[InspeCKD - Analysis of the use of diagnostics in patients at high risk for chronic kidney disease in German general practitioner (GP) practices]. / InspeCKD - Analyse zur Nutzung von Labordiagnostik im Kontext der chronischen Nierenerkrankung : Daten von Risikopatientinnen und -patienten in deutschen Hausarztpraxen.

BACKGROUND: Despite the high prevalence of chronic kidney disease (CKD) in Germany, only a small proportion of patients are currently diagnosed with CKD. Patients with hypertension, diabetes mellitus, and/or cardiovascular disease have a significantly increased risk of developing CKD and rapid disease progression and should therefore be screened and monitored in accordance with the guidelines. OBJECTIVES: The aim of this retrospective, cross-sectional study was to gain insights into appropriate diagnosis of patients at risk for CKD in German general practitioner practices. METHOD: For the analysis of the use of CKD-relevant diagnostics, electronic patient records from German general practitioner practices were analyzed. Adults with hypertension and/or diabetes mellitus and/or cardiovascular disease with a documented observation period of at least one year were included in the study. RESULTS: Data from a total of 448,837 patients from 1244 general practitioner practices were analyzed. 75.8% of patients had hypertension, 35.1% had cardiovascular disease, and 32.4% had diabetes mellitus. During a mean observation period of 1.7 years, serum creatinine was assessed at least once in 45.5% of patients. A urine dipstick test for albuminuria was performed in 7.9% of patients and in 0.4% of patients, urine albumin-to-creatine ratio (UACR) was measured. Laboratory diagnostics were initiated a little more frequently in high-risk patients compared to the overall cohort. CONCLUSIONS: The study highlights that despite known risk factors, guideline compliant CKD screening is rarely performed in German general practitioner practices, which implicates the need to increase the awareness of early diagnosis of CKD in patients at risk.

Twelve-month patency with the PAS-port proximal connector device: a single center prospective randomized trial.

BACKGROUND: The PAS-Port (Cardica Inc, Redwood City, CA) is an automated system that allows for the clampless anastomosis of vein grafts to the aorta. The intent of this study was to prospectively compare one year graft patency of this system with conventional hand-sewn anastomoses in a prospective, randomized trial. METHODS: A total of 99 patients undergoing elective off-pump coronary bypass surgery were randomized to receive their proximal anastomoses with either the hand-sewn conventional technique or with the PAS-Port system. Patient follow-up consisted of multislice computed tomographic scans performed at discharge and one year postoperatively. RESULTS: Three patients had to be converted to on-pump due to technical reasons. Fifty-one patients were randomly assigned to the PAS-Port group and 48 patients to the control group. In five patients in the control group severe atherosclerosis of the aorta required cross-over to the use of the PAS-Port device, and in one patient in the PAS-Port group conversion to a hand-sewn anastomosis. Sequential anastomoses were performed in 88% of the control group and 73% of PAS-Port group grafts. Time needed for completion of the proximal anastomosis including graft loading was 187 +/- 19 seconds for the PAS-Port group and 406 +/- 34 seconds for the control group (p < 0.001). One patient died unrelated to cardiac events due to septic multiorgan failure and one stroke was observed in the control group. There was a trend toward a lower rate of postoperative delirium in the PAS-Port group (11.7% vs 25%, p = 0.088). Patency at discharge (100% PAS-Port group vs 97.8% control group) and after one year (97.8% PAS-Port group vs 93.7% control group) were comparable. One patient of the PAS-Port group died during long-term follow-up as a result of a severe stroke due to cerebrovascular disease. CONCLUSIONS: This prospective randomized study demonstrated excellent short and midterm patency in both the hand-sewn and PAS-Port grafts. The PAS-Port system allowed for the rapid, safe, and effective creation of a proximal anastomosis without the need to clamp the aorta. Based on this study we consider this product a valid alternative for proximal anastomosis, especially in patients with severe aortic disease, to avoid side clamping of the aorta.

Hemodynamic assessment using apical suction versus pericardial retraction in beating heart surgery.

OBJECTIVE: : Aim of this study was to evaluate the perioperative hemodynamic function using an apical suction device (Xpose = XS) versus standard pericardial retraction sutures (PS) during off-pump myocardial revascularization. METHODS: : Twenty-seven consecutive patients (four female) with three-vessel disease receiving off-pump myocardial revascularization were prospectively evaluated. Mean age was 70 ± 8 years and mean ejection fraction was 55 ± 18%. Pulscontour continuous cardiac output, Swan Ganz catheter, and transesophageal echo measurements were performed. All patients received left internal mammary artery (LIMA)-left anterior descending grafting first. The XS or PS technique for marginal or right coronary artery branch exposure was used and after hemodynamic recovery the same measurements were performed using the other technique, thus each patient served as an intraindividual control. Finally, the anastomosis was performed in the respective territory. RESULTS: : All procedures were completed as off-pump coronary artery bypass without perioperative complications. The mean confidence interval (L/min/m)/mean arterial pressure (mm Hg) was 2.8 ± 0.5/87 ± 11 after opening the pericardium and 2.4 ± 0.4/75 ± 12 during left anterior descending exposure. During lateral wall exposure, it was 1.8 ± 0.6/67 ± 12 using XS and 1.9 ± 0.6/68 ± 12 using PS (P = ns). During inferior wall exposure, it was 2.1 ± 0.4/69 ± 12 using XS and 1.9 ± 0.4/68 ± 13 using PS (P = ns). No significant differences were seen comparing other parameters (cardiac output (CO), heart rate (HR), intrathoracic blood volume index) as well. CONCLUSIONS: : The lateral and inferior coronary arteries can be safely exposed on the beating heart with PS or XS technique. In individual patients, either XS or PS exposure yielded a better preservation of cardiac index and blood pressure compared with baseline.

Facilitated minimally invasive left ventricular epicardial lead placement.

PURPOSE: Atrial-synchronized biventricular pacing is an effective treatment option in patients with heart failure and interventricular conduction delay. Owing to a failed transvenous implantation in some patients, the left ventricular (LV) lead has to be placed surgically, usually by an anterolateral thoracotomy. We used a novel malleable epicardial lead placement tool (Epicardial Lead Implant Tool, Model 10626; Medtronic, Minneapolis, MN) that facilitates lead placement on the posterior aspect of the LV through an anterolateral minithoracotomy. DESCRIPTION: The tool consists of a malleable steel shaft with distal gripping tongs for the epicardial lead. Proximally, a thumbwheel and an actuator button allow fixation and release of the lead on the myocardium. EVALUATION: We used this tool in 7 patients through an anterolateral minithoracotomy. All patients had a safe, successful, and rather short procedure. No scopes were required. CONCLUSIONS: Epicardial LV lead placement through an anterolateral minithoracotomy is facilitated by using the Lead Implant Tool. Lead placement is achieved by the malleable shaft design, which enables perpendicular implantation of the lead pad on the posterior LV surface with an anterolateral approach.

Comparison of cardiac troponin I versus T and creatine kinase MB after coronary artery bypass grafting in patients with and without perioperative myocardial infarction.

BACKGROUND AND PURPOSE: Cardiac troponins have shown to be specific markers of myocardial injury. The aim of this prospective study was to compare patterns and kinetics of troponin I and T after coronary artery bypass grafting (CABG) with or without perioperative myocardial infarction (PMI). PATIENTS AND METHODS: 119 patients (male/female: 96/23, age 64 +/- 10 years) underwent first time elective CABG. Preoperative mean ejection fraction was 55.8% +/- 15.6%. The mean number of grafts was 3.1 +/- 1.1/patient, in 85.7% the internal mammary artery was used. Cardiac troponin I (cTnI) and T (cTnT) levels, total serum activities of creatine kinase (CK) and creatine kinase isoenzyme MB (CK-MB) were measured before operation, at arrival on the intensive care unit (ICU), and 6, 12, 24, 48, and 120 h after unclamping of the aorta. Twelve lead electrocardiograms (ECGs) were recorded preoperatively and at days 1, 2, and 5. Perioperative data and postoperative cTnI and cTnT levels were correlated statistically. RESULTS: Two patients died due to refractory myocardial failure in the early postoperative period. For further evaluation, patients were divided in two groups according to postoperative ECG changes (group I: patients without PMI, n = 107; group II: patients with PMI, n = 10: six of them with Q-wave and four of them with non-Q-wave PMI). Calculated best cutoff values for cTnI and cTnT were 8.35 microg/l and 0.768 microg/l in ROC (receiver-operator characteristic) analysis. Serum concentrations of cTnI, and cTnT were in the normal range preoperatively and increased significantly after surgery in both groups. In both groups, cTnI reached its medium peak level after 24 h (group I: 2.7 microg/l, 95% confidence interval [CI]: [2.1,3.2]); group II: 70.5 microg/l). CTnT reached its medium peak level in group I without PMI after 48 h (0.298 microg/l, 95% CI: [0.254,0.354]), in group II with PMI not until 120 h (3.0 microg/l) postoperatively. In group II serum level of both troponins remained considerably high at 120 h (cTnI median = 10.75 microg/l, cTnT median = 3 microg/l). CONCLUSION: Release patterns of cTnI and cTnT after CABG are different: cTnI reaches its postoperative peak value earlier and declines more quickly than cTnT. After uncomplicated CABG, serum levels of both cardiac troponins remain continuously low. Elevated concentrations reflect perioperative myocardial ischemia or infarction. CTnT shows a different release pattern in patients with or without myocardial infarction.

Interrupted aortic arch in an adult single-stage extra-anatomic repair.

Interrupted aortic arch is a rare congenital malformation of the aortic arch that occurs in 3 per million live births. Defined as a loss of luminal continuity between the ascending and descending portions of the aorta, this anomaly entails a very poor prognosis without surgical treatment. To our knowledge, the world medical literature contains only 12 reports of isolated interrupted aortic arch diagnosed in adults. Nine of these patients underwent successful surgical repair, but 1 died during the early postoperative period. We describe a 10th successful surgical repair, which involved a 42-year-old woman who had an asymptomatic type B interrupted aortic arch (characterized by interruption between the left subclavian and left carotid arteries). We performed a single-stage extra-anatomic repair by placing a 16-mm extra-anatomic Dacron graft between the ascending and descending portions of the thoracic aorta and by interposing a 7-mm extra-anatomic Dacron graft between the 16-mm graft and the left subclavian artery. The patient recovered uneventfully and continued to do well 6 months later.