid valve repair in acute infective
endocarditis are reported and discussed as an additional treatment
option. Between January 1988 and December 1993, 118 patients were
operated on for acute valve endocarditis at our institution. Eleven
of these patients had tricuspid valve endocarditis, isolated (n = 7)
or combined with endocarditis of a left-sided valve (n = 4). In the
cases with isolated tricuspid valve endocarditis, the indication for
surgery was intractable infection in six and hemodynamically
relevant tricuspid insufficiency in one out of seven patients. In
all patients with associated left-sided endocarditis, the indication
was hemodynamic deterioration. In eight patients the tricuspid valve
endocarditis was treated as follows: debridement, vegectomy, patch
reconstruction of the cusps, reducing the cusps to two. In three
patients reconstruction was not possible because of extensive
involvement of all parts of the valve, including the valve ring and
the papillary muscles. In these patients primary valve replacement
(n = 1) or valve excision with secondary replacement (n = 2) was
performed. In four patients tricuspid reconstruction was combined
with mitral (n = 1), aortic (n = 1) or double valve replacement (n =
2). Postoperatively, signs of infection vanished in all surviving
patients (n = 10) and tricuspid valve endocarditis healed without
recurrences. Implanted prosthetic material did not lead to recurrent
infection. One patient died early postoperatively after valve
excision, in septic shock and multi-organ failure. In seven patients
late echocardiographic follow-up showed tricuspid regurgitation
grade 0 in three patients, I in two, II in one and III in one. Our
results suggest that valve repair is a reasonable treatment option
for tricuspid valve endocarditis in all cases with localized
infection of the valve. Only if extensive valve destruction excludes
valve repair, would we now favor primary valve replacement over
simple valvulectomy. In all other cases primary valve reconstruction
is the treatment of choice for tricuspid valve endocarditis, if
surgery is indicated.
|
|
| |
|
| Lange R, Hagl S (1996):
|
| [Dynamic cardiomyoplasty:
current status and concepts of the mechanism of action]
|
| Z Kardiol. 1996; 85 Suppl 6:
309-15
|
| Abstract:Surgical treatment of
end-stage heart failure offers heart transplantation as a well
established and effective treatment option. In addition, the
permanent implantation of left-heart assist-devices is now gaining
increasing importance. Yet, both methods also have inherent
drawbacks and may not be available to all patients, so that new
methods are constantly evaluated. Cardiomyoplasty was introduced
into clinical practice 10 years ago, but still lacks general
acceptance as a routine method. Worldwide results show a
considerable symptomatic improvement with only small effects on
systolic cardiac function. Survival rate was significantly improved
by careful patient selection. As a mechanism of action the skeletal
muscle wrap exerts some active improvement of systolic wall motion
of the heart/skeletal muscle-complex. However, probably more
important is an acute and chronically persisting shift of the
pressure-volume relation to the left. This process results in a
"reverse remodeling" of the insufficient heart with an improvement
of the "contractility reserve". Cardiomyoplasty is indicated in
patients with contraindications to heart transplantation and as a
bridge-to-transplantation in patients with ventricular arrhythmia
and severely impaired left ventricular function, concomitant with
ICD implantation.
|
|
| |
|
| Lange R, Hagl S (1996):
|
| [Biomechanical heart and
cardiovascular support]
|
| Zentralbl Chir. 1996;
121(4): 263-77
|
| Abstract:A
surgical association between skeletal muscle and heart muscle dates
back to experiments at the beginning of this century. Initially, the
use of skeletal muscles aimed at plastic reconstructions of
myocardial defects and enhancement of myocardial blood flow. The
application of the contractile force of the skeletal muscle failed
because of skeletal muscle fatigue. In the late sixties,
investigations in muscle physiology demonstrated the "functional
plasticity" of muscle tissue: Chronic electrical stimulation induces
a transformational process of the cellular organelles, the
metabolism, the fiber proteins and the calcium regulatory systems
which results in "fatigue resistance" of the muscle. This was is a
prerequisite for the application of skeletal muscles for continuous
support of the circulation. Biomechanical support of the heart and
the circulation is experimentally performed as skeletal muscle
ventricles, chronic extraaortic counterpulsation and ventricular and
atrial cardiomyoplasty. The electrical stimulation is performed with
"burst" impulses, in order to increase the force and the length of
contraction. The first clinical application of ventricular
cardiomyoplasty is attributed to the French surgeon Alain
Carpentier. Clinical investigations show that cardiomyoplasty
results in an impressive symptomatic improvement of the patients
clinical condition with only moderate changes of objective
hemodynamic parameters. Further research will investigate the
clinical applicability of the other, thus far only experimental
techniques of biomechanical support. The introduction of
cardiomyoplasty has induced great scientific interest in all forms
of skeletal muscle circulatory support. Close collaboration between
basic researchers and clinical investigators is of utmost importance
for further developments in this field. The combined international
research effort can be expected to yield considerable progress
within the forthcoming years.
|
|
| |
|
| Preac-Mursic V, Marget W, Busch
U, Pleterski-Rigler D, Hagl S (1996):
|
| Kill kinetics of Borrelia
burgdorferi and bacterial findings in relation to the treatment of
Lyme borreliosis [published erratum appears in Infection 1996
Mar-Apr;24(2):169]
|
| Infection. 1996 Jan-Feb;
24(1): 9-16
|
| Abstract:For a
better understanding of the persistence of Borrelia burgdorferi
sensu lato (s.l.) after antibiotic therapy the kinetics of killing
B. burgdorferi s.l. under amoxicillin, doxycycline, cefotaxime,
ceftriaxone, azithromycin and penicillin G were determined. The
killing effect was investigated in MKP medium and human serum during
a 72 h exposure to antibiotics. Twenty clinical isolates were used,
including ten strains of Borrelia afzelii and ten strains of
Borrelia garinii. The results show that the kinetics of killing
borreliae differ from antibiotic to antibiotic. The killing rate of
a given antibiotic is less dependent on the concentration of the
antibiotic than on the reaction time. Furthermore, the data show
that the strains of B. afzelii and B. garinii have a different
reaction to antibiotics used in the treatment of Lyme borreliosis
and that different reactions to given antibiotics also exist within
one species. The B. garinii strains appear to be more sensitive to
antibiotics used in therapy. Furthermore, the persistence of B.
burgdorferi s.l. and clinical recurrences in patients despite
seemingly adequate antibiotic treatment is described. The patients
had clinical disease with or without diagnostic antibody titers to
B. burgdorferi.
|
|
| |
|
| Vahl CF, Meinzer HP, Thomas G,
Osswald BR, Hagl S (1996):
|
| [Quality assurance in
heart surgery: 8 years experience with a "feedback-control" system
in Heidelberg]
|
| Herz. 1996 Dec; 21(6):
371-82
|
| Abstract:An
important aspect of quality assurance in cardiac surgery covers the
epidemiological analysis of patient data. After an 8 year period of
clinical experience with quality assurance, we summarize and
evaluate current concepts and actual experiences regarding a special
type of database application and organisation ("feedback control
system") for quality assurance. It had been developed to meet and
solve the problems related to the data acquisition process, that are
typically present in the clinical routine of quality assurance. In
1988 the "feedback-control-system" was designed and implemented in
the Department of Cardiac Surgery at Heidelberg University. Since
then it had been continuously improved and adapted to satisfy
current needs in cardiac surgery. More than 1500 items are now
recorded routinely per patient. At present, detailed information of
more than 10,000 patients is available for the specific methods of
analysis in the field of quality assurance. The basic concept
included 1. the integration of the data acquisition in the daily
clinical routine, 2. the evaluation and improvement of collected
data material by means of "output-functions", that require
previously recorded reliable data (that is automatically computer
generated operation reports, letters, statistics, accounting etc.),
and 3. to ensure that the medical and non-medical staff members
participate in the advantages and the responsibilities of the
data-base system for quality assurance. Analyses of perioperative
risks and results, early discovery of trends, identification of
special subpopulations receiving special types of treatment in
cardiac surgery etc. have now become a regularly performed tool in
clinical routine. This includes the availability of "problem
profiles", "trend analysis", the use of simple concluding statistics
as well as the calculation of multivariable models. This internal
quality assurance is completed by "multicentric" comparisons with
further hospitals already using the same data-base system (external
quality assurance). Within 8 years, the feedback-control-system has
become a reliable and valuable tool for quality assurance in daily
routine. The high acceptance of the database system is related to
the advantages it provides for every participant. We conclude that
the concept of data evaluation and improvement by means of "output
functions" and "integration of data acquisition in clinical
routines" has proved to be efficient in everyday practice. The
sensitivity and specifity to such a feedback controlled system as a
tool for measuring surgical quality, however, still remains a matter
requiring further research.
|
|
|
|
|
| 1995: |
|
| Dengler TJ, Zimmermann R,
Tiefenbacher CP, Braun K, Sack FU, Kubler W (1995):
|
| Endothelin plasma levels
in acute graft rejection after heart transplantation
|
| J Heart Lung Transplant.
1995 Nov-Dec; 14(6 Pt 1): 1057-64
|
| Abstract:
Endothelin is an oligopeptide of endothelial origin with potent
vasoconstrictive and mitogenic properties, implicated in the
pathogenesis of cyclosporine-induced hypertension, graft
vasculopathy, and renal failure. Experimental animal data suggest a
role for endothelin in allograft rejection also. METHODS: To
determine the role of endothelin in acute graft rejection after
heart transplantation, we determined endothelin plasma levels in 165
blood samples from 79 cardiac allograft recipients (2 to 81 months
after the operation) with normal graft function and correlated our
findings with the histologic severity of acute graft rejection
according to International Society for Heart and Lung
Transplantation grading. For comparison endothelin levels were
determined in 30 healthy controls and in 22 early postoperative
transplant recipients (< 2 months after the operation). RESULTS:
Endothelin plasma levels were significantly higher in transplant
recipients than in controls (early postoperative: 7.97 = 7.53 pg/ml;
late postoperative: 3.68 +/- 1.72 pg/ml; controls: 1.55 +/- 0.89
pg/ml). Endothelin plasma levels were not significantly different
between groups of rejection grades 0 to 4. In the comparison of two
groups of no rejection or lower (International Society for Heart and
Lung Transplantation grade 0 and 1, n = 134) and higher
(International Society for Heart and Lung Transplantation grade >
or = 2, n = 31) rejection severity or comparing patients requiring
rejection therapy (n = 20) with those not requiring therapy (n =
145), endothelin levels did not differ significantly between the
groups. In 22 patients with three to six available consecutive
biopsy scores and endothelin levels, intraindividual longitudinal
analysis did also not show any significant correlation. The only
positive correlation of endothelin levels with other laboratory
parameters was found with serum creatinine concentrations (p <
0.001). In the early postoperative recipients, no correlation of
endothelin plasma levels with rejection severity was seen;
furthermore the only significant association was found with time
after operation. CONCLUSIONS: In this study endothelin plasma levels
were not influenced by acute allograft rejection after heart
transplantation. Therefore endothelin levels do not appear to be a
useful marker for noninvasive rejection diagnosis. Furthermore, a
relevant pathogenetic role of endothelin in the rejection process
cannot be derived from these data.
|
|
| |
|
| De Simone R, Lange R, Sack RU,
Mehmanesh H, Hagl S (1995):
|
| Atrioventricular valve
insufficiency and atrial geometry after orthotopic heart
transplantation
|
| Ann Thorac Surg. 1995 Dec;
60(6): 1686-93
|
| Abstract: The
etiology of tricuspid and mitral valve regurgitation (TR and MR)
after heart transplantation is still controversial. METHODS: We
studied 25 patients undergoing transplantation and intraoperative
transesophageal echocardiography to evaluate the incidence, the
degree, and the cause of TR and MR. The degree of valve
regurgitation was assessed by color Doppler echocardiography.
Cross-sectional areas of the recipient (R) and donor (D) portions of
the atria and their ratio (R/D) were measured to assess the
distortion of atrial geometry. Tricuspid and mitral valve annuli,
their systolic shortening, and hemodynamic indices were measured
preoperatively and perioperatively. RESULTS: Tricuspid valve
regurgitation was found in 21 of 25 patients (84%) and MR in 12 of
25 (48%). The degree of MR was mild, whereas TR was mild to
moderate. Mitral valve regurgitation did not show any correlation
with the studied indices; TR showed no correlation with the
hemodynamic indices but a significant correlation with R/D ratio (r
= 0.90; standard error of the estimate = 0.2). An inverse
correlation was found between the degree of TR and systolic
shortening of tricuspid annulus (r = -0.88; standard error of the
estimate = 0.03) and between R/D ratio and systolic shortening of
tricuspid annulus (r = -0.85; standard error of the estimate =
0.04). CONCLUSIONS: Tricuspid valve regurgitation has a higher
incidence than MR and occurs immediately after transplantation; MR
is mild and correlates with neither hemodynamic indices nor atrial
distortion. An increased R/D ratio, and hence distortion of right
atrial geometry, may lead to a reduction in systolic annulus
shortening, which in turn causes TR. Surgical attempts to reduce the
R/D ratio may decrease the incidence and the degree of TR after
heart transplantation.
|
|
| |
|
| Jakob H, Vahl CF, Lange R, Micek
M, Tanzeem A, Hagl S (1995):
|
| Modified surgical concept
for fulminant pulmonary embolism
|
| Eur J Cardiothorac Surg.
1995; 9(10): 557-60; discussion 561
|
| Abstract:Surgical intervention in
fulminant pulmonary embolism (PE) is still associated with an
overall 30% fatal outcome which increases to about 60% when
cardiopulmonary resuscitation (CPR) is necessary. Despite
unfavorable conditions like hemodynamic instability, failed lysis or
CPR, the surgical strategy might have a certain impact on the
patient's outcome since 30 40% of the surgical mortality is related
to persistent right heart failure and early thromboembolic
recurrence. From 1/88 to 8/94 a total of 25 patients (15 females, 10
men, mean age 57 [25 78]) years underwent emergency pulmonary
embolectomy with the use of the heart lung machine. Seventeen
patients were operated upon between 1988 and 1992. A standard
approach by central pulmonary artery incision with extraction of
adjacent pulmonary emboli using forceps, suction of Fogarty
catheters was used. Six of these patients (35%) died, with four out
of six operated upon under CPR. Since 1993 we have used a modified
surgical strategy in eight patients. Five patients (63%) were
operated on after or under CPR. In these cases, left and right
pulmonary arteries were incised peripherally and all segmental
arteries were desobliterated selectively using small suction
devices. Thereafter the right atrium was opened and inspected. After
removal of the inferior caval vein cannula all inferior body blood
was taken with cardiotomy suction while both legs and the abdomen
were massaged centripetally to mobilize additional fresh thrombotic
material. In three cases up to 50 cm long thrombi could be
delivered. All patients have survived to date with two patients
receiving a LGM caval filter placed percutaneously after bilateral
postoperative phlebography had revealed ongoing thrombotic disease.
We conclude that selective desobliteration of every segmental
pulmonary artery in combination with simultaneous clearance of major
body veins from additional thrombotic material will probably lower
surgical mortality in these critically ill patients.
|
|
| |
|
| Kurz T, Richardt G, Hagl S,
Seyfarth M, Schomig A (1995):
|
| Two different mechanisms
of noradrenaline release during normoxia and simulated ischemia in
human cardiac tissue
|
| J Mol Cell Cardiol. 1995
May; 27(5): 1161-72
|
| Abstract:Species-related differences
in the mechanisms of noradrenaline release during normoxia and
myocardial ischemia emphasize the need for studies on human hearts.
Therefore, the mechanisms of noradrenaline release were investigated
during normoxia and energy depletion in incubated human atrial
tissue and compared to the release characteristics in normoxic and
ischemic rat heart. Potential differences of atrial versus
ventricular myocardium were assessed by comparing catecholamine
release during electrical stimulation and ischemia in isolated rat
atrium with release characteristics in the intact perfused heart.
The overflow of endogenous noradrenaline and its deaminated
metabolite dihydroxyphenylethyleneglycol (DOPEG) were determined by
high pressure liquid chromatography and electrochemical detection.
During normoxia noradrenaline release was evoked by electrical field
stimulation. Stimulation-induced noradrenaline release depended on
the extracellular calcium concentration in both species and was
almost completely suppressed under calcium-free conditions. The
release was significantly inhibited by neuronal (N-type) calcium
channel blockers such as omega-conotoxin (100 nmol/l) and cadmium
chloride (100 mumol/l), indicating a predominant role of N-type
calcium channels in exocytotic noradrenaline release from
sympathetic neurons in human and rat heart. Desipramine (100 nmol/l)
enhanced the overflow of noradrenaline evoked by electrical
stimulation in both species by blocking neuronal catecholamine
uptake (uptake1). Myocardial ischemia was caused by interruption of
perfusion flow in rat heart and simulated by anoxic and glucose-free
incubation in human and rat atrial tissue. Ischemia- and
anoxia-induced noradrenaline release in rat heart and human atrial
tissue was unaffected by varying extracellular calcium
concentrations and occurred even after omission of calcium and
addition of EGTA (1 mmol/l). In both species neither omega-conotoxin
(100 nmol/l) nor cadmium chloride (100 mumol/l) affected
ischemia-induced noradrenaline overflow in both rat heart and atrium
as well as in human atrium. In human and rat atrial tissue, blockade
of energy metabolism in the presence of oxygen (cyanide model)
resulted in a desipramine-sensitive release of noradrenaline, which
was accompanied by DOPEG overflow, indicating increased axoplasmic
noradrenaline concentration. The data imply a dual mechanism of
noradrenaline release in the human heart. During normoxia
noradrenaline release is modulated by neuronal calcium influx
indicating exocytotic release. Ischemia-induced noradrenaline
release, however, is independent of calcium and inhibited by uptake1
blockade suggesting nonexocytotic release mechanism. The
characteristics of noradrenaline release in human atrial tissue
provide evidence for carrier-mediated release of noradrenaline from
sympathetic neurons operative in the ischemic human
myocardium.
|
|
| |
|
| Lange R, De Simone R,
Bauernschmitt R, Tanzeem A, Schmidt C, Hagl S (1995):
|
| [Surgical therapy of
acute tricuspid valve endocarditis: indications, technique and
results]
|
| Z Kardiol. 1995 Nov; 84(11):
921-9
|
| Abstract:Tricuspid valve endocarditis
is treated by antibiotics alone in the majority of the cases.
However, intractable infection or hemodynamic compromise may warrant
surgery. In those cases total valve excision or valve replacement
had been the most common surgical procedures. Both are controversial
in regards to the hemodynamic consequences and to the long term
prognosis. In the following, results of tricuspid valve repair in
acute infective endocarditis are reported and discussed as an
additional treatment option. Between January 1988 and December 1993,
118 patients were operated for acute valve endocarditis at our
institution. Eleven of these patients had tricuspid valve
endocarditis, isolated (n = 7) or combined with endocarditis of a
left-sided valve (n = 4). In the cases with isolated tricuspid valve
endocarditis, the indication for surgery was intractable infection
in 6 and hemodynamically relevant tricuspid-insufficiency in 1 out
of 7 patients, respectively. In all patients with associated
left-sided endocarditis, the indication was hemodynamic
deterioration. In 8 patients the tricuspid valve endocarditis was
treated as follows: Debridement, vegectomy, patch-reconstruction of
the cusps, bicuspidalization. In 3 patients reconstruction was not
possible because of extended involvement of all parts of the valve,
including the valve ring and the papillary muscles. In these
patients, primary valve-replacement (n = 1) or valve-excision with
secondary replacement (n = 2) was performed. In 4 patients
tricuspid-reconstruction was combined with mitral- (n = 1), aortic-
(n = 1) or double-valve replacement (n = 2).(ABSTRACT TRUNCATED AT
250 WORDS)
|
|
| |
|
| Lange R, Sack FU, Voss B, De
Simone R, Nair A, Thielmann M, Brachmann J, Fleischer F, Hagl
S (1995):
|
| Dynamic cardiomyoplasty:
indication, surgical technique, and results
|
| Thorac Cardiovasc Surg. 1995
Oct; 43(5): 243-51
|
| Abstract:The
efficacy of dynamic cardiomyoplasty is still controversial. To date
more than 400 patients have been operated worldwide. In recent years
the indication and the surgical technique have become more uniform,
which makes results from different centers eligible for comparison.
We performed cardiomyoplasty exclusively in patients with
contraindications for heart transplantation, such as chronic and
recurrent infections or severe, irreversible sequelae of diabetes.
Between August 1990 and October 1994, 8 isolated cardiomyoplasty
procedures were performed in patients with cardiomyopathy (EF
14-32%, all in NYHA III). One patient died 2 months after surgery.
Reported are the results of 7 patients after a mean follow-up of
41.1 +/- 14.1 months. Considerable symptomatic improvement was found
in 6 or 7 patients, 3 of whom went back to work. One patient with
severe pulmonary hypertension exhibited no improvement. In the
others NYHA class improved by at least one. Echocardiography showed
an increase in fractional shortening in all patients. LVEF increased
from 21.2 +/- 5.2% to 38.1 +/- 15.9% (n = 7, p < 0.015) at 1
year, to 36.6 +/- 17.6% (n = 6, p < 0.05) at two years, and to
36.4 +/- 18.9% (n = 5, NS) at three years. Pulmonary artery pressure
tended to decrease at rest over time. Resting lung function showed
no change of vital capacity and FEV1. No significant change in
exercise level and maximal O2-consumption during treadmill testing
was observed. One patient died 34 months after the operation from
sudden death. Our preliminary results show that patients after
cardiomyoplasty may exhibit an impressive clinical improvement with
less striking changes of objective hemodynamic parameters. This data
is in agreement with the results of all other investigators. Some
possible mechanisms of action are discussed and a risk profile
suggested. According to the current state of experience with
cardiomyoplasty, we do not consider this method an alternative to
heart transplantation, but reserve it for patients with
contraindications for heart transplantation.
|
|
| |
|
| Lange R, Sack FU, Voss B, De
Simone R, Thielmann M, Nair A, Brachmann J, Haussmann R, Fleischer
F, Hagl S (1995):
|
| Treatment of dilated
cardiomyopathy with dynamic cardiomyoplasty: the Heidelberg
experience
|
| Ann Thorac Surg. 1995 Nov;
60(5): 1219-25
|
| Abstract: Data
concerning the efficacy of dynamic cardiomyoplasty are still
inconsistent, especially in terms of improvement of left ventricular
function. METHODS. Between August 1990 and February 1994, eight
isolated cardiomyoplasty procedures were performed in patients with
cardiomyopathy (ejection fraction, 0.14 to 0.32; New York Heart
Association class III) and contraindications to heart
transplantation. RESULTS. Follow-up was 41.1 +/- 14.1 months. One
patient died 2 months and another 3 years after operation.
Considerable symptomatic improvement was found in 6 of 7 patients, 3
of whom went back to work. One patient with severe pulmonary
hypertension exhibited no improvement. Mean New York Heart
Association-class decreased from 3.0 to 1.9 (p < 0.001).
Echocardiography showed an increase in fractional shortening and in
peak aortic flow velocity in all patients. Left ventricular ejection
fraction increased from 0.21 +/- 0.05 to 0.38 +/- 0.16 (n = 7, p
< 0.015) at 1 year, to 0.37 +/- 0.18 (n = 6, p < 0.05) at 2
years, and to 0.36 +/- 0.19 (n = 5, not significant) at 3 years.
Pulmonary artery pressure tended to decrease over time. No
significant change in exercise level or maximal oxygen consumption
during treadmill testing was observed. CONCLUSIONS. Our preliminary
results show that patients may exhibit an impressive clinical
improvement after cardiomyoplasty, with only moderate changes in
objective hemodynamic indices. We do not consider cardiomyoplasty an
alternative to heart transplantation, but reserve it for patients
with contraindications to heart transplantation.
|
|
| |
|
| Morano I, Ritter O, Bonz A,
Timek T, Vahl CF, Michel G (1995):
|
| Myosin light chain-actin
interaction regulates cardiac contractility
|
| Circ Res. 1995 May; 76(5):
720-5
|
| Abstract:The
amino-terminal domain of the essential myosin light chain (MLC-1)
binds to the carboxy terminus of the actin molecule. We studied the
functional role of this interaction by two approaches: first,
incubation of intact and chemically skinned human heart fibers with
synthetic peptide corresponding to the sequences 5 through 14
(P5-14), 5 through 8 (P5-8), and 5 through 10 (P5-10) of the human
ventricular MLC-1 (VLC-1) to saturate actin-binding sites, and
second, incubation of skinned human heart fibers with a monoclonal
antibody (MabVLC-1) raised against the actin-interacting N-terminal
domain of human VLC-1 using P5-14 as antigen to deteriorate VLC-1
binding to actin. P5-14 increased isometric tension generation of
skinned human heart fibers at both submaximal and maximal Ca2+
activation, the maximal effective peptide dosage being in the
nanomolar range. A scrambled peptide of P5-14 with random sequence
had no effects up to 10(-8) mol/L, ie, where P5-14 was maximally
effective. P5-8 and P5-10 increased isometric force to the same
extent as P5-14, but micromolar concentrations were required.
Amplitude of isometric twitch contraction, rate of tension
development, rate of relaxation, and shortening velocity at
near-zero load of electrically driven intact human atrial fibers
increased significantly on incubation with P5-14. These alterations
were not associated with modulation of intracellular Ca2+ transients
as monitored by fura 2 fluorescence measurements. Incubation of
skinned human heart fibers with MabVLC-1 increased isometric tension
at both submaximal and maximal Ca2+ activation levels, having a
maximal effective concentration in the femtomolar range.
|
|
| |
|
| Sebening C, Hagl C, Szabó G,
Tochtermann U, Strobel G, Schnabel P, Amann K, Vahl CF, Hagl
S (1995):
|
| Cardiocirculatory effects
of acutely increased intracranial pressure and subsequent brain
death
|
| Eur J Cardiothorac Surg.
1995; 9(7): 360-72
|
| Abstract:Hemodynamic instability and
functional impairment of the donor heart are currently reported
problems in organ transplantation. Actual shortage of potential
donor hearts continues to raise controversial discussion about
adequate donor management with regard to graft quality. In an
experimental open chest model, physiopathologic effects of acutely
induced, irreversible intracranial hypertension (AIIHT) were
investigated in situ with respect to hemodynamics, cardiac pump and
muscle function, and hormonal parameters. Acutely induced
irreversible intracranial hypertension was induced by rapid
inflation of a subdural balloon catheter in 10 anesthetized dogs,
four animals serving as controls. The observation period in both
groups was 300 min. Cardiocirculatory stability was maintained by
continuous crystalloid volume substitution without the use of
inotropic or pressor agents. After AIIHT, three characteristic
hemodynamic response phases have been observed: 1) The "acute
hyperdynamic phase" lasting up to 15 min with marked increases of
heart rate (HR), left ventricular pressure (LVP), cardiac output
(CO) and myocardial contractility indices, 2) At the end of the
"early restabilization phase", (60 min), these parameters returned
close to control levels, except HR (+50%) and systemic vascular
resistance (SVR) (-40%), 3) During the "late restabilization phase",
filling pressures, LVP and CO remained within control limits at low
SVR, contractility indices showed a decreasing tendency. All
assessed plasmatic hormones (Catecholamines, triiodothyronine (T3),
thyroxine (T4), adrenocorticotropic hormone (ACTH), cortisol and
anti-diuretic hormone (ADH) showed a continuous fall to levels
significantly below control over the phases of restabilization.
Acutely induced irreversible intracranial hypertension leads to
multifactorial hemodynamic and hormonal changes. At low SVR, cardiac
pump function was preserved exclusively by continuous volume
substitution, while myocardial contractility indicated a slight
decrease. From this observed hemodynamic and functional state within
the donor organism, no reliable prediction on graft functional
capacity can be made.
|
|
| |
|
| Vahl CF, Bonz A, Hagl C, Timek
T, Herold U, Fuchs H, Kochsiek N, Hagl S (1995):
|
| "Cardioplegia on the
contractile apparatus level": evaluation of a new concept for
myocardial preservation in perfused pig hearts
|
| Thorac Cardiovasc Surg. 1995
Aug; 43(4): 185-93
|
| Abstract:The
concept of a reversible desensitization of the myocardial
contractile apparatus for calcium by 2,3 Butanedione Monoxime (BDM)
as a method to improve the myocardium's tolerance to cold ischemia
was evaluated in normal pig hearts (n = 14). The results were
compared to those obtained after application of Bretschneider's HTK
cardioplegic solution. METHODS: Series I) After BDM treatment
(concentrations: 0-30 mmol/L) the isometric force output and the
intracellular calcium transients (measured using the FURA-2 ratio
method) of electrically driven (1 Hz) isolated left-ventricular
muscle strips excised from beating pig hearts (n = 14) were recorded
simultaneously in order to analyse the mode of action of BDM; Series
II) The cardioprotective effects of BDM (30 mmol/L) and
Bretschneider's cardioplegic solution (HTK) were compared in a
large-animal model: after "in situ perfusion" of pig hearts with
either 2000 ml ice-cold BDM solution (30 mmol/L) (n = 7) or 2000 ml
HTK (n = 7) the hearts were explanted and stored at 4 degrees C in
the same solutions for up to 42 h. The contractile properties of
muscle fibres, excised after storage periods of 8, 24, and 42 h from
these hearts were analyzed in terms of isometric force development
and isotonic shortening. 280 muscle fibres from 14 pigs were used
for measurements. RESULTS: Series I) In pig myocardium a
dose-dependent reduction of isometric force development was found
after BDM application. The shape and the amplitude of the
intracellular calcium transient were also affected by BDM. At 30
mmol/L BDM no force development could be elicited despite the
presence of an intracellular calcium transient (amplitude < 70%
of the control). Series II) Shortening, calcium transient, and force
of left-ventricular muscle strips of pig myocardium excised after
storage periods for up to 42 h showed complete recovery when BDM was
applied. In contrast HTK perfusion allowed complete recovery of
these parameters when the storage period did not exceed 6 hours.
CONCLUSION: Under the given experimental conditions reversible
desensitization of the contractile apparatus for calcium results in
a considerable prolongation of the tolerance to cold ischemia in
explanted pig hearts. The present study shows that the protective
effects of BDM are not only present when isolate muscle fibres were
stored (and the extracellular space is large) but also after storage
of complete hearts in a solution in a solution containing BDM. Thus
BDM may become a useful agent to enlarge the storage period of donor
hearts in heart transplatation considerably.
|
|
| |
|
| Zimmermann R, Mall G, Rauch B,
Zimmer G, Gabel M, Zehelein J, Bubeck B, Tillmanns H, Hagl S, Kubler
W (1995):
|
| Residual 201Tl activity
in irreversible defects as a marker of myocardial viability.
Clinicopathological study
|
| Circulation. 1995 Feb 15;
91(4): 1016-21
|
| Abstract: The
objective of the present study was to characterize the relation
between the residual 201Tl activity in irreversible perfusion
defects and the extent of irreversible myocardial damage indicated
by the volume fraction of myocardial interstitial fibrosis in
patients with chronic coronary artery disease. METHODS AND RESULTS:
Stress planar 201Tl scintigraphy with tracer reinjection at rest was
performed in 37 patients with > or = 75% stenosis of the left
anterior descending coronary artery, and anteroseptal 201Tl activity
was quantified by computer-assisted placement of regions of interest
from the serial myocardial images. During coronary artery bypass
grafting (performed within 6 +/- 3 weeks after scintigraphy), two
transmural biopsy specimens were taken from the anterior wall of the
left ventricle and the amount of interstitial fibrosis was assessed
by use of light microscopic morphometry. A wide spectrum of
interstitial fibrosis was obtained, ranging from 15 vol% to 60 vol%.
Interstitial fibrosis was similar in patients with reversible (n =
11) or irreversible (n = 15) tracer defects in conventional
stress-redistribution images. However, interstitial fibrosis was
significantly lower in patients who had enhanced regional 201Tl
activity after tracer reinjection compared with those who did not
have enhancement of tracer activity after reinjection (28 +/- 8
vol%, n = 7, versus 41 +/- 12 vol%, n = 8; P = .031). The
correlation between relative poststenotic 201Tl activity and
interstitial fibrosis after tracer reinjection was significantly
improved compared with conventional redistribution images (r = -.622
versus r = -.851, n = 15; P < .01). CONCLUSIONS: The present data
demonstrate that the level of regional 201Tl activity in
redistribution and, in particular, reinjection images is
significantly related to the mass of preserved viable myocytes in
poststenotic left ventricular myocardium. Therefore, the residual
201Tl activity provides information about viability within
irreversible perfusion defects and may itself serve as marker of
myocardial viability.
|
|
|
|
|
| 1994: |
|
| Brachmann J, Sterns LD, Hilbel
T, Schoels W, Beyer T, Mehmanesh H, Lange R, Ruf-Richter J, Kraft P,
Hagl S, et al. (1994):
|
| Acute efficacy and
chronic follow-up of patients with non-thoracotomy third generation
implantable defibrillators
|
| Pacing Clin Electrophysiol.
1994 Mar; 17(3 Pt 2): 499-505
|
| Abstract:Non
thoracotomy implantation of implantable cardioverter defibrillators
(ICDs) has simplified the process of device insertion, promising to
decrease associated procedural complications while providing sudden
death protection at least equal to epicardial systems. This study
presents the acute and chronic results of 110 patients who underwent
attempted non thoracotomy ICD implantation with the Medtronic
Transvene lead system and PCD model 7217 or 7219. Of the 110
patients attempted, 100 (91%) had the system successfully implanted
without the need for an epicardial patch. One patient died 1 week
postoperatively of septic shock related to the implantation (0.9%
perioperative mortality). During follow up of 16 +/ 11 months, 45%
of the patients had an event detected as ventricular tachycardia;
26% of these detections were felt clinically to be due to
supraventricular rhythms. Of the remainder, 87% were successfully
treated with the first VT therapy, and 98% were terminated by the
final therapy; 66% of the patients had at least one episode of
ventricular fibrillation, of which 5% were felt to be inappropriate
detections; 85% of the appropriate episodes were successfully
treated with the first VF therapy, and all were converted by the
final therapy. Total mortality at 6, 12, and 24 months was 3%, 11%,
and 19% respectively. Only one patient had sudden cardiac death,
occurring at 13 months postimplant. Overall, the non-thoracotomy
lead system for this ICD displayed infrequent implant complications
and proved to be reliable at terminating arrhythmias and maintaining
a low rate of sudden cardiac death in this high risk
population.
|
|
| |
|
| De Simone R, Lange R, Iacono A,
Hagl S (1994):
|
| [Role of transesophageal
echocardiography in tricuspid valve repair]
|
| Cardiologia. 1994 Dec; 39(12
Suppl 1): 87-101
|
| Abstract:This
paper reviews the role of echocardiography in tricuspid valve repair
by analyzing the results of three clinical studies. The first
investigation was performed for assessing the outcome of two
surgical techniques in two groups of patients who underwent De
Vega's suture annuloplasty or Carpentier ring implantation. The
patients were studied by color Doppler echocardiography after a mean
follow-up of 28.7 +/- 11.1 months. The results showed lower degree
of tricuspid valve regurgitation in the group of patients who
underwent De Vega annuloplasty. The second study demonstrates a new
application of transesophageal echocardiography (TEE) for optimizing
tricuspid valve annuloplasty. Twenty-three patients with moderate to
severe tricuspid regurgitation underwent De Vega's annuloplasty.
After cardiopulmonary bypass the tension on the suture was adjusted
until the surgeon could not feel any regurgitant jet by the
intraatrial palpation; subsequently, the tension was further
adjusted under guidance of TEE. The data obtained by the traditional
palpation were compared with the data obtained by TEE. A significant
reduction of residual tricuspid regurgitation was obtained by TEE
when compared to the data obtained by intraatrial palpation. The
results showed that the use of TEE was able to optimize the De
Vega's annuloplasty by reducing residual tricuspid regurgitation.
The third study investigated tricuspid valve regurgitation commonly
observed after orthotopic cardiac transplantation (HTX). Aim of the
study was to assess the degree of regurgitation and its etiology.
Twenty-five patients undergoing HTX were studied intraoperatively by
TEE. The results showed that tricuspid regurgitation occurs in most
patients immediately after HTX; it is correlated to the ratio
recipient-donor right atrium; surgical techniques which reduce the
recipient atrium may decrease the occurrence and the degree of
tricuspid regurgitation. The above mentioned clinical investigations
showed a many-sided role of TEE in tricuspid valve repair. It
provides not only a useful diagnostic tool for evaluating residual
regurgitation, but it may actively guide the surgical procedures and
contribute to improve the surgical technique.
|
|
| |
|
| De Simone R, Lange R, Sack FU,
Mehmanesh H, Hagl S (1994):
|
| [Atrioventricular valve
insufficiency and atrial geometry in orthotopic heart
transplantation]
|
| Cardiologia. 1994 May;
39(5): 325-34
|
| Abstract:Tricuspid and mitral valve
regurgitation are commonly observed in patients after orthotopic
cardiac transplantation (HTX). The etiology is still controversial.
Aim of the present study was to assess the degree of regurgitation
and its etiology. Twenty-five patients (mean age 47.9 +/- 11.8
years) undergoing HTX were studied intraoperatively by
transesophageal echocardiography. The degree of tricuspid and mitral
valve regurgitation was assessed by planimetry of maximum systolic
area of the regurgitant jet (JA). The cross-sectional area of right
and left atrium and the recipient (R) and the donor (D)
cross-sectional area of the atria, and their ratio (R/D) were
assessed by two-dimensional echocardiography. The following
preoperative and perioperative hemodynamic parameters were measured:
systemic arterial pressure, cardiac index, pulmonary artery
pressure, and pulmonary vascular resistance. Tricuspid regurgitation
was found in 21/25 (84%) patients, mitral regurgitation in 12/25
(48%). The degree of mitral regurgitation showed no correlation to
any of the studied parameters. Tricuspid regurgitation showed no
correlation to the hemodynamic parameters, but showed significant
correlation to R/D ratio (JA versus R/D: r = 0.90; SEE = 0.2) and to
the dimensions of the recipient atrium (JA versus R: r = 0.89; SEE =
1.9). Three patients who underwent bicaval anastomoses did not show
tricuspid regurgitation. In conclusion, tricuspid regurgitation has
a higher prevalence than mitral regurgitation and occurs in most
patients immediately after HTX; mitral regurgitation was less
frequent than tricuspid regurgitation and was not correlated to the
hemodynamic parameters or to the distortion of atrial geometry;
tricuspid regurgitation was significantly correlated to the ratio of
recipient/donor right atrium; surgical techniques reducing the
recipient atrium may decrease the occurrence and the degree of
tricuspid regurgitation.
|
|
| |
|
| Vahl CF, Bonz A, Hagl C, Hagl
S (1994):
|
| Reversible
desensitization of the myocardial contractile apparatus for calcium
A new concept for improving tolerance to cold ischemia in human
myocardium?
|
| Eur J Cardiothorac Surg.
1994; 8(7): 370-8
|
| Abstract:The
influence of 2,3-Butanedione monoxime (BDM) on the human
myocardium's tolerance to cold ischemia was analyzed in two
experimental series. Methods: I) Left ventricular human muscle
fibers (0.6 x 4.0 mm) were obtained from recipient hearts (n = 10)
and loaded with the fluorescent dye Fura-2. Simultaneous
measurements of intracellular calcium transients ("ratio-method";
excitation wave lengths: 340 nm and 380 nm) and isometric force
development of electrically driven (1 Hz) muscle fibers were carried
out at BDM concentrations ranging from 0 to 30 mM at a bath
temperature of 37 degrees C; II) Left ventricular human muscle
strips were obtained from beating recipient hearts (n = 10), and
right atrial fibers from patients operated upon for aortic valve
stenosis or combined mitral valve disease (n = 14). Muscle strips of
these hearts were incubated for parallel measurements in the
following solutions: a) a 37 degrees C oxygenated Krebs-Henseleit
solution (KHS), b) a 4 degrees C Bretschneider's cardioplegic
solution (HTK) without oxygenation and c) a 4 degrees C KHS
containing 30 mM BDM without oxygenation (BDM solution). After
standardized time intervals the muscle fibers were removed from the
storage solutions, reperfused in KHS solution at 37 degrees C and
stretched to optimal length (supramaximal electrical stimulation).
After obtaining a steady state of force development, the contractile
behavior under isometric and isotonic measurement conditions was
measured. The influence of the incubation periods and the incubation
solution was analyzed. Results: I) BDM reduced the isometric force
development of the electrically driven isolated human myocardial
muscle strip in a dose-dependent way.(ABSTRACT TRUNCATED AT 250
WORDS)
|
|
| |
|
| Vahl CF, Bonz A, Timek T, Hagl
S (1994):
|
| Intracellular calcium
transient of working human myocardium of seven patients transplanted
for congestive heart failure
|
| Circ Res. 1994 May; 74(5):
952-8
|
| Abstract:The
afterload dependence of the intracellular calcium transient in
isolated working human myocardium was analyzed in both donor and
recipient hearts of seven patients undergoing transplantation
because of dilated cardiomyopathy. The intracellular calcium
transient (recorded by the fura 2 ratio method), force development,
and muscle shortening were simultaneously recorded in small (0.6 x
4.0-mm) electrically driven (60 beats per minute) trabeculas
contracting at constant preload against varying afterloads. When the
fibers contracted under isometric conditions, the intracellular
calcium transients of normal and failing myocardium were similar.
However, in dilated cardiomyopathy, stepwise afterload reduction and
the concomitant increase in shortening amplitudes were associated
with extraordinary alterations in the shape of the calcium
transients; the amplitude rose, the time to peak was delayed, and at
minimal afterloads, a long-lasting plateau was observed, and the
diastolic decay was retarded. The calcium-time integral during
shortening against passive resting force was 124 +/- 5% of the
isometric control in normal myocardium and 172 +/- 12% in end-stage
heart failure (P < .0001). We conclude that adequate
interpretation of intracellular calcium transients requires
simultaneous recordings of force and shortening. The extraordinary
afterload dependence of the calcium transient in end-stage heart
failure may be attributed to increased dissociation of calcium from
the contractile proteins, a reduced calcium reuptake rate of the
sarcoplasmic reticulum, or an increased calcium inflow due to
altered permeabilities of the calcium channels during shortening. A
potential role of mechanosensitive calcium channels has to be
considered.
|
|
|
|
|
| 1993: |
|
| De Simone R, Lange R, Tanzeem A,
Gams E, Hagl S (1993):
|
| Adjustable tricuspid
valve annuloplasty assisted by intraoperative transesophageal color
Doppler echocardiography [see comments]
|
| Abstract:Am J
Cardiol. 1993 Apr 15; 71(11): 926-31
|
| Intraoperative
transesophageal echocardiography (TEE) can play a major role in
active guidance of cardiac surgery. This study describes a new
application of TEE for assisting tricuspid suture annuloplasty.
Twenty-five patients (aged 52 +/- 11 years) who underwent mitral
valve replacement and tricuspid valve annuloplasty were studied
intraoperatively by TEE. After cardiopulmonary bypass, the suture
annuloplasty was adjusted on the beating heart until palpable
regurgitation was eliminated. Further adjustment of the suture was
performed under echocardiographic guidance until color Doppler flow
imaging showed the most adequate correction of tricuspid
regurgitation (TR). A significant decrease in the semiquantitative
grade of TR, of regurgitant jet area and of the ratio jet area/right
atrial area was obtained when the suture was adjusted under
echocardiographic guidance. The peak inflow velocity and the
gradient across the tricuspid valve did not show significant changes
throughout the procedures. The results showed that the tricuspid
suture annuloplasty guided by TEE enables a substantial reduction in
residual TR without creating valve stenosis.
|
|
| |
|
| Gams E, Schad H, Heimisch W,
Hagl S, Mendler N, Sebening F (1993):
|
| Importance of the left
ventricular subvalvular apparatus for cardiac performance
|
| J Heart Valve Dis. 1993 Nov;
2(6): 642-5
|
| Abstract:The
importance of the subvalvular mitral apparatus for left ventricular
performance was studied in eight anesthetized dogs. During
extracorporeal circulation St. Jude Medical mitral valve prostheses
were implanted preserving the chordae tendineae. Flexible wires were
slung around the chordae tendineae and brought to the outside
through the left ventricular wall to cut the chordae tendineae by
electrocautery in the closed beating heart. The left ventricular
diameters were measured by sonomicrometry, left ventricular stroke
volume and enddiastolic volume by dye dilution, and left ventricular
pressure by catheter tip manometer. Data were collected at different
preloads achieved by volume loading with blood before and after the
chordae tendineae were cut. The results showed that after the
chordae tendineae had been cut left ventricular systolic pressure,
heart rate, diastolic and systolic diameters of the left ventricle
along the minor axis were not different from the pre-cut values at
any left ventricular enddiastolic pressure. However, significant
differences were observed for maximum dp/dt (-15%), major axis
diastolic diameter (+10%) and systolic shortening (-40%),
enddiastolic volume (+18%) at any left ventricular enddiastolic
pressure, and stroke volume (-24%) at any enddiastolic volume level.
The data demonstrate that the subvalvular apparatus not only
maintains physiologic valve function, but contributes significantly
to left ventricular performance. The impairment of left ventricular
function following removal of the subvalvular apparatus might be
aggravated in pre-injured hearts in mitral valve disease.
Consequently, the subvalvular apparatus should be preserved in
mitral valve replacement whenever possible.
|
|
| |
|
| Seyfarth M, Feng Y, Hagl S,
Sebening F, Richardt G, Schomig A (1993):
|
| Effect of myocardial
ischemia on stimulation-evoked noradrenaline release. Modulated
neurotransmission in rat, guinea pig, and human cardiac tissue
|
| Circ Res. 1993 Sep; 73(3):
496-502
|
| Abstract:The
effect of myocardial ischemia and its major metabolic changes, such
as anoxia, acidosis, and hyperkalemia, on exocytotic noradrenaline
release was investigated in rat, guinea pig, and human cardiac
tissue. Noradrenaline release was evoked by electrical field
stimulation, and the effect of each experimental intervention on
stimulation-evoked noradrenaline release (S2) was intraindividually
compared with the release induced by a control stimulation (S1). In
perfused hearts, 10 minutes of global ischemia caused a reduction of
noradrenaline overflow in rat hearts (mean S2/S1, 0.31), whereas the
overflow was increased in guinea pig hearts (S2/S1, 1.89). This
species-dependent effect may be caused by quantitatively different
responses to facilitating and suppressing factors of noradrenaline
release in both species. Anoxia and substrate-free perfusion
increased noradrenaline overflow in guinea pig hearts (S2/S1, 2.40)
but had no significant effect in rat hearts (S2/S1, 0.75). Acidosis
(pH 6.0) resulted in a suppression of noradrenaline release in rat
hearts (S2/S1, 0.16), whereas it had only a minor inhibiting effect
in guinea pig hearts (S2/S1, 0.67). Hyperkalemia had a comparable
effect in both species (S2/S1 at 15 mmol/L K+, 1.17 in rat and 1.14
in guinea pig; and S2/S1 at 20 mmol/L K+, 0.64 in rat and 0.41 in
guinea pig). To obtain results regarding the modulation of
noradrenaline release in human myocardium, human atrial tissue was
incubated, and the effect of anoxia, acidosis, and hyperkalemia on
stimulation-evoked noradrenaline release was investigated.(ABSTRACT
TRUNCATED AT 250 WORDS)
|
|
| |
|
| Vahl CF, Bauernschmitt R, Bonz
A, Herold U, Amann K, Ziegler S, Hagl S (1993):
|
| Increased resistance
against shortening in myocardium from recipient hearts of 7 patients
transplanted for dilated cardiomyopathy
|
| Thorac Cardiovasc Surg. 1993
Aug; 41(4): 224-32
|
| Abstract:The
contractile behaviour of demembranized atrial and ventricular
myocardium of 7 patients transplanted for end-stage heart failure
(ESHF) was analyzed. Atrial muscle specimens of patients undergoing
coronary artery bypass surgery (n = 9) and pig papillary muscle were
used as reference preparations (n = 9). Extreme care was taken for
dissection and mounting the muscle fibres (0.3 x 6 mm) in order to
keep the passive series compliance small. Calcium sensitivity,
cross-bridge cycling rate (estimated by the force-clamping technique
and calculation of the shortening velocity at zero load [Vmax]) and
isometric force development were measured. Analysis on light- and
electronmicroscopic level was carried out. Results: 1) Calcium
sensitivity was not altered in ESHF patients; 2) the velocity of the
force generating process (cross-bridge cycling rate) was normal in
ventricular and reduced in atrial ESHF myocardium, 3) maximum
isometric force development was reduced in ventricular, but not in
atrial myocardium of ESHF patients, and 4) Vmax was significantly
reduced in ventricular and atrial ESHF myocardium (p < 0.0001).
Perimysial and endomysial fibrosis was present in ventricular, not
in atrial myocardium of ESHF patients. Conclusion: A normal
cross-bridge cycling rate in left-ventricular ESHF myocardium
combined with a decreased capability of muscle shortening indicates
the presence of a resistance against shortening localized either on
the cross-bridge level or/and due to intra- and pericellular
fibrosis. Left-ventricular contractile dysfunction in patients with
end-stage heart failure may be related to a normal contractile
apparatus contracting within an abnormal intracellular or
interstitial environment.
|
|
| |
|
| Waldecker B, Brachmann J,
Schmitt C, Offner B, Hurst T, Saggau W, Hagl S, Dapper F, Hehrlein
F, Tillmanns H, et al (1993):
|
| In-hospital experience
with multiprogrammable implantable antitachycardia/antifibrillation
devices
|
| Eur Heart J. 1993 Apr;
14(4): 492-8
|
| Abstract:Multiprogrammable, automatic
internal defibrillators with (n = 45) and without (n = 15)
antitachycardia pacing features were implanted in 60 consecutive
patients with refractory, malignant ventricular tachycardia (VT) (n
= 42) or fibrillation (VF) (n = 18). Left ventricular (LV) ejection
fraction was reduced to 39% +/ 12% as a result of structural heart
disease in 56 patients. The complexity of the systems caused no
additional risks to the surgical procedure or postoperative
management. VT/VF detection parameters were individually adjusted to
the arrhythmia type (detection cycle length 323 +/ 40 ms in patients
with VF vs 405 +/ 40 ms for VT patients, P < 0.05) and incidence
(longer detection periods if frequent nonsustained VT was also
present). Shock energy was reduced in patients with VT as compared
to VF (11J vs 24J, P < 0.05). Antitachycardia pacing was
activated in 19/28 (68%) patients with well tolerated VT. Signal,
telemetry, as detected by the device, combined with programmability
allowed the device to be checked for correct decisions (these were
inappropriate in four patients in three of whom corrections were
non-invasive) prior to discharge. In conclusion, in the automatic
tachyarrhythmia control devices we studied, programmability and
flexibility appeared to be clinically safe and useful. Prolonged
observation periods are required, however, to evaluate the true
clinical safety and persistent efficacy of device programmability
and flexibility.
|
|
| |
|
| Zimmermann R, Baki S, Dengler
TJ, Ring GH, Remppis A, Lange R, Hagl S, Kubler W, Katus
HA (1993):
|
| Troponin T release after
heart transplantation
|
| Br Heart J. 1993 May; 69(5):
395-8
|
| Abstract: For
the diagnosis of myocardial cell damage the measurement of the serum
concentrations of myofibrillar antigens has several potential
advantages over the assessment of traditional serological markers.
These include the expression of myofibrillar antigens as
cardiospecific isoforms and their high intracellular concentrations.
Recently a sensitive and specific enzyme immunoassay for cardiac
troponin T has been developed that shows little cross reactivity
with skeletal isoforms. OBJECTIVE To characterise myocardial cell
damage after orthotopic heart transplantation, concentration of
circulating troponin T were measured prospectively in serial blood
samples from 19 consecutive patients taken during the first three
months after transplantation. RESULTS--Mean (SD) serum
concentrations of cardiac troponin T reached a maximum of 3.6 (1.8)
micrograms/l at 7.1 (4.2) days after transplantation and remained
higher than 0.5 micrograms/l (twice the detection limit of the
assay) in all patients for at least 43 days (mean (SD) 59 (20)
days). There was considerable variation in cumulative troponin T
release (area under the concentration curve) between the patients
(ranging from 27 to 150 micrograms x days/l) that was not related to
the total ischaemic time before transplantation or to the patient's
renal or hepatic function, preoperative cardiac diseases, major
histocompatibility complex matching or the number of complications
related to rejection. CONCLUSIONS--Because the half life of cardiac
troponin T serum is 2 h the current data show that antigen continued
to be released from implanted hearts during the first postoperative
months in quantities similar to minor Q wave myocardial infarction.
Troponin T release after transplantation continued for much longer
than after myocardial infarction or other cardiac surgery. Processes
other than perioperative ischaemic damage must be responsible for
the considerable individual differences in the release of cardiac
troponin T.
|
|
|
|
|
| 1992: |
|
| De Simone R, Lange R, Saggau W,
Gams E, Tanzeem A, Hagl S (1992):
|
| Intraoperative
transesophageal echocardiography for the evaluation of mitral,
aortic and tricuspid valve repair. A tool to optimize surgical
outcome
|
| Eur J Cardiothorac Surg.
1992; 6(12): 665-73
|
| Abstract:The
present study reviews the clinical applicability and usefulness of
intraoperative transesophageal echocardiography (TEE) during valve
repair. Intraoperative TEE was performed in 48 consecutive patients,
who were divided into three groups: 1. mitral valve repair (MVR), 2.
aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual
valve regurgitation was assessed by color Doppler echocardiography
on a scale from 0 to 4. The ratios of the jet area (JA) to the left-
and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and
after cardiopulmonary bypass (CPB). In group 1, 14 patients were
scheduled for MVR, of which 4 patients underwent valve replacement
and 10 MVR. Post-repair TEE studies showed a significant decrease of
mitral regurgitation. In 2 of the 10 patients, TEE demonstrated
severe residual regurgitation requiring valve replacement during the
same thoracotomy. In group 2, 11 patients underwent aortic
commissurotomy. Post-repair TEE showed an increase in the systolic
opening diameter and opening area of the aortic valve. One patient
underwent valve substitution because of severe aortic regurgitation.
In group 3, 23 patients were scheduled for TVR. In 3 of them TEE
showed no significant regurgitation thus rendering tricuspid valve
surgery unnecessary. Twenty patients underwent TVR of whom two
showed unacceptable post-repair regurgitation requiring further
surgery. Eighteen patients showed a significant reduction of valve
regurgitation after TVR, and a further reduction was achieved by
adjusting the tricuspid annuloplasty under TEE guidance.
|
|
| |
|
| De Simone R, Lange R, Saggau W,
Tanzeem A, Hagl S (1992):
|
| [Intraoperative
evaluation of tricuspid valve annuloplasty with transesophageal
echocardiography]
|
| Cardiologia. 1992 Mar;
37(3): 195-201
|
| Abstract:The
present study shows a new application of transesophageal
echocardiography (TEE) to optimize tricuspid valve annuloplasty.
Eighteen patients with tricuspid regurgitation (TR) underwent De
Vega tricuspid annuloplasty. After cardiopulmonary bypass the
tension on the suture was adjusted until the surgeon could not feel
any regurgitant jet by intraatrial palpation; subsequently, the
tension was further adjusted on the basis of TEE. The post-pump
residual tricuspid regurgitation was assessed by semiquantitative
grading of tricuspid regurgitation (0 to 4+), area of regurgitant
jet and percentage of right atrial area subtended by jet area. The
data obtained by intraatrial palpation were compared with the data
obtained by TEE. A significant reduction of residual tricuspid
regurgitation was shown by TEE when compared to intraatrial
palpation. After a follow-up period of 2 weeks, no significant
changes in the grade of TR were observed. The results showed that
the use of TEE was able to optimize the De Vega's tricuspid
annuloplasty.
|
|
| |
|
| Gams E, Hagl S, Schad H,
Heimisch W, Mendler N, Sebening F (1992):
|
| Importance of the mitral
apparatus for left ventricular function: an experimental
approach
|
| Eur J Cardiothorac Surg.
1992; 6 Suppl 1: S17-23; discussion S24
|
| Abstract:In an
experimental study of 31 anesthetized dogs the importance of the
mitral apparatus for the left ventricular function was investigated.
During extracorporeal circulation bileaflet mitral valve prostheses
were implanted preserving the mitral subvalvular apparatus. Flexible
wires were slung around the chordae tendineae and exteriorized
through the left ventricular wall to cut the chordae by
electrocautery from the outside when the heart was beating again.
External and internal left ventricular dimensions were measured by
sonomicrometry, left ventricular stroke volume by electromagnetic
flowmeters around the ascending aorta, left ventricular
end-diastolic volume by dye dilution technique, and left ventricular
pressure by catheter tip manometers. Different preload levels were
achieved by volume loading with blood transfusion before and after
cutting the chordae tendineae. When the chordae had been divided
peak systolic left ventricular pressure did not change. Heart rate
only increased at the lowest left ventricular end-diastolic
pressures of 3-4 mmHg, but remained unchanged at higher preload
levels. Cardiac output decreased significantly up to -9% at left
ventricular end-diastolic pressures of 5-10 mmHg, while left
ventricular dp/dtmax showed a consistent reduction of up to -15% at
any preload level. Significant reductions were also seen in systolic
shortening in the left ventricular major axis (by external
measurements -27%, by internal recording -43%). Left ventricular
end-diastolic dimensions increased in the major axis by +2% when
recorded externally, by +10% when measured internally. Systolic and
diastolic changes in the minor axis were not consistent and
different in the external and internal recordings.(ABSTRACT
TRUNCATED AT 250 WORDS)
|
|
| |
|
| Saggau W, Sack FU, Lange R,
Werling C, De Simone R, Brachmann J, Hagl S (1992):
|
| Superiority of
endocardial versus epicardial implantation of the implantable
cardioverter defibrillator (ICD)
|
| Eur J Cardiothorac Surg.
1992; 6(4): 195-200
|
| Abstract:The
implantable cardioverter defibrillator (ICD) has proved to be an
efficient device for the treatment of severe ventricular
tachyarrhythmias (VT). From May 1985 to August 1991, the ICD was
implanted in 107 patients of whom 72% suffered from coronary artery
disease, 17% from cardiomyopathy, 5% from long QT-syndrome and 6%
from other heart disease. All patients had a life threatening
episode of VT or at least one episode of ventricular fibrillation.
Of 107 implants, 12% were combined with other heart surgery, 55%
were isolated epicardial implantations (epi I) and in 33%, the novel
endocardial (endo I) approach was chosen. Between epi I and endo I
we found no difference in operation time, but time for ICU and
in-hospital stay was significantly shorter using the transvenous
approach. In addition, sensing and pacing capability of the
endocardial screw-in electrode was superior and the need for
thoracotomy was avoided, a particular advantage in patients with
previous heart surgery. Complications after epi I were: temporary
low cardiac output, 1; perioperative death, 2; infection, 3, and
after endo I: electrode dislocation, 2. Hence, endo I may become the
method of choice for patients without concomitant surgery.
|
|
| |
|
| Vahl CF, Bauernschmitt R, Bonz
A, Herold U, Ziegler S, Lang A, Hagl S (1992):
|
| Contractile behaviour of
skinned papillary muscle in mitral valve disease
|
| Thorac Cardiovasc Surg. 1992
Oct; 40(5): 253-60
|
| Abstract:The
contractile behaviour of Triton X 100 skinned left ventricular
papillary muscle from 19 patients undergoing cardiac surgery for
mitral valve stenosis: n = 6, mitral valve incompetence: n = 7, or
combined mitral valve disease: n = 6 was analyzed. At supramaximal
activation the "vibration induced force clamping technique" was used
for isometric analysis of time course and extent of isometric
postvibration force recovery. Afterloaded contractions were applied
for extrapolation of the maximum shortening velocity at zero load
(Vmax). The Calcium sensitivity was analysed by variation of the
free EGTA-buffered Calcium concentration at a passive resting force
of 2 mN at 26 degrees C. In different types of mitral valve disease
the characteristics of isometric force development were unaltered in
terms of maximum force development, force per square mm, Calcium
sensitivity and the time course of isometric contraction after force
clamping. However the capability to shorten as expressed by Vmax was
reduced in mitral valve incompetence (3.87 +/- 0.37 ML/s) as
compared with mitral valve stenosis (5.29 +/- 0.35 ML/s) or combined
mitral valve disease (4.83 +/- 0.51 ML/s). The ratio between the
inverse value of Vmax and the time constant of isometric force
development after force clamping was significantly different in
mitral valve incompetence as compared with other types of mitral
valve disease (p < 0.0001). These data argue for the presence of
different resistances against shortening in various types of mitral
valve disease, due to altered cross-bridge cycling characteristics
or to morphological factors.
|
|
| |
|
| Zimmer G, Zimmermann R, Hess OM,
Schneider J, Kubler W, Krayenbuehl HP, Hagl S, Mall G (1992):
|
| Decreased concentration
of myofibrils and myofiber hypertrophy are structural determinants
of impaired left ventricular function in patients with chronic heart
diseases: a multiple logistic regression analysis
|
| J Am Coll Cardiol. 1992 Nov
1; 20(5): 1135-42
|
| Abstract: The
aim of this study was to perform a multiple logistic regression
analysis to identify independent structural determinants of impaired
left ventricular function. BACKGROUND. The association between
contractile failure and structural alterations of the myocardium has
been demonstrated in several studies, and multiple interactions
between myocardial structure and cardiac performance are likely.
METHODS. Morphometric data assessed from 130 left ventricular biopsy
specimens were analyzed. The endomyocardial specimens were obtained
from 57 patients with normal coronary arteries (17 with normal left
ventricular ejection fraction and 40 with impaired left ventricular
function [dilated cardiomyopathy]), 15 patients with hypertrophic
cardiomyopathy and 32 patients with aortic valve disease. Transmural
biopsy specimens were assessed in 6 donor hearts before heart
transplantation and in 20 patients with left anterior descending
coronary artery disease whose specimens were obtained from the left
ventricular anterior wall during aortocoronary bypass surgery.
Global or regional left ventricular function was evaluated from left
cineventriculograms. The volume fraction of cardiac fibrous tissue,
intracellular volume fraction of myofibrils, volume fraction of
myofibrils related to myocardial tissue (including fibrosis) and
myofiber diameters were determined from semithin sections of the
biopsy specimens with the use of light microscopic morphometry.
RESULTS. Multiple logistic regression analysis revealed decreased
volume fraction of myofibrils (p < 0.005) and increased fiber
diameter (p < 0.002) as independent determinants of impaired left
ventricular function. CONCLUSIONS. These data indicate that,
independent of the underlying heart disease, both decreased
concentration of contractile proteins and myocyte hypertrophy are
independently associated with impaired left ventricular
function.
|
|
|
|
|
| 1991: |
|
| Gams E, Hagl S, Schad H,
Heimisch W, Mendler N, Sebening F (1991):
|
| Significance of the
subvalvular apparatus for left-ventricular dimensions and systolic
function: experimental replacement of the mitral valve
|
| Thorac Cardiovasc Surg. 1991
Feb; 39(1): 5-12
|
| Abstract:To
study the significance of the subvalvular apparatus for
left-ventricular performance in mitral valve replacement, a new
experimental model was developed. In 21 dogs St. Jude prostheses
were implanted in the mitral position preserving the chordae
tendineae and the papillary muscles by plicating and fixing the
mitral leaflets with the prosthesis on the valvular annulus.
Flexible steel wires were slung around the chordae tendineae of the
anterior and the posterior papillary muscle separately and passed
through the left ventricular wall via insulating plastic cannulas.
Left-ventricular dimensions and global systolic function were
measured during volume loading with blood before and after severance
of the chordae tendineae by external application of electrocautery
to the steel wires. Thus the heart continued beating without any
interference following loss of the subvalvular apparatus. The
external left ventricular diameters in the major and minor axis were
determined by sonomicrometry. Left-ventricular systolic and
diastolic pressures were measured by catheter tip manometers, stroke
volume by electromagnetic measurements of flow in the ascending
aorta. When the chordae tendineae had been cut, left-ventricular
end-diastolic diameters in the major axis were increased ( + 2%), in
the minor axis decreased (-1%) at any left-ventricular end-diastolic
pressure. Systolic shortening of the major axis diameter was
considerably reduced (20-27%) at any left-ventricular end-diastolic
pressure following severance of the chordae tendineae. Significant
increase of the systolic shortening in the minor axis diameter
occurred at preload levels of 3-6 mmHg (15-8%), while at higher
left-ventricular end-diastolic pressure of 7-8 mmHg no significant
changes were present.(ABSTRACT TRUNCATED AT 250 WORDS)
|
|
| |
|
| Katus HA, Schoeppenthau M,
Tanzeem A, Bauer HG, Saggau W, Diederich KW, Hagl S, Kuebler
W (1991):
|
| Non-invasive assessment
of perioperative myocardial cell damage by circulating cardiac
troponin T
|
| Br Heart J. 1991 May; 65(5):
259-64
|
| Abstract:Troponin T is a unique
cardiac antigen which is continuously released from infarcting
myocardium. Its cardiospecificity as a marker protein might be
particularly useful in assessing myocardial cell damage in patients
undergoing cardiac surgery. Therefore, circulating troponin T was
measured in serial blood samples from 56 patients undergoing cardiac
surgery and in two control groups--22 patients undergoing minor
orthopaedic surgery and 12 patients undergoing lung surgery by
median sternotomy. In both control groups no troponin T could be
detected, whereas activities of creatine kinase were raised in all
12 lung surgery controls and activities of the MB isoenzyme were
raised in five of the 12 patients in the lung surgery group and in
four of the 22 patients in the orthopaedic surgery group,
respectively. All the patients undergoing coronary artery bypass
grafting (n = 47) and cardiac surgery for other reasons (n = 9) had
detectable concentrations of troponin T. Five patients had
perioperative myocardial infarction detected as new Q waves and R
wave reductions. In these five patients troponin T release persisted
and serum concentrations (5.5-23 micrograms/l) reached a peak on the
fourth postoperative day. In the 51 patients without perioperative
myocardial infarction serum concentrations and the release kinetics
of troponin T depended on the duration of cardiac arrest. In
patients in whom aortic cross clamping was short troponin T
increased slightly on the first postoperative days; in patients with
longer periods of aortic cross clamping troponin T concentrations
were higher and remained so beyond the fifth postoperative
day.(ABSTRACT TRUNCATED AT 250 WORDS)
|
|
| |
|
| Lange R, Sack FU, Saggau W, Vahl
CF, De Simone R, Hagl S (1991):
|
| Performance of dynamic
cardiomyoplasty related to the functional state of the heart
|
| J Card Surg. 1991 Mar; 6(1
Suppl): 225-35
|
| Abstract:Cardiomyoplasty (CMP) was
performed with the left Latissimus dorsi in five beagles (group 1)
with intact hearts and seven foxhounds (group 2) in whom the left
ventricle was enlarged by 31 +/- 11.9% of cross-sectional area.
Ventricular function curves were constructed at filling pressures
ranging from 15-40 mmHg (group 2). Myocardial contraction patterns
were investigated by epicardial 2-D echocardiography. Skeletal
muscle contraction caused a significant increase in aortic pressure,
dP/dt, stroke volume, work and performance in all animals. Function
curves were shifted upward in a parallel manner. Echocardiography
showed an increase of the LV cross-sectional delta area of 14.8% +/-
5.8% (group 1) and of 39.5% +/- 15.1%, and approximation of the
edges of the wall defects (group 2). In conclusion, dynamic CMP as
applied in this acute model, increased the performance of normal
canine hearts and hence, a model of cardiac failure may not be a
prerequisite for the investigation of certain technical aspects of
CMP. In the failing heart, a parallel upward shift of myocardial
function curves suggested increased performance of the
heart/skeletal muscle complex over a wide range of filling
pressures. However, the descending limb of the function curve with
increasing filling pressures was observed despite skeletal muscle
contraction. Hence, similar to other assist systems, the residual
function of the heart may be of considerable importance in the
overall performance of dynamic CMP.
|
|
| |
|
| Machens G, Vahl CF, Hofmann R,
Wolf D, Hagl S (1991):
|
| Entodermal inclusion cyst
of the tricuspid valve
|
| Thorac Cardiovasc Surg. 1991
Oct; 39(5): 296-8
|
| Abstract:This
is a report on an epithelial inclusion cyst covering the septal
leaflet of the tricuspid valve. The tumor was an accidental finding
in a 5 1/2 years-old boy with congenital heart disease including
double-chambered right ventricle, ventricular and atrial septal
defects and subvalvular aortic stenosis. Histological examination
showed a two-layered ciliated epithelium, typically present in the
respiratory system. Embryologic tissue heterotopia arising from
sequestered entodermal elements from the primitive foregut during
cardiac organogenesis is a possible explanation for the locality and
histology of the tumor. To our knowledge, a similar case has never
been presented before.
|
|
| |
|
| Vahl CF, Carl I, Muller-Vahl H,
Struck E (1991):
|
| Brachial plexus injury
after cardiac surgery. The role of internal mammary artery
preparation: a prospective study on 1000 consecutive patients
|
| J Thorac Cardiovasc Surg.
1991 Nov; 102(5): 724-9
|
| Abstract:Brachial plexus injury is a
typical complication after median sternotomy. A prospective study
was performed on 1000 consecutive patients to determine whether
preventive actions, including lower position and least possible
opening of the sternal retractor, help to reduce the complication
rate. Twenty-seven patients were observed with postoperative
brachial plexus injury. Nerve conduction measurements and
electromyography were performed. Patients without preparation of the
internal mammary artery had a complication rate of less than 1%,
whereas the complication rate of those patients with preparation of
the internal mammary artery was as high as 10.6%. The main symptoms
were continuous pain and motor and sensory disturbances. Most
frequent were lesions corresponding to the roots C8-T1. Six patients
had Horner's syndrome; three had ptosis only with no other signs of
Horner's syndrome. Symptoms persisted in eight patients more than 3
months after the operation, and one patient still had intractable
pain. Increasing use of internal mammary artery grafts in coronary
artery bypass demands measures to protect the brachial
plexus.
|
|
| |
|
| Vahl CF, Lange R, Bauernschmitt
R, Herold U, Tischmeyer K, Hagl S (1991):
|
| Analyzing contractile
responses in demembranized pig papillary muscle fibres: the
influence of calcium, resting force, and temperature
|
| Thorac Cardiovasc Surg. 1991
Dec; 39(6): 329-37
|
| Abstract:The
influence of calcium, resting force and temperature on the
contractile behaviour in isolated demembranized ("skinned") pig
papillary muscle fibers (n = 36) was analysed. Demembranisation
excludes the influence of any membrane related processes on the
contractile response as the myofilaments are in direct contact with
the bathing medium. Resting force (1 mN-9 mN), temperature (22
degrees C or 32 degrees C) and pCa 7.0-4.3 were varied and the
contractile response was analyzed by studying the time constant and
the extent of post vibration force recovery (PVFR) of the activated
preparations (the vibration method). Additional constant-load
experiments and detection of sarcomere-length were carried out.
There was an inverse-linear relationship between time constants of
post vibration force recovery and maximum shortening velocity as
estimated by constant load experiments. Resting force affected the
extent of force development but not the time constant of post
vibration force recovery and modulated the pCa-force relationship
without altering the calcium concentration required for half-maximal
activation (calcium sensitivity). In contrast lowering the bath
temperature from 32 degrees C to 22 degrees C caused a significant
leftward shift of the pCa-force relationship potentially due to
changes of the contractile filaments' calcium sensitivity. The
effect of temperature on the myocardial contractile system is of
special interest as hypothermia is frequently used in cardiac
surgery. Analysis of alterations of the contractile proteins'
calcium sensitivity during the rewarming period of the patient may
provide further insight in the pathophysiology of
reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)
|
|
| |
|
| Vahl CF, Meinzer HP, Hagl
S (1991):
|
| Three-dimensional
presentation of cardiac morphology
|
| Thorac Cardiovasc Surg. 1991
Dec; 39 Suppl 3: 198-204
|
| Abstract:The
results of a research project aiming to visualize cardiac anatomy in
a 3-dimensional form for surgical planning are presented. Based on
electronic data processing within a local area network environment,
serial slices of CT- and MRI-machines were used to construct a
3-dimensional data cube that was illuminated by calculated sources
of light. Light rays were traced through the entire "data volume".
Mathematically following each pathway of light through the space,
the intensity of changes along this path were calculated. The
results of applying this "Heidelberg Ray-tracing Technique" to
cardiac anatomy are 3-dimensional "computer movies" that appear on
any workstation within a computer network. Using special software,
the surgeon can "walk" in any direction through the heart or he can
break it into two or more parts in order to analyze regions of
interest in detail. Even small structures such as papillary muscles,
bifurcations, coronary arteries and cusps of cardiac valves become
visible. This new technique may enable the surgeon to open the heart
prior to surgery on the computer monitor working with a visualized
model that corresponds to the visual experience of his daily
intraoperative practice.
|
|
|
|
|
| 1990: |
|
| Borner C, Haberbosch W, Hagl S,
Mechtersheimer G, Kretzschmar U, Hild R (1990):
|
| [Primary right atrial
leiomyosarcoma in an adult]
|
| Z Kardiol. 1990 Dec; 79(12):
865-9
|
| Abstract:Primary leiomyosarcoma of the
heart is very rare, and in most cases the diagnosis is performed
during postmortem examinations. We report on a 71-year-old woman
with a large leiomyosarcoma of the right atrium. The preoperative
diagnosis of cardiac tumor was made by 2-D echocardiography,
transesophageal echocardiography, computed tomography, and
MR-imaging, and was confirmed by histological and immunhistological
findings of the resected part.
|
|
| |
|
| Gams E, Schad H, Heimisch W,
Hagl S, Mendler N, Sebening F (1990):
|
| Preservation versus
severance of the subvalvular apparatus in mitral valve replacement:
an experimental study
|
| Eur J Cardiothorac Surg.
1990; 4(5): 250-5; discussion 255-6
|
| Abstract:Preservation of the
subvalvular apparatus in mitral valve replacement has been suggested
to improve postoperative left ventricular performance. As it is
difficult to quantify the change in left ventricular performance
clinically, an experimental model was devised to demonstrate the
contribution of the subvalvular apparatus to left ventricular
function. In eight dogs mitral valve replacement (St. Jude
prostheses) was performed, preserving the subvalvular apparatus by
plicating the leaflets with the prosthesis on the mitral annulus.
Left ventricular function was assessed during volume loading with
blood before and after cutting the chordae tendineae by means of
electrocautery applied via flexible wires slung around the chordae
and exteriorized through the left ventricular wall. Left ventricular
internal diameters were measured by sonomicrometry. End-diastolic
volume (LVedV) and stroke volume were determined by dye dilution and
left ventricular pressure (LVP) by cathter tip manometer. The
results showed that after cutting the chordae the heart rate did not
differ from the pre-cut values at any LVedP. The peak left
ventricular pressure was only significantly reduced at an LVedP of 5
mmHg and minor axis diameters were only increased at an LVedP of
9-12 mmHg. Significant changes were observed, however, in LV
dP/dtmax (= maximum rise of LVP) (-15%), major axis end-diastolic
diameter (+10%) and systolic shortening (-40%), end-diastolic volume
(+18%) and ejection fraction (-16%) at any LVedP, and stroke volume
(-24%) at any LVedV.(ABSTRACT TRUNCATED AT 250 WORDS)
|
|
| |
|
| Hagl S, Vahl CF (1990):
|
| [Intraoperative
diagnosis--measuring heart time volume and assessment of shunts]
|
| Z Kardiol. 1990; 79 Suppl 4:
107-17
|
| Abstract:Intraoperative measurement of
hemodynamics provides objective data supporting improvement of
surgical and anaesthesiological treatment. Several methods including
the thermodilution method, application of ultrasonic flow meters,
use of the computed pressure gradient technique, application of
transoesophageal color flow mapping and other cardiovascular
applications of ultrasound are discussed with respect to their
benefits and limitations in a clinical routine environment in
cardiac surgery. According to our experiences the application of
intraoperative transoesophageal doppler echocardiography and use of
electromagnetic flow measurements are today the methods of choice.
However, methodological limitations have to be regarded and
additional intraoperative and clinical data are necessary whenever
semiquantitative measurements of ultrasound techniques are used as
basis for intraoperative judgement on the hemodynamic
situation.
|
|
| |
|
| Lohrer RM, Trammer AR, Dietrich
W, Hagl S, Linderkamp O (1990):
|
| The influence of
extracorporeal circulation and hemoseparation on red cell
deformability and membrane proteins in coronary artery disease [see
comments]
|
| J Thorac Cardiovasc Surg.
1990 Apr; 99(4): 735-40
|
| Abstract:Extracorporeal circulation
and hemoseparation may lead to coupled mechanical and chemical blood
trauma and thus influence red cell deformability. Ten patients with
coronary artery disease underwent coronary bypass. Patients' blood
samples were drawn preoperatively, after extracorporeal circulation,
and after hemoseparation. Ten healthy adults served as control
subjects. Red blood cell deformability was determined by direct
microscopic observation of red blood cells subjected to shear
stresses of 1.2 to 13.3 Pa with a counter-rotating rheoscope. Red
cell membrane proteins were separated by one-dimensional
polyacrylamide gel electrophoresis in the presence of sodium dodecyl
sulfate. At 1.2 Pa, preoperative red cell deformability was
significantly greater in patients with coronary artery disease than
in control subjects. Neither extracorporeal circulation nor
hemoseparation changed red cell deformability significantly.
Electrophoretic separation of membrane proteins failed to show any
quantitative or qualitative differences between patients and control
subjects. Moreover RBC membrane proteins of red blood cells in the
patients were not altered as a result of extracorporeal circulation
or hemoseparation. The preoperatively increased red cell
deformability in the patients may be drug-induced. Our data suggest
that the extracorporeal circulation and hemoseparation techniques
used in this study do not lead to red blood cell damage.
|
|
| |
|
| Schmidt-Ott SC, Bletz C, Vahl C,
Saggau W, Hagl S, Ruegg JC (1990):
|
| Inorganic phosphate
inhibits contractility and ATPase activity in skinned fibers from
human myocardium
|
| Basic Res Cardiol. 1990
Jul-Aug; 85(4): 358-66
|
| Abstract:During hypoxic heart failure,
inorganic phosphate (Pi) accumulates. We report the effects of Pi on
force development and on myofibrillar ATPase-activity of human
skinned atrial fibers, both at normal and at reduced levels of
Mg-ATP. Pi (10 mM) depressed force production at maximal calcium
activation (pCa 4.3) by about 40%. At higher pCa values (pCa 5.6),
force inhibition was even more pronounced, but at low concentrations
of Mg-ATP (10 microM), Pi was less effective. In contrast to
contractile force, myofibrillar ATPase was only inhibited by about
10% at pCa 4.3, whereas it could be inhibited by 40-50% at
submaximal calcium activation (pCa 5.6). As Pi inhibited contractile
force more than ATPase activity, the ratio of ATPase-activity to
force (tension cost) was increased by inorganic phosphate.
ATPase-activity and tension cost were significantly reduced by
lowering Mg-ATP concentration to 10 microM, whereas contractile
force was less affected. Pi did not affect ATPase under these
conditions at 10 mM Mg-ATP. Pi also shifted the calcium-force
relationship towards higher Ca++ concentrations, that is, it
decreased calcium sensitivity. In contrast, the calcium sensitivity
of myofibrillar ATPase was less affected. These findings suggest
that inorganic phosphate may affect the myocardium by altering
crossbridge kinetics rather than the calcium affinity of troponin-C.
Because of its inhibitory effect on myofibrillar ATPase, inorganic
phosphate may be partly cardioprotective in the hypoxic myocardium.
However, this "energy sparing' effect is probably offset by the
greater "tension cost' that decreases the "efficiency' of tension
maintenance in the presence of inorganic phosphate.
|
|
| |
|
| Vahl CF, Tochtermann U, Gams E,
Hagl S (1990):
|
| Efficiency of a computer
network in the administrative and medical field of cardiac surgery.
Concept of and experience with a departmental system
|
| Eur J Cardiothorac Surg.
1990; 4(12): 632-8
|
| Abstract:We
report on a pilot project implementing electronic data processing
(EDP) in the Department of Cardiac Surgery of the University of
Heidelberg, based on a concept of complete integration of a medical
database system into everyday clinical routine. A computer network
was installed and has been in use since August 1988 as a department
system supporting both the administrative and the medical side of
the department (documentation, information, research, archives,
organization, secretarial office, billing, statistics and
communication). With a computer-assisted documentation system and
standardized data acquisition, nearly 80% of letters and reports on
operations are written automatically without any further need for
dictation. Automatic computer controlled follow-up has been
initiated to cover all patients operated on in our hospital. The
complete integration of a new method of clinical documentation and
EDP into everyday clinical routine and the extensive use of
computer-derived information have proved to be significant advances.
Our practice of computer-assisted information management and
departmental organization serves the patient by; (1) providing
up-to-date valid information for the clinical staff; (2)
establishing and stabilizing contact and communication with
physicians elsewhere, e.g. cardiologists; (3) facilitating pre- and
postoperative contact with patients; (4) helping to optimize medical
treatment by routine statistical data analysis (quality assurance);
(5) creating a clear and logical computer-assisted departmental
organizational structure; (6) permitting long-term evaluation of
operative results based on a standardized computer-controlled
follow-up procedure; (7) improving the quality of medical and
administrative data.
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| 1989: |
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| Hambrecht R, Schuler G, Mall G,
Hagl S, Kubler W (1989):
|
| [Peracute constrictive,
idiopathic pericarditis--a case report of an acute life-threatening
disease picture]
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| Z Kardiol. 1989 Oct; 78(10):
680-2
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| Abstract:Generally, idiopathic
pericarditis is considered a benign, self-limiting disease.
Frequently, the exsudative phase of the disease is followed by a
mild form of transitory constriction of the pericardium. The case
reported here shows an unusual course of the disease. Shortly after
the symptoms of exsudative pericarditis subsided a life-threatening
form of pericardial constriction developed within weeks. In case of
chronic pericardial constriction perioperative mortality for partial
pericardiectomy is not insignificant. This is a result of myocardial
damage that is difficult to assess prior to surgery. For that reason
a partial pericardiectomy should be attempted as early as possible,
even in cases with acute pericardial constriction.
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| |
|
| Permanetter B, Sebening H, Hagl
S, Hartmann F, Sebening F, Blomer H (1989):
|
| [The significance of
heart rate for stress hemodynamics following heart
transplantation]
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| Z Kardiol. 1989 Apr; 78(4):
236-42
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| Abstract:Since
1985, orthotopic heart transplantation had been carried out in 20
patients. Seventeen patients are still alive. 341 +/ 156 days after
cardiac transplantation hemodynamics at rest were normalized. Left
ventricular ejection fraction at rest and during exercise was within
normal ranges for all patients except one. During symptom limited
bicycle exercise (121 +/ 35 Watt), pulmonary capillary wedge
pressure (PCP) and right atrial pressure (RAP) increased to
unphysiological high levels (PCP: 8.2 +/ 2.7 mmHg at rest, 19.1 +/
4.9 mmHg at exercise; RAP: 4.1 +/- 2.3 mmHg at rest, 12.1 +/- 3.9
mmHg at exercise), whereas cardiac index was elevated to a normal
level (3.6 l/min.m2 at rest; 6.9 l/min.m2 at exercise). Increase in
heart rate, however, was subnormal (from 90 +/- 13/min at rest to
122 +/- 15/min at exercise). To examine the influence of heart rate
on hemodynamics, in 8 patients with normal tricuspid valve function,
heart rate was gradually increased by atrial stimulation during
continuous exercise; PCP maximally could be reduced from 19.1 +/- 4
mmHg to 10.8 +/- 2.7 mmHg (p less than 0.01) at an optimum heart
rate of 139 +/- 9/min. Reduction of RAP was by far less pronounced
and normalization could not be achieved (from 12.2 +/- 3.7 mmHg to
9.5 +/- 3.4 mmHg, p less than 0.01), suggesting an impaired right
ventricular function. By atrial stimulation stroke volume was
reduced from 109.8 +/- 17.7 ml to 91.8 +/- 14.2 ml (p less than
0.01). These results indicate that, at exercise, the denervated
transplanted heart, to a large extent, increases cardiac output by
means of the Frank-Starling mechanism.(ABSTRACT TRUNCATED AT 250
WORDS)
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