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Objective : Cardiosurgical mitral valve repair (MVR) cannot be easily replaced by other interventional procedures due to the complexity of mitral valve regurgitation as well as physiologic and anatomic repair techniques. A wide variety of techniques have been adopted for proper reconstruction of posterior leaflet prolapse. We investigated the long-term results of quadrangular resections and compared them with a simplified reconstruction maneuver, the inverse plication. Methods : We retrospectively collected data from 1977 patients after mitral valve repair between 2004 and 2022. After considering inclusion and exclusion criteria, we analyzed data from 180 patients after MVR with and without concomitant procedures such as CABG and/or aortic valve replacement (AVR). All MVRs were performed with a semi-rigid annuloplasty ring. A total of 180 patients received quadrangular resection (QuadRes, N = 120)) or inverse plication (InvPlic, N = 60) of the posterior leaflet, among other measures. Demographic data, risk factors, procedure times, hospitalization time, early and long-term mortality as well as Kaplan-Meier survival were analyzed. Results : Age (65.3 vs. 63.1 years) and sex (28.8% female vs. 337.5% female) did not differ significantly, and the EuroSCORE was significantly higher in the InvPlic group (6.46 ± 2.75) than in the QuadRes group (5.68 ± 3.1). Procedural times did not differ for cardiopulmonary bypass, and were as follows: InvPlic 136 ± 44 min; QuadRes 140 ± 48 min; X-Clamp: InvPlic 91 ± 31 min; QuadRes 90 ± 32 min. Hospitalization time was slightly but insignificantly lower in the InvPlic group (15.5 days) than in the QuadRes group (16.1 days). Early mortality (5.08% vs. 8.33%) and re-do procedures (1.69% InvPlic; 6.67% QuadRes) did not differ significantly. However, long-term mortality was significantly lower in the InvPlic group (15.25% vs. 32.32%, p = 0.029). Conclusions : Among the surgical measures for the posterior leaflet, inverse plication appears to be non-inferior to quadrangular resection in unselected all-comer patients. Long-term results and absence of re-do procedures indicate very good stability. Thus, inverse plication not only allows correction of PML, but is also completely safe in the long term and can replace quadrangular resection, especially in patients where a reduction in technical challenges and procedure duration is desired., Competing Interests: The authors declare no conflicts of interest.

Objectives: Liver cirrhosis increases the risk of death in patients having cardiac surgery, and the risk is markedly dependent on the actual stage. The EuroSCORE II, however, does not specifically address the risk of death of patients with liver cirrhosis. We investigated the predictive power of EuroSCORE II in patients with liver cirrhosis., Methods: Between 2000 and 2020, a total of 218 patients with liver cirrhosis underwent cardiac surgery. To improve the predictive value of the EuroSCORE II, we calculated additional β-coefficients to include liver cirrhosis in the EuroSCORE IIb. The control group included 5,764 patients without liver cirrhosis from the same period., Results: Of the 5,764 patients without cirrhosis, 8.9% died early. Of those with cirrhosis, 8.9% of 146 patients with Child A stage, 52.9% of 51 patients with Child B stage and 100% of 21 patients with Child C stage died. Moreover, the EuroSCORE II showed a poor predictive value for patients in Child B and C stages. The resulting values of calculated β using the area under the curve of the receiver operating characteristic and bootstrapping for Child stages as predictors of mortality were as follows: βA = 0.1640205, βB= 2.9911625 and βC= 6.2501248. By calculating the updated EuroSCORE IIb and regenerating the receiver operating characteristic curves, we were able to demonstrate an improvement in area under the curve values. Postoperative complications, need for extracorporeal membrane oxygenation or intra-aortic balloon pump implants, intensive care unit stays and hospital stays were significantly higher in cirrhotic patients with cirrhosis compared with patients without cirrhosis. The most common cause of liver cirrhosis was alcohol abuse (55.5%)., Conclusions: Although patients with liver cirrhosis represent only a small proportion of cardiac surgical cases, the poor outcomes are particularly relevant in patients with advanced stages of the disease. Our study results show that Child class A patients show outcomes similar to those of patients without liver disease whereas Child class C patients appear to be nearly inoperable, i.e. can only be operated on with exceptional risks. Including these patients in the EuroSCORE II calculation would thus represent an improvement in preoperative mortality risk assessment., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Extracorporeal circulation (ECC) is an integral part of cardiac surgery. Yet, the contact with artificial surfaces, mechanical stress, shear, and suction forces within the ECC pose a pronounced risk for damaging the corpuscular components of the blood. These suction forces may be reduced by a repositioning of the roller pumps employed below the reservoir. Furthermore, the repeated compression of the involved silicone tubing is likely to cause degradation. We present our observations regarding changes in the ECC performance following this degradation process. In vitro experiments were performed in a standard as well as a simplified ECC setup and included measurements of pressure, effective flow, and tubing restoring force over a time frame of 12 hours with two different pump positions utilizing transit time flow measurement. Suction forces within the tubing could be significantly reduced by shifting the pump position below the reservoir. Regardless of the setup, the tubing showed significant loss of restoring force as well as effective flow over time. A shift of the pump position within the ECC setup can be recommended to prevent blood damaging negative pressures. Further research is necessary to evaluate the exact cause of the reduction of restoring force overtime as well as its risks for the patients. Finally, our results underline the importance of transit time flow measurements to collect reliable flow data., (© 2020 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background:  Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis., Methods:  From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis., Results:  While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase ( p  < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed ( p  < 0.001). An increase of device-related endocarditis was also noted ( p  < 0.001)., Conclusion:  Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: MitraClip (Abbott Inc.) is propagated as a palliative option for high-risk patients with mitral insufficiency considered not qualifying for surgical repair. A proportion of patients requires consecutive surgery because of technical failure or inappropriate clinical improvement. Furthermore, surgical reconstruction is impossible in almost all patients after MitraClip implantation. Consequently, these patients receive replacement although primary repair may have been possible. The outcome of those patients compared with patients receiving primary mitral valve replacement (MVR) or mitral valve repair (MVP) was analyzed., Methods: A total of 23 patients were retrospectively analyzed after MVR following MitraClip. Overall, 46 patients with corresponding demographic data and risk profile receiving primary MVR (23 patients) or MVP (23 patients) were retrieved for matched pair analysis., Results: Mean age was 70 years in all groups, log European system for cardiac operative risk evaluation (EuroSCORE) was 22.47% ± 16.30 in MVR after MitraClip (MC), 22.34% ± 16.23 in MVP, and 22.33% ± 16.14 in MVR group. Preoperative left ventricular ejection fraction (LVEF) was 44%, and postoperative LVEF was 48% in all groups. The 30-day mortality was 21.7% in the MitraClip group whereas it was 4.3% in the MVR and 13.0% in the MVP group. The 1-year survival was 56.5% in the MitraClip group while it was 95.6% in the MVR group and 82.6% in the MVP group (Wilcoxon test: p  = 0.007; chi - square test: p  = 0.001 MitraClip vs. MVR; p  = 0.054 MitraClip vs. MVP)., Conclusions: Patients requiring surgical MVR after the previous MitraClip fared worse than matched cohorts receiving primary MVR or MVP. Indication for MitraClip should, therefore, be made very cautiously given the excellent results gained with primary surgery., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Obesity is an ever-growing problem in contemporary cardiac surgery. Although it accounts for many perioperative comorbidities, it has not been shown to increase mortality. Body mass index (BMI) is therefore not considered in the European System for Cardiac Operative Risk Evaluation (EuroSCORE). We sought to confirm whether this holds true for our own single-centre patient population., Methods: Data from 15 314 consecutive patients receiving major cardiac surgery at our institution were analysed. Gender, age, BMI, EuroSCORE, urgency, redo status and all-cause in-hospital mortality were derived from our database. Mortality was grouped into 4 BMI categories. We created a logistic regression model to identify predictors of mortality., Results: There were 11 034 males and 4280 females. Categorical mortality was 8.79% (underweight), 7.04% (normal weight), 5.16% (overweight), 6.30% (obese), rendering an inverse J-shaped pattern known as obesity paradox. Univariable regression detected significant predictors of mortality: rising age, female gender, urgent procedures, redo surgery ( P  < 0.001). BMI was no predictor ( P  = 0.575) but became significant with the multivariable analysis ( P  = 0.004). Its effect on mortality was exclusively indirect, being mediated through age ( P  < 0.001). Receiver-operating characteristics curve analysis also confirmed that BMI did not qualify as a risk factor. However, the overweight category was a predictor of lower mortality., Conclusions: Our findings from >15 000 patients confirm the obesity paradox showing the least mortality in the overweight group. They support the current EuroSCORE model in that BMI is no independent predictor of early mortality. However, such patients still carry the risk of comorbidities. Likewise, special care is required with underweight patients who show the highest in-hospital mortality., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The surgeon's individual performance is a key component of total quality management (TQM) in cardiac surgery. Early mortality as well as postoperative complications can be stratified in order to develop a surgeon performance index (SPI)., Material and Methods: In three consecutive annual periods (3703 patients) data of board-certified cardiac surgeons were compared. Risk-adjustment of early mortality and postoperative complications was performed by logistical EuroSCORE (logES). Early mortality (EM), early rethoracotomy for bleeding (ReTh), sternal rewiring for instability (ReWr), and mediastinitis (Med) were assessed. ReTh, ReWr, and Med were weighted according to empiric data: (ReThx2; ReWrx1; Medx3). Surgeon performance index was computed as follows: SPI=(EM/logES+[((ReTh/logES)x2)+((ReWr/logES)x1)+((Med/logES)x3)]/6)/2. Ideal SPI was considered

Background: Demographic changes and aggressive medication with platelet aggregation inhibitors have resulted in a marked increase in blood and coagulation product expenditure and costs in cardiac surgery. We analyzed the bedside coagulation test (ROTEM) in order to verify clot forming quality and to find a cost-effective treatment algorithm., Patients and Methods: Annual treatment costs of all cardiosurgical patients were retrospectively analyzed before (729 patients) and after (693 patients) implementation of the bedside ROTEM test. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and the coagulation factors prothrombin complex concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. The number of rethoracotomies and early mortality were assessed and compared in both periods., Results: After ROTEM implementation cumulative RBC expenditure showed a 25% decrease and PltC a 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa was entirely omitted. Fibrinogen, however, showed a two-fold increase. Cumulative average monthly costs of all blood products decreased from 66,000 EUR to 45,000 EUR (-32%). Coagulation factor average monthly costs decreased from 60,000 EUR to 30,000 EUR (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1,580 EUR. The total number of rethoracotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable., Conclusions: Cumulative costs for treatment of perioperative coagulation disorders were reduced by bedside ROTEM analysis to achieve a selective substitution management. Saved costs for blood and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

Objective: Demographic changes and aggressive platelet inhibition have resulted in a marked increase in blood- and coagulation product expenditure and costs in cardiac surgery. We analyzed "bedside" coagulation test (ROTEM) in order to verify clot forming quality for the purpose of finding a cost-effective treatment path., Methods: Annual treatment costs of all cardiosurgical patients were analyzed before (729 patients) and after (693 patients) implementation of "bedside" ROTEM. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and coagulation factors: pooled coagulation concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. Number of resternotomies and early mortality was assessed and compared in both periods., Results: After ROTEM implementation cumulative RBC expenditure showed 25% decrease while PltC exhibited 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa were entirely omitted. Fibrinogen, however, increased two-fold. Cumulative average monthly costs of all blood products decreased from 66,000 euro to 45,000 euro (-32%). Coagulation factor average monthly costs decreased from 60,000 euro to 30,000 euro (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1.580 euro. Total number of resternotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable., Conclusion: Cumulative costs for treatment of perioperative coagulation disorders can be reduced by "bedside" ROTEM analysis to achieve a selective substitution management. Saved costs for blood- and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

Background: The steady rise in complex cardiac procedures as well as the increase in comorbidity often result in a prolonged intensive care unit (ICU) stay. As a consequence, considerable numbers of patients have to be transferred to other hospitals so that the primary institution can maintain its capacity. The purpose of this study was to investigate the outcome of these patients., Methods: 1,175 consecutive patients underwent various open heart procedures. 115 patients (9.8 %) requiring prolonged ICU treatment were retrospectively analyzed. 74 patients (EuroSCORE 8.1) underwent transferral to either rehabilitation units with ventilation capacity, multidisciplinary ICUs, or cardiac ICUs. 41 patients (EuroSCORE 7.9) remained in our hospital. Morbidity, mortality, and clinical condition were assessed and compared., Results: Transferred patients exhibited an overall mortality of 38 % compared to only 17 % in patients who remained. Mortality was 81 % in rehabilitation units, 30 % in multidisciplinary ICUs, and 16 % in cardiac ICUs. 66 % of the survivors among the transferred patients showed significantly impaired clinical condition (NYHA III-IV) compared to 33 % who showed a good postoperative condition (NYHA I-II). The patients who remained exhibited 44 % NYHA III-IV and 56 % NYHA I-II., Conclusion: Transferral of patients after prolonged intensive care stay to external hospitals carries significant risks for early death and impaired outcome. However, transferral to cardiac ICUs appears to be an adequate option. Further studies may identify potential subgroups of patients who do not benefit from transferral.

Unlabelled: Acute hypersensitivity reactions are serious complications of reexposure to aprotinin. Previous contact via infusions or fibrin tissue adhesives can induce specific antibodies. In this study, we aimed to elucidate the preoperative prevalence of aprotinin-specific antibodies in patients scheduled for cardiac operations. Sera of 520 consecutive cardiosurgical patients were collected preoperatively and screened retrospectively for aprotinin-specific IgG using a standard enzyme-linked immunosorbent assay (ELISA). Positive sera were analyzed also for aprotinin-specific IgA (ELISA) and IgE (fluorescence enzyme immunoassay). The histories of all patients were reviewed with focus on aprotinin preexposure. Of 520 patients, 22 (4%) had specific IgG. Only three of these had a documented aprotinin preexposure. Of 448 patients exposed to aprotinin intraoperatively, 15 had preformed specific antibodies. The only patient presenting with severe anaphylaxis was positive for both IgG and IgE, and had a recent IV preexposure in cardiovascular surgery. The presence of aprotinin-specific IgG alone seems not to induce adverse reactions on exposure. Exposure history alone is not sensitive enough to identify patients with aprotinin-specific antibodies., Implications: Anaphylaxis on IV reexposure to aprotinin is a medical emergency. The clinical significance of preformed aprotinin-specific IgG remains questionable, whereas preformed IgE was present in the only patient who suffered from severe anaphylaxis on reexposure to aprotinin. Preformed antibodies are not reliably predicted by exposure history.