Aortic valve replacement with the Cryolife-O'Brien stentless aortic bioprosthesis: five-year experience.

AIM: Improved hemodynamics with stentless bioprosthesis compared to stented valves have been well documented. It has been suggested that a simplified implant model, the Cryolife-O'Brien, offers less satisfactory outcomes compared with standard stentless models. This study was conducted to prospectively evaluate the midterm results after aortic valve replacement with the Cryolife-O'Brien stentless bioprosthesis. METHODS: In 1996, the prospective clinical trial using different stentless valves was initiated in our center. From September 1996 through August 2001, 132 consecutive patients with a mean age of 72.5 years underwent aortic valve replacement with the Cryolife-O'Brien porcine stentless bioprosthesis by the same surgeon. The predominant aortic valve lesion was stenosis in 110 cases and insufficiency in 22 cases. Patients have been followed-up from 2 to 60 months, mean 28 months. Echocardiography was performed by the same echocardiographer preoperatively, intraoperatively, postoperatively at discharge, 2 to 6 months later and annually thereafter. RESULTS: Sixty-five percent of patients received a valve 25 mm in diameter or larger, 42% had concomitant coronary bypass grafting. The 30-day operative mortality rate was 6.8 %. Nine late deaths, none related to the valve, have occurred. Severe aortic insufficiency caused by oversizing led to early reoperation in 3 patients. The peak and mean systolic gradients decreased significantly during the first 12 months after implantation (p<0.001) and the effective valve areas increased significantly during this time interval (p<0.001). Eleven patients have aortic insufficiency, trivial in 7 and mild in 4. The actuarial survival at 5 years was 86+/-3%. The rate for freedom from endocarditis was 100% and for freedom from thromboembolic events 92%. CONCLUSIONS: The Cryolife-OBrien stentless bioprosthesis has superior hemodynamics and a low rate of valve-related complications thus representing a very good alternative to conventional stented bioprosthesis. The midterm results are encouraging but further follow-up is needed to determine the valve's durability.

Comparison of three different types of stentless valves: full root or subcoronary.

BACKGROUND: It is believed that, compared with stented valves, stentless bioprostheses at the aortic position offer a larger orifice area. METHODS: During the past 45 months, we have implanted 211 various types of aortic prostheses in our clinic. In the subcoronary position, we have used the Medtronic Freestyle, Toronto SPV, and Cryolife O'Brien prostheses, and as an aortic root replacement, the Medtronic Freestyle. There were no special indications for selection of each prosthesis except in 8 patients suffering from a disease of the ascending aorta in addition or in a redo procedure because of endocarditis or valve degeneration in which we implanted the full root Freestyle prosthesis. All patients had echocardiographic examinations postoperatively and after 1 year. RESULTS: Although the implantations took significantly longer time initially, recently the complication rate has shown itself to be no greater than in comparable patients with stented prostheses. The hemodynamic results are very good with the exception of the Freestyle prosthesis implanted in the subcoronary position. The gradients of the remaining three prosthesis after 1 year are between 5 mm Hg and 10 mm Hg, and the effective valve orifice is between 2 and 3 cm2 depending on valve size. CONCLUSIONS: The use of stentless tissue valves offers better hemodynamic results than that of stented valves with essentially no increased operative risk.

[Coronary bypass surgery in May-Hegglin anomaly]. / Koronare Bypassoperation bei May-Hegglin-Anomalie.

HISTORY: Twelve years prior to hospitalization because of a severe bleeding, a 70 year old patient was diagnosed with a May-Hegglin anomaly, which is a rare autosomal dominant inherited form of thrombocytopenia. INVESTIGATIONS: The blood smear contained signs of the May-Hegglin anomaly: Döhle's inclusion bodies and giant platelets. Platelet counts were around 30 G/l. Coronary angiography revealed a highly severe left main stenosis. TREATMENT AND COURSE: Even using maximum drug therapy, angina pectoris could not be stabilized. Therefore emergency coronary artery bypass grafting had to be performed. Before skin incision 3 micrograms/kg DDAVP (Desmopressin) were administered and after extracorporeal circulation 8 units of platelets were transfused. In addition, perioperative coagulation management was performed according to usual standards. There were no bleeding complications. The patient could leave the clinic after 11 days in stable condition. CONCLUSION: Patients showing May-Hegglin anomaly, even with serious thrombocytopenia, can be operated using extracorporal circulation without a high risk of bleeding.

[The recanalization of the chronically occluded infarct vessel in single-vessel coronary disease. The reduction of cardiac events in long-term clinical follow-up]. / Rekanalisation des chronisch verschlossenen Infarktgefässes bei koronarer Ein-Gefäss-Krankheit. Reduktion kardialer Ereignisse im klinischen Langzeitverlauf.

OBJECTIVE: The prognostic significance of recanalisation of a chronically occluded infarct vessel in single-vessel coronary disease remains controversial, in contrast to early re-opening of the infarct vessel in the acute state of infarction. It was the purpose of this prospective study to discover whether successful recanalisation in the former influences the incidence of cardiac events (death, infarction, by-pass operation) and clinical symptoms in the long term. PATIENTS AND METHOD: Recanalisation procedures were successful in 58, unsuccessful in 41 of 99 patients (81 men, 18 women; mean age 55 [28-79] years) with anterior wall (n = 53) or posterior wall (n = 46) myocardial infarction (AMI and PMI, respectively). The two groups were similar with respect to age, sex, left-ventricular function, indication, exercise capacity and premedication. But the interval between infarction and recanalisation was shorter in the patients who had successful recanalisation (5.1 +/- 5.3 vs 7.8 +/- 7.6 months; P < 0.05). Mean follow-up period for all patients was 55.8 +/- 8.9 months after the recanalisation procedure. RESULTS: There were significantly fewer cardiac events after successful than failed recanalisation, both for the total group of patients (5% vs 23%; P < 0.01) and those with AMI (9 vs 36%; P = 0.012). In the patients with PMI there was only a trend in favour of those with successful recanalisation (0% vs 14%; P = 0.058). Symptomatic improvement was reported by 73% of patients after successful but only 40% after failed recanalisation (P < 0.01). CONCLUSION: The results provide pointers towards prognostic indications of recanalisation even after chronic occlusion of the infarct vessel. The procedure should therefore be attempted if the occlusion is morphologically suitable.

[Emergent percutaneous mitral valve repair with Inoue balloon-catheter in severe mitral stenosis and cardiogenic shock]. / Notfallmässige perkutane Mitralvalvuloplastie mit dem Inoue-Ballon bei hochgradiger Mitralstenose und kardiogenem Schock.

A 30-year-old woman with severe mitral stenosis was admitted to hospital in cardiogenic shock (tachycardia, hypotension, low cardiac output) requiring artificial ventilation. As the cardiovascular state failed to respond to drug treatment, percutaneous mitral valvoplasty (MVP) was performed as an emergency with the Inoue balloon catheter. This brought about immediate improvement in the clinical and haemodynamic condition. As later seen at open-heart surgery, the MVP had produced a tear in the anterior mitral leaflet with considerable regurgitation. Mitral valve replacement was performed as an elective procedure 4 weeks after the MVP, at a time when the patient was mobile. MVP with the Inoue catheter system can achieve a stable clinical and haemodynamic state when there is cardiogenic shock due to severe mitral stenosis and conservative measures have failed.

[Acute pericardial tamponade after percutaneous transluminal coronary angioplasty (PTCA). A rare life threatening complication]. / Die akute Perikardtamponade nach perkutaner transluminaler Koronarangioplastie (PTCA). Eine seltene lebensbedrohliche Komplikation.

Cardiac tamponade following coronary perforation is a rare complication in conventional balloon angioplasty. In a series of 8000 dilatations we observed this complication after PTCA in 2 female patients (0.25/1000). In both cases cardiac tamponade occurred 2 h after PTCA of small, in 1 case calcified, coronary arteries during monitoring on the coronary care unit. By immediate percutaneous pericardiocentesis and subsequent drainage by a pigtail catheter we could manage the complication. One patient suffered an acute myocardial infarction 3 days after PTCA because of a subacute occlusion of the perforated vessel.

[Long-term therapy of cancer pain. A controlled study on buprenorphine]. / Langzeittherapie von Krebsschmerzen. Kontrollierte Studie mit Buprenorphin.

Sublingual tablets of buprenorphine (Temgesic sublingual) were given in a controlled trial of 41 patients for 2804 patient-days. With a mean starting dose of 1.09 mg and a final dose of 1.53 mg buprenorphine daily there was a good pain-relieving effect. The interval between doses was six to eight hours. The trial did not reveal any direct pointers as to tolerance or addictiveness after long-term intake of the drug. Because of its effectiveness and good duration of action, as well as the absence of negative long-term effects, the drug can be recommended in the long-term management of cancer pain.

[Sublingual buprenorphine tablets: initial clinical experiences in long-term therapy of cancer pain]. / Buprenorphin-Sublingual-Tabletten: Erste klinische Erfahrungen bei der Langzeittherapie von Krebsschmerzen.

Buprenorphine sublingual tablets (0.2 mg) were investigated in therapy of cancer pain. In 67 patients there was a good analgetic effect in 60%, even in those cases treated with other opiates before. The induction time was quite long (60 min.) but is no problem in chronic administration. Effective pain relief was obtained even in final stages of cancer. The mean daily dose of buprenorphine had been 1.2-1.7 mg, the mean duration of analgesia being 6-8 hours with a single dose of 0.2-1.0 mg buprenorphine. Typical opiate-side-effects were registered and well tolerated after some days' treatment. There was no respiratory depression. Buprenorphine sublingual tablets are certainly a good alternative in orally available opioids.