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1.
BMC Cardiovasc Disord ; 23(1): 308, 2023 06 20.
Artículo en Inglés | MEDLINE | ID: mdl-37340354

RESUMEN

BACKGROUND: Left atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness. METHODS: 303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes. RESULTS: Average age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up. CONCLUSION: LAA amputation can be performed safely and completely leaving minimal to no LAA residual stump.


Asunto(s)
Apéndice Atrial , Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Accidente Cerebrovascular , Humanos , Masculino , Femenino , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Accidente Cerebrovascular/etiología , Ecocardiografía Transesofágica/efectos adversos , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Amputación Quirúrgica , Resultado del Tratamiento
2.
Artículo en Alemán | MEDLINE | ID: mdl-37192637

RESUMEN

The intraaortic ballon-pump (IABP) is a percutaneous mechanical circulatory support device, which is used in patients either with insufficient cardiac output or in patients with high-risk situation before cardiac intervention, like surgical revascularisation or percutaneous coronary intervention (PCI). Due to electrocardiographic or arterial pressure pulse the IABP augments diastolic coronary perfusion pressure and reduces systolic afterload. Thereby, myocardial oxygen supply-demand ratio is improved and cardiac output is increased. Many national and international cardiology, cardiothoracic and intensive care medicine societies and associations worked together in order to develop evidence-based recommendations and guidelines for the preoperative, intraoperative and postoperative management of the IABP. This manuscript is mainly based on the S3 guideline "Use of intraaortic balloon-pump in cardiac surgery" from the German Society for Thoracic and Cardiovascular Surgery (DGTHG).


Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Corazón Auxiliar , Intervención Coronaria Percutánea , Humanos , Contrapulsador Intraaórtico/efectos adversos
3.
Thorac Cardiovasc Surg ; 64(4): 304-10, 2016 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-25703734

RESUMEN

Background Postoperative stroke in cardiac surgical patients remains a serious adverse outcome. Methods A total of 2,784 consecutively operated cardiac surgical patients without preoperative neurologic impairment were analyzed retrospectively with regard to impact of preoperative carotid stenosis on the incidence of postprocedural new onset of stroke. Therefore, all analyzed patients were assigned to four groups depending on preoperative degree of carotid artery stenosis detected by carotid duplex sonography (group I: < 50%, group II: 50-75%, group III: 76-89%, and group IV: > 90%). Results All pre-, intra-, and postoperative risk factors for neurological disorders were comparable throughout the cohort. Of the 2,784 patients, 65 (2.3%) met the inclusion criteria (preoperatively neurologically asymptomatic status, preoperatively carotid duplex ultrasonography study not older than 6 months, heart surgery with extracorporeal circulation, stroke until 48 hours after operation). Of the 65 patients who met the inclusion criteria, 43 (66.2%) were in group I, 11 (16.9%) in group II, 5 (7.7%) in group III, and 6 (9.2%) in group IV (p = 0.175). The overall incidence of an ipsilateral stroke relating to the carotid stenosis was 38 (1.4%) patients. Of these, 27 (71.1%) patients were in group I, 6 (15.8%) patients in group II, 2 (5.3%) patients in group III, and 3 (7.9%) patients in group IV (p = 0.568). Conclusion This observational study demonstrates that the degree of carotid stenosis in neurologically asymptomatic cardiac surgical patients is not able to predict the probability of perioperative stroke. Until further results from prospective randomized trials with neurologically asymptomatic cardiac surgical patients are presented, a cautious attitude for concomitant carotid endarterectomy is still justified.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Estenosis Carotídea/complicaciones , Ataque Isquémico Transitorio/etiología , Accidente Cerebrovascular/etiología , Anciano , Enfermedades Asintomáticas , Estenosis Carotídea/diagnóstico , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico por imagen , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
4.
BMC Cardiovasc Disord ; 15: 41, 2015 May 12.
Artículo en Inglés | MEDLINE | ID: mdl-25964053

RESUMEN

BACKGROUND: Chronic hyperglycemia (CHG) with HbA1c as an indicator affects postoperative mortality and morbidity after coronary artery bypass grafting surgery (CABG). Acute kidney injury (AKI) is one of the frequent postoperative complications after CABG impacting short-and long-term outcomes. We investigated the association between CHG and postoperative incidence of AKI in CABG patients with and without history of diabetes mellitus (DM). METHODS: This cohort study consecutively enrolled patients undergoing CABG in 2009 at the department for cardiovascular surgery. CHG was defined as HbA1c ≥ 6.0%. Patients with advanced chronic kidney disease (CKD) were excluded. The incidence of postoperative AKI and its association with CHG was analyzed by univariate and multivariate logistic regression modeling. RESULTS: Three-hundred-seven patients were analyzed. The incidence of AKI was 48.2%. Patients with CHG (n = 165) were more likely to be female and had greater waist circumference as well as other comorbid conditions, such as smoking, history of DM, CKD, hypertension, pulmonary hypertension, and chronic obstructive pulmonary disease (all p ≤ 0.05). Preoperative eGFR, atrial fibrillation (AF), history of DM and CHG were associated with an increased risk of postoperative AKI in univariate analyses. In multivariate modelling, history of DM as well as preoperative eGFR and AF lost significance, while age, CHG and prolonged OP duration (p < 0.05) were independently associated with postoperative AKI. CONCLUSIONS: Our results suggest that CHG defined on a single measurement of HbA1c ≥ 6.0% was associated with the incidence of AKI after CABG. This finding might implicate that treatment decisions, including the selection of operative strategies, could be based on HbA1c measurement rather than on a recorded history of diabetes.


Asunto(s)
Lesión Renal Aguda/etiología , Puente de Arteria Coronaria/efectos adversos , Hiperglucemia/complicaciones , Factores de Edad , Anciano , Enfermedad Crónica , Creatinina/sangre , Complicaciones de la Diabetes/sangre , Femenino , Hemoglobina Glucada/análisis , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Prospectivos , Factores de Riesgo
5.
BMC Cardiovasc Disord ; 14: 117, 2014 Sep 12.
Artículo en Inglés | MEDLINE | ID: mdl-25212385

RESUMEN

BACKGROUND: Fatty acid binding protein (FABP) is an intracellular transport protein associated with myocardial damage size in patients undergoing cardiac surgery. Furthermore, elevated FABP serum concentrations are related to a number of common comorbidities, such as heart failure, chronic kidney disease, diabetes mellitus, and metabolic syndrome, which represent important risk factors for postoperative acute kidney injury (AKI). Data are lacking on the association between preoperative FABP serum level and postoperative incidence of AKI. METHODS: This prospective cohort study investigated the association between preoperative h-FABP serum concentrations and postoperative incidence of AKI, hospitalization time and length of ICU treatment. Blood samples were collected according to a predefined schedule. The AKI Network definition of AKI was used as primary endpoint. All associations were analysed using descriptive and univariate analyses. RESULTS: Between 05/2009 and 09/2009, 70 patients undergoing cardiac surgery were investigated. AKI was observed in 45 patients (64%). Preoperative median (IQR) h-FABP differed between the AKI group (2.9 [1.7-4.1] ng/ml) and patients without AKI (1.7 [1.1-3.3] ng/ml; p = 0.04), respectively. Patients with AKI were significantly older. No statistically significant differences were found for gender, type of surgery, operation duration, CPB-, or X-Clamp time, preoperative cardiac enzymes, HbA1c, or CRP between the two groups. Preoperative h-FABP was also correlated with the length of ICU stay (rs = 0.32, p = 0.007). CONCLUSIONS: We found a correlation between preoperative serum h-FABP and the postoperative incidence of AKI. Our results suggest a potential role for h-FABP as a biomarker for AKI in cardiac surgery.


Asunto(s)
Lesión Renal Aguda/epidemiología , Puente de Arteria Coronaria/efectos adversos , Proteínas de Unión a Ácidos Grasos/sangre , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/diagnóstico , Factores de Edad , Anciano , Biomarcadores/sangre , Proteína 3 de Unión a Ácidos Grasos , Femenino , Alemania/epidemiología , Humanos , Incidencia , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Regulación hacia Arriba
6.
Thorac Cardiovasc Surg ; 61(8): 733-43, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-23420333

RESUMEN

BACKGROUND: The purpose of this retrospective observational study is to analyze the value of multiple electrode platelet aggregometry (Multiplate analyzer, Verum Diagnostica, Munich) as a point-of-care (POC) device in adult cardiac surgical patients. METHODS: Two hundred and twenty-three cardiac surgical patients were analyzed preoperatively and postoperatively with multiple electrode platelet aggregometry by stimulation ADPtest, ASPItest, and TRAPtest. End points were postoperative bleeding, need for reexploration, and perioperative transfusions requirements. Furthermore, a literature survey using the key phrases "platelet function" and "cardiac surgery" was performed. RESULTS: When comparing patients with normal Multiplate test results concerning end points, patients with pathological ADPtest (n = 140) needed significant more platelet concentrates (PCs) (p = 0.009), patients with pathological ASPItest (n = 175) did not show any significant differences, and patients with pathological TRAPtest (n = 139) needed more red blood cells (p = 0.008) and PCs (p = 0.02). The literature survey showed 208 hits, spanning the publication years 2002 to 2012 resulted in 123 hits. CONCLUSIONS: The ADPtest and the TRAPtest significantly predict the requirement of perioperative blood transfusion. Therefore, multiple electrode platelet aggregometry is beneficial for POC testing in cardiac surgical patients. Prospective, randomized, and controlled clinical studies are rare.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Agregación Plaquetaria , Pruebas de Función Plaquetaria/instrumentación , Sistemas de Atención de Punto , Hemorragia Posoperatoria/diagnóstico , Adenosina Difosfato , Adulto , Anciano , Ácido Araquidónico , Transfusión Sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fragmentos de Péptidos , Hemorragia Posoperatoria/sangre , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/terapia , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
7.
J Cardiothorac Surg ; 16(1): 309, 2021 Oct 20.
Artículo en Inglés | MEDLINE | ID: mdl-34670594

RESUMEN

OBJECTIVE: The goal of this study was to monitor the compliance and impact on a protocol change of surgical antimicrobial prophylaxis in cardiac surgery favouring cefazolin instead cefuroxime, initiated by the hospital's antimicrobial stewardship team. METHODS: This quality improvement study was performed in a tertiary care hospital in collaboration with the department of cardiothoracic surgery and the hospitals antimicrobial stewardship team following a revision of the standard for surgical antimicrobial prophylaxis including 1029 patients who underwent cardiac surgery. 582 patients receiving cefuroxime and 447 patients receiving cefazolin respectively were compared without altering any other preventative perioperative measures including its postoperative duration of less than 24 h. Adherence and surgical site infections were compiled and analysed. RESULTS: A complete adherence was achieved. Overall surgical site infections occurred in 37 (3.6%) of the cases, 20 (3.4%) in cefuroxime patients and 17 (3.8%) in cefazolin patients (p value = 0.754). No statistically significant differences could be found in any of the primary endpoints, but there was a trend towards less deep sternal wound infections in the cefazolin group. CONCLUSIONS: The study supports the role of antimicrobial stewardship in cardiac surgery and mirrors the success of a multidisciplinary team aiming to minimize adverse events by optimizing antibiotic use.


Asunto(s)
Programas de Optimización del Uso de los Antimicrobianos , Procedimientos Quirúrgicos Cardíacos , Profilaxis Antibiótica , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cefazolina , Humanos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control
8.
J Card Surg ; 25(1): 116-9, 2010.
Artículo en Inglés | MEDLINE | ID: mdl-19549043

RESUMEN

A 49-year-old male patient suffering from end-stage ischemic cardiomyopathy with a left ventricular ejection fraction below 15% was presented to redo coronary artery bypass grafting (CABG). Coronary angiogram demonstrated an occluded left anterior descending artery and occluded right coronary artery, perfused retrogradely from the circumflex artery. Since positron emission tomography did not demonstrate viable left ventricular myocardium except for the basis of the left ventricle, CABG was considered futile. Cardiac transplantation was contra-indicated due to pharmacologically unresponsive pulmonary artery hypertension. The patient successfully underwent left ventricular assist device implantation in combination with right coronary artery revascularization. The article reflects the regimen of right ventricular preservation in this patient.


Asunto(s)
Cardiomiopatía Dilatada/terapia , Puente de Arteria Coronaria , Corazón Auxiliar , Hipertensión Pulmonar/terapia , Función Ventricular Derecha , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/terapia , Humanos , Masculino , Persona de Mediana Edad , Tomografía de Emisión de Positrones , Volumen Sistólico , Función Ventricular Izquierda
9.
Eur J Cardiothorac Surg ; 34(1): 132-8, 2008 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-18468447

RESUMEN

OBJECTIVE: Postoperative sternal wound complications (PSWC) including deep sternal wound infection (DSWI) and sternal dehiscence (SD) cause significant morbidity and mortality. Elderly patients with several risk factors are particularly prone to suffer PSWC. METHODS: We present (I) a subset of 86 patients, all aged > or =75 years out of 339 cardiac surgery patients prospectively randomised to receive either conventional sternal closure or a Robicsek type closure. Primary end-points were SD and DSWI; secondary end-points included a composite of clinical parameters; (II) we retrospectively assessed data of 54/5273 patients with mediastinitis regarding the influence of advanced age. In addition, we report an epidemiological overview of different sternal closure techniques. RESULTS: (I) The Robicsek technique showed an impact on SD and DSWI, and several secondary end-points: ventilator support (p=0.03), postoperative blood loss (p=0.04), and chest pain >3 days (p=0.04). (II) A total of 54/5273 (1.02%) patients developed postoperative mediastinitis. Twelve out of 54 (22%) patients died within 6 months of the initial operation. Predictors of mortality were insulin-dependent diabetes mellitus (p=0.05), renal insufficiency (p=0.01), delayed sternal closure (p=0.05), ICU-stay >10 days (p=0.01), and methicillin-resistant Staphylococcus aureus (p=0.03) or fungal infection (p=0.02). CONCLUSIONS: No statistical difference in sternal dehiscence or mediastinitis was found irrespective of whether the bilateral and longitudinal parasternal closure or the conventional peri/trans-sternal wiring technique was used, but there was an obvious, positive influence on sternal dehiscence, deep sternal wound infection, and clinical parameters. However, the study population is relatively small.


Asunto(s)
Mediastinitis/etiología , Esternón/cirugía , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/etiología , Técnicas de Sutura , Factores de Edad , Anciano , Anciano de 80 o más Años , Hilos Ortopédicos , Procedimientos Quirúrgicos Cardíacos , Femenino , Humanos , Masculino , Mediastinitis/prevención & control , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Dehiscencia de la Herida Operatoria/prevención & control , Infección de la Herida Quirúrgica/prevención & control
11.
Eur J Cardiothorac Surg ; 54(5): 826-831, 2018 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-29659778

RESUMEN

OBJECTIVES: The incidence of diabetes mellitus in patients with ischaemic cardiomyopathy is increasing. To evaluate the impact of diabetes mellitus on contractility, we examined the calcium-induced force in left and right atrial myofilaments of patients with and without diabetes. METHODS: We included 149 patients (106 without diabetes, 43 with diabetes), scheduled for elective coronary artery bypass grafting from August 2016 to June 2017. The left and right atria were excised and prepared for skinned fibre measurements (pCa-force curve). The unit for the force measurements is Millinewton (mN). Comprehensive demographic data as well as echocardiographic findings of the patients were collected. RESULTS: We observed a significant decrease of left atrial force values in patients with diabetes, averaged over all calcium concentrations (patients with diabetes 0.50 ± 0.19 mN vs 0.68 ± 0.23 mN in patients without diabetes, P = 0.002) as well as in right atrial fibres (patients with diabetes 0.35 ± 0.17 mN vs 0.47 ± 0.21 mN in patients without diabetes, P = 0.005). There was a significant influence of repeated measurements (of the calcium concentrations) on force in left atrial myofilaments (P < 0.001). There was also a significant impact of diabetes on the force values of the different calcium concentrations in left atrial myofilaments (P 0.002). In right atrial myofilaments we also found a significant influence of repeated measurements (of the calcium concentrations) on force (P < 0.001). Additionally the impact of diabetes on the force values was significant (P = 0.005). CONCLUSIONS: We demonstrated that diabetes mellitus has a significantly negative impact on calcium-induced force development in left and right atrial myofilaments.


Asunto(s)
Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Diabetes Mellitus/fisiopatología , Atrios Cardíacos/fisiopatología , Contracción Miocárdica/fisiología , Miofibrillas/fisiología , Anciano , Calcio/administración & dosificación , Calcio/farmacología , Estudios de Casos y Controles , Enfermedad de la Arteria Coronaria/fisiopatología , Relación Dosis-Respuesta a Droga , Ecocardiografía , Femenino , Atrios Cardíacos/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica/efectos de los fármacos , Miofibrillas/efectos de los fármacos , Técnicas de Cultivo de Tejidos
12.
Biomed Rep ; 6(3): 291-294, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28451388

RESUMEN

Body mass is reported to influence myocardial performance. Recent studies have emphasised the importance of negative inotropic adipocyte-derived factors and their impact on cardiac contractile function. However, the underlying mechanisms remain unclear. We aimed to determine whether body mass impacts cardiac force development on the level of the contractile apparatus. We examined the influence of body mass index (BMI) (3 groups: group I >25, group II 25-30, group III >30) on the myocardial performance of skinned muscle fibres. Right atrial tissue preparations of 70 patients undergoing aortocoronary bypass operation (CABG, 48 patients, group a) and aortic valve replacement (AVR, 22 patients, group b) were obtained. The fibres were exposed to a gradual increase in the calcium concentration, and the force values were recorded. The statistical analysis was performed using Pearson's correlation (P<0.05 significant). A BMI >30 (group III) was associated with less force (mean force 1.58±0.1 mN, P=0.02, max force 2.24±0.17 mN, P=0.02 vs. group II (mean force 1.8±0.3 mN, P=0.04, max force 2.59±0.2 mN, P=0.03) and group I (mean force 1.8±0.1 mN, P=0,03, max force 2.62±0.3 mN, P=0.03). Dividing the groups in the post-surgical procedure, the impact of BMI on force development in group III was more intense in the CABG group compared to the AVR group: 2.0±0.2 mN vs. 2.4±0.1 mN, P=0.04. In accordance with the literature, a BMI >30 is associated with reduced force capacities. Additionally, the underlying cardiac disease may aggravate the impact of weight on cardiac force. Further studies are needed to evaluate the clinical relevance of this experimental observation and the potential consequences for the treatment of cardiac function.

13.
J Cardiothorac Surg ; 12(1): 38, 2017 May 22.
Artículo en Inglés | MEDLINE | ID: mdl-28532425

RESUMEN

BACKGROUND: Mechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery. CASE PRESENTATION: We describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years-old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles. He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up. CONCLUSIONS: The combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Oxigenación por Membrana Extracorpórea/instrumentación , Insuficiencia Cardíaca/cirugía , Ventrículos Cardíacos/fisiopatología , Corazón Auxiliar , Complicaciones Posoperatorias , Choque Cardiogénico/terapia , Diseño de Equipo , Humanos , Masculino , Persona de Mediana Edad , Choque Cardiogénico/etiología
14.
J Thorac Cardiovasc Surg ; 154(3): 906-912, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28554673

RESUMEN

OBJECTIVES: Secondary sclerosing cholangitis in critically ill patients is a rapidly progressing disease leading to biliary fibrosis and cirrhosis. We describe the course of sclerosing cholangitis in critically ill patients after cardiac surgery and compare this with matched patients. METHODS: A retrospective search for "secondary sclerosing cholangitis" and "liver and/or hepatic failure" in all adult patients (aged 18-93 years) who underwent cardiac surgery from April 2007 to March 2016 identified 192 of 8625 patients. Of those, 12 were diagnosed with sclerosing cholangitis in critically ill patients (incidence, 0.14%). A 3:1 matching was performed. Laboratory values, pharmacologic requirements, ventilation times, mechanical circulatory support, and endoscopic retrograde cholangiopancreatography studies were extracted from the hospital database. RESULTS: A total of 9 men and 3 women were affected (age 71 years; range, 59.8-75.5 years). Critically ill patients with sclerosing cholangitis required vasoconstrictors and inotropes longer than control patients (norepinephrine 356.5 hours [264.5-621] vs 68 hours [15-132.5], P = .003; enoximone 177 hours [124.3-249.5] vs 48.5 hours [12-81 hours], P < .001, respectively). Critically ill patients with sclerosing cholangitis had longer intubation time (628.5 hours [377.3-883] vs 25 hours [9.8-117.5]; P < .001) and more surgical revisions (3 [2.5-6] vs 1 [0-2], P = .003) than the matching group. Bilirubin (23.3 mg/dL [14.4-32.9] vs 1 mg/dL [0.6-2.7]; P < .001), gamma-glutamyltransferase (1082.3 U/L [259.5-2265.7] vs 53.8 U/L [35.1-146]; P < .001), and alkaline phosphatase (751.5 U/L [372-1722.3] vs 80.5 U/L [53.3-122]; P < .001) were higher in critically ill patients with sclerosing cholangitis. One critically ill patient with sclerosing cholangitis underwent successful liver transplantation. A total of 11 patients sclerosing cholangitis died (92%) versus 12 patients (33%, P < .001) in the control group. CONCLUSIONS: Sclerosing cholangitis in critically ill patients is a fatal complication in patients undergoing cardiac surgery who have a complicated postoperative course with prolonged vasoconstrictor, inotropic, and respiratory therapy, or who require frequent surgical revisions. Liver transplantation remains the only curative option but is often precluded by the age and critical state of patients undergoing cardiac surgery.


Asunto(s)
Procedimientos Quirúrgicos Cardiovasculares , Colangitis Esclerosante/tratamiento farmacológico , Colangitis Esclerosante/mortalidad , Enfermedad Crítica , Complicaciones Posoperatorias/mortalidad , Anciano , Fosfatasa Alcalina/sangre , Bilirrubina/sangre , Cardiotónicos/uso terapéutico , Estudios de Casos y Controles , Femenino , Alemania/epidemiología , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Trasplante de Hígado/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Estudios Retrospectivos , Factores de Tiempo , Vasoconstrictores/uso terapéutico , gamma-Glutamiltransferasa/sangre
15.
J Cardiothorac Surg ; 12(1): 27, 2017 May 16.
Artículo en Inglés | MEDLINE | ID: mdl-28511707

RESUMEN

BACKGROUND: There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT. METHODS: Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted. RESULTS: Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23-27 mm vs. 23 mm; IQR 21-25; p = 0.009). CONCLUSIONS: Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings.


Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Toracotomía/métodos , Anciano , Femenino , Humanos , Masculino , Periodo Posoperatorio , Diseño de Prótesis , Factores de Tiempo , Resultado del Tratamiento
16.
Eur J Cardiothorac Surg ; 51(1): 67-72, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27365077

RESUMEN

OBJECTIVES: Surgical site infection (SSI) of the sternum is a devastating complication in cardiac surgery. The aim of this prospective randomized controlled two-centre clinical study was to compare the use of a gentamicin-collagen sponge (Genta-Coll® resorb) and of a cyanoacrylate-based microbial skin sealant (InteguSeal®) on the SSI rate of the sternum. METHODS: We analysed data from 996 consecutive patients following isolated coronary artery bypass grafting between 2012 and 2014. The patients were randomized into three groups: standard group (S-group), Genta-Coll group (G-group) and InteguSeal group (I-group). The primary study end-point was to analyse the incidence of superficial and deep sternal SSI. The secondary study end-point was to determine independent risk factors for an increased SSI rate. RESULTS: Of the 996 patients investigated, 332 patients were in S-group, 336 patients in G-group and 328 patients in I-group. The mean age was 67.7 ± 9.4 years, 18.6% were women and the overall SSI rate was 6.2% with 2.2% deep sternal wound infections. SSI rates were 8.3% (S-group), 5.4% (G-group) and 4.9% (I-group) (P 0.16). Multiple regression analysis demonstrated a preoperative body mass index (BMI) of >30 kg/m2 (P 0.047), re-thoracotomy for postoperative bleeding (P < 0.001) and sternum instability (P < 0.001) as independent predictors for an increased SSI rate. CONCLUSIONS: The application of InteguSeal® or Genta-Coll® resorb had no significant influence on the incidence of the sternal SSI rate in 996 consecutive cardiac surgery patients but demonstrated a trend towards a benefit from using these prophylactic approaches. Multiple regression analysis demonstrated a preoperative BMI of >30 kg/m2, re-thoracotomy for bleeding and sternum instability as independent predictors for an increased sternal SSI rate.


Asunto(s)
Profilaxis Antibiótica/métodos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Gentamicinas/administración & dosificación , Esternotomía/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Administración Tópica , Anciano , Antibacterianos/administración & dosificación , Procedimientos Quirúrgicos Cardíacos/métodos , Femenino , Estudios de Seguimiento , Alemania/epidemiología , Humanos , Incidencia , Masculino , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Tapones Quirúrgicos de Gaza , Infección de la Herida Quirúrgica/epidemiología
17.
Ann Thorac Cardiovasc Surg ; 22(3): 168-73, 2016 Jun 20.
Artículo en Inglés | MEDLINE | ID: mdl-27181390

RESUMEN

PURPOSE: In cardiac surgery candidates, a concomitant history of breast cancer suggests adverse outcomes. The possibility of internal mammary artery (IMA) utilization and its patency rate is frequently discussed. Secondary, blood loss and wound related infections might be important issues. However, publications focusing on these issues are limited. METHODS: We analyzed 32 patients with previously treated breast cancer undergoing cardiac bypass (CABG) and combined CABG surgery matched to 99 control subjects in a retrospective cohort study. Patients were analyzed regarding IMA utilization, blood loss and substitution and frequent perioperative complications as well as long-term mortality. RESULTS: No significant differences between groups were observed regarding duration of surgery, IMA-utilization, incidence of infections and postoperative complications or mortality. A pronounced decline of hemoglobin/hematocrit was evident within the first 6 postoperative hours (3.3 ± 1.8 vs. 2.5 ± 1.8 mg/dl; p = 0.03) in breast cancer patients not related to an increased drainage loss but associated with an increase of international normalized ratio (INR) (0.39 ± 0.16 vs. 0.29 ± 0.24; p <0.01). CONCLUSION: In breast cancer patients, CABG and combined CABG procedures can safely be performed with comparable short- and long-term results.


Asunto(s)
Neoplasias de la Mama/terapia , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Anciano , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/mortalidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Selección de Paciente , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
18.
Eur J Cardiothorac Surg ; 49(2): e54-62; discussion e62, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26586791

RESUMEN

OBJECTIVES: Levosimendan (LS) is increasingly used in case of myocardial failure after cardiac surgery. The impact of LS on myocardial mitochondrial functions, such as respiratory chain function (RCF), mitochondrial membrane potential (ΔΨm), Ca(2+) handling, mitochondrial permeability transition pore (mPTP) opening and ATP during ongoing ischaemia/reperfusion (IR) injury, is not well understood. Depending on LS, I/R injury or the combination of both, we analysed myocardial functions in a retrograde Langendorff-model followed by the analysis of subsarcolemmal mitochondrial (SSM) functions. METHODS: Rat hearts were divided into four study groups; two were subjected to 30 min of perfusion without (control) or with the application of 1.4 µmol/20 min LS (Levo). Experiments were repeated with hearts being subjected to 40 min of normothermic stop-flow ischaemia and 30 min of reperfusion without (IR) or with LS application (Levo-IR). Systolic left ventricular pressure (LVPsys), left ventricular contractility (LVdp/dtmax) and coronary flow were determined. SSM were analysed regarding RCF, ΔΨm, ATP, and Ca(2+) retention capacity (CRC), Ca(2+)-induced swelling and Ca(2+) fluxes after (re)perfusion. RESULTS: I/R injury suppressed LVdp/dtmax (1381 ± 927 vs 2464 ± 913 mmHg/s; P = 0.01 at 30 min (re-)perfusion time). IR revealed complex I-V state3 (19.1 ± 7.4 vs 27.6 ± 11.0 nmolO2/min; P < 0.044) and II-V state3 (20.6 ± 6.8 vs 37.3 ± 9.10 molO2/min; P < 0.0001) suppression and Levo limited I-V (14.8 ± 11.1 vs 27.6 ± 11.0 nmolO2/min; P < 0.001) and II-V (24.1 ± 6.4 vs 37.3 ± 9.10 molO2/min; P < 0.0001) function. After energizing, ΔΨm hypopolarization was observed in Levo (0.76 ± 0.04 vs 0.84 ± 0.04; P = 0.02), IR (0.75 ± 0.06 vs 0.84 ± 0.04; P = 0.007) and Levo-IR (0.75 ± 0.06 vs 0.06 ± 0.04; P = 0.01). IR (AUC: 626 vs 292; P = 0.023) and Levo-IR (AUC: 683 vs 292, P = 0.003) increased Ca(2+)-induced mPTP-opening susceptibility. CRC declined in IR (6.4 ± 2.1 vs 10.5 ± 2.6; P = 0.04) or Levo (6.5 ± 2.0 vs 10.5 ± 2.6; P = 0.023). Ca(2+) uptake was delayed in IR and Levo-IR without LS impact (P < 0.0001). Ca(2+) liberation was increased in Levo-IR. ATP synthesis was reduced in Levo (0.49 ± 0.14 vs 0.74 ± 0.14; P = 0.002) and Levo-I/R (0.34 ± 0.18 vs 0.74 ± 0.14; P < 0.002). CONCLUSION: LS limited RCF at complex IV and V with ΔΨm hypopolarization suggesting a specific [Formula: see text]-dependent pathway. Ca(2+) redistribution from SSM by LS during I/R injury possibly prevents from Ca(2+) overload due to mPTP flickering. LS-induced mPTP flickering did not promote permanent Ca(2+)-induced mPTP opening. LS-dependent inhibition of ATP generation presumably resulted from complex IV and V limitations and lowered ΔΨm. However, a resulting impact of limited ATP synthesis on myocardial recovery remains arguable.


Asunto(s)
Adenosina Trifosfato/biosíntesis , Cardiotónicos/farmacología , Hidrazonas/farmacología , Daño por Reperfusión Miocárdica/fisiopatología , Piridazinas/farmacología , Animales , Biomarcadores/metabolismo , Calcio/metabolismo , Transporte de Electrón/efectos de los fármacos , Masculino , Potencial de la Membrana Mitocondrial/efectos de los fármacos , Mitocondrias Cardíacas/efectos de los fármacos , Mitocondrias Cardíacas/metabolismo , Proteínas de Transporte de Membrana Mitocondrial/efectos de los fármacos , Proteínas de Transporte de Membrana Mitocondrial/metabolismo , Poro de Transición de la Permeabilidad Mitocondrial , Distribución Aleatoria , Ratas Wistar , Sarcolema/efectos de los fármacos , Simendán
19.
J Cardiothorac Surg ; 10: 25, 2015 Feb 26.
Artículo en Inglés | MEDLINE | ID: mdl-25880032

RESUMEN

BACKGROUND: All international guidelines recommend perioperative antibiotic prophylaxis (PAB) should be routinely administered to patients undergoing cardiac surgery. However, the duration of PAB is heterogeneous and controversial. METHODS: Between 01.01.2011 and 31.12.2011, 1096 consecutive cardiac surgery patients were assigned to one of two groups receiving PAB with a second-generation cephalosporin for either 56 h (group I) or 32 h (group II). Patients' characteristics, intraoperative data, and the in-hospital follow-up were analysed. Primary endpoint was the incidence of surgical site infection (deep and superficial sternal wound-, and vein harvesting site infection; DSWI/SSWI/VHSI). Secondary endpoints were the incidence of respiratory-, and urinary tract infection, as well as the mortality rate. RESULTS: 615/1096 patients (56,1%) were enrolled (group I: n = 283 versus group II: n = 332). There were no significant differences with regard to patient characteristics, comorbidities, and procedure-related variables. No statistically significant differences were demonstrated concerning primary and secondary endpoints. The incidence of DSWI/SSWI/VHSI were 4/283 (1,4%), 5/283 (1,7%), and 1/283 (0,3%) in group I versus 6/332 (1,8%), 9/332 (2,7%), and 3/332 (0,9%) in group II (p = 0,76/0,59/0,63). In univariate analyses female gender, age, peripheral arterial obstructive disease, operating-time, ICU-duration, transfusion, and respiratory insufficiency were determinants for nosocomial infections (all ≤ 0,05). Subgroup analyses of these high-risk patients did not show any differences between the two regimes (all ≥ 0,05). CONCLUSIONS: Reducing the duration of PAB from 56 h to 32 h in adult cardiac surgery patients was not associated with an increase of nosocomial infection rate, but contributes to reduce antibiotic resistance and health care costs.


Asunto(s)
Profilaxis Antibiótica/métodos , Procedimientos Quirúrgicos Cardíacos , Infección Hospitalaria/prevención & control , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Antibacterianos/administración & dosificación , Cefalosporinas/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Perioperativa/métodos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/prevención & control
20.
Asian Cardiovasc Thorac Ann ; 23(3): 282-8, 2015 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-25061221

RESUMEN

BACKGROUND: Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients. METHODS: A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy. RESULTS: The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents. CONCLUSION: This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.


Asunto(s)
Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Profilaxis Antibiótica/métodos , Infecciones Bacterianas/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Profilaxis Antibiótica/efectos adversos , Profilaxis Antibiótica/estadística & datos numéricos , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/microbiología , Procedimientos Quirúrgicos Cardíacos/mortalidad , Esquema de Medicación , Humanos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/microbiología , Encuestas y Cuestionarios , Resultado del Tratamiento
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