Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction.

STUDY OBJECTIVE: The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap. METHODS: T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity. RESULTS: Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves. CONCLUSION: Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample.

Five-Year Survival of Patients Treated with Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Compared with the General Swiss Population.

BACKGROUND: To evaluate the midterm follow-up and 5-year survival outcome of the minimally invasive direct coronary artery bypass (MIDCAB) procedure compared with the survival of the general Swiss population. METHODS: Retrospective study on preoperative data, intraoperative data, and postoperative outcome of patients who underwent MIDCAB surgery between June 2010 and February 2019. To assess validity of this surgical therapy, outcomes were compared with survival data of a gender- and age-matched cohort of the general Swiss population taken from the database of the Swiss Federal Statistical Office. RESULTS: A total of 88 patients were included. Median (interquartile range [IQR[) age was 66 (56-75) years, and 27% (n = 24) were female. The median (IQR) length of the in-hospital stay was 7 (6-8) days. No postoperative stroke occurred. The 30-day mortality was 1.1% (n = 1). Reintervention for failed left internal mammary artery was needed in 1.1% (n = 1). The median (IQR) ejection fraction was 58% (47-60) preoperatively and remained stable during follow-up. The median (IQR) follow-up period was 3 (1.1-5.2) years. Five years postoperatively, 83% (confidence interval, 69-91) of the patients were alive, showing an overlap with the range of survival of the matched subcohort of the general Swiss population (range, 84-100%). CONCLUSION: Though suffering from coronary heart disease, patients after MIDCAB show almost equal survival rates as an equivalent subcohort corresponding to the general Swiss population matched on age and gender. Thus, our data show this treatment to be safe and beneficial.

Transapical Transcatheter Mitral Valve Implantation with the Tendyne Valve: The Swiss Experience.

BACKGROUND: The aim of this study was to report outcomes of all patients undergoing transcatheter mitral valve implantation with the Tendyne Mitral Valve System (Tendyne) in Switzerland. METHODS: We retrospectively analyzed preoperative echocardiographic and computed tomography (CT) data, procedural findings, and 30-day and 1-year follow-up echocardiographic and clinical data of patients who underwent transcatheter mitral valve implantation with Tendyne in Switzerland. RESULTS: A total of 24 patients (age, 74.8 ± 7.8 years; 67% male) underwent transapical transcatheter mitral valve implantation with Tendyne between June 2020 and October 2022. Technical success rate was 96%. In five patients, concomitant interventions in the form of transcatheter aortic valve implantation (one patient), minimally invasive direct coronary artery bypass (one patient), and transcatheter edge-to-edge repair (three patients) were performed prior to or after the index procedure. There was one device embolization, and two patients required valve retrieval. In-hospital outcomes included one stroke and three major bleeding events. None of the patients died within 30 days. Two patients were rehospitalized for decompensated heart failure. At 1-year follow-up, there were three noncardiovascular-related deaths. CONCLUSION: Transcatheter mitral valve implantation with Tendyne is feasible to treat polymorbid patients suffering from complex mitral valve disease as well as patients with previous mitral interventions. Perioperative risk was acceptable and procedural success high.

Performance of the ESC 0/2h-algorithm using high-sensitivity cardiac troponin I in the early diagnosis of myocardial infarction.

The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.

Echocardiographic and Clinical Follow-up After Aortic Valve Neocuspidization Using Autologous Pericardium.

INTRODUCTION: Mid-term data from a single centre showed the safety and durability of aortic valve neocuspidization using autologous pericardium (OZAKI procedure). Since validation data from other centres are missing, aim of this study was to analyze echocardiographic and clinical results of our first patients that were operated with the OZAKI technique. METHODS: Thirty-five patients (24 males, median (IQR) age 72.0 (59.0, 76.0) years) with aortic stenosis (AS; n = 10), aortic insufficiency (AR; n = 13) or a combination of both (AS/AR; n = 12), underwent aortic valve neocuspidization in our institution between September 2015 and May 2017. Echocardiographic follow-up was performed using a standardized examination protocol. RESULTS: Clinical follow-up was completed in 97% of the patients. Median (IQR) follow-up time was 645 (430, 813) days. Mortality rate was 9% (n = 1: aspiration pneumonia; n = 1: unknown; n = 1: anaphylactic shock), and the reoperation rate was 3% (n = 1: endocarditis). No pacemaker implantation was necessary after isolated OZAKI procedures. Echocardiographic follow-up was performed in 83% of the patients (n = 29; median (IQR) time 664 (497, 815) days). Median (IQR) mean and peak gradients were 6 (5,9) mmHg and 12 (8, 17) mmHg. Moderate aortic regurgitation was seen in 2 patients (7%). No severe aortic regurgitation or moderate or severe aortic stenosis occurred within the follow-up period. CONCLUSIONS: The OZAKI procedure is reliable and reoperation due to structural valve deterioration nil within a median 645 days follow-up period. The low rate of moderate aortic regurgitation will be surveilled very closely. Further studies are required to evaluate the significance of this procedure in aortic valve surgery. CLINICAL REGISTRATION NUMBER: ClinicalTrials.gov (ID NCT03677804).

Impact of Modified Frozen Elephant Trunk Procedure on Downstream Aorta Remodeling in Acute Aortic Dissection: CT Scan Follow-Up.

OBJECTIVES: The aim was to evaluate the impact of a modified frozen elephant trunk procedure (mFET) on remodeling of the downstream aorta following acute aortic dissections. METHODS: Over a period of 8 years, 205 patients (mean age 62.6 ± 12.6 years) underwent a mFET (n = 69, 33.7%) or isolated ascending aorta replacement (n = 136, 66.3%) (iAoA). Aortic diameter was assessed at the aortic arch (AoA), at the mid of the thoracic aorta (mThA), at the thoracoabdominal transition (ThAbd) and at the celiac trunk level (AbdA). RESULTS: Mean follow-up was 3.3 ± 2.6 years. In-hospital mortality was 14% (n = 28), 7% in mFET and 17% in the iAoA group (p = 0.08). At the end of the follow-up, overall survival was 84% (95% CI 70-92%) and 75% (65-82%) and freedom from aorta-related reoperation was 100% and 95% (88-98%) for mFET and iAoA, respectively. At iAoA, the average difference in diameter change per year between mFET and iAoA was for total lumen 0 mm (- 0.95 to 0.94 mm, p = 0.99), and for true lumen, it was 1.23 mm (- 0.09 to 2.55 mm) per year, p = 0.067. False lumen demonstrated a decrease in diameter in mFET as compared to iAoA by - 1.43 mm (- 2.75 to - 0.11 mm), p = 0.034. In mFET, at the aortic arch level the total lumen diameter decreased from 30.7 ± 4.8 mm to 30.1 ± 2.5 mm (Δr + 2.90 ± 3.64 mm) and in iAoA it increased from 31.8 ± 4.9 to 34.6 ± 5.9 mm (Δr + 2.88 ± 4.18 mm). CONCLUSION: The mFET procedure provides satisfactory clinical outcome at short term and mid-term and has a positive impact on aorta remodeling, especially at the level of the aortic arch.

Microplegia versus Cardioplexol® in Coronary Artery Bypass Surgery with Minimal Extracorporeal Circulation: Comparison of Two Cardioplegia Concepts.

BACKGROUND: The aim of this study is to compare the combined use of the Myocardial Protection System and our microplegia (Basel Microplegia Protocol) with Cardioplexol® in coronary artery bypass grafting using the minimal extracorporeal circulation. METHODS: The analysis focused on propensity score matched pairs of patients in whom microplegia or Cardioplexol® was used. Primary efficacy endpoints were high-sensitivity cardiac troponin-T on postoperative day 1 and peak values during hospitalization. Furthermore, we assessed creatine kinase and creatinine kinase-myocardial type, as well as safety endpoints. RESULTS: A total of 56 patients who received microplegia and 155 patients who received Cardioplexol® were included. The use of the microplegia was associated with significantly lower geometric mean (confidence interval) peak values of high-sensitivity cardiac troponin-T (233 ng/L [194-280 ng/L] vs. 362 ng/L [315-416 ng/L]; p = 0.001), creatinine kinase (539 U/L [458-633 U/L] vs. 719 U/L [645-801 U/L]; p = 0.011), and creatinine kinase-myocardial type (13.8 µg/L [9.6-19.9 µg/L] vs. 21.6 µg/L [18.9-24.6 µg/L]; p = 0.026), and a shorter length of stay on the intensive care unit (1.5 days [1.2-1.8 days] vs. 1.9 days [1.7-2.1 days]; p = 0.011). Major adverse cardiac and cerebrovascular events occurred with roughly equal frequency (1.8 vs. 5.2%; p = 0.331). CONCLUSIONS: The use of the Basel Microplegia Protocol was associated with lower peak values of high-sensitivity cardiac troponin-T, creatinine kinase, and creatinine kinase-myocardial type and with a shorter length of stay on the intensive care unit, as compared with the use of Cardioplexol® in isolated coronary artery bypass surgery using minimal extracorporeal circulation.

Analysis of Myocardial Ischemia Parameters after Coronary Artery Bypass Grafting with Minimal Extracorporeal Circulation and a Novel Microplegia versus Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: To compare the performance of our institutionally refined microplegia protocol in conjunction with minimal extracorporeal circulation system (MiECC) with off-pump coronary artery bypass grafting (OPCAB). METHODS: We conducted a single center study including patients undergoing isolated CABG surgery performed either off-pump or on-pump using our refined microplegia protocol in conjunction with MiECC. We used propensity modelling to calculate the inverse probability of treatment weights (IPTW). Primary endpoints were peak values of high-sensitivity cardiac troponin T (hs-cTnT) during hospitalization, and respective first values on the first postoperative day. Endpoint analysis was adjusted for intraoperative variables. RESULTS: After IPTW, we could include 278 patients into our analyses, 153 of which had received OPCAB and 125 of which had received microplegia. Standardized differences indicated that treatment groups were comparable after IPTW. The multivariable quantile regression yielded a nonsignificant median increase of first hs-cTnT by 39 ng/L (95% CI -8 to 87 ng/L, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84. CONCLUSION: The use of our institutionally refined microplegia in conjunction with MiECC was associated with similar results with regard to ischemic injury, expressed in hs-cTnT compared to OPCAB. MACCE was seen equally frequent. ICU discharge was earlier if microplegia was used.

Aortic root and ascending aorta dimensions in acute aortic dissection.

OBJECTIVES: Aim of this study was to evaluate ascending aorta and aortic root dimension at acute type A dissection (acute aortic dissection) and to identify demographics elements being allied to the acute event. METHODS: In a period between 2009 and 2017, 225 (n = 71, 32% female, mean age = 63 ± 12 years) patients eligible for analysis of ascending aorta and 223 (n = 70, 31% female, mean age = 63 ± 13 years) of aortic root were included in this study. Aortic diameter was assessed in preoperative computed tomography scan. The predissection diameters were modeled from the diameters obtained at diagnosis, assuming 30% augmentation of the diameter at acute event. RESULTS: The mean diameter of the ascending aorta at dissection was 46 ± 8 mm and the modeled diameter was 32.3 ± 5.7 mm. The diameter of the aortic root at dissection was 42 ± 8 mm and modeled diameter was 29.5 ± 5.6 mm. In multivariate analysis, female gender (p = 0.026) and history of cerebrovascular event (p = 0.001) were associated with acute aortic dissection in small aortic root. Patient age (p < 0.001) and history of inguinal hernia (p = 0.001) in ascending aorta <55 mm correlated with acute aortic dissection. CONCLUSION: Modeling indicates that more than 90% of patients had aortic root and ascending aorta diameter <45 mm. It seems that the aortic diameter expansion over the 55 mm in development of acute aortic dissection is overestimated. Parameters other than aortic size were identified, which may be considered when patients at high risk for dissection were identified.

Bretschneider (Custodiol®) and St. Thomas 2 Cardioplegia Solution in Mitral Valve Repair via Anterolateral Right Thoracotomy: A Propensity-Modelled Comparison.

BACKGROUND: Single-dose cardioplegia is preferred in minimal invasive mitral valve surgery to maintain the adjustment of the operative site without change of preset visualization. The aim of our study was to compare two widely used crystalloid cardioplegias Bretschneider (Custodiol®) versus St. Thomas 2 in patients who underwent mitral valve repair via small anterolateral right thoracotomy. MATERIAL AND METHODS: From May 2012 until February 2019, 184 isolated mitral valve procedures for mitral valve repair via anterolateral right thoracotomy were performed using Bretschneider (Custodiol®) cardioplegia (n = 123) or St. Thomas (n = 61). Primary efficacy endpoint was peak postoperative high-sensitivity cardiac troponin (hs-cTnT) during hospitalization. Secondary endpoints were peak creatine kinase-muscle brain type (CK-MB) and creatine kinase (CK) as well as safety outcomes. We used inverse probability of treatment weighting (IPTW) in order to adjust for confounding by indication. RESULTS: Peak hs-cTnT was higher after use of Bretschneider (Custodiol®) (geometric mean 716 mg/L, 95% confidence interval (CI) 605-847 mg/L) vs. St. Thomas 2 (561 mg/L, CI 467-674 mg/L, p = 0.047). Peak CK-MB (geometric mean after Bretschneider (Custodiol®): 40 µg/L, CI 35-46, St. Thomas 2: 33 µg/L, CI 27-41, p = 0.295) and CK (geometric mean after Bretschneider (Custodiol®): 1370 U/L, CI 1222-1536, St. Thomas 2: 1152 U/L, CI 972-1366, p = 0.037) showed the same pattern. We did not see any difference with respect to postoperative complications between treatment groups after IPTW. CONCLUSION: Use of St. Thomas 2 cardioplegia was associated with lower postoperative peak levels of all cardiac markers that reflect cardiac ischemia such as hs-cTnT, CK, and CK-MB as compared to Bretschneider (Custodiol®) in propensity-weighted treatment groups.

"Chaotic Arrhythmia" During Successful Resuscitation After Ingestion of Yew (Taxus baccata) Needles.

OBJECTIVE: The study aims to describe the management of a case of life-threatening yew (Taxus baccata) intoxication. BACKGROUND: The needles of the yew tree contain highly cardiotoxic taxines. Intoxication with taxines, typically as part of suicide attempts, may lead to potentially lethal arrhythmias which often require prolonged cardiopulmonary resuscitation and other supportive measures. No specific therapy has been described. In some cases, extracorporeal life support has been used. CASE: After an attempted suicide with yew needles and out-of-hospital cardiac arrest, a female adolescent was resuscitated for 6 hours according to Advanced Cardiovascular Life Support guidelines. Complex ventricular tachycardias were treated by repeated direct current shocks and broad complex bradycardia managed with transvenous cardiac pacing. Antiarrhythmic drugs (amiodarone, lidocaine), magnesium sulfate, and supportive measures (intravenous lipids, sodium bicarbonate) were provided. The arrhythmias finally resolved, and the patient did not show any significant neurological or cardiac short-term sequelae after 24 hours. RESULTS: The authors describe the successful management of a case of severe taxine intoxication by prolonged conventional advanced cardiac life support lasting for more than 6 hours. CONCLUSIONS: In life-threatening yew intoxication, prolonged cardiopulmonary resuscitation is absolutely essential owing to the long duration of the cardiotoxic action of taxines and can lead to an outcome without cardiac or neurological sequelae.

Clinical implementation of a novel myocardial protection pathway in coronary artery bypass surgery with minimal extracorporeal circulation.

INTRODUCTION: The aim of this study was to report the clinical implementation of the joint use of the Myocardial Protection System (MPS®) and the minimal extracorporeal circulation system (MiECC), in conjunction with an institutionally refined dose/volume-dependent microplegia in coronary artery bypass grafting (CABG). METHODS: Patients with isolated CABG surgery were included. The final protocol to achieve cardioplegic arrest consisted of warm blood cardioplegia with 20 mmol potassium (K), 1.6 g magnesium (Mg) and 40 mg lidocaine per liter (L) blood. We prospectively collected intra- and postoperative data to monitor and validate this novel approach. RESULTS: Eighty patients were operated accordingly. Mean (SD) aortic clamping time and extracorporeal perfusion time were 67.5 (22.6) and 101.1 (31.9) minutes, respectively. Failure to induce cardiac arrest was seen in six patients at the early stage of refinement of the formula. Median (IQR) high -sensitivity cardiac troponin T (hs-cTnT) on the first postoperative day (POD) and peak hs-cTnT were 262.5 ng/L (194.3-405.8) and 265.5 ng/L (194.3-405.8), respectively. Median (IQR) creatine kinase-myocardial type (CK-MB) on POD 1 and peak CK-MB were 14.2 µg/L (10.5-22.7) and 14.2 µg/L (10.7-23.2), respectively. Median (IQR) creatine kinase (CK) on POD 1 and peak CK were 517.5 U/L (389.3-849.8) and 597.5 U/L (455.0-943.0), respectively. No patient died during hospitalization. CONCLUSIONS: The combination of this cardioplegic formula with MPS® and MiECC in CABG was safe and feasible. With the final chemical makeup, cardiac arrest was reliably achieved. Remarkably low postoperative cardiac markers indicate shielded cardiac protection during surgery.

Surgical repair of an esophageal perforation after radiofrequency catheter ablation for atrial fibrillation.

Recent reports have described the incidence of atrioesophageal fistulas (AEF), often resulting in death, from radiofrequency (RF) catheter ablation of atrial fibrillation (AF).1 Cases of esophageal perforation without concomitant AEF have not been described as extensively.1 The precise mechanisms leading to esophageal injury after catheter ablation without involvement of the left atrium are not fully understood. The surgical approach to treat esophageal perforation is strongly recommended.2 However, a unified surgical treatment approach has not yet been established. We describe a case of successful surgical repair of an esophageal perforation after ablation using surgical repair in combination with an omental wrap.

Impact of aortic root annuloplasty on 3D aortic root geometry.

BACKGROUND: The aim was to evaluate the impact of aortic root (AoR) annuloplasty on 3D AoR deformation. METHODS: In experimental setup, Yacoub procedure and Yacoub with annuloplasty were performed. Results were compared to native AoR. In each AoR modality, six microsonometric (2 mm, 200 Hz) crystals were implanted at the sinotubular junction (STJ) and at the AoR base (AoB). 3D deformation of the AoR was determined by AoR tilt (α) and rotation (ß) angle changes. RESULTS: Tilt angle in Yacoub AoR with annuloplasty and in Yacoub AoR was maximal at ejection, 26.71 ± 0.18° and 24.91 ± 0.13°, respectively, and minimal at diastole, 25.34 ± 0.15° and 21.90 ± 0.15°, respectively. Rotation angle in Yacoub AoR with and without annuloplasty was maximal at ejection, 27.04 ± 0.25° and 23.53 ± 0.54°, respectively, and minimal at diastole, 24.84 ± 0.14° and 21.62 ± 0.16°, respectively. In native AoR, tilt angle and rotation were minimal at ejection, 14.34 ± 0.81° and 18.1 ± 3.20°, respectively, and maximal at diastole, 18.78 ± 0.84° and 21.23 ± 021°, respectively. AoB and STJ had maximal expansion at ejection; 2.59 ± 2.40% and 6.05 ± 0.66 for Yacoub and 3.75 ± 0.66% and 3.08 ± 0.24% for Yacoub with annuloplasty. In native AoR, the expansion at ejection for AoB was 7.13 ± 2.68% and for STJ was 16.42 ± 0.63%. CONCLUSIONS: AoB annuloplasty reduces AoB deformation and has an impact on STJ dynamics. In both the Yacoub AoR modalities, during ejection, the AoR takes on more of a cone-like geometry, whereas in native AoR, it is of a cylinder-like shape.

Urine Biomarkers of Tubular Renal Cell Damage for the Prediction of Acute Kidney Injury After Cardiac Surgery-A Pilot Study.

OBJECTIVE: To evaluate the perioperative course of urine levels of the renal damage biomarkers tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) and to evaluate the predictive value of elevated TIMP-2 × IGFBP7 concentrations to predict acute kidney injury (AKI) early after cardiac on-pump surgery. DESIGN: Prospective, observational cohort study. SETTING: University hospital. PARTICIPANTS: The study comprised 110 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB) between January and March 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Urinary TIMP-2 × IGFBP7 levels were quantified using a commercially available kit at the following measurement points: before surgery, 1 hour after starting CPB, 4 hours after weaning from CPB, and 24 hours after weaning from CPB (time points 1-4). Postoperative AKI was defined according to Kidney Disease Improving Global Outcomes criteria. AKI after cardiac surgery was diagnosed in 9 patients (8%). The perioperative course of TIMP-2 × IGFBP7 was significantly different in patients with and without postoperative AKI (p < 0.001). TIMP-2 × IGFBP7 levels were significantly higher in patients with AKI 1 hour after CPB start and 24 hours after weaning from CPB (p < 0.05). TIMP-2 × IGFBP7 levels >0.40 (ng/mL)2/1,000 measured at 1 hour after starting CPB were found to be the optimal cut-off, with a sensitivity of 0.778 and a specificity of 0.641. The negative predictive value was 0.972. CONCLUSIONS: Urine levels of TIMP-2 × IGFBP7 are predictive for AKI at an early time point (1 hour after starting CPB). Renal damage biomarkers such as TIMP-2 and IGFBP7 might be recommended as a supplement to traditionally used criteria of AKI prediction.

Computed Tomography Scan Predicts Abdominal Interventions but Not Stroke after Surgery for Acute Type A Aortic Dissection.

BACKGROUND: We hypothesized that preoperative computed tomography (CT) is a predictor of abdominal intervention for visceral malperfusion and stroke after emergent surgery for acute type A aortic dissection (AAAD). METHODS: A total of 90 patients, mean (± SD [standard deviation]) age 62 (± 12) years, 76% males, undergoing emergent surgery for AAAD at our institution from May 2008 to August 2013 were included. All clinical data were collected prospectively and correlated to CT images. RESULTS: At initial presentation 9 (10%) patients showed preoperative focal neurologic deficit or coma, 10 patients (11%) complained of abdominal pain, and the logistic EuroSCORE was 44 (± 22). Hemiarch replacement was performed in 96%, total arch in 4%. The duration of hypothermic circulatory arrest (HCA) at 28°C bladder temperature was 26 (± 19) minutes. Cross-clamp time was 88 (± 39) minutes, and cardiopulmonary bypass (CPB) time 148 (± 49) minutes. Overall 30-day mortality was 13%. Moreover, 12 (13%) patients required postoperative abdominal interventions for suspected visceral malperfusion; stroke occurred in 25 (28%) patients. Logistic regression revealed that "dissection of the celiac trunk and/or the superior mesenteric artery" in preoperative CT images is a predictor of postoperative abdominal interventions for visceral malperfusion (p = 0.03), but preoperative abdominal pain is not similarly predictive. Postoperative stroke is best predicted by preoperative neurologic symptoms (p = 0.01), but not by supra-aortic vessel dissection in preoperative CT images. CONCLUSION: In patients undergoing surgery for AAAD, analysis of preoperative CT images allows identifying those with a high risk of postoperative abdominal intervention for visceral malperfusion. Postoperative stroke is best predicted by preoperative neurologic symptoms.

Sevoflurane and Isoflurane-Pharmacokinetics, Hemodynamic Stability, and Cardioprotective Effects During Cardiopulmonary Bypass.

OBJECTIVES: This study aimed to evaluate the pharmacokinetic profiles of sevoflurane and isoflurane during use of minimized extracorporeal circulation to perform coronary artery bypass graft surgery. Furthermore, cardiovascular stability during bypass and the postoperative release of troponins were evaluated. DESIGN: Prospective, randomized study. SETTING: University hospital. PARTICIPANTS: The study comprised 31 adult patients undergoing coronary artery bypass grafting. INTERVENTIONS: The pharmacokinetic measurements of the concentration of the volatile anesthetics in the arterial and venous blood, air inlet, air outlet, and gas exhaust of the extracorporeal circulation were recorded. Secondary end-points were cardiovascular stability during bypass, amount of postoperative release of troponin, time to extubation, time to discharge from the intensive care unit and the hospital, and 30-day mortality. MEASUREMENTS AND MAIN RESULTS: Thirty patients completed the protocol. The pharmacokinetics of isoflurane and sevoflurane were almost identical, with a rapid wash-in (time to reach 50% of arterial steady state) concentration of 0.87±0.97 minutes and 1.14±0.35 minutes for isoflurane and sevoflurane, respectively, and a biphasic venous elimination with a terminal half-life of approximately 10 minutes for both compounds. There was a correlation between the gas inlet and the gas exhaust of the extracorporeal circulation. No difference in cardiovascular stability was found. High-sensitivity troponin concentrations on the first postoperative morning were 0.355±0.312 µg/mL and 0.225±0.111 µg/mL in the isoflurane and sevoflurane groups, respectively (p = 0.147). CONCLUSIONS: The study found similar pharmacokinetics regarding wash-in and wash-out for sevoflurane and isoflurane. In addition, no difference in cardiovascular stability was found. The markers of cardiac damage were not different between the two anesthetics. Based on these data, sevoflurane and isoflurane might be used equivalently in patients undergoing coronary artery bypass graft surgery with extracorporeal circulation.

Transapical Transcatheter Aortic Valve Implantation Using the JenaValve: A One-Year Follow-up.

OBJECTIVE: Since the first transcatheter aortic valve implantation (TAVI) in 2002, TAVI technique has gained an increasing popularity especially in high-risk patients. In this study, we present the first echocardiographic midterm outcome with the second-generation transapical JenaValve TAVI system (JenaValve Technology GmbH, Munich, Germany) in patients with aortic stenosis (AS). METHODS: Between November 2011 and November 2012, a total of 28 patients received transapical TAVI using the JenaValve. Primary endpoint was a combined efficacy endpoint after 1 year, which included all-cause mortality after more than 30 days, failure of current therapy for AS requiring hospitalization for symptoms of valve-related cardiac decompensation or prosthetic heart valve dysfunction. Moreover, we analyzed secondary endpoints after 3 and 12 months including cardiovascular mortality; major stroke; and life-threatening, disabling, or major bleeding. Mean echocardiographic follow-up was 471.35 ± 102.72 days. RESULTS: Mean age was 80.43 ± 6.03 years and EuroSCORE II was 8.80 ± 7.21%. Successful implantation was accomplished in 100% (n = 28). Median transvalvular aortic mean pressure gradient was 44.5 mm Hg (interquartile range [IQR]: 34.5; 55.5) preoperatively, 12 mm Hg (IQR: 9; 16) postoperatively, and 11 mm Hg (IQR: 8; 16) after 1 year. After 12 months, no paravalvular leakage was seen in 52.38% of the patients and grade 1 paravalvular leakage was seen in 47.62% of the patients. There was no grade 2 or 3 leakage detected. Stroke, valve thrombosis or dislocation, myocardial infarction, or bleeding was also not observed. However, criteria for the combined efficacy endpoint after 1 year were met in five patients (17.86%). Thirty-day mortality was 14.29% (n = 4) and all-cause mortality after 1 year was 21.43% (n = 6). CONCLUSION: The JenaValve transapical TAVI system is a safe and feasible procedure with low peri- and postoperative complications and convincing midterm performance of the prosthesis.

Prasugrel increases the need for platelet transfusions and surgical reexploration rates compared with clopidogrel in coronary artery bypass surgery.

BACKGROUND: We hypothesized that patients treated with prasugrel compared with those treated with clopidogrel before coronary artery bypass graft (CABG) surgery are at increased risk of hemorrhagic complications needing transfusions and are more likely to need surgical reexploration. PATIENTS AND METHODS: Preoperative and postoperative clinical data were collected prospectively on 143 consecutive patients treated preoperatively with prasugrel (n = 59) or clopidogrel (n = 84) before undergoing isolated CABG at our institution from January 2011 to October 2012. RESULTS: Patients receiving prasugrel showed a slightly higher additive EuroSCORE I compared with those treated with clopidogrel (7 vs. 5, p = 0.001), and more often underwent urgent/emergent CABG (47 vs. 27%, p = 0.01). Patients treated with prasugrel were more likely than those treated with clopidogrel to need perioperative platelet transfusions (25 vs. 12%, p = 0.04). The numbers of transfusions of red blood cells, fresh-frozen plasma, or fibrinogen were high in both groups but showed no statistical differences. Patients treated with prasugrel, however, more often needed surgical reexploration for bleeding complications (8 vs. 1%, p = 0.03). Logistic regression revealed that preoperative therapy with prasugrel (RR 2.9, p = 0.01) and urgent/emergent surgery (RR 2.2, p = 0.04) were predictors for the composite endpoint "need for perioperative platelet transfusion and/or surgical reexploration." CONCLUSION: Pretreatment with prasugrel, compared with clopidogrel, in patients undergoing isolated CABG is associated with an increased need for platelet transfusions and a higher risk of surgical reexploration for bleeding complications.

First case of infective endocarditis caused by Helicobacter cinaedi.

BACKGROUND: Up to 20% of all infective endocarditis are blood culture-negative and therefore a diagnostic challenge. Here we present the case of an infective endocarditis due to Helicobacter cinaedi finally diagnosed using different molecular methods. This highly fastidious gram-negative spiral rod is increasingly recognized as a human pathogen, above all in immunocompromised patients. So far H. cinaedi has been associated with bacteremia, cellulitis, arthritis and meningitis. CASE PRESENTATION: A 71-year-old man presented with fever and progressive dyspnea for weeks. He was immunocompromised by long-term steroid therapy. As one major and two minor Duke's criteria (vegetation, fever and aortic valve stenosis as predisposition) were present, an infective endocarditis was suspected and an empiric therapy with amoxicillin/clavulanic acid and gentamicin was established. The persistent severe aortic regurgitation resulted in a valve replacement. Histological evaluation of the aortic valve showed a polypous-ulcerative endocarditis. Gram stain and culture remained negative. Broad-range bacterial PCR targeting the 16S rRNA gene on the biopsy of the aortic valve identified H. cinaedi as the causative agent. The antibiotic therapy was simplified accordingly to ceftriaxone and gentamicin with a recommended duration of 6 weeks. Ten days after valve replacement the patient was discharged. To complete our molecular finding, we sequenced nearly the complete 16S rRNA gene (accession number KF914917) resulting in 99.9% identity with H. cinaedi reference sequences. Based on this result, 2 species-specific PCR tests amplifying part of the ctd gene were established and applied to the valve specimen. The 2 PCRs confirmed H. cinaedi. In addition, we analyzed stool, urine and saliva from the patient using H. cinaedi PCR. The fecal and urine specimen showed a positive signal, saliva was PCR-negative. CONCLUSION: We identified H. cinaedi as causative agent of a culture-negative endocarditis in an immunocompromised patient using broad-range and specific PCR. In addition to 2 cases from Japan presented on international meetings in 2010 and 2013, our case report shows that H. cinaedi should be recognized as additional causative organism of infective endocarditis. The use of molecular diagnostic techniques proved to be a powerful complement for the detection of blood culture-negative infective endocarditis.