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.     

Expression patterns and functional evaluation of the UNC5B receptor during the early phase of peripheral nerve regeneration using the mouse median nerve model

Introduction: In this study, we evaluated the role of the Netrin‐1 receptor UNC5b (Uncoordinated), a neuronal guidance molecule, during peripheral nerve regeneration using the mouse median nerve model. Materials and methods: Using Western blot analysis, we examined the expression changes of UNC5b after transection and microsurgical repair of the mouse median nerve distal to the transection site. We evaluated the histomorphometrical changes and functional recovery of the grasping force after median nerve transection and repair in wild‐type (WT) mice and UNC5b^+/? heterozygous mice. Results: In Western blot analysis, we could show a high increase of UNC5b in the nerve segment distal to the injury site at day 14. Histomorphometrical analysis did not show any significant differences between WT animals and heterozygous animals. Using the functional grasping test, we could demonstrate that peripheral nerve regeneration is significantly diminished in heterozygous UNC5b^+/? mice. Conclusion: By using the mouse median nerve model in transgenic animals, we demonstrate that the Netrin‐1 receptor UNC5b plays an important role during peripheral nerve regeneration. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

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....     

Mitralklappenersatz mit Erhalt des subvalvulären Apparats

Despite the fact that mitral valve repair has become the most common approach in the treatment of mitral valve disease, particularly mitral regurgitation, prosthetic mitral valve replacement remains a standard procedure in cardiac surgery patients. After initial controversies regarding the importance of preservation of the subvalvular apparatus, it is today common sense that mitral valve replacement with partial or complete preservation of subvalvular structures is associated with an improved outcome. This article is intended to provide information about general techniques of mitral valve replacement, to describe the importance of the subvalvular structures for left ventricular function, and to discuss different approaches for the preservation of the subvalvular apparatus.     

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.