A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study.

BACKGROUND AND AIMS: There is significant potential to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the effect of implementing BENCHMARK best practices on the efficiency and safety of TAVI in 28 sites in 7 European countries. METHODS: This was a study of patients with severe symptomatic aortic stenosis (AS) undergoing TAVI with balloon-expandable valves before and after implementation of BENCHMARK best practices. Principal objectives were to reduce hospital length of stay (LoS) and duration of intensive care stay. Secondary objective was to document patient safety. RESULTS: Between January 2020 and March 2023, 897 patients were documented prior to and 1491 patients after the implementation of BENCHMARK practices. Patient characteristics were consistent with a known older TAVI population and only minor differences. Mean LoS was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001). Duration of intensive care was reduced from 1.8 to 1.3 days (median 1.1 vs. 0.9 days; P < .001). Adoption of peri-procedure best practices led to increased use of local anaesthesia (96.1% vs. 84.3%; P < .001) and decreased procedure (median 47 vs. 60 min; P < .001) and intervention times (85 vs. 95 min; P < .001). Thirty-day patient safety did not appear to be compromised with no differences in all-cause mortality (0.6% in both groups combined), stroke/transient ischaemic attack (1.4%), life-threatening bleeding (1.3%), stage 2/3 acute kidney injury (0.7%), and valve-related readmission (1.2%). CONCLUSIONS: Broad implementation of BENCHMARK practices contributes to improving efficiency of TAVI pathway reducing LoS and costs without compromising patient safety.

Statin loading before coronary artery bypass grafting: a randomized trial.

AIMS: Evidence suggests that a high-dose statin loading before a percutaneous coronary revascularization improves outcomes in patients receiving long-term statins. This study aimed to analyse the effects of such an additional statin therapy before surgical revascularization. METHODS AND RESULTS: This investigator-initiated, randomized, double-blind, and placebo-controlled trial was conducted from November 2012 to April 2019 at 14 centres in Germany. Adult patients (n = 2635) with a long-term statin treatment (≥30 days) who were scheduled for isolated coronary artery bypass grafting (CABG) were randomly assigned to receive a statin-loading therapy or placebo at 12 and 2 h prior to surgery using a web-based system. The primary outcome of major adverse cardiac and cerebrovascular events (MACCE) was a composite consisting of all-cause mortality, myocardial infarction (MI), and a cerebrovascular event occuring within 30 days after surgery. Key secondary endpoints included a composite of cardiac death and MI, myocardial injury, and death within 12 months. Non-statistically relevant differences were found in the modified intention-to-treat analysis (2406 patients; 1203 per group) between the statin (13.9%) and placebo groups (14.9%) for the primary outcome [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.74-1.18; P = 0.562] or any of its individual components. Secondary endpoints including cardiac death and MI (12.1% vs. 13.5%; OR 0.88, 95% CI 0.69-1.12; P = 0.300), the area under the troponin T-release curve (median 0.398 vs. 0.394 ng/ml, P = 0.333), and death at 12 months (3.1% vs. 2.9%; P = 0.825) were comparable between treatment arms. CONCLUSION: Additional statin loading before CABG failed to reduce the rate of MACCE occuring within 30 days of surgery.

Improving the effectiveness of CPR during interventional procedures.

INTRODUCTION: The number of interventional procedures, such as transcatheter aortic valve replacements or thoracic endovascular aortic repairs, is on the rise. Intraprocedural cardiac arrest is a rare occurrence during high-risk procedures. Modern hybrid-operating tables may adversely affect chest compression quality due to their flexibility. To investigate this relationship, we analyzed the blood pressure generated during chest compressions at different degrees of table extension and assessed the effect of an additional stabilization bar to secure the table. METHODS: A CPR manikin was connected to online blood pressure monitoring on a hybrid operating table. Chest compressions were administered using a mechanical device (at 100 bpm and 80 bpm). Hemodynamic effects were evaluated at various degrees of table extension (0%, 50%, 100% table extension) and with the addition of a stabilization bar. RESULTS: A greater degree of table extension was associated with lower diastolic blood pressure. The addition of a stabilization bar alleviated this drop in diastolic blood pressure and enabled the generation of higher mean arterial pressures at 50% and 100% table extension during chest compressions. CONCLUSION: The flexibility of a hybrid operating table adversely impacts the hemodynamic effect of chest compressions. This effect may be mitigated by using a stabilization bar. These results may be relevant for providing further recommendations for CPR guidelines in hybrid OR settings.

Impact of pulmonary hypertension on short-term outcomes in patients undergoing surgical aortic valve replacement for severe aortic valve stenosis.

OBJECTIVES: In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center. METHODS: In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data. RESULTS: Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR. CONCLUSION: In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.

Surgical Versus Interventional Treatment of Major Access Site Complications During Transfemoral TAVI Procedures at a Large Volume Center.

PURPOSE: Access-related vascular complications in transfemoral transcatheter aortic valve implantation (TAVI) can be treated endovascularly or surgically. The aim of this study was to evaluate the short- and long-term outcomes of endovascular treatment compared with surgical repair for access-related vascular complications. METHODS: This retrospective study was performed from January 1, 2018, to December 31, 2020. All transfemorally treated TAVI patients in whom a surgical or endovascular treatment for an access site complication was needed were included. The primary outcome was the need for any related vascular re-operation. RESULTS: In total, 1219 transfemoral TAVI procedures were conducted during the study period. 19 patients suffered an access complication requiring endovascular treatment, while 54 patients required surgical repair. No differences were seen with regard to re-operations (endovascular 15.8% vs surgical 14.8%; p=0.919), wound infections (endovascular 0% vs surgical. 11.1%; p=0.129), and wound healing disorders (endovascular 15.8% vs surgical 29.6%; p=0.237). Patients undergoing endovascular treatment were discharged earlier (endovascular 11.2 vs surgical 14.9 days; p=0.028). After surgical repair, patients received significantly more blood transfusions than endovascularly treated patients (endovascular 1.00 vs surgical 3.1 red blood cell concentrate bags; p<0.001). No differences were found regarding the new onset of walking pain, rest pain, and ischemic ulcers during follow-up. CONCLUSION: In this retrospective cohort, endovascular treatment of access-related vascular complications of transfemoral TAVI procedures was safe and feasible. During the hospital stay, endovascularly treated patients received fewer blood transfusions and were discharged faster than surgically treated patients. No differences regarding clinical outcomes and re-intervention rates were seen during the follow-up. CLINICAL IMPACT: Given the in this retrospective study demonstrated safety and feasibility of endovascular treatment for major access-related vascular complications, along with the in-hospital benefits and absence of follow-up disadvantages compared to surgical treatment, endovascular treatment should be considered in cases of major access-related vascular complications in transfemoral TAVI patients.

The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival. METHODS: From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters. RESULTS: Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005). CONCLUSION: In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.

Factor Xa Inhibitors for Patients after Mechanical Heart Valve Replacement?

Patients with a mechanical heart valve need a lifelong anticoagulation due to the increased risk of valve thrombosis and thrombo-embolism. Currently, vitamin K antagonists (VKA) are the only approved class of oral anticoagulants, but relevant interactions and side effects lead to a large number of patients not achieving the optimal therapeutic target international normalized ration (INR). Therefore, steady measurements of the INR are imperative to ensure potent anticoagulation within a distinctive range. Direct oral anticoagulants (DOACs) with newer agents could serve as a possible alternative to VKAs in this patient cohort. DOACs are approved for several indications, e.g., atrial fibrillation (AF). They only have a minor interaction potential, which is why monitoring is not needed. Thereby, DOACs improve the livability of patients in need of chronical anticoagulation compared with VKAs. In contrast to dual platelet inhibition using aspirin in combination with an ADP receptor antagonist and the direct thrombin inhibitor dabigatran, the oral factor Xa inhibitors apixaban and rivaroxaban show promising results according to current evidence. In small-scale studies, factor Xa inhibitors were able to prevent thrombosis and thrombo-embolic events in patients with mechanical heart valves. Finally, DOACs seem to represent a feasible treatment option in patients with mechanical heart valves, but further studies are needed to evaluate clinical safety. In addition to the ongoing PROACT Xa trial with apixaban in patients after aortic On-X valve implantation, studies in an all-comer collective with rivaroxaban could be promising.

Surgical versus Interventional Treatment of Concomitant Aortic Valve Stenosis and Coronary Artery Disease.

BACKGROUND: Coronary artery disease (CAD) is frequently diagnosed in patients with aortic valve stenosis. Treatment options include surgical and interventional approaches. We therefore analyzed short-term outcomes of patients undergoing either coronary artery bypass grafting with simultaneous aortic valve replacement (CABG + AVR) or staged percutaneous coronary intervention and transcatheter aortic valve implantation (PCI + TAVI). METHODS: From all patients treated since 2017, we retrospectively identified 237 patients undergoing TAVI within 6 months after PCI and 241 patients undergoing combined CABG + AVR surgery. Propensity score matching was performed, resulting in 101 matched pairs. RESULTS: Patients in the CABG + AVR group were younger compared with patients in the PCI + TAVI group (71.9 ± 4.9 vs 81.4 ± 3.6 years; p < 0.001). The overall mortality at 30 days before matching was higher after CABG + AVR than after PCI + TAVI (7.8 vs 2.1%; p = 0.012). The paired cohort was balanced for both groups regarding demographic variables and the risk profile (age: 77.2 ± 3.7 vs78.5 ± 2.7 years; p = 0.141) and EuroSCORE II (6.2 vs 7.6%; p = 0.297). At 30 days, mortality was 4.9% in the CABG + AVR group and 1.0% in the PCI + TAVI group (p = 0.099). Rethoracotomy was necessary in 7.9% in the CABG + AVR, while conversion to open heart surgery was necessary in 2% in the PCI + TAVI group. The need for new pacemaker was lower after CABG + AVR than after PCI + TAVI (4.1 vs 6.9%; p = 0.010). No paravalvular leak (PVL) was noted in the CABG + AVR group, while the incidence of moderate-to-severe PVL after PCI + TAVI was 4.9% (p = 0.027). CONCLUSION: A staged interventional approach comprises a short-term survival advantage compared with combined surgery for management of CAD and aortic stenosis. However, PCI + TAVI show a significantly higher risk of atrioventricular block and PVL. Further long-term trials are warranted.

Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era?

BACKGROUND: The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training. METHODS: Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching. RESULTS: The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable. CONCLUSION: Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option.

Valve-in-Valve TAVR versus Redo Surgical Aortic Valve Replacement: Early Outcomes.

OBJECTIVE: This study aimed to assess short-term outcomes of patients with failed aortic valve bioprosthesis undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) or redo surgical aortic valve replacement (rSAVR). METHODS: Between 2009 and 2019, 90 patients who underwent ViV-TAVR (n = 73) or rSAVR (n = 17) due to failed aortic valve bioprosthesis fulfilled the inclusion criteria. Groups were compared regarding clinical end points, including in-hospital all-cause mortality. Patients with endocarditis and in a need of combined cardiac surgery were excluded from the study. RESULTS: ViV-TAVR patients were older (78.0 ± 7.4 vs. 62.1 ± 16.2 years, p = 0.012) and showed a higher prevalence of baseline comorbidities such as atrial fibrillation, diabetes mellitus, hyperlipidemia, and arterial hypertension. In-hospital all-cause mortality was higher for rSAVR than in the ViV-TAVR group (17.6 vs. 0%, p < 0.001), whereas intensive care unit stay was more often complicated by blood transfusions for rSAVR patients without differences in cerebrovascular events. The paravalvular leak was detected in 52.1% ViV-TAVR patients compared with 0% among rSAVR patients (p < 0.001). CONCLUSION: ViV-TAVR can be a safe and feasible alternative treatment option in patients with degenerated aortic valve bioprosthesis. The choice of treatment should include the patient's individual characteristics considering ViV-TAVR as a standard of care.

Outcomes and Characteristics of Patients with Intraprocedural Cardiopulmonary Resuscitation during TAVR.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement (AVR) for higher risk patients. Periprocedural TAVR complications decreased with a growing expertise of implanters. Yet, TAVR can be accompanied by life-threatening adverse events such as intraprocedural cardiopulmonary resuscitation (CPR). This study retrospectively analyzed predictors and outcomes in a cohort of patients from a high-volume center undergoing periprocedural CPR during TAVR. METHODS: A total of 729 patients undergoing TAVR, including 59 with intraprocedural CPR, were analyzed with respect to peri- and postprocedural outcomes. RESULTS: Patients undergoing CPR showed a significantly lower left ventricular ejection fraction (LVEF) and lower baseline transvalvular mean and peak pressure gradients. The systolic blood pressure measured directly preoperatively was significantly lower in the CPR cohort. CPR patients were in a higher need for intraprocedural defibrillation, heart-lung circulatory support, and conversion to open heart surgery. Further, they showed a higher incidence of atrioventricular block grade III , valve malpositioning, and pericardial tamponade. The in-hospital mortality was significantly higher after intraprocedural CPR, accompanied by a higher incidence of disabling stroke, new pacemaker implantation, more red blood cell transfusion, and longer stay in intensive care unit. CONCLUSION: Impaired preoperative LVEF and instable hemodynamics before valve deployment are independent risk factors for CPR and are associated with compromised outcomes. Heart rhythm disturbances, malpositioning of the prosthesis, and pericardial tamponade are main causes of the high mortality of 17% reported in the CPR group. Nevertheless, mechanical circulatory support and conversion to open heart surgery reduce mortality rates of CPR patients.

Predictors of acute kidney injury in patients after extracorporeal cardiopulmonary resuscitation.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared with conventional CPR. Data after eCPR for acute kidney injury (AKI) are lacking. We sought to investigate factors predicting AKI in patients who underwent eCPR. METHODS: From January 2016 until December 2020, patients who underwent eCPR at our institution were retrospectively analyzed and divided into two groups: patients who developed AKI (n = 60) and patients who did not develop AKI (n = 35) and analyzed for outcome parameters. RESULTS: Overall, 63% of patients suffered AKI after eCPR and 45% of patients who developed AKI needed subsequent dialysis. Patients who developed AKI showed higher values of creatinine (1.1 mg/dL vs 1.5 mg/dL, p ⩽ 0.01), urea (34 mg/dL vs 42 mg/dL, p = 0.04), CK (creatine kinase) (923 U/L vs 1707 U/L, p = 0.07) on admission, and CK after 24 hours of ECMO support (1705 U/L vs 4430 U/L, p = 0.01). ECMO explantation was significantly more often performed in patients who suffered AKI (24% vs 48%, p = 0.01). In-hospital mortality (86% vs 70%; p = 0.07) did not differ significantly. CONCLUSION: Patients after eCPR are at high risk for AKI, comparable to those after conventional CPR. Baseline urea levels predict the development of AKI during the hospital stay.

Clinical results and 30-day outcomes of self-expanding transcatheter aortic valves: comparative case-matched analysis of CoreValve® versus ACURATE neo™.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is associated with excellent results in patients with severe aortic stenosis. In highly calcified aortic anuli with increased risk of annulus rupture and in favor of the supra-annular design, self-expandable prostheses are frequently used. In this regard, we aimed to perform a comparative analysis of clinical and 30-day outcomes after TAVR using the self-expanding CoreValve® Evolut R or ACURATE neo™ prosthesis. METHODS: Out of 343 consecutive patients treated with either CoreValve® Evolut R or ACURATE neo™ from January 2014 to December 2017, 76 patients were assigned each per group after 1:1 propensity score matching in regard of preoperative characteristics. Pre- and periprocedural outcomes were retrospectively collected and assessed. Outcomes at 30 days are reported according to the established Valve Academic Research Consortium (VARC-2) criteria. RESULTS: Device success and 30-day survival accounted for 93.4% (n = 71), respectively 97.4% (n = 74) in both groups (p = 1.00). No statistically significant differences regarding clinical parameters were observed. The combined safety endpoint at 30 days was comparable (84.2% (n = 64) CoreValve® vs 85.5% (n = 65) ACURATE neo™; p = 0.848). Except a trend toward higher stroke (p = 0.08) and pacemaker (p = 0.07) rate in the CoreValve® group, major vascular complications, incidence of life-threatening or disabling bleeding, and incidence of postoperative acute kidney injury were comparable. Postoperative hemodynamic parameters showed no significant differences between the implanted valves. CONCLUSION: Both self-expandable prostheses showed good postoperative hemodynamic performance with a low incidence of severe paravalvular leakage, all- cause mortality, and comparable clinical outcomes.

Heart surgery and simultaneous carotid endarterectomy - 10-years single-center experience.

BACKGROUND: Patients with coronary artery heart disease frequently suffer concomitant carotid vascular disease and are at high perioperative risk for neurological adverse events. Several concepts regarding the timing and modality of carotid revascularization are controversially discussed in patients with heart disease. Current guidelines recommendations on myocardial revascularization recommend a concomitant carotid endarterectomy (CEA) in patients with a history of stroke/transient ischemic attack (TIA) or 50-99% grade of the carotid stenosis. Our study aimed to analyze early outcome parameters of patients undergoing coronary artery bypass grafting (CABG), but also including concomitant heart valve surgery and simultaneous CEA. METHODS: This study retrospectively analyzed a cohort of 111 patients from our institutional database undergoing heart surgery with CABG or heart-valve surgery between 2010 and 2020 with concomitant carotid surgery due to significant carotid stenosis. RESULTS: Patients undergoing heart and simultaneous carotid surgery were 77 ± 8.0 years of age with a body mass index of 28 ± 1.7 kg/m2 and a mean EuroSCORE II of 6.5 ± 2.3. Most patients (61%) had a smoking history and arterial hypertension (97%). The preoperative mean grade of internal carotid stenosis was 87 ± 4.2%, 13% of patients suffered from internal carotid artery stenosis on both sites. In total, 4.5% of patients had previously undergone internal carotid artery intervention before and 6.3% had a history of stroke with a persistent neurologic disorder in 1.8%, 8.9% of cases had prior TIA. Thirty-day all-cause mortality was 6.3% and postoperative neurologic events occurred with 7.2% TIA and 4.5% of disabling stroke. CONCLUSION: Within the reported patient population of coronary artery heart disease and significant internal carotid stenosis, a one-time approach with CABG or heart-valve surgery and CEA is safe and feasible as justified by clinical and neurological postoperative outcomes.

Risk factors associated with in-hospital mortality for patients with ECLS due to postcardiotomy cardiogenic shock after isolated coronary surgery.

OBJECTIVES: Extracorporeal membrane oxygenation or extracorporeal life support (ECLS) in patients after cardiac surgery and postcardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. The aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG. METHODS: Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analyzed with risk factors of in-hospital mortality. RESULTS: In-hospital mortality added up to 61 patients (66%). Non-survivors were significantly older (60 ± 812 (S) vs. 67 ± 10 (NS); p = 0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p = 0.001). After 24 h of ECLS support, median lactate levels were significantly higher in NS (1.9 (1.3; 3.5) mmol/L (S) vs. 3.5 (2.1; 6.3) mmol/L (NS); p = 0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p = 0.002). CONCLUSION: Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.

Impact of left ventricular unloading using a peripheral Impella®-pump in eCPR patients.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to increasing survival rates in selected patients. Additional left ventricular mechanical unloading, using a transfemoral micro-axial blood pump (Impella® Denver, Massachusetts, USA), might improve patients' outcomes. In this regard, we sought to investigate patients who suffered OHCA (out-of hospital cardiac arrest) or IHCA (in-hospital cardiac arrest) with subsequent eCPR via VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and concomitant Impella® implantation based on survival and feasibility of ECMO weaning. METHODS: From January 2016 until December 2020, 108 patients underwent eCPR at our institution. Data prior to eCPR and early outcome parameters were analyzed comparing patients who were supported with an additional Impella® (2.5 or CP) (ECMO+Impella®, n = 18) and patients without additional (ECMO, n = 90) support during V-A ECMO therapy. The primary endpoint was in-hospital mortality; secondary endpoints were, among others: ECMO explantation, need for hemodialysis, stroke, and need for blood transfusions. RESULTS: Low-flow time was significantly lower in the ECMO+Impella group (60 min vs. 55 min, p = .01). All-cause mortality was significantly lower in the ECMO+Impella® group (82% vs. 56%, p = .01). The time of circulatory support was shorter in the ECMO cohort (2.0 ± 1.73 vs. 4.76 ± 2.88 p = .05). ECMO decannulation was significantly more feasible in patients with ECMO+Impella® (72% vs. 32%, p = .01). Patients treated with additional Impella® showed significantly more acute kidney injury with the need for dialysis (72% vs. 18%, p ≤ .01). CONCLUSION: Concomitant Impella® support might positively influence survival and ECMO weaning in eCPR patients. Treatment-associated complications such as the need for dialysis were more common in this highly selected patient group. Further studies with larger numbers are necessary to evaluate the clinical relevance of concomitant LV-unloading in eCPR patients using an Impella® device.

Ten-Year Long-Term Analysis of Mechanical and Biological Aortic Valve Replacement.

BACKGROUND: For patients undergoing aortic valve replacement (AVR), structural valve deterioration (SVD) of a bioprosthesis (BP) is substantially accelerated in younger patients and valve-in-valve implantation is not always a considerable option. The risk-benefit assessment between SVD versus the risk of bleeding and thromboembolic events in patients with a mechanical prosthesis (MP) resulted in an age limit shift irrespective of inconsistent results reported in literature. METHOD: This retrospective single-center study compared 10-year long-term outcomes in patients undergoing isolated AVR with MP or BP. The risk-adjusted comparison of patients undergoing isolated AVR (n = 121) was performed after 1:1 propensity score matching (PSM) for age, sex, endocarditis, and chronic renal impairment (caliper of 0.2) leading to 29 pairs. Short- and long-term outcomes with respect to reoperation, major bleeding, stroke, all-cause and cardiovascular mortality, and overall survival at 10 years were analyzed. RESULTS: After PSM, groups were comparable with respect to preoperative characteristics, including patients with a mean age of 65 ± 3 years (MP) and 66 ± 4 years (BP) and an incidence rate of 6.9% for infective endocarditis in both cohorts. Short-term outcomes (transient neurologic disorder = 0.0 vs. 6.9%; stroke = 0.0%; in-hospital mortality = 3.4%) and in-hospital stays were comparable between MP and BP. CONCLUSION: After isolated AVR with MP and BP, 10-year long-term outcomes were comparable in the reported single-center cohort. MP can still be implanted safely without a disadvantage as regards long-term survival.

Mitral valve surgery after failed MitraClip-Operation for the inoperable?

BACKGROUND: Percutaneous edge-to-edge mitral valve repair technique (MitraClip) is a widely used treatment for mitral regurgitation (MR) in patients assessed with high surgical risk or inoperability. Only limited experiences with this highest-risk patient population exist. Procedural failure for MitraClip or recurrent MR is a strong predictor of 1-year mortality. Open mitral valve surgery constitutes the last bailout for patients within this cohort. METHODS: This retrospective single-center cohort study analyzed 17 mitral valve surgery patients after failed MitraClip. We, therefore, analyzed a high-risk patient population (EuroSCORE II = 10 ± 2.0) with persistent mitral valve regurgitation, which was mainly caused by detachment or dislocation of the MitraClip. RESULTS: Symptomatic patients with failed MitraClip need a convenient operation (mean time to mitral valve surgery = 23 ± 44 days). The patient's collective showed many complex reoperations with the need for concomitant surgery. Considering the high-risk patient population, we showed an average 30-day all-cause mortality (18%, n = 3) accompanied by typical postoperative complications related to prolonged mechanical ventilation (44 ± 48 h) and ICU stay (11 ± 11 days), reflecting high-risk patients. Further, excellent valve-related outcomes were shown regarding adverse cardiac events (valve-related mortality 6%, n = 1) and postoperative echocardiographic results (moderate or severe paravalvular leak 6%, n = 1). CONCLUSION: Failure of MitraClip represents a challenging situation limited by high-risk profiles of patients and limits the possibility of surgical valve repair, shown by a high rate of mitral valve replacement (94%, n = 16). Secondary surgery was associated with moderate 30-day and postdischarge outcomes. Therefore, a careful evaluation of patients undergoing MitraClip is of paramount importance.

Results and outcomes for patients with atrioventricular groove disruption after mitral valve surgery.

BACKGROUND: Atrioventricular groove disruption (AVGD) is a rare and severe complication of mitral valve surgery (MVS). Current literature is limited to several case reports and series. Our aim was to analyze outcomes of patients with AVGD after MVS from our tertiary cardiac surgery center. METHODS: Between June 2010 and January 2019, 18 patients suffering AVGD were identified in our institutional database and included in our retrospective observation. Preoperative, intraoperative and outcome data were analyzed using IBM SPSS Statistics. Late survival was estimated by using the Kaplan-Meier survival analysis. RESULTS: The mean age of the study population was 76 ± 5 years. Most common indication for MVS was an isolated mitral valve insufficiency (67%). Severe annular calcification was present in four patients (22%). Majority of implanted valves were biological prosthesis (78%). Due to the location, 72% suffered type I rupture. External repair was performed in 94% of all patients. Second look operation in regard of excessive mediastinal hemorrhage was necessary in 67% of patients. Mean hospital stay of the presented collective was 13 ± 11 days with an intra-hospital mortality of 56%. Late follow-up was obtained in eight patients at an average of 3.1 (1.6-5.7) years postoperatively. CONCLUSION: Mortality rates for AVGD after MVS are high. However, way of managing AVGD depends on the underlying type of rupture and should be evaluated in regard of the myocardial damage. Due to the rare occurrence, registry data might help to address more scientific value concerning therapeutic measures and outcomes of this severe complication.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: first results and outcomes of a newly established ECPR program in a large population area.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) is associated with excessively high mortality rates. Recent studies suggest benefits from extracorporeal cardiopulmonary resuscitation (ECPR) performed in selected patients. We sought to present the first results from our interdisciplinary ECPR program with a particular focus on early outcomes and potential risk factors associated with in-hospital mortality. METHODS: Between January 2016 and December 2019, 44 patients who underwent ECPR selected according to our institutional ECPR protocol were retrospectively analyzed regarding pre-hospital, in-hospital, and early outcome parameters. Patients were divided into survivors (S) and non-survivors (NS). Statistical analysis of risk factors regarding in-hospital mortality of the patient cohort analyzed was performed. RESULTS: The mean age of the population was 53 ± 12 years, with most patients being male (n = 40). The leading cause of cardiac arrest (CA) was myocardial infarction (n = 24, 55%). The median hospital stay was 1 (1;13) day. Twenty-three percent of patients (n = 10) were discharged from hospital including eight patients (18%) with CPC 1-2. Survivors showed a trend toward shorter pre-hospital CPR duration (60 (59;60) min (S) vs 60 (55;90) min (NS), p = 0.07). CONCLUSION: Establishing ECPR programs in large population areas offers the option to improve survival rates for OHCA patients. Stringent compliance of institutional criteria (mainly age, witnessed arrest, and time of pre-hospital resuscitation) and providing ECPR to strictly selected patients seems to be a vital factor for such programs' success. Pre-clinical settings and therapeutic measures must be adjusted in this regard to improve outcomes for this highly demanding patient cohort.