Risk stratification with cardiac troponin I in patients undergoing elective coronary artery bypass surgery.

OBJECTIVE: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for postoperative prediction of patients outcome after coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients scheduled for elective CABG is currently unknown. METHODS: Therefore, a possible correlation between preoperative cTnI levels and perioperative major adverse events and in-hospital mortality after CABG was investigated. CTnI was measured within 24h before surgery in 1405 out of 3124 consecutive elective CABG patients. Out of these patients, 1178 had a preoperative cTnI level below 0.1ng/ml (group 1), 163 patients had a cTnI level between 0.11 and 1.5ng/ml (group 2), and 64 patients had a cTnI level above 1.5ng/ml (group 3). CTnI levels, electrocardiograms, clinical data, adverse events and in-hospital mortality were recorded prospectively. Patients with ST-elevation myocardial infarction less than 7 days before surgery were excluded from the study. RESULTS: Perioperative myocardial infarction (PMI) occurred in 69/1178 patients (5.9%) in group 1, 14/163 patients (8.6%; odds ratio (OR) 1.5, 95% confidence interval (CI): 0.8-2.8) in group 2, and 11/64 patients (17.2%; OR 3.3, CI: 1.6-7.0) in group 3 (overall: P<0.001, Cochran-Armitage trend test). Low cardiac output syndrome (LCOS) occurred in 19/1178 patients (1.6%), 9/163 (5.5%; OR 3.6, CI: 1.5-8.5), and 7/64 patients (10.9%; OR 7.5, CI: 2.7-19.8) (overall: P<0.001, group 1 vs. group 2: P<0.002), respectively. In-hospital mortality was 1.7% in group 1 and 3.1% in group 2, but 6.3% (OR 3.9, CI: 1.1-12.5) in group 3 (overall: P<0.01, group 1 vs. group 2: P=NS). Intensive care and hospital stay were significantly longer in group 3 compared to groups 1 and 2. Univariate and multivariate logistic regression analysis confirmed the statistically significant relationship between cTnI and PMI, LCOS and in-hospital mortality, respectively (P<0.001). CONCLUSIONS: Risk stratification by measurement of cTnI levels within 24h before elective CABG clearly identifies a subgroup of patients with increased risk for postoperative adverse outcome and in-hospital mortality.     

Excellent results of cardiac surgery in patients with previous liver transplantation.

Cardiovascular diseases requiring surgical therapy in patients with prior liver transplantation are rare. Little is known about the outcome of patients with liver allograft undergoing cardiac surgery. Herein we report our experience in this patient population with an emphasis on operative outcomes and mid-term survival. Between January 1998 and December 2004, 12 patients (mean +/- standard deviation age 68 +/- 9 years, 7 [58%] male) with previous liver transplantation who underwent cardiac surgery were identified. Main outcome measures were hospital mortality, postoperative complications, allograft function, and long-term survival. There was no in-hospital mortality. Three major complications (25%) occurred, including 1 each (8%) of respiratory failure, renal failure, and biliary leakage. All complications were resolved by the time of discharge. Allograft dysfunction determined by an increase of liver function parameters was noticed in 4 (33%) and recovered before discharge. The average length of stay in intensive care unit was 72 +/- 45 hours, and the mean length of stay in hospital was 22 +/- 17 days. One- and 5-year survival was 91% +/- 8% and 67% +/- 14%, respectively. Cardiac surgery can be performed safely in liver transplant recipients with extremely low mortality and acceptable morbidities. Allograft dysfunction is a common finding, but it is transient, with early functional recovery. Five-year survival of liver recipients undergoing cardiac procedures is similar to that of the general population undergoing cardiac surgery. Our data suggest that these patients should be considered for cardiac surgery in reference centers with expertise in complex cardiac procedures and perioperative management of these highly specific patients.     

Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center

Peripartum cardiomyopathy (PPCM) occurs toward the end of pregnancy or in the months after delivery without previously known structural heart disease. Development of therapy-refractory cardiogenic shock is described in the literature with a limited number of overall presented cases in this young patient cohort. To provide differences and key points in the therapy of end-stage PPCM patients, we present a case series of four young women with PPCM referred to our department for potential VA ECMO support.     

Endoskopische Ohrchirurgie in Deutschland

HNO - International hat sich die endoskopische Ohrchirurgie (?endoscopic ear surgery“, EES) fest etabliert. In Deutschland wird sie kontrovers diskutiert und unterschiedlich angewendet....     

Chirurgische Therapie der fulminanten Lungenembolie

Zusammenfassung Die fulminante Lungenembolie wird nur noch selten chirurgisch behandelt. Die Operation wird als „Ultima-Ratio“-Therapie insbesondere bei Patienten mit kardiopulmonaler Reanimation angesehen. Vor dem Hintergrund eines erheblichen Anteils von Patienten mit residualer Obstruktion nach Lysetherapie mit der Gefahr der Entwicklung einer chronischen pulmonalen Hypertonie und besserer Risikostratifizierung haben einzelne Zentren wieder mehr Patienten einer offenen chirurgischen Embolektomie zugeführt. Hier sind Überlebensraten bis 89% in der perioperativen Phase erzielt worden. Möglich war dies durch Operationen am schlagenden, normothermen Herzen unter Verwendung spezieller Instrumente, wie sie bei der Pulmonalisthrombendarteriektomie Verwendung finden. Die Bestätigung dieser guten Ergebnisse bei noch hämodynamisch stabilen Patienten mit mäßiger bis starker Einschränkung der rechtsventrikulären Funktion durch die Autoren und andere rechtfertigt den Einsatz dieses Verfahrens an Kliniken mit angeschlossener Herzchirurgie in einer früheren Phase, in welcher der Patient noch nicht reanimationspflichtig ist. Die Durchführung einer kontrollierten, randomisierten Studie zur Erfassung des tatsächlichen Stellenwerts im Vergleich zur Lysetherapie wäre wünschenswert im Sinne einer bestmöglichen Therapie für den Patienten. Abstract Surgical embolectomy for massive pulmonary embolism (PE) has become a rare procedure. Often, it is viewed as a last-chance option for patients undergoing cardiopulmonary resuscitation after massive PE. Thus thrombolytic therapy has become the treatment of choice. However, a significant proportion of patients suffers from residual obstruction after thrombolytic therapy and faces the development of chronic pulmonary hypertension. Therefore, some centers have regained interest in surgical embolectomy after improved risk stratification and reported very good results. Perioperative survival rates up to 89% have been reported. This was accomplished by surgery on the ECC-(extracorporeal circulation-)supported, beating, normothermic heart and utilization of special instruments. These encouraging results have been confirmed by the authors and others in patients with stable systemic hemodynamics but moderate to severe right ventricular dysfunction. The more widespread use of surgical embolectomy seems warranted. A randomized, controlled trial is overdue to determine the benefits of this therapy in stable patients compared with thrombolytic therapy if “best-practice” therapy is to be achieved for the patients’ benefit.     

Beneficial effect of sodium nitroprusside after coronary artery bypass surgery: pump function correlates inversely with cardiac release of proinflammatory cytokines

The authors studied the relationship between cardiac cytokine release and pump function and whether low-dose application of sodium nitroprusside (SNP) improves cardiac performance during coronary artery bypass graft (CABG) creation. Cardiac reperfusion and application of nitric oxide have an influence on cytokine release. However, the functional consequences are unclear. Patients with CABGs (n = 30) with severely compromised left ventricular ejection fraction (<40%) were treated with either SNP (0.5 microg/kg/min) or placebo for the first 60 minutes of reperfusion after cardiac arrest. Interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-alpha were determined in blood samples from the radial artery and coronary sinus during reperfusion (5, 35, and 75 minutes). Hemodynamic measurements were performed before and after cardiopulmonary bypass and at the end of surgery. In all patients, the cardiac index at the end of surgery correlated negatively with levels of TNF-alpha at 5 minutes (r = 0.398; P < 0.05), IL-8 at 35 minutes (r = 0.394; P < 0.05), and IL-6 at 75 minutes of reperfusion (r = 0.421; P < 0.025). Sodium nitroprusside improved the cardiac index immediately after reperfusion (4.4 L/min/m2 +/- 0.3 vs. 3.7 L/min/m2 +/- 0.1; P = 0.014) and at the end of surgery (3.8 L/min/m2 +/- 0.3 vs. 3.0 L/min/m2 +/- 0.2; P = 0.023). The negative correlation between cardiac index and transcardiac cytokines suggests that reducing cardiac inflammatory reaction improves postischemic cardiac function. This was achieved by treating CABG patients with the nitric oxide donor SNP at a dosage without vasodilatory action.     

Perfusing and ventilating the patient's lungs during bypass ameliorates the increase in extravascular thermal volume after coronary bypass grafting

BACKGROUND: To test the hypothesis that bilateral extracorporeal circulation (ECC) (Drew technique) ameliorates the increase in extravascular thermal volume (ETV) observed after conventional cardiopulmonary bypass (CPB) in patients undergoing coronary artery bypass grafting. METHODS: Thirty-four consecutive patients underwent either bilateral ECC (n = 24, additional cannulation of pulmonary artery and left atrium and lungs perfused and ventilated during bypass) or conventional CPB (n = 10, right atrial and aortic cannulation, lungs statically inflated to 4 mbar (0.41 cm H(2)O) with oxygen, 500 mL/min). Determinations of ETV (thermodye dilution technique) and intraoperative fluid balance were made before surgery, at the end of surgery, and 4 hours thereafter. In addition, interleukin (IL)-8, thromboxane B2 (TxB(2)), and endothelin (ET)-1 concentrations were measured in the right atrium and pulmonary vein at specified time points. RESULTS: Comparisons of ETV made at the start of surgery, after aortic declamping, and after termination of ECC, respectively, revealed an increase from 4.8 +/- 0.2 mL/kg (mean +/- SEM) to 6.7 +/- 0.4 mL/kg, and 6.3 +/- 0.3 mL/kg with conventional CPB but ETV remained unchanged at 5.2 +/- 0.3 mL/kg, 5.1 +/- 0.2 mL/kg, and 4.9 +/- 0.3 mL/kg with bilateral ECC. Priming volume (1,580 +/- 10 mL versus 2,213 +/- 77 mL, p < 0.001) and intraoperative fluid balance (+1,955 +/- 233 mL versus +2,654 +/- 210 mL, p < 0.05) were less with conventional CPB. Concentrations of IL-8, TxB(2), and ET-1 were not different between groups. CONCLUSIONS: Despite a significantly greater prime volume and a more positive intraoperative fluid balance, ETV did not change with bilateral ECC but increased with conventional CPB. Thus, using the patient's lungs as an oxygenator during bypass mitigates the increase in extravascular pulmonary fluid.