A. Zierer

Risk factors associated with adverse outcome following extracorporeal life support: analysis from 360 consecutive patients

Objective: Risk factors for adverse outcome after extracorporeal life support (ECLS) are yet to be defined. For this purpose, we reviewed our institutional data from more than a decade, focusing on patients with ECLS. Methods: Between December 2001 and June 2013, 360 consecutive cardiac surgical patients received ECLS for post-cardiotomy cardiogenic shock, with high mortality risk despite optimal conventional therapy. Patient demographics, clinical characteristics, ECLS-related morbidity, as well as in-hospital and long-term mortality were analysed. Multivariate logistic regression analysis was performed to identify independent predictors of adverse outcome (failed ECLS weaning, in-hospital mortality). Results: The mean age was 62±17 years, 76% were male and the mean preoperative ejection fraction was 35±16%. ECLS was established through peripheral (90%) or central thoracic cannulation. The mean duration of ECLS was 7±1 days. Intra-aortic balloon pumps were implanted in 22% of the patients. ECLS weaning was successful in 58% and 30% could be discharged from hospital. The main cause of death was sepsis (69%). Overall, major cerebrovascular events occurred in 12% (bleeding 3%, embolic 9%), limb ischaemia in 13%, gastrointestinal complications in 16% and renal replacement therapy in 61%. Independent risk factors for adverse outcome were prior cardiorespiratory resuscitation (OR: 4.1, 95%CI: 0.34-4.21, p=0.04), pH <7.1 (OR: 2.8, 95%CI: 0.45-3.28, p=0.01), serum lactate >120 mg/dL (OR: 2.6, 95%CI: 0.75-2.96, p< 0.01), norepinephrine dosage >0.5 µg/kg/min (OR: 2.4, 95%CI: 0.35-2.92, p=0.02) and age >75 years (OR: 2.0, 95%CI: 0.41-2.88, p=0.02). Kaplan Meier estimates for long-term survival were 26±3% at one year and 22±2% at five years. Conclusion: ECLS therapy offers one-year survival to one quarter of patients with an otherwise fatal prognosis. Procedural mortality is low and morbidity at the implantation site typically moderate. Thus, prolonged metabolic deterioration in combination with high-dose vasopressor support prior to ECLS therapy should be avoided, particularly in younger patients.

Patient-blood-Management

ZusammenfassungHintergrundDie präoperative Anämie hat in den Industrienationen eine Prävalenz von ungefähr 30u2009%, ist einer der stärksten Prädiktoren für die perioperative Gabe von Erythrozytenkonzentraten (EK) und zugleich ein eigenständiger und unabhängiger Risikofaktor für das Auftreten postoperativer Komplikationen. Im Bereich der Hämotherapie ist weltweit eine breite Variabilität der Indikationsstellung zum Einsatz von EK auffallend. Vor diesem Hintergrund wird seit 2011 von der Weltgesundheitsorganisation die Implementierung eines Patient-blood-Managements (PBM) gefordert.FragestellungPBM wird als mehrdimensionaler und interdisziplinärer Behandlungsansatz vorgestellt.Material und MethodeEs wurde eine selektive Literaturrecherche in den Datenbanken Medline und The Cochrane Library durchgeführt und nationale und internationale Leitlinien berücksichtigt.ErgebnissePBM ermöglicht den medizinisch und ethisch adäquaten Einsatz aller zur Verfügung stehenden Ressourcen, Techniken und Materialien zugunsten einer optimierten perioperativen Patientenversorgung. Patienteneigene Ressourcen werden gezielt geschont, gestärkt und genutzt. Im Detail gehören hierzu: Diagnostik und Therapie einer präoperativen Anämie, Minimierung des perioperativen Blutverlustes, blutsparende Operationstechniken, restriktive diagnostische Blutentnahmen, Ausschöpfung der individuellen Anämietoleranz, optimale Gerinnungs- und Hämotherapiekonzepte sowie leitliniengerechte, rationale Indikationsstellung des Einsatzes von EK.DiskussionDas PBM sollte als Anreiz gesehen werden, um lokale Gegebenheiten kritisch zu evaluieren und zu optimieren. Ein individuelles, interdisziplinär gestaltetes PBM-Maßnahmenbündel besitzt großes Potenzial, die Qualität der Patientenversorgung zu optimieren und sicherer zu machen.AbstractBackgroundPreoperative anemia has a prevalence of approximately 30u2009% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM).ObjectivesThis article provides information about PBM as a multidimensional and interdisciplinary approach.Material and methodsA selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines.ResultsA PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients’ own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions.ConclusionA PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.

[Patient blood management: Current state of the literature].

ZusammenfassungHintergrundDie präoperative Anämie hat in den Industrienationen eine Prävalenz von ungefähr 30u2009%, ist einer der stärksten Prädiktoren für die perioperative Gabe von Erythrozytenkonzentraten (EK) und zugleich ein eigenständiger und unabhängiger Risikofaktor für das Auftreten postoperativer Komplikationen. Im Bereich der Hämotherapie ist weltweit eine breite Variabilität der Indikationsstellung zum Einsatz von EK auffallend. Vor diesem Hintergrund wird seit 2011 von der Weltgesundheitsorganisation die Implementierung eines Patient-blood-Managements (PBM) gefordert.FragestellungPBM wird als mehrdimensionaler und interdisziplinärer Behandlungsansatz vorgestellt.Material und MethodeEs wurde eine selektive Literaturrecherche in den Datenbanken Medline und The Cochrane Library durchgeführt und nationale und internationale Leitlinien berücksichtigt.ErgebnissePBM ermöglicht den medizinisch und ethisch adäquaten Einsatz aller zur Verfügung stehenden Ressourcen, Techniken und Materialien zugunsten einer optimierten perioperativen Patientenversorgung. Patienteneigene Ressourcen werden gezielt geschont, gestärkt und genutzt. Im Detail gehören hierzu: Diagnostik und Therapie einer präoperativen Anämie, Minimierung des perioperativen Blutverlustes, blutsparende Operationstechniken, restriktive diagnostische Blutentnahmen, Ausschöpfung der individuellen Anämietoleranz, optimale Gerinnungs- und Hämotherapiekonzepte sowie leitliniengerechte, rationale Indikationsstellung des Einsatzes von EK.DiskussionDas PBM sollte als Anreiz gesehen werden, um lokale Gegebenheiten kritisch zu evaluieren und zu optimieren. Ein individuelles, interdisziplinär gestaltetes PBM-Maßnahmenbündel besitzt großes Potenzial, die Qualität der Patientenversorgung zu optimieren und sicherer zu machen.AbstractBackgroundPreoperative anemia has a prevalence of approximately 30u2009% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM).ObjectivesThis article provides information about PBM as a multidimensional and interdisciplinary approach.Material and methodsA selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines.ResultsA PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients’ own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions.ConclusionA PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.

Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?

Abstract Objectives Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate‐to‐mild systemic hypothermic circulatory arrest (≥ 28°C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of ≥ 60 minutes in moderate‐to‐mild hypothermia (≥ 28°C). Methods Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate‐to‐mild systemic hypothermia (≥ 28°C) with prolonged ACP and circulatory arrest times. Patients’ mean age was 59 ± 15 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow‐up was 6 ± 4 years and was 98% complete. Results Cardiopulmonary bypass time accounted for 245 ± 81 minutes and the myocardial ischemic time accounted for 140 ± 43 minutes. Mean duration of ACP was 74 ± 12 minutes. The mean lowest core temperature accounted for 28.9 ± 0.8°C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 ± 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients (n = 5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty‐day mortality and in‐hospital mortality were 8 (n = 5) and 11% (n = 7), respectively. Overall survival at 5 years was 76 ± 9%. Conclusion Our preliminary data suggest that selective ACP during moderate‐to‐mild systemic hypothermic circulatory arrest (≥ 28°C) can safely be applied for more than 1 hour even in the setting of AAD.

Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique

OBJECTIVESnu2003The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion.nnnMETHODSnu2003Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°Cu2009±u20090.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3u2009±u20092 years and was 98% complete. Clinical data were prospectively entered into our institutional database.nnnRESULTSnu2003Cardiopulmonary bypass time accounted for 198u2009±u200958 minutes and the myocardial ischemic time 109u2009±u200929 minutes. Selective antegrade cerebral perfusion time was 55u2009±u20096 minutes. Lower body circulatory arrest time was 39u2009±u200911 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4u2009±u20093 days. Thirty-day mortality was 5% (nu2009=u20092). Late survival at 3 years was 87u2009±u20093%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7u2009±u20092 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted.nnnCONCLUSIONSnu2003Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

First in man: Off-pump transapical transcatheter aortic valve implantation and mitral valve repair

We report the case of an 89-year-old man with severe aortic valve stenosis and concomitant severe mitral valvexa0regurgitation. Due to his age and comorbidities, the patient was not accepted for open heart surgery. After interdisciplinary discussion with the heart team, the patient underwent a minimally invasive off-pump procedure combining aortic valve replacement with mitral valve repair. Cardiac surgeons performed a transapical aortic valve replacement, followed by mitral valve repair applying the NeoChord device (NeoChord Inc, St. Louis Park, MN) under three-dimensional transesophageal echocardiographic guidance by an interventional cardiologist. The patients further clinical course was uneventful, and he did well on follow-up examinations.

Aortic events and reoperations after elective arch surgery: incidence, surgical strategies and outcomes

OBJECTIVESnThe true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres.nnnMETHODSnRetrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians.nnnRESULTSnOne hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7u2009months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (nu2009=u2009133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5u2009years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified rupture and diameter progression, older age at REDO and the REDO strategies frozen elephant trunk and no elephant trunk as predictors of increased in-hospital mortality. Multivariate analysis identified older age at REDO (Pu2009=u20090.008) as the only independent risk factor for in-hospital mortality.nnnCONCLUSIONSnAEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable.

Targeted gene expression analyses and immunohistology suggest a pro-proliferative state in tricuspid aortic valve-, and senescence and viral infections in bicuspid aortic valve-associated thoracic aortic aneurysms

BACKGROUND AND AIMSnDespite the potential life-threatening consequences of thoracic aortic aneurysms (TAAs), the pathogenesis of these diseases is still poorly understood. While some aspects of TAA formation have been elucidated, the role of vascular smooth muscle cells (SMCs) in both bicuspid aortic valve (BAV)-associated and degenerative tricuspid aortic valve (TAV)-associated TAAs has not yet been fully unravelled. Thus, this work was aimed at uncovering processes in SMC biology that may contribute to TAA formation.nnnMETHODSnUsing isolated SMCs and tissue samples from TAAs linked to BAV syndrome, TAV-associated degenerative TAAs and control aortas, we performed targeted mRNA expression profile analyses and conducted immunohistological analyses on aortic wall tissue sections.nnnRESULTSnWhile SMC expression profiles and tissue analyses in TAV-TAAs clearly point toward a pro-proliferative state of the aortic media SMCs, BAV-TAA SMCs and tissue provide evidence for DNA damage, DNA damage response signalling as well as profound TLR-3 signalling.nnnCONCLUSIONSnThe data presented in this study emphasizes the importance of SMCs in TAA development. Furthermore, our results provide evidence that the state of SMCs in the BAV-TAA (senescent) and TAV-TAA (pro-proliferative) differs significantly. For the first time, we also present findings that may argue for the occurrence of a viral infection in BAV-TAA SMCs.

Early and Late Outcomes Following Emergent Surgery for Iatrogenic Type A Aortic Dissection

Objectives: Iatrogenic ascending aortic dissection (iAAD) is a rare but potentially lethal complication of cardiac surgery and cardiac catheterization. Previous clinical outcomes studies have yielded controversial results. The aim of the study is to describe the clinical characteristics of patients with iAAD and to evaluate the early and the late clinical outcomes after emergent surgical treatment. Methods: From January 2005 to January 2015, 51 patients underwent emergent surgery for iAAD during moderate systemic hypothermia (≥28°C) and selective antegrade cerebral perfusion at two referral cardiac surgery centers in Germany. The patients mean age was 68u2009±u200911 years and 29 (57%) were men. Isolated ascending aortic replacement, bentall procedure, hemiarch replacement and total arch replacement were performed in 6 patients (12%), 3 patients (6%), 32 patients (68%) and 10 patients (20%), respectively. Operative data were prospectively entered into our computerized database. Mean late follow up was 4u2009±u20092 years and was 100% complete. Results: Mean cardiopulmonary bypass time was 174u2009±u200979 minutes and mean myocardial ischemic time was 106u2009±u200952 minutes. Isolated cerebral perfusion was performed for 41u2009±u200921 minutes. Mean core temperature amounted to 29,1°Cu2009±u20090,9°C. Unilateral cerebral perfusion was performed in 33 patients (65%), bilateral in 18 patients (35%). Mean intensive care unit stay was 5u2009±u20096 days. We observed new postoperative permanent neurologic deficits in 4 patients (8%) and transient neurologic deficits in 6 patients (12%). Thirty day mortality was 8% (nu2009=u20094). Late survival at 5 years was 75u2009±u20099%. Conclusions: Operative outcomes after emergent surgery for iAAD are favorable, bearing in mind that all patients present relevant cardiac co-morbidities. Early and mid-term results are comparable to those after spontaneous aortic dissection.

Patient-blood-Management@@@Patient blood management: Stand der aktuellen Literatur@@@Current state of the literature

ZusammenfassungHintergrundDie präoperative Anämie hat in den Industrienationen eine Prävalenz von ungefähr 30u2009%, ist einer der stärksten Prädiktoren für die perioperative Gabe von Erythrozytenkonzentraten (EK) und zugleich ein eigenständiger und unabhängiger Risikofaktor für das Auftreten postoperativer Komplikationen. Im Bereich der Hämotherapie ist weltweit eine breite Variabilität der Indikationsstellung zum Einsatz von EK auffallend. Vor diesem Hintergrund wird seit 2011 von der Weltgesundheitsorganisation die Implementierung eines Patient-blood-Managements (PBM) gefordert.FragestellungPBM wird als mehrdimensionaler und interdisziplinärer Behandlungsansatz vorgestellt.Material und MethodeEs wurde eine selektive Literaturrecherche in den Datenbanken Medline und The Cochrane Library durchgeführt und nationale und internationale Leitlinien berücksichtigt.ErgebnissePBM ermöglicht den medizinisch und ethisch adäquaten Einsatz aller zur Verfügung stehenden Ressourcen, Techniken und Materialien zugunsten einer optimierten perioperativen Patientenversorgung. Patienteneigene Ressourcen werden gezielt geschont, gestärkt und genutzt. Im Detail gehören hierzu: Diagnostik und Therapie einer präoperativen Anämie, Minimierung des perioperativen Blutverlustes, blutsparende Operationstechniken, restriktive diagnostische Blutentnahmen, Ausschöpfung der individuellen Anämietoleranz, optimale Gerinnungs- und Hämotherapiekonzepte sowie leitliniengerechte, rationale Indikationsstellung des Einsatzes von EK.DiskussionDas PBM sollte als Anreiz gesehen werden, um lokale Gegebenheiten kritisch zu evaluieren und zu optimieren. Ein individuelles, interdisziplinär gestaltetes PBM-Maßnahmenbündel besitzt großes Potenzial, die Qualität der Patientenversorgung zu optimieren und sicherer zu machen.AbstractBackgroundPreoperative anemia has a prevalence of approximately 30u2009% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM).ObjectivesThis article provides information about PBM as a multidimensional and interdisciplinary approach.Material and methodsA selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines.ResultsA PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients’ own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions.ConclusionA PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.