Objective Technical controversies exist in valve-preserving aortic root replacement. We sought to determine predictors of long-term stability of the aortic valve. Methods A total of 430 patients ...(aged 57 ± 15 years, 323 male) underwent valve-preserving aortic root surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the aortic valve (n = 25) were analyzed. Results Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the aortic cusp less than 9 mm were identified as significant predictors for late aortic valve regurgitation grade II or greater in multivariate analysis (both P < .001). Ten-year freedom from reoperation on the aortic valve was 89.3% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm ( P < .001), use of pericardial patch ( P = .022), and effective height of the aortic cusp less than 9 mm ( P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from aortic valve regurgitation grade II or greater ( P = .006) regardless of root procedures (remodeling, P = .011; reimplantation, P = .053). Conclusions Long-term stability of valve-preserving aortic root replacement was influenced not by the technique of root repair but by the preoperative aortic root geometry and postoperative cusp configuration.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Levosimendan in Sepsis Groesdonk, Heinrich‑Volker; Sander, Michael; Heringlake, Matthias
The New England journal of medicine,
02/2017, Volume:
376, Issue:
8
Journal Article
Objective Nonocclusive mesenteric ischemia (NOMI) may occur after cardiopulmonary bypass. It is crucial to early identify patients who are at risk of developing this complication. The aim of this ...prospective study was to evaluate perioperative risk factors in a large cohort of patients undergoing elective cardiac surgery. Methods From January 1, 2010, to March 31, 2011, all patients scheduled for elective cardiac surgery were screened for participation in this trial. If NOMI was suspected, arterial angiography was performed. NOMI and non-NOMI patients were compared with respect to all variables assessed in this study. Additionally, odds ratios were calculated. Linear discriminant analyses as well as logistic regression analyses were performed to develop a model that identifies patients at risk for developing NOMI. Results Eight hundred sixty-five patients were included in the study, of whom 78 developed NOMI. Among preoperative parameters, renal insufficiency, diuretic therapy, and age >70 years showed the highest odds ratios for postoperative NOMI. The highest odds ratios for development of NOMI were observed with postoperative variables. In particular, the need for intra-aortic balloon pump support and serum lactate concentrations >5 mmol/L proved to be serious risk factors. Using a linear discriminant analysis with 7 variables, 92.3% of patients were correctly classified (sensitivity 76.9%, specificity 93.8%). Conclusions A high index of suspicion for NOMI in patients with the above-mentioned risk factors may decrease the diagnostic and therapeutic delay. To identify at-risk patients the developed risk equation is a useful tool with a high specificity.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background: The intensive care unit (ICU) is a scarce resource in all health care systems, necessitating a well-defined utilization. Therefore, benchmarks are essential; and yet, they are limited due ...to heterogenous definitions of what an ICU is. This study analyzed the case distribution, patient characteristics, and hospital course and outcomes of 6,204,093 patients in the German Helios Hospital Group according to 10 derived ICU definitions. We aimed to set a baseline for the development of a nationwide, uniform ICU definition. Methods: We analyzed ten different ICU definitions: seven derived from the German administrative data set of claims data according to the German Hospital Remuneration Act, three definitions were taken from the Helios Hospital Group’s own bed classification. For each ICU definition, the size of the respective ICU population was analyzed. Due to similar patient characteristics for all ten definitions, we selected three indicator definitions to additionally test statistically against IQM. Results: We analyzed a total of 5,980,702 completed hospital cases, out of which 913,402 referred to an ICU criterion (14.7% of all cases). A key finding is the significant variability in ICU population size, depending on definitions. The most restrictive definition of only mechanical ventilation (DOV definition) resulted in 111,966 (1.9%) cases; mechanical ventilation plus typical intensive care procedure codes (IQM definition) resulted in 210,147 (3.5%) cases; defining each single bed individually as ICU or IMC (ICUᴧIMC definition) resulted in 411,681 (6.9%) cases; and defining any coded length of stay at ICU (LOSi definition) resulted in 721,293 (12.1%) cases. Further testing results for indicator definitions are reported. Conclusions: The size of the population, utilization rates, outcomes, and capacity assumptions clearly depend on the definition of ICU. Therefore, the underlying ICU definition should be stated when making any comparisons. From previous studies, we anticipated that 25–30% of all ICU patients should be mechanically ventilated, and therefore, we conclude that the ICUᴧIMC definition is the most plausible approximation. We suggest a mandatory application of a clearly defined ICU term for all hospitals nationwide for improved benchmarking and data analysis.
OBJECTIVES:To characterize volatile organic compounds in breath exhaled by ventilated care patients with acute kidney injury and changes over time during dialysis.
DESIGN:Prospective observational ...feasibility study.
SETTING:Critically ill patients on an ICU in a University Hospital, Germany.
PATIENTS:Twenty sedated, intubated, and mechanically ventilated patients with acute kidney injury and indication for dialysis.
INTERVENTIONS:Patients exhalome was evaluated from at least 30 minutes before to 7 hours after beginning of continuous venovenous hemodialysis.
MEASUREMENTS AND MAIN RESULTS:Expired air samples were aspirated from the breathing circuit at 20-minute intervals and analyzed using multicapillary column ion-mobility spectrometry. Volatile organic compound intensities were compared with a ventilated control group with normal renal function. A total of 60 different signals were detected by multicapillary column ion-mobility spectrometry, of which 44 could be identified. Thirty-four volatiles decreased during hemodialysis, whereas 26 remained unaffected. Forty-five signals showed significant higher intensities in patients with acute kidney injury compared with control patients with normal renal function. Among these, 30 decreased significantly during hemodialysis. Volatile cyclohexanol (23 mV; 2575th, 19–38), 3-hydroxy-2-butanone (16 mV, 9–26), 3-methylbutanal (20 mV; 14–26), and dimer of isoprene (26 mV; 18–32) showed significant higher intensities in acute kidney impairment compared with control group (12 mV; 10–16 and 8 mV; 7–14 and not detectable and 4 mV; 0–6; p < 0.05) and a significant decline after 7 hours of continuous venovenous hemodialysis (16 mV; 13–21 and 7 mV; 6–13 and 9 mV; 8–13 and 14 mV; 10–19).
CONCLUSIONS:Exhaled concentrations of 45 volatile organic compounds were greater in critically ill patients with acute kidney injury than in patients with normal renal function. Concentrations of two-thirds progressively decreased during dialysis. Exhalome analysis may help quantify the severity of acute kidney injury and to gauge the efficacy of dialysis.
Levosimendan in Sepsis Groesdonk, Heinrich-Volker; Sander, Michael; Heringlake, Matthias ...
The New England journal of medicine,
02/2017, Volume:
376, Issue:
8
Journal Article
Peer reviewed
Open access
To the Editor:
Like many critical care physicians, we excitedly awaited the results of the Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis (LeoPARDS) trial by Gordon et al. (Oct. ...27 issue)
1
to find out whether to use levosimendan in hemodynamically unstable patients with sepsis. The rationale for using levosimendan in sepsis is based on studies that have shown a mortality benefit among patients with septic cardiomyopathy who were treated with levosimendan.
2
,
3
Unfortunately, the number of patients with myocardial dysfunction who were included in the LeoPARDS trial was evidently rather low, according to the sparse hemodynamic information . . .
Background: To assess the risk of aspiration, nutrient tolerance, and gastric emptying of patients in ICUs, gastric ultrasound can provide information about the gastric contents. Using established ...formulas, the gastric residual volume (GRV) can be calculated in a standardized way by measuring the gastric antrum. The purpose of this study was to determine the GRV in a cohort of enterally fed patients using a miniaturized ultrasound device to achieve knowledge about feasibility and the GRV over time during the ICU stay. The findings could contribute to the optimization of enteral nutrition (EN) therapy. Methods: A total of 217 ultrasound examinations with 3 measurements each (651 measurements in total) were performed twice daily (morning and evening) in a longitudinal observational study on 18 patients with EN in the interdisciplinary surgical ICU of Saarland University Medical Center. The measured values of the GRV were analyzed in relation to the clinical course, the nutrition, and other parameters. Results: Measurements could be performed without interrupting the flow of clinical care and without pausing EN. The GRV was significantly larger with sparsely auscultated bowel sounds than with normal and excited bowel sounds (p < 0.01). Furthermore, a significantly larger GRV was present when using a high-caloric/low-protein nutritional product compared to an isocaloric product (p = 0.02). The GRV at the morning and evening measurements showed no circadian rhythm. When comparing the first and last ultrasound examination of each patient, there was a tendency towards an increased GRV (p = 0.07). Conclusion: The GRV measured by miniaturized ultrasound devices can provide important information about ICU patients without restricting treatment procedures in the ICU. Measurements are possible while EN therapy is ongoing. Further studies are needed to establish gastric ultrasound as a management tool in nutrition therapy.
BACKGROUND:Presepsin (soluble cluster-of-differentiation 14 subtype sCD14-ST) is a humoral risk stratification marker for systemic inflammatory response syndrome and sepsis. It remains unknown ...whether presepsin can be used to stratify risk in elective cardiac surgery. The authors therefore determined the usefulness of presepsin for risk stratification in patients having elective cardiac surgery.
METHODS:Eight hundred fifty-six cardiac surgical patients were prospectively studied. Preoperative plasma concentrations of presepsin, procalcitonin, N-terminal pro–hormone natriuretic peptide, cystatin C, and the additive European System of Cardiac Operative Risk Evaluation 2 were compared to mortality at 30 days (primary outcome), 6 months, and 2 yr. Discrimination was assessed with C statistic. Logistic regression analysis was used to calculate univariable and multivariable odds ratios.
RESULTS:Thirty-day mortality was 3.2%, 6-month mortality was 6.1%, and 2-yr mortality was 10.4% across the population. Median preoperative presepsin concentrations were significantly greater in 30-day nonsurvivors than in survivors842 pg/ml (interquartile range, 306 to 1,246) versus 160 pg/ml (interquartile range, 122 to 234); difference, 167 pg/ml (interquartile range, 92 to 301; P < 0.001). The results were similar for 6-month and 2-yr mortality. Compared to the European System of Cardiac Operative Risk Evaluation 2, presepsin concentration provided better discrimination for postoperative mortality at all follow-up periods, including 30 days (C statistic 0.88 vs. 0.74), 6 months (0.87 vs. 0.76), and 2 yr (0.81 vs. 0.74). Presepsin also provided better discrimination than cystatin C, N-terminal pro–hormone natriuretic peptide, or procalcitonin. Elevated presepsin remained an independent risk predictor after adjustment for potential confounding factors.
CONCLUSIONS:Elevated preoperative plasma presepsin concentration is an independent predictor of postoperative mortality in elective cardiac surgery patients and is a stronger predictor than several other commonly used assessments.
Transthoracic echocardiography is the primary imaging modality for diagnosing cardiac conditions but medical education in this field is limited. We tested the hypothesis that a structured theoretical ...and supervised practical course of training in focused echocardiography in last year medical students results in a more accurate assessment and more precise calculation of left ventricular ejection fraction after ten patient examinations.
After a theoretical introduction course 25 last year medical students performed ten transthoracic echocardiographic examination blocks in postsurgical patients. Left ventricular function was evaluated both with an eye-balling method and with the calculated ejection fraction using diameter and area of left ventricles. Each examination block was controlled by a certified and blinded tutor. Bias and precision of measurements were assessed with Bland and Altman method.
Using the eye-balling method students agreed with the tutor's findings both at the beginning (88%) but more at the end of the course (95.7%). The variation between student and tutor for calculation of area, diameter and ejection fraction, respectively, was significantly lower in examination block 10 than in examination block 1 (each p < 0.001). Students underestimated both the length and the area of the left ventricle at the outset, as complete imaging of the left heart in the ultrasound sector was initially unsuccessful.
A structured theoretical and practical transthoracic echocardiography course of training for last year medical students provides a clear and measurable learning experience in assessing and measuring left ventricular function. At least 14 examination blocks are necessary to achieve 90% agreement of correct determination of the ejection fraction.
Background
Procalcitonin (PCT) is a well-known prognostic marker after elective cardiac surgery. However, the impact of elevated PCT in patients with an initially uneventful postoperative course is ...still unclear. The aim of this study was to evaluate PCT levels as a prognostic tool for delayed complications after elective cardiac surgery.
Methods
A prospective study was performed in 751 patients with an apparently uneventful postoperative course within the first 24 h after elective cardiac surgery. Serum PCT concentration was taken the morning after surgery. All patients were screened for the occurrence of delayed complications. Delayed complications were defined by in-hospital death, intensive care unit readmission, or prolonged length of hospital stay (>12 days). Odds ratios (OR) with 95% confidence interval (CI) were calculated by logistic regression analyses and adjusted for confounders. Predictive capacity of PCT for delayed complications was calculated by ROC analyses. The cutoff value of PCT was derived from the Youden Index calculation.
Results
Among 751 patients with an initially uneventful postoperative course, 117 patients developed delayed complications. Serum PCT levels the first postoperative day were significantly higher in these 117 patients (8.9 ng/ml) compared to the remaining 634 (0.9 ng/ml;
p
< 0.001). ROC analyses showed that PCT had a high accuracy to predict delayed complications (optimal cutoff value of 2.95 ng/ml, AUC of 0.90, sensitivity 73% and specificity 97%). Patients with PCT levels above 2.95 ng/ml the first postoperative day had a highly increased risk of delayed complications (adjusted OR, 110.2; 95% CI 51.5–235.5;
p
< 0.001).
Conclusions
A single measurement of PCT seems to be a useful tool to identify patients at risk of delayed complications despite an initially uneventful postoperative course.
PDF
