Unraveling the Predictors for Delirium and ICU Stay Duration in Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) Undergoing Coronary Artery Bypass Grafting-A Multicentric Analysis.

Objective: This study assesses predictors for postoperative delirium (POD) and ICU stay durations in HFrEF patients undergoing CABG, focusing on ONCAB versus OPCAB surgical methods. Summary Background Data: In cardiac surgery, especially CABG, POD significantly impacts patient recovery and healthcare resource utilization. With varying incidences based on surgical techniques, this study provides an in-depth analysis of POD in the context of HFrEF patients, a group particularly susceptible to this complication. Methods: A retrospective analysis of 572 patients who underwent isolated CABG surgery with a preoperative ejection fraction under 40% was conducted at four German university hospitals. Patients were categorized into ONCAB and OPCAB groups for comparative analysis. Results: Age and Euro Score II were significant predictors of POD. The ONCAB group showed higher incidences of re-sternotomy (OR: 3.37), ECLS requirement (OR: 2.29), and AKI (OR: 1.49), whereas OPCAB was associated with a lower incidence of delirium. Statistical analysis indicated a significant difference in ICU stay durations between the two groups, influenced by surgical complexity and postoperative complications. Conclusions: This study underscores the importance of surgical technique in determining postoperative outcomes in HFrEF patients undergoing CABG. OPCAB may offer advantages in reducing POD incidence. These findings suggest the need for tailored surgical decisions and comprehensive care strategies to enhance patient recovery and optimize healthcare resources.

Influence of Obesity on Short-Term Surgical Outcomes in HFrEF Patients Undergoing CABG: A Retrospective Multicenter Study.

Background: This retrospective multicenter study investigates the impact of obesity on short-term surgical outcomes in patients with heart failure and reduced ejection fraction (HFrEF) undergoing coronary artery bypass grafting (CABG). Given the rising global prevalence of obesity and its known cardiovascular implications, understanding its specific effects in high-risk groups like HFrEF patients is crucial. Methods: The study analyzed data from 574 patients undergoing CABG across four German university hospitals from 2017 to 2023. Patients were stratified into 'normal weight' (n = 163) and 'obese' (n = 158) categories based on BMI (WHO classification). Data on demographics, clinical measurements, health status, cardiac history, intraoperative management, postoperative outcomes, and laboratory insights were collected and analyzed using Chi-square, ANOVA, Kruskal-Wallis, and binary logistic regression. Results: Key findings are a significant higher mortality rate (6.96% vs. 3.68%, p = 0.049) and younger age in obese patients (mean age 65.84 vs. 69.15 years, p = 0.003). Gender distribution showed no significant difference. Clinical assessment scores like EuroScore II and STS Score indicated no differences. Paradoxically, the preoperative left ventricular ejection fraction (LVEF) was higher in the obese group (32.04% vs. 30.34%, p = 0.026). The prevalence of hypertension, COPD, hyperlipidemia, and other comorbidities did not significantly differ. Intraoperatively, obese patients required more packed red blood cells (p = 0.026), indicating a greater need for transfusion. Postoperatively, the obese group experienced longer hospital stays (median 14 vs. 13 days, p = 0.041) and higher ventilation times (median 16 vs. 13 h, p = 0.049). The incidence of acute kidney injury (AKI) (17.72% vs. 9.20%, p = 0.048) and delirium (p = 0.016) was significantly higher, while, for diabetes prevalence, there was an indicating a trend towards significance (p = 0.051) in the obesity group, while other complications like sepsis, and the need for ECLS were similar across groups. Conclusions: The study reveals that obesity significantly worsens short-term outcomes in HFrEF patients undergoing CABG, increasing risks like mortality, kidney insufficiency, and postoperative delirium. These findings highlight the urgent need for personalized care, from surgical planning to postoperative strategies, to improve outcomes for this high-risk group, urging further tailored research.

On- vs. Off-Pump CABG in Heart Failure Patients with Reduced Ejection Fraction (HFrEF): A Multicenter Analysis.

OBJECTIVE: This study aimed to compare postoperative outcomes and 30-day mortality in patients with reduced ejection fraction (<40%) who underwent isolated coronary artery bypass grafting (CABG) with (ONCAB) and without (OPCAB) the use of cardiopulmonary bypass. METHODS: data from four university hospitals in Germany, spanning from January 2017 to December 2021, were retrospectively analyzed. A total of 551 patients were included in the study, and various demographic, intraoperative, and postoperative data were compared. RESULTS: demographic parameters did not exhibit any differences. However, the OPCAB group displayed notably higher rates of preoperative renal insufficiency, urgent surgeries, and elevated EuroScore II and STS score. During surgery, the ONCAB group showed a significantly higher rate of complete revascularization, whereas the OPCAB group required fewer intraoperative transfusions. No disparities were observed in 30-day/in-hospital mortality for the entire cohort and the matched population between the two groups. Subsequent to surgery, the OPCAB group demonstrated significantly shorter mechanical ventilation times, reduced stays in the intensive care unit, and lower occurrences of ECLS therapy, acute kidney injury, delirium, and sepsis. CONCLUSIONS: the study's findings indicate that OPCAB surgery presents a safe and viable alternative, yielding improved postoperative outcomes in this specific patient population compared to ONCAB surgery. Despite comparable 30-day/in-hospital mortality rates, OPCAB patients enjoyed advantages such as decreased mechanical ventilation durations, shorter ICU stays, and reduced incidences of ECLS therapy, acute kidney injury, delirium, and sepsis. These results underscore the potential benefits of employing OPCAB as a treatment approach for patients with coronary heart disease and reduced ejection fraction.

Gender-Related Discrepancies in Short-Term Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery.

The sex differences in patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery are still unclear. Our aim was to investigate the impact of gender on short-term outcomes in males and females after off-pump bypass procedures. Our research was designed as a double-center retrospective analysis. Generally, 343 patients (men (n = 255) and women (n = 88)) who underwent an OPCAB procedure were included in our study. To provide a statistical analysis of unequal cohorts, we created a propensity score-based matching (PSM) analysis (men, n = 61; women, n = 61). The primary endpoint was all-cause in-hospital mortality. Dialysis, transient ischemic attack (TIA), low cardiac output syndrome (LCOS), reoperation due to postoperative bleeding, wound infection and duration of hospital stay were secondary outcomes in our analysis. No significant differences were detected within the male and female groups regarding age (p = 0.116), BMI (p = 0.221), diabetes (p = 0.853), cardiogenic shock (0.256), STEMI (p = 0.283), NSTEMI (p = 0.555) and dialysis (p = 0.496). Males underwent significantly more frequently (p = 0.005) total-arterial revascularization with T-graft technique (p = 0.005) than females. In contrast, temporary pacer use was significantly higher (p = 0.022) in females compared to males. The in-hospital mortality rate was not significantly higher (p = 0.496) in the female group compared to the male group. Likewise, secondary outcomes did not differ significantly between the non-adjusted and the adjusted groups. Based on our findings, gender has no impact on short-term outcomes after OPCAB surgery.

Consequences of Obesity on Short-Term Outcomes in Patients Who Underwent Off-Pump Coronary Artery Bypass Grafting Surgery.

The correlation between off-pump coronary artery bypass (OPCAB) surgery and obesity-related outcomes is still uncertain. The aim of our study was to analyse the pre-, intra-, and postoperative short-term outcomes between obese and non-obese patients after off-pump bypass surgery. We performed a retrospective analysis from January 2017 until November 2022, including a total of 332 (non-obese (n = 193) and obese (n = 139)) patients who underwent an OPCAB procedure due to coronary artery disease (CAD). The primary outcome was all-cause in-hospital mortality. Our results showed no difference regarding mean age of the study population between both groups. The use of the T-graft technique was significantly higher (p = 0.045) in the non-obese group compared to the obese group. The dialysis rate was significantly lower in non-obese patients (p = 0.019). In contrast, the wound infection rate was significantly higher (p = 0.014) in the non-obese group compared to the obese group. The all-cause in-hospital mortality rate did not differ significantly (p = 0.651) between the two groups. Furthermore, ST-elevation myocardial infarction (STEMI) and reoperation were relevant predictors for in-hospital mortality. Therefore, OPCAB surgery remains a safe procedure even in obese patients.

Short-Term Outcomes and Risk Factors of In-Hospital Mortality in Patients Suffering Acute Mesenteric Ischemia after Cardiac Surgery: Role of Opioids and Lactic Acid.

Acute mesenteric ischemia (AMI) is associated with poor clinical results after cardiac surgery. The aim of this study was to analyse the influence of AMI on short-term outcomes and all relevant risk factors of in-hospital mortality after cardiac surgery. Moreover, we aimed to investigate the role of opioids and lactic acid in the detection and prevention of AMI. Between August 2011 and September 2015, 176 consecutive patients with gastrointestinal complications after undergoing open-heart surgery were identified and included in this study. All patients were divided into two groups: AMI group (n = 39) and non-AMI group (n = 137). In terms of comorbidities, the groups were fairly equal and showed no significant differences. Dialysis was significantly higher (p < 0.001) in patients that suffered from AMI. Moreover, gastro-intestinal symptoms such as muscular defense (p = 0.004) and the laparotomy rate (p < 0.001) were significantly higher in the AMI group. Likewise, in-hospital mortality (p < 0.001) was significantly higher in patients with detected AMI. Univariate (p < 0.001) and multivariate analysis (p = 0.025) of both groups revealed that lactic acid value >2 mmol/L and present treatment with opioids are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Moreover, multivariate analysis showed peripheral vascular disease (p = 0.004), dialysis (p = 0.010), and septic shock (p = 0.003) as relevant predictors of in-hospital mortality. Prolonged analgetic treatment with opioids and sudden increase of lactic acid levels are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Furthermore, peripheral vascular disease, dialysis, and septic shock are relevant predictors for in-hospital mortality.

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.

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.

Impact of Initial Operative Urgency on Short-Term Outcomes in Patients Treated with ECMO Due to Postcardiotomy Cardiogenic Shock.

The outcomes of patients with PCS and following ECMO therapy are associated with several preoperative risk factors. Our aim was to compare clinical presentation, ECMO-related data and in-hospital outcomes of patients treated with ECMO due to PCS after cardiac surgery, in regard to elective or emergent cardiac surgery procedures. Between April 2006 and October 2016, 164 consecutive patients that received VA-ECMO therapy due to PCS were identified and included in this retrospective cohort study. The patients were divided into groups based on the urgency of the initial procedures performed: elective group (ELG; n = 95) and an emergency group (EMG; n = 69). To compare the unequal patient groups, a propensity score-based matching (PSM) was applied (ELG, n = 56 vs. EMG, n = 56). The EMG primarily received ECMO intraoperatively (p ≤ 0.001). In contrast, the ELG were needed ECMO support more frequently postoperatively (p < 0.001). In-hospital mortality accounted for 71% (n = 40) in the ELG and 76% (n = 43) in the EMG (p = 0.518). Outcome data showed no major differences in the (abdominal ischemia (p = 0.371); septic shock (p = 0.393): rhythm disturbances (p = 0.575); emergency re-thoracotomy (p = 0.418)) between the groups. The urgency of the initial procedures performed is secondary in patients suffering PCS and following ECMO. In this regard, PCS itself seems to trigger outcomes in cardiac surgery ECMO patients substantially.

Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself-A Retrospective Double Center Analysis of Short-Term Outcomes.

Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates.

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.

Gender-related propensity score match analysis of ECMO therapy in postcardiotomy cardiogenic shock in patients after myocardial revascularization.

BACKGROUND: Gender is known to influence the pathophysiology and pathogenesis of the coronary vascular disease. Data on gender-related differences in patients with veno-arterial extracorporeal membrane oxygenation due to postcardiotomy cardiogenic shock is lacking in current literature. We aimed to analyze the impact of gender on intraoperative and short-term outcomes of vaECMO patients after coronary surgery and postcardiotomy cardiogenic shock. METHODS: Between 2006 and 2017, a total of 92 patients with PCS after CABG underwent vaECMO-implantation at our institution. After a 1:1 propensity score match (PSM) for relevant preoperative data, we identified a cohort of 32 patients, 16 males, and 16 females. Periprocedural and short-term outcome data were analyzed with respect to sex differences. RESULTS: The mean age was 64 ± 11 years, and 79% (n = 73) were male patients. Clinical outcomes showed a 30-day all-cause mortality of 64% (n = 59). After PSM, male patients showed a significantly smaller number of arterial grafts (0.4 ± 0.53 male vs 1.1 ± 0.7 female; p = 0.037). Thirty-day all-cause mortality did not differ between the groups (56% male vs 75% female; p = 0.262). In general, short-term outcome data were comparable without significant differences for the matched groups. CONCLUSION: Gender has no impact on patients with vaECMO therapy due to PCS in isolated coronary surgery.

Impact of Ischaemic and Dilated Cardiomyopathy on Short-Term and Long-Term Survival After Ventricular Assist Device Implantation: A Single-Centre Experience.

BACKGROUND: Prognosis of patients with end-stage heart failure is known to be impacted by the aetiology of heart failure (HF). Ischaemic cardiomyopathy (ICM) and dilated cardiomyopathy (DCM) are the most frequent pathologies necessitating ventricular assist device (VAD) support in these patients. However, the specific impact of ICM and DCM in clinical outcomes after VAD implantation remains unclear. Therefore, this study aimed to analyse clinical differences in ICM and DCM patients after LVAD surgery from the current institution. METHODS: All consecutive patients from the LVAD centre were included in this retrospective study. To analyse specific differences in in-hospital outcomes, patients were divided into two groups: ICM and DCM. Long-term follow-up was calculated by Kaplan-Meier estimation of survival. RESULTS: Between January 2010 and July 2020, 60 consecutive patients underwent LVAD implantation at the institution: 36 patients (60%) were supported due to end-stage ICM and 24 patients (40%) in regard of therapy-refractory DCM. Baseline characteristics showed no between-group differences. The ICM patients showed a clear trend to higher amount of additional cardiac procedures during VAD surgery (36% ICM vs 12% DCM; p=0.052). In-hospital mortality was comparable between ICM and DCM patients (36% ICM vs 21% DCM; p=0.206). A trend towards higher frequency of pump thrombosis was seen in DCM patients (p=0.080). Long-term survival was comparable between the groups. CONCLUSION: The aetiology of heart failure did not impact short-term or long-term clinical outcomes after VAD surgery. Multicentre registry data are necessary to substantiate these findings.

Multiple Grafting with Single Left Internal Mammary Artery as T-Graft with Itself.

BACKGROUND: Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material. METHODS: Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes. RESULTS: LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.2 ± 2.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 ± 0.5 distal anastomoses were performed. Mean flow of LIMA-left anterior descending anastomosis was 41.72 ± 12.11 mL/min with a mean pulsatility index (PI) of 1.01 ± 0.21. Mean flow of subsequent T-graft accounted for 26.31 ± 4.22 mL/min with a mean PI of 1.59 ± 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital. CONCLUSIONS: LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results.

Concomitant ECMO And IABP Support in Postcardiotomy Cardiogenic Shock Patients.

OBJECTIVES: Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. METHODS: Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. RESULTS: A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. CONCLUSION: This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.

Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock.

OBJECTIVES: Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. METHODS: Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. RESULTS: Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). CONCLUSION: Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.

Early and long-term outcomes comparing neonates, infants, and preadolescents requiring extracorporeal membrane oxygenation for heart failure.

BACKGROUND: Application of extracorporeal membrane oxygenation in pediatric patients with severe heart failure steadily increases. Differentiation of outcomes and survival of diverse pediatric groups is of interest for adequate therapy. METHODS: Between January 2008 and December 2016, a total of 39 pediatric patients needed veno-arterial extracorporeal membrane oxygenation support in our department. Patients were retrospectively divided into three groups: neonates (<30 days), infants (>30 days/<1 year), and toddlers/preadolescents (>1 year). Early outcomes as well as mid- and long-term survival up to 7-year follow-up were analyzed. RESULTS: Basic demographics significantly differed in terms of age, height, and weight among the groups in accordance with the intended group categorization (p < 0.05). Survival after 30 days of extracorporeal membrane oxygenation application was equally distributed among the groups, and 44% of all patients survived. In terms of survival to discharge, no significant differences were found among groups. In total, 28% of patients survived up to 7 years. Infants were significantly more likely to undergo elective surgery (p < 0.001) and were predominantly weaned off extracorporeal membrane oxygenation, whereas need for urgent surgery (p < 0.001) was significantly higher in neonate group in comparison to other groups. Multinominal logistic regression analysis revealed significantly higher odds for need for re-exposure in infant group in comparison to toddler/preadolescent group as well as for incidence of neurological impairment of toddler/preadolescent group in comparison to neonate group (odds ratio = 14.67, p = 0.009 and odds ratio = 34.67, p = 0.004, respectively). Kaplan-Meier survival estimation analysis revealed no significant differences in terms of mid- and long-term survival among the groups (Breslow p = 0.198 and log-rank p = 0.213, respectively). CONCLUSION: Veno-arterial extracorporeal membrane oxygenation is a lifesaving therapeutic chance for pediatric patients in the setting of either failure to wean from cardiopulmonary bypass or failed resuscitation from cardiac arrest. A fair part of patients could be saved by using this technology. Survival rate among the groups was similar.

Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures.

BACKGROUND: Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed. METHODS: A prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany. RESULTS: 464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages (p < 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common (p = 0.027), and length of hospital stay shortest (p = 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%; p = 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17, p = 0.002) and TAVR/PCI (HR: 1.63, p = 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39, p = 0.003 and HR: 1.63, p = 0.033). CONCLUSIONS: TAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options.

Prognostic implications of psoas muscle area in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: This study sought to assess the incremental prognostic value of the psoas muscle area in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS: A total of 1076 consecutive patients undergoing TAVI at 2 centres between 2010 and 2017 were prospectively included in this study. Computed tomography-derived cross-sectional area of the psoas muscle was measured at the superior border of the third (L3) and fourth (L4) lumbar vertebra and indexed to body surface area (PMAi) as well as stratified into tertiles. Multivariable logistic regression and Cox regression analyses were performed to investigate the value of PMAi as a predictor of 30-day and cumulative mortality. The incremental prognostic value of PMAi over the Society of Thoracic Surgeons (STS) score was assessed using a net reclassification analysis. RESULTS: The rate of 30-day mortality was 5.8% (n = 62). PMAi at the level of L3 [odds ratio 0.082, 95% confidence interval (CI) 0.011-0.589; P = 0.013] and L4 (odds ratio 0.049, 95% CI 0.005-0.536; P = 0.013) was independently associated with 30-day mortality. During a median follow-up of 435 days (interquartile range 139-904), 292 patients (27.1%) died. PMAi of L3 (hazard ratio 0.200, 95% CI 0.083-0.482; P < 0.001) and L4 (hazard ratio 0.083, 95% CI 0.029-0.235; P < 0.001) was independently associated with mortality during follow-up. The addition of PMAi to the STS score led to a net reclassification improvement for 30-day and cumulative mortality. CONCLUSIONS: PMAi emerged as a valuable outcome predictor in patients undergoing TAVI. The addition of PMAi to the established STS score led to an increase in its prognostic ability.