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In August 2021 the European Society for Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) updated their guidelines on the management of valvular heart disease. Since the publication of the previous version in 2017 new evidence regarding epidemiology, diagnosis and treatment of valvular heart diseases has been accumulating, which led to reassessment of several recommendations. Most importantly, the critical role of the heart team in treatment decision-making was reemphasized, the criteria for choosing the mode of aortic valve interventions were clarified, the definition of severe secondary mitral regurgitation was revised and the recommendation for transcatheter edge-to-edge mitral valve repair in patients with this condition was upgraded. Additionally, antithrombotic therapeutic regimens in patients with native valvular heart diseases and bioprostheses were reappraised, the indications for early surgery in selected asymptomatic patient groups were expanded and the potential of transcatheter tricuspid valve interventions in inoperable and high-risk patients was acknowledged, although the latter needs to be further evaluated. This review article summarizes the most important recommendations of the new guidelines.Im August 2021 haben die European Society of Cardiology (ESC) und die European Association for Cardio-Thoracic Surgery (EACTS) ihre Leitlinien zum Management von Herzklappenerkrankungen aktualisiert. Seit der Veröffentlichung der vorherigen Version im Jahr 2017 haben sich einige neue Erkenntnisse zur Epidemiologie, Diagnose und Behandlung von Herzklappenerkrankungen ergeben, die zu einer Neubewertung mehrerer Empfehlungen geführt haben. Dabei wurden insbesondere die kritische Rolle des Herzteams bei Therapieentscheidungen erneut hervorgehoben, die Kriterien für die Auswahl der Behandlungsmodalität der Aortenklappenstenose präzisiert, die Definition der schweren sekundären Mitralklappeninsuffizienz revidiert und die Empfehlung für eine katheterbasierte Edge-to-edge-Rekonstruktion der Mitralklappe bei Patienten mit dieser Erkrankung aufgewertet. Weiterhin wurden die antithrombotischen Therapieschemata bei Patienten mit nativen Herzklappenerkrankungen und Bioprothesen neu bewertet, die Indikationen für eine frühzeitige Operation bei ausgewählten asymptomatischen Patientengruppen erweitert sowie das Potenzial von kathetergestützten Trikuspidalklappeneingriffen bei inoperablen und Hochrisikopatienten anerkannt, auch wenn Letztere noch weiter evaluiert werden müssen. Dieser Übersichtsartikel fasst die wichtigsten Empfehlungen der neuen Leitlinien zusammen.

Die biologische Aortenklappenprothese ist Mittel der Wahl beim Aortenklappenersatz bei über 80-Jährigen Patienten. Aufgrund höherer operativer Zeiten und eines höheren Arbeitsaufwandes bei gerüstfreien Bioprothesen, wurden bisher gestentete Bioprothesen in dieser Altersgruppe verwendet. In dieser Studie ermitteln wir die Langzeitergebnisse vom ungestenteten biologischen Aortenklappenersatz bei über 80-Jährigen Patienten., In octogenarians, biological bioprostheses are the conduits of choice for aortic valve replacement. Because of a higher surgical time and effort compared to stented prostheses, stentless bioprostheses are rarely used in this age group. We sought to determine the results of stentless biological heart valve replacement in octogenarians.

Die biologische Aortenklappenprothese ist Mittel der Wahl beim Aortenklappenersatz bei über 80-Jährigen Patienten. Aufgrund höherer operativer Zeiten und eines höheren Arbeitsaufwandes bei gerüstfreien Bioprothesen, wurden bisher gestentete Bioprothesen in dieser Altersgruppe verwendet. In dieser Studie ermitteln wir die Langzeitergebnisse vom ungestenteten biologischen Aortenklappenersatz bei über 80-Jährigen Patienten. In octogenarians, biological bioprostheses are the conduits of choice for aortic valve replacement. Because of a higher surgical time and effort compared to stented prostheses, stentless bioprostheses are rarely used in this age group. We sought to determine the results of stentless biological heart valve replacement in octogenarians.

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or21 mm/m

Surgical aortic valve replacement still represents the gold standard in patients with severe symptomatic aortic valve stenosis. In addition to conventional aortic valve replacement by mechanical or biological prostheses via a median sternotomy, novel approaches including minimally invasive strategies and new devices, such as so-called rapid deployment prostheses, are becoming increasingly more established. Autologous replacement strategies including the Ross and the Ozaki procedures have evolved into reliable options at selected centers of excellence. These novel treatment approaches in aortic valve surgery result in excellent short and long-term outcomes with a reduction of procedure-related complications. Taken together, these modern surgical replacement strategies enable a personalized surgical treatment in patients with aortic valve stenosis, which are tailored to the individual patient.

In severe ocular surface disease with limbal stem cell deficiency associated with severe dry eye, penetrating keratoplasty is likely to fail. In these cases, and provided the posterior segment is normal, keratoprosthesis surgery (KPro) can achieve visual rehabilitation. In KPros with an autologous biological haptic, a bone-tooth-complex (osteo-odonto-keratoprothesis, OOKPro) or a piece of tibial cortex (tibia-keratoprosthesis, TKPro) is used to carry a PMMA cylinder. This construct can successfully be implanted even in severely dry eyes and in those with autoimmune disease, in which other KPro designs frequently fail. Herein we review the published anatomic long-term results of OOKPro and TKPro on our own patients. With a mean follow-up of 7.5 years (max. 20.6) for OOKPro and 4.5 years (max. 13.3) for TKPro patients, the retention rate was 91 and 86%, respectively. We are unaware of any other technique for artificial replacement of the cornea with equally positive long-term results as KPros with a biological haptic.Bei schweren Erkrankungen der Augenoberfläche mit limbaler Stammzellinsuffizienz, bei denen eine perforierende Keratoplastik, z. B. bei schwerem Sicca-Syndrom, nicht erfolgreich durchgeführt werden kann, lässt sich bei intakten hinteren Augenabschnitten durch die Implantation einer Keratoprothese (KPro) eine Visusrehabilitation erreichen. Bei einer KPro mit biologischer Haptik wird der Prothesenzylinder entweder über ein autologes Zahn-Knochen-Präparat (Osteo-Odonto-Keratoprothese, OOKPro) oder über den kortikalen Knochen der Tibia des Patienten (Tibia-Keratoprothese, TKPro) fest in der Körperoberfläche integriert. Aufgrund dieser anatomischen Integration kann auch bei Patienten mit einem schweren Sicca-Syndrom und autoimmunologischen Erkrankungen, bei denen andere Prothesendesigns häufig versagen, erfolgreich eine KPro implantiert werden. Wir berichten über die anatomischen Langzeitergebnisse von OOKPros und TKPros in der Literatur und bei unseren eigenen Patienten. Bei einer mittleren Nachbeobachtungszeit von 7,5 Jahren (max. 20,6) bei der OOKPro und 4,5 Jahren (max. 13,3) bei der TKPro bestand eine Retentionsrate von 91 bzw. 86%. Uns ist kein anderes Verfahren zum künstlichen Ersatz einer Hornhaut bekannt, das vergleichbar gute Langzeitergebnisse erreicht wie eine KPro mit biologischer Haptik.

Although corneal transplant surgery in avascular normal risk eyes is becoming even more minimally invasive and successful, treatment options for difficult to treat patients with high risk eyes are still limited. In these cases HLA typed allogeneic transplants and artificial corneas (keratoprostheses) can be used.This article combines a review of the literature in PubMed and own clinical experiences on the use of artificial corneas in high risk eyes. Osteo-odontokeratoprosthesis (OOKP), Boston Kpro, Miro Cornea® and KeraKlear® corneas were used as clinical keratoprostheses.Worldwide, the most experience exists for the use of Boston Kpro and OOKP in high risk eyes. Miro Cornea® and KeraKlear® are new procedures where only preliminary results are available and further evaluation is necessary. The longest experience and best anatomical long-term results have been achieved with OOKPs. Comparable cohorts are available for the Boston Kpro. The function of all keratoprostheses is threatened by secondary glaucoma. Implantation of the KeraKlear® prosthesis remains difficult. The Miro Cornea® shows an initially stable integration behavior.Keratoprostheses, such as the Boston Kpro and OOKP are valid treatment options for eyes which are not open to therapy with allogeneic corneal transplantation. Modern implants such as KeraKlear® prosthesis and Miro Cornea® need further prospective clinical evaluation.

Primary bone sarcomas typically arise in the long bones and the pelvis of children and adolescence but may also occur in adults. Meta/diaphysial tumour involvement resulting in the necessity of a joint replacement is more common than diaphysial tumour sites.In the treatment of these tumours, both endoprosthetic replacement and biological reconstruction techniques are used. Each technique has method-specific advantages and disadvantages.To choose the appropriate surgical method, a multitude of influencing parameters need to be considered. The age at treatment (soft tissue situation/estimated growth/biological potential of the bone), therapeutic concept (palliative vs. curative), the tumour site (upper/lower extremity), tumour expansion (diaphysis/metaphysis) and oncological treatment concept (chemotherapy/radiotherapy) are key factors significantly influencing the surgical technique in terms of functional outcome and longevity of the reconstruction.Surgical treatment of bone sarcoma requires broad-based experience of the oncological surgeon. Knowledge of the different surgical technics and reconstruction methods is decisive to offer the individual patient the best oncological and functional outcome.

Since the first successful heart valve replacement procedures were performed in the 1950s, a multitude of different heart valves have been developed and implanted. This review offers a structured overview of the most important mechanical and biological heart valves with special regard to the individual indications of mechanical versus biological heart valve replacement and to possible postoperative complications.

A 68-year-old woman presented with an enormous exophytic tumor on her forehead extending to the scalp. After complete resection of the tumor, the resulting defect was closed successfully using a bovine dermal substitute followed by a split-thickness skin graft.

In 2012 the new and collaborative "Guidelines on the management of valvular heart disease (version 2012)" were published by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). These guidelines emphasize that decision-making in patients with valvular heart disease should ideally be carried out by a"heart team" with particular expertise in valvular heart disease. In aortic regurgitation pathologies of the aortic root are frequent and in patients with Marfan syndrome, surgery is indicated when the maximal ascending aortic diameter is ≥50 mm, while the threshold for intervention should be lower in patients with risk factors for progression. Regarding aortic stenosis, transcatheter aortic valve implantation (TAVI) should be performed only in hospitals with on-site cardiac surgery and with a"heart team" available to assess patient risks. The TAVI procedure is indicated in patients with severe symptomatic aortic stenosis who are judged by the"heart team" to be unsuitable for surgery but have sufficient life expectancy. It should be considered for high-risk patients with severe symptomatic aortic stenosis based on the individual risk profile assessed by the"heart team". Furthermore, low flow - low gradient aortic stenosis with normal ejection fraction and the difficult topic of asymptomatic severe aortic stenosis and the indications for aortic valve replacement are discussed. With respect to mitral regurgitation, valve repair should be the preferred technique when it is expected to be durable. The topics of asymptomatic mitral regurgitation as well as percutaneous mitral valve repair using the edge to edge technique as an alternative for high risk patients are discussed. Tricuspid disease should not be forgotten and during left-sided valve surgery, tricuspid valve surgery should be considered in the presence of mild to moderate secondary regurgitation if there is significant annular dilatation. Last but not least, in patients with aortic bioprostheses the use of low-dose aspirin is now favored for a 3-month postoperative period.

1. Division of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; 2. Clinic for Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany; 3. Clinic for Cardiac Surgery, German Heart Center Munich, Munich, Germany; 4. Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany

With lower rates of postoperative renal failure, diabetes and cardiovascular disease, partial nephrectomy achieves longer overall survival and equally long tumor-specific survival. It is thus the current gold standard treatment for renal tumors and now also for those ≥ 4 cm in size. The main complications of nephron-sparing surgery, particularly for large and centrally located tumors, are postoperative parenchymal bleeding and urinary fistulas after opening the urinary collecting system (UCS).Between August 2003 and April 2012, 76 partial nephrectomies for tumors ≥ 4 cm in size were performed using porcine small intestinal submucosa (SIS, Surgisis®) to close the capsular, renal and in some cases, UCS defects.The median tumor size was 5.0 cm (range 4.0-13.0 cm) and the intervention was performed with warm ischemia in 25 cases (32.8 %), with cold perfusion in 16 cases (21.2 %) and without ischemia in 35 cases (46.0 %). A total of 4 patients (5.5 %) developed postoperative urinary fistulas and 4 (5.5 %) required revision surgery because of significant postoperative bleeding. There were no local infections or allergic reactions to the foreign material.Surgisis® enables a quick and technically uncomplicated closure of the renal defect after partial nephrectomy for tumors. It has the potential to further minimize postoperative bleeding and urinary fistulas and to facilitate the intervention to the extent that nephron-sparing surgery will gain broader acceptance even in patients with tumors ≥4 cm in size.

Surgery of carotid artery stenosis is an evidence-based procedure. In Germany approximately 25 percent of the strokes are caused by arteriosclerotic processes in the extracranial internal carotid artery and are consequently potentially avoidable by an appropriate treatment. The symptoms, the stenosis degree as well as the perioperative risk represent the basis for the indication. The perioperative complication rate should be under 3 percent for those cases with asymptomatic stenoses and under 6 percent for those with symptomatic stenoses.The most frequently applied operation procedures comprise carotid thrombo-endarterectomy (TEA) including patch graft and the eversion endarterectomy. In the following video we present both methods in a 76-year-old female patient with an asymptomatic 95 percent stenosis as well as in an 84-year-old female patient with an asymptomatic 85 percent stenosis operated under regional anaesthesia.Regional anaesthesia is performed through installation of a high cervical block under reclination of the head to the contralateral side. Then incision of the skin and the platysma along the front of the sternocleidomastoid muscle. Preparation of the carotid bifurcation with minimal manipulation as well as protection of the surrounding neural structures. Afterwards clamping of the vessels under permanent neurological monitoring and controlled hypertonia. Open thrombo-endarterectomy after longitudinal arterial incision with plaque removal en bloc and closure by using a bovine patch graft in four-point seam technique. This method should be preferred in cases with long-segment stenosis as well as in cases with a small lumen internal carotid artery. In the framework of eversion endarterectomy, we perform a tangential resection of the ACI on the bifurcation. The plaque cylinder is mobilised afterwards and is removed through eversion of the whole vessel. Then the reinsertion of the ACI in the bifurcation can be performed with an additional shortening of the artery in cases of kinking. In this way short- segment stenosis lend themselves to fast and safe treatment. In all cases digital subtraction angiography is recommended by the authors for intraoperative quality monitoring.In the hands of experienced vascular surgeons, the open carotid TEA including patch graft and the eversion endarterectomy under regional anaesthesia represent highly effective procedures for symptomatic/asymptomatic carotid stenosis. The S3-guidelines for the therapy of carotid artery stenosis will be published this year and should be consulted for the interdisciplinary therapy decision.

Regeneration and repair of corneal epithelium rely on a reservoir of unipotent progenitor cells, which is situated within the basal epithelial layer at the corneoscleral limbus. If these cells are lost, corneal surface integrity is disturbed, which may lead to a painful loss of vision. Since the late 1990s cultivated grafts of limbal epithelium are being used therapeutically. Limbal epithelial cells are obtained from the fellow eye or from an allogeneic donor, propagated in culture on different types of carriers, and subsequently transplanted. This process entails removal of progenitor cells from their natural environment. However, surrounding cells and extracellular matrix are widely believed to provide important stimuli for stem cell maintenance and for correct differentiation. Therefore, new approaches aim at providing this so-called stem cell niche ex vivo and following transplantation. Niche factors can also drive transdifferentiation of alternative progenitor cell types towards a corneal phenotype. This permits the use of autologous cells in cases of bilateral limbal stem cell insufficiency. Several biosynthetic substrates have been devised for culture, transdifferentiation and transplantation of donor cells. This work intends to provide an overview of constructs that are currently available and to some extent clinically employed. In addition, a summary is given of novel concepts which aim at integrating putative niche factors into the stem cell carriers to replicate the stem cell niche.

Prosthetic arteriovenous grafts have an inferior patency rate and greater morbidity than those with autogenous vessels and are therefore considered as secondary or tertiary vascular access for hemodialysis in patients with fatigued or unsuitable superficial arm veins. Prior access planning in accordance of patient characteristics, careful operative procedure and appropriate revision of complications can ensure long-term functioning of a vascular access using a large variety of possible prosthetic conduits. Arteriovenous grafts remain essential in vascular access surgery and their role may be increasing with higher comorbidities of patients and should be preferred to tunnelled cuffed catheters. This article reviews the indications, alternative configurations and characteristics of arteriovenous grafts.

30% of patients with significant aortic stenosis are not considered for operative aortic valve replacement because of the high perioperative risk. An alternative catheter based option for these patients is the transcatheter aortic valve replacement (TAVI). In general, there are two approaches for TAVI: transfemoral and transapical. Transfemoral aortic valve replacement is performed by transcatheter replacement of an aortic valve via the femoral arteries. Transapical valve replacement is achieved by transcatheter implantation via the fifth intercostal space. The most common complications are vessel injuries, bleeding complications, new onset of AV-block, development of paravalvular insufficiency, acute kidney injury, stroke and TIA. The first long-term observations suggest positive results. First clinical trials in a high-risk population show a promising outcome. Therefore TAVI offers a reasonable therapy option for patients with high perioperative risk. Further long-term clinical trials are still pending.

With the introduction of heart valve prostheses cardiac valvular disease has become much more accessible to therapeutic options. However, currently available prostheses display significant limitations, such as limited long-term durability (biological prostheses) and a long-term necessity for anticoagulation therapy. Hence, alternative prosthesis types have been extensively explored in recent years particularly aiming at the development of vital and regenerative prostheses by means of tissue engineering. In the scientific field, different competing concepts have been introduced, including biological or synthetic scaffolds which can be further enhanced by cellular or extracellular components to promote further in vivo development of the prosthesis after implantation. Nowadays, decellularized donor heart valves are among the most advanced prosthesis types experiencing growing clinical attention and widespread use.

The calcified aortic stenosis is the dominating valve disease. Patients affected are most common elderly people in the 8 (th) or 9 (th) decade of their life who often show associated comorbidities like reduced left ventricular function, impaired renal function, pulmonary hypertension, and further diseases (Diabetes mellitus, stroke, COPD). In many cases perioperative morbidity and mortality are too high for surgical valve replacement and up to 30 % of patients are rejected. Nevertheless, prognosis of aortic stenosis is worse if the typical symptoms like dyspnea on exertion, syncope, and angina occur. The transcatheter aortic valve implantation is a new method treating this particular group of patients. The aortic valve bioprothesis consists of a balloon-expandable stent or a self-expandable frame, in which a valve of bovine or porcine pericardium is incorporated. The implantation is performed by retrograde access via the femoral or subclavian artery; the balloon-expandable prosthesis can also be implanted by transapical approach. Recently, the PARTNER trial and other studies demonstrate a high implantation success rate and better survival in comparison to standard therapy but exhibit also cerebral vascular and peripheral vascular complications. A further reduction of the available delivery systems and new types of valves which are under experimental tests and clinical evaluation contribute to this development.

Severe aortic stenosis is a significant source of morbidity and mortality among the aging population. Due to prohibitive surgical risk, many patients are not candidates for surgery. Therefore, transcatheter aortic valve implantation has emerged as a promising technology for treating this group of high risk patients. With increasing experience, this procedure can be performed successfully and safely in selected high risk patients. Nevertheless, before widespread use and application to lower risk patients the results of randomized studies are mandatory. Primary (degenerative) and secondary (functional) mitral regurgitation (MR) is an important cause of heart failure. The double orifice technique of mitral valve repair using the MitraClip® system is one of many transcatheter approaches to treat significant MR in patients at high risk for conventional surgery. This technique is effective in reducing MR severity in patients suffering from both degenerative and functional MR. Percutaneous pulmonary valve implantation (PPVI) is an interventional treatment for adolescents and young adults with congenital heart disease. After corrective or palliative operation in infancy or early childhood, some patients regularly need reoperations for right ventricular outflow tract reconstruction. In the last decade, PPVI has evolved as an alternative treatment option with much less morbidity compared to repeated surgery.

Autogenous tissue has been the grafting material of choice in reconstruction of permanent tympanic membrane perforations. Although donor site complications are infrequent and morbidity from such harvest is usually quite low, there are nevertheless risks associated with additional incisions when autogenous tissue is used. In addition, in patients who have undergone several grafting attempts, there may be no suitable grafting material in the vicinity of the operative field. Several alternatives to native grafting material have recently become available, which have shown similar success rates of perforation closure as well as postoperative audiologic results. This article gives an overview on these non-autogenous grafts and alloplastic materials.

Cardiac function, including the heart muscle and valves, can be severely altered by congenital and acquired heart diseases. Several graft materials are currently used to replace diseased cardiac tissue and valvular segments. Implantable grafts are either non-vital or can trigger an immune response which leads to graft calcification and degeneration. None of the existing grafts have the ability to remodel and grow in tandem with the physiological growth of a child and therefore require re-operation. Novel approaches such as tissue engineering have emerged as possible alternatives for cardiac reconstruction. The main concept of tissue engineering includes the use of biological and artificial scaffolds that form the shape of the organ structures for subsequent tissue replacement, which will provide absolute biocompatibility, no thrombogenicity, no teratogenicity, long-term durability and growth.Heart valve tissue engineering represents an important field especially in pediatric patients with valve pathologies. In order to create an autologous valve equivalent myofibroblasts and/or endothelial cells are seeded on specially designed scaffolds. Here we describe the different types of cell sources and different types of matrices currently used in heart valve tissue engineering. Valve manufacture is carried out in specially designed bioreactors providing physiological conditions. The number of clinical studies using tissue engineered valves is still limited; however, several promising results have already demonstrated their durability and ability to grow.Myocardial tissue engineering aims to repair, replace and regenerate damaged cardiac tissue using tissue constructs created ex vivo. Conceivable indications for clinical application of tissue engineered myocardial-implant substitutes include ischemic cardiomyopathies, as well as right ventricular outflow tract reconstruction in patients with congenital heart diseases. Therapeutic application of functional (contractile) tissue engineered heart muscle appears feasible once key issues such as identification of the suitable human cell source, large scale expansion and suitable scaffolds are solved. In addition, the present article discusses the importance of vascularization as an important prerequisite for successful bio-artificial myocardial tissue.Further experimental and clinical research on cardiovascular tissue engineering is felt to be of great importance for others as well as for us in order to create an ideal heart valve/myocardial substitute and help our patients with advanced cardiac pathologies.

Various techniques for repair of an incisional hernia are available for the surgeon. Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of recurrence and therefore should only be used in exceptional cases. An underlying systemic disturbance of collagen metabolism is assumed to exist in patients with an incisional hernia. In such patients the mechanisms of wound healing and remodeling of the abdominal wall following laparotomy are insufficient, which necessitates reinforcement of the abdominal wall with a non-resorbable alloplastic mesh prosthesis to enable a long-term cure. The implantation of such meshes can be carried out laparoscopically or by an open approach. The gold standard of open repair techniques is the retromuscular placement of a mesh prosthesis. The retromuscular mesh placement as a reinforcement of the abdominal wall (augmentation) must be categorically differentiated into the abdominal wall replacement by mesh bridging. In this technique the mesh is likewise placed in the retromuscular space, however a complete closure of the ventral fascia is not necessary. Retromuscular augmentation enables an extra-peritoneal placement of the prosthesis, an optimization of tissue integration by plane coverage of the prosthesis by well vascularized muscular tissue and a sufficient overlap in cranio-caudal and lateral directions. Mesh fixation is best made with absorbable suture material but is better suited for technical simplification. The use of a prophylactic drainage should be decided depending on the individual patient's risk factors, because sufficient evidence-based data are currently not available. If augmentation is not possible bridging is necessary and then the mesh has to be fixed without underlying support. Current data reveal that the recurrence rate following incisional hernia repair by retromuscular mesh augmentation has decreased promisingly in comparison to simple suture techniques. In total the recurrence rate following retromuscular mesh placement ranges between 2 and 12%. Current results of prospective randomized multicentre trials are not available. However, it is to be expected that further development of mesh materials as well as improvement of surgical techniques with avoidance of typical pitfalls will lead to further reduction of the recurrence rate with an improvement in patient satisfaction.

Erkrankungen der Aortenklappe waren und sind aktuell hoch inzidente Erkrankungen in der Bevölkerung. Als kausaler Therapieansatz hat sich der Ersatz der erkrankten Aortenklappe zu einer Erfolgsgeschichte entwickelt. Der Herzchirurg ist heute in der Lage, seinem Patienten eine evidenzgesicherte, an seine Erkrankung und seinen Lebensstil adaptierte Therapie anzubieten. Die ATS Medical Modell 3F ist eine neue gerüstlose Aortenklappenprothese der dritten Generation. Innerhalb einer nicht randomisierten, prospektiven Studie wurden von März 2002 bis Oktober 2003 insgesamt 35 Patienten im Durchschnittsalter von 73 ± 6 Jahren erstmals mit diesem neuen gerüstlosen Aortenklappenersatz therapiert. Nachuntersuchungen erfolgten direkt postoperativ (Tag 2 bis 5) und im Zeitraum 3-6 und 11-14 Monate nach Operation. Präoperativ befanden sich 77 Prozent der Patienten in NYHA Klasse III-IV und zeigten im Überblick einen mittleren systolischen Druckgradienten von 58 ± 15 mmHg. In dieser Studie wurden Prothesen der Größe 25 mm in 31 Prozent, 27 mm in 29 Prozent und 29 mm in 26 Prozent der Patienten innerhalb einer Abklemmzeit der Aorta von 52 ± 8 Minuten (ohne zusätzliche Prozeduren) subcoronar implantiert. Es gab keine perioperativen Todesfälle und keine schweren intraoperativen Komplikationen. Im postoperativen Verlauf verbesserten sich die Parameter der Hämodynamik für die Klappengrößen 23 bis 29 mm statistisch signifikant. Es konnten im Überblick ein um den Faktor 5 gesenkter mittlerer Druckgradient von 12 mmHg, eine Verdopplung der effektiven Öffnungsfläche auf 1,46 cm² und ein Rückgang des linksventrikulären Masseindex auf 102 g/m², also in physiologische Wertebereiche festgestellt werden. Somit besteht ebenfalls ein Trend zur linksventrikulären Restitution. Die Majorität von 89 Prozent der Patienten befand sich postoperativ in NYHA Klasse I-II. In keinem Fall war eine Reoperation auf Grund einer Fehlfunktion der Prothese nötig. Die Mortalität und Morbidität befanden sich in den in der Literatur als normal beschriebenen Grenzen. Durch ihre Flexibilität resultierend aus dem neuen Ansatz in der Konstruktion, ist die 3F-Prothese leicht zu implantieren. Der postoperative Verlauf gestaltete sich komplikationsarm und alle Patienten bestätigten einen Gewinn an Lebensqualität. Eine Verbesserung der Hämodynamik gegenüber anderen gerüstlosen Bioprothesen, die in vitro vermutet wurde, konnte innerhalb des Studienkollektivs der Klinik für kardiovaskuläre Chirurgie der Charité – Universitätsmedizin Berlin jedoch nicht bewiesen werden. Zusätzlich zu dem Gewinn an Lebensqualität bezeichneten Kon et al als Ziel nach Aortenklappenersatz die Anpassung der Lebenserwartung an die eines Gleichaltrigen ohne Erkrankung der Aortenklappe. Ob die 3F Bioprothese diese Erwartung erfüllen kann, muss in weiteren Langzeitstudien erarbeitet werden., The ATS 3F equine aortic bioprosthesis is a new stentless pericardial valve which was undergoing evaluation in a prospective clinical trial and was considered to have superior hemodynamic performance. Herein is reported the initial experience with the 3F valve, focusing on the hemodynamic performance of the device. In 2002 and 2003 35 patients (age range 61-86 years) underwent aortic valve replacement with the ATS 3F valve implanted in the subcoronary position. Evaluation of valve hemodynamic performance was assessed at postoperative day 5 to 7, at 3-6 months, and at 11-14 months' follow up by transthoracic echocardiography. The mean preoperative transvalvular pressure gradient was 58 +/- 15 mmHg. Before surgery 77 % of patients were in NYHA class III or IV, despite aggressive medical treatment. The implanted valve sizes ranged from 21 to 29 mm with a mean size of 26,3 mm. There were no operative deaths and no major perioperative complications. After 12 months mean pressure gradients for the 23-, 25-, 27- and 29-mm valves were 13, 13, 12 and 9 mmHg respectively. Mean systolic pressure gradients and NYHA class were improved significantly after surgery. Mild paravalvular regurgitation and minimal central regurgitation were detected in some patients, but were of no clinical importance. Freedom from embolism was 91 %. Valve dysfunction or mechanical failure did not occur during the follow up period. Because of its unique design the 3F aortic bioprosthesis is simple to implant and no major adverse effects have been associated with such valve implantation at Charite- Hospital. Transprosthetic gradients appeared to regress at 6-12 months' follow up. The durability of the device is yet to be established in ongoing long-term trials.

Treatment of small congenital abdominal wall defects (e.g. omphalocele and gastroschisis) can be performed by direct closure. In large defects non-resorbable artificial materials (e.g. Gore-Tex) are necessary to close the fascia. The aim of this study was to find out whether a new procedure, the PAUL pocedure, might be suitable for the treatment of large abdominal wall defects. A full thickness abdominal wall defect was created in young Wistar Rats. These defects were then closed by implantation of a 1x2 cm sized piece of PTFE (Dual-Mesh), a polypropylene mesh (Prolene(R)) or by using the PAUL procedure. Over a period of 6 weeks no wound infections or hernias were monitored. In contrast to PTFE the PAUL procedure showed only minimal adhesion to the intestine and a high stability of the implanted material. A xenogenic extracellular matrix, such as that used in the PAUL procedure, may induce an immune response, which is comparable with a remodeling reaction rather than rejection. Based on these good results a large animal model study (Goettinger mini-piglets) was performed. No wound infections or hernias could be observed throughout the experiment. Control laparoscopy after 3, 6, 9, and 12 months showed only minimal adhesion to the intestine. Our results indicate that the PAUL procedure can be used easily and successfully for the therapy of congenital abdominal wall defects.

The degenerative, calcified aortic stenosis is the most common form of adult valvular heart disease. Surgical aortic valve replacement is the method of choice and can be performed at low risk in suitable candidates. However, a fair amount of patients is rejected from surgery due to old age and preexisting comorbidities increasing operative mortality. For this reason frequently operation is not accomplished. Today, with the development of percutaneous aortic valve replacement, the treatment of aortic stenosis has entered a new era providing a new durable treatment option.

To prospectively evaluate whether planimetric measurements of aortic valve area (AVA) with dual-source computed tomography (DSCT) correlate with measurements obtained by echocardiography and to correlate the amount of calcification of the aortic valve with AVA in a group of patients after aortic valve replacement.23 patients underwent dual-source computed tomography (DSCT) of the heart (Somatom Definition, Siemens Medical Solutions, Forchheim, Germany), without heart rate control (heart rate 52-113 beats/minute). All patients had undergone aortic valve replacement (homografts, mean time after surgery: 7+/-3 years). The AVA of the transplanted aortic valve graft was measured planimetrically by means of DSCT and compared with echocardiography as a standard of reference, to exclude post-surgical restenosis of the valve. Maximum AVA in systole planimetrically measured with CT was compared with calculated AVA values determined with the continuity equation, using transvalvular pressure gradients. The amount of calcification of the aortic valve was quantified and correlated (Spearman's R) with the AVA. To assess intra- and inter-reader reproducibility, the DCST data was re-analyzed by two readers 4 weeks after the initial review.All DSCT datasets were of diagnostic image quality concerning valve depiction. The mean AVA as measured by DSCT was 2.7+/-0.9 cm (2) compared to 1.8+/-0.5 cm (2) by echocardiography (p0.05). The planimetric evaluation of the CT data as compared to results of echocardiography showed a significant correlation of the results (Pearson's correlation coefficient R=0.78, p0.001). Intra- and inter-reader reproducibility was good with intra-class correlation coefficients of 0.86 and 0.81, respectively (p0.001). There was a significant negative correlation between the amount of aortic valve calcification and AVA as measured by echocardiography (R= -0.42; p0.05) and as measured by DSCT (R= -0.67; p=0.001).First experience indicates that DSCT is able to assess aortic valve opening area with high image quality and good intra- and inter-reader reproducibility in subjects after aortic valve replacement. The negative correlation between AVA and the amount of aortic valve calcification suggests that calcification is a possible risk factor for restenosis in subjects with aortic valve replacement.

Calcified aortic stenosis is the predominant valve disease. Patients affected are most commonly elderly people, who often show associated comorbidities like reduced left ventricular function, impaired renal function, and pulmonary hypertension. The risk of open-heart surgery is elevated. Balloon aortic valvuloplasty enables a reduction of symptoms, an increase in physical performance, and, therefore, an improved quality of life. However, a reduction in mortality cannot be reached with this method. New techniques and improved equipment induced a "revival" of balloon aortic valvuloplasty, which has been introduced almost 20 years ago. In addition, brachytherapy after balloon valvuloplasty has recently been investigated and represents an interesting approach to reduce early restenosis. The technical improvement of balloon valvuloplasty is the percutaneous heart valve, which is under present clinical investigation. The antegrade/transseptal and retrograde approaches are used, as is the transapical access to the left ventricle. Even if long-term results are not yet available and the procedures still require technical improvement, especially minimization of catheter size, percutaneous valve replacement is a new chapter in the treatment of the calcified aortic stenosis.

Due to the increasing incidence of severe aortic stenosis in old and multimorbid patients, the percutaneous implantation of aortic valve-carrying stents has become an alternative to the surgical replacement of aortic valves. Starting in 1995, the authors developed a self-expanding stent which transferred the necessary forces for anchoring up to the aorta ascendens-a conception taken over from CoreValve. The further improvement of this idea over the past 11 years has led to a self-expanding, relatively short stent-valve system that is reliably positioned in the cusps of the old aortic valve and holds the old valve like a paper clip, thus transferring the holding forces physiologically. As compared to conventional systems, the sophisticated insertion catheter requires further chronic animal tests so as to represent a true alternative to the conventional surgical procedure.

This paper gives an overview of the indications for surgical therapy of aortic valve stenosis. The current surgical management and the results of aortic valve replacement are outlined. The presented results of aortic valve replacement especially in elderly and high-risk patients compare favorably with other published data in respect to perioperative morbidity and mortality. All newly developed procedures for the treatment of aortic stenosis therefore will have to prove their superiority in future.

Patients with aortic valve (AV) pathology and severe comorbidities should benefit from reduced myocardial ischemic and extracorporeal circulation (ECC) time. Sutureless implantation of AV prosthesis may reduce myocardial ischemic and ECC time significantly. The authors report on their preliminary results with the first implants of the 3F-Enable sutureless AV prosthesis.The 3F-Enable prosthesis was implanted in five patients. Prostheses sizes were 27 mm (n = 3), 23 mm (n = 1), and 21 mm (n = 1), respectively. Intraoperatively, at patient's discharge as well as 3 and 6 months postoperatively, the AV prosthesis was evaluated by echocardiography.ECC time was 87 +/- 36 min (range 49-141 min), myocardial ischemic time 55 +/- 27 min (range 32-97 min), and AV implant time 184 +/- 195 s (range 10-420 s). The latest postoperative echo (5.2 +/- 1 months postoperatively) revealed a fully competent AV in three patients, in two patient paravalvular leakage was detected at the severity of an aortic regurgitation (AR) II degrees , and AR II degrees -III degrees , respectively. The mean pressure gradients were 5.8 +/- 1.3 mmHg (range 4.2-7.1 mmHg), valve orifice area was 3.2 +/- 0.4 cm2 (range 2.6-3.6 cm2).The first clinical results of the 3F-Enable sutureless AV prosthesis are feasible; however, a paravalvular leakage was detected in two patients (40%). Thus, device and procedural enhancements are required to assure positioning and anchoring of the prosthesis.