The discriminative value of blood gas analysis parameters in the differential diagnosis of transient disorders of consciousness.

AIM: The differentiation between epileptic and non-epileptic episodes can be challenging. Our aim was to compare lactate, anion gap (AG), bicarbonate and the Denver Seizure Score (DSS) as point-of-care test (POCT) markers for episodes of transient alterations of consciousness. METHODS: The blood serum parameters were drawn at arrival in the emergency department (ED) within 2 h of the episode. After calculating AG and DSS values, the four parameters were compared retrospectively between patients with generalized tonic-clonic seizures (GTCS) (n = 165) and patients with other disorders of consciousness [syncopes (n = 43), and psychogenic non-epileptic seizures (n = 15)]. Additionally, we compared all values among men and women. RESULTS: In GTCS patients, all four parameters differed significantly compared to non-epileptic episode patients (p < 0.001). Serum lactate showed significant additional benefit over the remaining values, with an AUC of 0.947 (95% CI 0.92-0.975) and a high sensitivity and specificity for an optimal cut-off value of 2.45 mmol/l. For DSS, the AUC was 0.857 (95% CI 0.808-0.906; cut-off: 0.35), and for AG 0.836 (95% CI 0.783-0.889; cut-off: 12.45 mmol/l). In the case of serum bicarbonate, the AUC was 0.831 (95% CI 0.775-0.886; cut-off: 22.75 mmol/l). In the sex-dependent comparison, the results were similar. Men showed more significant differences in the compared values than women. CONCLUSIONS: Serum lactate is best suited as POCT marker in the differential diagnosis of epileptic and non-epileptic episodes and is superior to AG, DSS and bicarbonate. The differences among sexes may pose a challenge in their implementation and interpretation.

[Laboratory diagnostics in transient loss of consciousness : Serum lactate compared to serum creatine kinase as diagnostic indicator for generalized tonic-clonic seizures]. / Labordiagnostik bei transienten Bewusstseinsstörungen : Serumlaktatwert im Vergleich zur Serumkreatinkinase als diagnostischer Indikator für generalisierte tonisch-klonische Anfälle.

BACKGROUND: Laboratory parameters can help in the differential diagnostics of acute episodes of transient loss of consciousness. Especially serum lactate and serum creatine kinase (CK) levels may provide valuable hints to distinguish generalized tonic-clonic seizures (GTCS) from syncope. MATERIAL AND METHODS: Serum lactate levels at admission and CK levels 10-48 h after the episodes that led to admission were compared between patients with GTCS (n = 30) and those with syncope (n = 15). In addition, sensitivity and specificity of lactate and CK as diagnostic markers for syncope and GTCS were determined. RESULTS: The serum lactate and serum CK levels were significantly increased in patients with GTCS as compared to syncope patients (serum lactate: p < 0.001; CK: p < 0.005). The area under the curve (AUC) for serum lactate as an indicator for GTCS was 0.94 (95% confidence interval [CI] 0.88-1.0). For CK the receiver operating characteristics (ROC) analysis produced an AUC of only 0.77 (95% CI: 0.63-0.9). CONCLUSION: The determination of the lactate value as point-of-care diagnostics appears to be highly relevant in the rapid clarification of unclear episodes with transient loss of consciousness. The CK level at follow-up is also suitable for distinguishing GTCS from syncope but is inferior to the serum lactate value.

Lactate as a diagnostic marker in transient loss of consciousness.

PURPOSE: The diagnostic classification of disorders of consciousness is often challenging, particularly the distinction between epileptic and non-epileptic seizures. The aim of the study was to examine serum lactate as a diagnostic marker of transient loss of consciousness. METHOD: Serum lactate levels in blood samples drawn within 2h of the event were compared retrospectively between patients with generalized tonic-clonic seizures (n=195) and patients with other seizures (syncopes [n=52], psychogenic non-epileptic seizures [n=17], and complex focal seizures [n=37]), respectively. RESULTS: Serum lactate in patients with generalized tonic-clonic seizures was significantly (p<0.001, Mann-Whitney-U test) increased in comparison to other forms of seizure incidences. The area under the ROC-curve was 0.94 (95% CI 0.91-0.96). For a cut-off concentration of 2.45mmol/l, the sensitivity was 0.88 and the specificity 0.87. CONCLUSIONS: Serum lactate levels in the acute diagnosis were an excellent biomarker for the discrimination of generalized seizures from psychogenic non-epileptic and syncopal events, corroborating its importance for the standard work-up of acute disturbances of consciousness.

[Mycoplasma Pneumoniae-Induced Meningoencephalitis]. / Mykoplasma-pneumoniae-assoziierte Meningoenzephalitis.

In clinical practice, secondary infections of the central nervous system (CNS) represent rare yet severe complications of their respective primary infections. In this case report, we describe a 22-year-old patient with a medical history of Asthma bronchiale, who developed significant neurological deficits after a respiratory infection. The neurological symptoms progressed despite antibiotic therapy with vancomycin, ampicillin and ceftriaxone. The patient's cerebrospinal fluid and a cranial magnetic resonance imaging (MRI) furnished evidence of acute meningoencephalitis. Microbiological assessment confirmed an acute mycoplasma pneumonia infection. Changing the patient's antibiotic regimen to minocycline and prednisolone led to significant clinical improvement. Pathomechanisms and therapeutic options to treat meningoencephalitis will be discussed in the following.

Rotation thromboelastography for the detection and characterization of lipoteichoid acid-induced activation of haemostasis in an in vitro sepsis model.

OBJECTIVES: In gram-positive sepsis, lipoteichoic acid (LTA) can induce alterations of haemostasis, potentially leading to disseminated intravascular coagulation. PATIENTS AND METHODS: Here, we demonstrate the effects of LTA on haemostasis in an in vitro model of gram-positive sepsis based on rotation thromboelastrography (ROTEM). RESULTS: In this model, LTA leads to time- and dose-dependent shortening of the clotting time (CT), whereas other ROTEM parameters are unaffected. Following heat shock simulation, the LTA effect was blunted with equal CTs in the presence and in the absence of LTA. In addition, the shortening of CT by LTA was inhibited by addition of the protein synthesis inhibitor. CONCLUSION: Our work demonstrates that the ROTEM system is capable of detecting the LTA effect on haemostasis and provides a sensitive in vitro tool for research into the links between gram-positive sepsis and coagulation.

Prone and ECMO - a contradiction per se?

Acute respiratory distress syndrome (ARDS) still represents a serious problem in clinical routine and is associated with a high mortality. Several concepts are known for special treatment, but, in some instances, the application of an extracorporeal membrane oxygenation (ECMO) is necessary for both the improvement of oxygenation and the elimination of carbon dioxide (CO(2)). One basic aspect in lung protective ventilation in this context is alveolar recruitment, which can be achieved by different approaches, such as "the open lung concept", according to Lachmann, or by additional kinetic therapy. The most exposed feature of this entity is 'prone', which may be quite challenging in patients requiring extracorporeal support or organ replacement therapy under ongoing critical illness. We report two outstanding cases of prone under conditions of a veno-venous ECMO therapy which improved significantly under this position. Furthermore, we reflect critically possible risk factors and adverse events of such procedures and afford a current view from the literature.

Rotation thromboelastography (ROTEM) parameters are influenced by age, gender, and oral contraception.

Rotation thromboelastography (ROTEM) is a screening method that allows the rapid detection of plasma- and platelet-related haemostatic abnormalities. To use this procedure more efficiently, reference values depending on gender, age, and oral contraception are required. In this study, five cohorts of healthy subjects were examined by ROTEM upon activation of the extrinsic or intrinsic pathway of coagulation, or recalcification alone. The cohorts comprised male subjects below (1) and above (2) 45 years of age, female subjects below 45 years of age with (3) or without (4) oral contraception, and female subjects above 45 years (5) without hormone replacement therapy. A significant influence of gender, age, and oral contraception on parameters determined by ROTEM was observed. Thus, adjustment for age, gender, and oral contraception is required when ROTEM is used to screen for distinct abnormalities of haemostasis.

Platelet function analyzer (PFA-100) as a useful tool for the prediction of transfusion requirements during aortic valve replacement.

BACKGROUND: Shear stress-induced hemostatic abnormalities, particularly loss of the hemostatically most competent, highest molecular weight von Willebrand factor multimers, are common in patients with aortic valve stenosis. Although controversially discussed, these hemostatic defects might be associated with an increased risk of bleeding during aortic valve replacement. Since the determination of closure times with a platelet function analyzer is sensitive for the detection of defects of primary hemostasis including shear stress-induced von Willebrand factor abnormalities, this study was performed to evaluate a method to predict intraoperative transfusion requirements in this setting. METHODS: Fifty patients (mean age ± SD: 68 ± 9 years, range 40-85 years) admitted for aortic valve replacement were enrolled in the study. Closure times of epinephrine/collagen and ADP/collagen cartridges were determined with a platelet function analyzer in the absence of antiplatelet agents. Results were compared to those obtained in healthy individuals without medication. The probability that a patient would require a transfusion of packed red cells (RBC) and fresh frozen plasma (FFP) was calculated for each obtained closure time using a multiple regression model. RESULTS: Compared to controls, patients undergoing aortic valve replacement had a significantly higher incidence of prolonged closure in the platelet function analyzer. The prolonged closure time of both epinephrine/collagen and ADP/collagen cartridges was significantly correlated with intraoperative transfusion of RBC, but not FFP. CONCLUSIONS: In patients undergoing aortic valve replacement, prolongation of closure times as determined by a platelet function analyzer is frequently observed, indicating the presence of shear stress-induced defects of primary hemostasis. Since the prolongation of closure times is significantly correlated to the probability of intraoperative transfusion, this method might offer a significant contribution to the preoperative risk stratification of patients.

Predictors of postoperative complications in octogenarians undergoing cardiac surgery.

OBJECTIVE: Aim of the study was to clarify the impact of different pre- and perioperative conditions on outcome in octogenarians undergoing cardiac surgery. METHODS: We retrospectively analyzed preoperative risk factors and intraoperative adverse events and studied in-hospital morbidity and mortality in 646 patients > or = 80 years of age (82.5 +/- 3.5 years) and in 6081 younger patients (70.3 +/- 3.4 years) who underwent cardiac surgery between 1/2001 and 12/2006. RESULTS: Preoperatively, octogenarians suffered significantly more from arterial hypertension, renal failure, previous neurological problems, unstable angina and NYHA class IV than younger subjects. The incidence of combined valve and coronary procedures and of urgent operations was also significantly higher in patients > or = 80 years (27.7 % vs. 18.2 %, P < 0.05, and 7.3 % vs. 4.2 %, P < 0.05, respectively). In-hospital mortality was higher (7.4 % vs. 3.7 %, P < 0.05), and average ICU and total in-hospital stay was longer in the older age group. Postoperative complications occurred in 15 % of patients > or = 80 years compared to 7.6 % of patients < or = 79 years ( P < 0.05). NYHA class IV, female sex and preoperative renal failure correlated with perioperative morbidity. Multivariate analysis could identify urgent procedures, redo surgery, mitral valve surgery and prolonged cross-clamping times as predictors of mortality. CONCLUSIONS: Cardiac surgery in octogenarians can be performed with an acceptable risk but an increased mortality and morbidity compared to younger patients. High-risk octogenarians, who require intensive perioperative management, should be identified to reduce the incidence of postoperative complications.

Platelet-function analyzer closure times indicate shear stress-induced hemostatic abnormalities in patients with aortic valve stenosis and correlate with perioperative transfusion requirements.

BACKGROUND: Shear stress-induced hemostatic abnormalities are highly prevalent in patients with aortic valve stenosis. In this study, we determined closure times with a platelet-function analyzer (PFA-100, Dade Behring, Marburg, Germany) in patients admitted for aortic valve replacement to assess the correlation with the severity of aortic valve stenosis, blood loss, perioperative transfusion requirements, and need for re-thoracotomy. PATIENTS AND METHODS: Fifty consecutive patients (mean age [+/- SD] 68 +/- 9 years) were enrolled. Closure times of epinephrin/collagen and adenosine diphosphate (ADP)/collagen cartridges were determined at least ten days after discontinuation of antiplatelet medication and compared to those of healthy control subjects without medication. RESULTS: Closure times of epinephrin/collagen (210 +/- 69 sec vs. 140 +/- 50 sec, p < 0.0001) and ADP/collagen (145 +/- 58 sec vs. 108 +/- 45 sec, p < 0.0001) cartridges were prolonged in patients with aortic valve stenosis. Intraoperative transfusion of red blood cell units was associated with the closure times of epinephrin/collagen (r = 0.28, p = 0.04) and ADP/ collagen cartridges (r = 0.28, p = 0.04). Total transfusion of red blood cell units was associated with ADP/ collagen closure times (r = 0.31, p = 0.02), but not epinephrin/collagen closure times (r = 0.26, p = 0.07). No significant association of closure times with intraoperative, postoperative and total transfusion of fresh frozen plasma units was observed. CONCLUSIONS: Prolongation of closure times determined with a platelet-function analyzer is highly prevalent in patients with aortic valve stenosis and appears to reflect shear stress-induced hemostatic abnormalities. Since prolonged closure times are associated with increased perioperative transfusion of red blood cell units, the assay could significantly contribute to the identification of individuals at risk.

Cardiac valve replacement in patients with end-stage renal failure: impact of prosthesis type on the early postoperative course.

BACKGROUND: It is still unclear whether biological or mechanical valves should be preferred in patients on chronic dialysis therapy. PATIENTS AND METHODS: We retrospectively analyzed data from 104 patients (66.5 +/- 8.6 years) with end-stage renal failure (RF) who underwent aortic or mitral valve replacement between 2002 and 4/2008. Mechanical valves were implanted in 44 (42 %) patients and bioprostheses in 60 (58 %). The two groups were comparable with regard to preoperative data, age and incidence of additional CABG procedures. We studied in-hospital morbidity and mortality, major postoperative complications and length of ICU and hospital stay. Additionally, parameters predicting a poor outcome were analyzed with multivariate regression analysis. RESULTS: The overall hospital mortality was 12.5 % and did not differ between the two groups (mechanical: 13.6 %, biological: 11.7 %, n. s.). In the postoperative course, duration of ventilation and ICU stay were similar, whereas hospital stay was significantly longer for patients with mechanical prostheses (19.5 +/- 5.4 vs. 15.6 +/- 4.1 days, P < 0.05). Mechanical valve patients had a significantly higher rate of postoperative cerebrovascular incidents (18.2 vs. 8.3 %, P < 0.05) and bleeding complications (15.9 vs. 11.7 %, P < 0.05). Reoperation, obesity, left ventricular ejection fraction < 30 % and previous neurological complications were independent predictors of hospital mortality. CONCLUSIONS: Our results demonstrate that in patients with end-stage RF, the use of mechanical valves is associated with a significant risk of complications. Because of the poor overall survival of patients on dialysis, bioprosthesis degeneration will not be a limiting factor. Therefore, preference should be given to biological valves in these patients.

The impact of pre- and postoperative renal dysfunction on outcome of patients undergoing coronary artery bypass grafting (CABG).

OBJECTIVE: Acute changes in renal function after elective coronary bypass surgery represent a challenging clinical problem. In this study, we evaluated perioperative risk factors for the development of postoperative renal dysfunction (PRD), and the impact of such an event on the perioperative course. Additionally, we investigated the influence of preoperatively mildly increased serum creatinine on perioperative mortality and morbidity. METHODS: We retrospectively analyzed data of 2511 patients undergoing isolated CABG between 2004 and 2007 with a preoperative serum creatinine < or = 2.2 mg/dL. There were 592 patients with a preoperative serum creatinine of between 1.4 and 2.2 mg/dl (mild renal dysfunction group) and 1919 patients with a serum creatinine < 1.4 mg/dl. Perioperative risk factors for PRD were analyzed by multivariate regression analysis. RESULTS: Global in-hospital mortality was 3.1 %.The incidence of PRD was 6.2 %. Mortality for patients who had PRD was 7.8 vs. 2.9 % for patients who did not ( P < 0.05). PRD increased the length of hospital stay by 3.7 days (12.2 vs. 15.9; P < 0.05). Multivariate logistic regression identified the following variables as independent predictors of PRD: age, angina class III/IV, diabetes mellitus, prolonged cardiopulmonary bypass time, and preoperative serum creatinine. With regard to preoperative renal function, we found that operative mortality was higher in the mild renal dysfunction group (5.7 % vs. 2.5 %; P < 0.05). New dialysis/hemofiltration (5.1 % vs. 1.2 %; P < 0.05) and postoperative stroke (5.1 % vs. 1.6 %; P < 0.05) were also more common in these patients. CONCLUSIONS: Mild renal dysfunction preoperatively is an important predictor of outcome after CABG. In these patients, PRD dramatically increases mortality, morbidity and length of hospital stay.

Predictors and outcome of ICU readmission after cardiac surgery.

OBJECTIVE: Readmission to the intensive care unit (ICU) after cardiac surgery is associated with higher costs and may be correlated with an increased mortality. We wanted to evaluate predictors of ICU readmission and to analyze the outcome of those patients. METHODS: 3523 patients who underwent CABG and/or valve surgery between 2004 and 2007 were reviewed retrospectively. The reasons for readmission and the postoperative course were analyzed. Furthermore, perioperative risk factors for readmission were determined by multivariate regression analysis. RESULTS: Of the 3374 patients discharged from the ICU, 5.9 % (198) of patients required a second stay in the intensive care (group r). The readmission rate was 4.8 % following CABG and 8.9 % following valve +/- CABG ( P < 0.05). The mean interval from ICU discharge to readmission was 3.3 +/- 6.2 days. Of the patients who were not readmitted, 1.3 % died in hospital, compared to 14.4 % in group r ( P < 0.05). After readmission, the mean length of stay in the ICU and in hospital was 7.1 +/- 5.9 and 21.3 +/- 11.1 days (3.1 +/- 1.2 and 13.1 +/- 5.1 days for all other patients [ P < 0.05]). Main reasons for readmission were respiratory failure (59 %), cardiovascular instability (25 %), renal failure (6.5 %), cardiac tamponade/bleeding (6 %), gastrointestinal complications (2 %) and sepsis (1.5 %). Multivariate logistic regression analysis revealed that preoperative renal failure, mechanical ventilation > 24 h, reexploration for bleeding and low cardiac output state were independent predictors for readmission. CONCLUSIONS: Patients after valve/combined surgery are more likely to require readmission to the ICU. Respiratory complications were the most common reasons for readmission. To reduce the readmission rate, it is necessary to treat cardio-respiratory problems early, particularly in patients showing predictive risk factors.

Intraaortic balloon pumping in patients with right ventricular insufficiency after cardiac surgery: parameters to predict failure of IABP Support.

BACKGROUND: The indications for intra-aortic balloon pump (IABP) in the case of a failing right ventricle after operations with extracorporeal circulation (ECC) are still discussed controversially. We investigated the benefit of IABP in patients with a predominantly right ventricular dysfunction after ECC. Additionally, we wanted to identify early and easily available prognostic markers for outcome in all patients receiving IABP support. PATIENTS AND METHODS: Between 1/2004 and 1/2008, 4550 patients underwent cardiac surgical procedures with ECC, 223 of whom (4.9 %) had an IABP inserted intra- or postoperatively (group 1). 79 of these patients were treated intraoperatively with IABP for early postoperative low cardiac output syndrome (LCOS) characterized by predominantly right ventricular failure (RV group). Clinical data and hemodynamic variables were recorded perioperatively. Multiple potential markers of mortality and postoperative complications were analyzed statistically, especially with regard to their predictive ability. RESULTS: 68 % of all IABP patients were successfully weaned from IABP support and 63 % survived to hospital discharge. In the RV group, cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.8 +/- 0.2 to 2.8 +/- 0.2, MAP 53 +/- 10 to 73 +/- 8, P < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased ( P < 0.05). 59 patients in the RV group (75 %) could be weaned from IABP successfully and 69 % survived to hospital discharge. Serum lactate of more than 11 mmol/L in the first 10 hours of IABP support predicted a 100 % mortality. A base deficit of more than 12 mmol/L, mean arterial pressure less than 55 mmHg, urine output of less than 50 ml/h for 2 hours, and dose of epinephrine or norepinephrine of more than 0.4 mg/kg/min were other highly predictive prognostic markers. Furthermore, multivariate analysis showed that patients with a left atrial pressure > 17 mmHg or a mixed venous saturation (SVO (2)) < 65 % had poor outcomes. CONCLUSIONS: In patients with IABP support for postcardiotomy cardiogenic shock, elevated serum lactate, elevated base deficit, hypotension, oliguria and large vasopressor doses are all predictors of mortality. In these patients, the use of another mechanical assist device should be considered in good time. Our study additionally shows that LCOS caused by predominantly right ventricular failure - particularly after CABG - may be an additional indication for IABP.

Intermediate coronary revascularization using the Deltastream blood pump: results from an experimental study.

BACKGROUND: Myocardial revascularization using a complete heart-lung machine may involve many problems, as do complete off-pump attempts. Thus, it was the aim of this study to evaluate the effects of intermediate on-pump/off-pump myocardial revascularization using the miniaturized Deltastream blood pump, on ischemia and hemolysis, in comparison with standard myocardial revascularization. METHODS: In a group of 8 mini-pigs, combined on-pump/off-pump myocardial revascularization was performed using the Deltastream blood pump as beating-heart support for the on-pump part of the operation (group A). Seven other animals served as controls and underwent standard myocardial revascularization with the same device as integrated pump of a complete heart-lung machine (group B). Blood samples for blood gas metabolism, creatine kinase (CK), troponin I, lactate dehydrogenase (LDH), and hydroxybutyrate dehydrogenase (HBDH) were taken before and after the entire operation. RESULTS: Comparing the baseline values, the increase of CK was more pronounced in group B than in group A (176.4-/+41.2 to 279.7-/+29 U/L vs. 274-/+142.7 to 288.1-/+118.6 U/L, respectively; p=0.0006). Increase of troponin I was significantly higher in group B than in group A (1-/+0.3 to 2.9-/+1 ng/mL vs. 1.1-/+0.9 to 3-/+3.8 ng/mL, respectively; p=0.002). LDH increase was also more pronounced in group B (231.7-/+54.3 to 299.9-/+39.8 U/L vs. 274.9-/+59.7 to 263.8-/+57.9 U/L, respectively; p=0.01). HBDH values increased significantly in group B after the operation (group A: 215.9-/+34.7 to 200-/+39.2 U/L vs. group B: 195.4-/+41.7 to 274.9-/+51.6 U/L; p=0.02). Hemodynamic measures and LDH values under luxation (group A: 1.9-/+0.6 U/L; B: 3.5-/+1 U/L,p=0.001) were also superior in the study group. CONCLUSION: The current set-up might be superior to conventional extracorporeal circulation and thus be an alternative for high-risk candidates to avoid the adverse events of a complete heart-lung machine, when they are scheduled for complete myocardial revascularization.

CABG-procedures in patients with pretreatment with the GPIIb/IIIa-receptor antagonist tirofiban (Aggrastat): modification of perioperative management?

In order to investigate the effects of tirofiban administration in cardiac surgery all patients undergoing coronary artery bypass grafting (CABG) which received this drug preoperatively between 1/2002 and 6/2005 (n=232) were studied. Three groups regarding the perioperative administration of antifibrinolytic drugs were compared: group A=controls (n=70), group B=aprotinin (n=110), group C=tranexamic acid (n=52) Furthermore we could differ the patients depending on the time when tirofiban was stopped (<2 h, 2-4 h, >4 h preoperatively). The postoperative blood loss was significantly higher in all tirofiban-patients (A-C) compared to a group of CABG-patients without tirofiban. The best results concerning blood loss, transfusion of red cell concentrates (rcc), fresh frozen plasma (ffp) and incidence of re-sternotomy could be found in patients with aprotinin. A further significant improvement could be seen in patients who received platelets, intraoperative hemofiltration and in which tirofiban was stopped >4 h preoperatively. We conclude that by early presurgical discontinuing of tirofiban-therapy and slight modifications of the perioperative management bleeding complications can significantly be reduced.

Predictive risk factors in double-valve replacement (AVR and MVR) compared to isolated aortic valve replacement.

BACKGROUND: The operative risk of combined aortic and mitral surgery is still between 5 and 13 %, whereas isolated AVR normally causes complications in less than 4 % of all patients. Thus, it was the aim of the study to compare both procedures and to evaluate risk stratification in our patient cohort. PATIENTS AND METHODS: The inhospital mortality and complication rates were analyzed in both groups over a period of 4 years. There were 396 patients with isolated AVR, and 98 patients with AVR and MVR. For both groups, we investigated 16 possible risk factors for perioperative death or severe complications, such as low cardiac output syndrome (LCOS). The risk factors were analyzed by univariate analysis, and factors with P < 0.01 were entered into a multivariate analysis. RESULTS: There were 11/396 perioperative deaths in patients with AVR (2.8 %) compared to 5/98 (5.1 %) in DVR. The incidence of major complications was 5.3 % in AVR vs. 11.2 % in DVR. As risk factors ( P < 0.05) for death, we found in AVR: former cardiac surgery, aortic stenosis, and pulmonary arterial pressure > 55 mmHg. In patients with DVR, we additionally found: left atrial pressure (LAP) > 20 mmHg and creatinine > 2 mg/dl. Risk factors for severe complications in AVR were: former cardiac surgery and creatinine > 2 mg/dl, in cases of DVR, additionally: tricuspid valve disease (TVD) and LAP > 20 mmHg. CONCLUSIONS: Our analysis of risk factors shows that in patients with DVR preoperative parameters, which sometimes are estimated to be unimportant, may cause an adverse outcome. The operation should be carried out before reaching advanced or even end-stage heart failure, and more attention should be paid to an individual perioperative concept and optimized myocardial protection in such patients.

Hemodynamic performance and clinical consequences of aortic valve replacement with 21-mm sized pericardial bioprostheses.

BACKGROUND: Aortic valve replacement (AVR) with a 21-mm sized bioprothesis is still discussed controversially. Since better results have been reported for pericardial valves, the aim of the current study was to analyze the hemodynamic performance as well as clinical parameters in our patients and to compare pericardial and standard porcine valves in particular. METHODS: 342 patients underwent AVR with a bioprosthesis between 1987 and 2000. A 21 mm prosthesis was used in 39 patients (group S), while 303 patients received at least a 23-mm sized valve (group L). Group S was further divided into 19 patients with a pericardial valve (group S1) and 20 patients with a standard porcine valve (group S2). The hemodynamic and clinical parameters were studied in all three groups. RESULTS: The peak and mean transprosthetic gradients were significantly lower in the pericardial group than in the porcine group, particularly between patients with 21 mm valves (peak/mean: S1: 24 +/- 9/20.8 +/- 6.5 mm Hg vs. S2: 38 +/- 15/33 +/- 9 mm Hg, p < 0.05) at discharge. We could also observe that the peak transprosthetic gradient 7 days postoperatively was not significantly higher in patients with a 21 mm pericardial valve compared to group L patients. Comparing clinical parameters, we found significantly more cerebral ischemic events, a prolonged mechanical ventilation, a higher mortality and a longer stay in hospital in the group S2 compared to the group S1. CONCLUSION: The current study shows that pericardial valves perform well, particularly in patients with small aortic roots. Postoperative hemodynamics and clinical results were better than for comparable standard porcine valves. As the outcome of patients with a 21 mm pericardial valve was no worse than that in patients with bigger valves, enlarging procedures for the aortic root are not necessary in the majority of these patients.

Ventricular constraint in dilated cardiomyopathy: a new, compliant textile mesh exerts prophylactic and therapeutic properties.

BACKGROUND: Dilated cardiomyopathy is associated with a progressive decrease in cardiac function, leading to end-stage heart failure. We aimed to stop this process by mechanically constraining the heart with a new, compliant textile mesh. METHODS: In 16 male Munich minipigs (50 +/- 7 kg), dilated cardiomyopathy with congestive heart failure was induced through 4 weeks of rapid ventricular pacing (220 beats/min). In the early-mesh group (n = 8), a polyvinylidene fluoride mesh was positioned around both ventricles before pacing was started. In the other group (n = 8), experimental dilated cardiomyopathy through rapid pacing was induced (no mesh). After mesh grafting, rapid pacing was continued (late mesh). RESULTS: Rapid pacing in the no-mesh group (control group) significantly decreased both systolic (cardiac output, peak systolic pressure, and the derivative of pressure increase [dP/dt(max)]) and diastolic (minimum rate of pressure rise [dP/dt(min)] and left ventricular end-diastolic pressure) variables, whereas these variables remained almost unchanged in the early-mesh group. In the late-mesh group the passive-elastic constraint not only prevented further deterioration but even exerted reverse remodeling to some extent (dP/dt(max) and left ventricular end-diastolic pressure, P < .05). CONCLUSIONS: Ventricular constraint with the new mesh seems to be a prophylactic and therapeutic option in cardiac insufficiency caused by ventricular dilation. This passive-elastic cardioplasty induced reverse remodeling of dilated hearts and significantly improved diastolic and systolic ventricular function.

Combined open heart surgery and replacement of the brachiocephalic trunk. A safe method for simultaneous central revascularization.

OBJECTIVE: We investigated the feasibility of open heart surgery with combined central vascular surgery and present the results from 9 years of experience. PATIENTS AND METHODS: Of a total of nine patients, eight received coronary artery bypass grafting and one patient aortic valve replacement. Concerning vascular surgery a replacement of the brachiocephalic trunk using a Dacron prosthesis as an end-to-end anastomosis or as a bifurcations prosthesis was performed. Two patients underwent additional ipsilateral desobliteration of the internal carotid artery. RESULTS: The hospital stay was between 8 and 30 days (median 15). The duration of the whole operation was median 318 min (range: 294-345 min), perfusion time 67 min (range: 62-146 min), myocardial ischemic time 27 min (range: 11-83 min). There was no case of in-hospital death. Follow-up was available up to 7.5 years in 7 patients. Five patients show a satisfactory cardiac status. A sign for ischemic cerebral events or embolization was not observed. CONCLUSION: Due to the low complication rate, we conclude that concomitant open heart surgery with replacement of the brachiocephalic trunk can be performed with low risk; it allows-in contrast to direct endarterectomy-complete central revascularization and hence should be preferred compared to surgical therapy in separate settings.