Endothelial dysfunction following coronary artery bypass grafting : Influence of patient and procedural factors.

BACKGROUND: Angiopoietin-2 (Angpt2) mediates endothelial dysfunction (ED) following coronary artery bypass grafting (CABG). Its triggers are, however, poorly understood. METHODS: We examined the time course of ED beyond the early phase of postoperative recovery in 75 patients following CABG with a special focus on different cardiopulmonary bypass (CPB) modes as potential triggers of Angpt2 release. RESULTS: Nine patients (12.0%) underwent off-pump coronary artery bypass (OPCAB), 31 patients (41.3%) received minimized extracorporeal circulation (MECC), and 35 patients (46.6%) were operated on with (conventional) CPB. Angpt2 levels steadily increased across the observation period (1.7 [1.4-2.1] to 3.4 [2.5-6.1] ng/ml, p < 0.001). Angpt2 levels did not differ between the MECC and CPB groups (p = 0.564). There was no difference between MECC and CPB patients regarding net fluid balance (p = 0.821) and other surrogate markers of postoperative ED. The magnitude of Angpt-2 increase correlated more strongly with baseline C­reactive protein (r = 0.459, p < 0.001) than with any other parameter. Hospital length of stay correlated more strongly with baseline Angpt2 levels (r = 0.512, p = 0.005) than with follow-up Angpt2 levels and appeared not to be influenced by CPB mode (p = 0.428). CONCLUSION: CABG is associated with prolonged ED, which is determined by the patient's preoperative inflammatory state rather than by CPB modifications.

Predictive value of ScvO2 monitoring for pericardial tamponade after cardiac surgery.

BACKGROUND: We examined the predictive value of central venous oxygen saturation (ScvO2) changes regarding the occurrence of pericardial tamponade following cardiac surgery. METHODS: We retrospectively identified 66 consecutive patients in whom ScvO2 and arterial lactate levels were analyzed during an 8­h time interval preceding pericardiotomy due to pericardial tamponade (PT), and at equivalent time points in 30 control patients (C) who had an uncomplicated course. RESULTS: The median age of the patients was 74 years (interquartile range, 63-78). Three percent of procedures were re-operations. There were no differences between the baseline values of PT and C patients. Pericardiotomy was performed on average 1 day (0-3.5) after cardiac surgery. PT patients displayed a significant decline (p < 0.001) to lower ScvO2 levels (p < 0.001) and a significant increase (p = 0.005) to higher arterial lactate levels (p = 0.019) during the 8 h preceding pericardiotomy, whereas C patients did not (p = 0.440 and p = 0.279, respectively). PT was associated with a longer hospital stay (p = 0.04) and a higher in-hospital mortality (p = 0.008). An ScvO2 decline below 60% (p = 0.018), a delta ScvO2 decline greater than 5% (p = 0.001), and a delta lactate increase greater than 0.18 mmol/l (p = 0.002) during the 8 h preceding pericardiotomy were independently associated with PT. None of these parameters predicted in-hospital mortality. CONCLUSION: Deteriorations in ScvO2 might serve as an early marker of PT following cardiac surgery.

Does pulsatile perfusion improve outcome after cardiac surgery? A propensity-matched analysis of 1959 patients.

OBJECTIVE: We analyzed the influence of pulsatile perfusion on recovery after coronary bypass grafting (CABG) or aortic valve replacement (AVR). PATIENTS AND METHODS: Between January 2008 and December 2010, 1959 consecutive patients underwent CABG, AVR, or both. The choice for pulsatile perfusion (PP, n=220) or non-pulsatile perfusion (NPP, n=1739) was made by the surgeon. Patient propensity score to receive PP or NPP was calculated according to 15 preoperative variables. Resulting propensity scores, logistic EuroSCORE, perfusion type and surgeon were analyzed to evaluate their role for mortality, length of postoperative ICU and hospital stay (LOHS), transfusion requirements and renal function. Risk stratified non-parametric univariate analyses and propensity adjusted multivariate analyses were performed. RESULTS: EuroSCORE and hospital mortality did not differ significantly between PP and NPP. EuroSCORE was the best predictive factor for all examined variables (p<0.001). PP was superior concerning LOHS (p=0.019) and this benefit increased with higher logistic EuroSCORE. The surgeon significantly influenced ventilation time, ICU stay and transfusion requirements. CONCLUSION: Pulsatile perfusion did not influence perioperative outcome parameters, renal function and mortality, but resulted in shorter hospital stay, especially in critically ill patients.

Simultaneous mitral valve replacement and liver transplantation.

We report the case of a 57-year-old man who underwent successful simultaneous surgery involving mitral valve replacement for acute endocarditis and orthotopic liver transplantation for end-stage liver disease.

[Cardiac surgery in elderly patients]. / Herzchirurgie im Alter.

Due to demographic changes in average life expectancy, the age of patients undergoing cardiac surgery is increasing. We have reviewed the literature to analyse whether and how far octogenarians benefit from cardiac surgical procedures. Different studies analysed the outcome of patients in different age groups after cardiac surgery. Octogenarians can undergo cardiac surgical procedures at a reasonable risk. The perioperative mortality and other postoperative complications are strongly dependent on comorbidities rather than on patients' age. Elderly patients benefit from improved functional status and quality of life.

[Minimally invasive therapy of submacular hemorrhage in exsudative age-related macular degeneration]. / Minimal-invasive Therapie submakulärer Blutungen bei exsudativer altersbedingter Makuladegeneration.

BACKGROUND: The purpose of this prospective observational study was to analyze the efficacy and safety of a minimally invasive approach in patients with subretinal hemorrhage secondary to exsudative age-related macular degeneration (ARMD). METHODS: A total of 34 eyes from 33 patients with submacular hemorrhage due to exsudative ARMD were included in the study and 18 of the 33 patients were under anticoagulant medication. Combined subretinal injection of recombinant tissue plasminogen activator (rTPA) and bevacizumab with subsegment core vitrectomy and gas tamponade with 1.8-2.2 ml pure sulphur hexafluoride gas (SF6) was applied using a single pars plana incision. The follow up period was 1-17 months and median 4.5 months. RESULTS: This approach achieved a sufficient SF6 gas filling in all cases without the requirement of strict face-down positioning. Postoperatively all patients had subjective improvement of central visual field. Visual acuity increased in 16 out of 33 patients and 12 out of 33 patients remained unchanged. As complications seven tears of the retinal pigment epithelium (RPE) and one recurrent subfoveal hemorrhage were observed, two cases of retinal detachment occurred and required buckling surgery. In 14 out of 33 patients further application of intravitreal anti-VEGF (vascular endothelial growth factor) was necessary. CONCLUSION: This minimally invasive approach seems to be a feasible and effective method to displace subretinal hemorrhages with tenable results.

[How can the shift of refraction due to vitreous substitutes be avoided? Posterior chamber intraocular lens for patients suffering from diabetic retinopathy]. / Wie ist die Refraktionsänderung bei Glaskörpertamponade zu vermeiden? Hinterkammerlinse für Patienten mit diabetischer Retinopathie.

Silicone filling of pseudophakic eyes usually results in strong unilateral hyperopia and binocularity is severely disturbed. This problem can be avoided by designing a concave posterior lens surface with the centre of curvature in the macula (Acri.Lyc 59RET®, haptics in capsular bag, body in vitreous cavity). The prospective study on 40 eyes with idiopathic macular foramen yields a mean refraction difference of 0.22 D with and without oil. The A-constant of the lens was found to be 115.7. Clinically relevant aniseikonia did not occur. The main indication is cataracts combined with diabetic retinopathy.

[Central serous chorioretinopathy (CSC)]. / Chorioretinopathia centralis serosa (CCS).

In the acute stage central serous chorioretinopathy (CSC) is characterized by serous retinal detachment. Monofocal or multifocal structural changes of the pigment epithelium layer are common. Unilateral blurred vision is the major clinical symptom. The pathogenesis is unclear but corticosteroids and stress may trigger the disease. Normal vision often returns spontaneously within a few months. Therapeutic options are at a low evidence level. Carbonic anhydrase, mild laser photocoagulation, selective retinal therapy, photodynamic therapy and the intravitreal injection of bevacizumab have been reported. The authors suggest a treatment strategy on the basis of the available data.

The minimized extracorporeal circulation system causes less inflammation and organ damage.

The minimized extracorporeal circulation system (MECC) is being used to reduce priming volume and blood/polymer contact during cardiac procedures. In this study, we evaluated the efficacy and potential advantages of the system in coronary artery bypass graft (CABG) patients. We included two groups of patients destined for CABG in a prospective, randomized study: Group A was operated on the usual pump (n = 30) while Group B was operated using the MECC (n = 50). Pre-operative demographics, intra-operative times and values as well as a series of post-operative outcome data (blood loss, transfusion requirements, ventilation time, ICU and hospital stay) were recorded. CK, CK-MB, troponin-T, IL-6 and IL-8 were measured. Pre-operative and post-operative lung function were assessed. In the MECC-operated group, patients developed less post-operative troponin-T (0.2 +/- 0.3 vs. 0.5 +/- 0.5 ng/mL, p=0.031) and less IL-8 (13.8 +/- 5 vs. 22.5 +/- 0.5 microg/L, p = 0.05). While blood loss was comparable in both groups, packed red blood cells and fresh frozen plasma were given less frequently in the MECC group (p = 0.015 resp. 0.022). The one-tailed Student's t-test revealed shorter bypass time in the MECC group (74 +/- 17 vs. 82 +/- 24 min). There was no difference in ventilation and ICU-time (patients were not treated in a fast-track fashion). The FEV1 was better in the MECC group (relative values: 70.1 +/- 18.2% vs. 61.1 +/- 12.3%, p = 0.02). Utilization of the MECC may cause less cytokine (IL-8) liberation, owing to less blood/tubing contact, as well as less red blood cell and fresh frozen plasma demand. It may also be the circuit in patients with chronic obstructive pulmonary disease (COPD).

Reduced susceptibility of electroporated tumor cell lines to killing by cytotoxic lymphocytes.

Electroporation is a widely applied method for gene or protein transfer into cells, and it is also used for electrochemotherapy of cancer. During gene transfection studies, electroporation was found to decrease transiently susceptibility of some tumor cell lines to alloreactive cytotoxic T lymphocytes (CTL) or lymphokine-activated killer (LAK) cells. In each cell line electroporation induced c-fos mRNA. In K562 cells HSP70 mRNA induction also occurred. Expression of Grp78, Bcl-2, CD95/Fas, or major histocompatibility complex class I molecules was not affected by electroporation.