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Abstract: Within the interdisciplinary R&D project VIONA a novel hard- and software system was developed to investigate the potential of an automatic infrared (IR) based health monitoring. The system developments and the comprehensive practical tests were focussed on the veterinary application dairy cows. Special attention was paid to the rough practical conditions in dairy farms. The system enables a complete automation of the workflow from IR image acquisition to alarm list generation for the veterinary personal. The development contains the three main issues: precise IR temperature measurement under varying ambient conditions, image processing to extract accurate temperature features of anatomic structures automatically and statistical diagnosis algorithms based on individual time series of temperature features.The studies on hundreds of dairy cows showed that with advanced IR technology and data processing the IR based approach has a significant potential to detect common inflammation diseases. [Copyright &y& Elsevier]

Data are missing on the diversity of Plasmodium spp. infecting apes that live in their natural habitat, with limited possibility of human-mosquito-ape exchange. We surveyed Plasmodium spp. diversity in wild chimpanzees living in an undisturbed tropical rainforest habitat and found 5 species: P. malariae, P. vivax, P. ovale, P. reichenowi, and P. gaboni. [ABSTRACT FROM AUTHOR]

Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y 12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y 12 inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period.Clinical registration number: ClinicalTrials.gov identifier: NCT05077124., (© 2024. The Author(s).)

Background: Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting., Methods: A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view., Results: The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb ® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability., Conclusions: The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy., (© 2024. The Author(s).)

Purpose: To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors., Methods: Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed., Results: At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001)., Conclusions: BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.

Objectives: Patients on ticagrelor undergoing urgent cardiac surgery are at high risk for perioperative bleeding complications. We sought to determine whether intraoperative hemoadsorption could remove ticagrelor and lower circulating drug concentrations., Methods: The hemoadsorption device was incorporated in the cardiopulmonary bypass (CPB) circuit and remained active for the duration of the pump run. Blood samples were collected before and after CPB. The main objective of the current analysis was to compare mean total plasma ticagrelor levels (ng/mL) at baseline with ticagrelor levels obtained at the end of CPB. Plasma ticagrelor levels were measured at a certified outside laboratory (LabConnect). Data are presented as mean ± standard deviation., Results: A total of 11 patients undergoing urgent coronary artery bypass grafting at 3 institutions were included (mean age, 67.9 ± 9.9 years; 91% male; mean European System for Cardiac Operative Risk Evaluation II of 3.0 ± 3.3%; range, 0.7%-12.4%). Mean intraoperative hemoadsorption duration was 97.1 ± 43.4 minutes with a mean flow rate through the device of 422.9 ± 40.3 mL/min. Mean ticagrelor levels pre-CPB were 103.5 ± 63.8 ng/mL compared with mean post-CPB levels of 34.0 ± 17.5 ng/mL, representing a significant 67.1% reduction ( P  < .001). Intraoperative integration of the device was simple and safe without any device-related adverse events reported., Conclusions: This is the first in vivo report demonstrating that intraoperative hemoadsorption can efficiently remove ticagrelor and significantly reduce circulating drug levels. Whether active ticagrelor removal can reduce serious perioperative bleeding in patients undergoing urgent cardiac surgery is currently being evaluated in the double-blinded, randomized Safe and Timely Antithrombotic Removal-Ticagrelor (STAR-T) trial., (© 2023 The Author(s).)

Background: Patients on direct oral anticoagulants are at high risk of perioperative bleeding complications. We analyzed the results of intraoperative hemoadsorption (HA) in patients undergoing cardiac surgery who were also on concurrent therapy with apixaban. Methods: we included 25 consecutive patients on apixaban who underwent cardiac surgery with the use of cardio-pulmonary bypass (CPB) at three sites. The first 12 patients underwent surgery without hemoadsorption (controls), while the next 13 consecutive patients were operated with the Cytosorb® (Princeton, NJ, USA) device integrated into the CPB circuit (HA group). The primary outcome was perioperative bleeding assessed by the Bleeding Academic Research Consortium (BARC) definition and secondary outcomes included 24 h chest-tube-drainage (CTD) and need for 1-deamino-8-d-arginine-vasopressin (desmopressin (DDAVP)) administration to achieve hemostasis. Results: Preoperative mean daily dose of apixaban was higher in the HA group (8.5 ± 2.4 vs. 5.6 ± 2.2 mg, p = 0.005), while time since last apixaban dose was longer in the controls (1.3 ± 0.9 vs. 0.6 ± 1.2 days, p < 0.001). No BARC-4 bleeding events and no repeat-thoracotomies occurred in the HA group compared with 3 and 1, respectively, in the controls. Postoperative 24 h CTD volume was significantly lower in the HA group (510 ± 152 vs. 893 ± 579 mL, p = 0.03) and there was no need for DDAVP compared to controls, who received an average of 10 ± 13.6 mg (p = 0.01). Conclusions: In patients on apixaban undergoing emergent cardiac surgery, the intraoperative use of hemoadsorption was feasible and safe. Compared to patients operated on without hemoadsorption, BARC-4 bleeding complications did not occur and the need for 24 h CTD and DDAVP was significantly lower.

Background: Antithrombotic drugs increase the risk of bleeding, especially in patients who need urgent surgery without an adequate wash-out period. This review aims to evaluate perioperative bleeding complications in patients on dual antiplatelet therapy (DAPT) or direct-acting oral anticoagulants (DOACs) undergoing high-bleeding risk cardiovascular surgery and to present currently available potential solutions to mitigate antithrombotic therapy-related bleeding complications., Methods: As a first step, we searched for relevant articles, over the last 10 years, in Medline (PubMed) and abstracted clinical information based on pre-defined criteria for bleeding complications. In the next step, an additional search evaluating potential solutions to mitigate bleeding complications was performed. The literature screening and selection process followed the principles derived from the PRISMA statement., Results: From all reviewed studies, a total of 19 articles could be included evaluating the risk for bleeding in cardiac surgery related to DAPT or DOACs and 10 papers evaluating antithrombotic drug reversal or removal in the setting of cardiovascular surgery. Reported bleeding rates ranged between 18% and 41%. The variability of the reported data is remarkable. Idarucizumab is reported to provide optimal perioperative hemostasis in up to 93% of patients. It has been observed that andexanet alfa causes unresponsiveness to the anticoagulant effects of heparin. Antithrombotic removal by intraoperative hemoadsorption is found to be associated with a significant decrease in re-thoracotomy rate, overall procedure duration, administered transfusion volumes, chest-tube drainage, and length of hospitalization., Discussion: Bleeding complications in patients treated with DAPT or DOACs in cardiac surgery are high. New costly reversal agents are available but have not been sufficiently tested in the cardio-surgical setting so far. Interestingly, bleeding-related complications seem to be effectively reduced by applying innovative intraoperative hemoadsorption techniques. Expected results from the ongoing trials should provide better insights concerning the efficacy and safety of several potential solutions. Currently, the variability of reports and the deficit of high-quality studies in this specific setting represent the major limitation for the unbiased conclusion of this review., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-428/coif). MMS is a full-time consultant to CytoSorbents. KH, SG and MT received honoraria for lectures by CytoSorbents. MT and RFS are the investigators in the STAR Registry (Clinical.Trials.gov, No. NCT05077124), sponsored by CytoSorbents. RFS and MS received honoraria for lectures and consultancy fees by CytoSorbents. HA, END, and DW are full-time employees of CytoSorbents. DW serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2022 to March 2024. The authors have no other conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Objective: To analyze the results of hemoadsorption in patients with cardiac surgery to thoracic aortic surgery, who had been loaded beforehand with either Factor Xa inhibitor rivaroxaban or P2Y12 receptor antagonist ticagrelor., Methods: We investigated 21 of 171 consecutive patients (median age 71 [interquartile range 62, 76] years) who underwent emergency cardiac operations for acute type A aortic dissection between 2014 and 2020. These patients were pretreated with rivaroxaban (n = 9) or ticagrelor (n = 12). In ten of 21 cases (since 2017), we installed a hemoadsorber into the heart-lung machine and compared the results to eleven patients done without hemoadsorber before that time., Results: The operation time was significantly shorter in the adsorber group (286 ± 40 min vs. 348 ± 79 min; p = 0.045). The postoperative 24-hour drainage volume was significantly lower after adsorption (p <0.001; 482 ± 122 ml vs. 907 ± 427 ml) and no rethoracotomy had to be performed (compared to two rethoracotomies [18.9%] among patients without adsorber use). Also, patients without hemoadsorption required significantly more platelet transfusions (p = 0.049)., Conclusions: In patients with acute type A aortic dissection who were pretreated with rivaroxaban and ticagrelor, the intraoperative use of CytoSorb hemoadsorption during cardiopulmonary bypass is reported for the first time. The method was found to be effective to prevent from bleeding and to improve the outcome in aortic dissection.

Aims: Failure of transcatheter mitral valve repair (fTMVR) therapy has a decisive prognostic influence, and complex retreatment is of higher risk. The aim of this analysis was to evaluate the survival outcome following percutaneous procedures and surgery after unsuccessful TMVR interventions for different aetiologies., Methods and Results: Of 824 consecutive patients who had been treated with the MitraClip device at our institution, between September 2009 and May 2019, 63 (7.6%) symptomatic patients with therapy failure and persistent or recurrent mitral regurgitation (MR) underwent reinterventions. An outcome analysis for primary (PMR) and secondary mitral regurgitation (SMR) and subsequent percutaneous versus surgical treatment was carried out. MitraClip reinterventions were performed in 36 patients (57.1%; n=26 SMR, n=10 PMR), while 27 (42.9%; n=13 SMR, n=14 PMR) underwent open heart surgery. Surgical patients with PMR showed lower mortality than patients with SMR (p<0.0001) and ReClip patients with PMR (p=0.073). Atrial fibrillation (HR 2.915, 95% CI: [1.311, 6.480]), prior open heart surgery (2.820 [1.215, 6.544]) and chronic obstructive pulmonary disease (2.506 [1.099, 5.714]) increased the risk of death. The level of post-interventional MR had no relevant impact on survival., Conclusions: We conclude that, after SMR and failed TMVR, reclipping is an appropriate treatment option for symptomatic patients. For PMR patients, surgery must be favoured over a reclipping procedure. However, patients with atrial fibrillation, prior open heart surgery and chronic obstructive pulmonary disease are at risk of reduced survival after reinterventions.

Background: The purpose of this study was to analyze the results of Cytosorb (CytoSorbents, Monmouth Junction, NJ) adsorption during emergency open heart operations in patients at high risk of bleeding due to treatment with coagulation-active substances., Methods: We investigated 55 consecutive patients (median age 70 years; interquartile range: 60 to 77) who underwent emergency cardiac surgery at our institution between June 2016 and June 2018. All patients were receiving therapy with either ticagrelor (n = 43) or rivaroxaban (n = 12). In 39 of 55 cases, we routinely installed standardized Cytosorb adsorption into the heart-lung machine. Bleeding complications during and after surgery were analyzed in detail and compared with 16 patients without adsorption., Results: In the Cytosorb adsorption group, no rethoracotomies had to be performed. Drainage volumes in 24 hours were only 350 mL (interquartile range: 300 to 450 mL) after ticagrelor administration and 390 mL (interquartile range: 310 to 430 mL) after rivaroxaban therapy. In the majority of patients, transfusions of blood products were not needed. Compared with that group, among the group of patients without adsorption, multiple bleeding complications occurred. These were associated with longer total operation (p = 0.0042), higher drainage volumes (p = 0.0037), more transfusions of red blood cells (p = 0.0119) and platelets (p = 0.0475), a significantly higher rethoracotomy rate (p = 0.0003), significantly prolonged stay in the intensive care unit (p = 0.0141), and a longer hospital stay (p = 0.0244)., Conclusions: The intraoperative use of Cytosorb adsorption of ticagrelor and rivaroxaban in emergency open heart operations is reported for the first time. The data show that the strategy is safe and is an effective method to reduce bleeding complications. We recommend the use for safety in patients with ticagrelor or rivaroxaban undergoing emergency cardiac surgery., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: Antegrade-transseptal approach to treat left ventricular tachyarrhythmia (LVT) is useful and widespread. Meanwhile, Mitraclip has been recently introduced as an alternative to mitral valve surgery for severe mitral regurgitation, usually coexisting with ventricular arrhythmias. However, data on the antegrade approach for mapping and ablating LVT in these patients are insufficient. We evaluated the feasibility and clinical impact of the antegrade approach for LVT after Mitraclip implantation., Methods and Results: We included five patients (all men; age 72.6 ± 10.5 years) with Mitraclip implantation who underwent catheter ablation for LVT and employed the antegrade approach. Post-ablation mitral valve function was systematically evaluated by transthoracic echocardiography. Six procedures with the antegrade approach were performed on the five patients; three of these patients developed electrical storm. The number of implanted Mitraclip was 1 in two patients, 2 in two patients, and 3 in one patient, for a mean duration of 417 ± 324 days before ablation. After 117-day median follow-up, there was no recurrence of electrical storm, but ventricular tachyarrhythmia recurred and required implantable cardioverter defibrillator therapy in one patient (only sporadic anti-tachycardia pacing); two patients died because of reasons other than ventricular arrhythmia. There was no procedure-related injury on the mitral valve immediately and 3 months after ablation., Conclusions: Antegrade ablation of LVT after Mitraclip implantation may be feasible. Non-arrhythmic death during follow-up suggested the need for comprehensive evaluation before and after ablation.

The objective of this study was to assess the results of catheter-based and surgical reinterventions in primary mitral regurgitation after failed MitraClip therapy. We report on 21 consecutive symptomatic patients with primary mitral regurgitation (median age 78 years) who underwent either repeat MitraClip therapy (n = 7) or mitral valve surgery (n = 14) after failure of the index procedure with 1-2 MitraClip implantations. At the time of reinterventions, 193 (interquartile range [IQR]: 32-622) days after the index procedure, patients had recurrent or persistent grade 3 mitral regurgitation. Early mortality at 30 days was 4.8%. Cardiac-related survival at 2 years was 85.4% (4 cardiac and 4 noncardiac deaths). Three of 7 patients with percutaneous reintervention were converted to surgery at 34, 52, and 56 days because repeat MitraClip therapy was ineffective because of pre-existing clip detachment or leaflet tear. Final therapy was biological mitral valve replacement in 14 of 21 patients (66.7%); 4 were treated with percutaneous repeat MitraClip repair (19%), and in 3 patients, surgical repairs were performed (14.3%). At follow-up with a median of 708 days, New York Heart Association class had improved significantly to class 2 (IQR: 1.0-2.5) (P = 0.0004), and the left ventricular end-diastolic diameter had decreased from 56 (IQR: 52-59) mm to 51 (48-58) mm (P = 0.0378), respectively. Recurrence of significant mitral regurgitation was absent in all but 1 patient with unsuccessful repeat MitraClip therapy who was deemed inoperable. Our data show that both repeat MitraClip and also mitral valve surgery are feasible and safe alternatives in patients without an excessively increased perioperative risk. We conclude that whenever leaflet insertion is not compromised, repeat catheter-based repair is a reasonable redo concept; in the remaining cases, surgery should be offered to the patient., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The study was performed to analyze the results of open-heart surgery and bleeding complications after administration of novel oral anticoagulants (NOAC)., Methods: We investigated 81 consecutive patients (median age 74 years, interquartile range [IQR]: 68 to 78) who underwent open-heart operations at our institution between July 2014 and June 2016. All patients presented for surgery while on NOAC therapy: 37 received rivaroxaban (45.7%), 35 apixaban (43.2%), and 9 dabigatran (11.1%). The calculated risk using the European System for Cardiac Operative Risk Evaluation II was 3.5% (IQR: 2.0% to 8.1%)., Results: Surgery was performed at a median 4 days (IQR: 3 to 6) after NOAC withdrawal. Reduced renal function was predictive for length of intensive care unit stay and administration of red blood cells (p < 0.0001 and p = 0.0291, respectively). The NOAC withdrawal interval significantly influenced postoperative drainage volume (p = 0.0056). Five patients needed rethoracotomy because of relevant bleeding (6.2%), 4 after apixaban (11.4%) and 1 after rivaroxaban therapy (2.7%). Apixaban showed a borderline influence on prolonged intensive care unit stay (p = 0.0736). Prolonged cardiopulmonary bypass time was predictive for thrombocyte administration (p = 0.0249). Intensive care unit stay was 2 days after NOAC withdrawal of 10 days, compared with 4.2 days without termination. Thirty-day mortality was 3.7%., Conclusions: A lengthy NOAC withdrawal period, particularly for patients with reduced renal function, is essential for safe open-heart surgery. We conclude that despite official recommendations, patients should whenever possible not be considered for elective cardiac surgery within 10 days of terminating NOAC treatment., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

While there have been huge advances in the field of biosensors during the last decade, their integration into a microfluidic environment avoiding external tubing and pumping is still neglected. Herein, we show a new microfluidic design that integrates multiple reservoirs for reagent storage and single-use electrochemical pumps for time-controlled delivery of the liquids. The cartridge has been tested and validated with a silicon nitride-based photonic biosensor incorporating multiple optical ring resonators as sensing elements and an immunoassay as a potential target application. Based on experimental results obtained with a demonstration model, subcomponents were designed and existing protocols were adapted. The newly-designed microfluidic cartridges and photonic sensors were separately characterized on a technical basis and performed well. Afterwards, the sensor was functionalized for a protein detection. The microfluidic cartridge was loaded with the necessary assay reagents. The integrated pumps were programmed to drive the single process steps of an immunoassay. The prototype worked selectively, but only with a low sensitivity. Further work must be carried out to optimize biofunctionalization of the optical ring resonators and to have a more suitable flow velocity progression to enhance the system's reproducibility.

Background: This study analyzed the results of atrial fibrillation (AF) ablation concomitant to open heart operations using continuous monitoring., Methods: We investigated 70 consecutive patients (mean age, 72.1 ± 6 years; European System for Cardiac Operative Risk Evaluation II: 9.7% ± 8.2%) who underwent AF ablation concomitant to cardiac operations in our institution between February 2012 and February 2013. For precise rhythm analysis we implanted Reveal XT devices (Medtronic Inc, Minneapolis, MN) in all patients at the end of operations. Twenty-two patients had paroxysmal (31.4%), 20 persistent (28.6%) and 28 longstanding-persistent AF (40%). AF duration time was at a median 18 months. Cardiac rhythm data were obtained by telemonitoring at 1-month intervals, and the AF burden was calculated at 3, 6, and 9 months and at 1 year postoperatively (ablation procedure success was defined as a burden of ≤ 0.5%). Further, a neurologic follow-up was performed at 1 year postoperatively., Results: Overall survival was 95.7% at 30 days and 84.3% at 1 year. At 1 year, 66.7% of patients were in stable sinus rhythm, and AF burden was significantly reduced even in nonresponders: 88.2% of patients were off antiarrhythmic drugs, and oral anticoagulation had been stopped in 92.1%. No late neurologic events had occurred. Sinus rhythm at discharge and paroxysmal type of AF were predictive for later sinus rhythm (p = 0.04 and p = 0.048, respectively)., Conclusions: Considering the long AF duration and the high proportion of longstanding-persistent AF, the overall success of ablation procedures was satisfactory. Even though oral anticoagulation was stopped in most patients, no neurologic events were detected., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The objective of this study was to analyze the results of open heart mitral valve operations for survival prediction in patients with previously unsuccessful MitraClip procedures., Methods: Thirty-three consecutive patients who underwent mitral valve surgery in our institution were studied. At a median of 41 days, they had previously undergone one to five futile MitraClip implantations. At the time of their operations, patients were 72.6 ± 10.3 years old, and the calculated risk, using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, was a median of 26.5%. Individual outcomes were recorded, and all patients were monitored postoperatively., Results: Thirty-day mortality was 9.1%, and the overall survival at 2.2 years was 60.6%. Seven cardiac-related and six noncardiac deaths occurred. Univariate survival regression models demonstrated a significant influence of the following variables on survival: EuroSCORE II (p = 0.0022), preoperative left ventricular end-diastolic dimension (p = 0.0052), left ventricular ejection fraction (p = 0.0249), coronary artery disease (p = 0.0385), and severe pulmonary hypertension (p = 0.0431). Survivors showed considerable improvements in their New York Heart Association class (p < 0.0001), left ventricular ejection fraction (p = 0.0080), grade of mitral regurgitation (p = 0.0350), and mitral valve area (p = 0.0486). Survival after mitral repair was not superior to survival after replacement., Conclusions: Indications for surgery after failed MitraClip procedures must be considered with the greatest of care. Variables predicting postoperative survival should be taken into account regarding the difficult decision as to whether to operate or not. Our data suggest that replacement of the pretreated mitral valve is probably the more reasonable concept rather than complex repairs. When the EuroSCORE II at the time of surgery exceeds 30%, conservative therapy is advisable., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to assess procedural details and outcomes of repeat MitraClip therapy., Background: MitraClip implantation is a safe and efficacious percutaneous approach to treat significant mitral regurgitation (MR)., Methods: Of 410 inoperable or high surgical risk patients treated with the MitraClip at our institution, 17 (4.1%) patients, as well as 4 patients initially treated at external institutions, underwent repeat MitraClip procedures. Mean age of the 21 patients (14 men [67%]) was 77 years; 15 patients (71%) had functional MR., Results: Repeat procedures performed at a median of 6.3 months (range 0.7 to 34 months) after the index intervention were successful (discharge MR grade ≤2+) in 13 patients (62%), with a pronounced difference in success rate observed between the 13 patients with adequate leaflet insertion at the time of the repeat intervention and the 8 patients in whom loss of leaflet insertion (LLI) (leaflet tear/perforation or partial clip detachment) was present (11 of 13 [85%] vs. 2 of 8 [25%], respectively). The 21 patients were followed for a median of 8.5 (interquartile range: 2.3 to 18.6) months; 13 patients (62%), 8 with adequate leaflet insertion and 5 with LLI, died during follow-up., Conclusions: Repeat MitraClip intervention for significant recurrent MR appears to be a viable therapeutic approach in patients in whom leaflet insertion into the MitraClip is not compromised. LLI is strongly associated with repeat procedural failure., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To report the first described case of a mitral valve infective endocarditis (IE) post MitraClip®., Methods and Results: An 88-year-old patient at high surgical risk (log. EuroSCORE 30.4%) underwent a MitraClip procedure for severe eccentric organic mitral regurgitation (MR) due to prolapse with a flail leaflet of the P2 segment (flail gap 6 mm). After one month, the patient was readmitted to our department for fever and recurrence of shortness of breath. An echocardiogram demonstrated severe MR recurrence due to ulceration in the region of the posterior leaflet despite good insertion of both clips, and a large vegetation of 1513 mm within the clip region. Blood cultures were positive for staphylococcus aureus. The patient was treated by cardiac surgery with mitral valve replacement due to IE despite a very high logistic EuroSCORE of 56.8%. Histological and bacteriological analysis of the clip devices confirmed active IE. After cardiac surgery, transthoracic echocardiography showed no mitral regurgitation and a mean gradient across the mitral valve bioprosthesis of about 5 mmHg. The patient was discharged to a rehabilitation department 15 days after cardiac surgery., Conclusions: Surgical treatment as bail-out therapy for MR recurrence secondary to IE after MitraClip can be successfully carried out despite a high surgical risk.

Background: This study analyzed the effect of failed percutaneous mitral intervention with the MitraClip device (Abbott Laboratories, Abbott Park, IL) on subsequent mitral valve (MV) operations., Methods: Nineteen patients (74 ± 9 years) with treatment failure after implantation of 37 MitraClips (mean, 1.9 ± 0.8; range, 1 to 4) for functional or degenerative MV disease underwent operations a median of 12 days later (range, 0 to 546 days). All patients were studied before and after the operation by clinical investigation and echocardiographic analysis. Intraoperative findings and the effect on the operation were analyzed and are described in detail. Data before clipping and at the time of operation were compared, and the surgical outcome was recorded., Results: There was a significant increase in risk between that at the time of clipping and that at subsequent operations, noted as a rise of the European System for Cardiac Operative Risk Evaluation II from a median 12.74% to 26.87%, respectively (p < 0.0001, Wilcoxon signed rank test). Severe clip implantation-induced tissue damage was found in most patients. Surgical MV repair could be performed in 5 of 6 patients (83%) with a 1-clip implant and in only 3 of 13 patients (23%) when 2 or more clips had been inserted (p = 0.0188, Wilcoxon-Mann-Whitney test). All patients required other associated procedures: closure of an artificial atrial septal defect that was caused by the clipping procedure (100%), tricuspid valve repair (37%), atrial fibrillation ablation operations (37%), coronary artery bypass grafting (16%), and aortic valve replacement (11%). Two early cardiac deaths (< 30 days) occurred. Survival at 1 year was 68%., Conclusions: There is a remarkable impact of failed clipping procedures on MV operations. We observed a severely aggravated cardiac pathology in parallel with a reduced preoperative clinical state compared with the original condition. Moreover, the likelihood of an optimal surgical solution with valve reconstruction was reduced thereafter. However, operations in the critical situation of an unsuccessful mitral clipping procedure should be discussed immediately, because it still seems to be an option compared with conservative therapy., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Recent data suggest continuous monitoring by implanted loop recorder (ILR) to be the criterion standard for rhythm surveillance after atrial ablation. Studies describing patient compliance and pitfalls in the perioperative period are lacking. It was the aim of this study to evaluate patient compliance and time invested by physicians for obtaining data during the follow-up period after implanting an ILR., Methods: We prospectively collected data of 70 consecutive patients undergoing concomitant cardiac surgery, atrial ablation, and implantation of an ILR. Patient compliance was calculated as the ratio of incoming/expected data transmission. We documented total time spent by physicians with preoperative and postoperative supervision., Results: Between February 2012 and February 2013, a total of 70 patients had an ILR implanted; 49 of 70 patients were eligible for evaluation of data at 3-month follow-up. The ratio of incoming/expected data transmission was 12/49 (24%). The mean ± SD time spent with ILR-related issues during hospital stay was 88 ± 19 minutes. Assessment of incoming data and information of the patient and the general practitioner took 132 ± 13 minutes per patient. Overall, a mean ± SD of 220 ± 16 minutes per patient was needed for appropriate data acquisition, from implantation to first data transmission., Conclusions: In the patients having an ILR after surgical atrial ablation, initial compliance regarding data transmission was low. A substantial time effort was necessary to obtain sufficient data on cardiac rhythm. Device-related complications were observed. Patient selection should therefore be handled with care. Beneficial therapeutic decisions can be expected only when reliable data are obtained by efficient management.

Objective: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence., Methods: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5-33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery., Results: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return ( P < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis ( P < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm., Conclusions: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: This analysis was undertaken to evaluate the results of persistent atrial fibrillation ablation procedures concomitant to open surgery and to identify risk factors for persistent atrial fibrillation recurrence., Methods: Since 2001, a total of 325 consecutive patients with persistent atrial fibrillation (duration, 0.5-33 years) have undergone persistent atrial fibrillation ablation concomitant to open surgery by creating 2 encircling isolation lesions around the left and right pulmonary veins and a connecting lesion between both with the use of radiofrequency ablation procedures. Patients were restudied at discharge, 3 months, and 3 years after surgery., Results: Survivals at the time of reexamination at discharge, 3 months, and 3 years were 97.8%, 96.2%, and 94.4%, respectively. Stable sinus rhythm could be documented in 72.1%, 73.9%, and 75.6% of surviving patients, respectively. Long-term persistent atrial fibrillation before surgery and a larger left atrium were predictive of postoperative persistent atrial fibrillation return (P<.001). Statistical analysis demonstrated cutoff points of 5 years for persistent atrial fibrillation and 55 mm for left atrium diameter; 89.7% of patients with persistent atrial fibrillation duration of less than 5 years and 84.5% of patients with left atrium size of 55 mm or less were in stable sinus rhythm at late follow-up. Cardiac rhythm at discharge and at 3 months was predictive of long-term rhythm prognosis (P<.001). Age, gender, concomitant diseases (eg, arterial hypertension, diabetes, renal insufficiency, or pulmonary disease), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm., Conclusions: The duration of persistent atrial fibrillation and the size of the left atrium are the most reliable preoperative variables to predict the success rate of ablation concomitant to open surgery. The probability of reestablishing stable sinus rhythm is excellent when persistent atrial fibrillation duration is short and left atrium size is small., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Catheter-based techniques of percutaneous valve intervention are recently being performed in an increasing number of patients. We finally report a case of successful, but complex surgical mitral valve repair 32 days after failed percutaneous intervention with severely aggravated mitral pathology caused by the catheter-based procedure. It is outlined that the conditions for surgery can be severely deteriorated, thereby reducing the chance for successful surgical repair after preceding mitral intervention., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to evaluate diastolic and systolic strain rate measurements for differentiation of transmural/nontransmural infarction during dobutamine stress echocardiography (DSE). An ameroid constrictor was placed around the circumflex artery in 23 pigs inducing chronic vessel occlusion. Five pigs without constrictor served as controls. During high-dose DSE systolic strain rates (SR(sys)), systolic and postsystolic strain values (epsilon(sys), epsilon(ps)) and early and late diastolic strain rates (SR(E) and SR(A)) were determined. At week 6, animals were evaluated regarding myocardial fibrosis. Histology revealed nontransmural in 14 and transmural infarction in 9 animals. In controls, dobutamine induced a linear increase of SR(sys) to 12.3 + or - 0.4 s(-1) at 40 microg/kg per minute (P = 0.001) and a linear decrease of SR(E) to -6.6 + or - 0.3 s(-1) (P = 0.001). In the nontransmural group, SR(sys), epsilon(sys), epsilon(ps) at rest, and during DSE were higher and SR(E) was lower than in the transmural infarction group (P = 0.01). Best predictors for viability were SR(sys) (ROC 0.96, P = 0.0003), SR(E) at 10 microg/kg per minute dobutamine stimulation (ROC 0.94, P = 0.001) and positive SR values during isovolumetric relaxation at 40 microg/kg per minute dobutamine (ROC 0.86, P = 0.004). The extension of fibrosis correlated with SR(sys) at rest, epsilon(sys) at rest, and SR(E) at rest (P < 0.001). For the detection of viability similar diagnostic accuracies of SR(E) and SRsys were seen (sensitivity 93%/93%, specificity 96%/94%, respectively). Diastolic SR analysis seems to be equipotent for the identification of viable myocardium in comparison to systolic SR parameters and allows the differentiation of nontransmural from transmural myocardial infarction with high diagnostic accuracy. (Echocardiography 2010;27:552-562).

Background: The aim of this study was to evaluate the cardioprotective effects of bone marrow-derived stem cells on myocardial compliance in a chronic ischemia model regarding strain rate (SR) parameters during dobutamine stress echocardiography (DSE)., Methods: Ameroid constrictors were placed around the circumflex arteries of 23 domestic pigs to induce chronic vessel occlusions. Fifteen pigs received transendocardially bone marrow derived stem cells, and 8 received placebo injections (a 0.9% solution of NaCl) into the ischemic region. At week 6, the animals were evaluated regarding myocardial fibrosis, neovascularization, apoptosis, and diastolic function during DSE., Results: Stem cell-injected hearts showed significantly less fibrosis, higher ejection fractions, significant neovascularization, and less ventricular dilatation than controls (P < .05). Strain rate imaging revealed improved diastolic function, with higher early diastolic SR values and lower E/Ea ratios compared with controls (P < .05). Early diastolic SR during DSE identifies viable myocardium (extent of fibrosis, r = 0.86, P = .0001)., Conclusion: The endocardial injection of stem cells improves diastolic function in chronic ischemic myocardium and helps attenuate postinfarction remodeling.

Background: Cell injection therapies have been introduced for the treatment of patients with coronary heart disease. However, intramyocardial injection of bone marrow (BM)-derived cells may generate proarrhythmogenicity., Methods: Two weeks after the placement of a circumflex artery-ameroid constrictor, 21 pigs received mesenchymal stem cells (MSC, n = 9), mononuclear (BM)-derived stem cells (MNC, n = 6), and placebo (n = 6) using a electromechanical mapping (EMM)-guided percutaneous transendocardial injection catheter. At week 6, EMM was repeated and the injected areas were analyzed in detail to evaluate local bipolar electrogram fragmentation, duration, and amplitude. Myocardial fibrosis was evaluated by a quantitative histological analysis., Results: At week 6, the injection of MSC or MNC did not increase local electrogram fragmentation (MSC group: 1.4 +/- 0.3 vs. 1.3 +/- 0.2; MNC group: 1.4 +/- 0.2 vs. 1.3 +/- 0.2; P = NS), prolong electrogram duration (MSC group: 27.1 +/- 7.8 ms vs. 23.7 +/- 2.0 ms; MNC group: 27.8 +/- 3.5 ms vs. 26.8 +/- 5.6 ms; P = NS), or decrease bipolar voltages (MSC group 2.7 +/- 0.9 mV vs. 2.8 +/- 1.0 mV; MNC group 2.0 +/- 1.0 mV vs. 1.7 +/- 0.4 mV). From week 2 to week 6, mean left ventricular ejection fraction increased in the MSC group (37.9 +/- 4.2% vs. 45.9 +/- 2.2%; P = 0.039) only. Histological analysis of the ischemic regions revealed 17.6 +/- 5% myocardial fibrosis in the MNC group vs. 13.6 +/- 3.4% MSC vs. 28.7 +/- 8.7% in the control group (P = 0.038 and P = 0.013). No death occurred in any animal after the injection procedure., Conclusion: Intramyocardial injection of MSC or MNC do not increase fragmentation and duration of endocardial electrograms in the injected ischemic myocardium but attenuate ischemic damage and therefore may not create an electrophysiological substrate for reentry tachycardias.

Background: The aim of this study was to evaluate potential cardioprotective effects of bone marrow-derived stem cells in chronic ischemic myocardium regarding strain rate parameters during dobutamine stress echocardiography., Methods: An ameroid constrictor was placed around the circumflex artery in 23 pigs to induce hibernating myocardium. Pigs received autologous mesenchymal stem cells (auto MSCs), allogeneic MSC (allo MSC), autologous mononuclear cells (auto MNCs), or placebo injections into the ischemic region. During dobutamine stress echocardiography, peak systolic strain rates (SR(sys)) and systolic and postsystolic strain values (epsilon(sys), epsilon(ps)) were determined. The animals were evaluated regarding myocardial fibrosis, neovascularization, apoptosis, and myocardial beta-adrenergic receptor density., Results: The median ejection fraction was reduced in the control group compared with the auto MSC-, allo MSC-, and auto MNC-treated pigs (36.5% vs 46.0% vs 46.0% vs 41.5%; P = .001, respectively). Histopathology revealed a decreased myocardial fibrosis in auto MSC- (16.3%), allo MSC- (11.3%), and auto MNC- (16.7%) treated pigs compared with controls (31.0%; P = .004). The fibrosis and echocardiographic deformation data correlated in the posterior walls: rest peak SR(sys)r = -0.92; epsilon(sys)r = -0.86; 10 microg dobutamine stimulation peak SR(sys)r = -0.88, epsilon(sys), r = -0.87 (P = .0001)., Conclusion: Endocardial injection of stem cells may induce cardioprotective effects in chronic ischemic myocardium and helps to keep the ischemic myocardium viable.

Objective: The study investigates the early and late results of permanent atrial fibrillation (AF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery., Methods: Between February 2001 and April 2006, a selective group of 80 patients with permanent AF (median: 48 months [Perc25/75 24/110; range: 6 - 360 months]) underwent either bipolar (n = 60) or monopolar (n = 20) radiofrequency (RF) ablation procedures concomitant to CABG and/or AV surgery (CABG: n = 39; AV: n = 30; AV + CABG: n = 11). All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (30 +/- 15 months). Data were analyzed exploratively., Results: Survival at 3 and 30 months was 98 % and 96 %, respectively. Stable SR could be documented in 73 % and 77 % of patients. Long-term AF before surgery and larger LA size were predictive for AF return after surgery ( P = 0.004 and P = 0.032, respectively). Neither age, gender, the application modus of the RF energy nor the underlying cardiac disease influenced the postoperative cardiac rhythm significantly. NYHA class improved significantly after surgery ( P < 0.0005), particularly when stable SR was achieved ( P = 0.049)., Conclusion: Preoperative permanent AF duration time and larger LA size are useful variables to predict the success rate of concomitant ablation surgery in CABG and/or AV patients. Further it could be demonstrated that established SR remained stable over time.

This study analyses the 5-year results of permanent atrial fibrillation (pAF) bipolar radiofrequency (RF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. Eighty-five patients with pAF (0.5-30 years) underwent bipolar RF ablation procedure concomitant to CABG/AV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class at 8+/-1 days and at 3+/-1 and 32+/-15 months after surgery. Survival at time of re-examination was 100%, 98% and 96%, respectively (three non-cardiac deaths), SR could be documented in 61%, 74% and 78% of patients. Long-term AF before surgery and larger size of the left atrium (LA) were predictive for postoperative AF return (P=0.005, P=0.03); 88% of patients with small preoperative LA-size (<50 mm) and 85% with pAF-duration time <5 years had stable SR at late follow-up. Cardiac rhythm at three months was predictive for long-term rhythm-prognosis (P<0.0001). NYHA-class improved significantly after surgery (P<0.0005), particularly when SR was achieved (P=0.046). Permanent AF bipolar RF ablation surgery revealed excellent results in AV/CABG patients. It could be demonstrated that established SR remained stable over time. Preoperative pAF-duration time and LA-size are useful variables to predict the success rate of ablation.

Objective: This study investigated the early and late results of restrictive mitral valve (MV) annuloplasty in patients with chronic mitral regurgitation (MR) and advanced ischemic (ICM) or dilated cardiomyopathy (DCM)., Methods: From October 2001 to September 2006, 121 patients (age: 69 +/- 9 years) with a left ventricular ejection fraction (LVEF) of 30 +/- 9 % and chronic MR grade 3 - 4 (ICM: n = 102, DCM: n = 19) underwent restrictive prosthetic ring annuloplasty (downsizing of 2.7 +/- 0.8 ring sizes). Eighty-five ICM-patients had indications for concomitant coronary artery bypass grafting (CABG). All patients were restudied at 7 +/- 1 days, 3 +/- 1 and 30 +/- 12 months after surgery to assess survival, residual MR, New York Heart Association (NYHA) class and left ventricular (LV) function (end-systolic/end-diastolic dimensions/volume indexes and LVEF). Data were analyzed exploratively., Results: 30-day mortality was 3.3 %; survival at follow-up was 95 % and 91 %, respectively. Postoperative recurrence of significant MR (> grade 2) was absent in all patients. NYHA class, LV dimensions/volume indexes and LVEF improved significantly after surgery in both groups ( P < 0.0005). A prediction of continuous postoperative improvement of myocardial function in the sense of reverse remodeling could be demonstrated by univariate logistic regression for ischemic etiology and concomitant CABG ( P = 0.0001). In DCM-patients or ICM-patients without CABG, the postoperative benefit on myocardial function was limited., Conclusion: Restrictive mitral valve (MV) annuloplasty corrected chronic MR in cardiomyopathy patients with low mortality and improved contractility. Surgery also prevented recurrence of significant MR, although the phenomenon of postoperative continuous reverse myocardial remodeling could not be verified in cases with a non-ischemic etiology or ICM without concomitant CABG.

Objective: The aim of this study was to evaluate the early and late results of a permanent atrial fibrillation (pAF) ablation concept carried out concomitantly with mitral valve (MV) surgery and to identify risk factors for ablation surgery failure., Methods: Between February 2001 and April 2006, 109 patients with pAF over a median time of 48 months (Perc25/75; range 6 - 396 months) underwent monopolar endocardial radiofrequency ablation procedures concomitantly with MV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (36 +/- 19 months). For data assessment an explorative data analysis including univariate and multivariate binary logistic regression was performed., Results: Early and late survival was 95 % and 91 %, respectively; at follow-up stable SR was documented in 76 % (74 %) of patients. NYHA class improved significantly after surgery ( P = 0.009), particularly when stable SR was achieved ( P = 0.042). Among these MV patients left atrial (LA) enlargement and pAF of long-time duration prior to surgery were detected as risk factors for postoperative recurrence and persistence of atrial fibrillation ( P = 0.026 and P = 0.002); furthermore, advanced age and significant tricuspidal regurgitation at the time of surgery were also relevant. The best prediction (95 % of patients) for SR, as demonstrated in a multivariate model, was based on the factors LA size and pAF duration ( P = 0.052 and 0.005)., Conclusion: Particularly the preoperative LA size and pAF duration seem to be useful parameters to evaluate the success rate of ablation performed concomitantly with MV surgery. It could be demonstrated that an established SR remains stable over time.

Background: This study analyzed 7 years of results for monopolar endocardial radiofrequency (RF) ablation of permanent atrial fibrillation (pAF) concomitant to mitral valve (MV) surgery., Methods: Between 2001 and 2007, 152 patients who had experienced pAF for a median of 4.0 years (interquartile range, 1.5-8.0 years; range, 0.5-33 years) underwent monopolar endocardial RF ablation procedures (pulmonary vein isolation plus a connecting lesion) concomitant to MV surgery. All patients were reexamined to assess survival, conversion rate to stable sinus rhythm (SR), and New York Heart Association (NYHA) class at 8 +/- 1 days after surgery and follow-ups at 3 +/- 1 months and 41 +/- 24 months postoperatively. Data were analyzed exploratatively., Results: The survival rates at the 3 reexamination times were 97%, 95%, and 92%, respectively (6 cardiac and 6 noncardiac deaths), and the corresponding SR rates were 74%, 75%, and 73%. The NYHA class of the patients improved significantly after surgery (P = .006), particularly when a stable SR had been achieved (P = .039). Long-term pAF prior to surgery and a larger left atrium (LA) preoperatively were predictive of the return of postoperative AF (P = .0002, and P = .0003, respectively). Ninety-one percent of the patients with a preoperative pAF duration of <5 years and 88% of the patients with an LA size of

Background: This study investigated the results of restrictive mitral annuloplasty with the semirigid Carpentier-Edwards Physio ring in patients with moderately severe to severe chronic ischemic mitral regurgitation (IMR) and advanced ischemic cardiomyopathy (ICM)., Methods: From 2003 to 2007, 100 consecutive patients (mean age +/- SD, 69 +/- 10 years) with chronic IMR of grades 3 to 4 (3.6 +/- 0.5) and a left ventricular ejection fraction (LVEF) of 31% +/- 9% (range, 12%-45%) underwent standardized restrictive prosthetic ring annuloplasty (ie, downsizing of 2.7 +/- 1.0 [range, 2-4] ring sizes) and concomitant coronary artery bypass grafting. All surviving patients were restudied 8 +/- 1 days, 3 +/- 1 months, and 2.5 +/- 1.0 years after surgery to assess survival, residual MR, New York Heart Association (NYHA) class, and LV function (end-systolic and end-diastolic dimension/volume indices and LVEF). Data were analyzed exploratatively., Results: Survival rates at the postoperative reexamination times were 98%, 97%, and 94%, respectively (1 noncardiac and 5 cardiac deaths). NYHA class improved from 3.5 +/- 0.5 to 1.4 +/- 0.5 (P < .0005). The residual MR grades at discharge, early follow-up, and late follow-up were 0.4 +/- 0.5, 0.5 +/- 0.5, and 0.4 +/- 0.6, respectively (P < .0005). Post-operative recurrence of significant IMR (>grade 2) was absent in all patients. The leaflet coaptation height was 8 +/- 1 mm and did not decrease significantly over time. All LV dimension and volume indices and the LVEF (41% +/- 9% at 2.5 years) improved significantly after surgery (P < .0005), even in patients with initially severely reduced myocardial function and a preoperative LVEF of <30% (n = 42; LVEF, 22% +/- 5% versus 33% +/- 6% at late follow-up; P < .0005)., Conclusion: Restrictive mitral valve annuloplasty using the semirigid Physio ring corrected chronic IMR in ICM patients with very low mortality and improved contractility. Surgery also prevented recurrence of significant IMR in parallel with the phenomenon of postoperative continuous reverse myocardial remodeling.

Aims: The aim of this study was to investigate whether erythropoietin (EPO) has cardioprotective effects in a chronic myocardial ischaemia model regarding strain-rate imaging parameters during dobutamine stress echocardiography (DSE)., Methods and Results: An ameroid constrictor was placed around the circumflex artery in 13 pigs to induce hibernating myocardium by a chronic vessel occlusion. The pigs were randomized 14 days later: seven pigs receiving 10,000 U EPO and six pigs receiving placebo injected into the ischaemic region using a NOGAtrade mark-guided transendocardial catheter. At weeks 2 and 6, animals were examined by DSE, electromechanical mapping, and coronary angiography. During incremental dobutamine infusion, regional radial function was monitored by measuring peak systolic strain-rates (SRsys), systolic strains (epsilonsys), and post-systolic strains (epsilonps). At week 6, the animals were pathohistologically investigated. Echocardiography revealed 2.2+/-0.8 hypokinetic segments in the EPO-treated animals in comparison with 3.3+/-0.9 akinetic segments per animal in the controls. The mean ejection fraction was reduced in the control group (55+/-3 vs. 66+/-4%, P=0.057). Strain-rate imaging revealed ischaemic myocardium in EPO-treated animals and non-viable myocardium in the controls (P=0.0001). Histological analysis of the ischaemic region revealed a reduction of myocardial fibrosis (8+/-1 vs. 27+/-5%) in the EPO-treated group. The transmural extension of fibrosis and the echocardiographic deformation data correlated in the posterior walls (EPO group): epsilonsys at rest r=0.83; peak SRsys during dobutamine stimulation r=0.92, P=0.01., Conclusion: Endocardial EPO injection may induce cardioprotective effects in chronic ischaemic myocardium and helps to obtain the myocardial contractile reserve, objectified by ultrasonic strain-rate imaging.

Objective: At present not much data is available on changes in myocardial function after combined coronary artery bypass grafting (CABG) and downsizing of the mitral valve (MV) by restrictive prosthetic ring annuloplasty in patients with chronic ischemic mitral regurgitation (IMR) and advanced cardiomyopathy., Methods: 63 patients with coronary artery disease, chronic IMR grade 3 - 4+, ischemic cardiomyopathy and reduced left ventricular (LV) function (LV ejection fraction [LVEF] of 30 +/- 9 %; range 12 - 45 %) underwent combined CABG and MV downsizing. Clinical follow-up and serial echocardiographic studies were performed to assess survival, New York Heart Association (NYHA) class, mitral regurgitation (MR), leaflet coaptation height (LCH), left atrial (LA) and LV end-systolic/end-diastolic dimensions/volumes and volume indices (LVESD, -EDD; LVESV, -EDV; LVESVI, -EDVI), fractional shortening (FS) and LVEF to evaluate the changes in myocardial function after surgery., Results: Early mortality (< 30 days) was 1.6 %, survival at follow-up was 95 % (3 +/- 1 months) and 83 % (2 +/- 1 years), respectively. Functional class improved significantly after surgery; recurrence of relevant MR was absent in all patients. In general, LA/LV dimensions/volumes and volume indices, FS and LVEF improved significantly, even in patients with already severely reduced preoperative LV function (LVEF

Background: Apart from its well-known stimulation of erythropoiesis, erythropoietin (EPO) exhibits angiogenic and anti-apoptotic effects. These cellular protective effects have also been described in experimental acute myocardial infarction models. We investigated the effects of EPO in a porcine model of chronic progressive myocardial ischaemia., Methods: At weeks 2 and 6 after implantation of a circumflex ameroid constrictor, endocardial electromechanical NOGA system (Biosense Webster, Inc., California, USA) mapping of the left ventricle, coronary and ventricular angiography, as well as echocardiography were performed. Two weeks after ameroid placement, 13 pigs were randomized with 7 pigs receiving 10.000 U EPO and 6 pigs receiving placebo into the ischaemic region using a NOGA guided percutaneous transendocardial injection catheter, MYOSTAR. After 6 weeks, histology (Masson's Trichrome) was analyzed., Results: Endocardial electromechanical mapping showed an increase of mean unipolar voltage (UV) amplitude in the ischaemic myocardial segments in the EPO-treated animals (8.5 mV pre and 10.6 mV post treatment) and a significantly reduced ischaemic surface area compared to the control group (19% vs. 41%) suggesting a decline in ischaemic injury. Echocardiography revealed 2,2 hypokinetic segments of the lateral wall in the EPO group vs. 3,3 in the control groups. The mean ejection fraction was 64% in the EPO group and 55% in the placebo group. Quantitative histological analysis of the ischaemic regions revealed a reduction of myocardial fibrosis (8% vs. 28%) in the EPO group., Conclusion: Endocardial EPO injection may induce cardioprotective effects in hibernating myocardium and may attenuate the progression of ischaemic tissue damage.

Background: Data on combined permanent atrial fibrillation (pAF) surgery and coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are scarce, and the mid- and long-term effects on survival and cardiac rhythm are unknown., Material and Methods: In a prospective analysis 125 patients (Group I: CABG and/or AVR, n = 50; Group II: mitral valve [MV] surgery, n = 75) with pAF (> or = 6 months) underwent either concomitant monopolar (Group I: n = 20; Group II: n = 75) or bipolar (Group I: n = 30) radiofrequency (RF) ablation procedures. Group I patients had a significantly smaller left atrial (LA) size than Group II patients (LA-diameter: 47.7 +/- 4.6 vs. 58.2 +/- 6.1 mm; p < 0.01). Regular follow-up was performed from 3 to 36 months after surgery to assess survival, NYHA-class, and conversion rate to stable sinus rhythm (SR)., Results: Early mortality (< 30 days) of Group I patients was 0% (Group II: 2.7%), cumulative survival at long-term follow-up was 0.95 vs. 0.82 (p = 0.31) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At follow-up 80% of Group I patients had SR (Group II: 70%). In Group I patients the bipolar approach was associated with significantly shorter ablation procedure times compared to the monopolar procedure (12.1 +/- 3.4 vs. 18.9 +/- 1.6 min; p < 0.05)., Conclusions: Concomitant pAF ablation surgery in CABG and/or AVR is safe and at least as effective as in MV surgery, presumably because severe LA enlargement is exceptionally rare in this group.

Background: Even if permanent atrial fibrillation (pAF) is a frequent concomitant problem in patients undergoing open heart surgery and particularly in those with advanced age, data of pAF ablation surgery in older aged patients are scarce. This study was performed to assess early and late results of combined open heart surgery and pAF ablation procedures in patients with advanced aged, compared to young patients., Material and Methods: A selective group of 126 patients (Group A: age =70 [76.4+/-4.8] years, n=70; Group B: age <70 [62.0+/-6.2] years: n=56) with pAF (=6 months) underwent either monopolar (Group A, B: n=51 vs. n=44) or bipolar (Group A, B: n=19 vs. n=12) radiofrequency (RF) ablation procedures concomitant to open heart surgery. Regular follow-up was performed 3 to 36 months after surgery to assess survival, New York Heart Association (NYHA) class and conversion rate to stable sinus rhythm (SR)., Results: Early mortality (<30 days) was 2.9% in Group A (Group B: 0%), cumulative survival at long-term follow up was 0.78 vs. 0.98 (p=0.03) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At 12-months follow-up 73% of Group A patients were in stable SR (Group B 78%)., Conclusion: Concomitant mono- and bipolar RF ablation surgery represents a safe option to cure pAF during open heart surgery with a very low risk, even in patients with advanced age.

The use of a cellular therapy offers a promising approach for the treatment of heart disease. Besides other precursor cells, bone marrow (BM)-derived stem cells were discovered that migrate into ischemic myocardium and participate in myogenesis as well as angiogenesis. A subpopulation of those are the mesenchymal stem cells (MSC), which may be potential candidates for repairing ischemic heart tissue. MSC are easy to prepare and can be used in an autologous strategy. Here we demonstrate the effect of transplanted MSC in our autologous rat model of myocardial injury. BM was isolated from tibiae and femurs of Wistar rats. After 24 h, the adhering MSC were separated, expanded, retrovirally transduced using green fluorescent protein (GFP), and cloned. A cryo-infarct was generated in the rat hearts, and immediately after this the cells were injected into the border zone of the lesion. After a 10-week follow up, the hearts were excised and the myocardial scar areas were measured using computer-guided morphometry. When comparing transplanted rats (n = 8) with control animals (n = 5) treated rats demonstrated a significant reduction in the width (p < 0.05) of the myocardial scar area. The depth of the scars of the cell therapy rats was less extended (p > 0.05) and the myocardium of these animals was thicker than in the controls (p > 0.05). Immunohistochemical analyses revealed neither evidence of MSC transdifferentiation into cardiomyocytes, nor could an increased neovascularization be found. In conclusion, MSC are responsible for a remarkable reduction of the myocardial scar size in the treated animals. But, whether this strategy is directly transferable to the patient suffering from heart disease has to be determined. In addition, the mechanism by which MSC act in the ischemic heart remains to be determined.

Objective: Data of combined mitral downsizing by restrictive prosthetic ring annuloplasty and coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy and moderately severe to severe mitral regurgitation (MR) are rare, and little is known about the effect on reverse left ventricular (LV) and left atrial (LA) remodeling., Methods: Thirty-eight patients (70.6+/-8.3 years) with coronary artery disease, ischemic cardiomyopathy (LV ejection fraction [LVEF] 31+/-8%) and moderately severe to severe MR (grade 3.6+/-0.5) underwent CABG and mitral downsizing by 2-4 ring sizes. Clinical follow-up and serial transthoracic echocardiographic studies were performed after surgery (discharge, 3+/-0.5 months, 13+/-7 months) to assess survival, NYHA class, MR, leaflet coaptation height, LA and LV dimensions/volumes, fractional shortening (FS) and LVEF., Results: Early mortality (<30 days) was 2.6%, survival at follow-up was 92 and 85%, respectively. NYHA class improved from 3.3+/-0.6 to 1.5+/-0.6 (P<0.001). Residual MR at discharge and at follow-up was grade 0.5 and 0.6, respectively (P<0.001). Leaflet coaptation height was 8+/-1 mm and did not change over time. LV end-diastolic, end-systolic and LA dimensions decreased from 60+/-7 to 57+/-8 mm, from 47+/-9 to 42+/-9 mm and from 51+/-5 to 45+/-4 mm, FS increased from 23+/-9 to 28+/-10% (P<0.001); LV end-diastolic and end-systolic volumes decreased from 188+/-33 to 171+/-30 ml and from 129+/-35 to 105+/-33 ml, LVEF increased from 31+/-8 to 39+/-10% (P<0.001)., Conclusions: Combined mitral downsizing and CABG surgery was performed with excellent clinical results: only minimal residual MR, a significant reduction of LA dimension and an increase of LV contractility due to reverse remodeling were observed.

Objective: In our population permanent atrial fibrillation (pAF) is a frequent concomitant problem in patients undergoing open heart surgery. A 3-year experience with a treatment strategy using mono- and bipolar radiofrequency (RF) ablation procedures in a heterogeneous group of patients is reported., Methods: In a prospective analysis the incidence of pAF among all patients undergoing open heart surgery in our department between February 2001 and July 2004 was evaluated. In a second step a selective group of 106 patients with pAF (primary mitral: n=63; aortic: n=24; CABG: n=16; aortic+mitral: n=3) underwent either monopolar (n=86) or bipolar (n=20) RF ablation procedures creating two encircling isolation lesions around the left and the right pulmonary veins (PVs) and a connection line between both. In addition amiodarone was given for 3 months after surgery. Regular follow-ups were performed 3, 6, 9, 12, 18, 24 and 36 months after surgery., Results: The incidence of pAF in the total group of 4.110 patients was 3.6%. While the rate was low in cases without severe heart valve disease (1.1%), a significantly higher presence of pAF in patients scheduled for heart valve surgery (10.3%) was observed (P<0.0001). The incidence was 30-39% in patients with degenerative and rheumatic mitral valve (MV) disease, and further particularly high in the older aged compared to younger patients (4.2-8.3% at 70-99 years; P<0.001). Hospital mortality after combined open heart and RF ablation surgery was 1.9%. Whereas patients with small left atrial size (LA-diameters <56 mm; n=59) had SR in almost 90% at follow-up, LA enlargement (LA-diameter > or =56 mm; n=47) was associated with a significant risk of persisting pAF after surgery (P=0.033, 0.002 and 0.006 at 3, 6 and 9 months follow-up)., Conclusion: The use of RF ablation procedures in combination with amiodarone therapy represents a safe and efficient option to cure pAF during open heart surgery in a selective group of patients. The preoperative LA size was of significant importance for the outcome in this investigation.

Objective: In our population, permanent atrial fibrillation (pAF) is a serious concomitant problem in patients scheduled for open heart surgery. The high incidence necessitates reliable methods of treating pAF efficiently. We report our 3-year experience with a safe concept of using monopolar and bipolar radiofrequency (RF) ablation procedures., Methods: Ninety patients (mitral, n = 56; aortic, n = 22; aortic and mitral, n = 1; coronary artery bypass grafting, n = 11) underwent either monopolar (n = 77) or, recently, bipolar (n = 13) RF ablation procedures that produced encircling isolation lesions around the left and the right pulmonary veins (PVs) and a connection line between the two. Amiodarone was given for 3 months after surgery., Results: Hospital mortality was 2.2%. At follow-up, 75% of the patients were in stable sinus rhythm (SR). Preoperative pAF duration, etiology of heart disease, and type of RF energy application were not predictive of the risk of persisting pAF after surgery. Whereas patients (50 of 90) with small preoperative left atrial (LA) diameters (<56 mm) had SR in almost 90% of cases, large preoperative LA diameters (>or=56 mm; 40 of 90 patients) were associated with a significant risk of persisting pAF (P < .05)., Conclusion: Particularly in cases of small preoperative LA diameters, isolation of the PVs using either monopolar or bipolar RF ablation procedures in combination with amiodarone therapy represents a safe and efficient option for curing pAF in patients undergoing open heart surgery.

Objective: Permanent atrial fibrillation (pAF) is a serious problem in cardiac surgery: An incidence of 3.5% among all patients scheduled for open heart surgery, 9.8% in heart valve cases and 45.6% among patients with severe rheumatic mitral valve (MV) disease was observed in our institution. Our experience with radiofrequency (RF) ablation procedures to treat pAF in these cases is reported., Methods: Since February 2001 monopolar endocardial RF ablation procedures creating two encircling isolation lesions around the left and the right pulmonary veins (LPVs, RPVs) and a connection line between both were performed in patients with pAF concomitant to heart valve surgery. Since March 2003 bipolar RF ablation was used as an adjunct to CABG surgery. Amiodarone was given for 3 months after surgery., Results: Sixty-two patients with pAF underwent surgical ablation procedures and primary valve (mitral: n=45; aortic: n=13; aortic+mitral: n=1; LA-diameter 55.6+/-7.3 mm) or CABG surgery (n=3). Follow-up was performed at 3, 6, 9, 12, 18 and 24 months; 75% had stable sinus rhythm (SR) at late follow-up. Almost 90% of the patients with a preoperative LA-diameter of <56 mm had SR., Conclusion: Isolation of the PVs using RF ablation procedures in combination with amiodarone therapy represents a safe and efficient option to cure pAF in patients undergoing open heart surgery.