Combining Minimally Invasive Surgery With Ultra-Fast-Track Anesthesia in HeartMate 3 Patients: A Pilot Study.

BACKGROUND: Minimally invasive surgery for left ventricular assist device implantation may have advantages over conventional sternotomy (CS). Additionally, ultra-fast-track anesthesia has been linked to better outcomes after cardiac surgery. This study summarizes our early experience of combining minimally invasive surgery with ultra-fast-track anesthesia (MIFTA) in patients receiving HeartMate 3 devices and compares the outcomes between MIFTA and CS. METHODS: From October 2015 to January 2019, 18 of 49 patients with Interagency Registry for Mechanically Assisted Circulatory Support profiles >1 underwent MIFTA for HeartMate 3 implantation. For bias reduction, propensity scores were calculated and used as a covariate in a regression model to analyze outcomes. Weighted parametric survival analysis was performed. RESULTS: In the MIFTA group, intensive care unit stays were shorter (mean difference, 8 days [95% CI, 4-13]; P<0.001), and the incidences of pneumonia and right heart failure were lower than those in the CS group (odds ratio, 1.36 [95% CI, 1.01-1.75]; P=0.016, respectively). At 6 and 12 hours postoperatively, MIFTA patients had a better hemodynamic performance with lower pulmonary wedge pressure (mean difference, 2.23 mm Hg [95% CI, 0.41-4.06]; P=0.028) and a higher right ventricular stroke work index (mean difference, -1.49 g·m/m2 per beat [95% CI, -2.95 to -0.02]; P=0.031). CS patients had a worse right heart failure-free survival rate (hazard ratio, 2.35 [95% CI, 0.96-5.72]; P<0.01). CONCLUSIONS: Compared with CS, MIFTA is a beneficial approach for non-Interagency Registry for Mechanically Assisted Circulatory Support 1 HeartMate 3 patients with lower adverse event incidences, better hemodynamic performance, and preserved right heart function. Future large multicentric investigations are required to verify MIFTA's effects on outcomes.

Video-Assisted Thoracoscopic Surgery Management of Subacute Retained Blood Syndrome after Cardiac Surgery.

PURPOSE: Blood loss along with inadequate evacuation after cardiac surgery leads to retained blood syndrome (RBS) in the pleural and/or pericardial cavity. Re-sternotomy is often needed for clot evacuation. Video-assisted thoracoscopic surgery (VATS) evacuation is a less-invasive procedure. However, sufficient evidence on safety and outcomes is lacking. METHODS: Thirty patients who developed hemothorax and/or hemopericardium after cardiac surgery and underwent VATS evacuation between April 2015 and September 2020 were included in this retrospective single-center analysis. RESULTS: The median patient age was 70 (interquartile range: IQR 62-75) years, body mass index (BMI) was 24.7 (IQR 22.8-29) kg/m2, time between initial cardiac surgery and VATS was 17 (IQR 11-21) days, 30% of the patients were female, 60% resided in the ICU, and 17% were nicotine users. Coronary artery bypass graft was the most frequent initial cardiac procedure. Median operation time was 120 (IQR 90-143) min, 23% of the patients needed an additional VATS, and the median length of hospital stay after VATS was 8 (IQR 5-14) days. All patients survived VATS, and we experienced no mortality related to the VATS procedure. CONCLUSION: In our study, VATS for evacuation of RBS after cardiac surgery was a feasible, safe, and efficient alternative approach to re-sternotomy in selected patients.

Speckle tracking ultrasonography as a new tool to assess diaphragmatic function: a feasibility study.

A reliable method of measuring diaphragmatic function at the bedside is still lacking. Widely used two-dimensional (2D) ultrasonographic measurements, such as diaphragm excursion, diaphragm thickness, and fractional thickening (FT) have failed to show clear correlations with diaphragmatic function. A reason for this is that 2D ultrasonographic measurements, like FT, are merely able to measure the deformation of muscular diaphragmatic tissue in the transverse direction, while longitudinal measurements in the direction of contracting muscle fibres are not possible. Speckle tracking ultrasonography, which is widely used in cardiac imaging, overcomes this disadvantage and allows observations of movement in the direction of the contracting muscle fibres, approximating muscle deformation and the deformation velocity. Several studies have evaluated speckle tracking as a promising method to assess diaphragm contractility in healthy subjects. This technical note demonstrates the feasibility of speckle tracking ultrasonography of the diaphragm in a group of 20 patients after an aortocoronary bypass graft procedure. The results presented herein suggest that speckle tracking ultrasonography is able to depict alterations in diaphragmatic function after surgery better than 2D ultrasonographic measurements.

Extracorporeal membrane oxygenation in patients with COVID-19: 1-year experience.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) in patients with coronavirus disease 2019 (COVID-19) showed reasonable outcomes. However, recent studies indicated a negative trend and analysis is needed. METHODS: Baseline characteristics, laboratory parameters, and outcomes of ECMO-supported patients with COVID-19 were analyzed in a retrospective single-center study. We included hospital admissions until February 28, 2021; patients were followed until discharge/death. Eventually, we compared data between patients hospitalized before and after September 1, 2020. RESULTS: Median age of patients treated with ECMO (n=39) was 56 years; most patients were males (n=28, 72%). Median mechanical ventilation time (prior to ECMO) was 6 days, while the median ECMO duration was 19 days. Overall survival rate was 41%. In the sub-analysis, survival until discharge in the first and second epidemic waves was 53% (n=19) and 30% (n=20), respectively (P=0.2). At baseline, compared with patients of the first wave, those of the second wave had higher median body mass index (28.2 vs. 31.1 kg/m2, respectively, P=0.02), bicarbonate (27 vs. 31.8 mmol/L, respectively, P=0.033), plasma free hemoglobin (36 vs. 58 mg/L, respectively, P=0.013), alanine aminotransferase (33 vs. 52 U/L, respectively, P=0.018), and pH (7.29 vs. 7.42, respectively, P=0.005), lower rate of pulmonary hypertension (32% vs. 0%, respectively, P=0.008), lower positive end-expiratory pressure (14 vs. 12 cmH2O, respectively, P=0.04), longer median ECMO duration (16 vs. 24.5 days, respectively, P=0.074), and more frequent major bleeding events (42% vs. 80%, respectively, P=0.022). CONCLUSIONS: ECMO-supported patients with COVID-19 had an overall survival rate of 41%. Similar to international registries, we observed less favorable outcomes during the second wave. Further research is needed to confirm this signal and find predictors for mortality.

A case report of transcatheter mitral valve repair in patient with severe acute mitral regurgitation, cardiogenic shock, and left atrial appendage thrombus as a rescue therapy: facing all enemies at once!

BACKGROUND: Transcatheter mitral valve repair (TMVR) in patients with severe acute mitral regurgitation (MR) and high surgical risk has been described. Moreover, the use of cerebral protection device (CPD) during TMVR in patients without evidence of intracardiac thrombus has been investigated. To the best of our knowledge, TMVR as a rescue therapy in a patient with acute ischaemic MR, cardiogenic shock, and left atrial appendage (LAA) thrombus with concurrent use of CPD has not been reported. CASE SUMMARY: A 59-year-old female with subacute lateral myocardial infarction caused by subacute stent thrombosis after stent implantation in the left circumflex artery 3 weeks previously presented with acute heart failure due to acute severe MR at a peripheral hospital. The patient was transferred to our tertiary centre for operative mitral valve repair. Transoesophageal echocardiogram revealed the presence of LAA thrombus. During the admission, the patient developed an electrical storm and cardiogenic shock. Because of the extremely high surgical risk and the lack of other therapeutic options, the patient was treated with TMVR (MitraClip™, Abbott Structural Heart Devices, Santa Clara, CA, USA) with the use of CPD (Sentinel™; Boston scientific) as a rescue therapy. After the procedure, the clinical and haemodynamic conditions of the patient improved significantly, and she could be discharged home without any neurological sequelae. CONCLUSION: TMVR with concurrent use of CPD as a rescue therapy may be considered in non-operable patients with cardiogenic shock caused by acute severe MR and evidence of LAA thrombus when no other therapy options are possible.

Thromboembolic and Bleeding Events in COVID-19 Patients receiving Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a potential treatment option in critically ill COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) if mechanical ventilation (MV) is insufficient; however, thromboembolic and bleeding events (TEBE) during ECMO treatment still need to be investigated. METHODS: We conducted a retrospective, single-center study including COVID-19 patients treated with ECMO. Additionally, we performed a univariate analysis of 85 pre-ECMO variables to identify factors influencing incidences of thromboembolic events (TEE) and bleeding events (BE), respectively. RESULTS: Seventeen patients were included; the median age was 57 years (interquartile range [IQR]: 51.5-62), 11 patients were males (65%), median ECMO duration was 16 days (IQR: 10.5-22), and the overall survival was 53%. Twelve patients (71%) developed TEBE. We observed 7 patients (41%) who developed TEE and 10 patients (59%) with BE. Upper respiratory tract (URT) bleeding was the most frequent BE with eight cases (47%). Regarding TEE, pulmonary artery embolism (PAE) had the highest incidence with five cases (29%). The comparison of diverse pre-ECMO variables between patients with and without TEBE detected one statistically significant value. The platelet count was significantly lower in the BE group (n = 10) than in the non-BE group (n = 7) with 209 (IQR: 145-238) versus 452 G/L (IQR: 240-560), with p = 0.007. CONCLUSION: This study describes the incidences of TEE and BE in critically ill COVID-19 patients treated with ECMO. The most common adverse event during ECMO support was bleeding, which occurred at a comparable rate to non-COVID-19 patients treated with ECMO.

Impact of pre-existing comorbidities on outcomes of patients undergoing surgical aortic valve replacement - rationale and design of the international IMPACT registry.

BACKGROUND: Degenerative aortic valve disease accounts for 10-20% of all cardiac surgical procedures. The impact of pre-existing comorbidities on the outcome of patients undergoing surgical aortic valve replacement (SAVR) needs further research. METHODS: The IMPACT registry is a non-interventional, prospective, open-label, multicenter, international registry with a follow-up of 5 years to assess the impact of pre-existing comorbidities of patients undergoing SAVR with the INSPIRIS RESILIA aortic valve on outcomes. IMPACT will be conducted across 25 sites in Austria, Germany, The Netherlands and Switzerland and intends to enroll approximately 500 patients. Patients will be included if they are at least 18 years of age and are scheduled to undergo SAVR with the INSPIRIS RESILIA Aortic Valve with or without concomitant ascending aortic root replacement and/or coronary bypass surgery. The primary objective is to determine all-cause mortality at 1, 3, and 5 years post SAVR. Secondary objectives include cardiac-related and valve-related mortality and structural valve deterioration including hemodynamics and durability, valve performance and further clinical outcomes in the overall study population and in specific patient subgroups characterized by the presence of chronic kidney disease, hypertension, metabolic syndrome and/or chronic inflammation. DISCUSSION: IMPACT is a prospective, multicenter European registry, which will provide much-needed data on the impact of pre-existing comorbidities on patient outcomes and prosthetic valve performance, and in particular the performance of the INSPIRIS RESILIA, in a real-world setting. The findings of this study may help to support and expand appropriate patient selection for treatment with bioprostheses. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04053088 .

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

PURPOSE: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients. METHODS: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks. RESULTS: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006). CONCLUSION: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Role of extracorporeal membrane oxygenation in critically Ill COVID-19 patients and predictors of mortality.

The role of extracorporeal membrane oxygenation (ECMO) in the management of critically ill COVID-19 patients remains unclear. Our study aims to analyze the outcomes and risk factors from patients treated with ECMO. This retrospective, single-center study includes 17 COVID-19 patients treated with ECMO. Univariate and multivariate parametric survival regression identified predictors of survival. Nine patients (53%) were successfully weaned from ECMO and discharged. The incidence of in-hospital mortality was 47%. In a univariate analysis, only four out of 83 pre-ECMO variables were significantly different; IL-6, PCT, and NT-proBNP were significantly higher in non-survivors than in survivors. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score was significantly higher in survivors. After a multivariate parametric survival regression, IL-6, NT-proBNP and RESP scores remained significant independent predictors, with hazard ratios (HR) of 1.069 [95%-CI: 0.986-1.160], P = .016 1.001 [95%-CI: 1.000-1.001], P = .012; and .843 [95%-CI: 0.564-1.260], P = .040, respectively. A prediction model comprising IL-6, NT-proBNP, and RESP score showed an area under the curve (AUC) of 0.87, with a sensitivity of 87.5% and 77.8% specificity compared to an AUC of 0.79 for the RESP score alone. The present study suggests that ECMO is a potentially lifesaving treatment for selected critically ill COVID-19 patients. Considering IL-6 and NT-pro-BNP, in addition to the RESP score, may enhance outcome predictions.

Rescue operation retrieving an incorrectly implanted cardiac event recorder from the left main pulmonary artery.

Continuous heart rhythm monitoring with cardiac event recorders is increasing in clinical practice and may be helpful in diagnosing a wide range of disorders and pathologies. This case study describes the case of an 80-year-old female patient with a medical history of previous cardiac surgery in which a cardiac event recorder had to be retrieved from the left main pulmonary artery.

Elevated circulating CD14++CD16+ intermediate monocytes are independently associated with extracardiac complications after cardiac surgery.

Elective cardiac surgery has low procedural complications. However, about 40% of patients develop extracardiac complications including delirium and acute kidney injury. We hypothesized that inflammatory processes and immune cell activation might be associated with these complications. We therefore prospectively included 104 patients undergoing cardiac surgery in our study. We assessed peripheral blood leukocyte populations by flow cytometry and circulating cytokines before operation, after surgery and at days one and four post-operatively. Patients undergoing cardiac surgery showed significantly elevated leukocytes and neutrophils after surgery. On the contrary, monocytes decreased after surgery and significantly increased at days 1 and 4, particularly classical (Mon1,CD14++CD16-) and intermediate (Mon2,CD14++CD16+) monocytes. While peripheral leukocyte subsets were unaltered in patients with infectious (n = 15) or cardiac complications (n = 31), post-operative leukocytes (p = 0.0016), neutrophils (p = 0.0061) and Mon2 (p = 0.0007) were clearly raised in patients developing extracardiac complications (n = 35). Using multiple logistic regression analyses, patient's age, ICU days, number of blood transfusions and elevated post-surgery Mon2 independently predicted extracardiac complications. Our findings demonstrate that elevated Mon2 after cardiac surgery are associated with an increased risk for extracardiac complications. These findings might improve the risk estimation after cardiac operations and the role of Mon2 for inflammation in cardiac surgery.

Radial Artery Tonometry to Monitor Blood Pressure and Hemodynamics in Ambulatory Left Ventricular Assist Device Patients in Comparison With Doppler Ultrasound and Transthoracic Echocardiography: A Pilot Study.

Noninvasive measurements of blood pressure (BP) and cardiac output (CO) are crucial in the follow-up of continuous-flow left ventricular assist device (CF-LVAD) patients. For our pilot study, we sought to compare BP measurements between a tonometry blood pressure pulse analyzer (BPPA) (DMP-Life, DAEYOMEDI Co., Ltd., Gyeonggi-do, South Korea) and Doppler ultrasound in CF-LVAD patients, as well as to compare the BPPA estimated CO to LVAD calculated blood flow and to the patient's intrinsic CO estimated with transthoracic echocardiography (TTE). Ambulatory CF-LVAD patients (6 HeartMate, 26 HeartMate II), were included. According to TTE findings, patients were then subdivided in two groups: patients with an opening aortic valve (OAV) [n = 21] and those with an intermittent opening aortic valve (IOAV) [n = 11]. We found a very good correlation of systolic BP (SBP) measurements between the two methods, BPPA and Doppler ultrasound (r = 0.87, P < 0.0001). Bland-Altman plots for SBP revealed a low bias of -4.6 mm Hg and SD of ±4.7 mm Hg. In CF-LVAD patients with IOAV, the BPPA-CO had a good correlation with the LVAD-flow (r = 0.78, P < 0.0001), but in OAV patients, there was no correlation. After adding the patient's intrinsic CO, estimated from TTE in patients with OAV to the LVAD-flow, we found a very good correlation between the BPPA-CO and LVAD-flow + TTE-CO (r = 0.81, P = 0.002). Our study demonstrated that compared with the standard clinical method, Doppler ultrasound, the BPPA measured BP noninvasively with good accuracy and precision of agreement. In addition, tonometry BPPA provided further valuable information regarding the CF-LVAD patient's intrinsic CO.

Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis.

PURPOSE: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition. METHODS: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC). RESULTS: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days. CONCLUSION: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.

In vitro comparison of the hemocompatibility of two centrifugal left ventricular assist devices.

OBJECTIVES: Shear stress from left ventricular assist devices induces von Willebrand factor degradation and platelet dysfunction, leading to nonsurgical bleeding. We characterized the hemostatic changes induced by 2 centrifugal left ventricular assist devices, the HeartMate 3 (Abbott Inc, Chicago, Ill) and the EVAHEART (Evaheart Inc, Houston, Tex), for comparison. METHODS: Whole blood from 8 healthy volunteers was used ex vivo. Blood from the same donor was used for 6 hours of circulation in a miniature mock-loop system consisting of 2 identical extracorporeal circuits to compare the following experimental settings: (1) optimal revolutions per minute (rpm) for the HeartMate 3 (n = 4; 5000 rpm) and the EVAHEART (n = 4; 2500 rpm) and (2) equal rpm (3000 rpm for the HeartMate 3 and EVAHEART, n = 4 vs n = 4). For both settings, blood flow was adjusted to 1 mock-loop filling volume per minute (HeartMate 3 = 82 mL/min, EVAHEART = 100 mL/min). A panel of coagulation markers was analyzed to investigate hemostatic changes. RESULTS: The free plasma hemoglobin concentration was significantly lower in the EVAHEART compared with the HeartMate 3 after 6 hours of mock-loop circulation under both settings (optimal: 37 ± 31 vs 503 ± 173 mg/dL, P < .0001; equal: 27 ± 4 vs 139 ± 135 mg/dL, P = .024). Loss of von Willebrand factor high-molecular-weight multimers occurred in both left ventricular assist devices and settings, but the von Willebrand factor:activity/von Willebrand factor:antigen ratio after 6 hours was significantly lower in optimal settings for the HeartMate 3 (P = .009). The thrombin-antithrombin complex level was significantly lower with the EVAHEART for both settings (P < .0001). CONCLUSIONS: The EVAHEART left ventricular assist device caused less hemolysis, resulted in lower coagulation activation, and provided better preservation of von Willebrand factor functional activity compared with the HeartMate 3 device. These findings prove that left ventricular assist device design plays a major role in minimizing blood damage during left ventricular assist device support.

Synchronous or Staged Carotid Endarterectomy and Coronary Artery Bypass Grafting? Propensity score matched study.

BACKGROUND: The optimal treatment strategy in patients presenting with hemodynamically significant carotid artery disease who are to undergo cardiac surgery, remains controversial. In this study, we retrospectively analyzed the outcome data of patients receiving synchronous or staged coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA). METHODS: Between 2011 and 2016, 3173 patients underwent CABG surgery in our institution, of whom 323 received CABG and CEA either as synchronous (N = 307) or as staged (N = 16) procedures. Patients´ characteristics, peri- and postoperative data were collected from our digital medical database. Propensity score matching was used to match each patient from the staged group to two appropriate patients (1:2 matching) from the synchronous group (synchronousmatched). RESULTS: The overall incidence of ischemic stroke (IS) and transitory ischemic attack (TIA) was 4.9% and 5.6%, respectively. No hemorrhagic stroke was noted in both groups. Incidence of IS did not differ significantly between matched groups (P = 1.000). Significantly higher rates of postoperative neurological complications, such as TIA and delirium, were found in the synchronousmatched group (P = .041 and P = .043, respectively) compared with the staged group. Additionally, there were more postoperative respiratory insufficiencies in the synchronousmatched group (P = .043). Thirty days mortality did not differ significantly between the matched groups. CONCLUSION: In this experience combined with the data given in literature, our findings suggest a possible superiority of the staged CABG/CEA approach. Large, randomized studies are required to verify our findings and to establish applicable guidelines.

Sildenafil Reduces the Risk of Thromboembolic Events in HeartMate II Patients with Low-Level Hemolysis and Significantly Improves the Pulmonary Circulation.

Low-level hemolysis (LLH) after left ventricular assist device implantation contributes to thromboembolic events (TE). Free plasma hemoglobin (fHb) scavenges nitric oxide (NO), which causes endothelial dysfunction and activates platelets. fHb also interacts with von Willebrand factor (vWF). We hypothesized that improved hemodynamic and enhanced NO signaling in HeartMate II (HMII) patients with LLH taking the phosphodiesterase-5 inhibitor sildenafil may reduce the risk of TE.From 2011 to 2015, 83 patients underwent HMII implantation. Patients with LLH as defined by elevated lactate dehydrogenase (400 < LDH ≤ 700 U/L) at hospital discharge were identified. Patients were categorized into 4 groups: 1) LLH + sildenafil, 2) LLH no sildenafil, 3) no LLH + sildenafil, and 4) no LLH no sildenafil. Adverse event-free survival was compared between the groups.Thirty-four patients (40.9%) were discharged with LLH and 22 (64.7%) of them took sildenafil. LDH and fHb remained significantly elevated in both LLH groups compared to the no LLH patients (P < 0.0001). Overall incidence of pump thrombosis (PT) was 4.8% and of ischemic stroke (IS) was 8.4%. HMII patients with LLH not on sildenafil had higher risk of TE (hazard ratio (HR): 14.4, 95%-CI: 1.8-117.1, P = 0.001). vWF activity and bleeding incidence did not differ between the LLH and no LLH patients. Mean pulmonary artery pressure and pulmonary vascular resistance decreased significantly in HMII taking sildenafil (P < 0.0001) while cardiac index increased (P < 0.0001).Sildenafil treatment among HMII patients with LLH reduced the risk of thromboembolic events and significantly improved and decompressed the pulmonary circulation during HMII support.

Is Systolic Right Ventricular Function Reduced after Thoracic Non-Cardiac Surgery? A Propensity Matched Echocardiographic Analysis.

PURPOSE: To assess whether thoracic non-cardiac surgery has an influence on right ventricular function (RVF) compared to known impaired postoperative RV function after cardiac surgery. METHODS: In all, 50 patients (mean age: 61 years), who underwent thoracic non-cardiac surgery were included and matched using propensity score to 50 patients, receiving coronary artery bypass graft surgery (CABG) (CABGmatched). All patients had transthoracic echocardiography (TTE) including two-dimensional speckle tracking (2D-STE) and tissue Doppler imaging (TDI) pre- and 1 week postoperatively. RESULTS: No significant changes in RV measurements including tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV), RV fractional area change (RV-FAC), and 2D-STE of the RV and RV freewall within the thoracic non-cardiac surgery patients comparing pre- and postoperative values. Comparing RV TTE values between CABGmatched patients and thoracic surgery patients, only TAPSE differed between groups preoperatively (p <0.0001), where postoperatively, all RV measurements differed significantly between the two groups: TAPSE (p <0.0001), TASV (p <0.001), RVFAC (p = 0.005), and RV 2D-STE (p <0.0001) indicating impairment of RV function post-CABG surgery compared to thoracic non-cardiac surgery. CONCLUSION: Thoracic non-cardiac surgery including an opening of the pleural cavity did not influence RV function early postoperative, whereas CABG surgery with pericardiotomy led to an impaired global RV function.

Volatile anesthetics versus propofol in the cardiac surgical setting of remote ischemic preconditioning: a secondary analysis of a Cochrane Systematic Review.

INTRODUCTION: So far, the concept of remote ischemic preconditioning (RIPC) failed its translation from experimental to clinical studies. In addition to our Cochrane Systematic Review, we systematically assessed the use of the intravenous anesthetic propofol, as a potential confounding factor. EVIDENCE ACQUISITION: We searched CENTRAL, MEDLINE, Embase and Web of Science. We included randomized controlled trials comparing RIPC with no RIPC in adult patients scheduled for coronary artery bypass graft surgery (with or without valve surgery) receiving either exclusively propofol or exclusively volatile anesthetics. Two authors independently assessed methodological quality and extracted data. We report odds ratios (ORs) with 95% confidence intervals as our summary statistics are based on random-effects models. EVIDENCE SYNTHESIS: We included 14 studies involving 4060 participants. We found no difference in treatment effect between the propofol and volatile anesthetic groups when RIPC or no RIPC is applied on a composite endpoint (all-cause mortality, non-fatal myocardial infarction and/or any new stroke), all-cause mortality, non-fatal myocardial infarction, stroke, or length of stay on ICU. On cardiac markers, RIPC did show a treatment effect on cardiac troponin T measured as AUC 72 hours (SMD -0.80, CI -1.34, -0.25) in the propofol group. However, these findings have to be interpreted with great caution, to date only a very limited number of patients received volatile anesthetics in RIPC trials (minimum N.=15, maximum N.=232). CONCLUSIONS: Present data do not permit a final assessment regarding the role of volatile or intravenous anesthetics as a possible confounding factor in RIPC trials.

The Effect of Ultrasound-Assisted Debridement Combined with Vacuum Pump Therapy in Deep Sternal Wound Infections.

PURPOSE: To assess whether a combined treatment of low-frequency (25 kHz) ultrasonic-debridement systems followed by vacuum-assisted wound closure (VAC) produces a better outcome in deep sternal wound infections (SWIs) compared to that of VAC alone. METHODS: We evaluated 45 consecutive patients (25 males) between January 2013 and December 2016, in whom deep SWI was treated with a combination of low-frequency ultrasonic debridement system followed by vacuum-assisted closure (group A, n = 23) or with only vacuum-assisted closure therapy (group B, n = 22). Our final step in both groups was a secondary wound closure with a musculocutaneous flap. RESULTS: In both groups, a similar variety of bacteria were isolated. The time between eradication and secondary wound closure was significantly shorter in group A (7.3 ± 4.8 vs. 19.9 ± 17.2 days, p = 0.001). After a third debridement session, 95.7% of microbiological cultures were negative in group A versus 54.5% in B ( p = 0.001). Duration of antibiotic treatment ( p = 0.003) and hospitalization time ( p = 0.0001) were significantly shorter in group A. CONCLUSION: The use of low-frequency ultrasonic debridement system is an effective, less invasive technique to combat wound infection. In combination with vacuum-assisted closure therapy, we documented good mid-term results in our patients.