Efficacy and frequency of cerebrospinal fluid drainage in operative management of thoracoabdominal aortic aneurysms.

BACKGROUND: Paraplegia remains the most dreaded complication following thoracoabdominal aortic repair. We investigated the efficacy of cerebrospinal fluid drainage as a spinal cord-protecting modality. We also evaluated the correlation between the frequency of cerebrospinal fluid drainage and the Crawford classification. METHODS: Spinal cord function was monitored during 20 open surgical procedures (group I) and 27 stent-graft implantations (group II). Evoked potentials and intracranial pressure were monitored in each operation. If intracranial pressure exceeded 15 mmHg, cerebrospinal fluid was drained. RESULTS: Cerebrospinal fluid drainage was necessary in 75 % of patients in group I (Crawford type I: 33 %, type II: 40 %, type III: 20 %, type IV: 7 %) and in 22 % of patients in group II (Crawford type I: 33 %, type II: 66 %). Evoked potential alterations correlated with an increase in intracranial pressure. Timely cerebrospinal fluid drainage reversed these changes in 72 %. Three patients remained paraplegic. CONCLUSION: Cerebrospinal fluid drainage is a valuable neuroprotective interventional tool to lower the risk of spinal cord ischemia. The combination of neurophysiological monitoring and cerebrospinal fluid drainage optimizes the prevention of paraplegia during aortic repair.

Development of a special balloon occlusion device to prevent adverse events in high-risk patients during open aortic surgery.

OBJECTIVE: To prevent clamp injury that may occur during aortic surgery, we aimed to develop a special balloon occlusion (BO) device to lower the thromboembolic risk in patients with severe atherosclerosis during aortic aneurysm repair. METHODS: The study comprised two test phases: a laboratory-testing series focussing on flexible artificial aortas, and an experimental series conducted on 10 pigs. RESULTS: The device proved to be effective during the laboratory tests and the experiments on pigs. No complications such as intraoperative balloon rupture, dislocation, or occlusion leaks occurred. No damage to the aortic vessels was observed in further histological examinations. CONCLUSIONS: This BO device has the potential to become an alternative to cross-clamping for vascular surgeons in patients with severely atherosclerotic vessels.

The Impella Recover microaxial left ventricular assist device reduces mortality for postcardiotomy failure: a three-center experience.

BACKGROUND: We evaluated patient outcomes and complications associated with the microaxial Impella Recover left ventricular assist device (Impella Cardiosystems AG, Aachen, Germany) for postcardiotomy low-output syndrome. This low-cost device is inserted across the aortic valve through a 10-mm vascular graft sewn to the ascending aorta. METHODS: Impella patients were compared with 198 patients treated with an intraoperative intra-aortic balloon pump between January 2000 and December 2002. Three risk scores were used: the Hausmann score, the Texas Heart Institute score, and the Cleveland intensive care unit score. Between September 2001 and March 2003, 24 patients were treated with the Impella Recover for low-output syndrome. Before device insertion, 21 could not be separated from cardiopulmonary bypass, and 3 had postoperative hemodynamic instability despite high-dose catecholamines. Sixteen were treated with the Impella and intra-aortic balloon pump and 8 with the Impella alone (no intra-aortic balloon pump because of peripheral vascular disease or because deemed unnecessary). RESULTS: No technical problems with device insertion occurred. Pump flow was 3.3 +/- 0.7 L/min at 28,000 +/- 4500 RPM. Support time was 61 +/- 56 hours (range, 7-228 hours). Four devices required repositioning. One device failed (leaking purge line) and was removed. Hemolysis was minimal (lactate dehydrogenase levels of 540 +/- 260 U/dL for Impella survivors). Mortality for Impella patients was 54% (13/24), similar to that for high-risk intra-aortic balloon pump patients (Hausmann score > or =2 [57%], intensive care unit score > or =2 [51%], Texas Heart Institute score > or =0.75 [55%], and cardiac index < or =2.3 [45%]). Cardiac output data were available in 19 Impella patients. Impella patients able to increase their cardiac output to 1 L/min or more above the pump flow of the Impella Recover had a 10% (1/10) mortality, versus 88% (8/9) in patients with a residual cardiac function of 1 L/min or less (P =.001). Comparison of high-risk intra-aortic balloon pump patients with Impella patients with residual cardiac function of 1 L/min or more showed a significant reduction in mortality, regardless of the high-risk definition used. Residual cardiac function was the strongest predictor of survival in Impella patients. CONCLUSIONS: The Impella Recover device provides 3 to 4 L/min flow. It improves survival in patients with low-output syndrome if the heart is able to pump 1 L/min or more above device flow.

[Mechanical circulatory assist devices in acute and chronic heart failure]. / Mechanische Kreislaufunterstützung bei akuter und chronischer Herzinsuffizienz - eine Standortbestimmung unter besonderer Berücksichtigung der Entwicklung in Deutschland.

The clinical use of mechanical circulatory assist devices as bridge to transplantation has been proved as life-saving therapy in a large population of patients. Learning from the clinical experience the construction of the blood pumps has been markedly improved over the last years. The better outcome of the patients has enabled a broader use of ventricular assist devices. The novel axial pumps are designed for long-term circulatory support. After further reduction of device related complications (first of all thromboembolic events) these systems may provide a future alternative to heart transplantation.

The Jarvik 2000 is associated with less infections than the HeartMate left ventricular assist device.

OBJECTIVES: Device-related infections remain a considerable problem of left-ventricular support. We compared the device-related-infections between the HeartMate left ventricular assist device (LVAD) and the Jarvik 2000 permanent LVAD, a device with a novel retroauricular power-supply. METHODS: Between December 2000 and September 2002 we implanted the HeartMate-vented, electrical-system in 11 patients and the permanent Jarvik 2000 in six patients. Total support time was 1626 patient-days (HeartMate, 26-271 days) versus 1246 patient-days (Jarvik 2000, 8-411 days). As potential risk factors for infection we analyzed age, preoperative hospital-days, total protein, cardiac index, maximal oxygen uptake, use of inotropes, LVAD risk-score-index and Aaronson-Mancini-score, intubation time, and intensive care unit stay. We used the Center of Disease Control definitions for surgical site infections. RESULTS: HeartMate-patients were younger than Jarvik 2000 patients (46+/-13 versus 58+/-6 years, P=0.056), there were no other differences in the risk factors. Four HeartMate-patients needed late (>or=48 h) surgical revisions for bleeding/hematomas versus no revisions in the Jarvik 2000 patients. In the HeartMate-patients, there were seven (64%) driveline-infections, five (45%) device-pocket infections, and three (27%) bloodstream-infections, or 0.43 device-related infections/100 patient-days. Infections occurred early (34+/-31 days). Three patients required urgent transplantation due to bloodstream infection. There were no adverse outcomes in the HeartMate-group due to infection. In the Jarvik 2000 patients, there was one driveline-infection (16%) after 270 days of support (0.08 device-related infections/100 patient-days), significantly less than in the HeartMate-group (P=0.044). Driveline infections resolved with antibiotics and local wound care in the Jarvik 2000 patient, but only in one of seven HeartMate-patients. CONCLUSIONS: Implantation of the Jarvik 2000 is associated with less device-related infections than the HeartMate-LVAD. The power-supply of the permanent Jarvik 2000 is suitable for long-term mechanical support.

Implantation of the permanent Jarvik-2000 left-ventricular-assist-device: surgical technique.

The Jarvik-2000 is an axial-flow left-ventricular-assist-device (LVAD) designed for permanent use. The power supply is provided by a cable plugged into a skull-pedestal mounted in the retro-auricular area. We describe the surgical technique and discuss potential and encountered problems.

Preoperative chemotherapy for lung cancer does not increase surgical morbidity.

BACKGROUND: Preoperative chemotherapy (C+S) for non-small cell lung cancer (NSCLC) has increased in an attempt to improve survival. Patients receiving C+S potentially may have an increase in postoperative morbidity and mortality compared with surgery alone (S). We reviewed our experience with C+S and S in a tertiary referral center. METHODS: Three hundred eighty consecutive patients underwent lobectomy or greater resection for NSCLC between August 1, 1996, and April 30, 1999: 335 patients (259 S; 76 C+S) were analyzed; 45 additional patients were excluded for prior NSCLC, other chemotherapy for other malignancy, or radiation. We compared morbidity and mortality overall, and by subset analysis (clinical stage, pathological stage, procedure, and by protocol use) for both C+S and S patients. RESULTS: Demographics, comorbidities, and spirometry were similar. We noted no significant difference in overall or subset mortality or morbidity including pneumonia, acute respiratory distress syndrome, reintubation, tracheostomy, wound complications, or length of hospitalization. CONCLUSIONS: C+S did not significantly affect morbidity or mortality overall, based on clinical stage, postoperative stage, or extent of resection. The potential for enhanced survival in resectable NSCLC justifies continued study of C+S.