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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2009.04.057 Byline: Andreas Zierer, Gerhard Wimmer-Greinecker, Sven Martens, Anton Moritz, Mirko Doss Abbreviations: AVI, aortic valve implantation; AVR, aortic valve replacement; CPB, cardiopulmonary bypass; PUS, partial upper sternotomy; PUS-AVR, minimally invasive aortic valve replacement via partial upper sternotomy; TAP-AVI, transapical aortic valve implantation (implant) Abstract: Transcatheter valve implants currently draw their justification for use from reduction of perioperative risk. However, patient age and comorbidities are independent predictors of adverse outcome after aortic valve replacement, regardless of surgical approach. Therefore, it is unclear whether transapical aortic valve implantation really improves outcomes in high-risk patients. Author Affiliation: Division of Cardiothoracic Surgery, Hospital of the Johann Wolfgang Goethe University Frankfurt am Main, Germany Article History: Received 9 May 2008; Revised 7 February 2009; Accepted 27 April 2009 Article Note: (footnote) Read at the Eighty-eighth Annual Meeting of The American Association for Thoracic Surgery, San Diego, Calif, May 10-14, 2008.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2008.06.028 Byline: Andreas Zierer (a), Gerhard Wimmer-Greinecker (a), Sven Martens (a), Anton Moritz (a), Mirko Doss (a) Abbreviations: AVI, aortic valve implantation; TAP-AVI, transapical aortic valve implantation; AVR, aortic valve replacement; CPB, cardiopulmonary bypass Abstract: Percutaneous aortic valve implantation has been performed clinically in high-risk patients with severe aortic stenosis. Transfemoral retrograde valve delivery is limited by concomitant peripheral vascular disease and the size of the delivery system. We report on the alternative transapical approach that allows accurate antegrade placement of a catheter-deliverable aortic valve. Author Affiliation: (a) Division of Cardiothoracic Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt/Main, Germany Article History: Received 1 April 2008; Revised 18 May 2008; Accepted 15 June 2008

A 58-year-old male underwent LVAD-Implantation after ECLS explantation. After removal of ECLS (A) transesophageal echocardiography revealed thrombus in the inferior vena cava (B) and right atrium (C). The thrombus was removed with a second pump run including RVAD-Implantation. (D) The diameter of thrombus formations was 6 × 1 cm and 5 × 1.5 cm.

The gold standard therapy for end-stage heart failure is cardiac transplantation. However, in the face of a donor shortage, a mechanical assist device such as the left ventricular assist device HeartMate 3 (Abbott Laboratories, Abbott Park, IL, USA) serves as bridging therapy to transplantation and/or destination therapy. Current guidelines recommend anticoagulation with a vitamin K antagonist in combination with low-dose aspirin. We herein report a challenging anticoagulation regimen in a patient with a HeartMate 3 in whom systemic anticoagulation with warfarin was not feasible for 4 years because of low compatibility and a rare X-factor deficiency. This is a rare hematological disorder, estimated to affect approximately 1 in every 500,000 to 1,000,000 people in the general population. The patient finally received a modified anticoagulation regimen involving the combination of rivaroxaban and clopidogrel without warfarin. Under this regimen, the patient remained free of thromboembolic complications for 4 years with in situplacement of the left ventricular assist device. This case illustrates that under specific circumstances, long-term absence of warfarin therapy is feasible in patients with a HeartMate 3.

In recent years, minimally invasive valve surgery (MIVS) has gained popularity in cardiac surgery centres across the globe.

Left Ventricular Assist Device (LVAD) is currently implanted not only as a bridge to transplant or recovery but also as destination therapy. One factor, affecting the device performance and treatment adequacy negatively is the development of aortic valve insufficiency (AI) after the implantation. Herein, we introduce a minimally invasive partial sternotomy aortic valve replacement with an expandable bio-prosthesis in a 74-year-old LVAD patient with severe AI.

Objective Preballooning (PB) of the stenotic aortic valve can be considered common standard during transcatheter aortic valve implantation (T-AVI). Transcatheter aortic valve implantation without preballooning (noPB) using the Edwards SAPIEN XT prosthesis has been described previously. The aim of this study was to evaluate the outcomes of next-generation SAPIEN 3 valve implantation without PB.Methods Since January 2013, a total of 66 patients received SAPIEN 3 valve implantation at our center using the transapical approach. Patients were treated using the standard PB technique (n = 17 [25.8%]) or no PB (n = 49 [74.2%]).Results Baseline characteristics of patient groups were comparable (38% women; mean age, 83 years; STS score, 8%, logistic EuroSCORE I and II, 30% and 8%, respectively). Patients in the PB group were exclusively treated in our earlier experience with this device. Overall 30-day mortality was 4.5% (6.1% for noPB vs. 0% PB; P=ns). Aortic regurgitation was grade 1 or less in 100% (PB) versus 93.9% (noPB); P = ns Median contrast use was 70 (60–95) mL (PB) versus 50 (40–50) mL (noPB); P < 0.001; and median radiation dose was 32.0(17–57) Gy × cm2(PB) versus 26.6 (16–36) Gy × cm2(noPB); P < 0.001. Postdilatation was required in one patient only (noPB). The rate of new pacemaker implantations was 41.2% (PB) versus 12.2% (noPB); P = 0.03. Periprocedural stroke occurred in one patient in each group (6% PB vs 2.0% no-PB); P = ns.Conclusions Direct transapical SAPIEN 3 valve implantation without PB is feasible and safe. The no-PB technique leads to further simplification of the procedures.

The purpose of the study was to compare the performance of late iodine–enhancement (LIE) dual-energy computed tomography (DECT) linear blending and selective myocardial iodine mapping for the detection of chronic myocardial infarction (CMI) with late gadolinium–enhancement (LGE) 3-T magnetic resonance imaging.

Untreated symptomatic high-grade aortic stenosis remains a lethal disease. Therefore, a comprehensive evaluation is necessary to obtain the best individual treatment for each patient. Recently, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for high-risk and inoperable patients. Persistent thrombocytopenia is an established risk for conventional open heart surgery, but is not covered by traditional surgical risk scores. The aim of the study was the investigation of safety and feasibility of TAVI in patients with severe thrombocytopenia. Because of the complicated outcome of patients with persistent thrombocytopenia undergoing heart surgery, we considered all patients with high-grade aortic stenosis and a thrombocyte count of less than 100 per nl as surgical high-risk patients. Out of these high-risk surgical patients, six patients with symptomatic high-grade aortic stenosis and severe thrombocytopenia were deemed to be TAVI candidates and underwent TAVI procedures in 2010 and 2011 (transfemoral: n=4; transapical: n=2) at the University Hospital of Frankfurt. The outcome of these patients was analyzed prospectively in order to document safety and feasibility of TAVI in such patients. All TAVI procedures were performed successfully with excellent functional results. There was no occurrence of major or minor bleeding complications, acute renal failure or nosocomial infection. One patient died of an ischemic stroke 12 days after the procedure. The five remaining patients were alive at the 12-month follow-up without relevant cardiovascular events and excellent valve performance. TAVI is an effective and well tolerated method to treat patients with chronic persistent thrombocytopenia and symptomatic high-grade aortic stenosis, and therefore a reasonable alternative to conventional heart surgery in such patients. The indication for TAVI in patients with thrombocytopenia and symptomatic high-grade aortic stenosis might be generated independently from conventional scoring systems.

Objective For elderly patients with symptomatic aortic valve stenosis, aortic valve replacement with tissue valves is still the treatment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time demanding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy.Methods The procedure was performed using CPB with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2).Results Implantation of the valve required 10 ± 6 minutes. Cardiopulmonary bypass and aortic crossclamp time were 87 ± 16 and 55 ± 11 minutes, respectively. Early mortality (<90 days) was 9% (2 patients). No paravalvular leakage was detected intraoperatively or in follow-up echocardiography. The mean transvalvular gradients were 9 ± 6 mm Hg at discharge and 8 ± 2 mm Hg at 1-year follow-up.Conclusions Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity.

Randomized trials comparing stentless to stented bioprostheses for aortic valve replacement in elderly are scarce. The aim of this study was early and mid-term evaluation of these bioprostheses, with regards to clinical outcome and hemodynamic performance.

Endovaskuläre Eingriffe an der deszendierenden thorakalen Aorta haben sich in den letzten 10 Jahren als Alternative zur offenen chirurgischen Therapie etabliert. Zunächst war der Einsatz von endovaskulären Stentgrafts auf elektive Patienten mit einem Hochrisikoprofil für eine offene Operation beschränkt. Doch die Indikation wurde bald auch auf den notfallmäßigen Einsatz ausgeweitet. Bei elektiven Eingriffen an der deszendierenden thorakalen Aorta führte die endovaskuläre Therapie zu einem deutlichen Absinken der perioperativen Mortalität und Morbidität (Tabellen 1 und 2). Diese hervorragenden perioperativen Ergebnisse konnten auch in der Notfallsituation reproduziert werden und waren daher der offenen chirurgischen Therapie deutlich überlegen (Tabelle 3). Es bleibt die Frage der Langzeithaltbarkeit endovaskulärer Prothesen. Während Patienten nach offener chirurgischer Therapie kaum mit Spätkomplikationen rechnen müssen, wird in der Literatur von Stentgraftversagen im späten Verlauf berichtet (Abbildungen 1 und 2). Das Auftreten von Endoleaks (Abbildungen 3 und 4), Rupturen des Aneurysmasacks, Graftmigration und Materialverschleiß an den Stentgrafts wirft Fragen bezüglich der Langzeithaltbarkeit auf. Im Lichte dieser Spätkomplikationen bleibt die regelmäßige Nachsorge dieser Patienten notwendig, um letztendlich eine valide Aussage über Vorteile und Risiken dieser innovativen Technologie machen zu können. Endovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well. In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at midand long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Management of extensive thoracic aortic disease may present an immense technical challenge. The choice of surgical access and subsequent exposure determines whether a single-stage or a 2-stage approach can be adopted.

BackgroundThe purpose of our study was to show the effectiveness of endovascular stent grafts in the treatment of acutely ruptured abdominal and thoracic aortic aneurysms as an alternative to the conventional surgical approach in an emergency setting. MethodsFrom October 1996 to October 1998 we deployed 9 emergent endovascular stent grafts—6 in the abdominal aorta and 3 in the thoracic aorta. Aortic rupture was confirmed before surgery with spiral-computed tomographic scan. The average interval from onset of symptoms to treatment was 4.5 hours. We used commercially manufactured stent grafts: 4 Corvita (Corvita Inc/Schneider Corp/Boston Scientific Corp, Natick, Mass), 3 Talent (World Medical Inc, Surise, Fla/Medtronic, Sunnyvale, Calif), and 2 Vanguard (Boston Scientific Corp, Natick, Mass). ResultsDeployment of the stent grafts was successful in all cases. Two patients died in the follow-up period (120 months) from myocardial infarction. No cases were seen of paraplegia or stent migration. However, 2 endoleaks, 1 in-stent stenosis, 1 temporary renal failure, and 1 brief episode of myocardial ischemia occurred. ConclusionOur experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in selected patients. (Am Heart J 2002;144:544-8.)

The surgical closure of ASDs and VSDs is a safe and effective procedure with low morbidity and mortality. Surgical correction of these defects has been performed for over 40 years. Percutaneous transcatheter techniques for the closure of ASDs and VSDs are also effective for certain forms of these defects. Frequently, young female patients or children require ASD closure. This has stimulated efforts to create cosmetically more appealing surgical incisions, and most recently, to use minimally invasive surgical techniques. These techniques allow skin incisions to be limited to 4‐6 cm in the submammary crease. For the latest robotically assisted technique only four stab wound incisions have to be performed on the chest. All surgical procedures described require cardiopulmonary bypass. This is associated with well‐known specific problems that can be reduced by recent modifications. Improved cosmesis, lower cost, shorter procedural time, and the ability to correct even more complex malformations with minimally invasive surgical techniques currently compete with the still complex percutaneous defect closures.

We report a case of leaflet escape in an Edwards-TEKNA bileaflet valve, in the mitral position. The examination findings of the explanted valve are compared with a similar case of leaflet escape in an original Edward-Duromedics prosthesis. Based on our findings alone, it is not certain whether the TEKNA valve continues to have a higher risk for fracture.