Publications by authors named "Jens Litmathe"

33 Publications

[Anticoagulation after heart valve replacement].

Wien Med Wochenschr 2021 May 5. Epub 2021 May 5.

Evangelisches Krankenhaus Wesel, Klinik für Akut- und Notfallmedizin, Rettungszentrum, Schermbecker Landstr. 88, 46485 Wesel, Wesel, Deutschland.

In patients after mechanical heart valve replacement anticoagulation is required for the prevention of thrombotic and thromboembolic events. In this setting oral anticoagulation can only be performed with vitamin K antagonists (VKA), while currently all available non-vitamin K dependent oral anticoagulants (NOAC) are contraindicated in patients with mechanical heart valve replacement. This review deals with anticoagulation in patients with mechanical heart valve replacement as well as coagulation inhibition after bioprosthetic or percutaneous valve replacement. In addition, recommendations are given for antithrombotic medication in patients with mechanical heart valve replacement in various clinical scenarios.
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http://dx.doi.org/10.1007/s10354-021-00845-7DOI Listing
May 2021

[Hematoma in lipedema: from cutaneous origin or defect of coagulation?]

Wien Med Wochenschr 2021 Mar 10;171(3-4):48-52. Epub 2020 Dec 10.

Zentrale Notaufnahme, Evangelisches Krankenhaus Wesel, Wesel, Deutschland.

Lipedema is a widespread in concern of etiology partially unknown disease especially in women. In many cases it is accompanied by bleeding complications. Our current work focuses on possible coagulation disorders as potential sources of such bleeding complications. Since only a minority of our patients showed a coagulation defect it is suggestive that the main underlying reason for bleeding in lipedema is of cutaneous origin what may only be forwarded by simultaneously existing coagulation disorders.
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http://dx.doi.org/10.1007/s10354-020-00792-9DOI Listing
March 2021

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study.

Epilepsy Behav 2019 12 30;101(Pt A):106565. Epub 2019 Oct 30.

Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany.

Aim: Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS.

Methods: Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients.

Results: Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation.

Conclusions: Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.
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http://dx.doi.org/10.1016/j.yebeh.2019.106565DOI Listing
December 2019

[Oral anticoagulation in atrial fibrillation: differential therapy with non vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists (VKA)].

MMW Fortschr Med 2019 Oct 5;161(Suppl 6):15-23. Epub 2019 Oct 5.

Klinik für Innere Medizin und Geriatrie, Evangelisches Klinikum Bethel, Bielefeld, Deutschland.

Background: Non-vitamin K-dependent oral anticoagulants (NOAC) have changed the management of patients with oral anticoagulation. This raises the question of which patients should preferably be anticoagulated with NOAC and which preferably with vitamin K antagonists (VKA). This discussion has so far been insufficiently conducted and often decided on a flat-rate basis in favor of the NOAC.

Method: To clarify the question owhich form of anticoagulation - NOAC or VKA - is the best choice for patients with atrial fibrillation, an interdisciplinary team of experts met.

Results And Conclusions: The experts discussed essential practical aspects of NOAC and VKA therapy. Based on typical clinical scenarios, they developed assistance, comments and tips on the differentiated use of oral anticoagulants in patients with atrial fibrillation. A criteria served amongst others practicability in daily medical practice, contraindications, side effects and interactions, but also the patient's desire. The advantages and disadvantages of therapy with VKA and NOAC were summarized in a table.
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http://dx.doi.org/10.1007/s15006-019-0920-yDOI Listing
October 2019

[39-Year-Old Female Patient with Diarrhoea and Muscle Weakness].

Dtsch Med Wochenschr 2019 09 12;144(18):1249-1250. Epub 2019 Sep 12.

Neurologische Klinik, Universitätsklinik der RWTH Aachen.

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http://dx.doi.org/10.1055/a-0750-2382DOI Listing
September 2019

[63-Year-Old Female Patient with a Reduced Movement of the Legs].

Dtsch Med Wochenschr 2019 03 14;144(6):373-374. Epub 2019 Mar 14.

Neurologische Klinik, Universitätsklinik der RWTH Aachen.

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http://dx.doi.org/10.1055/a-0736-0495DOI Listing
March 2019

[Risk factors for hypertensive and cerebral amyloid angiopathy associated intracerebral hemorrhage: a retrospective comparison].

Fortschr Neurol Psychiatr 2018 12 12;86(12):763-769. Epub 2018 Nov 12.

Klinik für Neurologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland.

Introduction: The aim of this study was to compare possible risk factors for the most common forms of spontaneous intracerebral hemorrhage (ICH), namely hypertensive and cerebral amyloid angiopathy (CAA) associated ICH.

Methods: Retrospectively, different parameters and factors were compared in patients with hypertensive ICH (n = 141) and patients with a CAAassociated ICH (n = 95). These included age, INR value and blood pressure at admission, cardiovascular risk factors as well as pre-medication. The Chi-square test with the Yates' continuity correction and the t-test were used as test methods.

Results: Patients of the group with CAA-associated ICH were significantly older than patients with a hypertensive ICH (p = 0.001). In addition, there was a significantly higher incidence of acetylsalicylic acid prior treatment (p = 0.042) and a previous stroke (p = 0.048) in the CAA patients. Patients of both groups had a high proportion of arterial hypertension as pre-diagnosis, which was significantly more common in patients with hypertensive ICH (p < 0,001). Patients with a hypertensive ICH also had significantly higher systolic and diastolic blood pressure values (p < 0.001) and higher INR values (p = 0.005) at admission. A subgroup analysis of all patients without anticoagulation (ZAA group: n = 78, hypertensive ICB group: n = 99) showed similar results. However, there was no significant difference (p = 0.037) for a previous stroke, but there was a significant difference in premedication with a statin (p = 0.032).

Discussion: Arterial hypertension is a relevant risk factor in both forms of intracerebral hemorrhage and should therefore receive adequate prophylaxis. For a more detailed classification of the other risk factors, further studies with larger cases are necessary.
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http://dx.doi.org/10.1055/a-0732-5523DOI Listing
December 2018

Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes.

Intern Emerg Med 2018 08 12;13(5):749-755. Epub 2017 Sep 12.

Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany.

Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope. The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2 h of the event in patients admitted with either a GTCS (n = 49) or a syncope (n = 36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p < 0.001). In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45 mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0). Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.
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http://dx.doi.org/10.1007/s11739-017-1745-2DOI Listing
August 2018

[Oral anticoagulation using coumarins - an update].

Wien Med Wochenschr 2018 Apr 12;168(5-6):121-132. Epub 2017 Jun 12.

Klinik für Neurologie, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Deutschland.

Vitamin K antagonists (VKA) are used for the prophylaxis and treatment of thrombotic and thromboembolic events. Most important indications are venous thrombosis and pulmonary embolism, atrial fibrillation, and mechanical heart-valve replacement. Hence they are from high relevance for the neurologist and his daily praxis in cardio-neurological routine. Here, we give an overview about VKA with focus on mode of action, indications and efficacy, practical aspects of treatment, side effects, and monitoring.
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http://dx.doi.org/10.1007/s10354-017-0577-zDOI Listing
April 2018

An unusual agent for an unusual localization of infective endocarditis.

Perfusion 2017 Nov 3;32(8):691-694. Epub 2017 Jun 3.

1 Department of Neurology, RWTH Aachen University, Aachen, Germany.

We report on a 32-year-old male patient with acute left-hemispheric stroke caused by embolism due to infective endocarditis affected from the HACEK group. Additionally, atypical findings from the transesophageal echocardiography (TEE) which showed fluttering structures belonging to the papillary muscle could be proven as infectious agents with the help of a glucose positron emission tomography (PET) scan. TEE controls showed increasing vegetation involving the mitral valve so that surgery became necessary. The current work reflects, in detail, the emergent clinical course of this young patient, suffering from both an unusual localization and an infrequent cause of endocarditis and focuses on an actual view to the literature.
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http://dx.doi.org/10.1177/0267659117712406DOI Listing
November 2017

[45-Year-Old Male Patient with Sudden Pain at Forefinger].

Dtsch Med Wochenschr 2017 Apr 7;142(7):541-542. Epub 2017 Apr 7.

Klinik für Neurologie, RWTH Aachen University, Aachen.

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http://dx.doi.org/10.1055/s-0043-101213DOI Listing
April 2017

[Health care economic guidance in Germany from the example Morbi-RSA].

Authors:
Jens Litmathe

Wien Med Wochenschr 2016 Apr 13;166(5-6):182-7. Epub 2016 Jan 13.

Klinik für Neurologie, Klinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.

Increasing costs in health care represent still a major challenge in most industrial contries. A lot of attempts especially in Germany have been made to manage such problems and for a fair allocation oft he underlying resources. One of this ist the Morbi-RSA. The current review reflects all historical, medical and economical aspects of the Morbi-RSA and gives a perspective to possible future developments.
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http://dx.doi.org/10.1007/s10354-015-0422-1DOI Listing
April 2016

Focus on direct oral anticoagulants (DOAC) for prophylaxis of venous thrombosis and pulmonary embolism in medically ill patients.

Int J Cardiol 2016 Jan 26;203:454-6. Epub 2015 Oct 26.

Department of Neurology, RWTH Aachen University, Pauwelsstr. 30, D-52074 Aachen, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2015.10.204DOI Listing
January 2016

Cardiovascular causes of emergency neurology presenting to an ICU.

Perfusion 2016 May 22;31(4):271-80. Epub 2015 Oct 22.

Department of Neurology, RWTH University, Aachen, Germany Jülich Aachen Research Alliance (JARA) - Translational Brain Medicine, Aachen, Germany.

Stroke or transient ischemic attacks (TIA) represent an urgent clinical entity that is not limited only to elderly patients. The underlying causes of stroke and TIA are diverse, with those of cardiovascular origin being among the most prominent. This review seeks to elucidate some of the most important aspects of the disease in the context of emergency and critical care practice.
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http://dx.doi.org/10.1177/0267659115613429DOI Listing
May 2016

Can We Close the Discussion on PFO-Closure?

Hellenic J Cardiol 2015 May-Jun;56(3):247-57

Department of Neurology, RWTH University, Aachen, Germany, Germany, Jülich Aachen Research Alliance (JARA) - Translational Brain Medicine.

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March 2016

Severe ARDS induced by fusobacterial infections: a rare clinical presentation of Lemierre syndrome.

Thorac Cardiovasc Surg 2013 Dec 5;61(8):754-7. Epub 2013 Apr 5.

Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany.

Acute respiratory distress syndrome (ARDS) poses a major challenge in intensive care settings. The main underlying causes of ARDS are trauma, pancreatitis, and pulmonary manifestation of systemic inflammatory response syndrome/sepsis.Lemierre syndrome represents a nearly forgotten entity arising from oropharyngeal infections with Fusobacterial species, and it is of renewed and increasing interest because of evolving antibiotic resistances.We report two cases of young female patients afflicted by Lemierre syndrome with additional severe ARDS and present an overview of the current literature.
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http://dx.doi.org/10.1055/s-0033-1336831DOI Listing
December 2013

Systemic inflammatory response syndrome after extracorporeal circulation: a predictive algorithm for the patient at risk.

Hellenic J Cardiol 2011 Nov-Dec;52(6):493-500

Department of Thoracic and Cardiovascular Surgery, Heinrich Heine University Hospital Düsseldorf, Germany.

Introduction: Perioperative systemic inflammatory response syndrome (SIRS) remains a catastrophe in cardiac surgery and adequate patient screening is still lacking. We present a prospective trial starting with preoperative data collection. For the first time, the postoperative outcomes of patients after open-heart surgery are evaluated to predict a hazard-constellation for the patient at risk of developing SIRS.

Methods: Of 2315 patients undergoing cardiac surgery over a 2-year period, 107 were considered likely to develop perioperative SIRS based on a high-risk stratification; 12 of them actually developed SIRS and were recruited for this study. Another 20 uneventful consecutive patients served as controls. Blood samples were collected from before the induction of anaesthesia until the morning of the second postoperative day and were analysed for complement, cytokines, adhesion-molecules, endothelin-1 (ET-1), plasminogen-activatorinhibitor (PAI), the coagulation and fibrinolysis cascade and routine laboratory analysis.

Results: Significant preoperative differences were observed in leukocytes, lymphocytes, alkaline phosphatase,ICAM-3 and VCAM-1 (p<0.05). Significant positive correlations were found for ET-1 and lactate in the SIRS group. The increase in these parameters was correlated with a prolonged duration of extracorporeal circulation. The best predictive combination for SIRS consisted of alkaline phosphatase, ET-1, ICAM-1, -2, -3, VCAM-1 and ELAM-1.

Conclusions: The results suggest a new theory regarding the development of perioperative SIRS. It is not the extracorporeal circulation itself that represents the main trigger, but rather an a priori activation of the endothelial cells, lymphocytes and leukocytes. This activation impairs the microcirculation and finally leads to multi-organ failure. The current data allow the identification of the patient at risk and can thus influence the individual operative schedule.
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May 2012

Aortic valve replacement in octogenarians: outcome and predictors of complications.

Hellenic J Cardiol 2011 May-Jun;52(3):211-5

Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University Hospital, Düsseldorf, Germany.

Introduction: We aimed to evaluate the outcome in octogenarians after aortic valve replacement (AVR) and to determine the perioperative parameters that were predictive of a complicated postoperative course.

Methods: The study population included 304 patients (65% male) aged 82.7 ± 3.5 years who underwent AVR alone (63%), in combination with coronary artery bypass grafting (28%) or with other procedures (9%), between 1998 and 1/2008. Most patients suffered from combined valve disease.

Results: Mechanical valves were implanted in 50% of the patients. The in-hospital mortality was 5.8%. The stay in the intensive care unit was 2.3 ± 0.5 days and in hospital 15.3 ± 2.6 days. After multivariate analysis we were able to identify some predictors for in-hospital mortality, such as preoperative cardiogenic shock (p<0.02), ejection fraction <0.3 (p<0.03), diameter of prosthesis <21 mm (p<0.05), and redo surgery. The most important predictors for postoperative complications after AVR were preoperative renal failure, additional surgical procedures (i.e. coronary artery bypass, mitral valve) and prolonged aortic crossclamping (all p<0.05).

Conclusions: The outcome after AVR in octogenarians is satisfactory; the operative risk is acceptable and might even be reduced with an individual approach to perioperative management in high-risk patients.
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October 2011

No evidence for increased intraoperative bleeding in aortic-valve stenosis: a comparative analysis of haemotherapy in 136 patients undergoing aortic-valve replacement.

Acta Cardiol 2010 Dec;65(6):675-9

LaboMed Coagulation Centre, Berlin, Germany.

Objective: An association of aortic-valve stenosis and abnormal bleeding, particularly from gastrointestinal angiodysplasia, has been reported. In this setting, high-shear stress generated by the transvalvular gradient leads to a conformational change of plasmic von Willebrand factor, making this adhesive protein more susceptible for proteolytic cleavage. Consequently, highest-molecular weight multimers of the von Willebrand factor are degraded through a von Willebrand factor specific protease leading to impaired platelet-related haemostasis.

Methods And Results: To assess the role of aortic-valve stenosis as a factor predicting abnormal intraoperative bleeding in patients suffering from aortic-valve stenosis, we compared the number of intraoperatively administered blood components during aortic-valve replacement for aortic-valve stenosis (n = 50), aortic-valve insufficiency (n = 19) and combined aortic-valve defects (n = 67). As a result, the three subgroups did not differ significantly regarding the mean number of transfused red-blood cell units (0.94 +/- 1.36, 0.4 +/- 0.9, or 0.86 +/- 1.3, respectively) and plasma units (0.04 +/- 0.28, 0.21 +/- 0.71, or 0.15 +/- 0.61, respectively). None of the patients received platelet concentrates. A multivariate logistic regression model adjusted for age and gender did not show an influence of the presence and severity of aortic-valve stenosis on intraoperatively applied haemotherapy.

Conclusion: Along with our findings, the presence or severity of aortic-valve stenosis does not predict an increased need for intraoperative transfusion of blood components. Thus, this cardiac defect does not seem to represent a major risk determinant for intraoperative bleeding despite the high prevalence of shear-stress induced von Willebrand factor abnormalities in this setting.
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http://dx.doi.org/10.1080/ac.65.6.2059865DOI Listing
December 2010

Cardiac surgery in nonagenarians: pushing the boundary one further decade.

Arch Gerontol Geriatr 2011 Sep-Oct;53(2):229-32. Epub 2010 Dec 18.

Department of Cardiothoracic Surgery, Klinikum Oldenburg, Rahel Straus Str 10, D-26133 Oldenburg, Germany.

With increasing age of the general population, the necessity for cardiac surgery in the collective of patients aged 90 and older has been increasing. To aid in the choice of adequate therapy we investigated our experience for the group of nonagenarians undergoing surgical interventions. From 6/2000 to 9/2007, 17 patients aged 90 and older underwent open-heart surgery at our institution. We performed a retrospective data analysis including baseline preoperative clinical status, intra- and postoperative results and the long-term survival in the further postoperative course. We performed cardiac surgical procedures in 17 patients (male/female ratio 6/11), including isolated aortic valve replacement (n = 7), aortic root replacement (n = 2), isolated coronary bypass surgery (n = 4), combined coronary and valve surgery (n = 5), re-operative valve replacement (n = 1) and root replacement with arch repair (n = 1). Emergency procedures were performed in 11.8% (2/17). Mean age was 91.9 ± 1.2 years, ranging 90.1-94.2. Mean follow-up was 3.2 ± 2.2 years. The 30-day mortality was 17.6% (3/17), overall mortality at 42.9 follow-up patient years was 58.8% (10/17). We conclude that cardiac surgery procedures can be performed with therapeutic benefit for selected nonagenarians safely and with acceptable operative risk. After analysis our clinical experience we believe age alone not to be a contraindication for surgical intervention, consideration of the physiologic status of the patient reflects on the postoperative outcome. Survival of the patients investigated that survived the initial 30-day postoperative period was similar to the estimated survival of the equally aged general population in Germany.
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http://dx.doi.org/10.1016/j.archger.2010.11.026DOI Listing
December 2011

Double ECMO in severe ARDS: report of an outstanding case and literature review.

Perfusion 2010 Nov 9;25(6):363-7. Epub 2010 Aug 9.

Department of Thoracic and Cardiovascular Surgery, Klinikum Oldenburg, Oldenburg, Germany.

We report on a 49-year-old male patient who suffered from severe herpes simplex (HSV) pneumonia after a fall-from-height injury, causing a circumscript type B aortic dissection.The subsequent occurrence of ARDS required a veno-venous ECMO circuit that was upgraded to a veno-arterial system due to further oxygenation deficits. Following continued respiratory deterioration, the ECMO system already in place had to be complemented by a second veno-arterial line. After the onset of recovery and because of a developing of a disseminated intravasal coagulation, the double ECMO circuit was replaced by a pumpless extracorporeal lung assist system (PECLA). The patient recovered completely under systemic virostatic therapy.
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http://dx.doi.org/10.1177/0267659110380771DOI Listing
November 2010

The use of autologous platelet gel (APG) for high-risk patients in cardiac surgery -- is it beneficial?

Perfusion 2009 Nov;24(6):381-7

Department of Thoracic- and Cardiovascular Surgery, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Duesseldorf, Germany.

Background: Wound healing in cardiac surgery has become a major problem due to the impaired risk profile of many patients. The aim of this study was to prove the influence of autologous platelet gel (APG) on wound healing in a special group of high-risk patients undergoing coronary surgery.

Patients And Methods: We performed a prospective, double-blind study in 44 patients with a special risk constellation relating to wound complications (obesity, diabetes, smoker, New York Heart Association (NYHA) III-IV and peripheral vascular disease). The study group was treated with APG, prepared using the Magellan platelet separator, the control group underwent conventional wound treatment.

Results: The incidence of major and minor wound complications at the thoracotomy, as well as in the area of saphenous vein harvesting, was not pronounced in either of the groups. Blood loss and pain sensations did not differ significantly either. Stay in the intensive care unit (ICU) and the in-hospital mortality were also comparable. The duration of the entire operation and the time until removing the chest-tubes were prolonged in the study group.

Conclusion: Despite promising results in other fields of surgery, APG shows no beneficial effect in high-risk patients undergoing cardiac surgery. Probably, it depends on different types of microcirculation in atherosclerotic patients, which are quite different from those of other surgical areas. This factor may offset the existing beneficial platelet effects which could be observed, for example, in maxillo-facial surgery.
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http://dx.doi.org/10.1177/0267659109358283DOI Listing
November 2009

Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: a multicenter analysis.

J Thorac Cardiovasc Surg 2009 Apr 18;137(4):840-5. Epub 2009 Jan 18.

Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, Essen, Germany.

Objectives: Do prior percutaneous coronary interventions adversely affect the outcome of subsequent coronary artery bypass grafting? We investigated this effect on a multicenter basis.

Methods: Eight cardiac surgical centers provided outcome data of 37,140 consecutive patients who underwent isolated first-time coronary bypass grafting between January 2000 and December 2005. Twenty-two patient characteristics and outcome variables were retrieved. Three groups of patients were analysed for in-hospital mortality and in-hospital major adverse cardiac events: patients without a previous percutaneous coronary intervention, with 1 previous intervention, and with 2 or more previous percutaneous coronary interventions before bypass grafting. A total of 29,928 patients with complete information for prior percutaneous coronary intervention underwent final analysis. Unadjusted univariate and risk-adjusted multivariate logistic regression analysis as well as computed propensity score matching were performed, based on 14 major risk factors to correct for and minimize selection bias.

Results: A total of 10.3% of patients had 1 previous percutaneous coronary intervention, and 3.7% of patients had 2 or more previous interventions. Risk-adjusted multivariate logistic regression analysis revealed a significant association of 2 or more previous percutaneous coronary interventions with in-hospital mortality (odds ratio [OR], 2.0; confidence interval [CI], 1.4-3.0; P = .0005) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0013). After propensity score matching, conditional logistic regression analysis confirmed the results of adjusted analysis. A history of 2 or more previous percutaneous coronary interventions was significantly associated with in-hospital mortality (OR, 1.9; CI, 1.3-2.7; P = .0016) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0019).

Conclusions: Multicenter analysis confirms that a history of multiple previous percutaneous coronary interventions increases in-hospital mortality and the incidence of major adverse cardiac events after subsequent coronary artery bypass grafting. Critical discussion of the treatment strategy in these patients is warranted.
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http://dx.doi.org/10.1016/j.jtcvs.2008.09.005DOI Listing
April 2009

Oxygenation failure after cardiac surgery: early re-intubation versus treatment by nasal continuous positive airway pressure (NCPAP) or non-invasive positive pressure ventilation (NPPV).

Monaldi Arch Chest Dis 2008 Jun;70(2):71-5

Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University Hospital, Duesseldorf, Germany.

Background: Due to an increasing incidence of respiratory failure after cardiac surgery we wanted to study whether nasal continuous positive airway pressure (NCPAP) may improve pulmonary oxygen transfer and may avoid reintubation after coronary operations. Additionally, we compared this protocol to non-invasive positive pressure ventilation (NPPV).

Methods: For a period of 2 years we analyzed all patients that were extubated within 12 hours after coronary surgery, and in whom oxygen transfer (PaO2/FIO2) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation: group A=immediate reintubation (n=88), group B=NCPAP-treatment (n=173), group C=NPPV (n=18).

Results: 25.4% of group B- and 22.2% of group C-patients were also intubated after a period of NCPAP or NPPV. All other patients of groups B and C could be weaned from these devices (B = 34.3 +/- 5.9 hours; C = 26.4 +/- 4.4 h; p < 0.05) and were well oxygenated by face mask at ambient pressure (Ratio PaO2/FIO2: B, 138 +/- 13; C, 140 +/- 13). In group A we found a higher mortality (7.95%) compared to group B (4.04%) and group C (5.55%). NCPAP-patients suffered more frequently from an impaired sternal wound healing (A = 4.5%, B = 8.6%; p < 0.05).

Conclusions: We conclude that reintubation after cardiac operations should be avoided since NCPAP and NPPV are safe and effective to improve arterial oxygenation in most patients with non hypercapnic respiratory failure.
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http://dx.doi.org/10.4081/monaldi.2008.425DOI Listing
June 2008

Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery?

Eur J Cardiothorac Surg 2007 Apr 16;31(4):614-7. Epub 2007 Feb 16.

Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University Hospital, Düsseldorf, Germany.

Objective: Enlargement of the ascending aorta is often combined with valvular, coronary, or other cardiac diseases. Reduction aortoplasty can be an optional therapy; however, indications regarding the diameter of aorta, the history of dilatation (poststenosis, bicuspid aortic valve), or the intraoperative management (wall excision, reduction suture, external reinforcement) are not established.

Methods: In a retrospective study between 1997 and 2005, we investigated 531 patients operated for aneurysm or ectasia of the ascending aorta (diameter: 45-76mm). Of these, in 50 patients, size-reducing ascending aortoplasty was performed. External reinforcement with a non-coated dacron prosthesis was added in order to stabilize the aortic wall.

Results: Aortoplasty was associated with aortic valve replacement in 47 cases (35 mechanical vs 12 biological), subvalvular myectomy in 29 cases, and CABG in 13 cases. The procedure was performed with low hospital mortality (2%) and a low postoperative morbidity. Computertomographic and echocardiographic diameters were significantly smaller after reduction (55.8+/-9mm down to 40.51+/-6.2mm (CT), p<0.002; 54.1+/-6.7mm preoperatively down to 38.7+/-7.1mm (echocardiography), p<0.002), with stable performance in long-term follow-up (mean follow-up time: 70 months).

Conclusions: As demonstrated in this study, size reduction of the ascending aorta using aortoplasty with external reinforcement is a safe procedure with excellent long-term results. It is a therapeutic option in modern aortic surgery in patients with poststenotic dilatation of the aorta without impairment of the sinotubular junction of the aortic valve and root.
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http://dx.doi.org/10.1016/j.ejcts.2007.01.028DOI Listing
April 2007

Abdominal complications following open-heart surgery: a report of 12 cases and review of the literature.

Acta Cardiol 2006 Jun;61(3):301-6

Department of Thoracic and Cardiovascular Surgery Heinrich-Heine-University Duesseldorf, Germany.

Introduction: Abdominal complications following open-heart surgery remain serious events as the mortality is reported to be tremendously high. The clinical presentation, the diagnostic strategy and the therapeutic management varies. We reviewed all records of those patients who developed abdominal complications with surgical consequences during the last five years, recorded a complete follow-up and compared the findings to a current view of the literature.

Patients And Methods: Altogether 5720 patients underwent open-heart surgery at our institution between 1/98 and 12/02. Out of these 12 (10 men, 2 women) developed severe gastrointestinal complications with surgical consequences. The mean age was 73.17 +/- 8.1 I1 years. Seven patients underwent isolated coronary artery bypass grafting (CABG), two patients combined aortic valve replacement (AVR) and CABG, one isolated AVR, one mitral valve replacement (MVR) and yet another one combined MVR and CABG. The clinical records of all these patients were examined and a complete follow-up was recorded.

Results: The duration of the entire cardiac operation was a mean of 212.67 +/- 36.97 min, perfusion time 103 +/- 29.32 min and myocardial ischaemic time 52.25 +/- 24.56 min. Length of ICU-stay was between I and 5 days after cardiac surgery. Concerning gastrointestinal complications nine patients suffered from ischaemic intestinal disease, two from gastrointestinal ulcer bleeding and one from a preoperatively unknown bowel tumour with subsequent ileus. Four patients died in the immediate postoperative course, one patient within two years and seven patients show a satisfactory status at follow-up.

Conclusions: A review from the literature shows an enormous mortality from abdominal complications following open-heart surgery. This was also found in our series. As many of these patients have a history of abdominal disease more attention should be paid to such anamnestic hints in the preparation before cardiac surgery. Hence we recommend early diagnostic measures and explorative laparotomy in doubtful situations in patients with positive anamnesis.
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http://dx.doi.org/10.2143/AC.61.3.2014832DOI Listing
June 2006

The Bad Oeynhausen concept of INR self-management.

J Thromb Thrombolysis 2005 Feb;19(1):25-31

Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine Westphalia, Clinic of the Ruhr University Bochum, Bad Oeynhausen, Germany.

Background: A significant number of patients depend on the intake of vitamin K antagonists for prevention and treatment of thromboembolic events. The development of portable anticoagulation monitors has enabled self-testing and self-adjustment of anticoagulation therapy.

Objective: To describe the principles of a training course to learn INR self-management and to illustrate reliability of our concept.

Description: The training is divided into an early postoperative training, an ambulatory training six months later, and a 24 hours care and consultation. According to our concept, each patient who depends on long-term anticoagulation therapy is able to learn INR self-management. Reliability of our concept has been proved in two prospective, randomized clinical trials.

Study Results: A study with 1,155 patients has demonstrated that INR values lie more often in the predetermined target range in the INR self-management group if compared to the conventional group (79.2% vs. 64.9%; P < 0.001). Moreover, this study has demonstrated that self-management can lead to a reduction of thromboembolism (1.5% vs. 2.8%; P < 0.05), and to a lower lethality if compared to conventional INR management (3.5% vs 6.0%; P < 0.025). A second study with 1,816 patients has confirmed that INR self-management results in a high percentage of INR values in the target range (76%), even though target INR-range is reduced and narrowed. Thus, low dose INR self-management did not increase the risk of thromboembolism while avoiding the zone of higher risk for bleeding, beginning from INR > 3.5.

Conclusions: The Bad Oeynhausen concept of INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. It can thus be successfully applied to patients with an indication for permanent anticoagulation therapy.
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http://dx.doi.org/10.1007/s11239-005-0937-1DOI Listing
February 2005

Simultaneous coronary artery bypass grafting, replacement of the innominate artery and subtotal thyroidectomy in a 61 year-old patient: a case-report.

Chin Med J (Engl) 2005 Apr;118(8):699-701

Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University Hospital, Moorenstrasse 5, D-40225 Duesseldorf, Germany.

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April 2005