Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

Late recurrence of a cardiac glomus tumor.

Glomus tumors, also known as paragangliomas or chemodectomas, arise from well-differentiated mesenchymal cells that are known to be benign. These tumors account for 2% of all soft tissue tumors. The first case of a cardiac glomus tumor was reported in 1924 by Masson.1 Glomus tumors located within the pericardial tissue are extremely rare. We present the case of a recurrent cardiac glomus tumor. The preoperative investigation, diagnostic problems and surgical treatment of this case will be highlighted. Moreover we wish to emphasize the importance of such an entity and to remind readers that it must be included in the differential diagnosis of a pericardial tumor.

[Unusual cause of Staphylococcus aureus septicemia in a 79-year-old male patient]. / Ungewöhnliche Ursache einer Staphylococcus-aureus-Septikämie bei einem 79-jährigen Patienten.

High grade fever in the context of Staphylococcus aureus bacteremia led to hospital admission of a 79 year old male patient. A covered perforation of the ascending aorta resulted in the formation of a pseudoaneurysm which was complicated by superinfection caused by hematogenic spread of Staphylococcus aureus. The infected pseudoaneurysm found per continuitatem contact to the pericardium and resulted in bacterial pericarditis. Antibiotic pretreatment was followed by operation with a complex procedure including resection of pseudoaneurysm and suture closure of the perforation site.

Antegrade selective cerebral perfusion--how to proceed?

Aortic surgery still carries a high risk of brain damage that dominates postoperative morbidity and mortality. The concept and advantages of antegrade selective cerebral perfusion, which allows for numerous variations in its implementation, have been clearly seen for more than a decade now, but the preferred way of positioning remains unanswered. Ideal perfusion during ascending aorta/arch surgery should allow the easy implementation of selective antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion during dissections.

Selective cerebral perfusion via right axillary artery direct cannulation for aortic arch surgery.

BACKGROUND: The risk of neurological complications is still a life-threatening event for patients undergoing proximal aortic arch or total aortic arch surgery. To prevent these complications, axillary artery cannulation and antegrade selective cerebral perfusion were utilized. We compared the effects of using hypothermic circulatory arrest (HCA) alone or with selective cerebral perfusion (SCP/AX) via right side axillary artery direct cannulation. METHODS: 120 patients, mean age 61 +/- 12 years (range 26 - 80), underwent proximal aortic or total aortic arch replacement between 1999 and 2004; 46 were female. We retrospectively compared the results of the two patient groups comparable for preoperative risk factors: 71 pts were operated using HCA beginning in 1999 and 49 pts using HCA/SCP via axillary artery direct cannulation since 2002. The indication for surgery was an aortic aneurysm in 80 (67 %) patients and aortic dissection in 36 (30 %) patients. The groups were well matched with regard to median age (60 vs. 62 yrs), urgency (emergent/urgent 36 vs. 44 %; elective 64 vs. 65 %), and several other known risk factors ( p = ns). RESULTS: Overall in-hospital mortality was 13 %: 10 % with HCA vs. 6 % with SCP/AX. Permanent neurological dysfunction occurred in 10 % with HCA vs. 6 % with SCP/AX. Transient neurological dysfunction (TND) in patients surviving without stroke was lower with SCP/AX (10 %) than with HCA (17 %) ( p = ns). Mean duration of HCA was 28 +/- 12 min when isolated HCA was used, and significantly shorter with 21 +/- 6 min when the combination of SCP/AX ( p = 0.03) was used. Mean duration of CPB was 202 +/- 55 min with HCA vs. 192 +/- 50 min with SCP/AX ( p = ns). Comparison of the groups who had comparable preoperative risk factors showed a trend towards lower in-hospital mortality, stroke and TND rates, a significant reduction in cardiac ( p = 0.034), infectious ( p = 0.025) and bleeding complications ( p = 0.04) in SCP/AX compared with HCA, as well as a significantly shorter duration of hospitalization ( p = 0.046) and shorter ICU stay ( p = ns). CONCLUSION: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By reducing embolic risk, as well as the duration of HCA, SCP with axillary artery direct cannulation may be the optimal technique for averting cerebral events, reducing complications, and shortening hospital stays following aortic arch repair.

Right ventricular assist device implantation--a new transcutaneous approach.

The necessity for a secondary right heart assist device (RVAD) is a disastrous complication in left ventricular assist device (LVAD) support with respect to both complications and outcome. We have developed a new technique for inflow and outflow cannulation via a transcutaneous cannula in the femoral vein and a prosthesis-supported arterial cannula into the pulmonary artery, which does not necessitate rethoracotomy for device explantation. In addition to the simplified RVAD removal this transcutaneous approach may reduce the complications in patients requiring RVAD support.

Lung retrieval from non-heart-beating donors: first experience with an innovative preservation strategy in a pig lung transplantation model.

OBJECTIVE: Lung transplantation is limited by the scarcity of donor organs. Lung retrieval from non-heart-beating donors (NHBD) might extend the donor pool and has been reported recently. However, no studies in NHBD exist using the novel approach of retrograde preservation with Perfadex solution. METHODS: Heparinized asystolic pigs (n = 5, 30-35 kg) were ventilated for 90 min. The lungs were retrogradely preserved with Perfadex solution and stored inflated at 4 degrees C for 3 h. Left lung transplantation in the recipient was followed by exclusion of the right lung. Results were compared to sham-operated animals. Oxygenation, hemodynamics and dynamic compliance were monitored for 4 h. Infiltration of polymorphonuclear cells (PMNs) and stereological quantification of alveolar edema was performed. Statistical analysis comprised Kruskal-Wallis and Mann-Whitney tests and ANOVA analysis with repeated measures. RESULTS: No mortality was observed. During preservation, continuous elimination of blood clots via the pulmonary artery venting site was observed. Oxygenation and compliance were similar between groups, but sham controls showed significantly lower pulmonary vascular resistance. Stereological quantification revealed higher volume fractions of intra-alveolar edema in NHBD grafts, while PMN infiltration was comparable to sham controls. CONCLUSIONS: Use of NHBD lungs results in excellent outcome after 90 min of warm ischemia followed by retrograde preservation with Perfadex solution. This novel approach can optimize lung preservation by eliminating clots from the pulmonary circulation and might clinically be considered in brain-dead organ donors who become hemodynamically unstable prior to organ harvest. Further trials with longer warm and cold ischemic periods are necessary to further elucidate this promising approach to donor pool expansion.

Post-operative hypoalbuminaemia and procalcitonin elevation for prediction of outcome in cardiopulmonary bypass surgery.

BACKGROUND: Because few studies have addressed postoperative hypoalbuminaemia in relation to hospital mortality, we evaluated this association and the prognostic value of increased procalcitonin (PCT) after cardiopulmonary bypass (CPB) surgery. METHODS: In 454 consecutive patients undergoing CPB, minimal serum albumin, colloid osmotic pressure (COP) and maximal PCT were retrospectively obtained from the 2nd to 10th postoperative day. Receiver operating characteristic (ROC) and multiple regression analyses determined independent predictive strength for 28-day mortality from preoperative albumin, Euroscore, postoperative minimal albumin and COP, and maximal PCT. Cut-off points for the four strongest predictors were calculated by the area under the curve (AUC) in the ROC for the 28-day mortality. RESULTS: Maximal PCT showed the largest AUC (0.85; 95% CI 0.79-0.90) and the highest relative risk (RR 12.17; 95%CI 5.26-28.16; P < 0.001), compared with postoperative albumin (AUC 0.72; 95% CI 0.62-0.81; RR 5.35; 95%CI 2.99-9.56; P < 0.001) and EuroSCORE (AUC 0.73; 95%CI 0.63-0.83; RR 4.48; 95%CI: 1.78-11.28; P < 0.01). By logistic regression, postoperative albumin was the strongest predictor of mortality (odds ratio 0.86; 95% CI 0.84-0.89). Cut-off values for predicting 28-day mortality were found for postoperative albumin and PCT at 17.8 g l(-1) and 2.5 ng l(-1), respectively. A slight but significant inverse correlation between PCT and albumin was found. Patients with albumin less than the cut-off showed significantly higher median values for PCT levels (2.5 vs. 1.0 g l-1), a higher 28-day mortality rate (20.8% vs. 4.5%), and a longer ICU stay (6 vs. 3 days) in comparison with patients with minimal albumin greater than 18 g l(-1). CONCLUSIONS: Post-operative serum albumin <18 g l(-1) and PCT >2.5 ng l(-1) are predictive for a higher 28-day mortality rate in cardiosurgical patients. Both peak PCT and minimal albumin were better outcome predictors than the Euroscore, which better represents the preoperative condition of the patient.