Transcaval and Intracardiac Extension of Type A Thymoma and Myxoma: A Report of Two Rare Cases.

We report two cases of rare invasive tumors presenting with transvenous and intracardiac extensions. In one instance, an unusual invasive thymoma type A penetrated into the heart chamber; the other case was an extension of a myxoma into the right atrium that was associated with superior vena cava syndrome. Our interest was stimulated by the rarity of these clinicopathological observations and the unusual clinical features of diagnostic and therapeutic methods presented by these cases.

Preprocedural assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation: Rationale and design of the EASE-IT CT registry.

BACKGROUND: Invasive coronary angiography (ICA) is the standard for pre-procedural assessment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI). However, it requires hospitalization and can be associated with complications. Computed tomography angiography (CTA) may be a viable alternative to rule out prognostically relevant CAD. METHODS: The EASE-IT CT Registry is an investigator-initiated, prospective, observational, multicentre pilot registry involving patients aged ≥75 years with severe aortic stenosis (AS) intended to implant a transcatheter heart valve (THV) of the SAPIEN family. A total of 150 patients will be recruited from four sites in Germany and Austria. The registry will consist of two prospective cohorts: the investigational CTA-only cohort and the CTA + ICA control cohort. The CTA-only cohort will enrol 100 patients in whom significant (≥50%) left main (LM) and/or proximal left anterior descending artery (LAD) stenosis are ruled out on CTA. The CTA + ICA control cohort will enrol 50 patients who have undergone both CTA and ICA before TAVI and in whom ≥50% LM/proximal LAD stenosis has been ruled out by CTA. Three composite endpoints will be assessed at 3 months post-TAVI: CAD-specific endpoints, VARC-3-defined device success and early safety. CONCLUSION: The EASE-IT CT Registry evaluates whether TAVI can be carried out safely without performing ICA if prognostically relevant CAD of the LM/proximal LAD is ruled out with CTA. If so, the omission of ICA would help streamline the pre-procedural workup of TAVI patients.

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.

Urgent Endovascular Aortic Repair Requiring Coverage of the Left Subclavian Artery.

BACKGROUND: Evaluation of the optimal left subclavian artery (LSA) management during thoracic endovascular aortic repair (TEVAR) involving the distal aortic arch in an urgent setting. METHODS: A total of 52 patients with acute aortic syndromes underwent TEVAR (March 2017 to May 2021) requiring proximal landing in the distal aortic arch. Decision for partial or complete LSA ostial endograft coverage, with or without additional bypassing, was made depending upon the aortic pathology and vascular anatomy. We focused on the patency of the circle of Willis and the unilateral dominance of one carotid or a vertebral artery: 35% underwent complete (complete LSA group) and 17% partial LSA coverage (partial LSA group), whereas in 48% the LSA was reached only by the bare springs of the endograft (control group). A total of 22% of the complete LSA group underwent LSA bypass before TEVAR, whereas 11% underwent cerebrospinal fluid drainage. Endpoints were 30-day and 1-year mortality, stroke, spinal cord ischemia (SCI), and malperfusion. RESULTS: Technical success was achieved in 96%. The endograft length was 171 ± 34 (complete LSA group) versus 151 ± 22 (partial LSA group) versus 181 ± 52 mm (control group), covering 6 ± 2 versus 5 ± 1 versus 7 ± 2 intercostal arteries. The 30-day mortality, stroke and SCI rates did not differ. One patient with arm malperfusion underwent LSA bypass post-TEVAR. After 1 year, aortic interventions occurred in 6 (complete LSA group) versus 22 (partial LSA group) versus 13% (control group). One-year mortality (0 vs. 0 vs. 8%), stroke (6 vs. 0 vs. 4%), and SCI (0 vs. 0 vs. 4%) were similar between groups. CONCLUSION: With an adequate analysis of vascular anatomy, coverage of the LSA for TEVAR is safe and may offer results similar to TEVAR starting distal to the LSA.

Early-Term Results of Rapid-Deployment Aortic Valve Replacement versus Standard Bioprosthesis Implantation Combined with Coronary Artery Bypass Grafting.

OBJECTIVES: Aortic stenosis is highly prevalent among patients with concomitant coronary artery disease. Surgical aortic valve replacement with coronary artery bypass grafting is usually the treatment of choice for patients with severe aortic stenosis and significant coronary disease. The aim of this study was to evaluate the outcome and hemodynamic results of the implantation of rapid-deployment valves (Rapid-Deployment Edwards Intuity Valve System [RDAVR]) versus conventional sutured valves (CSAVR) in combined surgery. METHODS: Between January 2012 and January 2017, 120 patients underwent replacement via RDAVR and 133 patients underwent replacement using CSAVR with concomitant coronary bypass grafting. Clinical and echocardiographic data were compared. RESULTS: The mean age was 76 ± 7 for RDAVR patients and 74 ± 6 years for CSAVR patients (p = 0.054); 48% in the RDAVR group were female versus 17% in the CSAVR group (p <0.002). Other characteristics such as diabetes mellitus, body-mass index, chronic obstructive pulmonary disease, nicotine consumption, and extracardiac arteriopathy were similar. Coronary three-vessel disease was more common in the RDAVR group (42.5 vs. 27.8%, p = 0.017). Both mean EuroSCORE II (6.6 ± 5.4 vs. 4.3 ± 3.0, p = 0.001) and STS score (5.4 ± 4.4 vs. 3.4 ± 2.4, p = 0.001) were significantly higher in the RDAVR group. Mean cross-clamp time (82 ± 25 vs. 100 ± 30 minutes, p < 0.001) and cardiopulmonary bypass time (119 ± 38 vs. 147 ± 53 minutes, p < 0.001) were shorter with RDAVR. The mean number of bypass grafts, length of hospital and ICU stays, and mechanical ventilation time were not statistically significant different. Hospital mortality was 2.5% for RDAVR and 9.7% for CSAVR (p = 0.019). There was a similar rate of stroke (5.8 vs. 6.0%, p = 0.990) and postoperative delirium (14.1 vs. 15.8%, p = 0.728). Mean gradients were 8.2 ± 4.1 mm Hg in the RDAVR group vs. 11.3 ± 4.6 mm Hg in the CSAVR group (p = 0.001) at discharge. CONCLUSION: RDAVR combined with coronary artery bypass grafting (CABG) can be performed extremely safely. Cross-clamp and cardiopulmonary bypass times can be significantly reduced with rapid deployment aortic valve system in the scenario of combined CABG. RDAVR resulted in lower gradients than CSAVR in patients implanted with prostheses of the same size.

Real-world 6-month outcomes of minimally invasive aortic valve replacement with the EDWARDS INTUITY Elite valve system.

OBJECTIVES: We report on real-world safety and performance outcomes of minimally invasive rapid-deployment aortic valve replacement using the EDWARDS INTUITY Elite aortic valve system. METHODS: The study valve system was used in a European, prospective, multicentre post-market study. Various procedural, haemodynamic and clinical outcomes were evaluated through 6 months of post-implant. RESULTS: A total of 276 patients out of 280 (98.6%) enrolments were successfully implanted with the study valve using a minimally invasive approach between February 2016 and April 2017. Of these 276 patients, 240 (87%) underwent partial sternotomy and 36 (13%) patients underwent right thoracotomy. Mean cross-clamp time was 51.9 [standard deviation (SD): 16.0] min. From baseline to 6 months, the mean effective orifice area increased from 0.8 (SD: 0.3) to 1.8 (SD: 0.6) cm2 and the mean systolic gradient decreased from 46.0 (SD: 14.1) to 8.8 (SD: 3.7) mmHg. After 6 months, 70.7% and 26.4% of patients were in New York Heart Association class I and II, respectively. Freedom from death, major bleeding, major paravalvular leak, reoperation and device explant at 6 months were 96.0%, 98.5%, 98.8%, 99.2% and 99.2%, respectively. CONCLUSIONS: These results demonstrate that the study valve is a safe and effective choice for patients undergoing aortic valve replacement via minimally invasive surgery. NAME AND REGISTRATION OF REGISTRY: MISSION (Assessing clinical outcomes using the EDWARDS INTUITY Elite Valve System in isolated AVR using Minimally InvaSive Surgery In a EurOpean multi-ceNter, active, post-market registry). clinicaltrials.gov ID #NCT02907463.

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.

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.

Thrombocytopenia after implantation of the Perceval S aortic bioprosthesis.

OBJECTIVE: The Perceval S bioprosthesis (LivaNova PLC, London, United Kingdom) is based on the Freedom Solo aortic bioprosthesis (LivaNova PLC), which has been reported to be associated with perioperative thrombocytopenia. We compared platelet counts after aortic valve replacement with the Perceval S with those with other aortic valve bioprostheses. METHODS: A total of 87 patients receiving aortic valve replacement were included in this retrospective study; 25 patients received the Perceval S, 23 patients received the Labcor TLPB-A (Labcor, Belo Horizonte, Brazil), and 39 patients received the Hancock II bioprosthesis (Medtronic, Minneapolis, Minn). Thrombocyte count was corrected for hematocrit. Multivariable analyses were performed to assess the potential effect of other variables. RESULTS: Preoperatively, there were no differences in platelet counts comparing the Perceval S group (median 200/nl, interquartile range, 157-252) and the control group (Labcor: median 213/nl, interquartile range, 160-246, Hancock: median 227/nl, interquartile range, 183-280, P = .23). Postoperatively, there was significant evidence that the minimum platelet count (median, Perceval: 47, interquartile range, 38-66; Labcor: 76, interquartile range, 61-110; Hancock: 78, interquartile range, 61-111/nl; P = .001), both absolute and corrected, was lower for the Perceval S, even after allowing for other variables. The significant difference in absolute platelet counts persisted until discharge or death. However, there were no significant differences regarding blood loss, transfusion requirements, or rates of reoperation for bleeding. CONCLUSIONS: After aortic valve replacement, platelet counts in patients with the Perceval S decrease more severely compared with other bioprostheses, but in our small study we found no evidence of a detrimental clinical effect of this phenomenon. Future studies have to confirm our findings and investigate a cause for this phenomenon.

Hematocrit and impact of transfusion in patients receiving extracorporeal life support.

INTRODUCTION: Increasing the hematocrit is considered to increase oxygen delivery to the patient, especially when hypoxic conditions exist and the patient may become more stable. The aim of this study was to evaluate the relationship between hematocrit and hospital mortality via subgroup analyses of trauma and non-trauma patients. METHODS: The hospital length of stay (LOS) and LOS in the intensive care unit (ICU) and hospital after extracorporeal life support (ECLS) treatment of 81 patients were analyzed and compared. In-hospital survival until extracorporeal membrane oxygen (ECMO) weaning and hospital discharge were defined as the clinical outcome. RESULTS: Significantly increased mortality, with a relative risk of 1.73 with a 95% confidence interval of 1.134 to 2.639, was identified in the group with an hematocrit greater than 31%. However, no significant differences in relative risk (95% confidence interval) of death for each group were found among groups with an hematocrit less than or equal to 25%, 26-28% and 29-31%. Additionally, no significant relationship between survival and median hematocrit level was observed at a significance level of 0.413 and an Exp (B) of 1.089 at a 95% confidence interval of 0.878 to 1.373 in binary logistic regression analysis; a model was established with a -2 log likelihood of 40.687 for the entire group of patients. Moreover, a significant increase in mortality was observed as the average number of transfusions per day in the hospital increased (significance level 0.024, Exp (B) 4.378, 95% confidence interval for Exp (B) 1.212 to 15.810). CONCLUSION: Because a variety of factors influence therapy, the indication for transfusion should be re-evaluated and adapted repeatedly on a case-by-case basis. Further studies are needed to demonstrate whether an acceptable outcome from ECLS device therapy can also be achieved with a low hematocrit and a restrictive indication for transfusion.

Off-Pump Coronary Artery Bypass Grafting and Stroke-Exploratory Analysis of the GOPCABE Trial and Methodological Considerations.

BACKGROUND: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke. METHODS: In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke. RESULTS: There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5-1.38]; p = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46-1.60]; clampless device: 1.8%; OR 0.67 [0.26-1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37-2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64-1.20]). CONCLUSION: Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.

Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure.

INTRODUCTION: To determine whether obese surgical patients are at a significant disadvantage in terms of outcomes after extracorporeal device (ECD) support, such as veno-venous extracorporeal membrane oxygenation (VV ECMO) or pumpless extracorporeal lung assist (pECLA), for respiratory failure, the relationship between body mass index (BMI) and hospital outcomes was analyzed. METHODS: This retrospective study included data on patients who were supported with an ECD between January 1, 2008 and December 31, 2014. The analysis included 89 patients (74 male). RESULTS: The median BMI was 30 kg/m2 (19-88.5). The median duration of the ECD support was 9.0 days, with a maximum of 37.1 days. The median LOS (length of stay) in the intensive care unit (ICU) was 21 days (range 0.06-197.6). The median hospital LOS was 34.9 days (range 0.1-213.8). VV ECMO was performed 72 times, and pECLA was performed 18 times. The number of patients successfully weaned off the ECD was 54 (60.6%). Survival at the discharge from the hospital was 48.3%. CONCLUSIONS: 54 (60.6%) patients were successfully weaned off the ECD; 43 (48.3%) patients survived and were discharged from the hospital. The analysis of correlations between BMI and outcomes of surgical patients treated with ECD showed no association between BMI and mortality. Complications (especially oxygenator clotting) were not more frequent in obese and extremely obese patients. We hypothesized that patients with higher or morbid BMIs would have increased mortality after ECD support. A BMI of 30.66 kg/m2 corresponded to the desired sensitivity and specificity to predict mortality. This finding applied only to the study group. Treatment with ECD in obese patients presents unique challenges, including percutaneous cannulation and increased staff requirements. However, based on these data, obesity should not be an exclusion criterion for ECD therapy.

Transcatheter aortic valve implantation using the ACURATE TA™ system: 1-year outcomes and comparison of 500 patients from the SAVI registries.

OBJECTIVES: The ACURATE TA TM system is a self-expanding transcatheter heart valve system designed for transapical access which has been proven to be safe and effective in the controlled setting of clinical trials. The SAVI-1 and SAVI-2 registries aimed to assess whether these promising outcomes can be translated into all-comers clinical routine. METHODS: From November 2011 to 2012 (SAVI-1), and November 2013 to 2014 (SAVI-2), a total of 500 patients were enrolled in the prospective, all-comers, multicentre, multinational SAVI registries. Patients were treated according to the standard of care at their respective hospitals. We report and compare 30-day and 1-year clinical outcomes between SAVI-1 and -2. RESULTS: Patients were 80.8 ± 6.1 years old, the mean logistic EuroSCORE-I was 23.4 ± 14.3%. Valves were deployed under rapid pacing in 71.3% of the procedures in SAVI-1, and in 3.6% in SAVI-2. There was no relevant difference in clinical and echocardiographic outcomes between SAVI-1 and SAVI-2. Overall mortality at 30 days and 1 year was 6.8% and 19.9%, the stroke rate was 2.2% and 3.7%, respectively; 10.2% of patients had received a permanent pacemaker, and no transcatheter valve-related complications after discharge were observed. Paravalvular leakage ≥2+ was reported in 1.9% of the patients at the early follow-up, and in 2.6% at the 1-year follow-up. CONCLUSIONS: The SAVI-registries have confirmed that transapical implantation using the ACURATE TA TM device is safe and effective in an all-comers setting with low complication rates and stable performance outcomes at short-term and 1 year; outcomes were similar between SAVI-1 and -2.

Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study.

This single-center retrospective study included a total of 99 extracorporeal life support (ECLS) cannulated patients assigned to a traumatic extracorporeal life-support cohort (TECLS) or a non-traumatic extracorporeal life-support cohort (NTECLS). Forty-nine TECLS patients and 50 NTECLS patients were compared. The TECLS patients were significantly younger [49.9 years 16.6-86.2 vs. 57.1 (21.4-78.6); p = 0.007] and had lower body mass indices (BMIs) [27.7 kg/m2 (20-37) vs. 32.5 (19-88.5); p = 0.001] than the NTECLS patients. The intensive care unit (ICU) survival rate [n = 34 (69.4%) vs. n = 13 (26%); p ≤ 0.001] and the hospital survival rate [n = 32 (65.3%) vs. n = 13 (26%); p ≤ 0.001] were significantly higher for the TECLS cohort than for the NTECLS cohort. The lengths of stay (LOSs) in the ICU [24 days (4.8-71.1) vs. 11.3 (0-88.6); p = 0.001] and in the hospital [46.6 days (2.9-197.6) vs. 21 (0.1-213.8); p = 0.001] were significantly longer for the TECLS patients than for the NTECLS patients.

The Effects of Propofol and Isoflurane Sedation on the Outcomes of Surgical Patients Receiving Extracorporeal Membrane Oxygenation.

This article resurrects a historical technique using a new technology by describing the results of a retrospective, observational, single-center study that investigated the effects of propofol compared with isoflurane sedation on patient outcomes after extracorporeal membrane oxygenation (ECMO). No differences in patient outcomes were observed between the propofol and isoflurane groups. Nevertheless, the results of this study might improve our understanding of the effects of sedation on patient outcomes after ECMO and provide insight into the effects of spontaneous breathing during ECMO.

Veno-venous ECMO as a safe bridge to recovery in a patient with severe peripartum cardiomyopathy - learning from errors.

Peripartum cardiomyopathy (PPCM) is a rare disorder of unknown etiology and pathogenesis. The most important tool for diagnostic confirmation is transthoracic echocardiography. The recommended management of PPCM in pregnancy is summarized by the European Society of Cardiology Heart Failure Guidelines. Few data exist on the treatment of patients with fulminant PPCM and the need for extracorporeal membrane oxygenation (ECMO) in this context. We report on a young multiparous woman with cardiogenic shock caused by severe PPCM who was successfully, but atypically, supported with veno-venous ECMO as a bridge to recovery immediately after the birth of her third child.

Infections and Extracorporeal Membrane Oxygenation: Incidence, Therapy, and Outcome.

The objective is to assess the influence of infections and the microbiological spectrum on the general outcome of patients undergoing therapy with extracorporeal devices (ECDs), extracorporeal membrane oxygenation, extracorporeal life support, and pumpless extracorporeal lung assist. We performed a single-center, retrospective analysis of 99 patients receiving ECD. Infections requiring ECD, nosocomial infections occurring during treatment, the use of guideline-based antiinfective therapies, and patient outcomes were described and statistically analyzed. We analyzed 88 patients-survivors and nonsurvivors-and subdivided the infections into primary and nosocomial infections. The median patient age was 54.0 years, 85.2% were men, and 45 (51.1%) survived. Surviving ECD patients had a higher risk of nosocomial infection because of their prolonged hospital stay. Our results indicated that early, focused, antiinfective therapy was important to avoid severe infection complications. Infections causing sepsis and multiorgan dysfunction were negatively associated with outcome and successful weaning of ECD. The percentages and types of pathogens in the ECD cohort did not differ from the general colonization of intensive care units. Because a significant correlation between pathogens, infections, and outcome was not detected, we recommend focusing on clinical parameters to decide whether patients will benefit from ECD support.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS.

BACKGROUND: The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS. MATERIAL AND METHODS: Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes. RESULTS: A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20-48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6-18), and the hospital stay was in mean of 60 days ± 34 (21-105). CONCLUSION: The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Spinal cord ischemia after selective cerebral perfusion in a porcine "frozen elephant trunk" simulation model.

BACKGROUND: The "frozen elephant trunk" procedure (FET) represents the therapy of choice for extended aortic diseases. The aim of our study was to analyze whether 90 minutes of selective cerebral perfusion (SCP) at 28 °C followed by permanent occlusion of the thoracic segmental arteries (TSA) would cause spinal cord ischemia in a porcine model. METHODS: 14 pigs (41 ± 3 kg) were cooled on CPB to 28 °C. After aortic clamping, SCP was established for 90 minutes. Randomly, in 7 animals the TSA were clipped (T4-T13); the TSA of 7 animals remained untouched. After the animals were weaned from CPB, hemodynamic data were registered for 120 minutes. Regional spinal cord blood flow (SCBF) was calculated, and motor-evoked potentials (MEP) were assessed at 6 time points. After sacrifice of the animals, the spinal cord was analyzed histologically by use of a schematic grading system (0 = normal; 8 = total necrosis). RESULTS: During SCP the SCBF was maintained at baseline (5.9 ± 2.4 mL/min/100 g) in the T4-T13 region but showed a decrease (from 8.4 ± 4.3 to 1.3 ± 1.5 mL/min/100 g) in the L1-L5 region. During reperfusion it increased, with two to three times higher values in the nonclipped animals. After 90 minutes of SCP, the MEP reached lower levels in the L1-L5 region of the TSA-clipped animals: 59% ± 7% vs 84 ± 15% (vastus medialis muscle) and 48% ± 6% vs 82% ± 26% (tibialis anterior muscle). The MEP recovered only in the nonclipped group. Higher ischemia rates were seen in the L1-L5 region of the TSA-clipped animals (score: 6.0 ± 0.6 vs 2.5 ± 2.3). CONCLUSIONS: 90 minutes of SCP provided sufficient spinal cord protection during arch replacement at 28 °C. In combination with permanent TSA occlusion, the lumbar spinal cord perfusion may be altered, which causes functional and structural damage.