Utilisation of blood components in cardiac surgery: a single-centre retrospective analysis with regard to diagnosis-related procedures.

BACKGROUND: More blood components are required in cardiac surgery than in most other medical disciplines. The overall blood demand may increase as a function of the total number of cardiothoracic and vascular surgical interventions and their level of complexity, and also when considering the demographic ageing. Awareness has grown with respect to adverse events, such as transfusion-related immunomodulation by allogeneic blood supply, which can contribute to morbidity and mortality. Therefore, programmes of patient blood management (PBM) have been implemented to avoid unnecessary blood transfusions and to standardise the indication of blood transfusions more strictly with aim to improve patients' overall outcomes. METHODS: A comprehensive retrospective analysis of the utilisation of blood components in the Department of Cardiac Surgery at the University Hospital of Münster (UKM) was performed over a 4-year period. Based on a medical reporting system of all medical disciplines, which was established as part of a PBM initiative, all transfused patients in cardiac surgery and their blood components were identified in a diagnosis- and medical procedure-related system, which allows the precise allocation of blood consumption to interventional procedures in cardiac surgery, such as coronary or valve surgery. RESULTS: This retrospective single centre study included all in-patients in cardiac surgery at the UKM from 2009 to 2012, corresponding to a total of 1,405-1,644 cases per year. A blood supply was provided for 55.6-61.9% of the cardiac surgery patients, whereas approximately 9% of all in-patients at the UKM required blood transfusions. Most of the blood units were applied during cardiac valve surgery and during coronary surgery. Further surgical activities with considerable use of blood components included thoracic surgery, aortic surgery, heart transplantations and the use of artificial hearts. Under the measures of PBM in 2012 a noticeable decrease in the number of transfused cases was observed compared to the period from 2009 to 2011 before implementation of the PBM initiative (red blood cells p < 0.002; fresh frozen plasma p < 0.0006; platelets p < 0.00006). CONCLUSION: Until now, cardiac surgery comes along with a significant blood supply. By using a case-related data evaluation programme, the consumption of each blood component can be linked to clinical performance groups and, if necessary, to individual patients. Based on the results obtained from this retrospective analysis, prospective studies are underway to begin conducting target / actual performance comparisons to better understand the individual decision-making by the attending physicians with respect to transfusions.

Need for psychosocial assistance in patients undergoing cardiothoracic surgery evaluated by a seven-item questionnaire.

BACKGROUND: Cardiothoracic surgery can have adverse effects on the patients' psychosocial well-being which may influence the overall prognosis. In this study, we tested the use of a seven-item screening instrument for the preoperative identification of need for psychosocial assistance in cardiothoracic patients. Methods and RESULTS: A total of 297 consecutive patients (69% male) with a median age of 70 years (59;75) completed the seven-item Hornheide Screening Instrument (HSI) on the day of admission. According to questionnaire scores predefined in the literature (cutoff ≥ 4), 130 patients (44%) exhibited a need for psychosocial support. We found female patients to have significantly higher need for psychosocial support than male patients, irrespective of their age, New York Heart Association classification or Canadian Cardiovascular Society classification, and the type of surgery they were undergoing (53 vs. 41%, p=0.034). In addition, we found that preoperative need for psychosocial support, using the predefined cutoff criterion as well as a higher absolute score, was associated with a prolonged length of hospitalization (p<0.05). CONCLUSION: We found the HSI to be a suitable tool to identify psychosocial need in cardiothoracic patients. The relatively high incidence of these patients in our study concurs with previous studies, which generally used more complex instruments. In addition, we found that preoperative scores were associated with prolonged length of stay. Therefore, the use of this questionnaire could represent an alternative, more rapid tool for the psychosocial assessment of cardiothoracic patients in daily routine.

Cardiac tumors--diagnosis and surgical treatment.

BACKGROUND: Primary tumors of the heart are rare even in major cardiac surgery centers. Because of the low case numbers, there is an insufficient evidence base to determine the optimal treatment, particularly for malignant tumors. METHOD: The authors review the pertinent literature retrieved by a selective PubMed search on the terms "cardiac tumor," "heart tumor," "cardiac myxoma," and "cardiac sarcoma." They also present operative techniques and their own long-term results in 181 patients with cardiac tumors. RESULTS: Patients with cardiac tumors generally have nonspecific symptoms depending on the site of the tumor and the extent of infiltration into the neighboring tissue. The diagnosis is based on the clinical history, echocardiography (in most cases), and, sometimes, computerized tomography and magnetic resonance imaging. Autopsy studies reveal a 0.02% prevalence of cardiac tumors, of which 75% are benign and 25% malignant. Myxoma is the most common benign tumor (50-70%); angiosarcoma is the most common malignant one (30%), followed by rhabdomyosarcoma (20%). About 10% of all tumor patients develop cardiac metastases, but these are only rarely clinically manifest. From 1989 to 2012, 181 patients underwent surgery for cardiac tumors in the authors' institution. The 5-year survival rates were 83% for benign tumors (139 patients), 30% for malignant tumors (26 patients), and 26% for cardiac metastases (16 patients). CONCLUSION: Patients with cardiac tumors should undergo surgery in a timely fashion in a specialized center. This holds for both malignant and benign tumors, particularly for atrial myxoma, which can cause serious secondary complications by embolization.

Longitudinal left ventricular 2D strain is superior to ejection fraction in predicting myocardial recovery and symptomatic improvement after aortic valve implantation.

BACKGROUND: Predicting improvement of myocardial function after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) remains a challenge. As ejection fraction (EF) may be of limited value in detecting early myocardial dysfunction and predicting outcome, we assessed the potential of echocardiographic longitudinal function in this setting. MATERIALS AND METHODS: Left ventricular (LV) function was assessed using EF, mitral annular plane systolic excursion (MAPSE), peak longitudinal 2D strain (LS) and strain rate (SR) in101consecutive patients with severe symptomatic AS (age 81 ± 11 years) undergoing TAVI. Echocardiography and assessment of clinical status including NYHA functional class were performed prior and after intervention (median 70 days). RESULTS: Pre-interventional EF was 57 ± 17% and 32 patients (32%) had an EF<50% while 58 patients (57%) were found to have an impaired LS. After TAVI there was no significant change in EF. In contrast, LS, SR and MAPSE improved significantly (-14.0 ± 4.4 vs. -15.5 ± 4.0%; p=0.007, 0.68 ± 0.24 vs. 0.78 ± 0.23/s, p=0.002; and 9.1 ± 3.2 vs. 10.2 ± 3.3mm, p=0.006, respectively). Receiver Operating Curve characteristic analysis identified a pre-TAVI LS>-13.3% as the optimal cut-off value for predicting lack of LS recovery post TAVI. There was a marked improvement in NYHA FC after intervention (p=0.0002). Among the studied echocardiographic parameters LS change correlated closest with NYHA class improvement (r=0.42, p=0.0008). CONCLUSION: Overall, LS appears to be more sensitive for detecting early myocardial damage in patients with AS compared to conventional echocardiographic parameters. More importantly, pre-interventional LS may identify irreversible myocardial dysfunction and LS improvement correlates with symptomatic improvement after intervention.

Initial clinical experience with the HeartWare left ventricular assist system: a single-center report.

BACKGROUND: The HeartWare ventricular assist device (HVAD) system (HeartWare International Inc, Framingham, MA) is a new centrifugal continuous-flow ventricular assist device. The aim of the present study is to review our institutional experience with this novel device. METHODS: We reviewed the files of 50 patients (39 men, 11 women) with a mean age of 50.6 ± 11.8 years (range, 19 to 70 years) who underwent HVAD implantation between July 2009 and November 2011. Two patients underwent HeartWare BIVAD implantation. The underlying heart diseases were end-stage ischemic heart disease (n = 12), acute myocardial infarction (n = 9), dilated cardiomyopathy (n = 27) and acute myocarditis (n = 2). Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles were level 1 (n = 11), 2 (n = 5), 3 (n = 10), and 4 (n = 24). RESULTS: After a cumulative support duration of 11,086 days, Kaplan-Meier analysis revealed a survival of 82.0%, 77.9%, 75.5%, at 1, 12, and 24 months, respectively. Causes of early death were right heart failure (n = 4), multiorgan failure (n = 2), septic shock (n = 2), and major neurologic complications (n = 4). One late death occurred due to a right heart failure. Comparison between patients operated on in cardiogenic shock (INTERMACS 1 and 2) and patients who underwent elective HVAD implantation (INTERMACS 3 and 4) revealed a survival of 61.5% and 44.1% for the INTERMACS 1 and 2 group and 90.3% and 87.1% for the INTERMACS 3 and 4 group at 1 and 12 months, respectively (odds ratio, 4.67; p = 0.003). One patient was weaned from the system after 2 years. Eleven patients (22%) were successfully bridged to transplantation. Mean time to transplantation was 209 days (range, 72 to 427 days). Posttransplant survival at the 1-year follow-up was 90.9% (11 patients). CONCLUSIONS: Our experience with HVAD shows satisfying results with an excellent posttransplantation survival. Moreover, the stratified survival based on the level of preoperative stability shows better outcomes in patients undergoing elective HVAD implantation.

Cardiopulmonary bypass during cardiac surgery modulates systemic inflammation by affecting different steps of the leukocyte recruitment cascade.

BACKGROUND: It is known that the use of a cardiopulmonary bypass (CPB) during cardiac surgery leads to leukocyte activation and may, among other causes, induce organ dysfunction due to increased leukocyte recruitment into different organs. Leukocyte extravasation occurs in a cascade-like fashion, including capturing, rolling, adhesion, and transmigration. However, the molecular mechanisms of increased leukocyte recruitment caused by CPB are not known. This clinical study was undertaken in order to investigate which steps of the leukocyte recruitment cascade are affected by the systemic inflammation during CPB. METHODS: We investigated the effects of CPB on the different steps of the leukocyte recruitment cascade in whole blood from healthy volunteers (n = 9) and patients undergoing cardiac surgery with the use of cardiopulmonary bypass (n = 7) or in off-pump coronary artery bypass-technique (OPCAB, n = 9) by using flow chamber experiments, transmigration assays, and biochemical analysis. RESULTS: CPB abrogated selectin-induced slow leukocyte rolling on E-selectin/ICAM-1 and P-selectin/ICAM-1. In contrast, chemokine-induced arrest and transmigration was significantly increased by CPB. Mechanistically, the abolishment of slow leukocyte rolling was due to disturbances in intracellular signaling with reduced phosphorylation of phospholipase C (PLC) γ2, Akt, and p38 MAP kinase. Furthermore, CPB induced an elevated transmigration which was caused by upregulation of Mac-1 on neutrophils. CONCLUSION: These data suggest that CPB abrogates selectin-mediated slow leukocyte rolling by disturbing intracellular signaling, but that the clinically observed increased leukocyte recruitment caused by CPB is due to increased chemokine-induced arrest and transmigration. A better understanding of the underlying molecular mechanisms causing systemic inflammation after CPB may aid in the development of new therapeutic approaches.

Impact of transcatheter aortic valve implantation or surgical aortic valve replacement on right ventricular function.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement (sAVR) in selected high risk patients. While improvement in left ventricular function after TAVI has been demonstrated, little is known about the impact on right ventricular (RV) function. Since postoperative RV dysfunction is linked to adverse outcomes, the authors sought to investigate the effect of TAVI and aortic valve replacement (AVR) on RV function using speckle tracking echocardiography. DESIGN: Cross-sectional study in tertiary healthcare setting. SETTING: 101 patients with severe symptomatic aortic stenosis (age 81 ± 11 yrs) who underwent TAVI and 22 patients who underwent sAVR were included. RV function was assessed using 2D longitudinal strain (RV-LS), fractional area change and tricuspid annular plain systolic excursion before and after sAVR and TAVI (median 89 days). RESULTS: Although the TAVI group had worse baseline characteristics, RV function remained unchanged in this group whereas significant deterioration of RV function was observed in patients undergoing conventional AVR: RV-LS (-25.2 ± 6.1 vs -20.0 ± 7.0%; p=0.009), RV-fractional area change (47.0 ± 7.0 vs 39.8 ± 10.7%, p=0.019) and tricuspid annular plain systolic excursion (24 ± 5 vs 16 ± 4 mm, p=0.0001). CONCLUSION: While TAVI did not affect RV function it deteriorated significantly in patients undergoing sAVR. The authors speculate that this may be related to the detrimental effects of pericardiotomy and, to a lesser degree, cardiopulmonary bypass. While further studies are required to assess the clinical significance of this finding, these data suggest that patients with pre-existing RV dysfunction may benefit from TAVI and that RV function should be incorporated into future risk scores.

Left ventricular dilation and functional impairment assessed by gated SPECT are indicators of cardiac allograft vasculopathy in heart transplant recipients.

BACKGROUND: Coronary angiography (CA) is the standard method for diagnosis of cardiac allograft vasculopathy (CAV). Little is known about the value of measuring left ventricular function over time, which can be derived from gated myocardial perfusion single-photon emission computed tomography (SPECT). We evaluated the potential of measuring myocardial perfusion and left ventricular function with gated SPECT, as compared with CA, to detect CAV in the follow-up of heart transplantation. METHODS: One hundred sixty-one heart transplant recipients (137 men, 24 women, age 50.7 ± 12.2 years) were followed-up for 4.2 ± 2.0 years by annual routine gated perfusion SPECT and consecutive CA. Myocardial perfusion was quantified by summed stress, rest and difference scores (SSS, SRS and SDS, respectively). Left ventricular function (ESV, EDV and LVEF) was derived from gated SPECT. Both were compared with angiographically defined stages of CAV. RESULTS: ESV/EDV derived from gated SPECT increased from 61 ± 25 ml/169 ± 39 ml in patients with no CAV over 74 ± 38 ml/188 ± 55 ml in patients with moderate CAV to 153 ± 75 ml/278 ± 86 ml in patients with severe CAV (p < 0.01 and p < 0.001), whereas LVEF decreased from 64 ± 10% over 62 ± 11% to 47 ± 13% in patients with severe CAV (p < 0.001). Perfusion quantified by SRS and SSS increased from 1.2 ± 1.5/1.9 ± 2.3 over 1.9 ± 1.4/2.8 ± 2.0 to 6.5 ± 5.1/7.7 ± 5.8 in patients with severe CAV (p < 0.01). Overall, for the prediction of severe CAV, accuracy was found to be higher for gated SPECT functional analysis as compared with perfusion analysis. CONCLUSIONS: Impaired left ventricular function, as assessed by gated SPECT, correlated significantly with CAV. Thus, for this purpose, gated SPECT offers higher sensitivity than analysis of perfusion while having a comparable specificity.

Role of implantable cardioverter defibrillator therapy in patients with acquired long QT syndrome: a long-term follow-up.

AIMS: The use of implantable cardioverter defibrillators (ICD) in patients with torsade de pointes (TdP) and ventricular fibrillation in the presence of acquired long QT syndrome (aLQTS) is under debate, partly due to the fact that aLQTS is potentially reversible and currently no long-term follow-up data are available. We aimed to evaluate the long-term follow-up of patients with acquired long QT syndrome (aLQTS) who had received an implantable cardioverter defibrillator (ICD) for secondary prevention of sudden cardiac arrest (SCA). METHOD AND RESULTS: Over a 10 year period, 43 patients with an ICD after survived cardiac arrest (SCA) due to an aLQTS were included [female n= 27 (63%); mean age 61 ± 16 years]. There was no clinical evidence for congenital LQTS (Schwartz score 1.25 ± 0.8). Structural heart disease was present in 29 patients (47%; ischaemic n= 13; dilated cardiomyopathy n= 9; mean EF 41%± 12). The most common proarrhythmic trigger happened to be antiarrhythmic drugs (n= 34; 79%). Other triggers included contrast agent (n= 1), haloperidol (n= 2), severe hypokalaemia (n= 2), drug abuse/alcohol (n= 2), and mere severe bradycardia (n= 2). Under trigger QTc interval measured 536 ± 58 vs. 438 ± 33 ms without trigger (P< 0.001). During a mean follow-up of 84 ± 55 months, appropriate shocks occurred in 19 patients (44%); inappropriate shocks in 13 patients (30%; only inappropriate n= 3). Appropriate shocks were almost as common in patients without as in those with structural heart disease (35 vs. 48%; P= 0.32). None of the patients were re-exposed to the initial trigger during the follow-up period. Beta-blocker medication did not prevent ICD shocks (12 of 19 vs. 11 of 24 on medication). CONCLUSION: Appropriate ICD shocks are a common finding in patients with aLQTS and SCA irrespective of the underlying cause or structural heart disease. Thus, even in the presence of relevant acquired proarrhythmia ICD may be beneficial.

Systematic analysis of gene expression differences between left and right atria in different mouse strains and in human atrial tissue.

BACKGROUND: Normal development of the atria requires left-right differentiation during embryonic development. Reduced expression of Pitx2c (paired-like homeodomain transcription factor 2, isoform c), a key regulator of left-right asymmetry, has recently been linked to atrial fibrillation. We therefore systematically studied the molecular composition of left and right atrial tissue in adult murine and human atria. METHODS: We compared left and right atrial gene expression in healthy, adult mice of different strains and ages by employing whole genome array analyses on freshly frozen atrial tissue. Selected genes with enriched expression in either atrium were validated by RT-qPCR and Western blot in further animals and in shock-frozen left and right atrial appendages of patients undergoing open heart surgery. RESULTS: We identified 77 genes with preferential expression in one atrium that were common in all strains and age groups analysed. Independent of strain and age, Pitx2c was the gene with the highest enrichment in left atrium, while Bmp10, a member of the TGFß family, showed highest enrichment in right atrium. These differences were validated by RT-qPCR in murine and human tissue. Western blot showed a 2-fold left-right concentration gradient in PITX2 protein in adult human atria. Several of the genes and gene groups enriched in left atria have a known biological role for maintenance of healthy physiology, specifically the prevention of atrial pathologies involved in atrial fibrillation, including membrane electrophysiology, metabolic cellular function, and regulation of inflammatory processes. Comparison of the array datasets with published array analyses in heterozygous Pitx2c(+/-) atria suggested that approximately half of the genes with left-sided enrichment are regulated by Pitx2c. CONCLUSIONS: Our study reveals systematic differences between left and right atrial gene expression and supports the hypothesis that Pitx2c has a functional role in maintaining "leftness" in the atrium in adult murine and human hearts.

Surgical approach to end-stage heart failure.

PURPOSE OF REVIEW: End-stage heart failure is a challenging disease with growing incidence. With decreasing heart transplant rates worldwide organ preserving therapies become, again, of interest. The purpose of the present review is to examine the potential challenges of surgical therapies in patients with end-stage heart failure. RECENT FINDINGS: The gold-standard for end-stage heart failure is and will be cardiac transplantation. However, due to organ shortage this therapy is limited to a few patients. Therefore implantation of ventricular assist devices (VADs) or long-term minimal-invasive partial support devices will increase. Improvements in device design with smaller devices, easier implantation techniques, and modified anticoagulation outcome and long-term success will likely improve. In addition, good quality of life as destination therapy is almost available. Organ conservation surgery (coronary artery bypass grafting and surgical ventricular restoration or surgical repair of mitral valve regurgitation) in end-stage heart failure patients could not prove the expected results. Transcatheter or minimal-invasive approaches of these therapies might become routine in the near future. SUMMARY: Due to the overwhelming outcome rates, cardiac transplantation is the most established surgical therapy for end-stage heart failure. VAD therapy is increasing and minimized VADs might further open the market for destination therapy/permanent support.

Aortic dissection associated with Cogans's syndrome: deleterious loss of vascular structural integrity is associated with GM-CSF overstimulation in macrophages and smooth muscle cells.

BACKGROUND: Cogan's syndrome is a rare disorder of unknown origin characterized by inflammatory ocular disease and vestibuloauditory symptoms. Systemic vasculitis is found in about 10% of cases. CASE PRESENTATION: A 46-year-old female with Cogans's syndrome and a history of arterial hypertension presented with severe chest pain caused by an aneurysm of the ascending aorta with a dissection membrane located a few centimeters distal from the aortic root. After surgery, histopathological analysis revealed that vascular matrix integrity and expression of the major matrix molecules was characterized by elastolysis and collagenolysis and thus a dramatic loss of structural integrity. Remarkably, exceeding matrix deterioration was associated with massively increased levels of granulocyte macrophage colony stimulating factor (GM-CSF). CONCLUSION: Our data suggest that the persistently increased secretion of the inflammatory mediator GM-CSF by resident inflammatory cells but also by SMC may be the trigger of aortic wall structural deterioration.

Pre-operative prediction of post-VAD implant mortality using easily accessible clinical parameters.

BACKGROUND: Mortality rates are high after implantation of a ventricular assist device (VAD), occurring mainly in the early phase post-implant during the time in the intensive care unit (ICU). Pre-operative selection criteria, which predict successful outcome, are difficult to evaluate. We implemented a pre-operative risk score to predict mortality in the ICU after VAD implantation by using easily obtained and quickly accessible clinical parameters. METHODS: In 241 VAD patients, 100 pre-operative markers were related to mortality in the ICU using univariate analysis and ROC curves, followed by multinomial logistic regression analyses. RESULTS: The mortality rate in the ICU was 32.0%. Univariate statistical analysis revealed 34 parameters that were significantly associated with mortality in the ICU. Of these, multinomial logistic regression identified 13 markers as significant risk factors. These included demographic data (age >50 years); clinically/procedurally relevant data (ischemic cardiomyopathy [ICM], re-do surgery, on extracorporeal membrane oxygenation [ECMO], on intra-aortic balloon pump [IABP], previous cardiac surgery, ventilation, emergency implant, inotropic support, renal replacement therapy, pre-operative resuscitation, transfusion) and laboratory values (blood urea nitrogen [BUN] >40 mg/dl, creatinine >1.5 mg/dl, lactate >3 mg/dl, platelets <100 x 10(3)/microl, white blood cell [WBC] count >13 x 10(3)/microl, C-reactive protein [CRP] >8 mg/dl, hemoglobin <12 g/dl, hematocrit <35%, lactate dehydrogenase [LDH] >500 U/liter, creatine kinase [CK] >200 U/liter, troponin >20 ng/ml). A weighted risk score was implemented with a maximum of 50 points. The risk for mortality in the ICU was as follows: low (15.8%), <15 points; medium (48.2%), 16 to 30 points; and high (65.2%), >30 points. CONCLUSIONS: Easily obtained and quickly accessible clinical parameters can inform potential patients, relatives, and physicians pre-operatively about the risk of death in the ICU after VAD implantation.