Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients.

OBJECTIVES: Excellent outcomes after minimally invasive aortic valve replacement (mini-AVR) have been reported. Therefore, mini-AVR has become a popular treatment option in many cardiac surgery centres. However, whether obese patients particularly benefit from mini-AVR remains unclear. The aim of the present study was to evaluate outcomes of AVR performed through partial upper sternotomy compared to AVR through a full sternotomy (full-AVR) in obese patients. METHODS: We retrospectively reviewed the medical records of all patients who underwent isolated AVR at our institution, and 217 consecutive obese [body mass index (BMI) >30 kg/m2] patients were identified. Outcomes of the mini-AVR group were compared with the full-AVR group. RESULTS: One hundred and twenty-six patients underwent mini-AVR and 91 patients had full-AVR. The mean age and BMI were 69.8 ± 10.4 years and 32.6 ± 3.1 kg/m2 in the mini-AVR group compared to 70.0 ± 10.5 years and 33.1 ± 3.0 kg/m2 in the full-AVR group. Mortality, myocardial infarction, stroke, renal failure and surgical site infections were equivalent. Mini-AVR was associated with decreased ventilation time [6 h (minimum, min 3 h; maximum, max 76 h) vs 8 h (min 3 h; max 340 h); P = 0.004], shorter intensive care unit (ICU) stay [2 days (min 1 day; max 25 days) vs 4 days (min 1 day; max 35 days); P = 0.031] and reduced transfusion requirements (26.5% vs 56.0%; P = 0.004). Total duration of hospital stay as well as postoperative pain levels were comparable. CONCLUSIONS: Patient safety was not affected by mini-AVR. Significant benefits in terms of decreased transfusion requirements, ventilator times and ICU times were found in the mini-AVR group. Consequently, mini-AVR, performed through partial upper sternotomy, should also be routinely offered to obese patients.

Continuous Glucose Monitoring in Patients Undergoing Extracorporeal Ventricular Assist Therapy.

BACKGROUND: Dysregulations of blood glucose (BG) are associated with adverse outcome in critical illness; controlling BG to target appears to improve outcome. Since BG-control is challenging in daily intensive care practice BG-control remains poor especially in patients with rapidly fluctuating BG. To improve BG-control and to avoid deleterious hypoglycemia, automated online-measurement tools are advocated. We thus evaluated the point-accuracy of the subcutaneous Sentrino® Continuous Glucose Monitoring System (CGM, Medtronic Diabetes, Northridge, California) in patients undergoing extracorporeal cardiac life support (ECLS) for cardiogenic shock. METHODS: Management of BG was performed according to institute's standard aiming at BG-levels between 100-145 mg/dl. CGM-values were recorded without taking measures into therapeutic account. Point-accuracy in comparison to intermittent BG-measurement by the ABL-blood-gas analyzer was determined. RESULTS: CGM (n = 25 patients) correlated significantly with ABL-values (r = 0.733, p<0.001). Mean error from standard was 15.0 mg/dl (11.9%). 44.2% of the readings were outside a 15% range around ABL-values. In one of 635 paired data-points, ABL revealed hypoglycemia (BG 32 mg/dl) whereas CGM did not show hypoglycemic values (132mg/dl). CONCLUSIONS: CGM reveals minimally invasive BG-values in critically ill adults with dynamically impaired tissue perfusion. Because of potential deviations from standard, CGM-readings must be interpreted with caution in specific ICU-populations.

Prospective study of everolimus with calcineurin inhibitor-free immunosuppression after heart transplantation: results at four years.

BACKGROUND: Immunosuppression is necessary after transplantation but it is associated with distinct adverse side effects. These negative effects could at least partially be overcome with the mammalian target of Rapamycin (mTOR) inhibitor everolimus. Few studies have examined everolimus therapy with calcineurin inhibitor (CNI) withdrawal in maintenance heart transplant patients (HTx). METHODS: In this prospective, single-arm, single-center study, maintenance patients after HTx were converted from CNI to everolimus. They were followed for 48 months. Primary endpoints were kidney-function and arterial hypertension. RESULTS: Forty-eight patients were recruited (mean post-transplant time 5.4 ± 3.5 years). Of these, 36 were followed for the entire 4-year period. Median calculated glomerular filtration rate increased from 40.7 (32.4 to 59.1) mL/minute at baseline to 48.9 (29.7 to 67)) mL/minute at month 48 (p = not significant). Median systolic and diastolic blood pressure, triglycerides, and high-density lipoprotein and low-density lipoprotein cholesterol, did not change significantly in a comparison of the values at baseline and at 48 months. Early resolution of most non-renal CNI-related adverse events was sustained. Due to adverse events, CNI therapy had to be reintroduced in 6 patients (12.5%). No significant changes in cardiac function parameters were observed. CONCLUSIONS: Calcineurin inhibitor-free immunosuppression with everolimus is an effective and safe option in selected maintenance HTx patients. Most adverse effects under everolimus occurred early after conversion and in most cases resolved without intervention within a few weeks. Refining selection criteria may help both in identifying patients who will profit most from switching and in alleviating the need to reintroduce CNI therapy.

Medically refractory pulmonary hypertension: treatment with nonpulsatile left ventricular assist devices.

BACKGROUND: Severe pulmonary hypertension refractory to medical treatment is a contraindication to orthotopic heart transplantation in most centers. We report our experience in treating severe pulmonary hypertension with mechanical left ventricular unloading using implantable nonpulsatile left ventricular assist devices (LVAD) with continuous flow properties. METHODS: In ten patients with severe pulmonary hypertension, refractory to medical treatment, an implantable nonpulsatile LVAD was placed for continuous mechanical left ventricular support. Pulmonary hemodynamics were assessed by right heart catheterization prior to and during LVAD implantation, and after orthotopic heart transplantation. RESULTS: The mean (+/-SD) interval of nonpulsatile support was 182 (+/-118) days. Pulmonary artery pressure (mean +/- SD) significantly decreased from 42 +/- 13 to 24 +/- 5 mm Hg (p < 0.005), the transpulmonary gradient (mean +/- SD) decreased from 20 +/- 6 to 11 +/-5 mm Hg (p < 0.005), and the pulmonary vascular resistance (mean +/- SD) from 4.8 +/- 1.8 to 2.2 +/- 0.8 Wood units (p < 0.005) during an interval of one to six months of LVAD support. No significant increases in pulmonary artery pressure, transpulmonary gradient, and pulmonary vascular resistance were observed during an interval of three to six months after orthotopic heart transplantation. CONCLUSIONS: This study supports that LVAD support and continuous nonpulsatile mechanical unloading of the left ventricle can reverse medically unresponsive pulmonary hypertension and render patients eligible for orthotopic heart transplantation.