Doxorubicin-induced heart failure is a rare but serious illness due to the well-known treatment difficulties. Prevention strategies have not demonstrated the expected success and unfortunately, this ...specific type of heart failure does not respond to the usual medical therapy as other kinds of heart failure. Therefore, surgical procedures may be necessary in some patients. Cardiac transplantation is performed in most cases but it requires the cure of the neoplastic disease. This usually requires a recurrence-free interval of several years which is associated with a high attrition rate in these patients due to their cardiac disease. Therefore, other conservative and surgical treatment concepts were developed during the last years. This review presents the most common procedures and discusses their efficacy as well as their clinical applicability.
To evaluate the perioperative risk of redo aortic valve replacement (AVR).
Sixty-three patients (53 males, 10 females) underwent redo AVR from 2001-2005. Forty-one bioprostheses had to be replaced ...for degeneration and/or paravalvular leakage, and 18 mechanical prostheses were changed because of thrombosis and/or paravalvular leakage. Four patients with a bicuspid aortic valve underwent a mechanical AVR after a primary reconstructive procedure. We compared the perioperative course of the redo AVR (group 2) with the primary procedure (group 1).
Fifty-two patients received a mechanical prosthesis and eight a biological one. Three patients underwent a refixation of the prosthesis for a paravalvular leakage. The durations of surgery (261.7 +/- 49.5 min vs. 191.7 +/- 31.6 min), cardiopulmonary bypass (130.3 +/- 37.1 min vs. 101.3 +/- 28.4 min), and cross-clamping (80.4 +/- 23.4 min vs. 66.4 +/- 20.6 min) were significantly longer in group 2 than in group 1. Forty-three patients had an uneventful postoperative course. There were 28 (8) postoperative complications in group 2 (1): Need for pacemaker insertion: 8 vs. 2; reexploration for bleeding: 4 vs. 1; temporary renal insufficiency: 3 vs. 4; cerebral confusion: 5 vs. 0; low cardiac output syndrome: 4 vs. 0; wound infection: 2 vs. 1; intestinal ischemia: 1 vs. 0. Four patients expired after redo AVR: two resulting from multiorgan failure, one suffered from an intestinal ischemia requiring bowel resection, and one expired as a result of an aortic rupture during resuscitation.
Conventional reoperative AVR is associated with an enhanced perioperative risk. Therefore these patients should be referred early for reoperation to avoid high-risk emergency operations with a significantly increased mortality.
Emergent coronary artery bypass grafting (CABG) remains a high-risk procedure in cardiac surgery. Therefore we performed this study to evaluate its current results.
From 2001 to 2007, fifty-seven ...patients with an acute coronary syndrome underwent an isolated CABG procedure emergently. Data were collected retrospectively from the patients' charts.
The mean age of the patients, 45 males (79%) and 12 females (21%), was 64.5 ± 11.5 years. Operations were performed on 40 patients (70%) with cardiopulmonary bypass (CPB) and cardioplegic cardiac arrest and on 6 without CPB. Eleven patients (11%) underwent on-pump beating heart procedures (19%). The operating times (minutes) were duration of surgery 215.2 ± 64.2; duration of CPB 116.9 ± 51.5; and X-clamp time 57.3 ± 19.9. The mean number of grafts per patient was 2.95 ± 0.97. Postoperative durations of mechanical ventilation (hours), Intensive Care Unit stay (days), and normal ward stay (days) were 45.8 ± 75.3, 8.9 ± 23.1, and 9.6 ± 8.0, respectively. The total number of complications was 57, and postoperative confusion (29.8%), revision for bleeding (22.8%), and renal insufficiency (21%) occurred most frequently. Seven of the 57 patients died: 5 succumbed to multiorgan failures, 1 to cardiac decompensation, and 1 to bleeding complications.
Emergent CABG is associated with an enhanced perioperative risk, and further developments are absolutely necessary to improve its results.
Anthracyclines are widely used in oncogenic therapy. Owing to their cardiotoxic side effects, their application is subdued to dose limitations. Many cardioprotective approaches have failed. This ...study examined the role of matrix metalloproteinases (MMP) in the remodeling process of extracellular matrix after treatment with doxorubicin (Adriamycin) as a toehold for a new therapeutic approach, for example, treatment with MMP inhibitors.
Severe heart failure was induced in 6 pigs by the repetitive intracoronary application of Adriamycin. Degree of dilatation and insufficiency were measured by echocardiography and hemodynamics. Before and after treatment, MMP activity (fluorogenic assay: MMP-1, MMP-2) and gene expression (reverse transcription-polymerase chain reaction RT-PCR: MMP-1, -2, -9; membrane type-1 matrix metalloproteinase, MT1MMP; tissue inhibitor of metalloproteinase 1 TIMP-1) were measured. Spatial distribution of MMP-1, MMP-2, and collagen were visualized in antibody-stained frozen sections. One-way analysis of variance was used for data analysis.
Severe myocardial insufficiency (ejection fractions < 50% of baseline values) developed in all animals. No severe side effects were encountered. We found a strong activation of MMP-1 and MMP-2 in fluorogenic and PCR assays. RT-PCR revealed a significant activation of MMP-9 and MT1-MMP and a weaker induction of TIMP-1. Histology showed typical signs of myocardial fibrosis, with myocardial cell loss, collagen disorder, and vacuoles.
We showed a strong transcriptional activation for several specific MMPs in Adriamycin-induced cardiac remodeling. Contrary to published data on myocardial infarction, early inhibitory therapy before myocardial injury is possible in Adriamycin-treated patients. Local application by our catheter-based system would additionally help to avoid systemic side effects.
Zusammenfassung
Mit der Digitalisierung des Gesundheitssystems ist zu erwarten, dass auch telemedizinische Anwendungen in den Versorgungsalltag eingeführt werden. Aktuell ist die Anzahl ...telemedizinischer Angebote im deutschen Gesundheitswesen aber noch gering und im internationalen Vergleich eher niedrig. Die ist umso auffälliger, da der Telemedizin allgemein ein großes Potential hinsichtlich der Verbesserung der medizinischen Versorgung und der Effizienzsteigerung zugeschrieben wird. Deswegen diskutiert die vorliegende Arbeit die Aspekte Angebote, Chancen und Kosteneffektivität der Telemedizin.
Cryoablation is a new surgical technique for the treatment of atrial fibrillation. Because long-term results are scarce, we report on our findings with this antiarrhythmic therapy.
Forty-three ...patients (men: 22; women: 21) with paroxysmal (20 patients) or permanent (23) atrial fibrillation underwent different cardiac procedures with simultaneous cryoablation from 2002 to 2007. Cryoablation was performed epicardially with the SurgiFrostTM Cryosurgical system in patients with closed-heart procedures and endocardially in patients with mitral valve surgery. Data were collected by reviewing charts of the patients. Follow-up data were obtained by phoning the general practitioners and/or cardiologists of the patients.
The mean age of the patients was 66.2 ± 9.0 years. Fifteen different operations were performed, with coronary artery bypass grafting and mitral valve replacement occurring most frequently. Four patients (9.3%) died postoperatively, 22 were discharged with sinus rhythm (56.4%), and the others demonstrated atrial fibrillation (43.6%). A cardioversion performed on 9 patients postoperatively was successful in 5. All patients were treated with phenprocoumon and amiodarone for a minimum of 6 months postoperatively. Follow-up data were collected 26 ± 15 months after surgery. The number of patients with sinus rhythm had increased to 26 (66.7%), whereas 13 (33.3%) patients still suffered from atrial fibrillation.
Cryoablation seems to be an effective tool in the treatment of atrial fibrillation.
The aim of this study was the development of an experimental cardiomyopathy induced with Adriamycin (Pharmacia & Upjohn, Erlangen, Germany) with selective toxic damage of the left ventricular ...myocardium that avoided an ischemic component.
An intracoronary catheter was implanted directly into the left main stem in pigs and connected to a percutaneous access port that was used for repetitive Adriamycin administration (3-5 x 25 mg weekly over a 1-hour period). Hemodynamic and echocardiographic variables were measured before Adriamycin administration, 1 week after, and at 4 weeks. Thereafter, all hearts were autopsied for detailed histologic examination. Statistical analysis was done by an analysis of variance for multiple parameters.
All pigs had normal baseline cardiac function. Measurements after Adriamycin administration and 4 weeks later demonstrated a continued increase of the central venous pressure, pulmonary artery pressure, pulmonary wedge pressure, and pulmonary vascular resistance, whereas cardiac output, stroke volume index, and left ventricular stroke work index decreased. These results were supported by the echocardiographic data depicting an increase of left ventricular diameters and volumes, accompanied by a decrease of intraventricular and left ventricular posterior wall thickness as well as left ventricular ejection fraction. Right ventricular volumes and function did not change during the trial. The histologic examination of the hearts revealed a selective toxic damage of the left ventricular myocardium with multifocal necroses and advanced tissue reorganization.
This animal model creates a selective left ventricular damage that avoids ischemic damage of the myocardium. Both aspects can improve research on Adriamycin-induced cardiomyopathy, especially preventive or therapeutic strategies.
Zusammenfassung
Hintergrund
Die arterielle Hypertonie ist eine Volkskrankheit, die zu schwerwiegenden Komplikationen führen kann. Daher sollte einerseits eine optimale Therapie erfolgen und ...andererseits aktiv nach Verbesserungen der derzeitigen Therapiestandards gesucht werden.
Fragestellung
Ziel dieser Arbeit ist es, eine Übersicht zum Thema „Medizinischer Nutzen von Telemonitoring bei arterieller Hypertonie“ zu erstellen. Zudem wird diskutiert, für welche Zielgruppen das Telemonitoring sinnvoll erscheint und welche Aussagen zur Kosteneffizienz derartiger Programme gemacht werden.
Methodik
Zuerst wurde mittels einer Suchstrategie und Ein- und Ausschlusskriterien nach Übersichtsarbeiten (2005–2015) gesucht. Darauf wurde in einem zweiten Schritt nach RCTs (2013–2015) recherchiert. Die finalen Studien (12 Übersichtsarbeiten/6 RCTs) wurden systematisch ausgewertet und qualitativ zusammengefasst.
Ergebnisse
Es ist eindeutig, dass Telemonitoring im Vergleich zur herkömmlichen Therapie zu einer zusätzlichen Blutdrucksenkung führt. Die Kosten von Telemonitoring werden in allen Studien initial als höher beschrieben. Bezieht man die Langzeiteffekte mit ein, wird das Telemonitoring jedoch als kosteneffektiv eingestuft (1 Studie). Weiterhin kann gezeigt werden, dass bestimmte Patientengruppen (z. B. Patienten mit schwer einstellbarer Hypertonie) besonders vom Telemonitoring profitieren.
Diskussion
Der medizinische Nutzen des Telemonitorings bei arterieller Hypertonie im Sinne einer zusätzlichen Blutdrucksenkung kann als nachgewiesen angesehen werden. Davon können Risikogruppen besonders profitieren. Zukünftige telemedizinische Studien sollten sich stärker auf gesundheitsökonomische Aspekte konzentrieren, da die Datenlage dazu bislang sehr eingeschränkt ist.
The purpose of this study was to evaluate modified adriamycin-induced cardiomyopathy in the dog for research on partial left ventriculectomy (PLV).
An intracoronary catheter was introduced into the ...left main stem via the first marginal branch in a retrograde fashion in 12 adult foxhound dogs. The catheter was connected to a percutaneous access port that was used for weekly adriamycin administration (10 mg over a 1-hour period on 5 occasions). Follow-up examinations (transthoracic echocardiography, hemodynamic parameters, cardiopulmonary status, neurohormones) were done before, 1 week after the last adriamycin administration, and then 6 weeks later. This protocol was performed in 6 dogs (control group: Group 1). The other 6 dogs underwent PLV 1 week after the last adriamycin administration (Group 2). After the last measurements, all dogs were killed with saturated potassium chloride under general anesthesia and the hearts were excised for histologic examination. All data were calculated as mean and standard error of the mean. Differences were calculated by the Wilcoxon signed-rank test for paired and unpaired data.
p < 0.05 was considered statistically significant.
One dog from each group died suddenly during adriamycin administration (probably due to ventricular arrhythmia). In addition, 1 dog from Group 2 suffered from a severe systemic inflammatory response syndrome after PLV and died 36 hours after surgery. Thus, 5 dogs from Group 1 and 4 from Group 2 underwent the entire study protocol. Adriamycin administration resulted in a severe dilated cardiomyopathy that was comparable in both groups (significant increase of central venous pressure, mean pulmonary artery pressure, pulmonary wedge pressure, left ventricular end-systolic and end-diastolic diameters, oxygen extraction, troponin I and anti-diuretic hormone, whereas cardiac output, ejection fraction and venous oxygen saturation decreased significantly). Deterioration of cardiac function continued after termination of adriamycin administration in Group 1 dogs, albeit not as progressively as during adriamycin administration. In contrast, cardiac function improved in Group 2 dogs after PLV, but did not reach baseline values. Cardiac index increased and oxygen extraction (
p = 0.03) decreased, resulting in an enhanced venous oxygen saturation (
p = 0.02). In particular, the distance of the papillary muscles at end diastole (
p = 0.02) and at end systole (
p = 0.02) at the mid-papillary level decreased significantly after PLV, resulting in reduced left ventricular diameter and volume (statistically significant for left ventricular end-systolic diameter and volume). All hearts had severe histologic alterations characteristic of adriamycin-induced toxicity, including cytoplasmic vacuolation, myocyte degeneration and increased fibrosis.
Modified adriamycin-induced cardiomyopathy in the dog may be suitable for research on PLV.
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