[The "sacrificial electrode" : A safe option for the management of pacemaker infections in pacemaker-dependent patients]. / Die "Opferelektrode" : Eine sichere Option zum Management von Schrittmacherinfektionen bei schrittmacherpflichtigen Patienten.

As the number of cardiac implantable electronic devices (CIEDs) increases, so does the need to revise such systems. Pacemaker-dependent patients with a CIED infection are particulary challenging for the attending physician. Here, the CIED cannot simply be removed without replacement. Gold standard therapy is a sufficient, prolonged antibiosis, the complete removal of the CIED, and the installation of a temporary pacemaker system - usually by means of a transvenous probe or epimyocardial probe via thoracotomy. The disadvantages of these therapies are the insecure positioning of the unfixed transvenous or the invasiveness of the epimyocardial probes. Alternatively, we have since 2015 established a concept with the so-called "sacrificial" electrode. For this purpose - during the explantation of the infected CIED - a conventional, transvenous screw electrode is anchored via the subclavian vein in the right ventricle and is then connected cutaneously to an aggregate. If the anti-infective therapy is successful, a new CIED is implanted whenever possible over the contralateral side in the usual way. Stimulation via the sacrificial electrode can be stopped and the probe removed. This method is technically easy to perform and offers great advantages: no dislocation of the probe and maintained patient mobility.

German Registry for Acute Aortic Dissection Type A: Structure, Results, and Future Perspectives.

The German Registry for Acute Aortic Dissection Type A (GERAADA) as an international registry for acute aortic dissection type A (AADA) offers a unique opportunity to answer questions regarding acute dissections that cannot be answered by single institution's database alone. GERAADA was started in 2006 by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and has collected more than 3,300 AADA patients' data from 56 centers in Germany, Austria, and Switzerland up to now. In the second generated validated dataset comprising the years from 2006 to 2010, 2,137 patients were surgically treated for AADA with an overall 30-day mortality of 16.9%, and a new postoperative neurologic dysfunction of 9.5%. Risk factors for neurologic dysfunction were malperfusion syndromes, dissections of the supra-aortic vessels, and longer operating time. Neuroprotective drugs had no influence on stroke rates. Hypothermic circulatory arrest and antegrade selective cerebral perfusion (ACP) led to similar results if arrest times were less than 30 minutes while ACP for longer arrest periods is advisable. Septuagenarians had an early mortality rate (15.8%) similar to the whole cohort's, but the mortality rate in octogenarians (34.9%) was much higher. GERAADA with its validated 2,137 patient files (2006-2010) is the largest database on AADA worldwide and continues to collect data. Structured follow-up of more than 5 years will be available in the future.

Endovascular treatment of symptomatic true-lumen collapse of the downstream aorta after open surgery for acute aortic dissection type A.

AIM: The aim of the present study was to evaluate the outcome of endovascular treatment of true-lumen collapse (TLC) of the downstream aorta after open surgery for acute aortic dissection type A (AADA). METHODS: Retrospective, observational study with follow-up of 16 ± 7.6 months. From April 2010 to January 2012, 89 AADA-patients underwent aortic surgery. Out of these, computed tomography revealed a TLC of the downstream aorta in 13 patients (14.6%). They all received additional thoracic endovascular aortic repair (TEVAR) in consequence of malperfusion syndromes. RESULTS: In all 13 TLC-patients, dissection after AADA-surgery extended from the aortic arch to the abdominal aorta and malperfusion syndromes occurred. Remodeling of the true-lumen was achieved by TEVAR with complemental stent disposal in abdominal and iliac arteries in all cases. One patient died on the third postoperative day due to intracerebral hemorrhage. Another patient, who presented under severe cardiogenic shock died despite AADA-surgery and TEVAR-treatment. Thirty-day mortality was 15.4% in TLC-patients (N = 2/13). In the follow-up period, 3 patients required additional aortic stents after the emergency TEVAR procedures. After 20 weeks, a third patient died secondary to malperfusion due to false-lumen recanalization. Therefore, late mortality was 23.1%. CONCLUSION: After proximal aortic repair for AADA, early postoperative computed tomography should be demanded in all patients to exclude a TLC of the descending aorta. Mortality is still substantial in these patients despite instant TEVAR application. Thus, in case of TLC and malperfusion syndrome of the downstream aorta, TEVAR should be performed early to alleviate or even prevent ischemic injury.

Acute aortic dissection type A.

BACKGROUND: Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges. METHODS: Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described. RESULTS: Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options. CONCLUSION: AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.

[German Registry for Acute Aortic Dissection Type A (GERAADA): initial results]. / Deutsches Register für akute Aortendissektion Typ A (GERAADA): Erste Ergebnisse.

BACKGROUND: The working group "Aortic Surgery and Interventional Vascular Surgery" of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) set up the German registry for acute aortic dissection type A (GERAADA) in July 2006. This web-based database was developed to record data of patients who had undergone surgery for aortic dissection type A (AADA). The aim of GERAADA is to learn from analyzing the data of AADA patients how to improve the perioperative management and surgical treatment of patients with AADA and to identify possible parameters affecting patient risk and outcome. PATIENTS AND METHODS: Between July 2006 and June 2009 (2010), 1558 (2137) patients with AADA were enrolled in the multi-center, prospective GERAADA database by 50 cardiac surgery centers in German-speaking countries in Europe. Data on patients' preoperative and intraoperative status, postoperative complications, midterm results and circumstances of death were recorded. Data were analyzed to identify risk factors influencing the outcome of these patients. The Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI) in Mainz performed the statistical analyses. RESULTS: Analyses from GERAADA reveal a thirty-day mortality of 17% in 2137 AADA patients. Only short interventions in aortic arch surgery are safe during hypothermic circulatory arrest even without selective cerebral perfusion. If circulatory arrest times of over 30 min. are anticipated, antegrade cerebral perfusion is strongly recommended during the entire arch intervention using cardiopulmonary bypass. Surgical strategy in terms of isolated ascending aortic replacement versus ascending aortic replacement combined with aortic arch repair had no statistical relevant influence on 30-day mortality. AADA surgical results in elderly patients are more encouraging than those treated without surgery. Surgery is even feasible in octogenarians with a 35% mortality rate. CONCLUSION: The aim of this registry is to optimize AADA patients' medical care, thereby reducing their morbidity and mortality. AADA treatment should always involve open surgery. Initial analyses from GERAADA provide clinically relevant insights concerning patients with AADA, and may enable therapeutic recommendations for improving perioperative and surgical management. Our latest study detected significant influencing risk factors for the outcome of AADA patients and may contribute to a consensus in setting guidelines for standard medical treatment. PERSPECTIVE: A European Registry of Aortic Diseases ("EuRADa") is being established this year under the leadership of the "Vascular Domain" of the European Association for Cardio-Thoracic Surgery (EACTS). This database will collect parameters on all aortic diseases, dissection types A and B, aneurysms, perforating ulcer (PAU), intramural wall hematoma (IMH), traumatic aortic ruptures, and all potential treatment strategies (medical treatment, open surgical and endovascular).

Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic replacement and endovascular repair.

BACKGROUND: The aim of our study was to analyze the neurophysiological monitoring method with regard to its potential problems during thoracic and thoracoabdominal aortic open or endovascular repair. Furthermore, preventive strategies to the main pitfalls with this method were developed. METHODS: Between 11/2000 and 05/2007 in 97 cases open surgery or endovascular stentgraft-implantation was performed on the thoracic or thoracoabdominal aorta. Intraoperatively, neurophysiologic motor- and somatosensory-evoked potentials were monitored. RESULTS: Our cases were divided into four groups: event-free patients with normal potentials (A, 63 cases), with correlation of modified evoked potentials and neurological outcome (B, 14 cases), false-positive or false-negative results (C, 4 cases), and medication interaction or technical issues (D, 16 cases). We observed a sensitivity of 93 % and a specificity of 96 % for the neurophysiological monitoring. CONCLUSIONS: Monitoring spinal cord function during surgical and endovascular interventions on the thoracic and thoracoabdominal aorta is necessary. It can be made more effective by precisely analyzing the interference factors of the neurophysiological monitoring method itself. Successful strategies of immediate troubleshooting could be identified.

German registry for acute aortic dissection type A (GERAADA)--lessons learned from the registry.

A German registry for acute aortic dissection type A (GERAADA) was initiated by the Working Group for Aortic Surgery and Interventional Vascular Surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in July 2006. This web-based database was developed to record the data of patients who had undergone surgery for aortic dissection type A. From analyzing the data, we aim to learn how to improve surgical treatment and to identify parameters affecting patient outcome. In the beginning, 33 cardiac centers participated via online access to the registry on the GSTCVS' homepage. Since then, 43 centers in Germany, Switzerland and Austria have begun entering data on the pre- and intraoperative status of their patients, postoperative complications, mid-term results and circumstances of death. We have succeeded in interpreting the initial results and trends from the registry now available to all of the participating centers, which benefit from this shared pool of analyzed data by optimizing their therapy regimes and comparing their success with that in the other centers.

Reevaluation of two techniques of harvesting the skeletonized internal mammary artery.

BACKGROUND: Selective skeletonization of the internal mammary artery (IMA) without adjacent vasculo-muscular structures reduces trauma to the chest wall, results in elongated grafts, makes ideal graft positioning possible, and eliminates the need to implant a dissected or hypoplastic graft with direct visual control of the vessel. We compared two techniques of skeletonizing the IMA in a prospective randomized trial. METHODS: 51 IMAs were randomly harvested and divided into two groups according to the technique of skeletonization. In group I (n = 31), IMAs were harvested in a skeletonized fashion with the Harmonic Ultrasonic scalpel, and in group II (n = 20) using scissors and hemostatic clips. We compared arterial wall histology, harvesting time, spasm frequency, and the use of hemostatic clips between the two groups. RESULTS: There were no significant morphological differences in the arterial wall in the two groups. Use of an ultrasonically-activated scalpel reduced the IMA's harvesting time (p < 0.001), the frequency of spasm (p = 0.01), and the use of hemostatic clips (p < 0.001). CONCLUSIONS: Ultrasonic harvesting of a skeletonized IMA is a non-traumatic preparatory technique that reduces the costs of surgical clips and that can be performed safely and quickly.