Patient-tailored silicone plug for HeartMate 3™ left ventricular assist device explantation.

Patient-tailored silicone plug for HeartMate 3™ left ventricular assist device explantation in two successive males proceeded successfully. Given medical therapeutic advancements, FDA-approved plug systems designed by LVAD manufacturers themselves will be necessary for the near future to provide a safe and simple device explantation alternative that fulfills all regulatory standards.

Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program.

INTRODUCTION: Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. METHODS: A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. RESULTS: Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (n = 38) and ring annuloplasty (n = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (n = 8), redo procedures (n = 2), severe endocarditis (n = 4), or contraindication for MICS such as PAD (n = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. CONCLUSION: Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

Retrograde washout of prepump LVAD thrombosis in a patient on HeartWare™ support.

The success of the left ventricular assist device (LVAD) as a treatment for terminal left-side heart failure is still restrained by some severe complications associated with mechanical circulatory support. Pump thrombus still affects many patients. It is associated with high morbidity and mortality. The therapeutic options include augmentation of anticoagulation and antiplatelet medication, intravenous or catheter-guided thrombolysis, and pump exchange. Heart transplantation would be a desirable option in this population, but unfortunately, it is only theoretical given the increasing number of LVAD implants and decreasing number of organ donors. A retrograde washout maneuver may be a treatment option in prepump thrombosis in selected patients. Therefore, the decision should be made on an individual basis after balancing the risks and benefits of different treatment approaches. In this context, we report a case of retrograde washout of prepump thrombus in a patient who has been on HeartWare™ support for more than 3 years, with a successful bailout strategy.

Recovery of a dilated left ventricle after cessation of cocaine and HVAD™ explantation using a titanium plug.

The ultimate goal in the treatment of end-stage heart failure is the recovery of cardiac function following mechanical assistance of the left ventricle. The HVAD™ pump (HeartWare Inc.) left ventricular assist device (LVAD) can be explanted without resternotomy. This article demonstrates that the use of a custom-made mechanical plug (manufactured by INNOVO Solutions GmbH), which can be inserted into the LVAD's sewing ring, is feasible. This mechanical plug explicitly designed for device explantation is a viable alternative to the current standard of care. This article adopts a less invasive technique to explant the pump. The following case illustrates this technique.

Management of Stroke in Patients with Left Ventricular Assist Devices.

INTRODUCTION: The number of patients with left ventricular assist devices (LVAD) is rapidly growing in industrialized countries. While cerebrovascular events comprise a significant complication, data on stroke etiology, clinical management and functional outcome are scarce. METHODS: Consecutive LVAD patients with ischemic or hemorrhagic stroke receiving treatment at an university stroke center between 2010 and 2018 were included into an institutional registry. Clinical characteristics, causes, management and functional outcome of stroke occurring within this cohort are reported. Acceptable functional outcome was defined as mRS 0-3. RESULTS: N = 30 acute strokes occurred in 20 patients (77% ischemic, 23% hemorrhagic, mean age 57 ± 13 years, 10% female, 8 patients (40%) had more than one event). 87% of all events happened with non-pulsatile devices, on average 9 (IQR 3-22) months after the implantation. All patients used oral anticoagulation with a Vitamin-K antagonist in combination with anti-platelets. The international normalized ratio (INR)-values were outside the therapeutic range in 39% of ischemic strokes and in 57% of hemorrhagic strokes. Ischemic strokes were predominantly of cardioembolic origin (92%) and of mild to moderate clinical severity (median NIHSS 6 (IQR 4-10). None qualified to receive intravenous thrombolysis or intra-arterial endovascular therapy. 61% of IS-patients showed an acceptable functional outcome after three months. 4/7 patients with hemorrhagic stroke received immediate reversal of anticoagulation without any thrombotic complications. CONCLUSION: The majority of LVAD patients with ischemic stroke had an acceptable functional outcome after three months. Future clinical research is warranted to improve therapeutic strategies for acute care and stroke prevention.

Glucocorticoids preserve the t-tubular system in ventricular cardiomyocytes by upregulation of autophagic flux.

A major contributor to contractile dysfunction in heart failure is remodelling and loss of the cardiomyocyte transverse tubular system (t-system), but underlying mechanisms and signalling pathways remain elusive. It has been shown that dexamethasone promotes t-tubule development in stem cell-derived cardiomyocytes and that cardiomyocyte-specific glucocorticoid receptor (GR) knockout (GRKO) leads to heart failure. Here, we studied if the t-system is altered in GRKO hearts and if GR signalling is required for t-system preservation in adult cardiomyocytes. Confocal and 3D STED microscopy of myocardium from cardiomyocyte-specific GRKO mice revealed decreased t-system density and increased distances between ryanodine receptors (RyR) and L-type Ca2+ channels (LTCC). Because t-system remodelling and heart failure are intertwined, we investigated the underlying mechanisms in vitro. Ventricular cardiomyocytes from failing human and healthy adult rat hearts cultured in the absence of glucocorticoids (CTRL) showed distinctively lower t-system density than cells treated with dexamethasone (EC50 1.1 nM) or corticosterone. The GR antagonist mifepristone abrogated the effect of dexamethasone. Dexamethasone improved RyR-LTCC coupling and synchrony of intracellular Ca2+ release, but did not alter expression levels of t-system-associated proteins junctophilin-2 (JPH2), bridging integrator-1 (BIN1) or caveolin-3 (CAV3). Rather, dexamethasone upregulated LC3B and increased autophagic flux. The broad-spectrum protein kinase inhibitor staurosporine prevented dexamethasone-induced upregulation of autophagy and t-system preservation, and autophagy inhibitors bafilomycin A and chloroquine accelerated t-system loss. Conversely, induction of autophagy by rapamycin or amino acid starvation preserved the t-system. These findings suggest that GR signalling and autophagy are critically involved in t-system preservation and remodelling in the heart.

Accuracy and Trending Ability of the Fourth-Generation FloTrac/EV1000 System in Patients With Severe Aortic Valve Stenosis Before and After Surgical Valve Replacement.

OBJECTIVE: Evaluate the accuracy and trending ability of the fourth-generation FloTrac/EV1000 (Edwards Lifesciences, Irvine, CA) system in patients with severe aortic valve stenosis by comparing FloTrac/EV1000-derived cardiac output (CCO-FT) with continuous thermodilution pulmonary artery catheter (CCO-PAC) measurements before and after surgical valve replacement. DESIGN: Prospective clinical study. SETTING: Anesthesia for cardiac surgery, operating room, single-center university hospital. PARTICIPANTS: Twenty-five patients were included. After exclusion, 20 patients undergoing elective aortic valve replacement were analyzed. INTERVENTIONS: After induction of general anesthesia, CCO-FT and CCO-PAC values were recorded every 30 seconds before and after aortic valve replacement with a bioprosthesis under cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: Data were analyzed separately from skin incision to last suture and before and after CPB. Regression analyses, Bland-Altman analyses, and trending analyses (4-quadrant plot, polar plot) were performed. The percentage errors of the FloTrac/EV1000 were 69.7% and 59.3% before and after CPB, respectively. The concordance rates (CRs) and angular CRs of the FloTrac/EV1000 were 50.9% and 57.1%, and 48.7% and 61.9% before and after CPB, respectively. CONCLUSION: This study revealed a low level of agreement and poor trending ability of the FloTrac/EV1000 system compared to continuous thermodilution pulmonary artery catheter in patients with severe aortic stenosis. Although there was a slight improvement after surgical valve replacement and CPB, the results were not within acceptable limits to replace CCO-PAC in this patient population.

DJ1 and microRNA-214 act synergistically to rescue myoblast cells after ischemia/reperfusion injury.

Ischemia/reperfusion injury is a tissue injury occurring post-reperfusion of tissues with pre-existing ischemia. A good blood supply to tissues aids in the survival of ischemic tissue, however, due to prolonged ischemia the levels of ATP decrease and pH declines leading to acidosis. Reduced ATP leads to an increase in the AMP/ATP ratio, causing cessation of intracellular calcium transport, hence calcium overload and cell death. In this study, we demonstrate the synergistic and antagonistic effect of DJ1 and microR-214 (miR-214) in rescuing myoblast C2C12 cells after ischemia/reperfusion in an in vitro model. Both DJ1 and miR-214 were cloned into a hypoxic inducible expression cassette and transfected into the C2C12 cells. We showed that DJ1 and miR-214 have synergistic effects in reducing intracellular lactate dehydrogenase and intracellular transient calcium levels after reoxygenation compared to control cells, in addition to reducing cell death via necrosis. Western blotting revealed a decrease in autophagosome formation in LC3II/I ratio and an increase in AKT expression in cells transfected with DJ1 and miR-214. Using quantitative real-time PCR, we demonstrated that DJ1 and miR-214 significantly reduced the expression of pro-apoptotic factors and autophagy compared to control. The results indicated DJ1 is an endogenous oxidative stress molecule and miR-214 is a potent inhibitor of the sodium calcium exchanger channel. DJ1 had the greatest effect to inhibiting mitochondrial cell death pathways by possibly acting as a modulator of autophagy. Additionally, we have concluded that miR-214 has an inhibitory effect on extrinsic cell death pathways such as necrosis and autophagy.

New Targets for the Prevention of Chronic Rejection after Thoracic Organ Transplantation.

The gold standard for the treatment of terminal heart failure and irreversible lung diseases includes thoracic organ transplantation. The major obstacle for long-term survival after successful transplantation is chronic rejection, an ongoing immunomodulatory disease so far without effective therapy. Therefore, the aim of this review is to elucidate scientific efforts targeting different new mechanisms of cardiac allograft vasculopathy (CAV) and chronic lung allograft dysfunction (CLAD). For this purpose, we performed a systematic review of the literature to assess recent strategies in transplant immunology research. We searched MEDLINE from 2015 up to date for articles addressing the following keywords: CAV, transplant vasculopathy, transplant arteriosclerosis, CLAD, bronchiolitis obliterans transplant, and obliterative bronchiolitis transplant. All articles including experimental models in the field of transplant immunology addressing new aspects for the prevention of chronic rejection after heart and lung transplantation were included in this review. The prevention of chronic rejection would clearly improve the survival of patients after heart and lung transplantation. Interesting targets were addressed in recent research, but further research is necessary to effectively treat this life-threatening disease in transplant recipients.

Clopidogrel significantly lowers the development of atherosclerosis in ApoE-deficient mice in vivo.

The anti-platelet drug clopidogrel has been shown to modulate adhesion molecule and cytokine expression, both playing an important role in the pathogenesis of atherosclerosis. The aim of this study was to investigate the impact of clopidogrel on the development and progression of atherosclerosis. ApoE(-/-) mice fed an atherogenic diet (cholesterol: 1 %) for 6 months received a daily dose of clopidogrel (1 mg/kg) by i.p. injection. Anti-platelet treatment was started immediately in one experimental group, and in another group clopidogrel was started 2 month after beginning of the atherogenic diet. Blood was analysed at days 30, 60 and 120 to monitor the lipid profile. After 6 months the aortic arch and brachiocephalic artery were analysed by Sudan IV staining for plaque size and by morphometry for luminal occlusion. Serum levels of various adhesion molecules were investigated by ELISA and the cellular infiltrate was analysed by immunofluorescence. After daily treatment with 1 mg/kg clopidogrel mice showed a significant reduction of atherosclerotic lesions in the thoracic aorta and within cross sections of the aortic arch [plaque formation 55.2 % (clopidogrel/start) vs. 76.5 % (untreated control) n = 8, P < 0.05]. After treatment with clopidogrel P-/E-selectin levels and cytokine levels of MCP-1 and PDGFß were significantly reduced as compared to controls. The cellular infiltrate showed significantly reduced macrophage and T-cell infiltration in clopidogrel-treated animals. These results show that clopidogrel can effectively delay the development and progression of 'de-novo' atherosclerosis. However, once atherosclerotic lesions were already present, anti-platelet treatment alone did not result in reverse remodelling of these lesions.

Amphetamine abuse as a rare cause of recurrent LVAD pump thrombosis.

We report a patient with recurrent left ventricular assist device (LVAD) thrombosis due to amphetamine addiction. The management of this complication is reviewed.

Single centre experience with prolonged waiting time on transplant list with "high-urgency" status.

INTRODUCTION: The waiting list for heart transplantation (HTx) in Eurotransplant area has grown to a record size of nearly 1,300 patients, whereas only around 600 hearts were transplanted last year. The prolonged time for patients awaiting HTx on the high-urgency (HU) status leads mostly to serious medical complications. OBJECTIVE: The aim of this study was to study the trend of changes in the frequency of ventricular assist device (VAD) implantation in patients on the HU status. METHODS: A total of 22 adult patients awaiting transplantation on the HU status at our hospital between January 2011 and December 2011 were analyzed, assessing risk profile, blood group, and complication rates in terms of VAD implantation or death. Results were compared with 16 consecutive patients who were on transplant list with the HU status between January 2010 and December 2010 at our institution. RESULTS: Mean age was 49.5 ± 12.1 (2010 group) years and 51.4 ± 10.7 years (2011 group; p = 0.62). Mean logEuroSCORES raised not significantly from 9.1 ± 6.3% (2010 group) to 10.7 ± 14.7% (2011 group; p = 0.68). Six patients died on the HU status and seven patients had to be supplied with a VAD in 2011. In comparison with the preceding year, only two patients died in 2010 and none of our patients on the HU status had to be provided with mechanical circulatory support. CONCLUSION: Because of the prolonged waiting time on the HU list, the earlier-mentioned data demonstrate a negative trend in transplant medicine. Especially when taking into consideration that five of seven patients who needed a VAD implantation during the HU waiting period had blood group O. Furthermore, the data derived from Eurotransplant show that the waiting period for patients with blood group O was considerably longer when compared with patients of the same average body height and weight but with other blood groups.

"How did you stay together so long?" Relationship longevity, a cross-generational qualitative study.

This global qualitative study adopted a cross-generational approach considering key factors contributing to relationship longevity. Relatively few studies consider factors leading to relationship longevity as articulated by couples themselves, and there is a paucity of research considering young couples' questions regarding relationship longevity. This study has two sample groups. In sample one (n = 137) we asked individuals in relationship of 3-15 years questions they would ask couples in marriages of 40+ years. We then asked our second sample of coupled individuals married 40+ years (n = 180) these questions. The primary question from the younger couples to couples in long-term marriages regarded their "secret" to relationship longevity. This study focuses on this one question and coupled individuals' self-articulation of their "secrets" to relationship longevity. The top seven were (1) commitment, (2) altruism, (3) shared values, (4) good communication, (5) compromise: give and take, (6) love, and (7) never give up. The clinical implications for couple therapists are discussed.

Double valve replacement in a case of Hedinger syndrome.

Hedinger Syndrome or carcinoid heart disease is a rare cardiac complication of neuroendocrine tumors (NET) affecting the tricuspid and pulmonary valves. Following is a case description of a patient undergoing treatment for a neuroendocrine tumor with liver metastasis, referred with symptomatic tricuspid valve regurgitation and pulmonary valve stenosis for surgical valve replacement. Planned surgical valve replacement was successfully performed before the onset of severe right ventricular failure or pulmonary hypertension in this case of carcinoid heart disease. An interdisciplinary approach and regular follow up is recommended in such cases.

Intraoperative visualization of a deformed left main stent during surgical aortic valve replacement.

BACKGROUND: While coronary artery bypass grafting is typically considered first choice for the treatment of left main stenosis, there is a trend towards left main stenting due to a steadily aging population in western countries with a high operative risk and patients with single vessel coronary artery disease affecting the left main artery. Nevertheless left main stenting remains controversial, especially in patients with concomitant indications for open-heart surgery. CASE PRESENTATION: We want to present a case of a 78-year-old male patient with high-grade aortic stenosis who underwent surgical aortic valve replacement at our heart center due to anatomical contraindications for transcatheter aortic valve replacement. Stenting of the left main coronary artery was performed three years earlier due to single vessel coronary artery disease while moderate aortic valve stenosis was under surveillance at the time of the intervention. Intraoperatively we found the stent to be deformed inside the left main coronary artery, covering nearly 25% of the coronary ostium. So injection of cardioplegia directly into this ostium, as we perform normally, was not possible without further damaging the stent and/or the opening of the ostium. We had to insert cardioplegia via the retrograde way, so via the coronary sinus. CONCLUSION: While left main stenting can be reasonable for a specific population of patients, it should be used cautiously in patients with concomitant indications for open-heart surgery in the near future and a low perioperative risk profile.

Corrigendum: long-term cultivation of human atrial myocardium.

[This corrects the article DOI: 10.3389/fphys.2022.839139.].

Left Atrial Appendage Occlusion on a Beating Heart during Minimally Invasive Valve Surgery Using an Aortic Endoclamp: A Case Report.

Concomitant LAA occlusion has been shown to be an effective and safe treatment for patients with atrial fibrillation during cardiac surgery to prevent embolic stroke. Minimally invasive procedures are challenging due to restricted access to and visibility of the surgical site. Also, aortic endoclamping has been developed as an alternative surgical approach to exoclamping. The aim of this article is to demonstrate the method of beating heart LAA occlusion with the Atriclip® (AtriCure, Mason, OH, USA) device during minimally invasive mitral valve surgery while using the endoclamping alternative for aortic cross-clamping.

A Dual-Pathogen Mitral Valve Endocarditis Caused by Coxiella burnetii and Streptococcus gordonii-Which Came First?

Infective endocarditis (IE) is still a life-threatening disease with high morbidity and mortality. While usually caused by a single bacterium, poly-microbial infective endocarditis (IE) is rare. Here, we report a (blood-culture-negative) dual pathogen mitral valve IE caused by Coxiella burnetii and Streptococcus gordonii: A 53-year-old woman was presented to an internal medicine department with abdominal pain for further evaluation. Within the diagnostic work up, transthoracic echocardiography (TTE) revealed an irregularly shaped echogenic mass (5 × 13 mm) adherent to the edge of the posterior mitral valve leaflet and protruding into the left atrium. As infected endocarditis was suspected, blood cultures were initially obtained, but they remained negative. Chronic Q fever infection was diagnosed using serologic testing. After the occurrence of cerebral thromboembolic events, the patient was admitted for mitral valve surgery. Intraoperatively, a massively destructed mitral valve with adhering vegetations was noted. Examination of the mitral valve by broad-range bacterial polymerase chain reaction (PCR) and amplicon sequencing confirmed Coxiella burnetii infection and yielded Streptococcus gordonii as the second pathogen. Based on the detailed diagnosis, appropriate antibiotic therapy of both pathogens was initiated, and the patient could be discharged uneventfully on the 11th postoperative day after a successful minimal-invasive mitral valve replacement.

Prolapsing Left Atrial Mass Presenting as Syncope.

Background Myxomas are the most common primary cardiac tumor in adults and are most commonly found within the left atrium. These are usually asymptomatic, detected incidentally, or present gradually with symptoms typical of heart failure. Case Description This case report is a description of a case of syncope caused by a large left atrial myxoma. Conclusion Atrial myxomas may present with transient loss of consciousness, especially when they prolapse through the atrioventricular valves or when embolization occurs. Non-invasive diagnostic tools (e.g., echocardiogram, cardiac computed tomography) should be considered to thoroughly evaluate cardiogenic causes of syncope.