Confirmation of Safety of Titanium Wire in Sternotomy Closure, A Randomized Prospective Study.

BACKGROUND: There are many factors that are known to increase the risk of sternal wound infection (SWI); some studies have reported that nickel is a risk factor for SWI. Titanium wires have only been used as an alternative to steel wires in patients with known allergy to nickel. However, there is a paucity of literature regarding the safety of using titanium wires compared to that on the safety of steel wires for sternum closure after cardiac surgery. Therefore, this study aimed to demonstrate the noninferiority of titanium wires, even in patients without a known allergy. METHODS: A total of 322 patients who underwent elective full median sternotomy were randomly assigned to sternal closure either by titanium wires (n = 161) or by stainless steel wires. RESULTS: Fourteen patients had sternal instability, six (3.7%) patients in the titanium group and eight (5%) patients in the stainless steel group (p = 0.585). There was no statistically significant difference between both groups in terms of postoperative wound infection (p = 0.147). Patients in the titanium group experienced statistically significant lower postoperative pain than those in the stainless steel group (p = 0.024). The wire type was not an independent risk factor for SI, as shown by univariate and logistic regression analyses. CONCLUSION: Titanium wires are a good alternative and have been proven to be safe and effective for sternal closure. The surgeon should be aware of the possibility of developing an allergic reaction to the wires, especially in patients with previous multiple allergic histories.

Mesenteric Ischemia after Cardiac Surgery.

BACKGROUND: Mesenteric ischemia (Me-Is) after cardiac surgery is underreported in present literature but has still earned the bad reputation of a dismal prognosis. This study adds clinical outcomes in a large patient cohort. METHODS: Between 2009 and 2019 of the 22,590 patients undergoing cardiac surgery at our facility 106 (0.47%) developed Me-Is postoperatively. Retrospective patient data was analyzed. Additionally, patients were stratified by outcome-survivors and nonsurvivors. RESULTS: Patients were predominantly male (n = 68, 64.2%), mean age was 71.2 ± 9.3 years. Most procedures were elective (n = 85, 80.2%) and comprised of more complex combined procedures (50.9%) and redos (17.9%). Mean EuroSCORE II averaged 10.9 ± 12.2%. Survival at 30 days was 49.1% (n = 52). Clinical baseline and procedural characteristics did not differ significantly between survivors and nonsurvivors. The median postoperative interval until symptom onset was 5 days in both groups. Survivors were more frequently diagnosed by computed tomography and nonsurvivors based on clinical symptoms. Me-Is was predominantly nonocclusive (n = 84, 79.2%). Laparotomy was the main treatment in both groups (n = 45, 78.8% vs. n = 48, 88.9%, p = 0.94). Predictors of mortality were maximum norepinephrine doses (hazard ratio [HR] 8.29, confidence interval [CI] 3.39-20.26, p < 0.0001), lactate levels (HR 1.06, CI 1.03-1.09), and usage of inotropes (HR 2.46, CI 1.41-4.30). CONCLUSION: The prognosis of Me-Is following cardiac surgery is poor-independently from diagnostic or treatment patterns. There exists a significant asymptomatic time period postoperatively, in which pathophysiologic processes seem to cross the Rubicon. After clinical demarcation, the further course can almost no longer be influenced.

Tissue requirements for the application of aortic valve neocuspidization - appropriate pericardium properties and homogeneity?

OBJECTIVE: Aortic valve neocuspidization (AVNeo) using autologous pericardium is a promising technique. Expected advantages are reduced immune response, appropriate biomechanics and lower treatment expenses. Nevertheless, autologous pericardium can be affected by patient's age and comorbidities. Usually, glutaraldehyde (GA) - fixed bovine pericardium is the basic material for aortic valve prostheses, easy available and carefully pre-examined in a standardized fabrication process. Aim of the study is the verification of autologous pericardial tissue homogeneity by analysing tissue thickness, biomechanics and extracellular matrix (ECM) composition. METHODS: Segments of human GA-fixed pericardium selected by the surgeon based on visual criteria for cusp pre-cut and remaining after surgical AV replacement were investigated in comparison to bovine standard tissue treated equivalently. Pericardium sampling was performed at up to three positions of each sutured cusp for histological or biomechanical analysis, according to tissue availability. RESULTS AND CONCLUSIONS: Human pericardia exhibited a higher heterogeneity in collagen content, density of vessel structures and elastic moduli. Thickness, vessel density and collagen and elastin content differed significantly between the species. In contrast, significant interindividual differences were detected in most properties investigated for human pericardial samples but only for tissue thickness in bovine tissues. Higher heterogeneity of human pericardium, differing vessel and collagen content compared to bovine state-of-the-art material might be detrimental for long term AV functionality or deterioration and have to be intensely investigated in patients follow up after autologous cusp replacement.

Cytokine Hemoadsorption During Cardiac Surgery Versus Standard Surgical Care for Infective Endocarditis (REMOVE): Results From a Multicenter Randomized Controlled Trial.

BACKGROUND: Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with postoperative organ dysfunction. We investigated the effect of hemoadsorption during IE surgery on postoperative organ dysfunction. METHODS: This multicenter, randomized, nonblinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption (integration of CytoSorb to cardiopulmonary bypass) or control. The primary outcome (change in sequential organ failure assessment score [ΔSOFA]) was defined as the difference between the mean total postoperative SOFA score, calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention to treat. A predefined intergroup comparison was performed using a linear mixed model for ΔSOFA including surgeon and baseline SOFA score as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in 6 organ systems, each scored from 0 to 4. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, duration of mechanical ventilation, and vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. RESULTS: Between January 17, 2018, and January 31, 2020, a total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and 2 in the control group were excluded because they did not undergo surgery. The primary outcome, ΔSOFA, did not differ between the hemoadsorption and the control group (1.79±3.75 and 1.93±3.53, respectively; 95% CI, -1.30 to 0.83; P=0.6766). Mortality at 30 days (21% hemoadsorption versus 22% control; P=0.782), duration of mechanical ventilation, and vasopressor and renal replacement therapy did not differ between groups. Levels of interleukin-1ß and interleukin-18 at the end of integration of hemoadsorption to cardiopulmonary bypass were significantly lower in the hemoadsorption than in the control group. CONCLUSIONS: This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of cardiopulmonary bypass, there was no difference in any of the clinically relevant outcome measures. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03266302.

Aprotinin does not Impair Vascular Function in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Bleeding is a major complication in coronary artery bypass graft surgery. Antifibrinolytic agents like serine protease inhibitor aprotinin can decrease postoperative bleeding and complications of cardiac surgery. However, the effects of aprotinin on vascular function are not completely elucidated. We compared the ex vivo vascular function of left internal mammary arteries from patients undergoing coronary artery bypass graft surgery with and without intraoperative application of aprotinin using a Mulvany Myograph. Human internal mammary arteries were treated with aprotinin ex vivo and tested for changes in vascular function. We analyzed the impact of aprotinin on vascular function in rat aortic rings. Finally, impact of aprotinin on expression and activity of endothelial nitric oxide synthase was tested in human endothelial cells. Intraoperative application of aprotinin did not impair ex vivo vascular function of internal mammary arteries of patients undergoing coronary artery bypass graft surgery. Endothelium-dependent and -independent relaxations were not different in patients with or without aprotinin after nitric oxide synthase blockade. A maximum vasorelaxation of 94.5%±11.4vs. 96.1%±5.5% indicated a similar vascular smooth muscle function in both patient groups (n=13 each). Long-term application of aprotinin under physiological condition preserved vascular function of the rat aorta. In vitro application of increasing concentrations of aprotinin on human endothelial cells resulted in a similar expression and activity of endothelial nitric oxide synthase. In conclusion, intraoperative and ex vivo application of aprotinin does not impair the endothelial function in human internal mammary arteries and experimental models.

Microbiological study of sternal osteomyelitis after median thoracotomy - a retrospective cohort study.

INTRODUCTION: Deep sternal wound infection is a rare but feared complication of median thoracotomies and is usually caused by microorganisms from the patient's skin or mucous membranes, the external environment, or iatrogenic procedures. The most common involved pathogens are Staphylococcus aureus, Staphylococcus epidermidis and gram-negative bacteria. We aimed to evaluate the microbiological spectrum of deep sternal wound infections in our institution and to establish diagnostic and treatment algorithms. METHODS: We retrospectively evaluated the patients with deep sternal wound infections at our institution between March 2018 and December 2021. The inclusion criteria were the presence of deep sternal wound infection and complete sternal osteomyelitis. Eighty-seven patients could be included in the study. All patients received a radical sternectomy, with complete microbiological and histopathological analysis. RESULTS: In 20 patients (23%) the infection was caused by S. epidermidis, in 17 patients (19.54%) by S. aureus, in 3 patients (3.45%) by Enterococcus spp., in 14 patients (16.09%) by gram-negative bacteria, while in 14 patients (16.09%) no pathogen could be identified. In 19 patients (21,84%) the infection was polymicrobial. Two patients had a superimposed Candida spp. INFECTION: Methicillin-resistant S. epidermidis was found in 25 cases (28,74%), while methicillin-resistant S. aureus was isolated in only three cases (3,45%). The average hospital stay for monomicrobial infections was 29.93 ± 13.69 days and for polymicrobial infections was 37.47 ± 19.18 (p = 0.03). Wound swabs and tissue biopsies were routinely harvested for microbiological examination. The increasing number of biopsies was associated with the isolation of a pathogen (4.24 ± 2.22 vs. 2.18 ± 1.6, p < 0,001). Likewise, the increasing number of wound swabs was also associated with the isolation of a pathogen (4.22 ± 3.34 vs. 2.40 ± 1.45, p = 0.011). The median duration of antibiotic treatment was 24.62 (4-90) days intravenous and 23.54 (4-70) days orally. The length of antibiotic treatment for monomicrobial infections was 22.68 ± 14.27 days intravenous and 44.75 ± 25.87 days in total and for polymicrobial infections was 31.65 ± 22.29 days intravenous (p = 0.05) and 61.29 ± 41.45 in total (p = 0.07). The antibiotic treatment duration in patients with methicillin-resistant Staphylococci as well as in patients who developed an infection relapse was not significantly longer. CONCLUSION: S. epidermidis and S. aureus remain the main pathogen in deep sternal wound infections. The number of wound swabs and tissue biopsies correlates with accurate pathogen isolation. With radical surgical treatment, the role of prolonged antibiotic treatment remains unclear and should be evaluated in future prospective randomized studies.

Pathological study of sternal osteomyelitis after median thoracotomy-a prospective cohort study.

PURPOSE: Osteomyelitis of the sternum may arise either as a primary condition or secondary to median thoracotomy after cardiac surgery, with the latter being decidedly more frequent. Deep sternal wound infections appear as a complication of median thoracotomy in 0.2 to 4.4% of cases and may encompass the infection of the sternal bone. To date, there are no exhaustive histopathological studies of the sternal osteomyelitis. METHODS: Our work group developed a surgical technique to remove the complete infected sternal bone in deep sternal wound infections. We therefore prospectively examined the en bloc resected sternal specimens. Seven standard histological sections were made from the two hemisternums. RESULTS: Forty-seven sternums could be investigated. The median age of the patients in the cohort was 66 (45-81) years and there were 10 females and 37 males. Two methods were developed to examine the histological findings, with one model dividing the results in inflammatory and non-inflammatory, while the second method using a score from 0 to 5 to describe more precisely the intensity of the bone inflammation. The results showed the presence of inflammation in 76.6 to 93.6% of the specimens, depending on the section. The left manubrial sections were more prone to inflammation, especially when the left mammary artery was harvested. No further risk factors proved to have a statistical significance. CONCLUSION: Our study proved that the deep sternal wound infection may cause a ubiquitous inflammation of the sternal bone. The harvest of the left mammary artery may worsen the extent and intensity of infection.

Pyoderma Gangrenosum after Cardiac Surgery.

BACKGROUND: Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection. METHODS: A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided. RESULTS: A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries. CONCLUSION: Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis-the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.

Acquired Thrombocytopenia in Contemporary Transcatheter Aortic Valve Prosthesis.

BACKGROUND: Postprocedural thrombocytopenia is a known phenomenon following transcatheter aortic valve implantation (TAVI). The aim of this study is to evaluate whether postinterventional platelet kinetics differ when comparing the current generation of balloon-expandable valve (BEV) and self-expanding valve (SEV) prostheses. METHODS: We performed a retrospective analysis of patients undergoing TAVI at our facility between 2017 and 2019. Patients were stratified according to the type of prosthesis used: BEV or SEV. Hematocrit-corrected platelet counts were calculated to account for dilution. Nadir platelet counts (lowest recorded platelet count), drop platelet counts (DPC; highest relative platelet drop from baseline), and severity of thrombocytopenia during the discourse and at discharge were assessed. RESULTS: Of the 277 included patients, 212 received SEV and 65 BEV. BEV patients were younger (81.8 ± 4.4 years vs 79.7 ± 6.8 years, p = 0.03). Further demographic characteristics were similar between groups. Implanted SEV were larger (p < 0.001) and had shorter procedural times (p < 0.01). There were no significant differences in postprocedural discourse. Postinterventional platelet drop was more pronounced in BEV patients in several evaluated metrics: mean DPC (24.3 ± 10.9% vs 18.8 ± 14.8%, p < 0.01), patients with DPC > 30% (n = 19, 29.2%, vs n = 33, 15.6%, p = 0.02), and also when comparing platelet kinetics. CONCLUSION: Despite improvements in outcome, the current generation of balloon-expandable TAVI prostheses carries a predisposition for postprocedural thrombocytopenia even when the effects of dilution are accounted for.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Aortic Valve Surgery.

Background and Objectives: Transaxillary access is one of the latest innovations for minimally invasive aortic valve replacement (MICS-AVR). This study compares clinical performance in a large transaxillary MICS-AVR group to a propensity-matched sternotomy control group. Materials and Methods: This study enrolled 908 patients undergoing isolated AVR with a mean age of 69.4 ± 18.0 years, logistic EuroSCORE of 4.0 ± 3.9%, and body mass index (BMI) of 27.3 ± 6.1 kg/m2. The treatment group comprised 454 consecutive transaxillary MICS-AVR patients. The control group was 1:1 propensity-matched out of 3115 consecutive sternotomy aortic valve surgeries. Endocarditis, redo, and combined procedures were excluded. The multivariate matching model included age, left ventricular ejection fraction, logistic EuroSCORE, pulmonary hypertension, coronary artery disease, chronic lung disease, and BMI. Results: Propensity-matching was successful with subsequent comparable clinical baselines in both groups. MICS-AVR had longer skin-to-skin time (120.0 ± 31.5 min vs. 114.2 ± 28.7 min; p < 0.001) and more frequent bleeding requiring chest reopening (5.0% vs. 2.4%; p < 0.010), but significantly less packed red blood cell transfusions (0.57 ± 1.6 vs. 0.82 ± 1.6; p = 0.040). In addition, MICS-AVR patients had fewer access site wound abnormalities (1.5% vs. 3.7%; p = 0.038), shorter intensive care unit stays (p < 0.001), shorter ventilation times (p < 0.001), and shorter hospital stays (7.0 ± 5.1 days vs. 11.1 ± 6.5; p < 0.001). No significant differences were observed in stroke > Rankin 2 (0.9% vs. 1.1%; p = 0.791), renal replacement therapy (1.5% vs. 2.4%; p = 0.4762), and hospital mortality (0.9% vs. 1.5%; p = 0.546). Conclusions: Transaxillary MICS-AVR is at least as safe as AVR by sternotomy and can be performed in the same time frame. Its advantages are fewer transfusions and quicker postoperative recovery with a significantly shorter hospital stay. The cosmetic result and unrestricted physical abilities due to the untouched sternum and ribs are unique advantages of transaxillary access.

Topical negative pressure wound therapy enhances the local tissue perfusion - A pilot study.

BACKGROUND: Topical negative pressure wound therapy (TNPWT) is a regularly used method in modern wound treatment with a growing and diverse potential for clinical use. So far positive effects on microcirculation have been observed and examined, although precise statements on the underlying mechanism appear unsatisfying. OBJECTIVE: The aim of our study was to extend the understanding of the effect of TNPWT on tissue perfusion and determine the time frame and the extent to which the tissue perfusion changes due to TNPWT. MATERIAL AND METHODS: TNPWT was applied to the anterior thighs of 40 healthy individuals for 30 min, respectively. Before and up to 90 min after the application, measurements of the amount of regional haemoglobin (rHb), capillary venous oxygen saturation (sO2), blood flow (flow) and velocity were conducted with spectrophotometry (combining white light spectrometry and laser Doppler spectroscopy) within two different depths/skin layers. A superficial measuring probe for depths up to 3 mm and a deep measuring probe for up to 7 mm were used. RESULTS: All parameters show significant changes after the intervention compared to baseline measurements. The greater effect was seen superficially. The superficially measured rHb, sO2 and flow showed a significant increase and stayed above the baseline at the end of the protocol. Whereas deeply measured, the rHb initially showed a decrease. The flow and sO2 showed a significant increase up to 60 min after the intervention. CONCLUSION: The application of TNPWT on healthy tissue shows an increase in capillary-venous oxygen saturation and haemoglobin concentration of at least 90 min after intervention. A possible use in clinical practice for preconditioning to enhance wound healing for high-risk patients to develop wound healing disorder, requires further studies to investigate the actual duration of the effect.

Aortic Thrombosis following COVID-19: A Systematic Review.

BACKGROUND: Arterial and venous thromboses associated with the coronavirus disease 2019 (COVID-19) have been well described. These events are caused by a hypercoagulable state due to endotheliopathy and infection-driven coagulopathy. There has been an ever-increasing number of documented cases of aortic thrombosis (AoT) in COVID-19 patients. We conducted a systematic review of current scientific literature to identify and consolidate evidence of AoT in COVID-19 patients. METHODS: A systematic review of literature was conducted between March 15, 2020, and May 1, 2021, on PubMed and Cochrane databases. Additionally, a case from our facility was included. RESULTS: A total of 38 studies (12 case series and 26 case reports) and a case from our facility describing AoT in 56 COVID-19 patients were included. Patients were aged 64.8 ± 10.5 years, were predominantly male (75%), and had several comorbidities. AoT was symptomatic in 82,14% of patients; however, when D dimers were reported, they were significantly elevated even in otherwise asymptomatic patients. Most patients had no previous history of aortic disease. Thrombosis was described in all parts of the aorta, with several cases reporting multiple locations. The median reported time until development of AoT was 10 days. Peripheral thrombosis occurred in 73.21% of cases, most commonly causing lower limb ischemia. Mortality rate was 30.4%. CONCLUSIONS: AoT can occur with no clinical symptoms or as a primary symptom in otherwise asymptomatic COVID-19 patients. D dimers are a highly sensitive diagnostic tool. Diagnosis of this condition prior to development of complications could be instrumental in saving many lives.

Redo surgery for noninfective isolated mitral valve disease: Initial outcome and further follow-up compared to primary surgery.

INTRODUCTION: Isolated redo-mitral valve replacement (iMVR) is underreported and often mixed up with endocarditis in the present literature. The present study compares first with redo iMVR in noninfective mitral disease. PATIENTS AND METHODS: A total of 3821 mitral valve procedures were analyzed. The study was restricted to isolated and noninfective mitral valve replacements done by sternotomy. Finally, 402 patients are included, consisting of 102 redo- and 300 first surgeries. The mean patient's age was 65.9 ± 10.4 years; the mean EuroSCORE II was 3.0 ± 2.2%. Median follow-up was 221 days, ranging up to 9.9 years with a total of 367 patient-years. RESULTS: Redo's had higher EuroSCORE II (5.1 ± 2.9% vs. 2.3 ± 1.4%; p < .01), more atrial fibrillation (31.1% vs. 46.1%; p = .01), chronic obstructive pulmonary disease (7.3% vs. 17.6%; p = .05), coronary artery disease (7.3% vs. 17.6%; p = .03) and more frequently reduced ejection fraction < 30% (3.0% vs. 11.8%; p = .02). Main outcomes showed comparable 30-days mortality (first: 4.1%, redo: 6.9%; p = .813). Postoperative morbidity of the redo's was associated with increased postoperative bleeding (p < .01) resulting in increased transfusions of packed red blood cells and fresh frozen plasma (each p < .01), more re-explorations (p < .01) and longer primary intensive care unit stay (p < .01). Postoperative occurrence of stroke, respiratory or renal failure, and myocardial infarction as well as hospital stay differed not significantly. Estimated 5-years survival was 65.5 ± 12.3% for all patients with no significant differences between the groups. Multivariate logistic regression respiratory failure as relevant for hospital (odds ratio [OR]: 12.3 [1.1-158]; p = .029) and stroke (OR: 4.8 [1.1-12.3]; p = .021) as relevant for long-term mortality. CONCLUSION: iMVR for noninfective reasons is infrequent and rare. Compared to primary surgery, redo's suffer mainly from bleeding-associated morbidity. This does not translate into prolonged hospital stay or inferior immediate or long-term outcomes. Redo mitral valve replacement can be performed at no significantly increased surgical risk compared with first surgery and the results are particularly not limited by the surgery itself.

Hemodynamic follow-up after valve-in-valve TAVR for failed aortic bioprosthesis.

BACKGROUND: "valve-in-valve" TAVR (VIV-TAVR) is established and provides good initial clinical and hemodynamic outcomes. Lacking long-term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3-years follow-up. METHODS: A total of 77 patients underwent VIV-TAVR for failing aortic bioprosthesis during a 7-years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4 ± 5.8 years and a logistic EuroSCORE of 30.8 ± 15.7%. The Society of Thoracic Surgeons-PROM averaged 5.79 ± 2.63%. Clinical results and hemodynamic outcomes are reported for 30-days, 1-, 2-, and 3-years. Completeness of follow-up was 100% with 44 patients at risk after 3-years. Follow-up ranged up to 7.1 years. RESULTS: Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1 ± 2.3 mm and true-ID of 20.4 ± 2.6 mm. A true-ID ≤21 mm had 58.4% of the patients. Self-expanding valves were implanted in 68.8% (mean labeled size 24.1 ± 1.8 mm) and balloon-expanded in 31.2% (mean size 24.1 ± 1.8 mm). No patient died intraoperatively. Hospital mortality was 1.3% and three-years survival 57.1%. All patients experienced an initial significant dPmean-reduction to 16.8 ± 7.1 mmHg. After 3-years mean dPmean raised to 26.0 ± 12.2 mmHg. This observation was independent from true-ID or type of transcatheter aortic valve replacement (TAVR)-prosthesis. Patients with a true-ID ≤21 mm had a higher initial (18.3 ± 5.3 vs. 14.9 ± 7.1 mmHg; p = .005) and dPmean after 1-year (29.2 ± 8.2 vs. 13.0 ± 6.7 mmHg; p = .004). There were no significant differences in survival. CONCLUSIONS: VIV-TAVR is safe and effective in the early period. In surgical valves with a true-ID ≤21 mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true-IDs showed steadily increasing transvalvular gradients. This raises concern about durability.

Aortic root reinforcement in aortic valve endocarditis with annular abscess: The Calamari procedure.

Treatment of infective endocarditis can often prove challenging due to its wide range of anatomical presentations. When complicated by an aortic root abscess, patients may require extensive root surgery, which on its own leads to a worse outcome. We present our experience with a surgical technique for reinforcing the aortic annulus with a ring from a Dacron aortic prosthesis placed in the left ventricular outflow tract to avoid the need for root replacement procedures or patch closures of the defect. The technique described in this paper provides a viable alternative to the standard techniques used for the treatment of annular abscesses in aortic valve endocarditis. Due to the relative simplicity and ease of use, this approach may present a means of reducing operation time and possibly postoperative complications of this severe condition.

Combined Bentall and Modified Ravitch Procedures: A Case Report and Systematic Review of the Evidence.

Background and Objectives: Marfan syndrome (MS) is a genetic disorder with autosomal dominant inheritance that affects the connective tissue and consequently many organ systems. The cardiovascular manifestations of MS are notorious and include aortic root dilatation or acute aortic dissection, which can cause morbidity and early mortality. However, surgical treatment of aortic pathology may be complicated by musculoskeletal deformity of the chest wall, as in pectus excavatum. In this regard, single-stage combined Bentall and Ravitch surgery is an extreme rarity that has also been scarcely reported in the literature. Patients and Methods: We present the medical history and single-stage Bentall and modified Ravitch surgical treatment of an 18-year-old male MS patient with symptomatic and severe pectus excavatum (PEX) in conjunction with a pear-shaped aortic root aneurysm. To discuss our case in the context of a synopsis of similar published cases, we present a systematic review of combined Bentall surgical aortic aneurysm repair and Ravitch correction of PEX. Results: A total of four studies (one case series and three case reports) and a case from our institution describing a single-stage combined Bentall and Ravitch operation were included. Patients were 22 ± 5.9 years of age (median = 22.5 years) and predominantly male (60%). All cases reported a midline vertical skin incision over the sternum. The most common surgical approach was midsternotomy (80%). In all cases metal struts were used to reinforce the corrected chest wall. Postoperative mortality was zero. Conclusions: Single-stage combined Bentall and Ravitch surgery is an underutilized surgical approach. Its use in MS patients with concomitant PEX and ascending aortic aneurysm that require surgical treatment warrants further investigation. Midsternotomy seems to be a viable access route that provides sufficient exposure in the single-stage surgical setting. Although operative time is long, the intraoperative and postoperative risks appear to be low and manageable.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Mitral Valve Surgery-A Propensity Matched Competitive Analysis.

Background and Objectives: Transaxillary access is a straightforward "single incision­direct vision" concept, based on a 5 cm skin incision in the right anterior axillary line. It is suitable for aortic, mitral and tricuspid surgery. The present study evaluates the hospital outcomes of the transaxillary access for isolated mitral valve surgery compared with full sternotomy. Patients and Methods: The final study group included 480 patients. A total of 160 consecutive transaxillary patients served as treatment group (MICS-MITRAL). Based on a multivariate logistic regression model including age, sex, body-mass-index, EuroScore II and LVEF, a 1:2 propensity matched control-group (n = 320) was generated out of 980 consecutive sternotomy patients. Redo surgeries, endocarditis or combined procedures were excluded. The mean age was 66.6 ± 10.6 years, 48.6% (n = 234) were female. EuroSCORE II averaged 1.98 ± 1.4%. Results: MICS-MITRAL had longer perfusion (88.7 ± 26.6 min vs. 68.7 ± 32.7 min; p < 0.01) and cross-clamp (64.4 ± 22.3 min vs. 49.7 ± 22.4 min; p < 0.01) times. This did not translate into longer procedure times (132 ± 31 min vs. 131 ± 46 min; p = 0.76). Both groups showed low rates of failed repair (MICS-MITRAL: n = 6/160; 3.75%; Sternotomy: n = 10/320; 3.1%; p = 0.31). MICS-MITRAL had lower transfusion rates (p ≤ 0.001), less re-exploration for bleeding (p = 0.04), shorter ventilation times (p = 0.02), shorter ICU-stay (p = 0.05), less postoperative hemofiltration (p < 0.01) compared to sternotomy patients. No difference was seen in the incidence of stroke (p = 0.47) and postoperative delirium (p = 0.89). Hospital mortality was significantly lower in MICS-MITRAL patients (0.0% vs. 3.4%; p = 0.02). Conclusions: The transaxillary access for MICS-MITRAL provides superior cosmetics and excellent clinical outcomes. It can be performed at least as safely and in the same time frame as conventional mitral surgery by sternotomy.

Surgery without Scars: Right Lateral Access for Minimally Invasive Aortic Valve Replacement.

As part of an institutionally driven holistic concept, named the "360-degree approach," all established surgical access routes -full sternotomy, partial upper sternotomy, and right anterolateral thoracotomy using the second interspace-are supported. The surgical toolbox now is completed by adding a further approach: through a 5- to7-cm skin incision in the right anterior axillary line, the third interspace is used for a minimally invasive aortic valve surgery providing striking exposition of the aortic valve and resulting in superior cosmetics with nearly no visible scars. The choice for the one or other method is institutionally driven and based on risk profiles, as well as anatomical and physiognomic considerations.

Sexual Quality of Life in Men <60 Years Old after Coronary Bypass Surgery.

PURPOSE: To explore the effect of undergoing coronary artery bypass grafting on sexual quality of life as an integral part of patients' health-related quality of life. METHODS: This cross-sectional study included 265 men ages 18 to 60 years (median age, 55) who underwent coronary artery bypass grafting 1 to 5 years before the study. Standardized questionnaires were implemented to evaluate participant pre- and postoperative sexual quality of life and the quality of counseling provided to patients. RESULTS: Among the patients, 77% were in a steady relationship. The general health score was 5.5 ± 2.8 (mean ± standard deviation) preoperatively and 6 ± 2.2 at follow-up (P = .01). No sexual counseling was given to 83% and 77% of the patients pre- and postoperatively, respectively. The mean sexual satisfaction score dropped from 6.5 ± 2.6 preoperatively to 4.7 ± 3 postoperatively (P < .001). The decline in sexual intercourse frequency and masturbation frequency was significant (P < .001 and P = .006, respectively). Linear regression analysis showed that general health status (P = .008), higher-quality counseling (P = .027), and preoperative sexual quality of life (P < .001) correlated positively with sexual quality of life, whereas sternal pain (P < .001), erectile dysfunction (P < .001), and fear of excessive cardiac burden (P < .001) correlated negatively. CONCLUSIONS: Middle-aged men experience decreased sexual quality of life after coronary artery bypass grafting. Preoperative sexual quality of life, general health, and higher-quality counseling positively affect postoperative sexual quality of life, whereas sternal pain, fear, and erectile dysfunction play a negative role. Pre- and postoperative care guidelines should be improved. Further prospective large cohort studies for males and females are required.

Estrogen determines sex differences in adrenergic vessel tone by regulation of endothelial ß-adrenoceptor expression.

Vessels of female rats constrict less and relax more to adrenergic stimulation than vessels of males. Although we have reported that these sex-specific differences rely on endothelial ß-adrenoceptors, the role of sex hormones in ß-adrenoceptor expression and related vessel tone regulation is unknown. We investigated the role of estrogen, progesterone and testosterone on ß-adrenoceptor expression and adrenergic vessel tone regulation, along with sex-specific differences in human mammary arteries. The sex-specific differences in vasoconstriction and vasorelaxation in rat vessels were eliminated after ovariectomy in females. Ovariectomy increased vessel vasoconstriction to norepinephrine more than twofold. Vasorelaxations by isoprenaline and a ß3-agonist were reduced after ovariectomy. Estrogen, but not progesterone substitution, restored sex-specific differences in vasoconstriction and vasorelaxation. Vascular mRNA levels of ß1- and ß3- but not ß2-adrenoreceptors were higher in vessels of females compared with males. Ovariectomy reduced these differences by decreasing ß1- and ß3- but not ß2-adrenoreceptor expression in females. Consistently, estrogen substitution restored ß1- and ß3-adrenoreceptor expression. Orchiectomy or testosterone treatment affected neither vasoconstriction and vasorelaxation nor ß-adrenoceptor expression in vessels of male rats. In human mammary arteries, sex-specific differences in vasoconstriction and vasorelaxation were reduced after removal of endothelium or treatment with l-NMMA. Vessels of women showed higher levels of ß1- and ß3-adrenoceptors than in men. In conclusion, the sex-specific differences in vasoconstriction and vasorelaxation are common for rat and human vessels. In rats, these differences are estrogen but not testosterone or progesterone dependent. Estrogen determines these differences via regulation of vascular endothelial ß1- and ß3-adrenoreceptor expression. NEW & NOTEWORTHY This study proposes a mechanistic concept regulating sex-specific differences in adrenergic vasoconstriction and vasorelaxation. Estrogen increases vascular ß1- and ß3-adrenoceptor expression in female rats. This and our previous studies demonstrate that these receptors are located primarily on endothelium and when activated by norepinephrine act via nitric oxide (NO). Therefore, ß-adrenergic stimulation leads to a more pronounced vasorelaxation in females. Coactivation of endothelial ß1- and ß3-adrenoreceptors leads to higher NO release in vessels of females, ultimately blunting vasoconstriction triggered by activation of smooth muscle α-adrenoceptors.