Circulatory efficiency in patients with severe aortic valve stenosis before and after aortic valve replacement.

BACKGROUND: Circulatory efficiency reflects the ratio between total left ventricular work and the work required for maintaining cardiovascular circulation. The effect of severe aortic valve stenosis (AS) and aortic valve replacement (AVR) on left ventricular/circulatory mechanical power and efficiency is not yet fully understood. We aimed to quantify left ventricular (LV) efficiency in patients with severe AS before and after surgical AVR. METHODS: Circulatory efficiency was computed from cardiovascular magnetic resonance (CMR) imaging derived volumetric data, echocardiographic and clinical data in patients with severe AS (n = 41) before and 4 months after AVR and in age and sex-matched healthy subjects (n = 10). RESULTS: In patients with AS circulatory efficiency was significantly decreased compared to healthy subjects (9 ± 3% vs 12 ± 2%; p = 0.004). There were significant negative correlations between circulatory efficiency and LV myocardial mass (r = - 0.591, p < 0.001), myocardial fibrosis volume (r = - 0.427, p = 0.015), end systolic volume (r = - 0.609, p < 0.001) and NT-proBNP (r = - 0.444, p = 0.009) and significant positive correlation between circulatory efficiency and LV ejection fraction (r = 0.704, p < 0.001). After AVR, circulatory efficiency increased significantly in the total cohort (9 ± 3 vs 13 ± 5%; p < 0.001). However, in 10/41 (24%) patients, circulatory efficiency remained below 10% after AVR and, thus, did not restore to normal values. These patients also showed less reduction in myocardial fibrosis volume compared to patients with restored circulatory efficiency after AVR. CONCLUSION: In our cohort, circulatory efficiency is reduced in patients with severe AS. In 76% of cases, AVR leads to normalization of circulatory efficiency. However, in 24% of patients, circulatory efficiency remained below normal values even after successful AVR. In these patients also less regression of myocardial fibrosis volume was seen. Trial Registration clinicaltrials.gov NCT03172338, June 1, 2017, retrospectively registered.

Efficacy of quadruple treatment on different types of pre-operative anaemia: secondary analysis of a randomised controlled trial.

In patients with pre-operative anaemia undergoing cardiac surgery, combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12 and oral folic acid reduces allogeneic blood product transfusions. It is unclear if certain types of anaemia particularly benefit from this treatment. We performed a post-hoc analysis of anaemic patients from a randomised trial on the 'Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery'. We used linear regression analyses to examine the efficacy of a combination anaemia treatment compared with placebo on the following deficiencies, each representing a part of the combination treatment: ferritin and transferrin saturation; endogenous erythropoietin; holotranscobalamine; and folic acid in erythrocytes. Efficacy was defined as change in reticulocyte count from baseline to the first, third and fifth postoperative days and represented erythropoietic activity in the immediate peri-operative recovery phase. In all 253 anaemic patients, iron deficiency was the most common cause of anaemia. Treatment significantly increased reticulocyte count in all regression analyses on postoperative days 1, 3 and 5 (all p < 0.001). Baseline ferritin and endogenous erythropoietin were negatively associated with change in reticulocyte count on postoperative day 5, with an unstandardised regression coefficient B of -0.08 (95%CI -0.14 to -0.02) and -0.14 (95%CI -0.23 to -0.06), respectively. Quadruple anaemia treatment was effective regardless of the cause of anaemia and its effect manifested early in the peri-operative recovery phase. The more pronounced a deficiency was, the stronger the subsequent boost to erythropoiesis may have been.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 2873­2926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is "0" and not "-". The corrected table is shown below.

[Ventricular long-term support with implantable continuous flow pumps: on the way to a gold standard in the therapy of terminal heart failure]. / Ventrikuläre Langzeitunterstützung mit implantierbaren kontinuierlichen Flusspumpen : Auf dem Weg zum Goldstandard in der Therapie der terminalen Herzinsuffizienz.

Mechanical circulatory support nowadays represents an important option in the treatment of patients with advanced heart insufficiency. Once developed as a bridging to heart transplantation, it is now a valuable option for permanent support in patients for whom a heart transplantation is not possible due to contraindications or a lack of available organs. Furthermore, it can be used as a bridging to myocardial recovery and explantation. The number of implantations of left ventricular assist devices (LVAD) has clearly increased in recent years and approximately one half of these implantations is already carried out in centers not specialized in transplantations. This development necessitates that every practicing physician is aware of the basic principles of mechanical circulatory support and with the possible complications. This article gives a summary of the current state of the technology and treatment of patients with long-term VADs.

Prognostic impact of disease-related complications in asymptomatic mitral regurgitation: a health insurance claims analysis.

BACKGROUND AND AIMS: The impact of mitral regurgitation (MR) in asymptomatic patients is not well defined. We aimed to determine the prevalence of MR-related complications and their association with 10-year survival in a large unselected asymptomatic MR cohort. METHODS: Health insurance claims data from Germany's second largest health insurance fund, BARMER, which maintains longitudinal data on 8.7 million German residents, were retrospectively analyzed. All patients with an outpatient diagnosis of MR in a minimum of two quarters during a calendar year and first recorded diagnosis between 2008 and 2011 were included. Patients with any complication attributable to MR or mitral valve intervention at index were excluded. Outcomes were compared between study group and age- and sex-matched controls (i.e., without known cardiac disease). MR-related complications of interest were new congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension, or cardiac decompensation. RESULTS: A total of 56,577 individuals (median age 68 years, 67% female) with asymptomatic MR were identified. At 10 years, MR-related complications were more frequent in the study group vs. control group (46.5% vs. 20.8%, OR 3.31, P < 0.0001). Furthermore, MR-related complications were more common in male vs. female patients with an asymptomatic MR (OR 2.65, P < 0.0001). The occurrence of at least one MR-related complication was associated with a reduced 10-year survival (OR 1.80, P < 0.0001). CONCLUSIONS: Almost half of patients with asymptomatic MR experience complications during a 10 year follow-up which result in impaired survival. These results imply the necessity of long-term disease management program. Furthermore, decision-making process and timing for mitral valve intervention in asymptomatic patients should be reevaluated.

Initial results of an optimized perfusion system.

BACKGROUND: In order to reduce the negative effects of extracorporeal circulation (ECC), the perfusion system and management were optimized at our institution. The goals of optimization were a reduction in the priming volume, in the foreign surface area and in microbubble activity, as well as optimization of suction blood management. METHODS: Sixty patients were included in this retrospective study. Patients were assigned to two groups, with regard to the use of an optimized perfusion system (OPS-group, n=30) and a standard perfusion system (SPS-group, n=30). All patients underwent elective procedures. RESULTS: There were no significant differences with respect to patient demographics and operation time. ECC time and cross-clamp time were significantly longer in the OPS group. Statistically significant differences in outcome between the two groups were seen with regard to the following variables: effective priming volume (OPS: 775±447ml; SPS: 1610±0ml; p<0.0001), hemoglobin drop after the start of ECC (OPS: 2.7±1.2g/dl; SPS: 4.2±0.8g/dl; p<0.0001), c-reactive protein on postoperative day 2 (OPS: 121.0±59.4 U/l; SPS: 164.0±50.2 U/l; p=0.003). With regard to the use of blood transfusions, a 33% reduction in the overall amount of transfused units was seen. The rate of patients without transfusions during the entire hospital stay increased from 37% (SPS) to 53% (OPS). The mean transfused red blood cell units per patient was lower in the OPS-group (1.6±2.4 units) than in the SPS-group (2.3±3.5 units). CONCLUSION: With the described optimized perfusion system, a significantly lower priming volume, leading to less hemodilution after the onset of CPB, was achieved. The amount of blood transfusions and the inflammatory response were reduced.

Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI).

BACKGROUND: Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI). OBJECTIVES: We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI. METHODS: In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA). RESULTS: Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each). CONCLUSIONS: Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Clinical usefulness of electronic drug-drug interaction checking in the care of cardiovascular surgery inpatients.

OBJECTIVES: Drug-related problems (DRPs) are events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes. This study tested the applicability of clinical decision support software in identifying and managing DRPs among cardiovascular surgery inpatients. METHODS: Two clinical pharmacologists attended ward rounds on a low-dependency cardiovascular surgery ward every 2 weeks over a 7-month period. Three hundred and three patients were assessed. On average, patients received 17 scheduled and 'as required' medicines. DRPs were identified 'manually' via assessment of electronic prescription charts and patient records and 'electronically' using clinical decision support software (Pharmavista). The numbers of alerts for optimizing medication safety generated by the two methods were compared. RESULTS: Manual checking identified 346 DRPs leading to 346 alerts in 201 patients (overall 1.1 alerts/patient). Relevant interactions accounted for 44% of DRPs detected by clinical pharmacologists. Clinical decision support software, which could only report interactions, however, generated 1,370 alerts (average 4.5 alerts/patient). Only 147 (11%) drug-drug interaction alerts were identical to those identified by manual checking; the remaining 89% were considered not clinically relevant. CONCLUSIONS: Compared to identification of DRPs by clinical pharmacologists, the clinical decision support software performed poorly due to over-alerting and inability to assess for problems not caused by drug-drug interactions.

Retrospective analysis of outcome data with regards to the use of Phisio®-, Bioline®- or Softline®-coated cardiopulmonary bypass circuits in cardiac surgery.

BACKGROUND: Numerous cardiopulmonary bypass circuits with various coatings designed to reduce the inflammatory response and to provide better hemocompatibility are available. The aim of this study was to compare the effect of phosphorylcholine-coated, albumin-heparin-coated and synthetic polymer-coated perfusion tubing systems on patient outcome. METHODS: We performed a retrospective database review of elective patients between January 1st 2010 and December 31st 2010. Demographics, preoperative, operative, postoperative data and follow-up were collected and statistically analysed. RESULTS: We identified 201 patients and formed three groups: Group 1 with phosphorylcholine coating (n=133), Group 2 with albumin-heparin coating (n=32) and Group 3 synthetic polymer coating (n=36). Mean age was 68 ± 11 years, additive Euroscore 5.8 ± 2.7. In-hospital outcomes were comparable between the groups without statistically significant differences. The overall 30-day and 1-year late survival were 98.5% and 96.7 ± 1.9%, respectively. CONCLUSIONS: Our findings suggest that in-hospital and follow-up outcomes are comparable in cardiac surgery patients after using either phosphorylcholine-coated, albumin-heparin-coated or synthetic polymer-coated circuits during cardiopulmonary bypass.

Defibrillator generator replacements in patients with left ventricular assist device support: The risks of hematoma and infection.

BACKGROUND: The majority (89%) of left ventricular assist device (LVAD) patients have an implantable cardioverter-defibrillator (ICD) in place. Due to the advances of modern-day LVAD therapy, more patients are on support for longer. This inevitably leads to more LVAD patients facing ICD generator battery depletion. Until now, there are insufficient data regarding periprocedural risks of generator replacements in a high-risk group like the LVAD cohort. METHODS: A retrospective, single-center analysis of pocket-related outcomes of all ICD generator replacements in LVAD and Non-LVAD patients between January 2014 and December 2018. The primary outcome was the combined endpoint of clinically significant pocket hematoma and/or cardiac implantable electronic device (CIED) infection in the first 6 months after ICD generator exchange. The clinically significant hematoma was defined as hematoma requiring reoperation, prolongation of hospitalization, or interruption of anticoagulation. The cumulative incidence function was calculated for the primary endpoint. RESULTS: Two hundred seventy-seven patients underwent ICD generator exchange in our clinic in this time. Of these, 251 patients had a complete 6-month follow-up regarding clinically significant pocket hematomas and pocket infections. One hundred ninety patients had no LVAD, and 61 patients were on LVAD support. The rate of the primary combined endpoint clinically significant pocket hematoma and/or CIED infection was 3.5 times higher in LVAD patients compared to the non-LVAD cohort (event rate 39.14 vs 11.07 per 100 patient-years, p = 0.048). Clinically significant pocket hematomas necessitating revision occurred nearly 4 times more often in the LVAD group (p = 0.042). Pocket device infection rates were around 16 times higher in LVAD patients compared to non-LVAD patients (p = 0.002). CONCLUSIONS: Compared to Non-LVAD patients, LVAD patients exhibit a relevant higher rate of clinically significant pocket hematoma and CIED infection after ICD generator exchange. This information should additionally be considered in the decision-making process regarding the indication for ICD generator exchange.

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography.

AIMS: We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair. METHODS AND RESULTS: In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height. CONCLUSION: Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

Sternal plate closure: indications, surgical procedure and follow-up.

OBJECTIVES: Titanium plate osteosynthesis (Synthes) is an alternative option for sternal closure. The indications and time point of application are still debated. This study investigated the application and feasibility of this technique after median sternotomy. METHODS: Forty-one patients (29 M/12F, mean age 63 ± 17 years) received the plate system for complicated sternal conditions. Indications, intraoperative course and postoperative follow-up were assessed. RESULTS: Sternal deformity was present in 5 % (2/41), sternal fractures in 17 % (7/41), bone defect in 12 % (5/41), wire loosening in 39 % (16/41) and pseudoarthrosis in 27 % (11/41). 54 % (22/41) of patients showed concomitant sternal infection. Two intraoperative complications were noted: mammary artery injury (1 patient), pleural injury (1 patient). At discharge the patients reported no pain (90 %, 37/41) or only occasional discomfort (10 %, 4/41). Postoperative complications were subcutaneous hematoma in 12 % (5/41), seroma in 12 % (5/41) and sternal reinfection in 7 % (3/41). 12 % (5/41) showed occasional discomfort and 7 % (3/41) had persistent pain leading to plate removal. CONCLUSION: The Titanium Sternal Fixation System is comfortable and easy to use. It can be used to treat a wide spectrum of indications, especially for pseudoarthrosis, an entity which has not yet received sufficient attention.

Delayed two-step free wall rupture of the right and left ventricular wall after myocardial infarction.

We present a 68-year-old female who suffered extensive complications after severe myocardial infarction (MI) in the circumflex (CX) territory. At 24 hours after the initial event, the patient presented with a covered right ventricular free wall rupture (FWR) which was followed by a rupture of the left posterior wall ten days later. We report here on a rare case of delayed two-step biventricular FWR after severe MI in the CX territory.

Effects of humidity and glidants on the flowability of pharmaceutical excipients. An experimental energetical approach during granular compaction.

Granular materials are part of the design, production and final products of different industrial sectors. Powder flowability is a major topic in manufacturing and transport as it is closely related to process feasibility. Nonetheless, the flows of granular materials are not easy to describe or quantify, even in the simple case of dry monodisperse cohesionless particles. Flowability assessment is not a standard or normalized issue; still, no test is able predict powder flow behavior in all the different mechanical situations encountered during processing. This study aims (1) to evaluate flowability, as device-related, through the force or the energy supplied to the powder bed and (2) to study the effect of glidants and moisture content on flowability. To illustrate these aims, the flowability of two well-known pharmaceutical excipients, Avicel® PH-102 and Retalac® mixed with four different types of precipitated nano-silica (SIPERNAT® D10, D17, 50 S and 500 LS), was assessed using two granular compaction devices: Densitap® and FT4® compaction cell. Our results show that the hydrophilicity of colloidal silica affects surface coverage, ranging from 6% to over 80%. Binary mixtures with hydrophobic additives, D10 and D17, generated smaller silica aggregates with a wider spread on the surface of host particles. For Retalac® conditioned at 20% RH, HR values changed from 1.30 (acceptable flow) to 1.17 (good flow). For Avicel® PH-102, conditioned at 60% RH, HR values changed from 1.22 (fair flow) to less than 1.10 (excellent flow).

[Artificial intelligence in cardiac surgery]. / Künstliche Intelligenz in der Herzchirurgie.

Less than 10 years ago a breakthrough was made in the world of computer science and artificial intelligence (AI) with the application of deep neural networks, which initially found little attention in medicine. In 2017 the first high-ranking publications on the medical application of AI were published. The potential of AI became known to many both in clinical medicine as well as in clinical and biomedical research. At the end of 2019 a phase of upheaval is occurring: first concepts for regulatory procedures have appeared, a large number of start-ups but also established companies are endeavoring to introduce AI-based medical devices into the market. This article discusses the basic principles for understanding AI-based medical devices as well as an overview of current AI-based solutions specific to cardiac surgery.

"When Aneurysm Ain't Aneurysm": sinus of Valsalva aneurysm mimicked by healed abscess cavity under the aortic valve.

In a 70-year-old patient with severe aortic valve stenosis, preoperative standard imaging (transthoracic echocardiography and angiography) detected an unclear subannular cavity structure. Initially interpreted as an aneurysm of Valsalva, the structure was identified intraoperatively as a huge chronic abscess cavity and exclusion was carried out by pericardial patch plasty. This case draws attention to the importance of a differential diagnosis of an abscess due to infective endocarditis in cases of unclear subannular structures rashly diagnosed as aneurysm of Valsalva.

[A 17-year-old with cardiac mass and pulmonary embolism]. / 17-jähriger Jugendlicher mit kardialer Raumforderung und Lungenembolie.

A 17-year-old man admitted with recurrent haemoptysis, fever and syncope. He complained about dyspnoea and chest pain since a few weeks. The clinical investigation, ECG and chest X-ray did not show any abnormalities. Laboratory investigations revealed signs of inflammation and increased D-dimer assay. A pulmonary embolism in both lungs with pulmonary infarctions and an intracardial structure in the right atrium were found on the CT-scan of the thorax. The transthoracic and transesophageal echocardiography showed a typical feature of myxoma as a cardiac mass in size of 3.3x3.6 cm in the right atrium attached to the atrial septum. Using cardiopulmonary bypass the tumor excision and the pulmonary embolectomy were performed. The myxoma specimens were histologically detected in the tumor mass as well as in the embolectomy material. The detection of the right atrial myxoma as an uncommon feature of the pulmonary embolism emphasizes the importance of the early echocardiography in the diagnosis of pulmonary embolism.

Publisher Correction: Model-Based Therapy Planning Allows Prediction of Haemodynamic Outcome after Aortic Valve Replacement.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.