Immunosuppressive Agents and Thoracic Aortic Aneurysm: Real Correlation or Mere Coincidence?

BACKGROUND: Atherosclerosis, hypertension, age, and fibrillopathies are well-known risk factors for the development of aortic aneurysm. We discovered that a significant proportion of our patients were previously on chemotherapy treatment or long-term treatment with cytostatic agents or immunosuppressive drugs. Thus, we examined this phenomenon. METHODS: A total of 224 patients with thoracic aorta aneurysm were retrospectively analyzed after aortic surgery from 2006 to 2016. Seventy-three patients received aortic wrapping and 151 patients underwent aortic replacement of which 89 had a valve-carrying conduit and 62 a supracoronary ascending replacement. Aortic morphology was assessed by means of compute tomography scan before and after surgery. Demographic data, risk profile, and postoperative complications were collected. Short- and long-term survival analysis was performed. Statistical analysis was performed with SPSS 19.0. RESULTS: Eighty-eight of 224 patients undergoing aortic surgery because of aortic aneurysm had previously or currently been treated with immunosuppressive agents. Dilatation of the ascending aorta was more pronounced in patients without such therapy. Demographic profile, intraoperative, as well as short- and long-term postoperative results did not differ significantly between both groups. CONCLUSION: The potential effect of immunosuppressant and cytostatic therapies on the development of an aortic aneurysm needs further study. Because of the astoundingly high proportion of these patients being found in an unselected aortic aneurysm cohort with immunosuppressive therapy in the past should be monitored for potential development of aortic aneurysm. If it occurs and requires treatment these patients can fortunately be operated upon with the same short- and long-term outcome than patients without such previous therapy.

Wrapping in Ascending Aortic Aneurysms as an Alternative for Replacement: Is It Beneficial?

BACKGROUND: Prosthetic replacement of aneurysms of the ascending aorta is the gold standard in terms of long-term stability. Wrapping seems to be a less invasive procedure. It has not yet been shown if it is as safe in terms of long-term outcome. METHODS: We present a single-center analysis of our experience over 13 years. We retrospectively analyzed data from patients who received either aortic prosthetic wrapping (AW) or aortic prosthetic replacement (AR) with or without aortic valve replacement and assessed them through phone calls. We used propensity score matching to adjust the baseline of the groups. RESULTS: Before propensity matching, 144 patients received AW and 91 patients underwent AR. Mean age was 64 ± 11.8 years. After propensity score matching and adjusting for significant differences in age, gender, body mass index, logistic EuroSCORE I, and left ventricular function, 69 patients in each group remained for further analysis. Rate of early reoperation due to tamponade, inhospital mortality, and survival rates did not differ. In both groups, the surgically treated aortic segment did not show enlargement, whereas the nontreated aortic arch showed comparable aneurysmatical progression. CONCLUSIONS: AW is safe and feasible and can be used in elderly or frail patients in order to avoid an AR. Progression of the remaining native aortic segments occurs, thus requiring strict life-long follow-up to ensure an elective and thus safe approach for appropriate consecutive surgical measures, if required.

Clinical Short-Term Outcome and Hemodynamic Comparison of Six Contemporary Bovine Aortic Valve Prostheses.

BACKGROUND: Conventional stented valves (CV) remain gold standard for aortic valve disease. Bovine prostheses have been improved and rapid deployment valves (RDV) have arrived in the recent decade. We compare clinical and hemodynamic short-term outcome of six bovine valves. METHODS: We retrospectively evaluated 829 consecutive patients (all-comers) receiving bovine aortic valve replacement (AVR). Four CV from different manufacturers (Mitroflow, Crown, Perimount, Trifecta) and two RDV (Perceval, Intuity) were compared in terms of pre-, intra-, and postprocedural data. A risk model for mortality was created. RESULTS: All valves reduced gradients. From 23 mm, all CV showed acceptable gradients. Twenty-one millimeter Mitroflow/Perceval and 19 mm Crown showed above-average gradients. As baseline data differed, we performed propensity matching between aggregated isolated CV and RDV groups. Cardiopulmonary bypass (CPB), clamp, and surgery times were shorter with RDV (87.4 ± 34.0 min vs 111.0 ± 34.2, 54.3 ± 21.1 vs 74.9 ± 20.4, 155.2 ± 42.9 vs 178.0 ± 46.8, p < 0.001). New pacemaker rate (10.1 vs 1.3%, p = 0.016) and the tendency toward neurologic events (8.9 vs 2.5%, p = 0.086) were higher using RDV, induced mainly by the Perceval. Early mortality was equal (2.5 vs 1.3%, p = 0.560). Revision for bleeding, dialysis, blood products, length-of-stay, gradients, and regurgitation was also equal. Risk analysis showed that low valve size, low ejection fraction, endocarditis, administration of red cells, and prolonged CPB time were predictors of elevated mortality. CONCLUSION: Isolated bovine AVR has low mortality. Valves ≥ 23 mm show comparable gradients while the valve model matters < 23 mm. RDV should be used with care. Procedure-related times are shorter than those of CV but pacemaker implantation and neurologic events are more frequent (Perceval). Early mortality is low and valve performance comparable to CV.

The influence of Erythropoietin on platelet activation, thrombin generation and FVII/active FVII in patients with AMI.

BACKGROUND: Erythropoietin (Epo) has been shown to improve myocardial function in models of experimental myocardial infarction, but has also been associated with a rise in thromboembolic events. Thus, the aim of this study was to investigate the influence of Epo on platelet activation and coagulation in patients with acute myocardial infarction (AMI). METHODS: The study was designed as a substudy of the randomised, double-blind, placebo controlled REVIVAL-3 (REgeneration of VItal Myocardium in ST-Segment EleVation MyocardiAL Infarction by Erythropoietin) study that investigated the effects of recombinant human Epo in AMI. Serial venous blood samples were collected before and after study medication. Circulating prothrombin fragment F1 + 2, FVII, active FVII, beta thromboglobulin (TG) and P-Selectin were measured before and 60 hours after randomization by immunoassay (n = 94). In a randomly selected subgroup platelet aggregation was measured using whole blood aggregometry (Multiplate Analyzer, n = 45). RESULTS: After 5 days an increase in FVII was observed after Epo as compared to placebo (P = 0.02), yet active FVII and prothrombin fragment F1 + 2 remained unchanged. Moreover, no statistically significant differences in circulating TG or P-selectin were observed between the groups. As an expected response to peri-interventional therapy with clopidogrel and aspirin, platelet aggregation after stimulation with ADP, TRAP, ASPI or collagen decreased 12 hours and 2 days after PCI. However, no difference between the Epo and the placebo group was observed. CONCLUSION: After treatment with Epo in patients with AMI a slight increase in circulating FVII after Epo was not associated with an increase in active FVII, prothrombin fragment F1 + 2, TG or P-selectin. Moreover, platelet aggregation was not altered after treatment with Epo as compared to placebo. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01761435.

The Impact of Gender and Age in Obese Patients on Sternal Instability and Deep-Sternal-Wound-Healing Disorders after Median Sternotomy.

OBJECTIVE: The aim of this study was to investigate the relationship between age and sex in regard to the development of deep sternal wound infections and sternal instability following median sternotomy. METHODS: A propensity-score-matching analysis was conducted on 4505 patients who underwent cardiac surgery between 2009 and 2021, all of whom had a BMI of ≥30 kg/m2. A total of 1297 matched pairs were determined in the sex group, and 1449 matched pairs we determined in the age group. The distributions of sex, age, diabetes mellitus, delirium, unstable sterna, wire refixation, wire removal, superficial vacuum-assisted wound closure, deep vacuum-assisted wound closure, clamp time, bypass time, logistic EuroSCORE, and BMI were determined. RESULTS: The 30-day in-hospital mortality was found to be similar in the older and younger groups (8.149% vs. 8.35%, p = 0.947), and diabetes mellitus was also equally distributed in both groups. However, postoperative delirium occurred significantly more often in the older group (29.81% vs. 17.46%, p < 0.001), and there was a significantly higher incidence in men compared with women (16.96% vs. 26.91%, p < 0.001). There were no differences found in the incidence of sternum instability, fractured sternum, superficial vacuum-assisted wound closure, and deep vacuum-assisted wound closure between the age and sex groups. CONCLUSIONS: In conclusion, this study found that sternal instability and deep-wound-healing problems occur with equal frequency in older and younger patients and in men and women following median sternotomy. However, the likelihood of postoperative delirium is significantly higher in older patients and in men. These findings suggest that a higher level of monitoring and care may be required for these high-risk patient groups to reduce the incidence of postoperative delirium and improve outcomes following median sternotomy.

How Can We Best Measure Frailty in Cardiosurgical Patients?

BACKGROUND: Frailty is gaining importance in cardiothoracic surgery and is a risk factor for adverse outcomes and mortality. Various frailty scores have since been developed, but there is no consensus which to use for cardiac surgery. METHODS: In an all-comer prospective study of patients presenting for cardiac surgery, we assessed frailty and analyzed complication rates in hospital and 1-year mortality, as well as laboratory markers before and after surgery. RESULTS: 246 included patients were analyzed. A total of 16 patients (6.5%) were frail, and 130 patients (52.85%) were pre-frail, summarized in the frail group (FRAIL) and compared to the non-frail patients (NON-FRAIL). The mean age was 66.5 ± 9.05 years, 21.14% female. The in-hospital mortality rate was 4.88% and the 1-year mortality rate was 6.1%. FRAIL patients stayed longer in hospital (FRAIL 15.53 ± 8.5 days vs. NON-FRAIL 13.71 ± 8.94 days, p = 0.004) and in intensive/intermediate care units (ITS/IMC) (FRAIL 5.4 ± 4.33 days vs. NON-FRAIL 4.86 ± 4.78 days, p = 0.014). The 6 min walk (6 MW) (317.92 ± 94.17 m vs. 387.08 ± 93.43 m, p = 0.006), mini mental status (MMS) (25.72 ± 4.36 vs. 27.71 ± 1.9, p = 0.048) and clinical frail scale (3.65 ± 1.32 vs. 2.82 ± 0.86, p = 0.005) scores differed between patients who died within the first year after surgery compared to those who survived this period. In-hospital stay correlated with timed up-and-go (TUG) (TAU: 0.094, p = 0.037), Barthel index (TAU-0.114, p = 0.032), hand grip strength (TAU-0.173, p < 0.001), and EuroSCORE II (TAU 0.119, p = 0.008). ICU/IMC stay duration correlated with TUG (TAU 0.186, p < 0.001), 6 MW (TAU-0.149, p = 0.002), and hand grip strength (TAU-0.22, p < 0.001). FRAIL patients had post-operatively altered levels of plasma-redox-biomarkers and fat-soluble micronutrients. CONCLUSIONS: frailty parameters with the highest predictive value as well as ease of use could be added to the EuroSCORE.

Living Longer or Better-Patient's Choice in Cardiac Surgery Is Gender-Dependent-A Multicenter Study.

In view of the increasing age of cardiac surgery patients, questions arise about the expected postoperative quality of life and the hoped-for prolonged life expectancy. Little is known so far about how these, respectively, are weighted by the patients concerned. This study aims to obtain information on the patients' preferences. Between 2015 and 2017, data were analyzed from 1349 consecutive patients undergoing cardiac surgery at seven heart centers in Germany. Baseline data regarding the patient's situation as well as a questionnaire regarding quality of life versus lifespan were taken preoperatively. Patients were divided by age into four groups: below 60, 60-70, 70-80, and above 80 years. As a result, when asked to decide between quality of life and length of life, about 60% of the male patients opted for quality of life, independent of their age. On the other hand, female patients' preference for quality of life increased significantly with age, from 51% in the group below sixty to 76% in the group above eighty years. This finding suggests that female patients adapt their preferences with age, whereas male patients do not. This should impact further the treatment decisions of elderly patients in cardiac surgery within a shared decision-making process.

Tourniquet fixing prior to knot tying reduces forces during aortic valve replacement: experimental results from 18 surgeons.

OBJECTIVES: To increase the safety of aortic valve replacement, we developed the 'Caput medusae' method, where the prosthesis is prefixed with circumferential tourniquets prior to knot tying. We assumed that an even distribution of forces may help reduce tissue damage. To confirm this theoretically, we compared forces between knots and tourniquets. METHODS: The experimental set-up included a device with movable acrylic plates, a mounted valve and a set of sutures. Traction forces were measured with a luggage scale. Two different tourniquets were compared individually and as bundles of 15. Force-path curves were generated. Knotting and tourniquet forces of 18 staff surgeons were then compared. Both modalities were measured 10 times on 2 days, resulting in 40 observations per surgeon, or 360 observations per modality. RESULTS: Polyvinyl chloride tourniquets were stiffer than silicone, expressed by a 1.5- to 1.7-fold higher regression-line slope. Fifteen simultaneous tubes produced force increments 7.9-8.9 times higher than their single counterparts. Overall knotting force was 13.64 ± 5.76 vs tourniquet 1.08 ± 0.48 N. Male surgeons' knotting forces were higher compared to female staff (14.76 ± 6.01 vs 10.73 ± 3.74 N; P < 0.001) while tourniquet forces did not differ (1.09 ± 0.47 vs 1.05 ± 0.49 N; P = 0.459). Dedicated valve surgeons (n = 10) tightened the tourniquets more strongly than inexperienced surgeons (1.20 ± 0.52 vs 0.94 ± 0.37 N; P < 0.001); knotting was similar. Multivariable analysis confirmed only valve experience as a predictor of tourniquet strength (experienced surgeons exerted higher force). CONCLUSIONS: Tourniquets exert less force on the tissue than knots. When distributed over the circumference, they can reduce local tension and avoid potential paravalvular leakage. Complete or partial use of tourniquets may thus be an additional option to enhance surgical safety.

Q-PULS, a new quasi-physiological pulsatile extracorporeal model to simulate heart function.

OBJECTIVES: The invention of new surgical procedures requires testing at different stages including animal models. To facilitate this process, we have developed a computer-controlled extracorporeal circulation system for testing of an explanted porcine heart simulating a variety of physiological parameters. Mitral valve function can be assessed before and after induced valve insufficiency and after valve repair. Accordingly, techniques and instruments can be modified at early stages of prototype development. METHODS: In the diastole, the left atrium is passively filled through the reservoir. The loading pressure of the atrium and flow rates can be widely adjusted. To simulate the systole, a linear motor-driven piston pump promotes volume into the left ventricle and the aorta. An additional circulatory pump compensates for undesired total emptying of the heart chambers. The processor control of the linear pump allows for various settings of flow rate, velocity and even irregular rhythm. Twenty-one isolated porcine hearts were used. The leaflet movement was filmed using a universal serial bus (USB)-probe camera. RESULTS: With 80 mm stroke and 1 m/s speed, a volume of 150 ml can be pumped at a heart rate of up to 73 bpm. Cardiac outputs of up to 10.9 l/min can be achieved. Constant visualization and continuous measurements of the pressure gradients before and after the induction of mitral insufficiency and after repair allowed quantitative verification of repair quality under beating-heart conditions. CONCLUSIONS: This model allows a controllable pulsation, loading and unloading of a porcine heart in a wide range. Thus, the function of the leaflets and repair results can be qualitatively and quantitatively evaluated under quasiphysiological conditions.

Successful Surgical Abdominal Aortic Debranching Preceding Stent Graft Implantation: A Case Report.

Background Acute endovascular aneurysm repair with stent grafts (thoracic endovascular aortic repair [TEVAR]) is safe and feasible. Case Description A 64-year-old female presented with a perforated aortic aneurysm of the thoracic descending aorta. Primary TEVAR resulted in good management of the perforation but a type Ib endoleakage remained postoperatively. To place another stent, abdominal debranching with saphenous vein bypass to the celiac trunk was required. In the same session, another endograft was inserted successfully. Conclusion Abdominal debranching is a safe alternative to open aortic repair in acute thoracic and abdominal aneurysms, instead of waiting for a custom-made device.