Analysis of Minimally Invasive Left Thoracotomy HVAD Implantation - A Single-Center Experience.

BACKGROUND: Minimally invasive left ventricular assist device (LVAD) implantation may reduce peri-/postoperative complications and risks associated with resternotomies. In this study, we describe our first results using a minimally invasive LVAD implantation technique (lateral thoracotomy [LT] group). These results were compared with LVAD implantations done via full median sternotomy (STX group). METHODS: HVAD (HeartWare, Framingham, Massachusetts, United States) implantations in 70 patients (LT group n = 22, 52 ± 15 years old; STX group n = 48, 59 ± 11 years old) were retrospectively analyzed. Minimally invasive access via left thoracotomy was feasible in 22 patients. Peri- and postoperative analyses of survival and adverse events were performed. RESULTS: No survival differences were observed between the LT and STX group (p = 0.43). LT patients without temporary right ventricular assist device (tRVAD) showed a significantly better survival rate compared to LT patients with concomitant tRVAD implantation (p = 0.02), which could not be demonstrated in the STX group (p = 0.11). Two LT and four STX patients were successfully bridged to heart transplantation and three STX patients were successfully weaned with subsequent LVAD explantations. LVAD-related infections (n = 4 LT group vs n = 20 STX group, p = 0.04) were less likely in the LT group. No wound dehiscence occurred in the LT group, whereas five were observed in the STX group (p = 0.17). The amount of perioperative blood transfusions (within the first 7 postoperative days) did not differ in both study groups (p = 0.48). CONCLUSION: The minimally invasive approach is a viable alternative with the possibility to reduce complications and should be particularly considered for bridge-to-transplant patients.

Head-to-head comparison of two continuous glucose monitoring systems on a cardio-surgical ICU.

In critical illness hypo-and hyperglycemia have a negative influence on patient outcome. Continuous glucose monitoring (CGM) could help in early detection of hypo-and hyperglycemia. A requirement for these new methods is an acceptable accuracy and precision in clinical practice. In this pilot study we prospectively evaluated the accuracy and precision of two CGM sensors (subcutaneous sensor: Sentrino®, Medtronic and intravasal sensor: Glucoclear®, Edwards) in 20 patients on a cardio-surgical ICU in a head to head comparison. CGM data were recorded for up to 48 h and values were compared with blood-gas-analysis (BGA) values, analysed with Bland-Altman-plots and color-coded surveillance error-grids. Shown are means ± standard deviations. In total 270/255 intravasal/subcutaneous pairs with BGA-values were analysed. The average runtime of the sensors was 28.4 ± 6.4 h. Correlation with BGA values yielded a correlation coefficient of 0.76 (subcutaneous sensor) and 0.92 (intravasal sensor). The Bland Altman Plots revealed an accuracy of 2.5 mg/dl, and a precision of + 43.0 mg/dl to - 38.0 mg/dl (subcutaneous sensor) and an accuracy of - 6.0 mg/dl, and a precision of + 12.4 mg/dl to - 24.4 mg/dl (intravasal sensor). No severe hypoglycemic event, defined as BG level below 40 mg/dl, occurred during treatment. Both sensors showed good accuracy in comparison to the BGA values, however they differ regarding precision, which in case of the subcutaneous sensor is considerable high.

Genomic analysis in patients with myxomatous mitral valve prolapse: current state of knowledge.

BACKGROUND: Myxomatous mitral valve prolapse is a common cardiac abnormality. Morbus Barlow is characterized by excess myxomatous leaflet tissue, bileaflet prolapse or billowing, chordae elongation and annular dilatation with or without calcification. Extensive myxoid degeneration with destruction of the normal three-layered leaflet tissue architecture is observed histologically in such patients. Autosomal dominant inheritance with an age and sex-dependent expression has long been recognised. This review explores the current understanding of the genetics of bileaflet prolapse, with a focus on genetic analysis and the role for echocardiographical screening of the first degree relatives of affected patients. METHODS: Systematic literature searches were performed using PubMed and Embase up to September 2017. In Disse et al.'s study (study one) first degree relatives of 25 patients with Morbus Barlow who underwent mitral valve repair were screened for bileaflet valve prolapse. In Nesta et al.'s study one family with three living generations of 43 individuals with 9 confirmed cases of MVP was screened. Genotyping was performed in four families for 344 microsatellite markers from Chromosome 1 to 16. RESULTS: In study one, autosomal dominant inheritance was shown in four pedigrees. Genome-wide linkage analysis of the most informative pedigree (24 individuals, three generations) showed a significant linkage for markers mapping to chromosome 16p. Linkage to this locus was confirmed in a second family within the same study, but was excluded in the remaining two pedigrees. In study two an autosomal dominant locus was mapped to chromosome 13. 8 of the 9 individuals affected were found to suffer from bileaflet prolapse. CONCLUSIONS: Barlow's disease is a heritable trait but the genetic causes remain largely elusive. Ch16p11.2-p12.1 is the only locus proven to be associated with bileaflet prolapse. Locus 13.q31.3-q32.1 was shown to cause bileaflet as well as posterior leaflet prolapse. This review intends to make physicians aware of genetic causes of myxomatous mitral valve prolapse, thereby emphasising the importance of cardiological examination of first-degree relatives of patients with Morbus Barlow. Integrated and more comprehensive studies are needed for identification of genes involved in this heterogenic disease. Further genomic studies may facilitate more individualised and accurate risk assessment and may help to develop possible preventive stategies for patients in the future.

Two Decades of Endovascular Repair of Popliteal Artery Aneurysm--A Meta-analysis.

OBJECTIVE/BACKGROUND: Over the last two decades endovascular repair (EVR) of popliteal artery aneurysms has emerged as a treatment alternative to conventional open surgical repair (OSR). The aim of this review was to evaluate the safety and efficiency of each repair method, comparing the following outcomes after EVR and OSR: (i) primary patency; (ii) operating time; (iii) length of hospital stay; (iv) peri-operative complications; (v) limb salvage; and (vi) patient survival. METHODS: The PubMed and Cochrane Central Register of Controlled Trials were searched for publications that compared outcomes after EVR and OSR (last search November 2014). Randomized controlled trials (RCTs), prospective and retrospective observational cohort studies were included. The quality of studies was evaluated using the Newcastle-Ottawa scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Random effect models were employed to estimate odds ratios (ORs), mean differences, and hazard ratios (HRs). RESULTS: One RCT combined with a prospective cohort study and four retrospective cohort studies with an overall total of 652 cases (236 EVR, 416 OSR) were identified. GRADE quality of evidence was low or very low for all outcomes. After a median follow up of 33 months, patients who received EVR showed equal primary patency rates to patients who received OSR (HR 1.46, 95% confidence interval [CI] 0.92-2.33). Lengths of operation and hospitalization were significantly shorter following EVR; rates of 30 day graft thrombosis (OR 3.16, 95% CI 1.31-7.62) and 30 day re-intervention (OR 2.15, 95% CI 1.02-4.55) were significant higher for patients who received EVR compared with those who received OSR. There was no effect on mortality (OR 2.31, 95% CI 0.37-14.49) or limb loss (OR 0.59, 95% CI 0.16-2.15). CONCLUSION: EVR of popliteal artery aneurysm showed mid-term results comparable to open surgery and appears to be a safe alternative to OSR. However, the existing empirical evidence base is too fragmentary to draw firm conclusions. Further research and the introduction of population based registries will be needed to allow reliable evaluation of EVR.

Severe bacterial superinfection based on influenza A (H1N1) pneumonia in a heart-lung transplant recipient.

A 47-year-old heart-lung transplant recipient presented to our outpatient transplant clinic with respiratory infection. Her nose and throat swabs for influenza A (H1N1) infection were negative. Broncheoalveolar lavage showed a positive result for H1N1 infection. Antiviral therapy was initiated. Because of superinfection with Pseudomonas aeruginosa and Aspergillus terreus, her clinical condition worsened. The clinical condition of the patient improved with antibiotic and antifungal treatment. Negative nose and throat swab results cannot rule out H1N1 infection safely. We therefore advocate to routinely perform broncheoalveolar lavage.

What's new in transapical aortic valve implantation: clinical experience with second generation devices.

Within 10 years after transcatheter aortic valve implantation (TAVI) was first accomplished for treatment of calcified aortic stenosis, this new technology has rapidly evolved to become clinical routine. Today it may be considered standard treatment for inoperable patients with superior outcomes compared to best medical therapy. Furthermore, it represents an alternative therapeutic option compared to surgical aortic valve replacement in high-risk patients. According to current international guidelines and expert consensus statements, TAVI should be performed as a joint effort by an interdisciplinary heart team to ensure input from multiple skill sets for optimal patient outcome. Major safety concerns include neurologic complications, acute kidney injury, access site complications, procedure-related conduction disturbances, paravalvular leakage valve durability. At present, only one device for transapical TAVI is in widespread clinical use: the Edwards Sapien transcatheter valve (Edwards Lifesciences, Irvine, CA, USA). Recently, however, a number of second generation devices for transapical TAVI have been developed in order to address some of the limitations of first generation valves. In this paper, current data on second generation devices for transapical TAVI will be reviewed and ongoing trials discussed.

Transcatheter aortic valve implantation: alternative access options.

Calcific aortic valve stenosis represents the most common acquired valvular heart disease in adults. Transcatheter aortic valve implantation (TAVI) has been established as a widely accepted therapeutic option in elderly and multimorbid patients with severe aortic stenosis not amenable to conventional surgery. Retrograde transfemoral and antegrade transapical approaches are commonly used for implantation. However, there are a certain number of patients who are not candidates for either approach due to poor vascular access, severe pulmonary dysfunction or other prohibitive chest pathologies. Recently, different alternative access route options have been proposed and described. These alternative access routes include approaches via the subclavian/axillary artery, the ascending aorta, the carotid artery, and the brachiocephalic artery.

Successful weaning from extracorporal circulation using a pumpless extracorporal lung assist device in a patient with intraoperative hypercapnic lung failure during aortic valve replacement.

We present a case of a 59-year-old female suffering from massive pulmonary edema with consecutive hypercapnic lung failure immediately following elective aortic valve replacement. Due to severe restrictive ventilation disorder, mechanical ventilation was inadequate. A pumpless lung assist (PECLA, iLA, Novalung®, Talheim, Germany)--a device for extracorporeal carbon dioxide elimination--was used for successful weaning from extracorporeal circulation (ECC). Within 24 hours respiratory function had normalized and the patient could be extubated. The further clinical course and follow-up at 3 months remained uneventful. This report describes the first intraoperative use of the PECLA device in a cardiac surgery patient to promote weaning from ECC.

Aortic arch repair: let it beat!

Objective aortic arch repair (AAR) on the beating heart may reduce cross-clamping times and offer improved postoperative cardiac function.Methods A single-center review of all patients (n = 24) who underwent surgical AAR during biventricular repair between 01/2006 and 01/2008 was done. All patients were operated on under cardiopulmonary bypass (CPB) with antegrade cerebral perfusion (ACP). During AAR, 13 patients (group 1) received cardioplegic arrest, and were compared to 11 patients (group 2) who underwent a beating-heart modification with selective myocardial perfusion. Seventeen patients had additional intracardiac lesions and underwent simultaneous correction during the procedure.Results Durations of CPB, AAR and ACP did not differ statistically between groups. Cardioplegic arrest time was significantly lower in group 1 (34 ± 13 vs. 76 ± 11 min, p = 0.02) and resulted in a subsequent reduction of myocardial ischemic damage as borne out by lower postoperative levels of troponin T and CK-MB (2.5 ± 0.7 vs. 7.1 ± 1.4 ng/mL, p = 0.02; 68.7 ± 11.5 vs. 149.1 ± 27.2 U/l, p = 0.03). We observed an enhanced patient recovery with shorter inotropic and ventilatory support times (p < 0.05).Conclusion Pediatric aortic arch correction on a CPB beating heart with selective myocardial perfusion is technically feasible and safe. The reduction of the myocardial ischemic time is effective and results in less myocardial damage.

Simultaneous transcatheter aortic and mitral valve-in-valve implantation in a patient with degenerated bioprostheses and high surgical risk.

Transcatheter valve-in-valve implantation is evolving as a promising alternative to reoperative valve replacement in selected high-risk patients, considering the increasing need for redo surgery due to bioprosthetic degeneration in the future. Reoperative double valve replacements are particularly associated with an elevated surgical risk. The transapical access provides the opportunity to approach the aortic and mitral valves during one intervention. We report the case of a successful transcatheter valve-in-valve implantation in the aortic and mitral position within a single procedure.

[Treating mitral regurgitation: a surgical and interventional update]. / Therapie der Mitralklappeninsuffizienz: Chirurgische und interventionelle Neuerungen.

Surgical mitral valve repair has constantly evolved to become the standard of care for severe mitral regurgitation (MR) with superior acute and long-term results compared to valve replacement. Minimally-invasive surgical techniques have been successful in reducing operative trauma while yielding equivalent or even superior results compared to the conventional sternotomy approach. However, due to elevated operative risk a growing proportion of patients are not referred for surgery, especially elderly patients with reduced ventricular function and functional MR who often present with relevant comorbidities. It is for these patients that transcatheter-based therapies may represent an attractive option. While most interventional techniques are still in experimental or early clinical stages of development, relevant clinical experience has been gained with the MitraClip® device. For successful implementation of a patient-centered mitral valve program, integration of surgical and interventional treatment modalities within a heart center is of paramount importance. This is best accomplished by an interdisciplinary dedicated heart team consisting of cardiologists and cardiac surgeons.

[Diagnosis and options for reconstructive heart valve surgery in the Marfan syndrome].

Marfan syndrome is a disorder of the connective tissue that is inherited in an autosomal-dominant fashion and that is caused by mutations in the gene coding for fibrillin-1, FBN1. Although complications of the syndrome may involve the eye, the lung and the skeleton, the high mortality of untreated cases results almost exclusively from cardiovascular complications, including aortic dissection, rupture and mitral valve regurgitation. The multiorgan involvement of many of these syndromes requires multidisciplinary expert centers that can increase the average life expectancy of affected patients from only 32 years to over 60 years. The present article both reviews classical standards of managing cardiovascular manifestations and highlights the surgical approach for aortic and mitral valve surgery in Marfan patients.

Early results of a real-world series with two transapical transcatheter mitral valve replacement devices.

AIMS: Transcatheter mitral valve replacement (TMVR) with dedicated devices promises to fill the treatment gap between open-heart surgery and edge-to-edge repair for patients with severe mitral regurgitation (MR). We herein present a single-centre experience of a TMVR series with two transapical devices. METHODS AND RESULTS: A total of 11 patients were treated with the Tendyne™ (N = 7) or the Tiara™ TMVR systems (N = 4) from 2016 to 2020 either as compassionate-use procedures or as commercial implants. Clinical and echocardiographic data were collected at baseline, discharge and follow-up and are presented in accordance with the Mitral Valve Academic Research Consortium (MVARC) definitions. The study cohort [age 77 years (73, 84); 27.3% male] presented with primary (N = 4), secondary (N = 5) or mixed (N = 2) MR etiology. Patients were symptomatic (all NYHA III/IV) and at high surgical risk [logEuroSCORE II 8.1% (4.0, 17.4)]. Rates of impaired RV function (72.7%), severe pulmonary hypertension (27.3%), moderate or severe tricuspid regurgitation (63.6%) and prior aortic valve replacement (63.6%) were high. Severe mitral annulus calcification was present in two patients. Technical success was achieved in all patients. In 90.9% (N = 10) MR was completely eliminated (i.e. no or trace MR). Procedural and 30-day mortality were 0.0%. At follow-up NYHA class was I/II in the majority of patients. Overall mortality after 3 and 6 months was 10.0% and 22.2%. CONCLUSIONS: TMVR was performed successfully in these selected patients with complete elimination of MR in the majority of patients. Short-term mortality was low and most patients experienced persisting functional improvement.

Aortic aneurysms after correction of aortic coarctation: a systematic review.

Despite advanced techniques for surgical or percutaneous therapy coarctation of the aorta continues to carry a high risk of aneurysmal formation. Mortality of these aneurysms ranges between <1 and >90%, reflecting remarkable differences in surgical strategies and the follow-up management of coarctation. We review the frequency, anatomical types, risk factors and mechanisms of aortic aneurysm forming late after surgical or percutaneous therapy of aortic coarctation. We emphasize that aneurysms do not form exclusively at the site of previous intervention, but also at remote locations such as the ascending aorta. Moreover, aneurysm formation may only in part be attributed to a specific technique of coarctation therapy, and we emphasize the role of a bicuspid aortic valve and inherent weakness of the aortic wall as significant risk factors for aneurysm after aortic coarctation. We report the presenting symptoms, follow-up protocols, and imaging criteria for local and proximal aneurysms. Finally, we discuss criteria for prophylactic intervention at the site of such aneurysms, and present therapeutic options for different types of aneurysms. With this systematic review, we wish to provide data for establishing more uniform strategies for preventing, diagnosing and treating aneurysms associated with aortic coarctation.

Marfan syndrome and the evolving spectrum of heritable thoracic aortic disease: do we need genetics for clinical decisions?

Marfan syndrome (MFS) is a disorder of the connective tissue that is inherited in an autosomal dominant fashion and that is classically caused by mutations in the gene coding for fibrillin-1, FBN1. The high mortality of untreated MFS results almost exclusively from aortic complications such as aortic dissection and rupture. However, more than half of patients with Marfan-like features do not have MFS, but have other diseases including inherited aortic aneurysms and dissections (TAAD). We elucidate the increasing spectrum of syndromes associated with Marfan-like features and discuss the clinical implications of these diseases. We performed a systematic review to tabulate all known inherited diseases and syndromes carrying a risk for thoracic aortic disease. We discuss evidence that different syndromes with different causative genes and mutations have different prognoses and profiles of cardiovascular manifestations. We conclude that future decisions for optimized management of patients with inherited TAAD require a comprehensive clinical and genetic work-up.

The Norwood procedure - does the type of shunt determine outcome?

BACKGROUND: Stage I palliation of hypoplastic left heart syndrome (HLHS) and its variants is usually performed by a Norwood operation. The management of pulmonary blood flow during this procedure remains controversial. The RV-to-PA conduit (RVPAC) has been proposed as the better alternative compared to a systemic-to-pulmonary shunt (SPS). METHODS: A retrospective single center chart review of consecutive patients who underwent a Norwood I procedure between 01/1997 and 09/2006 was performed. All patients were operated in deep hypothermia, with or without circulatory arrest, using different shunt modifications according to surgeon's preference. Patients were divided into two groups depending on surgical management for pulmonary blood flow (modified BT shunt [BT] and non-valved RVPAC [Sano]). RESULTS: Fifty-four patients were included in the study (BT: 31 patients vs. Sano: 23 patients). Diastolic blood pressure during the first 24 hours postoperatively was significantly lower in the BT group (BT: 38.6 +/- 6.9 mmHg vs. Sano: 42.4 +/- 7.2 mmHg; P < 0.01) with a trend towards a higher systolic blood pressure (BT: 74.1 +/- 13.5 mmHg vs. Sano: 69.8 +/- 12.1 mmHg; P = 0.08). Mean circulatory arrest time in the BT group was significantly longer compared to the Sano patients (BT: 41 +/- 21 min vs. Sano: 25 +/- 23 min; P < 0.01). The mean hospital stay was 18.5 days for BT patients and 20 days for Sano patients ( P = 0.45). Early mortality for the total cohort was 14.8 % (n = 8) (BT 19.4 % [n = 6] vs. Sano 8.7 % [n = 2]; P = 0.12). There was no significant difference in inter-stage mortality between the two groups (BT: 18.2 % vs. Sano: 21.1 %; P = 0.47). CONCLUSION: The results for both established surgical methods (BT and Sano) for the palliation of HLHS and its variants have improved over time and are reaching acceptable early mortality rates. There was a trend towards a favorable early outcome for Sano patients, which did not reach statistical significance in this study due to the low patient numbers.

Does statin therapy impact the proximal aortopathy in aortic valve disease?

BACKGROUND: Studies have demonstrated that statin therapy decreases the growth rate of abdominal aneurysms. However, the effect of statin therapy on the proximal aortic disease has not been sufficiently elucidated. AIM: We aimed to analyse the association between statin treatment and the severity of proximal aortopathy in patients with aortic valve disease. DESIGN: Cross-sectional study. METHODS: We prospectively identified 458 patients who were referred for aortic valve surgery from 2008 to 2014. Pre-operative measurement of the proximal aorta was performed by TEE, CT or MRT scan. Data of dyslipidemia treatment was obtained by questionnaire. RESULTS: The mean ascending aortic diameter in the whole study population was comparable in patients with vs. without statin therapy (i.e. 42.7 mm vs. 43.6 mm, P = 0.46). Logistic regression analysis showed no significant association between statin therapy and proximal aortopathy ≥ 40 mm in the whole study group (OR = 0.69, P = 0.10). For the BAV sub-group, HDL (OR = 0.54, P = 0.038) and cholesterol levels (OR = 2.00, P = 0.038) were found significantly associated with the proximal aortic disease. In the BAV cohort, the statin users with target HDL levels presented a significantly smaller proximal aortic diameter (40.1 mm vs. 46 mm, P = 0.02). CONCLUSION: Pre-operative statin therapy demonstrated no significant association with the expression of proximal aortopathy. However, more than 40% of the statin users presented uncontrolled lipid levels at the time of the study. In the BAV sub-group, the statins users with target HDL levels showed a significantly smaller ascending aorta diameter. Target HDL and cholesterol levels were strongly associated with proximal aortic dilation in BAV patients.

Is the malononitrilamide FK778 better for the prevention of acute or chronic rejection?

OBJECTIVE: The aim of this study was to assess the efficacy of FK778 to prevent acute and chronic allograft rejection compared with other immunosuppressive agents. MATERIALS AND METHODS: Heterotopic Brown-Norway (BN)-to-Lewis rat cardiac transplantations and heterotopic BN-to-Lewis tracheal transplantations were performed to study acute heart rejection and the development of chronic obliterative airway disease (OAD), respectively. Recipients were treated with FK778, tacrolimus, MMF, or sirolimus for 10 days (acute rejection study) or 28 days (chronic OAD study) at varying doses. RESULTS: In untreated recipients, cardiac allograft survival was 6.2 +/- 0.4 days. FK778 (20 mg/kg), tacrolimus (2 or 8 mg/kg), mycophenolate mofetil (MMF; 40 mg/kg), or sirolimus (0.5 or 2 mg/kg) significantly prolonged graft survival to 17.0 +/- 2.8, 18.5 +/- 2.7, 25.0 +/- 2.5, 20.7 +/- 3.8, 14.5 +/- 2.2, and 23.2 +/- 1.5 days, respectively (P < .05). Tracheal grafts in untreated recipients showed intense infiltration and complete luminal obliteration by day 28. FK778 (20 mg/kg), tacrolimus (1 or 4 mg/kg), MMF (10 or 40 mg/kg), or sirolimus (0.5 or 2 mg/kg) significantly inhibited tracheal luminal obliteration (19.5% +/- 16.4%, 44.2% +/- 33.6%, 12.3% +/- 3.3%, 61.7% +/- 18.6%, 18.3% +/- 11.3%, 55.0% +/- 30.9%, and 8.5% +/- 3.5% (P < .05). All 4 high-dose groups showed similar efficacy. CONCLUSIONS: When used in therapeutic doses, tacrolimus and sirolimus were more effective than FK778 to prolong cardiac allograft survival. However, with its antiproliferative effects on smooth muscle cells, its good tolerability, and its blockade of cytomegalovirus replication, FK778 proved effective to prevent chronic OAD development. Thus, FK778 may acquire an important role in maintenance therapy for the prevention of long-term fibroproliferative complications.