Treatment of cardiac implantable electronic device endocarditis in pacemaker-dependent patients utilizing a percutaneous aspiration system.

With the increasing use of cardiac implantable electronic devices, the number of patients with cardiac implantable electronic device-related endocarditis is also rising. The treatment of this type of endocarditis is a challenging clinical task, in particular if device removal is required in patients who are pacemaker dependent. This video tutorial describes a treatment strategy for cardiac implantable electronic device-related endocarditis involving the tricuspid valve in pacemaker-dependent patients. The proposed treatment strategy consists of implanting an epicardial pacemaker via a minimally invasive subxiphoid approach, percutaneous aspiration of tricuspid valve vegetations and complete transvenous explantation of the infected cardiac implantable electronic device system using advanced lead extraction tools.

Successful treatment of cardiogenic shock due to Takotsubo syndrome with implantation of a temporary microaxial left ventricular assist device in transaxillary approach.

OBJECTIVES: Cardiogenic shock (CS) can occur in patients with Takotsubo syndrome (TTS). As TTS has received increasing attention and has been more closely researched, several aspects of the pathogenesis have been identified, particularly that an excessive release of catecholamines plays an important role. Nevertheless, evidence on specific therapy concepts is still lacking. As a result, TTS with severe hemodynamic instability and low cardiac output creates unique challenges, and mechanical circulatory support is needed with as few inotropic drugs as possible. METHODS: We present a 77-year-old female patient who underwent minimally invasive surgical mitral valve replacement. After an uneventful course, the patient developed acute heart failure eleven days after surgery. Transthoracic echocardiography (TTE) revealed a new onset of TTS. The patient needed left ventricular venting and full haemodynamic flow. We successfully implanted a microaxial left ventricular assist device (Impella 5.5) using the transaxillary approach. The haemodynamic situation stabilised immediately. The patient was weaned and the Impella 5.5 was explanted after five days. CONCLUSION: We present the first-in-man implantation of a transaxillary Impella 5.5 in a patient with TTS. The patient benefitted from Impella 5.5 therapy with full haemodynamic support and venting of the left ventricle.

Epicardial left ventricular leads via minimally invasive technique: a role of steroid eluting leads.

BACKGROUND: We retrospectively assessed two types of sutureless screw-in left ventricular (LV) leads (steroid eluting vs. non-steroid eluting) in cardiac resynchronization therapy (CRT) implantation with regards to their electrical performance. METHODS: Between March 2008 and May 2014 an epicardial LV lead was implanted in 32 patients after failed transvenous LV lead placement using a left-sided lateral minithoracotomy or video-assisted thoracoscopy (mean age 64 ± 9 years). Patients were divided into two groups according to the type of implanted lead. Steroid eluting (SE) group: 21 patients (Myodex™ 1084 T; St. Jude Medical) and non-steroid eluting (NSE) group: 11 patients (MyoPore® 511,212; Greatbatch Medical). RESULTS: All epicardial leads could be placed successfully, without any intraoperative complications or mortality. With regard to the implanted lead following results were observed: sensing (mV): SE 8.8 ± 6.1 vs. NSE 10.1 ± 5.3 (p = 0.380); pacing threshold (V@0.5 ms): SE 1.0 ± 0.5 vs. NSE 0.9 ± 0.5 (p = 0.668); impedance (ohms): SE 687 ± 236 vs. NSE 790 ± 331 (p = 0.162). At the follow-up (2.6 ± 1.9 years) the following results were seen: sensing (mV): SE 8.7 ± 5.0 vs. NSE 11.2 ± 6.6 (p = 0.241), pacing threshold (V@0.5 ms): SE 1.4 ± 0.5 vs. NSE 1.0 ± 0.3 (p = 0.035), impedance (ohms): SE 381 ± 95 vs. NSE 434 ± 88 (p = 0.129). CONCLUSIONS: Based on the results no strong differences have been found between the both types of epicardial LV leads (steroid eluting vs. non-steroid eluting) in CRT implantation in short- and midterm.

Lead extraction technology and techniques: a surgeon's perspective.

Transvenous lead extraction procedures have gained substantial clinical importance during the past decade. With current tools and techniques, high success rates in combination with low complication rates can be achieved by experienced centres. Even in experienced hands, life-threatening complications can occur, and every physician performing such procedures must be prepared for this scenario. This necessitates immediately available access to extracorporeal circulation, and if the operator is a cardiologist, cardiac surgical standby is mandatory.

Tricuspid valve interventions: surgical techniques and outcomes.

The surgical treatment of isolated and concomitant tricuspid valve disease, especially functional tricuspid valve regurgitation, remains controversial. Functional tricuspid regurgitation may be classified into defined stages, and surgical treatment may be tailored to the extent of the disease. This report describes current surgical techniques for tricuspid valve surgery and their results.

Pancreatic stone protein predicts postoperative infection in cardiac surgery patients irrespective of cardiopulmonary bypass or surgical technique.

INTRODUCTION: We investigated the role of pancreatic stone protein (PSP) in predicting the occurrence of infection in the postoperative course of cardiac surgery patients. Several biomarkers indicating the presence of inflammation and infection are available in the clinical routine; yet, their utility in the postoperative course of patients following cardiac surgery remains uncertain. Moreover, cardiopulmonary bypass, also referred to as "on-pump surgery", increases the susceptibility to an exaggerated inflammatory state. However, the impact of such extracorporeal circulation on circulating PSP levels remains poorly understood. METHODS: In a prospective cohort of unselected patients undergoing cardiac surgery, we set out to elucidate the diagnostic accuracy of serum PSP levels as opposed to canonical biomarkers (CRP, WBC) of inflammation to discriminate between the presence of infection and surgical trauma,. In addition, we investigated whether the biomarkers were influenced by the surgical technique employed, i.e. on-pump vs. off-pump and minimally invasive surgery vs. sternotomy. Levels of circulating PSP and routine inflammatory biomarkers (CRP, WBC) were measured in samples taken from 120 patients at baseline as well as at postoperative day 1-3. RESULTS: Univariate analysis showed that among the biomarkers investigated, only PSP levels had discriminatory power to differentiate infection from surgical trauma in the postoperative course of the entire cohort of patients following cardiac surgery. With regard to cardiac surgical interventions, there was no significant association between the absence or presence of extracorporeal circulation and PSP levels. However, there was a significant difference in the slope of the rise of postoperative PSP between minimally invasive surgery as opposed to patients subjected to sternotomy. CONCLUSION: In an unselected population of cardiac surgery patients, post-operative serum PSP levels were significantly associated with the presence of infection in both the on-pump and off-pump setting. Of note, the surgical technique employed (sternotomy vs. minimally invasive approach) had a significant impact on postoperative PSP levels.

Use of extracellular matrix patches in cardiac surgery.

A noncellular xenogeneic extracellular matrix derived from the porcine small intestinal submucosa can be used as a new patch material with potential advantages. We review the literature on the use of this material in cardiac surgery.

Does body mass index impact the early outcome of surgical revascularization? A comparison between off-pump and on-pump coronary artery bypass grafting.

OBJECTIVES: To investigate the effects of body mass index (BMI) on early outcomes after revascularization using either on-pump or off-pump surgery. METHODS: Data for 3714 of 4314 patients who underwent surgical revascularization at our institution between 1999 and 2008 were analysed. Patients were divided into two groups [off-pump coronary artery bypass (OPCAB); n = 1958 and on-pump coronary artery bypass (ONCAB); n = 1756] and further assigned into five classes according to their BMI (underweight <20 kg/m(2), normal 20-24.99 kg/m(2), overweight 25-29.99 kg/m(2), obese 30-34.99 kg/m(2) and morbidly obese ≥35 kg/m(2)). Thirty-day mortality, occurrence of major adverse cardiac events (MACEs), occurrence of major non-cardiac adverse events (MNCAEs) and length of in-hospital stay were analysed in relation to BMI only (whole cohort analysis), to BMI and chosen surgical method (ONCAB versus OPCAB) as well as confounding factors. RESULTS: In the whole cohort analysis (n = 3714), no significant differences between BMI classes could be identified with regard to 30-day mortality (P = 0.78), MACEs (P = 0.72), MNCAEs (P = 0.45) or length of in-hospital stay (P = 0.94). With increasing BMI values, 30-day mortality tended to steadily increase (1.8% in BMI class 'underweight' vs 2.6% in BMI class 'morbidly obese'; P = 0.78), whereas MNCAEs tended to decrease with an increasing BMI (17.5% in BMI class 'underweight' vs 12.2% in BMI class 'morbidly obese'; P = 0.45). Compared with ONCAB, in patients with higher BMI values, OPCAB appeared to reduce slightly the frequency of 30-day mortality, MACEs and MNCAEs, while slightly increasing the length of in-hospital stay. Adjustment for other risk factors by covariate analysis in multiple regression models did not change the inferences drawn. CONCLUSIONS: Our study did not detect significant differences between BMI classes with regard to mortality and morbidity. However, a slight trend towards a steadily increasing short-term mortality was detectable for patients with higher BMI values. When comparing ONCAB versus OPCAB, patients with higher BMI values appeared to have a weak tendency towards a reduced short-term morbidity and mortality in favour of OPCAB.

Concept and first experimental results of a new ferromagnetic assist device for extra-aortic counterpulsation.

OBJECTIVES: Based on a ferromagnetic silicone cuff for extra-aortic counterpulsation, a new assist device concept was developed. The driving force is generated by an external magnetic field, which leads to contraction of a soft magnetic cuff. The force generation capacity of the device was tested in a silicone aorta model. METHODS: Magnetic elastomers can be constructed through dispersion of micro- or nanoparticles in polymer matrices and were designed to act as soft actuators. Two magnetically active silicone cuffs were produced with a nanomagnet loading of 250 wt% (Cuff 1) and a micromagnet loading of 67 wt% (Cuff 2). The magnetic cuffs were applied on a silicone aorta model and contracted against hydrostatic pressure. RESULTS: A full contraction of Cuff 1 was possible against a maximal hydrostatic pressure of 30 cmH2O (22 mmHg) at a magnetic flux density of 0.4 T (Tesla) and 65 cmH2O (48 mmHg) at a magnetic flux density of 1.2 T. A 50% contraction of Cuff 2 was possible against a maximal hydrostatic pressure of 80 cmH2O (59 mmHg) at a magnet-cuff-distance (MCD) of 0 cm. At MCDs of 1 and 2 cm a 50% contraction was possible against 33 cmH2O (24 mmHg) and 10 cmH2O (7 mmHg), respectively. CONCLUSIONS: Combining the advantages of magnetic elastomers with the principle of extra-aortic counterpulsation in a new assist device concept avoids the need for anticoagulation (no contact with bloodstream). With regard to the magnetic principle of action, no intra- to extracorporeal connection is needed. More experimental work is needed to further increase the force generated by the silicone cuff and to transfer the device concept into an in vivo setting.

Generator pocket adhesions of cardiac leads: classification and correlation with transvenous lead extraction results.

OBJECTIVES: Pacemaker (PM) and implantable cardioverter defibrillator (ICD) leads become encapsulated intravascularly and in the generator pocket by fibrotic adhesions that accumulate over time. These adhesions are responsible for the difficulty and risk of lead extraction procedures. We developed a classification scheme for pocket adhesions, classified all of the patients in the cohort, and examined the relationship between pocket adhesions and the outcome of the procedure. METHODS: The classification of adhesions with respect to the intraoperative adhesion coverage was as followed: class 0 = adhesion free; class 1 ≤ 30% of adhesion coverage; class 2 = 30-60% of adhesion coverage; and class 3 ≥ 60% coverage. Patient data between December 2010 and March 2012 were collected. A total of 100 leads were extracted from 58 patients (1.7 ± 0.8 leads/patient); the mean lead implant duration was 78.5 ± 66.7 months, and the percentage of PM/ICD leads was 68% (n = 68)/32% (n = 32). RESULTS: Distribution of the leads among classes: 0 = 10; 1 = 17; 2 = 25; and 3 = 48. Average implant times (months) according to the adhesion classes: 0 = 1.2 ± 0.4; 1 = 19.8 ± 19.2; 2 = 79.3 ± 46.6; and 3 = 115.1 ± 106.0 (correlation-coefficient 0.71; P ≤ 0.05). Average numbers of extraction tools used according to the adhesions: 0 = none; 1 = 0.4 ± 0.7; 2 = 1.6 ± 1.0; and 3 = 2.3 ± 1.2 (correlation coefficient = 0.67; P ≤ 0.05). Complete removal was achieved in 100% of the patients in classes 0 and 1; 96% in class 2 (n = 24); and 75% in class 3 (n = 36) (P ≤ 0.05). Mortality = 0. CONCLUSIONS: Extensive adhesions in the generator pocket predict the need for a higher number of extraction tools. High-grade pocket adhesions predict lower success rates with regard to complete lead extraction. Both findings suggest that the degree of pocket adhesions predicts the degree of intravascular adhesions.

Clampless off-pump surgery reduces stroke in patients with left main disease.

BACKGROUND: Surgical revascularization is the most appropriate therapy for patients with significant left main coronary-artery disease (LMD). An incidence of perioperative stroke remains an issue when compared to the early outcomes to percutaneous coronary intervention (PCI). This study evaluates the safety and impact of standardized "clampless" OPCAB techniques, composed of either complete in situ grafting or "clampless" device enabled techniques for stroke reduction in patients undergoing surgical revascularization for LMD. METHODS: Between 1999 and 2009, 1031 patients with LMD underwent myocardial-revascularization at our institution. Of these, 507 patients underwent "clampless" OPCAB and 524 patients underwent conventional on-pump CABG (ONCABG). Data-collection was performed prospectively and a propensity-adjusted regression-analysis was applied to balance patient characteristics. LMD was defined as a stenosis >50% and endpoints were mortality, stroke, a cardiac-composite (including death, stroke and myocardial-infarction); a non-cardiac composite and complete-revascularization. RESULTS: In OPCAB patients, the cardiac composite (3.0% vs. 7.8%; propensity-adjusted (PA)OR=0.27; CI95% 0.12-0.65; p=0.003) as well as the occurrence of stroke (0.4% vs. 2.9%; PAOR=0.04; CI95% 0.003-0.48; p=0.012) were significantly lower while the mortality-rate was well comparable between groups (1.8% vs. 2.5%; PAOR=0.44; CI95% 0.11-1.71; p=0.24). The non-cardiac composite was also significantly decreased after OPCAB (8.9% vs. 19.7%; PAOR=0.55; CI95% 0.34-0.89; p=0.014) and complete revascularization was achieved for similar proportions in both groups (95.1% vs. 93.7%; p=0.35). CONCLUSIONS: This study shows the superiority of OPCAB for patients with LMD with regards to risk-adjusted outcomes other than mortality. A "clampless OPCAB strategy", effectively reduces stroke yielding similar early outcomes as PCI.

Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage.

OBJECTIVES: The exclusion of the left atrial appendage (LAA) has been used to reduce the risk of stroke associated with atrial fibrillation (AF). While LAA exclusion has been associated with a reduced risk of stroke, the effect on the electrical activity of the LAA (a potential source of AF) remains unknown. As such, we sought to demonstrate whether surgical epicardial clip occlusion leads to the electrical isolation of the LAA. METHODS: From December 2010 until August 2011, 10 patients with paroxysmal AF underwent off-pump coronary artery bypass surgery with bilateral pulmonary vein isolation and an LAA clip occlusion with a new epicardial clip. Before and after the clip was placed, pacing manoeuvres were performed to assess the electrical exit and entry blocks from the LAA. RESULTS: All clips were applied successfully. The mean procedure time for the clip application was 4 ± 1 min. No complications occurred related to clip application. Prior to the pericardial closure, 18 ± 3 min after the clip placement, the LAA stimulation and pacing manoeuvres demonstrated complete electrical isolation of the LAA in all cases. CONCLUSIONS: Epicardial LAA clip occlusion leads to the acute electrical isolation of the LAA and may not only provide stroke prevention but also reduce the recurrence of AF.

Off-pump surgery for the poor ventricle?

Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF ≤35% underwent myocardial-revascularization. Patients received either OPCAB (n = 256) or ONCABG (n = 222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR) = 1.05; p = 0.93) and MACCE (13.7 vs. 17.6%; PS-OR = 1.22; p = 0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR = 0.39; p = 0.26), low cardiac output (2.3 vs. 4.7%; PS-OR = 0.75; p = 0.72) and stroke (2.3 vs. 2.7%; PS-OR = 0.69; p = 0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR = 0.54; p = 0.059) including renal dysfunction (PAOR = 0.77; 95% CI 0.31-1.9; p = 0.57), bleeding (PAOR = 0.42; 95% CI 0.14-1.20; p = 0.10) and respiratory failure (PAOR = 0.39; 95% CI 0.05-3.29; p = 0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR = 0.75; p = 0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularization.