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The inability of one of the two or both ventricles to contract normally and expel sufficient blood to meet the functional demands of the body results from a complex interplay between intrinsic abnormalities and extracardiac factors that limit ventricular pump function and is a major cause for heart failure (HF). Even if impaired myocardial contractile function was the primary cause for ventricular dysfunction, with the progression of systolic dysfunction, additionally developed diastolic dysfunction can also contribute to the severity of HF. Although at the first sight, the diagnosis of systolic HF appears quite easy because it is usually defined by reduction of the ejection fraction (EF), in reality this issue is far more complex because ventricular pumping performance depends not only on myocardial contractility, but also largely on loading conditions (preload and afterload), being also influenced by valvular function, ventricular interdependence, pericardial constraint, synchrony of ventricular contrac-tion and heart rhythm. Conventional echocardiography (ECHO) combined with new imaging techniques such as tissue Doppler and tissue tracking can detect early subclinical alteration of ventricular systolic function. However, no single ECHO parameter reveals alone the whole picture of systolic dysfunction. Multiparametric ECHO evaluation and the use of integrative approaches using ECHO-parameter combinations which include also the ventricular loading conditions appeared particularly useful especially for differentiation between primary (myocardial damage-induced) and secondary (hemodynamic overload-induced) systolic dysfunction. This review summarizes the available evidence on the usefulness and limitations of comprehensive evaluation of LV and RV systolic function by using all the currently available ECHO techniques., (Copyright © 2020 Elsevier B.V. All rights reserved.)

In carefully selected patients with ventricular assist devices (VADs), good long-term results after device weaning and explantation can be achieved when reverse remodelling and improvement of native cardiac function occur. Monitoring of cardiac size, geometry, and function after initial VAD implantation is necessary to identify such patients. Formal guidelines for recovery assessment in patients with VADs do not exist, and protocols for recovery assessment and criteria for device weaning and explantation vary among centres. Barriers to evaluation of cardiac recovery include technical problems in obtaining echo images in patients with VADs, time restrictions for necessary VAD reductions/interruptions during assessment, and regurgitant flow patterns that occur with interruption of continuous flow VADs. The few larger studies addressing cardiac recovery after VAD implantation employed varied study designs, limiting interpretation. Current clinical practice is guided largely by local practice patterns, case reports, and small case series, and the available body of research-consisting mostly of expert opinions-has not been systematically addressed. This summary reviews evidence and expert opinion on VAD-promoted cardiac recovery assessment, its reliability, and associated challenges., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The majority of children supported with ventricular assist devices (VADs) are bridged to heart transplantation. Although bridge to recovery has been reported, low recovery patient numbers has precluded systematic analysis. The aim of this study was to delineate recovery rates and predictors of recovery and to report on long-term follow-up after VAD explantation in children., Methods: Children bridged to recovery at our institution from January 1990 to May 2016 were compared with a non-recovery cohort. Clinical and echocardiographic data before and at pump stoppages and after VAD explantation were analyzed. Kaplan‒Meier estimates of event-free survival, defined as freedom from death or transplantation after VAD removal, were determined., Results: One hundred forty-nine children (median age 5.8 years) were identified. Of these, 65.2% had cardiomyopathy, 9.4% had myocarditis, and 24.8% had congenital heart disease. The overall recovery rate was 14.2%, and was 7.1% in patients with dilated cardiomyopathy. Predictors of recovery were age <2 years (recovery rate 27.8%, odds ratio [OR] 5.64, 95% confidence interval [CI] 2.0 to 16.6) and diagnosis of myocarditis (rate 57.1%; OR 17.56, 95% CI 4.6 to 67.4). After a median follow-up of 10.8 years, 15 patients (83.3%) were in Functional Class I and 3 (16.7%) in were in Class II. Mean left ventricular ejection fraction was 53% (range 28% to 64%). Ten- and 15-year event-free survival rates were both 84.1 ± 8.4%., Conclusions: Children <2 years of age and those diagnosed with myocarditis have the highest probability of recovery. Long-term survival after weaning from the VAD was better than after heart transplantation, as demonstrated in the excellent long-term stability of ejection fraction and functional class., (Copyright © 2018 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Diagnosing and monitoring acute rejection (AR) and cardiac allograft vasculopathy (CAV) is essential for graft and transplant patient survival and, consequently, a major objective for heart transplant patient surveillance. Because functionally relevant CAV can arise and progress without clinical symptoms and sub-clinical ARs can facilitate the development of CAV, standard surveillance of AR and CAV includes routine endomyocardial biopsy (EMB) and coronary angiography (CA) screenings at pre-defined time intervals. However, these invasive screenings (distressing and risky for the patients) cannot solely diagnose all sub-clinical AR episodes and also not always detect coronary stenoses before a clinical event. Additional close-meshed, non-invasive AR and CAV surveillance strategies are therefore mandatory. After the introduction of tissue Doppler imaging (TDI) and strain imaging for myocardial wall motion and deformation analysis, echocardiography became particularly promising for that purpose. Allowing quantification of minor myocardial dysfunction not detectable by standard echocardiography, TDI and strain imaging can reveal sub-clinical AR. Thus, these approaches can be a valuable supplement to EMB, enabling more efficient AR monitoring with fewer EMBs (only diagnostic EMBs) instead of unnecessary and distressing routine EMB screenings. Their use can also improve therapeutic decisions and monitoring of myocardial function during anti-rejection therapy. Myocardial velocity and deformation imaging is also suited to early detection of myocardial dysfunction induced by CAV and may be useful for prognostic evaluation and timing of CAs, with an aim of reducing the number of routine CA screenings. However, further studies are necessary before specific recommendations for the use of TDI and strain imaging for CAV surveillance become possible., (Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Primary cardiac tumors in infants and children are extremely rare; hence, there is very little literature available, and most knowledge is based on collections of case reports. This report is a comprehensive review of our 26-year experience with primary cardiac tumors in children with emphasis on surgical indications, strategies, and long-term outcome., Methods: Between 1986 and 2012, 47 children (mean age 5.9 ± 2.4 months; range, 1 day to 17 years) underwent either subtotal or total resection of cardiac tumors (rhabdomyoma, 13; fibroma, 12; teratoma, 9; myxoma, 8; hemangioma, 2; rhabdomyosarcoma, 1; non-Hodgkin's lymphoma, 1; lymphangioma, 1). The majority were diagnosed by echocardiography (n = 33). Clinical patterns were varied: 40 had an atypical heart murmur and 6 were asymptomatic. Outflow tract obstruction of more than 30 mm Hg was present in 11 children. Three patients had abnormal coronary arteries secondary to pressure from tumor bulk. Indications of resection were hemodynamic/respiratory compromise, severe arrhythmia, and a significant embolization risk. Strategy of resection varied according to location and hemodynamic status without damage to adjacent structures., Results: Morbidity included bleeding in a patient and a transient low output state in another. A 5-month-old infant with left ventricular fibroma underwent left ventricular assist device implantation secondary to failure from weaning off cardiopulmonary bypass, and she eventually underwent heart transplantation 17 days later. Early mortality (n = 2, 4.2%) included a 5-month-old infant who underwent complete resection of rhabdomyoma located in the left ventricle, with concomitant pulmonary valve replacement; unfortunately, he underwent left ventricular assist device implantation for postoperative heart failure and died on the 13th postoperative day. An 8-month-old child with 3 cm × 4 cm fibroma obstructing the right ventricular outflow tract compressing the right coronary artery died of severe right-side heart failure on the 13th postoperative day. One late death (2.1%) occurred; a 16-year-old with non-Hodgkin's lymphoma died 7 months after the surgery. Mean duration of follow-up is 11.6 ± 3.5 years. All survivors (93.4%) are well, free of tumor-related symptoms and tumor recurrence/progression, even when resection was incomplete., Conclusions: This study illustrates that although primary cardiac tumors in infants and children have a wide and unusual spectrum of clinical presentation, an individualized approach to tumor resection allows restoration of an adequate hemodynamic function and satisfactory long-term, tumor-free outcome., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Right ventricular (RV) size, shape and function are distinctly load-dependent and pulmonary load is an important determinant of RV function in patients with congestive heart failure (CHF) due to primary impaired left ventricular function and in those with pre-capillary pulmonary hypertension (PH). In a pressure overloaded RV, not only dilation and aggravation of tricuspid regurgitation, but also systolic dysfunction leading to RV failure (RVF) can occur already before the development of irreversible alterations in RV myocardial contractility. This explains RV ability for reverse remodeling and functional improvement in patients with post-capillary and pre-capillary PH of a different etiology, after normalization of loading conditions. There is increasing evidence that RV evaluation by echocardiography in relation with its loading conditions can improve the decision-making process and prognosis assessments in clinical praxis. Recent approaches to evaluate the RV in relation with its actual loading conditions by echo-derived composite variables which either incorporate a certain functional parameter (i.e. tricuspid annulus peak systolic excursion, stroke volume, RV end-systolic volume index, velocity of myocardial shortening) and load, or incorporate measures which reflect the relationship between RV load and RV dilation, also taking the right atrial pressure into account (i.e. "load adaptation index"), appeared particularly suited and therefore also potentially useful for evaluation of RV contractile function. Special attention is focused on the usefulness of RV echo-evaluation in relation to load for proper decision making before ventricular assist-device implantation in patients with CHF and for optimal timing of listing procedures to transplantation in patients with end-stage pre-capillary PH., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Infants and neonates with severe left ventricular outflow tract obstruction may require pulmonary autograft replacement of the aortic root. In this retrospective multicenter cohort study, we present our experience with the Ross procedure in neonates and infants with a focus on midterm survival and pulmonary autograft durability., Methods: A retrospective observational study was performed in 76 infants (aged less than 1 year) operated on in six congenital cardiac centers in The Netherlands and Germany between 1990 and 2013., Results: Patients had a pulmonary autograft replacement of the aortic valve with (68%) or without (32%) septal myectomy. Median patient age was 85 days (range, 6 to 347). Early mortality (n = 13, 17%) was associated with neonatal age, preoperative use of intravenous inotropic drugs, and congenital aortic arch defects. Five patients (9%) died during follow-up. Freedom from autograft reintervention was 98% at 10 years. Echocardiography demonstrated good valve function, with no or trace regurgitation in 73% of patients. Freedom from right ventricular outflow tract reintervention was 51% at 10 years. Univariable analysis demonstrated superior freedom from reintervention of pulmonary homografts compared with aortic homografts or xenografts., Conclusions: Pulmonary autograft replacement of the aortic valve in neonates and infants is a high-risk operation but offers a durable neoaortic valve. Midterm durability reflects successful adaptation of the autograft to the systemic circulation. Late mortality associated with heart failure was an unexpected finding., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Atrial septal defect closure using the Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) device is an established treatment option with excellent clinical outcome. However, several structural characteristics have been reported to be prognostic factors for failure of catheter interventional treatment. We report successful surgical removal of an Amplatzer septal occluder that had become dislocated and had migrated into the deep aortic arch. Compatible with previous reports, the patient presented with an atrial septal defect complicated by multiple anatomic deformities that were considered to be a contraindication for interventional treatment. Detailed structural assessment of the atrial septal defect is mandatory for successful treatment using the Amplatzer septal occluder., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Right ventricle (RV) performance is load dependent, and right-sided heart failure (RHF) is the main cause of death in pulmonary arterial hypertension (PAH). Prediction of RV worsening for timely identification of patients needing transplantation (Tx) is paramount. Assessment of RV adaptability to load has proved useful in certain clinical circumstances. This study assessed its predictive value for RHF-free and Tx-free outcome with PAH., Methods: Between 2006 and 2012, all potential Tx candidates with PAH, without RHF at the first evaluation, were selected for follow-up (except congenital heart diseases). At selection and at each follow-up, N-terminal prohormone brain natriuretic peptide (NT-proBNP) and the 6-minute walk distance were measured, and RV adaptability to load was assessed by echocardiography. Collected data were tested for the ability to predict RV stability and Tx-free survival., Results: During a 12-month to 92-month follow-up, RHF developed in 23 of 79 evaluated patients, despite similar medication and no differences in initial RV size and ejection fraction compared with the patients who remained stable. However, unstable patients had an initially lower RV load-adaptation index and afterload-corrected peak global systolic longitudinal strain-rate values as well as higher RV dyssynchrony, tricuspid regurgitation, and NT-proBNP levels (p ≤ 0.01). At certain cutoff values, these variables appeared predictive for 1-year and 3-year freedom from RHF and 3-year Tx-free survival. An RV load-adaptation index reduction of ≥20% showed the highest predictive value (90.0%) for short-term (≤1 year) RV decompensation., Conclusions: Assessment of RV adaptability to load allows prediction of RV function and Tx-free survival with severe PAH during the next 1 to 3 years. This can improve the timing of listing for Tx., (Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Annular rupture is an umbrella term covering different procedural-related injuries that may occur in the region of the aortic root and the left ventricular outflow tract during transcatheter aortic valve replacement. According to the anatomical location of the injury, there are 4 main types: supra-annular, intra-annular, subannular, and combined rupture. Annular rupture is a rare, unpredictable, and potentially fatal complication. It can be treated successfully if it is immediately recognized and adequately managed. The type of therapy depends on the location of the annular rupture and the nature of the clinical manifestations. Treatment approaches include conventional cardiac procedure, isolated pericardial drainage, and conservative therapy. This summary describes theoretical and practical considerations of the etiology, pathophysiology, classification, natural history, diagnostic and treatment strategies, and prevention approaches of annular rupture., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The use of mechanical circulatory support devices to keep patients alive until transplantation has become essential in the face of an increasing organ shortage. We report successful heart transplantations after 841 days of left ventricular assist device (LVAD) support in a child with hypoplastic left heart syndrome, and after 547 days of biventricular assist device (BVAD) support in another child with cardiomyopathy. To our knowledge, this report is the first on the longest-term (841 days) LVAD and the longest-term (547 days) BVAD support in children who were mobile and awake during the support, as a most effective bridge to heart transplantation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to test whether adaptive or maladaptive remodeling is associated with survival in women and men after aortic valve replacement (AVR)., Background: Women with isolated aortic valve stenosis (AS) develop more concentric left ventricular hypertrophy (LVH) than men in similar disease states. We recently reported less up-regulation of profibrotic genes at AVR and faster LVH regression post-operatively in women than in men, suggesting that there are sex differences in the adaptation to pressure overload and its regression., Methods: The study cohort included 128 patients (age 70.0 ± 9.6 years, 49% women) undergoing AVR for AS. Echocardiography was obtained before and 4.0 ± 1.6 years after surgery. Factor analysis was used to classify LVH as adaptive (combining smaller left ventricular [LV] mass/diameters and greater relative wall thicknesses) or maladaptive. Myocardial tissue samples from the LV septum were obtained during AVR to analyze cardiac fibrosis and associated key molecular regulators., Results: Before AVR, LVH was classified as adaptive in 62% of women and 45% of men (p < 0.050). Four years after AVR, adaptive LVH was observed in 75% of women and 49% of men (p < 0.031). At surgery, more cardiac fibrosis was present in men compared with women (p < 0.05). Higher levels of transforming growth factor beta 1 (p < 0.01), SMAD2 phosphorylation (p < 0.001), and periostin expression (p < 0.05) were found in men than in women. Women with maladaptive LVH had worse survival than women with adaptive LVH (p < 0.050), whereas the pattern of LVH did not affect survival in men (p < 0.307)., Conclusions: Women more frequently exhibit adaptive LV remodeling with less fibrosis than men. Maladaptive LVH is associated with worse survival in women. Thus, sex should be considered as a strong modulating factor when management of patients with AS is discussed., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: In line with our institutional strategy, we do not accept paravalvular leakage after transcatheter aortic valve implantation (TAVI). Apart from data from very limited initial experience, predictors of leakage in large cohorts treated with new types of TAVI prostheses are still lacking., Methods: From April 2008 to August 2013, 730 patients underwent transapical TAVI at our institution. The study group consisted of all 324 patients who received the new generation of balloon-expandable prostheses (SAPIEN XT; Edwards Lifesciences, LLC, Irvine, CA). Based on the Society of Thoracic Surgeons predicted risk of mortality, the arithmetic risk for surgery in the study cohort was 11% ± 9% (1% to 62%) and 20 (6%) patients were in cardiogenic shock., Results: In study cohort, the overall 30-day mortality rate was 4.0% (3.3% in patients without cardiogenic shock). The postprocedural grade of regurgitation was absent or trace in 269 of 324 patients (83%), mild in 52 of 324 (16%), and moderate in 3 of 324 (< 1%); there was no severe postprocedural regurgitation. Regurgitation occurred less often (p < 0.001) in patients who received the XT-type prosthesis. Patients with more than trace regurgitation presented with less oversizing of the prosthesis in terms of annular area (p < 0.001) and higher calcium scores of the device landing zone (p < 0.001). The presence of calcified plaques in the left ventricular outflow tract was the strongest predictor of leakage (odds ratio 10.23, 95% confidence interval 5.12 to 20.45, p < 0.001). The regurgitation grade was not predictive for follow-up mortality (hazard ratio 1.08, 95% confidence interval 0.61 to 1.90, p = 0.800)., Conclusions: In transapical TAVI, the risk of relevant paravalvular leakage may be eliminated completely. There is no negative impact on survival in patients with lesser, irrelevant grades of regurgitation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The pediatric Berlin Heart (BH) EXCOR device provides mechanical circulatory support as a bridge to transplantation or recovery in children. Despite the availability of various pump sizes, information on the impact of pump size on clinical outcome is still lacking. We aimed to evaluate whether pump size in relation to body surface area (BSA) has an impact on clinical outcome., Methods: Children requiring implantation of a BH between 2000 and 2013 were included in this retrospective study. Primary end-points were events leading to BH explantation (transplantation, recovery or death) and the secondary end-point was occurrence of thromboembolic events. Patients were categorized into three groups according to BH stroke volume per BSA: optimal (30 to 50 ml/m(2)); small (<30 ml/m(2)); and large (>50 ml/m(2))., Results: Eighty children (median age 2.2 years, median BSA 0.50 m(2)) underwent BH implantation. Fifty-five (69%) children had an optimally sized pump implanted, whereas 8 children (10%) had small pump and 17 (21%) large pump implantation. Overall survival rate was 69%. Weaning was possible in 15 children (19%), and 39 children (49%) were transplanted. Mortality, myocardial recovery and transplantation were not related to age, BSA or pump size. Thromboembolic events occurred significantly more frequently in children treated with large pumps., Conclusions: The broad range of body sizes in children from newborns to adolescents requires a wide choice of appropriately sized devices. Large pump size in relation to BSA is an independent risk factor for occurrence of thromboembolic events., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: In blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury., Methods: Relay Endovascular Registry for Thoracic Disease (RESTORE) is a multicenter, prospective European registry, which enrolled patients treated with the Relay stent graft for thoracic aortic diseases from April 2005 to January 2009. Regular follow-up examinations were conducted for up to 24 months. This paper analyzes the cohort of patients treated for traumatic aortic injury., Results: Forty adult trauma patients from 12 European centers underwent TEVAR. Mean age was 40 years and 34 patients were male. The proximal landing zone involved aortic arch zones 1 to 2 in 40% and zone 3 in 55% of procedures. Technical success was achieved in all cases. One (2.5%) patient suffered a rupture of the iliac artery. No patient developed procedure-related paraplegia or required conversion to open surgery. Follow-up imaging demonstrated complete exclusion of the traumatic tear and regression of the false aneurysms without endoleak or graft infolding. One late device-related complication was reported; penetration of the distal end of the stent graft treated by stent-graft extension. Thirty-day mortality was 2.5 % (n = 1), and late mortality 2.5% due to a secondary accident. Actuarial 2-year survival was 93.7%., Conclusions: Thoracic endovascular aortic repair with the Relay stent graft is a safe and effective treatment for patients with traumatic aortic injury., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Several surgical techniques for the treatment of congenital supravalvular aortic stenosis have been developed, yet there is no consensus about the optimal approach. We reviewed our institutional experience with 2- and 3-sinus reconstruction techniques., Methods: Thirty-eight patients operated on for supravalvular aortic stenosis between 1987 and 2012 in our institution were analyzed retrospectively. Eight patients (21%) were infants and in 5 (13.2%) diffuse stenosis was present. Mean peak pressure gradient was 86.1±28.7 mm Hg preoperatively. Surgical procedures included single-patch enlargement (McGoon, n=3), inverted bifurcated-patch aortoplasty (Doty, n=22), 3-sinus patch augmentation (Brom, n=8), and autologous slide aortoplasty (n=5). Major concomitant procedures were performed in 10 patients (26.3%)., Results: Early mortality was 2.6%. Follow-up continued for a median of 7.5 years (range 3 weeks to 22 years). Overall survival estimates were 94% and 90% and overall freedom from reoperation was 83% at 5 and 20 years, respectively. No differences were found between surgical techniques in respect to survival, clinical course, hemodynamic outcome, or freedom from reoperation rates. A significantly worse outcome in regard to survival and reoperation rates was observed in infants., Conclusions: Our study demonstrates equally good results for the repair of supravalvular aortic stenosis with both 2- and 3-sinus reconstruction. No evidence of a superior outcome for 3-sinus reconstruction techniques was found. Operation in infancy is an important factor associated with unfavorable outcome., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to test whether, and in which terms, the cumulative institutional experience in the field of transapical transcatheter aortic valve implantation (TAVI) might impact upon operative time and radiation exposure., Methods: This was a retrospective, single-center, observational cohort study of prospectively collected data from all 500 consecutive high-risk patients undergoing transapical TAVI at our institution between April 2008 and December 2011. Differences during the study period in baseline characteristics, procedural and post-procedural variables, and survival were analyzed. Nonparametric correlation and linear regression analyses were used to identify changes in operative time, contrast agent use, and radiation exposure according to institutional cumulative experience., Results: Median operating time was 90 minutes (interquartile range 75-115 min) and fluoroscopy time was 6.7 minutes (4.8-10.3 min). Combined planned percutaneous coronary intervention was performed in 57 (11.4%) patients. There was a significant correlation between operating time, fluoroscopy time, and institutional experience. A 5% reduction in operating time (95% CI 3% to 8%, p < 0.0001) and 15% reduction in radiation exposure time (95% CI 12% to 18%, p < 0.0001) was reported per 100 procedures performed., Conclusions: After introduction and implementation of a structured training program for transapical TAVI, operating time and radiation exposure are contained and reduced over the entire observation time in 500 consecutive patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Constrictive pericarditis causes hepatic congestion, which results in congestive hepatopathy and finally leads to cardiac cirrhosis. However, in previous studies, risk stratification from the viewpoint of liver dysfunction was not performed in patients who underwent pericardiectomy for constrictive pericarditis., Methods: Sixty-four patients with constrictive pericarditis who were operated on with de novo radical pericardiectomy through a left anterolateral thoracotomy in our institute were entered into the study. Patients with a Child-Pugh score less than 7 (class A) were assigned to group CP-A (n = 45) and those with a score of 7 or higher (class B or C) were assigned to group CP-BC (n = 19). Actuarial survival of patients after operation was studied in each group, and prognostic factors were analyzed with Cox regression analysis., Results: Survival after radical pericardiectomy in group CP-BC (Child-Pugh score ≥ 7) was significantly worse than in group CP-A (37.9% versus 80.8% for 5-year survival; p = 0.0001, log-rank test). After multivariate Cox analysis, a Child-Pugh score of 7 or more (hazard ratio [HR] 4.316; p = 0.0028), mediastinal irradiation (HR, 23.872; p < 0.0001), age (HR, 1.064; p = 0.0042), and end-stage renal disease (HR, 4.670; p = 0.029) were identified as independent prognostic factors for mortality after radical pericardiectomy., Conclusions: It is meaningful to apply the Child-Pugh scoring system for the prediction of mortality after radical pericardiectomy in patients with constrictive pericarditis., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The transcription factor TWIST1 has been described to regulate the microRNA (miR)-199/214 cluster. Genetic disruption of TWIST1 resulted in a cachectic phenotype and early death of the knock-out mice. This might be connected to the activity of the ubiquitin-proteasome-system (UPS), as miR-199a has been suggested to regulate the ubiquitin E2 ligases Ube2i and Ube2g1., Methods: Cardiac tissue from explanted hearts of 42 patients with dilated cardiomyopathy and 20 healthy donor hearts were analysed for protein expression of TWIST1 and its inhibitors Id-1, MuRF-1 and MAFbx, the expression of miR-199a, -199b and -214, as well as the activity of the UPS by using specific fluorogenic substrates., Results: TWIST1 was repressed in patients with dilated cardiomyopathy by 43% (p=0.003), while Id1 expression was unchanged. This was paralleled by a reduced expression of miR-199a by 38 ± 9% (p=0.053), miR-199b by 36 ± 13% (p=0.019) and miR-214 by 41 ± 11% (p=0.0158) compared to donor hearts. An increased peptidylglutamyl-peptide-hydrolysing activity (p<0.0001) was observed in the UPS, while the chymotrypsin-like and trypsin-like activities were unchanged. The protein levels of the rate limiting ubiquitin E3-ligases MuRF-1 and MAFbx were up-regulated (p=0.005 and p=0.0156, respectively). Mechanistically silencing of TWIST1 using siRNA in primary rat cardiomyocytes led to a down-regulation of the miR-199/214 cluster and to a subsequent up-regulation of Ube2i., Conclusion: The TWIST1/miR-199/214 axis is down-regulated in dilated cardiomyopathy, which is likely to play a role in the increased activity of the UPS. This may contribute to the loss of cardiac mass during dilatation of the heart., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

Background: Pulmonary arterial hypertension (PAH) is a fatal disease despite recent treatment advances. Individual risk stratification is important. Exercise capacity and invasive haemodynamic data are both relevant, but data on the combined prognostic power are lacking., Methods: 226 consecutive patients with idiopathic or familial PAH were included at seven specialised tertiary centres. All patients underwent right heart catheterization and cardiopulmonary exercise testing (CPET)., Results: During follow-up (1508 ± 1070 days) 72 patients died and 30 underwent transplantation. On multivariate analysis percentage of predicted peak oxygen uptake (%predicted peak VO2 [risk ratio 0.95]), pulmonary vascular resistance (PVR [1.105,]) and increase in heart rate during exercise (ΔHR [0.974]) were independent prognostic predictors (all p<0.0001). Peak VO2 allowed for risk stratification with a survival of 100, 92.9, 87.4 and 69.6% at 1 year and 97.7, 63.2, 41 and 23% at 5 years for the 4th, 3rd, 2nd and 1st quartiles, respectively. Dichotomizing by median peak VO2 and intra-group median PVR showed a worse 1-year survival for patients with low peak VO2/higher PVR compared to patients with low peak VO2/low PVR, high peak VO2/high PVR and high peak VO2/low PVR (65 vs. 93, 93, 100%, p<0.001). At 10 years survival was different for all 4 subgroups (19 vs. 25 vs. 48 vs. 75%, adjusted p<0.05)., Conclusions: Peak VO2, PVR and ΔHR independently predict prognosis in patients with PAH. Low peak VO2, high PVR and low ΔHR refer to poor prognosis. Combined use of peak VO2 and PVR provides accurate risk stratification underlining the complementary prognostic information from cardiopulmonary exercise testing and resting invasive haemodynamic data., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair., Methods: In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used., Results: The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia., Conclusions: The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This report aims to introduce the extraanatomic bypass technique to treat the midaortic syndrome and to document its long-term effectiveness and durability., Methods: Fourteen patients (mean age, 6.7 ± 3.76 years; range 8 months to 11 years) received diagnoses of midaortic syndrome, characterized by severe narrowing of the abdominal aorta with involvement of the renal and visceral branches. Angiography showed variable lengths of high-grade midaortic stenosis, with 7 children having visceral artery involvement and 9 having renal artery involvement. All children were hypertensive (mean blood pressure, 165 ± 15.7 mm Hg). Three had had previous nephrectomies. Six patients had had previous percutaneous transluminal renal artery angioplasties. The midaortic obstruction was relieved by descending abdominal aorta bypass (left thoracoabdominal approach) and by an ascending abdominal aorta bypass (median sternotomy and transabdominal approach) in 12 patients. No visceral artery revascularization was done., Results: There was a considerable blood pressure reduction in all patients and relief of intermittent claudication in 6 affected patients. One patient had a bilateral renal artery bypass 2 weeks postoperatively because of recurrence of renal hypertension. At a mean follow-up time of 5.8 ± 1.36 years (range, 9 months to 15 years), there was no further reoperation nor mortality. Twelve patients had complete relief of hypertension, and 2 had mild hypertension. All patients have normal renal function and no signs or symptoms of visceral malperfusion. Growth and development have proceeded normally. Follow-up magnetic resonance tomography showed patent grafts without any strictures., Conclusions: Extraanatomic bypass provides very effective and long-term relief of hypertension and any malperfusion in midaortic syndrome., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: An important number of patients are considered unsuitable for transcatheter aortic valve implantation because of a large native aortic valve. A new 29-mm balloon-expandable transcatheter valve offers the option to gain a maximal effective orifice area without paravalvular leakage. This study sought to define ranges of safe applicability in terms of device landing zone geometry. A second purpose was to determine performance of the prosthesis and clinical outcome., Methods: Between April 2011 and July 2012, the new 29-mm SAPIEN XT prosthesis was implanted by means of transapical access in 78 patients with large aortic annuli. The study group represents 32.9% of all transapical transcatheter aortic valve implantations performed at our institution during the observation period; 82 patients receiving 26-mm prosthesis served as a control group. Device landing zone morphology was analyzed by echocardiography and computed tomography., Results: The postimplant effective orifice area (study versus control group) was 2.7 cm(2) (interquartile range, 2.3 to 3.0 cm(2)) and 2.1 cm(2) (interquartile range, 1.7 to 2.4 cm(2)), respectively (p < 0.001), without any severe patient-prosthesis mismatch. Postprocedural regurgitation was similar in both groups (p = 0.892): absent in 56 (71.8%) and 54 (65.9%) patients, trace or mild in 21 (26.9%) and 27 (32.9%), and moderate in 1 (1.3%) and 1 (1.2%), respectively. Including patients in cardiogenic shock, the overall 30-day mortality rate of the study and control groups was 5.1% and 1.2%, respectively. One-year survival was 76.7% ± 8.6% with no difference from control patients (p = 0.743)., Conclusions: The new 29-mm balloon-expandable prosthesis broadens the indication for transcatheter aortic valve implantation to include patients with large annuli. The outcome is very favorable., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We analyzed risks for severe morbidity in the early period after extracardiac Fontan operation., Methods: Between November 1995 and May 2011, 140 patients (median age, 3.8 years) underwent extracardiac Fontan operation. We assumed as preoperative risk factors systemic right ventricle (n=51), heterotaxia (n=25), arterial oxygen saturation less than 75% (n=22), and adult age (>16 years, n=20) at time of surgery. Prolonged cardiopulmonary bypass time of longer than 120 minutes (n=30) and use of cardioplegia (n=26) were analyzed as intraoperative risks., Results: Heterotaxia was revealed as a risk factor for postoperative prolonged inotropic support, acute renal failure, prolonged mechanical ventilation, prolonged pleural effusions, and tachyarrhythmias. With the exception of pleural effusions, the same held true for right ventricle morphology. Low preoperative arterial oxygen saturation was found to be associated with an increased risk of prolonged inotropic support, acute renal failure, and prolonged mechanical ventilation. Adult age was identified as a risk factor for acute renal failure. Of the intraoperative factors, prolonged cardiopulmonary bypass time longer than 120 minutes was a risk factor for acute renal failure and prolonged pleural effusions, whereas use of cardioplegia was associated with an increased risk of prolonged inotropic support, prolonged mechanical ventilation, acute renal failure, and tachyarrhythmias. Multivariate analysis demonstrated heterotaxia, right ventricular morphology, and low preoperative arterial oxygen saturation to be independent risk factors for postoperative prolonged inotropic support and prolonged mechanical ventilation., Conclusions: Patients with heterotaxia, systemic right ventricle, and low preoperative arterial oxygen saturation are still at high risk for early Fontan failure after extracardiac Fontan operation and require special management for optimal outcome., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The degree of involvement of left ventricular inflow tract obstruction is the predominant factor determining outcome in Shone's anomaly. In this series of patients with Shone's anomaly, we evaluated the impact of mitral valve (MV) repair strategies performed to correct the components of this anomaly on growth of the valve and long-term functional outcome in children., Methods: In the last 25 years, 45 children, mean age 5.16 ± 5.0 years (median, 3.9; range, 2 months-16.8 years), underwent surgical correction of Shone's anomaly. Coarctation of the aorta was found in 40%, subaortic stenosis due to fibromuscular hypertrophy was found in 55%, and subvalvar membrane was found in 66% of these patients. Left ventricular inflow tract obstruction was brought about by fused commissures with dysplastic and shortened chordae in 53.3%, valve hypoplasia in 11.1%, supravalvar mitral ring in 100%, and parachute valve in 17.8 of patients%., Results: Various repair strategies were performed according to the presenting morphologic characteristics in patients with either previously corrected or concomitant correction of the left-sided obstructive lesions. Mean duration of follow-up was 17.5 ± 1.5 years. Freedom from reoperation was 52.8% ± 11.8%, wherein 23 patients underwent repeated MV repair and 1 patient underwent MV replacement after failed attempts at repair. The cumulative survival rate was 70.3% ± 8.9% at 15 years. Severity and type of mitral abnormalities, left ventricular outflow tract lesions, and pulmonary hypertension are risk factors for reoperation and mortality (p < 0.05)., Conclusions: Repair allowed growth of the MV. Long-term outcome of MV repair in Shone's anomaly is related to the degree that the obstructive lesions can be relieved., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of high-risk patients with aortic valve stenosis. Although a logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of more than 40% has been considered a contraindication for this new procedure, we routinely perform this procedure in this very high-risk patient group. We analyzed the results of TAVI patients with a EuroSCORE of over 40%., Methods: Between April 2008 and January 2012, 514 consecutive patients underwent TAVI. In the study group (group I, EuroSCORE > 40%) of 186 patients the EuroSCORE was 63% ± 16% (range 40 to 98) and the Society of Thoracic Surgeons predicted risk of mortality score was 23% ±14% (range 4 to 90); there were 26 (14%) patients in cardiogenic shock. The mean age was 81 ± 8 (range 36 to 99) years and there were 122 women and 64 men. Group II (the control group, EuroSCORE < 40%) consisted of 328 patients. In this group the EuroSCORE was significantly lower (23% ± 9%, range 2% to 40%). The STS mortality score was 11% ± 8% (1% to 48%). In this group were 196 men and 132 women with a mean age of 78 ± 8 (range 29 to 97) years., Results: Technically, in group I the valve was successfully implanted in 99.5% (185 of 186). In 25 (13%) patients the procedure was performed on the heart-lung machine and in 25 (13%) patients an elective percutaneous coronary intervention was performed in the same session. Postoperative echocardiography showed a low transvalvular gradient (mean 4.5% ± 2.5%, range 2 to 15) and a low rate of paravalvular regurgitation (grade 0 in 97, less than grade I in 49, less than grade II in 38 patients, and grade II in 2 patients). The overall 30-day mortality in patients with EuroSCORE of over 40% (group I), including that in patients in cardiogenic shock, was 6.5%, and in patients with EuroSCORE of over 40% (group I) and without cardiogenic shock it was 5.7%; the 1-year survival was 67% and 71%, respectively, and the 2-year survival was 54% and 56%, respectively., Conclusions: Patients with comorbidities, as mirrored by a EuroSCORE of more than 40% should not be refused for TAVI. On the contrary, this is a supreme indication for the TAVI procedure., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ascending aortic aneurysms grow circumferentially and longitudinally. This geometric dislocation with widening, flattening, or loss of the sinotubular junction by aortic dilatation distorts and causes incompetence of even a structurally normal valve. We described a technique of surgical correction of ascending aortic aneurysm and valve incompetence by relocating the displaced aortic annulus plane to its normal anatomic position., Methods: Between 1998 and 2011, 48 patients (median age, 66.5; range, 7 to 82 years) with ascending aortic aneurysm and elongation and severe aortic valve incompetence underwent ascending aortic replacement. The aneurysm was incised longitudinally, and an appropriately sized straight Dacron (DuPont, Wilmington, DE) graft was sutured onto the aorta approximately 5 mm above the commissures, recreating the sinotubular junction. When valve competence was assured, the graft, cut considerably shorter than the original length of the ascending aorta, was anastomosed distally. The valve plane was hence relocated in a more cranial/oblique position, restoring its normal alignment. Perioperative echocardiographic and computed tomography studies were done to document the degree of aortic valve incompetence and the morphology of the aortic root., Results: During a mean follow-up of 3.0±2.7 years, aortic insufficiency was absent to trivial in 34, mild in 12, and moderate in 2 patients. Postoperative computed tomography showed considerable aortic shortening, remarkable sinotubular junction narrowing, aortic root diameter reduction, and angular widening between the aortic root plane and longitudinal spinal axis corresponding to aortic incompetence reduction., Conclusions: Aortic relocation technique provided satisfactory results in management of ascending aortic aneurysm and elongation with aortic valve incompetence., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Continuous-flow (CF) ventricular assist devices (VAD) are an established option for treatment of end-stage heart failure. However, the effect of long-term CF with lack of peripheral arterial wall motions on blood pressure regulation and end-organ arterial wall sclerosis, especially in the case of long-term support (> 3 years), remains unclear., Methods: Tissue samples obtained at autopsy from liver, kidney, coronary arteries, and brain from 27 VAD recipients supported for > 180 days between 2000 and 2010 were histologically examined to assess vascular alterations, including perivascular infiltrate, intravascular infiltrate, wall thickness, thrombosis, endothelial cell swelling, vessel wall necrosis, and peri-vascular fibrosis. Pulsatile-flow (PF) devices had been inserted in 9 patients and CF devices had been inserted in 16. The pathologist was blinded to the group distribution. Demographic, pharmacologic, and clinical data were retrospectively analyzed before surgery and during the follow-up period of up to 24 months., Results: Median duration of support was 467 days (range, 235-1,588 days) in the PF group and 263 days (range, 182-942 days) in the CF group. Demographic and clinical data before and after surgery were similar. Amiodarone was more often used during follow-up in CF group than in the PF group (61% vs 10%, p = 0.009). Throughout the follow-up period, mean arterial pressure did not differ between recipients of the 2 pump types, nor did systolic and diastolic pressure, except at 2 weeks after VAD implantation, when systolic blood pressure was higher (p = 0.05) and diastolic lower (p = 0.03) in the PF group. Histologic studies did not identify any relevant differences in arterial wall characteristics between the 2 groups., Conclusion: Long-term mechanical circulatory support with CF devices does not adversely influence arterial wall properties of the end-organ vasculature., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Dilated cardiomyopathy (DCM) is a common cause of heart failure. After the identification of several immune regulatory abnormalities in DCM increasing attention has been focused on autoimmune mechanisms as potential key elements in the pathogenesis of the disease. DCM has appeared to be often related to elevated levels of autoantibodies against cardiac structural or functional proteins. Among several autoantibodies (AABs) which react against cardiac cellular proteins that have been detected in sera from DCM patients, those against β1-adrenoreceptors (β1-ARs) appeared particularly relevant from a pathophysiological point of view. The available experimental and clinical data suggest that in β1-AAB-positive patients with DCM the cardiomyopathy might be a β1-AR-targeted autoimmune disease. This review summarizes the present knowledge about β1-AABs, their role in DCM etiopathogenesis and the therapeutic benefits of β1-AAB removal. Special attention is focused on the possible origin of β1-AABs, their interaction with the β₁-ARs, the prevalence of β1-AABs in patients with DCM and the potential pathophysiologic impact of these AABs in the development and progression of the disease. Attention is also given to the amelioration of β1-AAB cardiotoxicity by β₁-AR antagonists and especially to immunoadsorption (IA) therapy. Responsiveness to IA therapy and its long-term efficiency, as well as post-IA reappearance of β₁-AABs and its impact on patients' outcome are also discussed in detail. Finally the important question of whether the therapeutic results of IA are indeed related to β₁-AAB removal is analyzed on the basis of available data. Overall the review aims to provide an exhaustive overview of the available experimental and clinical data on β₁-AABs in DCM and also a theoretical and practical basis for clinicians who are or intend in future to be engaged in this field., (Copyright © 2011. Published by Elsevier GmbH.)

We report transcatheter aortic valve implantation (TAVI) for pure aortic valve insufficiency in a patient with an otherwise normal aortic valve and a long-term left ventricular assist device (LVAD). An oversized 29-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) was implanted in the 21-mm native aortic valve annulus. Despite the complete absence of aortic calcifications, the prosthesis remained stably anchored inside the annulus. The reported experience demonstrates that TAVI is feasible even in patients with pure aortic valve regurgitation and can be a reasonable option in patients with aortic regurgitation after LVAD implantation., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Midterm results after transapical aortic valve implantation are still unknown in a large group of patients. We report our institutional experience in 300 high-risk patients., Methods: Since April 2008, transapical aortic valve implantation was performed in 300 patients (mean age, 80 ± 8 years). The mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 39% ± 19% and the mean Society of Thoracic Surgeons (STS) score was 19% ± 16%. Eighteen patients were in cardiogenic shock preoperatively. Follow-up was up to 31 months with a total of 3,500 months of follow-up., Results: Technical success of the procedure was 99.7% (299 of 300 patients). The 30-day mortality rate in all patients without cardiogenic shock was 3.9%. The overall 30-day mortality for the whole group of 300 patients was 4.7%. The mortality of the last 100 patients dropped to 2.0%. The cumulative survival was 83% at 1 year, 76% at 1.5 years, and 65% at 2 years and beyond. In patients with lower risk scores, cumulative survival reached 78% at 2 years and beyond., Conclusions: The outcome of transapical aortic valve implantation in very high-risk patients was very favorable not only early after the procedure but also later on. Preoperative risk scores were not indicators for early mortality but were for later mortality. Survival was mainly influenced by noncardiac (renal, pulmonary, and vascular) comorbidities as well as by signs of advanced cardiac failure., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Used frequently for right ventricular dysfunction (RVD), the clinical benefit of inhaled nitric oxide (iNO) is still unclear. We conducted a randomized, double-blind, controlled trial to determine the effect of iNO on post-operative outcomes in the setting of left ventricular assist device (LVAD) placement., Methods: Included were 150 patients undergoing LVAD placement with pulmonary vascular resistance ≥ 200 dyne/sec/cm(-5). Patients received iNO (40 ppm) or placebo (an equivalent concentration of nitrogen) until 48 hours after separation from cardiopulmonary bypass, extubation, or upon meeting study-defined RVD. For ethical reasons, crossover to open-label iNO was allowed during the 48-hour treatment period if RVD criteria were met., Results: RVD criteria were met by 7 of 73 patients (9.6%; 95% confidence interval, 2.8-16.3) in the iNO group compared with 12 of 77 (15.6%; 95% confidence interval, 7.5-23.7) who received placebo (p = 0.330). Time on mechanical ventilation decreased in the iNO group (median days, 2.0 vs 3.0; p = 0.077), and fewer patients in the iNO group required an RVAD (5.6% vs 10%; p = 0.468); however, these trends did not meet statistical boundaries of significance. Hospital stay, intensive care unit stay, and 28-day mortality rates were similar between groups, as were adverse events. Thirty-five patients crossed over to open-label iNO (iNO, n = 15; placebo, n = 20). Eighteen patients (iNO, n = 9; placebo, n = 9) crossed over before RVD criteria were met., Conclusions: Use of iNO at 40 ppm in the perioperative phase of LVAD implantation did not achieve significance for the primary end point of reduction in RVD. Similarly, secondary end points of time on mechanical ventilation, hospital or intensive care unit stay, and the need for RVAD support after LVAD placement were not significantly improved., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Inspiratory muscle weakness has been described in patients with congestive heart failure (CHF), and only recently in patients with idiopathic pulmonary arterial hypertension. However, the relationship between pulmonary hemodynamics and respiratory muscle function has not been investigated in patients with CHF., Methods and Results: In two tertial referral centers for CHF patients, 532 consecutive CHF patients (159 female, age 59 ± 12 years, NYHA I-IV) were studied by right heart catheterization, maximal inspiratory mouth occlusion pressure (Pi(max)) and pressure 0.1s after beginning of inspiration during tidal breathing at rest (P(0.1)). There was a significant correlation between Pi(max) and mean pulmonary artery pressure (PAPm) (r=-0.65, p=0.0023), mean pulmonary capillary wedge pressure (PCWPm) (r=-0.56; p=0.0018), PVR (r=-0.73; p=0.0031), and cardiac output (r=0.51; p=0.0022). Moreover, the ratio P(0.1)/Pi(max) showed a linear correlation with PAPm (r=0.54; p=0.0019), and with TPG (r=0.64; p=0.0014) respectively. Vital capacity was reduced in relation to increased PAPm (r=-0.54; p=0.0029). Pi(max) and P(0.1)/Pi(max) were independent from VC., Conclusions: This study provides the first evidence of a close relation between inspiratory muscle dysfunction, increased ventilatory drive and pulmonary hypertension in a large patient cohort with CHF. Pi(max) and P(0.1) can easily be measured in clinical routine and might become an additional parameter for the non-invasive monitoring of the hemodynamic severity of disease., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Purpose: This study was designed to demonstrate the safety and functional performance of the LIFEBRIDGE B2T system (Medizintechnik GmbH, Ampfing, Germany), a novel portable life support system, during human applications under controlled conditions., Description: The LIFEBRIDGE system was used as a modular closed-circuit miniaturized cardiopulmonary bypass system for total support of circulation and gas exchange in a series of 8 elective coronary artery bypass grafting procedures using normothermic cardioplegic arrest., Evaluation: Mean blood flow rates provided by the LIFEBRIDGE system were 4.82±0.47 L/min throughout the procedures (ie, 100% of calculated normal blood flow). Adequate gas exchange and arterial oxygenation were provided at all times. All patients survived the operations with no neurologic sequelae., Conclusions: The LIFEBRIDGE system provides sufficient circulatory support and gas exchange during cardiac arrest and apnea, which are the maximum stress conditions for a life support system. It is anticipated that the system will be widely used as a circulatory support system in future applications that require portability and rapid delivery of short-term mechanical circulatory support, such as with cardiogenic shock., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Weaning from left ventricular assist devices (LVADs) after myocardial recovery in patients with idiopathic dilated cardiomyopathy is a clinical option. With the broad application of continuous-flow pumps, we observed a decrease in the numbers of possible LVAD explanations due to myocardial recovery in these particular patients. We investigated this phenomenon and its causes., Methods: Between July 1992 and December 2009, 387 patients (age, 0.1 to 82 years) with idiopathic dilated cardiomyopathy underwent LVAD implantation at our institution. Patients were divided into two groups depending on whether they were weaned from the LVAD (group A) or not (group B). Univariate and multivariate analyses were performed on 24 different factors with a possible influence on myocardial recovery., Results: In 34 patients, LVAD removal due to myocardial recovery was performed with long-term stable cardiac function (weaning rate, 8.8%). Patients with a pulsatile-flow LVAD had an almost threefold chance for myocardial recovery (odds ratio, 2.719; 95% confidence interval, 1.182 to 6.254) than patients who received continuous-flow devices. Younger patients had significantly higher recovery rates than older patients (odds ratio, 1.036; 95% confidence interval, 1.016 to 1.057)., Conclusions: Pulsatile-flow LVADs and young age were important factors for myocardial recovery in idiopathic dilated cardiomyopathy patients in our analysis. Further studies should investigate whether pulsatility in itself or the different degrees of left ventricular unloading by the two types of systems play a role in myocardial recovery., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Small infants undergoing cardiac surgery are at high risk for regional malperfusion during cardiopulmonary bypass. We report a 13-day-old neonate who underwent reconstruction of the aortic arch and closure of atrial and ventricular septum defects. Near-infrared spectroscopy probes were placed on the forehead and the calf to monitor tissue oxygenation and hemoglobin concentrations. During rewarming, after deep hypothermic circulatory arrest, the patient's calf hemoglobin concentration immediately increased but oxygenation remained low. Repositioning of the venous cannula resolved this suspected venous congestion. Simultaneous monitoring of tissue oxygenation and hemoglobin concentration allows differentiation of arterial obstruction from venous congestion., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to describe initial experience with a new continuous flow, ventricular assist system in the pediatric population., Description: Seven children (aged 6 to 16 years) received implantation of a novel third-generation, continuous flow, ventricular assist device (HeartWare, HeartWare Inc, Miami Lakes, FL) as a bridge to cardiac transplantation., Evaluation: All children were in terminal heart failure despite inotropic support, and signs of renal or hepatic impairment developed. Six children had dilatative cardiomyopathy and 1 had congenital heart disease (hypoplastic left heart, total cavopulmonary connections with extracardiac conduit). Six patients have been successfully bridged to transplantation. Median support time was 75 days (range, 1 to 136 days). One child is still under continuous mechanical support. None of the patients suffered a thromboembolic event or an infection., Conclusions: The HeartWare assist system can be successfully used as a bridge to transplantation in children and adolescents with end-stage heart failure., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We analyzed the potential of endovascular stent grafts to treat late aortic pseudoaneurysms after coarctation repair., Methods: Eight patients (7 male; age 28 to 58, mean 43 years) presented with aortic pseudoaneurysms after primary repair performed at the age of 5 to 27 (mean 12) years; 2 patients had rupture with hemorrhagic shock. The mean interval between the procedures was 31 (19 to 42) years; one patient had 3 previous operations. This subset represents 2.2% of our overall experience in thoracic endovascular repair (n=368). Thoracic endografts were implanted using the transfemoral technique. Custom-made reverse tapered stent grafts were used in 4 cases. The left subclavian artery (LSA) was covered in 5 patients. Protective transposition of the left subclavian artery was performed in 4 patients., Results: Hospital mortality was 12.5%; 1 patient died from secondary rupture after emergency repair. Primary complete exclusion of the aneurysm was achieved in 6 patients. Secondary exclusion after implantation of a second stent graft was successful in the second rupture patient. No endoleak was present at discharge. All discharged patients are alive after 8 to 63 (mean 36) months. Follow-up computed tomography or transesophageal echocardiography revealed no secondary endoleaks or late expansion. The pseudoaneurysms had shrunk completely in 3 patients, were reduced in size in 2 patients, and remained unchanged in 2 patients. No late secondary interventions were noted., Conclusions: Single piece, reversed, tapered stent grafts adapt better to the special anatomy of the hypoplastic aortic arch. Midterm results are excellent; complete shrinkage in 50% is remarkable. However, the long-term behavior of these implants in young patients requires further evaluation and surveillance., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular assist device (LVAD) implantation is an accepted therapy for patients with end-stage heart failure. Post-operative right ventricular failure (RVF) still remains a major cause of morbidity and mortality in these patients. This study sought to identify echocardiography parameters to select patients with high risk of RVF after LVAD implantation., Methods: Prospectively collected pre-operative transesophageal echocardiography (TEE) and clinical data were evaluated in patients pre-selected for isolated LVAD or biventricular assist device (BiVAD) implantation. According to prevalence of RVF during the first post-operative 48 hours, patients were divided into those who developed RVF (isolated LVAD with RVF) and those who did not (isolated LVAD without RVF). Echocardiographic parameters for RV geometry, RV function, LV geometry, and the RV-to-LV end-diastolic diameter ratio (R/L ratio) were evaluated. For identification of the optimal cutoff of R/L ratio, receiver operating characteristics curves were constructed., Results: An isolated LVAD was implanted in 115 patients and BiVAD in 22 patients. RVF developed in 15 patients (13%) after isolated LVAD implantation. The R/L ratio was markedly increased in the isolated LVAD with RVF and BiVAD groups compared with the isolated LVAD without RVF group. According to the receiving operating curve, the cutoff for the R/L ratio to predict RVF was 0.72. The odds ratio that RVF will develop is 11.4 in patients with an R/L ratio >0.72 (p = 0.0001)., Conclusions: Increased R/L ratio successfully identifies patients with high risk of RVF after isolated LVAD implantation. Beyond standard measurements of RV function, the consideration of R/L ratio may be useful to improve risk stratification in patients before isolated LVAD implantation., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)