[Short version of the 2nd edition of the German-Austrian S3 guidelines "Cardiogenic shock complicating myocardial infarction-Diagnosis, monitoring and treatment"]. / Kurzversion der 2. Auflage der deutsch-österreichischen S3-Leitlinie "Infarkt-bedingter Kardiogener Schock ­ Diagnose, Monitoring und Therapie".

BACKGROUND: The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects. METHODS: Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions. RESULTS: A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. / Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR) : Konsensuspapier der DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI und GRC.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Vacuum-assisted wound closure is superior to primary rewiring in patients with deep sternal wound infection.

OBJECTIVE: Deep sternal wound infections are serious complications after cardiac surgery. The aim of the present study is to compare the outcome after vacuum-assisted wound closure to that after primary rewiring with disinfectant irrigation. The study additionally focuses on defining predictors for the failure of primary rewiring and its impact on postoperative outcome. METHODS: Retrospective analysis was performed in 5232 patients who underwent cardiac surgery with a median sternotomy. 192 patients postoperatively developed deep sternal wound infections and were distributed into 2 therapy groups: a vacuum-assisted wound closure (= VAC) group and a primary rewiring (= RW) group, which was subdivided into healing after rewiring (= RW-h) and failure of rewiring (= RW-f). These groups were compared statistically to reveal coincidental pre-, intra- and postoperative parameters. RESULTS: Compared to the VAC group, the RW group showed a poorer outcome, although RW baseline characteristics were apparently beneficial. Primary rewiring failed in 45.8 % of all cases, which led to even worse outcomes. Important predictors for failure of primary rewiring were morbid obesity, diabetes mellitus type II, chronic obstructive pulmonary disease, preoperatively impaired left ventricular function, postoperatively positive blood and wound cultures, bilateral harvesting of internal thoracic arteries and the need for surgical reexploration. CONCLUSIONS: In spite of patients being in a worse condition, vacuum-assisted wound closure therapy resulted in improved outcomes and thus should be preferred to primary rewiring. Moreover we report on predictors which may indicate whether there is a high risk of rewiring failure.

[Patient transport and networks for use of extracorporeal life support]. / Patiententransport und Netzwerke beim Einsatz des Extracorporeal Life Support.

New technologies and continuous further development of extracorporeal support systems have expanded the range of applications of extracorporeal life support (ECLS) in recent years. In addition to use in cardiogenic shock or resuscitation, the number of requests for the transfer of unstable patients from peripheral hospitals are increasing. Organizational challenges such as the establishment of networks and structured team training for all parties involved mean that the ECLS team is quickly available to reach the patient.

Early reintubation after cardiac operations: impact of nasal continuous positive airway pressure (nCPAP) and noninvasive positive pressure ventilation (NPPV).

BACKGROUND: Due to an increasing number of comorbidities there is still a significant incidence of respiratory failure after primary postoperative extubation in patients who undergo cardiosurgery. We wanted to study whether nCPAP could improve pulmonary oxygen transfer and avoid the necessity for reintubation after cardiac surgery. Additionally, we compared this protocol to noninvasive positive pressure ventilation (NPPV). PATIENTS AND METHODS: Over a period of 3 years we analyzed all patients who were extubated within 12 hours after cardiac surgery, and in whom pulmonary oxygen transfer (PaO2/FIO2) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation. There were three groups of patients: A = patients required immediate reintubation (n = 125); B = patients had nCPAP with intermittent mask CPAP (n = 264); and C = patients had NPPV (n = 36). RESULTS: 25.8 % of patients in Group B and 22.2 % of patients in Group C were also intubated after a period of CPAP or NPPV. All other patients of Groups B and C could be weaned from these devices (B: 33.4 ± 5.8 hours, C: 26.2 ± 4.2 h; P < 0.05) and were well oxygenated using a face mask at ambient pressures (PaO2/FIO2: B: 136 ± 12, C: 141 ± 12). In Group A, we found a higher mortality (8.8 %) than in Group B (4.2 %) and Group C (5.6 %). The ICU stay and in-hospital stay were significantly prolonged in Group A. The incidence of pulmonary infections (A: 24 %, B: 10.6 %, C: 13.8 %; P < 0.05) and the need for catecholamines were significantly increased in Group A, whereas nCPAP patients suffered significantly more often from impaired sternal wound healing (A: 4.8 %, B: 8.3 %; P < 0.05). CONCLUSIONS: We conclude that reintubation after cardiac operations should be avoided since nCPAP and NPPV are safe and effectively improve arterial oxygenation in the majority of patients with nonhypercapnic oxygenation failure. However, it is of great importance to pay special care to sternal wound complications in these patients.

Predictors of postoperative complications in octogenarians undergoing cardiac surgery.

OBJECTIVE: Aim of the study was to clarify the impact of different pre- and perioperative conditions on outcome in octogenarians undergoing cardiac surgery. METHODS: We retrospectively analyzed preoperative risk factors and intraoperative adverse events and studied in-hospital morbidity and mortality in 646 patients > or = 80 years of age (82.5 +/- 3.5 years) and in 6081 younger patients (70.3 +/- 3.4 years) who underwent cardiac surgery between 1/2001 and 12/2006. RESULTS: Preoperatively, octogenarians suffered significantly more from arterial hypertension, renal failure, previous neurological problems, unstable angina and NYHA class IV than younger subjects. The incidence of combined valve and coronary procedures and of urgent operations was also significantly higher in patients > or = 80 years (27.7 % vs. 18.2 %, P < 0.05, and 7.3 % vs. 4.2 %, P < 0.05, respectively). In-hospital mortality was higher (7.4 % vs. 3.7 %, P < 0.05), and average ICU and total in-hospital stay was longer in the older age group. Postoperative complications occurred in 15 % of patients > or = 80 years compared to 7.6 % of patients < or = 79 years ( P < 0.05). NYHA class IV, female sex and preoperative renal failure correlated with perioperative morbidity. Multivariate analysis could identify urgent procedures, redo surgery, mitral valve surgery and prolonged cross-clamping times as predictors of mortality. CONCLUSIONS: Cardiac surgery in octogenarians can be performed with an acceptable risk but an increased mortality and morbidity compared to younger patients. High-risk octogenarians, who require intensive perioperative management, should be identified to reduce the incidence of postoperative complications.

Heparin-induced thrombocytopenia type II after cardiac surgery: predictors and outcome.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a serious complication after cardiac surgery. The aim of the present study was to identify pre- and intraoperative predictors for the postoperative occurrence of HIT. The study additionally focused on the impact of HIT on postoperative outcome. METHODS: Retrospective analysis was performed for 5073 patients who had required extracorporeal circulation during cardiac surgery. Patients were divided into 3 groups: 1) patients who had postoperative HIT (HIT+); 2) patients with postoperative thrombocytopenia but without HIT (HIT-); and 3) patients with normal platelet count (C). The groups were statistically compared with regard to pre-, intra- and postoperative parameters. RESULTS: Statistically significant predictors were renal insufficiency, intravenous application of heparin for more than 3 days, previous percutaneous coronary intervention within the last 4 weeks, urgency/emergency operation, combined surgery, prolonged extracorporeal circulation or cross-clamping time, and low cardiac output syndrome. Postoperative HIT was associated with an enhanced risk of renal failure, infectious and thromboembolic complications and in-hospital mortality. CONCLUSION: Postoperative HIT increases morbidity and mortality. The predictors presented in this study can be used to identify patients at risk of developing HIT.

Cardiac valve replacement in patients with end-stage renal failure: impact of prosthesis type on the early postoperative course.

BACKGROUND: It is still unclear whether biological or mechanical valves should be preferred in patients on chronic dialysis therapy. PATIENTS AND METHODS: We retrospectively analyzed data from 104 patients (66.5 +/- 8.6 years) with end-stage renal failure (RF) who underwent aortic or mitral valve replacement between 2002 and 4/2008. Mechanical valves were implanted in 44 (42 %) patients and bioprostheses in 60 (58 %). The two groups were comparable with regard to preoperative data, age and incidence of additional CABG procedures. We studied in-hospital morbidity and mortality, major postoperative complications and length of ICU and hospital stay. Additionally, parameters predicting a poor outcome were analyzed with multivariate regression analysis. RESULTS: The overall hospital mortality was 12.5 % and did not differ between the two groups (mechanical: 13.6 %, biological: 11.7 %, n. s.). In the postoperative course, duration of ventilation and ICU stay were similar, whereas hospital stay was significantly longer for patients with mechanical prostheses (19.5 +/- 5.4 vs. 15.6 +/- 4.1 days, P < 0.05). Mechanical valve patients had a significantly higher rate of postoperative cerebrovascular incidents (18.2 vs. 8.3 %, P < 0.05) and bleeding complications (15.9 vs. 11.7 %, P < 0.05). Reoperation, obesity, left ventricular ejection fraction < 30 % and previous neurological complications were independent predictors of hospital mortality. CONCLUSIONS: Our results demonstrate that in patients with end-stage RF, the use of mechanical valves is associated with a significant risk of complications. Because of the poor overall survival of patients on dialysis, bioprosthesis degeneration will not be a limiting factor. Therefore, preference should be given to biological valves in these patients.

Predictors and outcome of ICU readmission after cardiac surgery.

OBJECTIVE: Readmission to the intensive care unit (ICU) after cardiac surgery is associated with higher costs and may be correlated with an increased mortality. We wanted to evaluate predictors of ICU readmission and to analyze the outcome of those patients. METHODS: 3523 patients who underwent CABG and/or valve surgery between 2004 and 2007 were reviewed retrospectively. The reasons for readmission and the postoperative course were analyzed. Furthermore, perioperative risk factors for readmission were determined by multivariate regression analysis. RESULTS: Of the 3374 patients discharged from the ICU, 5.9 % (198) of patients required a second stay in the intensive care (group r). The readmission rate was 4.8 % following CABG and 8.9 % following valve +/- CABG ( P < 0.05). The mean interval from ICU discharge to readmission was 3.3 +/- 6.2 days. Of the patients who were not readmitted, 1.3 % died in hospital, compared to 14.4 % in group r ( P < 0.05). After readmission, the mean length of stay in the ICU and in hospital was 7.1 +/- 5.9 and 21.3 +/- 11.1 days (3.1 +/- 1.2 and 13.1 +/- 5.1 days for all other patients [ P < 0.05]). Main reasons for readmission were respiratory failure (59 %), cardiovascular instability (25 %), renal failure (6.5 %), cardiac tamponade/bleeding (6 %), gastrointestinal complications (2 %) and sepsis (1.5 %). Multivariate logistic regression analysis revealed that preoperative renal failure, mechanical ventilation > 24 h, reexploration for bleeding and low cardiac output state were independent predictors for readmission. CONCLUSIONS: Patients after valve/combined surgery are more likely to require readmission to the ICU. Respiratory complications were the most common reasons for readmission. To reduce the readmission rate, it is necessary to treat cardio-respiratory problems early, particularly in patients showing predictive risk factors.

Intraaortic balloon pumping in patients with right ventricular insufficiency after cardiac surgery: parameters to predict failure of IABP Support.

BACKGROUND: The indications for intra-aortic balloon pump (IABP) in the case of a failing right ventricle after operations with extracorporeal circulation (ECC) are still discussed controversially. We investigated the benefit of IABP in patients with a predominantly right ventricular dysfunction after ECC. Additionally, we wanted to identify early and easily available prognostic markers for outcome in all patients receiving IABP support. PATIENTS AND METHODS: Between 1/2004 and 1/2008, 4550 patients underwent cardiac surgical procedures with ECC, 223 of whom (4.9 %) had an IABP inserted intra- or postoperatively (group 1). 79 of these patients were treated intraoperatively with IABP for early postoperative low cardiac output syndrome (LCOS) characterized by predominantly right ventricular failure (RV group). Clinical data and hemodynamic variables were recorded perioperatively. Multiple potential markers of mortality and postoperative complications were analyzed statistically, especially with regard to their predictive ability. RESULTS: 68 % of all IABP patients were successfully weaned from IABP support and 63 % survived to hospital discharge. In the RV group, cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.8 +/- 0.2 to 2.8 +/- 0.2, MAP 53 +/- 10 to 73 +/- 8, P < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased ( P < 0.05). 59 patients in the RV group (75 %) could be weaned from IABP successfully and 69 % survived to hospital discharge. Serum lactate of more than 11 mmol/L in the first 10 hours of IABP support predicted a 100 % mortality. A base deficit of more than 12 mmol/L, mean arterial pressure less than 55 mmHg, urine output of less than 50 ml/h for 2 hours, and dose of epinephrine or norepinephrine of more than 0.4 mg/kg/min were other highly predictive prognostic markers. Furthermore, multivariate analysis showed that patients with a left atrial pressure > 17 mmHg or a mixed venous saturation (SVO (2)) < 65 % had poor outcomes. CONCLUSIONS: In patients with IABP support for postcardiotomy cardiogenic shock, elevated serum lactate, elevated base deficit, hypotension, oliguria and large vasopressor doses are all predictors of mortality. In these patients, the use of another mechanical assist device should be considered in good time. Our study additionally shows that LCOS caused by predominantly right ventricular failure - particularly after CABG - may be an additional indication for IABP.

The impact of pre- and postoperative renal dysfunction on outcome of patients undergoing coronary artery bypass grafting (CABG).

OBJECTIVE: Acute changes in renal function after elective coronary bypass surgery represent a challenging clinical problem. In this study, we evaluated perioperative risk factors for the development of postoperative renal dysfunction (PRD), and the impact of such an event on the perioperative course. Additionally, we investigated the influence of preoperatively mildly increased serum creatinine on perioperative mortality and morbidity. METHODS: We retrospectively analyzed data of 2511 patients undergoing isolated CABG between 2004 and 2007 with a preoperative serum creatinine < or = 2.2 mg/dL. There were 592 patients with a preoperative serum creatinine of between 1.4 and 2.2 mg/dl (mild renal dysfunction group) and 1919 patients with a serum creatinine < 1.4 mg/dl. Perioperative risk factors for PRD were analyzed by multivariate regression analysis. RESULTS: Global in-hospital mortality was 3.1 %.The incidence of PRD was 6.2 %. Mortality for patients who had PRD was 7.8 vs. 2.9 % for patients who did not ( P < 0.05). PRD increased the length of hospital stay by 3.7 days (12.2 vs. 15.9; P < 0.05). Multivariate logistic regression identified the following variables as independent predictors of PRD: age, angina class III/IV, diabetes mellitus, prolonged cardiopulmonary bypass time, and preoperative serum creatinine. With regard to preoperative renal function, we found that operative mortality was higher in the mild renal dysfunction group (5.7 % vs. 2.5 %; P < 0.05). New dialysis/hemofiltration (5.1 % vs. 1.2 %; P < 0.05) and postoperative stroke (5.1 % vs. 1.6 %; P < 0.05) were also more common in these patients. CONCLUSIONS: Mild renal dysfunction preoperatively is an important predictor of outcome after CABG. In these patients, PRD dramatically increases mortality, morbidity and length of hospital stay.

Intermediate coronary revascularization using the Deltastream blood pump: results from an experimental study.

BACKGROUND: Myocardial revascularization using a complete heart-lung machine may involve many problems, as do complete off-pump attempts. Thus, it was the aim of this study to evaluate the effects of intermediate on-pump/off-pump myocardial revascularization using the miniaturized Deltastream blood pump, on ischemia and hemolysis, in comparison with standard myocardial revascularization. METHODS: In a group of 8 mini-pigs, combined on-pump/off-pump myocardial revascularization was performed using the Deltastream blood pump as beating-heart support for the on-pump part of the operation (group A). Seven other animals served as controls and underwent standard myocardial revascularization with the same device as integrated pump of a complete heart-lung machine (group B). Blood samples for blood gas metabolism, creatine kinase (CK), troponin I, lactate dehydrogenase (LDH), and hydroxybutyrate dehydrogenase (HBDH) were taken before and after the entire operation. RESULTS: Comparing the baseline values, the increase of CK was more pronounced in group B than in group A (176.4-/+41.2 to 279.7-/+29 U/L vs. 274-/+142.7 to 288.1-/+118.6 U/L, respectively; p=0.0006). Increase of troponin I was significantly higher in group B than in group A (1-/+0.3 to 2.9-/+1 ng/mL vs. 1.1-/+0.9 to 3-/+3.8 ng/mL, respectively; p=0.002). LDH increase was also more pronounced in group B (231.7-/+54.3 to 299.9-/+39.8 U/L vs. 274.9-/+59.7 to 263.8-/+57.9 U/L, respectively; p=0.01). HBDH values increased significantly in group B after the operation (group A: 215.9-/+34.7 to 200-/+39.2 U/L vs. group B: 195.4-/+41.7 to 274.9-/+51.6 U/L; p=0.02). Hemodynamic measures and LDH values under luxation (group A: 1.9-/+0.6 U/L; B: 3.5-/+1 U/L,p=0.001) were also superior in the study group. CONCLUSION: The current set-up might be superior to conventional extracorporeal circulation and thus be an alternative for high-risk candidates to avoid the adverse events of a complete heart-lung machine, when they are scheduled for complete myocardial revascularization.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. / Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR) : Konsensuspapier der DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI und GRC.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Simple technique of repair for Barlow syndrome with posterior resection and chordal transfer via minimally invasive approach: primary experience in a consecutive series of 22 patients.

OBJECTIVE: Current techniques for mitral valve repair (MVR) in Barlow's disease require high level of surgical expertise due to a complex anatomy. A novel and simple standardized technique that particularly considers the pathological changes of the mitral valve in Barlow's disease has been developed. METHODS: Between 2009 and 2013, 22 patients underwent minimally invasive MVR for Barlow's disease and severe mitral regurgitation (MR). A simple, standardized technique was applied, including resection of P2 segment of posterior mitral leaflet (PML) with preservation of the shortest chordae, transfer of the preserved chordae to A2, and implantation of a semi-rigid open ring. In 2015, all patients were contacted for follow-up by transthoracic echocardiography (TTE) and interviewed for their clinical status. RESULTS: During follow-up (mean 2.8 ± 1.1 years; 100% complete), one patient died due to abdominal bleeding 4 months after the initial MVR and one patient with severe calcification of PML underwent valve replacement due to recurrence of MR. Among the remaining cohort (mean follow-up 3.0 ± 1.0 years), NYHA class I, II and III was present in 13, 6, and 1, respectively. TTE demonstrated MR grade 0, 1+, or 2+ in 40, 55, and 5%, respectively, with mean and maximum transvalvular gradients ranging at 1.9 ± 1.7 and 4.7 ± 3.3 mmHg, respectively. CONCLUSIONS: A simple and standardized technique facilitates the repair of MR in the presence of Barlow's, simultaneously addressing the height of PML and the position of the anterior leaflet. This technique has proven durable in the mid-term follow-up in our small series and warrants further validation in larger cohorts.

Increased preoperative C-reactive protein (CRP)-values without signs of an infection and complicated course after cardiopulmonary bypass (CPB)-operations.

OBJECTIVE: C-Reactive protein (CRP) is known to be a sensitive indicator of infection. Since it is also involved in the acute phase reaction, it is of great interest, whether an isolated preoperative increase of CRP without further signs of infection is of any prognostic value for postoperative outcome after cardiac surgery with cardiopulmonary bypass (CPB), which itself is possibly causing a systemic inflammatory response syndrome (SIRS). METHODS: Fifty patients with an isolated CRP-elevation (>5 mg/l) (from 6.2 to 93.3 mg/l) were operated using CPB (group A). A control group (group B) consisted of 50 cardiac surgery patients, matched in the patterns of age, gender and kind of disease. No preoperative CRP-elevation (from 0 to 4.8 mg/l) occurred in this group. RESULTS: The postoperative course of both groups showed significant differences. Septic complications were seen more often in group A (20%) than in the controls (2%) (P < 0.01). Microbiology (blood culture, cultures from nose, tracheal aspirate and urine) was positive only in 10% of these patients. Catecholamine support (epinephrine, norepinephrine and/or doses of dopamine or dobutamine of more than 3 microg/kg per min) was needed in 26% of group A cases, whereas it was only needed in 10% of group B (P < 0.05). A significantly longer respiratory support was also necessary in patients with elevated CRP (25.2 +/- 6.4 h vs. 6.6 +/- 0.8 h) (P < 0.01). Furthermore there was a significant difference in the duration of intensive care (4.6 +/- 0.8 days vs. 2.6 +/- 0.3 days) (P < 0.05). CONCLUSIONS: These data show that patients without apparent infection or inflammation, who had elevated CRP-values preoperatively, face an increased risk of septic complications after extracorporeal circulation. As microbiology tests are negative in most cases, it may be speculated that the majority of septic complications are due to a SIRS.

Heart-type fatty acid binding protein (hFABP) in the diagnosis of myocardial damage in coronary artery bypass grafting.

OBJECTIVES: Heart-type fatty acid binding protein (hFABP) is an intracellular molecule engaged in the transport of fatty acids through myocardial cytoplasm and has been used as a rapid marker of myocardial infarction. However, its value in the evaluation of perioperative myocardial injury has not yet been assessed. METHODS: 32 consecutive patients undergoing coronary artery bypass grafting were included in a prospective, randomized study using standardized operative procedures and myocardial protection. Three patients with perioperative myocardial infarction were added. Serial blood samples were taken preoperatively, before ischemia, 5 and 60 min after declamping, 1 and 6 h postoperatively and on postoperative days 1, 2 and 10 and were tested for hFABP, creatine kinase isoenzyme MB (CKMB) and troponin I (TnI). RESULTS: Hospital mortality was zero. The kinetics of the biochemical parameters revealed a typical pattern for each marker. In routine patients, hFABP levels peaked as early as 1 h after declamping, whereas CKMB and TnI peaked only 1 h after arrival in the intensive care unit. Patients with perioperative infarction displayed peak levels some hours later in all marker proteins. Peak serum levels of hFABP correlated significantly with peak levels of CKMB (r=0.436, P=0.011) and TnI (r=0.548, P=0.001), indicating the degree of myocardial damage. CONCLUSIONS: hFABP is a rapid marker of perioperative myocardial damage and peaks earlier than CKMB or TnI. The kinetics of marker proteins in serial samples immediately after reperfusion is more suitable for the detection of perioperative myocardial infarction than a fixed cut-off level.

Mechanical assist devices as bridging systems to transplantation: A current review, possible risks, and perspectives.

Mechanical circulatory support is of increasing interest because of its considerable demographic importance concerning myocardial failure and because of stagnant transplantation volumes. This study offers an overview of the present state of the art. Institutions with a mechanical circulatory assist program usually dispose of a decision chart for the various systems. There are devices with intra- or extracorporeal pump positions and with long- or short-term application. The various possibilities of mechanical circulatory assistance are presented, along with their technical properties, indications, and results. Currently, the application is concerned with technical reliability and limited biocompatibility with thrombembolic, neurological, and infectious complications. With some further developments, the present state of the art is supposed to enable a widespread application as bridging systems and as long-term therapy of heart failure within the next few years.

Reverse remodeling by net cardioplasty in a model of dilated cardiomyopathy: results of an animal study.

AIM: End-stage heart failure is a growing clinical problem with only a few satisfactory therapeutical options. Dilated cardiomyopathy (DCM) is associated with a progressive decline in cardiac function. Our hypothesis was to arrest this worsening of cardiac function by mechanically containing the dilated heart with a special net. METHODS: In 16 pigs (50+/-7 kg) DCM congestive heart failure was initiated by rapid ventricular pacing (220 b/m). In series 1 (n=8) a polyester net was placed around both ventricles before pacing was induced, whereas in series 2 (n=8) ventricular wrapping was performed when DCM was established. RESULTS: Comparing hemodynamic data before re-operation of group 11-animals, the decrease of CO and dp/dt(max) was significantly lower in series 1 than in series 2 compared to the baseline values before pacing (CO: series 1:-22.6+/-3.3%, series 2:-52.4+/-6.4%, p<0.05; dp/dt: series 1: +16.4+/-2.8%, series 2: -51.5+/-5.9%, p<0.05). In series 2, after net implantation, we could furthermore show that deterioration of the animal stopped and hemodynamic data improved significantly in the following 2 weeks (CO: +62.9+/-10.5% and dp/dt +37.0+/-6.8%). CONCLUSION: Ventricular containment with a polyester net seems to be a therapeutic option in cardiac insuffiency caused by ventricular dilation. This cardioplasty induced a reverse remodeling of the dilated hearts with a significant improvement in diastolic and systolic ventricular function.