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BackgroundRemote extracorporeal life support (ECLS) implantation and mobile ECLS are increasingly applied to enable the treatment of patients with refractory heart failure at specialized care centers. Giant left atrium (GLA) is a rare cause but may lead to acute and devastating heart failure.Case reportAcute heart failure that gave rise to a prolonged period of out-of-hospital cardiopulmonary resuscitation in a patient who underwent remote ECLS implantation was found to have resulted from a GLA of impressive dimensions. There having no reasonable option for immediate surgical therapy, the patient was successfully bridged to recovery with a view to subsequent heart transplantation.ConclusionsThe threshold to rapid institution of ECLS should be low in patients with acute refractory heart failure, including those with uncommon pathologies. Remote ECLS implantation and interhospital transfer on mobile ECLS increase the chances of survival in cases requiring treatment by specialized care centers.

We present a T-shaped transseptal approach for mitral valve surgery that makes adequate exposure possible under challenging anatomic and surgical circumstances, hence eliminating the need for forceful retraction on potentially fragile tissues. Particularly suited for patients with complex mitral pathology, it also facilitates juxta-annular transseptal right atrial anchoring, especially in cases of endocarditic anterior mitral annular destruction.

Transfemoral aortic valve replacement (TAVR) has become a standard therapeutic option for patients with symptomatic severe aortic stenosis. Special anatomies can pose distinct challenges for vascular access and later closure of the access site, for example, in preoperated patients. Here, we elucidate a case of transfemoral TAVR with vascular access by direct puncture of an aorto-bifemoral bypass graft and illustrate the feasibility of vascular closure by an anchored collagen-plug vascular closure device (Teleflex MANTA® ).

BACKGROUND: The main aim of our study was to compare the results and value of angiography and multi-slice computed tomography (MSCT) after coronary artery bypass grafting using complex arterial conduit combinations. METHODS: Twenty-six patients underwent coronary surgery. In all patients, we utilized a T-graft (free arterial graft centrally implanted into the left internal thoracic artery IN SITU). Postoperative coronary angiography and MSCT were carried out prior to discharge. The results were interpreted separately by two different investigators. RESULTS: One hundred and thirteen distal anastomoses using 59 grafts for T-graft combinations were performed in 26 patients. A mean of 3.5 peripheral anastomoses was established per patient. Angiography showed a bypass graft patency rate of 94.6 % (56/59). In angiography, the patency rate of anastomoses was 96.5 % (109/113). All occlusions were identified in sequential anastomoses. The bypass patency rate measured by MSCT was 100 % and the patency rate of anastomoses 100 %. Based on these results, MSCT showed a sensitivity of 98.9 %. The specificity was 50.8 %, the positive predictive value was 94.6 % and the negative predictive value had a level of 99.9 %. CONCLUSION: MSCT is a simple, less invasive and useful method of monitoring results after coronary surgery including anastomosis and graft patency after complex arterial grafts. Its value may be restricted for sequential anastomoses and angiography should be preferentially used in these cases.

BACKGROUND In search of sensitive and specific markers of systemic infection procalcitonin (PCT) recently was promoted to the focus of clinical research. Little is known about the biology of PCT and until now no data have been presented about clinical importance of PCT in obstetric patients. PATIENT AND METHODS Daily PCT values in a 17 year old patient with septic abortion were compared with established markers of systemic inflammation. Cultivated monocytes were analyzed by the means of indirect immunofluorescence for intracellular distribution of PCT. Additionally, PCT release into culture medium was examined. RESULTS PCT values in comparison with established inflammation markers was demonstrated in the patient with septic abortion. Indirect immunofluorescence studies revealed the presence of PCT within monocytes. In the supernatants of monocyte cultures PCT was detectable under control conditions. Stimulation with lipopolysaccharide resulted in the increased PCT concentrations both in the supernatants of healthy and patient monocyte cultures. CONCLUSIONS In the given patient PCT was superior to other inflammation markers with regard to early and progression diagnosis. Peripheral blood monocytes appear to be a potential site of inflammation-induced PCT production. For the first time intracellular distribution pattern and release of PCT from human monocytes was described. DISCUSSION Based on the presented data broad clinical studies devoted to PCT evaluation in obstetric patients seem to be promising. As till now the interpretation of increased PCT values depended on empirical knowledge, extensive studies of the potential production site as well as its biological significance should be performed, too.

Objectives To determine correlations and predictive strength of surrogate markers (body temperature, leukocyte count, C-reactive protein [CRP], and procalcitonin [PCT]) with elevated levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in septic patients. Design Prospective consecutive case series. Setting Surgical intensive care unit (ICU) of a university hospital. Patients A total of 175 patients experiencing intensive care unit stays >48 hrs categorized for sepsis according to ACCP/ SCCM Consensus Conference criteria. Measurements and main results CRP and PCT were both significantly correlated with TNF-alpha and IL-6. Based on the area-under-the-curve of the receiver operating characteristics curves, predicting capability was highest for PCT (0.814 for TNF-alpha >40 pg/mL and 0.794 for IL-6 >500 pg/mL), moderate with CRP (0.732 and 0.716, respectively), and lowest for leukocyte count (0.493 and 0.483, respectively) and body temperature (0.587 and 0.589, respectively). Sensitivity, specificity, positive, and negative predictive values and test effectiveness all followed this same pattern of being highest for PCT followed by CRP, with leukocyte count and body temperature being lowest. Conclusion PCT may be an early and better marker of elevated cytokines than the more classic criteria of inflammation.

Prokalzitonin ist ein Propeptid von Kalzitonin. Bei Gesunden ist Prokalzitonin mit kommerziellen Tests im Blut nicht nachweisbar, seine Konzentration steigt aber bei schweren generalisierten bakteriellen, parasitaren und pilzbedingten Infektionen stark an. Bei lokal begrenzten Infektionen, bei viralen Infekten oder bei nichtinfektiosen inflammatorischen Erkrankungen steigt die Prokalzitoninkonzentration nicht oder nur gering an. Der Prokalzitoninspiegel steigt mit zunehmendem Schweregrad einer generalisierten Infektion an. Daher eignet sich Prokalzitonin als diagnostischer Parameter zur Differentialdiagnose und Verlaufskontrolle schwerer inflammatorischer Zustande. Bei Gesunden wird Prokalzitonin in den C-Zellen der Schilddruse produziert, bei Patienten mit schweren Infektionen werden andere Syntheseorte fur die hohen Prokalzitoninwerte verantwortlich gemacht. Die enge Assoziation mit anderen Mediatoren der Inflammation und eine erste tierexperimentelle Studie lassen vermuten, das Prokalzitonin als Mediator im Rahmen einer inflammatorischen Antwort auf eine Infektion bedeutsam ist. Weitere Studien sind notwendig, um den Bildungsort und die pathophysiologische Rolle dieses Parameters bei schweren Infektionen besser zu verstehen.

Procalcitonin (PCT), the precursor of calcitonin, was recently put forward as a diagnostic marker of systemic bacterial infection and sepsis. The major PCT production site in sepsis still remains unclear. Because of a certain association between increased levels of PCT and leukocyte-derived cytokines during sepsis, we assessed the possible expression of PCT in human peripheral blood mononuclear cells (PBMCs) and the modulation of PCT by lipopolysaccharides (LPS) and various sepsis-related cytokines by reverse transcriptase-polymerase chain reaction (RT-PCR) by using a novel primer set and flow cytometric analysis with intracellular staining with antibodies to the PCT components calcitonin and katacalcin. RT-PCR and flow cytometric analysis demonstrated that PBMCs express PCT both on mRNA and on protein levels. LPS and various proinflammatory cytokines (interleukin-1beta (IL-1beta), IL-6, tumor necrosis factor-alpha (TNF-alpha), IL-2) had pronounced stimulatory effects on the expression of PCT mRNA. Under identical experimental conditions the anti-inflammatory cytokine IL-10 had no effect on the expression of mRNA for PCT. Flow cytometric analysis demonstrated increased intracellular amounts of PCT components after LPS stimulation. Thus we demonstrate for the first time that PCT is expressed in PBMCs. This expression is modulated by bacterial LPS and sepsis-related cytokines. Therefore PBMCs may be among the sources of elevated PCT levels in patients with sepsis.

Wir berichten uber erste klinische Erfahrungen mit PCT bei Kindern mit hamolytisch-uramischem Syndrom (HUS) unter besonderer Berucksichtigung von Umgebungsuntersuchungen im Rahmen zweier HUS-Erkrankungen in einer kleinen Gemeinde bei Munchen im Winter 1997.

Objective: To compare the respiratory burst of neutrophils in sepsis and control patients using lipopolysaccharide (LPS), autologous plasma, and a combination of the two. Design: Prospective, consecutive case study. Setting: A 16-bed intensive care unit (ICU) in a university teaching hospital. Interventions: None. Patients: Plasma was obtained from 23 healthy patients scheduled for minor surgery immediately prior to induction of anesthesia (controls) and from 23 ICU patients within 24 h of diagnosis of sepsis or septic shock. Measurements and main results: Respiratory burst was determined by lucigenin chemiluminescence expressed as mean ± SEM of peak values of relative light units per neutrophil. There were no significant differences between neutrophils of septic patients and controls for the stimuli saline, phorbol myristate acetate, formyl-methionyl-leucyl-phenylalenine, and LPS alone. Septic patients showed a lower respiratory burst than controls (p < 0.05) under the following stimuli: plasma alone (5911 ± 803 vs 15 397 ± 3038) and LPS and plasma combined (13 857 ± 1537 vs 23 026 ± 2640). However, when stimulated with plasma after priming with LPS, septic patients elicited a higher value than control subjects (11 373 ± 1758 vs 5987 ± 1234, p < 0.05). Conclusions: (1) Some components of the plasma of septic patients may have a profound effect on neutrophil response; (2) plasma as a respiratory burst stimulus differentiates between sepsis and non-sepsis samples better than other common stimuli; (3) precautions must be taken when using plasma together with LPS because of the different response depending on whether LPS-priming precedes the plasma stimulus or both are introduced simultaneously and whether septic or nonseptic plasma is used.

Procalcitonin (PCT), ein aus 116 Aminosauren bestehendes Glykoprotein, wurde als neuer Parameter der schweren Infektion inauguriert. Sein Syntheseort in diesem Zusammenhang ist nicht bekannt. Mittels immunoluminometrischen Assays kann die PCT-Konzentration innerhalb von ca. 2 h aus 40 µl Serum oder Plasma bestimmt werden. PCT-Erhohungen sind u.a. mit Lipopolysaccharid und mit den Zytokinen TNF-α und IL-6 assoziiert. Bakterielle, parasitare und pilzbedingte generalisierte Infektionen weisen im Gegensatz zu lokal begrenzten Infekten haufig einen Wert uber 2 ng/ml auf, wobei die Spezifitat des Parameters mit der Hohe des Werts steigt. Therapeutische Masnahmen, die zur lokalen Begrenzung der Infektion fuhren, resultieren in einem Abfall von PCT. In den ersten Tagen nach grosen Operationen, Polytrauma, bei wenigen malignen Erkrankungen, Hitzschlag wie auch im Rahmen spezieller Behandlungen hamatologischer Krankheiten kann der Parameter erhoht sein, ohne das eine Sepsis oder schwere Infektion vorliegt. Bisherige Studien legen nahe, das PCT bei Patienten mit Sepsis im Vergleich zu traditionellen Entzundungs- bzw. Sepsisparametern Vorteile besitzt, wobei an erster Stelle die Eigenschaft, eine generalisierte Infektion anzuzeigen, zu nennen ist.

Objective To compare total plasma antioxidant capacity and selected individual antioxidants in patients with varying degrees of severity of sepsis. Design A prospective, observational, consecutive case study. Setting A 16-bed intensive care unit (ICU) in a university teaching hospital. Interventions None. Patients Forty-six healthy controls, ten ICU patients, nine patients with systemic inflammatory response syndrome (SIRS), 11 septic patients, and 14 septic shock patients. Plasma was obtained in healthy patients scheduled for minor surgery immediately before anesthesia and in ICU patients within 24 hrs of admittance to the unit or diagnosis of SIRS, sepsis, or septic shock. Measurements and main results Using the total peroxyl radical trapping method, we found plasma antioxidant capacity to be lower in septic patients but higher in septic shock patients, as compared with controls. Bilirubin was the greatest contributor to the increase with shock, followed by uric acid. Neopterin also correlated with the peroxyl radical trapping antioxidant parameter values. Conclusion Although total plasma antioxidant capacity is decreased from normal levels in septic patients, an increase in some oxidants contributes to an increased total antioxidant capacity in septic shock patients.

Procalcitonin ist das hormonell inaktive Propeptid des Calcitonins. Bei Gesunden wird Procalcitonin in den C-Zellen der Schilddruse produziert und proteolytisch gespalten, so das der Serumspiegel unter 0,1 ng/ml liegt. Bei schweren generalisierten Infektionen (durch Bakterien, Pilze oder Parasiten) mit systemischer Manifestation werden PCT-Serumspiegel bis zu 100 ng/ml erreicht. Schwere virale Infektionen und nicht-infektionsbedingte inflammatorische Reaktionen hingegen fuhren zu keiner oder nur geringer PCT-Erhohung. Der Syntheseort dieses Procalcitonins ist noch unbekannt, sicher ist aber, das auch sehr ausgepragte Erhohungen des Serumprocalcitoninspiegels nicht zu einem Ansteigen des Serumcalcitoninspiegels oder erhohter Calcitoninaktivitat fuhren. Procalcitoninverlaufskontrollen scheinen bei Patienten nutzlich, die gefahrdet sind, eine systemische Infektion bzw. Sepsis zu entwickeln. Ansteigende oder permanent erhohte PCT-Werte stellen die Indikation fur eine weitere Infektionsdiagnostik (Focussuche) dar. Die Procalcitoninbestimmung kann zur Unterscheidung zwischen infektiosen und nichtinfektiosen Ursachen bei der Differentialdiagnose von Erkrankungen, die mit den Zeichen der systemischen Inflammation einhergehen, hilfreich sein. Dies gilt auch fur die Unterscheidung zwischen der infektios-cholestatischen versus alkohol-toxischen Pankreatitis, des infektiosen versus nichtinfektiosen ARDS sowie in der Transplantationsmedizin zur Unterscheidung zwischen Abstosungsreaktionen und schweren infektiosen Komplikationen.

To prospectively evaluate whether planimetric measurements of aortic valve area (AVA) with dual-source computed tomography (DSCT) correlate with measurements obtained by echocardiography and to correlate the amount of calcification of the aortic valve with AVA in a group of patients after aortic valve replacement.23 patients underwent dual-source computed tomography (DSCT) of the heart (Somatom Definition, Siemens Medical Solutions, Forchheim, Germany), without heart rate control (heart rate 52-113 beats/minute). All patients had undergone aortic valve replacement (homografts, mean time after surgery: 7+/-3 years). The AVA of the transplanted aortic valve graft was measured planimetrically by means of DSCT and compared with echocardiography as a standard of reference, to exclude post-surgical restenosis of the valve. Maximum AVA in systole planimetrically measured with CT was compared with calculated AVA values determined with the continuity equation, using transvalvular pressure gradients. The amount of calcification of the aortic valve was quantified and correlated (Spearman's R) with the AVA. To assess intra- and inter-reader reproducibility, the DCST data was re-analyzed by two readers 4 weeks after the initial review.All DSCT datasets were of diagnostic image quality concerning valve depiction. The mean AVA as measured by DSCT was 2.7+/-0.9 cm (2) compared to 1.8+/-0.5 cm (2) by echocardiography (p0.05). The planimetric evaluation of the CT data as compared to results of echocardiography showed a significant correlation of the results (Pearson's correlation coefficient R=0.78, p0.001). Intra- and inter-reader reproducibility was good with intra-class correlation coefficients of 0.86 and 0.81, respectively (p0.001). There was a significant negative correlation between the amount of aortic valve calcification and AVA as measured by echocardiography (R= -0.42; p0.05) and as measured by DSCT (R= -0.67; p=0.001).First experience indicates that DSCT is able to assess aortic valve opening area with high image quality and good intra- and inter-reader reproducibility in subjects after aortic valve replacement. The negative correlation between AVA and the amount of aortic valve calcification suggests that calcification is a possible risk factor for restenosis in subjects with aortic valve replacement.

To determine the correlations and predictive strength of surrogate markers (body temperature, leukocyte count, C-reactive protein (CRP) and procalcitonin (PCT)) with elevated levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in septic patients on randomly chosen days.Prospective consecutive case series.Surgical intensive care unit (ICU) of a university hospital.Two hundred forty-three patients experiencing ICU stays of longer than 48 h categorized for sepsis according to ACCP/SCCM Consensus Conference criteria.CRP and PCT were both significantly correlated with TNF-alpha and IL-6. Based on the area under the curve (AUC) of the receiver operating characteristic (ROC) curves, predictive capability was highest for PCT (0.846 for TNF-alpha40 pg/ml and 0.837 for IL-6500 pg/ml), moderate with CRP (0.744 and 0.748, respectively), and lowest for leukocyte count (0.562 and 0.534, respectively) and body temperature (0.570 and 0.623, respectively). Sensitivity, specificity, positive and negative predictive values and test effectiveness all followed this same pattern of being highest for PCT followed by CRP, with leukocyte count and body temperature being lowest.PCT may be an early and better marker of elevated cytokines than the more classic criteria of inflammation.

The aim of this study was to evaluate the clinical potential of dual-source computed tomography (DSCT) in pre- and postsurgical diagnostics in the field of cardiac surgery.A total of 20 patients underwent DSCT of the heart. This CT system with two rotating X-ray tubes (Somatom Definition, Siemens Medical Solutions, Forchheim, Germany) achieves a temporal resolution of 83 ms and a spatial resolution of 0.4 x 0.4 x 0.4 mm. The patient cohort consisted of two subgroups. In a group of ten patients with known coronary artery disease (CAD), scheduled for bypass surgery (i.e., high pretest likelihood for having significant CAD), the results of DSCT coronary angiography (CTA) and invasive quantitative catheter angiography (QCA) were compared to assess the diagnostic accuracy of DSCT in the detection of significant coronary artery stenoses (50%). In a second group of ten patients with previous aortic valve replacement (homografts), the valve opening area of the transplanted aortic valve graft was measured by DSCT and compared with echocardiography as a standard of reference to exclude postsurgical restenosis of the valve.Of 150 coronary artery segments depicted by CT, 144 (96%) were classified as "assessable." A significant CAD was known in all patients, and altogether 43 significant stenoses were present according to the results of QCA. Blinded to these results, DSCTA reached a sensitivity and specificity of 95% (41/43) and 93% (103/111), yielding a positive and negative predictive value (PPV, NPV) of 79% (31/39) and 98% (103/105), respectively. In patients with aortic valve homografts, all DSCT datasets were considered as being of diagnostic image quality concerning valve depiction. The planimetric evaluation of the CT data as compared to results of echocardiography showed a significant correlation of the results (r=0.64, p=0.0467). A high-grade valve stenosis (opening area1.0 cm(2)) could be correctly excluded by DSCT in all patients.Dual-source CT shows great diagnostic potential in patients before or after cardiac surgery. DSCT provides a high diagnostic accuracy for detection of coronary artery stenosis before bypass surgery. DSCT also proved to be accurate in the assessment of patients who received aortic valve replacement.