Showing papers by "Heinz Jakob published in 2017"

Safety of Simultaneous Coronary Artery Bypass Grafting and Carotid Endarterectomy Versus Isolated Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

Abstract: Background and Purpose—The optimal operative strategy in patients with severe carotid artery disease undergoing coronary artery bypass grafting (CABG) is unknown. We sought to investigate the safet...

Aortic diameter remodelling after the frozen elephant trunk technique in aortic dissection: results from an international multicentre registry.

Abstract: Objectives The frozen elephant trunk (FET) technique allows one-stage hybrid repair approach in aortic dissection (AoD). Even if the effect of the FET technique on promoting false lumen (FL) thrombosis has been proved in the past, the relative importance of FL thrombosis on aortic remodelling at different levels of the distal aorta and the magnitude of this effect is not well known. The aim of the study was to evaluate aortic remodelling following a FET technique for AoD. Methods A multicentre international registry database was searched to identify all patients who underwent a FET procedure for an AoD. A total of 383 patients with AoD were operated on between January 2005 and March 2014 with the FET technique; 137 patients (65 acute AoD and 72 chronic AoD) who survived the initial repair with at least a 1-year follow-up CT scan were included in the study. Results The rate of FL thrombosis was higher in the mid-descending thoracic aorta (99.3%) and lower in the distal abdominal aorta (13.9%) but similar between acute and chronic AoDs. The negative remodelling rate was similar between acute and chronic AoDs in the abdominal aorta, but chronic AoD exhibited a higher rate of negative remodelling in the descending thoracic aorta (33% vs 17.5%, P = 0.040). Conclusions The FET technique provides an effective treatment for AoD, promoting FL thrombosis and remodelling in the descending thoracic aorta. Changes in the diameter of the aortic lumen depend mainly on the status of the FL and are similar between acute and chronic AoD. Changes in the diameter of true lumen are affected by both the FL status and the timing of the presentation. However, increased FL thrombosis and positive remodelling rates are not maintained at the level of the abdominal aorta, and strict follow-up is mandatory to detect early changes in the aortic dimensions, which may warrant further interventions.

Long-term experience with the E-vita Open hybrid graft in complex thoracic aortic disease†

Abstract: Objectives The E-vita Open hybrid stent graft is intended to achieve one-stage treatment of the proximal and distal thoracic aorta down to the mid-thoracic level in cases of acute (AAD) or chronic (CAD) type I aortic dissection and complex thoracic aortic aneurysm (TAA). We report our long-term results up to 10-year experience. Methods From February 2005 until March 2015, 178 consecutive patients (mean age 59 ± 11 years) underwent surgery using the E-vita Open hybrid graft for AAD ( n = 96), CAD ( n = 43) or TAA ( n = 39). Pre-, intra- and postoperative variables, influential procedural improvements and follow-up data including aortic remodelling analyses are presented. Results Overall 30-day mortality was 10%, 10% for AAD, 7% for CAD and 13% for TAA. Univariable analysis identified low left ventricular ejection fraction, peripheral arterial disease, chronic obstructive pulmonary disease and severely compromised haemodynamics as risk factors for in-hospital death. Logistic regression analysis defined compromised haemodynamics and duration of cardiopulmonary bypass as significant. After 7 years, estimated survival was 55% for AAD, 74% for CAD and 73% for TAA patients. Freedom from aorta-related late death was 94%, 91% in AAD, 100% in CAD and 97% in TAA. Positive or stable aortic remodelling down to the stent graft end was achieved in 92% AAD, 82% in CAD and full aneurysmal exclusion in 88%. Further downstream, negative remodelling was observed in 27% of the AAD, 41% of the CAD and 22% of the TAA patients. Freedom from endovascular intervention downstream was 96% in AAD, 75% in CAD and 74% in TAA patients. Freedom from thoraco-abdominal surgery was 97%, 65% and 93%, respectively. Conclusions The E-vita Open hybrid stent graft renders durable long-term performance without any proximal endoleakage or graft failure over time and represents the ideal landing or docking zone for either thoracic endovascular thoracic repair or thoraco-abdominal surgery, if required. No reinterventions were necessary down to the end of the stent graft, proving that the disease is overcome along the hybrid graft down to mid-thoracic level.

Accuracy of a diagnostic strategy combining aortic dissection detection risk score and D-dimer levels in patients with suspected acute aortic syndrome.

Abstract: Aims:The European Society of Cardiology recently proposed a novel diagnostic algorithm combining the aortic dissection detection (ADD) risk score with D-dimer level assessment for detecting acute aortic syndromes (AASs) in patients presenting with chest pain. The diagnostic accuracy of this strategy is yet to be validated.Methods:We retrospectively identified 376 patients with chest pain and available D-dimer on admission to the emergency department of our institution between January 2011 and May 2014. The ADD risk score was calculated using retrospective blinded chart review. A score ⩽1 was defined as ‘low probability’, whereas a score >1 as ‘high probability’. AASs were diagnosed in 85 (22.6%) patients.Results:Patients with AAS more frequently had a ‘high probability’ score than AAS-negative patients (63.5% vs 1.0%; P<0.001). An ADD risk score ⩾1 had a sensitivity of 98.8% and a specificity of 64.6% for diagnosing AAS with a failure rate of 0.5%, whereas an ADD risk score ⩾2 had a sensitivity of 63.5% a...

Minimal access versus conventional aortic valve replacement: a meta-analysis of propensity-matched studies.

Abstract: Conventional aortic valve replacement (CAVR) via a full sternotomy is the standard surgical approach for aortic valve replacement. Minimal access aortic valve replacement (MAAVR) is commonly performed via a partial sternotomy and a right minithoracotomy. Such procedures aim not only to reduce the invasiveness but to offer the same quality, safety and results of the conventional approach. Our goal was to compare both procedures by performing a meta-analysis of reports with risk adjustment that performed a propensity-matched analysis. Relevant articles were searched for in Medline, the Cochrane Database of Systematic Reviews and the Scopus database based on predefined criteria and end-points. The early and late outcomes and complications were compared in the selected studies. A total of 4558 patients from 9 studies were enrolled; 2279 (50%) underwent CAVR and 2279 (50%) underwent MAAVR. There was a significantly lower rate of postoperative low output syndrome (1.4% vs 2.3%, P = 0.05) and atrial fibrillation (11.7% vs 15.9%, P = 0.01) in the MAAVR than in the CAVR group, respectively. In contrast, aortic cross-clamp and cardiopulmonary bypass times were significantly longer in the MAAVR group (P < 0.05). Finally, the incidence of early deaths (1.5% vs 2.2%, P = 0.14), stroke (1.4% vs 2%, P = 0.20), myocardial infarction (0.4% vs 0.5%, P = 0.65), renal injury (4.5% vs 6%, P = 0.71), respiratory complications (9% vs 10.1%, P = 0.45), re-exploration for bleeding (4.9% vs 4.1%, P = 0.27) and pacemaker implantation (3.3% vs 4.1%, P = 0.31) was similar in both groups, respectively. In summary, even though MAAVR procedure, either through partial sternotomy or right minithoracotomy, provides patient satisfaction due to the smaller incision and better cosmetics, MAAVR is as safe as the CAVR procedure. Although MAAVR takes slightly longer, it was not associated with greater cardiopulmonary bypass-related adverse effects. Interestingly, MAAVR shows a lower incidence of low cardiac output syndrome and atrial fibrillation.

Potential humoral mediators of remote ischemic preconditioning in patients undergoing surgical coronary revascularization

Abstract: Remote ischemic preconditioning (RIPC) by repeated brief cycles of limb ischemia/reperfusion may reduce myocardial ischemia/reperfusion injury and improve patients‘ prognosis after elective coronary artery bypass graft (CABG) surgery. The signal transducer and activator of transcription (STAT)5 activation in left ventricular myocardium is associated with RIPC´s cardioprotection. Cytokines and growth hormones typically activate STATs and could therefore act as humoral transfer factors of RIPC´s cardioprotection. We here determined arterial plasma concentrations of 25 different cytokines, growth hormones, and other factors which have previously been associated with cardioprotection, before (baseline)/after RIPC or placebo (n = 23/23), respectively, and before/after ischemic cardioplegic arrest in CABG patients. RIPC-induced protection was reflected by a 35% reduction of serum troponin I release. With the exception of interleukin-1α, none of the humoral factors changed in their concentrations after RIPC or placebo, respectively. Interleukin-1α, when normalized to baseline, increased after RIPC (280 ± 56%) but not with placebo (97 ± 15%). The interleukin-1α concentration remained increased until after ischemic cardioplegic arrest and was also higher than with placebo in absolute concentrations (25 ± 6 versus 16 ± 3 pg/mL). Only interleukin-1α possibly fulfills the criteria which would be expected from a substance to be released in response to RIPC and to protect the myocardium during ischemic cardioplegic arrest.

Diagnostic role and prognostic implications of D-dimer in different classes of acute aortic syndromes.

Abstract: Background:The role of D-dimer (D-d) as a diagnostic biomarker and its prognostic value in patients with intramural hematoma (IMH) or penetrating aortic ulcer (PAU) are unknown.Methods:Clinical dat...

Early and long-term cognitive outcome after conventional cardiac valve surgery.

Abstract: Objectives Adverse cognitive outcome is well recognized after coronary artery bypass grafting (CABG) while little is known about the extent and duration of decline after cardiac valve surgery. We investigated changes in cognitive function following conventional cardiac valve surgery over up to 4 years. Methods Among 36 patients (65.2 ± 9.2 years, 36% women) who received valve surgery, we assessed serial cognitive function with a battery of 11 standardized tests across 3-4 years. Cognitive function was analysed to identify: (1) cognitive decline (i.e. within-patient changes in test scores) and (2) cognitive deficit (i.e. drop of score ≥1 SD in ≥3 tests). Diffusion-weighted magnetic resonance imaging (DW-MRI) was applied pre- and post-procedure to detect ischaemic brain injury. Data were compared to a historical cohort of 39 patients undergoing CABG. Results After both valve surgery and CABG, a significant decline at discharge was detected in 7 of 11 cognitive tests. The rate of patients with a cognitive deficit after valve surgery vs CABG was 39% vs 56% at discharge, 14% vs 23% at 3 months, and 16% vs 26% at 3-4 years (not significant, [n.s.]). After valve surgery, DW-MRI identified 19 (53%) patients with evidence of 50 new focal ischaemic lesions (CABG: 20 [51%] patients with 42 lesions, n.s.). Cumulative cerebral ischaemic load per patient was not significantly different between the valve surgery group and CABG group (503 ± 485 mm 3 vs 415 ± 234 mm 3 ). After correction for multiple potential risk factors in both groups, reduced verbal memory at discharge could be identified as a predictor of long-term cognitive impairment in CABG patients only ( P = 0.04). For both the valve surgery and CABG group, no association between cognitive impairment and new ischaemic cerebral lesions was found. Conclusions The course of cognitive performance after valve surgery and CABG was similar with early postoperative decline followed by subsequent recovery. Although silent small brain infarcts were present in about half of all patients, they did not impact cognitive performance neither at early nor during long-term follow-up.

The impact of entries and exits on false lumen thrombosis and aortic remodelling.

Abstract: OBJECTIVES In DeBakey Type I acute aortic dissection, the frozen elephant trunk technique is used for the combined treatment of both the proximal and distal thoracic aorta. Anatomical characteristics of the distal aorta and their impact on false lumen (FL) thrombosis and aortic remodelling were analysed in this study. METHODS Sufficient pre-, postoperative, and at least one 1-year follow-up computed tomography data sets were available for 63 of 94 patients treated with the frozen elephant trunk for Type I acute aortic dissection between March 2005 and March 2015. Aortic remodelling and FL thrombosis quotients were calculated volumetrically at the stent graft level (A), from A to the coeliac trunk (B) and from B to the bifurcation (C) and were correlated with the number and size of entry tears and aortic branches arising from the FL (exits) in each segment. RESULTS Positive or stable remodelling was found in Segments A (94%), B (64%) and C (54%), and the FL thrombosis quotient was 98% in A, 68% in B and 39% in C within the first year. FL thrombosis correlated negatively with the total size of the entry (P<0.001) and the number of exits (P<0.001) and positively with the number of true-lumen branches (P<0.001). The exit number was a risk factor for FL patency and a predictor of negative remodelling. CONCLUSIONS Using frozen elephant trunk technique to treat Type I acute aortic dissection facilitates positive or stable remodelling in nearly all patients at the stent graft level and distally in two-thirds of the patients. FL thrombosis and aortic remodelling are negatively influenced by the number of exits. New endovascular concepts aiming at reducing the number of exits may prevent negative remodelling.

Impact of Preoperative Anemia and Postoperative Hemoglobin Drop on the Incidence of Acute Kidney Injury and In-Hospital Mortality in Patients With Type B Acute Aortic Syndromes Undergoing Thoracic Endovascular Aortic Repair.

Abstract: Background:The impact of preoperative anemia and postoperative hemoglobin (Hb) drop on the incidence of acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) for type B acute ...

Proteomics/phosphoproteomics of left ventricular biopsies from patients with surgical coronary revascularization and pigs with coronary occlusion/reperfusion: remote ischemic preconditioning

Abstract: Remote ischemic preconditioning (RIPC) by repeated brief cycles of limb ischemia/reperfusion reduces myocardial ischemia/reperfusion injury. In left ventricular (LV) biopsies from patients undergoing coronary artery bypass grafting (CABG), only the activation of signal transducer and activator of transcription 5 was associated with RIPC’s cardioprotection. We have now used an unbiased, non-hypothesis-driven proteomics and phosphoproteomics approach to analyze LV biopsies from patients undergoing CABG and from pigs undergoing coronary occlusion/reperfusion without (sham) and with RIPC. False discovery rate-based statistics identified a higher prostaglandin reductase 2 expression at early reperfusion with RIPC than with sham in patients. In pigs, the phosphorylation of 116 proteins was different between baseline and early reperfusion with RIPC and/or with sham. The identified proteins were not identical for patients and pigs, but in-silico pathway analysis of proteins with ≥2-fold higher expression/phosphorylation at early reperfusion with RIPC in comparison to sham revealed a relation to mitochondria and cytoskeleton in both species. Apart from limitations of the proteomics analysis per se, the small cohorts, the sampling/sample processing and the number of uncharacterized/unverifiable porcine proteins may have contributed to this largely unsatisfactory result.

Transfemoral transcatheter aortic valve implantation in patients with end-stage renal disease and kidney transplant recipients

Abstract: Transcatheter aortic valve implantation (TAVI) has evolved to a treatment of choice in high-risk patients and is therefore ideal for patients with advanced chronic kidney disease, as patients with end-stage renal disease and kidney transplant recipients. Especially, outcome of this special patient group is very important. 22 patients with chronic kidney disease stage 5 undergoing intermittent hemodialysis treatment (CKD 5D) and 8 kidney transplant recipients (KT) with severe aortic valve stenosis underwent transfemoral TAVI. TAVI was successfully performed in all patients. Postinterventional acute kidney injury (AKI) occurred in four kidney transplant recipients (KDIGO grade 1: n = 3, grade 3: n = 1) but creatinine/eGFR returned to baseline values in all patients. Short-term (30-day) mortality was 3% (1 patient in CKD 5D group). KT had a higher 2-year mortality than CKD5D patients (31% vs. 53%; p = 0.309), and cause of death was non-cardiac because of sepsis in all cases. The amount of contrast medium during TAVI was not associated with the development of acute kidney injury. TAVI is feasible in patients with CKD5D and in KT. Postinterventional AKI in these patients is often mild and does not impact renal function at day 30, while infection/ sepsis is the leading cause of mid-term mortality.

The aspartate transaminase/alanine transaminase (DeRitis) ratio predicts mid-term mortality and renal and respiratory dysfunction after left ventricular assist device implantation.

Abstract: Objectives Preoperative liver dysfunction is a well-known risk factor for adverse events after major surgery. However, there is only little data regarding the precise role of the Model of End-Stage Liver Disease (MELD) score and the De Ritis ratio (DRR, alanine transaminase/aspartate aminotransferase) as a predictor for outcome after left ventricular assist device (LVAD) implantation. Methods A retrospective analysis of all patients undergoing LVAD implantation at our institution between January 2012 and August 2014 was performed. The primary outcome was survival at 180 days after surgery. Results During the observation period, 63 patients underwent LVAD implantation (mean age 59.9 ± 8.3 years, 50% male). Mean preoperative ejection fraction was 16.3 ± 7.7, 13 patients required preoperative renal replacement therapy and 9 patients were on extracorporeal life support. Mean Interagency Registry for Mechanically Assisted Circulatory Support level was 2.8 ± 1.3, mean preoperative MELD was 12.7 ± 7.2, mean preoperative DRR was 2.01 ± 4.4. Aspartate aminotransferase (102 ± 220.8 vs 57.8 ± 123.4 U/l, P = 0.041), MELD score (16.1 ± 8.8 vs 11.4 ± 6.1, P = 0.017) and DRR (4.2 ± 7.8 vs 1.1 ± 1.1, P = 0.001) were significantly higher in non-survivors than in survivors after 180 days. Using logistic regression analyses, a DRR >1.37 was an independent predictor for 30-day mortality [odds ratio (OR) 4.5] and 180-day mortality (OR 4.1). In addition, the DRR was associated with postoperative acute kidney injury with need for renal replacement therapy (OR 4.2) and prolonged postoperative ventilation time >72 h (OR 3.8). Using receiver operator characteristics analyses, DRR showed a sensitivity of 0.80 and a specificity of 0.81 (area under the curve 0.834, cut-off 1.37) for 180-day mortality. Conclusions The DRR is predictive of early and mid-term mortality as well as relevant morbidities in patients undergoing LVAD implantation. Therefore, the DRR should be considered within the preoperative risk stratification and patient selection for LVAD implantation.

Transcatheter aortic valve implantation (TAVI) in patients with aortic regurgitation

Abstract: Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly high-risk patients presenting severe and symptomatic aortic valve stenosis, while surgical aortic valve replacement (sAVR) is still considered as the treatment of choice for younger patients and patients with low and intermediate risk profiles (1,2). With more than 100,000 implants worldwide, TAVI has changed the paradigm in the treatment of aortic valve stenosis. The principle concept of TAVI is based on implanting a balloonor self-expandable transcatheter heart valve into the calcified native aortic annulus (3). Therefore, a certain amount of aortic annulus and/or valve calcification is presumably essential to anchor the valvemounted stent-frame into the annulus. This follows from the fact that, pure, severe aortic regurgitation has been considered as a relative contraindication to TAVI due to the absence of aortic calcification. This is also reflected by the instructions for use of all commercial TAVI systems. On the other hand, there is clearly an unmet clinical need for TAVI as high-risk patients frequently present with a combined aortic valve disease with predominant regurgitation without a reasonable amount of calcium or even pure aortic regurgitation without any aortic valve calcification. Up to now, those patients were mostly treated by sAVR. More recent experiences with TAVI in patients with aortic regurgitation has been reported in several case reports and small clinical studies. The first successful cases were reported as ‘off-label’ procedures by using the CoreValveTM (Medtronic, Minneapolis, Minnesota, USA) as well as the Edwards Sapien THV system (Edwards Lifesciences LLC, Irvine, CA, USA) (4-6). Since then, the only approved valve system to be used in pure aortic regurgitation is the JenaValveTM prosthesis (JenaValve Technology GmbH, Munich, Germany) (7,8). The J-valveTM system (JC Medical, Inc. Burlingame, CA, USA and Suzhou, China), a recently introduced new, also selfexpandable TAVI-system has also been used in pure aortic regurgitation (9) and just recently, the LotusTM valve system (Boston Scientific, Marlborough, MA, USA) was reported to be used successfully for treatment of patients with pure aortic regurgitation. Another interesting concept of a selfexpandable transcatheter valve, the Symetis ACURATE TATM device (Symetis S.A., Ecublens, Switzerland) has been introduced firstly for pure aortic regurgitation by our Essen TAVI group (10), being the largest single-center study published so far. In the following, a case example of a high-risk patient suffering from symptomatic pure aortic regurgitation undergoing a TAVI procedure is presented. This procedure was performed as a Live-case during the Aortic Live 2 Meeting in 2014 at the West-German Heart Center Essen.

Transient dilutional acidosis but no lactic acidosis upon cardiopulmonary bypass in patients undergoing coronary artery bypass grafting.

Abstract: INTRODUCTION Dilutional acidosis may result from the introduction of a large fluid volume into the patients' systemic circulation, resulting in a considerable dilution of endogenous bicarbonate in the presence of a constant carbon dioxide partial pressure. Its significance or even existence, however, has been strongly questioned. Blood gas samples of patients operated on with standard cardiopulmonary bypass (CPB) were analyzed in order to provide further evidence for the existence of dilutional acidosis. MATERIAL AND METHODS Between 07/2014 and 10/2014, a total of 25 consecutive patients scheduled for elective isolated coronary artery bypass grafting with CPB were enrolled in this prospective observational study. Blood gas samples taken regularly after CPB initiation were analyzed for dilutional effects and acid-base changes. RESULTS After CPB initiation, hemoglobin concentration dropped from an average initial value of 12.8 g/dl to 8.8 g/dl. Before the beginning of CPB, the mean value of the patients' pH and base excess (BE) value averaged 7.41 and 0.5 mEq/l, respectively. After the onset of CPB, pH and BE values significantly dropped to a mean value of 7.33 (p < 0.0001) and -3.3 mEq/l (p < 0.0001), respectively, within the first 20 min. In the following period during CPB they recovered to 7.38 and -0.5 mEq/l, respectively, on average. Patients did not show overt lactic acidosis. CONCLUSIONS The present data underline the general existence of dilutional acidosis, albeit very limited in its duration. In patients undergoing coronary artery bypass grafting it seems to be the only obvious disturbance in acid-base homeostasis during CPB.

Does Traumatic Donor Cause of Death Influence Outcome after Lung Transplantation? A Single-Centre Analysis

Abstract: Background Owing to the shortage of donor organs in lung transplantation (LuTX), liberalization of donor selection criteria has been proposed. However, some studies suggested that donor traumatic brain damage might influence posttransplantation allograft function. This article aimed to investigate the association of donor cause of death (DCD) and outcome after LuTX. Methods A retrospective analysis of 186 consecutive double LuTXs at our institution from January 2000 to December 2008 was performed. DCD was categorized into traumatic brain injury (TBI) and nontraumatic brain injury (NTBI). In addition, NTBI was sub classified as spontaneous intracerebral bleeding (B), hypoxic brain damage (H), and intracerebral neoplasia (N). Results DCD was classified as TBI in 50 patients (26.9%) and NTBI in 136 patients (73.1%): B in 112 patients (60.2%), H in 21 patients (11.3%), and N in 3 patients (1.6%). Young male donors predominated in group TBI (mean age 36.0 ± 14.5 vs. 42.8 ± 10.7, p < 0.01; 29 males in the TBI group [58.0%] vs. 48 males in the NTBI group [35.3%], p < 0.01). Groups of DCD did not differ significantly by recipient age or gender, recipient diagnosis, donor ventilation time, or paO2/FiO2 before harvesting. TBI donors received significantly more blood (3.4 ± 3.8 vs. 1.8 ± 1.9, p = 0.03). A chest trauma was evident only in group T (n = 7 [3.7%] vs. 0 [0%], p < 0.001). Mode of donor death did not affect the following indices of graft function: length of postoperative ventilation, paO2/FiO2 ratio up to 48 hours, and lung function up to 36 months. One- and three-year survival was comparable with 84.4 and 70.4% for TBI donors versus 89.4% and 69.2% for NTBI donors. Five-year survival tended to be lower in the TBI group but did not reach statistical significance (43.4 vs. 53.9%). Conclusion This study indicates that traumatic DCD does not affect outcome after LuTX. These results can be achieved with an ideal donor management combined with an individual case-to-case evaluation by an experienced LuTX surgeon.

Impact of previous cardiac surgery in patients undergoing transcatheter aortic valve implantation: a systematic review.

Abstract: Introduction Redo surgical aortic valve replacement after prior cardiac surgery is usually related to a higher risk of mortality and morbidity. Transcatheter aortic valve implantation (TAVI) became an alternative therapy for those patients in the past couple of years. Evidence acquisition We aimed in this study to analyze the outcomes of patients undergoing TAVI after a prior cardiac surgery especially those who underwent coronary artery bypass grafting (CABG) and to see if TAVI offers any advantages for those patients than conventional surgical aortic valve replacement. Evidence synthesis We searched for relevant articles in Medline and abstracted clinical information based on pre-defined criteria and endpoints. Data of nine studies including the baseline characteristics, implantation data, postoperative outcomes and major adverse cardiac complications, which were published between 2011 and 2015 were collected and evaluated. From all reviewed studies, 769 patients had a prior cardiac surgery and underwent TAVI for symptomatic severe aortic stenosis. Of these, 738 patients (96%) had prior CABG. Patients' age ranged from 78±3 to 82±5.8 years. The STS and EuroSCORE ranged from 4.5±3% to 14.7±12.3% and 25.6±16.2% to 37±18%, respectively. In all reviewed studies the 30-day mortality was about 5.6% and was not significantly higher compared to patients with no history of prior cardiac surgery. The total incidence of stroke was about 3.6%, myocardial infarction was 1.7%, acute kidney injury was 13.8% and permanent pacemaker implantation was about 14.2%. Conclusions However, patients presented with severe aortic valve disease after a previous cardiac surgery exhibited a higher preoperative STS and EuroSCORE than those without previous cardiac surgery. The 30-day mortality was not significantly higher in comparison to those patients without history of prior cardiac surgery. According to that, transcatheter aortic valve implantation should be considered as an attractive alternative for those patients.

Statin Therapy in Patients Undergoing Coronary Artery Bypass Grafting for Acute Coronary Syndrome.

Abstract: Background This study evaluates whether preoperative statin therapy improves clinical outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS). Methods A total of 1,151 patients undergoing CABG for ACS were prospectively entered into the North-Rhine-Westphalia surgical myocardial infarction registry and subdivided into two groups according to their preoperative statin status (statin naive vs. statin group). A logistic regression model was employed to analyze the impact of a statin therapy and dose for the endpoints in-hospital mortality and major adverse cardiac events (MACE). Results Demographics, pre- and intraoperative data of the statin-naive group (n = 208; 18%) and statin-treated group (n = 943, 82%) did not differ. In-hospital mortality (12.6 vs. 6.3%, p = 0.002) and MACE rates (22.1 vs. 9.7%, p Conclusion Statin therapy in patients with ACS undergoing CABG reduces in a dose-independent manner in-hospital mortality and MACE.

Postoperative Compensatory Ammonium Excretion Subsequent to Systemic Acidosis in Cardiac Patients.

Abstract: Background Postoperative acid-base imbalances, usually acidosis, frequently occur after cardiac surgery In most cases, the human body, not suffering from any severe preexisting illnesses regarding lung, liver, and kidney, is capable of transient compensation and final correction The aim of this study was to correlate the appearance of postoperatively occurring acidosis with renal ammonium excretion Materials and Methods Between 07/2014 and 10/2014, a total of 25 consecutive patients scheduled for elective isolated coronary artery bypass grafting with cardiopulmonary bypass were enrolled in this prospective observational study During the operative procedure and the first two postoperative days, blood gas analyses were carried out and urine samples collected Urine samples were analyzed for the absolute amount of ammonium Results Of all patients, thirteen patients developed acidosis as an initial disturbance in the postoperative period: five of respiratory and eight of metabolic origin Four patients with respiratory acidosis but none of those with metabolic acidosis subsequently developed a base excess > +2 mEq/L Conclusion Ammonium excretion correlated with the increase in base excess The acidosis origin seems to have a large influence on renal compensation in terms of ammonium excretion and the possibility of an overcorrection

Combined Procedures in Cardiac and Vascular Surgery

Abstract: As a systemic disease, atherosclerosis often involves multiple vascular territories, and thus a considerable number of patients with coronary artery disease (CAD) have concurrent incidence of significant carotid artery stenosis. Apart from aortic atheromatous disease, carotid stenosis, particularly with radiographic demonstration of previous stroke or history of transient ischemic attack (TIA) within the last 6 months, is the most important factor for predicting an increased risk of perioperative stroke. Over more than four decades, there is ongoing debate as to which strategy is optimal with regard to the incidence of perioperative complications and long-term outcomes after coronary artery bypass grafting (CABG). In the absence of randomized controlled trials, no systematic evidence exists that staged or synchronous carotid revascularization and coronary revascularization confer any benefit over isolated CABG without carotid endarterectomy (CEA). Whereas in patients with symptomatic carotid stenosis scheduled for CABG, CEA performed by experienced teams achieving a combined rate of stroke or death at 30 days of <6 % may be beneficial, the situation is even more difficult in patients with asymptomatic carotid stenosis, particularly when it is unilateral. This is because any potential benefit conferred by prophylactic carotid revascularization may be offset by the increased risk of combined staged or synchronous procedures. Conversely, any evidence backing the isolated CABG approach that leaves the severe carotid stenosis untouched is just as scarce. Therefore, as long as clear regulations on the management of patients with CAD and carotid disease are not available, it is recommended to individualize the indication for carotid revascularization after discussion by a multidisciplinary team involving a neurologist and to determine the timing of the procedure by local expertise and clinical presentation, targeting the most symptomatic territory first. Although a considerable portion of patients requiring abdominal aortic aneurysm (AAA) repair have concurrent coronary artery disease, prospective randomized trials demonstrated that preventive CABG preceding major vascular procedures was not necessary. Similarly, the coexistence of CAD and peripheral artery disease is very common at 42 %, but only patients with acute coronary syndrome should not undergo elective vascular surgery.

Editorial comment on the RESPOND study

Abstract: It was a real pleasure to write an Editorial comment for this issue of the Journal of Thoracic Disease. We read with great interest the paper of Volkmar Falk, submitted to the European Heart Journal describing the safety and efficacy of the transcatheter Lotus™ valve (Boston Scientific Corporation, Marlborough, Massachusetts, USA) (1). In Essen, we had the great opportunity to be involved within the early and first-in-man implantation of the predecessor of the Lotus™ valve, the Sadra™ TAVI (transcatheter aortic valve implantation) system, in collaboration with Raimund Erbel and Eberhard Grube in 2007. The abovementioned paper summarized the results of a prospective, multi-centre, open-label and single-arm registry (RESPOND: Repositionable Lotus Valve System-Post Market Evaluation of Real World Clinical Outcomes) from 41 centres in Europe, New Zealand and Latin America in a total of 1,014 patients.

Role of regional aortic wall properties in the pathogenesis of thoracic aortic dissection.

Abstract: Objectives. The mechanisms of the location and extension of acute aortic dissection (AD) are only poorly understood. The aim of this study was to compare the cohesion of the non-coronary aortic sinus (NAS) and the ascending aortic wall (AA) using the Dissectometer – a new device for analyses of the mechanical properties of the aorta. Design. The properties of the aortic wall were analyzed with the “Dissectometer” (parameters P7, P8 and P9) in adult patients undergoing aortic root (AR) replacement in two different segments: NAS and AA. The aortic wall thickness (AWT) was measured with a micrometer. Results. Thirty-three adult patients (mean age 65 ± 14 years, 80% male) were included in this study. The aortic wall of the NAS was significantly thinner than that of the AA (1.9 ± 0.4 vs. 2.3 ± 0.4, p < 0.01). In contrast, mechanical stability assessed by cohesion testing was diminished in AA samples compared to NAS samples (P7: 86.0 ± 55.0 vs. 152.3 ± 89.2, p < 0.01; P8: 2.5 ± 1.3 vs. 6.0 ± 3.1, p < 0....

GNAQ TT(-695/-694)GC Polymorphism Is Associated with Increased Gq Expression, Vascular Reactivity, and Myocardial Injury after Coronary Artery Bypass Surgery.

Abstract: Background:Angiotensin II receptor type 1–mediated activation of the α-subunit of the heterotrimeric Gq protein evokes increased vasoconstriction and may promote hypertrophy-induced myocardial damage. The authors recently identified a TT(-695/-694)GC polymorphism in the human Gq promoter, the GC all