Soluble urokinase plasminogen activator receptor and survival in elective cardiac surgery.

BACKGROUND: The study investigated the prognostic value of soluble urokinase plasminogen activator receptor (suPAR) in patients undergoing cardiac surgery and calculated a simplified biomarker score comprising suPAR, N-terminal pro B-type natriuretic peptide (NT-proBNP) and age. METHODS AND RESULTS: Biomarkers were assessed in a cohort of 478 patients undergoing elective cardiac surgery. After a median follow-up of 4.2 years, a total of 72 (15.1%) patients died. SuPAR, NT-proBNP and age were independent prognosticators of mortality in a multivariable Cox regression model after adjustment for EuroScoreII. We then calculated a simplified biomarker score comprising age, suPAR and NT-proBNP, which had a superior prognostic value compared to EuroScoreII (Harrel's C of 0.76 vs. 0.72; P for difference = 0.02). Besides long-term mortality, the biomarker score had an excellent performance predicting one-year mortality and hospitalization due to heart failure. CONCLUSION: The biomarker suPAR and NT-proBNP were strongly and independently associated with mortality in patients undergoing cardiac surgery. A simplified biomarker score comprising only three variables (age, suPAR and NT-proBNP) performed better than the established EuroScoreII with respect to intermediate and long-term outcome as well as hospitalization due to heart failure. As such, integration of established and upcoming biomarkers in clinical practice may provide improved decision support in cardiac surgery.

The impact of volume substitution on post-operative atrial fibrillation.

BACKGROUND: Post-operative atrial fibrillation (POAF) represents a common complication after cardiac valve or coronary artery bypass surgery. While strain of atrial tissue is known to induce atrial fibrillating impulses, less attention has been paid to potentially strain-promoting values during the peri- and post-operative period. This study aimed to determine the association of peri- and post-operative volume substitution with markers of cardiac strain and subsequently the impact on POAF development and promotion. RESULTS: A total of 123 (45.4%) individuals were found to develop POAF. Fluid balance within the first 24 hours after surgery was significantly higher in patients developing POAF as compared to non-POAF individuals (+1129.6 mL [POAF] vs +544.9 mL [non-POAF], P = .044). Post-operative fluid balance showed a direct and significant correlation with post-operative N-terminal pro-brain natriuretic peptide (NT-ProBNP) values (r = .287; P = .002). Of note, the amount of substituted volume significantly proved to be a strong and independent predictor for POAF with an adjusted odds ratio per one litre of 1.44 (95% CI: 1.09-1.31; P = .009). In addition, we observed that low pre-operative haemoglobin levels at admission were associated with a higher need of intraoperative transfusions and volume-demand. CONCLUSION: Substitution of larger transfusion volumes presents a strong and independent predictor for the development of POAF. Via the observed distinct association with NT-proBNP values, it can reasonably be assumed that post-operative atrial fibrillating impulses are triggered via increased global cardiac strain. Optimized pre-operative management of pre-existing anaemia should be considered prior surgical intervention in terms of a personalized patient care.

Negative pressure wound therapy for the treatment of sternal wound infections after cardiac surgery.

We retrospectively collected and analysed data from patients with sternal wound infections between 1995 and 2001, which were treated with different wound management strategies, and compared them with our patients from 2002 to 2011, who were treated with the sternal negative pressure wound therapy (NPWT). From 1995 to 2001, a total of 198 patients (group A) with a mean age of 65 ± 10 years developed sternal wound infection (67% deep) after cardiac surgery. Wound management consisted of surgical debridement and immediate sternal closure or open packing. From 2002 to 2011, a total of 326 patients (group B) (71% deep) were managed with NPWT at the time of surgical debridement. Total mortality was 10% in group A and 3·6% in group B. Recurrence rates were 34 and 8·5%, respectively, for the groups A and B. The meantime of NPWT was 11 days. In group B patients, 75% proceeded to sternal closure. With the introduction of NPWT, the treatment of sternal wound infections could be substantially improved. Particularly, the high recurrence rates could be minimised; furthermore, the goal to salvage the sternal bone is facilitated.

An Extended Duration of the Pre-Operative Hospitalization is Associated with an Increased Risk of Healthcare-Associated Infections after Cardiac Surgery.

Nosocomial infections are a common complication in clinical practice with major impact on surgical success and patient outcome. The probability of nosocomial infections is rapidly increasing during hospitalization. Therefore, we investigated the impact of a prolonged pre-operative hospital stay on the development of post-operative infection. Within this prospective observational study, 200 patients scheduled for elective cardiac surgery were enrolled. Patients were followed during hospital admission and screened for the development of nosocomial infection. Logistic regression analysis was used to assess the impact of a prolonged pre-operative hospital stay on the development of infection. A total of 195 patients were suitable for the final analysis. We found a strong and direct association of the duration of pre-operative hospital stay and the number of patients developing infection (+23.5%; p = 0.006). Additionally, the length of patients' pre-operative hospital stay was independently associated with the development of post-operative nosocomial infection, with an adjusted OR per day of 1.38 (95%CI: 1.02-1.86; p = 0.036). A prolonged pre-operative hospital stay was significantly associated with the development of nosocomial infection after cardiac surgery. Those findings need to be considered in future clinical patient management in order to prevent unnecessary antibiotic use and potential harm to patients.

V.A.C. Therapy in the management of paediatric wounds: clinical review and experience.

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

CD4+CD28null T Lymphocytes are Associated with the Development of Atrial Fibrillation after Elective Cardiac Surgery.

Post-operative atrial fibrillation (POAF) is postulated as a complex interaction of different pathogenic factors, suggesting inflammatory processes as a main trigger of this particular type of atrial fibrillation. Therefore, the study sought to assess the impact of cellular immunity on the development of POAF. Comparing patients developing POAF to individuals free of POAF the fraction of CD4+CD28null T Lymphocytes was significantly higher in individuals developing POAF (11.1% [POAF] vs. 1.9% [non-POAF]; p < 0.001). CD4+CD28null cells were independently associated with the development of POAF with an adjusted odds ratio per one standard deviation of 4.89 (95% CI: 2.68-8.97; p < 0.001). Compared to N-terminal Pro-Brain Natriuretic Peptide, the fraction of CD4+CD28null cells demonstrated an increased discriminatory power for the development of POAF (NRI: 87.9%, p < 0.001; IDI: 30.9%, p < 0.001). Interestingly, a pre-operative statin-therapy was associated with a lower fraction of CD4+CD28null cells (p < 0.001) and showed an inverse association with POAF (p < 0.001). CD4+CD28null cells proved to be predictive for the development of POAF after cardiac surgery. Our results potentially indicate an auto-immune impact of this preexisting, highly cytotoxic T cell subset in the pathogenesis of POAF, which might be modified via the anti-inflammatory potential of a pre-operative statin-therapy.

Direct sternal administration of Vancomycin and Gentamicin during closure prevents wound infection.

OBJECTIVES: Deep sternal wound infection is still a major complication in patients undergoing cardiac surgery. We previously identified mammary artery harvesting as a risk factor for decreased antibiotic tissue penetration. In addition, other risk factors including diabetes may inhibit sufficient tissue penetration of perioperative antibiotic prophylaxis. A novel closure protocol applying 2 topical antibiotics and further recommendations for sternal wiring was introduced at our department to decrease the incidence of sternal wound infections. METHODS: A 12-month period prior to (March 2013-February 2014) and after (July 2014-June 2015) the introduction of a novel sternal closure protocol was studied. All sternal wound infections resulting from an operation during this period were analysed. The closure protocol consisted of the intra-sternal application of vancomycin and the subcutaneous application of gentamicin. Furthermore, we increased the number of sternal wires for more uniform distribution of lateral forces. RESULTS: Patients in both groups were comparable regarding demographic data and risk factors. Fifty-three out of 919 patients operated prior to the protocol change developed an infection (5.8%). The introduction of the novel sternal closure protocol reduced this number to 19 out of 932 patients (2.0%; P < 0.001). A binary regression including common risk factors revealed a strong independent risk reduction by the novel protocol (OR 0.322, P < 0.001). The number of sternal wires was not significant in this analysis. CONCLUSIONS: The topical application of 2 antibiotic agents significantly reduced sternal wound infection. However, the results of this trial should be confirmed in a randomized trial.

Effect of laser perforation on the remodeling of acellular matrix grafts.

Autologous cells migrate only slightly into acellular matrix grafts. This study was carried out in small-diameter, allogeneic matrix grafts to investigate the effects on cell repopulation and remodeling caused by increased wall porosity induced by laser perforation. Allogeneic ovine carotid arteries were decellularized by dye-mediated photooxidation (Photofix). Matrix grafts (10 cm x 4 mm i.d.) were perforated with holes of 50 microm diameter at a density of 50 holes/cm(2) using a Ti-sapphire laser. The grafts were implanted in the carotid arteries of 10 sheep and were compared to nonperforated grafts implanted contralaterally. The prostheses were retrieved after 6 weeks or 3 or 6 months following implantation and were evaluated by histologic examination, immunohistochemical staining, and scanning electron microscopy. All grafts, except one of the perforated specimens, remained patent. Perforated implants, examined at 6 weeks, showed faster recellularization with endothelial cells than did the corresponding contralateral controls. Perforated grafts, examined at 6 months, showed a significantly thicker neointima and clear signs of neovascularization: endothelial cells, basal lamina, elastic fibers, circular and longitudinally orientated smooth muscle cells in comparison to nonperforated specimens. Repopulation of the decellularized matrix with host cells was higher in the perforated than in the nonperforated prostheses. These results suggest that the increased matrix porosity induced by laser perforation promotes graft remodeling and reconstitution with host cells.

Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair.

OBJECTIVES: To analyze outcome in elderly patients after surgical repair of the ascending aorta and the aortic arch as compared with their younger counterparts and to determine risk factors of mortality and permanent neurologic injury. Patients and methods Between January 1995 and February 2003, a total of 369 patients underwent ascending aortic and arch repair. Indications for surgical intervention were acute type A dissections in 174 (47%) patients (<75 years, n = 147; > or =75 years, n = 27) and chronic atherosclerotic aneurysms in 195 (53%) patients (<75 years, n = 168; > or =75 years, n = 27). Emergency surgery was performed in 167 (45%) patients; 202 patients (54.7%) underwent surgery requiring deep hypothermic circulatory arrest. Pre- and intraoperative factors were evaluated by means of stepwise logistic regression analysis to determine risk factors of mortality and permanent neurologic injury. RESULTS: Overall in-hospital mortality was 11.6%. In-hospital mortality with regard to indication for surgical intervention was comparable in both age groups (type A dissection: <75 years, 15.6%; > or =75 years, 18.5%; P =.731; chronic atherosclerotic aneurysm: <75 years, 7.7%; > or =75 years, 7.4%; P =.933). Permanent neurologic injury was observed in 5.0%. Permanent neurologic injury with regard to surgical intervention was comparable in both age groups (type A dissection: <75 years, 8.8%; > or =75 years, 3.7%; P =.359; chronic atherosclerotic aneurysm: <75 years, 3.0%; > or =75 years, 3.7%; P =.843). Stepwise logistic regression analysis revealed preoperative hemodynamic instability (odds ratio 4.3; P =.000), duration of cardiopulmonary bypass (odds ratio 2.1; P =.001), and permanent neurologic injury (odds ratio 1.7; P =.033) but not age as independent predictors affecting mortality. Utilization of but not duration of deep hypothermic circulatory arrest was the only independent predictor of permanent neurologic injury (odds ratio 2.8; P =.019). CONCLUSIONS: Age shows a trend toward a higher risk of mortality but does not predict a higher incidence of permanent neurologic injury after ascending aortic and arch repair. As utilization of deep hypothermic circulatory arrest remains the only independent predictor of permanent neurologic injury, alternative approaches to maintain cerebral perfusion during ascending aortic and arch repair are warranted.

The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest.

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.

Sealing of the mediastinum with a local hemostyptic agent reduces chest tube duration after complete mediastinal lymph node dissection for stage I and II non-small cell lung carcinoma.

BACKGROUND: We assessed the impact of coverage of the mediastinum with a local hemostyptic agent as well as the impact of perioperative thromboembolic prophylaxis on cumulative chest drain volume and on the duration of chest tubes after surgical resection with complete mediastinal lymph node dissection for stage I or II non-small cell lung cancer. METHODS: In a prospective, randomized two-by-two factorial design, 80 patients with clinical stage I or II non-small cell lung cancer were allocated to one of two surgical therapy arms (TachoComb or conventional surgical hemostasis) and one of two anticoagulation arms (enoxaparin 4,000 IU or dalteparin 5,000 IU). Primary end point was cumulative chest drain volume; secondary end point was duration of chest tubes. Additionally clinical data were obtained. RESULTS: Comparison of the surgical arms revealed significantly lower cumulative chest drain volumes and thereby an earlier chest tube removal in the TachoComb group (p = 0.045). With regard to thromboembolic prophylaxis, a significantly earlier chest tube removal was found for patients treated with dalteparin (p = 0.039). Analysis of the interaction of surgical and anticoagulation treatment revealed the combined use of TachoComb and dalteparin was superior to other combinations (cumulative chest drain volumes 498 +/- 67 mL versus 1,000 +/- 88 mL, 924 +/- 87 mL, and 895 +/- 118 mL; p = 0.008; mean duration of chest tubes 1.78 +/- 0.15 days versus 2.96 +/- 0.21 days, 2.93 +/- 0.17 days, and 3.06 +/- 0.27 days; p = 0.019). CONCLUSIONS: The combined use of a local hemostyptic agent and dalteparin seems superior as compared with other regimens of hemostasis and thromboembolic prophylaxis in patients undergoing surgical resection and complete mediastinal lymph node dissection for stage I and II non-small cell lung cancer with regard to cumulative chest drain volume as well as duration of chest tubes.

Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results.

BACKGROUND: The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta. METHODS: From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery. RESULTS: Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months). CONCLUSIONS: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.

The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery.

BACKGROUND: The VAC system (vacuum-assisted wound closure) is a noninvasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure by controlled suction to the wound surface. The method was introduced into clinical practice in 1996. Since then, numerous studies proved the effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation. METHODS: Eleven patients (5 men, 6 women) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting = 5, aortic valve replacement = 5, ascending aortic replacement = 1) were fitted with the VAC system by the time of initial surgical debridement. RESULTS: Complete healing was achieved in all patients. The VAC system was removed after a mean of 9.3 days (range 4 to 15 days), when systemic signs of infection resolved and quantitative cultures were negative. In 6 patients (54.5%), the VAC system was used as a bridge to reconstructive surgery with a pectoralis muscle flap, and in the remaining 5 patients (45.5%), primary wound closure could be achieved. Intensive care unit stay ranged from 1 to 4 days (median 1 day). Duration of hospital stay varied from 13 to 45 days (median 30 days). In-hospital mortality was 0%, and 30-day survival was 100%. CONCLUSIONS: The VAC system can be considered as an effective and safe adjunct to conventional and established treatment modalities for the therapy of sternal wound infections after cardiac surgery.

Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax.

BACKGROUND: To evaluate the role of apical lung wedge resection in patients with recurrent primary spontaneous pneumothorax with no endoscopic abnormalities at surgery as compared with simple apical pleurectomy. METHODS: We performed a retrospective analysis on 126 consecutive video-assisted thoracoscopic surgery (VATS) procedures in 113 patients treated for stage I recurrent PSP between January 1994 and December 2001. Two surgical strategies were applied: simple apical pleurectomy (57 procedures, 45.2%: group A) and apical pleurectomy together with an apical lung wedge resection (69 procedures, 54.8%: group B). RESULTS: Mean duration of chest tubes was 1.4 days (range, 1 to 7), mean hospital stay was 2.4 days. Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax. Mean follow-up was 38.7 months. Overall recurrence rate was 3.2%. Four patients in group A (7%) experienced recurrent ipsilateral pneumothoraces 4 to 73 weeks (mean, 30.2) after surgery. No recurrences were observed in group B (p = 0.009). CONCLUSIONS: In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.

Comparison of in vitro closure time (PFA-100) with whole blood electrical aggregometry and platelet surface antigen expression in healthy volunteers.

It was the aim of this study to compare in vitro closure time (PFA-100), reflecting platelet-related primary hemostasis, to more platelet-specific tests like whole blood electrical aggregometry and platelet surface antigen expression in healthy volunteers. In vitro closure time was measured using a PFA-100. Platelet surface antigen expression (CD63, CD62-P, CD42b, CD36, CD31) was determined in accordance with the consensus protocol for flow-cytometric characterisation of platelet function. Platelet aggregometry was performed using a whole blood electrical aggregometer (ADP and arachidonic acid as agonists). Analysis of the obtained data revealed only a few significant correlations between the different platelet function tests used. This finding can be explained by the various aspects of platelet function being focused by these tests in different extents. Whenever platelet function is analysed, the investigator should be aware of the specific and limited evidence of the method used. For screening purposes, it may be useful to introduce a platelet function index, referring to basal platelet activity, platelet adhesion and platelet aggregation at low and high shear stress forces.

Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta.

OBJECTIVE: The objective of the study was to evaluate mid-term durability and need for reinterventions after endovascular stent-grafting (ESG) in descending aortic aneurysms and dissections. PATIENTS AND METHODS: Between November 1996 and February 2003 a total of 80 patients underwent ESG for the following indications: atherosclerotic aneurysms (50/80; 63%), type B dissections (20/80; 25%), penetrating ulcers (6/80; 8%), traumatic aneurysms (4/80; 5%). Two types of commercially available ESG (Talent, Medtronic, Santa Rosa, CA and Excluder, WL GORE, Flagstaff, AZ) were inserted via the femoral artery in 53 patients, via the iliac artery in 21 patients and via the abdominal aorta in 6 patients. RESULTS: In-hospital mortality was 3.8% (n=3). Type I endoleak formation requiring endovascular reintervention was observed in 3.8% (n=3). Surgical reintervention became necessary in 4 patients (4/80; 5%). One patient experienced a retrograde type A dissection, detected in the 3 month control after ESG of an acute type B dissection, consecutively undergoing frozen elephant trunc repair. Three patients with late type I endoleak formation (mean interval: 62 months) after ESG (two atherosclerotic aneurysms, one penetrating ulcer) underwent open thoraco-abdominal repair in deep hypothermia or left heart bypass technique. All patients had an uneventful postoperative course. CONCLUSIONS: Occurrence of late endoleak formation requiring surgical reintervention after ESG is acceptably low. In atherosclerotic aneurysms the development of endoleaks is assumed to be causative related to progression of the underlying aortic disease. A close follow-up of patients after ESG is crucial.

Endovascular stent graft placement in patients with acute thoracic aortic syndromes.

OBJECTIVE: In the present study, the effectiveness of endovascular stent grafts (ESG) in the treatment of acute aortic complications, such as acute dissection type B, penetrating ulcer and traumatic aortic rupture is evaluated. PATIENTS AND METHODS: From June 1997 to February 2002, 66 patients were treated with ESG. Out of this cohort, 19 patients (28.8%) were subjected to stent grafting due to acute aortic syndromes. Acute dissection type B was present in 11 patients (16.6%), a penetrating ulcer was diagnosed in six patients (9%) and in 2 patients (3%) a traumatic aneurysm was the indication for operation. There were 16 male and three female patients with a mean age of 60 years (20-85 years). Excluder stent grafts (Gore) were used in 15 patients, the Talent device (Medtronic) was implanted in four patients. RESULTS: Stent graft placement was technically successful in all patients. Hospital mortality was 0%. Paraparesis occurred in one patient (5.2%), which could be managed successfully without remaining neurological deficit after installation of cerebrospinal fluid drainage for 72h. In another patient, overstenting of the left subclavian artery caused ischemia of the left arm and left subclavian to carotid artery bypass had to be performed. ICU-stay ranged from 1 to 6 days (mean 2.4 days) and the patients could be discharged after an average hospital stay of 8 days. In the follow-up period, one patient died due to myocardial infarction and one patient had to be re-operated due to contained rupture of the thoracic aorta caused by an endoleak. CONCLUSIONS: The study suggests that endovascular stent grafting is an excellent and effective treatment modality for the acute aortic accident, which can be recommended for high-risk patients too. However, close follow-up examination is indicated and long-term results have to be awaited to evaluate the real effectiveness of this method.

Aortic dissection type A after right atrial cryoablation during port access mitral valve surgery.

The case of a 63-year-old woman who underwent minimal invasive mitral and tricuspid valve repair and a concomitant CryoMaze is described. During creation of the last lesion of the right-sided maze procedure, dissection of the ascending aorta occurred that necessitated emergency sternotomy, replacement of the ascending aorta, and aortocoronary bypass grafting to the right coronary artery (RCA) because of detachment of the RCA from the aortic annulus. Repair of this complication was successful; nevertheless, the patient died 5 days after the operation because of multiorgan failure. The cause of this complication can only be speculated, but a relation to the CyroMaze is obvious. Because of the restricted incision with impaired vision especially in the area of the right atrial appendage, the cryoprobe could have come into contact with the orifice of the RCA during the last lesion, with subsequent detachment of the RCA from the aorta, which could subsequently have caused dissection.

Single rescuer exertion using a mechanical resuscitation device: a randomized controlled simulation study.

OBJECTIVES: The goal of this experimental study was to investigate rescuer exertion when using "Animax," a manually operated hand-powered mechanical resuscitation device (MRD) for cardiopulmonary resuscitation (CPR), compared to standard basic life support (BLS). METHODS: This was a prospective, open, randomized, crossover simulation study. After being trained, 80 medical students with substantial knowledge in BLS performed one-rescuer CPR using either the MRD or the standard BLS for 12-minute intervals in random order. The main outcome parameter was the heart rate pressure product (RPP) as an index of cardiac work. Secondary outcome parameters were physical exhaustion quantified by the Borg scale (measurement of perceived exertion), Nine Hole Peg Test (NHPT; measurement of fine motor skills), and capillary lactate concentration during testing. RESULTS: While no significant difference could be found for the RPP, a significantly increased mean heart rate during the final minute of standard BLS compared to the MRD was found (139 ± 22 beats/min vs. 135 ± 26 beats/min, p = 0.027). By contrast, subjective exertion using the MRD was rated significantly higher on the Borg scale (15.1 ± 2.4 vs. 14.6 ± 2.6, p = 0.027). Mean serum lactate concentration was significantly higher when the MRD was used compared to standard BLS (3.4 ± 1.5 mmol/L vs. 2.1 ± 1.3 mmol/L, p ≤ 0.001). CONCLUSIONS: Use of the MRD leads to a RPP of the rescuers comparable to standard BLS. These findings suggest that there is no clinically relevant reduction of exertion if this MRD is used by a single rescuer. If this kind of MRD is used for CPR, frequent changeovers with a second rescuer should be considered as the guidelines suggest for standard CPR.