Christoph Hoermann

Experience with percutaneous venoarterial cardiopulmonary bypass for emergency circulatory support.

ObjectiveMechanical circulatory support can maintain vital organ perfusion in patients with cardiac failure unresponsive to standard pharmacologic treatment. The purpose of the current study was to report complication and survival rates in patients supported with emergency percutaneous venoarterial cardiopulmonary bypass because of prolonged cardiogenic shock or cardiopulmonary arrest. DesignRetrospective clinical study. SubjectsA total of 46 patients supported with venoarterial cardiopulmonary bypass, 25 because of cardiogenic shock unresponsive to pharmacologic therapy and 21 because of cardiopulmonary arrest unresponsive to standard advanced cardiac life support. ResultsIn 41 of the 46 patients (89%), stable extracorporeal circulation was established; in five patients (11%), femoral cannulation was accomplished only after a surgical cutdown. A total of 28 patients were weaned from cardiopulmonary bypass (19 of 25 patients with cardiogenic shock vs. 9 of 21 patients with cardiopulmonary arrest, p = .03), and 13 patients had long-term survival (10 of 25 patients with cardiogenic shock vs. 3 of 21 patients with cardiopulmonary arrest, p = .1). Complications directly related to the use of cardiopulmonary bypass were found in 18 patients (39%), major complications related to femoral cannulation being the most common single cause for bypass-associated morbidity (eight patients, 17%) ConclusionsLong-term survival rates after emergency percutaneous cardiopulmonary bypass are encouraging in patients with an underlying cardiocirculatory disease amenable to immediate corrective intervention (angioplasty, surgery, transplantation).

Sevoflurane, but not Propofol, Significantly Prolongs the Q-T Interval

Prolongation of the Q-T interval may be associated with polymorphic ventricular tachycardia known as torsade de pointes, syncope and sudden death. Existing data show that isoflurane prolongs the Q-T interval, whereas halothane shortens it. The aim of this study was to determine whether sevoflurane or propofol affects the Q-T interval. Thirty female patients undergoing gynecologic surgery were randomly assigned to two groups, one receiving inhaled induction with sevoflurane and the other receiving total IV anesthesia with propofol. Before and 20 min after the induction, a six-lead electrocardiogram was recorded, and blood pressure was measured. The Q-T interval and heart rate adjusted Q-T interval (Q-Tc interval) were significantly prolonged during the administration of anesthesia with sevoflurane, while the Q-T interval was significantly shortened, and the Q-Tc interval was statistically unaffected during propofol anesthesia administration. We conclude that, in otherwise healthy female patients, sevoflurane prolongs the Q-Tc. Implications In this study, we evaluated the effect of sevoflurane induction and anesthesia versus propofol induction and anesthesia on the Q-T interval. Sevoflurane significantly prolonged the Q-T interval and the heart rate adjusted Q-T interval, whereas propofol shortened the Q-T interval but not the heart rate adjusted Q-T interval.

Continuous Positive Airway Pressure at 10 cm H2O During Cardiopulmonary Bypass Improves Postoperative Gas Exchange

Postbypass pulmonary dysfunction including atelectasis and increased shunting is a common problem in the intensive care unit. Negative net fluid balance and continuous positive airway pressure (CPAP) have been used to reduce the adverse effects of cardiopulmonary bypass (CPB) on the lung. To determi

Inert gas exchange during pneumoperitoneum at incremental values of positive end-expiratory pressure

UNLABELLED Laparoscopy is a surgical technique for a growing variety of abdominal operations. In patients undergoing this procedure, arterial blood oxygenation and hemodynamics are frequently depressed. This study evaluated the effect of different levels of positive end-expiratory pressure (PEEP) during intraperitoneal CO(2) insufflation on the lungs ventilation-perfusion distribution in a porcine model. We studied 13 anesthetized pigs with an intraperitoneal pressure of 15 cm H(2)O applied at either incremental values of PEEP (5-20 cm H(2)O, increments of 5 cm H(2)O) or a constant PEEP of 5 cm H(2)O. The effects of CO(2) pneumoperitoneum on inert gas exchange and hemodynamics were examined with the multiple inert gas elimination technique. During pneumoperitoneum, gas exchange was most augmented by 15 and 20 cm H(2)O of PEEP. Although the differences in hemodynamics between the individual settings were insignificant, 10 cm H(2)O of PEEP provided the smallest impairment of hemodynamics. We conclude that PEEP of 15 H(2)O during pneumoperitoneum resulted in a modest hemodynamic depression but significant gas exchange augmentation in our experiment. IMPLICATIONS Anesthetized pigs, with a pneumoperitoneum of 15 cm H(2)O, were treated either with incremental values of positive end-expiratory pressure (5-20 cm H(2)O, increments of 5 cm H(2)O) or with a constant positive end-expiratory pressure of 5 cm H(2)O. Fifteen and 20 cm H(2)O resulted in significantly improved pulmonary gas exchange compared with 5 cm H(2)O.

Caspofungin‐resistant Aspergillus flavus after heart transplantation and mechanical circulatory support: a case report

Abstract: Invasive aspergillosis (IA) is a severe complication in the post‐transplant period in recipients of solid organs. Therefore, early diagnosis and specific therapy of fungal infections in these patients are indispensable. We report the case of a 49‐year‐old patient, who suffered from IA after cardiac transplantation, which was complicated by post‐transplant right heart failure requiring mechanical circulatory support using veno‐arterial extracorporeal membrane oxygenation and a right ventricular assist device. Despite antifungal treatment, the patient died 3 weeks after transplantation because of multi‐organ failure secondary to IA. The isolated Aspergillus strains exhibited in vitro resistance to caspofungin.

Isoflurane and sevoflurane anesthesia in pigs with a preexistent gas exchange defect

Background Decreased arterial partial pressure of oxygen (Pao2) during volatile anesthesia is well-known. Halothane has been examined with the multiple inert gas elimination technique and has been shown to alter the distribution of pulmonary blood flow and thus Pao2. The effects of isoflurane and sevoflurane on pulmonary gas exchange remain unknown. The authors hypothesized that sevoflurane with a relatively high minimum alveolar concentration (MAC) would result in significantly more gas exchange disturbances in comparison with isoflurane or control. Methods This study was performed in a porcine model with an air pneumoperitoneum that generates a reproducible gas exchange defect. After a baseline measurement of pulmonary gas exchange (multiple inert gas elimination technique) during propofol anesthesia, 21 pigs were randomly assigned to three groups of seven animals each. One group received isoflurane anesthesia, one group received sevoflurane anesthesia, and one group was continued on propofol anesthesia (control). After 30 min of volatile anesthesia at 1 MAC or propofol anesthesia, a second measurement (multiple inert gas elimination technique) was performed. Results At the second measurement, inert gas shunt was 15 ± 3% (mean ± SD) during sevoflurane anesthesia versus 9 ± 1% during propofol anesthesia (P = 0.02). Blood flow to normal ventilation/perfusion (&OV0312;A/&OV0422;) lung areas was 83 ± 5% during sevoflurane anesthesia versus 89 ± 1% during propofol anesthesia (P = 0.04). This resulted in a Pao2 of 88 ± 11 mmHg during sevoflurane anesthesia versus 102 ± 15 mmHg during propofol anesthesia (P = 0.04). Inert gas and blood gas variables during isoflurane anesthesia did not differ significantly from those obtained during propofol anesthesia. Conclusions In pigs with an already existent gas exchange defect, sevoflurane anesthesia but not isoflurane anesthesia causes significantly more gas exchange disturbances than propofol anesthesia does.

Successful administration of levosimendan in a patient with low-gradient low-output aortic stenosis

SummaryAortic valve replacement in patients suffering from low-gradient aortic stenosis and congestive heart failure is associated with high operative mortality, and the perioperative use of inotropes is common. Levosimendan is a calcium sensitizer with positive inotropic and vasodilatory effects and has been developed for treatment of decompensated heart failure. Although its use in patients with low-gradient aortic stenosis is not established, we hypothesized that it might have beneficial effects on outcome after aortic valve replacement. We report on a high-risk operation in a 73-year-old man with low-gradient aortic stenosis, congestive heart failure and coronary artery disease. Levosimendan was administered perioperatively (0.1 mg/kg/min 16 hours prior to the operation without a loading dose) and allowed rapid recovery of the patient, who required only brief treatment in the intensive care unit. No levosimendan-specific adverse events were observed, in particular no hypotension. The excellent postoperative result was maintained after the patient was discharged from hospital.ZusammenfassungEin Aortenklappenersatz bei Patienten mit einer Aortenklappenstenose mit niedrigem Druckgradienten und hochgradig eingeschränkter Linksventrikelfunktion ist mit einer hohen Mortalität assoziiert und der perioperative Einsatz von positiv inotropen Substanzen ist häufig erforderlich. Levosimendan ist ein Kalzium-Sensitizer, der für die Therapie der akuten Herzinsuffizienz entwickelt wurde. Der Einsatz bei Patienten mit Aortenklappenstenose mit niedrigem Druckgradienten ist nicht etabliert, wir erwarteten jedoch vom perioperativen Einsatz dieses Medikaments einen positiven Einfluss auf das Überleben. Wir berichten über eine Hochrisiko-Operation bei einem 73-jährigen Mann mit einer Aortenklappenstenose mit niedrigem Druckgradienten, einer hochgradig eingeschränkten Linksventrikelfunktion und koronarer Herzkrankheit. Levosimendan wurde perioperativ verabreicht (0,1 mg/kg/min ohne Bolusgabe, Beginn 16 Stunden präoperativ), was die schnelle Erholung des Patienten und damit eine kurze Intensivtherapie begünstigte. Es traten keine Levosimendan-assoziierten Komplikationen, insbesondere keine Hypotonie, auf. Das exzellente postoperative Ergebnis ist auch im Langzeitverlauf stabil.

The pediatric mechanical circulatory support program in Innsbruck, Austria, and the impact of such programs on lack of donor hearts in Europe.

Strategy and results of the Innsbruck Mechanical Circulatory Support Program are presented, and the impact of such programs on pediatric heart transplantation (HTX) in Europe is discussed. Venoarterial extracorporeal membrane oxygenation (vaECMO) and ventricular assist devices (VADs) were used in 21 pediatric patients (median age 3.3 years, 2 days to 17 years) for acute heart failure (AHF) following a bridge or bridge-to-bridge strategy. Twelve patients were treated with vaECMO: eight were weaned after 2–10 days, two died, and two were switched to a VAD. Of the last, one was weaned 47 days later and the other underwent HTX 168 days later. In nine patients, VAD was implanted without preceding vaECMO. One such patient died (cerebral hemorrhage) after 236 days; of the remaining eight patients three were weaned and five underwent HTX. Waiting time for HTX (high-urgency status) varied from 4 to 372 days. Fifteen patients were discharged (follow up: 2–74 months); 14 are doing very well (New York Heart Association (NYHA) Functional Classification Class I, neurologically normal), whereas one suffers from severe neurologic damage, presumably from resuscitation before vaECMO. Data from Eurotransplant on pediatric HTX in 2004, 2005, and 2006 (33, 49, and 34 transplanted hearts, respectively; recipients <16 years of age) are discussed. Mechanical circulatory support (MCS) substantially improves survival with AHF in pediatric patients. Medium-term support (up to 400 days in our patients) is possible and outcome of survivors is excellent. Wide spread use of MCS might slightly aggravate the lack of donor organs, which could result in longer support times.

Interventional and medical treatment of acute heart failure due to inflammation: four cases.

Four patients (aged 15–41 years, mean age 26.7 years) with fulminant myocarditis undergoing mechanical circulatory support are reported. All patients suffered from acute low-output syndrome refractory to inotropic support. Diagnosis was confirmed by histology and immunohistochemistry. RT-PCR (reverse transcription-polymerase chain reaction) from endomyocardial biopsy specimens revealed parvovirus B19 in two patients and a coinfection with Chlamydia pneumoniae and parvovirus B19 in one patient. Midterm support with the biventricular Thoratec® system was preceded by implantation of an extracorporeal membrane oxygenation (ECMO) device in two patients. Two patients regained full cardiac function and were successfully weaned from the ventricular assist device (VAD) after 12 and 40 days. Heart transplantation was performed in another patient without evidence of myocardial recovery after 53 days. One patient died of cerebral hemorrhage on day 12 after VAD implantation. In summary, patients with life-threatening fulminant myocarditis can be successfully bridged to recovery or transplantation with mechanical circulatory support.ZusammenfassungDie fulminante Myokarditis ist eine seltene Manifestation der inflammatorischen Kardiomyopathie. Die rasche Entwicklung eines kardiogenen Schocks bzw. ei ner schweren kardialen Dysfunktion kennzeichnet diese Erkrankung. Die Langzeitprognose ist günstig, sofern der Patient die akute Erkrankungsphase überlebt. Berichtet wird über eigene Erfahrungen mit der Implantation mechanischer Unterstützungssysteme bei vier Patienten mit fulminanter Myokarditis.Die Diagnose wurde jeweils histologisch und immunhistochemisch gesichert. Mittels RT-PCR (reverse Transkription-Polymerase-Kettenreaktion) konnte im Myokard von Patientin A (24 Jahre) eine Koinfektion mit Chlamydia pneumoniae und Parvovirus B19, bei zwei Patienten (Patient B männlich, 41 Jahre; Patient C weiblich, 27 Jahre) eine isolierte Infektion mit Parvovirus B19 nachgewiesen werden. Bei Patient D (15 Jahre) fand sich kein Erreger. Patienten A und B erhielten Immunglobuline (2 ×10 g), Patientin A in Kombination mit einem Makrolidantibiotikum.Alle Patienten wiesen eine kurze Erkrankungsdauer mit rascher Entwicklung eines akuten Low-Output-Syndroms auf. Die Implantation des mechani schen Unterstützungssystems erfolgte wegen unzureichender Wirkung der medikamentösen inotropen Unterstützung. Bei zwei Patienten (A, B) wurde zunächst eine extrakorporale Membranoxygenie rung (ECMO) implantiert, welche nach 2 bzw. 4 Tagen durch ein biventrikuläres Unterstützungssystem (BVAD) ersetzt wurde. Zwei Patienten wurden primär mit diesem System versorgt.Bei zwei Patienten (A, D) zeigte sich eine sukzessive Erholung der kardialen Funktion, so dass das Unterstützungssystem nach 12 bzw. 40 Tagen entfernt werden konnte. Beide Patienten wiesen bei der Entlassung eine normale Ventrikelfunktion auf. Patient B wurde nach 53 Tagen wegen fehlender Verbesserung der Pumpfunktion erfolgreich einer Herztransplantation unterzogen. Patientin C verstarb am 12. Tag am Kunstherz an einer Hirnblutung. Als Ursache ist neben der notwendigen Antikoagulanzientherapie ein erworbenes Von-Willebrand-Syndrom anzunehmen.Insgesamt zeigte sich in dieser Serie, dass bei Patienten mit fulminanter Myokarditis mit Hilfe eines mechanischen Unterstützungssystems eine erfolgreiche Überbrückung bis zur Erholung des Myokards bzw. zur Herztransplantation möglich ist.

Interventional and Medical Treatment of Acute Heart Failure Due to Inflammation

Four patients (aged 15–41 years, mean age 26.7 years) with fulminant myocarditis undergoing mechanical circulatory support are reported. All patients suffered from acute low-output syndrome refractory to inotropic support. Diagnosis was confirmed by histology and immunohistochemistry. RT-PCR (reverse transcription-polymerase chain reaction) from endomyocardial biopsy specimens revealed parvovirus B19 in two patients and a coinfection with Chlamydia pneumoniae and parvovirus B19 in one patient. Midterm support with the biventricular Thoratec® system was preceded by implantation of an extracorporeal membrane oxygenation (ECMO) device in two patients. Two patients regained full cardiac function and were successfully weaned from the ventricular assist device (VAD) after 12 and 40 days. Heart transplantation was performed in another patient without evidence of myocardial recovery after 53 days. One patient died of cerebral hemorrhage on day 12 after VAD implantation. In summary, patients with life-threatening fulminant myocarditis can be successfully bridged to recovery or transplantation with mechanical circulatory support.ZusammenfassungDie fulminante Myokarditis ist eine seltene Manifestation der inflammatorischen Kardiomyopathie. Die rasche Entwicklung eines kardiogenen Schocks bzw. ei ner schweren kardialen Dysfunktion kennzeichnet diese Erkrankung. Die Langzeitprognose ist günstig, sofern der Patient die akute Erkrankungsphase überlebt. Berichtet wird über eigene Erfahrungen mit der Implantation mechanischer Unterstützungssysteme bei vier Patienten mit fulminanter Myokarditis.Die Diagnose wurde jeweils histologisch und immunhistochemisch gesichert. Mittels RT-PCR (reverse Transkription-Polymerase-Kettenreaktion) konnte im Myokard von Patientin A (24 Jahre) eine Koinfektion mit Chlamydia pneumoniae und Parvovirus B19, bei zwei Patienten (Patient B männlich, 41 Jahre; Patient C weiblich, 27 Jahre) eine isolierte Infektion mit Parvovirus B19 nachgewiesen werden. Bei Patient D (15 Jahre) fand sich kein Erreger. Patienten A und B erhielten Immunglobuline (2 ×10 g), Patientin A in Kombination mit einem Makrolidantibiotikum.Alle Patienten wiesen eine kurze Erkrankungsdauer mit rascher Entwicklung eines akuten Low-Output-Syndroms auf. Die Implantation des mechani schen Unterstützungssystems erfolgte wegen unzureichender Wirkung der medikamentösen inotropen Unterstützung. Bei zwei Patienten (A, B) wurde zunächst eine extrakorporale Membranoxygenie rung (ECMO) implantiert, welche nach 2 bzw. 4 Tagen durch ein biventrikuläres Unterstützungssystem (BVAD) ersetzt wurde. Zwei Patienten wurden primär mit diesem System versorgt.Bei zwei Patienten (A, D) zeigte sich eine sukzessive Erholung der kardialen Funktion, so dass das Unterstützungssystem nach 12 bzw. 40 Tagen entfernt werden konnte. Beide Patienten wiesen bei der Entlassung eine normale Ventrikelfunktion auf. Patient B wurde nach 53 Tagen wegen fehlender Verbesserung der Pumpfunktion erfolgreich einer Herztransplantation unterzogen. Patientin C verstarb am 12. Tag am Kunstherz an einer Hirnblutung. Als Ursache ist neben der notwendigen Antikoagulanzientherapie ein erworbenes Von-Willebrand-Syndrom anzunehmen.Insgesamt zeigte sich in dieser Serie, dass bei Patienten mit fulminanter Myokarditis mit Hilfe eines mechanischen Unterstützungssystems eine erfolgreiche Überbrückung bis zur Erholung des Myokards bzw. zur Herztransplantation möglich ist.