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Mendes V, Mamode J, Jolou J, Malki M, Ellenberger C, Cikirikcioglu M, Huber C. Effective Apixaban removal using hemoadsorption during emergent open-heart surgery: a case report and narrative literature review. J Cardiothorac Surg 2024; 19:185. [PMID: 38582888 PMCID: PMC10998397 DOI: 10.1186/s13019-024-02748-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/29/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND The management of hemostasis in patients medicated with apixaban (Eliquis) undergoing emergency cardiac surgery is exceedingly difficult. The body's natural elimination pathways for apixaban prove ineffective in emergency situations, and the impact of hemodialysis is limited. The application of Cytosorb® may attenuate the concentration of apixaban, thereby facilitating the stabilization of these patients. CASE PRESENTATION An 84-year-old man treated with apixaban, underwent emergency ascending aorta replacement surgery due to an acute type A aortic dissection. To address the challenges induced by apixaban, we integrated Cytosorb® cartridge into the Cardiopulmonary bypass circuit. There was a 63.7% decrease in perioperative apixaban-specific anti-factor Xa activity. The patient's postoperative course was favourable. CONCLUSION Hemoadsorption with Cytosorb® may offers a safe and feasible approach for reducing apixaban concentration in emergency cardiac surgery, thereby mitigating the risk of hemorrhagic complications.
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Affiliation(s)
- Vitor Mendes
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland.
| | - Jaid Mamode
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Jalal Jolou
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Mourad Malki
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology Division of Anesthesiology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret- Gentil 4, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Huber
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Ellenberger C, Pelosi P, de Abreu MG, Wrigge H, Diaper J, Hagerman A, Adam Y, Schultz MJ, Licker M. Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial. Eur J Anaesthesiol 2022; 39:875-884. [PMID: 36093886 PMCID: PMC9553219 DOI: 10.1097/eja.0000000000001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients. OBJECTIVES To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry. DESIGN A substudy of a randomised controlled trial. SETTING Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018. PATIENTS One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min. INTERVENTION Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83). MAIN OUTCOME MEASURES The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry. RESULTS Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively). CONCLUSION In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation. TRIAL REGISTRATION NCT02148692, https://clinicaltrials.gov/ct2.
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Affiliation(s)
- Christoph Ellenberger
- From the Department of Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, rue Gabriel-Perret-Gentil (CE, JD, AH, YA, ML), Faculty of Medicine, University of Geneva, Geneva, Switzerland (CE, ML), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP), Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany (MGdA), Department of Outcomes Research (MGdA), Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGdA), Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital (HW), Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany (HW), Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands (MJS)
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Huber C, Murith N, Roffi M, Müller H, Carcaterra A, Giraud R, Bendjelid K, Ellenberger C, Licker M, Cikirikcioglu M. [Cardiac surgery in the time of COVID19 - A narrative of three very unusual cases and lessons learned]. Rev Med Suisse 2022; 18:1186-1191. [PMID: 35703860 DOI: 10.53738/revmed.2022.18.786.1186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
COVID19 altered and impacted medical and surgical practice around the world. Standard of care and routine procedures are disrupted. Majors shift in personnel, and ad hoc new team as well as delocalization and working with new infrastructures are further challenges to be dealt with. This review of three very unusual scenarios illustrates pitfalls and dangers harbored in the re-shaped landscape of COVID19 exemplifying the narrow path bridging from the medical and surgical comfort zone to uncharted territory and eventually leading to collateral damage.
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Affiliation(s)
- Christoph Huber
- Service de chirurgie cardiovasculaire, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Nicolas Murith
- Service de chirurgie cardiovasculaire, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Marco Roffi
- Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Hajo Müller
- Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Andrea Carcaterra
- Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Raphael Giraud
- Service des soins intensifs, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Karim Bendjelid
- Service des soins intensifs, Hôpitaux universitaires de Genève, 1211 Genève 14
| | | | - Marc Licker
- Service d'anesthésiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Mustafa Cikirikcioglu
- Service de chirurgie cardiovasculaire, Hôpitaux universitaires de Genève, 1211 Genève 14
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Licker M, Tesoro R, Hagerman A, Molliqaj G, Ellenberger C. Cardioprotection with glucose insulin potassium (GIK) during non cardiac surgery in a patient with stress induced myocardial ischemia: A case report. Saudi J Anaesth 2022; 16:364-367. [PMID: 35898537 PMCID: PMC9311178 DOI: 10.4103/sja.sja_195_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/12/2022] Open
Abstract
The administration of glucose-insulin-potassium (GIK) has demonstrated cardioprotective effects in cardiac surgery. A 58-year-old male with severe disabling back pain due to posterolateral lumbar pseudarthrosis was scheduled for spine surgery. He previously experienced two episodes of acute coronary syndrome that required percutaneous coronary interventions (PCIs). Coronary angiogram showed intrastent occlusions and multiple coronary lesions that were not suitable for percutaneous or surgical revascularization. During pharmacological stress imaging, myocardial ischemia developed in 19% of the ventricular mass and was reduced to 7% when GIK was administered. After anesthesia induction, the GIK solution was also infused and surgery was uneventful, with no signs of postoperative myocardial injury. Four days later, the patient was successfully discharged to a rehabilitation center. This is the first clinical report of GIK pretreatment during non-cardiac surgery in a patient with ischemic heart disease (IHD).
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Ellenberger C, Schorer R, Diaper J, Jeleff A, Luise S, Hagermann A, Licker M. Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial. Surgery 2021; 171:1626-1634. [PMID: 34809970 DOI: 10.1016/j.surg.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery frequently occurs and may influence survival. The aims of this study were to examine the association between myocardial injury after noncardiac surgery and patient and procedural factors as well as its impact on postoperative clinical outcome. METHODS A retrospective analysis was conducted from data collected in adults enrolled in a randomized trial in elective major open abdominal surgery. Preoperative patient characteristics, intraoperative hemodynamic changes, and postoperative adverse events were analyzed, and Kaplan-Meier curves were built for postoperative survival probability. After adjustment for baseline patient and procedural characteristics, the effect of myocardial injury after noncardiac surgery on postoperative outcomes was analyzed in a propensity score matched cohort. RESULTS Among 394 patients, myocardial injury after noncardiac surgery was reported in 109 (27.7%) and was associated with a higher cardiovascular risk profile, prolonged surgery (333 ± 111 min vs 295 ± 134 min, P = .010), greater need for transfusions (41.3% vs 19.3%, P < .001), higher incidence of major adverse cardiac events (22.9% vs 6.7%, P < .001), pulmonary complications (31.2% vs 17.9%, P = .004) , acute kidney injury (30.3% vs 18.2%, P = .009), and systemic inflammatory syndrome (28.4% vs 13.0%, P < .001). After propensity score matching, the operative time and the need for blood transfusion remained higher among myocardial injury after noncardiac surgery patients who experienced more frequent major adverse cardiac events and acute kidney injury. In both the entire and matched cohorts, survival up to 30 months after surgery was determined mainly by the presence of cancer. CONCLUSION The burden of cardiovascular disease and operative stress surgery is predictive of myocardial injury after noncardiac surgery and, in turn, with a higher incidence of cardiac adverse events, whereas the presence of cancer is associated with poor survival in patients undergoing major open abdominal surgery. Further studies are needed to determine whether myocardial injury after noncardiac surgery can be prevented by better control of the patient's cardiovascular condition and implementation of less invasive of surgical procedures.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Alexandre Jeleff
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Stéphane Luise
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Andres Hagermann
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland.
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Licker M, Hagerman A, Jeleff A, Schorer R, Ellenberger C. The hypoxic pulmonary vasoconstriction: From physiology to clinical application in thoracic surgery. Saudi J Anaesth 2021; 15:250-263. [PMID: 34764832 PMCID: PMC8579502 DOI: 10.4103/sja.sja_1216_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/04/2022] Open
Abstract
More than 70 years after its original report, the hypoxic pulmonary vasoconstriction (HPV) response continues to spark scientific interest on its mechanisms and clinical implications, particularly for anesthesiologists involved in thoracic surgery. Selective airway intubation and one-lung ventilation (OLV) facilitates the surgical intervention on a collapsed lung while the HPV redirects blood flow from the "upper" non-ventilated hypoxic lung to the "dependent" ventilated lung. Therefore, by limiting intrapulmonary shunting and optimizing ventilation-to-perfusion (V/Q) ratio, the fall in arterial oxygen pressure (PaO2) is attenuated during OLV. The HPV involves a biphasic response mobilizing calcium within pulmonary vascular smooth muscles, which is activated within seconds after exposure to low alveolar oxygen pressure and that gradually disappears upon re-oxygenation. Many factors including acid-base balance, the degree of lung expansion, circulatory volemia as well as lung diseases and patient age affect HPV. Anesthetic agents, analgesics and cardiovascular medications may also interfer with HPV during the perioperative period. Since HPV represents the homeostatic mechanism for regional ventilation-to-perfusion matching and in turn, for optimal pulmonary oxygen uptake, a clear understanding of HPV is clinically relevant for all anesthesiologists.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland.,Faculty of Medicine, University of Geneva, Switzerland
| | - Andres Hagerman
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Alexandre Jeleff
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland.,Faculty of Medicine, University of Geneva, Switzerland
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Licker M, Hagerman A, Bedat B, Ellenberger C, Triponez F, Schorer R, Karenovics W. Restricted, optimized or liberal fluid strategy in thoracic surgery: A narrative review. Saudi J Anaesth 2021; 15:324-334. [PMID: 34764839 PMCID: PMC8579501 DOI: 10.4103/sja.sja_1155_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 11/16/2022] Open
Abstract
Perioperative fluid balance has a major impact on clinical and functional outcome, regardless of the type of interventions. In thoracic surgery, patients are more vulnerable to intravenous fluid overload and to develop acute respiratory distress syndrome and other complications. New insight has been gained on the mechanisms causing pulmonary complications and the role of the endothelial glycocalix layer to control fluid transfer from the intravascular to the interstitial spaces and to promote tissue blood flow. With the implementation of standardized processes of care, the preoperative fasting period has become shorter, surgical approaches are less invasive and patients are allowed to resume oral intake shortly after surgery. Intraoperatively, body fluid homeostasis and adequate tissue oxygen delivery can be achieved using a normovolemic therapy targeting a “near-zero fluid balance” or a goal-directed hemodynamic therapy to maximize stroke volume and oxygen delivery according to the Franck–Starling relationship. In both fluid strategies, the use of cardiovascular drugs is advocated to counteract the anesthetic-induced vasorelaxation and maintain arterial pressure whereas fluid intake is limited to avoid cumulative fluid balance exceeding 1 liter and body weight gain (~1-1.5 kg). Modern hemodynamic monitors provide valuable physiological parameters to assess patient volume responsiveness and circulatory flow while guiding fluid administration and cardiovascular drug therapy. Given the lack of randomized clinical trials, controversial debate still surrounds the issues of the optimal fluid strategy and the type of fluids (crystalloids versus colloids). To avoid the risk of lung hydrostatic or inflammatory edema and to enhance the postoperative recovery process, fluid administration should be prescribed as any drug, adapted to the patient's requirement and the context of thoracic intervention.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andres Hagerman
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Benoit Bedat
- Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Frederic Triponez
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
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Ellenberger C, Schorer R, Bedat B, Hagerman A, Triponez F, Karenovics W, Licker M. How can we minimize the risks by optimizing patient's condition shortly before thoracic surgery? Saudi J Anaesth 2021; 15:264-271. [PMID: 34764833 PMCID: PMC8579499 DOI: 10.4103/sja.sja_1098_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 11/22/2022] Open
Abstract
The “moderate-to-high-risk” surgical patient is typically older, frail, malnourished, suffering from multiple comorbidities and presenting with unhealthy life style such as smoking, hazardous drinking and sedentarity. Poor aerobic fitness, sarcopenia and “toxic” behaviors are modifiable risk factors for major postoperative complications. The physiological challenge of lung cancer surgery has been likened to running a marathon. Therefore, preoperative patient optimization or “ prehabilitation “ should become a key component of improved recovery pathways to enhance general health and physiological reserve prior to surgery. During the short preoperative period, the patients are more receptive and motivated to adhere to behavioral interventions (e.g., smoking cessation, weaning from alcohol, balanced food intake and active mobilization) and to follow a structured exercise training program. Sufficient protein intake should be ensured (1.5–2 g/kg/day) and nutritional defects should be corrected to restore muscle mass and strength. Currently, there is strong evidence supporting the effectiveness of various modalities of physical training (endurance training and/or respiratory muscle training) to enhance aerobic fitness and to mitigate the risk of pulmonary complications while reducing the hospital length of stay. Multimodal interventions should be individualized to the patient's condition. These bundle of care are more effective than single or sequential intervention owing to synergistic benefits of education, nutritional support and physical training. An effective prehabilitation program is necessarily patient-centred and coordinated among health care professionals (nurses, primary care physician, physiotherapists, nutritionists) to help the patient regain some control over the disease process and improve the physiological reserve to sustain surgical stress.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland.,Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Benoit Bedat
- Division of Thoracic and Endocrine Surgery , University Hospital of Geneva, Geneva, Switzerland
| | - Andres Hagerman
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Frederic Triponez
- Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Geneva, Switzerland.,Division of Thoracic and Endocrine Surgery , University Hospital of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Division of Thoracic and Endocrine Surgery , University Hospital of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland.,Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Geneva, Switzerland
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Diaper J, Schiffer E, Barcelos GK, Luise S, Schorer R, Ellenberger C, Licker M. Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: A randomized controlled trial. Surgery 2020; 169:1164-1174. [PMID: 33143931 DOI: 10.1016/j.surg.2020.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to compare the occurrence of postoperative complications in patients undergoing elective open abdominal surgery and receiving intraoperative goal-directed hemodynamic therapy or restrictive normovolemic therapy. METHODS A total of 401 patients were randomized in the goal-directed hemodynamic therapy or restrictive normovolemic therapy groups. A cardiac output monitor was used in all goal-directed hemodynamic therapy patients and was left at the discretion of anesthetists in charge of patients in the restrictive normovolemic therapy group. The primary outcome was a composite morbidity endpoint (30-day mortality and complications grade 2-4 according to Dindo-Clavien classification). Secondary outcomes were the hospital duration of stay, the incidence of pulmonary, cardiovascular, and renal complications up to 30 days after surgery, and midterm survival. RESULTS Intraoperatively, the goal-directed hemodynamic therapy group received higher intravenous fluid volumes (mean of 10.8 mL/kg/h and standard deviation of 4.0) compared with the restrictive normovolemic therapy group (mean of 7.2 mL/kg/h and standard deviation of 2.0; P < .001). On the first postoperative day, similar fluid volumes were infused in the 2 groups. The primary outcome occurred in 57.7% of goal-directed hemodynamic therapy and 53.0% of restrictive normovolemic therapy (relative risk, 1.09 [95% confidence interval, 0.91-1.30]), and there was no significant difference between groups for any secondary outcomes. CONCLUSION Among patients undergoing major open abdominal surgery, the goal-directed hemodynamic therapy and the restrictive normovolemic therapy were associated with similar incidence of moderate-to-severe postoperative complications and hospital resource use.
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Affiliation(s)
- John Diaper
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Gleicy Keli Barcelos
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Stéphane Luise
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland.
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Suppan M, Barcelos G, Luise S, Diaper J, Frei A, Ellenberger C, Adamopoulos D, Noble S, Licker M. Improved Exercise Tolerance, Oxygen Delivery, and Oxygen Utilization After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis. CJC Open 2020; 2:490-496. [PMID: 33305208 PMCID: PMC7710946 DOI: 10.1016/j.cjco.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022] Open
Abstract
Background Transcatheter aortic valve implantation (TAVI) represents an effective therapeutic procedure, particularly in patients with severe aortic stenosis. We hypothesized that the decreased afterload induced by TAVI would improve exercise capacity by enhancing oxygen uptake in working muscles. Methods A standardized exercise test was performed in patients with severe aortic stenosis the day before TAVI and within 5 days thereafter. The main study endpoint was the workload achieved during a 5-minute standardized exercise test. Using electrical cardiometry and near-infrared spectroscopy, we explored and compared the changes in cardiac index (CI), as well as muscular and cerebral tissue oximetry, during the 2 exercise tests. Results Thirty patients completed the study protocol. Compared with the pre-TAVI period, patients achieved a higher median workload after TAVI (316 Joules [interquartile range {IQR}: 169–494] vs 190 Joules [IQR: 131–301], P = 0.002). Baseline CI increased from 2.5 l/min per m2 (IQR: 2.1–2.9) to 2.9 l/min per m2 (IQR: 2.5–3.2; P = 0.009), whereas CI at the end of the exercise test increased from 4.5 l/min per m2 (IQR: 3.4–5.3) to 4.7 l/min per m2 (3.4–6.4; P = 0.019). At the end of the exercise test, cerebral tissue oximetry increased from 70% (IQR: 65–72) to 74% (IQR: 66–78), and muscle tissue oximetry increased from 62% (IQR: 58–65) to 71% (65–74; P = 0.046 and P < 0.001, respectively). Conclusions Early improvement of exercise capacity after TAVI is associated with increased CI and better oxygen utilization in the brain and skeletal muscles.
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Affiliation(s)
- Mélanie Suppan
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Gleicy Barcelos
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Luise
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Angela Frei
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | | | - Stéphane Noble
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Licker M, Diaper J, Ellenberger C. Accountability, research transparency and data reporting. BMC Anesthesiol 2020; 20:199. [PMID: 32795264 PMCID: PMC7427052 DOI: 10.1186/s12871-020-01107-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022] Open
Abstract
More than one published paper are often derived from analyzing the same cohort of individuals to make full use of the collected information. Preplanned study outcomes are generally mentioned in open databases while exhaustive information on methodological aspects are provided in submitted articles.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, CH-1211, Geneva, Switzerland.
| | - John Diaper
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland
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van Weteringen W, Goos TG, van Essen T, Ellenberger C, Hayoz J, de Jonge RCJ, Reiss IKM, Schumacher PM. Novel transcutaneous sensor combining optical tcPO 2 and electrochemical tcPCO 2 monitoring with reflectance pulse oximetry. Med Biol Eng Comput 2020; 58:239-247. [PMID: 31741291 PMCID: PMC6994448 DOI: 10.1007/s11517-019-02067-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 11/02/2019] [Indexed: 11/18/2022]
Abstract
This study investigated the accuracy, drift, and clinical usefulness of a new optical transcutaneous oxygen tension (tcPO2) measuring technique, combined with a conventional electrochemical transcutaneous carbon dioxide (tcPCO2) measurement and reflectance pulse oximetry in the novel transcutaneous OxiVenT™ Sensor. In vitro gas studies were performed to measure accuracy and drift of tcPO2 and tcPCO2. Clinical usefulness for tcPO2 and tcPCO2 monitoring was assessed in neonates. In healthy adult volunteers, measured oxygen saturation values (SpO2) were compared with arterially sampled oxygen saturation values (SaO2) during controlled hypoxemia. In vitro correlation and agreement with gas mixtures of tcPO2 (r = 0.999, bias 3.0 mm Hg, limits of agreement - 6.6 to 4.9 mm Hg) and tcPCO2 (r = 0.999, bias 0.8 mm Hg, limits of agreement - 0.7 to 2.2 mm Hg) were excellent. In vitro drift was negligible for tcPO2 (0.30 (0.63 SD) mm Hg/24 h) and highly acceptable for tcPCO2 (- 2.53 (1.04 SD) mm Hg/12 h). Clinical use in neonates showed good usability and feasibility. SpO2-SaO2 correlation (r = 0.979) and agreement (bias 0.13%, limits of agreement - 3.95 to 4.21%) in healthy adult volunteers were excellent. The investigated combined tcPO2, tcPCO2, and SpO2 sensor with a new oxygen fluorescence quenching technique is clinically usable and provides good overall accuracy and negligible tcPO2 drift. Accurate and low-drift tcPO2 monitoring offers improved measurement validity for long-term monitoring of blood and tissue oxygenation. Graphical abstract.
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Affiliation(s)
- Willem van Weteringen
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tom G Goos
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Tanja van Essen
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Rogier C J de Jonge
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Pediatric Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Licker M, Diaper J, Sologashvili T, Ellenberger C. Glucose-insulin-potassium improves left ventricular performances after aortic valve replacement: a secondary analysis of a randomized controlled trial. BMC Anesthesiol 2019; 19:175. [PMID: 31492103 PMCID: PMC6731577 DOI: 10.1186/s12871-019-0845-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/27/2019] [Indexed: 12/18/2022] Open
Abstract
Background Patients with left ventricular (LV) hypertrophy may suffer ischemia-reperfusion injuries at the time of cardiac surgery with impairment in left ventricular function. Using transesophageal echocardiography (TEE), we evaluated the impact of glucose-insulin potassium (GIK) on LV performances in patients undergoing valve replacement for aortic stenosis. Methods In this secondary analysis of a double-blind randomized trial, moderate-to-high risk patients were assigned to receive GIK (20 IU insulin with 10 mEq KCL in 50 ml glucose 40%) or saline over 60 min upon anesthetic induction. The primary outcomes were the early changes in 2-and 3-dimensional left ventricular ejection fraction (2D and 3D-LVEF), peak global longitudinal strain (PGLS) and transmitral flow propagation velocity (Vp). Results At the end of GIK infusion, LV-FAC and 2D- and 3D-LVEF were unchanged whereas Vp (mean difference [MD + 7.9%, 95% confidence interval [CI] 3.2 to 12.5%; P < 0.001) increased compared with baseline values. After Placebo infusion, there was a decrease in LV-FAC (MD -2.9%, 95%CI − 4.8 to − 1.0%), 2D-LVEF (MD -2.0%, 95%CI − 2.8 to − 1.3%, 3D-LVEF (MD -3.0%, 95%CI − 4.0 to − 2.0%) and Vp (MD − 4.5 cm/s, 95%CI − 5.6 to − 3.3 cm/s). After cardiopulmonary bypass, GIK pretreatment was associated with preserved 2D and 3D-LVEF (+ 0.4%, 95% 95%CI − 0.8 to 1.7% and + 0.4%, 95%CI − 1.3 to 2.0%), and PGLS (− 0.9, 95%CI − 1.6 to − 0.2) as well as higher Vp (+ 5.1 cm/s, 95%CI 2.9 to 7.3), compared with baseline. In contrast, in the Placebo group, 2D-LVEF (− 2.2%, 95%CI − 3.4 to − 1.0), 3D-LVEF (− 6.0%, 95%CI − 7.8 to − 4.2), and Vp (− 7.6 cm/s, 95%CI − 9.4 to − 5.9), all decreased after bypass. Conclusions Administration of GIK before aortic cross-clamping resulted in better preservation of systolic and diastolic ventricular function in patients with LV hypertrophy undergoing aortic valve replacement. Trial registration ClinicalTrials.gov: NCT00788242, registered on November 10, 2008.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, CH-1211, Geneva, Switzerland. .,Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital Geneva & Faculty of Medicine, CH-1206, Geneva, Switzerland.
| | - John Diaper
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland
| | - Tornike Sologashvili
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, CH-1211, Geneva, Switzerland
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Ellenberger C, Sologashvili T, Kreienbühl L, Cikirikcioglu M, Diaper J, Licker M. Myocardial Protection by Glucose-Insulin-Potassium in Moderate- to High-Risk Patients Undergoing Elective On-Pump Cardiac Surgery: A Randomized Controlled Trial. Anesth Analg 2019; 126:1133-1141. [PMID: 29324494 DOI: 10.1213/ane.0000000000002777] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Low cardiac output syndrome is a main cause of death after cardiac surgery. We sought to assess the impact of glucose-insulin-potassium (GIK) to enhance myocardial protection in moderate- to high-risk patients undergoing on-pump heart surgery. METHODS A randomized controlled trial was performed in adult patients (Bernstein-Parsonnet score >7) scheduled for elective aortic valve replacement and/or coronary artery bypass surgery. Patients were randomized to GIK (20 IU of insulin, 10 mEq of potassium chloride in 50 mL of glucose 40%) or saline infusion given over 60 minutes on anesthetic induction. The primary end point was postcardiotomy ventricular dysfunction (PCVD), defined as new/worsening left ventricular dysfunction requiring inotropic support (≥120 minutes). Secondary end points were the intraoperative changes in left ventricular function as assessed by transoesophageal echocardiography, postoperative troponin levels, cardiovascular and respiratory complications, and intensive care unit and hospital length of stay. RESULTS From 224 randomized patients, 222 were analyzed (112 and 110 in the placebo and GIK groups, respectively). GIK pretreatment was associated with a reduced occurrence of PCVD (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.25-0.66). In GIK-treated patients, the left systolic ventricular function was better preserved after weaning from bypass, plasma troponin levels were lower on the first postoperative day (2.9 ng·mL(-) [interquartile range {IQR}, 1.5-6.6] vs 4.3 ng·mL(-) [IQR, 2.4-8.2]), and cardiovascular (RR, 0.69; 95% CI, 0.50-0.89) and respiratory complications (RR, 0.5; 95% CI, 0.38-0.74) were reduced, along with a shorter length of stay in intensive care unit (3 days [IQR, 2-4] vs 3.5 days [IQR, 2-7]) and in hospital (14 days [IQR, 11-18.5] vs 16 days [IQR, 12.5-23.5]), compared with placebo-treated patients. CONCLUSIONS GIK pretreatment was shown to attenuate PCVD and to improve clinical outcome in moderate- to high-risk patients undergoing on-pump cardiac surgery.
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Affiliation(s)
| | - Tornike Sologashvili
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Lukas Kreienbühl
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- From the Department of Anesthesiology, Pharmacology and Intensive Care
| | - Marc Licker
- From the Department of Anesthesiology, Pharmacology and Intensive Care.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Licker M, Ellenberger C. Answer to the letter: Research transparency, preplanned study endpoints and availability of results. J Clin Monit Comput 2019; 34:189-190. [PMID: 31030331 DOI: 10.1007/s10877-019-00316-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Marc Licker
- Department of Acute Medicine, University Hospital of Geneva Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Christoph Ellenberger
- Department of Acute Medicine, University Hospital of Geneva Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Ellenberger C, Garofano N, Reynaud T, Triponez F, Diaper J, Bridevaux PO, Karenovics W, Licker M. Patient and procedural features predicting early and mid-term outcome after radical surgery for non-small cell lung cancer. J Thorac Dis 2018; 10:6020-6029. [PMID: 30622773 DOI: 10.21037/jtd.2018.10.36] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Postoperative cardiovascular and pulmonary complications (PCVCs and PPCs) are frequent and result in prolonged hospital stay. The aim of this study was to update the risk factors associated with major complications and survival after lung cancer surgery. Methods This is a post-hoc analysis of a randomized controlled trial that was designed to assess the benefits of preoperative physical training. After enrollment, clinical, biological and functional data as well as intraoperative details were collected. In-hospital PCVCs and PPCs were recorded and survival data were adjudicated up to 4 years after surgery. Results Data from 151 patients were analyzed. Thirty-day mortality rate was 2.6% and the incidence of PCVCs and PPCs was 15% and 33%, respectively. Stepwise logistic regression analysis showed that, PCVCs were mainly related to elevated plasma levels of brain natriuretic peptides [odds ratios (ORs) =6.0; 95% confidence interval (CI), 1.3-27.3] and performance of a pneumonectomy (OR =9.6; 95% CI, 2.9-31.5) whereas PPCs were associated with the presence of COPD (OR =5.9; 95% CI, 2.4-14.8), current smoking (OR =2.6; 95% CI, 1.1-6.5) and the need for blood transfusion (OR =5.2; 95% CI, 1.2-23.3). Preoperative physical training was a protective factor regarding PPCs (OR =0.13; 95% CI, 0.05-0.34). Cox proportional hazards regression analysis showed that ventilatory inefficiency during exercise (expressed by a ratio >40 of ventilation to carbon dioxide elimination), coronary artery disease, elevated plasma levels of brain natriuretic peptides and the occurrence of PPCs were all predictive of poor survival after surgery. Conclusions Besides smoking and the extent of lung resection, preexisting cardiopulmonary disease as evidence by elevated levels of brain natriuretic peptides and inefficient ventilation are associated with poor clinical outcome after lung cancer surgery.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Najia Garofano
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Thomas Reynaud
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Division of Thoracic Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | | | - Wolfram Karenovics
- Division of Thoracic Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
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Ellenberger C, Sologashvili T, Cikirikcioglu M, Verdon G, Diaper J, Cassina T, Licker M. Risk factors of postcardiotomy ventricular dysfunction in moderate-to-high risk patients undergoing open-heart surgery. Ann Card Anaesth 2018; 20:287-296. [PMID: 28701592 PMCID: PMC5535568 DOI: 10.4103/aca.aca_60_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction: Ventricular dysfunction requiring inotropic support frequently occurs after cardiac surgery, and the associated low cardiac output syndrome largely contributes to postoperative death. We aimed to study the incidence and potential risk factors of postcardiotomy ventricular dysfunction (PCVD) in moderate-to-high risk patients scheduled for open-heart surgery. Methods: Over a 5-year period, we prospectively enrolled 295 consecutive patients undergoing valve replacement for severe aortic stenosis or coronary artery bypass surgery who presented with Bernstein-Parsonnet scores >7. The primary outcome was the occurrence of PCVD as defined by the need for sustained inotropic drug support and by transesophageal echography. The secondary outcomes included in-hospital mortality and the incidence of any major adverse events as well as Intensive Care Unit (ICU) and hospital length of stay. Results: The incidence of PCVD was 28.4%. Patients with PCVD experienced higher in-hospital mortality (12.6% vs. 0.6% in patients without PCVD) with a higher incidence of cardiopulmonary and renal complications as well as a prolonged stay in ICU (median + 2 days). Myocardial infarct occurred more frequently in patients with PCVD than in those without PCVD (19 [30.2%] vs. 12 [7.6%]). By logistic regression analysis, we identified four independent predictors of PCVD: left ventricular ejection fraction <40% (odds ratio [OR] = 6.36; 95% confidence interval [CI], 2.59–15.60), age older than 75 years (OR = 3.35; 95% CI, 1.64–6.81), prolonged aortic clamping time (OR = 3.72; 95% CI, 1.66–8.36), and perioperative bleeding (OR = 2.33; 95% CI, 1.01–5.41). The infusion of glucose-insulin-potassium was associated with lower risk of PCVD (OR = 0.14; 95% CI, 0.06–0.33). Conclusions: This cohort study indicates that age, preoperative ventricular function, myocardial ischemic time, and perioperative bleeding are predictors of PCVD which is associated with poor clinical outcome.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gabriel Verdon
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Tiziano Cassina
- Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva; Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Perrin N, Perrin T, Hachulla AL, Frei A, Müller H, Roffi M, Cikirikcioglu M, Ellenberger C, Licker MJ, Burri H, Noble S. Conduction disorders using the Evolut R prosthesis compared with the CoreValve: has anything changed? Open Heart 2018; 5:e000770. [PMID: 29632681 PMCID: PMC5888433 DOI: 10.1136/openhrt-2017-000770] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 02/14/2018] [Accepted: 03/06/2018] [Indexed: 11/20/2022] Open
Abstract
Aim We compared early postprocedural and midterm evolution of atrioventricular and intraventricular conduction disorders following implantation of the new generation Evolut R (ER) prosthesis in comparison with the previous generation CoreValve (CV) system using routinely recorded ECG up to 6-month follow-up. Methods All consecutive patients treated by transcathether aortic valve implantation (TAVI) using the Medtronic self-expanding devices for symptomatic severe aortic stenosis in a single centre between October 2011 and February 2016 were considered for inclusion. ECGs recorded at baseline, day 1 after TAVI, discharge and 6 months were retrospectively analysed. At each time-point, intrinsic rhythm, PR interval, QRS axis and duration, and atrioventricular and intraventricular conduction were analysed. Atrioventricular and intraventricular conduction following TAVI at discharge and at 6 months were compared intrasubject at the different time intervals and between patients receiving the ER versus the CV prosthesis. Results Among the 113 patients included in the analysis (51% female, 83.3±6.2 years), 60 (53%) patients received the CV and 53 (47%) patients received the ER. Compared with patients in the CV group, those in the ER group had a lower Society of Thoracic Surgeons score (6.3±3.1vs 4.8±3.6, P=0.02). Patients in the ER group in comparison with those in the CV group more frequently had postprocedural PR interval (57%vs23%, respectively, P=0.004) and QRS prolongation (76%vs50%, P=0.03) at discharge. Incidence of complete atrioventricular block was similar between both groups (9%vs18%, P=0.3) up to 6-month follow-up. No difference in term of new left bundle branch block (LBBB) (34%vs28%, P=0.8) or permanent pacemaker implantation rates (32.1%vs31.7%, P=1.0) was reported. Conclusions Patients with the ER had greater postprocedural atrioventricular and intraventricular conduction delays than those with the CV at discharge, with however similar incidence of high-degree atrioventricular block, new LBBB and permanent pacemaker implantation up to 6-month follow-up.
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Affiliation(s)
- Nils Perrin
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | - Tilman Perrin
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | - Anne-Lise Hachulla
- Department of Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Angela Frei
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | - Hajo Müller
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | - Marco Roffi
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Marc-Joseph Licker
- Anaesthesiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Haran Burri
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
| | - Stephane Noble
- Cardiology Division, University Hospital of Geneva, Geneva, Switzerland
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Abstract
ZusammenfassungEs werden die Fälle einer disseminierten letalen Toxoplasmose bei einer Farbmaus (Mus musculus) und einem Roten Panda (Ailurus fulgens) vorgestellt. Es handelte sich um eine als Haustier gehaltene Farbmaus und einen Roten Panda aus einem sächsischen zoologischen Garten. Die pathologische Untersuchung ergab bei beiden Tieren eine systemische Toxoplasmeninfektion. Eine hochgradige nekrotisierende Hepatitis stellte in beiden Fällen den histologischen Hauptbefund dar. Parasitenzysten fanden sich massenhaft in der Leber, in mäßiger Zahl im Gehirn und in geringer Zahl in anderen Organen. Mittels PAS-Reaktion waren diese Zysten bei der Farbmaus kaum darstellbar, beim Roten Panda dagegen sehr deutlich. PCR bzw. Immunhistologie bestätigten die Diagnose.
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Karenovics W, Ellenberger C, Triponez F, Licker M. Reply to Cavalheri et al. Eur J Cardiothorac Surg 2017; 52:1009-1010. [PMID: 28977498 DOI: 10.1093/ejcts/ezx241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Wolfram Karenovics
- Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Fréderic Triponez
- Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
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Ellenberger C, Garofano N, Barcelos G, Diaper J, Pavlovic G, Licker M. Assessment of Haemostasis in patients undergoing emergent neurosurgery by rotational Elastometry and standard coagulation tests: a prospective observational study. BMC Anesthesiol 2017; 17:146. [PMID: 29065860 PMCID: PMC5655946 DOI: 10.1186/s12871-017-0440-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/19/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Rotational elastometry (ROTEM) has been shown useful to monitor coagulation in trauma patients and in major elective surgery. In this study, we aimed to evaluate the utility of ROTEM to identify hemostatic disturbances and to predict the need for transfusion, compared with standard coagulation tests (SCTs) in patients undergoing emergent neurosurgery. METHODS Over a four-year period, adult patients who met criteria for emergent neurosurgery lasting more than 90 min were included in the study. Blood was collected preoperatively and analyzed with SCTs (international normalized ratio [INR], fibrinogen concentration, prothrombin time [PT or Quick], partial thromboplastine time [PTT], fibrinogen concentration and platelet count), and ROTEM assays. Correlations between SCTs and ROTEM parameters as well as receiver operating characteristic curves were performed to detect a coagulopathic pattern based on standard criteria and the need for transfusing at least 3 units of packed red blood cells (PRBCs). RESULTS In a cohort of 92 patients, 39 (42%) required ≥3 PRBCs and a coagulopathic pattern was identified in 32 patients based on SCTs and in 19 based on ROTEM. There was a strong correlation between PTT and INTEM coagulation time (R = 0.76) as well as between fibrinogen concentrations and FIBTEM maximal clot firmess (R = 0.70). The need for transfusion (≥ 3 PRBCs) was best predicted by the maximal clot firmess of EXTEM and FIBTEM (AUC of 0.72 and 0.71, respectively) and by fibrinogen concentration (AUC of 0.70). CONCLUSIONS In patients undergoing emergent neurosurgery, ROTEM analysis provides valid markers of early coagulopathy and predictors of blood transfusion requirements.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland
| | - Najia Garofano
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland
| | - Gleicy Barcelos
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland
| | - Gordana Pavlovic
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, -1211, Geneva, CH, Switzerland. .,Faculty of Medicine, University of Geneva, -1211, Geneva, CH, Switzerland.
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Perrin N, Roffi M, Frei A, Hachulla AL, Ellenberger C, Müller H, Cikirikcioglu M, Licker M, Noble S. Seguimiento a 30 días tras el implante percutáneo de válvula aórtica CoreValve Evolut R: estudio prospectivo de pacientes no seleccionados. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ellenberger C, Sologashvili T, Bhaskaran K, Licker M. Impact of intrathecal morphine analgesia on the incidence of pulmonary complications after cardiac surgery: a single center propensity-matched cohort study. BMC Anesthesiol 2017; 17:109. [PMID: 28830362 PMCID: PMC5567923 DOI: 10.1186/s12871-017-0398-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/10/2017] [Indexed: 11/21/2022] Open
Abstract
Background Acute pain and systemic opioids may both negatively impact respiratory function after cardiac surgery. This study analyzes the local practice of using intrathecal morphine analgesia (ITMA) with minimal parenteral opioid administration in cardiac surgery, specifically the impact on postoperative pulmonary complications (PPCs). Methods Data from adult patients who underwent elective cardiac surgery between January 2002, and December 2013 in a single center were analyzed. Propensity scores estimating the likelihood of receiving ITMA were used to match (1:1) patients with ITMA and patients with intravenous analgesia (IVA). Primary outcome was PPCs, a composite endpoint including pneumonia, adult respiratory distress syndrome, and any type of acute respiratory failure. Secondary outcomes were in-hospital mortality, cardiovascular complications, and length of stay in the intensive care unit (ICU) and hospital. Results From a total of 1′543 patients, 920 were treated with ITMA and 623 with IVA. No adverse event consequent to the spinal puncture was reported. Propensity score matching created 557 balanced pairs. The occurrence of PPCs in patients with ITMA was 8.1% vs. 12.8% in patients with IVA (odds ratio, 0.6; 95% CI, 0.40–0.89; p = 0.012). Fewer patients with ITMA had a prolonged stay in the ICU (> 4 days; 16.5% vs. 21.2%, p = 0.047) or in the hospital (> 15 days; 25.5% vs. 31.8%. p = 0.024). In-hospital mortality and cardiovascular complications did not differ significantly between the two groups. Conclusion In this study involving cardiac surgical patients, ITMA was safely applied and was associated with fewer PPCs. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0398-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, -1211, Geneva, CH, Switzerland
| | - Tornike Sologashvili
- Division of Cardiovascular Surgery, University Hospital of Geneva, rue Gabrielle-Perret Gentil, Geneva, 1211, Switzerland
| | | | - Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, -1211, Geneva, CH, Switzerland.
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Karenovics W, Licker M, Ellenberger C, Christodoulou M, Diaper J, Bhatia C, Robert J, Bridevaux PO, Triponez F. Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: a randomized controlled study†. Eur J Cardiothorac Surg 2017; 52:47-54. [DOI: 10.1093/ejcts/ezx030] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/18/2016] [Indexed: 11/13/2022] Open
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Arroja JD, Hachulla AL, Ellenberger C, Müller H. Multimodality imaging evaluation of a mitro-aortic fibrosa pseudoaneurysm fistulizing into both atria. Echocardiography 2017; 34:139-140. [DOI: 10.1111/echo.13399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jose David Arroja
- Cardiology Department; Geneva University Hospital; Geneva Switzerland
| | | | | | - Hajo Müller
- Cardiology Department; Geneva University Hospital; Geneva Switzerland
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Perrin N, Roffi M, Frei A, Hachulla AL, Ellenberger C, Müller H, Cikirikcioglu M, Licker M, Noble S. Thirty-day Outcome Following CoreValve Evolut R Transcatheter Aortic Valve Implantation: An All-comers Prospective Study. ACTA ACUST UNITED AC 2016; 70:713-719. [PMID: 28034684 DOI: 10.1016/j.rec.2016.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/10/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R. METHODS Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded. RESULTS Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8±3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5±14.5mmHg at baseline to 7.7±4.0mmHg at discharge (P<.0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients. CONCLUSIONS The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves.
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Affiliation(s)
- Nils Perrin
- Division of Cardiology, University Hospital of Geneva, Geneva, Switzerland.
| | - Marco Roffi
- Division of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Angela Frei
- Division of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Anne-Lise Hachulla
- Department of Radiology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Hajo Müller
- Division of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, University Hospital of Geneva, Geneva, Switzerland
| | - Stephane Noble
- Division of Cardiology, University Hospital of Geneva, Geneva, Switzerland
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Licker M, Karenovics W, Diaper J, Frésard I, Triponez F, Ellenberger C, Schorer R, Kayser B, Bridevaux PO. Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial. J Thorac Oncol 2016; 12:323-333. [PMID: 27771425 DOI: 10.1016/j.jtho.2016.09.125] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/07/2016] [Accepted: 09/11/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications. In this randomized controlled trial, we hypothesized that a high-intensity interval training (HIIT) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications. METHODS Patients with operable lung cancer were randomly assigned to usual care (UC) (n = 77) or preoperative rehabilitation based on HIIT (Rehab) (n = 74). Maximal cardiopulmonary exercise testing and the 6-minute walk test were performed twice before surgery. The primary outcome measure was a composite of death and in-hospital postoperative complications. RESULTS The groups were well balanced in terms of patient characteristics. During the preoperative waiting period (median 25 days), the peak oxygen consumption and the 6-minute walking distance increased (median +15%, interquartile range, 25th to 75 percentile [IQR25%-75%, %] = +9% to +22%, p = 0.003 and +15%, IQR25%-75% = +8% to +28%, p < 0.001, respectively) in the Rehab group, whereas peak oxygen consumption declined in the UC group (median -8%, IQR25%-75% = -16% to 0%], p = 0.005). The primary end point did not differ significantly between the two groups: at least one postoperative complication developed in 27 of the 74 patients (35.5%) in the Rehab group and 39 of 77 patients (50.6%) in the UC group (p = 0.080). Notably, the incidence of pulmonary complications was lower in the Rehab compared with in the UC group (23% versus 44%, p = 0.018), owing to a significant reduction in atelectasis (12.2% versus 36.4%, p < 0.001), and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit (median -7 hours, IQR25%-75% = -4 to -10). CONCLUSIONS In this randomized controlled trial, preoperative HIIT resulted in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Wolfram Karenovics
- Division of Thoracic Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Isabelle Frésard
- Division of Internal Medicine, Hopital La Tour in Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Division of Thoracic Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Bengt Kayser
- Institute of Sports Science and Department of Physiology at the Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Pierre-Olivier Bridevaux
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Division of Pneumology, Hospital du Valais in Sion, Sion, Switzerland
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Licker M, Triponez F, Ellenberger C, Karenovics W. Fluid Therapy in Thoracic Surgery: A Zero-Balance Target is Always Best! Turk J Anaesthesiol Reanim 2016; 44:227-229. [PMID: 27909600 DOI: 10.5152/tjar.2016.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
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Perrin N, Ellenberger C, Licker M, Hachulla AL, Cikirikcioglu M, Frei A, Roffi M, Noble S. Management of vascular complications following transcatheter aortic valve implantation. Arch Cardiovasc Dis 2016; 108:491-501. [PMID: 26073229 DOI: 10.1016/j.acvd.2015.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 03/13/2015] [Accepted: 03/19/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vascular complications (VCs) after transcatheter aortic valve implantation (TAVI) are frequent and their management is challenging. AIM To report the incidence, predictors and management of VCs following percutaneous transfemoral TAVI (TF-TAVI) at a single centre. METHODS We analyzed 102 consecutive patients who underwent percutaneous TF-TAVI between August 2008 and December 2013. All endpoints were evaluated at 30 days and 6 months according to Valve Academic Research Consortium-2 criteria. VC percutaneous treatment success was defined as residual stenosis<30%, absence of blood extravasation and absence of surgical or repeat endovascular intervention at 30 days. RESULTS Twenty-two patients (22%) experienced VCs, including five patients (5%) with major VCs. Mortality at 30 days was significantly higher in patients with major VCs than in patients without major VCs (60% vs 3%; P=0.001). Patients with VCs had more life-threatening or major bleeding (23% vs 5%; P=0.02), but no difference in terms of need for blood transfusion was observed. Endovascular treatment was used in 13 of 22 patients with VCs (59%) and was successful in 11 of these 13 patients (85%). Primary surgical repair was necessary in only 1/22 (5%) patients, for a common femoral artery pseudoaneurysm 2 weeks after the TAVI procedure. CONCLUSIONS VCs following TF-TAVI are frequent. Major but not minor VCs are associated with increased mortality. Percutaneous management of VCs is feasible and safe, and surgery is rarely needed.
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Affiliation(s)
- Nils Perrin
- Cardiology Division, University Hospital of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland.
| | | | - Marc Licker
- Anaesthesiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Anne-Lise Hachulla
- Radiology Department, University Hospital of Geneva, Geneva, Switzerland
| | | | - Angela Frei
- Cardiology Division, University Hospital of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Marco Roffi
- Cardiology Division, University Hospital of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Stéphane Noble
- Cardiology Division, University Hospital of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
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Pavlovic G, Diaper J, Ellenberger C, Frei A, Bendjelid K, Bonhomme F, Licker M. Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial. J Clin Monit Comput 2015; 30:87-99. [PMID: 25851818 DOI: 10.1007/s10877-015-9691-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.
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Affiliation(s)
- Gordana Pavlovic
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Angela Frei
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Karim Bendjelid
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Faculty of medecine, University of Geneva, Geneva, Switzerland
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland. .,Faculty of medecine, University of Geneva, Geneva, Switzerland.
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Böttcher D, Gräfe H, Zimmermann G, Alexander H, Ellenberger C, Schoon HA. Transcription of equine chorionic gonadotropin/luteinizing hormone b subunit gene in the endometrium of non-pregnant mares. PFERDEHEILKUNDE 2014. [DOI: 10.21836/pem20140103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Böttcher D, Gräfe H, Zimmermann G, Alexander H, Ellenberger C, Schoon HA. Equine chorionic gonadotropin in the uterus of non-pregnant mares? Reprod Biol 2013. [DOI: 10.1016/j.repbio.2013.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Licker M, Diaper J, Cartier V, Ellenberger C, Cikirikcioglu M, Kalangos A, Cassina T, Bendjelid K. Clinical review: management of weaning from cardiopulmonary bypass after cardiac surgery. Ann Card Anaesth 2012; 15:206-23. [PMID: 22772515 DOI: 10.4103/0971-9784.97977] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. Various crisis management scenarios can be anticipated which emphasizes the importance of basic knowledge in applied cardiovascular physiology, knowledge of pathophysiology of the surgical lesions as well as leadership, and communication between multiple team members in a high-stakes environment. Since the mid-90s, transoesophageal echocardiography has provided an opportunity to assess the completeness of surgery, to identify abnormal circulatory conditions, and to guide specific medical and surgical interventions. However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.
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Affiliation(s)
- Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University of Geneva, CH-1211 Geneva, Switzerland.
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Lehmann J, Ellenberger C, Hoffmann C, Bazer FW, Klug J, Allen WR, Sieme H, Schoon HA. Morpho-functional studies regarding the fertility prognosis of mares suffering from equine endometrosis. Theriogenology 2012; 76:1326-36. [PMID: 21855986 DOI: 10.1016/j.theriogenology.2011.06.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 06/01/2011] [Accepted: 06/03/2011] [Indexed: 11/16/2022]
Abstract
The aim of the present study was to characterize the morpho-functional features of endometrosis in barren and foaling mares, using both conventional histopathological and immunohistochemical methods. Endometrial biopsy samples were collected during the physiological breeding season from 159 estrous, clinically healthy mares (mean age 12 years), and the quality and degree of endometrosis was histomorphologically defined. The mares were bred and those that foaled were put in the foaling group whereas those that did not foal were placed in the barren group. Foaling mares were then compared with barren mares. Sixty-four percent (101/159) of uterine samples showed varying degrees of endometrosis and were used for this study. The sample population consisted of 51 barren and 50 foaling mares suffering from endometrosis. Expression of steroid hormone receptors (estrogen receptor, progesterone receptor) and endometrial protein secretion patterns (uteroglobin [UG], uterocalin [UC], calbindin(D9k) [CAL], uteroferrin [UF]) was evaluated by immunohistochemistry (barren mares N = 51, foaling mares N = 31). In comparison with unaffected glands, fibrotic glands generally showed a cycle-asynchronous, partially patchy protein expression pattern which is interpreted as a sign of endometrial maldifferentiation within fibrotic areas. In barren mares (N = 51) more than half of biopsy samples (27/51) showed a destructive mostly moderate (20/27) type of endometrosis. In affected glands, staining for UG (17/21) was decreased (P < 0.001). Foaling mares (N = 50) frequently showed a mild, nondestructive endometrosis (35/50). Compared with barren mares, foaling mares had statistically (P < 0.05) more often a cycle-synchronous or increased UG expression pattern within fibrotic glands. Obvious deviations of either UG or UC rarely occurred. Within fibrotic foci, UF often demonstrated a cycle-synchronous or more intense expression pattern in both foaling (28/31) and barren mares (41/51), compared with healthy glands. Mares of both groups showed a cycle-asynchronous staining for estrogen receptor and progesterone receptor in the stromal cells in areas of periglandular fibrosis and the glandular epithelia. These findings indicate that affected areas become independent of the uterine control mechanisms and exhibit specific differentiation dynamics. Immunohistochemical investigations showed that the secretory patterns differ between barren and foaling mares. The findings in this study should be considered as a useful addition to the "classical" Kenney categorization.
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Affiliation(s)
- J Lehmann
- University of Leipzig, Faculty of Veterinary Medicine, Institute of Pathology, Leipzig, Germany.
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von Krosigk F, Steinmetz A, Ellenberger C, Oechtering G. [Magnetic resonance imaging and ultrasonography in dogs and cats with ocular and orbital diseases. Part 1: Ocular diseases]. Tierarztl Prax Ausg K Kleintiere Heimtiere 2012; 40:7-15. [PMID: 22331324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 12/03/2010] [Indexed: 05/31/2023]
Abstract
OBJECTIVE This two-part study describes the clinical usefulness and value of ultrasound and magnetic resonance imaging (MRI) in dogs and cats with ocular (n=30) and orbital diseases (n=31). MRI and ultrasonography characteristics are described in single cases with ocular and orbital disease. MATERIAL AND METHODS Ultrasonography and MRI were performed in 15 dogs and 15 cats with intraocular neoplasia or intraocular inflammatory disease. RESULTS In all patients with intraocular neoplasia, sonography revealed masses with increased echogenicity and fairly uniform echotexture, thus allowing the tentative diagnosis of an intraocular tumour. In these cases, MRI often proved to be a valuable diagnostic tool in showing the complete extent of intraocular lesion. An additional benefit of MRI was seen in the tissue characterization of tumours based on MRI signal characteristics and pattern of contrast enhancement. Discreet intraocular inflammatory alterations, in particular to the anterior and posterior segment of the eyeball, were more clearly shown by ultrasound than by MRI. Neoplasia could be excluded and inflammatory disease was successfully diagnosed using MRI due to the different image sequences with or without contrast medium administration. Traumatic ruptures of the lens capsule and the globe after trauma were depicted more clearly with MRI. CONCLUSIONS AND CLINICAL RELEVANCE When opacity of the anterior eye segment is present, various intraocular changes can be quickly diagnosed by ultrasound with high accuracy, without requiring anaesthesia of the patient. MRI of the globe allows differentiation of diverse pathologies, gives detailed information of infiltration in orbital structures and the exact degree of ocular lesions after trauma. This additional evidence often makes it easier to predict the correct prognosis and choose the best therapy.
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Affiliation(s)
- F von Krosigk
- Tierärztliche Klinik für Kleintiere, Dr. Michael Kühn & Dr. Peter Schmidt, Carl-Benz-Straße 2, 04451 Panitzsch (bei Leipzig).
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Stief B, Kiesow C, Ellenberger C. [Two cases of disseminated toxoplasmosis]. Tierarztl Prax Ausg K Kleintiere Heimtiere 2012; 40:64-69. [PMID: 22331331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 02/24/2011] [Indexed: 05/31/2023]
Abstract
Two cases of disseminated fatal toxoplasmosis of a pet mouse and a red panda are described. The pet mouse had a private owner; the red panda lived in a zoological garden in Saxony. At necropsy, both animals suffered from a systemic toxoplasmosis. A severe necrotizing hepatitis was the main histological feature in both animals. Parasitic cysts could be abundantly found in the liver, moderately in the brain and in a low number in other organs. With the PAS-reaction, cysts showed a weak staining in the mouse and a strong staining in the red panda. Diagnosis was confirmed by PCR and immunohistochemistry.
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Affiliation(s)
- B Stief
- Landesuntersuchungsanstalt Sachsen, Standort Dresden, Fachgebiet Pathologie/Bakteriologie, Jägerstraße 8/10, 01099 Dresden.
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Müller K, Ellenberger C, Hoppen HO, Schoon HA. Immunohistochemical study of angiogenesis and angiogenic factors in equine granulosa cell tumours. Res Vet Sci 2011; 92:471-7. [PMID: 21492887 DOI: 10.1016/j.rvsc.2011.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 02/03/2011] [Accepted: 02/17/2011] [Indexed: 12/01/2022]
Abstract
The first part of our study (Müller et al., 2009) characterized angiogenesis in the equine cycling ovary through histomorphological and immunohistochemical examinations (vascular endothelial growth factors A and B [VEGF A, VEGF B], vascular endothelial growth factor receptors 1 and 2 [VEGF-R1, VEGF-R2], vascular angiopoietins 1 and 2 [Ang1, Ang2], angiopoietin receptor [Tie2], and von Willebrand Factor). Since angiogenesis plays an important role in development and growth of numerous tumours, the second part of our study involved a similar examination of 70 equine granulosa cell tumours (GCTt). The results of the second study were compared with those of the normal equine ovary. Certain similarities in the expression pattern could be detected between normal, cyclical ovaries (Müller et al., 2009) and GCTt. The immunoreactivity of granulosa cells and Leydig-like cells in GCTt resembles granulosa cells and luteinized thecal cells in periovulatory cycling ovaries. The neoplastic cells support circulation, supply and growth of GCTt by contributing to angiogenesis.
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Affiliation(s)
- K Müller
- Institute of Pathology, Faculty of Veterinary Medicine, University of Leipzig, An den Tierkliniken 33, 04103 Leipzig, Germany.
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Kiesow C, Ellenberger C, Schoon HA. Pathogenesis of equine endometrosis: Relevance of the growth factors transforming growth factor- a, -b1, -b2 and -b3 and matrixmetalloproteinase-2. PFERDEHEILKUNDE 2011. [DOI: 10.21836/pem20110101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Diaper J, Ellenberger C, Villiger Y, Robert J, Inan C, Tschopp JM, Licker M. Comparison of cardiac output as assessed by transesophageal echo-Doppler and transpulmonary thermodilution in patients undergoing thoracic surgery. J Clin Anesth 2010; 22:97-103. [DOI: 10.1016/j.jclinane.2009.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Revised: 02/26/2009] [Accepted: 03/01/2009] [Indexed: 10/19/2022]
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Theuß T, Böttcher D, Kappe A, Schoon HA, Ellenberger C. Establishment of a new method for isolation and culture of equine endometrial epithelial and stromal cells. PFERDEHEILKUNDE 2010. [DOI: 10.21836/pem20100113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kiesow C, Ellenberger C, Sieme H, Schoon HA. Immunohistochemical identification of the growth factors Transforming growth factor-α, -β1, -β2 and -β3 as well as the matrixmetalloproteinase-2 in the cyclic equine endometrium. PFERDEHEILKUNDE 2010. [DOI: 10.21836/pem20100202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Böttcher D, Theuß T, Kappe A, Sobiraj A, Schoon HA, Ellenberger C. Morpho-functional characterization of equine endometrial epithelial cells in vitro – preliminary results. PFERDEHEILKUNDE 2010. [DOI: 10.21836/pem20100114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ocylok A, Brand K, Wippermann W, Ellenberger C. Granulomatous-necrotizing enteritis and cirrhosis of the liver in a trotter gelding. PFERDEHEILKUNDE 2010. [DOI: 10.21836/pem20100206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Müller K, Ellenberger C, Schoon HA. Histomorphological and immunohistochemical study of angiogenesis and angiogenic factors in the ovary of the mare. Res Vet Sci 2009; 87:421-31. [DOI: 10.1016/j.rvsc.2009.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 04/01/2009] [Accepted: 04/16/2009] [Indexed: 11/29/2022]
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Hoffmann C, Bazer FW, Klug J, Aupperle H, Ellenberger C, Özgen S, Schoon D, Schoon HA. Immunohistochemical and histochemical identification of proteins and carbohydrates in the equine endometrium: Reaction patterns in the cycling mare. PFERDEHEILKUNDE 2009. [DOI: 10.21836/pem20090303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hoffmann C, Bazer F, Klug J, Aupperle H, Ellenberger C, Schoon HA. Immunohistochemical and histochemical identification of proteins and carbohydrates in the equine endometrium. Theriogenology 2009; 71:264-74. [DOI: 10.1016/j.theriogenology.2008.07.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 07/08/2008] [Accepted: 07/12/2008] [Indexed: 11/29/2022]
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Diaper J, Ellenberger C, Villiger Y, Robert J, Tschopp JM, Licker M. Transoesophageal Doppler Monitoring For Fluid And Hemodynamic Treatment During Lung Surgery. J Clin Monit Comput 2008; 22:367-74. [DOI: 10.1007/s10877-008-9144-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 10/06/2008] [Indexed: 12/21/2022]
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