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M Rothenburger,
J Stypmann,
C Bruch,
T Wichter,
M Hoppe,
G Drees, E Berendes,
G Huelsken,
A Loeher,
H Welp,
C Röttger,
C Schmid,
H H Scheld,
T D T Tjan
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ABSTRACT: Aminoterminal B-type pro-natriuretic peptide (NT-proBNP) is a reliable indicator of heart failure severity. Levels of NT-proBNP are markedly increased in patients with coronary artery disease (CAD) and severely impaired left ventricular (LV) function. The aim of our study was to assess the impact of NT-proBNP levels after high-risk coronary artery bypass grafting (CABG) with regard to recovery potential.
Between 1998 and 2004, 121 patients with CAD and severely impaired LV function, who were undergoing CABG, were investigated. Their mean age was 64 +/- 11 years. All patients were in New York Heart Association (NYHA) Class III/IV status; LV ejection fraction (EF) was 20 +/- 6%. All survivors underwent follow-up (59 +/- 34 months) spiroergometric, electrocardiographic (ECG) and echocardiographic assessment and were tested for routine blood controls and NT-proBNP levels (Roche, Mannheim, Germany).
The survival rate after 8 years was 70%. All survivors received follow-up assessment. Among survivors the median NT-proBNP level at follow-up was 896 (521 to 1,687) pg/ml. The maximum oxygen uptake was 14.6 +/- 4.9 ml/min/kg, and EF increased to 42% at follow-up among all survivors. On dichotomizing survivors into two groups with NT-proBNP levels above and below the median, the post-operative body mass index was significantly higher in the high NT-proBNP group (p = 0.036). EF (p = 0.028) and NYHA classification (p < 0.05) improved significantly in both groups, with a tendency toward higher EF in the low NT-proBNP group.
Patients undergoing a high-risk CABG procedure have a survival rate comparable to heart transplantation patients and show a potential for clinical and myocardial recovery. NT-proBNP use a useful marker for recovery after a high-risk CABG procedure, with significant correlation with clinical parameters.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 05/2006; 25(5):596-602. · 3.54 Impact Factor
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ABSTRACT: Impedance cardiography (ICG) has been used extensively to estimate stroke volume (SV) and cardiac output (CO) from changes of thoracic electrical bioimpedance (TEB). However, studies comparing ICG with reference methods have questioned the reliability of this approach. Electrical velocimetry (EV) provides a new algorithm to calculate CO from variations in TEB. As the transoesophageal Doppler echocardiographic quantification of CO (TOE-CO) has emerged as a reliable method, the purpose of this study was to determine the limits of agreement between CO estimations using EV (EV-CO) and TOE-CO.
Standard ECG electrodes were used for non-invasive EV-CO measurements. These were placed on 37 patients scheduled for coronary artery surgery necessitating transoesophageal echocardiography monitoring. Simultaneous EV-CO and TOE-CO measurements were recorded after induction of anaesthesia. EV-CO was calculated using the Bernstein-Osypka equation. TOE-CO was measured across the aortic valve using continuous-wave Doppler echocardiography and a triangular orifice model.
A significant high correlation was found between the TOE-CO and the EV-CO measurements (r2=0.86). Data were related linearly. The slope of the line (1.10 (se 0.07)) was not significantly different from unity, and the point at which it intersected the ordinate (-0.46 (0.32) litre min(-1)) was not significantly different from zero. Bland-Altman analysis revealed a bias of 0.18 litre min(-1) with narrow limits of agreement (-0.99 to 1.36 litre min(-1)).
The agreement between EV-CO and TOE-CO is clinically acceptable, and these two techniques can be used interchangeably.
BJA British Journal of Anaesthesia 12/2005; 95(5):603-10. · 4.24 Impact Factor
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Baillière' s Best Practice and Research in Clinical Anaesthesiology 10/2005; 19(3):391-7.
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ABSTRACT: Substantial research using echocardiography has established that stroke volume (SV) or cardiac output (CO) can be measured non-invasively at the level of the aortic valve (AV) with high accuracy. Stroke volume is the product of the velocity time integral occurring at the sampling site and the effective systolic AV orifice area (AVOAeff). Nevertheless, a generally accepted method for the determination of AVOAeff is still lacking.
Aortic valve OAeff was measured in 228 consecutive patients scheduled for coronary artery surgery. Two widely adopted methods were applied to approximate the constantly changing orifice area of the AV: (1) the circular orifice model (AVOA-CM), and (2) the triangular orifice model (AVOA-TM). Aortic valve OA-CM assumes the shape of a circle as an appropriately time averaged geometrical model, and AVOA-TM takes the shape of an equilateral triangle for granted.
The AV was easily imaged by echocardiography in both short- and long-axis views in all patients. Relying on AVOA-CM, AVOAeff was 3.49+/-0.77 cm2. AVOA-TM estimates were 2.80+/-0.55 cm2 (mean+/-SD). The results did not agree (bias analysis).
The echocardiographic measurement of SV or CO at the level of the AV has to be reconsidered.
Acta Anaesthesiologica Scandinavica 10/2005; 49(8):1135-41. · 2.19 Impact Factor
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A. Hoffmeier,
M. E. Bode,
A. Löher,
T. D. T. Tjan,
G. Drees,
C. Schmid,
E. M. Fallenberg,
L. Hertle, E. Berendes,
O. A. Brinkmann,
H. H. Scheld
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ABSTRACT: Bei 5–10% der Patienten mit Nierentumoren wird eine Beteiligung im Sinne einer Infiltration oder eines intraluminalen Tumorwachstums in der Vena cava inferior (VCI) und/oder des rechten Vorhofes beobachtet. Wenn der Nierentumor einen sogenannten Cavazapfen gebildet hat, nimmt die Hhe der cavoatrialen Ausbreitung keinen Einfluss auf das berleben. Die radikale Entfernung des Tumors mitsamt Tumorzapfen stellt heute bei Patienten ohne lokale Lymphknotenmetastasen und ohne Fernmetastasen die Primrtherapie der Wahl dar. Wir berichten ber den Verlauf und die Therapie von 17 Patienten mit einem Nieren-Zell-Karzinom und cavoatrialer Tumorbeteiligung sowie ber 6 weitere Patienten mit anderen Tumorarten. Trotz aufwndiger Operation mit Herz-Lungenmaschine, tiefer Hypothermie und Kreislaufstillstand kommt es im Vergleich zur Tumornephrektomie ohne Beteiligung der Vena cava zu einer vertretbaren Erhhung der perioperativen Morbiditt und Letalitt. Ein Langzeitberleben ist trotz fortgeschrittenem Tumorstadium mit cavoatrialer Ausdehnung nach radikaler Resektion mglich.In approximately 5–10% of patients presenting with renal cell cancer, the transluminal propagation of a tumor thrombus into the vena cava inferior or the right atrium is also diagnosed. Recent investigations have indicated that the presence of neoplastic extension into the venous system does not reveal independent prognostic value regarding the clinical course of the disease. The complete surgical removal of the caval thrombosis in patients without simultaneously occurring regional lymph node or distant metastases has become a well-established treatment modality. We report on our experience with 17 patients with renal cell cancer and 6 patients with other tumors obstructing the inferior caval vein, and can show that long-term survival is possible after radical resection. We can demonstrate that using cardiopulmonary bypass, deep hypothermia and circulatory arrest—preferably, during the removal of intracaval thrombosis extending into the right atrium—does not result in a substantially increased treatment-related intra- or postoperative mortality.
Zeitschrift für Herz- Thorax- und Gefäßchirurgie 05/2004; 18(3):117-122.
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ains · Anästhesiologie · Intensivmedizin 12/2003; 38(11):679-80. · 0.41 Impact Factor
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ABSTRACT: Physicians, nurses and many other allied health professions join in intensive care as a team for the treatment of patients whose vital functions are either endangered or impaired. Apart from continuous monitoring, which represents the smallest common denominator of all types of intensive-care treatment, intensive-care therapy also encompasses continuous treatment and support of failing organ functions and likewise continuous intensive nursing. The complexity of intensive-care medicine is a strong argument against intensive-care becoming a medical specialty of its own. Nevertheless, the coordination of intensive care-medicine by an experienced intensive care physician is of utmost importance. The present situation in intensive-care medicine is characterised by an increasing tension between new and fascinating medical possibilities (such as right and left ventricular assistance device systems, liver support, pharmacologic treatment of sepsis, avoidance of the complications of critical illness) on the one hand, and limited budgets on the other hand. This conflict is reflected by two basic fears within the population: firstly, the fear that not everything medically possible is being done for the patient due to economic reasons, secondly, a fear of futile treatment at the end of life, merely prolonging inevitable death. Accordingly, ethical questions regarding intensive-care are emerging at all levels of the health system.
ains · Anästhesiologie · Intensivmedizin 05/2003; 38(4):264-72. · 0.41 Impact Factor
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ABSTRACT: Zusammenfassung Der Erfolg der Herztransplantation war in den Anfangsjahren dadurch beeintrchtigt, dass keine Medikamente zur Verfgung standen, die die akute Abstoung des transplantierten Organs unterdrcken konnten, ohne gleichzeitig das Risiko fr lebensgefhrliche Infektionen zu erhhen. Erst mit der Anwendung von Cyclosporin A als Basis fr eine Triple-Immunsuppression mit Azathioprin und Steroiden wurde ein entscheidender Durchbruch zur Verbesserung der berlebensrate nach Herztransplantation erzielt. Aufgrund des ausgeprgten Nebenwirkungsprofils dieser Medikamente wurde nach neuen Immunsuppressiva gesucht, mit dem Ziel, bei verbesserter immunsuppressiver Wirkung das Spektrum an unerwnschten Wirkungen zu reduzieren. Als Alternativen zu Cyclosporin A und Azathioprin wurden Tacrolimus und Mycophenolsure entwickelt. Von beiden Medikamenten konnte gezeigt werden, dass sie gegenber Cyclosporin A und Azathioprin Vorteile bei der Behandlung von akuten Abstoungen aufweisen. Eine signifikante Reduktion der unerwnschten Wirkungen konnte jedoch nicht erreicht werden. Neue Perspektiven erffneten sich mit Rapamycin und IL-2-Rezeptorantagonisten. Durch ihre Kombination mit etablierten Immunsuppressiva konnte eine weitere Verbesserung in der Therapie akuter Abstoungsreaktionen erreicht werden. Ihr Profil an unerwnschten Wirkungen sowie ihre immunsuppressiven Effekte im Langzeitverlauf konnten bisher noch nicht endgltig beurteilt werden. Das ultimative Ziel zur langfristigen Erhaltung der Transplantatfunktion ohne die Notwendigkeit fr eine lebenslange Behandlung des Empfngers mit Immunsuppressiva stellt die Induktion von Toleranz des Empfngers gegenber dem Spenderorgan dar. In tierexperimentellen Studien gelang dies durch die Kombination von spenderspezifischer Knochenmarktransplantation und Blockade der Kostimulation immunkompententer Lymphozyten des Empfngers. Bevor diese Therapie jedoch in klinischen Studien evaluiert werden kann, muss ihre Erprobung in Grotierversuchen erfolgen. Summary In the early years of heart transplantation, success of this therapy was limited by the lack of immunosuppressive drugs which could effectively suppress rejection without increasing the risk for life-threatening infection. Only the introduction of cyclosporin A as the basis for a triple immunosuppressive regimen including azathioprin and steroids improved survival after heart transplantation significantly. Since those immunosuppressants were associated with a wide spectrum of adverse events, a search for new agents with equivalent immunosuppressive activity and a reduced array of side effects was initiated. This led to the development of tacrolimus and mycophenolate mofetil as alternatives for cyclosporin A and azathioprin, respectively. Several clinical studies indicated that tacrolimus and mycophenolate mofetil were associated with a greater immunosuppressive potential as compared to cyclosporin A and azathioprin. However, the spectrum of side effects was still not negligible. New perspectives arose with the availability of rapamycin and IL-2-receptor antagonists. The combination of these drugs with the established immunosuppressive drugs resulted in a more sufficient suppression of acute rejection. Their spectrum of side effects and long-term immunosuppressive efficacy, however, have not clearly been identified so far. The ultimate goal of transplantation, however, is the induction of recipient tolerance towards the transplanted organ without the need for lifelong immunosuppression. Animal studies have shown that tolerance is inducible by simultaneous donor-specific bone marrow transplantation and costimulatory blockade of the recipient. Before this concept can be evaluated in the clinic, its test in large animal models is required.
Zeitschrift für Herz- Thorax- und Gefäßchirurgie 11/2002; 16.
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T Möllhoff,
C Schmidt,
H Van Aken, E Berendes,
H Buerkle,
P Marmann,
T Reinbold,
R Prenger-Berninghoff,
T D T Tjan,
H H Scheld,
M C Deng
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ABSTRACT: Myocardial ischaemia and infarction are major complications immediately after coronary artery bypass grafting. They may be due to incomplete surgical revascularization, perioperative anaesthetic management or vasospasm of arterial grafts, e.g. the internal mammary artery. Infusions of nifedipine or milrinone have been advocated to prevent spasm of the mammary artery. The study compared the incidence of myocardial ischaemia after continuous infusion of either nifedipine (0.2 microg kg(-1) min(-1)) or milrinone (0.375 microg kg(-1) min(-1)) in patients with compromised left ventricular function scheduled for elective coronary artery bypass graft.
After Institutional Review Board approval, this double-blinded randomized clinical study enrolled 30 adult patients with compromised left ventricular function (ejection fraction < 0.4) scheduled for elective coronary artery bypass grafting after written informed consent had been obtained. Ischaemia was detected by Holter electrocardiographic monitoring. The incidence of myocardial cell death was monitored by serial determinations of the creatine kinase-MB (CK-MB) and troponin-I.
New ST elevation > or = 0.2 mV or new ST depression < or = 0.1 mV occurred in five of 15 patients in the milrinone group (33.3%) and in 13 of 15 patients (86.6%) in the nifedipine group (P < 0.05). There were increases in CK-MB and troponin-I in both groups. Twenty-four hours postoperatively, CK-MB (P = 0.003) and troponin-I (P = 0.001) were significantly higher in the nifedipine group.
Perioperative continuous infusion of milrinone, compared with nifedipine, results in a significantly lower incidence of myocardial ischaemia and myocardial cell damage after elective coronary artery bypass grafting.
European Journal of Anaesthesiology 11/2002; 19(11):796-802. · 2.23 Impact Factor
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ABSTRACT: Atrial natriuretic peptide (ANP) release is increased in patients with ischaemic left ventricular dysfunction. A beneficial effect of naloxone on recovery from myocardial stunning was shown previously. The aim of this study was to investigate the effects of naloxone on ANP release during regional myocardial ischaemia and stunning in awake dogs.
Ten dogs were chronically instrumented for measurement of heart rate, left atrial, aortic, and left ventricular pressure (LVP), LV dP x dtmax/min(-1), and myocardial wall-thickening fraction. An occluder around the left anterior descending artery (LAD) allowed induction of reversible ischaemia in the LAD-perfused myocardium. Each dog underwent two ischaemic episodes (randomized crossover fashion; separate days): 10 min of LAD occlusion (1) after application of naloxone (63 microg kg(-1)), and (2) without naloxone. ANP levels were measured at baseline (BL) and at predetermined time points until complete recovery of myocardial stunning occurred.
LAD ischaemia-induced release of ANP (peak level: 182 (30) vs 27 (7) pg ml(-1) BL) only in the control group without naloxone. Between 1 and 180 min of reperfusion, ANP levels were significantly higher only in the control group (P<0.05).
Pre-ischaemic application of naloxone prevents this ischaemia-induced ANP-release in conscious dogs.
BJA British Journal of Anaesthesia 01/2002; 88(1):87-93. · 4.24 Impact Factor
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ABSTRACT: Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are cardiac hormones with natriuretic, vasorelaxant, and aldosterone-inhibiting properties. We analyzed the plasma of 178 critically ill patients for ANP, BNP, aldosterone, and serum sodium concentration, as well as serum and urine osmolality and sodium filtration fraction. Mean plasma concentrations of ANP and BNP were increased in critically ill patients compared with healthy controls (ANP, 14.3 +/- 5.8 pmol/L versus 8.8 +/- 3.2 pmol/L, P < 0.05; BNP, 26.2 +/- 10.7 pmol/L versus 4.6 +/- 2.8 pmol/L, P < 0.0001). The relative increases in ANP concentrations were comparable in all diseases. BNP concentrations, by contrast, showed a wider variation. The largest BNP concentrations were observed in patients who underwent cardiac surgical procedures and in patients with subarachnoid hemorrhage. ANP, but not BNP, was correlated with aldosterone levels (r = 0.4, P < 0.001), serum sodium (r = 0.42, P < 0.001), sodium filtration fraction (r = 0.3, P < 0.001), serum osmolality (r = 0.25, P < 0.01), urinary osmolality (r = -0.24, P < 0.01), and central venous pressure (r = 0.22, P < 0.01). ANP and BNP concentrations were increased in critically ill patients; however, this did not correlate with the severity of illness or mortality. Our data support a regulatory role for ANP in the maintenance of water and electrolyte balance. The physiologic role of BNP, by contrast, is less clear. ANP and BNP are not predictors for the severity of illness and mortality in critically ill patients.
Anesthesia & Analgesia 10/2001; 93(3):676-82. · 3.29 Impact Factor
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ABSTRACT: Tissue engineering is a promising approach for obtaining lifetime durability in biological heart valves. Basic questions with respect to the selection of suitable cell populations as well as scaffolds remain unsolved. The purpose of this study was to develop a tissue-like substitute in vitro for replacement of diseased valves in vivo.
Smooth-muscle cells (SMCs) were isolated from human and porcine aortic tissue using the 'explant technique' and endothelial cells from collagenase digestion. Seeding and cultivation of isolated cells was performed on a type-I collagen matrix. The scaffold-cell specimen was investigated using light and electron microscopy. Cupromeronic blue and immunoprecipitation were used for ultracytochemical staining.
SMCs were allowed to grow to multilayers and migrate into the collagen network. We found a tissue-like morphology in these samples characterised by several layers of cells, spaces between the cell layers filled with newly formed extracellular matrix components, compartmentalisation of proteoglycans and their association with fibrilar matrix and the cell surface. Endothelium cells covered the SMCs of the scaffold with a histological topography similar to heart valves.
This is an approach for in vitro modelling of tissue-like substitutes and preparing plane multicellular tissues as substitutes for heart valves. This model may also be used for cell biological investigations of cell-matrix interactions.
The Thoracic and Cardiovascular Surgeon 09/2001; 49(4):204-9. · 0.88 Impact Factor
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ABSTRACT: We hypothesized that a temporary cardiopulmonary bypass (CPB)-induced reduction of endotoxin antibody levels contributes to elevated endotoxin levels and the associated inflammatory consequences, with a significant influence on the postoperative ventilation time period.
Cardiac surgery using CPB induces a systemic inflammatory response syndrome with an associated risk of increased postoperative morbidity and mortality.
A total of 100 consecutive patients undergoing elective coronary artery bypass graft surgery using CPB were prospectively investigated. Endotoxin core antibodies (immunoglobulin [Ig] M/IgG against lipid A and lipopolysaccharide), endotoxin, interleukin (IL)-1-beta, IL-6, IL-8 and tumor necrosis factor-alpha were measured serially from 24 h preoperatively until 72 h postoperatively.
Eighty-five patients had no complications (group 1), whereas 15 patients required prolonged ventilation (group 2). In both groups, there was a decrease of all antibodies 5 min after CPB onset, compared with baseline values (p < 0.001), an increase of endotoxin and IL-8 peaking at 30 min postoperatively (p < 0.001) and an increase of IL-6 peaking 3 h postoperatively (p < 0.001). In group 2, preoperative antibody levels were lower (p < 0.01)--specifically, the decrease in IgM was significantly stronger and of longer duration (p < 0.002)--and levels of endotoxin (p < 0.001) and IL-8 (p < 0.001) were higher at 30 min postoperatively.
We conclude that an CPB-associated temporary reduction of anti-endotoxin core antibody levels contributes to elevated endotoxin and IL-8 release. Furthermore, lower levels of IgM anti-endotoxin core antibodies were associated with a greater rise in endotoxin and IL-8, as well as prolonged respirator dependence.
Journal of the American College of Cardiology 08/2001; 38(1):124-30. · 14.16 Impact Factor
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ABSTRACT: Primary tissue failure, which is mainly caused by calcification, is still the limiting factor in the long-term outcome of heart valve bioprostheses. Even though the precise nature of this process is not fully understood, in vitro tests have been developed to reproduce and predict calcification for individual bioprostheses.
In vitro calcification testing was performed by using an accelerated pulsatile valve tester which was adapted for testing stented as well as stentless bioprostheses with physiological fluid dynamics. A total of 84 bioprostheses (porcine, pericardial and stentless porcine of different manufacturers) were cyclically loaded at a test rate of 300/min at 37 degrees C within a rapid calcification fluid with CaxP = 130(mg/dl)2 at pH 7.4. Calcification was assessed by microradiography after 12 x 10(6) cycles. In a previous step, holographic interferometry was performed to identify irregularities of valve leaflets in order to predict later calcification. Selected specimens of calcified bioprostheses underwent histology, transmission (TEM) and scanning (SEM) electron microscopy. Tissue mineralization was investigated by coupling SEM, electron microprobe analysis (EMPA) and X-ray powder diffraction (XRPD) methods.
For all tested bioprostheses, a significant calcification was achieved within 4 to 6 weeks of ongoing testing, and the degree of calcification increased with time. A significant correlation between calcification and leaflet irregularities (detected by holographic interferometry) was found (r = 0.80, p = 0.001). Calcification varied between individual bioprostheses, and significant differences were detected for different groups (calculated as percentage of total leaflet area, mean +/- SD): porcine stented (37.3 +/- 12.0%), bovine stented (23.0 +/- 8.9%), porcine stentless (16.2 +/- 7.6%). Histological and ultrastructural investigation showed intrinsic calcification involving both the spongiosa and fibrosa with collagen fibrils, interfibrillar spaces and cells as early sites of calcification. There was clear evidence of apatite crystallization, and observations made with in vitro calcification were quite similar to those occurring with in vivo implanted bioprostheses.
In vitro tests can reproduce intrinsic calcification of bioprostheses even in the absence of viable biologic host factors. Moreover, degree and sites of calcification have become predictable. This enables the development and evaluation of bioprostheses with reduction of animal experiments. From our results obtained with a broad range of available bioprostheses, stented bovine and stentless porcine valves seem to be superior to conventional stented porcine bioprostheses with regard to leaflet calcification.
The Thoracic and Cardiovascular Surgeon 05/2001; 49(2):78-83. · 0.88 Impact Factor
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Anesthesiology 04/2001; 94(3):540-1. · 5.36 Impact Factor
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ABSTRACT: Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) can lead to a systemic inflammatory response syndrome with organ failure and increased morbidity and mortality. The mechanisms of these findings are still under discussion. We investigated whether anti-endotoxin core antibodies, endotoxin, and proinflammatory cytokines influence the clinical course after cardiac surgery. Seventy-eight patients undergoing CABG using CPB were investigated. Anti-endotoxin core antibodies, endotoxin, interleukin (IL)-6, IL-8, IL-1beta, and TNF-alpha were measured 24 h preoperatively and up to 72 h postoperatively. Patients with a postoperative mechanical ventilation time below 24 h (n = 65; Group A) were compared to patients with prolonged respirator therapy (>24 h; n = 13; Group B). Preoperative antibody levels were significantly lower in Group B (P < 0.001). In this group, antibody levels remained decreased during the observation period (P < 0.001). Endotoxin significantly increased 30' postoperatively in both groups (P < 0.002). The increase in Group B was 3-fold higher (P< 0.001). IL-8 increased postoperatively in both groups, peaking 3 h after surgery (P < 0.001). In Group B, the IL-8 release was significantly higher than in Group A (P < 0.001). IL-6 significantly increased in both groups, reaching its maximum 24 h postoperatively (P < 0.001). No differences between groups were observed. No significant changes of IL-1beta and TNF-alpha were observed. We conclude that anti-endotoxin core antibodies may be predictive of adverse outcome after cardiac surgery. The imbalance between antibodies and endotoxin results in an exaggerated increase in endotoxin and IL-8 with an impact on clinical outcome.
Shock 02/2001; 16 Suppl 1:44-50. · 2.85 Impact Factor
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H Reinecke,
T Fetsch,
N Roeder,
C Schmid,
A Winter,
M Ribbing, E Berendes,
M Block,
H H Scheld,
G Breithardt,
S Kerber
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ABSTRACT: We assessed the impact of patient and procedural characteristics on the outcome after emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) and temporal changes in these factors.
Patients who underwent PTCA and subsequent emergency CABG were identified from the databases of the Departments of Cardiology and Cardiothoracic Surgery.
Two periods of clinical practice were compared. In 1989 to 1993, 2,880 PTCAs were performed, 64 patients underwent emergency CABG (2.3%), and 7 patients died (10.9%). During 1994 to 1998, 46 patients of 3,801 PTCAs underwent emergency CABG (1.2%, p < 0.01), and 7 patients died (15.2%, NS). The average rate of stenting increased from 0.8% to 24% in 1994 to 1998 as well as the frequency of arterial bypass grafts (0% vs 39%). In the latter period, patients were older, were more often females, had more cardiovascular risk factors, a higher Cleveland score (each p < 0.05), and suffered more often from periprocedural myocardial infarctions (p < 0.001) and nonfatal periprocedural complications (p < 0.01).
Although the frequency of emergency CABG after failed PTCA declined, perioperative mortality tended to increase according to an unfavorable shift in patient risk factors and morbidity.
The Annals of Thoracic Surgery 12/2000; 70(6):1997-2003. · 3.74 Impact Factor
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H M Loick,
C Schmidt,
H Van Aken,
R Junker,
M Erren, E Berendes,
N Rolf,
A Meissner,
C Schmid,
H H Scheld,
T Möllhoff
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ABSTRACT: In this prospective study, we evaluated whether high thoracic epidural anesthesia (TEA) or i.v. clonidine, in addition to general anesthesia, affects the cardiopulmonary bypass- and surgery-associated stress response and incidence of myocardial ischemia by their sympatholytic properties. Seventy patients scheduled for elective coronary artery bypass graft (CABG) received general anesthesia with sufentanil and propofol. TEA was randomly induced before general anesthesia and continued during the study period in 25 (anesthetized dermatomes C6-T10). Another 24 patients received i.v. clonidine as a bolus of 4 microg/kg before the induction of general anesthesia. Clonidine was then infused at a rate of 1 microg x kg(-1) x h(-1) during surgery and at 0.2-0.5 microg x kg(-1) x h(-1) postoperatively. The remaining 21 patients underwent general anesthesia as performed routinely (control). Hemodynamics, plasma epinephrine and norepinephrine, cortisol, the myocardial-specific contractile protein troponin T, and other cardiac enzymes were measured pre- and postoperatively. During the preoperative night and a follow-up of 48 h after surgery, five-lead electrocardiogram monitoring was used for ischemia detection. Both TEA and clonidine reduced the postoperative heart rate compared with the control group without jeopardizing cardiac output or perfusion pressure. Plasma epinephrine increased perioperatively in all groups but was significantly lower in the TEA group. Neither TEA nor clonidine affected the increase in plasma cortisol. The release of troponin T was attenuated by TEA. New ST elevations > or = 0.2 mV or new ST depression > or = 0.1 mV occurred in > 70% of the control patients but only in 40% of the clonidine group and in 50% of the TEA group. We conclude that TEA (but not i.v. clonidine) combined with general anesthesia for CABG demonstrates a beneficial effect on the perioperative stress response and postoperative myocardial ischemia. Implications: Thoracic epidural anesthesia combined with general anesthesia attenuates the myocardial sympathetic response to cardiopulmonary bypass and cardiac surgery. This is associated with decreased myocardial ischemia as determined by less release of troponin T. These findings may have an impact on the anesthetic management for coronary artery bypass grafting.
Anesthesia & Analgesia 05/1999; 88(4):701-9. · 3.29 Impact Factor
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ABSTRACT: Compromised splanchnic perfusion and the resulting intestinal mucosal injury leads to a decreased mucosal barrier function, which allows translocation of intestinal flora and endotoxemia. The authors evaluated the effects of milrinone on splanchnic oxygenation, systemic inflammation, and the subsequent acute-phase response in patients undergoing coronary artery bypass grafting.
This open, placebo-controlled randomized clinical study enrolled 22 adult patients in two groups. Before induction of anesthesia, baseline values were obtained and patients were randomized to receive milrinone (30 microg/kg bolus administered progressively in 10 min, followed by a continuous infusion of 0.5 microg x kg(-1) x min(-1)) or saline. The following parameters were determined: hemodynamics; systemic oxygen delivery and uptake; arterial, mixed venous and hepatic venous oxygen saturation; intramucosal pH (pHi); and mixed and hepatic venous plasma concentrations of endotoxin, interleukin 6, serum amyloid A, and C-reactive protein.
Milrinone did not prevent gastrointestinal acidosis as measured by pHi, but its perioperative administration resulted in significantly higher pHi levels compared with control. Venous and hepatic venous endotoxin and the interleukin 6 concentration were reduced significantly in the milrinone group. Serum amyloid A values were attenuated in the milrinone group 24 h after surgery. No significant differences could be seen in routinely measured oxygen transport-derived variables.
Perioperative administration of low-dose milrinone may have antiinflammatory properties and may improve splanchnic perfusion in otherwise healthy patients undergoing routine coronary artery bypass grafting.
Anesthesiology 02/1999; 90(1):72-80. · 5.36 Impact Factor
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ABSTRACT: Als Folge des wissenschaftlichen Fortschritts in der Medizin werden immer mehr Patienten mit Vorerkrankungen, in hohem Lebensalter,
mit eingeschränkter kardialer Pumpfunktion, nach vorangegangenen Herzoperationen sowie unter Notfallbedingungen operiert.
Dieses erfordert eine Risikostratifizierung, mit denen sich das Operationsrisiko in „niedrig“, „mittel“ und „hoch“ einteilen
läßt. Es lassen sich prä-, intra- und postoperative patienten-, struktur- und behandlungsbezogene Faktoren unterscheiden.
Auf der Grundlage dieser Vorhersage läßt sich durch individuell maßgeschneidertes, prä-, intra- und postoperatives, multiprofessionell
und interdisziplinär organisiertes Management der perioperative Verlauf optimieren.
As a consequence of scientific advances, an increasing number of patients with advanced age, reduced myocardial performance,
previous cardiac surgery, comorbidities, and emergency indications are referred for cardiac surgery. This requires risk stratification
to predict “low”, “moderate”, and “high” operative risk. Risk factors can be divided into pre-, intra-, and postoperative
patient-, structure-, and procedure-related. On the basis of this risk prediction, the perioperative course can be optimized
by an individually tailored multiprofessional and interdisciplinary management.
Zeitschrift für Herz- Thorax- und Gefäßchirurgie 01/1999; 13(2):57-66.
