Changes in Serum Levels of Myokines and Wnt-Antagonists after an Ultramarathon Race.

BACKGROUND: Regular physical activities have a positive effect on the muscular skeletal system but overstrenuous exercise may be different. Transiently suppressed bone formation and increased bone resorption after participation in a 246-km ultradistance race has been demonstrated. PURPOSE: The aim of this study was to analyze effects of the Spartathlon race on novel musculoskeletal markers. METHODS: Venous blood samples were obtained before and immediately after the race from 19 participants of the Spartathlon. From 9 runners who were available 3 days after the start blood was drawn for a third time. Serum levels of myostatin, an inhibitor of myogenic differentiation, and its opponent follistatin as well as sclerostin and dickkopf-1, both of them inhibitors of the wnt signaling pathway, and markers of bone turnover were determined. RESULTS: Serum levels of myostatin were significantly higher after the race. Serum follistatin only showed a transient increase. Sclerostin levels did not significantly differ before and after the race, whereas dickkopf-1 levels were significantly decreased. At follow-up a decrement of sclerostin and dickkopf-1 levels was seen. Serum cathepsin K levels did not change. CONCLUSION: The increase of serum levels of myostatin appears to reflect muscle catabolic processes induced by overstrenuous exercise. After the short-term uncoupling of bone turnover participation in an ultradistance race seems to initiate a long-term positive effect on bone indicated by the low-level inhibition of the Wnt/ß-catenin signaling pathway.

Prevention of sternal wound complications after sternotomy: results of a large prospective randomized multicentre trial.

OBJECTIVES: A prospective randomized multicentre trial was performed to analyse the efficacy of a vest (Posthorax support vest®) to prevent sternal wound infection after cardiac surgery, and to identify risk factors. METHODS: From September 2007 to March 2010, 2539 patients undergoing cardiac surgery via median sternotomy were prospectively randomized into those who received a Posthorax® vest and those who did not. Patients were instructed to wear the vest postoperatively for 24 h a day for at least 6 weeks; the duration of follow-up was 90 days. Patients who did not use the vest within a period of 72 h postoperatively were regarded as study dropouts. Statistical calculations were based on an intention-to-treat (ITT) analysis. Further evaluations comprised all subgroups of patients. RESULTS: Complete data were available for 2539 patients (age 67 ± 11years, 45% female). Of these, 1351 were randomized to receive a vest, while 1188 received no vest. No significant differences were observed between groups regarding age, gender, diabetes, body mass index, chronic obstructive pulmonary disease (COPD), renal failure, the logistic EuroSCORE and the indication for surgery. The frequency of deep wound complications (dWC: mediastinitis and sternal dehiscence) was significantly lower in vest (n = 14; 1.04%) vs non-vest (n = 27; 2.27%) patients (ITT, P < 0.01), but superficial complications did not differ between groups. Subanalysis of vest patients revealed that only 933 (Group A) wore the vest according to the protocol, while 202 (Group BR) refused to wear the vest (non-compliance) and 216 (Group BN) did not use the vest for other reasons. All dWC occurred in Groups BR (n = 7) and BN (n = 7), although these groups had the same preoperative risk profile as Group A. Postoperatively, Group BN had a prolonged intubation time, a longer stay in the intensive care unit, greater use of intra-aortic balloon pump, higher frequency of COPD and a larger percentage of patients who required prolonged surgery. CONCLUSIONS: Consistent use of the Posthorax® vest prevented deep sternal wounds. The anticipated risk factors for wound complications did not prove to be relevant, whereas intra- and postoperative complications appear to be very significant.

Fate of the false lumen after combined surgical and endovascular repair treating Stanford type A aortic dissections.

BACKGROUND: The purpose of this study was to evaluate the alterations of the aorta by using a new combined surgical and endovascular technique for the treatment of aortic type A dissections. The diameter of the descending aorta, the implanted stent graft, and the false lumen were evaluated. METHODS: Between August 2005 and February 2009, 14 patients (aged 49 +/- 13 years; 11 men, 3 women) with type A dissection in the aorta were operated on the thoracic aorta by the frozen elephant trunk technique. The size dynamics of the false lumen were analyzed by deducting the diameter of the stent graft obtained on computed tomography from the maximum dimension of the aorta. RESULTS: The technical success rate was 100%. All patients survived during the follow-up period. The mean follow-up period was 21.4 months. No redisection or aortic rupture occurred during the follow-up period. Postoperative computed tomography scans showed complete thrombus formation of the false lumen in the perigraft space within the entire zone of the stented segment of the hybrid prosthesis during the first 2 weeks after surgery in 12 patients (86%), whereas all patients showed complete obliteration of the false lumen at the 3-month control. The follow-up computed tomography scan obtained after 12 months revealed shrinkage of the false lumen in 9 patients (64%). CONCLUSIONS: The combined surgical and endovascular technique described in this report proved effective for the treatment of extended aortic lesions. The perigraft space thrombosed completely and had shrunken after successful placement of the stent graft.

A prospective randomized multicenter trial shows improvement of sternum related complications in cardiac surgery with the Posthorax support vest.

Sternal instability, dehiscence and mediastinitis are major causes of morbidity and mortality in cardiac surgery. The aim of this analysis is to determine the effect of a Posthorax support vest (Epple Inc, Vienna, Austria) after median sternotomy. One thousand five hundred and sixty cases were included in a prospective randomized multicenter trial. Patients were randomized as follows: 905 received a flexible dressing postoperatively (group A) and 655 patients were given a Posthorax support vest (group B). Patients in groups A and B were well matched. Their mean age was 68 years (range: 34-87 years). The patient characteristics and operative data were equally distributed in both groups. The mean total hospital stay was significantly shorter in group B than in group A (A: 17.33+/-17.5; B: 14.76+/-7.7; P=0.04). Sternal wound complications necessitating reoperation during the 90 days follow-up period were observed in 4.5%. Reoperation rates were as follows: 3.9% in group A and 0.6% in group B (P<0.05). The use of the Posthorax sternum support vest is a valuable adjunct to prevent sternum-related complications after cardiac surgery. In the 90 days follow-up period, additional surgical procedures were significantly reduced by the use of the support vest.

A newly designed thorax support vest prevents sternum instability after median sternotomy.

OBJECTIVE: Sternum infection remains one of the primary causes of postoperative morbidity and mortality after median sternotomy. We report the clinical efficacy for primary reinforcement of the sternum with a new design of thorax support vest. METHODS: A prospective randomized study including 455 patients was started in September 2007 to evaluate the effectiveness of the Posthorax sternum vest (Epple Inc., Vienna, Austria). One hundred and seventy five patients were treated with the sternum dressing postoperatively (group A), 227 patients did not receive the vest (group B) and 53 patients refused it (group C). Several clinical and operative data were evaluated. All patients were recorded using the STS risk scoring analysis for mediastinitis after cardiac surgery. RESULTS: The median age and gender distribution were comparable in both groups. Preoperative data like renal failure, chronic obstructive pulmonary disease, peripheral artery disease, and myocardial infarction were not significant. There were more patients with diabetes in group A and C (A: 39.4%, B: 29.1%, C: 43.4%, p = 0.036). A total of 55.8% underwent coronary bypass grafting, 15.4% aortic valve replacement, 7.7% mitral valve repair and 21.1% concomitant cardiac procedures. The median risk factor analysis and body mass index were comparable. In the follow-up period up to 90 days, in group A we observed 0.6% sternum wound complications, in group B 4.9%, and in group C 9.4% (group A vs B: Fisher's exact test p = 0.0152 and group A vs C: p = 0.0029). CONCLUSIONS: The use of the Posthorax sternum vest shows a favourable outcome to prevent sternum instability after cardiac surgery. There was one reoperation in patients treated with this sternum vest compared to 16 in the control groups.

Is the urgent carotid endarterectomy in patients with acute neurological symptoms a safe procedure?

The aim of the present case-control study was to assess patients with acute neurological symptoms requiring urgent carotid endarterectomy (CEA) and compare the outcome of the procedure in this group with that achieved in stable patients. Twenty-eight CEAs were performed in patients with an acute neurological deficit and 302 in stable patients from December 2006 to April 2008. Those selected for urgent surgery fulfilled the following criteria: acute onset of hemispheric neurological symptoms or crescendo TIAs, significant carotid pathology, the absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Perioperative mortality in the stable patients' cohort was 0.33%. One patient died during the hospital stay because of myocardial infarction. Perioperative neurological events were observed in 2.2%: one ipsilateral stroke in stage II A, one contralateral stroke in stage I A, and a prolonged neurological deficit with complete restitution at the time of discharge in five patients. No mortality or neurological morbidity was encountered in those who underwent urgent CEA. Compared to stable patients with stage I, II or IV disease, neither mortality nor morbidity was increased in those who underwent urgent CEA. Urgent CEA after non-disabling stroke or crescendo TIAs is a safe procedure with a favorable outcome.

Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts.

OBJECTIVE: Based on a previous randomized study showing significantly superior patency rates for in vitro endothelialized expanded polytetrafluoroethylene (ePTFE) grafts we investigated whether it was feasible for a nontertiary institution to offer autologous in vitro endothelialization to all elective infrainguinal bypass patients who had no suitable saphenous vein available. METHODS: Over a period of 15 years, 310 out of 318 consecutive nonacute patients (age 64.7 +/- 8.6) received 341 endothelialized ePTFE grafts (308 femoropopliteal: 153 above knee [AK] and 155 below knee [BK] and 33 femorodistal). Autologous endothelial cells were harvested from short segments (3.9 +/- 1.1 cm) of subcutaneous veins (80% cephalic, 11% basilic, 2% external jugular, and 7% saphenous) and grown to mass cultures within 18.9 +/- 4.5 days before being confluently lined onto fibrin glue-coated ePTFE grafts. The graft diameter was 6 mm (64%) or 7 mm (36%). The overall procedure-related delay for graft implantation was 27.6 + 7.8 days. Growth failure prevented 2.5% of patients from receiving an endothelialized graft. The mean observation period was 9.6 years. Primary patencies were obtained from Kaplan-Meier survivorship functions. Explants for morphological analysis were obtained from eight patients. RESULTS: The overall primary patency rate of femoropopliteal grafts was 69% at 5 years (68% [AK] vs 71% [BK]) and 61% at 10 years (59% [AK] vs 64% [BK]). Primary patency of 7 mm vs 6 mm grafts was 78%/62% at 5 years and 71%/55% at 10 years. The difference between the two groups was statistically significant (log rank test P = .023; Breslow test P = .017). Stage I vs II/III patients showed 5-year patencies of 67% vs 73% (N.S.) and 10-year patencies of 61%% vs 53% (N.S.). The primary patency of femorodistal grafts was 52% at 5 years and 36% at 10 years. The limb salvage rate was 94% (fempop) vs 86% (femdistal) at 5 years and 89% vs 71% at 10 years. All retrieved samples showed the presence of an endothelium after 38.9 +/- 17.8 months. CONCLUSION: Autologous in vitro endothelialization was shown to be a feasible routine procedure at a nontertiary hospital. Explants confirmed the presence of an endothelium years after implantation while the primary patency in the particularly challenging subgroup of patients without a suitable saphenous vein resembles that of vein grafts.

Translumbar treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysm.

The modality of treatment and the appropriate time point to treat type II endoleaks after endovascular repair of abdominal aortic aneurysms (EVAR) remain controversial issues. The purpose of the present study was to assess the efficacy of translumbar embolization of type II endoleaks after endovascular repair of aortic aneurysm repair. Eighty-four consecutive patients after EVAR were analyzed for the onset of type II endoleaks. Of these, five patients had experienced translumbar embolization after ineffective intraartrial approach to exclude the endoleak. A combination of several liquid embolic agents was used as sealant. Post-procedural contrast-enhanced ultrasound (CEUS) was used to document the outcome of the embolization. Translumbar embolization was successful in four patients. Complete sealing of the nidus was seen on CEUS 24 h after the procedure. In one patient with a duplication of the inferior vena cava, the procedure was aborted because an additional type Ib endoleak was found. The procedure was well tolerated by all patients. The translumbar approach to treat growing aneurysm sacs in patients with persistent type II endoleaks is safe and well tolerated. The immediate post-interventional outcome as documented on CEUS is promising. Long-term follow-ups are yet to be performed.

Combined surgical and endovascular repair of complex aortic pathologies with a new hybrid prosthesis.

BACKGROUND: We evaluated the application of a new combined surgical and endovascular technique for the treatment of thoracic aortic aneurysms and dissections. The technique is used to treat extensive aortic disease by a single-stage procedure. Surgical outcomes and follow-up data are summarized and analyzed. METHODS: Between August 2005 and December 2006, 7 patients (2 women), aged 62 +/- 11 years, with aortic pathologies (5 dissections, 2 aneurysms) underwent replacement of the ascending aorta and the aortic arch and simultaneous stent graft implantation into the descending aorta. The stent graft used was the E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany), which was implanted using the technique of circulatory arrest and moderate hypothermia with selective antegrade cerebral perfusion. The stent graft was deployed under visual guidance through the open aortic arch into the true lumen. RESULTS: Intraoperative antegrade stenting of the descending aorta combined with the distal ascending aorta and aortic arch repair was performed successfully in all patients. The survival rate was 100%. One patient had a postoperative neurologic deficit but recovered completely. Four patients had fully thrombosed perigraft spaces within 11 days, whereas 1 patient showed complete obliteration of the false lumen at the 3-month control. CONCLUSIONS: The combined surgical and endovascular technique described in this report proved feasible for the treatment of extended aortic lesions. It serves as an additional option for aortic repair in a single-stage method and is associated with no elevated risk for the patient.

Descending necrotizing mediastinitis treated with rapid sternotomy followed by vacuum-assisted therapy.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a life-threatening emergency after oropharyngeal infection. The diagnosis must be established rapidly. DNM is associated with septic shock and respiratory insufficiency. Because mortality rates may be as high as 60%, aggressive surgical treatment is indicated. METHODS: Between December 2001 and December 2005, 5 patients (3 men, 2 women) with DNM, average age of 69 years (range, 24 to 72 years), were treated at our department. Surgical treatment consisted of one or more cervical drainages and drainage of the mediastinum through sternotomy after mediastinitis had been confirmed by computed tomography. The latter investigation also revealed mediastinal abscess and empyema. After radical debridement, a vacuum-assisted closure device was inserted. RESULTS: The outcome was favorable in 4 patients. A 72-year-old woman died of prolonged septic shock and subsequent multiple organ failure. Tracheotomy was performed in all patients to create an airway. The duration of the intensive care unit stay was 51 +/- 24.2 days. CONCLUSIONS: Rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful because it promotes tissue approximation and stimulates the ingrowth of granulation tissue.

Treatment of chronic aortic type A dissection with a new designed hybridprosthesis.

This report describes the use of a new combined surgical and endovascular treatment for chronic type A aortic dissection after Cabrol operation. Intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed using the E-vita open endoluminal stentgraft. The stentgraft was deployed under direct vision into the true lumen. Postperative CT scan revealed a partially thrombosed false lumen. This report shows that a combined surgical and endovascular approach of chronic type A aortic dissection in a single stage procedure is a feasible option and extends aortic repair without increase of risk.

Enhanced endothelial cell retention on shear-stressed synthetic vascular grafts precoated with RGD-cross-linked fibrin.

Clinical in vitro endothelialization has been shown to increase the patency of synthetic vascular grafts. The shear stress resistance of the cultured autologous endothelium represents a crucial cornerstone of the concept. We investigated whether an enrichment of the precoating matrix with adhesion sites can augment endothelial cell attachment. Adult human saphenous vein endothelial cells (AHSVECs) were seeded confluently ([58 +/- 11] x 10(3) AHSVECs/cm2) onto 10-cm-long ePTFE (expanded polytetrafluorethylene) vascular grafts (n = 24) precoated with commercial clinically approved fibrin gel (Tisseal) containing various concentrations of cross-linked RGD peptide (0.0, 4.0, 8.0, or 16.0 mg of RGD per milliliter of Tisseal fibrinogen component). Endothelialized grafts were postcultivated for 9 days before they were exposed to a pulsatile circulation model mimicking peak physiological shear stress conditions of the femoral artery (12 dyn/cm2; min/max, -60/+28 dyn/cm2). Cell loss after 24 h was quantitatively determined by image analysis of vital stains. Initial 24-h cell loss was 27.2 +/- 1.7% in grafts precoated with the non-RGD-enriched fibrin matrix. In contrast, cell loss was significantly less on fibrin containing 4.0 mg of RGD peptide per milliliter of Tisseal fibrinogen component (13.3 +/- 7.9%; p < 0.05). Cell loss on fibrin containing 8 and 16 mg of RGD per milliliter of Tisseal fibrinogen component was 41.0 +/- 27.4 and 43.0 +/- 23.2% (p > 0.05), respectively. We conclude that low concentrations of RGD peptide cross-linked into commercial fibrin matrices used for clinical in vitro lining of vascular grafts led to significantly increased endothelial cell retention. The failure of higher RGD concentrations to enhance endothelial cell attachment may be explained by competitive binding of endothelial cells to non-cross-linked RGD.

Is the transpulmonary pressure gradient a predictor for mortality after orthotopic cardiac transplantation?

Elevated pulmonary vascular resistance (PVR) is a well-known risk factor for right ventricular failure after orthotopic cardiac transplantation. The influence of preoperative transpulmonary pressure gradient (TPG) and PVR on post-transplant 30 days mortality was evaluated. To analyze the response of PVR and TPG to cardiac transplantation, we analyzed 718 adult patients undergoing primary cardiac transplantation. Indications for operation were: 35.2% ischemic cardiomyopathy (ICM), 61.2% idiopathic dilated cardiomyopathy (DCM), and 3.3% other diagnosis (e.g. hypertrophic cardiomyopathy). The mean age (51.9) and the mean ischemic time (169.7 min) were comparable between 30 days survivors and nonsurvivors. Student's t-tests and chi-square analysis were used to compare data from 30-day survivors and nonsurvivors. Statistical significance was defined as P < 0.05. Fisher's exact test and multiple logistic regression analysis was performed to evaluate the relationship between hemodynamic parameters and outcome after transplantation. Primary end-point was 30 days mortality and secondary end-point long-term survival of patient groups with different TPG and PVR values. In survivors the mean TPG was 10.3 +/- 5.1 (mean +/- SD) vs. 13 +/- 6.6 in patients who died after transplantation (P = 0.0012). The PVR was 2.6 +/- 1.4 vs. 3.5 +/- 2.2 (P = 0.0012). In multivariate logistic regression, the parameters TPG and PVR exhibit a significant influence between survivors and nonsurvivors after cardiac transplantation within 30 days (TPG: P = 0.0012; PVR: P = 0.0012). The mortality rates in patients with TPG > 11 mmHg and PVR < 2.8 Wood units or TPG < 11 mmHg and PVR > 2.8 Wood units were comparable to those with TPG < 11 mmHg and PVR < 2.8 mmHg. The TPG is an important predictor in nonrejection-related early mortality after orthotopic cardiac transplantation. The determination of TPG in combination with PVR is a more reliable predictor of early post-transplant survival than PVR alone.

Mitral valve repair with the Colvin-Galloway Future Band.

BACKGROUND: A new annuloplasty device, the Colvin-Galloway Future Band, has been developed to allow simple and safe mitral valve repair surgery. Here we report its clinical use and the clinical results after a short-term, 2-year follow-up. METHODS: We assessed the performance of this new device in 40 consecutive patients (55% male; mean age, 68.3 +/- 8.1 years) who were operated on for mitral valve incompetence between 2001 and 2002. Ninety percent of these patients had associated surgical procedures. Clinical and echocardiographic assessment was performed perioperatively and at a mean follow-up of 16.5 +/- 5.7 months (range, 6 to 25 months) in all patients (100%), permitting analysis of 55 patient-years. RESULTS: Thirty-eight patients survived surgery, resulting in an overall early mortality of 5.0%. There were four noncardiac-related late deaths, resulting in an overall late mortality of 10.0%. Perioperative echocardiography showed no incidences of systolic anterior movement at the time of discharge from the hospital and satisfactory mitral repair results in 36 (95%) patients. At the time of the 2-year follow-up, echocardiography showed satisfactory mitral valve function in all but 2 patients (94%) and a significant postoperative ventricular remodeling: the left ventricular end-diastolic diameter decreased from 64.5 +/- 6.2 mm preoperatively to 50.4 +/- 9.5 mm postoperatively (p < 0.1). At the time of follow-up, 29 (90.6%) patients were in New York Heart Association functional class I or II, all of them describing their quality of life as "significantly improved" if compared with their preoperative status. There were no late reoperations and no thromboembolic, bleeding, or other complications. CONCLUSIONS: The clinical results of the Colvin-Galloway Future Band in this short-term follow-up of patients undergoing complex mitral valve repair seem to be promising.

Stabilized autologous fibrin-chondrocyte constructs for cartilage repair in vivo.

Stabilization of fibrin-chondrocyte constructs with fibrinolytical inhibitors has been shown to be a feasible method for the reconstruction of cartilage in vitro. In this study, the method was tested in vivo. Autologous cultures were used to form stabilized fibrin-chondrocyte constructs that were injected into auricular cartilage defects of rabbits. Stabilization was achieved by high doses of fibrinolytic inhibitors. Samples were prepared for magnetic resonance imaging, histology, and immunohistochemistry after 1, 2, 4, and 6 months. Defects of the contralateral ear, which were treated with stabilized fibrin without cells, were used for controlled comparisons. In all cell-fibrin samples, cartilage-like tissue was present. Immunohistochemistry revealed the presence of collagen II. This finding was similar for all observations. In the control samples, only minor new cartilage could be detected at the cut edges. The reconstruction of cartilage in vivo by injecting fibrin-chondrocyte constructs, stabilized with inhibitors of fibrinolysis, is thus possible.

Hyperlipidemia coincides with reversible growth impairment of cultured human autologous endothelial cells.

Patient-related risk factors for the growth of autologous endothelial cells were assessed in a clinical series of 100 consecutive recipients of in vitro endothelialized prosthetic vascular grafts. For all patients, the indication for bypass operation was arteriosclerotic occlusive disease of the distal arteries. Endothelial cells were harvested from a small piece of subdermal vein and cultured in medium containing 20% of autologous serum. Growth was continually monitored. In cultures that failed to grow, the autologous serum supplement to the culture medium was replaced by pooled homologous serum from young healthy donors. The comparison of a multitude of serum parameters between patients whose endothelial cells failed to grow and those showing normal growth revealed a significant difference in serum lipid content: triglycerides: 4.76 +/- 3.36 versus 2.83 +/- 2.28 mmol/L (p = .001); cholesterol: 6.78 +/- 1.69 versus 5.69 +/- 1.32 mmol/L (p = .003); and lipoprotein (a): 35.9 +/- 28.3 versus 22.2 +/- 26.6 mg/dl (p = .04). Following serum exchange with low-lipid pool serum that contained 1.74 mmol/L triglycerides, 4.86 mmol/L cholesterol, 5 mg/dl lipoprotein (a), and 5.79 mmol/L glucose, a remarkable recovery occurred in 85% of these cultures, resulting in fully restored proliferative capacity. As a consequence, population doubling time did not differ between the two groups at any point in time and mass cultures sufficient for confluent graft endothelialization were obtained with hardly any delay. The authors conclude that hyperlipidemia may lead to growth impairment of cultured human endothelial cells. This growth inhibition is reversible if the supplemented autologous serum is replaced by pooled serum with low lipid content.