Need For Catecholamines Research Articles

Association of soluble ST2 with heart failure and other comorbidities in patients with severe coronary heart disease

Abstract Background Circulating levels of soluble suppression of tumorigenicity-2 (sST2) reflect vascular congestion, inflammation, and fibrosis. sST2 has been proposed as a useful biomarker to predict the mortality and hospitalization due to heart failure. However, there is limited evidence regarding the relationship between sST2 and heart failure, as well as other comorbidities, in severe coronary heart disease (CAD). Purpose This study aims to measure the circulating levels of soluble ST2 (sST2) in a large population of patients with severe CAD to determine its association with heart failure, cardiac function, inflammation, and other important comorbidities. Methods This subanalysis is part of the ongoing perspective observational study. Available serum samples from 520 patients undergoing elective coronary artery bypass grafting (CABG) were analysed for sST2 levels. The inclusion criteria were written informed consent and age between 18-85 years. Exclusion criteria for this analysis were severe valvular disease, severe chronic obstructive pulmonary disease, oxygen therapy, nocturnal positive airway pressure support or mechanical ventilation, and the need for catecholamines or circulatory assist devices. The circulating levels of human sST2 were measured from frozen serum (-80°C) using commercially available ELISA kits. The plasma was diluted 100 times to detect sST2 levels (assay range of 31.2 - 2,000 pg/mL). Two measurements were taken to account as means for intra-assay variabilities. Logarithmic transformation was used to convert non-normal distributed data. Student t' test and linear regression were applied to categorical or continuous variables as appropriate. Results sST2 levels (median 20.4 ng/ml, [IQR 15.5 – 28.8]) significantly predict worse left ventricular ejection fraction (β = -0.164, p = 0.006), and significantly correlate with levels of NT-proBNP (β = 3.263, p < 0.001), hs-Troponin T (β = 3.391, p < 0.001), high-sensitivity C-reactive protein (β = 2.472, p = 0.014) and heart failure (p= 0.002). Interestingly, common comorbidities such as chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m2, p = 0.004), diabetes mellitus (p = 0.001) and higher levels of glycated haemoglobin (HbA1c, β = 3.615, p < 0.001) showed also a significant association with sST2 levels. No significant association of sST2 was observed with arterial hypertension (p = 0.190), atrial fibrillation (p = 0.289), obesity (BMI ≥ 30 kg/m2, p = 0.302), sleep apnoea (apnoea-hypopnoea index ≥ 15/h, p = 0.068), peripheral artery disease (p = 0.823), or previous stroke (p = 0.861). Conclusion(s) Circulating levels of sST2 significantly correlate with heart failure, NT-proBNP, hs-TnT, and hs-CRP in patients with severe CAD. Additionally, sST2 levels were found to be elevated in patients with diabetes mellitus and chronic kidney disease.

Suprathel® and water-filtered infrared-A radiation (wIRA) as a new treatment strategy for toxic epidermal necrolysis (TEN): A prospective study

Toxic epidermal necrolysis (TEN) is a life-threatening condition with a mortality rate of approximately 25% to 30%. Early and adequate wound coverage is necessary due to largescale skin defects. Suprathel® is a modern wound dressing that shows promising results when treating superficial wounds such as scald, burns and abrasions. Previous reports on wound care in TEN patients using Suprathel® have described radical debridement of the entire affected body surface prior to the application of Suprathel®. However, the heavy wound secretion frequently results in the loss of a significant portions of Suprathel® over time. Prolonged operation time increases the risk of hypothermia. In addition, the large open wound areas result in an increased risk for hypovolemic shock, wound infection, and subsequent sepsis. This study presents a new strategy that involves serial hydrotherapeutic wound debridement and the stepwise application of Suprathel® to the affected areas. Water-filtered infrared A light (wIRA) was used to keep the Suprathel®-covered areas dry. Retrospective data from patients who received polyhexanide gel treatment (control group 1) and those who only received Suprathel® (control group 2) were collected for matched-pair analysis. The length of stay in the intensive care unit (ICU) and the need for catecholamines were compared among the three groups. By using serial debridement and combining wIRA treatment with Suprathel® dressings, we were able to significantly reduce the need for catecholamines, lower the risk of hypothermia and infection, and shorten ICU stay compared to the two control groups. We propose incorporating this methodology into the standard of care to promote wound closure and healing when treating TEN patients.

Normothermic Machine Perfusion Reduces Transfusion Requirements Even After Static Cold Storage: A 1 y Retrospective Single-center Analysis.

Normothermic machine perfusion (NMP) of liver grafts has been shown to reduce intraoperative catecholamine consumption and the need for allogenic blood products after reperfusion compared with organs undergoing classical static cold storage (SCS). This study aimed to investigate the effects of an NMP phase after SCS (NMP after SCS) of liver grafts in terms of postreperfusion hemodynamics and transfusion requirements. Eighteen recipients of NMP after SCS grafts were matched according to recipient age, donor age, and model for end-stage liver disease score in a 1:2 ratio with recipients of an SCS graft. Postreperfusion hemodynamics and the need for catecholamines, blood products, and clotting factors were compared. After reperfusion of the organ, patients in the NMP after SCS group showed significantly reduced transfusion requirements for packed red blood cells and platelet concentrates compared with patients of the SCS group (P < 0.001 and P = 0.018, respectively). In addition, patients in the NMP after SCS group received less fibrinogen concentrate (NMP after SCS group 0 [0-1.5] g versus SCS group 2 [0-4] g; P = 0.0163). No differences in postreperfusion hemodynamics could be detected between groups. This retrospective analysis shows that NMP reduces postreperfusion requirements of red blood cells, platelet concentrates, and fibrinogen concentrate even if installed after a phase of organ SCS, because it may be practiced on most centers where NMP is available.

Valve unit instead of intensive or intermediate care unit admission following transcatheter edge-to-edge mitral valve repair is safe and reduces postprocedural complications.

Transcatheter edge-to-edge mitral valve repair (M-TEER) is often performed in general anesthesia, and postprocedural monitoring is usually warranted on an intensive or intermediate care unit (ICU/IMC). We evaluated the implications of a dedicated valve unit (VU) instead of an ICU/IMC for monitoring after M-TEER. In total, 624 patients were retrospectively analyzed. A total of 312 patients were primarily transferred to either ICU or IMC following M-TEER, and 312 patients were scheduled for the VU in the absence of indications for ICU/IMC treatment. Hospital stay was significantly shorter in VU patients (median 6.0days (interquartile range (IQR) 5.0 - 8.0) vs. 7.0days (IQR 6.0 - 10.0), p < 0.001) and their risk for infections (2.9 vs. 7.7%, p = 0.008) and delirium (0.6 vs. 2.6%, p = 0.056) was substantially lower compared to ICU/IMC patients. In-hospital mortality was similar in both groups (0.6% vs. 1.3%, p = 0.41). Fifty patients (16.0%) in the VU group had to cross over to unplanned ICU/IMC admission. The most frequent indication was prolonged need for catecholamines (52.0%). Patients with ICU/IMC crossover had more advanced stages of heart failure (LV-EF < 30% in 36.0 vs. 16.0%, p = 0.001; severe concomitant tricuspid regurgitation in 48.0 vs. 27.8%, p = 0.005) and an LV-EF < 30% was independently associated with unplanned ICU/IMC admission. Following M-TEER postprocedural monitoring on a VU instead of an ICU/IMC is safe, reduces complications, and spares ICU capacities. Patients with advanced heart failure have a higher risk for unplanned ICU/IMC treatment after M-TEER.

Evaluation of New Cardiac Damage Biomarkers in Polytrauma: GDF-15, HFABP and uPAR for Predicting Patient Outcomes.

Background: Polytrauma is one of the leading mortality factors in younger patients, and in particular, the presence of cardiac damage correlates with a poor prognosis. Currently, troponin T is the gold standard, although troponin is limited as a biomarker. Therefore, there is a need for new biomarkers of cardiac damage early after trauma. Methods: Polytraumatized patients (ISS ≥ 16) were divided into two groups: those with cardiac damage (troponin T > 50 pg/mL, n = 37) and those without cardiac damage (troponin T < 12 pg/mL, n = 32) on admission to the hospital. Patients' plasma was collected in the emergency room 24 h after trauma, and plasma from healthy volunteers (n = 10) was sampled. The plasma was analyzed for the expression of HFABP, GDF-15 and uPAR proteins, as well as miR-21, miR-29, miR-34, miR-122, miR-125b, miR-133, miR-194, miR-204, and miR-155. Results were correlated with patients' outcomes. Results: HFABP, uPAR, and GDF-15 were increased in polytraumatized patients with cardiac damage (p < 0.001) with a need for catecholamines. HFABP was increased in non-survivors. Analysis of systemic miRNA concentrations showed a significant increase in miR-133 (p < 0.01) and miR-21 (p < 0.05) in patients with cardiac damage. Conclusion: All tested plasma proteins, miR-133, and miR-21 were found to reflect the cardiac damage in polytrauma patients. GDF-15 and HFABP were shown to strongly correlate with patients' outcomes.

CD44+ and CD31+ extracellular vesicles (EVs) are significantly reduced in polytraumatized patients with hemorrhagic shock - evaluation of their diagnostic and prognostic potential.

Hemorrhagic shock (HS) is responsible for approximately 2 million deaths per year worldwide and is caused in 80% by polytrauma. These patients need a precise and quick diagnostic, which should be based on a combination of laboratory markers and radiological data. Extracellular vesicles (EVs) were described as potential new markers and mediators in trauma. The aim of the present study was to analyze, whether the surface epitopes of plasma-EVs reflect HS in polytraumatized patients and whether cell-specific EV subpopulations are useful diagnostic tools. Plasma samples from polytraumatized patients (ISS ≥16) with HS (n=10) and without (n=15), were collected at emergency room (ER) and 24h after trauma. Plasma-EVs were isolated via size exclusion chromatography and EV-concentrations were detected by Coomassie Plus (Bradford) Assay. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with healthy controls (n=10). To investigate the diagnostic and prognostic potential of EVs subpopulations, results were correlated with clinical outcome parameters documented in the electronical patients' record. We observed a significant reduction of the total amount of plasma EVs in polytrauma patients with HS, as compared to polytrauma patients without HS and healthy controls. We found significant reduction of CD42a+ and CD41b+ (platelet-derived) EVs in all polytrauma patients, as well as a reduction of CD29+ EVs compared to healthy volunteers (*p<0.05). CD44+ and CD31+ EVs were specifically altered in patients with HS (*p<0.05). Both EV populations showed a moderate correlation (r² = 0.42) with the transfusion of erythrocyte concentrate, were associated with non-survival and the need for catecholamines (*p<0.05). Our data reveal that polytrauma patients with a hemorrhagic shock are characterized by a reduction of CD44+ and CD31+ plasma-EVs. Both EV populations showed a moderate correlation with the need of erythrocyte transfusion, were associated with non-survival and the need for catecholamines.

A Single-Center Retrospective Study of Selected Clinical Parameters and Intraoperative Fluid Management of Patients Undergoing Pancreatoduodenectomy.

BackgroundPancreatoduodenectomy is an extensive procedure with a very high risk of complications. Appropriate intraoperative fluid therapy is a subject of ongoing debate. The aim of this retrospective study was to analyze the relationship between selected preoperative parameters, intraoperative fluid therapy, and catecholamines administration during pancreatoduodenectomy.Material/Methods: From 2011 through 2017, among pancreatoduodenectomies performed at a single university hospital, 192 patients met the inclusion criteria of the study: 105 (54.7%) males and 87 (45.3%) females with a mean age of 60.06 (±11.63) years. Correlations were assessed between sex, age, body mass index (BMI), selected comorbidities, surgery duration, American Society of Anesthesiologists (ASA) Physical Status (PS) scale, preoperative endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative catecholamine administration, intraoperative fluid supply, red blood cell (RBC) concentrate and fresh frozen plasma (FFP) supply, blood loss, and diuresis.ResultsA need for catecholamines has been shown to be more frequent in smokers (P=0.01), patients with cardiovascular comorbidities (P=0.037), high ASA PS scores (P=0.003), and preoperative ERCP (P=0.011). The need for intraoperative transfusion of RBC concentrate was more frequent in smokers (P=0.005). Surgical time was significantly longer in males (P=0.014). Among females, liberal intraoperative fluid therapy (>7.9 ml/kg/h) was more frequent in patients with thyroid comorbidities (P=0.003).ConclusionsThe findings of this retrospective study demonstrate the influence of comorbidities, ASA PS class, and catecholamine use on fluid therapy during pancreatoduodenectomy.

Outcome After Thrombolysis in Patients With Intermediate High-Risk Pulmonary Embolism: A Propensity Score Analysis.

The role of thrombolytic treatment in patients with intermediate high-risk pulmonary embolism (IHR-PE) remains controversial. In this study, we assessed whether systemic thrombolysis decreases hemodynamic decompensation and mortality in a cohort of unselected patients with IHR compared with patients with conventional anticoagulation. Between January 2014 and December 2018, 137 patients with IHR-PE were identified among 539 consecutive patients treated for symptomatic PE. In 35 patients (25.5%), systemic thrombolysis was used. Propensity score matching was performed based on 17 pretreatment variables. The primary outcome was hemodynamic decompensation, defined by systolic hypotension, need for catecholamines or signs of end-organ hypoperfusion, and all-cause mortality during hospitalization. Secondary outcomes, such as 1-year survival, and safety outcomes, such as bleeding events, were analyzed. The effects of systemic thrombolysis and anticoagulation were compared in 55 matched patients with IHR-PE (systemic thrombolysis n=21; anticoagulation n=34). Thrombolysis was associated with a reduction (0% vs. 31%; p=0.004) of the primary outcome during hospitalization and a 1-year survival benefit (100% vs. 83.2%; p=0.036). Severe bleeding events occurred in 4.8% vs. 0% (p=0.382) and moderate bleeding was observed in 14.3% vs. 7.1% (p=0.359) in patients with thrombolysis compared with anticoagulation, respectively. Thrombolysis was associated with a significant reduction of the combined endpoint of hemodynamic decompensation and death during hospitalization and lower all-cause mortality after 1 year in an unselected group of patients with IHR-PE. Further studies are required to improve the therapy of IHR-PE and to identify the subgroup of patients that might benefit from thrombolytic therapy.

Midwall Fibrosis and Cardiac Mechanics: Rigid Body Rotation Is a Novel Marker of Disease Severity in Pediatric Primary Dilated Cardiomyopathy

BackgroundMidwall fibrosis (MWF) detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) predicts adverse outcome in adults with dilated cardiomyopathy (DCM). Its relevance in children and adolescents is relatively unknown. Left ventricular (LV) strain, rotation and twist are important parameters of cardiac function; yet, their role in pediatric heart failure is understudied. This study aimed to evaluate MWF and cardiac mechanics in pediatric DCM.MethodsPatients ≤21 years with primary DCM were prospectively enrolled and underwent standardized CMR including LGE. All participants were categorized according to the presence or absence of MWF (MWF+ vs. MWF–). Cardiac mechanics were assessed using CMR feature tracking. Impaired LV twist with apex and base rotating in the same direction was termed rigid body rotation (RBR).ResultsIn total, 17 patients (median age 11.2 years) were included. MWF was present in seven patients (41%). Median N-terminal pro brain natriuretic peptide (NT-proBNP) was higher (5,959 vs. 242 pg/ml, p = 0.887) and LV ejection fraction (LVEF) lower (28 vs. 39%, p = 0.536) in MWF+ vs. MWF– patients, yet differences were not statistically significant. MWF+ patients had reduced global longitudinal (GLS), circumferential (GCS) and radial strain (GRS), again without statistical significance (p = 0.713, 0.492 and 1.000, respectively). A relationship between MWF and adverse outcome was not seen (p = 0.637). RBR was more common in MWF+ (67 vs. 50%), and was associated with the occurrence of adverse events (p = 0.041). Patients with RBR more frequently were in higher New York Heart Association classes (p = 0.035), had elevated NT-proBNP levels (p = 0.002) and higher need for catecholamines (p = 0.001). RBR was related to reduced GLS (p = 0.008), GCS (p = 0.031), GRS (p = 0.012), LV twist (p = 0.008), peak apical rotation (p < 0.001), and LVEF (p = 0.001), elevated LV end-diastolic volume (p = 0.023) and LV end-systolic volume (p = 0.003), and lower right ventricular stroke volume (p = 0.023).ConclusionsMWF was common, but failed to predict heart failure. RBR was associated with clinical and biventricular functional signs of heart failure as well as the occurrence of adverse events. Our findings suggest that RBR may predict outcomes and may serve as a novel marker of disease severity in pediatric DCM.Clinical Trial Registration: https://clinicaltrials.gov/, identifier: NCT03572569.

Outcome of patients with non‐ischaemic cardiogenic shock supported by percutaneous left ventricular assist device

AimsPercutaneous left ventricular assist devices (pVADs) are used to haemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI). One out of every two patients has a non‐ischaemic cause of CS, and these patients differ profoundly from patients with AMI‐related CS. We assessed the usefulness of pVAD support for patients with non‐ischaemic CS.Methods and resultsWe analysed 106 patients with CS and Impella® support between 2015 and 2018. CS was non‐ischaemic in 36 patients and AMI‐related in 70 patients. Compared with the AMI group, those in the non‐ischaemic group were significantly younger [median age 62 (50.8, 70.8) years vs. 68 (58.0, 75.5) years, P = 0.007] and had more patients with severely reduced left ventricular function (94% vs. 79%, P = 0.035) and worse glomerular filtration rate [45 (27, 57) mL/min vs. 60 (44, 78) mL/min]. Propensity score matching yielded 31 patients with non‐ischaemic CS and 31 patients with AMI‐related CS, without a difference in baseline laboratory values or comorbidities. In both groups, pVAD support was performed along with haemodynamic stabilization, reduction of catecholamines and normalization of lactate levels. In 7 days, systolic blood pressure increased from 91 (80, 101) mmHg at baseline to 100 (100, 120) mmHg in the non‐ischaemic CS group (P = 0.001) and 89 (80, 100) mmHg at baseline to 112 (100, 128) mmHg in the AMI‐related CS group (P = 0.001). Moreover, in 7 days, the need of catecholamines (calculated as vasoactive‐inotropic score) decreased from 32.0 (11.1, 47.0) at baseline to 5.3 (0, 16.1) in the non‐ischaemic group (P = 0.001) and from 35.2 (18.11, 67.0) to zero (0, 0) in the AMI‐related CS group (P = 0.001). Lactate level decreased from 3.8 (2.8, 5.9) mmol/L at baseline to 1.0 (0.8, 2.1) mmol/L (P = 0.001) in the non‐ischaemic CS group and from 3.8 (2.6, 6.5) mmol/L to 1.2 (1.0, 2.0) mmol/L in the AMI‐related group (P = 0.001).In the non‐ischaemic CS group, eight patients (25.8%) were upgraded to veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) or long‐term mechanical circulatory support. Two of these upgraded patients received heart transplantation. In the AMI group, eight patients (25.8%) were upgraded to VA‐ECMO or long‐term mechanical circulatory support. Ninety‐day survival did not significantly differ between the groups (non‐ischaemic CS group 48.4%, AMI‐related CS group 45.2%, P = 0.799).ConclusionspVAD support is useful for haemodynamic stabilization of patients with non‐ischaemic CS and is valuable as a bridge to patients' recovery or long‐term left ventricular support and heart transplantation.

Pilot analysis of the usefulness of mortality risk score systems at resuscitated patients

Sudden cardiac death is one of the most significant cardiovascular causes of death worldwide. Although there have been immense methodological and technical advances in the field of cardiopulmonary resuscitation and following intensive care in the last decade, currently there are only a few validated risk-stratification scoring systems for the quick and reliable estimation of the mortality risk of these patients at the time of admission to the intensive care unit. Our aim was to correlate the mortality prediction risk points calculated by CardShock Risk Score (CSRS) and modified (m) CSRS based on the admission data of the post-cardiac arrest syndrome (PCAS) patients. The medical records of 172 out-of-hospital resuscitated cardiac arrest patients, who were admitted at the Heart and Vascular Centre of Semmelweis University, were screened retrospectively. Out of the 172 selected patients, 123 were eligible for inclusion to calculate CSRS and mCSRS. Based on CSRS score, we generated three different groups of patients, with scores 1 to 3, 4 to 6, and 7+, respectively. Mortality data of the groups were compared by log-rank test. Mean age of the patients was 63.6 years (69% male), the cause of sudden cardiac death was acut coronary syndrome in 80% of the cases. The early and late mortality was predicted by neurological status, serum lactate level, renal function, initial rhythm, and the need of catecholamines. Using mCSRS, a significant survival difference was proven in between the groups "1-3" vs "4-6" (p≤0.001), "4-6" vs "7+" (p = 0.006). Compared to the CSRS, the mCSRS expanded with the 2 additional weighting points differentiates more specifically the low-moderate and high survival groups in the PCAS patient population treated in our institute. Orv Hetil. 2021; 162(2): 52-60.

Abstract 16648: Covid-19 at the ICU: A Multiorgan Challenge

Introduction: About 5% of all COVID-19 patients require intensive care, mostly because of respiratory failure. Little is known about concomitant multi-organ manifestation under these circumstances. Methods: Retrospective observational study using routine data sets of 13 COVID-19 patients requiring mechanical ventilation in the Regiomed Hospital Coburg, Germany, between March 1 st and June 15 th , 2020. Results: Of 13 patients eligible for this study, all were intubated and ventilated mechanically, with signs of infiltration in chest radiographs. 4 suffered from renal failure and needed dialysis; 3 of these patients died, but none without renal failure. Proteinuria was found in all and microhematuria in all but one patients tested (n=11). All developed metabolic alkalosis (BEmax 9.75±0.99, mean ±SEM), and 6 afterwards polyuria (6.75 ±2.45l per day); both conditions resolved in all surviving patients but 1 spontaneously and were not related to prior renal failure. Liver enzymes were elevated in all patients (γGT 506 ±78U/l), but bilirubin levels only in 4; 2 of these died shortly after. Bacterial superinfection was found in 8 patients, and in all 3 ones finally dying. Rhabdomyolysis affected 12 patients (CKmax 1604±542U/l) and resolved later. All patients had slightly elevated troponin T (0.059 ±0.013ng/ml), and 7 had elevated nt-pro-BNP levels (3566±2359pg/ml), indicating cardiac COVID-19, and elevated d-dimer levels (18.1 ±6.68mg/dl) representing disseminated intravascular coagulation. No thromboembolic was observed. The need of catecholamines was low (&lt;1mg/h norepinephrine), as long as there was no septic complication. Conclusions: Our data indicate that severe COVID-19 is a multi-organ disease, even though ARDS is the leading problem; renal involvement - together with bacterial superinfection - seems to be a major risk factor for unfavorable disease development. Especially metabolic alkalosis and polyuria without overt renal failure have not been studied yet and require close clinical attention.

LEVOSIMENDAN AFTER CARDIAC SURGERY: A SINGLE-CENTER CASE SERIES

TYPE: Abstract Publication TOPIC: Critical Care PURPOSE: The purpose of this study is to describe the short-term effect of Levosimendan on hemodynamics and inotropic/vasopressor requirements after different types of cardiac surgery. METHODS: This retrospective review was conducted between April 2012 and November 2019 on patients recieving levosimendan after cardiac surgery. Exclusion criteria for analysis were heart transplantation, ECMO, assist devices and multiple levosimendan doses. Levosimendan was administered postoperatively as a continuous infusion, without a loading dose. Age, sex, mortality, dose and duration of levosimendan infusion, preoperative Euroscore II and need for renal replacement therapy (RRT) were collected from medical files. Mean arterial pressure (MAP), heart rate, lactate, dobutamine and noradrenaline requirements were collected before, at conclusion of, and 24 hours after levosimendan infusion. RESULTS: Data of 78 patients were retrieved: 49 (63%) of the patients were male and 29 (37%) were female. Age was 74 (±10) years. Euroscore II was 9.75 (±12.5). A total dose of 12.5 mg levosimendan was administered at 0.05-0.2 μg/kg/min. Duration of infusion was 34.4 (±15.4) hours. Heart rate, MAP, lactate and dobutamine/noradrenaline requirements are shown in Table 1. Fourteen patients (18%) had a intra-aortic balloon pump at the start of levosimendan infusion. Renal replacement therapy was needed in 26 patients (33.3%). ICU and 28-day mortality were 7.6% (n=6) and 2.5% (n=2), respectively. CONCLUSIONS: In patients with LCOS after cardiac surgery levosimendan infusion, without a loading dose, reduced the need for dobutamine and noradrenaline up to 24 hours postinfusion, without inducing hypotension. CLINICAL IMPLICATIONS: Levosimendan in LCOS after cardiac surgery is safe and reduces the need of catecholamines. DISCLOSURE: No significant relationships. KEYWORD: Levosimendan

Influence of low-opioid anesthesia in cardiac surgery on dynamics of pro-inflammatory interleukin-6.

IntroductionWith coronary artery bypass grafting, patients are subjected to additional risk caused by both surgical treatment itself and pathophysiological changes in homeostasis, provoked by the action of anesthetics and cardiopulmonary bypass.Material and methodsThe study involved 60 patients, who had been subjected to coronary artery bypass grafting with cardiopulmonary bypass. All patients were divided into two groups: group I (30 patients) – low-opioid scheme of anesthesia and group II (30 patients) – standard scheme of anesthetic management. Blood interleukin-6 (IL-6) was identified before and after cardiopulmonary bypass using an ELISA test.ResultsHaving compared IL-6 values between study groups after completion of cardiopulmonary bypass, it was established that IL-6 levels were 27.51% (p = 0.001) lower in patients of group I compared with the results of patients in group II. Patients in the first group had a significantly shorter time of mechanical ventilation compared to group II (2.1 ±0.7 hours vs. 3.9 ±0.9 hours, p = 0.021). Low cardiac output syndrome was significantly less frequently reported in patients of group I (10.0% vs. 33.3%, p = 0.028). In addition, patients in group I had a significantly shorter time of intensive care unit (ICU) stay (2.5 ±0.7 days vs. 3.5 ±1.0 days, p = 0.044).ConclusionsApplication of multimodal low-opioid anesthesia was associated with significantly lower IL-6 at the end of surgery, shorter mechanical ventilation duration, less frequent low cardiac output syndrome and need for catecholamines, and shorter ICU stays.

Anesthesia for Open Radical Retropubic Prostatectomy: A Comparison between Combined Spinal Epidural Anesthesia and Combined General Epidural Anesthesia.

Background Several anesthesiologic regimens can be used for open radical retropubic prostatectomy. The aim of this retrospective analysis was to compare the combined general epidural anesthesia and the combined spinal epidural anesthesia with regard to availability, efficacy, side effects, and perioperative time consumption in a high-volume center. Methods A retrospective analysis was performed by querying the electronic medical records of 1207 consecutive patients from the database of our online documentation software. All patients underwent open radical retropubic prostatectomy from 01/2008 to 08/2011 and met the study criteria. Linear and multivariate regression analyses were performed to identify differences in parameters such as time consumption in the operating unit, hemodynamic parameters, volume replacement, and catecholamine therapy. Results 698 (57.8%) patients have been undergoing open radical retropubic prostatectomy under combined spinal epidural anesthesia and 509 (42.2%) patients by combined general epidural anesthesia. Operating unit (p <0.0001) and post-anesthesia care unit stay (p <0.0001) as well as total hospital stay (p <0.0001) were significantly shorter in the combined spinal epidural anesthesia group. In addition, this group had reduced intraoperative volume need (p <0.0001) as well as lower need of catecholamines (p <0.0001). Conclusions This retrospective study suggests that the combined spinal epidural anesthesia seems to be a suitable and efficient anesthesia technique for patients undergoing open radical retropubic prostatectomy. This specific approach reduces time in the operation unit and length of hospital stay.

Prognostic relevance of serum lactate kinetics in critically ill patients.

Changes of lactate concentration over time were reported to be associated with survival in septic patients. We aimed to evaluate delta-lactate (ΔLac) 24h after admission (Δ24Lac) to an intensive care unit (ICU) in critically ill patients for short- and long-term prognostic relevance. In total, 26,285 lactate measurements of 2191 patients admitted to a German ICU were analyzed. Inclusion criterion was a lactate concentration at admission above 2.0mmol/L. Maximum lactate concentrations of day 1 and day 2 were used to calculate Δ24Lac. Follow-up of patients was performed retrospectively. Association of Δ24Lac and both in-hospital and long-term mortality were investigated. An optimal cut-off was calculated by means of the Youden index. Patients with lower Δ24Lac were of similar age, but clinically sicker. As continuous variable, higher Δ24Lac was associated with decreased in-hospital mortality (per 1% Δ24Lac; HR 0.987 95%CI 0.985-0.990; p < 0.001) and an optimal Δ24Lac cut-off was calculated at 19%. Δ24Lac ≤ 19% was associated with both increased in-hospital (15% vs 43%; OR 4.11; 95%CI 3.23-5.21; p < 0.001) and long-term mortality (HR 1.54 95%CI 1.28-1.87; p < 0.001), even after correction for APACHE II, need for catecholamines and intubation. We matched 256 patients with Δ24Lac ≤ 19% to case-controls > 19% corrected for APACHE II scores, baseline lactate level and sex: Δ24Lac ≤ 19% remained associated with lower in-hospital and long-term survival. Lower Δ24Lac was robustly associated with adverse outcome in critically ill patients, even after correction for confounders. Δ24Lac might constitute an independent, easily available and important parameter for risk stratification in the critically ill.

The role of different mechanical circulatory support devices and their timing of implantation on myocardial damage and mid-term recovery in acute myocardial infarction related cardiogenic shock.

Aim of the study was to assess in-hospital survival rate and the degree of myocardial recovery after MCS treatment (IABP or IMPELLA) at discharge and at 6 months in patients with AMI-CS and planned early percutaneous revascularization. All studies on MCS for acute myocardial infarction related cardiogenic shock (AMI-CS) focused on its impact on in-hospital mortality; however, few data about its role on myocardial recovery are available. Retrospective study on 64 patients: 36 patients (56%) received IABP and 28 (44%) Impella 2.5/CP. Patients treated with Impella were sicker compared to those treated with IABP as shown by a higher need of catecholamines (93% Impella vs 57% IABP, P = 0.002) and higher inotropic score before procedure: 8 (5-15) versus 4.5 (0-9), P = 0.02. In-hospital survival and MCS-related complications were comparable; hemolysis was more frequent in the Impella group (32% vs 0%, P < 0.0001). Myocardial damage was lower in those patients who were implanted with IMPELLA before PCI: lower troponin peak [3831 ng/dL (1441-8436) vs 16 581 (7802-23 675), P = 0.004] and lower CPK peak [893 UI/L (584-4082) vs 5797 (2483-9292) P = 0.04]. Impella patients had higher LVEF at 6 months [45 (38-52) vs 40 (33-45)%, P = 0.04]. LVEF increase at 6 months was statistically significant in both groups (P < 0.0001), with higher myocardial recovery in patients supported with Impella (absolute delta-LVEF increase 20% vs 10% P = 0.005). Cardiac unloading with IMPELLA in ACS-CS, especially if implanted before PCI, might provide lower myocardial damage and improved myocardial recovery which translates into significantly higher LVEF at 6 months.

Hospitalization and Life Support before Liver Transplantation – Easily available Predictors for Post-Transplant Patient Survival

Introduction Currently liver allocation is based on urgency in many countries, mostly represented by the MELD score. In contrast to allocation of other organs, e.g. lung, survival benefit is not included and to date no applicable outcome predictors have been implemented for liver allocation. Aim of this study was to analyze the prognostic value of hospitalization prior transplantation (Tx), pre-operative life support and the duration thereof for transplant outcome. Materials and Methods The electronic record system of the Charité - Berlin, Germany, was analyzed retrospectively for all patients who underwent liver Tx from 2005 to 2016 for hospitalization and life support before Tx. Life support was defined as dialysis accordingly to ET Liver Allocation system, mechanical ventilation and need of catecholamines. Results and Discussion From 1244 liver transplant recipients in this era, 264 underwent Tx coming from an intensive care unit (ICU), 178 patients from a regular ward and 802 from home. Of all recipients 187 required dialysis, 123 ventilation and 101 were under catecholamine therapy. Patients coming from the ICU were significantly younger but sicker according to their higher labMELD at day of Tx. Not surprisingly these patients had a significant lower 3 months, 1 year and 3 year survival compared to patients coming from home (ICU vs. home; 76,9% vs. 94,4% and 65,9% vs. 87,5% and 64,4% vs. 82,4%; all p=0,000). Interestingly differences between patients from the ICU and a regular ward showed no significance, not even for short term survival (3 month: 76,9% vs. 84,3%; p=0,057), decreased over time and did not have an influence on 1- and 3 year survival (1 year: 65,9% vs. 71,9%; p=0,132; 3 year: 64,4% vs. 65,2%; p=0,556). Subgroup analysis revealed that the length of ICU stay prior to Tx had a significant impact on patient survival if longer than 6 days (1-6 days vs. 7-14 days; 1 year p=0,036). Remarkably no changes between 7-14 days or >14 days could be noticed (p=0,469). Dialysis prior to Tx was associated with an inferior outcome compared to patients without renal placement (3 year: 56,1% vs. 79,7% p=0,000). These results remained significant even for patients receiving only dialysis and no other life support therapy whereas ventilation or catecholamines alone did not influence survival. There were no significant differences between the pre-operative labMELD of these three groups. However, recipients with ventilation and catecholamines showed similar results as patient with dialysis only (3 year: 61,3% vs. 60,6% p=0,890). Patients with the triad of dialysis, ventilation and vasopressor therapy had the worst outcome with a 3 year patient survival of only 47,4% compared to 80% of patients without life support (p=0,000). Conclusion Hospitalization status as well as life support before Tx are valuable predictors for patient survival following liver Tx and should be considered for the allocation process.

High body mass index is a risk factor for difficult deep sedation in percutaneous mitral valve repair.

BackgroundThe safety and efficacy of deep sedation (DS) in MitraClip® procedures have been shown previously. However, clinical experience demonstrates that in some patients DS is difficult to achieve. We hypothesize that some patient characteristics can predict difficult DS.MethodsWe prospectively analysed 69 patients undergoing MitraClip® procedures using DS. Application of DS was graded as simple (group 1) or difficult (group 2) depending on a cumulative score based on one point for each of the following criteria: decrease in oxygen saturation, retention of carbon dioxide, disruptive body movements, and the need for catecholamines. Patients with one point or less were classified as group 1, and patients with two or more points were classified as group 2.ResultsIn 58 of 69 patients (84.1%), the performance of DS was simple, while in 11 patients (15.9%), DS was difficult to achieve. Patients with difficult DS were characterized by a higher body mass index (33.7 ± 6.0 kg/m2 vs. 26.1 ± 4.1; p = 0.001), younger age (67 ± 13 years vs. 75 ± 13 years; p = 0.044), and reduced left ventricular ejection fraction (36% ± 10 vs. 45% ± 14; p = 0.051) and presented more often with an obstructive sleep apnoea syndrome (6.9% vs. 45.5%; p = 0.003). In the multivariate analysis, body mass index was an independent predictor of difficult DS. Using a body mass index of 31 kg/m2 as a cut-off value, the sensitivity of predicting difficult DS was 73%, and the specificity was 88%. Using a body mass index of 35 kg/m2 as a cut-off value, the specificity increased to 97%, with a sensitivity of 36%.ConclusionIn patients with a higher body mass index who undergo MitraClip® procedures, DS might be difficult to perform.

Effectiveness of Rescue Percutaneous Balloon Aortic Valvuloplasty in Patients With Severe Aortic Stenosis and Acute Heart Failure

The prognosis of patients with cardiogenic shock (CS) or refractory pulmonary edema because of severe aortic stenosis remains poor. The purpose of this study was to assess the outcomes of rescue percutaneous balloon aortic valvuloplasty (PBAV) in the transcatheter aortic valve implantation (TAVI) era. Patients were consecutively included between 2008 and 2016. CS was defined as ≥1 sign of systemic hypoperfusion and need of catecholamines. Refractory pulmonary edema was defined as not controlled by optimal medical treatment. A total of 40 patients, 22 men (55%), aged 79 ± 9 years, were included: 17 with CS (42.5%), 23 with refractory pulmonary edema (57.5%). After PBAV, mean transaortic gradient decreased from 47 ± 16 mm Hg to 32 ± 10 mm Hg (p < 0.001), aortic valve area increased from 0.60 ± 0.18 cm2 to 0.88 ± 0.22 cm2 (p < 0.0001), left ventricular ejection fraction increased from 35 ± 15 to 37 ± 14% (p = 0.02), and systolic pulmonary artery pressure decreased from 61 ± 15 to 48 ± 12 mm Hg (p = 0.002). There was no procedural death. Early death occurred in 12 patients (30%). After PBAV, 16 of the 28 survivors (57%) were bridged to surgical aortic valve replacement (SAVR; n = 7) or TAVI (n = 9), and 12 (43%) were denied definitive therapy. The 2-year estimated survival rate was 71 ± 17% after SAVR, 36 ± 19% after TAVI, and 8 ± 8% after PBAV alone. In conclusion, rescue PBAV is safe in patients with CS and high-risk aortic stenosis or refractory pulmonary edema and may improve their dismal prognosis when followed by TAVI or SAVR.