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Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic and vascular surgery procedures performed in 78 German heart surgery departments during the year 2021 are analyzed. Under more than extraordinary conditions of the further ongoing worldwide coronavirus disease 2019 (COVID-19) pandemic, a total of 161,261 procedures were submitted to the registry. In total, 92,838 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 27,947 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.2:1) was 97.3%. For the 36,714 isolated heart valve procedures (19,242 transcatheter interventions included) it was 96.7 and 99.0% for the registered pacemaker and International Classification of Diseases (ICD) procedures (19,490), respectively. Concerning short- and long-term circulatory support, a total of 3,404 ECLS/ECMO implantations and 750 assist device implantations (L-/ R-/ BVAD, TAH), respectively were registered. In 2021 329 isolated heart transplantations, 254 isolated lung transplantations, and one combined heart–lung transplantations were performed.This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

Background The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). Methods An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. Results A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). Conclusion Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

ZusammenfassungEine qualitativ hochwertige medizinische Behandlung von herzchirurgischen Patienten erfordert den Einsatz und die Rekrutierung von qualifiziertem Personal mit besonderem Blick auf die Fluktuation. Dieser Aspekt gestaltet sich unter den aktuellen Gegebenheiten des Fachkräftemangels wie auch den Rahmenbedingungen im deutschen Gesundheitswesen zunehmend schwieriger. Durch die Einbindung von Physician Assistants (PA) in herzchirurgischen Fachabteilungen kann das bestehende Personalkonzept innovativ, bedarfsgerecht und insbesondere nachhaltig ergänzt werden. Die jahrzehntelange Erfahrung aus anglo-amerikanischen Ländern belegt, dass mit einem PA-System eine hochwertige medizinische Behandlungsqualität nicht nur stabilisiert, sondern potenziell sogar verbessert werden kann. Gleichzeitig können Ärzte in der herzchirurgischen Facharzt-Weiterbildung von alltäglich anfallenden Tätigkeiten ohne ärztlichen Vorbehalt entlastet werden und somit freiwerdende Ressourcen für eine fundierte und vielfältige Facharztweiterbildung nutzen. Auch positive Effekte auf ökonomische Faktoren der Institution sind denkbar. Die erforderliche Delegation von ärztlichen Tätigkeiten auf nicht-ärztliche Mitarbeiter ist in Deutschland bereits jetzt gesetzlich verankert, ohne dass es spezifische, auf den Physician Assistant ausgerichtete rechtliche Rahmenbedingungen gibt. Die verbindliche Festlegung der Tätigkeiten für einen PA durch medizinische Fachgesellschaften sind in diesem Zusammenhang eine wichtige Aufgabe. In diesem Positionspapier werden unter Erörterung der medizinischen, rechtlichen und ökonomischen Aspekte Tätigkeiten für Physician Assistants in der Herzchirurgie strukturiert dargelegt.

The evolution and progress in cardiovascular medicine and substantial changes in the German health care system require both a reflection of the principles of patient-centered care in general and an update of the criteria that define a department of cardiac surgery in Germany. This position paper lists the core requirements for a cardiac surgical department with regard to infrastructure, facilities, necessary staff, and standard of care (processes). This standard may be used by hospitals and health care providers to ensure the safety and quality of cardiac surgical departments in Germany.

For documentation of COVID-19 pandemic-related changes in cardiac surgery in Germany, the German Society for Thoracic and Cardiovascular Surgery carried out a structured survey.From 79 German institutions for cardiac surgery, 53 took part in the survey. The cut-off date before the pandemic was taken as 1 January 2020 and 30 April 2021 as the cut-off date for data recruitment. At this point of time, the third wave of the pandemic in Germany had already ebbed away and the return to routine surgery seemed to be foreseeable.On 1 January 2020, in 53 German cardiac surgery departments 800 intensive care beds were allocated. In April 2021, this capacity was reduced by 25.6% to 595 beds. Accordingly, the number of operating rooms for cardiac surgery procedures was reduced from 207 to 152 (-26.9%) during the first two lockdowns. During the COVID-19 pandemic, hospital facilities were restructured: 50.9% of participants delegated medical personnel, and 75.5% had to transfer nursing personnel to special COVID-19 facilities in their hospitals.From the start of the COVID-19 pandemic until the end of the third wave during April 2021, cardiac surgery in Germany changed profoundly, leading to a substantial reduction of intensive care beds and operating rooms for patients requiring cardiac surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2019 are analyzed. For this period, a total of 175,705 procedures were submitted to the registry, 100,446 summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 34,224 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.3%. For the 36,650 isolated heart valve procedures (16,625 transcatheter interventions included), it was 96.4%. Concerning short- and long-term circulatory support, a total of 2,716 extracorporeal life support/extracorporeal membrane oxygenation implantations, resp. 953 assist device implantations (L-/ R-/ BVAD, TAH) were registered. In 2019, the number of isolated heart transplantations increased to 333, a rise of 6.7% compared to the previous year. The isolated lung transplantations amounted to 311, a decrease of 8.5%. This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

In den letzten Jahren ist aufgrund technischer Fortschritte mit einer Miniaturisierung der Systeme und Reduktion der postoperativen Komplikationen, Zunahme der Pravalenz der Herzinsuffizienz, dem Spendermangel im Bereich der Transplantation sowie steigender Lebenserwartung eine deutliche Zunahme der Patientenzahl mit permanenten Herzunterstutzungssystemen zu verzeichnen. Dieses sehr spezielle Patientenkollektiv kann sowohl akute systemassoziierte Notfalle, wie z. B. Pumpenthrombose oder Device-Fehlfunktion, aber auch nichtsystemassoziierte Notfalle aufweisen. Aufgrund der Besonderheiten in der Physiologie sowie potenzieller systembezogener Komplikationen ist die Versorgung dieser Patienten in Notfallsituationen komplex. Nationale oder internationale Empfehlungen fehlen bisher. Das vorliegende Konsensuspapier bietet, basierend auf einer konsentierten Expertenmeinung, den Vorschlag fur einen Algorithmus zur strukturierten und zugigen Evaluation von Notfallen bei Patienten mit permanenten Herzunterstutzungssystemen sowie deren Management.

High-quality care of cardiac surgical patients requires the employment and recruiting of qualified medical professionals with minimal fluctuation of staff members. This aspect becomes increasingly difficult due to the current shortage of skilled professionals as well as the present framework conditions of the German Healthcare System. The implementation of physician assistants (PA) in cardiac surgery departments may augment existing human resource concepts in an innovative and sustainable manner, tailored to meet department specific requirements. Long-term experiences from Anglo-American countries prove that the implementation of a PA system may stabilize or potentially even improve medical treatment quality. At the same time, cardiac surgical residents may be relieved from routine tasks, releasing additional time resources for a solid and diverse specialist training. Furthermore, positive effects on economic aspects of an institution may be possible. The required delegation of medical tasks to allied health professionals already has a legal basis in Germany, while a specific legal framework tailored to physician assistants does not exist yet. In this context, it is an important aspect that medical associations define a reliable catalog of tasks that may be delegated to physician assistants. Under evaluation of medical, legal and economic aspects and in a structured manner, this position paper defines medical tasks of physician assistants in cardiac surgery.Eine qualitativ hochwertige medizinische Behandlung von herzchirurgischen Patienten erfordert den Einsatz und die Rekrutierung von qualifiziertem Personal mit besonderem Blick auf die Fluktuation. Dieser Aspekt gestaltet sich unter den aktuellen Gegebenheiten des Fachkräftemangels wie auch den Rahmenbedingungen im deutschen Gesundheitswesen zunehmend schwieriger. Durch die Einbindung von Physician Assistants (PA) in herzchirurgischen Fachabteilungen kann das bestehende Personalkonzept innovativ, bedarfsgerecht und insbesondere nachhaltig ergänzt werden. Die jahrzehntelange Erfahrung aus anglo-amerikanischen Ländern belegt, dass mit einem PA-System eine hochwertige medizinische Behandlungsqualität nicht nur stabilisiert, sondern potenziell sogar verbessert werden kann. Gleichzeitig können Ärzte in der herzchirurgischen Facharzt-Weiterbildung von alltäglich anfallenden Tätigkeiten ohne ärztlichen Vorbehalt entlastet werden und somit freiwerdende Ressourcen für eine fundierte und vielfältige Facharztweiterbildung nutzen. Auch positive Effekte auf ökonomische Faktoren der Institution sind denkbar. Die erforderliche Delegation von ärztlichen Tätigkeiten auf nicht-ärztliche Mitarbeiter ist in Deutschland bereits jetzt gesetzlich verankert, ohne dass es spezifische, auf den Physician Assistant ausgerichtete rechtliche Rahmenbedingungen gibt. Die verbindliche Festlegung der Tätigkeiten für einen PA durch medizinische Fachgesellschaften sind in diesem Zusammenhang eine wichtige Aufgabe. In diesem Positionspapier werden unter Erörterung der medizinischen, rechtlichen und ökonomischen Aspekte Tätigkeiten für Physician Assistants in der Herzchirurgie strukturiert dargelegt.

Oxygen is a drug with specific properties, a defined dose-effect range and side effects. In 2015, in a sample of UK hospital patients, 14% were treated with oxygen, of which only 42% had a prescription. Health care workers are often uncertain about the relevance of hypoxemia, and there is limited awareness of the risks of hyperoxemia. Numerous randomized controlled trials on oxygen therapy have recently been published.As part of the guideline program of the Working Group of Scientific Medical Societies e. V. (AWMF), this S3 guideline was developed with the participation of 10 medical societies on the basis of a literature search up to 02/01/2021. The system of the Oxford Centre for Evidence-Based Medicine (CEBM) (The Oxford 2011 Levels of Evidence) was used to evaluate the literature. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE), and a formal consensus process of recommendations was performed.The guideline contains 34 evidence-based recommendations on the indication, prescription, monitoring, and discontinuation of oxygen therapy in acute care. The indication for oxygen is mainly hypoxemia. Hypoxemia and hyperoxemia should be avoided, since both increase mortality. The guideline recommends target ranges of oxygen saturation for acute oxygen therapy without differentiating between different diagnoses. Target areas depend on the risk for hypercapnia and ventilation status. The guideline provides an overview of available oxygen delivery systems and contains recommendations for their selection based on patient safety and comfort.This is the first German guideline on the use of oxygen in acute care. It is aimed at medical professionals who use oxygen in and outside hospitals and is valid until June 30th, 2024.HINTERGRUND: Sauerstoff (OIm Rahmen des Leitlinienprogramms der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) wurde unter Beteiligung von 10 Fachgesellschaften diese S3-Leitlinie auf Basis einer Literaturrecherche bis zum 01.02.2021 entwickelt. Zur Literaturbewertung wurde das System des Oxford Centre for Evidence-Based Medicine (CEBM; „The Oxford 2011 Levels of Evidence“) verwendet. Die Bewertung der Evidenzqualität erfolgte anhand des Grading of Recommendations Assessment, Development and Evaluation (GRADE) und die Leitlinienempfehlungen wurden formal konsentiert.Die Leitlinie enthält 34 evidenzbasierte Empfehlungen zu Indikation, Verordnung, Überwachung und Abbruch der Sauerstofftherapie in der Akutversorgung. Die Indikation für Sauerstoff ist hauptsächlich die Hypoxämie. Hypoxämie und Hyperoxämie sollten aufgrund der Assoziation mit einer erhöhten Sterblichkeit vermieden werden. Die Leitlinie empfiehlt Zielbereiche der Sauerstoffsättigung für die Sauerstoff-Akuttherapie ohne Differenzierung zwischen verschiedenen Diagnosen. Zielbereiche sind abhängig vom Hyperkapnierisiko und Beatmungsstatus. Die Leitlinie bietet einen Überblick über verfügbare Sauerstoffzufuhrsysteme und enthält Empfehlungen für deren Auswahl basierend auf Patientensicherheit und -komfort.Dies ist die erste nationale Leitlinie zum Einsatz von Sauerstoff in der Akutmedizin. Sie richtet sich an medizinisches Fachpersonal, das Sauerstoff außerklinisch und stationär anwendet, und ist bis zum 30.06.2024 gültig.

Oxygen (O A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024. Sauerstoff (O Im Rahmen des Leitlinienprogramms der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) wurde unter Beteiligung von 10 Fachgesellschaften eine S3-Leitlinie entwickelt und im Juni 2021 veröffentlicht. Bis zum 1. 2. 2021 wurde eine Literaturrecherche durchgeführt, um 10 Schlüsselfragen zu beantworten. Zur Klassifizierung von Studientypen hinsichtlich ihrer Validität wurde das Oxford Centre for Evidence-Based Medicine (CEBM) System („The Oxford 2011 Levels of Evidence“) verwendet. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) wurde verwendet und zur Bewertung der Evidenzqualität und zur Einstufung von Leitlinienempfehlungen wurde ein formaler Konsensbildungsprozess durchgeführt. Die Leitlinie enthält 34 evidenzbasierte Empfehlungen zu Indikation, Verordnung, Überwachung und Abbruch der Sauerstofftherapie in der Akutversorgung. Die Hauptindikation für die O Dies ist die erste nationale Leitlinie zum Einsatz von Sauerstoff in der Akutmedizin. Sie richtet sich an medizinisches Fachpersonal, das Sauerstoff außerklinisch und stationär anwendet. Sie ist bis zum 30. 06. 2024 gültig.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic and vascular surgery procedures performed in 78 German heart surgery departments during the year 2020 are analyzed. Under the more than extraordinary conditions of the ongoing worldwide coronavirus disease 2019 pandemic, a total of 161,817 procedures were submitted to the registry. A total of 92,809 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 29,444 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.6:1) was 97.2%. For the 35,469 isolated heart valve procedures, (17,471 transcatheter interventions included), the survival rate was 96.7%. Concerning short- and long-term circulatory support, a total of 2,852 extracorporeal life support/extracorporeal membrane oxygenation implantations, respectively, 843 assist device implantations (left/right/biventricular assist device, total artificial device), were registered. In 2020, the number of isolated heart transplantations increased to 340, a rise of 2.1% compared with the previous year. The isolated lung transplantations amounted to 291, a decrease of 6.4%.This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

Mechanical circulatory support using extracorporeal life support systems (ECLS) has significantly increased in recent years. These critically ill patients pose special challenges to the multiprofessional treatment team and require comprehensive, interdisciplinary and interprofessional concepts. For this reason, to ensure the best possible patient care a standardized ECLS training module has been created at national specialist society level, taking emergency and intensive care management into account.Die mechanische Kreislaufunterstützung mittels extrakorporaler Life-Support-Systeme (ECLS) hat in den letzten Jahren stark zugenommen. Diese kritisch Kranken stellen besondere Herausforderungen an das multiprofessionelle Behandlungsteam und erfordern umfassende, interdisziplinäre und interprofessionelle Konzepte. Aus diesem Grunde wurde zur Gewährleistung einer bestmöglichen Patientenversorgung ein standardisiertes „Ausbildungsmodul ECLS“ auf nationaler, fachgesellschaftlicher Ebene unter Berücksichtigung des notfall- und intensivmedizinischen Managements geschaffen.

Die mechanische Kreislaufunterstutzung mittels extrakorporaler Life-Support-Systeme (ECLS) hat in den letzten Jahren stark zugenommen. Diese kritisch Kranken stellen besondere Herausforderungen an das multiprofessionelle Behandlungsteam und erfordern umfassende, interdisziplinare und interprofessionelle Konzepte. Aus diesem Grunde wurde zur Gewahrleistung einer bestmoglichen Patientenversorgung ein standardisiertes „Ausbildungsmodul ECLS“ auf nationaler, fachgesellschaftlicher Ebene unter Berucksichtigung des notfall- und intensivmedizinischen Managements geschaffen.

The prevalence of patients living with long-term mechanical circulatory support (MCS) is rapidly increasing due to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. Patients with long-term MCS are very likely to require emergency medical support due to MCS-associated complications (e.g., right heart failure, left ventricular assist device malfunction, hemorrhage and pump thrombosis) but also due to non-MCS-associated conditions. Because of the unique characteristics of mechanical support, management of these patients is complicated and there is very little literature on emergency care for these patients. The purpose of this national scientific statement is to present consensus-based recommendations for the initial evaluation and resuscitation of adult patients with long-term MCS.

An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.

In Germany, there are currently many voices calling for a reform of hospital planning and reimbursement to correct some aberrations of the last decades and to enable the system to cope with future challenges. Some recent political decisions to change the structures of emergency medical services as well as the introduction of mandatory nurse-to-patient ratios and the exclusion of the cost for nursing from the case-based hospital reimbursement represent first steps of a reform, which also affects intensive care and emergency medicine. In this discussion paper a group of intensivists, emergency physicians, medical controllers, and representatives of nurses suggest more far-reaching changes, which can be summarized in 5 points: (1) General hospitals with intensive care units (ICU) and emergency departments (ED) which are part of the emergency medical system should be considered as an element of public service and be planned accordingly. (2) The planning of the intensive care infrastructure should be based on the three levels of emergency medical services to identify hospitals that are system relevant and to define appropriate criteria for structure and quality measures. (3) Hospital reimbursement should consist of a base amount (covering costs for hospital staff, infrastructure plus investments) and case-based fees (covering material costs). (4) To determine the requirements for nurses, physicians, and other medical staff, adequate tools for ICU and ED should be applied. (5) For these purposes as well as for quality management and optimal medical care, hospitals should be provided with a substantially improved IT-infrastructure.

Trauma ist weltweit die fuhrende Todesursache in der Altersgruppe zwischen 5 und 44 Jahren. Haufigste Todesursache in der Akutphase nach einem Trauma ist die nicht kontrollierte bzw. nicht kontrollierbare Blutung.

Although cardiac surgery is usually recognized as a discipline predominantly being performed in the operating room, several other components are required for a successful cardiac operation, one of the most important being represented by cardiac surgical intensive care medicine (CSICM). Therefore the key elements of CSICM are presented in this chapter starting with the basic principles of CSICM providing diagnostic and therapeutic concepts for patients with an uneventful postoperative course. Among the multiple problems which may be encountered after cardiac operations, hemodynamic deterioration is the most frequent and the most dangerous. Therefore, staged diagnosis and therapy of hemodynamic abnormalities are emphasized. In addition, an overview about how to realize and handle the most common problems of other organ systems is given.

There is controversy about the origin of the alterations in T helper 1 (TH1)/TH2 cell activity after major surgical procedures such as on-pump cardiac surgery. We hypothesized that a postoperative decrease in interferon (IFN) gamma-producing TH1 lymphocyte activity may be the sole cause of this TH1/TH2 shift and that the addition of recombinant IL-12 can reverse TH1 suppression. Peripheral blood mononuclear cell fractions from 20 low-risk elective cardiac surgery patients were analyzed preoperatively (d0) and on the first (d1), third (d3), and sixth (d6) postoperative days. We determined the absolute numbers of T helper lymphocytes, IFN-gamma-producing TH1 cells, and IL-4-producing TH2 cells after stimulation and measured IFN-gamma and IL-4 levels in the supernatants of stimulated peripheral blood mononuclear cell cultures, absolute monocyte counts, human leukocyte antigen-DR expression, and intracellular IL-12 synthesis under comparable conditions. Recombinant IL-12 alone or in combination with a neutralizing antibody was added. T helper lymphocyte counts were reduced postoperatively from d1 to d6 (P < 0.05). Absolute IFN-gamma- and IL-4-positive T helper lymphocyte counts were reduced on d1 (P < 0.05). Intracellular IL-4 production in T helper lymphocytes remained postoperatively unchanged. Interferon gamma synthesis was significantly reduced until d3 (P = 0.001) and significantly increased after IL-12 addition (P < 0.05). This effect was reversed by the addition of a neutralizing anti-IL-12 antibody. The TH1/TH2 shift after cardiac surgery seems to be caused primarily by a decrease in cellular IFN-gamma synthesis in TH1 lymphocytes. Because TH1 suppression can be reversed by IL-12, it is more likely to be the result of altered stimulation pathways than cellular defects.

Die Therapie mit implantierbaren Herzschrittmachern, Kardioverter-Defibrillatoren (ICD) und Resynchronisationssystemen (CRT) wird von unterschiedlich ausgebildeten medizinischen Spezialisten durchgefuhrt. Das fast ausschlieslich transvenose Vorgehen fuhrte zu einer Vereinfachung der chirurgischen Techniken und dazu, dass Implantationen zunehmend von Kardiologen vorgenommen werden. Inhalt dieser Empfehlungen ist die Strukturierung von Trainingsinhalten, die der Arzt unabhangig von seiner Fachrichtung (Internist, Kardiologe, Allgemein- oder Thorax-, Herz- und Gefaschirurgie) erlernen muss, um die Implantation und Nachsorge von implantierbaren Systemen durchzufuhren. Epikardiale Sondenimplantation bleiben Chirurgen vorbehalten. Es werden zwei qualitativ unterschiedliche Stufen der Ausbildung definiert: Stufe 1 fur die Herzschrittmachertherapie, Stufe 2 fur ICDs und CRTs. Operationen mit einer Fremdkorperimplantation benotigen den hochsten Standard in der Bauweise und Ausstattung des Operationssaales. Katheterlabors, in denen Implantationen vorgesehen sind, sollten an den Standards eines Operationssaales gemessen werden. Zur Qualitatssicherung ist die sorgfaltige Erfassung von Komplikationen zwingend notwendig.

HLA-DR expression on peripheral blood monocytes is reduced after cardiac surgery. Little is known about the reconstitution of HLA-DR expression on peripheral blood monocytes in patients suffering from early non-fatal perioperative complications. We conducted a prospective study to prove whether these complications adversely affect the recovery of HLA-DR expression. Before surgery (d0), on the first (d1), third (d3), fifth (5th) postoperative days, blood samples were collected from 90 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB). HLA-DR expression was analysed flow cytometrically. Eleven patients experienced postoperative complications [mechanical ventilation of 24-48 h (n=6); reinstitution of CPB (n=2) intraoperatively; laparotomy (n=1), re-thoracotomy (n=1), re-intubation (n=1) within the first 24 h after surgery]. All patients showed a reduced HLA-DR expression after surgery with nadirs at d1 and d3. Whereas the values increased from d3 to d5 in patients with an uneventful clinical course, HLA-DR expression remained suppressed in patients with complications. HLA-DR expression is reduced after cardiac surgery with CPB. A delayed recovery of HLA-DR expression is seen in patients with early perioperative complications. These non-fatal complications appear to represent a 'second hit' resulting in a prolonged deficiency of the innate immune system. This might predispose to further infectious and septic complications.

Although intra-aortic balloon pumping (IABP) is the most frequently used mechanical cardiac assist device in cardiothoracic surgery, there are only guidelines for substantive sections of aortic counterpulsation including prophylactic and postoperative use. In contrast, evidence-based recommendations are still lacking concerning intraoperative use, management, contraindication and other relevant issues. According to international surveys, important aspects of IABP usage show a wide variation in clinical practice. The results of a national questionnaire performed before initiation of this guideline confirmed these findings and demonstrated a clear need for the development of a consensus-based guideline. Therefore, the presented multidisciplinary S-3-guideline was developed under the direction of the German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG) to make evidence-based recommendations for the usage of aortic counterpulsation after cardiothoracic surgery according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF) and the Medical Centre for Quality (Ärztliches Zentrum für Qualität - (ÄZQ)). Main topics discussed in this guideline involve IABP support in the prophylactic, preoperative, intraoperative and postoperative setting as well as the treatment of right heart failure, contraindications, anticoagulation, monitoring, weaning, and limitations of IABP therapy. The presented 15 key messages of the guideline were approved after two consensus meetings under moderation of the AWMF with participation of the German Society of Cardiology (DGK), German Society of Anaesthesiology and Intensive Care Medicine (DGAI), German Interdisciplinary Association for Intensive Care (DIVI) and the German Society for Cardiovascular Engineering (DGfK).

Background The suppression of interferon gamma (IFN-gamma) synthesis after cardiac surgery is discussed as a cause of postoperative immunosuppression that predisposes to postoperative infectious complications. Because several studies have suggested that interleukin-12 (IL-12) production by monocytes and macrophages is reduced after cardiac surgery, this might cause a decrease in IFN-gamma release. To better understand these processes, we assessed the role of IL-12 in IFN-gamma synthesis in vitro before and after cardiac surgery. Methods Heparinized whole blood samples were obtained from 20 patients undergoing elective cardiac surgery preoperatively (day 0) and on the first (day 1), third (day 3), and fifth (day 5) postoperative days, and stimulated (24 hours) with staphylococcal enterotoxin B and lipopolysaccharide. Recombinant IL-12 was added at each time point investigated. Interferon-gamma, IL-12, IL-2, IL-4, and IL-5 concentrations and histocompatibility leukocyte antigen-DR (HLA-DR) expression on monocytes and macrophages were assayed by flow cytometry. Results The HLA-DR expression, IL-12 release, and IFN-gamma synthesis were significantly reduced on day 1, day 3, and day 5. Recovery began on day 3. Interleukin-12 caused a significant increase in IFN-gamma synthesis at each time point. When IL-12 was added, IFN-gamma synthesis returned to preoperative levels on days 3 and 5. Conclusions The synthesis of IFN-gamma is significantly reduced after cardiac surgery. The application of IL-12 causes an increase in IFN-gamma synthesis before surgery and a return of IFN-gamma to preoperative levels within a few days after surgery. These findings suggest that postoperative suppression of IFN-gamma release is caused by a decrease in IL-12 synthesis. In addition, IL-12 has a mainly proinflammatory effect both before and after surgery.

Objective: Due to the combination of local trauma, extracorporeal circulation (ECC), and pulmonary and myocardial reperfusion, cardiac surgery leads to substantial changes in the immune system and possibly to post-operative complications. Procedures without ECC, however, have failed to demonstrate clear advantages. We hypothesized that ECC is far less important in this context than the reperfusion/reventilation of the lung parenchyma and the surgical trauma. We therefore conducted a prospective observational study to compare immune reactions after cardiac operations with those after thoracic surgery. Methods: Serum levels of pro-inflammatory interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-alpha as well as C-reactive protein (CRP), lipoprotein-binding protein (LBP) and procalcitonin (PCT) were measured pre-operatively (d0), at the end of the operation (dx), 6 h after the operation (dxC), on the 1st (d1), 3rd (d3), and 5th (d5) post-operative days in 108 patients (pts) undergoing elective coronary artery bypass grafting (CAB) with ECC (nZ42, CPB CAB), off-pump coronary artery bypass surgery (nZ24, OP CAB) without ECC or thoracic surgery (nZ42, TS). Results: After cardiac surgery (CS), IL-6 and IL-8 increased and reached a maximum on dxC. IL-6 returned to baseline values at d3, whereas IL-8 remained elevated until d5. No difference was found between OP CAB and CPB CAB patients. In the TS patients, IL-6 increased later (dxC) and absolute levels were lower than in the CS patients. No increase in IL-8 was noted in the TS patients. Due to the high variation in the results obtained in all three groups, there was no significant change in TNF-alpha. A comparison of TS, OP CAB, and CPB CAB revealed that the CS patients had higher levels on d0, dx, d3, and d5. Serum levels of CRP, LBP, and IL-2R increased from dxC to d5 in all groups and reached maximum values on d3. Whereas we found no difference in CRP and IL-2R between the groups, LBP levels were significantly higher from dxC to d3 after OP CAB. PCT was elevated from dxC to d3 in all pts. Similar levels were noted for the TS and OP CAB patients. The CPB CAB patients showed the highest levels. Conclusions: Surgical trauma and reperfusion injury appear to represent the predominant factors resulting in immunologic changes after cardiac surgery. Cardiopulmonary bypass (CPB) may be less important for immune response and acute-phase reactions than previously suspected. In addition, our data indicate a relationship between IL-6 synthesis and the degree of surgical trauma. IL-8 appears to be elevated only after cardiac surgery whereas PCT liberation depended on the use of ECC. Q 2005 Elsevier B.V. All rights reserved.

Herausgegeben vom Vorstand derDeutschen Gesellschaft fur Kardiologie –Herz- und KreislaufforschungBearbeitet im Auftrag der Kommissionfur Klinische Kardiologie(R. Dietz, M. Gottwik, B. Levenson,T. Meinertz, A. Osterspey, J. Senges,R. Strasser, K. Werdan, auserdem:G. Arnold, D. Behrenbeck, E. Fleck,H.J. Trappe)

Background Cardiac surgery (CS) using cardiopulmonary bypass (CPB) is associated with cellular and humoral defense reactions termed the systemic inflammatory response syndrome. Leukocyte activation is one of its causative mechanisms which may be aggravated by additional infection. Methods and results Eighty-five patients undergoing CS with CPB were prospectively investigated. Leukocyte counts, elastase. and phagocytotic activity were measured from 24 hpreoperatively up to 7 days postoperatively. Seventy-nine patients had an uneventful course (group 1) while six patients developed a systemic infection (group 2). Leukocytes and elastase levels increased postoperatively (pConclusion Leukocyte activation after CS with CPB occurs. It is associated with a regular RES function and similarly leukocyte/elastase ratios in both groups, suggesting an adequate immune response. Therapeutic interventions resulting in depletion of leukocytes to alleviate reperfusion injury might impair the immune response of those patients acquiring perioperative infection and should be approached with caution. Leukocyte depletion maybe effective in patients for whom an extended period of CPB was required. Further investigations to prove this hypothesis awaits confirmation.

Background . Cardiac operation produces substantial alterations within the immune system, which possibly predispose postoperative complications. However, the interplay between proinflammatory and antiinflammatory reactions and the cells involved in this process are not completely clear. Therefore, we investigated serum levels, as well as synthesis patterns, of proinflammatory and antiinflammatory cytokines. Methods . Serum levels and production of interleukin (IL) IL-5, IL-6, IL-10, tumor necrosis factor-α, and interferon-γ, using a mixed cell culture, (ie, monocytes, macrophages, and lymphocytes), as well as a purified lymphocyte culture were measured preoperatively (day 0), on postoperative day 1, on postoperative day 3, and on postoperative day 5 in 25 patients undergoing cardiac operations and were compared with 10 healthy volunteers. Results . Serum level and mixed cell culture, production of IL-6, tumor necrosis factor-α, and IL-10 increased on postoperative day 1, but decreased in lymphocyte culture. Base line values were reached on postoperative day 5. Interferon-γ serum levels remained unchanged, whereas IL-5 serum levels increased on postoperative days 3 and 5. Cell culture synthesis showed a significant suppression for both mediators in both cell cultures, which returned to baseline on postoperative day 3 in mixed cell culture. Interferon-γ production by lymphocytes was suppressed until postoperative day 5, whereas IL-5 returned to preoperative values on postoperative day 5. Conclusions . Cardiac operation induces a biphasic immune response. The first phase (postoperative day 1) appears to represent the proinflammatory and antiinflammatory reaction of the innate immune system returning to base line on postoperative day 3. The second phase (postoperative day 5) may represent the response of the adaptive immune system and is characterized by an antiinflammatory type of reaction. This may explain why the systemic inflammatory response occurs immediately after cardiac operation, whereas infections occur later.

Background and objectives Due to the nonexistence of clear-cut recommendations for pacemaker lead selection, it was the objective of this retrospective observational study to define the clinical status of conventional leads. For this purpose, we compared our results with two conventional leads to modern and more expensive lead designs such as steroid-eluting and/or high impedance leads in the literature. Patients and methods Intra- and postoperative data of 231 patients who underwent implantation of 178 unipolar, carbon-coated atrial screw-in leads and 231 unipolar, tined leads with a sintered platinum lead tip in the ventricle between 1 Jan 1996 and 31 Dec 2000 were reviewed. Results Intraoperatively, we measured pacing thresholds of 0.87±0.35 V (range: 0.1-2.0V) in the atrium and 0.31±0.13 V (range: 0.1-1.1V) in the ventricle. P-wave amplitude was 3.3±1.5mV (range: 1.0-12.6mV) and R-wave amplitude 13.6±5.1mV (range: 4.2-25.0mV). Postoperatively, we found a chronic pacing threshold of ≤1.2V/1.0ms and 2.5V/0.2ms, respectively, in 97 out of 123 atrial (79%) and 136 out of 161 ventricular leads (85%) (n.s.). Chronic detection threshold measured 3.4±1.3mV in the atrium and 9.2±2.4 mV in the ventricle. Four out of 409 leads (1%) had to be reoperated due to diaphragmatic stimulation (n=1) and loss of capture (n=3). Conclusions 1) Conventional pacemaker leads show good results in the majority of cases. 2) However, modern lead concepts are reported to provide lower pacing thresholds as well as a lower current drain due to pacing. 3) Therefore, the implantation of these leads could be advantageous in younger patients and patients undergoing reoperation because of pacing threshold problems. 4) However, this requires in addition the usage of pulse generators with low internal current drain and optimized postoperative programming of output parameters. 5) Lead-related complication rates as well as the incidence of other perioperative problems should be reason enough to develop standards for pacemaker implantation.

We assessed the safety and efficacy of intravenous pentoxifylline [3,7-dimethyl-1-(5-oxohexyl)-xanthine] in patients at risk for developing multiple organ failure after major cardio-thoracic surgery in a single-center, randomized, placebo-controlled study. Of 816 consecutive patients who underwent major cardio-thoracic surgery, 40 who had Acute Physiology and Chronic Health Evaluation II score values > or = 19 at the first postoperative day after the surgery were included. Patients were randomized to receive either placebo (control; n = 25) or intravenous pentoxifylline treatment (pentoxifylline; n = 15) at a dosage of 1.5 mg/kg/h as an adjunct to standard supportive therapy. Main outcome measurements were duration of required ventilator support, intensive care unit stay, and incidence of renal failure. Thirty-seven patients were eligible for evaluation. No significant adverse events related to pentoxifylline treatment were observed. The duration of mechanical ventilation was significantly greater for control patients (8.3 +/- 3.1 days) compared with pentoxifylline-treated patients (3.1 +/- .9 days; p < .05). Patients treated with pentoxifylline experienced fewer days on hemofiltration (1.2 +/- .8 vs. 6.8 +/- 3.3; p < .05) and a shorter intensive care unit stay (5.2 +/- 1.1 vs. 11.4 +/- 3.1 days). There were no intergroup differences in mortality. Mortality was 33% in the pentoxifylline group and 36% among control group patients. In conclusion, supplemental pentoxifylline treatment may decrease the incidence of multiple organ failure in patients at risk of systemic inflammatory response syndrome after cardiac surgery. Additional studies are required to determine the validity of the observed effects.

In einer ersten klinischen Pilotstudie wurde die Wirksamkeit einer kontinuierlichen intravenosen Infusion des Xanthinderivates Pentoxifyllin zur Reduktion der Inzidenz des akuten Lungenversagens bei Hochrisiko-Patienten nach grosen herzchirurgischen Eingriffen untersucht. Unter 816 konsekutiv operierten Patienten wurden 40 Patienten mit einem hohen Risiko fur die Entwicklung eines Multiorganversagens anhand des APACHE II Scores (≥19) am ersten postoperativen Tag identifiziert. Die Patienten wurden in zwei Gruppen randomisiert: Standard-Behandlung (Kontrolle n=25) oder Standard-Behandlung+Pentoxifyllin-Therapie (Pentoxifyllin n=15). Primare Studienendpunkte waren die Dauer der Beatmungspflichtigkeit, die Inzidenz eines akuten Nierenversagens (Dialyse-/Hamofiltrationspflichtigkeit) und die Verweildauer auf der Intensivstation. Die Ergebnisse von 37 der 40 Patienten konnten ausgewertet werden. Die Pentoxifyllin-Therapie (kontinuierliche intravenose Infusion von 1,5 mg/kg/h) wurde gut toleriert; es wurden keine anhaltenden signifikanten Nebenwirkungen beobachtet. Die Dauer der Beatmung war signifikant kurzer in der Pentoxifyllin-Gruppe (3,1±0,9 die) als in der Kontrollgruppe (8,3+3,1 die, p=0,037) Im Vergleich zu den mit Pentoxifyllin behandelten Patienten trat bei den Kontroll-Patienten haufiger ein therapiepflichtiges Nierenversagen auf (Dialysetage 6,8±3,3 vs. Pentoxifyllin-Gruppe: 1,2+0,8 die, p=0,048). Die Verweildauer auf der Intensivstation war signifikant kurzer bei den Pentoxifyllin-behandelten Patienten (5,2±1,1 vs. 1,4±3,1 die; p

We developed criteria for implantation and programming of permanent endocardial pacemakers in patients with a nonthoracotomy ICD system. These criteria were prospectively used in 10 patients who recieved an ICD prior to (n = 5) or following (n = 5) implantation of a dual chamber (n = 6) or ventricular (n = 4) pacemaker with a unipolar (n = 4) or bipolar (n = 6) lead configuration. All patients were tested for interactions or malfunctions. Undersensing of ventricular fibrillation by the atrial sense amplifier and inadequate atrial pacing occurred in one patient with a unipolar dual chamber system programmed to AAIR but didn't impair ICD sensing. Transient or permanent loss of capture or sensing of the pacemaker was not observed after ICD shocks with the output programmed to double pulse width and voltage of stimulation threshold and the sensitivity to 50% of the detected R wave. One episode of transient reprogramming occurred without clinical consequences. One unipolar ventricular pacemaker lead had to be exchanged against a bipolar lead because of oversensing of the pacing artifact by the ICD. There was no failure of an ICD to detect ventricular arrhythmias due to inadequate pacemaker activity. During a follow-up period of 21 +/- 11 months, a total of 78 ventricular arrhythmias were effectively treated in six patients. Thus, a combined use of transvenous ICD and pacemaker is possible despite the close vicinity of pacing and defibrillations leads. Optimized programming different to the common settings is required. As interactions occurred only in unipolar pacemaker leads bipolar systems should be used in these patients.

It is always difficult to reply to someone who is so enthusiastic about his training program, as Joshi appears to be [1]. Looking at the Cardiothoracic Surgery Syllabus [2], it is getting even more difficult to do so, since I have to admit that at the end of this training, each trainee in the UK should be competent in the critical care of patients who have undergone cardiac surgery. However, this competency includes clinical and technical skills that require time to build up. Put simply: only practice makes perfect. If trainees in the UK had the opportunity to get enough training and experience in the various issues of critical care outlined in the Syllabus, without spending night shifts on the ICU, this would be fine and there would be nothing left to say about it. However, in the paper by Sadaba et al., nearly all of the respondents from various European countries were “ ... of the opinion that a 48-hour week would be insufficient to meet their learning needs.” The issue of structure of training and education was not the subject of my comment and it is beyond the scope of this reply to comment on it [3]. One final remark: Joshi points to the fact “that junior doctors are contacted when escalation of patient care is needed, ensuring they are kept in the loop when important decisions need to be made.” At first glance, this might work; however, one of the predominant goals of critical care after cardiac surgery is to prevent, rather than to treat, problems. For that purpose, you must become aware that a patient is going to develop a problem, and this can be done only by being near to the patient. In summary, whatever the structure of a training program may be, reaching full competence in treating a cardiosurgical patient on an ICU takes time. I do not say that night shifts must be a part of this time, but working at night on an ICU may help to attain competencies in the field of critical care.