[A telemetrically-guided program for weight reduction in overweight subjects (the SMART study)]. / Telemedizinisch betreutes Programm zur Gewichtsreduktion bei Ubergewichtigen (SMART-Studie).

BACKGROUND AND OBJECTIVE: Compliance with weight reducing programs can be improved by intensive care and control. We tested a telemetrically-guided weight reduction program in overweight and obese persons. PATIENTS AND METHODS: 200 outpatients (62 males) with a mean body mass index of 34 kg/m (2) and a mean age of 47 years participated in a prospective study for one year. During the first six months, telemetrical support (weight-transmission via Bluetooth (short range)-technology, 20-minutes telephone consultation with a nutritionist) was given weekly. After six months, participants were randomly assigned either to a group with further telemonitoring support (telemetric group) or to a group without contact to our clinic (control group). At baseline, and after six and twelve months, body weight, body composition (bioelectrical impedance analysis), and parameters of the metabolic syndrome were assessed at our clinic. RESULTS: 16 participants terminated the study prematurely during the first 6 months and 19 participants (10 from the telemetric group and 9 from the control group) during the second 6 months. According to the intention-to-treat principle, mean weight loss was 6.7 kg (p < 0,001), mean loss of body fat was 5.1 kg (p < 0,001), and mean loss of fat-free mass was 1.6 kg (p < 0,001) within the first six months. Moreover, metabolic and cardiovascular risk markers such as waist circumference, blood pressure, serum triglycerides and blood glucose declined significantly (p < 0,001). Prevalence of the metabolic syndrome fell from 49.5% to 42.0 % (p < 0,05). During the second six months body fat content, waist circumference, and blood glucose increased again in the control group but not in the telemetric group (p < 0,05-0,001). CONCLUSION: The telemetrically-guided weight loss program was a more efficacious measure than the less intensive support without telemonitoring.

Papillary fibroelastoma of the ascending aorta presenting with cardiogenic shock.

We describe an uncommon case of a 58-year-old woman who presented with cardiogenic shock. The echocardiography examination revealed a papillary fibroadenoma located in the ascending aorta which was subsequently surgically treated.

Acute myocardial infarction in a young adult: a case report and literature review.

Sudden cardiac death related to sports in young patients can have many causes. Hypertrophic cardiomyopathy, congenital coronary abnormalities, and myocarditis make up about half of the causes of sudden cardiac death after sports. Screening for all athletes is important to prevent such episodes. This involves yearly examinations including clinical examinations, stress echocardiograms, echocardiography, and laboratory investigations. Also, behavioral follow up should be addressed, as cocaine administration and doping can both lead to cardiac problems and sudden cardiac death after sports. We present a case of a 17-year-old boy who collapsed after an ice hockey competition as a result of an acute myocardial infarction, which was first represented by ventricular fibrillation. We also review the main causes of sudden cardiac death in such young athletes and the main investigations that have to be performed to reach the proper diagnosis and etiology of the condition.

Differential indication for mechanical circulatory support following heart transplantation.

PURPOSE: We describe our experience with ventricular assist devices (VAD) in patients with cardiogenic shock refractory to pharmacological therapy and support using intraaortic balloon pump after cardiac transplantation. PATIENTS: Between July 1987 and August 1997, 848 patients underwent cardiac transplantation in our hospital. INTERVENTIONS: Fifteen patients (1.8%) needed mechanical circulatory support for refractory cardiac failure due to right heart failure (six patients), primary graft failure (three patients), and acute rejection (six patients). Three pump systems were used: Biomedicus Centrifugal Pump, Abiomed BVS 500, and Thoratec VAD. The choice of system depended on the indication and quality of each device. Seven patients (47%) could be weaned from the mechanical circulatory support (MCS) system and three patients (20%) are long-term survivors. RESULTS: All 15 patients developed at least one serious complication, such as multiorgan failure (MOF), liver failure, acute renal failure or sepsis. Twenty-five per cent had severe bleeding and 13% had neurological complication. Mortality was due mostly to MOF, MOF and sepsis or sepsis. The survivors had a CI greater than 2.2 l.min.m2, total bilirubin less than 1.0 U/1, and did not undergo resuscitation. CONCLUSIONS: Heart failure after cardiac transplantation severe enough to require MCS is currently associated with several major complications and high mortality (80%).

International normalized ratio self-management after mechanical heart valve replacement: is an early start advantageous?

BACKGROUND: Severe thromboembolic and hemorrhagic complications after mechanical heart valve replacement essentially depend on the intensity of oral anticoagulation and the fluctuation of individual international normalized ratio (INR) values. METHODS: After heart valve replacement with Medtronic Hall, St. Jude Medical, and CarboMedics implants, patients were randomly divided into two groups, one controlling INR values at home, the other being monitored by family practitioners. RESULTS: Almost 80% of the INR values recorded by patients at home were within the stipulated therapeutic range, INR 2.5 to 4.5, compared with just 62% of INR values recorded by family practitioners. The overall complication rate (hemorrhages and thromboembolic events) of the self-management group was significantly (p < 0.05) decreased compared with the conventional group. CONCLUSIONS: Through INR self-management, an improvement in the quality of ongoing oral anticoagulation could be shown. Starting this form of therapeutic control early after mechanical heart valve replacement appears to effect a further reduction in anticoagulant-induced complications.

[Current diagnosis and therapy in heart valve diseases]. / Aktuelle Diagnostik und Therapie von Herzklappenerkrankungen.

We present a survey of the current standard in diagnosis and therapy of the most frequent heart valve lesions. During the last 50 years there has been a dramatic shift concerning the etiology of valve lesions with a rise of the age-dependent degenerative towards rheumatic valve diseases. The aim of the diagnostic evaluation of valve lesions is primarily the clinical and hemodynamic grading of the severity of the valve disease, the recognition of relevant coexisting cardiac and extracardiac diseases and furthermore, an optimal timing of surgery in close correlation with the cardiac surgeons.

[INR self-management after mechanical heart valve replacement: ESCAT (Early Self-Controlled Anticoagulation Trial)]. / INR-Selbstmanagement nach mechanischem Herzklappenersatz: ESCAT (Early Self-Controlled Anticoagulation Trial).

Severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement essentially occur due to intense oral anticoagulation and fluctuating individual INR values around the target range. INR self-management can help to minimize these fluctuations. Beginning this therapeutic control immediately after mechanical heart valve replacement further reduces anticoagulant-induced complications. Included in the study were 1200 patients. The quality of oral anticoagulation also improved through INR self-management. Over an observation period of two years, nearly 80% of INR values recorded by the patients themselves were within the target therapeutic range of 2.5-4.5. This corresponds to a high significance of p < = 0.001 in favor of INR self-management. Only 64.9% of INR values monitored by family practitioners were within the desired range. The results differed slightly in quality between patient groups with different levels of training (comprehensive, secondary modern, grammar with or without university). Of patients trained in INR self-management following mechanical heart valve replacement, 91.7% maintained their competence in this technique throughout the entire follow-up period. Only 8.3% of those trained immediately after surgery were unable to continue with INR self-management.

[Current standard in diagnosis and therapy of heart valve lesions]. / Aktuelle Diagnostik und Therapie von Herzklappenerkrankungen.

We present a survey of the current standard in diagnosis and therapy of the most frequent heart valve lesions. During the last 50 years there has been a dramatic shift concerning the etiology of valve lesions with a rise of the agedependent degenerative towards rheumatic valve diseases. The aim of the diagnostic evaluation of valve lesions is primarily the clinical and hemodynamic grading of the severity of the valve disease, the recognition of relevant coexisting cardiac and extracardiac diseases and furthermore, an optimal timing of surgery in close correlation with the cardiac surgeons.

[INR Self-management after mechanical heart valve replacement: ESCAT (Early Self-Controlled Anticoagulation Trial)]. / INR-Selbstmanagement nach mechanischem Herzklappenersatz: ESCAT (Early Self-Controlled Anticoagulation Trial).

Severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement essentially occur due to intense oral anticoagulation and fluctuating individual INR values around the target range. INR self-management can help to minimize these fluctuations. Beginning this therapeutic control immediately after mechanical heart valve replacement further reduces anticoagulant-induced complications. Included in the study were 1200 patients. The quality of oral anticoagulation also improved through INR self-management. Over an observation period of two years, nearly 80 % of INR values recorded by the patients themselves were within the target therapeutic range of 2.5-4.5. This corresponds to a high significance of p < = 0.001 in favor of INR self-management. Only 64.9 % of INR values monitored by family practitioners were within the desired range. The results differed slightly in quality between patient groups with different levels of training (comprehensive, secondary modern, grammar with or without university). Of patients trained in INR self-management following mechanical heart valve replacement, 91.7 % maintained their competence in this technique throughout the entire follow-up period. Only 8.3 % of those trained immediately after surgery were unable to continue with INR self-management.

Cardiopulmonary resuscitation after cardiac surgery: a two-year study.

OBJECTIVE: The aim of this study was to investigate the incidence of cardiopulmonary resuscitation (CPR) after cardiac surgery and to find predictors of survival. DESIGN: A retrospective study with data obtained by chart review. SETTING: A university hospital 24-bed cardiac surgical intensive care unit (ICU). PARTICIPANTS: Between 1993 and 1994, 4,968 consecutive adult patients who underwent cardiac surgery at the authors' hospital were studied. INTERVENTIONS: None. MAIN RESULTS: One hundred thirteen of these patients (2.3%) were resuscitated. Seventy-nine patients (70%) survived to be discharged from the hospital. Significant predictors of survival were the time between admission to the ICU and initiation of CPR, CPR time, and creatine kinase (CK) and CK-MB values. CONCLUSIONS: The incidence of CPR after cardiac surgery was 2.3% with no difference between valve surgery and CABG. Best results were achieved when arrhythmias or bleeding were the predisposing causes. Further studies have to be undertaken concerning long-term results and quality of life of the discharged patients.

Microanalysis and distribution of cardiac troponin I phospho species in heart areas.

Sequential phosphorylation and dephosphorylation of cTnI by the cAMP dependent protein kinase and by protein phosphatase 2A, respectively, produce the non-, mono- and bisphosphorylated species (Jaquet et al., 1995, Eur. J. Biochem. 231, 486-490). The aim of this study was to determine these forms even in small tissue samples, e.g. in biopsy probes of approximately 30 mg which would allow to define the phosphorylation state of cTnI in heart areas. In order to do so a micro isolation procedure for cTnI had to be established. cTnI is extracted from small bovine, rabbit and human heart tissue samples (30-100 mg) under special conditions avoiding dephosphorylation and is isolated by affinity chromatography on cTnC Sepharose. All three species, the bis-, mono- and dephospho cTnI, are precipitated quantitatively by acetone, then they are separated by non-equilibrium isoelectric focusing and quantified by scanning densitometry. The method presented here allows to quantify the three cTnI species reproducibly. No other phosphorylated species are detected. Truncated cTnI forms of each phospho species are found in human biopsy samples due to removal of a approximately 36 amino acid peptide from the C-terminus. In bovine, human and rabbit heart the pattern of the three cTnI phospho species is characteristic for left and right atrium, left and right ventricle and septum.

Long-term mechanical circulatory support.

Against the background of an increasing number of patients waiting for heart transplantation but a stagnating number of transplant procedures, long-term mechanical circulatory support is gaining major importance. We investigated the outcome of 20 patients (15 men, and 5 women, aged between 15 and 66 years) each supported for more than 100 days between September 1987 and August 1996. The indications for implantation were bridging in 17 patients, myocarditis in 2 patients, and postcardiotomy cardiogenic shock in one patient. 12 patients received the Novacor IVAD, 4 patients the Thoratec system, 3 patients the HeartMate device and one patient both Novacor and Thoratec. Mean duration of support was 178.1 days, 15 patients were transplanted, 14 of them could be discharged, 2 patients died, 4 patients are still waiting. The most frequent complication was device-related infection in 11 patients. The results have shown that all three systems are safe and reliable devices for supporting patients for more than 100 days.

Mechanical circulatory support: lessons from a single centre.

Over recent years, a number of different mechanical circulatory support (MCS) products have been developed to a stage where they are no longer investigational devices. Registry data provide some information, but this is limited by the mix of historical and contemporary data and the voluntary nature of the contributions. As yet, there are no clear guidelines for patient selection, the differential application of generically different devices or for optimal patient management. Ours is a busy centre offering a comprehensive cardiovascular service. This review details our experience since 1987 and 189 patients supported with five different types of device, used in all of the common applications. Our experience has permitted the formulation of some general principles and guidelines. Data published by registries and by individual manufacturers are, as yet, not standardized. We hope that our experience will be of interest to those centres wishing to establish a mechanical assist service.

Left ventricular function in heart valve surgery: a multidisciplinary challenge.

Between January 1988 and December 1994, 4,097 patients underwent heart valve replacement at the Heart Center North Rhine-Westfalia, Bad Oeynhausen, 1,388 (33.8%) of them suffered from impaired left ventricular (LV) function. Overall hospital mortality was 2.3% (n = 95). In the poor LV function group it was 1.8% (n = 25). There was a significant increase of mortality from 1.5% in patients younger than 60 years to 4.9% in patients 80 years of age and older. Reoperations and emergency operations showed an additional increase of mortality each: 6.2% and 18.2%, respectively. Medium term survival (maximum 48 months) was assessed in a group of 2,006 patients operated between January 1991 and December 1993. The cumulative mortality for patients with poor LV function (n = 148) was 12.8%, whereas for those with normal LV function it was 6.1%. Our data suggest that left ventricular function is of minor importance as far as primary operative results are concerned. In long term follow up patients with valve replacement and poor LV function show an increased mortality mainly due to cardiac causes.

Mechanical circulatory support: the Bad Oeynhausen experience.

From September 1987 to February 1994, we treated 147 patients ranging between 11 and 82 years old with different mechanical circulatory support systems. The applied devices were the Bio-Medicus centrifugal pump in 61 patients, the Abiomed BVS System 5000 in 49 patients, the Thoratec ventricular assist device in 42 patients, and the Novacor left ventricular assist device in 7 patients. On the basis of indication for mechanical circulatory support, the patients were divided into three groups: group 1 consisted of 72 patients with postcardiotomy cardiogenic shock; group 2, 50 patients in whom mechanical support was used as a bridge to cardiac transplantation; and group 3 (miscellaneous), 25 patients in cardiogenic shock resulting from acute myocardial infarction (n = 14), acute fulminant myocarditis (n = 3), primary graft failure (n = 2), right heart failure after heart transplantation (n = 3), and acute rejection (n = 3). Time of support ranged from 1 hour to 97 days (mean duration, 10.8 days). Seventy-five patients (51%) were discharged from the hospital. The best survival rate was achieved in group 2 with 72%, followed by group 1 with 44% and then group 3 with 28%. The most frequent complications in group 1 were bleeding (44%), multiple-organ failure (24%), neurologic disorders (18%), and acute renal failure (15%). In group 2, the major complications were bleeding (34%) and cerebrovascular disorders (22%) and in group 3, multiple-organ failure and sepsis (60%) and bleeding (32%).

[New avenues in therapy of postoperative low output syndrome]. / Neue Wege in der Therapie des postoperativen Low-output-Syndroms.

The present definitions of low-output syndrome (LOS) associated with cardiac surgery are based on data obtained via the Swan-Ganz-catheter. However, further important data such as signs of chronic renal insufficiency, arterial vascular disease, and perioperative volume overload have hardly been considered. At the Heart Center NRW, FRG, the Swan-Ganz-Catheter is not used routinely to monitor patients following cardiac surgery. According to our experience, the definition of low-output syndrome includes a wider spectrum of relevant criteria. In addition to the data obtained by means of a central venous catheter the clinical aspect of the patient as well as laboratory analysis should be regarded as well. In 1259 consecutive patients (pts) (914 with coronary surgery and 318 with valve surgery) the incidence and mortality of low-output syndrome were determined. In 49 of the 941 coronary surgery pts (5.2%) a postoperative low-output syndrome occurred. Nine pts (0.95%) died as a result of this complication. According to our therapeutical strategy, the low-output syndrome was treated medically in 28 pts (2.9%); in 14 pts (1.5%) IABP implantation was necessary, and 7 pts needed mechanical circulatory support. Surprisingly, the same incidence of LOS occurred in the valve surgery group of pts as in the coronary group. We saw a low-output syndrome in 17 of the 318 pts (5.3%), with fatal outcome in three pts. In 14 of these pts (4.4%) the LOS was treated medically, while the remaining three pts (0.9%) required diastolic augmentation of the IABP.

Long term follow-up of Mitroflow pericardial valve prostheses in the small aortic annulus.

Between January 1985 and April 1992 we implanted 477 Mitroflow pericardial bioprostheses in 476 patients in our clinic. All except one valve prostheses were implanted in the aortic position. There were 160 male and 316 female patients, with a mean age of 74.1 years (range 30-89 years). Combined cardiac procedures were performed concomitantly with aortic valve replacement in 45 patients (9.5%): coronary artery revascularisation (n = 38), endarterectomy of the internal carotid artery (n = 4) and multiple valve replacement (n = 3). The sizes of the implanted Mitroflow prostheses were 100% in 19 mm, 70% in 21 mm, 60% in 23 mm and 8% in more than 25 mm. The hospital mortality was 1.3% (n = 5). During the mean follow-up period of 47.6 months valve failure requiring reoperation occurred in 7 patients (1.2%). The actuarial freedom from tissue failure is 89.9 +/- 2.5% and the actuarial survival rate is 90.3 +/- 1.7% (27 deaths) at 7 years. These findings corroborate our policy to continue to implant a pericardial prosthesis in the aortic position, especially in elderly patients with a smaller aortic annulus.

Traumatic sinus of Valsalva fistula and aortic valve rupture.

A rare case of nonpenetrating trauma-induced fistula from the right sinus of Valsalva to the right atrium and aortic cusp disruption is reported. The trauma occurred 2 1/2 years previously. The fistula was closed with a Dacron patch, and the cusp tear was sutured.

Tricuspid valve regurgitation following blunt thoracic trauma.

Valvular lesions following blunt thoracic trauma are uncommon. Tricuspid valve regurgitation occurs very rarely. We report a successful tricuspid valve reconstruction for rupture of the chordae tendineae in a young man nine years after a motor vehicle accident. The value of echocardiography and transesophageal echocardiography for the diagnosis and quantification of this valve lesion is stressed.