Excess mortality in Aspirin and Dipyrone (Metamizole) co-medicated in patients with cardiovascular disease: a nationwide study

Background

Pain is a serious issue in our aging society. Metamizole is one of the most commonly used analgesics. In addition, metamizole has been shown to attenuate the pharmacodynamics response to aspirin as measured by platelet function tests. However, the extent to which this laboratory effect translates to clinical outcome in patients is unknown.

Methods

We conducted a nationwide analysis based on health insurance database including 9.2 million patients in Germany. All patients with a cardiovascular event in 2014 and subsequent secondary prevention with aspirin were followed up for 36 months. Inverse probability of treatment weighting (IPTW) analysis was performed to examine mortality rates between patients on aspirin-metamizole co-medication and aspirin medication alone. Myocardial infarction (MI) and stroke/transient ischemic attack (TIA) events were also documented.

Results

26,200 patients received continuous aspirin medication alone and 5,946 received co-medication with aspirin and metamizole. In the IPTW analysis, significantly increased mortality was observed in the co-medication group (15.6% vs. 24.4%, hazard ratio (HR)=1.66, 95% confidence interval (CI) 1.56–1.76; p<0.0001). MI and stroke/TIA were also increased (MI: 1,370 [5.2%] vs. 355 [5.9%]; HR=1.18, 95% CI 1.05–1.32; p=0.0066, relative risk (RR) 1.14, absolute risk increase (ARI) 0.71%, number needed to harm (NNH) 140. Stroke/TIA: 1,901 [7.3%] vs. 506 [8.5%]; HR=1.22, 95% CI 1.11–1.35; p<0.0001, RR 1.17, ARI 1.21%, NNH 82).

Conclusion

In this nationwide observational study, aspirin-metamizole co-medication was associated with excess mortality. This was partly due to ischemic events (MI and stroke/TIA), which were also more frequent in the co-medication patients. Therefore, metamizole should be used with caution in aspirin-treated patients for secondary prevention

Funding Acknowledgement

Type of funding sources: None.

Propofol versus midazolam sedation in patients with cardiogenic shock – an observational propensity-matched study

Introduction

Benzodiazepines are recommended as first line sedative agent in ventilated cardiogenic shock patients, although data regarding the optimal sedation strategy are sparse. On our cardiac ICU, midazolam was used as first line sedation until 2016, whereas soybean oil formulated propofol was used preferentially since 2017.

Purpose

The aim of this study was to investigate the hemodynamic effects of propofol versus midazolam sedation in our cardiogenic shock registry.

Methods

Mechanically ventilated patients suffering from cardiogenic shock were retrospectively enrolled from a cardiogenic shock registry. 174 patients treated predominantly with propofol were matched by propensity-score to 174 patients treated predominantly with midazolam.

Results

Catecholamine doses were similar on admission but significantly lower in the propofol group on days 1–4 of ICU stay (Figure 1). Mortality rate was 38% in the propofol and 52% in the midazolam group after 30 days (p=0.002, Figure 2). Rate of ≥BARC3 bleeding was significantly lower in the propofol group compared to the midazolam group (p=0.008). Age, gender, first lactate measured on ICU, first GFR measured on ICU, cardiac arrest, coaxial left ventricular assist device and sedation with midazolam were significantly associated with ICU mortality.

Conclusion

In this observational cohort study, sedation with propofol in comparison to midazolam was linked to a reduced dose of catecholamines, decreased mortality and bleeding rates for patients with cardiogenic shock. Based on this study and in contrast to current recommendations, propofol should be given consideration for sedation in cardiogenic shock patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

Effect of coagulation factors FXIa, FXIIa, F alpha-XIIa, F beta-XIIa and FXIIIa on platelet function

Background

FXa has recently been shown to active platelets via protease activated receptor. Direct inhibition of FXa leads to reduced platelet reactivity and arterial thrombosis. It is not known, if other coagulation factors besides FXa and FIIa directly activate platelets. In this study, we hypothesized that FXIa, FXIIa, Fα-XIIa, Fβ-XIIa and FXIIIa directly active platelets.

Purpose

Direct inhibitors of above mentioned factors are currently in clinical trials. Hence, investigation of coagulation factors' non-canonical effects beyond activation of the coagulation cascade are of great importance.

Methods

Platelet reactivity was measured using light transmission aggregometry (LTA) and flow cytometry. Ex-vivo stimulation of washed platelets was conducted using adenosine diphosphate (ADP) and thrombin receptor activator peptide (TRAP).

Results

FXIa, FXIIa, Fα-XIIa, Fβ-XIIa and FXIIIa have no direct effect on platelet function in terms of aggregation (Maximum of aggregation: FXIa: 2.799±1,823%, FXIIa: 1,174±1,080%, Fα-XIIa: 1,663±1,680%, Fβ-XIIa: 1,060±1,356%, Fα-XIIa + Fβ-XIIa 1,790±2,327% and FXIIIa: 1,345±1,060%). Also, incubation of platelets does not cause expression of P-selectin (FXIa: 4,346±4,650%, FXIIa: 7,072±6,098%, Fα-XIIa: 9,124±6,075%, Fβ-XIIa: 4,556±4,693%, Fα-XIIa + Fβ-XIIa 8,070±4,342% and FXIIIa: 5,166±5,512%).

Conclusion

FXIa, FXIIa, Fα-XIIa, Fβ-XIIa and FXIIIa have no direct effect on platelet function in terms of aggregation and P-selectin expression. Thus, existing pharmacological inhibitors of these factors are to be classified as purely anticoagulant and do not exert non-canonical effects on platelet activation.

Funding Acknowledgement

Type of funding sources: None.

Molecular investigation of the tandem Tudor domain and plant homeodomain histone binding domains of the epigenetic regulator UHRF2

Ubiquitin-like containing PHD and ring finger (UHRF)1 and UHRF2 are multidomain epigenetic proteins that play a critical role in bridging crosstalk between histone modifications and DNA methylation. Both proteins contain two histone reader domains, called tandem Tudor domain (TTD) and plant homeodomain (PHD), which read the modification status on histone H3 to regulate DNA methylation and gene expression. To shed light on the mechanism of histone binding by UHRF2, we have undergone a detailed molecular investigation with the TTD, PHD and TTD-PHD domains and compared the binding activity to its UHRF1 counterpart. We found that unlike UHRF1 where the PHD is the primary binding contributor, the TTD of UHRF2 has modestly higher affinity toward the H3 tail, while the PHD has a weaker binding interaction. We also demonstrated that like UHRF1, the aromatic amino acids within the TTD are important for binding to H3K9me3 and a conserved aspartic acid within the PHD forms an ionic interaction with R2 of H3. However, while the aromatic amino acids in the TTD of UHRF1 contribute to selectivity, the analogous residues in UHRF2 contribute to both selectivity and affinity. We also discovered that the PHD of UHRF2 contains a distinct asparagine in the H3R2 binding pocket that lowers the binding affinity of the PHD by reducing a potential electrostatic interaction with the H3 tail. Furthermore, we demonstrate the PHD and TTD of UHRF2 cooperate to interact with the H3 tail and that dual domain engagement with the H3 tail relies on specific amino acids. Lastly, our data indicate that the unique stretch region in the TTD of UHRF2 can decrease the melting temperature of the TTD-PHD and represents a disordered region. Thus, these subtle but important mechanistic differences are potential avenues for selectively targeting the histone binding interactions of UHRF1 and UHRF2 with small molecules.

[Utilization of Physical Therapy Services in Germany from 2004 until 2014: Analysis of Statutory Health Insurance Data]

Background: Both at the national and international levels, direct access for patients to physical therapy services is currently under debate. Direct access for patients seeking physical therapy care might reduce waiting time and costs, and thus be of benefit for patients and health insurance companies. To critically evaluate this situation, reliable and valid data are needed, but currently lacking. The aim of this study is to evaluate the health care situation for physical therapy services included in the catalogue of remedies from 2004 up to 2014 in Germany. Methods: To obtain information regarding physical therapy services included in the catalogue of remedies, the freely available "Heilmittel-Informations-System (GKV-HIS)" was used. Data from the regional Associations of Statutory Health Insurance Physicians as well as data from federal reports were extracted for the years from 2004 up to 2014. Results: Prescription of physical therapy increased continuously from 2004 and 2014. In 2004, 155 677 860 and in 2014, 254 695 514 physical therapies were prescribed (increase of 61%). The highest number of physical therapies was prescribed in Saxony for all years, whereas in North Rhine-Westphalia and Hessen the lowest number per 1 000 GKV insured persons. Gross sales from physical therapy services differed between federal states and were the highest in Saxony (2004: 59.8; 2009: 54.6, 2014: 76.7) and Baden-Wuerttemberg (2004: 60.0; 2009: 57.6; 2014: 68.0). Discussion: The results of this study show utilization of physical therapy services as defined in the catalogue of remedies in Germany to be heterogeneous. However, causal relationship cannot be identified on the basis of the analyzed data highlighting the need for further research. Criteria for structural-, process- and outcome-quality are needed to be able to evaluate the quality of physical therapy services. To ensure the quality of physical therapy services, interprofessional and patient relevant research is needed.

[Identification of Control Hospitals for the Implementation of the Nationwide and Standardized Evaluation of Model Projects According to § 64b SGB V: Analysis of Data from Structured Quality Reports]

BACKGROUND

Health care needs of mentally ill patients make special demands on cross-sectoral health care structures. § 64b SGB V enables care of mentally ill patients through model projects that are multi-professional, work across treatment periods and sectors and implement new forms of financing. These model projects in their hospitals (case hospitals) need to be evaluated and compared with standard treatment methods.

OBJECTIVES

The aim of this analysis is to identify matching hospitals according to a priori defined criteria for the establishment of a control group (control hospitals) using secondary data.

MATERIALS AND METHODS

A systematic analysis was conducted based on structured quality reports according to §+137 SGB V and matched data from the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). Based on a priori defined knock-out criteria, criteria based on patients (weighting 50%), structural features of hospitals (25%) and environmental factors (25%), a weighted similarity score was calculated for each of the 13 case hospitals, which could reach the maximum of 100 points (perfect match).

RESULTS

10 control hospitals per case hospital were identified according to the weighted similarity score. The median of the total deviation of potential control hospitals from the case hospitals was 34.3 (range: 17.6-66.7). The median of the 10 selected control hospitals per case hospital was 30.9 (range: 17.6-40.8).

DISCUSSION

The defined algorithm could be used to identify similar control hospitals. The method using the mentioned databases and derivation of specific criteria of structural similarity are generally suitable in controlled designs for the evaluation of complex interventions based on routine data.

A Consensus German Reporting Standard for Secondary Data Analyses, Version 2 (STROSA-STandardisierte BerichtsROutine für SekundärdatenAnalysen)

Although secondary data analyses have been established in recent years in health research, explicit recommendations for standardized, transparent and complete reporting of secondary data analyses do not exist as yet. Therefore, between 2009 and 2014, a first proposal for a specific reporting standard for secondary data analysis was developed (STROSA 1). Parallel to this national process in Germany, an international reporting standard for routine data analysis was initiated in 2013 (RECORD). Nevertheless, because of the specific characteristics of the German health care system as well as specific data protection requirements, the need for a specific German reporting standard for secondary data analyses became evident. Therefore, STROSA was revised and tested by a task force of 15 experts from the working group Collection and Use of Secondary Data (AGENS) of the German Society for Social Medicine and Prevention (DGSMP) and the German Society for Epidemiology (DGEpi) as well as from the working group Validation and Linkage of Secondary Data of the German Network for Health Services Research (DNVF). The consensus STROSA-2 checklist includes 27 criteria, which should be met in the reporting of secondary data analysis from Germany. The criteria have been illustrated and clarified with specific explanations and examples of good practice. The STROSA reporting standard aims at stimulating a wider scientific discussion on the practicability and completeness of the checklist. After further discussions and possibly resulting modifications, STROSA shall be implemented as a reporting standard for secondary data analyses from Germany. This will guarantee standardized and complete information on secondary data analyses enabling assessment of their internal and external validity.

Which factors predict incident pressure ulcers in hospitalized patients? A prospective cohort study

BACKGROUND

The prevention of pressure ulcers (PU) is an important public health issue owing to their substantial clinical and economic burden.

OBJECTIVES

To investigate predictors of incident PU in hospitalized patients and the performance of the Braden Scale in intensive care units (ICU) and normal care units (NCU).

METHODS

We conducted a prospective cohort study including all inpatients treated at the University Hospital Carl Gustav Carus Dresden, Germany, between 2007 and 2011. Documentation comprised patient characteristics, Braden Scale and clinical signs of PU. The primary outcome was incident PU during inpatient treatment. Predictors of PU were explored by using univariate and multivariate logistic regression models. To evaluate the performance of the Braden Scale a receiver operating characteristics (ROC) curve analysis was applied.

RESULTS

The overall incidence of PU during inpatient treatment was 0·78%. A higher rate of PU was observed at ICU vs. NCU (4·77% vs. 0·59%). Multivariate analysis identified age [odds ratio (OR) 1·04, 95% confidence interval (CI) 1·035-1·041 per year], female sex (OR 1·11, 95% CI 1·01-1·22), length of stay (OR 17·79, 95% CI 15·46-20·48 for 30 or more days vs. < 10 days) and admission from care facility compared with admission from home (OR 3·14, 95% CI 2·63-3·75) as significant predictors of incident PU. The area under the ROC curve was 84·89% at NCU and 69·0% at ICU.

CONCLUSIONS

The identified predictors for incident PU may inform targeted, evidence-driven preventive measures to decrease the burden of PU.

[Prioritization and Consentation of Criteria for the Appraisal, Funding and Evaluation of Projects from the German Innovationsfonds: A multi-perspective Delphi study]

BACKGROUND

The German Innovationsfonds provides the chance for evidence-based developments of the German healthcare system.

OBJECTIVE

Prioritization of recommendations for an effective, efficient, fair, transparent, and sustainable granting of funds through a transparent, evidence-driven consensus-process involving all relevant stakeholder groups.

METHODS

Representatives from health and research policy, payers, patient representatives, healthcare providers, and scientists were invited to nominate participants for an electronic 3 round iterative Delphi-study to prioritize the thematic focus, requirements concerning study methods, the team of applicants, evaluation, utilization of study results, and for the selection of reviewers. Criteria considered as relevant by at least 60% of the panel (consensus definition) in the first 2 Delphi rounds were rated as facultative, preferable, or obligatory criteria for project funding. Data were analyzed descriptively. (

REGISTRATION

Datenbank Versorgungsforschung Deutschland VfD_15_003561).

RESULTS

All invited stakeholder groups except payers participated. 34 (85%) of 40 nominated representatives participated in the Delphi-study. A total of 64 criteria were consented as relevant for project review and funding concerning the thematic focus (n=28), methodological requirements (n=13), requirements for applicants (n=4), for the evaluation (n=4), utilization (n=6), and selection of peer reviewers (n=9).

DISCUSSION

It is the collective responsibility of all stakeholders to spend the designated funds as efficient and sustainable as possible. The consented recommendations shall serve decision makers as a resource for the granting of funds and the evaluation of the Innovationsfonds.

[Recommendations for quality indicators in German S3 guidelines: a critical appraisal]

BACKGROUND

Assessment of the quality of medical care plays an increasingly important role in the German healthcare system. Requirements for quality indicators include validity, reliability, responsiveness, interpretability and feasibility. Because of the high impact of guidelines, quality indicators that are recommended in such guidelines are of special relevance.

METHODS

We conducted a systematic review of all German S3 guidelines (actual as of November 30(th), 2013) to investigate the proportion of guidelines recommending quality indicators, which categories to classify quality indicators were used, and whether quality indicators in German S3 guidelines were developed following evidence-based methods.

RESULTS

In 34 from 87 S3 guidelines (39%) a total of 394 quality indicators were defined. The vast majority of the recommended quality indicators focused on process quality. Outcome indicators were only recommended in 9 S3 guidelines (10%). None of the guidelines analysed reported the properties of the recommended quality indicators.

CONCLUSION

Despite the increasing relevance of quality assessment for all stakeholders in the German healthcare system only approximately 40% of the S3 guidelines define indicators to measure the quality of care. Recommendations to assess outcome indicators are only provided in 10% of S3 guidelines. The process of the development and recommendation of quality indicators is heterogeneous and frequently not transparently reported. The current practice for the recommendation and validation of quality indicators in German S3 guidelines does not meet the requirements of evidence-based healthcare.

Gene expression profiles in the acutely dissected human aorta

OBJECTIVES

heritable connective tissue abnormalities and arterial hypertension may predispose to aortic dissection. This study evaluates gene expression profiles in the acutely dissected human aorta.

DESIGN, MATERIALS AND METHODS

Atlas Human Broad Arrays I, II, and III (Clontech) were used to compare gene expression in acutely dissected (6 patients) and normal ascending aortas (6 multiorgan donors). The tissues were also compared macroscopically.

RESULTS

of 3537 genes analysed, 1250 (35%) were expressed in aortic tissue. For statistical analysis we focused on 627 genes, which had an intensity>0.95 of the mean patients or controls. Dissected and adjacent macroscopically intact aorta displayed similar gene expression patterns. On the contrary, 66 genes were expressed significantly different in dissected aorta, compared with undiseased control aorta of multiorgan donors. Genes, predominantly upregulated in dissection, are involved in inflammation, in extracellular matrix proteolysis, in proliferation, translation and transcription. Predominantly downregulated genes code for extracellular matrix proteins, adhesion proteins and cytoskeleton proteins.

CONCLUSION

our results demonstrate for the first time the complexity of the dissecting process on a molecular level. The ultimate dissection seems to be the dramatic endpoint of a long-lasting process of degradation and insufficient remodelling of the aortic wall. Altered patterns of gene expression suggest a pre-existing structural failure of the aortic wall, resulting in dissection.

Heart-type fatty acid binding protein (hFABP) in the diagnosis of myocardial damage in coronary artery bypass grafting

OBJECTIVES

Heart-type fatty acid binding protein (hFABP) is an intracellular molecule engaged in the transport of fatty acids through myocardial cytoplasm and has been used as a rapid marker of myocardial infarction. However, its value in the evaluation of perioperative myocardial injury has not yet been assessed.

METHODS

32 consecutive patients undergoing coronary artery bypass grafting were included in a prospective, randomized study using standardized operative procedures and myocardial protection. Three patients with perioperative myocardial infarction were added. Serial blood samples were taken preoperatively, before ischemia, 5 and 60 min after declamping, 1 and 6 h postoperatively and on postoperative days 1, 2 and 10 and were tested for hFABP, creatine kinase isoenzyme MB (CKMB) and troponin I (TnI).

RESULTS

Hospital mortality was zero. The kinetics of the biochemical parameters revealed a typical pattern for each marker. In routine patients, hFABP levels peaked as early as 1 h after declamping, whereas CKMB and TnI peaked only 1 h after arrival in the intensive care unit. Patients with perioperative infarction displayed peak levels some hours later in all marker proteins. Peak serum levels of hFABP correlated significantly with peak levels of CKMB (r=0.436, P=0.011) and TnI (r=0.548, P=0.001), indicating the degree of myocardial damage.

CONCLUSIONS

hFABP is a rapid marker of perioperative myocardial damage and peaks earlier than CKMB or TnI. The kinetics of marker proteins in serial samples immediately after reperfusion is more suitable for the detection of perioperative myocardial infarction than a fixed cut-off level.

T-cell-mediated rejection of vascularized xenografts in the absence of induced anti-donor antibody response

T cells are considered to play a major indirect role in the pathogenesis of xenograft vascular rejection, by promoting the induction of anti-donor antibodies that trigger complement- and antibody-dependent cell cytotoxicity. However, how vigorous the T cell xenoresponse is in vivo, and whether, besides their helper function, T cells are capable of directly affecting the graft is still unclear. We have previously shown that cyclosporine A (CsA) withdrawal in accommodated cardiac xenograft recipient allows for a rapid and dense T-cell infiltration, concomitant to an acute graft rejection. In this paper we further characterize the role of T cells in this rejection process and we demonstrate that adoptive transfer of CD4+ T cells in irradiated recipients of long-term cardiac xenografts is sufficient to trigger acute rejection, in the absence of any detectable induced anti-hamster antibody response. Therefore, our data suggest that unusually strong T-cell response will be another major barrier to xenotransplantation, even if antibody-mediated vascular rejection is controlled.

Procalcitonin (PCT) in cardiac surgery: diagnostic value in systemic inflammatory response syndrome (SIRS), sepsis and after heart transplantation (HTX)

PURPOSE

Since it is of great importance to distinguish between a systemic inflammatory response syndrome (SIRS) and an infection caused by microbes especially after heart transplantation (HTX), we examined patients following heart surgery by determining procalcitonin (PCT), because PCT is said to be secreted only in patients with microbial infections.

METHODS

Sixty patients undergoing coronary artery bypass grafting (CABG) and 14 patients after heart transplantation were included in this prospective study. In the CABG group we had 30 patients without any postoperative complications (group A). Furthermore we took samples of 30 patients who suffered postoperatively from a sepsis (group B, n=15) or a systemic inflammatory response syndrome (C, n=15). In addition we measured the PCT-levels in 65 blood samples of 14 patients after heart transplantation (Group I: rejection > IIa, II: viral infection (CMV), III: bacterial/fungal infection, IV: controls).

RESULTS

In all patients of group A the pre- and intraoperative PCT-values and the measurement at arrival on intensive care unit (ICU) were less than 0.2 ng/ml. On the second postoperative day the PCT-value was 0.33+/-0.15 ng/ml in the control group. At the same time it was 19.6+/-6.2 ng/ml in sepsis and 0.7+/-0.4 ng/ml in systemic inflammatory response syndrome patients (P<0.05). In transplanted patients we could find the following PCT-values: Gr.I: 0.18+/-0.06 II: 0.30+/-0.09 III: 1.63+/-1.16 IV: 0.21+/-0.09 ng/ml (P<0.05 comparing group III with I, II and IV).

CONCLUSIONS

These results show that extracorporeal circulation (ECC) and systemic inflammatory response syndrome do not initiate a PCT-secretion. Septic conditions cause a significant increase of PCT. In addition, PCT is a reliable indicator concerning the essential differentiation of bacterial or fungal--not viral--infection and rejection after heart transplantation.

Beta-adrenoceptor inhibition for induction of acute cardiac failure in pigs

For the testing of heart assist devices most animal models of acute cardiac failure that are usually used show certain disadvantages. We therefore developed a new method using the beta-adrenoceptor antagonist carazolol. We administered a bolus injection of 1 mg/kg followed by a continuous infusion of 1 mg/kg/h in adult German 'Landrasse' pigs. Blood pressure, heart rate, cardiac output and maximum left ventricular pressure rise time showed a significant (P < 0.05) reduction of the control value varying between 40% and 59%. The method is suitable for the testing of surgical approaches in heart failure.

Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW

BACKGROUND

In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant.

METHODS

Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed.

RESULTS

In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones.

CONCLUSIONS

A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

Hyperbaric oxygen therapy in deep sternal wound infection after heart transplantation

The results of orthotopic heart transplantation (OHTx) are still burdened with considerable early mortality due to graft rejection or infection. Sternum osteomyelitis is an infrequent postoperative complication. We report a case of deep sternal wound infection (2 months after OHTx) that was treated with hyperbaric oxygen therapy in addition to local surgical treatment.

Diagnostic value of procalcitonin: the influence of cardiopulmonary bypass, aprotinin, SIRS, and sepsis

BACKGROUND

The reasons for a systemic inflammatory response syndrome (SIRS) following ECC are not yet fully understood. Procalcitonin (PCT) blood levels may distinguish between bacterial infections and a non-bacterial systemic inflammation. We investigated the influence of ECC, ECC modified by application of aprotinin, systemic inflammation, and bacterial infection on the PCT values.

METHODS

20 CABG patients were randomized and divided in two groups. Group A served as the control group, while group B perioperatively received a high dose of aprotinin. Blood samples for measurement of PCT were taken 6 times perioperatively. Furthermore, blood samples were taken from 20 preoperatively comparable patients who suffered from bacterial infection (n = 10) (group C) or a SIRS (n = 10) (group D) after ECC; in these groups PCT was determined daily after the onset of inflammation.

RESULTS

There was no significant elevation of PCT in group A or B at any time. In sepsis patients a significant elevation of PCT was seen, with the peak level of 18.6+/-6.3 ng/ml on the second day after diagnosis; the PCT level of SIRS patients remained constantly low (<0.9 ng/ml).

CONCLUSIONS

In this study it was demonstrated that ECC and the use of aprotinin did not have any influence on the secretion of PCT. A systemic bacterial infection caused a significant increase of PCT, whereas PCT values remained normal in case of a SIRS. So it seems to be possible to distinguish between a primary SIRS and a bacterial sepsis by means of PCT.

[Ischemic cardiomyopathy--transplantation and bridging with mechanical assist systems]

The number of patients with ischemic cardiomyopathy and accompanying chronic pump failure of the left and/or right ventricle has tripled within the last 10 years. Ischemic cardiomyopathy represents numerically the greatest share as the reason for illness in heart transplantation today; their results are not different for patients following cardiac transplantation due to primary cardiomyopathy. Since heart transplantation has become a clinical routine method today, the discrepancy between the number of the available donor organs and the number of the needed organs becomes more and more obvious. The longer waiting lists and the longer waiting times are responsible for the increased use of bridging systems. Today the long-term results after heart transplantation are not worse in patients after bridging. With more experience in the field of mechanical support, better devices, and proved indications, frequent improvement of prerequisites for transplantation can be achieved in this group of patients. The implantable ventricles give the patient the change of full mobilization and, therefore, high clinical acceptance of this management can be registered.

Increased preoperative C-reactive protein (CRP)-values without signs of an infection and complicated course after cardiopulmonary bypass (CPB)-operations

OBJECTIVE

C-Reactive protein (CRP) is known to be a sensitive indicator of infection. Since it is also involved in the acute phase reaction, it is of great interest, whether an isolated preoperative increase of CRP without further signs of infection is of any prognostic value for postoperative outcome after cardiac surgery with cardiopulmonary bypass (CPB), which itself is possibly causing a systemic inflammatory response syndrome (SIRS).

METHODS

Fifty patients with an isolated CRP-elevation (>5 mg/l) (from 6.2 to 93.3 mg/l) were operated using CPB (group A). A control group (group B) consisted of 50 cardiac surgery patients, matched in the patterns of age, gender and kind of disease. No preoperative CRP-elevation (from 0 to 4.8 mg/l) occurred in this group.

RESULTS

The postoperative course of both groups showed significant differences. Septic complications were seen more often in group A (20%) than in the controls (2%) (P < 0.01). Microbiology (blood culture, cultures from nose, tracheal aspirate and urine) was positive only in 10% of these patients. Catecholamine support (epinephrine, norepinephrine and/or doses of dopamine or dobutamine of more than 3 microg/kg per min) was needed in 26% of group A cases, whereas it was only needed in 10% of group B (P < 0.05). A significantly longer respiratory support was also necessary in patients with elevated CRP (25.2 +/- 6.4 h vs. 6.6 +/- 0.8 h) (P < 0.01). Furthermore there was a significant difference in the duration of intensive care (4.6 +/- 0.8 days vs. 2.6 +/- 0.3 days) (P < 0.05).

CONCLUSIONS

These data show that patients without apparent infection or inflammation, who had elevated CRP-values preoperatively, face an increased risk of septic complications after extracorporeal circulation. As microbiology tests are negative in most cases, it may be speculated that the majority of septic complications are due to a SIRS.

A new method of mechanical circulatory support with an implantable multichamber pump system (IMPS): presentation and first experimental results

This paper presents a new cardiac support device for left ventricular failure which consists of two inflatable bellows positioned dorsally and ventrally to the left ventricle. The implantable multichamber pump system (IMPS) is driven by a pneumatic pump system and controlled by a microcomputer using ECG-trigger and pacemaker modules. It was implanted via thoracotomy in 8 pigs. The circulatory parameters were measured in the animals on beta-blockers, with cardiac failure and in ventricular fibrillation with an activated (IMPS on) and deactivated (IMPS off) system. IMPS significantly increased the left ventricular pressure (LVPsys IMPS off: 63 +/- 6 mmHg vs IMPS on: 96 +/- 8 mmHg) and the blood pressure in the common carotid artery (BPca, IMPS off: 69/38 mmHg vs IMPS on: 95/40 mmHg). The IMPS proved to be highly efficient in the therapy of animals with acute cardiac failure and in ventricular fibrillation in the experimental model. Apart from its efficiency the advantages with this system are the ease of handling and its high biocompatibility due to the lack of contact with circulating blood.

Pulmonary embolism: a frequent cause of acute fatality after lung resection

Between 1975 and 1993, lung resections were performed in 1735 patients because of malignancies, with an early postoperative mortality of 7.2% (125 patients). Early postoperatively acute cardiorespiratory failure was experienced by 32 patients (1.85%), of whom 26 died despite immediate resuscitation measures. In 20/26 patients autopsy was performed revealing central pulmonary embolism as the cause of death in 19 of them. In one patient a rupture of the free posterior left ventricular wall following transmural myocardial infarction was found. Two patients who could be resuscitated successfully were operated on with extracorporeal circulation after pulmonary angiography had been performed to confirm the diagnosis; however they died 2 days later of right heart failure. Of the survivors three cases had myocardial infarctions, one patient had arrhythmias of unknown etiology. Immediate embolectomy with the use of extracorporeal circulation was performed in two patients, only on the ground of suspected pulmonary embolism and without further diagnostic measures. Both patients survived. Of the 23 cases, with proven pulmonary embolism 17 were still under postoperative prophylaxis with heparin. Six patients were already fully mobilized. We conclude that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization. The only successful life-saving measure in the case of central pulmonary embolism is immediate pulmonary embolectomy, if necessary without further diagnostic measures.

Postoperative assessment of chordal preservation and changes in cardiac geometry following mitral valve replacement

Mitral valve replacement (MVR) is still associated with a relatively high mortality. To investigate the influence of chordal preservation in MVR on left ventricular size and function, we studied a series of 82 patients who underwent MVR either with (group A n = 50) or without (group B n = 32) preservation of the subvalvular structures and compared the two groups. Echocardiography was performed preoperatively, and 7 days and 3 months postoperatively. Echocardiographic investigations included left atrial and ventricular diameters, right ventricular diameters and left ventricular length. Preoperatively there were no difference between the two groups of patients. Intraoperative and postoperative management was similar in the groups. Three months postoperatively echocardiographic examinations demonstrated that chordal preservation in MVR resulted in smaller left ventricular systolic and diastolic diameters (LVESD: gr. A 43.4 +/- 7.8 mm vs gr. B 48.8 +/- 9.2 mm P < 0.05, LVEDD: 57.3 +/- 7.8 mm vs 62.9 +/- 10.5 mm P < 0.05) and a significantly decreased left ventricular length (87.1 +/- 4.2 mm in gr. A vs 97.5 +/- 5.7 mm in gr. B P < 0.05). In addition, left ventricular ejection fraction in group A was significantly improved compared to group B (54.2 +/- 11.2% vs 48.1 +/- 12.4%, P < 0.05). We conclude that chordal preservation in MVR improves left ventricular function and reduces left ventricular diameters and volumes compared to resection of the mitral subvalvular appartus and that these beneficial effects can be maintained in the postoperative course.

Effects of high-dose aprotinin on renal function in aortocoronary bypass grafting

BACKGROUND

To reduce blood consumption in cardiac surgery, aprotinin has been widely used for years. Because aprotinin is metabolized in the kidney, damage of the renal system has been discussed.

METHODS

To study these possibly unfavorable effects of aprotinin, a prospective, randomized, placebo-controlled study of 20 patients undergoing aortocoronary bypass operations was performed. A placebo group P was compared with group A, in which patients received high-dose aprotinin according to the "Hammersmith" regimen. Renal function was assessed for 5 postoperative days using sodium dodecyl sulfate gel electrophoresis and quantitative protein analysis of the urine.

RESULTS

During and after the operation, temporary renal dysfunction was found in all patients, with a substantial increase of all investigated indices. The alpha 1-microglobulin level in the urine was significantly increased in the aprotinin group for 5 days in comparison with the placebo group, with a maximum on the third postoperative day (64.8 +/- 13.7 versus 21.0 +/- 6.5 mg/L; p < 0.05). Similarly, after sodium dodecyl sulfate-polyacrylamide gel electrophoresis, the bands of proteins filtrated in the renal tubular system were almost tripled in the aprotinin group 5 days postoperatively (5.0 +/- 0.8 versus 2.1 +/- 0.2; p < 0.05). Although urine production was significantly increased in group A (4789 +/- 580 versus 3653 +/- 492 mL/24 h postoperatively; p < 0.05), no relevant changes in serum or urine creatinine levels could be observed in either group.

CONCLUSIONS

Patients undergoing aortocoronary bypass operations demonstrate a temporary renal dysfunction. Aprotinin impairs renal function in addition by overloading the tubular reabsorption mechanisms. Patients with normal renal function preoperatively--as were included in this study--are able to compensate for both the perioperative renal dysfunction caused by the extracorporeal circulation and the additional tubular damage due to aprotinin.

Preservation of the mitral subvalvular apparatus in multiple valve procedures

The advantages of chordal preservation in mitral valve replacement have been demonstrated, but there is no detailed information available on the effect of chordal preservation in patients undergoing multiple valve operations. We assessed therefore a series of 61 patients who underwent multiple valvular procedures either with (Group A, n = 42) or without (Group B, n = 19) preservation of the subvalvular structures. Echocardiographic examinations were performed preoperatively, seven days and three months postoperatively. In addition clinical and electrocardiographic examinations were performed. Echocardiographic investigations included left atrial, left and right ventricular diameters and left ventricular length. Preoperatively there were no differences between the two groups. Intra- and postoperative management was similar in the two groups. Postoperative clinical and echocardiographic examinations demonstrated that, although beneficial effects were evident in both groups, improvement of left ventricular function and decrease in left ventricular size were more pronounced in patients in whom chordal preservation was possible.