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Abstract: Objective: Demographic changes and aggressive platelet inhibition have resulted in a marked increase in blood- and coagulation product expenditure and costs in cardiac surgery. We analyzed ‘bedside’ coagulation test (ROTEM) in order to verify clot forming quality for the purpose of finding a cost-effective treatment path. Methods: Annual treatment costs of all cardiosurgical patients were analyzed before (729 patients) and after (693 patients) implementation of ‘bedside’ ROTEM. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and coagulation factors: pooled coagulation concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. Number of resternotomies and early mortality was assessed and compared in both periods. Results: After ROMTEM implementation cumulative RBC expenditure showed 25% decrease while PltC exhibited 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (−80%) while rFVIIa were entirely omitted. Fibrinogen, however, increased two-fold. Cumulative average monthly costs of all blood products decreased from 66,000€ to 45,000€ (−32%). Coagulation factor average monthly costs decreased from 60,000€ to 30,000€ (−50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1.580€. Total number of resternotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. Conclusion: Cumulative costs for treatment of perioperative coagulation disorders can be reduced by ‘bedside’ ROTEM analysis to achieve a selective substitution management. Saved costs for blood- and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective. [Copyright &y& Elsevier]

Objectives: Severe sclerosis of the native aortic annulus can result in a tilted implantation position of mechanical prostheses. In this study, the effects of tilting and rotation on the hemodynamic performance of standard bileaflet valves were assessed in an extracorporeal mock circulatory system. Methods: A pulsatile mock circulation driven by a Berlin Heart™ system was developed. Main physiological components of the human circulation were mimicked. SJM®-AHPJ prostheses (21, 23, 25 mm) were mounted in an artificial aortic root containing physiologically oriented coronary ostia. All experiments were performed under constant conditions (stroke volume 60 ml, heart rate 70 bpm, systolic pressure 130 mmHg). Hydrostatic pressures were measured via fluid-filled catheters, transvalvular flow by ultrasonic probes. Data were digitally recorded at 50 Hz. Multiple pressure, volume, energy, and dimension parameters were derived off-line. Each valve was tested in a 0° (untilted) versus 20° (tilted) position at three axial rotation angles (0°, 45°, 90°). Tilting was performed independent of rotation by elevation of the prosthesis in the non-coronary sinus. Results: In all valves and all rotation angles, tilting resulted in a size-dependent significant increase of mean pressure gradient (range, 28–35% [21 mm valve], 59–96% [23 mm valve], 124–220% [25 mm valve]), valvular resistance (39–51, 84–121, 177–332%), regurgitation volume (84–148, 32–131, 93–118%), and systolic energy loss (113–146, 30–132, 69–213%), as well as a decrease of total stroke volume (2–5, 0–11, 3–10%), effective stroke volume (6–11, 9–14, 14–22%), cardiac output (6–11, 8–14, 13–22%), and effective opening area (16–24, 32–37, 47–57%). The strongest impairment of hemodynamic performance was seen at 90° rotation with reference to total and effective stroke volume, cardiac output, mean pressure gradient, and regurgitation fraction. Conclusions: Tilting of bileaflet valves resulted in a significant impairment of systolic and diastolic hemodynamics. Superiority of larger valves diminished in the tilted position. The strongest tilting effect was seen at 90° rotation. Such a position should therefore be avoided or surgically corrected by rotating the valve. [Copyright &y& Elsevier]

The article presents a case study of a 84 year old male, who had undergone an apical transapical aortic valve implantation and subsequently went for reoperation for prosthetic endocarditis.

Abstract: Objective: Fibrin glue products and collagen surgical patches (TachoSil®) coated with coagulation factors I and IIa are increasingly being used to prevent oozing from distal or proximal coronary anastomosis. Furthermore, an increasing number of patients are being operated upon anti-platelet therapy. These patients often exhibit diffuse bleeding. Especially in an off-pump scenario surgeons refrain from placing additional stitches in order to avoid an impairment of the graft. In these situations, a biological glue can help resolve this dilemma. It is, however, assumed that these products may exert negative effects on the anastomosis. For obvious reasons a systematic histological assessment in humans is impossible. Therefore, a chronic, large animal model was developed to study the fate of these products on a coronary anastomosis. Methods: In 15 pigs receiving off-pump coronary artery bypass graft of the left mammary artery to the left anterior descending coronary artery, three groups were defined. Group A served as control. In group B the anastomosis was covered with 1ml fibrin glue; in group C TachoSil® coverage was performed. Bypass flow (BF) was measured using a Doppler probe. After 3 months the pigs were sacrificed and the anastomoses were evaluated macroscopically and by means of light microscopy regarding patency and fibrosis. Results: In group A, all five animals survived, three of the five anastomoses were patent and the mean BF was 26mlmin−1. In group B, three of the five animals survived, all anastomoses were patent. The BF was 21mlmin−1. In group C, all five animals survived, four of the five anastomoses were patent and BF was 21mlmin−1. Macroscopic and histological evaluation showed no differences between the groups. Remnants of Tachosil® or fibrin glue were not observed. Conclusions: In the chronic course, no evidence of adverse effects of TachoSil® or fibrin glue was noted. Both agents can therefore be used safely in clinical practice for haemostyptic or positioning purposes. [Copyright &y& Elsevier]

Abstract: Objective: Biological valves exhibit characteristic curves (CC) regarding transvalvular gradient, resistance, and effective orifice area when correlated with a physiological cardiac output range (CO). The slope of the curve of transvalvular resistance over a typical CO range characterizes the clinical performance of the valve. These information may support an individualized decision towards the most adequate valve type. Methods: In an extracorporeal mock circuit two types of stented biological aortic valves (constructed pericardial valves, Edwards Perimount: EP; porcine cusp valves, Medtronic Mosaic: MM) of 21, 23, and 25mm were investigated. Mean transvalvular gradient was measured over a range of 1.9 to 7.2l/min CO at a simulated heart rate of 70beats/min. Transvalvular resistance was calculated and presented as characteristic curves in a log–log-plot against cardiac output. Results: EP valves of all sizes demonstrated low slopes (resistance range; slope: 21mm: 53–79dynesscm−5; 0.29; 23mm: 44–56dynesscm−5; 0.12; 25mm: 38–45dynesscm−5; 0.12) while MM valves exhibited steep slopes (resistance range; slope: 21mm: 46–169dynesscm−5; 0.97; 23mm: 36– −146dynesscm−5; 0.95; 25mm: 27–64dynesscm−5; 0.68) Conclusions: While constructed pericardial valves demonstrate sufficient hemodynamic performance especially in the higher CO range porcine cusp valves exhibited minor resistance in the lower CO range. Patients who exercise regularly may therefore profit from a pericardial valve while patients with a small body surface area and little exercise who therefore remain in the lower CO range may be adequately treated with a porcine cusp valve. [Copyright &y& Elsevier]

Objective:  Endocarditis as a potentially life-threatening disease with high complication and mortality rates. In recent years, an increase in the incident of endocarditis has been reported throughout Europe. In the aging society, successful treatment is complex and challenging owing to the high rate of multimorbidity., Methods:  We initiated a statewide prospective multicenter endocarditis registry in 2020. Perioperative risk factors, comorbidities, microbiological, laboratory and imaging diagnostics, complications, and mortality including 1-year follow-up were collected. The present midterm analysis includes factors influencing mortality in the first 313 patients., Result:  In-hospital mortality and 1-year mortality were 28.4 and 40.9%, respectively. Preoperative risk factors include age ( p  < 0.001), EuroSCORE II ( p  < 0.001), coronary artery disease ( p  = 0.022), pacemaker probe infection ( p  = 0.033), preoperative left ventricular ejection fraction (LVEF), systemic inflammatory response syndrome (SIRS), pulmonary edema, heart failure, septic emboli, acute renal failure, impaired coagulation, hypalbuminemia ( p  < 0.001), and N-terminal prohormone of brain natriuretic peptide (NTproBNP) ( p  = 0.001). The presence of peri-annular abscess, perforation, and shunt were associated with increased mortality ( p  = 0.004, 0.001, and 0.004, respectively). In addition, cardiopulmonary bypass time influenced mortality ( p  = 0.002). The main postoperative causes of death were multi-organ failure, renal failure, vasoplegia, and low-output syndrome ( p  < 0.001). Previous endocarditis was 7.7%, while 35.5% were prosthetic valve recipients and 33.6% were redo surgeries., Conclusion:  Our first registry data show the complexity of endocarditis patients and the challenging treatment. Some risk factors can be treated preoperatively. For instance, hypalbuminemia and the duration of the procedure can be controlled with adequate albumin substitution and carefully planned procedures restricted to the essential requirements, that is, hybrid approaches with consecutive interventions., Competing Interests: None declared., (Thieme. All rights reserved.)