Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Association of air pollutants, weather variables, and myocardial infarction incidence in Berlin. A study of the Berlin Brandenburg Myocardial Infarction Registry (B2HIR) based on 17873 cases

Background

Harmful health effects of air pollutants have long been assumed. Respective associations with respiratory diseases have frequently been reported. Recently, studies also pointed at possible links between air pollution and cardiovascular disease. Currently, nitric oxide (NOx) and particulate matter are of concern in Germany.

Purpose

To investigate the association of NOx, particulate matter (PM10), and weather variables with the incidence of myocardial infarction (MI) in Berlin.

Methods

The Berlin Brandenburg myocardial infarction registry (B2HIR) is documenting symptom onset, patient characteristics, comorbidity, procedural data, and outcome of patients with acute MI (onset ≤24h before admission) in Berlin and Brandenburg. From 2008 to 2014 (study period) the stable number of enrolling cardiology departments enabled epidemiologic analyses. Daily (aggregate and variable-specific) MI incidence was assessed for the study period. The government of Berlin provides detailed regional air pollution data (BLUME network). Daily and local NOx and PM10 concentrations were assessed and grouped according to regions (downtown, main roads, suburbs). Preceding days (single and 3 day average) values were also assorted to every single day. Ambient temperature, precipitation, and sunshine duration were assessed from the Berlin-Tempelhof weather station. Bivariate correlations and Poisson regression were calculated to examine associations between air pollutants, weather parameters, and MI incidence.

Results

17873 MI cases were included over 7 years. Bivariate correlations and the Poisson regression model revealed a highly significant independent association of the overall MI incidence with same day NOx concentrations (mean values across all measuring stations) and with average PM10 concentration over three preceding days. Based on regression coefficient and interquartile range of pollutant concentrations, MI incidence variation with same day NOx was 3.2% (p&lt;0.001) and variation with three preceding days PM10 was 4.8% (p&lt;0.001). Daily peak ambient temperature was inversely related to MI incidence (p&lt;0.001), whereas for sunshine duration and precipitations no independent association could be identified. Interestingly, the MI incidence in current smokers was unaffected (p=0.145 and p=0.104, respectively) by NOx and PM10 pollution.

Conclusion

This study is the first to show significant associations between the air pollutants NOx (same day level) and PM10 (3 day preceding average level) and MI incidence in Berlin. MI incidence varied with these pollutants at single digit percentage points. A causal relationship appears likely, as continuously self-intoxicating smokers did not exhibit this association.

Funding Acknowledgement

Type of funding sources: None.

Electrocardiographic changes after TAVR and their clinical impact according to new ESC Pacing Guidelines

 

Conduction disturbances after transcatheter aortic valve replacement (TAVR) remain one of the most frequent complications.

The aim of this study was to analyze ECG changes after TAVR using contemporary valves and to detect risk factors for the need of further clinical evaluation according to new ESC pacing guidelines to evaluate pacemaker implantation.

In this retrospective analysis we included 850 patients (mean age 80±9 years, 51% female), who underwent TAVR in our institution from January 2019 until December 2020. A mean follow-up of 8.9±8.4 months and 217 (25.5%) patients was performed.

55% of the implanted valves were self-expandable, 45% balloon-expandable. After TAVR, 77 (9.1%) patients developed new LBBB and QRS &gt;150ms, 26 (3.1%) new PR-time &gt;240ms. Prolongation of PR-time and prolongation of QRS duration &gt;20ms were seen in 20 (2.4%) and 90 (10.6%) patients with preexisting conduction disturbances. 152 (17.9%) patients needed pacemaker implantation post TAVR.

Developing a PR-prolongation of &gt;20ms was associated with calcification of the annulus (OR 1.2 CI 95% 1.004–1.4; p=0.04). New LBBB (OR 0.45; CI 95% 0.25–0.79; p=0.006) and pacemaker implantation (OR 0.4; CI 95% 0.2–0.8; p=0.009) were correlated with the implantation of a self-expandable valve. Coronary heart disease (OR 3, CI 95% 1.07–8.2; p=0.04) and peripheral arterial disease (OR 2.6 CI 95% 1.18–5.6; p=0.02) were associated with prolongation of QRS &gt;20ms. New LBBB with QRS &gt;150ms was seen more often after post-dilatation (OR 1.03, CI 95% 1.01–1.05; p=0.05). Pre-existing AV block I° (OR 2.8, CI 95% 1.4–5.6; p&lt;0.001), pre-existing RBBB (OR 20.5, CI 95% 7.5–56; p&lt;0.001), nicotine abuse (OR 2, CI 95% 1.05–3.8; p=0.04), prosthesis oversizing (OR 1.06, CI 95% 1.006–1.11; p=0.03) and implantation depth (OR 1.13, CI 95% 1.006–1.26; p=0.04) were independent risk factors for pacemaker implantation.

During the follow-up 161 patients (18.9%) were hospitalized in 270 inpatient stays [cardiac decompensation (n=36, 13%), pacemaker implantation (n=9, 3.3%), acute coronary syndrome (n=12, 4.4%)]. 8 patients (80%) received a pacemaker implantation because of AV Block III° and 1 (10%) patient because of sick-sinus-syndrome (SSS). Analyzing the post TAVR ECG 5 (50%) had a new LBBB (3 (30%) with QRS &gt;150ms) and 4 (40%) patients showed LBBB together with AV Block I°.

According to new guidelines 213 (25.1%) patients would have needed further clinical evaluation (EP study or ECG monitoring) after TAVR. AV-conduction abnormalities were associated with annulus calcification. Self-expandable valves were associated with new LBBB and pacemaker implantation. There seems to be a correlation between arteriosclerotic diseases and QRS width post TAVR. Pre-existing RBBB, AV block I°, implantation depth and prosthesis oversizing are important risk factors for pacemaker implantation post TAVR. New LBBB after TAVR is associated with a higher risk for pacemaker implantation in the long-term analysis.

Funding Acknowledgement

Type of funding sources: None.

Phasic left atrial strain to predict diastolic dysfunction development in women: results from the prospective Berlin Female Risk Evaluation (BEFRI) follow up trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by the DZHK (German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research)

OnBehalf

BEFRI

Background/Introduction: During the past few years, left atrial strain (LAS) has been identified to be significantly associated with left ventricular diastolic dysfunction (DD). However, the predictive value of LAS reductions on the course of DD in patients without or mild DD has so far not been investigated.

Purpose

To assess the predictive impact of phasic left atrial strain (LAS) reductions on the development of left ventricular (LV) diastolic function in women with normal (DD0) or mildly impaired diastolic function in a longitudinal study design.

Methods

We reinvited 449 participants of the Berlin Female Risk Evaluation (BEFRI) study for follow-up examinations. A comprehensive clinical and echocardiographic assessment comprising the analysis of phasic LAS was performed in 256 participants. The diagnostic and predictive value of LAS analysis was assessed and compared with standard echocardiographic DD parameters using receiver operating characteristic (ROC) curve analyses and a multivariate logistic regression model. 

Results

After a mean time interval of 6.8 years, subjects with DD0 at baseline investigation and a worsening of diastolic function of at least one stage according to recent ASE / EACVI recommendations (DD_progress) showed a significantly reduced baseline LA reservoir strain (LASr) and conduit strain (LAScd) [LASr 28.1% (6.9) in DD_progress vs. 41.9% (8.5) in DD0 at follow up; and LAScd -13.2% (5.0) in DD_progress vs. -25.4% (9.1) in DD0 at follow up; p &lt; 0.001 respectively]. With an area under the curve (AUC) of 0.89 [95% confidence interval (CI) 0.83-0.94], and 0.85 (95% CI 0.80-0.90), LASr and LAScd showed the highest discriminative value to predict DD_progress while the echocardiographic standard DD parameter left atrial volume index (LAVI) featured a limited predictive diagnostic accuracy [AUC of 0.65 (95%CI 0.52-0.72)]. In a multivariate logistic regression model controlling for age, BMI, and other standard echocardiographic DD parameters including LAVI, only LASr and LAScd remained significantly associated with DD_progress over time. 

Conclusions

In addition to improving the diagnostic accuracy of the current DD algorithm, the analysis of phasic LAS reductions may be useful to predict the development of DD in previously healthy women.

Effects of medical graphic narratives (patient comic) on Patient Reported Outcome Measures (PROMs) in patients undergoing coronary angiography and PCI

Background/Introduction

Increasing evidence suggests that patients scheduled for invasive cardiac procedures such as coronary angiography / PCI feel insufficiently informed about the planned procedure.

Purpose

To improve the Patient Informed Consent (IC) before coronary angiography by using “medical graphic narratives” (patient comic) that illustrate central IC-related aspects in a simple and understandable manner.

Methods

A patient comic illustrating central steps of the procedure, risks, treatment alternatives and behavioural measures was created in collaboration with professional scientific visual communicators. In a randomised, controlled, prospective trial, we included 121 patients undergoing coronary angiography/PCI. Patients were randomised to a group that was informed about the procedure using the usual Patient IC approach (official consent form and conversation with physician; Control group) or a group that additionally obtained a patient comic for reading (graphic illustrations of central IC aspects based on the official consent form; Comic group). Patient Reported Outcome Measures (PROMs), i.e. satisfaction with and perceived quality of the patient IC, were tested in both groups comparing single items of the Client Satisfaction Questionnaire-8 (CSQ-8) and self-designed single items in both IC groups. Differences were compared using the Fisher's exact test. A p-value &lt;0.05 was considered statistically significant.

Results

PROMs showed significant benefits in favour of the Comic group: Quality of the patient IC was perceived to be “very good” in 45.0% of the Comic group compared to 24.9% of patients in the Control group (p=0.023). Only 23.0% of the patients in the Control group, compared to 40.0% in the Comic group, stated that the IC procedure completely met their expectations (p=0.012). 57.4% in the Control group and 76.7% in the Comic group stated that all of their questions were satisfactorily adressed before the procedure (p=0.015). 43.3% in the Comic group, in contrast to 18.0% in the Control group, declared to feel “very satisfied” with the obtained IC procedure (p=0.002). The acceptance of the patient comic was very high: no patient (0%) expressed feelings of not being taken seriously by reading the patient comic.

Conclusions

Our data confirm pronounced limitations of the usual Patient IC practice before coronary angiography. The use of a patient comic that narratively illustrates central steps of the procedure positively impacts on patient-centered endpoints and significantly improves the patient IC procedure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Friede Springer Herz Stiftung

Long-term morphological appearance of transcatheter valves left in the ascending aorta after valve dislocation during transcatheter aortic valve implantation

Background

Transcatheter valve embolization and migration (TVEM) is a potential complication of transcatheter aortic valve implantation (TAVI) (1). Registries suggest low incidence but clinical relevance due to increased acute and mid-term mortality with the majority embolizing in the aorta. However, there is little data on potential late complications such as leaflet and stent thrombosis or aortic wall alterations by migrated valves.

Purpose

The aim of our study was to analyze the incidence and clinical characteristics of TVEM in a large single center cohort of TAVI patients and to examine dislocated valves by ECG-gated computed tomography (CT).

Methods and results

Between July 2009 and May 2020, 40 TVEM occurred in 3387 TAVI procedures performed in our center (1.18%). TVEM was defined according to Valve Academic Research Consortium-2 (VARC-2) criteria (3). Majority of TVEM were left in the ascending aorta (31 ascending, 3 arch, 1 descending aorta). 90% of TVEM occurred with a self-expanding valve (SEV), with no difference between older and newer valve generations, 10% with a ballon-expandable valve. Analyzing a TAVI sample cohort (n=200), horizontal aorta (p&lt;0.001, OR 11.7, 95% CI: [3.9:34.8]), defined as aortic angulation &gt;48°(4), as well as the use of SEV (p&lt;0.001, OR 12.8, 95% CI: [3.1:53.9]) were identified as a predisposing risk factor for TVEM. OR in SEV was severely increased when isolating the analysis for patients with horizontal aorta only (p=0.003, OR 23.75, 95% CI: [2.8:129]). No other predisposing risk factors were identified in this cohort. Out of 35 patients still alive, 6 patients were willing to participate in our imaging sub-study. CT exams were performed on average 47 months after TAVI (IQR 50 months [25%Q: 16.8, 75%Q: 72.8]). We detected no leaflet or stent thrombosis, yet CT identified pin protrusions in the aorta in 3 out of 6 patients.

Conclusions

TVEM is a rare complication of TAVI. TVEM was significantly associated to the use of self-expanding valves and the presence of horizontal aorta. CT did detect pin protrusions in several cases which could bear the possible risk of perforation but showed no signs of long-term damage.

Funding Acknowledgement

Type of funding sources: None. Representative CT images after TVEM

Increased expression of inactive rhomboid protein 2 in circulating monocytes after acute myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG; Sachbeihilfe HE6092/2) DGK (Deutsche Gesellschaft für Kardiologie) Otto-Hess-Promotionsstipendium

Purpose

Tumor necrosis factor-alpha (TNF-α) levels in the blood increase in the course of an acute myocardial infarction (AMI) and TNF-α is involved in the impaired recovery of myocardial function following AMI. The interaction of inactive rhomboid protein 2 (iRhom2) with the TNF-α converting enzyme (TACE) is required for the proper shedding of TNF-α from the cell surface of immune cells. We hypothesized, that iRhom2 expression increases in circulating monocytes of patients following AMI. 

Methods

Circulating monocytes were MACS-sorted from peripheral blood of 50 patients with AMI (NSTEMI, n = 16; STEMI n = 34) at the day of admission (day 1) and 3 days after admission. 50 patients with chronic coronary syndrome (CCS) were recruited as control. mRNA was isolated from sorted monocytes and expression levels of iRhom2, TACE and TNF-α were evaluated by real-time RT-PCR. TNF-α protein levels were assessed in the serum. Levels of circulating classical, intermediate and non-classical monocyte subsets were determined by flow cytometry. 

Results

There was a significant increase of iRhom2 mRNA expression levels in monocytes (by 14%, p = 0.012), levels of circulating intermediate monocytes (p &lt; 0.001), and TNF-α serum levels (p &lt; 0.001) at day 3 following AMI compared to day 1 reaching levels similar to those observed in CCS patients. In contrast, TNF-α and TACE mRNA expression in circulating monocytes did not differ between day 1 and 3 following AMI. iRhom2 mRNA expression in monocytes on day 3 following AMI correlated with TACE mRNA expression in monocytes (r = 0.72, p &lt; 0.001), TNF-α serum levels (r = 0.33, p = 0.019), and levels of circulating intermediate monocytes (r = 0.37, p = 0.009).

Conclusions

Following AMI, iRhom2 expression in circulating monocytes increases in parallel to serum levels of TNF-α and levels of circulating intermediate monocytes. These findings suggest that iRhom2 contributes to inflammation following AMI and thus may serve as a potential therapeutic target.

Impact of caval vein implantation on severity of tricuspid regurgitation, renal and hepatic function in patients with severe secondary tricuspid regurgitation

Background

Severe tricuspid regurgitation (TR) is an important determinant for functional capacity and survival. It frequently occurs in patients with advanced heart failure resulting in progressive venous congestion with cardiorenal and cardiohepatic syndrome. The prospective, randomized TRICAVAL study reported the effect of inferior caval vein implantation of an Edwards Sapien XT valve (CAVI) in comparison to optimal medical therapy (OMT) in patients with severe TR. The study did not detect a superior functional outcome after CAVI, but a significant improvement in quality of life. Due to safety concerns, the study was stopped prematurely after 4 periprocedural complications.

Purpose

We hypothesised that CAVI reduces reflux into the inferior vena cava and leads to an increase in systolic right atrial pressure, which may result in an improvement of TR severity. The present subanalysis of the TRICAVAL study evaluates the impact of inferior caval vein implantation on TR severity, right heart parameters and renal and hepatic function.

Methods

Twenty-eight patients with severe TR were randomized in either CAVI group (n=14) with caval vein implantation of an Edwards Sapien XT valve or OMT group (n=14). Medical history, clinical examination, laboratory testing and echocardiographic measurements were analysed in patients with completed FUP (OMT [n = 10], CAVI [n = 8]). Follow-up examinations were performed at baseline and three months after enrolment.

Results

After three months, the CAVI group exhibited a significant reduction of systolic hepatic vein reflux volume (5.0 [1.3–11.0] ml vs. 14.0 [10.3–18.0] ml, p&lt;0.05) and hepatic vein diameter (10.8 [10.0–12.0] mm vs. 14.0 [11.5–15.0] mm, p&lt;0.05) in comparison to OMT. Compared to baseline, CAVI improved body weight (80.7 [69.0–87.7] kg versus 75.5 [63.8–84.6] kg, p&lt;0.05) and abdominal circumference (101.5±13.8 cm versus 96.3±15.4 cm, p≤0.01) paralleled by a trend to lower doses of diuretics. However, over the FUP period, there were no significant changes regarding TR severity, right heart function and morphology as well as renal and hepatic function within both groups, nor in the comparison between CAVI and OMT.

Conclusion

As a proof of our concept, CAVI resulted in a decrease in systolic hepatic vein reflux, hepatic vein diameter and clinical signs of venous congestion. However, TR severity, right heart function and morphology as well as renal and hepatic function remained stable.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Edwards Lifesciences, Incorporated (Irvine, CA)

P1537 Myocardial work in patients with aortic stenosis before and short term after transcatheter aortic valve replacement

Objective

The newly introduced noninvasive myocardial work analysis could potentially be beneficial in predicting the best timing for aortic valve replacement as well as clinical outcomes in patients with high grade aortic valve stenosis (AS), which is the leading valvular disease in the modern aging society. However, to date there is little data on the applicability of the method in the setting of extremely increased left ventricular (LV) afterload.

Purpose

In this pilot study, we aimed to apply myocardial work analysis in patients with increased LV afterload due to severe AS and to investigate the differences of myocardial work parameters in patients with different AS entities. In addition, we analyzed the early changes of myocardial work after the afterload reduction by transcatheter aortic valve replacement (TAVR).

Methods

We retrospectively studied echocardiographic data of 28 consecutive patients with severe AS before and 7 days after TAVR. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. In order to correct for underestimation of intraventricular pressure, we added the mean aortic valve pressure gradient to the peripheral systolic blood pressure used by the software.

Results

From the included patients (mean age 76 ± 10 years) 13 were classified as having normal flow (NF) severe AS, 8 had low flow low gradient (LFLG) and 7 paradoxical low flow low gradient (PLFLG) AS. GWI and GCW were significantly lower in patients with LFLG AS compared to patients with NF or PLFLG AS (936 ± 528 mmHg% vs. 2493 ± 485 mmHg% vs. 1959 ± 469 mmHg% [p &lt; 0.005] and 1132 ± 477 mmHg% vs. 2770 ± 507 mmHg% vs. 2189 ± 603 mmHg%, [p &lt; 0.005], respectively). 7 days after TAVR, GCW and GWI decreased significantly in patients with NF AS. In other AS entities, a trend towards increased GWI and GCW was observed, but the difference did not reach statistical significance. GWI and GCW remained significantly lower in LFLG AS group when compared to NF and PLFLG groups (1069 ± 378 mmHg% vs. 1919 ± 310 mmHg% vs. 2064 ± 842 mmHg% [p &lt; 0.005] and 1286 ± 346 mmHg% vs. 2107 ± 258 mmHg% vs. 2227 ± 949 mmHg% [p &lt; 0.005]) early after TAVR. GWE and GWW did not differ between the groups and were not influenced by TAVR.

Conclusion

In this pilot study we applied the adapted myocardial work analysis in patients with increased afterload due to severe AS. We have shown that GCW and GWI are significantly higher in patients with NF AS when compared to LFLG and PLFLG AS. The differences between the groups persisted early after TAVR in spite of significant reduction of GWI and GWC in patients with NF AS. The clinical and prognostic importance of these findings are still to be investigated in a bigger cohort study.

P727Metabolic and functional differences between male and female endothelial cells from umbilical cords (HUVEC) of twin pairs

Background

Personalised Medicine is one of the hallmarks of future medicine. Sex and gender differences exist in the incidence, clinical manifestation and outcome of cardiovascular diseases. Gonadal hormones are thought to account for most of these sex differences. However, besides hormones, sexual dimorphisms at the cellular level may also contribute to physiological and pathophysiological cardiovascular differences between women and men.

Purpose

To analyse intrinsic sex differences at the cellular level, we aimed to elucidate sex-specific differences in endothelial cell migration and energy metabolism under pro-migratory conditions in male and female HUVECs. To reduce biological variability, we used HUVECS obtained from umbilical cords from twin pairs of the opposite sex. These cells are exposed in utero to the same maternal environment, and therefore represent a valuable tool to study intrinsic sex-specific differences at the cellular level.

Methods

Vascular endothelial growth factor (VEGF)-stimulated migration was determined with IBIDI migration chambers. Sex-specific levels of proteins were studied using proteome profiling. Cellular metabolism was measured by Seahorse and levels of intracellular metabolites were analysed using GC-MS based technology.

Results

Female cells showed significantly higher VEGF-induced cell migration than male HUVECs. Proteomic profiling revealed a sex-specific response to VEGF treatment. Mitochondrial respiration rate was higher in VEGF-stimulated male HUVECs compared to female cells. Whereas mean glycolytic rates did not significantly differ between sexes, the ratio of glycolysis/mitochondrial respiration after VEGF stimulation was higher in female than in male HUVECs. Female cells had higher intracellular ATP levels after serum starvation and treatment with VEGF. Under both conditions, female cells showed altered levels of metabolite pools compared to male HUVECs.

Conclusions

Higher intracellular ATP and metabolite levels in female cells after serum starvation and VEGF may contribute to the observed functional sexual dimorphisms, and may also point to an increased stress tolerance of female cells. The results of our study provide a strong argument to discriminate between male and female cells in in vitro experiments.

Acknowledgement/Funding

The work was supported by the DZHK (German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research).

Fast-track pulmonary conditioning before urgent cardiac surgery in patients with insufficiently treated chronic obstructive pulmonary disease

AIM

Chronic obstructive pulmonary disease (COPD) is an important risk factor for perioperative morbidity and mortality in patients undergoing cardiac surgery. Despite high clinical relevance, current guidelines lack clear recommendations on the optimal approach for patients with insufficiently treated COPD and urgent need for cardiac surgery. The aim of the present study was to analyze the efficacy of short-term pulmonary conditioning (PC) in this subset of cardiopulmonary patients.

METHODS

Eighteen patients with urgent need for cardiac surgery were treated with 1 mg budenoside twice a day, 1.25 mg salbutamol four times a day and 15 mg ambroxol three times a day. On average, patients received pulmonary conditioning for 5.1 ± 2.1 days. Lung function was assessed before and after treatment.

RESULTS

Pulmonary conditioning improved forced expiratory volume in one second (FEV1) by 16% (P<0.001). Predicted FEV1 increased from 48.3 ± 13.6% at baseline to 55.4 ± 16.1% after treatment (P<0.001). Total resistance was reduced from 0.933 ± 0.418 kPa·s/L to 0.631 ± 0.344 kPa·s/L after PC (P=0.004). The percentage of patients in GOLD stages III-IV was reduced from 55.6% at baseline to 27.8% after treatment. After surgery, patients needed mechanical ventilation for 2 ± 3.4 days. One patient (5.6%) received a tracheostomy and four patients (22.2%) developed pneumonia; 30-day mortality was 5.6%.

CONCLUSION

Short-term treatment with budenoside, salbutamol and ambroxol significantly improved lung function parameters. If surgery can be delayed for several days, pulmonary conditioning should be considered for patients with insufficiently treated COPD.