Minimally Invasive Surgery in Mitral Valve Endocarditis.

BACKGROUND: To minimize the surgical damage, minimally invasive mitral valve surgery (MIMVS) has become the therapy of choice. However, this approach is technically more challenging, especially in endocarditis. The data on MIMVS in endocarditis are scarce, we therefore retrospectively analyzed the result at our institute. METHODS: From January 2011 and July 2017, 420 MIMVS were performed, out of which 44 (10%) were for endocarditis. Mean age was 55 ± 17 years and 41% (n = 18) were male. RESULTS: Euroscore II was 7.3 (range: 2-38). Operation times, cardiopulmonary bypass times, and clamp times were 230 (±77), 158 (±56), and 84 (±39) minutes, respectively. Seven cases (16%) were cardiac redo operations. Mitral valve repair and replacement was performed in 46 (n = 20) and 54% (n = 24) of patients, respectively. Overall in-hospital mortality, apoplexy, and reoperation rates (all for bleeding) were 7 (n = 3), 0 (n = 0), and 11% (n = 5), respectively. New onset of dialysis was required in three patients (7%). No patient developed superficial wound infection. Overall intensive care unit and hospital stay was 3 (±3) and 24 (±32) days, respectively. CONCLUSION: MIMVS can be performed with acceptable outcome and low perioperative morbidity in patients with mitral valve endocarditis. Especially absence of any postoperative wound infections and low rate of endocarditis recurrence; use of MIMVS must be encouraged as an eligible approach in most cases.

Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach?

BACKGROUND: Venoarterial extracorporeal membrane oxygenation support is a well-established tool in the care of severe refractory cardiac and respiratory failure. The application of this support may serve as a bridge to transplant, recovery or to implantation of a ventricular assist device. Venoarterial extracorporeal membrane oxygenation support can be administered through an open surgical access via the common femoral or axillary artery or a percutaneous approach using Seldinger technique. Both techniques may obstruct the blood flow to the lower limb and may cause a significant ischemia with possible limb loss. Malperfusion of the distal limb can be avoided using an ipsilateral distal limb perfusion, which may be established by adding a single-lumen catheter during venoarterial extracorporeal membrane oxygenation treatment to overcome the obstruction. The aim of this study is to distinguish the presence or absence of a distal limb perfusion regarding the incidence of distal limb ischemia. Furthermore, expected risk factors of open and percutaneous femoral venoarterial extracorporeal membrane oxygenation installation were evaluated for the development of distal limb ischemia. METHODS: Between January 2012 and September 2015, 489 patients received venoarterial extracorporeal membrane oxygenation support at our institution. In total, 307 patients (204 male, 103 female) with femoral cannulation were included in the analysis. The cohort was distinguished by the presence (group A; n = 237) or absence (group B; n = 70) of a distal limb perfusion during peripheral venoarterial extracorporeal membrane oxygenation treatment. Furthermore, a risk factor analysis for the development of distal limb ischemia was performed. RESULTS: The main indications for venoarterial extracorporeal membrane oxygenation therapy were a low cardiac output syndrome (LCOS) (53%) and failed weaning of extracorporeal circulation (23%). A total of 23 patients (7.49%) under venoarterial extracorporeal membrane oxygenation support developed severe distal limb malperfusion (3.38% in group A vs 21.42% in group B). Preemptive installation of distal limb perfusion extended the intervention-free intervals to 7.8 ± 19.3 days in group A and 6.3 ± 12.5 in group B. A missing distal limb perfusion (p = 0.001) was identified as a main risk factor for critical limb ischemia. Other comorbidities such as arterial occlusion disease (p = 0.738) were not statistically significantly associated. Surgical intervention due to vascular complications after extracorporeal membrane oxygenation explantation was needed in 14 cases (4.22% in group A and 5.71% in group B). CONCLUSION: We were able to identify the absence of distal limb perfusion as an independent risk factor for the development of critical distal limb ischemia during femoral venoarterial extracorporeal membrane oxygenation treatment. The application of a distal limb perfusion should be considered as a mandatory approach in the context of femoral venoarterial extracorporeal membrane oxygenation treatment regardless of the implantation technique.

Local Anesthetics delivered through Pleural Drainages improve Pain and Lung Function after Cardiac Surgery.

OBJECTIVE: Pleural tubes after coronary artery bypass graft (CABG) surgery usually cause pain resulting interalia in an impact of postoperative breathing. Therefore, the influence of intrapleural lidocaine application through special double-lumen chest tubes with respect to pain relief and lung function was investigated and compared with placebo. METHODS: In this study, 40 patients who underwent CABG got intrapleural injection either with 2% lidocaine (n = 20) or placebo (0.9% saline solution) (n = 20) on the first 2 days after surgery. Pain was measured by pain intensity numeric rating scale (NRS) (0 = no pain; 10 = the most intense pain) and lung function by portable spirometer. RESULTS: On the first postoperative day (POD1), mean pain reduction was NRS 1.9 for the lidocaine group with an improvement of the forced expiratory volume in 1 second (FEV1) of 0.51 L. Similar results were shown on the second postoperative day (POD2) with a decreased pain level of mean NRS 1.65 and an FEV1 improvement of 0.26 L. In comparison, results of the placebo group showed no significant pain reduction, neither on the POD1 (NRS 0.35; p = 0.429) nor on the POD2 (NRS 0.55; p = 0.159). Also, there was no significant influence of FEV1 after placebo on the POD1 (FEV1 = 0.048 L; p = 0.70) or on the POD2 (FEV1 = 0.0135 L; p = 0.925). CONCLUSION: Intrapleural application of lidocaine is a safe and feasible method to reduce drainage-related pain and improving lung function after CABG.

Minimally Invasive Mitral Valve Surgery in Re-Do Cases-The New Standard Procedure?

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) is superior to "classical" mitral valve surgery via a sternotomy regarding wound healing and postoperative pain. It is however a more challenging procedure. Patients' preference is leading clearly toward minimally invasive approaches, and surgeons are driven by upcoming new technologies in interventional procedures such as the MitraClip. Especially in re-do cases, the access via right mini-thoracotomy, as previously non-operated situs, is a possible advantage over a re-sternotomy. We therefore retrospectively analyzed our result regarding MIMVS in re-do cases at our institute. METHODS: From January 2011 and June 2016, 33 operations were MIMVS re-do procedures. Mean age was 60 years (±16 years), and 51% were male. RESULTS: Sixty-one percent were elective cases, 29% were urgent cases, and 9% were emergency operations. Operation times, cardiopulmonary bypass (CPB) times, and clamp times were 235 minutes (±51 min), 149 minutes (±42 min), and 62 minutes (±45min), respectively. Mitral valve repair and replacement was performed in 24% (n = 8) and 76% (n = 25), respectively. Overall in-hospital mortality, apoplexy, and re-operation rates (all for bleeding) were 0% (n = 0), 3% (n = 1), and 9% (n = 3). New onset of dialysis was required in two (6%) patients. Two (6%) patients developed superficial wound infection. Overall intensive care unit (ICU) and hospital stay was 3 days (±4 days) and 15 days (±7 days), respectively. CONCLUSION: MIMVS for re-do cases can be performed with minimal mortality and morbidity and therefore represents a safe alternative to conventional mitral valve surgery in cardiac re-do operations. However, postoperative morbidity is highly dependent on preoperative patient status.

The Unplanned Postoperative Coronary Angiogram after CABG: Identifying the Patients at Risk.

Objectives Coronary artery bypass grafting (CABG) is the "gold standard" for patients with multiple vessel coronary artery disease (CAD). However, there is no "gold standard" to control bypass patency immediately postoperatively. "Post-completion" control angiogram (CA) is not routinely performed. We retrospectively analyzed the data of all patients undergoing urgent coronary angiogram post-CABG at our center. Methods Between January 2005 and June 2011, a total of 6,025 patients underwent CABG (isolated or combined) for CAD in our hospital. In patients who underwent urgent postoperative CA, high serum cardiac enzymes (>100 CK-MB), severe new ECG changes, or unexpected low left ventricular function were present. Results A total of 106 patients (1.8%) underwent post-CABG urgent coronary angiogram. Overall 30-day mortality in this cohort was 8.5%. The average time between the cardiac operation and the coronary angiogram in these patients was 3.41 ± 5.68 days. The rates for an urgent coronary angiogram were 1.3% (n = 25), 2% (n = 65), and 1.8% (n = 16) for total arterial, combined arterial, and venous and solely venous CABG, respectively. Twenty-four percent of patients underwent CABG bypass revision, while 32% of the patients underwent PTCA, stenting, or both. Younger patients, female patients, smaller patients, and patients receiving a combined arterial and venous revascularization were at a higher risk for an unplanned postoperative CA in the multivariate risk analysis. Conclusion This study shows that the necessity for urgent post-CABG coronary angiogram is low (1.8%). However, more than half of the patients undergoing postoperative coronary angiogram needed reintervention, and, in spite of it, had high mortality. "Completion" control angiogram is not always feasible, patients at higher risk (e.g., female patients) should be identified and post-CABG coronary angiogram performed as soon as possible without undue delay, or a primary hybrid approach with an intraoperative CA should be applied.

Total Arterial Revascularization with Radial Artery T-grafts in Patients with Significant Left Main Stem Stenosis Is Not Associated with Higher Perioperative Risk.

BACKGROUND: Total arterial revascularization (TAR) has become a standard procedure for the treatment of coronary multivessel disease, due to the superior long-term patency rates of arterial grafts as compared with saphenous vein graft material. Controversies about the use of TAR in patients with left main coronary artery disease exist. Hence, we ought to determine whether left main coronary artery disease is a risk factor for early postoperative mortality and morbidity after TAR using the in situ left internal thoracic artery (LITA) and radial artery as composite T-graft. METHODS: A total of 904 consecutive patients were included in this retrospective study. They underwent first-time coronary artery bypass grafting surgery in our institution, receiving TAR using the in situ LITA and RA T-graft. Of these patients, 247 (27%) had left main coronary artery disease (Group LMSS) and 657 (73%) had no significant left main coronary artery stenosis (Group nLMSS). RESULTS: Results were comparable. Mortality and perioperative myocardial infarction rates were 0.4% LMSS versus 0.3% nLMSS, p = 1, and 2% LMSS versus 2% nLMSS, p = 0.81, respectively. Stroke rate, acute renal failure rate, and reoperation rates were 2% LMSS versus 1% nLMSS, p = 0.36, 7% LMSS versus 8% nLMSS, p = 0.41, and 2% LMSS versus 3% nLMSS, p = 0.5, respectively. Postoperative stay was shorter in the LMSS group (8.1 ± 4.3 days vs. 8.9 ± 6.1 days nLMSS, p = 0.048). CONCLUSION: Our perioperative results indicate that TAR in patients with left main stenosis is safe and feasible. Long-term results will have to be awaited to further evaluate prognostic outcome.

Is Bentall Procedure Still the Gold Standard for Acute Aortic Dissection with Aortic Root Involvement?

INTRODUCTION: The "ideal" treatment of acute aortic dissection type A (AADA) with dissected and dilated root is controversial. We compared the outcome of classical Bentall procedure (biological and mechanical) with valve-sparing David procedure. METHODS: Between January 2002 and July 2011, 119 patients with AADA and aortic root involvement underwent surgery at our center. Thirty-one patients (group 1) received biological conduits, 41 (group 2) received mechanical conduits, and 47 (group 3) underwent David procedures. RESULTS: Cross-clamp, cardiopulmonary bypass, and circulatory arrest times were 151 ± 52, 232 ± 84, and 36 ± 30 minutes (group 1); 148 ± 44, 237 ± 91, and 45 ± 29 minutes (group 2); and 160 ± 46, 231 ± 63, and 35 ± 17 minutes (group 3), respectively. The 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). The 1-year rates for freedom from valve-related reoperation were 100% (group 1), 92.5% (group 2), and 95.2% (group 3) (p = 0.172). The 1-year survival rates were 61% (group 1), 61% (group 2), and 84.1% (group 3) (p = 0.008). CONCLUSION: Even in AADA patients with root involvement, David procedure has acceptable results. David procedure (if possible) or a Bio-Bentall (for pathological valves) seems to be the optimal technique.

Feasibility, Accuracy, and Reproducibility of Aortic Valve Sizing for Transcatheter Aortic Valve Implantation Using Virtual Reality.

BACKGROUND: Detailed visualization and precise measurements of aortic valve dimensions are critical for the success of transcatheter aortic valve implantation and for the prevention of complications. Currently, multislice computed tomography is the gold standard for assessment of the aortic annulus and surrounding structures to determine the prosthesis size. New technologies such as virtual reality (VR) not only enable 3-dimensional (3D) visualization with the potential to improve understanding of anatomy and pathology but also allow measurements in 3D. This study aims to investigate the feasibility, accuracy, and reproducibility of VR for the visualization of the aortic valve, the surrounding structures, and its role in preprocedural sizing for transcatheter aortic valve implantation. METHODS AND RESULTS: Based on the preprocedural multislice computed tomography data, 3mensio measurements and 3D visualizations and measurements using VR software were performed retrospectively on 60 consecutive patients who underwent transcatheter aortic valve implantation at our heart center. There were no significant differences but strong correlations between the VR measurements compared with those performed with the 3mensio software. Furthermore, excellent or good intra- and interobserver reliability could be demonstrated for all values. In a structured questionnaire, users reported that VR simplified anatomical understanding, improved 3D comprehension of adjacent structures, and was associated with very good self-perceived depth perception. CONCLUSIONS: The use of VR for preprocedural transcatheter aortic valve implantation sizing is feasible and has precise and reproducible measurements. In addition, 3D visualization improves anatomical understanding and orientation. To evaluate the potential benefits of 3D visualization for planning further cardiovascular interventions, research in this field is needed.

Pathologic endothelial response and impaired function of circulating angiogenic cells in patients with Fabry disease.

Fabry disease is an X-chromosomal recessive deficiency of the lysosomal hydrolase alpha-galactosidase A (alpha-Gal). This results in an accumulation of globotriaosylceramide (GL-3) in a variety of cells often with subsequent functional impairment. Here, the impact of Fabry disease on the biology of circulating angiogenic cells (CACs) and the endothelial response to transient ischemia was investigated. Untreated patients with Fabry disease (n = 26), patients after initiation of alpha-Gal enzyme replacement therapy (ERT) (n = 16) and healthy controls (n = 26) were investigated. Endothelial function was assessed by the EndoPAT2000 device. CAC numbers were assessed by flow-cytometry, CAC function by a modified Boyden chamber assay. Fabry patients showed a pathologic endothelial response, which normalized after ERT. CACs were increased in number, but functionally impaired. Immunofluorescence and electron microscopy identified an accumulation of GL-3 in Fabry CACs. ERT attenuated CAC dysfunction and improved markers of oxidative stress response in Fabry patients via a reduction in GL-3 accumulation in vitro and in vivo. Silencing of alpha-Gal in healthy CACs impaired their migratory capacity underlining a key role of this enzyme for CAC function. CAC supernatant as well as CACs from Fabry patients impaired angiogenesis and migratory capacity of HUVECs providing a mechanistic link between CAC and endothelial dysfunction. CAC adhesion to TNF-α pre-stimulated HUVECs and tube formation was impaired by alpha-Gal knockdown. Fabry patients show a dysfunction of CAC and a pathologic endothelial response. ERT improves CAC and endothelial function and thus may attenuate development of cardiovascular disease in the long term in this patient population.

Reduction of driveline infections through doubled driveline tunneling of left ventricular assist devices.

The durability of ventricular assist device (VAD) therapy improved steadily over the past years. However, driveline infections remain a challenge. To test whether an improved surgical implantation technique may lower the incidence of infections, we analyzed all patients receiving a VAD implantation in the years 2008 and 2009 (group 1) and compared them with all patients who received a VAD in 2011 (group 2) after we changed our implantation method. The new technique involves tunneling of the driveline into the fascia of the musculus rectus abdominis, resulting in a longer, intrafascial run to achieve a better resistance against ascending infections. We retrospectively analyzed 40 patients in group 1 and 41 patients in group 2. One year after implantation, the infection rate was markedly reduced (22.5% [n = 9] group 1 vs. 4.9% [n = 2] group 2, P < 0.001) by the new implantation method. There was, however, no significant improvement in overall mortality. The Cox regression model identified the implantation method as an independent risk factor for 1 year after implantation driveline infection (P < 0.05). In conclusion, the new tunneling technique marks a great leap forward in long-term VAD treatment. However, overall mortality remains high and needs further improvement.

Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft.

OBJECTIVE: The frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. METHODS: A total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. RESULTS: The incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. CONCLUSIONS: Intraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.

The Role of Spatial Aortic Arch Architecture in Type B Aortic Dissection.

OBJECTIVE: The incidence of type B aortic dissection (TBAD) is increasing worldwide; however, the underlying pathomechanisms are not conclusively understood. This study explores the geometric architecture of the aortic arch and supra-aortic branches in TBAD patients as opposed to non-TBAD patients. METHODS: Patient characteristics were retrieved from archived medical records. Computer-assisted tomography (CAT) scans of patients with TBAD and carotid stenosis (CS) from two high-volume centers were analyzed. Various aortic arch parameters and take-off angles of the supra-aortic branches of TBAD patients were measured following centerline normalization in comparison CS patients. A compression index (C-index) was calculated from the para-sagittal, and a torsion index (T-index) was calculated from the para-coronal take-off angles of the supra-aortic branches to analyze aortic arch tortuosity. RESULTS: A total of 199 CAT scans were analyzed, namely, 85 in the TBAD group and 114 in the CS group. The average age was 61.5 ± 13.1 years among the TBAD patients and 71 ± 9.3 years among the CS patients. We found a significantly higher proportion of type III aortic arch configurations in TBAD patients compared with CS patients. Further, the aortic arch angle was steeper in the TBAD group. In the para-sagittal plane, the left subclavian artery (LSA) take-off angle was less steep in TBAD patients. In the para-coronal plane, the left carotid artery (LCA) had a less steep take-off angle, while the LSA had a more obtuse take-off angle in the TBAD group when compared with the CS group. In addition, the inter-vessel distance was increased in TBAD patients. Finally, the T-index was increased, suggesting a significant torsion resulting from the deviating take-off angles of the supra-aortic branches supplying the left half of the body as opposed to the innominate artery (IA) in TBAD patients. CONCLUSIONS: Our results suggest several aortic arch-specific geometric configurations in patients suffering from TBAD that significantly differ from those in CS patients. Further functional studies are needed to verify the pathogenetic relevance of our results and their disease-specific causality. Although our data are not mechanistically explorative, they may serve as a basis for identifying future patients with aortic arch morphology at higher risk for TBAD development and who may benefit from more stringent adjustment of risk factors as a primary prevention concept.

Short communication: asymmetric dimethylarginine impairs angiogenic progenitor cell function in patients with coronary artery disease through a microRNA-21-dependent mechanism.

RATIONALE: The endogenous nitric oxide synthase inhibitor asymmetrical dimethylarginine (ADMA) is increased in patients with coronary artery disease and may regulate function of circulating angiogenic progenitor cells (APCs) by small regulatory RNAs. OBJECTIVES: To study the role of microRNAs in ADMA-mediated impairment of APCs. METHODS AND RESULTS: By using microarray analyses, we established microRNA expression profiles of human APCs. We used ADMA to induce APC dysfunction and found 16 deregulated microRNAs. We focused on miR-21, which was 3-fold upregulated by ADMA treatment. Overexpression of miR-21 in human APCs impaired migratory capacity. To identify regulated miR-21 targets, we used proteome analysis, using difference in-gel electrophoresis followed by mass spectrometric analysis of regulated proteins. We found that transfection of miR-21 precursors significantly repressed superoxide dismutase 2 in APCs, which resulted in increased intracellular reactive oxygen species concentration and impaired nitric oxide bioavailability. MiR-21 further repressed sprouty-2, leading to Erk Map kinase-dependent reactive oxygen species formation and APC migratory defects. Small interference RNA-mediated superoxide dismutase 2 or sprouty-2 reduction also increased reactive oxygen species formation and impaired APC migratory capacity. ADMA-mediated reactive oxygen species formation and APC dysfunction was rescued by miR-21 blockade. APCs from patients with coronary artery disease and high ADMA plasma levels displayed >4-fold elevated miR-21 levels, low superoxide dismutase 2 expression, and impaired migratory capacity, which could be normalized by miR-21 antagonism. CONCLUSIONS: We identified a novel miR-21-dependent mechanism of ADMA-mediated APC dysfunction. MiR-21 antagonism therefore emerges as an interesting strategy to improve dysfunctional APCs in patients with coronary artery disease.

Impairment of endothelial progenitor cell function and vascularization capacity by aldosterone in mice and humans.

AIMS: Hyperaldosteronism is associated with vascular injury and increased cardiovascular events. Bone marrow-derived endothelial progenitor cells (EPCs) play an important role in endothelial repair and vascular homeostasis. We hypothesized that hyperaldosteronism impairs EPC function and vascularization capacity in mice and humans. METHODS AND RESULTS: We characterized the effects of aldosterone and mineralocorticoid receptor (MR) blockade on EPC number and function as well as vascularization capacity and endothelial function. Treatment of human EPC with aldosterone induced translocation of the MR and impaired multiple cellular functions of EPC, such as differentiation, migration, and proliferation in vitro. Impaired EPC function was rescued by pharmacological blockade or genetic ablation of the MR. Aldosterone protein kinase A (PKA) dependently increased reactive oxygen species formation in EPC. Aldosterone infusion in mice impaired EPC function, EPC homing to vascular structures and vascularization capacity in a MR-dependent but blood pressure-independent manner. Endothelial progenitor cells from patients with primary hyperaldosteronism compared with controls of similar age displayed reduced migratory potential. Impaired EPC function was associated with endothelial dysfunction. MR blockade in patients with hyperaldosteronism improved EPC function and arterial stiffness. CONCLUSION: Endothelial progenitor cells express a MR that mediates functional impairment by PKA-dependent increase of reactive oxygen species. Normalization of EPC function may represent a novel mechanism contributing to the beneficial effects of MR blockade in cardiovascular disease prevention and treatment.

Embryonic stem cell-derived endothelial cells engraft into the ischemic hindlimb and restore perfusion.

OBJECTIVE: We examined the effect of delivery modality on the survival, localization, and functional effects of exogenously administered embryonic stem cells (ESCs) or endothelial cells derived from them (ESC-ECs) in the ischemic hindlimb. METHODS AND RESULTS: Murine ESCs or ESC-ECs were stably transduced with a construct for bioluminescence imaging (BLI) and fluorescent detection. In a syngeneic murine model of limb ischemia, ESCs or ESC-ECs were delivered by intramuscular (IM), intrafemoral artery (IA), or intrafemoral vein injections (n=5 in each group). For 2 weeks, cell survival and localization were tracked by BLI and confirmed by immunohistochemistry, and functional improvement was assessed by laser Doppler perfusion. BLI showed that ESCs localized to the ischemic limb after IM or IA, but not after intrafemoral vein administration. Regardless of the route of administration, ESCs were detected outside the hindlimb circulation in the spleen or lungs. ESCs did not improve limb perfusion and generated teratomas. In contrast, ESC-ECs delivered by all 3 modalities localized to the ischemic limb, as assessed by BLI. Most surprisingly, ESC-EC injected intrafemoral vein eventually localized to the ischemic limb after initially lodging in the pulmonary circulation. Immunohistochemical studies confirmed the engraftment of ESC-ECs into the limb vasculature after 2 weeks. Notably, ESC-ECs were not detected in the spleen or lungs after 2 weeks, regardless of route of administration. Furthermore, ESC-ECs significantly improved limb perfusion and neovascularization compared with the parental ESCs or the vehicle control group. CONCLUSION: In contrast to parental ESCs, ESC-ECs preferentially localized in the ischemic hindlimb by IA, IM, and intrafemoral vein delivery. ESC-ECs engrafted into the ischemic microvasculature, enhanced neovascularization, and improved limb perfusion.

Minimal invasive temporary percutaneous right ventricular circulatory support after left ventricular assist device implantation.

OBJECTIVES: Cardiogenic shock is a life-threatening situation with high mortality rates. Mechanical unloading of the left ventricle may be achieved via left ventricular assist device (LVAD) implantation. Postoperative right ventricular (RV) failure, however, has very limited therapeutic options and is associated with increased postoperative mortality. In this paper, we describe a percutaneous right heart bypass for temporary postoperative RV support. METHODS: We retrospectively examined all patients receiving percutaneous RV mechanical support after LVAD implantation. All patients receiving trans-jugular mechanical right heart bypass during or after LVAD implantation in our tertiary medical centre between November 2014 and December 2019 were examined retrospectively. The venous draining cannula was placed in the femoral vein; the pulmonary cannula was placed in the pulmonary artery using fluoroscopy. RESULTS: In total, 14 patients received RV support using the trans-jugular technique. Mean age was 48.4 ± 14.9 years. Nine patients were treated with mechanical circulatory support before LVAD implantation. Biventricular support was done in 7 patients. All patients were treated with an Heartware HVAD . Mean postoperative intensive care unit stay was 46.3 ± 32.4 days. Mean right heart bypass support time was 10.6 ± 4.3 days. Twelve patients (86%) could be bridged to RV recovery, RV assist device implantation or heart transplantation. CONCLUSIONS: Percutaneous RV mechanical support is feasible, safe and shows acceptable outcome. Early implantation of RV support may contribute to successful outcome after LVAD implantation.

Coronary artery bypass grafts to chronic occluded right coronary arteries.

Background: The benefit of revascularizing chronically occluded coronary arteries remains debatable, and available long-term outcome reports are sparse. Current guidelines recommend revascularization of chronically occluded arteries only in patients with myocardial ischemia and/or symptoms associated with angina. We investigated outcome of patients with total chronic occlusion of the right coronary artery (RCA) receiving coronary artery bypass grafting (CABG) surgery with and without revascularization of the RCA. Methods: We retrospectively analyzed all patients with chronically occluded RCAs receiving CABG with (group 1 = RCA-CABG; n = 487) and without (group 2 = No-RCA-CABG; n = 100) revascularization of the RCA. In total, 587 patients with complete follow-up of a minimum of 6 years were included (92%). Results: In total, 82% in group 1 versus 86% in group 2 were male (P = .38). European System for Cardiac Operative Risk Evaluation II was comparable between both groups (4.35 ± 7.09% vs 4.80 ± 5.77%, P = .56) with no major differences regarding preoperative characteristics between groups. Patients in group 1 received 3.24 ± 0.79 distal anastomoses, whereas group 2 received 2.45 ± 0.83 distal anastomoses (P < .001). Although in-hospital mortality was comparable (2.9% in group 1 vs 5.0% in group 2, P = .27), long-term survival was significantly better in group 1 (P = .002). No difference in the incidence of further major adverse cardiac and cerebrovascular events was found. Conclusions: Patients with a chronically occluded RCA undergoing CABG who did not receive an RCA graft showed a significantly reduced long-term survival. Given the herein presented data, revascularization of chronically occluded right arteries during CABG should be recommended whenever technically feasible.

ECLS supported transport of ICU patients: does out-of -house implantation impact survival?

BACKGROUND: Extracorporeal life support (ECLS) is an established tool to stabilize severely ill patients with therapy-refractory hemodynamic or respiratory failure. Recently, we established a mobile ECLS retrieval service at our institution. However, data on the outcome of patients receiving ECLS at outside hospitals for transportation into tertiary hospitals is still sparse. METHODS: We have analyzed all patients receiving ECLS in outside hospitals (Transport group, TG) prior to transportation to our institution and compared the outcome to our in-house ECLS experience (Home Group, HG). RESULTS: Between 2012 and 2018, we performed 978 ECLS implantations, 243 of which were performed on-site in tertiary hospitals for ECLS supported transportation. Significantly more veno-venous systems were implanted in TG (n = 129 (53%) vs. n = 327 (45%), p = 0.012). Indication for ECLS support differed between the groups, with more pneumonia; acute respiratory distress syndromes in the TG group and of course, more postcardiotomy patients in HG. Mean age was 47 (± 20) (HG) vs. 48 (± 18) (TG) years, p = 0.477 with no change over time. No differences were seen in ECLS support time (8.03 days ±8.19 days HG vs 7.81 days ±6.71 days TG, p = 0.675). 30-day mortality (n = 379 (52%) (HG) vs. n = 119 (49%) (TG) p = 0.265) and death on ECLS support (n = 322 (44%) (HG) vs. n = 97 (40%) TG, p = 0.162) were comparable between the two groups, despite a more severe SAVE score in the v-a TG (HG: - 1.56 (± 4.73) vs. TG -3.93 (± 4.22) p < 0.001). Mortality rates did not change significantly over the years. Multivariate risk analysis revealed Influenza, Peak Insp. Pressure at implantation, pO2/FiO2 ratio and ECLS Score (SAVE/RESP) as well as ECLS support time to be independent risk factors for mortality. CONCLUSION: Mobile ECLS support is a tremendous challenge. However, it is justified to offer 24 h/7d ECLS standby for secondary and primary hospitals as a tertiary hospital. Increasing indications and total numbers for ECLS support raise the need for further studies to evaluate outcome in these patients.

Echocardiographic guided, transatrial closure of a patent foramen ovale.

BACKGROUND: The management of an incidental patent foramen ovale found during planned cardiac surgery remains a challenge, and current guidelines are not helpful. Although evidence is accumulating, that closure of an incidental found patent foramen ovale might be beneficial, especially in planned off-pump procedures, the diagnosis of a formerly unknown patent foramen ovale with the patient on the operation table has vast consequences by making it necessary to switch to on pump, bi-caval cannulation for patent foramen ovale closure. We therefore developed a technique for transatrial closure of a patent foramen ovale, guided by transesophageal echocardiography. RESULTS: We have performed this surgery in 9 patients. None of them had a previously diagnosed patent foramen ovale. Mean age was 74 (±5) years, Operation time was 175 min (± 34 min), Clamp time 35 min (± 16 min) and Cardiopulmonary bypass time 80 (±17 min). Mortality was 0%. Periprocedural transesophageal echocardiography revealed closure of the patent foramen ovale in all cases. CONCLUSION: We report a new surgical method for transoesophageal echocardiography controlled closure of a patent foramen ovale without the need for an atriotomy. This new technique is especially useful for the closure of patent foramen ovale in the setting of on-pump and off-pump coronary artery bypass graft surgeries alike.