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Objective The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve. Methods Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years. Results The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years. Conclusions This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

Backgrounds Aortic valve and prosthetic valve endocarditis present a challenging subgroup of patients at high risk. We analyzed our experience using the Medtronic Freestyle in full root technique for the treatment of these cases over 18-year time period. Methods We investigated the endocarditis subgroup from our cohort of 971 patients and compared results against other valve types with propensity score matching implementing nearest neighbor method. T-test, χ2 test, logistic regression, and Cox regression were performed. Results Fifty-four patients from the Freestyle group (FS) were matched against 54 patients from a cohort of 376 aortic valve/root endocarditis patients treated by other valve types (non-FS). Hospital mortality was 9/54 (16.7%) in the FS vs 13/54 (24.1%) in the non-FS group (P = .33). Variables age (P = .003) and renal impairment (P = .026) had an impact on mortality according to Cox regression analysis for early results. Variables with significant risk for long-term mortality included postoperative renal impairment (P = .0001) and multiorgan failure (P = .0001). Recurrent infection was low (1.8% for FS and 3.7% for non-FS group), and freedom from reoperation was 97.2%. Use of the Medtronic Freestyle was no significant risk factor for long-term mortality. Conclusion The Freestyle stentless xenograft is a viable alternative for treatment of valve/root and prosthetic endocarditis. In our experience, it showed good postoperative performance with low rate of reinfection while having an acceptable operative risk-profile for this high-risk cohort.

Objective To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement. Methods A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach. Results No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed to-mographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs. Conclusions Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Objective This study aimed to evaluate a novel device system for surgical aortic valve replacement (SAVR) using a unique new less invasive access approach. The hypothesis is that SAVR can be performed through a short transverse incision in the neck, similar to that used for transcervical thymectomy avoiding chest disruption. Methods A new device system was developed to provide retraction, step-by-step illumination, and on-screen visualization for the new approach. Preliminary feasibility studies were performed in cadavers. Comprehensive risk analysis was performed, and training was implemented in Thiel preserved cadavers. For the first-in-man clinical case, a 63-year-old woman with symptomatic critical aortic stenosis (The Society of Thoracic Surgeons risk, 11%) and heavily calcified aortic valve was selected. A short transverse incision was made in the neck; the device was introduced, and the sternum was elevated; femorofemoral cardiopulmonary bypass was established; substernal dissection was guided by the sequenced illumination, and highdefinition visualization was provided by the device, allowing for optimal exposition of the aorta and aortic valve; and a 23-mm Medtronic ENABLE sutureless valve prosthesis was implanted. Procedure success was evaluated according to the standardized composite end point definition of “device success” proposed by the Valve Academic Research Consortium. Results Access, delivery, and deployment of the valve prosthesis were successful. The correct position and intended performance of the valve were demonstrated (mean gradient, 6 mm Hg; aortic valve area, 2.5 cm2) with the absence of moderate or severe prosthetic aortic regurgitation. Only one valve prosthesis was used. Conclusions Transcervical SAVR with sutureless valve is feasible using this novel access system. The new approach has potential to offer patients substantially shorter stay and fewer, less serious complications, as has been observed in transcervical thymectomy. Further studies are merited.

A healthy woman with acute onset of pulmonary oedema and severely depressed left ventricular function underwent endomyocardial biopsy under the clinical suspicion of fulminant myocarditis. While awaiting the results of biopsy, the situation deteriorated to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and extracorporeal membrane oxygenation was implanted. Finally, immunohistochemistry in biopsy specimen corresponded to fulminant lymphocytic myocarditis, although active myocarditis was excluded. Furthermore, gene expression profiling identified giant cell myocarditis although multinuclear cells were absent. This prompted the start of immunosuppression with cortisone and cyclosporine. The patient fully recovered.

Currently available diagnostic modalities for the detection of graft vasculopathy following orthotopic heart transplantation are subject to various restrictions. We hypothesized that cardiogoniometry, a novel non-invasive diagnostic tool for the detection of atherosclerotic coronary vessel disease, is applicable in the graft vasculopathy setting. Cardiogoniometric results were obtained during routine follow-up in 49 consecutive, unselected heart transplant recipients and then retrospectively correlated blindly by an independent reader to recent angiographic findings. Sensitivity of cardiogoniometry was 100%, specificity 62.3%, positive predictive value 68.75%, negative predictive value 100%, negative likelihood ratio 0 and positive likelihood ratio 2.888. Cardiogoniometry is potentially applicable as an easy-to-perform, non-invasive screening tool predominantly for the exclusion but also for the detection of graft vasculopathy in heart transplant recipients.

Hyperbaric oxygenation (HBO₂) involves breathing 100% oxygen under elevated ambient pressure in a hyperbaric chamber, thereby dissolving oxygen in the plasma. This results in an increase of arterial partial pressure of oxygen (pO₂). Though well established in experimental studies, HBO₂ treatment for ischemic stroke is still under discussion.From 2002-2014 HBO₂ (2.2 bar, 90 minutes one/day; average number per patient: 4.7) was applied in 49 consecutive patients (32 males, 17 females, mean age: 68.8 years, range 31.2 - 83.9) with acute neurological deficit following cardiac surgery (CABG 15; combined surgery 14; valve surgery 11; aneurysm repair 8; malformation 1). Patients' history including TIA or stroke and carotid artery pathology were documented. Both degree and type of neurological deficit was evaluated by a scoring system (0-4) before and after HBO₂ treatment.Before HBO₂ therapy, the average motor deficit score was 2.45 and the average speech disorder score was 0.55, as compared with an average motor deficit of 1.12 and an average speech disorder of 0.27 afterward (α=0.0001, α=0.009). The majority of patients had an overall improvement of 2 score-points after HBO₂ therapy (n=23 patients). Probit analysis showed that for a 50% response/probability (LC50) of having an overall outcome of ≥2 scoring points, an estimate of 4.3 HBO₂ therapy sessions is necessary.HBO2₂ therapy was associated with significant improvement in patients with acute neurological deficits due to ischemic stroke following cardiac surgery. Though this fact suggests gas embolism as the most likely cause of stroke in this collective, other underlying pathologies cannot be ruled out. Randomized studies are needed for further evaluation.

Due to the declining instances of organ donation, total artificial heart (TAH) therapy is of increasing importance for the management of end-stage biventricular heart failure. We introduce the currently most important established and novel TAH systems (SynCardia, CARMAT, ReinHeart, BiVACOR), report clinical outcomes and discuss technical requirements for the successful implementation of TAH therapy as an alternative to cardiac transplantation.

Left ventricular (LV) assist device implantation is considered to be a therapeutic option only in highly selected cases of giant LV aneurysm because of concerns regarding tissue consistence, potential mobilization of intracardiac thrombotic material, and thrombogenic properties of aneurysmal tissue.1 To facilitate secure placement of the inflow cannula, avoid embolic events, and attain LV remodeling, implantation of the device is performed in combination with LV reconstruction. A 51-year-old, white male patient was admitted for evaluation of an end-stage heart failure because of ischemic cardiomyopathy. Echocardiographic examination revealed severe systolic dysfunction (LV ejection fraction of 10%), significant thrombus in the giant LV aneurysm, and a contained apical wall rupture resulting from acute myocardial infarction (Figure). Despite interventional revascularization of the left anterior descending artery with a drug-eluting stent and medical therapy, including inotropic …

BackgroundGastrointestinal complications following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality. We aimed to assess incidence, perioperative risk factors, treatment modalities and outcomes.Material and methodsA university medical center audit comprised 4883 consecutive patients (median age 69 [interquartile range IQR 60-76] years, 33% female, median logistic EuroScore 5 [IQR 3-11]) undergoing all types of cardiac surgery including surgery on the thoracic aorta; patients undergoing repair of congenital heart disease, implantation of assist devices or cardiac transplantation were excluded. Coronary artery disease was the leading indication for on-pump cardiac surgery (60%), patients undergoing cardiac surgery under urgency or emergency setting were included in analysis. We identified a total of 142 patients with gastrointestinal complications. To identify intra- and postoperative predictors for gastrointestinal complications, we applied a 1:1 propensity score matching procedure based on a logistic regression model.ResultsOverall, 30-day mortality for the entire cohort was 5.4%; the incidence of gastrointestinal complications was 2.9% and median time to complication 8 days (IQR 4-12). Acute pancreatitis (n = 41), paralytic ileus (n = 14) and acute cholecystitis (n = 18) were the leading pathologies. Mesenteric ischemia and gastrointestinal bleeding accounted for 16 vs. 18 cases, respectively. While 72 patients (51%) could be managed conservatively, 27 patients required endoscopic/radiological (19%) or surgical intervention (43/142 patients, 30%); overall 30-day mortality was 12.1% (pCommentProlonged skin-to-skin times and extended on-pump periods are important perioperative risk factors regardless of preoperative risk factors.

Background: Congestive hepatopathy (CH) and acute liver failure (ALF) are common among biventricular heart failure patients. We sought to evaluate the impact of total artificial heart (TAH) therapy on hepatic function and associated clinical outcomes. Methods: A total of 31 patients received a Syncardia Total Artificial Heart. Preoperatively 17 patients exhibited normal liver function or mild hepatic derangements that were clinically insignificant and did not qualify as acute or chronic liver failure, 5 patients exhibited ALF and 9 various hepatic derangements owing to CH. Liver associated mortality and postoperative course of liver values were prospectively documented and retrospectively analyzed. Results: Liver associated mortality in normal liver function, ALF and CH cases was 0%, 20% (P=0.03) and 44.4% (P=0.0008) respectively. 1/17 (5.8%) patients with a normal liver function developed an ALF, 4/5 (80%) patients with an ALF experienced a markedly improvement of hepatic function and 6/9 (66.6%) patients with CH a significant deterioration. Conclusions: TAH therapy results in recovery of hepatic function in ALF cases. Patients with CH prior to surgery form a high risk group with increased liver associated mortality.

Background Kawasaki disease (KD) without affection of the coronary artery system is rare. Optic nerve pathology together with KD has not been described earlier. Case presentation We present one case of KD in a 12-year-old girl predominantly with prolonged cholestasis, and a second case of multiple recurrent KD in a 9-year-old boy with hepatomegaly and ischemic optic nerve neuropathy. The coronary artery system was not involved in either case. Conclusions KD warrants rapid diagnosis and immediate specific treatment in order to prevent the high risk of coronary artery aneurysm and stenosis.

Until now, to our knowledge no case of bioprosthetic valvular thrombosis after implantation of the sutureless Sorin Perceval valve has been reported. Although sutureless aortic valve replacement has become a powerful tool in our daily practice, recent guidelines from the European Society of Cardiology, the European Association for Cardio-Thoracic Surgery, the American College of Cardiology, and the American Heart Association do not give specific recommendations on postoperative anticoagulation therapy. We report the first case of valve dysfunction resulting from thrombosis 12 months after implantation with a possible link to postoperative cortisole therapy.

Rupture of aneurysms and acute dissection of the thoracic aorta are life-threatening events which affect tens of thousands of people per year. The underlying mechanisms remain unclear and the aortic wall is known to lose its structural integrity, which in turn affects its mechanical response to the loading conditions. Hence, research on such aortic diseases is an important area in biomechanics. The present study investigates the mechanical properties of aneurysmatic and dissected human thoracic aortas via triaxial shear and uniaxial tensile testing with a focus on the former. In particular, ultimate stress values from triaxial shear tests in different orientations regarding the aorta's orthotropic microstructure, and from uniaxial tensile tests in radial, circumferential and longitudinal directions were determined. In total, 16 human thoracic aortas were investigated from which it is evident that the aortic media has much stronger resistance to rupture under ‘out-of-plane’ than under ‘in-plane’ shear loadings. Under different shear loadings the aortic tissues revealed anisotropic failure properties with higher ultimate shear stresses and amounts of shear in the longitudinal than in the circumferential direction. Furthermore, the aortic media decreased its tensile strength as follows: circumferential direction > longitudinal direction > radial direction. Anisotropic and nonlinear tissue properties are apparent from the experimental data. The results clearly showed interspecimen differences influenced by the anamnesis of the donors such as aortic diseases or connective tissue disorders, e.g., dissected specimens exhibited on average a markedly lower mechanical strength than aneurysmatic specimens. The rupture data based on the combination of triaxial shear and uniaxial extension testing are unique and build a good basis for developing a 3D failure criterion of diseased human thoracic aortic media. This is a step forward to more realistic modeling of mechanically induced tissue failure i.e. rupture of aneurysms or progression of aortic dissections.

OBJECTIVES: Acute aortic dissection type A (AADA) is associated with major adverse events, such as transient or persistent neurological dysfunction (ND), which may be patient-, disease- or surgery-related. There is a lack of consensus regarding risk factors for ND in AADA patients. The aim of this study was to analyse and identify risk factors for new postoperative ND after aortic repair for AADA. METHODS: Between July 2006 and June 2010, 2137 AADA patients were enrolled in the multi-centre, prospective German Registry of AADA (GERAADA). Perioperative data were prospectively gathered from 50 institutes in Austria, Switzerland and Germany, and multivariate logistic regression analysis was performed to determine the independent predictors of new onset ND. RESULTS: ND occurred in 20.3% of all patients prior to surgery, 12.6% of which resolved postoperatively and 7.7% persisted. New ND after AADA surgery occurred in 9.5% of patients. Risk factors for an increased rate of postoperative new ND were malperfusion syndrome of three or more territories prior to surgery [odds ratio (OR) = 2.206, P=0.0065], dissection of the supraaortic vessels (OR = 1.468, P=0.0103) and longer operating time (OR = 1.002 per min, P=0.0001). New postoperative ND was associated with an increased rate of mortality (22.5 vs. 16.1%, P=0.0087). Arterial cannulation site had no statistically significant impact on neurological outcomes. CONCLUSIONS: Neurological complications are associated with increased mortality post-AADA repair. New onset ND is associated with extensive malperfusion syndrome, supraaortic vessel dissection and operative time and does not seem to be affected by choice of arterial cannulation site.

To describe the use of a hybrid frozen elephant trunk technique to treat a patient suffering from a multisegmentally diseased, dextropositioned aortic arch and right descending aorta.The technique is illustrated in a 58-year-old woman who was diagnosed with chronic type A aortic dissection in a right aortic arch and descending aorta; a lusoric left subclavian artery passed behind the esophagus. Aneurysmal dilatation of the arch and descending aorta required treatment. A frozen elephant trunk procedure was performed in a single stage via a median sternotomy using a hybrid Chavan-Haverich endograft, with complete surgical replacement of aortic arch. The stents for the endograft were placed in the descending aorta in an antegrade fashion through the opened aortic arch.This case demonstrates the feasibility of treating complex pathologies of the thoracic aorta even in cases of aberrant anatomy. A conventional 2-stage approach for treatment of the complex pathology could have been complicated due to difficulties with exposure.

Background Aorto-esophageal fistula is a rare but life-threatening event evolving spontaneously or—more often—following therapeutic interventions at the esophagus or the aorta. Especially in presence of long-standing inflammation preceding the formation of the fistula, acute surgical closure of the aortic leakage is all but impossible and interdisciplinary treatment is mandatory. Methods Review of cases of aorto-esophageal fistula within the last 12 years. Results In our collective of patients undergoing esophagectomy since 2005 (N = 445) we observed 7 cases (1,5%) of aorto-esophageal fistula. In one case the fistula had developed spontaneously following aspergillosis, one patient had had aortic stenting 29 years before, another one had developed anastomotic dehiscence following intrathoracic esophago-jejunostomy and in 4 cases esophageal stenting had been done. 5 patients presented with slight to dramatic hematemesis which in 2 instances needed endoscopic intervention, 2 had no bleeding. Preoperative angio-CT confirmed aorto-esophageal fistula in 3 cases who underwent aortic stenting prior to the surgical intervention, in 3 patients the fistula was found intraoperatively (aortic replacement N = 1; suture followed by stenting N = 1; operation stopped; aortic stenting, operation the following day). All patients recovered from surgery. In one case inflammation had caused partial necrosis of the aortic wall causing fatal bleeding during operation. Retrospectively, the lesion of the aortic wall could be identified on CT in all but one patient. Conclusion By interdisciplinary management, involving preoperative stenting or aortic graft implantation in cases not amenable to stenting, patients with aorto-esophageal fistula can be saved and may undergo elective esophageal surgery. Disclosure All authors have declared no conflicts of interest.

We report on a 49-year-old male patient who suffered from severe herpes simplex (HSV) pneumonia after a fall-from-height injury, causing a circumscript type B aortic dissection.The subsequent occurrence of ARDS required a veno-venous ECMO circuit that was upgraded to a veno-arterial system due to further oxygenation deficits. Following continued respiratory deterioration, the ECMO system already in place had to be complemented by a second veno-arterial line. After the onset of recovery and because of a developing of a disseminated intravasal coagulation, the double ECMO circuit was replaced by a pumpless extracorporeal lung assist system (PECLA). The patient recovered completely under systemic virostatic therapy.

Management of end-stage heart failure patients requiring major general surgery is not well defined. Due to poor cardiorespiratory reserve, perioperative morbidity and mortality are excessively high. We report a case of temporary implementation of veno-arterial extracorporeal membrane oxygenation for haemodynamic support during excision of rectal carcinoma in an end-stage heart failure patient and describe perioperative management.

Ein deutschsprachiges Register fur akute Aortendissektionen Typ A (GERAADA) wurde von der Arbeitsgemeinschaft „Aortenchirurgie und interventionelle Gefaschirurgie“ der DGTHG im Juli 2006 eingefuhrt. Diese web-basierte Datenbank wurde entwickelt, um Daten von Patienten zu erfassen, die wegen einer akuten Aortendissektion Typ A operiert wurden. Ziel war es, aus den analysierten Daten zu lernen, wie man die chirurgische Behandlung verbessern konnte und welche Parameter das Patienten-Outcome moglicherweise beeinflussen. Zu Beginn nahmen 33 deutsche Herzzentren uber einen Online-Zugang zum Register auf der Homepage der DGTHG teil; mittlerweile sind es 43 Zentren. Es wurden Daten, die den pra- und intraoperativen Status der Patienten, postoperative Komplikationen, mittelfristige Ergebnisse und Todesursachen betrafen, eingebracht. Mittlerweile konnten aus dem Register erste Ergebnisse und Trends abgeleitet werden, die allen teilnehmenden Zentren zur Verfugung stehen. Mittelfristig konnen alle Zentren von dem gemeinsamen Datenpool profitieren und ihr Therapieregime bei ihren Patienten kontinuierlich optimieren und den eigenen Erfolg, in Relation zum Gesamtkollektiv, mit Hilfe des Registers vergleichen.

The aim of this study was to evaluate the role of percutaneous interventions in treating ischemia complicating aortic dissection. Forty-five patients with ischemia complicating aortic dissection were treated by balloon fenestration, true lumen stenting, angioplasty, or thrombolysis. Clinical and laboratory examinations were performed before and after intervention, and at the end of follow-up (median 37 months). Eighteen dissections were acute, 9 sub-acute, and 18 chronic. Mesenterohepatic ischemia resolved in 16 of 18 patients; lactate and SGOT values fell from 2.89 to 1.23 mmol/L (p = 0.006) and from 165.9 to 59.7 U/L (p = 0.034), respectively. In patients with renal ischemia, creatinine levels fell from 360.1 to 196.3 μmol/L (p = 0.007) accompanied by a significant reduction in blood pressure. Limb-threatening ischemia resolved in three of four patients; in 21 claudicants, the mean walking distance improved from 272 to 1,283 m (p = 0.001). Spinal ischemia resolved completely or partially in six of eight patients. Adjunctive surgical measures were necessary in six patients. Overall 30-day mortality in the 45 patients was 6.7%; all three deaths were in patients with acute dissections (mortality in this subgroup 16.7%). Ischemia complicating aortic dissection can be effectively treated by percutaneous interventions resulting in good early and mid-term outcomes.

Objective: The technically demanding full root aortic valve replacement necessitating coronary ostia reimplantation apparently leads to hesitation by some surgeons despite the superior hemodynamics and excellent long-term clinical performances of the stentless xenografts. Clinical data of stentless full root replacements was retrospectively analyzedin this perspective for validation.Methods:From November 1999 to March 2007, 317 adult patients (male: 196, female, 121) underwent modified Bio-Bentall procedure using the Medtronic Freestyle xenograft as a full root replacement. Two hundred and three patients received an isolated root replacement or a root and ascending aortic replacement (ARR). In 114 patients a variety of concomitant procedures including coronary artery bypass grafting (n = 32), mitral valve repair (n = 11) and aortic arch replacement (n = 36) were performed. (ARR+). Results: Mean patient age was 70.3 10.2 years (range 17—94 years), 97 patients were 75 and older at time of procedure. Mean operative time for the ARR was 190 57 min with a clamp time of 88 27 min. Mean operative time for ARR+ groupwas282 93 minwith anaverageclamptimeof110 32 min.Overalloperativemortalitywas7.9%(25/317),forARRit was5.4%(11/203). Mean ICU stay was 4.9 8.1 days, mean hospital stay being 9.8 8.1 days. Necessity for bailout bypass surgery among patients with ARR was low at 1.5% (3/203) comparable to stented xenograft implantations. Echocardiography demonstrated excellent clinical results with low transvalvular gradients especially when a single suture inflow anastomosis technique was used. Conclusions: Full root stentless valve implantation preserving porcine root integrity is a valuable option in aortic valve/ascending aorta surgery. Though technically a more challenging operation, it does not lead to increased perioperative morbidity and mortality and can be beneficial mainly for elderly patients with small aortic roots with or without aortic root pathology. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reseved.

Purpose: To report a novel complication of a hybrid “frozen elephant trunk” endograft used in the treatment of a multisegmentally diseased aorta. Case Report: A 53-year-old man with chronic type A aortic dissection and previous replacement of the supracoronary ascending aorta underwent a “frozen elephant trunk” procedure using a hybrid endograft. The stent-graft was placed deep in the descending aorta to cover the multiple distal re-entries. Due to ineffective covering of the re-entries, a patent false lumen led to rapid repressurization of the false lumen immediately distal to the circumferential elephant trunk anastomosis. Compression of the non-stented portion of the hybrid endograft caused a functional aortic stenosis, with severe hemodynamic consequences. Endovascular treatment of the compression by retrograde transfemoral placement of a stent-graft in the non-stented portion of the hybrid endograft achieved free flow in the distal aorta. Conclusion: This case documents a new complication of the frozen elephant trunk procedure; a pseudocoarctation from a repressurized proximal false lumen was successfully managed with a stent-graft to support the non-stented segment of the hybrid endograft.

Objective The aim of our retrospective study was to evaluate early and midterm clinical outcomes of two surgical techniques: open anastomosis in deep hypothermic circulatory arrest (DHCA) compared to anastomosis with clamped aorta while continuing on extracorporeal circulation (CECC). Methods Between November 1997 and February 2002, 67 patients were operated for acute type A aortic dissection. Records of 35 patients with isolated replacement of the ascending aorta without intervention on the aortic arch were retrospectively reviewed. The influence of two techniques (DHCA n = 15, CECC n = 20) on clinical outcome and midterm follow up was investigated. Results There were no statistically significant differences in preoperative data. Female gender in the DHCA group was coincidentally more frequent. Intraoperative management did not result in different early clinical outcome. 30-day mortality was not statistically different. Mean follow up time was 20.7 +/- 11.1 months in the DHCA group and 28.7 +/- 14.3 months in the CECC group. One-year and 3-year survival estimates in DHCA group were 85%+/- 7% and 79%+/- 9%, respectively. In the CECC group similar survivals were 80%+/- 10% and 73%+/- 11%, respectively. No statistically significant differences between the two groups were obtained in early or midterm outcome. Conclusion While there is no difference in clinical outcome in surgical treatment of acute type A aortic dissection with or without circulatory arrest, there are some practical technical advantages if the distal anastomosis is performed in an open manner. Probably the long-term outcome too is better with this anastomosis technique.

We report the results of a first-in-man application of a newly developed approach for direct aortic (DA) transcatheter aortic valve replacement (TAVR) using a novel device system (CoreVista, CardioPrecision Ltd., Glasgow, United Kingdom) designed to provide access to the ascending aorta from a

Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self expanding CoreValve prosthesis is implanted retrogradely with

OBJECTIVES - After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves. METHODS - Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts. RESULTS - Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19–27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves. CONCLUSION - The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.

We report the case of a 69-year-old man with a history of 2,3diphosphoglycerate deficiency and consecutive splenectomy due to hemolytic anemia. He presented in emergency room following a sudden onset of severe pain in the right upper abdomen and mild dyspnea. One week before, he had suffered short-lasting chest pain after cycling. There was no history of congenital heart or lung disease, chest trauma or anticoagulant medication. The ECG was normal, but there were diminished breath sounds and dullness to percussion on the right side of the thorax. Ultrasound showed a right-sided pleural effusion, and surprisingly, thoracentesis revealed a bloody effusion with a hematocrit identical to the peripheral blood. Computer tomography confirmed a large right-sided hemothorax, caused by an ongoing bleeding out of a vascular malformation (Fig. 1). With incipient shock, the patient was transferred to the intensive care unit, and emergency cardiac surgery was initiated. While the pericardial and the left pleural cavity were without pathological findings, the right pleural cavity was filled with blood originating from the right lower lobe. A trial to improve the visibility using a double-lumen endotracheal tube was not tolerated hemodynamically, and cardiopulmonary bypass became necessary. A vascular malformation, a vessel connecting the descending aorta with a pulmonary vessel of the lower lobe could be demonstrated. The bleeding originated from a rupture of this major aorto-pulmonary collateral artery (MAPCA) close to the aortic branch-off. The ligation of this vessel stopped all

Background . Occlusion of coronary arteries during beating heart surgery bears the potential for mechanical trauma to the arterial wall with consequent endothelial injury. The aim of this study was to elucidate the effects of local occlusion on the beating heart in human coronary arteries. Methods . Coronary arteries of patients with dilated cardiomyopathy (n = 7) or ischemic heart disease (n = 10) undergoing heart transplantation were locally occluded after starting cardiopulmonary bypass. Immediately after excision of the diseased heart, the vessels were fixed. Unoccluded segments served as controls. Integrity of endothelial lining was observed with scanning electron microscopy. Results . Scanning electron microscopy revealed significantly more severe endothelial injury in the area of occlusion than in the adjacent, not manipulated control segments. In the region of local occlusion, plaque rupture was noted in three of 34 atherosclerotic vessel specimens, injury to side branches was evident in two of 44, and local microthrombus formation was evident in six of 44 samples. Conclusions . Local occlusion of human coronary arteries during beating heart coronary surgery may cause focal endothelial denudation, local microthrombosis, atherosclerotic plaque rupture, and injury to target vessel side branches.

BACKGROUND A significant number of patients with coronary artery disease is diagnosed with additional carotid artery disease. This subset of patients has been identified as a high-risk group for cardiac and cerebral complications following surgical intervention. METHODS In a retrospective analysis we investigated the perioperative outcome of combined single-stage carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in 63 patients operated between January 1989 and August 1998. In all of these patients, CEA was performed prior to CABG and before initiation of cardiopulmonary bypass. RESULTS Perioperative mortality rate was 7.9% (5/63) for simultaneous CEA and CABG and was due to cardiac complications in all patients. Postoperative unilateral neurological symptoms were diagnosed in 1 patient (1.7%) and were completely reversible. No neurologic events suggestive for permanent cerebral damage were observed during the 30 d postoperative period. CONCLUSIONS In our study combined single-stage CEA and CABG was associated with low cerebral morbidity and patient outcome was mainly determined by cardiac complications. In this subset of patients, simultaneous CEA and CABG appears to be a safe method.

Objectives: In the surgical treatment of cervical carcinoma the conservation of ovaries in premenopausal women is a common procedure. To date, however, there have been no controlled studies to prove that the risk of recurrence or death from disease is not elevated among women who do not undergo oophorectomy. Study Design: We performed a matched pairs analysis according to the tumor volume, comparing the outcomes of patients with in situ conservation of ≥1 ovary with those of control subjects who underwent bilateral oophorectomy. From among 658 patients, 150 pairs with International Federation of Gynecology and Obstetrics stage I disease were matched. Kaplan-Meier survival curves were compared with the log rank test. Results: Among patients who retained their ovaries 5- and 10-year overall survival rates were 98% and 96%, respectively, versus 97% and 97% for the oophorectomy control group. The corresponding figures for progression-free survival were 95% and 94%, respectively, versus 97% and 93%. Outcomes were equal with sufficient power to detect a 10% difference. Three of 214 patients with conservation of ovaries (1.3%) subsequently required oophorectomy, all because of benign ovarian diseases. Conclusions: Our results confirm that ovarian conservation is safe in International Federation of Gynecology and Obstetrics stage I disease and that the occurrence of subsequent complications in ovaries retained in situ is rare. (Am J Obstet Gynecol 1999;180:963-9.)

Objective: The relevance of regional LV myocardial ischemia/reperfusion induced by temporary left anterior descending (LAD) coronary artery occlusion during minimally invasive direct coronary artery bypass (MIDCAB) grafting is controversial. The purpose of our study was (1) to determine the impact of conventional LAD occlusion during left internal thoracic artery (LITA)-LAD anastomosis on regional LV myocardial ischemia and function, and (2) to evaluate if intra-LAD shunt insertion during LITA-LAD anastomosis prevents potential regional LV ischemia and dysfunction in a pig model. Methods: In 20 anesthetized, mechanically ventilated pigs we performed LITA-LAD anastomosis on the beating heart without cardiopulmonary bypass during either 15 min LAD occlusion (occlusion-group; n = 10) or 15 min intra-LAD shunt insertion to maintain blood supply to the myocardium beyond the anastomosis (shunt-group; n = 10). Besides standard hemodynamics we determined the global and regional LV wall motion score index (WMSI) using epimyocardial echocardiograpy. To quantitate structural myocardial alteration we determined the inducible heat-shock protein-70 (HSP-70) in LV anterior wall myocardial biopsies. Data were recorded at baseline, at 15 min of LAD occlusion or shunt insertion, respectively, and at 30 min of reperfusion. At the end of the experiments we determined myocardial adenine nucleotide (ATP, ADP, AMP) and glycogen content. Results: In both groups WMSI was not significantly different at 15 min LAD occlusion or shunt insertion, respectively, as compared to baseline. However, at 30 min reperfusion both global and regional WMSI demonstrated significant LV dysfunction in the occlusion-group, whereas LV function in the shunt-group remained normal. This was associated with higher myocardial HSP-70 expression in the occlusiongroup (P , 0.05). Myocardial adenine nucleotide and glycogen contents were significantly better preserved in the shunt-group. Conclusions: Our data show that in a porcine MIDCAB model 15 min LAD occlusion and 30 min reperfusion result in significant myocardial stunning. In contrast, maintenance of LAD perfusion using intracoronary shunt insertion minimizes ischemia/reperfusion injury and prevents regional LV dysfunction. Although our experiments were conducted in healthy pig hearts absent from coronary artery disease, similar results may ‐ at least partially ‐ be expected in humans, and thus, intracoronary shunts could be a useful tool for myocardial protection during ‘off-pump revascularization’. © 1999 Elsevier Science B.V. All rights reserved.

Objective: Continuous perfusion of the coronary arteries with b-blocker (esmolol)-enriched normothermic blood during cardiac surgery has been suggested as an alternative technique for myocardial protection. The aim of the present study was to compare the b-blocker technique to Buckberg’s blood cardioplegia during coronary artery bypass grafting (CABG). Methods: Sixty patients with coronary artery disease were randomly assigned to either the esmolol group (ES, n = 30) or the blood cardioplegia group (BC, n = 30). During aortic crossclamp ES patients received continuous normothermic coronary perfusion with esmolol-enriched blood. Hearts of the BC group were protected by antegrade cold blood cardioplegia according to Buckberg. We measured left ventricular (LV) contractility using TEE (fractional area of contraction, FAC) and hemodynamic parameters prior to cannulation for cardiopulmonary bypass (CPB), after decannulation, and 4 h postoperatively. Myocardial lactate release was measured prior to aortic cross-clamp, during cross-clamp, and after decannulation. LV biopsies for determination of heat-shock protein (HSP-70), actin pattern and intercellular adhesion-molecule (ICAM-I) as indicators for structural changes were collected prior CPB, at the end of the aortic cross-clamp period, and prior to weaning off CPB. Results: There was no significant difference between both groups with respect to grafts and cross-clamp time. ES hearts did not release lactate during cross-clamp. In contrast, BC hearts released significant amounts of lactate. Post CPB FAC and hemodynamics under similar inotropic stimulation showed no difference between groups, whereas at 4 h post CPB measurements showed slightly better values in the ES group: cardiac index: ES: 2.9 ∠ 0.1 (SEM) versus BC: 2.6 ∠ 0.1 L/min per m 2 (P , 0.05); FAC: ES: 55 ∠ 3 versus BC: 48 ∠ 3% (P , 0.05). HSP-70 and actin pattern showed no difference between groups; however, ICAM-I showed a significantly higher degree of structural changes in BC hearts: 18 ∠ 2 versus ES: 11 ∠ 1% (P , 0.05). Conclusion: Our data demonstrate that application of the bblocker technique during routine CABG was associated with slightly better functional recovery and less structural myocardial alteration as compared with intermittent cold blood cardioplegia, however, both techniques provided equivalent myocardial protection in terms of patient outcome. Future studies are required to investigate if myocardial ischemia minimization by use of the b-blocker technique may be beneficial in compromized hearts. © 1999 Elsevier Science B.V. All rights reserved.

Patients suffering from end-stage renal disease are an inhomogeneous high-risk group with a substantial perioperative mortality and morbidity when undergoing cardiac surgical procedures[1-3]. Myocardial ischemia, reperfusion injury and myocardial edema are a few of the deleterious consequences of the traditional use of cardioplegic arrest when performing valve surgery,irrespective of the type of cardioplegia used [4-7]. Novel operative techniques are required to reduce these induced perioperative risks. Clinical studies in the past have demonstrated the efficacy of beating heart valve surgery in the high-risk patient using retrograde, antegrade or combined coronary perfusion with warm oxygenated blood [8, 9]. We chose to combine the superior hemodynamic profile of stentless xenografts with the concept of performing valve replacement on the empty beating heart with continuous antegrade application of oxygenated blood in 2 chronic hemodialysis patients.

We investigated the net myocardial release of creatine kinase isoenzyme MB (CKMB), myoglobin, cardiac troponin T (cTnT), cardiac troponin I (cTnI), and cardiac β-type myosin heavy chain (β-MHC) into the coronary circulation after cardioplegic cardiac arrest in humans. Cardiac markers were measured in paired arterial, central venous, and coronary sinus blood in 19 patients undergoing elective coronary artery bypass grafting (CABG) before aortic cross-clamping and 1, 5, 10, and 20 min after aortic declamping. cTnT and cTnI were released into the coronary sinus in parallel to each other and almost simultaneously to myoglobin and CKMB within 20 min of reperfusion. In contrast, no β-MHC was released in the same patients during the study period. The average soluble cTnT and cTnI pools in right atrial appendages of 11 patients with right atrial and right ventricular pressures within reference values were comparable and were ∼8% of total myocardial troponin content. The soluble β-MHC pool was

Superior long-term patency rates of the internal mammary artery (IMA) versus saphenous vein (SV) after coronary artery bypass grafting are well documented. Higher production rates of vasodilating and platelet-inhibiting mediators (prostacyclin and nitric oxide) by the IMA seem to have a major impact on its long-term durability and resistance to coronary artery graft disease. For the right gastroepiploic artery (RGEA) marked release of protective mediators is reported as well. The vasodilating effect of cyclic guanosine monophosphate (cGMP) released after stimulation by atrial natriuretic peptide might serve as another graft protective system. The aim of the present study was to determine cGMP release by IMA, RGEA, and SV after atrial natriuretic peptide challenge.Samples of human IMA (n = 19), RGEA (n = 7), and SV (n = 18) discarded during coronary artery bypass grafting were stimulated with 10(-6) mol/L atrial natriuretic peptide after a resting phase in nutrient medium. Release of cGMP was determined by 125-iodide radioimmunoassay.Basal cGMP production rates of the IMA (759.9 +/- 277.0 fmol/cm2) and RGEA (739.9 +/- 186.0 fmol/cm2) were higher than production rates of SV (281.2 +/- 64.0 fmol/cm2). Application of atrial natriuretic peptide led to a statistically significant increase of cGMP release in IMA grafts (1,939.3 +/- 778.0 fmol/cm2), whereas RGEA (618.4 +/- 141.3 fmol/cm2) and SV (221.7 +/- 64.5 fmol/cm2) remained at basal levels (p0.05).From these data we conclude that the IMA in comparison with the RGEA and SV produces more extracellular cGMP when stimulated by atrial natriuretic peptide. This effect might support the cGMP-mediated protective properties of nitric oxide and could underline the extraordinary suitability of the IMA as a bypass conduit.

A direct comparison of the three coronary artery bypass conduits internal mammary artery (IMA), right gastroepiploic artery (RGEA), and saphenous vein (SV) concerning arachidonic acid (AA) stimulated release of the vasodilating and platelet inhibiting mediator prostacyclin was the aim of the present study. Pieces of saphenous vein (n = 16), right gastroepiploic artery (n = 8), and internal mammary artery (n = 19) were obtained from patients undergoing coronary artery bypass grafting. After a resting phase of 30 min in HEPES medium arachidonic acid (AA) was added in order to stimulate prostacyclin release. Time-dependent production of the stable prostacyclin metabolite 6-keto-prostaglandin F1 alpha was determined following stimulation. Under basal conditions the IMA (12.4 ng/cm2) and RGEA (12.0 ng/cm2) released more prostacyclin than saphenous vein (4.0 ng/cm2). After AA stimulation 6-keto-prostaglandin F1 alpha release at 30 min was as follows: IMA 806.0 ng/cm2, RGEA 35.9 ng/cm2, SV 82.3 ng/cm2 (p < 0.0001 within grafts, p < 0.0001 between grafts, ANOVA for repeated measures). The internal mammary artery in comparison with the right gastroepiploic artery and saphenous vein seems to be better protected against local thrombotic events and development of coronary artery graft disease with the aid of the vasodilating and platelet inhibiting mediator prostacyclin.

In order to set the basis for detailed clinical investigations, mitochondrial creatine kinase (Mi-CK) was purified to homogeneity from human cardiac muscle. Biophysical characterization by SDS-PAGE, gel permeation chromatography and by electron microscopy of negatively stained single molecules demonstrated that, similar to other vertebrate Mi-CKs, human sarcomeric Mi-CK occurs in two different oligomeric forms, dimers and octamers, that are readily interconvertible. The apparent MTs of Mi-CK protomers, dimers and octamers were 43,600 +/- 800, 79,700 +/- 800 and 371,000 +/- 3000, respectively. In addition, isoelectric focussing proved to be a suitable technique for routinely distinguishing Mi-CK from cytosolic MM-CK and gave pl values of 8.30 +/- 0.04 and 7.44 +/- 0.04 for octameric and dimeric human sarcomeric Mi-CK. Circumstantial evidence suggests that both the highly symmetrical structure and the high pI value of Mi-CK octamers are crucial determinants for the physiological functions of this enzyme.

Malignant mixed mesodermal tumors (MMMT) are the most malignant neoplasms known to occur in the uterus. The most important prognostic factors are the extent of tumor at diagnosis, depth of myometrial invasion, and, as regarded by some authors, the sarcomatous component. We report on a retrospective analysis in 83 patients with MMMT. By univariate analysis survival was dependent on stage, depth of myometrial invasion, kind of therapy, age at menopause, and parity. However, the sarcomatous component did not significantly influence survival. Using the multivariate Cox regression analysis stage and parity or depth of myometrial invasion and parity were found to independently predict prognosis. Despite an interval of more than 20 years from the last childbirth to tumor appearance a beneficial influence of parity on the prognosis of MMMT was identified. This is unique in oncology. Especially patients with more than three children formed a subgroup of long-term survivors. It is interesting to note that parity was found by means of a Cox regression analysis to be statistically independent, and no correlation with other classical prognostic factors was detected.