Long-term results after the Ross procedure with the decellularized AutoTissue Matrix P® bioprosthesis used for pulmonary valve replacement.

OBJECTIVES: Since 1967, the Ross procedure has been performed to treat aortic valve disease using homografts for pulmonary valve replacement. The decellularized Matrix P® prosthesis was developed to overcome (some) limitations of homografts. Until now, the long-term outcome data have been unavailable. METHODS: Between 2002 and 2010, the Ross procedures using the Matrix P prosthesis were performed in 492 adult patients (mean age 57.2 ± 10.6 years, range 21-73 years) at our institution. Patient data were prospectively collected and analysed (3617.3 patient-years, mean follow-up 7.7 ± 4.3 years). Completeness of follow-up at 1, 5 and 10 years was 98.4%, 94.5% and 91.0%, respectively. RESULTS: Hospital mortality was 3.9% (n = 19). During follow-up, 121 patients died resulting in a survival rate at 5, 10 and 12.5 years of 82.8 ± 1.7%, 70.4 ± 2.3% and 62.4 ± 2.9%, respectively. Echocardiography revealed a high incidence of relevant dysfunction of the Matrix P prosthesis and subsequent right ventricular failure. Primary reoperation/reintervention was necessary for 150 Matrix P and 48 autografts. Freedom from pulmonary valve reoperation at 5, 10 and 12.5 years was 76.2 ± 2.1%, 58.6 ± 2.9% and 53.4 ± 3.4%, respectively. The autograft function and the left ventricular function showed similar results as previously reported with a freedom from autograft reoperation at 5, 10 and 12.5 years of 91.8 ± 1.4%, 86.1 ± 2.0% and 86.1 ± 2.0%, respectively. CONCLUSIONS: The Matrix P prosthesis used for the right ventricular outflow tract reconstruction in the Ross procedure showed unfavourable long-term echocardiographic results with a high rate of reoperation/reintervention for structural pulmonary valve failure. As a consequence, long-term survival of this patient cohort was impaired. Based on these findings, the use of the Matrix P prosthesis for pulmonary valve replacement for Ross procedures in adults should not be recommended.

Hemodynamics of Pericardial Aortic Valves: Contemporary Stented versus Stentless Valves in a Matched Comparison.

PURPOSE: Hemodynamic performance of aortic valve bioprostheses is essential for reliable function and durability. So far, the supra-annularly implanted stentless Sorin Freedom Solo (SFS) demonstrated unsurpassed hemodynamic properties. As contemporary stented and externally mounted pericardial bioprostheses, like the Labcor Dokimos Plus (LDP), also improve hemodynamic performance, these types of valves were compared in this study. METHODS: A total of 218 patients, who underwent aortic valve replacement with the LDP or the SFS, were matched retrospectively 1:1 on variables affecting hemodynamic measurements: implanted valve size, age, sex, and body surface area (BSA). With matching tolerance for valve size and gender of 0%, for age and BSA of 5%, 57 patient-pairs were yielded. Operative data, clinical, and hemodynamic outcome were analyzed. RESULTS: Except for slightly higher left ventricular function and lower procedural times in the SFS group, preoperative, operative, and postoperative characteristics of patient-pairs did not differ significantly. Mean pressure gradients, effective orifice areas (EOAs), and indexed EOAs were comparable. Corresponding to valve sizes of 21, 23, 25, and 27 mm, the indexed EOAs of the LDP and SFS prostheses were 1.08 ± 0.33, 0.92 ± 0.19, 0.93 ± 0.24, 0.99 ± 0.13 cm2/m2 and 0.81 ± 0.13, 0.92 ± 0.28, 0.95 ± 0.20, 1.04 ± 0.27 cm2/m2, respectively. CONCLUSION: Contemporary stented and stentless pericardial bioprostheses showed excellent hemodynamic properties without significant differences in EOAs and indexed EOAs.

EDC Cross-linking of Decellularized Tissue: A Promising Approach?

BACKGROUND: Decellularization of xenogenous cardiovascular structures is a promising approach to create scaffolds for tissue engineering. Unfortunately, handling and pliability of the unfixed tissue is challenging. N-(3-dimethylaminopropyl)-N9-ethylcarbodiimide (EDC) is an alternative cross-linking agent to glutaraldehyde (GA). Applied in native tissue, it provides biocompatibility and shows no potential for calcification. In addition, EDC can be used to link growth factors (GFs) to tissue scaffolds after decellularization. EDC cross-linking could thereby help to improve decellularized tissue without the toxicity of GA. MATERIAL AND METHODS: Porcine aortic wall tissue specimens (TS) were decellularized, treated with EDC, and coated with fibroblast growth factor (FGF) or vascular endothelial growth factor (VEGF). Afterward, TS were subcutaneously implanted in 36 Lewis rats along with one decellularized TS without EDC treatment. After 2, 4, and 6 weeks TS were explanted from 12 rats, respectively. Vital cells were evaluated by RNA quantification, general cellular infiltration by hematoxylin and eosin staining (H&E), macrophage infiltration by CD68 staining, calcification by Von-Kossa staining, and tissue degradation by measurement of TS thickness. RESULTS: Quantification of vital cells showed reduced reseeding of EDC-treated TS compared to noncross-linked TS after 2 (p < 0.05) and 4 weeks (p < 0.05), while after 6 weeks only EDC+VEGF showed fewer viable cells (p < 0.01). Histological evaluation confirmed a reduced infiltration of EDC-treated TS. Macrophage infiltration decreased in all groups from 2 to 6 weeks, with the smallest population in EDC+VEGF-treated TS (p > 0.05). In EDC+FGF-treated TS, macrophages were reduced after 2 weeks compared to noncross-linked TS (p < 0.05), while after 4 and 6 weeks no significant difference was found (p > 0.05). Von-Kossa staining revealed no calcification in any of the specimens. Thickness of noncross-linked and EDC+FGF-treated TS was not different at the respective times of explantation, but decreased in both groups toward 6 weeks. CONCLUSION: EDC cross-linking combined with GF coating of decellularized aortic wall tissue showed encouraging results. The treatment did not impair the advantages of decellularized tissue such as long-term recellularization, absence of calcification, and tissue integrity. Based on the low macrophage infiltration and minimal tissue degradation, treatment with EDC and VEGF could be useful after decellularization. However, further research is necessary to verify these findings in models, including mechanical stress.

Redo procedures for degenerated stentless aortic xenografts and the role of valve-in-valve transcatheter techniques.

Objectives: This study evaluates reinterventions for degenerated stentless aortic xenografts. Methods: Between 2010 and 2015, 52 consecutive patients (age 72.3 ± 9.7 years, EuroSCORE II 11.1 ± 8.9%) underwent reintervention for failed stentless aortic valves (60% porcine, 40% pericardial, 87% sub-coronary, 81% isolated/combined regurgitation). Results: Based on age, EuroSCORE II, the presence of pulmonary hypertension, renal failure, a patent internal mammary artery graft and required concomitant procedures, the heart team assigned 25 patients to reoperation and 27 to valve-in-valve transcatheter aortic valve implantation (ViV-TAVI). Valve implantation was successful in all surgical (24% root replacement) and in 24 transcatheter cases (93% trans-femoral, 56% balloon-expandable). Procedural complications were aortic dissection ( n = 1) during reoperation and coronary obstruction ( n = 4), device malpositioning ( n = 3), deployment of >1 valve ( n = 2) and vascular access site complications ( n = 2) during ViV-TAVI. Thirty-day mortality (10%, three ViV-TAVI patients, two surgical patients, P = 1.0) was associated with preoperative renal failure, >1 concomitant procedure, life-threatening bleeding, coronary obstruction and necessity for prolonged circulatory support. ViV-TAVI was beneficial regarding ventilation time, transfusion requirements and the incidence of sepsis. Overall, functional (94% New York Heart Association Class I/II) and echocardiographic results (indexed effective orifice area 0.95 ± 0.27 cm 2 /m 2 , mean transvalvular gradient 14 ± 6.8 mmHg) were favourable. After ViV-TAVI, aortic regurgitation was mild and moderate in two and three patients. One-year survival was 82.3 ± 5.4% and similar after surgery (83.1 ± 7.7%) and ViV-TAVI (81.5 ± 7.5%, P = 0.76). Conclusions: Reinterventions for degenerated stentless aortic valves are challenging. Although ViV-TAVI is appropriate in high-risk patients, limitations and potential complications must be considered. Redo surgery has its place in low-risk patients and if concomitant procedures are required.

Clinical outcome and hemodynamic behavior of the Labcor Dokimos Plus aortic valve.

BACKGROUND: The Labcor Dokimos Plus (LDP) is a stented externally mounted pericardial aortic bioprosthesis, which was recently introduced in Europe. Aims of the study are evaluation of operative and postoperative results as well as hemodynamic performance. METHODS: One hundred consecutive patients with a mean age of 65.9 ± 10.7 years (range 35-87) and a mean EuroSCORE II of 3.1 ± 3.9 (range 0.67-24.5) underwent aortic valve replacement with the LDP. Mean valve-size was 25.2 ± 1.7 mm. Concomitant procedures were performed in 34% of the cases. Postoperative clinical data were analyzed and hemodynamic performance of the prostheses was evaluated by transthoracic echocardiography. Clinical follow-up was 100%, echocardiographic follow-up was 93% complete. RESULTS: Intraoperatively no peculiarities occurred. Mean cross clamp times for isolated and complex procedures were 74.5 ± 20.0 min and 103.7 ± 37.1 min, respectively. Patients were extubated after a mean of 9.4 ± 15.8 h. There were no perioperative strokes. Bleeding events occurred in 4 patients. 30-day-mortality was 2%. One case of early endocarditis occurred. Echocardiography showed maximum and mean pressure gradients of 18.1 ± 6.4 and 9.6 ± 3.7 mmHg, respectively. Correspondingly to valve sizes 21, 23, 25 and 27 mm, mean pressure gradients were 17.3, 9.5, 8.5 and 10.2 mmHg, effective orifice areas were 1.92, 1.79, 2.0, 2.16 cm2 and indexed effective orifice areas were 1.08, 0.95, 0.99 and 1.01 cm2/m2, respectively. No relevant regurgitations occurred. CONCLUSIONS: The LDP showed operatively no peculiarities and a satisfactory clinical outcome with low perioperative morbidity and mortality. The hemodynamic performance of the implanted valve sizes was satisfactory.

From baby to man with a piggyback heart: long-term success of heterotopic heart transplantation.

We present a case of a young man, who underwent heterotopic heart transplantation 20 years ago, when he was 6 months old. The baby suffered from severe intractable cardiomyopathy. In this desperate situation only a miniature, compromised donor heart became available. Today, the young man is fully active under minimal immunosuppression. His surgical course is reviewed and described.

Impaired Endothelial Regeneration Through Human Parvovirus B19-Infected Circulating Angiogenic Cells in Patients With Cardiomyopathy.

Human parvovirus B19 (B19V) is a common pathogen in microvascular disease and cardiomyopathy, owing to infection of endothelial cells. B19V replication, however, is almost restricted to erythroid progenitor cells (ErPCs). Endothelial regeneration attributable to bone marrow-derived circulating angiogenic cells (CACs) is a prerequisite for organ function. Because of many similarities of ErPCs and CACs, we hypothesized that B19V is a perpetrator of impaired endogenous endothelial regeneration. B19V DNA and messenger RNA from endomyocardial biopsy specimens, bone marrow specimens, and circulating progenitor cells were quantified by polymerase chain reaction analysis. The highest B19V DNA concentrations were found in CD34(+)KDR(+) cells from 17 patients with chronic B19V-associated cardiomyopathy. B19V replication intermediates could be detected in nearly half of the patients. Furthermore, chronic B19V infection was associated with impaired endothelial regenerative capacity. B19V infection of CACs in vitro resulted in expression of transcripts encoding B19V proteins. The capsid protein VP1 was identified as a novel inducer of apoptosis, as were nonstructural proteins. Inhibition studies identified so-called death receptor signaling with activation of caspase-8 and caspase-10 to be responsible for apoptosis induction. B19V causally impaired endothelial regeneration with spreading of B19V in CACs in an animal model in vivo. We thus conclude that B19V infection and damage to CACs result in dysfunctional endogenous vascular repair, supporting the emergence of primary bone marrow disease with secondary end-organ damage.

Predictive Power and Implication of EuroSCORE, EuroSCORE II and STS Score for Isolated Repeated Aortic Valve Replacement.

OBJECTIVE: We evaluated the predictive power of the EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons (STS) score for isolated redo aortic valve replacement. MATERIALS AND METHODS: 78 consecutive patients underwent the aforementioned procedure mainly with a stentless valve prosthesis at our institution. Observed mortality was compared to the predicted mortality, Receiver Operating Characteristics (ROC) curves were calculated and the area under the curve (AUC) analyzed. RESULT: Observed mortality was 11.5%. EuroSCORE and EuroScore II predicted a mortality of 28.2 ± 21.6% (p <0.001) and 10.2 ± 11.8% (p = 0.75), respectively. AUC of the EuroSCORE was 0.74 (95% CI: 0.62-0.83), p = 0.009 and of the EuroSCORE II 0.86 (95% CI: 0.76-0.93), p <0.0001. Optimal Youden index of the EuroSCORE II was 0.59 referring to a predicted mortality of 9.9% (sensitivity: 77.8% and specificity: 81.2%). Predicted mortality of STS score was 17.8 ± 10.6% (p = 0.08) and AUC was 0.64 (95% CI: 0.53-0.75), p = 0.06. CONCLUSION: EuroSCORE II calculation was not only superior to EuroSCORE and STS score but led to a very realistic mortality prediction for this special procedure at our institution. A EuroSCORE II greater 10 should encourage to consider an alternative treatment.

Suitability of the rat subdermal model for tissue engineering of heart valves.

BACKGROUND: Tissue engineering (TE) is a promising approach to overcome problems associated with biological heart valve prosthesis. Currently several animal models are used to advance this method. The rat subdermal model is uncomplicated and widely used, but its suitability for TE has not yet been shown. MATERIAL AND METHODS: Using the rat subdermal model we implanted two decellularized porcine aortic wall specimens (of which one was endothelialized) and one native porcine aortic wall specimen in 30 Lewis rats, respectively. Endothelial cells (EC) were harvested from the rat jugular veins. After explantation Hematoxylin/Eosin-staining, CD-68-positive cell staining, fibroblast-staining and Von-Willebrand factor staining were performed. RESULTS: All animals survived without complications. Endothelialization was confirmed to be effective by Giemsa staining. Histological evaluation of specimens in Hematoxylin/Eosin staining showed significant decrease (p<0.05) of inflammatory reaction (confirmed by CD-68-positive cell staining) after decellularization. All specimens showed strongest inflammatory reactions at areas of destroyed extracellular matrix. Fibroblasts could be detected in all specimens, with strongest infiltration in decellularized specimens (p<0.05). Surrounding endothelialized specimens had no monolayer of endothelial cells, but a higher density of blood vessels occurred (p<0.05). CONCLUSIONS: The subdermal model provides excellent contact of host tissue with implanted specimens leading to rapid cellular infiltration; therefore, we could ascertain reduced inflammatory response to decellularized tissue. Due to the subdermal position, an absence of blood stream and mechanical stress occurs, which influences cellular repopulation; therefore, endothelialization did not lead to an EC monolayer, but rather to increased vascularization. Thus, the model appears ideal for investigating basic biological compatibility, but further questions must be researched using other models.

Cerebroprotective effect of preoperative dual antiplatelet therapy in patients undergoing coronary bypass surgery.

OBJECTIVES: Reduction of cognitive function is a possible side effect after coronary artery surgery using cardiopulmonary bypass (CPB). We investigated the effect of single versus dual antiplatelet therapy on cognitive performance in patients undergoing coronary artery bypass grafting (CABG) with CPB. METHODS: 50 consecutive CABG patients with preoperative intake of aspirin were compared to 49 consecutive patients with aspirin and clopidogrel. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day. To assess the overall cognitive function and the degree of cognitive decline across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: Patients had a mean age of 66.1 ± 9.3 years, received a mean of 2.8 ± 1.0 bypasses within an average of 87 ± 31 minutes on cardiopulmonary bypass. These parameters as well as the preoperative combined neurocognitive score were not significantly different between the groups. After the operation there was a significant deterioration of the combined neuropsychological score in both groups (single: preop -0.2 ± 1.5 vs. postop -1.8 ± 1.7, p = 0.000 and dual: preop 0.2 ± 1.5 vs. postop -0.5 ± 2.1, p = 0.004). However, the patients operated under dual antiplatelet therapy showed a significant less decline of overall cognitive function compared to the single antiplatelet therapy patients (dual: 0.7 ± 1.5 vs single: 1.6 ± 1.6, p = 0.004). CONCLUSION: Dual antiplatelet therapy has a cerebroprotective effect in patients undergoing coronary artery bypass surgery. Compared to single antiplatelet therapy it reduces an early postoperative substantial decline of neuropsychological abilities.

Transfemoral versus conventional aortic valve implantation--early postoperative cognitive outcome.

OBJECTIVES: Reduction of cognitive function is a possible side effect after cardiac surgery. We investigated the effect of transfemoral versus conventional aortic valve replacement on cognitive performance early after surgery. METHODS: 50 patients with transfemoral, catheter-based aortic valve implantations were compared to 50 patients with conventional surgical aortic valve replacement. Six neuropsychological subtests from the Syndrom Kurz Test and Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day in a double blind fashion. To assess the overall cognitive function and the degree of cognitive change across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: The preoperative (Spre), as well as postoperative (Spost) overall cognitive function scores, were not significantly different between the groups and showed deterioration within both groups (Spre conv. 0.2 ± 1.0 vs Spost conv. -0.6 ± 1.1, p <0.0005 and Spre transfem. -0.2 ± 1.0 vs Spost transfem. -0.6 ± 1.1, p = 0.002). This decline (Spre -Spost) was not associated with the type of operation (p = 0.1). CONCLUSION: Transfemoral aortic valve implantation has no cerebroprotective advantage since it leads also to an early postoperative decline of neuropsychological abilities, which is comparable to conventional aortic valve replacement.

Effect of different pump heads for CPB on early cognitive outcome after coronary artery bypass surgery.

OBJECTIVES: Reduction of cognitive function is a possible side effect after coronary artery surgery using cardiopulmonary bypass (CPB). We investigated the effect of roller versus centrifugal pumps for CPB on cognitive performance in patients undergoing coronary artery bypass grafting (CABG). METHODS: 50 consecutive CABG patients operated with centrifugal pump were compared to 50 roller pump patients matched for age and duration of CPB. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day in a double blind fashion. To assess the overall cognitive function and the degree of cognitive decline across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: Patients with a mean age of 63.9±8.4 years received a mean of 3.0±0.9 bypasses within an average of 80.6±20.7 mins on CPB. These parameters as well as the preoperative combined neurocognitive score were not significantly different between the groups. After the operation there was a significant deterioration of the combined neuropsychological score in both groups (centrifugal: preop 0.41±2.49 vs.postop -2.86±2.70, p <0.0005 and roller: preop -0.41±2.35 vs. postop -2.73±3.16, p <0.0005). However, the patients operated with a centrifugal pump had a significantly greater decline of overall cognitive function compared to the roller pump patients(3.3±1.7 vs. 2.3±2.7, p = 0.04). CONCLUSION: Roller pumps have a less cerebro-damaging effect than centrifugal pumps since they lead to a smaller postoperative decline of neuropsychological abilities in coronary bypass patients.

Cardiac effects of experimental intravenous bone marrow cell transplantation after myocardial infarction.

OBJECTIVES: Chronic heart failure after myocardial infarction is still a serious problem without a fundamental therapy. Direct intramyocardial transplantation of bone marrow cells (BMC) is promising but difficult to perform. Therefore, cardiac effect of experimental intravenous application of BMC after myocardial infarction (MI) is evaluated. METHODS: 20 Lewis rats underwent suture ligation of the LAD. One month after the MI, they were randomized to receive either intravenous Lewis-BMC or saline injection. Hearts were explanted and histologically examined another month later. Transthoracic echocardiography was performed before MI and intravenous injection as well as before explantation. RESULTS: BMC transplanted animals developed less cartilaginous metaplasia (BMC-group: 30% vs Control-group: 50%, p <0.01). Moreover, systolic thickness of the interventricular septum (IVSs) increased significantly in the BMC-group only: pre-Tx 1.4 ± 0.5 mm vs post-Tx 2.3 ± 0.5 mm, p = 0.02; whereas, systolic left ventricular posterior wall diameter (LVPWD) increased in the control groups only: pre-Tx 2.6 ± 0.5 mm vs post-Tx 3.4 ± 0.8 mm, p = 0.04. BMC transplantation showed a tendency towards a smaller infarct area (BMC group, 11% vs. Control group, 13%; p = 0.07) and increases in LVEF and FS after an intravenous injection (p = 0.08). CONCLUSION: Intravenous BMC-Tx led to less calcifying remodelling and a compensatory hypertrophy within the infarction area that probably contributes to functional recovery.

Use of an antimicrobial skin sealant reduces surgical site infection in patients undergoing routine cardiac surgery.

BACKGROUND: With high morbidity and potentially devastating consequences, surgical site infections (SSIs) after cardiac surgery add substantially to the healthcare burden. Inhibiting migration of skin microbes is likely to reduce contamination of the surgical incision by endogenous potential pathogens. We studied the effect of treatment with a cyanoacrylate-based antimicrobial skin sealant (INTEGUSEAL®) on the SSI rate in cardiac surgery patients. METHODS: In a consecutive series of 910 prospective patients undergoing routine cardiac surgery, standard pre-operative preparation was performed on 721 patients of whom 189 also received antimicrobial skin sealant. A further 189 consecutive patients who received only standard pre-operative care were studied retrospectively. The primary study endpoint was occurrence of superficial or deep SSI according to the definitions of the U.S. Centers for Disease Control and Prevention. RESULTS: The mean (standard deviation) SSI risk score based on combined pre-operative and intra-operative factors according to the Society of Thoracic Surgeons risk scoring system was significantly higher for the skin sealant group (9.1±1.0) than for the prospective (7.1±3.2; p<0.001) and retrospective (8.7±0.8; p<0.001) control groups. Surgical site infections occurred in two patients (1.1%) in the sealant group, 33 patients (4.6%) in the prospective control group (p<0.025), and nine patients (4.8%) in the retrospective control group (p<0.032). CONCLUSIONS: When added to existing pre-operative measures to reduce bacterial contamination of surgical incisions that are employed routinely at this cardiovascular surgery unit, use of antimicrobial skin sealant decreased the incidence of SSI in cardiac surgery patients.

Ten years of clinical results with a tissue-engineered pulmonary valve.

BACKGROUND: This study was performed to collect prospective safety and effectiveness data from a tissue-engineered heart valve implanted for reconstruction of the right ventricular outflow tract during the Ross operation. METHODS: From May 2000 until June 2002, 11 consecutive patients, mean age 39.6 ± 10.3 years, received a tissue-engineered heart valve (additive and logistic European System for Cardiac Operative Risk Evaluation, respectively, 3.3 ± 1.3 and 2.8% ± 1.4%). Two to four weeks prior to the Ross operation a piece of forearm vein or saphenous vein was harvested to isolate, characterize, and expand endothelial cells. A cryopreserved pulmonary allograft was decellularized, coated, and seeded with autologous vascular endothelial cells, using a specially developed bioreactor. Cell seeding density was 1.1 × 10(5) ± 0.5 × 10(5) cells/cm(2) with a viability of 93.2% ± 2.1%. RESULTS: All patients survived surgery. Postoperatively no fever of unknown origin was evident. Currently all patients are in New York Heart Association class I. Evaluation of the tissue-engineered heart valve by transthoracic echocardiography showed a mean pressure gradient of 5.4 ± 2.0 mm Hg at 10 years. Multislice computed tomography showed no calcification up to 10 years. CONCLUSIONS: Tissue-engineered heart valves showed excellent hemodynamic performance and may prevent degeneration during long-term follow-up.

Encouraging experience with intracardiac transplantation of unselected autologous bone marrow cells concomitant with coronary artery bypass surgery after myocardial infarction.

BACKGROUND: Chronic heart failure after myocardial infarction is still a serious problem without a fundamental therapy. Experimental transplantation of bone marrow cells (BMC) into infarcted myocardium resulted in regeneration and functional improvement. OBJECTIVE: Clinical investigation of safety and efficacy of intracardiac transplantation of unselected autologous BMC. METHOD: 22 patients scheduled for elective and isolated coronary artery bypass grafting (CABG) with a reduced LVEF due to myocardial infarction were included. Intraoperatively, sternal bone marrow blood was aspirated, and a sterile buffy coat was prepared and applicated. 19 age, LVEF and coronary disease matched patients served as controls. Heart function, geometry, and scar proportion were assessed by echocardiography and Gadolinium-MRI at the time of the operation and 6 months thereafter. RESULTS: Transplanted patients received a mean number of 360 × 106 BMC. We did not notice any significant differences in early or late complications in the transplant group as compared to controls. At six months follow up only the transplanted patients showed a significant improvement of NYHA classes from 2.7 to 1.5 and of LVEF from 36 to 43 %, (p < 0.05). Furthermore, only CABG concomitant with BMC-TX led to a significant reduction of left ventricular end diastolic diameter (LVEDD) from 59 to 54 mm and of scar proportion of the infarcted segments from 2.53 to 2.42, (p < 0.05). CONCLUSION: Intracardiac transplantation of unselected, autologous BMC is safe and feasible. In adjunct with coronary revascularization it leads to an improvement of ventricular geometry and function. Moreover, it reduces myocardial scar proportion and heart failure symptoms.

Noninvasive monitoring of cardiac function in a chronic ischemic heart failure model in the rat: assessment with tissue Doppler and non-Doppler 2D strain echocardiography.

OBJECTIVES: Feasibility of noninvasive monitoring of cardiac function after surgically induced ischemic cardiomyopathy with tissue Doppler and non-Doppler 2D strain echocardiography in rats. BACKGROUND: The optimal method for quantitative assessment of global and regional ventricular function in rats with chronic heart failure for research purposes remains unclear. METHODS: 20 rats underwent suture ligation of the left anterior descending coronary artery via a left thoracotomy to induce ischemic cardiomyopathy. Echocardiographic examination with estimation of left ventricular wall thickness, diameters, fractional shortening, ejection fraction, wall velocities as well as radial strain were performed before and 4 weeks after surgery. RESULTS: Mean LVEF decreased from 70 ± 6% to 40 ± 8% (p < 0.0001) one month after the operation. LVEDD increased from 7 ± 1 mm to 9 ± 1 mm (p < 0.0001), systolic anterior velocity decreased from 0.79 ± 0.25 cm/s to 0.18 ± 0.19 cm/s (p < 0.0001). Radial 2D strain was significantly reduced after myocardial infarction of the septal (18.2 ± 6.6% vs 7.0 ± 5.9%, p < 0.001), anteroseptal (17.3 ± 5.2% vs 4.6 ± 3.0%, p < 0.0001), anterior (18.9 ± 5.9% vs 5.6 ± 2.5%, p < 0.0001), lateral (21.4 ± 4.9% vs 8.1 ± 3.5%, p < 0.0001) as well as posterior myocardial segments (19.3 ± 5.2% vs 15.4 ± 5.5%, p < 0.01). Inferior segments (19.2 ± 7.9% vs 17.8 ± 7.9%, ns) did not change at all. CONCLUSION: It is feasible to assess dimensions, global function, and regional contractility with echocardiography in rats suffering from chronic heart failure after myocardial infarction. Particularly regional function can be exactly evaluated if tissue Doppler and 2D strain is used.

Cerebroprotective effect of piracetam in patients undergoing open heart surgery.

OBJECTIVES: Reduction of cognitive function is a possible side effect after the use of cardiopulmonary bypass (CPB) during cardiac surgery. Since it has been proven that piracetam is cerebroprotective in patients undergoing coronary bypass surgery, we investigated the effects of piracetam on the cognitive performance of patients undergoing open heart surgery. METHODS: Patients scheduled for elective open heart surgery were randomized to the piracetam or placebo group in a double-blind study. Patients received 12 g of piracetam or placebo at the beginning of the operation. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on day 3, postoperatively. To assess the overall cognitive function and the degree of cognitive decline across all tests after the surgery, we combined the six test-scores by principal component analysis. RESULTS: A total of 88 patients with a mean age of 67 years were enrolled into the study. The mean duration of CPB was 110 minutes. Preoperative clinical parameters and overall cognitive functions were not significantly different between the groups. The postoperative combined score of the neuropsychological tests showed deterioration of cognitive function in both groups (piracetam: preoperative 0.19 ± 0.97 vs. postoperative -0.97 ± 1.38, p <0.0005 and placebo: preoperative -0.14 ± 0.98 vs. postoperative -1.35 ± 1.23, p <0.0005). Patients taking piracetam did not perform better than those taking placebo, and both groups had the same decline of overall cognitive function (p = 0.955). CONCLUSION: Piracetam had no cerebroprotective effect in patients undergoing open heart surgery. Unlike the patients who underwent coronary surgery, piracetam did not reduce the early postoperative decline of neuropsychological abilities in heart valve patients.

Clinical experience with expanded use of the Ross procedure: a paradigm shift?

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the short-term survival and functional outcome after the Ross procedure, with expanded inclusion criteria. METHODS: A total of 91 patients (21 females, 70 males; mean age 57.3 +/- 13.1 years; range: 0.1-74 years) underwent aortic valve replacement (AVR) with a Ross procedure at the authors' institution during the year 2007. The underlying valve diseases were stenosis in 60 patients, regurgitation in 17, and a mixed lesion in 14. Seven patients suffered from acute infective endocarditis, and in five patients the Ross operation was a reoperative procedure. Forty-four patients (48%) underwent surgery in association with concomitant procedures, which included predominantly coronary artery bypass surgery, mitral valve repair or replacement, or procedures of the ascending aorta. RESULTS: The mean cardiopulmonary bypass and aortic cross-clamp times were 147 +/- 31 min (range: 87-246 min) and 124 +/- 26 min (range: 73-195 min), respectively. Hospital mortality was 2.2%. No patient died during the follow up period. The aortic gradient was decreased from 5.1 +/- 2 mmHg at discharge, to 3.2 +/- 1 mmHg during follow up (p < 0.05); at the same times, the mean gradient of the decellularized tissue-engineered pulmonary valve was 2.8 +/- 1 mmHg and 2.7 +/- 1 mmHg, respectively. An echocardiographic examination of neo-aortic valve competence at 12 months revealed no or trivial aortic valve regurgitation in 80 patients, and mild (grade 1+) regurgitation in nine patients. No patient required reoperation of the autograft during follow up. Two patients underwent reconstruction of the right ventricular outflow tract. At 12 months' follow up, all patients enjoyed normal social interactions, were in NYHA functional class I or II, and free from complications. CONCLUSION: The Ross procedure can be offered as an alternative to standard prosthetic AVR with an excellent short-term outcome. The former inclusion/exclusion criteria for this procedure should be re-evaluated.

Overestimation of the operative risk by the EuroSCORE also in high-risk patients undergoing aortic valve replacement with a stentless biological prosthesis.

BACKGROUND: The EuroSCORE generally overestimates the risk of standard aortic valve replacement (AVR). The predictive value of this risk algorithm for high-risk patients undergoing stentless AVR is unclear; therefore, we compared the EuroSCORE prediction with our results in this patient population. METHODS: One hundred thirty-two patients with a logistic EuroSCORE of at least 10 (mean, 25) underwent primary isolated AVR with a stentless bioprosthesis between January 2004 and December 2007. Seventy-one patients (54%) were octogenarians or nonagenarians, 62 (47%) had a reduced left ventricular ejection fraction, and 46 (35%) had an extracardiac arteriopathy. RESULTS: Maximum/mean pressure gradients for the implanted valve prostheses were 19/11 mm Hg, and the mean regurgitation grade was 0.06. Stroke occurred in 3% of the patients, and a permanent pacemaker was required in 3%. The 30-day mortality rate was 8%. Another 5% of the patients died after the 30th postoperative day but within the same hospital admission. The predicted mortality was almost 100% greater than the observed mortality. CONCLUSION: We observed a mortality rate that was 50% lower than that predicted by the logistic EuroSCORE. Therefore, one should not hesitate to use stentless valves in high-risk patients because the EuroSCORE greatly overestimates their surgical risk.