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Purpose: ECMO support is an ultimate ratio therapy for patients in refractory cardiogenic shock and is linked to high mortality. We assessed the dynamic characteristics of lactate during ECMO therapy and its predictive role on 30-day mortality., Materials and Methods: Data were retrospectively collected in all patients receiving ECMO support longer than 48h for cardiogenic shock from 01/2008 to 12/2016. Blood lactate was recorded before ECMO implantation, at prespecified timepoints during ECMO support, 1h and 6h post-ECMO as well as peak lactate during ECMO and peak within 24h after ECMO support. Statistical analysis included t-test and ROC-curves to identify cut-off levels for lactate levels to predict 30-day mortality., Results: 139 patients underwent ECMO therapy longer than 48h for refractory cardiogenic shock resulting in a 30-day mortality of 68%. Lactate before ECMO and peak lactate level during ECMO support showed no significant connection to mortality, while lactate and lactate clearance at 24h were predictive for 30-day mortality with cut-off values of 2.15mmol/l and 0.687 respectively., Conclusions: Dynamic course of lactate during ECMO therapy is a valuable tool to assess effective circulatory support and is superior to single lactate measurements as a predictive marker for 30-day mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Extracorporeal life support emerged as a salvage option in patients with therapy-refractory severe hemodynamic or respiratory failure. However, this promising therapy option has been limited by the use of experienced teams in highly specialized tertiary-care centers. Thus, in order to provide this standard of care in local hospitals and due to increasing evidence on improved outcomes using ECMO devices and setting for patients with heart and lung failure, an increasing number of experienced ECMO centers have launched mobile ECMO retrieval services in recent years. Areas covered: This review provides a summary on the current scientific status concerning use, indications and complications of mobile ECMO devices and services. A scientific literature research was conducted in MEDLINE, Embase, Cochrane and Web of Science databases using keywords denoted. Expert commentary: Mobile ECMO devices and setting offer severely ill patients refractory to maximal conventional treatment an option of hemodynamic and/or respiratory stabilization and subsequent transportation to specialized care centers for further treatment. Compared to in-hospital ECMO support, out-of-hospital mobile ECMO implantation, transport and retrieval of patients require additional organizational, logistical and clinical efforts. This review provides a summary on the current scientific status concerning use, indications and complications of mobile ECMO services.

Background: The frequency of circulating endothelial cells (CEC) in patients' peripheral blood can be assessed as a direct marker of endothelial damage. However, conventional enumeration methods are extremely challenging. We developed a novel, automated approach to determine CEC frequencies and tested this method on two groups of patients undergoing conventional (CAVR) versus trans-catheter aortic valve implantation (TAVI)., Methods: CEC frequencies were assessed by a flow cytometric approach, including automated pre-enrichment of CD34 positive blood cell subpopulation and isotype controls. The efficacy and reproducibility of the CEC enumeration method was validated by spiking blood samples of healthy control donors with defined numbers of endothelial cells., Results: CEC frequencies were significantly higher in the TAVI group before (9.8 ± 4.1 vs. 5.5 ± 2.2, p = 0.019) and 1 h after surgery (13.4 ± 5.1 vs. 8.2 ± 4.1, p = 0.030) corresponding to higher Euroscore, STS score in higher risk patients from the TAVI group. Five days after surgery, CEC frequencies became significantly higher in the more invasive CAVR group (39.0 ± 13.0 vs. 14.3 ± 4.4, p < 0.001) compared to minimally invasive TAVI approach., Conclusions: The new flow cytometric approach might be a robust and reliable method for CEC enumeration. Initial results show that CEC frequency is a valid clinical marker for the assessment of pre-operative risk, invasiveness of surgical procedure and clinical outcome. Further studies are necessary to validate the practical clinical usefulness and the potential superiority compared to conventional markers.

Objectives: Previous research suggests that female gender is associated with increased mortality rates after surgery for Stanford A acute aortic dissection (AAD). However, women with AAD usually present with different clinical symptoms that may bias outcomes. Moreover, there is a lack of long-term results regarding overall mortality and freedom from major cerebrovascular events. We analysed the impact of gender on long-term outcomes after surgery for Stanford A AAD by comparing genders with similar risk profiles using propensity score matching., Methods: A total of 240 patients operated for Stanford A AAD were included in this study. To control for selection bias and other confounders, propensity score matching was applied to gender groups., Results: After propensity score matching, the gender groups were well balanced in terms of risk profiles. There were no statistically significant differences regarding duration of cardiopulmonary bypass ( P  = 0.165) and duration of aortic cross-clamp time ( P  = 0.111). Female patients received less fresh frozen plasma ( P  = 0.021), had shorter stays in the intensive care unit ( P  = 0.031), lower incidence of temporary neurological dysfunction ( P  < 0.001) and lower incidence of dialysis ( P  = 0.008). There were no significant differences regarding intraoperative mortality ( P  = 1.000), 30-day mortality ( P  = 0.271), long-term overall cumulative survival ( P  = 0.954) and long-term freedom from cerebrovascular events ( P  = 0.235) with up to a 9-year follow-up., Conclusions: Considering patients with similar risk profiles, female gender per se is not associated with worse long-term survival and freedom from stroke after surgical aortic repair. Moreover, female patients might even benefit from a smoother early postoperative course and lower incidence of early postoperative complications., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Coronary complications during coronary angiography or intervention (percutaneous coronary intervention [PCI]) are uncommon. However, PCI-related coronary artery perforation, dissection, or acute occlusion frequently result in myocardial ischemia followed by hemodynamic instability and need of urgent coronary artery bypass grafting (coronary artery bypass grafting [CABG]). This single-center study aimed to investigate clinical outcomes of patients undergoing urgent CABG after life-threatening PCI complications., Materials and Methods: Data were retrospectively obtained using our institutional patient database. All patients admitted for urgent CABG following PCI-related complications from April 2010 to June 2015 were included into this study. Univariate analysis was performed to identify possible predictors for cardiac mortality., Results: From a total of 821 urgent CABG patients, 52 patients (6.3%, 66.4 ± 9.4 years) underwent CABG for coronary complication following PCI. Logistic EuroSCORE was 21.8 ± 15.0%. At admission, 22 of 52 (42%) presented in cardiogenic shock, and 24 of 52 (46%) had significant electrocardiogram alterations indicating ST-elevation myocardial infarction (STEMI). Surgical revascularization was performed by targeting the injured coronary vessel with additional revascularization of other compromised vessels as indicated (mean number of grafts 2.4 ± 0.8). In-hospital cardiac mortality of the patient cohort was 13.5% (7/52) with 15.4% (8/52) in-hospital all-cause mortality. Preoperative resuscitation, cardiogenic shock, and STEMI were predictors for in-hospital cardiac mortality (P < 0.05) in univariate analysis. In contrast, noncardiac comorbidities, type of PCI complication, and localization of the culprit lesion were not associated to increased mortality., Conclusions: Emergent or urgent CABG for treatment of acute coronary complications following PCI is feasible and has acceptable clinical results that worsen in the presence of STEMI, cardiogenic shock, or resuscitation. Because preoperative status is crucial for clinical outcomes in these patients, immediate transfer to cardiac surgery is necessary., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: Prophylactic intra-aortic balloon pump (IABP) support for high-risk patients before coronary artery bypass grafting (CABG) is controversial. This meta-analysis sought to determine the current role of preoperative IABP support., Methods: We performed a meta-analysis of randomized (RCT) and observational trials (OT) that fulfilled the following criteria: (1) Group comparison of patients with prophylactic IABP implantation before CABG with a control group; (2) reporting at least one desired clinical endpoint, including all-cause mortality, myocardial infarction, cerebrovascular accident (CVA), and renal failure. Pooled treatment effects (odds ratio [OR] or weighted mean difference, and 95% confidence intervals [95%CI]) were assessed using a fixed or random effects model., Results: A total of 9,212 patients from 23 studies (7 RCT, 16 OT) were identified after a literature search of major databases using a predefined keyword list. Absolute risk reduction for mortality in RCTs was 4.4% (OR 0.43; 95%CI 0.25-0.73; p = 0.0025). Prophylactic IABP use before CABG surgery also decreased the risk for myocardial infarction (OR 0.58; 95%CI 0.43-0.78; p = 0.004), CVA (OR 0.67; 95%CI 0.47-0.97; p = 0.042), and renal failure (OR 0.62; 95%CI 0.47-0.83; p = 0.0014). Length of intensive care unit stay (p < 0.0001) and length of hospital stay (p < 0.0001) were significantly reduced in patients with preoperative IABP use., Conclusion: Current evidence from RCT and OT suggests beneficial effects for the IABP in high-risk patients before CABG surgery., (© 2017 Wiley Periodicals, Inc.)

Background: The choice of an optimal cannulation site for aortic repair in patients with Stanford A acute aortic dissection remains controversial. The aim of this study was to compare the early results and long-term outcomes of axillar and direct aortic cannulation., Methods: A total of 235 consecutive patients who underwent surgical aortic repair with the use of axillar or direct aortic cannulation from January 2006 to April 2015 were analyzed. The primary end points were long-term overall cumulative survival and freedom from major cerebrovascular events with up to 10 years of follow-up. The secondary end points were early postoperative clinical characteristics and rates of adverse events. To control for confounders, a 1:3 propensity score matching was performed., Results: After matching, there were no statistically significant differences between the two groups regarding baseline characteristics. Both groups were associated with comparable outcomes; among other things, the length of stay in the intensive care unit (ICU) (p = 0.220), mechanical ventilation (p = 0.177), total hospital stay (p = 0.243), and hospital rates of adverse events. There were no statistically significant differences (p = 0.625) in terms of freedom from major cerebrovascular events. However, both early (p = 0.009) and late (p = 0.016) overall survival were significantly poorer for patients undergoing aortic cannulation., Conclusions: The outcomes were comparable regarding early hospital outcomes and rates of adverse events. Whereas postoperative freedom from major cerebrovascular events was similar, survival over long-term follow-up was significantly poorer when direct aortic cannulation was used. More investigations are needed to enable an understanding of the underlying factors for potentially higher late mortality when direct aortic cannulation is used during a surgical procedure for acute Stanford A dissection., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Severe bleeding related to cardiac surgery is associated with increased morbidity and mortality. Thromboelastography (TEG) and thromboelastometry (ROTEM) are point-of-care tests (POCT). Bedside ROTEM/TEG can rapidly detect changes in blood coagulation and therefore provide a goal-directed, individualized coagulation therapy. In this meta-analysis, we aimed to determine the current evidence for or against POCT-guided algorithm in patients with severe bleeding after cardiac surgery., Methods: We performed a meta-analysis of randomized controlled trials and observational trials retrieved from a literature search in PubMed, EMBASE, and Cochrane Library. Only trials comparing transfusion strategy guided by TEG/ROTEM with a standard of care control group undergoing cardiac surgery were included. In addition, at least one clinical outcome had to be mentioned: mortality, surgical re-exploration rate, sternal wound infection, and acute kidney injury (AKI). Also, surrogate parameters such as transfusion requirements and amount of blood loss were analyzed. The pooled treatment effects (odds ratio [OR] and 95% confidence intervals [CI]) were assessed using a fixed or random-effects model., Results: The literature search retrieved a total of 17 trials (nine randomized controlled trial and eight observational trials) involving 8332 cardiac surgery patients. POCT-guided transfusion management significantly decreased the odds for patients to receive allogeneic blood products (OR 0.63, 95% CI 0.56-0.71; P < 0.00001) and the re-exploration rate due to postoperative bleeding (OR 0.56, 95% CI 0.45-0.71; P < 0.00001). Furthermore, the incidence of postoperative AKI (OR 0.77, 95% CI 0.61-0.98; P = 0.0278) and thromboembolic events (OR 0.44, 95% CI 0.28-0.70; P = 0.0006) was significantly decreased in the TEG/ROTEM group. No statistical differences were found with regard to inhospital mortality, cerebrovascular accident, or length of intensive care unit and hospital stay., Conclusions: TEG/ROTEM-based coagulation management decreases the risk of allogeneic blood product exposure after cardiac surgery. Furthermore, it results in significantly lower re-exploration rate, decreased incidence of postoperative AKI, and thromboembolic events in cardiac surgery patients. Results of this meta-analysis indicate that POCT-guided transfusion therapy is superior to the current standard of care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In the present systematic review with meta-analysis, we sought to determine the current strength of evidence for or against off-pump and on-pump coronary artery bypass grafting (CABG) with regard to hard clinical end-points, graft patency and cost-effectiveness. We performed a meta-analysis of only randomized controlled trials (RCT) which reported at least one of the desired end-points including: (i) major adverse cardiac and cerebrovascular events (MACCE), (ii) all-cause mortality, (iii) myocardial infarction, (iv) cerebrovascular accident, (v) repeat revascularization, (vi) graft patency and (vii) cost-effectiveness. The pooled treatment effects [odds ratio (OR) or weighted mean difference, 95% confidence intervals (95% CIs)] were assessed using a fixed or random effects model. A total of 16 904 patients from 51 studies were identified after literature search of the major databases using a predefined keyword list. The incidence of MACCE did not differ between the groups, neither during the first 30 days (OR: 0.93; 95% CI: 0.82-1.04) nor for the longest available follow-up (OR: 1.01; 95% CI: 0.92-1.12). While the incidence of mid-term graft failure (OR: 1.37; 95% CI: 1.09-1.72) and the need for repeat revascularization (OR: 1.55; 95% CI: 1.33-1.80) was increased after off-pump surgery, on-pump surgery was associated with an increased occurrence of stroke (OR: 0.74; 95% CI: 0.58-0.95), renal impairment (OR: 0.79; 95% CI: 0.71-0.89) and mediastinitis (OR: 0.44; 95% CI: 0.31-0.62). There was no difference with regard to hard clinical end-points between on- or off-pump surgery, including myocardial infarction or mortality. The present systematic review emphasizes that both off- and on-pump surgery provide excellent and comparable results in patients requiring surgical revascularization. The choice for either strategy should take into account the individual patient profile (comorbidities, life expectancy, etc.) and importantly, the surgeon's experience in performing on- or off-pump CABG in their routine practice., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: In patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents., Case Presentation: We report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique., Conclusions: The transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon.

Background: The aim of this study was to determine whether intermittent warm blood cardioplegia (IWC) is associated with comparable myocardial protection compared to cold blood cardioplegia (ICC) in patients undergoing elective vs. emergent CABG procedures., Methods: Out of 2292 consecutive patients who underwent isolated on-pump CABG surgery using cardioplegic arrest either with ICC or IWC between January 2008 and December 2010, 247 consecutive emergent patients were identified and consecutively matched 1:2 with elective patients based on gender, age (<50 years, 50-70 years, >70 years) and ejection fraction (<40 %, 40-50 %, >50 %). Perioperative outcomes and long-term mortality were compared between ICC and IWC strategies and predictors for 30-day mortality and perioperative myocardial injury were identified in both elective and emergent subgroups of patients., Results: Preoperative demographics and baseline characteristics, logistic Euroscore, CPB-time, number of distal anastomoses and LIMA-use were comparable. Aortic cross clamp time was significantly longer in the IWC-group regardless of the urgency of the procedure (p = 0.05 and p = 0.015 for emergent and elective settings). There were no significant differences regarding ICU-stay, ventilation time, total blood loss and need for dialysis. The overall 30-day, 1-, 3- and 6-year survival of the entire patient cohort was 93.7, 91.8, 90.4 and 89.1 %, respectively, with significantly better outcomes when operated electively (p < 0.001) but no differences between ICC and IWC both in elective (p = 0.857) and emergent (p = 0.741) subgroups. Multivariate analysis did not identify the type of cardioplegia as a predictor for 30-day mortality and for perioperative myocardial injury. However, independent factors predictive of 30-day mortality were: EF < 40 % (OR 3.66; 95 % CI: 1.79-7.52; p < 0.001), atrial fibrillation (OR 3.33; 95 % CI: 1.49-7.47; p < 0.003), peripheral artery disease (OR 2.51; 95 % CI: 1.13-5.55; p < 0.023) and COPD (OR 0.26; 95 % CI: 1.05-6.21; p < 0.038); predictors for perioperative myocardial infarction were EF < 40 % (OR 2.04; 95 % CI: 1.32-3.15; p < 0.001), preoperative IABP support (OR 3.68; 95 % CI: 1.34-10.13; p < 0.012), and hemofiltration (OR 3.61; 95 % CI: 2.22-5.87; p < 0.001)., Conclusion: Although the aortic cross clamp time was prolonged in the IWC group our results confirm effective myocardial protection under IWC, regardless of the urgency of the procedure. We suggest that intermittent warm cardioplegia in emergent CABG setting is a low-cost alternative and safe. It is associated with similar long-term outcomes both in elective and emergent settings compared to intermittent cold cardioplegia.

Objectives: Antifibrinolytics are widely used in cardiac surgery to save blood perioperatively. In the present study we evaluated the hemostatic effects of tranexamic acid (TXA) to decrease bleeding tendency and transfusion requirements in high-risk patients following transapical aortic valve implantation (TA-AVI)., Methods: A retrospective analysis was performed on aortic stenosis patients undergoing TA-AVI with or without intraoperative TXA administration to determine postoperative blood loss and transfusion requirements. From January 2009 to August 2010 in total 92 patients were treated without intraoperative TXA administration, from August 2010 to July 2011 54 patients received TXA intraoperatively., Results: Early postoperative (24 h) blood loss was significantly lower in TXA-group than in non-TXA group (327 ± 274 mL vs. 481.1 ± 318.8 mL; p = 0.003). In the TXA group 53.7% of patients received allogeneic blood products during the hospital stay as compared to 72.8% in the non-TXA group (p = 0.242). TXA group required fewer transfusions (2.1 ± 1.9 vs. 2.9 ± 3.5 Units; p = 0.046) and had no increased incidence of thrombotic or neurological complications. There was no significant difference in the length of ICU, hospital stay, or 30-day mortality. Administration of tranexamic acid was found to be significantly associated with lower blood loss postoperatively (p = 0.002). Furthermore, there was a significant correlation between the postoperative blood loss (p = 0.036) and red blood cell transfusion (p = 0.001) with 30-day mortality., Conclusion: Low dose prophylactic intraoperative administration of tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products following TA-AVI.

Percutaneous coronary intervention (PCI) and minimally invasive direct coronary artery bypass (MIDCAB) grafting are both established therapeutic options for single-vessel disease of the left anterior descending artery (LAD). The present systematic review with meta-analysis aims to determine the current strength of evidence for or against PCI and MIDCAB for revascularization of the LAD. Therefore, we performed a meta-analysis of randomized, controlled trials (RCTs) and observational trials (OTs) that reported clinical outcome after isolated LAD revascularization. Analysed postoperative outcomes included major adverse cardiac and cerebrovascular events (MACCEs), all-cause mortality, myocardial infarction and stroke. Pooled treatment effects [odds ratio (OR) or weighted mean difference (WMD), 95% confidence intervals (95% CI)] were assessed using a fixed- or random-effects model. A total of 2885 patients from 12 studies (6 RCTs, 6 OTs) were identified after a literature search of major databases using a predefined list of keywords. PCI of the LAD was performed in 60.7% (n = 1751) and MIDCAB in 39.3% of patients (n = 1126). Pooled-effect estimates revealed an increased incidence for MACCEs after PCI (OR 1.98; 95% CI 1.45-2.69; P < 0.0001) 6 months after the procedure. Especially, PCI was particularly associated with an increased odds for target vessel revascularization (OR 2.11; 95% CI 1.00-4.47; P = 0.0295). No differences with regard to stroke, myocardial infarction and all-cause mortality were observed between both revascularization strategies. Patients after PCI had a shorter length of hospital stay (WMD -3.37 days; 95% CI (-)4.92 to (-)1.81; P < 0.0001). In conclusion, the present systematic review underscores the superiority of MIDCAB over PCI for treatment of single-vessel disease of the LAD., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Ischemic heart disease is the main cause of death in western countries and its burden is increasing worldwide. It typically involves irreversible degeneration and loss of myocardial tissue leading to poor prognosis and fatal outcome. Autologous cells with the potential to regenerate damaged heart tissue would be an ideal source for cell therapeutic approaches. Here, we compared different methods of conditional culture for increasing the yield and cardiogenic potential of murine skeletal muscle-derived stem cells. A subpopulation of nonadherent cells was isolated from skeletal muscle by preplating and applying cell culture conditions differing in support of cluster formation. In contrast to static culture conditions, dynamic culture with or without previous hanging drop preculture led to significantly increased cluster diameters and the expression of cardiac specific markers on the protein and mRNA level. Whole-cell patch-clamp studies revealed similarities to pacemaker action potentials and responsiveness to cardiac specific pharmacological stimuli. This data indicates that skeletal muscle-derived stem cells are capable of adopting enhanced cardiac muscle cell-like properties by applying specific culture conditions. Choosing this route for the establishment of a sustainable, autologous source of cells for cardiac therapies holds the potential of being clinically more acceptable than transgenic manipulation of cells.

Objective: This review was performed to pool the current surgical strategies for cardiac liposarcoma., Methods: A literature search was performed and all studies published in full-text or abstract forms were eligible for inclusion without applying any language restrictions. Case reports without surgical intervention, reporting noncardiac liposarcoma, animal cases, or review articles were excluded after initial abstract review. Analyzed postoperative outcomes included intraoperative and in-hospital mortality, longest reported survival, and recrudescence., Results: After a critical evaluation 53 unique surgically treated case reports published between the years 1966 and December 2012 were included in this review. Most of the reported cardiac liposarcoma are myxoid (49.1%), pleomorphic liposarcoma occur with a prevalence of 20.8%, and well-differentiated tumors are observed in 13.2%. One-year survival rate increases the more differentiated the tumor is categorized: 54.5% for pleomorphic, 65.4% for myxoid, and 100% for well-differentiated liposarcoma (p = 0.096)., Conclusion: Total surgical resection of cardiac liposarcoma is the only curative option, as it tends to local and distant recurrence. Therefore, a frequent follow-up examination should be considered., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To introduce a novel percutaneous technique to stop blood entry at the lesser aortic arch curvature by coil embolisation in type Ia endoleak after TEVAR., Methods: A 61-year-old Marfan patient presented with type Ia endoleak of the aortic arch and a growing aortic arch pseudoaneurysm after TEVAR. Multiple preceding operations and interventions made an endovascular approach unsuccessful. Direct percutaneous puncture of the aneurysmal sac would have cured the sign, but not the cause of blood entry at the lesser curvature of the aortic arch. Direct CT-guided percutaneous puncture of the blood entry site in the aortic arch with fluoroscopically guided coil embolisation using detachable extra-long coils was successfully performed., Results: Three weeks after the intervention, the patient developed fever because of superinfection of the pseudoaneurysm. The blood cultures and CT-guided mediastinal aspirate were sterile. After intravenous administration of antibiotics, the fever disappeared and the patient recovered. Six-month follow-up showed permanent closure of the endoleak and a shrinking aneurysmal sac., Conclusions: Direct percutaneous puncture of the aortic arch at the blood entry site of a thoracic type Ia endoleak after TEVAR and double-chimney stent-grafts with coil embolisation of the wedge-shaped space between the lesser aortic curvature and the stent-graft is possible., Key Points: Endoleaks after thoracic endovascular aortic repair are common in 15-30 %. Most endoleaks can be treated by endovascular means. Direct percutaneous endoleak repair is described as a bail-out option. Direct percutaneous aortic arch coil embolisation of type 1a endoleak is possible. Antibiotic prophylaxis should be administered case by case, considering individual risk factors.

The objective of this systematic literature review with meta-analysis was to determine the strength of evidence for a preoperative statin on the reduction of adverse postoperative outcomes in patients undergoing cardiac surgery. Randomized controlled (RCT) and observational trials were searched in online databases that reported about the effects of preoperative statin therapy on major adverse clinical outcomes after cardiac surgery. Analysed outcomes included early all-cause mortality, myocardial infarction, atrial fibrillation (AF), stroke and renal failure using a priori-defined criteria. Effect estimates were calculated and are given as odds ratio (OR) with 95% confidence intervals (95% CI) using fixed- or random-effect models. Literature search of all major databases retrieved 2371 studies. After screening, a total of 54 trials were identified (12 RCT, 42 observational) that reported outcomes of 91 491 cardiac surgery patients with (n = 46 614; 51%) or without (n = 44 877; 49%) preoperative statin therapy. Preoperative statin use resulted in a 0.9% absolute risk (2.6 vs 3.5%) and a 31% odds reduction for early all-cause mortality (OR 0.69; 95% CI 0.59-0.81; P < 0.0001). In addition, statin treatment before surgery was associated with a substantial reduction (P < 0.01) in the postoperative end-points AF (OR 0.71; 95% CI 0.61-0.82), new-onset AF (OR 0.68; 95% CI 0.54-0.85), stroke (OR 0.83; 95% CI 0.74-0.93), stay on intensive care unit (weighted mean difference [WMD] -0.14; 95% CI -0.23 to -0.03; P < 0.01) and in-hospital stay (WMD -0.57; 95% CI -0.76 to -0.38; P < 0.01). No statistical differences were found between groups with regard to myocardial infarction or renal failure. In conclusion, the current systematic review strengthens the evidence that preoperative statin therapy extends substantial clinical benefit to early postoperative outcomes in cardiac surgery patients.

Statin intake before cardiac surgery is associated with favorable outcomes. We sought to analyze the evidence for statin pretreatment before isolated coronary artery bypass graft surgery and aortic valve replacement surgery. In this meta-analysis, we demonstrate beneficial results for the endpoints mortality, stroke, atrial fibrillation, and length of stay in hospital in 36,053 statin-pretreated coronary artery bypass graft surgery patients compared with control subjects retrieved from 32 studies, but fail to detect relevant advantages through preoperative statin therapy for 3,091 patients undergoing aortic valve replacement from four trials. Strict adherence to guidelines recommending statin treatment before CABG surgery is therefore mandatory., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We assessed the short-term outcomes and predictors of 30-d mortality in patients requiring temporary, peripheral extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiac failure., Methods: The data were retrospectively obtained using our institutional patient database. All patients who had received peripheral ECMO support after surgery for acquired heart disease from 2006 to 2010 were included in the present study. The demographic and perioperative variables of the 30-d survivors and nonsurvivors were compared using the chi-square and t-test, and multivariate logistic regression analysis was performed to identify the predictors of 30-d all-cause mortality., Results: A total of 77 patients with a mean age of 60 ± 13 years were included in the present analysis. Successful weaning from peripheral ECMO was achieved in 62% after 79 ± 57 h of ECMO support. The overall 30-d mortality rate was 70%, and mortality was reduced to 52% in the patients in whom ECMO support could be weaned successfully. Age (per year) at ECMO implantation was the only independent preoperative predictor of 30-d mortality (odds ratio 1.09, 95% confidence interval 1.03-1.15; P = 0.003). In addition, greater lactate levels after 24 h of ECMO therapy, a longer duration of ECMO support, and the presence of any ECMO-related or gastrointestinal complications were independent predictive factors for 30-d mortality (P < 0.05)., Conclusions: ECMO therapy provides a valuable therapeutic strategy for postcardiotomy myocardial failure but is still limited by high complication rates with fewer than 30% of patients discharged from the hospital. Patient age appears to be an essential preoperative predictor for mortality, and the blood lactate level is a relevant marker for the assessment of efficient ECMO support., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Percutaneous dilatational tracheotomy (PDT) is a common procedure. Coagulation disorders represent a relative contraindication for PDT and, therefore, normalization of hemostasis parameters is recommended. Especially patients undergoing cardiac surgery after valve replacement and with any kind of assist device need to require an adequate anticoagulation. This study investigated the impact of impaired hemostasis as a risk factor for bleeding complications retrospectively., Methods: Patients who underwent PDT (November 2007 to November 2010) were stratified into a high-risk (HR) and low-risk (LR) group in regard to bleeding complications. The following determining factors activated partial thromboplastin time (aPTT > 50 seconds, prothrombin time (PT < 50%), international normalized ratio (INR > 1.4), and platelet count (< 50,000/µL) were assessed., Results: A total of 213 patients underwent PDT (HR = 5/85; LR = 8/128). There was no difference in demographics or intraoperative data. Patients of both groups showed mild bleeding without the need for surgical intervention or transfusion (p = 0.957). There were no severe bleeding nor other procedure-related complications., Conclusion: Percutaneous tracheotomy is a safe and feasible procedure in patients with coagulation disorders. Therefore, discontinuation of anticoagulation treatment or normalization of hemostasis prior to the procedure is not necessary., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: To determine the current strength of evidence for or against endoscopic vein harvesting (EVH) in patients undergoing coronary artery bypass grafting (CABG)., Materials and Methods: A meta-analysis of randomized controlled trials (RCT) and observational trials (OT) was performed that reported the impact of EVH on adverse clinical outcomes after CABG. Analyzed postoperative outcomes included wound infection, postoperative pain, myocardial infarction (MI), vein graft failure, length of hospital stay, and mortality. Pooled treatment effects (OR or weighted mean difference (WMD), 95%CI) were assessed using a fixed or random effects model., Results: A total of 27,789 patients from 43 studies (16 RCT, 27 OT) were identified who underwent saphenectomy by endoscopic (46%; n = 12,822) or conventional technique (54%; n = 14,967). Pooled effect estimates revealed a reduced incidence (P < 0.001) for wound infections (OR 0.27; 95% CI 0.22 to 0.32), pain (WMD -1.26, 95% CI -2.07 to -0.44; P = 0.0026), and length of hospital stay (WMD -0.6 d, 95% CI -1.08 to -0.12; P = 0.0152). EVH was associated to an increase of the odds for vein graft failure (OR 1.38; 95% CI 1.01 to 1.88; P = 0.0433), a finding that lost statistical difference after pooled analysis of RCT and studies with high methodological quality. Similarly, graft-related endpoints, including mortality and MI, did not differ between the harvesting techniques., Conclusion: The present systematic review underscores the safety of EVH in patients undergoing CABG. EVH reduces leg wound infections without increasing the midterm risk for vein graft failure, MI, or mortality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background/purpose: Recent evidence suggests that statin-mediated cardioprotection after chronic statin therapy decreases over time and can be reactivated by preprocedural high-dose statin reloading therapy. We tested in a porcine cardiopulmonary bypass (CPB) model whether statin-related cardioprotection is further enhanced by a preoperative rosuvastatin reloading therapy., Methods: Control (n = 6), rosuvastatin-pretreated (n = 6; 20 mg/day for 7 days p.o.) and rosuvastatin-reloaded (n = 6; p.o. treatment plus 0.10 mg/kg/h i.v. during surgery) pigs (Deutsche Landrasse) were subjected to CPB for 2 h with 1 h of cardioplegic cardiac arrest. Systemic hemodynamics, cardiac index (CI), coronary blood flow (CBF) and left ventricular (LV) function [pressure-volume area (PVA), preload recruitable stroke work (PRSW)] were determined before and 4 h after CPB. Myocardial expression (PCR) and protein content (Western blot) of endothelial NO synthase (eNOS) and phosphatase and tensin homolog deleted on chromosome ten (PTEN) were measured, and right coronary relaxation was assessed postmortem. All data are given as mean ± SD., Results: Preoperative plasma LDL, HDL and cholesterol did not differ between treatment groups. Compared to control, oral treatment improved post-CPB CI, CBF, first derivative of maximal LV-pressure (LVdp/dt) and PVA (p < 0.05). Significant enhancement was achieved with perioperative reloading therapy (CI: 5.2 ± 1.0 vs. 3.9 ± 1.5 l/min/m(2); CBF: 76 ± 32 vs. 43 ± 8 ml/min; LVdp/dt: 1,980 ± 333 vs. 1,249 ± 461 mm Hg/s; PVA: 6,954 ± 941 vs. 3,252 ± 1,822 mm Hg·ml; p < 0.05) with improved in vitro NO-dependent coronary relaxation (102 ± 10 vs. 79 ± 14%; p = 0.003). Irrespective of recapture therapy statin pretreatment augmented myocardial eNOS and PTEN (p < 0.05), but failed to increase cardiac eNOS or PTEN expression after CPB., Conclusions: Periprocedural statin reloading therapy enhances myocardial and coronary function after cardiac surgery with CPB and may therefore provide a valuable therapeutic approach for the reduction of myocardial ischemia-reperfusion injury., (Copyright © 2013 S. Karger AG, Basel.)