Karl-Christian Koch

Cardiac resynchronization therapyhomogenizes myocardial glucosemetabolism and perfusion in dilatedcardiomyopathy and left bundle branch block

Abstract Objectives We investigated whether cardiac resynchronization therapy (CRT) affects myocardial glucose metabolism and perfusion in dilated cardiomyopathy (DCM) and left bundle branch block (LBBB). Background Patients with DCM and LBBB present with asynchronous left ventricular (LV) activation, leading to reduced septal glucose metabolism. Cardiac resynchronization therapy recoordinates LV activation, but its effects on myocardial glucose metabolism and perfusion remain unknown. Methods In 15 patients (10 females; 61 ± 13 years) with DCM and LBBB (QRS width 165 ± 15 ms), gated 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and technetium-99m ( 99m Tc)-sestamibi single-photon emission computed tomography were performed before and after two weeks of CRT. Uptake of FDG and 99m Tc-sestamibi was determined in four LV wall areas. Ejection fraction and volumes were calculated from gated PET. Results Baseline FDG uptake was heterogeneous (p 99m Tc-sestamibi uptake was modest (lowest septal 65 ± 10%; maximum lateral 84 ± 5%) and also reduced with CRT, although some heterogeneity (p 99m Tc-sestamibi uptake (0.77 ± 0.13 to 0.85 ± 0.16, p Conclusions Glucose metabolism is reduced more than perfusion in the septal compared with LV lateral wall in patients with DCM and LBBB. Cardiac resynchronization therapy restores homogeneous myocardial glucose metabolism with less influence on perfusion.

Evaluation of the SOFA score: a single-center experience of a medical intensive care unit in 303 consecutive patients with predominantly cardiovascular disorders

Objective: To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score, the total maximum SOFA (TMS) score, and a derived variable, the ΔSOFA (TMS score minus total SOFA score on day 1) in medical, cardiovascular patients as a means for describing the incidence and severity of organ dysfunction and the prognostic value regarding outcome. Design: Prospective, clinical study. Setting: Medical intensive care unit in a university hospital. Patients: A total of 303 consecutive patients were included (216 men, 87 women; mean age 62 ± 12.6 years; SAPS II 26.2 ± 12.7). They were evaluated 24 h after admission and thereafter every 24 h until ICU discharge or death between November 1997 and March 1998. Readmissions and patients with an ICU stay shorter than 12 h were excluded. Main outcome measure: Survival status at hospital discharge, incidence of organ dysfunction/failure. Interventions: Collection of clinical and demographic data and raw data for the computation of the SOFA score every 24 h until ICU discharge. Measurements and main results: Length of ICU stay was 3.7 ± 4.7 days. ICU mortality was 8.3 % and hospital mortality 14.5 %. Nonsurvivors had a higher total SOFA score on day 1 (5.9 ± 3.7 vs. 1.9 ± 2.3, p < 0.001) and thereafter until day 8. High SOFA scores for any organ system and increasing number of organ failures (SOFA score ≥ 3) were associated with increased mortality. Cardiovascular and neurological systems (day 1) were related to outcome and cardiovascular and respiratory systems, and admission from another ICU to length of ICU stay. TMS score was higher in nonsurvivors (1.76 ± 2.55 vs. 0.58 ± 1.39, p < 0.01), and ΔSOFA/total SOFA on day 1 was independently related to outcome. The area under the receiver-operating characteristic curve was 0.86 for TMS, 0.82 for SOFA on day 1, and 0.77 for SAPS II. Conclusions: The SOFA, TMS, and ΔSOFA scores provide the clinician with important information on degree and progression of organ dysfunction in medical, cardiovascular patients. On day 1 both SOFA score and TMS score had a better prognostic value than SAPS II score. The model is closely related to outcome and identifies patients who are at increased risk for prolonged ICU stay.

Influence of a platelet GPIIb/IIIa receptor antagonist on myocardial hypoperfusion during rotational atherectomy as assessed by myocardial Tc-99m sestamibi scintigraphy

OBJECTIVES This study evaluated the effect of the glycoprotein IIb/IIIa (GPIIb/IIIa) antagonist abciximab on myocardial hypoperfusion during percutaneous transluminal rotational atherectomy (PTRA). BACKGROUND PTRA may cause transient ischemia and periprocedural myocardial injury. A platelet-dependent risk of non-Q-wave infarctions after directional atherectomy has been described. The role of platelets for the incidence and severity of myocardial hypoperfusion during PTRA is unknown. METHODS Seventy-five consecutive patients with complex lesions were studied using resting Tc-99m sestamibi single-photon emission computed tomography prior to PTRA, during, and 2 days after the procedure. The last 30 patients received periprocedural abciximab (group A) and their results were compared to the remaining 45 patients (group B). For semiquantitative analysis, myocardial perfusion in 24 left ventricular regions was expressed as percentage of maximal sestamibi uptake. RESULTS Baseline characteristics did not differ between the groups. Transient perfusion defects were observed in 39/45 (87%) patients of group B, but only in 10/30 (33%) patients of group A (p < 0.001). Perfusion was significantly reduced during PTRA in 3.3 +/- 2.5 regions in group B compared to 1.4 +/- 2.5 regions in group A (p < 0.01). Perfusion in the region with maximal reduction during PTRA in groups B and A was 76 +/- 15% and 76 +/- 15% at baseline, decreased to 56 +/- 16% (p < 0.001) and 67 +/- 14%, respectively, during PTRA (p < 0.01 A vs. B), and returned to 76 +/- 15% and 80 +/- 13%, respectively, after PTRA. Nine patients in group B (20%) and two patients in group A (7%) had mild creatine kinase and/or troponin t elevations (p = 0.18). Patients with elevated enzymes had larger perfusion defects than did patients without myocardial injury (4.2 +/- 2.7 vs. 2.3 +/- 2.5 regions, p < 0.05). CONCLUSIONS These data indicate that GPIIb/IIIa blockade reduces incidence, extent and severity of transient hypoperfusion during PTRA. Thus, platelet aggregation may play an important role for PTRA-induced hypoperfusion.

Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest

IntroductionThe purpose of this study was to investigate the costs and health status outcomes of intensive care unit (ICU) admission in patients who present after sudden cardiac arrest with in-hospital or out-of-hospital cardiopulmonary resuscitation.MethodsFive-year survival, health-related quality of life (Medical Outcome Survey Short Form-36 questionnaire, SF-36), ICU costs, hospital costs and post-hospital health care costs per survivor, costs per life year gained, and costs per quality-adjusted life year gained of patients admitted to a single ICU were assessed.ResultsOne hundred ten of 354 patients (31%) were alive 5 years after hospital discharge. The mean health status index of 5-year survivors was 0.77 (95% confidence interval 0.70 to 0.85). Women rated their health-related quality of life significantly better than men did (0.87 versus 0.74; P < 0.05). Costs per hospital discharge survivor were 49,952 €. Including the costs of post-hospital discharge health care incurred during their remaining life span, the total costs per life year gained were 10,107 €. Considering 5-year survivors only, the costs per life year gained were calculated as 9,816 € or 14,487 € per quality-adjusted life year gained. Including seven patients with severe neurological sequelae, costs per life year gained in 5-year survivors increased by 18% to 11,566 €.ConclusionPatients who leave the hospital following cardiac arrest without severe neurological disabilities may expect a reasonable quality of life compared with age- and gender-matched controls. Quality-adjusted costs for this patient group appear to be within ranges considered reasonable for other groups of patients.

Identification and characterization of errors and incidents in a medical intensive care unit.

Background:  To assess the frequency, type, consequences, and associations of errors and incidents in a medical intensive care unit (ICU).

Five-year survival, quality of life, and individual costs of 303 consecutive medical intensive care patients: A cost-utility analysis

Objective:To assess long-term survival, health-related quality of life, and associated costs 5 yrs after discharge from a medical intensive care unit. Design:Prospective cohort study. Setting:Medical intensive care unit of a German university hospital. Patients:Three hundred and three consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between November 1997 and February 1998 with an intensive care unit length of stay >24 hrs. Interventions:None. Measurements and Main Results:Demographic data, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and individual intensive care unit and hospital costs were prospectively recorded. Primary outcomes included 5-yr survival, functional status, health-related quality of life (Medical Outcome Short Form, SF-36), effective costs per survivor, and costs per life year and per quality-adjusted life year gained. Of 303 patients, 44 (14.5%) died in the hospital. Among the remaining 259 patients, 190 (73%) survived the 5-yr follow up and 173 patients (91%) completed the questionnaire. Baseline demographics including gender, age, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and admission diagnosis were similar between hospital and long-term survivors (p > .05 for all). The health status index of those patients surviving the 5-yr follow-up was 0.88, independent of patients’ severity of illness. The average effective costs per survivor were 8.827 &U20AC; for intensive care unit costs and 14.130 &U20AC; for intensive care unit and hospital costs. Mean costs per life year and per quality-adjusted life year gained amounted to 19.330 &U20AC; and 21.922 &U20AC;, respectively. Increasing severity of illness was associated with higher costs. Conclusions:Considering the severity of illness and the patients’ outcome, the costs associated with both life year and quality-adjusted life year gained were within generally accepted limits for other potentially life-saving treatments.

Myocardial viability assessment by endocardial electroanatomic mapping: comparison with metabolic imaging and functional recovery after coronary revascularization

OBJECTIVES The objective of this study was to compare electroanatomic mapping for the assessment of myocardial viability with nuclear metabolic imaging using positron emission computed tomography (PET) and with data on functional recovery after successful myocardial revascularization. BACKGROUND Animal experiments and first clinical studies suggested that electroanatomic endocardial mapping identifies the presence and absence of myocardial viability. METHODS Forty-six patients with prior (> or =2 weeks) myocardial infarction underwent fluorine-18 fluorodeoxyglucose (FDG) PET and Tc-99m sestamibi single-photon emission computed tomography (SPECT) before mapping and percutaneous coronary revascularization. The left ventricular endocardium was mapped and divided into 12 regions, which were assigned to corresponding nuclear regions. Functional recovery using the centerline method was assessed in 25 patients with a follow-up angiography. RESULTS Regional unipolar electrogram amplitude was 11.0 mV +/- 3.6 mV in regions with normal perfusion, 9.0 mV +/- 2.8 mV in regions with reduced perfusion and preserved FDG-uptake and 6.5 mV +/- 2.6 mV in scar regions (p < 0.001 for all comparisons). At a threshold amplitude of 7.5 mV, the sensitivity and specificity for detecting viable (by PET/SPECT) myocardium were 77% and 75%, respectively. In infarct areas with electrogram amplitudes >7.5 mV, improvement of regional wall motion (RWM) from -2.4 SD/chord +/- 1.0 SD/chord to -1.5 SD/chord +/- 1.1 SD/chord (p < 0.01) was observed, whereas, in infarct areas with amplitudes <7.5 mV, RWM remained unchanged at follow-up (-2.3 SD/chord +/- 0.7 SD/chord to -2.4 SD/chord +/- 0.7 SD/chord). CONCLUSIONS These data suggest that the regional unipolar electrogram amplitude is a marker for myocardial viability and that electroanatomic mapping can be used for viability assessment in the catheterization laboratory.

Effect of catheter-based transendocardial delivery of stromal cell-derived factor 1α on left ventricular function and perfusion in a porcine model of myocardial infarction

BackgroundMyocardial regeneration after myocardial infarction can occur via stem cell recruitment. Stromal cell-derived factor 1α (SDF-1α) has been shown to be critical for stem cell homing to injured tissue.MethodsMyocardial infarction was induced in pigs via microembolization of the distal left anterior descending artery. Two weeks after myocardial infarction animals underwent catheter-based transendocardial injection of SDF-1α into the periinfarct myocardium (18 injections, 5 ìg per injection) (n = 12) or sham-intervention (n = 8). Tc99m sestamibi single-photon emission computed tomography (SPECT) and electromechanical mapping (EMM) of the left ventricle were performed two and seven weeks after myocardial infarction.ResultsInfarct size by tetrazolium staining was similar in both groups (8.9 ±1.2% of left ventricle vs. 8.9 ± 2.6%). Vessel density in the periinfarct area was significantly higher in SDF-1α treated animals than in controls (349 ± 17/mm2 vs. 276 ± 21/mm2, p < 0.05). Myocardial perfusion (SPECT) did not change in either group. Ejection fraction and stroke volume (EMM) decreased in SDF-1α animals and increased in controls (difference between groups p = 0.05 for ejection fraction and p < 0.05 for stroke volume). Linear local shortening (EMM) did not change in controls (11.4 ± 1.3% to 11.5 ± 0.5%) but decreased significantly in SDF-1α treated animals (12.1 ± 0.9% to 8.4 ± 0.9%, p < 0.05, p < 0.05 for difference between groups). SDF-1 delivery was associated with a substantial loss of collagen in the periinfarct area (32±5% vs. 61±6% in control animals, p < 0.005).ConclusionA strategy to augment stem cell homing by catheter-based transendocardial delivery of SDF-1α in experimental myocardial infarction increases periinfarct vessel density, fails to improve myocardial perfusion, is associated with loss of collagen in the periinfarct area and impairs left ventricular function.

Kostenanalyse und Prognoseabschätzung internistischer Intensivpatienten mittels des “Therapeutic Intervention Scoring System” (TISS und TISS-28)

Zusammenfassung.Hintergrund und Ziel: Das “Therapeutic Intervention Scoring System” (TISS) und die vereinfachte Version TISS-28 erfassen die pflegerischen und therapeutischen Arbeitsleistungen und erlauben somit u.a. eine Einschätzung der Krankheitsschwere intensivmedizinischer Patienten. Anhand der Daten von 303 konsekutiven Patienten mit einer Liegedauer von > 24 h wurde die Anwendbarkeit von TISS und TISS-28 zur Kostenanalyse und Prognoseabschätzung in der internistischen Intensivmedizin evaluiert. Patienten und Methodik: Von den eingeschlossenen Patienten waren 216 männlich (71%), das mittlere Alter betrug 62 ± 12 Jahre, die Liegedauer auf der Intensivstation 3,7 ± 4,7 Tage und der SAPS II (Simplified Acute Physiology Score) 26 ± 13 Punkte. Insgesamt verstarben 44 Patienten (14,5%), davon 25 Patienten (8,3%) auf der Intensivstation. Ergebnisse: Die Erhebung des TISS dauerte signifikant länger verglichen mit dem TISS-28. Die Korrelation von TISS und TISS-28 war am Aufnahmetag exzellent (r2 = 0,91; p < 0,001). Die Fläche unter der Receiver-Operating-Characteristic-(ROC-)Kurve zeigte eine befriedigende Diskriminationsfähigkeit für TISS (0,79 ± 0,04), TISS-28 (0,76 ± 0,04) und SAPS II (0,77 ± 0,04) hinsichtlich des Überlebens und Versterbens der Patienten.Die patientenspezifischen Kosten pro TISS-28-Punkt waren mit EURO 36,- signifikant höher als die Kosten pro TISS-Punkt (EURO 25,-; p < 0,05). Die Personalkosten (42%) stellten den größten Kostenfaktor dar, und patientenspezifische Kosten verursachten insgesamt zwei Drittel der Gesamtkosten. Weder der Schweregrad der Erkrankung noch die Anzahl der Organversagen waren mit den Gesamtkosten der Patienten assoziiert. Einzig die Liegedauer der Patienten auf der Intensivstation zeigte eine deutliche Korrelation mit den individuellen Therapiekosten (r2 = 0,79; p < 0,001). Schlussfolgerung: Die signifikant kürzere Erhebungszeit und Uniformität stellen klinisch und wissenschaftlich einen klaren Vorteil für das TISS-28 dar. Zusätzlich ermöglicht das TISS-28 im Rahmen eines klinisch akzeptablen Zeitaufwandes die Berechnung individueller Patientenkosten. In der Summe stellt das TISS-28 ein geeignetes Instrument der Qualitätssicherung und Kostenanalyse internistischer Intensivpatienten dar.Abstract.Background and Purpose: The “Therapeutic Intervention Scoring System” (TISS) and the simplified version TISS-28 obtain the therapeutic workload in the critically ill and may be used for outcome prediction. The feasibility and applicability regarding cost analysis and outcome prediction of TISS and TISS-28 have been assessed in 303 consecutive medical patients staying longer than 24 h in the intensive care unit (ICU). Patients and Methods: The mean age of the enrolled patients was 62 ± 12 years, 216 (71%) patients were male, length of ICU stay 3.7 ± 4.7 days, and SAPS II (Simplified Acute Physiology Score) 26 ± 13 points. The overall mortality was 44 patients (14.5%) with 25 patients (8.3%) dying while on the ICU. Results: The data collection process for TISS took significantly longer than for TISS-28. On the day of admission, the correlation of TISS and TISS-28 was excellent (r2 = 0.91; p < 0.001). The discriminatory power as assessed by the area under the receiver operating characteristic (ROC) curve was satisfactory for TISS (0.79 ± 0.04), TISS-28 (0.76 ± 0.04), and SAPS II (0.77 ± 0.04) with regard to outcome prediction.Patient-specific costs per TISS-28 point amounted to EURO 36.- and were significantly higher than the EURO 25.- calculated per TISS point. Staff costs (42%) were the most prominent cost-generating factor, and patient-specific costs contributed two thirds to the total ICU costs. There was no association of severity of illness or number of organ failure and costs. Only the length of ICU stay correlated strongly with the costs of the individual patients during the ICU stay (r2 = 0.79; p < 0.001). Conclusion: The faster data collection process as well as the uniformity of the system are strong clinical and scientific advantages of the TISS-28. In addition, TISS-28 is capable of calculating individual costs in an acceptable time frame. Therefore TISS-28 serves as a valuable tool for quality assurance and cost analysis purposes in the medical ICU.

Superiority of sirolimus eluting stent compared with intracoronary β radiation for treatment of in-stent restenosis: a matched comparison

Objective: To compare acute and follow up clinical and angiographic results after treatment of in-stent restenosis (ISR) by sirolimus eluting stents (SES) with results obtained after intracoronary radiation therapy (IRT). Design: Matched pair analysis. Methods: 62 consecutive ISR lesions (< 30 mm lesion length, reference diameter < 3.5 mm) in 62 patients were treated with SES. From a database of 174 lesions (n  =  141 patients) treated for ISR by intracoronary β radiation, 62 lesions (62 patients) were pair matched with the SES group for diabetes mellitus, lesion length, vessel size, and pattern of ISR. Six month angiographic and 12 month clinical follow up results were obtained. Results: Baseline clinical and angiographic characteristics were similar between the groups (not significant). SES implantation resulted in significantly lower postprocedural in-lesion diameter stenosis than did IRT (mean (SD) 14.2 (9.5)% v 21.1 (10.6)%, p  =  0.001), significantly higher minimum lumen diameter at follow up (1.91 (0.58) v 1.55 (0.72) mm, p  =  0.005), and a higher net gain (1.16 (0.55) v 0.77 (0.70) mm, p  =  0.002). Angiographic binary in-lesion restenosis rate at six months was 11% in the SES group and 29% in the IRT group (p  =  0.046). In 16 ISR lesions SES were used after failed IRT and in 46 lesions for first time ISR. In-lesion late loss was higher after use of SES for failed IRT than after use of SES for first time ISR (0.61 (0.67) mm v 0.24 (0.41) mm, p  =  0.018). In a multivariate analysis prior failed IRT was the only independent predictor for recurrent restenosis after SES for ISR (p  =  0.052, odds ratio 5.8). Six patients (10%) in the SES group and 17 patients (27%) in the IRT group underwent target lesion revascularisation during the 12 months of follow up (p  =  0.022). Conclusions: In this non-randomised matched cohort SES achieved acute and follow up results superior to IRT for treatment of ISR even if cases of failed IRT are included. Failed IRT is a predictor of impaired SES effectiveness.