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BACKGROUND A neurocognitive decline is an undesirable event that can be observed in patients after cardiac surgery. It has been related to the use of cardiopulmonary bypass (CPB). Minor embolic or hyperinflammatory mechanisms are thought to be responsible. In this issue of the Journal of Cardiac Surgery, the neurocognitive decline was observed in 22 of 30 patients after cardiac surgery with CPB. Repeatable neuropsychological status tests were used and scores 4 days after surgery were 5%-15% lower than before. Mechanistic investigations with glycemic control and transcriptomic and cytokine analyses failed to provide an explanation but the frequency of this observation is worrisome. DISCUSSION However, available evidence suggests that neurocognitive dysfunction disappears within a few months, and later on no difference to controls that did not undergo surgery can be detected. In addition, similar degrees of neurocognitive dysfunction can be observed after noncardiac surgery and even after percutaneous coronary intervention (PCI). A most recent comparison of memory decline after CABG and PCI also suggests no difference between the two invasive treatment options for coronary artery disease. All these findings argue against a primarily CPB-associated mechanism. Interestingly, test subjects from a consumer investigation showed a 10% decline in their working memory just by placing their cell phone on the table, suggesting that being distracted may also affect neurocognitive function. Given the reversibility of surgery- and intervention-associated neurocognitive dysfunction, we question destructive, embolic, or inflammatory-associated mechanisms. Distractive aspects of intervention-associated stress may also play a role. CONCLUSION In any case, neurocognitive decline after cardiac surgery does not appear to be surgery-specific.

Objectives: Non-ST-elevation acute coronary syndrome (NSTE-ACS) affects millions of patients. Although an invasive strategy can improve survival, the optimal treatment (i.e., percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) is not clear. We performed a meta-analysis of studies reporting outcomes between PCI and CABG in patients with NSTE-ACS.Methods: MEDLINE, EMBASE and Cochrane Library were assessed. The primary outcome was long-term mortality. Inverse variance method and random model were performed.Results: We identified 13 observational studies (48,891 patients). No significant difference was found in the primary endpoint (CABG vs. PCI, incidence rate ratio [IRR]= 0.93, 95% confidence interval [CI] 0.70; 1.23). CABG was associated with lower long-term major adverse cardiovascular events (MACE) (IRR= 0.64, 95% CI 0.54; 0.76) and lower long-term re-revascularization (IRR= 0.37, 95% CI 0.30; 0.47). There was no significant difference in long-term myocardial infarction (CABG vs. PCI, IRR= 0.96, 95% CI 0.50; 1.84) and peri-operative mortality (CABG vs. PCI, odds ratio [OR]= 1.36, 95% CI 0.94; 1.95).Conclusion: For the treatment of NSTE-ACS, CABG and PCI are associated with similar rates of long-term mortality and myocardial infarction. CABG is associated with lower rates of long-term MACE and re-revascularization. Randomized comparisons in this setting are necessary.

In 2020, nearly 30,000 published references appeared in the PubMed for the search term “cardiac surgery.” While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information.

Wie im letzten Jahr wird eine Ubersicht uber interessante und relevante Literatur aus dem Bereich der Klappenchirurgie – im vorliegenden Beitrag fur das Jahr 2018 – prasentiert. Therapieentscheidungen bei Vorliegen einer relevanten Aortenklappenerkrankung sind gepragt von Empfehlungen aus individuellen Entscheidungen im Herzteam, mit immer starker werdender Evidenz fur die „transcatheter aortic valve implantation“ (TAVI) bei niedrigem Risiko, ohne dass bisher zwingend benotigte Langzeitergebnisse vorliegen. Es wird in diesem Abschnitt nur auf die TAVI-Publikationen eingegangen, die unmittelbare Relevanz fur die klassischen chirurgischen Verfahren aufweisen, die ansonsten im vorliegenden Beitrag hauptsachlich beleuchtet werden. Die Publikationen im Bereich der Atrioventrikularklappen lieferten neue Erkenntnisse zur Pravalenz von Mitral- und Trikuspidalinsuffizienz und unterstrichen damit die bekannten Aussagen, dass eine Mitralklappenrekonstruktion bei struktureller Mitralinsuffizienz die Lebenserwartung steigern kann. Bei funktioneller Mitralinsuffizienz hat v. a. die Publikation der Studien MITRA FR und COAPT im Zusammenhang mit dem MitraClip grose Aufmerksamkeit erregt. Auserdem unterstutzen weitere Studienergebnisse die aggressive Therapie der isolierten Trikuspidalinsuffizienz. Diese Aspekte werden im Folgenden erlautert, obwohl Ubersichten wie diese nie komplett oder frei von personlicher Neigung sein und nie alle potenziell relevanten Arbeiten berucksichtigen konnen. Unter diesem Caveat wunschen die Autoren Freude beim Lesen.

In den letzten Jahren hat sich im therapeutischen Bereich der stabilen koronaren Herzkrankheit (KHK) die folgende Erkenntnis kontinuierlich konsolidiert: Die Bypass-Chirurgie bleibt der Goldstandard bei komplexer KHK, insbesondere bei Dreigefaserkrankung mit oder ohne Hauptstammbeteiligung. Sie ist die einzige Therapieform, die nach den aktuellen Daten das Potenzial birgt, das Leben des Patienten zu verlangern. Die Bypass-Operation kann damit eine prognostische Indikation haben. Die 2018 neu erschienenen Leitlinien zur Myokardrevaskularisation haben die Unterscheidung zur perkutanen Koronarintervention (PCI) jetzt genauer differenziert und geben erstmals Empfehlungen zu operativen Details der Revaskularisation. Der Fokus dieser Literaturubersicht liegt auf den chirurgisch relevanten Aspekten. Weitere therapierelevante Informationen zu Diagnostik und medikamentoser Therapie sind ebenfalls ubersichtlich zusammengefasst. Die aus dem Jahr 2018 masgebliche Literatur zur chirurgischen Revaskularisation lasst sich in folgende Punkte untergliedern: 1. PCI vs. Bypass-Chirurgie, 2. neue diagnostische Verfahren fur die Bypass-Chirurgie, 3. Rolle der medikamentosen Therapie fur die Bypass-Chirurgie und 4. technische Aspekte der Bypass-Chirurgie.

For the year 2018, more than 22,000 published references can be found in PubMed when entering the search term "cardiac surgery". As in the last 4 years, this review focusses on conventional cardiac surgery publications which provide important and interesting information especially relevant for non-surgical colleagues. Interventional techniques have been considered if they were published in the context of classic surgical techniques. We have again reviewed the fields of coronary revascularization and valve surgery and briefly touched on aortic surgery and surgery for terminal heart failure. For revascularization of complex coronary artery disease, bypass grafting was reconfirmed as gold standard and computer-tomographic angiography established equipoise for decision-making with classic angiography. For aortic valve treatment, some new longer-term outcomes from TAVI vs. SAVR trials confirmed equipoise of both treatments for high and medium risk. New information was provided for INR-management of mechanical aortic valves as well as long-term experiences for alternatives to mechanical valves (i.e., Ross and the relatively new Ozaki procedure). In the mitral and tricuspid field, prevalence data illustrate a significant amount of under-treatment for mitral and tricuspid valve regurgitation and evidence for life prolonging-effects of surgery. Finally, elongation of the ascending aorta was identified as new risk factor for aortic dissection and 2 years outcome of the newest generation of left ventricular assist devices demonstrate impressive improvements in outcome. While this article attempts to summarize the most pertinent publications, it does not expect to be complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery and a stimulus for in-depth reading.

Objectives Minimally invasive surgery is increasingly performed for isolated aortic or mitral valve procedures. However, combined minimally invasive aortic and mitral valve surgery is rare. We report our initial experience performing multiple valve procedures through a right-sided mini-thoracotomy (RMT) compared with sternotomy. Methods A total of 264 patients underwent aortic and mitral with or without tricuspid valve surgery through RMT (n = 25) or sternotomy (n = 239). Propensity score matching was used for outcome comparisons. Results Of the 264 patients, 25 (age: 72 ± 10 years; 72% male) underwent double (n = 19) and triple valve surgery (n = 6) through RMT and 239 (age: 71 ± 11 years; 54% male) underwent double (n = 176) and triple valve surgery (n = 63) through sternotomy. Sternotomy patients had more co-morbidities and preoperative risk factors (EuroSCORE II 10.25 ± 10.89 vs. RMT 3.58. ± 4.98; p Conclusion Combined aortic plus mitral with or without tricuspid valve surgery can safely be performed through a RMT with a trend toward better mid-term outcomes.

Objective New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery. Methods We performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted. Results POAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66). Conclusions The results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.

Background Device complications in complex percutaneous coronary interventions are rare but potentially deadly. Surgical removal is often required. However, an evaluation of surgical therapy beyond case reports is practically not existent. Methods We prospectively followed all cases of retained guide wires and/or other devices referred to us for surgical removal between 2015 and 2019 and retrospectively searched our database for such cases between 2010 and 2014. Results From 2015 on, eight cases were referred for surgical removal from six different cardiology departments. In the 5 years before, there was not a single case. Six patients were operated emergently. Patients were 60.5 ± 5.42 years old, overweight (body mass index 30.1 ± 3.77) and except for one case (left ventricular-assist device) showed preserved ejection fraction (EF) (mean EF 57 ± 18.01). The retained devices were mostly located in the right coronary artery (50%), followed by the circumflex artery (37.5%) and diagonal branch (12.5%). The devices were remnants of guide wires (n = 4), balloon catheters (n = 3), and in one case a rotablator. Full sternotomy was performed in six patients and two received a left-sided minithoracotomy (n = 2). The operations were performed on-pump in five (62.5%) and off-pump in three patients. Complete extraction of the foreign bodies was possible in all patients. Two patients died; one in unrelated multiorgan failure and one due to retained-device-related right heart failure. The other patients survived and had uneventful postoperative courses. Conclusions Retained foreign bodies from cardiac interventions can be completely removed surgically using individualized approaches. There appears to be a trend toward a rising incidence of such interventional complications.

For the year 2019, almost 25,000 published references can be found in PubMed when entering the search term “cardiac surgery.” We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach for article selection and reviewed the main fields of adult cardiac surgery (i.e., coronary, valve, aortic, and heart failure surgery). The past decade has experienced an enormous development of interventional techniques that compete more and more with classic surgery. This contest was broadly visible in 2019. It peaked over the interpretation of the EXCEL trial data, where percutaneous coronary intervention and coronary artery bypass grafting (CABG) for left main disease were compared. A novel pathomechanism for CABG was proposed, potentially answering open questions in the field. In aortic valve surgery, two low-risk trials comparing transcatheter aortic valve implantation (TAVI) to classic aortic valve replacement (surgical aortic valve replacement) received attention for showing equal or superior short-term outcomes for TAVI. Longer follow-up information from recent trials became available presenting results emphasizing the need for joint decision making. While publications addressing surgery on the aorta and the mitral and tricuspid valves were less abundant, there was substantial activity regarding left ventricular assist device support and heart transplantation. This article attempts to summarize the most pertinent publications. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide a condensed summary of 2019s publications with a stimulus for in-depth reading and a basis supporting patient information.

Introduction Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor. Methods We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including “surgeon” as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients). Results Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan–Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis. Conclusion The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term "cardiac surgery". This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

Die Koronarchirurgie ist ein wichtiger Bestandteil der Behandlung der koronaren Herzkrankheit (KHK). Seit der Einfuhrung der perkutanen Koronarintervention (PCI), speziell der „drug-eluting stents“, nimmt die Zahl der koronaren Bypass-Operationen kontinuierlich ab. Bisher hat keine Studie gezeigt, dass eine elektive Koronarintervention das Uberleben der Patienten verlangern oder das Auftreten neuer Herzinfarkte verringern kann. Die Bypass-Operation ist die einzige Therapieform, die diese Wirkung haben kann. Allerdings wird dieser Effekt von vielen Faktoren beeinflusst und ist v. a. bei Patienten mit komplexer KHK sichtbar. Das ist der Grund dafur, dass in den aktuellen Guidelines die PCI der Bypass-Operation bei weniger ausgepragter KHK (niedrigem SYNTAX-Score) therapeutisch gleichgestellt ist und dass die Bypass-Operation primar bei Patienten mit komplexer KHK (hoher SYNTAX-Score) empfohlen wird. Zu den Faktoren, die die Ergebnisse nach Bypass-Operation und die Langzeitoffenheitsraten beeinflussen, ist 2017 viel Interessantes publiziert worden. Folgende Aussagen werden unterstutzt: 1. Die Bypass-Operation bei komplexer Mehrgefaserkrankung beinhaltet einen moglichen Uberlebensvorteil gegenuber PCI und medikamentoser Therapie und bleibt der Goldstandard. 2. Die vollarterielle Revaskularisation ist mit den besten Ergebnissen verbunden. 3. „Off-pump“-Techniken konnen v. a. bei Vermeidung von Aortenmanipulationen der „On-pump“-Technik uberlegen sein. Die Ergebnisse scheinen abhangig vom Operateur zu sein. 4. Die nichtinvasive bildgebende Koronarcomputertomographie (Koronar-CT) nimmt einen immer groseren Stellenwert ein und kann die Entscheidungsfindung bei der Therapie der KHK stark beeinflussen.

For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term "cardiac surgery". The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

Purpose Cardiac implantable electronic device infections (CIED) reflect life threatening complication for LVAD patients. Despite antibiotic treatment removal or exchange of all foreign surfaces may be required for cure. However, there is limited published data and we here present to our knowledge the largest case series of CIED removal in LVAD patients. Methods Since 2011, 161 patients underwent LVAD Implantation at our institution. We identified 7 patients who underwent infection related CIED removal and report outcome. Patient and infection characteristics, management strategy, and clinical outcomes are described. Results Of the 7 patients one was female; mean age was 54 years (range 42-64). Three of 7 patients had an ischemic cardiomyopathy, and 2 of 7 patients had a continuous flow LVAD placed as destination therapy. All patients presented with clinical signs of infection, lead-related endocarditis and vegetations. In one patient additional pocket infection was present. Causative pathogens included staphylococcus aureus (1), staphylococcus epidermidis (1), enterococcus faecalis (1), candida albicans (2), and culture negative (2). All patients underwent laser assisted complete CIED removal along with antimicrobial therapy. The mean implanted age of the removed leads was 5 years (2-10 years), and 3 of the 7 patients experienced a procedural complication (pocket hematoma) from CIED removal. Infection was successfully treated in all patients, except one. No re-occurrence of endocarditis was observed and no LVAD exchange was needed. One patient died within 30 days after CIED explantation due to multi organ failure and persistent sepsis. Five patients remained alive at latest follow-up with a median duration of 15 months (0.1-55 months) from the time of CIED explantation. Conclusion Complete CIED removal combined with optimal antimicrobial therapy may be an effective and safe therapy for CIED infections in LVAD patients.

Background Isolated tricuspid valve (TV) surgery is considered a high risk-procedure. The optimal surgical approach is controversial. We analyzed our experience with isolated TV redo surgery performed either minimally invasively (redo-MITS) or through sternotomy. Methods We retrospectively analyzed all patients with previous cardiac surgery who underwent redo-MITS (n = 26) and compared them to redo-Sternotomy (n = 17). A group of primary-MITS (n = 61) served as control. Results The redo-MITS approach consisted of a right anterolateral mini-thoracotomy, transpericardial right atrial access, and beating heart TV surgery without caval occlusion. Redo-MITS patients were oldest and had the most comorbidities (EuroScore II: 9.83 ± 6.05% versus redo-Sternotomy: 8.42 ± 7.33% versus primary-MITS: 4.15 ± 4.84%). There were no intraoperative complications or conversions to sternotomy in both MITS groups. Redo-Sternotomy had the highest 30-day mortality (24%), the poorest long-term survival, and the highest perioperative complication rate. Redo-MITS did not differ in perioperative outcome from primary-MITS. Multivariable logistic regression analysis identified redo-Sternotomy (odds ratio [OR] = 9.76; 95% confidence interval [CI] 1.88–63.26), liver cirrhosis (OR = 9.88; 95% CI 2.20–54.20), and body mass index (BMI) (OR = 1.16; 95% CI 1.02–1.35) as independent predictors of 30-day mortality. The Cox model revealed redo-Sternotomy (hazard ratio [HR] = 2.67; 95% CI 1.18–6.03), liver cirrhosis (HR = 3.31; 95% CI 1.45–7.58), and pulmonary hypertension (HR = 2.26; 95% CI 1.04–4.92) as risk factors for poor long-term survival. TV surgery significantly reduces NYHA class. Conclusion Minimally invasive, isolated TV surgery as reoperation without caval occlusion and on the beating heart can be safe and may improve clinical outcome.

For the year 2014, more than 17,000 published references can be found in Pubmed when entering the search term "cardiac surgery". The last year has been characterized by a vivid discussion in the fields where classic cardiac surgery and modern interventional techniques overlap. Specifically, there have been important contributions in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery as well as in the fields of interventional valve therapy. Here, the US core valve trial with the first demonstration of a survival advantage at 1 year with transcatheter valves compared to surgical aortic valve replacement or the 5-year outcome of the SYNTAX trial with significant advantages for bypass surgery has been the landmark. However, in addition to these most visible publications, there have been several highly relevant and interesting contributions. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices) and aortic surgery. This condensed summary will provide the reader with "solid ground" for up-to-date decision-making in cardiac surgery.

Background Coronary artery bypass surgery can be performed without (Off-Pump) or with cardiopulmonary bypass (On-Pump). Extracorporeal circulation and cardioplegic arrest may cause alterations in the plasma metabolome. We assessed metabolomic changes in patients undergoing On-Pump or Off-Pump coronary artery bypass surgery. Methods We assessed five analyte classes (41 acylcarnitines, 14 amino acids, 92 glycerophospholipids, 15 sphingolipids, sugars, lactate) using a mass-spectrometry-based kit (Biocrates AbsoluteIDQ® p150) in paired arterial and coronary sinus blood obtained from 10 consecutive On-Pump and 10 Off-Pump patients. Cardioplegia for On-Pump was warm blood Calafiore. On-Pump outcomes were corrected for hemodilution through crystalloid priming. Results Demographic data were equal in both groups with normal ejection fraction, renal and liver function. Patients received 2.25 ± 0.64 bypass grafts. All postoperative courses were uneventful. Of 164 measured metabolites, only 13 (7.9%) were altered by cardiopulmonary bypass. We found more long-chain acylcarnitines Off-Pump and more short-chain acylcarnitines On-Pump. Glycerophospholipids showed lower concentrations On-Pump and arginine (as the only different amino acid) Off-Pump. Interestingly, plasma arginine (nitric oxide precursor) concentration at the end of surgery correlated inversely with postoperative vasopressor need (r = −0.7; p

Table S1. List of metabolites used in the analysis and corresponding abbreviations. (DOCX 27 kb)

Das hamodynamische Ergebnis nach Aortenklappenersatz (AKE) mit einer Klappenprothese wird durch das Design und die prothesenspezifische Strategie zur Grosenauswahl („sizing“) beeinflusst. Das Design bestimmt die tatsachliche Offnungsflache der Prothese relativ zum Ausendurchmesser, wahrend durch das Sizing die Grose der jeweilig zu implantierenden Klappe festgelegt wird. Derzeitig wird das hamodynamische Ergebnis dieser Prozedur durch Messung der Restgradienten (nach Bernoulli) und/oder mit der effektiven Offnungsflache („effective orifice area“, EOA) bestimmt. Die EOA wird mithilfe der Kontinuitatsgleichung aus der Flussgeschwindigkeit des Blutstroms und der Querschnittsflache des linksventrikularen Ausflusstrakts („left ventricular outflow tract area“, LVOTA) bestimmt und entspricht einer virtuellen Offnungsflache der Klappe in dem jeweiligen Patienten. Sie stimmt nicht unbedingt mit der maximalen Offnungsflache der vorhandenen Klappe uberein. Unabhangig von dieser Erkenntnis wird die Frage, ob eine Klappenprothese die angemessene Grose fur den Patienten aufweist, derzeit durch eine Beziehung der EOA auf die Korperoberflache beantwortet [“effective orifice area indexed“ (EOAi)]. Die Klappe wird als zu klein eingestuft, wenn ein moderates (EOAi zwischen 0,65 und 0,85 cm2/m2) oder schweres (EOAi ≤ 0,65 cm2/m2) Patient-Prothese-Missverhaltnis (PPM) vorliegt. Derzeit bestreitet etwa die Halfte der Publikationen zu diesem Thema eine Auswirkung eines so gemessenen PPM auf das Langzeituberleben. Es ist aber gut moglich, dass eine Messproblematik Ursache fur diese Kontroverse ist. Der vorliegende Beitrag beschreibt die derzeitigen Standards in der Bewertung der Hamodynamik nach Klappenersatz und weist auf die Probleme in der Messmethode und der Bewertung von PPM hin. Weiterhin wird die Prosthesis-Annulus-Relation(PAR)-I-Studie vorgestellt, die ein neues Konzept zu Bewertung und Vorhersage von hamodynamischen Ergebnissen und von PPM beinhaltet.

[Figure][1] [![Graphic][3] ][3] We show autopsy images of a deformed Edwards Sapien XT (Edwards Lifesciences Corp., Irvine, California) valve from a patient requiring cardiopulmonary resuscitation (CPR) 5 days after uneventful transapical valve implantation. Postoperative