Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update.

PURPOSE: Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS: One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION: As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.

[S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]. / S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten : Hämodynamisches Monitoring und Herz-Kreislauf ­ ein Update.

An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.

[GSTCVS certificate for cardiac pacemaker, ICD and CRT therapy]. / DGTHG-Zertifizierung zur Herzschrittmacher-, ICD- und CRT-Therapie.

Medical qualifications to perform operations with cardiac electronic implantable devices as well as for preoperative and postoperative therapy, including follow-up in this patient population are not well defined. Based on recommendations which have been worked out and published by an interdisciplinary consensus of cardiac surgeons, cardiologists and electrophysiologists, a certificate with three modules has been developed by the Working Group for Electrophysiologic Surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS, Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG). First examinations for this certificate will be held in 2013 and transitional regulations apply until 1st April 2014. Further details are available on the homepage of the GSTCVS.

Clinical impact of the publication of S3 guidelines for intensive care in cardiac surgery patients in Germany: results from a postal survey.

INTRODUCTION: The development and implementation of practice guidelines might be an important tool to evaluate the different practices and to consider different local strategies. METHODS: A postal questionnaire with 37 questions was sent to the leading physicians of 80 intensive care units in Germany, treating patients after cardiothoracic surgery. The survey covered the same core questions on current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support, and transfusions before and after the publication of an S3 guideline. RESULTS: A total of 77.5 % of the completed questionnaires were returned. Monitoring changed to increased use of central venous oxygen saturation (S(cv)O(2)) in 55.1% (2005: 20.9%), end-tidal CO(2)-monitoring 36.2% (2005: 24.3%), and decreased use of the left atrial pressure with 12.3% (2005: 23.3%) and pulmonary artery catheter 47.5% (2005: 58.2%). For volume therapy, there is a decreased use of Hydroxyethyl starch (HES) with 38.7% (2005: 63.4%) and an increased use of crystalloids 41.9% (2005: 22.4%). For inotropes, there is a trend to a decreased use of dopamine with 9.7% (2005: 29.1%, P = 0.074). The clinical relevance of the guidelines was judged 'high' by 43.5% and 'medium' by 50% of the responding physicians; however, change of treatments was reported by one quarter of respondents. CONCLUSION: Despite ongoing variability in the use of monitoring devices, volume replacement and vasopressor/inotrope use in cardiac surgery patients, there have been some changes in the therapy of these patients after publication of the guidelines. Because the guideline has been considered as clinically relevant, further interdisciplinary development and implementation support should be considered.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

[Training requirements for transvenous implantation of pacemakers and cardioverter-defibrillators]. / Empfehlungen zur strukturierung der herzschrittmacher- und defibrillatortherapie.

Therapy with implantable pacemakers, cardioverter defibrillators (ICD), and devices for cardiac resynchronization (CRT) is performed by various medical and surgical specialists. With the change from implantation by thoracotomy to the transvenous approach, an increasing number of devices are implanted by cardiologists. The purpose of this paper is to establish training requirements for transvenous device therapy, implantation and follow-up examinations, regardless of the implanting person, an internist, cardiologist, general surgeon, or cardiothoracic surgeon. Epicardial lead placement should be performed only by surgeons. Two levels of training topics are defined, level 1 for pacemakers and level 2 for ICD and CRT devices. Surgery that involves the implantation of foreign material should demand the highest standards of operating rooms design and environment. Catheter laboratories used for implantations should meet operating room standards. Complications need to be documented carefully for quality control.

Procalcitonin levels after different types of conventional thoracic surgery.

BACKGROUND: Procalcitonin (PCT) is currently discussed as an indicator of postoperative complications following thoracic surgery. Serum levels of PCT are different after thoracoscopic and conventional surgical approaches. We conducted this study to test the hypothesis that different types of conventional thoracic surgery are associated with different postoperative serum levels of acute-phase proteins or pro-inflammatory mediators. METHODS: Serum levels of interleukin (IL)-6, C-reactive protein (CRP), lipoprotein-binding protein (LBP) and PCT were measured preoperatively (pre), immediately after surgery (0 h), 6 hours after surgery (6 h), and on the 1st (d1), 3rd (d3) and 5th (d5) postoperative days in 48 patients undergoing elective conventional pneumonectomy (n = 6), lobectomy (n = 20) or wedge resection (n = 22). RESULTS: In all study groups, IL-6 and PCT increased after surgery, peaking at 6 h and on d1, respectively. The time courses of IL-6, CRP, LBP and PCT release were not influenced by the type of surgical procedure. All parameters increased more markedly after lobectomy and wedge resection than after pneumonectomy. CONCLUSIONS: Surgical trauma and lung ischaemia/reperfusion injury could be the main factors determining the release of IL-6 and PCT after surgery. From an immunological point of view, pneumonectomy is less severe than wedge resection or lobectomy in terms of tissue injury. Different types of conventional thoracic surgery are associated with differences in postoperative PCT and IL-6 synthesis. For this reason, expected ranges of PCT and IL-6 levels should be established for the various surgical procedures before these parameters can be used as indicators of postoperative complications.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. / Die intensivmedizinische Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf-Therapie S3-Leitlinie der Deutschen Gesellschaft für Thorax-, Herz- und Gefässchirurgie (DGTHG) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey.

BACKGROUND: In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. METHODS: A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. RESULTS: Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. CONCLUSION: Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.

Immunoglobulin levels and lymphocyte subsets following cardiac operations: further evidence for a T-helper cell shifting.

BACKGROUND: Recent data indicate that cardiac surgery with cardiopulmonary bypass (CPB) results in an imbalance of T-helper cell subsets towards the anti-inflammatory pathway mediating humoral immune response. However, little is known about immunoglobulin levels as an important part of humoral immune response after CPB. Therefore, the objectives of this study were 1) to elucidate the effects of CPB on perioperative immunoglobulin levels, and 2) to find out if alterations in lymphocyte subsets are related to these findings. METHODS: Blood samples from 83 patients undergoing elective cardiac operation were taken preoperatively (d0), on the first (d1), third (d3), and fifth day (d5) after operation. Levels of immunoglobulin (Ig) E, IgM, and IgG, including the subclasses IgG 1 - 4, were measured. IgG2/IgE-ratio was used as indicator for TH1/TH2 shifting, and production of tetanus antibodies (AB) was investigated as an in vivo parameter of humoral immune reaction. The number and percentage of T- and B-lymphocyte subsets were assessed in a subgroup of 50 patients to answer the second question. RESULTS: Clinically, no mortality or major morbidity were observed. IgE levels did not change until d3 and increased significantly on d5. In contrast, both IgG and IgM levels decreased significantly on d1. While IgM returned to baseline (BL) on d5, IgG levels remained below BL until d5. IgG2/IgE-ratio decreased significantly on d1, reached its nadir on d3 and remained depressed until d5. The number of T-lymphocytes decreased on d1 as well as the number of B-cells. T-cells returned to BL on d5, B-cells on d3. However, while the percentage of T-cells decreased on d1, the percentage of B-cells increased. The percentage of T-cells returned to BL on d3, and B-cell percentage returned to BL on d5. Tetanus AB production did not change until d5 when it increased significantly. CONCLUSIONS: 1) Increase of IgE and tetanus AB production indicate that humoral immune response is not affected by CPB, but possibly even enhanced. The relative increase of B-cells is in line with this hypothesis. 2) Postoperative changes in immunoglobulin levels provide further evidence for a TH1/TH2-shifting. 3) The transient deficit in IgM-and IgG levels did not result in clinically adverse events. Thus, therapeutic intervention appears not to be required.

Alterations of cell-mediated immunity following cardiac operations: clinical implications and open questions.

Cardiac surgery with cardiopulmonary bypass (CPB) is known to induce an immune response whose nature has been increasingly elucidated during the recent decade. Clinically, patients usually show two to three of the four symptoms, which define the so-called systemic inflammatory response syndrome (SIRS). In addition, all parameters of the innate, nonspecific immune system, e.g., polymorphonuclear cells, elastase, and complement, are activated. This also applies to the proinflammatory mediators interleukin (IL)-1beta, -6, and -8, and tumor necrosis factor (TNF)-alpha. Within the adaptive, specific immune system, a decrease of T lymphocytes and T helper (TH) cells is observed, whereas suppressor/ cytotoxic T cells and B cells appear to be nearly unaffected. Cytokine measurements provide more detailed information: IL-2 and IL-12, which are important for the activation of the type-1 TH-cell (TH1)-mediated immune response, are depressed following cardiac operation. In contrast, IL-10 and transforming growth factor-beta essential to TH2-mediated humoral or anti-inflammatory immune response, are upregulated. In vivo tests, e.g., delayed type hypersensitivity skin reaction and tetanus antibody production, confirm the polarization of the adaptive immune response towards the TH2 pathway. However, all these alterations usually do not result in clinical adverse events. Therefore, more information is needed about the immune response of patients at high preoperative risk or with serious perioperative complications to find out whether clinically relevant events are correlated to alterations of immune response. For this purpose, more readily available, standardized methods for immunologic monitoring appear highly desirable.

Detection of acute phase response and infection. The role of procalcitonin and C-reactive protein.

OBJECTIVE: Established parameters, e.g. C-reactive protein (CRP), do not differentiate specifically enough between patients developing an infection and those exhibiting an acute phase response following cardiac surgery. The objective of this prospective study was to investigate if procalcitonin (PCT) is more helpful than CRP. METHODS: During a 1-year period, seven out of 563 patients (1.2%) developed systemic infections (group A) after cardiac operations with cardiopulmonary bypass (CPB), and additional eight patients (1.4%) had local wound infections requiring surgical therapy (group B). Blood samples for PCT and CRP measurements were taken preoperatively, at the onset of infection (d1), as well as on the third day (d3), fifth day (d5), and seventh day (d7) following diagnosis of infection. Forty-four randomly selected patients undergoing cardiac surgery with CPB without clinical signs of infection, additional intensive care unit (ICU) management or additional antibiotic treatment served as control (group C) to assess the PCT and CRP contribution to acute phase response. PCT and CRP levels were measured preoperatively, on the first (d1), third (d3) and fifth day (d5) after operation. RESULTS: At the onset of infection, PCT levels (median interquartile range 25%-75%) increased significantly in group A as compared to baseline values (10.86 (3.28-15.13) ng/ml vs. 0.12 (0.08-0.21) ng/ml), and decreased during treatment to still significantly elevated values on d5 (0.56 (0.51-0.85) ng/ml). CRP levels were significantly elevated on all days investigated with no trend towards normalisation (d1: 164.5 (137-223) mg/l) vs. 1.95 (1.1-2.8) mg/l preoperatively, d5: 181.1 (134-189.6) mg/l. In group B, no increase in PCT levels, but a significant increase of CRP from d1 (165.9 (96.6-181.6) mg/l) vs. 3.7 (2-4.3) mg/l preoperatively) until d5 98 (92.8-226.2) mg/l was detected. In group C, postoperative PCT levels increased slightly but significantly in the absence of infection on d1 (0.46 (0.26-0.77) ng/ml vs. 0.13 (0.08-0.19) ng/ml preoperatively), and d3 (0.37 (0.2-0.65) ng/ml and reached baseline on d5 (0.24 (0.11-0.51) ng/ml)). CRP levels were significantly elevated as compared to baseline on all postoperative days investigated (baseline: 1.75 (0.6-2.9) mg/l, d1: 97.5 (74.5-120) mg/l), d3: 114 (83.05-168.5) mg/l, d5: 51.4 (27.4-99.8) mg/l)). PCT showed a significant correlation to CRP in group A (r =0.48, p < 0.001), a weak correlation in group C (r=0.27, p=0.002) and no correlation in group B. Intergroup comparison revealed a significant difference for PCT between all groups (A>C>B) and significantly higher CRP levels in group A vs. C and in group B vs. C. Thus, the pattern high PCT/high CRP appears to indicate a systemic infection, while low PCT/high CRP indicates either acute phase response or local wound problems, but no systemic infection. The cost for PCT measurements was 5.6-fold higher as compared to CRP. CONCLUSION: Due to the significant differences in the degree of increase, PCT appears to be useful in discriminating between acute phase response following cardiac surgery with CPB or local problems and systemic infections, with additional CRP-measurement increasing the specificity.

Current practice of peri- and postoperative antibiotic therapy in cardiac surgery in Germany. Working Group on Cardiothoracic Surgical Intensive Care Medicine of the German Society for Thoracic and Cardiovascular Surgery.

BACKGROUND: The increasing development of antimicrobial resistance of common bacterial pathogens presents one of the most significant challenges to clinical medicine, particularly intensive care medicine. One factor which has contributed to this development is the (over)use of antibiotic treatment. Therefore the objective of this study was to scrutinize the current practice of empiric antibiotic therapy in cardiac surgery in Germany for 1) perioperative prophylaxis and 2) postoperative therapy prior to the availability of susceptibility patterns for the infecting pathogen. METHODS: A questionnaire was sent to all centers performing cardiac surgery in Germany. Questions referred to drugs used as well as dosage, homogeneity and duration of antibiotic prophylaxis, time and/or reason for changing this regimen, drugs used for first-, second-, and third-line empiric postoperative antibiotic treatment, and homogeneity of antibiotic usage. RESULTS: All but 3 institutions (96.3%) answered. 1. Perioperative prophylaxis: All but 4 centers (94%) use first- (n = 32 = 43%) or second-generation cephalosporins (n = 38 = 51%) most commonly for 24 hours (n = 60 = 81%). Prophylaxis never exceeds 3 days. 74% of all institutions (n = 55) use the same antimicrobial agent for all cardiac procedures performed, while 26% (n = 19) change their regimen in selected patient groups, most commonly for heart transplantation. The entire prophylaxis is changed mainly according to susceptibility patterns (n = 63 = 85%), 7 centers (10%) change according to a fixed time schedule, while 4 institutions (5%) never change the antimicrobial drug. 2. Empiric postoperative therapy: A total of 29 different antibiotics out of 8 subclasses are used. No major differences between 1st-, 2nd-, and 3rd-line therapy could be detected, with the exception of a decreasing usage of beta-lactams (carbapenems excluded) from 60% in 1st-line to 23% in 3rd-line therapy and an increasing usage of glycopeptides from 5% in 1st-line to 18% in 3rd-line therapy. 41 institutions (55%) use the same antibiotic regimen on the intensive care unit and the normal ward, 9 centers (12%) use the same drug for perioperative prophylaxis and postoperative therapy, and 12 institutions (16%) prescribe a combination therapy. CONCLUSIONS: Perioperative prophylaxis in cardiac surgery in Germany is performed on a relatively uniform basis and at low cost. The heterogeneity of antibiotic regimens for postoperative therapy may indicate the need for recommendations and/or guidelines for this type of treatment. The indications for the usage of reserve antibiotics, e.g. vancomycin, implying the possible risk of creating pathogens with untreatable resistance patterns, as well as strategies aimed at preventing the development of resistance should be the subject of further discussions.

Pentoxifylline decreases the incidence of multiple organ failure in patients after major cardio-thoracic surgery.

We assessed the safety and efficacy of intravenous pentoxifylline [3,7-dimethyl-1-(5-oxohexyl)-xanthine] in patients at risk for developing multiple organ failure after major cardio-thoracic surgery in a single-center, randomized, placebo-controlled study. Of 816 consecutive patients who underwent major cardio-thoracic surgery, 40 who had Acute Physiology and Chronic Health Evaluation II score values > or = 19 at the first postoperative day after the surgery were included. Patients were randomized to receive either placebo (control; n = 25) or intravenous pentoxifylline treatment (pentoxifylline; n = 15) at a dosage of 1.5 mg/kg/h as an adjunct to standard supportive therapy. Main outcome measurements were duration of required ventilator support, intensive care unit stay, and incidence of renal failure. Thirty-seven patients were eligible for evaluation. No significant adverse events related to pentoxifylline treatment were observed. The duration of mechanical ventilation was significantly greater for control patients (8.3 +/- 3.1 days) compared with pentoxifylline-treated patients (3.1 +/- .9 days; p < .05). Patients treated with pentoxifylline experienced fewer days on hemofiltration (1.2 +/- .8 vs. 6.8 +/- 3.3; p < .05) and a shorter intensive care unit stay (5.2 +/- 1.1 vs. 11.4 +/- 3.1 days). There were no intergroup differences in mortality. Mortality was 33% in the pentoxifylline group and 36% among control group patients. In conclusion, supplemental pentoxifylline treatment may decrease the incidence of multiple organ failure in patients at risk of systemic inflammatory response syndrome after cardiac surgery. Additional studies are required to determine the validity of the observed effects.

Early extubation after cardiac surgery: a prospective clinical trial including patients at risk.

BACKGROUND: Recent evidence suggests that early extubation after cardiac surgery can be performed without increased morbidity, resulting in economic advantages. However, most studies on this subject exclude patients with preoperative risk factors described as predictors for prolonged mechanical ventilation. The purpose of our prospective clinical trial was to decide whether early extubation is feasible independent of preoperative patient status, in particular independent of preoperative risk factors. METHODS: From 12/96 to 6/97, 266 patients underwent cardiac surgery, most commonly CABG and valve replacement. 65 patients (24.4%) formed the risk group, showing preoperatively at least one of the following risk factors: emergency surgery, severe left-ventricular dysfunction, previous heart surgery, recent myocardial infarction, age 75 years or older, history of several myocardial infarctions. The remaining 201 patients (75.6%) formed the control group. The percentage of patients extubated within 12 hours represented the primary endpoint. 38 patients (10 risk, 28 control) had to be excluded from further analyses due to intra- or perioperative complications. RESULTS: No differences between 55 risk patients and 173 control patients could be detected in extubation rate within 12 hours (100% vs 100%), mean extubation time (6:04 h vs 6:01 h), and incidence of complications after extubation (5.5% vs 5.2%). Risk patients were discharged 0.33 days later from the intensive care unit (2.00 d vs 1.67 d; p = 0.047). CONCLUSIONS: 1. All patients are basically suitable for early extubation, with the presence of preoperative risk factors used in this study being poor predictors of prolonged ventilation. 2. The necessity of prolonged ventilation is primarily determined by intra- or perioperative complications.

Surgical therapy for coronary artery disease in patients with a left ventricular ejection fraction of 25% or less.

BACKGROUND: In patients with advanced coronary artery disease (CAD) and markedly decreased left ventricular ejection fraction (EF) symptoms of myocardial ischemia and insufficiency may be complicated by ventricular arrhythmias. Appropriate surgical therapy must be tailored to the individual symptoms. The aim of this study was to compare the different current methods. METHODS: From 9/1990 to 9/1994 138 patients with coronary artery disease and a left ventricular EF of < or = 25% were operated. Patients with dominating Angina pectoris and vital myocardium were revascularized (ACB; n = 17); two of these patients were 12 and 37 months p.o. transplanted. Because of dominating dyspnea, diffuse CAD and missing AP heart transplantation seemed indicated (HTX; n = 102). In two of these patients ventricular assist devices were implanted as a bridge to transplantation; both patients survived. Patients with malign tachycardias received either an implantable cardio-defibrillator (ICD; n = 16) or had arrhythmia surgery (ARS; n = 3). Patients of the HTX-Group were younger (54 vs 60 years; p < 0.05), had more often previous surgery (28% vs 20%) and were in worse conditions (NYHA 3.5 vs 3.0; p < 0.05). RESULTS: The main cause of death after transplantation was multi-organ failure (MOF; 14/102; 13.8%). The best long-term survival (87% after 3.2 years, p < 0.01 vs HTX)-with low average functional classes (NYHA 2.9)-had the patients after ICD implantation. The best quality of live (NYHA 1.1; p < 0.01 vs ICD)-associated with a high mortality due to preoperatively impaired organ-systems (62% operative survival, 57% 4-years survival)-was achieved by transplantation. In patients with a history of ventricular arrhythmias, who are waiting for a transplantation, the implantation of an ICD should be considered. Bypass surgery as well as arrhythmia surgery showed good survival (1-year survival 82% and 66% respectively) and functional results (NYHA 1.7 and 1.5 respectively).

An imbalance in T-helper cell subsets alters immune response after cardiac surgery.

Growing evidence indicates that cell-mediated immunity is altered after cardiac surgery with cardiopulmonary bypass (CPB). The objective of this prospective randomized study was to investigate (1) if an imbalance in T-helper cell (TH) subsets, i.e. TH1/TH2, may be responsible for these alterations and (2) if they can be counteracted. Twenty patients formed control group A. Twenty group B patients received indomethacin and thymopentin for immunomodulation. In vitro tests included measurements of TH, interleukin (IL)-2 as a cytokine primarily produced by TH1 cells, and IL-6 as a cytokine primarily produced by TH2. Delayed-type hypersensitivity (DTH) skin response and specific antibody (AB) production were used as in vivo tests for TH1- and TH2-induced immune response, respectively. Postoperatively, group A patients showed a persistent, significant reduction of TH, IL-2 synthesis and DTH skin response as compared to baseline values, while IL-6 synthesis remained unaltered and AB production increased (P < 0.05). In group B patients no change in TH, IL-2 and IL-6 synthesis, or DTH skin response was observed (P < 0.05 vs A). Postoperative AB production increased significantly in group B. These results indicate a significant suppression of TH1-induced cell-mediated immune response following CPB, while TH2-induced response remains normal. A normal TH2 response may be helpful for recovery following cardiac surgery by cleaning the body of the byproducts of CPB. A suppression of TH1 response may gain clinical significance whenever a postoperative infection requires this response, but can be effectively counteracted by immunomodulatory intervention with indomethacin and thymopentin.

Osteosynthetic reconstruction in a patient with Gardner-Diamond syndrome.

Based on clinical observations in one female patient who suffered from Gardner-Diamond syndrome, we noticed that surgery can be performed without any bleeding complications, although operations normally are contraindicated in persons with this condition. Additionally, a correlation seems to exist between ASS and sexual and hormonal maturity.