Christof Schmid

University Hospital Regensburg, Ratisbon, Bavaria, Germany

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Publications (438)1161.55 Total impact

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    ABSTRACT: Interhospital transfer of patients experiencing circulatory failure and shock has a significant risk of cardiovascular deterioration and death. Extracorporeal life support (ECLS) is a rescue tool for hemodynamic stabilization that makes patient transportation much safer. Demographic data, clinical course, and outcome data were reviewed for patients who underwent placement of a venoarterial ECLS in a remote hospital and were transported to our tertiary care facility. 68 patients were transported to our center with ECLS. The majority of these patients (79%) underwent cardiopulmonary resuscitation during or immediately prior to ECLS initiation.The mean patient age was 52 years, and 53 patients were male. The most common underlying diagnosis was acute coronary syndrome (60%). Overall, 23 patients underwent consecutive cardiosurgical procedures, including coronary artery bypass grafting in 12, and left ventricular assist device and biventricular assist device implantation in 11. The median duration of ECLS was 5 days. None of the patients died during transportation. Twelve of the surgically treated patients survived, as well as 21 patients with non-surgical treatment, which resulted in an overall survival of 33 patients (48.5%). ECLS-facilitated patient transfer enables safe interhospital transfer of critically ill patients. In this study, a relevant percentage of patients were in need of a cardiosurgical intervention. The long-term survival rate of these patients supports the further use of this time-, cost- and personnel-demanding strategy. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Resuscitation 06/2015; 93. DOI:10.1016/j.resuscitation.2015.05.021 · 3.96 Impact Factor
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    ABSTRACT: Advanced age is a known risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Minimized extracorporeal circulation (MECC) has been shown to reduce the negative effects associated with conventional extracorporeal circulation (CECC). This trial assesses the impact of MECC on the outcome of elderly patients undergoing CABG. Eight hundred and seventy-five patients (mean age 78.35 years) underwent isolated CABG using CECC (n=345) or MECC (n=530). The MECC group had a significantly shorter extracorporeal circulation time (ECCT), cross-clamp time and reperfusion time and lower transfusion needs. Postoperatively, these patients required significantly less inotropic support, fewer blood transfusions, less postoperative hemodialysis and developed less delirium compared to CECC patients. In the MECC group, intensive care unit (ICU) stay was significantly shorter and 30-day mortality was significantly reduced [2.6% versus 7.8%; p<0.001]. In conclusion, MECC improves outcome in elderly patients undergoing CABG surgery. © The Author(s) 2015.
    Perfusion 06/2015; DOI:10.1177/0267659115588634 · 1.08 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2015; 34(4):S264. DOI:10.1016/j.healun.2015.01.738 · 5.61 Impact Factor
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    ABSTRACT: OBJECTIVES We demonstrate a multislice computed tomography (MSCT)-based method to calculate the prediction of the so-called ‘line of perpendicularity’ (LOP) and the ‘implanter's views’ (IVs) for transcatheter aortic valve implantation (TAVI) procedures. The LOP represents all possible angiographic angulations that result in an orthogonal view to the aortic annulus plane. The IVs allow visual confirmation of correct implantation planes, and are crucial for the commissural aligned implantation of second-generation TAVI prostheses.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2015; DOI:10.1093/ejcts/ezv095 · 2.81 Impact Factor
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    ABSTRACT: Anti-endothelial cell antibodies (AECA) may be involved in the development of heart allograft rejection. Its detection might be a cheap and noninvasive method to identify high-risk patients. An indirect immunofluorescence method on human umbilical vein endothelial cells was used to investigate the presence of AECAs in 260 pre- and post-transplant serum samples sequentially collected from 34 patients within the first year after heart transplantation (HTX). The presence of AECAs before (23.5 %) and early after HTX (14.7 %) was associated with a significantly increased risk of early acute rejection (75 and 60 %, respectively) compared to 33 % in AECA-negative patients (p = 0.049). Moreover, rejections from AECA-positive patients were more severe (p = 0.057) with a significantly increased incidence of multiple (p = 0.025). The mean number of the sum of rejection episodes was significantly higher in AECA-positive patients (p ≤ 0.05). Patients free of AECAs mainly received mycophenolate mofetil as primary immunosuppression (p = 0.067). Nevertheless, the presence of AECAs did not affect long-term outcome and mortality of HTX patients. Despite a low number of patient samples, the detection of AECAs before and early after HTX could be used as a biomarker for an increased risk of early acute rejection in high-risk patients. This easy method might be a valuable tool to support screening procedures to improve individualized immunosuppressive therapy.
    Heart and Vessels 03/2015; DOI:10.1007/s00380-015-0666-0 · 2.11 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A785. DOI:10.1016/S0735-1097(15)60785-9 · 15.34 Impact Factor
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    ABSTRACT: Transcatheter valve-in-valve (VIV) implantation evolved as a therapeutic alternative, despite an increased risk of coronary obstruction in comparison with a regular transcatheter aortic valve implantation (TAVI). We report a comprehensive single-institution experience emphasizing strategies to reduce the risk of myocardial ischemia. Since 2009, 639 patients underwent a TAVI procedure in our institution. All patients are prospectively collected into an institutional registry. In total 31 patients underwent a VIV procedure at our institution (age 77.8 ± 6.3 years; The Society or Thoracic Surgeons predicted risk of mortality 20.9% ± 8.8%; New York Heart Association (NYHA) 3.0 ± 0.6). Degenerated bioprostheses included 24 Mitroflow, 6 Edwards Perimount, and Cryo-Valve O' Brien with label sizes from 21 to 27 mm. The type of failure was mostly regurgitation with or without concomitant stenosis (78%). Patients were provided with 5 Medtronic CoreValves, 15 Edwards SapienXT, 1 Edwards Sapien 3, 7 Medtronic Engager, and 3 Symetis Acurate TA valves. The procedural success rate was 88%. The left main stem was occluded in 1 patient (Sapien XT 26 in a Mitroflow 25 mm) who underwent emergent revascularization. Two patients suffering from a degenerated Mitroflow prosthesis needed a second valve (Sapien XT). Two patients with a degenerated Mitroflow prosthesis treated with a Sapien XT developed postprocedural myocardial ischemia and deceased on postoperative days 1 and 2, accounting to an overall incidence of coronary insufficiency associated to the VIV procedure of 10%. With the introduction of valves allowing commissural alignment (Acurate TA) and leaflet capturing as well (Engager) no further coronary insufficiency occurred. The mean gradient decreased significantly from 39.3 ± 14.0 to 16.1 ± 7.2 mm Hg (p = 0.002). Post-procedural regurgitation was classified as trace in 7 patients (23%) and moderate in 4 patients (13%). The 30-day survival was 77% with a significantly improved NYHA class of 1.79 ± 0.58 (p = 0.001). Jeopardizing coronary blood flow is likely in stenotic and calcified bioprostheses, particularly in tubelike aortic sinuses. Planning, imaging, and the use of valves allowing commissural alignment as well as leaflet capturing seem to reduce the risk. Further studies are necessary to support this hypothesis. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of Thoracic Surgery 02/2015; 99(5). DOI:10.1016/j.athoracsur.2014.11.047 · 3.63 Impact Factor
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    ABSTRACT: Cerebral thromboembolism builds the Achilles heel for patients on left ventricular support (LVAD). Thrombolytic therapy is usually contraindicated considering the increased risk of intracranial hemorrhage in LVAD patients under therapeutic oral anticoagulation with concomitant platelet inhibition. We report on an alternative approach to this dilemma. On day 1091 of LVAD support (INCOR(R) Berlin Heart) a 69-year-old male patient was admitted to a rural hospital unconscious with a left sided hemiplegia. Cerebral computed tomography (cCT) with CT-angiography revealed a thrombembolic distal basilar artery occlusion. The patient was immediately transported to our medical center, where an interventional thrombectomy restored full patency of the vessel. The patient recovered without neurological sequelae within days. This case highlights the fact that patients on LVAD support with a neurological event should be immediately transferred to a neurovascular center for appropriate treatment including a neurointervention.
    ASAIO Journal 01/2015; 61(3):e17-e18. DOI:10.1097/MAT.0000000000000223 · 1.39 Impact Factor
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    ABSTRACT: Human umbilical vessels have been recognized as a valuable and widely available resource for vascular tissue engineering. Whereas endothelium-denuded human umbilical veins (HUVs) have been successfully seeded with a patient-derived neoendothelium, decellularized vessels may have additional advantages, due to their lower antigenicity. The present study investigated the effects of three different decellularization procedures on the histological, mechanical and seeding properties of HUVs. Vessels were decellularized by detergent treatment (Triton X-100, sodium deoxycholate, IGEPAL-CA630), osmotic lysis (3 m NaCl, distilled water) and peroxyacetic acid treatment. In all cases, nuclease treatments were required to remove residual nucleic acids. Decellularization resulted in a partial loss of fibronectin and laminin staining in the subendothelial layer and affected the appearance of elastic fibres. In addition to removing residual nucleic acids, nuclease treatment weakened all stainings and substantially altered surface properties, as seen in scanning electron micrographs, indicating additional non-specific effects. Detergent treatment and osmotic lysis caused failure stresses to decrease significantly. Although conditioned medium prepared from decellularized HUV did not severely affect endothelial cell growth, cells seeded on decellularized HUV did not remain viable. This may be attributed to the partial removal of essential extracellular matrix components as well as to changes of surface properties. Therefore, decellularized HUVs appear to require additional modifications in order to support successful cell seeding. Replacing the vessels' endothelium may thus be a superior alternative to decellularization when creating tissue-engineered blood vessels with non-immunogenic luminal interfaces. Copyright © 2012 John Wiley & Sons, Ltd.
    Journal of Tissue Engineering and Regenerative Medicine 01/2015; 9(1). DOI:10.1002/term.1603 · 4.43 Impact Factor
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    ABSTRACT: Technical complications are a known hazard in veno-venous extracorporeal membrane oxygenation (vvECMO). Identifying these complications and predictive factors indicating a developing system-exchange was the goal of the study. Retrospective study on prospectively collected data of technical complications including 265 adult patients (Regensburg ECMO Registry, 2009-2013) with acute respiratory failure treated with vvECMO. Alterations in blood flow resistance, gas transfer capability, hemolysis, coagulation and hemostasis parameters were evaluated in conjunction with a system-exchange in all patients with at least one exchange (n = 83). Values presented as median (interquartile range). Patient age was 50(36-60) years, the SOFA score 11(8-14.3) and the Murray lung injury Score 3.33(3.3-3.7). Cumulative ECMO support time 3411 days, 9(6-15) days per patient. Mechanical failure of the blood pump (n = 5), MO (n = 2) or cannula (n = 1) accounted for 10% of the exchanges. Acute clot formation within the pump head (visible clots, increase in plasma free hemoglobin (frHb), serum lactate dehydrogenase (LDH), n = 13) and MO (increase in pressure drop across the MO, n = 16) required an urgent system-exchange, of which nearly 50% could be foreseen by measuring the parameters mentioned below. Reasons for an elective system-exchange were worsening of gas transfer capability (n = 10) and device-related coagulation disorders (n = 32), either local fibrinolysis in the MO due to clot formation (increased D-dimers [DD]), decreased platelet count; n = 24), or device-induced hyperfibrinolysis (increased DD, decreased fibrinogen [FG], decreased platelet count, diffuse bleeding tendency; n = 8), which could be reversed after system-exchange. Four MOs were exchanged due to suspicion of infection. The majority of ECMO system-exchanges could be predicted by regular inspection of the complete ECMO circuit, evaluation of gas exchange, pressure drop across the MO and laboratory parameters (DD, FG, platelets, LDH, frHb). These parameters should be monitored in the daily routine to reduce the risk of unexpected ECMO failure.
    PLoS ONE 12/2014; 9(12):e112316. DOI:10.1371/journal.pone.0112316 · 3.53 Impact Factor
  • M Freundt, A Haneya, C Schmid, S Hirt
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    ABSTRACT: Patients with left ventricular assist devices (LVADs) who develop stage IV sacral pressure sores (SPS) have an increased procedural risk. We present the complications, including severe intra- and postoperative bleeding, diarrhea with metabolic acidosis, volume loss and acute on chronic renal failure, flap dehiscence and late LVAD outflow cannula thrombosis, in a 54-year-old male who underwent diverting ileostomy (DI) and subsequent fasciocutaneous flap (FCF) surgery for stage IV SPS while supported with an LVAD. Our experience suggests that, despite continuous heparinization, life-threatening thrombotic complications, such as device clotting, can occur. Therefore, the benefit of intervention has to outweigh the risk of bleeding, which should be managed with meticulous surgical technique and substitution of red blood cells rather than the reversal of heparinization or the substitution of clotting factors. Continuation of double anti-platelet therapy should also be considered.
    Perfusion 11/2014; DOI:10.1177/0267659114560043 · 1.08 Impact Factor
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    ABSTRACT: Polymethylpentene membrane oxygenators used in venovenous extracorporeal membrane oxygenation (vvECMO) differ in their physical characteristics. The aim of the study was to analyze the gas transfer capability of different ECMO systems in clinical practice, as the choice of the appropriate system may be influenced by the needs of the patient.
    Intensive Care Medicine 10/2014; DOI:10.1007/s00134-014-3489-z · 5.54 Impact Factor
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    ABSTRACT: Objectives Re-exploration after cardiac surgery remains a frequent complication with adverse outcomes. The aim of this study was to evaluate the impact of timing and indication of re-exploration on outcome. Methods A retrospective, observational study on a cohort of 209 patients, who underwent re-exploration after cardiac surgery between January 2005 and December 2011, was performed. The cohort was matched for age, gender, and procedure with patients who were not re-explored during the same period. Results The intraoperative and postoperative transfusion requirements were higher in the re-exploration group (p < 0.01). Patients in the re-exploration group had significantly higher incidences of postoperative acute renal injury (10.0 vs. 3.3%), sternal wound (9.1 vs. 2.4%) and pulmonary (13.4 vs. 4.3%) infections, longer ventilation time (22 [range, 14-52] vs. 12 [range, 9-16] hours) and intensive care unit stay (5 [range, 3-7] vs. 2 [range, 2-4] days), and higher mortality rate (9.6 vs. 3.3%). However, the multivariate logistic regression analysis demonstrated that not the re-exploration itself, but the deleterious effects of re-exploration (blood loss and transfusion requirement) were independent risk factors for mortality. Mortality was 5.3% for patients who were re-explored within the first 12 hours and 20.3% for patients who were re-explored after 12 hours (p = 0.003). Mortality was 3.6% for patients with bleeding and 31.4% for patients with cardiac tamponade for indication of re-exploration (p < 0.001). Conclusions This study suggests that re-exploration after cardiac surgery is associated with increased mortality and morbidity. Patients with delayed re-exploration and suffering from cardiac tamponade have adverse outcome.
    The Thoracic and Cardiovascular Surgeon 09/2014; 63(01). DOI:10.1055/s-0034-1390154 · 1.08 Impact Factor
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    ABSTRACT: Objective of this study was to evaluate the impact of age on comparative early outcomes after coronary artery bypass graft surgery (CABG) with minimized (MECC) and conventional extracorporeal circulation (CECC).
    Journal of Cardiothoracic Surgery 08/2014; 9(1):143. DOI:10.1186/s13019-014-0143-3 · 3.05 Impact Factor
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    ABSTRACT: Oxygenator thrombosis is a serious complication in extracorporeal membrane oxygenation (ECMO) and may necessitate a system exchange. Coagulation and fibrinolysis parameters, flow dynamics and gas transfer performance are currently used to evaluate the degree of oxygenator thrombosis, but there is no technical approach for direct visualization and quantification of thrombotic deposits within the membrane oxygenator (MO).We used multidetector computed tomography (MDCT) with 3D post-processing to assess the incidence of oxygenator thrombosis, to quantify thrombus extent, and to localize clot distribution. Twenty heparin-coated MOs after successful weaning were analyzed. Mean ECMO support time was 7 ± 4 days, mean activated partial thromboplastin time (aPTT) during ECMO was 59 ± 20 seconds. Thrombotic deposits were detected in all MOs. The mean clot volume was 51.7 ± 22.3 cm³. All thrombotic deposits were located in the venous, i.e. inlet part of the device, without apparent evidence of embolization in patients. There was no correlation between clot volume and ECMO support time or aPTT.Clot formation within the MO is a common finding in ECMO despite adequate systemic anticoagulation. The clinical significance of thrombus formation and its influence on gas exchange capacity and hemostatic complications have to be addressed in further studies.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 08/2014; DOI:10.1097/MAT.0000000000000133 · 1.39 Impact Factor
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    ABSTRACT: Zusammenfassung Eine pulmonale Hypertonie kann sowohl kardiale als auch pulmonale Ursachen haben und führt in der Herz-Thorax-Chirurgie zu einer signifikant erhöhten Letalität. Nachfolgend werden die medikamentösen und chiurgischen Therapieansätze dafür erläutert.
    Zeitschrift für Herz- Thorax- und Gefäßchirurgie 06/2014; 16(3). DOI:10.1007/s00398-002-0346-0
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    ABSTRACT: Background LVAD speed adjustment according to a functioning aortic valve has hypothetic advantages but could lead to submaximal support. The consequences of an open aortic valve policy on exercise capacity and hemodynamics have not yet been investigated systematically. Methods Ambulatory patients under LVAD support (INCOR®, Berlin Heart, mean support time 465 ± 257 days, average flow 4.0 ± 0.3 L/min) adjusted to maintain a near normal aortic valve function underwent maximal cardiopulmonary exercise testing (CPET) and right heart catheterization (RHC) at rest and during constant work rate exercise (20 Watt). Results Although patients (n = 8, mean age 45 ± 13 years) were in NYHA class 2, maximum work-load and peak oxygen uptake on CPET were markedly reduced with 69 ± 13 Watts (35% predicted) and 12 ± 2 mL/min/kg (38% predicted), respectively. All patients showed a typical cardiac limitation pattern and severe ventilatory inefficiency with a slope of ventilation to carbon dioxide output of 42 ± 12. On RHC, patients showed an exercise-induced increase of mean pulmonary artery pressure (from 16 ± 2.4 to 27 ± 2.8 mmHg, p < 0.001), pulmonary artery wedge pressure (from 9 ± 3.3 to 17 ± 5.3 mmHg, p = 0.01), and cardiac output (from 4.7 ± 0.5 to 6.2 ± 1.0 L/min, p = 0.008) with a corresponding slight increase of pulmonary vascular resistance (from 117 ± 35.4 to 125 ± 35.1 dyn*sec*cm−5, p = 0.58) and a decrease of mixed venous oxygen saturation (from 58 ± 6 to 32 ± 9%, p < 0.001). Conclusion An open aortic valve strategy leads to impaired exercise capacity and hemodynamics, which is not reflected by NYHA-class. Unknown compensatory mechanisms can be suspected. Further studies comparing higher vs. lower support are needed for optimization of LVAD adjustment strategies.
    Journal of Cardiothoracic Surgery 05/2014; 9(1):93. DOI:10.1186/1749-8090-9-93 · 3.05 Impact Factor
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    ABSTRACT: Veno-venous extracorporeal membrane oxygenation (vvECMO) can be a life-saving therapy in patients with severe acute lung failure refractory to conventional therapy. Nevertheless, vvECMO is a procedure associated with high costs and resource utilization. The aim of this study was to assess published models for prediction of mortality following vvECMO and optimize an alternative model. Established mortality risk scores were validated to assess their usefulness in 304 adult patients undergoing vvECMO for refractory lung failure at the University Medical Center Regensburg from 2008 to 2013. A parsimonious prediction model was developed based on variables available before ECMO initiation using logistic regression modelling. We then assessed whether addition of variables available one day after ECMO implementation enhanced mortality prediction. Models were internally validated and calibrated by bootstrapping (400 runs). Predictive ability, goodness-of-fit and model discrimination were compared across the different models. In the present study population, existing mortality prediction tools for vvECMO patients showed suboptimal performance. Evaluated before vvECMO initiation, a logistic prediction model comprising age, immunocompromised state, artificial minute ventilation, pre-ECMO serum lactate and haemoglobin concentrations showed best mortality prediction in our patients (area under curve, AUC: 0.75). Additional information about norepinephrine dosage, fraction of inspired oxygen, C-reactive protein and fibrinogen concentrations the first day following ECMO initiation further improved discrimination (AUC: 0.79, P = 0.03) and predictive ability (likelihood ratio test, P < 0.001). When classifying patients as lower (<40%) or higher (>80%) risk based on their predicted mortality, the pre-ECMO and day1-on-ECMO models had negative/positive predictive values of 76%/82% and 82%/81%, respectively. While pre-ECMO mortality prediction remains a challenge due to large patient heterogeneity, evaluation one day after ECMO initiation may improve the ability to separate lower- and higher-risk patients. Our findings support the clinical perception that chronic health condition, high comorbidity and reduced functional reserves are strongly related to survival during and following ECMO support. Renewed evaluation the first day after ECMO initiation may provide enhanced guidance for further handling of ECMO patients. Despite the usefulness of prediction models, thorough clinical evaluation should always represent the cornerstone in decision for ECMO.
    Critical care (London, England) 04/2014; 18(2):R67. DOI:10.1186/cc13824
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    The Thoracic and Cardiovascular Surgeon 02/2014; 62(S 01). DOI:10.1055/s-0034-1367253 · 1.08 Impact Factor
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    ABSTRACT: Postoperative Acute Kidney Injury (AKI) after coronary artery bypass grafting (CABG) is a common complication associated with significant morbidity and mortality. Cardiopulmonary bypass (CPB) is accepted to contribute to the occurrence of AKI and is of particular importance as it can be avoided by using the off-pump technique. However the renoprotective properties of off-pump (CABG) are controversial. This analysis evaluates the impact of cardiopulmonary bypass on renal function. A matched-pair analysis of 1428 patients undergoing coronary artery bypass grafting was conducted. The patients were stratified according to their preoperative renal function and to risk factors for postoperative AKI. The development of the glomerular filtration rate (GFR) from before surgery until hospital discharge was analyzed. Incidence of AKI were analyzed. Furthermore the impact of CPB duration on postoperative GFR was assessed. The occurrence of AKI increases the risk of thirty-day mortality (odds ratio of 4.3). The postoperative GFR decreases significantly after coronary artery bypass grafting but does not differ between onpump and offpump CABG (60.2 +/- 24.5 vs 60.7 +/- 24.8; p = 0.54). No difference regarding the incidence (26.6% vs 25%) and severity of AKI between cardiopulmonary bypass and the off-pump technique could be found. Duration of cardiopulmonary bypass does not correlate with the decline in postoperative glomerular filtration rate (Pearson Product Moment Correlation; p > 0.050). Neither the mere use nor duration of cardiopulmonary bypass proofed to be a risk factor for developing postoperative AKI in CABG patients with a comparable preoperative risk profile for postoperative renal dysfunction. Furthermore, the severity of postoperative AKI is not affected by the use of cardiopulmonary bypass.
    Journal of Cardiothoracic Surgery 01/2014; 9(1):20. DOI:10.1186/1749-8090-9-20 · 3.05 Impact Factor

Publication Stats

3k Citations
1,161.55 Total Impact Points

Institutions

  • 2008–2015
    • University Hospital Regensburg
      • Klinik und Poliklinik für Herz-, Thorax- und herznahe Gefäßchirurgie
      Ratisbon, Bavaria, Germany
    • Universität Regensburg
      • Department of Cardiac, Thoracic and Vascular Surgery near the Heart
      Ratisbon, Bavaria, Germany
  • 2011–2013
    • Universitätsklinikum Freiburg
      Freiburg an der Elbe, Lower Saxony, Germany
  • 2004–2012
    • University of Duisburg-Essen
      • • Institut für Psychologie
      • • Department of Internal and Integrative Medicine
      Essen, North Rhine-Westphalia, Germany
  • 1996–2010
    • Universitätsklinikum Münster
      • Department für Kardiologie und Angiologie
      Muenster, North Rhine-Westphalia, Germany
    • Justus-Liebig-Universität Gießen
      • Department of Internal Medicine
      Gieben, Hesse, Germany
  • 1995–2010
    • University of Münster
      • Department of Neurology
      Muenster, North Rhine-Westphalia, Germany
  • 2009
    • Martin Luther University of Halle-Wittenberg
      • Clinic for Internal Medicine III
      Halle-on-the-Saale, Saxony-Anhalt, Germany
  • 2002–2004
    • Columbia University
      New York, New York, United States