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Die Aortenklappenimplantation mithilfe der kathetergestutzten „Valve-in-valve“-Technik (TAViVI) ist eine Therapieoption fur Patienten mit degenerierten chirurgischen Bioprothesen („surgical aortic valve bioprostheses“, SAVB) und hohem Operationsrisiko. Die hamodynamischen Ergebnisse sind exzellent, allerdings gibt es Bedenken hinsichtlich Koronarobstruktionen, v. a. bei SAVB mit ausen liegendem Perikard, wie beispielsweise der Trifecta (Fa. St. Jude Medical Inc., St. Paul, USA). In vitro wurden Koronarfluss sowie Hydrodynamik vor und nach TAViVI, mit einer kleineren Transkatheterklappe („transcatheter heart valve“ [THV]; Sapien XT; Fa. Edwards Lifesciences LLC, Irvine, USA) als empfohlen, in SAVB mit ausen liegendem Perikard (Trifecta) bestimmt. Die Konstruktion von Aortenwurzelmodellen orientierte sich an bekannten Risikofaktoren. Zur Validierung der Modelle wurde TAViVI nach aktuellen Empfehlungen durchgefuhrt (26-mm-Sapien XT in 25-mm-Trifecta). Im Anschluss erfolgte die Implantation einer kleineren Sapien XT (23 mm). Hydrodynamik und Koronarfluss (links-/rechtskoronarer Fluss [lCF/rCF]) wurden vor und nach TAViVI sowie bei unterschiedlicher Koronarostienhohe (COH, 8 und 10 mm) in einem Pulsduplikator bestimmt. Die Validierung des Modells zeigte eine Koronarobstruktion (p < 0,001). Bei Verwendung einer kleineren THV trat keine signifikante Koronarobstruktion auf (lCF: COH 8 mm, 0,90–0,87 ml/Schlag; COH 10 mm, 0,89–0,82 ml/Schlag; rCF: COH 8 mm, 0,64–0,60 ml/Schlag; COH 10 mm, 0,62–0,58 ml/Schlag). Der mittlere Druckgradient stieg nach TAViVI signifikant an (4–5 mm Hg, p < 0,001). In diesem In-vitro-Modell konnte eine Koronarobstruktion nach TAViVI, die in eine moderne SAVB erfolgte, durch die Verwendung einer kleineren THV vermieden werden.

Importance: There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. Objective: To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. Design, Setting, and Participants: A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Main Outcomes and Measures: Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. Results: During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Conclusions and Relevance: Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure..

Background: The purpose of this study was to evaluate the single-center experience in initial femoral versus central cannulation of the extracorporeal circulation for acute aortic dissection type A (AADA). Methods: Between January 2003 and December 2015, 235 patients underwent repair of AADA. All patients were evaluated for the type of arterial cannulation (femoral vs . central) for initial bypass. Demographic data and outcome parameters were accessed. Results: One hundred and twenty seven (54.0%) were initially cannulated in the central aortic vessels (ascending aorta or subclavian/axillary artery) and 108 (46.0%) in the femoral artery. Patients were comparable between age (62.4±14.4 vs . 62.9±14.4 years, P=0.805), gender (male, 62.2 vs . 69.4%, P=0.152) and previous sternotomy (15.7 vs . 16.7%, P=0.861) between both cannulation groups; while EuroSCORE I (11.5±4.0 vs . 12.7±4.2, P=0.031) and ASA Score (3.5±0.81 vs . 3.8±0.57, P=0.011) were significantly higher in the femoral artery cannulation group. Bypass (249±102 vs . 240±81 min, P=0.474), X-clamp (166±85 vs . 157±67 min, P=0.418) and circulatory arrest time (51.6±28.7 vs . 48.3±21.7 min, P=0.365) were similar between the groups as were lowest temperature (18.1±2.0 vs . 18.1±2.2, P=0.775). Postoperative neurologic deficit and 30-day mortality were comparable between both cannulation groups (11.7 vs . 7.2%, P=0.449 and 20.2 vs . 16.9%, P=0.699, central vs . peripheral cannulation). Multivariate analysis revealed only EuroScore I above 13 as single preoperative predictor for mortality. Conclusions: AADA can be operated with both femoral and central cannulation with similar results. Risk for early mortality was driven by the preoperative clinical and hemodynamic status before operation rather than the cannulation technique.

OBJECTIVES: Since blood flow impairment by aortic valve prosthesis is characteristically dynamic, this dynamic component is best and thoroughly appreciated by exercise Doppler echocardiography. We sought to determine the haemodynamics of a new pericardial aortic bioprosthesis [Trifecta™-aortic valve bioprosthesis (T-AVB), St Jude Medical, MN, USA] at rest and during exercise and a 10-min recovery period in comparison with alternative aortic valve prostheses, e.g. Ross operation (RO), stentless aortic valve [Medtronic freestyle-aortic valve bioprosthesis (MF-AVB)] and a healthy control group (CO). METHODS: Haemodynamics at rest and during supine exercise stress testing and a 10-min recovery period were evaluated in 32 patients (mean age: 70.8±6.7 years) with T-AVB (mean follow-up: 5±2 months), 49 with RO (mean age: 43.5±13.7 years), 39 with an MF-AVB (mean age: 64.6±9.4 years) and 26 healthy patients (mean age: 39±9 years). Measurements included mean outflow tract gradient (δp mean, mmHg), effective orifice area index (EOAI, cm 2 /m 2 ) and valvular resistance (vR, dyn s cm −5 ). RESULTS: Mean body surface area for T-AVB was 1.93±0.24 m 2 (median 1.97 m 2 ). Mean δp mean at rest was 7.2±3.4 mmHg, mean EOAI 0.86±0.23 cm 2 /m 2 and mean vR 50.7±23.2 dyn s cm −5 . Supine stress testing did increase the mean EOAI to 0.98±0.27 cm 2 /m 2 ,t he mean vR to 62.6±25.3 dyn s cm −5 and the mean δp mean to 10.21±4.7 mmHg, respectively (P

Background: The Ross operation provides the advantage of growth potential of the pulmonary autograft in the aortic position. However, development of autograft dilatation and regurgitation may occur. We sought to assess the progression of autograft diameters and aortic regurgitation (AR) with regard to patient age at the time of the Ross operation. Methods: Autograft echo dimensions from 48 children Results: The mean z values of all patients showed a significant increase with follow-up time at the sinus (0.5 ± 0.1/year, P < .001) and the sinotubular junction (0.7 ± 0.2/year, P < .001) but not at the annulus (0.1 ± 0.1/year, P = .59). There was no significant difference in the z values of sinus and the sinotubular junction between younger and older children at implantation and with time. The initial annulus z value was significantly larger in younger children ( P < .0001), whereas the annual increase was significantly higher in older children ( P = .021). Age at operation has no impact on the initial AR grade ( P = .60). The AR tends to increase more quickly in older patients ( P = .040). Sinus and sinotubular junction dilate with time, regardless of patient age. Conclusions: Young children show larger initial annulus sizes than older children. However, annulus diameters tend to normalize in young children, whereas they increase in older children. Autograft regurgitation develops slowly, but significantly, and predominantly in older children. Stabilizing measures to prevent autograft root dilatation are warranted in adolescents, but they are not required in young children.

Left ventricular assist device implantation disrupts the natural intracavitary blood flow path through the heart, introducing flow patterns potentially associated with thrombosis, especially around the inflow cannula. We describe a novel technique for completely excluding the left ventricle with an assist device by using a cone shaped ring-reinforced prosthesis.

Dilatation of the ascending aorta is a common occurrence in patients with bicuspid aortic valve (BAV). The aim of the current study was to characterize collagen content in advanced glycation end products (AGEs) of dilated aortic tissue from two distinct areas, concave and convex aortic sites in patients with BAV and TAV. Collagen contents extracted from 100 mg tissue was isolated by enzymatic digestion using pepsin and the nondigested material was further digested using cyanogen bromide, insoluble collagen fraction (ICF) was extracted by hydrochloric acid hydrolysis. BAV tissue showed diminished fluorescence of the pepsin extracted fraction (PEF) compared with TAV tissue (12.4 ± 1.0% vs 32.9 ± 7.6%, p = 0.05). Patients with BAV had PEF of collagens significantly diminished in the dilated ascending aorta, especially in its convex portion, in course of aging and increment of dilated diameters. It is suggestible that BAV patients present more highly AGE-modified collagens in their ascending aorta.

Im Jahr 2010 hat eine interdisziplinare Arbeitsgruppe mit Vertretern der Europaischen Gesellschaft fur Kardiologie (ESC) sowie der Assoziation Europaischer Herz-Thorax-Chirurgen (EACTS) eine gemeinsame Leitlinie zur koronaren Revaskularisation erstellt. Das Heart Team soll uber eine konsensuelle Entscheidungsfindung im lokalen Kontext die entscheidende Rolle in der praktischen Umsetzung dieser Leitlinie einnehmen.

OBJECTIVES: The Ross operation in the setting of a bicuspid aortic valve (BAV) remains controversial. Using data from the German Ross Registry, we sought to investigate the effect of the presence of a BAV on autograft function and diameters over time after the Ross operation compared with the presence of a tricuspid aortic valve (TAV). METHODS: A total of 1277 patients (mean age 42.2 + or - 15.3 years) with intra-operatively documented aortic valve morphology during the Ross operation were analysed in the present study (sub-coronary technique, n=648, root replacement technique, n=629 patients). A BAV was present in 70.9% of patients. Clinical and echocardiographic follow-up was performed preoperatively and at pre-specified intervals (mean follow-up 5.7 + or - 3.8 years, 6806 patient-years). Hierarchical multilevel modelling techniques were used for the statistical analysis of serial measurements and comparisons among groups. RESULTS: Initial neo-aortic regurgitation was lower in the BAV group (0.52 vs 0.62 aortic insufficiency (AI) grades, p=0.008), whereas the annual increase of it did not differ among groups. In both surgical techniques, no significant development of neo-aortic regurgitation (

Apoptosis of vascular smooth muscle cells (VSMCs) is involved in bicuspid aortic valve (BAV) ascending aorta aneurysms characteristically affecting the convex site. Caspase-3 is a pivotal effector of the apoptosis machinery. The aim of this study was to investigate the impact of an inhibited caspase-3 pathway on apoptosis in convex and concave sites VSMCs of ascending aortic tissue in vitro. Specimens from the convex and concave sites of ascending aortic aneurysm were collected from nine patients with BAV (mean age 58.7+/-14.8). Cultured VSMCs were characterized morphologically and immunohistochemically. Apoptosis activity was measured in VSMCs using Annexin V-APC with propidium iodide nuclear staining in flow cytometry. To investigate apoptotic modulation, caspase-3 was inhibited by N-acetyl-Asp-Glu-Val-Asp-CHO (Ac-DEVD-CHO). Apoptosis was initiated by calcium chloride. Inhibition of caspase-3 with Ac-DEVD-CHO protected VSMCs against calcium chloride apoptosis significantly more in the concave site than in the convex site (25.8+/-9.8 versus 38.5+/-8.0% apoptotic cells, p=0.01). Morphological scanning using light microscopy revealed typical VSMCs. We provide evidence that VSMCs show a different behavior with respect to apoptosis in the concave versus the convex sites in BAV ascending aortic aneurysm. Inhibition of caspase-3 resulted in a significantly increased protection of VSMCs against apoptosis in the concave site compared with the convex site in ascending aortic aneurysm in BAV. These findings may have some implications on understanding aneurysmal formation and its potential modulation.

Objective: The use of stentless bioprostheses for aortic valve replacement provides excellent haemodynamics; however, these valves bear the potential risk of progressive regurgitation over time. To overcome this disadvantage, a new generation of pericardial stentless prostheses has been developed. This study aims to assess the tolerance of such bioprotheses against progressive sinotubular junction dilatation. Methods: Five specimens of both the 3F Aortic and Sorin Solo stentless bioprotheses (diameter 25 mm) were investigated in a pulsatile flow simulator incorporating a device for gradual expansion of the sinotubular junction diameter. Closing characteristics were obtained by high-speed video imaging and the corresponding regurgitations were determined by ultrasonic flow measurements. The diameters DR, at which primary distinct regurgitation occurs, were correlated to the original diameters DA and expressed as percentage values. Results: The highest tolerance against sinotubular junction dilatation was found for the 3F Aortic (156 5%) compared to the Sorin Solo (145 6%, p = 0.0127) bioprothesis. Visualisation of the valves revealed strong leaflet folding at labelled diameter, similar in both valve types. Conclusions: New-generation pericardial stentless bioprotheses provide favourable adaptability to sinotubular junction dilatation, more pronounced for the 3F prosthesis. Whether undue leaflet folding caused by the redundant tissue influences long-term function remains to be established. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVE: Transmyocardial laser revascularization for angina relief and intramyocardial autologous endothelial progenitor cell injection for neoangiogenesis may offer a new treatment strategy for patients with intractable ischemic heart disease. METHODS: Transmyocardial laser revascularization and intramyocardial injection of bone marrow-derived CD133+ cells was performed in six highly symptomatic patients. Transmyocardial laser channels were created and isolated CD133+ cells were injected intramyocardially. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: One patient died shortly after the operation due to refractory heart failure. In the five survivors, CCS class improved as well as left ventricular ejection fraction. Left ventricular end-diastolic volume and myocardial perfusion varied between the patients. All patients described a considerable improvement in quality of life postoperatively. Repeated 24-hour Holter monitoring revealed no significant arrhythmias. CONCLUSIONS: In this small patient cohort, intramyocardial CD 133+ cell injection combined with transmyocardial laser revascularization led to an improvement in clinical symptomatology in all patients and in left ventricular function in 4 out of 5 patients, with an unclear effect on myocardial perfusion. Caution is advised when employing this therapy in patients with severely depressed left ventricular function.

Background: For children who require aortic valve replacement, the pulmonary autograft may be the ideal substitute. However, re-operations for conduit exchange in the pulmonary position are inevitable. In addition, re-operations on the autograft may be necessary due to dilatation and neo-aortic insufficiency. We sought to assess predictors for re-intervention in an international Ross-operated paediatric population. Methods: Data of 152 children below 16 years of age at the time of the Ross operation were analysed using Cox proportional hazard modelling. Mean follow-up time was 6.1 +/- 4.2 years. Results: The median age at the time of the Ross operation was 10.1 years (range 54 days to 15 years). Early mortality was 2.6%. Survival at 5 and 10 years was 93.9 +/- 2.0% and 90.4 +/- 3.1%, respectively. Seven patients required autograft re-intervention (explantation n = 6 and reconstruction n = 1). Freedom from autograft re-intervention at 5 and 10 years was 99.3 +/- 0.7% and 95.5 +/- 2.7%, respectively. Prior endocarditis (p = 0.061), prior aortic regurgitation ( p = 0.061) and longer follow-up time (p = 0.036) emerged as risk factors for autograft re-intervention. Seventeen patients required 36 conduit re-interventions (replacement n = 16, percutaneous valvuloplasty n = 10). Freedom from conduit re-intervention at 5 and 10 years was 89.3 +/- 2.9% and 79.6 +/- 6.1%, respectively. Implantation of an aortic homograft (p = 0.013), and smaller conduit size (p = 0.074) emerged as risk factors for conduit re-intervention. Conclusions: There is a consistent need for conduit re-intervention following the Ross operation in children. Re-interventions on the autograft are rare within the first decade after surgery. However, the number of autograft re-interventions may increase after the first decade, since longer follow-up time is a risk factor for autograft failure. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background Valve competence in valve-sparing aortic root replacement has been described as being influenced by commissural height as well as graft size. The aim of this study was to investigate the impact of a gradual reduction of commissural height and graft diameter on aortic insufficiency under physiological conditions in an IN VITRO model. Methods Porcine aortic valves were reimplanted into a tubular graft and a native commissural height was obtained. Subsequently the height was reduced by 10 % and 20 %, respectively. To investigate the impact of graft size, a 30 % reduction of the prosthesis diameter was carried out in valves with both native and reduced commissural heights. All conditions were investigated under pulsatile flow simulation and static pressure exposure. Results Reduction of commissural height caused regurgitation at both 10 % and 20 % lower heights, which was more pronounced in grafts with 20 % reduction. Graft undersizing resulted in significant reflux, with regurgitation even occurring with valves in a native commissural position. Conclusions Valve competence is impaired both by the reduction of commissural height and by reduced graft size. In particular, reimplantation of aortic valves into undersized grafts promotes valve insufficiency even if commissural height is well adjusted.

A major concern with mechanical heart valve prostheses is still the need for lifelong anticoagulation to prevent valve thrombosis and thrombembolism. Knowledge of the localization of initial thrombus formation on the prosthesis may help to improve valve design. Since observation of early clot deposition in vivo is difficult, the aim of this study was a detailed assessment of the initial stages of thrombus formation at bileaflet mechanical heart valves by means of an in-vitro clotting model. Four different bileaflet mechanical heart valves (St. Jude Medical, CarboMedics, ATS and On-X) were investigated in a mock circulation in aortic position using enzyme-activated milk resembling blood clotting potential. Initial development of clot formation on the valves was documented photographically and frequency of occurrence was analyzed for both location and valve type. For the bileaflet valves, clot depositions could be found in a distinct pattern similar in all types. In initial stages, clots developed downstream of the leaflets near the orifice ring, 61.5+/-5.8% of which were hinge associated, but 38.5+/-5.8% were located isolated laterally and medially remote of the hinge region, providing new information on thrombus formation potentially useful for improvement of valve design.

Background. The Ross operation may be the ideal aortic valve replacement in pediatric patients. However, reoperations for replacement of the homograft in the pulmonary position are inevitable. This study determined influencing factors for the development of homograft stenosis and regurgitation in pediatric Ross patients. Methods. Follow-up echocardiograms of 116 children (86 boys) undergoing Ross operations at a mean age, 9.3 +/- 4.9 years were analyzed using hierarchic multilevel modeling. Mean duration of the echocardiographic follow- up was 5.3 +/- 4.2 years (609 patient-years, 398 examinations). Results. Median homograft diameter z value was 0.3 (range -2.2 to +7.3). Mean homograft pressure gradient at implantation was 5.0 mm Hg with a significant increase of 4.2 mm Hg/y (p < 0.001) within the first 2 years and a steady state thereafter. Older donor age was significantly associated with lower mean pressure gradient at implantation (p = 0.037). Larger z value had no significant influence on the annual increase of pressure gradient (p = 0.87). Mean grade of regurgitation at implantation was 0.9, without significant annual increase (0.02 grade/y, (p = = 0.32). Older recipient (p = 0.005) and donor age (p < 0.0001) were significantly associated with lower mean regurgitation at implantation. Larger z value was associated with a higher annual increase of regurgitation (p = 0.014). Conclusions. Relevant midterm homograft regurgitation is rare in children after the Ross operation. However, a significant annual increase occurs in the pressure gradient that cannot be influenced by larger graft size. Homograft oversizing may lead to a higher annual increase of regurgitation. (Ann Thorac Surg 2009; 88: 609-15) (C) 2009 by The Society of Thoracic Surgeons

BackgroundAcute aortic dissection (AAD) is a life-threatening condition with high mortality and a relatively unclarified pathophysiological mechanism. Although differentially expressed genes in AAD have been recognized, interactions between these genes remain poorly defined. This study was conducted to gain a better understanding of the molecular mechanisms underlying AAD and to support the future development of a clinical test for monitoring patients at high risk.Materials and MethodsAortic tissue was collected from 19 patients with AAD (mean age 61.7 ± 13.1 years), and from eight other patients (mean age 32.9 ± 12.2 years) who carried the mutated gene for Marfan syndrome (MS). Six patients (mean age 56.7 ± 12.3 years) served as the control group. The PIQOR™ Immunology microarray with 1076 probes in quadruplicates was utilized; the differentially expressed genes were analysed in a MedScan search using PathwayAssist software. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and protein analysis were performed.ResultsInteractions of MS fibrillin-1 (FBN1) in the MedScan pathway analysis showed four genes, fibulin-1 (FBLN1), fibulin-2 (FBLN2), decorin (DCN) and microfibrillar associated protein 5 (MFAP5), which were differentially expressed in all tissue from AAD. The validation of these genes by qRT-PCR revealed a minimum of three-fold downregulation of FBLN1 (0.5 ± 0.4 vs. 6.1 ± 2.3 fold, p = 0.003) and of DCN (2.5 ± 1.0 vs. 8.5 ± 4.7 fold, p = 0.04) in AAD compared to MS and control samples.ConclusionsDownregulation of fibrillin-1 (FBN1) may weaken extracellular components in the aorta and/or interfer with the transmission of cellular signals and eventually cause AAD. Additional research on these four identified genes can be a starting point to develop a diagnostic tool.

Summary The glandular stem cell cardiomyopexy should become a treatment option for end-stage heart failure. It combines an expected regenerative potential of transformed adult glandular stem cells into cardiomyocytes within the myocardium or onto the myocardium of the recipient and the potential of a hypercapillarized latissimus dorsi muscle (LDM) wrapped around the heart for stem cell nutrition and girdling.

BACKGROUND: The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. METHODS: From July 1993 to April 2006, 56 patients (mean age 55 ± 16 years, range 25 to 80 years, 62.5 % males) underwent elective surgical repair of the descending (n = 37, 66.1 %) and thoracoabdominal aorta (n = 19, 33.9 %), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n = 21), type B aortic dissection (n = 24), and Marfan's syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n = 11), respectively. Most patients were operated using deep hypothermic circulatory arrest. RESULTS: Thirty-day mortality was 5.4 % (n = 3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6 % (n = 2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78 %. CONCLUSIONS: If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.

Mit der Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) steht seit 2001 fur den angloamerikanischen Sprachraum ein Verfahren zur Diagnostik des Delirs zur Verfugung, mit dem auch maschinell beatmete Patienten testbar sind. Die vorliegende Untersuchung sollte folgende Fragen beantworten: 1. Ist die deutsche Version der CAM-ICU an kardiochirurgischen Patienten anwendbar? 2. Wie hoch ist die Pravalenzrate vom postoperativen Delir nach kardiochirurgischen Interventionen bei Diagnostik mit der CAM-ICU? 3. Unterscheiden sich Patienten mit und ohne Diagnose „Delir“ nach CAM-ICU in klinischen Merkmalen, die fur das Auftreten eines postoperativen Delirs im kardiochirurgischen Bereich bekannt sind? Die Analysestichprobe bildeten 194 kardiochirurgische Patienten (85,5% einer angestrebten Vollerhebung). Postoperativ erfolgte an 5 Tagen die Diagnostik mit der CAM-ICU. Soziodemographische und klinische Variablen dienten als Hinweis auf die Validitat des Verfahrens. Die Selbstbeurteilung des postoperativen Patientenbefindens erfolgte mit dem Anasthesiologischen Nachbefragungsbogen fur Patienten (ANP). Bei nahezu allen Patienten war die CAM-ICU postoperativ problemlos durchfuhrbar. Die Pravalenzrate fur das Auftreten eines Delirs betrug 28,4%. In 85,5% der Diagnosen lag bei der Erstmanifestation eine hypoaktive Form des Delirs vor. Patienten mit der Diagnose Delir nach CAM-ICU waren alter (p

Acute aortic dissection (AAD) is a common fatal disease that affects the aorta and requires an urgent clinical intervention. A clinical feature of AAD is the characteristic tearing retrosternal pain often confused with that of myocardial infarction. In type A after Stanford, the biluminal progression is in the ascending aorta, the lethality of all untreated patients is about 50% within the first 48 hours. Most of AAD patients do not present a known connective tissue disorder. This makes the diagnosis more difficult and often late established. Similar as in myocardial infarction, a rapid test for the diagnosis establishment would be vitally helpful. This review summarizes, with examples taken from recent patents, novel strategies maintaining the development and validation of biomarkers of acute aortic dissection and compares them to known biomarkers of myocardial infarction.

Background The Ross procedure has gained increasing interest as an attractive alternative to a prosthetic aortic valve substitute within the last decade. Because of a probably better resistance to infection as one of its advantages, the pulmonary autograft is theoretically preferable for active endocarditis. Methods Between June 1994 and July 2003, the Ross procedure was performed using the subcoronary and inclusion technique in 296 patients (231 male, 65 female). Twenty patients had an active endocarditis of the aortic valve at the time of operation. A bicuspid valve was present in 10 patients. One patient had previous aortic valve surgery. Clinical and echocardiographic follow-up was complete. Results Early mortality was 1, late mortality was 0. There were no recurrence of endocarditis and no neurologic events during the mean follow-up of 47.3 ± 28.6 months. All patients were in New York Heart Association class I. Mean and maximum pressure gradient across the autograft was 3.5 ± 2.0 and 6.5 ± 3.4, respectively, with no autograft insufficiency in 15, 1+ in 4. Comparing postoperative with the last investigations, there were no significant changes of pressure gradients or grade of regurgitation. Mean and maximum homograft pressure gradients were 7.9 ± 3.7 and 16.2 ± 8.1 mm Hg, respectively, at last investigation; most patients had no or mild homograft regurgitation (0+, n=13; 1+, n=5; 2+, n=1). Conclusions Native valve endocarditis can be treated with excellent results using the Ross procedure with the subcoronary and inclusion technique, with low mortality and morbidity rates and a very low recurrence rate of endocarditis.

ObjectiveThe Ross procedure has gained increasing interest as an attractive alternative for aortic valve replacement. Despite its advantages, there is a certain risk of structural valve deterioration, especially of the pulmonary homograft as a result of shrinkage and subsequent stenosis predominantly at the muscular annulus. Theoretically, reduction of homograft muscle tissue could reduce this risk.MethodsFrom February 1996 through December 2002, a total of 238 patients (mean age 44 ± 13.2 years) underwent the Ross procedure with the subcoronary technique with follow-up investigations before discharge and after 12 and 24 months. To estimate the importance of homograft muscle reduction within our institution-specific risk factor scale for change of transhomograft pressure gradient with time, we performed a generalized estimating equation approach, which identified homograft muscle reduction, higher body surface area in male patients, younger patient age, smaller homograft diameter, blood transfusions, and follow-up time as independent risk factors demonstrating a high β value (−2.8638) for muscle reduction. To find out whether muscle reduction influences transhomograft pressure gradient, we compared patients with (group A, n = 39) and without (group B, n = 199) muscle reduction. The other mentioned independent risk factors were not different between groups, except for blood transfusions (group A greater than B, P < .01), indicating a negative bias for group A.ResultsThe maximum pressure gradient across the homograft was lower in patients with muscle reduction before discharge (4.5 ± 2.8 mm Hg group A vs 6.2 ± 3.8 mm Hg group B, P = .004) and after 1 (9.3 ± 5.8 vs 13.1 ± 8.4 mm Hg, P = .028) and 2 years (10.8 ± 7.6 vs 13.7 ± 7.5 mm Hg, P = .013). No significant differences were found concerning homograft insufficiency.ConclusionsWe provide some evidence that transhomograft pressure gradient can be reduced significantly within the first 2 years after operation by homograft muscle reduction. Longer term follow-up is necessary to evaluate this promising operative technique further.

Atrial fibrillation (AF) is associated with increased risks of stroke, cardiac failure, and mortality. The underlying mechanisms and pathology of AF remain elusive. The aim of this study is to proteomically analyze the left atrial appendage tissue obtained from patients suffering from subtypes (paroxysmal, persistent, and long-standing persistent) AF. MALDI Imaging mass spectrometry (MALDI-IMS) was applied to differentiate in classification of pathophysiological AF subtypes, through the direct (in situ) analysis of formalin-fixed paraffin embedded (FFPE) left atrial appendage (LAA) tissue. FFPE LAA tissue were collected from patients with predisposed paroxysmal (n = 9, mean age 69.0±3.1 years), persistent (n = 18, mean age 67.0±2.7 years), and long-standing persistent AF (n = 19, mean age 71.0±2.0 years). Sections were dewaxed and thereupon soused by trypsin solutions using an automated spraying device. Spectra were acquired at a mass range of m/z 800-3500Da and lateral resolution of 80 μm. Two hundred laser shots were acquired per pixel and random walk of 50/position. Data analyses were performed using SCiLS Lab software. Component analysis of MALDI Imaging data through probabilistic latent semantic analysis results in a clear discrimination in the first 3 components of atrial fibrillation. Employing receiver operating characteristic analysis (AUC > 0.7), characteristic intensity distribution in given m/z values, which are discriminative for the considered cluster, was determined to distinguish between paroxysmal vs. persistent AF, and persistent vs. long-persistent AF, m/z values were determined between persistent vs long-persistent AF (1.59±0.12 vs 6.85±3.02, p = 0.02). Follow-up of neurological events in case-controlled assessment presented 13±12% in paroxysmal, 56±12% in persistent and 42±12% long-persistent AF. The tissue-based proteomic approach provides clinically relevant beneficial information in improving risk stratification for AF patients. In the future, this obtained information might be considered new biomarker to support the diagnosis of the severity of AF status. They also suggest a new criterion to determine the most appropriate procedure for each AF subtype to improve postoperative outcomes.

The aortic valve consists of three cusps attached to the wall of the aortic root. During the cardiac cycle, the aortic root undergoes complex movements that precede and aid opening and closing of the aortic valve. The aortic valve cusps themselves form thin-walled pocket-like structures, made from specialized tissue with fibrous, elastic, nervous, and muscular properties. The complex interactions of this tissue with the aortic root and within the cardiac cycle are only incompletely understood yet. In summary, the aortic valve is a complex structure which shows a perfect function in systole and diastole and under a wide range of hemodynamic conditions. No valve prosthesis (so far) can keep up with the function of the native aortic valve. Therefore, surgical techniques have been invented that aim at sparing the aortic valve or replacing it with very similar autologous tissue. Besides the resulting (near) normal valve function, one appealing advantage of these techniques is that oral anticoagulation can be abandoned completely. If the valve cusps themselves are normal, but the aortic root is aneurysmatic or dissected (with or without resulting secondary aortic insufficiency), the aortic valve can be spared by resecting the aortic root tissue and replacing it by a vascular graft. The aortic valve can then be implanted into the vascular graft in a way described by David, or can be remodeled into it (Yacoub technique) - in this case, the graft first needs to be incised at its base so that the three commissures of the valve can be sewn into the three incisions. This way pseudosinuses within the vascular graft are created. The sinuses within the aortic root are considered important for aortic valve function and coronary perfusion. On the other hand, incisions at the base of the vascular graft harbor the potential for redilatation of the aortic root because of a missing circular fixation. Such a fixation is achieved by the David technique. Therefore, there is a great debate in the surgical community which valve-sparing technique is the best and numerous modifications of the original techniques exist. A clear clinical advantage of one technique over the other could not be demonstrated so far, but many authorities advise that the David technique is to be used preferentially in patients with Marfan's syndrome (or other connective tissue disorders) and those with a very wide basal aortic root. If the aortic valve cusps themselves are diseased and cannot be reconstructed, the autologous pulmonary valve is the most physiological substitute. Replacing the aortic valve with the autologous pulmonary valve is named Ross procedure. The defect in the right ventricular outflow tract that is created while harvesting the autograft must be reconstructed during the same procedure; usually, a pulmonary valve allograft is used for this purpose. With all reconstructive surgical techniques and with all autologous replacements there is a risk of reoperation, mainly (besides technical issues) because it is feared that leaving autologous tissue in place leads to recurrence of the original illness. The published results, however, with aortic valve-sparing surgery and with the Ross procedure show that the risk of reoperation appears to be very acceptable. This statement is especially true for the Ross procedure for which more and longer experience exists worldwide. Echocardiographic studies show that the aortic valve function after valve-sparing techniques and - especially - after the Ross procedure is indeed excellent. Therefore, patients with aortic root pathologies or aortic valve diseases should be informed about valve-sparing aortic root reconstructive techniques or the Ross procedure. The choice of technique should be made in close contact between patient, cardiologist, and cardiac surgeon. However, the described techniques require extensive experience within the surgical team.

Mitochondrial DNA (mtDNA) mutations appear to be associated with a wide spectrum of human disorders and proposed to be a potential contributor of aging. However, in an age-dependent increase of the common 4977 bp deletion of human mtDNA still many unanswered questions remain. Comparing mtDNA copy levels in different tissues revealed that cardiac muscle had the highest, while the cortex cerebelli showed the lowest copy number of mtDNA in every donor. Intriguingly, mtDNA copy number showed no changes during aging. In heart tissue, the amount of 4977 bp mtDNA deletion increased in an age-dependent manner showing significant differences at the age of 40 years and older (p

Die kongenitale bikuspide Aortenklappe (BAV) ist die haufigste Herzmissbildung. Sie tritt bei ca. 1–2% der Weltbevolkerung auf. Die Pathogenese ist unklar und genaue genetische Analysen liegen nicht vor. Die Suche nach moglichen Kandidatgenen wies auf eine Beteiligung des Gens „Ubiquitin Fusion Degradation 1-Like“ (UFD1L) hin: Das UFD1L-Gen ist wahrend der Embryonalentwicklung in den mesodermalen Zellen hochreguliert. Diese wandern aus der Neuralleiste in die konotrunkale Herzregion und bilden u. a. die Klappentaschen. Eine molekulargenetische Untersuchung des UFD1L-Gens an Gewebeproben von insgesamt 77 Patienten, davon 39 Patienten mit BAV (mittleres Alter 56.8±18.1, Gruppe A) und von 38 Kontrollgruppen-Patienten (mittleres Alter 61.7±16.1, Gruppe B) wurde durchgefuhrt. Die angewandten Methoden waren Fluoreszenz-In-situ-Hybridisierung (FISH), quantitative reverse Transkription-Polymerasekettenreaktion (quantitative Real-time RT-PCR) und Proteinanalyse (Western-Blot) BAV-Patienten wiesen keine Mikrodeletion auf. Jedoch wurde eine verminderte Genexpression des UFD1L-Gens im Klappentaschen-Gewebe von Patienten mit BAV, verglichen mit der Kontrollgruppe (787 vs 10887 fold, p=0,001), festgestellt. Die Konzentration des Ufd1l-Proteins bei BAV-Patienten war ebenfalls vermindert, verglichen mit der Kontrollgruppe (3.9±2.6 gegen 8.4±4.8 optische Dichte, p

Transannular patching is often performed to relieve congenital pulmonary stenosis, especially in tetralogy of Fallot. Theoretically, a monocusp patch can reduce patch-related pulmonary regurgitation, but the optimal size relation between the implant and the native hypoplastic pulmonary root is not well defined.In 11 pigs, peak pressure gradient and regurgitation fraction across the pulmonary root were measured. During cardiopulmonary bypass, two cusps including the pulmonary artery wall were resected and the midpoint of the free margin of the remaining cusp was sutured to the sinus wall to imitate a hypoplastic pulmonary root. Transannular patching was performed using a noncoronary segment of a porcine aortic root. After discontinuation of cardiopulmonary bypass, all measurements were repeated. Thereafter, the cusp of the patch was resected, and all measurements again repeated. Anatomic dimensions were determined after the pigs had been sacrificed.Regurgitation fraction increased from 0.2% +/- 3.4% at baseline to 15.5% +/- 6.2% after reconstruction with a monocusp patch and to 60.0 +/- 18.6% after the cusp of the monocusp patch had been resected (p0.001). The median peak pressure gradient increased from 0 to 1 to 6 mm Hg (p = 0.013), respectively. The regurgitation fraction negatively correlated with the ratio of the length of the monocusp patch to that of the hypoplastic pulmonary root (r = -0.63, p = 0.037).A monocusp patch for reconstruction of a hypoplastic pulmonary root results in significantly less regurgitation than a nonvalved patch of the same size, while the peak pressure gradient remains normal. The lowest regurgitation fraction was observed with a monocusp patch two-times the length of the circumference of the hypoplastic pulmonary root.

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62 9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality. Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the IV ejection fraction (p=0.001), the number of stenosed coronary arteries (p = 0.004), and the extent of akinesis (p = 0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.

Background: Increased cardiac troponins in blood are observed after virtually every open heart surgery, indicating perioperative myocardial cell injury. We sought to determine the optimum time point for blood sampling and the respective cutoff value of cardiac troponin T (cTnT) for risk assessment in patients undergoing cardiac surgery. Methods: In a series of 204 patients undergoing scheduled open heart surgery, mainly for coronary artery bypass grafting (n = 132) or valve repair (n = 27), cTnT concentrations were measured before and 4 and 8 h after cross-clamping and then daily for 7 days. Individual risk was assessed by use of the Cleveland Clinic Foundation Risk score and intraoperative risk indicators such as duration of cardiopulmonary bypass, cross-clamping, and perioperative release of cardiac markers. Patients were followed for 28 months. Results: Cardiac mortality, all-cause mortality rates, and rates of nonfatal acute myocardial infarction (AMI) at 28 months were 6.9%, 8.8%, and 6.8%, respectively. cTnT was higher in patients with Q-wave AMI or postoperative heart failure requiring inotropic support, and in nonsurvivors. The ROC curve revealed a cTnT ≥0.46 μg/L at 48 h as the optimum discriminator for long-term cardiac mortality. Stepwise logistic regression identified higher Cleveland Clinic Risk Score [odds ratio (OR) = 2.6 per point], cross-clamp time >65 min (OR = 6.6), and cTnT (OR = 4.9) as significant and independent predictors of long-term cardiac mortality. Conclusions: A single postoperative cTnT measurement can be used to estimate myocardial cell injury that impacts long-term survival after open heart surgery. It adds independently to established risk indicators.

The pathologic modifications characterizing vein graft disease resemble those observed in native arteriosclerosis, but in accelerated form. Although both disorders are considered to be inflammatory diseases, it remains to be determined whether diseased vein grafts and atherosclerotic coronary arteries differentially express inflammatory mediators. Therefore, we examined whether differences in the expression of proinflammatory cytokines by these two distinct vascular pathologies favor the accelerated inflammation within diseased vein grafts.The messengerRNA expression of various cytokines (interleukin-1 beta [IL-1 beta], IL-6, IL-8, tumor necrosis factor-alpha [TNF-alpha], interferon-gamma [IFN-gamma]) was quantified using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) in tissue samples of native saphenous veins (NSV, n = 5), diseased coronary arteries (CAD, n = 25), and diseased vein grafts (VG, n = 13).Native saphenous veins did not contain any detectable transcripts except for IFN-gamma. As expected, CAD was characterized by the expression of IL-1 beta, IL-6, IL-8, IFN-gamma, and TNF-alpha mRNA. Interestingly VG also expressed these mediators, but at markedly higher levels. Quantification by RT-PCR revealed that, compared with specimens from the CAD group, VG specimens contained 5.8 +/- 1.2 times, 286 +/- 22 times, and 29 +/- 7.3 times as many transcripts for the cytokines IL-1 beta, IL-6 and TNF-alpha, respectively, as well as 25 +/- 8.3 times more transcripts for the chemokine IL-8. In contrast, the expression of IFN-gamma transcripts did not differ among the groups.The elevated expression of proinflammatory cytokine transcripts supports the hypothesis that diseased vein grafts, compared with atherosclerotic coronary arteries, are characterized by enhanced inflammatory activity that might accelerate atherosclerotic modifications. This may implicate new therapeutic strategies for the prevention of vein graft disease.

Background and Objectives During transmyocardial laser revascularization (TMLR), multiple microembolic signals (MES) can be detected in cerebral arteries. We sought to characterize composition and clinical relevance of these MES and to evaluate strategies to reduce cerebral microembolization during TMLR. Study Design/Materials and Methods TMLR was performed in pigs. Laser energy was set to 4–10 J (group A) or 80 J (group B). Oxygen concentration was varied between 21 and 100%. MES were recorded in the ophthalmic artery. Brain and spinal cord were investigated histologically after 10 days. Results More MES could be detected during high- compared to low-energy laser procedures. Ventilation with 100% oxygen reduced the number of MES. No lesions were found on histology. Conclusions The number of MES depends on the laser energy. Laser-induces cavitation-effects lead to an additional release of nitrogen bubbles. Thus, the microembolic load can be reduced by ventilation with 100% oxygen and by decreasing the laser energy. Lasers Surg. Med. 34:379–384, 2004. © 2004 Wiley-Liss, Inc.

Background Aortic valve-sparing operations for acute type A dissection are appealing and innovative but less well defined surgical techniques requiring further evaluation. Methods We reviewed all consecutive patients with acute type A dissection who underwent either the remodeling (group 1, n=21) or the reimplantation valve-sparing technique (group 2, n=15) since October 1994. Patients were followed up clinically and echocardiographically for as long as 41.3 months (group 1) and 87 months (group 2). Results Hospital mortality was 19% (n = 4) for group 1 and 20% (n = 3) for group 2. Permanent new neurologic symptomatology occurred in 1 patient (3.6%). Three patients in group 1 required reoperation owing to redissection. No patient had an aortic insufficiency of more than grade 1. No late neurologic or thrombembolic events occurred. There was no statistically significant difference between both groups with respect to clinical and hemodynamic data. Conclusions Remodeling and reimplantation aortic valve-preserving operations in acute type A dissection can be performed with adequate perioperative risk and excellent midterm aortic valve function. We found no evidence of one technique being superior to the other, however durability of the remodeling technique needs critical consideration especially in Marfan syndrome and when glue is used.

Objective: The value of prophylactic brachytherapy on vein graft disease is unknown. Methods and results: Vein bypass grafts in 23 hypercholesterolemic pigs after ex vivo gamma irradiation of the vein grafts (10, 20, and 40 Gy) and 16 control veins were analyzed regarding: (1) expression of platelet-derived growth factor (PDGF-AA and -BB, ELISA); (2) smooth muscle cell (SMC) proliferation/cell death (double-immunohistochemistry Mib-1/TUNEL/SMC a-actin); and (3) vessel wall dimensions. Planimetric data on vessel wall dimensions revealed no positive effect of gamma radiation on neointima formation and inner lumen diameter. On the contrary, vein grafts subjected to 40 Gy were significantly more likely to be occluded and to have reduced inner lumen and increased neointima formation. Radiation therapy had no effect on PDGF expression and SMC proliferation/cell death. The mean inner lumen diameter decreased as PDGF-AA expression increased. Conclusions: Prophylactic gamma radiation of unaffected vein grafts failed to prevent vein graft disease in a hypercholesterolemic porcine model. High-dose radiation (40 Gy) resulted in more frequent graft occlusion and vein sclerosis. q 2003 Elsevier Science B.V. All rights reserved.

Introduction: MicroRNAs (miRNAs) are critical regulators of most major cellular processes and seem to play a vital role in the pathogenesis of numerous diseases including atrial fibrillation, the most commonly encountered cardiac rhythm disorder. Among the several miRNAs that appear to be involved in pathogenesis of atrial fibrillation, miRNA 208a is linked to fibrosis and proper cardiac conduction. Methods and Results: By employing whole miRNA microarrays, 30 upregulated und 3 downregulated miRNAs were identified. The validation of the microarrays dataset in 19 left atrial appendage tissue samples (2 paroxysmal, 10 persistent, 7 long-standing persistent) was picked miRNA208, the most differentially expressed one. The relative expression level of miRNA 208a was 2.33 ± 1.99-fold of calibrator in atrial fibrillation tissue, whereas it was 1.4 E−4 ± 2.4 E−4 in RNA obtained from healthy donors control tissue, thus confirming the cardiac specific expression of this miRNA. Atrial fibrillation sub-categories revealed miRNA 208a expression levels of 2.32 ± 2.12 in paroxysmal, 3.26 ± 2.30 in persistent, and 1.14 ± 0.67 in long-standing persistent arrhythmias. The difference in miRNA 208a expression levels between persistent and long-standing persistent atrial fibrillation proved to be significant (p = 0.02). Discussion: The findings from our study suggest a decline in miRNA 208a expression with ongoing arrhythmia, possibly preceded by a rise in expression from paroxysmal to persistent atrial fibrillation or even long-standing persistent. The significant changes in miRNA 208a expression over the course of the disease may be used as an additional diagnostic tool to monitor the progression of atrial fibrillation.

Die Aortenklappe gewahrleistet eine unubertroffene, dauerhafte Ventilfunktion ohne Druckgradient und Ruckfluss. Rekonstruktionen oder Imitationen dieser anatomischen Strukturen im Rahmen der Aortenklappenchirurgie sollten theoretisch zu optimalen Ergebnissen fuhren. Aortenklappenrekonstruktion: Die isolierte Rekonstruktion der Aortenklappe wie die Entkalkung, Kommissurotomie, Ringplikatur, Klappenplikatur bei dreitaschiger Klappenanlage oder Klappenextension sind selten indiziert, wohl aber die Rekonstruktion der bikuspiden insuffizienten Aortenklappe. Bei ausgefeilter Indikation und Technik sind die mittelfristigen hamodynamischen und klinischen Ergebnisse viel versprchend. Fur Aortenwurzelaneurysmen und/oder Typ A-Dissektionen sind rekonstruktive Verfahren nach David oder Yacoub in den letzten 10 Jahren zur Routine geworden. Die hamodynamischen und klinischen Ergebnisse sind exzellent, die Reoperationsrate bei sehr niedrigem Thrombembolierisiko gering. Generell ist bei einem maximalen Durchmesser der Aortenwurzel von 5 cm die Indikation zur operativen Intervention gegeben. Bei Marfan-Patienten sollte der Eingriff bereits bei kleineren Durchmessern erfolgen. Dies gilt vor allem dann, wenn eine Aorteninsuffizienz vorliegt und/oder eine deutliche Grosenprogression dokumentiert wurde. Ross-Operation: Die Ross-Operation beinhaltet den Ersatz der erkrankten Aortenklappe mit einem pulmonalen Autograft sowie den Ersatz der exzidierten Pulmonalklappe in der Regel mit einer Spenderklappe (Homograft). Die hamodynamischen und klinischen Ergebnisse sind bei niedriger Reoperations- und Thromboembolierate viel versprechend. Die Indikation ist gegeben bei korperlich aktiven, jungen Patienten, Frauen mit Kinderwunsch, Sportlern und Patienten, die eine Antikoagulation vermeiden wollen. In Einzelfallen kann der Homograft eine Dysfunktion entwickeln, meistens in Form einer Stenose mit nachfolgend notwendiger Reoperation. Neuartige dezellularisierte Homografts mit dem Potential der Wiederbesiedlung durch autologe Zellen sind in klinischer Erprobung und konnen in Zukunft die Ergebnisse noch verbessern. Bei der Indikationsstellung zu diesen verschiedenem Operationstechniken muss das Risiko der Reoperation bei fehlenden Langzeiterfahrungen von bis zu 20 Jahren abgewogen werden gegen die Vorteile der sehr niedrigen Hospital- und klappenbezogenen Spatletalitat, der exzellenten Hamodynamik, der sehr niedrigen Makro- und Mikroembolierate sowie der fehlenden Notwendigkeit der Dauerantikoagulation bei weitestgehend uneingeschranktem Lebensstil.

Background: Postoperative neurologic complications in cardiac surgery patients are considered to be associated with the design of an aortic cannula and its hydrodynamic profile. To gain knowledge about the hydrodynamics of a new cannula type, based on the integration of a helical stator in its tip, was the aim of the present study. Methods: Pressure gradients and back pressures of the new Medos aortic cannula were measured and compared with a commonly used single-stream cannula at varying flow rates in a mock circulation. Additionally, flow visualization was performed by ink injection. Results: Pressure gradients across the Medos cannula were 25.5-31.8% lower at all flow rates measured when compared to the reference cannula. Back pressures of the Medos cannula were 64.1-67.9% lower than reference back pressures. Conclusions: The Medos cannula provides improved hydrodynamic characteristics, probably reducing the risk of atherosclerotic embolism and cerebral malperfusion by avoidance of high back pressures and sandblasting effect.

Acute aortic dissection is a disease with high mortality. Whereas acute dissection of the ascending aorta (Standford type A) is treated surgically, acute dissection of Stanford type B (descending aorta) is principally treated conservatively, but surgically in case of complications. Recently, another therapeutical option for the treatment of type B dissection has been developed using endovascular stent-grafts. We report on a 64-year-old woman with typical signs of acute aortic dissection. Computer tomography and transesophageal echocardiography demonstrated Stanford type B dissection. The patient was treated with an endovascular stent-graft, because of malperfusion of the right leg and chest pain. After successful closure of the entry by the stent, the patient developed acute right-sided hemiplegia one day after the intervention due to retrograde dissection into the aortic arch and ascending aorta. Upon immediate operation, the origin of the initially type B dissection was still sufficiently occluded by the endovascular stent-graft; however, there was another entry between the innominate artery and the left carotic artery near one proximal end of the stent's strut. Using deep hypothermia and selective antegrade cerebral perfusion, the ascending aorta and proximal arch were replaced with a 28 mm Dacron-Velour tube and the aortic root was remodelled with a tongue-shaped Dacron graft preserving the valve cusps according to a modified Yacoub procedure. After the operation, neurological symptoms diminished and the patient could walk on the ward on day eleven. This case demonstrates retrograde type A dissection as a complication after interventional treatment of type B dissection using an endovascular stent-graft. The reason for this delayed complication is speculative. Aortic wall damage during stent inserting could be a possible cause. It is also likely that the patient initially had type B dissection with retrograde dissection of the distal part of the aortic arch. Therefore, one of the straight struts of the proximal end of the stent may have caused additional damage to the vulnerable dissected aortic wall in the arch, leading to retrograde type A dissection. Careful patient selection, detailed diagnosis of the aortic arch, improved stent designs and materials, especially regarding the stent's ends and careful insertion of the stent into the aortic arch, could contribute to prevention of the described problems.

Background — As shown previously in goats, clenbuterol increased the power of electrically conditioned skeletal muscle ventricles (SMVs) of clinically relevant size (150 mL), which were constructed around a mock system. They pumped against a pressure of 60 to 70 mm Hg immediately during surgery and up to several months after, finally at >1 L/min. SMVs without clenbuterol administration failed. Thus, we expected that clenbuterol-supported SMVs might become integrated into the circulation by a 1-step operation instead of the 2-step procedure required up to now. Methods and Results — In adult Boer goats (n=5), latissimus dorsi muscle was wrapped around a polyurethane chamber of 150 mL that was connected to the descending aorta. This muscular flow-through pumping chamber containing a stabilizing inner layer (called a biomechanical heart [BMH]) was formed and immediately made to work against a systemic load with the support of clenbuterol (5×150 μg/wk). During surgery, the mean stroke volume of BMHs was 53.8±22.4 mL. One month after surgery, in peripheral arterial pressure, the mean diastolic (P MD ) and minimal diastolic (P min ) pressures of BMH-supported heart cycles differed significantly from unsupported ones (P MD =+2.9±1.1 mm Hg [ P min =−2.4±0.9 mm Hg [ P max , increased by 20.5±8.1% ( P Conclusions — Under support of clenbuterol, BMHs of a clinically relevant size can be trained effectively in the systemic circulation after a 1-step operation and offer the prospect of a sufficient volume shift and probably unloading of the left ventricle.