Ergebnisse rekonstruktiver Operationsverfahren an der Aortenklappe

Die Aortenklappe ist aufgrund der hohen Druckverhältnisse im großen Kreislauf die Herzklappe, die am häufigsten von pathologischen und degenerativen Veränderungen betroffen ist. Zur Behandlung solcher Pathologien hat sich der Aortenklappenersatz mittels mechanischer oder biologischer Prothesen bereits bewährt. Allerdings ist dieses Verfahren mit diversen Limitationen, wie der Antikoagulation bzw. der begrenzten Haltbarkeit, behaftet. Ein Erhalt der nativen Aortenklappe führt neben der fehlenden Notwendigkeit für eine orale Antikoagulation mit Vitamin-K-Antagonisten, nicht nur zu den besten hämodynamischen Verhältnissen und zu geringeren klappenspezifischen Komplikationen, sondern auch zur vergleichbaren Freiheit von erneuten Operationen wie nach einem konventionellen Klappenersatz. Dieser rekonstruktive Operationsansatz ist vor allem anzustreben, wenn die Aortenklappe an sich nicht pathologisch verändert ist, sondern die zu behandelnde Insuffizienz allein durch ein Aneurysma der Aorta ascendens zustande kommt. Aber auch gering pathologisch veränderte Klappen müssen nicht zwangsläufig ersetzt werden. In unserer Studie verglichen wir Patienten, die einen alleinigen Aortenklappen-erhaltenden Ersatz der Aorta ascendens (David-Prozedur) erhielten mit Patienten, bei welchen zusätzliche Reparaturmanöver an den Klappenkuspen notwendig waren. Der Vergleich erfolgte sowohl hinsichtlich prä-, intra- und postoperativer Aspekte, als auch im Hinblick auf den mittelfristigen Verlauf. Neben der Funktionalität der Klappe wurde ebenfalls die Lebensqualität mit Hilfe einer modifizierten Version des SF-36-Fragebogens nach dem jeweiligen Eingriff betrachtet. Hierbei kamen wir zu den Ergebnissen, dass die reparativen Eingriffe an den Klappenkuspen bei ausgewählten Patienten zu sehr guten mittelfristigen Ergebnissen führen. Bei einer statistisch nicht signifikant längeren Operationsdauer (242,5 min vs. 245,3 min; p=0,721) konnten wir eine niedrige operative und Langzeitmortalität beobachten (5-Jahres-Freiheit kardialer Todesursachen 98%). Ebenso die 5-Jahres-Freiheit für eine Reoperation (96% vs. 89%; p=0,305) bzw. für das Auftreten einer erneuten höhergradigen Aortenklappeninsuffizienz (100% vs. 93%; p=0,110), fiel in der Gruppe mit den zusätzlichen Reparaturmanövern nicht signifikant niedriger aus. In den echokardiographischen Nachuntersuchungen konnte eine gute Funktionalität der Aortenklappen gezeigt werden. Die Lebensqualität wurde in dieser Patientengruppe besser bewertet. Dabei hatten Patienten, die zusätzlich noch über einen minimal invasiven Zugang operiert wurden, die höchste Lebensqualität. Eine Aortenklappenrekonstruktion sollte, auch mit zusätzlichen Reparaturschritten an den Klappenkuspen, durchgeführt werden, sofern die Patienten eine gute Qualität des Kuspengewebes aufweisen und eine Reparatur prinzipiell möglich erscheint. Auch Patienten, die einen oder gar mehrere zusätzliche kardiale Eingriffe benötigen, sollten an der Aortenklappe eine Rekonstruktion erhalten. Weiterhin sollte aus Gründen der Lebensqualität die Aortenklappenrekonstruktion über eine partielle Sternotomie erfolgen, um den Patienten eine schnelle Rekonvaleszenz zu ermöglichen

Integrated care for older multimorbid heart failure patients:protocol for the ESCAPE randomized trial and cohort study

ESCAPE Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients. Therapeutic Area Healthcare interventions for the management of older patients with multiple morbidities. Aims Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients. Hypothesis A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months. Methods Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan—customized to the patients' individual needs and preferences—into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months. Conclusions If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond

Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review

Background!#!The German hospital-to-home discharge management of geriatric patients has long been criticized. The implementation of the American Transitional Care Model (TCM) could help to reduce readmissions and costs. The objective of this review was to check the scientific evidence of the cost-effectiveness of the TCM.!##!Methods!#!A systematic literature search in six databases for the time period of 26 years was conducted. The studies had to meet all pre-defined inclusion criteria. The data extraction is based on a criteria chart from literature. The methodological quality was assessed using the tools of the National Heart, Lung, and Blood Institute as well as the Consensus Health Economic Criteria list. The results transferability to German health care system was explained based on the criteria from the literature.!##!Results!#!Three American studies met all criteria. They showed partial cost analyses but no full economic analyses. It could be assumed that the economic effect of the TCM changes over time. The costs of a care coordinator could not be determined because few detailed information was reported. The TCM may have negative consequences for hospitals. The results are not transferable to Germany.!##!Conclusion!#!There is no scientific evidence for the cost-effectiveness of the defined TCM. The optimal TCM duration still needs to be clarified. A detailed overview with units and prices and an additional consideration of the hospital perspective could help to make the information more transparent when deciding about the TCM implementation. A full economic analysis under German conditions or for similar European countries is necessary

Thirty-Eight-Negative Kinase 1 Is a Mediator of Acute Kidney Injury in Experimental and Clinical Traumatic Hemorrhagic Shock

Trauma represents a major socioeconomic burden worldwide. After a severe injury, hemorrhagic shock (HS) as a frequent concomitant aspect is a central driver of systemic inflammation and organ damage. The kidney is often strongly affected by traumatic-HS, and acute kidney injury (AKI) poses the patient at great risk for adverse outcome. Recently, thirty-eight-negative kinase 1 (TNK1) was proposed to play a detrimental role in organ damage after trauma/HS. Therefore, we aimed to assess the role of TNK1 in HS-induced kidney injury in a murine and apost hocanalysis of a non-human primate model of HS comparable to the clinical situation. Mice and non-human primates underwent resuscitated HS at 30 mmHg for 60 min. 5 h after the induction of shock, animals were assessed for systemic inflammation and TNK1 expression in the kidney.In vitro, murine distal convoluted tubule cells were stimulated with inflammatory mediators to gain mechanistic insights into the role of TNK1 in kidney dysfunction. In a translational approach, we investigated blood drawn from either healthy volunteers or severely injured patients at different time points after trauma (from arrival at the emergency room and at fixed time intervals until 10 days post injury; identifier: NCT02682550,). A pronounced inflammatory response, as seen by increased IL-6 plasma levels as well as early signs of AKI, were observed in mice, non-human primates, and humans after trauma/HS. TNK1 was found in the plasma early after trauma-HS in trauma patients. Renal TNK1 expression was significantly increased in mice and non-human primates after HS, and these effects with concomitant induction of apoptosis were blocked by therapeutic inhibition of complement C3 activation in non-human primates. Mechanistically,in vitrodata suggested that IL-6 rather than C3 cleavage products induced upregulation of TNK1 and impaired barrier function in renal epithelial cells. In conclusion, these data indicate that C3 inhibitionin vivomay inhibit an excessive inflammatory response and mediator release, thereby indirectly neutralizing TNK1 as a potent driver of organ damage. In future studies, we will address the therapeutic potential of direct TNK1 inhibition in the context of severe tissue trauma with different degrees of additional HS

Risk Factors for Hospitalization and Medical Intensive Care Unit (MICU) Admission Among HIV-Infected Veterans

OBJECTIVE: With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score. METHODS: We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002–2008. Data were obtained from the electronic medical record, VA administrative databases and patient questionnaires, and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization. RESULTS: 1141/3410 (33.5%) patients were hospitalized within 2 years; 203/1141 (17.8%) included a MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only) and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease and prior cancer predicted MICU admission. CONCLUSIONS: The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses

Longitudinal relationship between B-type natriuretic peptide and anxiety in coronary heart disease patients with depression

Objective: Patients with coronary heart disease (CHD) suffer from physical limitations, but also from psychological distress. Natriuretic peptides may be involved in the neurobiological processes that modulate psychological adaptation, as they are increased in heart disease and seem to have an anxiolytic-like function. Longitudinal data on this association are scarce. Methods: To assess the relationship between NT-proBNP and anxiety (Hospital Anxiety and Depression Scale (HADS)), we used secondary data from a multicenter trial from baseline to 24 months. Patients (N = 308, 80.8% male, mean age 60.1 years) had stable CHD and moderate levels of depression (HADS >= 8). Results: Multiple linear regression adjusted for age, sex, BMI, and physical functioning revealed NT-proBNP as a significant predictor for anxiety at baseline, 1, 6, 12, 18, and 24 months (all p < .05). Linear mixed model analysis with the six anxiety measures as level-1 variable and NT-proBNP as fixed factor revealed a significant time*NT-proBNP interaction (t(1535.99) = -2.669, p = .01) as well as a significant time*NT-proBNP*sex-interaction (1(1535.99) = 3.277, p = .001), when NT-proBNP was dichotomized into lowest vs. the three highest quartiles. Conclusion: Our results indicate a stable negative association of baseline NT-proBNP with anxiety over two years. In men and women, different pathways modulating this relationship appear to be in effect. Female patients with very low NT-proBNP levels, despite their cardiac disease, show persistently higher levels of anxiety compared to women with higher levels of NT-proBNP and compared to men