Advanced risk prediction for aortic dissection patients using imaging-based computational flow analysis.

Patients with either a repaired or medically managed aortic dissection have varying degrees of risk of developing late complications. High-risk patients would benefit from earlier intervention to improve their long-term survival. Currently serial imaging is used for risk stratification, which is not always reliable. On the other hand, understanding aortic haemodynamics within a dissection is essential to fully evaluate the disease and predict how it may progress. In recent decades, computational fluid dynamics (CFD) has been extensively applied to simulate complex haemodynamics within aortic diseases, and more recently, four-dimensional (4D)-flow magnetic resonance imaging (MRI) techniques have been developed for in vivo haemodynamic measurement. This paper presents a comprehensive review on the application of image-based CFD simulations and 4D-flow MRI analysis for risk prediction in aortic dissection. The key steps involved in patient-specific CFD analyses are demonstrated. Finally, we propose a workflow incorporating computational modelling for personalised assessment to aid in risk stratification and treatment decision-making.

Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data.

OBJECTIVES: Decellularized aortic homografts (DAH) may provide an additional aortic valve replacement option for young patients due to their potential to overcome the high early failure rate of conventional allogenic and xenogenic aortic valve prostheses. METHODS: A prospective, European Union-funded, single-arm, multicentre, safety study was conducted in 8 centres evaluating non-cryopreserved DAH for aortic valve replacement. RESULTS: One hundred and forty-four patients (99 male) were prospectively enrolled between October 2015 and October 2018, mean age 33.6 ± 20.8 years; 45% had undergone previous cardiac operations. Mean implanted DAH diameter 22.6 ± 2.4 mm and mean durations for the operation, cardiopulmonary bypass and cross-clamp were 341 ± 140, 174 ± 80 and 126 ± 43 min, respectively. There were 2 early deaths (1 LCA thrombus on day 3 and 1 ventricular arrhythmia 5 h postop) and 1 late death due to endocarditis 4 months postoperatively, resulting in a total mortality of 2.08%. One pacemaker implantation was necessary and 1 DAH was successfully repaired after 6 weeks for early regurgitation following subcoronary implantation. All other DAH were implanted as a free-standing root. After a mean follow-up of 1.54 ± 0.81 years, the primary efficacy end points peak gradient (mean 11.8 ± 7.5 mmHg) and regurgitation (mean 0.42 ± 0.49, grade 0-3) were excellent. At 2.5 years, freedom from explantation/endocarditis/bleeding/stroke was 98.4 ± 1.1%/99.4 ± 0.6%/99.1 ± 0.9%/99.2 ± 0.8%, respectively, with results almost identical to those in an age-matched Ross operation cohort of 212 patients (mean age 34 years) despite DAH patients having undergone >2× more previous procedures. CONCLUSIONS: The initial results of the prospective multicentre ARISE trial show DAH to be safe for aortic valve replacement with excellent haemodynamics in the short follow-up period.

Giant cell aortitis in treatment-naive human immunodeficiency virus and hepatitis C coinfection.

Giant cell arteritis is a common form of vasculitis, although involvement of the aorta is unusual. There is no established association between giant cell aortitis and human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We present the case of a 46-year-old female coinfected with HIV and HCV who had never received antiretroviral therapy and developed symptoms of deteriorating shortness of breath on exertion. Investigations demonstrated aortic root and ascending aorta dilatation, along with severe aortic valve regurgitation, for which the patient underwent valve-sparing aortic root replacement (a David procedure). Histopathology confirmed giant cell aortitis.

Increased expression of GDF-15 may mediate ICU-acquired weakness by down-regulating muscle microRNAs.

RATIONALE: The molecular mechanisms underlying the muscle atrophy of intensive care unit-acquired weakness (ICUAW) are poorly understood. We hypothesised that increased circulating and muscle growth and differentiation factor-15 (GDF-15) causes atrophy in ICUAW by changing expression of key microRNAs. OBJECTIVES: To investigate GDF-15 and microRNA expression in patients with ICUAW and to elucidate possible mechanisms by which they cause muscle atrophy in vivo and in vitro. METHODS: In an observational study, 20 patients with ICUAW and seven elective surgical patients (controls) underwent rectus femoris muscle biopsy and blood sampling. mRNA and microRNA expression of target genes were examined in muscle specimens and GDF-15 protein concentration quantified in plasma. The effects of GDF-15 on C2C12 myotubes in vitro were examined. MEASUREMENTS AND MAIN RESULTS: Compared with controls, GDF-15 protein was elevated in plasma (median 7239 vs 2454 pg/mL, p=0.001) and GDF-15 mRNA in the muscle (median twofold increase p=0.006) of patients with ICUAW. The expression of microRNAs involved in muscle homeostasis was significantly lower in the muscle of patients with ICUAW. GDF-15 treatment of C2C12 myotubes significantly elevated expression of muscle atrophy-related genes and down-regulated the expression of muscle microRNAs. miR-181a suppressed transforming growth factor-ß (TGF-ß) responses in C2C12 cells, suggesting increased sensitivity to TGF-ß in ICUAW muscle. Consistent with this suggestion, nuclear phospho-small mothers against decapentaplegic (SMAD) 2/3 was increased in ICUAW muscle. CONCLUSIONS: GDF-15 may increase sensitivity to TGF-ß signalling by suppressing the expression of muscle microRNAs, thereby promoting muscle atrophy in ICUAW. This study identifies both GDF-15 and associated microRNA as potential therapeutic targets.

Long-term results of mechanical and biological heart valves in dialysis and non-dialysis patients.

INTRODUCTION: We wanted to answer the question whether biological heart valves are inferior compared to mechanical heart valves in end-stage renal disease (ESRD) patients. METHODS: Between 01/1996 und 12/2006, 44 of 3293 patients undergoing aortic valve replacement (AVR) in a single institution suffered from dialysis-dependent ESRD and underwent a follow-up investigation after 1.9 years (median). Twelve (28.9 %) of these patients received a biological, 32 (71.1 %) of these patients a mechanical aortic valve prosthesis. To evaluate a possible influence of the valve type (biological/mechanical) on survival, uni- and multivariate logistic regression was used. RESULTS: ESRD patients after AVR had a relatively poor short-term (30-day mortality: 22.7 %) and long-term survival (median survival time: 24.7 months; 95 % CI: 0.2-47.7 months), irrespective of the type of heart valve prosthesis (hazard ratio for mortality depending on heart valve type in dialysis patients: 1.31, P = 0.400). Dialysis-dependent patients were not reoperated due to valve-related reasons. CONCLUSIONS: The long-term survival of dialysis-dependent patients after AVR is low (5-year survival: 29.5 %) irrespective of the type of heart valve prosthesis. Therefore, the use of biological AVR is not contraindicated in this group of patients.

[Transparency of medical quality data. Ethical obligation to deliver or instrument to create unfair competitive advantage?]. / Transparenz medizinischer Qualitätsdaten. Ethische Bringschuld oder Instrument zur Schaffung unlauterer Wettbewerbsvorteile?

Annually about 100,000 acute cardiac deaths occur in Germany. For this reason, there is the obvious need, from a public health perspective, to inform the population about possible measures of their prevention and treatment. Ultimately every patient or admission referring doctor can be thought of as a recipient of "marketing". Other than within the context of economics, in medicine the subject of marketing is likely to produce a negative response. Any doctor engaging in marketing is quickly considered to be engaging in unfair competition at the expense of colleagues ("economic competitors"). However, despite some reservations it would seem sensible to provide transparency concerning the results of treatment. If the manner of competition is the right one, i.e. one that has as its aim to improve patient care, it can at the same time improve such care, motivate doctors and frequently also reduce costs. Transparency of the various aspects of improved medical care in this way represent a "pay-back" to everyone working in the health services. It is desirable to establish an external process of assessing any published data and, as far as possible, exclude all incorrect data from relevant measures of comparison. Competition can then be to the patient's benefit.

Fracture of Colvin-Galloway-Future band in a patient with mitral valve annuloplasty.

Annuloplasty with various annuloplasty ring systems is a fundamental part of mitral valve repair and has been frequently performed since its introduction by Carpentier in 1969. Due to the different advantages or disadvantages of each system, some controversies exist regarding the best type of ring annuloplasty support. Here we describe, for the first time, the case of a female patient in which a fracture of a semi-rigid open annuloplasty ring occurred, leading to annular deformation and mitral regurgitation.

[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.

On-line variable live-adjusted displays with internal and external risk-adjusted mortalities. A valuable method for benchmarking and early detection of unfavourable trends in cardiac surgery.

OBJECTIVE: Benchmarking and early detection of unfavourable trends. METHODS: We implemented a dedicated project-orientated data warehouse, which continuously supplies data for on-line computing of the variable live-adjusted displays (VLADs). To calculate the expected cumulative mortality, we used the multi-variate logistic regression model of the EuroSCORE model. In addition to the external EuroSCORE standard, we calculated a centre-specific risk score for internal standards by analysing the data of 9135 patients, which enables both internal and external comparisons. The VLADs are embedded into the multi-purpose web-based information portal, so that the physicians can investigate several types of VLADs interactively: performance of different types of surgery and individual surgeons for different time intervals. We investigated clinically important events such as modification of operative techniques and personnel changes of the team by the VLADs. RESULTS: We found transient declines in the performance curves during major changes in patient management, indicating that systemic--rather than accidental or patient related factors--were involved in the mortality risk. The internal standard line represents these clusters more clearly than the external line. We evaluated examples of how periods of increased risk could be monitored by the VLAD curves: (1) the introduction of OPCAB surgery; (2) training of surgeons; (3) staff changes and staff-related management. CONCLUSIONS: On-line VLADs based on a day-to-day updated database, displaying both internal and external standards, are a helpful visualisation tool for earlier detection of unfavourable trends. They enable the surgeon teams and clinical management to take countermeasures at an early stage.

[Is age an independent predictor of mortality in cardiac surgery as postulated in EuroScore?]. / Ist das Alter eine unabhängige Determinante der Letalität in der Herzchirurgie, wie es im EuroScore behauptet wird?

The number of "older" patients undergoing cardiac surgery is steadily increasing. In the year 2000, 37% of all patients who underwent a cardiac operation in Germany were 70 years of age or older. Looking at data form our institution, we focused on the topic, whether age on its own is an independent determinant for mortality in cardiac surgery. Data from 8769 patients who underwent cardiac surgery in our institution from January 1996 until January 2002 were analyzed. For all patients, EuroScore and the corresponding age-stripped value was calculated. All recorded postoperative complications and 30-day mortality were statistically analyzed. EuroScore as well as the age-stripped EuroScore showed a significant rise with increasing age in the total number of patients as well as in the patients, who did not die during the first 30 days after the operation. The 30 day mortality and the incidence of postoperative complications increased significantly with age. While the EuroScore showed a significant age-dependent increase in patients who died within 30 days after the operation, the age-stripped EuroScore did not reveal a significant discrepancy in mortality with respect to age. Arterial hypertension, diabetes mellitus and atrial fibrillation, parameters not mentioned in EuroScore, showed significant differences among age groups. According to univariate analysis, arterial hypertension and diabetes mellitus were significant predictors of mortality. Entered into a multivariate logistic regression analysis, only diabetes mellitus achieved statistical significance. Our data and the known age-associated functional and structural changes of different organ systems show that age integrates risk factors together. In order to limit mortality in the steadily growing number of older and multi-morbid patients undergoing cardiac surgery, exceptional emphasis has to be put on patient selection and therapeutic measures to improve preoperative status.

Is there any impact of the shape of aortic end-hole cannula on stroke occurrence? clinical evaluation of straight and bent-tip aortic cannulae.

OBJECTIVE: To compare the impact of straight and bent-tip aortic cannulae on stroke occurrence, location, and severity. METHODS: Prospective data were collected on 8,129 patients (coronary artery bypass grafting (CABG) and/or valvular surgery). 'Bent-tip' aortic cannulae were used in 15.6% of cases and 'straight' end-hole cannulae in 84.4% of cases. RESULTS: There were a total of 137 strokes: right anterior 52, left anterior 39, bilateral 23, posterior 18, and location not established 5. With the use of bent-tip cannulae, the incidence of strokes was 0.9% versus 1.8% with straight cannulae (chi2, p = 0.026). Bilateral and posterior strokes occurred more often with the use of straight cannulae (chi2, p = 0.015). Straight cannulae also related to the severity of strokes (chi2, p = 0.003). CONCLUSIONS: There is an influence of the type of cannula on the occurrence, location, and severity of strokes. Straight cannulae cause significantly more often and more severe bilateral and posterior strokes than bent-tip cannulae.

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.

Gadolinium-enhanced elliptically reordered three-dimensional MR angiography in the assessment of hand vascularization before radial artery harvest for coronary artery bypass grafting: first experience.

RATIONALE AND OBJECTIVES: To assess the suitability of contrast-enhanced magnetic resonance angiography (MRA) in the preoperative evaluation of hand vasculature in potential candidates for radial artery bypass grafting. METHODS: In 21 patients, gadobenate dimeglumine-enhanced, three-dimensional gradient-echo sequences of both hands were performed, as well as a Doppler ultrasound study with radial artery compression. Doppler findings were correlated with MRA, focusing on the assessment of anastomoses between the vascular bed of the ulnar and radial arteries. RESULTS: One individual had to be excluded because of accidentally disclosed metal foreign bodies. Sufficient depiction of the hand vasculature was achieved in the remainder. Seventeen patients had evidence of adequate collateral flow between the ulnar and radial artery supply on Doppler ultrasound. Three patients exhibited inadequate collateral flow, with angiographic signs of vessel occlusion or missing collaterals between the palmar arches. Two patients presented with stenosis or occlusion of the radial artery. Magnetic resonance angiograms displayed great variations in hand vasculature and collateral formation, with no mismatch compared with Doppler ultrasound results. CONCLUSIONS: Contrast-enhanced MRA displays vascularization of the hand in detail and supplies ultrasound flow measurements for radial artery harvest, with high-resolution angiographic data about possible vessel variations and the presence of anastomoses between the radial or ulnar artery supply.

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.

[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.

Coincidence of nutritional habits and esophageal cancer in Germany.

INTRODUCTION: The incidence rates for adenocarcinoma (AC) of the esophagus have risen rapidly in Western nations, whereas the incidence rates for esophageal squamous cell carcinoma (SCC) have remained nearly stable. There are studies about body mass index, smoking, alcohol, and development of AC or SCC. The aim of this study was to evaluate differences in nutritional habits of patients with AC or SCC compared with the population in Cologne. PATIENTS AND METHODS: From January 1, 1997 to December 31, 1998, 85 patients with esophageal cancer (SCC n = 45, AC n = 40) were interviewed about their nutritional habits using a computerized program (EBIS). By random sample, 100 citizens of Cologne who were similar of age, residence, and nationality were chosen as healthy control group (CG) and were also interviewed with EBIS. RESULTS: The known risk factors, alcohol and tobacco for SCC as well as alcohol and a high body mass index for AC, were confirmed in this study. The CG had a higher daily intake of calcium, magnesium and iron compared to patients with esophageal cancer (p < 0.05). In addition, the tumor group had a significant lower daily supply of carbohydrates, fruits, and dietary fiber (p < 0.001). About 80% of the patients ate more than 100 g meat/day in comparison to 50% of participants in the CG. Patients with AC consumed more magnesium, milk, and animal protein than patients with SCC or the participants of the CG. CONCLUSION: There are differences in nutrition between healthy controls and patients with esophageal cancer and between patients with SCC and AC. Patients with cancer of the esophagus had a nutritonal deficit in fresh fruit, vegetables, dietary fiber, and carbohydrates. Compared with the other groups, patients with AC had a higher intake of protein, fat, and milk.

[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.

[Perioperative complications after heart valve replacement]. / Perioperative Komplikationen nach Herzklappenersatz.

These days, the majority of perioperative complications resulting from operations on heart valves are more a consequence of the increasing age and morbidity of the patients and, despite all cardiac surgical and intensive care innovations, are still more the effect of the procedure on the other organ systems of the patient than being purely of a surgical nature. The surgical short- and long-term results after heart valve operations are significantly influenced by the early detection and adequate management of these manifold complications.