Search

Objectives: Clinical deterioration during the waiting time impairs the prognosis of patients listed for heart transplantation. Reduced muscle mass increases the risk for mortality after cardiac surgery, but its impact on resilience against deterioration during the waiting time remains unclear. Methods: We retrospectively analyzed data from 93 patients without a VAD who were listed in Eurotransplant status "high urgent (HU)" for heart transplantation between January 2015 and October 2020. The axial muscle area of the erector spinae muscles at the level of thoracic vertebra 12 indexed to body surface area (TMESA/BSA) measured in the preoperative thoracic computed tomography scan was used to measure muscle mass. Results: Forty patients (43%) underwent emergency VAD implantation during the waiting time and four patients (4%) died during the waiting time. The risk of emergency VAD implantation/death during the waiting time decreased by 10% for every cm 2 /m 2 increase in muscle area [OR 0.901 (95% CI: 0.808-0.996); p = 0.049]. After adjusting for gender [OR 0.318 (95% CI: 0.087-1.073); p = 0.072], mean pulmonary artery pressure [OR 1.061 (95% CI: 0.999-1.131); p = 0.060], C-reactive protein [OR 1.352 (95% CI: 0.986-2.027); p = 0.096], and hemoglobin [OR 0.862 (95% CI: 0.618-1.177); p = 0.360], TMESA/BSA [OR 0.815 (95% CI: 0.698-0.936); p = 0.006] remained an independent risk factor for emergency VAD implantation/death during the HU waiting time. Conclusion: Muscle area of the erector spinae muscle appears to be a potential, easily identifiable risk factor for emergency VAD implantation or death in patients on the HU waiting list for heart transplantation. Identifying patients at risk could help optimize the outcome and the timing of VAD support., Competing Interests: VF reports grants from Medtronic GmbH, Abbottt GmbH & Co. KG, Boston Scientific, Edwards Lifesciences, JOTEC/CryoLife and other financial activities from Berlin Heart, Biotronik SE & Co., Novartis Pharma GmbH, Zurich Heart outside of the submitted work. FS reports other financial activities from Novartis, Abbott, Orion Pharma, Astra Zeneca and non-financial support from Medtronic outside of the submitted work. LR reports grants from German Heart Foundation during the conduct of the study, share holdings of Alianz SE, Carl Zeiss Meditec AG, CompuGroup Medical SE & Co. KGaA, Evotec SE, Fresenius Medical Care AG & Co. KGaA outside of the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Roehrich, Suendermann, Just, Kopp Fernandes, Schnettler, Kelle, Solowjowa, Stein, Hummel, Knierim, Potapov, Knosalla, Falk and Schoenrath.)

Background: Systemic infections and chronic graft rejection represent common causes of mortality and morbidity in heart transplant patients. In severe cases, cardiogenic shock (CS) may occur and require hemodynamic stabilization with temporary mechanical circulatory support (tempMCS). Under these devastating circumstances, treatment of sequelae of left ventricular dysfunction, such as secondary mitral regurgitation (MR) is challenging, especially when surgical repair is deemed futile. In nontransplant patients, interventional mitral valve repair strategies such as the MitraClip system (Abbott Cardiovascular) have been used to successfully treat secondary MR and allow for weaning from tempMCS., Case Summary: We report about the first patient in whom profound CS after heart transplantation was stabilized with tempMCS followed by interventional elimination of secondary MR., (© 2021 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Background: In patients with aortic stenosis, computed tomography (CT) provides important information about cardiovascular anatomy for treatment planning but is limited in determining relevant hemodynamic parameters such as the transvalvular pressure gradient (TPG). Purpose: In the present study, we aimed to validate a reduced-order model method for assessing TPG in aortic stenosis using CT data. Methods: TPG CT was calculated using a reduced-order model requiring the patient-specific peak-systolic aortic flow rate (Q) and the aortic valve area (AVA). AVA was determined by segmentation of the aortic valve leaflets, whereas Q was quantified based on volumetric assessment of the left ventricle. For validation, invasively measured TPG catheter was calculated from pressure measurements in the left ventricle and the ascending aorta. Altogether, 84 data sets of patients with aortic stenosis were used to compare TPG CT against TPG catheter . Results: TPG catheter and TPG CT were 50.6 ± 28.0 and 48.0 ± 26 mmHg, respectively ( p = 0.56). A Bland-Altman analysis revealed good agreement between both methods with a mean difference in TPG of 2.6 mmHg and a standard deviation of 19.3 mmHg. Both methods showed good correlation with r = 0.72 ( p < 0.001). Conclusions: The presented CT-based method allows assessment of TPG in patients with aortic stenosis, extending the current capabilities of cardiac CT for diagnosis and treatment planning., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Franke, Brüning, Yevtushenko, Dreger, Brand, Juri, Unbehaun, Kempfert, Sündermann, Lembcke, Solowjowa, Kelle, Falk, Kuehne, Goubergrits and Schafstedde.)

Calcific aortic valve (AV) disease is associated with increased stiffness and reduced motion of AV leaflets, has a progressive course, and can develop into aortic stenosis (AS). Our aim was to evaluate whether two-dimensional speckle-tracking echocardiography (STE) may be used for the assessment of AV stiffness. We applied STE to AV leaflets in patients with various degrees of degenerative changes of AV and measured strain as an absolute value of the radial deformation of AV leaflets. Deformation of AV expressed as averaged AV strain was greatest in patients with a normal AV (23.4 ± 6.4%), compared to those with aortic sclerosis (12.9 ± 3.2%), moderate-to-severe AS (11.9 ± 4%), and severe AS (10.9 ± 3.5%) (p < 0.01). A non-linear relationship and moderate correlation of AV strain with transvalvular hemodynamic parameters was observed. In patients with mild-to-moderate AS, the strain of AV leaflets also correlated negatively with AV calcification (r = -0.59, p = 0.008). Good inter-observer agreement was obtained for averaged AV strain with a coefficient of variation of 0.15 and an interclass correlation coefficient of 0.94 (p < 0.0001). In this study we demonstrated that deformation of AV leaflets as assessed by STE might be a potential method for a non-invasive evaluation of AV biomechanical properties and of the progression of calcific aortic disease. Further development of the two-dimensional speckle tracking technique specifically for valve structures is needed to enable a better quantification of leaflet deformation., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: The present study sought to develop a reliable calcium score (Ca-score) to predict paravalvular leak (PVL) in patients undergoing transcatheter aortic valve (AV) implantation., Methods: A total of 965 patients were prospectively included from 2012 to 2019. Preprocedural contrast-media-enhanced computed tomography scans were analysed regarding the amount of AV cusp calcification and the presence of upper and lower left ventricular outflow tract calcification. The calcium volume threshold of each AV cusp [non-coronary cusp (NCC); left coronary cusp (LCC); right coronary cusp (RCC)] with optimal PVL prediction was defined using the Youden index value derived from receiver operating characteristic analysis. The final score was developed based on the multivariable regression analysis, while individual variables were weighted based on their corresponding odds ratio., Results: The AV calcium volume threshold with optimal PVL prediction was 733.6, 296.0 and 131.2 mm3 for the NCC, RCC and LCC respectively. Overall, calcification of the upper left ventricular outflow tract was present in 233 (23%), 111 (12%) and 304 (32%) of patients below the NCC, RCC and LCC respectively, while 260 (27%), 44 (5%) and 217 (23%) patients suffered from calcification under the NCC, RCC and LCC, respectively. A total Ca-score of ≥4 was present in 356 (37%) of patients and was independently associated with ≥ mild PVL [odds ratio 3.662; 95% confidence interval (2.740-4.911); P < 0.001]. The area under the curve of the Ca-score was 0.713 [95% confidence interval (0.678-0.748); P < 0.001]., Conclusion: The provided Ca-score independently correlates with the development of PVL and improves risk stratification in patients undergoing transcatheter AV implantation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The diagnostic value of a visual assessment of aortic valve (AV) morphology for grading aortic stenosis (AS) remains unclear. A visual score (VS) for assessing the AV was developed and its reliability with respect to Doppler measurements and the calcium score (ctCS) derived by multislice computed tomography was evaluated. 99 Patients with AS of various severity and 38 patients without AS were included in the analysis. Echocardiographic studies were evaluated using the new VS which includes echogenicity, thickening, localization of lesions and leaflet mobility, with a total score ranging from 0 to 11. The association of VS with ctCS and the severity of AS was analyzed. There was a significant correlation of VS with AV hemodynamic parameters and with ctCS. The cut-off value for the detection of AS of any grade was a VS of 6 (sensitivity 95%, specificity 85% for women; sensitivity 85%, specificity 88% for men). A VS of 9 for women and of 10 for men was able to predict severe AS with a high specificity (96% in women and 94% in men, AUC 0.8 and 0.86, respectively). The same cut-off values were identified for the detection of ctCS of ≥ 1600 AU and ≥ 3000 AU with a specificity of 77% and 82% (AUC 0.69 and 0.81, respectively). Assessment of aortic valve morphology can serve as an additional diagnostic tool for the detection of AS and an estimation of its severity.

Outflow graft obstruction in left ventricular assist devices (LVADs) is a rare complication whose clinical presentation may be subtle. We present six cases of outflow graft obstruction in patients on HeartMate 3 LVAD detected between 648 and 1,222 days on support. Detection principles are described and treatment strategies discussed. Three patients were successfully managed with stents, one underwent surgical revision, one patient died despite emergency treatment, and the last patient without symptoms was listed for heart transplantation., (Copyright © ASAIO 2020.)

Surgical ventricular reconstruction is a proven option for treating patients who have heart failure due to a postinfarction scar or an aneurysm of the left ventricle. The BioVentrix Revivent TC System offers a reliable alternative to the conventional, more invasive surgical ventricular restoration. The system requires no sternotomy, no heart-lung machine, and no cardioplegic arrest.  In this video tutorial, we present our technique for using the Revivent TC System to reconstruct the normal left ventricular shape and volume in a patient with a postinfarction, anteroapical scar., (© The Author 2020. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after the implantation of the left ventricular assist device (LVAD)., Case Report: In this study, we describe the case of a 67-year-old patient on LVAD support who developed a late pseudoaneurysm of the OG anastomosis (to the descending aorta) causing OG stenosis at the level of the anastomosis. The patient was treated with a customized fenestrated endovascular stent graft placed into the descending aorta and stent implantation into the OG., (© 2020 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Background: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after left ventricular assist device (LVAD) implantation., Case Summary: We describe the case of a 51-year-old patient on LVAD support who developed significant OG kinking and external OG obstruction due to a fibrin mass causing severe stenosis. Both the OG kinking and external obstruction were eliminated via a left lateral thoracotomy., (© 2020 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

We describe the transcatheter management of severe aortic regurgitation in a middle-aged patient with a porcelain aorta who underwent implantation of an apicoaortic valved conduit 12 years ago. Instantaneous relief of heart failure symptoms was achieved by restoring antegrade blood flow to the ascending aorta. ( Level of Difficulty: Advanced. )., Competing Interests: Drs. Unbehaun, Gerckens, Klein, and Kempfert have served as proctors to Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2020 The Authors.)

Precise procedural planning is crucial to achieve excellent results in patients undergoing Transcatheter aortic valve implantation (TAVI). The aim of this study was to compare the semi-automated 3mensio (3 m) software to the fully-automated HeartNavigator3 (HN) software. We randomly selected 100 patients from our in-house TAVI-registry and compared aortic annulus and perimeter as well as coronary distances between 3m-measurements and post-hoc HN-measurements. Finally, we retrospectively simulated prosthesis choice based on HN-measurements and analyzed the differences compared to routinely used 3 m based strategy. We observed significant differences between the two software packages regarding area (3 m 464 ± 88 mm², HN 482 ± 96 mm², p < 0.001), perimeter (3 m 77 ± 7 mm, HN 79 ± 8 mm, p < 0.001) and coronary distances (LCA: 3 m 13 ± 3 mm, HN 12 ± 3 mm, p < 0.001; RCA: 3 m 16 ± 3 mm, HN 15 ± 3 mm, p < 0.001). Prosthesis choice simulation based on newly obtained HN-measurements would have led to a decision change in 18% of patients, with a further reduction to 4% following manual adjustment of HN-measurements. The fully-automatic HN-software provides higher values for annular metrics and lower annulus-to-coronary-ostia distances compared to 3m-software. Measurement differences did not influence clinical outcome. Both, the HN-software and the 3m-software are sophisticated, reliable and easy to use for the clinician. Manual adjustment of HN-measurements may increase precision in complex aortic annulus anatomy.

In this study, we used a single commercially available software solution to assess global longitudinal (GLS) and global circumferential strain (GCS) using cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) feature tracking (FT). We compared agreement and reproducibility between these two methods and the reference standard, CMR tagging (TAG). Twenty-seven patients with severe aortic stenosis underwent CMR and cardiac CT examinations. FT analysis was performed using Medis suite version 3.0 (Leiden, The Netherlands) software. Segment (Medviso) software was used for GCS assessment from tagged images. There was a trend towards the underestimation of GLS by CT-FT when compared to CMR-FT (19.4 ± 5.04 vs. 22.40 ± 5.69, respectively; p = 0.065). GCS values between TAG, CT-FT, and CMR-FT were similar ( p = 0.233). CMR-FT and CT-FT correlated closely for GLS ( r = 0.686, p < 0.001) and GCS ( r = 0.707, p < 0.001), while both of these methods correlated moderately with TAG for GCS ( r = 0.479, p < 0.001 for CMR-FT vs. TAG; r = 0.548 for CT-FT vs. TAG). Intraobserver and interobserver agreement was excellent in all techniques. Our findings show that, in elderly patients with severe aortic stenosis (AS), the FT algorithm performs equally well in CMR and cardiac CT datasets for the assessment of GLS and GCS, both in terms of reproducibility and agreement with the gold standard, TAG.

Future left ventricular assist devices (LVADs) are expected to respond to the physiologic need of patients; however, they still lack reliable pressure or volume sensors for feedback control. In the clinic, echocardiography systems are routinely used to measure left ventricular (LV) volume. Until now, echocardiography in this form was never integrated in LVADs due to its computational complexity. The aim of this study was to demonstrate the applicability of a simplified ultrasonic sensor to fit an LVAD cannula and to show the achievable accuracy in vitro. Our approach requires only two ultrasonic transducers because we estimated the LV volume with the LV end-diastolic diameter commonly used in clinical assessments. In order to optimize the accuracy, we assessed the optimal design parameters considering over 50 orientations of the two ultrasonic transducers. A test bench was equipped with five talcum-infused silicone heart phantoms, in which the intra-ventricular surface replicated papillary muscles and trabeculae carnae. The end-diastolic LV filling volumes of the five heart phantoms ranged from 180 to 480 mL. This reference volume was altered by ±40 mL with a syringe pump. Based on the calibrated measurements acquired by the two ultrasonic transducers, the LV volume was estimated well. However, the accuracies obtained are strongly dependent on the choice of the design parameters. Orientations toward the septum perform better, as they interfere less with the papillary muscles. The optimized design is valid for all hearts. Considering this, the Bland-Altman analysis reports the LV volume accuracy as a bias of ±10% and limits of agreement of 0%-40% in all but the smallest heart. The simplicity of traditional echocardiography systems was reduced by two orders of magnitude in technical complexity, while achieving a comparable accuracy to 2D echocardiography requiring a calibration of absolute volume only. Hence, our approach exploits the established benefits of echocardiography and makes them applicable as an LV volume sensor for LVADs., (© 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

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.

Objectives: Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms., Methods: Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD)., Results: Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD., Conclusions: MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: We introduce a technique of posterior annulus shortening to augment leaflet coaptation which addresses the restrictive mitral leaflet mobility in ischemic mitral incompetence (IMI), and report its long-term outcome., Methods: Between 1992 and 2012, 75 patients (mean age, 64.6±10.4 years; median, 66.0 years; range, 35.0-86.1 years) underwent repair of IMI by posterior annulus shortening to augment leaflet coaptation surface area. This technique reduces the annular diameter to between 23 and 25 mm and decreases the valve orifice to between 3.5 to 4.5 cm(2), which is sufficient to ensure an adequate leaflet coaptation area. An untreated pericardial strip is used to reinforce the shortened annulus in order to avoid redilatation. This augments the posterior leaflet by increasing the ratio of leaflet area/valve orifice where the coaptation gap is the greatest. The tissue strip increases and heightens the area which the posterior leaflet offers to the anterior leaflet for coaptation during closure, making valve closure possible in advanced leaflet restriction., Results: During a mean follow-up of 7.62±0.66 (median 8.53, range, 3.6-20.9) years, New York Heart Association (NYHA) functional class significantly improved, left ventricular ejection fraction (LVEF) increased and there was a tremendous abatement of MI (P<0.01). Annular area was reduced from 9.2 to 5.8 cm(2). Coaptation area was increased from a complete lack thereof to 6.6 mm(2) post-repair. CT showed posterior annulus size reduction from 70.4 to 54 mm and an increase in posterior leaflet length from 15.9 to 19.6 mm. A remarkable CT finding was the increase in coaptation length from 5.2 to 8.2 mm. Eighteen-year freedom from moderate MI, freedom from reoperation and survival rates were 80.7%±9%, 84.9%±4.2% and 65.1%±6.3%, respectively., Conclusions: Posterior annulus shortening with pericardial strip augmentation addressing the lack of leaflet coaptation is a simple, reproducible and highly effective technique to restore valve competence in IMI.

A left ventricular pseudoaneurysm develops when myocardial rupture is contained by the pericardium. Although left ventricular pseudoaneurysm has been a topic of discussion since the pioneering days of open heart surgery, it still remains a technical challenge in reconstructive cardiac surgery. Reoperation following pseudoaneurysm repair is also frequent. We report surgical treatment in two patients with a pseudoaneurysm on the left ventricular posterolateral wall. The pseudoaneurysm and left ventricular cavity communicated at a point just between the anterolateral and posteromedial papillary muscle attachments. Such a manifestation is highly infrequent but potentially lethal. During aneurysmectomy, special attention was paid to avoid the development of mitral regurgitation because the papillary muscle geometry changes after removal of the pseudoaneurysm. In both cases, surgical decision-making was facilitated by preoperative assessment using electrocardiographic-gated multislice computed tomography., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: In line with our institutional strategy, we do not accept paravalvular leakage after transcatheter aortic valve implantation (TAVI). Apart from data from very limited initial experience, predictors of leakage in large cohorts treated with new types of TAVI prostheses are still lacking., Methods: From April 2008 to August 2013, 730 patients underwent transapical TAVI at our institution. The study group consisted of all 324 patients who received the new generation of balloon-expandable prostheses (SAPIEN XT; Edwards Lifesciences, LLC, Irvine, CA). Based on the Society of Thoracic Surgeons predicted risk of mortality, the arithmetic risk for surgery in the study cohort was 11% ± 9% (1% to 62%) and 20 (6%) patients were in cardiogenic shock., Results: In study cohort, the overall 30-day mortality rate was 4.0% (3.3% in patients without cardiogenic shock). The postprocedural grade of regurgitation was absent or trace in 269 of 324 patients (83%), mild in 52 of 324 (16%), and moderate in 3 of 324 (< 1%); there was no severe postprocedural regurgitation. Regurgitation occurred less often (p < 0.001) in patients who received the XT-type prosthesis. Patients with more than trace regurgitation presented with less oversizing of the prosthesis in terms of annular area (p < 0.001) and higher calcium scores of the device landing zone (p < 0.001). The presence of calcified plaques in the left ventricular outflow tract was the strongest predictor of leakage (odds ratio 10.23, 95% confidence interval 5.12 to 20.45, p < 0.001). The regurgitation grade was not predictive for follow-up mortality (hazard ratio 1.08, 95% confidence interval 0.61 to 1.90, p = 0.800)., Conclusions: In transapical TAVI, the risk of relevant paravalvular leakage may be eliminated completely. There is no negative impact on survival in patients with lesser, irrelevant grades of regurgitation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This report aims to introduce the extraanatomic bypass technique to treat the midaortic syndrome and to document its long-term effectiveness and durability., Methods: Fourteen patients (mean age, 6.7 ± 3.76 years; range 8 months to 11 years) received diagnoses of midaortic syndrome, characterized by severe narrowing of the abdominal aorta with involvement of the renal and visceral branches. Angiography showed variable lengths of high-grade midaortic stenosis, with 7 children having visceral artery involvement and 9 having renal artery involvement. All children were hypertensive (mean blood pressure, 165 ± 15.7 mm Hg). Three had had previous nephrectomies. Six patients had had previous percutaneous transluminal renal artery angioplasties. The midaortic obstruction was relieved by descending abdominal aorta bypass (left thoracoabdominal approach) and by an ascending abdominal aorta bypass (median sternotomy and transabdominal approach) in 12 patients. No visceral artery revascularization was done., Results: There was a considerable blood pressure reduction in all patients and relief of intermittent claudication in 6 affected patients. One patient had a bilateral renal artery bypass 2 weeks postoperatively because of recurrence of renal hypertension. At a mean follow-up time of 5.8 ± 1.36 years (range, 9 months to 15 years), there was no further reoperation nor mortality. Twelve patients had complete relief of hypertension, and 2 had mild hypertension. All patients have normal renal function and no signs or symptoms of visceral malperfusion. Growth and development have proceeded normally. Follow-up magnetic resonance tomography showed patent grafts without any strictures., Conclusions: Extraanatomic bypass provides very effective and long-term relief of hypertension and any malperfusion in midaortic syndrome., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ascending aortic aneurysms grow circumferentially and longitudinally. This geometric dislocation with widening, flattening, or loss of the sinotubular junction by aortic dilatation distorts and causes incompetence of even a structurally normal valve. We described a technique of surgical correction of ascending aortic aneurysm and valve incompetence by relocating the displaced aortic annulus plane to its normal anatomic position., Methods: Between 1998 and 2011, 48 patients (median age, 66.5; range, 7 to 82 years) with ascending aortic aneurysm and elongation and severe aortic valve incompetence underwent ascending aortic replacement. The aneurysm was incised longitudinally, and an appropriately sized straight Dacron (DuPont, Wilmington, DE) graft was sutured onto the aorta approximately 5 mm above the commissures, recreating the sinotubular junction. When valve competence was assured, the graft, cut considerably shorter than the original length of the ascending aorta, was anastomosed distally. The valve plane was hence relocated in a more cranial/oblique position, restoring its normal alignment. Perioperative echocardiographic and computed tomography studies were done to document the degree of aortic valve incompetence and the morphology of the aortic root., Results: During a mean follow-up of 3.0±2.7 years, aortic insufficiency was absent to trivial in 34, mild in 12, and moderate in 2 patients. Postoperative computed tomography showed considerable aortic shortening, remarkable sinotubular junction narrowing, aortic root diameter reduction, and angular widening between the aortic root plane and longitudinal spinal axis corresponding to aortic incompetence reduction., Conclusions: Aortic relocation technique provided satisfactory results in management of ascending aortic aneurysm and elongation with aortic valve incompetence., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Atrial fibrillation (AF) is associated with electroanatomical remodelling of the left atrium (LA), especially with LA dilatation. However, little is known about the changes of the three-dimensional structure of the LA, regarding the type of atrial fibrillation and their prognostic value after an ablative treatment., Methods: One hundred fifteen patients (72 males, 59 ± 11 years) with an indication for AF ablation were prospectively included. Preoperatively, all patients underwent cardiac computed tomography (CCT). A reconstruction of the LA and the pulmonary veins (PV) was made from CCT data using specialized software (EP PreNavigator, Philips, The Netherlands). Left atrial volume (LAV) after exclusion of the atrial appendage (LAA) and the PV was determined. The LA was then arbitrarily divided by a cutting plane, between the anterior segment of the PV ostia and the atrial appendage and parallel to the posterior wall, to anterior-(LA-Ant.) and posterior-LA (LA-Post.). The ratio LA-Ant./LAV was defined as asymmetry index (ASI). The cardiac CT data, of 25 patients (11 women, 47 ± 11 years) without organic heart disease, were similarly studied for the same parameters, as a control group., Results: Patients with paroxysmal AF (n = 63) had significantly higher LAV (131 ± 31 vs. 95 ± 18 ml, p < 0.001) and higher ASI (61 ± 6 % vs. 57 ± 4, p = 0.002) than the control group. Patients with persistent AF (n = 34) in comparison with paroxysmal AF showed significantly larger volumes (154 ± 44 vs. 131 ± 31 ml, p = 0.007) but no difference in the ASI (60 ± 8% vs. 61 ± 6%, p = 0.63). Finally, patients with long-term persistent AF (n = 18) showed a bigger asymmetry index than the patients with persistent AF (64 ± 5% vs. 60 ± 8%, p = 0.06) but no significant difference in volumes (161 ± 21 vs. 154 ± 44 ml, p = 0.49). LAA and partial LA volumes had a dilatation pattern similar to LAV. During a follow-up of over 25 ± 7 months, AF recurred in 31 (27%) patients. Multivariate analysis showed that ASI and LAV were the only two significant predictors of AF recurrence after ablative treatment. Independent of LAV, an ASI over 60% predicted AF recurrence with 74% sensitivity and 73% specificity., Conclusion: Characteristic differences of both left atrial volume and geometry exist between the different forms of atrial fibrillation (paroxysmal, persistent and long-term persistent). The asymmetry index is a simple parameter derived by cardiac CT data that reflects these changes of LA geometry and predicts the outcome after the pulmonary vein isolation.

Background: Three-dimensional (3D) image of left atrium (LA) can greatly facilitate ablation of atrial fibrillation (AF). Reconstructing method using computed tomography (CT) has certain limitations. The 3D image of LA can be intraprocedurally reconstructed by a rotational angiography technique., Methods: Forty-six patients undergoing AF ablation were included in this study. Preprocedural CT imaging and intraprocedural reconstructing 3D rotational angiogram (3DRA) of LA were performed in all the patients. Rapid ventricular pacing (RVP, 300 ms) was used to inhibit the drainage of atrium. During RVP, contrast medium was injected into the LA, and rotational angiography was performed. The 3DRA was reconstructed and was registered with the live fluoroscopy. The 3DRA was evaluated in comparison to the CT image. In the navigation of the registered 3DRA, the ablation of AF was performed., Results: Forty-four 3DRAs (95.7%) were successfully reconstructed and registered with the live fluoroscopy. The LA anatomy was delineated in the 3DRA in comparison to a CT image. AF ablation was successfully performed in the 44 patients in the navigation of the registered 3DRA. There were good correlations in the PV ostial diameter and the LA volume as assessed by 3DRA in comparison to a CT image (r>=0.87). The radiation exposure in rotational angiography was substantially less than that in CT scanning (2.7+/-0.9 mSv vs. 24.9+/-3.1 mSv, P<0.001)., Conclusions: It is feasible to reconstruct and register the 3DRA with live fluoroscopy using the RVP method during the ablation of AF.

Background: Invasive screenings at predefined time intervals for acute rejection and transplant coronary artery disease (TxCAD) are standard procedures. However, cardiac biopsies and catheterizations are distressing and risky for the patients and are also costly. We assessed the reliability of pulsed-wave tissue Doppler imaging (PW-TDI) for the timing of invasive examinations in heart recipients in an attempt to avoid unnecessary endomyocardial biopsies (EMBs) and catheterizations., Methods and Results: PW-TDI obtained at the basal left ventricular posterior wall before 408 EMBs and 293 catheterizations was tested for its diagnostic value regarding rejection and TxCAD with the use of International Society of Heart and Lung Transplantation biopsy grading, coronary angiography, and intravascular ultrasound as standards. Early diastolic peak wall motion velocity and relaxation time showed high sensitivities for clinically relevant rejection diagnosis (90.0% and 93.3%, respectively). The negative and positive predictive values for rejection of diastolic parameter changes appeared high enough (up to 96% and 92%, respectively) to allow a reliable noninvasive PW-TDI monitoring with efficiently timed, instead of routinely scheduled, EMBs. At definite cutoff values for systolic parameters, the probability for TxCAD reached 92% to 97%. The Fisher classification functions allowed TxCAD exclusion with 80% probability., Conclusions: Without diastolic parameter changes, acute rejection can be practically excluded, and serial PW-TDI can save patients from routine EMBs. The high specificity and negative predictive value for TxCAD of reduced systolic peak velocities and extended systolic time allow optimized timed catheterizations. Peak systolic velocity and systolic time allow diagnostic classifications that enable patients without known TxCAD but with high risk for catheterization to be spared routine angiographies.

To minimize surgical trauma, the use of Port Access cardiac surgery was initiated in patients (pts) with coronary artery disease (CAD) (42 pts) or mitral valve disease (MVD) (24 pts) in March 1996 at our institution. Altogether 42 pts (36 men, 6 women; age 31-75 years, median 59.0 years) with isolated lesions of the left anterior descending (LAD) artery underwent Port Access coronary artery surgery (PACAS). A small (5-9 cm) incision was done parasternally on top on the fourth rib. The left internal mammary artery (LIMA) was dissected through the minithoracotomy or by using an additional thoracoscopic approach. A total of 24 pts (12 men, 12 women; age 30-75 years, median 62 years) underwent Port Access mitral valve surgery (PAMVS). In these pts the procedure was performed through a small right thoracotomy (6-8 cm). In all cases, endovascular cardiopulmonary bypass (CPB) was instituted through femoral cannulation, and an additional endoaortic balloon catheter was introduced into the ascending aorta for aortic occlusion. In pts with PACAS the survival was 98% (41/42) and in the PAMVS group 100%. All pts but one survived the PACAS and are well today. There were no deaths in the PAMVS group. The hospital stay was reduced by 1 day on average after PACAS and 3 days after PAMVS. Thus in well selected patients Port Access cardiac surgery represents a safe and feasible minimally invasive surgical approach that avoids the potential complications of a sternotomy while offering the advantages and safety of CPB and cardioplegic arrest. This minimally invasive approach offers a shortened hospital stay and earlier rehabilitation.

Different variants of interstitial electrophoresis elaborated in the hospital were used with the aim of raising the effectiveness of treatment of acute abscess of the lungs, of abscessing pneumonia and acute empyema of the chest. The principle of electroelimination of medicinal preparations from the vessels or directly from the suppurative cavity into the surrounding tissue is the basis of interstitial electrophoresis. As the result of experimental and clinical observations the following variants of interstitial electrophoresis are proposed: intrapulmonary, endobronchial, cavitary, intracavitary and combined. The use of the proposed method of treatment in acute pleuropulmonary suppuration permitted to achieve substantial raising of the effectiveness of the used complex therapy. The method of interstitial electrophoresis is recommended for wide use in practical pulmonary and thoracic surgery.