Pericardial Closure With Expanded Polytetrafluoroethylene Patch in Left Ventricular Assist Device Surgery.

To reduce adhesions after left ventricular assist device (LVAD) implantation, pericardial closure using an expanded polytetrafluoroethylene (ePTFE) patch has been suggested. However, as foreign material, ePTFE patches could increase the risk of infectious complications. In this single-center retrospective study, we investigated outcomes of pericardial closure using an ePTFE patch in LVAD implantation. We included all patients who underwent LVAD implantation at our center between 2011 and 2020 (n = 166). Primary endpoint was development of mediastinitis at any point of time between LVAD implantation and heart transplantation (HTx) or death. Secondary endpoint was overall survival. Preoperative and postoperative clinical data were collected to ensure comparability between the groups. We included 166 patients with LVAD. A total of 116 patients (70%) underwent pericardial closure using an ePTFE patch. There were significant differences between the groups in treatment setting, previous cardiac surgery, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level, development of driveline infection, and HTx. Patients with an ePTFE patch developed mediastinitis more frequently (16%) than patients without ePTFE patch (4%) ( p = 0.039). A significant difference in overall survival between the groups could not be confirmed ( p = 0.29). The use of PTFE patches for pericardial closure in LVAD implantation was associated with a higher incidence of mediastinitis, but not with a difference in overall survival.

Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery.

Objectives: Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle. Methods: Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed. Results: A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation. Conclusions: The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.

Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia.

INTRODUCION: Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT. MATERIAL AND METHODS: This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups. RESULTS: A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups. CONCLUSION: The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.

Long-term paracorporeal pulsatile mechanical circulatory support in adolescent and adult patients.

OBJECTIVES: Our goal was to analyse adverse events in adolescent and adult patients with the Berlin Heart EXCOR and to assess the outcome of a subsequent heart transplant (HTX). METHODS: From 2006 to 2020, a total of 58 patients (12-64 years old) received a biventricular assist device (BIVAD) at our institution and were included in this study. RESULTS: The causes of biventricular heart failure were nonischaemic cardiomyopathy (62.1%), ischaemic cardiomyopathy (22.4%) and myocarditis (15.5%). The median INTERMACS score was I (I-III). The median age was 49 years (interquartile range, 34-55 years), and 82.8% were male. Causes of death were multiorgan failure (25.0%), septic shock (17.9%), cerebral haemorrhage (14.3%), bleeding (14.3%) and embolic events (14.3%). Major bleeding was more frequent in the patients who died while on BIVADs (60.7 vs 6.7%, P < 0.001). Wound infections were more prevalent in HTX recipients (n = 21, 70.0%). After BIVAD thrombosis, 104 chamber exchanges were performed in 28 patients (48.3%). HTXs were performed in 52.6% of the patients after a BIVAD support time of 316 ± 240 days. The mean time to follow-up of 30 HTX recipients was 1722 ± 1368 days. One-, 6- and 12-month survival after an HTX were 96.7%, 90.0% and 76.7%, respectively. Long-term survival after 5 and 10 years was 69.7%. CONCLUSIONS: Pump thrombosis, infections and bleeding after receiving a BIVAD did not preclude a successful HTX. Although only 50% of patients with BIVADs were successfully given a transplant, long-term survival after an HTX in patients with BIVAD was noninferior compared to that of other recipients.

Treatment of atrial fibrillation with doxapram: TASK-1 potassium channel inhibition as a novel pharmacological strategy.

AIMS: TASK-1 (K2P3.1) two-pore-domain potassium channels are atrial-specific and significantly up-regulated in atrial fibrillation (AF) patients, contributing to AF-related electrical remodelling. Inhibition of TASK-1 in cardiomyocytes of AF patients was shown to counteract AF-related action potential duration shortening. Doxapram was identified as a potent inhibitor of the TASK-1 channel. In this study, we investigated the antiarrhythmic efficacy of doxapram in a porcine model of AF. METHODS AND RESULTS: Doxapram successfully cardioverted pigs with artificially induced episodes of AF. We established a porcine model of persistent AF in domestic pigs via intermittent atrial burst stimulation using implanted pacemakers. All pigs underwent catheter-based electrophysiological investigations prior to and after 14 days of doxapram treatment. Pigs in the treatment group received intravenous administration of doxapram once per day. In doxapram-treated AF pigs, the AF burden was significantly reduced. After 14 days of treatment with doxapram, TASK-1 currents were still similar to values of sinus rhythm animals. Doxapram significantly suppressed AF episodes and normalized cellular electrophysiology by inhibition of the TASK-1 channel. Patch-clamp experiments on human atrial cardiomyocytes, isolated from patients with and without AF could reproduce the TASK-1 inhibitory effect of doxapram. CONCLUSION: Repurposing doxapram might yield a promising new antiarrhythmic drug to treat AF in patients.

Aortic arch replacement with frozen elephant trunk technique - a single-center study.

BACKGROUND: The frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes. METHODS: From 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n = 57) or the Vascutek Thoraflex hybrid prosthesis (n = 11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each. RESULTS: Early mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p = 0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p = 0.797 and spinal cord injury: 8.8 vs. 5.9%; p = 0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2 ± 73.5 and 148.3 ± 34 min vs. 189.2 ± 47.8 and 116.3 ± 34.5 min; p <  0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p = 0.575. CONCLUSION: The FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.

Stretch-activated two-pore-domain (K2P) potassium channels in the heart: Focus on atrial fibrillation and heart failure.

Two-pore-domain potassium (K2P) channels modulate cellular excitability. The significance of stretch-activated cardiac K2P channels (K2P2.1, TREK-1, KCNK2; K2P4.1, TRAAK, KCNK4; K2P10.1, TREK-2, KCNK10) in heart disease has not been elucidated in detail. The aim of this work was to assess expression and remodeling of mechanosensitive K2P channels in atrial fibrillation (AF) and heart failure (HF) patients in comparison to murine models. Cardiac K2P channel levels were quantified in atrial (A) and ventricular (V) tissue obtained from patients undergoing open heart surgery. In addition, control mice and mouse models of AF (cAMP-response element modulator (CREM)-IbΔC-X transgenic animals) or HF (cardiac dysfunction induced by transverse aortic constriction, TAC) were employed. Human and murine KCNK2 displayed highest mRNA abundance among mechanosensitive members of the K2P channel family (V > A). Disease-associated K2P2.1 remodeling was studied in detail. In patients with impaired left ventricular function, atrial KCNK2 (K2P2.1) mRNA and protein expression was significantly reduced. In AF subjects, downregulation of atrial and ventricular KCNK2 (K2P2.1) mRNA and protein levels was observed. AF-associated suppression of atrial Kcnk2 (K2P2.1) mRNA and protein was recapitulated in CREM-transgenic mice. Ventricular Kcnk2 expression was not significantly altered in mouse models of disease. In conclusion, mechanosensitive K2P2.1 and K2P10.1 K+ channels are expressed throughout the heart. HF- and AF-associated downregulation of KCNK2 (K2P2.1) mRNA and protein levels suggest a mechanistic contribution to cardiac arrhythmogenesis.

Central extracorporeal life support with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure.

BACKGROUND: The purpose of this prospective study was to evaluate the effects and functional outcome of central extracorporeal life support (ECLS) with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. METHODS: Between August 2010 and August 2013, 12 consecutive patients (2 female) with a mean age of 31.6 ± 15.1 years received central ECLS with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. Underlying disease was acute cardiac decompensation due to dilated cardiomyopathy (n = 3, 25%), coronary artery disease with acute myocardial infarction (AMI) (n = 3, 25%), and acute myocarditis (n = 6, 50%). We routinely implemented ECLS by cannulating the ascending aorta, right atrium and inserting a left ventricular decompression cannula vent via the right superior pulmonary vein. RESULTS: All patients were successfully bridged to either recovery (n = 3, 25%), long-term biventricular support (n = 6, 50%) or cardiac transplantation (n = 3, 25%). Seven patients (58.3%) were discharged after a mean hospital stay of 42 ± 11.9 days. The overall survival from ECLS implantation to the end of the study was 58.3%. The cumulative ICU stay was 23.1 ± 9.6 days. The length of support was 8.0 ± 4.3 days (range 3-17 days). CONCLUSIONS: We strongly recommend left ventricular decompression in refractory cardiogenic shock and lung failure to avoid pulmonary edema, left heart distension and facilitate myocardial recovery.

Surgical treatment of aortic valve endocarditis with left ventricular-aortic discontinuity.

BACKGROUND: The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity. METHODS: Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete. RESULTS: Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up. CONCLUSIONS: Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe.

Reendothelialization of human heart valve neoscaffolds using umbilical cord-derived endothelial cells.

BACKGROUND: Heart valve tissue engineering represents a concept for improving the current methods of valvular heart disease therapy. The aim of this study was to develop tissue engineered heart valves combining human umbilical vein endothelial cells (HUVECs) and decellularized human heart valve matrices. METHODS AND RESULTS: Pulmonary (n=9) and aortic (n=6) human allografts were harvested from explanted hearts from heart transplant recipients and were decellularized using a detergent-based cell extraction method. Analysis of decellularization success was performed with light microscopy, transmission electron microscopy and quantitative analysis of collagen and elastin content. The decellularization method resulted in full removal of native cells while the mechanical stability and the quantitative composition of the neoscaffolds was maintained. The luminal surface of the human matrix could be successfully recellularized with in vitro expanded HUVECs under dynamic flow conditions. The surface appeared as a confluent cell monolayer of positively labeled cells for von Willebrand factor and CD 31, indicating their endothelial nature. CONCLUSIONS: Human heart valves can be decellularized by the described method. Recellularization of the human matrix resulted in the formation of a confluent HUVEC monolayer. The in vitro construction of tissue-engineered heart valves based on decellularized human matrices followed by endothelialization using HUVECs is a feasible and safe method, leading to the development of future clinical strategies in the treatment of heart valve disease.

Tricuspid valve endocarditis with septic pulmonary emboli in a drug addict.

Presented is a case of a young, polytoxicomaniac male with a history of intravenous drug abuse. He arrived at our department in a septic state with fever and showed signs of right-sided decompensated cardiac insufficiency. The patient tested positive for hepatitis C, and blood cultures were positive for Staphylococcus aureus. A thoracic computed tomographic scan revealed bilateral, multiple septic pulmonary emboli. Transesophageal echocardiography disclosed large mobile vegetations on the tricuspid valve associated with severe regurgitation. The infected tricuspid valve was replaced with a mechanical heart valve, and the patient recovered uneventfully from surgery.

Ruptured pseudoaneurysm of the pulmonary artery--rare manifestation of a primary pulmonary artery sarcoma.

A 64-year-old male developed chest pain while gardening. Aortic dissection and coronary artery disease were excluded but chest computed tomography (CT) scan showed an aneurysmic enlargement of the pulmonary artery and a fluttering structure within. He underwent immediate sternotomy for replacement of the pulmonary artery. Histology showed an intimal sarcoma of both branches of the pulmonary artery. The pulmonary artery was replaced by a T-shaped Gore-Tex-prosthesis.

High defibrillation threshold in patients with implantable defibrillator: how effective is the subcutaneous finger lead?

OBJECTIVE: Even in the era of high output implantable cardioverter defibrillator (ICD) devices, a certain proportion of patients cannot be successfully defibrillated with 10 J safety margin. In practice, either the use of a single- or double-coil lead does not guarantee successful termination of induced ventricular fibrillation. Therefore, we investigated the effectiveness of the subcutaneous finger lead placed at the subcutaneous tissue dorsal to the left ventricle in terms of defibrillation threshold (DFT) lowering. METHODS: Two thousand, eight hundred and three consecutive, unselected patients underwent first-time ICD implantation or ICD device exchange from 6/1999 through 3/2007. The mean age of the patients was 65.4 years. A total of 79.3% of the patients were male. The only implanted subcutaneous lead was the 6996 model by Medtronic Inc. RESULTS: One hundred and seventy-seven patients (6.3%) received a subcutaneous finger lead implantation. According to the current institutional DFT testing protocol, any failure of the two standard DFT tests in first-time ICD implantation or a failure at the single test in ICD exchange operations was the trigger for subcutaneous finger lead implantation. The proportion of subcutaneous finger lead implantations increased parallel to a markedly larger amount of implantations. Since high output devices became standard, the implantation number of subcutaneous finger leads decreases. The mean of unsuccessful DFTs prior to subcutaneous finger lead implantation was 27.2+/-5.3 J. After subcutaneous finger lead implantation, the mean successful DFT was 17.9+/-3.3 J. No complication due to subcutaneous finger lead implantation occurred. CONCLUSION: The subcutaneous finger lead is a quick, safe and effective method for DFT lowering.

Overestimation of aortic valve replacement risk by EuroSCORE: implications for percutaneous valve replacement.

AIMS: The EuroSCORE has been proposed to identify patients at high risk for surgical aortic valve replacement (AVR) and estimate for them the risk-benefit of percutaneous valve replacement. The aim of our study was to investigate the validity of this proposal. METHODS AND RESULTS: From 1994 to March 2006, 1545 consecutive patients with aortic stenosis underwent isolated surgical AVR at the Department of Cardiac Surgery of Heidelberg. Both additive and logistic EuroSCOREs were calculated for each patient and summed for expected 30-day mortality. Expected and observed mortalities were compared, particularly with respect to 'high-risk' status and era of operation. Overall, 30-day mortality was low (34/1545, 2.2%) and substantially overestimated by both additive (6.1%) and logistic (9.3%) EuroSCOREs. Although both EuroSCOREs stratified patients monotonically with respect to mortality risk, high-risk patients had a 3.6% mortality (29/833), whereas additive and logistic EuroSCOREs predicted 8.3 and 14.8%. Indeed, none of the 71 patients with a EuroSCORE of 11-20 (extremely high risk) died. The more recent the era of operation, the more pronounced was the discrepancy between expected and observed mortalities. CONCLUSION: Although the EuroSCORE still successfully stratifies patients undergoing surgical AVR relative to 30-day mortality, it has become increasingly uncalibrated with absolute risk, resulting in overestimation of 30-day mortality. Inaccurately predicted mortality, especially in 'high-risk' patients, renders it unsuitable for assessing risk reduction of percutaneous valve replacement.

Septic rupture of the ascending aorta after aortocoronary bypass surgery.

We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient.

Minimal touch surgical implantable cardioverter defibrillator implantations.

A growing number of patients with contraindication for transvenous implantable cardioverter defibrillator (ICD) implantation or need for system upgrade of a pre-existent pacemaker system is to be observed. Therefore, unconventional system constellation may be necessary to provide patient safety by using a minimal invasive access avoiding sternotomy. Two similar cases are presented to demonstrate configuration solutions which can be easily individually modified. Simple pacemaker and ICD implantation is nowadays mostly performed by cardiologists and/or general surgeons. As soon as partial or total thoracotomy becomes necessary, the patient will be referred to a department of cardiac surgery. Hence, in the very near future, cardiac surgeons will face a large number of redo procedures for pacemaker- and ICD systems including the necessity for mixed transvenous and epicardial solutions. To avoid significant morbidity deriving from sternotomy and pericardiotomy, concepts for as less invasive as possible solutions are presented.