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The coronavirus disease 2019 (COVID-19) pandemic continues to disrupt the provision of cardiac procedural services due to overwhelming interval surges in COVID-19 cases and the associated crisis of cardiac intervention deferment. Despite the availability of widespread testing, highly efficacious vaccines, and intensive public health efforts, the pandemic is entering its third year, where new severe acute respiratory syndrome-coronavirus-2 variants have increased the likelihood that patients scheduled for a cardiac intervention will contract COVID-19 in the perioperative period. The Society of Thoracic Surgeons (STS) Workforce on Critical Care, the STS Workforce on Adult Cardiac and Vascular Surgery, and the Canadian Society of Cardiac Surgeons have developed this document, endorsed by the STS and affirmed by the Society of Cardiovascular Angiography and Interventions and the Canadian Association of Interventional Cardiology, to provide guidance for cardiac procedure deferment and intervention timing for preoperative patients diagnosed with COVID-19. This document is intended for the perioperative cardiac surgical team and outlines the present state of the pandemic, the impact of COVID-19 on intervention outcome, and offers a recommended algorithm for individualized cardiac procedure triage and timing.

This study examined whether baseline (3–14 days pre-surgery) levels of (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs moderate the effects of additional preoperative interventions before coronary artery bypass graft surgery on (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs 1 day before surgery, 1 week and 6 months after surgery. In the PSY-HEART trial, 115 patients were assessed. They were randomized into one of three groups: 1. receiving standard medical care only (SMC), additional psychological interventions: 2. aiming to optimize patients’ expectations (EXPECT), or 3. focusing on emotional support. Patients with a higher baseline level of depressive symptoms receiving a preoperative psychological intervention indicated lower depressive symptoms 6 months after surgery compared to SMC. EXPECT increased personal control and concern levels in patients with low baseline personal control/concern 1 day before surgery. Brief preoperative psychological interventions can improve psychological outcomes in heart surgery patients. Baseline status may moderate these effects. The study has been approved by the medical ethics committee of the Philipps University of Marburg and has been pre-registered at www.clinicaltrials.gov (NCT01407055) on August 1, 2011.

The PSY-HEART-I trial indicated that a brief expectation-focused intervention prior to heart surgery improves disability and quality of life 6 months after coronary artery bypass graft surgery (CABG). However, to investigate the clinical utility of such an intervention, a large multi-center trial is needed to generalize the results and their implications for the health care system. The PSY-HEART-II study aims to examine whether a preoperative psychological intervention targeting patients' expectations (EXPECT) can improve outcomes 6 months after CABG (with or without heart valve replacement). EXPECT will be compared to Standard of Care (SOC) and an intervention providing emotional support without targeting expectations (SUPPORT). In a 3-arm multi-center randomized, controlled, prospective trial (RCT), N = 567 patients scheduled for CABG surgery will be randomized to either SOC alone or SOC and EXPECT or SOC and SUPPORT. Patients will be randomized with a fixed unbalanced ratio of 3:3:1 (EXPECT: SUPPORT: SOC) to compare EXPECT to SOC and EXPECT to SUPPORT. Both psychological interventions consist of 2 in-person sessions (à 50 minute), 2 phone consultations (à 20 minute) during the week prior to surgery, and 1 booster phone consultation post-surgery 6 weeks later. Assessment will occur at baseline approx. 3-10 days before surgery, preoperatively the day before surgery, 4-6 days later, and 6 months after surgery. The study's primary end point will be patients' illness-related disability 6 months after surgery. Secondary outcomes will be patients' expectations, subjective illness beliefs, quality of life, length of hospital stay and blood sample parameters (eg, inflammatory parameters such as IL-6, IL-8, CRP). This large multi-center trial has the potential to corroborate and generalize the promising results of the PSY-HEART-I trial for routine care of cardiac surgery patients, and to stimulate revisions of treatment guidelines in heart surgery.

Introduction Inflammation has been related to several somatic and psychological disorders and may moderate effects of psychological interventions. In the PSY-HEART trial patients benefitted from preoperative psychological interventions before undergoing coronary artery bypass graft surgery (CABG) and, if necessary, concomitant valvular surgery, compared to standard medical care. In this study we examined whether patients’ baseline inflammatory status moderated the intervention effects. Material and methods In a prospective three-arm randomized clinical trial with 6-months follow-up, 124 patients scheduled for CABG surgery alone or concomitant with valvular surgery were randomized to (i) standard medical care only (SMC) or two preoperative psychological interventions: (ii) CBT-based optimizing expectations (EXPECT) and an (iii) an active control group focusing on emotional support (SUPPORT). Available baseline CRP- (n = 79), IL-6- (n = 78), IL-8- (n = 78) and TNF-alpha-(n = 80) parameters were considered as potential moderators (CRP as a categorical and continuous moderator). Linear mixed model analyses were calculated to test whether baseline inflammatory levels moderated intervention effects on disability, mental and physical quality of life at 6 months after surgery. Results IL-8 moderated intervention effects on patients’ disability and categorical CRP moderated intervention effects on mental quality of life. Follow-up tests indicated that EXPECT (and in part SUPPORT) led to lower postoperative disability and higher mental quality of life compared to SMC in patients with low baseline inflammatory markers. EXPECT indicated higher mental quality of life compared to SUPPORT in the high CRP subgroup. Patients in the SMC group had higher mental quality of life in the high CRP subgroup compared to the low CRP subgroup. Conclusion Especially for patients with a lower inflammatory baseline status preoperative psychological interventions might be helpful to optimize long-term CABG surgery outcomes.

The aim of the study was to examine whether preoperative psychological interventions targeting patients' expectations are capable of influencing the biological stress response after coronary artery bypass graft (CABG) surgery and could thus improve recovery after heart surgery.Randomized controlled trial with assessments 10 days before surgery, after psychological intervention (day of hospital admission, but before surgery), postoperative (6-8 days later), and at follow-up (6 months after surgery). Eligible patients (N = 124) scheduled for elective on-pump CABG or CABG with valve replacement surgery were approached before hospital admission. Standard medical care (SMC) was compared with two additional preoperative psychological interventions: (a) an expectation manipulation intervention to optimize patients' expectations about course and outcomes or (b) supportive therapy, containing the same amount of therapeutic attention, but without specifically focusing on expectations. Postoperative plasma adrenaline, noradrenaline, and cortisol levels were a secondary outcome of our study (primary outcome patients' disability 6 months after surgery and other secondary patient-reported or clinical outcomes were reported elsewhere).Expectation manipulation intervention (3.68 ln pg/mL, 95% confidence interval = 3.38-3.98, p = .015) and supportive therapy (3.70 ln pg/mL, 95% confidence interval = 3.38-4.01, p = .026) led to significantly lower postoperative adrenaline levels compared with SMC (4.26 ln pg/mL, 95% confidence interval = 3.99-4.53) only. There were no treatment effects of the preoperative intervention for noradrenaline (p = .90) or cortisol (p = .30). Higher postoperative adrenaline levels predicted disability 6 months after surgery (r = .258, p = .018).In addition to SMC, preoperative psychological interventions seem to buffer psychobiological stress responses and could thus facilitate recovery from CABG surgery. Patients' postoperative stress responses could be an important factor for explaining trajectories of long-term outcomes.www.clinicaltrials.gov(NCT01407055).

Background The left atrial (LA) appendage (LAA) is the main source of thromboembolism in atrial fibrillation. This study addressed initial pressure resistance of surgical LAA closures. Methods In an experimental model, pneumatic pressure resistances of different surgical closure techniques were examined, and variations in technique and access were studied. In preparations of the LA from freshly slaughtered pigs, pneumatic pressure was applied to the LAA. Burst pressures (mbar) of various closure techniques (n = 12 specimens per group) were measured: (1) epicardial double-layer suture, (2) epicardial stapler closure (staple height 2 mm), (3) epicardial stapler closure (staple height 4, 4.5, and 5 mm), (4) endocardial inverse double-layer suture, (5) endocardial inverse stapler seam (staple height 2 mm), and (6) endocardial inverse stapler seam (staple height 4, 4.5, and 5 mm). Results The mean burst pressure in group 1 was 175.5 ± 19.35 mbar. There was no significant difference compared with group 2 (174.5 ± 28.45 mbar) or group 3 (176 ± 27.69 mbar). Group 4 scored significantly higher than all other groups (198.9 ± 18.35 mbar). Burst pressures in group 5 (136.2 ± 16.68 mbar) were significantly lower than in group 4 and in group 6 (165.1 ± 21.94 mbar), but the differences between groups 5 and 6 were also significant. Conclusions In an ex vivo model, double-layer suturing of the inverted LAA from an internal LA access led to higher burst pressures compared with epicardial suturing and with both endocardial and epicardial stapled closures.

Objective Reported are initial 12-month outcomes of patients with chronic symptomatic aortic dissection managed by the Streamliner Multilayer Flow Modulator (SMFM; Cardiatis, Isnes, Belgium). Primary end points were freedom from rupture- and aortic-related death, and reduction in false lumen index. Secondary end points were patency of great vessels and visceral branches, and freedom of stroke, paraplegia, and renal failure. Methods Out of 876 SMFM implanted globally, we have knowledge of 542. To date, 312 patients are maintained in the global registry, of which 38 patients were identified as having an aortic dissection (12.2%). Indications included 35 Stanford type B dissections, two Stanford type A and B dissections, and one mycotic Stanford type B dissection. Results There were no reported ruptures or aortic-related deaths. All cause survival was 85.3% Twelve-month freedom from neurologic events was 100%, and there were no incidences of end-organ ischemia, paraplegia or renal insult. Morphologic analysis exhibited dissection remodeling by a reduction in longitudinal length of the dissected aorta, and false lumen volume. A statistically significant reduction in false lumen index ( P = .016) at 12 months, and a borderline significant increase in true lumen volume ( P = .053) confirmed dissection remodeling. Conclusions The SMFM is an option in management of complex pan-aortic dissection. Results highlight SMFM implantation leads to dissection stabilization with no further aneurysm progression, and no retrograde type A dissection. Thoracic endovascular aneurysm repair by SMFM ensued in freedom from aortic rupture, neurologic stroke, paraplegia and renal failure. Further analysis of the global registry data will inform long-term outcomes.

Background: Formation of clots in the left atrial appendage (LAA) may lead to embolism and consecutive cerebral stroke. This risk is reduced by closure and resection. To address the efficacy of surgical LAA closure, resilience to pneumatic pressure was studied. Different surgical techniques were compared in an experimental model. Methods: From freshly slaughtered pigs cardiopulmonary preparations were taken. The left atrium was clamped airtight and the LAA was cannulated. Via a manually operated pump pressure was applied and a digital pressure gauge was connected. Four groups (each n=12) with different epicardial closures were studied: (I) purse string; (II) single layered continuous suture; (III) double layered suture; (IV) surgical stapler. A nonparametric test was used for group comparisons of mean burst pressures (mmHg). Statistical significance was defined at P Results: Mean burst pressures in group 1 amounted to 97.1±13.0 mmHg, in group 2 to 105.5±13.3 mmHg, in group 3 to 124.6±14.2 mmHg and in group 4 to 136.6±12.5 mmHg. Excepting differences between groups 1 and 2 comparisons between groups were significantly different. Conclusions: In an ex vivo model surgical staplers and double layered hand crafted sutures proved well suitable for closure of the LAA. They were significantly superior to single layered sutures in terms of resilience to pneumatic pressure. This may be relevant to durability and should be discussed with regard to clinical choice.

The aim of this study was to investigate not only preoperative expectations (as shown previously), but also postoperative expectations of patients predict clinical outcomes six months after cardiac surgery. Furthermore, the study sought to examine illness behavior as a possible pathway through which expectations may affect postoperative well-being. Seventy patients scheduled for cardiac surgery were examined one day before surgery, ~7-10 days after surgery, and six months after surgery. Regression analyses indicated that disability at follow-up (primary outcome) was significantly predicted by postoperative (

Zusammenfassung. Theoretischer Hintergrund: Depressivität und Ängstlichkeit beeinträchtigen den Behandlungserfolg von herzchirurgischen Patienten. Fragestellung: Untersucht wurde, ob und wie präoperative Patientenerwartungen mit postoperativer Depressivität und Ängstlichkeit zusammenhängen und welche präoperativen Erwartungen hierbei den höchsten prädiktiven Wert haben. Methoden: 124 aortocoronare Bypass-Patienten bearbeiteten eine Woche vor der Operation einen Fragebogen, der verschiedene Aspekte von Erwartungen mischt (Positive Health Expectation Questionnaire; PHES) und einen Fragebogen, der einzelne Erwartungsaspekte getrennt erfasst (Expected Illness Perception Questionnaire, IPQ-E) und eine Woche vor sowie eine Woche nach der Operation Fragen zu ihrer Depressivität und Ängstlichkeit (Hospital Anxiety and Depression Scale (HADS)). Ergebnisse: Postoperative Depressivität wird durch präoperative Erwartungen vorhergesagt (R2 = 0.32, F = 3.13, p = .02). Der einzig signifikante Prädiktor hierbei sind positive Gesundheitserwartungen gemessen mit dem PHES. Auch postoperative Ängstlichkeit wird durch präoperative Erwartungen vorhergesagt (R2 = 0.27, F = 2.55, p

Three-dimensional (3D) wall motion tracking (WMT) based on ultrasound imaging enables estimation of aortic wall motion and deformation. It provides insights into changes in vascular compliance and vessel wall properties essential for understanding the pathogenesis and progression of aortic diseases. In this report, we employed the novel 3D WMT analysis on the ascending aorta aneurysm (AA) to estimate local aortic wall motion and strain in case of a patient scheduled for replacement of the aortic root. Although progression of the diameter indicates surgical therapy, at present we addressed the question for optimal surgical time point. According to the data, AA in our case has enlarged diameter and subsequent reduced circumferential wall strain, but area tracking data reveals almost normal elastic properties. Virtual remodeling of the aortic root opens a play list for different loading conditions to determine optimal surgical intervention in time.

In this article the case of a patient who received a total of 35 inappropriate defibrillator shocks due to insulation failure with externalized conductor of a Biotronik Linox® lead is described. The implanted defibrillator was immediately inactivated and the failed lead was extracted using a laser sheath system.

Background The endovascular approach has become a mainstay in the treatment of aortic aneurysms. While the transfemoral approach is most commonly used, it is often inaccessible due to a vascular pathology, such as occlusion, tortuosity or heavy calcifications. The transapical access provides an alternative approach. The goal of this study is to report the feasibility of the transapical approach for total endovascular repair of thoracic aortic aneurysms (TEVAR). Methods Three patients with thoracic aortic aneurysms with inaccessible femoral arteries underwent TEVAR via the transapical approach. For access, the apex of the left ventricle was exposed by a mini-thoracotomy. After left ventricular puncture, a stiff guidewire was placed through the aortic valve into the descending thoracic aorta. All stent grafts were delivered under fluoroscopic guidance. Results All three procedures were technically successful with complete exclusion of the aneurysm without endoleak. One patient suffered spinal ischemia with subsequent paraplegia on day 4 after the procedure. The same patient died on day 43 after the procedure due to esophageal rupture. The two remaining patients did not present procedure-related problems. Conclusion The transapical access is a feasible and safe alternative to the transfemoral route in selected cases scheduled for TEVAR. Key Points Citation Format

Formation of clots in the left atrial appendage (LAA) may lead to embolism and consecutive cerebral stroke. This risk is reduced by closure and resection. To address the efficacy of surgical LAA closure, resilience to pneumatic pressure was studied. Different surgical techniques were compared in an experimental model.From freshly slaughtered pigs cardiopulmonary preparations were taken. The left atrium was clamped airtight and the LAA was cannulated. Via a manually operated pump pressure was applied and a digital pressure gauge was connected. Four groups (each n=12) with different epicardial closures were studied: (I) purse string; (II) single layered continuous suture; (III) double layered suture; (IV) surgical stapler. A nonparametric test was used for group comparisons of mean burst pressures (mmHg). Statistical significance was defined at P0.05.Mean burst pressures in group 1 amounted to 97.1±13.0 mmHg, in group 2 to 105.5±13.3 mmHg, in group 3 to 124.6±14.2 mmHg and in group 4 to 136.6±12.5 mmHg. Excepting differences between groups 1 and 2 comparisons between groups were significantly different.In an

Purpose This study addresses the effect of short myocardial ischemia on inhibitory effect of ATP for mitochondrial cytochrome c oxidase (CytOx) activity in myocardium and subsequent hemodynamic alterations. The activity of CytOx is inhibited by ATP (primary substrate control). This additional mechanism was proposed to be switched off at higher mitochondrial membrane potential values in case of stress. The ATP-dependent allosteric enzyme inhibition (second respiratory control) is suggested to reduce the formation of reactive oxygen species and thus is pivotal for cytoprotection. This report addresses the possible involvement of this mechanism in case of myocardial preconditioning. Methods Rat hearts were perfused in a Langendorff system (n = 5 each group). The first two groups underwent short recurrent ischemic periods (three times 5 min) and subsequent high or low reperfusion for 40 min. Besides four control groups, hearts were exposed to an ischemia of 15 min and high flow reperfused for 30 min, in addition. Hemodynamic data were evaluated in parallel. Mitochondria were separated for the polarographic respiration measurements in the presence of ADP or ATP, respectively. Phosphorylation patterns of the CytOx subunits were studied by immunoblotting with P-Ser, P-Thr, and P-Tyr antibodies. Results Short recurrent episodes of ischemia result in an ATP-dependent inhibition of CytOx. Electrophoretic analysis and blotting techniques reveal different phosphorylation patterns of the enzyme. Frequent short-lasting ischemic impacts and subsequent increased coronary flow seem to be essential for this effect. Conclusion The procedure of preconditioning is likely to be dependent on the mechanism of ATP-dependent inhibition of CytOx activity.

Computational analysis of the biomechanics of the vascular system aims at a better understanding of its physiology and pathophysiology. To be of clinical use, however, these models and thus their predictions, have to be patient specific regarding geometry, boundary conditions and material. In this paper we present an approach to determine individual material properties of human aortae based on a new type of in vivo full field displacement data acquired by dimensional time resolved three dimensional ultrasound (4D-US) imaging. We developed a nested iterative Finite Element Updating method to solve two coupled inverse problems: The prestrains that are present in the imaged diastolic configuration of the aortic wall are determined. The solution of this problem is integrated in an iterative method to identify the nonlinear hyperelastic anisotropic material response of the aorta to physiologic deformation states. The method was applied to 4D-US data sets of the abdominal aorta of five healthy volunteers and verified by a numerical experiment. This non-invasive in vivo technique can be regarded as a first step to determine patient individual material properties of the human aorta.

Background Aortic wall strains are indicators of biomechanical changes of the aorta due to aging or progressing pathologies such as aortic aneurysm. We investigated the potential of time-resolved three-dimensional ultrasonography coupled with speckle-tracking algorithms and finite element analysis as a novel method for noninvasive in vivo assessment of aortic wall strain. Methods Three-dimensional volume datasets of 6 subjects without cardiovascular risk factors and 2 abdominal aortic aneurysms were acquired with a commercial real time three-dimensional echocardiography system. Longitudinal and circumferential strains were computed offline with high spatial resolution using a customized commercial speckle-tracking software and finite element analysis. Indices for spatial heterogeneity and systolic dyssynchrony were determined for healthy abdominal aortas and abdominal aneurysms. Results All examined aortic wall segments exhibited considerable heterogenous in-plane strain distributions. Higher spatial resolution of strain imaging resulted in the detection of significantly higher local peak strains ( p ≤ 0.01). In comparison with healthy abdominal aortas, aneurysms showed reduced mean strains and increased spatial heterogeneity and more pronounced temporal dyssynchrony as well as delayed systole. Conclusions Three-dimensional ultrasound speckle tracking enables the analysis of spatially highly resolved strain fields of the aortic wall and offers the potential to detect local aortic wall motion deformations and abnormalities. These data allow the definition of new indices by which the different biomechanical properties of healthy aortas and aortic aneurysms can be characterized.

Objective To examine the effect of a preoperative expectation-optimizing psychological intervention on length of stay in the hospital and time spent in the Intensive Care Unit (ICU) in patients undergoing elective cardiac surgery. Methods In a randomized controlled trial, 124 patients prior to undergoing coronary artery bypass grafting (CABG) or CABG combined with heart valve surgery were randomized to either a) standard medical care alone (SMC) or an additional preoperative intervention, b) an additional expectation manipulation intervention (EXPECT) to optimize patients' expectations, or c) an additional supportive therapy (SUPPORT), containing the same amount of therapeutic attention but without a specific focus. Participants were followed-up post-operatively to assess their length of hospital stay and the time spent in the ICU. Results Patients in both psychological intervention groups spent significantly less days in the hospital then patients in the SMC group ( M (EXPECT) = 12.62, M (SUPPORT) = 14.13, M (SMC) = 17.27, p = 0.028). There was a significant linear trend ( F (1112) = 7.68, p = 0.009) showing that the more specific the intervention patients received the shorter they stayed in the hospital. The effect of the intervention on time spent in the ICU was only marginally significant ( M (EXPECT) = 103.76, M (SUPPORT) = 103.10, M (SMC) = 158.45, p = 0.066). Conclusion Changing patients' preoperative expectations via a psychological intervention leads to less days spent in the hospital. The psychological interventions are associated with positive cost-benefit ratios. Specific psychological mechanisms underlying the effect of our intervention remain unclear and need to be investigated further. Trial Registration: www.clinicaltrials.gov ( NCT01407055 ).

Pericardial cytokine patterns in various diseases are not well established. We have analyzed pericardial proinflammatory (interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha) and immunoregulatory cytokines (transforming growth factor (TGF)-beta1 and interferon (IFN)-gamma) in patients with pericarditis, myocarditis, and ischemic heart disease. Pericardial fluid was obtained in 30 subsequent patients undergoing pericardiocentesis (Group 1: 60 % males, 52.4 ± 14.2 years) and in 21 patients during aortocoronary bypass surgery (Group 2: 42.9 % males, age 67.2 ± 7.4 years). After clinical, laboratory, echocardiography examination, fiberoptic pericardioscopy (Storz-AF1101Bl, Germany) and pericardial/epicardial biopsy Group 1 was subdivided to 40 % neoplastic, 36.6 % autoreactive, 10 % iatrogenic, and 13.3 % viral pericarditis. Samples were promptly aliquoted, frozen, and stored at −70 °C. The cytokines were estimated using quantikine enzyme amplified-sensitivity immuno-assays (R&D Systems, USA) and the results compared between neoplastic, viral, iatrogenic, and autoreactive pericarditis and surgical groups. IL-6 was significantly increased in PE versus serum in all forms of pericarditis (except in autoreactive) and increased in comparison with pericardial fluid of surgical patients. TNF-alpha was increased only in PE of patients with viral pericarditis in comparison with Group 2. TGF-beta1 was strikingly lower in the PE than in the serum of all pericarditis patients. However, TGF-beta1 levels in PE were significantly higher in Group 1 than in Group 2, except in viral pericarditis. IFN-gamma levels did not significantly differ between PE and serum or in comparison with Group 2. The cytokine pattern “high TNF-alpha/low TGF-beta1” was found in viral pericarditis and low IL-6 in autoreactive PE. Different etiologies of pericardial inflammation did not influence the IFN-gamma levels. IL-6 pericardial to serum ratio was significantly higher in autoreactive PE than in viral and neoplastic forms. However, TNF-alpha and IFN-gamma pericardial to serum ratios were significantly higher in viral than in autoreactive and neoplastic PE.

In this study, the microvascular tissue oxygenation and oxidative muscle metabolism during graded hypoxia and reoxygenation were examined in a rabbit model by near-infrared (NIR) spectroscopy and correlated with high-energy phosphates measured by (31)P nuclear magnetic resonance (NMR) spectroscopy.Graded hypoxia was performed in a New Zealand rabbit model (n = 20, 2.0 ± 0.4 kg) by a stepwise reduction of the fraction of inspired oxygen (FiO(2)) from 0.3 to 0.05 (intervention group versus control group). Recovery and reoxygenation were achieved using FiO(2) of 0.3. A noninvasive NIR spectroscopy sensor and NMR probe was positioned on the surface of the prepared pedicled latissimus dorsi muscle. Microvascular tissue oxygenation (oxyhemoglobin, HbO(2); deoxyhemoglobin, HHb) and redox state of cytochrome oxidase (CytOx) were measured by NIR spectroscopy and correlated with standard values of oxidative muscle metabolism (phosphocreatine, PCr; adenosine triphosphate, ATP) measured by time-resolved (31)P NMR spectroscopy (4.7T).Significant correlation was found between PCr and HbO(2) (r = 0.85, P0.001) and HHb (r = -0.75, P0.001). β-ATP levels correlated significantly with CytOx (r = 0.87, P0.001).The data suggest that changes in high-energy phosphates (PCr- and ATP-levels) correlate closely with microvascular tissue oxygenation (HbO(2), HHb, CytOx) measured by NIR spectroscopy.

Background: The pathogenetic role of vascular endothelial growth factor (VEGF) in malignant pericardial effusion and diagnostic value of pericardial VEGF levels to discriminate malignant from benign pericardial effusions are uncertain. Hypothesis: We hypothesized that pericardial VEGF levels would be higher in malignant than benign pericardial effusion and that VEGF would be a useful marker for the diagnosis of malignant pericardial effusion. Methods: Using an enzyme-linked immunosorbent assay, we assessed pericardial and serum VEGF levels in patients with malignant pericardial effusion (n = 19), in patients with nonmalignant pericardial effusion (n = 30), and for control, in patients without pericardial disease (n = 26). Results: Vascular endothelial growth factor pericardial levels in malignant pericardial effusion (13 593.8 ± 22 410.24 pg/mL) were significantly higher compared with VEGF in nonmalignant effusion (610.63 ± 1289.08 pg/mL; P = 0.001) and pericardial fluid (5.5 ± 15.97 pg/mL; P < 0.001). In serum, VEGF was significantly higher in patients with nonmalignant pericardial effusion (188.3 ± 240.35 pg/mL) compared with patients with malignant pericardial effusion (67.52 ± 125.77 pg/mL; P = 0.024) and coronary artery disease patients (29.13 ± 76.26 pg/mL; P < 0.001). Pericardial VEGF levels were significantly higher than matched serum levels only in patients with malignant pericardial effusion (P = 0.023). Pericardial VEGF levels ≥2385 pg/mL had 75% sensitivity and 90% specificity for the recognition of malignant pericardial effusion in patients with breast or lung cancer. Conclusions: Vascular endothelial growth factor levels in pericardial effusion are markedly elevated in patients with malignant pericardial effusion, indicating abundant local release within the pericardial cavity. It is thus possible that VEGF participates in the pathogenesis of malignant pericardial effusion. Measurement of VEGF in pericardial effusion offers potential as a diagnostic tool to discriminate malignant from benign effusions in patients with breast or lung cancer. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Background. The role of inflammatory and angiogenic cytokines in patients with inflammatory pericardial effusion still remains uncertain.Methods. We assessed pericardial and serum levels of VEGF, bFGF, IL-1βand TNF-αby ELISA in patients with inflammatory pericardial effusion (PE) of autoreactive () and viral () origin, and for control in pericardial fluid (PF) and serum () of patients with coronary artery disease (CAD) undergoing coronary artery bypass graft surgery.Results. VEGF levels were significantly higher in patients with autoreactive and viral PE than in patients with CAD in both PE ( for autoreactive and for viral PE) and serum ( for autoreactive and for viral PE). Pericardial bFGF levels were higher compared to serum levels in patients with inflammatory PE and patients with CAD ( for CAD; for autoreactive PE; for viral PE). Pericardial VEGF levels correlated positively with markers of pericardial inflammation, whereas pericardial bFGF levels showed a negative correlation. IL-1βand TNF-αwere detectable only in few PE and serum samples.Conclusions. VEGF and bFGF levels in pericardial effusion are elevated in patients with inflammatory PE. It is thus possible that VEGF and bFGF participate in the pathogenesis of inflammatory pericardial disease.

Modern analyses of data for scientific reporting and healthcare management purposes require standardized and consistent definitions, something which also holds true for aortic root surgery, as part of the cardiovascular surgery spectrum. The aim of the present study was to investigate the currently employed nomenclature of the aortic root components. A questionnaire was constructed on the terminology of aortic root components, providing a list of common definitions including anatomical descriptions, as well as fields for custom responses. Responses were received from 534 cardiothoracic surgeons registered at www.ctsnet.org. Remarkable variations in definitions were detected. The most unanimously accepted terms were: 'aortic leaflets', the freely moving parts (52.6% of responses); 'commissures', the distal part of the leaflet attachments plus the peripheral area of the free edges of the leaflets (52.2%); 'semi-lunar leaflet attachment', the anatomic site of leaflet attachment (58%); 'annulus', the circular line defined by the nadirs of the leaflets (38%); 'interleaflet triangle', the tissue between two leaflets and annulus (23%); 'aortic valve', the three leaflets only (55%); 'aortic root' as composed of sinuses, tissue between the leaflets, sinutubular junction, leaflets and their wall attachment (63%). The remarkable variability on the everyday-used definitions of the aortic root components can potentially lead to misinterpretation of data. More stringent adoption of consistent, standardized definitions of aortic root components is necessary in the modern era of data collection and management.

The molecular events occurring during myocardial infarction and cardioprotection are described with an emphasis on the changes of the mitochondrial membrane potential (ΔΨ(m)). The low ΔΨ(m) values of the normal beating heart (100-140 mV) are explained by the allosteric ATP-inhibition of cytochrome c oxidase (CcO) through feedback inhibition by ATP at high [ATP]/[ADP] ratios. During ischemia the mechanism is reversibly switched off by signaling through reactive oxygen species (ROS). At reperfusion high ΔΨ(m) values cause a burst of ROS production leading to apoptosis and/or necrosis. Ischemic preconditioning is suggested to cause additional phosphorylation of CcO, protecting the enzyme from immediate dephosphorylation via ROS signaling.

Simultaneous measurements of extracellular pH, potassium (K(+)), and calcium (Ca(2+)) activity might be indicative of myocardium vitality or ischemia. Ten consecutive patients undergoing elective coronary artery bypass grafting were studied. Epicardial extracellular pH, potassium, and calcium were measured by a miniaturized disposable multi-sensor probe. Blood gases and electrolytes were derived with measurements of arterial and mixed venous blood samples at intervals during surgery. The mean epicardial baseline levels for pH in all patients were 8.04+/-0.22 arbitrary units (AU) for the right ventricle (RV) and 8.03+/-0.21 AU for the left ventricle (LV); for Ca(2+) 0.23+/-0.07 mmol/l (RV) and 0.20+/-0.10 mmol/l (LV); and for K(+) 4.54+/-1.51 mmol/l (RV) and 4.38+/-0.57 mmol/l (LV). Before ischemia, epicardial pH was moderately (p

Effective myocardial oxygen supply should not be compromised during cardiac surgery as it is essential to avoid circulatory and cardiac dysfunction. Local measurement of myocardial oxygen partial pressure (pO2) was therefore introduced into the operative monitoring of myocardial ischemia. The aim of the present study was to assess whether myocardial oxygen partial pressure correlates with the content of high energy phosphates (HEPs). Seven male rabbits were examined in parallel with measurement of myocardial pO2 by an implanted Clark electrode and 31phosphorus-NMR spectroscopy. The ventilatory management established hyperoxygenation followed by systemic hypoxia with hypercapnia for 20 min. Additionally, analysis of end-expiratory gas composition in combination with blood gas analysis was performed simultaneously, and hemodynamic parameter was recorded. Under hypoxic conditions the cardiovascular system was severely compromised, whereas the myocardial pO2 was only moderately impaired (pO2M 45.0+/-16.0 mm Hg). Immediately before cardiac arrest, low values of arterial and venous pO2 were found (17.6+/-6.0 and 12.9+/-6.1 mm Hg). In contrast to near normal myocardial pO2, HEP content in the myocardium was considerably reduced and inorganic phosphorus was increased. Artificial ventilation leading to systemic hypoxia and eventually circulatory arrest resulted in almost normal myocardial pO2 but severely compromised HEP content. This somewhat unexpected finding requires further clarification, but is in accordance with findings reported previously where regulatory mechanisms have been shown to play a role in the pathophysiology of severe hypoxic conditions such as those for cellular oxygen delivery and demand, P/O coupling and finally control of HEP production facilitating the interaction between respiratory chain and myoglobin oxygen transport.

Aims In mechanical heart valve recipients, low-dose international normalized ratio (INR) self-management of oral anticoagulants can reduce the risk of developing thrombo-embolic events and improve long-term survival compared with INR control by a general practitioner. Here, we present data on the safety of low-dose INR self-management. Methods and results In a prospective, randomized multi-centre trial, 1346 patients with a target INR range of 2.5–4.5 and 1327 patients with a target INR range of 1.8–2.8 for aortic valve recipients and an INR range of 2.5–3.5 for mitral or double valve recipients were followed up for 24 months. The incidence of thrombo-embolic events that required hospital admission was 0.37 and 0.19% per patient year in the conventional and low-dose groups, respectively ( P = 0.79). No thrombo-embolic events occurred in the subgroups of patients with mitral or double valve replacement. The incidence of bleeding events that required hospital admission was 1.52 and 1.42%, respectively ( P = 0.69). In the majority of patients with bleeding events, INR values were < 3.0. Mortality rate did not differ between the study groups. Conclusion Data demonstrate that low-dose INR self-management does not increase the risk of thrombo-embolic events compared with conventional dose INR self-management. Even in patients with low INR target range, the risk of bleeding events is still higher than the risk of thrombo-embolism.

In this article the case of a patient who received a total of 35 inappropriate defibrillator shocks due to insulation failure with externalized conductor of a Biotronik Linox® lead is described. The implanted defibrillator was immediately inactivated and the failed lead was extracted using a laser sheath system.

Background Bypass graft stenosis after venous revascularisation procedures is characterised by massive neointimal and vascular smooth muscle cell proliferation triggered via endothelin-1 synthesis in the vessel wall. Decoy oligodesoxynucleotides (ODN) against the transcription factor activator protein-1 (AP-1) inhibits pre-pro-endothelin-1 expression. Methods In 20 rabbits, an end-to-side jugular vein bypass to the carotid artery was performed: (group A) 8 grafts were treated with consensus AP-1 decoy ODN, (group B) 8 with mutated control ODN and (group C) 4 received no treatment. Explantation, histomorphometric and immunohistochemical evaluation was performed after 28 days. Results Median intimal thickness of groups: (A) 28.3 microm, (B) 48.4 microm, (C) 71.1 microm. The decoy ODN-treated group showed a significant reduction of neointima formation ( P = 0.029) and a downregulation of the endothelin receptor. Conclusions In this model, neointima formation was reduced by local transfection with consensus decoy ODN against AP-1. Endothelin A and B receptor expression is downregulated. Molecular target nucleic acid-based therapies seem to be a future means of overcoming neointima proliferation in pressure-induced venous graft failure. Intraoperative local application makes it easy to use in routine revascularisation procedures.

Background International normalized ratio (INR) self-management can significantly reduce INR fluctuations, bleeding, and thromboembolic events compared with INR control managed by general practitioners. However, even patients with INR self-management may have an increased risk of bleeding if their INR value is above 3.5. This study evaluated the compliance, clinical complications, and survival of patients after mechanical heart valve replacement with low-dose INR self-management compared with conventional-dose anticoagulation. Methods Group 1 (n = 908) received low-dose anticoagulation with a target INR range of 1.8 to 2.8 for aortic valve replacement and 2.5 to 3.5 for mitral or double valve replacement. Group 2 (n = 910) received conventional-dose anticoagulation with a target INR range of 2.5 to 4.5 for all heart valve prostheses. Results In groups 1 and 2, 76% and 75% of INR values, respectively, were in the target range. Results did not differ according to schooling and age. The rate of thromboembolic events per patient year was 0.18% in group 1 and 0.40% in group 2 (p = 0.210). The rate of bleeding complications was 0.74% for group 1 and 1.20% for group 2 (p = 0.502). In most patients with clinically relevant bleeding, these complications occurred although their measured INR values were below 3.5. The survival rate did not differ between the study groups (p = 0.495). Conclusions Low-dose INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. INR self-management is applicable for all patients in whom permanent anticoagulation therapy is indicated. Even INR values below 3.5 can bear the risk of bleeding complications.

We investigated a total of 15 mitral valves with myxomatous degeneration and compared these with normal mitral valves. In normal mitral valves, stromal cells located in the fibrosa and spongiosa showed small bipolar cytoplasmic processes and were found to be positive for CD34, suggesting a close relationship to CD34+ fibrocytes. In cases of myxomatous degeneration, stromal cells showed an altered morphology in that they exhibited multipolar cytoplasmic processes, appeared to be hyperplastic, and were increased in number. This study is the first to report on CD34+ fibrocytes making up the majority of mitral valve stromal cells. Major factors in the development of myxomatous valve degeneration are MMP-9, as well as collagen I and III, which have been reported to be secreted by CD34+ fibrocytes. Therefore, it is likely that CD34+ fibrocytes are involved in the pathogenesis of myxomatous mitral valve degeneration.

Stress response caused by endotracheal intubation may be harmful for the coronary or cerebral circulation of high-risk patients. This study evaluated the hypothesis that tracheal intubation via an intubating laryngeal mask airway is associated with less cardiovascular and endocrine stress response than the conventional technique using direct laryngoscopy.Randomized, patient-blinded trial.University department (single center).Eighty-six patients undergoing elective coronary artery surgery.Tracheal intubation was performed via an intubating laryngeal mask or by conventional direct laryngoscopy after standardized induction of anesthesia.Electrocardiogram with automatic ST-segment analysis and invasive measured blood pressure were recorded continuously and blood samples to analyze norepinephrine plasma levels were taken at 4 times. Catecholamine concentrations and the pressure-rate product were analyzed by using an analysis of variance for repeated measures. In both groups, the pressure-rate product (p = 0.003) and norepinephrine concentrations (p0.0001) significantly decreased after induction of anesthesia. However, the fall was more marked in the patients intubated via the laryngeal mask (p = 0.031) than in patients receiving direct laryngoscopy. There were neither signs of cardiac ischemia nor major adverse events during induction of anesthesia.Reduction of cardiovascular and endocrine stress response associated with endotracheal intubation is more pronounced when performed via the intubating laryngeal mask. Thus, this technique can be helpful in high-risk cardiac patients.

In diesem Beitrag wird uber einen Patienten mit insgesamt 35 inadaquaten Defibrillatorschocks aufgrund eines Isolationsdefekts einer Biotronik-Linox®-Elektrode mit externalisiertem Leiter berichtet. Der implantierte Defibrillator wurde umgehend inaktiviert und die defekte Elektrode mit einem Lasersheath-System extrahiert.

We sought to validate and evaluate 2 novel intraoperative ultrasound probes for epicoronary and epiaortic imaging.The noninvasive intraoperative assessment of successful coronary artery bypass grafting remains a challenge.A total of 19 consecutive patients (4 female, 15 male; mean age 60.5 +/- 13.8 years SD, range 34-84) underwent coronary artery bypass grafting. The epivascular probes (GE Ultrasound) were validated in vitro and intraoperatively. Coronary arteries, grafts, and ascending aorta were imaged and quantified.Mean adjusted flow measured by flowmeter was 3.25 L, SE 0.47 (range: 1-5.5 L) and was 3.15 L, SE 0.46 (range: 1-5.0 L) by ultrasound, with r = 0.97, P.0001. Intraoperatively, 56 native coronary vessels were bypassed using 15 left internal mammary artery grafts, 25 vein grafts, and 16 venous jump grafts. A total of 15 left internal mammary artery grafts (100%), 12 left internal mammary artery anastomoses (80%), 20 vein grafts (15 left anterior descending coronary arteries, left circumflex artery grafts, 5 right coronary artery grafts) (80%), 4 jump grafts (25%), and 15 ascending aortas (78%) were successfully imaged by inexperienced surgeons. Doppler flow measurements were possible in 50 vessels (89%). Mean lumen diameter for graft arteries (veins) was 2 mm (2.87 mm), maximal velocity was 72 cm/s (46 cm/s), and mean velocity was 29 cm/s (21 cm/s) with a mean flow rate of 70 mL/m (55 mL/m).We conclude that: (1) the novel intraoperative probes measure validated flow; (2) intraoperative hemodynamic assessment of graft patency is feasible without a learning curve; and (3) these findings should encourage the routine use of these intraoperative epivascular digital ultrasound probes.

Objectives: The second mechanism of mitochondrial respiratory control was proposed to be physiologically most important for the regulation of complex IV (CytOx) activity, and also of mitochondrial respiration. According to this mechanism the mitochondrial ROS concentrations in myocardium is kept under low healthy values 1 by regulating the mitochondrial respiration and membrane potential 2. In an new experimental setting we show the correlation between 'kinetics' of CytOx activity and mitochondrial membrane potential together with ROS production in heart mitochondria. Methods: Rat heart mitochondria were isolated by standard procedure of isolation (n = 3 in each group). Protein estimation was performed by BCA method. In kinetics studies (w/wo inhibition of CytOx), oxygen consumption by CytOx in intact mitochondria was measured polarographically. Changes in mitochondrial membrane potential and ROS concentrations were detected by DIOC6(3) and MitoSOX method, respectively, in fluorescence-based assays. Results: For the first time, a direct correlation of CytOx kinetics studies to the concentrations of ROS in intact mitochondria is shown. We found a sharp decrease in the ROS concentrations when the activity of CytOx is measured in the presence of ATP and regenerating system (Phosphoenolpyruvate + Pyruvate Kinase). Moreover, in the presence of allosteric ATP inhibition of CytOx, lowest concentrations of ROS were measured in intact rat heart mitochondria. Conclusion: ATP dependent inhibition of CytOx activity is crucial for mitochondrial bioenergetics as it maintains the redox balance by keeping the ROS concentrations at low values. References

Wir berichten uber einen 41-jahrigen Patienten mit progredienter, sei 7 Jahren bestehender atypischer Angina-pectoris-Symptomatik und subjektiv empfundenen Rhythmusstorungen bei Vorliegenden von zwei mediastinalen Raumforderungen. Im Rahmen einer Rontgenubersichtsaufnahme des Thorax fiel dem Hausarzt eine mediastinale Verbreiterung auf, deren weitere diagnostische Abklarung mittels Computer-(CT) und Magnetresonanztomographie (MRT) sowie Herzkatheteruntersuchung den Verdacht auf zwei bronchogene Zysten lenkte. Nach medianer Sternotomie und Perikarderoffnung zeigten sich zwei zystische Lasionen am Dach und dorsal in Nachbarschaft des rechten Vorhofs. Nach Resektion war der Patient prompt beschwerdefrei. Die histologische Aufarbeitung ergab keinen Anhalt fur Malignitat.

Early detection of myocardial ischaemia is a central problem in cardiological and cardiosurgical intensive care. A new approach is the use of ion-selective electrodes implanted directly on the myocardium, enabling detection of increased potassium activity as an indication of general hypoxia. After a comprehensive study of the electrode parameters, an animal experiment was carried out, in which it was found that respiration-induced hypoxia resulted in an increase in epicardial potassium activity (p < 0.01). Blood gas analysis performed simultaneously revealed reduced arterial pO2, but no acidosis. Haemodynamic data evidenced hypoxic depression of circulatory parameters. Histological examinations of the myocardium beneath the electrodes revealed typical lymphocytic infiltration. Electron microscopy demonstrated crystolysis in the mitochondria as an early sign of hypoxia, thus confirming the sensitivity of these electrodes. This underscores the potential of ion-selective electrodes for the detection of myocardial ischaemia, and they should now be investigated in the clinical setting.

Perioperative cardiosurgical management of volume therapy remains one of the challenging tasks in cases of patients with severe heart disease. Early detection of congestive cardiac failure prevents subsequent low output and worse outcome. An effective method for controlling extracorporeal circulation is created by developing a non-invasive intraoperative method for right ventricular strain analysis through digital image contrast correlation.

Heart surgery patients' expectations have been shown to be related to surgery outcome, independent of medical status. However, it is unclear which factors determine patients' expectations about disability following heart surgery.Investigating the associations of patients' disability expectations with demographic, medical, and psychosocial factors as well as other aspects of patients' expectations might help to tailor psychological interventions more specifically to optimize patient's expectations.Eighty-three patients were invited to a psycho-educational intervention to optimize expectations prior to elective coronary artery bypass graft (CABG). Before the psychological intervention and before surgery, disability expectations, demographical, medical, psychosocial variables as well as patient and treatment related expectations were collected via questionnaires and patients' files. Associations with disability expectations were assessed using hierarchical linear multiple regression analysis.Patients self-rated disability (β = 0.50; p 0.001) and beliefs about treatment efficacy (β = -0.42; p 0.001) was independently associated with disability expectations. Expectations about the efficacy of patients' own health behavior as well as demographical variables, psychological distress, perceived social support, and measures of medical morbidity did not explain any additional variance in patients' disability expectations.CABG patients seem to form their disability expectations upon their perceptions about their current disability and their expectations about the efficacy of treatment. Patients' disability expectations appear to be independent from scientifically established risk factors and other psychosocial patient characteristics in heart surgery. Future research is necessary to further determine what factors psychological interventions should focus on to modify patients' disability expectations.