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Objectives: To analyze outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to postcardiotomy cardiogenic shock (PCCS) related to coronary malperfusion. Methods: Retrospective single-center analysis in patients with normal preoperative LVEF treated with VA-ECMO for coronary malperfusion-related PCCS between May 1998 and May 2018. The primary outcome was 30-day mortality, which was compared using the Kaplan-Meier method and the log-rank test. Multivariable logistic regression was performed to identify predictors of mortality. Results: During the study period, a total of 62,125 patients underwent cardiac surgery at our institution. Amongst them, 59 patients (0.1%) with normal preoperative LVEF required VA-ECMO support due to coronary malperfusion-related PCCS. The mean duration of VA-ECMO support was 6 days (interquartile range 4–7 days). The 30-day mortality was 50.8%. Under VA-ECMO therapy, a complication composite outcome of bleeding, re-exploration for bleeding, acute renal failure, acute liver failure, and sepsis occurred in 51 (86.4%) patients. Independent predictors of 30-day mortality were lactate levels > 9.9 mmol/l before VA-ECMO implantation (odds ratio [OR]: 3.3; 95% confidence interval [CI] 1.5–7.0; p = 0.002), delay until revascularization > 278 minutes (OR: 2.9; 95% CI 1.3–6.4; p = 0.008) and peripheral arterial artery disease (OR: 3.3; 95% 1.6–7.5; p = 0.001). Conclusions: Mortality rates are high in patients with normal preoperative LVEF who develop PCCS due to coronary malperfusion. The early implantation of VA-ECMO before the development of profound tissue hypoxia and early coronary revascularization increases the likelihood of survival. Lactate levels are useful to define optimal timing for the VA-ECMO initiation. [ABSTRACT FROM AUTHOR]

Background The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). Methods An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. Results A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), Sv O2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). Conclusion Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P  = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P  < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety. [ABSTRACT FROM AUTHOR]

Background: Transesophageal echocardiography (TEE) is a powerful diagnostic tool which has become an integral part in the management of cardiac surgery patients. We developed a one-day 3D TEE workshop specifically designed to meet the needs of perioperative cardiac anaesthesiologists. We hypothesized that participation in the workshop would increase the uptake of 3D TEE in routine perioperative practice.Aims: To examine the impact of one-day 3D TEE workshop on 3D TEE image acquisition and incorporation into routine perioperative practice.Setting: Tertiary care hospital.Design: Prospective observational monocentric study.Subjects and Methods: A convenience sample of 20 cardiac anesthesiologists (with an option to attend the one- day workshop midway through the study) from a single center consented to have their intraoperative TEE images collected during the course of the study reviewed for research purposes. Images acquired 6 months before, immediately after, and 6 months following the workshop and images were examined by a blinded, expert echocardiographer.Results: Data collected for 16 participants (8 workshop attendees, 8 non-attendees) indicate that the TEE workshop increased the number of 3D TEE images, but not x images acquired immediately following the workshop (P=0.006). No difference was observed in number of 3D images at six months' post workshop. Workshop participants obtained more 3D and multi-plane images after the workshop and more 3D images at 6 months compared to those who did not attend the workshop.Conclusion: Our study suggests that a single day hands-on 3D TEE workshop may have had an impact on the implementation of intraoperative 3D TEE in experienced echocardiographers. [ABSTRACT FROM AUTHOR]

Introduction: Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination.Subject and Methods: A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups.Results: Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students.Conclusions: Both teaching methods are effective and lead to the intended level of knowledge and skills. [ABSTRACT FROM AUTHOR]

Aims Whereas haemodynamic and echocardiographic studies suggest benefits for left ventricular (LV) function and cardiac output following reduction in LV preload by interventional edge-to-edge repair for mitral regurgitation (MR), there is limited data on volumetric and functional LV and right ventricular (RV) changes using cardiac magnetic resonance (CMR) imaging. Methods and results Patients with moderate to severeMRand high surgical risk underwent MitraClipTM-implantation andCMRimaging before and within 7 days after the procedure. In addition to volumetric and flow studies, myocardial feature tracking (FT) technology for quantification of myocardial strainwas applied.Twenty patients (age: 76+8 years) with functional (n = 15) or degenerative MR (n = 5) with a mean logistic Euroscore I of 33+16 underwent both successful MitraClipTM implantation and CMR imaging. MR fraction (36+10 vs. 19+12%; P , 0.001) and LV end-diastolic volume (115+36 vs. 105+41 mL/m2; P = 0.002) decreased significantly, whereas LV ejection fraction (42+15 vs. 41+16%, P = 0.8) and cardiac index (1.7+0.5 vs. 1.8+0.4 L/min/2, P = 0.4) remained unchanged. MitraClipTM implantation resulted in a significant impairment of circumferential (212.8+4.8 vs. 28.2+3.3; P = 0.002) and radial strain (15.4+7.7 vs. 9.6+5.3; P = 0.02) on basal short-axis view. On RV level, there were no significant changes in end-diastolic volume (83+19 vs. 84+18 mL/2, P = 0.8), ejection fraction (42+9 vs. 43+11%, P = 0.8), or tricuspid regurgitation fraction (24+17 vs. 25+19%, P = 0.7). MitraClipTM implantation led to a significant improvement in New York Heart Association functional class (patients in functional class III-IV pre 100% vs. post 45%; P , 0.001). Conclusion In severely compromised patients, marked reduction in MR by MitraClipTM implantation might not result in immediate improved cardiac output and effective biventricular forward flow. [ABSTRACT FROM AUTHOR]

To the Editor, Thank you indeed for your important comments concerning our article "Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students".[[1]] We fully agree that well-trained, experienced patients as educators can bridge the gap between examining simulators and patients with cardiac disease, especially when teaching goals in patient encounters include "telling their story", stimulating reflection, sharing perspectives or problem-solving, as suggested by Cheng I et al i .[[2]] Reviews have been published highlighting not only the benefits, but also the challenges of patient educators involved in clinical teaching.[[3]] One central issue of involving patient educators in medical education is the principle that "what is taught should be what the patient educators want students to learn, in the way they want to teach it, and at the location of their choosing".[[4]] In our study, the students involved in the case-control study were students with no prior experience in echocardiography techniques, with the aim of comparing simulator-based TTE teaching with live-human-model-teaching to elucidate which teaching method accomplishes the learning goal of achieving maximum points in all FATE examination standard views. We feel that high accomplishment in standard echocardiography examination techniques should be prerequisite before exposing students to patient educators or patients with chronic heart disease. REFERENCES 1 Patterson B, Antram E. Impact of simulator based training on acquisition of transthoracic echocardiography skills in medical students Medical students' perspective. [Extracted from the article]

The article discusses a research study on the use of Medtrionic CoreValue (MCV) system in transcatheter aortic valve implantation in high-risk patients with aortic valve bioprosthesis failure. Researchers considered 65-year-old and older patients with failing aortic valve bioprosthesis and recorded clinical events then performed a transthoracic echocardiography to evaluate MCV impact on hemodynamics. Conclusions indicated the feasibility and safety of MCV implantation in older patients.

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55–120) min vs. off-pump 80 (55–120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the results of minimally invasive transapical aortic valve implantation (TA-AVI) in patients requiring redo surgery. Methods: Twenty-five high risk patients with symptomatic aortic valve stenosis and previous cardiac surgical interventions received TA-AVI using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN™) since February 2006. All valves were implanted in a hybrid operative theater. Patient age was 78 years, 60% were female, logistic EuroSCORE and STS score risk for mortality were 39% and 17%, respectively. Previous cardiac surgery was CABG in 17, valve surgery in 5 and other in 3 patients. Results: TA-AVI was performed successfully in 24 (96%) of the patients. One patient required early conversion to sternotomy and one patient required temporary ECMO support. A total of 21 patients (84%) were treated completely off-pump, one early patient was treated on-pump by intention and three patients required secondary cardiopulmonary bypass support. Echocardiography revealed good valve function in all but the converted patient, with trivial to mild (1°) paravalvular incompetence in 40%. Three patients died within 30 days of the procedure and during follow-up four patients died, all with good valve function at most recent echo. Thirty-day survival was 88% and one-year survival was 72%. There were no new-onset neurological events. Conclusions: TA-AVI can be performed with excellent results and minimal stroke risk in high risk patients requiring redo cardiac surgery. TA-AVI represents an important alternative to conventional surgery in elderly high risk patients requiring reoperative procedures. [Copyright &y& Elsevier]