Revascularization surgery as a treatment concept for heart failure.

Patients with heart failure symptoms due to ischemic cardiomyopathy face a poor prognosis without adequate treatment. In these patients with viable ischemic myocardium, revascularization surgery is not a new but an established treatment concept. the CASS study, published in 1983, was already able to document the superiority of coronary artery revascularization in patients with poor left ventricular function. It is of utmost importance to predict regional functional recovery in order to assess viability and, thus, the indication for revascularization. Late gadoliniium enhancement cardiovascular magnetic resonance is the new gold standard. By applying this technique, it can be demonstrated that the transmural extent of a scar predicts segmental functional recovery. Numerous studies describe the predictors of survival of surgical revascularization, the indication and impact of medical antiarrhythmic treatment or choice of graft. In addition to conventional surgery, off-pump procedures, minimal extracorporeal circulation and hybrid revascularization have a special role in the treatment of patients with ischemic cardiomyopathy. Surgical techniques and medical therapies continue to improve. The future revascularization in these patients will focus on improving results and making coronary artery bypass grafting for elective revascularization less invasive and safer. Technical evolution, including the use of robotics and anastomotic connectors, intraoperative imaging and protein enzyme therapies, have to be defined concerning their special impact in these patients.

Coronary artery surgery: now and in the next decade.

In coronary artery surgery the superiority of the internal mammary artery graft in 10-year survival was documented in 1986. In 1999 it was demonstrated that death, reoperation and percutaneous transluminary coronary angioplasty were more frequent in patients undergoing single rather than bilateral internal mammary artery grafting. Today coronary artery bypass grafting surgery is challenged by the success story of modern interventional cardiology. The Syntax Study, however, clearly underlined the better outcome for patients with triple-vessel and/or left main disease undergoing coronary artery bypass grafting in terms of repeat revascularization. Another point of ongoing discussion is the comparison between on-pump and off-pump coronary artery revascularization techniques. Even if mixed results exists in the literature, in experienced hands the combination of aortic no-touch and total arterial revascularization, probably leads to the superiority in off pump coronary artery bypass grafting in terms of significantly decreased rates of mortality, stroke, major adverse cardiac and cerebral vascular events. Coronary artery surgery in the next decade will be influenced by the further progression of minimally invasive surgical principles and by a variety of other factors. The role of robotics and hybrid surgery has yet to be defined. Alternatives within surgery will not only need to move to a less disruptive strategy (e.g. from on-pump to off-pump bypass) but also have to secure sustained innovation, as we can be sure that the current coronary artery bypass grafting activity will change substantially.

Management of sterno-mediastinitis.

With an incidence rate of 1-4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%. Risk factors for sternal instability are insulin-dependent diabetes mellitus, obesity, immunosuppressed state, chronic obstructive pulmonary disease, osteoporosis, history of radiation, renal failure, body height, smoking and nutritional state. The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically. As a result of interdisciplinary cooperation, a therapy concept has developed which is adapted to the patient individually. Therapy begins with the simplest measures and, if deemed necessary, this is then escalated step by step. The aim of the treatment is to bring the infection under control, which requires radical surgical debridement, removal of infected and necrotic tissue, removal of all foreign bodies (including wires and osteosynthesis material) and the removal of all infected, necrotic osseous material if necessary followed by vacuum-assisted closure therapy. The reconstruction of defects of the anterior chest wall is achievable using different muscle flaps. Mostly the muscle pectoralis major is used unilaterally or bilaterally with or without disinsertion of the tendon. Other options are the omental flap, the muscle latissimus dorsi flap or the muscle rectus abdominis flap. A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved successful and can be carried out with a high standard of safety.

Stentless aortic valves. Current aspects.

The design of stentless valve prostheses is intended to achieve a more physiological flow pattern and superior hemodynamics in comparison to stented valves. First - generation stentless bioprosthesis were the Prima valve, the Freestyle valve and the Toronto stentless porcine valve. The second generation of stentless valves, as the Super stentless aortic porcine valve, need only one suture line. The Sorin Pericarbon Freedom and the Equine 3F heart Valve belong to the third generation of stentless valve pericardial bioprostheses. A stentless valve to replace a full root can be implanted by several surgical techniques: complete or modified subcoronary, root inclusion and full root. The full root technique is accompanied by the lowest incidence of patient-prothesis mismatch. Our own clinical experience reflects more than 3000 stentless valve implantations since April 1996. Randomized study trials showed a hemodynamic advantage for stentless valves, but several could not reach a significant level. Also reported was a significant advantage of stentless bioprostheses concerning transvalvular gradients, effective valve area and quicker regression of the left ventricular mass 6 months after the operation, but at 12 months. Advantages are obvious in patients with a decreased left ventricle ejection fraction of less than 50% and in smaller implanted valve size, concomitant aortic root pathology (e.g. dissection) and aortic valve endocarditis. A survival advantage for stentless bioprostheses in comparison to stented ones has been reported by all studies in the literature. Stentless valves enrich the surgical armamentarium. Time will define the place of stentless valves in the future.

[Examination of the opportunity costs and turnover situation in patients with deep sternal infections]. / Kostennutzenanalyse der Therapie von Risikopatienten am Beispiel tiefer Sternuminfektionen.

BACKGROUND: Each and every hospital of any kind is forced, due to increased cost pressure, to work as economically and as efficiently as possible. This even applies when the operational orientations of the hospitals institutions are different. In the present article an analysis of the repercussions of the treatment of postoperative complications in terms of entrepreneurial practice is given. Our focus is on the opportunity cost. METHOD: A theoretical calculation of opportunity costs is made based on the example of postoperative infections following cardiac surgery and the resulting treatment. The bases of the examinations are the results collected at the hospital Mediclin Herzentrum Lahr / Baden in 2008. The wound healing disorders were recorded from November 2004 until November 2007 and include 3675 patients who were operated on using a median sternotomy. Out of the 3675 patients 45 (1.2 %) were affected. Various treatment options are at hand. The used therapy algorithm in our practice is dependent on the stage and the development of the infection. RESULTS: If the high trim point, the medial trim point and the low trim point of the mediastinitis patients, as well as the average revenue and the surcharge omission on exceeding the high trim point (these data can be found in the annual accounts) and knowledge of the actual length of stay of the mediastinitis patient are known, the opportunity cost, respectively potential turnover increases, can be calculated. Reducing the medial trim point from 48.43 to, for example, 36.37 days could potentially produce a turnover increase of as much as 10 633.41 €. CONCLUSION: Keeping patient safety in mind, significant turnover increases can be achieved with adequate planning. The considered sales situation, however, can only be achieved under the same terms: these being free operating room and bed capacities, available personnel, equal cost of materials as well as enough patients. The consideration of opportunity costs could be important for entrepreneurs if staff shortage continues and, in economical terms, non-expendable capacities are created.

In search of a standardized treatment for poststernotomy mediastinitis.

Poststernotomy mediastinitis following median sternotomy procedures such as open heart surgery is a rare complication which nevertheless has a mortality rate of up to 50 %. Several treatment options are currently available; however, none of them are standardized. Based on the experience gained from open heart surgery performed at the MediClin Heart Institute Lahr/Baden, a therapeutic algorithm was developed. The treatment steps consist of repeated radical surgical debridement, sternal restabilization, vacuum-assisted closure therapy (VAC) as well as a surgical reconstruction via M. pectoralis plasty (MPP). This approach had a 30-day mortality of 0 % and a hospital mortality of 10.4 %. The approach proved to be safe and advantageous for specific patient groups operated on at the MediClin Heart Institute Lahr/Baden.

Female gender does not increase perioperative risk in coronary bypass surgery.

INTRODUCTION: Female gender has been identified as an independent risk factor for perioperative mortality in several risk scores for cardiac surgery. Since no explanation has been given for this, this study aimed to evaluate potential differences in the distribution of other risk factors between the genders. PATIENTS AND METHODS: 10 714 consecutive coronary bypass patients were analyzed retrospectively. The distribution of the risk factors as used in the EuroSCORE was evaluated. Diabetes mellitus was added to the analysis as an additional risk factor. Patients aged between 60 and 70 years without any additional risk factors were directly compared in a subgroup analysis. Statistical analysis was done using the T-test or chi-square test where appropriate. RESULTS: Female patients were significantly older compared to male ones (69.1 ± 8.5 vs. 65.4 ± 4 years, P < 0.05). The distribution of the analyzed risk factors did not differ except for diabetes mellitus: female patients were more likely to present with diabetes (42 % vs. 29 %, P < 0.05) and in diabetic patients, the incidence of insulin dependency was higher in female patients (50 % vs. 33 %, P < 0.05). Overall perioperative mortality was higher in female patients (2.7 % vs. 1.8 %, P < 0.05). This difference increased when diabetes was present (3.9 % vs. 1.8 %, P < 0.05) and was even higher in insulin-dependent patients (4.9 % vs. 1.9 %, P < 0.05). However, when adjusting for age and diabetes, the differences were reduced. This was most evident when subgroups of age-adjusted patients without any additional risk factors were analyzed: no gender-specific difference in perioperative mortality was observed. CONCLUSIONS: Female gender itself did not present as an independent risk factor. The presence of diabetes mellitus increased the risk in female patients significantly more than in male patients. The higher prevalence of diabetes in female patients in combination with the older age at presentation might result in the higher overall mortality observed in female patients compared to men.

Preoperative platelet inhibition with ASA does not influence postoperative blood loss following coronary artery bypass grafting.

INTRODUCTION: Platelet inhibition is thought to increase perioperative blood loss in patients with planned coronary artery bypass grafting (CABG). This retrospective study reviews the results of over 10 000 patients with CABG, comparing continued platelet inhibition with preoperative disruption of this therapy. PATIENTS AND METHODS: From 1995 to 2007, 12 023 patients underwent isolated CABG and were included in this study. The data were evaluated with regard to preoperative aspirin therapy, EuroScore relevant risk factors, and the operative results. Parameters of the operative outcome were in-hospital mortality, perioperative infarctions, reexploration rate, strokes, pericardial tamponade, blood transfusions, and perioperative drainage loss. RESULTS: The patients were divided into two groups: group A (continuous aspirin therapy till surgery [n = 2519]), and group B (patients with preoperative interruption of their aspirin therapy for at least five days [n = 9504]). There was no difference between the groups with regard to age, EuroScore (4.3 +/- 2.8 vs. 4.2 +/- 2.9), emergency cases (8.8 % vs. 8.7 %), left main stenoses (17.9 % vs. 17.6 %), duration of surgery (198 +/- 53 vs. 198 +/- 52 min.) and sex distribution. The postoperative drainage loss did not differ between groups A and B (834 +/- 781 ml vs. 902 +/- 811 ml), nor did the number of postoperatively administered red cell packages (0.88 +/- 2.7 vs. 1.01 +/- 2.9). When analyzing the three subgroups "on-pump primary CABG", "OPCAB procedures", and "redo CABG", again no difference was found in the main outcome parameters. Only the redo CABG of group B had a higher reexploration rate compared to group A (5 % vs. 3.3 %, P < 0.05). CONCLUSION: Preoperative aspirin therapy does not seem to influence the operative outcome of isolated CABG. Therefore, the often given recommendation to stop this therapy prior to elective CABG procedures should be abandoned.

Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis.

In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with M. pectoralis muscle flaps as treatment for deep sternal wound infections. Our group performed a retrospective analysis of 3630 consecutive cardiac surgical patients using median sternotomy from 11/2004 to 11/2007. After removing sternal wires, necrotic debris and potentially infective material, restabilisation of the sternum was performed and VAC therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Of the analysed patients 16 female and 29 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus odds ratio (OR 3.5), chronic obstructive pulmonary disease (COPD) (OR 2.9), use of bilateral mammarian artery (OR 2.0) and obesity (1.8). The median age of patients with deep sternal infections was similar to control patients. Staphylococcus epidermis was the most common pathogen (37.8%) followed by Enterococcus faecilis (22.2%) and Staphylococcus aureus (17.8). In 22.2% no pathogen could be detected. The 30 day mortality was 0%, the in-hospital mortality was 15.6%. The results of our studies demonstrate that vacuum therapy in conjunction with early and aggressive debridement is an effective strategy for treating poststernotomy mediastinitis. We consider pectoralis major muscle flap reconstruction as a safe technique and regard it as the primary choice for wound closure in poststernotomy mediastinitis.

Safety of a cardiac surgical training program over a twelve-year period.

INTRODUCTION: The operative results of cardiac surgical procedures performed either by staff surgeons or trainees were compared to evaluate whether there is any additional risk to the patient in operations carried out by trainees. PATIENT AND METHODS: Between 1994 and 2006, 13 197 operations were done by 9 staff surgeons (S-group) and were compared to 1925 operations performed by 10 residents during their training program (R-group). In both groups, subgroups were defined in which patients either underwent isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). Isolated CABG was performed in 8725 cases (S-group) and 1706 cases (R-group). AVR was done in 1273 patients (S-group) and 191 patients in the R-group. The groups were compared with regard to length of surgery, in-hospital mortality, reexploration for bleeding, sternal wound complications, preoperative infarction and stroke. For overall risk stratification, the EuroSCORE was used. In the CABG groups, the KCH score was additionally used. RESULTS: Overall mortality was 0.5 % in the R-group (predicted mortality: 4.6 +/- 5 %) compared to 2 % in the S-group (predicted mortality: 6.9 +/- 7.9 %). Analyzing the CABG groups, mortality was 0.7 % in the R-group (predicted: 1.9 +/- 1.8 %) compared to 1.3 % in the S-group (predicted: 2.1 +/- 2.3 %). The rate of reexplorations for bleeding was 1 % in the R-group compared to 2 % in the S-group ( P < 0.05). Duration of extracorporeal circulation (ECC) was slightly longer in the R-group (95.8 +/- 33 compared to 85.5 +/- 28.3 minutes) without reaching statistical significance ( P > 0.05). Analyzing the AVR group, there was a 0.6 % mortality in the R-group (predicted: 6.5 +/- 6 %) compared to 3.1 % in the S-group (predicted: 8.8 +/- 8 %). Again, there were significantly more reexplorations for bleeding in the S-group (0.6 % vs. 2.8 %, P < 0.05). Time on ECC was longer in the R-group (101.6 +/- 21.6 vs. 96.6 +/- 35 minutes) with a resulting longer cross-clamping time (71.2 +/- 17.1 vs. 63.5 +/- 21 minutes). CONCLUSIONS: Training in cardiac surgery can be done with excellent results and no additional risk to the patients. Both groups performed similarly and had outcomes better than the predicted mortality. Training was mostly performed with isolated coronary artery bypass grafting procedures, resulting in only a small surgical spectrum at the time of board certification.

Off-pump myocardial revascularisation in an octogenarian patient with dextrocardia and situs inversus.

Dextrocardia associated with situs inversus totalis is a rare condition and there are few reports of myocardial revascularisation in such patients. An 82-year-old woman with dextrocardia and situs inversus totalis underwent successful off-pump coronary artery bypass grafting using internal mammary arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. However, for a right-handed surgeon the operation was easier standing on the left side of the patient.

[Experiences collected in more than 2,300 diabetics undergoing coronary artery bypass grafting: patients with a specific risk profile]. / Erfahrungen mit Diabetikern in der Koronarchirurgie--Patienten mit einem besonderen Risikoprofil.

BACKGROUND: The objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases. METHODS: The data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests. RESULTS: In cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p < 0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p < 0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p < 0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p < 0.05). CONCLUSION: In coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.

Intraoperative bypass flow measurement reduces the incidence of postoperative ventricular fibrillation and myocardial markers after coronary revascularisation.

OBJECTIVE: Sudden ventricular fibrillation (VF) and myocardial infarction (MI) are life-threatening complications after coronary artery bypass grafting (CABG). We prospectively analysed the impact of intraoperative bypass flow measurement with the transit time flow Doppler method (TTFD) on the incidence and outcome of postoperative VF and MI. METHODS: In 1995 a standardized algorithm for the treatment of postoperative VF was introduced in our institution. The rate of postoperative VF was therefore exactly registered. In 1998 the TTFD method was implemented as a standard in all CABG cases. Whenever insufficient bypass graft flow was detected, anastomoses were redone and technical problems affecting the grafts were excluded. The incidence of postoperative VF and CK/CK-MB fraction was observed prospectively and the new data was compared to the data from 1995 to 1998. RESULTS: From 1/95 to 7/98 a total of 4321 patients (group A) were operated on with isolated CABG procedures using extracorporeal circulation. In the period from 8/98 to 10/02 a total of 3421 patients (group B) was operated on with isolated CABG procedures under the same conditions, except that the TTFD method was used in every case. The treatment of VF was standardised in both groups according to the algorithm. The most striking effect was the significant reduction of VF from 0.66% to 0.44% when TTFD was introduced and the steep decrease in mortality from 30% to 12.2% in patients with VF when the algorithm and TTFD were routinely applied. Furthermore the rate of insufficient bypass flow detected by angiography was reduced by 66%. CONCLUSION: Routinely the use of TTFD significantly reduced the incidence of postoperative VF, postoperative CK/CK-MB fraction, and angiographically detected bypass malfunction. A simultaneously implemented algorithm reduced the mortality with VF after CABG. The consequent use of TTFD intraoperatively reduced the incidence of postoperative anastomosis and technically related complications of bypass surgery and led to a significant reduction of postoperative mortality in CABG procedures.

Mid term outcome and quality of life after aortic valve replacement in elderly people: mechanical versus stentless biological valves.

OBJECTIVE: To assess the benefit for patients older than 65 years of aortic valve replacement with stentless biological heart valves in comparison with mechanical valves. DESIGN: Multiple regression analysis of a retrospective follow up study. SETTING: Single cardiothoracic centre. PATIENTS: Between 1996 and 2001, 392 patients with a mean age of 74 years underwent aortic valve replacement with stentless Freestyle bioprostheses or mechanical St Jude Medical prostheses. MAIN OUTCOME MEASURE: Operative mortality and morbidity, postoperative morbid events, mid term survival, and New York Heart Association (NYHA) class improvement, and quality of life. RESULTS: No significant differences were found between patients receiving stentless biological valves and patients receiving mechanical prostheses. However, analysis of subgroups showed that patients older than 75 years with mechanical valves had an increased risk of major bleeding events (p = 0.007). Patients requiring anticoagulation by means of coumarin had a twofold increased risk of an impaired emotional reaction (p = 0.052). However, for patients who received a mechanical valve for severe combined aortic valve disease a survival advantage (p = 0.045) and a decreased risk of prolonged ventilation (p = 0.001) was observed. On the other hand, patients receiving a stentless bioprosthesis had an increased risk of a prolonged stay in intensive care (p = 0.04) and stroke (p = 0.01) if they had severely reduced cardiac function (NYHA class IV). CONCLUSIONS: Elderly people receiving stentless bioprostheses benefit emotionally because of the avoidance of coumarin. However, in patients with severe hypertrophied ventricles and extraordinary calcifications, stentless bioprostheses should be chosen with caution.

Postoperative evaluation of radial artery grafts for coronary artery bypass grafting by transit-time Doppler flow measurements.

UNLABELLED: Due to the histological configuration of the vessel wall, the radial artery is prone to spasm as a result of handling or harvesting. Therefore, certain degrees of arterial wall spasm are unpreventable, even with appropriate pharmacologic treatment, while using the radial artery as a bypass graft in CABG. Consequently, the radial artery is only reluctantly used compared to saphenous vein grafts in CABG. In our clinical experience, the radial artery, if harvested carefully, has proved to be an excellent bypass graft. This investigation was undertaken to study the differences in blood flow measured directly after extracorporeal circulation in radial artery grafts and venous grafts. Both grafts were compared to the left internal mammarian artery anastomosed to the LAD. METHODS: Between January 1998 and December 1999, 198 patients who were undergoing coronary artery revascularization with two grafts were retrospectively investigated. In all patients, the left internal mammarian artery (LIMA) was anastomosed to the left anterior descending branch (LAD). For the second graft, either the saphenous vein or the radial artery was used. Proximal anstomoses were performed as end-to-side into the ascending aorta. Patients were divided into four groups: Group 1: n = 79 IMA-LAD, vein to the circumflex artery; Group 2: n = 56 IMA-LAD, vein to the right coronary artery; Group 3: n = 34; IMA-LAD, radial artery to the circumflex artery; Group 4: n = 29 IMA-LAD, radial artery to the right coronary artery. Graft-flow measurements were performed using the transit-time method after extracorporeal circulation was terminated. The mean systolic, diastolic, and mean blood flow were measured, and the pulsatility index was calculated. Statistical analysis was performed using the of t-test analysis between the variables mean blood flow and pulsatility index. A p-value of < 0.05 was defined as statistically significant. RESULTS: There were no statistically significant differences in mean blood flow or pulsatility index between radial artery and saphenous vein grafts to the right coronary artery and the circumflex artery, respectively. Also, there were no differences regarding vein grafts to the right coronary artery and to the circumflex artery, or regarding radial artery grafts to the two coronaries, respectively. In group 4, significantly lower blood flow to the LAD was found compared to group 1, and a significantly higher pulsatility index compared to groups 2 and 3. CONCLUSIONS: Radial artery grafts compared to saphenous vein grafts do not show significant differences early after operation in mean blood flow or pulsatility index. Further studies are needed to evaluate long-term performance of radial arteries as coronary bypass grafts and to compare the radial artery to the right mammarian artery and the standard saphenous vein graft.

Aortic valve replacement with or without concomitant coronary artery bypass grafting in the ninth decade of life.

Due to demographic changes in average life expectancy, the age of patients undergoing cardiac surgery is increasing. We have reviewed the short- and long-term outcome after aortic valve replacement with or without concomitant coronary artery bypass grafting in patients over 80 years of age. From 1 January 1995 until 30 June 1999, 114 patients (83 women and 31 men, 80-89 years of age, 82.8+/-2.4 years) with symptomatic aortic valve disease underwent aortic valve replacement. Of these patients, 54% (group A) received isolated valve replacement and 46% (group B) underwent myocardial revascularization as well. The perioperative mortality rate was 4.8% for group A and 7.7% for group B. The 30-day hospital mortality rate was 4.8% for group A and 15.4% for group B. The follow-up time ranged between 3 months and 63 months (32+/-15 months). None of the patients had to be reoperated for prosthetic valve dysfunction or endocarditis. Bleeding complications due to anticoagulation therapy were not observed. Of the 15 deaths during the follow-up period, seven (47%) were cardiac in nature and two (13%) were related to stroke. Actuarial survival rates for group A were 90%, 84%, and 76% at 1, 2, and 3 years, respectively, and for group B were 75%, 71%, and 68%. One year after the operation, permanent nursing care was not required by 100% of patients in group A (2 years, 98%; 3 years, 95%) and by 100% of patients in group B (2 years, 95%; 3 years, 91%). At a 1-year interval after the operation, 98% of patients in group A had not been hospitalized as a result of cardiac disorders (2 years, 98%; 3 years, 95%). The rates for group B were 90%, 85%, and 85%. Compared with younger age groups, aortic valve replacement in patients 80 years of age and older is associated with a distinctly increased mortality and morbidity. However, our data suggest that, considering the poor prognosis of conservative therapy of symptomatic aortic valve disease, functional status as well as life expectancy in this age group seem to be positively influenced by aortic valve replacement.

[The impact of morbid obesity on the peri- and postoperative course after aortocoronary bypass surgery]. / Der Einfluss von extremer Adipositas auf den peri- und postoperativen Verlauf nach aortokoronarer Bypassoperation.

BACKGROUND AND OBJECTIVE: Excessive obesity is considered to be a risk factor in coronary bypass grafting. The aim of the current study was to examine if grossly overweight patients with a body mass index (BMI) > 35 suffer from higher morbidity and mortality when compared with patients with normal body weight (BMI = 20-25). PATIENTS AND METHODS: 206 extremely obese patients (group A) and 206 patients with normal body weight (group B) originating from a total of 5614 patients undergoing coronary bypass grafting in the time span between 1.4.1996-1.10.2000 were studied retrospectively and consecutively. The data were obtained from case histories, questionnaires and interviews. Statistical analysis was performed by the chi 2 test after Pearson, the t test and the Kaplan-Meier method depending on the statistical problem analysed using the SPSS software v. 8.0. RESULTS: The comparison of group A with group B revealed a significantly higher incidence of diabetes mellitus (p < 0.001), hypertension (p < 0.001) and hyperlipidaemia (p < 0.01) in group A. The only significant differences regarding the surgical procedure were the longer operation time (212.3 +/- 44.6 min, mean +/- SD) and aortic cross-clamp time (53.8 +/- 17.4 min, mean +/- SD) in group A (p < 0.05). The duration of mechanical ventilation, the incidence of respiratory insufficiency and the stay in the intensive care unit were not significantly different. The disorders of wound healing both in the sternal and the graft removal regions occurred significantly more frequently in group A (p < 0.001). The 30 days mortality rate in group A (1.5%) was not significantly different from group B (p < 0.001). The 30 days mortality rate in group A (1.5%) was not significantly different from group B (2.9%). The follow-up analysis of the 30 days mortality rate in different age groups revealed no significant differences in patients aged between 60 and 75 years. The mean survival rate after 4 years was 87.2% in group A and 86.4% in group B. CONCLUSION: In spite of higher morbidity our results did not reveal significantly higher mortality in extremely obese patients. After operation the patients considered their state improved, therefore elective coronary surgery in grossly overweight patients seems to be indicated also without previous weight reduction.

[Short and long term results of aortic valve replacement in patients 80 years of age and older]. / Kurz- und Langzeitergebnisse des Aortenklappenersatzes bei 80- und über 80-Jährigen.

BACKGROUND: Due to demographic changes in average life expectancy the age of patients undergoing cardiac surgery is increasing as well. We have reviewed the short- and long-term outcome in patients over 80 years of age after aortic valve replacement with or without concomitant coronary grafting. PATIENTS AND METHOD: From 1.1.1995 until 31.12.1999, 126 patients (93 women, 33 men between 80 and 89 years, 82.8 +/- 2.4) underwent aortic valve replacement. 64 patients (group A) received isolated valve replacement, 62 (group B) underwent myocardial revascularization as well. RESULTS: The 30-day hospital mortality rate was 6.3% for group A and 14.5% for group B. The follow-up time ranged between 3 and 63 months (32 +/- 16). None of the patients had to be reoperated for prosthetic valve dysfunction or endocarditis. Bleeding complications due to anticoagulation therapy were observed by one patient from group A 3 years after the operation. Of the 15 deaths during the follow-up period seven (47%) were cardiac in nature and two (13%) related to stroke. Acturial survival rates for group A were 89%, 85% and 77% at 1, 2 and 3 years, and for group B 76%, 72% and 70%. Permanent nursing care was not required 1 year after the operation by 100% of patients in group A (2 years: 98%, 3 years 95%) and by 100% of patients in group B (2 years: 93%, 3 years: 90%). At an interval of 1 year after the operation 96% of patients in group A had not been hospitalized as a result of cardiac disorders (2 years: 96%, 3 years: 94%). The rates for group B were 88%, 81% and 75%. CONCLUSION: Compared with younger age groups, aortic valve replacement in patients 80 years of age and older is associated with a distinctly increased mortality and morbidity. However, our data suggest that considering the poor prognosis of conservative therapy of symptomatic aortic valve disease, functional status as well as life expectancy in this age group seem to be positively influenced by aortic valve replacement.

[Risk of perioperative mortality and complications following biological aortic valve replacement in elderly patients: stented vs. unstented prostheses]. / Perioperatives Mortalitäts- und Komplikationsrisiko nach biologischem Aortenklappenersatz bei älteren Patienten: ungestentete vs. gestentete Bioprothesen.

Recently published studies suggest that the hemodynamic advantage of stentless bioprostheses in comparison to stented bioprostheses positively influence the long-term survival after aortic valve replacement. However, the more complex and time consuming implantation technique may increase the risk of operative death. Between April 1996 and September 2000, 201 patients with the mean age of 75 +/- 5 years underwent aortic valve replacement (AVR) with a stentless Medtronic Freestyle Bioprosthesis (FP) and 166 patients with a mean age of 77 +/- 5 years received a stented Medtronic Mosaic Bioprosthesis (MP). Patients requiring concomitant procedures other than coronary artery bypass grafting (CABG) were excluded. The operative mortality was 3.5% after AVR with the FP and 6% after AVR with the MP. Multiple logistic regression analysis considering the different patient populations revealed no increased risk of operative death after AVR with FB (p = 0.46). Previously heart operations (p = 0.046) and emergency operation (p = 0.022) were risk factors for operative death after AVR with the biological bioprostheses. The risk for postoperatively neurological impairment (p = 0.15) and other complications (p = 0.46) was furthermore not increased after implantation of a Freestyle stentless valve. The risk of delayed mobilization (p < 0.001) was 2.4-fold increased for patients after AVR with the Freestyle valve. A positive influence on survival due to the implantation of a stentless Freestyle valve could not be shown within the observed period. However, in spite of the more complex and time-consuming operation technique, the risk of operative death and postoperative complications is not increased after aortic valve replacement with the stentless FB.