S. Martens

Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery.

Background Difficulties in prediction and early identification of (acute kidney injury) AKI have hindered the ability to develop preventive and therapeutic measures for this syndrome. We tested the hypothesis that a urine test measuring insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), both inducers of G1 cell cycle arrest, a key mechanism implicated in acute kidney injury (AKI), could predict AKI in cardiac surgery patients. Methods We studied 50 patients at high risk for AKI undergoing cardiac surgery with cardiopulmonary bypass (CPB). Serial urine samples were analyzed for [TIMP-2]*[IGFBP7] concentrations. The primary outcome measure was AKI as defined by international consensus criteria following surgery. Furthermore, we investigated whether urine [TIMP-2]*[IGFBP7] could predict renal recovery from AKI prior to hospital discharge. Results 26 patients (52%) developed AKI. Diagnosis based on serum creatinine and/or oliguria did not occur until 1–3 days after CPB. In contrast, urine concentration of [TIMP-2]*[IGFBP7] rose from a mean of 0.49 (SE 0.24) at baseline to 1.51 (SE 0.57) 4 h after CPB in patients who developed AKI. The maximum urinary [TIMP-2]*[IGFBP7] concentration achieved in the first 24 hours following surgery (composite time point) demonstrated an area under the receiver-operating characteristic curve of 0.84. Sensitivity was 0.92, and specificity was 0.81 for a cutoff value of 0.50. The decline in urinary [TIMP-2]*[IGFBP7] values was the strongest predictor for renal recovery. Conclusions Urinary [TIMP-2]*[IGFBP7] serves as a sensitive and specific biomarker to predict AKI early after cardiac surgery and to predict renal recovery. Clinical Trial Registration Information: www.germanctr.de/, DRKS-ID: DRKS00005062

Effect of Remote Ischemic Preconditioning on Kidney Injury Among High-Risk Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

IMPORTANCE No interventions have yet been identified to reduce the risk of acute kidney injury in the setting of cardiac surgery. OBJECTIVE To determine whether remote ischemic preconditioning reduces the rate and severity of acute kidney injury in patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS In this multicenter trial, we enrolled 240 patients at high risk for acute kidney injury, as identified by a Cleveland Clinic Foundation score of 6 or higher, between August 2013 and June 2014 at 4 hospitals in Germany. We randomized them to receive remote ischemic preconditioning or sham remote ischemic preconditioning (control). All patients completed follow-up 30 days after surgery and were analyzed according to the intention-to-treat principle. INTERVENTIONS Patients received either remote ischemic preconditioning (3 cycles of 5-minute ischemia and 5-minute reperfusion in one upper arm after induction of anesthesia) or sham remote ischemic preconditioning (control), both via blood pressure cuff inflation. MAIN OUTCOMES AND MEASURES The primary end point was the rate of acute kidney injury defined by Kidney Disease: Improving Global Outcomes criteria within the first 72 hours after cardiac surgery. Secondary end points included use of renal replacement therapy, duration of intensive care unit stay, occurrence of myocardial infarction and stroke, in-hospital and 30-day mortality, and change in acute kidney injury biomarkers. RESULTS Acute kidney injury was significantly reduced with remote ischemic preconditioning (45 of 120 patients [37.5%]) compared with control (63 of 120 patients [52.5%]; absolute risk reduction, 15%; 95% CI, 2.56%-27.44%; P = .02). Fewer patients receiving remote ischemic preconditioning received renal replacement therapy (7 [5.8%] vs 19 [15.8%]; absolute risk reduction, 10%; 95% CI, 2.25%-17.75%; P = .01), and remote ischemic preconditioning reduced intensive care unit stay (3 days [interquartile range, 2-5]) vs 4 days (interquartile range, 2-7) (P = .04). There was no significant effect of remote ischemic preconditioning on myocardial infarction, stroke, or mortality. Remote ischemic preconditioning significantly attenuated the release of urinary insulinlike growth factor-binding protein 7 and tissue inhibitor of metalloproteinases 2 after surgery (remote ischemic preconditioning, 0.36 vs control, 0.97 ng/mL2/1000; difference, 0.61; 95% CI, 0.27-0.86; P < .001). No adverse events were reported with remote ischemic preconditioning. CONCLUSIONS AND RELEVANCE Among high-risk patients undergoing cardiac surgery, remote ischemic preconditioning compared with no ischemic preconditioning significantly reduced the rate of acute kidney injury and use of renal replacement therapy. The observed reduction in the rate of acute kidney injury and the need for renal replacement warrants further investigation. TRIAL REGISTRATION German Clinical Trials Register Identifier: DRKS00005333.

Survival results after implantation of intrapericardial third-generation centrifugal assist device: an INTERMACS-matched comparison analysis.

Reports on third-generation centrifugal intrapericardial pumps (HeartWare International, Inc., Framingham, MA, USA) have shown better survival results than the previous-generation devices. However, outcomes depending on the preoperative level of stability can substantially differ, resulting in a limited analysis of potentialities and drawbacks of a given device. In the present study we sought to compare in our single-center experience the survival results of this third-generation device with previous left ventricular systems taking into account the different preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels. Between February 1993 and March 2012, 287 patients underwent assist device implantation in our university hospital (INTERMACS Level 1-2 = 158 patients; INTERMACS Level 3-4-5 = 129 patients). Assist devices implanted were: Group A (HVAD HeartWare, n = 52), group B (previous continuous-flow ventricular assist device [VAD], InCor [Berlin Heart, Berlin, Germany], n = 37; VentrAssist [VentraCor, Inc., Chatswood, NSW, Australia], n = 7; DeBakey [MicroMed Cardiovascular, Inc., Houston, TX, USA], n = 32), and group C (pulsatile systems, n = 159). After cumulative support duration of 54 436 days and a mean follow-up of 6.21 ± 7.46 months (range 0-45.21 months), log-rank analysis revealed a survival for group A of 82.0%, 70.4%, and 70.4%; for group B of 84.0%, 48.2%, 33.7%; and for group C of 71.6%, 46.1%, 33.8%, at 1, 12, and 24 months respectively, with a significantly (P = 0.013) better outcome for group A. When stratifying the survival on the basis of INTERMACS level, no significant survival improvement was observed among all patients who underwent VAD implantation in INTERMACS 1-2 (P = 0.47). However, among patients who underwent elective VAD implantation (INTERMACS 3-4-5), group A had a significantly better outcome (P = 0.005) compared with the other INTERMACS-matched groups (B,C) with a survival rate of 88.8% in group A versus 34.2% in group B and 45.6% in group C at 24 months, respectively. Elective HVAD system implantation shows improved survival benefit over the other INTERMACS-matched devices. Moreover, preoperative unstable hemodynamics resulted in a poor prognosis independently from the pump generation.

Postoperative Complications and Long-Term Results after Primary Cardiac Sarcoma Resection

Background Primary malignant cardiac tumors rarely occur in clinical care. Little is known about the impact of a parameter on postoperative survival. Methods From May 1991 to May 2014, a total of 24 patients underwent surgical treatment of a primary cardiac sarcoma in our center. We analyzed our clinical database retrospectively for information on patient characteristics and treatment data. The follow‐up could be completed to 91.7%. Results Angiosarcoma and non‐otherwise‐specified sarcoma were the most common tumor entities. R0 resection was achieved in most cases. Postoperative mortality within the first 30 days was 20.8% (n = 5). In four of these five cases, postoperative low‐output cardiac failure was the leading cause of death. The cumulative survival rate was 77.3% after 30 days, 68.2% after 3 months, 50.0% after 6 months, 45.0% after 12 months, and 18.0% after 24 months. The mean survival time in the whole group was 47.0 months. A low tumor differentiation was associated with low mean survival, but this was not statistically significant. Mean survival of sarcoma was higher after R0 resection. There was no significant rate of survival difference regarding the adjuvant therapy concept. Conclusion Extended surgery alone or in combination with chemo‐ and/or radiotherapy may be successful in certain cases and may offer a satisfactory quality of life. The establishment of a multicenter heart tumor register in Germany is necessary to increase the number of cases in studies, get more remarkable study results, and standardize the diagnosis and therapy.

Cardiac Ischemic Complications Following Cardiac Surgery - Angiographic Findings and Predictors of In-hospital Mortality

Objective: To describe findings and predictors of in-hospital mortality in patients requiring repeated coronary angiogram for cardiac ischemic complications following heart surgery. Methods: Between January 2005 and January 2015, out of 10,759 (3.1%) 336 patients underwent postoperative coronary angiogram because clinical signs of cardiac ischemia occurred. Operative procedures included CABG in 294 patients, 84 valve and 14 aortic procedures. A logistic regression analysis was performed to identify significant risk factors for in-hospital mortality. Results: Graft failure including distal anastomotic stenosis, kinking or graft thrombosis was found in 121 angiograms (36%). A new native coronary artery occlusion was found in 96 patients (28.6%). A combination of graft-related and non-graft-related occlusions occurred in 36 patients (10.7%), while 83 patients (24.7%) had normal postoperative graft-related angiograms. Revision CABG and percutaneous coronary intervention was performed in 56 (16.7%) and 120 (35.7%) patients respectively. In hospital mortality was 15.8% (53 patients). After multivariate adjustment emergency admission (p< 0.0001; OR 5.3), absence of preoperative sinus rhythm (p = 0.006; OR 3.2), female sex (p = 0.007; OR 2.7), aortic valve surgery (p = 0.01; OR 2.8), aortic surgery (0.01; OR 2.8), history of decompensation (p = 0.02; OR 2.9) and surgery duration (p = 0.04; OR 1.004) turned out to be independent predictors of in hospital mortality. Conclusion: Postoperative ischemic heart complications with the need of re-coronary angiogram generally results in a notably bad outcome in terms of mortality. Patients with abovementioned risk factors for mortality deserve particular care and expertise to avoid ischemic complications.

Miteinander erfolgreich statt gegeneinander erfolglos

ZusammenfassungStörungen in der Kommunikation und Zusammenarbeit von leitenden Ärzten und Geschäftsführungen sind immer wieder zu beobachten. Über diesen Störungen schwebt häufig eine noch in vielen Köpfen verankerte klassische Rollenteilung: Der leitende Arzt ist für die fachliche und qualitätsorientierte Behandlung der Patienten zuständig; die Geschäftsführung hat sich um die Bereitstellung der Mittel hierfür zu kümmern. Leitende Ärzte stehen jedoch gemeinsam mit der Geschäftsführung in der Verantwortung, eine qualitativ hochwertige, aber auch wirtschaftlich effiziente Leistungserbringung sicherzustellen. Bekleiden sie als leitende Ärzte in einem Universitätsklinikum gleichzeitig eine Universitätsprofessur, müssen sie zudem das Fach in Forschung und Lehre vertreten. Ärzte, die eine tradierte Rollenteilung weiterleben, werden mit großer Wahrscheinlichkeit nicht erfolgreich ihre Interessen bei der Ausgestaltung und Weiterentwicklung ihrer Fachabteilung durchsetzen können. Darüber hinaus besteht die Gefahr, dass sie sich fortwährend von der Geschäftsführung unverstanden fühlen und eine Rolle in permanenter Opposition zur Geschäftsführung ausfüllen.AbstractProblems in communication and cooperation of senior physicians and hospital management are constantly being observed. In many cases these problems can be attributed to a traditional understanding of roles: senior physicians are responsible for the professional and quality-oriented treatment of patients whereas the management is responsible for providing relevant resources for this purpose. However, senior physicians and hospital management also share a responsibility to ensure a high quality of care and to deliver services efficiently. In university hospitals the senior physicans in the clinical department are often also university professors and under these circumstances they have an additional task in education and research. Physicians who strictly hold on to the traditional division of roles will most likely be unable to successfully enforce their interests in the design and development of the department. In addition, there is a risk that they will constantly feel misunderstood by the management and fulfill a role in permanent opposition to the management.

Long-term effects of remote ischaemic preconditioning in high risk patients undergoing cardiac surgery: follow-up of a randomised clinical trial

Acute kidney injury (AKI) is a common complication after cardiac surgical procedures and is associated with an increased morbidity and mortality.