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Heart transplantation is the gold-standard in the treatment of terminal heart failure. The shortage of donor hearts represents the major obstacle in patient care and necessitates the creation of waiting lists and allocation algorithms. The Transplantation Act regulates donor heart allocation according to the urgency and the prospects of success. Donor hearts can be implanted following the classical biatrial or the modern bicaval valve implantation technique with a slightly lower spectrum of complications. Modern mechanical perfusion systems enable extended transport times. After heart transplantation rejection reactions must be controlled by an individually adjusted immunosuppression to guarantee long-term survival with as few complications as possible. [ABSTRACT FROM AUTHOR]

Cardiac myxomas are one of the most common types of primary cardiac tumors and are associated with embolization, angina, and sudden death. Most cardiac myxomas arise from the fossa ovalis, while those that arise from the mitral valve are exceedingly rare and those that arise from the chordae are even rarer. We report the case of a 28-year-old Caucasian woman who suffered from a brain infarction. A duplex ultrasound showed no cerebrovascular stenosis or occlusion, but an echocardiogram revealed a left ventricle pedunculated mobile mass (5 mm in diameter) that was attached to the mitral valve chordae tendineae. We elected cardiac surgery to resect the cardiac tumor and to avoid further embolic events. The traditional surgical strategy--mitral valve replacement through full sternotomy--has many disadvantages, particularly for young women. Therefore we desided to use the Premeasured Gore-Tex chordal loop method followed by annuloplasty using a minimally invasive video-assisted approach. Exploration of the mitral valve showed a globular tumor involving the anterior mitral leaflet chordae tendineae, which was removed along with the involved chordae tendineae. Histopathological examination of the tissue revealed a benign polypoid myxoma. The patient had an uneventful recovery and has remained symptom-free. Echocardiography one week after surgery showed satisfactory valve function. We believe our surgical treatment was the most appropriate option for this case and it resulted in an excellent medical outcome and improved the quality of life, including only a small lateral scar without the need for teratogenic anticoagulants. [ABSTRACT FROM AUTHOR]

Abstract: Globally, cardiovascular disease (CVD) is the number one cause of death, being responsible for approximately 30% of deaths worldwide. Urbanization and a westernized lifestyle are thought to play a major role in the development of CVD. There is accumulating evidence that vitamin D is a nonclassical risk factor for CVD. The active vitamin D metabolite, 1,25-dihydroxyvitamin D, which is synthesized from its precursor 25-hydroxyvitamin D (25[OH]D), down-regulates several negative and up-regulates various protective pathways in the heart and vasculature. First randomized trials demonstrate that vitamin D supplementation leads to vasodilatation and suppresses cardiovascular risk markers such as triglycerides and the inflammation marker tumor necrosis factor-α. Solar UV-B radiation is the major source of vitamin D for humans. Consequently, the vitamin D status is largely influenced by season, geographic latitude, daily outdoor activities, and the percentage of body surface exposed to solar UV-B. A significant proportion of individuals in Europe and North America have vitamin D concentrations in the deficiency range (25[OH]D<25nmol/l). Available data indicate that low solar UV-B exposure and/or low 25(OH)D concentrations are associated with an increased risk of CVD. Large nonrandomized studies indicate that CVD mortality is more than twice as high in older individuals with deficient 25(OH)D concentrations compared with those individuals who have adequate 25(OH)D concentrations (>75nmol/l). Together, experimental and epidemiological evidence does support a plausible role for improving vitamin D status in CVD prevention in the population at large. Nevertheless, future randomised clinical trials are needed to evaluate whether vitamin D is effective with respect to primary, secondary, and/or tertiary prevention of CVD. [Copyright &y& Elsevier]

Background:The role of Swan-Ganz catheterization for cardiac surgery and perioperative management has recently been scrutinized. Methods:Prospective observational study for serious complications related to Swan-Ganz catheterization. 7150 patients undergoing cardiac operations at a major European heart center and academic setting. 3730 Swan-Ganz catheter placements for cardiac surgery (7.5 French Swan-Ganz Catheter Baxter, heparin coated). Results:We observed four serious complications related to Swan-Ganz catheterization and placement (0.1%): A right ventricular free wall perforation occurred, one trouble with knotting, and two pulmonary artery ruptures. The right ventricular perforation was controlled with a suture, the knot was tightened, and the catheter withdrawn through insertion. The first case of pulmonary artery rupture was treated conservatively. All of these patients survived. The other pulmonary artery rupture occurred during coronary artery bypass grafting. Emergency lobectomy was performed. This patient died due to bleeding during the early postoperative course. Conclusion:The incidence of serious Swan-Ganz catheter complications in our patient population is comparable to the incidence reported in the literature. Based on these results the use of Swan-Ganz catheters in cardiac surgery is still justified since the rate of associated serious complications is extremely low. Despite the rare occurrence of serious complications and the infrequent fatal outcomes, the benefit of its use in selected cases of cardiac surgery overweight its associated complications. [ABSTRACT FROM AUTHOR]

Objective: To define predictors for prolonged ICU stay in order to improve patient outcome and reduce costs.Patients and Methods: Prospective data on 10,759 patients undergoing coronary artery bypass grafting with and without use of cardiopulmonary bypass (coronary artery bypass grafting, CABG; n =8,917; off-pump coronary artery bypass grafting, OPCAB; n =765; minimally invasive direct coronary artery bypass grafting, MIDCAB; n =1,077) between April 1996 and August 2001 were subjected to univariate and, consecutively, to multivariate logistic regression analysis. Prolonged ICU stay was defined as intensive care treatment for three postoperative days and longer.Measurements and Results: Mean duration of ICU stay was 3.8+/-6.9 days; overall prevalence of prolonged ICU stay was 37.1%. The hospital mortality was 3.5% (ICU > or =3 days: 5.9%; ICU <3 days: 2.0%). Out of 39 selected pre- and intraoperative patient- and treatment-related variables, by univariate analysis, 32 variables having a high association with prolonged ICU stay were identified. Using a stepwise logistic regression model, 20 variables were shown to be independent predictors for prolonged ICU stay. Both OPCAB and MIDCAB surgery were identified as having a significantly lower association with prolonged ICU stay.Conclusion: As prolonged ICU stay is associated with poor patient outcome and increased costs it is of utmost importance to identify patients at a high risk for prolonged ICU stay. More frequent off-pump CABG may optimize patient outcome. [ABSTRACT FROM AUTHOR]

Objective: Patients with end stage cardiomyopathy frequently present with additional severe mitral regurgitation. We analyzed the outcome of mitral valve reconstruction in this high risk patient group. Methods: Sixty-six patients with significant mitral regurgitation and an ejection fraction (EF) below 30% (dilated cardiomyopathy=53, ischemic cardiomyopathy (ICM)=13) were retrospectively evaluated from 07/96 and 02/02. All received annuloplasty ring implantation and additional repair (n=4) if required. Mean follow-up was 28±18 months. Results: Mitral valve repair (MVR) was technically feasible in all patients. Intraoperative transesophageal echocardiography (TEE) revealed none (n=60) or only trivial (n=6) residual mitral regurgitation. Thirty day mortality was 6.1%. Actuarial survival after 1 and 5 years was 86±4 and 66±8%, respectively. During follow-up seven patients were transplanted due to lack of clinical improvement after 10±7 months (range 1–23). Echocardiography revealed a significant improvement in EF (25±10.5% pre-op, 34±15% post-op) and a slight decrease in left ventricular end-diastolic diameter (69±10 mm pre-op, 67±13 mm follow up). Patients were in NYHA functional -class 3 (median) preoperatively and in class 2 at long term-follow-up. Gender, left ventricular enddiastolic diameter, preoperative ejection fraction or type of surgical approach (sternotomy, right lateral minithoracotomy) had no significant influence on patient outcome. Patients with ICM or patients older than 60 years showed an increased risk for clinical events both early post-operatively and at long-term follow-up. Conclusion: MVR can be performed with low perioperative morbidity and mortality even in patients with advanced heart failure, modifying selection criteria for potential candidates may further improve long term outcome. [Copyright &y& Elsevier]

Background: Acute right ventricular failure is a critical complication after left ventricular assist device (LVAD) implantation, often managed with a temporary paracorporeal right ventricular assist device (RVAD). This study examined three extracorporeal life support (ECLS) systems regarding mortality, bleeding complications, and intensive care unit (ICU) stay duration. Methods: This monocentric, retrospective case–control study included all patients receiving LVAD with paracorporeal RVAD between 2009 and 2020. Three patient groups were formed: CentrimagTM (A), CardiohelpTM (B), and DeltastreamTM (C). Results: A total of 245 patients were included. Preoperative parameters were similar between the CentrimagTM and DeltastreamTM groups, but CardiohelpTM patients had worse Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Scores (A: 1.7 ± 0.8, B: 1.36 ± 0.5, C: 1.9 ± 0.9; p < 0.05). In-hospital death rates were A: 61 (41.8%), B: 15 (32.6%), C: 29 (54.7%); p < 0.05, and reoperation due to bleeding rates were A: 32 (21.9%), B: 8 (17.4%), C: 25 (47.2%); p < 0.05, with the DeltastreamTM group showing the highest rates. This group also had increased thrombocyte consumption and prolonged ICU stays. Conclusions: Temporary RVADs lead to bleeding complications, affecting patient outcomes. The DeltastreamTM group had significantly higher bleeding complications, likely due to high pump revolution rates and thrombocyte decline. Due to the study's retrospective nature and complex patient profiles, these interesting findings should be validated in future studies. [ABSTRACT FROM AUTHOR]

Summary: Sleep‐disordered breathing is common in patients with coronary artery disease undergoing coronary artery bypass grafting. Sleep‐disordered breathing is associated with increased perioperative morbidity, arrhythmias (e.g. atrial fibrillation) and mortality. This study investigated the impact of sleep‐disordered breathing on the postoperative course after coronary artery bypass grafting, including development of atrial fibrillation. This prospective single‐centre cohort study included adults undergoing coronary artery bypass grafting. All were screened for sleep‐disordered breathing (polygraphy) and atrial fibrillation (electrocardiogram) preoperatively; those with known sleep‐disordered breathing or atrial fibrillation were excluded. Endpoints included new‐onset atrial fibrillation, duration of mechanical ventilation, time in the intensive care unit, and postoperative infection. Regression analysis was performed to identify associations between sleep‐disordered breathing and these outcomes. A total of 508 participants were included (80% male, median age 68 years). The prevalence of any (apnea–hypopnea index ≥ 5 per hr), moderate (apnea–hypopnea index = 15–30 per hr) and severe (apnea–hypopnea index > 30 per hr) sleep‐disordered breathing was 52.9%, 9.3% and 10.2%, respectively. All‐cause 30‐day mortality was 0.98%. After adjustment for age and sex, severe sleep‐disordered breathing was associated with longer respiratory ventilation support (crude odds ratio [95% confidence interval] 5.28 [2.18–12.77]; p < 0.001) and higher postoperative infection rates (crude odds ratio 3.32 [1.45–7.58]; p < 0.005), but not new‐onset atrial fibrillation or mortality. New‐onset atrial fibrillation was significantly associated with postoperative infection and prolonged hospital stay. The significant associations between sleep‐disordered breathing and several adverse outcomes after coronary artery bypass grafting support the need for preoperative sleep‐disordered breathing screening in individuals undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Congenitally corrected transposition of the great arteries (ccTGA) is an infrequent and complex congenital malformation, which accounts for approximately 0.5% of all congenital heart defects. This defect is characterized by both atrioventricular and ventriculoarterial discordance, with the right atrium connected to the morphological left ventricle (LV), ejecting blood into the pulmonary artery, while the left atrium is connected to the morphological right ventricle (RV), ejecting blood into the aorta. Due to this double discordance, the blood flow is physiologically normal. Most patients have coexisting cardiac abnormalities that require further treatment. Untreated natural course is often associated with progressive failure of the systemic right ventricle (RV), tricuspid valve (TV) regurgitation, arrhythmia, and sudden cardiac death, which occurs in approximately 50% of patients below the age of 40. Some patients do not require surgical intervention, but most undergo physiological repair leaving the right ventricle in the systemic position, anatomical surgery which restores the left ventricle as the systemic ventricle, or univentricular palliation. Various types of anatomic repair have been proposed for the correction of double discordance. They combine an atrial switch (Senning or Mustard procedure) with either an arterial switch operation (ASO) as a double-switch operation or, in the cases of relevant left ventricular outflow tract obstruction (LVOTO) and ventricular septal defect (VSD), intra-ventricular rerouting by a Rastelli procedure. More recently implemented procedures, variations of aortic root translocations such as the Nikaidoh or the half-turned truncal switch/en bloc rotation, improve left ventricular outflow tract (LVOT) geometry and supposedly prevent the recurrence of LVOTO. Anatomic repair for congenitally corrected ccTGA has been shown to enable patients to survive into adulthood. [ABSTRACT FROM AUTHOR]

Patients with severe calcified ascending aorta ("porcelain aorta") present a surgical challenge. Off-pump coronary artery bypass grafting (OPCAB), using new automated proximal anastomotic devices, provide a surgical alternative for patients who are not candidates for in situ arterial grafting. We present a 74-year-old male with double-vessel disease and a large calcified aneurysm of the left anterior wall. Left ventricular function was poor with an ejection fraction of 24%. The beating heart technique was used for the distal anastomosis and ventriculoplasty. The proximal anastomosis was constructed with an automated aortic connector system, thereby avoiding clamping of the severely diseased aorta. [ABSTRACT FROM AUTHOR]

Aims Methods and results Conclusion This EUROMACS study was conducted with the primary aim of investigating the association between a centre's annual caseload and postoperative outcomes among patients undergoing left ventricular assist device (LVAD) implantation.A total of 4802 patients identified between 2011 and 2020 from 35 participating centres were dichotomized based on the annual caseload of the treating centre at the time of device implant (≤30 vs. >30 LVAD implantations/year). The primary endpoint was 1‐year survival. Secondary outcomes included overall survival analysis, device‐related adverse events and readmissions. Cumulative follow‐up was 10 003 patient‐years, with a median follow‐up of 1.54 years (interquartile range 0.52–3.15). Patients from higher volume centres more frequently presented in INTERMACS levels 1 and 2, suffered from right heart dysfunction and needed inotropic support. No difference was observed in adjusted 1‐year survival. Adjusted overall survival probability was lower in higher volume centres (p = 0.002). In the subgroup analysis of HeartMate 3 devices only, higher volume centres were associated with decreased odds of 1‐year survival (adjusted odds ratio 0.43, 95% confidence interval 0.20–0.97, p = 0.041). Similar findings were observed in the cumulative (i.e. learning curve) caseload analyses.In patients undergoing LVAD implantation, centre volume was not associated with 1‐year survival, but was related to device‐related adverse events. Patient profiles differed with respect to centre size. These findings underscore the necessity for ongoing quality improvement initiatives in all centres, regardless of their annual caseload. Efforts are needed to standardize patient selection and preconditioning to further improve patient outcome. [ABSTRACT FROM AUTHOR]

Dextro-transposition of the great arteries (D-TGA) is the second most common cyanotic heart disease, accounting for 5–7% of all congenital heart defects (CHDs). It is characterized by ventriculoarterial (VA) connection discordance, atrioventricular (AV) concordance, and a parallel relationship with D-TGA. As a result, the pulmonary and systemic circulations are separated [the morphological right ventricle (RV) is connected to the aorta and the morphological left ventricle (LV) is connected to the pulmonary artery]. This anomaly is included in the group of developmental disorders of embryonic heart conotruncal irregularities, and their pathogenesis is multifactorial. The anomaly's development is influenced by genetic, epigenetic, and environmental factors. It can occur either as an isolated anomaly, or in association with other cardiac defects. The typical concomitant cardiac anomalies that may occur in patients with D-TGA include ventriculoseptal defects, patent ductus arteriosus, left ventricular outflow tract obstruction (LVOTO), mitral and tricuspid valve abnormalities, and coronary artery variations. Correction of the defect during infancy is the preferred treatment for D-TGA. Balloon atrial septostomy (BAS) is necessary prior to the operation. The recommended surgical correction methods include arterial switch operation (ASO) and atrial switch operation (AtrSR), as well as the Rastelli and Nikaidoh procedures. The most common postoperative complications include coronary artery stenosis, neoaortic root dilation, neoaortic insufficiency and neopulmonic stenosis, right ventricular (RV) outflow tract obstruction (RVOTO), left ventricular (LV) dysfunction, arrhythmias, and heart failure. Early diagnosis and treatment of D-TGA is paramount to the prognosis of the patient. Improved surgical techniques have made it possible for patients with D-TGA to survive into adulthood. [ABSTRACT FROM AUTHOR]

Background: Mitochondria play a crucial role in adapting to fluctuating energy demands, particularly in various heart diseases. This study investigates mitochondrial morphology near intercalated discs in left ventricular (LV) heart tissues, comparing samples from patients with sinus rhythm (SR), atrial fibrillation (AF), dilated cardiomyopathy (DCM), and ischemic cardiomyopathy (ICM). Methods: Transmission electron microscopy was used to analyze mitochondria within 0–3.5 μm and 3.5–7 μm of intercalated discs in 9 SR, 10 AF, 9 DCM, and 8 ICM patient samples. Parameters included mean size in µm2 and elongation, count, percental mitochondrial area in the measuring frame, and a conglomeration score. Results: AF patients exhibited higher counts of small mitochondria in the LV myocardium, resembling SR. DCM and ICM groups had fewer, larger, and often hydropic mitochondria. Accumulation rates and percental mitochondrial area were similar across groups. Significant positive correlations existed between other defects/size and hydropic mitochondria and between count/area and conglomeration score, while negative correlations between count and size/other defects and between hydropic mitochondria and count could be seen as well. Conclusion: Mitochondrial parameters in the LV myocardium of AF patients were similar to those of SR patients, while DCM and ICM displayed distinct changes, including a decrease in number, an increase in size, and compromised mitochondrial morphology. Further research is needed to fully elucidate the pathophysiological role of mitochondrial morphology in different heart diseases, providing deeper insights into potential therapeutic targets and interventions. [ABSTRACT FROM AUTHOR]

Right heart failure (RHF) is associated with poor outcomes, especially in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to identify predictors of RHF after LVAD implantation. Of 129 consecutive patients (mean age 56 ± 11 years, 89% male) undergoing LVAD implantation, 34 developed RHF. Compared to patients without RHF, those with RHF required longer invasive mechanical ventilation and had longer intensive care unit and hospital stays (p < 0.01). One-year all-cause mortality was significantly higher in patients with versus without RHF after LVAD implantation (29.4% vs. 1.2%; hazard ratio 35.4; 95% confidence interval 4.5–277; p < 0.001). Mortality was highest in patients with delayed RHF after initial LVAD-only implantation (66.7%). Patients who did versus did not develop RHF had significantly higher baseline pulmonary vascular resistance (PVR; 404 ± 375 vs. 234 ± 162 dyn/s/cm5; p = 0.01). PVR > 250 dyn/s/cm5 was a significant predictor of survival in patients with RHF after LVAD implantation. These data confirm the negative impact of RHF on morbidity and mortality after LVAD implantation. Preoperative PVR > 250 dyn/s/cm5 determined using invasive right heart catheterization was an independent predictor of developing RHF after LVAD implantation, and of subsequent mortality, and could be used for risk stratification in the setting for deciding between single or biventricular support strategy. [ABSTRACT FROM AUTHOR]

In 873 propensity score–matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement. [ABSTRACT FROM AUTHOR]

We investigated whether in patients undergoing off-pump coronary artery bypass grafting surgery a single bolus of 1 g tranexamic acid (TXA) impacts the risk of postoperative delirium using the propensity score matching approach. In 2,757 pairs, the risk of delirium was 4.2% (TXA group) and 5.0% (non-TXA group), with a relative risk in the TXA versus the non-TXA group of 0.83 (95% confidence interval: 0.65–1.07; p = 0.16). There was no significant interaction between TXA administration and renal function on the risk of delirium (p = 0.12). Data indicate that a single bolus of 1 g TXA does not increase the risk of delirium in patients undergoing off-pump surgery. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Transfusion of 1 and 2 units of red blood cells does not increase mortality and organ failure in patients undergoing isolated coronary artery bypass grafting" in a previous issue is presented.

Midventricular hypertrophic obstructive cardiomyopathy (HOCM) is characterized by hypertrophy of the interventricular septum (IVS) and - in rare cases - of the papillary muscles (PM), which subsequently can cause dynamic left ventricular outflow tract obstruction (LVOTO) and severe heart failure symptoms. We report on a rare case of a 44-year-old patient suffering from midventricular HOCM with hypertrophic anterolateral PM and an additional chorda between the PM and the IVS. We describe a new surgical approach via right anterolateral thoracotomy in 3-dimensional (3D) video-assisted minimal-invasive technique with resection of hypertrophic PMs as well as the entire mitral valve-apparatus and valve replacement avoiding septal myectomy and potentially associated complications. After an uneventful procedure clinical symptoms improved from NYHA III-IV at baseline to NYHA 0-I postoperatively and remained stable over a follow-up period of 24 months. Therefore, the presented technique may be considered as a new and alternative approach in patients with hypertrophic PMs and hypertrophic IVS as subtype of midventricular HOCM. [ABSTRACT FROM AUTHOR]

Background: Isolated congenital ostial stenosis of the left coronary artery (LCA) is extremely rare, and available literature is limited. Long-term treatment success is key in the choice of treatment strategy due to the mostly young age of the patients. Here, we present a clinical case and shed light on the surgical treatment strategies including their pitfalls. Case presentation: We describe a 20-year-old male who presented to the emergency department with recurrent typical angina pectoris symptoms (CCS class II). Computed tomography and coronary angiography revealed isolated ostial stenosis of the LCA, with prominent collaterals from the right coronary artery. The patient was operated on and intra-operative findings showed a severely narrowed LCA ostium that appeared to be fibrotic, and to originate from a similarly fibrotic left coronary sinus of the aortic root. The LCA was excised from the left coronary sinus, and trimmed until the coronary artery lumen appeared macroscopically normal. The fibrotic left coronary sinus was resected and replaced with a bovine pericardial patch, into which the coronary artery was re-inserted. During weaning from cardiopulmonary bypass, we faced a diminished left ventricular function. We attributed this to insufficient myocardial protection. Isolated antegrade cardioplegia had been used, which, for technical reasons, had to be administered separately to the right and left coronary artery after aortotomy. In the setting of huge collaterals from the right to the left coronary artery, a steal-effect likely occurred. After prolonged reperfusion, the left ventricular function recovered, and the further post-operative course was unremarkable. Conclusions: For the surgical treatment of congenital ostial stenosis of the LCA, both ostium reconstruction and coronary artery bypass grafting have been described. The advantage of ostium reconstruction as chosen here is to create a physiological flow and supply situation to the affected myocardial areas. Furthermore, in case of other downstream events, such as the development of coronary artery disease, all further therapeutic options are preserved. Special attention should be paid to the administration of cardioplegia in these patients. Combined ante and retrograde cardioplegia administration probably would have achieved more extensive myocardial protection in our case. [ABSTRACT FROM AUTHOR]

Cardiac myxomas are one of the most common types of primary cardiac tumors and are associated with embolization, angina, and sudden death. Most cardiac myxomas arise from the fossa ovalis, while those that arise from the mitral valve are exceedingly rare and those that arise from the chordae are even rarer. We report the case of a 28-year-old Caucasian woman who suffered from a brain infarction. A duplex ultrasound showed no cerebrovascular stenosis or occlusion, but an echocardiogram revealed a left ventricle pedunculated mobile mass (5 mm in diameter) that was attached to the mitral valve chordae tendineae. We elected cardiac surgery to resect the cardiac tumor and to avoid further embolic events. The traditional surgical strategy-mitral valve replacement through full sternotomy-has many disadvantages, particularly for young women. Therefore we desided to use the Premeasured Gore-Tex chordal loop method followed by annuloplasty using a minimally invasive video-assisted approach. Exploration of the mitral valve showed a globular tumor involving the anterior mitral leaflet chordae tendineae, which was removed along with the involved chordae tendineae. Histopathological examination of the tissue revealed a benign polypoid myxoma. The patient had an uneventful recovery and has remained symptom-free.Echocardiography one week after surgery showed satisfactory valve function. We believe our surgical treatment was the most appropriate option for this case and it resulted in an excellent medical outcome and improved the quality of life, including only a small lateral scar without the need for teratogenic anticoagulants. [ABSTRACT FROM AUTHOR]

Keywords: left ventricular assist device; heart transplantation; survival; complications; HeartWare ventricular assist device EN left ventricular assist device heart transplantation survival complications HeartWare ventricular assist device 482 492 11 09/14/22 20220901 NES 220901 Conflict of Interest None declared. Freedom from major complications with ongoing HVAD support did not generally differ between INTERMACS level 1-patients and INTERMACS levels 2 to 4 patients, except for ischemic stroke, which occurred more frequently in INTERMACS level-1 patients (Fig. Peri-procedural Characteristics INTERMACS level 1-patients and BTT-patients were preoperatively more frequently supported by temporary MCS-devices when compared with INTERMACS level 2 to 4-patients and DT patients, respectively (Table 2). There was no significant survival difference in these HVAD patients not undergoing heart transplantation during follow-up when comparing INTERMACS level 1 and INTERMACS levels 2 to 4 patients ( I p i >0.05; Fig. [Extracted from the article]

Investigates the mechanisms of action of mycophenolate mofetil (MMF) in vivo using whole blood assays of multiple lymphocyte functions. Antiproliferative effect of MMF; Proliferation of lymphocytes and surface antigen expression; Correlations between MMF pharmacodynamic effects over time with both MMF dose and plasma concentrations.

Background: Genetics of sudden cardiac deaths (SCD) remains frequently undetected. Genetic analysis is recommended in undefined selected cases in the 2021 ERC-guideline. The emergency medical service and physicians (EMS) may play a pivotal role for unraveling SCD by saving biomaterial for later molecular autopsy. Since for high-throughput DNA-sequencing (NGS) high quality genomic DNA is needed. We investigated in a prospective proof-of-concept study the role of the EMS for the identification of genetic forms of SCDs in the young.Methods: We included patients aged 1-50 years with need for cardiopulmonary resuscitation attempts (CPR). Cases with non-natural deaths were excluded. In two German counties with 562,904 residents 39,506 services were analysed. Paired end panel-sequencing was performed, and variants were classified according to guidelines of the American College of Medical Genetics (ACMG).Results: 769 CPR-attempts were recorded (1.95% of all EMS-services; CPR-incidence 68/100,000). In 103 cases CPR were performed in patients < 50y. 58% died on scene, 26% were discharged from hospital. 24 subjects were included for genotyping. Of these 33% died on scene, 37.5% were discharged from hospital. 25% of the genotyped patients were carriers of (likely) pathogenic (ACMG-4/-5) variants. 67% carried variants with unknown significance (ACMG-3). 2 of them had familial history for arrhythmogenic cardiomyopathy or had to be re-classified as ACMG-4 carriers due to whole exome sequencing.Conclusion: The EMS contributes especially in fatal OHCA-cases to increase the yield of identified genetic conditions by collecting a blood sample on scene. Thus, the EMS can contribute significantly to primary and secondary prophylaxis in affected families. [ABSTRACT FROM AUTHOR]

The purpose of the study was to investigate the outcome of secondary surgical aortic valve replacement (sSAVR) in patients with severe aortic regurgitation (AR) in the context of ventricular assist device (VAD) therapy. From 2009 to 2020, 792 patients underwent cf‐LVAD implantation [HVAD (Medtronic, USA), n = 585, and HM 3 (Abbott, USA), n = 207]. All cf‐LVAD patients with severe AR requiring secondary AVR were enrolled in this study. A total of six patients (median, 40 years, IQR; 34‐61 years, 50% male) underwent secondary surgical aortic valve replacement (sSAVR) after cf‐LVAD implantation. Median time of previous LVAD support was 26 months (IQR: 21‐29 months). Two patients required additional tricuspid valve repair (TVR) and one patient underwent SAVR after failed TAVR. Four patients needed temporary right ventricular assist device (RVAD) with a median of 30 days (IQR; 29‐33 days). Three patients were bridged to urgent heart transplantation due to persevering right heart failure, whereas two destination therapy (DT) candidates survived without any associated complications. An additional DT patient died of pneumonia 1 month after sSAVR. Secondary surgical aortic valve replacement in ongoing LVAD patients is an advanced procedure for a complex cohort. In our series, sSAVR was safely performed and effective, but involved a high‐risk for subsequent right heart failure, requiring urgent heart transplantation. In LVAD patients with severe AR requiring treatment where TAVR is not feasible, sSAVR can be evaluated as salvage option for bridge to transplant patients or selected destination therapy candidates. [ABSTRACT FROM AUTHOR]

In cardiac surgery, use of the antifibrinolytic agent tranexamic acid (TXA) and acute perioperative stroke are both associated with convulsive seizures. We hypothesized that an older (preoperative) stroke increases the risk of TXA-associated seizures as well. To test this hypothesis, we retrospectively analyzed data from 16,110 patients who had undergone open-heart valvular surgery at our institution between 2009 and 2020. The dosing of TXA was moderate. Use of TXA and a history of stroke were both independently associated with convulsive seizure with an adjusted odds ratio (OR) of 2.40 (95%CI: 1.71–3.37) and 1.79 (95%CI: 1.27–2.54), respectively. Compared to patients without TXA administration, the adjusted OR of experiencing a seizure in TXA patients without a history of stroke was 2.44 (95%CI: 1.71–3.46) and in patients receiving TXA with a history of stroke 4.30 (95%CI: 2.65–6.99). However, there was no significant interaction between TXA use and preoperative stroke on convulsive seizures (P = 0.77). Compared to patients without seizure, for patients with seizure, the inverse probability-weighted ORs of in-hospital mortality and 30-day mortality were 3.58 (95%CI: 2.20–5.83) and 4.04 (95%CI: 2.34–6.98), respectively. We conclude that, in patients undergoing open-heart surgery, a history of stroke is independently associated with convulsive seizures but is not a contraindication for TXA use. [ABSTRACT FROM AUTHOR]

Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all‐cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge‐to‐transplantation LVAD patients [median age at LVAD implantation: 32.5 years (IQR: 24.8‐39.5 years); four male, HVAD, n = 3; HM II, n = 1; HM 3, n = 2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n = 2), dilated (n = 2), or ischemic (n = 2). Median INTERMACS class was 1.5 (IQR; 1.0‐2.8). Median time on LVAD support to DC procedure was 33 months (IQR: 16‐48 months). The indication for DC was intraparenchymal hemorrhage (n = 4), subdural hematoma (n = 1), and malignant middle cerebral artery infarction (n = 1). After a median time of 4 months (IQR: 3.3‐4.0 months, range; 2.0‐10 months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26 months (IQR: 21‐42 months) follow‐up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Myocardial recovery is a rare phenomenon in left ventricular assist device (LVAD) therapy. Surgical LVAD removal is associated with the risk of cardiac failure, and the individual evaluation of sufficient myocardial recovery is crucial. Thus, complete device explantation is not consistently performed to minimize perioperative risk. However, the remaining ventricular assist device components bear significant risks of infection or thrombosis. Therefore, we developed this study to evaluate a complete LVAD explantation protocol. METHODS All patients in our institution who had an LVAD explanted were enrolled in the study. Explant surgery involved removal of the driveline, pump housing, sewing ring and outflow graft. The ventricular wall was reconstructed by double patch plasty. Our analysis focused on surgical and postoperative outcome parameters, including all-cause mortality and major adverse cardiac and cerebrovascular events. RESULTS A total of 12 patients (HVAD, n  = 5; HeartMate II, n  = 3; HeartMate 3, n  = 4) had myocardial recovery and qualified for our LVAD explantation study protocol [median age: 40 years, interquartile range (IQR) 33–52 years; 50% men]. Primary heart failure aetiology: myocarditis (n  = 5), dilated cardiomyopathy (n  = 4), toxic cardiomyopathy (n  = 2) and valvular heart failure (n  = 1). The median average duration on LVAD was 10 months (25–75%: IQR 8.5–30 months). The median left ventricular ejection fraction was 15% (IQR 13–18%) at LVAD implantation and 50% (IQR 45–50%) before LVAD explantation (P  = 0.0025).The 30-day survival was 100%. The 1-year survival was 91.7%. All patients were discharged after a median 13 days (IQR 10–18 days) postoperatively. No patient had major adverse cardiac and cerebrovascular events. The New York Heart Association functional class remained consistent during the follow-up period (median New York Heart Association functional class: II, IQR II–II class) including preservation of ventricular function. CONCLUSIONS Complete LVAD explantation with ventricular patch plasty is feasible and has consistent long-term results. [ABSTRACT FROM AUTHOR]

We performed "Papillary muscle heads focalization" for three patients with severe functional mitral regurgitation with severe leaflet tethering (coaptation distance ≥1 cm and/or posterior leaflet angle ≥45 degrees). All separated papillary muscle heads were sutured together and both the anterolateral and posteromedial papillary muscles were reconstructed as single head papillary muscles. The stitches are positioned to adjust the levels of mitral leaflet tips, concerning the length of the marginal chordae connected to each head. A downsized annuloplasty is performed concomitantly. At discharge, no patient showed moderate/severe mitral regurgitation. Their coaptation lengths were 7.1, 8.5, and 8.3 mm. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Clinical experience with continuous flow ventricular assist devices (VADs) in patients with transposition of the great arteries (TGA) including dextro-TGA and congenitally corrected TGA is rare, and indications as well as potential benefits or specific hurdles remain unclear. Therefore, our goal was to report on our experience regarding VAD therapy in adult patients with TGA as a bridge to candidacy. METHODS We performed a single-centre retrospective study of all adult patients with TGA with systemic right ventricular failure who had continuous flow VAD implants between 2010 and 2018. Study end points were all causes of death, major cardiac and cerebrovascular adverse events or pump thrombosis. Follow-up continued until the time of the heart transplant. RESULTS A total of 6 patients (4 men) had a continuous flow VAD implanted in the context of a failing systemic right ventricle (dextro-TGA after the Mustard procedure: n  = 3; congenitally corrected TGA: n  = 3). Demographics: mean age 32 ± 5.7 years; median Interagency Registry for Mechanically Assisted Circulatory Support: level II (range 1–4), mean pulmonary artery 48 ± 13 mmHg, mean pulmonary vascular resistance 5.6 ± 3.5 Wood units. Postoperative data: intensive care unit stay: 16 ± 9.7 days; in-hospital survival: 100%; no early VAD-related complications occurred. Mean follow-up: 33 ± 18 months; persistent left-side paresis: n  = 1; minor (non-disabling) stroke: n  = 2. Post-VAD pulmonary artery: 19 ± 3.4 mmHg; P  < 0.005; post-VAD pulmonary resistance: 2.2 ± 0.55 Wood units; P  = 0.066. Four patients had heart transplants after a mean waiting time of 30 months after the VAD was implanted; 2 patients are still on the waiting list (waiting time: 52 and 24 months). CONCLUSIONS Continuous flow VAD therapy is a feasible therapeutic option in adult patients with TGA and a failing systemic right ventricle as a bridge to candidacy and a bridge to a heart transplant. [ABSTRACT FROM AUTHOR]

The remedē system is a novel fully implantable transvenous phrenic nerve stimulation (TPNS) device developed to treat central sleep apnea. No information is published on how to explant or replace its leads. An eighty‐one year‐old had a fractured lead and we removed it over a wire. However, unbreachable resistances occurred with a new lead deployed over the enclosed wire and interventional endovascular techniques were performed to reimplant a new fully functioning system. This first report demonstrates TPNS lead exchange is possible but can be challenging. Interventional maneuvers and techniques, including balloon angioplasty, can facilitate this procedure. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the study was to analyze early mortality after continuous-flow left ventricular assist device (LVAD) implantation which remains high. Methods: We analyzed consecutive (n = 2689) patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) undergoing continuous-flow LVAD implantation. The primary outcome was early (< 90 days) mortality. Secondary outcomes were differential causes of early post-operative death following LVAD implantation. Results: Univariable and multivariable analysis as well as regression analysis were used to examine determinants and differential causes of early (< 90 days) mortality after LVAD implantation. During the first 90 days, 2160 (80%) patients were alive with ongoing LVAD support, 40(2%) patients underwent heart transplantation, and 487(18%) deceased. The main causes of early death were MOF (36%), sepsis (28%), cardiopulmonary failure (CPF; 10%), CVA (9%), and right-sided heart failure (RHF, 8%). Furthermore, MOF and sepsis are 70% of causes of death in the first week. Independent clinical predictors of early death were age, female sex, INTERMACS profile 1 to 3, and ECMO. Laboratory predictors included elevated serum creatinine, total bilirubin, lactate, and low hemoglobin. Furthermore, hemodynamic predictors included elevated RA-to-PCWP ratio, pulmonary vascular resistance, and low systemic vascular resistance. Longer total implantation time was also independent predictor of early mortality. A simple model of 12 variables predicts early mortality following LVAD implantation with a good discriminative power with area under the curve of 0.75. Conclusions: In the EUROMACS registry, approximately one out of five patients die within 90 days after LVAD implantation. Early mortality is primarily dominated by multiorgan failure followed by sepsis. A simple model identifies important parameters which are associated with early mortality following LVAD implantation. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide Mechanical circulatory support gained a significant value in the armamentarium of heart failure therapy because of the increased awareness of the prevalence of heart failure and the tremendous advances in the field of mechanical circulatory support during the last decades. Current device technologies already complement a heart transplant as the gold standard of treatment for patients with end-stage heart failure refractory to conservative medical therapy. This article reviews important aspects of mechanical circulatory support therapy and focuses on currently debated issues. [ABSTRACT FROM AUTHOR]

Purpose: Observational studies indicate a positive association between circulating 25-hydroxyvitamin D (25OHD) and testosterone (T) concentrations. Because low 25OHD concentrations and T deficiency are considered to be a generalized phenomenon in patients with advanced heart failure (HF), we aimed to investigate whether vitamin D supplementation has beneficial effects on T indices in these patients. Methods: In a pre-specified secondary analysis of the EVITA (effect of vitamin D on mortality in heart failure) randomized controlled trial, we analyzed in male subjects with 25OHD concentrations < 75 nmol/L the effect of a daily vitamin D3 supplement of 4000 IU for 3 years (n = 71) vs. placebo (n = 62) on total T (TT), sex hormone-binding globulin (SHBG), free T (fT), and bioactive T (BAT). We assessed changes from baseline until study termination and between-group differences at study termination. Results: 25OHD increased in the placebo group from 36.6 nmol/L by 9.2 nmol/L (95% CI 3.2–15.1 nmol/L; P = 0.003) and in the vitamin D group from 36.5 nmol/L by 63.9 nmol/L (95% CI 52.6–75.3 nmol/L; P < 0.001), with a significant between-group difference at study termination (P < 0.001). TT and SHBG concentrations did not change significantly, neither in the placebo group nor in the vitamin D group (P = 0.845–0.082), but concentrations of fT and BAT declined significantly in both groups (P = 0.025–0.008). At study termination, there were no between-group differences in TT (P = 0.612), SHBG (P = 0.393), fT (P = 0.861), or BAT (P = 0.960). Conclusions: In male patients with advanced HF and low 25OHD concentrations, a daily vitamin D3 supplement of 4000 IU for 3 years did not prevent the decline in testosterone indices. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to investigate the effect of a moderately high vitamin D dose on lipid parameters and biochemical markers of vascular calcification (VC) in patients with established cardiovascular disease. Methods: We included in this pre-specified secondary analysis of a randomized controlled trial 161 patients with advanced heart failure and 25-hydroxyvitamin D (25OHD) concentrations < 75 nmol/L (vitamin D group: n = 80; placebo group: n = 81), who received a daily vitamin D3 supplement of 4,000 IU for 3 years. We assessed between-group differences of the lipid parameters total-cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, and triglycerides, and the VC markers fetuin-A and non-phosphorylated undercarboxylated matrix gla protein (MGP) at study termination, with adjustment for baseline values. Results: Lipid parameters, the percentage of patients with dyslipoproteinemia, and VC markers did not differ significantly between groups at study termination (p values: 0.395–0.939). Likewise, vitamin D achieved no significant treatment effect on these markers in subgroup analyses in patients with 25OHD concentrations < 30 nmol/L, nonusers of lipid-lowering drugs, or diabetic patients (p values: 0.245–0.998). Conclusion: Our data indicate that vitamin D does not improve the lipid profile and does not influence the calcification inhibitors fetuin-A and non-phosphorylated undercarboxylated MGP in patients with advanced heart failure. [ABSTRACT FROM AUTHOR]

Objective. 1,25-Dihydroxyvitamin D (1,25([OH]2D) is considered to be a negative endogenous regulator of the renin-angiotensin-aldosterone system (RAAS), but the effect of vitamin D supplementation on the RAAS is inconclusive. Design. In this prespecified secondary analysis of a randomized controlled trial, we assessed in 165 patients with heart failure (vitamin D group: n=83; placebo group: n=82) the effect of three years of vitamin D supplementation with 4000 IU daily on parameters of the RAAS (renin and aldosterone) and on circulating 1,25(OH)2D, plasma phosphate, and fibroblast growth factor (FGF)-23. We assessed age- and baseline-adjusted between-group differences at study termination. Results. Almost all patients were under treatment with beta-blockers, inhibitors of the RAAS, and diuretics. Initially, the frequency of concentrations above the laboratory-specific reference range (renin: >23.9 mIU/L; aldosterone: >232 ng/L) in the vitamin D and placebo group was 87.7% and 92.7%, respectively (renin), and 24.1% and 32.5%, respectively (aldosterone). Vitamin D increased adjusted 1,25(OH)2D concentrations significantly (mean treatment effect and 95% CI: 18.3 pmol/L,7.3 to 29.3 pmol/L; P<0.001) but had no significant effects on phosphate (0.18 mmol/L, −0.00 to 0.35 mmol/L; P=0.051), FGF-23 (685 RU/mL, −213 to 1585 RU/mL; P=0.134), renin (312 mIU/L, −279 to 902 ng/L; P=0.298), or aldosterone (−0.19 ng/L, −5.09 to 4.70 ng/L; P=0.938). Vitamin D supplementation was, however, associated with an increase in renin concentrations in the subgroup with baseline 25-hydroxyvitamin D below 30 nmol/L (n=67; 1365 mIU/, 343 to 2386 mIU/L; P=0.010). Conclusions. In patients with advanced heart failure treated according to evidence-based guidelines, vitamin D supplementation did not significantly influence parameters of the RAAS in the entire study cohort but was associated with an increase in plasma renin concentrations in the subgroup with low baseline 25-hydroxyvitamin D concentrations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Prolonged support with a left ventricular assist device (LVAD) has evolved as an alternative treatment strategy for patients with end-stage heart disease. This requires a shift in focus on sexual activity and psychosocial outcomes in patients with an LVAD and their partners. METHODS: This cross-sectional study was designed to capture Sexual Activities in Left Ventricular Assist Device Patients Or PaRtners (SALVADOR) perceptions on illness-related changes in the quality of sexual activity and its impact on quality of life, anxiety and depression using standardized patient-reported outcome scales (Sexual Adjustment Scale, 36-Item Short Form Health Survey, Hospital Anxiety and Depression Scale). A total of 72 patients with LVADs (50% response rate) along with 48 partners participated. RESULTS: For patients with an LVAD (median age 60 years; 84.7% male), median time on the device was 650 days; 69.5% stayed in longterm partnerships (median 23 years). Prevalence rates for illness-related changes in the quality of sexual activity were 58.3% for patients and 52.1% for partners. Device-related disturbances in sexual activities occurred due to battery pockets (patients/partners: 59.2%/37.6%; P = 0.006) and the driveline (46.3%/37.5%; P = 0.033) and led to significantly increased distress in patients/partners (battery pockets: 53.5%/ 41.3%; P = 0.006; driveline 54.9%/37.5%; P = 0.004). Disturbances in sexual activity were independently associated with higher rates of depression (odds ratio 1.33, 95% confidence interval 1.14-1.55; P = 0.001) in patients and lower mental quality of life (odds ratio 6.18, 95% confidence interval 1.13-33.98; P = 0.036) in partners. CONCLUSIONS: Disturbances in sexual activity are common in patients with an LVAD and their partners while the patients are on durable long-term support. Counselling on long-term adjustment should provide a platform for information seeking on illness-related changes in the quality of sexual activity. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to derive and validate a novel risk score for early right-sided heart failure (RHF) after left ventricular assist device implantation.Methods: The EUROMACS (European Registry for Patients with Mechanical Circulatory Support) was used to identify adult patients undergoing continuous-flow left ventricular assist device implantation with mainstream devices. Eligible patients (n=2988) were randomly divided into derivation (n=2000) and validation (n=988) cohorts. The primary outcome was early (<30 days) severe postoperative RHF, defined as receiving short- or long-term right-sided circulatory support, continuous inotropic support for ≥14 days, or nitric oxide ventilation for ≥48 hours. The secondary outcome was all-cause mortality and length of stay in the intensive care unit. Covariates found to be associated with RHF (exploratory univariate P<0.10) were entered into a multivariable logistic regression model. A risk score was then generated using the relative magnitude of the exponential regression model coefficients of independent predictors at the last step after checking for collinearity, likelihood ratio test, c index, and clinical weight at each step.Results: A 9.5-point risk score incorporating 5 variables (Interagency Registry for Mechanically Assisted Circulatory Support class, use of multiple inotropes, severe right ventricular dysfunction on echocardiography, ratio of right atrial/pulmonary capillary wedge pressure, hemoglobin) was created. The mean scores in the derivation and validation cohorts were 2.7±1.9 and 2.6±2.0, respectively (P=0.32). RHF in the derivation cohort occurred in 433 patients (21.7%) after left ventricular assist device implantation and was associated with a lower 1-year (53% versus 71%; P<0.001) and 2-year (45% versus 58%; P<0.001) survival compared with patients without RHF. RHF risk ranged from 11% (low risk score 0-2) to 43.1% (high risk score >4; P<0.0001). Median intensive care unit stay was 7 days (interquartile range, 4-15 days) versus 24 days (interquartile range, 14-38 days) in patients without versus with RHF, respectively (P<0.001). The c index of the composite score was 0.70 in the derivation and 0.67 in the validation cohort. The EUROMACS-RHF risk score outperformed (P<0.0001) previously published scores and known individual echocardiographic and hemodynamic markers of RHF.Conclusions: This novel EUROMACS-RHF risk score outperformed currently known risk scores and clinical predictors of early postoperative RHF. This novel score may be useful for tailored risk-based clinical assessment and management of patients with advanced HF evaluated for ventricular assist device therapy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Meta-analyses from observational and randomized studies have demonstrated benefits of off-pump surgery for hard and surrogate endpoints. In some of them, increased re-revascularization was noted in the off-pump groups, which could impact their longterm survival. Therefore, we analyzed the course of all patients undergoing isolated coronary surgery regarding the major cardiac and cerebrovascular event (MACCE) criteria. METHODS: A prospective register was taken from a high-volume off-pump center recording all anaortic off-pump (ANA), clampless offpump (PAS-Port) and conventional (CONV) coronary artery bypass operations between July 2009 and June 2015. Propensity Score Matching was performed based on 28 preoperative risk variables. RESULTS: We identified 935 triplets (N = 2805). Compared with CONV, in-hospital mortality of both the ANA group (OR for ANA [95% CI] 0.25 [0.06; 0.83], P = 0.021), and the PAS-Port group was lower (OR for PAS-Port [95% CI] 0.50 [0.17; 1.32], P = 0.17). In the mid-term followup there were no significant differences between the groups regarding mortality (HR for ANA [95%-CI] 0.83 [0.55-1.26], P = 0.38; HR for PAS-Port [95%-CI] 1.06 [0.70-1.59], P = 0.79), incidence of stroke (HR for ANA 0.81 [0.43-1.53], P = 0.52; HR for PAS-Port 0.78 [0.41-1.50], P = 0.46), myocardial infarction (HR for ANA 0.53 [0.22-1.31], P = 0.17; HR for PAS-Port 0.78 [0.37-1.66], P = 0.52) or re-revascularization rate (HR for ANA 0.99 [0.67-1.44], P = 0.94; HR for PAS-Port 0.95 [0.65-1.38], P = 0.77). CONCLUSIONS: Both off-pump clampless techniques were associated with lower in-hospital mortality compared with conventional CABG. The mid-term course showed no difference with regard to the MACCE criteria between anaortic off-pump, clampless off-pump using PAS-Port and conventional CABG. [ABSTRACT FROM AUTHOR]

Background: Calcium and phosphate are central for myocardial contractility and energy metabolism, and low levels of the calciotropic hormone 1,25-dihydroxyvitamin D (1,25(OH)2D), as well as high levels of the phosphaturic hormone fibroblast growth factor (FGF)-23, are independently associated with poor clinical outcome in heart failure (HF) patients. We therefore aimed to investigate the postoperative time course of the aforementioned hormones in HF patients supported with a left-ventricular assist device (LVAD) implant. Methods: For the present study, stored biobank plasma samples of 69 patients, collected before LVAD implantation (t0) and 12 days (t1), 30 days (t2), 83 days (t3), and 300 days (t4) post-intervention, were used to measure circulating FGF-23, parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), 1,25(OH)2D, and kidney function. Results: Most patients were male and had baseline INTERMACS levels and cardiac index values ≤ 3 and ≤ 2.7 L/min/m2, respectively. There were significant time effects on estimated glomerular filtration rate (eGFR), FGF-23 and 1,25(OH)2D, but not on PTH or 25OHD. Notably, eGFR values increased and FGF-23 levels decreased only transiently, whereas 1,25(OH)2D increased continuously until t4. The rise in 1,25(OH)2D was largely influenced by those patients who survived the first post-implant year, and was not seen in non-survivors. Variations in 1,25(OH)2D levels could only partly be explained by eGFR values or FGF-23, 25OHD, and PTH levels (multiple R2 = 0.305;P<0.001). Conclusions: The present study indicates that LVAD implantation has only transient effects on circulating FGF-23 levels, but is associated with a continuous increase in circulating 1,25(OH)2D levels, especially in survivors. [ABSTRACT FROM AUTHOR]

On the basis of a long-standing voluntary registry, which was founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all heart, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during 2015 are analyzed. In 2015, a total of 103,967 heart surgery procedures (implantable cardioverter defibrillator, pacemaker, and extracardiac procedures without ECC excluded) were submitted to the database. Approximately 14.8% of the patients were at least 80 years old, resulting in an increase of 0.6% compared with the data of 2014. For 38,601 isolated coronary artery bypass grafting procedures (relationship on-/off-pump: 5:1), the unadjusted inhospital mortality was 2.7%. Concerning the 32,346 isolated heart valve procedures (including 10,606 catheter-based implantations) an unadjusted inhospital mortality of 4.4% was observed. This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, demonstrates advancements in heart medicine, and enables internal/external quality assurance for all participants. In addition, the registry demonstrates that the provision of heart surgery in Germany is appropriate and patients are treated nationwide in a round-the-clock service. [ABSTRACT FROM AUTHOR]

Background: Vitamin D has immunomodulatory properties and seems to reduce the risk of infections. Whether low vitamin D concentrations are independent risk factors for nosocomial postoperative infections in surgical patients remains to be studied in detail. Methods: In 3,340 consecutive cardiac surgical patients, we investigated the association of circulating 25-hydroxyvitamin D (25OHD; indicator of nutritional vitamin D status) and 1,25-dihydroxyvitamin D (1,25[OH]2D; active vitamin D hormone) with nosocomicial infections. The primary endpoint was a composite of thoracic wound infection, sepsis, and broncho-pulmonary infection. Vitamin D status was measured on the last preoperative day. Infections were assessed until discharge. Logistic regression analysis was used to examine the association between vitamin D metabolite concentrations and the composite endpoint. Results: The primary endpoint was reached by 5.6% (n = 186). In patients who reached and did not reach the endpoint, in-hospital mortality was 13.4% and 1.5%, respectively (P<0.001). Median (IQR) 25OHD and 1,25(OH)2D concentrations were 43. 2 (29.7–61.9) nmol/l and 58.0 (38.5–77.5) pmol/l, respectively. Compared with the highest 1,25(OH)2D quintile (>81.0 pmol/l), the multivariable–adjusted odds ratio of infection was 2.57 (95%CI:1.47–4.49) for the lowest 1,25(OH)2D quintile (<31.5 pmol/l) and 1.85 (95%CI:1.05–3.25) for the second lowest quintile (31.5–49.0 pmol/l). There was no significant association between 25OHD concentrations and the primary endpoint. Conclusions: Our data indicate an independent association of low 1,25(OH)2D levels with the risk of postoperative infections in cardiac surgical patients. Future studies should pay more attention on the clinical relevance of circulating 1,25(OH)2D and its regulation. [ABSTRACT FROM AUTHOR]

Background. The clinical relevance of circulating 1,25-dihydroxyvitamin D (1,25(OH)2D) is probably underappreciated, but variations in the measurement of this difficult analyte between different methods limit comparison of results. Methods. In 129 clinical samples, we compared a new automated assay with a commercially available liquid chromatography tandem mass spectrometry (LC-MS/MS) kit. Results. Median (interquartile range) 1,25(OH)2D concentrations with the automated assay and the LC-MS/MS method were 26.6 pg/mL (18.5–39.0 pg/mL) and 23.6 pg/mL (16.1–31.3 pg/mL), respectively (P=0.001). Using the method-specific cut-offs for deficient 1,25(OH)2D levels (<20 pg/mL for the automated assay and <17 pg/mL for the LC-MS/MS method), the percentage of patients classified as 1,25(OH)2D deficient was 28.7% and 27.1%, respectively. However, concordance between the two methods for deficient levels was only 62% and the concordance correlation coefficient was poor (0.534). The regression equation resulted in an intercept of −1.99 (95% CI: −7.33–1.31) and a slope of 1.27 (95% CI: 1.04–1.52) for the automated assay. The mean bias with respect to the mean of the two methods was −3.8 (1.96 SD: −28.3–20.8) pg/mL for the LC-MS/MS method minus the automated assay. Conclusions. The two methods show only modest correlation and further standardization is required to improve reliability and comparability of 1,25(OH)2D test procedures. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In cardiac surgery, the association between red blood cell (RBC) transfusion and clinical outcome is elusive. We investigated in a large cohort of patients who underwent isolated coronary artery bypass grafting (CABG) the effect of transfusion of 1-2 units of leucocyte- depleted RBCs on mortality and multiorgan failure. METHODS: The investigation included all patients from July 2009 to June 2014 who underwent CABG at our institution and received no (n = 1478) or 1-2 units of RBCs (n = 1528). The primary end-point was 30-day mortality; secondary end-points were major organ dysfunction. A subgroup analysis assessed the effect of the duration of RBC storage on patient outcome. Statistical analysis was performed using propensity score (PS) adjustment. RESULTS: The 30-day mortality rate was 0.3% in the RBC- group and 0.2% in the RBC+ group. Compared with the RBC- group, PS-adjusted odds ratio (OR) of 30-day mortality in the RBC+ group was 0.29 [95% confidence interval (CI): 0.06-1.50; P = 0.14]. PS-adjusted OR of a 'prolonged intensive care unit (ICU) stay' (>48 h) was significantly higher in the RBC+ group than in the RBC- group [OR 1.49 (95% CI: 1.14-1.95); P = 0.004], but major clinical complications such as low cardiac output syndrome, stroke, haemofiltration, wound infection and prolonged mechanical ventilator support (>24 h) did not differ significantly between groups. Duration of blood storage was not independently associated with clinical outcome. CONCLUSIONS: Our data do not indicate a transfusion-related increase in mortality and multiorgan failure in patients undergoing isolated CABG. [ABSTRACT FROM AUTHOR]

Background Heart transplantation (HTx) is still considered the therapeutic gold standard in end-stage heart failure. Methods In "high urgent" (HU)-listed patients for HTx (n = 274) and patients receiving left ventricular assist device (LVAD) implants (n = 332), we compared 1-year overall survival (primary endpoint) and 1-year probability of HTx and therapy failure (the need for LVAD implantation in HU-listed patients or the need for HU listing in LVAD patients) (secondary endpoints). Results In the HU and LVAD group, 1-year survival was 86.8 and 64.7%, respectively (p < 0.001). The propensity score (PS)-adjusted hazard ratio of mortality did not differ between the groups and for the LVAD group (reference = HU group) was = 1.36 (95% confidence interval [CI]: 0.85-2.19; p = 0.198). The PS-adjusted hazard ratio for the failure to receive HTx for the LVAD group (reference = HU group) was = 9.77 (95% CI: 6.00-15.89; p < 0.001). The corresponding hazard ratio for therapy failure for the LVAD group was = 0.16, 95% CI: 0.10-0.27; p < 0.001). Conclusion Despite considerable differences in the probability of HTx and therapy failure, 1-year overall survival was similar in HU and LVAD patients. [ABSTRACT FROM AUTHOR]

Background Left ventricular assist device (LVAD) implants bear the risk of driveline/ device infections and technical failures. Methods We assessed clinical outcome in LVAD patients with device-related complications. Group 1 (n = 12) received device exchange (DEx) as destination therapy (DT), group 2 (n = 15) received DEx as a bridge to transplant (BTT), group 3 (n = 34) was allocated to receive high-urgency (HU) heart transplantation (HTx), and group 4 (n = 27) had device-related complications that could only be solved by HTx. Primary endpoint was 1-year overall survival. Results Age and Simplified Acute Physiology Score II differed significantly between groups and were highest in group 1, lowest in group 3. One-year survival in groups 1 to 4 was 66.7, 60.0, 82.4, and 70.4% (p = 0.30). Covariate-adjusted odds ratio of 1-year survival (reference: group 1) was for group 2 = 1.52 (95% confidence interval [CI]: 0.42-5.57), for group 3 = 1.13 (95% CI: 0.28-4.56), and for group 4 = 1.89 (95% CI: 0.51-7.04; p for trend 0.70). Clinical complications (need of mechanical ventilator support, extracorporeal circulatory membrane oxygenation (ECMO) implants, kidney/ liver dialysis) were comparable between groups. Conclusion Data indicate similar 1-year clinical outcomes in LVAD patients with device-related complications receiving DEx or HTx. [ABSTRACT FROM AUTHOR]

Background: Preoperative anemia is considered an independent risk factor of poor clinical outcome in cardiac surgical patients. Low vitamin D status may increase anemia risk. Methods: We investigated 3,615 consecutive patients scheduled for cardiac surgery to determine the association between preoperative anemia (hemoglobin [Hb] <12.5 g/dL) and circulating levels of the vitamin D metabolites 25-hydroxyvitamin D (25OHD) and 1,25-dihydroxyvitamin D (1,25[OH]2D). Results: Of the study cohort, 27.8 % met the criteria for anemia. In patients with deficient 25OHD levels (<30 nmol/l) mean Hb concentrations were 0.5 g/dL lower than in patients with adequate 25OHD levels (50.0–125 nmol/l; P<0.001). Regarding 1,25(OH)2D, mean Hb concentrations were 1.2 g/dL lower in the lowest 1,25(OH)2D category (<40 pmol/l) than in the highest 1,25(OH)2D category (>70 pmol/l; P<0.001). In multivariable–adjusted logistic regression analyses, the odds ratios for anemia of the lowest categories of 25OHD and 1,25(OH)2D were 1.48 (95%CI:1.19-1.83) and 2.35 (95%CI:1.86-2.97), compared with patients who had adequate 25OHD levels and 1,25(OH)2D values in the highest category, respectively. Anemia risk was greatest in patients with dual deficiency of 25OHD and 1,25(OH)2D (multivariable-adjusted OR = 3.60 (95%CI:2.40-5.40). Prevalence of deficient 25OHD levels was highest in anemia of nutrient deficiency, whereas low 1,25(OH)2D levels were most frequent in anemia of chronic kidney disease. Conclusion: This cross-sectional study demonstrates an independent inverse association between vitamin D status and anemia risk. If confirmed in clinical trials, preoperative administration of vitamin D or activated vitamin D (in case of chronic kidney disease) would be a promising strategy to prevent anemia in patients scheduled for cardiac surgery. [ABSTRACT FROM AUTHOR]