Secondary analysis of potential associations between oral health and infection-related parameters in patients with severe heart failure-results of a German cohort.

OBJECTIVES: Aim of this retrospective cohort study was to evaluate whether oral health parameters would be associated with infection-related parameters and overall survival of patients with severe heart failure (HF). METHODS: Patients with severe HF, heart transplantation (HTx) and left-ventricular assist device (LVAD), which underwent a full oral examination between 2017 and 2018 were included. Infection-related and survival data were assessed from the patient´s medical records. The oral examination included: remaining teeth, caries and periodontal condition, including periodontal probing depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP), and diagnosis (staging/grading). In addition, the periodontal inflamed surface area (PISA) was determined. Statistical analysis included Chi-square, Fisher´s exact and Mann-Whitney-U test, as well as a logistic regression, considering age, gender, body-mass-index (BMI), diabetes and several oral health parameters with regard to overall survival and infections at heart/driveline. RESULTS: 329 patients (HTx: 34%, LVAD: 38.9%, HF: 27.1%), were included. Patients had on average 18.96 ± 8.90 remaining teeth, whereby the majority had a periodontitis stage III or IV (88.7%) and a grade B (80.5%). Higher BOP was associated with infections at heart/driveline (p = 0.04) and outside the heart (p < 0.01) during follow-up. Increased PISA was significantly associated with bacterial infections outside the heart (p < 0.01) and sepsis (p = 0.02). Only BMI of 25 or higher correlated with an increased risk of infections at heart/driveline in regression analysis (OR 3.063, CI95 1.158-8.101, p = 0.02), while no associations between oral health parameters and infections at heart/driveline or overall survival were confirmed. CONCLUSIONS: In patients with severe HF, periodontal inflammation might be associated with infection-related parameters. Improved dental care, especially including periodontal therapy and maintenance might be favourable to support prevention of infections in patients with severe HF.

Comparison of periodontal parameters between patients with ischemic and dilative cardiomyopathy.

BACKGROUND: This cross-sectional study aimed in the comparison of periodontal parameters, number of remaining teeth and oral behaviour between patients with ischemic- (ICM) and non-ischemic dilative cardiomyopathy (DCM). METHODS: Patients with HF from the Department for Cardiac Surgery at the Heart Center Leipzig were included. The two groups (ICM and DCM) were composed by matching according to age, gender and smoking habits. All participants received a comprehensive periodontal examination, including a periodontal probing on six measurement points of each tooth. RESULTS: A total of 226 patients (n = 113 each group) was included. Patients in DCM group used interdental cleaning significantly more often than ICM (23.9% vs. 12.5%, p = 0.04). The majority of patients in both groups (ICM: 83.6%, DCM: 84.6%, p = 0.23) were diagnosed with stage III-IV periodontitis. Periodontal parameters were comparable between groups (p > 0.05). Variance analysis revealed no influence of the group (ICM vs. DCM) on the number of remaining teeth (p = 0.16), periodontitis stage (p = 0.27) or the periodontal inflamed surface area (p = 0.62). CONCLUSIONS: Patients with severe HF show high periodontal burden, without any differences between ICM and DCM group. Therefore, increased attention should be payed to periodontal health of patients with severe heart disease, irrespective of their underlying disease.

Oral health-related quality of life in patients with heart failure and left ventricular assist devices-results of a cross-sectional study.

OBJECTIVES: The aim of this cross-sectional study was to compare oral health-related quality of life (OHRQoL) of patients with left ventricular assist device (LVAD) and heart failure (HF). MATERIAL AND METHODS: Seventy-four patients with LVAD were recruited from University Department for Cardiac Surgery, Leipzig Heart Center, Germany. A group of 72 patients with HF was composed by matching (age, gender, smoking). The German short form of oral health impact profile (OHIP G14) was applied. Health-related quality of life (HRQoL) was measured by short form 36 survey (SF-36). Dental conditions (decayed-, missing- and filled-teeth [DMF-T]), remaining teeth and periodontal findings were assessed. STATISTICS: t-test, Mann-Whitney U test, Kruskal-Wallis test, chi-square or Fisher test, linear regression. RESULTS: Age, gender, smoking, underlying disease, co-morbidities and oral findings were comparable between groups (p > 0.05). OHIP G14 sum score was 3.53 ± 6.82 (LVAD) and 2.92 ± 5.35 (HF; p = 0.70), respectively. The scales SF-36 physical functioning (p = 0.05) and SF-36 social functioning (p < 0.01) were worse in LVAD. In the LVAD group, the DMF-T and remaining teeth negatively correlated with OHIP G14 sum score (p < 0.01). In HF patients, positive correlations were found between OHIP G14 and D-T (p < 0.01) and remaining teeth (p = 0.04). Moreover, DMF-T (p = 0.03) and remaining molars/premolars (p = 0.02) were negatively correlated with SF-36 scales in HF. CONCLUSIONS: Oral health and OHRQoL was comparable between LVAD and HF; thereby, OHRQoL reflected the clinical oral status. CLINICAL RELEVANCE: Dental care, with beginning in early stage of HF, should be fostered to preserve teeth and support quality of life before and after LVAD implantation.

Oral health-related quality of life of patients after heart transplantation and those with heart failure is associated with general health-related quality of life: a cross-sectional study.

PURPOSE: The aim of this cross-sectional study was to examine the oral health-related quality of life (OHRQoL) in patients after heart transplantation (HTx) and those with heart failure (HF). METHODS: In total, 186 participants (HTx: 104, HF: 82) were recruited from the University Department for Cardiac Surgery, Leipzig Heart Centre, Germany. OHRQoL was assessed with the German short form of the oral health impact profile (OHIP-G14). Health-related quality of life (HRQoL) was evaluated using the short form 36 survey (SF-36). Furthermore, the dental and periodontal treatment need was recorded. RESULTS: With an OHIP-G14 sum score of 6.58 ± 6.40 [5; 2.5-8] in the HTx group and 5.54 ± 5.47 [5; 2-7] in the HF group, no clinically relevant or statistically significant difference was apparent (p = 0.39). The SF-36 scales for physical functioning, role-physical, general health and vitality were significantly worse in the HF group compared with the HTx group (pi < 0.01). A worse SF-36 physical component summary was significantly associated with a higher OHIP-G14 sum score (HTx: p < 0.01, HF: p = 0.04). In the HTx group, a significant association was also observed for the mental component summary (p < 0.01). Multiple regression analysis revealed physical component summary (p = 0.04) and mental component summary (p < 0.01) in HTx, and physical component summary (p = 0.02), mental component summary (p = 0.02) and smoking (p < 0.01) as significant predictors for OHIP G14 in HF. CONCLUSION: The OHRQoL in HF and HTx patients appears to be mainly associated with general HRQoL. Therefore, multidisciplinary dental care concepts may be recommended to improve oral health conditions in these patients.

Evaluation of risk factors for a fulminant Clostridium difficile infection after cardiac surgery: a single-center, retrospective cohort study.

BACKGROUND: Clostridium difficile (CD) is the most common pathogen causing nosocomial diarrhea. The clinical presentation ranges from mild diarrhea to severe complications, including pseudomembranous colitis, toxic megacolon, sepsis, and multi-organ failure. When the disease takes a fulminant course, death ensues rapidly in severe and complex cases. Preventive screening or current prophylactic therapies are not useful. Therefore, this study was conducted to detect risk factors for a fulminant CD infection (CDI) in patients undergoing cardiac surgery. METHODS: Between April 1999 and April 2011, a total of 41,466 patients underwent cardiac surgery at our institution. A review of our hospital database revealed 1256 patients (3.0%) with post-operative diarrheal disease who tested positive for CD; these patients comprised the cohort of this observational study. A fulminant CDI occurred in 153 of these patients (12.2%), which was diagnosed on the basis of gastrointestinal complications, e.g. pseudomembranous colitis, and/or the need for post-cardiac surgery laparotomy. Demographic, peri-operative, and survival data were analyzed, and predictors of a fulminant CDI were assessed by binary logistic regression analysis. RESULTS: The 30-day mortality was 6.1% (n = 77) for the entire cohort, with significantly higher mortality among patients with a fulminant CDI (21.6% vs. 4.0%, p <  0.001). Overall mortality (27.7%, n = 348) was also higher for patients with a fulminant course of the disease (63.4% vs. 22.8%, p <  0.001), and a laparotomy was required in 36.6% (n = 56) of the fulminant cases. Independent predictors of a fulminant CDI were: diabetes mellitus type 2 (OR 1.74, CI 1.15-2.63, p = 0.008), pre-operative ventilation (OR 3.52, CI 1.32-9.35, p = 0.012), utilization of more than 8 units of red blood cell concentrates (OR 1.95, CI 1.01-3.76, p = 0.046) or of more than 5 fresh-frozen plasma units (OR 3.38, CI 2.06-5.54, p <  0.001), and a cross-clamp time > 130 min (OR 1.93, CI 1.12-3.33, p = 0.017). CONCLUSIONS: We identified several independent risk factors for the development of a fulminant CDI after cardiac surgery. Close monitoring of high-risk patients is important in order to establish an early onset of therapy and thus to prevent a CDI from developing a fulminant course after cardiac surgery.

Tricuspid Valve Surgery in Patients with Isolated Tricuspid Valve Endocarditis: Analysis of Perioperative Parameters and Long-Term Outcomes.

Background The aim of this study was to evaluate the perioperative characteristics and the short- and mid-term outcomes in patients undergoing tricuspid valve (TV) surgery for isolated TV endocarditis. Patients and Methods A total of 56 patients with isolated TV endocarditis underwent TV surgery at a single center between June 1995 and February 2012. Mean age of patients was 53.8 ± 17.1 years, 39 (69.6%) being male. The mean left ventricular ejection fraction was 60.4 ± 13.6% and 13 (23.2%) patients had diabetes mellitus. Average logistic EuroSCORE was 19.4 ± 17.0%. Mean follow-up was 4.7 ± 3.8 years. Results Microbiological investigations revealed positive blood cultures in 89.1% of patients and positive intraoperative swabs in 51.9%. The most common pathogen (42.9%) isolated was Staphylococcus aureus, followed by coagulase-negative staphylococcus (17.9%). Discussion A history of intravenous drug abuse (IVDA) was recorded in 11 patients (19.6%), of which 8 patients additionally had hepatitis C. A total of 15 patients (26.8%) had a permanent pacemaker/implantable cardioverter-defibrillator in situ. TV replacement was performed in 22 patients (39.3%) and TV repair was performed in 34 patients (60.7%). Overall 30-day mortality was 12.5%. Five-year survival was 63.9 ± 7.2% (95% confidence interval [CI]: 64.0-137.5 months). Freedom from reoperation for recurrent TV endocarditis was 91.7 ± 4.0% (95% CI: 152.3-179.3 months) at 5 years. Conclusion Blood culture is the most important tool to detect the causative pathogen causing IE of TV. The high risk of hepatitis C in patients with IVDA and IE of the TV should be mentioned.

Gender-Based Long-Term Surgical Outcome in Patients with Active Infective Aortic Valve Endocarditis.

BACKGROUND The aim of this observational, single-center study was to evaluate the impact of gender on surgical outcome in patients with active infective endocarditis (AIE) of the aortic valve. MATERIAL AND METHODS Between October 1994 and January 2011, 755 patients (558 men and 297 women) underwent surgery for AIE at the Leipzig Heart Center, Germany, according to the modified Duke criteria. Data were collected before surgery and as the study was ongoing. Gender influence on survival was evaluated (Kaplan-Meier curves). Cox proportional models were used to evaluate gender differences in relation to early mortality (within 30 days) and late mortality (up to 10 years). RESULTS The early mortality rate was 15.0% among men and 23.0% among women, which was statistically significant different (p=0.01). In male patients, variables associated with overall mortality were age (HR 1.63, 95% CI 1.43-1.86; p<0.001), insulin-dependent diabetes mellitus (HR 2.02, 95% CI 1.48-2.75; p<0.001), preoperative low ejection fraction (OR 0.99, 95% CI 0.98-0.99; p=0.002), previous cardiac surgery (OR 1.62, 95% CI 1.22-2.13; p=0.001), preoperative ventilation (OR 1.77, 95% CI 1.14-2.75; p=0.012), preoperative dialysis (OR 1.89, 95% CI 1.20-2.98; p=0.006), NYHA Class IV (OR 1.56, 95% CI 1.12-2.15; p=0.008), and involvement of multiple valves (OR 1.65, 95% CI 1.24-2.19; p=0.001) had a statistically significant influence on the late mortality. Focus identification (OR 1.75, 95% CI 1.08-2.77; p=0.023), involvement of multiple valves (OR 1.52, 95% CI 1.02-2.26; p=0.040), preoperative dialysis (OR 3.65, 95% CI 1.96-6.77; p<0.001), and age (OR 1.53, 95% CI 1.28-1.82; p<0.004) were predictive risk factors for late mortality in women with AIE (OR 3.6, 95% CI 1.5-8.4; p<0.004). CONCLUSIONS This study demonstrated distinct gender-based differences in risk of mortality in patients with AIE (who were undergoing surgical treatment) with different early and long-term outcomes.

No Association between Clinical Periodontal Conditions and Microbiological Findings on Driveline of Patients with Left-Ventricular Assist Devices (LVAD).

The aim of this retrospective study was to investigate whether there would be an association between periodontal disease parameters and positive bacterial findings at the driveline of patients with a left ventricular assist device (LVAD). Patients with an LVAD, who underwent a full oral and microbiological examination between 2016 and 2018, were included. During oral examination, periodontitis severity (stage and grade) and the periodontal inflamed surface area (PISA) were evaluated. A microbiological analysis was performed from swabs of the driveline, whereby different bacterial species were cultivated and analyzed. A total of 73 patients were included in the current study. The majority of participants (80.8%) had at least one positive bacterial finding during the study period. Most patients had a periodontitis stage of III-IV (80.9%). The determined PISA of the total group was 284.78 ± 352.29 mm2. No associations were found between the periodontal disease parameters and the bacterial findings in general, the bacterial findings on the day of oral examination or the bacterial findings 12 months prior to/after the oral examination (p > 0.05). Periodontitis is not associated with cultivated microbiological findings at the driveline of patients with an LVAD and thus appears not to be a risk indicator for driveline colonization. Nevertheless, the high periodontal burden in LVAD patients underlines the need for their improved periodontal care.

Lack in Periodontal Care of Patients Suffering from Severe Heart Diseases-Results after 12 Months Follow-Up.

BACKGROUND: To assess whether the standardized recommendation of patients with heart failure (HF), left-ventricular assist device (LVAD) and heart transplantation (HTx) to visit their dentist leads to improved oral conditions after 12 months. METHODS: Patients from the Department of Cardiothoracic Surgery, Leipzig Heart Centre, Germany were examined at baseline and after 12 months. A dental (decayed-, missing-, and filled-teeth index (DMF-T)) and periodontal examination (periodontal probing depth, clinical attachment loss) was performed. At baseline, patients received a standardized recommendation to visit their dentist. At follow-up, a standardized questionnaire regarding the dental consultation was applied. RESULTS: Eighty-eight participants (HTx: 31, LVAD: 43, HF: 14) were included. The majority of patients (79.5%) followed the recommendation to visit their dentist. Within the total cohort, periodontal treatment need was significantly reduced from 91% (baseline) to 75% (follow-up; p < 0.01). Only 10% of total cohort stated that they received periodontal treatment. The outcome in periodontal and dental treatment need at follow-up appointment revealed no statistically significant associations to the questionnaire regarding dentist consultation (p > 0.05). Conclusions: The simple recommendation to visit the dentist appears not enough to obtain sufficient dental and periodontal conditions in patients with severe heart diseases. Thereby, a lack in periodontal treatment of patients with HF, HTx and LVAD was identified, making interdisciplinary dental special care programs recommendable.

Oral health and dental behaviour of patients with left ventricular assist device: a cross-sectional study.

AIMS: The aim of this cross-sectional study was the assessment of dental behaviour, oral health, as well as oral health-related quality of life of patients with left ventricular assist device (LVAD). METHODS AND RESULTS: Patients (128) with LVAD were recruited from the University Department for Cardiac Surgery at Heart Center, Leipzig, Germany. A healthy control group (HC, n = 113) was included. Dental behaviour was assessed with a standardized questionnaire, and to evaluate oral health-related quality of life, the German short form of oral health impact profile was applied. The presence of decayed, missing, and filled teeth; dental treatment need; periodontitis severity; and periodontal treatment need were assessed. These findings were correlated to disease-related and device-related factors. The minority of patients used aids for interdental hygiene (16.4%). For the LVAD patients, a German short form of oral health impact profile sum score of 4.96 ± 8.67 [0.5; 0-6] was assessed. The LVAD group suffered from more missing teeth (11.91 ± 9.13 vs. 3.70 ± 3.77; P < 0.01) than HC. More severe periodontitis was found in LVAD group (LVAD = 41.4% and HC = 27.4%; P < 0.01). Periodontal treatment need was high in both groups, without a significant difference (LVAD = 84.4% vs. HC = 86.7%; P = 0.71). LVAD therapy as bridge to transplantation was correlated with periodontal treatment need (odds ratio = 11.48 [1.27; 103.86]; P = 0.03). Further correlations between treatment need and disease specific factors were not detected. CONCLUSIONS: Patients with LVAD suffer from a high periodontal treatment need and a lack in oral behaviour. Interdisciplinary special care concepts appear recommendable to improve oral health in LVAD patients.

Treatment of hypercholesterolaemia with PCSK9 inhibitors in patients after cardiac transplantation.

BACKGROUND: Hypercholesterolaemia is common in patients after cardiac transplantation. Monoclonal antibodies that inhibit proprotein convertase subtilisin-kexin type 9 (PCSK9) reduce low-density lipoprotein (LDL) cholesterol levels and subsequently the risk of cardiovascular events in patients with dyslipidaemia. There are no published data on the effect of this medication class on cholesterol levels in patients after cardiac transplantation. METHODS: In this retrospective study we investigated patients who were treated with PCSK9 inhibitors either because of intolerance of statins or residual hypercholesterolaemia with evidence of cardiac allograft vasculopathy. We compared the data of patients prior to the start with these medications with their most recent dataset. RESULTS: Ten patients (nine men; mean age 58±6 years) underwent cardiac transplantation 8.3±4.5 (range 3-15) years ago. The treatment duration of Evolocumab or Alirocumab was on average 296±125 days and lead to a reduction of total Cholesterol (281±52 mg/dl to 197±36 mg/dl; p = 0.002) and LDL Cholesterol (170±22 mg/dl to 101±39 mg/dl; p = 0.001). No significant effects on HDL Cholesterol, BNP, Creatin Kinase or hepatic enzymes were noticed. There were no unplanned hospitalisations, episodes of rejections, change of ejection fraction or opportunistic infections. Both patients on Alirocumab developed liver pathologies: One patient died of hepatocellular carcinoma and the other developed hepatitis E. CONCLUSIONS: Our study demonstrates that the PCSK9 inhibitors Evolocumab and Alirocumab lead to a significant reduction of LDL Cholesterol in heart transplantation recipients. No effect on cardiac function or episodes of rejections were noticed. Larger and long-term studies are needed to establish safety and efficacy of PCSK9 inhibitors after cardiac transplantation.

Insufficient Oral Behaviour and the High Need for Periodontal Treatment in Patients with Heart Insufficiency and after Heart Transplantation: A Need for Special Care Programs?

BACKGROUND: The aim of this cross-sectional study was the assessment of dental behaviour and oral health condition of heart transplant recipients (HTx) in comparison to patients with heart insufficiency (HI). METHODS: Patients attending the Department for Cardiac Surgery, Leipzig Heart Center, Germany were recruited. Standardized questionnaires regarding dental behaviour and periodontal complaints were applied. A dental (decayed-, missing- and filled-teeth index) and periodontal examination (periodontal probing depth (PPD) and clinical attachment loss (CAL)) was performed. Based on the oral findings, dental and periodontal treatment need was determined. STATISTICS: T-test, Mann-Whitney U test, Chi-square test, and Fisher-test (p < 0.05). RESULTS: A total of 201 patients (HTx: 112, HI: 89) were included. HTx patients were significantly more often allocated to dentists (p < 0.01). Furthermore, the HTx patients rated feeling informed appropriately about oral health more often (p < 0.01). HTx patients used interdental cleaning (p < 0.01) and mouth rinse (p = 0.02) more often than HI patients. No differences between groups were present regarding dental status and periodontitis severity (p > 0.05). Periodontal treatment need was high, showing prevalence of 79.5% (HTx) and 87.6% (HI, p = 0.14), respectively. CONCLUSIONS: Both groups show insufficient oral behaviour and a high need for periodontal treatment. Special care programs for HTx candidates and recipients appear recommendable.

Cardiac Surgery Compared With Antibiotics Only in Patients Developing Infective Endocarditis After Transcatheter Aortic Valve Replacement.

Background Infective endocarditis ( IE ) after transcatheter aortic valve replacement is a devastating complication associated with a high mortality. Our objective was to determine the impact of cardiac surgery (CS) and antibiotics ( IE - CS ) compared with medical treatment with antibiotics only ( IE - AB x) on 1-year mortality in patients developing IE after transcatheter aortic valve replacement. Methods and Results Patients developing IE after transcatheter aortic valve replacement were included in this retrospective analysis. All-cause 1-year mortality was the primary end point. A total of 20 patients underwent IE - CS compared with 44 patients treated by IE - AB x. In this unmatched cohort, patients treated by IE - AB x were older ( P=0.006), had a higher Society of Thoracic Surgeons score ( P=0.029), and more often had severe chronic kidney disease ( P=0.037). One-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 68.2%; P=0.802). The rate of any complication during treatment was higher in the IE - CS group ( P=0.024). In a matched cohort, baseline characteristics were not significantly different. All-cause 1-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 75%; P=0.490). A Cox regression analysis revealed any indication for surgery (hazard ratio, 6.20; 95% confidence interval, 1.80-21.41; P=0.004), sepsis on admission (hazard ratio, 4.03; 95% confidence interval, 1.97-8.24; P<0.001), and mitral regurgitation ≥2 (hazard ratio, 2.91; 95% confidence interval, 1.33-6.37) as factors associated with 1-year mortality. Conclusions In patients developing IE after transcatheter aortic valve replacement, mortality was predicted by the severity of IE and concomitant mitral regurgitation. In this small, and therefore statistically limited, but high-risk patient cohort, CS provided no significant mortality benefit compared with medical therapy. Individual decision making by a "heart and endocarditis team" is necessary to offer those patients the most reasonable treatment option.

Replacing cardiopulmonary bypass with extracorporeal membrane oxygenation in lung transplantation operations.

OBJECTIVE: Cardiopulmonary bypass (CPB) support is required in some lung transplantation (LTX) operations. CPB support and full-dose heparin increases the risks of bleeding and early graft dysfunction. We report our experiences of replacing CPB with heparin-bonded low-dose heparin extracorporeal membrane oxygenation (ECMO) support in LTX surgery. METHODS: From 2003 to 2005 forty-seven patients were transplanted. Thirty-seven LTX patients were retrospectively evaluated for this study (10 patients were excluded due to heart-lung-, lung-kidney transplantation, LTX with bypass grafting, and ASD closure or emergency CPB support). Extracorporeal circulation support was necessary in 40% of the 37 LTX patients due to severe primary or secondary pulmonary hypertension (P or SPHTN), right heart dysfunction, or hemodynamic instability. There were seven LTX procedures with CPB and eight implantations with ECMO support. CPB (high-dose heparin) and ECMO support (ACT 160-220 s) was always set up through femoral veno-arterial canulation. All patients had limited access thoracotomies without transsection of the sternum. Normothermia was maintained in all patients. CPB patients: PPH 15%, COPD 15%, IPF with mean PAP>40 mmHg 70%. ECMO patients: PPH 13%, COPD 13%, IPF with severe PAP pressure elevation 74%. RESULTS: In patients undergoing LTX for PPH, the ECMO support was directly extended into the post-operative period. Packed red blood cell (PRBC) transfusion requirements during the operation and the first 24h were 13.25+/-1.6 PRBC units versus 5.1+/-2.8 PRBC units on CBP (p=0.02). Operative time was longer (p=0.11) in the ECMO LTX (451 min+/-76 vs 346+/-140). The increased 90-day mortality rate of the ECMO patients showed a trend toward significance (p=0.056), which was related to infectious complications (3 vs 1 patient). Severe graft ischemia/reperfusion injury occurred in 9% in the CPB versus 13% in the ECMO group. The 1-year survival was significantly reduced in ECMO patients (p=0.004, log-rank test). CONCLUSIONS: The advantages of femoral canulation rather than conventional central connections in lung transplantation procedures led to an undisturbed operative field. A significantly higher blood product amount was required in ECMO patients, which might lead to increased infection and mortality rates. CPB, obviously, should remain the standard support technique if extracorporeal circulation is required in lung transplantation surgery.

Use of over-the-scope clips (OTSC) for hemostasis in gastrointestinal bleeding in patients under antithrombotic therapy.

Background and study aims In patients taking different regimens of antithrombotic and/or anticoagulant therapy, endoscopic management of gastrointestinal bleeding represents a major challenge due to failing endogenous hemostasis. In this retrospective study we report on success rates with the over-the-scope clip (OTSC) system in upper and lower gastrointestinal bleeding in this high-risk patient population. Patients and methods Between February 2011 and June 2014, 75 patients were treated with an OTSC for active gastrointestinal bleeding. Success rates with the first endoscopic therapy, rebleeding episodes, their management and the influence of antithrombotic or anticoagulant therapy were analyzed retrospectively. Results Application of the OTSC resulted in immediate hemostasis (primary success rate) in all 75 patients. However, in 34.7 % a rebleeding episode was noted that could be treated by further endoscopic interventions. Only 3 patients had to be sent to the operating room because of failure of endoscopic therapy. In the rebleeding group the use of antiplatelet therapies was higher (73.1 % vs. 48.9 %). Conclusions Application of the OTSC in GI bleeding results in a high rate of primary hemostasis. Rebleeding occurs in up to 35 % of patients receiving antithrombotic/anticoagulant therapy but can be managed successfully with further endoscopic treatments. Patients in the rebleeding group were more frequently treated with antiplatelet agents. Radiological or surgical therapy was reserved for a small subgroup not successfully managed by repeated endoscopic therapies. OTSC application is the treatment of choice in high-risk patients when conventional clips used as first-line treatment fail.

Left ventricular reverse remodeling after surgical therapy for aortic stenosis: correlation to Renin-Angiotensin system gene expression.

BACKGROUND: Surgical therapy for aortic stenosis leads to reverse remodeling, with normalization of left ventricular hypertrophy (LVH). The aim of this study was to examine Renin-Angiotensin system (RAS) gene expression in this setting. METHODS: Growing sheep (n=44) underwent supracoronary aortic banding for controlled induction of LVH at the age of 6 to 8 months (A=baseline). Surgical revision to completely release the pressure gradient was performed 8.3+/-1 months later (B). The animals were sacrificed after another 10.1+/-2 months (C). Along with hemodynamic measurements, subtractive hybridization and competitive polymerase chain reaction were applied to quantify mRNA expression for angiotensin-converting enzyme (ACE) and angiotensin receptors 1 and 2 (AT1-R and AT2-R). RESULTS: Left ventricular mass index was 82+/-21 g (A), 150+/-33 g (B), and 78+/-18 g (C), P<0.01. Left ventricular function and cardiac index remained stable. Myocardial fiber diameter was 11.3+/-0.8 (A), 15.9+/-1.2 (B), and 11.4+/-1 (C) microm, P<0.01. Gene expression was as follows: ACE 0.8+/-0.05 (A), 1.3+/-0.08 (B), and 0.9+/-0.06 (C), P<0.01; AT1-R 0.7+/-0.06 (A), 0.9+/-0.07 (B), and 0.3+/-0.04 (C), P<0.01; AT2-R 0.5+/-0.05 (A), 0.2+/-0.04 (B), and 0.5+/-0.05 (C), P<0.01. CONCLUSION: LVH in aortic stenosis coincides with significant alterations of the RAS. Surgical therapy leads to reverse remodeling, which is paralleled by regression of RAS gene expression.

Outcome of aortic valve replacement for active infective endocarditis in patients on chronic hemodialysis.

BACKGROUND: The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. METHODS: Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed. RESULTS: Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause. CONCLUSIONS: In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE.

Secundum ASD closure using a right lateral minithoracotomy: five-year experience in 122 patients.

BACKGROUND: Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques. METHODS: From May 1996, February 2002, 177 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (LMT) was used in 122 patients and a conventional approach, in 55. Diagnoses included secundum ASD in 106 patients in the LMT group and 40 in the conventional group, sinus venosus ASD in 13 patients in each group, and status post interventional closure in 3 and 2 patients, respectively. Mean age was 37 +/- 17 years in the LMT group and 43 +/- 20 years, in the conventional group and mean body weight was 66 +/- 17 kg and 70 +/- 16 kg, respectively. In the LMT group, femoral cannulation was performed for cardiopulmonary bypass. RESULTS: Direct ASD closure was carried out in 67.2% of patients in the LMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was one death: A patient in the conventional group who required explantation of an Amplatzer device because of infection died postoperatively. Average stay in the intensive care unit was 1.2 +/- 0.5 days. Two patients required reoperation for residual ASD after direct closure; 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital. CONCLUSIONS: Secundum ASD closure by LMT has become as standard and safe an operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus LMT is an attractive option for patients who are not suitable for closure using catheter-based devices.