Immunophenotyping of Monocyte Migration Markers and Therapeutic Effects of Selenium on IL-6 and IL-1ß Cytokine Axes of Blood Mononuclear Cells in Preoperative and Postoperative Coronary Artery Disease Patients.

Multivessel coronary artery disease (CAD) is characterized by underlying chronic vascular inflammation and occlusion in the coronary arteries, where these patients undergo coronary artery bypass grafting (CABG). Since post-cardiotomy inflammation is a well known phenomenon after CABG, attenuation of this inflammation is required to reduce perioperative morbidity and mortality. In this study, we aimed to phenotype circulating frequencies and intensities of monocyte subsets and monocyte migration markers, respectively, and to investigate the plasma level of inflammatory cytokines and chemokines between preoperative and postoperative CAD patients and later, to intervene the inflammation with sodium selenite. We found a higher amplitude of inflammation, postoperatively, in terms of CCR1high monocytes and significantly increased pro-inflammatory cytokines, IL-6, IL-8, and IL-1RA. Further, in vitro intervention with selenium displayed mitigating effects on the IL-6/STAT-3 axis of mononuclear cells derived from postoperative CAD patients. In addition, in vitro selenium intervention significantly reduced IL-1ß production as well as decreased cleaved caspase-1 (p20) activity by preoperative (when stimulated) as well as postoperative CAD mononuclear cells. Though TNF-α exhibited a positive correlation with blood troponin levels in postoperative CAD patients, there was no obvious effect of selenium on the TNF-α/NF-κB axis. In conclusion, anti-inflammatory selenium might be utilized to impede systemic inflammatory cytokine axes to circumvent aggravating atherosclerosis and further damage to the autologous bypass grafts during the post-surgical period.

Experimental Studies for Small Diameter Grafts in an In Vivo Sheep Model-Techniques and Pitfalls.

BACKGROUND: Scientific attempts to create the "ideal" small diameter vascular graft have been compared with the "search of the holy grail." Prosthetic material as expanded polytetrafluoroethylene or Dacron shows acceptable patency rates to large caliber vessels, while small diameter (< 6 mm) prosthetic conduits present unacceptably poor patency rates. Vascular tissue engineering represents a promising option to address this problem. MATERIAL AND METHODS: Thirty-two female Texel-sheep aged 6 months to 2 years underwent surgical common carotid artery (CCA) interposition using different tissue-engineered vascular substitutes. Explantation of the grafts was performed 12 (n = 12) and 36 (n = 20) weeks after surgery. Ultrasound was performed on postoperative day 1 and thereafter every 4 weeks to evaluate the graft patency. RESULTS: The average length of implanted substitutes was 10.3 ± 2.2 cm. Anesthesia and surgical procedure could be performed without major surgical complications in all cases.The grafts showed a systolic blood flow velocity (BFV) of 28.24 ± 13.5 cm/s, a diastolic BFV of 9.25 ± 4.53 cm/s, and a mean BFV of 17.85 ± 9.25 cm/s. Native vessels did not differ relevantly in hemodynamic measurements (systolic: 29.77 cm/s; diastolic: 7.99 cm/s ± 5.35; mean 15.87 ± 10.75). There was no incidence of neurologic complications or subsequent postoperative occlusion. Perioperative morbidity was low and implantation of conduits was generally well tolerated. CONCLUSION: This article aims to give a precise overview of in vivo experiments in sheep for the evaluation of small diameter vascular grafts performing CCA interposition, especially with regard to pitfalls and possible perioperative complications and to discuss advantages and disadvantages of this approach.

Case series of late complications after transcatheter mitral annuloplasty using Cardioband and surgical treatment options.

BACKGROUND: Treatment of functional mitral regurgitation using transcatheter techniques such as the Cardioband annuloplasty device (Edwards Lifesciences) has gained wide acceptance in the recent years. However, complications of such devices are rarely reported. METHODS: Here, we present a case series involving two patients with dislocation of the Cardioband device and discuss the surgical management. RESULTS: In the former the valve was re-repaired by surgical implantation of an annuloplasty ring, and in the latter the valve had to be replaced due to severe damage of the mitral valve annulus. Both patients had an uncomplicated course and were discharged to rehabilitation Center. CONCLUSION: Dislocation of the Cardioband devices can be successfully managed by surgical approaches. Depending on the extent of damage to the mitral valve annulus, the valve could be re-repaired or should be repalced.

Delicate Role of PD-L1/PD-1 Axis in Blood Vessel Inflammatory Diseases: Current Insight and Future Significance.

Immune checkpoint molecules are the antigen-independent generator of secondary signals that aid in maintaining the homeostasis of the immune system. The programmed death ligand-1 (PD-L1)/PD-1 axis is one among the most extensively studied immune-inhibitory checkpoint molecules, which delivers a negative signal for T cell activation by binding to the PD-1 receptor. The general attributes of PD-L1's immune-suppressive qualities and novel mechanisms on the barrier functions of vascular endothelium to regulate blood vessel-related inflammatory diseases are concisely reviewed. Though targeting the PD-1/PD-L1 axis has received immense recognition-the Nobel Prize in clinical oncology was awarded in the year 2018 for this discovery-the use of therapeutic modulating strategies for the PD-L1/PD-1 pathway in chronic inflammatory blood vessel diseases is still limited to experimental models. However, studies using clinical specimens that support the role of PD-1 and PD-L1 in patients with underlying atherosclerosis are also detailed. Of note, delicate balances in the expression levels of PD-L1 that are needed to preserve T cell immunity and to curtail acute as well as chronic infections in underlying blood vessel diseases are discussed. A significant link exists between altered lipid and glucose metabolism in different cells and the expression of PD-1/PD-L1 molecules, and its possible implications on vascular inflammation are justified. This review summarizes the most recent insights concerning the role of the PD-L1/PD-1 axis in vascular inflammation and, in addition, provides an overview exploring the novel therapeutic approaches and challenges of manipulating these immune checkpoint proteins, PD-1 and PD-L1, for suppressing blood vessel inflammation.

Left ventricular thrombus formation in patients undergoing femoral veno-arterial extracorporeal membrane oxygenation.

INTRODUCTION: Profoundly impaired left ventricular (LV) function in patients undergoing femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can result in intra-cardiac stasis and thrombus formation. There have been several attempts to improve LV unloading in patients with peripheral VA-ECMO, either by improving contractility or by venting the LV. METHODS: Data from all patients who underwent femoral VA-ECMO between 2007 and 2015 due to cardiogenic decompensation were retrospectively analysed regarding intra-cardiac thrombus formation. RESULTS: In total, 11 of 281 patients (3.91%) with femoral VA-ECMO developed an intra- or extra-cardiac thrombus despite adequate anticoagulation therapy. None of the patients survived this serious complication. CONCLUSION: Management strategies for patients with femoral VA-ECMO support and severely impaired LV function must be reassessed to avoid insufficient LV unloading at an early stage of ECMO therapy. Early LV decompression should be considered in patients with insufficient unloading of the LV to prevent intra-cardiac thrombus formation.

Outcome after coronary bypass grafting for coronary complications following coronary angiography.

BACKGROUND: Coronary complications during coronary angiography or intervention (percutaneous coronary intervention [PCI]) are uncommon. However, PCI-related coronary artery perforation, dissection, or acute occlusion frequently result in myocardial ischemia followed by hemodynamic instability and need of urgent coronary artery bypass grafting (coronary artery bypass grafting [CABG]). This single-center study aimed to investigate clinical outcomes of patients undergoing urgent CABG after life-threatening PCI complications. MATERIALS AND METHODS: Data were retrospectively obtained using our institutional patient database. All patients admitted for urgent CABG following PCI-related complications from April 2010 to June 2015 were included into this study. Univariate analysis was performed to identify possible predictors for cardiac mortality. RESULTS: From a total of 821 urgent CABG patients, 52 patients (6.3%, 66.4 ± 9.4 years) underwent CABG for coronary complication following PCI. Logistic EuroSCORE was 21.8 ± 15.0%. At admission, 22 of 52 (42%) presented in cardiogenic shock, and 24 of 52 (46%) had significant electrocardiogram alterations indicating ST-elevation myocardial infarction (STEMI). Surgical revascularization was performed by targeting the injured coronary vessel with additional revascularization of other compromised vessels as indicated (mean number of grafts 2.4 ± 0.8). In-hospital cardiac mortality of the patient cohort was 13.5% (7/52) with 15.4% (8/52) in-hospital all-cause mortality. Preoperative resuscitation, cardiogenic shock, and STEMI were predictors for in-hospital cardiac mortality (P < 0.05) in univariate analysis. In contrast, noncardiac comorbidities, type of PCI complication, and localization of the culprit lesion were not associated to increased mortality. CONCLUSIONS: Emergent or urgent CABG for treatment of acute coronary complications following PCI is feasible and has acceptable clinical results that worsen in the presence of STEMI, cardiogenic shock, or resuscitation. Because preoperative status is crucial for clinical outcomes in these patients, immediate transfer to cardiac surgery is necessary.

Preoperative intra-aortic balloon pump use in high-risk patients prior to coronary artery bypass graft surgery decreases the risk for morbidity and mortality-A meta-analysis of 9,212 patients.

AIMS: Prophylactic intra-aortic balloon pump (IABP) support for high-risk patients before coronary artery bypass grafting (CABG) is controversial. This meta-analysis sought to determine the current role of preoperative IABP support. METHODS: We performed a meta-analysis of randomized (RCT) and observational trials (OT) that fulfilled the following criteria: (1) Group comparison of patients with prophylactic IABP implantation before CABG with a control group; (2) reporting at least one desired clinical endpoint, including all-cause mortality, myocardial infarction, cerebrovascular accident (CVA), and renal failure. Pooled treatment effects (odds ratio [OR] or weighted mean difference, and 95% confidence intervals [95%CI]) were assessed using a fixed or random effects model. RESULTS: A total of 9,212 patients from 23 studies (7 RCT, 16 OT) were identified after a literature search of major databases using a predefined keyword list. Absolute risk reduction for mortality in RCTs was 4.4% (OR 0.43; 95%CI 0.25-0.73; p = 0.0025). Prophylactic IABP use before CABG surgery also decreased the risk for myocardial infarction (OR 0.58; 95%CI 0.43-0.78; p = 0.004), CVA (OR 0.67; 95%CI 0.47-0.97; p = 0.042), and renal failure (OR 0.62; 95%CI 0.47-0.83; p = 0.0014). Length of intensive care unit stay (p < 0.0001) and length of hospital stay (p < 0.0001) were significantly reduced in patients with preoperative IABP use. CONCLUSION: Current evidence from RCT and OT suggests beneficial effects for the IABP in high-risk patients before CABG surgery.

Class IA Phosphatidylinositol 3-Kinase Isoform p110α Mediates Vascular Remodeling.

OBJECTIVE: Neointima formation after vascular injury remains a significant problem in clinical cardiology, and current preventive strategies are suboptimal. Phosphatidylinositol 3'-kinase is a central downstream mediator of growth factor signaling, but the role of phosphatidylinositol 3'-kinase isoforms in vascular remodeling remains elusive. We sought to systematically characterize the precise role of catalytic class IA phosphatidylinositol 3'-kinase isoforms (p110α, p110ß, p110δ), which signal downstream of receptor tyrosine kinases, for vascular remodeling in vivo. APPROACH AND RESULTS: Western blot analyses revealed that all 3 isoforms are abundantly expressed in smooth muscle cells. To analyze their significance for receptor tyrosine kinases-dependent cellular responses, we used targeted gene knockdown and isoform-specific small molecule inhibitors of p110α (PIK-75), p110ß (TGX-221), and p110δ (IC-87114), respectively. We identified p110α to be crucial for receptor tyrosine kinases signaling, thus affecting proliferation, migration, and survival of rat, murine, and human smooth muscle cells, whereas p110ß and p110δ activities were dispensable. Surprisingly, p110δ exerted noncatalytic functions in smooth muscle cell proliferation, but had no effect on migration. Based on these results, we generated a mouse model of smooth muscle cell-specific p110α deficiency (sm-p110α(-/-)). Targeted deletion of p110α in sm-p110α(-/-) mice blunted growth factor-induced cellular responses and abolished neointima formation after balloon injury of the carotid artery in mice. In contrast, p110δ deficiency did not affect vascular remodeling in vivo. CONCLUSIONS: Receptor tyrosine kinases-induced phosphatidylinositol 3'-kinase signaling via the p110α isoform plays a central role for vascular remodeling in vivo. Thus, p110α represents a selective target for the prevention of neointima formation after vascular injury, whereas p110ß and p110δ expression and activity do not play a significant role.

In vivo application of tissue-engineered blood vessels of bacterial cellulose as small arterial substitutes: proof of concept?

BACKGROUND: Tissue-engineered blood vessels (TEBVs) represent an innovative approach for overcoming reconstructive problems associated with vascular diseases by providing small-caliber vascular grafts. This study aimed to evaluate a novel biomaterial of bacterially synthesized cellulose (BC) as a potential scaffold for small-diameter TEBV. METHODS: Small-diameter blood vessels with a supramolecular fiber network structure consisting of tubular hydrogels from biodesigned cellulose were created using Gluconacetobacter strains and Matrix reservoir technology. BC tubes (length: 100 mm, inner diameter: 4.0-5.0 mm) were applied to replace the carotid arteries of 10 sheep for a period of 3 mo to gain further insights into (a) functional (in vivo) performance, (b) ability of providing a scaffold for the neoformation of a vascular wall and (c) their proinflammatory potential, and the (d) technical feasibility of the procedure. RESULTS: Preoperative analysis revealed a bursting strength of the grafts of approximately 800 mm Hg and suture retention strength of 4-5 N. Postexplantation analysis showed a patency rate of 50% (n = 5) and physiological performance of the patent grafts at 4, 8, and 12 wk postoperatively, compared with native arteries. Histologic analysis revealed a neoformation of a vascular wall-like structure along the BC scaffold consisting of immigrated vascular smooth muscle cells and a homogeneous endothelialization of the inner graft surface without signs of prothrombogenic or inflammatory potential. Scanning electron microscopy revealed a confluent luminal endothelial cell layer and the immigration of vascular smooth muscle cells into the BC matrix. CONCLUSIONS: BC grafts provide a scaffold for the neoformation of a three-layered vascular wall exhibit attractive properties for their use in future TEBV programs for cardiovascular surgery.

Baroreflex activation therapy in patients with pre-existing implantable cardioverter-defibrillator: compatible, complementary therapies.

AIMS: The Neo™ System (CVRx) is an implantable device, CE certified for the treatment of resistant hypertension and investigationally used to treat systolic heart failure by electrical stimulation of the carotid baroreceptors. It is unknown whether interaction might exist between the Neo System and implantable cardioverter-defibrillators (ICDs). METHODS AND RESULTS: Compatibility of the Neo device was tested in seven consecutive patients with pre-existing ICDs. Intra- and post-operative testing was completed with ICD and Neo settings programmed to provoke interaction. Intracardiac electrograms were printed to determine interaction with the ICD. Interaction testing during implantation and follow-up showed that there was no device-device interaction. No interaction was observed at maximum atrial and ventricular sensitivity settings and maximum Neo output settings. CONCLUSION: Combined therapy with the Neo device and at least in this study reported that transvenous ICD systems can be performed safely.

Sutureless Perceval aortic valve in comparison with the stented Carpentier-Edwards Perimount aortic valve.

BACKGROUND AND AIM OF THE STUDY: The Sorin Perceval S (SP) sutureless bioprosthesis was developed as an advancement of conventional biological aortic valve replacement (AVR) with stented bioprostheses, and perhaps also as an alternative to the transcatheter aortic valve implantation (TAVI) procedure, especially for high-risk patients. Herein are described the authors' early results with SP valve replacement, compared to AVR with Carpentier-Edwards Perimount (EP) stented valves. METHODS: Between September 2012 and February 2013, a total of 14 patients was enrolled in a single-center SP study group, and their data were analyzed in a prospective manner. For comparison, 14 patients who received an EP valve replacement during the same period were matched with the SP group, in a retrospective manner. Hemodynamic parameters and clinical outcome were monitored until discharge of the patients in order to analyze the early results of the two groups. RESULTS: The cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times needed for AVR with SP valves were significantly shorter than with EP valves. The mean CPB time for SP valve replacement without concomitant procedures was 58.4 +/- 11.0 min, compared to 71.8 +/- 11.3 min in the EP group (p = 0.015), while the mean ACC times were 37.3 +/- 6.8 and 49.1 +/- 11.2 min, respectively (p = 0.006). Permanent pacemaker implantation was required in four patients after SP valve replacement, but in only one patient after EP valve replacement (p = 0.326). The mean transprosthetic peak and mean gradients were 24.8 +/- 5.2 mmHg and 13.3 +/- 3.3 mmHg, respectively, in the SP group, and 19.0 +/- 6.5 mmHg and 10.4 +/- 3.0 mmHg, respectively, in the EP group (p = 0.024 and p = 0.087). The mean valve size was 23.8 +/- 1.3 mm and 23.3 +/- 1.5 mm in the SP and EP groups, respectively. The fall in platelet count after SP valve replacement was 180.4 +/- 79.4 x 10(3)/microl on the first postoperative day (POD), and 114.1 +/- 51.2 x 10(3)/microl with a minimum of 42 x 10(3)/microl and a maximum of 230 x 10(3)/microl at the nadir on POD 2.6 +/- 4.0. The mean minimum values at the nadir corresponded to 40% of the initial preoperative value. CONCLUSION: The sutureless SP bioprosthesis seems to represent a good alternative to conventional stented bioprostheses, especially in older patients with a high-risk profile, and particularly if concomitant surgical procedures are planned.

Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock: a single-center experience.

BACKGROUND: We assessed the short-term outcomes and predictors of 30-d mortality in patients requiring temporary, peripheral extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiac failure. METHODS: The data were retrospectively obtained using our institutional patient database. All patients who had received peripheral ECMO support after surgery for acquired heart disease from 2006 to 2010 were included in the present study. The demographic and perioperative variables of the 30-d survivors and nonsurvivors were compared using the chi-square and t-test, and multivariate logistic regression analysis was performed to identify the predictors of 30-d all-cause mortality. RESULTS: A total of 77 patients with a mean age of 60 ± 13 years were included in the present analysis. Successful weaning from peripheral ECMO was achieved in 62% after 79 ± 57 h of ECMO support. The overall 30-d mortality rate was 70%, and mortality was reduced to 52% in the patients in whom ECMO support could be weaned successfully. Age (per year) at ECMO implantation was the only independent preoperative predictor of 30-d mortality (odds ratio 1.09, 95% confidence interval 1.03-1.15; P = 0.003). In addition, greater lactate levels after 24 h of ECMO therapy, a longer duration of ECMO support, and the presence of any ECMO-related or gastrointestinal complications were independent predictive factors for 30-d mortality (P < 0.05). CONCLUSIONS: ECMO therapy provides a valuable therapeutic strategy for postcardiotomy myocardial failure but is still limited by high complication rates with fewer than 30% of patients discharged from the hospital. Patient age appears to be an essential preoperative predictor for mortality, and the blood lactate level is a relevant marker for the assessment of efficient ECMO support.

Endoscopic vein harvesting for coronary artery bypass grafting: a systematic review with meta-analysis of 27,789 patients.

BACKGROUND: To determine the current strength of evidence for or against endoscopic vein harvesting (EVH) in patients undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS: A meta-analysis of randomized controlled trials (RCT) and observational trials (OT) was performed that reported the impact of EVH on adverse clinical outcomes after CABG. Analyzed postoperative outcomes included wound infection, postoperative pain, myocardial infarction (MI), vein graft failure, length of hospital stay, and mortality. Pooled treatment effects (OR or weighted mean difference (WMD), 95%CI) were assessed using a fixed or random effects model. RESULTS: A total of 27,789 patients from 43 studies (16 RCT, 27 OT) were identified who underwent saphenectomy by endoscopic (46%; n = 12,822) or conventional technique (54%; n = 14,967). Pooled effect estimates revealed a reduced incidence (P < 0.001) for wound infections (OR 0.27; 95% CI 0.22 to 0.32), pain (WMD -1.26, 95% CI -2.07 to -0.44; P = 0.0026), and length of hospital stay (WMD -0.6 d, 95% CI -1.08 to -0.12; P = 0.0152). EVH was associated to an increase of the odds for vein graft failure (OR 1.38; 95% CI 1.01 to 1.88; P = 0.0433), a finding that lost statistical difference after pooled analysis of RCT and studies with high methodological quality. Similarly, graft-related endpoints, including mortality and MI, did not differ between the harvesting techniques. CONCLUSION: The present systematic review underscores the safety of EVH in patients undergoing CABG. EVH reduces leg wound infections without increasing the midterm risk for vein graft failure, MI, or mortality.

Coagulation disorders do not increase the risk for bleeding during percutaneous dilatational tracheotomy.

BACKGROUND: Percutaneous dilatational tracheotomy (PDT) is a common procedure. Coagulation disorders represent a relative contraindication for PDT and, therefore, normalization of hemostasis parameters is recommended. Especially patients undergoing cardiac surgery after valve replacement and with any kind of assist device need to require an adequate anticoagulation. This study investigated the impact of impaired hemostasis as a risk factor for bleeding complications retrospectively. METHODS: Patients who underwent PDT (November 2007 to November 2010) were stratified into a high-risk (HR) and low-risk (LR) group in regard to bleeding complications. The following determining factors activated partial thromboplastin time (aPTT > 50 seconds, prothrombin time (PT < 50%), international normalized ratio (INR > 1.4), and platelet count (< 50,000/µL) were assessed. RESULTS: A total of 213 patients underwent PDT (HR = 5/85; LR = 8/128). There was no difference in demographics or intraoperative data. Patients of both groups showed mild bleeding without the need for surgical intervention or transfusion (p = 0.957). There were no severe bleeding nor other procedure-related complications. CONCLUSION: Percutaneous tracheotomy is a safe and feasible procedure in patients with coagulation disorders. Therefore, discontinuation of anticoagulation treatment or normalization of hemostasis prior to the procedure is not necessary.

Clinical and hemodynamic outcomes of the Perceval sutureless aortic valve from a real-world registry.

OBJECTIVES: Perceval sutureless valve has been in clinical use for >15 years. The aim of this study is to report the real-word clinical and haemodynamic performance from the SURE-aortic valve replacement international prospective registry in patients who underwent aortic valve replacement with Perceval valve. METHODS: From 2011 to 2021, patients from 55 institutions received a Perceval valve. Postoperative, follow-up, and echocardiographic outcomes were analysed. RESULTS: A total of 1652 patients were included; mean age was 75.3 ± 7.0 years (53.9% female); mean EuroSCORE II was 4.1 ± 6.3. Minimally invasive approach was performed in 45.3% of patients; concomitant procedures were done in 35.9% of cases. Within 30 days, 0.3 and 0.7% valve-related reinterventions were reported. Transient ischaemic attack, disabling and non-disabling strokes were limited (0.4%, 0.4% and 0.7%, respectively). Pacemaker implant was required in 5.7% of patients. Intra-prosthetic regurgitation ≥2 was present in 0.2% of cases, while paravalvular leak ≥2 in only 0.1%. At a maximum follow-up of 8 years, 1.9% of cardiovascular deaths and 0.8% of valve-related reintervention occurred. Among the 10 cases of structural valve deterioration (mean 5.6 ± 1.4 years after implant; range: 2.6-7.3 years), 9 were treated with a transcatheter vale-in-valve implantation and 1 with explant. Mean pressure gradient decreased from 45.8 ± 16.5 mmHg preoperatively to 13.3 ± 5.2 mmHg at discharge and remained stable during follow-up. CONCLUSIONS: This experience represents the largest prospective real-world cohort of patients treated with Perceval showing that Perceval is a safe and effective alternative to conventional surgical aortic valve replacement, providing favourable clinical and haemodynamic results also at mid-term follow-up.

Outcomes of patients with coronavirus disease versus other lung infections requiring venovenous extracorporeal membrane oxygenation.

Background: Patients with Coronavirus Disease (COVID-19) often develop severe acute respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation (MV), and venovenous extracorporeal membrane oxygenation (V-V ECMO).Mortality in COVID-19 patients on V-V ECMO was exceptionally high; therefore, whether survival can be ameliorated should be investigated. Methods: We collected data from 85 patients with severe ARDS who required ECMO support at the University Hospital Magdeburg from 2014 to 2021. The patients were divided into the COVID-19 group (52 patients) and the non-COVID-19 group (33 patients). Demographic and pre-, intra-, and post-ECMO data were retrospectively recorded. The parameters of mechanical ventilation, laboratory data before using ECMO, and during ECMO were compared. Results: There was a significant difference between the two groups regarding survival: 38.5% of COVID-19 patients and 63.6% of non-COVID-19 patients survived 60 days (p = 0.024). COVID-19 patients required V-V ECMO after 6.5 days of MV, while non-COVID-19 patients required V-V ECMO after 2.0 days of MV (p = 0.048). The COVID-19 group had a greater proportion of patients with ischemic heart disease (21.2% vs 3%, p = 0.019). The rates of most complications were comparable in both groups, whereas the COVID-19 group showed a significantly higher rate of cerebral bleeding (23.1 vs 6.1%, p = 0.039) and lung bacterial superinfection (53.8% vs 9.1%, p = <0.001). Conclusion: The higher 60-days mortality among patients with COVID-19 with severe ARDS was attributable to superinfection, a higher risk of intracerebral bleeding, and the pre-existing ischemic heart disease.

Transapical minimally invasive aortic valve implantation and conventional aortic valve replacement in octogenarians.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has been developed to minimize the operative trauma in high-risk patients. Patient selection for TAVI is still subject to debate and octogenarians are often regarded as high-risk patients. METHODS: In this single-center study, data of 169 octogenarians who received conventional AVR (90) or TAVI (79) have been analyzed retrospectively according to the endpoint definitions of the Valve Academic Research Consortium to answer the following questions: (a) Should patients due to their age of 80 years or older be considered as high risk? (b) Is the EuroSCORE a suitable tool for estimating mortality after AVR or TAVI in octogenarians? (c) Is TAVI the procedure of choice for octogenarians? RESULTS: TAVI patients showed higher comorbid conditions concerning an existing renal dysfunction (31 vs. 56%, p = 0.001), peripheral vascular disease (6 vs. 30%, p < 0.001), diabetes (19% vs. 49%, p < 0.001), a decreased ejection fraction (LVEF < 30%: 2 vs. 13%, p < 0.05), and pulmonary hypertension (23 vs. 48%; p < 0.005) with an increase of the perioperative risk represented by logistic EuroSCORE (AVR 11% ± 1.27 vs. TAVI 38% ± 1.35; p < 0.0005) and STS Score (7% ± 0.52 vs. 14% ± 0.56; p < 0.0005). All-cause and cardiovascular-cause in-hospital or 30-day mortality was 5.6% (n = 5) and 3.4% (n = 3) in the AVR cohort and 8.8% (n = 7) and 7.6% (n = 6) in TAVI-patients (p = 0.55; p = 0.31), respectively. The overall combined safety endpoint at 30 days was 22.2% (n = 20) in AVR patients and 29.1% (n = 23) with regard to the TAVI group (p = 38). Analysis of cerebrovascular complications, vascular complications, and pacemaker revealed no significant differences. In the AVR group, actuarial survival at 6 months and 1 and 2 years was 89, 78, and 74%, respectively. Data of the TAVI patients are only available for a follow-up of 6 months and revealed a survival of 85%. CONCLUSION: AVR and TAVI in octogenarians show comparable results, but the analyzed cohorts differ significantly in their risk profile. The results indicate an overrated perioperative mortality using the EuroSCORE but on the other hand logistic EuroSCORE represents articulately the different risk profile of the two groups. For this reason, we consider the EuroSCORE still to be a useful tool for preoperative risk assessment. Moreover, octogenarians cannot per se be considered as "true high risk" patients. Differentiated clinical judgment is most important for reasonable decision making.

Transapical aortic valve implantation: experiences and survival analysis up to three years.

BACKGROUND: We determined our 30-day results after transapical aortic valve implantation (TA-AVI) according to Valve Academic Research Consortium criteria, analyzed midterm outcome, and summarize our institutional learning experience. METHODS: From February 2008 to July 2011, 150 high-risk patients underwent TA-AVI. Endpoints of this retrospective analysis were safety as indicated by morbidity and 30-day mortality and midterm survival with a follow-up period up to 3.4 years (mean follow-up 14.1 months). In addition we analyzed our institutional learning curve by comparing the outcome of our first 50 patients (group 1) to the following 100 patients (group 2). RESULTS: Procedural success was 98% (147 patients). All-cause and cardiovascular cause 30-day mortality was 11.3% (n = 17) and 7.3% (n = 11), respectively. The cumulative survival rates were 78.7% at one year, 62.8% at two years, and 50.8% at three years. As compared to group 1, there was a significantly reduced incidence of relevant bleeding complications (0% vs. 14%[n = 7]; p < 0.001) and a reduced incidence of acute kidney injury (35%[n = 35] versus 56% (n = 28); p < 0.05) in group 2, resulting in a combined safety endpoint at 30 days of 22% in group 2 versus 40% in group 1 (p < 0.05). One-year mortality (group 2, n = 20 [20%] versus group 1, n = 10 [20%]; p = 1) and midterm survival (p = 0.998; Hazard ratio 1.001; 95% CI 0.5141 to 1.949) did not differ significantly. CONCLUSIONS: Although the incidence of technical complications decreased significantly over time, 30-day and midterm mortality were unaltered, most likely due to patients' comorbidities. The development of more accurate risk scores may improve future outcome.

Bacterial Nanocellulose-Based Grafts for Cell Colonization Studies: An In Vitro Bioreactor Perfusion Model.

With the aging population, the demand for artificial small diameter vascular grafts is constantly increasing, as the availability of autologous grafts is limited due to vascular diseases. A confluent lining with endothelial cells is considered to be a cornerstone for long-term patency of artificial small diameter grafts. We use bacterial nanocellulose off-the-shelf grafts and describe a detailed methodology to study the ability of these grafts to re-colonize with endothelial cells in an in vitro bioreactor model. The viability of the constructs generated in this process was investigated using established cell culture and tissue engineering methods, which includes WST-1 proliferation assay, AcLDL uptake assay, lactate balancing and histological characterization. The data generated this straight forward methodology allow an initial assessment of the principal prospects of success in forming a stable endothelium in artificial vascular prostheses.

Activation of the stress response among the cardiac surgical residents: comparison of teaching procedures and other (daily) medical activities.

BACKGROUND: The aim of this Pilot study was to investigate the cardiac surgical residents' workload during different surgical teaching interventions and to compare their stress levels with other working time spent in the intensive care unit or normal ward. METHODS: The objective stress was assessed using two cardiac surgical residents' heart rate variability (HRV) both during surgical activities (32 selected teaching operations (coronary artery bypass graft n = 26 and transcatheter aortic valve implantation n = 6), and during non-surgical periods. Heart rate, time and frequency domains as well as non-linear parameters were analyzed using the Wilcoxon test. RESULTS: The parasympathetic activity was significantly reduced during the surgical phase, compared to the non-surgical phase: Mean RR (675.7 ms vs. 777.3 ms), RMSSD (23.1 ms vs. 34.0 ms) and pNN50 (4.7% vs. 10.6%). This indicates that the residents had a higher stress level during surgical activities in comparison to the non-surgical times. The evaluation of the Stress Index during the operations and outside the operating room (8.07 vs. 10.6) and the parasympathetic nervous system index (- 1.75 to - 0.91) as well as the sympathetic nervous system index (1.84 vs. 0.65) confirm the higher stress level during surgery. This can be seen too used the FFT Analysis with higher intraoperative LF/HF ratio (6.7 vs. 3.8). CONCLUSION: HRV proved to be a good, objective method of identifying stress among physicians both in and outside the operating room. Our results show that residents are exposed to high psychological workloads during surgical activities, especially as the operating surgeon.