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.
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.
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.
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.
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.
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.
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.
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]
Z Kardiol. 1989 Oct; 78(10): 680-2
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.
Permanetter B, Sebening H, Hagl S, Hartmann F, Sebening F, Blomer H (1989):
[The significance of heart rate for stress hemodynamics following heart transplantation]
Z Kardiol. 1989 Apr; 78(4): 236-42
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)