Impact of implantation technique on hemodynamic results of the Pericarbon Freedom stentless valve.

BACKGROUND: The Pericarbon Freedom stentless valve has shown excellent hemodynamic results in the midterm course. However, there is no information as to whether a continuous or interrupted suture technique at the inflow site has an impact on postoperative hemodynamics. METHODS: 139 patients were enrolled in a non-randomized, prospective matched trial. An interrupted suture line technique was used in 68 patients and a continuous suture line technique was used in 71 at the inflow site. Isolated valve replacement was performed in 70.4% of the continuous and 67.6% of the interrupted suture group. Pre- and postoperative hemodynamics and one-year follow-up were obtained by echocardiography and expressed as mean and peak gradients and grade of regurgitation. RESULTS: No significant difference between continuous and interrupted suture techniques were noted with respect to mean (11.8 +/- 6.3 vs. 12.5 +/- 6.2 mm Hg, p = 0.251) and peak gradients (21.0 +/- 9.6 vs. 22.0 +/- 10.9 mm Hg, p = 0.292) as well as to the degree of regurgitation. Bypass and cross-clamping times decreased by 22.4 and 20.6 minutes, respectively, with the use of the continuous suture technique. One year follow-up showed a further, significant decrease of mean and peak gradients. CONCLUSIONS: The Pericarbon Freedom stentless valve appears to offer excellent postoperative performance. The suture line technique at the inflow site does not result in any hemodynamic differences.

Quality management system of a university cardiac surgery department according to DIN EN ISO 9001 : 2000.

BACKGROUND: A quality management system (QMS) will improve quality in health care units. This report describes the introduction of a QMS according to ISO 9001:2000 in a university cardiovascular surgery department. METHODS: First, a thorough analysis of all processes of patient treatment and clinical research was obtained. Multiple interfaces were defined to different departments as well as to administration units. We evaluated and optimized all necessary resources, evaluating customer satisfaction using patients' and referring physicians' surveys. We started quality rounds including surgeons, nurses and technicians. Based on this preparation, we redefined and explained all processes including their responsibilities and necessary resources in the quality manual. RESULTS: After a process of 18 months, an independent, accredited organization recommended that our QMS be given certification according to ISO 9001:2000. CONCLUSIONS: Certification of a university cardiovascular surgery department according to ISO 9001:2000 is possible, and may represent the first step towards total quality management (TQM). In complex health care units, certification of separate departments may help generate a consciousness of quality on the way to TQM.

Use of desmopressin and erythropoietin in an anaemic Jehovah's Witness patient with severely impaired coagulation capacity undergoing stentless aortic valve replacement.

Cardiac surgery in Jehovah's Witness patients remains a challenge in the presence of concomitant congenital or acquired coagulation disorders and anaemia. We report a case of a 66-year-old female Jehovah's Witness suffering from severe calcified aortic valve stenosis requiring aortic valve replacement. The anaemic patient suffered from concomitant platelet dysfunction and deficiency of factors V and VII due to gammopathy of immunoglobulin G. The patient was preoperatively treated with recombinant erythropoietin in combination with folic acid and iron, which resulted in an increase of the haematocrit from 0.335 to 0.416 after 22 days of treatment. Haemostasis was improved by high dose aprotinin and additional desmopressin, which could be demonstrated to be effective by a preoperative test. The patients intra- and postoperative course was uneventful, her total chest tube loss was 130 ml, and she was able to be discharged without the need of any blood transfusions. The beneficial properties of erythropoietin and desmopressin in Jehovah's Witness patients are discussed.

Pumpless arteriovenous extracorporeal lung assist: what is its role?

Extracorporeal lung assist (ECLA) is an established treatment of severe pulmonary failure. Since extracorporeal perfusion is applied in a long-term fashion in this setting, the negative impact on blood compounds is of tremendous importance. Pumpless arteriovenous ECLA (av-ECLA) is an alternatively introduced technique that focuses on reduced blood traumatization. However, due to determining technical and physiological aspects, its clinical application is limited to a highly selected group of patients. Membrane oxygenators with minimal pressure gradients, as well as stable patients' haemodynamics providing a sufficient cardiac output, are the most important prerequisites. With respect to recent reports, characteristic features of av-ECLA, with special emphasis on its physiological background, are reviewed. Accordingly, reasonable indications for its beneficial use are discussed. It is concluded that av-ECLA is a feasible technique when its limitations are accepted. For adequate clinical use, more data concerning indications, as well as time- and technique-related directions are required.

Anticoagulation in extracorporeal circulation using recombinant hirudin: a case report.

Heparin-induced thrombocytopenia (HIT) is a severe complication following the application of heparin; antibodies against complexes of heparin and PDF4 initiate activation of platelets. This may lead to massive thrombembolism, which is associated with a slight and transient drop of platelets in HIT I or a drop below 50% after approximately 5 days in HIT II. Further administration of heparin has to be strictly avoided in these patients. Immunologic evidence for HIT can easily be obtained by the heparin-induced platelet aggregation assay. If anticoagulation is necessary, different, alternative drugs are available. Recombinant hirudin (r-hirudin) is a well-established drug for safe anticoagulation. Monitoring is possible by estimating the plasma level of r-hirudin from the ecarin-clotting time. We report a case of a patient with prosthetic aortic valve endocarditis and HIT II who suffered from massive postoperative bleeding requiring massive substitution of blood components and coagulants caused by free circulating r-hirudin due to the use of a hemofilter.

Severe heart valve calcification in a young patient with Werner syndrome.

Werner syndrome is a rare autosomal recessive disorder characterized by the appearance of premature aging. We report on severe aortic and mitral valve calcification in an 18-year-old girl, necessitating double valve replacement. These special cardiovascular findings are discussed with regard to diagnosis and treatment.

Hemostasis management by use of Hepcon/HMS: increased bleeding without increased need for blood transfusion.

BACKGROUND: Extracorporeal circulation forces complete anticoagulation, most frequently achieved by complete heparinization. Activated clotting time (ACT) is the gold standard for monitoring, although there is a lack of correlation between heparin plasma level and ACT. Several systems for the estimation of free heparin have been developed: in this study we focused investigating on the influence of the Hepcon/HMS system on postoperative bleeding and transfusion requirements. METHODS: 114 patients were randomly assigned to one group monitored by use of Hepcon/HMS (group hepcon) and another group by use of ACT (ACT group); 7 patients were excluded due to re-exploration. 12 patients did not receive aprotinin; this part of the study was stopped early due to massive increased bleeding. 46 and 49 patients of groups hepcon and ACT, respectively, received aprotinin. RESULTS: Using aprotinin, in group hepcon total administered heparin was elevated by 13 % in contrast to group ACT while administered protamine was reduced by 20%. The ratio of antagonization was 82 +/- 17 % and 51 +/- 12 %, respectively. Coagulation parameters were not influenced except for increased postoperative ACT and PTT in the hepcon group. Bleeding of patients in that group was significantly increased during the first 6 hours, which led to an increased autologous retransfusion. Need for substitution of other blood components was not increased postoperatively. CONCLUSIONS: Use of the Hepcon/HMS-system for monitoring of heparinization during extracorporeal circulation is possible without increased risk of thromboembolism. Postoperative blood loss was slightly but significantly increased but there was no need for more heterogenous transfusion.