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OBJECTIVES: Mechanical circulatory support is an established therapy in end-stage heart failure. The EUROMACS registry was created to promote research in these patients. The aim of this report was to present our 12 year experience with the durable mechanical circulatory support devices and compare it with the EUROMACS registry. METHODS: Data from the entire EUROMACS registry from January 2011 to April 2019 were included (4704 implantations in 4410 patients). During the 12 years of our experience, until April 2019,125 mechanical support devices were implanted, in 122 patients. We compare patients´ characteristics, operative data and results with the EUROMACS registry and we report the major complications during the observational period. RESULTS: Primary end-point (death) occurred in 40 (32.8 %) patients in our cohort during the followup period, representing the survival rate 75 %, 68 %, and 58 % for 6, 12, 24 months respectively, which compares favourably with the data, reported by the EUROMACS registry, the survival 66 % and 53 % after 1 and 2 years respectively. Cerebrovascular accident occurred in 7 %, a bleeding event in 32 %, signifi cant infection (driveline) in 78 % and a device malfunction in 13 % of the patients. Forty- three patients underwent a heart transplant with hospital and long-term mortality of 11.6 % and 14 % respectively. CONCLUSION: Mechanical circulatory support is a valuable therapeutic option with excellent survival rates, nevertheless it is associated with clinically signifi cant complications rates. The direct comparison between our cohort and the EUROMACS registry showed that early implantation strategy and mini invasive approach may improve survival rates and decrease postoperative complications (Tab. 3, Fig. 3, Ref. 16). Text in PDF www.elis.sk

BackgroundThe published experience of lung transplantation in acute respiratory distress syndrome (ARDS) is limited. The aim of this study was to investigate the contemporary results of lung transplantation attempts in ARDS in major European centres.MethodsWe conducted a retrospective multicentre cohort study of all patients listed for lung transplantation between 2011 and 2019. We surveyed 68 centres in 22 European countries. All patients admitted to the waitlist for lung transplantation with a diagnosis of “ARDS/pneumonia” were included. Patients without extracorporeal membrane oxygenation (ECMO) or mechanical ventilation were excluded. Patients were followed until 1 October 2020 or death. Multivariable analysis for 1-year survival after listing and lung transplantation was performed.Results55 centres (81%) with a total transplant activity of 12 438 lung transplants during the 9-year period gave feedback. 40 patients with a median age of 35 years were identified. Patients were listed for lung transplantation in 18 different centres in 10 countries. 31 patients underwent lung transplantation (0.25% of all indications) and nine patients died on the waitlist. 90% of transplanted patients were on ECMO in combination with mechanical ventilation before lung transplantation. On multivariable analysis, transplantation during 2015–2019 was independently associated with better 1-year survival after lung transplantation (OR 10.493, 95% CI 1.977–55.705; p=0.006). 16 survivors out of 23 patients with known status (70%) returned to work after lung transplantation.ConclusionsLung transplantation in highly selected ARDS patients is feasible and outcome has improved in the modern era. The selection process remains ethically and technically challenging.

OBJECTIVES The present study compared the clinical outcomes between minimally invasive surgery (MIS) and median sternotomy (MS) in patients with native mitral valve infective endocarditis. METHODS From 2009 to 2019, a total of 154 patients with acute (n = 131, 85%) or subacute (n = 23, 15%) native mitral valve infective endocarditis were included in the study. One-to-one nearest neighbour propensity score matching considering endocarditis severity using the dedicated De Feo score and 19 other clinically relevant baseline variables resulted in a population of 39 matched pairs. The matched cohort was investigated regarding operative and postoperative outcomes. RESULTS Both groups showed similar results regarding cardiopulmonary bypass time [MIS: 96 min (77–138), MS: 99 min (88–127); P = 0.780] and aortic cross-clamp time [MIS: 64 min (54–90), MS: 65 min (59–83); P = 0.563], whereas overall operative time was shorter through minimally invasive access [MIS: 138 min (112–196), MS: 187 min (175–230); P = 0.005]. Although the rate of revision for bleeding was similar in both groups [MIS: 12.8% (n = 5), MS: 10.3% (n = 4); P = 1.000], MIS was associated with fewer red blood cell unit transfusions [MIS: 1 unit (0–4), MS: 4 units (2–10); P = 0.001] and fewer fresh frozen plasma unit transfusions [MIS: 0 units (0–0), MS: 1 unit (0–5); P = 0.002]. MIS was associated with a shorter ventilation time [MIS: 708 min (429–1236), MS: 1440 min (659–4411); P = 0.024] and a lower rate of reintubation after extubation [MIS: 5.1% (n = 2), MS: 25.6% (n = 10); P = 0.021]. CONCLUSIONS In patients suffering from native mitral valve infective endocarditis, MIS provides significant clinical benefits over sternotomy in selected patients. Subject collection 117, 121.

BACKGROUND: The therapeutic success in patients with congenital heart disease (CHD) leads to a growing number of adults with CHD (adult CHD [ACHD]) who develop end-stage heart failure. We aimed to determine patient characteristics and outcomes of ACHD listed for heart transplantation. METHODS: Using data from all the patients with ACHD in 20 transplant centers in the Eurotransplant region from 1999 to 2015, we analyzed patient characteristics, waiting list, and post-transplantation outcomes. RESULTS: A total of 204 patients with ACHD were listed during the study period. The median age was 38 years, and 62.3% of the patients were listed in high urgency (HU), and 37.7% of the patients were in transplantable (T)-listing status. A total of 23.5% of the patients died or were delisted owing to clinical worsening, and 75% of the patients underwent transplantation. Median waiting time for patients with HU-listing status was 4.18 months and with T-listing status 9.07 months. There was no difference in crude mortality or delisting between patients who were HU status listed and T status listed (p = 0.65). In multivariable regression analysis, markers for respiratory failure (mechanical ventilation, hazard ratio [HR]: 1.41, 95% CI: 1.11-1.81, p = 0.006) and arrhythmias (anti-arrhythmic medication, HR: 1.42, 95% CI: 1.01-2.01, p = 0.044) were associated with a higher risk of death or delisting. In the overall cohort, post-transplantation mortality was 26.8% after 1 year and 33.4% after 5 years. CONCLUSIONS: Listed patients are at high risk of death without differences in the urgency of listing. Respiratory failure requiring invasive ventilation and possibly arrhythmias requiring anti-arrhythmic medication indicate worse outcomes on waiting list. (C) 2020 International Society for Heart and Lung Transplantation. All rights reserved.

Background: The impact of postural changes on various electrocardiography (ECG) characteristics has only been assessed in a few small studies. This large prospective trial was conducted to confirm or refute preliminary data and add important results with immediate impact on daily clinical practice. Methods: ECGs in supine and upright position from 1028 patients were analyzed. Evaluation was made according to changes in T-wave vector and direction, ST-segment deviation, heart rate, QT interval and QTc interval was performed. Findings were correlated with the medical history of patients. Results: Positional change from supine to upright resulted in a significantly increased heart rate (8.05 ± 7.71 bpm) and a significantly increased QTc interval after Bazetts (18 ± 23.45 ms) and Fridericas (8.84 ± 17.30) formula. In the upright position significantly more T-waves turned negative (14.7%) than positive (5.7%). ST elevation was recorded in only 0.4% and ST depression in not more than 0.2% of all patients. Conclusions: The majority of the patients do not show significant morphological changes in their ECG by changing the body position from supine to upright. Changes of QTc time instead, are significant and the interval might be overestimated in upright. Therefore assessment of the QTc interval should strictly be done in a supine position.

Pediatric heart transplantation (pHTx) represents only a small proportion of cardiac transplants. Due to these low numbers, clinical data relating to induction therapy in this special population are far less extensive than for adults. Induction is used more widely in pHTx than in adults, mainly because of early steroid withdrawal or complete steroid avoidance. Antithymocyte globulin (ATG) is the most frequent choice for induction in pHTx, and rabbit antithymocyte globulin (rATG, Thymoglobulin®) (Sanofi Genzyme) is the most widely-used ATG preparation. In the absence of large, prospective, blinded trials, we aimed to review the current literature and databases for evidence regarding the use, complications, and dosages of rATG. Analyses from registry databases suggest that, overall, ATG preparations are associated with improved graft survival compared to interleukin-2 receptor antagonists. Advantages for the use of rATG have been shown in low-risk patients given tacrolimus and mycophenolate mofetil in a steroid-free regimen, in sensitized patients with pre-formed alloantibodies and/or a positive donor-specific crossmatch, and in ABO-incompatible pHTx. Registry and clinical data have indicated no increased risk of infection or post-transplant lymphoproliferative disorder in children given rATG after pHTx. A total rATG dose in the range 3.5-7.5 mg/kg is advisable.

Background Smartphone manufacturers offer mobile health monitoring technology to their customers, including apps using the built-in camera for heart rate assessment. This study aimed to test the diagnostic accuracy of such heart rate measuring apps in clinical practice. Methods The feasibility and accuracy of measuring heart rate was tested on four commercially available apps using both iPhone 4 and iPhone 5. 'Instant Heart Rate' (IHR) and 'Heart Fitness' (HF) work with contact photoplethysmography (contact of fingertip to built-in camera), while 'Whats My Heart Rate' (WMH) and 'Cardiio Version' (CAR) work with non-contact photoplethysmography. The measurements were compared to electrocardiogram and pulse oximetry-derived heart rate. Results Heart rate measurement using app-based photoplethysmography was performed on 108 randomly selected patients. The electrocardiogram-derived heart rate correlated well with pulse oximetry ( r = 0.92), IHR ( r = 0.83) and HF ( r = 0.96), but somewhat less with WMH ( r = 0.62) and CAR ( r = 0.60). The accuracy of app-measured heart rate as compared to electrocardiogram, reported as mean absolute error (in bpm ± standard error) was 2 ± 0.35 (pulse oximetry), 4.5 ± 1.1 (IHR), 2 ± 0.5 (HF), 7.1 ± 1.4 (WMH) and 8.1 ± 1.4 (CAR). Conclusions We found substantial performance differences between the four studied heart rate measuring apps. The two contact photoplethysmography-based apps had higher feasibility and better accuracy for heart rate measurement than the two non-contact photoplethysmography-based apps.

OBJECTIVES Pump thrombosis (PT) and thromboembolic events (TEs) remain major adverse events in left ventricular assist device (LVAD) therapy at an annual rate of 6–8% supported with the HeartWare HVAD and HeartMate II. PT and TEs are multifactorial events. Understanding the predisposing risk factors for PT and TE is paramount to define preventive strategies. Preoperative atrial fibrillation (AF) is considered a significant and potentially modifiable risk factor. This study investigates whether LVAD patients with AF exhibit a higher rate of PT and TE than those in sinus rhythm (SR). METHODS We evaluated medical records of consecutive patients who underwent implantation of the HeartMate II (n = 195; 25.4%) and HeartWare HVAD (n = 574; 74.6%) at our institution between 2006 and 2015. Only visually confirmed PT was included in the study. TE was defined as any peripheral embolism or cerebral embolism according to the INTERMACS definitions. RESULTS SR was documented preoperatively in 211 patients (SR group) and AF in 558 patients (AF group). The median duration of support was 0.78 years in the AF group and 1.03 years in the SR group. The mean age was 60.27 years in the AF group and 52.04 years in the SR group. In the AF group, 83.0% of the patients were male, compared to 77.3% in the SR group. The cumulative incidence of PT in the SR group was 2.5% [95% confidence interval (CI) 0.3–4.7%] after 1 year and 5.7% (95% CI 2.2–9.2%) after 2 years, and in the AF group 4.9% (95% CI 3.0–6.7%) and 7.8% (95% CI 5.4–10.2%), respectively (P = 0.129). TEs were recorded in the SR group in 4.4% (95% CI 1.6–7.2%) after 1 year and in 6.3% (95% CI 2.8–9.8%) after 2 years, and occurred after a median support time of 214 days (range 120–768). In the AF group, the cumulative incidence was 8.4% (95% CI 6.0–10.7%) and 10.7% (95% CI 8.0–13.4%), respectively, after a median support time of 116 days (range 37–375), P-value = 0.163. In the multivariate analysis, event-free survival was not influenced by the preoperative SR [hazard ratio (HR) 0.86, 95% CI 0.68–1.1; P = 0.19]. CONCLUSIONS Our study showed that the preoperative rhythm has no impact on survival, PT and TEs despite different preoperative risk factor profiles in the AF and SR group. Thus, the effect of a maze procedure, catheter ablation or left atrial appendage closure on PT and TE’s for AF patients during LVAD implantation is questionable. However, to obtain a definitive answer, a prospective study would be of value.

Background For patients with coronary artery disease undergoing coronary bypass surgery, acetylsalicylic acid (ASA) currently represents the gold standard of antiplatelet treatment. However, adverse cardiovascular event rates in the first year after coronary artery bypass grafting (CABG) still exceed 10%. Graft failure, which is predominantly mediated by platelet aggregation, has been identified as a major contributing factor in this context. Therefore, intensified platelet inhibition is likely to be beneficial. Ticagrelor, an oral, reversibly binding and direct-acting P2Y 12 receptor antagonist, provides a rapid, competent, and consistent platelet inhibition and has shown beneficial results compared with clopidogrel in the subset of patients undergoing bypass surgery in a large previous trial. Hypothesis Ticagrelor is superior to ASA for the prevention of major cardiovascular events within 1 year after CABG. Study design The TiCAB trial (NCT01755520) is a multicenter, phase III, double-blind, double-dummy, randomized trial comparing ticagrelor with ASA for the prevention of major cardiovascular events within 12 months after CABG. Patients undergoing CABG will be randomized in a 1:1 fashion to either ticagrelor 90 mg twice daily or ASA 100 mg once daily. The study medication will be started within 24 hours after surgery and maintained for 12 months. The primary end point is the composite of cardiovascular death, myocardial infarction, stroke, and repeat revascularization at 12 months after CABG. The sample size is based on an expected event rate of 13% of the primary end point within the first 12 months after randomization in the control group, a 2-sided α level of .0492 (to preserve the overall significance level of .05 after planned interim analysis), a power of 0.80%, 2-sided testing, and an expected relative risk of 0.775 in the active group compared with the control group and a dropout rate of 2%. According to power calculations based on a superiority design for ticagrelor, it is estimated that 3,850 patients should be enrolled. Summary There is clinical equipoise on the issue of optimal platelet inhibition after CABG. The TiCAB trial will provide a pivotal comparison of the efficacy and safety of ticagrelor compared with ASA after CABG.

Objectives No continuous-flow right ventricular assist device for long-term support is available at the moment. Two continuous-flow ventricular assist devices used in a continuous-flow biventricular assist device configuration is an emerging option which has proven its feasibility but still is not approved for routine use. We present our technique and results of modifying the left ventricular assist device and making it suitable for right ventricular support. Methods Between September 2009 and October 2017, 39 patients received implantation of a continuous-flow ventricular assist device for right ventricular support in a continuous-flow biventricular assist device configuration. For implantation of the HeartWare® manufacturers name of the pump HeartWare HVAD pump (HVAD)® centrifugal ventricular assist device, we performed 2 major modifications: banding of the outflow graft and reducing the intracaval length of the inflow cannula. The HVAD® could be safely implanted into the right atrium or ventricle. The HeartMate 3® left ventricular assist device needed no banding, but we increased the extraventricular part of the inflow cannula. Results The overall 30-day survival for the group receiving primarily a continuous-flow biventricular assist device was 72.7% (9.5% standard error of the mean (SEM)), and the 1-year survival was 45.0% (10.7% SEM). The overall 30-day survival for the group receiving a subsequent pump for right ventricular support in a continuous-flow biventricular assist device configuration after temporary right ventricular support was 71.4% (12.1% SEM), and 1-year survival was 40.8% (13.6% SEM). Conclusions At the moment, there is a lack of a continuous-flow right ventricular assist device especially designed and approved for right ventricular support. Therefore, modifications in continuous-flow ventricular assist devices designed for the left ventricle are done to make them suitable for right ventricular support. However, more information is needed regarding the optimal surgical technique, patient selection and the optimal time point of implantation.

Purpose Durable left ventricular assist devices (LVAD) have been validated in randomized trials for bridge to transplantation and destination therapy in patients with advanced heart failure. To guide treatment outside of selected study populations, a reliable tool for risk assessment is needed, especially for contemporary devices. The aim of this project is to derivate and validate a European risk score for assessment of long-term outcome after LVAD implantation in advanced heart failure patients. Methods The EUROMACS Registry, a multi-centre, European database of consecutive patients implanted with a LVAD was used for this project. From the database, patients with primarily LVAD implantation and available follow-up information were selected. The primary endpoint was all-cause mortality at different time points; patients were censored at the event of LVAD explantation for recovery or heart transplantation. Results 2881 patients were identified from the registry. Mean age was 53.76 ±12.29 years and 81.8% of the patients were male. Mean length of follow-up was 455.35 ±479.79 days. The rate of the primary endpoint was 42.1%. Multiple variables (such as age, mitral regurgitation, use of vasopressors, functional status) were independently associated with the primary endpoint. For the risk score, a non-random split will be used to create a derivation and a validation cohort. Hereafter, the least absolute shrinkage and selection operator method will be used to select variables best suited for the predictive score. The score accuracy will then be tested in the validation cohort. Results will be presented at the ISHLT annual meeting 2019. Conclusion The EUROMACS- Score can serve as a viable tool to guide therapeutic decisions in advanced heart failure patients. Importantly, this score will be based on the largest European database using contemporary devices and should be able to minimize regional bias.

Donor-specific antibodies (DSA) are integral to the development of antibody-mediated rejection (AMR). Chronic AMR is associated with high mortality and an increased risk for cardiac allograft vasculopathy (CAV). Anti-donor HLA antibodies are present in 3-11% of patients at the time of heart transplantation (HTx), with de novo DSA (predominantly anti-HLA class II) developing post-transplant in 10-30% of patients. DSA are associated with lower graft and patient survival after HTx, with one study suggesting a three-fold increase in mortality in patients who develop de novo DSA (dnDSA). DSA against anti-HLA class II, notably DQ, are at particularly high risk for graft loss. Although detection of DSA is not a criterion for pathologic diagnosis of AMR, circulating DSA are found in almost all cases of AMR. MFI thresholds of ~5000 for DSA against class I antibodies, 2000 against class II antibodies, or an overall cut-off of 5-6000 for any DSA, have been suggested as being predictive for AMR. There is no firm consensus on pre-transplant strategies to treat HLA antibodies, or for the elimination of antibodies after diagnosis of AMR. Minimizing the risk of dnDSA is rational but data on risk factors in HTx are limited. The effect of different immunosuppressive regimens is largely unexplored in HTx, but studies in kidney transplantation emphasize the importance of adherence and maintaining adequate immunosuppression. One study has suggested a reduced risk for dnDSA with rabbit antithymocyte globulin induction. Management of DSA pre- and post-HTx varies but typically most centers rely on a plasmapheresis or immunoadsorption, with or without rituximab and/or intravenous immunoglobulin. Based on the literature and a multi-center survey, an algorithm for a suggested surveillance and therapeutic strategy is provided.

Acute aortic dissection is a rare but life-threatening condition with a lethality rate of 1 to 2% per hour after onset of symptoms in untreated patients. Therefore, its prompt and proper diagnosis is vital to increase a patient's chance of survival and to prevent grievous complications. Typical symptoms of acute aortic dissection include severe chest pain, hypotension or syncope and, hence, mimic acute myocardial infarction or pulmonary embolism. Advanced age, male gender, long-term history of arterial hypertension and the presence of aortic aneurysm confer the greatest population attributable risk. However, patients with genetic connective tissue disorders such as Marfan, Loeys Dietz or Ehlers Danlos syndrome, and patients with bicuspid aortic valves are at the increased risk of aortic dissection at a much younger age. Imaging provides a robust foundation for diagnosing acute aortic dissection, as well as for monitoring of patients at increased risk of aortic disease. As yet, easily accessible blood tests play only a small role but have the potential to make diagnosis and monitoring of patients simpler and more cost-effective.

A 67-year-old man presented with dyspnoea and angina symptoms in a peripheral hospital. A CT scan of the chest was performed because of suspicion of pulmonary embolism. After application of the contrast agent, an anaphylactic shock occurred. After successful reanimation, a transoesophageal echocardiography displayed a large sinus Valsalva aneurysm (diameter 75 mm). Thereafter, the patient …

There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.

2012 wurden beim Kongress der Europaischen Gesellschaft fur Herzinsuffizienz die zurzeit gultige Leitlinie zur Diagnostik und Therapie der akuten und chronischen Herzinsuffizienz vorgestellt, deren Bearbeitung etwa 1½ Jahre vorher begonnen hatte. Sie integriert die wesentlichen Erkenntnisse der Jahre 2011 und 2012 und lasst aber auch zahlreiche Fragen aufgrund noch ungeklarter Probleme offen. Sie betreffen unteranderem Themen zur Diagnostik und Bildgebung, zu pharmakologischen und nicht-pharmakologischen Therapieansat-zen sowie zu Device Systemen und zur Herztransplantation. Im Folgenden werden wir auf einen Teil dieser Themen, zu denen nun neue Erkenntnisse hinzugekommen sind, eingehen und diskutieren, welchen moglichen Einfluss sie auf unser heutiges Handeln bereits haben konnten. Im Fruhjahr 2016 wird eine weitere offizielle Aktualisierung der europaischen Herzinsuffizienzleitlinien erwartet, nach deren Veroffentlichung jedoch erst eine abschliesende Bewertung unserer heutigen Einschatzung moglich sein wird.

IntroductionWe investigated the role of pancreatic stone protein (PSP) in predicting the occurrence of infection in the postoperative course of cardiac surgery patients. Several biomarkers indicating the presence of inflammation and infection are available in the clinical routine; yet, their utility in the postoperative course of patients following cardiac surgery remains uncertain. Moreover, cardiopulmonary bypass, also referred to as "on-pump surgery", increases the susceptibility to an exaggerated inflammatory state. However, the impact of such extracorporeal circulation on circulating PSP levels remains poorly understood.MethodsIn a prospective cohort of unselected patients undergoing cardiac surgery, we set out to elucidate the diagnostic accuracy of serum PSP levels as opposed to canonical biomarkers (CRP, WBC) of inflammation to discriminate between the presence of infection and surgical trauma,. In addition, we investigated whether the biomarkers were influenced by the surgical technique employed, i.e. on-pump vs. off-pump and minimally invasive surgery vs. sternotomy. Levels of circulating PSP and routine inflammatory biomarkers (CRP, WBC) were measured in samples taken from 120 patients at baseline as well as at postoperative day 1-3.ResultsUnivariate analysis showed that among the biomarkers investigated, only PSP levels had discriminatory power to differentiate infection from surgical trauma in the postoperative course of the entire cohort of patients following cardiac surgery. With regard to cardiac surgical interventions, there was no significant association between the absence or presence of extracorporeal circulation and PSP levels. However, there was a significant difference in the slope of the rise of postoperative PSP between minimally invasive surgery as opposed to patients subjected to sternotomy.ConclusionIn an unselected population of cardiac surgery patients, post-operative serum PSP levels were significantly associated with the presence of infection in both the on-pump and off-pump setting. Of note, the surgical technique employed (sternotomy vs. minimally invasive approach) had a significant impact on postoperative PSP levels.