Search

Purpose: Baroreflex activation therapy has favorable effects in heart failure patients. We report the results of a single-center study of baroreflex activation therapy in heart failure with reduced ejection fraction including cardiopulmonary exercise testing for the first time to show the effect on exercise capacity., Methods: A total of 17 patients were treated with baroreflex activation therapy. Eligibility criteria were the New York Heart Association class ⩾III and ejection fraction ⩽35% on guideline-directed medical and device therapy. The New York Heart Association class, quality of life, and 6-min hall walk distance were assessed in all patients. Twelve patients underwent cardiopulmonary exercise testing before and 8.9 ± 6.4 months after initiation of baroreflex activation therapy., Results: The New York Heart Association class and 6-min hall walk distance improved after baroreflex activation therapy, while quality of life remained stable. Weight-adapted peak oxygen uptake increased significantly from 10.1 (8.2-12.9) ml/min/kg to 12.1 (10.4-14.6) ml/min/kg ( p = 0.041). Maximal heart rate was stable. Maximal oxygen pulse increased from 9.7 (5.5-11.3) to 9.9 (7.1-12.1) ml/heartbeat ( p = 0.047) in 10 patients with low maximal oxygen pulse at baseline (<16.5 ml/heartbeat). There was no significant change in maximal oxygen pulse in the whole cohort. Ventilatory efficiency remained stable., Conclusion: Weight-adapted peak oxygen uptake improved after baroreflex activation therapy, pointing to an enhanced exercise capacity. Ventilatory efficiency and heart rate did not change, while oxygen pulse increased in patients with low oxygen pulse at baseline, indicating an improvement in circulatory efficiency, that is, a beneficial effect on stroke volume and peripheral oxygen extraction.

SARS-CoV-2 (COVID-19) infections have been recently shown to be associated with a high rate of thromboembolic events due to pro-coagulative mechanisms that have not yet been fully understood. This paper reports on a 55-year-old female COVID-19 patient with severe ARDS and pulmonary embolism (PE) complicated by cardiogenic shock after 12 days of hospitalization under initial prophylactic anticoagulation with low molecular weight heparin (LMWH). An ultima-ratio va (veno-arterial) ECMO implantation and subsequent rapid upgrade to vvaECMO due to insufficient oxygenation was performed. The patient developed severe coagulopathy with intrapulmonary bleeding. The present report aims to highlight and discuss the pros and cons of various anticoagulation strategies in COVID-19 patients focusing on current scientific debates to address this frequently observed complication in the current situation worldwide.

Purpose: Baroreflex activation therapy (BAT) has been shown to lower blood pressure in patients with resistant hypertension. The purpose of this study was to analyze whether this translates into a reduction of more relevant clinical endpoints., Methods: Patients with resistant hypertension were treated with the second-generation BAT system. Records on hospitalization (dates of admission and discharge, main diagnosis) were obtained from medical insurance companies., Results: Records on hospitalization were available for a period of 1 year before BAT in two patients and 2 years in 22 patients. The total number of hospitalizations per patient was 3.3 ± 3.5/year before BAT and 2.2 ± 2.7/year after BAT (p = 0.03). Hospitalizations related to hypertension were significantly decreased from 1.5 ± 1.6/year before BAT to 0.5 ± 0.9/year after BAT (p < 0.01). The cumulative duration of hypertension-related hospital stays was significantly reduced from 8.0 ± 8.7 days/year before BAT to 1.8 ± 4.8 days/year after BAT (p < 0.01). Office cuff blood pressure was 183 ± 27 mmHg over 102 ± 17 mmHg under 6.6 ± 2.0 antihypertensive drugs before BAT and 157 ± 32 mmHg over 91 ± 20 mmHg (both p < 0.01) under 5.9 ± 1.9 antihypertensive drugs (p = 0.09 for number of drugs) at latest follow-up. Daytime ambulatory blood pressure was 164 ± 21 mmHg over 91 ± 14 mmHg before BAT and 153 ± 21 mmHg (p = 0.03) over 89 ± 15 mmHg (p = 0.56) at latest follow-up. Heart rate was 75 ± 16 bpm before BAT and 72 ± 12 bpm at latest follow-up (p = 0.35)., Conclusions: Rate and duration of hypertension-related hospitalizations in patients with severe resistant hypertension were lowered after BAT. Whether the response is mediated through improvements in blood pressure control requires further studies.

Background: There has been conflicting evidence concerning the effect of levosimendan on clinical outcomes in patients undergoing cardiac surgery. Therefore, we performed a systematic review and conducted this meta-analysis to provide evidence for/against the administration of levosimendan in cardiac surgery patients., Methods: We performed a meta-analysis from literature search in PubMed, EMBASE, and Cochrane Library. Only randomized controlled trials comparing the administration of levosimendan in cardiac surgery patients with a control group (other inotrope, standard therapy/placebo, or an intra-aortic balloon pump) were included. In addition, at least one clinical outcome had to be mentioned: mortality, myocardial infarction, low cardiac output syndrome (LCOS), acute kidney injury, renal replacement therapy, atrial fibrillation, prolonged inotropic support, length of intensive care unit, and hospital stay. The pooled treatment effects (odds ratio [OR], 95% confidence intervals [CI]) were assessed using a fixed or random effects model., Results: The literature search retrieved 27 randomized, controlled trials involving a total of 3,198 patients. Levosimendan led to a significant reduction in mortality (OR: 0.67; 95% CI: 0.49-0.91; p  = 0.0087). Furthermore, the incidence of LCOS (OR: 0.56, 95% CI: 0.42-0.75; p  < 0.0001), acute kidney injury (OR: 0.63; 95% CI: 0.46-0.86; p  = 0.0039), and renal replacement therapy (OR: 0.70; 95% CI: 0.50-0.98; p  = 0.0332) was significantly decreased in the levosimendan group., Conclusion: Our meta-analysis suggests beneficial effects for the prophylactic use of levosimendan in patients with severely impaired left ventricular function undergoing cardiac surgery. The administration of levosimendan was associated with a reduced mortality, less LCOS, and restored adequate organ perfusion reflected in less acute kidney injury., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  The latest generation of balloon-expandable valve, the Edwards Sapien 3 valve (S3V), was designed to reduce paravalvular regurgitation (PVR). We retrospectively compared S3V with Edwards Sapien XT valve (SXTV) with regard to postprocedural transvalvular pressure gradients (PGs)., Methods:  Analysis of 152 patients receiving SXTV and 125 patients receiving S3V between February 2009 and April 2015 was performed. Transvalvular PGs and the incidence and extent of aortic regurgitation (AR) were compared postprocedurally by echocardiography for each valve size., Results:  Postprocedurally, mean PGs for the 23 mm valves were 10.9 ± 5.3 versus 13.9 ± 5.1 ( p  = 0.017), whereas maximum PGs were 19.9 ± 8.3 versus 26.1 ± 10.4 mm Hg ( p  = 0.005) in SXTV and S3V patients, respectively. For the 26 mm valves, gradients were also significantly higher in S3V patients (mean PG: 11.6 ± 4.9 vs. 9.2 ± 4.2 [ p  = 0.004]; maximum PG: 23.0 ± 10.1 vs. 17.2 ± 7.4 mm Hg [ p  < 0.001]). Analysis revealed no significant differences in postprocedural transvalvular PGs for 29 mm valves (mean PG of 9.3 ± 3.9 and 11.2 ± 4.3 mm Hg [ p  = ns] and maximum PG of 17.5 ± 7.2 vs. 20.9 ± 6.8 mm Hg [ p  = ns]) between SXTV and S3V groups, respectively. With respect to PVR, the incidence of AR was significantly lower in S3V group ( p  = 0.001)., Conclusion:  S3V shows lower incidence of PVR; however, it is associated with significantly higher postprocedural transvalvular PGs for 23 and 26 mm valve sizes. These data might contribute to the scientific discussion, especially with respect to prosthesis selection in individual patients with small annular dimension., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:: There is still much controversy about whether meteorological conditions influence the occurrence of acute aortic dissection (AAD). The aim of the present study was to investigate the possible correlation between atmospheric pressure, temperature, lunar cycle and the event of aortic dissection in our patient population., Methods:: The clinical data for 348 patients with AAD (73% type Stanford A) were confronted with the meteorological data provided by the Cologne weather station over the same period., Results:: There were no statistically significant differences between meteorological parameters on days of AAD events compared with control days. A logistic regression model showed that air pressure (odds ratio [OR] 1.004, 95% confidence interval [CI] 0.991-1.017, p = 0.542), air temperature (OR 0.978, 95% CI 0.949-1.008, p = 0.145), season ( p = 0.918) and month of the event ( p = 0.175) as well as presence of full moon (OR 1.579, 95% CI 0.763-3.270, p = 0.219) were not able to predict AAD events. Also, no predictive power of meteorological data and season was found on analysing their impact on different types of AAD events., Conclusions:: Our study did not reveal any dependence of atmospheric pressure, air temperature or the presence of full moon on the incidence of different types of AAD.

Background:: Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD., Methods:: From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed., Results:: There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke ( p = 0.034), need for reopening due to bleeding ( p = 0.031) and in-hospital mortality ( p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival ( p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke ( p = 0.023), reopening for bleeding ( p = 0.010) and in-hospital mortality ( p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke ( p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified., Conclusions:: With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.

Objectives: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in older patients and requiring immediate surgical repair. The aim of this study was to evaluate early outcome and short- and long-term survival of patients under and above 65 years of age., Methods: Two hundred and forty patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015 in our center. After statistical analysis and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up, comprising patients under and above 65 years of age., Results: The proportion of patients above 65 years of age suffering from Stanford A AAD was 50% (n=120). The group of patients above 65 years of age compared to the group under 65 years of age showed statistically significant differences in terms of higher odds ratios (OR) for hypertension (p=0.012), peripheral vascular disease (p=0.026) and tachyarrhythmia absoluta (p=0.004). Patients over 65 years of age also showed significantly poorer short- and long-term survival. Our subgroup analysis revealed that male patients (Breslow p=0.001, Log-Rank p=0.001) and patients suffering with hypertension (Breslow p=0.003, Log-Rank p=0.001) were reasonable for these results whereas younger and older female patients showed similar short- and long-term outcome (Breslow p=0.926, Log-Rank p=0.724). After stratifying all patients into 4 age groups (<45; 55-65; 65-75; >75years), short-term survival of the patients appeared to be significantly poorer with increasing age (Breslow p=0.026, Log-Rank p=0.008) whereas long-term survival of patients free from cerebrovascular events (Breslow p=0.0494, Log-Rank p=0.489) remained similar., Conclusions: All patients referred to our hospital for repair of Stanford A AAD with higher age had poorer short- and long-term survival, caused by male patients and patients suffering from hypertension, whereas survival of women and survival free from cerebrovascular events of the entire patient cohort was similar, irrespective of age.

Background: The aim of the present study was to determine whether raised preoperative serum creatinine affected the long-term outcome in patients undergoing surgical aortic repair for Stanford A acute aortic dissection (AAD)., Methods: A total of 240 patients diagnosed with Stanford A AAD underwent surgical repair from January 2006 to April 2015. A propensity score matching was applied, resulting in 73 pairs consisting of one group with normal and one group with preoperative elevated creatinine levels. The cohorts were well balanced for baseline and preoperative clinical characteristics. Both groups were compared regarding their early postoperative variables, as well as estimated survival with up to 9-year follow up. Also, the impact of acute postoperative kidney injury and its severity on long-term survival was analyzed., Results: The proportion of patients suffering Stanford A AAD with raised creatinine levels was 31.3% ( n = 75). After propensity matching, there were no statistically significant differences regarding demographics, comorbidities, preoperative baseline and clinical characteristics. Postoperatively matched patients with elevated creatinine had longer intensive care unit ( p < 0.001) and total hospital stay ( p = 0.002), prolonged intubation times ( p = 0.014), higher need for hemofiltration ( p < 0.001), higher incidence of temporary neurological disorders ( p = 0.16), infection ( p = 0.005), and trend toward higher incidence of sepsis ( p = 0.097). However, there were no significant differences regarding 30-day mortality (20.5% versus 20.5%, p = 1.000) and long-term overall survival. Further, neither the incidence nor the different stages of acute kidney injury according to the Acute Kidney Injury Network showed any statistically significant differences in terms of long-term survival for both groups [log rank p = 0.636, Breslow (generalized Wilcoxon) p = 0.470, Tarone-Ware p = 0.558]., Conclusions: Patients with elevated creatinine levels undergoing surgical repair for Stanford A AAD demonstrate higher rate of early postoperative complications. However, 30-day mortality and long-term survival in this patient cohort is not significantly impaired.

Background: Choice of cardioplegic solution plays a pivotal role in special subgroups of patients referred for on-pump cardiac surgery. This retrospective analysis aimed to assess the impact of intermittent warm (Calafiore, Cala) versus intermittent cold blood cardioplegia (Buckberg, Buck) in patients referred to coronary artery bypass graft (CABG) surgery due to acute coronary syndromes (ACS)., Methods: From 2008 to 2015, all consecutive patients undergoing urgent on-pump CABG surgery due to ACS ( n  = 950) were retrospectively analyzed. Intraoperative cardiac arrest was achieved using Buck ( n  = 273) or Cala ( n  = 677). Patients were compared regarding clinical outcomes and perioperative myocardial injury (PMI). Propensity score matching was performed to control for differences in preoperative patient characteristics., Results: Prevalences of left main stenosis >50%, COPD, and advanced New York Heart Association (NYHA) class were higher for intermittent warm blood cardioplegia (IWC)-patients while more Buck-patients had preoperative intra-aortic balloon pump (IABP) and redo procedures. Buck-patients needed more intraoperative defibrillations and showed longer cardiopulmonary bypass (CPB) and aortic clamping times. 30-day all-cause mortality (10.6 versus 9.3%), major adverse cardiac events (MACE) (52.7 versus 48.6%), and PMI (50.5 versus 55.7%; all p  > 0.05) rates were comparable for Buck- and Cala-patients. Propensity score matching resulted in equal group sizes ( n  = 212 each) and balanced distribution of preoperative covariates. Although more Buck-patients still needed inotropic support >24 hours postoperatively (25.7 versus 14.7%; p  = 0.005) compared with Cala-group, outcome variables of interest did not differ between treatment groups (30-day mortality: 7.5 versus 9.0%; MACE: 49.5 versus 40.6%; PMI: 48.1 versus 37.3%; all p  > 0.05)., Conclusion: Buckberg and Calafiore cardioplegia offer comparable myocardial protection and similar postoperative results in patients undergoing CABG surgery due to ACS., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD., Methods: In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up., Results: The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients., Conclusions: Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Aims: To identify predictors of paravalvular regurgitation (PVR) and permanent pacemaker implantation (PPI) following TAVR with a next-generation self-expanding device., Methods and Results: Device landing zone (DLZ) calcification, angiographic implantation depth, and baseline and procedural characteristics were analyzed in 212 patients being treated with the ACURATE neo aortic bioprosthesis. PVR was none/trace in 57.1% and ≥ mild in 42.9% (37% mild, 6% moderate). DLZ calcification (705 (IQR 240-624) vs. 382 (IQR 240-624) mm 3 ; P < 0.001) as well as absolute calcium asymmetry (233 ± 159 vs. 151 ± 151 mm 3 ; P < 0.001) was significantly higher in patients with PVR ≥ mild. On multivariate analysis, calcification of the aortic valve cusps (AVC) > 410.6 mm 3 was independently associated with PVR ≥ mild. PPI rate was 10.3% (n = 20). Patients with and without need for PPI had similar total DLZ calcium volume (740 (IQR 378-920) vs. 536 (IQR 315-822) mm 3 ; P = 0.263), but exhibited different calcium distribution patterns: LVOT calcium > 41.4 mm 3 in the sector below the left coronary cusp (LVOT LC ) was associated with increased PPI risk (26.9 vs. 7.7%; P = 0.008)., Conclusions: The quantity of AVC calcium predicts residual PVR. Multivariable analysis identified LVOT LC calcium, pre-existing RBBB, and age > 82.7 years as independent predictors of PPI. Based on these risk factors, a patient's individual PPI risk can be stratified ranging from 3.8 to 100%.

The aim of this study was to provide early and mid-term results of the newly established extracorporeal membrane oxygenation (ECMO) retrieval service in a tertiary cardiothoracic center using the miniaturized portable Cardiohelp System (Maquet, Rastatt, Germany). A particular attention was paid to organizational and logistic specifics as well as challenges and pitfalls associated with initial phase of the program. From January 2015 until January 2017 a heterogenic group of 28 consecutive patients underwent ECMO implantation in distant hospitals for acute cardiac, pulmonary or combined failure as a bridge-to-decision and were subsequently transported to our institution. Each cannulation was performed bedside on intensive care units (ICU) using the Seldinger's technique. Early outcomes and mid-term overall survival with up to two-year follow-up along with the impact of ongoing cardiopulmonary resuscitation (CPR) on outcome were presented. Also, changes in hemodynamics and tissue perfusion factors 24 h after ECMO implantation were evaluated. ECMO implantations were performed in 15 distant departments with the median distance of 23(10;40) (maximum 60) km. A total of 15 patients (54%) were cannulated under CPR with the median duration of 30(20;110) (maximum 180) min. After 24 h of support there were significant improvements in SvO 2 (P = 0.021), mean arterial pressure (P = 0.027), FiO 2 (P = 0.001), lactate (P = 0.001), and pH (P < 0.001). The mean ECMO support duration was 96 ± 100 (maximum 384) hours, whereas 11 patients (40%) were weaned off support and discharged from hospital. Overall cumulative survival in patients without the need for CPR was 61.5% at one week and 38.5% at 1 month, 6 month, and 1 year, whereas patients requiring CPR survived in 40% at one week, and 33.3% at 1 month, 6 month, and 1 year (Log-Rank (Mantel-Cox) P = 0.374, Breslow (Generalized Wilcoxon) P = 0.162). Our initial experience shows that launching new ECMO retrieval programs in centers with sufficient ICU capacities and local ECMO experience can be feasible and associated with acceptable "real world" results despite the initial learning curve. Rapid logistical organization and team flexibility are the key points to ensure comparable survival of patients requiring prolonged CPR., (© 2017 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

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.

Objectives: The objective of the current work was to evaluate flow and turbulent kinetic energy in different transcatheter aortic valve implants using highly undersampled time-resolved multi-point 3-directional phase-contrast measurements (4D Flow MRI) in an in vitro setup., Materials and Methods: A pulsatile flow setup was used with a compliant tubing mimicking a stiff left ventricular outflow tract and ascending aorta. Five different implants were measured using a highly undersampled multi-point 4D Flow MRI sequence. Velocities and turbulent kinetic energy values were analysed and compared., Results: Strong variations of turbulent kinetic energy distributions between the valves were observed. Maximum turbulent kinetic energy values ranged from 100 to over 500 J/m 3 while through-plane velocities were similar between all valves., Conclusion: Highly accelerated 4D Flow MRI for the measurement of velocities and turbulent kinetic energy values allowed for the assessment of hemodynamic parameters in five different implant models. The presented setup, measurement protocol and analysis methods provides an efficient approach to compare different valve implants and could aid future novel valve designs.

Background: We investigated the application and feasibility of a novel software tool designed for the visualization of the aortic root during transcatheter aortic valve implantation (TAVI). The final positioning of the device prior deployment remains the most critical phase during TAVI., Methods: Philips "Vascular Outlining" prototype application was used during balloon expandable Edwards Lifesciences SapienXT valve deployment. It processes any angiographic sequences, extracting the static outline of vessels and projecting the two-dimensional vessel margins as a roadmap on live fluoroscopy. Preoperational planning, sizing and anatomical assessment of access routes were performed using computed tomography scans and the Philips "HeartNavigator" software., Results: Fifteen high-risk aortic stenosis patients (mean age 82.0±6.6 years) underwent TAVI via transfemoral (N.=8), transapical (N.=4), and transaortic (N.=3) access routes. Mean logistic EuroSCOREs and STS-scores were 19.7±4.3% and 7.9±3.1%, respectively, mean aortic gradient was 66.3±18.3 mmHg. All valves were implanted successfully with none or trivial paravalvular regurgitation in 11 patients, mild in 3 patients, and moderate in 1 patient. TAVI was performed in all cases with only one aortic root contrast media injection during valve deployment. No major stroke or cardiovascular death occurred within 30 days., Conclusions: "Vascular Outlining"-guided implantation of the SapienXT valve is feasible. This new feature might increase the accuracy of valve placement and also may reduce the need for extra contrast media use during valve deployment. However, the lack of real-time motion compensation limits its wide application, as the overlay does not move together with respiratory and cardiac motion.

Background: The aim of this study was to evaluate the effects of rapid deployment aortic valve replacement (RDAVR) on surgical outcome and hemodynamics compared with standard aortic valve replacement (AVR)., Methods: One hundred sixty-three RDAVR patients (isolated, n = 67; combined with coronary artery bypass graft surgery [CABG], n = 96) were compared with a propensity matched control group (n = 163). Primary endpoints included association between valve type and procedure times, prosthesis size, transvalvular gradient, and indexed effective orifice area. Secondary endpoints were postoperative mortality and morbidity., Results: Aortic cross-clamp and cardiopulmonary bypass times in the RDAVR group were 55 ± 23 and 88 ± 38 minutes, respectively, compared with 77 ± 22 and 105 ± 38 minutes in the control group (p < 0.001). In the subgroup of patients undergoing isolated RDAVR (n = 67 of 163), the aortic cross-clamp and cardiopulmonary bypass times were 38 ± 13 and 66 ± 22 minutes, respectively, compared with 55 ± 14 and 81 ± 18 minutes in the control group (n = 67 of 163; p < 0.001). The RDAVR patients received larger prostheses (23.3 ± 1.8 mm) compared with standard AVR (22.8 ± 1.5 mm; p = 0.002). Mean transvalvular gradients and indexed effective orifice areas were 9 ± 5 mm Hg and 1.11 ± 0.11, respectively, in the RDVAR group compared with 13 ± 5 mm Hg and 0.95 ± 0.08 in the control group (p < 0.001). Hospital mortality was similar in both groups (1.8%, n = 3 of 163; p = 1.000). Postoperative pacemaker rates were 3.5% (n = 3 of 67) for isolated RDAVR versus 3.0% (n = 2 of 67; p = 0.649) for isolated AVR and 12.5% (n = 12 of 96) for RDAVR/CABG versus 4.2% (n = 4 of 96; p = 0.032) for AVR/CABG., Conclusions: RDAVR facilitates reduced aortic cross-clamp and cardiopulmonary bypass times compared with standard AVR, particularly in patients undergoing concomitant procedures, allowing the use of larger prostheses and resulting in lower transvalvular gradients and higher indexed effective orifice area compared with standard AVR. Therefore, RDAVR may help to overcome patient-prosthesis mismatch in some patients., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The progression of heart failure with reduced ejection fraction is promoted by sympathovagal imbalance. Baroreflex activation therapy (BAT) by the electrical stimulation of baroreceptors at the carotid sinus significantly improved exercise capacity and NT-proBNP levels in a randomized trial; however, no significant difference in left ventricular ejection fraction (LV-EF) between groups was found. Here, we report the case of a 30-year-old man with a long history of dilated cardiomyopathy and severely reduced LV-EF despite optimal medical therapy, who was treated with BAT since October 2014 and showed a remarkable improvement in both symptoms and LV-EF under this treatment.

The thoracotomy approach for pericardial window surgery was shown to be more effective at preventing effusion recurrence and the need for repeat surgery. However, cardiac herniation remains a common complication after extensive pericardial excision. This technical note describes a simple and effective technique to prevent potential heart herniation through the pericardial window and at the same time to avoid potential obstruction of the left artery descending., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Surgical aortic valve replacement in patients with small annular dimensions is challenging because they are at increased risk for prosthesis-patient mismatch and impaired outcomes. Transcatheter aortic valve replacement might be a good alternative; however, comparative data on different transcatheter heart valves are missing., Methods and Results: This multicenter, propensity score-matched study compared hemodynamics and early clinical outcomes in 246 patients with an aortic annulus area <400 mm 2 undergoing transcatheter aortic valve replacement with either a self-expanding transcatheter heart valve (Symetis ACURATE neo, n=129) or a balloon-expandable transcatheter heart valve (Edwards SAPIEN 3, n=117). The 1:1 propensity score matching resulted in 92 matched pairs. For ACURATE neo versus SAPIEN 3-treated patients, 30-day mortality (0.0% versus 1.0%), 1-year mortality (8.3% versus 13.3%), incidence of stroke (3.3% versus 2.2%), life-threatening bleeding (1.1% versus 1.1%), and major vascular complications (2.2% versus 6.5%), as well as pacemaker implantation rate (12.0% versus 15.2%), were similar. Paravalvular regurgitation ≥moderate was rare in both groups (4.5% versus 3.6%). The ACURATE neo presented lower mean transvalvular gradients (9.3 versus 14.5 mm Hg; P <0.001), larger indexed effective orifice areas (0.96 versus 0.80 cm 2 /m 2 ; P =0.003), and lower rates of severe prosthesis-patient mismatch (3% versus 22%; P =0.004). Hemodynamics were sustained at 1-year follow-up., Conclusions: Albeit a similar safety profile with low clinical event rates, transcatheter aortic valve replacement with the ACURATE neo valve resulted in lower transvalvular gradients and consequently less prosthesis-patient mismatch compared with the SAPIEN 3 in patients with small annulus. These results emphasize the need of careful prosthesis selection in each individual patient., (© 2017 American Heart Association, Inc.)

Background: The frequency of circulating endothelial cells (CEC) in patients' peripheral blood can be assessed as a direct marker of endothelial damage. However, conventional enumeration methods are extremely challenging. We developed a novel, automated approach to determine CEC frequencies and tested this method on two groups of patients undergoing conventional (CAVR) versus trans-catheter aortic valve implantation (TAVI)., Methods: CEC frequencies were assessed by a flow cytometric approach, including automated pre-enrichment of CD34 positive blood cell subpopulation and isotype controls. The efficacy and reproducibility of the CEC enumeration method was validated by spiking blood samples of healthy control donors with defined numbers of endothelial cells., Results: CEC frequencies were significantly higher in the TAVI group before (9.8 ± 4.1 vs. 5.5 ± 2.2, p = 0.019) and 1 h after surgery (13.4 ± 5.1 vs. 8.2 ± 4.1, p = 0.030) corresponding to higher Euroscore, STS score in higher risk patients from the TAVI group. Five days after surgery, CEC frequencies became significantly higher in the more invasive CAVR group (39.0 ± 13.0 vs. 14.3 ± 4.4, p < 0.001) compared to minimally invasive TAVI approach., Conclusions: The new flow cytometric approach might be a robust and reliable method for CEC enumeration. Initial results show that CEC frequency is a valid clinical marker for the assessment of pre-operative risk, invasiveness of surgical procedure and clinical outcome. Further studies are necessary to validate the practical clinical usefulness and the potential superiority compared to conventional markers.

Cardiac rupture (CR) is one of the most serious and life-threatening complications of blunt chest trauma (BCT) usually associated with high mortality. Moreover, its diagnosis and treatment strategies may be extremely challenging for clinicians due to various anatomical localisations of the tear. Whereas most injuries fall under the category of right atrial ruptures, left ventricular lesions represent a rare type of this injury, with greater mortality, particularly in cases of multi-chamber injuries. However, not only cardiac chamber or great vessel ruptures may occur as a result of BCT; a growing number of reports also describe BCT-induced isolated coronary artery injuries, including ruptures. Whereas CR requires immediate surgical treatment, less invasive interventional techniques, such as stent placement and closure with fibrin glue or coils, can be the treatment of choice in selected cases of hemodynamically less relevant coronary artery ruptures. In this report, we present a rare case of a ventricular rupture following BCT, with the tear localized in the right ventricular wall and an occult connection to the left ventricle without ventricular septum injury. Also, another contemporaneous emergency in our department that had to be managed at the same time resulted in challenging the decision-making process. As such an emergency constellation is difficult to manage, this report may help clinicians in difficult situations in terms of diagnosis and choosing the right treatment strategy.

Objectives: Previous research suggests that female gender is associated with increased mortality rates after surgery for Stanford A acute aortic dissection (AAD). However, women with AAD usually present with different clinical symptoms that may bias outcomes. Moreover, there is a lack of long-term results regarding overall mortality and freedom from major cerebrovascular events. We analysed the impact of gender on long-term outcomes after surgery for Stanford A AAD by comparing genders with similar risk profiles using propensity score matching., Methods: A total of 240 patients operated for Stanford A AAD were included in this study. To control for selection bias and other confounders, propensity score matching was applied to gender groups., Results: After propensity score matching, the gender groups were well balanced in terms of risk profiles. There were no statistically significant differences regarding duration of cardiopulmonary bypass ( P  = 0.165) and duration of aortic cross-clamp time ( P  = 0.111). Female patients received less fresh frozen plasma ( P  = 0.021), had shorter stays in the intensive care unit ( P  = 0.031), lower incidence of temporary neurological dysfunction ( P  < 0.001) and lower incidence of dialysis ( P  = 0.008). There were no significant differences regarding intraoperative mortality ( P  = 1.000), 30-day mortality ( P  = 0.271), long-term overall cumulative survival ( P  = 0.954) and long-term freedom from cerebrovascular events ( P  = 0.235) with up to a 9-year follow-up., Conclusions: Considering patients with similar risk profiles, female gender per se is not associated with worse long-term survival and freedom from stroke after surgical aortic repair. Moreover, female patients might even benefit from a smoother early postoperative course and lower incidence of early postoperative complications., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background  Patients referred to transcatheter aortic valve implantation (TAVI) present with multiple risk factors for intraprocedural complications. Case Description  We describe a TAVI procedure with sudden hemodynamic collapse and cardiopulmonary resuscitation. Therefore, extracorporeal membrane oxygenation cannulas were immediately implanted via vessels of the groin. A Y-connector was inserted into the arterial line of the extracorporeal membrane oxygenator using an additional sheath facilitating to insert a pigtail catheter to guide the further valve implantation. Conclusion  This case report provides an option to insert a pigtail catheter after implantation of extracorporeal membrane oxygenator cannulas without need for additional vascular access.

Objectives: The aim of this study was to identify predictors of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter valve (Edwards SAPIEN 3)., Background: New-onset conduction disturbances requiring PPMI remain a major concern following TAVR. Predictors are not yet well defined., Methods: The influence of angiographic implantation depth, device landing zone calcium volume, oversizing, pre- and post-dilation, and baseline conduction disturbances on PPMI rate was analyzed in 229 patients undergoing TAVR with the SAPIEN 3 device., Results: PPMI was performed in 14.4% of patients. Patients requiring PPMI had higher left ventricular outflow tract (LVOT) calcium volume in the area below the left coronary cusp (LVOT LC ) and the area below right coronary cusp (LVOT RC ) (LVOT LC median calcium 23.7 mm 3 vs. 3.0 mm 3 ; p < 0.001; LVOT RC median calcium 6.6 mm 3 vs. 0.3 mm 3 ; p = 0.014), a higher prevalence of pre-existing right bundle branch block (15% vs. 2%, p = 0.004), and lower implantation depth (ventricular portion of the stent frame 29 ± 12% vs. 21 ± 5%; p < 0.001). On multivariate regression analysis, LVOT LC calcium volume >13.7 mm 3 , LVOT RC calcium volume >4.8 mm 3 , pre-existing right bundle branch block, and implantation depth >25.5% emerged as independent predictors of PPMI. Upon modification of the implantation technique, aiming at a high final valve position, implantation depth decreased from 24% ventricular portion to 21% (p = 0.012), accompanied by a decrease in PPMI rate (19.2% vs. 9.2%; p = 0.038)., Conclusions: LVOT LC and LVOT RC calcium load, baseline right bundle branch block, and implantation depth were identified as independent predictors of the need for PPMI post-TAVR. Patient groups with different PPMI risk could be stratified using these 4 predictors. A slightly higher valve implantation site may prevent excessive PPMI rates., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The choice of an optimal cannulation site for aortic repair in patients with Stanford A acute aortic dissection remains controversial. The aim of this study was to compare the early results and long-term outcomes of axillar and direct aortic cannulation., Methods: A total of 235 consecutive patients who underwent surgical aortic repair with the use of axillar or direct aortic cannulation from January 2006 to April 2015 were analyzed. The primary end points were long-term overall cumulative survival and freedom from major cerebrovascular events with up to 10 years of follow-up. The secondary end points were early postoperative clinical characteristics and rates of adverse events. To control for confounders, a 1:3 propensity score matching was performed., Results: After matching, there were no statistically significant differences between the two groups regarding baseline characteristics. Both groups were associated with comparable outcomes; among other things, the length of stay in the intensive care unit (ICU) (p = 0.220), mechanical ventilation (p = 0.177), total hospital stay (p = 0.243), and hospital rates of adverse events. There were no statistically significant differences (p = 0.625) in terms of freedom from major cerebrovascular events. However, both early (p = 0.009) and late (p = 0.016) overall survival were significantly poorer for patients undergoing aortic cannulation., Conclusions: The outcomes were comparable regarding early hospital outcomes and rates of adverse events. Whereas postoperative freedom from major cerebrovascular events was similar, survival over long-term follow-up was significantly poorer when direct aortic cannulation was used. More investigations are needed to enable an understanding of the underlying factors for potentially higher late mortality when direct aortic cannulation is used during a surgical procedure for acute Stanford A dissection., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The purpose of this publication is to describe the intraoperative experience along with long-term safety and efficacy of the second-generation baroreflex activation therapy (BAT) system in patients with heart failure (HF) and reduced ejection fraction HF (HFrEF). In a randomized trial of New York Heart Association Class III HFrEF, 140 patients were assigned 1:1 to receive BAT plus medical therapy or medical therapy alone. Procedural information along with safety and efficacy data were collected and analyzed over 12 months. Within the cohort of 71 patients randomized to BAT, implant procedure time decreased with experience, from 106 ± 37 minutes on the first case to 83 ± 32 minutes on the third case. The rate of freedom from system- and procedure-related complications was 86% through 12 months, with the percentage of days alive without a complication related to system, procedure, or underlying cardiovascular condition identical to the control group. The complications that did occur were generally mild and short-lived. Overall, 12 months therapeutic benefit from BAT was consistent with previously reported efficacy through 6 months: there was a significant and sustained beneficial treatment effect on New York Heart Association functional Class, quality of life, 6-minute hall walk distance, plasma N-terminal pro-brain natriuretic peptide, and systolic blood pressure. This was true for the full trial cohort and a predefined subset not receiving cardiac resynchronization therapy. There is a rapid learning curve for the specialized procedures entailed in a BAT system implant. BAT system implantation is safe with the therapeutic benefits of BAT in patients with HFrEF being substantial and maintained for at least 1 year., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Progression of heart failure with reduced ejection fraction (HFrEF) is promoted by sympathovagal imbalance. Baroreflex activation therapy, i.e., electrical stimulation of baroreceptors at the carotid sinus, can restore sympathovagal balance. Large animal studies of baroreflex activation therapy revealed improvements in cardiac function, susceptibility to ventricular arrhythmias, and a survival benefit as compared to untreated controls. Recently, the first randomized and controlled trial of optimal medical and device therapy alone or plus baroreflex activation therapy in patients suffering from HFrEF was published. It demonstrated a reasonable safety profile in this severely ill patient population. Moreover, the study found significant improvements in New York Heart Association class, quality of life, 6-min walk distance, and NT-proBNP levels. This review provides an overview on baroreflex activation therapy for the treatment of HFrEF-from the concept and preclinical findings to most recent clinical data and upcoming trials.

Background: In patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents., Case Presentation: We report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique., Conclusions: The transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon.

Objectives: We have previously demonstrated the impact of univentricular pacing modalities on bypass graft flow (BGF) in the coronary artery bypass graft (CABG) patient with permanent atrial fibrillation (AF). The aim of the present study was to determine the mechanism of this improved coronary conduit and, in addition, to explore the possible benefits with biventricular pacing in patients with and without severe left ventricular dysfunction., Methods: In 43 CABG patients [mean age 69.5 ± 1.3 years; ejection fraction (EF) 49 ± 2%] with AF, we analysed coronary vascular resistances (CVRs) and the contemporary changes in the BGF obtained during right ventricular outflow tract (RVOT), right- (RV), left- (LV) and right-left ventricular pacing (biventricular pacing, BiVP) using the ultrasonic transit-time methodology., Results: BiVP resulted in the highest percentage decrease of CVR in the overall study group by 17.5 ± 3.0% (P < 0.001), followed by RVOT pacing with 13.9 ± 3.9%. Accordingly, the highest mean BGF was achieved during BiVP, resulting in a 21.6 ± 2.6% increase when compared with no pacing and 16 ± 3.7% when compared with RV pacing. Analysis of patients according to their preoperative LV function (EF ≥50%, n = 26; EF <50%, n = 17) showed significantly lower CVR (P < 0.037) and higher BGF during BiVP in patients with lower EF., Conclusions: Placement of an additional LV pacing wire offered a significant improvement in BGF by minimizing CVR in patients with AF and poor EF., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Perioperative complications in patients undergoing transcatheter aortic valve implantation remain a major issue affecting outcome. Because preoperative risk adjustment remains challenging and a valid scoring system is missing, we sought to determine the incidence of peri- and postprocedural complications of transapical (TA) or transaortic (TAO) access to define the influence of specific complications on early safety, 30-day mortality, and 1-year survival. Furthermore, we aimed to develop a risk-stratification model to allow an estimation of the perioperative risk and the 1-year survival rate, based on the individual preoperative condition of each patient., Methods: We performed an outcome analysis of 230 consecutive patients who underwent aortic valve implantation via transapical or transaortic access between 2008 and 2012, with regard to Valve Academic Research Consortium II criteria, including univariate and multivariable regression analysis, to develop a risk-stratification model., Results: Thirty-day mortality was 12.7%. Estimated 1-year survival was 0.69 (95% confidence interval [CI], 0.631-0.757), and 3-year survival was 0.554 (95% CI, 0.474-0.634). Univariate logistic regression analysis revealed a significant influence on 30-day mortality in case of life-threatening bleeding (16.1-fold), abdominal complications (8.5-fold), and acute kidney injury (3.2-fold). Pacemaker implantation (odds ratio, 1.55; 95% CI, 0.42-5.81; P = .512) was not a significant predictor. Concerning use of intraprocedural hemodynamic bridging therapy via cardiopulmonary bypass (CPB), Cox regression analysis revealed no significant survival difference after 1 year. A preoperative risk-stratification model for 1-year survival revealed that a logistic European System for Cardiac Operative Risk Evaluation score >20%, preoperative existing coronary artery disease, and prior myocardial infarction appeared to be significant predictors for diminished survival., Conclusions: Concerning intraprocedural complications, CPB support for hemodynamic stabilization is a safe treatment option. Therefore, the heart team approach with CPB standby represents a life-saving option. Attention should also be drawn to specialized and individual postoperative care, because nonprocedure-specific complications clearly affect postoperative short- and long-term outcome. In addition, the risk-stratification model might facilitate preoperative decision making., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Baroreflex activation therapy (BAT) by electrical stimulation of baroreceptors at the carotid sinus is a promising therapeutic approach to reduce elevated blood pressure (BP). To assess the efficacy of long-term BAT, we investigated acute BP alterations after device deactivation and reactivation (on/off effects) in patients on chronic BAT, as well as chronic BP reductions., Method: Resistant hypertension patients (n = 17) were enrolled in an open-label, single-arm evaluation of unilateral BAT after exclusion of secondary hypertension. Initial eligibility criteria were SBP≥  140 mmHg, despite stable medical therapy with at least three antihypertensive drugs including at least one diuretic. For on/off testing, several office cuff BP measurements were performed: at rest with activated device, 4-6 min after deactivation, and 4-6 min after reactivation., Results: Before BAT, mean office cuff BP was 179 ± 25 over 98 ± 18 mmHg. At the time of on/off testing (15.1 ± 8.7 months after initial activation and before deactivation), BP was reduced to 147 ± 29 over 84 ± 20 mmHg. On deactivation, SBP increased to 158 ± 38 mmHg (P = 0.004) and DBP to 89 ± 23 mmHg (P = 0.04). After reactivation, SBP decreased to 144 ± 34 mmHg (P = 0.002 vs. deactivation) and DBP to 83 ± 23 mmHg (P = 0.009). There was no correlation between duration of chronic BAT and systolic or diastolic acute on/off response., Conclusion: Unilateral BAT reduces BP in patients with resistant hypertension in the long term. There is a significant on/off effect on BP, supporting the efficacy of BAT. The acute on/off response to BAT does not depend on treatment duration. Thus, no evidence of tolerance over time to chronic BAT was found.

Objectives: Antifibrinolytics are widely used in cardiac surgery to save blood perioperatively. In the present study we evaluated the hemostatic effects of tranexamic acid (TXA) to decrease bleeding tendency and transfusion requirements in high-risk patients following transapical aortic valve implantation (TA-AVI)., Methods: A retrospective analysis was performed on aortic stenosis patients undergoing TA-AVI with or without intraoperative TXA administration to determine postoperative blood loss and transfusion requirements. From January 2009 to August 2010 in total 92 patients were treated without intraoperative TXA administration, from August 2010 to July 2011 54 patients received TXA intraoperatively., Results: Early postoperative (24 h) blood loss was significantly lower in TXA-group than in non-TXA group (327 ± 274 mL vs. 481.1 ± 318.8 mL; p = 0.003). In the TXA group 53.7% of patients received allogeneic blood products during the hospital stay as compared to 72.8% in the non-TXA group (p = 0.242). TXA group required fewer transfusions (2.1 ± 1.9 vs. 2.9 ± 3.5 Units; p = 0.046) and had no increased incidence of thrombotic or neurological complications. There was no significant difference in the length of ICU, hospital stay, or 30-day mortality. Administration of tranexamic acid was found to be significantly associated with lower blood loss postoperatively (p = 0.002). Furthermore, there was a significant correlation between the postoperative blood loss (p = 0.036) and red blood cell transfusion (p = 0.001) with 30-day mortality., Conclusion: Low dose prophylactic intraoperative administration of tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products following TA-AVI.

Objective: Skeletal myoblasts fuse to form functional syncytial myotubes as an integral part of the skeletal muscle. During this differentiation process, expression of proteins for mechanical and electrical integration is seized, which is a major drawback for the application of skeletal myoblasts in cardiac regenerative cell therapy, because global heart function depends on intercellular communication., Methods: Mechanically preconditioned engineered tissue constructs containing neonatal mouse skeletal myoblasts were transplanted epicardially. A Y-chromosomal specific polymerase chain reaction (PCR) was undertaken up to 10 weeks after transplantation to confirm the presence of grafted cells. Histologic and electrophysiologic analyses were carried out 1 week after transplantation., Results: Cells within the grafted construct expressed connexin 43 at the interface to the host myocardium, indicating electrical coupling, confirmed by sharp electrode recordings. Analyses of the maximum stimulation frequency (5.65 ± 0.37 Hz), conduction velocity (0.087 ± 0.011 m/s) and sensitivity for pharmacologic conduction block (0.736 ± 0.080 mM 1-heptanol) revealed effective electrophysiologic coupling between graft and host cells, although significantly less robust than in native myocardial tissue (maximum stimulation frequency, 11.616 ± 0.238 Hz, P < .001; conduction velocity, 0.300 ± 0.057 m/s, P < .01; conduction block, 1.983 ± 0.077 mM 1-heptanol, P < .001)., Conclusions: Although untreated skeletal myoblasts cannot couple to cardiomyocytes, we confirm that mechanical preconditioning enables transplanted skeletal myoblasts to functionally interact with cardiomyocytes in vivo and, thus, reinvigorate the concept of skeletal myoblast-based cardiac cell therapy., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Sympathovagal imbalance plays a major role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT) by electrical stimulation of baroreceptors located at the carotid sinus can reduce sympathetic and increase parasympathetic tone. This review provides an overview on the concept of BAT in heart failure with reduced ejection fraction and available preclinical and clinical data. Animal studies of BAT in heart failure with reduced ejection fraction have demonstrated a decline in plasma norepinephrine, an improved left ventricular ejection fraction, a reduced susceptibility to induced ventricular arrhythmias and a survival benefit. First clinical data from uncontrolled studies suggest a relevant improvement in muscle sympathetic nerve activity, ejection fraction, 6-min walk distance, New York Heart Association (NYHA) class and hospitalization rate. BAT appears to be safe in this severely ill patient population.

Objective: Cardiac reoperations have been associated with increased morbidity and mortality compared with first-time surgery. We analyzed our experience with reoperative aortic valve replacement (redo-AVR) and compared these results with those from patients who had undergone transapical aortic valve implantation (TA-AVI) as a second heart operation., Methods: In the present retrospective observational comparative study, we analyzed the outcome of 136 patients with previous cardiac surgery who had undergone conventional redo-AVR (n = 59; since 2006) or TA-AVI (n = 77; since 2008) with respect to the 30-day outcomes (Valve Academic Research Consortium criteria), 1- and 3-year survival, and the risk factors for both approaches after previous heart surgery., Results: Neither group differed significantly in their risk profile, leading to similar Society of Thoracic Surgeon score and EuroSCORE. The 30-day mortality was 3.39% (n = 2) in the redo-AVR group and 7.8% (n = 6) in the redo TA-AVI group (P = .465). The overall combined safety endpoint at 30 days was significantly lower for the TA-AVI patients (18.1% vs 33.9% in redo-AVR; P = .036). The unadjusted and adjusted 1-year survival showed no difference between the 2 groups. The unadjusted 3-year survival revealed a 2.1-fold greater mortality risk after TA-AVI (P = .055). Adjustment by multivariate Cox regression analysis (hazard ratio, 1.427; 95% confidence interval, 0.635-3.209; P = .389) and propensity score (hazard ratio, 1.571; 95% confidence interval, 0.575-4.291; P = .378) led to a >50% risk reduction, resulting in similar 3-year survival in the 2 groups., Conclusions: Redo-AVR can be performed with acceptable results in high-risk patients and still serves as the reference standard. Reoperative valve surgery by TA-AVI is feasible and results in comparable short- and mid-term survival., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: This review was performed to pool the current surgical strategies for cardiac liposarcoma., Methods: A literature search was performed and all studies published in full-text or abstract forms were eligible for inclusion without applying any language restrictions. Case reports without surgical intervention, reporting noncardiac liposarcoma, animal cases, or review articles were excluded after initial abstract review. Analyzed postoperative outcomes included intraoperative and in-hospital mortality, longest reported survival, and recrudescence., Results: After a critical evaluation 53 unique surgically treated case reports published between the years 1966 and December 2012 were included in this review. Most of the reported cardiac liposarcoma are myxoid (49.1%), pleomorphic liposarcoma occur with a prevalence of 20.8%, and well-differentiated tumors are observed in 13.2%. One-year survival rate increases the more differentiated the tumor is categorized: 54.5% for pleomorphic, 65.4% for myxoid, and 100% for well-differentiated liposarcoma (p = 0.096)., Conclusion: Total surgical resection of cardiac liposarcoma is the only curative option, as it tends to local and distant recurrence. Therefore, a frequent follow-up examination should be considered., (Georg Thieme Verlag KG Stuttgart · New York.)

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., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

The use of non-heart-beating donor (NHBD) lungs may help to overcome the shortage of lung grafts in clinical lung transplantation, but warm ischaemia and ischaemia/reperfusion injury (I/R injury) resulting in primary graft dysfunction represent a considerable threat. Thus, better strategies for optimized preservation of lung grafts are urgently needed. Surfactant dysfunction has been shown to contribute to I/R injury, and surfactant replacement therapy is effective in enhancing lung function and structural integrity in related rat models. In the present study we hypothesize that surfactant replacement therapy reduces oedema formation in a pig model of NHBD lung transplantation. Oedema formation was quantified with (SF) and without (non-SF) surfactant replacement therapy in interstitial and alveolar compartments by means of design-based stereology in NHBD lungs 7 h after cardiac arrest, reperfusion and transplantation. A sham-operated group served as control. In both NHBD groups, nearly all animals died within the first hours after transplantation due to right heart failure. Both SF and non-SF developed an interstitial oedema of similar degree, as shown by an increase in septal wall volume and arithmetic mean thickness as well as an increase in the volume of peribron-chovascular connective tissue. Regarding intra-alveolar oedema, no statistically significant difference could be found between SF and non-SF. In conclusion, surfactant replacement therapy cannot prevent poor outcome after prolonged warm ischaemia of 7 h in this model. While the beneficial effects of surfactant replacement therapy have been observed in several experimental and clinical studies related to heart-beating donor lungs and cold ischaemia, it is unlikely that surfactant replacement therapy will overcome the shortage of organs in the context of prolonged warm ischaemia, for example, 7 h. Moreover, our data demonstrate that right heart function and dysfunctions of the pulmonary vascular bed are limiting factors that need to be addressed in NHBD., (© 2014 Anatomical Society.)

Objective: Contrast-induced nephropathy (CIN) is the third most common cause of acute renal failure and is associated with increased morbidity and in-hospital mortality. Some recent studies identified female sex as a risk factor of CIN. The aim of this study was to determine the relative impact of female sex on the development and clinical outcome of CIN in patients with preexisting renal impairment after transapical transcatheter aortic valve implantation (TAVI)., Methods: From February 2008 to February 2011, a total of 55 TAVI patients [82.4 (6.5) years] with preprocedural serum creatinine level of greater than 1.1 mg/dL were retrospectively investigated. The incidence of postprocedural CIN, lengths of intensive care unit and hospital stay, and short-term mortality among men and women were compared. Contrast-induced nephropathy was defined as a creatinine increase of greater than 0.5 mg/dL or greater than 25% from baseline within 3 days after contrast medium (CM) exposure., Results: The women had significantly lower body surface area [1.8 (0.18) vs 1.95 (0.17) m2; P = 0.002), lower hemoglobin levels [11.5 (1.3) vs 12.7 (1.6) g/dL, P < 0.001], and lower estimated glomerular filtration rate [34.2 (9.7) vs 49.4 (12.3) mL/min per 1.73 m2, P = 0.002]. The amount of CM given was significantly higher in the women relative to body surface area [67.3 (42.5) vs 48.3 (16.6) mL/m2, P = 0.043]. The women received a higher number of blood cell transfusion units [4.4 (3.4) vs 2.1 (2.7) U, P = 0.006]. The frequency of CIN within 72 hours after CM exposure was significantly higher in the women (62.1% vs 26.9%, P = 0.009). A total of 31% of the women (n = 9) versus 7.7% of the men (n = 2) needed hemodialysis (P = 0.031). Analysis of the postoperative morbidity in terms of length of intensive care unit and hospital stay revealed no significant difference between the two groups. Mortality results reached a significant difference at 60 days, with 31% (n = 9) mortality in the women compared with 7.7% (n = 2) in the men (P = 0.031)., Conclusions: Women with preexisting renal impairment are at higher risk than men for CIN, with resultant higher early mortality after transapical TAVI.

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., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Non-heart-beating donor (NHBD) utilization can significantly increase the limited donor lung pool. However, optimal preservation of organ function is crucial as the development of ischemia/reperfusion injury (IRI) can result in severe surfactant inactivation. Exogenic surfactant application is effective in prevention and therapy of IRI. Studies on optimal timing of Curosurf, including application in NHBDs, have not been done, but could help to optimize NHBD lung transplantation., Methods: The extracorporeal screening model (ESM) included rat lungs (Sprague-Dawley, n = 5/group) preserved with Perfadex. In 3 test groups, Curosurf was administered before flush preservation (T1), after 4-hour ischemia (T2) or during reperfusion (T3). Results after extracorporeal reperfusion were compared with controls. The transplantation model (TM) consisted of asystolic pigs (n = 5/group) ventilated for 7 hours with warm ischemia (WIT, Groups 1 and 2). In Group 2, 100 mg/kg BW Curosurf was bronchoscopically administered before preservation. After 3-hour cold storage, left lung transplantation was performed and data were compared with sham control data (Group 3)., Results: For the ESM, T1 lung oxygenation (SurfT1 167±47.4 mm Hg) was superior to others (SurfT2 47.3±15.3 mm Hg, SurfT3 77.2±48.8 mm Hg, controls 65.5±46.2 mm Hg; p<0.02). Stereology demonstrated poorer intra-alveolar edema formation in controls (1.86±2.53% of parenchyma) compared with surfactant-treated lungs (<0.02% of parenchyma) (p<0.02). Intra-alveolar erythrocyte sequestration as an indicator of vascular leakage was significantly lower in T1 lungs (0.15±0.12% of parenchyma) compared with all other groups (>0.74% of parenchyma). For TM, mortality was 80% in the untreated group and 100% in the Curosurf group, suggesting that a 7-hour WIT is above the limit for NHBD utilization., Conclusions: Donor lung pre-treatment with endobronchial pre-preservation Curosurf offers optimal preservation quality when compared with post-ischemic application or during reperfusion and results in improved functional outcome when compared with controls. Expensive NHBD pre-treatment with Curosurf cannot improve poor allograft outcome after extended WIT and should therefore not be considered. Seven-hour WIT seems generally to be above the limits for use in NHBD lung donors., (Copyright © 2013 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background/purpose: Recent evidence suggests that statin-mediated cardioprotection after chronic statin therapy decreases over time and can be reactivated by preprocedural high-dose statin reloading therapy. We tested in a porcine cardiopulmonary bypass (CPB) model whether statin-related cardioprotection is further enhanced by a preoperative rosuvastatin reloading therapy., Methods: Control (n = 6), rosuvastatin-pretreated (n = 6; 20 mg/day for 7 days p.o.) and rosuvastatin-reloaded (n = 6; p.o. treatment plus 0.10 mg/kg/h i.v. during surgery) pigs (Deutsche Landrasse) were subjected to CPB for 2 h with 1 h of cardioplegic cardiac arrest. Systemic hemodynamics, cardiac index (CI), coronary blood flow (CBF) and left ventricular (LV) function [pressure-volume area (PVA), preload recruitable stroke work (PRSW)] were determined before and 4 h after CPB. Myocardial expression (PCR) and protein content (Western blot) of endothelial NO synthase (eNOS) and phosphatase and tensin homolog deleted on chromosome ten (PTEN) were measured, and right coronary relaxation was assessed postmortem. All data are given as mean ± SD., Results: Preoperative plasma LDL, HDL and cholesterol did not differ between treatment groups. Compared to control, oral treatment improved post-CPB CI, CBF, first derivative of maximal LV-pressure (LVdp/dt) and PVA (p < 0.05). Significant enhancement was achieved with perioperative reloading therapy (CI: 5.2 ± 1.0 vs. 3.9 ± 1.5 l/min/m(2); CBF: 76 ± 32 vs. 43 ± 8 ml/min; LVdp/dt: 1,980 ± 333 vs. 1,249 ± 461 mm Hg/s; PVA: 6,954 ± 941 vs. 3,252 ± 1,822 mm Hg·ml; p < 0.05) with improved in vitro NO-dependent coronary relaxation (102 ± 10 vs. 79 ± 14%; p = 0.003). Irrespective of recapture therapy statin pretreatment augmented myocardial eNOS and PTEN (p < 0.05), but failed to increase cardiac eNOS or PTEN expression after CPB., Conclusions: Periprocedural statin reloading therapy enhances myocardial and coronary function after cardiac surgery with CPB and may therefore provide a valuable therapeutic approach for the reduction of myocardial ischemia-reperfusion injury., (Copyright © 2013 S. Karger AG, Basel.)

A technique is described by which an effective stabilisation of the apical introducer sheath is achieved by a pneumatic holding arm, during transapical aortic valve implantation procedure.