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A 63-year-old woman underwent replacement of the aortic root, ascending aorta, and partial arch due to Type A aortic dissection. Shortly thereafter, a replacement of the distal aortic arch and descending aorta was performed. Three years later, the patient developed an aortoesophageal fistula (AEF) resulting in re-replacement of the distal aortic arch and proximal descending aorta with a cryopreserved aortic homograft. Six weeks post-discharge, the patient was readmitted due to recurrent AEF. A thoracic endovascular stent graft was implanted to cover the aortic rupture, followed by correction of an esophageal lesion. The patient was monitored closely over time.

Background Triple valve surgery (TVS) is associated with an elevated risk for operative mortality and thus remains a surgical challenge. We report our experience and results of TVS procedures, especially with respect to identification of preoperative risk factors, to improve patient selection. Methods Between December 1994 and January 2013, 487 consecutive patients (240 male, 247 female) underwent TVS at the Heart Center Leipzig, University of Leipzig. The data were prospectively collected and retrospectively analyzed. Univariate and multivariable regression analyses were performed to identify risk factors. Results The 30-day mortality was 16.1% and the long-term survival at 1 year and 5 years was 71.8% and 54.6%, respectively. Multivariable logistic regression analysis identified previous myocardial infarction to be the only significant predictor for early mortality. Age, New York Heart Association functional class IV, previous myocardial infarction, dialysis, and liver dysfunction were identified as preoperative predictors for late mortality. Furthermore, an increase of operative risk, given for each year, was observed during the study period. In contrast, 30-day mortality decreased during the observation time. Conclusion TVS is associated with a high surgical risk. Long-term survival is decreased, but acceptable for these high-risk patients. The series demonstrates that increasing surgical risk, age, and comorbidities are the future challenges in TVS.

Increased body mass index (BMI) is often found to be a risk factor for cardiac disease. However, it is unclear whether BMI also affects the gap junction remodeling process in atrial fibrillation (AF). The aim of the study was to see if BMI can influence the connexin43 (Cx43) distribution in patients with sinus rhythm (SR) and AF.We investigated a total of 51 white Caucasian patients of both gender (mean age: 69 years, 30% diabetes mellitus, ejection fraction [EF] 50%) with SR or AF, with either BMI 27 or ≥ 27 undergoing cardiac surgery for mitral valve repair, aortic valve repair, or coronary heart disease. We obtained human right atrial tissue for immunohistochemistry and investigated the CX43-positive polar and lateral membrane length in the different BMI (BMI 27, BMI ≥ 27) and rhythm groups (SR or AF).In lean SR patients, Cx43 (BMI 27) was found mainly at the cell poles while only 2% of the lateral membrane stained positive for Cx43. In obese SR patients (BMI 27), 6.7 ± 0.7% of the lateral membrane was positive (p 0.05). In AF generally, there was significantly more lateral Cx43 staining, which was significantly enhanced in obese AF patients. In lean AF patients, lateral Cx43 positivity increased to 14 ± 1% (p 0.05), while in BMI 27 AF patients, this was significantly enhanced to 22 ± 2% (p 0.05). The BMI effect was independent from left atrial diameter, EF, and comorbidity.Enhanced BMI is associated with increased remodeling effects of AF on irregular Cx43 distribution.

Paraplegia remains the most devastating complication of open and endovascular thoracic/thoracoabdominal aortic aneurysm (TAA/A) repair. However, the assessment of currently available neuromonitoring modalities remains challenging and difficult to interpret. Near-infrared spectroscopy (NIRS) has been introduced as a strategy for noninvasive, real-time monitoring of the paraspinous collateral network (CN) to detect potential spinal cord ischemia at our institution. Prior to TAA/A repair, a cerebrospinal fluid catheter is placed and four NIRS optodes are bilaterally positioned on the patient's back to transcutaneously monitor regional muscle oxygenation at the thoracic and lumbar levels. Indirect surveillance of the spinal cord by NIRS seems to be a tempting option with increasing evidence supporting the CN concept.

Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients.

Unter einem „Heart Team“ versteht man ein Team kardiologischer Spezialisten bestehend aus einem Kardiochirurgen, einem interventionellen Kardiologen und einem nicht interventionellen Kardiologen. Diese arbeiten taglich eng zusammen mit dem Ziel, die Patientenversorgung bestmoglich zu optimieren. Der klinische und wissenschaftliche Fokus eines Heart Teams kann jedoch sehr unterschiedlich sein, da sich in der praktischen Umsetzung verschiedene Subspezialisierungen herausgebildet haben. So unterscheidet man voneinander unabhangige Heart Teams fur die Behandlung der Aortenklappenstenose, der Mitralklappeninsuffizienz, der koronaren Herzkrankheit und der Herzinsuffizienz. Von besonderer Bedeutung fur jedes Heart Team ist die Bereitschaft der einzelnen Mitglieder und Abteilungen, intensiv miteinander zu kooperieren. Nichtsdestotrotz ist nach Meinung der Autoren der „Heart-Team“-Ansatz die derzeit beste Form der interdisziplinaren Kooperation und er wird in der Zukunft eine absolute Voraussetzung fur eine Herzmedizin auf hochstem Niveau sein.

Background The authors wanted to investigate whether the remodeling process in AF regarding gap junction proteins, collagen I, and amyloid may be gender dependent in humans. Methods In total, 123 patients with sinus rhythm (SR, n = 41) or atrial fibrillation (AF, n = 82) suffering from mitral valve disease undergoing cardiac surgery were included. Of the 123 patients, 66 patients (SR: n = 17, AF: n = 49) were investigated biochemically for the expression of the atrial gap junction proteins connexin40 (Cx40), connexin43 (Cx43) and collagen I and 57 patients (SR: n = 24; AF: n = 33) using histochemical methods for possible amyloid depositions. Results AF led to increased levels of Cx40, Cx43, and collagen I protein. Regarding Cx40 this upregulation was significantly higher in female than in male patients. For AF-induced changes in collagen or Cx43, there were no significant gender-dependent differences. Amyloid depositions were found with increasing age, but were not significantly related to AF or gender. Conclusions Remodeling in AF seems to be similar in men and women, with a tendency for women exhibiting somewhat stronger AF-induced changes in Cx40, which is probably a secondary effect because there is nothing known about hormone sensitivity of the Cx40 promoter, and a not significant tendency for higher Cx43 and collagen I.

Objectives: The aim of this study was to evaluate the surgical outcome in patients with mitral regurgitation (MR), who were assigned for percutaneous mitral valve repair (PMVR), but were declined for PMVR by the heart team and afterwards scheduled for conventional mitral valve (MV) surgery. The clinical outcome for this group has not been well described. Methods: The reasons for declination of PMVR, perioperative and operative data, 30-day mortality and 1-year survival after conventional MV surgery were retrospectively analyzed. Results: Between August 2009 to August 2013, 118 patients were assigned for PMVR. 29 patients (mean age 77 ± 8 years; 62% male) with high surgical risk (logistic EuroSCORE 17.3 ± 10.8%) were declined for PMVR by the heart team due to contraindication according EVEREST-criteria (n = 13; 42%), relevant tricuspid regurgitation (n = 13; 42%), possibility for conventional MV repair (MVR) (n = 6; 19%), relevant coronary artery disease in 2 patients (6%) or no indication for MV intervention in 1 patient (3%). Two (6%) patients had an indication for left ventricular assist device (LVAD) implantation. Isolated minimally invasive MVR were successfully performed in 6 patients (21%), MVR with tricuspid valve repair (TVR) in 5 patients (17%), isolated MV replacement in 6 patients (21%), MV replacement with TVR in 7 patients (24%) and isolated coronary artery bypass grafting in 1 patient (3%). LVAD implantation was performed in 2 patients (7%). The 30-day mortality was 0%, and the estimated overall 1-year survival was 77.8%. The observed mortality was significantly lower than predicted by EuroSCORE. Conclusion: Conventional MV surgery in MitraClip candidates can be performed without 30-day mortality and promising 1-year survival in experienced centers. The conventional MV surgery could be considered in MitraClip candidates with surgical relevant co-morbidities and contraindication according EVEREST-criteria. Furthermore, the data underline the importance of interdisciplinary heart team decision for each MitraClip candidate.

In recent years, catheter-based aortic valve interventions have become established procedures for the treatment of high-risk and advanced age patients with aortic valve pathologies. One of the limitations of the widespread applicability of this procedure is the annulus size. Until recently, no prosthesis was available to treat patients with a large annulus. We report on a patient with high-grade aortic stenosis (AS) and a 27-mm annulus, who underwent transapical implantation (TAP) of an Edwards SAPIEN® 29-mm prosthesis (Edwards LifeScience, Irvine, CA, USA). Due to insufficient dilation of his heavily calcified, functionally bicuspid aortic valve leaflets during balloon aortic valvuloplasty (BAV), the TAP prosthesis did not anchor adequately. This was determined during follow-up as he developed progressive aortic insufficiency and orthopnea, and an echocardiography revealed that the valve had been displaced into the LVOT. A conventional aortic valve replacement and ascending aorta replacement were performed, at which time the TAP prosthesis was removed. The patient recovered uneventfully, and was discharged with a well-functioning aortic bioprosthetic valve and in good general condition.

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

Our study aimed to elucidate whether bone marrow stem cell (BMC) treatment might result in a cellular response in cardiomyocytes IN VITRO. Subconfluent neonatal rat cardiomyocyte cultures were cocultured for three days with Vybrant CM-DiI labeled BMC from human sternal bone marrow and underwent immunohistological staining for the proto-oncogene c-Myc and the cell cycle proteins CDK2, CDK4 and ATF-3. β-adrenoceptor density was analyzed using [125I]-iodocyanopindolol (ICYP) histoautoradiography. Quantitative analysis of immunohistochemical images revealed significantly increased expression and upregulation of c-Myc, and its downstream targets ATF-3, CDK2 and CDK4 in neighboring cardiomyocytes to BMC, depending on their distance to the BMC compared to cardiomyocytes far from the BMC. Histoautoradiography revealed a significantly higher β-adrenoceptor density in cardiomyocytes in the immediate vicinity to the BMC. With increasing distance to the BMC, β-adrenoceptor density in cardiomyocytes declined. Thus, a small number of BMC can affect a larger number of cardiomyocytes by activating an intracellular signaling cascade and enhancing β-adrenoceptor density.

BACKGROUND: Little data is available regarding the safety of using the serine protease inhibitor aprotinin in off-pump cardiac surgery. We retrospectively assessed the risks of administering the drug to adult patients undergoing off-pump coronary artery bypass grafting (OPCABG). METHODS: Aprotinin was administered as a bolus of 1 or 2 million kallikrein inhibiting units to 391 patients following median sternotomy; 370 control patients underwent surgery during the same time period without receiving aprotinin. No other antifibrinolytic agents were administered. RESULTS: Preoperative characteristics, length of ICU and hospital stay were similar between the mostly medium-risk aprotinin and the control patients. Postoperative cardiac, renal, neurological, and respiratory complications and hospital mortality occurred with comparable frequencies in both groups. Levels of myocardial enzymes during the first 72 h after surgery also did not differ significantly. CONCLUSION: Use of aprotinin in OPCABG was not associated with a higher incidence of hospital mortality, cardiovascular, renal, or other complications. Given the good safety profile in this large patient population we suggest that aprotinin could still be a valid antifibrinolytic treatment option in OPCABG.

Although several antiarrhythmic drugs of chemical origin are in clinical use since decades, their application is often limited by their adverse effects and especially by their inherited proarrhythmic risk, which can lead to a significantly increased mortality in patients receiving these compounds. On the other hand, aqueous extracts from the aerial parts of the European Lamiaceae Leonurus cardiaca (Ph.Eur.) have been used for centuries as a remedy against tachyarrhythmia and other cardiac disorders. Nevertheless, a scientific basis for the claim of direct cardiac electrophysiological, antiarrhythmic, or functional effects of Leonurus cardiacae herba (LCH) preparations has not been established until now. In order to enrich the active constituents from the primary extract which was tested as the most cardioactive, namely the aqueous Soxhlet extract, and to eliminate undesired substances such as the dichloromethanic fraction or potassium, a bioassay guided fractionation procedure was applied, resulting in the development of a Leonurus cardiaca refined extract (LCRE) which was characterised together with Leonurus crude extracts by a newly developed gradient elution HPLC fingerprint analysis for separation and quantification of six major phenolics as well as by qNMR for determining the stachydrine content. This refined extract was applied intracoronarily in isolated rabbit hearts perfused according to the Langendorff technique. Mapping experiments with 256 electrodes on the heart surface showed a reduction of left ventricular pressure and an increase of relative coronary flow at concentrations of 1.0 and 2.0 mg/mL LCRE. Furthermore, the PQ-interval was prolonged and both the basic cycle length and the activation recovery interval increased. In addition, voltage-clamp measurements were performed on the following cell models in order to characterise the electrophysiological profile of LCRE: neonatal rat ventricular cardiomyocytes to investigate the effect on I(Na) and I(Ca.L), sinoatrial node cells and ventricular myocytes isolated from adult guinea pigs to test effects on I(f) and action potential (AP) duration, as well as HERG-transfected HEK 293 cells to analyse the influence on the I (K.r). In these voltage clamp experiments LCRE exerted a calcium-antagonistic activity by I(Ca.L) blockade, reduced the repolarising current I(K.r), and prolonged the AP-duration, while I(Na) was not affected. Although LCRE displayed only weak effects on the I(f) amplitude and voltage dependence, it significantly prolonged the activation time constant of I(f). Thus, LCRE acts on multiple electrophysiological targets, specifically I(Ca.L), I(K.r), and I(f), observed both at whole organ and single cell level.

BACKGROUND: The aim of this prospective study was to determine the differences in left ventricular (LV) lead positioning for cardiac resynchronization therapy (CRT): comparing a percutaneous transvenous approach via the coronary sinus versus epimyocardial placement via a left lateral mini-thoracotomy. METHODS: Eighty consecutive patients with symptomatic left ventricular dysfunction and an indication for CRT were randomized to receive either a transvenous (n = 40) or epicardial (n = 40) LV-lead placement. Postoperative follow-up included assessment of NYHA functional class, ECG and echocardiography. RESULTS: The transvenous group had a shorter ICU stay (0.66 vs. 3.8 days) and shorter ventilation times (0.34 vs. 3.2 h). The epicardial group had less exposure to radiation (7.4 vs. 23 min) and required less use of contrast medium (3.24 vs. 61 ml). At 6 months follow-up, no major differences in LV-lead parameters (threshold, sensing, and impedance) were observed. CONCLUSION: Both epicardial and transvenous LV-lead placement for CRT therapy are safe and effective. The transvenous approach is less invasive and should be considered the standard procedure for patients without renal insufficiency. However, in a case of difficult coronary venous anatomy with the inability to position the lead as desired, epicardial LV-lead placement remains an alternative option.

We report on a male newborn requiring repair of a huge left apical diverticulum leading to progressive heart failure and extensive ventricular arrhythmia. At the age of 11 days, a modified Dor procedure using an autologous endoventricular pericardial patch was performed. Postoperatively, a significant reduction of ventricular extrasystole was evident. One year postoperatively, the infant demonstrates a normal cognitive and somatic development without clinical signs of cardiac failure.

Objectives: Coronary artery bypass graft surgery (CABG) utilizing total arterial revascularization (TAR) can be performed by constructing a composite Y/T-graft using either bilateral internal mammary arteries (BIMA) or the left internal mammary and radial arteries (LIMA-rad). The aim of our study was to compare the early and long-term clinical outcomes in patients, who received BIMAs with those who received LIMA-rad, both groups of patients being exclusively revascularized with the Y/T composite graft. Methods: A total of 504 patients underwent TAR solely with Y/T composite grafts at our institution from January 2001 through June 2010. Of these, BIMAs were used in 210 patients and LIMA-rad in 294 patients. Comparison of the 2 groups with regard to cumulative long-term mortality and major adverse cardiac and cerebrovascular events (MACCE) was performed using the competing risks method after matching for age, gender, number of diseased coronary arteries and presence of left main disease. The matched groups contained 186 patients each. Multivariate logistic regression analysis identified the significant predictors and the independent effect of the type of TAR (BIMA or LIMA-rad) on 30-day MACCE. Hazard ratios for late mortality and MACCE were estimated by Cox regression analysis. Results: The overall 30-day mortality amongst the matched groups was 1.6%, being 2.2% and 1.1% in the BIMA and LIMA-rad groups (p = 0.7), respectively. All-cause mortality (11·9% in BIMA group vs 12·4% in LIMA-rad group; p = 0·7) and acute myocardial infarction (1.1% vs 0.8%; p = 0·09) at 6 years were not significantly different between the matched groups. However, stroke rate was significantly higher in the BIMA group (5.8%) than in the LIMA-rad group (0.5%) (p = 0.007). Conversely, the rate of repeat revascularization was higher in patients with LIMA-rad (7.4%) than those with BIMA (4%), although it did not reach statistical significance (p = 0.16). Conclusions: TAR using BIMA or LIMA-rad in a Y/T configuration is associated with excellent early and long-term outcomes. Patients, who received BIMA, had a higher propensity of developing a stroke, but a lower repeat revascularization rate than those receiving LIMA-rad at follow-up.

Objectives: Proximal aortic aneurysms (pAA) are frequently associated with severe atherosclerosis but the underlying pathomechanism has not yet been understood. Recent studies suggested an elevation in inflammation markers accompanying aneurysm development. Whether alterations in calcification, inflammatory and autophagy response within the proximal aortic wall of patients with bicuspid aortic valve(BAV) is distinct from that in tricuspid aortic valve(TAV) pts has not yet been investigated. Methods: Aortic wall tissue of 14 TAV & 12 BAVs with pAA was assessed distinguishing between the greater and lesser curvature. Protein expression of characteristic tissue indicators were evaluated by western blot:(1)periostin (integrin ligand supporting adhesion/migration)- a marker for mechanical stress (2)tissue interleukin-6(tIL6) as marker of local inflammation. Systemic C-reactive protein (CRP) was measured in blood. Tissue autophagy was assessed by osteopontin (OPN, found in atheromatous plaques). Furthermore, microtubule-associated protein-1 light chain 3(LC3) and α-smooth-muscle-actin(α-SMA) were analyzed. Results: Protein expression of tIL-6 was higher in TAV- vs BAV-pAA(180 ± 58 vs. 42 ± 24; p