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Background: Mechanisms of repair failure after mitral valve repair (MVr) using chordal replacement and annuloplasty for degenerative mitral regurgitation were analyzed., Methods: All mitral valve reoperations after isolated MVr using solely chordal replacement and annuloplasty for degenerative mitral regurgitation at the German Heart Center Munich were reviewed. This retrospective observational study aims to analyze mechanisms of repair failure leading to reoperations., Results: Between 2003 and 2010, a total of 344 patients received MVr with chordal replacement and annuloplasty. During a mean follow-up of 9.7 years (0.00 - 15.9 years) in 38 (11.0%) cases reoperation on the mitral valve was necessary. Reoperations were performed after a mean of 6.8 years (0.00 - 14.1 years). The mechanisms of MVr failure were disease progression (39.5%), technical failure (36.8%) and endocarditis (18.4%). Re-repair was performed in 28.9% and was accomplished using redo annuloplasty (90.9%), chordal replacement (90.9%), resection techniques (27.3%) and leaflet patch reconstruction (9.1%). One patient (2.6%) received transcatheter edge-to-edge repair for reoperation. Mitral valve replacement (MVR) was necessary in 63.2%. Redo MVr was mainly performed in cases of technical failure and MVR was more frequently performed in cases with mitral valve sclerosis. Re-reoperation was necessary in 3/24 cases of MVR and in 2/11 cases of redo MVr after a median of 3.8 (0.01 - 10.04) years., Conclusions: MVr using chordal replacement allows a variety of methods for re-repair including transcatheter solutions. Redo MVr is more often feasible in cases of technical failure, while MVR for reoperation is more frequently necessary in mitral valve sclerosis., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: The optimal surgical approach for the treatment of functional mitral regurgitation (FMR) remains controversial. Current guidelines suggest that the surgical approach has to be tailored to the individual patient. The aim of the present study was to clarify further aspects of this tailored treatment. Methods: From 01/2006 to 12/2015, 390 patients underwent mitral valve (MV) surgery for FMR (ischemic n = 241, non-ischemic n = 149) at our institution. A regression analysis was used to determine the effect of MV repair or replacement on survival. The patients were analyzed according to the etiology of the MR (ischemic or non-ischemic), different age groups (<65 years, 65-75 years, and >75 years), LV function, and LV dimensions, as well as the underlying heart rhythm. Results: The overall survival rates for the repair group at 1, 5, and 8 years were 86.1 ± 1.9%, 70.6 ± 2.6%, and 55.1 ± 3.1%, respectively. For the same intervals, the survival rates in patients who underwent MV replacement were 75.9 ± 4.5%, 58.6 ± 5.4%, and 40.9 ± 6.4%, respectively ( p = 0.003). Patients younger than 65 years, with an ischemic etiology of FMR, poor ejection fraction (<30%), severe dilatation of left ventricle (LVEDD > 60mm), and presence of atrial fibrillation had significantly higher mortality rates after MV replacement (HR, 3.0; CI, 1.3-6.9; p = 0.007). Patients between 65 and 75 years of age had a higher risk of death when undergoing mitral valve replacement (HR, 1.7; CI, 1.0-2.8; p = 0.04). In patients older than 75 years, the surgical approach (MV repair or replacement) had no effect on postoperative survival (HR, 0.8; CI, 0.4-1.3; p = 0.003). Conclusions: Our data demonstrate that, in patients younger than 65 years, the treatment of choice for FMR should be MV repair. This advantage was even more evident in patients with an ischemic origin of MR, a poor ejection fraction, a severe LV dilatation, and atrial fibrillation.

Background: The long-term outcomes of mitral valve repair by nonresection techniques, such as annuloplasty and chordal replacement, for degenerative mitral valve regurgitation were investigated., Methods: All consecutive patients with degenerative mitral regurgitation who received solely chordal replacement and annuloplasty for mitral valve repair between 2003 and 2010 at the German Heart Center Munich were reviewed. The endpoints of this retrospective study were survival, cumulative incidence of reoperation on the mitral valve, and cumulative incidence of significant recurrent mitral regurgitation., Results: A total of 346 patients were evaluated. The median follow-up period was 10.86 (range, 0.01-15.86) years. The 30-day mortality rate was 0.58% (n = 2 of 346), whereas the 5-year survival was 92.97% ± 1.41%. At 5 years, cumulative incidence of recurrent mitral regurgitation was 6.87% ± 1.57% and cumulative incidence of reoperation on the mitral valve was 3.69% ± 1.05%. Survival at 10 years was 83.35% ± 2.15%. At 10 years, cumulative incidence of recurrent mitral regurgitation was 13.31% ± 2.22% and cumulative incidence of reoperation was 7.84% ± 1.55%. Cox regression analysis identified age, diabetes mellitus, and reduced left ventricular ejection fraction <55% as independent risk factors for death. Left ventricular ejection fraction <55% was revealed as independent risk factor for significant recurrent mitral regurgitation., Conclusions: This study demonstrated excellent long-term outcomes with low incidence of reoperation after mitral valve repair using chordal replacement in a highly selected patient cohort. Our findings emphasized the importance of early intervention in severe degenerative mitral regurgitation, especially in patients with reduced left ventricular ejection fraction., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Minimally invasive mitral valve repair (MVR) promises major advantages over median sternotomy regarding cosmetic results and faster recovery. However, the long-term functional outcome of minimally invasive MVR has been questioned by critics because the limited access may not exclusively promise high-quality repair. This study examines the long-term outcome regarding survival and reoperation rate., Methods: All patients undergoing minimally invasive MVR from February 2000 until March 2020 were included in this study. Baseline clinical and surgical characteristics were summarized from the internal database. Primary end points were survival and freedom from reoperation, analysed via Kaplan-Meier curves. Secondary end points were periprocedural complications after minimally invasive MVR and incidence for recurrent mitral regurgitation &gt;II°., Results: A total of 1194 patients underwent minimally invasive MVR, in 17 cases mitral valve replacement was required. The mean age was 55.1 years [47.6; 62.7]. The successful minimally invasive repair rate was 97%. The 30-day mortality was 0.6%. Survival was 96.7% [standard deviation (SD): 5.8%], 91.6% (SD: 1.1%) and 80.0% (SD: 11.2%) at 5, 10 and 20 years. The incidence of reoperation was 4.4% (SD: 3.2%), 10.3% (SD: 7.4%) and 16.7% (SD : 7.4%) at 5, 10 and 20 years, respectively. Concomitant procedures such as tricuspid valve repair and modified Cryo-maze procedure were performed in 263 cases., Conclusions: Minimally invasive MVR for degenerative mitral regurgitation is safe, shows excellent functional long-term results and is associated with low perioperative and late mortality., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Backround: Mitral valve (MV) repair in the case of a large anterior-posterior diameter and redundant valve tissue remains challenging and favors repair with a ring that exhibits a large anterior-posterior diameter. Compared to other available rings, the Medtronic Simulus annuloplasty ring shows the largest anterior-posterior diameter. This study reports for the first time mid-term results using this annuloplasty ring., Methods: Between 11/2015 and 12/2019, a total of 378 patients underwent MV repair for degenerative mitral regurgitation using the Medtronic Simulus ring, according to the following selection criteria: large MV annuli, abundant leaflet tissue (i.e., Barlow disease), and risk for SAM., Results: Overall survival after 5 years was 90.8 ± 4.6%. Five patients required valve-related reoperations because of ring dehiscence ( n = 1), progression of native valve disease ( n = 2), dehiscence of quadrangular resection suture ( n = 1), and endocarditis ( n = 1). The cumulative incidence of valve-related reoperation at 5 years was 1.3 ± 0.5%. At latest follow-up, echocardiography demonstrated excellent valve function with no/mild MR in 299 patients (94.6%). Two patients (0.6%) had more than moderate MR. No patient developed SAM after repair., Conclusion: Repair of MV with large annuli and abundant leaflet tissue with the Medtronic Simulus annuloplasty ring shows excellent mid-term results regarding reoperation rates and recurrent MR.

Background: Tricuspid valve (TV) repair is the recommended treatment for severe functional tricuspid regurgitation (fTR) in patients undergoing left-sided surgery. For this purpose, a wide range of annuloplasty devices differing in form and flexibility are available. This study reports the results using a three-dimensional annuloplasty ring (Medtronic, Contour 3D Ring) for TV repair and analysis of risk factors., Methods: A cohort of 468 patients who underwent TV repair (TVr) with a concomitant cardiac procedure from December 2010 to January 2017 was retrospectively analyzed., Results: At follow-up, 96.1% of patients had no/trivial or mild TR. The 30-day mortality was 4.7%; it significantly differed between electively performed operations (2.7%) and urgent/emergent operations (11.7%). Risk factors for recurrent moderate and severe TR were LVEF < 50%, TAPSE < 16 mm, and moderate mitral valve (MV) regurgitation at follow-up. Preoperatively reduced renal function lead to a higher 30-day and overall mortality. Reoperation of the TV was required in six patients (1.6%). Risk factors for TV related reoperations were preoperative TV annulus over 50 mm and an implanted permanent pacemaker., Conclusions: TVr with the Contour 3D annuloplasty ring shows low TR recurrence and reoperation rates. Risk-factor analysis for the recurrence of TR revealed the importance of left- and right-ventricular function.

Purpose: The Sentinel Cerebral Protection System (Sentinel-CPS) is increasingly used in transcatheter aortic valve replacement (TAVR). However, the impact of inserting the Sentinel-CPS inside the brain-supplying arteries on cerebral perfusion and oxygenation is unknown., Methods: Twenty patients undergoing transfemoral TAVR with (n = 10) and without (n = 10) cerebral embolic protection using the Sentinel-CPS were prospectively observed. All patients received conscious sedation and cerebral oxygen saturation (rSO 2 ) was continuously measured with near-infrared spectroscopy (NIRS). The cumulative perioperative cerebral desaturation was calculated for each patient by multiplying rSO 2 below an individualized desaturation threshold by time. In addition, rSO 2 values at the time of Sentinel-CPS insertion, filter positioning, and device retraction were analyzed., Results: There was no significant difference in cumulative cerebral desaturation in patients with Sentinel-CPS (median [IQR]) (0 [0/81] s%) and without (median [IQR]) (0 [0/23] s%), p = .762. A total of 6 patients (33.3%) experienced a perioperative decrease in rSO 2 below the individualized desaturation threshold (n = 3 with Sentinel-CPS, n = 3 without Sentinel-CPS; p = 1.000). Cerebral desaturation was detected during valve deployment (n = 5) and after postdilatation (n = 1). No desaturation events occurred during Sentinel-CPS insertion, filter positioning, or retraction., Conclusion: Our pilot study revealed no difference in cumulative perioperative cerebral desaturation between TAVR with and without Sentinel-CPS. Catheter- and filter-based manipulations in the brain-supplying arteries for Sentinel-CPS application were not associated with a decrease of cerebral perfusion and oxygenation., (© 2021 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Objectives: For tailored treatment of primary mitral regurgitation (MR), surgeons developed different repair techniques. One of them, the edge-to-edge repair has recently seen a revival, especially for Barlow's disease., Methods: This study was designed to assess the outcomes of the edge-to-edge technique in mitral valve (MV) repair. Preoperative, periprocedural, and postoperative data were prospectively collected in a dedicated database and analyzed retrospectively., Results: Between March 1999 and July 2019, a total of 152 patients (mean age: 60 ± 13) received an edge-to-edge repair combined with annuloplasty for degenerative MR at our institution. MR resulted from posterior leaflet prolapse in 23 patients (15.1%), anterior leaflet prolapse in 19 (12.5%), and bileaflet prolapse in 110 (72.4%). Of those who had a bileaflet prolapse, 91 (82.7%) had Barlow's disease. Follow-up was complete in 97.4% (6.4 ± 5.7 years). Echocardiographic assessment was achieved in 85.5% (5.1 ± 5.6 years). Overall survival after 10 years was 73.7 ± 5.0%. Twelve patients required valve-related reoperations due to ring dehiscence (n = 2), leaflet suture dehiscence (n = 2), progression of native valve disease (n = 6), or due to device failure (ring fracture) (n = 2). The cumulative incidence of valve-related reoperation at 10 years was 8.4 ± 3.0% (5.2 ± 4.1% in patients with Barlow's disease). At latest follow-up, echocardiography revealed excellent valve function with no or mild MR in 93 patients (88.6%). The mean gradient was 2.9 ± 1.3 mmHg at discharge and decreased to 2.4 ± 1.3 mmHg. Three patients (2.8%) had more than moderate MR., Conclusion: Edge-to-edge MV repair is a simple method with excellent results in terms of valvular function and durability especially in patients with Barlow's disease., (© 2021 The Authors. Journal of Cardiac Surgery Published by Wiley Periodicals LLC.)

Background: Mitral valve (MV) repair in children is challenging because of the broad spectrum of lesions and anticipated patient growth. The purpose of the study was to evaluate the outcome of MV repair in children below 10 years of age., Methods: We reviewed all MV repair procedures performed in children below 10 years of age. Endpoints of the study were survival after MV repair and cumulative incidence of reoperation., Results: MV repair was performed in 40 patients with congenital MV disease (MVD) and in 10 patients with acquired MVD. Median age at time of repair for congenital MVD was 1.2 years (range, 14 days to 9.8 years) and for acquired MVD 1.9 years (range, 10 days to 9.9 years). Indication for MV repair was mitral regurgitation in 31 congenital MVD patients (77.5%) and in all acquired MVD patients. In patients with congenital MVD operative mortality was 5% and late mortality was 10%. No deaths occurred in patients with acquired MVD. Patients with congenital mitral regurgitation showed a better, yet not significant, 6-year survival than patients with congenital mitral stenosis (85.3% ± 8.2% vs 60% ± 18.2%, P = .1). In patients with congenital MVD cumulative incidence of reoperation at 6 years was 38.6% ± 8.3%., Conclusions: In children below 10 years of age, MV repair is an effective treatment option for MVD. However it often just delays the time to valve replacement., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Three-dimensional saddle-shaped annuloplasty rings have been shown to create a larger surface of leaflet coaptation in mitral valve repair (MVR) for functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR) which may increase repair durability. For the first time, this study reports mid-term results after MVR for DMR and FMR using a rigid three-dimensional ring (Profile 3D, Medtronic)., Methods: Between June 2009 and June 2012, 369 patients with DMR ( n  = 326) or FMR ( n  = 43) underwent MVR (mean age 62.3 ± 12.6 years). A total of 205 patients (55.6%) underwent isolated MVR and 164 patients (44.4%) a combined procedure. Follow-up examinations were performed in 94.9% (mean 4.9 ± 0.9 years). Echocardiographic assessment was complete in 93.2% (mean 4.3 ± 1.2 years)., Results: The 30-day mortality was 1.5% (5/326) for DMR (1.5% for isolated and 1.6% for combined procedures) and 9.3% (4/43) for FMR (0% for isolated and 10.5% for combined procedures). Survival at 6 years was 92.1 ± 1.9% for DMR (92.9 ± 2.6% for isolated and 90.7 ± 2.7% for combined procedures) and 66.4 ± 7.9% for FMR (80.0 ± 17.9% for isolated and 63.7 ± 8.9% for combined procedures). Cumulative risk for mitral valve-related reoperation at 6 years was 0% for FMR and 7.1 ± 1.5% for DMR. At echocardiographic follow-up, one patient presented with mitral regurgitation (MR) more than moderate. The only predictor of recurrent MR after MVR for DMR was residual mild MR at discharge., Conclusion: Repair of FMR with the three-dimensional Profile 3D annuloplasty ring shows excellent mid-term results with regard to recurrence of MR. In cases of DMR, the results are conforming to the current literature., Competing Interests: Ruediger Lange and Bernhard Voss are consultants for Medtronic. All the other authors have no conflict of interest to declare., (Thieme. All rights reserved.)

Background: Sternal dehiscence after median sternotomy is a challenging problem in situations of frail bone, fractures, or complete sternectomy. Plate osteosynthesis offers a promising approach to restore sternal integrity. However, there is only scarce data on mid-term outcome., Methods: Mid-term data on 34 patients with unstable thorax after open heart operation, requiring sternal refixation with the Synthes Titanium Sternal Fixation System (Oberdorf, Switzerland) between 2005 and 2011, were analyzed. The Titanium Sternal Fixation System was used if conventional rewiring had failed or if failure of rewiring was expected because of risk factors. Follow-up examinations included clinical tests, computed tomographic scans, and pain assessment to evaluate sternal integrity and persistent pain., Results: Median follow-up time was 1.4 years (range, 0.3 to 6.6 years). Clinical examination showed thoracic stability in all patients. Computed tomographic scans demonstrated complete bone consolidation in 25.8%, nearly complete in 38.7%, partial in 9.7%, and missing in 25.8% of patients. Pain assessment revealed no sternal pain in 16 patients (48.5%), mild pain in 9 (27.3%), moderate pain in 3 (9.1%), and severe pain in 5 patients (15.1%). Pain on movement was reported in 12 patients and 5 patients had chronic pain. A total of 13 patients (38%) required plate removal due to pain (n = 8) or infection (n = 5) after a median of 10.9 and 2 months, respectively., Conclusions: With the use of plates, it was possible to achieve thoracic stabilization in complicated dehiscence. However, the rate of postoperative infection and pain is not negligible. Thus, we recommend plate reconstruction only in sternal high-risk patients, who are unsuitable for standard reclosure., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Obtaining hemostasis during cardiovascular procedures can be a challenge, particularly around areas with a complex geometry or that are difficult to access. While several topical hemostats are currently on the market, most have caveats that limit their use in certain clinical scenarios such as pulsatile arterial bleeding. The aim of this study was to assess the effectiveness and safety of Veriset™ hemostatic patch in treating cardiovascular bleeding., Methods: Patients (N=90) scheduled for cardiac or vascular surgery at 12 European institutions were randomized 1:1 to treatment with either Veriset™ hemostatic patch (investigational device) or TachoSil ® (control). After application of the hemostat, according to manufacturer instructions for use, time to hemostasis was monitored. Follow-up occurred up to 90 days post-surgery., Results: Median time to hemostasis was 1.5 min with Veriset™ hemostatic patch, compared to 3.0 min with TachoSil ® ( p <0.0001). Serious adverse events within 30 days post-surgery were experienced by 12/44 (27.3%) patients treated with Veriset™ hemostatic patch and 10/45 (22.2%) in the TachoSil ® group ( p =0.6295). None of these adverse events were device-related, and no reoperations for bleeding were required within 5 days post-surgery in either treatment group., Conclusion: This study reinforces the difference in minimum recommended application time between Veriset™ hemostatic patch and TachoSil ® (30 s versus 3 min respectively). When compared directly at 3 min, Veriset™ displayed no significant difference, showing similar hemostasis and safety profiles on the cardiovascular bleeding sites included in this study., Competing Interests: Disclosure All authors or their institutions received support from Covidien (the manufacturer of Veriset™) to conduct this study. The authors report no other conflicts of interest in this work.

Background: Mitral valve (MV) repair through a right minithoracotomy (RT) is technically more demanding than through a median sternotomy (MS) and has been cited for a higher rate of reoperation, increased postoperative bleeding, thromboembolic events, poor visualization, and longer operative times. Randomized studies are not available, however, and specific characteristics of patients who undergo operation with either technique are usually highly different. Therefore, a propensity matching study was performed to reduce selection bias., Methods: A retrospective analysis was made of 745 patients, 501 in group RT (67%) and 244 in group MS (33%), who underwent isolated MV repair between 2000 and 2010. Propensity matching identified 97 matched patient pairs for comparison of functional outcome, survival, incidence of reoperation, and quality of life after MV repair., Results: Propensity matched patients in group RT had longer cardiopulmonary bypass time (120 ± 28 versus 99 ± 30 minutes, p < 0.001) and cross-clamp time (86 ± 23.5 versus 74 ± 25 minutes, p < 0.001). Thirty-day mortality was similar for both groups (RT, 0%; MS, 1%; p = 0.13). There were no significant differences in other outcomes such as amount of red blood cell transfusion, ventilation time, and hospital stay. Five-year survival in group RT (93.5% ± 3.7%) versus group MS (87.4% ± 3.6%, p = 0.556) and freedom from MV reoperation (93.3% ± 2.9% versus 97.9% ± 1.5%, respectively; p = 0.157) were not different. Functional outcome and quality of life variables were similar., Conclusions: Mitral valve surgery through a right minithoracotomy is a safe procedure associated with a very low operative mortality comparable to the standard sternotomy approach. In addition to improved cosmetics, minimally invasive MV surgery provides equally durable results as the standard sternotomy approach., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The MitraClip procedure has shown promising results in patients with high surgical risk. However, data concerning outcomes of open mitral valve surgery for failed MitraClip procedures are sparse. In a retrospective clinical investigation, baseline characteristics, intraoperative and histopathological findings, surgical indications and results of patients who required surgery after a failed MitraClip procedure were collected. Between March 2010 and May 2016, 25 patients presented at our department with severe mitral valve regurgitation following a failed MitraClip procedure. Leaflet destruction or severe adhesions between leaflets and the implanted clip were the commonest intraoperative findings. Upon surgery, the mitral valve was either repaired (n=5, 20%) or replaced (n=20, 80%) with a biological prosthesis. Four patients who had presented in cardiogenic shock prior to the operation died within the first 30 days. In the majority of cases, mitral valve replacement is preferred over repair due to severe leaflet damage following the MitraClip procedure. Only those patients who present in cardiogenic shock are at extremely high risk for in-hospital mortality.

Mechanical circulatory support devices have become an important treatment tool for severe acute and chronic heart failure, since heart transplantation cannot meet the demands because of a lack of available donor organs. Since implantation of the first ventricular assist device a constant development of the suitability of these devices has been made. This review will introduce different generations of left ventricular assist devices (LVAD) and elaborate on clinical indications, risk stratification and current literature., Competing Interests: The authors have no conflicts of interest to declare.

Background Various devices have been proposed for ring annuloplasty in patients with degenerative mitral valve disease. This study reports for the first time midterm results with the rigid three-dimensional Medtronic Profile 3D (Medtronic, Minneapolis, Minnesota, United States) annuloplasty ring. Methods Between June 2009 and June 2011, 200 patients (mean age 61 ± 13 years, 70% male) with severe degenerative mitral regurgitation underwent mitral valve repair using the Medtronic Profile 3D annuloplasty ring. A total of 106 patients (53.0%) underwent isolated mitral valve repair and 94 patients (47.0%) underwent a concomitant procedure such as coronary artery bypass grafting (n = 21), tricuspid valve surgery (n = 49), AF ablation (n = 17), and aortic valve surgery (n = 13). The follow-up is 94.5% complete (mean 2.5 ± 0.5 years). Results Thirty-day mortality was 1.5%. Survival at 3 years was 97.1 ± 1.6% for isolated procedures and 92.4 ± 2.8% for combined procedures (p = 0.137). Freedom from mitral valve-related reoperation at 3 years was 97.1 ± 1.7% for isolated procedures and 95.5 ± 2.2% for combined procedures (p = 0.561). Seven patients (3.5%) required a mitral valve-related reoperation. Two of these reoperations were required for endocarditis, two for ring dehiscence, one for progression of the native disease (flail leaflet), one for leaflet suture dehiscence, and one for persistent systolic anterior motion. Conclusion The three-dimensional Medtronic Profile 3D annuloplasty ring is suitable for mitral valve repair for degenerative diseases. This saddle-shaped annuloplasty device provides excellent early results with a very good functional outcome at midterm either in isolated or combined procedures., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: During the last decade, various plate fixation systems have been developed for the treatment of complicated sternal dehiscence after open-heart surgery. One of them is the Modular Sternal Cable System© (MSCS), which promises optimal distribution of forces along the whole sternum by using plates, cannulated screws and cables. However, in comparison with other systems, there is a lack of outcome data., Methods: Sternal reconstruction with the MSCS was performed in 11 patients (male n = 10, age 72.0 ± 7.3 years) with complicated sternal dehiscence following cardiac surgery, and 73% of them had a history of sternal infection. Sternal reconstruction included bilateral longitudinal plating and thoracic re-closure with 4-9 cables. Patients received postoperative examination, focusing on sternal wound conditions and clinical stability. If there was any suspicion of recurrent wound infection, computed tomographic scans were done in the early postoperative period or in the long term, in order to evaluate bony consolidation and integrity of osteosynthetic material., Results: The mean operation time was 165 ± 59 min, the mean intubation time 4.7 ± 5.3 min and the mean intensive care unit length of stay was 1 day (median) (range 1-23 days), with a total hospital stay of 9 days (median) (range 5-64 days). Operative mortality was 0%. One patient died on the 65th postoperative day of a non-MSCS-related cause. Sternal wound infection occurred in 6 patients (54.5%) and made hardware removal necessary in 5 of them early postoperatively (median 14 days) and in 1 patient late postoperatively (1058 days). In another patient, material was removed 715 days after MSCS application due to persisting sternal pain., Conclusions: A high incidence of postoperative wound infections was observed after implantation of the MSCS. It may be speculated that hardware design (e.g. the absence of a locking system, large screws) compromises osseous microcirculation, favouring the development of infection. This should be kept in mind for further development of sternal reconstruction systems., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The impact of permanent pacemaker (PPM) leads on functional outcome of tricuspid valve (TV) repair has not been clearly demonstrated. Therefore, controversy exists as to whether transvalvular PPM leads should be explanted and replaced by epicardial leads at the time of valve repair. This study evaluates the influence of PPM leads on functional outcome, TV-related reoperations and survival in patients undergoing TV repair for functional tricuspid regurgitation (TR)., Methods: We retrospectively reviewed 415 consecutive patients who underwent TV ring annuloplasty at our institution from July 2007 to February 2013. In 112 patients (27%), a PPM was implanted either pre- or postoperatively. The follow-up is 94% complete (mean: 24.4 months; cumulative total 845 patient-years)., Results: The mean age was 70.2 ± 9.8 years and the mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.4%. Of note, 76.6% of the patients were in New York Heart Association class III or IV. Echocardiography documented moderate or severe TR in 96.4% of the patients, with a mean annulus diameter of 44.8 ± 5.4 mm. 95.4% of the patients underwent a combined procedure and 16.4% an urgent or emergent operation. The 30-day mortality was 7.5%. The preoperative TR grade was reduced from 2.47 ± 0.52 to 0.70 ± 0.54 (P < 0.001). At hospital discharge, residual ≥II TR was present in 7.1% of the patients. Freedom from recurrent ≥II TR at 5 years was 86.7 ± 3.2%. Upon uni- and multivariate analyses, the presence of a transvalvular PPM was not a risk factor for recurrent ≥II TR and late mortality. Freedom from TV-reoperations was 98.1 ± 0.8% at 5 years without significant difference between groups., Conclusion: The presence of a transvalvular PPM lead is not a risk factor for recurrent TR, TV-related reoperations and late mortality in patients undergoing ring annuloplasty for functional TR., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

To date, closure of a patent foramen ovale (PFO) by the transcatheter technique is the preferred method, and an operation with cardiopulmonary bypass is reserved for special indications. Although different closure devices are used with high efficacy, adverse events after transcatheter PFO closure have been reported. We describe an unusual case of a cardiac perforation occurring 10 years after transcatheter PFO closure. The device was explanted surgically, and the interatrial communication was closed with a polytetrafluoroethylene patch., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Vertebrate heart development is strictly regulated by temporal and spatial expression of growth and transcription factors (TFs). We analyzed nine TFs, selected by in silico analysis of an Nkx2.5 enhancer, for their ability to transactivate the respective enhancer element that drives, specifically, expression of genes in cardiac progenitor cells (CPCs). Mzf1 showed significant activity in reporter assays and bound directly to the Nkx2.5 cardiac enhancer (Nkx2.5 CE) during murine ES cell differentiation. While Mzf1 is established as a hematopoietic TF, its ability to regulate cardiogenesis is completely unknown. Mzf1 expression was significantly enriched in CPCs from in vitro differentiated ES cells and in mouse embryonic hearts. To examine the effect of Mzf1 overexpression on CPC formation, we generated a double transgenic, inducible, tetOMzf1-Nkx2.5 CE eGFP ES line. During in vitro differentiation an early and continuous Mzf1 overexpression inhibited CPC formation and cardiac gene expression. A late Mzf1 overexpression, coincident with a second physiological peak of Mzf1 expression, resulted in enhanced cardiogenesis. These findings implicate a novel, temporal-specific role of Mzf1 in embryonic heart development. Thereby we add another piece of puzzle in understanding the complex mechanisms of vertebrate cardiac development and progenitor cell differentiation. Consequently, this knowledge will be of critical importance to guide efficient cardiac regenerative strategies and to gain further insights into the molecular basis of congenital heart malformations.

Objectives: To examine the influence of different surgical procedures on clinical outcome in patients undergoing aortic root replacement for ascending aorta aneurysm (AAA) with or without concomitant aortic valve regurgitation (AR)., Methods: Between 2000 and 2011, a total of 370 patients (mean age 52 ± 17 years) underwent aortic root replacement. Patients were retrospectively assigned to three groups according to the surgical procedures: valve-sparing root replacement (VSRR) (Group A; n = 178), Bentall procedure with a biological conduit (Group B; n = 91) and with a mechanical conduit (Group C; n = 101). All patients were studied with clinical assessment and echocardiography during a mean follow-up time of 4.3 years., Results: Estimated 5-year survival probability rates for Groups A, B and C were 95.2 ± 1.8, 80.9 ± 4.4 and 79.3 ± 4.5%, respectively (P < 0.01; log-rank). Estimated 5-year survival probability rates for patients who had undergone elective operations for Groups A, B and C were 96.1 ± 1.8, 88.9 ± 4.4 and 82.3 ± 4.9%, respectively (P = 0.02; log-rank). Actuarial overall 5-year freedom from valve-related reoperations was 94.3 ± 1.9%, without being significantly different between groups (P = 0.13; log-rank). Estimated 5-year probability rates for freedom from major bleeding events for Groups A, B and C were 99.3 ± 0.7, 100 and 93.0 ± 3.4%, respectively (P = 0.03; log-rank). Actuarial overall 5-year freedom from thromboembolism and endocarditis were 93.6 ± 0.2% (P = 0.53; log-rank) and 96.1 ± 1.5% (P = 0.46; log-rank), respectively, without significant differences between groups., Conclusions: The data from the present study support the VSRR strategy in patients undergoing aortic root replacement. Furthermore, if Bentall operation is unavoidable, biological valved conduit should be preferred in order to avoid late bleeding complications., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Undersized ring annuloplasty is the treatment of choice for functional mitral regurgitation. However, recurrence of mitral regurgitation within the first years is frequent. The aim of this study was to analyze the functional and clinical outcome after mitral valve repair with the 3-dimensional saddle-shaped Edwards GeoForm (Edwards Lifesciences LLC, Irvine, Calif) annuloplasty ring in patients with ischemic mitral regurgitation., Methods: Between November 2006 and November 2012, 70 patients (mean age, 68 ± 10 years; mean left ventricular ejection fraction, 40% ± 15%) with functional mitral regurgitation due to ischemic cardiomyopathy underwent mitral valve repair with the Edwards GeoForm annuloplasty ring. Concomitant procedures, such as coronary artery bypass grafting (75.7%), tricuspid valve repair (25.7%), aortic valve replacement (8.6%), and the Maze procedure (4.3%), were performed in 92.9% of patients. Follow-up is 97% complete (mean, 3.0 ± 1.7 years). Transthoracic echocardiography was obtained 2.4 ± 1.7 years postoperatively., Results: Thirty-day mortality was 5.9%. Overall survival at 5 years was 71.3% ± 6.9%. At 4 years, overall freedom from recurrence of mitral regurgitation grade 3+ or greater was 92.5% ± 3.6%, and freedom from recurrence of mitral regurgitation grade 2+ or greater was 71.0% ± 8.7%. Three patients required a mitral valve-related reoperation for ring dehiscence. New York Heart Association functional class improved from 3.6 ± 0.6 to 1.6 ± 0.6 during follow-up (P < .05). Mean mitral valve pressure gradient was 3.3 ± 1.8 mm Hg across all ring sizes at the time of follow-up., Conclusions: Mitral valve repair with the 3-dimensional saddle-shaped Edwards GeoForm annuloplasty ring in case of ischemic mitral regurgitation shows a low rate of recurrent regurgitation at 4 years. Clinically relevant mitral stenosis was not detected. The importance of secure anchoring of the device in the mitral annulus has to be emphasized to prevent ring dehiscence., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background and Aim of the Study: The study aim was to examine the hemodynamic performance of the BioValsalva porcine aortic valve conduit in the aortic root position., Methods: Between February 2007 and April 2012, a total of 223 patients underwent aortic root replacement at the authors' institution. The BioValsalva valved conduit was implanted in 131 patients, and 86 of these patients (mean age 64.7 +/- 9.7 years) consented to participate in the present study. The parameters assessed to evaluate prosthetic valve function included mean pressure gradient (MPG) as measured by transthoracic Doppler echocardiography, and the effective orifice area (EOA) by means of the continuity equation. Hemodynamic data were obtained from all 86 patients within 10 days and six months postoperatively., Results: The mean aortic cross-clamp time was 103 +/- 30 min. Concomitant procedures were performed in 50 patients (56.5%). Four patients developed valve dysfunction due to endocarditis, and underwent a reoperation without the need to perform a redo Bentall. The early MPG across the implanted valve was 12 +/- 4.6 mmHg (range: 4-24.8 mmHg), and the early mean EOA was 1.81 +/- 0.6 cm2 (range: 0.9-3.2 cm2). After six months the MPG was 11.6 +/- 4.6 mmHg (range: 2.2-25.5 mmHg) and the EOA was 1.69 +/- 0.43 cm2 (range: 0.8-2.6 cm2)., Conclusion: Based on its special design with a stentless valve, which is not incorporated into the proximal suture line, the BioValsalva conduit has an advantage over intraoperatively prepared conduits in cases of reoperation. Besides simplified intraoperative handling, the BioValsalva conduit exhibits good systolic hemodynamic performance with large EOAs.

Background: An increasing number of octogenarians are referred for cardiac surgical procedures. In this subset of patients, information on the health-related quality of life (HrQoL) is critical for decision making. However, there is a paucity of prospective data. Thus, we sought to prospectively evaluate the HrQoL in octogenarians undergoing cardiac surgery., Methods: A prospective HrQoL analysis was performed in 106 elective patients (median age 83.0 ± 2.6 years, range 80-91.8 years, 59.4% male) undergoing cardiac surgery. The standardized SF-36 Health Survey questionnaire was answered preoperatively, and three and 12 months postoperatively. Preoperative data, perioperative outcome, and postoperative morbidity were analyzed., Results: SF-36 scores for physical functioning (44.3 ± 2.3 vs. 52.0 ± 2.7; p < 0.001), role physical (25.2 ± 3.3 vs. 41.5 ± 4.1; p < 0.001), bodily pain (57.8 ± 3.2 vs. 70.7 ± 2.8; p < 0.01), general health (54.9 ± 1.7 vs. 59.6 ± 1.7; p < 0.001), vitality (41.1 ± 2.1 vs. 50.6 ± 2.1; p < 0.001), and mental health (67.5 ± 2.0 vs. 72.4 ± 1.9; p < 0.05) significantly improved from baseline to three months. Social functioning (75.4 ± 2.6 vs. 76.1 ± 2.5; p = 0.79) and role emotional (56.8 ± 4.5 vs. 58.0 ± 4.6; p = 0.29) improved slightly without reaching statistical significance. Correspondingly, at three months, physical component scores increased significantly compared to baseline (34.3 ± 1.0 vs. 39.4 ± 1.0; p < 0.001). SF-36 scores remained stable between three months and one year. No significant change was seen in the mental component score from baseline to three months (48.6 ± 1.2 vs. 49.8 ± 1.1; p = 0.18)., Conclusions: Physical HrQoL is significantly improved in octogenarians three months after cardiac surgery remaining stable at one year postoperatively when compared to baseline., (© 2013 Wiley Periodicals, Inc.)

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR. Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Objectives: We aimed at evaluating the results of aortic valve-sparing root replacement (AVSRR) in children with aortic root aneurysm (ARA) due to genetic disorders in terms of mortality, reoperation and recurrent aortic valve regurgitation (AVR)., Methods: Thirteen patients (mean age 9.7 ± 6.5 years, 10 months-18 years) underwent AVSRR for ARA between 2002 and 2011. Six of the 13 patients had Marfan syndrome, 3 Loeys-Dietz syndrome (LDS), 2 bicuspid aortic valve syndrome and 2 an unspecified connective tissue disorder. AVR was graded as none/trace, mild and severe in 5, 7 and 1 patient, respectively. The mean pre-operative root diameter was 45 ± 10 mm (mean Z-score 10.3 ± 2.0). Remodelling of the aortic root was performed in 4 patients, reimplantation of the aortic valve in 9 and a concomitant cusp repair in 4. The diameter of the prostheses used for root replacement varied from 22 to 30 mm (mean Z-score = 2.3 ± 3). The follow-up was 100% complete with a mean follow-up time of 3.7 years., Results: There was no operative mortality. One patient with LDS died 2.5 years after the operation due to spontaneous rupture of the descending aorta. Root re-replacement with mechanical conduit was necessary in 1 patient for severe recurrent AVR 8 days after remodelling of the aortic root. At final follow-up, AVR was graded as none/trace and mild in all patients. Eleven patients presented in New York Heart Association functional Class I and 1 in Class II., Conclusions: In paediatric patients with ARA, valve-sparing root replacement can be performed with low operative risk and excellent mid-term valve durability. Hence, prosthetic valve-related morbidity may be avoided. Due to the large diameters of the aortic root and the ascending aorta, the size of the implanted root prostheses will not limit later growth of the native aorta.

Objectives: Tricuspid regurgitation (TR) secondary to left heart disease is the most common aetiology of tricuspid valve (TV) insufficiency. Valve annuloplasty is the primary treatment for TV insufficiency. Several studies have shown the superiority of annuloplasty with a prosthetic ring over other repair techniques. We reviewed our experience with different surgical techniques for the treatment of acquired TV disease focusing on long-term survival and incidence of reoperation., Methods: A retrospective analysis of 717 consecutive patients who underwent TV surgery between 1975 and 2009 with either a ring annuloplasty [Group R: N = 433 (60%)] or a De Vega suture annuloplasty [Group NR: no ring; N = 255 (36%)]. Twenty-nine (4%) patients underwent other types of TV repair. A ring annuloplasty was performed predominantly in the late study period of 2000-09. TV aetiology was functional in 67% (479/717) of the patients. Ninety-one percent of the patients (n = 649) underwent concomitant coronary artery bypass grafting and/or mitral/aortic valve surgery., Results: Patients who received a ring annuloplasty were older (67 ± 13 vs 60 ± 13 years; P < 0.001). Overall 30-day mortality was 13.8% (n = 95) [Group R: n = 55 (12.7%) and Group NR: n = 40 (15.7%)]. Ten-year actuarial survival after TV repair with either the De Vega suture or ring annuloplasty was 39 ± 3 and 46 ± 7%, respectively (P = 0.01). Twenty-eight (4%) patients required a TV reoperation after 5.9 ± 5.1 years. Freedom from TV reoperation 10 years after repair with a De Vega annuloplasty was 87.9 ± 3% compared with 98.4 ± 1% after the ring annuloplasty (P = 0.034)., Conclusions: Patients who require TV surgery either as an isolated or a combined procedure constitute a high-risk group. The long-term survival is poor. Tricuspid valve repair with a ring annuloplasty is associated with improved survival and a lower reoperation rate than that with a suture annuloplasty.

Aims: N-terminal pro-brain natriuretic peptide (NT-proBNP) has been found to correlate with the severity of aortic valve stenosis and to provide prognostic information in aortic stenosis patients undergoing surgical aortic valve replacement. There is a paucity of data describing the association between clinical outcomes after TAVI and NT-proBNP levels. We investigated the evolution and prognostic value of NT-proBNP levels after TAVI., Method and Results: We prospectively collected data on the baseline characteristics, NT-proBNP levels (baseline, post-treatment and discharge) and adverse clinical outcomes of patients undergoing TAVI from 2007 to 2010. Using a univariable and multivariable Cox regression model, pre- and postimplantation NT-proBNP tertile levels were correlated to 30-day and 1-year mortality. A total of 373 patients underwent TAVI with either the Medtronic CoreValve or Edwards SAPIEN prosthesis. The cumulative 30-day and 1-year mortality was 7.3% and 18%, respectively. Rehospitalization for heart failure was observed in 0.8% at 30 days and 7.8% at 1 year. The tertile baseline NT-proBNP levels were identified as ≤1570 ng/L, 1571 to 4690 ng/L and ≥4691 ng/L. In the univariable analysis, baseline (HR, 1.01; 95% CI, 1.001-1.02; P=.02) and post-treatment NT-proBNP (HR 1.02; 95% CI, 1.002-1.04; P=.04) were predictors for 1-year mortality. In the multivariable analysis, however, only baseline NT-proBNP and atrial fibrillation were identified as predictors for the 1-year mortality (HR, 1.02; 95% CI, 1.01-1.05; P=.006 and HR, 3.4; 95% CI, 1.25-9.5; P=.017, respectively)., Conclusions: NT-proBNP and atrial fibrillation were predictors for 1-year mortality, offer independent prognostic information, and identify patients being at increased risk for mortality. Thus, NT-proBNP reveals more incremental value for patient selection and should be included in the risk stratification of patients undergoing TAVI.

Recently, it has been demonstrated that transcatheter aortic valve implantation (TAVI) can result in significant improvement in patients' quality of life (QOL) in the short term. At present, however, little is known about the long-term improvements in QOL after TAVI. Thus, our aim was to prospectively assess the 1-year QOL outcome of patients undergoing TAVI. We performed a prospective analysis of 186 patients with symptomatic severe aortic valve stenosis ineligible for conventional aortic valve replacement, who underwent TAVI with either the Medtronic CoreValve or Edwards Sapien device. A total of 106 patients completed the 1-year follow-up protocol. The QOL was measured using the Medical Outcomes Study 36-item short-form health survey questionnaire at baseline and at 3 months and 1 year of follow-up. At 1 year of follow-up, significant improvements in the Medical Outcomes Study 36-item short-form health survey questionnaire scores for physical functioning (baseline 34.6 ± 2.3 vs 1 year of follow-up 45.6 ± 2.7; p <0.001), role physical (20 ± 3.0 vs 34.2 ± 4.4; p <0.001), bodily pain (59.9 ± 3 vs 70 ± 2.7; p <0.01), general health (47.3 ± 1.5 vs 55.2 ± 2.1, p <0.001), vitality (35.9 ± 2 vs 48.5 ± 2; p <0.001), and mental health (62.2 ± 2.2 vs 67.3 ± 1.8; p <0.05) were observed compared to baseline. No significant improvement could be detected for social functioning (75.4 ± 2.5 vs 76.5 ± 2.6; p = 0.79) and role emotional (61.1 ± 4.3 vs 66.5 ± 4.7; p = 0.29). At 1 year of follow-up, the various physical and mental scores were comparable to an age-matched standard population. In conclusion, the present study has demonstrated that TAVI can improve the QOL status of high-surgical risk patients with severe aortic valve stenosis that can be maintained for ≤1 year postproceduraly in survivors. Although the mental subscales improved slightly, the mental component summary score failed to reach statistical significance in our study population., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to investigate the evolution of patient selection criteria for transcatheter aortic valve implantation (TAVI) and its impact on clinical outcomes., Background: Anecdotal evidence suggests that patient selection for TAVI is shifting toward lower surgical risk patients. The extent of this shift and its impact on clinical outcomes, however, are currently unknown., Methods: We conducted a single-center study that subcategorized TAVI patients into quartiles (Q1 to Q4) defined by enrollment date. These subgroups were subsequently examined for differences in baseline characteristics and 30-day and 6-month mortality rate. The relationship between quartiles and mortality rate was examined using unadjusted and adjusted (for baseline characteristics) Cox proportional hazard models., Results: Each quartile included 105 patients (n = 420). Compared with Q4 patients, Q1 patients had higher logistic EuroSCORES (25.4 ± 16.1% vs. 17.8 ± 12.0%, p < 0.001), higher Society of Thoracic Surgeons scores (7.1 ± 5.5% vs. 4.8 ± 2.6%, p > 0.001), and higher median N-terminal pro-B-type natriuretic peptide levels (3,495 vs. 1,730 ng/dl, p < 0.046). From Q1 to Q4, the crude 30-day and 6-month mortality rate decreased significantly from 11.4% to 3.8% (unadjusted hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.11 to 1.01; p = 0.053) and from 23.5% to 12.4% (unadjusted HR: 0.49; 95 CI: 0.25 to 0.95; p = 0.07), respectively. After adjustment for baseline characteristics, there were no significant differences between Q1 and Q4 in 30-day mortality rate (adjusted HR ratio: 0.29; 95% CI: 0.08 to 1.08; p = 0.07) and 6-month mortality rate (HR: 0.67; 95% CI: 0.25 to 1.77; p = 0.42)., Conclusions: The results of this study demonstrate an important paradigm shift toward the selection of lower surgical risk patients for TAVI. Significantly better clinical outcomes can be expected in lower than in higher surgical risk patients undergoing TAVI., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs., Methods: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months., Results: Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97)., Conclusions: The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The use of human saphenous vein grafts (HSVGs) as a bypass conduit is a standard procedure in the treatment of coronary artery disease while their early occlusion remains a major problem., Methods: We have developed an ex vivo perfusion system, which uses standardized and strictly controlled hemodynamic parameters for the pulsatile and non-static perfusion of HSVGs to guarantee a reliable analysis of molecular parameters under different pressure conditions. Cell viability of HSVGs (n = 12) was determined by the metabolic conversion of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) into a purple formazan dye., Results: Under physiological flow rates (10 mmHg) HSVGs remained viable for two weeks. Their exposure to arterial conditions (100 mmHg) was possible for one week without important reduction in viability. Baseline expression of matrix metalloproteinase-2 (MMP-2) after venous perfusion (2.2 ± 0.5, n = 5) was strongly up-regulated after exposure to arterial conditions for three days (19.8 ± 4.3) or five days (23.9 ± 6.1, p < 0.05). Zymographic analyses confirmed this increase on the protein level. Our results suggest that expression and activity of MMP-2 are strongly increased after exposure of HSVGs to arterial hemodynamic conditions compared to physiological conditions., Conclusion: Therefore, our system might be helpful to more precisely understand the molecular mechanisms leading to an early failure of HSVGs.

Background: The radial artery (RA) is known as an atherosclerosis-prone vessel in contrast to the atherosclerosis-resistant internal thoracic artery (ITA). The purpose of the present study was to compare the gene expression profile of these arteries from the same patient in order to identify genes involved in atherogenesis or intimal hyperplasia., Methods: Paired specimens of RA and ITA (n=6) were analyzed by histomorphometry and whole genome microarray. The microarray data underwent pathway analysis to identify biological networks. Laser microdissection (LMD) was used to identify the cellular expression of candidate genes in the intimal or medial layer of the ITA and RA., Results: Histomorphometric analyses revealed a significantly higher degree of intimal hyperplasia in the RA compared to the ITA. 552 genes were differentially expressed in the ITA and RA. qRT-PCR confirmed a significant up-regulation of six anti-apoptotic genes. p21 (11.8-fold, p=0.011), CCL2 (5.4-fold, p=0.034), SOCS3 (7.2-fold, p=0.002), IER3 (4.1-fold, p=0.048), MCL-1 (2.6-fold, p=0.025) and IL-6 (17.8-fold, p=0.046) were up-regulated in the ITA. LMD confirmed that cells of the intimal layer of the ITA consistently expressed higher levels of all six candidate genes than those of the RA., Conclusions: Microarray analysis and qRT-PCR identified significantly up-regulated genes in the ITA involved in an anti-apoptotic network. LMD revealed a higher expression of all anti-apoptotic genes in the intimal area of the ITA. These genes may play an important role in protecting the intima of the ITA from developing hyperplasia and atherosclerosis., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Patients aged 80 years and older who require cardiac surgical procedures are an increasing population and usually present with considerable comorbidity. Detailed operative risk stratification versus long-term survival and quality of life after surgery is mandatory., Methods: A retrospective analysis was performed on 1,003 patients aged 82.3 years (range, 80 to 94 years) who underwent aortic valve replacement (n = 303), coronary artery bypass grafting (n = 403), or aortic valve replacement with coronary artery bypass grafting (n = 297) between 1987 and 2006. Preoperative data, operative outcome, long-term survival, and predictors for early and late mortality were analyzed. Furthermore, the Short Form 36 Health Status questionnaire was used to evaluate the quality of life., Results: Overall in-hospital mortality was 7.1%. Overall actuarial survival at 1, 5, and 10 years was 81.6% ± 1.2%, 60.4% ± 1.9%, and 23.3% ± 2.6% (mean survival time, 6.25 ± 0.2 years) and showed no significant difference compared with an age- and sex-matched general population. Multivariate analysis showed that preoperative creatinine concentration greater than 1.3 mg/dL (p < 0.001), preoperative atrial fibrillation (p < 0.005), and postoperative prolonged ventilation (p < 0.001) were independent predictors for poor long-term survival. The physical health summarized score of the Short Form 36 Health Status questionnaire was significantly increased in the study population compared with a German standard population aged 80 years and older (p < 0.05)., Conclusions: Despite an increased operative mortality, octogenarians showed a considerable quality of life and an excellent long-term survival. To further improve surgical outcome in octogenarians, patient selection should be done with consideration of the identified independent preoperative risk factors., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood and has a poor prognosis. Here we assessed the capability of ex vivo expanded cytokine-induced killer cells to lyse both alveolar and embryonic rhabdomyosarcoma cell lines and investigated the mechanisms involved., Design and Methods: Peripheral blood mononuclear cells from six healthy donors were used to generate and expand cytokine-induced killer cells. The phenotype and composition of these cells were determined by multiparameter flow cytometry, while their cytotoxic effect against rhabdomyosarcoma cells was evaluated by a europium release assay., Results: Cytokine-induced killer cells efficiently lysed cells from both rhabdomyosarcoma cell lines. Antibody-mediated masking of either NKG2D molecule on cytokine-induced killer cells or its ligands on rhabdomyosarcoma cells (major histocompatibility antigen related chain A and B and UL16 binding protein 2) diminished this effect by 50%, suggesting a major role for the NKG2D molecule in rhabdomyosarcoma cell killing. No effect was observed after blocking CD11a, CD3 or TCRalphabeta molecules on cytokine-induced killer cells or CD1d on rhabdomyosar-coma cells. Remarkably, cytokine-induced killer cells used tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) to activate caspase-3, as the main caspase responsible for the execution of apoptosis. Accordingly, blocking TRAIL receptors on embryonic rhabdomyosarcoma cell lines significantly reduced the anti-tumor effect of cytokine-induced killer cells. About 50% of T cells within the cytokine-induced killer population had an effector memory phenotype, 20% had a naïve phenotype and approximately 30% of the cells had a central memory phenotype. In addition, cytokine-induced killer cells expressed low levels of activation-induced markers CD69 and CD137 and demonstrated a low alloreactive potential., Conclusions: Our data suggest that cytokine-induced killer cells may be used as a novel adoptive immunotherapy for the treatment of patients with rhabdomyosarcoma after allogeneic stem cell transplantation.

Background: Transcatheter aortic valve implantation (TAVI) has been introduced to offer a new treatment option for patients who are not eligible for conventional aortic valve replacement. Especially in this subset of patients, the expected improvement of quality of life (QoL) after valve implantation will be critical for decision-making for TAVI., Methods: We performed a prospective analysis of 99 patients (41 male) aged 82 years (range 57-94 years) who underwent TAVI. For assessment of QoL, the Short Form 36 Health Survey Questionnaire was used preoperatively and 3 months after TAVI., Results: Thirty-day mortality rate was 10.1%. The Short Form 36 Health Survey Questionnaire scores for physical functioning (34.7 +/- 2.8 vs 48.5 +/- 3.4, P < .001), bodily pain (61.7 +/- 3.1 vs 73.2 +/- 2.9, P < .01), general health (47.1 +/- 1.9 vs 54.1 +/- 2.3, P < .01), and vitality (37 +/- 2.8 vs 46.1 +/- 2.7, P < .01) increased significantly 3 months after TAVI compared with preoperative scores. No significant changes were found for role-physical (21.7 +/- 4.1 vs 31.1 +/- 5.1, P < .08), social functioning (74.6 +/- 3.4 vs 74.6 +/- 3.1, P = 1), and mental health (63 +/- 2.9 vs 67.4 +/- 2.2, P = .17) 3 months after TAVI. Only the score for role-emotional (69.3 +/- 5.6 vs 51.7 +/- 6, P = .02) decreased significantly 3 months after TAVI compared with the preoperative score. Corresponding to these results, the physical health summarized score (31.2 +/- 1.2 vs 38.6 +/- 1.6, P < .001) was significantly increased 3 months after TAVI compared with the preoperative score, whereas the mental health summarized score (48.5 +/- 1.8 vs 47.3 +/- 1.7, P = .5) showed no changes., Conclusion: In patients who are not eligible for conventional aortic valve replacement, TAVI leads to a considerable QoL improvement within 3 months after valve implantation., (2010 Mosby, Inc. All rights reserved.)

In patients with ischemic cardiomyopathy, coronary artery bypass grafting (CABG) offers an important therapeutic option but is still associated with high perioperative mortality. Although previous studies suggest a benefit from revascularization for patients with defined viability by a non-invasive technique, the role of viability assessment to determine suitability for revascularization in patients with ischemic cardiomyopathy has not yet been defined. This study evaluates the hypothesis that the use of PET imaging in the decision-making process for CABG will improve postoperative patient survival. We reviewed 476 patients with ischemic cardiomyopathy (LV ejection fraction 70 (P = 0.016). Preoperative assessment of myocardial viability via PET identifies patients, who will benefit most from CABG.

Background: In the past, chordal replacement techniques with expanded polytetrafluoroethylene sutures have been primarily reserved for anterior leaflet pathology, whereas the more frequent posterior leaflet prolapse was treated by resection. This study reports midterm results of isolated posterior prolapse repair with chordal replacement without resection as opposed to the quadrangular resection., Methods: An analysis was made of 397 consecutive patients who underwent mitral valve repair for isolated posterior leaflet prolapse between 2000 and 2007. Of them, 205 patients (52%) underwent quadrangular resection (group R, "resection") and 192 patients (48%) underwent a neochordal repair (group NR, "no resection"). The follow-up is 98% complete (mean follow-up of 383 survivors is 1.9+/-1.4 years)., Results: Overall 30-day mortality was 1.0% (4 of 397). Ten patients (2.5%) died late. Actuarial survival at 4 years for group R and group NR was 94%+/-3% and 98%+/-1%, respectively (p=0.99). Ten patients (2.5%) required a mitral valve-related reoperation after an average of 1.9+/-2 months. Freedom from reoperation at 4 years was 96%+/-1% for group R and 99%+/-1% for group NR (p=0.08). Generally, in patients of group NR, a larger annuloplasty ring could be implanted (mean size 32+/-2.5 versus 30+/-2, p<0.001). At latest follow-up, 94% of the patients showed no or grade I regurgitation, with no difference between groups., Conclusions: Repair of posterior mitral leaflet prolapse by chordal replacement is equally effective as classic quadrangular resection, permits the use of larger annuloplasty rings, offers a potentially more physiological repair with preserved leaflet mobility, and can be performed with excellent midterm results and a low incidence of reoperation., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Advocates of pulsatile flow postulate that the flow pattern during extracorporeal circulation (ECC) should be similar to the physiological one. However, the waveforms generated by clinically used pulsatile pumps are by far different from the physiological ones. Therefore, we constructed a new computer-controlled pulsator which can provide nearly physiological perfusion patterns during ECC. We compared its effect (group 1) with pulsatile (group 2) and non-pulsatile (group 3) perfusion generated by a conventional roller pump., Methods: Thirty pigs (10 per group) underwent 180 min ECC with an aortic cross-clamp time of 120 min. Pulse pressure, peak aortic flow, dp/dt(max), pulsatility index and energy-equivalent pressure were measured online. Renal and intestinal blood flow was calculated by fluorescent microspheres. The inflammatory response was assessed by the level of interleukin 6/1ra, the haemolysis by the free haemoglobin, and the escape rate of plasma protein by the disappearance rate of Evans Blue dye., Results: When compared to the preoperative curves, pulsatile waveforms during ECC were similar in group 1 and severely damped in group 2. Inflammatory response increased without significant differences between the groups. There were no differences between groups in renal and bowel blood flow. Free haemoglobin after ECC was higher in the pulsatile groups (group 1=43+/-144 mg dl(-1), group 2=40+/-164 mg dl(-1), group 3=11+/-4mgdl(-1); group 1 vs 2 (ns); group 1 or 2 vs 3 (p<0.001)). The escape rate of Evans Blue increased after ECC in group 1 1.8-fold (p<0.05), in group 2 1.45-fold (p<0.05) and in group 3 1.27-fold (ns)., Conclusion: Even when using pulsatile flow patterns which mimic closely the physiological waveforms, there is no advantage concerning organ perfusion or inflammatory response. Moreover, the extent of haemolysis and capillary leak is higher compared to non-pulsatile perfusion. Efforts to optimise pulsatility are not justified., (Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

The LIFEBRIDGE B2T is a new portable cardiopulmonary bypass (CPB) system designed for temporary circulatory support. The LIFEBRIDGE B2T consists of a disposable patient unit with a CPB circuit, a control, and a base unit. The system weighs 20 kg. We used the LIFEBRIDGE B2T in four patients for circulatory support in beating heart coronary artery bypass graft for complete revascularization. The LIFEBRIDGE B2T was connected via femoral cannulation. Concentrations of free hemoglobin (fHb), interleukin (IL)-6, and -8 were measured. For venous blood drainage, 22-24 Fr cannulae and for arterial cannulation, 16-20 Fr cannulae were used. Average extracorporeal circulation (ECC) time was 61 +/- 18 minutes. During circulatory support, the system delivered an arterial blood flow between 3.1 and 4.1 L/min. The negative pressure at the venous drainage was between -79 and -45 mm Hg. During circulatory support, fHb concentration increased from 5.8 +/- 1.7 mg/dL to a maximum of 10.2 +/- 6.2 mg/dL. Also, IL-6 and -8 increased from 2.1 +/- 0.06 to 503.3 +/- 400.7 U/L and 5.9 +/- 0.9 to 66.5 +/- 46.8 U/L, respectively. The LIFEBRIDGE B2T is a new portable and safe circulatory support system. Connected via femoral cannulation, the system provides adequate arterial blood flow and an acceptable negative pressure at the venous cannula. The fHb concentration showed only a moderate increase during ECC.

Background: The benefit of cardiac surgery in octogenarians is well described. Today, nearly every second patient who undergoes cardiac surgery is older than 70 years. The time between primary cardiac surgery and reoperation is 7 to 13 years. Therefore, in the future we can expect to see an increasing number of reoperations in octogenarians., Methods: We studied 71 patients (41 male) with a mean age of 83 +/- 2.8 years, who underwent cardiac reoperation between 1994 and 2006. These patients were compared with 71 octogenarians who underwent primary cardiac operation. Patients were matched for age, sex, year of operation, and surgical procedure. Demographic profiles, operative data, long-term survival, and quality of life by the Short-Form 36-Item Health Survey questionnaire were analyzed., Results: Average time between previous operation and reoperation was 10.8 +/- 5.6 years (range: 1.7 to 30.6). The 30-day mortality rate was 14.7% in the reoperation group and 8.5% (p = 0.43) in the control group. Actuarial survival at 1, 3, and 6 years was 71% +/- 5.5%, 60.5% +/- 6.1%, and 30% +/- 8.1% for patients who underwent cardiac reoperation; and 77.2% +/- 5%, 58.3% +/- 6.3%, and 36.3% +/- 7.8% for matched octogenarians who underwent primary cardiac surgery (p = 0.68). No significant differences were found between groups regarding the physical health summarized score (40.7 +/- 9.4 versus 39.1 +/- 10; p = 0.55) and the mental health summarized score (51.9 +/- 10.9 versus 48 +/- 12.9; p = 0.24) of the Short-Form 36-Item Health Survey questionnaire., Conclusions: Octogenarians exhibit a similar long-term survival and quality of life after primary and redo cardiac surgery. Therefore, cardiac reoperation should not be a contraindication per se in octogenarians.

Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. For sternal refixation, the principles of rigid plate and screw osteosynthesis gained from orthopedic surgery have been recommended by several authors. We present a new system for sternal reconstruction consisting of reconstruction plates, steel cables, and cannulated screws.

Objective: Endoscopic radial artery harvesting remarkably improves cosmetic results after coronary artery bypass surgery. The aim of this study was to investigate neurologic sequelae of the donor arm compared with those occurring after the conventional harvesting technique., Methods: Fifty-three patients who had undergone endoscopic radial artery harvesting were followed up 1 year after the coronary artery bypass operation by means of questionnaire analysis and clinical neurologic investigation (ENDO group). Fifty-three patients who had conventional radial artery harvesting during the same time frame served as control subjects (OPEN group)., Results: Postoperative wound revision was required in 4 patients of the OPEN group (P = .045 vs the ENDO group). Neurologic symptoms of the donor arm were present in 22 (OPEN group) versus 34 (ENDO group) patients (P = .020): a lesion of the superficial radial nerve was shown in 12 (OPEN group) versus 24 (ENDO) patients (P = .014), and a lesion of the lateral antebrachial cutaneous nerve occurred only in the control group in 12 patients (P < .001). Paraesthesia without impaired sensibility was present in 3 (OPEN group) versus 10 (ENDO group) patients (P = .038). Clinical investigation revealed that temperature, pain, and touch sensation, as well as spatial discrimination, were equally impaired in symptomatic patients, whereas vibration sensation was not affected., Conclusion: After endoscopic radial artery harvesting, impaired sensibility in the region of the superficial radial nerve and paresthesia are more frequent than after the open procedure. However, in contrast to the sequelae of the open procedure, wound revision and injury of the lateral antebrachial cutaneous nerve did not occur. Because of the excellent cosmetic results and avoidance of wound complications, we have opted to use endoscopic radial artery harvesting as the technique of choice, despite the higher incidence of sensory disturbances.

Objective: Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. The use of titanium plates is a promising approach for sternal reconstruction., Methods: Titanium plate fixation was used in 15 patients (67+/-5.9 years, 171+/-8.2 cm, 93.6+/-14.9 kg, body mass index 32+/-5 kg/m(2)) with unstable thorax after failed attempts of sternal closure and patients in whom failure of conventional rewiring would be expected due to one or more serious risk factors (e.g. multiple fractures or loss of sternum, excessive overweight). In six patients, one of whom had an infection, the Synthes Titanium Sternal Fixation System was used as transverse plate fixation (series 1). In nine other patients, longitudinal titanium plating of the sternum was performed with 2.4mm Synthes locking reconstruction plates, which were cross-connected by wires (series 2). In six of these patients the cross-connection was reinforced by additional short transverse plates. In series 2, sternal instability was complicated by multiple fragments of sternum (n=8) and/or infection (n=3). In case of infection, initial debridement was performed with consecutive antibiotic and topical negative pressure therapy (median 13 days). Clinical examination was done 3-12 months postoperatively., Results: Mean operation time was 133+/-21 min (series 1) and 110+/-12 min (series 2). Transverse plating required more extensive mobilization of pectoral muscle. All patients had an uneventful early postoperative course and were extubated 5.1+/-5.9h (median 4 h) after surgery. Postoperatively, all patients had a stable thorax, but in the long-term three patients from series 1 complained of plate-related pain during breathing, with the subsequent need of plate removal. One multi morbid patient from series 1 died on the 31st postoperative day. The cause of death was not related to the sternal plate refixation., Conclusion: Titanium plate fixation is an effective method to stabilize complicated sternal dehiscence. The longitudinal plating technique is easier to apply and seems to be associated with fewer complications.

Background: Surgical ablation techniques using microwave energy are an alternative to catheter-based ablation therapy in the treatment of atrial fibrillation. We investigate electrical conduction properties of linear lesions after epicardial ablation in a pig model by using an electroanatomic mapping system., Methods: After medial sternotomy in eight pigs epicardial pacing wires were placed on the anterior and posterolateral wall of the right atrium. Endocardial electroanatomical mapping was performed during pacing from anterior and posterolateral. Epicardial ablation was implemented in between the superior and inferior caval vein using microwave energy. Mapping was repeated to demonstrate conduction block or gap across the ablation line. When conduction gap was present the ablation procedure was repeated. Hearts were removed for histologic evaluation., Results: Conduction block was observed in two pigs after the first ablation and in two additional pigs after the second ablation. Conduction gap was present in three pigs after the second ablation. One animal died during the second ablation. Histologic evaluation showed more severe transmural cellular damage in lesions with conduction gap. Complete lesions with conduction block more often showed moderate alterations., Conclusions: Epicardial microwave ablation can induce bidirectional conduction block, which is believed to be essential for therapeutic efficacy. However, the intraoperative macroscopic visible lesion and histological findings are not reliable markers of bidirectional conduction block. The Carto-Qwik-Map-System is an effective system to evaluate epicardial microwave lesions and to locate conduction gap areas intraoperatively. This increased the success rate regarding acute bidirectional conduction block after ablation in our experimental setting.

Objective: Various devices have been proposed for ring stabilization in patients with mitral valve disease. This study reports the intermediate-term results of mitral valve repair with a new semirigid partial annuloplasty ring in a large series of patients., Methods: A total of 437 consecutive patients were analyzed who underwent mitral valve reconstruction with annuloplasty using the Colvin-Galloway Future band at the German Heart Center in Munich between 2001 and 2005. A total of 237 patients (54.2%) underwent isolated mitral valve repair, and 200 patients (45.8%) underwent a combined procedure. The follow-up is 97% complete (mean follow-up of 405 survivors 2.1 +/- 1.1 years)., Results: Overall 30-day mortality was 2.7%. Twenty patients (4.6%) died later after an average of 1.1 +/- 1.1 years. Actuarial survival at 4 years after isolated mitral valve reconstruction and combined procedures was 91% +/- 4% and 87% +/- 2.5%, respectively (P < .001). Twelve patients (2.7%) required a mitral valve reoperation after an average of 4.5 +/- 4.3 months. Five of these reoperations were required for band dehiscence, and 1 reoperation was required for band fracture. Freedom from reoperation at 4 years was 97% +/- 0.9%. At the latest follow-up, 93.5% of the patients showed trivial or mild mitral valve regurgitation, and 86.4% of the patients showed New York Heart Association functional class I or II., Conclusion: Mitral valve annuloplasty with the Colvin-Galloway Future band can be performed with a low early and late mortality and an excellent functional outcome. The low incidence of reoperation demonstrates that the Colvin-Galloway Future band is a safe and effective device. The importance of secure anchoring of the device in the mitral annulus has to be emphasized to prevent band dehiscence.