The certification of transplant coordinators in Europe.

The appropriate clinical management of the integrated process of Donation and Transplantation implies the participation of the Transplant Coordinator. The aim of this article is to present the process of Certification of Transplant Coordinators in Europe since 2001, in accordance with the Council of Europe Recommendations and the evolving model implemented in 2008 under the auspices of the UEMS, reporting the longest running European standardized assessment of Transplant Coordination skills and knowledge. It includes the rationale for development of a certification process, how the examinations were developed and updated, eligibility to take the examination, and relationship with standards of practice for Transplant Coordinators. A total of 455 healthcare professionals were certified in two phases: 1(st) ETCO certification since 2001 to 2007 (390) and 2(nd) ETCO/UEMS certification from 2008 to 2011 (65).

Organ donation in Switzerland: a survey on marginal or extended criteria donors (ECD) from 1998 to 2009.

BACKGROUND: The widening gap between the numbers of patients on the waiting list for organ transplantation and the insufficient numbers of organ donors results in the use of "critical" donors, so-called marginal donors or extended criteria donors. Data concerning the evaluation of extended criteria donors (ECD) in Switzerland are sparse. METHODS: All organ donors in Switzerland between 1.1.1998 and 30.6.2009 have been evaluated for special criteria. ECD were defined on the basis of at least one of seven criteria: six DOPKI criteria (ECD-DOPKI) and/or age ≥60 yr (ECD-Age). Once included in the study, special features, short time follow-up (first 7 days after transplantation) and the cold ischaemia time of all the transplanted organs were evaluated. RESULTS: During the period 1.1.1998 to 30.6.2009, a total of 408 organ donors were classified as ECD, reflecting 39% of all organ donors in this time period. Despite the fact that all organ donors in this study fulfilled at least one inclusion criterion, the number of recipients with satisfactory primary organ function was always higher than the respective number with a negative primary outcome within the first seven days after transplantation. A longer cold ischaemia time was associated with organs showing insufficient primary organ function compared to organs with satisfactory primary function. A relevant causal relationship cannot be investigated on the basis of our limited data. In addition, a longer observation period would be necessary to draw a more precise conclusion. CONCLUSIONS: ECD as defined by DOPKI and/or age represent a high proportion of all organ donors in Switzerland but show a remarkably good outcome.

Is there a place for D-dimers in acute type A aortic dissection?

Plasma concentrations of D-dimer may prove a valuable addition in the diagnostic work-up of acute type A aortic dissection, but not as means of predicting mortality.

[The Sorin pericardial bioprosthesis--a stentless aortic valve with very good hemodynamic performance]. / Die Sorin Perikard-Bioprothese--eine Stentless Aortenklappe mit sehr guter hämodynamischer Leistung.

BACKGROUND: The Sorin Pericarbon Freedom Stentless aortic valve has the potential to provide superior hemodynamic function and durability. In this study we assessed the hemodynamic performance of this valve and its impact on LV-mass regression after aortic valve replacement. METHODS: 31 consecutive patients who received a Sorin Pericarbon Freedom Stentless aortic valve were analysed. Mean age of the patients (16 female and 15 male) was 64 +/- 17 years. Five patients had isolated aortic stenosis, three isolated aortic regurgitation and one combined aortic valve disease. Three patients had combined aortic and mitral valve disease, 14 patients concomitant coronary artery disease, one congenital aortic coarctation. Three patients had an acute aortic valve endocarditis. 18 patients were classified as high-risk patients (mean EuroSCORE 9 +/- 2). Mean left ventricular ejection fraction was 52.5 +/- 15.0%. RESULTS: Valve sizes from 21 mm to 29 mm were implanted. The valves were oversized by 2 mm compared to measurement. 16 patients received isolated aortic valve replacement, Three patients aortic valve replacement and mitral valve reconstruction. 12 patients had concomitant CABG. Three procedures were reoperations. Hospital mortality was 6.4% (two patients). Both deaths occurred in high-risk patients and were not valve-related. Four patients had perioperative low-output-syndrome and needed IABP. After six months a follow up echocardiography was performed. Mean and peak gradients were 9.6 +/- 4.4 and 20.6 +/- 5.9 mmHg, respectively. Significant reduction of left ventricular hypertrophy (LV mass index 126.5 +/- 27.3 vs. 189.6 +/- 45.3 g/m2, p = 0.0313) and improvement of the ejection fraction (58 +/- 9.8 vs. 52.5 +/- 15.0%, p = 0.9749) as compared with preoperative valve. CONCLUSIONS: The hemodynamic performance of the Sorin Pericarbon Freedom Stentless aortic valve is excellent and the patient outcome is satisfying. However the implantation technique requires longer ischemic time, the prosthesis offers very satisfying hemodynamic function and accelerates probably the LV-mass regression in the mid term follow-up. Late performance and durability of the valve have to be assessed.

Endovascular stent-grafting for diseases of the descending thoracic aorta.

PRINCIPLES: Endoluminal stent-grafts are emerging as a less invasive alternative to conventional open surgery in the management of descending thoracic aortic dissections and aneurysms. We describe our experience with endovascular stent-grafting in the treatment of thoracic aorta pathology. METHODS: 17 Patients were treated with 23 endovascular stents. The underlying pathology was an atherosclerotic aneurysm verum (n = 5), a type B dissection with contained rupture (n = 3), an intramural haematoma with contained rupture (n = 1) and a false aneurysm of unknown origin (n = 1). One patient had Marfan's syndrome and six patients had a traumatic rupture of the descending aorta. RESULTS: Overall 23 stent-grafts were implanted. In one patient, conversion to an open graft replacement of the descending aorta was necessary. One patient died. In four patients (23.5%) a left carotid-subclavia bypass or transposition was performed to achieve a sufficient neck for the proximal stent-graft landing zone. The postoperative control-CT scans revealed a total of six endoleaks (EL) (four type I, one type II and one type IV). Two patients needed a graft extension in a second operation (4 days and 18 month after the first operation), two EL (one type I and one type II) disappeared after 9 and 18 months, respectively and two EL are still under observation. One patient developed a paresis after conversion to open graft replacement. CONCLUSIONS: A variety of diseases of the descending aorta can be treated by endoluminal stent-grafting, which seems to be a valid alternative to open repair in well selected cases. Mortality and morbidity in our small series were low. Continuous follow-up is mandatory.

Aprotinin reduces blood loss in off-pump coronary artery bypass (OPCAB) surgery.

OBJECTIVE: Effects of aprotinin in off-pump coronary artery bypass (OPCAB) surgery have not yet been described. This study analyses hemostasiologic changes and potential benefit in OPCAB patients treated with aprotinin. METHODS: In a prospective, double-blind, randomized study 47 patients undergoing OPCAB surgery were investigated. Patients received either aprotinin (2 x 10(6) KIU loading dose and 0.5 x 10(6) KIU/h during surgery, n=22) or saline solution (control, n=25). Activated clotting time was adjusted to a target of 250 s intraoperatively. Blood samples were taken up to 18h postoperatively: complete hematologic and hemostasiologic parameters including fibrinopeptide A (FPA) and D-dimer in a subgroup of 31 patients were analyzed. Blood loss, blood transfusion and other clinical data were collected. RESULTS: Both groups showed comparable demographic and intraoperative variables. Forty-one (87%) patients of the whole study group received aspirin within 7 days prior to surgery. Number of grafts per patient were comparable (2.9+/-1.0 [mean+/-SD] in the aprotinin group and 2.8+/-1.2 in control, P=0.83). Blood loss during the first 18 h in intensive care unit was significantly reduced in patients treated with aprotinin (median [25th-75th percentiles]: 500 [395-755] ml vs. 930 [800-1170] ml, P<0.001). Postoperatively only two patients (10%) in the aprotinin group received packed red blood cells, whereas eight (35%) in the control group (P=0.07). Perioperatively FPA levels reflecting thrombin generation were elevated in both groups. The increase in D-dimer levels after surgery was significantly inhibited in the aprotinin group (P<0.001). Early clinical outcome was similar in both groups. CONCLUSIONS: Aprotinin significantly reduces blood loss in patients undergoing OPCAB surgery. Inhibition of enhanced fibrinolysis can be observed. FPA generation during and after OPCAB surgery seems not to be influenced by aprotinin.

Unnecessary emergency caesarean section due to silent CTG during anaesthesia?

We present a case of a probably unnecessary Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia. A 27-yr-old patient in her 30th week of an uneventful, normal first pregnancy presented with a deep venous thrombosis in the pelvic region. She was to undergo an emergency thrombectomy under general anaesthesia. During the operation, the CTG showed a lack of beat-to-beat heart rate variation (silent pattern CTG) with normal fetal heart rate. This silent CTG pattern was probably a result of the effect of general anaesthesia on the fetus. The CTG pattern was interpreted as indicating fetal distress, and an emergency Caesarean section was performed after the thrombectomy. The infant was apnoeic and had to be resuscitated and admitted to the neonatal intensive care unit. The pH at delivery was 7.23 and the baby was extubated 2 days later. Mother and child recovered without short-term sequelae. In the absence of alternative explanations, reduced fetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.

Prospective evaluation of 3 risk stratification scores in cardiac surgery.

BACKGROUND: The aim of the study was to evaluate 3 different risk stratification scores in cardiac surgery, based on the hospital results of 1,299 patients. METHODS: From June 1995 to December 1997, all patients (n = 1,299) undergoing coronary artery bypass grafting (CABG) and/or heart valve surgery were prospectively enrolled. The postoperative in-hospital outcome (mortality, morbidity and length of hospital stay) was analysed in relation to three different risk stratification scores (Parsonnet, Higgins and French score). RESULTS: The results of 1,299 patients (mean age 62.8 +/- 10.2 years) were analysed. 10 patients died, accounting for a total mortality of 0.8%. 13 patients (1%) underwent cardiopulmonary resuscitation. In 25 patients (1.9%), perioperative myocardial infarction occurred. Performance of the 3 systems was assessed by evaluating discrimination with receiver operating characteristic (ROC) curves. The area under the ROC curve was 0.761 for Parsonnet, 0.786 for Higgins and 0.798 for French score. The French and the Higgins score showed an increase of in-hospital mortality, morbidity and length of stay in relation to increasing risk classes. CONCLUSION: For objective evaluation of the outcome in cardiac surgery, case-mix severity needs to be considered, which is reflected by preoperative risk stratification scores. In our study, all the 3 scores showed a high discrimination and are appropriate tools to assess mortality in cardiac surgery. Especially the French and the Higgins score (restricted to 5 groups), due to their simplicity, were useful to predict postoperative outcome in clinical routine.

Influence of the ultrasound contrast agent Levovist on human nailfold capillary microcirculation.

Little is known about the behavior of ultrasound contrast microbubbles in human capillaries. The evaluation of circulatory effects of echo contrast media may bring valuable information for the interpretation of echo contrast phenomena in the human myocardium. In 12 healthy volunteers (aged 31 +/- 6.7 years; five women), nailfold capillaries were examined by means of TV microscopy. The authors investigated acral microcirculation at rest and after local cold application with and without saccharide-based microbubbles (10 mL Levovist 300 mg/mL IV). The mean blood flow velocity at rest was 1.18 +/- 0.18 mm/s (mean value +/-1 SD) and 1.11 +/- 0.11 mm/s (mean value +/- 1 SD) after the injection of Levovist (ns). One minute after local cold exposure a decrease of the blood flow velocity by 61% before and by 75% after intravenous Levovist was found. In both groups the cold-induced decrease of blood flow velocity was statistically significant (p<0.01), whereas there was no significant difference in flow reaction between the two groups. No wall adhesion of blood cells or extravasation of contrast into the surrounding tissue was detected. After intravenous injection of a regular dose of saccharide-based microbubbles Levovist, no change of blood cell flow velocity and no wall adhesion or extravasation could be found at rest and after cold application in human nailfold capillaries. Since microcirculatory flow characteristics in the finger nailfold capillaries are not influenced by Levovist, it might be assumed also that myocardial blood flow behavior remains unchanged, so that this contrast agent may be used as a flow tracer for cardiac investigation.

Troponin-I for prediction of early postoperative course after pediatric cardiac surgery.

OBJECTIVES: It was the aim of the study to test the prognostic value of cardiac troponin-I (cTnI) concerning the early postoperative course after pediatric cardiac surgery. BACKGROUND: Cardiac troponin-I is a very specific and sensitive marker of myocardial damage in adults and children. As perioperative myocardial damage may be a significant factor of postoperative cardiac performance, serial cTnI values were analyzed in children undergoing open heart surgery. METHODS: Seventy-three children undergoing elective correction of congenital heart disease including atrial and ventricular surgical manipulation were studied. Cardiac troponin-I levels were measured serially and correlated with intra- and postoperative parameters (such as doses and length of inotropic support, renal and hepatic function, duration of intubation). Patients with prolonged postoperative recovery were analyzed with special attention to the cTnI levels. RESULTS: The cutoff point for the definition of a high and a low risk group of cTnI values was set at 25 microg/liter, 4 h after admission to the intensive care unit (ICU) and at 35 microg/liter considering the maximal value of cTnI in the first 24 h in the ICU. The results showed a highly significant correlation between the need for inotropic support, the severity of renal dysfunction and the duration of intubation in relation to the serum levels of cTnI. CONCLUSIONS: Cardiac troponin-I serum levels after open heart surgery in children and infants 4 h after admission to the ICU allowed anticipation of the postoperative course and correlated with the incidence of significant postoperative complications.

[Pleural and pericardial effusion after pacemaker implantation as first manifestation of malignant tumors]. / Pleura- und Perikarderguss nach Schrittmacherimplantation als Erstmanifestation einer malignen Erkrankung.

We report 2 cases with unusual "complications" after pacemaker implantation. One patient developed hemorrhagic pleural and 1 patient pericardial effusion. Both manifestations of hemorrhage were felt to be due to complications in relation to the pacemaker implantation. However, in both patients cytologic analysis of the effusion revealed malignant cells, in 1 case from an ovarian cell carcinoma, in the other case from an adenocarcinoma of unknown origin. Our report indicates, that under rare circumstances pleural or pericardial effusion after pacemaker implantation may be the first manifestation of a malignant process independent of the pacemaker implantation procedure.

[Status and after-care of young adults with congenital heart defects]. / Zustand und Nachbetreuung von jungen Erwachsenen mit angeborenem Herzfehler.

INTRODUCTION: We studied patients with congenital heart defects born in 1975 and followed by our institution. We were interested in the outcome of these patients at the age of 20 years with regard to professional status, physical activity and psychosocial aspects. Furthermore, we investigated the handover from the paediatric to the adult cardiologist as well as the information level concerning antibiotic prophylaxis against bacterial endocarditis. METHODS: From a previous follow-up study to the age of 16 years, we knew 224 patients with congenital heart disease born in 1975, 119 were considered to need further cardiological follow-up. In 112 (94%) we have a complete follow-up to the age of 20 years with a structured interview by phone. RESULTS: Mortality and medical care during the period between 16 and 20 years of age were at a lower level than in the previous periods. Except in patients suffering from complex or surgically treated cyanotic heart disease, the results, compared to the standard population at the age of 20 years, are better with regard to professional status, and equal for physical activity and psychosocial integration. Only 60% of the patients were followed by an adult cardiologist and only 45% of the patients needing antibiotic prophylaxis against bacterial endocarditis are aware of this. CONCLUSION: Except in patients with complex congenital or surgically treated cyanotic heart diseases, the outcome at the age of 20 years with regard to professional status, physical activity and psychosocial integration is very good compared with the standard population at the age of 20 years. The handover to the adult cardiologist is inadequate and knowledge and awareness of antibiotic prophylaxis against bacterial endocarditis is also insufficient-both aspects need improvement.

Comparison of troponin-I and troponin-T after pediatric cardiovascular operation.

BACKGROUND: Although the diagnostic value of troponin-T in childhood is documented, little is known about the significance of troponin-I. It was the aim of this study to compare the diagnostic value of troponin-I and troponin-T in children and newborns to assess the perioperative potential myocardial damage. METHODS: Forty-eight children, mean, 51+/-54 months (mean value +/-1 standard deviation) (range, 1 day to 204 months) undergoing cardiac operation were prospectively enrolled in the present study. Troponin-I, troponin-T, creatine kinase (CK), and the MB isoenzyme were measured before operation and postoperatively within 2 days. RESULTS: Postoperative values of troponin-I for children undergoing extracardiac operation were in the normal range. In children with interventions through the right atrium (n = 10) the mean value increase to 6.5+/-6.1 microg/L (range, 1.8 to 24.3 microg/L) and even to a mean of 29.9+/-21.1 microg/L (range, 7.5 to 90 microg/L) (p<0.01) in children with atrial and additional ventricular surgical approach (n = 23). Troponin-I was of equal specificity and sensitivity compared to troponin-T, excepted in patients with postoperative renal failure in whom troponin-T raised to false pathological results. CONCLUSIONS: For detection of perioperative myocardial damage troponin-I shows a higher specificity than CK-MB activity and CK-MB mass. The diagnostic value of troponin-I is similar to troponin-T, but compared with troponin-T, it has the advantage of not being influenced by renal failure.

[Isolated tuberculosis of the heart: a clinical and echocardiography follow-up]. / Isolierte Tuberkulose des Herzens: Eine klinische und echokardiographische Verlaufsbeobachtung.

A case of isolated right ventricular myocardial tuberculoma with pericardial effusion is presented. The diagnosis of myocardial tuberculoma was initially suggested by echocardiography and later by magnetic resonance imaging. The diagnosis of cardiac tuberculosis was confirmed by demonstration of tubercle bacilli in the pericardial fluid. This is a very rare condition which is usually diagnosed only by necropsy. Myocardial tuberculoma should figure on the list of intraparietal masses visualized at echocardiography.

Troponin-T: improved diagnostic assessment of myocardial damage in childhood.

Troponin-T (cTnT) as a marker of myocardial damage is well established in adults, but not yet in children. cTnT was measured in 85 children (aged 1 day-204 months, mean 46 months). Twenty-five children were non-surgical patients, with possible myocardial damage suspected on clinical grounds. The other 60 patients had cardiac surgery leading to a defined myocardial damage. In these children, troponin-T (cTnT), creatine kinase activity (CK), creatine kinase-MB activity (CK-MB), and creatine kinase-MB-Mass (CK-MB-Mass) were measured preoperatively and 3-4 times during the first 55 postoperative h. Except in four children with probable preoperative myocardial damage, all troponin-T values were in the normal range (< 0.1 microg/l). All children with intracardiac surgery showed a postoperative increase in troponin-T. Children with extracardiac surgery of the great vessels showed no postoperative increase of troponin-T. For the assessment of myocardial damage, troponin-T was more specific and more sensitive than the other markers tested, troponin-T might significantly improve the diagnostic assessment of myocardial damage in children.

[Congenital heart defects: prevalence and course during the school years (8 to 16 years)]. / Angeborene Herzfehler: Vorkommen und Verlauf während der Schulzeit (8. bis 16. Lebensjahr).

In continuation of former studies regarding the first year of life and the preschool period, the prevalence and course of congenital heart disease in children during compulsory schooling has been studied. Compared with the preschool period, few cardiac defects are discovered, the prevalence up to 16 years of age being 9.9/1000. The mortality rate (2.7%) and also the rate of spontaneous normalization (4%) is significantly lower (compared to 18.7% and 21% respectively in the preschool period). Medical measures are needed less frequently, with 10 times fewer operations and 15 times fewer heart catheterizations being performed. Apart from the decline of hospital stays, checkups in the outpatient clinic also declined 3-4 times in comparison with the period between birth and school entry. School performance is very good. Only 4% of the children are unable to attend a normal school for cardiac reasons, and the percentage of pupils attending secondary school is higher than normal. In 5% of the children exercise tolerance is decreased due to the cardiac condition. In 85%, the quality of life is normal during the compulsory school period. Impairment is most often caused by additional non-cardiac malformations or very severe heart disease.