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The aim of this study was to compare outcomes of transcatheter and surgical aortic valve implantation in chronic dialysis patients with aortic valve stenosis (AS). Chronic dialysis patients undergoing heart valve surgery are at higher risk for morbidity and mortality. Whether interventional techniques can reduce this risk is unclear because dialysis patients have thus far been excluded from randomized trials. Chronic dialysis patients with AS enrolled in the German Aortic Valve Registry (GARY) between 2012 and 2015 were analyzed to compare transcatheter aortic valve implantation (TAVI n = 661) with surgical aortic valve replacement (SAVR n = 457). Propensity scores for inverse probability of treatment weighting (IPTW) were used to adjust the comparison of the two treatment groups for potential confounders. TAVI patients were older (78 ± 7.3 vs. 69 ± 10.2 years, p

In 2020, nearly 30,000 published references appeared in the PubMed for the search term “cardiac surgery.” While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information.

Wie im letzten Jahr wird eine Ubersicht uber interessante und relevante Literatur aus dem Bereich der Klappenchirurgie – im vorliegenden Beitrag fur das Jahr 2018 – prasentiert. Therapieentscheidungen bei Vorliegen einer relevanten Aortenklappenerkrankung sind gepragt von Empfehlungen aus individuellen Entscheidungen im Herzteam, mit immer starker werdender Evidenz fur die „transcatheter aortic valve implantation“ (TAVI) bei niedrigem Risiko, ohne dass bisher zwingend benotigte Langzeitergebnisse vorliegen. Es wird in diesem Abschnitt nur auf die TAVI-Publikationen eingegangen, die unmittelbare Relevanz fur die klassischen chirurgischen Verfahren aufweisen, die ansonsten im vorliegenden Beitrag hauptsachlich beleuchtet werden. Die Publikationen im Bereich der Atrioventrikularklappen lieferten neue Erkenntnisse zur Pravalenz von Mitral- und Trikuspidalinsuffizienz und unterstrichen damit die bekannten Aussagen, dass eine Mitralklappenrekonstruktion bei struktureller Mitralinsuffizienz die Lebenserwartung steigern kann. Bei funktioneller Mitralinsuffizienz hat v. a. die Publikation der Studien MITRA FR und COAPT im Zusammenhang mit dem MitraClip grose Aufmerksamkeit erregt. Auserdem unterstutzen weitere Studienergebnisse die aggressive Therapie der isolierten Trikuspidalinsuffizienz. Diese Aspekte werden im Folgenden erlautert, obwohl Ubersichten wie diese nie komplett oder frei von personlicher Neigung sein und nie alle potenziell relevanten Arbeiten berucksichtigen konnen. Unter diesem Caveat wunschen die Autoren Freude beim Lesen.

Background Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOTA) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome. Methods We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR. Results In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not. Conclusion We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies.

Background Heater–cooler devices (HCD) have been implicated in a cardiosurgical contamination scenario causing prosthetic valve endocarditis. Aim We characterized contamination of new HCDs and assessed the risk of intraoperative microorganism transmission from the HCD to the operating field. Methods We initially acquired four new FlexTherm and then four new Maquet HCU40 HCDs and assessed occurrence and speed of microbial contamination (including mycobacteria) assessing swab and water samples from the device. In parallel, we collected repeated samples from different sites in the operating room either by swab sticks or by exposing different sample plates to room air. We also reviewed microbiological results from the hospital and compared them to cardiosurgical wound infections and endocarditis cases. Finally, we simulated cardiosurgical conditions and assessed the devices' ability to expel air to the operative field. Results All new HCDs were clean before first use. Despite authority-mandated decontamination procedures, microbial growth (Fusarium solani, Sphingomonas paucimobilis, Pseudomonas aeruginosa, Mycobacterium chelonae, and gordonae) was identified in all HCDs over time and could not be permanently eliminated. Four of these mircoorganisms were also found in tap water. However, none of the HCD-organisms were found inside the laminar airflow operating area. Importantly, except for P. aeruginosa, none of the HCD organisms were found in patients with surgical wound infections or endocarditis. HCD-expelled air did not rise more than 40 cm above ground. Conclusion HCDs cannot be expected to remain sterile despite extensive decontamination procedures. However, airborne transmission of microorganisms directly from the HCD to the operating field appears unlikely.

Background We report our starting experience with parasternal minimally-invasive aortic valve replacement. Methods From 7/14 to 8/18, 192 received classic aortic valve surgery using a 5 cm parasternal incision and percutaneous groin cannulation. Patients were selected based on anatomic feasibility judged by preoperative computed tomography-scan. Except for porcelain aorta, left-sided aortic location, or endocarditic abscess, there were no exclusions. Results Patients were divided into two groups (first and second half of experience). Demographics were equal. Patients' mean ejection fraction was 59%, with preoperative stroke (12%), severe chronic obstructive pulmonary disorder (11%), and endocarditis (2%). All cases were elective or urgent. The Euroscore II was 3.37 ± 3.31 in the first and 3.68 ± 3.97 in the second group (n.s.). Biological prostheses were implanted in 90%. Operating times in the first group were just under 3 hours, with bypass times of 129 ± 32 minutes and clamp times of 77 ± 20 minutes. In the second group, these times changed only minimally. There were three conversions to sternotomy in the first, but only one in the second group. Similarly, three patients died in the first and one in the second group. There were fewer complications in the second group regarding revision for bleeding (7 vs 1%), stroke (4 vs 0%) dialysis (3 vs 1%), and pericardial effusions (3 vs 1%). The O/E ratio dropped from 0.93 to 0.28. Conclusions Parasternal minimally-invasive aortic valve replacement is a feasible technique associated with a slow learning curve but the potential to achieve improved outcomes. Considering the transcatheter alternatives, the relative risk reduction may be worth investigating in future trials.

Die Herzklappenchirurgie hat sich in den letzten Jahren stark verandert. Im Bereich der Aortenklappenchirurgie ist der Einfluss der Katheterklappen bereits am Ruckgang der aktuellen Zahlen isolierter Aortenklappenersatze (AKE) zu erkennen. Die vielen Studien zum Vergleich von chirurgischem und interventionellem AKE haben bisher entweder eine Nichtunterlegenheit oder sogar eine leichte Uberlegenheit fur das Katheterverfahren (besonders im intermediaren Risikobereich) nachgewiesen. Diese Entwicklung hat dazu gefuhrt, dass es im mittleren bis hohen Risikobereich eine primare Empfehlung sowohl fur den chirurgischen Eingriff als auch fur die interventionelle Versorgung gibt. Zusatzlich wurde eine Serie von Tabellen erarbeitet, die die Generierung einer individualisierten Therapieempfehlung durch das Herzteam ermoglichen soll. Fur den niedrigen Risikobereich bleibt die primare Empfehlung zum chirurgischen Ersatz. Im Bereich der Mitralklappe wurden wesentliche Erkenntnisse zu Wirksamkeit und Prognose von Mitralklappenrekonstruktion und -ersatz gewonnen. Eine erfolgreiche und haltbare Rekonstruktion bei primarer Mitralinsuffizienz kann die Lebenserwartung verbessern und ggf. normalisieren. Die Erfahrung des Operateurs spielt eine wesentliche Rolle fur die Reparaturwahrscheinlichkeit und die Haltbarkeit. Weiterhin hat die Bedeutung der Trikuspidalinsuffizienz(TI)-Behandlung zugenommen, sodass die Leitlinien eine Trikuspidalklappenrekonstruktion bei einer durch andere pathologische Veranderungen indizierten Herzoperation bereits bei Vorliegen einer geringgradigen TI mit Hinweis auf eine Anulusdilatation empfehlen. Schlieslich besteht ein deutlicher Trend zur Ausweitung der minimalinvasiven Techniken. Die wichtigsten und interessantesten Arbeiten aus dem Jahr 2017 sind im Folgenden zusammengefasst.

Die Versorgung terminal herzinsuffizienter Patienten mit einem permanenten linksventrikularen Herzunterstutzungssystem („left ventricular assist device“, LVAD) hat sich zu einer weit verbreiteten und etablierten Therapie entwickelt. Bedingt durch die stete Weiterentwicklung dieser Therapieform und den Ruckgang an Herztransplantationen steigt die Zahl der LVAD-Patienten kontinuierlich an. Somit gewinnt die operative Versorgung extrakardialer Erkrankungen bei zunehmender Unterstutzungsdauer am LVAD an Bedeutung. Hauptsachlich verteilen sich die Eingriffe auf die Fachbereiche der Gastroenterologie, Allgemein- und Viszeralchirurgie sowie Herzschrittmacher und ICD/CRT systembezogene Chirurgie. Prinzipiell konnen alle weiteren Fachbereiche involviert sein. Extrakardiale Operationen sind bei LVAD-Patienten mit einer gesteigerten Morbiditat und Letalitat assoziiert; daher gelten die Betroffenen als Hochrisikokollektiv. Das erhohte Risiko beruht auf der Grunderkrankung und den weiteren, meist zahlreichen Komorbiditaten sowie auf der Notwendigkeit zur Antikoagulation und der durch das LVAD selbst verursachten Koagulopathie. Perioperativ auftretende schwerwiegende Blutungen stellen die fuhrende Komplikation dar. Bei sorgfaltiger interdisziplinarer Vorbereitung, pra-, intra- und postoperativer Anpassung des Monitoring, Planung der operativen Strategie und spezieller Uberwachung der Hamostaseologie lassen sich extrakardiale Eingriffe an erfahrenen VAD-Zentren mit akzeptablem Risiko durchfuhren. Im vorliegenden Beitrag werden die wesentlichen Themenkomplexe diskutiert, die bei der Durchfuhrung extrakardialer Operationen zu berucksichtigen sind. Daruber hinaus wird eine Literaturubersicht zum Thema geliefert.

Background: Fractional flow reserve (FFR) is a reliable tool for the functional assessment of coronary stenoses. FFR computed tomography (CT) derived (FFR CT ) has shown to be accurate, but its clinical usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the impact of FFR CT on heart team’s treatment decision-making and selection of vessels for revascularization in patients with 3-vessel coronary artery disease. Methods: The trial was an international, multicenter study randomizing 2 heart teams to make a treatment decision between percutaneous coronary interventions and coronary artery bypass grafting using either coronary computed tomography angiography or conventional angiography. The heart teams received the FFR CT and had to make a treatment decision and planning integrating the functional component of the stenoses. Each heart team calculated the anatomic SYNTAX score, the noninvasive functional SYNTAX score and subsequently integrated the clinical information to compute the SYNTAX score III providing a treatment recommendation, that is, coronary artery bypass grafting, percutaneous coronary intervention, or equipoise coronary artery bypass grafting-percutaneous coronary intervention. The primary objective was to determine the proportion of patients in whom FFR CT changed the treatment decision and planning. Results: Overall, 223 patients were included. Coronary computed tomography angiography assessment was feasible in 99% of the patients and FFR CT analysis in 88%. FFR CT was available for 1030 lesions (mean FFR CT value 0.64±13). A treatment recommendation of coronary artery bypass grafting was made in 24% of the patients with coronary computed tomography angiography with FFR CT . The addition of FFR CT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as reference, FFR CT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile. Conclusions: In patients with 3-vessel coronary artery disease, a noninvasive physiology assessment using FFR CT changed heart team’s treatment decision-making and procedural planning in one-fifth of the patients. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02813473.

Background Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA. Methods Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patient's quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36). Results Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire. Conclusions Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes.

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke. Methods In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke. Results There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5–1.38]; p = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46–1.60]; clampless device: 1.8%; OR 0.67 [0.26–1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37–2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64–1.20]). Conclusion Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.

More than 100 minerals have been reported from the Silver Coin Mine, Nevada USA; five new minerals have been discovered here, due to the unusual geochemical environment. The present study reports on the investigation of a greenish clayey sample from the Silver Coin Mine. After the separation of a fine fraction to enrich the clay minerals, sauconite, a rare Zn-rich smectite, was found by X-ray diffraction (XRD) and was further characterized by differential thermal analysis (DTA), infrared (IR) spectroscopy and scanning electron microscopy (SEM). The Zn-rich smectite is accompanied by illite, minor kaolinite/halloysite and traces of gibbsite (as was indicated by the IR spectroscopy). The occurrence indicates an acidic environment probably caused by oxidation of sulfides.The determination of the structural formula, to further characterize the Zn-rich smectite, was difficult because of the multi-clay mineral assembly. However, different SEM-EDX (energy dispersive X-ray) approaches as well as transmission electron microscopy (TEM)-EDX analysis helped to characterize the smectite as Al-rich sauconite with some exchangeable K+.

Infective endocarditis (IE) is often associated with multiorgan dysfunction and mortality. The impact of perioperative liver dysfunction (LD) on outcome remains unclear and little is known about factors leading to postoperative LD. We performed a retrospective, single-center analysis on 285 patients with left-sided IE without pre-existing chronic liver disease referred to our center between 2007 and 2013 for valve surgery. Sequential organ failure assessment (SOFA) score was used to evaluate organ dysfunction. Chi-square, Cox regression, and multivariate analyses were used for evaluation. Preoperative LD (Bilirubin >20 μmol/L) was present in 68 of 285 patients. New, postoperative LD occurred in 54 patients. Hypoxic hepatitis presented the most common origin of LD, accompanied with high short-term mortality. In-hospital mortality was higher in patients with preoperative and postoperative LD compared to patients without LD (51.5, 24.1, and 10.4%, respectively, p

Das hamodynamische Ergebnis nach Aortenklappenersatz (AKE) mit einer Klappenprothese wird durch das Design und die prothesenspezifische Strategie zur Grosenauswahl („sizing“) beeinflusst. Das Design bestimmt die tatsachliche Offnungsflache der Prothese relativ zum Ausendurchmesser, wahrend durch das Sizing die Grose der jeweilig zu implantierenden Klappe festgelegt wird. Derzeitig wird das hamodynamische Ergebnis dieser Prozedur durch Messung der Restgradienten (nach Bernoulli) und/oder mit der effektiven Offnungsflache („effective orifice area“, EOA) bestimmt. Die EOA wird mithilfe der Kontinuitatsgleichung aus der Flussgeschwindigkeit des Blutstroms und der Querschnittsflache des linksventrikularen Ausflusstrakts („left ventricular outflow tract area“, LVOTA) bestimmt und entspricht einer virtuellen Offnungsflache der Klappe in dem jeweiligen Patienten. Sie stimmt nicht unbedingt mit der maximalen Offnungsflache der vorhandenen Klappe uberein. Unabhangig von dieser Erkenntnis wird die Frage, ob eine Klappenprothese die angemessene Grose fur den Patienten aufweist, derzeit durch eine Beziehung der EOA auf die Korperoberflache beantwortet [“effective orifice area indexed“ (EOAi)]. Die Klappe wird als zu klein eingestuft, wenn ein moderates (EOAi zwischen 0,65 und 0,85 cm2/m2) oder schweres (EOAi ≤ 0,65 cm2/m2) Patient-Prothese-Missverhaltnis (PPM) vorliegt. Derzeit bestreitet etwa die Halfte der Publikationen zu diesem Thema eine Auswirkung eines so gemessenen PPM auf das Langzeituberleben. Es ist aber gut moglich, dass eine Messproblematik Ursache fur diese Kontroverse ist. Der vorliegende Beitrag beschreibt die derzeitigen Standards in der Bewertung der Hamodynamik nach Klappenersatz und weist auf die Probleme in der Messmethode und der Bewertung von PPM hin. Weiterhin wird die Prosthesis-Annulus-Relation(PAR)-I-Studie vorgestellt, die ein neues Konzept zu Bewertung und Vorhersage von hamodynamischen Ergebnissen und von PPM beinhaltet.

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.

Fur die Spezifikation von eingebetteten Systemen wird die Gesamtfunktion durch ereignisdiskrete und kontinuierliche Teilfunktionen mit ihren zeitlichen Anforderungen festgelegt. Die Zuordnung dieser Teilaufgaben (Tasks) auf Hardware und Software erfolgt auf Basis ihrer Komplexitat und Zeitanforderungen (Partitionierungskriterien). Mit Hilfe von Codegeneratoren werden aus den Taskspezifikationen Hardware- und Software-Codes erzeugt, deren Kommunikation durch geeignete Schnittstellen unterstutzt wird. Fur die Erprobung in Realzeit (Rapid Prototyping) wird eine (uberdimensionierte) Zielarchitektur verwendet, wobei die Zuteilung der Tasks an die einzelnen Funktionstrager (Prozessoren, FPGAs) durch eine Realzeitanalyse gesteuert wird (Einhaltung aller Zeitbedingungen auch im ungunstigsten Fall). An ahnlichen Techniken zum Entwurf kostenoptimierter Zielsysteme wird ebenfalls gearbeitet.

Objectives: Patients on phenprocoumon presenting for surgery are often converted to heparin preoperatively. We assessed the impact of this conversion on outcome in cardiac surgery patients. Methods: From November 2007 to September 2013, 115 patients with phenprocoumon therapy presented for surgery and were operated either before or after the international normalized ratio (INR) had normalized (group A, INR > 1.3, n = 71; group B, INR ⩽ 1.3, n = 44 at day of surgery; group C, matched control cohort without preoperative phenprocoumon, INR ⩽ 1.3, n = 60). Results: Patients received a mix of cardiac surgical procedures (including valves, coronary artery bypass grafting, ventricular assist devices, and transplantation) without intergroup differences. Surgery was emergent in 11%, 2%, and 13% in groups A, B, and C, respectively (p = 0.2). Preoperative hospital stay was longest in group B (p Conclusion: Patients presenting for cardiac surgery with preoperative phenprocoumon represent a high-risk population. Bleeding complications for these patients are higher but do not seem to be influenced by preoperative INR. Our data question the need for conversion to heparin.