Showing papers by "Volkmar Falk published in 2017"

Standards defining a 'heart valve centre': esc working group on valvular heart disease and european association for cardiothoracic surgery viewpoint

Abstract: The increasing number of patients with heart valve disease and the wider range of therapeutic options now available, demands the standardization of organizational structures. The ‘heart valve clinic’ is already established as a specialist outpatient clinic linked with multidisciplinary inpatient care as well as education and training. Recent international guidelines extend this specialist concept to a ‘Heart Valve Centre of Excellence’ or ‘Heart Valve Centre’. These centres were proposed in order that durable mitral valve repair could be virtually guaranteed at close to zero risk in patients with asymptomatic severe mitral regurgitation caused by prolapse. The intention was that invasive valve interventions should not occur outside Heart Valve Centres. The standards defining such a centre have not previously been described and this is the purpose of this document. A Heart Valve Centre includes a heart valve clinic, but also multidisciplinary heart teams for the care of patients with mitral valve disease, tricuspid valve disease, diseases of the aorta and aortic valve and infective endocarditis (Table 1). [...]

A Soft Total Artificial Heart-First Concept Evaluation on a Hybrid Mock Circulation.

Abstract: The technology of 3D-printing has allowed the production of entirely soft pumps with complex chamber geometries. We used this technique to develop a completely soft pneumatically driven total artificial heart from silicone elastomers and evaluated its performance on a hybrid mock circulation. The goal of this study is to present an innovative concept of a soft total artificial heart (sTAH). Using the form of a human heart, we designed a sTAH, which consists of only two ventricles and produced it using a 3D-printing, lost-wax casting technique. The diastolic properties of the sTAH were defined and the performance of the sTAH was evaluated on a hybrid mock circulation under various physiological conditions. The sTAH achieved a blood flow of 2.2 L/min against a systemic vascular resistance of 1.11 mm Hg s/mL (afterload), when operated at 80 bpm. At the same time, the mean pulmonary venous pressure (preload) was fixed at 10 mm Hg. Furthermore, an aortic pulse pressure of 35 mm Hg was measured, with a mean aortic pressure of 48 mm Hg. The sTAH generated physiologically shaped signals of blood flow and pressures by mimicking the movement of a real heart. The preliminary results of this study show a promising potential of the soft pumps in heart replacements. Further work, focused on increasing blood flow and in turn aortic pressure is required.

Safety and efficacy of a repositionable and fully retrievable aortic valve used in routine clinical practice: the RESPOND Study

Abstract: Aims RESPOND is a prospective, open-label, single-arm study evaluating the outcomes following transcatheter aortic valve implantation (TAVI) with the repositionable and fully retrievable Lotus Valve used in routine clinical practice for the treatment of patients with aortic valve stenosis. Methods and results RESPOND enrolled 1014 patients at sites across Europe, New Zealand, and Latin America; 996 patients received a Lotus Valve (mean age: 80.8 years; 50.8% female; Society of Thoracic Surgeons score: 6.0 ± 6.9). Repositioning was attempted in 29.2% of patients, with 99% success. The rate of all-cause mortality in the intent-to-treat population at 30 days (primary endpoint) was 2.6% (P < 0.001 vs. pre-specified performance goal). Thirty-day clinical follow-up was completed for 97.3% of patients. Among patients who received a Lotus Valve, the 30-day overall and disabling stroke rates were 3.0% and 2.2%, respectively. The 30-day permanent pacemaker implantation rate was 30.0% in all patients, and 34.6% in pacemaker-naive patients. Echocardiographic data at baseline and pre-discharge were assessed by an independent core laboratory. Mean aortic valve gradient declined from 37.7 ± 15.2 mmHg at baseline to 10.8 ± 4.6 mmHg at hospital discharge (P < 0.001). Aortic valve area increased from 0.7 ± 0.2 cm2 at baseline to 1.8 ± 0.4 cm2 at discharge (P < 0.001). At hospital discharge, paravalvular leak (PVL) was absent or trace in 92% of patients; no patients had severe PVL, 0.3% of patients exhibited moderate PVL, and 7.7% of patients had mild PVL. Clinical follow-up in RESPOND will extend to 5 years. Conclusion The results of RESPOND confirm the safety and efficacy of TAVI with the Lotus Valve in routine clinical practice. Trial registration ClinicalTrials.gov #NCT 02031302.

Corrigendum to '2017 ESC/EACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg 2017;52:616-664].

Abstract: Corrigendum to ‘2017 ESC/EACTS Guidelines for the management of valvular heart disease’ [Eur J Cardiothorac Surg 2017;52:616-664]† Authors/Task Force Members: Volkmar Falk (EACTS Chairperson) (Germany), Helmut Baumgartner (ESC Chairperson) (Germany), Jeroen J. Bax (The Netherlands), Michele De Bonis (Italy), Christian Hamm (Germany), Per Johan Holm (Sweden), Bernard Iung (France), Patrizio Lancellotti (Belgium), Emmanuel Lansac (France), Daniel Rodriguez Mu~ noz (Spain), Raphael Rosenhek (Austria), Johan Sjögren (Sweden), Pilar Tornos Mas (Spain), Alec Vahanian (France), Thomas Walther (Germany), Olaf Wendler (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain)

Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review.

Abstract: Minimally invasive surgical mitral valve repair (MVRepair) has become routine for the treatment of mitral valve regurgitation, and indications have been expanded to include reoperations. Current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the management of valvular heart disease recommended standards in terms of mitral valve disease differentiation, timing of intervention and surgical techniques to improve patient care. Numerous minimally invasive techniques to lessen the invasiveness have been described, such as the minimal-access J-sternotomy (ministernotomy), the parasternal incision, the port-access technique and the right minithoracotomy. Despite the development of catheter-based techniques, surgical repair remains the gold standard today for nearly all patients with degenerative valvular diseases and the majority of patients with other types of valvular diseases. Techniques include resection of the prolapsed segment, neo-chordae implantation and ring annuloplasty. In this review, the current indications for mitral valve surgery are summarised and state-of-the-art MVRepair techniques are highlighted.

Рекомендации esc по диагностике и лечению острой и хронической сердечной недостаточности 2016

Abstract: 2016 ESC GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF ACUTE AND CHRONIC HEART FAILURE. The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Redo procedures for degenerated stentless aortic xenografts and the role of valve-in-valve transcatheter techniques.

Abstract: Objectives This study evaluates reinterventions for degenerated stentless aortic xenografts. Methods Between 2010 and 2015, 52 consecutive patients (age 72.3 ± 9.7 years, EuroSCORE II 11.1 ± 8.9%) underwent reintervention for failed stentless aortic valves (60% porcine, 40% pericardial, 87% sub-coronary, 81% isolated/combined regurgitation). Results Based on age, EuroSCORE II, the presence of pulmonary hypertension, renal failure, a patent internal mammary artery graft and required concomitant procedures, the heart team assigned 25 patients to reoperation and 27 to valve-in-valve transcatheter aortic valve implantation (ViV-TAVI). Valve implantation was successful in all surgical (24% root replacement) and in 24 transcatheter cases (93% trans-femoral, 56% balloon-expandable). Procedural complications were aortic dissection ( n = 1) during reoperation and coronary obstruction ( n = 4), device malpositioning ( n = 3), deployment of >1 valve ( n = 2) and vascular access site complications ( n = 2) during ViV-TAVI. Thirty-day mortality (10%, three ViV-TAVI patients, two surgical patients, P = 1.0) was associated with preoperative renal failure, >1 concomitant procedure, life-threatening bleeding, coronary obstruction and necessity for prolonged circulatory support. ViV-TAVI was beneficial regarding ventilation time, transfusion requirements and the incidence of sepsis. Overall, functional (94% New York Heart Association Class I/II) and echocardiographic results (indexed effective orifice area 0.95 ± 0.27 cm 2 /m 2 , mean transvalvular gradient 14 ± 6.8 mmHg) were favourable. After ViV-TAVI, aortic regurgitation was mild and moderate in two and three patients. One-year survival was 82.3 ± 5.4% and similar after surgery (83.1 ± 7.7%) and ViV-TAVI (81.5 ± 7.5%, P = 0.76). Conclusions Reinterventions for degenerated stentless aortic valves are challenging. Although ViV-TAVI is appropriate in high-risk patients, limitations and potential complications must be considered. Redo surgery has its place in low-risk patients and if concomitant procedures are required.

Left Ventricular Assist Devices Challenges Toward Sustaining Long-Term Patient Care

Abstract: Over the last few decades, the left ventricular assist device (LVAD) technology has been tremendously improved transitioning from large and noisy paracorporeal volume displacement pumps to small implantable turbodynamic devices with only a single transcutaneous element, the driveline Nevertheless, there remains a great demand for further improvements to meet the challenge of having a robust and safe device for long-term therapy Here, we review the state of the art and highlight four key areas of needed improvement targeting long-term, sustainable LVAD function: (1) LVADs available today still have a high risk of thromboembolic and bleeding events that could be addressed by the rational fabrication of novel surface structures and endothelialization approaches aiming at improving the device hemocompatibility (2) Novel, fluid dynamically optimized pump designs will further reduce blood damage (3) Infection due to the paracorporeal driveline can be avoided with a transcutaneous energy transmission system that additionally allows for increased freedom of movement (4) Finally, the lack of pump flow adaptation needs to be encountered with physiological control systems, working collaboratively with biocompatible sensor devices, targeting the adaptation of the LVAD flow to the perfusion requirements of the patient The interdisciplinary Zurich Heart project investigates these technology gaps paving the way toward LVADs for long-term, sustainable therapy

Interventional and surgical occlusion of the left atrial appendage.

Abstract: With a steadily increasing prevalence, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide and an independent risk factor for stroke caused by thromboembolic events. The left atrial appendage (LAA) is the primary source of thromboemboli in patients with nonvalvular AF who have a stroke. Novel strategies (such as mechanical and nonpharmacological intervention) targeting the LAA in patients with AF for stroke prevention have become a major focus during the past decade. Some devices for percutaneous LAA occlusion are supported by robust clinical data obtained from randomized trials or large registries, and are a valid alternative to pharmacological stroke prevention. However, the incidence of periprocedural complications and the presence of device-related thrombi or residual LAA leaks, whose long-term clinical implications are still unknown, are limiting factors in wider acceptability of these techniques. In this Review, we discuss the available techniques for LAA occlusion in patients with nonvalvular AF at high risk of stroke. We describe the pharmacological and mechanical approaches to LAA occlusion, and provide the current clinical evidence for various strategies. We particularly focus on the current management of the LAA, and discuss the challenges and future implications of the available approaches to LAA occlusion.

Adverse events while awaiting myocardial revascularization: a systematic review and meta-analysis

Abstract: OBJECTIVES The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.

Standards defining a 'Heart Valve Centre': ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint.

Abstract: The increasing number of patients with heart valve disease and the wider range of therapeutic options now available, demands the standardization of organizational structures. The ‘heart valve clinic’ is already established as a specialist outpatient clinic linked with multidisciplinary inpatient care as well as education and training. Recent international guidelines extend this specialist concept to a ‘Heart Valve Centre of Excellence’ or ‘Heart Valve Centre’. These centres were proposed in order that durable mitral valve repair could be virtually guaranteed at close to zero risk in patients with asymptomatic severe mitral regurgitation caused by prolapse. The intention was that invasive valve interventions should not occur outside Heart Valve Centres. The standards defining such a centre have not previously been described and this is the purpose of this document. A Heart Valve Centre includes a heart valve clinic, but also multidisciplinary heart teams for the care of patients with mitral valve disease, tricuspid valve disease, diseases of the aorta and aortic valve and infective endocarditis (Table 1). [...]

The flaws in the detail of an observational study on transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate-risks patients

Abstract: The PARTNER group recently published a comparison between the latest generation SAPIEN 3 transcatheter aortic valve implantation (TAVI) system (Edwards Lifesciences, Irvine, CA, USA) and surgical aortic valve replacement (SAVR) in intermediate-risk patients, apparently demonstrating superiority of the TAVI and suggesting that TAVI might be the preferred treatment method in this risk class of patients. Nonetheless, assessment of the non-randomized methodology used in this comparison reveals challenges that should be addressed in order to elucidate the validity of the results. The study by Thourani and colleagues showed several major methodological concerns: suboptimal methods in propensity score analysis with evident misspecification of the propensity scores (PS; no adjustment for the most significantly different covariates: left ventricular ejection fraction, moderate-severe mitral regurgitation and associated procedures); use of PS quintiles rather than matching; inference on not-adjusted Kaplan-Meier curves, although the authors correctly claimed for the need of balancing score adjusting for confounding factors in order to have unbiased estimates of the treatment effect; evidence of poor fit; lack of data on valve-related death. These methodological flaws invalidate direct comparison between treatments and cannot support authors' conclusions that TAVI with SAPIEN 3 in intermediate-risk patients is superior to surgery and might be the preferred treatment alternative to surgery.

Comparison of 1-Year Survival and Frequency of Paravalvular Leakage Using the Sapien 3 Versus the Sapien XT for Transcatheter Aortic Valve Implantation for Aortic Stenosis

Abstract: Transcatheter aortic valve implantation shortcomings such as relevant paravalvular leakage (PVL) have been shown to negatively impact survival. The Sapien 3 prosthesis has added features to address these problems. We compared the functional performance of the Sapien 3 (S3) and its predecessor Sapien XT (XT), with a particular focus on PVL. We analyzed 601 patients presenting with severe native aortic valve stenosis treated with either Sapien XT (n = 405, 2011 to 2014, mean STS-PROM [Society of Thoracic Surgeons predicted risk of mortality] 11.0%) or Sapien 3 prosthesis (n = 196, 2014 to 2016, mean STS-PROM 9.2%). Beside a propensity score-based comparison, we modeled the likelihood of PVL as a function of oversizing and prosthesis. Primary end points were 1-year survival, degree of oversizing, and occurrence of PVL. One-year survival (stratified log-rank p = 1.00) and 30-day mortality (S3: 10 of 126 vs XT: 10 of 126, p = 1.00) did not differ. In the matched cohort, oversizing was less common in the S3 group (absolute median difference of 7% in oversizing, interquartile range 1.1% to 12.7%, p = 0.025). PVL > = 1° was similar in both groups (S3: 13 of 126 vs XT: 20 of 126, p = 0.296). Mean gradients were lower in the XT group (median difference 1.0 mm Hg, interquartile range 0.3 to 1.8 mm Hg, p = 0.005). Rate of postdilatation, implantation of a second valve (valve-in-valve), annular rupture, and new pacemaker implantation were similar (all p = 1.00). In conclusion, compared with the Sapien XT, the redesigned Sapien 3 prosthesis offers effective sealing against PVL without grossly compromising hemodynamic performance or increasing the necessity for new pacemaker implantation.

Risks and Challenges of Surgery for Aortic Prosthetic Valve Endocarditis.

Abstract: Background Prosthetic valve endocarditis is the most severe form of infective endocarditis. This study assessed the risks and challenges of surgery for aortic prosthetic valve endocarditis. Methods In total, 116 consecutive patients (98 males, age 65.2 ± 12.7 years), who underwent redo-surgery for active aortic prosthetic valve endocarditis between 2000 and 2014, were reviewed. Cox regression analysis was used to identify factors for aortic root destructions as well as for morbidity and mortality. Median follow-up was 3.8 years (0–13.9 years). Results Aortic root destructions (42 limited and 29 multiple lesions) were associated with early prosthetic valve endocarditis and delayed diagnosis (≥14 d), but not with mortality. There were 16 (13.8%) early (≤30 d) and 32 (27.6%) late (>30 days) deaths. Survival at 1, 5, and 10 years was 72 ± 4.3%, 56 ± 5.4%, and 46 ± 6.4%, respectively. The cumulative incidence of death, reinfection, and reoperation was 19.0% at 30 days and 36.2% at 1 year. Delayed diagnosis, concomitant procedures, and EuroSCORE II >20% were predictors for early mortality and need for mechanical circulatory support, age >70 years, and critical preoperative state were predictors for late mortality. In their absence, survival at 10 years was 70 ± 8.4%. Reinfections and reoperations occurred more frequently if ≥1 risk factor for endocarditis and aortic root destructions were present. At 10 years, freedom from reinfection and reoperation was 89 ± 4.2% and 91 ± 4.0%. Conclusions The risks of death, reinfection, and reoperation are significant within the first year after surgery for aortic prosthetic valve endocarditis. Early diagnosis and aortic root destructions are the most important challenges, but advanced age, critical preoperative state, and the need for mechanical circulatory support determine long-term survival.

Myocardial Regeneration via Progenitor Cell-Derived Exosomes

Abstract: In the past 20 years, a variety of cell products has been evaluated in terms of their capacity to treat patients with acute myocardial infarction and chronic heart failure. Despite initial enthusiasm, therapeutic efficacy has overall been disappointing, and clinical application is costly and complex. Recently, a subset of small extracellular vesicles (EVs), commonly referred to as “exosomes,” was shown to confer cardioprotective and regenerative signals at a magnitude similar to that of their donor cells. The conceptual advantage is that they may be produced in industrial quantities and stored at the point-of-care for off-the-shelf application, ideally without eliciting a relevant recipient immune response or other adverse effects associated with viable cells. The body of evidence on beneficial exosome-mediated effects in animal models of heart diseases is rapidly growing. However, there is significant heterogeneity in terms of exosome source cells, isolation process, therapeutic dosage, and delivery mode. This review summarizes the current state of research on exosomes as experimental therapy of heart diseases and seeks to identify roadblocks that need to be overcome prior to clinical application.

Heart Failure After 5 Years on LVAD: Diagnosis and Treatment of Outflow Graft Obstruction.

Abstract: HeartWare assist device outflow graft obstruction is an uncommon but severe complication, and it may be because of several reasons. We present a case of recurrence of heart failure in a young patient supported with left ventricular assist device and on the waiting list for heart transplantation. After a complex diagnostic workout, a stenosis of the graft anastomosis was found and successfully stented.

Emergency procedures for patients with a continuous flow left ventricular assist device

Abstract: The number of ventricular assist devices (VADs) being implanted for terminal heart failure is rising at an exponential rate. These implanted patients have a decreased mortality, but still have significant morbidities, as the prevalence of these patients increases in the community. When VAD patients are discharged to home, they will very likely require emergency medical services (EMSs) and emergency medical doctors (EDs) with their future care. The interface of these patients with the community would suggest an increasing prevalence of encounters requiring the need for acute medical care. This will place the initial responsibility of these patients in the hands of EMS first responders and emergency room providers. To date, there is very little literature published on out-of-hospital or ED care for VAD patients. Most EMS personnel and ED feel uncomfortable treating a patient with a VAD because they have not had sufficient exposure. The cardiovascular treatment of VAD patients in the field can pose different challenges typically encountered including difficulties measuring a pulse and sometimes undetectable BP. Despite these unique challenges, official guidelines or even standard operating procedures regarding the emergency treatment of VAD patients are still lacking. We present a basic overview of the most commonly used left VAD systems and propose guidelines that should be followed in the event of an emergency with a VAD patient out of hospital.

Model-Based Therapy Planning Allows Prediction of Haemodynamic Outcome after Aortic Valve Replacement

Abstract: Optimizing treatment planning is essential for advances in patient care and outcomes. Precisely tailored therapy for each patient remains a yearned-for goal. Cardiovascular modelling has the potential to simulate and predict the functional response before the actual intervention is performed. The objective of this study was to proof the validity of model-based prediction of haemodynamic outcome after aortic valve replacement. In a prospective study design virtual (model-based) treatment of the valve and the surrounding vasculature were performed alongside the actual surgical procedure (control group). The resulting predictions of anatomic and haemodynamic outcome based on information from magnetic resonance imaging before the procedure were compared to post-operative imaging assessment of the surgical control group in ten patients. Predicted vs. post-operative peak velocities across the valve were comparable (2.97 ± 1.12 vs. 2.68 ± 0.67 m/s; p = 0.362). In wall shear stress (17.3 ± 12.3 Pa vs. 16.7 ± 16.84 Pa; p = 0.803) and secondary flow degree (0.44 ± 0.32 vs. 0.49 ± 0.23; p = 0.277) significant linear correlations (p < 0.001) were found between predicted and post-operative outcomes. Between groups blood flow patterns showed good agreement (helicity p = 0.852, vorticity p = 0.185, eccentricity p = 0.333). Model-based therapy planning is able to accurately predict post-operative haemodynamics after aortic valve replacement. These validated virtual treatment procedures open up promising opportunities for individually targeted interventions.

Kommentar zu den Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Diagnostik und Behandlung der akuten und chronischen Herzinsuffizienz@@@Comments on the guidelines of the European Society of Cardiology (ESC) on the diagnostics and treatment of acute and chronic heart failure

Abstract: ZusammenfassungDie Prävalenz der Herzinsuffizienz wird weiter deutlich zunehmen. Die neuen Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) [1] ersetzen die Leitlinien der Europäischen Gesellschaft für akute und chronische Herzinsuffizienz von 2012 und werden von der Deutschen Gesellschaft für Kardiologie übernommen. Dieser Kommentar diskutiert die neuen Aspekte der Leitlinie. Hierzu gehören insbesondere die neue Einteilung der Herzinsuffizienz in 3 Gruppen, erhaltene (HFpEF), mäßiggradig eingeschränkte (HFmrEF) und reduzierte linksventrikuläre Ejektionsfraktion (LV-EF), sowie Empfehlungen zum Einsatz des neuen Angiotensin-Rezeptor-Neprilysin-Inhibitors (ARNI) und zur kardialen Resynchronisationstherapie (CRT). Weiterhin finden sich neue Empfehlungen zur Diagnostik und Therapie der akuten Herzinsuffizienz.AbstractThe prevalence of heart failure will continue to increase. The new guidelines of the European Society of Cardiology (ESC) replace the 2012 ESC guidelines for the diagnostics and treatment of acute and chronic heart failure and are adopted by the German Cardiac Society. These comments discuss the new aspects of the guidelines. These include the novel classification of heart failure into three groups: preserved (HFpEF), mid-range (HFmrEF) and reduced (HFrEF) left ventricular ejection fraction (LV-EF) as well as recommendations on the clinical use of the angiotensin receptor neprilysin inhibitor (ARNI) and new data on cardiac resynchronization therapy (CRT). In addition, new recommendations on the diagnostics and treatment of acute heart failure are discussed.

Beating heart mitral valve surgery: results in 120 consecutive patients considered unsuitable for conventional mitral valve surgery.

Abstract: Objectives The purpose of the study was to test whether a beating heart mitral valve operation was a valuable option in a heterogeneous group of patients considered very high risk for conventional mitral valve surgery Methods We conducted a retrospective, single-centre, observational cohort study of 120 patients (mean age 637 ± 121 years, range 253-888 years; mean logistic EuroSCORE 261 ± 206%, range 15-843%) undergoing beating heart mitral valve operations using normothermic cardiopulmonary bypass without aortic cross-clamping and without cardioplegia between September 2002 and April 2014 Preoperatively, 14 (117%) patients were in cardiogenic shock, 16 (13%) on a ventilator, 33 (275%) receiving inotropic support, 12 (10%) on dialysis and 1 on extracorporeal membrane oxygenation Sixty-five (54%) patients had had at least 1 (range 1-6) previous heart operation The mean follow-up period was 920 ± 973 days Results A mitral valve procedure was performed alone in 75 (625%) patients and combined with additional cardiac procedures in 45 (375%) Fifty-eight (49%) patients had emergency or urgent procedures and 62 (51%), elective procedures The mean cardiopulmonary bypass time was 103 ± 39 min (median 94 min, range 45-252, interquartile range 75-1215 min) There were no conversions to conventional procedures and no intraoperative deaths The 30-day mortality rate for patients without cardiogenic shock was 75% (8 deaths among 106 patients) Among 14 (117%) patients who underwent an operation in cardiogenic shock, 4 died during the first 30 days (30-day mortality rate = 286%, Fisher's exact test P = 0338 versus patients without shock) The lowest 30-day mortality rate was in patients operated on with the beating heart because of a porcelain aorta (n = 8 patients, 30-day mortality rate = 0%) Conclusions Patients considered unsuitable for a conventional mitral valve operation had favourable postoperative outcomes if the operation was performed on the beating heart

Ticagrelor, but not clopidogrel active metabolite, displays antithrombotic properties in the left atrial endocardium.

Abstract: Aims Oral anticoagulation is considered standard therapy for stroke prevention in atrial fibrillation (AF). Endocardial activation triggers expression of pro-thrombotic mediators including tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1), and contributes to thrombus formation in the left atrial appendage (LAA) of AF patients. Recently, pleiotropic effects of specific P2Y12 receptor antagonists were demonstrated; however, whether these drugs possess antithrombotic effects on LAA endocardial cells currently remains unknown. Methods and results LAA were obtained from 14 patients with known AF undergoing elective cardiac surgery including LAA removal at the University Hospital Zurich. LAA endocardial cells were isolated and pre-incubated with ticagrelor (10−7, 10−6, 10−5M) or clopidogrel active metabolite (CAM) (1.5 × 10−8, 1.5 × 10−7, 1.5 × 10−6 M) before stimulation with tumour necrosis factor-alpha (TNF-α) (10 ng/mL). Finally, TF and PAI-1 expression and activity were analysed. Ticagrelor, unlike CAM, concentration dependently decreased TNF-α-induced TF expression and TF activity in LAA endocardial cells. Further, ticagrelor, but not CAM reduced PAI-1 expression and enzyme activity in TNF-α-stimulated LAA endocardial cells. In contrast, TF pathway inhibitor (TFPI) remained unaffected by both dugs. Conclusion Ticagrelor, but not CAM, reduces expression and activity of TF and PAI-1 in LAA endocardial cells isolated from patients with AF, indicating possible local antithrombotic effects. Such pleiotropic properties of ticagrelor may contribute to a reduction in thromboembolic complications in patients with AF.

Processing of Human Cardiac Tissue Toward Extracellular Matrix Self-assembling Hydrogel for In Vitro and In Vivo Applications

Abstract: Acellular extracellular matrix preparations are useful for studying cell-matrix interactions and facilitate regenerative cell therapy applications. Several commercial extracellular matrix products are available as hydrogels or membranes, but these do not possess tissue-specific biological activity. Because perfusion decellularization is usually not possible with human heart tissue, we developed a 3-step immersion decellularization process. Human myocardial slices procured during surgery are first treated with detergent-free hyperosmolar lysis buffer, followed by incubation with the ionic detergent, sodium dodecyl sulfate, and the process is completed by exploiting the intrinsic DNase activity of fetal bovine serum. This technique results in cell-free sheets of cardiac extracellular matrix with largely preserved fibrous tissue architecture and biopolymer composition, which were shown to provide specific environmental cues to cardiac cell populations and pluripotent stem cells. Cardiac extracellular matrix sheets can then be further processed into a microparticle powder without further chemical modification, or, via short-term pepsin digestion, into a self-assembling cardiac extracellular matrix hydrogel with preserved bioactivity.