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Background: Historically, the majority of patients admitted to inpatient exercise-based cardiac rehabilitation (EBCR) have undergone open heart surgery (OHS). However, with advances in minimally invasive cardiac surgery (MICS), these patient groups are also increasingly referred for inpatient EBCR. Herein, we aimed to compare the progress of these groups during rehabilitation., Methods: In this prospective, nonrandomized study, 403 inpatient EBCR patients were recruited from December 2022 until September 2023 and stratified into two groups: OHS, and MICS. Participants completed a 3-4-week certified EBCR program. The primary endpoint was defined as a change in the 6-minute walk test (6MWT). Moreover, a comprehensive panel of quality-of-life (QoL) assessments were performed at admission and discharge., Results: At baseline, patients with OHS were older (66 years [IQR 59 - 72]), more often male (83%), and underwent emergency/urgent procedures more often (20%) than patients with MICS. Furthermore, patients with MICS showed a better 6MWT at admission (426 meters [IQR 336 - 483]) compared to patients with OHS (381 meters [IQR 299 - 453]). While all patients were able to increase the distance in the 6MWT, regression analyses in fully adjusted models showed no difference in improvements between the two groups (β -5, 95% CI, -26 - 14, p = 0.58). Moreover, during EBCR, we observed significant improvements in all QoL measures in all groups., Conclusions: In this study, improvements in fitness, as assessed by the 6WMT were observed in all groups. Furthermore, multiple QoL measures improved equally across all groups. These encouraging results emphasize the importance of EBCR., (© 2024. The Author(s).)

Background: Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting., Methods: A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view., Results: The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb ® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability., Conclusions: The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy., (© 2024. The Author(s).)

Background: This study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution., Methods: From January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment., Results: Overall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61-11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81-7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65-100 procedures., Conclusions: Mitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve., Trial Registration: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020)., (© 2024. The Author(s).)

Aim of the Study: In patients undergoing cardiac surgery, preoperative depressive and anxiety symptoms and increased postoperative C-reactive protein (CRP) levels have been associated with adverse outcomes. We tested the hypothesis that preoperative depressive and anxiety symptoms predict elevated in-hospital CRP levels after cardiac surgery., Methods: The study participants were 96 consecutive patients (mean age [SD], 67.6 [10.3] years, 78.1% men) from a single cardiac surgery centre who underwent either isolated coronary artery bypass grafting (CABG) (n = 34), isolated valve surgery (n = 29), combined procedures (including different combinations of CABG, valve surgery, aortic surgery, and others) (n = 30), or other cardiac surgical procedures (n = 3). Participants self-rated depressive and anxiety symptoms using the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder (GAD-7) questionnaire before undergoing elective surgery. CRP levels were measured every 24 h up to 10 days post-surgery. Linear mixed (random effects) regression analysis examined the association between preoperative depressive and anxiety symptoms and CRP levels over time, adjusting for pre-surgery CRP levels, demographics, cardiovascular risk factors, medications, and surgery-related variables., Results: Before surgery, 32.2% of patients had clinically relevant depressive symptoms (PHQ-9 score ≥5) and 32.2% of patients had clinically relevant anxiety symptoms (GAD-7 score ≥5). More severe depressive symptoms (estimate [95% CI]: 0.081 [0.023, 0.139], p = 0.007) and more severe anxiety symptoms (0.059 [0.005, 0.113], p = 0.032) predicted CRP levels over 10 days, independent of covariates. Furthermore, CRP levels were higher in patients with than in those without clinically relevant depressive symptoms (0.697 [0.204, 1.191], p = 0.006) and were predicted by both more severe somatic (0.132 [0.035, 0.229], p = 0.008) and cognitive (0.128 [0.014, 0.242], p = 0.029) depressive symptoms., Conclusions: Preoperative depressive and anxiety symptoms were independent predictors of elevated CRP levels up to 10 days post-surgery. Such a mechanism may help explain the increased morbidity and mortality risk in patients with depression and anxiety who undergo cardiac surgery.

Objectives: Concerns exist about higher rates of pacemaker implantation using the extended superior transseptal approach for mitral valve surgery. This study aims to compare the extended superior transseptal and the left atrial approach regarding the need for pacemaker implantation after mitral valve surgery., Methods: We performed a retrospective analysis of the data of patients undergoing mitral valve surgery through either a sternotomy and transseptal approach or a mini-thoracotomy and left atrial approach in a single centre in the period January 2010 to May 2021. The primary outcome was the evaluation of the postoperative pacemaker implantation rate., Results: Overall, 677 patients were included, 333 with transseptal and 344 with left atrial approach, and 58 (8.6%) patients underwent pacemaker implantation postoperatively. There was no significant difference in the rate of pacemaker implantation between the 2 groups [overall: 34 (10.2%) vs 24 (7%), P = 0.133; for sinus node dysfunction: 12 (3.6%) vs 9 (2.6%), P = 0.459; for high-degree atrioventricular block: 22 (6.6%) vs 15 (4.4%), P = 0.199; transseptal vs left atrial approach, respectively]. A subgroup analysis of the relative effect of transseptal versus left atrial approach on the rate of postoperative pacemaker implantation revealed mitral replacement as a statistically significant confounder (P = 0.019). The exclusion of patients undergoing concomitant cardiac procedures did not lead to a statistically significant difference in the pacemaker implantation rate between the 2 approaches., Conclusions: The analysis of the data of these patients shows no significant difference in the rate of permanent pacemaker implantation between the extended superior transseptal and the left atrial approach for mitral valve surgery., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aims of the Study: Chest tubes inserted to drain shed mediastinal blood after cardiac surgery often become clogged, limiting their capacity to evacuate blood, and leading to blood retention and retained blood syndrome. The aim of this study was the assessment of the efficacy of an active tube clearance (ATC) system in the reduction of retained blood syndrome after cardiac surgery., Methods: This study included 2461 adult patients undergoing major cardiac surgery. Patients receiving conventional chest tubes only (n = 1980) were compared with patients receiving an ATC tube in the retrosternal position (n = 481) for interventions caused by retained blood syndrome (re-exploration for bleeding or tamponade and interventions for pleural effusion or pneumothorax), kidney replacement therapy, postoperative atrial fibrillation, sternal infection and chest tube output before and after propensity score matching., Results: Propensity score matching generated 471 patient-pairs balanced for their baseline characteristics. Matched patients with an ATC tube in the retrosternal position had no statistically significant difference in the rate of intervention for retained blood syndrome (33% vs 31%, p = 1), re-exploration because of bleeding or tamponade (2.5% vs 4%, p = 1), intervention for pneumothorax (4.7% vs 4.9%, p = 1) and intervention for pleural effusion (28% vs 28%, p = 1), but had statistically significantly less chest tube output on the first postoperative day (median 480, IQR 316–700 ml vs median 590, IQR 380–905 ml; p <0.0001) and second postoperative day (median 505, IQR 342–800 ml vs median 597, IQR 383–962 ml; p = 0.0012)  in comparison with patients with conventional chest tubes only., Conclusion: An ATC tube in the retrosternal position reduced chest tube output but showed no reduction in the rate of intervention for retained blood syndrome. Further research should be performed to test the combination of ATC in the retrosternal and the inferior pericardial space.

Background: Functional hemodynamic parameters such as stroke volume and pulse pressure variation (SVV and PPV) have been shown to be reliable predictors of fluid responsiveness in mechanically ventilated patients. Today, different minimally- and non-invasive hemodynamic monitoring systems measure functional hemodynamic parameters. Although some of these parameters are described by the same name, they differ in their measurement technique and thus may provide different results. We aimed to test the performance of seven functional hemodynamic parameters simultaneously in the same clinical setting., Methods: Hemodynamic measurements were done in 30 cardiac surgery patients that were mechanically ventilated. Before and after a standardized intravenous fluid bolus, hemodynamics were measured by the following monitoring systems: PiCCOplus (SVV PiCCO , PPV PiCCO ), LiDCO rapid (SVV LiDCO , PPV LiDCO ), FloTrac (SVV FloTrac ), Philips Intellivue (PPV Philips ) and Masimo pulse oximeter (pleth variability index, PVI). Prediction of fluid responsiveness was tested by calculation of receiver operating characteristic (ROC) curves including a gray zone approach and compared using Fisher's Z-Test., Results: Fluid administration resulted in an increase in cardiac output, while all functional hemodynamic parameters decreased. A wide range of areas under the ROC-curve (AUC's) was observed: AUC-SVV PiCCO  = 0.91, AUC-PPV PiCCO  = 0.88, AUC-SVV LiDCO  = 0.78, AUC-PPV LiDCO  = 0.89, AUC-SVV FloTrac  = 0.87, AUC-PPV Philips  = 0.92 and AUC-PVI = 0.68. Optimal threshold values for prediction of fluid responsiveness ranged between 9.5 and 17.5%. Lowest threshold values were observed for SVV LiDCO , highest for PVI., Conclusion: All functional hemodynamic parameters tested except for PVI showed that their use allows a reliable identification of potential fluid responders. PVI however, may not be suitable after cardiac surgery to predict fluid responsiveness., Trial Registration: NCT02571465 , registered on October 7th, 2015 (retrospectively registered).

Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient's coagulation status by glass bead-activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot., Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation., Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = -14.7%). Comparing S2 and S1, the glass bead-activated tests showed mean percentage differences of -18.9% (gbACTs), +37.4% (CR), and -3.7% (PF)., Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2., (© The Author(s) 2016.)

Aim: The present study investigates the geometry of failing left ventricles with a special focus on apical deformation. A new surgical remodelling technique is evaluated., Methods: In 124 patients with impaired left ventricular function (EF<40%) undergoing coronary artery bypass grafting (CABG) left ventricular (LV) geometry was evaluated by MRI scanning before and after surgery. Besides the sphericity index (SI) two further indices were calculated, longitudinal EF (LEF) and an apical conicity index (ACI). The results were compared to 15 patients with coronary heart disease and normal LV function and 10 test persons. In 35 patients with impaired LV function perpendicular apical compression (AC) stitches were placed., Results: In failing left ventricles indexed LV length increased (5.3 ± 0.6 cm/m2 vs. 4.7 ± 0.8 cm/m2 in control patients and 4.6 ± 0.3 cm/m2 in test persons, P=0.03). LEF was reduced (6% ± 4 versus 22% ± 6 and 19% ± 7 P=0.04). The classical SI was 0.56 ± 0.06 in heart failure patients, 0.50 ± 0.05 in control patients and 0.48 ± 0.04 in test persons. The ACI were 0.75 ± 0.06, 0.58 ± 0.06 and 0.57 ± 0.04 respectively (P<0.05), indicating a pronounced dilatation at the apex. After apical compression LEF improved to 15 ± 1%, the ACI to 0.64 ± 0.04 (P=0.04). LVEDV (166 ± 11 mL [AC] vs. 196 ± 14 mL [without AC]) as well as LV-EF (48 ± 3% [AC] vs. 36 ± 2% [without AC]) significantly improved only after remodelling (P<0.05)., Conclusion: Apical compression improved ventricular geometry and ventricular function in patients with dialatation of the left ventricular apex.

Background: Cardiopulmonary bypass is associated with systemic inflammation that may contribute to increased perioperative mortality. Depletion of circulating leukocytes may reduce the inflammatory response. We studied the effect of a leukocyte depleting filter on leukocyte activation during cardiopulmonary bypass in high risk patients., Methods: Fifty patients undergoing coronary artery bypass grafting with a preoperative high risk were randomly placed in an arterial line leukocyte filter group (n = 25) with a leukocyte depleting filter. Blood sampling took place from the arterial line to analyze polymorphnuclear elastase and myeloperoxidase at six time points, including: A) before the induction of anesthesia, B) before the induction of the cardiopulmonary bypass C) 1 min after the release of the aorta clamp, D) the end of the operation, E) 1 h postoperative, and F) 24 h postoperative., Results: Levels of polymorphonuclear elastase, (PMNE), and myeloperoxidase (MPO) were found to be higher after the release of the aortic cross clamp in the leukocyte filter group; these levels remained elevated until 24 hours after surgery and were high in comparison to preoperative baseline levels. The differences in PMNE between both groups at time points C and D (p < 0.005) and E (p < 0.05) were statistically significant. The serum levels of the S-100B and neuron specific enolase (NSE) were found to be elevated between time points C and E in both groups without statistical significance. The in-hospital mortality was 16% (4 patients) in leukocyte filter group and 4% in control group (1 patient)., Conclusions: Interestingly, the activation of neutrophils was more pronounced in the LF group. The use of a leucocyte depleting filter was not advantageous for this patient cohort for clinical or biomedical endpoints.

Background: This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement., Methods: Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months., Results: Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %., Conclusion: The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.

Aim of the Study: Atrial fibrillation (AF) commonly occurs following open heart surgery especially in the high-risk group of old patients with reduced left ventricular function. Via Syncrus heart wires implanted on the left and right atrium internal cardioversion shocks can be applied. This prospective nonrandomized multicenter study compares duration of AF periods and clinical outcome in patients treated with Syncrus wires to a control group treated conventionally., Methods: In 88 patients Syncrus heart wires were implanted. Upon detection of AF antiarrhythmic medication was started for at least 6 hours followed by internal cardioversion. The results of this treatment were compared to a control group of 86 patients with an identical risk profile., Results: In the Syncrus group 53.4% of patients suffered from postoperative AF compared with 50.0% in the control group. Internal cardioversion led to restoration of sinus rhythm in 60% of patients at the first series of shocks (mean energy 7.7 +/- 1.3 J) and 95.8% with the second series (mean energy 8.6 +/- 0.5 J). Length of AF periods was 12.4 +/- 7.2 hours in the Syncrus group versus 42.9 +/- 19.6 hours in control patients., Conclusions: Internal cardioversion using Syncrus heart wires demonstrated effectiveness in treating postoperative AF. Especially, length of AF periods could be diminished by the system with the expectation of reduction in hospital length of stay.

Background and Aim of the Study: Quadrangular resections for posterior mitral leaflet prolapse create a defect that requires readaptation of the annulus as well as the leaflet cut edges. A variety of techniques has been described to narrow the posterior mitral annulus. Herein is described a simple compression stitch that allows compensation of annular size reduction even for large resections of the mural leaflet., Methods: The annular compression stitch consists of four bites: the first stitch is placed from the atrium into the ventricle; the second takes a piece of ventricular myocardium parallel to the mitral ring; the third returns the needle into the atrium some millimeters outside the opposite cut edge of the mitral leaflet; and the fourth stitch grabs atrial myocardium parallel to the previous ventricular stitch. Tying the knots compresses the annulus to an extent that allows reanastomosis of the two leaflet cut edges., Results: This new technique was used in 212 patients undergoing mitral valve repair. Intraoperative outcome was excellent, and after a mean follow up period of 2.5 years no reoperation was needed due to failure of the annular compression stitch., Conclusion: The new compression stitch simplifies the repair, avoids the creation of a trench, and allows readaptation of the two mural leaflet edges without tension, even in large posterior resections.

Objectives: Severe sternum necrosis requiring extended resection necessitates plastic reconstruction of the resulting defect and stabilization of the chest. We analyzed the outcome of patients undergoing bilateral pectoralis major flap repair on functional and cosmetic results, chest stabilization and pulmonary function., Methods: Twelve patients undergoing cardiac surgery between 1997 and 2001 suffered from a deep mediastinal wound infection and sternum necrosis. After a mean of two attempts of extensive wound debridement, all 12 patients underwent complete sternal resection with plastic reconstruction by bilateral pectoralis major flaps. Risk factors were obesity (n=10) and diabetes (n=11). Six months postoperatively patients underwent physical examination, pulmonary function testing and functional CT scan., Results: Three patients died in hospital (two septic multiorgan failure, one heart failure) and nine were discharged with complete wound closure. One patient suffered a lethal stroke during follow-up. At 6-month follow-up no recurrent sternum infection had occurred. Chest stability was satisfactory without impairment of pulmonary function (VC 77.5+/-12.1% at follow-up vs 77.8+/-12.5% preoperatively). Mobility and force of arms and shoulder were adequate; at CT scan the maximum distance change between the former sternoclavicular joint in inspiration versus expiration was minimal. Quality of life questionnaires showed no significant limitations except a disturbed sleep and mild restriction of executing hobbies and social activities., Conclusions: Bilateral pectoralis major flap repair is a safe technique to cure severe mediastinitis necessitating complete sternal resection. Wounds close without extensive reconstructive surgery. Cosmetic results as well as stabilization of the chest were good. Patients reported an almost uncompromised quality of life without respiratory impairment.

Objective and Design: The functional activity and pathophysiological effects of polymorphonuclear elastase (PMNE) in cardiac surgery patients are unknown. This in vitro study was done to evaluate whether PMNE activity in patient blood samples may be correlated with decreased endothelial wall integrity., Methods and Subjects: PMNE was serially analyzed by PMNE activity in plasma samples from 40 high risk cardiac surgery patients. Endothelial cell cultures were used to study the influence of patient serum on the intercellular integrity., Results: Ex vivo, samples with high PMNE activity (>1.0 mg/ ml), found in 14 patients (35%), neither induced hyperpermeability in cultured endothelial cells nor resulted in intracellular redistribution of the junction molecules cadherin-5 or beta-catenin. However, pretreatment of endothelial cells with these samples but not with low activity (<0.5 mg/ml) samples augmented neutrophil transendothelial migration (>20-fold) in conjunction with formation of intercellular gaps and irregular membrane-associated beta-catenin staining. Neutrophil transmigration was inhibited by blocking neutrophil beta1 integrin but not by the proteinase inhibitor methoxysuccinyl-Ala-Ala-Pro-Ala., Conclusions: Augmented PMNE activity in cardiac surgery patients does not directly induce endothelial leakage but may indirectly promote neutrophil extravasation and thus perioperative endothelial hyperpermeability.

Background and Aim of the Study: A prospective randomized study was performed to compare conventional with minimally invasive aortic valve replacement (AVR)., Methods: Forty consecutive patients scheduled for elective aortic valve surgery were prospectively randomized either to the conventional group (group A, complete median sternotomy) or minimally invasive group (group B, partial upper sternotomy). Intraoperative and postoperative clinical data, and markers of myocardial and cerebral protection were determined. Neuropsychological tests were carried out to quantify psychological disorders., Results: Operative time and cardiopulmonary bypass time were slightly longer in group B, but not significantly so. No significant inter-group differences were found for postoperative pain scores and respiratory function. Chest tube drainage was significantly less in group B (495 +/- 165 versus 240 +/- 69 ml, p = 0.008). Creatine kinase (CK), CK-MB and troponin T levels were similar in both groups. Neither S-100B protein nor neuron-specific enolase levels differed significantly between groups at all sampling times. There were no strokes in the entire cohort. None of the neuropsychological tests yielded significant inter-group differences between conventional and minimally invasive surgery., Conclusion: The safety and reliability of AVR via a partial upper sternotomy is reported. Minimally invasive AVR can be performed with only slightly longer operative times, good cosmetic results and significantly less blood loss. A limited surgical access affected neither the patients' neurological outcome nor the efficacy of myocardial protection.

Atrial fibrillation (AF) is the most common dysrhythmia following open heart surgery with or without cardiopulmonary bypass. In previous studies, the AF incidence varied between 25.0% and 60.0% of all patients. The conventional treatment of postoperative AF periods consists of antiarrhythmic medication, most frequently calcium channel antagonists, beta-adrenergic blockers, or amiodarone. If the pharmacological treatment is ineffective or leads to further impairment of hemodynamics, external electrical cardioversion under general anesthesia and simultaneous transesophageal echocardiography is performed. Systemic heparinization is recommended to prevent neurological events related to AF. In 1995, a new method for internal electrical cardioversion using epicardial wire electrodes with low shock energies was developed in a canine model. Since June 1997, this device for internal cardioversion that consisted of two multifilament stainless steel wires has been available clinically (TADpole followed by Syncrus heart wires, Guidant Corporation C and VS, Cupertino, California, USA). The safety and efficacy of this innovative strategy for treatment of postoperative AF has been investigated in two pilot studies. These studies demonstrated a success rate of internal cardioversion up to 92.9% with optimized pre-shock treatment that leads to a significant shortening of AF periods, with the expectation of reduction in hospital length of stay.

Objective and Design: The beneficial effects of leukocyte filtration on the outcome of cardiac surgery with cardiopulmonary bypass (CPB) is probably due to the limitation of pathogenesis mediated by over-stimulated neutrophils. However, the influence of leukocyte filtration on the functional neutrophil activity has not been studied in detail. Therefore, by using different filtration timing strategies we determined neutrophil effector functions before and after the filter passage as well as blood surrogate markers for neutrophil activation., Methods: We randomly assigned 80 cardiac surgery patients to four groups (n = 20 each) without (1) and with three different filtration timing strategies (II-IV). As functional end points neutrophil phagocytic activity and oxidative burst upon ex vivo stimulation with E.coli were analyzed from blood of 31 patients whereas polymorphonuclear elastase (PMNE), myeloperoxidase, and malondialdehyde (MDA), a marker for lipid peroxidation was determined in plasma samples from 80 patients. Blood was harvested immediately before and behind the filter (Pall LG6) at different times during CPB., Results: We found that none of the filtration strategies either reduced the number of neutrophils capable of eliciting phagocytic activity and oxidative burst or the activity per cell. In contrast, PMNE and MPO levels in peripheral venous blood were found to be significantly increased in groups II-IV compared with group I throughout the entire filtration period in all patients. MDA was not enhanced in the filter groups., Conclusions: Our results show that the leukocyte depletion filter in the arterial line of the heart-lung machine failed to limit neutrophil stimulation but rather augmented PMNE plasma levels. We speculate that augmented PMNE and MPO levels mainly stem from neutrophils that are captured within the mesh of the leukocyte filter.

Leukocyte filtration has evolved as an important technique in cardiac surgery with cardiopulmonary bypass to prevent pathogenic effector functions mediated by activated leukocytes. The underlying mechanisms that result in an improvement of laboratory variables as well as clinical outcome are not resolved yet. Moreover, the optimum strategy for the use of current filtration technology has not been systematically evaluated. This paper, therefore, reviews how activated leukocytes may lead to tissue damage, summarizes the known effects of leukocyte filtration on clinical outcome and laboratory parameters, and deals with current experimental and clinical efforts to further limit the pathogenic effects of leukocytes in cardiac surgery.