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Die Assistentenumfragen der Jahre 2007 und 2013 haben gezeigt, dass unter den Weiterbildungsassistenten in den herzchirurgischen Fachabteilungen eine gewisse Unzufriedenheit mit der Weiterbildungssituation herrscht und das Fachgebiet Herzchirurgie fur den Nachwuchs an Attraktivitat verliert. Als Konsequenz hat die Deutsche Gesellschaft fur Thorax‑, Herz- und Gefaschirurgie (DGTHG) einige Neuerungen bei der Weiterbildung umgesetzt. Die Assistentenumfrage 2016 hatte zum Ziel, den aktuellen Stand der Weiterbildung in den herzchirurgischen Abteilungen sowie die Auswirkungen der von der DGTHG initiierten Neuerungen zu erfassen und weiteres Verbesserungspotenzial zu erkennen. Eine wenig strukturierte Weiterbildung, nicht umgesetzte Weiterbildungskonzepte in den herzchirurgischen Fachabteilungen sowie eine zu geringe Zahl an Weiterbildungsoperationen bedingen eine Weiterbildungszeit, die das geforderte Mas von 6 Jahren bei Weitem ubersteigt. Die Folgen sind nach wie vor unzufriedene Weiterbildungsassistenten und ein Attraktivitatsverlust der Fachdisziplin Herzchirurgie fur den Nachwuchs. Hierzu tragen auch eine ungunstige Work-Life-Balance und die zunehmende Arbeitsbelastung bei. Dennoch bekunden die Weiterbildungsassistenten ein ausgesprochen hohes Interesse an den Kerngebieten der Herzchirurgie. Um dieser Unzufriedenheit und einem moglichen zukunftigen Nachwuchsmangel weiter entgegenzuwirken, mussen die von der DGTHG initiierten Masnahmen zur Verbesserung der herzchirurgischen Weiterbildung weiter forciert werden.

Introduction: Dilutional acidosis may result from the introduction of a large fluid volume into the patients' systemic circulation, resulting in a considerable dilution of endogenous bicarbonate in the presence of a constant carbon dioxide partial pressure. Its significance or even existence, however, has been strongly questioned. Blood gas samples of patients operated on with standard cardiopulmonary bypass (CPB) were analyzed in order to provide further evidence for the existence of dilutional acidosis. Material and methods: Between 07/2014 and 10/2014, a total of 25 consecutive patients scheduled for elective isolated coronary artery bypass grafting with CPB were enrolled in this prospective observational study. Blood gas samples taken regularly after CPB initiation were analyzed for dilutional effects and acid-base changes. Results: After CPB initiation, hemoglobin concentration dropped from an average initial value of 12.8 g/dl to 8.8 g/dl. Before the beginning of CPB, the mean value of the patients' pH and base excess (BE) value averaged 7.41 and 0.5 mEq/l, respectively. After the onset of CPB, pH and BE values significantly dropped to a mean value of 7.33 (p < 0.0001) and -3.3 mEq/l (p < 0.0001), respectively, within the first 20 min. In the following period during CPB they recovered to 7.38 and -0.5 mEq/l, respectively, on average. Patients did not show overt lactic acidosis. Conclusions: The present data underline the general existence of dilutional acidosis, albeit very limited in its duration. In patients undergoing coronary artery bypass grafting it seems to be the only obvious disturbance in acid-base homeostasis during CPB. OA gold

Background Acute mesenteric ischemia following cardiovascular surgery is a rare but fatal complication. We established a new rat model for hemodynamic monitoring during mesenteric ischemia/reperfusion (I/R) and evaluated the impact of mesenteric I/R on hemodynamics and remote organ injury. Methods Mesenteric I/R was induced in male Wistar rats by superior mesenteric artery occlusion for 90 minutes, followed by 120 minutes of reperfusion. Before I/R, ventilation and hemodynamic monitoring including mean arterial blood pressure (MAP) and cardiac output (CO) were established. During reperfusion Geloplasma (I/R + Geloplasma, N = 6) and Ringer's solution (I/R + Ringer, N = 6) were titrated according to CO and compared with I/R without volume resuscitation (I/R only, N = 6) and a sham group (sham, N = 6). Blood samples were regularly taken for serum marker measurements. After reperfusion organs were harvested for histology studies. Results After acute mesenteric I/R, MAP and CO decreased (p Conclusion A new model for CO monitoring after mesenteric I/R injury demonstrated severe hypovolemic shock during reperfusion followed by remote myocardial and lung injury. Far less colloid volume is needed for hemodynamic stabilization after I/R compared with crystalloid volume.

OBJECTIVES In DeBakey Type I acute aortic dissection, the frozen elephant trunk technique is used for the combined treatment of both the proximal and distal thoracic aorta. Anatomical characteristics of the distal aorta and their impact on false lumen (FL) thrombosis and aortic remodelling were analysed in this study. METHODS Sufficient pre-, postoperative, and at least one 1-year follow-up computed tomography data sets were available for 63 of 94 patients treated with the frozen elephant trunk for Type I acute aortic dissection between March 2005 and March 2015. Aortic remodelling and FL thrombosis quotients were calculated volumetrically at the stent graft level (A), from A to the coeliac trunk (B) and from B to the bifurcation (C) and were correlated with the number and size of entry tears and aortic branches arising from the FL (exits) in each segment. RESULTS Positive or stable remodelling was found in Segments A (94%), B (64%) and C (54%), and the FL thrombosis quotient was 98% in A, 68% in B and 39% in C within the first year. FL thrombosis correlated negatively with the total size of the entry (P

Heart-type fatty acid binding protein (hFABP) and ischemia-modified albumin (IMA) have been put forward as novel biomarkers to detect myocardial injury shortly after onset of ischemia. We compared hFABP and IMA with cardiac troponin I (cTnI) for speed and reliability in the diagnosis of perioperative myocardial infarction (PMI) after coronary artery bypass graft surgery (CABG).In all, 210 consecutive patients undergoing isolated CABG with cardiopulmonary bypass were enrolled in a prospective study. Blood samples were taken perioperatively and throughout the first 72 hours after surgery; clinical data and events were recorded. In cohort A, serum concentrations of hFABP and cTnI were measured using a combined quantitative bedside assay. In cohort B, IMA and cTnI serum concentrations were measured using an albumin cobalt binding test. Perioperative myocardial infarction was defined using a cTnI cutoff of greater than 10.5 ng/mL occurring within 24 hours of CABG or new electrocardiographic changes.In cohort A, 14 patients were identified with PMI (group 1), whereas 94 had no PMI and served as controls (group 2). Both hFABP and cTnI were increased in group 1 as compared with group 2 (p0.001). Although cTnI did not differ before 12 hours, hFABP diverged much earlier, at 1 hour postoperatively (p0.001). An hFABP concentration of 20 μg/mL at 1 hour detected PMI with an area under the curve of 77.1%. In cohort B, 18 patients were identified with PMI (group 3), and 84 patients served as controls (group 4). No difference in cTnI values could be observed between the groups until 12 hours postoperatively. Ischemia-modified albumin failed to differentiate at any postoperative time point; the low discriminative power of IMA was confirmed with an area under the curve of 53.3% at 1 hour, 48.5% at 6 hours, and 39.3% at 12 hours postoperatively.Heart-type fatty acid binding protein is a sensitive and rapid biomarker that detected PMI reliably at 1 hour after CABG, much earlier than cTnI. The diagnostic value of IMA for detection of PMI appears to be very limited in this setting.

OBJECTIVES: To avoid a two-stage surgical approach for complex thoracic aortic disease with its additive mortality and morbidity, a hybrid stent graft prosthesis was introduced 6 years ago for simultaneous treatment of the ascending, arch and descending aortas, relying proximally on a surgical suture line with an integrated distal stent graft for downstream splinting. We report the mid-term single-centre experience. METHODS: Between January 2005 and March 2011, 77 patients (mean age 59 years, male 75%) with acute (AAD, n= 39) or chronic aortic dissection (CAD, n= 23) DeBakey type I or an extensive thoracic aortic aneurysm (TAA, n= 15) underwent one-stage repair. Periodic follow-up studies (100%, mean 29 months) included repeat aortic computed tomography imaging. Major adverse events (MAEs) were defined as permanent stroke, spinal cord injury and dialysis. RESULTS: In-hospital mortality was 10% (8 of 77). The incidence of MAE in AAD, CAD and TAA was 5, 13 and 20%, respectively. At the last follow-up, the complete thrombosis of the thoracic false lumen was 92% for AAD, 91% for CAD and the full exclusion of aneurysms 100% in TAA. Throughout the follow-up, freedom from aortic disease-related death was 93% and 5-year survival 79%. Freedom from distal reoperation was 94% in AAD, 95% in CAD and 100% in TAA and the incidence of distal stent graft extension 10% (8 of 77). CONCLUSIONS: The durable hybrid one-stage repair of complex thoracic aortic disease is feasible with acceptable mortality. Distal reintervention is infrequent and associated with low risk; thus, the indication for the optimization of the peripheral flow using the endovascular aortic repair techniques is gradually widened.

Purpose: To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR). Methods: This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9). Results: TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively]. Conclusion: Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.

Objective: Mesenteric ischemia (MESI) is a rare but often fatal complication for patients after cardiac surgery. Non-specific clinical symptoms and lack of specific laboratory parameters complicate diagnosis. We evaluated potential serum markers for MESI in cardiac surgery patients. Methods: Between 03/2011 and 10/2012 serial serum samples of cardiothoracic patients were collected. In patients receiving laparotomy for suspected MESI serum concentrations of potential markers (α-glutathione-S-transferase: αGST; intestinal-fatty-acid-binding-protein-2: iFABP2; D-lactate) were measured retrospectively in samples taken 1, 24 and 48 h after the initial cardiac operation and compared with an collective of 12 uncomplicated CABG patients. Results: Laparotomy was performed in 18 patients 11 ± 7 days after cardiac surgery. MESI was found in 9/18 patients. Already 1h after cardiac surgery D-lactate (37 ± 4 versus 16 ± 2 nmol/µl, p = 0.0005) and iFABP2 (1 ± 0.2 versus 0.06 ± 0.05 ng/ml, p = 0.0013) serum concentrations of patients experiencing laparotomy were significantly increased compared with the control group. These differences remained highly significant in the 24 hour and 48 hour serum samples. In the subgroup analysis of patients with and without MESI a significant difference was only found for iFABP2 after 24 h (1.1 ± 0.4 vs 2.9 ± 0.6 ng/ml, p = 0.04). No significant differences were found for αGST. Conclusions: D-Lactat and iFABP2 are increased significantly in the first postoperative hours in patients experiencing laparotomy within their postoperative course. Systematically used these markers might help to identify patients at risk for laparotomy.

Intravascular ultrasound (IVUS) provides real-time imaging of aortic pathology during aortic interventions. The objective of the present study was to validate IVUS measurements using computed tomography (CT) angiography in a sufficiently large cohort.From October 2010 to February 2014, 57 consecutive patients with acute aortic syndrome underwent both IVUS and spiral CT for a total of 509 comparable thoracic aorta segments. Minimum, maximum, and mean diameters were determined at each measurement point.IVUS measurements of the thoracic aorta (aortic root, brachiocephalic trunk, left common carotid artery, left subclavian artery) ranged from 18-48.5 (mean 33.0) mm, versus 18-48.4 (mean 31.7) mm on CT, with a significant mean difference of 5.1% (p0.05). The correlation between methods was generally good, but IVUS tended toward larger diameters than CT in the aortic arch, especially the left subclavian artery. In 78% of measurement sites, total mean diameters were larger on IVUS measurements of the thoracic aorta than on CT measurements.IVUS is a reliable tool for measuring aortic diameter, especially in the descending part of the aorta. However, its pitfalls must be considered to prevent choosing an incorrectly sized stent graft in the acute setting of thoracic endovascular aortic repair.

OBJECTIVES: Frozen elephant trunk (FET) can be used for continuous downstream aorta treatment in acute aortic dissection (AAD) and chronic aortic dissection (CAD). The study reports the changes in the lumen volumes along the downstream aorta towards remodelling. METHODS: In 70 patients (22 CAD, 48 AAD), pre-, postoperative and at least the 1-year follow-up aortic imaging was available. Volume changes of aortic lumen (AL) and true lumen (TL) between examinations along the stent graft aortic segment (A), downstream to coeliac trunk (B) and distally to bifurcation (C) were used for quantification. TL increase >10% with stable AL or AL decrease >10% with stable TL were classified as positive, changes within a 10% threshold as stable, and all other changes as negative remodelling. RESULTS: In AAD, positive or stable remodelling occurred in A (90%), B (65%), C (58%) within 1 year, thereafter in 26 patients (follow-up: 47 ± 21 months) in A (92%), B (65%), C (62%). Negative remodelling in ≥2 segments was found in 5/26 (19%) patients. In CAD, positive or stable remodelling occurred in A (100%), B (86%), C (77%) within 1 year, thereafter in 16 patients (follow-up: 46 ± 20 months) in A (75%), B (44%), C (38%). Negative remodelling in ≥2 segments was found in 7/16 (43%) patients, 5 underwent reintervention, and stabilized thereafter. CONCLUSIONS: FET facilitates positive remodelling in AAD and CAD down to stent graft level. Distally, 20% AAD and 40% CAD patients remain at risk for secondary reintervention, and can be identified by negative remodelling in ≥2 segments in the follow-up examinations.

Die Assistentenbefragung 2013 wurde in elektronischer Form durchgeführt und soll einerseits einen Überblick der aktuellen Gegebenheiten erstellen und andererseits Unterschiede im Vergleich zu den vorangegangenen Umfragen aufzeigen. Auch wenn das Fachgebiet der Herzchirurgie nicht direkt an Nachwuchsmangel leidet, scheint dennoch ein Attraktivitätsverlust vorzuliegen. Dieser wird zum größten Teil der unstrukturierten und nichttransparenten Weiterbildung zugeschrieben. Zusätzlich sind eine Zunahme der durchschnittlichen Arbeitszeit und ein erhöhtes Vorkommen von nur befristet eingestellten Kollegen nachweisbar. Dies geht einher mit einer gestiegenen Anzahl unverheirateter und kinderloser Mitarbeiter. Gleichzeitig kam es zu einem zunehmenden Angleichen des Geschlechterverhältnisses. Eine ungünstige „work-life balance“ und das Fehlen von Zukunftsperspektiven sind weitere wesentliche Aspekte in diesem Kontext. Fachärztliche Zusatzbezeichnungen und spezielle Zertifikate scheinen für den herzchirurgischen Nachwuchs zunehmend interessanter und können nach dem Facharzt besondere berufliche Entwicklungsmöglichkeiten bieten. Mithilfe der neuen Musterweiterbildungsordnung und einem modularen Weiterbildungsangebot soll die herzchirurgische Facharztweiterbildung durch Modernisierung verbessert werden.

In complex thoracic aortic disease endovascular techniques and the use of hybrid stent grafts enables a combination therapy of the aortic arch and the descending aorta through a median sternotomy. This emphasizes the importance of intraoperative visualization of the descending aorta and its pathologies. Intraoperative angioscopy is a new diagnostic method for the assessment of distal aortic disease and assists in therapeutic decision-making and navigation of endovascular techniques in the descending aorta. This study presents the angioscopic results of 62 patients (mean age 60±12 years, 73% male, 54 aortic dissections, eight aortic aneurysms) during surgery of the thoracic aorta. Visualization of the extent of pathology along the downstream aorta was feasible in all patients. The implantation of a hybrid stent graft prosthesis was assisted by angioscopy in 34 patients and endovascular balloon dilatation of the stent graft was navigated by angioscopy in 11 patients. Angioscopy has become an indispensable tool in the intraoperative treatment of complex thoracic aortic disease in our clinic, particularly in the navigation of endovascular interventions in the distal thoracic aorta through the aortic arch.

With the establishment of a hybrid room 7 years ago, it was possible for the first time to unite a full range of diagnostics and surgical therapy under the sterile conditions of an operating theatre in life-threatening aortic dissection. Thus, the early phase associated with high mortality rates (3%-5% per hour) could be significantly reduced from 8 h to 4 h. Multidisciplinary teams consisting of a cardiac surgeon, a cardiologist and an anaesthetist enable competent and rapid life-saving measures. In the case of acute and persistent visceral and/or peripheral malperfusion over many hours, primary endovascular reconstitution of perfusion precedes delayed surgical replacement of the ascending aorta with or without the aortic arch. Additional strategic and technical surgical developments have helped reduce overall hospital mortality from 15%-20% to 10%-15%. Though expensive to build, a high-technology hybrid room enables interdisciplinary specialization and concentration, as demonstrated by the exponential growth in the development of transcatheter aortic valve implants or the endovascular treatment of aortic disease.

Bei komplexen thorakalen Aortenerkrankungen erlauben endovaskulare Techniken und die Verwendung eines Hybrid-Stent-Grafts eine Kombinationstherapie des Aortenbogens und der deszendierenden Aorta uber eine mediane Sternotomie. Hierbei nimmt die Bedeutung der intraoperativen Visualisierung der Aorta descendens und ihrer Pathologien zu. Die Angioskopie ist ein neues intraoperatives diagnostisches Verfahren zur Beurteilung der distalen Aortenerkrankung und unterstutzt bei der Therapieentscheidung und der Navigation von endovaskularen Techniken in der Aorta descendens. In dieser Studie werden die Ergebnisse der Angioskopie von 62 Patienten (54 Aortendissektionen, 8 Aortenaneurysmen) wahrend einer Operation der thorakalen Aorta dargestellt. Die Angioskopie erlaubte die Beurteilung der Ausdehnung der Aortenpathologie bei allen Patienten, die Steuerung der Implantation einer Hybrid-Stent-Graft-Prothese (n=34) und die Navigation einer endovaskularen Ballondilatation (n=11). Die Angioskopie entwickelte sich in unserer Klinik zu einem unverzichtbaren intraoperativen Instrument bei der Behandlung komplexer thorakaler Aortenerkrankungen, insbesondere zur Unterstutzung von endovaskularen Interventionen in der distalen thorakalen Aorta durch den Aortenbogen.