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- Klinik und Poliklinik für Thorax-, Herz- u. Thorakale Gefäßchirurgie (8) (remove)
Background:
There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT.
Methods:
Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted.
Results:
Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23–27 mm vs. 23 mm; IQR 21–25; p = 0.009).
Conclusions:
Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings.
Despite medical achievements, the number of patients with end-stage kidney disease keeps steadily raising, thereby entailing a high number of surgical and interventional procedures to establish and maintain arteriovenous vascular access for hemodialysis. Due to vascular disease, aneurysms or infection, the preferred access—an autogenous arteriovenous fistula—is not always available and appropriate. Moreover, when replacing small diameter blood vessels, synthetic vascular grafts possess well-known disadvantages. A continuous multilayered gradient electrospinning was used to produce vascular grafts made of collagen type I nanofibers on luminal and adventitial graft side, and poly-ɛ-caprolactone as medial layer. Therefore, a custom-made electrospinner with robust environmental control was developed. The morphology of electrospun grafts was characterized by scanning electron microscopy and measurement of mechanical properties. Human microvascular endothelial cells were cultured in the graft under static culture conditions and compared to cultures obtained from dynamic continuous flow bioreactors. Immunofluorescent analysis showed that endothelial cells form a continuous luminal layer and functional characteristics were confirmed by uptake of acetylated low-density-lipoprotein. Incorporation of vancomycin and gentamicin to the medial graft layer allowed antimicrobial inhibition without exhibiting an adverse impact on cell viability. Most striking a physiological hemocompatibility was achieved for the multilayered grafts.
Background
Chronic kidney disease (CKD) is a common comorbid condition in coronary heart disease (CHD). CKD predisposes the patient to acute kidney injury (AKI) during hospitalization. Data on awareness of kidney dysfunction among CHD patients and their treating physicians are lacking. In the current cross-sectional analysis of the German EUROASPIRE IV sample we aimed to investigate the physician’s awareness of kidney disease of patients hospitalized for CHD and also the patient’s awareness of CKD in a study visit following hospital discharge.
Methods
All serum creatinine (SCr) values measured during the hospital stay were used to describe impaired kidney function (eGFR\(_{CKD-EPI}\) < 60 ml/min/1.73m2) at admission, discharge and episodes of AKI (KDIGO definition). Information extracted from hospital discharge letters and correct ICD coding for kidney disease was studied as a surrogate of physician’s awareness of kidney disease. All patients were interrogated 0.5 to 3 years after hospital discharge, whether they had ever been told about kidney disease by a physician.
Results
Of the 536 patients, 32% had evidence for acute or chronic kidney disease during the index hospital stay. Either condition was mentioned in the discharge letter in 22%, and 72% were correctly coded according to ICD-10. At the study visit in the outpatient setting 35% had impaired kidney function. Of 158 patients with kidney disease, 54 (34%) were aware of CKD. Determinants of patient’s awareness were severity of CKD (OR\(_{eGFR}\) 0.94; 95%CI 0.92–0.96), obesity (OR 1.97; 1.07–3.64), history of heart failure (OR 1.99; 1.00–3.97), and mentioning of kidney disease in the index event’s hospital discharge letter (OR 5.51; 2.35–12.9).
Conclusions
Although CKD is frequent in CHD, only one third of patients is aware of this condition. Patient’s awareness was associated with kidney disease being mentioned in the hospital discharge letter. Future studies should examine how raising physician’s awareness for kidney dysfunction may improve patient’s awareness of CKD.
Background
40–50% of patients with colorectal cancer (CRC) will develop liver metastases (CRLM) during the course of the disease. One third of these patients will additionally develop pulmonary metastases.
Methods
137 consecutive patients with CRLM, were analyzed regarding survival data, clinical, histological data and treatment. Results were stratified according to the occurrence of pulmonary metastases and metastases resection.
Results
39% of all patients with liver resection due to CRLM developed additional lung metastases. 44% of these patients underwent subsequent pulmonary resection. Patients undergoing pulmonary metastasectomy showed a significantly better five-year survival compared to patients not qualified for curative resection (5-year survival 71.2% vs. 28.0%; p = 0.001). Interestingly, the 5-year survival of these patients was even superior to all patients with CRLM, who did not develop pulmonary metastases (77.5% vs. 63.5%; p = 0.015). Patients, whose pulmonary metastases were not resected, were more likely to redevelop liver metastases (50.0% vs 78.6%; p = 0.034). However, the rate of distant metastases did not differ between both groups (54.5 vs.53.6; p = 0.945).
Conclusion
The occurrence of colorectal lung metastases after curative liver resection does not impact patient survival if pulmonary metastasectomy is feasible. Those patients clearly benefit from repeated resections of the liver and the lung metastases.
Background/Aims:
Acute kidney injury (AKI) is a postoperative complication after cardiac surgery with a high impact on mortality and morbidity. Nephrocheck® [TIMP-2*IGFBP7] determines markers of tubular stress, which occurs prior to tubular damage. It is unknown at which time-point [TIMP-2*IGFBP7] measurement should be performed to ideally predict AKI. We investigated the association of [TIMP-2*IGFBP7] at various time-points with the incidence of AKI in patients undergoing elective cardiac surgery including cardio-pulmonary bypass.
Methods: In a prospective cohort study, serial blood and urine samples were collected from 150 patients: pre-operative, at ICU-admission, 24h and 48h post-surgery. AKI was defined as Serum-Creatinine rise >0.3 mg/dl within 48hrs. Urinary [TIMP-2*IGFBP7] was measured at pre-operative, ICU-admission and 24h post-surgery; medical staff was kept blinded to these results.
Results: A total of 35 patients (23.5%) experienced AKI, with a higher incidence in those with high [TIMP-2*IGFBP7] values at ICU admission (57.1% vs. 10.1%, p<0.001). In logistic regression [TIMP-2*IGFBP7] at ICU admission was independently associated with the occurrence of AKI (Odds Ratio 11.83; p<0.001, C-statistic= 0.74) after adjustment for EuroSCORE II and CBP-time.
Conclusions: Early detection of elevated [TIMP-2*IGFBP7] at ICU admission was strongly predictive for postoperative AKI and appeared to be more precise as compared to subsequent measurements.
Background:
Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation.
Methods:
Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered.
Results:
509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription.
Conclusions:
In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists.
Trial registration:
This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.
Background:
Mechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery.
Case Presentation:
We describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years—old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles.
He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up.
Conclusions:
The combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.
Im Rahmen der vorliegenden Studie an der Klinik und Poliklinik für Herz-, Thorax- und thorakale Gefäßchirurgie der Uniklinik Würzburg im Zeitraum von Januar 2010 bis Mai 2013 wurden 148 kardiochirurgische konsekutive Patienten mit Vorhofflimmern und Amputation des linken Vorhofohres retrospektiv untersucht. Zielsetzung war zu evaluieren inwiefern die Vorhofohramputation ein sicheres Verfahren darstellt.
2,7% des Patientenkollektivs erlitten perioperativ einen Apoplex. Die Tatsache, dass alle Patienten in der Aufwachphase bzw. direkt post extubationem mit einem fokal-neurologischen Defizit auffällig geworden waren und in allen Fällen ein ischämischer cerebraler Insult radiologisch nachweisbar war, legt nahe, dass es sich um embolische Infarkte im direkten Zusammenhang mit der Operation handelte. Die Apoplexpatienten, bei denen perioperativ eine TAA nachweisbar war (50%), hatten das cerebrale Ereignis bereits vor Auftreten der TAA. 50% der Apoplexpatienten entsprechen mit der Kombination aus operativer Myokardrevaskularisation und einem Eingriff an der Aortenklappe dem in der Literatur beschriebenen höchsten Risiko für einen Apoplex bei kardiochirurgischen Eingriffen [4]. Aufgrund der geringen Fallzahl der Studie war die Erhebung von bestimmten Risikoprofilen für das Auftreten eines Apoplex nicht möglich, auffällig war jedoch, dass 75% der Apoplexpatienten an intermittierendem Vorhofflimmern litten. Darüberhinaus zeigten die Apoplexpatienten eine signifikant (p=0,008) längere Nachbeatmungszeit. Eine Aussage über die Effektivität der Vorhofohramputation in Hinblick auf die Prophylaxe eines Apoplex ist in der vorliegenden Studie aufgrund des kurzen Beobachtungszeitraums bis zum Zeitpunkt der Entlassung nicht möglich. Zu diesem Zweck bedarf es weiteren Studien, in der das Patientenkollektiv postoperativ in Intervallen hinsichtlich eines cerebralen Insults und der Antikoagulation nachverfolgt wird.
Darüber hinaus kann - wie in der Literatur beschrieben – vermutet werden, dass Patienten mit präoperativem Vorhofflimmern ein erhöhtes perioperatives Mortalitäts- und Morbiditätsrisiko haben.
Die Letalität war mit 8,1% in der untersuchten Patientenkohorte deutlich höher als in der Literatur, bei genauerer Betrachtung der Auswahl der Patienten zeigt sich jedoch, dass das Einschlusskriterium der Diagnose Vorhofflimmern als Risikofaktor eine große Rolle spielt [4]. Des Weiteren wurde mit 11,8% bei den Kombinationsoperationen eine deutlich höhere Letalität im Gegensatz zu den isolierten CABG-OPs mit 4,8% festgestellt. Es konnte gezeigt werden, dass die perioperativ verstorbenen Patienten gemäß den Risikostratifizierungen aus der Literatur ein deutlich erhöhtes Risikoprofil für Morbidität besaßen [25-30]. Insbesondere das mit 76 (SD±9) Jahren signifikant (p=0,001) höhere Lebensalter der Patienten und die signifikant (0,001) längere Operationszeit, v.a. eine mit 197 Minuten (SD±11) signifikant längere EKZ-Dauer, scheinen eine entscheidende Rolle in der Betrachtung der perioperativen Morbidität zu spielen.
Eine TAA trat perioperativ bei 31,1% der Patienten auf. Im Hinblick auf eine Kardioversion konnte festgestellt werden, dass die medikamentöse Kardioversion 94,7% Sinusrhythmus bei Entlassung der elektrischen Kardioversion mit 61,1% Sinusrhythmus bei Entlassung überlegen war. Des Weiteren zeigte die vorliegende Studie, dass eine Cryoablation mit einer Steigerung der Rate an Sinusrhythmus von präoperativ 53,0% auf 69,7% bei Entlassung erfolgreich zu sein scheint. Zur weiteren Evaluation der Cryoablation müssen jedoch gesonderte Studien durchgeführt werden, da in der vorliegenden Studie zu beachten ist, dass sowohl Patienten mit chronischem Vorhofflimmern als auch Patienten mit intermittierendem Vorhofflimmern berücksichtigt wurden.
Die Revisionsrate aufgrund einer Blutung war mit 7,4% höher als Vegleichswerte in der Literatur [37-39]. Die Kombinationsoperationen hatten mit 11,3% eine mehr als doppelt so hohe Revisionsrate als die isolierten Koronarchirurgieeingriffe mit 3,9%. Herzchirurgische Kombinationseingriffe werden in der Literatur mit einem erhöhten Revisionsrisiko beschrieben. In der vorliegenden Studie scheint, wie auch in der Literatur [40,41], die Dauer der Herzlungenmaschinenzeit eine Rolle zu spielen. In der vorliegenden Studie war diese mit 152 Minuten (±52,35) bei den Kombinationsoperationen im Gegensatz zu 106 Minuten (±54,76) bei den isolierten CABG-OPs deutlich länger und entspricht mit >150 Minuten auch einer in der Literatur beschriebenen Zeitgrenze für ein signifikant höheres Risiko einer Revision [41].
Auf der Basis der im Rahmen dieser Untersuchung genannten Ergebnisse kann davon ausgegangen werden, dass die chirurgische Amputation des linken Vorhofohres ein sicheres Verfahren ist, das die Operationszeit nur unwesentlich verlängert. Inwieweit die chirurgische Vorhofohramputation auch einen benefiziellen Aspekt im Sinne der Reduktion der Rate von postoperativ neuaufgetretenen Apoplexen eine Rolle spielt bzw. das Verzichten auf eine Antikoagulationstherapie bei Patienten mit Vorhofflimmern möglich macht, müssen weiterführende prospektiv-randomisierte Studien zeigen.