Search

Bioprosthetic surgical aortic valve replacement (SAVR) is increasingly adopted in younger patients. We aimed to analyze mid-term follow-up data after SAVR to assess the performance of the prosthesis.Data were collected from a single-center series of 154 patients, who underwent SAVR with a bioprosthetic heart valve with the RESILIA tissue at our Heart Centre in Siegburg. All procedural and midterm patient outcomes were documented.Patients had a mean age of 56.8 ± 9.9 years, 35.7% were female, and the mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was 3.4 ± 3.6%. Diabetes (12.3%), atrial fibrillation (10.4%), and chronic obstructive pulmonary disease (COPD) (5.8%) were common comorbidities. The mean surgery duration was 163.8 ± 73.4 min, with the 23 mm (34.4%) and 25 mm (33.8%) heart valves being most frequently implanted. At 3-year follow-up, mean pressure gradient was 13.9 ± 5.9 mmHg, peak gradient was 23.6 ± 7.7 mmHg, and effective orifice area (EOA) was 1.9 ± 0.4 cm². No patient died during the operation, 3 (2.1%) patients within 30 days, and 4 (2.7%) thereafter with an overall mortality of n = 7. Of the surviving patients, 97.8% were in New York Heart Association (NYHA) class I/II and none had structural valve deterioration (SVD).Results of our single-center study indicate favorable procedural outcomes. The safety outcomes confirm preliminary earlier results of this novel bioprosthesis but include more patients and a longer midterm follow-up.

(1) Background: Despite optimal surgical therapy, replacement of the ascending aorta leads to a significant reduction in the quality of life (QoL). However, an optimal result includes maintaining and improving the QoL. The aim of our study was to evaluate the long-term outcome and the QoL in patients with aneurysms in the ascending aorta; (2) Methods: Between 2014 and 2020, 121 consecutive patients who underwent replacement of the ascending aorta were included in this study. Acute aortic pathologies were excluded. A standard short form (SF)-36 questionnaire was sent to the 112 survivors. According to the surgical procedure, patients were divided into two groups (A: supracoronary replacement of the aorta, n = 35 and B: Wheat-, David- or Bentall-procedures, n = 86). The QoL was compared within these groups and to the normal population, including myocardial infarction (MI), coronary artery disease (CAD) and cancer (CAN) patients; (3) Results: 83 patients were males (68.6%) with a mean age of 62.0 ± 12.5 years. Early postoperative outcomes showed comparable results between groups A and B, with a higher re-thoracotomy rate in B (A: 0.0% vs. B: 22.1%, p = 0.002). The 30-day mortality was zero. Overall, mortality during the follow-up was 7.4%. The SF-36 showed a significant decay in both the Physical (PCS) and Mental Component Summary (MCS) in comparison to the normal population (PCS: 41.1 vs. 48.4, p < 0.001; MCS: 42.1 vs. 50.9, p < 0.001) but without significant difference between both groups. Compared to the MI and CAD patients, significantly higher PCS but lower MCS scores were detected (p < 0.05); (4) Conclusions: Replacement of the ascending aorta shows low risk regarding the operative and postoperative outcomes with satisfying long-term results in the QoL. The extent of the surgical procedure does not influence the postoperative QoL.

Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors.Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgeries were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs.Cardiopulmonary bypass time and cross-clamp time were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.001 and p 0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.005, p = 0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.046). No significant differences in 30-day mortality (p = 1.000) and 1-year mortality (p = 0.543) were noted. Kaplan-Meier survival estimates were 96.3% in the right anterior mini-thoracotomy group and 92.7% in the partial upper sternotomy group after 4 years (log rank 0.169), respectively.Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons.

Background Transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy is possible with existence of substantial mitral valve disease. We present herein our experience of minimally invasive transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy in the past 4 years at our institution. Methods Between March 2017 and October 2020, 14 patients with hypertrophic obstructive cardiomyopathy and mitral valve disease required minimally invasive transmitral septal myectomy combined with mitral valve reconstruction or replacement at our institution. Mean age of patients was 54.2 ± 11.4 and 42.9% (n = 6) were female. Twelve patients (85.1%) were in New York Heart Association class III to IV and 6 patients (42.9%) presented with persistent atrial fibrillation. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 140.2 ± 32.6 minutes and the myocardial ischemic time was 78.5 ± 12.4 minutes. Thirty-day mortality and overall mortality were zero. Peak ventricular outflow gradient decreased from 75.2 ± 12.7 to 9.4 ± 2.3 mm Hg (p Conclusion Transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy can be performed safely with excellent surgical outcomes.

Introduction Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT. Methods Between April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm2, peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg. Conclusion Our preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

Objective Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years. Methods Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%). Conclusions Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.

We describe our modification of reconstruction of the aortic root, the left ventricular outflow tract, and the intervalvular fibrous body with neighboring structures after radical resection after extensive infective endocarditis. This technique may be useful for patients who otherwise would be nonoperable.

OBJECTIVES Extensive infective endocarditis (IE) stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyse our experience with our modified surgical technique for extensive IE during the last 4 years. METHODS Between March 2017 and February 2021, all patients with extensive IE required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study. RESULTS Our modified technique was performed on 41 patients during the study period. The age median was 74 [interquartile range (IQR): 66.5–76.5] and 61.0% (n = 25) were female. Thirty-three patients (80.5%) were in New York Heart Association Class III–IV and 7 patients (17.1%) in cardiogenic shock. The median logistic European system for cardiac operative risk evaluation II as predicted risk of mortality was 35% (IQR: 28–78%). The median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5–191) and 78 (IQR: 55.5–108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients) and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5–12) and 14 (IQR: 12.5–20.5) days, respectively. One-year mortality and 4-year mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan–Meier survival estimates were 60.3% (95% confidence interval: 46.2–78.6%) at 3 years. CONCLUSIONS Our modified technique can be performed in patients with extensive IE with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Die chirurgische Therapie der infektiosen Endokarditis stellt eine grose Herausforderung in der Herzchirurgie dar. Diese gestaltet sich noch um einiges schwieriger, wenn sich die Infektion bereits auf die Strukturen, die die Aortenklappen umgeben, wie beispielsweise die Aortenwurzel, die aortomitrale Kontinuitat, die Mitralklappe oder den linksventrikularen Ausflusstrakt, ausgedehnt hat. Die Rekonstruktion dieser Strukturen ist technisch sehr aufwendig und erfordert eine besondere chirurgische Expertise, allen voran in der Rekonstruktionschirurgie. Um die chirurgische Technik dieser komplexen pathologischen Storung zu optimieren, die peri- und postoperative Morbiditat und Mortalitat zu reduzieren sowie die Langzeituberlebensrate zu verbessern, wurde die chirurgische Rekonstruktionstechnik der Strukturen, die von einer ausgedehnten infektiosen Endokarditis betroffen sind, modifiziert. Diese Modifikation umfasst die Rekonstruktion der Aortenwurzel, der aortomitralen Kontinuitat, der Mitralklappe und des linksventrikularen Ausflusstrakts. Bei dieser entwickelten Technik wird die Aortenwurzel mithilfe einer Rohrprothese und einer Abwandlung des Ansatzes nach Cabrol rekonstruiert. Der linksventrikulare Ausflusstrakt wird mit der gleichen Rohrprothese, aber als „elephant trunk“ wiederhergestellt. Zur Rekonstruktion der aortomitralen Kontinuitat wird ein einzelnes Rinder-Patch verwendet; zudem werden die infizierten Klappen ersetzt.

OBJECTIVES Both surgical and percutaneous femoral accesses for the establishment of extracorporeal circulation are used in minimally invasive cardiac surgeries. The goal of this study was to compare the outcomes with the MANTA vascular closure device after percutaneous arterial decannulation via the surgical approach. METHODS Between November 2018 and January 2021, a total of 490 consecutive patients underwent minimally invasive cardiac operations at our institution. Cannulation and decannulation of femoral vessels were under direct vision surgically or percutaneously. The MANTA system was used to close the femoral artery in all patients with percutaneous cannulation. Demographic, clinical and procedural data were collected retrospectively. RESULTS Surgical cut-down and suture closure of the femoral artery was performed in 222 patients (45.3%); percutaneous access and closure with the MANTA system was used in 268 patients (54.7%). The surgical group presented a significantly higher incidence of any access site complication compared to the percutaneous group [18 patients (8.1%) vs 6 patients (2.2%); P = 0.003]. Lymph fistula and wound healing disorders occurred more frequently in the surgical group (3.2% vs 0% [P = 0.004] and 3.6% vs 0% [P = 0.002], respectively). Median procedural duration and stays in the intensive care unit were significantly lower in the percutaneous group {127 [interquartile range (IQR) 97–158] min vs 150 (IQR 117–185) min (P CONCLUSIONS Percutaneous access and closure with the MANTA system are feasible, safe and associated with lower incidences of all-cause access site complications and shorter stays in the intensive care unit compared to surgical access and closure in minimally invasive cardiac surgeries.

Objectives The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. Methods Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. Conclusions Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

Objective We report our experience with a staged hybrid approach for the treatment of extended aortic disease, also known as "mega aortic syndrome." Methods A total of 15 patients (10 male, 5 female) underwent staged repair of the thoracoabdominal aorta, consisting of 3 separate stages (repair of ascending aorta and aortic arch using the frozen elephant trunk technique and hybrid thoracoabdominal repair with debranching of the renovisceral branches and stent graft implantation). Results The procedure was completed in 14 patients. After the first stage (repair of ascending aorta and aortic arch), no mortality or spinal cord ischemia occurred. One patient required temporary dialysis. After the thoracoabdominal repair, permanent paraplegia developed in 1 patient. One patient died intraoperatively after aneurysm rupture. The in-hospital mortality for the complete repair reached 6.7%. None of the surviving patients required permanent dialysis. Interval aortic events consisted of 1 contained rupture. Conclusions The concept of a staged hybrid repair of the mega aortic syndrome is technically feasible. The frozen elephant trunk technique represents an attractive treatment option, offering an adequate landing zone for later thoracoabdominal repair in patients with extended aortic disease. For completion of the repair, a staged hybrid approach with renovisceral debranching and aneurysm exclusion using off-the-shelf stent grafts shows promising results with low surgical morbidity and mortality.

Background We analyzed our experience with the aortic arch operations performed through a minimally invasive approach, with emphasis on safety and feasibility, early and late outcomes. Material and methods We reviewed the medical records of 71 adult patients with aortic arch aneurysm (58, 82%), dissection (10, 14%) or porcelain aorta (3, 4%) who underwent primary arch surgery through a partial upper sternotomy. Results The aortic arch was replaced partially in 45 (63%), or totally in 26 (37%) patients. The repair was further extended with the elephant trunk procedure, conventional in 8 (11.3%) or frozen in 15 (21.1%) patients. No conversion to full sternotomy was needed. New permanent renal failure occurred in 1 (1.4%), temporary neurologic deficit in 2 (2.8%) and permanent neurologic deficit in 3 (4.2%) patients. Early mortality was observed in 4 (5.6%) patients. Actuarial survival was 79.2 ± 8.3% at 4 years and cumulative reoperation-free survival was 76.4 ± 9.4% at 4 years. Conclusion Minimally invasive aortic arch surgery is safe and feasible. Early outcomes are at the lower range compared to other published series. Late outcomes are not adversely influenced, as the desired extent of aortic resection can be achieved, producing a durable aortic repair.

Objectives Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of ≥ 60 minutes in moderate-to-mild hypothermia (≥ 28°C). Methods Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate-to-mild systemic hypothermia (≥ 28°C) with prolonged ACP and circulatory arrest times. Patients' mean age was 59 ± 15 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow-up was 6 ± 4 years and was 98% complete. Results Cardiopulmonary bypass time accounted for 245 ± 81 minutes and the myocardial ischemic time accounted for 140 ± 43 minutes. Mean duration of ACP was 74 ± 12 minutes. The mean lowest core temperature accounted for 28.9 ± 0.8°C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 ± 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients (n = 5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty-day mortality and in-hospital mortality were 8 (n = 5) and 11% (n = 7), respectively. Overall survival at 5 years was 76 ± 9%. Conclusion Our preliminary data suggest that selective ACP during moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) can safely be applied for more than 1 hour even in the setting of AAD.

Background Whether selective antegrade cerebral perfusion (ACP) during moderate-to-mild systemic hypothermia (≥28°C) is applicable to aortic arch surgery without restrictions including the emergency setting of an acute type A aortic dissection or extensive total arch procedures such as elephant and frozen elephant trunk techniques is an ongoing subject of controversy. Methods Between January 2000 and January 2015, 587 consecutive all-comers underwent aortic arch surgery at our institution uniformly applying selective ACP (unilateral: n = 393 [67%]; bilateral: n = 194 [33%]) during moderate-to-mild systemic hypothermia (28.7 ± 0.6°C). Patients' mean age was 68 ± 16 years, 405 patients (69%) were men, and 219 patients (37%) had acute type A aortic dissection. Hemiarch replacement was performed in 386 patients (66%) whereas the remaining 201 patients (34%) underwent total arch replacement including elephant trunk (n = 74 [13%]) and frozen elephant trunk (n = 37 [6%]) procedures. Fifty-six patients (10%) have had previous aortic arch surgery. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 183 ± 67 min and myocardial ischemic time reached 110 ± 45 min. Mean duration of selective ACP was 48 ± 21 (range, 12 to 135) min. Chest tube drainage during the first 24 h accounted for 597 ± 438 mL. Mean ventilation time was 31 ± 18 h. Reexploration for bleeding and postoperative renal replacement therapy was necessary in 74 patients (13%) and 49 patients (8%), respectively. Mean intensive care unit stay was 4 ± 5 days. We observed new postoperative permanent neurologic deficits in 34 patients (6%; stroke: n = 33 [6%]; paraplegia: n = 1 [0.17%]) and transient neurologic deficits in 29 patients (5%). Thirty-day mortality was 6% (n = 36). Conclusions Current data suggest that selective ACP in combination with moderate-to-mild systemic hypothermia offers sufficient neurologic and visceral organ protection to all-comers requiring aortic arch surgery without pathological or procedural limitations.

We describe herein the first experience with a surgical technique for aortic valve replacement using a video-assisted minimally invasive approach via a left anterior mini-thoracotomy in patient with dextrocardia and situs inversus totalis. This procedure was performed safely with good clinical and cosmetic results.

Objective Surgery for acute type A aortic dissection remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurological morbidity and mortality. The following study investigates the clinical results after surgical treatment for acute type A aortic dissection using selective antegrade cerebral perfusion and moderate-to-mild systemic hypothermia (≥28 °C). Methods Between January 2000 and January 2015, 453 consecutive patients underwent surgical treatment for acute type A aortic dissection at two aortic referral centres in Germany. Patient mean age was 67 ± 13 years, 298 patients (66%) were male. Selective unilateral or bilateral cerebral perfusion under moderate-to-mild systemic hypothermia was used in all patients. Ascending aortic replacement, hemiarch replacement and total arch replacement was performed in 9 patients (2%), 342 patients (75%) and 102 patients (23%), respectively. Clinical data were prospectively entered into the institutional databases. Mean late follow-up was 6 ± 3 years and was 98% complete. Results Cardiopulmonary bypass time totalled 181 ± 68 min and the myocardial ischaemic time 107 ± 43 min. Mean duration of selective antegrade cerebral was 46 ± 23 min. Mean lowest core temperature amounted to 28.8 ± 0.6 °C. Unilateral cerebral perfusion was performed in 298 patients (66%) and bilateral in 155 patients (34%). Mean intensive care unit stay was 5 ± 7 days. We observed new postoperative permanent neurological deficits in 27 patients (6%) and transient neurological deficits in 31 patients (7%). Thirty-day mortality was 7% (n = 32). Overall survival rate at 5 years was 77 ± 6%. Conclusions Our data suggest that selective antegrade cerebral perfusion in combination with moderate-to-mild systemic hypothermia (≥28 °C) can be safely and reproducibly applied to surgery for acute type A aortic dissection and offers sufficient neurological and visceral organ protection.

Objectives Classically, repair of extensive thoracic aortic pathologies including the aortic arch and descending aorta required two separate major surgical procedures via full sternotomy and a subsequent left lateral thoracotomy. We describe herein our preliminary institutional experience with minimally invasive single-stage extended thoracic aortic replacement employing the frozen elephant trunk (FET) technique via partial upper sternotomy (PUS) in 14 patients. Methods Between December 2013 and January 2015, 14 consecutive patients with elective indications for FET underwent minimally invasive FET via PUS (PUS-FET) during moderate systemic hypothermia (28°C) and selective antegrade cerebral perfusion (ACP) using the E-vita Open® hybrid prosthesis (Jotec GmbH, Hechingen, Germany). The patients' mean age was 66 ± 6 years, and 9 patients (64%) were male. The arch vessels were reimplanted en bloc in all patients. Clinical data were prospectively entered into our institutional database. Results The surgical procedure was successful in all patients with no need for conversion to full sternotomy. An additional David procedure was performed in 1 patient, whereas 2 patients received a concomitant Bentall procedure. There was no perioperative death or 30-day mortality. The mean cardiopulmonary bypass time was 214 ± 35 min, and the myocardial ischaemic time was 125 ± 14 min. The ACP time was 54 ± 9 min, whereas the ventilation time reached 11 ± 4 h. Intensive care unit stay was 2 ± 3 days. Chest tube drainage within the first 24 h was 460 ± 130 ml. None of the 14 patients required re-exploration for bleeding. Patients were discharged after a hospital length of stay of 9 ± 2 days. No postoperative permanent neurological complication occurred. Two patients (14%) experienced temporary delirium with complete resolution of symptoms prior to discharge from the hospital. Conclusions Our preliminary experience suggests that minimally invasive single-stage extended thoracic aortic replacement can safely and reproducibly be performed by employing the concept of PUS-FET.

A 19-year-old woman underwent ASD closure with patch in the childhood. Fifteen years later, she presented with severe cyanosis and dyspnea on exertion. Clinical diagnostics revealed a dislocation of the patch resulting in a right-to-left shunt (RLS) that was compensated in the past years by a recurrent ASD allowing a left-to-right shunt (LRS). The existing balance between interatrial shunts vanished by the growth of the patient leading to the clinical deterioration. After successful redo surgery, the patient was discharged home 8 days postoperatively.

Background Despite limited data, the necessity for immediate surgical intervention in octogenarians with acute type A aortic dissection (AAD) has recently been questioned because the surgical risk may outweigh its potential benefits. At the same time, evolving stent graft technologies are pushing in the market for pathology within the ascending aorta, even for treatment of AAD. Against this background, we analyzed our institutional experience in this patient cohort during the last 8 years. Methods Between October 2005 and October 2013, 39 patients aged older than 80 years (82 ± 2 years) underwent surgical repair for AAD, of which 29 patients (74%) were men. Owing to patient age and comorbidities, we aimed to limit the operation to supracoronary hemiarch replacement whenever possible. Clinical data were prospectively entered into our institutional database. Late follow-up was 3.6 ± 2.8 years and was 100% complete. Results Hemiarch replacement was performed in 32 patients (82%), and full arch replacement was necessary in the remaining 7. In 31 patients (79%), the aortic root could be glued and reconstructed or remained untouched. The remaining 8 patients (21%) underwent the bio-Bentall procedure. Mean ventilation time was 46 ± 23 hours, and the intensive care unit stay was 5 ± 9 days. We observed new postoperative permanent neurologic deficits in 2 patients (5%) and transient neurologic deficits in 3 (8%). The 30-day mortality was 26% (n = 10). Kaplan-Meier estimates for late survival were 46% ± 16% at 5 years. Conclusions Given the guidelines regarding the predicted risk of death in patients with untreated AAD, current data suggest a survival benefit with immediate open surgical intervention even in octogenarians. Similarly to the early days of transcatheter-based aortic valve implantation, open surgical reference data are warranted to set the bar for upcoming endovascular treatment of AAD in octogenarians.

Background The aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure. Methods Being one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge. Results Fast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89–6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99–7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27–6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28–7.46). Conclusions Fast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.

Objectives The use of selective antegrade cerebral perfusion (ACP) makes deep hypothermia nonessential for aortic arch replacement. Consequently, a growing tendency to increase the body temperature during circulatory arrest with ACP has recently been reported from various institutions. However, very little is known about the clinical effect of different modes of ACP (unilateral vs bilateral) on neurologic morbidity. Also, the safe limits of this approach for spinal chord and visceral organ protection are yet to be defined. Methods Between January 2000 and January 2011, 1002 consecutive patients underwent aortic arch repair during ACP (unilateral, 673; bilateral, 329) with mild systemic hypothermia (30°C ± 2°C; range, 26°-34°C) at 2 centers in Germany. The mean patient age was 62 ± 14 years, 663 patients (66%) were men, and 347 patients (35%) had acute type A dissection. Hemiarch replacement was performed in 684 patients (68%), and 318 (32%) underwent total arch replacement. Results The cardiopulmonary bypass time accounted for 158 ± 56 minutes and the myocardial ischemic time, 101 ± 41 minutes. Isolated ACP was performed for 36 ± 19 minutes (range, 9-135). We observed new postoperative permanent neurologic deficits in 28 patients (3%; stroke in 25 and paraplegia in 3) and transient neurologic deficits in 42 patients (4%). All 3 cases of paraplegia occurred in patients with acute type A dissection and a broad range of ACP times (24, 41, and 127 minutes). A trend was seen toward a reduced permanent neurologic deficit rate after unilateral ACP ( P = .06), but no difference was seen in the occurrence of transient neurologic deficits ( P = .6). Overall, the early mortality rate was 5% (n = 52). Temporary dialysis was necessary primarily after surgery in 38 patients (4%). When corrected for the unequal distribution of type A dissection, neurologic morbidity, early mortality, and the need for temporary dialysis were independent of the duration of ACP and were not affected by unilateral versus bilateral ACP. Conclusions Current data suggest that ACP and mild systemic hypothermic circulatory arrest can be safely applied to complex aortic arch surgery even in a subgroup of patients with up to 90 minutes of ACP. Unilateral ACP offers at least equal brain and visceral organ protection as bilateral ACP and might be advantageous in that it reduces the incidence of embolism arising from surgical manipulation on the arch vessels.

Echocardiographic measures of left ventricular (LV) dyssynchrony in pediatric patients with heart failure (HF) have not been adequately evaluated. The aim of this study was to evaluate LV systolic dyssynchrony in pediatric patients with HF and normal children.Among a total of 68 patients, 22 had HF and 46 were normal. Doppler tissue imaging, M-mode echocardiography, and pulsed-wave Doppler echocardiography were performed. Intraventricular dyssynchrony using the maximal difference in time to peak myocardial systolic contraction (Ts), the standard deviation of Ts of 12 LV segments, septal-to-posterior wall motion delay, and interventricular dyssynchrony by measuring aortic and pulmonary pre-ejection delays were obtained.The maximal difference in Ts (patients with HF, 91.27 ± 31.18 msec; controls, 45.93 ± 21.29 msec; P.001), the standard deviation of Ts (patients with HF, 31.05 ± 10.68 msec; controls, 15.60 ± 7.70 msec; P.001), septal-to-posterior wall motion delay (patients with HF, 117.14 ± 45.18 msec; controls, 48.69 ± 16.63 msec; P.001) and interventricular dyssynchrony (patients with HF, 21.60 ± 16.27 msec; controls, 11.56 ± 9.38 msec; P = .03) were significantly prolonged in the HF group. Defining systolic dyssynchrony as a standard deviation of Ts31 msec (+2 standard deviations of normal controls) and a maximal difference in Ts89 msec in normal controls and 18 patients with HF due to dilated cardiomyopathy was included for analysis of systolic dyssynchrony; it was present in three (6.5%) and two (4.3%) controls and in nine (50%) and 10 (55%) patients with HF due to dilated cardiomyopathy, respectively. Low ejection fraction, elevated LV end-diastolic volume, and elevated LV end-systolic volume had significant correlations with systolic dyssynchrony. QRS duration was not significantly correlated with measures of dyssynchrony.Systolic mechanical dyssynchrony is common in pediatric patients with HF. QRS duration is not a determinant of systolic dyssynchrony in pediatric patients. Echocardiographic measurements of systolic dyssynchrony are feasible in pediatric patients.

Aneurysms of the ascending aorta are an outstanding challenge to clinicians as they may persist asymptomatic until they present with dissection or rupture. Intensive research is performed to reveal the molecular mechanisms causing aneurysm formation. Calpains are ubiquitous non-lysosomal cysteine proteases which are classically activated by calcium signaling. The two major forms of the calpain-family are calpain-I and calpain-II. Calpastatin specifically inhibits the proteolytic activity of calpain-I and -II. Recently it has been demonstrated in aneurysm tissues from ascending aortas obtained from Marfan syndrome patients that calpain-II expression is increased and calpastatin expression is decreased. Thus, we were interested in the probable role of calpains in aneurysms of ascending aorta in non-Marfan patients. Therefore, ascending aortic samples of dilated and non-dilated aortas were analyzed according to their calpain-I, -II and calpastatin content as well as the expression levels of MMPs and elastin as well as the infiltration of inflammatory cells. We have found significant differences in calpain-I and calpastatin protein expression and serum levels in patients with aneurysm of the ascending aorta. Furthermore, MMP-1 and MMP-3 expression levels correlate with calpain-I protein levels. Due to our findings we conclude that calpain-1 seems to be related to fibrotic alteration in aortic aneurysm tissue in our experimental group. The change in calpain-1 modulates the structure of aortic tissue causing alteration in elastin structure, thus enabling macrophage infiltration and elevation of MMP levels. Circulating levels of calpain-1 may be used as a prognostic marker in the future if further correlation analyses are done.

Aortic pseudoaneurysms have the potential for eroding bony structures in the chest, including the sternum, over time. Here, we report the case of a 54-year old woman with a giant pseudoaneurysm of the ascending aorta, 19 years after aortic root (mechanical conduit) and hemiarch replacement. The patient presented to her primary-care physician with a pulsatile presternal subcutaneous protrusion in the midline of her median sternotomy scar. We performed a challenging midline resternotomy after the establishment of a surgical safety net for cerebral and visceral organ protection followed by a supracoronary ascending and hemiarch replacement including a reinsertion of the coronary ostia employing selective antegrade cerebral perfusion and mild systemic hypothermic circulatory arrest. We discuss here the specific surgical considerations of this case.

Introduction: World Health Organization announced on April 2009 a public health emergency of international concern caused by swine-origin influenza A (H1N1) virus. Acute respiratory distress syndrome (ARDS) has been reported to be the most devastating complications of this pathogen. Extracorporeal membrane oxygenator (ECMO) therapy for patients with H1N1 related ARDS has been described once all other therapeutic options have been exhausted. Here, we report the case of a child (German, male) with H1N1-associated fulminate respiratory and secondary hemodynamic deterioration who was rescued by initial emergent ECMO established through a dialysis catheter and subsequent switch to central cannulation following median sternotomy. This report highlights several important issues. First, it describes a successful use of a dialysis catheter for the establishment of a veno-venous ECMO in an emergency case by child. Second, it highlights the importance of a closely monitoring of clotting parameters during ECMO therapy and third, if severe respiratory failure is complicated by cardiogenic shock, veno-atrial ECMO support via median sternotomy should be considered as a viable treatment option without further delay.

Objectives Antegrade cerebral perfusion during mild systemic hypothermia has been successfully used in aortic arch surgery. Whether bilateral antegrade cerebral perfusion is more neuroprotective then unilateral antegrade cerebral perfusion has been the subject of much debate. Methods Between 2000 and 2012, 1097 patients underwent aortic arch replacement using 28°C to 30°C antegrade cerebral perfusion perfusate during mild systemic hypothermia in a pressure-controlled manner (≥70 mm Hg). After excluding acute type A dissections, 738 elective surgeries with unilateral (n = 477) or bilateral (n = 261) antegrade cerebral perfusion underwent logistic regression analysis with covariates among 9 patient variables (age, coronary disease, diabetes, renal failure, stroke, antegrade cerebral perfusion time, partial vs total arch replacement, aortic valve replacement, and cardiopulmonary bypass time). By using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 246 patients each. Operative outcomes were analyzed for differences. Results There was no significant difference between unilateral and bilateral antegrade cerebral perfusion groups in early mortality (9/246:4% vs 11/246:4%; P = .8) and transient neurologic deficits (12/246:5% vs 10/246:4%; P = .8). A trend toward a higher incidence of stroke with bilateral antegrade cerebral perfusion (5/246:2% vs 14/246:6%; P = .06) was observed. Similar results regarding transient neurologic deficits (6/91:7% vs 5/93:5%; P = .7) and the incidence of stroke (2/91:3% vs 9/93:9%; P = .06) were observed in matched patients with total arch replacement only. Conclusions Using unilateral antegrade cerebral perfusion in a pressure-controlled manner during mild systemic hypothermia is a safe protection strategy in elective aortic arch surgery, associated with similar morbidity and mortality in comparison with bilateral antegrade cerebral perfusion, even if total arch replacement is required. Bilateral antegrade cerebral perfusion reveals a trend of higher incidence of stroke, probably due to manipulation on the arch vessels.

The right axillary artery has become the cannulation site of choice for establishment of extracorporeal membrane oxygenator support in many centers. Dissection and cannulation of this vessel are simple and safe in the majority of patients. Typically, a side graft is used to avoid malperfusion of the right arm. Although this protocol offers many advantages, a common complication is the critical hyperperfusion of the right arm. Subsequent compartment syndrome and decline of antegrade inflow of oxygenated blood, especially into the brain and coronary arteries, can be life threatening in such critical patients. We describe herein a simple yet effective and controlled technique to avoid this particular problem.

Background and aims: External support of vein grafts by fibrin glue possibly prevents overdistension, vascular remodeling, and neointimal hyperplasia. Previous animal models of neointimal hyperplasia showed conflicting results. Here, long-term effects of external fibrin glue support were studied in a new rat model of jugular vein to abdominal aorta transposition. Materials and methods and methods: In male Wistar rats (250300 g) right jugular vein (1.01.5 cm) was transposed to the infrarenal aorta. Fibrin glue (0.25 ml) covered the vein before releasing the vascular clamps (n=6). Control vein grafts were exposed directly to blood pressure. After 16 weeks vein grafts were pressure-fixed for histology. Intima thickness, luminal and intimal area were measured by planimetry and elastic fibers demonstrated by Elastica van Giesson staining. Results: Intimal thickness (74.04 ± 6.7 µm vs 1245 ± 187 µm, control vs fibrin treatment; p

Purpose. Recent studies have demonstrated that ventricular rate control is a viable treatment strategy for patients in atrial fibrillation (AF). The purpose of this study was to determine whether or not the benefits of coupled pacing (ie, a proposed rate control therapy) could be used during persistent AF. Description. Six mongrel dogs were chronically implanted with endocardial atrial and ventricular pacemaker leads and two standard dual-chamber pacemakers. With the use of two custom “Y”-lead adapters, the pacemakers were used to induce AF and to apply coupled pacing. Left ventricular end-diastolic and systolic volumes were measured by echocardiography to determine ejection fractions. Evaluation. Persistent AF significantly increased both ventricular rate and left ventricular dimensions. After sustained coupled pacing had been applied for 3 to 4 weeks, left ventricular volumes and contractile rate were significantly reduced and returned toward the values measured prior to the induction of persistent AF. Coupled pacing increased the ejection fraction that had been reduced by persistent AF. Conclusions. Coupled pacing reversed the left ventricular remodeling caused by the tachycardia resulting from AF.

Heart failure patients who are candidates for CRT frequently display longitudinal rotation (LR) - a swinging motion of the heart when imaged in a horizontal long-axis plane.To identify the magnitude and predictors of LR in patients with ischaemic (ICM) and idiopathic dilated (DCM) cardiomyopathy, and to assess predictive value of LR in patients undergoing cardiac resynchronisation therapy (CRT).A retrospective study in a tertiary heart care setting.Echocardiography was performed in 45 ICM and 41 DCM patients who were CRT candidates and 16 control subjects. Global LR, segmental strains and segmental LR were assessed from echocardiograms using speckle tracking. Repeat echocardiography40 days after the beginning of CRT was performed in 64 patients.While DCM patients with QRS duration of both130 ms andor =130 ms displayed significant clockwise LR (p0.001 for both vs 0), ICM patients and control subjects had LR that did not differ from 0. The most significant LR predictor was end-diastolic volume (p0.001) followed by the absence of ischaemia (p0.001) and QRS duration (p = 0.05). DCM patients with prominent clockwise LR had lower septal but higher lateral strains than DCM patients with minimal LR, or ICM patients with counterclockwise LR. LR correlated with decrease of end-systolic volume in DCM (r = 0.49, p = 0.004), while no relationship was observed in ICM.Clockwise LR is linked to presence of DCM, with the small impact of QRS duration. LR is a moderately strong predictor of end-systolic volume decrease during CRT in DCM.