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Coverage of a deep sternal wound infection with a greater omentum flap. Due to a persistent infection caused by an infected aortic prosthesis, the primarily performed reconstruction with a latissimus dorsi flap had to be revised, and an alternative solution had to be found.A deep sternal wound infection is a rare but devastating complication following median sternotomy. If the commonly used muscle flap is not sufficient and artificial material is still present in the wound, for instant drivelines or a vascular prosthesis, the greater omentum flap is a useful option due to its immunologic capacity.After an exploration of the persisting infected deep sternal wound, a radical debridement is performed followed by a jet lavage. The soft tissue from the greater omentum is prepared via median laparotomy and transferred through a tunnel created in the diaphragm. Then it is pulled into the wound cavity and can be used for tension-free sheathing of the aortic prosthesis. The previously used muscle flap can additionally be used for superficial soft tissue coverage.Due to its immunologic competence, the greater omentum flap is a good treatment alternative to the commonly used muscle flaps in defects with infected artificial material.Defektdeckung einer persistierenden, sternalen Wundheilungsstörung, die nach frustranem Deckungsversuch mittels eines gestielten Latissimus-dorsi-Lappens durch eine Omentumplastik zur Ausheilung gebracht wurde.Tiefe sternale Wundheilungsstörungen sind seltene, aber schwerwiegende Komplikationen nach medianer Sternotomie. Wenn reguläre Deckungsverfahren fehlschlagen oder nicht zu entfernendes Fremdmaterial wie „Drivelines“ oder Gefäßprothesen mittels Muskellappen nicht zur Ausheilung gebracht werden können, bildet der Omentumlappen, aufgrund seiner immunologischen Kompetenz, eine sinnvolle Alternative.Nach Exploration des persistierenden, sternalen Defekts schießt sich das radikale tangentiale Débridement und die Spülung der Wunde mittels einer Jet-Lavage an. Das Gewebe des Omentums wird nach Medianlaparotomie und Präparation des Lappens durch einen im vorderen Diaphragma angelegten Tunnel in den Defekt verlagert und kann hier spannungsfrei zur Ummantelung der Prothese verwendet werden. Der im Vorfeld verwendete Latissimuslappen wird in diesem Fall für den oberflächlichen Weichteilverschluss wiederverwendet.Insbesondere bei infiziertem, nicht entfernbarem Restmaterial stellt der Omentumlappen aufgrund seiner immunologischen Kompetenz eine gute Behandlungsalternative zu Muskellappen dar.

Surgical aortic valve replacement is still considered the first-line treatment for patients suffering from severe aortic valve stenosis. In recent years, transcatheter aortic valve implantation (TAVI) has emerged as an alternative for selected high-risk patients. According to the latest results of the German external quality assurance program, mandatory by law, the initially very high mortality and procedural morbidity have now decreased to approximately 6 and 12%, respectively. Especially in Germany, the number of patients treated by TAVI has increased exponentially. In 2013, a total of 10.602 TAVI procedures were performed. TAVI is claimed to be minimally invasive. This is true concerning the access, but it does not describe the genuine complexity of the procedure, defined by the close neighborhood of the aortic valve to delicate intracardiac structures. Hence, significant numbers of life-threatening complications may occur and have been reported. Owing to the complexity of TAVI, there is a unanimous concordance between cardiologists and cardiac surgeons in the Western world demanding a close heart team approach for patient selection, intervention, handling of complications, and pre- as well as postprocedural care, respectively. The prerequisite is that TAVI should not be performed in centers with no cardiac surgery on site. This is emphasized in all international joint guidelines and expert consensus statements. Today, a small number of patients undergo TAVI procedures in German hospitals without a department of cardiac surgery on site. To be noted, most of these hospitals perform less than 20 cases per year. Recently, the German Cardiac Society (DGK) published a position paper supporting this practice pattern. Contrary to this statement and concerned about the safety of patients treated this way, the German Society for Thoracic and Cardiovascular Surgery (DGTHG) still fully endorses the European (ESC/EACTS) and other actual international guidelines and consensus statements. Only the concomitance of departments for cardiac surgery and cardiology on site can provide optimal TAVI care. This commentary by the DGTHG delineates the data and resources upon which its opinion is based.

According to the current guidelines coronary revascularization in acute coronary syndromes (ACS) is primarily performed by percutaneous coronary interventions (PCI). However, in several scenarios like complex coronary pathologies, unsuccessful PCI, complicated PCI or cardiogenic shock, surgical coronary revascularization might be indicated. Then, timing of the operation is based on clinical symptoms, coronary artery pathology, and the type of underlying ACS (Figure 1). Surgical strategies among others include the use of beating-heart strategies. Furthermore, a modern perioperative management allows improved results in a more aged and comorbid patient population as well as in patients presenting with hemodynamic instability. In cardiogenic shock, a variety of different cardiopulmonary assist devices are available today including intra-aortic balloon pump, several ventricular assist devices, and extracorporeal membrane oxygenation (Figure 2).In the literature, results of coronary artery bypass grafting (CABG) in ACS patients vary significantly because of different patient populations, different timing of the operation, and different hemodynamic status. Thus, comparison of surgical concepts is almost impossible. Until today, randomized surgical trials for ACS patients are pending. However, hospital survival of95% is reported even in emergency CABG patients during the last 5 years (Table 1). For all surgical candidates a close and direct communication between interventionalist and cardiac surgeon is mandatory to early identify the best treatment strategy and to achieve best possible revascularization results.

To evaluate the clinical results after stentless (SMV) in comparison to mitral valve repair (MV-rep) and conventional mitral valve replacement (MVR) at 5 years.From 08/1997 onward, 155 patients with degenerative mitral valve (MV) disease received an SMV (n=53, 68+/-8 years, 37 female), MV-rep (n=51, 69+/-9 years, 32 female), or MVR (n=51, 66+/-9 years, 32 female). The underlying MV disease was stenosis in 13 (SMV)/1 (MV-rep)/4 (MVR), incompetence in 13 (SMV)/50 (MV-rep)/30 (MVR), and combined lesion in 27 (SMV)/0 (MV-rep)/12 (MVR) patients, respectively. Preoperative New York Heart Association (NYHA) functional class was 3.1+/-0.6 (SMV)/2.9+/-0.5 (MV-rep)/2.9+/-0.6 (MVR), Euroscore 5.2+/-2.3 (SMV), 5.0+/-1.9 (Mv-rep), 4.8+/-2.6 (MVR), left ventricular ejection fraction 60.5+/-10% (SMV)/57.3+/-13% (MV-rep)/58.7+/-13% (MVR), and cardiac index 2.1+/-0.8/2+/-0.7/2+/-0.8 l/min/m2 (not significant). Follow-up includes 64+/-18 months (21-89 months).Surgery was performed via conventional sternotomy (32 SMV/20 MVR-rep/34 MVR) or right anterolateral minithoracotomy (21/31/17). Cross-clamp duration was 81+/-33 (SMV)/58+/-24 (MV-rep)/54+/-23 min (MVR; p0.05). Mean pressure gradients amounted to 4.8+/-1.9/3.6+/-1.7/4.3+/-1.4 mmHg, and valve opening areas to 2.5+/-0.6/3+/-0.9/2.6+/-0.9 cm2, respectively. In-hospital mortality was 1 (SMV)/2 (MV-rep)/5 (MVR) patients (p0.05). During follow-up, repeat surgical interventions were required in 6 (SMV)/2 (MV-rep)/3 (MVR) patients. 5-year survival was 80.5+/-4.4% (SMV)/82.6+/-5.6% (MV-rep)/80.2+/-5.5% (MVR; not significant); this was comparable to an age-matched normal population.At 5 years, the SMV compares favorably with conventional standards when taking the patients' risk profile into account. The SMV with its reliable functional and hemodynamic outcome may be the mitral prosthesis of choice in future.

Since the introduction of off-pump coronary artery bypass grafting (OPCAB) for coronary multivessel disease there was growing interest to evaluate the impact of OPCAB surgery compared to conventional coronary artery bypass grafting (CCAB) with cardiopulmonary bypass and cardioplegic arrest. However, subsequent prospective randomized studies and meta-analyses comparing OPCAB and CCAB surgery were performed on low-risk patients or mixed-risk populations. They usually failed to demonstrate a significant benefit of OPCAB surgery on early mortality or perioperative major cardiac and cerebrovascular events. In recent years, efforts were made to analyze the meaning of beating-heart concepts for patients with specific cardiac and extracardiac risks like ischemic cardiomyopathy, older age, renal failure, acute coronary syndrome, left main stenosis and others. For these subsets of patients several mono- and multicenter studies are available today. Even if most of them were nonrandomized and thus failed to reach evidence level A according to the AHA/ACC (American Heart Association/American College of Cardiology) definition, they still allow analyzing interim results for each specific perioperative risk factor. Particularly multi-risk patients and patients with severely reduced left ventricular function seem to benefit in terms of perioperative mortality and major morbidity by avoiding cardiopulmonary bypass and cardioplegic arrest. Analyzing early results and long-term follow-up of 364 patients with severely reduced ejection fraction20%, the authors found a long-term benefit for patients when using OPCAB strategies particularly due to reduced perioperative mortality. Moreover, for most subsets of patients with significant extracardiac risk factors the incidence or perioperative stroke was reduced. In patients with preoperative renal and pulmonary dysfunction a decrease of corresponding organ failure was found for OPCAB strategy. For most risk populations transfusion requirements were significantly lower in OPCAB compared to CCAB surgery. In none of the patients an unfavorable outcome of beating-heart surgery compared to CCAB was shown. For emergency patients with an acute coronary syndrome presenting stable and unstable hemodynamics the authors found a clinical benefit by using beating-heart strategies. Particularly in patients with cardiogenic shock, cardiopulmonary bypass was often required to guarantee adequate perioperative organ perfusion. However, these patients seemed to benefit from avoiding global cardiac ischemia and maintaining native coronary blood flow. Follow-up results were comparable for these patients. In conclusion, beating-heart coronary artery bypass grafting seems to be advantageous in various risk populations and should be considered for patients with more than average risks for cardiopulmonary bypass and cardioplegic arrest.

Currently, heart transplantation is the gold standard of treatment for patients with end-stage heart failure. With the number of donor organs steadily decreasing, new surgical strategies have evolved. Selected patients with ischaemic cardiomyopathy or mitral valve insufficiency may be suitable candidates for conventional surgical procedures. New developments regarding assist devices such as LVAD and TAH increase our chances of employing these systems as a definite treatment option (destination therapy). New innovative concepts like external ventricular reshaping (Myosplints, CorCap) or left ventricular reconstruction are currently undergoing clinical evaluation. The clinical results of cardiac resynchronisation therapy offer a new treatment option for patients with LBB. The value of different treatment options and their role in modern surgical heart failure management is discussed.