Thoracic and Cardiovascular Surgeon - THORAC CARDIOVASC SURG, 1990
Four patients are described with pulmonary atresia and ventricular septal defect, in whom the pul... more Four patients are described with pulmonary atresia and ventricular septal defect, in whom the pulmonary circulation was dependent on a fistula from the left coronary artery to the pulmonary artery. The issue in this complex anomaly is complete preoperative diagnosis, including anatomic information on the coronary artery fistula and the pulmonary vasculature. This was achieved in the last 2 patients. In the last patient echocardiography turned out to be an important diagnostic tool in this rare anomaly and facilitated selective angiocardiography. All 4 patients were successfully operated by closing the fistula, closing other aortopulmonary connections and inserting a valved conduit between right ventricle and pulmonary artery. The ventricular septal defect was closed in 3 patients with a patch. In the setting of an already existing pulmonary hypertension and a possibly inadequate pulmonary arterial system at surgery, a perforated patch was inserted in the ventricular septal defect of the remaining patient.
Twenty-three patients underwent cardiac surgery for valve replacement, valve reconstruction, aort... more Twenty-three patients underwent cardiac surgery for valve replacement, valve reconstruction, aorto-coronary bypass grafting, aneurysmectomy or combinations of these. Excised cardiac tissue was obtained from left ventricular (LV) papillary muscle (17 patients), LV outflow tract (3 patients), or LV aneurysms (3 patients). A total of 34 myocardial samples, collected from excised cardiac tissue, were analysed for creatine kinase (CK), CK-isoenzymes, cytoplasmic and mitochondrial isoenzymes of aspartate aminotransferase (cAST and mAST, respectively), and lactate dehydrogenase (LDH) isoenzymes. Myocardial CK activity correlated positively with preoperative LV ejection fraction (p less than 0.001), negatively with the preoperatively measured extent of LV wall motion abnormalities (p less than 0.001), and negatively with preoperative LVEDP (p less than 0.02). Myocardial CK activity was negatively correlated with preoperative validity class (p less than 0.005). However, no correlation existed between myocardial CK activity and postoperative validity. Excluding the biopsies from LV aneurysms, myocardial CK activity was positively correlated with the fraction H-subunits in LDH (p = 0.02), and was negatively correlated with the fraction mAST in total AST (p less than 0.005). While cAST activity was proportional to CK activity in the biopsies from VL papillary muscle and LV outflow tract, mAST activity declined only with 2.4 +/- 1.2% per 10% fall of CK. The increase of mAST/cAST ratio with decreasing CK, together with the decrease of LDH-H/LDH and CK-M/CK ratios with decreasing CK, indicated the presence of an adaptation process in a myocardium with low CK activity rather than a process of necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)
To investigate the timing of surgery in active infective endocarditis, the data of 54 patients, c... more To investigate the timing of surgery in active infective endocarditis, the data of 54 patients, consecutively operated for this reason from September 1973 to May 1989, were analysed. Native valves were involved in 31 patients (57%): the aortic valve in 22, the mitral valve in 6, and both valves in 3 cases. Prosthetic valves were involved in 23 patients (43%): the aortic valve in 14, the mitral valve in 7, and both valves in 2 cases. There were no significant differences between involvement of native or prosthetic valves and mortality, morbidity, or consequences of morbidity. No significant correlation was found between causative microorganism and mortality, morbidity, or consequences of morbidity. The indication for operation was cardiac failure in 15 patients (28%), ongoing infection in 24 (44%) or a combination of these in 15 (28%). Major embolization occurred in 12 patients (22%) and affected women more than men (p = 0.05). Hospital mortality was 8 (15%). Morbidity involved 15 more patients; structural deterioration of the valve prosthesis occurred in 1 patient; nonstructural dysfunction of the valve prosthesis occurred 11 times in 10 patients; anticoagulation-related hemorrhage involved 2 patients (1 with nonstructural dysfunction of the valve prosthesis); endocarditis was diagnosed in 3 patients. The consequences of these morbid events concerned 14 patients; reoperations were done 9 times in 8 patients; mortality was valve related in 6 cases. Because 2 more patients died during the course of the study, total late mortality was 8. Probability of survival 5 years after operation was 72% (95% cl 56-83) and at 10 years 47% (95% cl 21-70).(ABSTRACT TRUNCATED AT 250 WORDS)
In 2 patients, a lusoric artery was compressing the mediastinal structures during a one-stage rep... more In 2 patients, a lusoric artery was compressing the mediastinal structures during a one-stage repair of type B aortic arch interruption and ventricular septal defect. In order to prevent the long-term complications of sacrifice of the subclavian artery, the lusoric artery was not simply divided but converted into a regular right subclavian artery by re-implantation of the abberant vessel at the origin of the right carotid artery during the one-stage repair. At follow up, both patients have normal right radial arterial pulsations. In one patient, angiography was repeated and confirmed a well functioning right subclavian artery. Conversion of a lusoric artery into a right subclavian artery during one-stage repair of aortic arch anomalies and intracardiac defects is not only feasible but also indicated to preserve subclavian artery function and to prevent compression of the mediastinal structures by a vascular ring.
A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhim... more A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhimurium in a patient on immunosuppressive therapy following kidney transplantation. After initial medical treatment, surgery consisted of local debridement and implantation of an aortic prosthesis. Lifelong antibiotic treatment was prescribed because of the combination of immunosuppressive therapy, the history of recurrent S. typhimurium bacteremia and the presence of an aortic prosthesis.
Objective. Valvotomy and the autograft procedure are the most common surgical treatment options f... more Objective. Valvotomy and the autograft procedure are the most common surgical treatment options for children with valvular aortic stenosis. We evaluated the results of these surgical procedures in our institution.
A patient with Cantrell's syndrome is presented with ectopia cordis, ventricular septal d... more A patient with Cantrell's syndrome is presented with ectopia cordis, ventricular septal defect and a left ventricular as well as a right ventricular diverticulum. One-stage correction was performed with resection of both diverticula. Closure of the ventricular septal defect was complicated due to exposure problems as a result of the malposition of the heart. Although the presentation of Cantrell's syndrome can be variable, one-stage repair is technically feasible and should be considered as the treatment of choice in this rare syndrome.
Joint Commission journal on quality and patient safety / Joint Commission Resources, 2006
Six Sigma, a process-focused strategy and methodology for business improvement, can be used to im... more Six Sigma, a process-focused strategy and methodology for business improvement, can be used to improve care processes, eliminate waste, reduce costs, and enhance patient satisfaction. Six Sigma was introduced in 2001 at the 384-bed Red Cross Hospital (Beverwijk). During the Green Belt training, every participant was required to participate in at least one Six Sigma project. The hospital's total savings in 2004 amounted to 1.4 million dollars, for an average savings of 67,000 dollars for each of the completed 21 projects. In one project, the team designed a new admission process for the operating rooms, resulting in an average starting time nine minutes earlier. This relatively minor improvement made it possible to operate on an additional 400 patients a year and to achieve a net savings of >273,000 dollars. A second project reduced the number of patients receiving intravenous (IV) antibiotics by switching to oral administration, yielding annual savings, based on medication co...
Background: The ideal substitute for a diseased aortic valve remains unclear. Usually, the aortic... more Background: The ideal substitute for a diseased aortic valve remains unclear. Usually, the aortic full root replacement (FRR) technique is used, in which the native aortic root is removed and entirely replaced with the homograft aortic root, the coronary arteries being reimplanted into the homograft. The aim of the present study was to examine alterations in aortic size and stiffness in patients after FRR. Methods and patients: The study comprised 13 patients (mean age 46 ± 15 years, 10 males) who underwent FRR because of acute aortic regurgitation due to endocarditis in 6 patients (46%) and aortic valve stenosis with or without regurgitation in 7 patients (54%). These patients underwent transthoracic two-dimensional echocardiography before FRR, before discharge (9 ± 8 days post-FRR), and 6 months and 24 months after FRR. Systolic and diastolic ascending aortic diameters were recorded in M-mode at the middle of the ascending aorta, 3 to 4 cm above the aortic valve from a parasternal long-axis view. An aortic stiffness index (β) was calculated. The results were compared to 13 age-, gender-and risk factor-matched controls. Results: The aortic stiffness index first non-significantly deteriorated from 12.7 ± 8.1 to 16.4 ± 9.1 immediately after FRR. Subsequently, an improvement to 14.2 ± 7.1 (after 6 months) and 7.1 ± 4.8 (after 24 months, P b 0.05) was seen. Conclusions: FRR is associated with a transient immediate post-FRR deterioration followed by a progressive improvement in aortic distensibility.
Circulation: Arrhythmia and Electrophysiology, 2015
-The incidence of atrial fibrillation (AF) is rising in the aging patients with congenital heart ... more -The incidence of atrial fibrillation (AF) is rising in the aging patients with congenital heart disease (CHD). However, studies reporting on AF in CHD patients are scarce. The aim of this multicenter study was to examine in a large cohort of patients with a variety of CHD 1) the age of onset and initial treatment of AF, co-existence of atrial tachyarrhythmia 2) progression of paroxysmal to (long-standing) persistent/permanent AF during long-term follow-up. -Patients (N=199) with 15 different CHD and documented AF episodes were studied. AF developed at 49±17 years. Regular atrial tachycardia (AT) co-existing with AF occurred in 65 (33%) patients; 65% initially presented with regular AT. At the end of a follow-up period of 5 (0-24) years, the ECG showed AF in 81 patients (41%). In a subgroup of 114 patients, deterioration from paroxysm of AF to (long-standing) persistent/permanent AF was observed in 29 patients (26%) after only 3 (0-18) years of the first AF episode. Cerebrovascular accidents/transient ischemic attacks occurred in 26 patients (13%), although a substantial number (N=16) occurred before the first documented AF episode. -Age at development of AF in CHD patients is relative young compared to patients without CHD. Co-existence of episodes of AF and regular AT occurred in a considerable number of patients; most of them initially presented with regular AT. The fast and frequent progression from paroxysmal to (long-standing) persistent or permanent AF episodes justifies close follow-up and early, aggressive therapy of both AT and AF.
Interactive CardioVascular and Thoracic Surgery, 2008
Delirium after cardiac surgery is a risk factor for adverse outcome and even death. Disturbance o... more Delirium after cardiac surgery is a risk factor for adverse outcome and even death. Disturbance of motor activity is a core feature of delirium, but hypoactive delirium often remains unrecognized. We explored wrist-actigraphy as a tool to objectively quantify postoperative recovery of 24-h rest-activity patterns to improve the early recognition of delirium after surgery. Motor activity was recorded by wrist-actigraphy after cardiac surgery in 88 patients over 65 years of age. Patients were assessed daily by using the CAM-ICU. Our final analyses were based on 32 non-delirious patients and 38 patients who were delirious on the first day after surgery. The delirious patients showed lower mean activity levels during the first postoperative night (P<0.05), reduced restlessness during the first day (P<0.05), and a lower mean activity of the 5 h with lowest activity within the first 24 h (P=0.01), as compared to the non-delirious patients. Already at a very early stage after cardiac surgery, a difference in motor activity was observed between patients with and without a delirium. As an unobtrusive method, actigraphy has the potential to be a screening method that may lead to early diagnosis and treatment of delirium.
More than 20% of patients of 65 years or older may develop a delirium after cardiac surgery. Pati... more More than 20% of patients of 65 years or older may develop a delirium after cardiac surgery. Patients with delirium frequently show a disturbed 24-hr motor activity pattern, but objective and quantitative data are scarce. Our aim was to quantify motor activity patterns in elderly patients with or without a postcardiotomy delirium after elective cardiac surgery. Wrist-actigraphy was used to quantify 24-hr motor activity patterns for a 5-day period following cardiac surgery in 79 patients of 65 years or older. Clinical state was monitored daily by means of the Confusion Assessment Method-Intensive Care Unit and the Delirium Rating Scale-Revised 98. The activity Amplitude, and the daytime Activity/minute and Restlessness index were significantly higher and the daytime number of Immobility minutes significantly lower for the patients without delirium or with short delirium episodes, as compared to patients with a sustained delirium (>3 days). Actigraphy proves to be a valuable instrument for evaluating motor activity patterns in relation to clinical state in patients with a postcardiotomy delirium.
The Journal of thoracic and cardiovascular surgery
To report the results of aortic root reoperations after pulmonary autograft implantation. All con... more To report the results of aortic root reoperations after pulmonary autograft implantation. All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technica...
The study aims to report results of re-operations after aortic allograft root implantation. All c... more The study aims to report results of re-operations after aortic allograft root implantation. All consecutive patients in our prospective allograft database, who underwent aortic allograft root implantation, were selected for analysis, and additional information for patients who subsequently underwent re-operation was obtained from hospital records. From 1989 to 2009, 262 aortic allograft root implantations were performed. Thirty-day mortality was 5.7%. During follow-up, 69 patients died. The actuarial survival was 77.0% (95% confidence interval (CI) 71-83%) after 10 years, and 65.1% (95% CI 57-74%) after 14 years. A total of 52 patients required re-operation. The actuarial freedom from allograft re-operation was 82.9% (Standard Error (SE) 2.9%) after 10 years and 55.7% (SE 5.7%) after 14 years. The actuarial median time to re-operation was 14.8 years. The indications for re-operation were structural valve dysfunction in 46 patients, endocarditis in two patients and non-structural valve dysfunction in four patients. The re-operations included 23 aortic valve replacements (mechanical prostheses 20 and bioprostheses 3), 27 aortic root replacements (mechanical conduits 21, aortic allografts five, and biological conduit one), one trans-apical valve implantation and one primary closure of a false aneurysm. The additional procedures were mitral valve repair (N = 5), mitral valve replacement (N = 1), ascending aortic replacement (N = 5), and coronary artery bypass grafting (CABG) (N = 4; in two patients unforeseen). Thirty-day mortality after re-operation occurred in two patients (3.9%). Five patients died during follow-up. The survival after re-operation was 87.1% (SE 5.5%) after 1 year and 79.3% (SE 7.4%) after 9 years. Re-operations after aortic allograft root implantation will be required in a substantial and growing number of patients. These re-operations, although technically demanding, can be performed with satisfying results.
Thoracic and Cardiovascular Surgeon - THORAC CARDIOVASC SURG, 1990
Four patients are described with pulmonary atresia and ventricular septal defect, in whom the pul... more Four patients are described with pulmonary atresia and ventricular septal defect, in whom the pulmonary circulation was dependent on a fistula from the left coronary artery to the pulmonary artery. The issue in this complex anomaly is complete preoperative diagnosis, including anatomic information on the coronary artery fistula and the pulmonary vasculature. This was achieved in the last 2 patients. In the last patient echocardiography turned out to be an important diagnostic tool in this rare anomaly and facilitated selective angiocardiography. All 4 patients were successfully operated by closing the fistula, closing other aortopulmonary connections and inserting a valved conduit between right ventricle and pulmonary artery. The ventricular septal defect was closed in 3 patients with a patch. In the setting of an already existing pulmonary hypertension and a possibly inadequate pulmonary arterial system at surgery, a perforated patch was inserted in the ventricular septal defect of the remaining patient.
Twenty-three patients underwent cardiac surgery for valve replacement, valve reconstruction, aort... more Twenty-three patients underwent cardiac surgery for valve replacement, valve reconstruction, aorto-coronary bypass grafting, aneurysmectomy or combinations of these. Excised cardiac tissue was obtained from left ventricular (LV) papillary muscle (17 patients), LV outflow tract (3 patients), or LV aneurysms (3 patients). A total of 34 myocardial samples, collected from excised cardiac tissue, were analysed for creatine kinase (CK), CK-isoenzymes, cytoplasmic and mitochondrial isoenzymes of aspartate aminotransferase (cAST and mAST, respectively), and lactate dehydrogenase (LDH) isoenzymes. Myocardial CK activity correlated positively with preoperative LV ejection fraction (p less than 0.001), negatively with the preoperatively measured extent of LV wall motion abnormalities (p less than 0.001), and negatively with preoperative LVEDP (p less than 0.02). Myocardial CK activity was negatively correlated with preoperative validity class (p less than 0.005). However, no correlation existed between myocardial CK activity and postoperative validity. Excluding the biopsies from LV aneurysms, myocardial CK activity was positively correlated with the fraction H-subunits in LDH (p = 0.02), and was negatively correlated with the fraction mAST in total AST (p less than 0.005). While cAST activity was proportional to CK activity in the biopsies from VL papillary muscle and LV outflow tract, mAST activity declined only with 2.4 +/- 1.2% per 10% fall of CK. The increase of mAST/cAST ratio with decreasing CK, together with the decrease of LDH-H/LDH and CK-M/CK ratios with decreasing CK, indicated the presence of an adaptation process in a myocardium with low CK activity rather than a process of necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)
To investigate the timing of surgery in active infective endocarditis, the data of 54 patients, c... more To investigate the timing of surgery in active infective endocarditis, the data of 54 patients, consecutively operated for this reason from September 1973 to May 1989, were analysed. Native valves were involved in 31 patients (57%): the aortic valve in 22, the mitral valve in 6, and both valves in 3 cases. Prosthetic valves were involved in 23 patients (43%): the aortic valve in 14, the mitral valve in 7, and both valves in 2 cases. There were no significant differences between involvement of native or prosthetic valves and mortality, morbidity, or consequences of morbidity. No significant correlation was found between causative microorganism and mortality, morbidity, or consequences of morbidity. The indication for operation was cardiac failure in 15 patients (28%), ongoing infection in 24 (44%) or a combination of these in 15 (28%). Major embolization occurred in 12 patients (22%) and affected women more than men (p = 0.05). Hospital mortality was 8 (15%). Morbidity involved 15 more patients; structural deterioration of the valve prosthesis occurred in 1 patient; nonstructural dysfunction of the valve prosthesis occurred 11 times in 10 patients; anticoagulation-related hemorrhage involved 2 patients (1 with nonstructural dysfunction of the valve prosthesis); endocarditis was diagnosed in 3 patients. The consequences of these morbid events concerned 14 patients; reoperations were done 9 times in 8 patients; mortality was valve related in 6 cases. Because 2 more patients died during the course of the study, total late mortality was 8. Probability of survival 5 years after operation was 72% (95% cl 56-83) and at 10 years 47% (95% cl 21-70).(ABSTRACT TRUNCATED AT 250 WORDS)
In 2 patients, a lusoric artery was compressing the mediastinal structures during a one-stage rep... more In 2 patients, a lusoric artery was compressing the mediastinal structures during a one-stage repair of type B aortic arch interruption and ventricular septal defect. In order to prevent the long-term complications of sacrifice of the subclavian artery, the lusoric artery was not simply divided but converted into a regular right subclavian artery by re-implantation of the abberant vessel at the origin of the right carotid artery during the one-stage repair. At follow up, both patients have normal right radial arterial pulsations. In one patient, angiography was repeated and confirmed a well functioning right subclavian artery. Conversion of a lusoric artery into a right subclavian artery during one-stage repair of aortic arch anomalies and intracardiac defects is not only feasible but also indicated to preserve subclavian artery function and to prevent compression of the mediastinal structures by a vascular ring.
A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhim... more A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhimurium in a patient on immunosuppressive therapy following kidney transplantation. After initial medical treatment, surgery consisted of local debridement and implantation of an aortic prosthesis. Lifelong antibiotic treatment was prescribed because of the combination of immunosuppressive therapy, the history of recurrent S. typhimurium bacteremia and the presence of an aortic prosthesis.
Objective. Valvotomy and the autograft procedure are the most common surgical treatment options f... more Objective. Valvotomy and the autograft procedure are the most common surgical treatment options for children with valvular aortic stenosis. We evaluated the results of these surgical procedures in our institution.
A patient with Cantrell's syndrome is presented with ectopia cordis, ventricular septal d... more A patient with Cantrell's syndrome is presented with ectopia cordis, ventricular septal defect and a left ventricular as well as a right ventricular diverticulum. One-stage correction was performed with resection of both diverticula. Closure of the ventricular septal defect was complicated due to exposure problems as a result of the malposition of the heart. Although the presentation of Cantrell's syndrome can be variable, one-stage repair is technically feasible and should be considered as the treatment of choice in this rare syndrome.
Joint Commission journal on quality and patient safety / Joint Commission Resources, 2006
Six Sigma, a process-focused strategy and methodology for business improvement, can be used to im... more Six Sigma, a process-focused strategy and methodology for business improvement, can be used to improve care processes, eliminate waste, reduce costs, and enhance patient satisfaction. Six Sigma was introduced in 2001 at the 384-bed Red Cross Hospital (Beverwijk). During the Green Belt training, every participant was required to participate in at least one Six Sigma project. The hospital's total savings in 2004 amounted to 1.4 million dollars, for an average savings of 67,000 dollars for each of the completed 21 projects. In one project, the team designed a new admission process for the operating rooms, resulting in an average starting time nine minutes earlier. This relatively minor improvement made it possible to operate on an additional 400 patients a year and to achieve a net savings of >273,000 dollars. A second project reduced the number of patients receiving intravenous (IV) antibiotics by switching to oral administration, yielding annual savings, based on medication co...
Background: The ideal substitute for a diseased aortic valve remains unclear. Usually, the aortic... more Background: The ideal substitute for a diseased aortic valve remains unclear. Usually, the aortic full root replacement (FRR) technique is used, in which the native aortic root is removed and entirely replaced with the homograft aortic root, the coronary arteries being reimplanted into the homograft. The aim of the present study was to examine alterations in aortic size and stiffness in patients after FRR. Methods and patients: The study comprised 13 patients (mean age 46 ± 15 years, 10 males) who underwent FRR because of acute aortic regurgitation due to endocarditis in 6 patients (46%) and aortic valve stenosis with or without regurgitation in 7 patients (54%). These patients underwent transthoracic two-dimensional echocardiography before FRR, before discharge (9 ± 8 days post-FRR), and 6 months and 24 months after FRR. Systolic and diastolic ascending aortic diameters were recorded in M-mode at the middle of the ascending aorta, 3 to 4 cm above the aortic valve from a parasternal long-axis view. An aortic stiffness index (β) was calculated. The results were compared to 13 age-, gender-and risk factor-matched controls. Results: The aortic stiffness index first non-significantly deteriorated from 12.7 ± 8.1 to 16.4 ± 9.1 immediately after FRR. Subsequently, an improvement to 14.2 ± 7.1 (after 6 months) and 7.1 ± 4.8 (after 24 months, P b 0.05) was seen. Conclusions: FRR is associated with a transient immediate post-FRR deterioration followed by a progressive improvement in aortic distensibility.
Circulation: Arrhythmia and Electrophysiology, 2015
-The incidence of atrial fibrillation (AF) is rising in the aging patients with congenital heart ... more -The incidence of atrial fibrillation (AF) is rising in the aging patients with congenital heart disease (CHD). However, studies reporting on AF in CHD patients are scarce. The aim of this multicenter study was to examine in a large cohort of patients with a variety of CHD 1) the age of onset and initial treatment of AF, co-existence of atrial tachyarrhythmia 2) progression of paroxysmal to (long-standing) persistent/permanent AF during long-term follow-up. -Patients (N=199) with 15 different CHD and documented AF episodes were studied. AF developed at 49±17 years. Regular atrial tachycardia (AT) co-existing with AF occurred in 65 (33%) patients; 65% initially presented with regular AT. At the end of a follow-up period of 5 (0-24) years, the ECG showed AF in 81 patients (41%). In a subgroup of 114 patients, deterioration from paroxysm of AF to (long-standing) persistent/permanent AF was observed in 29 patients (26%) after only 3 (0-18) years of the first AF episode. Cerebrovascular accidents/transient ischemic attacks occurred in 26 patients (13%), although a substantial number (N=16) occurred before the first documented AF episode. -Age at development of AF in CHD patients is relative young compared to patients without CHD. Co-existence of episodes of AF and regular AT occurred in a considerable number of patients; most of them initially presented with regular AT. The fast and frequent progression from paroxysmal to (long-standing) persistent or permanent AF episodes justifies close follow-up and early, aggressive therapy of both AT and AF.
Interactive CardioVascular and Thoracic Surgery, 2008
Delirium after cardiac surgery is a risk factor for adverse outcome and even death. Disturbance o... more Delirium after cardiac surgery is a risk factor for adverse outcome and even death. Disturbance of motor activity is a core feature of delirium, but hypoactive delirium often remains unrecognized. We explored wrist-actigraphy as a tool to objectively quantify postoperative recovery of 24-h rest-activity patterns to improve the early recognition of delirium after surgery. Motor activity was recorded by wrist-actigraphy after cardiac surgery in 88 patients over 65 years of age. Patients were assessed daily by using the CAM-ICU. Our final analyses were based on 32 non-delirious patients and 38 patients who were delirious on the first day after surgery. The delirious patients showed lower mean activity levels during the first postoperative night (P<0.05), reduced restlessness during the first day (P<0.05), and a lower mean activity of the 5 h with lowest activity within the first 24 h (P=0.01), as compared to the non-delirious patients. Already at a very early stage after cardiac surgery, a difference in motor activity was observed between patients with and without a delirium. As an unobtrusive method, actigraphy has the potential to be a screening method that may lead to early diagnosis and treatment of delirium.
More than 20% of patients of 65 years or older may develop a delirium after cardiac surgery. Pati... more More than 20% of patients of 65 years or older may develop a delirium after cardiac surgery. Patients with delirium frequently show a disturbed 24-hr motor activity pattern, but objective and quantitative data are scarce. Our aim was to quantify motor activity patterns in elderly patients with or without a postcardiotomy delirium after elective cardiac surgery. Wrist-actigraphy was used to quantify 24-hr motor activity patterns for a 5-day period following cardiac surgery in 79 patients of 65 years or older. Clinical state was monitored daily by means of the Confusion Assessment Method-Intensive Care Unit and the Delirium Rating Scale-Revised 98. The activity Amplitude, and the daytime Activity/minute and Restlessness index were significantly higher and the daytime number of Immobility minutes significantly lower for the patients without delirium or with short delirium episodes, as compared to patients with a sustained delirium (>3 days). Actigraphy proves to be a valuable instrument for evaluating motor activity patterns in relation to clinical state in patients with a postcardiotomy delirium.
The Journal of thoracic and cardiovascular surgery
To report the results of aortic root reoperations after pulmonary autograft implantation. All con... more To report the results of aortic root reoperations after pulmonary autograft implantation. All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technica...
The study aims to report results of re-operations after aortic allograft root implantation. All c... more The study aims to report results of re-operations after aortic allograft root implantation. All consecutive patients in our prospective allograft database, who underwent aortic allograft root implantation, were selected for analysis, and additional information for patients who subsequently underwent re-operation was obtained from hospital records. From 1989 to 2009, 262 aortic allograft root implantations were performed. Thirty-day mortality was 5.7%. During follow-up, 69 patients died. The actuarial survival was 77.0% (95% confidence interval (CI) 71-83%) after 10 years, and 65.1% (95% CI 57-74%) after 14 years. A total of 52 patients required re-operation. The actuarial freedom from allograft re-operation was 82.9% (Standard Error (SE) 2.9%) after 10 years and 55.7% (SE 5.7%) after 14 years. The actuarial median time to re-operation was 14.8 years. The indications for re-operation were structural valve dysfunction in 46 patients, endocarditis in two patients and non-structural valve dysfunction in four patients. The re-operations included 23 aortic valve replacements (mechanical prostheses 20 and bioprostheses 3), 27 aortic root replacements (mechanical conduits 21, aortic allografts five, and biological conduit one), one trans-apical valve implantation and one primary closure of a false aneurysm. The additional procedures were mitral valve repair (N = 5), mitral valve replacement (N = 1), ascending aortic replacement (N = 5), and coronary artery bypass grafting (CABG) (N = 4; in two patients unforeseen). Thirty-day mortality after re-operation occurred in two patients (3.9%). Five patients died during follow-up. The survival after re-operation was 87.1% (SE 5.5%) after 1 year and 79.3% (SE 7.4%) after 9 years. Re-operations after aortic allograft root implantation will be required in a substantial and growing number of patients. These re-operations, although technically demanding, can be performed with satisfying results.
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