Remote ECLS-Implantation and Transport for Retrieval of Cardiogenic Shock Patients.

OBJECTIVE: Extracorporeal life support (ECLS) emerges as a salvage option in therapy refractory cardiogenic shock but is limited to highly specialized tertiary care centers. Critically ill patients are often too unstable for conventional transport. Mobile ECLS programs for remote implantation and subsequent air or ground-based transport for patient retrieval could solve this dilemma and make full-spectrum advanced cardiac care available to patients in remote hospitals in whom shock otherwise might be fatal. METHODS: From December 2012 to March 2016, 40 patients underwent venoarterial ECLS implantation in remote hospitals with subsequent transport to our center and were retrospectively analyzed. The mobile ECLS team was available 24/7, implantation was performed percutaneously bedside, and compact support systems designed for transport were used. RESULTS: Twenty percent of the patients were female; the mean age was 55 ± 10 years, and the mean Interagency Registry for Mechanically Assisted Circulatory Support score was 1.3 ± 0.5. Patient retrieval was accomplished via ground-based (n = 29, 72.5%, mean distance = 27.9 ± 29.7 km [range, 5.6-107.1 km]) or air (n = 11, mean distance = 62.4 ± 27.2 km [range, 38.9-116.4 km]) transport. No ECLS-related complications occurred during transport. The ECLS system could be explanted in 65.0% (n = 26) of patients, and the 30-day survival rate was 52.5% (n = 21). CONCLUSION: Remote ECLS implantation and interfacility transport on ECLS are feasible and effective. Interdisciplinary teams and full-spectrum cardiac care are essential to achieve optimal outcomes. Rapid-response ECLS networks have the potential to substantially increase the survival of cardiogenic shock patients.

Root Replacement for Graft Infection Using an All-Biologic Xenopericardial Conduit.

BACKGROUND AND AIM OF THE STUDY: The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material. METHODS: Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%). RESULTS: The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen. CONCLUSIONS: Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.

Immediate, Early and Late Failure after Transcatheter Aortic Valve Implantation: How to Deal with the Inoperable?

BACKGROUND: Currently, the use of transcatheter aortic valve implantation (TAVI) is constantly increasing, whilst cardiosurgical back-up varies substantially. Besides immediate conversion to surgical aortic valve replacement (SAVR) for periprocedural complications, SAVR for TAV failure may be necessary within the early or late post-implant course. The etiology, incidence, risk-stratification, management and outcome for both scenarios are largely unclear. The study aim was to provide details of the authors' experience of SAVR after the failure of TAVI at a single institution. METHODS: Nineteen patients (14 males, five females) underwent SAVR after TAVI at the authors' institution between June 2008 and December 2015. The patients' initial EuroSCORE II was 8.54 ± 9.81. In eight cases (42%; 50% transfemoral) an immediate conversion was necessary due to paravalvular leakage and insufficiency (n = 1), valve-malpositioning (n = 1), valve dislocation (n = 3), valve-trapping in mitral chordae (n = 1), and annular rupture (n = 2). The 50% transfemoral EuroSCORE II was 19.06 ± 8.61. In 11 patients transcatheter valve failure occurred at a mean of 18 ± 17 months after TAVI (two patients with structural valve failure and one with severe paravalvular leakage, seven with prosthetic valve endocarditis, and one patient with aortic aneurysm); the mean EuroSCORE II was 13.42 ± 13.06. RESULTS: For immediate conversion, the cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 104 ± 40 min and 60 ± 16 min, respectively. Concomitant procedures were necessary in two patients, one patient required hypothermic circulatory arrest (HCA) and one died intraoperatively. For early and late failure, the CPB and cross-clamp times were 115 ± 32 min and 82 ± 20 min, respectively. HCA was necessary in one patient, and concomitant procedures in seven patients. The 30-day survival was 63% for immediate SAVR and 100% for early and late SAVR, even though one more patient died on postoperative day 31 after immediate SAVR. Besides, the longest follow up periods were 29 ± 15 months and 19 ± 14 months for immediate and early/late failure, respectively. In both groups, one patient died from cardiovascular-related causes, and one from non-valve-related causes. CONCLUSIONS: SAVR after previous TAVI will become increasingly relevant. Due to the increasing use of TAVI in medium- or lower-risk patients, adequate strategies must be established since, in comparison to multimorbid patients, not taking action in these patients is not an option. Due to potentially high-risk patients and unique technical implications, SAVR after TAVI differs from conventional (redo) AVR. Under optimal conditions, acceptable survival rates can be achieved, but effective interdisciplinary approaches are essential.

Aortic Valve Replacement in Patients with End-Stage Liver Disease: A Modified Perfusion Concept in High-Risk Patients.

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery with the use of cardiopulmonary bypass in patients with end-stage liver disease is associated with a high risk of postoperative morbidity and mortality due to bleeding, and a high incidence of bacterial infection with associated secondary complications. Minimized extracorporeal perfusion circuits (MECCs) with a lower priming volume, reduced foreign surface area, and interdisciplinary preoperative and postoperative treatment may address these negative effects and improve patient outcomes. The study aim was to evaluate the feasibility of the MECC and optimized supportive therapy in patients with advanced-stage liver cirrhosis. METHODS: Seven consecutive male patients (median age 56 years; range 54-67 years) with hepatic cirrhosis (Child-Pugh score B, median Model of End-stage Liver Disease (MELD) score 14; range 8-26) underwent aortic valve replacement (AVR) using MECC. Supportive preoperative and postoperative management included digestive decontamination, antioxidant supplements, and adjusted anti-infective therapy. RESULTS: All patients survived the hospital course, with 30-, 60-, and 90-day mortality of 0%. The median intensive care unit and in-hospital lengths of stay were 3 days (range: 1-5 days) and 13 days (range: 5-18 days), respectively. One patient required reexploration due to bleeding, and another suffered from a seizure without permanent neurologic deficits. No patient required new-onset hemodialysis. At a median follow up of 22 months (range: 2-46 months) all patients were alive but displayed only minor improvements in cardiac symptoms (median NYHA class III (range: II-III) at baseline versus II (range: II-III) postoperatively) and hepatic symptoms. CONCLUSION: Conventional AVR in patients with advanced-stage liver cirrhosis using MECC and optimal medical treatment is feasible. Further studies are required to evaluate the impact of alternative interventional techniques in this high-risk cohort.

Diagnosis of coronary affection in patients with AADA and treatment of postcardiotomy myocardial failure using extracorporeal life support (ECLS).

BACKGROUND: Myocardial ischemia due to concomitant coronary artery disease (CAD) or coronary dissection in patients with acute aortic dissection type Stanford A (AADA) is associated with myocardial failure and poor outcomes. Preoperative coronary angiography in this group of patients is still debated. The use of CT scan to diagnose coronary affection along with the establishment of high-pitched dual-spiral CT protocols are essential for improving outcomes. METHODS: We retrospectively analyzed six AADA patients with heart failure who were treated using extracorporeal life support (ECLS). Options for diagnosing coronary affection and different therapeutic strategies for postcardiotomy cardiogenic shock in this patient cohort are discussed. RESULTS: Retrospective review of CT images showed coronary abnormalities in 83% (n=5). Four patients (67%) underwent unplanned coronary artery bypass grafting (CABG). ECLS was instituted in 67% (n=4) due to left heart failure and in 33% (n=2) due to right heart failure. Thirty day mortality was 67% (n=4). The two patients that received ECLS for right ventricular support survived and both had undergone CABG. CONCLUSION: Besides preoperative evaluation of the extent of the dissection, focus on coronary affection in CT-scans helps to triage the operative procedure. Hybrid operating rooms allow for immediate interventional and/or surgical treatment and enable for immediate control of revascularization results. The use of ECLS over other types of ventricular support systems may allow for myocardial recovery in selected cases.

Emergency cesarean section due to acute aortic dissection type A (Debakey I) without Marfan syndrome: a case report and review of the literature.

BACKGROUND: Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature. OBJECTIVES: The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature. CASE REPORT: We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively. CONCLUSION: This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.

Minimally invasive aortic valve replacement with self-anchoring Perceval valve.

BACKGROUND AND AIM OF THE STUDY: Although minimally invasive aortic valve replacement (AVR) has been proposed to cause less morbidity in patients, it still has not seen broad application. The study aim was to evaluate the implantation of the self-anchoring aortic valve (Perceval S; Sorin) via a mini-sternotomy. METHODS: As a part of a multicenter, European, prospective, non-randomized, clinical trial, 35 patients (30 females, five males; mean age 80 +/- 4 years) with isolated aortic valve stenosis (mean gradient 48 +/- 21 mm Hg) were operated on at the authors' center. Perceval S self-anchoring valves were implanted following a mini-sternotomy, extracorporeal circulation (ECC), aortic cross-clamping, cardioplegic arrest and removal of the calcified native valve. The mean EuroSCORE and STS score were 12 +/- 9% and 4 +/- 2%, respectively. RESULTS: There were no failures of deployment, and nor was there any intra-procedure or 30-day mortality. The mean ECC-time was 70 +/- 24 min, and cross-clamp time 34 +/- 10 min. The valve implantation time was 9 +/- 5 min. Perioperative echocardiography revealed no significant aortic insufficiency or paravalvular leakage. The postoperative mean gradient was 16 +/- 6 mmHg. At follow up, there was no paravalvular leakage or significant valvular insufficiency. No migration or dislodgement of the prosthesis occurred. CONCLUSION: This trial highlights the advantages of the Perceval S self-anchoring valve which, technically is a more reproducible alternative for minimally invasive AVR. As the valve does not need to be sutured, the limited exposure is not a disadvantage even in patients with calcified or small aortic roots. This also potentially reduces the cross-clamp and ECC-times. This valve may enable a broader application of minimally invasive AVR.

[Evaluation of the "TeleCOVID Hesse" project after 1 year in operation]. / Evaluation des Projekts "TeleCOVID Hessen" nach einjährigem Betrieb.

BACKGROUND: The SARS-CoV­2 pandemic posed unexpected challenges for hospitals worldwide and in addition to the supply emergency, simultaneously caused a high pressure to innovate. Due to the high number of cases of COVID-19 patients requiring intensive care, structured networking of hospitals gained particular importance. The tele-ICU communication platform TeleCOVID was developed to improve the quality of intensive care both by enabling teleconsultations and by supporting patient transfers. OBJECTIVE: The present study aimed to survey user experiences with TeleCOVID. The study investigated the extent to which the app is used, the user experiences of the participating hospitals, and the resulting implications for the further development of the telemedicine application. MATERIAL AND METHODS: A user survey was conducted in May 2022 using an online questionnaire. The survey contained both closed and open questions with a free text field. It was sent via the Hessian Ministry of Social Affairs and Integration (HMSI). All 135 hospitals in Hesse were contacted by e­mail and invited to participate in the study. The results of the closed questions were analyzed using descriptive statistics, and the results of the open questions were clustered and thematically summarized using qualitative content analysis. RESULTS: The study showed that TeleCOVID was used primarily for transfer requests, followed by the need for a treatment consultation without a transfer request. Most often, ECMO treatment or treatment in a hospital of a higher care level was required. The content analysis showed that users particularly rated the possibility of a data protection-compliant and structured transfer of patient data as advantageous. It is also worth mentioning that in almost 25% of the cases a transfer of patients could be prevented by TeleCOVID. Disadvantages frequently mentioned by respondents were the lack of connection to the electronic hospital information system, the increased time required for the registration process, and the poor primary accessibility of contact persons. CONCLUSION: In a further development of the application the connection to the electronic hospital information system should be considered particularly urgent. In addition, the time expenditure should be reduced by a simplified login process. Due to interface barriers, an alternative data infrastructure would also be conceivable to create interoperability. The introduction of a web client could also increase usability. The main beneficiaries of hospital networking are physicians and patients in a context associated with a high workload and specific medical issues. Continuation and expansion of the app to intensive care medicine and beyond are therefore recommended. In further studies on the project, personal interviews with decision makers could be useful to conduct a more targeted needs analysis.

Aortic valve re-replacement after Bentall procedure with a biological valved conduit in a sheep model.

BACKGROUND AND AIM OF THE STUDY: The Bentall procedure is the 'gold standard' for the repair of a combined pathology of ascending aorta and aortic valve. Because there is no need for long-term anticoagulation, biological-valved conduits have become increasingly popular; however, the possible need for reoperation due to valve degeneration is a major disadvantage. The aim of this animal-based study was to prove the feasibility of an isolated replacement of the aortic valve prosthesis six months after a previous implantation of a biological valved conduit (BioValsalva) in a sheep model. A total aortic root replacement, using the BioValsalva conduit, was performed in 10 juvenile sheep. After six months, the surviving sheep were reoperated on, and the stentless valve was replaced with a stented biological valve placed inside the previously implanted vascular conduit. RESULTS: Five animals survived the initial implantation of a BioValsalva conduit. During reoperation, the triple-layered vascular graft with polytetrafluoroethylene on the outside showed only slight adhesions with the surrounding tissue. The stentless valve was removed in one piece, after which a new stented valve was implanted inside the conduit. An X-radiographic examination of the explanted valve showed moderate calcification of the leaflet, and severe calcification of the aortic wall. CONCLUSION: The results of this animal study confirmed that a degenerated stentless biological valve inside the BioValsalva conduit could be replaced with a new valve, without having to remove the entire conduit.

Advanced age: a contraindication for triple-valve surgery?

BACKGROUND AND AIM OF THE STUDY: With the changing age structure of the population, cardiothoracic surgeons must deal with an increasing number of patients suffering from degenerative valve disease. Septuagenarians with triple valve disease may be refused surgery due to a potentially high perioperative risk related to co-morbidities. The study aim was to elucidate the indications and compare outcome, with a focus on age-related mortality and morbidity. METHODS: Between December 1996 and July 2010, a total of 90 consecutive patients (45 males, 45 females; mean age 68 +/- 9 years; logistic EuroSCORE 21 +/- 16%) underwent triple-valve surgery at Hannover Medical School. Of these patients, 70% had degenerative disease, 19% endocarditis, and 11% a rheumatic cause, while 24% underwent cardiac redo-surgery. For further analysis, the cohort was divided into two groups according to age: < or = 70 years (n=44) and >70 years (n=46). The follow up was performed according to current guidelines for reporting mortality and morbidity after cardiac valve interventions, including a quality of life assessment (Minnesota Living With Heart Failure Questionnaire; MLHFQ). RESULTS: Mortality among the patients was 16%, 24%, and 26% at 30, 60, and 90 days, respectively. The one-year survival was 69% for the whole cohort, and no difference was seen between the age groups. Follow up (mean 46 months) was complete in 96% of all patients who survived at least three months (n=67). Valve-related morbidity was low in both groups, with predominantly a recurrence of tricuspid insufficiency. The MLHFQ score was similar in both groups. CONCLUSION: Triple-valve surgery is associated with a high perioperative risk. However, the acceptance of elderly patients for this surgery is not associated with a higher mortality or valve-related morbidity. The patients' quality of life was acceptable during follow up, and not affected by age. Hence, the refusal of surgery should depend not on old age alone but rather on an individualized assessment of the patient.

Rhesus monkey cardiosphere-derived cells for myocardial restoration.

BACKGROUND AIMS: Cardiosphere-derived cells (CDC) have been proposed as a promising myocardial stem cell source for cardiac repair. They have been isolated from human, porcine and rodent cardiac biopsies. However, their usefulness for myocardial restoration remains controversial. We aimed to determine the survival, differentiation and functional effects of Rhesus monkey CDC (RhCDC) in a mouse model of myocardial infarction. METHODS: RhCDC were isolated and characterized by flow cytometry and reverse transcriptase (RT)-polymerase chain reaction (PCR) and compared with human CDC. They were injected intramyocardially into severe combined immune deficiency (SCID) beige mice after ligature of the left anterior descending artery (LAD). Phosphate-buffered saline (PBS) served as placebo. Medium treatment alone was used to distinguish between cellular and non-cellular effects. Animals were divided into a non-infarcted control group (n = 7), infarct control groups (n = 24), medium-treated infarct groups (n = 35) and RhCDC-treated infarct groups (n = 33). Follow-up was either 1 or 4 weeks. LV function was assessed by pressure-volume loop analysis. Differentiation was analyzed by immunhistochemical profiling and RT-PCR. RESULTS: Proliferating RhCDC grafts were detected after transplantation in an acute infarct model. RhCDC as well as medium treatment protected myocardium within the infarct area and improved LV function. RhCDC had a superior regenerative effect than medium alone. CONCLUSIONS: For the first time, RhCDC have been used for the restoration of infarcted myocardium. RhCDC proliferated in vivo and positively influenced myocardial remodeling. This effect could be mimicked by treatment with unconditioned medium alone, emphasizing a non-cellular paracrine therapeutic mechanism. However, as a robust cardiac stem cell source, CDC might be useful to evoke prolonged paracrine actions in cardiac stem cell therapy.

The first fifty consecutive Bentall operations with a prefabricated tissue-valved aortic conduit: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: Composite replacement is the standard treatment for the repair of aortic aneurysm with aortic valve pathology. With improved long-term durability and no requirement for long-term anticoagulation, tissue-valved conduits have become increasingly popular. Herein are reported the results achieved with 50 consecutive 'Bentall' operations, using the first commercially available prefabricated stentless tissue-valved conduit (Vascutek BioValsalva). METHODS: Between September 2007 and September 2009, a total of 50 patients (10 females, 40 males; mean age 65 +/- 7 years) received a BioValsalva conduit. Concomitant procedures included coronary artery bypass grafting (CABG; n = 15), other valve (n = 5), and aortic arch replacement with circulatory arrest (n = 20; three of these had an additional frozen elephant trunk). Four of the procedures were re-operations. A six-month follow up with echocardiography and clinical examination was completed in 25 patients. RESULTS: The 30-day mortality was 8% (4/50). Three of these patients underwent concomitant procedures. The cardiopulmonary bypass (CPB) and cross-clamp times were 178 +/- 30 min and 106 +/- 7 min, respectively. The triple-layered vascular graft proved to be hemostatic, without suture-line bleeding. Both, the initial and follow up echocardiography showed no valvular insufficiency, with a mean gradient of 13 +/- 5 mmHg. All patients were in NYHA class I-II. CONCLUSION: The BioValsalva prefabricated tissue-valved conduit showed very good early results. The ischemic time required to construct a 'home-made' stentless tissue-valved conduit was eliminated, thus reducing the cross-clamp time. The conduit also offered the hemodynamic advantages of a stentless valve.

Aortic root reoperation: a technical challenge.

BACKGROUND AND AIM OF THE STUDY: It is well known that aortic root re-replacement presents a formidable technical challenge. Thus, the study aim was to describe the authors' experience with this high-risk cohort. METHODS: Between August 1996 and January 2009, a total of 26 patients (mean age 51 years; range: 16-72 years) underwent aortic root re-replacement surgery at the authors' institution. Previous aortic root operations included mechanical valved conduit (n = 9), tissue valved conduit (n = 5), Ross procedure (n = 4), homograft (n = 4), David procedure (n = 2) and Yacoub procedure (n = 2). The indications for surgery included endocarditis (n = 16), Ross procedure failure (n = 4), valve degeneration (n = 3), anastomotic aneurysm (n = 2), and severe valve insufficiency (n = 1). RESULTS: The reoperations performed were classified as follows: aortic homograft (n = 11), mechanical conduit (n = 9), tissue valved conduit (n = 4) and David procedure (n = 2). The mean cardiopulmonary bypass time was 219 min (range: 101-398 min), and the mean cross-clamp time 142 min (range: 89-253 min). The mean ICU stay was 8 days (range: 1-45 days), and the mean hospital stay 20 days (range: 3-64 days). Four rethoracotomies were performed for postoperative bleeding or tamponade (14%). Two patients (8%) died within 30 days of surgery, and three (12%) required pacemaker implantation due to atrioventricular block (grade III). CONCLUSION: Aortic root reoperation, even in the setting of endocarditis, can be carried out with excellent results. The major goals of this concept include a clinical examination and preoperative diagnosis, in addition to computed tomography to identify possible pitfalls during re-sternotomy. Care must also be taken to provide adequate myocardial and organ protection, by utilizing blood cardioplegia and individual selective perfusion techniques.

Sutureless Perceval S aortic valve replacement: a multicenter, prospective pilot trial.

BACKGROUND AND AIM OF THE STUDY: A European, multicenter, prospective, non-randomized, clinical pilot trial was designed to evaluate the feasibility of the Perceval S sutureless aortic valve prosthesis. A clinical and echocardiographic follow up was performed at the time of hospital discharge and subsequently after one, three, six, and 12 months. METHODS: The valve was implanted following sternotomy, extracorporeal circulation (ECC), aortic cross-clamping, cardioplegic arrest, and removal of the native valve. Implantation suturing was not required. Optimal annular sealing was obtained with brief low-pressure balloon dilation. If coronary bypass was indicated, a distal anastomosis was performed first. Between April 2007 and February 2008, 30 patients (mean age: 81 +/- 4 years) underwent aortic valve replacement. The prevalence of pure aortic stenosis was 76.7%, and that of mixed lesion 23.3%. The mean logistic EuroSCORE was 13.18%, and the NYHA class was III and IV in 93.3% and 6.7% of patients, respectively. The implanted valve size was 21 and 23 mm in 37% and 63% of patients, respectively, and 14 (46.7%) underwent coronary artery bypass grafting (11 internal mammary artery, nine vein grafts). RESULTS: The mean aortic cross-clamp and ECC times were 34 +/- 15 min and 59 +/- 21 min, respectively. There was one in-hospital death (3.3%), and three deaths occurred within 12 months of follow up (one death was valve-related, and two deaths were independent of the valve implantation). A total of 28 patients was assessed at one month post-implantation, and 23 after 12 months. No migration or dislodgement of the valve had occurred, but there were two mild paravalvular leakages and two mild intravalvular insufficiencies. CONCLUSION: The preliminary results of the trial confirmed the safety and efficacy of the Perceval S sutureless aortic valve. In this high-risk subset of patients, shortening the aortic cross-clamp and ECC times may help to reduce mortality and morbidity.

Potential impact of oxygenators with venous air trap on air embolism in veno-arterial Extracorporeal Life Support.

BACKGROUND: Air embolism is a potentially fatal but underrecognized complication in Extracorporeal Life Support (ECLS). Oxygenators containing venous air traps have been developed to minimize the risk of air embolism in daily care. OBJECTIVE: We reproduced air embolism as occurring via a central venous catheter in an experimental setting to test the potential of oxygenators with and without venous bubble trap (VBT) to withhold air. METHODS: An in vitro ECLS circuit was created and a central venous catheter with a 3-way stopcock and a perforated male luer cap was inserted into the inflow line. Three different oxygenators with and without VBT and their capability to withhold air were examined. After 60 seconds of stable ECLS flow, the stopcock was opened towards the atmosphere for 3 minutes. Afterwards, air accumulation within the oxygenator was determined. RESULTS: Comparison of the total air entrapment showed a significant superiority of the oxygenators with VBT (p < 0.001). All oxygenators were able to partly withhold macro air boli, however, the capacity of oxygenators with VBT was higher. Passing through the oxygenator resulted in a reduction of microbubbles in all cases. CONCLUSIONS: Macro air emboli can be substantially reduced by usage of oxygenators that contain a VBT, whereas the capability to withhold microbubbles to a vast extent seems to depend on the intrinsic oxygenator's membrane.

Decade of aortic valve sparing reimplantation: are we pushing the limits too far?

BACKGROUND: This single center study assesses the outcome of aortic valve sparing reimplantation (AVS) in 284 consecutive patients who were operated on for various indications during the last 11 years. METHODS AND RESULTS: From July, 1993, to July, 2004, 284 patients underwent AVS. Mean age was 53+/-16 (range 8 to 84) years. Of the 284 patients, 184 were male (64.8%) and 54 (19%) experienced Marfan's syndrome. Acute aortic dissection Stanford type A was present in 53 patients (19%) and a bicuspid aortic valve was present in 17 patients (6%). Concomitant arch replacement was necessary in 120 patients (42%). Additional procedures were performed in 66 patients (23.2%). Mean follow-up time was 41+/-32 (range 0 to 130) months. The 30-day mortality was 3.2% overall, 11.3% in emergency patients, and 1.3% in elective patients. Mean bypass time was 174+/-48 (range 90 to 440) minutes and aortic cross clamp time was 132+/-33 (range 64 to 283) minutes. In patients undergoing arch replacement, circulatory arrest was 25+/-17 (range 7 to 99) minutes. Rethoracotomy for bleeding was required in 4.6% of patients. During follow-up, there were 20 (7.3%) late deaths. Reoperation of the reconstructed valve was required in 15 patients (5.3%); underlying reasons were endocarditis (n=4) and aortic insufficiency (n=11) requiring aortic valve replacement. Average grade of aortic insufficiency increased significantly from 0.23+/-0.46 postoperatively to 0.34+/-0.59 at latest evaluation (P=0.026). Two patients experienced a transient ischemic attack early postoperatively; no further thromboembolic complications were noticed. The majority of patients (96%) presented with a favorable exercise tolerance at last contact. CONCLUSIONS: The aortic valve reimplantation technique leads to excellent clinical outcome in patients with various pathologies. Lack of anticoagulation and favorable durability should encourage the extension of indications for this technique.

Hypothermic circulatory arrest with moderate, deep or profound hypothermic selective antegrade cerebral perfusion: which temperature provides best brain protection?

OBJECTIVE: Selective antegrade cerebral perfusion (SACP) seems to be associated with a better outcome compared to hypothermic circulatory arrest (HCA) alone. This study was undertaken to evaluate the influence of different SACP temperatures on the neurological integrity. METHODS: Twenty-six pigs were included in the study and assigned to 100 min HCA at 20 degrees C body temperature without (n = 6) or with either 10 degrees C (n = 6), 20 degrees C (n = 7) or 30 degrees C (n = 7) of SACP. Haemodynamics, metabolics and neurophysiology (EEG, SSEP, ICP, sagittal sinus saturation) were monitored. Animals were sacrified 4h after reperfusion and brains perfused for histological and molecular genetic assessment. RESULTS: There were no clinically relevant differences in haemodynamics between groups. The rise in ICP during SACP was significantly more marked in the 30 degrees C group (p < 0.05) and remained high during the entire experiment. In the 10 degrees C group the rise in ICP was postponed, but increased during reperfusion. The 20 degrees C group showed a slight increase of ICP over time, but remained significantly lower compared to HCA (p < 0.05). Sagittal sinus saturation decreased during SACP at 30 degrees C (p < 0.05). EEG recovery was most complete in the 20 degrees C group (p < 0.05). RT-PCR analysis of brain tissue revealed a reduction for heat shock protein (HSP-72) in 20 degrees C (p < 0.05) and 10 degrees C animals (p = 0.095). Histopathological evaluation showed a reduction of edema and eosinophilic cells in the groups treated with SACP. CONCLUSION: In this model, SACP is superior to HCA alone. Regarding the optimal temperature for SACP, it seems that 20 degrees C provides adequate brain protection in comparison to the potential detrimental effects of moderate (30 degrees C) and profound (10 degrees C) temperatures.

Short moderate hypothermic circulatory arrest without any adjunctive cerebral protection for surgical repair of the ascending aorta extending into the proximal aortic arch: is it safe?

INTRODUCTION: We have been using only moderate hypothermic circulatory arrest (HCA) for patients with ascending aortic aneurysms extending into the proximal aortic arch if the distal anastomoses seem to be simple and easy. The aim of this study is to evaluate the early and midterm results of the use of moderate HCA without any adjunctive cerebral protection in such patients. METHODS: Between October 2000 and March 2005, 23 patients with an age range of 39 to 77 years (mean, 59.7 +/- 12.2 years) received surgical repair of the ascending aorta extending into the proximal aortic arch using HCA without any adjunctive cerebral protection. Mean circulatory arrest time was 7.5 +/- 2.0 minutes (range, 2-13 minutes), and mean core temperature at induction of the circulatory arrest was 26.7 +/- 1.4 degrees C (range, 24-30 degrees C). RESULTS: Operative mortality was 4.3% (1/23) due to unknown cause after successful extubation. Temporary neurological dysfunction was observed in only 1 patient (4.3%), and no persistent neurologic event was observed in any of the patients. One patient died 3 months after the operation due to a mediastinitis. No other cardiac or neurologic event was observed in the 21 surviving patients. CONCLUSION: Our results suggest that moderate HCA at 26 degrees C to 28 degrees C without any adjunctive cerebral protection within 10 minutes is safe in selected patients.

When all else fails: extracorporeal life support in therapy-refractory cardiogenic shock.

OBJECTIVES: No guidelines for mechanical circulatory support in patients with therapy-refractory cardiogenic shock and multiorgan failure including ongoing cardiopulmonary resuscitation (CPR) exist. To achieve immediate cardiopulmonary stabilization, we established an interdisciplinary concept with on-site percutaneous extracorporeal life support (ECLS) implantation. METHODS: From February 2012 to November 2014, 96 patients were deemed eligible for ECLS implantation. Establishing ECLS was successful in 87 patients (mean age 54 ± 13 years, 16% female, initial flow 4.4 ± 0.9 l/min). Aetiologies included acute coronary syndromes (n = 52, 60%), cardiomyopathies (n = 25, 29%) and other pathologies. Fifty-nine patients (68%) had been resuscitated, and in 27 (31%), implantation was performed during CPR; 11 patients (13%) were awake at implantation and 20 (23%) underwent implantation in the referring hospital. RESULTS: Metabolic parameters differed in non-survivors versus survivors before ECLS implantation (pH 7.15 ± 0.23 vs. 7.27 ± 0.18, P = 0.007; lactate levels 10.90 ± 6.00 mmol/l vs. 8.79 ± 5.78 mmol/l, P = 0.091) and 6 h postimplantation (pH 7.27 ± 0.11 vs. 7.37 ± 0.11, P < 0.001; lactate levels 10.19 ± 5.52 mmol/l vs. 5.52 ± 4.17 mmol/l, P < 0.001). Altogether 44 patients could be weaned, and 9 were bridged to assist device implantation and 1 to heart transplantation. The mean time of support was 6 days, and the 30-day survival rate was 47% (n = 41). CONCLUSIONS: ECLS serves as a bridge-to-decision and bridge-to-treatment device. Our interdisciplinary ECLS programme achieved acceptable survival of critically ill patients despite a substantial percentage of patients having been resuscitated and no absolute exclusion criteria. Further studies defining inclusion- and exclusion criteria might additionally improve outcome.

The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up.

OBJECTIVE: The 'frozen' elephant trunk technique allows for single-stage repair of combined aortic arch and descending aortic aneurysms using a 'hybridprosthesis' with a stented and a non-stented end. This report summarizes the operative- and follow-up data (mean follow-up 14 months) with this new treatment. METHODS: Between 09/01 and 4/04, 22 patients (62+/-9 years; 9 female) with different aortic pathologies (15 aortic dissections, 7 aneurysms) were operated on after approval from the local institutional review board. The stented end of the hybridprosthesis was deployed in the descending aorta through the opened aortic arch during hypothermic circulatory arrest and selective antegrade cerebral perfusion. RESULTS: All patients survived the procedure but one patient died of acute hemorrhage due to rupture of the false lumen in the descending aorta on the second postoperative day. Two patients required reexploration of the chest for bleeding complications. In 2 of 4 patients who developed neurological dysfunction, symptoms resolved completely. In one of them, the descending aorta was perforated intraoperatively due to misplacement of the stented end of the hybridprosthesis. In all follow-up CT-scans thrombus formation in the descending aortic aneurysm excluded by the stented end of the hybridprosthesis has been observed. CONCLUSIONS: This procedure is performed through median sternotomy and combines the concepts of the elephant trunk operation and endovascular stenting of descending aortic aneurysms. Favourable intraoperative and postoperative results during follow-up with regard to thrombus formation around the stented descending aortic segment encourage us to evaluate all patients with thoracic aneurysms extending to proximal and distal of the left subclavian artery for this treatment.