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Die Therapie der Wahl fur die funktionelle hochgradige Trikuspidalklappeninsuffizienz (TI) ist die Klappenrekonstruktion. Die konventionelle Herzklappenoperation einer schweren TI ist mit einer hohen Krankenhaussterblichkeit verbunden. Bisher publizierte minimalinvasive Ansatze zur TI-Therapie weisen eine Reihe von Limitationen auf. Ziel der vorgestellten Arbeit ist die Entwicklung einer katheterbasierten minimalinvasiven Methode zur Therapie einer schweren TI. Im Tiermodell am Schaf (n = 7) konnten im Akutversuch Effektivitat und Machbarkeit der neuen Transkatheter-Trikuspidalklappen-Implantation (TTVI) mit einer klappentragenden Gefasprothese demonstriert werden. Diese Implantationstechnik zeigte sich effektiv und technisch machbar. Als Nachstes wird ein Langzeitversuch notwendig, um die Sicherheit und die hamodynamischen Vorteile der TTVI zu uberprufen.

There are many complex cardiac malformations that are characterized by a functionally univentricular physiology. Staged surgical repair according to the Fontan principle separates the systemic and pulmonary circulations by connecting the systemic venous return to the pulmonary arteries. However, long-term follow-up studies demonstrate a gradual deterioration of cardiac function, particularly from the second or third decade. Noninvasive evaluation of the cardiac function is, therefore, important in the follow-up of these patients. The cardiac index (CI) is a reliable hemodynamic parameter and represents an important marker of cardiac function. We compared CI values determined by cardiac MRI (CMRI) with values obtained by noninvasive inert gas rebreathing (IGR; Innocor® system). Sixteen patients (age range: 7.2–32.7 years) with functionally univentricular hearts (UVH) following total cavopulmonary connection (TCPC) were compared with 12 healthy subjects (age range: 8.5–18.6 years). The standard treadmill protocol of the German Society of Pediatric Cardiology was used for exercise testing. CI was determined at rest and at two standardized submaximal exercise levels. In all subjects, CI increased under exercise conditions, but the values were significantly lower in patients with UVH. There was no significant difference between patients with UVH and predominantly right- or left-ventricular morphology. In comparison with CMRI measurements, the CI values obtained by the IGR method tended to be lower, with a mean difference of 1.02 l/min/m2. Noninvasive measurement of CI with the IGR method is feasible at rest and during exercise, and appears to be suited for routine determination of CI in patients with UVH following TCPC.

Background To analyze the effects of residual mitral regurgitation (MR) and mean mitral valve pressure gradient (MVPG) after percutaneous edge-to-edge mitral valve repair (PMVR) using the MitraClip-system on long term outcome. Methods and results Two hundred fifty-five patients who underwent PMVR were analyzed. Kaplan-Meier and Cox regression analyses were performed to evaluate the impact of residual MR and MVPG on clinical outcome. A combined clinical endpoint (all-cause mortality, MV surgery, redo procedure, implantation of a left ventricular assist device) was used. After PMVR, mean MVPG increased from 1.6±1.0 mmHg to 3.1±1.5 mmHg (p4.4 mmHg was not according to Kaplan-Meier and Cox regression analyses. We then analyzed the cohort with degenerative and that with functional MR separately to account for these different entities.In the cohort with degenerative MR, elevated MVPG was associated with increased occurrence of the primary endpoint, whereas this was not observed in the cohort with functional MR. Conclusions MVPG >4.4 mmHg after MitraClip-implantation was predictive for clinical outcome in the patient cohort with degenerative MR. In the patient cohort with functional MR, MVPG >4.4 mmHg was not associated with increased clinical events. Acknowledgement/Funding This study was supported by grants from the German Research Foundation (KFO 274), the Volkswagen Foundation (Lichtenberg Program) and the German Heart

Seit einigen Jahren ist ein stetig ansteigender Einsatz von mechanischen extrakorporalen Herz-Kreislauf- und Lungenunterstutzungssystemen (ECLS/ECMO) zu verzeichnen. So wurden im Jahr 2015 in Deutschland bei mehr als 2800 Patienten ECLS/ECMO-Systeme implantiert. Trotz dieser haufigen Anwendung der Systeme existieren zurzeit national und international nur Leitlinien, in denen zu unterschiedlichen Erkrankungen der Einsatz der ECMO/ECLS nur einen Teilaspekt komplexer Therapiekaskaden darstellt. Vor diesem Hintergrund erscheint es notwendig, evidenzbasierte Empfehlungen zum komplexen Management von Patienten, die eine ECLS/ECMO-Therapie benotigen und erhalten, zu verfassen, in denen personelle, prozessuale und infrastrukturelle Anforderungen definiert werden.

Der kardiopulmonale Bypass („cardiopulmonary bypass“, CPB) kann erhebliche pulmonale und extrapulmonale inflammatorische Vorgange auslosen, die sowohl zu Beeintrachtigungen der Lungenfunktion, als auch zu Storungen anderer Organe wie Niere und Leber fuhren konnen. Wir konnten im Tiermodell am Schwein zeigen, dass sowohl eine Normalisierung der Lungenperfusion wahrend der extrakorporalen Zirkulation (EKZ), als auch eine pulmonale Prakonditionierung mit inhalativem Kohlenmonoxid (250 ppm) die durch den CPB induzierte Lungenschadigung reduzieren kann. Ein moglicher Mechanismus der durch Kohlenmonoxid vermittelten Reduktion der Inflammation und des Lungenschadens ist daruber hinaus eine Induktion der Hitzeschockantwort. Hierdurch kann auch die CPB-bedingte Beeintrachtigung extrapulmonaler Organe reduziert werden. Die durch den CPB induzierte Inflammation und der damit verbundene Gewebeschaden sind durch eine Lungenminderperfusion und die folgende Reperfusion bedingt. Dies kann sowohl durch eine aktive pulmonale Perfusion als auch durch die Inhalation von Kohlenmonoxid vermindert werden. Eine Kombination von aktiver Lungenperfusion und inhaliertem Kohlenmonoxid kann den pulmonalen Schaden zusatzlich verringern.

Out-of-hospital sudden cardiac death is a frequent cause of death in industrialized countries. In Germany prehospital cardiac arrest occurs in 80–100 of 100 000 inhabitants per year. Common causes of ventricular tachycardia and fibrillation are structural heart disease like coronary heart disease. In a population of younger people these include certain forms of cardiomyopathies, fulminant myocarditis or disturbances of cardiac impulse generation and conduction. Assist devices are used for bridge to transplant or bridge to recovery. Reports of patients with functional cardiac arrest through recurrent refractory ventricular fibrillation without initial reduction of left ventricular function are rare. We report a case of a 25 year old male with recurrent ventricular fibrillation followed by ultimo ratio implantation of a biventricular assist device to maintain circulation.

The objective was to identify abdominal lymphatic malformations in pediatric patients with protein-losing enteropathy after palliation of complex congenital heart disease with total cavo-pulmonary connection (TCPC). In 2006, we performed complete hemodynamic and laboratory workup and thoracic and abdominal MRT screens in three patients who newly presented with symptoms of protein-losing enteropathy. All three patients, aged 3, 5, and 7 years, showed excellent TCPC hemodynamics with central venous pressures of 10-13 mm Hg. None of the patients had right-to-left overflow. All three patients showed extensive thoracic and mesenterial lymphangiomatosis. One patient died after 18 months of therapy, which included long-term parenteral nutrition, somatostatin, subcutaneous heparin injections, and frequent albumin and immunoglobulin substitution. The other two patients are in stable condition. Lymphangiomatosis might play an unknown role in the pathogenesis of protein-losing enteropathy after TCPC. It remains unclear whether lymphangiomatosis is a primary congenital disease related to the cardiac disease or if it is triggered by repeated surgery or venous congestion. The presence of lymphangiomatosis should be given diagnostic and therapeutic consideration in TCPC patients in the future.

Background: Inefficiently cleaned surgical instruments may cause the transfer of infections. The control of the efficieny of medical cleaning of reusable instruments is a challenge in every medical facility. Various control-methods have been developed over time. Here we present the use of the Polymerase Chain Reaction (PCR) to evaluate the success of cleaning efforts of surgical instruments. Methods: Stainless steel surgical instruments were “contaminated” with defined synthetic Single-Stranded DNA (ssDNA) – containing solutions. After undergoing the cleaning process rests of the ssDNA were washed out of the instruments using solutions that do not interfere with the effectiveness of the polymerase. The residual ssDNA- amount in these eluates was detected using real-time PCR. Results: Through the use of sequence specific ssDNA samples and real-time PCR we were able to detect and quantify the residual DNA amount on the instruments. Since we used defined ssDNA- specific primers we could avoid the amplification of possible residual genomic DNA on the instruments e.g. through pollution with patient-DNA material. As our defined ssDNA cannot be found in nature we could thus achieve a ultra high sensitivity in our testing method. Discussion: Quantitative PCR methods are a common technique to both detect and quantify DNA samples. Here we used this method in order to detect ssDNA samples on surgical instruments after medical cleaning. This control method appears to be highly sensitive as well as specific and should be considered a valuable instrument to evaluate cleaning methods of reusable instruments in order to reduce undesirable infections.

Objectives: To assess the impact of balanced ultrafiltration and peritoneal dialysis (PD) on plasma and urinary cytokines and renal dysfunction after cardiopulmonary bypass (CPB) surgery in newborns and infants. Methods: Twenty-three newborns and infants weighing less than 7 kg and scheduled for operation on congenital malformation were enrolled in this descriptive open clinical study. All patients received conventional ultrafiltration in the CPB rewarming period. Eleven newborns underwent Tenckhoff-catheter implantation in the operation theatre as a routine institutional procedure and received PD after admission to the ICU (the PD [+] group). No PD was used in another 12 patients (the PD [- ] group). Interleukins (IL) 6 and 8 were measured four times pre- and post-operatively. Kidney function was assessed by creatinine clearances and urine protein and enzyme analyses. Results: All patients had an uneventful clinical course. Age (10 ± 2 days, PD [+] vs. 96 ± 19 days, PD [-]), CPB duration (215 ± 23 vs. 143 ± 20 min), and degree of hypothermia (26 ± 1.3 vs. 31 ± 0.1 °C) differed significantly between the groups. Age, CPB duration and ultrafiltration influenced post-operative IL-levels in an analysis of variance. While there were few differences immediately after the end of ultrafiltration, post-operative levels of IL-6 and IL-8 were higher and more sustained in the newborns (PD [+]) than in the older infants (PD [- ]). The median amount of IL-6 and IL-8 removed by ultrafiltration came to 28 and 59% compared to the amount of IL-6 and IL-8 remaining in the blood at the end of CPB. IL-clearance by ultrafiltration was more than 1000-fold and by PD more than 100-fold as effective as IL-clearance by the kidney. While the kidneys showed an unselective mixed glomerular and tubular pattern of injury, during CPB higher serum IL-concentrations correlated with lower urinary IL-clearances in both study groups. Conclusions: Ultrafiltration and PD are highly effective in removing proinflammatory cytokines. Impaired kidney function was associated with proinflammatory IL-serum concentrations. Thus, we raise the hypothesis that glomerular-filtered proinflammatory ILs damage the proximal tubular cells of the kidney in newborns and infants, thus contributing to post-operative renal dysfunction. Conversely, we conclude that removing proinflammatory ILs by ultrafiltration and PD acts renoprotectively. A future prospective randomised study could demonstrate whether this can indeed improve clinical outcome.

Objective: To study the regional and directional compliance of the healthy aorta in the porcine model and to develop a model of the pathophysiology of aortic dissection. Methods: We developed a custom made pulse duplicator capable perfusing complete aortas ex vivo. Fresh porcine aortas (n = 13) were perfused with defined hemodynamic parameters, aortic compliance was measured optically. Additionally tissue strips of aortas were analyzed in a static tensile tester. Regional (ascendens, arch, descendens) and directional (transversal, longitudinal) compliance is studied under dynamic and static conditions. Results: The custom made pulse duplicator is capable perfusing the entire aorta with eligible hemodynamic parameters (pressures, resistance and frequencies) and a physiologic pulse curve (30% systole and 70% diastole). Aortic compliance is pressure and stress dependent, under hypertensive conditions, above 200 mm Hg the porcine aorta acts inelastic. Compliance of aortic tissue is highest in the ascending aorta and significantly decreases in the course of the vessel. The longitudinal compliance in the ascending aorta significantly exceeds the circumferential compliance, in the descending aorta there are no relevant differences in directional compliance. Under dynamic conditions, the compliance of the outer curvature in the ascending aorta significantly exceeds the compliance of the inner curvature. However, under static conditions, this effect is not verifiable. Conclusion: The new custom made pulse duplicator allows studying entire aortas under dynamic and preferably realistic conditions ex vivo. Though dynamic compliance data are largely comparable to data generated using the classic method of static tensile testing, we also find some relevant differences between the methods, particularly regarding the regional compliance of the inner- and outer curvatures of the ascending aorta. The longitudinal compliance of the ascending aorta and especially of the outer curvature is predominantly responsible for the Windkessel effect. The three dimensional configuration of the ascending aorta, its punctual fixation on the root and the supraaortic branches and its movement during the cardiac cycle determines regionally different mechanical stress and consecutive deformation of the aortic wall. Elongation and pronounced angulation of the ascending aorta may increase the stress on the outer curvature and might be important factors in the development of aortic dissection.