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This article discusses the surgical treatment of postinfarction ventricular septal defect (VSD) and its high mortality rate. The study analyzed data from 46 patients treated at a single institution over a 10-year period. The primary endpoint of the study was 1-year survival, and the results showed a 50% survival rate for the whole group. The study suggests that beating-heart techniques should be considered to avoid additional myocardial ischemia. [Extracted from the article]

Background: Hybrid coronary revascularisation benefits patients with multivessel disease, as it amalgamates the minimally invasive direct coronary artery bypass (MIDCAB) procedure and percutaneous coronary intervention (PCI). We present a 63-year-old female with triple-vessel coronary artery disease including marked ostial stenosis of the left main coronary artery, as well as moderate stenosis of the right coronary artery. The risk of death following heart surgery (EuroSCORE II) is 4.27%. The patient exhibited multiple morbidities including chronic obstructive pulmonary disease, renal impairment, extracardiac arteriopathy, and multiple prior gastrointestinal surgeries, as well as a recent episode of paroxysmal atrial fibrillation. A MIDCAB procedure without electrocoagulation was stipulated by the ENT specialist due to the patient's cochlear implant., Conclusion: A successful MIDCAB procedure omitting electrocoagulation was performed for the first time for multivessel coronary disease in a multimorbid patient as part of a hybrid approach., Competing Interests: Declarations. Ethical approval: All procedures involving the human participant were performed in accordance with the ethical standards of the institutional and/or national research committee. The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD) is the only commercially available option considered suitable for long-term circulatory support. External compression of the outflow graft causing obstruction (eOGO) is a serious adverse event affecting patients on long-term support. The obstruction occurs due to the accumulation of gelatinous substance between the bend relief and outflow graft. This systematic review evaluated all available studies with regard to the diagnosis and therapy of eOGOs. Methods: A systematic literature review and analysis of individual patient data was performed using MEDLINE/PubMed following PRISMA guidelines. Original works dating up to 31 October 2024 were considered. Results: Twenty-four publications that met the inclusion criteria were identified, providing individual data from 113 patients with a median support time to eOGO diagnosis of 809 days [588, 1095] and follow-up after treatment of 365 days [33, 605]. eOGO severity classification was performed on 108 patients according to our grading system. For treatment, most patients underwent surgery ( n = 38) or stenting ( n = 29). A hazard ratio of 0.75 [0.28, 2.03] was calculated for the surgical group versus the stenting group ( p = 0.570). Conclusions: Concerning 30-day mortality, we did not find a significant difference between the eOGO severity of survivors and non-survivors. We found no significant differences in outcome between patients with differing eOGO severity and treatment strategy, namely stenting and surgery. Due to an increase in eOGO incidence after one year of support, we propose that clinicians monitor their patients for this complication when support time surpasses one year.

Aims: Debulking of infective mass to reduce the burden if infective material is a fundamental principle in the surgical management of infection. The aim of this study was to investigate the validity of this principle in patients undergoing transvenous lead extraction in the context of bloodstream infection (BSI)., Methods and Results: We performed an observational single-centre study on patients that underwent transvenous lead extraction due to a BSI, with or without lead-associated vegetations, in combination with a percutaneous aspiration system during the study period 2015-22. One hundred thirty-seven patients were included in the final analysis. In patients with an active BSI at the time of intervention, the use of a percutaneous aspiration system had a significant impact on survival (log-rank: P = 0.0082), while for patients with a suppressed BSI at the time of intervention, the use of a percutaneous aspiration system had no significant impact on survival (log-rank: P = 0.25)., Conclusion: A reduction of the infective burden by percutaneous debulking of lead vegetations might improve survival in patients with an active BSI., Competing Interests: Conflict of interest: C.S. has received workshop fees, consulting fees, educational grants, and research support from Cook Medical and consulting fees from AngioDynamics. R.H. has received research support from AngioDynamics., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement., Methods: All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration., Results: The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13)., Conclusions: Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study., Methods: A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases., Results: Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%)., Conclusions: Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant., (Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.)

The introduction of fast-track protocols decreased length of hospital stay and improved rehabilitation and outcomes in total joint arthroplasty. Despite improved clinical results published in many papers, the patient perspective of these protocols is less investigated. Purpose of this study was to explore the patient perspective of fast-track protocols in arthroplasty. A systematic search for articles of patient experiences in total hip, knee, and shoulder arthroplasty was conducted using EMBASE, MEDLINE, Cochrane, and Web-of-Science for articles published from inception to February 14, 2023. In total 12 studies were included involving 672 patients. Most patients were satisfied with short length of hospital stay and preferred rehabilitation at home with relatives for support. Various experiences were reported regarding pain and postoperative out of hospital physical therapy. Frequently, feelings of insecurity were reported because of lack of personalized information. Based on current qualitative literature, patients are satisfied with short length of hospital stay in fast-track total joint arthroplasty. Improvements in personalized information and physical therapy protocols is needed.

Background: Takotsubo syndrome is, by definition, a reversible form of acute heart failure. If cardiac output is severely reduced, Takotsubo syndrome can cause cardiogenic shock, and mechanical circulatory support can serve as a bridge to recovery. To date, there are no recommendations on when to use mechanical circulatory support and on which device is particularly effective in this context. Our aim was to determine the best treatment strategy., Methods: A systematic literature research and analysis of individual patient data was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until 31 July 2023., Results: A total of 93 publications that met the inclusion criteria were identified, providing individual data from 124 patients. Of these, 62 (50%) were treated with veno-arterial extracorporeal life support (va-ECLS), and 44 (35.5%) received a microaxial left ventricular assist device (Impella). Eighteen patients received an Impella CP and twenty-one an Impella 2.5. An intra-aortic balloon pump (IABP) without other devices was used in only 13 patients (10.5%), while other devices (BiVAD or Tandem Heart) were used in 5 patients (4%). The median initial left ventricular ejection fraction was 20%, with no difference between the four device groups except for the IABP group, which was less affected by cardiac output failure ( p = 0.015). The overall survival was 86.3%. Compared to the other groups, the time to cardiac recovery was shorter with Impella ( p < 0.001)., Conclusions: Though the Impella treatment is new, our analysis may show a significant benefit of Impella compared to other MCS strategies for cardiogenic shock in Takotsubo syndrome.

With the increasing use of cardiac implantable electronic devices, the number of patients with cardiac implantable electronic device-related endocarditis is also rising. The treatment of this type of endocarditis is a challenging clinical task, in particular if device removal is required in patients who are pacemaker dependent. This video tutorial describes a treatment strategy for cardiac implantable electronic device-related endocarditis involving the tricuspid valve in pacemaker-dependent patients. The proposed treatment strategy consists of implanting an epicardial pacemaker via a minimally invasive subxiphoid approach, percutaneous aspiration of tricuspid valve vegetations and complete transvenous explantation of the infected cardiac implantable electronic device system using advanced lead extraction tools., (© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Cardiogenic shock (CS) can occur in patients with Takotsubo syndrome (TTS). As TTS has received increasing attention and has been more closely researched, several aspects of the pathogenesis have been identified, particularly that an excessive release of catecholamines plays an important role. Nevertheless, evidence on specific therapy concepts is still lacking. As a result, TTS with severe hemodynamic instability and low cardiac output creates unique challenges, and mechanical circulatory support is needed with as few inotropic drugs as possible., Methods: We present a 77-year-old female patient who underwent minimally invasive surgical mitral valve replacement. After an uneventful course, the patient developed acute heart failure eleven days after surgery. Transthoracic echocardiography (TTE) revealed a new onset of TTS. The patient needed left ventricular venting and full haemodynamic flow. We successfully implanted a microaxial left ventricular assist device (Impella 5.5) using the transaxillary approach. The haemodynamic situation stabilised immediately. The patient was weaned and the Impella 5.5 was explanted after five days., Conclusion: We present the first-in-man implantation of a transaxillary Impella 5.5 in a patient with TTS. The patient benefitted from Impella 5.5 therapy with full haemodynamic support and venting of the left ventricle., (© 2023. The Author(s).)

Ex vivo machine perfusion (EVMP) is an emerging technique for preserving explanted solid organs with primary application in allogeneic organ transplantation. EVMP has been established as an alternative to the standard of care static-cold preservation, allowing for prolonged preservation and real-time monitoring of organ quality while reducing/preventing ischemia-reperfusion injury. Moreover, it has paved the way to involve expanded criteria donors, e.g., after circulatory death, thus expanding the donor organ pool. Ongoing improvements in EVMP protocols, especially expanding the duration of preservation, paved the way for its broader application, in particular for reconditioning and modification of diseased organs and tumor and infection therapies and regenerative approaches. Moreover, implementing EVMP for in vivo -like preclinical studies improving disease modeling raises significant interest, while providing an ideal interface for bioengineering and genetic manipulation. These approaches can be applied not only in an allogeneic and xenogeneic transplant setting but also in an autologous setting, where patients can be on temporary organ support while the diseased organs are treated ex vivo , followed by reimplantation of the cured organ. This review provides a comprehensive overview of the differences and similarities in abdominal (kidney and liver) and thoracic (lung and heart) EVMP, focusing on the organ-specific components and preservation techniques, specifically on the composition of perfusion solutions and their supplements and perfusion temperatures and flow conditions. Novel treatment opportunities beyond organ transplantation and limitations of abdominal and thoracic EVMP are delineated to identify complementary interdisciplinary approaches for the application and development of this technique., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Iske, Schroeter, Knoedler, Nazari-Shafti, Wert, Roesel, Hennig, Niehaus, Kuehn, Ius, Falk, Schmelzle, Ruhparwar, Haverich, Knosalla, Tullius, Vondran and Wiegmann.)

Implantation of a temporary percutaneous right ventricular assist device (RVAD) in patients with right heart failure after left ventricular assist device (LVAD) implantation is an established technique that may cause complications. We present a 60-year-old male patient who underwent urgent LVAD implantation. On the second postoperative day the patient developed acute right heart failure. We implanted a temporary percutaneous RVAD with two cannulas via the right internal jugular vein and the right femoral vein. Transesophageal echocardiography revealed severe pulmonary insufficiency. After performing re-sternotomy we anastomosed a prosthetic graft to the pulmonary trunk (PT), performed subxiphoid tunneling of the graft and replaced the transjugular outflow cannula. The pulmonary regurgitation caused by the percutaneous transvalvular cannula disappeared. In such case a direct anastomosis to the PT is the solution., Competing Interests: LW, None. PL, None. SO, None. JM, None. CTS, Payment to his institution related to his activity as speaker fees, honoraria, consultancy, advisory board fees, investigator, committee member from Angiodynamics, Abiomed, Medtronic, Spectranetics, Biotronik, Liva Nova (Sorin) and Cook Medical and departmental or institutional research funding from Cook Medical. VF, Grants or contracts from any entity: Medtronic GmbH, Biotronik SE & Co., Abbott GmbH & Co. KG, Boston Scientific, Edwards Lifesciences, Berlin Heart, Novartis Pharma GmbH, JOTEC/Cryolife GmbH, LivaNova, Zurich Heart (I hereby declare that I have relevant (institutional) financial activities outside the submitted work with the mentioned commercial entities in relation to Educational Grants (including travel support), fees for lectures and speeches, fees for professional consultation, research and study funds. EVP, Consulting fees: Abbott (institutional grants), Medtronic (institutional grants), Abiomed (institutional grants). Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Abbott (institutional grants), Medtronic (institutional grants), Abiomed (institutional grants). Support for attending meetings and/or travel: Abbott (institutional grants), Medtronic (institutional grants), Abiomed (institutional grants). Participation on a Data Safety Monitoring Board or Advisory Board: Abbott, Medtronic., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2023.)

Transaxillary implantation of a temporary microaxial left ventricular assist device in patients suffering from cardiogenic shock is an established technique. We present a 77-year-old female patient with severe mitral regurgitation. She underwent minimally invasive surgical mitral valve replacement. After an uneventful postoperative course, the patient developed acute heart failure on the 11th postoperative day. Transthoracic echocardiography revealed new onset of Takotsubo cardiomyopathy with a severely decreased left ventricular ejection fraction. Implantation of a microaxial flow pump for left ventricular decompression was scheduled. Preoperative computed tomography revealed a rectangular course of the right subclavian artery. To advance the Impella, we employed an introducer fitted over the guidewire behind the Impella device as a 'cue stick' to move the rigid part of the pump forward to overcome the kinking using a 'shuffleboard technique'. The haemodynamic situation stabilized immediately after implantation. The Impella 5.5 was successfully weaned after 6 days of support. In the event of (rectangular) kinking of the subclavian artery, the 'shuffleboard technique' can be used for the successful positioning of the pump., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: The "UFO procedure" was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called "UFO procedure" including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day., Conclusion: Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary., (© 2023. The Author(s).)

Minimally invasive aortic valve replacement has become a feasible approach to treat various aortic valve pathologies with limited procedural trauma. Several minimally invasive aortic valve replacement approaches with different levels of complexity and technical requirements are currently available., (© The Author 2022. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The introduction of the transcatheter aortic valve implantation procedure has revolutionized the standards of care in patients with aortic valve pathologies and has significantly increased the quality of the medical treatment provided. The durability and constant technical improvements in the modern transcatheter aortic valve implantation procedure have broadened the indications towards younger patient groups with low-risk profiles. Therefore, transcatheter aortic valve implantation now represents an effective alternative for surgical aortic valve replacement in a large number of cases. Currently, various technical methods for the transcatheter aortic valve implantation procedure are available. The contemporary transcatheter aortic valve implantation procedure focuses on optimization of postoperative results and reduction of complications such as paravalvular leakage and permanent pacemaker implantation. Another goal of transcatheter aortic valve implantation is the achievement of a valid lifetime concept with secure coronary access and conditions for future valve-in-valve interventions.  In this case report, we demonstrate a standard transfemoral transcatheter aortic valve implantation procedure with a self-expandable supra-annular device, one of the most commonly performed methods., (© The Author 2022. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high-risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace and/or none), mild (1), moderate (2) or moderate to severe (3-4). The patients were 74 ± 7.8 years old. 65% of the patients were male. Mean cardiopulmonary bypass time was 115 ± 37 minutes and mean cross-clamp time was 71 ± 23 minutes. There was a significant improvement in preoperative vs postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); P = 0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months' (range 3 - 19 months') and in 16 patients at a median of 34 months' postoperatively (range 21 - 53 months') showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months' were 88% and 81% respectively. Mitral valve reoperation was conducted in 1 patient (2%), who was suffering of endocarditis. Stroke occurred in 2 patients (7%). Cardiac arrhythmia was observed in 15 patients (35%). 8 patients (19%) suffered from atrial fibrillation and 7 patients (16%) displayed atrioventricular blockage. 10 patients (23%) could be treated conservatively and 5 patients (12%) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high-risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66% of them could be treated successfully by conservative procedures., (Copyright © 2021. Published by Elsevier Inc.)

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible., (© The Author 2021. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Outflow graft obstruction in left ventricular assist devices (LVADs) is a rare complication whose clinical presentation may be subtle. We present six cases of outflow graft obstruction in patients on HeartMate 3 LVAD detected between 648 and 1,222 days on support. Detection principles are described and treatment strategies discussed. Three patients were successfully managed with stents, one underwent surgical revision, one patient died despite emergency treatment, and the last patient without symptoms was listed for heart transplantation., (Copyright © ASAIO 2020.)

Background: The HeartMate 3 (HM3; Abbott Laboratories, Lake Forest, Ill) left ventricular assist device (LVAD) received its Conformité Européenne mark for Europe in October 2015 and is currently under investigation of the Food and Drug Administration to gain approval in the United States. Within this study, we present the first real-world experiences, 1-year outcomes, and adverse events of a single-center cohort treated with the HM3., Methods: We prospectively studied midterm results of 27 consecutive patients receiving the HM3 at a single institution. After HM 3 implantation, survival, causes of death, and complications were recorded for all patients. Follow up was 100% complete., Results: Twenty-seven patients were enrolled into the study. Within 1 year after HM3 implantation, 3 patients underwent heart transplantation and 3 patients died. Thirty-day survival was 88.9%, 6-month 85.2%, and 1-year survival 85.2%. No pump thrombosis and no strokes were observed within the study group. One incident of gastrointestinal bleeding was observed (3.7%). Right heart failure was diagnosed in 1 patient after HM3 implantation (3.7%). No technical complications of the pump were documented. No pump exchanges were necessary. The main complication was LVAD-related infection (22.2%)., Conclusions: The novel LVAD HM3 has already shown excellent Conformité Européenne mark trial results. Within this cohort, 1-year survival after HM3 implantation was 85%. The HM3 showed excellent midterm results with 0% stroke and 0% pump thrombosis rates 1 year after implantation., (Copyright © 2018. Published by Elsevier Inc.)

Background: Driveline infection (DLI) is one of the leading causes for unplanned re-admissions of patients undergoing therapy with left ventricular assist devices (LVAD). In previous studies our group was able to show that a double tunneling implantation technique could significantly reduce infection rates one year after implantation. We now report the results of the five-year-follow up of patients receiving the double tunneling technique., Methods: We retrospectively analyzed patients receiving LVAD therapy with the HeartWare ventricular assist device (HVAD) (Medtronic, Minnesota, MN, USA) LVAD. For 36 patients (group 1) the driveline was tunneled via a conventional technique. In the remaining 33 patients (group 2) the drivelines were implanted by means of a double tunneling technique. The double tunnel driveline technique involved placement of the driveline in the sheath of the rectus muscle in the umbilical direction and then subcutaneously to the left (alternatively right) upper quadrant. We retrospectively compared both groups. Primary outcome parameters were infection rate and mortality., Results: Five years after LVAD implantation the DLI rate of patients operated by a double tunneling technique was significantly lower than in the conventional technique group [61% (n=22) group 1 vs. 30% (n=10) group 2, P=0.004]. The 5-year mortality was lower in group 2 [42% (n=15) group 1 vs. 27% (n=9) group 2] but did not achieve statistical significance (P=0.10). The days of LVAD support between the two groups were comparable (1,275.56±885.89 group 1 vs. 1,321.94±711.37 group 2). The tunnel technique itself showed to be strongly associated with the occurrence of DLI. Other elevated variables are liver disease and dilated cardiomyopathy as primary disease., Conclusions: Double tunneling technique for driveline implantation leads to significantly lowered infection rates after 5 years of LVAD therapy and it is associated with a lower mortality., Competing Interests: Conflicts of Interest: JD Schmitto and G Dogan are consultants of Medtronic. The other authors have no conflicts of interest to declare.

Background: Device thrombosis is one of the main complications in left ventricular assist devices (LVAD) therapy and remains a challenging issue. Data on device thrombosis management, especially on the application of direct thrombin inhibitors such as argatroban, is limited and a consensus on thrombosis management has not yet been established., Methods: In this study we analysed retrospective clinical data obtained from 26 patients on VAD therapy who received argatroban for suspected VAD thrombosis, between April, 2012 and February, 2017., Results: Thirteen patients (50%) showed resolution of thrombus after argatroban therapy. Eight of 26 patients (30.8%) were free of thrombotic events 90 days after discharge. Argatroban therapy was unsuccessful in 13 patients of the study cohort, leading to subsequent VAD-exchange. Six of 13 patients with first VAD-exchange had no thrombotic events 90 days after discharge. Six patients (23.1%) suffered from bleeding, especially gastrointestinal bleeding. No hemorrhagic strokes were observed. Three patients (11.5%) did not survive the follow-up period., Conclusions: Argatroban appears to be an alternative to other pharmacological treatment options in VAD thrombosis. Efficacy and safety characteristics are acceptable, but further investigation on larger populations is necessary., Competing Interests: Conflicts of Interest: JD Schmitto and G Dogan are consultants of Medtronic Corporation. JD Schmitto receives consultation fees and financial grants from Abbott Laboratories. The other authors have no conflicts of interest to declare.

Background: Left ventricular assist device (LVAD) (HVAD, Medtronic, Minneapolis, MN, USA) implantation is already a widely accepted treatment option for end-stage heart failure (HF) but also still considered as a rescue therapy for patients suffering from cardiogenic shock. Standard LVAD implantation techniques are often associated with high mortality rates and can result in severe complications, like bleeding or right heart failure (RHF). The aim of our study was to assess the outcome of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (so called "crash and burn" patients) undergoing a LVAD implantation by standard or less invasive surgery., Methods: We performed a retrospective evaluation of the 1-year outcome of 32 consecutive HF patients in cardiogenic shock, who underwent LVAD implantation in our institution. A total of 32 INTERMACS 1 patients were emergently operated. Fourteen patients (group A) were operated by using the "Hannover-VAD-technique", which is widely known to be less invasive (upper hemisternotomy and a left-sided anterolateral thoracotomy). In contrast, 18 patients (group B) were implanted with LVAD by using the standard technique (full sternotomy). The primary endpoint was survival after 1 year without device-related re-operations. Secondary endpoints included combined analyses of rates of RHF, respiratory failure and bleeding during the trial period., Results: Baseline characteristics were similar in both groups. Survival after 1 year was higher in group A (69.7% vs. 50.0%). Technique-related adverse events (AEs) were also lower in the minimally invasive group, including a lower RHF (35.7% vs. 61.1%) and of further postoperative bleeding requiring surgery (14.3% vs. 33.3%)., Conclusions: LVAD surgery in INTERMACS 1 patients is associated with remarkably good outcome considering the already very high mortality of those patients, and compared to previously reported surgical outcomes. Our study indicates that minimally invasive LVAD implantation in cardiogenic shock decreases mortality and the incidence of postoperative AEs., Competing Interests: Conflicts of Interest: JD Schmitto and G Dogan are consultants of Medtronic; LC Napp received lecture honoraria from Abiomed and Maquet. The other authors have no conflicts of interest to declare.

Background: End-stage heart failure is associated with severe after-effects such as heart valve insufficiency, cardiac arrhythmias or end-organ dysfunctions. Renal failure or 'cardiorenal syndrome' is a critical end-organ disorder associated with advanced heart failure, which occurs due to low-output failure. Drug therapy or surgical interventions involving left ventricular assist device (LVAD) implantation may impede the progress of heart insufficiency and its after-effects including renal failure. In this study, we investigated the impact of a minimally invasive ventricular assist device implantation through upper hemisternotomy combined with anterolateral thoracotomy on renal function, in patients with perioperative renal failure., Methods: We analyzed data obtained from 103 patients (80 males, 23 females; mean age 53.8±11.7) who underwent LVAD implantation at our clinic within a 15-year interval (2001-2016) and were dialyzed due to renal dysfunction. 90 patients were operated with the conventional LVAD implantation technique (standard approach surgery, SAS) and 13 underwent less invasive approach implantation (less invasive surgery, LIS)., Results: For all patients, data analysis showed significant increase of glomerular filtration rate (GFR) (44.2±56.48 mL/min; 95% CI: 33.81-55.28; P<0.001) along with a significant decrease in the levels of creatinine (-1.08±1.83 mg/dL; 95% CI: 0.75-1.46; P<0.001) and urea (-4.62±13.66 mmol/L; 95% CI: 1.95-7.29; P<0.001). There was a considerable difference in change of renal parameters in patients treated with LIS in comparison to patients who underwent SAS, which was however not statistically significant (GFR: P=0.494; creatinine: P=0.543; urea P=0.918)., Conclusions: LVAD implantation improves kidney function in patients with renal dysfunction. A considerable difference in the change of renal parameters was detected in patients with LIS as compared to SAS, which was not significant possibly due to the limited size of the patient cohort (n=13)., Competing Interests: Conflicts of Interest: JDS is a consultant for Thoratec Corporation as well as HeartWare Inc. The other authors have no conflicts of interest to declare.

Background: Pump thrombosis is the most severe and acute complication of left ventricular assist device (LVAD) therapy and treatment remains challenging. Whilst lysis therapy is often not successful, the exchange of the occluded LVAD is currently the most applied therapeutic treatment for this event. With this study we examine the effects of minimal-invasive LVAD exchange on the rate re-thrombosis and outcomes as well as adverse events in the study group., Methods: Between February 2004 and December 2015 more than 600 LVADs were implanted at our institution. We retrospectively studied a patient cohort of 41 patients who underwent LVAD exchange because of pump thrombosis at a single institution. Outcomes, rates of re-thrombosis and adverse events were analyzed., Results: Between February 2004 and December 2015, 87 exchanges of LVADs were performed at a single center. In 41 cases pump thrombosis was the reason for LVAD exchange. A total of 28 patient years (10,276 days) were analyzed. Average ICU stay was 15.8±20.4 days and average in-hospital stay 38.1±37.3 days after LVAD exchange. After thirty days the survival rate was 80.5%, 75.6% after 6 months and 70.7% one year after LVAD exchange. Out of the study cohort, three patients have successfully undergone heart transplantation. Twelve patients suffered a stroke postoperatively (29%). Twelve patients needed postoperative dialysis (29%). No technical complications of the VAD were recorded in the study group. Two patients underwent successful LVAD explantation due to myocardial recovery. One year after LVAD exchange, 14 patients underwent re-exchange due to pump thrombosis (34%). Eight patients suffered from a LVAD related infection out of which two patients were treated by pump exchange. A total of 12 patients died during the complete one year follow up of this study (29%). Four patients died in the second, two in the third and one in the fourth year after LVAD exchange. The remaining 17 patients are still ongoing on the device. Conclusions: It is generally feasible to treat pump thrombosis via LVAD exchange. Yet, the exchange procedure is not without risk and the risk of re-thrombosis (34%), stroke (29%), postoperative dialysis (29%) and perioperative complications remains high., Competing Interests: Conflicts of Interest: JD Schmitto receives consultation fees from Thoratec Cooperation. JD Schmitto and G Dogan are consultants for HeartWare Cooperation. The other authors have no conflicts of interest to declare.

Background: Pressure ulcers are a major healthcare problem and caused by pressure and shear-forces. Although shear-force is understood to be a major contributing factor, no preventive interventions are specifically aimed at relieving the effect of shear on skin to improve skin viability., Methods: A physical model was used to apply a combined loading of 2.4kPa pressure and 14.5N shear-force on skin in humans. Loading was applied on the volar aspect of both forearms for 30min in ten healthy volunteers. One arm received loading on skin with a wound dressing, the other arm (control) received loading directly on skin. The following parameters were determined before and after loading: IL-1α/Total Protein-ratio (used as a measure of skin damage); Cutaneous blood cell flux ((CBF) measure of reactive hyperaemia); Lactate concentration (measure of tissue ischemia). Three different dressings were tested on three different days. The order of dressing application, dressing arm and start of the intervention were randomized., Results: Participants mean age was 22.5±1.6 year with a BMI of 22.3±2.4kg/m(2). IL-1α/Total Protein-ratio of the skin was significantly lower after the application of pressure and shear when the Mepilex® (P<0.01), Allevyn (P<0.05) or Aquacel(TM) dressing (P<0.01) was used compared with the control measurement. The Mepilex® dressing was more effective in reducing post-load IL-1α/Total Protein-ratio compared to the Allevyn dressing (P<0.01). Post-load CBF was significantly lower when the Mepilex® or Aquacel dressing was used (P<0.001). Both dressings induced significantly less post-load CBF than the Allevyn dressing (P<0.01 and P<0.001, respectively). The concentration of lactate was not significantly increased after the application of pressure and shear and could not be used as a measure with this model., Conclusion: This is the first in vivo study to demonstrate that the effects of pressure in combination with shear on skin viability can be improved with foam dressings. In this study, the multi-layered dressings perform better than the single-layered dressing., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The toxicity and antileishmanial activity of 20 betulin derivatives were studied. The toxicity of betulin and synthesized compounds was determined using a bacterial test (Microtox) and two mammalian cell lines (CHO-K1 and J774). The antileishmanial activity of compounds (50  μM) was examined in both the promastigote and intracellular amastigote stages of Leishmania infantum and L. donovani. No correlation was found among the toxicity tests. All the compounds showed significant antipromastigote activity. The antiproliferative capacity of derivatives was dependent on the parasite stage studied, and no substantial differences were found between Leishmania species. Betulin, 3,28-di-O-acetylbetulin and L-aspartyl amide of betulonic acid showed moderate activity against amastigotes. The highest inhibition of intracellular amastigote multiplication was achieved with a low micromolar concentration (IC(50) ca 9  μM) of heterocyclic betulin derivative 3,28-di-O-acetyllup-13(18)-ene with N-ethyltriazolo moiety 16, without significant toxicity for mammalian cells. These results point to the interest of this lead compound for further in vitro and in vivo tests.