Candidemia in the intensive care unit: analysis of direct treatment costs and clinical outcome in patients treated with echinocandins or fluconazole.

Direct treatment costs caused by candidemia in German intensive care unit (ICU) patients are currently unknown. We analyzed treatment costs and the impact of antifungal drug choice. Comprehensive data of patients who had at least one episode of candidemia while staying in the ICU between 01/2005 and 12/2010 were documented in a database using the technology of the Cologne Cohort of Neutropenic Patients (CoCoNut). A detailed analysis of all disease-associated treatment costs was performed. Patients treated with echinocandins (i.e., anidulafungin, caspofungin, micafungin) or fluconazole were analyzed separately and compared. Forty-one and 64 patients received echinocandins and fluconazole, respectively. The mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 114 (95 % confidence interval [CI]: 106-122) vs. 95 (95 % CI: 90-101, p = <0.001). Twenty-three (56 %) and 33 (52 %, p = 0.448) patients survived hospitalization, while 17 (41 %) and 22 (34 %, p = 0.574) survived one year after diagnosis. In the echinocandin and fluconazole groups, the mean costs per patient of ICU treatment were 20,338 (95 % CI: 12,893-27,883) vs. 11,932 (95 % CI: 8,016-15,849, p = 0.110), and the total direct treatment costs per patient were 37,995 (95 % CI: 26,614-49,376) vs. 22,305 (95 % CI: 16,817-27,793, p = 0.012), resulting in daily costs per patient of 1,158 (95 % CI: 1,036-1,280) vs. 927 (95 % CI: 828-1,026, p = 0.001). Our health economic analysis shows the high treatment costs of patients with candidemia in the ICU. Sicker patients had a prolonged hospitalization and were more likely to receive echinocandins, leading to higher treatment costs. Outcomes were comparable to those achieved in less sick patients with fluconazole.

[Prioritization of intensive medical treatment places - Concept proposal]. / Priorisierung intensivmedizinischer Behandlungsplätze ­ Konzeptvorschlag.

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.

[MRI of the heart following implantation of a left ventricular apico-aortic conduit]. / Kernspintomografie zur umfassenden Untersuchung des Herzens nach Implantation von linksventrikulären apikoaortalen Conduits.

PURPOSE: To investigate the potential of ECG-triggered MRI for the evaluation of postoperative anatomy and function of the heart and conduit following implantation of a left-ventricular apico-aortic conduit. MATERIALS AND METHODS: 5 patients (2 female, 3 male, mean age 72.5 years) were examined using a 1.5 Tesla whole-body MRI (Gyroscan Intera, Philips Medical Systems, Best, The Netherlands) following apico-aortic conduit surgery due to severe aortic valve stenosis. The reason for performing conduit implantation instead of aortic valve replacement was the risk of injuring a bypass graft from prior coronary artery bypass surgery. Cine steady-state-free-precession (SSFP) sequences were used to assess ventricular function, navigator-gated 3D-SSFP and breath-hold, time-resolved contrast-enhanced MR angiography was used to display the postoperative anatomy, and 2D-gradient echo sequences with an inversion pulse to suppress the signal of the healthy myocardium were used to evaluate potential myocardial scarring. Flow sensitive gradient echo sequences were performed to determine the blood flow in the conduit. RESULTS: In all patients the apico-aortic conduit proved to be open with a maximum flow velocity of 126 (+ 43) cm/s. The postoperative anatomy was able to be evaluated in all patients and perioperative myocardial infarction was able to be ruled out. The mean ejection fraction of the left ventricle was 44.2 + 6.2 % with a mean volume of 80 + 20.6 ml per heart beat. CONCLUSION: ECG-triggered MRI is a reliable method for the evaluation of postoperative anatomy and function following implantation of a left ventricular apico-aortic conduit.

Prospectively randomized comparison of different mechanical aortic valves.

BACKGROUND: The aim of this prospectively randomized study was to evaluate the hemodynamic and functional outcomes after aortic valve replacement with 3 different bileaflet mechanical valves. METHODS AND RESULTS: Three hundred consecutive patients were randomly assigned to receive ATS (n=100), Carbomedics (n=100), or St Jude Medical Hemodynamic Plus (n=100) mechanical aortic valve replacement. There were no significant differences regarding patient age (average 61+/-8 years), body surface area (1.9+/-0.2 m(2)), left ventricular function (ejection fraction 0.59+/-0.17), and presence of aortic stenosis (90%, 89%, and 91%), respectively. All patients had postoperative as well as 6-month and 1-year follow-ups that included transthoracic echocardiography. Multivariate statistical analysis was performed. Implanted valve sizes were comparable at 24+/-2 (ATS), 23.7+/-1.6 (CM), and 23.6+/-1.9 (SJMHP) mm (NS). At 1-year follow-up, the following incidence of events was noted: death 3/1/1, all non-valve related; stroke 0/1/1; trivial transvalvular incompetence 3/3/2; paravalvular leak 2/3/2; and reoperation 0/1/1, respectively (NS). Transvalvular flow velocities were 2.5/2.6/2.4 m/s postoperatively (P:=0.03) and 2.4/2.4/2.3 m/s at 6-month follow-up, respectively (NS). There was a significant decrease in left ventricular mass for all patients but no significant differences among the groups. CONCLUSIONS: There are no clinically relevant differences among the tested bileaflet aortic valves. Regardless of valve type, there was a low complication rate. On the basis of these findings, all 3 bileaflet prostheses are well suited for aortic valve replacement.

Regression of left ventricular hypertrophy after stentless versus conventional aortic valve replacement.

The goal of this study was to analyze regression of left ventricular hypertrophy after randomization to conventional biological versus stentless aortic valve replacement. Stentless (Freestyle, Toronto, n = 106) or conventional biological aortic valves (Carpentier-Edwards, n = 74) were evaluated prospectively. Preoperatively there were no differences with regard to aortic valve pathology, left ventricular function, and pressure gradients between the two patient groups. The patient annulus index (13.55 vs. 13.46 mm; NS) measured intraoperatively was used as baseline for further comparison. Postoperatively, left ventricular mass index was 213+/-77 g/m2 (stentless) compared with 202+/-72 (conventional group) g/m2 (NS), whereas after 6 months it was 141+/-41 g/m2 in the stentless and 170+/-43 g/m2 in the conventional group (P<.05). Regression of left ventricular hypertrophy occurs in all patients after aortic valve replacement. Nevertheless, the use of stentless bioprostheses leads to a significant enhancement, which may result in a reduction of the cardiac risk profile for the patient.

Comparison of On-X and SJM HP bileaflet aortic valves.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the hemodynamic function after aortic valve replacement (AVR) using the On-X valve, in comparison with St. Jude Medical (SJM) HP bileaflet valves. METHODS: Patients received either the On-X (n = 20) or SJM HP prosthesis (n = 20) for AVR. The control (SJM HP) group was computer-matched with the On-X group for age, gender, aortic stenosis as underlying disease, body surface area, NYHA functional class, left ventricular size, mass and function, transvalvular pressure gradients and cardiac index. Mean implanted valve size was 23.5 mm (three 21 mm, ten 23 mm, six 25 mm, one 27 mm) in both groups. All patients underwent postoperative, and six- and 12-month follow up echocardiography. RESULTS: The intra- and postoperative course was uneventful in all patients. There were no significant differences in cross-clamp and cardiopulmonary bypass times, intensive care unit stay, in-hospital stay and postoperative NYHA functional class. Two patients (both On-X) had paravalvular leakage postoperatively and at follow up. Five patients in the control group had additional myocardial revascularization. Transvalvular flow velocities were 2.38 +/- 0.3 versus 2.38 +/- 0.4 m/s (p = NS) postoperatively, and 2.08 +/- 0.2 versus 2.22 +/- 0.3 m/s (p = NS) at one year follow up for On-X and SJM HP valves, respectively. Maximum pressure gradients were 16.9 +/- 6.0 versus 18.5 +/- 8.0 mmHg (p = NS) postoperatively and 14.0 +/- 3.7 versus 16.5 +/- 5.7 mmHg (p = NS) at one year for the two valve types, respectively. A relatively pronounced transvalvular reflux was diagnosed for On-X valves. CONCLUSION: At one year after implantation, the On-X bileaflet prosthesis is equally suited for AVR in comparison with the 'standard' therapy (SJM HP). Exact sizing requires some experience. There were no significant differences between the two prostheses with regard to hemodynamic parameters either postoperatively or at one-year follow up. Long-term prospective randomized studies yet have to be carried out.

[Percutaneous tracheostomy with use of a laryngeal mask]. / Alternative Punktionstracheotomie mit Hilfe der Larynxmaske.

The percutaneous tracheostomy is a conventional procedure in patients undergoing long term ventilation on ICU. It both facilitates weaning and reduces the ventilation and tracheal tube associated risks.Usually the tracheostomy is accomplished via the tracheal tube. The alternative implies extubation and reinsertion of a laryngeal mask. This method itself affords a better overview for the bronchoscoping person accompanied by a lower risk for cuff or bronchoscope lesions. An accidental extubation as well as an injuring of the vocal cords (because of the inflated cuff during accidental extubation) appears impossible in this method.This paper gives a general survey on indication, contraindication, advantages and disadvantages of the percutaneous tracheostomy via laryngeal mask. We also described the procedure itself, step by step.

[Extracorporeal life support given to a 16-year-old girl with cystic fibrosis, candida pneumonia and acute respiratory distress syndrome]. / Extrakorporale Membranoxygenierung bei einer jungen Patientin mit ARDS durch eine Pilzpneumonie bei Mukoviszidose.

HISTORY: Small bowel resection had to be performed because of an acute ileus in a 16-year old girl with mucoviscidosis. Severe respiratory insufficiency developed and she was transferred to the intensive care unit. INVESTIGATIONS: The clinical signs of a severe ARDS were demonstrated: Horowitz index < 200, pO (2) 57 mm Hg, FiO (2) 1,0, pCO (2) 82 mm Hg. Candida serology was positive (titer 1 : 5120), and there was a leukocytosis (20 000/µl), hypalbuminemia (14 g/l) and elevation of C-reactive protein (190 mg/l). TREATMENT AND COURSE: Because all non invasive treatment options had failed to improve the patient's condition, an extracorporal membrane oxygenation (ECMO) device was connected. Seven days later, after the pulmonary situation had improved, the device was successfully removed; the patient was discharged in a satisfactory condition after another month. CONCLUSION: ECMO is a another treatment option for serious ARDS in infection-related worsening of pulmonary cystic fibrosis.

Impact of pressure recovery in the evaluation of the Omnicarbon tilting disc valve.

BACKGROUND: Pressure recovery is not taken into account when calculating trans-prosthetic gradients after mechanical valve replacement using Doppler echocardiography. This may lead to underestimation of valvular performance. METHODS: Simultaneous measurement of Doppler and direct trans-prosthetic gradients was performed in a circulatory mock loop simulator with physiologic parameters at different heart rates and cardiac outputs for small-sized aortic Omnicarbon tilting disc valves (19 - 21 mm). RESULTS: In all adjustments the Doppler gradient significantly overestimated the net transvalvular gradient. The amount of pressure recovery averaged 59.3 %. CONCLUSIONS: Doppler echocardiography does not allow for pressure recovery, which is a significant phenomenon in the hemodynamic function of the Omnicarbon tilting disc valve. Valve performance is much better than expected from Doppler gradients.

APOE alleles are not associated with calcific aortic stenosis.

OBJECTIVES: To analyse the association of APOE alleles with aortic stenosis (AS) in a large study population. METHODS: Patients with AS (n = 538) and a control group of the same age without heart disease (n = 536) were recruited. Left heart catheterisation was performed and mean gradient, aortic valve area, presence of stenotic coronary artery disease (CAD) and cardiovascular risk factors (hypercholesterolaemia, hypertension, smoking, diabetes mellitus and family history of CAD) were assessed. The frequency of the APOE major alleles e2, e3 and e4 was assessed by genotyping the polymorphisms APOE334 and APOE472 with a 5' exonuclease assay (TaqMan). RESULTS: Mean gradient across the aortic valve in cases was 50 (SD 20) mm Hg corresponding to a mean aortic valve area of 0.84 (SD 0.34) cm(2). 270 patients with AS had stenotic CAD. Among patients with AS, the prevalence of hypercholesterolaemia (64% v 40%, p < 0.001), smoking (43% v 27%, p < 0.001), diabetes (27% v 17%, p < 0.01), family history of CAD (30% v 21%, p 0.10). CONCLUSION: APOE e4 is not associated with AS, reflecting the different genetic backgrounds of CAD and AS.

Prospectively randomized evaluation of stentless versus conventional biological aortic valves: impact on early regression of left ventricular hypertrophy.

BACKGROUND: The aim of this prospectively randomized study was to evaluate left ventricular hypertrophy and its regression after stentless versus conventional biological aortic valve replacement. METHODS AND RESULTS: From March 1996 through April 1998, 180 patients were prospectively selected; 106 patients received a stentless aortic valve (SAV), and 74 received a conventional stented bioprosthesis (CSB). Of these patients, 95% and 96%, respectively, had aortic stenosis. Their mean age was 72.3 and 74.8 years, and there were no significant differences in left ventricular function, preoperative pressure gradients, and NYHA functional status. Aortic annulus diameter indexes were comparable at 13.46 (SAV) versus 13.55 (CSB) mm (P=NS). Larger SAVs were implanted because of the oversizing technique. In-hospital mortality (n=3 and 1 for SAV and CSB) was not valve related. At follow-up, all patients were in NYHA class 1 or 2. Baseline end-diastolic left ventricular posterior wall thickness was 15.6 (SAV) and 14.8(CSB) mm (P=NS) and decreased to 11. 8 (SAV) and 13.2 (CSB) mm (P<0.05) at 6 months. Left ventricular mass index was 213 and 202 g/m(2) at baseline (P=NS), whereas after 6 months, it was 141 (SAV) and 170 (CSB) g/m(2) (P<0.05). CONCLUSIONS: Regression of left ventricular hypertrophy occurs in all patients after aortic valve replacement but is significantly enhanced after SAV implantation. This possibly is due to improved transvalvular hemodynamics.

Quadrileaflet stentless mitral valve replacement.

BACKGROUND: The study evaluates clinical results and hemodynamic parameters one year after implantation of a stentless quadrileaflet mitral valve (QMV). METHODS: Since August 1997 28 patients received the QMV, patient age was 69 +/- 8 years; 13 had predominant mitral stenosis and 15 incompetence, preoperative NYHA functional class was III or IV and cardiac index 1.8 +/- 0.6 L/min/m2. RESULTS: Surgery was performed using a conventional (25) or a minimally invasive approach (3). 20 patients received a medium and 8 a large-size prosthesis, crossclamp time was 58 +/- 19 min. Additional procedures were myocardial revascularization in four, tricuspid repair in two, and left-atrial radiofrequency ablation to restore sinus rhythm in six patients. Perioperative mortality (1) was not valve-related. All other patients were discharged on time. At postoperative, 6-, and 12-months follow-up mean transvalvular pressure gradients were 4.2 +/- 1.5 / 4 +/- 0.9/ 3.8 +/- 1.4 mmHg and mitral valve orifice area index was 1.5 +/- 0.3 / 1.6 +/- 0.3 / 1.6 +/- 0.4, NYHA class was I or II. CONCLUSIONS: The QMV is well suited for mitral valve replacement. The anulo-ventricular continuity is preserved and the QMV function resembles native mitral valve function. If its performance is maintained in the long term the QMV may be the mitral prosthesis of choice.