[Interdisciplinary differential treatment of structural heart disease : When operation and when catheter-based intervention?]. / Interdisziplinäre Differenzialtherapie struktureller Herzerkrankungen : Wann Operation und wann kathetergestützte Intervention?

The demographic changes in society lead to an increasing number of patients with aortic valve stenosis and mitral regurgitation. Simultaneously the higher age of patients is associated with an increase in multimorbidity with a high surgical risk so that they cannot be referred to surgery. Besides the current gold standard of surgery, minimally invasive therapeutic options are increasingly becoming established for these patients. For the differentiated indications and therapeutic success, a multidisciplinary heart team assumes an important role. The next generation of transcatheter aortic valve implantation (TAVI) systems will lead to improvement in the results, lower complication rates and mortality and as a result there is a general trend towards expanding the indications. New innovative minimally invasive mitral valve devices are still undergoing clinical trials and will define future therapy options.

Inter-hospital transfer of ECMO-assisted patients with a portable miniaturized ECMO device: 4 years of experience.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) in patients with severe pulmonary failure is able to keep patients alive until organ regeneration, until shunting out for further diagnostic and therapeutic options or until transportation to specialized centers. Nonetheless, extracorporeal techniques require a high degree of expertise, so that a confinement to specialized centers is meaningful. Following from this requirement, the need for inter-hospital transfer of patients with severely compromised pulmonary function is rising. METHODS: We report about our experience with a portable ECMO system during inter-hospital air or ground transfer of patients with cardiopulmonary failure. RESULTS: The portable ECMO system was used for transportation to the center and in-hospital treatment in 36 patients with an average age of 53 years suffering from respiratory failure. Accordingly, the ECMO system was implanted as a veno-venous extracorporeal system. Pre-ECMO ventilation time was 5.2 (2-9) days. Twelve patients were transported to our institution by ground and 24 patients by air ambulance over a median distance of 46 km. With the assistance of the ECMO device, prompt stabilization of cardiopulmonary function could be achieved in all patients without any technical complications. Post-ECMO ventilation was 9.8 days. Weaning from the ECMO system was successful in 61% of all patients after a median device working period of 12.7 days; median ICU stay was 34 days and a survival rate of 64% of patients was achieved. Technical (8%) and device-associated bleeding (11%)/thromboembolic (8%) complication rates showed very acceptable levels. CONCLUSION: Our experience demonstrates that miniaturized, portable ECMO therapy allows location-independent, out-of-center stabilization of pulmonary compromised patients with consecutive inter-hospital transfer and further in-house treatment, so that sophisticated ECMO therapy can be offered to every patient, even in hospitals with primary healthcare.

First experiences with a combined usage of veno-arterial and veno-venous ECMO in therapy-refractory cardiogenic shock patients with cerebral hypoxemia.

The use of extracorporeal membrane oxygenation (ECMO) is becoming a popular tool in the treatment of cardiogenic shock. We present two case reports where classical veno-arterial peripherally cannulated ECMO therapy proved insufficient with profuse cerebral hypoxemia. After augmenting the setting into veno-veno-arterial ECMO, we achieved a remarkable improvement of all oxygenation parameters. The simultaneous use of veno-venous and veno-arterial ECMO might display as a novel strategy to counteract the coronary and cerebral hypoxemia in veno-arterial ECMO therapy in patients with therapy-refractory cardiogenic shock or in combined cardiopulmonary failure. In this manuscript, the veno-veno-arterial ECMO setup is described in full detail and different venous cannulas are discussed.

Immediate effects of individualized heparin and protamine management on hemostatic activation and platelet function in adult patients undergoing cardiac surgery with tranexamic acid antifibrinolytic therapy.

OBJECTIVE: This randomized prospective study was initiated to clarify whether individualized heparin and protamine dosing has immediate effects on hemostatic activation and platelet function in adult cardiac surgery. METHODS: Sixty adults undergoing elective coronary artery bypass grafting (CABG) were assigned to receive individualized heparin and protamine (HMS group, n= 29) or a standard dose (ACT group, n=24). Measures of thrombin generation and Multiplate (Verum Diagnostica, Munich, Germany) platelet function tests were performed before and after cardiopulmonary bypass (CPB). RESULTS: HMS patients received higher heparin (p = 0.006) and lower protamine (p<0.001) doses. Post-CPB, HMS managed patients showed significantly lower thrombin generation (thrombin-antithrombin (TAT) p<0.02) than the ACT group. Moreover, HMS managed patients had a better preservation of platelet function (COL p = 0.013; ADP p = 0.04; TRAP p = 0.04). CONCLUSION: An individualized and stable heparin concentration and appropriate dosing of protamine can reduce thrombin generation and preserve platelet function, even in short-time CPB.

[Infective endocarditis : emergency treatment and long-term surveillance]. / Infektiöse Endokarditis : Notfallbehandlung und Langzeitbetreuung.

Infective endocarditis is a serious disease that is often diagnosed with a considerable delay in clinical practice and therefore has a high mortality rate; therefore, early diagnosis and antibiotic treatment are extremely important. Epidemiological shifts in the age profile, new risk factors and the increasing use of intravascular prosthetic materials have led to changes in the microbial spectrum and clinical symptoms, which must be taken into account in the diagnostic efforts and therapy. Nonspecific symptoms and the increase in nosocomial endocarditis, especially in critically ill and immunocompromised patients require a high level of diagnostic expertise. With diagnostic algorithms based on guideline recommendations antibiotic treatment has to be initiated as early as possible. For patients with severe infective endocarditis a cardiac surgeon has to be involved from an early stage of the disease as in about 50 % of cases conservative antibiotic therapy alone does not alleviate the infection. Also early surgical treatment should be sought with the onset of complications. After effective treatment and patient survival there will always be an increased risk of suffering from renewed endocarditis. This is taken into account in the new recommendations of the European Society of Cardiology for the prevention of infective endocarditis.

[Protein glycation as a pathological mechanism in diabetes]. / Proteinglykierung als pathophysiologischer Mechanismus bei Diabetes.

The incidence of diabetes has increased in the recent years. Diabetes is characterized by increased sugar concentrations in the blood. Due to this dysregulation, more carbohydrate-induced modification of proteins - so-called advanced glycation end products (AGEs) - are formed endogenously by non-enzymatic reactions. These are discussed to be at least in part responsible for diabetes-associated diseases. The accumulation of AGEs in the tissue can be used as a biomarker for patient outcome. In contrast, the effects of the uptake of AGEs from nutrition are still unclear.

Knowledge and attitude of dental health workers towards fluoride in Riyadh area.

OBJECTIVE: To assess the knowledge, attitudes, and beliefs of the dentists and hygienists in the Riyadh area of the Kingdom of Saudi Arabia towards fluoride. METHODS: One hundred and thirty dentists and hygienist working in dental clinics in Riyadh were randomly selected. Self-administered questionnaires covered the following areas: general information, the use and application of fluoride, pharmacodymanics and pharmacokinetics of fluoride. The subjects responded to each of the statements by ticking one of the 3-scaled options from "agree" to "disagree". RESULTS: The majority of the respondents (65%) supported an assessment of the pattern of dental caries before fluoridating the water, 23% disagreed and 5% did not know. Also one hundred and three (79%) of the sample supported fluoridation of water, 16 (12%) disagreed, and 4 (3%) did not know. Fifty-five (42%) agreed that dental caries are expected to increase if fluoridating water is discontinued for one year, while 52 (40%) disagreed and 16 (12%) did not know. In addition, there was a low score concerning knowledge of side effects and toxicity of fluoride among health care workers. Overall, there was no statistical significance between academics and non-academics. CONCLUSION: There was a good attitude and knowledge of fluoride as a preventive measure among dentists. This study also demonstrated that the majority of the health care professionals in Riyadh area were in favor of water and milk fluoridation, however; there was a lack of knowledge regarding side effects and toxicity.

European research and commercialisation activities in the field of tissue engineering and liver support in world wide competition.

Tissue engineering is seen as an interesting field of technology which could improve medical therapy and could also be considered as a commercial opportunity for the European biotechnological industry. Research in the state of the art of science using the MedLine and the Science Citation Index databases, in the patent situation and of the industry dealing with tissue engineering was done. A special method, based on the Science Citation Index Journal Citation Report 1993, for evaluating scientific work was defined. The main countries working in the field of tissue engineering were evaluated in regard to their scientific performance and their patents. The R&D of German industry was investigated as an exemplary European country. Out of all activities, different tissues were rated with respect to the attention received from research and industry and with regard to the frequency in which patents were applied for. USA, Germany and Japan rank first in most tissues, especially liver. After comparing German patents with the German scientific and industrial work, it seems that the potential in German patents and research is underestimated by German industry and inefficiently exploited.