Zeitschrift fur Herz Thorax und Gefasschirurgie最新文献

New technologies and continuous further development of extracorporeal support systems have expanded the range of applications of extracorporeal life support (ECLS) in recent years. In addition to use in cardiogenic shock or resuscitation, the number of requests for the transfer of unstable patients from peripheral hospitals are increasing. Organizational challenges such as the establishment of networks and structured team training for all parties involved mean that the ECLS team is quickly available to reach the patient.

Introduction: The year 2020 will always stand in the shadow of the pandemic triggered by the coronavirus 2019 (COVID-19). The first three quarter years of 2020 were characterized by an unprecedented reduction of elective inpatient services and a prioritization of intensive care capacity for the treatment of COVID-19 patients. This also resulted in clear consequences for the services provided in cardiac surgery. In addition, during the course of the year the personnel in hospitals were confronted with a plethora of amendments in the legal framework conditions. Nevertheless, the modified German diagnosis-related groups (G-DRG) system 2021 was calculated by the Institute for the Remuneration System in Hospitals (InEK). This article describes and assesses the most important amendments of the modified G‑DRG system 2021 for cardiac, thoracic and vascular surgery.

Methods: Analysis of the relevant diagnoses, procedures and G‑DRG structures in the system versions for 2020 and 2021 based on the information published by the InEK and the German Federal Institute for Drugs and Medical Devices (BfArM).

Results: Expansions of the relevant classification systems for diagnoses (ICD-10-GM 2021) and procedures (OPS 2021) lead to an increase in specific coding of essential interventions and operations in cardiovascular surgery. Within the framework of the adaptation of the G‑DRG structures, the condensation of the previous fixed rates for heart transplantation to G‑DRG A05Z and devaluation of coronary bypass operations and reconstructive vascular interventions are particularly important.

Conclusion: For cardiovascular surgery there are manifold amendments with sometimes substantial repercussions for the case proceeds. Additionally, for many German hospitals the effects of the corona pandemic are not yet finally foreseeable. A further increasingly more urgent influencing factor particularly affecting vascular medicine is the increasing pressure to promote outpatient treatment. In this respect, the catalogue for outpatient operations in hospitals (AOP), which is expected in 2022 and will presumably be much expanded, will once again clearly increase the enforcement of outpatient performance of services that were previously performed as inpatient treatment.

Lung transplantation is an established therapeutic option for selected patients with various end stage pulmonary diseases which prolongs survival and improves quality of life. A multitude of pulmonary and non-pulmonary complications can lead to significant morbidity thus impairing short and long-term survival. Early recognition and fast treatment of these complications are fundamental measures to prevent secondary destructive incidents. This article reviews the most frequent complications arising after lung transplantation.

The use of extracorporeal support systems in cardiac and/or pulmonary failure is an established treatment option. Although scientific evidence is limited there is an increasing amount of data from individual studies, e.g. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial 2010, suggesting that extracorporeal membrane oxygenation (ECMO) as a veno-venous pump-driven system is a life-saving procedure in severe respiratory failure. Initially established as a rescue option for postcardiotomy cardiac failure extracorporeal life support (ECLS) as a pump-driven veno-arterial cardiovascular support system is increasingly being used in cardiogenic shock after myocardial infarction, as bridging to transplantation or as part of extended cardiopulmonary resuscitation. The pumpless extracorporeal lung assist (pECLA) as an arterio-venous pumpless system is technically easier to handle but only ensures sufficient decarboxylation and not oxygenation. Therefore, this method is mainly applied in primarily hypercapnic respiratory failure to allow lung protective ventilation. Enormous technical improvements, e.g. extreme miniaturization of the extracorporeal assist devices must not obscure the fact that this therapeutic option represents an invasive procedure frequently associated with major complications. With this in mind a widespread use of this technology cannot be recommended and the use of extracorporeal systems should be restricted to centers with high levels of expertise and experience.

In the view of off-label use, special concern should be granted to obtaining informed consent from the patient. It is important to point out the test character of the treatment. The patient has to be informed about the risks that exist with the treatment. The patient has to know that a drug not yet approved for this treatment is being used and the risks linked with its use have to be addressed. In addition, informed consent has to be documented and the differences compared with the standard treatment have to be pointed out.

Pulmonary hypertension comprises a group of diseases with heterogeneous etiology characterized by an increase of hydrostatic pressure in the pulmonary vascular bed. While secondary pulmonary hypertension predominantly results from acute or chronic left ventricular failure, characteristic gene defects or predisposing risk factors lead to various forms of primary pulmonary hypertension. Despite its diverse pathogenesis, pulmonary hypertension exhibits a uniform cellular pathophysiology in the pulmonary microcirculation.    The dysfunction of lung vascular endothelial cells, which are the front line in response to hemodynamic changes in the pulmonary circulation, is the pathophysiological driving force of pulmonary hypertension. Endothelial dysfunction is characterized by a reduced production of vasodilative, anti-proliferative mediators and an increased release of vasoconstrictive, proliferative factors. This apparent imbalance not only enhances pulmonary vasoconstriction, but supports pathologic remodeling processes in the vascular intima and media. In addition, the pulmonary endothelium recruits platelets and leukocytes, thus, contributing to further release of vasoconstrictive and proliferative mediators and characteristic thrombus formation. These endothelium-derived pathomechanisms amplify each other, further enhance pulmonary vascular resistance, and finally result in fixation of the hypertensive state.    Hence, pulmonary hypertension not only describes an alteration of lung hemodynamics, but comprises a complex set of pathophysiological events in both lung parenchymal cells and circulating blood cells. For development of new therapeutical strategies, the multifactorial character of the disease should be considered.