[Anesthesiological implications of minimally invasive valve interventions : Transcatheter aortic valve implantation, clip reconstruction on the mitral and tricuspid valve]. / Anästhesiologische Implikationen bei minimal-invasiven Klappeninterventionen : "Transkatheter aortic valve implantation", MitraClip und Trikuspidalklappe.

Catheter-guided interventional implantation of cardiac valves is one of the main developments in cardiology over the past 15 years. It is characterized by a close interdisciplinary cooperation in the heart team (H-team), which consists of cardiac anesthesiologists, cardiologists and heart surgeons. This co-responsibility for anesthesia, which is demanded by the legislator (Federal Joint Committee, G­BA, July 2015), includes not only qualified training for the cardiac anesthesiologist, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) but also several years of experience in cardiac anesthesia and correlates with the recommendations of the German Society for Anaesthesiology and Intensive Care Medicine. In accompaniment with the demographic development, the number of heart valve diseases increases with age. More than 50% of all heart operations are performed on patients over the age of 70 years and nearly 20% on patients over the age of 80 years. Minimally invasive procedures are outstanding opportunities for patients who were initially classified as inoperable. Therefore, anesthesiologists must have precise knowledge of the possible complications related to the procedure itself. Additionally, it challenges the anesthesiologist with unconventional situations in the care of older patients who are exposed to a higher risk. The aforementioned risks are organic functional restrictions, increasing number of comorbidities and more severe exposure due to malnutrition and frailty; however, monitoring methods are also being developed aiming for patient-specific anesthesia management and analgesia treatment. This article discusses the interventional procedures of heart valvular diseases as well as the hemodynamic changes associated with the procedures from the anesthesiologist's point of view. To present examples, we have selected transcatheter aortic valve replacement (TAVR) and the interventional procedure of mitral and tricuspid valve insufficiency called MitraClip and TricaClip. A thorough examination of the procedural risk rate shows that despite minimizing the surgical intervention by miniaturizing the devices, the presence of an experienced cardiac anesthesiologist is obligatory.

Does heart surgery change the capacity of α1-antitrypsin to inhibit the ATP-induced release of monocytic interleukin-1ß? A preliminary study.

Heart surgery involving cardiopulmonary bypass induces systemic inflammation that is, at least in part, caused by extracellular ATP originating from damaged cells and by proteases secreted by activated neutrophils. The anti-protease α1-antitrypsin (AAT) forms complexes with several proteases including neutrophil elastase, resulting in a mutual loss of activity. We demonstrated recently that AAT inhibits the ATP-induced release of the pro-inflammatory cytokine interleukin-1ß by human monocytes by a mechanism involving activation of metabotropic functions at nicotinic acetylcholine receptors. Interleukin-1ß importantly contributes to the pathogenesis of sterile inflammatory response syndrome. Thus, AAT might function as an endogenous safeguard against life-threatening systemic inflammation. In this preliminary study, we test the hypothesis that during cardiopulmonary bypass, AAT is inactivated as an anti- protease and as an inhibitor of ATP-induced interleukin-1ß release. AAT was affinity-purified from the blood plasma of patients before, during and after surgery. Lipopolysaccharide-primed human monocytic U937 cells were stimulated with ATP in the presence or absence of patient AAT to test for its inhibitory effect on interleukin-1ß release. Anti-protease activity was investigated via complex formation with neutrophil elastase. The capacity of patient AAT to inhibit the ATP-induced release of interleukin-1ß might be slightly reduced in response to heart surgery and complex formation of patient AAT with neutrophil elastase was unimpaired. We conclude that surgery involving cardiopulmonary bypass does not markedly reduce the anti-inflammatory and the anti-protease activity of AAT. The question if AAT augmentation therapy during heart surgery is suited to attenuate postoperative inflammation warrants further studies in vivo.

[S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]. / S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten : Hämodynamisches Monitoring und Herz-Kreislauf ­ ein Update.

An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.