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Background Acute aortic dissection type A (AADA) is one of the most life-threatening situations and surgical demanding procedures even today. Usually AADA develops spontaneously, but it can be related also to interventional procedures. Methods We analyzed the data of 14 patients surgically treated in our institution with catheter-induced AADA (ciAADA) during coronary angiography between January 2004 and December 2014. Data were compared with overall AADA patients in this time period (n = 288). Results Nine of the 14 patients were female. Subjects were significantly older compared to the AADA patients (69 ± 11 vs. 62 ± 11; p = 0.021). At admission, ciAADA patients were more often hemodynamically instable and mechanically ventilated. Twelve patients underwent replacement of the ascending aorta and two patients received a modified Bentall operation. Cardiopulmonary bypass time (210 ± 92 vs. 172 ± 51 min) and cross-clamp time (122 ± 63 vs. 92 ± 40 min) were significantly longer due to additional coronary artery bypass grafts in 71.4 versus 3.1% due to myocardial ischemia. Operative mortality (7.1 vs. 2.1%, p = 0.29) and 30-day mortality (50.0 vs. 10.7%, p Conclusion Coronary angiography–induced AADA is a rare but severe complication. Due to additional myocardial ischemia and preoperative hemodynamic instability, patients with ciAADA have adverse outcome compared to overall AADA patients.

Timely and reliable distinction of sepsis from non-infectious systemic inflammatory response syndrome (SIRS) supports adequate antimicrobial therapy and saves lives but is clinically challenging. Blood transcriptional profiling promises to deliver insights into the pathomechanisms of SIRS and sepsis and to accelerate the discovery of urgently sought sepsis biomarkers. However, suitable reference genes for normalizing gene expression in these disease conditions are lacking. In addition, variability in blood leukocyte subtype composition complicates gene profile interpretation. Here, we aimed to identify potential reference genes in natural killer (NK) cells and granulocytes from patients with SIRS and sepsis on intensive care unit (ICU) admission. Discovery by a two-step probabilistic selection from microarray data followed by validation through branched DNA assays in independent patients revealed several candidate reference genes in NK cells including AKIRIN1, PPP6R3, TAX1BP1, and ADRBK1. Initially, no candidate genes could be validated in patient granulocytes. However, we determined highly similar AKIRIN1 expression also in SIRS and sepsis granulocytes and no change by in vitro LPS challenge in granulocytes from healthy donors. Inspection of external neutrophil transcriptome datasets further support unchanged AKIRIN1 expression in human systemic inflammation. As a potential new reference gene in NK cells and granulocytes in infectious and inflammatory diseases, AKIRIN1 may improve our pathomechanistic understanding of SIRS and sepsis and help identifying new sepsis biomarkers.

Intervention time plays a very important role for stroke outcome and affects different therapy paths. Automatic detection of an ischemic condition during emergency imaging could draw the attention of a radiologist directly to the thrombotic clot. Considering an appropriate early treatment, the immediate automatic detection of a clot could lead to a better patient outcome by reducing time-to-treatment. We present a two-stage neural network to automatically segment and classify clots in the MCA+ICA region for a fast pre-selection of positive cases to support patient triage and treatment planning. Our automatic method achieves an area under the receiver operating curve (AUROC) of 0:99 for the correct positive/negative classification on unseen test data.

Coronary bypass surgery (CABG) forms the majority of all cardiac surgical procedures. This is due to the high incidence of coronary vessel disease in the western nations and their ageing populations.

Coronary artery bypass grafting (CABG) has been established as a safe concept in the treatment of unprotected left main coronary artery (ULMCA) disease and is considered the first-line treatment in current interdisciplinary guidelines. Regardless of the complexity of the lesion and the concomitant diseases, CABG is associated with excellent long-term results. Randomized controlled trials investigating the role of percutaneous coronary intervention in the setting of ULMCA lesions are frequently underpowered and suggest that, when restricted to less complex lesions, percutaneous coronary intervention is associated with results comparable to surgery. Thus, there is an urgent need for further randomized controlled trials RCTs with all-comers design to supply precise data under real-life conditions representative of the left main stem anatomy. Until then, an interdisciplinary approach to patients with ULMCA lesions is mandatory in view of the existing guidelines.

Herzchirurgische Patienten werden immer alter und kranker. Fur den Erfolg einer Operation kommt daher, neben dem kardiochirurgischen Eingriff selbst, der postoperativen Intensivtherapie wachsende Bedeutung zu. Wir untersuchten das mittelfristige Outcome nach einem protrahierten postoperativen Intensivaufenthalt und welche perioperativen Faktoren mit einer ungunstigen Prognose assoziiert sind. Alle Patienten, die von Anfang 2000 bis Ende 2004 in unserer Klinik am Herzen operiert wurden und postoperativ 1 Woche und langer auf der herzchirurgischen Intensivstation behandelt werden mussten, wurden untersucht. Patienten mit komplexen angeborenen Herzfehlern oder nach Herz- oder Lungentransplantation wurden ausgeschlossen. Von 230 Patienten wurden 31 perioperative Variablen erfasst; das Follow-up erfolgte 1 Jahr postoperativ. Von den Patienten mit herzchirurgischem Eingriff benotigten 4,3% einen verlangerten Intensivaufenthalt. Die Einjahressterblichkeit der Langzeitlieger betrug 26,9%. Der starkste Pradiktor fur den Tod binnen des ersten postoperativen Jahres war das postoperative Nierenversagen mit der Notwendigkeit zur vorubergehenden Dialysebehandlung (Odds Ratio 4,98), gefolgt von der postoperativen Tracheotomie und praoperativ bekanntem Vorhofflimmern. Das mittelfristige Uberleben der untersuchten Patienten mit kompliziertem Verlauf nach einer Herzoperation ist erfreulich hoch. Die identifizierten Risikofaktoren fur eine schlechte Prognose konnen Ansatzpunkte fur weitere Therapieverbesserungen und generelle Therapieentscheidungen geben.

Background: Respiratory variations in plethysmographic waveform amplitudes derived from pulse oximetry are believed to predict fluid responsiveness. The non-invasive pleth variability index (PVI) is a variable based on the calculation of changes in the perfusion index (PI). The aim of the following study was to examine whether the predictive power of PVI depends on different values of PI. Methods: Eighty-one patients undergoing elective coronary artery surgery were studied before operation: at baseline after induction of anaesthesia and during passive leg raising (PLR). Each patient was monitored with central venous pressure (CVP), the PiCCO monitor and the non-invasive Masimo monitoring system. Stroke volume index by transpulmonary thermodilution (SVI(TPTD)), pulse pressure variation (PPV), stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured using the PiCCO monitoring system. PI and PVI were obtained by pulse oximetry. Results: Responders were defined to increase their SVI(TPTD) > 15 after PLR. The highest area under the curve (AUC) was found for PPV (AUC: 0.83, P

BACKGROUND: Minimized extracorporeal circulation is intended to reduce the negative effects associated with cardiopulmonary bypass. This prospective study was performed to evaluate whether minimized extracorporeal circulation has a clinical benefit for coronary artery surgery patients compared to standard extracorporeal circulation. METHODS: Sixty patients were randomized into two study groups: 30 patients underwent coronary artery bypass grafting using minimized extracorporeal circulation and 30 patients were operated using standard extracorporeal circulation. Baseline characteristics, intraoperative details, postoperative data, perioperative blood chemistry determinations of hematocrit, platelets, muscle-brain fraction of the creatine kinase, cardiac troponin T and colloid osmotic pressure as measurements of intrathoracic blood volume index and extravascular lung water index were compared. RESULTS: Baseline characteristics and intraoperative details of both groups were similar. Patients who underwent minimized extracorporeal circulation showed more short-term dependency on norepinephrine ( P > 0.01). Their maximal postoperative muscle-brain fraction of the creatine kinase was lower ( P > 0.05) and their hematocrit on arrival in the intensive care unit was higher ( P > 0.01). No other significant differences were found. In both collectives, values for hematocrit ( P > 0.001), platelets ( P > 0.001), colloid osmotic pressure ( P > 0.001) and intrathoracic blood volume index ( P > 0.05) decreased, while the extravascular lung water index did not change significantly during cardiopulmonary bypass. CONCLUSIONS: A clinical advantage of minimized over standard extracorporeal circulation was not found. Furthermore, a higher number of patients in the minimized extracorporeal circulation group required postoperative norepinephrine infusions for hemodynamic stabilization. In summary, the presumed superiority of minimized extracorporeal circulation for coronary artery bypass grafting in standard patients could not be confirmed.

Objectives Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients. Methods We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery. Results The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12). Conclusions Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Introduction Biological stented prostheses are currently the main type of prosthetic valve used for aortic valve replacement. The ratio of bioprotheses to mechanical prostheses has switched in the last 15 years; the percentage of biological prostheses implanted has risen from 30 % to 85 %. Moreover the total number of implanted stented bioprostheses remained stable over the last years despite competing procedures like stentless prostheses or transcatheter aortic valve implantation. Methods A literature search of all published aortic valve replacement studies was performed from January 2000 through May 2012. Results The recommendations guiding the type of heart valve replacement have been revised in recent years. Of particular interest are the new generation of biological prostheses with extended durability, a decrease in mortality of reoperation and an increase in life expectancy. Comorbidities such as chronic renal insufficiency or chronic atrial fibrillation are no longer contraindications to bioprostheses. Conclusion Overall, even in face of more innovative biological alternatives the implantation of stented bioprostheses is still a very interesting option and represents actually the most frequent valve implantation technique for aortic stenosis.

PLoS one 8(2), e56267 (2013). doi:10.1371/journal.pone.0056267, Published by PLoS [u.a.], Lawrence, Kan.

Uncalibrated semi-invasive continous monitoring of cardiac index (CI) has recently gained increasing interest. The aim of the present study was to compare the accuracy of CI determination based on arterial waveform analysis with transpulmonary thermodilution. Fifty patients scheduled for elective coronary surgery were studied after induction of anaesthesia and before and after cardiopulmonary bypass (CPB), respectively. Each patient was monitored with a central venous line, the PiCCO system, and the FloTrac/Vigileo-system. Measurements included CI derived by transpulmonary thermodilution and uncalibrated semi-invasive pulse contour analysis. Percentage changes of CI were calculated. There was a moderate, but significant correlation between pulse contour CI and thermodilution CI both before (r2=0.72,P<0.0001) and after (r2=0.62,P<0.0001) CPB, with a percentage error of 31% and 25%, respectively. Changes in pulse contour CI showed a significant correlation with changes in thermodilution CI both before (r2=0.52,P<0.0001) and after (r2=0.67,P<0.0001) CPB. Our findings demonstrated that uncalibrated semi-invasive monitoring system was able to reliably measure CI compared with transpulmonary thermodilution in patients undergoing elective coronary surgery. Furthermore, the semi-invasive monitoring device was able to track haemodynamic changes and trends.

The newly introduced Nexfin(®) device allows analysis of the blood pressure trace produced by a non-invasive finger cuff. We compared the cardiac output derived from the Nexfin and PiCCO, using transcardiopulmonary thermodilution, during cardiac surgery. Forty patients with preserved left ventricular function undergoing elective coronary artery bypass graft surgery were studied after induction of general anaesthesia and until discharge to the intensive care unit. There was a significant correlation between Nexfin and PiCCO before (r(2) = 0.81, p0.001) and after (r(2) = 0.56, p0.001) cardiopulmonary bypass. Bland-Altman analysis demonstrated the mean bias of Nexfin to be -0.1 (95% limits of agreement -0.6 to +0.5, percentage error 23%) and -0.1 (-0.8 to +0.6, 26%) l.min(-1).m(-2), before and after cardiopulmonary bypass, respectively. After a passive leg-raise was performed, there was also good correlation between the two methods, both before (r(2) = 0.72, p0.001) and after (r(2) = 0.76, p0.001) cardiopulmonary bypass. We conclude that the Nexfin is a reliable method of measuring cardiac output during and after cardiac surgery.

Objectives: Median sternotomy is still the main access for cardiac surgery. Despite the “gold” standard of closing the sternum using single steel wires, there are tremendous different sternum closure systems available (“clips”, “screws and plates”, etc.). We present our experience with the ZipFix sternal closure system (Synthes) for primary sternal closure and a video how to use it. The ZipFix system is a biocompatible zip tie (polyetheretherketon) with a large area of contact between the zip and the sternum with an increase of carrying capacity and sternal stability. The technique for sternal closure is almost similar to using single steel wires. Methods: Between May 2011 and September 2011 twenty consecutive patients were operated on CABG (coronary artery bypass grafting) and CABG combined with AVR (aortic valve replacement) using the ZipFix sternal closure system (Synthes). Results: All primary sternal closures were successful using the ZipFix sternal closure system (Synthes) (figure 1). Eleven patients received only the ZipFix sternal closure system while in nine patients additional steel wires were used for the manubrium sterni. The mean age was 78.0 years for eight female patients with a mean BMI of 28.5 and 70.5 years for twelve male patients with a mean BMI of 28.7, respectively. Only one patient received a superficial site wound infection postoperatively. The sternal closure time was slightly extended by approximately 5 minutes compared to standard technique. The costs for this new sternal closure device are twofold compared to steel wires. Conclusions: The ZipFix system (Synthes) is a new, safe and easy to use sternal closure system with a large area of contact between the zip and the sternum to increase sternal stability. A combination of steel wires and the ZipFix system is possible for sternal closure. In future, we will use the ZipFix system for primary sternal closure in high risk patients for postoperative sternal wound complications.

The ability of the global end-diastolic volume index (GEDVI) and respiratory variations in left ventricular outflow tract velocity (ΔVTI(LVOT)) for prediction of fluid responsiveness is still under debate. The aim of the present study was to challenge the predictive power of GEDVI and ΔVTI(LVOT) compared with pulse pressure variation (PPV) and stroke volume variation (SVV) in a large patient population.Ninety-two patients were studied before coronary artery surgery. Each patient was monitored with central venous pressure (CVP), the PiCCO system (Pulsion Medical Systems, Munich, Germany), and transesophageal echocardiography. Responders were defined as those who increased their stroke volume index by greater than 15% (ΔSVI(TPTD)15%) during passive leg raising.Central venous pressure showed no significant correlation with ΔSVI(TPTD) (r = -0.06, P = .58), in contrast to PPV (r = 0.71, P.0001), SVV (r = 0.61, P.0001), GEDVI (r = -0.54, P.0001), and ΔVTI(LVOT) (r = 0.54, P.0001). The best area under the receiver operating characteristic curve (AUC) predicting ΔSVI(TPTD) greater than 15% was found for PPV (AUC, 0.82; P.0001) and SVV (AUC, 0.77; P.0001), followed by ΔVTI(LVOT) (AUC, 0.74; P.0001) and GEDVI (AUC, 0.71; P = .0006), whereas CVP was not able to predict fluid responsiveness (AUC, 0.58; P = .18).In contrast to CVP, GEDVI and ΔVTI(LVOT) reliably predicted fluid responsiveness under closed-chest conditions. Pulse pressure variation and SVV showed the highest accuracy.

Respiratory variations in plethysmographic waveform amplitudes derived from pulse oximetry are believed to predict fluid responsiveness. The non-invasive pleth variability index (PVI) is a variable based on the calculation of changes in the perfusion index (PI). The aim of the following study was to examine whether the predictive power of PVI depends on different values of PI.Eighty-one patients undergoing elective coronary artery surgery were studied before operation: at baseline after induction of anaesthesia and during passive leg raising (PLR). Each patient was monitored with central venous pressure (CVP), the PiCCO monitor and the non-invasive Masimo monitoring system. Stroke volume index by transpulmonary thermodilution (SVI(TPTD)), pulse pressure variation (PPV), stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured using the PiCCO monitoring system. PI and PVI were obtained by pulse oximetry.Responders were defined to increase their SVI(TPTD)15% after PLR. The highest area under the curve (AUC) was found for PPV (AUC: 0.83, P0.0001) and SVV (AUC: 0.72, P=0.002), in contrast to PVI (AUC: 0.60, P=0.11) and CVP (AUC: 0.60, P=0.13). The accuracy of PVI to predict fluid responsiveness was improved on analysing patients with higher PI values. PI of about 4% (n=45) achieved statistical significance (AUC: 0.72, P=0.01).The PVI was not able to predict fluid responsiveness with sufficient accuracy. In patients with higher perfusion states, the PVI improved its ability to predict haemodynamic changes, strongly suggesting a relevant influence of the PI on the PVI.

The number of patients of advanced age and with severe comorbidities undergoing cardiac surgery is rising. Therefore, in addition to the cardiac surgery procedure itself, postoperative intensive care treatment plays an increasingly important role. The mid-term outcome of patients with postoperative long-term stays in intensive care and perioperative risk factors for an adverse outcome have not been sufficiently evaluated.All patients who underwent cardiac surgery in our institution between 2000 and 2004 and who required intensive care treatment on our cardiac surgery intensive care unit for at least 1 week were analyzed. Patients who received heart or lung transplantation or surgery for congenital heart failure were excluded. A total of 31 perioperative variables were evaluated for 230 patients. Follow-up was performed 1 year postoperatively.In all, 4.3% of our patients required a prolonged stay in intensive care following cardiac surgery. Overall 1-year mortality among patients with a long-term stay in intensive care was 26.9%. The logistic regression identified postoperative renal failure requiring dialysis (OR 4.98) as the strongest predictor for mortality within the first year after surgery, followed by postoperative tracheotomy and preoperatively known atrial fibrillation.Mid-term survival among patients who underwent cardiac surgery followed by a complicated postoperative course is encouragingly high. The risk factors identified for an adverse prognosis may be helpful in improving therapy strategies and general therapy decision-making.

Die koronare Herzkrankheit (KHK) ist die Manifestation der Atherosklerose an den Herzkranzgefasen. Die damit einhergehenden Verengungen der Koronarien fuhren zu einem verminderten koronaren Blutfluss und dadurch zur Myokardischamie bis hin zum Infarkt. Neuere Untersuchungen konnten zeigen, dass fur die Krankheitsentstehung neben denbekannten Risikofaktoren auchbesonders genetische Faktoren ursachlich sind (Samani et al. 2007).

The quality of ICU treatment is very important with regard to the outcome of patients requiring prolonged ICU stay following cardiac surgery. We conducted an internal quality survey and observed a one-year survival rate of almost 75 % after protracted ICU stay. In order to optimize the quality we identified pulmonary hypertension and prolonged mechanical ventilation as predictors for an adverse outcome. According to our findings the risk for a prolonged postoperative course is higher in patients with impaired renal function and in patients undergoing complex procedures. In these patients preoperative right heart catheterization should be performed without exception. If treatment of high pulmonary resistance leads to a benefit in terms of survival should be a matter of future investigations. There are several causes which may lead to prolonged mechanical ventilation and most of them can hardly be affected. It is known that the application of CPB impairs the respiratory function. Own studies demonstrated that the utilization of a minimized CPB does not lead to shorter ventilation times. Since there is no promising approach to reduce ventilation time by standardized means, early extubation remains the main measure. It is a long and stony way to implement quality standards on the basis of quality surveys. Finding an effective approach to optimize quality is often difficult. However, discouragement has to be avoided at al costs, since the continuous endeavor after quality and improvement of quality are basic requirements of medical progress.