Hj Geissler

The effect of preoperative antiplatelet therapy in coronary artery surgery: blood transfusion requirements for patients on cardiopulmonary bypass

SUMMARY Introduction: Bleeding after heart operations remains a common complication and contributes to morbidity and death. Recent studies have suggested that antiplatelet therapy (APT) may not increase homologous blood requirements in coronary bypass surgery. The purpose of this study was to examine the influence of APT therapy on haemorrhage and transfusion requirements in patients undergoing coronary artery bypass (CABG) on cardiopulmonary bypass (CPB). Materials and methods: Records from 290 consecutive patients who underwent CABG with CPB were retrospectively reviewed, including 145 patients who received APT within 5 days prior to surgery and 145 control patients (CON). Blood loss was measured up to 24 h. Demographic and clinical patient data were collected until hospital discharge. Results: Both groups were well matched with respect to demographic and intra-operative data. There was significantly ( p < 0.0005) more mediastinal tube drainage at 24 h in the APT group (1123 mL ± 537 mL) compared to CON patients (874 mL ± 351 mL). In addition, the APT group received significantly more units of blood (APT: 2.6 ± 2.5 vs CON: 1.6 ± 1.8; p < 0.0005), platelet units (APT: 1.2 ± 1.8 vs CON: 0.2 ± 0.8; p < 0.0005), and fresh frozen plasma units (APT: 2.0 ± 2.2 vs CON: 1.3 ± 2.0; p = 0.01). Conclusion: This study suggests consideration should be given to delaying elective CABG for patients who have received APT treatment until APT is discontinued for at least 5 days.

Increased vascular selectivity and prolonged pharmacological efficacy of the L-type Ca2+ channel antagonist lercanidipine in human cardiovascular tissue

1. The present study investigates the vasoselectivity of lercanidipine (LER), a 1,4‐dihydropyridine calcium channel blocker, compared with amlodipine (AML) and nifedipine (NIF) in human cardiovascular tissue. Experiments were performed either in human left ventricular failing myocardium (orthotopic heart transplants) or in isolated right atrial trabeculae and isolated vessel preparations of arteria mammaria obtained from patients undergoing aortocoronary bypass operation.

Risk stratification models fail to predict hospital costs of cardiac surgery patients

Das Ziel dieser prospektiven Studie war festzustellen, ob präoperative Risikoscores die Gesamtkosten in der Herzchirurgie vorhersagen können. Zwischen dem 1. Oktober und 31. Dezember 2003 wurden alle konsekutiven erwachsenen Patienten, die sich einem herzchirurgischen Eingriff mit Herz-Lungenmaschine unterzogen, mittels sieben verschiedener Risikostratifizierungsmodelle klassifiziert: EuroSCORE, Cleveland, Parsonnet, Ontario, French, Pons und CABDEAL. Die Gesamtkosten des Krankenhauses wurden für jeden Patienten täglich prospektiv berechnet. In die Analyse wurden Kosten der präoperativen Diagnostik, der operativen Prozedur, der Verbrauchsmaterialien, der Medikamente, der Blutprodukte, der Personalkosten und die Fixkosten des Krankenhauses nach Angaben des Kalkulationshandbuches Version 2,0 mit eingerechnet. Die Korrelation zwischen den erreichten Scorepunkten und den entstandenen Kosten erfolgte mit den Korrelationskoeffizienten nach Spearman. Die Erlöse aller Patienten wurden mit ihren Zu- und Abschlägen für das Jahr 2003 ermittelt. Insgesamt wurden 252 erwachsene Patienten mit Herz-Lungenmaschine operiert. Davon erhielten 175 Patienten eine Bypassoperation, 39 Patienten eine Klappenoperation, 21 Patienten eine kombinierte Bypass- und Klappenoperation, 13 Patienten eine Operation an der thorakalen Aorta. Außerdem wurden 2 Patienten wegen eines Myxoms, 1 Patient wegen eines Vorhofseptumdefekts und 1 Patient wegen einer fulminanten Lungenembolie operiert. Das mittlere Alter der Patienten lag bei 66,0±11,4 Jahre, 29,4% der Patienten waren weiblich. Die Intensivliegedauer lag bei 3,3±6,3 Tagen, und die 30-Tageletalität lag bei 6,7%. Die Korrelationskoeffizienten zwischen den 7 Risikomodellen und den Klinikkosten war mit einem r<0,33 (p=0,0001) sehr niedrig. Eine deutliche Korrelation r=0,94 (p=0,0001) konnte jedoch zwischen der Intensivverweildauer und Kosten ermittelt werden. Die Krankenhauskosten können mit der Länge des Intensivaufenthaltes gut prognostiziert werden. Eine Kostenprognose war jedoch mit keinem Risikomodell möglich. The aim of this prospective study was to determine if commonly used risk stratification models can predict total hospital costs in cardiac surgical patients. Between October 1st and December 31st 2003, all consecutive adult patients undergoing cardiac surgery on CPB at our institution were classified using seven risk stratification scoring systems: EuroSCORE, Cleveland, Parsonnet, Ontario, French, Pons, and CABDEAL. Total hospital costs for each patient were calculated on a daily basis including preoperative diagnostic tests, operating room costs, disposable materials, drugs, blood components, costs for personnel, and hospital fixed-costs. Linear regression analysis was used to determine the correlation between costs and the seven risk stratifications models as well as length of stay (LOS) on ICU. The Spearman correlation coefficient was calculated from the regression line, and an analysis of residuals was performed to determine the quality of the regression. A total of 252 patients were operated for CABG (n=175), valve (n=39), CABG plus valve (n=21), thoracic aorta (n=13) and miscellaneous (2 myxoma, 1 ASD, 1 pulmonary embolism). Mean age of the patients was 66.0±11.4 years, 29.4% were female. LOS on ICU was 3.3±6.3 days and the 30-day mortality rate was 6.7%. Spearman correlation between the seven risk stratification models and hospital costs was below r=0.32 (p=0.0001), but was r=0.94 (p=0.0001) between ICU LOS and costs. Total hospital costs can be identified by length of ICU stay. None of the common risk stratification models accurately predicted total hospital costs in cardiac surgical patients.

Risikostratifizierung in der Herzchirurgie : Entscheidungshilfe bei der Indikationsstellung

Various risk scores have been developed for the assessment of operative risk in cardiac surgery. Although risk stratification has been acknowledged as a useful tool to analyze trends in therapy and changes in patient populations, its relevance in assessing the indication for surgery has been questioned. It was the goal of this prospective study to compare 6 common risk scores with regard to the predictive value for mortality in individual patients.¶   Between September 1998 and February 1999 all adult patients undergoing heart surgery were prospectively scored according to the following scores: initial Parsonnet, Cleveland Clinic, French, Euro, Pons, and the Ontario Province Risk score. Early lethality was assessed within 30 days postoperatively. Follow-up was completed in 504 patients.¶   With the exception of the Ontario Province Risk score, lethality in the high risk group was overestimated by all scores, whereas lethality in low to moderate risk groups was underestimated by several scores. Mean scores of surviving and deceased patients showed a broad overlap with high standard deviations.¶   Preoperative risk scores are effective tools for stratification of patient populations and the analysis of surgical outcome. With the aid of risk scores, operative risk can be sufficiently predicted for patient populations or subpopulations. The Euro score best predicted the outcome of our patients.¶   However, when the indication for surgery is to be determined in an individual patient, risk scores should be only considered as an orientation in the decision process. Zur Einschätzung des operativen Risikos ist eine Vielzahl von Risikoscores für die Herzchirurgie entwickelt worden. Obwohl sich die Risikostratifizierung als Instrument zur Analyse von Veränderungen der Patientenpopulation und des operativen Standards bewährt hat, stellt sich die Frage nach ihrer Bedeutung für die Operationsindikation und einer Verbesserung der Operationsergebnisse. Es war das Ziel dieser prospektiven Studie, 6-gängige Risikoscores in Bezug auf ihre Vorhersagekraft für die Mortalität des individuellen Patienten zu vergleichen.¶   Zwischen September 1998 und Februar 1999 wurden alle herzchirurgischen Patienten, die älter als 18 Jahre waren, prospektiv gescort. Folgende Scoresysteme kamen zum Einsatz: der initiale Parsonnet, Cleveland Clinic, French, Pons, Ontario Province Risk und der Euro Score. Die operative Frühletalität wurde bis zum 30. Tag post-OP erfasst. Ein vollständiges Follow-up konnte bei 504 Patienten erreicht werden.¶   Mit Ausnahme des Ontario Province Risk Scores wurde die Letalität in der Hochrisikogruppe von allen Scoresystemen überschätzt, während mehrere Scores die Letalität in den Gruppen mit niedrigem oder mäßigem Risiko unterschätzten. Im Vergleich zeigten die mittleren Scorewerte der überlebenden und verstorbenen Patienten bei allen Scoresystemen einen breiten Überlappungsbereich mit hohen Standardabweichungen.¶   Risikoscores haben sich zur Risikostratifizierung von Patientenpopulationen und zur objektiven Analyse der chirurgischen Ergebnisse bewährt. Hierbei hat sich der Euro-Score von allen untersuchten Scores als der aussagekräftigste erwiesen. Bei der Indikationsstellung zur Operation sollte ihnen jedoch nur eine orientierende Bedeutung beigemessen werden.

Impact of myocardial protection during coronary bypass surgery on patient outcome

We have recently shown that continuous coronary perfusion with warm blood enriched with the ultra-short acting beta-blocker Esmolol (ES) improves functional and structural myocardial protection during coronary artery surgery as compared with conventional cardioplegia (CP). The purpose of the present study was to compare both myocardial protection techniques in terms of patient outcome. We retrospectively analyzed the charts of 150 consecutive patients subjected to coronary artery surgery using the ES-technique; 150 patients matched for age, gender, preoperative left ventricular function, history of renal failure, and history of neurological symptoms undergoing surgery with conventional CP during the same time period served as control group. There were no significant differences between both groups with respect to perioperative myocardial infarction rate, need for positive inotropic medication, need for mechanical circulatory support, duration of mechanical ventilation, duration of intensive care unit stay, time of mobilization, postoperative renal failure, cardiac arrhythmias, neurological symptoms, infections or in-hospital mortality. ES-patients were less frequently readmitted to the intensive care unit (ES: 3/150; 2.2% [95% confidence interval: 0-4.2%] vs. CP: 13/150; 8.7% [4.2-13.2%]; P=0.010) and total hospital stay was shorter (ES: 12.3+/-4.8 days [95% CI: 11.5-13.0] vs CP: 13.5+/-3.8 [12.9-14.1] days; P=0.0013), thus saving 159 patient days on the normal ward. Procedural costs were less for the ES-technique (US

Anti-oxidative therapy protects renal function in cardiac surgery patients

60 per patient) as compared to the cardioplegia technique (US

Beeinflusst die Myokardprotektion während koronarer Bypassoperationen die klinischen Patientenergebnisse

120 per patient). These data suggest that myocardial protection using the ES-technique does not improve clinical outcome in patients subjected to routine coronary artery surgery, but may save costs.

Activation of myocardial constitutive nitric oxide synthase during coronary artery surgery

Objectives: Oxygen-derived free radical formation induced by cardiopulmonary bypass (CPB) may contribute to renal dysfunction associated with cardiac surgery. As anti-oxidants have been shown to attenuate free radical-induced renal dysfunction in medical patients, we hypothesized that the anti-oxidant N-acetylcysteine (NAC) protects renal function in patients subjected to cardiac surgery on CPB. Material and Methods: Forty coronary artery surgery patients (66±9[SD] years, 9 women and 31 men) with normal preoperative renal function (serum creatinine <0.9mg/dl) subjected to CPB and CA were randomized in a double-blind fashion to receive either NAC (100mg/kg into CPB prime followed by infusion at 20mg/kg/h; n=20) or Placebo (n=20). We measured serum creatinine levels pre- and post-operatively (1. day post CPB) as well as urinary output and diuretic medication. Creatinine clearance was calcuted using the Cockroft equation. Results: In the Placebo group, serum creatinine increased from 93.1±35.4 mmol/l pre-operatively to 115.9±47.2 mmol/l on post-op day 1 (p<.001, 95% CI for mean change: 13.9 to 31.7). In the NAC group, change in serum creatinine was not statistically significant (92.3±31.3 mmol/l pre-operatively; 99.3±25.4 mmol/l on post-op day 1; p=.084, 95% CI for mean change: –0.5 to 14.5). Creatinine clearance decreased significantly in the Placebo group compared to NAC (–16.9±3.2ml/min vs. –7.5±4.2ml/min, p=0.04). Hemodynamics as well as clinical outcome were similar between NAC and Placebo. Conclusions: Our data show that NAC protects renal function post CPB, thus, radical-scavenging may reduce renal dysfunction associated with cardiac surgery.

Emergency coronary artery surgery after failed PTCA: myocardial protection with continuous coronary perfusion of beta-blocker-enriched blood.

Zusammenfassung In Vorstudien konnten wir belegen, dass kontinuierliche antegrade Koronarperfusion mit warmen ultrakurz wirkendem Beta-Blocker (Esmolol/ES) angereichertem Blut den funktionellen und strukturellen Schutz der Herzmuskelzellen unter aortokoronaren Bypassoperation im Vergleich mit konventioneller Brettschneider-Kardioplegie (BKP) verbessert. Ziel unserer Studie war der Vergleich der beiden Protektionstechniken in Bezug auf die postoperativen klinischen Ergebnisse. Hierfür analysierten wir 150 aufeinanderfolgende Patienten retrospektiv, die mit herkömmlicher Brettschneidertechnik protektioniert worden waren und verglichen diese mit 150 Patienten, die mit kontinuierlichen warmen Blut, welches mit einem ultrakurz wirkenden Beta-Blocker angereichert war, am schlagenden Herzen mit arteriellen und venösen koronaren Bypässen versorgt worden waren. Beide Gruppen zeigten vergleichbare Werte für Alter, Geschlecht, präoperativer linksventrikulärer Funktion, präoperatives Vorhandensein von Niereninsuffizienz und neurologischen Vorschädigungen. Sie wurden im gleichen Zeitraum operiert. Es ergaben sich keine signifikanten Unterschiede zwischen den Gruppen in Bezug auf die perioperative Infarktrate, Gabe von positiv inotroper Medikation, Anwendung von kreislaufunterstützenden Systemen, Dauer der Nachbeatmung, Dauer des postoperativen Intensivstationsaufenthaltes, des Mobilisationszeitraum, Häufigkeit der postoperativer Niereninsuffizienz, Herzrhythmusstörungen, neurologischen Auffälligkeiten, Infektionshäufigkeit und 30-Tage-Mortalität. Esmolol-Patienten (ES) wurden signifikant seltener auf die Intensivstation zurückverlegt (3 von 150=2,2% [95% Konfidenzinterval: 0-4-2%] gegen 13 von 150=8,7% [KI 4,2–13,2%]; p=0,010). Außerdem wiesen ES-Patienten eine kürzere Krankenhausverweildauer auf (ES: 12,3±4,8Tage [95%-Konfidenzinterval 11,5–13,0] im Vergleich BKP-Patienten 13,5±3,8 [95%-KI 12,9–14,1] Tage; p=0,013). Damit wurden 159 Patiententage auf Normalstation gespart. Zusätzlich lagen die Kosten für die Beta-Blockade-Behandlung bei durchschnittlich 60 Euro im Vergleich zu 120 Euro für die Brettschneider-Kardioplegie-Technik pro Patient. Unsere Daten zeigten keine Unterschiede im klinischen Ergebnis zwischen den Gruppen, jedoch sehr wohl einen Unterschied in den tatsächlichen Kosten.Summary Recently it was shown that continuous coronary perfusion with warm blood enriched with the ultra-short acting β-blocker Esmolol (ES) improves functional and structural myocardial protection during coronary artery surgery as compared with conventional cardioplegia (CP). The aim of the presented study was to compare both myocardial protection techniques in terms of patient outcome. We therefore retrospectively analyzed data of 150 consecutive patients planed for coronary artery surgery using the ES-technique; 150 patients matched for age, gender, preoperative left ventricular function, history of renal failure, and history of neurological symptoms undergoing surgery with conventional CP during the same time period served as control group. There were no significant differences between both groups with respect to perioperative myocardial infarction rate, need for positive inotropic medication, need for mechanical circulatory support, duration of mechanical ventilation, duration of intensive care unit stay, time of mobilization, postoperative renal failure, cardiac arrhythmias, neurological symptoms, infections or in-hospital mortality. ES-patients were less frequently readmitted to the intensive care unit (ES: 3/150; 2.2% [95% confidence interval: 0–4.2%] vs CP: 13/150; 8.7% [4.2–13.2%]; p=0.010) and total hospital stay was shorter (ES: 12.3±4.8 days [95% CI: 11.5–13.0] vs CP: 13.5±3.8 [12.9–14.1] days; p=0.0013), thus saving 159 patient days on the normal ward. Costs of myocardial protection were less for the ES-technique (60 Euro per patient) compared to the cardioplegia technique (120 Euro per patient). These data suggest that myocardial protection using the ES-technique does not improve clinical outcome in patients subjected to routine coronary artery surgery, but may save costs.