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Objectives: Although indications for the MitraClip are becoming increasingly liberal, the number of patients requiring valve surgery after an insufficient outcome of the procedure is growing. Referral to surgery is, however, frequently delayed. During this time, the patients often deteriorate. We retrospectively analysed patients before MitraClip implantation and after mitral valve surgery., Methods: A total of 49 patients who received a mitral valve replacement (average 8 ± 12 months after MitraClip implantation) were assessed. Of these, 53% had 2-4 clips inserted. The mean age was 73 years, and the mean log EuroSCORE was 20.79 ± 14.42%. Echocardiographic data obtained prior to MitraClip implantation and preoperatively, 10 days and 6 and 12 months after cardiac surgery were reviewed. Survival analysis, risk profile and postoperative complications were analysed., Results: The 30-day and 1-year mortality was 26.5% and 59.2%, respectively. Prior to MitraClip implantation, 42.8% of patients had mild tricuspid insufficiency and 6.1% had moderate tricuspid insufficiency. Prior to surgery, 26.5% showed mild, 32.7% moderate and 38.8% severe tricuspid insufficiency (P < 0.001). Furthermore, right heart function assessed by tricuspid annular plane systolic excursion deteriorated significantly after Implantation of the MitraClip (P < 0.001). In patients with a MitraClip, the pulmonary artery pressure was significantly higher at the time of mitral replacement than it was before the MitraClip was implanted (P < 0.001)., Conclusions: A subgroup of patients does not benefit from a MitraClip and shows progressive deterioration in cardiac function, making valve replacement under difficult circumstances inevitable. The earlier these patients are operated on, the better it is. It can be assumed that some patients would be better off with primary surgery, especially if mitral reconstruction is then still feasible. Therefore, the indications for MitraClip implantation should be carefully considered and caution should be exercised during monitoring., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To date, little is known about the radiation exposure and the amount of contrast medium given during the transcatheter aortic valve implantation (TAVI) procedure. This study compares our data between the transfemoral (TF) approach and the transapical (TA) approach., Patients and Methods: A total of 216 TA and 180 TF implantations of the Edwards SAPIEN (Edwards Lifesciences, Irvine, California, United States) valve were consecutively performed by our heart team, consisting of cardiac surgeons and cardiologists. Fluoroscopy time, dose area product, and contrast volume were compared between both the approaches., Results: TF-TAVI showed higher values of fluoroscopy time (13.1 ± 5.9 vs. 7.0 ± 5.7 minutes, p < 0.001), dose area product (5.0 ± 3.9 vs. 2.7 ± 1.9 mGy·m(2), p < 0.001), and contrast volume (196.7 ± 72.7 vs. 109.2 ± 33.8 mL, p < 0.001). All physicians performing the TF approach exceeded the mean values of the surgeons performing the TA approach. Some physicians showed a trend toward lower values with growing experience. Vascular complications and postdilatation had only a minor impact on the study parameters., Conclusion: TA-TAVI showed an advantage over TF-TAVI in terms of lower fluoroscopy time, dose area product, and contrast use. This was hardly reflected in the past and should be considered when comparing invasiveness of both methods. However, human factors also play a role as most physicians showed a learning curve toward lower values over time., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Comparative volumetric assessment of the left ventricle by magnetic resonance imaging (MRI) and electron beam tomography (EBT) in patients with ischemic and dilated cardiac disease., Methods: Thirty-two patients underwent cine MRI and EBT in the multislice mode. All studies were triggered to the ECG. Left ventricular ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), and myocardial mass (MM) were determined by 3D-volumetry by MRI and EBT and results were compared., Results: The correlation between MRI and EBT for EF, EDV, ESV, and MM were r = 0.86, r = 0.95, r = 0.95, and r = 0.93, respectively., Conclusions: There is an excellent correlation between MRI and EBT in determining left-ventricular parameters. Both methods are suitable for volumetric assessment of the left ventricle.

Background and Aims of the Study: Although pulmonary valve stenosis may be treated by percutaneous balloon valvulotomy, surgery is preferred in adult patients with dysplastic valves., Methods: Recently a 50-year-old man with isolated, calcific pulmonary stenosis and concomitant coronary artery disease was referred for surgery. Preoperatively, he suffered from dyspnea (NYHA class I-II) and angina pectoris (CCS class I-II). During catheterization a peak-to-peak gradient of 120 mmHg was measured across the pulmonary valve, while angiography revealed two-vessel coronary artery disease., Results: During surgery, after opening the main pulmonary artery, an unsuspected small ventricular septal defect (VSD) and a severely calcified, altered pulmonary valve were detected. The VSD was closed and the valve replaced with a stentless bioprosthesis; concomitant double coronary artery bypass grafting was performed. The postoperative course was uneventful., Conclusions: Adult patients with pulmonary valve stenosis and concomitant coronary artery disease can be treated simultaneously by surgery with excellent results. Replacement devices may be homografts, or as in this patient, a stentless xenograft.

Prior to the FK506 era, OKT3 was primarily used for treatment of steroid-resistant rejection. Initially FK506 has been used as a last treatment of refractory acute or chronic rejection. We provide strong evidence that the use of FK506 is more successful if rescue therapy is performed early instead of using it as the last resort. Between September 1988 and March 1995 a total of 600 liver transplantations were performed in 550 patients. Of these 550 patients, 426 received primarily cyclosporine A (CsA)-based immunosuppression. Of the 426 CsA patients, 70 (16.4%) required either FK506 (51.4%), or OKT3 rescue therapy (27.1%), or a combination of the two drugs (21.5%). The latter group of patients received first OKT3 and then FK506 rescue when OKT3 therapy failed. Treatment was initiated simultaneously (within 1 week) in 11 patients, and 4 patients received FK506 rescue later during the course of rejection. The highest success rates (88.9%) were observed in patients given FK506 rescue therapy. Retransplantation was necessary more often in patients receiving OKT3 than in those with FK506 rescue therapy (15.8% versus 5.5%, respectively). Retransplantation and death due to chronic rejection increased with the need for additional FK506 rescue therapy after OKT3 failure. This increase was most pronounced in patients receiving FK506 during the late course of rejection, reaching a failure rate of 75.0% (50. 0% of deaths were due to chronic rejection). The lowest incidence of cytomegalovirus infection and of infectious, neurologic, and renal complications was observed in the FK506 rescue group. We conclude that early FK506 rescue therapy may be the treatment of choice for acute steroid-resistant rejection.