COVID-19 Pulmonary Failure and Extracorporeal Membrane Oxygenation: First Experience from Three European Extracorporeal Membrane Oxygenation Centers.

On April 17, 2020, a coronavirus disease 2019 (COVID-19) webinar was held by selected international experts in the field of intensive care and specialized respiratory ECMO centers from Germany, Italy, Spain, and the United Kingdom, which was hosted by the German Heart Centre Berlin/Charité. The experts shared their experience about the treatment of 42 patients with severe acute respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). Patients were predominantly male (male-to-female ratio: 3:1), with a mean age of 51 years (range: 25-73 years). VV-ECMO support was indicated in 30% of the ventilated COVID-19 patients. The mean time requiring mechanical ventilation was 16.5 days, with a mean duration of ECMO support of 10.6 days. At the time of the webinar, a total of 17 patients had already been decannulated from ECMO, whereas six died with multiorgan failure. 18 patients remained on ECMO, with their final outcomes unknown at the time of the webinar. Hospital mortality was 25.6% (as of April 17, 2020). In this respect, VV-ECMO, provided by expert centers, is a recognized and validated mode of advanced life-support during the recent COVID-19 pandemic with good outcomes.

Cardiac surgery capacity in sub-saharan Africa: quo vadis?

BACKGROUND: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. METHODS: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). RESULTS: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. CONCLUSION: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.

Rheumatic mitral valve repair: 22-year clinical results.

BACKGROUND AND AIM OF THE STUDY: Rheumatic mitral valve disease presents a surgical and a medical challenge to surgeons in the developing and developed world. Comprehensive reproducible repair techniques of the anatomic units in individual patients are required to restore the normal mitral valve anatomy and function. METHODS: Between April 1986 and December 2009, a total of 2,211 patients underwent mitral valve repair at the authors' institution. Of these patients, 50 (32 women, 18 men) underwent repair at a median age of 45.6 years. Pure mitral stenosis was identified in four cases (8%), pure mitral regurgitation in 37 (74%), and mixed lesions in nine (18%). Posterior leaflet plication, Paneth posterior suture and autologous pericardial strip annuloplasty, chordal transfer and papillary muscle splitting were used to repair a rheumatically diseased mitral valve with leaflet prolapse, annulus dilatation and elongated or restricted chordae and malformed papillary muscle. RESULTS: Three deaths (6%) occurred in hospital (< or = 30 days), and 14 late deaths occurred between 60 days and 14 years. The overall survival was 94.1 +/- 3.3%, 87.5 +/- 4.8%, 84.7 +/- 5.4%, 66.9 +/- 7.9% and 50.2 +/- 9.3% at 30 days and one, five, 10 and 15 years, respectively. Successful repair was achieved in 39 cases (78%). Actuarial freedom from severe mitral regurgitation and reoperation at one, five and 10 years was 92.7 +/- 4.1%, 77.3 +/- 7.2% and 53.4 +/- 9.6%, respectively, and was 78% for Paneth posterior suture and autologous pericardial strip annuloplasty at five and 10 years. The linearized rate for reoperation in the age groups < 20 years and > 20 years was 4.5%/pt-yr (range: 2.0-10.2%/pt-yr) and 4.3%/pt-yr (range: 2.5-7.2%/pt-yr), respectively. CONCLUSION: Mitral valve repair in rheumatic disease is feasible, but the results are suboptimal. Pure mitral incompetence may be reparable and long-lasting, whilst mixed lesions may be reparable but fail subsequently. The predictability of repair and long-term functional results was determined by perioperative echocardiographic evaluation and the application of an appropriate repair technique to treat the complex pathology of the mitral valve apparatus.

Surgical therapy in patients with active infective endocarditis: seven-year single centre experience in a subgroup of 255 patients treated with the Shelhigh stentless bioprosthesis.

OBJECTIVE: We investigated outcomes after surgical therapy in patients with active infective endocarditis (AIE) with regard to survival in relation to surgical urgency, valve position, number of valves implanted and abscess formation. We aimed to identify independent risk factors for early mortality. METHODS AND RESULTS: Two hundred and fifty-five patients received Shelhigh bioprostheses between February 2000 and March 2007. A total of 74.1% had native and 25.9% prosthetic AIE. Surgery was regarded as urgent in 57.3% and as an emergency procedure in 38.4%. There was a highly significant difference in survival rate between patients who were operated on urgently versus in an emergency (p<0.0001), between single and double valve replacement (p=0.0206) and between patients with and without abscess formation (p=0.0245). There were two cases of early reinfection (0.78%) and six of late reinfection (2.35%) leading to re-operation. CONCLUSIONS: The survival of patients differs significantly in dependence on their surgical urgency. Better outcome could have been achieved if patients had been referred earlier for surgery and operated upon before heart failure or septic shock developed. Long-term survival was better in patients without abscess formation. The low reinfection rate of Shelhigh bioprostheses in AIE is promising and the early and mid-term results achieved need to be verified in the long-term course.

Heart valve operations in solid organ recipients: an 18-year single-center experience.

BACKGROUND: We retrospectively analyzed the outcome of heart valve operations in solid organ recipients, who were referred for operation to our institution. METHODS: Over an 18-year period, 23 heart (group 1) and 16 renal (group 2) transplant recipients in New York Heart Association (NYHA) classes III and IV underwent valve operation. The mean interval from the time of transplantation to cardiac surgery was 77.9 months with a mean follow-up time of 34.6 months in group 1 and 87.2 months with a mean follow-up time of 39.2 months in group 2. RESULTS: Group 1 underwent tricuspid valve replacement (n=12), tricuspid valve reconstruction (n=7), aortic valve replacement (AVR, n=3), and mitral valve replacement (MVR, n=1). In group 2, mechanical valve replacement was performed in 14 patients (9 AVR, 3 MVR, 2 AVR and MVR) and tricuspid or mitral valve reconstruction in two patients. There was no operative death. During hospitalization, multiorgan failure due to sepsis was the main cause of mortality (2 in both groups). In the mean follow-up period of 41.2 months, there were four late non-cardiac-related deaths in group 1. Currently 29 surviving transplant recipients (16 heart, 69.6% and 13 renal, 81.3%) are in NYHA classes I and II. CONCLUSION: In heart and renal recipients, valve operations can be performed effectively and safely with acceptable mortality, low cardiac morbidity, and excellent clinical results, although infection is the most serious complication.

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.

Seventeen-year clinical results of 1,037 Mitroflow pericardial heart valve prostheses in the aortic position.

BACKGROUND AND AIM OF THE STUDY: It is generally believed that the pericardial tissue valve is associated with a greater propensity to early structural failure and subsequent valve-related complications. However, a modified valve design during recent years has considerably improved the clinical durability of this bioprosthesis. METHODS: Between April 1986 and December 2003, single Mitroflow pericardial valve prostheses were inserted in the aortic position in 1,037 patients (mean age 72.4 +/- 8.4 years). Coronary artery bypass grafting (CABG) was performed in 373 patients (36%). Preoperative echocardiographic findings of structural valve deterioration (SVD) were confirmed at reoperation. Total follow up was 5,022 patient-years (pt-yr) (mean 4.85 +/- 4.7 years) and was 99.7% complete (three patients lost). RESULTS: Early (30-day) mortality was 2.9% for elective surgery; 434 patients (41.9%) died during the follow up period. Actuarial survival at 17 years was 23.2 +/- 2%. Actuarial freedom from valve-related mortality at 17 years was 92.0 +/- 2.2%, whereas the linearized mortality rate was 0.4%/pt-yr. Linearized valve-related complications occurred at a rate of 3.6%/pt-yr (n = 122). SVD of Mitroflow bioprostheses occurred at a rate of 1.0%/pt-yr, and caused stenosis (36.7%), insufficiency (20.4%) and combined stenosis and insufficiency (42.9%). Actual freedom from SVD at 17 years was 95.3 +/- 0.7% for all patients, 96.2 +/- 0.6% for those aged > 60 years, and 99.0 +/- 0.4% for those aged > 70 years. CONCLUSION: The Mitroflow pericardial bioprosthesis, in the aortic position, provides an excellent clinical performance and a low rate of valve-related morbidity, mortality and reoperation for up to 17 years. The prosthesis also demonstrates satisfactory hemodynamic performance, and is therefore recommended for patients aged > or = 70 years and for those aged 60-69 years with comorbidities.

Aortic root abscess and secondary infective mitral valve disease: results of surgical endocarditis treatment.

OBJECTIVE: Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women. METHODS: Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality. RESULTS: In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV. CONCLUSIONS: Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.

Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess.

BACKGROUND: The valve substitute of choice in active infective aortic valve endocarditis complicated by annulus abscess in our institution is the cryopreserved homograft. To avoid implantation of any prosthetic material, the Shelhigh No-React stentless valves and conduits may be considered an alternative when no suitable homograft is available. METHODS: Between March 1986 and January 2001, 452 homografts were implanted in the aortic position. From January 2000 to August 2001, 75 Shelhigh No-React prostheses were implanted at our institution. In 25 consecutive patients (study group) with aortic annulus abscess, urgent aortic valve replacement with the Shelhigh SuperStentless and Stentless Aortic Valve Conduit was undertaken. Patients (16 male, 9 female; age, 49 +/- 19 years) were studied with follow-up until March 2002. The control group comprised 68 consecutive historical patients (46 male, 22 female; age, 53 +/- 14.4 years) with similar disease treated between January 1997 and December 1999 in whom an aortic homograft was implanted. This group was also followed up until March 2002. Demographic data and preoperative characteristics of the patients were without significant differences. Patients were studied by echocardiography. RESULTS: Sixty-day mortality was 16% (11 patients) in the control group compared with 12% (3 patients) in the study group. Recurrent infection occurred in 4% in both groups. The instantaneous and mean Doppler gradients yielded no significant differences (19.4 +/- 10.4 mm Hg and 11.8 +/- 5.7 mm Hg versus 18.2 +/- 8.7 mm Hg and 10.9 +/- 5.3 mm Hg, respectively). The mean effective orifice area calculated from Doppler flow velocity for the stentless valve was 2.3 +/- 0.6 cm2. Preoperative evaluation of left ventricular dimensions and global left ventricular systolic function did not vary significantly between the two groups. However, postoperatively evaluated left ventricular end-diastolic diameter dimensions in the study group were significantly smaller than those in the control group (47.6 +/- 7.9 mm versus 56 +/- 9.5 mm; p = 0.05). Ejection fraction was similar in both groups (56.2% +/- 12.8% for the study [Shelhigh] and 52.6% +/- 16.8% for the control [homograft] group). CONCLUSIONS: Our experience with both the Shelhigh No-React SuperStentless and Stentless Aortic Valve Conduit in patients with native or prosthetic aortic valve endocarditis appears to demonstrate good results, similar to those of cryopreserved homografts. Ease of implantation and favorable effective orifice area and pressure gradients, as well as the No-React anticalcification treatment, are promising factors.

Implantation of a left ventricular assist device in situs inversus.

A 42-year-old man with situs inversus was referred to our institution because of end-stage ischemic cardiomyopathy. Cardiac arrest occurred after admission, and the patient underwent cardiopulmonary resuscitation. An extracorporeal left ventricular assist device (Berlin Heart) was implanted as a bridge to transplantation. This is one of the first reports of left ventricular assist device implantation in a patient with situs inversus and ischemic cardiomyopathy.

Cannulation of the right axillary artery for surgery of acute type A aortic dissection.

OBJECTIVE: The optimal choice of the arterial inflow site during operations for type A aortic dissection is not clearly defined. The aim of the prospective study was to identify whether cannulation of the right axillary artery instead of the femoral artery may improve the results of surgery for acute type A aortic dissection. METHODS: Seventy consecutive patients were operated on because of acute type A aortic dissection from January 2000 to February 2002. The only difference in surgical strategy was the site of arterial cannulation: the right axillary artery was used in 20 patients [axillary group] and the left femoral artery in 50 patients [femoral group]. All patients had aortic surgery with open distal anastomosis during deep hypothermic arrest and retrograde cerebral perfusion. The mean age was 58.7 +/- 12 years with a range from 28 to 88 years (axillary group, 56.6 +/- 13 years; femoral group, 59.4 +/- 12 years; P = 0.435). Preoperatively evident organ malperfusion was identified in five (25%) patients of the axillary group and in seven (14%) of the femoral group. RESULTS: There was no perioperative death. The hospital mortality rate was 5.0% for the axillary group and 22% for the femoral group (all patients, 17%). Major neurological complications occurred postoperatively in 5% of patients from the axillary group (one out of 20 patients) and in 8% of patients from the femoral group (four out of 50 patients) (all patients, 7%). CONCLUSION: Cannulation of the right axillary artery improved the outcome of surgery for acute type A aortic dissection. However, postoperative complications occurred after both axillary and femoral artery cannulation.

Factors influencing the results of double-valve surgery in patients with fulminant endocarditis: the importance of valve selection.

BACKGROUND: Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome. PATIENTS: Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age (+/-SD) was 53 +/- 14.2 years; there were 37 men and 16 women. METHODS: The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion. RESULTS: All patients with destructive endocarditic doublevalve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis. Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 +/- 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 +/- 10.4 mm Hg and 12 +/- 5.7 mm Hg, respectively, for the homografts and 24 +/- 8.4 mm Hg and 15 +/- 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular out- flow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation. CONCLUSIONS: The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.

In memoriam: Mr Donald Nixon Ross 4 October 1922 to 7 July 2014 (91 years).

We are deeply saddened by the loss of our great teacher Donald Ross, a truly global mentor in cardiac surgery, a friend, a respectful colleague, an admirer, and custodian of our profession, who passed away on July 7, 2014.

Mitroflow aortic pericardial bioprosthesis--clinical performance.

OBJECTIVE: Advancing life expectancy with the increased prevalence of aortic valve degenerative disease brings the need for an aortic bioprosthesis with excellent haemodynamic performance and comparable durability. The Mitroflow bioprosthesis has been on the worldwide market, except in the United States, since 1982, while the current model (1991) has only recently gained regulatory approval in the latter country. This study was primarily performed to determine the durability of the current Mitroflow bioprosthesis. METHODS: The contemporary Mitroflow bioprosthesis was implanted in 381 patients in three centres. The mean age was 76.4 years (range 53-91 years) and the mean follow-up period was 5.4+/-3.4 years, a total of 2048.7 years of evaluation. Prosthesis-patient mismatch (PPM) was classified by reference effective orifice area index categories: normal > or = 0.85 cm(2) m(-2) (53.9%), mild 0.84-0.76 cm(2) m(-2) (33.9%), moderate < or = 0.75-0.66 cm(2) m(-2) (11.7%) and severe < or = 0.65 cm(2) m(-2) (0.5%). RESULTS: The survival, at 10 years, was 39.9+/-7.9% for 50-69 years, 27.0+/-3.7% for 70-79 years and 16.6+/-4.4% for > or = 80 years (p=0.011). There was a trend (p=0.063) influencing survival for moderate-to-severe PPM. Of the independent predictors influencing survival--moderate-to-severe projected effective orifice area index (pEOAI) (Hazard Ratio (HR) 1.6, p=0.0142) and left ventricular dysfunction (ejection fraction < 35%) (HR 1.9, p=0.0193) were included. The 10-year freedom from structural valve deterioration (SVD) at explant assessing the same age groups as survival was not different (p=0.081). The 10-year actual/actuarial freedom from SVD, at explant was for > or = 60 years--94.4+/-1.4% (85.2+/-3.9%), for > or = 65 years--94.2+/-1.4% (85.0+/-4.0%), for 61-70 years--97.4+/-2.6% (95.7+/-4.3%) and for > 70 years--94.0+/-1.5% (83.2+/-4.6%). CONCLUSIONS: The Mitroflow external mounted, pericardial aortic bioprosthesis with documented excellent haemodynamics (especially for the small aortic root), demonstrates that prosthesis-patient mismatch in moderate and severe categories can essentially be eliminated, with durability performance comparable to other heterograft (porcine and pericardial) bioprostheses.