Regional anticoagulation with citrate during renal replacement therapy (RRT) reduces the risk of bleeding, extends dialyzer lifespan and is cost-effective. Therefore, current guidelines recommend its ...use if patients are not anticoagulated for another reason and if there are no contraindications against citrate. RRT with regional citrate anticoagulation has been established in critically ill patients as continuous veno-venous hemodialysis (CVVHD) to reduce citrate load. However, CVVHD is inferior regarding middle molecule clearance compared to continuous veno-venous hemofiltration (CVVH). The use of a high cut-off dialyzer in CVVHD may thus present an option for middle molecule clearance similar to CVVH. This may allow combining the advantages of both techniques.
In this prospective, randomized, single-blinded single-center-trial, sixty patients with acute renal failure and established indication for renal replacement therapy were randomized 1:1 into two groups. The control group was put on CVVHD using regional citrate anticoagulation and a high-flux dialyzer, while the intervention group was on CVVHD using regional citrate anticoagulation and a high-cut-off dialyzer. The concentrations of urea, creatinine, β2-microglobulin, myoglobin, interleukin 6 and albumin were measured pre- and post-dialyzer 1, 6, 12, 24 and 48 hours after initiating CVVHD.
Mean plasma clearance for β2-microglobulin was 19.6±5.8 ml/min in the intervention group vs. 12.2±3.6 ml/min in the control group (p<0.001). For myoglobin (8.0±4.5 ml/min vs. 0.2±3.6 ml/min, p<0.001) and IL-6 (1.5±4.3 vs. -2.5±3.5 ml/min, p = 0.002) a higher mean plasma clearance using high-cut-off dialyzer could be detected too, but no difference for urea, creatinine and albumin could be observed concerning this parameter between the two groups.
CVVHD using a high cut-off dialyzer results in more effective middle molecule clearance than that with high-flux dialyzer.
German Clinical Trials Register (DRKS00005254, registered 26th November 2013).
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In a multivariate binary logistic regression analysis, chronic hemodialysis (hazard ratio HR: 8.37; 95% confidence interval CI: 2.54 to 27.63; p < 0.001) and peripheral artery disease (HR: 3.77; 95% ...CI: 1.88 to 7.58; p < 0.001) remained the only independent predictors for developing IE. Negative imaging 15/47 (31.9) Total patients with affected prosthetic valve 22/47 (46.8) Vegetation only on prosthetic valve 12/47 (25.5) Vegetation on prosthetic valve and other valve 7/47 (14.9) Vegetation on prosthetic valve and PM/ICD lead 1/47 (2.1) Vegetation on prosthetic valve, PM/ICD lead and other valve 2/47 (4.3) Paravalvular abscess 9/47 (19.1) Vegetation on other valve than prosthetic valve 4/47 (8.5) Vegetation on PM/ICD lead 3/47 (6.4) Vegetation on PM/ICD lead and other valve 3/47 (6.4) Table 1 Characteristics of Patients Without and With Development of Infective Endocarditis Values are mean ± SD, median (interquartile range), or n (%).AR = aortic regurgitation; CKD = chronic kidney disease stage; COPD = chronic obstructive lung disease; ICD = implantable cardioverter-defibrillator; IE = infective endocarditis; PAD = peripheral artery disease; PM = pacemaker; STS = Society of Thoracic Surgeons; TOE = transesophageal echocardiography; ViV = valve-in-valve.
Remote proctoring by advanced digital technologies may help to overcome pandemic, geographic, and resource-related constraints for mentoring and educating interventional cardiology skills. We present ...a case series of patients undergoing high-risk percutaneous coronary intervention (HR-PCI) with mechanical circulatory support (MCS) guided by remote proctoring to gain insights into a streaming technology platform with regard to video/audio quality, visibility of all structural and imaging details, and delay in transmission. According to our experience, remote proctoring appears to be a reliable, quick, and resource-conserving way to disseminate, educate and improve MCS-supported HR-PCI with implications far beyond the COVID-19 pandemic.
Background
Impaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve ...replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement.
Methods and Results
Patients treated by transcatheter aortic valve replacement were primarily separated into normal flow (NF; stroke volume index >35 mL/m2) and low flow (LF; stroke volume index ≤35 mL/m2). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” (NF‐LG), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF, which was characterized by a higher 30‐day (P=0.041) and 3‐year (P<0.001) mortality. LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P=0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P=0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF–high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF–high gradient (24.8%) and NF‐LG (27.9%) (P=0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity.
Conclusions
LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.
Background Infective endocarditis ( IE ) after transcatheter aortic valve replacement is a devastating complication associated with a high mortality. Our objective was to determine the impact of ...cardiac surgery (CS) and antibiotics ( IE - CS ) compared with medical treatment with antibiotics only ( IE - AB x) on 1-year mortality in patients developing IE after transcatheter aortic valve replacement. Methods and Results Patients developing IE after transcatheter aortic valve replacement were included in this retrospective analysis. All-cause 1-year mortality was the primary end point. A total of 20 patients underwent IE - CS compared with 44 patients treated by IE - AB x. In this unmatched cohort, patients treated by IE - AB x were older ( P=0.006), had a higher Society of Thoracic Surgeons score ( P=0.029), and more often had severe chronic kidney disease ( P=0.037). One-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 68.2%; P=0.802). The rate of any complication during treatment was higher in the IE - CS group ( P=0.024). In a matched cohort, baseline characteristics were not significantly different. All-cause 1-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 75%; P=0.490). A Cox regression analysis revealed any indication for surgery (hazard ratio, 6.20; 95% confidence interval, 1.80-21.41; P=0.004), sepsis on admission (hazard ratio, 4.03; 95% confidence interval, 1.97-8.24; P<0.001), and mitral regurgitation ≥2 (hazard ratio, 2.91; 95% confidence interval, 1.33-6.37) as factors associated with 1-year mortality. Conclusions In patients developing IE after transcatheter aortic valve replacement, mortality was predicted by the severity of IE and concomitant mitral regurgitation. In this small, and therefore statistically limited, but high-risk patient cohort, CS provided no significant mortality benefit compared with medical therapy. Individual decision making by a "heart and endocarditis team" is necessary to offer those patients the most reasonable treatment option.
Background
Patients undergoing transcatheter aortic valve replacement (TAVR) are often characterized by risk factors not reflected in conventional risk scores. In this context, little is known about ...the outcome of patients suffering from an active cancer disease (ACD). The objective was to determine the prevalence, clinical characteristics, perioperative outcomes, and mortality of patients with ACD undergoing TAVR compared to those with a history of cancer (HCD) and controls without known tumor disease.
Methods
TAVR patients between 02/2006 and 09/2014 were stratified according to the presence of ACD, HCD, and control. All‐cause‐mortality at 1‐year was the primary end point. All end point definitions were subject to the Valve Academic Research Consortium II definitions.
Results
Overall, 1821 patients were included: 99 patients (5.4%) suffered from ACD and 251 patients (13.8%) had HCD. ACD was related to a solid organ or hematological source in 72.7% and 27.3%, respectively. Patients with ACD were more often male (P = 0.004) and had a lower logisticEuroScore I (P = 0.033). Overall rates of VARC‐II defined periprocedural myocardial infarction, stroke, bleeding, access‐site complications, and acute kidney injury were not different between groups. Thirty‐day mortality did not differ between patients with ACD, HCD, and controls (6.1% vs 4.4% vs 7.6%, P = 0.176). All‐cause 1‐year mortality was higher in patients with ACD compared HCD and controls (37.4% vs 16.4% vs 20.8%, P < 0.001). ACD was an independent predictor of all‐cause 1‐year mortality (HR 2.10, 95%‐CI 1.41‐3.13, P < 0.001).
Conclusion
The presence of ACD in patients undergoing TAVR is associated with significantly higher 1‐year mortality.
Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was the aim of this ...study to identify a simple and reproducible hemodynamic parameter for the assessment of AR.
Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes.
Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPT indexadj = (DPT index/systolic blood pressure) × 100.
Patients with angiographically nonrelevant AR (grade <2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade ≥2) (26.2 ± 5.8) (p < 0.05). Patients with DPT indexadj ≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p log rank-test < 0.001). In multivariate regression analysis, DPT indexadj ≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p < 0.001).
DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiate between relevant and nonrelevant AR after TAVR.
Abstract Objectives Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was ...the aim of this study to identify a simple and reproducible hemodynamic parameter for the assessment of AR. Background Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes. Methods Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPT indexadj = (DPT index/systolic blood pressure) × 100. Results Patients with angiographically nonrelevant AR (grade <2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade ≥2) (26.2 ± 5.8) (p < 0.05). Patients with DPT indexadj ≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p log rank-test < 0.001). In multivariate regression analysis, DPT indexadj ≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p < 0.001). Conclusions DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiate between relevant and nonrelevant AR after TAVR.
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