Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center.

BACKGROUND: We evaluate the outcome of aortic root surgery via an upper J: -shaped mini-sternotomy (MS) versus full sternotomy (FS) in an intermediate-volume center. METHODS: Between November 2011 and February 2019, 94 consecutive patients underwent aortic root surgery: 62 (66%) patients were operated via a J: -shaped MS (group A) and 32 (34%) patients via FS (group B). The primary endpoints were mortality, major adverse cardiac and cerebral events (MACCE), and reoperation in a 2-year follow-up. The secondary endpoints were perioperative complications and patient's satisfaction with the procedural results. RESULTS: Valve sparing root replacement (David procedure) was performed in 13 (21%) of the MS and 7 (22%) of the FS patients. The Bentall procedure in MS versus FS was 49 (79%) versus 25 (78%), respectively. Both groups presented similar mean operation, cardiopulmonary bypass, and cross-clamp times. Postoperative bleeding was 534 ± 300 and 755 ± 402 mL (p = 0.01) in MS and FS, respectively, erythrocyte concentrate substitution was 3 ± 3 and 5.3 ± 4.8 (p = 0.018) in MS and FS, respectively, and pneumonia rates were 0 and 9.4% (p = 0.03) in MS and FS, respectively. The 30-day mortality was 0% in both groups, whereas MACCE was 1.6 and 3% (p = 0.45) in MS and FS, respectively. After 2 years, the mortality and MACCE were 4.6 and 9.5% (p = 0.11) and 4.6 and 0% (p = 0.66) in MS and FS, respectively. The number of patients who were satisfied with the surgical cosmetic results in groups A and B was 53 (85.4%) and 26 (81%), respectively. CONCLUSION: Aortic root surgery via MS is a safe alternative to FS even in an intermediate-volume center. It offers a shorter recovery time and similar midterm results.

Outcomes in Patients with Left Bundle Branch Block after Rapid Deployment Aortic Valve Replacement.

OBJECTIVES: Increased rates of postoperative left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) frequently occur after implantation of rapid deployment valves. The impact of LBBB on follow-up outcomes remains controversial. So far, no data regarding long-term outcomes exist. AIM: The aim of this study was to analyze the impact of LBBB on postoperative outcomes after rapid deployment aortic valve replacement (RDAVR). METHODS: A total of 620 consecutive patients without preexisting LBBB or PPI who underwent rapid deployment AVR between March 2012 and September 2019 were included. New-onset LBBB was defined as any new LBBB that persisted at hospital discharge. The median follow-up time for clinical data was 1.7 years post-RDAVR. RESULTS: At discharge, new-onset LBBB was seen in 109 patients (17.5%). There were no differences between the LBBB groups and no-LBBB groups regarding baseline characteristics. At a median follow-up of 1.7 years, no difference was found between LBBB groups and no-LBBB groups concerning all-cause mortality (12.8 vs. 11.7%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.74-1.53; p = 0.54). Nevertheless, new-onset LBBB was associated with significant higher pacemaker implantation rates at follow-up (10.1 vs. 6.3%; HR: 3.58; 95% CI: 1.89-6.81 p < 0.001). CONCLUSION: After a median follow-up of 1.7 years, new-onset LBBB was not associated with increased mortality. Nevertheless, higher pacemaker implantation rates were observed in patients with new-onset LBBB after RDAVR.

Use of On-Site Digital Subtraction Angiography for Left Subclavian Artery Management During Hybrid Aortic Arch Repair in DeBakey I Dissection.

PURPOSE: A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies. CASE REPORT: We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days. CONCLUSION: Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

Incidence and Impact of Routine Inflammatory Parameters on Outcome after Transcatheter Aortic Valve Replacement.

BACKGROUND: Previous research reported adverse clinical outcomes in association with systemic inflammation (SI) after transcatheter aortic valve replacement (TAVR). However, data characterizing the impact of SI, as reflected by postprocedural routine inflammatory parameters (pRIP), on clinical outcome of patients undergoing TAVR are sparse. OBJECTIVES: In light of this, the present work aimed to analyze incidence and clinical significance of pRIP after transapical (TA) and transfemoral (TF)-TAVR. METHODS AND RESULTS: Data of 81 high-risk consecutive patients undergoing TAVR in our center from 2017 to 2018 were analyzed in a retrospective manner. 40 out of 81 patients (49, 4%) were treated via TF access (group A) and 41 patients via TA access (group B). Incidence, cause, and amplitude of pRIP were analyzed in relation to pre- and peri-interventional data. Assessment of outcomes was conducted according to the valve academic research consortium (VARC-2). Postprocedural C-reactive protein (pCRP) and leucocytes (pL) were significantly increased in patients undergoing TA-TAVR (group B) vs. TF-TAVR (group A; 12.1 ± 9.7 vs. 22.1 ± 7.9 mg/dl, p < 0.001 and 12.8 ± 4.0 vs. 14.2 ± 3.8/nl, p = 0.002); however, there was no significant difference regarding incidence of postprocedural fever (pF) ≥38.0°C (12.5% vs. 22%, p = 0.37). Furthermore, we observed a vast (though insignificant) trend towards a longer fever duration in group B vs. group A (9.9 ± 14.9 vs. 3.2 ± 5.9 hours, p = 0.06). Further analysis identified pCRP >30 mg/dl (hazard ratio (HR) 3.15, confidence interval (CI) 1.22-8.14, p = 0.018) and European System for Cardiac Operative Risk Evaluation (logistic EuroSCORE I (ES)) >20% (HR 2.95, CI 1.17-7.47, p = 0.02) as predictors of mortality; in this context, we also discovered a marginally significant trend for pL > 14/nl (HR 2.44, CI 0.97-6.14, p = 0.05). Multivariate analysis by use of the fisher`s exact test revealed a significant association between pCRP >30 mg/dl and ES >20% (p < 0.001). CONCLUSION: pRIP are significantly increased in patients undergoing TA-TAVR. pCRP >30 mg/dl, ES>20%, and pL > 14/nl are hallmark of adverse prognosis and require further investigation.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions.

OBJECTIVES: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures. METHODS: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared. RESULTS: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02). CONCLUSIONS: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

Outcomes after transcatheter aortic valve replacement in older patients.

BACKGROUND: The prevalence of aortic valve stenosis is increasing due to the continuously growing geriatric population. Data on procedural success and mortality of very old patients are sparse, raising the question of when this population may be deemed as "too old even for transcatheter aortic valve replacement (TAVR)." We, therefore, sought to evaluate the influence of age on outcome after TAVR and the impact of direct implantation. METHODS: The data of 394 consecutive patients undergoing TF-TAVR were analyzed. Patients were divided into four age groups: ≤75 (group 1, n = 28), 76-80 (group 2, n = 107), 81-85 (group 3, n = 148), and >85 (group 4, n = 111) years. Direct implantation was performed when possible according to current recommendations. Survival was evaluated by Kaplan-Meier analysis. RESULTS: Mortality at 30 days and 1 year was not significantly different between the four age groups (3.6 vs. 6.7 vs. 5.4 vs. 2.7% and 7.6 vs. 17 vs. 14.5 vs. 13%m respectively, log-rank p = 0.59). Direct implantation without balloon aortic valvuloplasty was more frequently performed on patients aged >85 vs. ≤85 years (33.3 vs. 14.1%, p < 0.001). the incidence of procedural complications frequently associated with advanced age (stroke, vascular complications) was not significantly increased in group 4. CONCLUSION: Outcome after TF-TAVR is comparable among different age cohorts, even in very old patients. Direct implantation simplifies the procedure and could therefore play a role in reducing the incidence of peri-interventional complications in patients of advanced age.

Single-Center Outcomes with Rapid Deployment Aortic Valve Replacement.

OBJECTIVES: Rapid-deployment valves can reduce procedural times and may facilitate minimally invasive surgery. In our institution, more than 500 patients underwent rapid deployment aortic valve replacement (AVR). METHODS: A total of 510 patients underwent rapid deployment AVR between March 2012 and September 2017, of whom 270 patients underwent isolated AVR and 240 underwent AVR with concomitant procedures. The cumulative follow-up time was 1,444 patient-years, the median follow-up time 2.8 years, respectively RESULTS: An early all-cause mortality of 3.5% (n = 18) was seen with a cumulative survival of 91.9 ± 2.2% after 12 months. Mean cross-clamp times were 37 ± 19 minutes for isolated AVR and 93 ± 29 minutes for AVR with concomitant procedures. The rate of new pacemaker implantation was 7.8% (n = 40). No case of structural degeneration occurred in the follow-up. Three (0.6%) cases of endocarditis were registered. CONCLUSIONS: Rapid deployment AVR can be performed safely with low complication rates and good hemodynamic results. Therefore, the relevance in aortic valve surgery can be stressed.

Undersizing but overfilling eliminates the gray zones of sizing for transcatheter aortic valve replacement with the balloon-expandable bioprosthesis.

BACKGROUND: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing. METHODS: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics. RESULTS: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physicians choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005). CONCLUSION: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.

Intermediate Outcomes after Rapid Deployment Aortic Valve Replacement in Multiple Valve Surgery.

BACKGROUND: Multiple valve surgery is associated with significant higher operative risks. Reduced cross-clamp and cardiopulmonary bypass times in multiple valve surgery may potentially be beneficial as they can be considered independent risk factors for increased morbidity and mortality following cardiac surgery. We report first intermediate outcomes of the Edwards Intuity valve system (Edwards Lifesciences, Irvine, California, United States) in combined procedures METHODS: Fifty-eight patients underwent rapid deployment aortic valve replacement with concomitant mitral valve surgery between January 2014 and November 2017 in our institution. The valve was assessed echocardiographically after 12 months. The median follow-up was 1.7 years with a cumulative follow-up time of 115.3 patient years. RESULTS: The mean age was 73.5 ± 6.2 years and the mean logistic Euroscore was 11.6 ± 3.1%. Concomitant mitral valve repair was performed in 43 cases (74.1%), and mitral valve replacement in 15 cases (19.0%). The mean cross-clamp time was 93 ± 21 minutes along with a mean bypass time of 118 ± 24 minutes. All-cause mortality after 30 days was 8.6%. Overall actuarial survival at 1 year was 87.2 ± 4.5% and after 2 years 82.8 ± 5.3%, respectively. CONCLUSIONS: Rapid deployment aortic valve replacement in multiple valve surgery can be performed safely with good intermediate outcomes in elderly, high-risk patients.

Feasibility of Transfemoral Aortic Valve Implantation in Patients With Aortic Disease and Simultaneous or Sequential Endovascular Aortic Repair.

OBJECTIVES: The transfemoral approach for transcatheter aortic valve implantation (TF-TAVI) is associated with a significant survival benefit for intermediate and high-risk patients. Due to the increased procedural risk, many operators avoid TF-TAVI in patients with aortic disease. Moreover, significant peri-interventional device interaction may occur in patients with previous endovascular aortic repair (EVAR). We evaluated the feasibility of TF-TAVI in patients with aortic disease in combination with simultaneous or sequential EVAR. METHODS: Data from 15 TF-TAVI patients with concomitant aortic disease treated between 2009 and 2019 in three German heart centers representing 4410 TAVI procedures were analyzed. RESULTS: Two patients with progressive penetrating atherosclerotic ulcers (PAUs) in the descending thoracic aorta underwent sequential and simultaneous thoracic EVAR (TEVAR), respectively. One patient with stable PAU and 4 patients with not yet relevant abdominal aortic aneurysm (AAA) underwent isolated TF-TAVI. One patient with relevant AAA underwent TF-TAVI and sequential EVAR. Seven patients with previous EVAR due to an AAA underwent TF-TAVI (5 with a bifurcated graft and 2 with a straight graft). TF-TAVI and sequential or simultaneous TEVAR were technically successful in all patients. Vascular complications occurred in 1 patient. One patient died within 30 days and 2 patients died within 12 months. CONCLUSION: TF-TAVI can be performed successfully in patients with aortic disease or previous endovascular aortoiliac intervention. Simultaneous and sequential (T)EVAR is feasible.

Two-stage weaning strategy using veno-veno-arterial perfusion for patients on extracorporeal membrane oxygenation following cardiogenic shock.

OBJECTIVES: Veno-arterial extracorporeal membrane oxygenation represents the last therapy option in refractory cardiogenic shock. Successful weaning becomes difficult if the myocardial function recovers but pulmonary impairment persists. We present our experience with a new weaning strategy, using a stepwise mode-switch from veno-arterial to veno-veno-arterial and veno-venous extracorporeal membrane oxygenation setting for patients with primary cardiogenic shock and subsequent respiratory failure. METHODS: From 81 patients treated with veno-arterial extracorporeal membrane oxygenation following acute cardiogenic shock between January 2014 and April 2018, eight patients with cardiac and pulmonary failure were identified to be treated using the following protocol: patients were put on veno-arterial extracorporeal membrane oxygenation, a second inflow cannula was inserted via the right jugular vein and cardiac weaning was performed via veno-veno-arterial support. Finally, patients were pulmonary weaned via veno-venous extracorporeal membrane oxygenation mode. RESULTS: In the mode-switch group, etiologies of cardiogenic shock were cardiac arrest (12.5%), myocardial infarction (12.5%) and post-cardiotomic heart failure (75%). Mean time between onset of cardiogenic shock and start of veno-arterial extracorporeal membrane oxygenation was 76 ± 117 min. At implantation, lactate and pH values were 9.5 ± 5.0 mmol/L and 7.2 ± 0.2. Total extracorporeal membrane oxygenation-time was 9.3 ± 4.7 days, with a mode-switch from veno-arterial to veno-veno-arterial after 3.9 ± 2.7 days. The weaning rate in the mode-switch group was 75% (vs. 41% in the entire cohort) and the 30-day survival was 50% (vs 32% in the cohort). 38% of the patients presented a favorable neurological outcome. CONCLUSION: Mode-switch from veno-arterial to veno-veno-arterial and weaning via veno-venous extracorporeal membrane oxygenation mode is feasible for combined cardiac and pulmonary failure, with promising results due to an optimized pre-pulmonary oxygenation.

Open transcatheter aortic valve implantation on a degenerated bioprosthetic valve conduit.

The degeneration of bioprosthetic aortic Conduit with hemodynamic dysfunction mostly requires a re-do surgery, which is associated with an increased perioperative risk. Considering this, an open implantation of a transcatheter aortic bioprothesis (TAVI) after resection of the degenerated valve leaflets could be of great benefit, reducing cross-clamp and cardiopulmonary bypass duration, especially in combined surgery in high-risk patients. This is a case of a high-risk female (78 years, EuroScore 59%) treated with an open TAVI as an alternative to conventional valve or aortic conduit replacement for degenerative aortic valve due to endocarditis lente, 2 years following a bio-Bentall procedure.

Rapid deployment aortic valve replacement in a minimal access setting: intermediate clinical and echocardiographic outcomes.

OBJECTIVES: Transcatheter procedures have overtaken conventional operations in Germany. Considering that this is a highly competitive field, a rate of 25% for minimal access aortic valve replacement seems to be disappointingly low. One way to promote minimal access techniques is through the systematic use of rapid deployment valves. METHODS: A total of 143 patients underwent rapid deployment aortic valve replacement via upper right hemisternotomy between March 2012 and September 2015. All patients were followed up annually. Echocardiographic assessment of the valve was performed after 12 months. The cumulative follow-up time was 275.2 patient-years. The median follow-up time was 1.9 years. RESULTS: The mean age was 76.4 ± 6.2 years, and the mean logistic EuroSCORE was 11.0 ± 4.3%. Early all-cause mortality was 2.8% (n = 4). Actuarial survival after 1 year was 91.6 ± 2.4%, and after 3 years, it was 84.4 ± 3.6%. Mean transprosthetic gradient after 12 months was 10.3 ± 3.8 mmHg. New onset of higher grade paravalvular leakage did not occur during the follow-up period. Perioperatively, higher grade paravalvular leakage (aortic insufficiency >1+) occurred in 2 cases (1.4%) . CONCLUSIONS: Rapid deployment aortic valve replacement can be performed safely in a minimal access setting with low complication rates and good haemodynamic results. Therefore, rapid deployment valves are a relevant option in minimal access surgery.

The Use of Rapid Deployment Valves in Combined Aortic and Mitral Valve Surgery: One-Year Clinical and Echocardiographic Outcomes.

OBJECTIVE: Patients undergoing multiple valve surgery represent a high-risk group who could potentially benefit from a reduction of cross-clamp and cardiopulmonary bypass times because prolonged bypass and cross-clamp times are considered independent risk factors for increased morbidity and mortality after cardiac surgery. METHODS: Between July 2013 and November 2014, 16 patients underwent rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in the setting of concomitant mitral disease. Fifteen patients showed mitral regurgitation, whereas one patient had severe mitral stenosis. Fourteen patients received mitral valve repair and two patients received biological mitral valve replacement. Tricuspid valve repair was performed additionally in two patients. The mean ± SD age was 72.8 ± 8.4 years, and the mean ± SD logistic EuroSCORE II is 8.7% ± 3.4%. RESULTS: Within a 30-day perioperative period, no patient was lost (n = 0). The mean ± SD follow-up time was 11 ± 2 months. At 1 year, the overall survival was 81% (n = 13). A mean ± SD transaortic gradient of 10.7 ± 2.3 mm Hg and a mean ± SD effective orifice area of 1.7 ± 0.3 cm were measured echocardiographically. No higher-grade paravalvular leak (aortic insufficiency > 1+) occurred. Eight patients (61%) had no residual mitral regurgitation, four patients (30%) showed trivial regurgitation (1/4), and one patient (7.3%) had moderate mitral regurgitation (2/4). No interference of the subannular stent frame with the reconstructed valve or the biological mitral prosthesis was seen. CONCLUSIONS: Rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in combined aortic and mitral valve surgery can be performed safely with reproducible results. One-year follow-up data of this small series shows encouraging results potentially justifying the extension of the indication for rapid deployment valves to patients with concomitant mitral disease. Especially elderly patients undergoing multiple valve surgery may benefit from a reduction of cardiopulmonary bypass and myocardial ischemic times.

Rapid-Deployment Aortic Valve Replacement after Previous Mechanical Valve Implantation.

Recent studies report a reproducible reduction of myocardial ischemic and cardiopulmonary bypass times along with excellent hemodynamics and low rates of paravalvular leakage for rapid-deployment valves. A 68-year-old female patient with aortic stenosis and a mechanical mitral valve which was implanted in 2006 received rapid-deployment aortic valve replacement. The procedure could be performed with a cross-clamp time of 45 minutes and a cardiopulmonary bypass time of 60 minutes. Postoperative course was uncomplicated and the patient was discharged to the referring hospital on postoperative day 8.

Low-flow lower body perfusion for spinal protection in a frozen elephant trunk simulation model.

OBJECTIVES: The frozen elephant trunk (FET) procedure using isolated selective cerebral perfusion (SCP) at moderate hypothermia is associated with an increased risk for spinal cord ischaemia. The aim of this study was to evaluate the benefit of a combined selective cerebral and low-flow lower body perfusion (CLBP) in a porcine model. METHODS: Twenty pigs (46 ± 5 kg) were cooled on cardiopulmonary bypass (CPB) to 28°C. After aortic clamping and occlusion of the thoracic segmental arteries (TSAT4-T13), a pressure-controlled SCP (50 mmHg) was established for 90 min. Randomly, in n = 10 animals, an additional lower body perfusion (LBP) was performed with 15 ml/kg/min (CLBP). Regional spinal cord blood flow (SCBF), cerebrospinal fluid pressure (CSFP) and motor-evoked potentials (MEPs) were registered at six time points. The animals were sacrificed after 120 min of weaning from CPB, and the spinal cord was analysed histologically using a schematic scoring system (0 = normal, 8 = total necrosis). RESULTS: Isolated SCP led to an SCBF decrease from 18.5 ± 9.4 to 0.9 ± 1.4 ml/min/100 g in the L1-L5 region (P = 0.005). CLBP preserved an almost physiological lumbar SCBF of 11.3 ± 5.3 ml/min/100 g. CSFP decreased in both groups during cooling and SCP/CLBP to 70-80% and increased during reperfusion to 150%, without showing significant differences between groups. The MEP amplitude decreased in both groups, with certain regional differences: T7-T11. MEP recording revealed a more pronounced amplitude decrease in the CLBP group (52.5 ± 2.0 vs 71.3 ± 0.9%), but MEP amplitudes recovered in both groups (SCP: 73.7 ± 0.5 vs CLBP: 82.6 ± 0.1%). During selective hypothermic perfusion, SCP-treated animals showed significant lower MEP amplitudes, when compared with CLBP-treated animals: 60 ± 9 vs 90 ± 3% (P < 0.001). After weaning, CLBP animals showed a better MEP recovery, especially in the L1-L5 region (99 ± 7 vs 70 ± 13%; P < 0.001). The histological analysis did not show significant differences in the necrosis extension in the thoracic spinal cord. A different situation was seen in the L1-L5 area: all animals with isolated SCP, but only 50% of the CLBP animals presented a score of >5. A higher grade of lumbar ischaemia could be seen after isolated SCP (score: 5.9 ± 0.6 vs 3.6 ± 2.9). CONCLUSION: The prolonged SCP provides an insufficient lumbar spinal cord protection during the FET procedure at 28°C. The use of a low-flow LBP in addition to SCP may reduce functional and structural spinal damage.

Simultaneous double valve-in-valve TAVI procedure for failed bioprostheses.

A 78-year-old female patient who had undergone double valve replacement in 2010 presented in 2014 with severe New York Heart Association grade IV dyspnea. The decision was made to perform a transapical valve-in-valve transcatheter aortic valve implantation (TAVI) procedure in the mitral and aortic positions simultaneously. The postoperative course was uneventful, and the patient was extubated 6 hours after the TAVI procedure.

Minimal access rapid deployment aortic valve replacement: initial single-center experience and 12-month outcomes.

OBJECTIVES: A single-center observational study was initialized to evaluate the feasibility of rapid deployment aortic valve replacement using the Edwards Intuity valve system (Edwards Lifesciences Corp, Irvine, Calif) in a minimally invasive setting. A total of 60 implantations have been performed at the Ruhr University Hospital Bergmannsheil using a minimal access technique. We present the first short-term and 12-month clinical and hemodynamic results. METHODS: Aortic valve replacement using a partial sternotomy was performed in all patients. Patients' mean age was 75.5 (±6.2) years. The mean logistic European System for Cardiac Operative Risk Evaluation was 8.4 ± 4.2, and 39% (n = 23) of patients were female. A clinical follow-up for echocardiographic assessment was performed after 12 months. RESULTS: The 30-day mortality rate was 1.7% (n = 1). The mean postoperative transprosthetic gradient was 11.7 (±4.3) mm Hg. The mean effective orifice area was 1.8 (±0.3) cm(2). One case of higher-grade regurgitation (aortic insufficiency >+1) occurred. The late mortality rate was 5.1% (3/59). After 12 months, the mean transprosthetic gradient was 10.3 (±3.8) mm Hg. The mean effective orifice area of 1.8 (±0.3) cm(2) remained unchanged. The mean implantation time was 9 (±3) minutes. The mean crossclamp time was 26 (±7) minutes. The average bypass time was 56 (±16) minutes. CONCLUSIONS: Reproducible short crossclamp and bypass times were achieved in a minimally invasive setting. The valve shows good hemodynamic performance comparable to other sutureless or rapid deployment valves. Nevertheless, future follow-up investigation has to be awaited to gain more data concerning durability and safety issues.

Chronic pericardial hematoma with suppression of the right ventricle: a rare complication of a coronary artery aneurysm.

We present a case of a 67-year-old patient referred to our department with a pericardial mass lesion measuring 11 × 4 × 7.5 cm as diagnosed in computed tomography scan. The patient showed a history of progredient dyspnea. Video-assisted thoracoscopy as well as an explorative full sternotomy to resect the mass lesion had been performed at the referring hospital subsequently before admission to our department. Intermittent hemodynamic instability caused the procedure to stop and a transfer to the cardiothoracic surgery department, following which a resternotomy was performed. Inspection of the surgical site and subsequent intraoperative rapid section revealed an old organized and dense pericardial hematoma adherent to the right ventricle. The suspicion of covered coronary artery perforation led to an intraoperative coronary angiography, which revealed a large proximal coronary aneurysm of the right coronary artery and a subtotal stenosis of the circumflex branch. The hematoma could be removed with decompression of the right ventricle under cardiopulmonary bypass conditions. The further postoperative course was uncomplicated with retransfer to the referring hospital on the postoperative day 8.