How Well Are Patients Doing Up to 30 Years after a Mustard Operation?

BACKGROUND

Right heart failure and baffle complications may affect the health status of patients with transposition of the great arteries after an atrial switch operation.

METHODS

This study aims to identify risk factors for late death, the incidence of reoperations, and the functional status of 88 patients who underwent a Mustard operation with a mean follow-up of 20.9 +/- 10.0 years.

RESULTS

There were 7 early and 19 late deaths. Follow-up was complete for 97 % of the hospital survivors. Survival and freedom from reoperation of the hospital survivors at 20 years was 83.7 +/- 4.2 %, and 70.6 +/- 5.4 %, respectively. Seven reoperations were performed for systemic ventricular failure, and 24 for baffle complications, with no operative mortality. Presence of a ventricular septal defect at the time of the Mustard operation was predictive for late death in multivariate analysis ( P = 0.040). At follow-up, 82 % of the patients were able to work full-time, 11 % part-time, and 7 % experienced noticeable limitations of their activities.

CONCLUSIONS

Presence of a VSD at the time of the Mustard operation defines a distinct subgroup with an increased risk for late death. Long-term survivors were in a good functional status but had to be reoperated frequently due to baffle complications that seemed to increase in adulthood.

Alternatives to Heart Transplantation

Heart transplantation is currently the treatment of first choice in patients with end-stage refractory heart failure. But already the demand for donor organs cannot be met, and patients face long waiting times for transplantation. In the future waiting times will become even longer as life expectancy increases and the number of heart-failure patients requiring transplantation grows. Consequently, in view of the poor prognosis of the disease in its advanced stages, alternatives to heart transplantation are increasingly gaining importance. In recent years new innovative treatment methods and techniques have been developed which have already proved clinically successful in patients with end-stage heart failure, especially as bridging measures. Some of these techniques appear suitable for long-term use and could therefore serve as an alternative to heart transplantation in some patients. Interesting new avenues of research may even lead to cardiac cell replacement therapies in the future. These approaches are currently undergoing initial clinical trials. This report presents surgical and cardiologic treatments for end-stage heart failure that have already been clinically investigated as well as techniques that are still in the preclinical stage and discusses their potential as alternatives to heart transplantation.

Chronic dose effects of reboxetine on motor skill acquisition and cortical excitability

BACKGROUND

Enhancement of cortical excitability is thought to be beneficial for synaptic plasticity associated with motor skill acquisition. Single dose application of the selective norepinephrine reuptake inhibitor reboxetine (RBX) increases motor cortex excitability. In this study, we tested if a chronic dose application of RBX improved motor skill acquisition and modulated cortical excitability.

METHODS

The study was randomised, double blind and placebo-controlled. Twelve healthy subjects received four milligram RBX twice a day for four days preceded by two milligram RBX twice a day for two days. Each subject served as his own control. The time interval between the verum and the placebo session was 16 days or more. Measurement of cortical excitability by means of paired pulse transcranial magnetic stimulation (ppTMS) was conducted before and after the motor skill acquisition task in each session. The task was to lift two fingers of the right hand at once while the hand was positioned sprawled out on the table. The movements were self-paced and subjects had to perform as many moves as possible in 60 sec. Between seven blocks of self-paced movements six blocks with 60 single trials at a fixed interstimulus intervall were presented. Two equally difficult versions of the task using different finger combinations were established in order to avoid carry over effects in performance. The finger movements were recorded with a three-dimensional ultrasound movement analysis system (Zebris).

RESULTS

All subjects had substantial gain in performance across the selfpaced blocks. Average increase in number of correct moves was 87% (from 27.8 to 51.9). There was no significant difference neither between the versions of the task nor between placebo vs. verum. Also, there was no significant difference between first and second session, indicating that there was no carry over effect in performance. ppTMS revealed no significant differences in cortical excitability between groups.

CONCLUSION

The newly developed skill acquisition task yields robust single subject gain of performance. As the two versions of the task do not interact, it is suitable to be used in cross-over designs. In contrast to studies using single doses of RBX, motor cortex excitability seems to be unaffected in a steady-state induced by repeated drug applications. This could explain why RBX did not modulate motor behavior.

Surgical Closure of Atrial Septal Defect in Patients Older than 30 Years: Risk Factors for Late Death from Arrhythmia or Heart Failure

BACKGROUND

Little is known about prognostic markers for late cardiac-related death after surgical atrial septal defect (ASD) closure in adults.

METHODS

Long-term follow-up data of 281 patients who underwent surgical secundum ASD closure when they were older than 30 years, were retrospectively examined.

RESULTS

Mean age at surgery was 43.8 +/- 10.0 years (30 to 76 years). There were 2 early deaths. Mean follow-up was 14.1 +/- 8.4 years (0.4 to 28.9 years). Death from arrhythmia or heart failure occurred in 9 patients (3.6 %) at a mean time of 8.5 +/- 6.6 years after the operation. Patients > 43 years exhibited significantly higher pulmonary artery pressures. Preoperative systolic pulmonary artery pressure > 36 mmHg, and mean pulmonary artery pressure > 21 mmHg were predictive of late death from arrhythmia or heart failure. However, age at operation was not.

CONCLUSIONS

Older age at the time of ASD closure is not a risk factor for late death from arrhythmia or heart failure in adults. However, older patients presented more often with pulmonary hypertension. Since elevated pulmonary artery pressure is predictive of late death from arrhythmia or heart failure, timely ASD closure is warranted.

Micro-plasma textured Ti-implant surfaces

The surface state of titanium implants modulates bone response and implant anchorage. This evidence brought implant manufacturers to switch from the standard surface refinements and implement new surface treatments for more bone apposition and enhanced interfacial strength measured by removal torque or push-out tests. Anodic plasma-chemical treatment of implant surfaces is a cost-effective process to modify surface topography and chemistry. This technique is used for structuring connected with a coating of implant surfaces. The aim of our investigations, here, is to texture the implant surface in the nanoscale without coating. Ti disks with different mechanical pre-treatment (grinded, glass blasted) were used as substrate. Micro-plasma texturing was carried out in an aqueous electrolyte. By applying a pulsed DC voltage to the specimen, micro-plasma discharge was generated in the thin steam film between immersed specimen and electrolyte. The electrical process parameter current density was varied. The micro-plasma textured Ti surfaces were characterised optically by SEM and electrochemically by CV- (for testing the corrosion parameters), CA- (to give the enlargement of the real surface) and EIS-measurement in range of 100 kHz-100 microHz. We found that the initial structure of the material surface has small or no influence on the results of the micro-plasma treatment. The properties of the thick oxide layer resulting from the plasma process are influenced by electrical process parameters. After removal of the thick oxide layer a fine, micro- and nanoscaled surface structure of the titanium remains.

Optimal port placement and enhanced guidance in robotically assisted cardiac surgery

BACKGROUND

Optimal port placement and enhanced guidance in robotically assisted cardiac surgery is required to improve preoperative planning and intraoperative navigation.

METHODS

Offline optimal port placement is planned on a three-dimensional virtual reconstruction of the patient's computed tomography scan. Using this data, an accurate in vivo port placement can be performed, which is achieved by augmented reality techniques superimposing virtual models of the thorax and the teleoperator arms on top of the real worldview.

RESULTS

A new system incorporating both port placement planning and intraoperative navigation in robotically assisted minimally invasive heart surgery was established to aid the operative workflow. A significant reduction of operation time by improved planning and intraoperative support is anticipated.

CONCLUSIONS

The enhanced intraoperative orientation possibilities may lead to further decrease in operation time and have the continuing ability to improve quality.

[Sympathomimetic syndrome caused by autointoxication with methylphenidate]

A 31-year-old man claimed that he had ingested more than 100 tablets of methylphenidate (10 mg), 20 tablets ofibuprofen (400 mg) and 2 bottles of wine. At admission, signs of sympathomimetic syndrome were observed, including agitation, hallucinations, mydriasis and sinus tachycardia. The patient was treated with activated charcoal and an oral laxative. Given the possibly lethal dose of methylphenidate, the patient was admitted to the intensive care unit for observation. He made a full recovery and was discharged 36 hours after admission. Toxicological analysis indicated a plasma-ethanol concentration of 0.27% and a maximum serum-methylphenidate concentration of 176 microg/l (therapeutic range: 5-40 microg/l). The active metabolite ethylphenidate was also present at toxic concentrations. Treatment of potentially lethal methylphenidate poisoning includes prevention of absorption, careful observation and support of vital functions as necessary.

Timing of Repair in Ventricular Septal Defect with Aortic Insufficiency

OBJECTIVE

Trusler's valvuloplasty technique and its modifications are the standard approach for the repair of aortic insufficiency in combination with ventricular septal defect. However, recurrent aortic insufficiency may occur after repair. The timing of surgical intervention in patients with ventricular septal defect and aortic insufficiency is still controversial.

METHODS

Between 1985 and 2000, 33 patients were analyzed retrospectively focusing on echocardiographic findings. For statistical analysis, the patients were divided into two groups according to the grade of preoperative aortic insufficiency: there were 5 patients with preoperative severe aortic insufficiency and 28 patients with mild to moderate aortic insufficiency.

RESULTS

The mean age at operation was 6.05 +/- 3.61 years. The aortic valve was repaired by means of Trusler's valvuloplasty in the majority of the patients. All but three had patch closure of the ventricular septal defect, with a transaortic approach in 54 %. Mean follow-up was 5.1 years with a maximum of 16.9 years (168.9 patient years). Rates for freedom from reoperation at 1, 3, and 8 years were 90 %, 85 %, and 75 %, respectively. In 3 patients, a mechanical prosthesis was implanted at the time of reoperation. One sudden death occurred after 3.6 years. Patients with preoperative severe aortic insufficiency were reoperated significantly more often (P < 0.03). In patients with preoperative severe aortic insufficiency, the underlying pathology (insufficiency) was detected earlier on in life (8.4 +/- 10 months) than in patients (45.0 +/- 30 months) with mild to moderate aortic insufficiency at the time of intervention (P < 0.05).

CONCLUSION

Severe aortic insufficiency at the time of operation has less favorable long-term results. Therefore, early surgical intervention, even in young patients, seems warranted to avoid potential reoperation or valve replacement.