Abstract
Post-operative atrial fibrillation (POAF) is postulated as a complex interaction of different pathogenic factors, suggesting inflammatory processes as a main trigger of this particular type ...of atrial fibrillation. Therefore, the study sought to assess the impact of cellular immunity on the development of POAF. Comparing patients developing POAF to individuals free of POAF the fraction of CD4
+
CD28
null
T Lymphocytes was significantly higher in individuals developing POAF (11.1% POAF vs. 1.9% non-POAF; p < 0.001). CD4
+
CD28
null
cells were independently associated with the development of POAF with an adjusted odds ratio per one standard deviation of 4.89 (95% CI: 2.68–8.97; p < 0.001). Compared to N-terminal Pro-Brain Natriuretic Peptide, the fraction of CD4
+
CD28
null
cells demonstrated an increased discriminatory power for the development of POAF (NRI: 87.9%, p < 0.001; IDI: 30.9%, p < 0.001). Interestingly, a pre-operative statin-therapy was associated with a lower fraction of CD4
+
CD28
null
cells (p < 0.001) and showed an inverse association with POAF (p < 0.001). CD4
+
CD28
null
cells proved to be predictive for the development of POAF after cardiac surgery. Our results potentially indicate an auto-immune impact of this preexisting, highly cytotoxic T cell subset in the pathogenesis of POAF, which might be modified via the anti-inflammatory potential of a pre-operative statin-therapy.
Sternal wound infections are an infrequent but serious complication of cardiac surgery, leading to a prolonged hospital stay, increased costs and greater morbidity. To prevent bacterial colonisation ...of the suture material, which disables local mechanisms of wound decontamination, sutures coated with triclosan were developed. The current study set out to evaluate the effectiveness of such sutures against the development of sternal wound infections after cardiac surgery.
Between October 2006 and October 2007, a total of 963 patients underwent cardiac surgery with a standard median sternotomy and cardiopulmonary bypass at the General Hospital of Vienna (AKH). A total of 198 patients had their wounds closed with normal sutures, and 765 with the new triclosan-coated sutures. Of these 765 patients, 678 received total closure (sternal fascia, subcutaneous tissue and skin) using the new sutures, whereas in 87 patients the new sutures were used only for the sternal fascia. The study was designed as not being double-blinded, and evaluation was carried out retrospectively.
The rate of sternal wound infection was 3.0% in the conventionally closed group, 2.3% in the group with only the sternal fascia closed using triclosan sutures, and 3.2% in the group with total triclosan suture closure (fascia, subcutaneous tissue and skin).
Triclosan-coated sutures therefore showed no advantage in avoiding or reducing sternal wound infections. As the cost of these new materials is higher, the rationale for using these sutures remains to be determined.
To analyze outcome in elderly patients after surgical repair of the ascending aorta and the aortic arch as compared with their younger counterparts and to determine risk factors of mortality and ...permanent neurologic injury.
Between January 1995 and February 2003, a total of 369 patients underwent ascending aortic and arch repair. Indications for surgical intervention were acute type A dissections in 174 (47%) patients (<75 years, n = 147; ≥75 years, n = 27) and chronic atherosclerotic aneurysms in 195 (53%) patients (<75 years, n = 168; ≥75 years, n = 27). Emergency surgery was performed in 167 (45%) patients; 202 patients (54.7%) underwent surgery requiring deep hypothermic circulatory arrest. Pre- and intraoperative factors were evaluated by means of stepwise logistic regression analysis to determine risk factors of mortality and permanent neurologic injury.
Overall in-hospital mortality was 11.6%. In-hospital mortality with regard to indication for surgical intervention was comparable in both age groups (type A dissection: <75 years, 15.6%; ≥75 years, 18.5%;
P = .731; chronic atherosclerotic aneurysm: <75 years, 7.7%; ≥75 years, 7.4%;
P = .933). Permanent neurologic injury was observed in 5.0%. Permanent neurologic injury with regard to surgical intervention was comparable in both age groups (type A dissection: <75 years, 8.8%; ≥75 years, 3.7%;
P = .359; chronic atherosclerotic aneurysm: <75 years, 3.0%; ≥75 years, 3.7%;
P = .843). Stepwise logistic regression analysis revealed preoperative hemodynamic instability (odds ratio 4.3;
P = .000), duration of cardiopulmonary bypass (odds ratio 2.1;
P = .001), and permanent neurologic injury (odds ratio 1.7;
P = .033) but not age as independent predictors affecting mortality. Utilization of but not duration of deep hypothermic circulatory arrest was the only independent predictor of permanent neurologic injury (odds ratio 2.8;
P = .019).
Age shows a trend toward a higher risk of mortality but does not predict a higher incidence of permanent neurologic injury after ascending aortic and arch repair. As utilization of deep hypothermic circulatory arrest remains the only independent predictor of permanent neurologic injury, alternative approaches to maintain cerebral perfusion during ascending aortic and arch repair are warranted.
Purpose:
To determine midterm durability and need for reinterventions after stent-graft placement in atherosclerotic descending thoracic aortic aneurysms.
Methods:
Fifty-four patients (38 men; mean ...age 68 years, range 33–87) underwent stent-graft repair of chronic atherosclerotic aneurysms of the descending thoracic aorta between November 1996 and December 2002. Acute aortic syndromes (type B aortic dissections, perforating ulcers, and traumatic dissections) were excluded from analysis. Two types of commercially available stent-grafts were used (Talent and Excluder).
Results:
The primary technical success rate was 94.4%. In-hospital mortality was 3.7% (2/54). No adverse neurological events were encountered. Of 3 (5.6%) early type I endoleaks, 2 (3.7%) required reintervention; the other type I endoleak closed spontaneously. Mean follow-up was 38 months (range 1–72) in the 52 surviving patients. Four (7.7%) type I, 7 (13.5%) type II, and 4 (7.7%) type III endoleaks were seen. Three 3 patients had additional treatment for endoleaks (proximal stenting type Ia, open thoracoabdominal repair type Ib, and embolization type II). Two of the 3 reinterventions were performed in the first year of follow-up. One additional patient with a type Ia endoleak not suitable for reintervention is under close observation. There were no differences in the number of endoleaks between the 2 types of stent-grafts. Three-year event-free survival was 63%.
Conclusions:
Midterm durability of endovascular stent-graft placement in atherosclerotic descending aortic aneurysms seems promising, as the rate of endoleaks requiring reintervention is acceptably low. In our series, endoleak formation occurred during the first year after stent-graft placement, so close follow-up of patients after aortic aneurysm repair is crucial. Further studies are warranted to evaluate long-term durability of this new treatment modality.
The case of a 63-year-old woman who underwent minimal invasive mitral and tricuspid valve repair and a concomitant CryoMaze is described. During creation of the last lesion of the right-sided maze ...procedure, dissection of the ascending aorta occurred that necessitated emergency sternotomy, replacement of the ascending aorta, and aortocoronary bypass grafting to the right coronary artery (RCA) because of detachment of the RCA from the aortic annulus. Repair of this complication was successful; nevertheless, the patient died 5 days after the operation because of multiorgan failure. The cause of this complication can only be speculated, but a relation to the CyroMaze is obvious. Because of the restricted incision with impaired vision especially in the area of the right atrial appendage, the cryoprobe could have come into contact with the orifice of the RCA during the last lesion, with subsequent detachment of the RCA from the aorta, which could subsequently have caused dissection.
Objective: In the present study, the effectiveness of endovascular stent grafts (ESG) in the treatment of acute aortic complications, such as acute dissection type B, penetrating ulcer and traumatic ...aortic rupture is evaluated. Patients and methods: From June 1997 to February 2002, 66 patients were treated with ESG. Out of this cohort, 19 patients (28.8%) were subjected to stent grafting due to acute aortic syndromes. Acute dissection type B was present in 11 patients (16.6%), a penetrating ulcer was diagnosed in six patients (9%) and in 2 patients (3%) a traumatic aneurysm was the indication for operation. There were 16 male and three female patients with a mean age of 60 years (20–85 years). Excluder™ stent grafts (Gore) were used in 15 patients, the Talent™ device (Medtronic) was implanted in four patients. Results: Stent graft placement was technically successful in all patients. Hospital mortality was 0%. Paraparesis occurred in one patient (5.2%), which could be managed successfully without remaining neurological deficit after installation of cerebrospinal fluid drainage for 72 h. In another patient, overstenting of the left subclavian artery caused ischemia of the left arm and left subclavian to carotid artery bypass had to be performed. ICU-stay ranged from 1 to 6 days (mean 2.4 days) and the patients could be discharged after an average hospital stay of 8 days. In the follow-up period, one patient died due to myocardial infarction and one patient had to be re-operated due to contained rupture of the thoracic aorta caused by an endoleak. Conclusions: The study suggests that endovascular stent grafting is an excellent and effective treatment modality for the acute aortic accident, which can be recommended for high-risk patients too. However, close follow-up examination is indicated and long-term results have to be awaited to evaluate the real effectiveness of this method.
Objectives
The goal of this experimental study was to investigate rescuer exertion when using “Animax,” a manually operated hand‐powered mechanical resuscitation device (MRD) for cardiopulmonary ...resuscitation (CPR), compared to standard basic life support (BLS).
Methods
This was a prospective, open, randomized, crossover simulation study. After being trained, 80 medical students with substantial knowledge in BLS performed one‐rescuer CPR using either the MRD or the standard BLS for 12‐minute intervals in random order. The main outcome parameter was the heart rate pressure product (RPP) as an index of cardiac work. Secondary outcome parameters were physical exhaustion quantified by the Borg scale (measurement of perceived exertion), Nine Hole Peg Test (NHPT; measurement of fine motor skills), and capillary lactate concentration during testing.
Results
While no significant difference could be found for the RPP, a significantly increased mean heart rate during the final minute of standard BLS compared to the MRD was found (139 ± 22 beats/min vs. 135 ± 26 beats/min, p = 0.027). By contrast, subjective exertion using the MRD was rated significantly higher on the Borg scale (15.1 ± 2.4 vs. 14.6 ± 2.6, p = 0.027). Mean serum lactate concentration was significantly higher when the MRD was used compared to standard BLS (3.4 ± 1.5 mmol/L vs. 2.1 ± 1.3 mmol/L, p ≤ 0.001).
Conclusions
Use of the MRD leads to a RPP of the rescuers comparable to standard BLS. These findings suggest that there is no clinically relevant reduction of exertion if this MRD is used by a single rescuer. If this kind of MRD is used for CPR, frequent changeovers with a second rescuer should be considered as the guidelines suggest for standard CPR.
Resumen
El Esfuerzo de un Unico Reanimador Mediante el Uso de un Dispositivo de Resucitación Mecánica: Un Estudio de Simulación Controlado con Asignación Aleatorizada
Objetivos
El objetivo de este estudio experimental fue investigar el esfuerzo de un reanimador cuando se utiliza “Animax”, un dispositivo manual de resucitación mecánica (DRM) para la resucitación cardiopulmonar (RCP), en comparación con el soporte vital básico (SVB) estándar.
Método
Estudio prospectivo de simulación cruzado, abierto y con asignación aleatoria. Tras un entrenamiento inicial, 80 estudiantes de medicina con formación en la realización de SVB llevaron a cabo una RCP con un único resucitador, bien mediante el uso del DRM o mediante SVB estándar durante intervalos de 12 minutos de forma aleatorizada. El resultado principal fue el producto de la presión y la frecuencia cardiaca (PTF) como un indicador de trabajo cardiaco. Los resultados secundarios fueron el cansancio físico cuantificado con la escala de Borg (medida del esfuerzo percibido), el test de Nine Hole Peg (medida de las habilidades motoras finas) y la concentración de lactato capilar durante la prueba.
Resultados
A pesar de no encontrarse una diferencia significativa para la PTF, se encontró un incremento significativo en la media de la frecuencia cardiaca durante el minuto final del SVB comparado con el uso del DRM (139 ± 22 vs. 135 ± 26 lpm, p = 0,027). Por otro lado, el esfuerzo subjetivo fue significativamente mayor en la escala de Borg al usar el DRM (15,1 ± 2,4 vs. 14,6 ± 2,6, p = 0,027). La concentración media de lactato sérico fue significativamente mayor cuando se usó el DRM en comparación con el SVB (3,4 ± 1,5 mmol/l vs. 2,1 ± 1,3 mmol/l, p ≤ 0,001).
Conclusiones
El uso del DRM produce una PTF de los reanimadores comparable con el SVB estándar. Estos hallazgos sugieren que no hay una reducción clínicamente relevante del esfuerzo si el DRM se usa por un único reanimador. Si se usa este tipo de DRM para la RCP, debería considerarse realizar cambios frecuentes con un segundo reanimador tal como sugieren las guías clínicas para la RCP clásica.
Objective: The objective of the study was to evaluate mid-term durability and need for reinterventions after endovascular stent-grafting (ESG) in descending aortic aneurysms and dissections. Patients ...and Methods: Between November 1996 and February 2003 a total of 80 patients underwent ESG for the following indications: atherosclerotic aneurysms (50/80; 63%), type B dissections (20/80; 25%), penetrating ulcers (6/80; 8%), traumatic aneurysms (4/80; 5%). Two types of commercially available ESG (Talent, Medtronic, Santa Rosa, CA and Excluder, WL GORE, Flagstaff, AZ) were inserted via the femoral artery in 53 patients, via the iliac artery in 21 patients and via the abdominal aorta in 6 patients. Results: In-hospital mortality was 3.8% (n=3). Type I endoleak formation requiring endovascular reintervention was observed in 3.8% (n=3). Surgical reintervention became necessary in 4 patients (4/80; 5%). One patient experienced a retrograde type A dissection, detected in the 3 month control after ESG of an acute type B dissection, consecutively undergoing frozen elephant trunc repair. Three patients with late type I endoleak formation (mean interval: 62 months) after ESG (two atherosclerotic aneurysms, one penetrating ulcer) underwent open thoraco-abdominal repair in deep hypothermia or left heart bypass technique. All patients had an uneventful postoperative course. Conclusions: Occurrence of late endoleak formation requiring surgical reintervention after ESG is acceptably low. In atherosclerotic aneurysms the development of endoleaks is assumed to be causative related to progression of the underlying aortic disease. A close follow-up of patients after ESG is crucial.
Abstract
Objective: Integrin-linked kinase (ILK) is a cell membrane-bound molecule implicated in the metastatic progression of many tumour types. It phosphorylates the downstream target AKT ...(phosphorylated AKT, pAKT), and, by doing this, it activates anti-apoptotic pathways. We have recently shown ILK expression in malignant pleural mesothelioma (MPM). To determine whether ILK expression in MPM is connected with pAKT expression, and whether ILK and pAKT expression have any influence on the patient's prognosis, we correlated ILK and pAKT expression, as assessed by immunohistochemistry, with disease-related survival in a retrospective cohort of 80 MPM patients. Material and methods: The paraffin specimens of 80 MPM cases treated from 1990 to 2006 (52 surgical cases, 28 conservative cases) have been retrieved from the archive. The median (range) patients' age was 62 (28-83 years) years; the male-to-female ratio was 3:1. Fifty percent of the patients had an epitheloid subtype. The samples have been stained with anti-ILK as well as with anti-pAKT and scored by two independent pathologists. Intensity of ILK and pAKT expression has been correlated with disease-related survival. Results: In total, 73 of 80 (91%) MPM samples expressed ILK; 65 of 74 (88%) MPM samples expressed pAKT. Comparing the 5-year disease-related survival according to ILK or pAKT expression, no statistically significant difference could be found between ILK and pAKT expressing or non-expressing patients. However, in the subgroup of conservatively treated MPM patients, those with strong ILK expression had a longer 5-year disease-related survival (p ≪ 0.0001). In total, the only prognostic factor across all ILK, pAKT and therapy subgroups was the histological subtype (p = 0.01). The prognostic significance of the histological subtype has been confirmed in multivariate analysis (p = 0.005). Conclusion: The expression of ILK in MPM is connected with the expression of the downstream target pAKT, but neither ILK nor pAKT expression has a measurable influence on the patient's prognosis, except for certain subgroups of MPM. However, to shed light on the true prognostic impact of ILK and pAKT expression in MPM, prospective trials are needed.
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