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Doris Hutschala

Publications and source records attributed to Doris Hutschala.

18 recordsLinked to original sources
PubMed2006

Impaired target site penetration of vancomycin in diabetic patients following cardiac surgery.

Soft tissue infections constitute a serious complication following surgery in diabetic patients and frequently require the administration of vancomycin. However, despite antibiotic treatment, mortality of patients with postoperative infections remains high and might be related to an impaired penetration of anti-infective agents to target tissues. Therefore, the present study was designed to measure vancomycin tissue concentrations in six diabetic and six nondiabetic patients after cardiac surgery. Vancomycin was administered as a continuous intravenous infusion at an infusion rate of 80 to 120 mg/h. Vancomycin concentrations in soft tissues and plasma were measured in all patients during steady state as "therapeutic window" concentrations in plasma by microdialysis on day 8+/-4 after initiation of vancomycin treatment. Vancomycin tissue concentrations in diabetic patients were significantly lower than in nondiabetics (3.7 mg/liter versus 11.9 mg/liter; P=0.002). The median vancomycintissue/vancomycinplasma concentration ratio was 0.1 in diabetic patients and 0.3 in nondiabetics (P=0.002). Our study demonstrated that vancomycin penetration into target tissues is substantially impaired in diabetic patients versus nondiabetics. Insufficient tissue concentrations could therefore possibly contribute to failure of antibiotic treatment and the development of antimicrobial resistance in diabetic patients.

Aged↗
PubMed2005

In vivo measurement of levofloxacin penetration into lung tissue after cardiac surgery.

Nosocomial pneumonia is a severe complication after cardiac surgery (CS). Levofloxacin, a fluoroquinolone, qualifies for the therapy of postoperative pneumonia. However, penetration properties of levofloxacin into the lung tissue could be substantially affected by CS: atelectasis, low cardiac output after CS, high volume loads, and inflammatory capillary leak potentially influence drug distribution. The aim of our study was to gain information on interstitial antibiotic concentrations in lung tissue in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Therefore, six patients undergoing elective CS participated in this prospective study. A dose of 500 mg of levofloxacin was administered intravenously in addition to standard antibiotic prophylaxis immediately after the end of surgery. Time versus concentration profiles of levofloxacin in the interstitial lung tissue and plasma were determined. A microdialysis technique was used for lung interstitial concentration measurements. The microdialysis procedure was well tolerated in all patients and no adverse events were observed. The median area under the concentration curve (AUC) of levofloxacin in interstitial lung fluid was 18.6 microg.h/ml (range, 10.1 to 33.6). The median AUC for tissue (AUC(tissue)) of unbound levofloxacin/AUC(total) in plasma was 0.6 (range, 0.4 to 0.9). The median unbound AUC(tissue)/MIC was 2.4 (range, 1.3 to 4.2) for Pseudomonas aeruginosa. Our study demonstrated the feasibility and safety of microdialysis in human lung tissue in vivo after CS. The unbound AUC/MIC ratio revealed that levofloxacin used in the described manner was borderline sufficient for the treatment of nosocomial pneumonia caused by Klebsiella pneumoniae and insufficient for the treatment of pneumonia caused by Pseudomonas aeruginosa, because the breakpoint of 30 to 40 for AUC/MIC could not be reached by the conventionally used dosage schema in our post-CS setting. Penetration was lower than in previous reports.

Aged↗
PubMed2005

Total endoscopic CABG using robotics on beating heart.

BACKGROUND: The implementation of a total endoscopic coronary surgery on the beating heart with the aid of the Da Vinci surgical system (Intuitive, Sunnyvale, CA) requires a stepwise learning process. After cadaveric training and clinical start of the program in November 2002, we gained experience with arrested heart procedures starting in May 2003. In November 2003, we moved to beating heart surgery. METHODS: From November 2003 to January 2005, 14 patients with coronary artery disease (mean age of 62 +/- 5 years, female to male ratio 2:12) were operated with the intention to perform a beating heart TECAB (totally endoscopic coronary artery bypass grafting) procedure. RESULTS: Total conversion rate was 35% (5/14), due to pleural adhesions in 2 patients, injury of the lung during port placement, inability to occlude the LAD with saddle loops, atherosclerotic diseased mammary artery in 1 patient each. Mean operating time was 298 +/- 110 minutes with a steady decline throughout the study period (first 5 patients: 342 +/- 61 minutes, patients 6 to 9: 337 +/- 87 minutes, last 4 patients: 290 +/- 53 minutes), resulting in a 60 minute shorter operating time. Mean ICU stay was 1.3 days and hospital stay lasted on average 8.4 +/- 2.8 days. CONCLUSION: Total endoscopic bypass surgery on the beating heart with the Da Vinci surgical system can be safely implemented in clinical use. The learning curve results in a constantly decreasing procedure time due to a more effective table team-console surgeon-robotic system interaction and a moderate conversion rate.

Coronary Artery Bypass, Off-Pump↗
PubMed2004

Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations.

OBJECTIVE: This retrospective study evaluates, if recent refinements in peri-operative management, have an impact on clinical outcome of patients undergoing elective repair of their ascending thoracic aorta. METHODS: One hundred sixty five (n = 165) consecutive patients were operated during a 7 year period at our department. The cohort was divided in an early group I (from Jan 1997 to Dec 1999, n = 75) and a late group II (from Jan 2000 to Jan 2003, n = 90). The mean age was 60.9+/-13.1 years in group I versus 58.1+/-13.6 years in group II. In group I 50 patients (66.6%) underwent replacement of the ascending thoracic aorta alone, 17 patients (22.6%) received a composite graft, 8 patients (10.6%) had an additional aortic valve replacement and 14 patients (18.6%) needed concomitant coronary artery bypass grafting. In group II the procedures were as follows: interposition graft alone in 58 patients (64.4%), composite graft in 26 patients (28.8%), aortic valve replacement in 6 (6.6%) and CABG in 11 patients (12.2%). RESULTS: Overall hospital mortality for the entire cohort was 6.6% (11/165) with no significant differences between the early and late group with 6.6% (5/75) and 6.6% (6/90), respectively, P = 0.985. Causes were multi organ failure in 63.3% (n = 7), stroke in 9% (n = 1) myocardial infarction in 18.1% (n = 2) and refractory bleeding in 9% (n = 1). Concomitant CABG, repair of the aortic valve and composite graft, emerged as independent risk factor for mortality in multivariate logistic regression analysis with P = 0.001. Differences, became apparent in ICU as well as hospital stay with a median ICU stay in group I of 7.1+/-12.9 days versus 4.4+/-6.8 days in group II, and median hospital stay of 16.7+/-5.3 days versus 9.5+/-8.4 days for group I and II, P < 0.05, respectively. Furthermore through the implementation of blood conservation techniques, a substantial reduction of transfusion requirements could be achieved (PRBC from 3.2+/-4 to 1.1+/-1.7 units, FFP 5.2+/-3 to 2.3+/-0.5 units, Platelets from 1.3+/-2 to 0.3+/-0.07 units). CONCLUSIONS: Even with the implementation of various refinements in surgical and anaesthetic techniques, the current risk of mortality for ascending aortic aneurysm repair has not changed in the last 7 years. However, shortened ICU and hospital stays as well as diminished usage of blood derivates are mainly the result of a more aggressive and improved peri- and post-operative management due to economic considerations.

Adult↗
PubMed2004

Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta.

OBJECTIVE: The objective of the study was to evaluate mid-term durability and need for reinterventions after endovascular stent-grafting (ESG) in descending aortic aneurysms and dissections. PATIENTS AND METHODS: Between November 1996 and February 2003 a total of 80 patients underwent ESG for the following indications: atherosclerotic aneurysms (50/80; 63%), type B dissections (20/80; 25%), penetrating ulcers (6/80; 8%), traumatic aneurysms (4/80; 5%). Two types of commercially available ESG (Talent, Medtronic, Santa Rosa, CA and Excluder, WL GORE, Flagstaff, AZ) were inserted via the femoral artery in 53 patients, via the iliac artery in 21 patients and via the abdominal aorta in 6 patients. RESULTS: In-hospital mortality was 3.8% (n=3). Type I endoleak formation requiring endovascular reintervention was observed in 3.8% (n=3). Surgical reintervention became necessary in 4 patients (4/80; 5%). One patient experienced a retrograde type A dissection, detected in the 3 month control after ESG of an acute type B dissection, consecutively undergoing frozen elephant trunc repair. Three patients with late type I endoleak formation (mean interval: 62 months) after ESG (two atherosclerotic aneurysms, one penetrating ulcer) underwent open thoraco-abdominal repair in deep hypothermia or left heart bypass technique. All patients had an uneventful postoperative course. CONCLUSIONS: Occurrence of late endoleak formation requiring surgical reintervention after ESG is acceptably low. In atherosclerotic aneurysms the development of endoleaks is assumed to be causative related to progression of the underlying aortic disease. A close follow-up of patients after ESG is crucial.

Aged↗
PubMed2004

Stent-graft placement in atherosclerotic descending thoracic aortic aneurysms: midterm results.

PURPOSE: To determine midterm durability and need for reinterventions after stent-graft placement in atherosclerotic descending thoracic aortic aneurysms. METHODS: Fifty-four patients (38 men; mean age 68 years, range 33-87) underwent stent-graft repair of chronic atherosclerotic aneurysms of the descending thoracic aorta between November 1996 and December 2002. Acute aortic syndromes (type B aortic dissections, perforating ulcers, and traumatic dissections) were excluded from analysis. Two types of commercially available stent-grafts were used (Talent and Excluder). RESULTS: The primary technical success rate was 94.4%. In-hospital mortality was 3.7% (2/54). No adverse neurological events were encountered. Of 3 (5.6%) early type I endoleaks, 2 (3.7%) required reintervention; the other type I endoleak closed spontaneously. Mean follow-up was 38 months (range 1-72) in the 52 surviving patients. Four (7.7%) type I, 7 (13.5%) type II, and 4 (7.7%) type III endoleaks were seen. Three 3 patients had additional treatment for endoleaks (proximal stenting [type Ia], open thoracoabdominal repair [type Ib], and embolization [type II]). Two of the 3 reinterventions were performed in the first year of follow-up. One additional patient with a type Ia endoleak not suitable for reintervention is under close observation. There were no differences in the number of endoleaks between the 2 types of stent-grafts. Three-year event-free survival was 63%. CONCLUSIONS: Midterm durability of endovascular stent-graft placement in atherosclerotic descending aortic aneurysms seems promising, as the rate of endoleaks requiring reintervention is acceptably low. In our series, endoleak formation occurred during the first year after stent-graft placement, so close follow-up of patients after aortic aneurysm repair is crucial. Further studies are warranted to evaluate long-term durability of this new treatment modality.

Adult↗
PubMed2003

A double patch sandwich technique for surgical repair of acute aortic dissection type A.

BACKGROUND: This study compares two groups of patients with acute aortic dissection type A in whom two different techniques of anastomotic reinforcement were used, and evaluates the impact of these two techniques on perioperative blood loss and surgical outcome. METHODS: One hundred eighty-five consecutive patients with acute aortic dissection type A between 1998 and 2002 were grouped according to the technique utilized for reinforcing the aortic anastomotic site. Group A consisted of 21 patients in whom a novel double patch sandwich technique was used, whereas in group B (164 patients) conventional Teflon felt strips served as reinforcement. RESULTS: Preoperative profiles were comparable for both groups. Deep hypothermia and circulatory arrest were used in 180 patients (97%). Retrograde cerebral perfusion and retrograde cardioplegia were used in 70 patients (38%). Hospital mortality for the two groups was 4.7% (1 of 21) and 18% (29 out of 164), p < 0.30, respectively. On average 2 versus 6 U of PRBC (p < 0.21), and 3 versus 5 U of FFP (p < 0.004) were given during operation in groups A and B, respectively, and indicates reduced suture line bleeding in group A. CONCLUSIONS: Modifications in the surgical technique for repair of acute aortic dissection type A, and in anastomotic reinforcement in particular, may lead to substantial reduction of suture line bleeding and diminished blood loss and transfusion requirements, and favorably affects patient outcome. Nevertheless, continued effort is mandatory to further enhance surgical outcome in this patient population.

Acute Disease↗
PubMed2003

The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest.

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.

Age Factors↗
PubMed2003

Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair.

OBJECTIVES: To analyze outcome in elderly patients after surgical repair of the ascending aorta and the aortic arch as compared with their younger counterparts and to determine risk factors of mortality and permanent neurologic injury. Patients and methods Between January 1995 and February 2003, a total of 369 patients underwent ascending aortic and arch repair. Indications for surgical intervention were acute type A dissections in 174 (47%) patients (<75 years, n = 147; > or =75 years, n = 27) and chronic atherosclerotic aneurysms in 195 (53%) patients (<75 years, n = 168; > or =75 years, n = 27). Emergency surgery was performed in 167 (45%) patients; 202 patients (54.7%) underwent surgery requiring deep hypothermic circulatory arrest. Pre- and intraoperative factors were evaluated by means of stepwise logistic regression analysis to determine risk factors of mortality and permanent neurologic injury. RESULTS: Overall in-hospital mortality was 11.6%. In-hospital mortality with regard to indication for surgical intervention was comparable in both age groups (type A dissection: <75 years, 15.6%; > or =75 years, 18.5%; P =.731; chronic atherosclerotic aneurysm: <75 years, 7.7%; > or =75 years, 7.4%; P =.933). Permanent neurologic injury was observed in 5.0%. Permanent neurologic injury with regard to surgical intervention was comparable in both age groups (type A dissection: <75 years, 8.8%; > or =75 years, 3.7%; P =.359; chronic atherosclerotic aneurysm: <75 years, 3.0%; > or =75 years, 3.7%; P =.843). Stepwise logistic regression analysis revealed preoperative hemodynamic instability (odds ratio 4.3; P =.000), duration of cardiopulmonary bypass (odds ratio 2.1; P =.001), and permanent neurologic injury (odds ratio 1.7; P =.033) but not age as independent predictors affecting mortality. Utilization of but not duration of deep hypothermic circulatory arrest was the only independent predictor of permanent neurologic injury (odds ratio 2.8; P =.019). CONCLUSIONS: Age shows a trend toward a higher risk of mortality but does not predict a higher incidence of permanent neurologic injury after ascending aortic and arch repair. As utilization of deep hypothermic circulatory arrest remains the only independent predictor of permanent neurologic injury, alternative approaches to maintain cerebral perfusion during ascending aortic and arch repair are warranted.

Adult↗
PubMed2003

Endovascular stent graft placement in patients with acute thoracic aortic syndromes.

OBJECTIVE: In the present study, the effectiveness of endovascular stent grafts (ESG) in the treatment of acute aortic complications, such as acute dissection type B, penetrating ulcer and traumatic aortic rupture is evaluated. PATIENTS AND METHODS: From June 1997 to February 2002, 66 patients were treated with ESG. Out of this cohort, 19 patients (28.8%) were subjected to stent grafting due to acute aortic syndromes. Acute dissection type B was present in 11 patients (16.6%), a penetrating ulcer was diagnosed in six patients (9%) and in 2 patients (3%) a traumatic aneurysm was the indication for operation. There were 16 male and three female patients with a mean age of 60 years (20-85 years). Excluder stent grafts (Gore) were used in 15 patients, the Talent device (Medtronic) was implanted in four patients. RESULTS: Stent graft placement was technically successful in all patients. Hospital mortality was 0%. Paraparesis occurred in one patient (5.2%), which could be managed successfully without remaining neurological deficit after installation of cerebrospinal fluid drainage for 72h. In another patient, overstenting of the left subclavian artery caused ischemia of the left arm and left subclavian to carotid artery bypass had to be performed. ICU-stay ranged from 1 to 6 days (mean 2.4 days) and the patients could be discharged after an average hospital stay of 8 days. In the follow-up period, one patient died due to myocardial infarction and one patient had to be re-operated due to contained rupture of the thoracic aorta caused by an endoleak. CONCLUSIONS: The study suggests that endovascular stent grafting is an excellent and effective treatment modality for the acute aortic accident, which can be recommended for high-risk patients too. However, close follow-up examination is indicated and long-term results have to be awaited to evaluate the real effectiveness of this method.

Adult↗
PubMed2003

Elective endovascular stent-graft repair of atherosclerotic thoracic aortic aneurysms: clinical results and midterm follow-up.

OBJECTIVE: The purpose of this study was to evaluate the clinical and midterm results after endovascular treatment of atherosclerotic thoracic aortic aneurysms. MATERIALS AND METHODS: Twenty-eight consecutive patients who were 53-82 years old (mean age, 71.6 years) were treated with a commercially available endoprosthesis. Subclavian transposition or bypass surgery was performed before the procedure in eight patients. Size dynamics of the aneurysms were analyzed on the basis of diameter and thrombus volume measurements obtained on three-dimensional CT reconstructions before hospital discharge (n = 22) and at the 1-year (n = 22), 2-year (n = 12), and 3-year (n = 5) follow-ups. RESULTS: The technical success rate was 100%. There was no 30-day mortality. None of the patients had symptoms due to spinal cord ischemia. The survival rate at 1, 2, and 3 years was 96.1%, 90.9%, and 80.2%, respectively. During the perioperative period, patients presented with leukocytosis (37%), fever (36%), elevated C-reactive protein value (92%), pleural effusion (50%), and periaortic atelectasis (41%). Three early type I endoleaks sealed spontaneously. Three early type II endoleaks persisted over time, and one late type II endoleak was detected. In patients with type II endoleaks, thrombus volume of the aneurysms was constant (n = 2) or increased (n = 2). In patients without endoleaks, mean thrombus volume decreased (-53.2 +/- 56.8 mL, -40%) significantly (p = 0.001) during the first year. There was no significant interval decrease between the 1- and 2-year follow-ups (mean, -2.4 mL, p = 0.92) and between the 2- and 3-year follow-ups (mean, -0.4 mL, p = 0.68). CONCLUSION: Endovascular treatment of atherosclerotic thoracic aortic aneurysms may result in a substantial reduction of the aneurysm sac in patients without endoleaks.

Aged↗
PubMed2002

Surgical treatment of acute type A dissection: is rupture a risk factor?

BACKGROUND: The purpose of this study was to evaluate the significance of aortic rupture on clinical outcome in patients after aortic repair for acute type A dissection. METHODS: One hundred and twenty patients underwent aortic operations with resection of the intimal tear and open distal anastomosis. Median age was 60 years (range 16 to 87); 78 were male. Thirty-six patients had only ascending aortic replacement, 82 had hemiarch repair, and 2 had the entire arch replaced. Retrograde cerebral perfusion was utilized in 66 patients (53%). Rupture defined as free blood in the pericardial space was present in 60 patients (50%). Univariate and multivariate analyses were performed to assess the risk factors for mortality and neurologic dysfunction. RESULTS: Overall hospital mortality rate was 24.2% +/- 4.0% (+/- 70% confidence level) but did not differ between patients with aortic rupture or without (p = 0.83). The incidence of permanent neurologic dysfunction was 9.4% overall, 10.5% with rupture and 8.3% without rupture (p = 0.75). Multivariate analysis revealed absence of retrograde cerebral perfusion and any postoperative complication as statistically significant indicators for in-hospital mortality (p < 0.05). Overall 1- and 5-year survival was 85.3% and 33.7%; among discharged patients, survival in the nonruptured group was 89% and 37%, versus 81% and 31% in the ruptured group (p = 0.01). CONCLUSIONS: Aortic rupture at the time of surgery does not increase the risk of hospital mortality or permanent neurologic complications in patients with acute type A dissections. However, aortic rupture at the time of surgery does influence long-term survival.

Acute Disease↗
PubMed2002

Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results.

BACKGROUND: The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta. METHODS: From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery. RESULTS: Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months). CONCLUSIONS: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.

Acute Disease↗