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Zusammenfassung. Ein Patient stellt sich mit einer Allgemeinzustandsverschlechterung, Schüttelfrost und Belastungsdyspnoe vor. Bei St.n. Aortenklappenersatz in der Vorgeschichte besteht der Verdacht auf eine infektiöse Endokarditis, die jedoch aufgrund zunächst negativer Bildgebung mittels TEE und bei negativen Blutkulturen nicht bestätigt werden kann. Eine verlängerte Bebrütung der Blutkulturen, das Auftreten embolischer Komplikationen sowie ein typischer Befund im PET-CT ermöglicht schliesslich die Diagnose einer Kunstklappenendokarditis mit Cutibacterium acnes.

Background To evaluate the midterm follow-up and 5-year survival outcome of the minimally invasive direct coronary artery bypass (MIDCAB) procedure compared with the survival of the general Swiss population. Methods Retrospective study on preoperative data, intraoperative data, and postoperative outcome of patients who underwent MIDCAB surgery between June 2010 and February 2019. To assess validity of this surgical therapy, outcomes were compared with survival data of a gender- and age-matched cohort of the general Swiss population taken from the database of the Swiss Federal Statistical Office. Results A total of 88 patients were included. Median (interquartile range [IQR[) age was 66 (56–75) years, and 27% (n = 24) were female. The median (IQR) length of the in-hospital stay was 7 (6–8) days. No postoperative stroke occurred. The 30-day mortality was 1.1% (n = 1). Reintervention for failed left internal mammary artery was needed in 1.1% (n = 1). The median (IQR) ejection fraction was 58% (47–60) preoperatively and remained stable during follow-up. The median (IQR) follow-up period was 3 (1.1–5.2) years. Five years postoperatively, 83% (confidence interval, 69–91) of the patients were alive, showing an overlap with the range of survival of the matched subcohort of the general Swiss population (range, 84–100%). Conclusion Though suffering from coronary heart disease, patients after MIDCAB show almost equal survival rates as an equivalent subcohort corresponding to the general Swiss population matched on age and gender. Thus, our data show this treatment to be safe and beneficial.

The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.

We present the case of a 72-year-old female patient with acute contained rupture of a biological composite graft, 21 months after replacement of the aortic valve and the ascending aorta due to an aortic dissection. Auramine-rhodamine staining of intraoperative biopsies showed acid-fast bacilli, but classical culture and molecular methods failed to identify any organism. Metagenomic analysis indicated infection with Mycobacterium chelonae, which was confirmed by target-specific qPCR. The complexity of the sample required a customized bioinformatics pipeline, including cleaning steps to remove sequences of human, bovine ad pig origin. Our study underlines the importance of multiple testing to increase the likelihood of pathogen identification in highly complex samples.

Better Late than Never - Fever of Unknown Origin in a Patient with a Prosthetic Valve

Purpose of the Review The aim of this article is to describe the technique of aortic valve neocuspidization using autologous pericardium (AVNeo, “OZAKI procedure”) in adult cardiac surgery, to analyze recent findings, and to discuss benefits and limitations of this technique. Recent Findings Potential benefits of this technique include excellent hemodynamic performances, minimal use of foreign material, low rates of permanent pacemaker implantation, and omission of oral anticoagulation. However, data regarding the durability of the procedure are hitherto limited, and the procedure is associated with a higher complexity compared to aortic valve replacement. Summary AVNeo using autologous pericardium in adult cardiac surgery is a promising technique providing several benefits. However, there is a major unmet need for more data, especially regarding long-term durability. Thus, based on currently available data, we recommend careful patient selection within the heart team and shared decision-making with the informed patient.

A 70-year-old female heart failure patient could not be weaned from temporary left ventricular mechanical support with Impella CP (Abiomed Inc, Danvers, MA) after myocardial infarction; therefore, she underwent left ventricular assist device implantation (HeartMate 3; Abbott, Chicago, IL). After uneventful surgery, the patient had an early postoperative thrombus in the aortic root, and surgical thrombectomy on extracorporeal circulation was performed on the seventh postoperative day. The patient recovered well and presented in good condition with no neurologic symptoms at the 6-month follow-up visit. Surgical excision of aortic root thrombus is a feasible option even for frail patients with a left ventricular assist device. Résumé: Après un infarctus du myocarde, une patiente de 70 ans présentant une insuffisance cardiaque n'a pas pu être sevrée d'une assistance mécanique temporaire pour le ventricule gauche par dispositif Impella CP (Abiomed Inc, Danvers, MA); elle a donc subi l'implantation d'un dispositif d'assistance ventriculaire gauche (HeartMate 3; Abbott, Chicago, IL). Après une intervention sans incident, la patiente a présenté un thrombus postopératoire précoce dans l'anneau aortique, et une thrombectomie chirurgicale sous circulation extracorporelle a été réalisée le septième jour suivant l'intervention. La patiente s'est bien rétablie et semblait en bonne santé, sans symptômes neurologiques, au moment de la visite de suivi six mois plus tard. L'excision chirurgicale du thrombus de l'anneau aortique est une option réaliste même chez les patients fragiles ayant un dispositif d'assistance ventriculaire gauche.

A 78-year-old patient underwent his third biological aortic valve replacement (25 mm, Inspiris Resilia™, Edwards Lifesciences LLC, Irvine, CA, USA) with COR-KNOT® (LSI Solutions, Victor, NY, USA) due to valve degeneration in 2018 at a foreign hospital. In 2021, the patient was diagnosed with severe aortic regurgitation and admitted to our hospital for his fourth surgery. Intraoperatively, a total of 7 perforations in all 3 valve leaflets have been observed, which were obviously induced by the rigid metallic fasteners. Redo isolated aortic valve replacement (29 mm, Perimount Magna Ease, Edwards Lifesciences LLC) was performed with conventionally knotted, pledget enforced braided threads. Postoperative course was uneventful. This report shows that COR-KNOT-induced defects do not appear immediately after surgery but within the first 4 postoperative months. Since failure of aortic bioprostheses due to aortic insufficiency is often rated as ‘early degeneration’ and degenerated aortic bioprostheses are mostly replaced by valve-in-valve strategy, the true incidence of this serious complication might be underestimated. COR-KNOT should be used with caution in biological aortic valve replacement and patients should undergo close postoperative follow-ups.

Objectives: The main aim was a systematic evaluation of the current evidence on outcomes for patients undergoing right ventricular assist device (RVAD) implantation following left ventricular assist device (LVAD) implantation. Methods: This systematic review was registered on PROSPERO (CRD42019130131). Reports evaluating in-hospital as well as follow-up outcome in LVAD and LVAD/RVAD implantation were identified through Ovid Medline, Web of Science and EMBASE. The primary endpoint was mortality at the hospital stay and at follow-up. Pooled incidence of defined endpoints was calculated by using random effects models. Results: A total of 35 retrospective studies that included 3260 patients were analyzed. 30 days mortality was in favour of isolated LVAD implantation 6.74% (1.98–11.5%) versus 31.9% (19.78–44.02%) p = 0.001 in LVAD with temporary need for RVAD. During the hospital stay the incidence of major bleeding was 18.7% (18.2–19.4%) versus 40.0% (36.3–48.8%) and stroke rate was 5.6% (5.4–5.8%) versus 20.9% (16.8–28.3%) and was in favour of isolated LVAD implantation. Mortality reported at short-term as well at long-term was 19.66% (CI 15.73–23.59%) and 33.90% (CI 8.84–59.96%) in LVAD respectively versus 45.35% (CI 35.31–55.4%) p ⩽ 0.001 and 48.23% (CI 16.01–80.45%) p = 0.686 in LVAD/RVAD group respectively. Conclusion: Implantation of a temporary RVAD is allied with a worse outcome during the primary hospitalization and at follow-up. Compared to isolated LVAD support, biventricular mechanical circulatory support leads to an elevated mortality and higher incidence of adverse events such as bleeding and stroke.

Frontiers in Cardiovascular Medicine 9, 1-9 (2022). doi:10.3389/fcvm.2022.879378 special issue: "Palliative Care for People Living with Heart and Lung Disease", Published by Frontiers Media, Lausanne

Objectives: Aim of this study was to evaluate ascending aorta and aortic root dimension at acute type A dissection (acute aortic dissection) and to identify demographics elements being allied to the acute event. Methods: In a period between 2009 and 2017, 225 (n = 71, 32% female, mean age = 63 ± 12 years) patients eligible for analysis of ascending aorta and 223 (n = 70, 31% female, mean age = 63 ± 13 years) of aortic root were included in this study. Aortic diameter was assessed in preoperative computed tomography scan. The predissection diameters were modeled from the diameters obtained at diagnosis, assuming 30% augmentation of the diameter at acute event. Results: The mean diameter of the ascending aorta at dissection was 46 ± 8 mm and the modeled diameter was 32.3 ± 5.7 mm. The diameter of the aortic root at dissection was 42 ± 8 mm and modeled diameter was 29.5 ± 5.6 mm. In multivariate analysis, female gender (p = 0.026) and history of cerebrovascular event (p = 0.001) were associated with acute aortic dissection in small aortic root. Patient age (p < 0.001) and history of inguinal hernia (p = 0.001) in ascending aorta Conclusion: Modeling indicates that more than 90% of patients had aortic root and ascending aorta diameter

Background The aim of this study is to compare the combined use of the Myocardial Protection System and our microplegia (Basel Microplegia Protocol) with Cardioplexol® in coronary artery bypass grafting using the minimal extracorporeal circulation. Methods The analysis focused on propensity score matched pairs of patients in whom microplegia or Cardioplexol® was used. Primary efficacy endpoints were high-sensitivity cardiac troponin-T on postoperative day 1 and peak values during hospitalization. Furthermore, we assessed creatine kinase and creatinine kinase-myocardial type, as well as safety endpoints. Results A total of 56 patients who received microplegia and 155 patients who received Cardioplexol® were included. The use of the microplegia was associated with significantly lower geometric mean (confidence interval) peak values of high-sensitivity cardiac troponin-T (233 ng/L [194–280 ng/L] vs. 362 ng/L [315–416 ng/L]; p = 0.001), creatinine kinase (539 U/L [458–633 U/L] vs. 719 U/L [645–801 U/L]; p = 0.011), and creatinine kinase-myocardial type (13.8 µg/L [9.6–19.9 µg/L] vs. 21.6 µg/L [18.9–24.6 µg/L]; p = 0.026), and a shorter length of stay on the intensive care unit (1.5 days [1.2–1.8 days] vs. 1.9 days [1.7–2.1 days]; p = 0.011). Major adverse cardiac and cerebrovascular events occurred with roughly equal frequency (1.8 vs. 5.2%; p = 0.331). Conclusions The use of the Basel Microplegia Protocol was associated with lower peak values of high-sensitivity cardiac troponin-T, creatinine kinase, and creatinine kinase-myocardial type and with a shorter length of stay on the intensive care unit, as compared with the use of Cardioplexol® in isolated coronary artery bypass surgery using minimal extracorporeal circulation.

OBJECTIVES Technical skills are an essential component of cardiac surgery, and the operating room is becoming an even more challenging environment for trainees who want to acquire such skills. Simulation, which partially overcomes this limitation, represents a valid adjunct to surgical education. We describe an original simulator and provide results in terms of trainees’ evaluations and ratings. METHODS We used a humanoid that is a silicone replica of the chest of an adult human that provides a complete anatomical platform for hands-on skin-to-skin practice of surgical techniques in arrested heart coronary artery bypass graft (CABG) surgery cases. Learners were residents in cardiac surgery. The teaching sessions included 2 full three-vessel CABG procedures using both mammary arteries and a hydrogel vein. Five board-certified cardiovascular surgeons scored the surgical activity of all trainees. The trainees were asked to complete an exit questionnaire to evaluate their course. RESULTS Overall, 16 residents participated in the simulation, including 5 women and 11 men, with a mean age of 30 ± 4 years, all of whom had at least 2 years of cardiac surgery training. All participants completed the 2 CABG operations. Three mammary arteries (4.6%) were seriously damaged during harvesting. In 1 case (3.1%), an aortic tear occurred during aortic cannulation. Each trainee performed overall 6 distal and 2 proximal coronary anastomoses. All participants agreed that the ‘humanoid reproduces real-life situations, the feeling is realistic, and they are now more confident in performing coronary anastomosis’. CONCLUSIONS Trainees involved in this simulation curriculum acquired and refined technical skills that could be applied directly to human patients. In addition, we were able to foster a higher level of teamwork within the operating room team., Technical skills are an essential component of cardiac surgery.

In March 2020, a 64-year-old female with mitral valve insufficiency and persistent atrial fibrillation underwent preoperative noninvasive mapping for developing an ablation strategy. In the computed tomography (CT) scan, typical signs of COVID-19 were described. Since the consecutive polymerase chain reaction (PCR) test was negative, the severely symptomatic patient was planned for urgent surgery. Noninvasive mapping showed that atrial fibrillation was maintained by left atrial structures and pulmonary veins only. On admission day, the preoperative routine COVID-19 PCR test was positive, and after recovery, uneventful mitral valve repair with cryoablation of the left atrium and pulmonary veins was performed. Our case describes the potential benefit of preoperative noninvasive mapping for the development of a surgical ablation strategy, as well as the challenges in managing urgent surgical patients during the COVID-19 pandemic and the corresponding diagnostic relevance of CT.

Aims Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG). Methods and results Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P Conclusions Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients. ClinicalTrials.gov registry Number NCT00470587.

Background In Switzerland, long-term circulatory support programs have been limited to heart transplant centers. In 2014, to improve the management of patients with end-stage heart failure not eligible for transplantation, we implemented a left ventricular assist device (LVAD) program for destination therapy at the University Hospital of Basel. Methods We described the program set-up with practical aspects. Patients aged 65 and above with therapy refractory end-stage heart failure without major contraindication for LVAD implantation were included. Younger patients with bridge-to-candidacy profile were also considered. Using the Kaplan-Meier estimate, we retrospectively analyzed the overall survival and freedom from major adverse events after LVAD implantation. We compared our results to internationally reported data. Results Between October 2014 and September 2019, 16 patients received an LVAD in our center. The mean age at implantation was 67.1 years. The mean EuroSCORE II was 24.4% and the median INTERMACS level was 4. Thirteen patients received an LVAD as destination therapy and three patients as bridge-to-candidacy. The overall survival was 87.5 and 70% at 1 and 2 years, respectively. Freedom from stroke was 81.3% at 1 and 2 years. Freedom from device infection was 67.7 and 58.7% at 1 and 2 years, respectively. Freedom from gastrointestinal bleeding was 75 and 56.3% at 1 and 2 years, respectively. Freedom from readmission was 50 and 31.3% and at 6 months and 1 year, respectively. Conclusions The Basel experience demonstrated the possible implementation of an LVAD program for destination therapy or bridge-to-candidacy in a non-transplant comprehensive heart-failure center with midterm survival results and freedom from major adverse events comparable to international registries. Patient selection remains crucial. Trial registration This study was registered on the ClinicalTrials.gov database (NCT04263012).

Mid-term data from a single centre showed the safety and durability of aortic valve neocuspidization using autologous pericardium (OZAKI procedure). Since validation data from other centres are missing, aim of this study was to analyze echocardiographic and clinical results of our first patients that were operated with the OZAKI technique. Thirty-five patients (24 males, median (IQR) age 72.0 (59.0, 76.0) years) with aortic stenosis (AS; n = 10), aortic insufficiency (AR; n = 13) or a combination of both (AS/AR; n = 12), underwent aortic valve neocuspidization in our institution between September 2015 and May 2017. Echocardiographic follow-up was performed using a standardized examination protocol. Clinical follow-up was completed in 97% of the patients. Median (IQR) follow-up time was 645 (430, 813) days. Mortality rate was 9% (n = 1: aspiration pneumonia; n = 1: unknown; n = 1: anaphylactic shock), and the reoperation rate was 3% (n = 1: endocarditis). No pacemaker implantation was necessary after isolated OZAKI procedures. Echocardiographic follow-up was performed in 83% of the patients (n = 29; median (IQR) time 664 (497, 815) days). Median (IQR) mean and peak gradients were 6 (5,9) mmHg and 12 (8, 17) mmHg. Moderate aortic regurgitation was seen in 2 patients (7%). No severe aortic regurgitation or moderate or severe aortic stenosis occurred within the follow-up period. The OZAKI procedure is reliable and reoperation due to structural valve deterioration nil within a median 645 days follow-up period. The low rate of moderate aortic regurgitation will be surveilled very closely. Further studies are required to evaluate the significance of this procedure in aortic valve surgery. ClinicalTrials.gov (ID NCT03677804)

Background. To compare the performance of our institutionally refined microplegia protocol in conjunction with minimal extracorporeal circulation system (MiECC) with off-pump coronary artery bypass grafting (OPCAB). Methods. We conducted a single center study including patients undergoing isolated CABG surgery performed either off-pump or on-pump using our refined microplegia protocol in conjunction with MiECC. We used propensity modelling to calculate the inverse probability of treatment weights (IPTW). Primary endpoints were peak values of high-sensitivity cardiac troponin T (hs-cTnT) during hospitalization, and respective first values on the first postoperative day. Endpoint analysis was adjusted for intraoperative variables. Results. After IPTW, we could include 278 patients into our analyses, 153 of which had received OPCAB and 125 of which had received microplegia. Standardized differences indicated that treatment groups were comparable after IPTW. The multivariable quantile regression yielded a nonsignificant median increase of first hs-cTnT by 39 ng/L (95% CI -8 to 87 ng/L, p=0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p=0.16), when microplegia was used, as compared to OPCAB. Major adverse cardiac and cerebrovascular events (MACCE) occurred with equal frequency in both groups (7.8% vs. 5.0%; p=0.51), and length of stay in the intensive care unit (ICU) was significantly shorter after the use of microplegia (geometric mean 1.6 days versus 1.3 days; p=0.01). Conclusion. The use of our institutionally refined microplegia in conjunction with MiECC was associated with similar results with regard to ischemic injury, expressed in hs-cTnT compared to OPCAB. MACCE was seen equally frequent. ICU discharge was earlier if microplegia was used.

The aim was to evaluate the impact of a modified frozen elephant trunk procedure (mFET) on remodeling of the downstream aorta following acute aortic dissections. Over a period of 8 years, 205 patients (mean age 62.6 ± 12.6 years) underwent a mFET (n = 69, 33.7%) or isolated ascending aorta replacement (n = 136, 66.3%) (iAoA). Aortic diameter was assessed at the aortic arch (AoA), at the mid of the thoracic aorta (mThA), at the thoracoabdominal transition (ThAbd) and at the celiac trunk level (AbdA). Mean follow-up was 3.3 ± 2.6 years. In-hospital mortality was 14% (n = 28), 7% in mFET and 17% in the iAoA group (p = 0.08). At the end of the follow-up, overall survival was 84% (95% CI 70–92%) and 75% (65–82%) and freedom from aorta-related reoperation was 100% and 95% (88–98%) for mFET and iAoA, respectively. At iAoA, the average difference in diameter change per year between mFET and iAoA was for total lumen 0 mm (− 0.95 to 0.94 mm, p = 0.99), and for true lumen, it was 1.23 mm (− 0.09 to 2.55 mm) per year, p = 0.067. False lumen demonstrated a decrease in diameter in mFET as compared to iAoA by − 1.43 mm (− 2.75 to − 0.11 mm), p = 0.034. In mFET, at the aortic arch level the total lumen diameter decreased from 30.7 ± 4.8 mm to 30.1 ± 2.5 mm (Δr + 2.90 ± 3.64 mm) and in iAoA it increased from 31.8 ± 4.9 to 34.6 ± 5.9 mm (Δr + 2.88 ± 4.18 mm). The mFET procedure provides satisfactory clinical outcome at short term and mid-term and has a positive impact on aorta remodeling, especially at the level of the aortic arch.

Background. Single-dose cardioplegia is preferred in minimal invasive mitral valve surgery to maintain the adjustment of the operative site without change of preset visualization. The aim of our study was to compare two widely used crystalloid cardioplegias Bretschneider (Custodiol®) versus St. Thomas 2 in patients who underwent mitral valve repair via small anterolateral right thoracotomy. Material and Methods. From May 2012 until February 2019, 184 isolated mitral valve procedures for mitral valve repair via anterolateral right thoracotomy were performed using Bretschneider (Custodiol®) cardioplegia (n=123) or St. Thomas (n=61). Primary efficacy endpoint was peak postoperative high-sensitivity cardiac troponin (hs-cTnT) during hospitalization. Secondary endpoints were peak creatine kinase-muscle brain type (CK-MB) and creatine kinase (CK) as well as safety outcomes. We used inverse probability of treatment weighting (IPTW) in order to adjust for confounding by indication. Results. Peak hs-cTnT was higher after use of Bretschneider (Custodiol®) (geometric mean 716 mg/L, 95% confidence interval (CI) 605-847 mg/L) vs. St. Thomas 2 (561 mg/L, CI 467-674 mg/L, p=0.047). Peak CK-MB (geometric mean after Bretschneider (Custodiol®): 40 μg/L, CI 35-46, St. Thomas 2: 33 μg/L, CI 27-41, p=0.295) and CK (geometric mean after Bretschneider (Custodiol®): 1370 U/L, CI 1222-1536, St. Thomas 2: 1152 U/L, CI 972-1366, p=0.037) showed the same pattern. We did not see any difference with respect to postoperative complications between treatment groups after IPTW. Conclusion. Use of St. Thomas 2 cardioplegia was associated with lower postoperative peak levels of all cardiac markers that reflect cardiac ischemia such as hs-cTnT, CK, and CK-MB as compared to Bretschneider (Custodiol®) in propensity-weighted treatment groups.

We studied myocardial protection during coronary artery bypass graft surgery using low-volume cardioplegia (Cardioplexol) and minimal extracorporeal circulation (MECC) for different types of coronary artery diseases. In total, 426 consecutive patients were included and divided into four groups: those with left main stem stenosis (n = 45), those with three-vessel disease (n = 200), those with both (n = 141), and those with neither (n = 40). The peak postoperative myocardial markers and 30-day mortality were analyzed. Both myocardial markers and 30-day mortality were significantly elevated in patients with isolated main stem stenosis. We conclude that the use of low-volume cardioplegia and MECC is safe. However, patients with underlying isolated left main stem stenosis might be less protected.

This systemic review of the literature and meta-analysis examined the current state of the evidence in long-term outcomes for and/or against aortic valve reimplantation (RAV) versus composite valve graft (CVG) intervention in patients with an acute type A dissection. Descriptive statistics were used to summarize the baseline characteristics of patients across studies. A random-effects metaregression was performed across study arms with logit-transformed proportions weighted by the study size for each of these outcomes. The results are presented as odds ratios with the RAV procedure as compared to the CVG procedure, including 95% confidence intervals (CIs) and P-values. Further outcomes are summarized with medians, interquartile ranges and the range and number of patients at risk. A total of 27 retrospective studies that included a combined 3058 patients were analysed. In-hospital mortality was in favour of the RAV procedure, which was 2% vs 8% for the CVG procedure. Survival rate at midterm was 98.8% (95% CI 91.7-100%) for RAV and 81.3% (CI 78.5-83.9%) for CVG. Freedom from valve-related reintervention was 100% (CI 93.7-100%) for RAV and 94.6% (CI 86.7-99.1%) for CVG. For an acute type A aortic dissection in the mid-term period, RAV provides a superior outcome over CVG, both in terms of aortic-valve-related reintervention and survival rate.

Background The aim was to evaluate the impact of aortic root (AoR) annuloplasty on 3D AoR deformation. Methods In experimental setup, Yacoub procedure and Yacoub with annuloplasty were performed. Results were compared to native AoR. In each AoR modality, six microsonometric (2 mm, 200 Hz) crystals were implanted at the sinotubular junction (STJ) and at the AoR base (AoB). 3D deformation of the AoR was determined by AoR tilt (α) and rotation (β) angle changes. Results Tilt angle in Yacoub AoR with annuloplasty and in Yacoub AoR was maximal at ejection, 26.71 ± 0.18° and 24.91 ± 0.13°, respectively, and minimal at diastole, 25.34 ± 0.15° and 21.90 ± 0.15°, respectively. Rotation angle in Yacoub AoR with and without annuloplasty was maximal at ejection, 27.04 ± 0.25° and 23.53 ± 0.54°, respectively, and minimal at diastole, 24.84 ± 0.14° and 21.62 ± 0.16°, respectively. In native AoR, tilt angle and rotation were minimal at ejection, 14.34 ± 0.81° and 18.1 ± 3.20°, respectively, and maximal at diastole, 18.78 ± 0.84° and 21.23 ± 021°, respectively. AoB and STJ had maximal expansion at ejection; 2.59 ± 2.40% and 6.05 ± 0.66 for Yacoub and 3.75 ± 0.66% and 3.08 ± 0.24% for Yacoub with annuloplasty. In native AoR, the expansion at ejection for AoB was 7.13 ± 2.68% and for STJ was 16.42 ± 0.63%. Conclusions AoB annuloplasty reduces AoB deformation and has an impact on STJ dynamics. In both the Yacoub AoR modalities, during ejection, the AoR takes on more of a cone-like geometry, whereas in native AoR, it is of a cylinder-like shape.

The aim was to evaluate the impact of a bicuspid aortic valve (BAV) on local shear stress and on the pressure profile on the elements of the aortic root (AoR). The experiment setup included a BAV with aortic valve stenosis (n = 5 pigs, 67 ± 3.5 kg) and insufficiency (n = 5 pigs, 66.7 ± 4.4 kg). By implanting 6 high-fidelity microsonometric crystals in each AoR, we determined the 3-dimensional (3D) geometry of the AoR. Experimental and geometric data were used to create a 3D time- and pressure-dependent computed fluid dynamic model of the AoR with the BAV. 3D AoR geometry was determined by AoR tilt (α) and rotation angle (β). Both values were maximal at the end of diastole: 24.41 ± 1.70° (α) and 20.90 ± 2.11° (β) for BAV with stenosis and 31.92 ± 11.51° (α) and 20.84 ± 9.80° (β) for BAV with insufficiency and minimal at peak ejection 23.42 ± 1.65° (α), 20.38 ± 1.61° (β) for stenosis and 26.62 ± 7.86° (α), 19.79 ± 8.45° (β) for insufficiency. In insufficiency, low shear stress of 0-0.08 Pa and moderate pressure (60-80 mmHg) were present. In BAV with stenosis, low shear stress of 0-0.5 Pa and moderate pressure (0-20 mmHg) were present at diastole; at peak ejection high shear stress >2 Pa and elevated pressure of >80 mmHg were present. In a BAV with aortic valve stenosis, the haemodynamics are less favourable. The elevated pressure with elevated shear stress may over the long term promote degenerative processes in the leaflets and consequently valve function failure.

Background Mechanical chest compression using a piston device during reanimation is often the only way to ensure stable chest compression at a constant rate and force. However, its use can be associated with severe fractures of the thoracic rib cage and endanger the clinical course of the patient. Thus, the usage of such a piston device during the reanimation has currently been classified as a mere Class IIB indication. Case presentation We present a case of a 66-year-old male who underwent emergent CABG surgery after receiving out-of-hospital resuscitation as a result of myocardial infarction using the LUCAS system. Due to severe bilateral rib fractures a concomitant emergency chest-wall stabilization surgery had to be performed to ensure uncompromised graft flow to obtain stable cardiac function and hemodynamics. Conclusions Reanimation using LUCAS-System might enable stable resuscitation conditions. However, it is crucial not to underestimate potential collateral damage which can in turn aggravate patient’s clinical condition.

OBJECTIVES We investigated the impact of mechanical unloading with a left ventricular assist device (LVAD) on the myocardial proteome. METHODS We collected 11 patient-matched samples of myocardial left ventricular tissue of patients with non-ischaemic dilate cardiomyopathy, harvested at time of LVAD implant ('pre-LVAD') and heart transplant ('post-LVAD'). Samples were studied by quantitative proteomics. Further we performed histological assessment of deposited collagens and immune infiltration in both pre- and post-LVAD samples. RESULTS A core set of >1700 proteins was identified and quantified at a false discovery rate

Objectives To evaluate whether the modified frozen elephant trunk (mFET) procedure provides comparable outcome compared with the standard approach for DeBakey type I aortic dissection. Methods From November 2008 to December 2018, 262 (mean age 62.7 ± 12.4 years) patients with acute DeBakey type I aortic dissection were included. mFET was performed in 100 (38.2%) patients and isolated ascending aorta and hemiarch replacement (iAoA) were performed in 162 (61.8%). Outcome analyses included in-hospital mortality, stroke rate, incidence of composite cardiovascular events, survival, freedom from aorta-related intervention, as well as freedom from neurologic event. Inverse probability of treatment weighting was applied. Results After inverse probability of treatment weighting, in-hospital mortality was greater in the iAoA group. The incidence of cardiac cause of death, new postoperative renal failure, as well as stroke rate were similar in both groups. The survival at 1 year, 3 years, and 4 years was 84%, 81%, and 77%, respectively, in the iAoA group and 91%, 86%, and 86%, P = .025, respectively, in the mFET group. Cause-specific HR for aortic reoperation 1.03 (confidence interval [CI], 0.43-2.48, P = .95) and neurovascular event 2.72 (CI, 0.62-11.93, P = .19) was similar in 2 groups. Subhazard ratio (sHR) for mortality as competing outcome for aorta-related reintervention sHR of 0.52 (CI, 0.32-0.86, P = .011) and neurologic event sHR of 0.45 (95% CI, 0.26-0.76, P = .003) was significantly lower in mFET. Conclusions The mFET procedure as surgical treatment modality for DeBakey type I acute aortic dissection may be considered as viable alternative with beneficial mid-term outcome.

BACKGROUND Our aim was to investigate the impact of the non-skeletonized (pedicled) versus the skeletonized left internal mammary (LIMA) harvesting technique on the postoperative sternal and parasternal skin perfusion in patients undergoing coronary artery bypass grafting (CABG), as compared to patients undergoing non-CABG heart surgery. METHODS We included 142 patients who underwent non-bypass (N.=39) or CABG surgery (N.=103). CABG cases were differentiated according to the LIMA harvesting technique: skeletonized (N.=74) or non-skeletonized (N.=29). Parasternal and sternal skin perfusion measurements via a Laser Doppler Imaging tool were performed on the preoperative day and 5-7 days postoperatively, using a grid of 15 spatially segregated measurement points across the chest and normalization to a distinct reference point. Data were analyzed retrospectively. RESULTS In the CABG group, the non-skeletonized LIMA harvesting resulted in a near-significant (P=0.057, two-sided Student t-test, 95% CI -[0.111, 0.002]), and the skeletonized LIMA harvesting in a significant (P< 0.001, 95% CI [-0.096, -0.032]) post-surgical decrease of left-sided parasternal skin perfusion in arbitrary perfusion units (APU), as compared to right-sided parasternal skin perfusion. No corresponding differences were found for the non-bypass group (P=0.5, 95% CI [-0.065, 0.033]). The harvesting techniques did not yield significantly different post-surgical parasternal skin perfusion measures in the CABG group (P=0.6). CONCLUSIONS Measurement of parasternal skin perfusion using Laser Doppler Imaging is feasible. Both harvesting techniques resulted in a reduced parasternal/sternal skin perfusion upon removal of the internal mammary artery.

Post‐operative right coronary artery occlusion is a serious complication that demands acute coronary revascularization to prevent myocardial infarction. We present two cases with acute right coronary artery obstruction caused by (1) transfemoral aortic valve implantation and (2) acute type A aortic dissection. Although coronary artery bypass grafting was performed intraoperatively, right heart failure was observed in both cases. The Impella RP® device offers temporary right ventricular mechanical support; wherefore, we decided to deploy it in both patients. The devices were uneventfully and successfully implanted to bridge for recovery of the right heart. We report the perioperative course of the patients as well as their condition at 1 year follow‐up.

Afternoon aortic valve replacement surgery may provide perioperative myocardial protection and improve patient outcomes compared with morning surgery. The results of our large observational study based on Swiss cardiac surgical site infection surveillance data suggest that the current evidence is insufficient to generally promote afternoon cardiac surgeries.