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Objectives: Bridging from a temporary microaxial left ventricular assist device (tLVAD) to a durable left ventricular assist device (dLVAD) is playing an increasing role in the treatment of terminally ill patients with heart failure. Scant data exist about the best implant strategy. The goal of this study was to analyse differences in the dLVAD implant technique and effects on patient outcomes., Methods: Data from 341 patients (19 European centres) who underwent a bridge-to-bridge implant from tLVAD to dLVAD between January 2017 and October 2022 were retrospectively analysed. The outcomes of the different implant techniques with the patient on cardiopulmonary bypass, extracorporeal life support or tLVAD were compared., Results: A durable LVAD implant was performed employing cardiopulmonary bypass in 70% of cases (n = 238, group 1), extracorporeal life support in 11% (n = 38, group 2) and tLVAD in 19% (n = 65, group 3). Baseline characteristics showed no significant differences in age (P = 0.140), body mass index (P = 0.388), creatinine level (P = 0.659), the Model for End-Stage Liver Disease (MELD) score (P = 0.190) and rate of dialysis (P = 0.110). Group 3 had significantly fewer patients with preoperatively invasive ventilation and cardiopulmonary resuscitation before the tLVAD was implanted (P = 0.009 and P < 0.001 respectively). Concomitant procedures were performed more often in groups 1 and 2 compared to group 3 (24%, 37% and 5%, respectively, P < 0.001). The 30-day mortality data showed significantly better survival after an inverse probability of treatment weighting in group 3, but the 1-year mortality showed no significant differences among the groups (P = 0.012 and 0.581, respectively). Postoperative complications like the rate of right ventricular assist device (RVAD) implants or re-thoracotomy due to bleeding, postoperative respiratory failure and renal replacement therapy showed no significant differences among the groups. Freedom from the first adverse event like stroke, driveline infection or pump thrombosis during follow-up was not significantly different among the groups. Postoperative blood transfusions within 24 h were significantly higher in groups 1 and 2 compared to surgery on tLVAD support (P < 0.001 and P = 0.003, respectively)., Conclusions: In our analysis, the transition from tLVAD to dLVAD without further circulatory support did not show a difference in postoperative long-term survival, but a better 30-day survival was reported. The implant using only tLVAD showed a reduction in postoperative transfusion rates, without increasing the risk of postoperative stroke or pump thrombosis. In this small cohort study, our data support the hypothesis that a dLVAD implant on a tLVAD is a safe and feasible technique in selected patients., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled., Methods: Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied., Results: Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality., Conclusions: Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication., (© 2024 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Aortic regurgitation (AR) is a known complication after left ventricular assist device (LVAD) implantation potentially leading to recurrent heart failure. Possible pathomechanisms include valvular pathologies and aortic root dilatation. We assessed aortic root dimensions in a group of consecutive LVAD patients who received HeartMate 3., Methods: Since 11/2015, we identified 68 patients with no or mild AR at the time of HeartMate 3 implantation who underwent serial echocardiography to assess AR and aortic root dimensions (annulus, sinus, and sinotubular junction). Median follow-up was 40 months (2-94 months). Results were correlated with clinical outcomes., Results: Patients were 60 ± 10 years old, predominantly male (88%) and 35% presented in preoperative critical condition as defined by INTERMACS levels 1 and 2. During follow-up, 23 patients developed AR ≥ II (34%). Actuarial incidence was 8% at 1 year, 29% at 3 years and 41% at 5 years. Echocardiography revealed practically stable root dimensions at the latest follow-up compared to the preoperative state (annulus: 23 ± 3 mm vs. 23 ± 2 mm, sinus: 32 ± 4 mm vs. 33 ± 3 mm, sinotubular junction: 27 ± 3 mm vs. 28 ± 3 mm), irrespective of the development of AR. Serial CT angiograms were performed in 13 patients to confirm echocardiographic findings. Twenty-one patients died during LVAD support leading to a 5-year survival of 71%, showing no difference between patients with and without AR ≥ II (p = 0.573)., Conclusions: At least moderate AR develops over time in a substantial fraction of patients (one-third over 3 years). The mechanism does not seem to be related to dilatation of the aortic annulus or root., (© 2024 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Circulatory support with a catheter-based microaxial flow pump (mAFP) plays a major role in the treatment of severe cardiogenic shock. In most patients who fail to recover while on temporary mechanical circulatory support (tMCS) and who are not eligible for heart transplantation, durable left ventricular assist device (dLVAD) implantation is usually considered a reliable option. This study aimed to describe the outcome of dLVAD therapy following mAFP support and to identify predictors of mortality., Methods: This was a retrospective analysis of data from a multicenter registry on patients who underwent dLVAD implantation following tMCS with a mAFP between January 2017 and October 2022 (n = 332) from 19 European centers., Results: Patients were supported with an Impella 5.5 (n = 92), 5.0 (n = 153) or CP (n = 87) and were transitioned to a HeartWare HVAD (n = 128) or Heartmate 3 (n = 204) during the same period. One hundred and twenty-five patients (39.2%) also required extracorporeal life support before and/or during mAFP therapy. The 30-day and 1-year survival were 87.8% and 71.1%, respectively. The following risk factors for 1-year mortality were identified: age (odds ratio [OR], 1.02), specifically age over 55 years (OR, 1.09), body mass index >30 kg/m 2 (OR, 2.2), female sex (OR for male sex, 0.43), elevated total bilirubin (OR, 1.12), and low platelet count (OR, 0.996)., Conclusions: Based on the identified risk factors, a risk score for estimating 1-year mortality was calculated to optimize patient selection for dLVAD implantation., Competing Interests: M.O. is a member of the advisory board for A biomed. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days-0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2-4 points) in 19 and low (0-2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF.

Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MI). However, CABG benefits are unclear in octogenarians, where surgical risk is often perceived as higher and PCI is chosen more liberally. We performed a meta-analysis of studies comparing outcomes in octogenarians with left main or multivessel disease who underwent CABG or PCI. Primary outcome was late mortality (> 5 years). Secondary outcomes were perioperative mortality, MI, re-revascularization (R-R), acute renal failure (ARF), and stroke. Fourteen studies with 17,942 patients were included. CABG was associated with lower late mortality (hazard ratio, HR: 1.23, 95% confidence interval: CI 1.05-1.44, p < 0.01). In the pooled Kaplan-Meier analysis CABG showed significantly lower risk of death in the follow-up compared to PCI (HR: 1.08, 95%CI 1.02-1.41, p = 0.005). Landmark analyses confirmed the survival advantage of CABG over PCI after 21.5 months of follow-up (HR: 1.31, 1.19-1.44, p < 0.0001), but suggested advantage of PCI over CABG in the first 30-days (HR: 0.72, 0.64-0.82, p < 0.0001) and comparable survival from 1 to 21.5 months (HR: 0.98, 0.92-1.05, p = 0.652). We found lower risk for MI and R-R after CABG but higher perioperative mortality and no differences in ARF and stroke. CABG appears superior to PCI over time in octogenarians with complex CAD. This survival advantage is associated with fewer events of MI and R-R; however, it comes with an increased risk in perioperative mortality., (© 2023. The Author(s).)

Background: Making the right decision in stressful situations is required for goal-oriented action in cardiac surgery. Current labor laws prevent residents to be subjected to situations that test their stress tolerance. These situations often occur only later in the career. We simulated such conditions in a structured non-stop 36-hour cardiac surgical training course and assessed the participant's performance., Methods: Fourteen advanced residents/junior staff surgeons were selected. The course was conducted in collaboration with the national antiterror police forces that provided coaching for teamplay, leadership, and responsibility awareness. The candidates attended graded and evaluated workshops/lectures and performed academic and surgical tasks. Psychological and surgical skill assessments were conducted at times 0, 12, 24, 36 hours., Results: Progressive reductions in individual motivation, associated with increased stress and irritability levels, worsening mood, and fatigue were observed. Long- and short-term memory functions were unaffected and practical surgical performance even increased over time., Conclusion: Among the candidates, 36 hours of sleep deprivation did not lead to relevant changes in the skills required from a cardiac surgeon in daily life. Importantly, group dynamics substantially improved during the course, suggesting advances in the perception of responsibility and teamwork., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Isolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population., Methods: We calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes., Results: Patients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality., Conclusions: For isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to examine the incidence and predictors of stroke after minimally invasive mitral valve surgery (mini-MVS) and to assess the role of preoperative CT scan on surgical management and neurological outcomes in the large cohort of Mini-Mitral International Registry., Methods: Clinical, operative and in-hospital outcomes in patients undergoing mini-MVS between 2015 and 2021 were collected. Univariable and multivariable analyses were used to identify predictors of stroke. Finally, the impact of preoperative CT scan on surgical management and neurological outcomes was assessed., Results: Data from 7343 patients were collected. The incidence of stroke was 1.3% (n = 95/7343). Stroke was associated with higher in-hospital mortality (11.6% vs 1.5%, P < 0.001) and longer intubation time, ICU and hospital stay (median 26 vs 7 h, 120 vs 24 h and 14 vs 8 days, respectively). On multivariable analysis, age (odds ratio 1.039, 95% confidence interval 1.019-1.060, P < 0.001) and mitral valve replacement (odds ratio 2.167, 95% confidence interval 1.401-3.354, P < 0.001) emerged as independent predictors of stroke. Preoperative CT scan was made in 31.1% of cases. These patients had a higher risk profile and EuroSCORE II (median 1.58 vs 1.1, P < 0.001). CT scan influenced the choice of cannulation site, being ascending aorta (18.5% vs 0.5%, P < 0.001) more frequent in the CT group and femoral artery more frequent in the no CT group (97.8% vs 79.7%, P < 0.001). No difference was found in the incidence of postoperative stroke (CT group 1.5, no CT group 1.4%, P = 0.7)., Conclusions: Mini-MVS is associated with a low incidence of stroke, but when it occurs it has an ominous impact on mortality. Preoperative CT scan affected surgical cannulation strategy but did not led to improved neurological outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

PubMed displayed almost 37,000 hits for the search term "cardiac surgery AND 2022." As before, we used the PRISMA approach and selected relevant publications for a results-oriented summary. We focused on coronary and conventional valve surgery, their overlap with interventional alternatives, and briefly assessed surgery for aorta or terminal heart failure. In the field of coronary artery disease (CAD), key manuscripts addressed prognostic implications of invasive treatment options, classically compared modern interventions (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass grafting [CABG]), and addressed technical aspects of CABG. The general direction in 2022 confirms the superiority of CABG over PCI in patients with anatomically complex chronic CAD and supports an infarct-preventative effect as underlying mechanism. In addition, the relevance of proper surgical technique to achieve durable graft patency and the need for optimal medical treatment in CABG patients was impressively illustrated. In structural heart disease, the comparisons of interventional and surgical techniques have been characterized by prognostic and mechanistic investigations underscoring the need for durable treatment effects and reductions of valve-related complications. Early surgery for most valve pathologies appears to provide significant survival advantages, and two publications on the Ross operation prototypically illustrate an inverse association between long-term survival and valve-related complications. For surgical treatment of heart failure, the first xenotransplantation was certainly dominant, and in the aortic surgery field, innovations in arch surgery prevailed. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for decision-making and patient information., Competing Interests: None declared., (Thieme. All rights reserved.)

The use of mechanical circulatory support using percutaneous ventricular assist devices (pVAD) has increased rapidly during the last decade without substantial new evidence for their effect on outcome. In addition, many gaps in knowledge still exist such as timing and duration of support, haemodynamic monitoring, management of complications, concomitant medical therapy, and weaning protocols. This clinical consensus statement summarizes the consensus of an expert panel of the Association for Acute CardioVascular Care, European Society of Intensive Care Medicine, European Extracorporeal Life Support Organization, and European Association for Cardio-Thoracic Surgery. It provides practical advice regarding the management of patients managed with pVAD in the intensive care unit based on existing evidence and consensus on best current practice., Competing Interests: Conflict of interest: J.E.M.: speaker honorarium from Abbott, Abiomed, Boehringer Ingelheim, and Orion. Institutional research grant: Abiomed, Novo Nordic Foundation, and Danish Heart Foundation; A.S.: no disclosures, N.A.: no disclosures, A.A.: no disclosures, J.B.: consultant for Getinge, Abiomed, and Xenios; D.B.: no disclosures, G.F.: no disclosures, C.G.T.: no disclosures, A.M.: has received grants from Roche Diagnostics, Abbott Laboratories, 4TEEN4, and Windtree Therapeutics; has received honoraria for lectures from Roche Diagnostics, Bayer, and MSD; and is a consultant for Corteria Pharmaceuticals, S-Form Pharma, FIRE-1, Implicity, 4TEEN4, and Adrenomed; S.P.: no disclosures, J.S.: no disclosures, H.T.: no disclosures, and C.H.: speaker honorarium from Abiomed., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery. Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer., Methods: We analysed the largest registry of mitral and/or tricuspid valve surgery patients (mini-mitral international registry (MMIR)) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015 to 2021, 7513 consecutive patients underwent mini-mitral and/or tricuspid valve surgery in 17 international Heart-Valve-Centres. Data were collected according to Mitral Valve Academic Research Consortium (MVARC) definitions and 6878 patients with 1 cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times., Results: Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (Inpatient Quality Reporting (IQR): 0.80-2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional tricuspid valve surgery and 19% Atrial Fibrillation (AF)-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR: 107-173) and 85 min (IQR: 64-111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all P < 0.001). Age, low ejection fraction and emergent surgery were risk factors, but variables of 'increased complexity' (redo, endocarditis, concomitant procedures) were not., Conclusions: Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Left ventricular assist devices (LVAD) and extracorporeal membrane oxygenation (ECMO) are well established therapies in heart failure (HF) management. Their use is generally associated with a sudden increase in inflammatory mediators, which are often already elevated in patients with HF prior to device implantation. An exaggerated release of proinflammatory cytokines is associated with organ dysfunction and increased mortality. Hemoadsorption has been shown to reduce inflammatory mediators during cardiopulmonary bypass., Objective: To investigate the role of hemoadsorption during the management of acute or chronic heart failure with mechanical circulatory support and its impact on survival., Methods: We systematically searched MEDLINE selecting all studies comparing the use of hemoadsorption during LVAD implantation or veno-arterial (v.a.) ECMO therapy. Records were screened by two different investigators. Reports without a control group and duplicates were excluded., Results: Our search delivered six studies. One was randomized and five were retrospective studies, of which three were risk-adjusted. During LVAD implantation, one study showed no difference in mortality but higher incidence of respiratory insufficiency in the hemoadsorption group (54% vs 30%, p = 0.024) and the other study found higher mortality in the hemoadsorption group (33% vs 0%, p = 0.01). During ECMO therapy, three of four studies including the randomized one found no difference in survival or major adverse cardiac events between the hemoadsorption and the control groups. Only one study found lower mortality in the hemoadsorption group (20% vs 60%. p = 0.02)., Conclusions: The results of this literature review suggest that the use of hemoadsorption in patients undergoing LVAD implantation might be associated with higher morbidity and mortality. The majority of studies on the use of hemoadsorption during v.a. ECMO therapy showed no effect on mortality or organ dysfunction, while only one small study showed that hemoadsorption was able to reduce mortality. The results are limited by the retrospective nature and the small sample sizes of the majority of the studies included., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2023 The Author(s). Published by IMR Press.)

Background: There is limited evidence on the association of sex with outcomes among patients undergoing coronary bypass surgery (CABG) and treated with ticagrelor monotherapy or aspirin., Methods: This was a pre-specified sub-analysis of TiCAB, an investigator-initiated placebo-controlled randomized trial. Primary efficacy endpoint was the composite of cardiovascular death, myocardial infarction, stroke, or repeat revascularization 1 year after CABG. Safety endpoint was BARC type 2, 3 or 5 bleeding., Results: A total of 280 (15.0%) women and 1579 (85.0%) men were included. Compared with men, women were older (66.1 ± 10.2 vs. 70.1 ± 9.3 years) with more acute presentation (17.0% vs 21.1%). The incidence of the primary endpoint was similar between women and men (9.2% vs. 8.9%, HR 1.08, 95%CI 0.71-1.66, P = 0.71). Cardiovascular death occurred more often in women (2.9% vs 1.0%, adjusted HR 2.87, 95%CI 1.23-6.70, P = 0.02). The incidence of bleeding was similar between the sexes (2.2% vs. 2.5%, HR 0.91, 95% CI 0.51-1.65, P = 0.77). Ticagrelor vs aspirin was associated with a similar risk of the primary endpoint in women (10.6% vs. 7.9%, HR 1.39, 95%CI 0.63-3.05, P = 0.42) and men (9.5% vs. 8.2%, HR 1.15, 95%CI 0.82-1.62, P = 0.41;p interaction  = 0.69), and a similar risk of bleeding in women (2.9% vs. 1.4%, HR 2.09, 95%CI 0.38-11.41, P = 0.40) and men (2.2% vs. 2.8%, HR 0.80, 95%CI 0.42-1.52, P = 0.49;p interaction  = 0.35)., Conclusions: Among women and men undergoing CABG, ticagrelor monotherapy was associated with a similar risk of the primary efficacy endpoint and bleeding compared with aspirin. The risk of cardiovascular death was increased in women irrespective of antiplatelet therapy., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: Patients with left ventricular assist devices may experience external obstruction of the outflow graft through a gelatinous substance within the bend relief (BR; a stiff tube graft guiding the outflow graft). Preventative strategies have been missing. Having faced this problem, we decided to fenestrate the BR to avoid outflow graft obstruction (OGO)., Methods: Since December 2010, 167 patients underwent left ventricular assist device implantation using HeartMate II or 3. BR fenestration was introduced on July 2018 (108 patients before, 59 after the introduction of BR fenestration). Follow-up computed tomography scans were obtained from all patients and were screened for OGO by 3 independent investigators. Results were correlated with log file history, echocardiographic and clinical outcomes., Results: Demographic data were comparable between groups, with mostly male patients. Patients with BR fenestration were older [63 (standard deviation (SD):10.6) vs 58 (SD: 10.7) years] and had shorter support duration [494 (SD: 383) vs 951 (SD: 875) days]. OGO was observed in 5 patients and occurred only in patients without fenestration. Importantly, it occurred late on postoperative Days 412, 462, 1043, 1184 and 1506. Three patients are still asymptomatic. Surgical revision was required in the other 2 patients for pump thrombosis or continuous low flow. One of them died 36 days after revision due to right heart failure., Conclusions: Our results suggest that fenestration of the BR may be a preventative strategy to avoid external OGO. OGO occurred late, which suggests a careful long-term follow-up., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

PubMed displayed more than 35,000 hits for the search term "cardiac surgery AND 2021." We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) approach and selected relevant publications for a results-oriented summary. As in recent years, we reviewed the fields of coronary and conventional valve surgery and their overlap with their interventional alternatives. COVID reduced cardiac surgical activity around the world. In the coronary field, the FAME 3 trial dominated publications by practically repeating SYNTAX, but with modern stents and fractional flow reserve (FFR)-guided percutaneous coronary interventions (PCIs). PCI was again unable to achieve non-inferiority compared with coronary artery bypass graft surgery (CABG) in patients with triple-vessel disease. Survival advantages of CABG over PCI could be linked to a reduction in myocardial infarctions and current terminology was criticized because the term "myocardial revascularization" is not precise and does not reflect the infarct-preventing collateralization effect of CABG. In structural heart disease, new guidelines were published, providing upgrades of interventional treatments of both aortic and mitral valve disease. While for aortic stenosis, transcatheter aortic valve implantation (TAVI) received a primary recommendation in older and high-risk patients; recommendations for transcatheter mitral edge-to-edge treatment were upgraded for patients considered inappropriate for surgery. For heart team discussions it is important to know that classic aortic valve replacement currently provides strong signals (from registry and randomized evidence) for a survival advantage over TAVI after 5 years. This article summarizes publications perceived as important by us. It can neither be complete nor free of individual interpretation, but provides up-to-date information for decision-making and patient information., Competing Interests: None declared., (Thieme. All rights reserved.)

Mitral valve regurgitation is the second most common valve disease in the western world. Surgery is currently the best tool for generating a long-lasting elimination of mitral valve regurgitation. However, the mitral valve apparatus is a complex anatomical and functional structure, and repair results and durability show substantial heterogeneity. This is not only due to differences in the underlying mitral valve regurgitation pathophysiology but also due to differences in repair techniques. Repair philosophies differ substantially from one surgeon to the other, and consensus for the technically best repair strategy has not been reached yet. We had previously addressed this topic by suggesting that ring sizing is "voodoo". We now review the available evidence regarding the various repair techniques described for structural and functional mitral valve regurgitation. Herein, we illustrate that for structural mitral valve regurgitation, resuspension of prolapsing valve segments or torn chordae with polytetrafluoroethylene sutures and annuloplasty can generate the most durable results paired with the best achievable hemodynamics. For functional mitral valve regurgitation, the evidence suggests that annuloplasty alone is insufficient in most cases to generate durable results, and additional subvalvular strategies are associated with improved durability and possibly improved clinical outcomes. This review addresses current strategies but also implausibilities in mitral valve repair and informs the mitral valve surgeon about the current evidence. We believe that this information may help improve outcomes in mitral valve repair as the heterogeneity of mitral valve regurgitation pathophysiology does not allow a one-size-fits-all concept., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2022, Turkish Society of Cardiovascular Surgery.)

Background:  Research and scientific publications are important for the advancement of science but also for the individual career development. While women have become the majority of students in medicine we do not know about female presence and scientific activity in cardiac surgery. We thus aimed to compare scientific output of women and men in German University departments of cardiac surgery with cardiology departments focusing on the same organ and surgical departments not addressing the heart (general surgery) of 34 universities in Germany., Methods:  Personnel working at University departments was identified on the institutions internet homepage in 2014. Publications in 2011 to 2013 on PubMed were identified. Author and manuscript characteristics were determined., Results:  A lower proportion of women were working in cardiac surgery (25%) compared with cardiology (35%) and general (32%) surgery independent of executive function or academic degree. Scientifically active women published fewer manuscripts per capita than men both, in total and as first author. Additionally, the mean and the cumulated journal impact factor of the journals chosen was lower for women compared with men in cardiology but not in cardiac and general surgery., Conclusion:  We conclude that the differences in scientific activity between women and men are more pronounced in cardiology compared with general and cardiac surgery, indicating that a higher proportion of women in a field does not result in reduced differences between sexes. The low number of women together with the lower number of manuscripts in cardiac surgery may render the appointment of women as directors challenging., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Heater-cooler devices (HCD) have been implicated in a cardiosurgical contamination scenario causing prosthetic valve endocarditis., Aim:  We characterized contamination of new HCDs and assessed the risk of intraoperative microorganism transmission from the HCD to the operating field., Methods:  We initially acquired four new FlexTherm and then four new Maquet HCU40 HCDs and assessed occurrence and speed of microbial contamination (including mycobacteria) assessing swab and water samples from the device. In parallel, we collected repeated samples from different sites in the operating room either by swab sticks or by exposing different sample plates to room air. We also reviewed microbiological results from the hospital and compared them to cardiosurgical wound infections and endocarditis cases. Finally, we simulated cardiosurgical conditions and assessed the devices' ability to expel air to the operative field., Results:  All new HCDs were clean before first use. Despite authority-mandated decontamination procedures, microbial growth ( Fusarium solani , Sphingomonas paucimobilis , Pseudomonas aeruginosa , Mycobacterium chelonae , and gordonae ) was identified in all HCDs over time and could not be permanently eliminated. Four of these mircoorganisms were also found in tap water. However, none of the HCD-organisms were found inside the laminar airflow operating area. Importantly, except for P. aeruginosa , none of the HCD organisms were found in patients with surgical wound infections or endocarditis. HCD-expelled air did not rise more than 40 cm above ground., Conclusion:  HCDs cannot be expected to remain sterile despite extensive decontamination procedures. However, airborne transmission of microorganisms directly from the HCD to the operating field appears unlikely., Competing Interests: None declared., (Thieme. All rights reserved.)

In 2020, nearly 30,000 published references appeared in the PubMed for the search term "cardiac surgery." While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information., Competing Interests: None., (Thieme. All rights reserved.)

Objectives: The aim of this study was to compare outcomes of transcatheter and surgical aortic valve implantation in chronic dialysis patients with aortic valve stenosis (AS)., Background: Chronic dialysis patients undergoing heart valve surgery are at higher risk for morbidity and mortality. Whether interventional techniques can reduce this risk is unclear because dialysis patients have thus far been excluded from randomized trials., Methods: Chronic dialysis patients with AS enrolled in the German Aortic Valve Registry (GARY) between 2012 and 2015 were analyzed to compare transcatheter aortic valve implantation (TAVI n = 661) with surgical aortic valve replacement (SAVR n = 457). Propensity scores for inverse probability of treatment weighting (IPTW) were used to adjust the comparison of the two treatment groups for potential confounders., Results: TAVI patients were older (78 ± 7.3 vs. 69 ± 10.2 years, p < 0.01, unadjusted) and had more comorbidities. Mortality at 1 year was the same (TAVI: 33.4% vs. SAVR 35.0%, p = 0.72, IPTW-adjusted) while it was lower with TAVI at 30 days (8.6% vs. 15.0%, p = 0.02, IPTW-adjusted). TAVI patients required more pacemaker implantation and showed more aortic regurgitation. SAVR patients required more blood transfusions and had longer hospital stay. Diabetes mellitus, atrial fibrillation, previous PCI, urgent procedure and EuroSCORE were associated with elevated 30-day mortality. Atrial fibrillation and older age were independent risk factor of 1-year mortality in both groups., Conclusions: Chronic dialysis patients with AS undergoing TAVI or SAVR had the same 1-year mortality, although survival at 30 days was better with TAVI. These results suggest that TAVI may improve peri-procedural outcomes.

Background: Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOT A ) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome., Methods: We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR., Results: In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not., Conclusion: We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies., Competing Interests: Author T.D. received occasional honoraria from St. Jude Medical, Inc. for lectures on aortic valve topics. All other authors have nothing to disclose., (Thieme. All rights reserved.)

Background: We report our starting experience with parasternal minimally-invasive aortic valve replacement., Methods: From 7/14 to 8/18, 192 received classic aortic valve surgery using a 5 cm parasternal incision and percutaneous groin cannulation. Patients were selected based on anatomic feasibility judged by preoperative computed tomography-scan. Except for porcelain aorta, left-sided aortic location, or endocarditic abscess, there were no exclusions., Results: Patients were divided into two groups (first and second half of experience). Demographics were equal. Patients' mean ejection fraction was 59%, with preoperative stroke (12%), severe chronic obstructive pulmonary disorder (11%), and endocarditis (2%). All cases were elective or urgent. The Euroscore II was 3.37 ± 3.31 in the first and 3.68 ± 3.97 in the second group (n.s.). Biological prostheses were implanted in 90%. Operating times in the first group were just under 3 hours, with bypass times of 129 ± 32 minutes and clamp times of 77 ± 20 minutes. In the second group, these times changed only minimally. There were three conversions to sternotomy in the first, but only one in the second group. Similarly, three patients died in the first and one in the second group. There were fewer complications in the second group regarding revision for bleeding (7 vs 1%), stroke (4 vs 0%) dialysis (3 vs 1%), and pericardial effusions (3 vs 1%). The O/E ratio dropped from 0.93 to 0.28., Conclusions: Parasternal minimally-invasive aortic valve replacement is a feasible technique associated with a slow learning curve but the potential to achieve improved outcomes. Considering the transcatheter alternatives, the relative risk reduction may be worth investigating in future trials., (© 2020 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals, Inc.)

Background: Fractional flow reserve (FFR) is a reliable tool for the functional assessment of coronary stenoses. FFR computed tomography (CT) derived (FFR CT ) has shown to be accurate, but its clinical usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the impact of FFR CT on heart team's treatment decision-making and selection of vessels for revascularization in patients with 3-vessel coronary artery disease., Methods: The trial was an international, multicenter study randomizing 2 heart teams to make a treatment decision between percutaneous coronary interventions and coronary artery bypass grafting using either coronary computed tomography angiography or conventional angiography. The heart teams received the FFR CT and had to make a treatment decision and planning integrating the functional component of the stenoses. Each heart team calculated the anatomic SYNTAX score, the noninvasive functional SYNTAX score and subsequently integrated the clinical information to compute the SYNTAX score III providing a treatment recommendation, that is, coronary artery bypass grafting, percutaneous coronary intervention, or equipoise coronary artery bypass grafting-percutaneous coronary intervention. The primary objective was to determine the proportion of patients in whom FFR CT changed the treatment decision and planning., Results: Overall, 223 patients were included. Coronary computed tomography angiography assessment was feasible in 99% of the patients and FFR CT analysis in 88%. FFR CT was available for 1030 lesions (mean FFR CT value 0.64±13). A treatment recommendation of coronary artery bypass grafting was made in 24% of the patients with coronary computed tomography angiography with FFR CT . The addition of FFR CT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as reference, FFR CT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile., Conclusions: In patients with 3-vessel coronary artery disease, a noninvasive physiology assessment using FFR CT changed heart team's treatment decision-making and procedural planning in one-fifth of the patients., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02813473.

Background:  Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA., Methods:  Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patient's quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36)., Results:  Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire., Conclusions:  Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes., Competing Interests: The authors report no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: The 30-day and 1-year follow-up analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients) revealed no significant difference in the composite end point consisting of death, stroke, myocardial infarction, new renal replacement therapy, or repeat revascularization. The 5-year follow-up data of this trial are reported here., Methods: From June 2008 to September 2011, a total of 2539 patients aged ≥75 years were randomly assigned to undergo off-pump or on-pump coronary artery bypass grafting (CABG) at 12 centers in Germany. The primary outcome was all-cause mortality at 5 years. The secondary 5-year outcomes were a composite of death, myocardial infarction, and repeat revascularization. Furthermore, the impact of complete versus incomplete revascularization was assessed., Results: After a median follow-up of 5 years, 361 patients (31%) assigned to off-pump CABG and 352 patients (30%) assigned to on-pump CABG had died (hazard ratio off-pump/on-pump CABG, 1.03; 95% CI, 0.89-1.19; P=0.71). The composite outcome of death, myocardial infarction, and repeat revascularization occurred in 397 (34%) after off-pump and in 389 (33%) after on-pump CABG (hazard ratio, 1.03; 95% CI, 0.89-1.18; P=0.704). Incomplete revascularization occurred in 403 (34%) patients randomly assigned to off-pump and 354 (29%) patients randomly assigned to on-pump CABG ( P<0.001). Five-year survival rates were 72% (95% CI, 67-76) with incomplete versus 76% (95% CI, 74-80) with complete revascularization (log-rank test: P=0.02) after off-pump CABG and 72% (95% CI, 67-76) versus 77% (95% CI, 74-80) after on-pump CABG (log-rank test: P=0.03), respectively. Cox regression analysis revealed a hazard ratio incomplete/complete revascularization of 1.19 (95% CI, 1.01-1.39; P=0.04)., Conclusions: In elderly patients ≥75 years of age, the 5-year survival rates and the combined outcome of death, myocardial infarction, and repeat revascularization, as well, were similar after on-pump and off-pump CABG. Incomplete revascularization was associated with a lower 5-year survival rate, irrespective of the type of surgery., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00719667.

Background: Isolated tricuspid valve (TV) surgery is considered a high risk-procedure. The optimal surgical approach is controversial. We analyzed our experience with isolated TV redo surgery performed either minimally invasively (redo-MITS) or through sternotomy., Methods: We retrospectively analyzed all patients with previous cardiac surgery who underwent redo-MITS ( n  = 26) and compared them to redo-Sternotomy ( n  = 17). A group of primary-MITS ( n  = 61) served as control., Results: The redo-MITS approach consisted of a right anterolateral mini-thoracotomy, transpericardial right atrial access, and beating heart TV surgery without caval occlusion. Redo-MITS patients were oldest and had the most comorbidities (EuroScore II: 9.83 ± 6.05% versus redo-Sternotomy: 8.42 ± 7.33% versus primary-MITS: 4.15 ± 4.84%). There were no intraoperative complications or conversions to sternotomy in both MITS groups. Redo-Sternotomy had the highest 30-day mortality (24%), the poorest long-term survival, and the highest perioperative complication rate. Redo-MITS did not differ in perioperative outcome from primary-MITS. Multivariable logistic regression analysis identified redo-Sternotomy (odds ratio [OR] = 9.76; 95% confidence interval [CI] 1.88-63.26), liver cirrhosis (OR = 9.88; 95% CI 2.20-54.20), and body mass index (BMI) (OR = 1.16; 95% CI 1.02-1.35) as independent predictors of 30-day mortality. The Cox model revealed redo-Sternotomy (hazard ratio [HR] = 2.67; 95% CI 1.18-6.03), liver cirrhosis (HR = 3.31; 95% CI 1.45-7.58), and pulmonary hypertension (HR = 2.26; 95% CI 1.04-4.92) as risk factors for poor long-term survival. TV surgery significantly reduces NYHA class., Conclusion: Minimally invasive, isolated TV surgery as reoperation without caval occlusion and on the beating heart can be safe and may improve clinical outcome., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke., Methods: In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke., Results: There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5-1.38]; p  = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46-1.60]; clampless device: 1.8%; OR 0.67 [0.26-1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37-2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64-1.20])., Conclusion: Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke., Competing Interests: All authors declare that there was no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work, (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Infective endocarditis (IE) is often associated with multiorgan dysfunction and mortality. The impact of perioperative liver dysfunction (LD) on outcome remains unclear and little is known about factors leading to postoperative LD., Methods: We performed a retrospective, single-center analysis on 285 patients with left-sided IE without pre-existing chronic liver disease referred to our center between 2007 and 2013 for valve surgery. Sequential organ failure assessment (SOFA) score was used to evaluate organ dysfunction. Chi-square, Cox regression, and multivariate analyses were used for evaluation., Results: Preoperative LD (Bilirubin >20 μmol/L) was present in 68 of 285 patients. New, postoperative LD occurred in 54 patients. Hypoxic hepatitis presented the most common origin of LD, accompanied with high short-term mortality. In-hospital mortality was higher in patients with preoperative and postoperative LD compared to patients without LD (51.5, 24.1, and 10.4%, respectively, p < 0.001). 5-year survival was worse in patients with pre- or postoperative LD compared to patients without LD (20.1, 37.1, and 57.0% respectively). A landmark analysis revealed similar 5-year survival between groups after patient discharge. Quality of life was similar between groups when patients survived the perioperative period. Logistic regression analysis identified duration of cardiopulmonary bypass and S. aureus infection as independent predictors of postoperative LD., Conclusions: Perioperative liver dysfunction in patients with infective endocarditis is an independent predictor of short- and long-term mortalities. After surviving the hospital stay, 5-year prognosis is not different and quality of life is not affected by LD. S. aureus and duration of cardiopulmonary bypass represent risk factors for postoperative LD.

Background: Over the past two decades, minimally invasive techniques for classic heart valve surgery and isolated bypass surgery have been developed that enable access to the heart via partial sternotomy for most aortic valve procedures and via sternotomy-free mini-thoracotomy for other procedures., Methods: We review the current evidence on minimally invasive cardiac surgery on the basis of pertinent randomized studies and database studies retrieved by a selective search in the MEDLINE and PubMed Central databases, as well as by the Google Scholar search engine., Results: A PubMed search employing the search term "minimally invasive cardiac surgery" yielded nearly 10 000 hits, among which there were 7 prospective, randomized, controlled trials (RCTs) on aortic valve replacement, with a total of 477 patients, and 3 RCTs on mitral valve surgery, with a total of 340 patients. Only limited reports of specified centers are currently available for multiple valvular procedures and multiple coronary artery bypass procedures. The RCTs reveal that the minimally invasive techniques are associated with fewer wound infections and faster mobilization, without any difference in survival. Minimally invasive procedures are technically demanding and have certain anatomical prerequisites, such as appropriate coronary morphology for multiple bypass operations and the position of the aorta in the chest for sternotomy-free aortic valve procedures. The articles reviewed here were presumably affected by selection bias, in that patients in the published studies were preselected, and there may have been negative studies that were not published at all., Conclusion: Specialized surgeons and centers can now carry out many cardiac valvular and bypass operations via minithoracotomy rather than sternotomy. According to current evidence, these minimally invasive techniques yield results that are at least as good as classic open-heart surgery.

We report a case of delayed onset Takotsubo cardiomyopathy (TC) in a 69-year-old woman, associated with minor stressors, two weeks after mitral valve replacement. After suffering several minor complications she had fully recovered and her discharge was planned. On the 14th postoperative day she had to be resuscitated due to cardiogenic shock. TC was diagnosed based on reduced ventricular function with apical ballooning and normal coronaries. Treatment with catecholamines and intra-aortic balloon pump led to full recovery. She continues to do well two years after surgery. TC should be considered as a potential cause of delayed ventricular dysfunction in postcardiac surgery patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

We would like to present our experience of surgical excision of intracardiac tumors using a video-assisted minimally-invasive cardiac surgery (MIC) technique. An 83-year-old female patient received video-assisted cardiac surgery for excision of a left atrial tumor. The surgery was performed through a right anterior submammary minithoracotomy and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro-femoral bypass. The myocardium was protected by single-dose antegrade crystalloid cardioplegia. The tumor was excised completely recording a 61-minute bypass time and a 103-minute total operative time. Histopathological examination revealed left atrial myxoma. Transthoracic echocardiography examination showed good ventricular function and the absence of residual tumors. The patient was satisfied by the cosmetic healing of the wound and was discharged eight days after the surgery. Video-assisted MIC surgery is technically feasible and could be applied as a routine access in all left atrial tumors without the fear of inadequate intraoperative exposure and its drawbacks.

Aims: Left ventricular hypertrophy is a risk factor for heart failure. However, it also is a compensatory response to pressure overload, accommodating for increased workload. We tested whether the changes in energy substrate metabolism may be predictive for the development of contractile dysfunction., Methods and Results: Chronic pressure overload was induced in Sprague-Dawley rats by aortic arch constriction for 2, 6, 10, or 20 weeks. Contractile function in vivo was assessed by echocardiography and by invasive pressure measurement. Glucose and fatty acid oxidation as well as contractile function ex vivo were assessed in the isolated working heart, and respiratory capacity was measured in isolated cardiac mitochondria. Pressure overload caused progressive hypertrophy with normal ejection fraction (EF) at 2, 6, and 10 weeks, and hypertrophy with dilation and impaired EF at 20 weeks. The lung-to-body weight ratio, as marker for pulmonary congestion, was normal at 2 weeks (indicative of compensated hypertrophy) but significantly increased already after 6 and up to 20 weeks, suggesting the presence of heart failure with normal EF at 6 and 10 weeks and impaired EF at 20 weeks. Invasive pressure measurements showed evidence for contractile dysfunction already after 6 weeks and ex vivo cardiac power was reduced even at 2 weeks. Importantly, there was impairment in fatty acid oxidation beginning at 2 weeks, which was associated with a progressive decrease in glucose oxidation. In contrast, respiratory capacity of isolated mitochondria was normal until 10 weeks and decreased only in hearts with impaired EF., Conclusion: Pressure overload-induced impairment in fatty acid oxidation precedes the onset of congestive heart failure but mitochondrial respiratory capacity is maintained until the EF decreases in vivo. These temporal relations suggest a tight link between impaired substrate oxidation capacity in the development of heart failure and contractile dysfunction and may imply therapeutic and prognostic value.

Polarized cell movement represents an essential prerequisite for the progression and metastasis of malignant diseases. Protein kinase C (PKC) which physically associates with integrins has been implicated in the promotion of a migratory cell phenotype. In order to identify a direct link between PKC and integrins in renal cell carcinoma (RCC) the influence of PKC isoforms on integrin expression and possible consequences on proliferation and cell migration was analyzed in RCC cells. The constitutive expression of the PKC isoforms alpha, betaI, betaII, gamma, delta, epsilon, eta, theta, xi, lambda and micro was determined in the RCC cell line CCF-RC1. In addition, the influence of PKC inhibitors RO31-8220, GF109203X and GO6976 on the beta1, beta2 and beta3 integrin expression and cell proliferation of RCC cells was investigated by flow cytometry and by BrdU incorporation, respectively. Furthermore, the motility of CCF-RC1 cells was assessed through chamber chemotaxis analysis. All PKC isoforms tested were expressed in CCF-RC1 cells with the exception of PKClambda and theta. The PKC inhibitor RO31-8220 reduced beta1 integrin expression by 92% and inhibited proliferation by 42% of untreated cells, whereas cell migration remained uninfluenced by RO31-8220. GF109203X and GO6976 reduced beta1 integrin expression to approximately 50% of untreated cells. In contrast, beta2 and beta3 integrins were only weakly affected by RO31-8220, GF109203X and GO6976 treatment. The most significant influence on beta1 integrin expression was obtained by the PKC inhibitor RO31-8220. This leads to the assumption that PKCepsilon is involved in the regulation of beta1 integrin expression. Downregulation of beta1 integrins by RO31-8220 was associated with reduced proliferation, but did not influence migration. These findings provide a conceptual basis for treatment of renal cell carcinoma by interfering with tumor cell proliferation.

Background: The expression of all eleven PKC-isoforms in clear cell RCCs (ccRCC) and in the corresponding normal renal tissue was quantified. A possible association of PKC-isoforms with histopathological parameters was examined., Materials and Methods: Proteins were isolated from tumor and normal tissue of 43 patients with ccRCC. Expression of PKC-isoforms were quantified by Western blot analysis., Results: In both, ccRCCs and the corresponding normal renal tissue, all PKC-isoforms apart from PKC gamma and theta were detectable. Striking associations between PKC-isoforms and histopathological parameters were observed: (i) a 3-fold increase in PKC eta of grade 3 and 4 versus grade 1 and 2 tumors (p = 0.025), (ii) a decrease of PKC alpha in tumor versus normal tissue of 18% (p = 0.020) and (iii) a 20% increase of PKC zeta in grade 3 and 4 versus grade 1 and 2 tumors (p = 0.092)., Conclusion: The major result is a clear correlation of PKC eta expression with tumor progression. This observation-is in agreement with the known oncogenic properties of PKC eta. Similarly, oncogenic PKC zeta also increased with tumor progression. PKC alpha, with known tumor-suppressor properties, was decreased in ccRCC versus normal tissue. These findings may become important for both classification and treatment of ccRCC.

The tumor suppressor gene PTEN (phosphatase and tensin homologue deleted from chromosome 10) encodes a dual specific protein and phospholipid phosphatase that affects cell proliferation, apoptosis and migration. In our study, we examined protein expression of PTEN in renal carcinogenesis. PTEN protein levels were examined in 42 clear cell renal cell carcinomas (ccRCC) and oncocytomas as well as in the corresponding normal renal tissue of the same patients using Western blot analysis. Cellular localization was analyzed by immunohistochemistry. PTEN was highly expressed in all investigated normal renal tissue specimens. Immunohistochemical analysis showed an almost exclusive staining of proximal tubulus epithelial cells known to be precursor cells of ccRCC. Within the proximal tubulus cells, PTEN exhibited a membrane predominant immunostaining pattern. In ccRCCs PTEN expression was markedly reduced to an average of less than 10% compared with normal tissue as evidenced by Western blot analysis (p < 0.001). The degree of reduction was similar in highly differentiated (G1) carcinomas and in less differentiated (G2-G4) carcinomas. These observations were reproduced by immunohistochemical studies, which revealed a loss of the characteristic membrane predominant immunostaining pattern in ccRCC. In contrast to the PTEN positive proximal tubulus epithelial cells, the distal tubulus epithelial cells, which are precursor cells of the benign oncocytomas, exhibited only a very weak PTEN expression. Compared with the distal tubulus epithelial cells, no downregulation of PTEN was seen in oncocytomas. We conclude that PTEN expression and PTEN membrane localization are lost during early renal cell carcinogenesis and may therefore be a valuable RCC tumor marker., (Copyright 2002 Wiley-Liss, Inc.)

Prostaglandin E2 and F2 alpha were measured in ejaculates from 10 fertile and 55 infertile men. Prostaglandin F2 alpha was negatively correlated with motility (r = 0.77; p less than 0.01) in normal men. In patients with disturbed fertility, prostaglandin F2 alpha was always higher than in the controls, while prostaglandin E2 was elevated only in patients with persisting varicocele and in those with very low sperm counts and severely impaired motility. There was neither de novo synthesis of prostaglandins in spermatozoa nor were binding sites for prostaglandin E2 and F2 alpha detectable. Inactivation of seminal prostaglandins by incubation with prostaglandin 15-hydroxydehydrogenase resulted in a dramatic fall in motility. The results suggest that prostaglandin F2 alpha act on motility, but the action is not mediated by receptors.

A double-blind cross-over study was carried out in five healthy male volunteers to investigate the renal tolerance of 40 mg penbutolol, a receptor-specific beta-blocking agent, during exercise and to compare its effects with a placebo. The effects of exercise were compared with a resting state after a medication on the placebo. Urine was collected in fractions for seven hours on each trial day. The urine volume and the excretion of alanine aminopeptidase (AAP), N-acetyl-beta-D-glucosaminidase (NAG) and gamma glutamyltransferase (GGT) per fraction were determined. The findings for the kidney enzymes AAP, NAG and GGT show that the renal tolerance of penbutolol was good. Physical exercise per se did not cause any increase in the excretion of the above-mentioned enzymes. Slight diurnal variation was seen in the excretion of the renal enzymes after both the placebo and penbutolol.

A double-blind crossover trial was carried out in 7 healthy male volunteers to investigate the effects of penbutolol and a placebo on plasma atrial natriuretic peptide (ANP) and antidiuretic hormone (ADH) levels before and after exercise. Each subject underwent several bicycle ergometric exercises lasting 6 min before and after the application of test medications. Ergometric exercises were performed before medication, and at 2, 5, 9 and 24 hours after medication. Blood samples for ANP and ADH levels were drawn before, after 15 min, after 2 hours (immediately after ergometry) and 5, 7, 9, and 24 hours after medication (immediately before ergometry). Urine was collected as follows: -2 to 0, 0 to 2, 2 to 4, 4 to 7, 7 to 14 and 14 to 24 hours after medication, and the volume as well as sodium excretion were documented. Penbutolol caused suppression of the exercise-induced increase in ANP. The 2 to 4 hour fractional sodium excretion was significantly decreased from 12.1 +/- 4.9 mmol/fraction after placebo treatment to 7.8 +/- 3.0 mmol/fraction after penbutolol application (p less than 0.03). There were no differences in the urinary outputs between penbutolol and placebo until 4 hours after medication, but penbutolol caused the total urinary output to increase from 1390 +/- 388 ml/24 hr during placebo treatment to 1725 +/- 549 ml/24 hr (p less than 0.02) due to the last collection fraction. Blood pressure and pulse rate both decreased during exercise after penbutolol. As opposed to the suppressing influence of penbutolol on ANP, ADH plasma levels were increased after exercise.(ABSTRACT TRUNCATED AT 250 WORDS)