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(1) Introduction: Simultaneous ECMO and IABP therapy is frequently used. Haemodynamic changes responsible for the success of the concomitant mechanical circulatory support system approach are rarely investigated. In a large-animal model, we analysed haemodynamic parameters before and during ECMO therapy, comparing central and peripheral ECMO circulation with and without simultaneous IABP support. (2) Methods: Thirty-three female pigs were divided into five groups: (1) SHAM, (2) (peripheral)ECMO(-)IABP, (3) (p)ECMO(+)IABP, (4) (central)ECMO(-)IABP, and (5) (c)ECMO(+)IABP. Pigs were cannulated in accordance with the group and supported with ECMO (+/- IABP) for 10 h. Systemic haemodynamics, cardiac index (CI), and coronary and carotid artery blood flow were determined before, directly after, and at five and ten hours on extracorporeal support. Systemic inflammation (IL-6; IL-10; TNF alpha; IFN gamma), immune response (NETs; cf-DNA), and endothelial injury (ET-1) were also measured. (3) Results: IABP support during antegrade ECMO circulation led to a significant reduction of left ventricular pressure in comparison to retrograde flow in (p)ECMO(-)IABP and (p)ECMO(+)IABP. Blood flow in the left anterior coronary and carotid artery was not affected by extracorporeal circulation. (4) Conclusions: Concomitant central ECMO and IABP therapy leads to significant reduction of intracavitary cardiac pressure, reduces cardiac work, and might therefore contribute to improved recovery in ECMO patients.

Background Coronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed. Methods and Results We aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North-Rhine-Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in-hospital all-cause mortality and major adverse cardio-cerebral event. Patients were 68 +/- 11 years of age, had 3-vessel and left main-stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non-ST-segment-elevation myocardial infarction, and 23.5% in ST-segment-elevation myocardial infarction. A history of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non-ST-segment-elevation myocardial infarction, and 16.1% in ST-segment-elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non-ST-segment-elevation myocardial infarction and 17.2% in ST-segment-elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In-hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI <24 hours, and 14.1% with failed PCI (P<0.003). The in-hospital major adverse cardio-cerebral event rate was 16.4% without PCI, but 17.4% with prior PCI >24 hours, 25.6% with prior PCI <24 hours, and 41.3% with failed PCI (P=0.014). Multivariable logistic regression analysis showed prior PCI (P=0.039), as well as failed PCI (P=0.001) to be predictors for in-hospital all-cause mortality and major advers

Background Performing cardiac surgery in patients with cardiovascular risk factors incorporates a steady risk for the development of postoperative complications. Perioperative statin intake was associated with an improvement of perioperative outcomes in these patients. However, the European Association for Cardio-Thoracic Surgery guidelines regarding the perioperative statin treatment were changed recently due to large studies reporting about relevant adverse effects related to statin therapy. Methods All relevant databases were searched including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and the metaRegister of Controlled Trials. Various registries were screened (National Research Register, the ClinicalTrials.gov, and gray literature) with search on online conference indices of relevant scientific meetings. No language restrictions were applied. Results We identified 10 randomized controlled studies summarizing 3,468 participants undergoing various kinds of cardiac surgical procedures. All included studies presented with marked differences regarding study design. Pooled analysis indicated that statin pretreatment was associated with a formally reduced incidence of postoperative atrial fibrillation (AF) (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.39-1.00; p =0.05) but with an increased incidence of renal failure (OR 1.20, 95% CI 1.01-1.44; p =0.04) compared with control. Substantial heterogeneity was observed among studies reporting about AF. Conclusion Current but sparse evidence reveals that statin pretreatment is associated with a higher rate of postoperative renal failure compared with control therapy but is ineffective to substantially reduce postoperative AF. Given the relevant heterogeneity among included studies, statin pretreatment cannot be generally recommended.

Objective There is an increasing need for small diameter vascular grafts with superior host hemo- and cytocompatibilities, such as low activation of platelets and leukocytes. Therefore, we aimed to investigate whether the preparation of bacterial nanocellulose grafts with different inner surfaces has an impact on in vitro host cytocompatibility. Methods We have synthesized five different grafts in a bioreactor, namely open interface surface (OIS), inverted (INV), partially air dried (PAD), surface formed in air contact (SAC) and standard (STD) that were characterized by a different surface roughness. The grafts (length 55 mm, inner diameter 5 mm) were attached to heparinized polyvinyl chloride tubes, loaded with human blood and rotated at 37 degrees C for 4 hours. Then, blood was analyzed for frequencies of cellular fractions, oxidative products, soluble complement and thrombin factors. The results were compared to clinically approved grafts made of polyethylene terephthalate and expanded polytetrafluoroethylene. Additionally, blood platelets were labelled with(111)Indium-oxine to visualize the distribution of adherent platelets in the loop by scintigraphy. Results SAC nanocellulose grafts with the lowest surface roughness exhibited superior performance with 65% leukocyte and >90% thrombocyte loss. Of note, SAC nanocellulose grafts showed lowest radioactivity with scintigraphy analyses, indicating reduced platelet adhesion. Although the levels of reactive oxygen species and cell free DNA did not differ significantly, the levels of thrombin-antithrombin complexes were lowest in SAC grafts. However, all nanocellulose grafts exhibited enhanced complement activation. Conclusion The systematic variation of the inner surfaces of BNC vascular grafts significantly improves biocompatibility. Especially, SAC grafts exhibited the lowest loss of platelets as well as leukocytes and additionally significantly diminished activation of the coagulation system. Further animal studies

Background-Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non-ST-segment-elevation myocardial infarction (NSTEMI) and ST-segment-elevation myocardial infarction (STEMI). Methods and Results-Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in-hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9 +/- 17 versus 3 +/- 6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On-pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions-Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Background Patients with acute myocardial infarction (AMI) are at high risk when undergoing emergency coronary artery bypass graft (CABG)-surgery. Their outcome remains poor despite increased use of extracorporeal membrane oxygenation (ECMO). We investigated the impact of timing for perioperative ECMO-support in these patients. Methods In this retrospective double-center study, we evaluated 201 patients with AMI undergoing CABG, dividing them into the following groups: No-ECMO (n = 101), preoperative ECMO (pre-ECMO, n = 6), intraoperative ECMO (ECC-ECMO, n = 67), and postoperative ECMO (post-ECMO, n = 27). We evaluated the impact of ECMO timing on postoperative mortality, organ function, and length of stay, comparing these to predicted outcome using different risk-scores. Results Post-ECMO patients showed lowest 30-day-survival (40.7%), while earlier ECMO-start was associated with better outcome (50.7% in extracorporeal circulation [ECC]-ECMO and 66.7% in pre-ECMO patients). On admission, only pre-ECMO and ECC-ECMO patients showed higher surgery- and intensive-care-unit (ICU)-related risk-scores. In pre- and ECC-ECMO patients, the first significant increase in lactate-levels (>4 mmol/L) was observed preoperatively, while this occurred 1 hour postoperatively in post-ECMO patients. Bilirubin was increased in all patients, decreasing after 3 and 12 days in pre- and ECC-ECMO patients, respectively, but only after 18 days in post-ECMO patients. Multiple ICU risk-scores did not discriminate survival-probability correctly. Only the ECMO-related survival after veno-arterial-ECMO-score correctly predicted the significantly lower survival in post-ECMO patients. Conclusion Our study shows that timely ECMO-support is associated with earlier bilirubin-downtrend and higher survival in patients with AMI after CABG. Lactate-increase greater than 4 mmol/L seems to be a helpful threshold to trigger the timely onset of ECMO-therapy, providing better survival.

Introduction: Profoundly impaired left ventricular (LV) function in patients undergoing femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can result in intra-cardiac stasis and thrombus formation. There have been several attempts to improve LV unloading in patients with peripheral VA-ECMO, either by improving contractility or by venting the LV. Methods: Data from all patients who underwent femoral VA-ECMO between 2007 and 2015 due to cardiogenic decompensation were retrospectively analysed regarding intra-cardiac thrombus formation. Results: In total, 11 of 281 patients (3.91%) with femoral VA-ECMO developed an intra- or extra-cardiac thrombus despite adequate anticoagulation therapy. None of the patients survived this serious complication. Conclusion: Management strategies for patients with femoral VA-ECMO support and severely impaired LV function must be reassessed to avoid insufficient LV unloading at an early stage of ECMO therapy. Early LV decompression should be considered in patients with insufficient unloading of the LV to prevent intra-cardiac thrombus formation.

Background This study evaluates whether preoperative statin therapy improves clinical outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS). Methods A total of 1,151 patients undergoing CABG for ACS were prospectively entered into the North-Rhine-Westphalia surgical myocardial infarction registry and subdivided into two groups according to their preoperative statin status (statin naive vs. statin group). A logistic regression model was employed to analyze the impact of a statin therapy and dose for the endpoints in-hospital mortality and major adverse cardiac events (MACE). Results Demographics, pre- and intraoperative data of the statin-naive group (n = 208; 18%) and statin-treated group (n = 943, 82%) did not differ. In-hospital mortality (12.6 vs. 6.3%, p = 0.002) and MACE rates (22.1 vs. 9.7%, p < 0.001) were significantly higher in statin naive when compared with statin-treated patients with ACS, respectively. Mevalonic acid revealed that both low- and high-dose statin treatment was associated to a reduction in in-hospital mortality and MACE, without a dose-dependent statin effect. Conclusion Statin therapy in patients with ACS undergoing CABG reduces in a dose-independent manner in-hospital mortality and MACE.

Background Choice of cardioplegic solution plays a pivotal role in special subgroups of patients referred for on-pump cardiac surgery. This retrospective analysis aimed to assess the impact of intermittent warm(Calafiore, Cala) versus intermittent cold blood cardioplegia (Buckberg, Buck) in patients referred to coronary artery bypass graft (CABG) surgery due to acute coronary syndromes (ACS). Methods From 2008 to 2015, all consecutive patients undergoing urgent on-pump CABG surgery due to ACS (n = 950) were retrospectively analyzed. Intraoperative cardiac arrest was achieved using Buck (n = 273) or Cala (n = 677). Patients were compared regarding clinical outcomes and perioperative myocardial injury (PMI). Propensity score matching was performed to control for differences in preoperative patient characteristics. Results Prevalences of left main stenosis > 50%, COPD, and advanced New York Heart Association (NYHA) class were higher for intermittent warm blood cardioplegia (IWC)-patients while more Buck-patients had preoperative intra-aortic balloon pump (IABP) and redo procedures. Buck-patients needed more intraoperative defibrillations and showed longer cardiopulmonary bypass (CPB) and aortic clamping times. 30-day all-cause mortality (10.6 versus 9.3%), major adverse cardiac events (MACE) (52.7 versus 48.6%), and PMI (50.5 versus 55.7%; all p > 0.05) rates were comparable for Buck- and Cala-patients. Propensity score matching resulted in equal group sizes (n = 212 each) and balanced distribution of preoperative covariates. Although more Buck-patients still needed inotropic support > 24 hours postoperatively (25.7 versus 14.7%; p = 0.005) compared with Cala-group, outcome variables of interest did not differ between treatment groups (30-day mortality: 7.5 versus 9.0%; MACE: 49.5 versus 40.6%; PMI: 48.1 versus 37.3%; all p > 0.05). Conclusion Buckberg and Calafiore cardioplegia offer comparable myocardial protection and similar postoperative results in patients underg

AIMS: Prophylactic intra-aortic balloon pump (IABP) support for high-risk patients before coronary artery bypass grafting (CABG) is controversial. This meta-analysis sought to determine the current role of preoperative IABP support. METHODS: Weperformed a meta-analysis of randomized (RCT) and observational trials (OT) that fulfilled the following criteria: (1) Group comparison of patients with prophylactic IABP implantation before CABG with a control group; (2) reporting at least one desired clinical endpoint, including all-cause mortality, myocardial infarction, cerebrovascular accident (CVA), and renal failure. Pooled treatment effects (odds ratio [OR] or weighted mean difference, and 95% confidence intervals [95% CI]) were assessed using a fixed or random effects model. RESULTS: A total of 9,212 patients from 23 studies (7 RCT, 16 OT) were identified after a literature search of major databases using a predefined keyword list. Absolute risk reduction for mortality in RCTs was 4.4% (OR 0.43; 95% CI 0.25-0.73; p = 0.0025). Prophylactic IABP use before CABG surgery also decreased the risk for myocardial infarction (OR 0.58; 95% CI 0.43-0.78; p = 0.004), CVA (OR 0.67; 95% CI 0.47-0.97; p = 0.042), and renal failure (OR 0.62; 95% CI 0.47-0.83; p = 0.0014). Length of intensive care unit stay (p < 0.0001) and length of hospital stay (p < 0.0001) were significantly reduced in patients with preoperative IABP use. CONCLUSION: Current evidence from RCT and OT suggests beneficial effects for the IABP in high-risk patients before CABG surgery.

OBJECTIVES: Previous research suggests that female gender is associated with increased mortality rates after surgery for Stanford A acute aortic dissection (AAD). However, women with AAD usually present with different clinical symptoms that may bias outcomes. Moreover, there is a lack of long-term results regarding overall mortality and freedom from major cerebrovascular events. We analysed the impact of gender on long-term outcomes after surgery for Stanford A AAD by comparing genders with similar risk profiles using propensity score matching. METHODS: A total of 240 patients operated for Stanford A AAD were included in this study. To control for selection bias and other con-founders, propensity score matching was applied to gender groups. RESULTS: After propensity score matching, the gender groups were well balanced in terms of risk profiles. There were no statistically significant differences regarding duration of cardiopulmonary bypass (P = 0.165) and duration of aortic cross-clamp time (P = 0.111). Female patients received less fresh frozen plasma (P = 0.021), had shorter stays in the intensive care unit (P = 0.031), lower incidence of temporary neurological dysfunction (P < 0.001) and lower incidence of dialysis (P = 0.008). There were no significant differences regarding intraoperative mortality (P = 1.000), 30-day mortality (P = 0.271), long-term overall cumulative survival (P = 0.954) and long-term freedom from cerebrovascular events (P = 0.235) with up to a 9-year follow-up. CONCLUSIONS: Considering patients with similar risk profiles, female gender per se is not associated with worse long-term survival and freedom from stroke after surgical aortic repair. Moreover, female patients might even benefit from a smoother early postoperative course and lower incidence of early postoperative complications.

Purpose: ECMO support is an ultimate ratio therapy for patients in refractory cardiogenic shock and is linked to high mortality. We assessed the dynamic characteristics of lactate during ECMO therapy and its predictive role on 30-day mortality. Materials and methods: Data were retrospectively collected in all patients receiving ECMO support longer than 48 h for cardiogenic shock from 01/2008 to 12/2016. Blood lactate was recorded before ECMO implantation, at prespecified timepoints during ECMO support, 1 h and 6 h post-ECMO as well as peak lactate during ECMO and peak within 24 h after ECMO support. Statistical analysis included t-test and ROC-curves to identify cut-off levels for lactate levels to predict 30-day mortality. Results: 139 patients underwent ECMO therapy longer than 48 h for refractory cardiogenic shock resulting in a 30-day mortality of 68%. Lactate before ECMO and peak lactate level during ECMO support showed no significant connection to mortality, while lactate and lactate clearance at 24 h were predictive for 30-day mortality with cutoff values of 2.15 mmol/l and 0.687 respectively. Conclusions: Dynamic course of lactate during ECMO therapy is a valuable tool to assess effective circulatory support and is superior to single lactate measurements as a predictive marker for 30-day mortality. (C) 2017 Elsevier Inc. All rights reserved.