Reliability of prognostic biomarkers after prehospital extracorporeal cardiopulmonary resuscitation with target temperature management

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) performed at the emergency scene in out-ofhospital cardiac arrest (OHCA) can minimize low-flow time. Target temperature management (TTM) after cardiac arrest can improve neurological outcome. A combination of ECPR and TTM, both implemented as soon as possible on scene, appears to have promising results in OHCA. To date, it is still unknown whether the implementation of TTM and ECPR on scene affects the time course and value of neurological biomarkers. Methods: 69 ECPR patients were examined in this study. Blood samples were collected between 1 and 72 h after ECPR and analyzed for S100, neuron-specific enolase (NSE), lactate, D-dimers and interleukin 6 (IL6). Cerebral performance category (CPC) scores were used to assess neurological outcome after ECPR upon hospital discharge. Resuscitation data were extracted from the Regensburg extracorporeal membrane oxygenation database and all data were analyzed by a statistician. The data were analyzed using non-parametric methods. Diagnostic accuracy of biomarkers was determined by area under the curve (AUC) analysis. Results were compared to the relevant literature. Results: Non-hypoxic origin of cardiac arrest, manual chest compression until ECPR, a short low-flow time until ECPR initiation, low body mass index (BMI) and only a minimal need of extra-corporeal membrane oxygenation support were associated with a good neurological outcome after ECPR. Survivors with good neurological outcome had significantly lower lactate, IL6, D-dimer, and NSE values and demonstrated a rapid decrease in the initial S100 value compared to non-survivors. Conclusions: A short low-flow time until ECPR initiation is important for a good neurological outcome. Hypoxiainduced cardiac arrest has a high mortality rate even when ECPR and TTM are performed at the emergency scene. ECPR patients with a higher BMI had a worse neurological outcome than patients with a normal BMI. The prognostic biomarkers S100, NSE, lactate, D-dimers and IL6 were reliable indicators of neurological outcome when ECPR and TTM were performed at the emergency scene

Sleep-Disordered Breathing, Advanced Age, and Diabetes Mellitus Are Associated with De Novo Atrial Fibrillation after Cardiac Surgery

Background: Postoperative de novo atrial fibrillation (POAF) is one of the most frequently encountered complications following cardiac surgery. Despite the identification of several risk factors, the link between sleep-disordered breathing (SDB) and POAF has barely been examined. The objective of this prospective observational study was to determine whether severe SDB is associated with POAF in patients after elective coronary artery bypass grafting (CABG) surgery. Study design and methods: The incidence and preoperative predictors of in-hospital POAF were assessed in 272 patients undergoing CABG surgery at the University Medical Center Regensburg (Germany). In-hospital POAF was detected by continuous telemetry-ECG monitoring and 12-lead resting ECGs within the first seven postoperative days. POAF that occurred after hospital discharge within 60 days post CABG surgery was classified as post-hospital POAF and was ascertained by standardized phone interviews together with the patients’ medical files, including routinely performed Holter-ECG monitoring at 60 days post CABG surgery. The night before surgery, portable SDB monitoring was used to assess the presence and type of severe SDB, defined by an apnea–hypopnea index ≥ 30/h. Results: The incidence of in-hospital POAF was significantly higher in patients with severe SDB compared to those without severe SDB (30% vs. 15%, p = 0.009). Patients with severe SDB suffered significantly more often from POAF at 60 days post CABG surgery compared to patients without severe SDB (14% vs. 5%, p = 0.042). Multivariable logistic regression analysis showed that severe SDB (odds ratio, OR [95% confidence interval, CI]: 2.23 [1.08; 4.61], p = 0.030), age ≥ 65 years (2.17 [1.04; 4.53], p = 0.038), and diabetes mellitus (2.27 [1.15; 4.48], p = 0.018) were significantly associated with in-hospital POAF. After additional adjustment for heart failure, the association between sleep apnea and postoperative atrial fibrillation was attenuated (1.99 [0.92; 4.31], p = 0.081). Conclusions: Amongst established risk factors, severe SDB was significantly associated with in-hospital POAF in patients undergoing CABG surgery. Whether SDB contributes to POAF independently of heart failure and whether risk for POAF may be alleviated by proper treatment of SDB merits further investigation

Predictors of Nocturnal Hypoxemic Burden in Patients Undergoing Elective Coronary Artery Bypass Grafting Surgery

Nocturnal hypoxemia has been linked to increased cardiovascular morbidity and mortality. Several common diseases, such as sleep-disordered breathing (SDB), heart failure (HF), obesity, and pulmonary disease, coincide with an elevated nocturnal hypoxemic burden with and without repetitive desaturations. Research question: This study aimed to evaluate the association of relevant common diseases with distinctive metrics of nocturnal hypoxemic burden with and without repetitive desaturations in patients undergoing coronary artery bypass grafting surgery. Study design and methods: In this subanalysis of the prospective observational study, CONSIDER-AF (NCT02877745) portable SDB monitoring was performed on 429 patients with severe coronary artery disease the night before cardiac surgery. Pulse oximetry was used to determine nocturnal hypoxemic burden, as defined by total recording time spent with oxygen saturation levels < 90% (T90). T90 was further characterized as T90 due to intermittent hypoxemia (T90desaturation) and T90 due to nonspecific and noncyclic SpO2-drifts (T90non-specific). Results: Multivariable linear regression analysis identified SDB (apnea–hypopnea-index ≥ 15/h; B [95% CI]: 6.5 [0.4; 12.5], p = 0.036), obesity (8.2 [2.5; 13.9], p = 0.005), and mild-to-moderate chronic obstructive pulmonary disease (COPD, 16.7 [8.5; 25.0], p < 0.001) as significant predictors of an increased nocturnal hypoxemic burden. Diseases such as SDB, obesity and HF were significantly associated with elevated T90desaturation. In contrast, obesity and mild-to-moderate COPD were significant modulators of T90non-specific. Interpretation: SDB and leading causes for SDB, such as obesity and HF, are associated with an increased nocturnal hypoxemic burden with repetitive desaturations. Potential causes for hypoventilation syndromes, such as obesity and mild-to-moderate COPD, are linked to an increased hypoxemic burden without repetitive desaturations. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT02877745

Eine prolongierte Reanimation nach häuslichem Kollaps

Zusammenfassung Diese Kasuistik schildert eine prolongierte Reanimation eines 34-jahrigen Mannes nach Herz-Kreislauf-Stillstand im hauslichen Umfeld (out-of-hospital cardiac arrest, OHCA). Nach Kontaktaufnahme zu einem uberregionalen Krankenhaus der Maximalversorgung in 100km Entfernung und Anforderung eines ECMO-Teams per RTH konnte bei dem Patienten nach 88-minutiger Reanimation eine venoarterielle Kreislaufunterstutzung etabliert werden. Nach Verlegung des Patienten mit RTH konnte ein akuter Verschluss der rechten Koronararterie interventionell wieder eroffnet werden. Abstract This manuscript reports an out-of-hospital cardiac arrest case of a 34-year-old man at home with subsequent prolonged resuscitation. After request for an ECPR-team based at a university hospital over a 100km distance the patient could be stabilized by a veno-arterial ECLS system after an 88 minute resuscitation. After patient transfer to the hospital by helicopter, an acute occlusion of the right coronary artery could be reopened by interventional drug-eluting stent placement

Early postoperative blood pressure and blood loss after cardiac surgery: A retrospective analysis

Background: Increased blood loss after cardiac surgery is a risk factor for patient morbidity and mortality. Guidelines for postoperative haemodynamics management recommend normotensive blood pressure to avoid increased chest drain volumes. The aim of this study was to verify the correlation of early postoperative hypertension and blood loss in patients after cardiac surgery during the early postoperative period. Methods: Postoperative mean blood pressure values and chest drain volumes of 431 patients were registered by an intensive care monitoring system during first 60 minutes after intensive care admission. Correlation between blood pressure and blood loss was calculated by linear regression analysis. Results: In the entire patient cohort and in various subgroup analyses (body-mass-index, type of surgery, comorbidity, emergency surgery, preoperative anticoagulation therapy) no association between early mean blood pressure >80 mmHg and increased blood loss was evident in simple regression analysis. Merely, after aortic surgery a correlation of hypertension and blood loss was found. Multiple regression revealed postoperative INR values >1.5 and thrombocyte counts <100.000/nL to impact blood loss in contrast to postoperative hypertension. Conclusion: Evidence for strict blood pressure management to reduce blood loss after cardiac surgery is scarce. Instead, in face of higher INR and low thrombocytes increasing postoperative blood loss, achieving and maintaining a physiological coagulation is essential. (C) 2017 Elsevier Ltd. All rights reserved

Delayed cardiac tamponade after open heart surgery - is supplemental CT imaging reasonable?

Cardiac tamponade is a severe complication after open heart surgery. Diagnostic imaging is challenging in postoperative patients, especially if tamponade develops with subacute symptoms. Hypothesizing that delayed tamponade after open heart surgery is not sufficiently detected by transthoracic echocardiography, in this study CT scans were used as standard reference and were compared with transthoracic echocardiography imaging in patients with suspected cardiac tamponade. METHOD: Twenty-five patients after open heart surgery were enrolled in this analysis. In case of suspected cardiac tamponade patients underwent both echocardiography and CT imaging. Using CT as standard of reference sensitivity, specificity, positive and negative predictive values of ultrasound imaging in detecting pericardial effusion/hematoma were analyzed. Clinical appearance of tamponade, need for re-intervention as well as patient outcome were monitored. RESULTS: In 12 cases (44%) tamponade necessitated surgical re-intervention. Most common symptoms were deterioration of hemodynamic status and dyspnea. Sensitivity, specificity, positive and negative predictive values of echocardiography were 75%, 64%, 75%, and 64% for detecting pericardial effusion, and 33%, 83%, 50, and 71% for pericardial hematoma, respectively. In-hospital mortality of the re-intervention group was 50%. CONCLUSION: Diagnostic accuracy of transthoracic echocardiography is limited in patients after open heart surgery. Suplemental CT imaging provides rapid diagnostic reliability in patients with delayed cardiac tamponade

A decade of surgical therapy in an all-comer cohort with type A aortic dissection

BACKGROUND: We reported on a decade of aortic surgery for type A aortic dissection to assess surgical techniques employed and outcomes over time in an all-corner analysis of a mid-size university cardiosurgical center. METHODS: From 2009 to 2018, 283 patients (189 males and 94 females, mean age 62 years, range 30-85 years), who underwent surgical therapy for type A aortic dissection in our institution were included in a retrospective statistical analysis. RESULTS: Among all the patients, 55.5% of them were hemodynamically stable, 10.3% came in intubated. A neurological deficit was present in 18.9% of cases, extremity malperfusion was noted in 17.4%, and abdominal malperfusion detected in 8.2%. The extent of the aortic dissection corresponded to DeBakey type I in 88% of cases, a thoracoabdominal involvement was seen in 64%. In 51.9% of patients, only the ascending aorta replaced, another 40.6% of patients had proximal arch replacement too. A separate stent placement into the descending aorta was achieved in 13.4% of patients, during surgery (5.7%) or thereafter (7.7%). Overall survival to discharge was 79.5%. Most frequent complications were stroke and paralysis (15.2%). but only visceral malperfusion (OR 9.0) and heart failure mandating ECMO therapy (OR 29.5) were associated with significantly increased mortality. CONCLUSIONS: Surgery for type A aortic dissection is still challenging. Along with the refinement of surgical techniques, the indication for the various procedures has moved from a simplified general strategy to a more individualized concept

Outcome after veno‐venous extracorporeal membrane oxygenation in elderly compared to younger patients: A 14‐year retrospective observational study

Background The outcome after veno-venous extracorporeal membrane oxygenation in elderly patients is supposed to be unsatisfactory. Our primary aim was to determine the influence of advanced age on short- and long-term outcomes; the secondary aim was to analyze risk factors for impaired outcomes. Methods Between January 2006 and June 2020, 755 patients received V-V ECMO support at our department. Patients were grouped according to age (18–49.9, 50–59.9, 60–69.9, ≥70 years old), and then retrospectively analyzed for short- and long-term outcomes. Risk factors for in-hospital mortality and death during follow-up were assessed using multivariate regression analysis. Results Duration of V-V ECMO support was comparable between all groups median (8–10 days, p = 0.256). Likewise, the weaning rate was comparable in all age groups 68.2%–76.5%; (p = 0.354), but in-hospital mortality was significantly climbing with increasing age (<50 years 30.1%/n = 91 vs. 50–59.9 years 37.1%/n = 73, vs. 60–69.9 years 45.6%/n = 78 vs. ≥70 years 51.8%/n = 44; p < 0.001). Older age groups also showed significantly reduced cerebral performance category scores. The multivariate logistic analysis yielded age, acute and chronic hemodialysis, bilirubin on day 1 of support, malignancy, and primary lung disease as relevant risk factors for in-hospital mortality. Age, coronary artery disease, presence of another primary lung disease, malignancy, and immunosuppression were risk factors for death during follow-up. Conclusion In V-V ECMO patients, advanced age is associated with more comorbidity, impaired short- and long-term outcome, and worse neurological outcome