Left ventricular non-compaction cardiomyopathy and left ventricular assist device: a word of caution.

BACKGROUND: In patients with left ventricular non-compaction (LVNC), implantation of a left ventricular assist device (LVAD) may be performed as a bridge to transplantation. In this respect, the particular characteristics of the left ventricular myocardium may represent a challenge. CASE PRESENTATION: We report a patient with LVNC who required urgent heart transplantation for inflow cannula obstruction nine months after receiving a LVAD. LVAD parameters, echocardiography and examination of the explanted heart suggested changes of left ventricular configuration brought about by LVAD support as the most likely cause of inflow cannula obstruction. CONCLUSIONS: We conclude that changes experienced by non-compacted myocardium during LVAD support may give rise to inflow cannula obstruction and flow reduction. Presence of LVNC mandates tight surveillance for changes in LV configuration and LVAD flow characteristics and may justify urgent transplantation listing status.

Hypoxic reoxygenation during initial reperfusion attenuates cardiac dysfunction and limits ischemia-reperfusion injury after cardioplegic arrest in a porcine model.

OBJECTIVE: In clinical practice, reperfusion of ischemic myocardium usually occurs under high arterial oxygen levels. However, this might aggravate cardiac ischemia-reperfusion injury caused by excessive oxidative stress. In an experimental in vivo study, the cardioprotective role of hypoxic reoxygenation during initial reperfusion was assessed. METHODS: Twenty-one adult pigs were started on cardiopulmonary bypass with aortic crossclamping (90 minutes) and cardioplegic arrest. During initial reperfusion, 10 pigs underwent standard hypoxic reoxygenation (Pa(O(2)), 250-350 mm Hg), whereas gradual reoxygenation (Pa(O(2)), 40-90 mm Hg) was performed in 11 pigs. Cardiac function was analyzed by means of the thermodilution method and conductance catheter technique. RESULTS: In both groups cardiac index was decreased 10 minutes after cardiopulmonary bypass compared with preoperative values. Sixty minutes after cardiopulmonary bypass, cardiac index improved significantly after gradual reoxygenation compared with that after hypoxic reoxygenation (3.2 +/- 0.6 vs 2.5 +/- 0.5 L min(-1) m(-2), P = .04). Correspondingly, end-systolic pressure-volume relationship and peak left ventricular pressure increase were significantly less decreased in the gradual reoxygenation group. During and after reperfusion, malondialdehyde and troponin T values within the coronary sinus were significantly lower after gradual reoxygenation (60 minutes after declamping: malondialdehyde, 7.6 +/- 0.8 vs 4.6 +/- 0.5 micromol/L [P = .007]; troponin, 0.12 +/- 0.02 vs 0.41 +/- 0.12 ng/mL [P = .02]). CONCLUSION: Hypoxic reoxygenation at the onset of reperfusion attenuates myocardial ischemia-reperfusion injury and helps to preserve cardiac performance after myocardial ischemia in a pig model.

[Cardiac perforation after vertebroplasty]. / Palacos im Herzen.

For more than 20 years percutaneous vertebroplasty has been used in the minimally invasive treatment of vertebral fractures. We report on a patient with embolisation of bone cement into the pulmonary artery and the right ventricle, which was perforated. The final diagnosis was delayed due to a combination of complications, previous disorders as well as a second embolisation.

Artificial chordae for mitral valve repair: mid-term clinical and echocardiographic results.

BACKGROUND: This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement. METHODS: Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months. RESULTS: Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %. CONCLUSION: The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.

Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection.

OBJECTIVE: Antegrade cerebral perfusion has proved to be a reliable method of brain protection during surgery of thoracic aneurysms. In addition, the drawbacks of deep hypothermia may be avoided. This study examines the outcome after surgery for acute type A aortic dissections (AAD) using moderate (30 degrees C) systemic hypothermia compared with conventional techniques of cerebral protection. METHODS: Between January 1999 and August 2003, 74 patients underwent repair of acute type A aortic dissection. Moderate systemic hypothermia (30 degrees C) with selective antegrade cerebral perfusion through subclavian artery (group A) was used in 18 patients. Deep hypothermia (20 - 24 degrees C) was employed using either retrograde (18 patients, group B) or antegrade (38 patients, group C) cerebral perfusion. Tube graft replacement was performed in 55, valve-sparing procedure in 8, and composite graft replacement in 11 patients. RESULTS: The 30-day mortality was 5.5 % in group A, 5.5 % in group B, and 15.8 % in group C (A vs. C and B vs. C; p < 0.01). New postoperative permanent neurologic deficit occurred in 5.5 % of patients in group A, 16.7 % in group B, and 13.2 % in group C. Mean chest tube drainage within the first 24 h in groups A, B and C was 703 +/- 338, 1178 +/- 820, and 1447 +/- 802 ml, respectively (A vs. B and A vs. C; p < 0.01). Cardiopulmonary bypass, ICU, and hospital times were significantly shorter in group A. CONCLUSIONS: Selective antegrade cerebral perfusion with moderate systemic hypothermia appears to be a safe and sufficient tool for brain protection during AAD repair. In avoiding deep hypothermia, this technique may help to reduce cardiopulmonary bypass time and hypothermia-related side effects.

Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system.

BACKGROUND: Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature. METHODS: The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon. RESULTS: The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 +/- 58, 25 +/- 10, and 18 +/- 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique. CONCLUSIONS: The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

Transplantation or alternative surgical treatment of patients with ischemic dilative cardiomyopathy and aneurysmatic dilation of the left ventricular cavity.

BACKGROUND: Patients with terminal ischemic heart disease (IHD), severely depressed pump function with large LV dyskinesis with or without fibrosis do not benefit from revascularization alone; in time they are listed for transplantation. The long waiting list and lack of organ donors have imposed implementation of Direct Circular Repair (DCR) with total revascularization as an alternative. METHODS: DCR was performed on 17 patients with terminal IHD, after total revascularisation. The resected dyskinetic tissue was pathohistologicaly examined. Transesophageal ultrasound was performed pre- and early post-operatively and hemodynamic parameters measured invasively. RESULTS: Pathohistology showed that even in macroscopically viable myocardium where only dyskinesia without fibrosis persists, there are irreversible lesions on the ultrastructural level. Along with revascularization, with the application of DCR the LV spherical geometry was reconstructed with hemodynamic improvement. CONCLUSION: Total revascularisation with DCR offers an alternative to transplantation in patients with wide anterior wall dyskinesia with or without fibrosis due to terminal IHD, the most frequent group listed for transplantation.