CSA-Induced PRES after Heart Transplantation-Report of Two Cases and Review

Background  Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease possibly associated with the use of calcineurin inhibitors (CNI) like cyclosporine A. Case Description  The case of a patient who developed severe PRES under CNI therapy shortly after heart transplantation is presented here. Cerebral computed tomography led to the diagnose of PRES in our patient. New therapy strategy with a quadruple immunosuppressive protocol (cortisone, mycophenolate mofetil, low-dose CNI, and a mechanistic target of rapamycin inhibitor) was started. Conclusion  Under the quadruple therapy, a neurologic recovery occurred. In PRES, the presented alternative therapy strategy may lead to improving neurological conditions and preserved transplant organ functions

Minimized extracorporeal circulation is improving outcome of coronary artery bypass surgery in the elderly

Advanced age is a known risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Minimized extracorporeal circulation (MECC) has been shown to reduce the negative effects associated with conventional extracorporeal circulation (CECC). This trial assesses the impact of MECC on the outcome of elderly patients undergoing CABG. Eight hundred and seventy-five patients (mean age 78.35 years) underwent isolated CABG using CECC (n=345) or MECC (n=530). The MECC group had a significantly shorter extracorporeal circulation time (ECCT), cross-clamp time and reperfusion time and lower transfusion needs. Postoperatively, these patients required significantly less inotropic support, fewer blood transfusions, less postoperative hemodialysis and developed less delirium compared to CECC patients. In the MECC group, intensive care unit (ICU) stay was significantly shorter and 30-day mortality was significantly reduced [2.6% versus 7.8%; p<0.001]. In conclusion, MECC improves outcome in elderly patients undergoing CABG surgery

Preoperative Predictors of Adverse Clinical Outcome in Emergent Repair of Acute Type A Aortic Dissection in 15 Year Follow Up

Background Acute type A aortic dissection (AAAD) has high mortality. Improvements in surgical technique have lowered mortality but postoperative functional status and decreased quality of life due to debilitating deficits remain of concern. Our study aims to identify preoperative conditions predictive of undesirable outcome to help guide perioperative management. Methods We performed retrospective analysis of 394 cases of AAAD who underwent repair in our institution between 2001 and 2018. A combined endpoint of parameters was defined as (1) 30-day versus hospital mortality, (2) new neurological deficit, (3) new acute renal insufficiency requiring postoperative renal replacement, and (4) prolonged mechanical ventilation with need for tracheostomy. Results Total survival/ follow-up time averaged 3.2 years with follow-up completeness of 94%. Endpoint was reached by 52.8%. Those had higher EuroSCORE II (7.5 versus 5.5), higher incidence of coronary artery disease (CAD) (9.2% versus 3.2%), neurological deficit (ND) upon presentation (26.4% versus 11.8%), cardiopulmonary resuscitation (CPR) (14.4% versus 1.6%) and intubation (RF) before surgery (16.9% versus 4.8%). 7-day mortality was 21.6% versus 0%. Hospital mortality 30.8% versus 0%. Conclusions This 15-year follow up shows, that unfavorable postoperative clinical outcome is related to ND, CAD, CPR and RF on arrival

Early results of coronary artery bypass grafting with coronary endarterectomy for severe coronary artery disease

<p>Abstract</p> <p>Background</p> <p>Despite the existence of controversial debates on the efficiency of coronary endarterectomy (CE), it is still used as an adjunct to coronary artery bypass grafting (CABG). This is particularly true in patients with endstage coronary artery disease. Given the improvements in cardiac surgery and postoperative care, as well as the rising number of elderly patient with numerous co-morbidities, re-evaluating the pros and cons of this technique is needed.</p> <p>Methods</p> <p>Patient demographic information, operative details and outcome data of 104 patients with diffuse calcified coronary artery disease were retrospectively analyzed with respect to functional capacity (NYHA), angina pectoris (CCS) and mortality. Actuarial survival was reported using a Kaplan-Meyer analysis.</p> <p>Results</p> <p>Between August 2001 and March 2005, 104 patients underwent coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) in the Department of Thoracic-, Cardiac- and Vascular Surgery, University of Goettingen. Four patients were lost during follow-up. Data were gained from 88 male and 12 female patients; mean age was 65.5 ± 9 years. A total of 396 vessels were bypassed (4 ± 0.9 vessels per patient). In 98% left internal thoracic artery (LITA) was used as arterial bypass graft and a total of 114 vessels were endarterectomized. CE was performed on right coronary artery (RCA) (n = 55), on left anterior descending artery (LAD) (n = 52) and circumflex artery (RCX) (n = 7). Ninety-five patients suffered from 3-vessel-disease, 3 from 2-vessel- and 2 from 1-vessel-disease. Closed technique was used in 18%, open technique in 79% and in 3% a combination of both. The most frequent endarterectomized localization was right coronary artery (RCA = 55%). Despite the severity of endstage atherosclerosis, hospital mortality was only 5% (n = 5). During follow-up (24.5 ± 13.4 months), which is 96% complete (4 patients were lost caused by unknown address) 8 patients died (cardiac failure: 3; stroke: 1; cancer: 1; unknown reasons: 3). NYHA-classification significantly improved after CABG with CE from 2.2 ± 0.9 preoperative to 1.7 ± 0.9 postoperative. CCS also changed from 2.4 ± 1.0 to 1.5 ± 0.8</p> <p>Conclusion</p> <p>Early results of coronary endarterectomy are acceptable with respect to mortality, NYHA & CCS. This technique offers a valuable surgical option for patients with endstage coronary artery disease in whom complete revascularization otherwise can not be obtained. Careful patient selection will be necessary to assure the long-term benefit of this procedure.</p

Acute aortic dissection type A discloses Corpus alienum

We report an unusual case of an aortic type A dissection with a corpus alienum which compresses the right ventricle. The patient successfully underwent an aortic root replacement in deep hypothermia with re-implantation of the coronary arteries using a modified Bentall procedure and the resection of the corpus alienum. Intraoperative finding reveals 3 greatly adhered gauze compresses, which were most likely forgotten in the operation 34 years ago

Early results of coronary artery bypass grafting with coronary endarterectomy for severe coronary artery disease

Die Atherosklerose gewinnt in den westlichen Industrienationen als Krankheitsbild multifaktorieller Genese mit seinen unterschiedlichen Ausprägungen zunehmend an Bedeutung. Im Jahre 2005 mussten sich mehr als 67.000 Patienten in Deutschland einer ACB-Operation unterziehen. In dieser klinischen, monozentrischen und retrospektiven Studie wurden 104 Patienten mit schwerster diffuser koronarer Herzkrankheit (KHK) in dem Zeitraum zwischen August 2001 und Marz 2005 in der Klinik für Thorax-, Herz- und Gefäßchirurgie der Universitätsmedizin Göttingen (Direktor Prof. Dr. Dipl.-Phys. F. A. Schöndube), einer aortokoronaren Bypass-Operation (ACB) mit zusätzlicher koronarer Thrombendarteriektomie (TEA) von mindestens einer Koronararterie unterzogen. Der Beobachtungszeitraum (Follow-up) dieser Untersuchung betrug insgesamt 48,8 Monate und war für insgesamt 100 Patienten, dies entsprach 96%, vollständig. Insgesamt wurden in 100 Operationen 399 arterielle und/oder venöse Bypässe (Grafts) angelegt. Dies entsprach im Mittel 4 (±0,9) Bypässen pro Patient. In 97% aller Operationen wurde die linke Arteria mammaria interna (IMA) verwendet; dies machte einen Anteil von 25,3% aller gelegten Grafts aus. Trotz der Schwere der vorliegenden koronaren Atherosklerose lag die Krankenhaus-Letalität (30-Tage) bei nur 5% (n=5). Während des Beobachtungszeitraumes (Follow-up), der zu 96% vollständig war (vier Patienten gingen während der Studie aufgrund von Umzug und dadurch neuen, unbekannten Adressen verloren ), starben acht weitere Patienten. Alle Verstorbenen, bis auf eine Ausnahme, waren männlichen Geschlechts. Die durchschnittliche Überlebenszeit betrug für die gesamte Kohorte 24,5 (± 13,4) Monate. Gemäß der Einteilung der Canadian-Cardiovascular-Society (CCS) veränderte sich der Mittelwert signifikant von präoperativ 2,4 (± 1,0) auf postoperativ 1,5 (± 0,8). Die Patienten verbesserten sich ebenfalls bezüglich der NYHA-Klassifizierung: präoperativ errechnete sich ein Mittelwert von 2,2 (± 0,9), der sich postoperativ auf 1,7 (± 0,9) signifikant verbesserte. Gemessen am präoperativen Gesundheitszustand der Patienten erscheint dieses Verfahren als letzte Möglichkeit, um im Alltag wieder Fuß fassen zu können. Nichtsdestotrotz müssen in diesem Sektor weitere Untersuchungen angetrieben werden, um die bisher unbekannten Langzeitergebnisse aufdecken zu können

Impact of Elevated Donor Troponin I as Predictor of Adverse Outcome in Adult Heart Transplantation: A Single-center Experience

Background Due to globally increasing donor organ shortage, investigation of previously described risk factors for utilizing marginal donor hearts is needed. The aim of this study was to determine the impact of elevated donor serum troponin I (TnI) levels on outcome after heart transplantation (HTx). Methods Between January 1996 and August 2013, 161 patients were reviewed for donor TnI serum levels (>0.3 ng/mL was considered elevated), postoperative outcome parameters, 30-day mortality, and 1-, 3-, and 5-year survival. Results TnI levels were elevated in 45 (28.0%) donors. Recipients of hearts with elevated TnI had higher incidence of postoperative systolic dysfunction, prolonged inotropic support, prolonged mechanical ventilation, and longer intensive care unit (ICU) stay ( p <0.001). This group had higher 30-day mortality (22.2% vs 8.6%, p =0.03) and lower 1-, 3-, and 5-year survival (56%, 53%, and 50% versus 82%, 76%, and 69%, p =0.032). Elevated TnI was the only independent risk factor for 30-day mortality (odds ratio [OR] 3.63, 95% confidence interval [CI] 1.28-10.27, p =0.015). Conclusions Elevated donor TnI serum concentration seems to be a marker for adverse outcome and increased short- and long-term mortality after HTx. Nevertheless, many other perioperative variables and parameters can be associated with outcome

Patients under Psychiatric Medication Undergoing Cardiac Surgery Have a Higher Risk for Adverse Events

Objective The percentage of patients undergoing cardiac surgery under some sort of psychiatric medication (PM) is not negligible. Thus, this study aimed to evaluate a possible impact of preoperative PM on the outcome after cardiac surgery. Methods A matched case-control study was conducted by including all patients who underwent myocardial revascularization and/or surgical valve operation in our institution from December 2008 till February 2011 by chart review and institutional quality assurance database (QS) analysis. Results Out of 1,949 patients included, 184 patients (9%) were identified with PM medication (group A). A control group matched for logistic EuroSCORE II, ejection fraction and age was generated (group C). Patients with PM were in mean significantly longer on the intensive care unit (A: 4.94 days; 95% confidence interval (CI), 3.9-5.9 days vs. C: 3.24 days; CI, 2.84-3.64 days; p = 0.003), had longermechanical ventilation times (A: 36.70 hours; CI, 19.81-53.59 hours vs. C: 20.14 hours; CI, 14.61-25.68 hours; p = 0.258), and significantly more episodes of respiratory insufficiencies (A: 31 episodes [17%] vs. C: 17 episodes [9%]; p = 0.002). Regression analysis revealed preoperative PM as a significant risk factor for respiratory insufficiency (odds ratio: 1.99, CI: 1.0-3.74; p = 0.04). Chest tube drainage (A: 690 mL, CI: 571-808 mL vs. C: 690 mL; CI: 496-884 mL, p = 0.53) and the total amount of red blood cell transfusion units were similar (A: 1.69 units; CI: 1.21-2.18 units vs. C: 1.50 units; CI: 1.04-1.96 units; p = 0.37). Sternal dehiscence requiring sternal refixation was significantly more frequent in A (12 patients [7%] vs. C: 2 patients [1%]; odds ratio: 6.3, CI: 1.4-28.7; p = 0.01). The 30-day mortality was similar in both groups (A: 6 patients [3%] vs. C: 4 patients [2%]; odds ratio: 1.5; CI: 0.4-5.4; p = 0.5); however, the 100-daymortality was near significantly higher in group A (A: 14 patients (8%) vs. C: 6 patients (3%); odds ratio: 2.4, CI: 0.9-6.5, p =0.057). Conclusion Patients with preoperative PM developed complications more frequently compared with a matched control group. The underlying multifactorial mechanisms remain unclear. Patients under PM need to be identified and particular care including optimal pre-and postoperative psychiatric assistance is recommended

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