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Purpose: In a recent study our group established an acute animal model of percutaneous pulmonary valve replacement using self-expanding nitinol stents. The present study was performed to evaluate these valved stents over a 3-month period. Description: Bovine jugular xenografts were sutured into nitinol stents. Transfemoral implantation in the pulmonary position using a modified commercially available application device (with a 22-French outer diameter) was evaluated in 9 sheep. Evaluation: Two sheep died shortly after successful valved stent implantation due to internal venous hemorrhage. Another 1 sheep died 2.5 months after the procedure due to vegetations on the neovalve leading to subtotal stenosis. All other animals survived the 3-month study time (n = 6). An orthotopic pulmonary valved stent position was achieved in 4 animals and a supravalvular position in 1. During the deployment procedure, rhythm disturbances occurred in all animals, and mean arterial blood pressure dropped from 83.9 ± 26.0 mm Hg to 68.3 ± 22.3 mm Hg (p = 0.006) (n = 5). The peak-to-peak transvalvular gradient was 5.1 ± 4.0 mm Hg initially (n = 5), and 3.6 ± 1.6 mm Hg at follow-up (n = 5). Three-month angiographic and echocardiographic follow-up confirmed competent neovalves without paravalvular leakages. Conclusions: After 3 months of implantation, percutaneously implanted memory nitinol valved stents demonstrated good function in the sheep. [Copyright &y& Elsevier]

We report two cases of rare invasive tumors presenting with transvenous and intracardiac extensions. In one instance, an unusual invasive thymoma type A penetrated into the heart chamber; the other case was an extension of a myxoma into the right atrium that was associated with superior vena cava syndrome. Our interest was stimulated by the rarity of these clinicopathological observations and the unusual clinical features of diagnostic and therapeutic methods presented by these cases., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Postoperative cognitive decline (POCD) after cardiosurgical interventions are well described through objective psychometric tests. However, a patient's subjective perception is essential to clinical assessment and quality of life. This study systematically evaluated patient-reported POCD between subjects undergoing coronary artery bypass grafting and heart valve replacement., Methods: This study was a multicentre, prospective questionnaire survey conducted at the cardiac surgery departments at the Kerckhoff Clinic in Bad Nauheim and the University Hospital in Giessen, Germany. We included patients undergoing elective coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral valve replacement or reconstruction (MVR), and combined surgery (CABG + valve replacement [VR]) with extracorporeal circulation. The Hospital Anxiety and Depression Scale, the Cognitive Failures Questionnaire (CFQ) for Self-assessment (CFQ-S), and the external assessment (CFQ-foreign [F]) were completed preoperatively, as well as at 3 and 12 months postoperatively., Results: A total of 491 patients were available for analyses (CABG = 182, AVR = 134, MVR = 93, CABG + VR = 82). POCD and postoperative depression increase (PODI) were observed for each surgical procedure. (At the 3-month follow-up: CFQ-S [CABG = 7.1%, AVR = 3.7%, MVR = 9.7%, CABG + VR = 9.8%]; CFQ-F [CABG = 9.9%, AVR = 9.7%, MVR = 9.7%, CABG + VR = 15.9%]; PODI [CABG = 7.7%, AVR = 9.7%, MVR = 6.5%, CABG + VR = 8.5%]. At the 12-month follow-up: CFQ-S [CABG = 6.6%, AVR = 7.5%, MVR = 15.1%, CABG + VR = 7.3%]; CFQ-F [CABG = 7.1%, AVR = 14.9%, MVR = 10.8%, CABG + VR = 9.8%]; PODI [CABG = 10.4%, AVR = 11.2%, MVR = 6.5%, CABG + VR = 4.9%]). No significant between-group effects were observed for the CFQ-S, CFQ-F, or the Hospital Anxiety and Depression Scale., Conclusions: For clinicians, paying attention to patients' self-reported experiences of reduced cognitive function and symptoms of depression following cardiac surgery is important. Such reporting is an indication that interventions such as cognitive training or psychotherapy should be considered., (© 2023 The Authors.)

Cardiac surgery is regularly associated with postoperative delirium (POD), affected by neuro-inflammation and changes in cholinergic activity. Therefore, this prospective observational study aimed to evaluate whether pre- and perioperative changes in blood acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity were associated with POD development in patients undergoing isolated elective coronary artery bypass graft (CABG) surgery. It included 93 patients. Pre- and postoperative blood AChE and BChE activities were measured with photometric rapid-point-of-care-testing. The Intensive Care Delirium Screening Checklist and the Confusion Assessment Method for the Intensive Care Unit were used to screen patients for POD. POD developed in 20 patients (21.5%), who were older ( p = 0.003), had higher EuroSCOREs ( p ≤ 0.001), and had longer intensive care unit stays ( p < 0.001). On postoperative day one, BChE activity decreased from preoperative values more in patients with (31.9%) than without (23.7%) POD (group difference p = 0.002). Applying a cutoff of ≥32.0% for BChE activity changes, receiver operating characteristic analysis demonstrated a moderate prediction capability for POD (area under the curve = 0.72, p = 0.002). The risk of developing POD was 4.31 times higher with a BChE activity change of ≥32.0% ( p = 0.010). Monitoring the pre- to postoperative reduction in BChE activity might be a clinically practicable biomarker for detecting patients at risk of developing POD after CABG surgery.

Background: Patients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA)., Aims: Herein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification., Methods: Of all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31-50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm 2 , 0.60 to < 0.80 cm 2 , 0.40 to < 0.60 cm 2 , and 0.20 to < 0.40 cm 2 )., Results: Overall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] - 1.694 mmHg [- 2.123 to - 1.265], p < 0.0001 and - 6.954 mmHg [- 7.725 to - 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: - 0.007cm 2 [- 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm 2 ; LVEF 31-50%: AVA 0.60 to 0.80 cm 2 )., Conclusions: In patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented. In patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach., (© 2022. The Author(s).)

Increased activation of sympathetic nervous system contributes to congestive heart failure (CHF) progression, and inhibition of sympathetic overactivation by beta-blockers is successful in CHF patients. Similarly, caloric restriction (CR) reduces sympathetic activity but mediates additional effects. Here, we compared the cardiac effects of CR (- 40% kcal, 3 months) with beta-blocker therapy (BB), diuretic medication (DF) or control diet in 18-months-old Wistar rats. We continuously recorded blood pressure, heart rate, body temperature and activity with telemetric devices and analysed cardiac function, activated signalling cascades and markers of apoptosis and mitochondrial biogenesis. During our study, left ventricular (LV) systolic function improved markedly (CR), mildly (BB) or even deteriorated (DF; control). Diastolic function was preserved by CR and BB but impaired by DF. CR reduced blood pressure identical to DF and BB and heart rate identical to BB. Plasma noradrenaline was decreased by CR and BB but increased by DF. Only CR reduced LV oxidative damage and apoptosis, induced AMPK and Akt phosphorylation and increased mitochondrial biogenesis. Thus, additive to the reduction of sympathetic activity, CR achieves protective effects on mitochondria and improves LV function and ROS damage in aged hearts. CR mechanisms may provide additional therapeutic targets compared to traditional CHF therapy.

Background: Because hearts in acute myocardial infarction are often prone to ischemia-reperfusion damage during cardiac surgery, we investigated the influence of intracellular crystalloid cardioplegia solution (CCP) and extracellular blood cardioplegia solution (BCP) on cardiac function, metabolism, and infarct size in a rat heart model of myocardial infarction., Methods: Following euthanasia, the hearts of 50 rats were quickly excised, cannulated, and inserted into a blood-perfused isolated heart apparatus. A regional myocardial infarction was created in the infarction group (18 hearts) for 120 min; the control group (32 hearts) was not subjected to infarction. In each group, either Buckberg BCP or Bretschneider CCP was administered for an aortic clamping time of 90 min. Functional parameters were recorded during reperfusion: coronary blood flow, left ventricular developed pressure (LVDP) and contractility (dp/dt max). Infarct size was determined by planimetry. The results were compared between the groups using analysis of variance or parametric tests, as appropriate., Results: Cardiac function after acute myocardial infarction, 90 min of cardioplegic arrest, and 90 min of reperfusion was better preserved with Buckberg BCP than with Bretschneider CCP relative to baseline (BL) values (LVDP 54 ± 11% vs. 9 ± 2.9% [p = 0.0062]; dp/dt max. 73 ± 11% vs. 23 ± 2.7% [p = 0.0001]), whereas coronary flow was similarly impaired (BCP 55 ± 15%, CCP 63 ± 17% [p = 0.99]). The infarct in BCP-treated hearts was smaller (25% of myocardium) and limited to the area of coronary artery ligation, whereas in CCP hearts the infarct was larger (48% of myocardium; p = 0.029) and myocardial necrosis was distributed unevenly to the left ventricular wall., Conclusions: In a rat model of acute myocardial infarction followed by cardioplegic arrest, application of BCP leads to better myocardial recovery than CCP.

In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in all investigated populations with a greater effect in the total population [fixed-effects model: standard mean difference (SMD) -0.931 ± 0.198, P < 0.001] as well as in the subgroup of CAGB patients (fixed-effects model: SMD -1.240 ± 0.156, P < 0.001), compared with the off-pump group (fixed-effects model: SMD -0.723 ± 0.128, P < 0.001). Despite contradictory results from recent trials, the present study confirms the findings of previous meta-analyses that prophylactic aortic counterpulsation reduces hospital mortality, incidence of LCOS and ICU requirement in high-risk patients undergoing on-pump cardiac surgery. However, owing to small sample sizes and the lack of a clear-cut definition of high-risk patients, an adequately powered, prospective RCT is necessary to find a definite answer to the question, if certain groups of patients undergoing cardiac surgery benefit from a prophylactic IABP insertion., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Although intra-aortic balloon pumping (IABP) is the most frequently used mechanical cardiac assist device in cardiothoracic surgery, there are only guidelines for substantive sections of aortic counterpulsation including prophylactic and postoperative use. In contrast, evidence-based recommendations are still lacking concerning intraoperative use, management, contraindication and other relevant issues. According to international surveys, important aspects of IABP usage show a wide variation in clinical practice. The results of a national questionnaire performed before initiation of this guideline confirmed these findings and demonstrated a clear need for the development of a consensus-based guideline. Therefore, the presented multidisciplinary S-3-guideline was developed under the direction of the German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG) to make evidence-based recommendations for the usage of aortic counterpulsation after cardiothoracic surgery according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF) and the Medical Centre for Quality (Ärztliches Zentrum für Qualität - (ÄZQ)). Main topics discussed in this guideline involve IABP support in the prophylactic, preoperative, intraoperative and postoperative setting as well as the treatment of right heart failure, contraindications, anticoagulation, monitoring, weaning, and limitations of IABP therapy. The presented 15 key messages of the guideline were approved after two consensus meetings under moderation of the AWMF with participation of the German Society of Cardiology (DGK), German Society of Anaesthesiology and Intensive Care Medicine (DGAI), German Interdisciplinary Association for Intensive Care (DIVI) and the German Society for Cardiovascular Engineering (DGfK)., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Contrast-induced acute kidney injury (CI-AKI) is a serious complication of procedures requiring contrast media associated with rising costs, prolonged hospitalization, and increased mortality. The aim of this study was to assess whether prophylactic administration of standard dosages of intravenous N-acetylcysteine or ascorbic acid reduce the incidence of CI-AKI in patients with chronic renal insufficiency undergoing elective cardiac catheterization., Methods: In a single-center, prospective, randomized, double-blind, placebo-controlled trial, the preventive effects of N-acetylcysteine and ascorbic acid were evaluated in 520 patients with chronically impaired renal function (serum creatinine ≥1.3 mg/dL) undergoing elective cardiac catheterization. The study drugs (600 mg N-acetylcysteine, 500 mg ascorbic acid, placebo) were administered intravenously twice (at 24 hours and 1 hour before the procedure). Serum creatinine, estimated glomerular filtration rate (eGFR) and serum urea were assessed at baseline and at 24 hours and 72 hours after contrast media exposure. CI-AKI was defined as a postangiographical increase in serum creatinine ≥0.5 mg/dL. Results. The incidence of CI-AKI was 27.6% in the N-acetylcysteine group (P=.20 vs placebo group) and in 24.5% in the ascorbic acid group (P=.11 vs placebo group). CI-AKI occurred in 32.1% of the placebo group., Conclusions: Standard doses of N-acetylcysteine and ascorbic acid did not prevent CI-AKI in patients at high risk undergoing cardiac catheterization with non-ionic, low-osmolality contrast agent.

Aims: Transient ischaemia of non-vital tissue has been shown to enhance the tolerance of remote organs to cope with a subsequent prolonged ischaemic event in a number of clinical conditions, a phenomenon known as remote ischaemic preconditioning (RIPC). However, there remains uncertainty about the efficacy of RIPC in patients undergoing cardiac surgery. The purpose of this report is to describe the design and methods used in the "Remote Ischaemic Preconditioning for Heart Surgery (RIPHeart)-Study"., Methods: We are conducting a prospective, randomized, double-blind, multicentre, controlled trial including 2070 adult cardiac surgical patients. All types of surgery in which cardiopulmonary bypass is used will be included. Patients will be randomized either to the RIPC group receiving four 5 min cycles of transient upper limb ischaemia/reperfusion or to the control group receiving four cycles of blood pressure cuff inflation/deflation at a dummy arm. The primary endpoint is a composite outcome (all-cause mortality, non-fatal myocardial infarction, any new stroke, and/or acute renal failure) until hospital discharge., Conclusion: The RIPHeart-Study is a multicentre trial to determine whether RIPC may improve clinical outcome in cardiac surgical patients.

Background: The use of access-site closure devices in interventional cardiology has expanded rapidly in the past several years. Initial reports indicated remarkable safety with these devices but there are a small number of major complications. This single-center, retrospective study was carried out to investigate the efficacy of percutaneous transluminal angioplasty (PTA) of inadvertent occlusion or severe stenosis of the femoral artery after deployment of the Angio-Seal closure device. From April 1995 to August 2009 a total of 8,587 Angio-Seal devices were deployed immediately after cardiac catheterization. Within 7 days after deployment, clinical signs of acute arterial occlusion or severe stenosis of the femoral artery were evident in 6 patients (0.07%). They were immediately referred for diagnostic angiography and subsequent PTA. Angiography revealed occlusion of the femoral artery at the puncture site level in 4 patients and a severe stenosis in 2 patients. Using a cross-over access from the opposite groin, PTA of the closed or highly stenosed femoral artery was feasible in all cases. At routine follow up 12 months thereafter, there was no clinical evidence of symptomatic restenosis. Inadvertent occlusion or high-grade stenosis of the femoral artery after Angio-Seal closure device deployment is a rare but severe complication. PTA appears to be a safe and effective method of treatment, avoiding surgical removal of the plug.

Objective: The purpose of this study is to evaluate the safety and efficacy of a novel 30 degrees end-to-side coronary anastomotic coupler (Converge Medical, Inc., Sunnyvale, CA) that facilitates a non-penetrating, sutureless vein graft to coronary artery anastomosis., Material and Methods: The Coupler utilizes a set of concentric mating frames approximating adjacent vessel tissue allowing for biological healing of the anastomosis. The frames are manufactured from Nitinol, a nickel titanium super-elastic metal alloy. The Nitinol frames attach the bypass graft to the coronary artery in a 30 degrees end-to-side configuration. Between November 2002 and March 2003 a total of 46 patients (44 male) with a mean age of 63.6+/-7.5 years were admitted for coronary artery revascularization and included in the study. The mean LVEF was 60.6+/-12.4%., Results: Thirty-three patients were successfully treated with the Coupler. Nine patients did not meet the intraoperative inclusion criteria, and were excluded from the study due to small (

Background: Off-pump coronary artery bypass (OPCAB) surgery for posterior and inferior wall vessels requires heart displacement, which leads to hemodynamic instability. Based on results indicating that displacement primarily alters right heart function, this study evaluates the safety and efficacy of right heart support during OPCAB surgery to the posterior and inferior wall vessels., Methods: In a multi-center, prospective study, 25 patients underwent multi-vessel OPCAB surgery. Right heart support was carried out using the Enabler circulatory support system (Hemodynamics Systems Ltd., Upper Yokneam, Israel). Hemodynamic measurements were recorded at baseline and during heart displacement with and without right heart support., Results: No mortality was recorded. Mean graft number was 2.25 +/- 0.36. Inability to position the Enabler system occurred in five cases. Once the Enabler was properly positioned, there was no case of conversion to cardiopulmonary bypass (CPB) due to failure of the Enabler to provide adequate support. Cardiac index (CI) declined from 2.4 +/- 0.5 L/min x /m2 to 1.6 +/- 0.6 L/min x /m2 (p <0.05) during heart displacement and increased to 2.3 +/- 0.6 L/min x /m2 (p <0.05) following Enabler activation. Mean arterial blood pressure (MAP) dropped from 82 +/- 18.6 mmHg to 53.1 +/- 16.6 mmHg (p <0.001) during heart displacement and was restored to 69.8 +/- 19.4 mmHg (p <0.001) with Enabler support., Conclusions: Heart displacement caused a significant hemodynamic deterioration that was stabilized with right heart support. The Enabler system is safe and effective in facilitating multi-vessel OPCAB surgery. However, there are still serious technical problems during cannula insertion that cause an unacceptable failure rate of device utilization.