[Recommendations of the S3 Guideline "Use of Extracorporeal Circulation (ECLS/ ECMO) for Cardiac and Circulatory Failure" of the Association of Scientific Medical Societies in Germany]. / Empfehlungen der S3-Leitlinie (AWMF) "Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen".

In recent years, the use of mechanical support for patients with cardiac or circulatory failure has continuously increased, leading to 3,000 ECLS/ECMO (extracorporeal life support/extracorporeal membrane oxygenation) implantations annually in Germany. Due to the lack of guidelines, there is an urgent need for evidence-based recommendations addressing the central aspects of ECLS/ECMO therapy. In July 2015, the generation of a guideline level S3 according to the standards of the Association of the Scientific Medical Societies in Germany (AWMF) was announced by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS). In a well-structured consensus process, involving experts from Germany, Austria and Switzerland, delegated by 16 scientific societies and the patients' representation, the guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" was created under guidance of the GSTCVS, and published in February 2021. The guideline focuses on clinical aspects of initiation, continuation, weaning and aftercare, herein also addressing structural and economic issues. This article presents an overview on the methodology as well as the final recommendations.

Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact.

Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation.

Surviving the Struggle of COVID-19: Practical Recommendations for Pediatric/Adult Cardiology and Cardiac Surgical Programs in Resource-Limited Settings: a Review.

INTRODUCTION: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. RESULTS: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. CONCLUSION: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients - which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic - is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.

Prediction of Acute Kidney Injury by Cystatin C and [TIMP-2]*[IGFBP7] after Thoracic Aortic Surgery with Moderate Hypothermic Circulatory Arrest.

(1) Background: Acute kidney injury (AKI) is a common complication following thoracic aortic surgery (TAS), with moderate hypothermic circulatory arrest (MHCA). However, prediction of AKI with classical tools remains uncertain. Therefore, it was the aim of the present study to evaluate the role of new biomarkers in patients after MHCA. (2) Methods: 101 consecutive patients were prospectively enrolled. Measurements of urinary [TIMP-2]*[IGFBP7] and Cystatin C in the blood were performed perioperatively. Primary endpoint was the occurrence of AKI stage 2 or 3 (KDIGO-classification) within 48 h after surgery (AKI group). (3) Results: Mean age of patients was 69.1 ± 10.9 years, 35 patients were female (34%), and 13 patients (13%) met the primary endpoint. Patients in the AKI group had a prolonged ICU-stay (6.9 ± 7.4 days vs. 2.5 ± 3.1 days, p < 0.001) as well as a higher 30-day-mortality (9/28 vs. 1/74, p < 0.001). Preoperative serum creatinine (169.73 ± 148.97 µmol/L vs. 89.74 ± 30.04 µmol/L, p = 0.027) as well as Cystatin C (2.41 ± 1.54 mg/L vs. 1.13 ± 0.35 mg/L, p = 0.029) were higher in these patients. [TIMP-2]*[IGFBP7] increased significantly four hours after surgery (0.6 ± 0.69 mg/L vs. 0.37 ± 0.56 mg/L, p = 0.03) in the AKI group. Preoperative Cystatin C (AUC 0.828, p < 0.001) and serum creatinine (AUC 0.686, p = 0.002) as well as [TIMP-2]*[IGFBP7] 4 h after surgery (AUC 0.724, p = 0.020) were able to predict postoperative AKI. The predictive capacity of Cystatin C was superior to serum creatinine (p = 0.0211) (4) Conclusion: Cystatin C represents a very sensitive and specific biomarker to predict AKI in patients undergoing thoracic surgery with MHCA even before surgery, whereas the predictive capacity of [TIMP-2]*[IGFBP7] is only moderate and inferior to that of serum creatinine.

Surviving the Struggle of COVID-19: Practical Recommendations for Pediatric/Adult Cardiology and Cardiac Surgical Programs in Resource-Limited Settings: a Review

ABSTRACT Introduction: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. Methods: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. Results: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. Conclusion: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients — which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic — is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. / Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen : Kurzversion der AWMF-S3-Leitlinie.

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. / Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen : Kurzversion der AWMF-S3-Leitlinie.

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

The German-Austrian S3 Guideline "Cardiogenic Shock Due to Myocardial Infarction: Diagnosis, Monitoring, and Treatment".

Despite advances in the treatment of acute myocardial infarction with subsequent mortality reduction, which are mainly caused by the early timing of revascularization, cardiogenic shock still remains the leading cause of death with mortality rates still approaching 40 to 50%. Cardiogenic shock is characterized by a multiorgan dysfunction syndrome, often complicated by a systemic inflammatory response syndrome that affects the outcome more than the reduction of the cardiac contractile function. However, both European and American guidelines on myocardial infarction focus on interventional or surgical aspects only. Therefore, experts from eight German and Austrian specialty societies including the German Society for Thoracic and Cardiovascular Surgery published the German-Austrian S3 guideline "cardiogenic shock due to myocardial infarction: diagnosis, monitoring, and treatment" to provide evidence-based recommendations for the diagnosis and treatment of infarction-related cardiogenic shock in 2010 covering the topics of early revascularization, revascularization techniques, intensive care unit treatment including ventilation, transfusion regimens, adjunctive medical therapy, and mechanical support devices. Within the last 3 years, this guideline was updated as some major recommendations were outdated, or new evidence had been found. This review will therefore outline the management of patients with cardiogenic shock complicating acute myocardial infarction according to the updated guideline with a major focus on evidence-based recommendations which have been found relevant for cardiac surgery.

Prediction of acute kidney injury after left ventricular assist device implantation: Evaluation of clinical risk scores.

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVAD patients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the Cleveland Clinic Score (CCS), the Society of Thoracic Surgeons Score (STS), and the Simplified Renal Index Score (SRI) were evaluated. 76 patients underwent LVAD implantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stay on the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P < .01). Whereas the Thakar Score (7.43 ± 1.75 vs 6.44 ± 1.44, P = .02) and the Mehta Score (28.12 ± 15.08 vs 21.53 ± 5.43, P = .02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96 ± 1.15 vs 3.44 ± 1.05, P = .08). Using ROC analyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P = .040), 0.637 ± 0.079 (P = .792), and 0.618 ± 0.075 (P = .764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De Ritis Ratio (OR 2.67, P = .034) and MELD (OR 1.11, P = .028) were identified as predictors of postoperative RRT. Risk scores which are predictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population.

[Acute right heart failure on the intensive care unit : Pathophysiology, monitoring and management]. / Akutes Rechtsherzversagen auf der Intensivstation : Pathophysiologie, Monitoring, Therapie.

Right ventricular heart failure is a frequent and serious but often undetected and complex clinical challenge on the intensive care unit. The commonest causes include acute decompensation of pulmonary hypertension, pulmonary embolism, sepsis, acute respiratory distress, and cardiothoracic surgery. The gold standard of bedside diagnosis is a combination of clinical symptoms, biochemical markers (NT-proBNP) and echocardiography. For the purposes of hemodynamic monitoring and treatment management, the indication to place a pulmonary artery catheter should be made generously. The major components of management include treating the underlying disease and triggering factors, reducing pulmonary vascular resistance, increasing contractility, volume optimization, and maintenance of adequate perfusion. Mechanical circulatory support should be considered before irreversible end-organ failure develops.

Multiplex polymerase chain reaction to diagnose bloodstream infections in patients after cardiothoracic surgery.

BACKGROUND: Sepsis and other infectious complications are major causes of mortality and morbidity in patients after cardiac surgery. Whereas conventional blood culture (BC) suffers from low sensitivity as well as a reporting delay of approximately 48-72 h, real-time multiplex polymerase chain reaction (PCR) based technologies like "SeptiFast" (SF) might offer a fast and reliable alternative for detection of bloodstream infections (BSI). The aim of this study was to compare the performance of SF with BC testing in patients suspected of having BSI after cardiac surgery. METHODS: Two hundred seventy-nine blood samples from 169 individuals with suspected BSI were analyzed by SF and BC. After excluding results attributable to contaminants, a comparison between the two groups were carried out. Receiver operating characteristic (ROC) curves were generated to determine the accuracy of clinical and laboratory values for the prediction of positive SF results. RESULTS: 14.7% (n = 41) of blood samples were positive using SF and 17.2% (n = 49) using BC (n.s. [p > 0.05]). In six samples SF detected more than one pathogen. Among the 47 microorganisms identified by SF, only 11 (23.4%) could be confirmed by BC. SF identified a higher number of Gram-negative bacteria than BC did (28 vs. 12, χ2 = 7.97, p = 0.005). The combination of BC and SF increased the number of detected microorganisms, including fungi, compared to BC alone (86 vs. 49, χ2 = 13.51, p < 0.001). C-reactive protein (CRP) (21.7 ± 11.41 vs. 16.0 ± 16.9 mg/dl, p = 0.009), procalcitonin (28.7 ± 70.9 vs. 11.5 ± 30.4 ng/dl, p = 0.015), and interleukin 6 (IL 6) (932.3 ± 1306.7 vs. 313.3 ± 686.6 pg/ml, p = 0.010) plasma concentrations were higher in patients with a positive SF result. Using ROC analysis, IL-6 (AUC 0.836) and CRP (AUC 0.804) showed the best predictive values for positive SF results. CONCLUSION: The SF test represent a valuable method for rapid etiologic diagnosis of BSI in patients after cardiothoracic surgery. In particular this method applies for individuals with suspected Gram-negative blood stream. Due to the low performance in detecting Gram-positive pathogens and the inability to determine antibiotic susceptibility, it should be used in addition to BC only (Pilarczyk K, et al., Intensive Care Med Exp ,3(Suppl. 1):A884, 2015).

The aspartate transaminase/alanine transaminase (DeRitis) ratio predicts mid-term mortality and renal and respiratory dysfunction after left ventricular assist device implantation.

OBJECTIVES: Preoperative liver dysfunction is a well-known risk factor for adverse events after major surgery. However, there is only little data regarding the precise role of the Model of End-Stage Liver Disease (MELD) score and the De Ritis ratio (DRR, alanine transaminase/aspartate aminotransferase) as a predictor for outcome after left ventricular assist device (LVAD) implantation. METHODS: A retrospective analysis of all patients undergoing LVAD implantation at our institution between January 2012 and August 2014 was performed. The primary outcome was survival at 180 days after surgery. RESULTS: During the observation period, 63 patients underwent LVAD implantation (mean age 59.9 ± 8.3 years, 50% male). Mean preoperative ejection fraction was 16.3 ± 7.7, 13 patients required preoperative renal replacement therapy and 9 patients were on extracorporeal life support. Mean Interagency Registry for Mechanically Assisted Circulatory Support level was 2.8 ± 1.3, mean preoperative MELD was 12.7 ± 7.2, mean preoperative DRR was 2.01 ± 4.4. Aspartate aminotransferase (102 ± 220.8 vs 57.8 ± 123.4 U/l, P = 0.041), MELD score (16.1 ± 8.8 vs 11.4 ± 6.1, P = 0.017) and DRR (4.2 ± 7.8 vs 1.1 ± 1.1, P = 0.001) were significantly higher in non-survivors than in survivors after 180 days. Using logistic regression analyses, a DRR >1.37 was an independent predictor for 30-day mortality [odds ratio (OR) 4.5] and 180-day mortality (OR 4.1). In addition, the DRR was associated with postoperative acute kidney injury with need for renal replacement therapy (OR 4.2) and prolonged postoperative ventilation time >72 h (OR 3.8). Using receiver operator characteristics analyses, DRR showed a sensitivity of 0.80 and a specificity of 0.81 (area under the curve 0.834, cut-off 1.37) for 180-day mortality. CONCLUSIONS: The DRR is predictive of early and mid-term mortality as well as relevant morbidities in patients undergoing LVAD implantation. Therefore, the DRR should be considered within the preoperative risk stratification and patient selection for LVAD implantation.

Does Traumatic Donor Cause of Death Influence Outcome after Lung Transplantation? A Single-Centre Analysis.

Background Owing to the shortage of donor organs in lung transplantation (LuTX), liberalization of donor selection criteria has been proposed. However, some studies suggested that donor traumatic brain damage might influence posttransplantation allograft function. This article aimed to investigate the association of donor cause of death (DCD) and outcome after LuTX. Methods A retrospective analysis of 186 consecutive double LuTXs at our institution from January 2000 to December 2008 was performed. DCD was categorized into traumatic brain injury (TBI) and nontraumatic brain injury (NTBI). In addition, NTBI was sub classified as spontaneous intracerebral bleeding (B), hypoxic brain damage (H), and intracerebral neoplasia (N). Results DCD was classified as TBI in 50 patients (26.9%) and NTBI in 136 patients (73.1%): B in 112 patients (60.2%), H in 21 patients (11.3%), and N in 3 patients (1.6%). Young male donors predominated in group TBI (mean age 36.0 ± 14.5 vs. 42.8 ± 10.7, p < 0.01; 29 males in the TBI group [58.0%] vs. 48 males in the NTBI group [35.3%], p < 0.01). Groups of DCD did not differ significantly by recipient age or gender, recipient diagnosis, donor ventilation time, or paO2/FiO2 before harvesting. TBI donors received significantly more blood (3.4 ± 3.8 vs. 1.8 ± 1.9, p = 0.03). A chest trauma was evident only in group T (n = 7 [3.7%] vs. 0 [0%], p < 0.001). Mode of donor death did not affect the following indices of graft function: length of postoperative ventilation, paO2/FiO2 ratio up to 48 hours, and lung function up to 36 months. One- and three-year survival was comparable with 84.4 and 70.4% for TBI donors versus 89.4% and 69.2% for NTBI donors. Five-year survival tended to be lower in the TBI group but did not reach statistical significance (43.4 vs. 53.9%). Conclusion This study indicates that traumatic DCD does not affect outcome after LuTX. These results can be achieved with an ideal donor management combined with an individual case-to-case evaluation by an experienced LuTX surgeon.

Early prediction of acute kidney injury after transapical and transaortic aortic valve implantation with urinary G1 cell cycle arrest biomarkers.

BACKGROUND: Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) leading to increased mortality and morbidity. Urinary G1 cell cycle arrest proteins TIMP-2 and IGFBP7 have recently been suggested as sensitive biomarkers for early detection of AKI in critically ill patients. However, the precise role of urinary TIMP-2 and IGFBP7 in patients undergoing TAVI is unknown. METHODS: In a prospective observational trial, 40 patients undergoing TAVI (either transaortic or transapical) were enrolled. Serial measurements of TIMP-2 and IGFBP7 were performed in the early post interventional course. The primary clinical endpoint was the occurrence of AKI stage 2/3 according to the KDIGO classification. RESULTS: Now we show, that ROC analyses of [TIMP-2]*[IGFBP7] on day one after TAVI reveals a sensitivity of 100 % and a specificity of 90 % for predicting AKI 2/3 (AUC 0.971, 95 % CI 0.914-1.0, SE 0.0299, p = 0.001, cut-off 1.03). In contrast, preoperative and postoperative serum creatinine levels as well as glomerular filtration rate (GFR) and perioperative change in GFR did not show any association with the development of AKI. Furthermore, [TIMP-2]*[IGFBP7] remained stable in patients with AKI ≤1, but its levels increased significantly as early as 24 h after TAVI in patients who developed AKI 2/3 in the further course (4.77 ± 3.21 vs. 0.48 ± 0.68, p = 0.022). Mean patients age was 81.2 ± 5.6 years, 16 patients were male (40.0 %). 35 patients underwent transapical and five patients transaortic TAVI. 15 patients (37.5 %) developed any kind of AKI; eight patients (20 %) met the primary endpoint and seven patients required renal replacement therapy (RRT) within 72 h after surgery. CONCLUSION: Early elevation of urinary cell cycle arrest biomarkers after TAVI is associated with the development of postoperative AKI. [TIMP-2]*[IGFBP7] provides an excellent diagnostic accuracy in the prediction of AKI that is superior to that of serum creatinine.

Safety and Efficiency of Percutaneous Dilatational Tracheostomy With Direct Bronchoscopic Guidance for Thoracic Transplant Recipients.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is the standard airway access in critically ill patients who require prolonged mechanical ventilation. However, the literature lacks reports about the effectiveness and safety of this procedure in thoracic organ transplant recipients, who have increased risks of bleeding and infection. METHODS: We retrospectively reviewed the records of subjects who underwent thoracic organ transplantation at our institution between January 2004 and March 2011 followed by PDT (using the Ciaglia Blue Rhino technique with direct bronchoscopic guidance). RESULTS: From a total of 312 thoracic transplant recipients, we identified 93 (29.8%) subjects with PDT. Of these, 79 had undergone double lung transplant, 11 had undergone heart transplant, 2 had undergone combined heart-lung transplant, and 1 had undergone combined heart-kidney transplant. Mean age was 49.5 ± 11.2 y, and 58% of subjects were female. The mean time from intubation to PDT was 3.7 ± 3.4 d, and mean time from transplant to PDT was 12.6 ± 28.3 d. Thirty-two subjects (34.4%) underwent PDT after re-intubation. Thirty-nine subjects were receiving renal replacement therapy (41.9%), and 28 had a coagulopathy (30.1%). Moderate but not significant bleeding was observed in 3 subjects. There were no major complications during PDT procedures. Forty-five subjects (48.4%) could be weaned successfully from the ventilator and the tracheostoma could be removed. Forty-eight subjects (51.6%) died due to sepsis, multi-organ failure, or transplant failure. No procedure-related deaths were noted. There were no significant late complications. Among the 45 who survived their stay in the ICU, the functional and cosmetic outcomes of PDT were excellent. CONCLUSIONS: PDT can be safely performed on patients with acute respiratory failure after thoracic organ transplantation. Therefore, we recommend the use of this technique for prolonged airway management in these patients.

Preoperative intra-aortic counterpulsation in high-risk patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials†.

In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in all investigated populations with a greater effect in the total population [fixed-effects model: standard mean difference (SMD) -0.931 ± 0.198, P < 0.001] as well as in the subgroup of CAGB patients (fixed-effects model: SMD -1.240 ± 0.156, P < 0.001), compared with the off-pump group (fixed-effects model: SMD -0.723 ± 0.128, P < 0.001). Despite contradictory results from recent trials, the present study confirms the findings of previous meta-analyses that prophylactic aortic counterpulsation reduces hospital mortality, incidence of LCOS and ICU requirement in high-risk patients undergoing on-pump cardiac surgery. However, owing to small sample sizes and the lack of a clear-cut definition of high-risk patients, an adequately powered, prospective RCT is necessary to find a definite answer to the question, if certain groups of patients undergoing cardiac surgery benefit from a prophylactic IABP insertion.

Urinary [TIMP-2]*[IGFBP7] for early prediction of acute kidney injury after coronary artery bypass surgery.

BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiac surgery. Currently, prediction of AKI with classical tools remains uncertain. Therefore, it was the aim of the present study to evaluate two new urinary biomarkers-insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2) in patients after coronary artery bypass surgery (CABG). METHODS: In a prospective cohort study, 60 consecutive patients undergoing isolated on-pump CABG were enrolled. Urine samples collected every 12 h in the postoperative course were analyzed for the product of TIMP-2 and IGFBP7. Urinary output, serum creatinine and estimated glomerular filtration rate (eGFR) were recorded simultaneously. Primary clinical endpoint was the development of AKI stage 2 or 3 according to the classification of the KDIGO within 48 h after surgery. RESULTS: 48 male and 12 female patients with a mean age of 69.61 ± 8.4 years were included. 19 patients developed an AKI (31.6 %), six patients met the endpoint with AKI 2 or 3 (10 %). Urinary [TIMP-2]*[IGFBP7] increased significantly as early as 4 h after CABG in patients with AKI 2/3 (1.83 ± 2.15 vs. 0.23 ± 0.45, p < 0.05) whereas serum creatinine did not increase until 48 h after surgery. The diagnostic accuracy of [TIMP 2]*[IGFBP7] on day one after surgery for the prediction of AKI 2/3 was significantly better (sensitivity 0.89, specificity 0.81, AUC 0.817, 95 % CI 0.622-1.0 SE 0.099, p = 0.022, cut-off 0.817) than for serum creatinine (AUC 0.359, sensitivity 0.50, specificity of 0.52, cut-off value 1.17 mg/dl) and eGFR. CONCLUSION: Urinary [TIMP-2]*[IGFBP7] represents a sensitive and specific biomarker to predict moderate to severe AKI very early after CABG. Analyses from our ongoing larger study are necessary to confirm these findings and probably increase sensitivity and specificity.

Tracheostomy After Cardiac Surgery With Median Sternotomy and Risk of Deep Sternal Wound Infections: Is It a Matter of Timing?

OBJECTIVE: To assess the impact of timing of percutaneous dilatational tracheotomy (PDT) on incidence of deep sternal wound infections (DSWI) after cardiac surgery with median sternotomy. DESIGN: Retrospective study between 2003 and 2013. SETTING: Single-center university hospital. PARTICIPANTS: Eight hundred seventy-nine patients after cardiac surgery with extracorporeal circulation and median sternotomy. INTERVENTIONS: PDT using the Ciaglia-technique with direct bronchoscopic guidance. MEASUREMENT AND MAIN RESULTS: Mean time from surgery and (re)intubation to PDT was 6.7±9.9 and 3.8±3.3 days, respectively. Incidence of DSWI was 3.9% (34/879). The incidence of DSWI was comparable between patients with PDT performed before postoperative day (POD) 10 and those with PDT after POD 10 (29/755 [3.8%] v 5/124 [4.0%], p = n.s.). However, the authors observed an association of timing of PDT and DSWI: The incidence of DSWI was significantly higher in patients with PDT performed≤POD 1 compared to those with PDT after POD 2 (12/184 [6.52%] v 22/695 [3.16%], p = 0.046). In multivariate analysis, obesity, use of bilateral internal mammary arteries, ICU stay>30 days and PDT<48 hours after surgery (OR 3.519, 95% CI 1.242-9.976, p = 0.0018) were independent predictors of DSWI. In 15/34 patients (44.1%), similarity of microorganisms between sternotomy site and tracheal cultures was observed, indicating a possible cross-contamination. CONCLUSIONS: PDT within the first 10 postoperative days after cardiac surgery with median sternotomy can be performed safely without an increased risk of DSWI. In contrast, very early PDT within 48 hours after surgery is associated with an increased risk of mediastinitis and should, therefore, be avoided.

Detection of aortic wall instability with the new dissectometer: Correlation with histological findings.

OBJECTIVES: Although risk stratification for aortic dissection or rupture based on aortic diameter is quite suboptimal, alternative methods for the assessment of the aortic wall stability are rare. We assessed the mechanical properties of the aortic wall by a new custom-made device mimicking transversal aortic wall shear stress during open heart surgery in comparison with histological examination. MATERIAL AND METHODS: One-hundred and five aortic walls were tested by the 'dissectometer' (seven different measured and two calculated values) as well as histological examination was performed. RESULTS: Histological examination classified the aortic wall as normal in 54 (51.4%) patients and pathologic in 51 (48.6%) patients. Six out of nine parameters assessed by the dissectometer showed a significant correlation to histological findings. Using ROC-analysis, the most reliable parameter (P9) showed a sensitivity of 93.3% and a specificity of 80.4% with an area under the curve of 0.89 when using a cut-off value of 3.4. In the logistic regression analysis, P9 was an independent predictor for aortic wall instability (OR 28.983, 95% CI 11.507-72.993, p < 0.0001). CONCLUSION: The dissectometer is suitable for discriminating between stable and unstable aortic walls with a good correlation to histological examination holding promise for direct and quick intraoperative identification of aortic walls at risk for dissection.