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Biomedical subjects

E Kilger

Publications and source records attributed to E Kilger.

At least 19 recordsLinked to original sources
PubMed2006

Association between vasopressor dependence and early outcome in patients after cardiac surgery.

Arterial hypotension with vasopressor dependence is a major problem after cardiac surgery. We evaluated the early postoperative course of 1558 consecutive patients scheduled for cardiac surgery, and compared the outcome of patients with and without vasopressor dependence (defined as the need for > 0.1 microg x kg(-1) x h(-1) noradrenaline for > 3 h in the face of normovolaemia). Vasopressor dependence was diagnosed in 424 patients (27%) and was associated with a higher incidence of postoperative renal failure (67 (15.7%) vs 7 (0.6%), respectively; p < 0.0001), a longer duration of ventilation (median IQR [range]) 14 (8-26 [6-39]) h vs 8 (5-11 [4-32]) h; p < 0.0001), a greater need for red cell transfusion (3 (1-5 [0-10]) units vs 1 (0-2 [0-4]) units; p < 0.001) and a longer length of stay in the ICU (4 (2-6 [2-9] days) vs 2 (1-3 [1-6] days; p < 0.001). Vasopressor dependence could be predicted from a combination of factors, including pre-operative ejection fraction < 37%, cardiopulmonary bypass lasting > 94 min, and postoperative interleukin-6 > 837 pg x ml(-1).

Aged↗
PubMed2004

Assessing fluid responsiveness during open chest conditions.

BACKGROUND: Measurement of ventilation-induced left ventricular stroke volume variations (SVV) or pulse pressure variations (PPV) is useful to optimize preload in patients after cardiac surgery. The aim of this study was to investigate the ability of SVV and PPV measured by arterial pulse contour analysis to assess fluid responsiveness in patients undergoing coronary artery bypass surgery during open-chest conditions. METHODS: We studied 22 patients immediately after midline sternotomy. We determined SVV, PPV, left ventricular end-diastolic area index by transoesophageal echocardiography, global end-diastolic volume index and cardiac index by thermodilution before and after removal of blood 500 ml and after volume substitution with hydroxyethyl starch 6%, 500 ml. RESULTS: Blood removal resulted in a significant increase in SVV from 6.7 (2.2) to 12.7 (3.8)%. PPV increased from 5.2 (2.5) to 11.9 (4.6)% (both P<0.001). Cardiac index decreased from 2.9 (0.6) to 2.3 (0.5) litres min(-1) m(-2) and global end-diastolic volume index decreased from 650 (98) to 565 (98) ml m(-2) (both P<0.025). Left ventricular end-diastolic area index did not change significantly. After fluid loading SVV decreased significantly to 6.8 (2.2)% and PPV decreased to 5.4 (2.1)% (both P<0.001). Concomitantly, cardiac index increased significantly to 3.3 (0.5) litres min(-1) m(-2) (P<0.001) and global end-diastolic volume index increased significantly to 663 (104) ml m(-2) (P<0.005). Left ventricular end-diastolic area index did not change significantly. We found a significant correlation between the increase in cardiac index caused by fluid loading and SVV as well as PPV before fluid loading (SVV, R=0.74, P<0.001; PPV, R=0.61, P<0.005). No correlations were found between values of global end-diastolic volume index or left ventricular end-diastolic area index before fluid loading and the increase in cardiac index. CONCLUSION: Measurement of SVV or PPV allows assessment of fluid responsiveness in hypovolaemic patients under open-chest and open-pericardium conditions. Thus, measuring heart-lung interactions may improve haemodynamic management during surgical procedures requiring mid-line sternotomy.

Adult↗
PubMed2004

Effects of mid-line thoracotomy on the interaction between mechanical ventilation and cardiac filling during cardiac surgery.

BACKGROUND: Mid-line thoracotomy is a standard approach for cardiac surgery. However, little is known how this surgical approach affects the interaction between the circulation and mechanical ventilation. We studied how mid-line thoracotomy affects cardiac filling volumes and cardiovascular haemodynamics, particularly variations in stroke volume and pulse pressure caused by mechanical ventilation. METHODS: We studied 19 patients during elective coronary artery bypass surgery. Before and after mid-line thoracotomy, we measured arterial pressure, cardiac index (CI) and global end-diastolic volume index (GEDVI) by thermodilution, left ventricular end-diastolic area index (LVEDAI) by transoesophageal echocardiography and the variations in left ventricular stroke volume and pulse pressure during ventilation by arterial pulse contour analysis. RESULTS: After thoracotomy, CI increased from 2.3 (0.4) to 2.9 (0.6) litre min(-1) m(-2), GEDVI increased from 605 (110) to 640 (94) litre min(-1) m(-2), and LVEDAI increased from 9.2 (3.7) to 11.2 (4.1) cm(2) m(-2). All these changes were significant. In contrast, stroke volume variation (SVV) decreased from 10 (3) to 6 (2)% and pulse pressure variation (PPV) decreased from 11 (3) to 5 (3)%. Before thoracotomy, SVV and PPV significantly correlated with GEDVI (both P<0.01). When the chest was open, similar significant correlations of SVV (P<0.001) and PPV (P<0.01) were found with GEDVI. CONCLUSION: Thoracotomy increases cardiac filling and preload. Further, thoracotomy reduces the effect of mechanical ventilation on left ventricular stroke volume. However, also under open chest conditions, SVV and PPV are preload-dependent.

Adult↗
PubMed2003

Surgical treatment of permanent atrial fibrillation using microwave energy ablation: a prospective randomized clinical trial.

OBJECTIVE: Radiofrequency or the use of microwave energy in combination with atrial size reduction during open heart surgery have been reported to be effective in up to 75% in the treatment of permanent atrial fibrillation. However, no data from prospective randomized trials using microwave energy are available. METHODS: Forty-three patients with permanent atrial fibrillation undergoing open-heart surgery were randomly stratified into treatment group receiving microwave ablation and atrial size reduction (n=24) or control group (n=19). Patients in either group were treated with amiodarone or sotalol for 3 months if sinus rhythm or any atrioventricular rhythm was successfully restored. Follow-up time points were at 3, 6 and 12 month after surgery. RESULTS: In the treatment group 22 out of 24 patients (91,7%) were successfully converted to sinus rhythm by using intraoperative microwave ablation therapy whereas only six out of 19 (31.5%) patients converted to sinus rhythm directly after surgery. At 12-month follow-up there were still a significantly higher percentage of patients in the treatment group free from atrial fibrillation when compared to control (80 vs. 33.3%, P=0.036). CONCLUSION: The preliminary data from this first prospectively randomized trial indicate that microwave ablation combined with atrial size reduction is a safe and highly efficient treatment in permanent atrial fibrillation.

Aged↗
PubMed2003

Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance.

BACKGROUND AND OBJECTIVE: The efficacy of the Trendelenburg position, a common first step to treat suspected hypovolaemia, remains controversial. We evaluated its haemodynamic effects on cardiac preload and performance in patients after cardiac surgery. METHODS: Twelve patients undergoing mechanical ventilation of the lungs who demonstrated left ventricular 'kissing papillary muscles' by transoesophageal echocardiography, thus suggesting hypovolaemia, were positioned 30 degrees head down for 15 min immediately after cardiac surgery. Cardiac output by thermodilution, central venous pressure, pulmonary artery occlusion pressure, left ventricular end-diastolic area by transoesophageal echocardiography and intrathoracic blood volume by thermo- and dye dilution were determined before, during and after this Trendelenburg manoeuvre. RESULTS: Trendelenburg's manoeuvre was associated with increases in central venous pressure (9 +/- 2 to 12 +/- 3 mmHg) and pulmonary artery occlusion pressure (8 +/- 2 to 11 +/- 3 mmHg). The intrathoracic blood volume index increased slightly (dye dilution from 836 +/- 129 to 872 +/- 112 mL m(-2); thermodilution from 823 +/- 129 to 850 +/- 131 mL m(-2)) as did the left ventricular end-diastolic area index (7.5 +/- 2.1 to 8.1 +/- 1.7 cm2 m(-2)), whereas mean arterial pressure and the cardiac index did not change significantly. After supine repositioning, the cardiac index decreased significantly below baseline (3.0 +/- 0.6 versus 3.5 +/- 0.8 L min(-1) m(-2)) as did mean arterial pressure (76 +/- 12 versus 85 +/- 11 mmHg), central venous pressure (8 +/- 2 mmHg) and pulmonary artery occlusion pressure (6 +/- 4 mmHg). The intrathoracic blood volume index and left ventricular end-diastolic area index did not differ significantly from baseline. CONCLUSIONS: Trendelenburg's manoeuvre caused only a slight increase of preload volume, despite marked increases in cardiac-filling pressures, without significantly improving cardiac performance.

Blood Volume↗
PubMed2002

Optimizing fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations. Comparison with aortic systolic pressure variations.

BACKGROUND: Mechanical ventilation causes changes in left ventricular preload leading to distinct variations in left ventricular stroke volume and systolic arterial pressure. Retrospective off-line quantification of systolic arterial pressure variations (SPV) has been validated as a sensitive method of predicting left ventricular response to volume administration. We report the real-time measurement of left ventricular stroke volume variations (SVV) by continuous arterial pulse contour analysis and compare it with off-line measurements of SPV in patients after cardiac surgery. METHODS: SVV and SPV were determined before and after volume loading with colloids in 20 mechanically ventilated patients. RESULTS: SVV and SPV decreased significantly after volume loading and were correlated (r=0.89; P<0.001). Changes in SVV and changes in SPV as a result of volume loading were also significantly correlated (r=0.85; P<0.005). Changes in SVV correlated significantly with changes in stroke volume index (SVI) (r=0.67; P<0.005) as did changes in SPV (r=0.56; P<0.05). SVV determined before volume loading correlated significantly with changes in SVI (R=0.67; P <0.005). Using receiver operating characteristics curves, the area under the curve was statistically greater for SVV (0.824; 95% confidence interval: [CI] 0.64-1.0) and SPV (0.81; CI: 0.62-1.0) than for central venous pressure (0.451; CI: 0.17-0.74). CONCLUSIONS: Monitoring of SVV enables real-time prediction and monitoring of the left ventricular response to preload enhancement in patients after cardiac surgery and is helpful for guiding volume therapy.

Aorta, Abdominal↗
PubMed2001

Continuous cardiac output measurements do not agree with conventional bolus thermodilution cardiac output determination.

PURPOSE: To evaluate the performance of two different continuous cardiac output monitoring systems based on the thermodilution principle in critically ill patients. METHODS: Nineteen cardiac surgical patients were randomly assigned to continuous cardiac output monitoring using one of the two systems under study (group I, IntelliCath(TM) catheter, n=9; group II, Opti-Q(TM) catheter, n=10). Each patient was studied over a period of three hours. Conventional bolus thermodilution cardiac output measurements were carried out every 15 min leading to 13 measurements in each patient. The continuous cardiac output values were compared with the bolus thermodilution measurements. Bias (mean difference between continuous and bolus thermodilution) and precision (SD of differences) were calculated as a measure of agreement between the respective continuous method and conventional bolus thermodilution. RESULTS: The range of measured cardiac outputs was 3.8-15.4 L*min(-1) (IntelliCath(TM)) and 3.5-8.3 L*min(-1) (OptiQ(TM)). Bias and precision was 0.06 +/- 0.76 L*min(-1) (IntelliCath(TM)) and -0.04 +/- 0.74 L*min(-1) (OptiQ(TM)), respectively. There was no difference in bias between the two systems (P=0.38). +/- 2 SD of the differences (i.e., 95% of the differences) did not fall within the predetermined limits of agreement of +/- 0.5 L*min(-1). CONCLUSIONS: There was no difference between the two systems regarding the agreement with conventional bolus thermodilution as the standard. A discrepancy between bolus and continuous thermodilution cardiac output measurement techniques above the clinically acceptable limits suggest that they are not interchangeable.

Adult↗
PubMed2001

Intensive care after minimally invasive and conventional coronary surgery: a prospective comparison.

OBJECTIVE: The purpose of this study was to compare the intensive care course of patients after minimally invasive coronary surgery to conventional coronary artery bypass grafting. DESIGN: Prospective observational study. SETTING: Intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: One hundred and five patients with two-vessel disease consecutively scheduled for elective coronary bypass surgery were enrolled. INTERVENTIONS: Two techniques of revascularization were performed: the Octopus procedure via median sternotomy without cardiopulmonary bypass (n = 52) and conventional coronary artery bypass grafting CABG (n = 53). MEASUREMENTS AND RESULTS: Three major categories describing the patients' postoperative course were defined: (1) clinical and laboratory findings, i.e., transfusion rate, catecholamine support, duration of ventilation, Simplified Acute Physiology Score II (SAPS II), serum levels of cardiac enzymes and lactic acid; (2) postoperative complications, i.e., incidence of myocardial infarction (MI), atrial fibrillation (AF), and neurological deficits; (3) this category was defined as "the extent of care" as represented by the Therapeutic Intervention Scoring System (TISS), and the length of stay in the ICU and in the hospital. In the Octopus group significantly lower figures were noted for duration of ventilation [6.1(5.5/9.5) vs 10.2(8.2/11.8) h], cardiac enzymes (CK-MB-Mass [5.1(2.0/8.3) vs 31.3(21.4/39.3) ng/ml], and lactic acid [2.0(1.5/3.3) vs 3.2(2.2/6.5) mmol/l]), incidence of AF (2/52 vs 9/53), and neurological deficits (0/52 vs 4/53), TISS score [72(44/83) vs 84(73/93)], LOS in the ICU [2(1/2) vs 2(2/2) days], and in the hospital [6(5/9) vs 9(8/12) days]. Catecholamine support, SAPS II scores, and incidence of MI of each group did not differ significantly. CONCLUSIONS: Off-pump coronary surgery via the Octopus technique was superior to conventional CABG regarding the course of patients in the early postoperative period. This implies benefits for the patients and the entire healthcare system.

APACHE↗
PubMed2001

Re-OPCAB vs. Re-CABG for myocardial revascularization.

BACKGROUND: The present study compared redo coronary artery bypass grafting (Re-OPCAB) techniques with conventional redo coronary artery bypass grafting (Re-CABG) with particular focus on myocardial damage and clinical outcome parameters. METHODS: Redo OPCAB (Re-OPCAB) was performed on 20 consecutive patients (15 males, mean age 63.2 +/- 9.3 years) using either the anterolateral approach for minimally invasive direct coronary artery bypass (n = 4) or the Octopus technique with regular sternotomy (n = 16). The Re-CABG group consisted of 20 consecutive patients (18 males, mean age 67.1 +/- 6.6 years). Groups did not differ in the number of atherosclerotic risk factors, or left ventricular, renal or liver function. RESULTS: Duration of surgery, number of bypass grafts and amount of transfused red blood cells did not differ significantly between both groups. Requirement of epinephrine (mg/h) within the first 24 h was lower in the Re-OPCAB group (Re-OPCAB: 0.14 +/- 0.22 vs. CABG: 0.88 +/- 0.97; p<0.01). In addition, CKMB levels at 24 h after operation were lower in the Re-OPCAB group (Re-OPCAB: 10.0 +/- 10.1 vs. Re-CABG: 38.7 +/- 28.1 U/l, p<0.001). There were no acute myocardial infarctions or deaths in the perioperative period. In the CABG group, there was a longer time period to extubation (hours) (Re-OPCAB: 9.8 +/- 3.9 vs. Re-CABG: 28.7 +/- 25.5; p<0.001), and the length of ICU stay was significantly prolonged (OPCAB: 1.3 +/- 0.5 versus Re-CABG: 4.4 +/- 8.7; p<0.001). The graft patency rate at follow-up was 95% in the Re-OPCAB group. CONCLUSION: Re-OPCAB results in decreased cardiac specific enzyme release, reduced requirement of inotropes and comparable clinical outcome in the early postoperative period. It is an appropriate alternative to conventional Re-CABG in selected patients awaiting reoperation for myocardial revascularization. Larger prospective and randomized trials are required to select the appropriate patient who benefits most from one or the other treatment regime.

Aged↗
PubMed2001

[Perioperative antiarrhythmic drug management].

Perioperative arrhythmias are common. In 2.5 % they result in a severe adverse outcome. This review discusses the normal physiology of the myocardial conduction system and the etiology and pathophysiology of the most common perioperative dysrhythmias. Subsequently some important antiarrhythmic drugs are described and treatment plans for the most frequent dysrhythmias are presented.

Anti-Arrhythmia Agents↗
PubMed2000

Markers of myocardial ischemia after minimally invasive and conventional coronary operation.

BACKGROUND: The purpose of this study was to evaluate the course of serum markers of myocardial tissue damage after two different types of minimally invasive coronary surgical procedures (MICS) as compared with conventional coronary artery bypass grafting (CABG). METHODS: We enrolled 87 patients with one- or two-vessel disease scheduled for one of the three procedures: minimally invasive direct coronary artery bypass grafting (MIDCABG) by lateral thoracotomy (n = 29), the OCTOPUS method by median sternotomy (n = 27), and CABG (n = 31). Creatine kinase activity (CK), creatine kinase MB activity (CK-MB act), creatine kinase MB mass concentration (CK-MB mass), myoglobin concentration (MG), and cardiac troponin I concentration (cTnI) were measured perioperatively until the second postoperative day. RESULTS: Creatine kinase-MB, CK-MB mass, and cTnI were significantly higher after CABG and were nearly maintained within the normal range in MICS. Creatine kinase and MG were significantly lower in the OCTOPUS group than in the MIDCABG or CABG groups. CONCLUSIONS: Minimally invasive coronary surgical procedures cause less myocardial injury than CABG as indicated by specific serum markers. However, higher CK and MG reflect more substantial skeletal muscle trauma during MIDCABG operation compared with OCTOPUS procedures.

Adult↗
PubMed2000

Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: a prospective criterion standard study in patients after cardiac surgery.

OBJECTIVE: To evaluate the accuracy of a new pulse contour method of measuring cardiac output in critically ill patients. DESIGN: A prospective criterion standard study. SETTING: Cardiac surgery intensive care unit in a university hospital. PARTICIPANTS: Nineteen cardiac surgery patients requiring intensive care treatment with pulmonary artery catheters after surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The pulse contour cardiac output monitor uses transpulmonary bolus thermodilution measurements to calibrate the system. In each patient, the pulse contour cardiac output values were compared with conventional thermodilution. The method described by Bland and Altman and linear regression analysis were used for comparison. The mean difference (bias) +/- standard deviation of differences (precision) was 0.31 +/- 1.25 L/min for pulmonary bolus thermodilution cardiac output versus pulse contour cardiac output and 0.21 +/- 0.73 L/min for pulmonary bolus thermodilution cardiac output versus transpulmonary bolus thermodilution cardiac output. Linear regression (correlation) analyses were pulse contour cardiac output = 0.97 thermodilution + 0.53 (r = 0.88), and transpulmonary cardiac output = 0.87 thermodilution + 1.09 (r = 0.96). There was a small increase 60 minutes after recalibration but not a statistically significant difference between pulse contour cardiac output and pulmonary bolus thermodilution cardiac output (p = 0.52). CONCLUSIONS: Bias and precision are acceptable, and the system provides results that agree with conventional thermodilution. This study demonstrates the clinical applicability of the pulse contour cardiac output monitoring system.

Adult↗
PubMed2000

Intermittent atrial level right-to-left shunt with temporary hypoxemia in a patient during support with a left ventricular assist device.

We report a 56-year-old male patient developing hypoxemia after surgical replacement of infected valves of a left ventricular assist device (LVAD, Novacor) which had supported him during the previous 15 months. Contrast transesophageal echocardiography (TEE) revealed an atrial septal defect with intermittent right-to-left shunt across a patent foramen ovale. We postulate that the shunt detected in this patient occurred as a consequence of reduced pulmonary vascular compliance due to positive end-expiratory pressure (PEEP) and an increase of mean intrathoracic pressure. Furthermore, we hypothesize that synchronized LVAD operation exacerbates any potential right-to-left shunt due to the profound left ventricular unloading which occurs during LVAD support. In this first report of a right-to-left shunt from a previously unrecognized patent foramen ovale in a Novacor patient, the subsequent transient hypoxemia could be managed by avoiding PEEP of more than 3 mmHg, and mean airway pressure of more than 11 mmHg and by careful volume replacement in order to prevent the pump from completely emptying the left ventricle (LV) and the left atrium (LA). Thus, prior to every LVAD implantation a transesophageal contrast echocardiography with Valsalva maneuver should be performed to identify intracardiac right-to-left shunt.

Heart Septal Defects, Atrial↗